The use of anti-TNF therapy for ankylosing spondylitis in everyday rheumatology practice and the relationship to disease activity, work disability and diagnostic delay.

BACKGROUND: Ankylosing spondylitis (AS) is characterised by insidious onset lower back pain. Poor symptom recognition results in delays in diagnosis of up to 11 years. Despite the widespread use of anti-tumour necrosis factor alpha (anti-TNFα) therapy, work disability remains a challenging problem in AS. METHODS: A retrospective review of AS patients attending our physiotherapy service was carried out. Data regarding patient demographics, delay in diagnosis, treatment and disease activity were recorded. RESULTS: Ninety-two patients were identified of which 80 % were male. Just over 60 % of patients were on treatment with a TNF inhibitor and the average delay in diagnosis was 6 years. Clinically relevant changes in disease activity after 3 months of anti-TNFα therapy were demonstrated with a reduction in Bath AS Metrology Index, Bath AS Functional Index and Bath AS Disease Activity Index of 1, 1.99 and 2.39, respectively. In patients under the age of 65 years only 55.4 % of patients were employed. There was no relationship identified between diagnostic delay, employment status and treatment with an anti-TNF agent. CONCLUSIONS: Delays in diagnosis of AS remain unacceptably high; however, delays of 6 years compare favourably to reported data. Despite this and the appropriate use of anti-TNFα agents, we continue to see high rates of unemployment in this patient group which can impact both on the person and society and bears further consideration.

An unusual presentation of Fournier's gangrene.

INTRODUCTION: Fournier's gangrene is a rare severe necrotising fasciitis of the genitalia. CASE: A case of Fournier's gangrene caused by perforated sigmoid diverticulitis in a patient with systemic lupus erythematosus is presented along with a review of the relevant literature.

The use of abatacept in debilitating cavitating lung disease associated with rheumatoid arthritis, bronchocentric granulomatosis and aspergillosis.

A case of debilitating cavitating lung disease associated with rheumatoid arthritis and bronchocentric granulomatosis, which failed to respond to conventional medical or surgical treatment, is described. The patient was treated over 10 years with steroids, antimicrobial agents, disease-modifying antirheumatoid drugs and surgery. Lung function continued to decline and the patient presented for admission with recurrent pneumonia. Abatacept was initiated to modify the underlying immunopathology. Following 12 months of treatment with abatacept the patient has demonstrable improvement in lung function and lung anatomy, and has not presented to hospital with pneumonia. She has tolerated the treatment without complication. The use of abatacept has stabilised the lung disease in this case in the medium term and prevented readmission to hospital. These results suggest a larger role for abatacept in those with such disease in the future and may warrant further investigation.

Fine mapping of the MHC Class III region demonstrates association of AIF1 and rheumatoid arthritis.

OBJECTIVES: The heritability of RA has been estimated to be approximately 55%, of which the MHC contributes about one-third. HLA-DRB1 alleles are strongly associated with RA, but it is likely that significant non-DRB1 MHC genetic susceptibility factors are involved. Previously, we identified two three-marker haplotypes in a 106-kb region in the MHC class III region immediately centromeric to TNF, which are strongly associated with RA on HLA-DRB1*0404 haplotypes. In the present study, we aimed to refine these associations further using a combination of genotyping and gene expression studies. METHODS: Thirty-nine nucleotide polymorphisms (SNPs) were genotyped in 95 DRB1*0404 carrying unrelated RA cases, 125 DRB1*0404-carrying healthy controls and 87 parent-case trio RA families in which the affected child carried HLA-DRB1*04. Quantitative RT-PCR was used to assess the expression of the positional candidate MHC class III genes APOM, BAT2, BAT3, BAT4, BAT5, AIF1, C6orf47, CSNK2beta and LY6G5C, and the housekeeper genes, hypoxanthine-guanine phosphoribosyltransferase (HPRT) and beta(2)-microglobulin (B2M) in 31 RA cases and 21 ethnically, age- and sex-matched healthy controls. Synovial membrane specimens from RA, PsA and OA cases were stained by an indirect immunoperoxidase technique using a mouse-anti-human AIF1 monoclonal antibody. RESULTS: Association was observed between RA and single markers or two marker haplotypes involving AIF1, BAT3 and CSNK. AIF1 was also significantly overexpressed in RA mononuclear cells (1.5- to 1.9-fold difference, P = 0.02 vs HPRT, P = 0.002 vs B2M). AIF1 protein was clearly expressed by synovial macrophages in all the inflammatory synovial samples in contrast to the non-inflammatory OA samples. CONCLUSIONS: The results of the genotyping and expression studies presented here suggest a role for AIF1 in both the aetiology and pathogenesis of RA.

