Publications by authors named "Ângela Luzia Branco Pinto Duarte"

55 Publications

Interleukin-18 in Brazilian Rheumatoid Arthritis Patients: Can Leflunomide Reduce It?

Autoimmune Dis 2021 10;2021:6672987. Epub 2021 May 10.

Laboratory of Immunomodulation and New Therapeutic Approaches (LINAT), Research Group on Immunomodulation and New Therapeutic Approaches Suely Galdino (Nupit SG), Federal University of Pernambuco, Recife, Brazil.

Objectives: Rheumatoid arthritis affects about 1% of the world's population. This is a chronic autoimmune disease. It is predominant in females with progressive joint damage. Immune cells are involved, especially Th1/Th17 lymphocytes and their inflammatory cytokines. These proteins have different functions in the immune system, such as IL-16 is a chemotactic factor; IL-18 can activate NFB transcription producing inflammatory proteins; IL-31 can activate the JAK/STAT pathway which leads to the production of inflammatory factors in chronic diseases; IL-33 promotes IL-16 secretion which causes lymphocyte recruitment, and IL-32 and IL-34 appear to increase TNF secretion by macrophages activation in AR. The aim of this study was to evaluate serum levels of IL-16, IL-18, IL-31, IL-32, IL-33, and IL-34 and compare them with the severity and treatment of RA patients if there are any correlations.

Methods: A total of 140 RA patients and 40 healthy donors were recruited from the Department of Rheumatology at Hospital das Clínicas from the Federal University of Pernambuco. 60 AR patients were naïve for any treatment. Serum cytokine levels were determined using an ELISA kit.

Results: Serum IL-16 ( = 0.0491), IL-18 ( < 0.0001), IL-31 ( = 0.0004), and IL-32 ( = 0.0040) levels were significantly increased in RA patients compared with healthy donors. It was observed that patients using leflunomide had the lowest IL-18 levels, close to controls levels ( = 0.0064).

Conclusion: IL-16, IL-18, IL-31, and IL-32 are increased in the serum of RA patients. IL-18 is at lower levels in those AR who are taking leflunomide as treatment.
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http://dx.doi.org/10.1155/2021/6672987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8131162PMC
May 2021

Genetic variants in are related to lower galectin-3 serum levels and clinical outcomes in systemic sclerosis patients: A case-control study.

Autoimmunity 2021 Jun 11;54(4):187-194. Epub 2021 May 11.

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas (LINAT), Núcleo de Pesquisa em Inovação Terapêutica - Suely Galdino (NUPIT-SG), Universidade Federal de Pernambuco (UFPE), Recife, PE, Brazil.

Introduction: Systemic sclerosis (SSc) is a rare complex disease characterized by vascular damage, autoimmunity, and extensive skin and internal organs fibrosis. Galectin-3 (Gal-3) is encoded by gene (Lectin, Galactoside-Binding, Soluble, 3; 14q22.3) and it has been reported to play a central role in self-tolerance, inflammation, and fibrosis.

Objective: To investigate associations among single nucleotide polymorphisms (SNPs) and serum levels Gal-3 and SSc susceptibility and their clinical features.

Methods: A case-control study with 88 patients and 151 matched controls was performed. variants were analyzed by the TaqMan real-time polymerase chain reaction (PCR) system whereas Gal-3 serum levels were measured by sandwich enzyme linked immunosorbent assay (ELISA). Associations among genotypes, clinical features, and Gal-3 levels were performed by univariable and multivariable analysis through statistical packages.

Results: The rs4652 A/C genotype was more frequent in SSc patients than controls according to overdominant model [OR 1.89 (CI 95% 1.01 - 3.52);  = .046]. Also, rs4652 C/C polymorphic genotype was associated with lower patient Gal-3 levels ( = .03) and control group ( = 0.005), as noted by generalized linear model (GLM). The rs1009977 G/T controls showed higher Gal-3 levels than wild-type and polymorphic genotypes ( = .03); however, in SSc patients, no difference was found. None of the SNPs or Gal-3 levels was associated with clinical manifestations in SSc patients. Considering only the SSc group, GLM analysis pointed rs4652 and rs2075601, pulmonary arterial hypertension (PAH), myopathy, and health assessment questionnaire (HAQ) and scleroderma health assessment questionnaire (SHAQ) as important predictors for Gal-3 levels.

Conclusion: The rs4652 A/C was more frequent in SSc patients and related to lower Gal-3 levels. These findings were corroborated through a GLM to estimate Gal-3 values. Also, by model equations, Gal-3 levels may be predicted by HAQ, SHAQ, PAH, myopathy, and rs4652 and rs2075601 factors. In these ways, we suggest that galectins may be promising biomarkers to identify susceptibility to SSc as well as to identify HAQ, SHAQ, PAH, and myopathy outcomes.
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http://dx.doi.org/10.1080/08916934.2021.1919881DOI Listing
June 2021

Long-Term Persistence of Serum-Specific Anti-Chikungunya IgM Antibody - A Case Series of Brazilian Patients.

Rev Soc Bras Med Trop 2021 12;54:e0855. Epub 2021 Apr 12.

Universidade Federal de Pernambuco, Hospital das Clínicas, Recife, PE, Brasil.

The persistence of serum-specific anti-chikungunya IgM antibodies (CHIKV-IgM) can vary after chikungunya fever (CHIK) infection. However, the factors related to its production are not yet known. We described a case series drawn up from data collected from 57 patients between 12 and 36 months after the acute phase of CHIK infection in Northeastern Brazil. CHIKV-IgM was detectable in 7/57 (12.3%) patients after 28.3 months of infection. No frequency differences in chronic musculoskeletal manifestations and underlying conditions were detected between patients with or without CHIKV-IgM. CHIKV-IgM was detected for up to 35 months in Brazilian patients after CHIK infection.
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http://dx.doi.org/10.1590/0037-8682-0855-2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047711PMC
April 2021

Psoriatic Arthritis Quality of Life Questionnaire: translation, cultural adaptation and validation into Brazilian Portuguese language.

Adv Rheumatol 2021 02 25;61(1):13. Epub 2021 Feb 25.

Hospital das Clinicas da Universidade Federal de Pernambuco, Recife, Brazil.

