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Although the concept of precision medicine, in which healthcare is tailored to the molecular and clinical characteristics of each individual, is not new, its implementation in clinical practice has been heterogenous. In some medical specialties, precision medicine has gone from being just a promise to a reality that achieves better patient outcomes. This is a fact if we consider, for example, the great advances made in the genetic diagnosis and subsequent treatment of countless hereditary diseases, such as cystic fibrosis, which have improved the life expectancy of many of the affected children. In the field of oncology, the development of targeted therapies has prolonged the survival of patients with breast, lung, colorectal, melanoma, and hematological malignancies. In other disciplines, clinical milestones are perhaps less well known, but no less important. The current challenge is to expand and generalize the use of technologies that are central to precision medicine, such as massively parallel sequencing, to improve the management (prevention and treatment) of complex conditions such as cardiovascular, kidney, or autoimmune diseases. This process requires investment in specialized expertise, multidisciplinary collaboration, and the nationwide organization of genetic laboratories for diagnosis of specific diseases.

Background In patients with immune-mediated rheumatic diseases (RMD), the development of T-cell responses against SARS-CoV-2 may be impaired by either the immune disturbances associated with the disease, or by the effects of immunosuppressive therapies. We aimed at determining the magnitude of SARS-CoV-2-specific interferon (IFN)-γ-producing T-cell response after COVID-19 recovery in a cohort of patients with RMD on different immunosuppressive therapies. Patients and methods 53 adult patients with inflammatory or autoimmune RMD and 61 sex and age-matched non-RMD patients with confirmed COVID-19 were included. Peripheral blood mononuclear cells were obtained and T-cell-IFN-γ antigen-specific responses against the S1 domain of the spike glycoprotein, the nucleoprotein (N) and the membrane (M) protein from SARS-CoV-2 were assessed by FluoroSpot assay. Results Patients with RMD and COVID-19 showed positive T-cells-IFN-γ responses to SARS-COV-2 antigens, in a similar proportion and magnitude as non-RMD patients at a median of 298 [151–316] and 165 [162–167] days after COVID-19 respectively. Among RMD patients 83%, 87% and 90%, and among non-RMD patients, 95%, 87% and 93% responded to S1, N and M protein respectively. Similar responses were observed in the different diagnostic and therapeutic groups, including conventional synthetic disease-modifying anti-rheumatic drugs (csDMARDs), TNF-α inhibitors, IL-17 inhibitors, rituximab, JAK inhibitors or other immunosuppressants. Conclusion T-cell responses to the main SARS-CoV-2 antigens are present after COVID-19 recovery in most patients with RMD and are not impaired by immunosuppressive therapies.

The mechanisms by which lamin A/C in CD4+ T-cells control intestinal homeostasis and can cause inflammatory bowel disease (IBD) are unknown. Here, we explore lamin A/C in a mouse model of IBD. Adoptive transfer to Rag1-/- mice of Lmna-/- CD4+ T-cells, which have enhanced regulatory T-cells (Treg) differentiation and function, induced less severe IBD than wild-type T-cells. Lamin A/C deficiency in CD4+ T-cells enhanced transcription of the Treg master regulator FOXP3, thus promoting Treg differentiation, and reduced Th1 polarization, due to epigenetic changes in the Th1 master regulator T-bet. In mesenteric lymph nodes, retinoic acid (RA) released by CD103+ dendritic cells downregulated lamin A/C in CD4+ T-cells, enhancing Treg differentiation. However, non-RA-producing CD103- dendritic cells predominated in peripheral lymph nodes, facilitating lamin A/C expression in CD4+ T-cells and therefore Th1 differentiation. Our findings establish lamin A/C as a key regulator of Th differentiation in physiological conditions and show it as a potential immune-regulatory target in IBD. © 2019 Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd. This study was supported by grants to PC from the Research Council of Norway, to JMG-G from ISCIII (PI14/00526; PI17/01395; CP11/00145; CPII16/00022; EuroCellNet COST Action CA15214), the Miguel Servet Program and Fundación Ramón Aréces; to VA (RD12/0042/0028 SAF2013-46663-R, SAF2016-79490-R); to FS-M (SAF2017-82886-R; ERC-2011-AdG 294340-GENTRIS, CIBER CARDIOVASCULAR, PIE 13.0004-BIOIMID and CAM-B2017/BMD-3671-INFLAMUNE), to GC and JLP (PI16/00032 and RETICs RD16/0012 RIER), and to JV (BIO2015-67580-P; PRB3, IPT17/0019 - ISCIII-SGEFI/ERDF, ProteoRed) with co-funding from the European Regional Development Fund (ERDF) “Una manera de hacer Europa”. The CNIC is supported by the Instituto de Salud Carlos III (ISCIII), the Ministerio de Ciencia, Innovación y Universidades (MCNU) and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (SEV-2015-0505). RTF is supported by the Fundación Ramón Aréces, VZG by ISCIII, BHF by the Instituto de Investigación Hospital 12 de Octubre (i+12), and JMG-G by the ISCIII Miguel Servet Program, i+12 and Universidad Autónoma de Madrid (UAM). Sí

Artritis psoriàsica; Artritis reumatoide; Sinovitis Artritis psoriásica; Artritis reumatoide; Sinovitis Psoriatic arthritis; Rheumatoid arthritis; Synovitis Background: Undifferentiated arthritis (UA) is defined as an inflammatory arthritis that does not fulfill criteria for a definite diagnosis. Delay in reaching a specific diagnostic and therapy may lead to impaired functional outcomes. Our aim was to identify synovial biomarkers associated with definitive diagnostic classification in patients with UA. Methods: DMARD-naïve UA patients with available initial synovial tissue (ST) and a final diagnosis of rheumatoid arthritis (RA) or psoriatic arthritis (PsA) during follow-up were included and compared with patients with well-defined disease (RA or PsA). Clinical, arthroscopic, and pathological data were compared between groups. Pathology included quantitative immunohistochemical (IHC) analysis of cell types and human interferon-regulated MxA. Principal component analysis (PCA) was performed to extract disease patterns. Results: One hundred and five patients were included: 31 patients with DMARD-naïve UA (19 evolving to RA and 12 to PsA during a median follow up of 7 years), 39 with established RA, and 35 with established PsA. ST from the UA group showed higher macrophage density compared with the established RA and PsA groups. Patients with UA evolving to RA (UA-RA) showed higher MxA expression and CD3+ T-cell density compared with established RA. UA patients evolving to PsA (UA-PsA) showed increased vascularity and lining synovial fibroblast density compared with established PsA. Synovitis of UA-PsA patients showed more mast cells and lining fibroblasts compared with UA-RA. No between-group differences in local or systemic inflammation markers were found. Conclusions: Our results show differences in the cellular composition of UA synovium compared with RA and PsA, with higher density of the cellular infiltrate in the UA groups. Initial expression of the interferon inducible gene MxA could be a biomarker of progression to RA, while higher mast cell and fibroblastic density may be associated with PsA progression. This research was supported by Instituto de Salud Carlos III (ISCIII) through the PI14/00785 and RD16/0012 RETICS program, cofinanced by the European Regional Development Fund (FEDER), “Una manera de hacer Europa”. AC also received grants from Sociedad Española de Reumatología (BECA FER-2015), Hospital Clinic de Barcelona, Projectes Fi de Residencia: Premis Emili Letang, and from Sociedad Catalana de Reumatología.

Peyronie and Dupuytren are pathologies characterized by the appearance of localized fibrotic lesions in an organ. These disorders originate from an excessive production of collagen in the tissue provoking dysfunction and functional limitations to the patients. Local administration of collagenase is the most used treatment for these fibrotic-type diseases, but a high lability of the enzyme limits its therapeutic efficacy. Herein, we present a novel methodology for the preparation of collagenase nanocapsules without affecting its enzymatic activity and capable of releasing the enzyme in response to an ultraviolet A (UVA) light stimulus. Polymeric coating around collagenase was formed by free-radical polymerization of acrylamide-type monomers. Their degradation capacity under UVA irradiation was provided by incorporating a novel photocleavable acrylamide-type crosslinker within the polymeric framework. This property allowed collagenase release to be triggered in a controlled manner by employing an easily focused stimulus. Additionally, UVA irradiation presents considerable benefits by itself due to its capacity to induce collagenase production in situ. An expected synergistic effect of collagenase nanocapsules in conjunction with UVA effect may present a promising treatment for these fibrotic diseases.

