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Neumann E, Tarner IH. [Inflammation in the blood: what's behind it?]. Inn Med (Heidelb) 2023; 64:304-312. [PMID: 36662357 DOI: 10.1007/s00108-023-01472-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/21/2023]
Abstract
Inflammation is the body's defensive response to mostly harmful stimuli, usually in response to pathogens or toxic substances. However, the immune response in chronic inflammation is usually directed against harmless antigens, such as allergens, or commensal pathogens, such as herpes viruses, or against the body's own structures, as in autoimmune diseases. The body reacts to the respective stimulating factors with a relatively uniform inflammatory response. Besides the initial reaction of the innate immune system, the activation of immune cells and the release of pro-inflammatory cytokines are in the foreground. Accordingly, inflammatory changes that can be detected in the blood usually do not arise in the blood itself, but in a specific tissue or organ system. In the case of long-term or chronic inflammation, the inflammatory response can be detected in the blood by means of various factors, and both general inflammatory parameters as well as specific parameters can be used for diagnostic purposes. However, the long-term systemic inflammatory response itself also affects the patients suffering from chronic inflammation. This article provides an overview of systemic inflammatory factors relevant for laboratory diagnostics, of how they contribute to specific diseases, and of the systemic effects induced by chronic inflammation.
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Affiliation(s)
- Elena Neumann
- Rheumatologie und Klinische Immunologie, Justus-Liebig-Universität Gießen, Campus Kerckhoff, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland.
| | - Ingo H Tarner
- Rheumatologie und Klinische Immunologie, Justus-Liebig-Universität Gießen, Campus Kerckhoff, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland
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Klemm P, Preusler P, Hudowenz O, Asendorf T, Müller-Ladner U, Neumann E, Lange U, Tarner IH. Multimodal rheumatologic complex treatment in patients with spondyloarthritis - a prospective study. Eur J Intern Med 2021; 93:42-49. [PMID: 34344550 DOI: 10.1016/j.ejim.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 07/05/2021] [Accepted: 07/15/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Aim of this study was to prospectively assess the effects of multimodal rheumatologic complex treatment (MRCT), a special concept of in-patient physical treatment (PT) for treating spondyloarthritis (SpA), namely radiographic (r-) and non-radiographic (nr-) axial (ax-) SpA and psoriatic arthritis (PsA). METHODS r-, nr-axSpA and PsA patients receiving a 16-day MRCT were eligible. MRCT was delivered to participants over 64 PT sessions of various modalities with a minimum of 1,400 min of treatment. Primary outcome was a change in pain levels measured on a numeric rating scale (NRS, 0 - 10) between baseline and discharge. Secondary outcomes were assessments of i) disease activity ii) functional disabilities iii) serum cytokine levels iv) analgesic usage v) patient global health assessment and patients' satisfaction with their therapeutic response to MRCT from baseline to discharge and over a 12-week follow-up. RESULTS 50 patients completed the study and were analysed. Pain levels were improved significantly (p < 0.001, 95% confidence interval -2.25 to -0.8,). Further analyses revealed no influencing factors or relevant inter-group differences. Positive effects of MRCT lasted up to 12 weeks after discharge. Analgesic usage was reduced compared to baseline. Patient global health assessment continued to be improved throughout the whole follow-up. No MRCT-related harms were recorded. CONCLUSION MRCT as a multimodal treatment concept with a strong emphasis on PT reduces pain in SpA meaningfully and facilitates reduced analgesic usage.
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Affiliation(s)
- Philipp Klemm
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Benekestr. 2-8, 61231 Bad Nauheim, Germany.
| | - Paulina Preusler
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Ole Hudowenz
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Center Göttingen, Humboldtallee 32, 37073 Göttingen, Germany
| | - Ulf Müller-Ladner
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Elena Neumann
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Uwe Lange
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
| | - Ingo H Tarner
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Benekestr. 2-8, 61231 Bad Nauheim, Germany
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Lóránd V, Nagy G, Bálint Z, Komjáti D, Minier T, Kumánovics G, Farkas N, Tarner IH, Müller-Ladner U, Czirják L, Varjú C. Sensitivity to change of joint count composite indices in 72 patients with systemic sclerosis. Clin Exp Rheumatol 2021; 39 Suppl 131:77-84. [PMID: 33734965 DOI: 10.55563/clinexprheumatol/cl3bbb] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 11/30/2020] [Indexed: 11/13/2022]
Abstract
OBJECTIVES We validated the responsiveness of joint count composite indices (JCCIs) in 72 patients with systemic sclerosis (SSc). METHODS Changes in Disease Activity Score of 28 Joints using ESR and CRP (DAS28-ESR, DAS28-CRP), Simplified Disease Activity Index (SDAI) and the Clinical Disease Activity Index (CDAI) were evaluated in a one-year follow-up study. Charts of patients including swollen/tender joint counts, laboratory signs of inflammation, and visual analogue scales referring to disease activity, severity and pain were also blindly categorized by two rheumatologists as improved, unchanged or deteriorated. These categories were used as references for the determination of effect size (ES) and standardised response mean (SRM). RESULTS Articular inflammation improved in 15, deteriorated in 12, and remained unchanged in 45 (63%) patients with SSc based on the concordant opinion of two clinical investigators. All four JCCIs were sensitive to changes (ES>1; SRM>1). The correlation between changes in JCCIs and the physicians' evaluation was high (r >0.68; p<0.001). Arthritis was predominantly prone to change in patients with high JCCIs, impaired functional status, anti-RNA polymerase III antibodies and patients on DMARD therapy. Synovitis was more prevalent in patients with early diffuse SSc, and tended to improve during the follow-up. CONCLUSIONS All four JCCIs were sensitive to changes, if tender/swollen joints were present at baseline. Articular inflammation was most prone to change in patients with high JCCIs, impaired functional status and already decreased health-related quality of life at baseline.
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Affiliation(s)
- Veronika Lóránd
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Hungary
| | - Gabriella Nagy
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Hungary
| | - Zsófia Bálint
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Hungary
| | - Dalma Komjáti
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Hungary
| | - Tünde Minier
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Hungary
| | - Gábor Kumánovics
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Hungary
| | - Nelli Farkas
- Institute of Bioanalysis, Medical School, University of Pécs, Hungary
| | - Ingo H Tarner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Campus Kerckhoff, Bad Nauheim, Germany
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Campus Kerckhoff, Bad Nauheim, Germany
| | - László Czirják
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Hungary
| | - Cecília Varjú
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Hungary.
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Klemm P, Preusler P, Hudowenz O, Asendorf T, Müller-Ladner U, Neumann E, Lange U, Tarner IH. Effects of multimodal rheumatologic complex treatment in patients with rheumatoid arthritis: a monocentric prospective study. Clin Exp Rheumatol 2021; 40:1343-1351. [DOI: 10.55563/clinexprheumatol/lmbdlm] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022]
Affiliation(s)
- Philipp Klemm
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany.
| | - Paulina Preusler
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany
| | - Ole Hudowenz
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Center Göttingen, Germany
| | - Ulf Müller-Ladner
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany
| | - Elena Neumann
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany
| | - Uwe Lange
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany
| | - Ingo H. Tarner
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff, Justus-Liebig-University Gießen, Bad Nauheim, Germany
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Klemm P, Hudowenz O, Asendorf T, Dischereit G, Müller-Ladner U, Lange U, Tarner IH. Multimodal physical therapy for treating primary and secondary fibromyalgia – German multimodal rheumatologic complex treatment. European Journal of Physiotherapy 2020. [DOI: 10.1080/21679169.2020.1821767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Philipp Klemm
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff of Justus Liebig University Gießen, Bad Nauheim, Germany
| | - Ole Hudowenz
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff of Justus Liebig University Gießen, Bad Nauheim, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Gabriel Dischereit
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff of Justus Liebig University Gießen, Bad Nauheim, Germany
| | - Ulf Müller-Ladner
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff of Justus Liebig University Gießen, Bad Nauheim, Germany
| | - Uwe Lange
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff of Justus Liebig University Gießen, Bad Nauheim, Germany
| | - Ingo H. Tarner
- Department of Rheumatology, Immunology, Osteology and Physical Medicine, Campus Kerckhoff of Justus Liebig University Gießen, Bad Nauheim, Germany
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Hasseli R, Frommer KW, Schwarz M, Hülser ML, Schreiyäck C, Arnold M, Diller M, Tarner IH, Lange U, Pons-Kühnemann J, Schönburg M, Rehart S, Müller-Ladner U, Neumann E. Adipokines and Inflammation Alter the Interaction Between Rheumatoid Arthritis Synovial Fibroblasts and Endothelial Cells. Front Immunol 2020; 11:925. [PMID: 32582145 PMCID: PMC7280538 DOI: 10.3389/fimmu.2020.00925] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 04/21/2020] [Indexed: 01/05/2023] Open
Abstract
Objective: The long-distance migration of rheumatoid arthritis synovial fibroblasts (RASFs) in the severe combined immunodeficiency (SCID) mouse model of rheumatoid arthritis (RA) suggests that an interaction between RASFs and endothelial cells (EC) is critical in this process. Our objective was to assess whether immunomodulatory factors such as adipokines and antirheumatic drugs affect the adhesion of RASFs to ECs or the expression of surface molecules. Methods: Primary ECs or human umbilical vein endothelial cell (HUVEC) and primary RASFs were stimulated with adiponectin (10 μg/mL), visfatin (100 ng/mL), and resistin (20 ng/mL) or treated with methotrexate (1.5 and 1,000 μM) and the glucocorticoids prednisolone (1 μM) and dexamethasone (1 μM), respectively. The expression of adhesion molecules was analyzed by real-time polymerase chain reaction. The interaction of both cell types was analyzed under static (cell-to-cell binding assay) and dynamic conditions (flow-adhesion assay). Results: Under static conditions, adipokines increased mostly binding of RASFs to EC (adiponectin: 40%, visfatin: 28%, tumor necrosis factor α: 49%). Under flow conditions, visfatin increased RASF adhesion to HUVEC (e.g., 0.5 dyn/cm2: 75.2%). Reduced adhesion of RASFs to E-selectin was observed after treatment with dexamethasone (e.g., 0.9 dyn/cm2: −40%). In ECs, tumor necrosis factor α (TNF-α) increased expression of intercellular adhesion molecule 1 (20-fold) and vascular cell adhesion molecule 1 (77-fold), whereas P-selectin was downregulated after stimulation with TNF-α (−6-fold). Conclusion: The adhesion of RASFs to EC was increased by visfatin under static and flow conditions, whereas glucocorticoids were able to decrease adhesion to E-selectin. The process of migration and adhesion of RASFs to ECs could be enhanced by adipokines via adhesion molecules and seems to be targeted by therapeutic intervention with glucocorticoids.
