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We read with great interest the correspondence of Novella-Navarro et al on our paper regarding the European League Against Rheumatism (EULAR) definition of difficult-to-treat rheumatoid arthritis (D2T RA).1 2 We appreciate their acknowledgement of the need for uniform terminology and a uniform definition to describe the concept of D2T RA. Previously, this need had also been underlined by rheumatologists participating in an international survey.3 The use of heterogeneous terminology and definitions might hamper research and management of these patients.4–9 Novella-Navarro et al compared their definition of multirefractory RA in their recently conducted retrospective study with the three criteria of the EULAR definition of D2T RA (box 1).2 10 They classified patients with RA as having ‘multirefractory’ disease after failing ≥2 biological and/or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) with different mechanisms of action or ≥3 b/tsDMARDs with the same target, and as having ‘non-refractory’ disease if achieving low disease activity or remission on the first bDMARD. Noteworthy, 96% of their multirefractory patients met the EULAR definition of D2T RA (box 1),2 which supports the clinical usefulness of our definition.1 Box 1 ### EULAR definition of difficult-to-treat rheumatoid arthritis1 1. Treatment according to EULAR recommendations and failure of ≥2 b/tsDMARDs (with different mechanisms of action)* after failing csDMARD therapy (unless contraindicated)† 2. Signs suggestive of active/progressive disease, defined as ≥1 of: 1. At least moderate disease activity (according to validated composite measures including joint counts, eg, DAS28-ESR>3.2 or CDAI>10) 2. Signs (including acute phase reactants and imaging) and/or symptoms suggestive of active disease (joint related or other) 3. Inability to taper …

Összefoglaló. Bevezetés: A SARS-CoV-2 koronavírus okozta COVID–19 általános egészségügyi és gazdasági krízist idézett elő. Célkitűzés: A megfigyeléses vizsgálat célja a BNT162b2 mRNS-Pfizer–BioNTech-vakcina hatásosságának, biztonságosságának és immunogenitásának igazolása a Budai Irgalmasrendi Kórház dolgozóin. Módszer: A vakcina adása után elemeztük a COVID–19-fertőzés előfordulását, az oltások utáni reakciókat, valamint a „spike” (S-) protein és a nukleokapszid (N)-protein elleni ellenanyag szintjének változását. Eredmények: A felmérésben részt vevő 295 dolgozó közül az oltást megelőzően 36 dolgozó esett át COVID–19-fertőzésen (COVID–19-pozitív csoport). A második oltás után a megfigyelési időszak három hónapjában COVID–19-fertőzés nem alakult ki a felmérésben részt vevő oltott dolgozók körében. Az oltási reakciók enyhék voltak. A COVID–19-pozitív csoportban az N-antitestek medián küszöbértékindexe az első vakcina után 4 héttel mérve szignifikánsan magasabb volt (28,37), mint a COVID–19-negatív (0,085) csoportban (pKövetkeztetések: A második vakcina utáni megfigyelési időszakban új COVID–19-fertőzés nem volt az oltott dolgozók körében. A fertőzésen át nem esett COVID–19-negatív egyének esetén az S-antitest emelkedése mérsékelt az első oltás után, míg a második oltás után lényegesen emelkedik. A COVID–19-fertőzésen átesett egyének csoportjában már az első vakcina is jelentős S-antitest-termelődést vált ki. Orv Hetil. 2021; 162(39): 1551–1557. Summary. Introduction: The coronavirus disease 2019 (COVID-19) pandemic caused global public health and economic crises. Objective: The aim of this observation study was to estimate the effectiveness, safety and elicited immune response of the BNT162b2 mRNA Pfizer–BioNTech vaccine in healthcare workers of the Buda Hospital of the Hospitaller Order of St. John of God. Method: After vaccination, the infection rate, adverse events and the kinetics of anti-SARS-CoV-2 spike (S) protein and anti-SARS-CoV-2 nucleocapsid (N) protein antibodies were evaluated. Results: Before vaccination, from the 295 healthcare workers 36 recovered from prior COVID-19 infection (COVID-19-positive group). After the second vaccination, there was no COVID-19 infection during the three-month follow-up period. The adverse events were mild. In the COVID-19-positive group, the median cut-off index of anti-N antibodies measured at 4 weeks after the first vaccination were significantly (pConclusions: After the second vaccination, there was no COVID-19 infection during the follow-up. In the COVID-19-negative group, the anti-S antibody titer is moderate after the first vaccination and increases significantly after the second vaccine. In the COVID-19-positive group, the first vaccine induces significant anti-S antibody production. Orv Hetil. 2021; 162(39): 1551–1557.

Objective The aim of the present study was to analyse the incidence, prevalence, mortality and cause of death data of adult SLE patients and matched controls in a full-populational, nationwide, retrospective study. Methods This non-interventional study was based on database research of the National Health Insurance Fund of Hungary. A total of 7888 patients were included in the analyses, within which two subgroups of incident patients were created: the ‘All incident SLE patients’ group consisted of all incident SLE patients (4503 patients), while the ‘Treated SLE patients’ group contained those who received relevant therapy in the first 6 months after diagnosis (2582 patients). Results The median age of the SLE population was found to be 46.5 years (women 85%). The incidence rate was 4.86 and 2.78 per 100 000 inhabitants in the ‘All incident SLE patients’ and ‘Treated SLE patients’ groups, respectively. The standardized mortality ratio was 1.63 and 2.09 in the ‘All incident SLE patients’ and ‘Treated SLE patients’ groups, respectively. Overall survival was significantly lower (P Conclusion Infections, especially sepsis, had the largest positive effect on top of the extra mortality of SLE. This highlights that SLE patients are at increased risk of infection-related death.

ObjectiveTo develop evidence-based European Alliance of Associations for Rheumatology (EULAR) points to consider (PtCs) for the management of difficult-to-treat rheumatoid arthritis (D2T RA).MethodsAn EULAR Task Force was established comprising 34 individuals: 26 rheumatologists, patient partners and rheumatology experienced health professionals. Two systematic literature reviews addressed clinical questions around diagnostic challenges, and pharmacological and non-pharmacological therapeutic strategies in D2T RA. PtCs were formulated based on the identified evidence and expert opinion. Strength of recommendations (SoR, scale A–D: A typically consistent level 1 studies and D level 5 evidence or inconsistent studies) and level of agreement (LoA, scale 0–10: 0 completely disagree and 10 completely agree) of the PtCs were determined by the Task Force members.ResultsTwo overarching principles and 11 PtCs were defined concerning diagnostic confirmation of RA, evaluation of inflammatory disease activity, pharmacological and non-pharmacological interventions, treatment adherence, functional disability, pain, fatigue, goal setting and self-efficacy and the impact of comorbidities. The SoR varied from level C to level D. The mean LoA with the overarching principles and PtCs was generally high (8.4–9.6).ConclusionsThese PtCs for D2T RA can serve as a clinical roadmap to support healthcare professionals and patients to deliver holistic management and more personalised pharmacological and non-pharmacological therapeutic strategies. High-quality evidence was scarce. A research agenda was created to guide future research.

ObjectivesTo summarise the evidence on diagnostic issues in difficult-to-treat rheumatoid arthritis (D2T RA) informing the EULAR recommendations for the management of D2T RA.MethodsA systematic literature review (SLR) was performed regarding the optimal confirmation of a diagnosis of rheumatoid arthritis (RA) and of mimicking diseases and the assessment of inflammatory disease activity. PubMed and Embase databases were searched up to December 2019. Relevant papers were selected and appraised.ResultsEighty-two papers were selected for detailed assessment. The identified evidence had several limitations: (1) no studies were found including D2T RA patients specifically, and only the minority of studies included RA patients in whom there was explicit doubt about the diagnosis of RA or presence of inflammatory activity; (2) mostly only correlations were reported, not directly useful to evaluate the accuracy of detecting inflammatory activity in clinical practice; (3) heterogeneous, and often suboptimal, reference standards were used and (4) (thus) only very few studies had a low risk of bias.To ascertain a diagnosis of RA or relevant mimicking disease, no diagnostic test with sufficient validity and accuracy was identified. To ascertain inflammatory activity in patients with RA in general and in those with obesity and fibromyalgia, ultrasonography (US) was studied most extensively and was found to be the most promising diagnostic test.ConclusionsThis SLR highlights the scarcity of high-quality studies regarding diagnostic issues in D2T RA. No diagnostic tests with sufficient validity and accuracy were found to confirm nor exclude the diagnosis of RA nor its mimicking diseases in D2T RA patients. Despite the lack of high-quality direct evidence, US may have an additional value to assess the presence of inflammatory activity in D2T RA patients, including those with concomitant obesity or fibromyalgia.

