Rheumatoid arthritis (RA) is a chronic inflammatory disease of autoimmune origin affecting approximately 1% of adult population worldwide. The clinical course of RA is highly variable, ranging from self-limiting to severe disease, with considerable individual and socio-economic implications. It is now well acknowledged that early diagnosis and treatment equates to better long-term outcomes. However, despite major therapeutic advances in recent decades, the management of RA remains challenging as a significant proportion of patients presents with active disease despite maximization of therapy. It is also difficult to predict which patients will respond adequately to various treatment regimens. The identification of biomarkers of clinical outcome capable of stratifying patients into accurate prognostic categories and guide pharmacological intervention is therefore urgently needed. Notably, along with clinical variability, RA is characterised by high biological heterogeneity at the tissue level. The cellular infiltrate of the RA synovium can be distinguished into at least three main patterns according to the degree and organisation of the immune cells: the 'Lymphoid' pattern characterised by predominant B and T lymphocytes which tend to cluster in discrete aggregates resembling ectopic lymphoid structures; the 'Myeloid' pattern characterised by absence of lymphocytic aggregates but significant expression of sublining macrophages; the 'Pauci-immune' pattern, that hardly shows any infiltrating immune cells. The hypothesis of this thesis was to determine whether these distinct synovial pathotypes may define specific disease subsets and predict response to therapy in patients with RA. Specifically, this work aims at: 1. evaluating whether the synovial pathotype associates with the presence of specific clinical, serological, radiological and ultrasonographic findings in an early RA cohort (< 1 year onset); 2. exploring the potential role of the synovial pathotype as a predictor of response to conventional synthetic disease-modifying antirheumatic drugs (csDMARD) after 6 months in an early RA cohort; 3. exploring the potential role of the synovial pathotype as a predictor of response to anti-TNFα treatment after 3 months in a csDMARD-failure established RA cohort.

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Disease progression in rheumatoid arthritis (RA) is assessed by standard clinical, radiological and functional measures. Clinical disease activity in RA is graded as no disease (remission), low, moderate and high disease, based on validated criteria. Radiological progression in RA is monitored by serial x-rays of hands and feet, and by quantification of structural damage, using various scoring methods. This proves to be a valuable outcome measure in RA studies. RA patients with active disease usually develop progressive radiological damage. However, it has been shown that clinical disease activity may not correlate with radiological damage, particularly in early RA. Therefore, this thesis was mainly aimed to test the hypothesis that, „radiological damage can progress despite clinical disease inactivity or remission‟ and to investigate possible underlying mechanisms including disease heterogeneity, treatment effect and scoring methodology. Disease progression, outcomes and prognostic factors were analysed in an inception cohort of early RA (Early Rheumatoid Arthritis Study/ERAS) for this thesis. In this study of early RA patients, sustained remission was less frequent than remission at individual time points and baseline variables such as gender, duration of symptoms, disease activity (DAS) and health assessment questionnaire (HAQ) scores have shown predictive value for sustained remission. Structural damage on x-rays progressed despite clinical disease inactivity or remission in a subgroup of patients and disease heterogeneity was the most likely explanation for the disconnect between clinical disease activity and radiological damage in the ERAS cohort. This study has also found that scoring methods as well as reading order of x-ray films could influence radiographic progression in early RA, particularly at individual level. Male sex, rheumatoid factor (RF) and radiographic damage at baseline showed prognostic value in predicting radiographic progression despite remission. Study patients with persistent clinical disease inactivity have shown better radiological, surgical, functional, and other outcomes compared to relapsing-remitting or persistent disease activity. There was no significant difference in functional and other outcomes between patients in remission with x-ray progression and those in remission without xray progression. Therefore, x-rays of hands and feet at regular intervals are valuable in determining true disease progression in early RA, even during clinical disease inactivity. Scoring methodology in itself could have an influence on the type of radiographic progression in RA studies. Sustained disease inactivity in RA is more favourable than relapsingremitting disease.