Introduction: Psoriatic arthritis (PsA) is a multifaceted inflammatory disease that can cause joint destruction and impair quality of life. The Psoriatic Arthritis Quality of Life Questionnaire (PsAQoL) was the first disease-specific tool for determining the impact of the disease on the quality of life of people with PsA.

Objectives: The primary objective was to develop and validate a Brazilian Portuguese version of the PsAQoL.

Methods: The UK PsAQoL was translated into Brazilian Portuguese using two translation panels. This translation then checked for face validity and construct validity with new samples of patients. Finally, a test-retest validation study was conducted with 52 patients with PsA. The survey included the Nottingham Health Profile (NHP) as a comparator instrument.

Results: Internal consistency and reproducibility were both excellent for the new adaptation (0.91 and 0.90 respectively Scores on the PsAQoL were found to correlate as expected with the comparator measure and the instrument was able to detect differences in score related to perceived severity of PsA, general health status and presence of a flare.

Conclusion: The Brazilian PsAQoL was found easy to understand and complete and has excellent reliability and construct validity. The new measure will be a valuable new tool for use in routine PsA practice and clinical trials.
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http://dx.doi.org/10.1186/s42358-021-00168-6DOI Listing
February 2021

Validation of the Toronto Psoriatic Arthritis Screen II (ToPAS II) questionnaire in a Brazilian population.

Clin Rheumatol 2021 May 16;40(5):1889-1892. Epub 2020 Nov 16.

Hospital das Clínicas da Universidade Federal de Pernambuco, 1235 Professor Moraes Rego Avenue, 133, Recife, 50670-901, Brazil.

The Toronto Psoriatic Arthritis Screen II (ToPAS II) was developed as a tool to screen patients with probable psoriatic arthritis. We aimed to evaluate the validation of the ToPAS II questionnaire in a Brazilian population. The Portuguese translation of the ToPAS II was sent to us by the developer authors of the original index, and adapted to Brazilian Portuguese. Subjects were recruited from dermatology, general, and rheumatology outpatient clinics. After patients completed the questionnaire, they were assessed by a rheumatologist, according to standard protocol. Receiver operating characteristics (ROC) was used to obtain the sensitivity and specificity of the Brazilian Portuguese version of the ToPAS II questionnaire. One hundred and eighty-four subjects were recruited in the study. There were 70 subjects from the psoriasis group, 44 subjects from the psoriatic arthritis (PsA) group, 40 subjects from the rheumatology (non-PsA) group, and 45 healthy controls. Twenty-four patients (34.3%) in the psoriasis group had inflammatory pain and met the CASPAR classification criteria. The area under the ROC curve was 0.96, which indicates that an excellent predictor and optimum cutoff threshold to discriminate patients diagnosed with PsA used was eight as originally chosen. The overall sensitivity and specificity based on the cutoff threshold of eight were 91.3 and 90.9%, respectively. The Portuguese Brazilian version of the ToPAS II has good sensitivity and specificity and is a useful tool to screen for PsA. Key Points • Among these psoriasis patients, almost 35% in fact had psoriatic arthritis without correct diagnosis. Keeping alert of the need to disclose screening tool's use. • The TOPAS II can facilitate the screening of patients suggestive of inflammatory joint disease (with high probability of rheumatologic diagnosis) decreasing morbidity of these patients.
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http://dx.doi.org/10.1007/s10067-020-05509-2DOI Listing
May 2021

Update on the treatment of musculoskeletal manifestations in chikungunya fever: a guideline.

Rev Soc Bras Med Trop 2020 31;53:e20190517. Epub 2020 Jul 31.

Departamento de Medicina Clínica, Universidade Federal de Pernambuco, Recife, PE, Brasil.

Since the emergence of the chikungunya virus in Brazil in 2014, more than 700,000 cases have been reported throughout the country, corresponding to one-third of all cases reported in the Americas. In addition to its high attack rates, resulting in hundreds of thousands of cases, the disease has high chronicity rates with persistent joint manifestations for more than 3 months, which can spread to more than half of the patients affected in the acute phase. Pain associated with musculoskeletal manifestations, often disabling, has an effect on patients' quality of life at different stages of the disease. Currently, the challenge faced by specialists is identifying the best therapy to be instituted for symptom relief despite the limited number of published intervention studies. In 2016, a multidisciplinary group published pharmacological treatment protocols for pain in patients with chikungunya, which was incorporated into the guidelines for clinical management of the Brazilian Ministry of Health in 2017; in that same year, a consensus was published by the Brazilian Society of Rheumatology about diagnosis and treatment. After 5 years of experience with chikungunya epidemics, in 2019, specialists involved in the protocols of the Brazilian Society of Rheumatology and Brazilian Ministry of Health prepared an update with the main objective of developing flowcharts for the therapeutic approach of musculoskeletal manifestations in adult patients to enable specialists at different levels of healthcare to spread and apply this guideline in a systematic and simplified manner.
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http://dx.doi.org/10.1590/0037-8682-0517-2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7405653PMC
August 2020

Increased serum levels of galectin-9 in patients with chikungunya fever.

Virus Res 2020 09 18;286:198062. Epub 2020 Jun 18.

Programa de Pós-Graduação em Inovação Terapêutica (PPGIT)/ UFPE, Brazil; Núcleo de Pesquisa em Inovação Terapêutica - Sueli Galdino (Nupit-SG), Brazil.

