Die Rheumatoide Arthritis ist die häufigste inflammatorische Arthritis mit einer Prävalenz von 0.5-1%. Pathophysiologisch spielen intrinsische Dysregulationen der Zytokinexpression insbesondere von TNF von Monozyten eine bedeutende Rolle. Die Regulation der TNF Expression ist komplex und manifestiert sich in erster Linie posttranslational. Hier steht das proteolytische Shedding durch die Metalloproteinase TACE, sowie deren Inhibierung durch TIMP-3 im Vordergrund. Ziel der Arbeit war die Aufdeckung potentieller Fehlsteuerungen der monozytären TNF Expression und der betreffenden regulatorischen Proteine, sowohl auf Ebene der mRNA Expression als auch posttranslational. Es konnte gezeigt werden, das Monozyten von RA Patienten vermehrt intrazelluläres TNF exprimieren. Der Anteil TIMP-3 positiver Monozyten scheint bei RA Patienten tendenziell vermindert zu sein.:1. Einleitung 1 1.1. Die Rheumatoide Arthritis 1 1.1.1. Epidemiologie und Klinik 1 1.1.2. Ätiologie und Pathogenese 1 1.2 Der Tumornekrosefaktor 3 1.2.1 Struktur und Signaltransduktion von TNF 4 1.2.2 Regulationsmechanismen der TNF Expression in Monozyten 5 1.3 Fragestellung und Ziele 9 2. Material und Methoden 11 2.1 Rekrutierung von Patienten und gesunden Probanden 11 2.2 Materialien 12 2.3 Methoden 15 2.3.1 Separation von PBMCs mittels Dichtegradientenzentrifugation 15 2.3.2 Separation von Monozyten mit negativer Magnetseparation 15 2.3.3 Bestimmung der monozytären Expression von TACE mittels Durchflusszytometrie 16 2.3.4 Bestimmung der intrazellulären Expression von TNF, TIMP-3 und PR-3 in Monozyten 17 2.3.5 Messung der TNF und TNF Rezeptor 2 Sekretion von Monozyten mit Hilfe eines ELISA 17 2.3.6 Bestimmung der RNA Expression von TNF, TIMP-3,TACE und PR-3 in Monozyten mittels Real Time PCR 19 2.4 Statistische Auswertung 20 3. Ergebnisse 21 3.1 Deskriptive Statistik der Kohorten 21 3.2 Expression der mRNA von TNF, TACE, TIMP-3 und PR-3 in Monozyten 22 3.3 Expression von TACE auf Monozyten 23 3.4 Expression von intrazellulärem TNF, TIMP-3 und PR-3 in Monozyten 24 3.5 Sekretion von TNF und TNFR2 von Monozyten 28 4. Diskussion 32 4.1 Expression von TNF sowie regulatorischer Moleküle auf mRNA Ebene 32 4.2 Expression von tmTNF und TACE auf der Oberfläche von Monozyten 35 4.3 Intrazelluläres Vorkommen von TNF sowie regulatorischer Moleküle in Monozyten 36 4.4 Sekretion von TNF und TNFR2 durch Monozyten 39 5. Zusammenfassung 42 6. Literaturverzeichnis 47 7. Abbildungsverzeichnis 61 8. Eigenständigkeitserklärung 63 9. Lebenslauf 63 10. Danksagung 65

Abstarct Analysis of the Therapy in Patients with Juvenile Idiopathic Arthritis Author: Martina Procházková Tutor: PharmDr. Josef Malý, Ph.D. Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové, Charles University Introduction and aims: Methotrexate (MTX) is an effective and safe drug used for the treatment of juvenile idiopathic arthritis (JIA) and is well-known like a golden standart in the treatment of this serious illness. The aim of this study was analysis of therapy in patients with JIA focusing on MTX and faktors affecting its intolerance. Methods: The study was undertaken from January 2017 to February 2018 at the Department of Paediatrics and Adolescent Medicine, 1st Faculty of Medicine, Charles University in Prague. Patients younger than 18 years old, who have become ill with JIA for the first time or repeatedly between years 2015-2017 and were treated by MTX were included in this study. The prevalence of MTX intolerance was measured by "Methotrexate Intolerance Severity Score" questionaire every 3 months during regular rheumatological examinations. Simultaneously, medical records were reviewed. Data analysis was performed by means of descriptive statistics, correlation dependence and statistical signifikance of dependence was assessed with statistical two-choice...