Rheumatoid arthritis (RA) is a progressive disease, often leading to disability. Because the disease course develops rapidly during the first years after diagnosis, more knowledge is needed about the early disease course to minimize later disability. This thesis describes the course of disability in early RA such as hand function, pain intensity, activity limitation and sick leave. In addition, this thesis compares disability between women and men and compares disability between RA patients and referents. This thesis is primarily based on data from the 320 patients that were included in the multi-centre project in Sweden called ‘Early interventions in rheumatoid arthritis’ (TIRA). A wide range of outcome variables was registered between 1996 and 2006 during regular follow-ups from time for diagnosis through the eight-year follow-up. Outcome regarding disease activity and disability of RA patients still remaining in TIRA at the three and five year follow-up respectively are used in this thesis. Data concerning sick leave were obtained for the patients during six years (1993-2001) – three years before and three years after diagnosis. Referents were included in two of the studies. Data regarding disability in referents were obtained according to hand function and activity limitation using the Health Assessment Questionnaire (HAQ). Data for sick leave were obtained for six years in referents, for the same period as the RA patients. For most variables, disability in RA was most pronounced at time of diagnosis but before intervention started. Disability was then reduced already at the 3-month follow-up and thereafter affected but stable during the following five years. The exception was participation, reflected by sick leave, a variable that was stable from inclusion to three years from diagnosis. Activity limitation, pain intensity and sick leave in RA that represents different aspects of disability were explained by other aspects of disability and contextual factors rather than by disease activity. RA affects women and men differently in some aspects. Women had more severe course of activity limitations than men according to HAQ. Men were more affected than women in range of motion, although the differences were small in a clinical perspective. However, pain intensity and frequency of sick leave did not differ between women and men. Patients with RA have pronounced disability in relation to referents although several variables improve soon after diagnosis. This discrepancy refers to hand function as well as activity limitations and sick leave. The frequency of sick leave increased during the year before diagnosis in relation to referents and was thereafter high compared to sick leave in referents.

Rheumatoid arthritis is a chronic inflammatory autoimmune disease. Measurement of the level of serum markers (sRAGE, S100A9, S100A8 and S100A12) and genetic testing for the presence of the PTPN22 genetic polymorphism could help elucidate the underlying cause of inflammation and complications in RA, such as atherosclerosis. Therefore, serum levels of sRAGE, S100A9, S100A8 and S100A12 were measured by ELISA in patients with established RA (n=138). The associations between the serum levels of these molecules; and inflammatory markers and RA complications were analysed by multiple linear regression modelling. Established RA patients (n=192) were investigated for the PTPN22 C1858T genetic polymorphism by PCR-RFLP. Multiple logistic regression modelling was used to examine the association between PTPN22 C1858T genetic polymorphism and inflammatory markers and RA complications. In RA patients, we found that serum levels of S100A9 were associated with the body mass index (BMI); and the presence of S100A8 and S100A12. The serum levels of S100A8 in RA patients were associated with the presence of anti-citrullinated peptide antibodies, rheumatoid factor and S100A9. The serum levels of S100A12 in RA patients were associated with the presence of anti-citrullinated peptide antibodies and S100A9; and a history of diabetes. Inflammatory markers and RA complications were not associated with the PTPN22 genetic polymorphism in established RA patients; serum level of triglyceride was the only variable associated with PTPN22 C1858T in multiple logistic regression analysis. Taken together, these data suggest that serum levels of sRAGE, S100A9 and S100A12 protein may be useful correlates of inflammation and autoantibody production in RA patients. Further studies are recommended to determine whether these markers predict clinical outcomes when measured at the onset of RA.

