Vivek Anand Manivel

Anti-type II collagen immune complex-induced granulocyte reactivity is associated with joint erosions in RA patients with anti-collagen antibodies

IntroductionRheumatoid arthritis (RA) patients with autoantibodies against collagen type II (CII) are characterized by acute RA onset with elevated inflammatory measures and early joint erosions as well as increased production of tumor necrosis factor-α (ΤΝF-α) by peripheral blood mononuclear cells (PBMC) stimulated by anti-CII immune complexes (IC) in vitro. Polymorphonuclear granulocytes (PMN) are abundant in RA synovial fluids, where they might interact directly with anti-CII IC in the articular cartilage, but no studies have investigated PMN responses towards anti-CII IC. The aim was to investigate whether PMN react towards anti-CII IC, and to what extent such reactivity might relate to the clinical acute onset RA phenotype associated with elevated levels of anti-CII.MethodsPMN and PBMC isolated from healthy donors were stimulated with IC made with a set of 72 baseline patient sera (24 anti-CII positive, 48 anti-CII negative) chosen from a clinically well-characterized RA cohort with two-year radiological follow-up with Larsen scoring. PMN expression of cluster of differentiation (CD)11b, CD66b, CD16 and CD32 was measured by flow cytometry, whereas PMN production of myeloperoxidase (MPO) and interleukin (IL)-17, and PBMC production of ΤΝF-α was measured with enzyme linked immunosorbent assay.ResultsPMN expression of CD11b, CD66b and MPO, and PBMC production of ΤΝF-α were upregulated whereas PMN expression of CD16 and CD32 were downregulated by anti-CII IC. CD16, CD66b, and MPO production correlated to serum anti-CII levels (Spearman’s ρ = 0.315, 0.675 and 0.253, respectively). CD16 was associated with early joint erosions (P = 0.024, 0.034, 0.046 at baseline, one and two years) and CD66b was associated with changes in joint erosions (P = 0.017 and 0.016, at one and two years compared to baseline, respectively). CD66b was associated with baseline C-reactive protein and PBMC production of ΤΝF-α was associated with baseline erythrocyte sedimentation rate, in accordance with our earlier findings. No clinical associations were observed for MPO or IL-17.ConclusionPMN responses against anti-CII IC are more closely associated with early joint erosions than are PBMC cytokine responses. PMN reactivity against anti-CII IC may contribute to joint destruction in newly diagnosed RA patients with high levels of anti-CII.

Cathepsin S and cathepsin L in serum and synovial fluid in rheumatoid arthritis with and without autoantibodies

OBJECTIVES Cathepsin S and cathepsin L are endosomal proteolytic enzymes involved in the degradation of extracellular matrixes, angiogenesis and antigen presentation. Cathepsins could thus play several roles in the disease process of RA. The aim of this study was to examine differences in cathepsin S and cathepsin L levels in serum and SF of RA patients with and without ACPA and RF. METHODS In this study 121 patients with RA and clinical signs of knee synovitis were recruited. Patient characteristics were collected and matched samples of serum and SF were analysed for cathepsin S, cathepsin L, ACPA, IgA and IgM RF, CRP and MMP3. RESULTS SF levels of cathepsin L, cathepsin S and MMP3 were significantly higher than in serum. Serum levels of both cathepsins were significantly higher in patients with ACPA, IgM-RF and IgA-RF compared with patients without these antibodies. SF levels of both cathepsins correlated with DAS28 and CRP in ACPA- and RF-positive but not in seronegative patients. CONCLUSION The differences in cathepsin S and cathepsin L between RA patients with and without autoantibodies indicate that these cathepsins have a specific role in the disease process of seropositive RA. In this phenotype, cathepsin serum levels may reflect the autoimmune activity, whereas the levels in SF may reflect the local inflammatory and matrix degrading process in the joint.

