Tuberculosis and other opportunistic infections in tofacitinib-treated patients with rheumatoid arthritis.

OBJECTIVES: To evaluate the risk of opportunistic infections (OIs) in patients with rheumatoid arthritis (RA) treated with tofacitinib. METHODS: Phase II, III and long-term extension clinical trial data (April 2013 data-cut) from the tofacitinib RA programme were reviewed. OIs defined a priori included mycobacterial and fungal infections, multidermatomal herpes zoster and other viral infections associated with immunosuppression. For OIs, we calculated crude incidence rates (IRs; per 100 patient-years (95% CI)); for tuberculosis (TB) specifically, we calculated rates stratified by patient enrolment region according to background TB IR (per 100 patient-years): low (≤0.01), medium (>0.01 to ≤0.05) and high (>0.05). RESULTS: We identified 60 OIs among 5671 subjects; all occurred among tofacitinib-treated patients. TB (crude IR 0.21, 95% CI of (0.14 to 0.30)) was the most common OI (n=26); median time between drug start and diagnosis was 64 weeks (range 15-161 weeks). Twenty-one cases (81%) occurred in countries with high background TB IR, and the rate varied with regional background TB IR: low 0.02 (0.003 to 0.15), medium 0.08 (0.03 to 0.21) and high 0.75 (0.49 to 1.15). In Phase III studies, 263 patients diagnosed with latent TB infection were treated with isoniazid and tofacitinib concurrently; none developed TB. For OIs other than TB, 34 events were reported (crude IR 0.25 (95% CI 0.18 to 0.36)). CONCLUSIONS: Within the global tofacitinib RA development programme, TB was the most common OI reported but was rare in regions of low and medium TB incidence. Patients who screen positive for latent TB can be treated with isoniazid during tofacitinib therapy.

Degradation of mouse invariant chain: roles of cathepsins S and D and the influence of major histocompatibility complex polymorphism.

Antigen-presenting cells (APC) degrade endocytosed antigens into peptides that are bound and presented to T cells by major histocompatibility complex (MHC) class II molecules. Class II molecules are delivered to endocytic compartments by the class II accessory molecule invariant chain (Ii), which itself must be eliminated to allow peptide binding. The cellular location of Ii degradation, as well as the enzymology of this event, are important in determining the sets of antigenic peptides that will bind to class II molecules. Here, we show that the cysteine protease cathepsin S acts in a concerted fashion with other cysteine and noncysteine proteases to degrade mouse Ii in a stepwise fashion. Inactivation of cysteine proteases results in incomplete degradation of Ii, but the extent to which peptide loading is blocked by such treatment varies widely among MHC class II allelic products. These observations suggest that, first, class II molecules associated with larger Ii remnants can be converted efficiently to class II-peptide complexes and, second, that most class II-associated peptides can still be generated in cells treated with inhibitors of cysteine proteases. Surprisingly, maturation of MHC class II in mice deficient in cathepsin D is unaffected, showing that this major aspartyl protease is not involved in degradation of Ii or in generation of the bulk of antigenic peptides.

Interferon gamma induction of pulmonary emphysema in the adult murine lung.

Chronic inflammation containing CD8(+) lymphocytes, neutrophils, and macrophages, and pulmonary emphysema coexist in lungs from patients with chronic obstructive pulmonary disease. Although this inflammatory response is believed to cause the remodeling that is seen in these tissues, the mechanism(s) by which inflammation causes emphysema have not been defined. Here we demonstrate that interferon gamma (IFN-gamma), a prominent product of CD8(+) cells, causes emphysema with alveolar enlargement, enhanced lung volumes, enhanced pulmonary compliance, and macrophage- and neutrophil-rich inflammation when inducibly targeted, in a transgenic fashion, to the adult murine lung. Prominent protease and antiprotease alterations were also noted in these mice. They included the induction and activation of matrix metalloproteinase (MMP)-12 and cathepsins B, H, D, S, and L, the elaboration of MMP-9, and the selective inhibition of secretory leukocyte proteinase inhibitor. IFN-gamma causes emphysema and alterations in pulmonary protease/antiprotease balance when expressed in pulmonary tissues.

