Synthetische Glycopeptide mit Sulfatyl-Lewis X-Struktur als potenzielle Inhibitoren der Zelladhäsion

Zelladhäsionsprozesse sind von großer Bedeutung für zahlreiche biologische Prozesse, wie etwa die Immunantwort, die Wundheilung und die Embryogenese. Außerdem spielen sie eine entscheidende Rolle im Verlauf inflammatorischer Prozesse. An der Zelladhäsion sind verschiedene Klassen von Adhäsionsmolekülen beteiligt. Die erste leichte „rollende“ Adhäsion von Leukozyten am Ort einer Entzündung wird durch die Selektine vermittelt. Diese binden über die Kohlenhydrat-Strukturen Sialyl-Lewisx und Sialyl-Lewisa über eine calciumabhängige Kohlenhydrat-Protein-Bindung an ihre spezifischen Liganden und vermitteln so den ersten Zellkontakt, bevor andere Adhäsionsmoleküle (Cadherine, Integrine) die feste Adhäsion und den Durchtritt durch das Endothel bewirken. Bei einer pathogenen Überexpression der Selektine kommt es jedoch zu zahlreichen chronischen Erkrankungen wie z. B. rheumatoider Arthritis, Erkrankungen der Herzkranzgefäße oder dem Reperfusions-syndrom. Außerdem wird eine Beteiligung der durch die Selektine vermittelten Zellkontakte bei der Metastasierung von Karzinomzellen angenommen. Ein Ansatzpunkt für die Behandlung der oben genannten Erkrankungen ist die Gabe löslicher kompetitiver Inhibitoren für die Selektine. Ziel der Arbeit war die Modifikation des Sialyl-Lewisx-Leitmotivs zur Steigerung der metabolischen Stabilität und dessen Einbau in die Peptidsequenz aus der für die Bindung verantwortlichen Domäne des endogenen Selektin-Liganden PSGL-1. Dazu wurden mit einer modifizierten Lewisx-Struktur glycosylierte Aminosäurebausteine dargestellt (Abb.1). Die Verwendung von Arabinose und des Sulfatrestes anstelle von Fusose und Sialinsäure sollte außerdem zu einer gesteigerten metabolischen Stabilität des synthetischen Liganden beitragen. Die so erhaltenen Glycosylaminosäuren sollten nun in die Festphasenpeptidsynthese eingesetzt werden. Aufgrund der großen säurelabilität konnte hier nicht auf das Standartverfahren (Wang-Harz, Abspaltung mit TFA) zurückgegriffen werden. Deshalb kam ein neuartiges UV-labiles Ankersystem zum Einsatz. Dazu wurde ein Protokoll für die Synthese und Abspaltung von Peptiden an diesem neuen System entwickelt. Daran gelang die Synthese des nichtglycosylierten Peptidrückgrats sowie eines mit der dem sulfatierten Lewisx-Motiv versehenen Glycopeptids. Ein vierfach sulfatiertes Glycopeptid, welches durch den Einsatz von im Vorfeld chemisch sulfatierer Tyrosin-Bausteinen dargestellt werden sollte, konnte massenspektrometrisch nachgewiesen werden.

Mucinartige Glycopeptide als Inhibitoren selektinvermittelter Zelladhäsionsprozesse