Anticollagen type II antibodies are associated with an acute onset rheumatoid arthritis phenotype and prognosticate lower degree of inflammation during 5 years follow-up

Objective Antifibrillar collagen type II (anti-CII) antibody-positive patients with rheumatoid arthritis (RA) have early but not late signs of increased inflammation and joint erosions. We wanted to replicate this in a large RA cohort, and to relate to human leukocyte antigen (HLA)-DRB1* alleles. Methods Anti-CII and anti-cyclic citrullinated peptide (CCP)2 were measured at baseline in 773 patients with RA from the Swedish Epidemiological Investigation in Rheumatoid Arthritis (EIRA) study with clinical follow-up data from the Swedish Rheumatology Quality Register (SRQ) registry, and 1476 with HLA-DRB1* information. Comparisons were done concerning C reactive protein (CRP), erythrocyte sedimentation rate (ESR), tender joint count (TJC), swollen joint count (SJC), Disease Activity Score encompassing 28 joints based on ESR (DAS28), DAS28CRP, pain-Visual Analogue Scale (VAS), global-VAS and Health Assessment Questionnaire Score (HAQ) at eight occasions during 5 years, and association with HLA-DRB1* alleles. Results Anti-CII associated with elevated CRP, ESR, SJC, DAS28 and DAS28CRP at diagnosis and up to 6 months, whereas anti-CCP2 associated with SJC and DAS28 from 6 months to 5 years, but not earlier. The anti-CII-associated phenotype was strong, and predominated in anti-CII/anti-CCP2 double-positive patients. Anti-CII was associated with improvements in CRP, ESR, SJC, TJC and DAS28, whereas anti-CCP2 was associated with deteriorations in SJC and DAS28 over time. Anti-CII-positive patients achieved European League Against Rheumatism good or moderate response more often than negative patients. Anti-CII was positively associated with HLA-DRB1*01 and HLA-DRB1*03, with significant interaction, and double-positive individuals had >14 times higher mean anti-CII levels than HLA double negatives. Whereas smoking was associated with elevated anti-CCP2 levels, smokers had lower anti-CII levels. Conclusions Anti-CII seropositive RA represents a distinct phenotype, in many respects representing the converse to the clinical, genetic and smoking associations described for anticitrullinated protein peptide autoantibodies. Although not diagnostically useful, early anti-CII determinations predict favourable inflammatory outcome in RA.

Pentraxin 3 in serum and synovial fluid of patients with rheumatoid arthritis with and without autoantibodies

Objectives: Pentraxin 3 (PTX3) is a locally produced multifunctional protein involved in inflammation, matrix deposition, and immunity. As patients with seropositive rheumatoid arthritis (RA) have a more severe disease course and higher risk of joint destruction than seronegative patients, the aim of the present study was to examine differences in PTX3 in synovial fluid (SF) (and serum) in seropositive compared to seronegative RA, and other local markers of inflammation and destruction. Method: Ninety-seven RA patients with knee effusion were included. Serum and SF levels of PTX3, as well as serum levels of anti-citrullinated protein antibody and rheumatoid factor of immunoglobulin A and M subclasses, and markers of inflammation and potential destruction in SF: white blood cell counts, tumour necrosis factor, interleukin-6, vascular endothelial growth factor, metalloproteinase 3, and cartilage oligomeric matrix protein, were analysed. In addition, a radiographic knee examination was performed. Results: Seropositive patients had significantly higher PTX3 levels in SF than seronegative patients, whereas there was no difference for serum levels. SF-PTX3 levels correlated with disease activity and with local inflammatory markers, especially polymorphonuclear cells, and with autoantibody levels. There was no correlation between PTX3 levels in serum and SF. Conclusion: The correlation of disease activity and autoantibody levels with SF-PTX3 levels in antibody-positive patients suggests a role for PTX3 in the inflammatory process specifically in seropositive RA joints, and supports the hypothesis that seropositive and seronegative RA are different disease entities. Polymorphonuclear granulocytes may be an important source of PTX3 in RA SF.

Granulocyte-augmented chemokine production induced by type II collagen-containing immune complexes is mediated via TLR4 in rheumatoid arthritis patients

