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1.
Eur J Immunol ; : e2350685, 2024 Jun 18.
Artículo en Inglés | MEDLINE | ID: mdl-38890809

RESUMEN

Unsaturated fatty acids (UFA) are crucial for T-cell effector functions, as they can affect the growth, differentiation, survival, and function of T cells. Nonetheless, the mechanisms by which UFA affects T-cell behavior are ill-defined. Therefore, we analyzed the processing of oleic acid, a prominent UFA abundantly present in blood, adipocytes, and the fat pads surrounding lymph nodes, in CD4+ T cells. We found that exogenous oleic acid increases proliferation and enhances the calcium flux response upon CD3/CD28 activation. By using a variety of techniques, we found that the incorporation of oleic acid into membrane lipids, rather than regulation of cellular metabolism or TCR expression, is essential for its effects on CD4+ T cells. These results provide novel insights into the mechanism through which exogenous oleic acid enhances CD4+ T-cell function.

2.
iScience ; 27(4): 109496, 2024 Apr 19.
Artículo en Inglés | MEDLINE | ID: mdl-38558932

RESUMEN

T cells are the most common immune cells in atherosclerotic plaques, and the function of T cells can be altered by fatty acids. Here, we show that pre-exposure of CD4+ T cells to oleic acid, an abundant fatty acid linked to cardiovascular events, upregulates core metabolic pathways and promotes differentiation into interleukin-9 (IL-9)-producing cells upon activation. RNA sequencing of non-activated T cells reveals that oleic acid upregulates genes encoding key enzymes responsible for cholesterol and fatty acid biosynthesis. Transcription footprint analysis links these expression changes to the differentiation toward TH9 cells, a pro-atherogenic subset. Spectral flow cytometry shows that pre-exposure to oleic acid results in a skew toward IL-9+-producing T cells upon activation. Importantly, pharmacological inhibition of either cholesterol or fatty acid biosynthesis abolishes this effect, suggesting a beneficial role for statins beyond cholesterol lowering. Taken together, oleic acid may affect inflammatory diseases like atherosclerosis by rewiring T cell metabolism.

3.
JCI Insight ; 8(20)2023 Oct 23.
Artículo en Inglés | MEDLINE | ID: mdl-37725442

RESUMEN

Many autoimmune diseases (AIDs) are characterized by the persistence of autoreactive B cell responses, which have been directly implicated in disease pathogenesis. How and why these cells are generated or how they are maintained for years is largely unknown. Rheumatoid arthritis (RA) is among the most common AIDs and is characterized by autoantibodies recognizing proteins with posttranslational modifications (PTMs). This PTM-directed autoreactive B cell compartment is ill defined. Here, we visualized the B cell response against the three main types of PTM antigens implicated in RA by spectral flow cytometry. Our results showed extensive cross-reactivity of PTM-directed B cells against all three PTM antigens (citrulline, homocitrulline, and acetyllysine). Unsupervised clustering revealed several distinct memory B cell (mBC) populations. PTM-directed cells clustered with the most recently activated class-switched mBC phenotype, with high CD80, low CD24, and low CD21 expression. Notably, patients also harbored large fractions of PTM-directed plasmablasts (PBs). Both PTM-directed mBCs and PBs showed high expression of CXCR3, a receptor for chemokines present in abundance in arthritic joints. Together, our data provide detailed insight into the biology of B cell autoreactivity and its remarkable, seemingly exhaustless persistence in a prominent human AID.


Asunto(s)
Artritis Reumatoide , Células B de Memoria , Humanos , Linfocitos B , Células Plasmáticas , Autoanticuerpos , Antígenos , Receptores CXCR3
4.
J Am Chem Soc ; 144(41): 18938-18947, 2022 10 19.
Artículo en Inglés | MEDLINE | ID: mdl-36197299