Es wurden Glycopeptide mit einer Partialsequenz aus der N-terminalen Domäne des natürlichen Selektinliganden PSGL-1 synthetisiert, welche prinzipiell als kompetitive Inhibitoren unerwünschter selektinvermittelter Zelladhäsionsphänomene fungieren könnten. Grundsätzlich könnte es möglich sein, auf diesem Wege entsprechende chronisch entzündliche Krankheiten wie rheumatoide Arthritis zu behandeln und bestimmte akut eintretende schwere Schädigungen von gesundem Gewebe sowie die Metastasenbildung maligner Tumore zu unterdrücken. Das tatsächliche Potential der hergestellten Glycopeptide als Liganden der Selektine kann nun in biologischen Tests geprüft werden. Der gewählte Ausschnitt aus dem P-Selektin-Glycoprotein-Liganden-1 (PSGL-1) reicht von Tyr48 bis Pro59 und umfasst so sämtliche Aminosäurereste der Sequenz, die für das Auftreten einer hochaffinen Rezeptorbindung erforderlich sind. Dabei ist die Seitenkette von Thr57 mit einem O-Glycan modifiziert, welches das in natürlichen Selektinliganden häufig vorkommende Tetrasaccharid Sialyl-Lewisx bzw. ein Mimetikum desselben enthält und die für Mucine typische Form der Anbindung an das peptidische Rückgrat über eine N-Acetyl-α-D-galactosamineinheit aufweist. Zum Aufbau der komplexen Glycopeptidstrukturen wurde zunächst eine Strategie für die Synthese des an die Hydroxylaminosäure gebundenen Oligosaccharids im Gramm-Maßstab ausgearbeitet. Dabei kam der Wahl eines geeigneten Schutzgruppenmusters besondere Bedeutung zu. Das entwickelte Konzept basiert allein auf chemischen Methoden und ermöglicht die parallele Herstellung potentieller Mimetika. So wurde in dieser Arbeit L-Fucose durch D-Arabinose und N-Acetyl-D-neuraminsäure durch (S)-Cyclohexylmilchsäure ersetzt. Die erhaltenen Glycosylaminosäure-Bausteine wurden schließlich in die Glycopeptid-synthesen an der festen Phase eingebracht, welche nach vollständiger Deblockierung die gewünschten Zielverbindungen lieferten.rn

Die Synthese eines Sialyl-Lewis X-Mimetikums als Baustein zur Herstellung von Glycopeptid-Zelladhäsionsinhibitoren für Selektine

Zelladhäsionsphänomene spielen eine wichtige Rolle in vielen biologischen Vorgängen, wie z. B. in der Embryogenese, der Wundheilung, der Immunantwort und Entzündungsprozessen. So wird die inflammatorische Kaskade durch P- und E-Selektin vermittelte Adhäsion der im Blutstrom zirkulierenden Leukozyten an Endothelzellen eingeleitet. Übermäßige Zelladhäsion kann hingegen eine Vielzahl von Krankheiten bewirken. Nachgewiesen ist eine solche Beteiligung der Selektine u. a. bei rheumatoider Arthritis, Erkrankungen der Herzkranzgefäße und dem Reperfusionssyndrom. Ein Ansatz zur Therapie besteht in der Verabreichung löslicher Selektinliganden, die kompetitiv an die Selektine binden und deren Aktivität dadurch mindern. Die wichtigste Leitstruktur für pharmakologisch aktive Selektinliganden stellt hierbei das Tetrasaccharid-Epitop Sialyl-Lewisx (sLex) dar.rnrnIn dieser Arbeit wurde nach einer nicht enzymatischen Strategie ein auf der sLex Struktur basierender Baustein für die Festphasen-Peptidsynthese synthetisiert. Aus diesem sollen nach Schutzgruppen-Manipulationen durch Einsatz in automatisierten Festphasen-Peptidsynthesen, verschiedene Glycopeptide als Zelladhäsionsinhibitoren für Selektine gewonnen werden. Der rasche Abbau der sLex-Struktur im Organismus schränkt die pharmakologische Nutzung von sLex-Derivaten jedoch stark ein. Das synthetisierte Kohlenhydrat Epitop weist daher gegenüber der natürlichen sLex-Struktur mehrere Modifikationen auf, die zu einer erhöhten metabolischen Stabilität führen sollen, ohne die für eine effektive Bindung zum Rezeptor nötigen Wechselwirkungen zu beeinträchtigen. rnrnAus diesem Grund wurde der synthetisch anspruchsvolle Sialinsäure-Baustein durch die L-Cyclohexylmilchsäure substituiert. Die Anbindung des Kohlenhydrat-Epitops an das Peptid wird im Gegensatz zur natürlichen N-glycosidischen Verknüpfung hier über eine zusätzliche Glucosamin-Einheit O-glycosidisch an die Aminosäure L-Threonin bewirkt. Außerdem wird der labile Fucose-Rest durch die D-Arabinose ersetzt, die nicht im menschlichen Organismus vorkommt, jedoch die drei essentiellen pharmakophoren Hydroxylfunktionen in der gleichen dreidimensionalen Orientierung präsentiert wie die L-Fucose.

