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钟 华, 徐 丽, 白 明, 苏 茵. [Effect of chemokines CXCL9 and CXCL10 on bone erosion in patients with rheumatoid arthritis]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2021; 53:1026-1031. [PMID: 34916676 PMCID: PMC8695154 DOI: 10.19723/j.issn.1671-167x.2021.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To detect the serum level of soluble chemokines CXCL9 and CXCL10 in patients with rheumatoid arthritis (RA), and to analyze their correlation with bone erosion, as well as the clinical significance in RA. METHODS In the study, 105 cases of RA patients, 90 osteoarthritis (OA) patients and 25 healthy controls in Peking University People's Hospital were included. All the clinical information of the patients was collected, and the serum CXCL9 and CXCL10 levels of both patients and healthy controls were measured by enzyme-linked immune sorbent assay (ELISA). CXCL9 and CXCL10 levels among different groups were compared. The correlation between serum levels with clinical/laboratory parameters and the occurrence of bone erosion in RA were analyzed. Independent sample t test, Chi square test, Mann-Whitney U test, Spearman's rank correlation and Logistic regression were used for statistical analysis. RESULTS The levels of CXCL9 and CXCL10 were significantly higher in the RA patients [250.02 (126.98, 484.29) ng/L, 108.43 (55.16, 197.17) ng/L] than in the OA patients [165.05 (75.89, 266.37) ng/L, 69.00 (33.25, 104.74) ng/L] and the health controls [79.47 (38.22, 140.63) ng/L, 55.44 (18.76, 95.86) ng/L] (all P < 0.01). Spearman's correlation analysis showed that the level of serum CXCL9 was positively correlated with swollen joints (SJC), rheumatoid factor (RF) and disease activity score 28 (DAS28) (r=0.302, 0.285, 0.289; P=0.009, 0.015, 0.013). The level of serum CXCL10 was positively correlated with tender joints (TJC), SJC, C-reactive protein (CRP), immunoglobulin (Ig) A, IgM, RF, anti-cyclic citrullinated peptide antibody (ACPA), and DAS28 (r=0.339, 0.402, 0.269, 0.266, 0.345, 0.570, 0.540, 0.364; P=0.010, 0.002, 0.043, 0.045, 0.009, < 0.001, < 0.001, 0.006). Serum CXCL9 and CXCL10 levels in the RA patients with bone erosion were extremely higher than those without bone erosion [306.84 (234.02, 460.55) ng/L vs. 149.90 (75.88, 257.72) ng/L, 153.74 (89.50, 209.59) ng/L vs. 54.53 (26.30, 83.69) ng/L, respectively] (all P < 0.01). Logistic regression analysis showed that disease duration, DAS28 and serum level of CXCL9 were correlated with bone erosion in the RA patients (P < 0.05). CONCLUSION Serum levels of CXCL9 and CXCL10 were remarkably elevated in patients with RA, and correlated with disease activities and occurrence of bone erosion. Chemokines CXCL9 and CXCL10 might be involved in the pathogenesis and bone destruction in RA.
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Affiliation(s)
- 华 钟
- />北京大学人民医院风湿免疫科,风湿病机制及免疫诊断北京市重点实验室,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital; Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing 100044, China
| | - 丽玲 徐
- />北京大学人民医院风湿免疫科,风湿病机制及免疫诊断北京市重点实验室,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital; Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing 100044, China
| | - 明欣 白
- />北京大学人民医院风湿免疫科,风湿病机制及免疫诊断北京市重点实验室,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital; Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing 100044, China
| | - 茵 苏
- />北京大学人民医院风湿免疫科,风湿病机制及免疫诊断北京市重点实验室,北京 100044Department of Rheumatology and Immunology, Peking University People's Hospital; Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing 100044, China
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MMP3 is a reliable marker for disease activity, radiological monitoring, disease outcome predictability, and therapeutic response in rheumatoid arthritis. Best Pract Res Clin Rheumatol 2019; 32:550-562. [PMID: 31174824 DOI: 10.1016/j.berh.2019.01.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Matrix metalloproteinase-3 or MMP3 also known as stromelysin-1 is an enzyme that is actively involved in joint destruction in rheumatoid arthritis (RA) patients. Screening the last three decades, it appears that serum levels of MMP3 reflect positively RA disease activity, joint and bone injury, and radiological erosion and predict disease outcome and drug responsiveness as summarized in several publications reporting outcomes on more than 8000 patients with RA. MMP-3 monitoring should be embedded in the routine assessment and accompany therapeutic modalities, in personalized medical RA management.