RESUMEN

The fish oil constituent docosahexaenoic acid (DHA, 22:6 n-3) is a signaling lipid with anti-inflammatory properties. The molecular mechanisms underlying the biological effect of DHA are poorly understood. Here, we report the design, synthesis, and application of a complementary pair of bio-orthogonal, photoreactive probes based on the polyunsaturated scaffold DHA and its oxidative metabolite 17-hydroxydocosahexaenoic acid (17-HDHA). In these probes, an alkyne serves as a handle to introduce a fluorescent reporter group or a biotin-affinity tag via copper(I)-catalyzed azide-alkyne cycloaddition. This pair of chemical probes was used to map specific targets of the omega-3 signaling lipids in primary human macrophages. Prostaglandin reductase 1 (PTGR1) was identified as an interaction partner that metabolizes 17-oxo-DHA, an oxidative metabolite of 17-HDHA. 17-oxo-DHA reduced the formation of pro-inflammatory lipids 5-HETE and LTB4 in human macrophages and neutrophils. Our results demonstrate the potential of comparative photoaffinity protein profiling for the discovery of metabolic enzymes of bioactive lipids and highlight the power of chemical proteomics to uncover new biological insights.


Asunto(s)
Ácidos Docosahexaenoicos , Ácidos Grasos Omega-3 , Humanos , Ácidos Docosahexaenoicos/metabolismo , Ácidos Docosahexaenoicos/farmacología , Azidas , Cobre/farmacología , Biotina/farmacología , Leucotrieno B4/farmacología , Ácidos Grasos Omega-3/farmacología , Macrófagos , Aceites de Pescado/farmacología , Antiinflamatorios/farmacología , Alquinos/farmacología , Prostaglandinas , Oxidorreductasas
5.
Sci Adv ; 8(6): eabm1759, 2022 Feb 11.
Artículo en Inglés | MEDLINE | ID: mdl-35138894

RESUMEN

The hallmark autoantibodies in rheumatoid arthritis are characterized by variable domain glycans (VDGs). Their abundant occurrence results from the selective introduction of N-linked glycosylation sites during somatic hypermutation, and their presence is predictive for disease development. However, the functional consequences of VDGs on autoreactive B cells remain elusive. Combining crystallography, glycobiology, and functional B cell assays allowed us to dissect key characteristics of VDGs on human B cell biology. Crystal structures showed that VDGs are positioned in the vicinity of the antigen-binding pocket, and dynamic modeling combined with binding assays elucidated their impact on binding. We found that VDG-expressing B cell receptors stay longer on the B cell surface and that VDGs enhance B cell activation. These results provide a rationale on how the acquisition of VDGs might contribute to the breach of tolerance of autoreactive B cells in a major human autoimmune disease.

6.
Clin Exp Rheumatol ; 39(3): 570-577, 2021.
Artículo en Inglés | MEDLINE | ID: mdl-32896247

RESUMEN

OBJECTIVES: Antibodies targeting post-translationally modified proteins, such as anti-carbamylated protein antibodies (anti-CarP antibodies) are present in the sera of rheumatoid arthritis (RA) patients. These autoantibodies associate with increased risk of RA development and with severity of joint destruction. It is not known which proteins in the RA joint are recognised by anti-CarP antibodies. Therefore, we investigated the presence and identity of carbamylated proteins in the human (inflamed) joint. METHODS: We obtained synovium, cartilage and synovial fluid from RA joints. Cartilage and synovium were obtained from controls. Samples were processed and used for immunohistochemistry or mass-spectrometric analysis to investigate the presence of carbamylated proteins. Anti-CarP antibody reactivity towards identified carbamylated proteins was tested by ELISA. RESULTS: Immunohistochemistry showed extensive staining of RA and control synovial tissue. Whole proteome analyses of the joint tissues revealed a large number of carbamylated peptidyllysine residues. We identified many carbamylated proteins in cartilage and were also able to detect carbamylation in synovial tissue and synovial fluid. Carbamylation was not exclusive to the RA joint and was also present in the joints of controls. Anti-CarP antibodies in the sera of RA patients were able to recognise the identified carbamylated proteins. CONCLUSIONS: We conclude that numerous carbamylated proteins are present in the RA joint. These carbamylated proteins can be recognised by anti-CarP antibodies, substantiating the notion that anti-CarP antibodies may play a role in the pathogenesis of RA.