Prozessierung des humanen GARP–Rezeptors und die physiologischen Auswirkungen

GARP (Glycoprotein A Repetitions Predominant) ist ein Oberflächenrezeptor auf regulatorischen T–Zellen (TRegs), der den latenten TGF–β (Transforming Growth Factor–β) bindet. Ein Funktionsverlust von T Regs hat gravierende Autoimmunerkrankungen wie das Immunodysregulation Polyendocrinopathy Enteropathy X–linked Syndrome (IPEX), Multiple Sklerose (MS) oder Rheumatoide Arthritis (RA) zur Folge. GARP stellt über eine Erhöhung der Aktivierbarkeit von TGF–β den regulatorischen Phänotyp von TRegs sicher und inhibiert die Ausbreitung von autoreaktiven TH17 Zellen.rn In dieser Arbeit stand die Regulation von GARP selbst im Mittelpunkt. Es konnte gezeigt werden, dass es sich innerhalb der kiefertragenden Vertebraten um ein strikt konserviertes Protein handelt. Datenbankanalysen machten deutlich, dass es zuerst in basalen Knochenfischen zusammen mit anderen Komponenten der adaptiven Immunantwort auftritt. Ein 3D–Modell, welches über Homologiemodellierung erstellt wurde, gab Aufschluss über die Struktur des Rezeptors und mögliche intramolekulare Disulfidbrücken. Für in vitro Versuche wurde eine lösliche Variante von GARP durch einen Austausch der Transmembrandomäne durch C–terminale Meprin α Domänen konstruiert. Diese Variante wurde in der eukaryotischen Zellkultur zuverlässig in den Überstand sezerniert und konnte chromatografisch gereinigt werden. Mit diesem rekombinanten GARP wurden Prozessierungsversuche mit Autoimmunpathogenese assoziierten Proteasen durchgeführt. Dabei zeigte sich, dass die Serinproteasen Trypsin, Neutrophile Elastase und Plasmin, sowie die Metalloprotease MMP2 in der Lage sind, GARP vollständig zu degradieren. In TGF–β sensitiven Proliferationsuntersuchungen stellte sich heraus, dass die entstandenen Fragmente immer noch in der Lage waren die Aktivierbarkeit von TGF–β zu erhöhen. Neben der Degradierung durch die oben genannten Proteasen konnte ebenfalls beobachtet werden, dass MMP9 und Ovastacin in der Lage sind GARP spezifisch zu schneiden. Ovastacin mRNA wurde in dieser Arbeit das erste Mal außerhalb der Oocyte, in T–Zellen beschrieben. Mit GARP wurde zudem das zweite Proteinsubstrat, neben dem Zona Pellucida Protein 2 identifiziert. Das durch MMP9 erzeugte N–terminale Fragment besitzt zwar die Eigenschaft, an TGF–β zu binden, kann aber die Aktivierbarkeit von TGF–β nicht mehr wie das intakte GARP erleichtern. rnDiese Arbeit zeigte, dass GARP durch Proteolyse reguliert wird, wobei die entstehenden Fragmente unterschiedlichen Einfluss auf die Aktivierbarkeit von TGF–β haben. Dieses Wissen bildet die Grundlage für weitere Untersuchungen im translationalen Forschungsbereich, um die gewonnenen Erkenntnisse zur Immunmodulation in der Therapie verschiedener Krankheiten einsetzen zu können.rn

Interaction of pregnancy and autoimmune rheumatic disease

During pregnancy, the fetus represents a natural allograft that is not normally rejected. While the maternal immune system retains the ability to respond to foreign antigens, tolerance mechanisms are up-regulated to protect the fetus from immunologic attacks by the mother. The profound immunologic adaptations during and after pregnancy do influence maternal autoimmune rheumatic diseases in several ways. One is triggering the onset of a rheumatic disease in the post partum period, the other influencing disease activity of established rheumatic disease. The review will discuss the mechanisms of increased susceptibility of rheumatoid arthritis (RA) in the first year post partum with a specific emphasis on the role of fetal cells or antigens persisting in the maternal circulation (so called microchimerism). Furthermore, the different influences of pregnancy on established rheumatic diseases will be highlighted. A marked beneficial effect of pregnancy is observed on RA whereas several other rheumatic diseases as ankylosing spondylitis (AS) and systemic lupus erythematosus (SLE) show either no particular effect or an aggravation of symptoms during pregnancy. Differences emerging in regard to modulation of disease symptoms during pregnancy seem related to response to hormones, the type of cytokine profile and immune response prevailing as well as further downstream interactions of molecular pathways that are important in disease pathogenesis.

