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Süß P, Rothe T, Hoffmann A, Schlachetzki JCM, Winkler J. The Joint-Brain Axis: Insights From Rheumatoid Arthritis on the Crosstalk Between Chronic Peripheral Inflammation and the Brain. Front Immunol 2020; 11:612104. [PMID: 33362800 PMCID: PMC7758283 DOI: 10.3389/fimmu.2020.612104] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 11/10/2020] [Indexed: 12/27/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by erosive polyarthritis. Beyond joint pathology, RA is associated with neuropsychiatric comorbidity including depression, anxiety, and an increased risk to develop neurodegenerative diseases in later life. Studies investigating the central nervous system (CNS) in preclinical models of RA have leveraged the understanding of the intimate crosstalk between peripheral and central immune responses. This mini review summarizes the current knowledge of CNS comorbidity in RA patients and known underlying cellular mechanisms. We focus on the differential regulation of CNS myeloid and glial cells in different mouse models of RA reflecting different patterns of peripheral immune activation. Moreover, we address CNS responses to anti-inflammatory treatment in human RA patients and mice. Finally, to illustrate the bidirectional communication between the CNS and chronic peripheral inflammation, we present the current knowledge about the impact of the CNS on arthritis. A comprehensive understanding of the crosstalk between the CNS and chronic peripheral inflammation will help to identify RA patients at risk of developing CNS comorbidity, setting the path for future therapeutic approaches in both RA and neuropsychiatric diseases.
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Affiliation(s)
- Patrick Süß
- Department of Molecular Neurology, Friedrich-Alexander-University Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany.,Department of Neurology, Friedrich-Alexander-University Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Tobias Rothe
- Department of Internal Medicine 3, Friedrich-Alexander-University Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Alana Hoffmann
- Department of Molecular Neurology, Friedrich-Alexander-University Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
| | - Johannes C M Schlachetzki
- Department of Cellular and Molecular Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Jürgen Winkler
- Department of Molecular Neurology, Friedrich-Alexander-University Erlangen-Nürnberg, University Hospital Erlangen, Erlangen, Germany
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Hand LE, Gray KJ, Dickson SH, Simpkins DA, Ray DW, Konkel JE, Hepworth MR, Gibbs JE. Regulatory T cells confer a circadian signature on inflammatory arthritis. Nat Commun 2020; 11:1658. [PMID: 32245954 PMCID: PMC7125185 DOI: 10.1038/s41467-020-15525-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 02/26/2020] [Indexed: 12/12/2022] Open
Abstract
The circadian clock is an intrinsic oscillator that imparts 24 h rhythms on immunity. This clock drives rhythmic repression of inflammatory arthritis during the night in mice, but mechanisms underlying this effect are not clear. Here we show that the amplitude of intrinsic oscillators within macrophages and neutrophils is limited by the chronic inflammatory environment, suggesting that rhythms in inflammatory mediators might not be a direct consequence of intrinsic clocks. Anti-inflammatory regulatory T (Treg) cells within the joints show diurnal variation, with numbers peaking during the nadir of inflammation. Furthermore, the anti-inflammatory action of Treg cells on innate immune cells contributes to the night-time repression of inflammation. Treg cells do not seem to have intrinsic circadian oscillators, suggesting that rhythmic function might be a consequence of external signals. These data support a model in which non-rhythmic Treg cells are driven to rhythmic activity by systemic signals to confer a circadian signature to chronic arthritis.
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Affiliation(s)
- L E Hand
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - K J Gray
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - S H Dickson
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - D A Simpkins
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK
| | - D W Ray
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK and Oxford Centre for Diabetes, Endocrinology and Metabolism, University of Oxford, Oxford, UK
| | - J E Konkel
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Oxford Road, Manchester, UK
| | - M R Hepworth
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Oxford Road, Manchester, UK
| | - J E Gibbs
- Centre for Biological Timing, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester, UK.
- Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Oxford Road, Manchester, UK.