Role for cathepsin F in invariant chain processing and major histocompatibility complex class II peptide loading by macrophages.

The major histocompatibility complex (MHC) class II-associated invariant chain (Ii) regulates intracellular trafficking and peptide loading of MHC class II molecules. Such loading occurs after endosomal degradation of the invariant chain to a approximately 3-kD peptide termed CLIP (class II-associated invariant chain peptide). Cathepsins L and S have both been implicated in degradation of Ii to CLIP in thymus and peripheral lymphoid organs, respectively. However, macrophages from mice deficient in both cathepsins S and L can process Ii and load peptides onto MHC class II dimers normally. Both processes are blocked by a cysteine protease inhibitor, indicating the involvement of an additional Ii-processing enzyme(s). Comparison of cysteine proteases expressed by macrophages with those found in splenocytes and dendritic cells revealed two enzymes expressed exclusively in macrophages, cathepsins Z and F. Recombinant cathepsin Z did not generate CLIP from Ii-MHC class II complexes, whereas cathepsin F was as efficient as cathepsin S in CLIP generation. Inhibition of cathepsin F activity and MHC class II peptide loading by macrophages exhibited similar specificity and activity profiles. These experiments show that cathepsin F, in a subset of antigen presenting cells (APCs), can efficiently degrade Ii. Different APCs can thus use distinct proteases to mediate MHC class II maturation and peptide loading.

Effects of inhaled human insulin on airway lining fluid composition in adults with diabetes.

Inhaled human insulin (Exubera (human insulin of rDNA origin) Inhalation Powder) causes small, early and reversible changes in pulmonary function in subjects with diabetes mellitus. The present study assessed whether changes occur in cellular and soluble constituents of airway lining fluid consistent with inflammation as a possible cause for Exubera-associated lung function alterations. Two 31-week, open-label, sequential design phase 2 studies were conducted, one with 20 subjects with type 1 and one with 24 subjects with type 2 diabetes. After run-in, all subjects received subcutaneous insulin for 12 weeks, followed after 1 week by 12 weeks of Exubera. Bronchoalveolar lavage fluid cell counts and protein constituents were determined at baseline, after 12 weeks of subcutaneous insulin and after 12 weeks of Exubera. Baseline cellular and soluble constituents of lavage fluid were similar to those reported for nondiabetic adults. Exubera produced no consistent clinically or statistically significant changes in total or differential lavage fluid cell counts or protein concentrations, even though Exubera-associated changes in pulmonary function are known to be fully manifest within 12 weeks. Therefore, 12 weeks of Exubera treatment is not associated with evidence of pulmonary inflammation. The treatment effects on lung function observed in Exubera trials are not caused by lung inflammation.

Inducible targeting of IL-13 to the adult lung causes matrix metalloproteinase- and cathepsin-dependent emphysema.

Cigarette smoke exposure is the major cause of chronic obstructive pulmonary disease (COPD). However, only a minority of smokers develop significant COPD, and patients with asthma or asthma-like airway hyperresponsiveness or eosinophilia experience accelerated loss of lung function after cigarette smoke exposure. Pulmonary inflammation is a characteristic feature of lungs from patients with COPD. Surprisingly, the mediators of this inflammation and their contributions to the pathogenesis and varied natural history of COPD are not well defined. Here we show that IL-13, a critical cytokine in asthma, causes emphysema with enhanced lung volumes and compliance, mucus metaplasia, and inflammation, when inducibly overexpressed in the adult murine lung. MMP-2, -9, -12, -13, and -14 and cathepsins B, S, L, H, and K were induced by IL-13 in this setting. In addition, treatment with MMP or cysteine proteinase antagonists significantly decreased the emphysema and inflammation, but not the mucus in these animals. These studies demonstrate that IL-13 is a potent stimulator of MMP and cathepsin-based proteolytic pathways in the lung. They also demonstrate that IL-13 causes emphysema via a MMP- and cathepsin-dependent mechanism(s) and highlight common mechanisms that may underlie COPD and asthma.