[Proteins in rheumatology and clinical immunology]

Twelve years ago the tumour necrosis factor (TNF) inhibitors revolutionised the therapy of rheumatoid arthritis and other inflammatory rheumatic diseases. Today, in addition to anti-cytokine strategies, immunosuppressive biologicals have been developed that delete B-lymphocytes or inhibit the activation of T-lymphocytes. The spectrum of indications for these protein drugs will broaden substantially in the near future and will likely include also diseases with orphan status (incidence below 1:10'000). Used in the right indication and with knowledge of molecular effects as well as clinical adverse effects these new drugs do not appear to be more dangerous than conventional disease modifying agents (DMARDs).

Ginger phenylpropanoids inhibit IL-1beta and prostanoid secretion and disrupt arachidonate-phospholipid remodeling by targeting phospholipases A2

The rhizome of ginger (Zingiber officinale) is employed in Asian traditional medicine to treat mild forms of rheumatoid arthritis and fever. We have profiled ginger constituents for robust effects on proinflammatory signaling and cytokine expression in a validated assay using human whole blood. Independent of the stimulus used (LPS, PMA, anti-CD28 Ab, anti-CD3 Ab, and thapsigargin), ginger constituents potently and specifically inhibited IL-1β expression in monocytes/macrophages. Both the calcium-independent phospholipase A(2) (iPLA(2))-triggered maturation and the cytosolic phospholipase A(2) (cPLA(2))-dependent secretion of IL-1β from isolated human monocytes were inhibited. In a fluorescence-coupled PLA(2) assay, most major ginger phenylpropanoids directly inhibited i/cPLA(2) from U937 macrophages, but not hog pancreas secretory phospholipase A(2). The effects of the ginger constituents were additive and the potency comparable to the mechanism-based inhibitor bromoenol lactone for iPLA(2) and methyl arachidonyl fluorophosphonate for cPLA(2), with 10-gingerol/-shogaol being most effective. Furthermore, a ginger extract (2 μg/ml) and 10-shogaol (2 μM) potently inhibited the release of PGE(2) and thromboxane B2 (>50%) and partially also leukotriene B(4) in LPS-stimulated macrophages. Intriguingly, the total cellular arachidonic acid was increased 2- to 3-fold in U937 cells under all experimental conditions. Our data show that the concurrent inhibition of iPLA(2) and prostanoid production causes an accumulation of free intracellular arachidonic acid by disrupting the phospholipid deacylation-reacylation cycle. The inhibition of i/cPLA(2), the resulting attenuation of IL-1β secretion, and the simultaneous inhibition of prostanoid production by common ginger phenylpropanoids uncover a new anti-inflammatory molecular mechanism of dietary ginger that may be exploited therapeutically.

Proteins encoded in genomic regions associated with immune-mediated disease physically interact and suggest underlying biology

Genome-wide association studies (GWAS) have defined over 150 genomic regions unequivocally containing variation predisposing to immune-mediated disease. Inferring disease biology from these observations, however, hinges on our ability to discover the molecular processes being perturbed by these risk variants. It has previously been observed that different genes harboring causal mutations for the same Mendelian disease often physically interact. We sought to evaluate the degree to which this is true of genes within strongly associated loci in complex disease. Using sets of loci defined in rheumatoid arthritis (RA) and Crohn's disease (CD) GWAS, we build protein-protein interaction (PPI) networks for genes within associated loci and find abundant physical interactions between protein products of associated genes. We apply multiple permutation approaches to show that these networks are more densely connected than chance expectation. To confirm biological relevance, we show that the components of the networks tend to be expressed in similar tissues relevant to the phenotypes in question, suggesting the network indicates common underlying processes perturbed by risk loci. Furthermore, we show that the RA and CD networks have predictive power by demonstrating that proteins in these networks, not encoded in the confirmed list of disease associated loci, are significantly enriched for association to the phenotypes in question in extended GWAS analysis. Finally, we test our method in 3 non-immune traits to assess its applicability to complex traits in general. We find that genes in loci associated to height and lipid levels assemble into significantly connected networks but did not detect excess connectivity among Type 2 Diabetes (T2D) loci beyond chance. Taken together, our results constitute evidence that, for many of the complex diseases studied here, common genetic associations implicate regions encoding proteins that physically interact in a preferential manner, in line with observations in Mendelian disease.