Η λεπτίνη είναι μια ορμόνη 16 kD που κωδικοποιείται απότογονίδιο obκαι παράγεται από τα λιποκύτταρα ρυθμίζοντας το ενεργειακό ισοζύγιο. Τα επίπεδα λεπτίνης στο πλάσμα είναι ανάλογα με το δείκτη σωματικής μάζας (BMI), ενώ η έκφρασή της εξαρτάται από τη νηστεία και τη σίτιση, την ινσουλίνη, τα γλυκοκορτικοειδή, καθώς και από προφλεγμονώδεις κυτταροκίνες, κύριως τον TNF-α και την IL-1. Το μόριο της λεπτίνης παρουσιάζει ομοιότητες με τη μακριά έλικα των κυτταροκινών και δρά μέσω του υποδοχέα της (OB-R), ο οποίος ανήκει στην υπεροικογένεια των υποδοχέων των κυτταροκινών και εμφανίζεται σε ποικιλία ισομορφών ενώ εκφράζεται σε διάφορους ιστούς και κύτταρα του νευροενδοκρινικού, αναπαραγωγικού, αιματοποιητικού και ανοσοποιητικού συστήματος. Η λεπτίνη εμπλεκεται και σε αυτοάνοσες καταστάσεις με το να προάγει τη διατήρηση παθογόνων Th1 κυτταρικών υποπληθυσμών. Στην παρούσα μελέτη προκειμένου να διερευνήσουμε το ρόλο της λεπτίνης σε αυτοάνοσες καταστάσεις μετρήσαμε τα επίπεδα αυτής και του υποδοχέα της σε ασθενείς με ρευματοειδή αρθρίτιδα, μια χρόνια συστεμική αυτοάνοση νόσο, για να δούμε εάν αυτά σχετίζονται με το στάδιο της νόσου ή τη θεραπεία. Ακόμη μελετήθηκε η εμπλοκή της λεπτίνης στην έκφραση προ- και αντιφλεγμονωδών κυτταροκινών στον ορό ασθενών και μαρτύρων. Τα αποτελέσματα δείχνουν πως τα επίπεδα λεπτίνης είναι υψηλά στους ασθενέις με ΡΑ. Επιπλέον τα επίπεδα λεπτίνης δεν βρέθηκε να σχετίζονται με το στάδιο της νόσου ή τη χορηγούμενη θεραπεία. Παρόλα αυτά τα αυξημένα επίπεδα λεπτίνης σε ασθενείς με ρευματοειδή αρθρίτιδα καταδεικνύουν ενδεχομένως έναν παθογενετικό ρόλο της λεπτίνης. / Leptin is a 16 kD peptide hormone, encoded by the ob gene and synthesized mainly by adipocytes to regulate the energy balance. In humans, leptin plasma levels are strongly correlated with body mass index (BMI) and the expression of leptin is regulated by fasting and feeding, insulin, glucocorticoids and pro-inflammatory cytokines, mainly TNFa and IL-1. Leptin is structurally similar to long-chain helical cytokines and it signals through its receptor, OB-R, which is a member of the cytokine receptor superfamily. OB-R comes in a variety of protein isoforms, and is expressed in several tissues and cells of the neuroendocrine system as well as the reproductive, hematopoietic and immune systems. Leptin has also been implicated in the pathogenesis of autoimmunity. It has also been suggested that leptin may promote the expansion and maintenance of pathogenic Th1-cell populations in autoimmune diseases. In this study to investigate the role of leptin in human autoimmunity, we measured leptin and OB-Rs levels inthe sera of patients suffering from rheumatoid arthritis (RA), a common chronicsystemic inflammatory disease, and tested for a possible correlation with disease activity and type of treatment. In addition, we studied whether leptin has an effect on the expression patterns of pro- and anti-inflammatory cytokine genes in PBMC isolated from RA patients and controls.Our results showed significantly elevated serum leptin levels in the rheumatoid population compared to the healthy controls.In addition, there was an absence of correlation between serum leptin levels and disease activity, as well as the nature and quantity of the medications administered to the patients. The absence of correlation between serum leptin levels and disease activity, coupled with the significantly and stably elevated levels of this hormone in the rheumatoid sera compared to the controls, are probably indicative of an insiduous pathogenetic role of leptin in rheumatoid arthritis.