Cathepsin S activity regulates antigen presentation and immunity.

MHC class II molecules display antigenic peptides on cell surfaces for recognition by CD4(+) T cells. Proteolysis is required in this process both for degradation of invariant chain (Ii) from class II-Ii complexes to allow subsequent binding of peptides, and for generation of the antigenic peptides. The cysteine endoprotease, cathepsin S, mediates Ii degradation in human and mouse antigen-presenting cells. Studies described here examine the functional significance of cathepsin S inhibition on antigen presentation and immunity. Specific inhibition of cathepsin S in A20 cells markedly impaired presentation of an ovalbumin epitope by interfering with class II-peptide binding, not by obstructing generation of the antigen. Administration of a cathepsin S inhibitor to mice in vivo selectively inhibited activity of cathepsin S in splenocytes, resulting in accumulation of a class II-associated Ii breakdown product, attenuation of class II-peptide complex formation, and inhibition of antigen presentation. Mice treated with inhibitor had an attenuated antibody response when immunized with ovalbumin but not the T cell-independent antigen TNP-Ficoll. In a mouse model of pulmonary hypersensitivity, treatment with the inhibitor also abrogated a rise in IgE titers and profoundly blocked eosinophilic infiltration in the lung. Thus, inhibition of cathepsin S in vivo alters Ii processing, antigen presentation, and immunity. These data identify selective inhibition of cysteine proteases as a potential therapeutic strategy for asthma and autoimmune disease processes.

Cathepsins and compartmentalization in antigen presentation.

Intracellular trafficking and cell surface expression of MHC class II molecules is a tightly regulated process and is to a large extent, determined by the fate of the class II chaperone, the invariant chain. Inhibition of endosomal proteases critical to invariant chain proteolysis reveals marked shunting of class II complexes to lysosomal compartments. Regulation of endosomal protease activity by expression of cystatin C directs class II cell surface expression during maturation of dendritic cells. These studies highlight the taut interactions between class-II-invariant-chain complexes and endosomal proteases during MHC class II maturation.

Multidisciplinary team functioning.

This paper advocates the need to move beyond interdisciplinary team composition as a minimum criterion for multidisciplinary functioning in child abuse treatment. Recent developments within the field reflect the practice of shared professional responsibility for detection, case management and treatment. Adherence to this particular model for intervention requires cooperative service planning and implementation as task related functions. Implicitly, this model also carries the potential to incorporate the supportive functioning essential to effective group process. However, explicit attention to the dynamics and process of small groups has been neglected in prescriptive accounts of multidisciplinary child abuse team organization. The present paper therefore focuses upon the maintenance and enhancement aspects of multidisciplinary group functioning. First, the development and philosophy of service for the Alberta Children's Hospital Child Abuse Program are reviewed. Second, composition of the team, it's mandate for service, and the population it serves are briefly described. Third, the conceptual framework within which the program functions is outlined. Strategies for effective group functioning are presented and the difficulties encountered with this model are highlighted. Finally, recommendations are offered for planning and implementing a multidisciplinary child abuse team and for maintaining its effective group functioning.

Laparoscopic artificial insemination in sheep.

