Update on the profile of the EUSTAR cohort: an analysis of the EULAR Scleroderma Trials and Research group database.

OBJECTIVES: Systemic sclerosis (SSc) is a rare disease requiring multicentre collaboration to reveal comprehensive details of disease-related causes for morbidity and mortality. METHODS: The European League Against Rheumatism (EULAR) Scleroderma Trials and Research (EUSTAR) group initiated a database to prospectively gather key data of patients with SSc using a minimal essential dataset that was reorganised in 2008 introducing new items. Baseline visit data of patients who were registered between 2004 and 2011 were analysed using descriptive statistics. RESULTS: In June 2011, 7655 patients (2838 with diffuse cutaneous (dc) and 4481 with limited cutaneous (lc) SSc who fulfilled the American College of Rheumatology diagnostic criteria had been registered in 174 centres, mainly European. The most prominent hallmarks of disease were Raynaud's phenomenon (96.3%), antinuclear antibodies (93.4%) and a typical capillaroscopic pattern (90.9%). Scleroderma was more common on fingers and hands than on any other part of the skin. Proton pump inhibitors (65.2%), calcium channel blockers (52.7%), and corticosteroids (45.3%) were most often prescribed. Among the immunosuppressant agents, cyclophosphamide was used more often in dcSSc than in lcSSc. CONCLUSIONS: The EUSTAR database provides an abundance of information on the true clinical face of SSc that will be helpful in improving the classification of SSc and its subsets and for developing more specific therapeutic recommendations.

Antitumor necrosis factor-α antibody-coupled gold nanorods as nanoprobes for molecular optoacoustic imaging in arthritis.

Optoacoustic molecular imaging can provide spatially resolved information about the presence of molecular markers in vivo. We synthesized elongated gold nanorods having an absorption maximum in the range of 1064 nm modified with the antibodies infliximab and certolizumab for targeting TNF-α to detect inflammation in arthritic mouse knees. We showed an differential enhancement of optoacoustic signal amplitudes after the injection of infliximab-, but not certolizumab-modified and PEGylated control particles on arthritic and healthy control mice by using a fast-scanning optoacoustic imaging platform based on a pulsed Nd:YAG laser and a single focused ultrasound transducer. The excellent photoacoustic properties of the gold nanorods confirmed the overexpression of TNF-α in arthritic knees. Due to the uncomplicated coupling chemistry and the scalability of ultrasound-based imaging approaches, these results potentially allow a transfer to various preclinical and clinical applications. From the Clinical Editor: Gold nanorods were modified with TNF-α targeting antibodies and used to detect inflammation in arthritic mouse knees via optoaoustic imaging. A fast-scanning optoacoustic imaging platform based on a pulsed Nd:YAG laser and a single focused ultrasound transducer was utilized for imaging. The excellent photoacoustic properties of these gold nanorods confirmed the overexpression of TNF-α, paving the way towards further preclinical and future clinical applications.

Endogenous regeneration after collagenase-induced knee joint damage in the adult newt Notophthalmus viridescens.

OBJECTIVES: To determine whether adult newts (Notophthalmus viridescens) are able to repair experimentally-induced joint damage in order to generate a model system for the study of endogenous joint regeneration. METHODS: Joint instability and articular cartilage lesions of the knee joint of adult newts (N viridescens) were induced by intra-articular injection of collagenase. The changes over time were analysed clinically, by MRI, histologically and by reverse transcription PCR to detect selected relevant markers. RESULTS: After rapid onset of disease with joint luxation, loss of proteoglycans and cartilage volume, the signs ameliorated continuously by regeneration of the affected joint compartments. The majority of joints were morphologically intact and functionally operative after 10 weeks. Upregulation of chondrogenic key genes, homogenous expression levels of factors implicated in cartilage homeostasis and limb regeneration as well as the distribution of the blastemal marker 22/18 in both treated and untreated knees suggest that joint regeneration in adult newts only partially invokes pathways of embryological organogenesis. CONCLUSIONS: Newts are able to regenerate articular cartilage injuries and to restore tissue integrity and function after induction of damage using a procedure known to induce experimental osteoarthritis in murine models. Further analysis of the underlying molecular mechanisms may contribute to the development of novel treatment approaches in joint failure.

Animal models for arthritis.

Animal models for rheumatic diseases complement human investigations to study in detail pathogenic hypotheses and therapeutic strategies. An overview of animal studies in the last years shows examples for ideas taken from bench to bedside and from bedside to bench. Depending on the disease studied, progress includes a refinement of physiological and pathogenic thinking and a better definition of promising cellular and molecular therapeutic targets.