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Affiliation(s)
- Rebecca Hasseli
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Klaus W Frommer
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Maria Schwarz
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Marie-Lisa Hülser
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Carina Schreiyäck
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Mona Arnold
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Magnus Diller
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Ingo H Tarner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Uwe Lange
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Joern Pons-Kühnemann
- Medical Statistics, Institute of Medical Informatics, Justus-Liebig University Giessen, Giessen, Germany
| | - Markus Schönburg
- Department of Cardiac Surgery, Kerckhoff-Klinik, Bad Nauheim, Germany
| | - Stefan Rehart
- Department of Orthopedics and Trauma Surgery, Agaplesion Markus Hospital, Frankfurt, Germany
| | - Ulf Müller-Ladner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
| | - Elena Neumann
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff, Bad Nauheim, Germany
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Klemm P, Hudowenz O, Asendorf T, Dischereit G, Müller-Ladner U, Lange U, Tarner IH. Evaluation of a special concept of physical therapy in spondyloarthritis: German multimodal rheumatologic complex treatment for spondyloarthritis. Clin Rheumatol 2020; 39:1513-1520. [DOI: 10.1007/s10067-019-04887-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/20/2019] [Accepted: 12/09/2019] [Indexed: 12/27/2022]
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Valentini G, Huscher D, Riccardi A, Fasano S, Irace R, Messiniti V, Matucci-Cerinic M, Guiducci S, Distler O, Maurer B, Avouac J, Tarner IH, Frerix M, Riemekasten G, Siegert E, Czirják L, Lóránd V, Denton CP, Nihtyanova S, Walker UA, Jaeger VK, Del Galdo F, Abignano G, Ananieva LP, Gherghe AM, Mihai C, Henes JC, Schmeiser T, Vacca A, Moiseev S, Foeldvari I, Gabrielli A, Krummel-Lorenz B, Rednic S, Allanore Y, Müeller-Ladner U. Vasodilators and low-dose acetylsalicylic acid are associated with a lower incidence of distinct primary myocardial disease manifestations in systemic sclerosis: results of the DeSScipher inception cohort study. Ann Rheum Dis 2019; 78:1576-1582. [PMID: 31391176 DOI: 10.1136/annrheumdis-2019-215486] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 07/12/2019] [Accepted: 07/31/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the influence of vasodilator drugs on the occurrence of features depending on myocardial ischaemia/fibrosis (ventricular arrhythmias, Q waves, cardiac blocks, pacemaker implantation, left ventricular ejection fraction (LVEF) <55%, and/or congestive heart failure and sudden cardiac death) in systemic sclerosis (SSc). METHODS 601 patients with SSc were enrolled from 1 December 2012 to 30 November 2015 and had a second visit 0.5-4 years apart. 153 received no vasodilators; 448 received vasodilator therapy (ie, calcium channel blockers and/or ACE inhibitors or angiotensin II receptor blockers or combinations of them), 89 of them being also treated with either endothelin receptor antagonists or PDE5 inhibitors or prostanoids. Associations between the occurrence of myocardial disease manifestations and any demographic, disease and therapeutic aspect were investigated by Cox regression analysis. A Cox frailty survival model with centre of enrolment as random effect was performed. RESULTS During 914 follow-up patient-years, 12 ventricular arrhythmias, 5 Q waves, 40 cardiac blocks, 6 pacemaker implantations and 19 reduced LVEF and/or congestive heart failure (CHF) occurred. In multivariate Cox regression analysis, vasodilator therapy was associated with a lower incidence of ventricular arrhythmias (p=0.03); low-dose acetylsalicylic acid (ASA) with a lower incidence of cardiac blocks and/or Q waves and/or pacemaker implantation (p=0.02); active disease with a higher incidence of LVEF <55% and/or CHF and cardiac blocks and/or Q waves and/or pacemaker implantation (p=0.05). CONCLUSIONS The present study might suggest a preventative effect on the occurrence of distinct myocardial manifestations by vasodilator therapy and low-dose ASA.
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Affiliation(s)
- Gabriele Valentini
- Department of Precision Medicine, Section of Rheumatology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Dörte Huscher
- Institute of Biostatistics and Clinical Epidemiology, Charité Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany
| | - Antonella Riccardi
- Department of Precision Medicine, Section of Rheumatology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Serena Fasano
- Department of Precision Medicine, Section of Rheumatology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Rosaria Irace
- Department of Precision Medicine, Section of Rheumatology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Valentina Messiniti
- Department of Precision Medicine, Section of Rheumatology, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Britta Maurer
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Jérôme Avouac
- Department of Rheumatology, Cochin Hospital, University of Paris Descartes, Paris, France
| | - Ingo H Tarner
- Department of Rheumatology and Clinical Immunology, Justus Liebig Universitat Giessen, Bad Nauheim, Germany
| | - Marc Frerix
- Department of Rheumatology and Clinical Immunology, Justus Liebig Universitat Giessen, Bad Nauheim, Germany
| | - Gabriela Riemekasten
- Department of Rheumatology, Universitatsklinikum Schleswig Holstein-Campus Lubeck, Lübeck, Germany
| | - Elise Siegert
- Department of Rheumatology and Clinical Immunology, Charité - Universitäetsmedizin Berlin, Berlin, Germany
| | - László Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Veronika Lóránd
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Christopher P Denton
- Department of Rheumatology, University College London, Royal Free Hospital, London, United Kingdom
| | - Svetlana Nihtyanova
- Department of Rheumatology, University College London, Royal Free Hospital, London, United Kingdom
| | - Ulrich A Walker
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | | | - Francesco Del Galdo
- Leeds Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
| | - Giuseppina Abignano
- Leeds Biomedical Research Centre and Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom.,Rheumatology Institute of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy
| | - Lidia P Ananieva
- Institute of Rheumatology, Russian Academy of Medical Science, Moscow, Russian Federation
| | - Ana Maria Gherghe
- Internal Medicine and Rheumatology Department, Cantacuzino Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Carina Mihai
- Internal Medicine and Rheumatology Department, Cantacuzino Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Joerg Christoph Henes
- Department of Internal Medicine II, University Hospitals Tübingen, Tübingen, Germany
| | - Tim Schmeiser
- Department of Rheumatology and Immunology, Saint Josef Hospital, Wuppertal, Germany
| | | | - Sergey Moiseev
- Sechenov First Moscow State Medical University and Lomonosov Moscow State University, Moscow, Russia
| | - Ivan Foeldvari
- Klinikum Eilbek, Hamburger Zentrum für Kinder- und Jugendrheumatologie, Hamburg, Germany
| | - Armando Gabrielli
- Clinical Medicine, Department of Clinical and Molecular Sciences, Polytechnic University of Marche, Ancona, Italy
| | | | - Simona Rednic
- Department of Rheumatology, University of Medicine and Pharmacy 'luliu Hatieganu' Cluj, Cluj-Napoca, Romania
| | - Yannick Allanore
- Department of Rheumatology, Cochin Hospital, University of Paris Descartes, Paris, France
| | - Ulf Müeller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus Liebig Universitat Giessen, Bad Nauheim, Germany
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Lange U, Bogensperger S, Tarner IH, Müller-Ladner U. The effects of a single carbon dioxide and hot water hand bath on acral perfusion in systemic sclerosis: A randomized, clinical study. J Scleroderma Relat Disord 2019; 4:160-162. [PMID: 35382392 PMCID: PMC8922646 DOI: 10.1177/2397198318819919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 11/27/2018] [Indexed: 08/04/2023]
Abstract
Secondary Raynaud's phenomenon is the most common manifestation of systemic sclerosis, affecting more than 99% of systemic sclerosis patients, and a major cause of morbidity. Frequent and prolonged secondary Raynaud's phenomenon attacks not only cause severe discomfort and pain but also ischemic acral tissue damage. In addition to vasoactive drugs, carbon dioxide (CO2) hand bath and hot water bath are potential non-pharmacological treatment options which can be self-administered by affected patients at any time. In order to compare the efficacy of these two physical measures, this randomized, clinical study evaluated the effects of a single CO2 hand bath in patients with systemic sclerosis and secondary Raynaud's phenomenon and a healthy control group versus a single hot water hand bath on acral perfusion in systemic sclerosis by Doppler ultrasonography. None of the patients had currently digital ulcers, a vasoactive medication or a concomitant vascular disease. CO2 immersion induced an acute hemodynamic response, whereas hot water immersion had no significant effect on acral perfusion in systemic sclerosis.
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Affiliation(s)
- Uwe Lange
- Uwe Lange, Department of Rheumatology, Clinical Immunology, Osteology and Physical Medicine, Kerckhoff-Klinik and Justus Liebig University Giessen, Benekestr. 2–8, 61231 Bad Nauheim, Germany.
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Vogt S, Tarner IH, Müller-Ladner U, König R. Motivation for and Barriers to Participation in Clinical Trials From the Perspective of Patients With Rheumatic Diseases and Chronic Musculoskeletal Pain. Open Rheumatol J 2018. [DOI: 10.2174/1874312901812010332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Clinical studies are indispensable for the development and clinical introduction of new therapies. Particularly in the field of rheumatology, there is a high need for the development of new drugs because for most rheumatic diseases a curative treatment is not yet available. Furthermore, a large percentage of patients are not even treated adequately with approved treatment options. Treatment is particularly challenging for those entities that belong to the so-called orphan diseases because effective drugs have yet to be developed and approval of new drugs is difficult due to the fact that only small numbers of affected patients can be recruited for clinical trials. Despite the need for new developments and thus clinical studies, patient recruitment for clinical trials in Germany is generally difficult. Therefore, sponsors frequently use non-European study centers to enroll the necessary numbers of patients as inadequate patient recruitment leads to increased costs and delayed implementation of new medical knowledge.
Objective:
Given the overall limited recruitment rates for clinical studies in Germany, it was the aim of this work to gain insights into motivations for and barriers to participating in clinical trials in Germany from the patients’ point of view.
Methods:
Data was collected using a structured questionnaire in three groups of patients who are suffering from a rheumatic disease and are receiving specialist care. The completely anonymous questionnaire included a total of 32 questions, divided into four main topics. All questions could only be answered by yes or no or by selecting or not selecting a choice of the answer provided. Per question, proportions of patients selecting yes or no or any of the choices were compared between groups and between males and females.
Results:
It was found that there is a lack of education and knowledge about the nature and offer of clinical trials among patients with rheumatic diseases. This issue represents one of the main barriers to patient recruitment for clinical trials. In addition, a large proportion of patients are concerned about the possible adverse effects of study drugs and about being used as “guinea pigs”. While the internet and daily newspapers are rarely used for education regarding study participation, it became clear that the family doctor as a trusted person and possible network partner has a special role in improving patient willingness to participate in trials. Furthermore, interviewees hope for shorter waiting times at the doctor's office and a better, regular, more intensive medical care when participating in a clinical trial.
Conclusion:
Better and broader information of patients can be regarded as a key to better recruitment for clinical trials since many patients, on the one hand, have certain concerns about clinical trials but at the same time do see the potential for personal advantages when participating in a trial. Information events by patient organizations and specialist centers could be a way to reach out to patients and to break down barriers with regard to participation in clinical trials. Presentations by sponsors and established clinical trial centers and intensified networking with general practitioners and specialists could probably also enhance patient recruitment.
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11
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Sluszniak M, Tarner IH, Thiele A, Schmeiser T. [The rich diversity of Whipple's disease]. Z Rheumatol 2018; 78:55-65. [PMID: 30552512 DOI: 10.1007/s00393-018-0573-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Whipple's disease (WD) is a rare, chronic multiorgan disease which can caused by Tropheryma whipplei, a ubiquitous gram positive bacterium. Detection of T. whipplei is mostly performed histologically using periodic acid-Schiff (PAS) staining in affected tissues to visualize characteristic PAS-positive macrophages and by the polymerase chain reaction (PCR). Clinically, WD is often characterized by gastrointestinal symptoms (diarrhea, colic-like abdominal pain and weight loss). Arthritis is a common presentation of WS, often leading to a misdiagnosis of seronegative rheumatoid arthritis and as a consequence to immunosuppressive therapy. The clinical presentation of WD is highly polymorphic affecting different organ systems (e. g. cardiac or neurological manifestation) and making an appropriate clinical diagnosis and even the diagnostic process itself difficult. This article reports on three cases presenting with completely different leading symptoms (initially misdiagnosed as seronegative rheumatoid arthritis, spondyloarthritis and adult onset of Still's disease, respectively) that illustrate the rich diversity of WD. The cases were chosen to draw attention to the fact that although WD is mainly associated with the field of gastroenterology and gastrointestinal (GI) involvement is common, it may appear without GI symptoms. In cases of a clinical suspicion of WD, diagnostic efforts should be made to detect the bacterium in the affected organ. The German S2k guidelines on GI infections and WD published in January 2015 summarized the current state of the art for WD. The currently recommended primary treatment is antibiotics that can infiltrate the cerebrospinal fluid, e. g. ceftriaxone, followed by cotrimoxazole, which should be maintained over several months.