Asunto(s)
Artritis Reumatoide , Autoanticuerpos , Ensayo de Inmunoadsorción Enzimática , Humanos , Espectrometría de Masas , Membrana Sinovial
7.
J Immunol ; 205(10): 2840-2849, 2020 11 15.
Artículo en Inglés | MEDLINE | ID: mdl-33008950

RESUMEN

Polyunsaturated fatty acids (PUFAs) and their metabolites are potent regulators of inflammation. Generally, omega (n)-3 PUFAs are considered proresolving whereas n-6 PUFAs are classified as proinflammatory. In this study, we characterized the inflammatory response in murine peritonitis and unexpectedly found the accumulation of adrenic acid (AdA), a poorly studied n-6 PUFA. Functional studies revealed that AdA potently inhibited the formation of the chemoattractant leukotriene B4 (LTB4), specifically in human neutrophils, and this correlated with a reduction of its precursor arachidonic acid (AA) in free form. AdA exposure in human monocyte-derived macrophages enhanced efferocytosis of apoptotic human neutrophils. In vivo, AdA treatment significantly alleviated arthritis in an LTB4-dependent murine arthritis model. Our findings are, to our knowledge, the first to indicate that the n-6 fatty acid AdA effectively blocks production of LTB4 by neutrophils and could play a role in resolution of inflammation in vivo.


Asunto(s)
Antiinflamatorios/metabolismo , Artritis Experimental/inmunología , Ácidos Grasos Omega-6/metabolismo , Ácidos Grasos Insaturados/metabolismo , Peritonitis/inmunología , Animales , Antiinflamatorios/análisis , Ácido Araquidónico/metabolismo , Artritis Experimental/patología , Células Cultivadas , Ácidos Grasos Omega-6/análisis , Ácidos Grasos Insaturados/análisis , Humanos , Leucotrieno B4/metabolismo , Lipidómica , Macrófagos/inmunología , Macrófagos/metabolismo , Masculino , Ratones , Ratones Transgénicos , Neutrófilos/inmunología , Neutrófilos/metabolismo , Lavado Peritoneal , Peritonitis/patología , Cultivo Primario de Células , Células THP-1 , Zimosan/administración & dosificación , Zimosan/inmunología
9.
Eur J Immunol ; 48(3): 471-481, 2018 03.
Artículo en Inglés | MEDLINE | ID: mdl-29283192

RESUMEN

Emerging evidence indicates that a dynamic interplay between the immune system and adipocytes contributes to the disturbed homeostasis in adipose tissue of obese subjects. Recently, we observed IL-6-secretion by CD4+ T cells from the stromal vascular fraction (SVF) of the infrapatellar fat pad (IFP) of knee osteoarthritis patients directly ex vivo. Here we show that human IL-6+ CD4+ T cells from SVF display a more activated phenotype than the IL-6- T cells, as evidenced by the expression of the activation marker CD69. Analysis of cytokines secretion, as well as expression of chemokine receptors and transcription factors associated with different Th subsets (Treg, Th1, Th2, Th17 and Tfh) revealed that IL-6-secreting CD4+ T cells cannot be assigned to a conventional Th subset. TCRß gene analysis revealed that IL-6+ and IL-6- CD4+ T cells appear clonally unrelated to each other, suggesting a different specificity of these cells. In line with these observations, adipocytes are capable of enhancing IL-6 production by CD4+ T cells. Thus, IL-6+ CD4+ T cells are TCRαß T cells expressing an activated phenotype potentially resulting from an interplay with adipocytes that could be involved in the inflammatory processes in the OA joint.


Asunto(s)
Tejido Adiposo/citología , Tejido Adiposo/inmunología , Linfocitos T CD4-Positivos/inmunología , Interleucina-6/metabolismo , Anciano , Linfocitos T CD4-Positivos/clasificación , Femenino , Humanos , Inmunofenotipificación , Técnicas In Vitro , Masculino , Persona de Mediana Edad , Osteoartritis de la Rodilla/inmunología , Osteoartritis de la Rodilla/patología , Fenotipo , Receptores de Antígenos de Linfocitos T alfa-beta/metabolismo , Subgrupos de Linfocitos T/inmunología
10.
Arthritis Res Ther ; 19(1): 186, 2017 08 11.
Artículo en Inglés | MEDLINE | ID: mdl-28800775