Expression of PSACH-associated mutant COMP in tendon fibroblasts leads to increased apoptotic cell death irrespective of the secretory characteristics of mutant COMP.

OBJECTIVE: Pseudoachondroplasia (PSACH) is a dominantly inherited chondrodysplasia associated with mutations of cartilage oligomeric matrix protein (COMP), characterized clinically by disproportionate dwarfism and laxity of joints and ligaments. Studies in chondrocytes and cartilage biopsies suggest that the cartilage disease is caused by retention of mutant COMP in the endoplasmic reticulum of chondrocytes and by disruption of the collagen network of the extracellular matrix. The pathogenesis of the tendon disease remains unclear in the absence of a cell culture model, with available tendon biopsies leading to conflicting results with respect to the intracellular retention of mutant COMP. METHODS: We established a cell culture model using adenoviral gene transfer in tendon fibroblast cultures. We compared the effect of expression of three PSACH-associated COMP mutants and the wildtype protein on COMP secretion, matrix composition and cellular viability. RESULTS: Our results show that mutants D475N and D469Delta are retained within the endoplasmic reticulum of tendon cells similar to what is known from chondrocytes, whereas mutant H587R is secreted like wildtype COMP. In spite of this difference, the collagen I matrix formed in culture appears disturbed for all three mutants. All COMP-mutants induce apoptotic cell death irrespective of their differing secretion patterns. CONCLUSION: Pathogenic pathways leading to tendon disease in humans appear to be heterogeneous between different COMP mutants.

Pseudoachondroplasia is caused through both intra- and extracellular pathogenic pathways.

Pseudoachondroplasia is a dominantly inherited chondrodysplasia associated with mutations in cartilage oligomeric matrix protein (COMP). Investigations into the pathogenesis of pseudoachondroplasia are hampered by its rarity. We developed a cell culture model by expressing mutant COMP in bovine primary chondrocytes using a gutless adenoviral vector. We show that mutant COMP exerts its deleterious effects through both intra- and extracellular pathogenic pathways. Overexpression of mutant COMP led to a dose-dependent decrease in cellular viability. The secretion of mutant COMP was markedly delayed, presumably due to a prolonged association with chaperones in the endoplasmic reticulum (ER). The ECM lacked organized collagen fibers and showed amorphous aggregates formed by mutant COMP. Thus, pseudoachondroplasia appears to be an ER storage disease, most likely caused by improper folding of mutant COMP. The growth failure of affected patients may be explained by an increased cell death of growth-plate chondrocytes. Dominant interference of the mutant protein on collagen fiber assembly could contribute to the observed failure of the ECM of cartilage and tendons.

Comparison of three dsDNA-ELISAs with regard to their efficiency in the diagnosis of systemic lupus erythematosus.

We compared the performance of three commercially available anti-double-stranded DNA antibody ELISA kits with respect to their precision, accuracy, linearity, and the detection limit. We tested six sets of patients (lupus erythematosus, scleroderma, rheumatoid arthritis, psoriatic arthritis, hepatitis C, malignancies) to assess specificity, sensitivity, and diagnostic efficiency of the three assays. The diagnostic efficiency of the Crithidia luciliae immunofluorescence test was analyzed as a reference. The sensitivity of the evaluated enzyme immunoassays ranged from 55.6 to 66.7%, the specificity from 98.4 to 100%, and the diagnostic efficiency from 90.2-92.7%. All ELISAs were superior to the immunofluorescence test, both with respect to sensitivity, specificity, and diagnostic efficiency. The commercial kits tested were comparable with respect to their performance characteristics.

Low-field magnetic resonance imaging study on carpal arthritis in systemic sclerosis--low-grade erosive arthritis of carpal bones is an unexpected and frequent disease manifestation.

INTRODUCTION: The aim of the present study was to assess the prevalence and characteristics of subclinical arthritis of carpal and metacarpophalangeal joints in patients with systemic sclerosis (SSc). METHODS: Low-field (0.2 T) magnetic resonance imaging (MRI) was performed in consecutive patients with SSc attending our center between January 2010 and March 2011. Results were assessed in a standardized manner using the Rheumatoid Arthritis Magnetic Resonance Imaging Score (RAMRIS) and standardized assessments of all hand joints. Patients with arthritis due to overlap syndromes were excluded. RESULTS: Of 38 inpatients and eight outpatients who were screened for inclusion, 30 patients participated in the study and 26 patients could be evaluated. Erosions, bone marrow edema, synovitis, and joint effusions were found in 87%, 37%, 68%, and 58%, respectively, and 24% of patients had additional tenovaginitis. Arthritis affected only a low number of joints per analyzed hand. All bones and joints could be affected, but synovitis and bone marrow edema occurred predominantly in the proximal row of carpal bones, most frequently affecting the lunate bone. The extent of inflammatory changes measured with the RAMRIS correlated significantly with the functional status assessed with the validated German functional score questionnaire Funktionsfragebogen Hannover. CONCLUSION: Low-grade arthritic changes on low-field MRI are frequent in patients with pure SSc. The features of arthritis in SSc differ from rheumatoid arthritis. The distribution, the MRI pattern and the predilection for the lunate bone raise the hypothesis that arthritis in SSc may be caused not only by immunological inflammation but also by ischemic mechanisms.