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Affiliation(s)
- M Sluszniak
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland.
| | - I H Tarner
- Abt. für Rheumatologie, Klinische Immunologie, Osteologie und Physikalische Medizin, Kerckhoff-Klinik GmbH Bad Nauheim, Bad Nauheim, Deutschland.,Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | - A Thiele
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland
| | - T Schmeiser
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland
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12
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Rieth AJ, Richter MJ, Berkowitsch A, Frerix M, Tarner IH, Mitrovic V, Hamm CW. Intravenous sildenafil acutely improves hemodynamic response to exercise in patients with connective tissue disease. PLoS One 2018; 13:e0203947. [PMID: 30235235 PMCID: PMC6147445 DOI: 10.1371/journal.pone.0203947] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 08/29/2018] [Indexed: 11/18/2022] Open
Abstract
Background Hemodynamic assessment during exercise may unmask an impaired functional reserve of the right ventricle and the pulmonary vasculature in patients with connective tissue disease. We assessed the effect of intravenous sildenafil on the hemodynamic response to exercise in patients with connective tissue disease. Methods In this proof-of-concept study, patients with connective tissue disease and mean pulmonary arterial pressure (mPAP) >20 mm Hg were subjected to a supine exercise hemodynamic evaluation before and after administration of intravenous sildenafil 10 mg. Results Ten patients (four with moderately elevated mPAP 21–24 mm Hg; six with mPAP >25 mm Hg) underwent hemodynamic assessment. All of them showed markedly abnormal exercise hemodynamics. Intravenous sildenafil was well tolerated and had significant hemodynamic effects at rest and during exercise, although without pulmonary selectivity. Sildenafil reduced median total pulmonary resistance during exercise from 6.22 (IQR 4.61–8.54) to 5.24 (3.95–6.96) mm Hg·min·L-1 (p = 0.005) and increased median pulmonary arterial capacitance during exercise from 1.59 (0.93–2.28) to 1.74 (1.12–2.69) mL/mm Hg (p = 0.005). Conclusions In patients with connective tissue disease who have an abnormal hemodynamic response to exercise, intravenous sildenafil improved adaption of the right ventricular-pulmonary vascular unit to exercise independent of resting mPAP. The impact of acute pharmacological interventions on exercise hemodynamics in patients with pulmonary vascular disease warrants further investigation. Trial registration Clinicaltrials.gov NCT01889966.
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Affiliation(s)
- Andreas J. Rieth
- Department of Cardiology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
- * E-mail:
| | - Manuel J. Richter
- Department of Pneumology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
- Department of Internal Medicine, Justus Liebig University Giessen, Universities of Giessen and Marburg Lung Center (UGMLC), member of the German Center for Lung Research (DZL), Giessen, Germany
| | | | - Marc Frerix
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
| | - Ingo H. Tarner
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
| | - Veselin Mitrovic
- Department of Cardiology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
| | - Christian W. Hamm
- Department of Cardiology, Kerckhoff-Klinik GmbH, Bad Nauheim, Germany
- Department of Cardiology, Justus Liebig University Giessen, Universities of Giessen and Marburg, Giessen, Germany
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13
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Jaeger VK, Distler O, Maurer B, Czirják L, Lóránd V, Valentini G, Vettori S, Del Galdo F, Abignano G, Denton C, Nihtyanova S, Allanore Y, Avouac J, Riemekasten G, Siegert E, Huscher D, Matucci-Cerinic M, Guiducci S, Frerix M, Tarner IH, Garay Toth B, Fankhauser B, Umbricht J, Zakharova A, Mihai C, Cozzi F, Yavuz S, Hunzelmann N, Rednic S, Vacca A, Schmeiser T, Riccieri V, García de la Peña Lefebvre P, Gabrielli A, Krummel-Lorenz B, Martinovic D, Ancuta C, Smith V, Müller-Ladner U, Walker UA. Functional disability and its predictors in systemic sclerosis: a study from the DeSScipher project within the EUSTAR group. Rheumatology (Oxford) 2018; 57:441-450. [PMID: 28499034 DOI: 10.1093/rheumatology/kex182] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Indexed: 11/12/2022] Open
Abstract
Objectives The multisystem manifestations of SSc can greatly impact patients' quality of life. The aim of this study was to identify factors associated with disability in SSc. Methods SSc patients from the prospective DeSScipher cohort who had completed the scleroderma health assessment questionnaire (SHAQ), a disability score that combines the health assessment questionnaire and five visual analogue scales, were included in this analysis. The effect of factors possibly associated with disability was analysed with multiple linear regressions. Results The mean SHAQ and HAQ scores of the 944 patients included were 0.87 (s.d. = 0.66) and 0.92 (s.d. = 0.78); 59% of the patients were in the mild to moderate difficulty SHAQ category (0 ⩽ SHAQ < 1), 34% in the moderate to severe disability category (1 ⩽ SHAQ < 2) and 7% in the severe to very severe disability category (2 ⩽ SHAQ ⩽ 3). The means of the visual analogue scales scores were in order of magnitude: overall disease severity (37 mm), RP (31 mm), pulmonary symptoms (24 mm), gastrointestinal symptoms (20 mm) and digital ulcers (19 mm). In multiple regression, the main factors associated with high SHAQ scores were the presence of dyspnoea [modified New York Heart Association (NYHA) class IV (regression coefficient B = 0.62), modified NYHA class III (B = 0.53) and modified NYHA class II (B = 0.21; all vs modified NYHA class I)], FM (B = 0.37), muscle weakness (B = 0.27), digital ulcers (B = 0.20) and gastrointestinal symptoms (oesophageal symptoms, B = 0.16; stomach symptoms, B = 0.15; intestinal symptoms, B = 0.15). Conclusion SSc patients perceive dyspnoea, pain, digital ulcers, muscle weakness and gastrointestinal symptoms as the main factors driving their level of disability, unlike physicians who emphasize objective measures of disability.
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Affiliation(s)
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Britta Maurer
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Laszlo Czirják
- Department of Rheumatology and Immunology, Medical Center, University of Pécs, Pécs, Hungary
| | - Veronika Lóránd
- Department of Rheumatology and Immunology, Medical Center, University of Pécs, Pécs, Hungary
| | | | - Serena Vettori
- Department of Rheumatology, Second University of Naples, Naples, Italy
| | - Francesco Del Galdo
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Giuseppina Abignano
- NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds
| | - Christopher Denton
- Department of Rheumatology, University College London, Royal Free Hospital, London, UK
| | - Svetlana Nihtyanova
- Department of Rheumatology, University College London, Royal Free Hospital, London, UK
| | - Yannick Allanore
- Department of Rheumatology, University of Paris Descartes, Paris, France
| | - Jerome Avouac
- Department of Rheumatology, University of Paris Descartes, Paris, France
| | | | - Elise Siegert
- Department of Rheumatology and Clinical Immunology, University Hospital Charité
| | | | | | - Serena Guiducci
- Department of Rheumatology, University of Florence, Florence, Italy
| | - Marc Frerix
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Ingo H Tarner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Beata Garay Toth
- Federation of European Scleroderma Associations Aisbl, Budapest, Hungary
| | | | | | | | - Carina Mihai
- Department of Internal Medicine and Rheumatology, Dr Ion Cantacuzino Clinical Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Franco Cozzi
- Rheumatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Sule Yavuz
- Department of Rheumatology, University of Marmara, Altunizade-Istanbul, Turkey
| | | | - Simona Rednic
- Clinica Reumatologie, University of Medicine & Pharmacy, Cluj-Napoca, Romania
| | - Alessandra Vacca
- II Chair of Rheumatology, University of Cagliari-Policlinico Universitario, Monserrato, Italy
| | - Tim Schmeiser
- Department of Rheumatology and Immunology, Krankenhaus St Josef, Wuppertal, Germany
| | - Valeria Riccieri
- Divisione di Reumatologia, Università di Roma La Sapienza, Roma, Italy
| | | | - Armando Gabrielli
- Istituto di Clinica Medica Generale, Ematologia ed Immunologia Clinica, Università Politecnica delle Marche, Ancona, Italy
| | | | - Duska Martinovic
- Division of Rheumatology, University Hospital of Split, Split, Croatia
| | - Codrina Ancuta
- Rheumatology 2 Department, Clinical Rehabilitation Hospital, University of Medicine and Pharmacy 'Grigore T. Popa', Iasi, Romania
| | - Vanessa Smith
- Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Ulf Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Justus-Liebig University Giessen, Kerckhoff Clinic Bad Nauheim, Bad Nauheim, Germany
| | - Ulrich A Walker
- Department of Rheumatology, University Hospital Basel, Basel
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14
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Lefèvre S, Schwarz M, Meier FMP, Zimmermann-Geller B, Tarner IH, Rickert M, Steinmeyer J, Sauerbier M, Rehart S, Müller-Ladner U, Neumann E. Disease-Specific Effects of Matrix and Growth Factors on Adhesion and Migration of Rheumatoid Synovial Fibroblasts. J Immunol 2017; 198:4588-4595. [PMID: 28500074 DOI: 10.4049/jimmunol.1600989] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 04/10/2017] [Indexed: 01/15/2023]
Abstract
In rheumatoid arthritis (RA), cartilage and bone matrix are degraded, and extracellular matrix (ECM) proteins, acting as cellular activators, are liberated. Similar to ECM proteins, matrix-bound chemokines, cytokines, and growth factors (GFs) influence functional properties of key cells in RA, especially synovial fibroblasts. The role of these molecules on attachment, migration, and proinflammatory and prodestructive activation of RASFs was analyzed. Adhesion/migration of RASFs were examined under GF-enriched (GF+) or -reduced (GF-) conditions with or without addition of matrix-associated GFs, TGF-β, and platelet-derived GF to GF- or culture supernatants. Fibroblast adhesion and alterations in proinflammatory/prodestructive properties (e.g., IL-6/matrix metalloproteinase 3-release) in response to matrix-associated molecules were compared. Effects of GF+, GF-, and other ECM components on human RASF-mediated cartilage invasion were examined in the SCID mouse model. RASF adhesion under GF- conditions was significantly lower compared with GF+ conditions (6.8- versus 8.3-fold). This effect was specific for RA because control cells showed opposite effects (e.g., osteoarthritis synovial fibroblasts [SF]; GF- versus GF+: 10.7- versus 8-fold). Addition of TGF-β to GF- increased RASF attachment (12.7-fold) compared with other matrices and components. RASF adhesion to GF+ matrix resulted in the strongest IL-6 and matrix metalloproteinase-3 release, and was even more pronounced compared with supplementation of single GFs. In vivo, GF- matrix decreased RASF-mediated cartilage invasion compared with GF+ matrix. ECM components and especially GFs when bound within ECM actively enhance RASF attraction and cartilage adhesion. This observation was specific for RASFs as a reverse behavior was observed for controls.
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Affiliation(s)
- Stephanie Lefèvre
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, Kerckhoff Clinic, 61231 Bad Nauheim, Germany
| | - Maria Schwarz
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, Kerckhoff Clinic, 61231 Bad Nauheim, Germany
| | - Florian M P Meier
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, Kerckhoff Clinic, 61231 Bad Nauheim, Germany
| | - Birgit Zimmermann-Geller
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, Kerckhoff Clinic, 61231 Bad Nauheim, Germany
| | - Ingo H Tarner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, Kerckhoff Clinic, 61231 Bad Nauheim, Germany
| | - Markus Rickert
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg, 35392 Giessen, Germany
| | - Jürgen Steinmeyer
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Giessen and Marburg, 35392 Giessen, Germany
| | - Michael Sauerbier
- Department of Plastic, Hand and Reconstructive Surgery, BG Trauma Center, 60389 Frankfurt, Germany; and
| | - Stefan Rehart
- Department of Orthopaedics and Trauma Surgery, Agaplesion Markus-Hospital, 60431 Frankfurt, Germany
| | - Ulf Müller-Ladner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, Kerckhoff Clinic, 61231 Bad Nauheim, Germany
| | - Elena Neumann
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, Kerckhoff Clinic, 61231 Bad Nauheim, Germany;
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15
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Zhou B, Liao Y, Guo Y, Tarner IH, Liao C, Chen S, Kermany MH, Tu H, Zhong S, Chen P. Adoptive Cellular Gene Therapy for the Treatment of Experimental Autoimmune Polychondritis Ear Disease. ORL J Otorhinolaryngol Relat Spec 2017; 79:166-177. [PMID: 28463837 DOI: 10.1159/000452767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 10/19/2016] [Indexed: 11/19/2022]
Abstract
In the past, the clinical therapy for autoimmune diseases, such as autoimmune polychondritis ear disease, was mostly limited to nonspecific immunosuppressive agents, which could lead to variable responses. Currently, gene therapy aims at achieving higher specificity and less adverse effects. This concept utilizes the adoptive transfer of autologous T cells that have been retrovirally transduced ex vivo to express and deliver immunoregulatory gene products to sites of autoimmune inflammation. In the animal model of collagen-induced autoimmune polychondritis ear disease (CIAPED), the adoptive transfer of IL-12p40-expressing collagen type II (CII)-specific CD4+ T-cell hybridomas resulted in a significantly lower disease incidence and severity compared with untreated or vector-only-treated animals. In vivo cell detection using bioluminescent labels showed that transferred CII-reactive T-cell hybridomas accumulated in the inflamed earlobes of the mice with CIAPED. In vitro analysis demonstrated that IL-12p40-transduced T cells did not affect antigen-specific T-cell activation or systemic anti-CII Ab responses. However, IL-12p40-transduced T cells suppressed IFN-γ and augmented IL-4 production, indicating their potential to act therapeutically by interrupting Th1-mediated inflammatory responses via augmenting Th2 responses. These results indicate that the local delivery of IL-12p40 by T cells could inhibit CIAPED by suppressing autoimmune responses at the site of inflammation.
