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Tamm S, Lensmar C, Andreasson A, Axelsson J, Forsberg Morén A, Grunewald J, Gyllfors P, Karshikoff B, Kosek E, Lampa J, Olgart Höglund C, Strand V, Cervenka S, Lekander M. Objective and Subjective Sleep in Rheumatoid Arthritis and Severe Seasonal Allergy: Preliminary Assessments of the Role of Sickness, Central and Peripheral Inflammation. Nat Sci Sleep 2021; 13:775-789. [PMID: 34168509 PMCID: PMC8216747 DOI: 10.2147/nss.s297702] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/18/2021] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Disturbed sleep in inflammatory disorders such as allergy and rheumatoid arthritis (RA) is common and may be directly or indirectly related to disease processes, but has not been well characterized in these patient groups, especially not with objective methods. AIM The present study aimed to characterize objective and subjective sleep in patients with allergy or RA using sleep diaries, one-channel EEG and actigraphy. It also aimed to investigate if sleep measures were associated with central immune activation, assessed using translocator protein (TSPO) positron emission tomography, as well as cytokine markers of peripheral inflammation and disease-specific symptoms or general symptoms of sickness. METHODS In total, 18 patients with seasonal pollen allergy, 18 patients with RA and 26 healthy controls were included in the study. Allergy patients and matched controls were assessed twice, in and out of pollen season, and RA patients and controls were assessed once. Sleep was recorded for approximately 1 week at each occasion. RESULTS Patients with allergy had increased levels of slow-wave sleep during pollen season. In contrast, patients with RA had less SWS compared to healthy controls, while no differences were observed in sleep duration or subjective sleep quality. Across groups, neither proinflammatory cytokines, grey matter TSPO levels nor general sickness symptoms were associated with objective or subjective measures of sleep. Rhinitis, but not conjunctivitis, was correlated to worse subjective sleep and more slow wave sleep in allergy. Functional status, but not disease activity, predicted lower subjective sleep in RA. CONCLUSION This study tentatively indicates that both patients with allergy and RA display sleep alterations but does not support inflammation as an independent predictor of the sleep disturbance across these patient groups.
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Affiliation(s)
- Sandra Tamm
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stress Research Institute, Stockholm University, Stockholm, Sweden
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Catarina Lensmar
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Anna Andreasson
- Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - John Axelsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - Anton Forsberg Morén
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services,Region Stockholm, Stockholm, Sweden
| | - Johan Grunewald
- Department of Medicine and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Pär Gyllfors
- Asthma & Allergy Clinic at S:t Görans Hospital, Stockholm, Sweden
| | - Bianka Karshikoff
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stress Research Institute, Stockholm University, Stockholm, Sweden
| | - Eva Kosek
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Jon Lampa
- Department of Medicine, Rheumatology Unit, Center of Molecular Medicine (CMM), Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline Olgart Höglund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medicine and Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Victoria Strand
- Asthma & Allergy Clinic at S:t Görans Hospital, Stockholm, Sweden
| | - Simon Cervenka
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, & Stockholm Health Care Services,Region Stockholm, Stockholm, Sweden
| | - Mats Lekander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Stress Research Institute, Stockholm University, Stockholm, Sweden
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Bergqvist V, Hertervig E, Gedeon P, Kopljar M, Griph H, Kinhult S, Carneiro A, Marsal J. Vedolizumab treatment for immune checkpoint inhibitor-induced enterocolitis. Cancer Immunol Immunother 2017; 66:581-592. [PMID: 28204866 PMCID: PMC5406433 DOI: 10.1007/s00262-017-1962-6] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 01/27/2017] [Indexed: 12/11/2022]
Abstract
Immune checkpoint inhibitors (ICPI), such as ipilimumab [anti-cytotoxic T-lymphocyte antigen-4 (CTLA-4) antibody] and nivolumab or pembrolizumab [anti-programmed cell death protein-1 (PD-1) antibodies], improve survival in several cancer types. Since inhibition of CTLA-4 or PD-1 leads to non-selective activation of the immune system, immune-related adverse events (irAEs) are frequent. Enterocolitis is a common irAE, currently managed with corticosteroids and, if necessary, anti-tumor necrosis factor-α therapy. Such a regimen carries a risk of serious side-effects including infections, and may potentially imply impaired antitumor effects. Vedolizumab is an anti-integrin α4β7 antibody with gut-specific immunosuppressive effects, approved for Crohn’s disease and ulcerative colitis. We report a case series of seven patients with metastatic melanoma or lung cancer, treated with vedolizumab off-label for ipilimumab- or nivolumab-induced enterocolitis, from June 2014 through October 2016. Clinical, laboratory, endoscopic, and histologic data were analyzed. Patients initially received corticosteroids but were steroid-dependent and/or partially refractory. One patient was administered infliximab but was refractory. The median time from onset of enterocolitis to start of vedolizumab therapy was 79 days. Following vedolizumab therapy, all patients but one experienced steroid-free enterocolitis remission, with normalized fecal calprotectin. This was achieved after a median of 56 days from vedolizumab start, without any vedolizumab-related side-effects noted. The patient in whom vedolizumab was not successful, due to active ulcerative colitis, received vedolizumab prophylactically. This is the first case series to suggest that vedolizumab is an effective and well-tolerated therapeutic for steroid-dependent or partially refractory ICPI-induced enterocolitis. A larger prospective study to evaluate vedolizumab in this indication is warranted.