Endocardial and myocardial involvement in systemic sclerosis--is there a relevant inflammatory component?

OBJECTIVES: Myocardial manifestations of systemic sclerosis are mainly due to fibrotic remodeling. We report on two cases, where an endocardial and myocardial inflammation may be a relevant component of cardiac disease. CASE SERIES: Case 1 presented with fulminant tricuspid failure in the absence of pulmonary hypertension and with newly developing systemic sclerosis. Myocardial biopsy and MRI supported endocardial and myocardial inflammation. Treatment with cyclophosphamide resulted in stabilization of cardiac function and normalization of cardiac enzymes. The patient died due to infectious complications. Case 2, also newly developed systemic sclerosis, presented with renal crisis and pulmonary alveolitis. Elevated cardiac troponin T persisted in the presence of cyclophosphamide treatment, subsequent MRI suggested myocardial inflammation. After stepping up treatment by addition of rituximab cardiac enzymes normalized and cardiac function stabilized. CONCLUSION: We hypothesize that low-grade endocardial and myocardial inflammation may be more relevant in systemic sclerosis than appreciated previously.

Arthritis in patients with systemic sclerosis.

BACKGROUND: Systemic sclerosis (SSc) is a connective tissue diseases characterised by excessive thickening of the dermis in addition to affection of internal organs. Many patients experience musculoskeletal symptoms, but arthritis is still considered to be a rare manifestation. Therefore, we analysed a cohort of SSc patients in our department and related the findings to published data. METHODS: Clinical data on inpatients with SSc between February 2007 and February 2008 were analysed retrospectively for the presence of clinically overt and documented arthritis. In addition, X-rays of these patients were reassessed. A systematic literature search using PubMed was performed to find studies on arthritis in SSc patients; suitable studies were included in a meta-analysis based on the random-effect-model. The search terms were scleroderma, systemic sclerosis, arthritis, inflammatory joint disease, hand involvement, foot involvement and musculoskeletal findings in various combinations. Original articles not written in English and articles which were not dealing with arthritis in SSc patients were excluded from the study. We included articles in which the examined cohorts corresponds to the ACR- or LeRoy criteria for SSc and arthritis was diagnosed based on clinical and/or radiological data. All manuscripts were read and reviewed by two independent investigators. RESULTS: In our cohort of 58 patients, 31% had signs of arthritis, 19% clinically and 26% radiologically. In a meta-analysis of 7 studies, a prevalence of 26% (95% CI [16.7, 36.1]) for radiologically detectable arthritis in SSc patients was observed. For clinical arthritis, the prevalence was calculated to be 23% (95% CI [14.9, 30.9]). Of interest, no difference in the occurrence of arthritis in diffuse and limited SSc was observed radiologically (OR=1.1, 95% CI [0.47, 2.57]) or clinically (OR=1.11, 95% CI [0.6, 2.05]). CONCLUSION: Arthritis is frequent manifestation of SSc. Its role in joint dysfunction has to be established in further studies.

Expression of Brachyury in mesenchymal progenitor cells leads to cartilage-like tissue that is resistant to the destructive effect of rheumatoid arthritis synovial fibroblasts.

Our objectives were to determine the chondrogenic potential of a murine Brachyury-transformed mesenchymal progenitor cell line in the presence of rheumatoid arthritis-activated synovial fibroblasts (RASFs). Brachyury-transformed mesenchymal progenitor cells were implanted alone or combined with RASFs isolated from diseased human joints in each of six immunodeficient SCID mice. De novo tissue formation was analysed by histology and immunohistochemistry after 60 days. Spheroid nodules resembling cartilage morphologically and by the expression of proteoglycans and collagen II developed in four of six implants in the absence and in five of six implants in the presence of RASFs. No evidence for hypertrophic differentiation could be observed. Mesenchymal progenitor cells transformed with Brachyury are able to produce a cartilage like tissue in vivo over an extended period of time that is resistant to the destructive effect of RASF. This observation may provide opportunities for a cell-based reconstructive treatment in joint disease.