A subgroup of patients with SARS-CoV-2 infection was thought to have developed cytokine release syndrome and were treated with tocilizumab; however, a significant percentage of patients evolved. This study aimed to determine the usefulness of anakinra as a rescue treatment for patients with tocilizumab-refractory COVID-19 disease. A prospective cohort of patients with COVID-19 pneumonia who received anakinra as salvage therapy after failure of tocilizumab were compared (1:1) with selected controls in a historical cohort of patients treated with tocilizumab. Cases and controls were matched by age, comorbidities, pulse oximetry oxygen saturation to fraction of inspired oxygen (SpO2/FiO2) ratio at baseline, and time elapsed since the initiation of treatment with tocilizumab. The primary outcome was the improvement in clinical status measured by a 6-point ordinal scale, from baseline to day 21. The study included 20 cases and 20 controls (mean age 65.3 ± 12.8 years, 65% males). No differences were found in the clinical improvement rates at 7, 14 and 21 days of follow-up. The in-hospital mortality rate for patients receiving anakinra was 55% vs. 45% in the control group (P = 0.527). Treatment with anakinra was not useful in improving the prognosis of patients with tocilizumab-refractory severe COVID-19. This work was supported by Instituto de Salud Carlos III, Spanish Ministry of Science and Innovation (COV20/00181) — co‐financed by European Development Regional Fund “A way to achieve Europe”. M.F.R. holds a research contract “Miguel Servet” (CP18/00073) from the Spanish Ministry of Science and Innovation, Instituto de Salud Carlos III. Sí

BackgroundThe role of combination immunomodulatory therapy with systemic corticosteroids and tocilizumab (TCZ) for aged patients with COVID-19-associated cytokine release syndrome remains unclear.MethodsWe conducted a retrospective single-center study including consecutive patients ≥65 years that developed severe COVID-19 between March 3 and May 1, 2020 and were treated with corticosteroids at various doses (methylprednisolone [0.5 mg/Kg/12 hours to 250 mg/24 hours]), either alone (“CS group”) or associated to intravenous tocilizumab (400-600 mg, one to three doses) (“CS-TCZ group”). Primary outcome was all-cause mortality by day +14, whereas secondary outcomes included mortality by day +28 and clinical improvement (discharge and/or a ≥2-point decrease on a six-point ordinal scale) by day +14. Propensity score (PS)-based adjustment and inverse probability of treatment weights (IPTW) were applied.ResultsOverall, 181 and 80 patients were included in the CS and CS-TCZ groups. All-cause 14-day mortality was lower in the CS-TCZ group, both in the PS-adjusted (hazard ratio [HR]: 0.34; 95% confidence interval [CI]: 0.17 – 0.68;P-value = 0.002) and IPTW-weighted models (odds ratio [OR]: 0.38; 95% CI: 0.21 – 0.68;P-value = 0.001). This protective effect was also observed for 28-day mortality (PS-adjusted HR: 0.38; 95% CI: 0.21 – 0.72;P-value = 0.003). Clinical improvement by day +14 was higher in the CS-TCZ group in the IPTW analysis only (OR: 2.26; 95% CI: 1.49 – 3.41;P-value ConclusionsThe combination of corticosteroids and TCZ was associated with better outcomes among patients ≥65 years with severe COVID-19.

Carlos Gavín,1 Francisco J Blanco,2 José L Pablos,3 Miguel A Caracuel,4 José Rosas,5 Enrique Gómez-Barrena,6 Francisco Navarro,7 María Pilar Coronel,8 Mercedes Gimeno8 1Hospital Universitario Fundación Alcorcón, Madrid, Spain; 2Complejo Hospitalario Universitario aCoruña, La Coruña, Spain; 3Hospital Universitario 12 de Octubre, Madrid, Spain; 4Hospital Universitario Reina Sofía, Córdoba, Spain; 5Hospital Marina Baixa, Villajoyosa, Alicante, Spain; 6Hospital Universitario La Paz, Madrid, Spain; 7Hospital General Universitario de Elche, Alicante, Spain; 8Meiji Pharma Spain, Alcalá de Henares, Madrid, SpainCorrespondence: Mercedes GimenoClinical Development Department, Meiji Pharma Spain, Av Madrid 28802, Alcalá de Henares, Madrid, SpainTel +34 918 870 980Email m.gimeno@meiji.esPurpose: To assess the efficacy and safety of a single injection of a new formulation of hyaluronic acid (MPS-HA2%) in patients with symptomatic knee osteoarthritis after 12 months’ follow-up.Patients and Methods: Prospective, single-arm, multicentre, open-label, 12-month follow-up study. Patients with Kellgren–Lawrence (KL) 2– 3 and visual analogue scale (VAS) pain scores of ≥ 40–< 80 mm received a single injection of MPS-HA2%. The primary outcome was the reduction in VAS pain scores from baseline, and the secondary outcomes were the Western Ontario and McMaster (WOMAC) Universities Osteoarthritis Index, the minimum clinically important improvement (MCII), and patient and investigator global assessments (PGA, IGA) measured on 5-point Likert scale. Adverse events were recorded throughout the study for safety purposes.Results: A total of 101 patients (mean age: 68 years; 74% female; and 78% overweight) were included. The mean reduction in pain at 12 months was 37.7%; the total WOMAC score improved by 36.5% and the pain, stiffness and physical function subscores returned improvements of 32.1%, 34.1% and 32.7%, respectively (p=0.0001 with respect to baseline). At 12 months, a statistically significant 62.2% of patients obtained an improvement equal to or greater than the MCII. The mean PGA score at baseline was 2.44 and 1.46 at 12 months (p< 0.05), and the mean IGA scores at equivalent timepoints were 2.29 and 1.48 (p< 0.05). Fourteen patients received a second injection at the 6-month follow-up visit. Eight patients reported a total of 12 treatment-related adverse events that were local, non-serious and of mild-to-moderate intensity.Conclusion: With just a single intra-articular injection, this not controlled trial suggests that MPS-HA2% is effective 12 months after the procedure in most cases. Patient tolerability and safety were both optimal (NCT03852914).Keywords: osteoarthritis, pain, hyaluronic acid, viscosupplementation

Mitochondrial dysfunction associates with several pathological processes and contributes to chronic inflammatory and ageing-related diseases. Mitochondrial transcription factor A (TFAM) plays a critical role in maintaining mtDNA integrity and function. Taking advantage of Tfamfl/fl UBC-Cre/ERT2+/+ mice to investigate mitochondrial dysfunction in the stromal cell component, we describe an inducible in vitro model of mitochondrial dysfunction by stable depletion of TFAM in primary mouse skin fibroblasts (SK-FBs) after 4-hydroxytamoxifen (4-OHT) administration. Tfam gene deletion caused a sustained reduction in Tfam and mtDNA-encoded mRNA in Cre(+) SK-FBs cultured for low (LP) and high (HP) passages that translated into a loss of TFAM protein. TFAM depletion led to a substantial reduction in mitochondrial respiratory chain complexes that was exacerbated in HP SK-FB cultures. The assembly pattern showed that the respiratory complexes fail to reach the respirasome in 4-OHT-treated Cre(+) SK-FBs. Functionally, mito-stress and glycolysis-stress tests showed that mitochondrial dysfunction developed after long-term 4-OHT treatment in HP Cre(+) SK-FBs and was compensated by an increase in the glycolytic capacity. Finally, expression analysis revealed that 4-OHT-treated HP Cre(+) SK-FBs showed a senescent and pro-inflammatory phenotype., Summary: TFAM depletion in skin fibroblasts ex vivo results in a senescent and inflammatory phenotype, providing a valuable model to investigate the role of mitochondrial dysfunction in ageing and inflammatory pathologies.

Pro-inflammatory CD4+CD28&minus, T cells are characteristic of immunosenescence, but also of several autoimmune/inflammatory diseases. Vasoactive intestinal peptide (VIP) acts as an anti-inflammatory and immunomodulatory mediator on these cells. Our objective was to study the mutual influence between senescent Th cells and VIP axis in early arthritis (EA), comparing with non-EA donors. We characterized the correlation between senescent Th cells and clinic parameters of EA as well as the behavior of senescent Th biomarkers by real-time PCR. Clinical data were systematically recorded at baseline and after 6 months of follow-up. The number of CD4+CD28&minus, T cells measured by sorting is higher in patients who initially meet ACR classification criteria for rheumatoid arthritis (RA) compared to those who were classified as undifferentiated arthritis (UA). A slight positive correlation between EA CD4+CD28&minus, T cells and CRP or ESR and a negative correlation with bone mineral density were found. Th senescent biomarkers in EA CD4+CD28&minus, T cells were similar to donors, however some of them increased after 6 months of follow-up. VPAC receptors were analyzed by real-time PCR and immunofluorescence, and CD4+CD28&minus, T cells showed higher expression of VPAC2 and lower of VPAC1, VPAC2 showing a significant increased expression in EA cells. Sorted CD4+CD28&minus, T cells were in vitro expanded in presence of VIP, wherein VIP increased senescent biomarker CD27, while it diminished CD57 or NKG2 senescent biomarkers. Our study demonstrates for the first time the existence of a link between senescent Th cells and the VIP axis.