Rheumatoid arthritis (RA) is a chronic inflammatory condition of unknown etiology for which there is no cure. It is one of the most disabling diseases and affects about 1% of the world‟s population. Recent developments in the field of molecular biology have resulted in the production of new drugs used in the treatment RA. Despite these advancements, achieving optimal disease control and prevention of disease progression is still difficult in many patients, leading to a continued search for treatment methods that will improve patient outcomes. Non-biologic forms of treatment that are still being investigated include the use of statins as an adjunct therapy due to their reported antiinflammatory effects. Some studies have shown that the use of statins in patients with RA help in reducing disease activity and swollen joint count in addition to lowering cardiovascular risk. As evidence continue to increase on the anti-inflammatory effect of statins, researchers have started investigating possible benefits that may result from the use of statins in treatment of RA, a chronic disease marked by high levels of systemic and local inflammation. This study investigated the anti-inflammatory effect of statins in rheumatoid arthritis patients with associated risks for cardiovascular disease, using simvastatin as the investigational product. Patients with moderately active RA despite being on maximum disease-modifying antirheumatic drugs (DMARDs) therapy and having associated risks for cardiovascular disease were screened for the study. Eligible patients were randomized into two groups, 1 and 2. Patients in group 1 received simvastatin treatment (20mg/day) for a period of 3 months in addition to their usual DMARDs after which they stopped simvastatin treatment and were followed up for a further 3 months off simvastatin treatment. Those in group 2 were allowed to continue on their usual DMARDs without simvastatin treatment for the first 3 months of the study after which they received 20mg/day simvastatin for a period of 3 months in addition to their usual DMARDs. The anti-inflammatory effect of simvastatin was assessed by monitoring the inflammatory variables; erythrocyte sedimentation rate (ESR) and c-reactive protein (CRP) and disease activity in the two groups at screening, at the crossover point and at end of the study. Disease activity was significantly reduced with simvastatin treatment in the two groups. The mean change in disease activity score with simvastatin treatment was 1.30 (p = 0.01) in group 1 and 1.74 (p = 0.01) in group 2. ESR was significantly reduced with simvastatin treatment in group 1 with a mean change of 19.0 (p = 0.005) and marginally reduced in group 2 with a mean change 26.0 (p = 0.09). There was no significant change in CRP with simvastatin treatment in the two groups. The mean change in CRP with simvastatin treatment was 7.0 (p = 0.24) in group 1 and 14.7 (p =0.20) in group 2. All the patients benefited from the lipid-lowering effect of simvastatin. These findings suggest that statins may have mild anti-inflammatory properties and will be good adjuvant in RA patients with associated risks for cardiovascular disease. / Dissertation (MSc)--University of Pretoria, 2013. / gm2014 / Pharmacology / unrestricted

La polyarthrite rhumatoïde (PR) est le rhumatisme inflammatoire chronique le plus fréquent. La PR est une maladie génétique où il existe plusieurs allèles de susceptibilité HLA-DRB1. Les auto-anticorps anti-protéines citrullinées sont les plus spécifiques de la PR. Ils sont détectés par les tests anti-peptides cycliques citrullinés (anti-CCP). 1/L’objectif de notre premier travail était de montrer l’influence des allèles susceptibilité HLA-DR sur la présence d’anti-CCP dans notre population marseillaise de PR. Nous avons montré que les allèles de susceptibilité HLA-DR ne sont pas nécessaires à la présence des anticorps anti-CCP. Nous avons mis en évidence une association entre l’allèle HLA-DRB1*04:04 et la présence des anti-CCP.2/Environ un tiers des patients présentant une PR n’ont pas d’anticorps anti-CCP. Nous avons donc recherché des nouveaux auto-anticorps pour le diagnostic de la maladie.Les auto-anticorps dirigés contre le domaine catalytique de la protéine B-Raf (v raf murine sarcoma viral oncogen homologue B1) ont été identifiés par la technique des puces à protéines chez les patients PR. B-Raf est une sérine-thréonine kinase qui est impliquée dans la voie des MAP-kinases. Nous avons montré que les auto-anticorps anti-B-Raf activent B-Raf. Nous avons montré que le peptide p25 de B-Raf est spécifiquement reconnu par les auto-anticorps des PR. Les auto-anticorps anti-p25 identifient 21% des patients PR sans anticorps anti-CCP.3/En utilisant des puces à protéines, nous avons identifié 24 nouveaux auto-antigènes associés aux PR débutantes. Quatre de ces auto-antigènes ont été validés par ELISA : GABA(A) receptor associated protein like, zinc finger protein 706, tropomyosin 2 et WIBG (within BGCN homolog (Drosophila)). Les auto-anticorps anti-WIBG identifient exclusivement les PR.Ces nouveaux auto-antigènes pourront être utilisés dans le diagnostic des PR débutantes et des PR sans anticorps anti-CCP. / Rheumatoid arthritis (RA) is a chronic inflammatory disease with a prevalence of 0.5% wordwilde. HLA-DR genes are the strongest genetic prevalence in RA. The sera of RA patients contain many auto-antibodies. The most characteristic are directed at citrullinated proteins (ACPA). ACPA can be detected by commercially available enzyme-linked immune-absorbent assays using synthetic cyclic citrullinated peptides (CCP).1/In the first work we tested whether the presence of RA associated HLA-DRB1 alleles individually influences anti-CCP production in a population of RA from Marseille. We showed RA associated HLA-DR alleles are not mandatory for the production of anti-CCP. HLA-DRB1*04:04 was the most strongly associated with the presence of anti-CCP in RA sera. 2/ Anti-CCP antibodies are detected in 65% of RA patients. We wanted to detect new auto-antibodies for the diagnosis of RA.By screening protein arrays we found that B-Raf (v raf murine sarcoma viral oncogen homologue B1) is a major non-citrullinated auto-antigen recognized by 35% of RA patients’sera. B-Raf encodes a serine threonine-kinase involved in the MAPK signaling pathway. We showed that anti-B-Raf auto-antibodies activate the in vitro phosphorylation of MEK1 mediated by B-Raf.We found that one peptide of B-Raf, p25, is specifically recognized by auto-antibodies from RA patients. Of interest, anti-p25 auto-antibodies are detected in 21% of anti-CCP negative RA patients.3/We identified 24 new auto-antigens associated with RA patients with disease duration less than one year using 8000 human protein arrays. We identified four auto-antigens recognized almost uniquely by sera of early RA patients: GABA(A) receptor associated protein like, zinc finger protein 706, tropomyosin 2 and WIBG (within BGCN homolog (Drosophila)). These reactivities were confirmed by ELISA on purified proteins. Auto-antibodies to anti-WIBG identify exclusively RA patients’sera. These new auto-antigens could be used for the diagnosis of anti-CCP negative RA patients and in early RA.