A 3 year old Hispanic male presented with fevers, skin rash, left neck swelling and refusal to walk of several days duration. Physical exam revealed a febrile, fussy toddler with a tender, cystic lesion in the left submandibular region. Both ankles had tender cystic lesions on the lateral malleolar regions. Labs: WBC 33,000 with neutrophilia, bandemia, thrombocytosis, and increased ESR and CRP. MRI of the neck and ankles revealed cystic lymphatic malformations with no communication with the joints.ENT specialist was consulted and neck cystic lesion was aspirated to rule out a septic focus. Bone scan of the lower extremities ruled out infectious or malignant etiology. He was started on multiple antibiotics with a presumed diagnosis of sepsis. An ECHO on the 4th hospital day showed a pericardial effusion which required a pericardial window. He also developed bilateral pleural effusions which resolved with supportive treatment. Aspirates from the cystic lesions, pericardial fluid, blood and urine cultures were sterile. Even in the second week of hospital stay, he continued to spike high fevers (Tmax 107) with high white counts and left shift inspite of treatment with antibiotics. A diagnosis of systemic onset juvenile idiopathic arthritis (SOJIA) was made with input from rheumatologist. Antibiotics were discontinued and steroids were started with good response. Cystic lesions were treated with percutaneous sclerotherapy with doxycycline. He was discharged home on oral steroids, NSAID’s and weekly methotrexate. Etanercept was added to decrease dependence on oral steroids. He remains in good health 2 years since initial presentation. Discussion: A febrile toddler who refuses to walk is a common clinical presentation in pediatrics. Differential diagnosis of such a patient includes osteomyelitis, septic arthritis, acute rheumatic fever, leukemia and non-accidental trauma. The presence of systemic extra-articular symptoms as in our patient must alert the pediatrician to systemic onset juvenile rheumatoid arthritis (SOJIA). It accounts for 10-20% of all juvenile idiopathic arthritis (JIA) patients with an incidence of 0.4-0.8 per 100,000. SOJIA differs from other conditions in its multisystem involvement. Clinical features like pleurisy, pericarditis, spiking fevers, hepatosplenomegaly and lymphadenopathy overshadow the joint symptoms. The joint involvement may be completely absent or may be a late clinical feature. These patients have leukocytosis, thrombocytosis and high inflammatory markers simulating a septic focus. In our patient, the accurate diagnosis was complicated by the confounding presence of multiple cystic lymphatic lesions. Treatment of SOJIA is challenging. Oral steroids, NSAID’s, methotrexate, etanercept and the newer anakinra have been used with varying success. Our case underlines the importance of considering a diagnosis of systemic onset JIA in a febrile toddler even in the absence of overt joint involvement.

In der nicht vollständig geklärten Pathogenese der juvenilen idiopathischen Arthritis (JIA) spielen insbesondere Effektor-T-Zellen und regulatorische T-Zellen (Tregs), sowie das Kontinuum ihrer plastischen Zelltypen eine wichtige Rolle. Im arthritischen Milieu, das auch Interleukin-17 (IL-17) beinhaltet, verschiebt sich das Gleichgewicht dieser Zellen hin zur Inflammation. Ziel dieser Arbeit war es, die T-Zellbalance im peripheren Blut von JIA-Patienten mit gesunden Kontrollen (HC) zu vergleichen, sowie den Einfluss von IL-17, anti-IL-17 und eines Th17-stimulierenden, proinflammatorischen Zytokinmilieus auf Phänotyp und Funktion der Tregs zu untersuchen. Es erfolgte die durchflusszytometrische Analyse des Lymphozytenpools von 16 JIA- und 10 HC-Probanden. Isolierte CD25+CD127-CD4+ Tregs wurden mit den genannten Stimuli kultiviert und danach durchflusszytometrisch phänotypisch