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Xu H, Zhang X, Lv Z, Huang F, Zou Y, Wang C, Ding F, Sun Y. Computational exploration of the self-aggregation mechanisms of phenol-soluble modulins β1 and β2 in Staphylococcus aureus biofilms. Colloids Surf B Biointerfaces 2025; 248:114498. [PMID: 39778221 DOI: 10.1016/j.colsurfb.2025.114498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2024] [Revised: 01/01/2025] [Accepted: 01/03/2025] [Indexed: 01/11/2025]
Abstract
The formation of functional bacterial amyloids by phenol-soluble modulins (PSMs) in Staphylococcus aureus is a critical component of biofilm-associated infections, providing robust protective barriers against antimicrobial agents and immune defenses. Clarifying the molecular mechanisms of PSM self-assembly within the biofilm matrix is essential for developing strategies to disrupt biofilm integrity and combat biofilm-related infections. In this study, we analyzed the self-assembly dynamics of PSM-β1 and PSM-β2 by examining their folding and dimerization through long-timescale atomistic discrete molecular dynamics simulations. Our findings revealed that both peptides primarily adopt helical structures as monomers but shift to β-sheets upon dimerization. Monomeric state, PSM-β1 exhibited frequent transitions between helical and β-sheet forms, while PSM-β2 largely retained a helical structure. Upon dimerization, both peptides showed pronounced β-sheet formation around conserved C-terminal residues 21-44. Residues 21-33, largely unstructured as monomers, demonstrated strong tendencies for β-sheet formation and intermolecular interactions, underscoring their central role in the self-assembly of both peptides. Additionally, the PSM-β1 N-terminus formed β-sheets only when interacting with the C-terminus, whereas the PSM-β2 N-terminus remained helical and uninvolved in β-sheet formation. These distinct aggregation behaviors likely contribute to biofilm dynamics, with C-terminal regions facilitating biofilm formation and N-terminal regions influencing stability. Targeting residues 21-33 in PSM-β1 and PSM-β2 offers a promising therapeutic approach for disrupting biofilm integrity. This study advances our understanding of PSM-β1 and PSM-β2 self-assembly and presents new targets for drug design against biofilm-associated diseases.
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Affiliation(s)
- Huan Xu
- School of Physical Science and Technology, Ningbo University, Ningbo 315211, China
| | - Xiaohan Zhang
- School of Physical Science and Technology, Ningbo University, Ningbo 315211, China
| | - Zhongyue Lv
- Department of Neurology, the Affiliated LiHuiLi Hospital of Ningbo University, Ningbo 315211, China
| | - Fengjuan Huang
- Ningbo Institute of Innovation for Combined Medicine and Engineering (NIIME), the Affiliated LiHuiLi Hospital of Ningbo University, Ningbo 315211, China
| | - Yu Zou
- Department of Sport and Exercise Science, Zhejiang University, Hangzhou 310058, China
| | - Chuang Wang
- School of Basic Medical Science, Health Center, Ningbo University, Ningbo, Zhejiang 315211, China.
| | - Feng Ding
- Department of Physics and Astronomy, Clemson University, Clemson, SC 29634, United States.
| | - Yunxiang Sun
- School of Physical Science and Technology, Ningbo University, Ningbo 315211, China; Department of Physics and Astronomy, Clemson University, Clemson, SC 29634, United States.