The goal of any AI program is to create improved offspring, and the achievement of this objective will depend on the breeding value of the ram and ewe selected. Laparoscopic AI is being utilized in the sheep industry to extend the use of superior rams, and it offers the producer the opportunity to maximize the reproductive potential of superior sheep. Rapid genetic trait infusion of known superior stud rams into the flock is the primary economic benefit of laparoscopic AI. The success of laparoscopic AI depends on events and factors that interrelate in a complex way. Once the selection and preparation of the ewe have been accomplished, one of the more important steps in the program is the successful synchronization of the ewe to deliver the necessary ova to the site of fertilization at a specific time. One of the best methods of synchronization for laparoscopic AI is the use of a progesterone product for a controlled time period and the administration of PMSG upon its removal. Detecting the onset of estrus is critical, and the addition of sterile (e.g., vasectomized) males is helpful, even essential, to accurately determine when each ewe begins her estrus. The ram effect has been shown to stimulate ovulation and estrus. Ewes must be inseminated within a narrow window of time after the synchronization product is removed. Ewes should be inseminated in the order in which they begin to exhibit signs of behavioral estrus, but age, stage of lactation, duration of behavioral estrus, and breed must be taken into account when this order is established. Fresh-extended semen works well throughout this preferred time frame established for laparoscopic AI, but frozen semen gives best results when used near the end. Advancement in manufacturing technology today removes equipment as a variable factor. It is important, therefore, that the inseminator develop a level of expertise in laparoscopy to ensure maximum fertilization rates. If available, fresh-extended semen is preferred over frozen semen, using at least the minimal number of spermatozoa necessary for fertilization. Evaluation of the post-thaw frozen or fresh semen is necessary to determine motility, morphology, and concentration, all of which help determine the volume of the insemination dose. The minimum necessary for laparoscopic AI in fine-wooled breeds is 20 X 10(6) normal motile spermatozoa; however, the more seasonal and less fertile American sheep need approximately 40 to 50 X 10(6) normal motile sperm to achieve acceptable fertility rates.(ABSTRACT TRUNCATED AT 400 WORDS)

Crystal-cell interactions: crystal binding to rat renal papillary tip collecting duct cells in culture.

Retention of stone crystallites by urothelium is clearly one of the prime requisites for urinary stone disease. Studies in the literature as early as 1937 have highlighted that the initiation of renal calculi followed the formation of subepithelial calcified plaques in the renal pelvis. The renal papilla is one of the primary sites for crystal fixation and stone maturation. We have developed an in vitro model system for the study of kidney stone crystal retention to tubular epithelium using rat renal papillary collecting tubule (RPCT) cells in primary culture. We have qualitatively and quantitatively analyzed the binding of preformed calcium oxalate monohydrate (COM), hydroxyapatite (HA), and uric acid (UA) crystals to RPCT cells. Our goal was to determine if three common urinary stone crystals evidenced different crystal-cell binding characteristics. Also, since these crystals are frequently observed admixed in stones, we have studied the inhibitive binding characteristics of these crystals with RPCT cells. The RPCT cells in culture grow both as the typical polygonal cells in monolayer and as clumps of aggregated cells. The cells in the aggregates are viable epithelial cells that have lost their attachment to the basement membrane, resulting in the exposure of surface molecules that would not normally be present unless the cells were damaged or if there was a loss of intercellular tight junctions. COM, HA, and UA crystals all preferentially bound to the aggregated cells and all exhibited similar saturable binding patterns.(ABSTRACT TRUNCATED AT 250 WORDS)

Emerging roles for cysteine proteases in human biology.

Cysteine proteases have traditionally been viewed as lysosomal mediators of terminal protein degradation. However, recent findings refute this limited view and suggest a more expanded role for cysteine proteases in human biology. Several newly discovered members of this enzyme class are regulated proteases with limited tissue expression, which implies specific roles in cellular physiology. These roles appear to include apoptosis, MHC class II immune responses, prohormone processing, and extracellular matrix remodeling important to bone development. The ability of macrophages and other cells to mobilize elastolytic cysteine proteases to their surfaces under specialized conditions may also lead to accelerated collagen and elastin degradation at sites of inflammation in diseases such as atherosclerosis and emphysema. The development of inhibitors of specific cysteine proteases promises to provide new drugs for modifying immunity, osteoporosis, and chronic inflammation.

Specificity in calcium oxalate adherence to papillary epithelial cells in cultures.