sowie in Co-Kultur mit peripheren mononukleären Zellen (PBMCs) auf ihre Suppressionsfunktion untersucht. Wir stellten erhöhte Proportionen von Th17-Zellen, Tregs und effector-like Tregs in JIA-Patienten fest. Bei Stimulation mit dem Th17-Cocktail zeigte sich eine verminderte Suppression der Effektor-Zellen durch Tregs bei zeitgleich vermehrter FoxP3-Expression insbesondere in JIA-Tregs. Secukinumab bewirkte eine Anpassung der FoxP3-Expression der Tregs in der Patientengruppe auf etwa das Niveau der gesunden Kontrollen. Insgesamt bestätigt diese Arbeit eine proinflammatorische Dysbalance bei JIA-Patienten mit Shift zu Th17-like Tregs als möglicherweise pathologischen Phänotyp. Ursache für die verminderte Suppression ist vermutlich eine gesteigerte Resistenz der Effektor-Zellen durch das Inflammationsmilieu. Die vermehrte FoxP3-Expression der JIA-Tregs ist am ehesten durch eine gesteigerte Zellaktivierung zu erklären. Diese erhöhte Sensitivität der Tregs für inflammatorische Stimuli mit vermehrter Aktivierung ist ein möglicher Ansatzpunkt für zukünftige Therapien. Die Adjustierung der FoxP3-Expression unter Secukinumab in der JIA-Gruppe auf Niveau der Kontrollen bildet daher einen denkbaren zusätzlichen therapeutischen Effekt der IL-17A Blockade durch potenzielle intrinsische Stabilisierung des Phänotyps der Tregs bei der JIA ab. / Background and Objective: As the exact pathophysiology of juvenile idiopathic arthritis (JIA) is yet not fully resolved, an important focus of research lays nowadays in the delicate balance between regulatory T cells (Tregs) and effector T-cells. In an arthritic milieu, involving interleukin-17 (IL-17), plasticity towards proinflammatory cell types is seen. The aim of the study was to analyze the distribution of Tregs and effector T-cells in the peripheral blood of JIA patients and healthy controls (HC). Besides that, the influence of IL-17, of anti-IL-17 and of a Th17-stimulating environment on phenotype and function of Tregs was investigated to determine a possible drift away from or towards an antiinflammatory immune status. Methods: Peripheral blood mononuclear cells (PBMCs) were obtained from blood samples of 16 JIA patients and 10 HC and compared for differences in the lymphocytes’ characteristics. Isolated CD25+CD127-CD4+ Tregs were analyzed with flow cytometry after cultivation with the above-mentioned stimulating agents. Furthermore, suppression assays were performed to assess the Treg-mediated inhibition on proliferation of autologous PBMC proliferation after co-culture. Results: A shift towards pro-inflammatory T cells with elevated Th17-levels and concomitant increased amount of Tregs and Th17-like Tregs in JIA patients was detected. A diminished suppression of PBMC proliferation by Tregs in the Th17-stimulation environment was determined. This environment also promoted an increased FoxP3-expression on Tregs, especially in JIA. Secukinumab lead to adjustment of FoxP3-expression in JIA-Tregs to levels found in HC. Conclusion: Our results implicate that the increased proportions of Th17 cells and Th17-like Tregs might play an important part in the pathophysiology of JIA mediating the proinflammatory dysbalance. The mitigated inhibition of PBMC-proliferation in the Th17-environment is most likely the result of an effector cell resistance. The augmented FoxP3-expression in Th17-environment may be due to an increased cell activation, which especially JIA Tregs were prone to. This increased sensitivity of Tregs to inflammation might open new therapeutic approaches. The difference of FoxP3-activation was less pronounced after cultivation with Secukinumab, suggesting an adjustment of Treg activation in JIA to levels found in HC. This could demonstrate an additional benefit in IL-17A-inhibition in JIA possibly via intrinsically stabilizing the Treg phenotype.