Chikungunya fever (CHIKF) is an arboviral disease that has caused an epidemic burst of chronic inflammatory joint disease in Latin America in the last few years. Efforts are being spent in understanding the mechanisms by which it may cause such articular damage and in determining possible biomarkers of the disease. Galectins (GAL) are a family of animal lectins with an affinity for beta-galactosides. They have multiple functions including working as receptors in innate immunity and as a control for inflammatory responses in both innate and adaptive immunity. They regulate functions of immune cells, such as lymphocytes and macrophages, which have a main role in the chikungunya inflammatory process. Galectins are also involved in chronification of viral diseases, participate in the immunopathogenesis of chronic joint diseases such as rheumatoid arthritis, and have a role in inflammation in other arboviral diseases, such as dengue. Thus, we intended to determine the serum levels of galectin-1, -3, -4, -7, and -9 in patients with subacute and chronic articular manifestations of CHIKF and to evaluate their associations with clinical manifestations. We evaluated 44 patients with clinical manifestations of CHIKF and serological confirmation with IgM and/or IgG chikungunya virus (CHIKV) antibodies. Forty-nine age- and gender-matched healthy individuals served as controls. Anti-CHIKV IgM and IgG antibodies and galectins serum levels were measured by ELISA. We found higher levels of GAL-9 (patients median 2192 [1500-2631] pg/mL, controls median 46.88 [46.88-46.88] pg/mL, p < 0.0001) and lower levels of GAL-3 (patients median 235.5 [175.5-351.8] pg/mL, controls median 2236.0 [1256.0-2236.0] pg/mL, p < 0.0001) in patients than in controls. There was no statistical difference in levels of GAL-1, -4 and -7 between patients and control groups. There was no difference in GAL-9 serum levels between patients with subacute or chronic symptoms (median 2148 [1500-2722] pg/mL x 2212 [1844-2500] pg/mL, p = 0.3626). A significant association of GAL-9 with joint stiffness, both in its duration and intensity, was found. These results may reflect the participation of GAL-9 in the immunopathogenesis of the inflammatory process in chikungunya fever, as morning stiffness may reflect the systemic inflammatory process.
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http://dx.doi.org/10.1016/j.virusres.2020.198062DOI Listing
September 2020

Sjögren's syndrome in systemic sclerosis: Impact on oral features.

Oral Dis 2020 10 13;26(7):1594-1595. Epub 2020 Jul 13.

Oral Medicine Unit, Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, Recife, Brazil.

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http://dx.doi.org/10.1111/odi.13497DOI Listing
October 2020

Increased levels of the soluble oncostatin M receptor (sOSMR) and glycoprotein 130 (sgp130) in systemic sclerosis patients and associations with clinical parameters.

Immunobiology 2020 05 22;225(3):151964. Epub 2020 May 22.

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife, PE, Brazil. Electronic address:

Objective: The objective of the present study was to evaluate the serum levels of soluble oncostatin M (OSM), OSM receptor (sOSMR) and glycoprotein130 (sgp130) in patients with systemic sclerosis (SSc), and the possible associations and correlations with clinical parameters.

Methods: Serum levels of OSM, sOSMR and sgp130 were evaluated by ELISA in eighty-four SSc patients and eighty-four healthy volunteers.

Results: SSc patients had significantly elevated levels of sOSMR and sgp130 when compared with healthy individuals (p < 0.0001 and p = 0.025, respectively). Diffuse cutaneous SSc and limited cutaneous SSc patients also presented higher levels of sOSMR when compared with healthy individuals (p = 0.003 and p = 0.0001, respectively). Patients with digital ulcers presented higher levels of sOSMR when compared to those without ulcers (p = 0.034). However, sOSMR levels were lower in patients with esophageal dysfunction than patients without this involvement (p = 0.038). OSM levels were undetectable in serum from SSc patients and healthy volunteers.

Conclusion: Serum levels of sOSMR and sgp130 are elevated in patients with systemic sclerosis. In addition, associations were observed with important clinical manifestations, suggesting that sOSMR is a candidate biomarker of this disease. More studies are needed to clarify the functions of IL-6 family cytokines in systemic sclerosis.
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http://dx.doi.org/10.1016/j.imbio.2020.151964DOI Listing
May 2020

Arboviruses related with chronic musculoskeletal symptoms.

Best Pract Res Clin Rheumatol 2020 08 18;34(4):101502. Epub 2020 Apr 18.

Rheumatology Department, Hospital das Clínicas, Universidade Federal de Pernambuco, Brazil.

Arboviruses (ARthropods BOrne VIRUSES) are disease-causing viruses transmitted through the bite of hematophagous arthropods, such as mosquitoes and ticks. Among these, the alphavirus, genus of the Togaviridae family, is considered the most arthritogenic species, responsible for diseases such as chikungunya fever (CHIK), O'nyong-nyong virus fever, Ross River virus disease, Barmah Forest virus disease, Sindbis virus disease, and Mayaro fever. These arboviral diseases, especially CHIK, have impacted public health in recent decades, leading to devastating epidemics, particularly in developing countries, due to their high potential for chronicity, functional impairment, and great impact on the quality of life. In a similar way, chronic musculoskeletal symptoms have been described in all alphavirus infections. However, CHIK is the best studied. The purpose of this article is to review physiopathology, clinical manifestations, diagnosis, and treatment of alphaviruses, focusing on CHIK and chronic evolution of musculoskeletal symptoms.
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http://dx.doi.org/10.1016/j.berh.2020.101502DOI Listing
August 2020

Atorvastatin inhibits IL-17A, TNF, IL-6, and IL-10 in PBMC cultures from patients with severe rheumatoid arthritis.

Immunobiology 2020 05 30;225(3):151908. Epub 2020 Jan 30.

Laboratory of Immunomodulation and New Therapeutic Approaches (LINAT), Suely-Galdino Therapeutic Innovation Research Center (NUPIT-SG), Federal University of Pernambuco (UFPE), Recife, PE, Brazil.

Background: Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by joint damage, and it may present with comorbidities at the systemic level. The Th1/Th2/Th17 CD4 lymphocyte imbalance produces inflammatory cytokines, which begin to act, injuring joint tissue. Atorvastatin is a cholesterol- lowering drug with a range of biological effects including anti-inflammatory potential. Patients with rheumatoid arthritis who used statins exhibited clinical improvement. However, the mechanism is not fully understood. Therefore, we aimed to evaluate the RA immunomodulatory activity of atorvastatin.

Methods: Peripheral blood mononuclear cells (PBMCs) of RA patients and healthy donors were exposed to atorvastatin in different concentrations following a cytotoxicity assay. Th1, Th2, and Th17 cytokines profiles were evaluated in the culture supernatant by cytometric bead array (CBA). Data were analyzed using the Wilcoxon test, and differences were considered significant when p < 0.05.

Results: Atorvastatin showed no toxicity at the tested doses in RA PBMC cultures, and at 10μM, it showed the most significant results, reducing IL-17A (p = 0.002), TNF (p = 0.002), and IL-6 (p = 0.008) supernatant levels. The outcomes also revealed that only patients with more severe disease activity and those sensitive to corticoid treatments were responders to atorvastatin in vitro.