ObjectivesTo summarise, by a systematic literature review (SLR), the evidence regarding pharmacological and non-pharmacological therapeutic strategies in difficult-to-treat rheumatoid arthritis (D2T RA), informing the EULAR recommendations for the management of D2T RA.MethodsPubMed, Embase and Cochrane databases were searched up to December 2019. Relevant papers were selected and appraised.ResultsTwo hundred seven (207) papers studied therapeutic strategies. Limited evidence was found on effective and safe disease-modifying antirheumatic drugs (DMARDs) in patients with comorbidities and other contraindications that limit DMARD options (patients with obesity, hepatitis B and C, risk of venous thromboembolisms, pregnancy and lactation). In patients who previously failed biological (b-)DMARDs, all currently used b/targeted synthetic (ts-)DMARDs were found to be more effective than placebo. In patients who previously failed a tumour necrosis factor inhibitor (TNFi), there was a tendency of non-TNFi bDMARDs to be more effective than TNFis. Generally, effectiveness decreased in patients who previously failed a higher number of bDMARDs. Additionally, exercise, psychological, educational and self-management interventions were found to improve non-inflammatory complaints (mainly functional disability, pain, fatigue), education to improve goal setting, and self-management programmes, educational and psychological interventions to improve self-management.The identified evidence had several limitations: (1) no studies were found in patients with D2T RA specifically, (2) heterogeneous outcome criteria were used and (3) most studies had a moderate or high risk of bias.ConclusionsThis SLR underscores the scarcity of high-quality evidence on the pharmacological and non-pharmacological treatment of patients with D2T RA. Effectiveness of b/tsDMARDs decreased in RA patients who had failed a higher number of bDMARDs and a subsequent b/tsDMARD of a previously not targeted mechanism of action was somewhat more effective. Additionally, a beneficial effect of non-pharmacological interventions was found for improvement of non-inflammatory complaints, goal setting and self-management.

Background Pigmented villonodular synovitis (PVNS) is a rare disorder with the benign tumoral proliferation of the synovium. The surgical treatment of PVNS alone in most cases is unsatisfactory, because if a few cells have not been removed, the disease will recur.1 Post-synovectomy adjuvant treatment with intra-articular injection of Yttrium-90 (90Y) or Holmium-166 (166Ho) yielded better results. The radiosynoviorthesis (RSO) is an effective way of treating the chronic synovitis, with this method we are eliminate the inflammation in 75 percent of the cases.2 Objectives To study efficacy of radiosynoviorthesis after the surgical synovectomy in pigmented villonodular synovitis of the knee. Methods Between May 1986 and August 2018, 17 patients (seven men and ten women aged 14–68 years) with diffuse PVNS were treated. All patients had monoarticular arthritis of the knee with histologically proved PVNS. The patients underwent 33 operations, two patients had four surgical procedures, one patient underwent three surgeries, eight patients had two surgeries and six patients had one surgical procedure (Table 1.). The radiosynoviorthesis was performed according to the method accepted in the national protocol.Yttrium-citrate injectable suspension marked by 185 MBq 90Y-citrate injectable suspension, and 40 mg of 1 ml triamcinolone acetonide and 1 ml of lidocaine 1%.3 Holmium-phytate injectable suspension marked by 600 MBq 166Ho-phytate injectable suspension, and 40 mg of 1 ml triamcinolone acetonide and 1 ml of lidocaine 1%.3 Evaulation was based on the criteria as described by Muller, Rau and Schutte the score system was developed by the authors.4 The circumference of joint-swelling, the joint function, the measure of flexio-contracture, pain in state of rest and load on a pain analogue scale 1-10, joint warmth, walking capacity, the numbers of joint-punctions after the treatment, whether operation was necessary or not after the treatment were examined. Results Mean follow-up time was 56 months (range from 4 to 144 months). All patients were followed up using clinical assesment. After the first injection excellent and good results were recorded in 41%. After the second radiosynoviorthesis thirteen patients (76%) showed excellent and good response (Table 2.). The mean functional evaluation score of 17 patients was 28 (range 16-34). Most of the ratings were excellent or good, in four cases moderate (24%). No complications were noticed after surgery or after the radiosynoviorthesis. Conclusion A combination of debulking surgery with radiosynoviorthesis of Yttrium or Holmium for diffuse PVNS of the knee joint is a reliable treatment method, with good results. References [1] Jaffe HL, Lichtenstein L, Sutro CJ (1941) Pigmented villonodular synovitis: bursitis and tenosynovitis. Arch Pathol. 31:731–765. [2] Jahangier ZN, Moolenburgh JD, Jacobs JWG, et al. The effect of radiation synovectomy in patients with persistent arthritis: A prospective study. Clin. and Exp. Rheumatol. 2001; 19:417-424. [3] EANM Procedure Guidelines for Radiosynovectomy, Eur J Nucl Med(2003) 30:BP12–BP16, Vol. 30, No. 3,March2003. [4] Rau R, Schutte H. Results of radiosynoviorthesis with yttrium 90 in chronic synovitis: a long-term prospective study. I. Total results and effect of local factors. Z Rheumatol. 1983; 42: 265-70. Disclosure of Interests None declared

Career situation of first and presenting author Instructor. Introduction Osteoporosis has been associated with systemic sclerosis (SSc). Objectives We wished to determine bone alterations in SSc patients by conventional densitometry (DXA), peripheral quantitative computed tomography (pQCT) and bone biomarkers. Methods We included 44 SSc patients and 33 age-matched healthy controls. Lumbar spine and femoral neck bone mineral density (BMD) was assessed by DXA. Volumetric BMD was measured by pQCT at the radius. FRAX, 25-hydroxyvitamin-D3 (25-OH-D3), parathyroid hormone, osteocalcin, C-terminal collagen telopeptide and procollagen type I amino-terminal propeptide were also assessed. Results SSc patients had lower L2–4 BMD (0.880±0.108 vs. 0.996±0.181 g/cm2; p=0.019) and femoral neck (FN) BMD (0.786±0.134 vs. 0.910±0.090 g/cm2; p=0.007) by DXA. In SSc vs controls, pQCT indicated lower mean cortical (328.03±103.32 vs 487.06±42.45 mg/cm3; p Conclusions The results of our study suggest that bone loss in SSc patients may be associated with lower BMI, anti Scl70 positivity, and the presence of pulmonary manifestations and digital ulcers. Both DXA and pQCT are appropriate tools to evaluate the bone alterations in SSc patients. Acknowledgements This research was supported by Hungarian National Scientific Research Fund (OTKA) grant No. K 105073 (H.P.B. and Z.S.); by the European Union and the State of Hungary and co-financed by the European Social Fund in the framework of TAMOP-4.2.4.A/2-11/1-2012-0001 ‘National Excellence Program ’(Z.S.); by the European Union grants GINOP-2.3.2-15-2016-00015 and GINOP-2.3.2-15-2016-00050 (Z.S.). Disclosure of Interest None declared.