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A Bayesian mixed treatment comparison of efficacy of biologics and small molecules in early rheumatoid arthritis. Clin Rheumatol 2019; 38:1309-1317. [PMID: 30628014 DOI: 10.1007/s10067-018-04406-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/18/2018] [Indexed: 01/05/2023]
Abstract
The current paradigm in the management of rheumatoid arthritis (RA) is to treat patients in the early stage of the disease (ERA). Previous meta-analysis-based mixed treatment comparisons (MTCs), aimed to identify the most effective drugs in ERA, are biased by the wide "window" of early definition, ranging from 6 months to 2 years. The aim of this study was to estimate through a Bayesian Network Meta-Analysis which biologics or small molecules are more likely to achieve a 1-year good clinical response in ERA patients with disease duration < 1 year. According to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement, randomized controlled trials (RCTs) of biologic agents and small molecules in combination with MTX to treat patients affected with ERA lasting < 1 year were searched through MEDLINE, EMBASE, Cochrane Library, and Clinicaltrials.gov between 1990 and September 2017. The outcome of interest was the achievement of American College of Rheumatology (ACR) 50 and ACR 70 response at 1 year. WinBUGS 1.4 software (MRC Biostatistics Unit, Cambridge, UK) was used to perform the analyses, using a fixed effect model. Fourteen studies were included in the analysis. Tofacitinib (64.83%) followed by Etanercept (23.26%) were the drugs with the highest probability of achieving ACR50 response. Rituximab showed the highest probability of inducing ACR70 response (52.81%) followed by Etanercept (26.85%). This is the first MTC involving only RCTs on ERA patients with disease duration < 1 year. Tofacitinib and rituximab were the drugs ranked first in inducing 1-year ACR50 and ACR70 response, respectively.
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Migliore A, Bizzi E, Petrella L, Bruzzese V, Cassol M, Integlia D. The Challenge of Treating Early-Stage Rheumatoid Arthritis: The Contribution of Mixed Treatment Comparison to Choosing Appropriate Biologic Agents. BioDrugs 2016; 30:105-15. [PMID: 26905069 DOI: 10.1007/s40259-016-0164-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Use of biologic drugs is approved for treatment in rheumatoid arthritis (RA), both in established disease and at the early stage of RA (ERA). Identification of ERA and an early therapeutic strategy would lead to greater clinical improvement. Only a few indirect comparisons of the efficacy of different biologic agents in established RA have been performed and, to date, no studies reporting direct comparisons have been performed in ERA. OBJECTIVE The aim of this study was to compare, by use of a mixed treatment comparison (MTC), the efficacy profiles of biologic agents in ERA. METHODS An extensive literature search was performed to identify results of randomized, controlled trials (RCTs) evaluating biologic agents at licensed doses to treat patients affected by ERA. The primary end points for the analysis were the American College of Rheumatology 20% improvement (ACR20), ACR50, and ACR70 responses from baseline to various times of follow-up. WinBUGS 1.4 software (MRC Biostatistics Unit, Cambridge, UK) was used to perform the analyses. The MTC results are reported as the relative risk of a response for every single treatment coadministered with methotrexate, versus methotrexate plus placebo, which was used as a comparator in all RCTs. RESULTS Ten scientific papers met the study inclusion criteria and were included in the analysis. Data on the use of infliximab, adalimumab, etanercept, abatacept, golimumab, and rituximab were included. No studies reported on the use of certolizumab pegol or tocilizumab in ERA. All biologic agents coadministered with methotrexate proved to be more efficacious than methotrexate plus placebo in inducing ACR20, ACR50, and ACR70 responses. The biologic agent characterized by the highest probability of inducing an ACR70 response was adalimumab (33.28%). Etanercept was the biologic agent with the highest probability of inducing ACR20 and ACR50 responses, in comparison with all other biologic agents, with probability rates of 62.95 and 37.1%, respectively. CONCLUSION In our analysis, adalimumab proved to be the biologic agent with the highest probability of inducing an ACR70 response in patients affected by ERA, while etanercept was the biologic agent with the highest probability of inducing ACR50 and ACR20 responses.
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Affiliation(s)
- Alberto Migliore
- Rheumatology Department, San Pietro Fatebenefratelli Hospital, via Cassia 600, 00189, Rome, Italy.,International Society For Pharmacoeconomics and Outcomes Research (ISPOR), Rome, Italy
| | - Emanuele Bizzi
- Rheumatology Department, San Pietro Fatebenefratelli Hospital, via Cassia 600, 00189, Rome, Italy.
| | - Lea Petrella
- Methods and Models for Economics, Territory and Finance (MEMOTEF) Department, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Bruzzese
- Internal Medicine and Gastroenterology Department, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Maurizio Cassol
- Internal Medicine Department, San Pietro Fatebenefratelli Hospital, Rome, Italy
| | - Davide Integlia
- Integrated Solutions Health Economics and Organization (ISHEO), Rome, Italy
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Zeidler H, Hudson AP. Causality of Chlamydiae in Arthritis and Spondyloarthritis: a Plea for Increased Translational Research. Curr Rheumatol Rep 2016; 18:9. [PMID: 26769308 DOI: 10.1007/s11926-015-0559-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Current molecular genetic understanding of the metabolically active persistent infection state of Chlamydia trachomatis and Chlamydia pneumoniae in the synovium in patients with arthritis and spondyloarthritis favors a causal relationship. Here, we examine how adequately the accepted criteria for that etiologic relationship are fulfilled, emphasizing the situation in which these microorganisms cannot be cultivated by standard or other means. We suggest that this unusual situation of causality by chlamydiae in rheumatic disease requires establishment of a consensus regarding microorganism-specific terminology as well as the development of new diagnostic and classification criteria. Recent studies demonstrate the value of molecular testing for diagnosis of reactive arthritis, undifferentiated spondyloarthritis, and undifferentiated arthritis caused by C. trachomatis and C. pneumoniae in clinical practice. Data regarding combination antibiotic therapy is consistent with the causative role of chlamydiae for these diseases. Observations of multiple intra-articular coinfections require more research to understand the implications and to respond to them.
