[show abstract][hide abstract] ABSTRACT: Background: Anti-TNFa therapies are highly effective in the treatment of rheumatoid arthritis (RA) but a significant proportion of patients have an inadequate response. Given the important role of TNFa in regulating systemic and localized metabolism, we sought to determine if the metabolic profile of patients prior to therapy could be used to predict responses to anti-TNFa agents. Methods: Urine was collected from 16 patients with RA before and during therapy with infliximab or etanercept as part of a multicentre study. All patients were female and the mean age was 51.5. 14 patients were positive for rheumatoid factor and 14 for the anti-CCP antibody. All patients had a DAS28>4 at baseline. Urine metabolic profiles were assessed using NMR spectroscopy. The relationship between metabolic profiles and clinical outcomes was assessed (using partial least square discriminant analysis (PLSDA), Galgo and PLS-R analysis) and relevant metabolites were identified (using metabolite databases and Chenomix). Results: Baseline urine metabolic profiles were able to discriminate between RA patients who did (7 patients) or did not (9 patients) have a good response to anti-TNFa therapy according to EULAR criteria with a sensitivity of 85.9% and specificity of 85.7% with several metabolites (in particular citrate, creatinine and cresol) contributing. There was a significant correlation between baseline metabolic profiles in the urine samples and the extent of change in DAS 28 (PLS-R analysis p¼0.04). In patients with RA who responded to TNFa antagonists, a good response to therapy was associated with changes in the following urinary metabolites: erythritol, phenylacetic acid, cresol, propionic acid, methylamine, citrate, hippuric acid and creatinine. Urine samples were also available for 20 patients with psoriatic arthritis (PsA). Similar metabolites were identified in the urine samples of the patients with PsA that responded to TNFa antagonists. We were unable to study the ability of baseline urinary metabolite profiles to predict response in PsA as all but one of the PsA patients responded according to predefined criteria. Conclusions: There are clear differences in the metabolic profiles of baseline urine samples of RA patients who go on to respond well to anti-TNFa therapy. This may be relevant in the development of clinically useful predictive strategies.
Disclosure statement: C.B, B.F, I.M., P.T.: Merck provided funding for the clinical study (but not for the metabolomic analysis reported here). All other authors have declared no conflicts of interest.
[show abstract][hide abstract] ABSTRACT: OBJECTIVE: To investigate factors that influence beliefs about medicines in patients of South Asian origin with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). METHODS: Qualitative methodology was used to explore the health beliefs of South Asian patients and in particular the factors that influenced their beliefs about medicines and disease modifying anti-rheumatic drugs (DMARDs). Thirty two patients with RA and SLE took part in focus group discussions. Patients who chose to participate in focus groups conducted in English were compared with those who chose to participate groups conducted in Punjabi or Urdu. Results: Three main themes emerged to explain patients beliefs about medicines: (1) Beliefs about the necessity of DMARDs; (2) Concerns about DMARDs and other prescribed medicines including: (a) long-term side-effects; (b) the apparent lack of efficacy of some therapies; (c) concerns about changing from one drug to another and the large numbers of different medicines being taken; (3) Contextual factors which informed the patient's view on the necessity for particular medicines and concerns about them including: (a) beliefs about the causes of disease and the influence of religious beliefs on this; (b) barriers to communication with health care professionals about the medications being prescribed in clinic. In addition, our data revealed that these beliefs about DMARDs had important consequences for patient behaviour, including the use of traditional dietary and other non-pharmacological approaches. There were differences in views expressed between those who chose to speak in English and those who did not. Conclusion: This study has identified themes that explain previous findings of negative beliefs about medicines in patients of South Asian origin. Beliefs about the causes of disease had an important impact on the way some patients viewed medicines for RA and SLE. This will have implications for educational programmes designed to promote patient involvement in disease management.
