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Objective Obesity is complicated by inflammatory activation of the innate immune system. Stimulation of the calcium-sensing receptor (CaSR) by extra-cellular calcium ions ([Ca2+]ex) can trigger NLRP3 inflammasome activation and inflammation. We hypothesised, that this mechanism might contribute to the activation of adipose tissue (AT) in obesity, and investigated [Ca2+]ex-induced, CaSR mediated IL-1β release by macrophages in obesity. Methods [Ca2+]ex-induced IL-1β release was investigated in monocyte-derived macrophages (MDM) generated from peripheral blood of patients with obesity and from normal-weight controls. Visceral and subcutaneous AT biosamples were stimulated with [Ca2+]ex, and IL-1β release, as well as expression of NLRP3 inflammasome and cytokine genes, was determined. Results Both MDM and AT readily responded with concentration-dependent IL-1β release already at low, near physiological concentrations to addition of [Ca2+]ex, which was more than 80 fold higher than the LPS-induced effect. IL-1β levels induced by [Ca2+]ex were significantly higher not only in MDM from patients with obesity compared to controls, but also in visceral versus subcutaneous AT. This fat-depot difference was also reflected by mRNA expression levels of inflammasome and cytokine genes. Conclusions Obesity renders macrophages more susceptible to [Ca2+]ex-induced IL-1β release and pyroptosis. Increased susceptibility was independent of the response to LPS and circulating CRP arguing against mere pro-inflammatory pre-activation of monocytes. Instead, we propose that CaSR mediated signalling is relevant for the deleterious innate immune activation in obesity.

The Nursing and Midwifery Council’s Standards of proficiency for midwives1 states midwives need to be aware of how to administer blood safely. However, not all students are exposed to blood transfusions in the clinical area throughout their training. At Coventry University, an innovative approach to address the theory-practice gap in caring for women undergoing a blood transfusion was designed using high fidelity simulation. We developed a simulation scenario that provided this learning to students whilst also addressing some of the challenges of providing simulation education within the higher education setting.

Objectives CD4+CD8+ double-positive (DP) T cells are expanded in the peripheral blood of a subset of patients with RA. This study examines the clinical significance of DP T cells in RA. Methods In 70 RA patients, DP T cells were measured by flow cytometry. Clinical data were obtained, and hand and feet radiographs were scored according to the Sharp/van der Heijde (SvdH) method. The association between DP T cell frequency and erosive joint destruction was analysed by correlation and multiple logistic regression analysis. Results Nineteen RA patients (27.1%) displayed increased DP T cell frequencies, which correlated with age (r = 0.288, P =0.016). Expansion of DP T cells was associated with the occurrence of erosions (94,7% vs 43,1%, P Conclusion Expansion of DP T cells is associated with joint damage and frequent escalation of therapy, possibly suggesting a contribution to more severe RA.

Objectives Successful vaccination is key to overcoming the COVID-19 pandemic. Immunosuppressive medication is known to potentially compromise vaccination responses, and expansion of our knowledge on vaccination efficacy in patients with autoimmune inflammatory rheumatic diseases (AIIRD) is therefore of utmost importance. Methods We conducted a single-centre observational study and evaluated the efficacy of approved COVID-19 vaccines in 303 adult AIIRD patients. Serum levels of IgG antibodies against the S1 subunit of SARS-CoV-2 spike proteins (anti-S IgG) were measured at least two weeks after vaccination. In a subgroup of patients without humoral response, T-cell responses were determined using an interferon-γ gamma release assay. Results Overall seropositivity rate was 78.5% and was significantly lower in patients under immunosuppressive therapy (75.7 vs 93.2%, P = 0.009). No difference regarding the vaccination type was observed. Glucocorticoids, mycophenolate-mofetil, TNF inhibitors, tocilizumab, abatacept and rituximab were all associated with non-response after proper vaccination. The risk was highest under RTX therapy (OR 0.004, 95% CI 0.001, 0.023, P Conclusions COVID-19 vaccination in patients with AIIRD is effective using any approved vaccine. Humoral response might be impaired depending on the individual immunosuppressive medication. The risk of non-response is highest under rituximab therapy. Anti-S IgG antibody levels wane over time after mRNA vaccination. Importantly, 50% of humoral non-responders showed a T-cellular response, suggesting T-cell-mediated protection to a certain extent.

Systemic disease demands systemic thinkers. In this mission statement we define rheumatology, describe the role of the German Society of Rheumatology and the rheumatologist's spirit to their discipline. Rheumatologists are dedicated to improving the quality of life of their acute, chronic, and rehabilitative patients on the basis of up to date evidence and strong physician-patient relations. We think, act and interact systemically, scientifically, consistently, transparently, reliably, inclusively, innovatively and enthusiastically.Bei einer systemischen Erkrankung ist systemisches Denken erforderlich. In diesem Leitbild definieren wir Rheumatologie, beschreiben die Rolle der Deutschen Gesellschaft für Rheumatologie und umschreiben den rheumatologischen „Geist“, der uns für und in unserem Fach antreibt. Rheumatologen widmen sich der Verbesserung der Lebensqualität ihrer Patienten im akuten, chronischen und Rehabilitationsstadium auf Basis der aktuellen Datenlage und einer tragfähigen Arzt-Patienten-Beziehung. Wir denken, handeln und interagieren systemisch, wissenschaftlich, konsequent, transparent, verlässlich, integrativ, innovativ und begeistert.