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Affiliation(s)
- Henning Zeidler
- Division of Clinical Immunology and Rheumatology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Alan P Hudson
- Department of Immunology and Microbiology, Wayne State University School of Medicine, Detroit, MI, USA
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The Relationship of Cytokines IL-13 and IL-17 with Autoantibodies Profile in Early Rheumatoid Arthritis. J Immunol Res 2016; 2016:3109135. [PMID: 27579330 PMCID: PMC4989068 DOI: 10.1155/2016/3109135] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 06/05/2016] [Accepted: 06/21/2016] [Indexed: 12/04/2022] Open
Abstract
Aims. In the present study, we aimed to assess the concentrations of IL-13 and IL-17 in serum of patients with early rheumatoid arthritis (eRA), the investigation of correlation between the concentrations of these cytokines and disease activity score, and the concentration of some autoantibodies and the evaluation of the utility of IL-13 and -17 concentration measurements as markers of disease activity. Materials and Methods. Serum samples were collected from 30 patients and from 28 controls and analysed parameters. Results. The serum concentrations of IL-13, IL-17, anti-CCP, and IgM-RF were statistically significantly higher in patients with eRA, compared to the controls. IL-13 concentrations in the severe and moderate groups with eRA were statistically higher than in the mild and control groups. Also, in the case of IL-17, serum concentrations increased proportionally with the disease activity of eRA. We observe that concentrations of IL-13 and -17 did not correlate with autoantibodies. IL-17 concentration significantly positively correlated with CRP, while IL-13 concentration significantly negatively correlated with CRP. Disease activity score, DAS28, was strongly positively correlated with levels of ESR and weakly positively correlated with concentrations of anti-RA33 autoantibodies. IL-13 has a higher diagnostic utility than IL-17, CRP, ESR, IgM-RF, and anti-CCP as markers of disease activity. Conclusions. The presence of higher IL-13 and IL-17 serum levels in patients, compared with those of controls, confirms that these markers, found with high specificity, might be involved in the pathogenesis of eRA. IL-13 and IL-17 might be of better usefulness in the prediction of eRA activity status than IgM-RF and anti-CCP.
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Self-limiting arthritis among patients fulfilling the 2010 ACR/EULAR classification criteria for rheumatoid arthritis in a very early arthritis cohort. Semin Arthritis Rheum 2016; 46:272-278. [PMID: 27546493 DOI: 10.1016/j.semarthrit.2016.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 06/24/2016] [Accepted: 07/18/2016] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To study occurrence of and factors associated with self-limiting arthritis among patients fulfilling the 2010 ACR/EULAR classification criteria for rheumatoid arthritis (RA) (2010 RA criteria) in patients with ≤16 weeks׳ duration of joint swelling. METHODS We applied the 2010 RA criteria in 1118 patients included in a 2-year longitudinal cohort. In all, 256 patients fulfilled the 2010 RA criteria at baseline; outcome was defined as either "self-limiting arthritis" (no DMARD use during follow-up, no swollen joints at last assessment, and no final clinical diagnosis of RA) or "persistent disease." The associations between baseline characteristics, including the components of the 2010 RA criteria score, and outcomes were studied. RESULTS In total, 36 of 256 patients (14.1%) classified as having RA had self-limiting arthritis. These patients differed from patients with persistent disease according to ACPA positivity (11.1% vs. 65.0%, p < 0.001), duration of joint swelling (median = 47.5 vs. 66.0 days, p = 0.002), 2010 RA criteria points (median = 6.0 vs. 7.0, p < 0.001), and ever smoking (52.8% vs. 74.5%, p = 0.01). Having no serology points and no duration points were independent predictors of self-limiting arthritis. The rate of self-limiting arthritis was 2.7% vs. 29.4% among ACPA positive vs. ACPA negative patients (p < 0.001), and 32.5% when duration of joint swelling was <4 weeks vs. 10.6% with longer duration (p < 0.001). CONCLUSIONS Negative ACPA status, short duration of joint swelling and being a never smoker were factors associated with self-limiting arthritis in early arthritis patients classified as having RA at presentation. Our findings contribute to identify patients who potentially do not need DMARDs and who should not be included in early RA clinical drug trials.
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Espinoza F, Fabre S, Pers YM. Remission-induction therapies for early rheumatoid arthritis: evidence to date and clinical implications. Ther Adv Musculoskelet Dis 2016; 8:107-18. [PMID: 27493689 DOI: 10.1177/1759720x16654476] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Recent guidelines on rheumatoid arthritis (RA) point to the importance of achieving remission as soon as possible during the course of the disease. The appropriate use of antirheumatic drugs is critical, particularly in early RA patients, before 24 weeks, since this is a 'window of opportunity' for treatment to modify disease progression. A treat-to-target strategy added to an aggressive therapeutic approach increases the chance of early remission, particularly in early RA patients. We conducted an overview of current therapeutic strategies leading to remission in early RA patients. We also provide interesting predictive factors that can guide the RA management strategy with regard to disease-modifying treatment and/or drug-free remission.