International audience; The relapse rate in antiphospholipid syndrome (APS) remains high, i.e. around 20%–21% at 5 years in thrombotic APS and 20–28% in obstetrical APS [2, 3].Hydroxychloroquine (HCQ) appears as an additional therapy, as it possesses immunomodulatory and anti-thrombotic various effects [4–16].Our group recently obtained the orphan designation of HCQ in antiphospholipid syndrome by the European Medicine Agency.Furthermore, the leaders of the project made the proposal of an international project, HIBISCUS, about the use of Hydroxychloroquine in secondary prevention of obstetrical and thrombotic events in primary APS. This study has been launched in several countries and at now, 53 centers from 16 countries participate to this international trial.This trial consists in two parts: a retrospective and a prospective study.The French part of the trial in thrombosis has been granted by the French Minister of Health in December 2015 (the academic trial independent of the pharmaceutical industry PHRC N PAPIRUS) and is coordinated by one of the members of the leading consortium of HIBISCUS.

The five TNF inhibitors currently approved for the treatment of RA are characterised by differences in their molecular structures, half-lives, administration routes, dosing intervals, immunogenicity, and use in women who wish to become pregnant. TNF inhibitors still represent the first biologic after conventional synthetic DMARD (csDMARD) in the majority of patients according to registry data. This was possibly because they were historically the first biological agents available (biological DMARDS with a different mechanism of action or targeted synthetic DMARDs did not become available until 2006s), and so switching from one to another was frequent in the case of an inadequate response and/or side effects. TNF inhibitors are also efficacious for other inflammatory joint and spine diseases, and have been approved for inflammatory bowel disease, uveitis and psoriasis. In addition, national registries have provided long-term safety data and demonstrated their beneficial effect on cardiovascular morbidity and mortality. However, approximately 30-40% of patients discontinue anti-TNF treatment because of primary failure, secondary loss of response, or intolerance. The options for managing anti-TNF treatment failures include switching to an alternative anti-TNF (cycling) or to another class of targeted drug with a different mechanism of action (swapping). The aim of this review is to evaluate the pros and cons of whether it is more appropriate to choose a second anti-TNF biological agents after the failure of the first or swap treatment early.

Introduction Chronic pancreatitis is an inflammatory disease associated with structural and functional damage to the pancreas, causing pain, maldigestion and weight loss and thus worsening the quality of life. Aims and methods Our aim was to find correlations from a multicentre database representing the epidemiological traits, diagnosis and treatment of the disease in Hungary. The Hungarian Pancreatic Study Group collected data prospectively from 2012 to 2014 on patients suffering from chronic pancreatitis. Statistical analysis was performed on different questions. Results Data on 229 patients (74% male and 26% female) were uploaded from 14 centres. Daily alcohol consumption was present in the aetiology of 56% of the patients. 66% of the patients were previously treated for acute exacerbation. One third of the patients had had previous endoscopic or surgical interventions. Pain was present in 69% of the cases, endocrine insufficiency in 33%, diarrhoea in 13% and weight loss in 39%. Diagnosis was confirmed with US (80%), CT scan (52%), MRI-MRCP (6%), ERCP (39%), and EUS (7,4%). A functional test was carried out in 5% of the patients. In 31% of the cases, an endoscopic intervention was performed with the need for re-intervention in 5%. Further elective surgical intervention was necessitated in 44% of endoscopies. 20% of the registered patients were primarily treated with surgery. The biliary complication rate for surgery was significantly smaller (2%) than endoscopy (27%); however, pancreatic complications were higher in the patients treated with surgery. Patients who smoked regularly needed significantly more surgical intervention following endoscopy (66.7% vs. 26.9%, p = 0.002) than non-smokers, and the ratio of surgical intervention alone was also significantly higher (27.3% vs. 10.8%, p = 0.004). The ratio of surgery in patients who smoked and drank was significantly higher (30.09% vs. 12.5%, p = 0.012) than in abstinent and non-smoking patients, similarly to the need for further surgical intervention after endoscopic treatment (71.43% vs. 27.78%, p = 0.004). Conclusions According to the data analysed, the epidemiological data and the aetiological factors in our cohort differ little from European trends. The study highlighted the overuse of ERCP as a diagnostic modality and the low ratio of use of endoscopic ultrasonography. The results proved that alcohol consumption and smoking represent risk factors for the increased need for surgical intervention. Chronic pancreatitis should be treated by multidisciplinary consensus grounded in evidence-based medicine.

The authors present the case of a 73-year-old diabetic woman who was referred to hospital because of the suspicion of lower limb peripheral arterial stenosis. During evaluations signs of the subclavian artery occlusion were found. In addition to diabetes, the patient had several risk factors revealed by medical history. Subclavian artery occlusion was solved by angiography guided stenting, and angiography also showed the presence of abnormalities in renal arteries. This case draws the attention to the importance of screening old diabetic patients for arterial stenosis and the importance of accurate risk factor assessment. Orv. Hetil., 2012, 153, 1475–1479.

Introduction The primary objective of our study was to explore the changes of antioxidant, inflammatory, and metabolic parameters in obese and hypertension people patients during balneotherapy and to evaluate the safety of balneotherapy in these participants. Methods Following randomisation, 22 obese and 20 hypertensive patients underwent balneotherapy with thermal water of 38 °C temperature, in 15 sessions of 30 minutes. An additional 22 obese and 20 hypertensive patients served as controls. Antioxidant, inflammatory, and metabolic parameters were determined at baseline, as well as post-treatment and at the end of follow-up (at 15 weeks). Results As regards changes observed in hypertensive patients subjected to balneotherapy, differences could be detected between baseline and post-treatment albumin and haemoglobin A 1c levels only; however, these were no longer significant after 3 months. Although the difference between transferrin levels determined at the end of balneotherapy and 3 months later was significant, it remained within the physiological range, as well as it was accompanied by normal serum iron level and therefore, it was considered irrelevant. C-reactive protein levels of balneotherapy patients decreased significantly after treatment. In obese patients, haemoglobin A 1c level decreased after balneotherapy, but this difference was not observed either after 3 months. Similarly, both transferrin and C-reactive protein levels changed from baseline, but not between groups. Conclusions This study contributes important information regarding the safety of balneotherapy in hypertensive and obese diabetics by showing no alterations of antioxidant, inflammatory, or metabolic indices. The findings of this study confirm that balneotherapy is not contraindicated for hypertensive or obese patients.

Microparticles are recently recognized players of intercellular communication. They are involved in signal transduction, cell activation and apoptosis. Their importance is also suggested in autoimmune diseases such as rheumatoid arthritis and systemic sclerosis. We investigated the role of microparticles in polymyositis/dermatomyositis, a group of rare autoimmune diseases, characterized by specific skin lesions and muscle weakness. The plasma concentration of monocyte and lymphocyte derived microparticles of 20 patients with polymyositis/dermatomyositis and 20 healthy controls were determined by flow cytometry. The structure of microparticles was visualized by electron microscopy. Significantly elevated numbers of monocyte (CD14 positive), T-lymphocyte (CD3 positive) and B-lymphocyte (CD19 positive) derived microparticles were found in the plasma samples of polymyositis/dermatomyositis patients, compared to healthy controls (p=0.001, 0.01 and 0.006, respectively). Furthermore, the plasma levels of monocyte and B-lymphocyte derived microparticles correlated with the manual muscle strength test (r=0.497, p=0.027; r=0.508, p=0.023; respectively). Patients with anti-Jo-1 antibody and lung involvement had significantly higher numbers of T- and B-lymphocyte and monocyte derived MPs (p=0.006, 0.012 and 0.007, respectively, for anti-Jo-1; p=0.013, 0.016 and 0.025, respectively, for lung involvement). After ultracentrifugation, CK activity could be detected only in traces in the resuspended pellet containing microparticles of healthy and diseased individuals. The electron microscopy revealed slightly different microparticles in the samples of patients with polymyositis/dermatomyositis. These results suggest that immune cell derived microparticles may contribute to the inflammatory process in polymyositis/dermatomyositis, however, CK-positive, possibly muscle derived microparticles do not seem to be present in the blood of patients with polymyositis/dermatomyositis.