Objective In autoimmune arthritis, TCR signalling is attenuated by peripheral tolerance mechanisms. We have described previously a population of inhibitory receptor LIR-1 expressing autoreactive CD8+ T cells in rheumatoid arthritis. Here, we investigated the role of CD8+ T cells in murine autoimmune arthritis by analysing their expression of the mouse orthologue of LIR-1, PIR-B. Methods Frequencies of PIR-B+CD8+ T cells were determined in the SKG arthritis model. The phenotype of those cells was determined ex vivo by FACS and functionality was investigated by means of cytokine production and cytolytic potential upon activation in vitro. Results SKG mice, under non-SPF (specific pathogen-free) conditions with clinical symptoms of arthritis, were found to harbour significantly increased frequencies of PIR-B+CD8+ T cells. Those cells showed a pro-inflammatory phenotype with preferential production of IL-17 and IFN-γ. The frequency of those cells correlated inversely with the arthritis score, indicating that they might represent autoreactive, but functionally inhibited, CD8+ T cells. Conclusion PIR-B+CD8+ T cells from SKG mice show a cytotoxic and pro-inflammatory phenotype. Inhibition of CD8+ T cell autoreactivity by PIR-B/LIR-1 receptor signalling might be a counter-regulatory mechanism to curb autoreactivity and arthritis.

(1) Background: To date, the response of patients with rheumatoid arthritis (RA) to the various biologic DMARD available cannot be predicted due to a lack of reliable biomarkers. Based on our preliminary work on tmTNF reverse signaling, we developed a whole-blood assay measuring tmTNF crosslinking-induced IL-10 production to predict the response to TNF inhibitor (TNFi) therapy. (2) Methods: This prospective study included patients with active RA. Depending on the clinical judgment of the attending rheumatologist, either therapy with a TNF or JAK inhibitor was initiated. Clinical parameters and blood samples were obtained at baseline and after 8 weeks of therapy. The blood samples were collected using a newly developed whole-blood assay based on the principle of tmTNF reverse signalling. Subsequently, IL-10 was measured via enzyme-linked immunosorbent assay (ELISA) technique. (3) Results: 63 patients with RA were enrolled. In fifteen patients, TNFi therapy was initiated, while eight patients started a JAKi treatment. The cross-sectional analysis of all patients showed a positive correlation between tmTNF crosslinking-induced IL-10 and parameters of disease activity (CRP [r = 0.4091, p = 0.0009], DAS28 [r = 0.3303, p = 0.0082]) at baseline. In the TNFi treatment study, IL-10 was found to be significantly higher in EULAR responders than in non-responders (p = 0.0033). After initiation of JAKi treatment, in contrast, IL-10 induction was not linked to response. Longitudinal analysis of the TNFi-treated patients revealed IL-10 to decrease in responders (p = 0.04), but not in non-responders after 8 weeks of therapy. Of importance, the IL-10 production at baseline correlated inversely with TNFi response determined by ΔDAS28 in patients with TNFi treatment (r = −0.5299, p = 0.0422) while no such link was observed under JAKi therapy (p = 0.22). Receiver operation characteristics (ROC) analysis demonstrated a high performance of tmTNF/crosslinking-induced IL-10 in predicting a TNFi therapy response according to the EULAR criteria (AUC = 0.9286, 95% Confidence interval 0.7825–1.000, p = 0.0055). (4) Conclusions: In this pilot investigation, we demonstrated the feasibility of a whole-blood assay measuring tmTNF-induced IL-10 to predict clinical response to TNF inhibitor treatment. This approach might support rheumatologists in their decision for an individually tailored RA therapy.

A few days after the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was declared a pandemic, the German Society for Rheumatology (DGRh) compiled the first group of recommendations for the care of patients with inflammatory rheumatic diseases in light of SARS-CoV-2/coronavirus disease 2019 (COVID-19). These first recommendations were based on an expert consensus and were largely non-evidence-based. Now that the first scientific data from registries, cross-sectional studies, case reports and case series are available, the DGRh has developed a timely update. This update is based on a literature search of publications available through 15 June 2020 and addresses preventive measures (such as hygiene measures or vaccinations) and the use of immunomodulatory/immunosuppressive drugs. Driven by the commitment to let patients benefit from these new evidence-based recommendations as quickly as possible, the DGRh published the update in German on its homepage and in the Zeitschrift für Rheumatologie immediately after completion. Here we report the key recommendations to make them available to the international community, provide the scientific methodology used to develop the recommendations, give additional thoughts and advice for the management of patients with rheumatic diseases during the COVID-19 pandemic and discuss our recommendations in the context of other international recommendations.

Die Behandlung von rheumatischen Erkrankungen mit Biologika hat die Prognose der Patienten deutlich verbessert. Heute stehen in Deutschland 13 Praparate fur die Behandlung von Patienten mit entzundlich rheumatischen Erkrankungen zur Verfugung. Diese Originalpraparate geniesen meist 15 Jahre Patentschutz, Unterschiede der einzelnen Lander ausen vor gelassen. Sobald dieser abgelaufen ist, konnen behordlich zugelassene Nachahmerprodukte, sog. Biosimilars, in den Verkehr gebracht werden. Fur die Zulassung eines Biosimilars verlangen Behorden wie die European Medical Agency oder die amerikanische Food and Drug Administration den Nachweis der grostmoglichen Vergleichbarkeit zum Original- oder Referenzprodukt hinsichtlich Wirksamkeit und Sicherheit. In der Europaischen Union, den USA, Japan und in anderen Landern wurden seit 2015 Biosimilars von Infliximab, Adalimumab, Etanercept und Rituximab zugelassen. Fur diese Referenzprodukte sind weitere Biosimilars fur die Behandlung rheumatologischer Erkrankungen in Entwicklung. Aus gesellschaftlicher und arztlicher Sicht eroffnet dies Moglichkeiten, die Verfugbarkeit biopharmazeutischer Produkte fur Patienten aufgrund niedrigerer Preise zu erhohen. In Deutschland wird diese Moglichkeit bereits genutzt: Kassenarztliche Vereinigungen haben Quoten fur Biosimilars eingefuhrt, um ihre und die Ausgaben im Gesundheitswesen zu senken. Das kann zu Preissenkungen der Originalprodukte fuhren, was in Deutschland bereits geschehen ist. Biosimilars konnen bei Neueinstellungen auf die Substanz eingesetzt werden oder als Wechsel vom Original zum Nachahmerpraparat. Beim Wechsel wird zwischen dem individuellen Wechsel („interchangeability“), der in individueller Absprache zwischen Arzt und Patient getroffen wird, und dem „nonmedical switching“ („substitution“) unterschieden. Letzteres geschieht anhand systematischer Entscheidungen auf gesellschaftlicher oder staatlicher Ebene, die im Rahmen der Kostendammung im Gesundheitswesen getroffen und dann z. B. auf Apothekerebene umgesetzt werden. Zur Substitution liegen inzwischen erste Daten aus Norwegen und Danemark auf Basis von Ergebnissen groser Studien bzw. von Registern vor, in denen systematisch gewechselt wurde. Das bisherige Fazit ist, dass sich hieraus fur die Patienten keine neuen Probleme ergeben. Die Deutsche Gesellschaft fur Rheumatologie erkennt die Vorteile der Einfuhrung von Biosimilars in Deutschland, empfiehlt deren Einsatz aber vor allem basierend auf einer gemeinsamen Entscheidung von behandelndem Arzt und Patienten.