PDCD1: a tissue-specific susceptibility locus for inherited inflammatory disorders.

Variation in genes encoding costimulatory molecules expressed on lymphocytes has been expected to contribute to the genetic component of inflammatory disease, but only the gene encoding the inhibitory protein, CTLA-4, seems consistently to confer disease susceptibility. Studies in murine models implicate the inhibitory product of the pd1 gene, programmed death-1, in the maintenance of peripheral tolerance to self-antigens. We identify 22 single-nucleotide polymorphisms (SNPs) in the equivalent human gene, PDCD1, a number of which show significant associations with the specific immunoglobulin E response to grass allergens in atopic individuals. Stepwise analyses indicate that four of the disease-associated SNPs have independent effects. The two most common haplotypes show positive and negative associations but rarer haplotypes are also likely to be of influence. In a case-control study, multiple regression analysis of genotypic data implies that PDCD1 also confers susceptibility to rheumatoid arthritis. Along with work linking PDCD1 with susceptibility to another autoimmune condition, systemic lupus erythematosus, our data identify PDCD1 as a second immunomodulatory gene with pleiotropic effects in human disease. Genes encoding negative regulators may generally confer a significant fraction of the genetic risk associated with inherited inflammatory disorders.

Genetic and genomic studies of PADI4 in rheumatoid arthritis.

OBJECTIVES: Strong genetic association of rheumatoid arthritis (RA) with PADI4 (peptidyl arginine deiminase) has previously been described in Japanese, although this was not confirmed in a subsequent study in the UK. We therefore undertook a further study of genetic association between PADI4 and RA in UK Caucasians and also studied expression of PADI4 in the peripheral blood of patients with RA. METHODS: Seven single-nucleotide polymorphisms (SNP) were genotyped using polymerase chain reaction (PCR)-restriction fragment length polymorphism in 111 RA cases and controls. A marker significantly associated with RA (PADI4_100, rs#2240339) in this first data set (P = 0.03) was then tested for association in a larger group of 439 RA patients and 428 controls. PADI4 transcription was also assessed by real-time quantitative PCR using RNA extracted from peripheral blood mononuclear cells from 13 RA patients and 11 healthy controls. RESULTS: A single SNP was weakly associated with RA (P = 0.03) in the initial case-control study, a single SNP (PADI4_100) and a two marker haplotype of that SNP and the neighbouring SNP (PADI4_104) were significantly associated with RA (P = 0.02 and P = 0.03 respectively). PADI4_100 was not associated with RA in a second sample set. PADI4 expression was four times greater in cases than controls (P = 0.004), but expression levels did not correlate with the levels of markers of inflammation. CONCLUSION: PADI4 is significantly overexpressed in the blood of RA patients but genetic variation within PADI4 is not a major risk factor for RA in Caucasians.

A review of the MHC genetics of rheumatoid arthritis.

Rheumatoid arthritis is a common complex genetic disease, and, despite a significant genetic element, no gene other than HLA-DRB1 has been clearly demonstrated to be involved in the disease. However, this association accounts for less than half the overall genetic susceptibility. Investigation of other candidate genes, in particular those that reside within the major histocompatibility complex, are hampered by the presence of strong linkage disequilibrium and problems with study design.

Non-inherited maternal HLA alleles are associated with rheumatoid arthritis.

BACKGROUND: Rheumatoid arthritis (RA) is strongly associated with a series of HLA-DRB1 alleles that encode a conserved sequence of amino acids ((70)Q/R K/R R A A(74)) in the DRbeta1 chain, known as the shared epitope (SE). However 30% of patients are negative for DRB1*04 and 15% are SE-negative. Exposure to these alleles as non-inherited maternal antigens (NIMA) might explain this discrepancy. We undertook a family study to investigate the role of NIMA in RA. METHODS: One hundred families, including the RA proband and both parents, were recruited. HLA-DRB1 genotyping was performed using an allele-specific polymerase chain reaction by standard methods. The frequencies of NIMA and non-inherited paternal antigens (NIPA) were compared using contingency tables and a two-tailed P test. We then reviewed four previously published studies of NIMA in RA and conducted an analysis of the combined data RESULTS: We identified 36 families in which the proband was DRB1*04-negative and 13 in which the proband lacked the SE. There was an excess of DRB1*04 and SE NIMA (P=0.05) compared with NIPA. Combined analysis with previous studies showed that 53/231 mothers (23%) versus 25/205 fathers (12%) had a non-inherited DRB1*04 (P=0.003) and 30/99 mothers versus 18/101 fathers had a non-inherited SE allele (P=0.03). CONCLUSION: A role for HLA NIMA in RA is suggested by these results.

