Lecture Series on Chronic Inflammation

Inflammatory rheumatic diseases frequently affect women of childbearing age and often interfere with family planning. To control disease activity of the rheumatic disease, effective treatment might be required during pregnancy. On the other hand, the rheumatic disease itself might bear risks for maternal or foetal complications. Information on the safety of a substantial number of drugs when used before or during pregnancy and on the outcomes of pregnancies in women with rheumatic diseases is urgently desired.

This lecture gives an overview about current literature on the disease course of spondyloarthritis during pregnancy and on course and outcomes of pregnancy in women with spondyloarthritis. Moreover, the approach of a joint data analysis within the European Network for Pregnancy Registers in Rheumatology will be presented.

Genetically engineered T cells are powerful new medicines, offering hope for curative responses in patients with cancer. Chimeric antigen receptors (CARs) are a class of synthetic receptors that reprogram lymphocyte specificity and function.

Advances in the selection of optimal T cells, genetic engineering, and cell manufacturing are poised to broaden T-cell-based therapies and foster new applications in infectious diseases and autoimmunity. In this lecture, we will review the current situation of CAR-T cell therapy.

The prevalence of obesity has been on the rise for decades. It is nowadays viewed as a mild chronic inflammatory disease and has been shown to be a risk factor for developing rheumatoid arthritis (RA).

Moreover, obesity may affect the effectiveness of RA treatment. The talk tries to give an overview on the topic, starting with some biologic background and ending with latest results on RA treatment with biologic drugs from the RABBIT cohort study at the DRFZ.

Mast cells are commonly known for triggering allergic reactions and anaphylaxis. However, in this lecture you will experience that mast cells are much more than just mediators of bothersome allergies. Strategically located in all vascularized tissues of the human body and equipped with a multitude of surface receptors they are able to respond to a variety of immunologic (IgE, IgG, MHCII) and non-immunologic stimuli (e.g. TLRs, PAF receptor, complement receptors, G protein-coupled receptors). You will get inside into the fascinating mast cell biology and will explore how mast cells orchestrate immune reactions either contributing to allergy, chronic inflammation, pathogen defense or resolution of inflammation.

Different subsets of T helper cells can be identified by lineage-defining transcription factors and the production of specific effector cytokines that mediate the appropriate immune response. However, not only the type of cytokine produced but also its amount needs to be tightly regulated in order to prevent excessive immunopathology. In individual T helper type 1 memory cells, specific T-bet amounts and graded interferon-γ (IFN-γ) production levels persist in vivo for several weeks, showing that IFN-γ expression is stably imprinted on a quantitative level.

In this lecture, the concept of quantitative regulation of effector cytokines will be explained and hypotheses of the underlying mechanisms will be discussed.

This talk will give an overview, which analyses can be done with claims data from the German statutory health insurance funds. Not all patient groups with chronic inflammatory diseases have the same access to therapies like medication or physical therapy. I will show some results that demonstrate how this is associated with gender, age, geographic region and the medical specialty of the primary care physician. We will explore reasons for regional variation in pneumococcal vaccination in Germany and assess if there is an effect on hospitalizations for pneumonia in persons with rheumatoid arthritis.

T follicular helper (Tfh) cells are a specialized subset of CD4+ T cells which provide help to B cells during the germinal center reaction. They are essential for the generation of highly specific memory B cells and long-lived plasma cells, which equip the body with long-lasting immunity against recurrent infections. Vaccinations require efficient activation of Tfh cells, whereas many autoimmune diseases are associated with aberrant Tfh cell numbers. Consequently, the boosting of protective Tfh cell responses as well as the abrogation of harmful Tfh cell reactions are of great clinical interest. This lecture will deal with circumstances driving Tfh development as well as factors which facilitate their maintenance.

Analyzing the transcriptional state of cells has become one of the pillars of omics-science in the field of molecular biology over the last two decades. Identifying differences of different cell populations concerning expression of marker genes is just one of many questions that can be answered by this kind of data. With the growing number of data sets available it becomes more and more important to establish an understanding of what sort of information can be drawn from these massive amounts of data, and where its limitations are. There are various algorithms available to choose from, but not every algorithm fits the questions you want to answer with your data. Distinguishing between hypotheses driven algorithms and unbiased approaches to analyze your data, is as important at the data itself. A clear cut experimental design is an important step to ensure the newly generated data is really able to address the questions that should be answered. Especially with the new technique of single cell sequencing becoming more and more popular the rigid setup and documentation of experiments has become an essential step to ensure the quality of your data. It’s important to keep in mind, that every algorithm you use is only as good as the way you raise your question, because algorithms will only return a positive or negative answer. The interpretation is still up to the scientist.