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Affiliation(s)
- Francisco Espinoza
- Department of Rheumatology, School of Medicine, University of Los Andes, Santiago, Chile
| | - Sylvie Fabre
- Clinical Immunology and Osteoarticular Diseases Therapeutic Unit, CHU Lapeyronie, Montpellier, France
| | - Yves-Marie Pers
- Clinical Immunology and Osteoarticular Diseases Therapeutic Unit, CHU Lapeyronie, 371, avenue du doyen Gaston Giraud, 34295 Montpellier, France
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Kim JY, Choi YY, Kim CW, Sung YK, Yoo DH. Bone Scintigraphy in the Diagnosis of Rheumatoid Arthritis: Is There Additional Value of Bone Scintigraphy with Blood Pool Phase over Conventional Bone Scintigraphy? J Korean Med Sci 2016; 31:502-9. [PMID: 27051232 PMCID: PMC4810331 DOI: 10.3346/jkms.2016.31.4.502] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 12/18/2015] [Indexed: 01/15/2023] Open
Abstract
We aimed to investigate the value of bone scintigraphy with additional blood pool phase (BSBP), compared with conventional bone scintigraphy (CBS), in the assessment of rheumatoid arthritis (RA). A total of 242 patients (43 males, 199 females; 14-78 years) with arthralgia, and underwent BSBP were retrospectively analyzed. On the first physical examination, active arthritis was found in 128 of the 242 patients. Clinical diagnosis was made by a rheumatologist on the basis of the 1987 American College of Rheumatology (ACR) criteria, which are considered to be the gold standard. The diagnostic performances and prognostic value of BSBP and CBS were analyzed in the total patients with arthralgia and in the patients with arthritis. The sensitivity of BSBP (84.2%, 80/95) were significantly higher than that of CBS (74.8%, 72/95) in the patients with arthralgia (P = 0.039). When BSBP was interpreted with the results of elevated/positive anti-CCP antibody, its accuracy over CBS also became significantly higher (86.0%, 208/242 vs. 83.1%, 201/242 respectively, P = 0.021). The diagnostic odds ratio of BSBP positivity was higher than CBS positivity in the patients with arthralgia (26.0, 12.9-52.4 vs. 21.1, 10.8-41.3) and with arthritis (12.0, 4.9-29.4 vs. 10.0, 4.2-23.4). Both BSBP and CBS appear to provide acceptable accuracy and comparable diagnostic performance for diagnosis of RA. However, in the patients with arthralgia, BSBP was found to be more sensitive than CBS and more accurate when interpreted with the result of anti-CCP antibody. This could help physicians diagnose RA in daily clinical practice.
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Affiliation(s)
- Ji Young Kim
- Department of Nuclear Medicine, Hanyang University College of Medicine, Hanyang University Medical Center, Seoul, Korea
| | - Yun Young Choi
- Department of Nuclear Medicine, Hanyang University College of Medicine, Hanyang University Medical Center, Seoul, Korea
| | - Chan Woo Kim
- Department of Nuclear Medicine, Hanyang University College of Medicine, Hanyang University Medical Center, Seoul, Korea
| | - Yoon-Kyoung Sung
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine and the Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
| | - Dae-Hyun Yoo
- Division of Rheumatology, Department of Internal Medicine, Hanyang University College of Medicine and the Hospital for Rheumatic Diseases, Hanyang University Medical Center, Seoul, Korea
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Khairnar A, Marchand F, Vidal A, Etienne M, Miladi I, Auzeloux P, Cachin F, Eschalier A, Chezal JM, Ardid D, Miot-Noirault E. 99mTc-NTP 15-5 Imaging for Cartilage Involvement in Experimental Rheumatoid Arthritis: Comparison with Routinely Used Molecular Imaging Methods and Sensitivity to Chronic Nonsteroidal Antiinflammatory Drug Treatment. J Nucl Med 2015; 56:798-804. [PMID: 25840975 DOI: 10.2967/jnumed.114.151415] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/10/2015] [Indexed: 01/01/2023] Open
Abstract
UNLABELLED This study determined, using the intraarticular complete Freund adjuvant arthritis mice model, whether the radiotracer (99m)Tc-N-(triethylammonium)-3-propyl-[15]ane-N5 ((99m)Tc-NTP 15-5) targeting proteoglycans has a pathophysiologic validity for in vivo imaging of rheumatoid arthritis (RA) and its response to chronic nonsteroidal antiinflammatory drugs. METHODS We investigated the time course of cartilage remodeling by (99m)Tc-NTP 15-5 scintigraphy, bone damages by (99m)Tc-hydroxymethylene diphosphonate imaging, inflammation by (18)F-FDG PET, and joint proteoglycan content and pain behavior in animals, without and with meloxicam treatment. Paw circumference, thermal pain behavior, and histology as well as proteoglycan content of the whole joint were determined. RESULTS (99m)Tc-NTP 15-5 showed specific tracer accumulation within RA joints, with a significant increase in scintigraphic ratio observed in RA versus shams from day 3 to day 28. (18)F-FDG evidenced uptake in RA joints from day 15 to day 29. Animals treated with meloxicam (5 mg/kg) exhibited a dose-dependent decrease in both (99m)Tc-NTP 15-5 and (18)F-FDG uptake ratios versus saline-treated animals. (99m)Tc-hydroxymethylene diphosphonate bone scans were only positive at day 14 in RA versus shams, with a significant effect of meloxicam. An increase in proteoglycans of RA joint and thermal pain behavior were observed and were dose-dependently reduced by meloxicam. CONCLUSION These experimental results bring data in favor of the (99m)Tc-NTP 15-5 radiotracer for assessing, in vivo, cartilage remodeling in RA that could be used to monitor therapy.