We thank Wu et al for their interest in our study reporting on the prevalence of COVID-19 in patients with rheumatic diseases (RMD).1 Wu et al suggest that potential detection bias due to more frequent regular visits to hospitals in patients with RMD may explain the observed greater prevalence of hospital COVID-19 cases in these patients. However, this is highly unlikely since the identification of hospital PCR+ cases was performed in April 2020, still in the peak phase of COVID-19 pandemic in Spain, when the regular scheduled follow-up visits had been cancelled and restricted to urgent medical care. In addition, PCR test shortage resulted in the need to restrict testing to ‘COVID-19-likely’ symptomatic patients at emergency departments, making unlikely preferential testing of RMD or other specific patients. Nevertheless, we cannot exclude other biases such as greater …

Background Rheumatoid arthritis (RA) is one of the leading chronic inflammatory rheumatism. First-line therapy with synthetic disease-modifying antirheumatic drugs (sDMARD) is insufficiently effective in 40% of cases and these patients are treated with biotherapies. The increased use of these drugs each year is becoming a public health issue with considerable economic burden. This cost is 20 times higher than that of sDMARD. However, among patients treated with biotherapies, clinical practice shows that about one third will not respond to the selected drug. In nonresponse cases, practitioners currently have no choice but to perform an empirical switching between different treatments, because no tool capable of predicting the response or nonresponse to these molecules is currently available. Methods The study is a prospective, phase III, controlled, multicenter, and randomized, single-blind (patient) clinical trial, including RA patients with a previous failure to anti-TNF therapies. The main objective is the analysis of the clinical and pharmacoeconomic impact after 6 months of treatment. Intervention arm: prescription of biotherapy (rituximab, adalimumab, abatacept) using SinnoTest® software, a prediction software based on proteomic biomarkers. Control arm: prescription of biotherapy based on current practice, without the SinnoTest® software (any biotherapy). In addition, a substudy will be carried out within this trial to generate a biobank and further analyze the proteomic profile of the patients and their modification throughout the study. Discussion This clinical trial study will be the first validation study of a biotherapy response prediction software, bringing personalized medicine into the management of RA. We expect that the findings from this study will bring several benefits for the patient and the Health Care System. Trial registration ClincalTrials.gov NCT04147026. Registered on 31 October, 2019.

Coronavirus disease 2019 (COVID‐19) can lead to a massive cytokine release. The use of the anti‐interleukin‐6 receptor monoclonal antibody tocilizumab (TCZ) has been proposed in this hyperinflammatory phase, although supporting evidence is limited. We retrospectively analyzed 88 consecutive patients with COVID‐19 pneumonia that received at least one dose of intravenous TCZ in our institution between 16 and 27 March 2020. Clinical status from day 0 (first TCZ dose) through day 14 was assessed by a 6‐point ordinal scale. The primary outcome was clinical improvement (hospital discharge and/or a decrease of ≥2 points on the 6‐point scale) by day 7. Secondary outcomes included clinical improvement by day 14 and dynamics of vital signs and laboratory values. Rates of clinical improvement by days 7 and 14 were 44.3% (39/88) and 73.9% (65/88). Previous or concomitant receipt of subcutaneous interferon‐β (adjusted odds ratio [aOR]: 0.23; 95% confidence interval [CI]: 0.06‐0.94; P = .041) and serum lactate dehydrogenase more than 450 U/L at day 0 (aOR: 0.25; 95% CI: 0.06‐0.99; P = .048) were negatively associated with clinical improvement by day 7. All‐cause mortality was 6.8% (6/88). Body temperature and respiratory and cardiac rates significantly decreased by day 1 compared to day 0. Lymphocyte count and pulse oximetry oxygen saturation/FiO2 ratio increased by days 3 and 5, whereas C‐reactive protein levels dropped by day 2. There were no TCZ‐attributable adverse events. In this observational single‐center study, TCZ appeared to be useful and safe as immunomodulatory therapy for severe COVID‐19 pneumonia., Highlights COVID‐19 can lead to a hyperinflammatory state that mirrors the cytokine release syndrome.The off‐labeluse of the anti‐interleukin‐6 receptor monoclonal antibody tocilizumab has been proposed to abrogate this deleterious inflammatory response, although the supporting evidence is scarce.In the present single‐centre study comprising 88 consecutive patients with COVID‐19 pneumonia that received at least one dose of intravenous tocilizumab between March 16 and 27, 2020, the rates of clinical improvement (defined by discharge to home and/or a decrease of = 2 points on a six‐point ordinal scale) were 44.3% (39/88) and 73.9% (65/88) by days 7 and 14, respectively.The previous or concomitant use of interferon‐β and baseline serum lactate dehydrogenase levels >450 U/L were negatively associated with clinical improvement by day 7. All‐cause mortality was 6.8%, with no tocilizumab‐attributable adverse events.

Objectives: To analyze ultrasound (US) differences between rheumatoid arthritis (RA) patients according to their autoantibody status and characterize the clinical, immunological and radiological features associated with the US pattern of seropositive patients.Methods: We collected clinical and immunological data along with bilateral hand US images of RA patients. Serum biomarkers, MRI of dominant hand and immunostaining of synovial biopsies were performed.Results: Two hundred and five RA patients were collected (84.8% seropositive). No significant differences in disease activity/therapy were found according to autoantibodies status. An extreme proliferative US pattern, encompassing synovial hypertrophy grade II-III with Power Doppler signal that we called US Proliferative Synovitis (US PS) was present in 55.5% of seropositive and 16.1% of seronegative patients, (p=0.0001). In the multivariate analysis, erosions [OR 4.90 CI 95% (2.17-11.07). p=0.0001] and ACPA [OR 3.5 CI 95% (1.39-10.7), p=0.09] but not RF status [OR 0.74 CI 95% (0.31-1.71), p=0.483] were independently associated with the presence of US PS. Ninety-four per cent of joints with US PS scored 2-3 in RAMRIS synovitis sub-index. At synovial level, US PS was significantly associated with higher density of vessels (p=0.042). Moreover, significantly higher serum levels of angiogenic and inflammatory cytokines were found in patients with US PS. After a mean of 46 months of follow-up, US PS was independently associated with change of therapy (OR 2.63, 95% CI 1.20-5.77, p=0.016).Conclusions: ACPA+ RA was associated with US PS. This US pattern significantly detected erosive disease and an enhanced need to change therapy in the long-term.

BackgroundThe impact of inflammatory rheumatic diseases on COVID-19 severity is poorly known. Here we compare the outcomes of a cohort of rheumatic patients with a matched control cohort to identify potential risk factors for severe illness.MethodsIn this comparative cohort study, we identified hospital PCR+ COVID-19 rheumatic patients with chronic inflammatory arthritis (IA) or autoimmune/immunomediated diseases (AI/IMID). Non-rheumatic controls were randomly sampled 1:1, and matched by age, sex, and PCR date. The main outcome was severe COVID-19, defined as death, invasive ventilation, ICU admission, or serious complications. We assessed the association between the outcome and potential prognostic variables, adjusted by COVID treatment, using logistic regression.ResultsThe cohorts were composed of 456 rheumatic and non-rheumatic patients, in equal numbers. Mean age was 63 [IQR 53-78] and male sex 41% in both cohorts. Rheumatic diseases were IA (60%) and AI/IMID (40%). Most patients (74%) had been hospitalised, and the risk of severe COVID was 31.6% in the rheumatic and 28.1% in the non-rheumatic cohort. Ageing, male sex and previous comorbidity (obesity, diabetes, hypertension, cardiovascular, or lung disease) increased the risk in the rheumatic cohort by bivariate analysis. In logistic regression analysis, independent factors associated with severe COVID were increased age (OR 5.31; CI 3.14-8.95), male sex (2.13; CI 1.35-3.36) and having an AI/IMID (OR 1.98; CI 1.15-3.41).ConclusionIn patients with chronic inflammatory rheumatic diseases aging, sex and having an AI/IMID but not IA nor previous immunosuppressive therapies were associated with severe COVID-19.