Conclusion: These findings suggest the potential immunomodulatory action of atorvastatin as a mechanism in rheumatoid arthritis treatment.
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http://dx.doi.org/10.1016/j.imbio.2020.151908DOI Listing
May 2020

Differential expression of the inflammasome complex genes in systemic lupus erythematosus.

Immunogenetics 2020 05 5;72(4):217-224. Epub 2020 Feb 5.

Laboratory of Immunopathology Keizo Asami, Federal University of Pernambuco, Recife, Pernambuco, Brazil.

Systemic lupus erythematosus (SLE) is a complex autoimmune disorder involving heterogeneous clinical manifestations and numerous susceptibility genes. Several findings evidence the critical role of inflammasomes in the predisposition to autoimmune diseases and in SLE. We investigated whether inflammasome polymorphins could affect susceptibility to develop and/or severity SLE. Moreover, differences in inflammasome activation in peripheral blood were also evaluated in SLE patients and controls. The distribution of 13 SNPs in eight inflammasome genes was evaluated. To assess inflammasome priming in peripheral blood monocytes of SLE and controls, differential expression of selected inflammasome genes and IL-1ß production was analyzed in resting condition as well as after LPS and ATP stimulation. Results showed that the gain-of-function variant rs10754558 (NLRP3) was significantly more frequent in SLE patients with nephritis, reinforcing the concept of a key role of NLRP3 inflammasome not only in SLE but also especially in kidney disease. SLE monocytes in resting condition showed a higher level of IL-1ß expression and produced higher levels of IL-1ß when stimulated with LPS+ATP comparing to controls. The stimulation induced a significant expression of NLRP1, AIM2, CASP1, and IL1B genes, suggesting that the NLRP1 inflammasome is responsible for the IL-1ß production observed in monocytes. These data emphasized once more the important contribution of inflammasome in SLE-associated inflammation.
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http://dx.doi.org/10.1007/s00251-020-01158-6DOI Listing
May 2020

Sensitivity and specificity of Interleukin 29 in patients with rheumatoid arthritis and other rheumatic diseases.

Immunol Lett 2020 04 16;220:38-43. Epub 2020 Jan 16.

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife-PE, Brazil. Electronic address:

Background: Rheumatoid arthritis (RA) is a systemic autoimmune disease characterized by chronic and progressive inflammation that can cause a high degree of disability in affected individuals. Proinflammatory cytokines play central roles in the development of degradative and inflammatory responses in RA. IL-29 has been identified in RA and reported as a biomarker of the disease.

Objective: To analyze serum levels and accuracy of IL-29 in RA patients compared to healthy subjects and patients with other rheumatic diseases.

Methods: IL-29 serum levels were measured in 121 patients with RA, 53 patients with systemic lupus erythematosus (SLE), 60 patients with systemic sclerosis (SSc), 29 patients with fibromyalgia (FM), 50 patients with osteoarthritis (OA) and 68 healthy individuals as controls. IL-29 levels in serum were investigated by ELISA. Sensitivity, specificity and likelihood ratios (LR) for having RA were calculated.

Results: Serum levels of IL-29 were increased in RA patients 113.6 (IQR = 31.25-308.5) pg/ml compared to non-RA patients (SLE, SSc, OA, and FM) (31.25 pg/ml) and healthy controls (31.25 pg/ml, p < 0.001). The IL-29 cut-off values to distinguish patients with RA from non-RA patients were 61.11 pg/ml (sensitivity 57.02, specificity 92.71, LR: 7.82) and for all subjects 32.96 pg/ml (sensitivity 64.46, specificity 87.31, LR: 5.08). Additionally, IL-29 correlated negatively with age (r=-0189, p = 0.038) and disease duration (-0.192, p = 0.037). Interestingly, IL-29 correlated positively with neutrophil count in RA patients positive for rheumatoid factor (r = 0.259, p = 0.022).

Conclusion: IL-29 is higher in the serum of patients with RA compared to non-RA subjects and may have potential for use as a biological marker.
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http://dx.doi.org/10.1016/j.imlet.2020.01.004DOI Listing
April 2020

Nutritional risk in patients with systemic sclerosis.

Clin Rheumatol 2020 01 23;39(1):295-297. Epub 2019 Nov 23.

Rheumatology Department of Hospital das Clínicas, Universidade Federal de Pernambuco (UFPE), Recife, Brazil.

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http://dx.doi.org/10.1007/s10067-019-04861-2DOI Listing
January 2020

Galectin-9 gene (LGALS9) polymorphisms are associated with rheumatoid arthritis in Brazilian patients.

PLoS One 2019 10;14(10):e0223191. Epub 2019 Oct 10.

Laboratory of Immunomodulation and New Therapeutic Approaches (LINAT), Suely-Galdino Therapeutic Innovation Research Center (NUPIT-SG), Federal University of Pernambuco (UFPE), Recife, Pernambuco, Brazil.

Introduction: Rheumatoid arthritis (RA) is a chronic autoimmune disease characterized by synovial inflammation and hyperplasia, as well as cartilage and bone destruction. Several proteins are associated with the pathogenesis of the disease. Galectin-9 belongs to the family of lectins that are involved in various biological processes and have anti-inflammatory activity.

Objective: To investigate associations between the SNPs of the GAL-9 gene (LGALS9) and serum levels in rheumatoid arthritis patients. We extracted DNA from 356 subjects, 156 RA patients and 200 healthy controls from northeastern Brazil. Three polymorphisms (rs4795835, rs3763959, and rs4239242) in the LGALS9 gene were selected and genotyped using TaqMan SNP genotyping assay. Serum concentrations of galectin-9 were analyzed by ELISA.

Results: The rs4239242 TT genotype showed a positive association with RA (p = 0.0032, odds ratio = 0.28), and heterozygous TC were prevalent in the control group compared to RA patients (p = 0.0001, odds ratio = 7.99). Galectin-9 serum levels were significantly increased in RA patients compared to the control group (p<0.0001). Patients in remission had high levels of galectin compared to the moderate activity group (p<0.0001). Regarding the Clinical Disease Activity Index (CDAI), patients in remission or low activity presented high levels of galectin when compared to patients in severity (p<0.0001). Patients performing moderate activity had a significant value compared to patients who were in high disease severity (p = 0.0064). Interestingly, the AG genotype (rs3763959) has been associated with a higher presence of bone erosion in RA patients (p = 0.0436). The SNP rs4239242 TT genotype showed a positive association with RA in comparison to the control group. The AG genotype (rs3763959) has been associated with a higher presence of bone erosion in RA patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0223191PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6786579PMC
March 2020

Galectin-1, -4, and -7 Were Associated with High Activity of Disease in Patients with Rheumatoid Arthritis.