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Ebbinghaus M, Müller S, Segond von Banchet G, Eitner A, Wank I, Hess A, Hilger I, Kamradt T, Schaible HG. Contribution of Inflammation and Bone Destruction to Pain in Arthritis: A Study in Murine Glucose-6-Phosphate Isomerase-Induced Arthritis. Arthritis Rheumatol 2019; 71:2016-2026. [PMID: 31332965 DOI: 10.1002/art.41051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 07/16/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Arthritis is often characterized by inflammation and bone destruction. This study was undertaken to investigate the contribution of inflammation and bone destruction to pain. METHODS Inflammation, bone resorption, pain-related behaviors, and molecular markers (activating transcription factor 3 [ATF-3], p-CREB, and transient receptor potential vanilloid channel 1) in sensory neurons were measured in murine glucose-6-phosphate isomerase (G6PI)-induced arthritis, a model of rheumatoid arthritis. Depletion of Treg cells before immunization changed self-limiting arthritis into nonremitting arthritis with pronounced bone destruction. Zoledronic acid (ZA) was administered to reduce bone resorption. RESULTS Compared to nondepleted mice, Treg cell-depleted mice exhibited arthritis with more severe bone destruction and higher guarding scores (P < 0.05; n = 10 mice per group) as well as more persistent thermal hyperalgesia (P < 0.05), but displayed similar mechanical hyperalgesia at the hindpaws (n = 18-26 mice per group). These pain-related behaviors, as well as an up-regulation of the neuronal injury marker ATF-3 in sensory neurons (studied in 39 mice), appeared before the clinical score (inflammation) became positive and persisted in Treg cell-depleted and nondepleted mice. In the late stage of arthritis, Treg cell-depleted mice treated with ZA showed less bone resorption (<50%; P < 0.01) and less thermal hyperalgesia (P < 0.01) than Treg cell-depleted mice without ZA treatment (n = 15 mice per group), but ZA treatment did not reduce the clinical score and local mechanical hyperalgesia. CONCLUSION Pain-related behaviors precede and outlast self-limiting arthritis. In nonremitting arthritis with enhanced bone destruction, mainly local thermal, but not local mechanical, hyperalgesia was aggravated. The up-regulation of ATF-3 indicates an early and persisting affection of sensory neurons by G6PI-induced arthritis.
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Affiliation(s)
- Matthias Ebbinghaus
- Jenna University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Sylvia Müller
- Jenna University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | | | - Annett Eitner
- Jenna University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Isabel Wank
- Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Andreas Hess
- Friedrich-Alexander University Erlangen-Nuremberg, Erlangen, Germany
| | - Ingrid Hilger
- Jenna University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Thomas Kamradt
- Jenna University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Hans-Georg Schaible
- Jenna University Hospital, Friedrich Schiller University Jena, Jena, Germany
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Xu C, Zhu H, Shen R, Feng Q, Zhou H, Zhao Z. IL-35 is a Protective Immunomodulator in Brain Ischemic Injury in Mice. Neurochem Res 2018; 43:1454-1463. [PMID: 29916094 DOI: 10.1007/s11064-018-2560-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2017] [Revised: 05/04/2018] [Accepted: 05/24/2018] [Indexed: 11/25/2022]
Abstract
IL-35 has been identified as a novel anti-inflammatory cytokine that belongs to the IL-12 cytokine family and has been verified to play a protective role in autoimmune diseases. In this study, we investigated the protective effects of IL-35 on cerebral ischemia/reperfusion (I/R) injury in a middle cerebral artery occlusion mouse model. We determined that the expression of IL-35 was initially decreased and subsequently increased in I/R injury. Moreover, IL-35 (i.c.v.) pre- and posttreatment significantly reduced the infarct volume and improved neurological deficits after 45 min of ischemia and 24 h of reperfusion. Importantly, IL-35 treatment improved neurological function recovery, particularly in balance ability, at 14 days after treatment. Finally, our results showed that IL-35 treatment reduced the expression of IL-6 and IL-1β, which are confirmed proinflammatory cytokines, thus indicating that these cytokines have both been linked to the anti-inflammatory mechanisms of IL-35. Therefore, IL-35 may be a key immune mediator in brain ischemic injury and appears to have promising potential for clinical trials.