Acquisition of complement inhibitor serine protease factor I and its cofactors C4b-binding protein and factor H by Prevotella intermedia

Infection with the Gram-negative pathogen Prevotella intermedia gives rise to periodontitis and a growing number of studies implies an association of P. intermedia with rheumatoid arthritis. The serine protease Factor I (FI) is the central inhibitor of complement degrading complement components C3b and C4b in the presence of cofactors such as C4b-binding protein (C4BP) and Factor H (FH). Yet, the significance of complement inhibitor acquisition in P. intermedia infection and FI binding by Gram-negative pathogens has not been addressed. Here we show that P. intermedia isolates bound purified FI as well as FI directly from heat-inactivated human serum. FI bound to bacteria retained its serine protease activity as shown in degradation experiments with (125)I-labeled C4b. Since FI requires cofactors for its activity we also investigated the binding of purified cofactors C4BP and FH and found acquisition of both proteins, which retained their activity in FI mediated degradation of C3b and C4b. We propose that FI binding by P. intermedia represents a new mechanism contributing to complement evasion by a Gram-negative bacterial pathogen associated with chronic diseases.

Crohn's disease-associated polymorphism within the PTPN2 gene affects muramyl-dipeptide-induced cytokine secretion and autophagy

The single nucleotide polymorphism (SNP) rs2542151 within the gene locus region encoding protein tyrosine phosphatase non-receptor type 2 (PTPN2) has been associated with Crohn's disease (CD), ulcerative colitis (UC), type-I diabetes, and rheumatoid arthritis. We have previously shown that PTPN2 regulates mitogen-activated protein kinase (MAPK) signaling and cytokine secretion in human THP-1 monocytes and intestinal epithelial cells (IEC). Here, we studied whether intronic PTPN2 SNP rs1893217 regulates immune responses to the nucleotide-oligomerization domain 2 (NOD2) ligand, muramyl-dipeptide (MDP).

Cytokines and pregnancy in rheumatic disease

Cytokines are important mediators involved in the successful outcome of pregnancy. The concept of pregnancy as biased toward a Th2 immune response states that Th1 type cytokines are associated with pregnancy failure and that Th2 cytokines are protective and counteract pregnancy-related disorders. Studies at the level of the maternal-fetal interface, in the maternal circulation and in cells of peripheral blood have shown that the Th2 concept of pregnancy is an oversimplification. Both Th1 and Th2 type cytokines play a role at different stages of pregnancy and are adapted to the localization and function of cells and tissues. The changes of local and systemic cytokine patterns during pregnancy correspond to neuroendocrine changes with hormones as powerful modulators of cytokine expression. Several autoimmune disorders show a modulation of disease activity during and after pregnancy. In rheumatic diseases with a predominance of a Th1 immune response, a shift to a Th2 type immune response during pregnancy has been regarded as beneficial. Studies of pregnant patients with rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) have shown a cytokine expression similar to that found in healthy pregnant women. Significant differences were present only for a few cytokines and seemed related to the activity of the underlying disease. Interestingly, a gestational increase of cytokine inhibitors interleukin 1 receptor antagonist (IL-1ra) and soluble tumor necrosis factor receptor (sTNFR) in the circulation corresponded to low disease activity in RA. The influence of hormones and cytokines on autoimmune disease is an issue for further study.

What has ageing to do with periodontal health and disease?

Periodontitis is a multi-factorial disease and in most cases also a disease with a chronic progression. Exposure to factors which contribute to periodontitis occurs over a long period, so that at the time of diagnosis it may be difficult to identify and evaluate what co-factors have contributed to its development. These include exposure to bacteria and viruses, inflammation, genetic factors, health behaviours and a variety of social factors, socio-economic status, behavioural and nutritional habits, the ability to cope with stress and the ability of the immune system to fight infections. Many patients in their 50s also experience other conditions such as heart disease, diabetes mellitus, or rheumatoid arthritis and recent reports on the associations and potential biological mechanisms by which periodontitis can be linked to other systemic diseases suggest that the patient with periodontitis is a challenged individual. Neither individuals nor their oral health care providers are currently prepared for the challenges in oral health care as the expectation of successful ageing with remaining and aesthetically functional teeth is increasing. The scientific evidence is, however, growing, and while the opportunities to prepare for successful ageing exist they must be included in the educational process of both current and future oral health care providers and their patients.