RESUMEN

BACKGROUND: Obesity is associated with the development and progression of osteoarthritis (OA). Although the infrapatellar fat pad (IFP) could be involved in this association, due to its intracapsular localization in the knee joint, there is currently little known about the effect of obesity on the IFP. Therefore, we investigated cellular and molecular body mass index (BMI)-related features in the IFP of OA patients. METHODS: Patients with knee OA (N = 155, 68% women, mean age 65 years, mean (SD) BMI 29.9 kg/m2 (5.7)) were recruited: IFP volume was determined by magnetic resonance imaging in 79 patients with knee OA, while IFPs and subcutaneous adipose tissue (SCAT) were obtained from 106 patients undergoing arthroplasty. Crown-like structures (CLS) were determined using immunohistochemical analysis. Adipocyte size was determined by light microscopy and histological analysis. Stromal vascular fraction (SVF) cells were characterized by flow cytometry. RESULTS: IFP volume (mean (SD) 23.6 (5.4) mm3) was associated with height, but not with BMI or other obesity-related features. Likewise, volume and size of IFP adipocytes (mean 271 pl, mean 1933 µm) was not correlated with BMI. Few CLS were observed in the IFP, with no differences between overweight/obese and lean individuals. Moreover, high BMI was not associated with higher SVF immune cell numbers in the IFP, nor with changes in their phenotype. No BMI-associated molecular differences were observed, besides an increase in TNFα expression with high BMI. Macrophages in the IFP were mostly pro-inflammatory, producing IL-6 and TNFα, but little IL-10. Interestingly, however, CD206 and CD163 were associated with an anti-inflammatory phenotype, were the most abundantly expressed surface markers on macrophages (81% and 41%, respectively) and CD163+ macrophages had a more activated and pro-inflammatory phenotype than their CD163- counterparts. CONCLUSIONS: BMI-related features usually observed in SCAT and visceral adipose tissue could not be detected in the IFP of OA patients, a fat depot implicated in OA pathogenesis.


Asunto(s)
Adipocitos/metabolismo , Tejido Adiposo/metabolismo , Índice de Masa Corporal , Macrófagos/metabolismo , Osteoartritis de la Rodilla/metabolismo , Rótula/metabolismo , Tejido Adiposo/diagnóstico por imagen , Anciano , Antígenos CD/metabolismo , Antígenos de Diferenciación Mielomonocítica/metabolismo , Citocinas/metabolismo , Femenino , Humanos , Mediadores de Inflamación/metabolismo , Lectinas Tipo C/metabolismo , Imagen por Resonancia Magnética , Masculino , Receptor de Manosa , Lectinas de Unión a Manosa/metabolismo , Persona de Mediana Edad , Obesidad/complicaciones , Obesidad/diagnóstico por imagen , Obesidad/metabolismo , Osteoartritis de la Rodilla/complicaciones , Osteoartritis de la Rodilla/diagnóstico por imagen , Rótula/diagnóstico por imagen , Receptores de Superficie Celular/metabolismo
11.
J Rheumatol ; 43(4): 771-8, 2016 Apr.
Artículo en Inglés | MEDLINE | ID: mdl-26980579

RESUMEN

OBJECTIVE: To get a better understanding of inflammatory pathways active in the osteoarthritic (OA) joint, we characterized and compared inflammatory cells in the synovium and the infrapatellar fat pad (IFP) of patients with knee OA. METHODS: Infiltrating immune cells were characterized by flow cytometry in 76 patients with knee OA (mean age 63.3, 52% women, median body mass index 28.9) from whom synovial tissue (n = 40) and IFP (n = 68) samples were obtained. Pain was assessed by the visual analog scale (VAS; 0-100 mm). Spearman rank correlations and linear regression analyses adjusted for sex and age were performed. RESULTS: Macrophages and T cells, followed by mast cells, were the most predominant immune cells in the synovium and IFP, and were equally abundant in these tissues. Macrophages and T cells secreted mostly proinflammatory cytokines even without additional stimulation, indicating their activated state. Accordingly, most CD4+ T cells had a memory phenotype and contained a significant population of cells expressing activation markers (CD25+, CD69+). Interestingly, the percent of CD69+ T cells was higher in synovial than IFP CD4+ T cells. Preliminary analyses indicated that the number of synovial CD4+ T cells were associated with VAS pain (ß 0.51, 95% CI 0.09-1.02, p = 0.02). CONCLUSION: Our data suggest that the immune cell composition of the synovium and the IFP is similar, and includes activated cells that could contribute to inflammation through secretion of proinflammatory cytokines. Moreover, preliminary analyses indicate that synovial CD4+ T cells might associate with pain in patients with endstage OA of the knee.