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Affiliation(s)
- Chen Xu
- Department of Neurology, The Affiliated Suzhou Hospital, Nanjing Medical University, Suzhou, China
| | - Hao Zhu
- Department of Neurology, The Affiliated Suzhou Hospital, Nanjing Medical University, Suzhou, China
| | - Rong Shen
- Department of Neurology, The Affiliated Suzhou Hospital, Nanjing Medical University, Suzhou, China
| | - Qian Feng
- Department of Neurology, The Affiliated Suzhou Hospital, Nanjing Medical University, Suzhou, China
| | - Hua Zhou
- Department of Neurology, The Affiliated Suzhou Hospital, Nanjing Medical University, Suzhou, China.
| | - Zhong Zhao
- Department of Neurology, The Affiliated Suzhou Hospital, Nanjing Medical University, Suzhou, China.
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Kanashiro A, Shimizu Bassi G, de Queiróz Cunha F, Ulloa L. From neuroimunomodulation to bioelectronic treatment of rheumatoid arthritis. ACTA ACUST UNITED AC 2018; 1:151-165. [PMID: 30740246 DOI: 10.2217/bem-2018-0001] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Neuronal stimulation is an emerging field in modern medicine to control organ function and reestablish physiological homeostasis during illness. The nervous system innervates most of the peripheral organs and provides a fine tune to control the immune system. Most of these studies have focused on vagus nerve stimulation and the physiological, cellular and molecular mechanisms regulating the immune system. Here, we review the new results revealing afferent vagal signaling pathways, immunomodulatory brain structures, spinal cord-dependent circuits, neural and non-neural cholinergic/catecholaminergic signals and their respective receptors contributing to neuromodulation of inflammation in rheumatoid arthritis. These new neuromodulatory networks and structures will allow the design of innovative bioelectronic or pharmacological approaches for safer and low-cost treatment of arthritis and related inflammatory disorders.
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Affiliation(s)
- Alexandre Kanashiro
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil.,Department of Physiological Sciences, Federal University of São Carlos (UFSCAR), São Carlos, SP, Brazil
| | - Gabriel Shimizu Bassi
- Yueyang Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Fernando de Queiróz Cunha
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Luis Ulloa
- Department of Surgery, Center of Immunology & Inflammation, Rutgers-New Jersey Medical School, Rutgers University, Newark, NJ 07101, USA
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Schaible HG, Chang HD, Grässel S, Haibel H, Hess A, Kamradt T, Radbruch A, Schett G, Stein C, Straub RH. [Research consortium Neuroimmunology and pain in the research network musculoskeletal diseases]. Z Rheumatol 2018; 77:24-30. [PMID: 29654392 DOI: 10.1007/s00393-018-0459-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The research consortium Neuroimmunology and Pain (Neuroimpa) explores the importance of the relationships between the immune system and the nervous system in musculoskeletal diseases for the generation of pain and for the course of fracture healing and arthritis. MATERIAL AND METHODS The spectrum of methods includes analyses at the single cell level, in vivo models of arthritis and fracture healing, imaging studies on brain function in animals and humans and analysis of data from patients. RESULTS Proinflammatory cytokines significantly contribute to the generation of joint pain through neuronal cytokine receptors. Immune cells release opioid peptides which activate opioid receptors at peripheral nociceptors and thereby evoke hypoalgesia. The formation of new bone after fractures is significantly supported by the nervous system. The sympathetic nervous system promotes the development of immune-mediated arthritis. The studies show a significant analgesic potential of the neutralization of proinflammatory cytokines and of opioids which selectively inhibit peripheral neurons. Furthermore, they show that the modulation of neuronal mechanisms can beneficially influence the course of musculoskeletal diseases. DISCUSSION Interventions in the interactions between the immune system and the nervous system hold a great therapeutic potential for the treatment of musculoskeletal diseases and pain.