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Affiliation(s)
- Viktoria Bergqvist
- Department of Gastroenterology, Skane University Hospital, 22185, Lund, Sweden
| | - Erik Hertervig
- Department of Gastroenterology, Skane University Hospital, 22185, Lund, Sweden
- Section of Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Peter Gedeon
- Department of Gastroenterology, Skane University Hospital, 22185, Lund, Sweden
| | - Marija Kopljar
- Department of Gastroenterology, Skane University Hospital, 22185, Lund, Sweden
| | - Håkan Griph
- Department of Respiratory Medicine, Skane University Hospital, Lund, Sweden
| | - Sara Kinhult
- Department of Oncology, Skane University Hospital, Lund, Sweden
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Ana Carneiro
- Department of Oncology, Skane University Hospital, Lund, Sweden
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jan Marsal
- Department of Gastroenterology, Skane University Hospital, 22185, Lund, Sweden.
- Immunology Section, Department of Experimental Medical Science, Lund University, Lund, Sweden.
- Section of Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden.
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Andréasson K, Alrawi Z, Persson A, Jönsson G, Marsal J. Intestinal dysbiosis is common in systemic sclerosis and associated with gastrointestinal and extraintestinal features of disease. Arthritis Res Ther 2016; 18:278. [PMID: 27894337 PMCID: PMC5126986 DOI: 10.1186/s13075-016-1182-z] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 11/11/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Recent evidence suggests a link between autoimmunity and the intestinal microbial composition in several rheumatic diseases including systemic sclerosis (SSc). The objective of this study was to investigate the prevalence of intestinal dysbiosis in SSc and to characterise patients suffering from this potentially immunomodulatory deviation. METHODS This study consisted of 98 consecutive patients subject to in-hospital care. Stool samples were analysed for intestinal microbiota composition using a validated genome-based microbiota test (GA-map™ Dysbiosis Test, Genetic Analysis, Oslo, Norway). Gut microbiota dysbiosis was found present as per this standardised test. Patients were examined regarding gastrointestinal and extraintestinal manifestations of SSc by clinical, laboratory, and radiological measures including esophageal cineradiography, the Malnutrition Universal Screening Tool (MUST), levels of plasma transthyretin (a marker of malnutrition) and faecal (F-) calprotectin (a marker of intestinal inflammation). RESULTS A majority (75.5%) of the patients exhibited dysbiosis. Dysbiosis was more severe (rs = 0.31, p = 0.001) and more common (p = 0.013) in patients with esophageal dysmotility. Dysbiosis was also more pronounced in patients with abnormal plasma levels of transthyretin (p = 0.045) or micronutrient deficiency (p = 0.009). In 19 patients at risk for malnutrition according to the MUST, 18 exhibited dysbiosis. Conversely, of the 24 patients with a negative dysbiosis test, only one was at risk for malnutrition. The mean ± SEM levels of F-calprotectin were 112 ± 14 and 45 ± 8 μg/g in patients with a positive and negative dysbiosis test, respectively. Dysbiosis was more severe in patients with skin telangiectasias (p = 0.020), pitting scars (p = 0.023), pulmonary fibrosis (p = 0.009), and elevated serum markers of inflammation (p < 0.001). However, dysbiosis did not correlate with age, disease duration, disease subtype, or extent of skin fibrosis. CONCLUSIONS In this cross-sectional study, intestinal dysbiosis was common in patients with SSc and was associated with gastrointestinal dysfunction, malnutrition and with some inflammatory, fibrotic and vascular extraintestinal features of SSc. Further studies are needed to elucidate the potential causal relationship of intestinal microbe-host interaction in this autoimmune disease.
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Affiliation(s)
- Kristofer Andréasson
- Section of Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Zaid Alrawi
- Section of Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Anita Persson
- Section of Rheumatology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Göran Jönsson
- Section of Infectious Diseases, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Jan Marsal
- Department of Clinical Sciences, Lund University, Lund, Sweden
- Immunology Section, Lund University, Lund, Sweden
- Department of Gastroenterology, Skåne University Hospital, Lund, Sweden
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