Genetic epidemiology of rheumatoid arthritis.

Building on the spectacular success of molecular genetics in defining the biological basis of many rare single gene disorders over the past decade, epidemiologists have turned their attention to unravelling the complex genetic mysteries of common disorders, such as rheumatoid arthritis (RA). As a prelude to any such endeavour it is obviously important to establish that there is a significant genetic component to the disease. The classical approaches of twin and other family recurrence risk studies, coupled with prevalence studies in different ethnic and migrant populations, have been used to estimate the environmental and genetic contributions to RA. However, developing a consensus on these estimates has proved difficult, thereby providing an early warning to the unwary investigator that the road to gene discovery in RA is likely to be a rough ride.

Modulation of native and recombinant GABA(A) receptors by endogenous and synthetic neuroactive steroids.

Upon administration, certain pregnane steroids produce clear behavioural effects including, anxiolysis, sedation, analgesia, anaesthesia and are anti-convulsant. This behavioural profile is characteristic of compounds that act to enhance the actions of GABA acting at the GABA(A) receptor. In agreement, numerous studies have now demonstrated these steroids to be potent, positive allosteric modulators of the GABA(A) receptor. The pregnane steroids are synthesized in the periphery by endocrine glands such as the adrenals and the ovaries, but are also made by neurons and glial cells in the central nervous system itself. Hence, these compounds could play both an endocrine and a paracrine role to influence neuronal excitability by promoting inhibition. Here we review evidence that the pregnane steroids are highly selective and extremely potent GABA(A) receptor modulators and that their effects at 'physiological' concentrations (low nanomolar) may be influenced by the subunit composition of the GABA(A) receptor. This feature may underlie recent findings demonstrating the effects of the neurosteroids on inhibitory synaptic transmission to be brain region dependent, although recent reports suggest that phosphorylation mechanisms may additionally influence neurosteroid sensitivity of the GABA(A) receptor. Numerous synthetic steroids have been synthesized in an attempt to therapeutically exploit the behavioural effects of the pregnane steroids and progress with this approach will be discussed. However, the demonstration that the steroids may be made within the central nervous system offers the alternative strategy of targeting the enzymes that synthesize/metabolise the neurosteroids to exploit this novel endocrine/paracrine interaction.

Neurosteroid modulation of recombinant and synaptic GABAA receptors.

Certain pregnane steroids are now established as potent, positive allosteric modulators of the gamma-aminobutyric acid type A (GABAA) receptor. These compounds are known to be synthesized in the periphery by endocrine glands, such as the ovaries and the adrenal glands, and can rapidly cross the blood-brain barrier. Therefore, such steroids could act as endogeneous modulators of the major inhibitory receptor in the mammalian central nervous system. However, the demonstration that certain neurons and glia can synthesize the pregnane steroids (i.e., neurosteroids) additionally suggests that they may serve a paracrine role by influencing GABAA-receptor function through their local release in the brain itself. Here, we demonstrate that these neurosteroids are highly selective and extremely potent modulators of the GABAA receptor. The subunit composition of the GABAA receptor may influence the actions of the neurosteroids, particularly when considering concentrations of these agents thought to occur physiologically, which may underlie their reported differential effects at certain inhibitory synapses. However, recent work suggests that the phosphorylation status of either the synaptic GABAA receptor or its associated proteins may also influence neurosteroid sensitivity; these findings are discussed. Upon administration, the neurosteroids exhibit clear behavioral effects, including sedation, anticonvulsant actions, and behaviors predictive of anxiolysis; when given at high doses, they induce general anesthesia. Numerous synthetic steroids have been synthesized in an attempt to therapeutically exploit these properties, and these data are reviewed in this chapter. However, targeting the brain enzymes that synthesize and metabolize the neurosteroids may offer a new approach to exploit this novel endocrine-paracrine neurotransmitter interaction.