8p.-6 fig., OBJECTIVES: Methotrexate (MTX) is the anchor drug for treatment of rheumatoid arthritis (RA), but the mechanism of its anti-inflammatory action is not fully understood. In RA, macrophages display a proinflammatory polarisation profile that resembles granulocyte-macrophage colony-stimulating factor (GM-CSF)-differentiated macrophages and the response to MTX is only observed in thymidylate synthase+ GM-CSF-dependent macrophages. To determine the molecular basis for the MTX anti-inflammatory action, we explored toll-like receptor (TLR), RA synovial fluid (RASF) and tumour necrosis factor receptor (TNFR)-initiated signalling in MTX-exposed GM-CSF-primed macrophages., METHODS:Intracellular responses to TLR ligands, TNFα or RASF stimulation in long-term low-dose MTX-exposed human macrophages were determined through quantitative real-time PCR, western blot, ELISA and siRNA-mediated knockdown approaches. The role of MTX in vivo was assessed in patients with arthritis under MTX monotherapy and in a murine sepsis model., RESULTS:MTX conditioned macrophages towards a tolerant state, diminishing interleukin (IL)-6 and IL-1β production in LPS, LTA, TNFα or RASF-challenged macrophages. MTX attenuated LPS-induced MAPK and NF-κB activation, and toll/IL-1R domain-containing adaptor inducing IFN-beta (TRIF1)-dependent signalling. Conversely, MTX increased the expression of the NF-κB suppressor A20 (TNFAIP3), itself a RA-susceptibility gene. Mechanistically, MTX-induced macrophage tolerance was dependent on A20, as siRNA-mediated knockdown of A20 reversed the MTX-induced reduction of IL-6 expression. In vivo, TNFAIP3 expression was significantly higher in peripheral blood cells of MTX-responsive individuals from a cohort of patients with arthritis under MTX monotherapy, whereas MTX-treated mice exhibited reduced inflammatory responses to LPS., CONCLUSIONS:MTX impairs macrophage proinflammatory responses through upregulation of A20 expression. The A20-mediated MTX-induced innate tolerance might limit inflammation in the RA synovial context, and positions A20 as a potential MTX-response biomarker., This work was supported by grants from Instituto de Salud Carlos III/FEDER (PI14/00075 and PI17/00037) to AP-K, PI14/00422 to IG-A, RIER RD16 to JLP, IG-A and AP-K, Ministerio de Economía y Competitividad SAF2014-54423-R to ALC. FEDER, Fondo Europeo de Desarrollo Regional: una manera de hacer Europa. SF-R and AP-K are supported by FIBHGM.

Objective To determine clinical and sonographic biomarkers predicting structural damage progression at 12 months of follow-up as measured by magnetic resonance imaging (MRI) in rheumatoid arthritis (RA) patients in clinical remission. Patients and methods We included patients with RA in clinical remission, defined as 28-joint disease activity score (DAS28)-erythrocyte sedimentation rate (ESR) 6 months. Ultrasound scans of both hands and knees and MRI of the dominant hand were performed at baseline and at 12 months. Results Out of 55 patients, 42 completed the follow-up. Among them, 78% were female, aged (median) 54 years; disease duration was 93 months. In total, 12 (28%) patients were taking oral prednisone, 34 (81%) conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and 20 (47%) biological therapies. At baseline, 45% fulfilled criteria previously defined for ultrasound-defined active synovitis (UdAS) [PD (power Doppler) signal + synovial hyperplasia ≥2]. Multivariate analysis showed significant associations between baseline MRI erosion score, body mass index (BMI), disease duration, prednisone treatment, absence of biologic and csDMARDs, UdAS, and MRI erosion score progression after 12 months. In an exploratory analysis, serum levels of calprotectin correlated significantly with bone edema progression. Conclusions We identified clinical and sonographic markers of structural damage progression after 12 months follow-up in patients with RA in clinical remission. Meeting the criteria of ultrasound active synovitis, defined as simultaneous relevant synovial hyperplasia and PD, was associated with erosion progression after 12 months. Calprotectin was associated with bone edema, in an exploratory analysis.

Increased glycolysis and HIF-1α activity are characteristics of cells under hypoxic or inflammatory conditions. Besides, in normal O environments, elevated rates of glycolysis support critical cellular mechanisms such as cell survival. The purpose of this study was to analyze the contribution of HIF-1α to the energy metabolism and survival of human synovial fibroblasts (SF) under normoxic conditions. HIF-1α was silenced using lentiviral vectors or small-interfering RNA (siRNA) duplexes. Expression analysis by qRT-PCR and western blot of known HIF-1α target genes in hypoxia demonstrated the presence of functional HIF-1α in normoxic SF and confirmed the glycolytic enzyme glyceraldehyde-3-phosphate dehydrogenase (GAPDH) as a HIF-1α target even in normoxia. HIF-1α silencing induced apoptotic cell death in cultured SF and, similarly, treatment with glycolytic, but not with OXPHOS inhibitors, induced SF death. Finally, in vivo HIF-1α targeting by siRNA showed a significant reduction in the viability of human SF engrafted into a murine air pouch. Our results demonstrate that SF are highly dependent on glycolytic metabolism and that HIF-1α plays a regulatory role in glycolysis even under aerobic conditions. Local targeting of HIF-1α provides a feasible strategy to reduce SF hyperplasia in chronic arthritic diseases., Fondo de Investigación Sanitaria, Instituto de Salud Carlos III (FIS 12/439, RETICS RD12/009 RIER, and Miguel Servet program CP13/00014 to GC) cofinanced by European Regional Development Fund (FEDER), and by the Comunidad de Madrid (RAPHYME-CM S2010/BMD2350)

Background:Different Jakinibs (JAKi) have shown efficacy in rheumatoid arthritis (RA) but in an important proportion of patients, insufficient response leads to therapy withdrawal. The different JAKi show variable selectivity for the four Jak isoforms (Jak1,2,3 y Tyk2) but there are no clinical trials analyzing the response to a JAKi after the suspension of another JAKi and therefore, observational data may be useful in this regard.Objectives:To describe efficacy and safety of the second JAKi in patients with suspension of the first due to failure or side effects.Methods:Spanish observational multicentric study. Data were retrospectively obtained from medical records of 28 patients with RA sequentially treated with baricitinib o tofacitinib in any order.Results:We identified 28 patients with RA treated with baricitinib and tofacitinib. Patient´s characteristics are summarized in Table 1. Half of the patients received tofacitinib first, and the other half baricitinib as the first JAKi. Mean survival for the first JAKi was 7,6 ± 6,1 months. The reason for withdrawal was inefficacy in 17 cases (61%) and adverse effects in 11 (39%). Mean follow-up after starting on the second JAKi was 9,6 ± 5,6 [3-19] months. Disease activity data along follow-up are depicted in Table 2. Survival on the second JAKi was 82% at 3, 76% at 6, and 62% at 12 months when 13 of the 21 patients maintained the therapy. In all 8 patients who discontinued the second JAKi, the reason was inefficacy. The treatment suspension rate was similar among patients discontinuing the first JAKi for inefficacy (n=5, 29,4%) or for adverse effects (n=3; 27,3%).Table 1.Baseline Charateristics.N 28Clinical characteristicsFemale24 (86%)Age*61.2 ± 13.2ACPA (+)19 (67,9%)Erosions13 (46,4%)Extra-articular manifestations8 (28,6%)TJC*10,8 ± 5,4SJC *7,4 ± 4,6DAS28-CPR*5,4 ± 0,91 High disease activity71,5% Moderate disease activity23,8% Low disease activity4,7%Previous treatmentbDMARD24 (86%)N° of previous bDMARDs *3,9±2,2 iTNF75% No-iTNF67,9%(*) Mean ± SDTabla 2.Treatment results during the follow-up period.Baseline (n 28)3 m (n 28)6 m (n 25)12 m (n 21)TJC10,8±5,43,8±3,34,23±2,51,9±1,5SJC7,2±4,61,8±1,71,7±20,7±1CPR mg/dL1±0,60,54±0,480,64±0,90,33±0,24DAS28CPR5,4±0,913,29±0,973,15±1,22,15±0,6Prednisone mg7,2±4,26,8±3,55,3±2,53,1±2,1Conclusion:Our data show that therapy with a second JAKi is a safe and efficacious option after discontinuation of the first JAKi due to either inefficacy or side effects. The response rate to the second JAKi is similar in patients with inefficacy or side effects which suggests that failure to the first does not reduce the chance of response to the second.Acknowledgments:M. Retuerto was recipient of a training grant from Sociedad Española de Reumatología (SER).Disclosure of Interests:None declared

Medicaments biològics; Inflamació; Psoriasi Biological drugs; Inflammation; Psoriasis Medicamentos biológicos; Inflamación; Psoriasis Interleukin 17 (IL-17) is a proinflammatory cytokine that has been the focus of intensive research because of its crucial role in the pathogenesis of different diseases across many medical specialties. In this context, the present review in which a panel of 13 experts in immunology, dermatology, rheumatology, neurology, hematology, infectious diseases, hepatology, cardiology, ophthalmology and oncology have been involved, puts in common the mechanisms through which IL-17 is considered a molecular target for the development of novel biological therapies in these different fields. A comprehensive review of the literature and analysis of the most outstanding evidence have provided the basis for discussing the most relevant data related to IL-17A blocking agents for the treatment of different disorders, such as psoriasis, psoriatic arthritis, rheumatoid arthritis, ankylosing spondylitis, cardiovascular disorders, non alcoholic fatty liver disease, multiple sclerosis, inflammatory bowel disease, uveitis, hematological and solid cancer. Current controversies are presented giving an opening line for future research. This work was supported by Novartis Pharmaceuticals Spain.