Secondary and tertiary lymphoid tissue is in large part self-organizing, through positive-feedback cycles between tissue stromal cells, vascular endothelium, and circulating immune cells recruited to inflamed tissue. One consequence of this is that almost any tissue can be converted into an organized lymphoid tissue capable of supporting germinal center function, given sufficiently persistent inflammation. Ectopic lymphoid structures may be found in response to mucosal infection with certain bacteria or viruses, but is more common today in conjunction with pathological autoimmunity. This self-organizing ability means that chronic tissue inflammation can be self-perpetuating through positive feedback, but these feedback interactions also offer new targets for pharmacologic interventions.

Despite increasing research efforts, when compared to other infections fungal infections are still understudied and often misdiagnosed, leading to a high mortality rate.

Candida albicans is a commensal fungus commonly found in gastrointestinal, oral and vaginal mucosal tissues of healthy individuals, estimated to be found in approximately 70% of the human population.

This benign commensal can, however, cause severe infections in immunocompromised hosts, being in fact one of the most common fungal pathogens of humans and one of the leading causes of nosocomial infections. Data from 2012 estimate that every year more than 400 000 individuals suffer from life-threatening Candida albicans infections, these presenting a mortality rate of 46-75%.

These facts highlight the urgent need to better understand the interplay between fungal pathogens and the human immune system – the main aspect to be addressed in this lecture.

This lecture will give an overview over next generation /deep sequencing, the technical advances, challenges and how it can be used to investigate immune cells and chronic inflammation. After a basic introduction to the Illumina sequencing technology, it will be explained how libraries can be prepared from different types of starting material. Furthermore, the lecture will cover a number of methods and technical approaches that make use of next generation sequencing to answer different scientific questions beyond transcriptional changes, such as chromatin accessibility, transcription factor binding, translational control and TCR/BCR repertoires. Finally, I will briefly describe methods for single cell sequencing and give some examples how using these can increase our knowledge about immunological responses and chronic inflammation.

Immune response is a result of a very delicate balance between activating and inhibitory signals provided by the molecules expressed on the surface
of immune cells.
While too little inflammation results in the increased susceptibility to pathogens and possible outgrowth of malignant cells, the consequence of too
much inflammation is autoimmunity and immune pathology.
In the recent decade, cancer therapy was revolutionized by the development of drugs targeting immune checkpoints, receptors such as CTLA-4 and
PD-1, thus interrupting the inhibitory signal and unleashing the T cell mediated anti-tumor response.
This lecture will give an overview on the current progress in targeting T cell checkpoints, both co-stimulatory and inhibitory receptors, as well as how
the experience from treating cancer with checkpoint blockade could be used as a therapeutic approach in autoimmune rheumatic diseases.

MicroRNAs (miRNAs) are small (~ 22 nucleotide long), single-stranded non-coding RNAs. They are important regulators of gene expression in
cells and are critical in a multitude of cellular processes such as cell division, cell survival or migration. Recent studies demonstrated that miRNAs
can contribute to the pathogenesis of chronic inflammatory diseases. This lecture will highlight the relationship between miRNAs and chronic
inflammatory conditions and focus on mechanistic functions of miRNAs in the pathology of chronic inflammation.

More than one hundred years ago Paul Ehrlich developed chemotherapy and thereby pioneered drug discovery. Since then, this research area has
turned into a multi-billion-dollar business which was for a long time dominated by the pharma industry. However, this is about to change: drug
discovery in academic institutions becomes more and more popular again. Based on my own experience and using several examples I will
highlight the value of academic drug discovery for the development of sophisticated therapeutic approaches especially for indications with unmet
medical need.