Development of electrical rhythmicity in the murine gastrointestinal tract is specifically encoded in the tunica muscularis.

1. Interstitial cells of Cajal (ICCs) have been identified as pacemaker cells in the gastrointestinal (GI) tracts of vertebrates. We have studied the development of ICCs in pacemaker regions and the onset of electrical rhythmicity in the gastric antrum, small bowel and proximal colon of the mouse. 2. ICCs, as detected by c-Kit immunofluorescence, were found during embryogenesis in regions of the GI tract that eventually become pacemaker areas. Prior to birth, these cells were organized into well-structured networks, and by the end of the embryonic period the morphology of ICC networks in pacemaker regions appeared very similar to that observed in adult animals. 3. Electrical rhythmicity was recorded prior to birth (by E18) in the proximal GI tract (stomach and jejunum), and this activity developed to adult-like behaviour within a week after birth. In the ileum and proximal colon rhythmicity developed after birth, and adult-like characteristics were apparent within the first week. 4. Post-junctional responses of smooth muscles to neural inputs could be recorded at birth, and stimulation of intrinsic nerves often led to oscillatory activity resembling slow waves for up to several minutes following brief stimuli. Nerve stimulation augmented spontaneous activity in the proximal portions of the GI tract and elicited rhythmic activity temporarily in quiescent tissues of the distal GI tract. 5. ICCs and rhythmicity developed in an apparently normal manner in tissues isolated at birth and placed in organ culture. These data suggest that the tunica muscularis provides a suitable microenvironment for the development of ICCs and rhythmicity without the need for extrinsic stimuli. 6. Treatment of small intestinal tissues taken from embryos at E15 with neutralizing c-Kit antibodies abolished ICC development and the organization of ICCs into networks that typically occurs during the late embryonic period. Treatment of muscles taken from newborn animals with c-Kit antibodies blocked postnatal development of ICCs, disrupted already established and functional ICC networks, and rendered muscles electrically quiescent. 7. In summary, ICC networks develop in the pacemaker regions of the murine GI tract before birth. Development and organization of ICCs of the myenteric plexus region into networks precedes the development of electrical rhythmicity. Post-natal development of electrical rhythmicity is mainly characterized by enhancement of the amplitude and frequency of slow waves. The development of ICCs and electrical rhythmicity persists in vitro. ICCs appear to be necessary for the initiation of electrical rhythmicity. These findings provide further evidence for the pacemaker role of ICCs.

Impaired development of interstitial cells and intestinal electrical rhythmicity in steel mutants.

Electrical rhythmicity in the gastrointestinal tract may originate in interstitial cells of Cajal (IC). Development of IC in the small intestine is linked to signaling via the tyrosine kinase receptor, c-kit. IC express c-kit protein, and disruption of c-kit signaling causes breakdown in IC networks and loss of slow waves. We tested whether mutations in steel factor, the ligand for c-kit, affect the development of IC networks. IC were found in the region of the myenteric plexus (IC-MY) in mice with steel mutations (i.e., Sl/Sld) at 5-10 days postpartum, but these cells formed an abnormal network. IC-MY were not observed in adult Sl/Sld animals. IC in the deep muscular plexus (IC-DMP) appeared normal in Sl/Sld animals. Electrical slow waves, normally present in the small intestine, were absent in Sl/Sld animals (10-30 days postpartum). Neural inputs were intact in Sl/Sld animals. Steel factor appears important for the development of certain classes of IC, and IC-MY appear to be involved in the generation of electrical rhythmicity in the small intestine.

Cell wall constituents of Leuconostoc citrovorum and Leuconostoc mesenteroides.

The cell wall constituents of Leuconostoc citrovorum 8082, L. mesenteroides 10830a, and L. mesenteroides 11449 have been ascertained. All three strains contained glycerol. Glucose and rhamnose were the major reducing sugar constituents. Alanine, glutamic acid, lysine, glucosamine, and muramic acid were the principal amino acids and amino sugars in all three strains. In addition, strain 10830a contained l-serine as a major cell wall component. Quantitative amino acid analyses indicate that glutamic acid, lysine, glucosamine, muramic acid, and serine may be present in the cell walls in equimolar amounts and that alanine is present in three to four times these quantities. The similarities and differences between the cell wall constituents of the leuconostocs and those of the lactobacilli and streptococci are discussed.