Objective To identify biomarkers of treatment change and radiographic progression in patients with RA under remission. Patients and methods RA patients in remission (DAS28-ESR 10.47 (small detectable change). Results Sixty patients were included, 81.6% were ACPA+ and 45% were taking biological DMARDs. At baseline, 66.6% had Power Doppler signal. After 5 years, 73.3% of patients remained in remission. Change of therapy was performed in 20 patients (33.3%) and was associated with BMI [odds ratio (OR) 1.3, 95% CI: 1, 1.7], lack of biological DMARD therapy (OR 24.7, 95% CI: 2.3, 257.2), first-year progression of MRI erosions (OR 1.2, 95% CI: 1, 1.3) and calprotectin serum levels (OR 2.8, 95% CI: 1, 8.2). Radiographic progression occurred in six (10%) patients. These patients had higher first-year progression of MRI erosions (P = 0.03) and bone oedema (P = 0.04). Among 23 patients undergoing synovial biopsy, mast cell density was independently associated with clinical flares. Conclusions One-third of RA patients lost clinical remission and changed therapy throughout the 5 years of follow-up, which was independently associated with BMI, lack of biological DMARDs therapy and first-year progression of MRI erosion score and calprotectin serum levels. Significant radiographic progression was uncommon.

BackgroundAccumulation of senescent cells has been associated with pro-inflammatory effects with deleterious consequences in different human diseases. The purpose of this study was to analyze cell senescence in human synovial tissues (ST), and its impact on the pro-inflammatory function of synovial fibroblasts (SF).ResultsThe expression of the senescence marker p16INK4a (p16) was analyzed by immunohistochemistry in rheumatoid arthritis (RA), osteoarthritis (OA), and normal ST from variably aged donors. The proportion of p16(+) senescent cells in normal ST from older donors was higher than from younger ones. Although older RA and OA ST showed proportions of senescent cells similar to older normal ST, senescence was increased in younger RA ST compared to age-matched normal ST. The percentage of senescent SA-β-gal(+) SF after 14 days in culture positively correlated with donor’s age. Initial exposure to H2O2or TNFα enhanced SF senescence and increased mRNA expression ofIL6,CXCL8,CCL2andMMP3and proteins secretion. Senescent SF show a heightenedIL6,CXCL8andMMP3mRNA and IL-6 and IL-8 protein expression response upon further challenge with TNFα. Treatment of senescent SF with the senolytic drug fenofibrate normalizedIL6,CXCL8andCCL2mRNA expression.ConclusionsAccumulation of senescent cells in ST increases in normal aging and prematurely in RA patients. Senescence of cultured SF is accelerated upon exposure to TNFα or oxidative stress and may contribute to the pathogenesis of synovitis by increasing the production of pro-inflammatory mediators.

Background:. There are reports on high psychological morbidity, mainly personality disorders, among people opting for cosmetic surgery. This study aims to describe the personality traits, level of self-esteem, and anxiety in women seeking cosmetic surgery with body contouring, such as liposculpture or lipoabdominoplasty with or without placement of breast implants. Methods:. Subjects were 87 women between 18 and 60 years of age in Mexico City who went to a private clinic with the intention of undergoing cosmetic surgery with body contouring. A psychiatric interview was performed using three scales: the Salamanca questionnaire for screening for personality disorders, the Hamilton Anxiety Rating Scale, and the Rosenberg Self Esteem Scale. Results:. The average age was 31 years, with 35% of participants having previously undergone body-contouring surgery. Regarding personality, the patients did not show a psychopathology level for diagnosing a personality disorder. Regarding anxiety, 92% of the patients showed an average level of anxiety. High level of self-esteem was exhibited by 81 participants (93.15%), and six participants (6.9%) exhibited average self-esteem. Notably, no participant exhibited low self-esteem. Conclusions:. The level of psychopathology of the patients was lower than expected, the self-esteem was not affected prior to the surgical procedure, and the level of anxiety did not cause dysfunction.

Objectives The aim of this study was to develop and assess the effectiveness of a patient decision aid (PDA) to support treatment decision making in Spanish patients with moderate-to-severe rheumatoid arthritis (RA) who fail to achieve the therapeutic goal with the current disease-modifying antirheumatic treatment strategy. Methods The PDA was developed in accordance with the International Patient Decision Aids Standards recommendations. A steering group led the project. Three literature reviews and two focus groups were performed to develop the PDA prototype. To check its comprehensibility, acceptability, and feasibility, alpha-testing was performed using the Decision Support Acceptability Scale (DSAS). Beta-testing was conducted to assess preliminary evidence of PDA efficacy using the Decisional Conflict Scale (DCS) before and after PDA use. Readiness was evaluated using the Preparation for Decision Making Scale (PDMS). Results The PDA included (1) a brief description of RA, (2) treatment information, and (3) a values clarification section. Alpha-testing revealed that most patients considered that the information was presented in a good or excellent way and it could help clarify their values and facilitate treatment decision making. Most rheumatologists agreed that the PDA was easy to understand, to use, and allowed them to reach a shared decision. Beta-testing showed that PDA significantly reduced overall patients’ decisional conflict [33.2 (DE: 21.4) vs 24.6 (23.5); p

Background: The availability of oral janus kinase inhibitors, as tofacitinib, has extended the treatment pathways for management of patients with rheumatoid arthritis (RA) Objectives: To assess the cost-effectiveness of tofacitinib as second-line treatment compared to treatment sequences containing standard biological-therapies in patients with moderate to severe RA after failure to disease-modifying antirheumatic drugs (DMARDs) from the Spanish National Health System perspective. Methods: A patient-level microsimulation model was used to compare the lifetime cost and quality-adjusted life-years (QALY) for treatment sequences initiating with tofacitinib (5mg BID) followed by biological therapies versus sequences of biological treatments excluding tofacitinib. The sequences were selected by a panel of experts based on clinical practice in Spain. Concomitant treatment with methotrexate (MTX) was considered along all the therapies in the treatment sequences. Model parameters included age, weight, initial Health Assessment Questionnaire (HAQ) score and clinical response to short and long treatment. Efficacy was measured by means of HAQ score changes using mixed-treatment-comparisons (for the first 6 months) and data from long-term extension trials (for later periods). Serious adverse event (SAE) information derived from literature. The estimation of total cost for sequences included: drugs acquisition (public ex-factory prices with mandatory deduction or reference prices) and parenteral administration, disease progression and SAE management. Local unitary costs (€, 2018) were applied. Additional comparisons were explored testing other potential sequences. Results: The base case results showed that sequences initiating with tofacitinib provided greater outcomes than the correspondent sequences excluding tofacitinib. In scenario 1 tofacitinib+MTX→Rituximab+MTX→sc Tocilizumab+MTX→Etanercept+MTX→Certolizumab+MTX provided 13.99 QALYs versus 13.92 QALYs for adalimumab+MTX→Rituximab+MTX→sc Tocilizumab+MTX→Etanercept+MTX→Certolizumab+MTX. In scenario 2 tofacitinib+MTX→Adalimumab+MTX→Rituximab+MTX→sc Tocilizumab+MTX→Etanercept+MTX provided 13.75 QALYs versus 13.62 QALYs for Baricitinib+MTX→Adalimumab+MTX→Rituximab+MTX→sc Tocilizumab+MTX→Etanercept+MTX. Tofacitinib-containing sequences provided lower total costs than the alternative sequences (-€5,783 and -€13,975 for the pairwise comparisons previously described), resulting, therefore, dominant options versus sequences excluding tofacitinib. On the probabilistic sensitivity analyses, sequences initiating with tofacitinib resulted cost-effective in 64.0% (scenario 1) and 56.9% (scenario 2) of the 1,000 iterations performed, because incremental cost-effectiveness ratio fell below a €25,000/QALY gained willingness to pay threshold. Conclusion: These results suggest that the inclusion of tofacitinib could be a dominant strategy for treatment of moderate to severe RA patients after DMARDs failure in Spain. Disclosure of Interests: Carmen Peral Shareholder of: Carmen Peral is employee of and shareholder in Pfizer, Employee of: Carmen Peral is employee of and shareholder in Pfizer, Alejandro Balsa Grant/research support from: Abbvie, Pfizer, Novartis, BMS, Nordic, Sanofi, Consultant for: Abbvie, Pfizer, Novartis, BMS, Nordic, Sanofi, Sandoz, Lilly, Paid instructor for: Pfizer, Speakers bureau: Pfizer, Novartis, UCB, Nordic, Sanofi, Sandoz, Lilly, Federico Navarro Grant/research support from: Pfizer, Consultant for: Pfizer, Jose Luis Pablos: None declared, Jose Manuel Martinez Sesmero Consultant for: Pfizer, Susana Gomez Employee of: I am a current employee of Pfizer., Monica Valderrama Shareholder of: Have received shares from Pfizer, Employee of: employee in Pfizer, Itziar Oyaguez Consultant for: I am employee of PORIB a consultant company which has received financial support from Grunenthal for development of this project, Miguel Angel Casado Grant/research support from: Pfizer, Consultant for: Pfizer, Fernando De Andres Grant/research support from: Pfizer, Employee of: Pfizer, Maria Montoro Shareholder of: Maria Montoro is employee of and shareholder in Pfizer, Employee of: Maria Montoro is employee of and shareholder in Pfizer