Autoimmune Dis 2019 22;2019:3081621. Epub 2019 Jul 22.

Laboratory of Immunomodulation and New Therapeutic Approaches (LINAT), Suely-Galdino Therapeutic Innovation Research Center (NUPIT-SG), Federal University of Pernambuco (UFPE), Recife, PE, Brazil.

Background: Due to the variety of functions that galectins (Gal) possess, it is clear that they participate in the pathogenesis of rheumatoid arthritis (RA). Although some studies demonstrate their functions, there is still no correlation with the clinical data of the disease, having the physiological meaning still unknown.

Objectives: To compare serum levels of Gal-1, -4, and -7 in patients with RA and healthy controls and to correlate them with clinical parameters.

Methods: Serum samples were collected from patients with RA and healthy donors to determine the serum levels of Gal-1, -4, and -7.

Results: Serum levels of Gal-1, -4, and -7 were significantly higher in RA patients compared to controls. We evaluated disease activity (CDAI) with serum levels of galectins and found that patients who were high in disease activity had high levels of galectin compared to the moderate activity group. Galectin-4 had higher levels in patients who were in high activity when compared to the group in remission or low activity. Evaluating the activity of the individual disease (DAS28), patients in high individual activity had high levels of Gal-4 when compared to the group in remission or low activity. We also found an association between positive rheumatoid factor and Gal-1 and Gal-4 levels.

Conclusion: Our results show for the first time the relationship between serum levels of galectin and the clinical parameters of patients with RA. Demonstrating their role in pathogenesis, new studies with galectins are needed to assess how they function as a biomarker in RA.
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http://dx.doi.org/10.1155/2019/3081621DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6681614PMC
July 2019

Oral features of systemic sclerosis: A case-control study.

Oral Dis 2019 Nov 13;25(8):1995-2002. Epub 2019 Sep 13.

Oral Medicine Unit, Departamento de Clínica e Odontologia Preventiva, Universidade Federal de Pernambuco, Recife, Brazil.

Objective: The aim of this study was to evaluate the orofacial parameters of systemic sclerosis (SSc) and its related systemic features.

Subjects And Methods: A descriptive case-control study was performed from November 2015 to October 2016. Ninety-three individuals were included and divided into SSc group (n = 50) and healthy controls (C, n = 43).

Results: Systemic sclerosis individuals were mostly women (43/50, 86%), with a mean age of 46 years (±11.6 years). Telangiectasia (42/50, 84%) and reduced mouth opening (35/50, 70%) were the most frequent orofacial findings. The periodontitis frequency was much higher in SSc individuals than in healthy controls (90.7% × 48.83%; p < .001). In addition, SSc individuals presented a distinctive pattern of periodontitis, with low probing pocket depth (2 ± 0.65 mm × 2 ± 0.24; p < .001), higher gingival recession (4 ± 2.13 × 0.14 ± 0,22; p < .001), higher periodontal attachment loss (6 ± 1.34 mm × 2 ± 0.43, p < .001), and lower gingival bleeding index values (7.05 ± 7.25 × 21.57 ± 15.66; p < .001).

Conclusions: Orofacial manifestations were common in SSc and included a unique pattern of periodontal manifestation, characterized by lower gingival bleeding index, higher periodontal attachment loss, and low probing depth.
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http://dx.doi.org/10.1111/odi.13174DOI Listing
November 2019

DAPSA versus cDAPSA: Do we need to use CRP?

Ann Rheum Dis 2020 11 22;79(11):e142. Epub 2019 Jul 22.

Department of Rheumatology, Clinical Hospital of Federal University, Recife, Pernambuco, Brazil.

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http://dx.doi.org/10.1136/annrheumdis-2019-215960DOI Listing
November 2020

IL-7 is a Key Driver Cytokine in Spondyloarthritis?

J Immunol Res 2019 29;2019:7453236. Epub 2019 May 29.

Hospital das Clínicas de Pernambuco, Brazil.

The rationale for a type 17 signature in the pathogenesis of spondyloarthritis (SpA) has been increasing and being ratified in studies recently. IL-7 is a cytokine whose ability to stimulate IL-17 production in both innate and adaptive immunity cells has made it a promising target not only for a better understanding of the disease as well as an important potential therapeutic target in patients with SpA.
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http://dx.doi.org/10.1155/2019/7453236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6560328PMC
December 2019

Pilates method in the treatment of patients with Chikungunya fever: a randomized controlled trial.

Clin Rehabil 2019 Oct 24;33(10):1614-1624. Epub 2019 Jun 24.

Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Pernambuco, Recife, Brasil.

Objective: The aim of this study was to evaluate the effects of the Pilates method on the reduction of pain, improvement of joint function, and quality of life of patients with chronic Chikungunya fever.

Design: This is a randomized, controlled, blind trial for the evaluators.

Setting: The study was conducted at the Advanced Laboratory in Physical Education and Health at Federal University of Pernambuco, Brazil.

Subjects: A total of 51 patients were allocated randomly and divided into 2 groups: a Pilates group (26 patients) and a control group (25 patients). After 12 weeks, 4 patients in the Pilates group and 5 in the control group were lost to follow-up.

Intervention: The Pilates group performed 24 Pilates method intervention sessions; the control group continued to receive standard clinical treatment at the outpatient clinic.

Main Measures: The main measures were as follows: visual analogue scale (VAS) for pain, functional capacity evaluated by Health Assessment Questionaire (HAQ), quality of life measured by the 12-Item Short-Form Health Survey (SF-12), and range of joint motion by goniometry.

Results: After 12 weeks, patients in the Pilates group presented lower VAS ( < 0.001), lower HAQ scores ( < 0.001), and higher quality-of-life scores ( < 0.001) compared with the control group. We found statistically significant results for the Pilates group in the range of movement for shoulder, knee, ankle, and lumbar spine ( < 0.001). In the intragroup analysis, there was a significant improvement in all outcomes evaluated.