BACKGROUND: Knee osteoarthritis is a chronic disease that frequently results in pain, activity limitations and difficulties performing social and community activities. Despite the growing prevalence of arthritis and associated participation restrictions, few studies have measured the long-term impact of the environment and psychological factors on participation restriction in this population. METHODS: Participants from the Multicenter Osteoarthritis Study (MOST) self-reported participation at baseline, 30, 60, and 84 months using the Instrumental Role subscale of the Late Life Disability Index. For study 1, participants’ environmental features were assessed at baseline from the Home and Community Environment questionnaire administered in the MOST-Knee Pain & Disability study, an ancillary study of MOST. The relative risk of participation restriction at 60 months due to community mobility barriers and transportation facilitators was calculated using binomial regression, adjusting for covariates. For study 2, baseline levels of positive and negative affect were assessed with the Center for Epidemiological Studies Depression Scale. The relative risk of incident participation restriction over 84 months due to 1) low positive affect (vs. high positive affect), 2) high negative affect (vs. low negative affect), and 3) combinations of low/high positive and negative affect (vs. high positive affect/low negative affect) were calculated in separate analyses using binomial regression, adjusting for covariates. RESULTS: In study 1, 69 (27%) of the 322 participants developed participation restriction by 60 months. Participants reporting high community mobility barriers at baseline had 1.8 times the risk [95% CI: 1.24, 2.73] of participation restriction at 60 months, after adjusting for covariates, whereas the risk due to high transportation facilitators was not significant. In study 2, 470 participants (26%) had incident participation restriction over 7 years. The adjusted relative risks of incident participation restriction over 7 years across the three analyses were: 1) low positive affect (vs. high positive affect): RR: 1.2 [95% CI: 1.0, 1.4], 2) high negative affect (vs. low negative affect): RR: 1.5 [95% CI: 1.3, 1.7], 3) low positive affect and high negative affect (vs. high positive and low negative affect): RR: 1.8 [95% CI: 1.4, 2.1]. CONCLUSIONS: These studies highlight that people with knee osteoarthritis who have certain contextual features, such as environmental barriers or low positive and high negative affect, are at increased risk of participation restriction over time. / 2018-07-07T00:00:00Z

Diese Arbeit betrachtet die Medikamentenadhärenz bei Patienten mit rheumatoider Arthritis (RA) und den Einfluss verschiedener Faktoren. Im Vordergrund steht dabei der Zusammenhang zwischen der Adhärenz und dem zusätzlichen Vorhandensein eines Fibromyalgie-Syndroms (FMS). Des Weiteren werden Parameter wie das Alter und Geschlecht, die Schmerzintensität, die Krankheitsaktivität, die Funktionseinschränkung sowie die Medikation und ihr Wirken auf die Adhärenz betrachtet. Ein besonderes Augenmerk liegt zusätzlich auf dem Einfluss der Erwartungshaltung hinsichtlich der medikamentösen Behandlung. Untersucht wird, inwieweit die Überzeugung von der Notwendigkeit der Medikation oder die Sorgen bezüglich der Therapie in Zusammenhang mit der Adhärenz stehen. Die Einstellung zu Medikamenten im Allgemeinen und ihr Einfluss auf die Adhärenz ist ebenfalls Thema dieser Arbeit.:1. Inhaltsverzeichnis 2. Abkürzungsverzeichnis 3. Einführung 3.1 Rheumatoide Arthritis 3.2 Fibromyalgie-Syndrom 3.3 Adhärenz bei RA- und FMS-Patienten 4. Aufgabenstellung und Ziel der Untersuchung 5. Materialien und Methoden 5.1 Patientenkollektiv 5.2 Ablauf der Untersuchung 5.3 