The chronic, destructive autoimmune arthritis in SKG mice, which closely resembles human rheumatoid arthritis, is the result of self-reactive T cells escaping thymic deletion. Since the inhibitory receptor LIR-1 is up-regulated on auto-reactive T cells in human rheumatoid arthritis, the role of its murine ortholog PIR-B was investigated. Peripheral CD4+ T cells from SKG mice were found to frequently express PIR-B, and this population produces more frequently IL-17 upon in vitro stimulation compared to PIR-B- cells. A much larger fraction of PIR-B+ T cells, however, was found to secret no IL-17, but IFN-γ. With regards to the clinical course of the disease, high frequencies of PIR-B+ CD4+ T cells were found to be associated with a milder course of arthritis, suggesting that the net effect of PIR-B expression is suppression of autoreactive T cells. Our results indicate that overexpression of PIR-B on IL-17-producing SKG CD4+ T cells might represent an effective counter-regulatory mechanism against the destructive potential of those cells. More importantly, a major population of PIR-B+ T cells in SKG mice appears to play an inhibitory role by way of their IFN-γ production, since high frequencies of those cells ameliorate the disease.

Objective The evolution of the “cholinergic anti-inflammatory pathway” and the fact that the α 7 subunit of the nicotinic acetylcholine receptor (α7nAChR) is present in the spleen, joint and on the surface of lymphocytes, opened up the prospective in this study of targeting the α7nAChR by the anticholinesterase and cholinergic drug, galantamine, to control inflammation in rheumatoid arthritis (RA). Methods Twelve-adjuvant arthritic rats were exposed to the selective α7nAChR blocker methylcaconitine citrate 15 min before galantamine treatment. As control, six adjuvant arthritic rats were treated with galantamine and six others were untreated. After five days TNF-α levels were assessed in spleen and joints, while reduced glutathione was measured in blood and joint tissue. In the second part, magnetically sorted CD4 + T cells from peripheral blood mononuclear cells of RA patients and healthy donors were used to sort CD4 + CD25 – primary T cells (Tresp) and CD4 + CD25 + CD127low Tregs. The suppressive function of Tregs was investigated after incubation with galantamine using flow cytometry. Cell culture supernatants were analyzed for TNF-α and IL-10 levels after three days incubation period of Tregs with Tresp. The effect of galantamine on Tregs was then blocked by α-Bungarotoxin and the same assay has been repeated. Results & conclusion Selective α7nAChR blockade interrupted the anti-inflammatory effect of galantamine in the spleen and joints of arthritic rats. In healthy donors, galantamine could strengthen the suppressive activity of Tregs; while in RA patients it did not modulate the function of Tregs significantly. Further studies are necessary to investigate whether modulation of the cholinergic nervous system, especially α7nAChR, could have impact on the disturbed immune system in RA, which may open up a new treatment option of autoimmune diseases.

Background:CD4+/CD8+ double-positive T (dpT) cells are a set of pathologic T cells, representing about 1% of peripheral blood T cells and increasing with age in healthy individuals. Patients with rheumatoid arthritis (RA) more frequently have expanded dpT cells compared to age-matched controls, up to a frequency of 8% [1]. However, whether dpT cell expansion harbors clinical significance in RA is not known.Objectives:The goal of the study was to assess possible associations of DPT expansion with clinical features of patients with RA.Methods:In this cross-sectional study, dpT cells were measured in RA patients (n=70) via fluorescence-activated flow cytometry. Clinical data including age, sex, disease duration, treatment history, disease activity parameters, and radiographic structural damage was collected. Radiographs of hands and feet were used to determine the modified Sharp/van der Heijde (SvdH) score. Expansion of dpT cells was defined as a frequency of >2% of the total T cell pool, based on reference ranges determined in a large cohort of healthy individuals [2]. Mann-Whitney-U test was used to compare groups and X2 test was used for contingency tables. Statistical analyses were conducted using GraphPad Prism v8 (GraphPad Software, San Diego, USA).Results:DpT cells were expanded in more than a quarter of our cohort (n=19, 27.1%). Patients with expanded dpT cells more often used biologics or targeted synthetic DMARDs than patients with low dpT cells (68.4% vs. 38%, p=0.02). Radiographic damage was also significantly worse in patients with DPT expansion, as shown in their higher SvdH score (median 24.5 vs. 6, p=0.008) and its component scores for erosion (median 19 vs. 0, p=0.004) and joint space narrowing (median 8 vs. 2, p=0.017) (figure 1A). There was no difference regarding sex, age, disease duration, seropositivity and disease activity between the groups (figure 1B).Conclusion:DpT cell expansion is associated with higher scores of radiographic structural damage despite more frequent use of highly effective therapeutics. An expansion of dpT cells is not uncommon in RA, and affected patients represent a subset at high risk for a more severe disease course.References:[1]Quandt D, Rothe K, Scholz R, et al. Peripheral CD4CD8 Double Positive T Cells with a Distinct Helper Cytokine Profile Are Increased in Rheumatoid Arthritis. PLoS ONE 2014;9:e93293. doi:10.1371/journal.pone.0093293[2]Apoil PA, Puissant-Lubrano B, Congy-Jolivet N, et al. Reference values for T, B and NK human lymphocyte subpopulations in adults. Data Brief 2017;12:400–4. doi:10.1016/j.dib.2017.04.019Figure 1.DpT cell expansion is associated with radiographic progression. SvdH, modified Sharp/van der Heijde Score; DpT, CD4+/CD8+ double-positive T cells.Disclosure of Interests:None declared