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Affiliation(s)
- Bin Zhou
- Department of Medicine, Renmin Hospital, Hubei University of Medicine, Shiyan, PR China
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16
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Zhou B, Liao Y, Guo Y, H Tarner I, Liao C, Chen S, Habiby Kermany M, Tu H, Zhong S. Adoptive cellular gene therapy for the treatment of experimental autoimmune polychondritis ear disease (THER2P.966). The Journal of Immunology 2015. [DOI: 10.4049/jimmunol.194.supp.67.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Abstract
Clinical therapy of autoimmune diseases used to be limited to non-specific immune-suppressive agents and was, for the most part, based on chance observations. Currently, gene therapy research aims at achieving higher specificity and thus less adverse side effects. This concept comprises the adoptive transfer of autologous T-cells that have been retrovirally transduced ex vivo to express and deliver immune-regulatory gene products to sites of autoimmune inflammation. In the animal model of collagen-induced autoimmune polychondritis ear disease (CIAPED), the adoptive transfer of IL-12p40 expressing collagen type II (CII)-specific CD4+ T-cell hybridomas resulted in a significantly lower disease incidence and severity compared with untreated or vector-only treated animals. In vivo cell detection using bioluminescent labels showed that transferred CII-reactive T-cell hybridomas accumulated in inflamed ear lobes in mice with CIAPED. In vitro analysis demonstrated that IL-12p40-transduced T-cells did not affect the antigen-specific T-cell activation or systemic anti-CII antibody responses. However, IL-12p40-transduced T-cells suppressed IFN-γ and augmented IL-4 production, indicating its potential to act therapeutically by interrupting Th1-mediated inflammatory responses via augmenting Th2 responses. These results indicate that the local delivery of IL-12p40 by T-cells could inhibit CIAPED by suppressing autoimmune responses at the site of inflammation.
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Affiliation(s)
- Bin Zhou
- 1Department of Medicine, Renmin Hospital, Hubei University of Medicine, Shiyan, China
- 3Department of Physiology, East Carolina University, Greenville, NC
| | - Yonggan Liao
- 1Department of Medicine, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Yunkai Guo
- 2Department of Otolaryngology and Institute of Hearing Research, Xiangya Second Hospital, Central South University, Changsha, China
| | - Ingo H Tarner
- 6Division of Immunology and Rheumatology, Stanford University, Stanford, CA
| | - Chunfen Liao
- 1Department of Medicine, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Sisi Chen
- 1Department of Medicine, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | | | - Hanjun Tu
- 5Department of Medicine, Hubei University of Medicine, Shiyan, China
| | - Sen Zhong
- 1Department of Medicine, Renmin Hospital, Hubei University of Medicine, Shiyan, China
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17
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Tarner IH, Albrecht K, Fleck M, Gromnica-Ihle E, Keyßer G, Köhler L, Kötter I, Krüger K, Kuipers J, Nüßlein H, Rubbert-Roth A, Wollenhaupt J, Schneider M, Manger B, Müller-Ladner U. [Evidence-based recommendations for the management of undifferentiated peripheral inflammatory arthritis (UPIA). The German perspective on the international 3e initiative]. Z Rheumatol 2014; 73:363-73. [PMID: 24590079 DOI: 10.1007/s00393-013-1249-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Peripheral arthritis is the most common presenting complaint in clinical rheumatology. Unequivocal identification of the underlying entity can be difficult, particularly at an early stage. Such cases are commonly referred to as undifferentiated peripheral inflammatory arthritis (UPIA). Since evidence-based recommendations for the clinical management of UPIA are lacking, this international 3e initiative convened 697 rheumatologists from 17 countries to develop appropriate recommendations. METHODS Based on a systematic literature research in Medline, EMBASE, Cochrane Library, and the ACR/EULAR abstracts of 2007/2008, 10 multinational recommendations were developed by 3 rounds of a Delphi process. In Germany, a national group of experts worked on 3 additional recommendations using the same method. The recommendations were discussed among the members of the 3e initiative and the degree of consensus was analyzed as well as the potential impact of the recommendations on clinical practice. RESULTS A total of 39,756 references were identified, of which 250 were systematically reviewed for the development of 10 multinational recommendations concerning differential diagnosis, diagnostic and prognostic value of clinical assessments, laboratory tests and imaging techniques, and monitoring of UPIA. In addition, 3 national recommendations on the diagnostic and prognostic value of a response to anti-inflammatory therapy on the analysis of synovial fluid and on enthesitis were developed by the German experts based on 35 out of 5542 references. CONCLUSIONS The article translates the 2011 published original paper of the international 3e initiative (Machado et al., Ann Rheum Dis 70:15-24, 2011) and reports the methods and results of the national vote and the additional 3 national recommendations.
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Affiliation(s)
- I H Tarner
- Abt. für Rheumatologie, Klinische Immunologie, Osteologie und Physikalische Medizin,Kerckhoff-Klinik, Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Gießen, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland
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18
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Moinzadeh P, Aberer E, Ahmadi-Simab K, Blank N, Distler JHW, Fierlbeck G, Genth E, Guenther C, Hein R, Henes J, Herich L, Herrgott I, Koetter I, Kreuter A, Krieg T, Kuhr K, Lorenz HM, Meier F, Melchers I, Mensing H, Mueller-Ladner U, Pfeiffer C, Riemekasten G, Sárdy M, Schmalzing M, Sunderkoetter C, Susok L, Tarner IH, Vaith P, Worm M, Wozel G, Zeidler G, Hunzelmann N. Disease progression in systemic sclerosis-overlap syndrome is significantly different from limited and diffuse cutaneous systemic sclerosis. Ann Rheum Dis 2014; 74:730-7. [PMID: 24389298 PMCID: PMC4392314 DOI: 10.1136/annrheumdis-2013-204487] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Systemic sclerosis (SSc)-overlap syndromes are a very heterogeneous and remarkable subgroup of SSc-patients, who present at least two connective tissue diseases (CTD) at the same time, usually with a specific autoantibody status. OBJECTIVES To determine whether patients, classified as overlap syndromes, show a disease course different from patients with limited SSc (lcSSc) or diffuse cutaneous SSc (dcSSc). METHODS The data of 3240 prospectively included patients, registered in the database of the German Network for Systemic Scleroderma and followed between 2003 and 2013, were analysed. RESULTS Among 3240 registered patients, 10% were diagnosed as SSc-overlap syndrome. Of these, 82.5% were female. SSc-overlap patients had a mean age of 48±1.2 years and carried significantly more often 'other antibodies' (68.0%; p<0.0001), including anti-U1RNP, -PmScl, -Ro, -La, as well as anti-Jo-1 and -Ku antibodies. These patients developed musculoskeletal involvement earlier and more frequently (62.5%) than patients diagnosed as lcSSc (32.2%) or dcSSc (43.3%) (p<0.0001). The onset of lung fibrosis and heart involvement in SSc-overlap patients was significantly earlier than in patients with lcSSc and occurred later than in patients with dcSSc. Oesophagus, kidney and PH progression was similar to lcSSc patients, whereas dcSSc patients had a significantly earlier onset. CONCLUSIONS These data support the concept that SSc-overlap syndromes should be regarded as a separate SSc subset, distinct from lcSSc and dcSSc, due to a different progression of the disease, different proportional distribution of specific autoantibodies, and of different organ involvement.
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Affiliation(s)
- Pia Moinzadeh
- Department of Dermatology, Cologne University Hospital, Cologne, Germany
| | - Elisabeth Aberer
- Department of Dermatology, Medical University of Graz, Graz, Germany
| | | | - Norbert Blank
- Department of Internal Medicine, Division of Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Joerg H W Distler
- Department of Rheumatology, University of Erlangen, Erlangen, Germany
| | | | - Ekkehard Genth
- Department of Rheumatology, Clinic of Rheumatology of Aachen, Aachen, Germany
| | - Claudia Guenther
- Department of Dermatology, University-Hospital Carl Gustav Carus, Dresden, Germany
| | - Ruediger Hein
- Department of Dermatology, Munich University of Technology, Munich, Germany
| | - Joerg Henes
- Department of Rheumatology, University of Tuebingen, Tuebingen, Germany
| | - Lena Herich
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Ilka Herrgott
- Department of Dermatology and Venereology, University of Muenster, Muenster, Germany
| | - Ina Koetter
- Department of Internal Medicine and Nephrology (Centre for interdisciplinary Rheumatology), Robert-Bosch-Hospital, Stuttgart, Germany
| | - Alexander Kreuter
- Department of Dermatology, Helios Clinic Oberhausen, Oberhausen, Germany
| | - Thomas Krieg
- Department of Dermatology, Cologne University Hospital, Cologne, Germany
| | - Kathrin Kuhr
- Institute of Medical Statistics, Informatics and Epidemiology, University of Cologne, Cologne, Germany
| | - Hanns-Martin Lorenz
- Department of Haemato-Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Florian Meier
- Department of Rheumatology and Clinical Immunology, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Inga Melchers
- Clinical Research Unit for Rheumatology, University Medical Center Freiburg, Freiburg, Germany
| | | | - Ulf Mueller-Ladner
- Department of Rheumatology and Clinical Immunology, Kerckhoff Clinic, Bad Nauheim, Germany
| | | | - Gabriela Riemekasten
- Department of Rheumatology and Clinical Immunology, University of Berlin, Charité, Germany
| | - Miklós Sárdy
- Department of Dermatology and Allergology, Ludwig Maximilian University, Munich, Germany
| | - Marc Schmalzing
- Department of Rheumatology, University of Tuebingen, Tuebingen, Germany
| | - Cord Sunderkoetter
- Department of Dermatology and Venereology, University of Muenster, Muenster, Germany
| | - Laura Susok
- Department of Dermatology and Venereology, Ruhr University Bochum, Bochum, Germany
| | - Ingo H Tarner
- Department of Rheumatology and Clinical Immunology, Kerckhoff Clinic, Bad Nauheim, Germany
| | - Peter Vaith
- Department of Rheumatology and Clinical Immunology, University Medical Center Freiburg, Freiburg, Germany
| | - Margitta Worm
- Department of Dermatology and Venerology, University of Berlin, Charité, Berlin, Germany
| | - Gottfried Wozel
- Department of Dermatology, University-Hospital Carl Gustav Carus, Dresden, Germany
| | - Gabriele Zeidler
- Department of Rheumatology, Johanniter-Hospital, Treuenbrietzen, Germany
| | - Nicolas Hunzelmann
- Department of Dermatology, Cologne University Hospital, Cologne, Germany
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Abeler-Dörner L, Rieger CC, Berger B, Weyd H, Gräf D, Pfrang S, Tarner IH, Schwarting A, Lorenz HM, Müller-Ladner U, Krammer PH, Kuhn A. Interferon-α abrogates the suppressive effect of apoptotic cells on dendritic cells in an in vitro model of systemic lupus erythematosus pathogenesis. J Rheumatol 2013; 40:1683-96. [PMID: 24037549 DOI: 10.3899/jrheum.121299] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE An increased incidence of apoptotic cells and an increased activation of dendritic cells (DC) may be involved in the pathogenesis of systemic lupus erythematosus (SLE). We investigated the characteristics of apoptotic neutrophils and monocyte-derived DC of patients with SLE, their interaction, and the influence of autoantibodies and inflammatory cytokines on this interaction. METHODS Kinetics of neutrophil apoptosis and DC activation were studied by flow cytometry. To analyze the interaction of apoptotic cells with phagocytes, crossover coculture experiments were performed with DC from patients with SLE and apoptotic Jurkat T cells as well as with apoptotic neutrophils from patients with SLE and the monocytic cell line U937. SLE serum and cytokines were added to this coculture, and activation and suppression of DC were quantified by levels of inflammatory cytokine secretion. RESULTS Apoptotic neutrophils and DC from patients with SLE showed no inherent defects compared to healthy controls, and the suppressive nature of their interaction was not affected. Autoantibodies as well as the inflammatory cytokines interleukin 17 (IL-17) and IL-1β had no influence on the interaction in this setup. Interferon (IFN)-α, however, substantially reduced the suppressive effect of apoptotic cells on DC. CONCLUSION The data suggest that aberrant immune reactivity in SLE is not generally due to an intrinsic defect in apoptotic cells, their processing, or their interaction with DC, but likely arises from the milieu in which this interaction takes place. Our study highlights the importance of IFN-α during early stages of SLE and its potential as a therapeutic target.