Attachment of microcrystallites to cellular membranes may be an important component of the pathophysiology of many diseases including urolithiasis. This study attempts to characterize the interaction of calcium oxalate (CaOx) crystals and apatite (AP) crystals with renal papillary collecting tubule (RPCT) cells in primary culture. Primary cultures of RPCT cells showed the characteristic monolayer growth with sporadically interspersed clumped cells. Cultures were incubated with [14C]CaOx crystals, and the crystals that bound were quantified by microscopy and adherent radioactivity. Per unit of cross-sectional area, 32 times more CaOx crystals were bound to the clumps than to the monolayer. CaOx adherence demonstrated concentration-dependent saturation with a beta value (fraction of cell culture area binding CaOx crystals) of 0.179 and a 1/alpha ox value (maximum micrograms of crystallites adhering to 1 cm2 of binding area) of 287 micrograms/cm2. On coincubation with AP crystals, CaOx binding demonstrated concentration-dependent inhibition with a 1/alpha AP value of 93 micrograms/cm2. Microcrystallite adherence to RPCT cells demonstrates selectivity for cellular clumps, saturation, and inhibition. These features suggest specific binding.

Cell polarity and calcium oxalate crystal adherence to cultured collecting duct cells.

The relationship between cell membrane polarity and calcium oxalate (CaOx) crystal binding was studied in rat renal inner medullary collecting duct (IMCD) cells in primary culture. Cultures grew as simple monolayers (M) with interspersed cellular aggregates (A), and CaOx bound preferentially to A. An antibody that recognizes an exclusively basolateral epitope in intact IMCD binds to some of the cells in A but not to cells in M. Lysing of intercellular junctions with 3 mM EGTA (monitored by transepithelial resistance, R) resulted in basolateral antibody binding to the previously negative cells in M and a 21-fold increase in CaOx adherence to M over control (P less than 0.01). Enhanced CaOx attachment appeared to lag behind the fall in R by 5-10 min. Crystal attachment returned to control between 30 and 120 min after removal of EGTA and readdition of Ca. These data suggest that loss of epithelial membrane polarity may result in enhanced capacity to bind CaOx. Such loss of cell membrane polarity may occur in IMCD with some forms of epithelial injury and repair and may provide a site of crystal fixation to initiate nephrolithiasis.

Uric acid crystal binding to renal inner medullary collecting duct cells in primary culture.

Attachment of microcrystals to cellular membranes may be an important component in the pathophysiology of urolithiasis. This study characterizes the concentration-dependent binding of uric acid crystals to rat renal inner medullary collecting duct cells in primary culture. Collecting duct cell cultures grew as monolayers with interspersed aggregates of rounded cells. Cultures were incubated with 14C-uric acid crystals, and the crystals that bound were quantitated by adherent radioactivity. Uric acid crystal adherence demonstrated concentration dependent saturation with a 1/alpha value (maximum micrograms of crystals adhering to 1 cm2 of binding area) of 645 micrograms/cm2. The beta values (fraction of cross-sectional area which bound crystals) of uric acid (mean = 0.15) and calcium oxalate monohydrate (mean = 0.13) crystals did not differ significantly. Uric acid crystal binding was inhibited by pre-bound calcium oxalate monohydrate crystals in a concentration dependent manner. These data suggest that uric acid and calcium oxalate crystals exhibit similar binding patterns to rat renal inner medullary collecting duct cells in primary culture.

Developmental plasticity of CNS microglia.

Microglia arise from CD45(+) bone marrow precursors that colonize the fetal brain and play a key role in central nervous system inflammatory conditions. We report that parenchymal microglia are uncommitted myeloid progenitors of immature dendritic cells and macrophages by several criteria, including surface expression of "empty" class II MHC protein and their cysteine protease (cathepsin) profile. Microglia express receptors for stem cell factor and can be skewed toward more dendritic cell or macrophage-like profiles in response to the lineage growth factors granulocyte/macrophage colony-stimulating factor or macrophage colony-stimulating factor. Thus, in contrast to other organs, where terminally differentiated populations of resident dendritic cells and/or macrophages outnumber colonizing precursors, the majority of microglia within the brain remain in an undifferentiated state.