Introduction To evaluate the efficacy and safety of secukinumab 150 mg, with or without a loading regimen, using a self-administered prefilled syringe in patients with ankylosing spondylitis (AS) over 104 weeks from the MEASURE 4 study. Methods Patients (N = 350) with active AS were randomized (1:1:1) to receive subcutaneous secukinumab 150 mg with loading dose (150 mg), without loading dose (150 mg no load), or placebo. All patients received secukinumab or placebo at baseline, weeks 1, 2, and 3 and every 4 weeks starting at week 4. The primary endpoint was the Assessment of SpondyloArthritis international Society criteria for 20% improvement (ASAS20) at week 16. Results A total of 96.9% of patients (339/350) completed 16 weeks and 82.6% (289/350) completed 104 weeks of treatment. The ASAS20 response rate at week 16 was 59.5% and 61.5% with 150 and 150 mg no load groups, respectively, versus placebo (47%; P = 0.057 and 0.054, respectively); the primary endpoint was not met. Increases in response rates achieved with secukinumab for ASAS20 at week 16 were sustained through week 104. The safety profile of secukinumab 150 mg, with or without a loading regimen, showed no new or unexpected safety signals. Conclusions Secukinumab 150 mg, with or without loading regimen, provided rapid and sustained decreases in the signs and symptoms of patients with AS, but the differences were not statistically significant at week 16 due to higher than expected placebo responses. The responses and safety profile were consistent with previous phase 3 studies and sustained through 2 years. Trial registration ClinicalTrials.gov identifier, NCT02159053. Funding Novartis Pharma AG, Basel, Switzerland. Electronic supplementary material The online version of this article (10.1007/s40744-018-0123-5) contains supplementary material, which is available to authorized users.

Background: In Germany, the number of clinical fellows, who decide for a scientific career in basic research, is decreasing, leading to a growing lack of junior physician scientists (PS) highly needed to advance basic research.1 Structured mentoring and funding programs as well as other incentives might be necessary to attract young physicians and support starting a scientific career in basic science. Objectives: To identify expectations, motivating factors and barriers of final year medical students interested in rheumatology, of fellows and of physicians in rheumatology to start a scientific career in basic research. Methods: An online survey was distributed by email and via facebook and twitter to members of the German Network of Young Rheumatologists (rheumadocs), medical students in their final year participating in a student program of the German Society for Rheumatology (DGRh), and by direct contact to PS. The questions focused on demographics, scientific background (including experience in basic research), expectations such as scientific self-realization, acquirement of a postdoctoral degree, enhanced career options, as well as motivating factors (e.g. “fun”, financial benefits, travel bursaries, mentoring programs and others) and barriers (e.g. positions in basic science, exemption from clinical duties, lack of experience and/or assistance in fund-raising and scientific methods) with regard to a career in basic research. Results: Of the 91 responders, 75% was aged below 35 years (11% 29 yrs) and 58% were female. 19% were currently working in basic research. 23% were students. 35% were fellows currently in the clinic. 23% were primary attendants. Basic research experience was reported by 49% of all clinicians. Only 10% indicated not to be interested in performing basic research. Among the students, 48% were currently performing a laboratory-based medical thesis. Of interest, no substantial differences in expectations or barriers were found between students, PS and clinicians. As to motivational factors, PS named time spent in research accounted for rheumatology training (74%), support by excellence programs (71%) and enhanced career options with a postdoctoral degree (65%) more often than clinicians and students (57%, 50% and 42% respectively). Other common motivational factors were “fun” (76%) and travel bursaries for international meetings (62%). Financial benefits in terms of standard or even senior physician salaries were no major motivators (41% and 24%, respectively). Regarding expectations, 71% indicated scientific self-realization, 58% named enhanced career options. 78% indicated lacking exemption from clinical duties and lack of experience in fund-raising and scientific methods (58% and 48%) as a barrier for basic research. Conclusions: This study shows a high interest among young rheumatologists and students to work in basic research, and indicates a need for programs, which facilitate the start of a career as physician scientist by providing a general framework with no drawbacks regarding rheumatology specialty training, (at least partial) exemption from clinical duties and support in development of research projects. Reference 1. Scholmerich J. Where Have All the Physician Scientists Gone. German Research2010;32(2–3). Disclosure of Interest: None declared

Objective Leukocyte immunoglobulin-like receptor 1 (LIR-1) is up-regulated by cytomegalovirus (CMV), which in turn, has been associated with premature aging and more severe joint disease in patients with rheumatoid arthritis (RA). The aim of this study was to investigate the expression and functional significance of LIR-1 in CMV-positive RA patients. Methods We determined the phenotype, cytolytic potential, CMV-specific proliferation, and HLA–G–triggered, LIR-1–mediated inhibition of interferon-γ secretion of LIR-1+ T cells in RA patients and healthy controls. Results We found increased frequencies of CD8+ T cells with CMV pp65–specific T cell receptors in CMV-positive RA patients as compared to CMV-positive healthy controls. CMV-specific CD8+ T cells in these patients were preferentially LIR-1+ and exhibited a terminally differentiated polyfunctional phenotype. The numbers of LIR-1+CD8+ T cells increased with age and disease activity, and showed high levels of reactivity to CMV antigens. Ligation of LIR-1 with soluble HLA–G molecules in vitro confirmed an inhibitory role of the molecule when expressed on CD8+ T cells in RA patients. Conclusion We propose that latent CMV infection in the context of a chronic autoimmune response induces the recently described “chronic infection phenotype” in CD8+ T cells, which retains anti-infectious effector features while exhibiting autoreactive cytolytic potential. This response is likely dampened by LIR-1 to avoid overwhelming immunopathologic changes in the setting of the autoimmune disease RA. The known deficiency of soluble HLA–G in RA and the observed association of LIR-1 expression with disease activity suggest, however, that LIR-1+ T cells are insufficiently controlled in RA and are still likely to be involved in the pathogenesis of the disease.