Hypertensive TGR(mRen2)27 (TGR) rats represent a strain with genetically upregulated renin-angiotensin-aldosterone system. Simultaneously with development of hypertension, a daily profile in blood pressure (BP) inverts and in mature TGR rats BP is higher during the lighttime (L) than the darktime (D). Physiological mechanisms of inverted BP rhythm generation are not understood. In our study we determined circadian profiles of plasma hormones related to BP control (aldosterone, corticosterone, melatonin, prolactin) in TGR and control Sprague-Dawley (SD) rats over 24 h and expression of genes encoding catecholamine synthesizing enzymes, tyrosine hydroxylase (TH), dopamine-beta-hydroxylase (DBH), and phenylethanolamine-N-methyltransferase (PNMT) in adrenals and stellate ganglia. Plasma levels of corticosterone and aldosterone were higher in TGR than SD rats but acrophases of their rhythms were not changed. Darktime peak of prolactin in TGR rats was decreased in comparison with SD animals and pineal melatonin levels started to rise earlier in TGR than in SD rats. In adrenals we found upregulated expression of TH, DBH, and PNMT mRNA at the beginning of the lighttime in TGR compared to SD rats. Expression of TH and DBH in stellate ganglia was not different in TGR rats in comparison with SD, but PNMT expression was higher during L compared to D in TGR rats. We hypothesize that upregulated adrenal medulla functioning in the morning and disturbed communication between circadian oscillators and mechanisms involved in BP control can explain the reversed BP profile in TGR rats.

Systemic Lupus Erythematosus (SLE) is a disease primarily targeting fertile women. The odds of spontaneous miscarriage, preeclampsia, intrauterine growth restriction is higher in pregnant women with SLE as well as there are increased risks of preterm delivery and perinatal fetal death. The occurrence of spontaneous abortion is closely related to the presence of antiphospholipid antibodies. The disease on its own is not a contraindication of pregnancy but at least a six-month remission is suggested prior conception. The physiological changes in the course of pregnancy might have close resemblance to the symptoms of lupus, therefore these changes should be differentiated from symptoms caused by lupus. For mothers suffering from SLE, regular visits not only to their obstetricians but also to a rheumatologist are also recommended in order to allow at proper time recognition of potential complications and their appropriate treatment. Thorough check of the maternal disease is of high importance not only during but also prior to and following pregnancy. An overview is given of the opportunities of recent diagnosis and opportunities of therapeutic approaches including biological as well as stem cell treatments. The antithrombotics treatment increases the chance of survival and healthy child birth in the case of pregnant women suffering from antiphospholipid syndrome. Although occurring rarely, neonatal SLE has significantly higher morbidity and mortality compared to healthy births. Recent studies show positive results in the case of prophylactic treatment of neonatal lupus. Prenatal care is recommended to be conducted at an institute where the obstetrician is experienced in the possible complications of lupus and where consultation with a rheumatologist, and the treatment of neonates with low birth weight are ensured.

A circadian rhythm is documented in duodenal melatonin in rats, peaking 16.8 hours after light onset. This component is more readily detected after log10-transformation of the data. It differs between male and female rats, females having a larger circadian amplitude and an earlier acrophase. The circadian rhythm in duodenal melatonin is also found to lead that of pineal melatonin. The results are qualified by the presence at the start of mapping of the second extremum of a double magnetic storm.

Despite considerable advances in the management of rheumatoid arthritis, results are still not satisfactory for all patients. The treatment goal in rheumatoid arthritis is remission, and there currently are numerous conventional and biological medications available to reach this aim. There are also different treatment strategies but with only limited comparative evidence about their efficacies. More patients now achieve remission while on treatment, but it remains elusive in the majority of patients. Treatment-free remission, the ultimate goal of therapy, is only achieved in very few patients; even when this happens, it is most likely due to the natural course of the disease rather than to any specific therapies. Modern treatment is based on the initiation of aggressive therapy as soon as the diagnosis is established, and on modifying or intensifying therapy guided by frequent assessment of disease activity. In this commentary we will discuss the current treatment paradigm as well as the possibility of an induction-maintenance regimen with biological disease-modifying antirheumatic drugs in early rheumatoid arthritis.

We have examined the mitochondrial formation of NAD(P)H in rat adrenal glomerulosa cells. A short-term elevation of the K+ concentration from 3.6 to 8.4 mM induced a reversible increase in the formation of reduced pyridine nucleotides. Potassium applied after the addition of rotenone had no further effect, confirming that the redox signal was of mitochondrial origin. Inhibition of aldosterone synthesis by aminoglutethimide in K+-stimulated cells decreased the rate of decay of the NAD(P)H signal upon the termination of stimulation, indicating that the NADPH formed was consumed in aldosterone synthesis. When the NAD(P)H signal was measured simultaneously with the cytoplasmic free Ca2+ concentration ([Ca2+]i), elevation of the K+ concentration to 6.6 or 8.4 mM induced parallel increases in [Ca2+]i and NAD(P)H formation. The rates of increase and decrease of NAD(P)H were lower than for [Ca2+]i, confirming that the redox signal was secondary to the Ca2+ signal. Angiotensin II (100 pM–1 nM) induced an oscillatory NAD(P)H signal which usually returned to a lower baseline concentration, while a sustained signal with superimposed oscillations was observed at higher concentrations. Simultaneous measurements showed that NAD(P)H levels followed the [Ca2+]i pattern evoked by angiotensin II. Vasopressin (100 nM) also induced parallel oscillations of [Ca2+]i and NAD(P)H. A sustained rise in the extramitochondrial Ca2+ concentration to 1 μM induced a sustained elevation of the intramitochondrial Ca2+ concentration in permeabilized cells, as measured with rhod-2. A sustained rise in [Ca2+]i evoked by long-term stimulation with 8.4 mM K+ or 2.5 nM angiotensin II resulted in sustained NAD(P)H production. These Ca2+-dependent changes in the mitochondrial redox state support the biological response, i.e. aldosterone secretion by glomerulosa cells.

Since the 1970s, numerous reports have described elevated hexosaminidase activities in rheumatoid arthritis. However, due to the overlapping substrate specificities of different hexosaminidases, identification of the exact enzyme(s) responsible for the elevated activity remains incomplete. In this work we tested if the recently described enzyme, hexosaminidase D was expressed in human arthritic joints, and could contribute to the elevated hexosaminidase activity in rheumatoid arthritis. Thermostable β-d-N-acetyl-galactosaminidase (hexosaminidase D) activities were determined in synovial fluid samples, synovial membranes, synovial fibroblast cell strains and synovial fibroblast-derived extracellular vesicles of patients with rheumatoid arthritis and osteoarthritis using chromogenic substrates. Expression of the HEXDC gene was detected both in steady state and in TGF-β treated synovial fibroblasts by real time PCR. Strikingly, hexosaminidase D accounted for approximately 50% of the total β-N-acetyl-galactosaminidase activity in synovial membranes and synovial fibroblasts, and it was responsible for the vast majority of the β-d-N-acetyl-galactosaminidase activity in synovial fluid samples. TGF-β downregulated the expression of hexosaminidase D in synovial fibroblasts dose-dependently. Of note, significant activity of hexosaminidase D was also found in association with extracellular vesicles released by synovial fibroblasts. This first study that describes the expression and disease relevance of the HEXDC gene in humans demonstrates the expression of this novel enzyme within the joints, and suggests that its activity may significantly contribute to the overall local exoglycosidase activity.