Essential role for cathepsin S in MHC class II-associated invariant chain processing and peptide loading.

Destruction of li by proteolysis is required for MHC class II molecules to bind antigenic peptides, and for transport of the resulting complexes to the cell surface. The cysteine protease cathepsin S is highly expressed in spleen, lymphocytes, monocytes, and other class II-positive cells, and is inducible with interferon-gamma. Specific inhibition of cathepsin S in B lymphoblastoid cells prevented complete proteolysis of li, resulting in accumulation of a class II-associated 13 kDa li fragment in vivo. Consequently, the formation of SDS-stable complexes was markedly reduced. Purified cathepsin S, but not cathepsin B, H, or D, specifically digested li from alpha beta li trimers, generating alpha beta-CLIP complexes capable of binding exogenously added peptide in vitro. Thus, cathepsin S is essential in B cells for effective li proteolysis necessary to render class II molecules competent for binding peptides.

Cathepsin S required for normal MHC class II peptide loading and germinal center development.

Major histocompatibility complex (MHC) class II molecules acquire antigenic peptides after degradation of the invariant chain (Ii), an MHC class II-associated protein that otherwise blocks peptide binding. Antigen-presenting cells of mice that lack the protease cathepsin S fail to process Ii beyond a 10 kDa fragment, resulting in delayed peptide loading and accumulation of cell surface MHC class II/10 kDa Ii complexes. Although cathepsin S-deficient mice have normal numbers of B and T cells and normal IgE responses, they show markedly impaired antibody class switching to IgG2a and IgG3. These results indicate cathepsin S is a major Ii-processing enzyme in splenocytes and dendritic cells. Its role in humoral immunity critically depends on how antigens access the immune system.

Regulation of CD1 function and NK1.1(+) T cell selection and maturation by cathepsin S.

NK1.1(+) T cells develop and function through interactions with cell surface CD1 complexes. In I-A(b) mice lacking the invariant chain (Ii) processing enzyme, cathepsin S, NK1.1(+) T cell selection and function are impaired. In vitro, thymic dendritic cells (DCs) from cathepsin S(-/-) mice exhibit defective presentation of the CD1-restricted antigen, alpha-galactosylceramide (alpha-GalCer). CD1 dysfunction is secondary to defective trafficking of CD1, which colocalizes with Ii fragments and accumulates within endocytic compartments of cathepsin S(-/-) DCs. I-A(k), cathepsin S(-/-) mice do not accumulate class II-associated Ii fragments and accordingly do not display CD1 abnormalities. Thus, function of CD1 is critically linked to processing of Ii, revealing MHC class II haplotype and cathepsin S activity as regulators of NK T cells.

Proteases involved in MHC class II antigen presentation.

Major histocompatibility complex class II antigen presentation requires the participation of lysosomal proteases in two convergent processes. First, the antigens endocytosed by the antigen-presenting cells must be broken down into antigenic peptides. Second, class II molecules are synthesized with their peptide-binding site blocked by invariant chain (Ii), and they acquire the capacity to bind antigens only after Ii has been degraded in the compartments where peptides reside. The study of genetically modified mice deficient in single lysosomal proteases has allowed us to determine their role in these processes. Cathepsins (Cat) B and D, previously considered major players in MHC class II antigen presentation, are dispensable for degradation of Ii and for generation of several antigenic determinants. By contrast, Cat S plays an essential role in removal of Ii in B cells and dendritic cells, whereas Cat L apparently does so in thymic epithelial cells. Accordingly, the absence of Cat S and L have major consequences for the onset of humoral immune responses and for T-cell selection, respectively. It is likely that other as yet uncharacterized lysosomal enzymes also play a role in Ii degradation and in generation of antigenic determinants. Experiments involving drugs that interfere with protein traffic suggest that more than one mechanism for Ii removal, probably involving different proteases, can co-exist in the same antigen-presenting cell. These findings may allow the development of protease inhibitors with possible therapeutic applications.