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Affiliation(s)
- Lucie Abeler-Dörner
- From the Division of Immunogenetics, Tumor Immunology Program, German Cancer Research Center, Heidelberg; Department of Rheumatology and Clinical Immunology, University of Giessen, Giessen; Internal Medicine I, Division of Rheumatology, University of Mainz, Mainz; Internal Medicine V, Division of Rheumatology, University of Heidelberg, Heidelberg; Department of Dermatology, University of Münster, Münster, Germany
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Englbrecht M, Tarner IH, van der Heijde DM, Manger B, Bombardier C, Müller-Ladner U. Measuring pain and efficacy of pain treatment in inflammatory arthritis: a systematic literature review. J Rheumatol Suppl 2013; 90:3-10. [PMID: 22942322 DOI: 10.3899/jrheum.120335] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To systematically review the available literature on measuring pain and the efficacy of pain treatment in inflammatory arthritis (IA), as an evidence base for generating clinical practice recommendations. METHODS A systematic literature search was performed in Medline, Embase, Cochrane Library, and the American College of Rheumatology/European League Against Rheumatism 2008/2009 meeting abstracts, searching for studies evaluating clinimetric properties of pain measurement tools in IA (convergent validity, internal consistency, retest reliability, responsiveness, feasibility, and standardization). Studies that presented information on these properties were reviewed and their data were integrated into the pool of results available for pain measures in IA. RESULTS In total, 51 articles were included in the review. Validated information on pain was available for tools covering different facets such as overall pain, anatomically specific pain, or a mixture of both. Data from these studies showed that single pain-related items such as the visual analog scale (VAS), numeric rating scale (NRS), or verbal rating scale (VRS) provide sufficient clinimetric information. Similar results were obtained for the pain subscales of the Arthritis Impact Measurement Scales (AIMS/AIMS2) and the bodily pain subscale of the Medical Outcome Study Short-Form Survey 36. Most clinimetric coefficients showed acceptable results with respect to validity, reliability, and sensitivity to change, while the degree of standardization and feasibility mostly filled at least 2 of 3 predefined criteria. CONCLUSION A variety of pain measures are available to cover different aspects of pain such as intensity, frequency, or location. Single-item tools such as VAS, NRS, or VRS can be recommended to measure overall pain in clinical practice. If more specific issues need to be addressed, more sophisticated tools should be taken into account.
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Affiliation(s)
- Matthias Englbrecht
- Department of Internal Medicine 3 and Institute for Clinical Immunology, University of Erlangen-Nuremberg, Ulmenweg 18, 91054 Erlangen, Germany.
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Akbayrak E, Dinser R, Müller-Ladner U, Tarner IH. Low-field magnetic resonance imaging study on carpal arthritis in systemic sclerosis--low-grade erosive arthritis of carpal bones is an unexpected and frequent disease manifestation. Arthritis Res Ther 2013; 15:R2. [PMID: 23289906 PMCID: PMC3672762 DOI: 10.1186/ar4128] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 01/02/2013] [Indexed: 11/10/2022] Open
Abstract
Introduction The aim of the present study was to assess the prevalence and characteristics of subclinical arthritis of carpal and metacarpophalangeal joints in patients with systemic sclerosis (SSc). Methods Low-field (0.2 T) magnetic resonance imaging (MRI) was performed in consecutive patients with SSc attending our center between January 2010 and March 2011. Results were assessed in a standardized manner using the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) and standardized assessments of all hand joints. Patients with arthritis due to overlap syndromes were excluded. Results Of 38 inpatients and eight outpatients who were screened for inclusion, 30 patients participated in the study and 26 patients could be evaluated. Erosions, bone marrow edema, synovitis, and joint effusions were found in 87%, 37%, 68%, and 58%, respectively, and 24% of patients had additional tenovaginitis. Arthritis affected only a low number of joints per analyzed hand. All bones and joints could be affected, but synovitis and bone marrow edema occurred predominantly in the proximal row of carpal bones, most frequently affecting the lunate bone. The extent of inflammatory changes measured with the RAMRIS correlated significantly with the functional status assessed with the validated German functional score questionnaire Funktionsfragebogen Hannover. Conclusion Low-grade arthritic changes on low-field MRI are frequent in patients with pure SSc. The features of arthritis in SSc differ from rheumatoid arthritis. The distribution, the MRI pattern and the predilection for the lunate bone raise the hypothesis that arthritis in SSc may be caused not only by immunological inflammation but also by ischemic mechanisms.
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Müller-Ladner U, Lefèvre S, Zimmermann B, Tarner IH, Dinser R, Pap T, Gay S, Neumann E. Evidence for synovial fibroblasts spreading rheumatoid arthritis. Arthritis Res Ther 2012. [PMCID: PMC3332411 DOI: 10.1186/ar3570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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23
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Dischereit G, Tarner IH, Müller-Ladner U, Lange U. Infliximab improves bone metabolism and bone mineral density in rheumatoid arthritis and ankylosing spondylitis: a prospective 2-year study. Clin Rheumatol 2012. [PMID: 23179009 DOI: 10.1007/s10067-012-2128-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Gabriel Dischereit
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Benekestrasse 2-8, D-61231 Bad Nauheim, Germany
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Tarner IH, Englbrecht M, Schneider M, van der Heijde DM, Müller-Ladner U. The role of corticosteroids for pain relief in persistent pain of inflammatory arthritis: a systematic literature review. J Rheumatol Suppl 2012; 90:17-20. [PMID: 22942324 DOI: 10.3899/jrheum.120337] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE To conduct a systematic review of the available literature addressing the effectiveness, safety, and role of corticosteroids for pain relief in persistent pain of inflammatory arthritis (IA), as part of the international 3e (Evidence, Expertise, Exchange) Initiative. METHODS A systematic literature research (SLR) was carried out in Medline, Embase, the Cochrane Library, and the American College of Rheumatology/European League Against Rheumatism meeting abstracts, searching for studies evaluating the use of steroids for the treatment of residual pain in IA despite adequate antiinflammatory therapy. RESULTS Of 3887 references retrieved by SLR, 2 randomized controlled studies and 35 review articles underwent full-text review. No article was found to adequately address the research question. CONCLUSION No data on the efficacy and safety of systemic corticosteroids in residual pain in IA could be identified from the literature.
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Affiliation(s)
- Ingo H Tarner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Department of Rheumatology, Clinical Immunology, Osteology and Physical Medicine Kerckhoff-Klinik, Benekestrasse 2-8, D-61231 Bad Nauheim, Germany.
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25
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Wagner KH, Tarner IH, Lange U. [In-vitro study on dissection of inflamed synovial tissue by hydro-jet cutting]. Z Rheumatol 2012; 71:707-10. [PMID: 22911435 DOI: 10.1007/s00393-012-1010-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Surgical synovectomy is a useful therapeutic option for rheumatoid arthritis patients with ongoing active synovitis despite optimal medical therapy. The present experimental study evaluated the novel, minimally invasive surgical technique of hydro-jet cutting in vitro using synovial biopsies. Depending on the selected water pressure (30-100 bar) it is possible to achieve precise and selective dissection of the synovial membrane. It was found that application of a water jet at 60 bar for 15 s is ideal for dissecting the stratum synoviale from the stratum fibrosum without any alteration of the joint capsule. This finding was confirmed by histological analyses. This novel and precise dissection technique promises to be an excellent alternative to the established techniques of synovectomy in the near future.
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Affiliation(s)
- K-H Wagner
- Universitätshautklinik, UKGM Gießen, Gießen, Deutschland
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Whittle SL, Colebatch AN, Buchbinder R, Edwards CJ, Adams K, Englbrecht M, Hazlewood G, Marks JL, Radner H, Ramiro S, Richards BL, Tarner IH, Aletaha D, Bombardier C, Landewé RB, Müller-Ladner U, Bijlsma JWJ, Branco JC, Bykerk VP, da Rocha Castelar Pinheiro G, Catrina AI, Hannonen P, Kiely P, Leeb B, Lie E, Martinez-Osuna P, Montecucco C, Ostergaard M, Westhovens R, Zochling J, van der Heijde D. Multinational evidence-based recommendations for pain management by pharmacotherapy in inflammatory arthritis: integrating systematic literature research and expert opinion of a broad panel of rheumatologists in the 3e Initiative. Rheumatology (Oxford) 2012; 51:1416-25. [PMID: 22447886 PMCID: PMC3397467 DOI: 10.1093/rheumatology/kes032] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 01/25/2012] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To develop evidence-based recommendations for pain management by pharmacotherapy in patients with inflammatory arthritis (IA). METHODS A total of 453 rheumatologists from 17 countries participated in the 2010 3e (Evidence, Expertise, Exchange) Initiative. Using a formal voting process, 89 rheumatologists representing all 17 countries selected 10 clinical questions regarding the use of pain medications in IA. Bibliographic fellows undertook a systematic literature review for each question, using MEDLINE, EMBASE, Cochrane CENTRAL and 2008-09 European League Against Rheumatism (EULAR)/ACR abstracts. Relevant studies were retrieved for data extraction and quality assessment. Rheumatologists from each country used this evidence to develop a set of national recommendations. Multinational recommendations were then formulated and assessed for agreement and the potential impact on clinical practice. RESULTS A total of 49,242 references were identified, from which 167 studies were included in the systematic reviews. One clinical question regarding different comorbidities was divided into two separate reviews, resulting in 11 recommendations in total. Oxford levels of evidence were applied to each recommendation. The recommendations related to the efficacy and safety of various analgesic medications, pain measurement scales and pain management in the pre-conception period, pregnancy and lactation. Finally, an algorithm for the pharmacological management of pain in IA was developed. Twenty per cent of rheumatologists reported that the algorithm would change their practice, and 75% felt the algorithm was in accordance with their current practice. CONCLUSIONS Eleven evidence-based recommendations on the management of pain by pharmacotherapy in IA were developed. They are supported by a large panel of rheumatologists from 17 countries, thus enhancing their utility in clinical practice.
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Affiliation(s)
- Samuel L Whittle
- Rheumatology Unit, The Queen Elizabeth Hospital, Woodville South, South Australia 5011, Adelaide, Australia.
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Fournelle M, Bost W, Tarner IH, Lehmberg T, Weiß E, Lemor R, Dinser R. Antitumor necrosis factor-α antibody-coupled gold nanorods as nanoprobes for molecular optoacoustic imaging in arthritis. Nanomedicine 2011; 8:346-54. [PMID: 21740888 DOI: 10.1016/j.nano.2011.06.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 04/27/2011] [Accepted: 06/23/2011] [Indexed: 10/18/2022]
Abstract
Optoacoustic molecular imaging can provide spatially resolved information about the presence of molecular markers in vivo. We synthesized elongated gold nanorods having an absorption maximum in the range of 1064 nm modified with the antibodies infliximab and certolizumab for targeting TNF-α to detect inflammation in arthritic mouse knees. We showed an differential enhancement of optoacoustic signal amplitudes after the injection of infliximab-, but not certolizumab-modified and PEGylated control particles on arthritic and healthy control mice by using a fast-scanning optoacoustic imaging platform based on a pulsed Nd:YAG laser and a single focused ultrasound transducer. The excellent photoacoustic properties of the gold nanorods confirmed the overexpression of TNF-α in arthritic knees. Due to the uncomplicated coupling chemistry and the scalability of ultrasound-based imaging approaches, these results potentially allow a transfer to various preclinical and clinical applications. From the Clinical Editor: Gold nanorods were modified with TNF-α targeting antibodies and used to detect inflammation in arthritic mouse knees via optoaoustic imaging. A fast-scanning optoacoustic imaging platform based on a pulsed Nd:YAG laser and a single focused ultrasound transducer was utilized for imaging. The excellent photoacoustic properties of these gold nanorods confirmed the overexpression of TNF-α, paving the way towards further preclinical and future clinical applications.