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Affiliation(s)
- H-G Schaible
- Institut für Physiologie 1/Neurophysiologie, Universitätsklinikum Jena, Friedrich Schiller Universität Jena, Teichgraben 8, 07743, Jena, Deutschland.
| | - H-D Chang
- Deutsches Rheuma-Forschungszentrum Berlin, ein Institut der Leibniz-Gemeinschaft, Berlin, Deutschland
| | - S Grässel
- Klinik und Poliklinik für Orthopädie, Experimentelle Orthopädie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - H Haibel
- Abteilung für Rheumatologie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | - A Hess
- Institut für Pharmakologie, Universitätsklinikum Erlangen-Nürnberg, Erlangen, Deutschland
| | - T Kamradt
- Institut für Immunologie, Universitätsklinikum Jena, Friedrich Schiller Universität Jena, Jena, Deutschland
| | - A Radbruch
- Deutsches Rheuma-Forschungszentrum Berlin, ein Institut der Leibniz-Gemeinschaft, Berlin, Deutschland
| | - G Schett
- Klinik für Innere Medizin, Universitätsklinikum Erlangen-Nürnberg, Erlangen, Deutschland
| | - C Stein
- Klinik für Anästhesie, Charité Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | - R H Straub
- Klinik für Innere Medizin 1, Universitätsklinikum Regensburg, Regensburg, Deutschland
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Atkinson SM, Hoffmann U, Hamann A, Bach E, Danneskiold-Samsøe NB, Kristiansen K, Serikawa K, Fox B, Kruse K, Haase C, Skov S, Nansen A. Depletion of regulatory T cells leads to an exacerbation of delayed-type hypersensitivity arthritis in C57BL/6 mice that can be counteracted by IL-17 blockade. Dis Model Mech 2016; 9:427-40. [PMID: 26822477 PMCID: PMC4852503 DOI: 10.1242/dmm.022905] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 01/22/2016] [Indexed: 12/19/2022] Open
Abstract
Rodent models of arthritis have been extensively used in the elucidation of rheumatoid arthritis (RA) pathogenesis and are instrumental in the development of therapeutic strategies. Here we utilise delayed-type hypersensitivity arthritis (DTHA), a model in C57BL/6 mice affecting one paw with synchronised onset, 100% penetrance and low variation. We investigate the role of regulatory T cells (Tregs) in DTHA through selective depletion of Tregsand the role of IL-17 in connection with Tregdepletion. Given the relevance of Tregsin RA, and the possibility of developing Treg-directed therapies, this approach could be relevant for advancing the understanding of Tregsin inflammatory arthritis. Selective depletion of Tregswas achieved using aFoxp3-DTR-eGFPmouse, which expresses the diphtheria toxin receptor (DTR) and enhanced green fluorescent protein (eGFP) under control of theFoxp3gene. Anti-IL-17 monoclonal antibody (mAb) was used for IL-17 blockade. Numbers and activation of Tregsincreased in the paw and its draining lymph node in DTHA, and depletion of Tregsresulted in exacerbation of disease as shown by increased paw swelling, increased infiltration of inflammatory cells, increased bone remodelling and increased production of inflammatory mediators, as well as increased production of anti-citrullinated protein antibodies. Anti-IL-17 mAb treatment demonstrated that IL-17 is important for disease severity in both the presence and absence of Tregs, and that IL-17 blockade is able to rescue mice from the exacerbated disease caused by Tregdepletion and caused a reduction in RANKL, IL-6 and the number of neutrophils. We show that Tregsare important for the containment of inflammation and bone remodelling in DTHA. To our knowledge, this is the first study using theFoxp3-DTR-eGFPmouse on a C57BL/6 background for Tregdepletion in an arthritis model, and we here demonstrate the usefulness of the approach to study the role of Tregsand IL-17 in arthritis.