INTRODUCTION: Microvesicles (MVs), earlier referred to as microparticles, represent a major type of extracellular vesicles currently considered as novel biomarkers in various clinical settings such as autoimmune disorders. However, the analysis of MVs in body fluids has not been fully standardized yet, and there are numerous pitfalls that hinder the correct assessment of these structures. METHODS: In this study, we analyzed synovial fluid (SF) samples of patients with osteoarthritis (OA), rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA). To assess factors that may confound MV detection in joint diseases, we used electron microscopy (EM), Nanoparticle Tracking Analysis (NTA) and mass spectrometry (MS). For flow cytometry, a method commonly used for phenotyping and enumeration of MVs, we combined recent advances in the field, and used a novel approach of differential detergent lysis for the exclusion of MV-mimicking non-vesicular signals. RESULTS: EM and NTA showed that substantial amounts of particles other than MVs were present in SF samples. Beyond known MV-associated proteins, MS analysis also revealed abundant plasma- and immune complex-related proteins in MV preparations. Applying improved flow cytometric analysis, we demonstrate for the first time that CD3(+) and CD8(+) T-cell derived SF MVs are highly elevated in patients with RA compared to OA patients (p = 0.027 and p = 0.009, respectively, after Bonferroni corrections). In JIA, we identified reduced numbers of B cell-derived MVs (p = 0.009, after Bonferroni correction). CONCLUSIONS: Our results suggest that improved flow cytometric assessment of MVs facilitates the detection of previously unrecognized disease-associated vesicular signatures.

Nitric oxide (NO) has been shown to regulate T cell functions under physiological conditions, but overproduction of NO may contribute to T lymphocyte dysfunction. NO-dependent tissue injury has been implicated in a variety of rheumatic diseases, including systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Several studies reported increased endogenous NO synthesis in both SLE and RA, and recent evidence suggests that NO contributes to T cell dysfunction in both autoimmune diseases. The depletion of intracellular glutathione may be a key factor predisposing patients with SLE to mitochondrial dysfunction, characterized by mitochondrial hyperpolarization, ATP depletion and predisposition to death by necrosis. Thus, changes in glutathione metabolism may influence the effect of increased NO production in the pathogenesis of autoimmunity.

The goal of this study is to determine and compare the β-endorphin levels in the synovial fluid of patients with different joint disorders (avascular necrosis, AVN; osteoarthritis, OA; and rheumatoid arthritis, RA of the hip or knee). Eighty-seven patients were involved in our study with an average age of 62 years. Thirty-three patients had AVN (18 hips, 15 knees). Twenty-three patients were diagnosed with OA (14 hips, 9 knees), and 31 patients suffered from RA (12 hips, 19 knees). We measured the β-endorphin levels of the synovial fluids -harvested from surgery—with radioimmunoassay. No significant difference was found in the β-endorphin levels of the synovial fluid from AVN comparing to OA and RA, however β-endorphin level was significantly higher in RA group than among patients with OA (p = 0.01). Synovial β-endorphin level was slightly lower in knee comparing to hip joint p = (0.06). When examining the different joints separately in compliance with diagnoses, we concluded that the synovial β-endorphin level from AVN was between the values of OA and RA without significant difference, whereas it was significantly higher in the knee of RA, than of OA groups (p = 0.05 knee, p = 0.2 hip). Our results confirmed those experiments which stated that there is a significant increase in synovial β-endorphin level in patients with inflammatory autoimmune diseases (e.g., RA), comparing to the level measured in degenerative conditions (e.g., OA).

CHI3L1 gene encodes for a glycoprotein (HC-gp39 or YKL40) secreted by synovial fibroblasts, macrophages, neutrophil granulocytes and chondrocytes. Its expression is under the control of NF-kB. It is regarded as an acute phase protein, and its levels are significantly elevated in rheumatic diseases. Furthermore, HC-gp39 has been shown to be recognized by autoreactive T cells in rheumatoid arthritis. In the present study, we have examined two functional variants of the promoter region of CHI3L1 gene (CHI3L1-1 (rs4950928) and CHI3L1-2 (rs10399931) that have been reported earlier to be associated with schizophrenia and sarcoidosis. We used TaqMan allelic discrimination assays to study the genotypes of Hungarian patients with rheumatoid arthritis (n = 182) and of healthy controls (n = 194). No significant association of the investigated SNPs with the disease was found. Here we report that CHI3L1 SNPs, shown to be involved in the predisposition of schizophrenia, are not associated with rheumatoid arthritis.

An increasing body of evidence substantiating the effectiveness of balneotherapy has accumulated during recent decades. In the present study, 42 ambulatory patients (23 males and 19 females, mean age 59.5 years) with degenerative musculoskeletal disease were randomised into one of two groups—bathing in tap water or in mineral water at the same temperature—and subjected to 30-min balneotherapy sessions on 15 occasions. Study parameters comprised serum levels of sensitised C-reactive protein (CRP), plasma lipids, heat shock protein (HSP-60) and total antioxidant status (TAS). In both groups, CRP levels followed a decreasing tendency, which still persisted 3 months later. At 3 months after balneotherapy, serum cholesterol levels were still decreasing in patients who had used medicinal water, but exhibited a trend towards an increase in the control group. Triglyceride levels followed a decreasing trend in both patient groups. TAS showed a declining tendency in both groups. No changes of HSP-60 levels were observed in either group. Balneotherapy with the thermal water from Hajduszoboszlo spa had a more pronounced physiological effect compared to that seen in the control group treated with tap water in a 3 month period.

Objective: To assess the prevalence of xerostomia and the related oral and extraoral dryness symptoms in Hungary, to evaluate the association of those symptoms with the unstimulated whole saliva (UWS) flow rate, and to find correlation between the level of UWS flow rate and the oral health status of the questioned patients. Subjects And Methods: A total of 600 patients between the age of 18 and 92 years, 265 male, 335 female, were selected in accordance with the current regional age and residence distribution scheme of the Hungarian Statistical Office. A questionnaire was designed to determine the subjective presence or absence of the sicca symptoms. UWS flow rate and the dental and periodontal status were determined. Results: The percentages of subjective symptoms in the questioned subjects were oral dryness, 34%; reduced salivation, 11%; mucous saliva, 15%; dysphagia, 13%; glossopyrosis, 7%; dysphonia, 31%; dysgeusia, 9%; nasal dryness, 32%; ocular dryness, 21%; itching, 40% and xeroderma, 60%. Vaginal dryness was 14%, vaginal itching was 16% in the interviewed women. The grade of xerostomia, dysphagia, tiredness, and additionally the gingival bleeding index showed a negative correlation with the UWS flow rate. After all decayed, missing and filled teeth (DMF-T) mean values, gingival bleeding index and plaque index were significantly higher in hyposalivators, compared with those who had normal flow rates Conclusion: This cross sectional study, representative of the Hungarian population, clearly shows that one-third of the adult population suffers from xerostomia. The clinical severity of the xerostomia demonstrated a strong relationship with the lower levels of UWS flow rate. Reduced levels of UWS flow rate in this study were also shown to be associated with dysphagia, fatigue, and increased DMF-T numbers. The data show that oral dryness, its associated desiccation symptoms and its clinical manifestations are significant health problems in Hungary.

Histamine is a key regulator of the immune system. Several lines of evidence suggest the role of histamine in T cell activation and accelerated Th1 immune response is a hallmark of histidine decarboxylase knockout (HDC-KO) mice, with a complete lack of endogenously produced histamine. According to our previous work, T lymphocytes produce NO upon activation, and NO is necessary for effective T cell activation. To study the role of histamine in T cell activation, we investigated cytokine production and T cell signal transduction in HDC-KO and wild-type (WT) mice. In the absence of histamine, an elevated IFN-γ mRNA and protein levels of splenocytes (p < 0.001; p = 0.001, respectively) were associated with a markedly increased (2.5-fold, p = 0.0009) NO production, compared with WT animals. Furthermore, histamine treatment decreased the NO production of splenocytes from both WT and HDC-KO mice (p = 0.001; p = 0.0004, respectively). NO precursor (Z)-1-[2-(2-aminoethyl)-N-(2-ammonioethyl) amino] diazen-1-ium-1,2-diolate-diethylenetriamine elicited IFN-γ production (p = 0.0002), whereas NO synthase inhibitors NG-monomethyl-l-arginine and nitronidazole both inhibited IFN-γ production (p = 0.002 and p = 0.01, respectively), suggesting the role of NO in regulating IFN-γ synthesis. Cytoplasmic Ca2+ concentration of unstimulated T cells was increased in the HDC-KO mice (p = 0.02), whereas T cell activation-induced δ Ca2+-signal was similar in both HDC-KO and WT animals. Our present data indicate that, in addition to its direct effects on T lymphocyte function, histamine regulates cytokine production and T cell signal transduction through regulating NO production.