Conclusion: In this study, patients undertaking Pilates method for 12 weeks had less pain, better function and quality of life, and increased range of joint movement.
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http://dx.doi.org/10.1177/0269215519856675DOI Listing
October 2019

CCL3, IL-7, IL-13 and IFNγ transcripts are increased in skin's biopsy of systemic sclerosis.

Exp Dermatol 2019 10 3;28(10):1172-1175. Epub 2019 Jul 3.

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Recife, Brazil.

Although several cytokines and chemokines have been investigated as possible mediators of fibrosis in systemic sclerosis (SSc), specific correlation between cytokines and organ involvement have not been found yet, and a cytokine profile characteristic of SSc is far to be identified. We studied the profile of antifibrotic and profibrotic transcripts involved in skin of SSc patients. The mRNA expression was detected by fluorescence-based quantitative real-time PCR (qPCR) in skin's biopsies from 14 patients with SSc and 5 healthy controls. PDGF-A, CTGF, CCL3, IL-6, IL-13, IL-7, IFNγ, IL-17, IL-22 and RORc were analysed in these samples. CCL3, IL-7, IL-13 and IFN-γ were more expressed in skin's biopsy of patients with SSc (P = 0.0002, P = 0.0082, P = 0.0243, P = 0.0335, respectively) when compared with healthy controls. We also found a positive correlation between CCL3 and IL-7 transcripts (P = 0.0050 r = 0.7187). Furthermore, we observed that patients with lung involvement had lower expression of PDGF-A (P = 0.0385). We found an increase in IL-7, IFN-γ, CCL3 and IL-13 relative mRNA expressions on the skin's biopsy of patients with SSc, and a positive correlation between IL-7 and CCL3. These molecules are involved in the pathogenesis of SSc, and how their interactions occur should be the subject of further studies.
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http://dx.doi.org/10.1111/exd.13982DOI Listing
October 2019

IL-27 in patients with Chikungunya fever: A possible chronicity biomarker?

Acta Trop 2019 Aug 7;196:48-51. Epub 2019 May 7.

Serviço de Reumatologia - Hospital das Clínicas da Universidade Federal de Pernambuco, Núcleo de Pesquisa em Inovação Terapêutica Suely Galdino (Nupit-SG)/ UFPE, Endereço: Av. Prof. Moraes Rego, 1235 - Cidade Universitária, Recife, PE, CEP: 50670-901, Brazil.

Background/purpose: Although many patients with chikungunya virus disease (CHIKVD), an arboviral disease characterized by sudden fever and incapacitating poliartralgia, develop chronic articular symptoms, the mechanisms involved in CHIKVD's chronification and its possible biomarkers remain poorly understood. Interleukin (IL)-17A, IL-21, IL-22, IL-29, and transforming growth factor (TGF)-β have been implicated in the pathogenesis of other inflammatory joint diseases, including rheumatoid arthritis, psoriatic arthritis, and ankylosing spondylitis. Since chronic manifestations of CHIKVD share many clinical and immunological characteristics with those diseases, we assessed the serum levels of those cytokines and analyzed their associations with clinical manifestations in patients with CHIKVD.

Methods: We evaluated 45 patients (36 female, mean age: 55.2 ± 13.8 years) with CHIKVD serologically confirmed by enzyme-linked immunosorbent assay (ELISA), articular manifestations upon evaluation, and no previous history of inflammatory rheumatologic diseases, along with 49 healthy age- and sex-matched controls. We tested anti-Chikungunya IgM and IgG antibodies and measured IL-17A, IL-21, IL-22, IL-27, IL-29, and TGF-β serum levels with specific ELISA kits.

Results: IL-27, IL-17A, and IL-29 appeared in most patients but not in controls. IL-27 serum levels were higher in patients with chronic symptoms (median: 523.0 pg/mL [62.5-1,048]) than in ones in the acute or subacute stage (median: 62.5 pg/mL [62.5-483.8], p = .008). In patients with CHIKVD, we found significant correlations between IL-27 levels and tender joint counts (r = .32, p = .006), along with associations between IL-17A levels and swollen joint counts (r = .315, p = .0352). Furthermore, patients with arthritis had higher IL-17A levels (median: 23.14 pg/mL [20.6-25.86]) than ones without (median: 20.29 pg/mL [3.91-22.43], p = .0352). We did not detect IL-22 in either group or IL-21 in patients with CHIKVD.

Conclusion: Serum levels of IL-17A, IL-27, and IL-29 were high in patients with CHIKVD and had important associations with articular manifestations, which might indicate the inflammatory nature of Chikungunya infection in patients with joint symptoms and the roles of those cytokines in the disease's pathophysiology.
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http://dx.doi.org/10.1016/j.actatropica.2019.05.005DOI Listing
August 2019

Dexamethasone inhibits cytokine production in PBMC from systemic sclerosis patients.

Inflammopharmacology 2019 Aug 8;27(4):723-730. Epub 2019 May 8.

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica, Universidade Federal de Pernambuco, Avenida Professor Moraes Rêgo, 1235, Cidade Universitária, Recife, PE, 50670-901, Brazil.

Glucocorticoids (GC) are widely used in the treatment of SSc, although there is not much evidence to prove the benefits offered by these drugs in this disease. In this study, we evaluated the effects of a GC on cytokine production in peripheral blood mononuclear cells (PBMC) of SSc patients. The effect of dexamethasone (DEX) was evaluated in PBMC of 21 SSc patients and 10 healthy volunteers after stimulation of cells with anti-CD3 and anti-CD28. Cytokines IL-2, IL-4, IL-6, IL-10, IL-17A, IL-17F, IFN-γ, TNF, and IL-1β were quantified in the culture supernatant by CBA or ELISA. Of the patients evaluated in this study, 8 (38%) were taking corticosteroids, and esophageal dysfunction was more frequent in these patients when compared to those who did not take corticosteroids. DEX (1.000 nM) treatment in PBMC of SSc patients stimulated with anti-CD3 and anti-CD28 promoted a significant reduction in IL-2, IL-4, IL-6, IL-10, IL-17A, IFN-γ, TNF, IL-1β (p < 0.001 for all), and IL-17F (p = 0.023) cytokines levels. We did not observe differences in response to in vitro treatment with DEX between groups of patients taking or not taking corticosteroids. In PBMC from healthy volunteers, we observed that DEX treatment significantly reduced IL-4, IFN-γ (p = 0.003 for both), IL-6, IL-10, IL-17A, and TNF (p = 0.002 for all) cytokines. These results show that DEX treatment in PBMC of SSc patients reduced the production of important cytokines involved in the pathogenesis of the disease, suggesting a possible mechanism of action of the CG in the treatment of SSc.
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http://dx.doi.org/10.1007/s10787-019-00600-wDOI Listing
August 2019

2017 recommendations of the Brazilian Society of Rheumatology for the pharmacological treatment of rheumatoid arthritis.