[show abstract][hide abstract] ABSTRACT: Background
Low vitamin D status is associated with an increased risk of autoimmune diseases, including rheumatoid arthritis. Thus, understanding how vitamin D modifies immune reactions holds therapeutic potential. The authors have shown that 1,25(OH)2D3, acts directly upon human CD4 T cells, suppressing inflammatory cytokines (interleukin (IL)-17, IL-21, IFNγ and IL-22) while enhancing regulatory-markers (CTLA-4, CD25, FoxP3 and IL-10). However, the short half life of 1,25(OH)2D3 and its low serum level imply that local conversion of 25(OH)D3, the major circulating form of vitamin D, by 1α-hydroxylase (CYP27B1), is necessary for immune regulation in vivo. Thus, the authors have studied the effect of 25(OH)D3 upon T cell responses. In view of the critical role of CTLA-4 in immune-regulation and its strong sensitivity to 1,25(OH)2D3, the authors have also investigated CTLA-4 function in vitamin D-modified immune responses.MethodsCD4+CD25− T cells were purified from human peripheral blood (PB) and stimulated with LPS-matured allogenic dendritic cells (DCs) plus anti-CD3 or with anti-CD3/CD28 beads in the presence and absence of 25(OH)D3. FoxP3, CTLA-4 and cytokines were measured by flow cytometry and CYP27B1 by qPCR. In function assays, CTLA-4 was blocked with anti-CTLA-4 and T cell division monitored. DC expression of CD80 and CD86 was assessed by FACS. PB and synovial fluid (SF) mononuclear cells, from patients with synovitis, were stimulated with antiCD3 in the presence and absence of 1,25(OH)2D3 and cytokines examined by FACS.ResultsStimulation of T cells by DCs in the presence of 25(OH)D3 led to strong suppression of IL-17 and IFNγ but upregulation of CTLA-4 and CTLA-4+FoxP3+ frequencies. By contrast, in the absence of DCs, 25(OH)D3 caused modest CTLA-4 induction and IFNγ suppression (p
Annals of The Rheumatic Diseases - ANN RHEUM DIS. 01/2011; 70(2).
[show abstract][hide abstract] ABSTRACT: Synovial fibroblasts and osteoblasts generate active glucocorticoids by means of the 11beta-hydroxysteroid dehydrogenase type 1 (11beta-HSD1) enzyme. This activity increases in response to proinflammatory cytokines or glucocorticoids. During inflammatory arthritis synovium and bone are exposed to both these factors. This study hypothesised that glucocorticoids magnify the effects of inflammatory cytokines on local glucocorticoid production in both synovium and bone.
The effects of inflammatory cytokines (IL-1beta/tumour necrosis factor alpha; TNFalpha) and glucocorticoids, alone or combined, were assessed on the expression and activity of 11beta-HSD1 in primary synovial fibroblasts, primary human osteoblasts and MG-63 osteosarcoma cells. A range of other target genes and cell types were used to examine the specificity of effects. Functional consequences were assessed using IL-6 ELISA.
In synovial fibroblasts and osteoblasts, treatment with cytokines or glucocorticoids in isolation induced 11beta-HSD1 expression and activity. However, in combination, 11beta-HSD1 expression, activity and functional consequences were induced synergistically to a level not seen with isolated treatments. This effect was seen in normal skin fibroblasts but not foreskin fibroblasts or adipocytes and was only seen for the 11beta-HSD1 gene. Synergistic induction had functional consequences on IL-6 production.
Combined treatment with inflammatory cytokines and glucocorticoids synergistically induces 11beta-HSD1 expression and activity in synovial fibroblasts and osteoblasts, providing a mechanism by which synovium and bone can interact to enhance anti-inflammatory responses by increasing localised glucocorticoid levels. However, the synergistic induction of 11beta-HSD1 might also cause detrimental glucocorticoid accumulation in bone or surrounding tissues.
Annals of the rheumatic diseases 07/2009; 69(6):1185-90. · 8.11 Impact Factor
[show abstract][hide abstract] ABSTRACT: Lactoferrin is an iron-binding protein that is released from activated neutrophils at sites of inflammation and has anti-microbial as well as anti-inflammatory properties. This study set out to determine whether lactoferrin can delay neutrophil apoptosis and could act as a survival factor for neutrophils in SF.
Human peripheral blood and SF neutrophils were incubated with iron-free lactoferrin and apoptosis determined after 9 h. SF from patients with RA was added to isolated neutrophils, with or without immunodepletion of lactoferrin, and effects on neutrophil apoptosis determined. Levels of lactoferrin in SF were assessed and related to disease duration and markers of disease activity.
Iron-free lactoferrin significantly delayed apoptosis of peripheral blood neutrophils, in a concentration-dependent manner after 9 h in culture (P < 0.04). Lactoferrin could also delay apoptosis of neutrophils isolated from SF of patients with RA. SF from patients with established RA delayed apoptosis of peripheral blood neutrophils and this effect was significantly reduced by depletion of lactoferrin (P < 0.03). Lactoferrin levels in SF from patients with established RA did not correlate with disease severity, but did correlate with markers of inflammation (CRP) and with the presence of RF. SF from patients with arthritis of <12 weeks duration did not contain significant levels of lactoferrin.