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Affiliation(s)
- Marc Fournelle
- Fraunhofer Institut für Biomedizinische Technik, Division of Ultrasound, St. Ingbert, Germany
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Beyer C, Distler JHW, Allanore Y, Aringer M, Avouac J, Czirják L, Cutolo M, Damjanov N, Del Galdo F, Fligelstone K, Guiducci S, Kowal-Bielecka O, van Laar JM, Martucci-Cerinic M, Müller-Ladner U, Riemekasten G, Tarner IH, Tyndall A, Kennedy AT, Valentini G, Vettori S, Walker UA, Denton C, Distler O. EUSTAR biobanking: recommendations for the collection, storage and distribution of biospecimens in scleroderma research. Ann Rheum Dis 2011; 70:1178-82. [PMID: 21285118 DOI: 10.1136/ard.2010.142489] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The European League Against Rheumatism Scleroderma Trials and Research Group (EUSTAR) has established an online database with clinical data of currently more than 8200 patients with systemic sclerosis (SSc). In addition to clinical research, EUSTAR fosters biomolecular studies to develop novel biomarkers and therapies for SSc. High-quality biospecimens are the basis for successful biomolecular studies. The EUSTAR biobanking group has therefore developed recommendations to standardise the collection, storage and distribution of SSc biospecimens at EUSTAR centres. These recommendations consider the scientific challenges associated with biomolecular research in SSc and the organisational requirements of EUSTAR. They were approved by the EUSTAR executive committee as well as the EUSTAR board. Once they become effective, these recommendations will be the basis for international EUSTAR studies with large numbers of SSc biospecimens. These recommendations might also be followed by other SSc consortia to enable exchange of biosamples between different SSc initiatives and might serve as a template for biobanking initiatives in other rheumatic diseases.
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Affiliation(s)
- Christian Beyer
- Department of Internal Medicine, Institute for Clinical Immunology, University of Erlangen-Nuremberg, Germany
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Avouac J, Fransen J, Walker UA, Riccieri V, Smith V, Muller C, Miniati I, Tarner IH, Randone SB, Cutolo M, Allanore Y, Distler O, Valentini G, Czirjak L, Müller-Ladner U, Furst DE, Tyndall A, Matucci-Cerinic M. Preliminary criteria for the very early diagnosis of systemic sclerosis: results of a Delphi Consensus Study from EULAR Scleroderma Trials and Research Group. Ann Rheum Dis 2010; 70:476-81. [PMID: 21081523 DOI: 10.1136/ard.2010.136929] [Citation(s) in RCA: 253] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To identify a core set of preliminary items considered as important for the very early diagnosis of systemic sclerosis (SSc). METHODS A list of items provided by European League Against Rheumatism (EULAR) Scleroderma Trial and Research(EUSTAR) centres were subjected to a Delphi exercise among 110 experts in the field of SSc. In round 1, experts were asked to choose the items they considered as the most important for the very early diagnosis of SSc. In round 2, experts were asked to reconsider the items accepted after the first stage. In round 3, the clinical relevance of selected items and their importance as measures that would lead to an early referral process were rated using appropriateness scores. RESULTS Physicians from 85 EUSTAR centres participated in the study and provided an initial list of 121 items. After three Delphi rounds, the steering committee, with input from external experts, collapsed the 121 items into three domains containing seven items, developed as follows: skin domain (puffy fingers/puffy swollen digits turning into sclerodactily); vascular domain (Raynaud's phenomenon, abnormal capillaroscopy with scleroderma pattern) and laboratory domain (antinuclear, anticentromere and antitopoisomerase-I antibodies). Finally, the whole assembly of EUSTAR centres ratified with a majority vote the results in a final face-to-face meeting. CONCLUSION The three Delphi rounds allowed us to identify the items considered by experts as necessary for the very early diagnosis of SSc. The validation of these items to establish diagnostic criteria is currently ongoing in a prospective observational cohort.
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Affiliation(s)
- J Avouac
- Rheumatology A department, Cochin Hospital, 27 rue du Faubourg Saint Jacques, 75014 Paris, France.
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Tarner IH, Lange U, Madlener K, Classen K, Kandolf R, Sperzel J, Müller-Ladner U. [A wolf in sheep's clothing: atypical systemic lupus erythematosus (SLE) presenting as cardiovascular disease]. ACTA ACUST UNITED AC 2010; 105:300-4. [PMID: 20455054 DOI: 10.1007/s00063-010-1048-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CASE REPORT A 51-year-old woman diagnosed as having valvular cardiomyopathy since age 34 was admitted for an evaluation for a heart transplant because of progressive congestive heart failure. When antiphospholipid antibodies were detected, the diagnosis of a thus far undetected systemic lupus erythematosus (SLE) was confirmed, manifesting primarily by cardiac involvement and an antiphospholipid antibody syndrome. Despite an advanced stage of heart failure, the patient responded well to azathioprine. Nevertheless, the potential necessity of a heart transplant remained. Its atypical presentation impeded a timely diagnosis of SLE significantly, however, in retrospect the correct diagnosis would have been possible at an earlier time point. CONCLUSION Though rare, SLE represents an important differential diagnosis in cases of severe valvular disease and cardiomyopathy, particularly in young women.
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Affiliation(s)
- Ingo H Tarner
- Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Giessen, Abteilung für Rheumatologie, klinische Immunologie, Osteologie und physikalische Medizin, Kerckhoff-Klinik, Bad Nauheim, Germany.
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Tarner IH, Müller-Ladner U. [Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with the focus on rheumatoid arthritis. Integration of a systematic literature research with the expert opinion of a large international panel of rheumatologists within the framework of the 3e initiative]. Z Rheumatol 2010; 69:250-2. [PMID: 19756660 DOI: 10.1007/s00393-009-0540-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- I H Tarner
- Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Giessen, Abteilung für Rheumatologie und klinische Immunologie, Kerckhoff-Klinik, Benekestrasse 2-8, 61231 Bad Nauheim, Deutschland.
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Neumann E, Riepl B, Knedla A, Lefèvre S, Tarner IH, Grifka J, Steinmeyer J, Schölmerich J, Gay S, Müller-Ladner U. Cell culture and passaging alters gene expression pattern and proliferation rate in rheumatoid arthritis synovial fibroblasts. Arthritis Res Ther 2010; 12:R83. [PMID: 20462438 PMCID: PMC2911867 DOI: 10.1186/ar3010] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2005] [Revised: 05/14/2008] [Accepted: 05/12/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Rheumatoid arthritis synovial fibroblasts (RASF) are key players in synovial pathophysiology and are therefore examined extensively in various experimental approaches. We evaluated, whether passaging during culture and freezing has effects on gene expression and cell proliferation. METHODS RASF were passaged for up to 8 passages. RNA was isolated after each passage and cDNA arrays were performed to evaluate the RNA expression pattern during passaging. In addition, doubling time of the cells was also measured. RESULTS From passages 2-4, mRNA expression did not change significantly. Gene expression in RASF started to change in passages 5-6 with 7-10% differentially expressed genes. After passages 7-8, more than 10% of the genes were differentially expressed. The doubling rate was constant for up to 5 passages and decreased after passages 6-8. After freezing, gene expression of the second passage is comparable to gene expression prior to freezing. CONCLUSIONS The results of this study show, that experiments, which examine gene expression of RASF and shall reflect or imitate an in vivo situation, should be limited to early culture passages to avoid cell culture effects. It is not necessary to stop culturing SF after a few passages, but to keep the problems of cell culture in mind to avoid false positive results. Especially, when large-scale screening methods on mRNA level are used. Of note, freezing does not affect gene expression substantially.
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Affiliation(s)
- Elena Neumann
- Department of Internal Medicine and Rheumatology, University of Giessben, Kerckhoff-Klinik, D-61231 Bad Nauheim, Benekestr, 2-8, Germany.
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Müller-Ladner U, Tarner IH, Hamm C, Lange U. Cardiovascular risk management in patients with inflammatory arthritis: what is good for the joint is good for the heart and vice versa! F1000 Med Rep 2010; 2. [PMID: 20948858 PMCID: PMC2948399 DOI: 10.3410/m2-27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Owing to the prominent long-term systemic inflammatory reaction in patients with arthritides and a growing body of data illustrating that this inflammatory reaction imposes a considerable risk for the development or aggravation of cardiovascular (CV) disease or overall CV risk, numerous researchers and clinicians have put enormous effort into the analysis of the effects of risk factors on the course of CV disease in these patients and the therapeutic options to antagonize progressive atherosclerosis. To achieve this challenging goal, investigators have shown that all treatment strategies must include the ‘non-rheumatic’ approaches, such as lowering blood pressure, stopping smoking, and improving metabolic status, in tight association with lowering the overall disease activity of the underlying rheumatic entity using antiphlogistic drugs and conventional as well as biologic disease-modifying drugs.
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Affiliation(s)
- Ulf Müller-Ladner
- Department of Internal Medicine and Rheumatology, Justus-Liebig University GiessenGiessenGermany
- Department of Rheumatology and Clinical Immunology, Kerckhoff Clinic Bad NauheimBenekestrasse 2-8, 61231 Bad NauheimGermany
| | - Ingo H Tarner
- Department of Internal Medicine and Rheumatology, Justus-Liebig University GiessenGiessenGermany
- Department of Rheumatology and Clinical Immunology, Kerckhoff Clinic Bad NauheimBenekestrasse 2-8, 61231 Bad NauheimGermany
| | - Christian Hamm
- Department of Cardiology, Kerckhoff Clinic Bad NauheimBenekestrasse 2-8, 61231 Bad NauheimGermany
| | - Uwe Lange
- Department of Rheumatology and Clinical Immunology, Kerckhoff Clinic Bad NauheimBenekestrasse 2-8, 61231 Bad NauheimGermany
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Tarner IH. [Interdisciplinary emergencies in rheumatic diseases]. Dtsch Med Wochenschr 2010; 135:683-94; quiz 695-8. [PMID: 20358496 DOI: 10.1055/s-0030-1251920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Rheumatic disease can affect and severely damage vital organs and thus cause acute emergencies and life-threatening complications. As systemic diseases they can cause any presenting complaint commonly encountered in emergency medicine. Because of their relative rarity in general practice, a high level of vigilance is required in order to recognize an emergency caused by an underlying rheumatic disease in individual cases. The most important rheumatological emergencies comprise septic arthritis, gout, atlantoaxial subluxation, renal crisis and digital ulcers in systemic sclerosis, amaurosis fugax in giant cell arteritis, the catastrophic anti-phospholipid antibody syndrome and the pulmonary-renal syndrome. This article provides an overview over these rheumatological emergencies in order to aid recognition of these entities in individual cases and to thus facilitate immediate and adequate treatment, which is of vital importance for affected patients.
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Affiliation(s)
- I H Tarner
- Abteilung für Rheumatologie, klinische Immunologie, Osteologie und Physikalische Medizin, Kerckhoff-Klinik, Bad Nauheim.
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Purath U, Creusot RJ, Garrison Fathman C, Muller-Ladner U, Neumann E, Tarner IH. Adoptive cellular gene therapy of autoimmune arthritis using a combination of lentivirally transduced dendritic cells. Ann Rheum Dis 2010. [DOI: 10.1136/ard.2010.129650a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lefèvre S, Knedla A, Tennie C, Kampmann A, Wunrau C, Dinser R, Korb A, Schnäker EM, Tarner IH, Robbins PD, Evans CH, Stürz H, Steinmeyer J, Gay S, Schölmerich J, Pap T, Müller-Ladner U, Neumann E. Synovial fibroblasts spread rheumatoid arthritis to unaffected joints. Nat Med 2009; 15:1414-20. [PMID: 19898488 PMCID: PMC3678354 DOI: 10.1038/nm.2050] [Citation(s) in RCA: 456] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Accepted: 09/21/2009] [Indexed: 01/29/2023]
Abstract
Active rheumatoid arthritis originates from few joints but subsequently affects the majority of joints. Thus far, the pathways of the progression of the disease are largely unknown. As rheumatoid arthritis synovial fibroblasts (RASFs) which can be found in RA synovium are key players in joint destruction and are able to migrate in vitro, we evaluated the potential of RASFs to spread the disease in vivo. To simulate the primary joint of origin, we implanted healthy human cartilage together with RASFs subcutaneously into severe combined immunodeficient (SCID) mice. At the contralateral flank, we implanted healthy cartilage without cells. RASFs showed an active movement to the naive cartilage via the vasculature independent of the site of application of RASFs into the SCID mouse, leading to a marked destruction of the target cartilage. These findings support the hypothesis that the characteristic clinical phenomenon of destructive arthritis spreading between joints is mediated, at least in part, by the transmigration of activated RASFs.