Beta-endorphin (betaE) is an important reliever of pain. Various stressors and certain modalities of physiotherapy are potent inducers of the release of endogenous betaE to the blood stream. Most forms of exercise also increase blood betaE level, especially when exercise intensity involves reaching the anaerobic threshold and is associated with the elevation of serum lactate level. Age, gender, and mental activity during exercise also may influence betaE levels. Publications on the potential stimulating effect of manual therapy and massage on betaE release are controversial. Sauna, mud bath, and thermal water increase betaE levels through conveying heat to the tissues. The majority of the techniques for electrical stimulation have a similar effect, which is exerted both centrally and--to a lesser extent--peripherally. However, the parameters of electrotherapy have not yet been standardised. The efficacy of analgesia and the improvement of general well-being do not necessarily correlate with betaE level. Although in addition to blood, increased brain and cerebrospinal fluid betaE levels are also associated with pain, the majority of studies have concerned blood betaE levels. In general, various modalities of physical therapy might influence endorphin levels in the serum or in the cerebrospinal fluid--this is usually manifested by elevation with potential mitigation of pain. However, a causal relationship between the elevation of blood, cerebrospinal fluid or brain betaE levels and the onset of the analgesic action cannot be demonstrated with certainty.

Objective: The purpose of this study was to describe the oral properties of Sjogren's syndrome (SS), including the determination of palatal saliva (PS) flow rate. Subjects and methods: Forty-nine SS patients and 43 healthy controls participated. Subjective symptoms were recorded and clinical assessments of the oral mucosal, dental and periodontal status were made. Unstimulated whole saliva (WS) and PS flow rates, the number of decayed, missing and filled teeth (DMF-T number), the gingival bleeding index (GBI) and the periodontal probing depth (PPD) were determined. Results: Despite the decrease in the flow rate of WS in SS patients, PS was not different from those of the controls (1.57 ± 1.02 and 1.35 ± 2.5 μl cm−2 min−1, respectively). GBI (20.0% vs. 10.5%, respectively), DMF-T (27.1 ± 6.12 vs. 23.0 ± 6.99, respectively) and PPD (2.28 ± 1.09 mm vs. 1.82 ± 0.73 mm, respectively) were higher in SS compared with the controls (P

During 7 consecutive days, blood and several tissues were collected during daytime working hours only, three times per day at 4-h intervals from inbred Wistar rats, which had been previously standardized for 1 month in two rooms on a regimen of 12 h of light (L) alternating with 12 h of darkness (LD12:12). In one room, lights were on from 09:00 to 21:00 and in the other room, lights were on from 21:00 to 09:00 (DL12:12; reversed lighting regimen). This setup provides a convenient design to study circadian and extracircadian variations over long (e.g., 7-day) spans. Prior checking of certain circadian rhythms in animals reared in the room on reversed lighting (DL) as compared with animals in the usual (LD) regimen provided evidence that the 180 degrees phase-shift had occurred. These measurements were limited to the circadian (and not extended to infradian) variation. As marker rhythm, the core temperature of a subsample of rats was measured every 4 h around the clock (by night as well as by day) before the start of the 7-day sampling. An antiphase of the circadian rhythm in core temperature was thus demonstrated between rats in the LD vs. DL rooms. A sex difference in core temperature was also found in each room. A reversed rhythm in animals kept in DL and an antiphase between rats kept in DL vs. LD was again shown for the circulating corticosterone rhythm documented in subsamples of 8 animals of each sex sampled around the clock during the first approximately 1.5 day of the 7-day sampling. The findings were in keeping with the proposition that sampling rats at three timepoints 4 h apart during daytime from two rooms on opposite lighting regimens allows the assessment of circadian changes, the daytime samples from animals kept on the reversed lighting regimen accounting for the samples that would have to be obtained by night from animals kept in the room with the usual lighting regimen. During the 7-day-long follow-up, circadian and extracircadian spectral components were mapped for serum corticosterone, taking into account the large day-to-day variability. A third check on the synchronization of the animals to their respective lighting regimen was a comparison (and a good agreement) between studies carried out earlier on the same variables and the circadian results obtained on core temperature and serum corticosterone in this study as a whole. The present study happened to start on the day of the second extremum of a moderate double magnetic storm. The study of any associations of corticosterone with the storm is beyond our scope herein, as are the results on circulating prolactin, characterized by a greater variability and a larger sex difference than corticosterone. Sex differences and extracircadian aspects of prolactin and endothelin determined in the same samples are reported elsewhere, as are results on melatonin. Prior studies on melatonin were confirmed insofar as a circadian profile is concerned by sampling on two antiphasic lighting regimens, as also reported elsewhere. Accordingly, a circadian map for the rat will eventually be extended by the result of this study and aligned with other maps with the qualification of the unassessed contribution in this study of a magnetic storm.

The aim of this pilot study was to determine the presence of complement activation products in tears from pre- and postkeratoplasty eyes and the fellow eyes in order to investigate the activation of the classical and alternative pathways of the complement system in the early postkeratoplasty period.Tear samples from both eyes of 19 prekeratoplasty patients were tested. From 10 patients, samples were taken before operation, one week and 3 weeks after penetrating keratoplasty. Only baseline and 1 weak samples, and baseline and 3 week samples were available from 5 and 2 patients, respectively, while only baseline tear samples were collected from 2 patients. Tear concentration of two complement activation products, C1rs-C1inh and C3bBbP were determined by enzyme-linked immunosorbent assay.There was no difference (p = 0.339) between baseline samples of the eyes waiting for operation (0.93 +/- 0.51 AU/ml, mean +/- SEM) and the fellow eyes (0.33 +/- 0.33 AU/ml) in respect of mean C1rs-C1inh complex concentration. The one-week samples of the operated eyes revealed significantly (p = 0.006) elevated levels of C1rs-C1inh complexes (18.8. +/- 6.37 AU/ml), compared to their baseline samples (1.18 +/- 0.64 AU/ml), whereas the one-week values of the fellow eyes did not differ from the baseline values. Compared to the increased one-week values, the three-week values decreased to the baseline values in the operated eyes. C3bBbP could be detected in 3/68 tear samples.In our study we demonstrated the increased concentration of C1rs-C1inh complex in several tear samples taken early after human penetrating keratoplasty. These findings provide direct evidence that the classical pathway of complement may be activated in the early postoperative period after penetrating keratoplasty.

In certain types of solid tumours and lymphomas prolactin (PRL) potentiates tumour cell proliferation and exerts anti-apoptotic effect. Tumour cells themselves can produce PRL and express PRL-receptors. Hyperprolactinemia is associated with different tumours, also. Multiple myeloma (MM) is a haematological malignancy caused by the clonal expansion of terminally differentiated plasma cells in the bone marrow. Recently, we demonstrated PRL immunostaining in bone marrow cells of MM patients and an elevated level of serum PRL of MM patients with advanced disease. In the present study, we tested the effect of PRL on a U266 human myeloma cell line and demonstrated constitutive and melphalan-stimulated intracytoplasmic PRL in U266 cells. Exogeneous PRL inhibited the proliferation and immunoglobulin (Ig) production of U266 myeloma cells. Concerning etoposide-induced apoptosis, PRL had a double-faceted effect depending on the applied dose: high, pharmacological doses (corresponding to hyperprolactinemia), inhibited apoptosis, whereas near physiological doses exerted a pro-apoptotic effect. These data indicate a definite effect of PRL on a human myeloma cell line. We demonstrated a direct inhibition of PRL on tumour cell growth, while its reciprocal effect on apoptosis refers to an important regulatory role of PRL.