Patienteninterview 5.4 Disease activity score (DAS28-CRP) und Simplified disease activity index (SDAI) 5.5 Compliance-Questionnaire-Rheumatology (CQR-19) 5.6 Beliefs about Medicines Questionnaire (BMQ) 5.7 Fragebogen Fibromyalgie-Syndrom (FMS-Score) nach ACR-Kriterien 2010/11 5.8 Health Assessment Questionnaire-Disability Index (HAQ-DI) 5.9 PainDETECT-Questionnaire (PD-Q) 5.10 Beck-Depressions-Inventar (BDI-II) 5.11 Statistische Methoden 6. Ergebnisse 6.1 Patientenkollektiv 6.1.1 Demographische Daten 6.1.2 Untersuchte Subpopulationen 6.1.3 Medikation der RA-Patienten 6.2 Adhärenz bei RA-Patienten 6.2.1 Selbstbeurteilung der Adhärenz durch RA-Patienten 6.2.2 Einfluss allgemeiner Faktoren auf die Adhärenz bei RA-Patienten 6.2.3 Die Meinung von RA-Patienten zu Medikamenten 6.2.4 Zusammenhang zwischen der Adhärenz und der Meinung von RA-Patienten zu Medikamenten 6.2.5 Haupteinflussfaktoren der Adhärenz bei RA-Patienten 6.3 Adhärenz bei Patienten mit RA und FMS 6.3.1 Vergleich der Adhärenz von RA/FMS(+)- und RA/FMS(-)-Patienten 6.3.2 Vergleich der Adhärenz von RA/FMS(+)-Patienten und FMS-Kontrollgruppe (FMS-KG) 6.3.3 Vergleich der Adhärenz von RA/FMS(-)-Patienten und FMS-Kontrollgruppe (FMS-KG) 6.3.4 Vergleich der Meinung zu Medikamenten zwischen RA/FMS(+)-, RA/FMS(-)-Patienten und FMS-Kontrollgruppe (FMS-KG) 7. Diskussion 7.1 Allgemeines 7.1.1 Patientenpopulationen und demographische Daten 7.1.2 Aussagekraft der Adhärenz-Messung 7.1.3 Bewusste und unbewusste Nicht-Adhärenz 7.1.4 Limitationen der Untersuchung 7.2 Adhärenz bei RA-Patienten 7.2.1 Selbstbeurteilung der Adhärenz durch die RA-Patienten im Interview 7.2.2 Die Adhärenz bei RA-Patienten und Einflussfaktoren 7.2.3 Die Meinung von RA-Patienten zu Medikamenten 7.2.4 Haupteinflussfaktoren und Vorhersage der Adhärenz 7.3 Adhärenz bei Patienten mit RA und FMS 7.3.1 Unterschiede in der Adhärenz zwischen RA-Patienten mit und ohne FMS sowie primären FMS-Patienten 7.3.2 Unterschiede bezüglich der Meinung zu Medikamenten zwischen RA-Patienten mit und ohne FMS sowie primären FMS-Patienten 8. Zusammenfassung 9. Literaturverzeichnis 10. Tabellen- und Abbildungsverzeichnis 11. Anlagen 11.1 Klassifikationskriterien der rheumatoiden Arthritis 11.2 Compliance-Questionnaire-Rheumatology (CQR-19) 11.3 Beliefs about Medicines Questionnaire (BMQ) 11.4 Fragebogen Fibromyalgie-Syndrom nach ACR-Kriterien 2010/11 11.5 Weitere Fragebögen 11.6 Multiple lineare Regression: Analysen in SPSS 12. Selbstständigkeitserklärung 13. Lebenslauf und Publikationen 14. Danksagung

Introduktion/Bakgrund: En procent av världens befolkning är drabbade av den kroniska autoimmuna inflammatoriska sjukdomen Reumatoid artrit (RA) som kan orsaka värk, trötthet, stela leder, svullnad och som bidrar till minskad livskvalitet. I dagsläget är den farmakologiska behandlingen en central del av patienternas liv vilket kan bromsa sjukdomsförloppet men inte bota den. Litteraturstudien undersöker hur alternativa behandlingsmetoder upplevs av patienter med RA. Syfte: Syftet var att belysa patienters upplevelser av alternativa behandlingsmetoder vid RA. Metod: Litteraturstudien genomfördes utifrån Polit och Becks (2021) nio steg. Litteratursökningarna gjordes i databaserna Cinahl och PubMed. Tio artiklar var relevanta för litteraturstudiens syfte och granskades med hjälp av granskningsmallar. Resultat: Resultatet baseras på tio vetenskapliga artiklar, sju kvalitativa och två kvantitativa, samt att en artikel hade mixad metod. I sammanställningen framkom två teman: Positiva upplevelser och Negativa upplevelser. Slutsats: Alternativa behandlingsmetoder bidrog till att majoriteten av patienterna upplevde minskad smärta, ångest och depression. De upplevde även att socialt stöd från andra patienter bidrog till positivt välmående samt ökat självförtroende.