Genetic association studies under the population stratification, family pedigree and application to genome-wide association studies

This dissertation has three separate parts: the first part deals with the general pedigree association testing incorporating continuous covariates; the second part deals with the association tests under population stratification using the conditional likelihood tests; the third part deals with the genome-wide association studies based on the real rheumatoid arthritis (RA) disease data sets from Genetic Analysis Workshop 16 (GAW16) problem 1. Many statistical tests are developed to test the linkage and association using either case-control status or phenotype covariates for family data structure, separately. Those univariate analyses might not use all the information coming from the family members in practical studies. On the other hand, the human complex disease do not have a clear inheritance pattern, there might exist the gene interactions or act independently. In part I, the new proposed approach MPDT is focused on how to use both the case control information as well as the phenotype covariates. This approach can be applied to detect multiple marker effects. Based on the two existing popular statistics in family studies for case-control and quantitative traits respectively, the new approach could be used in the simple family structure data set as well as general pedigree structure. The combined statistics are calculated using the two statistics; A permutation procedure is applied for assessing the p-value with adjustment from the Bonferroni for the multiple markers. We use simulation studies to evaluate the type I error rates and the powers of the proposed approach. Our results show that the combined test using both case-control information and phenotype covariates not only has the correct type I error rates but also is more powerful than the other existing methods. For multiple marker interactions, our proposed method is also very powerful. Selective genotyping is an economical strategy in detecting and mapping quantitative trait loci in the genetic dissection of complex disease. When the samples arise from different ethnic groups or an admixture population, all the existing selective genotyping methods may result in spurious association due to different ancestry distributions. The problem can be more serious when the sample size is large, a general requirement to obtain sufficient power to detect modest genetic effects for most complex traits. In part II, I describe a useful strategy in selective genotyping while population stratification is present. Our procedure used a principal component based approach to eliminate any effect of population stratification. The paper evaluates the performance of our procedure using both simulated data from an early study data sets and also the HapMap data sets in a variety of population admixture models generated from empirical data. There are one binary trait and two continuous traits in the rheumatoid arthritis dataset of Problem 1 in the Genetic Analysis Workshop 16 (GAW16): RA status, AntiCCP and IgM. To allow multiple traits, we suggest a set of SNP-level F statistics by the concept of multiple-correlation to measure the genetic association between multiple trait values and SNP-specific genotypic scores and obtain their null distributions. Hereby, we perform 6 genome-wide association analyses using the novel one- and two-stage approaches which are based on single, double and triple traits. Incorporating all these 6 analyses, we successfully validate the SNPs which have been identified to be responsible for rheumatoid arthritis in the literature and detect more disease susceptibility SNPs for follow-up studies in the future. Except for chromosome 13 and 18, each of the others is found to harbour susceptible genetic regions for rheumatoid arthritis or related diseases, i.e., lupus erythematosus. This topic is discussed in part III.

Management of RA medications in pregnant patients

A desire for children or the presence of pregnancy limits the drug therapy options for a woman with rheumatoid arthritis. Combination therapies that include methotrexate or new drugs that have not been studied or used in pregnant patients must be excluded, even though they might be highly efficacious. With few exceptions, the reason for this exclusion is not the proven teratogenicity of the drugs, but the absence of proven safety for the fetus. Whereas methotrexate, leflunomide, abatacept and rituximab must be withdrawn before a planned pregnancy, tumor necrosis factor inhibitors and bisphosphonates can be continued until conception. Antimalarial agents, sulfasalazine, azathioprine and ciclosporin are compatible with pregnancy, and so can be administered until birth. Corticosteroids and analgesics such as paracetamol (acetaminophen) can also be used throughout pregnancy. NSAIDs can be safely administered until gestational week 32. The most important consideration when managing rheumatoid arthritis medications during pregnancy is that therapy must be tailored for the individual patient according to disease activity.

The OMERACT ultrasound task force -- Advances and priorities

This article reports the most recent work of the OMERACT Ultrasound Task Force (post OMERACT 8) and highlights of future research priorities discussed at the OMERACT 9 meeting, Kananaskis, Canada, May 2008. Results of 3 studies were presented: (1) assessing intermachine reliability; (2) applying the scoring system developed in the hand to other joints most commonly affected in rheumatoid arthritis (RA); and (3) assessing interobserver reliability on a deep target joint (shoulder). Results demonstrated good intermachine reliability between multiple examiners, and good applicability of the scoring system for the hand on other joints (including shoulder). Study conclusions were discussed and a future research agenda was generated, notably the further development of a Global OMERACT Sonography Scoring (GLOSS) system in RA, emphasizing the importance of testing feasibility and added value over standard clinical variables. Future disease areas of importance to develop include a scoring system for enthesitis and osteoarthritis.