Adv Rheumatol 2018 May 24;58(1). Epub 2018 May 24.

Serviço de Reumatologia, Hospital do Servidor Público Estadual de São Paulo, Instituto de Assistência Médica ao Servidor Público Estadual, São Paulo, Brazil.

The objective of this document is to provide a comprehensive update of the recommendations of Brazilian Society of Rheumatology on drug treatment of rheumatoid arthritis (RA), based on a systematic literature review and on the opinion of a panel of rheumatologists. Four general principles and eleven recommendations were approved. General principles: RA treatment should (1) preferably consist of a multidisciplinary approach coordinated by a rheumatologist, (2) include counseling on lifestyle habits, strict control of comorbidities, and updates of the vaccination record, (3) be based on decisions shared by the patient and the physician after clarification about the disease and the available therapeutic options; (4) the goal is sustained clinical remission or, when this is not feasible, low disease activity. Recommendations: (1) the first line of treatment should be a csDMARD, started as soon as the diagnosis of RA is established; (2) methotrexate (MTX) is the first-choice csDMARD; (3) the combination of two or more csDMARDs, including MTX, may be used as the first line of treatment; (4) after failure of first-line therapy with MTX, the therapeutic strategies include combining MTX with another csDMARD (leflunomide), with two csDMARDs (hydroxychloroquine and sulfasalazine), or switching MTX for another csDMARD (leflunomide or sulfasalazine) alone; (5) after failure of two schemes with csDMARDs, a bDMARD may be preferably used or, alternatively a tsDMARD, preferably combined, in both cases, with a csDMARD; (6) the different bDMARDs in combination with MTX have similar efficacy, and therefore, the therapeutic choice should take into account the peculiarities of each drug in terms of safety and cost; (7) the combination of a bDMARD and MTX is preferred over the use of a bDMARD alone; (8) in case of failure of an initial treatment scheme with a bDMARD, a scheme with another bDMARD can be used; in cases of failure with a TNFi, a second bDMARD of the same class or with another mechanism of action is effective and safe; (9) tofacitinib can be used to treat RA after failure of bDMARD; (10) corticosteroids, preferably at low doses for the shortest possible time, should be considered during periods of disease activity, and the risk-benefit ratio should also be considered; (11) reducing or spacing out bDMARD doses is possible in patients in sustained remission.
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http://dx.doi.org/10.1186/s42358-018-0005-0DOI Listing
May 2018

Correction to: Statins Inhibit Cytokines in a Dose-Dependent Response in Patients with Systemic Sclerosis.

Inflammation 2019 04;42(2):412

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas Suely Galdino, Universidade Federal de Pernambuco, Recife, Brazil.

One of the author's surname was incorrect. Anderson Ferreira de Almeida should be captured as Anderson Rodrigues de Almeida. The correct name is now presented above.
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http://dx.doi.org/10.1007/s10753-018-0916-2DOI Listing
April 2019

Statins Inhibit Cytokines in a Dose-Dependent Response in Patients with Systemic Sclerosis.

Inflammation 2019 Apr;42(2):407-411

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas Suely Galdino, Universidade Federal de Pernambuco, Recife, Brazil.

Although statins have been successfully administered in the treatment of hypercholesterolemia and cardiovascular disease due to their lipid-lowering and anti-atherosclerotic action, they have shown immunomodulatory effects in several studies with immune-mediated diseases. The aim of this study was to investigate the effects of statins treatment on Th1, Th2, and Th17 cytokines production from stimulated peripheral blood mononuclear cells (PBMCs) obtained from Systemic Sclerosis (SSc) patients. We recruited 21 patients classified according to the American College of Rheumatology criteria for SSc for PBMCs culture analysis. Cytokine levels (IL-2, IL-4, IL-6, IL-10, TNF, IFN-γ, IL-17A, and IL-17F) were quantified by ELISA or CBA, and patients were assessed for clinical and exam's variables. Simvastatin and atorvastatin at 50 μM promoted reduction in all cytokine levels with statistical significance, except for IL-6, which had its reduction only induced by the use of simvastatin. Statins, particularly simvastatin, appear to have an immunosuppressive effect in reducing all cytokine secretion levels from PBMCs of SSc in a dose-dependent manner.
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http://dx.doi.org/10.1007/s10753-018-0907-3DOI Listing
April 2019

Different profile of cytokine production in patients with systemic sclerosis and association with clinical manifestations.

Immunol Lett 2018 06 27;198:12-16. Epub 2018 Mar 27.

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas - Núcleo de Pesquisa em Inovação Terapêutica (LINAT-NUPIT) - UFPE, Av. Prof. Moraes Rego, 1235, Cidade Universitária, Recife, PE, CEP: 50670-901, Brazil.