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Affiliation(s)
- Amit Khairnar
- Clermont Université, Université d'Auvergne, Imagerie Moléculaire et Thérapie Vectorisée, BP 10448, Clermont-Ferrand, France INSERM, U 990, Clermont-Ferrand, France Clermont Université, Université d'Auvergne, Pharmacologie Fondamentale et Clinique de la Douleur, Clermont-Ferrand, France INSERM U1107 NEURO-DOL, Clermont-Ferrand, France; and
| | - Fabien Marchand
- Clermont Université, Université d'Auvergne, Pharmacologie Fondamentale et Clinique de la Douleur, Clermont-Ferrand, France INSERM U1107 NEURO-DOL, Clermont-Ferrand, France; and
| | - Aurélien Vidal
- Clermont Université, Université d'Auvergne, Imagerie Moléculaire et Thérapie Vectorisée, BP 10448, Clermont-Ferrand, France INSERM, U 990, Clermont-Ferrand, France
| | - Monique Etienne
- Clermont Université, Université d'Auvergne, Pharmacologie Fondamentale et Clinique de la Douleur, Clermont-Ferrand, France INSERM U1107 NEURO-DOL, Clermont-Ferrand, France; and
| | - Imen Miladi
- Clermont Université, Université d'Auvergne, Imagerie Moléculaire et Thérapie Vectorisée, BP 10448, Clermont-Ferrand, France INSERM, U 990, Clermont-Ferrand, France
| | - Philippe Auzeloux
- Clermont Université, Université d'Auvergne, Imagerie Moléculaire et Thérapie Vectorisée, BP 10448, Clermont-Ferrand, France INSERM, U 990, Clermont-Ferrand, France
| | - Florent Cachin
- Clermont Université, Université d'Auvergne, Imagerie Moléculaire et Thérapie Vectorisée, BP 10448, Clermont-Ferrand, France INSERM, U 990, Clermont-Ferrand, France CLCC Jean Perrin, Clermont-Ferrand, France
| | - Alain Eschalier
- Clermont Université, Université d'Auvergne, Pharmacologie Fondamentale et Clinique de la Douleur, Clermont-Ferrand, France INSERM U1107 NEURO-DOL, Clermont-Ferrand, France; and
| | - Jean-Michel Chezal
- Clermont Université, Université d'Auvergne, Imagerie Moléculaire et Thérapie Vectorisée, BP 10448, Clermont-Ferrand, France INSERM, U 990, Clermont-Ferrand, France
| | - Denis Ardid
- Clermont Université, Université d'Auvergne, Pharmacologie Fondamentale et Clinique de la Douleur, Clermont-Ferrand, France INSERM U1107 NEURO-DOL, Clermont-Ferrand, France; and
| | - Elisabeth Miot-Noirault
- Clermont Université, Université d'Auvergne, Imagerie Moléculaire et Thérapie Vectorisée, BP 10448, Clermont-Ferrand, France INSERM, U 990, Clermont-Ferrand, France
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Chan MM, Gray BD, Pak KY, Fong D. Non-invasive in vivo imaging of arthritis in a collagen-induced murine model with phosphatidylserine-binding near-infrared (NIR) dye. Arthritis Res Ther 2015; 17:50. [PMID: 25889786 PMCID: PMC4396543 DOI: 10.1186/s13075-015-0565-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 02/18/2015] [Indexed: 01/30/2023] Open
Abstract
Introduction Development of non-invasive molecular imaging techniques that are based on cellular changes in inflammation has been of active interest for arthritis diagnosis. This technology will allow real-time detection of tissue damage and facilitate earlier treatment of the disease, thus representing an improvement over X-rays, which detect bone damage at the advanced stage. Tracing apoptosis, an event occurring in inflammation, has been a strategy used. PSVue 794 is a low-molecular-weight, near-infrared (NIR)-emitting complex of bis(zinc2+-dipicolylamine) (Zn-DPA) that binds to phosphatidylserine (PS), a plasma membrane anionic phospholipid that becomes flipped externally upon cell death by apoptosis. In this study, we evaluated the capacity of PSVue 794 to act as an in vivo probe for non-invasive molecular imaging assessment of rheumatoid arthritis (RA) via metabolic function in murine collagen-induced arthritis, a widely adopted animal model for RA. Methods Male DBA/1 strain mice were treated twice with chicken collagen type II in Freund’s adjuvant. Their arthritis development was determined by measuring footpad thickness and confirmed with X-ray analysis and histology. In vivo imaging was performed with the NIR dye and the LI-COR Odyssey Image System. The level of emission was compared among mice with different disease severity, non-arthritic mice and arthritic mice injected with a control dye without the Zn-DPA targeting moiety. Results Fluorescent emission correlated reliably with the degree of footpad swelling and the manifestation of arthritis. Ex vivo examination showed emission was from the joint. Specificity of binding was confirmed by the lack of emission when arthritic mice were given the control dye. Furthermore, the PS-binding protein annexin V displaced the NIR dye from binding, and the difference in emission was numerically measurable on a scale. Conclusions This report introduces an economical alternative method for assessing arthritis non-invasively in murine models. Inflammation in feet and ankles can be measured longitudinally using the PSVue 794 probe for cell death and with a commonly available multipurpose imager. This technique provides metabolic and functional information that anatomical measurement of footpad swelling or visual determination of arthritic index cannot. It also may decrease the number of animals required per experiment because tissue damage will not necessarily require evaluation by harvesting joints for histology.