Rheumatoid arthritis (RA) patients with early elevations of antibodies against collagen type II (CII) have a distinct acute onset phenotype, associated with cytokine induction by surface‐bound anti‐CII‐containing immune complexes (ICs) and high C‐reactive protein (CRP) and erythrocyte sedimentation rate (ESR). Polymorphonuclear granulocytes (PMNs) and peripheral blood mononuclear cells (PBMCs) are abundant in the vicinity of CII in RA joints, and both PMN and PBMC reactivity against anti‐CII IC individually relate to early joint destruction and early elevation of CRP and ESR in RA. We searched for CII‐dependent mechanisms that might attract PMNs and PBMCs to RA joints. Human PBMCs and PMNs were stimulated with anti‐CII ICs and control ICs, either individually or in cocultures. Cocultured PMNs and PBMCs stimulated with anti‐CII ICs synergistically augmented production of the chemokines CXCL8, RANTES and MCP‐1, whereas downregulation was seen with control IC. This upregulation was unique to chemokines, as TNF‐α, IL‐1β, and GM‐CSF were downregulated in anti‐CII IC‐stimulated cocultures. The coculture‐associated chemokine upregulation depended on endogenous TLR4 ligand(s) and functionally active PMN enzymes, and was partially mediated by GM‐CSF. As anti‐CII levels peak around the time of RA diagnosis, this mechanism can attract inflammatory cells to joints in early RA and intensify the anti‐CII‐associated acute onset RA phenotype.

Anti-type II collagen immune complex-induced granulocyte reactivity is associated with joint erosions in ra patients with anti-collagen antibodies

Objective RA patients with anti-collagen antibodies (anti-CII) are characterised by acute RA onset (Mullazehi et al, ARD 2007) and early joint erosions (Mullazehi et al ART 2012), as well as increased production of TNF by peripheral blood mononuclear cells from anti-CII immune complexes (IC) in vitro (Mullazehi et al A&R 2006). We have previously (abstract EWRR 2012) shown that polymorphonuclear neutrophil granulocytes (PMN) react towards anti-CII IC. The aim was to investigate whether functional PMN responses are associated with the clinical acute onset RA phenotype. Methods A set of 72 baseline patient sera (24 anti-CII positive, 24 anti-CII negative/RF positive and 24 anti-CII negative/RF negative) was chosen from a clinically well-characterised RA cohort with 2-year radiological follow-up (Larsen score). PMN and PBMC isolated from healthy donors were stimulated with anti-CII IC prepared with sera from the patients. PMN expression of CD16 and CD66b were measured by flow cytometry, and PMN production of myeloperoxidase (MPO) and IL-17, and PBMC production of TNF was measured with ELISA. Results CD66b, MPO, and TNF were significantly up-regulated and CD16 was significantly down-regulated by IC made with anti-CII positive sera. Even anti-CII low positive sera were able to impact the expression of CD16, CD66b and TNF. There was linear correlation to CD16, CD66b, MPO and TNF production in relation to anti-CII levels (r = -0.3152, 0.6755, 0.2532 and 0.5846, respectively). CD16 correlated with early joint erosion (p = 0.024, 0.034, 0.046 at baseline, one and two years) and CD66b was associated with changes in joint erosion (p = 0.017 and 0.016, at one and two years compared to baseline, respectively). CD66b was associated with baseline CRP and PBMC production of TNF was associated with baseline ESR, in accordance to our earlier findings. No correlations were observed with IL-17. Conclusion We have earlier shown that PBMC anti-CII IC-induced production of TNF was associated with CRP and ESR in newly diagnosed RA patients. Here we show that PMN reactivity against anti-CII IC is uniquely associated with joint destruction. PMN reactivity towards anti-CII IC in cartilage of patients can contribute to joint destruction in newly diagnosed RA patients.

A1.04 Type II collagen immune complex induce granulocyte dependent augmentation of chemokines via TLR4; a possible therapeutic target in early ra