Lactoferrin contributes to extended neutrophil survival in the rheumatoid joint in the established phase of RA but not in very early arthritis.
[show abstract][hide abstract] ABSTRACT: Effective treatment can only be given during the early stages of RA if patients are seen early. However, many patients delay for prolonged periods before seeking medical advice. This study explores factors influencing the decision to seek medical advice in RA patients.
In-depth, semi-structured interviews were carried out with 24 patients. Purposive sampling ensured a cross-section in terms of time to presentation, gender, age and ethnic background. Interview transcripts were analysed and themes identified using established methods.
Four main themes influenced the decision to seek medical advice: (i) symptom experience: the severity of symptoms and their impact on functional ability; (ii) symptom evaluation: the patient's explanation for their symptoms and recognition of their significance; (iii) knowledge of RA and available therapies; and (iv) experience of and attitudes towards health care providers. A significant and rapid impact of the disease on functional ability characterized those presenting early. Many developed an explanation for their symptoms that related to preceding activities. Recognition that this explanation was inadequate to explain symptom progression frequently prompted a consultation. Only one patient sought advice because she thought that she might have RA.
Symptom evaluation is a key factor influencing how quickly medical advice is sought in other diseases. In contrast to the situation with many cancers where there is widespread association of symptoms and signs with the eventual diagnosis, this was not the case in RA. Our findings should inform strategies to reduce delays in help-seeking in people with early RA.
[show abstract][hide abstract] ABSTRACT: To assess whether patients with RA and SLE who are of South Asian origin have different beliefs about medicines in general, and about DMARDs in particular, compared with patients of White British/Irish origin.
One hundred patients of South Asian origin (50 RA; 50 SLE) and 100 patients of White British/Irish origin (50 RA; 50 SLE) were recruited. Demographic and disease-related details and responses to the Beliefs about Medicines Questionnaire (BMQ), the SF-36 and the HAQ were collected.
Patients of South Asian origin had significantly higher General Overuse (GO), General Harm (GH) and Specific Concern (SC) scores compared with patients of White British/Irish origin. Forward stepwise multivariable regression analysis showed that ethnic origin was an independent predictor of the GO, GH and SC scores with patients of South Asian origin having higher scores in these three scales of the BMQ.
RA and SLE patients of South Asian origin have very high levels of concern about DMARDs and are generally worried about prescribed medicines. This may have an impact on adherence in this group of patients and further work is needed to understand the reasons underlying these beliefs.
[show abstract][hide abstract] ABSTRACT: Annexin-1 (Anx-A1) has been recently shown to play a key role in T-cell activation and to be highly expressed in T cells from RA patients. Here, we investigated the effects of glucocorticoids (GCs) on Anx-A1 expression in T cells in vitro and in vivo.
To evaluate the effects of dexamethasone (Dex) on Anx-A1 expression, human peripheral blood T cells were incubated with Dex and then analysed by real-time PCR and western blotting. Similar experiments were carried out in vivo by measuring Anx-A1 levels in T cells from patients with RA before and after administration of steroids.
Incubation of T cells with Dex decreased Anx-A1 levels in a time-dependent fashion and almost abolished its expression after 12 h. Stimulation of T cells pre-incubated with Dex for 12 h with anti-CD3/CD28 led to significant reduction of IL-2 production. Addition of human recombinant Anx-A1 to Dex-treated cells reversed the inhibitory effects of the steroids on anti-CD3/CD28-induced IL-2 production. Treatment of RA patients with steroid decreased Anx-A1 expression in T cells.
GCs suppress Anx-A1 expression in T cells in vitro and in vivo. These results provide evidence for a novel pathway by which steroids regulate the adaptive immune response and suggest that Anx-A1 may represent a target for the treatment of autoimmune diseases.
[show abstract][hide abstract] ABSTRACT: To study the delay from the time of symptom onset to assessment by a Rheumatologist in patients with rheumatoid arthritis (RA) and to determine the contributions of patient and physician dependent factors to this delay.
Data were collected from 169 consecutive patients with RA at the time of assessment by Rheumatologists working in hospitals serving an inner city population in Birmingham, UK. Dates were recorded for: (i) onset of inflammatory joint symptoms; (ii) initial assessment in primary care; and (iii) referral from primary to secondary care. (iv) initial assessment by a rheumatologist in secondary care.
