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Baral A, Hussaini F, Lee SC, Matthew BP, Ferrante EA, Brofferio A, Cudrici CD, Rollison SF, Chen MY, Boehm M, Wen H. Images in Vascular Medicine: High-resolution CT imaging of arterial calcification in the hands and legs of patients with CD73 deficiency. Vasc Med 2024; 29:342-344. [PMID: 38131150 PMCID: PMC11421826 DOI: 10.1177/1358863x231214711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Affiliation(s)
- Aneesha Baral
- Biochemistry and Biophysics Center, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Farah Hussaini
- Biochemistry and Biophysics Center, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Simone C. Lee
- Biochemistry and Biophysics Center, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Brianna P. Matthew
- Biochemistry and Biophysics Center, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elisa A. Ferrante
- Translational Vascular Medicine Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alessandra Brofferio
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cornelia D. Cudrici
- Translational Vascular Medicine Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Shirley F. Rollison
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Marcus Y. Chen
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Manfred Boehm
- Translational Vascular Medicine Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Han Wen
- Biochemistry and Biophysics Center, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Ferrante EA, Cudrici CD, Rashidi M, Fu YP, Huffstutler R, Carney K, Chen MY, St Hilaire C, Smith K, Bagheri H, Katz JD, Ferreira CR, Gahl WA, Boehm M, Brofferio A. Pilot study to evaluate the safety and effectiveness of etidronate treatment for arterial calcification due to deficiency of CD73 (ACDC). Vasc Med 2024; 29:245-255. [PMID: 38568107 PMCID: PMC11608424 DOI: 10.1177/1358863x241235669] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND Arterial calcification due to deficiency of CD73 (ACDC; OMIM 211800) is a rare genetic disease resulting in calcium deposits in arteries and small joints causing claudication, resting pain, severe joint pain, and deformities. Currently, there are no standard treatments for ACDC. Our previous work identified etidronate as a potential targeted ACDC treatment, using in vitro and in vivo disease models with patient-derived cells. In this study, we test the safety and effectiveness of etidronate in attenuating the progression of lower-extremity arterial calcification and vascular blood flow based on the computed tomography (CT) calcium score and ankle-brachial index (ABI). METHODS Seven adult patients with a confirmed genetic diagnosis of ACDC were enrolled in an open-label, nonrandomized, single-arm pilot study for etidronate treatment. They took etidronate daily for 14 days every 3 months and were examined at the NIH Clinical Center bi-annually for 3 years. They received a baseline evaluation as well as yearly follow up after treatment. Study visits included imaging studies, exercise tolerance tests with ABIs, clinical blood and urine testing, and full dental exams. RESULTS Etidronate treatment appeared to have slowed the progression of further vascular calcification in lower extremities as measured by CT but did not have an effect in reversing vascular and/or periarticular joint calcifications in our small ACDC cohort. CONCLUSIONS Etidronate was found to be safe and well tolerated by our patients and, despite the small sample size, appeared to show an effect in slowing the progression of calcification in our ACDC patient cohort.(ClinicalTrials.gov Identifier NCT01585402).