Objective Dysregulated apoptosis of monocytes is a pathogenic feature of rheumatoid arthritis (RA). The aim of this study was to investigate the role of TRAIL and TRAIL-induced apoptosis in patients with RA. Methods Cell surface expression and serum concentrations of TRAIL were determined in 63 patients with RA, and TRAIL-induced monocyte apoptosis was quantified. Surface expression of TRAILR-1, TRAILR-2, TRAILR-3, TRAILR-4, CXCR1, and CXCR2 was determined, and intracellular signal transduction was investigated. In 8 patients with RA, clinical and laboratory parameters of disease activity were investigated longitudinally, before and after initiation of treatment with tumor necrosis factor (TNF) inhibitors. Results Serum concentrations of both TRAIL and interleukin-8 (IL-8) were increased in patients with RA, while cell surface expression of the TRAIL receptors TRAILR-1, TRAILR-2, TRAILR-3, and TRAILR-4 was diminished. TRAIL-induced monocyte apoptosis was significantly decreased in RA due to increased TRAIL-induced IL-8 secretion by RA monocytes. The combined effect of TRAIL and IL-8 on monocytes resulted in activation of antiapoptotic pathways, including p42/44 MAPK and p38. Susceptibility to TRAIL-induced apoptosis was restored in RA monocytes after 3 months of TNF inhibition. Conclusion In RA, circulating monocytes with the potential to produce proinflammatory cytokines appear to have defects in several pathways of apoptosis induction, among which is a deficiency in TRAIL-induced apoptosis. Although this resistance to apoptosis might contribute to perpetuation of the disease, it remains to be determined whether specific induction of apoptosis could be therapeutically beneficial.

Monocytes enter sites of microbial or sterile inflammation as the first line of defense of the immune system and initiate pro-inflammatory effector mechanisms. We show that activation with bacterial lipopolysaccharide (LPS) induces them to undergo a metabolic shift toward aerobic glycolysis, similar to the Warburg effect observed in cancer cells. At sites of inflammation, however, glucose concentrations are often drastically decreased, which prompted us to study monocyte function under conditions of glucose deprivation and abrogated Warburg effect. Experiments using the Seahorse Extracellular Flux Analyzer revealed that limited glucose supply shifts monocyte metabolism toward oxidative phosphorylation, fueled largely by fatty acid oxidation at the expense of lipid droplets. While this metabolic state appears to provide sufficient energy to sustain functional properties like cytokine secretion, migration, and phagocytosis, it cannot prevent a rise in the AMP/ATP ratio and a decreased respiratory burst. The molecular trigger mediating the metabolic shift and the functional consequences is activation of AMP-activated protein kinase (AMPK). Taken together, our results indicate that monocytes are sufficiently metabolically flexible to perform pro-inflammatory functions at sites of inflammation despite glucose deprivation and inhibition of the LPS-induced Warburg effect. AMPK seems to play a pivotal role in orchestrating these processes during glucose deprivation in monocytes.

Patients who have had inadequate response to tumour necrosis factor inhibitors have fewer treatment options and are generally more treatment refractory to subsequent therapeutic interventions than previously untreated patients. We report the efficacy and safety of ixekizumab, a monoclonal antibody that selectively targets interleukin-17A, in patients with active psoriatic arthritis and previous inadequate response to tumour necrosis factor inhibitors.In this double-blind, multicentre, randomised, placebo-controlled, phase 3 study (SPIRIT-P2), patients were recruited from 109 centres across ten countries in Asia, Australia, Europe, and North America. Patients were aged 18 years or older, had a confirmed diagnosis of psoriatic arthritis for at least 6 months, and had a previous inadequate response, distinguished by being refractory to therapy or had loss of efficacy, or were intolerant to tumour necrosis factor inhibitors. Patients were randomly assigned (1:1:1) by a computer-generated random sequence to receive a subcutaneous injection of 80 mg ixekizumab every 4 weeks or every 2 weeks after a 160 mg starting dose or placebo. The primary endpoint was the proportion of patients who attained at least 20% improvement in the American College of Rheumatology response criteria (ACR-20) at week 24. This study is registered with ClinicalTrials.gov, number NCT02349295.Between March 3, 2015, to March 22, 2016, 363 patients were randomly assigned to placebo (n=118), ixekizumab every 4 weeks (n=122), or ixekizumab every 2 weeks (n=123). At week 24, a higher proportion of patients attained ACR-20 with ixekizumab every 4 weeks (65 [53%] patients; effect size vs placebo 33·8% [95% CI 22·4-45·2]; p0·0001) and ixekizumab every 2 weeks (59 [48%] patients; 28.5% [17·1-39.8]; p0·0001) than did patients with placebo (23 [20%] patients). Up to week 24, serious adverse events were reported in three (3%) patients with ixekizumab every 4 weeks, eight (7%) with ixekizumab every 2 weeks, and four (3%) with placebo; no deaths were reported. Infections were reported in 47 (39%) patients with ixekizumab every 4 weeks, 47 (38%) with ixekizumab every 2 weeks, and 35 (30%) with placebo. Three (2%) serious infections, all in patients in the ixekizumab every 2 weeks group, were reported.Both the 2-week and 4-week ixekizumab dosing regimens improved the signs and symptoms of patients with active psoriatic arthritis and who had previously inadequate response to tumour necrosis factor inhibitors, with a safety profile consistent with previous studies investigating ixekizumab.Eli Lilly and Company.