The median delay from the onset of symptoms to a patient being assessed in secondary care was 23 weeks (IQR 12-54 weeks). The median delay before the patient was assessed in primary care was 12 weeks (IQR 4-28 weeks). For 96 patients (57%) more than half of the overall delay in assessment in secondary care was accounted for by a delay in assessment in primary care.
Patient dependent factors, leading to a delay in consulting primary care physicians, are the principal reasons for the delay in patients with RA being seen by Rheumatologists in our population. A considerable body of evidence demonstrates that the earlier that therapy is introduced the better the clinical outcome. Consequently it is important to understand why some patients with RA delay in seeking medical advice, in order to allow effective interventions to reduce this delay.
[show abstract][hide abstract] ABSTRACT: Systemic lupus erythematosus (SLE) patients suffer from excess cardiac deaths due to accelerated atherosclerosis. Endothelial dysfunction is a marker of early atherosclerosis. We tested the hypothesis that SLE patients have impaired endothelial function and assessed the relationship between endothelial function and clinical outcome over the subsequent five years. Thirty-six female SLE patients were compared with 22 healthy age and sex matched controls. Endothelial dependent vasodilatation (EDD) was assessed at the brachial artery in response to shear stress. Endothelium-independent dilatation induced by glyceryl trinitrate was also measured. Patients were followed for up to five years and the development of damage in the cardiovascular and other systems recorded. SLE patients showed significantly impaired endothelial function (median EDD 5.6%, IQR 3.1-7.2%) compared with healthy controls (median EDD 8.0%, IQR 6.3-9.3%; P = 0.001). Endothelium independent dilatation did not differ between the two groups. Endothelial function was significantly worse in postmenopausal compared with premenopausal women (median EDD 6.6%, IQR 3.9-7.8% versus 3.1%, IQR 2.6-5.1%; P = 0.016). Total cholesterol was inversely correlated with endothelial function in SLE patients (Spearman correlation r = -0.422, P = 0.025). There was no relationship between endothelial function and the development of damage in any organ system, including the cardiovascular system during patient follow-up. Patients with SLE have impaired endothelial Lupus (2007) 16, 84-88.
[show abstract][hide abstract] ABSTRACT: To assess the immediate effects of tumour necrosis factor alpha (TNFalpha) blockade on endothelial function in systemic vasculitis.
Endothelial function was assessed by laser Doppler flowmetry in patients with active vasculitis after 10 infusions of infliximab. For comparison endothelial responses were assessed after five infusions of cyclophosphamide plus methylprednisolone.
Endothelial dependent vasodilatation (EDV) improved significantly within 24 hours of infliximab infusion. The median change in red blood cell flux (interquartile range) was 5.7 (4.3-8.2) before infusion v 8.4 (7.5-10.9) at 24 hours; p=0.027. This was not maintained at day 14. No improvement was seen in EDV after cyclophosphamide plus methylprednisolone infusion.
The rapid but transient improvement in EDV after TNFalpha inhibition suggests that TNFalpha may have a direct role in the impairment of endothelial function.
Annals of the Rheumatic Diseases 08/2006; 65(7):946-8. · 9.11 Impact Factor
[show abstract][hide abstract] ABSTRACT: Background : Global profiling of the network of proteins or metabolites found in cells, tissues or fluids can increase our understanding of the multiple interacting processes involved in complex systems. One such approach is metabolomics, which we have applied here to analyse metabolite fingerprints in serum of patients with early arthritis, using high-resolution 1 H-nuclear magnetic resonance spectroscopy in conjunction with principal component analysis (PCA). Methods: Serum was collected from 101 patients with synovitis of 3 months duration whose outcome was determined at clinical follow-up. Samples were diluted 1:1 with D 2 O and one dimensional 1 H spectra acquired using a standard spin-echo pulse sequence with water suppression using excitation sculpting on a Bruker DRX 500MHz NMR spectrometer equipped with a cryoprobe. Spectra were segmented into 0.005-ppm (2.5 Hz) chemical shift 'bins' between 0.2 and 9.0 ppm, and the spectral area within each bin was integrated (1). Bins between 4.5 and 5.0 ppm containing residual water were removed. Principal Components Analysis (PCA) of the pre-processed data was conducted using PLS_Toolbox (Eigenvector Research) within MATLAB. Results: It was not possible to discriminate outcomes (RA vs. non-RA persistent arthritis vs. self-limiting arthritis) using PCA analysis of serum samples obtained at presentation. However, there was a clear relationship between each samples' score on the PCA plot and the level of CRP at the time of sampling. This form of spectroscopy gives rise to signals only from low molecular weight species and so this differentiation was not due to CRP itself, but rather small metabolites that alter as the inflammatory load changes. Conclusions: The metabolomic fingerprints assessed here reflected inflammatory disease activity in patients with synovitis. Such an analysis may be useful in monitoring the responses to treatment. In a previous study of coronary heart disease (2) conventional chemometric analysis of clinical data was unable to determine the severity of disease while analysis of NMR spectra of sera was able to do so. Thus 1 H-NMR-based metabolomics may provide a useful measure of the severity of complex diseases such as RA and may complement conventional markers.