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Affiliation(s)
- Elisa A Ferrante
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cornelia D Cudrici
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Mahmood Rashidi
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yi-Ping Fu
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rebecca Huffstutler
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Katherine Carney
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Marcus Y Chen
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Cynthia St Hilaire
- Departments of Medicine and Bioengineering, Vascular Medicine Institute, University of Pittsburg, PA, USA
| | - Kevin Smith
- Clinical Center Nursing Department, Hatfield Clinical Center at the National Institutes of Health, Bethesda, MD, USA
| | - Hadi Bagheri
- Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - James D Katz
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Carlos R Ferreira
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - William A Gahl
- National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Manfred Boehm
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Alessandra Brofferio
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Novais EJ, Narayanan R, Canseco JA, van de Wetering K, Kepler CK, Hilibrand AS, Vaccaro AR, Risbud MV. A new perspective on intervertebral disc calcification-from bench to bedside. Bone Res 2024; 12:3. [PMID: 38253615 PMCID: PMC10803356 DOI: 10.1038/s41413-023-00307-3] [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: 10/15/2023] [Revised: 12/04/2023] [Accepted: 12/05/2023] [Indexed: 01/24/2024] Open
Abstract
Disc degeneration primarily contributes to chronic low back and neck pain. Consequently, there is an urgent need to understand the spectrum of disc degeneration phenotypes such as fibrosis, ectopic calcification, herniation, or mixed phenotypes. Amongst these phenotypes, disc calcification is the least studied. Ectopic calcification, by definition, is the pathological mineralization of soft tissues, widely studied in the context of conditions that afflict vasculature, skin, and cartilage. Clinically, disc calcification is associated with poor surgical outcomes and back pain refractory to conservative treatment. It is frequently seen as a consequence of disc aging and progressive degeneration but exhibits unique molecular and morphological characteristics: hypertrophic chondrocyte-like cell differentiation; TNAP, ENPP1, and ANK upregulation; cell death; altered Pi and PPi homeostasis; and local inflammation. Recent studies in mouse models have provided a better understanding of the mechanisms underlying this phenotype. It is essential to recognize that the presentation and nature of mineralization differ between AF, NP, and EP compartments. Moreover, the combination of anatomic location, genetics, and environmental stressors, such as aging or trauma, govern the predisposition to calcification. Lastly, the systemic regulation of calcium and Pi metabolism is less important than the local activity of PPi modulated by the ANK-ENPP1 axis, along with disc cell death and differentiation status. While there is limited understanding of this phenotype, understanding the molecular pathways governing local intervertebral disc calcification may lead to developing disease-modifying drugs and better clinical management of degeneration-related pathologies.
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Affiliation(s)
- Emanuel J Novais
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Unidade Local de Saúde do Litoral Alentejano, Orthopedic Department, Santiago do Cacém, Portugal
| | - Rajkishen Narayanan
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Koen van de Wetering
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alan S Hilibrand
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Orthopedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Makarand V Risbud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
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Cassini T, Montano C, Guan B. An Alternate Explanation. N Engl J Med 2023; 389:1249-1250. [PMID: 37754297 PMCID: PMC11382613 DOI: 10.1056/nejmc2305289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Affiliation(s)
| | | | - Bin Guan
- National Eye Institute, Bethesda, MD
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Bach N, Winzer R, Tolosa E, Fiedler W, Brauneck F. The Clinical Significance of CD73 in Cancer. Int J Mol Sci 2023; 24:11759. [PMID: 37511518 PMCID: PMC10380759 DOI: 10.3390/ijms241411759] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 07/04/2023] [Accepted: 07/10/2023] [Indexed: 07/30/2023] Open
Abstract
The search for new and effective treatment targets for cancer immunotherapy is an ongoing challenge. Alongside the more established inhibitory immune checkpoints, a novel potential target is CD73. As one of the key enzymes in the purinergic signalling pathway CD73 is responsible for the generation of immune suppressive adenosine. The expression of CD73 is higher in tumours than in the corresponding healthy tissues and associated with a poor prognosis. CD73, mainly by the production of adenosine, is critical in the suppression of an adequate anti-tumour immune response, but also in promoting cancer cell proliferation, tumour growth, angiogenesis, and metastasis. The upregulation of CD73 and generation of adenosine by tumour or tumour-associated immune cells is a common resistance mechanism to many cancer treatments such as chemotherapy, radiotherapy, targeted therapy, and immunotherapy. Therefore, the inhibition of CD73 represents a new and promising approach to increase therapy efficacy. Several CD73 inhibitors have already been developed and successfully demonstrated anti-cancer activity in preclinical studies. Currently, clinical studies evaluate CD73 inhibitors in different therapy combinations and tumour entities. The initial results suggest that inhibiting CD73 could be an effective option to augment anti-cancer immunotherapeutic strategies. This review provides an overview of the rationale behind the CD73 inhibition in different treatment combinations and the role of CD73 as a prognostic marker.