Immune dysregulation is a central process in the pathogenesis of systemic sclerosis (SSc). Cytokines produced by lymphocytes and monocytes are important mediators and induce tissue damage, recruit additional inflammatory cells, and promote extracellular matrix production and fibrosis. In the present research, we aimed to study the associations between levels of cytokines in serum and culture supernatants from peripheral blood mononuclear cells (PBMCs) and clinical manifestations in SSc patients. Serum samples were obtained from 56 SSc patients and 56 unrelated age- and gender-matched healthy individuals. Resting and anti-CD3/CD28-stimulated PBMC cultures were obtained from 19 SSc patients and 8 healthy controls. IL-2, IL-4, IL-6, IL-10, IL-17A, TNF, and IFN-γ levels were measured by ELISA or CBA. Serum cytokines, except IL-17A, were below the kit detection limit in most of the patients and controls. In unstimulated PBMC, the production of TNF(p = 0.004), IL-10(p = .048), IL-2(p < 0.001), and IL-6 (p = 0.01) was higher in SSc patients than in healthy controls. After anti-CD3/CD28 stimulation, scleroderma PBMCs had lower concentrations of TNF(p = 0.009), IL-10(p = .018), and IL-2(p = .002) than HC. In unstimulated PBMC, IL-2 concentration was higher in patients with esophageal dysmotility (p = 0.04), and IL-10 levels had a positive correlation with modified Rodnan score (p = 0.03). After anti-CD3/CD28 stimulation, higher levels of IL-2 and IL-4 were observed in SSc patients with lung fibrosis (p = 0.01 and 0.006, respectively), and higher levels of IL-10 (p = 0.04) and IL-4 (p = 0.04) in patients with digital ulcers. In conclusion, SSc patients have a different profile of cytokine production and this was associated with clinical manifestations.
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http://dx.doi.org/10.1016/j.imlet.2018.03.011DOI Listing
June 2018

IL-17 and related cytokines involved in systemic sclerosis: Perspectives.

Autoimmunity 2018 02 19;51(1):1-9. Epub 2017 Dec 19.

b Laboratório de Imunomodulação e Novas Abordagens Terapêuticas Suely Galdino , Universidade Federal de Pernambuco , Recife , Brazil.

Systemic sclerosis (SSc) is a multisystemic, complex, and rare disease of connective tissue, with high morbidity and mortality, and without specific treatment. The disease is characterized by three main principles: vascular disease, autoantibody production and inflammation, and fibrosis. Since it is well defined that SSc is characterized by elevated production of TGF-β, IL-6, and IL-1, all of them cytokines related to Th17 differentiation, the hypothesis is that this disease may be strongly related to a polarization of the immune response towards the Th17 pathway. Considering the importance of a better understanding of the pathophysiology of Th17 pathway in SSc, this article aims to propose an update for a better understanding of current knowledge on main cytokines secreted by the Th17 cells (IL-17 A, IL-21, and IL-22) and the future prospects in the current disease.
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http://dx.doi.org/10.1080/08916934.2017.1416467DOI Listing
February 2018

Corticosteroid inhibits chemokines production in systemic sclerosis patients.

Steroids 2017 11 1;127:24-30. Epub 2017 Sep 1.

Laboratório de Imunomodulação e Novas Abordagens Terapêuticas, Núcleo de Pesquisa em Inovação Terapêutica (NUPIT), Universidade Federal de Pernambuco, Recife, PE, Brazil.

In this study, we evaluated glucocorticoids (GC) effects on cytokine/chemokine levels in serum samples and peripheral blood mononuclear cell (PBMC) production from systemic sclerosis (SSc) patients. We evaluated cytokine and chemokine levels in serum samples from SSc patients taking or not taking systemic glucocorticoids. PBMCs response to methylprednisolone (MP) was examined from 15 SSc patients and 8 healthy control subjects following PBMC stimulation with anti-CD3/CD28. Cytokine (IFN-γ, TNF, IL-2, IL-4, IL-6, IL-10, and IL-17A) and chemokine (CXCL8/IL-8, CCL5/RANTES, CXCL9/MIG, CCL2/MCP-1, and CXCL10/IP-10) levels were quantified in serum and in PBMC culture supernatants by CBA or ELISA. Compared with patients not taking corticosteroids, we did not observe any significant differences in cytokines/chemokines serum levels in patients using systemic corticosteroids. After stimulation with anti-CD3/CD28, PBMCs treated with MP (100μM), showed a significant reduction of CCL2/MCP-1 (p=0.001), CCL5/RANTES (p=0.04), and CXCL8/IL-8 (p=0.003) levels in SSc patients. In PBMC from healthy controls, we observed decreased IFN-γ, TNF, IL-2, and IL-10 levels after MP treatment, compared with stimulated condition (p<0.01 for all). However in SSc patients, we did not find any significant reduction in these cytokine levels after MP treatment. In conclusion, CCL2/MCP-1, CCL5/RANTES, and CXCL8/IL-8 are chemokines that are potentially modulated by corticosteroids in vitro in SSc patients, but no effect was observed on IL-2, IL-4, IL-6, IL-10, IL-17A, TFN, and IFN-γ secretion. These results suggest a potential effect of GCs on SSc treatment and may reflect the benefit of their use in some patients.
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http://dx.doi.org/10.1016/j.steroids.2017.08.012DOI Listing
November 2017

Recommendations of the Brazilian Society of Rheumatology for diagnosis and treatment of Chikungunya fever. Part 1 - Diagnosis and special situations.

Rev Bras Reumatol Engl Ed 2017 25;57 Suppl 2:421-437. Epub 2017 Jul 25.

Instituto de Medicina Integral Professor Fernando Figueira (IMIP), Hospital Miguel Arraes, Paulista, PE, Brazil.

Chikungunya fever has become a relevant public health problem in countries where epidemics occur. Until 2013, only imported cases occurred in the Americas, but in October of that year, the first cases were reported in Saint Marin island in the Caribbean. The first autochthonous cases were confirmed in Brazil in September 2014; until epidemiological week 37 of 2016, 236,287 probable cases of infection with Chikungunya virus had been registered, 116,523 of which had serological confirmation. Environmental changes caused by humans, disorderly urban growth and an ever-increasing number of international travelers were described as the factors responsible for the emergence of large-scale epidemics. Clinically characterized by fever and joint pain in the acute stage, approximately half of patients progress to the chronic stage (beyond 3 months), which is accompanied by persistent and disabling pain. The aim of the present study was to formulate recommendations for the diagnosis and treatment of Chikungunya fever in Brazil. A literature review was performed in the MEDLINE, SciELO and PubMed databases to ground the decisions for recommendations. The degree of concordance among experts was established through the Delphi method, involving 2 in-person meetings and several online voting rounds. In total, 25 recommendations were formulated and divided into 3 thematic groups: (1) clinical, laboratory and imaging diagnosis; (2) special situations; and (3) treatment. The first 2 themes are presented in part 1, and treatment is presented in part 2.
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http://dx.doi.org/10.1016/j.rbre.2017.05.006DOI Listing
August 2019