[show abstract][hide abstract] ABSTRACT: To compare the accuracy of palpation-guided and high frequency ultrasound-guided needle placement in small joints and to develop a technique to obtain synovial fluid from these joints for diagnosis and research.
The accuracy of needle placement during palpation-guided proximal interphalangeal (PIP) or metacarpophalangeal (MCP) joint injection was assessed. This was compared with the accuracy of ultrasound-guided needle placement. A joint lavage technique was developed to obtain synovial fluid from these joints.
Needle positioning was intra-articular in 59% of palpation-guided injections (6/12 PIP and 4/5 MCP joints). No fluid could be aspirated prior to injection. With ultrasound guidance, initial needle placement was intra-articular in 96% of cases (24/26 PIP and 27/27 MCP joints). Synovial fluid cells were lavaged from 63% of joints (19/25 PIP and 14/27 MCP joints). In only one case was a large effusion seen and this was aspirated directly.
The use of high frequency ultrasound to guide needle placement within a small joint allows for significantly greater accuracy than a palpation-guided approach. When followed by lavage, synovial fluid cells and diluted synovial fluid can be obtained from the majority of small joints. This has important clinical and research implications.
[show abstract][hide abstract] ABSTRACT: Excess cardiovascular mortality complicates systemic rheumatic disease, suggesting an accelerated atheromatous process, which it has been proposed relates to the vascular inflammation common in such diseases. Impaired endothelium dependent vasodilatation is an early marker of atheromatous disease. It has previously been shown that such endothelial cell dysfunction (ECD) occurring in the brachial artery can complicate primary systemic necrotising vasculitis (SNV).
To determine if ECD occurs in a wider spectrum of primary SNV, if it is restricted to the major arteries, and whether vasculitis subgroup, ANCA status, or renal involvement influenced the endothelial responses.
Fifty four patients attending the Birmingham vasculitis clinic, including patients with a range of ANCA and non-ANCA associated primary vasculitides, and a group of age matched controls were recruited. The length of patient follow up and disease activity was variable. Disease activity, damage scores, and cardiovascular risk factors were recorded before assessment of flow mediated brachial artery vasodilatation by high resolution ultrasound. Dermal microvascular responses to acetylcholine were also measured in 32 patients and 21 controls by laser Doppler flowmetry.
ECD was demonstrated in all primary SNV subgroups of patients with ANCA associated vasculitis and in polyarteritis nodosa, compared with controls. Significant impairment occurred in both vascular beds, regardless of vessel size targeted in the inflammatory vasculitis, ANCA association and titre, or renal involvement.
Diffuse endothelial dysfunction, a predictor of atherosclerotic disease, is found extensively in primary systemic vasculitis. Involvement of different vascular beds is independent of target vessel size or ANCA association, and is unrelated to local disease expression. It is suggested that this results from a systemic response that may be a consequence of primary vasculitis, but is distinct from the local inflammatory vasculitic process.
Annals of the Rheumatic Diseases 03/2003; 62(2):162-7. · 9.11 Impact Factor
[show abstract][hide abstract] ABSTRACT: Membrane microdomains known as lipid rafts have been shown recently to be involved in Fas signalling and apoptosis in T and B cell lines. Here, we have investigated further the role of lipid rafts in Fas-induced apoptosis in non-transformed human CD4 T cells. We show that Fas-induced apoptosis in CD4 T cells was inhibited by the lipid raft disrupter methyl-beta-cyclodextrin. When lipid rafts were isolated from control and Fas ligand treated cells, we found that a small proportion of Fas was present in the raft fraction in untreated cells and that this was greatly increased upon Fas ligation. The other components of the Death Inducing Signalling Complex (DISC), FADD, and procaspase 8, were also present at higher levels in the raft fraction isolated from Fas ligand treated cells. We conclude that formation of the DISC occurs in lipid rafts and that these membrane microdomains are required for efficient Fas signalling and apoptosis.
Biochemical and Biophysical Research Communications 11/2002; 297(4):876-9. · 2.41 Impact Factor