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Affiliation(s)
- Niklas Bach
- Department of Immunology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Riekje Winzer
- Department of Immunology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Eva Tolosa
- Department of Immunology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Walter Fiedler
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald University Cancer Center, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Franziska Brauneck
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald University Cancer Center, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
- Mildred Scheel Cancer Career Center HaTriCS4, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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Alsaigh T, Dhaliwal G, Fukaya E, Leeper NJ, Sayed N. An Alternate Explanation. N Engl J Med 2023; 388:1318-1324. [PMID: 37018496 PMCID: PMC10409491 DOI: 10.1056/nejmcps2210419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
A 48-year-old man with long-standing type 2 diabetes mellitus (recent glycated hemoglobin level, 6.5%) and chronic kidney disease (baseline creatinine level, 3.3 mg per deciliter [292 μ mol per liter]; glomerular filtration rate, 24 ml per minute per 1.73 m2 of body-surface area) presented to his primary care physician with a 3-month history of numbness, tingling, and faint violaceous discoloration of the tips of multiple fingers and toes. His physical examination showed reduced light-touch sensation in a glove-and-stocking distribution; the radial and pedal pulses were palpable. The vitamin B12 level was 260 pg per milliliter (192 pmol per liter; normal range, 190 to 950 pg per milliliter [140 to 701 pmol per liter]). He did not smoke tobacco, drink alcohol, or use illicit drugs. One month later, a nontraumatic wound developed on the left foot. The ankle–brachial index (ABI) was 1.2 on both sides (normal range, 0.91 to 1.3). Wound care was initiated for a presumed neuropathic ulcer.
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Affiliation(s)
- Tom Alsaigh
- From the Division of General Internal Medicine, Department of Medicine, and the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla (T.A.), the Department of Medicine, University of California San Francisco School of Medicine, and Medical Service, San Francisco VA Medical Center, San Francisco (G.D.), and the Division of Vascular Surgery, Department of Surgery (E.F., N.J.L., N.S.), and the Division of Cardiovascular Medicine, Department of Medicine (N.J.L.), Stanford University School of Medicine, and the Stanford Cardiovascular Institute, Stanford University (N.J.L., N.S.), Stanford - all in California
| | - Gurpreet Dhaliwal
- From the Division of General Internal Medicine, Department of Medicine, and the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla (T.A.), the Department of Medicine, University of California San Francisco School of Medicine, and Medical Service, San Francisco VA Medical Center, San Francisco (G.D.), and the Division of Vascular Surgery, Department of Surgery (E.F., N.J.L., N.S.), and the Division of Cardiovascular Medicine, Department of Medicine (N.J.L.), Stanford University School of Medicine, and the Stanford Cardiovascular Institute, Stanford University (N.J.L., N.S.), Stanford - all in California
| | - Eri Fukaya
- From the Division of General Internal Medicine, Department of Medicine, and the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla (T.A.), the Department of Medicine, University of California San Francisco School of Medicine, and Medical Service, San Francisco VA Medical Center, San Francisco (G.D.), and the Division of Vascular Surgery, Department of Surgery (E.F., N.J.L., N.S.), and the Division of Cardiovascular Medicine, Department of Medicine (N.J.L.), Stanford University School of Medicine, and the Stanford Cardiovascular Institute, Stanford University (N.J.L., N.S.), Stanford - all in California
| | - Nicholas J Leeper
- From the Division of General Internal Medicine, Department of Medicine, and the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla (T.A.), the Department of Medicine, University of California San Francisco School of Medicine, and Medical Service, San Francisco VA Medical Center, San Francisco (G.D.), and the Division of Vascular Surgery, Department of Surgery (E.F., N.J.L., N.S.), and the Division of Cardiovascular Medicine, Department of Medicine (N.J.L.), Stanford University School of Medicine, and the Stanford Cardiovascular Institute, Stanford University (N.J.L., N.S.), Stanford - all in California