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Giraldo-Osorno PM, Wirsig K, Asa'ad F, Omar O, Trobos M, Bernhardt A, Palmquist A. Macrophage-to-osteocyte communication: Impact in a 3D in vitro implant-associated infection model. Acta Biomater 2024; 186:141-155. [PMID: 39142531 DOI: 10.1016/j.actbio.2024.08.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/23/2024] [Accepted: 08/04/2024] [Indexed: 08/16/2024]
Abstract
Macrophages and osteocytes are important regulators of inflammation, osteogenesis and osteoclastogenesis. However, their interactions under adverse conditions, such as biomaterial-associated infection (BAI) are not fully understood. We aimed to elucidate how factors released from macrophages modulate osteocyte responses in an in vitro indirect 3D co-culture model. Human monocyte-derived macrophages were cultured on etched titanium disks and activated with either IL-4 cytokine (anti-inflammatory M2 phenotype) or Staphylococcus aureus secreted virulence factors to simulate BAI (pro-inflammatory M1 phenotype). Primary osteocytes in collagen gels were then stimulated with conditioned media (CM) from these macrophages. The osteocyte response was analyzed by gene expression, protein secretion, and immunostaining. M1 phenotype macrophages were confirmed by IL-1β and TNF-α secretion, and M2 macrophages by ARG-1 and MRC-1.Osteocytes receiving M1 CM revealed bone inhibitory effects, denoted by reduced secretion of bone formation osteocalcin (BGLAP) and increased secretion of the bone inhibitory sclerostin (SOST). These osteocytes also downregulated the pro-mineralization gene PHEX and upregulated the anti-mineralization gene MEPE. Additionally, exhibited pro-osteoclastic potential by upregulating pro-osteoclastic gene RANKL expression. Nonetheless, M1-stimulated osteocytes expressed a higher level of the potent pro-osteogenic factor BMP-2 in parallel with the downregulation of the bone inhibitor genes DKK1 and SOST, suggesting a compensatory feedback mechanisms. Conversely, M2-stimulated osteocytes mainly upregulated anti-osteoclastic gene OPG expression, suggesting an anti-catabolic effect. Altogether, our findings demonstrate a strong communication between M1 macrophages and osteocytes under M1 (BAI)-simulated conditions, suggesting that the BAI adverse effects on osteoblastic and osteoclastic processes in vitro are partly mediated via this communication. STATEMENT OF SIGNIFICANCE: Biomaterial-associated infections are major challenges and the underlying mechanisms in the cellular interactions are missing, especially among the major cells from the inflammatory side (macrophages as the key cell in bacterial clearance) and the regenerative side (osteocyte as main regulator of bone). We evaluated the effect of macrophage polarization driven by the stimulation with bacterial virulence factors on the osteocyte function using an indirect co-culture model, hence mimicking the scenario of a biomaterial-associated infection. The results suggest that at least part of the adverse effects of biomaterial associated infection on osteoblastic and osteoclastic processes in vitro are mediated via macrophage-to-osteocyte communication.
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Affiliation(s)
- Paula Milena Giraldo-Osorno
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Katharina Wirsig
- Faculty of Medicine, Centre for Translational Bone, Joint and Soft Tissue Research, Technische Universität Dresden, Germany
| | - Farah Asa'ad
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Department of Oral Biochemistry, Institute of Odontology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Omar Omar
- Department of Biomedical Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Margarita Trobos
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anne Bernhardt
- Faculty of Medicine, Centre for Translational Bone, Joint and Soft Tissue Research, Technische Universität Dresden, Germany.
| | - Anders Palmquist
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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3
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Luo Z, Xi H, Huang W, Liu MF, Yuan L, Chen Q, Xiao Y, Zhu Q, Zhao R, Sheng YY. The role of male hormones in bacterial infections: enhancing Staphylococcus aureus virulence through testosterone-induced Agr activation. Arch Microbiol 2024; 206:401. [PMID: 39261350 DOI: 10.1007/s00203-024-04130-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Revised: 08/23/2024] [Accepted: 09/04/2024] [Indexed: 09/13/2024]
Abstract
Staphylococcus aureus is a notorious pathogen predominantly involved in skin and soft tissue infections, exhibiting a distinct innate sex bias. This study explores the influence of testosterone on the virulence of S. aureus and elucidates its underlying mechanisms. Utilizing a skin abscess model in intact and castrated male mice, we assessed the effects of testosterone on S. aureus pathogenicity. Compared to controls, castrated mice showed significantly reduced abscess sizes and decreased bacterial loads, highlighting the role of testosterone in modulating the severity of S. aureus infections. In vitro experiments revealed that testosterone enhances the hemolytic activity, cytotoxicity, and oxidative stress resistance of S. aureus. Real-time quantitative PCR analysis showed a significant upregulation of the genes encoding α-hemolysin (hla) and phenol-soluble modulin (psmα). Importantly, testosterone treatment significantly enhanced the expression of the accessory gene regulator (Agr) quorum-sensing system components (agrC, agrA, agrB, agrD), while the SaeRS system (saeR, saeS, and sbi) exhibited only slight changes. Gene knockout experiments revealed that deletion of agrC, rather than saeRS and agrBD, abolishes the testosterone-induced enhancement of hemolysis and gene expression, underscoring the key role of AgrC. Molecular docking simulations indicated a direct interaction between testosterone and AgrC protein, with a strong binding affinity at the active site residue SER201. This study provides new insights into the mechanistic basis of how testosterone enhances the pathogenicity of S. aureus, potentially contributing to increased male susceptibility to S. aureus infections and offering a targeted approach for therapeutic interventions.