Background RA patients with anti-collagen type II (CII) antibodies have a distinct acute onset phenotype, associated with cytokine induction by surface-bound anti-CII immune complexes (IC). Mononuclear cells and PMN are accumulated both in the synovial fluid and tissue, in close proximity to hyaline cartilage where anti-CII IC might form. Therefore we wanted to investigate to what extent these two cell types cooperate in anti-CII IC induced responses. Methods Healthy donor granulocytes (PMN) and PBMC were stimulated individually or together (cocultures) with surface-bound IC (anti-CII IC, tetanus toxoid (TT)/anti-TT IC, directly bound IgG), GM-CSF or LPS. Blocking and neutralising studies were performed with antibodies against TLR4, FcgγRIIa, FcgγRIII and GM-CSF. Supernatant cytokine and chemokine levels were analysed with ELISA or ALBIA. Results Anti-CII IC induced cytokine production by PBMC, whereas PMN alone produced negligible cytokine levels. TNF-aα production was downregulated in all coculture systems compared to PBMC cultures, whereas levels of CXCL8, RANTES and MCP-1 were specifically upregulated in anti-CII IC-stimulated cocultures. The CXCL8 upregulation was dependent on anti-CII IC, as CXCL8 production was downregulated in cocultures stimulated with other IC or LPS. The increase of CXCL8 in anti-CII IC stimulated cocultures was totally dependent on TLR4, partly on PMN enzymes, FcgγRIIa, FcgγRIII, and density of anti-CII in IC. Like anti-CII IC, GM-CSF induced coculture-dependent CXCL8 enhancement, and GM-CSF neutralisation diminished the anti-CII IC-dependent CXCL8 enhancement. Conclusion In anti-CII-positive RA patients, PMN amplify accumulation of inflammatory cells by inducing chemokines. This mechanism is dependent on TLR4, PMN enzymes, GM-CSF and the joint-specific autoantigen CII. Local TLR4 blockade, PMN enzyme inhibition or GM-CSF neutralisation might be used to suppress acute joint inflammation in early RA.

PMN Reactivity Contribute to Acute Onset Joint Inflammation By Increasing CXCL8 Production in Joints of RA Patients with Anti-Collagen II Antibodies