Differentiation of resting memory T helper (Th) cells occurs independently of that of effector follicular T helper (Tfh) cells

IL-2 signaling is crucial for the differentiation of resting memory Th cells

B cells control the bifurcated differentiation programs for effector and resting memory Th cell lineages

Virchow noticed this association 150 years ago, that many sites of chronic inflammation are associated with the subsequent development of cancer.
Genetic evidence has clarified the mechanisms by which this occurs, how chronic inflammatory signaling can induce the development of certain
lymphoid and non-lymphoid malignancies, and how inhibition of inflammation can prevent this. Recently, the development of immune-modulating
drugs to induce anti-tumor T cell responses has shown the converse of this, how tumors use chronic exposure to antigen to desensitize T cells and
prevent adaptive immune responses to tumor neoantigens. Better understanding of the mechanisms by which peripheral tolerance is maintained,
and how this is manipulated by cancers, can lead to improved therapies.

Modern optical methods represent essential tools that are widely used to study complex processes in biology. Progress in technology increased
the level of research functionality allowing to perform experiments and address scientific questions that were not possible before. This lecture will
give an overview to the principles of different advanced optical techniques, such as multiphoton microscopy, super-resolution methods, optical
coherence tomography, fluorescence life-time imaging. We will discuss the application of these techniques to study the pathology of chronic
inflammation in different organs.

Some of the pivotal pro-inflammatory mediators, including the cytokines tumor necrosis factor alpha (TNFα), interleukin 1 (IL-1) and interleukin 6
(IL-6), as well as the acute-phase reactant C-reactive protein (CRP), are involved in atherogenesis and eventually in the development of coronary
artery diseases. The autoimmune disease of rheumatoid arthritis is characterized by chronic inflammation primarily affecting the joints. However,
patients with rheumatoid arthritis have an increased burden of cardiovascular morbidity and mortality compared to the general population. This
lecture will summarize current insights into chronic inflammation as a link between cardiovascular events and rheumatoid arthritis. Furthermore,
experiences from the German observational cohort RABBIT (Rheumatoid Arthritis: Observation of Biologic Therapy) with regard to cardiovascular
diseases will be presented.