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Affiliation(s)
- Stephanie Lefèvre
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany
| | - Anette Knedla
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany
| | - Christoph Tennie
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany
| | - Andreas Kampmann
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany
| | - Christina Wunrau
- Institute of Experimental Muskuloskeletal Medicine, University Hospital Muenster, Germany
| | - Robert Dinser
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany
| | - Adelheid Korb
- Department of Internal Medicine D, Nephrology and Rheumatology, University Hospital Muenster, Germany
| | | | - Ingo H. Tarner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany
| | - Paul D. Robbins
- Department of Microbiology and Molecular Genetics, University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | | | - Henning Stürz
- Department of Orthopedics and Orthopedic Surgery, University Hospital Giessen and Marburg, Giessen, Germany
| | - Jürgen Steinmeyer
- Deptment of Orthopedics and Experimental Orthopedics, University Hospital Giessen and Marburg Giessen, Germany
| | - Steffen Gay
- Center for Experimental Rheumatology, Zürich Center for Integrative Human Physiology, USZ, Zürich, Switzerland
| | | | - Thomas Pap
- Institute of Experimental Muskuloskeletal Medicine, University Hospital Muenster, Germany
| | - Ulf Müller-Ladner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany
| | - Elena Neumann
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University Giessen, Kerckhoff-Clinic, Bad Nauheim, Germany
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Müller-Ladner U, Neumann E, Tarner IH. Clinically relevant advances in rheumatoid arthritis therapy. F1000 Med Rep 2009; 1. [PMID: 20948712 PMCID: PMC2948302 DOI: 10.3410/m1-68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Owing to the success of biologics in the treatment of rheumatoid arthritis (RA), several novel drugs have been introduced in the therapeutic armamentarium, although not all of them have been approved in all countries worldwide. Among the drugs are tumour necrosis factor (TNF) inhibitors such as certolizumab pegol and golimumab (the latter of which was the first TNF blocker shown to be effective in patients who had been unsuccessfully treated with other TNF blockers and which can be applied only once a month), and the interleukin-6 receptor antagonist tocilizumab, which not only opens up a completely new field of anti-inflammatory modulation of RA pathophysiology, but also highlights the challenge of novel potential side effects. Moreover, aside from clinical studies showing efficacy in the inhibition of osteoclast activation by the anti-RANKL (receptor activator of nuclear factor-kappa B ligand) antibody denosumab, an improved form of steroid application known as slow-release ‘tempus tablet’ for treatment of RA and several developments in the small-molecule area have been addressed by clinical trials.
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Affiliation(s)
- Ulf Müller-Ladner
- Department of Internal Medicine and Rheumatology, Justus-Liebig University Giessen, Division of Rheumatology and Clinical Immunology, Kerckhoff ClinicBenekestrasse 2-8, D-61231 Bad NauheimGermany
| | - Elena Neumann
- Department of Internal Medicine and Rheumatology, Justus-Liebig University Giessen, Division of Rheumatology and Clinical Immunology, Kerckhoff ClinicBenekestrasse 2-8, D-61231 Bad NauheimGermany
| | - Ingo H Tarner
- Department of Internal Medicine and Rheumatology, Justus-Liebig University Giessen, Division of Rheumatology and Clinical Immunology, Kerckhoff ClinicBenekestrasse 2-8, D-61231 Bad NauheimGermany
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Abstract
Rheumatoid arthritis (RA) is a severe immune-mediated disease characterized by chronically progressive inflammation and destruction of joints and associated structures. Significant advances in our understanding of its pathophysiology and early diagnosis have led to improved therapy and better outcome. Nevertheless, a number of details in the pathogenesis of RA are still unknown and thus the disease cannot be cured at present. Therefore, current therapy aims at accomplishing complete and long-lasting remission. However, this goal is only achieved in a small proportion of patients, and partial remission and frequent relapses are a common problem. A significant number of patients still do not respond at all to available treatments. In addition, all antirheumatic and immune-modulating drugs developed so far carry a considerable risk of adverse effects, some of which can be severe or even life threatening. This is due, at least in part, to a lack of specificity of most drugs for the target tissue, and to a high volume of distribution for systemic application, which, together with rapid clearance of most drugs, requires frequent application of high dosages. Targeted drug delivery and prolongation of bioavailability would alleviate this issue significantly. This article, therefore, reviews a selection of studies that report promising strategies for joint specific delivery of antiarthritic drugs.
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Affiliation(s)
- Ingo H Tarner
- Department of Internal Medicine and Rheumatology, Division of Rheumatology and Clinical Immunology, Justus-Liebig-University of Giessen, D-61231 Bad Nauheim, Germany
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Härle P, Pongratz G, Albrecht J, Tarner IH, Straub RH. An early sympathetic nervous system influence exacerbates collagen-induced arthritis via CD4+CD25+ cells. ACTA ACUST UNITED AC 2008; 58:2347-55. [PMID: 18668589 DOI: 10.1002/art.23628] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Activation of the sympathetic nervous system (SNS) ameliorates collagen-induced arthritis (CIA) in the late phase of the disease but aggravates it in the presymptomatic phase. The aim of the present study was to determine whether CD4+CD25+ T cells are influenced by the SNS of mice and play a disease-modifying role in the early symptomatic phase of the disease. METHODS We tested the effects of the SNS on arthritis by transferring CD4+CD25+ T cells from sympathectomized mice immunized with type II collagen and from immunized, SNS-intact animals (controls). We further characterized transferred cells by studying forkhead box P3 (FoxP3) expression, cell proliferation, and cytokine secretion. RESULTS Using anti-dopamine-beta-hydroxylase antibodies for systemic sympathectomy, we noticed a time-dependent disease amelioration (strongest when sympathectomy was performed 7 days before immunization, with no effect 30 days after immunization). When CD4+CD25+ T cells from immunized and sympathectomized animals were transferred into mice with CIA (on day 32), disease severity was reduced compared with that in controls. However, the number of CD4+CD25+FoxP3+ cells and the FoxP3 expression level in CD4+CD25+ cells were not changed by sympathectomy. In a mixed assay of donor CD4+CD25- and CD4+CD25+ cells, proliferation was reduced when cells from sympathectomized animals were studied. In the same assay, secretion of tumor necrosis factor, interleukin-17 (IL-17), IL-10, and IL-4 (not interferon-gamma) was markedly reduced when cells were taken from sympathectomized animals. Culture of CD4+CD25+ cells with norepinephrine (10(-5)M) for 24 hours before transfer worsened the arthritis. CONCLUSION The SNS increases disease severity in the early phase of symptomatic CIA by stimulating several proinflammatory aspects of CD4+CD25+ T cells.
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Affiliation(s)
- Peter Härle
- University Hospital Regensburg, Regensburg, Germany
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40
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Soderstrom K, Comenero P, Purath U, Müller‐Ladner U, Zhang AL, Tarner IH, Engelman E. Monocytes differentiate into osteoclasts in the presence of RANKL and M‐CSF expressing natural killer cells. FASEB J 2008. [DOI: 10.1096/fasebj.22.1_supplement.668.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Ulrich Purath
- Department of Internal Medicine and RheumatologyJustus‐Liebig University of GiessenKerckhoff‐KlinikBad NauheimGermany
| | - Ulf Müller‐Ladner
- Department of Internal Medicine and RheumatologyJustus‐Liebig University of GiessenKerckhoff‐KlinikBad NauheimGermany
| | - Angel L Zhang
- Department of PathologyStanford UniversityPalo AltoCA
| | - Ingo H Tarner
- Department of Internal Medicine and RheumatologyJustus‐Liebig University of GiessenKerckhoff‐KlinikBad NauheimGermany
| | - Ed Engelman
- Department of PathologyStanford UniversityPalo AltoCA
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Abstract
Systemic sclerosis (SSc) belongs to the family of autoimmune connective tissue diseases and is still a challenge to every practicing physician. The disorder is characterized by progressing fibrosis of the skin and internal organs, abnormal activation of the immune system, and distinct changes in microcirculation. Although it is rare--with a prevalence of about 20:100000--patients need to be cared for in a daily setting. In general thickening of the skin is the first sign of the disease, so dermatologists are most frequently consulted first. Two subtypes exist, limited and diffuse forms. Both entities usually involve internal organs, and therefore interdisciplinary cooperation is mandatory. The increased morbidity and mortality depend predominantly on the grade of involvement of the affected organs. Therefore it is essential to diagnose systemic sclerosis early and to identify and monitor all complications closely. In this respect gastrointestinal involvement is frequently neglected, owing to its primarily non-life-threatening character, resulting in substantially delayed therapy.
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Affiliation(s)
- P Saar
- Abt. für Rheumatologie und klinische Immunologie, Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie der Justus-Liebig-Universität Giessen, Kerckhoff-KlinikBad Nauheim, Benekestrasse 2-8, 61231, Bad Nauheim, Germany.
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Manetti M, Neumann E, Milia AF, Tarner IH, Bechi P, Matucci-Cerinic M, Ibba-Manneschi L, Müller-Ladner U. Severe fibrosis and increased expression of fibrogenic cytokines in the gastric wall of systemic sclerosis patients. ACTA ACUST UNITED AC 2007; 56:3442-7. [PMID: 17907149 DOI: 10.1002/art.22940] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is a connective tissue disorder characterized by fibrosis of the skin and internal organs. Although the esophagus is the most frequently affected part of the gastrointestinal tract, all other segments can be involved. The present study was undertaken to evaluate the fibrotic process and the expression of fibrogenic cytokines in the gastric wall of SSc patients with gastroesophageal involvement. METHODS Full-thickness surgical and endoscopic gastric biopsy samples were obtained from 14 SSc patients and 10 controls. Tissue sections were either stained with Masson's trichrome or by immunohistochemistry and analyzed for the expression of types I, III, and IV collagen, alpha-smooth muscle actin (alpha-SMA), transforming growth factor beta (TGFbeta), connective tissue growth factor (CTGF), and endothelin 1 (ET-1). RESULTS In the gastric wall of SSc patients, Masson's trichrome staining and immunohistochemistry for types I and III collagen revealed a high amount of collagen in the lamina propria that increased toward the muscularis mucosae. In addition, muscle layers showed features of atrophy, with wide areas of focal fibrosis surrounding smooth muscle cells. Type IV collagen was present around glands and small vessels, suggesting a thickening of the basal lamina. The expression of the fibrogenic cytokines TGFbeta and CTGF, ET-1, and the myofibroblast marker alpha-SMA was stronger in SSc patients than in controls. CONCLUSION A pronounced deposition of collagen, the presence of myofibroblasts, and increased expression of several profibrotic factors are important hallmarks in the stomach of patients with SSc. The fibrotic involvement of the gastric wall may account for muscle atrophy leading to stomach hypomotility in SSc.
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43
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Zhang AL, Colmenero P, Purath U, Teixeira de Matos C, Hueber W, Klareskog L, Tarner IH, Engleman EG, Söderström K. Natural killer cells trigger differentiation of monocytes into dendritic cells. Blood 2007; 110:2484-93. [PMID: 17626840 PMCID: PMC1988958 DOI: 10.1182/blood-2007-02-076364] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Circulating monocytes can differentiate into dendritic cells (moDCs), which are potent inducers of adaptive immune responses. Previous reports show that granulocyte macrophage-colony-stimulating factor (GM-CSF) and interleukin-4 induce monocyte differentiation into moDCs in vitro, but little is known about the physiological requirements that initiate moDC differentiation in vivo. Here we show that a unique natural killer (NK) cell subset (CD3(-)CD56(bright)) that accumulates in lymph nodes and chronically inflamed tissues triggers CD14(+) monocytes to differentiate into potent T-helper-1 (T(H)1) promoting DC. This process requires direct contact of monocytes with NK cells and is mediated by GM-CSF and CD154 derived from NK cells. It is noteworthy that synovial fluid (SF) from patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA), but not osteoarthritis (OA), induces monocytes to differentiate into DC. However, this process occurs only in the presence of NK cells. We propose that NK cells play a role in the maintenance of T(H)1-mediated inflammatory diseases such as RA by providing a local milieu for monocytes to differentiate into DC.