Are Ankylosing Spondylitis, Psoriatic Arthritis and Undifferentiated Spondylarthritis Associated with an Increased Risk of Cardiovascular Disease?For a searchable version of these abstracts, please visit www.acrabstracts.org. Please Note: It may take several minutes for this file to download.Background/Purpose: Person-centred care (PCC) is a holistic approach with respectful and individualized care allowing negotiation of care where persons with health problems are empowered to be involved in health decisions. Patients’ illness narratives constitute a starting point for building a collaboration with health care professionals and to empower them to play an active role in their health care. Little is known of the impact of PCC vs. regular care on patients’ skills as health care consumers. The aim was to study the impact on effective consumers’ skills over 6 and 12 months as measured by the Effective Consumer Scale (EC17) in patients undergoing biological therapy and randomly assigned to either a nurse-led rheumatology clinic (NLC) based on PCC or to a rheumatologist-led clinic (RLC) based on regular care.Methods: A 12 month RCT in 107 patients with chronic inflammatory arthritis1. Inclusion criteria were ongoing biological therapy and a DAS28 ≤3.2. All patients met a rheumatologist at inclusion and after 12 months, while the 6 month follow-up was randomized to either at an NLC (PCC) or at an RLC (regular care). Outcome measure was the EC17, developed and endorsed by the OMERACT, including five subscales; 1. Use of health information, 2. Clarifying personal priorities, 3. Communicating with others, 4. Negotiating roles and 5. Deciding and taking action. EC17 total score ranges from 0-100, worse to best. Differences between and within NLC and RLC were analyzed with Friedmans’ test or Mann Whitney U-test.Results: After 12 months 97 patients completed the RCT (NLC n=47, RLC n=50), mean (SD) age 55.4 (12.7) years, disease duration 16.7 (11.5) years, DAS28 2.1 (0.7), HAQ 0.54 (0.38), global health 20.4 (17.1), pain 21.1 (18.0) and 56% were women. There were no statistically significant differences within or between the two intervention groups at baseline nor in EC17 total score mean (SD) at baseline (NLC 83.5 (9.4) vs. RLC 83.2 (10.8), 6 months (NLC 85.4 (10.4) vs. RLC 82.9 (10.9) and 12 months (NLC 85.3 (11.1) vs. RLC 82.3 (10.9)). However, in NLC there was a statistically significant improvement in EC17 subscale “1. Use of health information” at both 6 and 12 months (p=0.041 and p=0.004 respectively).Conclusion: Replacing just one of three visits over 12 months to an NLC based on PCC instead of an RLC based on regular care resulted in more effective consumers concerning the use of health information. Larger studies over longer time frames focusing on PCC are needed to better understand its full impact on effective consumer skills measured by EC17.References:1. Larsson I, et al. Randomized controlled trial of a nurse-led rheumatology clinic for monitoring biological therapy. J Adv Nurs 2014;70:164-75.Background/Purpose: Chronic widespread pain (CWP), one of the hallmarks of fibromyalgia, is not uncommon in adolescents and it has previously been shown that adolescents with pain often become young adults with pain. CWP often co-varies with anxiety, depression, and stress symptoms in adults, but the knowledge regarding this is small in youth and young adults.The aim was to study the associations between CWP, anxiety, depression and stress in adolescents attending first year of high school.Methods: A computerized questionnaire to 296 adolescents attending Swedish high school, with validated questions regarding presence and distribution of pain (Epipain mannequin), stress symptoms (ELO question), anxiety and depression (Hospital Anxiety and Depression Scale – HADS), and health related quality of life (HRQL as measured by EQ5D). Pain was considered chronic when persistent for more than three months, and the subgroup CWP was defined according to the 1990 ACR criteria for fibromyalgia. Statistical analyses in SPSS v21 with comparison of means by Student’s t-test and proportions by chi2-test or Fischer’s exact test.Results: 257 (87%) out of 296 eligible students, mean (SD) age 16.1 (0.7) and 65.8% girls, responded to the questionnaire. Prevalence of chronic pain was 20.8% and that of the subgroup CWP was 4.7%, without any gender differences (boys 18.2% vs girls 22.2%; p=0.224, and 3.4% vs 5.4%; p=0.692). High level (4 or 5 on a 5 point scale) of stress symptoms were less common in boys (16.0% vs 28.2%; p=0.015), as was possible or probable anxiety (17.1% vs 44.4%; p<0.001), but not depression (10.3% vs 12.5%; p=0.764). Students with high level of stress reported CWP five times more often than those with less stress (30.4% vs 5.8%; p=0.001). Students with probable anxiety reported CWP ten times more often than students with no anxiety (17.6% vs 1.8%; p=0.001), and CWP was also more common, but not statistically significant, in students with probable depression (20.0% vs 3.1%; p=0.163). Those reporting CWP had significantly lower HRQL (0.58 vs 0.87; p=0.038) than students with no chronic pain.Conclusion: The high prevalence of chronic pain and the strong associations between CWP and reports of stress and anxiety in adolescents highlights that a multifactorial background to chronic pain must be considered early in life. An apparent lower score in EQ5D also indicates that the presence of CWP has an marked impact on HRQL also in adolescents.Background/Purpose: The treatment target for axial spondyloarthritis (SpA) is to maximize health-related quality of life (HRQoL) by controlling disease activity and improving functioning. The treatment cornerstones are a combination of patient education, pharmacological and non-pharmacological treatment. Health professionals are familiar with providing patient education but the knowledge is scarce concerning how this education is experienced by the patients.The aim was to describe patients’ experiences of education in SpA management.Methods: The study had a descriptive design with a qualitative conventional content analysis approach performed in seven steps in accordance with Graneheim & Lundman (1). The analysis aimed to describe and preserve contextual meanings. After coding and subgrouping meaningful parts of the text were merged into categories. Eleven interviews were conducted between 2014-2015 in patients with SpA based on a strategic sampling in order to achieve variation with regard to sex (7 men, 4 women), age (38-66 years), subdiagnoses (5 patients with AS, 6 with USpA), quality of life (EQ5D 0.29-1.0), disease activity (BASDAI 1-6), physical function (BASFI 0-5), and global health (BASG 0-7) .Results: Three categories representing patients’ experiences of patient education in disease management emerged; guiding education, reliable education and available education. Guiding education comprised SpA management including disease knowledge such as symptoms, prognosis, treatment, self-management, climate impact, heredity, and assisting devices. Reliable education meant how and by whom the education was communicated and was considered reliable if it was based on science and communicated by specialists, for example by physician, nurse, PT, dietician and senior patients with experience of rheumatic diseases. The patients experienced difficulties in assessing the large flow of education coming from various sources. Individualized education also increased the reliability. Available education meant that the education can and should be presented in varied formats, and that the amount of information could be chosen. The education could be given orally (through meetings, videos, lectures), in writing (by pamphlets, e-mails, journals, webpages) or obtained through own personal experiences. There were requests to utilize newer media like skype, video and chat forums. Furthermore, individual contacts with healthcare professionals when needed were of importance.Conclusion: This study highlights the importance of obtaining a guiding, reliable and available patient education for management of SpA. Health care professionals need to consider the importance of presenting varied formats of education based on patients’ experiences and expectations.References:1.Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse education today 2004;24(2):105-12.PMN Reactivity Contribute to Acute Onset Joint Inflammation By Increasing CXCL8 Production in Joints of RA Patients with Anti-Collagen II AntibodiesBig Data International Primary Sjogren Syndrome Registry : Baseline Characterization and Diagnostic Approach in 6047 Patients Fulfilling the 2002 AE CriteriaThe Link Between DAS28 and the Short-Term Risk of Acute Coronary Syndrome in RA, and Its Driving FactorsHypomethylation in Enhancer and Promoter Regions of Interferon Regulated Genes in Multiple Tissues Is Associated with Primary Sjogrens SyndromeReceptor Activator of Nuclear Factor Kappa-B Ligand (RANKL) and Sclerostin Are Related to Joint Destruction in Early Rheumatoid Arthritis Unrelated to Polymorphisms of the Genes