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Affiliation(s)
- Marion M Chan
- Department of Microbiology and Immunology, Temple University School of Medicine, 3400 North Broad Street, Philadelphia, PA, 19140, USA.
| | - Brian D Gray
- Molecular Targeting Technologies, Inc., 833 Lincoln Avenue, West Chester, PA, 19380, USA.
| | - Koon Y Pak
- Molecular Targeting Technologies, Inc., 833 Lincoln Avenue, West Chester, PA, 19380, USA.
| | - Dunne Fong
- Department of Cell Biology and Neuroscience, Rutgers, The State University of New Jersey, 604 Allison Road, Piscataway, NJ, 08854, USA.
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Performance of the 2010 ACR/EULAR classification criteria for rheumatoid arthritis in a prospective early arthritis cohort in Kerala, India. INDIAN JOURNAL OF RHEUMATOLOGY 2014. [DOI: 10.1016/j.injr.2014.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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13
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Scrivo R, Casadei L, Valerio M, Priori R, Valesini G, Manetti C. Metabolomics approach in allergic and rheumatic diseases. Curr Allergy Asthma Rep 2014; 14:445. [PMID: 24744271 DOI: 10.1007/s11882-014-0445-5] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Metabolomics is the analysis of the concentration profiles of low molecular weight compounds present in biological fluids. Metabolites are nonpeptide molecules representing the end products of cellular activity. Therefore, changes in metabolite concentrations reveal the range of biochemical effects induced by a disease or its therapeutic intervention. Metabolomics has recently become feasible with the accessibility of new technologies, including mass spectrometry and high-resolution proton nuclear magnetic resonance, and has already been applied to several disorders. Indeed, it has the advantage of being a nontargeted approach for identifying potential biomarkers, which means that it does not require a preliminary knowledge of the substances to be studied. In this review, we summarize the main studies in which metabolomic approach was used in some allergic (asthma, atopic dermatitis) and rheumatic diseases (rheumatoid arthritis, systemic lupus erythematosus) to explore the feasibility of this technique as a novel diagnostic tool in these complex disorders.
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Affiliation(s)
- Rossana Scrivo
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Sapienza Università di Roma, Viale del Policlinico 155, 00161, Rome, Italy,
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14
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Carpenter T, Katz SJ. Review of a rheumatology triage system: simple, accurate, and effective. Clin Rheumatol 2013; 33:247-52. [DOI: 10.1007/s10067-013-2413-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Revised: 10/02/2013] [Accepted: 10/12/2013] [Indexed: 10/26/2022]
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15
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Clinical features and independent predictors in the further development of rheumatoid arthritis in undifferentiated arthritis. Rheumatol Int 2013; 33:2827-32. [DOI: 10.1007/s00296-013-2799-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 06/06/2013] [Indexed: 11/26/2022]
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16
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Heimans L, Wevers-de Boer KVC, Visser K, Goekoop RJ, van Oosterhout M, Harbers JB, Bijkerk C, Speyer I, de Buck MPDM, de Sonnaville PBJ, Grillet BAM, Huizinga TWJ, Allaart CF. A two-step treatment strategy trial in patients with early arthritis aimed at achieving remission: the IMPROVED study. Ann Rheum Dis 2013; 73:1356-61. [PMID: 23716067 DOI: 10.1136/annrheumdis-2013-203243] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess which treatment strategy is most effective in inducing remission in early (rheumatoid) arthritis. METHODS 610 patients with early rheumatoid arthritis (RA 2010 criteria) or undifferentiated arthritis (UA) started treatment with methotrexate (MTX) and a tapered high dose of prednisone. Patients in early remission (Disease Activity Score <1.6 after 4 months) tapered prednisone to zero and those with persistent remission after 8 months, tapered and stopped MTX. Patients not in early remission were randomised to receive either MTX plus hydroxychloroquine plus sulfasalazine plus low-dose prednisone (arm 1) or to MTX plus adalimumab (ADA) (arm 2). If remission was present after 8 months both arms tapered to MTX monotherapy; if not, arm 1 changed to MTX plus ADA and arm 2 increased the dose of ADA. Remission rates and functional and radiological outcomes were compared between arms and between patients with RA and those with UA. RESULTS 375/610 (61%) patients achieved early remission. After 1 year 68% of those were in remission and 32% in drug-free remission. Of the randomised patients, 25% in arm 1 and 41% in arm 2 achieved remission at year 1 (p<0.01). Outcomes were comparable between patients with RA and those with UA. CONCLUSIONS Initial MTX and prednisone resulted in early remission in 61% of patients with early (rheumatoid) arthritis. Of those, 68% were in remission and 32% were in drug-free remission after 1 year. In patients not in early remission, earlier introduction of ADA resulted in more remission at year 1 than first treating with disease-modifying antirheumatic drug combination therapy plus prednisone.