Asunto(s)
Tejido Adiposo/patología , Articulación de la Rodilla/patología , Macrófagos/patología , Osteoartritis de la Rodilla/patología , Membrana Sinovial/patología , Linfocitos T/patología , Tejido Adiposo/metabolismo , Anciano , Antígenos CD/metabolismo , Antígenos de Diferenciación de Linfocitos T/metabolismo , Citocinas/metabolismo , Femenino , Humanos , Inflamación/metabolismo , Inflamación/patología , Subunidad alfa del Receptor de Interleucina-2/metabolismo , Articulación de la Rodilla/metabolismo , Lectinas Tipo C/metabolismo , Macrófagos/metabolismo , Masculino , Persona de Mediana Edad , Osteoartritis de la Rodilla/metabolismo , Membrana Sinovial/metabolismo , Linfocitos T/metabolismo
12.
J Rheumatol ; 41(5): 853-7, 2014 May.
Artículo en Inglés | MEDLINE | ID: mdl-24692529

RESUMEN

OBJECTIVE: To investigate whether high molecular weight adiponectin (hmwAPN) mediates the associations of total adiponectin (totAPN) with radiographic progression in rheumatoid arthritis (RA) and hand osteoarthritis (HOA). METHODS: Associations between baseline hmwAPN or totAPN levels with radiographic progression were determined using multivariate linear regression or generalized estimated equations. RESULTS: In patients with RA, totAPN associated positively, whereas in patients with HOA it associated negatively with radiographic progression. In contrast, hmwAPN did not associate significantly with radiographic progression in either cohort. CONCLUSION: Our data indicate that the differential effects associated between totAPN and radiographic progression in either RA or HOA are not mediated by hmwAPN.


Asunto(s)
Adiponectina/sangre , Artritis Reumatoide/sangre , Artritis Reumatoide/diagnóstico por imagen , Osteoartritis/sangre , Osteoartritis/diagnóstico por imagen , Adiponectina/química , Adulto , Anciano , Anciano de 80 o más Años , Biomarcadores/sangre , Progresión de la Enfermedad , Femenino , Mano/diagnóstico por imagen , Humanos , Modelos Lineales , Masculino , Persona de Mediana Edad , Peso Molecular , Análisis Multivariante , Radiografía
13.
J Immunol ; 191(3): 1356-63, 2013 Aug 01.
Artículo en Inglés | MEDLINE | ID: mdl-23817431

RESUMEN

Previous studies have shown accumulation and an enhanced proinflammatory profile of macrophages in adipose tissue of obese mice, indicating the presence of an interaction between adipocytes and macrophages in this tissue. However, the consequences of this interaction in humans are yet incompletely understood. In this study, we explored the modulating effects of adipocytes on the phenotype of macrophages in humans and studied the possible molecular pathways involved. Adipocyte-conditioned media (ACM) treatment of macrophages for 48 h strongly reduced the LPS-induced IL-12p40 secretion by macrophages, whereas the production of TNF-α and other cytokines remained largely unaffected. This effect was independent of the source of adipocytes. Interestingly, the level of inhibition correlated directly with body mass index (BMI) of the adipocyte donor. Because adipocytes release many different cytokines, adipokines, and lipids, we have separated the protein and lipid fractions of ACM, to obtain insight into the molecular nature of the soluble mediators underlying the observed effect. These experiments revealed that the inhibitory effect resided predominantly in the lipid fraction. Further studies revealed that PGE2 and linoleic and oleic acid were potent inhibitors of IL-12p40 secretion. Interestingly, concentrations of these ACM-derived lipids increased with increase in BMI of the adipocyte donor, suggesting that they could mediate the BMI-dependent effects of ACM. To our knowledge, these results provide first evidence that obesity-related changes in adipose tissue macrophage phenotype could be mediated by adipocyte-derived lipids in humans. Intriguingly, these changes appear to be different from those in murine obesity.