| | - Nazish Sayed
- From the Division of General Internal Medicine, Department of Medicine, and the Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Diego, La Jolla (T.A.), the Department of Medicine, University of California San Francisco School of Medicine, and Medical Service, San Francisco VA Medical Center, San Francisco (G.D.), and the Division of Vascular Surgery, Department of Surgery (E.F., N.J.L., N.S.), and the Division of Cardiovascular Medicine, Department of Medicine (N.J.L.), Stanford University School of Medicine, and the Stanford Cardiovascular Institute, Stanford University (N.J.L., N.S.), Stanford - all in California
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Sayegh MN, Cooney KA, Han WM, Cicka M, Strobel F, Wang L, García AJ, Levit RD. Hydrogel delivery of purinergic enzymes improves cardiac ischemia/reperfusion injury. J Mol Cell Cardiol 2023; 176:98-109. [PMID: 36764383 PMCID: PMC10006353 DOI: 10.1016/j.yjmcc.2023.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/23/2023] [Accepted: 02/05/2023] [Indexed: 02/11/2023]
Abstract
RATIONALE The innate immune response contributes to cardiac injury in myocardial ischemia/reperfusion (MI/R). Neutrophils are an important early part of the innate immune response to MI/R. Adenosine, an endogenous purine, is a known innate immune modulator and inhibitor of neutrophil activation. However, its delivery to the heart is limited by its short half-life (<30 s) and off-target side effects. CD39 and CD73 are anti-inflammatory homeostatic enzymes that can generate adenosine from phosphorylated adenosine substrate such as ATP released from injured tissue. OBJECTIVE We hypothesize that hydrogel-delivered CD39 and CD73 target the local early innate immune response, reduce neutrophil activation, and preserve cardiac function in MI/R injury. METHODS AND RESULTS We engineered a poly(ethylene) glycol (PEG) hydrogel loaded with the adenosine-generating enzymes CD39 and CD73. We incubated the hydrogels with neutrophils in vitro and showed a reduction in hydrogen peroxide production using Amplex Red. We demonstrated availability of substrate for the enzymes in the myocardium in MI/R by LC/MS, and tested release kinetics from the hydrogel. On echocardiography, global longitudinal strain (GLS) was preserved in MI/R hearts treated with the loaded hydrogel. Delivery of purinergic enzymes via this synthetic hydrogel resulted in lower innate immune infiltration into the myocardium post-MI/R, decreased markers of macrophage and neutrophil activation (NETosis), and decreased leukocyte-platelet complexes in circulation. CONCLUSIONS In a rat model of MI/R injury, CD39 and CD73 delivered via a hydrogel preserve cardiac function by modulating the innate immune response.
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Affiliation(s)
- Michael N Sayegh
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, United States of America; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States of America
| | - Kimberly A Cooney
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, United States of America; Department of Biological Sciences, Tennessee State University, Nashville, TN, United States of America
| | - Woojin M Han
- Woodruff School of Mechanical Engineering, Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, United States of America; Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Markus Cicka
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, United States of America
| | - Frederick Strobel
- Department of Chemistry, Emory University, Atlanta, GA, United States of America
| | - Lanfang Wang
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, United States of America
| | - Andrés J García
- Woodruff School of Mechanical Engineering, Petit Institute for Bioengineering and Bioscience, Georgia Institute of Technology, Atlanta, GA, United States of America
| | - Rebecca D Levit
- Division of Cardiology, Department of Medicine, Emory University, Atlanta, GA, United States of America; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, United States of America.