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Affiliation(s)
- Sara Marie Atkinson
- Department of Diabetes Complications Research, Global Research, Novo Nordisk A/S, Maaloev 2760, Denmark Department of Veterinary Disease Biology, University of Copenhagen, Frederiksberg 1870, Denmark
| | - Ute Hoffmann
- Experimentelle Rheumatologie, Deutsches Rheuma-Forschungszentrum and Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Alf Hamann
- Experimentelle Rheumatologie, Deutsches Rheuma-Forschungszentrum and Charité-Universitätsmedizin Berlin, Berlin 10117, Germany
| | - Emil Bach
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen 2100, Denmark
| | | | - Karsten Kristiansen
- Laboratory of Genomics and Molecular Biomedicine, Department of Biology, University of Copenhagen, Copenhagen 2100, Denmark
| | | | - Brian Fox
- Immunexpress, Seattle, WA 98109, USA
| | - Kim Kruse
- Department of Diabetes Complications Research, Global Research, Novo Nordisk A/S, Maaloev 2760, Denmark
| | - Claus Haase
- Department of Diabetes Complications Research, Global Research, Novo Nordisk A/S, Maaloev 2760, Denmark
| | - Søren Skov
- Department of Veterinary Disease Biology, University of Copenhagen, Frederiksberg 1870, Denmark
| | - Anneline Nansen
- Department of Pharmacology, Zealand Pharma, Glostrup 2600, Denmark
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Gill D, Veltkamp R. Dynamics of T cell responses after stroke. Curr Opin Pharmacol 2015; 26:26-32. [PMID: 26452204 DOI: 10.1016/j.coph.2015.09.009] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 09/17/2015] [Accepted: 09/21/2015] [Indexed: 01/27/2023]
Abstract
T cells are integral to the pathophysiology of stroke. The initial inflammatory cascade leads to T cell migration, which results in deleterious and protective effects mediated through CD4(+), CD(8)+, γδ T cells and regulatory T cells, respectively. Cytokines are central to the T cell responses, with key roles established for TNF-α, IFN-γ, IL-17, IL-21 and IL-10. Through communication with the systemic immune system via neural and hormonal pathways, there is also transient immunosuppression after severe strokes. With time, the inflammatory process eventually transforms to one more conducive of repair and recovery, though some evidence also suggests ongoing chronic inflammation. The role of antigen-specific T cell responses requires further investigation. As our understanding develops, there is increasing scope to modulate the T cell response after stroke.
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Affiliation(s)
- Dipender Gill
- Clinical Pharmacology and Therapeutics, Imperial College Healthcare NHS Trust, United Kingdom.
| | - Roland Veltkamp
- Neurology, Chair of Department of Stroke Medicine, Division of Brain Sciences, Imperial College London, United Kingdom.
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Liesz A, Hu X, Kleinschnitz C, Offner H. Functional role of regulatory lymphocytes in stroke: facts and controversies. Stroke 2015; 46:1422-30. [PMID: 25791715 DOI: 10.1161/strokeaha.114.008608] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2014] [Accepted: 02/24/2015] [Indexed: 01/02/2023]
Affiliation(s)
- Arthur Liesz
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München, Munich, Germany (A.L.); Munich Cluster for Systems Neurology (SyNergy), Munich, Germany (A.L.); Department of Neurology, University of Pittsburgh, PA (X.H.); Department of Neurology, University Hospital Würzburg, Würzburg, Germany (C.K.); Department of Neurology and Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland (H.O.); and Neuroimmunology Research, Portland, OR (H.O.).
| | - Xiaoming Hu
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München, Munich, Germany (A.L.); Munich Cluster for Systems Neurology (SyNergy), Munich, Germany (A.L.); Department of Neurology, University of Pittsburgh, PA (X.H.); Department of Neurology, University Hospital Würzburg, Würzburg, Germany (C.K.); Department of Neurology and Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland (H.O.); and Neuroimmunology Research, Portland, OR (H.O.)
| | - Christoph Kleinschnitz
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München, Munich, Germany (A.L.); Munich Cluster for Systems Neurology (SyNergy), Munich, Germany (A.L.); Department of Neurology, University of Pittsburgh, PA (X.H.); Department of Neurology, University Hospital Würzburg, Würzburg, Germany (C.K.); Department of Neurology and Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland (H.O.); and Neuroimmunology Research, Portland, OR (H.O.)
| | - Halina Offner
- From the Institute for Stroke and Dementia Research, Klinikum der Universität München, Munich, Germany (A.L.); Munich Cluster for Systems Neurology (SyNergy), Munich, Germany (A.L.); Department of Neurology, University of Pittsburgh, PA (X.H.); Department of Neurology, University Hospital Würzburg, Würzburg, Germany (C.K.); Department of Neurology and Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland (H.O.); and Neuroimmunology Research, Portland, OR (H.O.)
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