The role of prolactin (PRL) in the physiological regulation of the immune system and in hematopoiesis is well known. There is also evidence of the significance of PRL in several pathological conditions such as autoimmune diseases and some malignancies, e.g. colon and breast carcinomas and also B cell malignancies. Multiple myeloma is known as a B cell malignancy. It is the result of malignant transformation of a single clone of neoplastic plasma cells that synthesize abnormal amounts of monoclonal immunoglobulins or immunoglobulin fragments. In our present studies, the possible expression of PRL in bone marrow cells obtained from diagnosed multiple myeloma (17 cases) or nonmyeloma (5 cases) patients was examined by the method of immunocytochemistry. Samples obtained from those multiple myeloma patients (13 cases) who had not received chemotherapy for 6 months prior to these studies showed a positive immunocytochemical reaction for PRL. Bone marrow smears of patients diagnosed with multiple myeloma who had received chemotherapy within 6 months of the study and also the smears of patients without diagnosed multiple myeloma failed to show a positive immune reaction for PRL. In the case of a patient who was examined prior to and also after a period of 3 months of chemotherapy, the PRL-immunopositive bone marrow cells had disappeared due to the treatment. According to the light microscopic analysis of the cell morphology, PRL-immunopositive cells in the bone marrow were mainly, but not exclusively, plasma cells. There was no correlation between the positive PRL staining of cells and the type of monoclonal immunoglobulin or the ratio of plasma cells detected in the bone marrow. Taken together, our results indicate a possible role of PRL in multiple myeloma. Further experiments are necessary to identify the prognostic value of PRL in multiple myeloma.

Complement activation products, such as C1rs-C1inh, specific for the activation of the classical pathway, C3b(Bb)P, specific for the activation of the alternative pathway and SC5b-9, specific for common terminal pathway of the complement cascade, were measured in healthy donors and in patients with clinically active and inactive systemic lupus erythematosus (SLE). Plasma levels of C3b(Bb)P and SC5b-9 were moderately, those of C1rs-C1inhibitor (C1rs-C1inh) were markedly elevated in patients with clinically inactive SLE, compared with healthy controls. The difference between active and inactive stages of the disease was best reflected by C3b(Bb)P plasma concentration (P < 0.001), which also showed the highest correlation with the SLEDAI (Rs = 0.41 P < 0.001) and which was the most useful in distinguishing active and inactive sample pairs as well. The difference between SC5b-9 levels in the active and inactive stages was also significant (P = 0.007), while that of C1rs-C1inh did not differ significantly (P = 0.136). The correlation of the SLEDAI with SC5b-9 was 0.3 (P = 0.015), while with C1rs-C1inh it was 0.21 (P = 0.089). These findings suggest that the measurement of complement activation products, especially that of the alternative pathway, are sensitive markers of the activity of SLE and can be used for clinical purposes.

Background and Objectives Rheumatoid arthritis (RA) is a common, relapsing autoimmune disease, which affects approximately 1% of the population worldwide. While the specific molecular events that lead to initiation and onset of RA are not known, an uncontrolled activation of the immune system is considered to be a critical component of the disease. B lymphocytes undoubtedly play a critical role in disease aetiology. Antigen binding to B-cell receptor (BCR) triggers B cell activation, although the threshold of activation can be influenced by other receptors, such as TLR9. TLR9 has received substantial attention as a pathogenic co-stimulator of autoreactive B cell responses. Our aim was to compare basal activity and induced phosphorylation of AKT, ERK, p38 MAPK and CREB after stimulation of B cells from RA patients and healthy individuals via BCR and/or TLR9. Materials and Methods Blood samples were collected from healthy donors and RA patients having moderate (DAS28 3.2 5.1) disease. B cells were stimulated with anti-Ig (Fab’) 2 and/or CpG ODN. Naive and memory B cells were identified by anti-CD20-A647 and anti-CD27-PE Phosphorylation level of AKT, ERK, p38 and CREB was detected before and after the stimuli by specific phospho-antibodies using multiparameter phospho-flow analysis. Results were evaluated by the FlowJo software. Results The basal level of phosphorylation of signalling molecules was significantly higher in RA patients as compared to healthy donors. The induced level of phosphorylation was also higher in RA samples in most of cases, CpG stimulated memory B cells from patients with active disease have shown the highest values. In anti-Ig plus CpG ODN stimulated samples phosphorylation of all molecules was significantly higher in both naive and memory RA B cells as compared to healthy controls. However, when compared to unstimulated cells, the increment of phosphorylation in the stimulated cells was the same or lower in RA samples. Conclusions We have shown differences in the activation state of AKT, ERK, p38 and CREB in B cells from healthy individuals and RA patients. The higher basal phosphorylation level indicates the activated state of RA B cells. The lower capability of activation-induced phosphorylation may be a result of lower responsiveness of RA B cells. The analysis of phosphorylation signature in RA B-cells may provide new information to a better understanding of the disease.

Besides atherosclerosis and lung cancer, smoking is considered to play a major role in the pathogenesis of autoimmune diseases. It has long been known that there is a connection between rheumatoid factor-positive rheumatoid arthritis and cigarette smoking. Recently, an important gene–environment interaction has been revealed; that is, carrying specific HLA-DRB1 alleles encoding the shared epitope and smoking establish a significant risk for anti-citrullinated protein antibody-positive rheumatoid arthritis. We summarize how smoking-related alteration of the cytokine balance, the increased risk of infections (the possibility of cross-reactivity) and modifications of autoantigens by citrullination may contribute to the development of rheumatoid arthritis.

Increased numbers of mast cells are found in the synovial tissues and fluids of patients with rheumatoid arthritis, and at sites of cartilage erosion. Mast cell activation has been reported for a significant proportion of rheumatoid specimens. Because the mast cell contains potent mediators, including histamine, its potential contributions to the processes of inflammation and matrix degradation have recently become evident; thereafter, we investigated the potential protective effect of histamine deficiency against aggrecan-induced arthritis. To study the role of histamine in rheumatoid arthritis we investigated cartilage proteoglycan (aggrecan)-induced arthritis in histidine decarboxylase knockout (HDC-KO) mice, with complete lack of endogenously produced histamine. Aggrecan-induced arthritis was similar in HDC-KO and wild-type (WT) mice. Arthritis was even more severe in HDC-KO mice than in the WT animals 10 weeks following the immunization with aggrecan (arthritis score 1.2 ± 1.5 and 0 ± 0, respectively; P = 0.01). At later time points, arthritis scores were similar in both HDC-KO and WT mice. Since T-lymphocyte dysfunction has an important role in the pathogenesis of rheumatoid arthritis, next we investigated T-cell signal transduction and cytokine production in HDC-KO and WT mice. In the absence of histamine, elevated INFγ mRNA and protein levels of splenocytes (P < 0.001 and P = 0.001, respectively) were associated with a markedly increased (2.5-fold, P = 0.0009) nitric oxide (NO) production, compared with WT animals. Furthermore, histamine treatment decreased the NO production of splenocytes from both WT and HDC-KO mice (P = 0.001 and P = 0.0004, respectively). NO precursor (Z)-1-[2-(2-aminoethyl)-N-(2-ammonioethyl) amino]diazen-1-ium-1,2-diolate-diethylenetriamine (NOC-18) elicited IFNγ production (P = 0.0002), suggesting the role of NO in regulating IFNγ synthesis. The cytoplasmic Ca2+ concentration of unstimulated T cells and the T-cell activation-induced Ca2+ signal were increased in T cells from the HDC-KO mice (P = 0.02 and P = 0.04, respectively), while the T-cell activation-induced CD3 internalization was similar in both HDC-KO and WT animals. Our present data indicate that histamine deficiency does not protect against aggrecan-induced arthritis. The Th1 cytokine pattern and increased NO production may both contribute to the sensitivity of HDC-KO mice to aggrecan-induced arthritis. Furthermore, our data indicate that histamine, in addition to its direct effects on T-lymphocyte function, regulates cytokine production and T-cell signal transduction through regulating NO production.