Objective Torque teno virus (TTV) is a highly prevalent non-pathogenic anellovirus whose plasma levels may be a biomarker of immunosuppression. The aim of this study was to assess whether specific immune-targeting with different biologic drugs may differentially modulate TTV viremia in arthritis patients. Methods TTV DNA load was quantified by PCR in a cross-sectional sample of 79 patients with chronic arthritis on biologic therapy (abatacept, infliximab, rituximab or tocilizumab), 31 patients treated with conventional DMARDs (methotrexate and/or leflunomide), and 54 healthy individuals. Longitudinal changes in TTV load were analysed in a second group of 59 patients at baseline and 4-months after biologic therapy. Correlations between clinical or biological characteristics of recruited patients and TTV viremia were also analysed. Results In the cross-sectional study, TTV load was significantly higher in patients who received abatacept, infliximab or tocilizumab compared to healthy individuals. Patients treated with rituximab or conventional DMARDs showed TTV loads similar to healthy controls. In the longitudinal study, an increase in the TTV load was observed after anti-TNF, tocilizumab, abatacept and rituximab, but not after secukinumab therapy. Correlations between TTV load and clinical variables such as disease duration, concomitant glucocorticoid or DMARDs therapy, lymphocytes or previous infections were not found. A non-significant trend towards higher TTV load was observed in therapy responders. Conclusion Patients with chronic arthritis on biologic but not on conventional DMARD or anti-IL17 therapy have increased TTV viremia. This observation provides a basis to prospectively explore the potential value of TTV load as a potential pharmacodynamic biomarker.

Background:Osteoarthritis (OA) is a leading cause of chronic pain and disability, and its prevalence is expected to increase worldwide (1) being the knee the most affected joint, especially in older adults. Intra-articular hyaluronic acid (HA) could be of particular benefit in OA patients with co-morbidities, and in case of inadequate response to other pharmacological treatments (2). HA has been generally administered in cycles of 3-5 injections, however, due to the pressure on public health systems, the trend is to reduce the number of injections maintaining the duration of effects as longer as possible.Objectives:To assess the effectiveness and safety of a new formulation of HA, up to one year after one single injection to patients in the SOYA (Symptomatic Osteoarthritis one Year Assessment) study.Methods:Patients with Kellgren-Lawrence (KL) grade 2-3 and Visual Analogue Scale (VAS) pain >=40-=20% relative change for VAS pain) and patient and investigator assessments (PGA, IGA) (Likert scale 0-4 points) were also estimated. Adverse events were recorded for safety assessment.Results:One hundred and one patients (mean age 68 years, 74% female and 78% with overweight) were included. Mean pain at baseline in the target knee was 63.57mm and 57% were grade 3 KL with a mean evolution of 7.5 years. Table 1 shows the improvement in VAS and WOMAC scores at 6 and 12 months in the mITT population. Similar results were obtained in PP population.Table 1.Changes in VAS and WOMAC scores, expressed as mean valuesSCOREBaseline6 months12 monthsvaluevalue% variation (95% CI)value% variation (95% CI)VAS pain63.5737.59-39.74* (-49.23; -30.25)38.37-37.67* (-47.82; -27.52)WOMACtotal50.1931.88-37.96* (-46.83; -29.09)31.65-36.47* (-46.20; -26.73)pain49.3732.01-32.92* (-43.37; -22.46)31.08-32.07* (-43.19; -20.95)stiffness49.1228.35-35.24** (-53.22; -17.23)28.71-34.08* (-49.30; 18.86)function52.0735.30-33.95* (-43.49; -24.40)35.15-32.71* (-42.80; -22.62)*p-value: 0.0001; **p-value: 0.0002. Student testThe MCII was achieved by 66.3% of patients at 6m and 62.2% at 12m. Regarding PGA mean score was 2.44 at baseline, 1.35 at 6m and 1.46 at 12m (Wilcoxon, p-value Fourteen patients received a second injection at 6m and 50% of them achieved at 12m a significant and clinically relevant improvement compared to baseline, above the 20% established for the MCII.In total, 12 adverse events (8 patients) were reported, all of them local, non-serious, and of mild-moderate intensity.Conclusion:Viscosupplementation with a single intra-articular injection of MPS-HA2% has proven to be effective and well tolerated up to 12 months after treatment. The re-infiltration of the joint in appropriate cases has proven to be effective in a significant number of patients. The acceptability of the treatment by the patient was optimal.References:[1]Sebbag E, Felten R, Sagez F, et al. The world-wide burden of musculoskeletal diseases: a systematic analysis of the World Health Organization Burden of Diseases Database. Ann Rheum Dis. 2019 Jun;78(6):844-848.[2]Bruyère O, Cooper C, Pelletier JP, et al. An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum. 2014 Dec;44(3):253-63.Disclosure of Interests:Carlos Gavín: None declared, Francisco Moreno: None declared, Francisco J. Blanco: None declared, José Luis Pablos: None declared, Miguel A. Caracuel-Ruiz: None declared, Jose Rosas: None declared, Pablo Hernández-Esteban: None declared, Francisco Navarro: None declared, PILAR CORONEL Employee of: Meiji Pharma Spain, S.A., Mercedes Gimeno Employee of: Employee of Meiji Pharma Spain, S.A.

Objective Acquired tracheal stenosis (ATS) is an unusual disease often secondary to prolonged mechanical trauma. Acquired tracheal stenosis pathogenesis involves inflammation and subsequent fibrosis with narrowing of the tracheal lumen. Transforming growth factor-β1 (TGF-β) represents a pivotal factor in most fibrotic processes, and therefore a potential target in this context. The aim of this study is to analyze the role of TGF-β as a target for anti-fibrotic interventions in tracheal stenosis. Methods Human stenotic tracheobronchial tissues from patients with benign airway stenosis and normal controls from pneumonectomy specimens were analyzed. Tracheal stenosis was induced in adult NZ rabbits by a circumferential thermal injury to the mucosa during open surgery and re-anastomosis. Rabbits were treated postoperatively with a peritracheal collagen sponge containing a TGF-β peptide antagonist (p17) or vehicle. Fibrosis was determined by Masson's trichrome staining, and smooth muscle cell α-actin+ (α-SMA+ Confirm accuracy.) myofibroblasts, connective tissue growth factor (CTGF), and p-Smad2/3 expression by immunohistochemistry. Results Human and rabbit stenotic tissues showed extensive submucosal fibrosis, characterized by significantly increased α-SMA+ myofibroblasts and CTGF expression. In human stenotic lesions, increased p-Smad2/3+ nuclei were also observed. p17 treatment significantly reduced the fibrotic thickness, as well as the density of α-SMA+ myofibroblasts and CTGF+ cells in rabbit stenotic lesions, but failed to improve the luminal area. Conclusion ATS is characterized by a TGF-β dependent fibrotic process, but reduction of the fibrotic component by TGF-β1 antagonist therapy was not sufficient to improve tracheal narrowing, suggesting that fibrosis may not be the main contributor to luminal stenosis. Level of Evidence NA. Laryngoscope, 127:561–567, 2017