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Affiliation(s)
- Angela L Zhang
- Department of Pathology, Stanford University School of Medicine, Palo Alto, CA 94304-1204, USA
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44
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Tarner IH, Müller-Ladner U, Gay S. Emerging targets of biologic therapies for rheumatoid arthritis. ACTA ACUST UNITED AC 2007; 3:336-45. [PMID: 17538565 DOI: 10.1038/ncprheum0506] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2006] [Accepted: 03/06/2007] [Indexed: 12/31/2022]
Abstract
Advances in molecular biology and the clinical success of strategies that target tumor necrosis factor (TNF) have led to further research into the pathophysiology of human rheumatoid arthritis. Several novel therapeutic targets have emerged from these efforts, including not only molecules that regulate TNF (e.g. TNF-alpha converting enzyme), the complex cytokine network (e.g. interleukin [IL]-6, IL-15, IL-17) and several adipokines, but also targets that originate from cellular and subcellular components of the disease. Strategies that aim at cellular targets include antibodies to CD20 or BLyS (also known as TNF ligand family member 13b), which deplete or inhibit B cells, as well as approaches that interfere with membrane-derived microparticles. Components of subcellular pathways, which are predominantly upstream of the central regulator of transcription nuclear factor kappaB, have also been studied. Of these, strategies that target mitogen-activated protein kinases have a leading role and are on the verge of clinical use; approaches that target specific molecules such as Janus kinases, signal transducer and activator of transcription proteins, and suppressor of cytokine signaling proteins also seem to show promise and might have a clinical application in the future.
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Affiliation(s)
- Ingo H Tarner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, and Division of Rheumatology and Clinical Immunology at the Kerckhoff-Klinik Bad Nauheim, Germany
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Abstract
Avascular necrosis (AVN) of the hip is one of the unsolved problems in orthopedics, especially with regard to drug therapy. Only a few studies exist using a long-term approach with vasodilating agents such as prostaglandins, anticoagulants, hormones, as well as lipid lowering and bone protective drugs such as bisphosphonates. However, using these medications several studies have demonstrated a significant reduction in pain, in the destruction of the femoral head as well as in overall disability. This resulted in a reduced need for joint replacement in patients with AVN and to a substantial improvement in quality of life. Of note, drug therapy should be initiated in the early phases of AVN as later stages appear to be less responsive to medication.
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Affiliation(s)
- I H Tarner
- Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie der Justus-Liebig Universität Giessen
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46
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Meyringer R, Neumann E, Judex M, Landthaler M, Kullmann F, Scholmerich J, Gay S, Tarner IH, Distler O, Müller-Ladner U. Analysis of gene expression patterns in systemic sclerosis fibroblasts using RNA arbitrarily primed-polymerase chain reaction for differential display. J Rheumatol 2007; 34:747-53. [PMID: 17407232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
OBJECTIVE To identify genes that are differentially expressed in systemic sclerosis (SSc) fibroblasts of clinically involved and noninvolved skin compared to normal dermal fibroblasts, using RNA arbitrarily primed-polymerase chain reaction (RAP-PCR) for differential display. METHODS We examined 12 fibroblast cultures derived from clinically involved skin, 3 fibroblast cultures from noninvolved skin, and 4 fibroblast cultures from healthy skin. After extraction of total RNA, the first step of RAP-PCR was performed using different arbitrary 10-12-base primers for first-strand cDNA synthesis. Second-strand synthesis was achieved by cycling using different arbitrary 10-base primers, followed by sequence analysis of the amplified fingerprint products. The resulting sequences were aligned to the GenBank database using Blast Search. Confirmation of differential expression was performed with specific primers using real-time PCR. RESULTS Using 8 different primer combinations, in total 48 cDNA were differentially expressed between SSc and healthy dermal fibroblasts. Sequence analysis identified distinct PCR products, which were overexpressed in SSc as highly homologous to gene segments of gremlin protein, lysyl oxidase, c-cbl proto-oncogene, an estrogen-responsive element, fibronectin, and collagen type XIIa1 precursor. CONCLUSION Our results show that RAP-PCR is a suitable method to identify differentially expressed genes in SSc fibroblasts. Further, we identified genes that have not yet been described in the pathophysiology of SSc and that may be involved in matrix synthesis and cellular interaction.
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Affiliation(s)
- Rotraud Meyringer
- From the Department of Internal Medicine I, University of Regensburg
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47
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Neumann E, Knedla A, Meier F, Tarner IH, Büchler C, Schäffler A, Müller-Ladner U. Adipozytokine als treibende Faktoren bei rheumatoider Arthritis. Z Rheumatol 2007; 66:139-41. [PMID: 17333076 DOI: 10.1007/s00393-007-0158-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- E Neumann
- Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Giessen, Kerckhoff-Klinik, Bad Nauheim, Benekestr. 2-8, 61231 Bad Nauheim.
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48
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Hashimoto A, Tarner IH, Bohle RM, Gaumann A, Manetti M, Distler O, Steinmeyer J, Ulfgren AK, Schulz A, Gay S, Müller-Ladner U, Neumann E. Analysis of vascular gene expression in arthritic synovium by laser-mediated microdissection. ACTA ACUST UNITED AC 2007; 56:1094-105. [PMID: 17393418 DOI: 10.1002/art.22450] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE In rheumatoid arthritis (RA), formation of new blood vessels is necessary to meet the nutritional and oxygen requirements of actively proliferating synovial tissue. The aim of this study was to analyze the specific synovial vascular expression profiles of several angiogenesis-related genes as well as CD82 in RA compared with osteoarthritis (OA), using laser-mediated microdissection (LMM). METHODS LMM and subsequent real-time polymerase chain reaction were used in combination with immunohistochemical analysis for area-specific analysis of messenger RNA (mRNA) and protein expression of vascular endothelial growth factor (VEGF), VEGF receptor 1 (VEGFR-1), VEGFR-2, hypoxia-inducible factor 1alpha (HIF-1alpha), HIF-2alpha, platelet-derived growth factor receptor alpha (PDGFRalpha), PDGFRbeta, inhibitor of DNA binding/differentiation 2 (Id2), and CD82 in RA and OA synovial microvasculature and synovial lining. RESULTS Expression of Id2 mRNA was significantly lower in RA synovial vessels compared with OA synovial vessels (P=0.0011), whereas expression of VEGFR-1 was significantly higher in RA (P=0.0433). No differences were observed for the other parameters. At the protein level, no statistically significant differences were observed for any parameter, although Id2 levels were 2.5-fold lower in RA (P=0.0952). However, the number of synovial blood vessels and the number of VEGFR-2-expressing blood vessels were significantly higher in RA compared with OA. CONCLUSION Our results underscore the importance of area-specific gene expression analysis in studying the pathogenesis of RA and support LMM as a robust tool for this purpose. Of note, our results indicate that previously described differences between RA and OA in the expression of angiogenic molecules are attributable to higher total numbers of synovial and vascular cells expressing these molecules in RA rather than higher expression levels in the individual cells.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Arthritis, Rheumatoid
- Basic Helix-Loop-Helix Transcription Factors
- Female
- Gene Expression
- Humans
- Hypoxia-Inducible Factor 1, alpha Subunit/genetics
- Hypoxia-Inducible Factor 1, alpha Subunit/metabolism
- Inhibitor of Differentiation Protein 2/genetics
- Inhibitor of Differentiation Protein 2/metabolism
- Kangai-1 Protein/genetics
- Kangai-1 Protein/metabolism
- Male
- Microdissection
- Middle Aged
- Neovascularization, Pathologic/genetics
- Neovascularization, Pathologic/metabolism
- Neovascularization, Pathologic/pathology
- Osteoarthritis
- RNA, Messenger/metabolism
- Receptor, Platelet-Derived Growth Factor alpha/genetics
- Receptor, Platelet-Derived Growth Factor alpha/metabolism
- Receptor, Platelet-Derived Growth Factor beta/genetics
- Receptor, Platelet-Derived Growth Factor beta/metabolism
- Synovial Membrane/blood supply
- Synovial Membrane/metabolism
- Synovial Membrane/pathology
- Transcription Factors/genetics
- Transcription Factors/metabolism
- Vascular Endothelial Growth Factor A/genetics
- Vascular Endothelial Growth Factor A/metabolism
- Vascular Endothelial Growth Factor Receptor-1/genetics
- Vascular Endothelial Growth Factor Receptor-1/metabolism
- Vascular Endothelial Growth Factor Receptor-2/genetics
- Vascular Endothelial Growth Factor Receptor-2/metabolism
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Affiliation(s)
- Atsushi Hashimoto
- Department of Medicine and Rheumatology, Justus-Liebig-University of Giessen, Giessen, and University Hospital Regensburg, Germany
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Tarner IH, Fathman CG. Does our current understanding of the molecular basis of immune tolerance predict new therapies for autoimmune disease? ACTA ACUST UNITED AC 2006; 2:491-9. [PMID: 16951704 DOI: 10.1038/ncprheum0272] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2005] [Accepted: 07/13/2006] [Indexed: 12/29/2022]
Abstract
The creation of specific immune tolerance has often been referred to as the ultimate goal of immunotherapy, because it would allow autoimmune disease to be reversed without the need for nonspecific and potentially harmful immunosuppressive therapy. Studies performed during the past decade have been immensely fruitful in terms of advances in our understanding of the cellular and molecular mechanisms of immune tolerance, and have paved the way for successful exploitation of these mechanisms for therapeutic purposes. Important developments include an increased understanding of central and peripheral tolerance, and treatment strategies that mimic the mechanisms behind deletion of self-reactive cells, the identification of crucial gene products that are involved in the induction of anergy, and the characterization of regulatory T cells and protocols for their induction and expansion for therapeutic applications. These landmarks of immune-tolerance research are summarized and their potential use in the immunotherapy of autoimmune disease discussed.
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Affiliation(s)
- Ingo H Tarner
- Department of Internal Medicine and Rheumatology, Justus-Liebig-University of Giessen, Kerckhoff-Klinik Bad Nauheim, Division of Rheumatology and Clinical Immunology, Bad Nauheim, Germany
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Li DH, Tung JW, Tarner IH, Snow AL, Yukinari T, Ngernmaneepothong R, Martinez OM, Parnes JR. CD72 down-modulates BCR-induced signal transduction and diminishes survival in primary mature B lymphocytes. J Immunol 2006; 176:5321-8. [PMID: 16621999 DOI: 10.4049/jimmunol.176.9.5321] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
CD72, a 45-kDa type II transmembrane glycoprotein carrying an ITIM motif, is believed to be an inhibitory coreceptor of the BCR. Mature B cells lacking CD72 show enhanced Ca(2+) mobilization and are hyperproliferative in response to BCR ligation. However, the signal transduction pathways downstream of BCR signaling that transmit the inhibitory effect of CD72 in mature B cells remain unknown. To address this question, we used hen egg lysozyme-specific BCR transgenic mice to elucidate the differential cell signaling between wild-type and CD72-deficient B cells in response to hen egg lysozyme Ag stimulation. Our results demonstrate that CD72 predominantly down-regulates the major signal transduction pathways downstream of the BCR, including NF-AT, NF-kappaB, ERK, JNK, p38-MAPK, and PI3K/Akt in mature B cells. CD72 ligation with anti-CD72 Ab (K10.6), which mimics the binding of CD100 (a natural ligand for CD72) to release the inhibitory function of CD72, augments cell proliferation, Ca(2+) flux, IkappaBalpha activation, and ERK MAPK activity upon Ag stimulation in wild-type B cells. In addition, we show direct evidence that CD72 promotes cell cycle arrest and apoptosis after Ag stimulation in mature B cells. Taken together, our findings conclude that CD72 plays a dominant role as a negative regulator of BCR signaling in primary mature B lymphocytes.
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Affiliation(s)
- Daniel H Li
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine, 269 Campus Drive, Stanford, CA 94305, USA
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