Asunto(s)
Adipocitos/metabolismo , Subunidad p40 de la Interleucina-12/metabolismo , Macrófagos/metabolismo , Tejido Adiposo/citología , Tejido Adiposo/metabolismo , Índice de Masa Corporal , Comunicación Celular/inmunología , Medios de Cultivo Condicionados , Dinoprostona/metabolismo , Humanos , Ácido Linoleico/metabolismo , Lípidos , Lipopolisacáridos , Macrófagos/inmunología , Obesidad/metabolismo , Ácido Oléico/metabolismo , Fenotipo , Factor de Necrosis Tumoral alfa/biosíntesis
14.
Eur J Immunol ; 43(6): 1578-87, 2013 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-23504601

RESUMEN

Adipose tissue contains several immune cells whose number and phenotype vary depending on the adiposity. In the present study, we show that IFN-γ(+) CD4(+) T cells are enriched in human adipose tissue compared with in blood. To gain insight into the underlying mechanisms, we investigated the possibility that human adipocytes modulate CD4(+) T-cell cytokine production and proliferation and show that CD4(+) T cells produced increased levels of IFN-γ when activated in the presence of adipocytes. This effect was mediated by soluble mediators, as shown in transwell and adipocyte-conditioned medium (ACM) transfer experiments. Additionally, ACM induced increased proliferation of CD4(+) T cells upon activation. Intriguingly, the proliferation-enhancing effect resided mainly in the lipid fraction of ACM, as shown upon separation of the protein and lipid fraction. Further separation of these lipids based on polarity revealed that the modulatory effect is confined to fractions containing free fatty acids. All identified fatty acids were able to individually enhance T-cell proliferation. These data indicate that adipocytes can modulate CD4(+) T-cell function through the release of lipids. Remarkably, free fatty acids were the most prominent modulators of T-cell proliferation, possibly leading to an accumulation of these cells in adipose tissue.


Asunto(s)
Adipocitos/inmunología , Linfocitos T CD4-Positivos/inmunología , Ácidos Grasos no Esterificados/inmunología , Obesidad/inmunología , Adipocitos/patología , Tejido Adiposo/patología , Comunicación Celular , Proliferación Celular , Células Cultivadas , Técnicas de Cocultivo , Medios de Cultivo Condicionados/química , Ácidos Grasos no Esterificados/aislamiento & purificación , Humanos , Inmunomodulación , Interferón gamma/inmunología
15.
Arthritis Rheum ; 63(9): 2567-74, 2011 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-21567382

RESUMEN

OBJECTIVE: Adipose tissue can secrete soluble mediators (adipokines) with potent immune regulatory functions. Some adipokines have been previously associated with radiographic damage in patients with rheumatoid arthritis (RA). In the present study, we investigated the capacity of baseline adipokine levels to predict radiographic progression over a period of 4 years and studied their contribution relative to that of other known risk factors, such as anti-cyclic citrullinated peptide (anti-CCP) antibodies. METHODS: Serum concentrations of leptin, visfatin, resistin, adiponectin, adipsin, tumor necrosis factor α (TNFα), and interleukin-6 (IL-6) were determined in serum samples obtained at baseline from 253 patients with RA from the Early Arthritis Cohort. The association between levels of these adipokines and radiographic progression was determined using a multivariate normal regression model correcting for age, sex, treatment strategy, body mass index (BMI), and the presence of anti-CCP antibodies. RESULTS: Levels of IL-6, TNFα, visfatin, and adiponectin were positively associated with radiographic progression over 4 years. This association was independent of BMI. However, only adiponectin levels remained significantly associated with radiographic progression when the model was corrected for the presence of anti-CCP antibodies, whereas a trend was observed for IL-6. The association of both TNFα and visfatin with radiographic damage disappeared after correction for the presence of anti-CCP antibodies, which is consistent with the fact that the levels of both cytokines correlated significantly with anti-CCP antibody levels in these patients. CONCLUSION: Our results indicate that adipokines are predictors of radiographic progression in RA, possibly through distinct underlying biologic mechanisms.


Asunto(s)
Adipoquinas/sangre , Artritis Reumatoide/sangre , Artritis Reumatoide/diagnóstico por imagen , Progresión de la Enfermedad , Adulto , Anciano , Autoanticuerpos/sangre , Biomarcadores/sangre , Femenino , Pie/diagnóstico por imagen , Mano/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Péptidos Cíclicos/sangre , Péptidos Cíclicos/inmunología , Valor Predictivo de las Pruebas , Radiografía
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