Background The polymyalgia rheumatica is a rheumatic inflammatory disease more frequent in the eldest population The classic therapy is based on medium doses of corticosteroids followed by a maintenance phase of low doses, generally lasting form 1–2 years. Recurrences frequently require an escalation of dose, thus lengthening the treatment time, and that entails important comorbidity. Methotrexate (MTX) has been tested in 3 randomised clinical trials, showing in two of them the efficacy as a steroid sparing agent, but it has never been tested as monotherapy. Objectives To analyse the results of an alternative therapy in order to avoid the oral corticotherapy through the use of low dose of MTX and joint infiltration with a total duration of 24 months. Methods A prospective observational study in which patients that had been diagnosed with 2012 EULAR/ACR criteria were evaluated in outpatient medical consultations of Rheumatology at “Doce de Octubre” Hospital between 2015–2017, with the restriction of not having received previous steroid treatment. Right after diagnosis, the treatment with MTX 5–7.5 mg/w plus the infiltration of triamcinolone acetonide in both shoulders begins, being repeated if necessary after 15 or 30 days, or in case of subsequent relapse. Results 26 patients were included, with an average follow-up 19±5 months.12–24 The age average at diagnosis was 74±7 years,55–83 being 56% women. 73% had symmetrical hand arthritis and 27% structural pathology of the rotator cuff. 96% had moderate-severe pain (VAS) in shoulders, 73% in hips and 54% in hands. These percentages after a month of treatment were 15%, 11.5% and 7.7%. From the onset of symptoms until the start of treatment 104±54 days passed,30–180 applying an initial dose of 5 mg of MTX in half of cases and 7.5 mg in the other half. There are no significant differences between precocity of the treatment or initial dose regarding a faster remission. The average of infiltrations in the shoulder per year is 2±1.4 (1–4). 25% of patients showed reactivation with good response to the MTX dose increase [maximum dose 8±1.7 (5–12.5)] plus/or joint infiltration. The average time until the revision (subjective clinical evaluation, HAQ and APR) was 2.7±1 months,1–6 being significantly higher (p The treatment was stopped in 12% because of adverse effects (digestive intolerance, alopecia and respiratory infection in a patient with COPD). A patient showed mild plaquetopenia in wich not necessary to suspend the treatment with MTX. 8 patients were monitored during ≥2 years, in 87% of them MTX has been removed with an average follow-up after the suspension of 3±1.7 months1–6 with no need to restart it in any case. Conclusions The use of low dose of MTX and local joint infiltration with corticosteroids (initial and on demand) is an efficient therapeutic strategy with a low complication rate in PMR. All these results must be confirmed with controlled studies and a longer period of follow-up after the suspension of treatment. Disclosure of Interest None declared

Background Rituximab (RTX) is a chimeric monoclonal antibody directed against CD20 antigens in B lymphocytes (BL) surface, producing selective depletion of BL, without affecting mature plasmatic cells. Current guidelines recommend optimisation of biologic therapy once remission has achieved in rheumatoid arthritis (RA) patients. A serum biomarker able to predict what patients would maintain remission after optimisation in RTX treated RA patients is lacking. Objectives To analyse the predictive value of CD19 serum level prior to RTX infusion for the long term maintenance of therapeutic response, and it’s utility as a biomarker for optimisation in RA patients treated with RTX. Methods all RA patients treated with RTX in our centre during 2016 and 2017 for at least 6 months, and with 12 months follow-up, were included. Demographic data, clinical data related to RA, including activity parameters (DAS28, HAQ, ESR, RCP), number of infections, optimisation and serum levels of lymphocytic subpopulations (CD19, CD3 and CD56) and immunoglobulins (Ig) prior to each RTX cycle were collected. Optimisation was defined as any dose decrease (lower dose for cycle and/or increase interval between cycles). Recurrent infections were defined as three or more infections in one year. Descriptive statistics, correlation between basal levels of CD19, CD3 or CD56, and activity parameters or Ig levels at 6 and 12 months, and association studies between lymphocyte subpopulations and optimisation or recurrent infections were performed. Results Thirty patients (25 females, 60±12 year) with RA (24 RF/aCCP +, 17±11 years from disease onset), treated with RTX during 52±40 months, with an accumulated dose of 13±10 g were included. At study inclusion, DAS28 was 3,77±1,65, HAQ was 1,28±0,78 and 22 had been optimised. CD19 levels were lower than 2% in 22 patients (79%), including 10 with undetectable levels. CD19 levels (cels/mm³) were lower in optimised patients (73 vs 14, p=,03), and were correlated with DAS28 at 6 months (r=0,5; p=,007) and 12 months (r=0,44; p=,03), and with ESR at 6 m (r=0,6; p=,002). CD19 levels did not correlate with IgG levels, and were not associated with recurrent infections. CD3 and CD56 levels did not show any relevant association or correlation. Conclusions In RA patients treated with RTX for more than 6 months, CD19 levels correlate with long term therapeutic response, being low or undetectable levels predictors of good outcome, without association with Ig levels or increased infections. Our results suggest that CD19 levels before every RTX cycle might be a useful biomarker to select candidate patients for optimisation with this therapy. Disclosure of Interest None declared

Fibrosis is a common lesion in different pathologic diseases and is defined by the excessive accumulation of collagen. Different approaches have been used to treat different conditions characterized by fibrosis. FDA and EMA approved collagenase to treat palmar fibromatosis, Dupuyten disease. EMA approved additionally its use in severe Peyronie disease, but it has been used off label in other conditions.1, 2. Approved treatment includes up to 3, in palmar fibromatosis or up to 8, in penile fibromatosis, injections followed by finger extension or penile modelling procedures, typically causing severe pain. Frequently single injections are enough to treat palmar fibromatosis. 3, The need to inject repeatedly doses of this enzyme can be originated by by the labile nature of collagenase which exhibits a complete activity loss after short periods of time. Herein, a novel strategy to manage this enzyme based on the synthesis of polymeric nanocapsules which contains collagenase housed within their matrix is presented. These nanocapsules have been engineered for achieving a gradual release of the encapsulated enzyme for longer times which can be up to ten days. The efficacy of these nanocapsules have been tested in murine model of local dermal fibrosis yielding higher fibrosis reduction in comparison with the injection of free enzyme which represent a significant improvement over conventional therapy., Comment: 32 pages, 5 figures

Chronic inflammation is a common process connecting pathologies that vary in their etiology and pathogenesis such as cancer, autoimmune diseases, and infections. The response of the immune system to tissue damage involves a carefully choreographed series of cellular interactions between immune and non-immune cells. In recent years, it has become clear that stromal resident cells have an essential role perpetuating the inflammatory environment and dictating in many cases the outcome of inflammatory based pathologies. Signal transduction pathways remain the main focus of study to understand how stimuli contribute to perpetuating the inflammatory response, mainly due to their potential role as therapeutic targets. However, molecular events orchestrated in the nucleus by transcription factors add additional levels of complexity and may be equally important for understanding the phenotypic differences of activated stromal components during the chronic inflammatory process. In this review, we focus on the contribution of transcription factors to the selective regulation of inducible proinflammatory genes, with special attention given to the regulation of the stromal fibroblastic cell function and response.

15 p.-6 fig.-1 tab., Peripheral serotonin (5-hydroxytryptamine, 5-HT) regulates cell growth and differentiation in numerous cell types through engagement of seven types of cell surface receptors (HTR1–7). Deregulated 5-HT/ HTR levels contribute to pathology in chronic inflammatory diseases, with macrophages being relevant targets for the physio-pathological effects of 5-HT. In fact, 5-HT skews human macrophage polarization through engagement of 5-HT2BR and 5-HT7R receptors. We now report that 5-HT primes macrophages for reduced pro-inflammatory cytokine production and IFN type I-mediated signaling, and promotes an anti-inflammatory and pro-fibrotic gene signature in human macrophages. The acquisition of the 5-HT-dependent gene profile primarily depends on the 5-HT7R receptor and 5-HT7R-initiated PKAdependent signaling. In line with the transcriptional results, 5-HT upregulates TGFβ1 production by human macrophages in an HTR7- and PKA-dependent manner, whereas the absence of Htr7 in vivo results in diminished macrophage infiltration and collagen deposition in a mouse model of skin fibrosis.Our results indicate that the anti-inflammatory and pro-fibrotic activity of 5-HT is primarily mediated through the 5-HT7R-PKA axis, and that 5-HT7R contributes to pathology in fibrotic diseases., This work was supported by grants from Ministerio de Economía y Competitividad (SAF2011-23801 and SAF2014-52423-R to MAV and ALC, and PI I12/439 to JLP), “Programa de Actividades de I + D” from the Comunidad de Madrid/FEDER (RAPHYME S2010/BMD-2350 to JLP and ALC), and RIER (Red de Investigación en Inflamación y Enfermedades Reumáticas, RD12/09 to ALC and JLP) from the Instituto de Salud Carlos III,Ministerio de Economía y Competitividad, Spain (co-financed by FEDER, European Union). MCE was supported by an FPI predoctoral fellowship (BES-2009-021465) from Ministerio de Economía e Innovación.

Vitamin D analogues can reduce TGF-b pro- fibrotic signaling in dermal fibroblasts, but they may also induce a potentially pro-fibrotic thymic stromal lympho- poietin (TSLP)-dependent Th2 cytokine local response. We have analyzed the net effect of topical vitamin D analogue calcipotriol (CPT) on the cytokine profile and the develop- ment of fibrosis in experimental model of bleomycin-induced fibrosis. Mice were simultaneously treated with topical CPT or vehicle cream and skin fibrosis was measured by collagen deposition, Masson's trichrome staining and hydroxyproline content. Cytokine and TSLP gene expression was evaluated by quantitative RT-PCR. We showed that in bleomycin injected skin, CPT administration significantly enhanced TSLP and IL-13 gene expression, but did not modify the expression of other cytokines. Skin fibrosis and hydroxy- proline content were significantly reduced in CPT compared to vehicle-treated mice. In normal skin, topical administration of CPT lacked a direct pro-fibrotic effect. Our results dem- onstrate that topical CPT superinduces the expression of the TSLP/IL-13 Th2 axis in fibrotic skin, but it has a net anti- fibrotic effect. These data support the therapeutic use of topical vitamin D analogues for skin fibrosis.