Experimental and clinical evidence for T-cell involvement in the pathogenesis of rheumatoid arthritis (RA) is compelling, and points to a local dysregulation of T-cell function in the inflamed joint. Nitric oxide (NO) has been shown to regulate T-cell function under physiological conditions, but overproduction of NO may contribute to lymphocyte dysfunction in RA. NO has recently been recognized as a key signaling intermediate for T-cell activation and mitochondrial biogenesis. NO is synthesized from L-arginine by NO synthetases (NOS). Three distinct isoforms of NOS are known, including neuronal NOS (nNOS), inducible NOS (iNOS), and endothelial NOS (eNOS) enzymes. We previously detected the expression of eNOS and nNOS and the absence of iNOS in human PBL, while during inflammation macrophages and monocytes express iNOS. Systemic lupus erythematosus (SLE) is a systemic autoimmune disease of unknown origin characterized by the involvement of multiple organs. Several studies carried out on patients with both RA and SLE have documented increased endogenous NO synthesis, but its contribution to T-lymphocyte mitochondrial biogenesis and T-cell dysregulation is not known. We investigated the role of NO in T-cell mitochondrial biogenesis in RA and SLE. The mitochondrial mass, NO production and cytoplasmic Ca2+ levels were measured by flow cytometry. Mitochondria were visualized using transmission electron microscope. T cells from RA patients produce >2.5 times more NO than T cells from healthy donors (P < 0.001). Unexpectedly, the mitochondrial mass was found to be similar in RA and control T cells (P = 0.65), whilst increased NO production was associated with increased cytoplasmic Ca2+ concentrations in RA T cells (P < 0.001). We observed that T-cell NO production decreased in most RA patients following anti-TNF treatment. Although lupus T cells produced comparable amounts of NO to normal T cells, lupus monocytes produced twice as much NO as normal monocytes (P = 0.015). We also observed increased mitochondrial mass (47.7 ± 2.8%; P = 0.00017) and increased cytoplasmic (38 ± 6.4%; P = 0.0023) Ca2+ content in T cells from SLE patients when compared with control donors. Electron microscopy revealed that T cells of lupus patients contained 8.76 ± 1 mitochondria, while control donors contained 3.18 ± 0.28 mitochondria per cell (P = 0.0009). In addition, lupus lymphocytes harbor several-fold enlarged mega-mitochondria. These data suggest that monocytes are the primary source of NO in SLE, while T lymphocytes are the primary source of NO in RA. Although the iNOS pathway is not as rapid as eNOS or nNOS, it is thought to be capable of generating much larger quantities of NO (nanomolar range) than the constitutive NOS isoforms (picomolar range), explaining the differences in T-cell mitochondrial biogenesis in SLE and RA. Since mitochondria can take up, store and release Ca2+, increased mitochondrial mass may account for altered Ca2+ handling in SLE. Furthermore increased NO production may contribute to T-cell dysfunction in both SLE and RA.

In order to study the role of the serotoninergic innervation of the hypothalamic suprachiasmatic nucleus (SCN) in the development of the circadian rhythm of corticosterone 5,7-dihydroxytryptamine (5,7-DHT) selectively destroying the serotoninergic structures was injected into the cell group of 16-day-old male rats prior to the appearance of the corticosterone rhythm. Rats treated with 5,7-DHT did not show circadian fluctuations in plasma corticosterone concentrations 3, 5 and 7 weeks after the injection of the neurotoxin. Their hypothalamo-pituitary-adrenal system responded to ether stress. Immunocytochemistry revealed that only a very few serotonin immunoreactive elements were visible in the SCN of the 5,7-DHT-treated rats. The results indicate that serotoninergic innervation of the SCN is essential for the development of the corticosterone rhythm.

The decreases in plasma prolactin (PRL) levels in lactating rats that follow the separation of mother and pups have been studied. Blood samples were taken via an indwelling cannula from conscious primiparous animals between days 5 and 11 of lactation. Significant depressions of plasma prolactin levels have been detected within 3 min of separation. These decreases in hormone levels were most pronounced after 3 min, and continued up to the end of the 1st hour, but did not change during the 2nd hour. Disappearance of PRL from the blood during the first 3 min was identical to that occurring after hypophysectomy. Pretreatment of mothers, 90 min prior to separation, with α-methyl-p-tyrosine (250 mg/kg i.p.), pimozide (2 mg/kg i.p.), or haloperidol (2 mg/kg i.p.), completely blocked the decreases in PRL levels. L-Dopa (20 mg/rat i.p.) counteracted the inhibitory effect of α-methyl-p-tyrosine. These data suggest that separation of lactating rats from their litter resulted in a marked and complete blockade of PRL release from the pituitary. They also suggest that a dopaminergic mechanism plays an important role in this inhibition of PRL release.

In order to characterize the secretion pattern of prolactin and GH in freely behaving lactating rats, frequent serial blood samples were collected through indwelling atrial cannulae and their prolactin and GH concentrations determined by radioimmunoassay. At the time of blood sampling, physical contact with the pups was recorded. Plasma prolactin and GH levels showed episodic changes which were independent of each other and there was no apparent correlation between hormone levels and contact between mother and pups. The data suggest that there are episodic fluctuations in plasma prolactin and GH concentrations in lactating rats. These changes do not appear to be closely correlated with the proximity of the mother to her pups. J. Endocr. (1986) 111, 137–142

Suckling stimulus did not induce significant release of prolactin (PRL) in lactating homozygous Brattleboro rats, whereas it did it in heterozygous animals. Daily treatment of homozygous rats with vasopressin partly restored the PRL response to suckling. Findings suggest that vasopressin-neurophysin-glycopeptide precursor missing in homozygous Brattleboro rats may play a role in suckling-induced PRL release.

In anesthetized dogs electrocardiogram and monophasic action potentials (MAPs) were recorded from the right atrium and the right ventricle by intracardiac suction electrode technique. The animals were subjected, by means of ventilation with CO2 and hyperventilation, to periods of respiratory acidosis and respiratory alkalosis, respectively. Pronounced respiratory acidosis induced an increased sympathetic activity followed by a decrease in heart rate and prolongation of the A-V conduction time whereas the shape and duration of the atrial and ventricular MAPs remained unaltered. Arterial hypoxia in combination with pronounced respiratory acidosis did not influence the MAP durations. Respiratory alkalosis resulted in an increased sympathetic influence on the heart activity whereas the shape and duration of the atrial and the ventricular MAPs remained unaffected. During pronounced hyperventilation with increasing central venous pressure an increased parasympathetic influence on the heart activity with decrease in the heart rate, prolongation of the A-V conduction time and shortening of the atrial MAP duration was recorded.

All of the classically-described hypothalamic, hypophysiotropic factors that regulate anterior pituitary hormone secretion have now been isolated and identified except for prolactin releasing factor. We report here that the 39-amino acid glycopeptide comprising the carboxyterminus of the neurohypophysial vasopressin-neurophysin precursor stimulates prolactin release from cultured pituitary cells as potently as does thyrotropin releasing hormone but has no effect on the secretion of other pituitary hormones. Furthermore, antisera to the glycopeptide administered to lactating rats attenuated suckling-induced prolactin secretion. Thus, this glycopeptide appears to be the neurohypophysial prolactin releasing factor.

The advent of new medications and new treatment strategies for rheumatoid arthritis has made it possible to achieve remission in more patients than before. Furthermore, recent clinical trials and register studies suggest that some patients who initially required aggressive therapy may achieve biologic-free remission or even the ultimate goal of therapy, drug-free remission, resembling recovery. Here, we present a discursive review of the most important studies addressing these issues. Based on the overall results, it remains unclear if achieving biologic-free and drug-free remissions are primarily due to the natural course of the disease or to the early therapeutic intervention according to the ‘window of opportunity’ hypothesis. Although medication-free remission is only achievable in a small subset of patients, characterizing this patient cohort may provide important information about beneficial prognostic factors and the underlying mechanisms. In summary, in a subset of patients biologic-free and even drug-free remission can be achieved; pursuing these possibilities in practice may decrease the risk for long-term side effects and attenuate the economic burden of the disease.