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Affiliation(s)
- Zhaoxia Luo
- Department of Clinical Laboratory, Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Huimin Xi
- Jiangxi Provincial Key Laboratory of Respiratory Diseases, Jiangxi Institute of Respiratory Diseases, The Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Wei Huang
- Department of Clinical Laboratory, Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Mei-Fang Liu
- Department of Clinical Laboratory, Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Lei Yuan
- Department of Clinical Laboratory, Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Qiang Chen
- Department of Clinical Laboratory, Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Yanghua Xiao
- Jiangxi Provincial Key Laboratory of Respiratory Diseases, Jiangxi Institute of Respiratory Diseases, The Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Qing Zhu
- Department of Clinical Laboratory, Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China
| | - Rui Zhao
- Department of Clinical Laboratory, Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China.
| | - Yi-Yun Sheng
- Department of Pathology, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, 330006, China.
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Deshmukh M, Hu Z, Mohammad M, Jin T. Utilization of In Vivo Imaging System to Study Staphylococcal Sepsis and Septic Arthritis Progression in Mouse Model. Pathogens 2024; 13:652. [PMID: 39204252 PMCID: PMC11357683 DOI: 10.3390/pathogens13080652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/29/2024] [Accepted: 07/31/2024] [Indexed: 09/03/2024] Open
Abstract
Staphylococcus aureus [S. aureus] is a leading cause of sepsis and septic arthritis, conditions that pose significant medical challenges due to their high mortality and morbidity. No studies have used an in vivo imaging system [IVIS] to monitor S. aureus sepsis and septic arthritis. Here, we employed a bioluminescent reporter strain of S. aureus, Newman AH5016, administered intravenously to induce sepsis and intra-articularly to induce local septic arthritis in mice. Disease progression was monitored using IVIS to capture bioluminescent signals from kidneys, joints, and whole mice. Cytokines in the blood and joints were measured. The efficacy of cloxacillin treatment was evaluated. In the sepsis model, bioluminescent signals from kidneys, but not from whole mice, were correlated with kidney bacterial load and abscess formation. Ex vivo kidney imaging detected increased bacterial load and abscess formation from day 3 to day 10. Antibiotic treatment significantly reduced kidney signals, correlating with decreased bacterial counts and IL-6 levels, indicating effective infection control. In the local infection model, early-phase bioluminescent signals from joints were correlated with macroscopic arthritis and bacterial burden. Thus, signal detection from kidneys using IVIS is useful for monitoring S. aureus sepsis and assessing antibiotic efficacy, though it may only be effective for early-phase monitoring of local septic arthritis.
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Affiliation(s)
- Meghshree Deshmukh
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41346 Gothenburg, Sweden; (M.D.); (Z.H.); (M.M.)
| | - Zhicheng Hu
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41346 Gothenburg, Sweden; (M.D.); (Z.H.); (M.M.)
- Center for Clinical Laboratories, The Affiliated Hospital of Guizhou Medical University, Guiyang 550001, China
| | - Majd Mohammad
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41346 Gothenburg, Sweden; (M.D.); (Z.H.); (M.M.)
| | - Tao Jin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, 41346 Gothenburg, Sweden; (M.D.); (Z.H.); (M.M.)
- Department of Rheumatology, Sahlgrenska University Hospital, 41345 Gothenburg, Sweden
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Yamazaki Y, Ito T, Tamai M, Nakagawa S, Nakamura Y. The role of Staphylococcus aureus quorum sensing in cutaneous and systemic infections. Inflamm Regen 2024; 44:9. [PMID: 38429810 PMCID: PMC10905890 DOI: 10.1186/s41232-024-00323-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/15/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Staphylococcus aureus is a leading cause of human bacterial infections worldwide. It is the most common causative agent of skin and soft tissue infections, and can also cause various other infections, including pneumonia, osteomyelitis, as well as life-threatening infections, such as sepsis and infective endocarditis. The pathogen can also asymptomatically colonize human skin, nasal cavity, and the intestine. S. aureus colonizes approximately 20-30% of human nostrils, being an opportunistic pathogen for subsequent infection. Its strong ability to silently spread via human contact makes it difficult to eradicate S. aureus. A major concern with S. aureus is its capacity to develop antibiotic resistance and adapt to diverse environmental conditions. The variability in the accessory gene regulator (Agr) region of the genome contributes to a spectrum of phenotypes within the bacterial population, enhancing the likelihood of survival in different environments. Agr functions as a central quorum sensing (QS) system in S. aureus, allowing bacteria to adjust gene expression in response to population density. Depending on Agr expression, S. aureus secretes various toxins, contributing to virulence in infectious diseases. Paradoxically, expressing Agr may be disadvantageous in certain situations, such as in hospitals, causing S. aureus to generate Agr mutants responsible for infections in healthcare settings. MAIN BODY This review aims to demonstrate the molecular mechanisms governing the diverse phenotypes of S. aureus, ranging from a harmless colonizer to an organism capable of infecting various human organs. Emphasis will be placed on QS and its role in orchestrating S. aureus behavior across different contexts. SHORT CONCLUSION The pathophysiology of S. aureus infection is substantially influenced by phenotypic changes resulting from factors beyond Agr. Future studies are expected to give the comprehensive understanding of S. aureus overall profile in various settings.