1. Avina-Zubieta JA, Choi HK, Sadatsafavi M, Etminan M, Esdaile JM, Lacaille D. Risk of cardiovascular mortality in patients with rheumatoid arthritis: a meta-analysis of observational studies. Arthritis Rheum. 2008;59(12):1690-7.
2. Avina-Zubieta JA, Thomas J, Sadatsafavi M, Lehman AJ, Lacaille D. Risk of incident cardiovascular events in patients with rheumatoid arthritis: a meta-analysis of observational studies. Ann Rheum Dis. 2012;71(9):1524-9.
3. Gabriel SE, Crowson CS, Kremers HM, Doran MF, Turesson C, O’Fallon WM, Matteson EL. Survival in rheumatoid arthritis: a population-based analysis of trends over 40 years. Arthritis Rheum. 2003;48(1):54-8.
4. del Rincon ID, Williams K, Stern MP, Freeman GL, Escalante A. High incidence of cardiovascular events in a rheumatoid arthritis cohort not explained by traditional cardiac risk factors. Arthritis Rheum. 2001;44(12):2737-45.
5. Symmons DP, Gabriel SE. Epidemiology of CVD in rheumatic disease, with a focus on RA and SLE. Nat Rev Rheumatol. 2011;7(7):399-408.
6. van Vollenhoven RF. Unresolved issues in biologic therapy for rheumatoid arthritis. Nat Rev Rheumatol. 2011;7(4):205-15.
7. Meissner Y, Zink A, Kekow J, Rockwitz K, Liebhaber A, Zinke S, Gerhold K, Richter A, Listing J, Strangfeld A. Impact of disease activity and treatment of comorbidities on the risk of myocardial infarction in rheumatoid arthritis. Arthritis Res Ther. 2016;18(1):183.
8. Behrouz R. The risk of ischemic stroke in major rheumatic disorders. J Neuroimmunol. 2014;277(1-2):1-5.
9. Ovbiagele B, Nguyen-Huynh MN. Stroke epidemiology: advancing our understanding of disease mechanism and therapy. Neurotherapeutics. 2011;8(3):319-29.
10. Navi BB, Reiner AS, Kamel H, Iadecola C, Elkind MSV, Panageas KS, DeAngelis LM. Association between incident cancer and subsequent stroke. Annals of Neurology. 2015;77(2):291-300.
11. Meissner Y, Richter A, Manger B, Tony HP, Wilden E, Listing J, Zink A, Strangfeld A. Serious adverse events and the risk of stroke in patients with rheumatoid arthritis: results from the German RABBIT cohort. Ann Rheum Dis. 2017;76(9):1583-90.
12. Nicola PJ, Crowson CS, Maradit-Kremers H, Ballman KV, Roger VL, Jacobsen SJ, Gabriel SE. Contribution of congestive heart failure and ischemic heart disease to excess mortality in rheumatoid arthritis. Arthritis Rheum. 2006;54(1):60-7.
13. Nicola PJ, Maradit-Kremers H, Roger VL, Jacobsen SJ, Crowson CS, Ballman KV, Gabriel SE. The risk of congestive heart failure in rheumatoid arthritis: a population-based study over 46 years. Arthritis Rheum. 2005;52(2):412-20.
14. Meissner Y, Schäfer M, Manger B, Zänker M, Ochs W, Listing J, Strangfeld A. THU0142 The prognosis of heart failure in patients with rheumatoid arthritis. 2018;77(Suppl 2):291-2.
15. Liao KP. Cardiovascular disease in patients with rheumatoid arthritis. Trends Cardiovasc Med. 2017;27(2):136-40.
16. Nurmohamed MT, Heslinga M, Kitas GD. Cardiovascular comorbidity in rheumatic diseases. Nat Rev Rheumatol. 2015;11(12):693-704.
17. Barnabe C, Martin BJ, Ghali WA. Systematic review and meta-analysis: anti-tumor necrosis factor alpha therapy and cardiovascular events in rheumatoid arthritis. Arthritis Care Res (Hoboken). 2011;63(4):522-9.
18. Micha R, Imamura F, Wyler von Ballmoos M, Solomon DH, Hernan MA, Ridker PM, Mozaffarian D. Systematic review and meta-analysis of methotrexate use and risk of cardiovascular disease. Am J Cardiol. 2011;108(9):1362-70.
19. Ridker PM, Everett BM, Thuren T, MacFadyen JG, Chang WH, Ballantyne C, Fonseca F, Nicolau J, Koenig W, Anker SD, Kastelein JJP, Cornel JH, Pais P, Pella D, Genest J, Cifkova R, Lorenzatti A, Forster T, Kobalava Z, Vida-Simiti L, Flather M, Shimokawa H, Ogawa H, Dellborg M, Rossi PRF, Troquay RPT, Libby P, Glynn RJ, Group CT. Antiinflammatory Therapy with Canakinumab for Atherosclerotic Disease. N Engl J Med. 2017;377(12):1119-31.
20. Ridker PM, Everett BM, Pradhan A, MacFadyen JG, Solomon DH, Zaharris E, Mam V, Hasan A, Rosenberg Y, Iturriaga E, Gupta M, Tsigoulis M, Verma S, Clearfield M, Libby P, Goldhaber SZ, Seagle R, Ofori C, Saklayen M, Butman S, Singh N, Le May M, Bertrand O, Johnston J, Paynter NP, Glynn RJ, Investigators C. Low-Dose Methotrexate for the Prevention of Atherosclerotic Events. N Engl J Med. 2018.

InflammationLecture YM 181128

Mass cytometry permits deep cellular phenotyping in clinical immunology and basic research, with more than 40 parameters that can be measured
simultaneously at single-cell level in one assay. This is achieved by combining principles of flow cytometry and inductively coupled plasma mass
spectrometry (ICP-MS), a technology that has been developed for trace metal analysis.
This lecture introduces the principles of mass cytometry and its potential applications in the context of immunology research. We will explore how
questions in chronic inflammation can be addressed by mass cytometric assays and will discuss an example of a system-level analysis of
peripheral blood immune cells in patients with rheumatoid arthritis.

What derives a plasma cell to become memory? Is it an intrinsic competence or extrinsic stimulation or combination? Which internal signals are involved in this process? What are external supporters? What are survival factors in inflammation and autoreactive disease? More information about maintenance of protective ad autoreactive memory cells will help scientists in one hand, to design more effective vaccines inducing life-long protection against infectious diseases, in the other hand, to target efficiently autoreactive memory plasma cells. I will discuss about the internal and external factors in maintenance of memory plasma cells.