Synovial fibroblasts spread rheumatoid arthritis to unaffected joints.

Active rheumatoid arthritis originates from few joints but subsequently affects the majority of joints. Thus far, the pathways of the progression of the disease are largely unknown. As rheumatoid arthritis synovial fibroblasts (RASFs) which can be found in RA synovium are key players in joint destruction and are able to migrate in vitro, we evaluated the potential of RASFs to spread the disease in vivo. To simulate the primary joint of origin, we implanted healthy human cartilage together with RASFs subcutaneously into severe combined immunodeficient (SCID) mice. At the contralateral flank, we implanted healthy cartilage without cells. RASFs showed an active movement to the naive cartilage via the vasculature independent of the site of application of RASFs into the SCID mouse, leading to a marked destruction of the target cartilage. These findings support the hypothesis that the characteristic clinical phenomenon of destructive arthritis spreading between joints is mediated, at least in part, by the transmigration of activated RASFs.

Disruption of extracellular matrix structure may cause pseudoachondroplasia phenotypes in the absence of impaired cartilage oligomeric matrix protein secretion.

Pseudoachondroplasia and multiple epiphyseal dysplasia are two dominantly inherited chondrodysplasias associated with mutations in cartilage oligomeric matrix protein (COMP). The rarely available patient biopsies show lamellar inclusions in the endoplasmic reticulum. We studied the pathogenesis of these chondrodysplasias by expressing several disease-causing COMP mutations in bovine primary chondrocytes and found that COMP-associated chondrodysplasias are not exclusively storage diseases. Although COMP carrying the mutations D469Delta and D475N was retained within the endoplasmic reticulum, secretion of COMP H587R was only slightly retarded. All pseudoachondroplasia mutations impair cellular viability and cause a disruption of the extracellular matrix formed in alginate culture irrespective of the degree of cellular retention. The mutation D361Y associated with the clinically milder disease multiple epiphyseal dysplasia gave mild retention and limited matrix alterations, but the transfected cells showed normal viability. The effect of mutated COMP on matrix formation and cell-matrix interaction may be a major element in the pathogenesis of COMP-associated chondrodysplasias.

Fibroblast activation protein is expressed by rheumatoid myofibroblast-like synoviocytes.

Fibroblast activation protein (FAP), as described so far, is a type II cell surface serine protease expressed by fibroblastic cells in areas of active tissue remodelling such as tumour stroma or healing wounds. We investigated the expression of FAP by fibroblast-like synoviocytes (FLSs) and compared the synovial expression pattern in rheumatoid arthritis (RA) and osteoarthritis (OA) patients. Synovial tissue from diseased joints of 20 patients, 10 patients with refractory RA and 10 patients with end-stage OA, was collected during routine surgery. As a result, FLSs from intensively inflamed synovial tissues of refractory RA expressed FAP at high density. Moreover, FAP expression was co-localised with matrix metalloproteinases (MMP-1 and MMP-13) and CD44 splice variants v3 and v7/8 known to play a major role in the concert of extracellular matrix degradation. The pattern of signals appeared to constitute a characteristic feature of FLSs involved in rheumatoid arthritic joint-destructive processes. These FAP-expressing FLSs with a phenotype of smooth muscle actin-positive myofibroblasts were located in the lining layer of the synovium and differ distinctly from Thy-1-expressing and non-proliferating fibroblasts of the articular matrix. The intensity of FAP-specific staining in synovial tissue from patients with RA was found to be different when compared with end-stage OA. Because expression of FAP by RA FLSs has not been described before, the findings of this study highlight a novel element in cartilage and bone destruction of arthritic joints. Moreover, the specific expression pattern qualifies FAP as a therapeutic target for inhibiting the destructive potential of fibroblast-like synovial cells.

Successful treatment of disseminated aspergillosis with the combination of voriconazole, caspofungin, granulocyte transfusions, and surgery followed by allogeneic blood stem cell transplantation in a patient with primary failure of an autologous stem cell graft.

The treatment of disseminated aspergillus infections in neutropenic patients remains a major challenge in spite of several new antifungal drugs. We report the case of a patient with multiple myeloma in prolonged neutropenia after primary failure of an autologous stem cell graft who developed invasive aspergillosis despite voriconazole monotherapy. He responded to a combination of voriconazole and caspofungin, supported by granulocyte transfusions and surgery. A subsequent allogeneic peripheral blood stem cell transplantation did not lead to recurring aspergillus infection. The patient is well and free of clinical disease with respect to the fungal infection and myeloma more than 18 months after the allogeneic transplantation.