The pathophysiology of numerous human disorders, such as atherosclerosis, diabetes, obesity and Alzheimer's disease, is accompanied by increased production of reactive oxygen species (ROS). ROS can oxidatively damage nearly all biomolecules, including lipids, proteins and nucleic acids. In particular, (poly)unsaturated fatty acids within the phospholipid (PL) structure are easily oxidized by ROS to lipid peroxidation products (LPP) carrying reactive carbonyl groups. Carbonylated LPP are characterized by high in vivo toxicity due to their reactivity with nucleophilic substrates (Lys-, Cys-and His-residues in proteins or amino groups of phosphatidylethanolamines [PE]). Adducts of unsaturated LPP with PE amino groups have been reported before, whereas less is known about the reactivity of saturated alkanals – which are significantly increased in vivo under oxidative stress conditions – towards nucleophilic groups of PLs. Here, we present a study of new alkanal-dipalmitoyl-phosphatidylethanolamine (DPPE) adducts by MS-based approaches, using consecutive fragmentation (MSn) and multiple reaction monitoring techniques. At least eight different DPPE–hexanal adducts were identified, including Schiff base and amide adducts, six of which have not been reported before. The structures of these new compounds were determined by their fragmentation patterns using MSn experiments. The new PE-hexanal adducts contained dimeric and trimeric hexanal conjugates, including cyclic adducts. A new pyridine ring containing adduct of DPPE and hexanal was purified by HPLC, and its biological effects were investigated. Incubation of peripheral blood mononuclear cells and monocytes with modified DPPE did not result in increased production of TNF-α as one selected inflammation marker. However, incorporation of modified DPPE into 1,2-dipalmitoleoyl-sn-phosphatidylethanolamine multilamellar vesicles resulted in a negative shift of the transition temperature, indicating a possible role of alkanal-derived modifications in changes of membrane structure. © 2014 The Authors. Journal of Mass Spectrometry published by John Wiley & Sons, Ltd.

Inhibition of return (IOR) is an important psychological construct describing inhibited responses to previously attended locations. In humans, it is investigated using Posner’s cueing paradigm. This paradigm requires central visual fixation and detection of cued stimuli to the left or right of the fixation point. Stimuli can be validly or invalidly cued, appearing in the same or opposite location to the cue. Although a rat version of the spatial cueing paradigm (the covert orienting of attention task) does exist, IOR has so far not been demonstrated. We therefore investigated whether IOR could be robustly demonstrated in adult male rats using the covert orienting of attention task. This task is conducted in holed wall operant chambers with the central three holes mimicking the set-up for Posner cueing. Across four samples of rats (overall n = 84), we manipulated the following task parameters: stimulus onset asynchronies (Experiments 1–3), cue brightness (Experiment 1b) and the presence of a central reorienting event (Experiment 4). In Experiment 1, we also investigated strain differences by comparing Lister Hooded rats to Sprague–Dawley rats. Although Lister Hooded rats briefly showed evidence of IOR (Experiment 1a, and see Online Resource 1 data), we were unable to replicate this finding in our other experiments using different samples of this strain. Taken together, our findings suggest that IOR cannot be robustly demonstrated in the rat using the covert orienting of attention task conducted in holed wall operant chambers.

Background Monocytes can be divided in classical monocytes (CM), intermediate monocytes (IM) and non-classical monocytes (NCM). CD56+ monocytes are part of the classical monocytes. Aim of the study was to assess the occurrence of the different monocyte subpopulations in human obesity. Methods 110 age-matched subjects were included in the study and classified according to the definition of the World Health Organization into lean (n=27), overweight (n=23) and obese (n=60). Monocyte subpopulations were analyzed by flow cytometry (antibody staining of CD14, CD16, CD56). Results Obese subject showed a higher BMI, fat mass, and waist circumference, deterioration of metabolic parameters, and the absolute amount of leukocytes and monocytes were increased. The calculated absolute numbers of CM, IM and CD56+ monocytes were significantly increased in obese subjects compared to lean and overweight. In contrast, the absolute numbers of NCM were equal between lean, overweight and obese subjects. Strong associations between the absolute numbers of CM, IM and CD56+ monocytes with the BMI, fat mass, and waist circumference were detectable in the whole cohort. Triglyceride, HDL-c values and HbA1c were also strongly correlated with numbers of CM, IM and CD56+ monocytes. Obese subjects with impaired glucose tolerance had increased numbers of CD56+ monocytes in comparison to obese subsects with normal glucose tolerance. Stratification of obese subjects in subjects with and without type 2 diabetes mellitus showed no difference in absolute numbers of CM but significant increased numbers of IM and NCM. Conclusion The amount of CM, IM and CD56+ monocytes are expanded in the blood of obesity subjects and contribute to monocytosis in obesity.

Calcium and phosphate are well known as the main minerals in bone ossification. But they also have an immunomodulatory potential as components of calciprotein particles. Such particles precipitate spontaneously in body fluids if the calcium and phosphate homeostasis is disturbed. An abnormally increased mineral load could lead to soft tissue calcification. In our study we investigated the cellular response of freshly isolated peripheral blood monocytes in serum-containing medium under precipitating (high calcium and high phosphate content) conditions. Using dynamic mass redistribution analyses with the EPIC® system and IL-1β measurements as readout, we identified phosphate as a necessary co-modulator of calcium-triggered overall cellular responses and NLRP3 inflammasome activation. Moreover, flow cytometry and ImageStream® analyses revealed the uptake of spontaneously formed nanoparticles under stimulating conditions, which depends on the activation of the G protein-coupled receptor Calcium-sensing receptor (CaSR). Our study unraveled a GPCR-mediated mechanism by which monocytes detect imbalances in calcium phosphate homeostasis in the extracellular space resulting in an enormous pro-inflammatory cellular response.