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Couto AR, Parreira B, Power DM, Pinheiro L, Madruga Dias J, Novofastovski I, Eshed I, Sarzi-Puttini P, Pappone N, Atzeni F, Verlaan JJ, Kuperus J, Bieber A, Ambrosino P, Kiefer D, Khan MA, Mader R, Baraliakos X, Bruges-Armas J. Evidence for a genetic contribution to the ossification of spinal ligaments in Ossification of Posterior Longitudinal Ligament and Diffuse idiopathic skeletal hyperostosis: A narrative review. Front Genet 2022; 13:987867. [PMID: 36276944 PMCID: PMC9586552 DOI: 10.3389/fgene.2022.987867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/16/2022] [Indexed: 11/25/2022] Open
Abstract
Diffuse Idiopathic Skeletal Hyperostosis (DISH) and Ossification of the Posterior Longitudinal Ligament (OPLL) are common disorders characterized by the ossification of spinal ligaments. The cause for this ossification is currently unknown but a genetic contribution has been hypothesized. Over the last decade, many studies on the genetics of ectopic calcification disorders have been performed, mainly on OPLL. Most of these studies were based on linkage analysis and case control association studies. Animal models have provided some clues but so far, the involvement of the identified genes has not been confirmed in human cases. In the last few years, many common variants in several genes have been associated with OPLL. However, these associations have not been at definitive levels of significance and evidence of functional significance is generally modest. The current evidence suggests a multifactorial aetiopathogenesis for DISH and OPLL with a subset of cases showing a stronger genetic component.
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Affiliation(s)
- Ana Rita Couto
- Hospital de Santo Espirito da Ilha Terceira EPER, SEEBMO, Angra do Heroísmo, Portugal
- Comprehensive Health Research Centre, Hospital de Santo Espírito da Ilha Terceira, Lisbon, Portugal
| | - Bruna Parreira
- Hospital de Santo Espirito da Ilha Terceira EPER, SEEBMO, Angra do Heroísmo, Portugal
- Comprehensive Health Research Centre, Hospital de Santo Espírito da Ilha Terceira, Lisbon, Portugal
| | - Deborah M. Power
- University of Algarve, Center of Marine Science (CCMAR), Faro, Portugal
| | - Luís Pinheiro
- Hospital de Santo Espirito da Ilha Terceira EPER, Orthopedics Service, Angra do Heroísmo, Portugal
| | - João Madruga Dias
- Centro Hospitalar Do Medio Tejo EPE Unidade de Torres Novas, Rheumatology Department, Santarém, Portugal
- CHRC Campus Nova Medical School, EpiDoc Research Unit, CEDOC, Lisboa, Portugal
| | | | | | | | - Nicola Pappone
- Istituti Clinici Scientifici Maugeri IRCCS, Neuromotor Rehabilitation Unit of Telese Terme Institute, Pavia, Italy
| | - Fabiola Atzeni
- Universita Degli Studi di Messina, Rheumatology Unit, Clinical and Experimental Medicine, Messina, Italy
| | - Jorrit-Jan Verlaan
- University Medical Centre, Department of Orthopedics, Utrecht, Netherlands
| | | | - Amir Bieber
- Emek Medical Center, Rheumatology Unit, Afula, Israel
| | - Pasquale Ambrosino
- Istituti Clinici Scientifici Maugeri IRCCS, Cardiac Rehabilitation Unit of Telese Terme Institute, Pavia, Italy
| | - David Kiefer
- Ruhr-Universitat Bochum, Rheumazentrum Ruhrgebiet, Bochum, Germany
| | | | - Reuven Mader
- Emek Medical Center, Rheumatology Unit, Afula, Israel
- Rappaport Faculty of Medicine, Technion, Haifa, Israel
- Ruhr University Bochum, Rheumazentrum Ruhrgebiet, Herne, Germany
| | | | - Jácome Bruges-Armas
- Hospital de Santo Espirito da Ilha Terceira EPER, SEEBMO, Angra do Heroísmo, Portugal
- Comprehensive Health Research Centre, Hospital de Santo Espírito da Ilha Terceira, Lisbon, Portugal
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