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Affiliation(s)
- L Heimans
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - K V C Wevers-de Boer
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - K Visser
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - R J Goekoop
- Department of Rheumatology, Haga Hospital, The Hague, the Netherlands
| | - M van Oosterhout
- Department of Rheumatology, Groene Hart Hospital, Gouda, The Netherlands
| | - J B Harbers
- Department of Rheumatology, Franciscus Hospital, Roosendaal, The Netherlands
| | - C Bijkerk
- Department of Rheumatology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - I Speyer
- Department of Rheumatology, Bronovo Hospital, The Hague, The Netherlands
| | - M P D M de Buck
- Department of Rheumatology, Medical Center Haaglanden, The Hague, The Netherlands
| | - P B J de Sonnaville
- Department of Rheumatology, Admiraal de Ruyter Hospital, Goes, The Netherlands
| | - B A M Grillet
- Department of Rheumatology, Zorgsaam, Terneuzen, The Netherlands
| | - T W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - C F Allaart
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
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17
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Systemic literature review of the performance of the 2010 ACR/EULAR classification criteria for rheumatoid arthritis: good news of debatable significance. Ann Rheum Dis 2013; 72:e21. [DOI: 10.1136/annrheumdis-2013-203842] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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18
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Current World Literature. Curr Opin Rheumatol 2013; 25:398-409. [DOI: 10.1097/bor.0b013e3283604218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Woodworth T, Ranganath V, Furst DE. Rheumatoid arthritis in the elderly: recent advances in understanding the pathogenesis, risk factors, comorbidities and risk–benefit of treatments. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/ahe.13.15] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Rheumatoid arthritis (RA) increases in incidence and prevalence with age, with a peak in the sixth decade of life. Elderly onset RA (EORA) may be genetically different from younger onset RA, and with immune dysfunction associated with aging, environmental factors may also influence EORA onset. Smoking, periodontitis and viral infections are examples of environmental factors that have been shown to be associated with development of EORA, and even hormonal changes with menopause may be a source of RA activation in older patients. EORA can be distinguished from polymyalgia rheumatica, inflammatory hand osteoarthritis or psoriatic arthritis by rheumatoid factor or anticitrullinated protein antibodies. Comorbidities influence treatment risk–benefit and require proactive management; these include arteriosclerotic cardiovascular disease, obesity, diabetes, GI tract conditions, lung disease, renal disease or malignancies, as well as susceptibility to infection. As inclusion of older RA patients is lower in clinical trials, safety data in this group are limited and this influences treatment choice, especially for biologics. Despite the efficacy of biologics, they are less likely to be used in older RA patients. This is problematic as glucocorticoids, when used in the elderly, are associated with serious infections, cardiovascular and fracture risk, among other side effects. Similarly, analgesics and NSAIDs should be used cautiously. Taking into account comorbidities, treat-to-target strategies with nonbiologic disease-modifying antirheumatic drugs and biologics can be applied with an expectation of acceptable risk–benefit in these patients.
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Affiliation(s)
- Thasia Woodworth
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Veena Ranganath
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA 90095, USA
| | - Daniel E Furst
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA 90095, USA.
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20
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Treatment strategies in early rheumatoid arthritis and prevention of rheumatoid arthritis. Curr Rheumatol Rep 2013; 14:472-80. [PMID: 22773387 DOI: 10.1007/s11926-012-0275-1] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Data now suggest that current strategies in the treatment of rheumatoid arthritis (RA) should focus on early identification and diagnosis, followed by early initiation of DMARD therapy. Initiation of treatment in early RA-ideally, less than 3-6 months after symptom onset-improves the success of achieving disease remission and reduces joint damage and disability. While the optimal treatment regimen in early RA is unclear, use of initial DMARD mono- or combination therapy with prompt escalation to achieve low disease activity or remission is an appropriate approach. Ultimately, the goal of RA management should be the prevention of inflammatory joint disease and, thereby, prevention of disability. To date, studies have shown that pharmacologic interventions can delay progression from undifferentiated inflammatory arthritis to classifiable RA. However, further investigation is needed to identify asymptomatic individuals at high risk for future RA and to intervene early enough in the pathogenesis of RA to prevent progression to clinical disease.
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21
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Bykerk VP, Jamal S, Boire G, Hitchon CA, Haraoui B, Pope JE, Thorne JC, Sun Y, Keystone EC. The Canadian Early Arthritis Cohort (CATCH): patients with new-onset synovitis meeting the 2010 ACR/EULAR classification criteria but not the 1987 ACR classification criteria present with less severe disease activity. J Rheumatol 2012; 39:2071-80. [PMID: 22896026 DOI: 10.3899/jrheum.120029] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Our objective was to describe characteristics of Canadian patients with early arthritis and examine differences between those fulfilling 1987 and 2010 rheumatoid arthritis (RA) classification criteria. METHODS The Canadian Early Arthritis Cohort (CATCH) is a national, multicenter, observational, prospective cohort of patients with early inflammatory arthritis, receiving usual care, recruited since 2007. Inclusion criteria include age > 16 years; symptom duration 6-52 weeks; swelling of ≥ 2 joints or ≥ 1 metacarpophalangeal/proximal interphalangeal joint; and 1 of rheumatoid factor ≥ 20 IU, positive anticitrullinated protein antibodies (ACPA), morning stiffness ≥ 45 min, response to nonsteroidal antiinflammatory drug, or positive metatarsophalangeal joint squeeze test. Data from patients enrolled to March 15, 2011, were analyzed. RESULTS In total, 1450 patients met the eligibility criteria (1187 were followed). At baseline, mean age was 53 ± 15 years, symptom duration was 6.1 ± 3.2 months, Disease Activity Score (DAS28) was 4.9 ± 1.6, Health Assessment Questionnaire-Disability Index was 1.0 ± 0.7. Forty-one percent (n = 450) of patients had moderate (3.2 < DAS28 ≤ 5.1) and 46% (n = 505) had high (DAS28 > 5.1) disease activity; 28% of those with baseline radiographs (n = 250/908) had radiographic evidence of erosions. ACPA status was available for 70% (n = 831) of patients; 55% (n = 453) tested positive. Sixty percent (n = 718) of patients were treated with methotrexate (MTX) initially. Of 612 patients without erosions, 63% and 83% fulfilled 1987 and 2010 RA classification criteria, respectively. Seventy-three percent (n = 166) of those who did not fulfill 1987 criteria were newly identified by the 2010 criteria. These patients had less severe disease and more were MTX-naive compared to those satisfying the 1987 criteria. Forty-seven percent of all patients achieved remission at 1 year. CONCLUSION Patients with early RA present with moderate high disease activity; < 50% achieve remission at 1 year, despite MTX treatment in the majority. The 2010 RA classification criteria identify more patients with RA who would previously have been designated as having undifferentiated disease. However, these patients have lower disease activity at the time of identification.