京都大学 / 新制・論文博士 / 博士(人間健康科学) / 乙第13504号 / 論人健博第11号 / 新制||人健||7(附属図書館) / 京都大学大学院医学研究科人間健康科学系専攻 / (主査)教授 田村 恵子, 教授 若村 智子, 教授 森信 暁雄 / 学位規則第4条第2項該当 / Doctor of Human Health Sciences / Kyoto University / DFAM

In this longitudinal pilot study, magnetic resonance imaging (MRI) and Early Erosions in Rheumatoid Arthritis (EERA) software were used to quantify bone erosive damage in the metacarpophalangeal (MCP) 2-5 joints of the worst-affected hand (i.e. greatest swelling and tenderness at baseline) of patients with rheumatoid arthritis (n=35). Firstly, Spearman’s rho (rs) was used to evaluate the correlation between total change in sum erosive damage and change in functional ability, as well as the correlation between rate of change in sum erosive damage and change in functional ability. The rs (p-value) for total change and rate of change in sum erosive damage was 0.099 (0.585) and 0.104 (0.565), respectively. Therefore, the null hypothesis that neither variable was associated with change in functional ability could not be rejected. Participants were also classified into three groups based on total change in sum erosive damage (improvement, stable or progression) and were examined for possible differences in a variety of measures using an exploratory, non-statistical approach. Most notably, participants in the improvement group had more than five times the mean sum erosive damage at baseline compared to the progression group and also appeared to be the least aggresively medicated of the three cohorts. This study is the first to apply EERA in a way that helps to address clinically important questions related to change in erosive damage and functional ability. Future studies should use the ideas and concepts generated in this pilot study to further explore the use of this highly reproducible erosion quantification software, with the ultimate goal of expanding the applications of EERA in both the research and clinical settings. / Thesis / Master of Science (MSc) / In this study, the hands of patients with rheumatoid arthritis (RA) were assessed using magnetic resonance imaging (MRI) to investigate how erosive damage to the bone changes over time. Specialized computer software entitled Early Erosions in Rheumatoid Arthritis (EERA) was used to perform this analysis. Firstly, change in erosive damage was not found to be related to change in functional ability (e.g. eating, grip, etc.). Secondly, it appeared that individuals who demonstrated improvement in bone damage over time had significant damage at the beginning of the study period. Overall, this study provides new information for researchers and clinicians in terms of how this unique software can be used to enhance our understanding of RA. Future studies will continue to explore ways in which this software can be applied to address questions that are important to RA patients.

Circulating endothelial cells (CECs) and endothelial progenitor cells (EPCs) are sensitive markers of cardiovascular damage and repair, respectively. The aim of this thesis was to advance the state of knowledge regarding CECs and EPCs, and the factors affecting their concentrations, in children and adolescents. The first and second studies demonstrated that CECs and EPCs were similar when participants were split by sex, chronological age (8-10 vs. 14-16 years), and biological age (≤ -1 vs. ≥ +1 year from peak height velocity). Moreover, CECs, but not EPCs, were positively associated with aerobic fitness and negatively related to daily moderate-to-vigorous physical activity. Neither CECs nor EPCs were related to level of adiposity. Although there was a large degree of inter-individual variability in both cell types, most of our data were clustered towards one end of the reported range. These observations highlighted the need to examine these cells in children with chronic conditions associated with an increased risk of poor cardiovascular health. Therefore, CECs and EPCs were examined at rest and in response to acute exercise in juvenile idiopathic arthritis (JIA) and healthy controls. Resting levels of CECs and EPCs were similar in both groups, which may be attributable to the low disease activity in the participants with JIA. High intensity, intermittent exercise (HIIE) and moderate intensity, continuous exercise (MICE) had no effect on CECs in both groups. Conversely, MICE led to a robust increase in EPCs in healthy controls; no such change was observed in youth with JIA. This thesis represents the first comprehensive assessment of CECs and EPCs in the context of fitness, physical activity, and acute exercise in children and adolescents. Future research should examine the function and fate of these cells in youth, as well as the potential mechanisms underlying the blunted EPC response to exercise in JIA. / Thesis / Doctor of Philosophy (PhD) / Fitness and physical activity are critical for maintaining and improving cardiovascular health in children and adults. We don’t know exactly how they do this but the evidence in adults suggests it may be related to rare cells in the blood involved in repairing damaged blood vessels. The main objective of this thesis was to learn more about these cells, called circulating endothelial cells and endothelial progenitor cells, in children. We found that only circulating endothelial cells were related to fitness and physical activity. We also found that endothelial progenitor cells increased when healthy children performed 60 minutes of cycling. On the other hand, these cells did not change when children with juvenile idiopathic arthritis performed the same exercise. More research is needed to determine exactly why these cells responded to exercise in healthy but not sick children, and to help us identify the optimal exercise to improve these cells in youth.