Granulocyte Reactivity is Associated with Cartilage Destruction in Patients with Anti-collagen Antibodies

Aatonen, M, WS1.10 Abrahamsen, A, WS2.9 Achour, A, WS2.12 Adams, RH, WS1.4 Agace, W, WS2.13, WS3.8, WS3.15, WS3.16 Agerberth, B, WS1.20, WS1.22 Agnarsson, B, WS1.17, WS6.14 Ahava, M, WS6.6 Åivo, J, WS6.9 Åkesson, L, WS6.10 Alam, C, WS1.2 Alfredsson, L, WS4.2 Andersson, J, WS4.19 Andesen, L, WS5.13 Antvorskov, JC, WS1.26 Appel, S, WS2.4, WS4.6, WS4.12, WS5.15 Ärlestig, L, WS4.3 Arnardóttir, M, WS1.21, WS1.23, WS6.16 Askling, J, WS4.2 Assadi, G, WS1.8 Asslaber, D, WS5.11 Auer, M, WS6.11 Awoniyi, L, WS2.7Granulocyte Reactivity is Associated with Cartilage Destruction in Patients with Anti-collagen Antibodies

A5.24 Neutrophil Granulocytes Respond to Surface-Bound Immune Complexes Containing Anti-Type II Collagen Antibodies from RA Patients

Background and Objectives We have earlier shown that surface-bound immune complexes containing anti-type II collagen antibodies (anti-CII IC) from rheumatoid arthritis (RA) patients and anti-CII IC stimulate monocyte proinflammatory cytokine production, associated with an acute onset RA phenotype. Anti-CII IC in joint cartilage are exposed to cells in the synovial fluid (SF). Neutrophil granulocytes are the major cell type in SF, where they co-localise with mononuclear cells (MNC). The objective was to investigate whether also granulocytes respond to anti-CII IC, and whether such a response was dependent on interaction with other cells in SF. Materials and Methods An anti-CII RA serum together with human native collagen (CII) was used to create surface-bound anti-CII IC. Heparinised blood from 8 healthy donors was separated into neutrophil granulocytes (>95% purity) and MNC. For each donor, the granulocyte cell fractions as well as co-cultures (granulocytes + MNC) (0.5 × 10E6/ml of each cell fraction) was cultured on anti-CII IC as well as on negative control IC prepared with normal human serum on CII and in a positive control IC system with purified IgG coated onto plastic. After 18 hours, cells were harvested for the measurement of CD11b, CD66b, CD16 and CD32 on granulocytes by flow cytometry, and supernatant levels of TNF and IL-8 was measured by ELISA. Results In granulocyte cultures both anti-CII IC and control IC induced significant up-regulation of CD11b and CD66b, and significant down-regulation of CD16 and CD32. When the granulocytes were co-cultured with MNC, there was a significant increase in CD11b up-regulation and CD16 down-regulation than granulocytes, with no effect on CD32 and CD66b. In the co-culture system, the anti-CII IC-induced production of IL-8 was significantly increased, but no such difference was noted for TNF. Isolated granulocyte fractions produced very low levels of TNF and IL-8 after IC stimulation. Conclusions Isolated granulocytes respond to RA anti-CII IC in a model system mimicking IC in RA cartilage. The granulocyte responses depend on interaction with MNC. Our anti-CII dependent RA phenotype is a human counterpart to collagen antibody-induced arthritis. Strong granulocyte reactivity to anti-CII IC might therefore be related to the Ncf1 gene involved in NADPH activity important in collagen-induced arthritis models.