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Affiliation(s)
- Vivian P Bykerk
- Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
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22
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Ortiz EC, Shinada S. Evolution of classification criteria for rheumatoid arthritis: how do the 2010 criteria perform? Rheum Dis Clin North Am 2012; 38:345-53. [PMID: 22819088 DOI: 10.1016/j.rdc.2012.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Classification criteria are created in an attempt to produce a homogenous group of subjects with rheumatoid arthritis (RA) who can be used for clinical and basic research. The 1987 revised criteria lead to improved performance and more confidence in correct classification compared with the 1958 criteria. As therapies were introduced and early, aggressive approaches to RA management became common, there was a growing need for clinical trials focusing on early RA. The 2010 criteria were created to facilitate study of subjects at earlier stages in the disease. This article reviews the diagnostic performance of the 2010 criteria.
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Affiliation(s)
- Elizabeth C Ortiz
- Division of Rheumatology, Keck School of Medicine, University of Southern California, 2011 Zonal Avenue HMR 711, Los Angeles, CA 90033, USA.
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23
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Navalho M, Resende C, Rodrigues AM, Ramos F, Gaspar A, Pereira da Silva JA, Fonseca JE, Campos J, Canhão H. Bilateral MR imaging of the hand and wrist in early and very early inflammatory arthritis: tenosynovitis is associated with progression to rheumatoid arthritis. Radiology 2012; 264:823-33. [PMID: 22723498 DOI: 10.1148/radiol.12112513] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To identify bilateral hand and wrist findings of synovial inflammation associated with progression to rheumatoid arthritis (RA) in very-early-RA cohort (VERA) (duration, <3 months) and early-RA cohort (ERA) (duration, <12 but >3 months), to test tenosynovitis as a magnetic resonance (MR) imaging additional parameter for improving diagnostic accuracy of the 2010 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) RA classification criteria, and to evaluate the symmetry of joint and tendon involvement. MATERIALS AND METHODS With institutional review board approval and informed consent, 32 women and three men (mean age, 45 years) with untreated recent-onset inflammatory arthritis participated in this prospective study and underwent MR imaging of both wrists and hands. After 12-month follow-up, 25 patients fulfilled the criteria for RA (10 VERA and 15 ERA patients). Ten patients did not fulfill the criteria for RA (non-RA [control] group). Possible associations between synovitis for each joint and tendon and RA diagnosis at 12 months were tested (univariate logistic regression analysis). Diagnostic performance of the ACR/EULAR RA classification criteria was evaluated (receiver operating characteristic curve analysis). Asymmetry prevalence (all joints and tendons in the analysis) was calculated. RESULTS Tenosynovitis of the extensor carpi ulnaris (odds ratio, 3.21) and flexor tendons of the second finger (odds ratio, 14.61) in VERA group and synovitis of the radioulnar joint (odds ratio, 8.79) and tenosynovitis of flexor tendons of the second finger (odds ratio, 9.60) in ERA group were significantly associated with progression to RA (P < .05). Consideration of tenosynovitis improved areas under the receiver operating characteristic curve of ACR/EULAR criteria performance for the diagnosis of RA from 0.942 (P < .0001; sensitivity, 52%; specificity, 100%) to 0.972 (P < .0001; sensitivity, 76%; specificity, 100%), with cutoff score of 6 or greater. Asymmetry was found in 80.0% (62 of 77) (VERA patients) and 69.3% (106 of 153) (ERA patients) of joint or tendon pairs (P < .05). CONCLUSION Tenosynovitis is an imaging finding in early RA, and its inclusion as a scoring criterion might contribute for a better diagnostic performance of the 2010 ACR/EULAR classification; early RA is an asymmetric disease.
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Affiliation(s)
- Márcio Navalho
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina da Universidade de Lisboa, Av Prof Egas Moniz, 1649-028 Lisbon, Portugal.
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Davatchi F, Abari IS, Soroosh S, Soroosh M, Abdollahi BS. Performance of the 2010 rheumatoid arthritis classification criteria. Int J Rheum Dis 2012; 15:455-61. [DOI: 10.1111/j.1756-185x.2012.01766.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Fereydoun Davatchi
- Rheumatology Research Center; Tehran University of Medical Sciences; Tehran; Iran
| | - Iraj Salehi Abari
- Rheumatology Research Center; Tehran University of Medical Sciences; Tehran; Iran
| | - Soosan Soroosh
- Department of Rheumatology; Army University of Medical Sciences; Tehran; Iran
| | - Mohsen Soroosh
- Department of Rheumatology; Army University of Medical Sciences; Tehran; Iran
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