Background: The prevalence of herpes zoster (HZ) is high in patients with rheumatic diseases. Systemic lupus erythematosus (SLE) doubles the risk for developing HZ. However, little is known about natural humoral immunity against varicella zoster virus (VZV) in patients with SLE. Hence, we compared VZV IgG antibody concentrations in a group of SLE patients with healthy controls and patients with rheumatoid arthritis (RA). Methods: n = 56 patients with SLE, n = 54 patients with RA, and n = 56 healthy controls were included in this study. The VZV IgG antibody concentration was measured using an enzyme-linked immunosorbent assay (ELISA). The antibody concentrations were compared between the groups. Results: Overall IgG antibody titers for VZV in SLE patients were comparable to healthy controls but higher when compared to patients with rheumatoid arthritis (p = 0.0012). In consequence, antibody levels in controls were higher than in RA patients (p = 0.0097). Stratification by age revealed highest titers among SLE patients in the fourth life decade (p = 0.03 for controls, p = 0.0008 for RA patients) whereas RA patients in their sixth decade had the lowest antibody concentration (p = 0.03 for controls, p = 0.04 for SLE patients). Regarding the individual HZ history, antibody levels of SLE patients with a positive history exceeded all other groups. Conclusions: Although humoral VZV immunity in SLE patients is comparable to healthy controls it seems to be pronounced in young SLE patients between 30 and 39. The lowest VZV IgG levels were found in RA patients. HZ seems to induce antibody production, particularly in patients with SLE. Immunological processes might contribute to VZV antibody levels in SLE patients, but further investigations are needed to substantiate this hypothesis. Even though the increased HZ prevalence seems to be independent of humoral immunity in SLE patients, reduced humoral immunity might contribute to HZ in RA patients. The available HZ subunit vaccination might be an appropriate way to reduce the HZ risk in patients with rheumatic diseases.

Rheumatoid Arthritis (RA) is a disease in which the body has "turned on itself", with its immune system attacking mobility. In RA, an immune mechanism attacks and destroys the joints and limits mobility, in some circumstances to the point of needing replacement of joints. The aim of this research is the development of a less costly, widely accessible, passive sensing technology that provides a quantitative assessment of RA and that monitors the therapeutic effectiveness on joint-debilitating diseases. The proposed solution relies on a quantitative evaluation of human gestures. Such a quantitative assessment supports the comparison between the motion capabilities of a patient and that of a healthy person, using a kinematic model of the human skeleton. Criteria for the classification of severity were established, and tables were generated to classify the levels of severity as a function of the measurements extracted from processed videos of a subject performing predefined movements. This research project, while contributing a new tool to the process of classification of RA level of severity, opens the way for using widely accessible digital imaging for diagnosing and monitoring the evolution of the illness. Replacing MRI or HRUS with a cheaper and more accessible technology would have a major impact on health care services. From the clinical point of view, the proposed techniques based on digital images processing combined with a monitoring approach based on infrared images that was previously developed may provide a utility of care for patients with RA, as well as an alternative and automated approach for early detection of RA and active inflammation at a critical time.