The generation of T cell receptor excision circle (TREC)–positive recent thymic emigrants (RTEs) in humans declines progressively with increasing age. Homeostatic proliferation is possibly an extrathymic mechanism for the generation of new T cells, and lymphopenia and common γ-chain cytokines appear to be the main driving force (1). However, thymic generation of TREC-positive RTEs can be restimulated throughout adult life if an increased supply of T cells is required under conditions of lymphopenia. Rheumatoid arthritis (RA) is associated with phenotypic alterations of T helper lymphocytes reminiscent of premature immunosenescence (2). In addition, RA is characterized by an age-inappropriate decrease in the number of CD4+ naive T cells and TREC-positive T cells (3), indicating decreased thymic output, diluting effects due to increased homeostatic maintenance proliferation, or both. Accelerated homeostatic proliferation of CD4+ T cells has also been observed in individuals who were thymectomized in early childhood, resulting in premature aging of T cells (4). In theory, thymic output in RA could be insufficient due to a shortage of thymus-seeding precursor cells. In the human system, those precursors were initially characterized in bone marrow as lineage-negative (Lin−) CD34+CD10+ common lymphoid progenitors (CLPs) (5), and their phenotype was subsequently refined to Lin−CD34highCD45RA+CD10+ (6). Six et al showed that CD34+CD10+CD24− progenitor cells are capable of migrating from the bone marrow and seeding the thymus (7). CLPs have recently been shown to have robust T cell potential regardless of CD7 expression, which appears to be a less important marker (8). Therefore, we decided to use CD10 expression as a marker defining the lymphoid commitment of human cells, in order to analyze the frequency of the best-characterized lymphoid-restricted progeny of hematopoietic stem cells (HSCs) (i.e., Lin−CD34+CD10+ CD24− CLPs) in the peripheral blood of patients with RA and healthy control subjects. In order to simultaneously determine thymic output, we measured the frequency of CD4+CD31+CD45RA+ T cells, which represents a well-established surrogate marker for TREC-positive RTEs (9). The results of the current study show a strong correlation between the frequencies of CLPs and RTEs in healthy control subjects. Compared with control subjects, patients with RA had a deficiency of RTEs despite a significantly increased number of thymic progenitors. Therapy with the tumor necrosis factor (TNF) inhibitor etanercept increased the frequency of thymic progenitors even further and almost normalized the deficient thymic output.

Objective The cytokine tumor necrosis factor (TNF) plays a central role in the pathogenesis of rheumatoid arthritis (RA), but its disease-specific effector mechanisms have not been fully elucidated. This study was undertaken to investigate the role of TNF in T cell accumulation and migration in the synovitic joints of RA patients. Methods Vital tissue sections from rheumatoid synovium were generated using a horizontally oscillating microtome and were coincubated with fluorescence-labeled CD4+ T cells. Migration was detected by fluorescence and confocal microscopy. Migrating T cells were recovered from the tissue and analyzed for phenotype. Chemotaxis of CD4+ T cells from RA patients in response to increasing concentrations of TNF was analyzed in Transwell experiments. Results CD4+ T cells from RA patients migrated into the tissue sections in significantly higher numbers than T cells from healthy controls. Migrating CD4+ T cells differed from nonmigrating ones in their increased expression of TNF receptor type I (TNFRI), which was expressed on a fraction of circulating CD4+ T cells from RA patients, but not from controls. CD4+ T cells from the peripheral blood of RA patients were also found to migrate along TNF concentration gradients ex vivo. Accordingly, blockade of either TNF or TNFRI nearly abrogated in vitro T cell migration in synovial tissue. Conclusion Our findings indicate that the interaction of TNF with TNFRI is pivotal for T cell migration in synovial tissue in vitro, and thereby suggest a relevant role of the cytokine for in vivo T cell trafficking to synovitic joints.

The chronic, destructive autoimmune arthritis in SKG mice, which closely resembles human rheumatoid arthritis, is the result of self-reactive T cells escaping thymic deletion. Since the inhibitory receptor LIR-1 is up-regulated on auto-reactive T cells in human rheumatoid arthritis, the role of its murine ortholog PIR-B was investigated. Peripheral CD4

"Pain and fatigue in adult patients with rheumatoid arthritis : association with demographic factors, disease related factors, body awareness, emotional and psychosocial factors"

Activated CD4+ T-cells are found in joints of patients with rheumatoid arthritis and are involved in the joint destroying autoimmune response. Besides proinflammatory cytokine production T-cells are indispensable for the activation of B-cells, the so-called T-cell help for B-cells. However, the recognition of autoantigens by T-cells seems of utmost importance for the pathogenesis of rheumatoid arthritis. Selective inhibition of this process is therefore one of the most interesting therapeutic targets for the future.

Rheumatoid arthritis (RA) is a chronic rheumatic disease of unknown aetiology and variable severity. It is now well known that several risk factors are involved in its pathogenesis, including genetic factors and sex hormones as well as environmental factors, i.e. infections and stress. In particular stress is now recognised as an important risk factor for the onset and even more for the modulation of disease activity in RA. Many studies have clearly shown that chronic mild stress (family or professional stress) may lead to proinflammatory effects, increasing disease activity. Furthermore, a positive correlation between the stress level at the onset of RA and radiological progression could be demonstrated. The onset of RA was associated with moderate stress at work, underlining the possible interactions between the various stress systems and the immune system. In this respect it could be demonstrated that coping strategies reduce stress episodes and change stress management with a positive impact on disease activity in RA. However, more studies are warranted to further explore the pathophysiological implications of stress on onset and activity of chronic autoimmune diseases.