This lecture will give an overview on gene regulatory mechanisms that play an important role in establishing and maintaining chronic inflammation
and that are driven by RNA molecules. These are on the one hand miRNAs, which modulate gene expression by directly binding to their target
mRNAs and promoting translational repression or degradation. Other non-coding RNAs were also described to be involved in inflammatory
processes, even though their molecular functions are not fully understood. On the other hand the translation and stability of mRNA molecules, particularly cytokine mRNAs, is tightly regulated via sequence elements within the 3’ untranslated region. As an outlook, novel diagnostic and therapeutic approaches that make use of the above-mentioned mechanisms will be discussed.

List of reviews

Alexander M and O‘Connell RM, Noncoding RNAs and chronic inflammation: Micro-managing the fire within. Bioessays. 2015 Sep;37(9):1005-15
https://doi.org/10.1002/bies.201500054

Chew CL at al., Noncoding RNAs: Master Regulators of Inflammatory Signaling. Trends Mol Med. 2018 Jan;24(1):66-84
https://doi.org/10.1016/j.molmed.2017.11.003

Schwerk J and Savan R, Translating the Untranslated Region. J Immunol. 2015 Oct 1;195(7):2963-71
https://doi.org/10.4049/jimmunol.1500756

Inflammation, since it was defined two millenia ago, is primarily a characteristic of tissues. Even when systematic inflammation occurs, it manifests
very differently in various tissues, depending on the tissue’s physiological role. For example, resident memory T cells perform immunosurveillance
in the peripheral tissues where pathogens enter the body, while germinal center reactions occur in secondary lymphoid organs and ectopic tertiary
lymphoid tissue. The physiology of immune cells and pathogens is influenced by many parameters, including oxygen tension, temperature, perfusion,
secreted factors derived from cells or microbial flora, and contacts with other cells and extracellular matrix. As the influence of these parameters on
cellular function is different for each cell type involved in immune responses, we argue that a comprehensive analysis can only be performed in
intact, living tissue. This requires specialized imaging techniques, the uses of which both clinically and in basic research will be discussed.

It has recently been acknowledged that a variety of immune cells that cause long-term inflammation depend not only on inflammatory mediators
and antigen but also on survival factors that are thought to be secreted by tissue-resident stromal cells. In these niches, cells proved to be
refractory to conventional therapies, hence an important therapeutical question emerged what separates a benign from a malign niche.

Cusick, M. F., Libbey, J. E., & Fujinami, R. S. (2012). Molecular mimicry as a mechanism of autoimmune disease. Clinical Reviews in Allergy and Immunology, 42(1), 102–111. http://doi.org/10.1007/s12016-011-8294-7

Smart, B. A. (2008). Duration of Humoral Immunity to Common Viral and Vaccine Antigens. Pediatrics, 122(Supplement 4), S228.1-S228. http://doi.org/10.1542/peds.2008-2139LLLL

Bernardo, M. E., & Fibbe, W. E. (2013). Mesenchymal stromal cells: Sensors and switchers of inflammation. Cell Stem Cell, 13(4), 392–402. http://doi.org/10.1016/j.stem.2013.09.006

Mikkola, H. K. A. (2006). The journey of developing hematopoietic stem cells. Development, 133(19), 3733–3744. http://doi.org/10.1242/dev.02568

Buckley, C. D., Barone, F., Nayar, S., Bénézech, C., & Caamaño, J. (2015). Stromal Cells in Chronic Inflammation and Tertiary Lymphoid Organ Formation. Annual Review of Immunology, 33(1), 715–745. http://doi.org/10.1146/annurev-immunol-032713-120252

Barone, F., Nayar, S., Campos, J., Cloake, T., Withers, D. R., Toellner, K.-M., … Buckley, C. D. (2015). IL-22 regulates lymphoid chemokine production and assembly of tertiary lymphoid organs. Proceedings of the National Academy of Sciences, 112(35), 11024–11029. http://doi.org/10.1073/pnas.1503315112

Hand, T. W., Vujkovic-Cvijin, I., Ridaura, V. K., & Belkaid, Y. (2016). Linking the Microbiota, Chronic Disease, and the Immune System. Trends in Endocrinology and Metabolism: TEM, 27(12), 831–843. http://doi.org/10.1016/j.tem.2016.08.003