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Affiliation(s)
- Yuriko Yamazaki
- Cutaneous Allergy and Host Defense, Immunology Frontier Research Center, Osaka, University, Osaka, 565-0871, Japan
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Tomoka Ito
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Masakazu Tamai
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Seitaro Nakagawa
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan
| | - Yuumi Nakamura
- Cutaneous Allergy and Host Defense, Immunology Frontier Research Center, Osaka, University, Osaka, 565-0871, Japan.
- Department of Dermatology, Osaka University Graduate School of Medicine, Osaka, 565-0871, Japan.
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Jin T. Exploring the role of bacterial virulence factors and host elements in septic arthritis: insights from animal models for innovative therapies. Front Microbiol 2024; 15:1356982. [PMID: 38410388 PMCID: PMC10895065 DOI: 10.3389/fmicb.2024.1356982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 01/18/2024] [Indexed: 02/28/2024] Open
Abstract
Septic arthritis, characterized as one of the most aggressive joint diseases, is primarily attributed to Staphylococcus aureus (S. aureus) and often results from hematogenous dissemination. Even with prompt treatment, septic arthritis frequently inflicts irreversible joint damage, leading to sustained joint dysfunction in a significant proportion of patients. Despite the unsatisfactory outcomes, current therapeutic approaches for septic arthritis have remained stagnant for decades. In the clinical context, devising innovative strategies to mitigate joint damage necessitates a profound comprehension of the pivotal disease mechanisms. This entails unraveling how bacterial virulence factors interact with host elements to facilitate bacterial invasion into the joint and identifying the principal drivers of joint damage. Leveraging animal models of septic arthritis emerges as a potent tool to achieve these objectives. This review provides a comprehensive overview of the historical evolution and recent advancements in septic arthritis models. Additionally, we address practical considerations regarding experimental protocols. Furthermore, we delve into the utility of these animal models, such as their contribution to the discovery of novel bacterial virulence factors and host elements that play pivotal roles in the initiation and progression of septic arthritis. Finally, we summarize the latest developments in novel therapeutic strategies against septic arthritis, leveraging insights gained from these unique animal models.
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Affiliation(s)
- Tao Jin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Hu Z, Kopparapu PK, Deshmukh M, Jarneborn A, Gupta P, Ali A, Fei Y, Engdahl C, Pullerits R, Mohammad M, Jin T. The Impact of Aging and Toll-like Receptor 2 Deficiency on the Clinical Outcomes of Staphylococcus aureus Bacteremia. J Infect Dis 2023; 228:332-342. [PMID: 36808423 PMCID: PMC10420399 DOI: 10.1093/infdis/jiad046] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 02/08/2023] [Accepted: 02/16/2023] [Indexed: 02/22/2023] Open
Abstract
Staphylococcus aureus (S. aureus) causes a broad range of infections. Toll-like receptor (TLR) 2 senses the S. aureus lipoproteins in S. aureus infections. Aging raises the risk of infection. Our aim was to understand how aging and TLR2 affect the clinical outcomes of S. aureus bacteremia. Four groups of mice (wild type/young, wild type/old, TLR2-/-/young, and TLR2-/-/old) were intravenously infected with S. aureus, and the infection course was followed. Both TLR2 deficiency and aging enhanced the susceptibility to disease. Increased age was the main contributing factor for increased mortality rates and changes in spleen weight, whereas other clinical parameters, such as weight loss and kidney abscess formation, were more TLR2 dependent. Importantly, aging increased mortality rates without relying on TLR2. In vitro, both aging and TLR2 deficiency down-regulated cytokine/chemokine production of immune cells with distinct patterns. In summary, we demonstrate that aging and TLR2 deficiency impair the immune response to S. aureus bacteremia in distinct ways.
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Affiliation(s)
- Zhicheng Hu
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Center for Clinical Laboratories, the Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Pradeep Kumar Kopparapu
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Meghshree Deshmukh
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Anders Jarneborn
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Priti Gupta
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Abukar Ali
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ying Fei
- Center for Clinical Laboratories, the Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Cecilia Engdahl
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Rille Pullerits
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Clinical Immunology and Transfusion Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Majd Mohammad
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Tao Jin
- Department of Rheumatology and Inflammation Research, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Rheumatology, Sahlgrenska University Hospital, Gothenburg, Sweden
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