Interleukin-21 (IL-21) is an important promoter for differentiation of human B cells into immunoglobulin (Ig)–secreting cells. The objective of this study was to evaluate an IL-21–based approach to induce immunoglobulin production in B cells from patients with common variable immunodeficiency (CVID) or selective IgA deficiency (IgAD). We show that a combination of IL-21, IL-4, and anti-CD40 stimulation induces class-switch recombination to IgG and IgA and differentiation of Ig-secreting cells, consisting of both surface IgG+ (sIgG+) and sIgA+ B cells and CD138+ plasma cells, in patients with CVID or IgAD. Stimulation with IL-21 was far more effective than stimulation with IL-4 or IL-10. Moreover, spontaneous apoptosis of CD19+ B cells from patients with CVID or IgAD was prevented by a combination of IL-21, IL-4, and anti-CD40 stimulation. Analysis of IL-21 and IL-21 receptor (IL-21R) mRNA expression upon anti-CD3 stimulation of T cells, however, showed no evidence for defective IL-21 expression in CVID patients and sequencing of the coding regions of the IL21 gene did not reveal any mutations, suggesting a regulatory defect. Thus, our work provides an initial basis for a potential therapeutic role of IL-21 to reconstitute immunoglobulin production in CVID and IgAD.

Genome-wide association studies have dramatically increased our knowledge about the genetic contribution to autoimmune diseases. The identified genes are indicators for signal transduction pathways involved in disease pathogenesis and could contribute to potential new therapeutic approaches.

T-helper (Th) cells activated by cytokines in the absence of T-cell receptor ligation are suspected to participate in inflammatory processes by production of interferon-gamma (IFN-gamma). Still, the relevance of such a mechanism has not been addressed in humans. Here we demonstrate that a subset of human effector-memory Th cells expressing functional interleukin-12R (IL-12R), IL-18Ralpha, and CCR5 ex vivo can be induced to secrete IFN-gamma by cytokines signaling via the IL-2R common gamma-chain in combination with IL-12 and IL-18. Cytokine-driven IFN-gamma production depends on JAK3- and p38 mitogen-activated kinase signals and is sensitive to suppression by CD25(++) regulatory T cells. Contrary to IFN-gamma(+) Th cells induced upon antigen-specific stimulation, their cytokine-activated counterparts characteristically lack expression of costimulator 4-1BB (CD137). Strikingly, the majority of Th cells infiltrating inflamed joints of rheumatoid arthritis patients is equipped with receptors prerequisite for cytokine-induced IFN-gamma secretion. Among these cells, we detected a substantial fraction that secretes IFN-gamma directly ex vivo but lacks 4-1BB expression, indicating that cytokine-induced IFN-gamma(+) Th cells operate in autoimmune inflammation. Our data provide a rationale for how human effector-memory Thcells can participate in perpetuating inflammatory processes in autoimmunity even in the absence of T-cell receptor ligation.

Die rheumatoide Arthritis (RA) ist mit einer gesteigerten kardiovaskularen Morbiditat und Mortalitat verbunden. Erhohte Konzentrationen von Akute-Phase-Proteinen und Zytokinen sowie die endotheliale Dysfunktion, welche auch bei Fehlen der traditionellen Risikofaktoren nachweisbar ist, werden hierfur verantwortlich gemacht. Modifiziert wird das Auftreten von kardiovaskularen Ereignissen durch die antirheumatische Therapie.

Objective To evaluate antibodies against cyclic citrullinated peptide (anti-CCP antibodies) for their predictive value for severe joint destruction in rheumatoid arthritis (RA) and to examine their relationship to shared epitope (SE)-positive DRB1 alleles. Methods Concentrations of anti-CCP antibodies were determined in sera from 126 patients with recent onset RA who had been followed prospectively for 6 yr. Progression of joint destruction was evaluated according to Larsen by scoring radiographs from the hand and feet taken at baseline and after 1, 2, 4 and 6 yr of observation. In addition to clinical parameters, the presence of SE-positive DRB1 alleles and of rheumatoid factor IgM and IgA was determined. Results Anti-CCP antibodies were found more frequently and in higher concentrations in both DRB1*01-positive and in DRB1*04-positive SE-positive patients compared with SE-negative patients. Severe joint destruction as defined by a Larsen score in the upper third of the study population was predicted by positivity for anti-CCP antibodies, by the presence of SE-positive DRB1*04 alleles and by the presence of erosive disease at initial presentation. Multiple logistic regression analysis revealed that SE-positive DRB1*04 alleles and anti-CCP antibodies exerted a significant influence on the progression of joint destruction. Conclusion The association of anti-CCP antibodies with DRB1*01 and with SE-positive DRB1*04 alleles implies a functional role for the SE sequence motif. The determination of SE-positive DRB1*04 alleles and of anti-CCP antibody positivity facilitates the prediction of disease course and prognosis at the time of initial presentation.

Objectives: Lipid second messengers, e.g. lysophosphatidylcholines (LPC) are involved in the pathogenesis of inflammatory diseases, for instance, rheumatoid arthritis (RA). Unfortunately, the analysis of LPC in complex mixtures as present in body fluids is still challenging. Design and methods: Matrix-assisted laser desorption and ionization time-of-flight mass spectrometry (MALDI-TOF MS) was applied for phospholipid (PL) analysis of organic extracts of synovial fluids from patients with RA as well as the corresponding plasma. These data were compared with results obtained by high resolution 31 P NMR spectroscopy. Results: Synovial fluids may be replaced by plasma since the analysis of both body fluids gives very similar results. Patients undergoing treatment with TNF-α inhibitors (ADALIMUMAB (HUMIRA®)) were examined in order to investigate whether the clinically-significant attenuation of disease activity is accompanied by changes of the PL composition of plasma. It will be shown that especially the PC/LPC ratios of plasma represent a reliable measure of inflammation and increase upon therapy. Conclusions: Since plasma samples are readily available, our approach might be useful to draw conclusions before puncture of the affected joints is necessary and the PC/LPC ratio detected in plasma may serve as an indicator of RA in early stages.