Summary The aim of this study was to analyse the distribution of regulatory and inhibitory mothers against decapentaplegic homologue (Smad) proteins as markers of active transforming growth factor (TGF)-β signalling in rheumatoid arthritis (RA) synovial tissue and to investigate the effect of TGF-β blockade in the development and progression of collagen-induced arthritis. The expression of Smad proteins in synovial tissues from RA, osteoarthritic and healthy controls was analysed by immunohistochemistry. Arthritis was induced in DBA/1 mice by immunization with chicken type-II collagen (CII). TGF-β was blocked in vivo with the specific peptide p17 starting at the time of immunization or on the day of arthritis onset. T cell population frequencies and specific responses to CII were analysed. The expression of cytokines and transcription factors was quantified in spleen and joint samples. Statistical differences between groups were compared using the Mann–Whitney U-test or one-way analysis of variance (anova) using the Kruskal–Wallis test. p-Smad-2/3 and inhibitory Smad-7 expression were detected in RA and control tissues. In RA, most lymphoid infiltrating cells showed nuclear p-Smad-2/3 without Smad-7 expression. Treatment with TGF-β antagonist did not affect clinical severity, joint inflammation and cartilage damage in collagen-induced arthritis. Frequency of T cell subsets, mRNA levels of cytokines and transcription factors, specific proliferation to CII, serum interleukin (IL)-6 and anti-CII antibodies were comparable in p17 and phosphate-buffered saline (PBS)-treated groups. The pattern of Smad proteins expression demonstrates active TGF-β signalling in RA synovium. However, specific TGF-β blockade does not have a significant effect in the mice model of collagen-induced arthritis.

ObjetiveSystemic sclerosis (SSc) is an autoimmune disease characterised by progressive fibrosis. Although SSc shares pathogenetic features with other autoimmune diseases, the participation of profibrotic Th2 cytokines is unique to SSc, but the mechanisms of Th2 skewing are unknown. We have analysed the expression and function of thymic stromal lymphopoietin (TSLP), a central regulator of Th2-mediated allergic inflammation, in human SSc, primary lung fibrosis and in a mouse model of scleroderma.MethodsTSLP expression was analysed by immunohistochemistry in human SSc skin, primary lung fibrosis and mouse bleomycin-induced skin fibrosis, and by quantitative RT-PCR in mouse skin and cultured fibroblasts. The regulation of TSLP expression by specific toll-like receptors (TLR)-2, -3 and -4 agonists was analysed in human dermal fibroblast cultures. The role of TSLP in skin fibrosis and local cytokine expression was analysed in TSLP receptor (TSLPR)-deficient mice.ResultsTSLP was overexpressed by epithelial cells, mast cells and fibroblasts in human SSc skin and lung fibrosis, and in the bleomycin model of scleroderma. In cultured human and mouse skin fibroblasts, TSLP expression was inducible by activation of TLR, particularly TLR3. In TSLPR-deficient mice, bleomycin-induced fibrosis was significantly reduced in parallel with significantly reduced local expression of IL-13.ConclusionsThese data provide the first evidence of TSLP overexpression in SSc and other non-allergic fibrotic conditions, and demonstrate a profibrotic role that is potentially meditated by specific changes in the local cytokine milieu. Thus, modulating TSLP may have antifibrotic therapeutic implications.

Objectives ABP 501 is a Food and Drug Administration-approved biosimilar to adalimumab; structural, functional and pharmacokinetic evaluations have shown that the two are highly similar. We report results from a phase III study comparing efficacy, safety and immunogenicity between ABP 501 and adalimumab. Methods In this randomised, double-blind, active comparator-controlled, 26-week equivalence study, patients with moderate to severe active rheumatoid arthritis (RA) despite methotrexate were randomised (1:1) to ABP 501 or adalimumab (40 mg) every 2 weeks. Primary endpoint was risk ratio (RR) of ACR20 between groups at week 24. Primary hypothesis that the treatments were equivalent would be confirmed if the 90% CI for RR of ACR20 at week 24 fell between 0.738 and 1.355, demonstrating that ABP 501 is similar to adalimumab. Secondary endpoints included Disease Activity Score 28-joint count-C reactive protein (DAS28-CRP). Safety was assessed via adverse events (AEs) and laboratory evaluations. Antidrug antibodies were assessed to determine immunogenicity. Results A total of 526 patients were randomised (n=264, ABP 501; n=262 adalimumab) and 494 completed the study. ACR20 response at week 24 was 74.6% (ABP 501) and 72.4% (adalimumab). At week 24, the RR of ACR20 (90% CI) between groups was 1.039 (0.954, 1.133), confirming the primary hypothesis. Changes from baseline in DAS28-CRP, ACR50 and ACR70 were similar. There were no clinically meaningful differences in AEs and laboratory abnormalities. A total of 38.3% (ABP 501) and 38.2% (adalimumab) of patients tested positive for binding antidrug antibodies. Conclusions Results from this study demonstrate that ABP 501 is similar to adalimumab in clinical efficacy, safety and immunogenicity in patients with moderate to severe RA. Trial registration number NCT01970475; Results.

Aims: To assess the contribution of fibroblast-like synoviocytes (FLS) to the inflammatory joint microenvironment under different pathogenic stimuli and their potential to respond to interleukin (IL)-17 and to determine whether the neuroimmunomodulatory vasoactive intestinal peptide (VIP) is able to modulate IL-17 receptor (IL-17R) and related cytokines. Methods: The effect of proinflammatory cytokines [tumor necrosis factor α (TNFα) and IL-17] and Toll-like receptor (TLR) ligands [poly(I:C) and lipopolysaccharide (LPS)] on IL-17R expression and IL-12 and IL-23 production was studied in osteoarthritis (OA)- and rheumatoid arthritis (RA)-FLS, involved in Th1/Th17 differentiation. The effect of VIP was also determined. IL-17RA, IL-17RC, IL-12p35 and IL-23p19 expression was measured by real-time polymerase chain reaction. IL-12 and IL-23 protein levels were measured by ELISA in supernatant cultures. Results: TNFα, LPS and poly(I:C) induced an increase in IL-17RA in RA-FLS, whereas TNFα, TNFα plus IL-17 and poly(I:C) enhanced IL-17RC transcripts in FLS. VIP diminished the upregulated expression of IL-17RA in RA-FLS following TNFα and poly(I:C). TNFα, LPS and poly(I:C) increased IL-12 and IL-23 levels in cells derived from patients presenting both pathologies. However, IL-17A decreased IL-12 and augmented IL-23. VIP decreased IL-12p35 mRNA upregulation by poly(I:C) and IL-23p19 transcripts in LPS-treated FLS. Conclusions: Inflammatory cytokines and TLR ligands modulate IL-17R, IL-12 and IL-23 possibly favoring the cross talk between FLS and Th1/Th17 cells. The ability of VIP to counteract the enhancing effect of proinflammatory molecules on IL-17R and the IL-12 family of cytokines corroborates and amplifies the beneficial effect of this endogenous neuroimmunopeptide in rheumatic diseases.

An efficient mode of HIV-1 infection of CD4 lymphocytes occurs in the context of infectious synapses, where dendritic cells (DCs) enhance HIV-1 transmission to lymphocytes. Emergence of CXCR4-using (X4) HIV-1 strains occurs late in the course of HIV-1 infection, suggesting that a selective pressure suppresses the switch from CCR5 (R5) to X4 tropism. We postulated that SDF-1/CXCL12 chemokine production by DCs could be involved in this process. We observed CXCL12 expression by DCsin vivoin the parafollicular compartment of lymph nodes. The role of mature monocyte-derived dendritic cells (mMDDCs) in transmitting R5 and X4 HIV-1 strains to autologous lymphocytes was studied using anin vitroinfection system. Using this model, we observed a strong enhancement of lymphocyte infection with R5, but not with X4, viruses. This lack of DC-mediated enhancement in the propagation of X4 viruses was proportional to CXCL12 production by mMDDCs. When CXCL12 activity was inhibited with specific neutralizing antibodies or small interfering RNAs (siRNAs), the block to mMDDC transfer of X4 viruses to lymphocytes was removed. These results suggest that CXCL12 production by DCs resident in lymph nodes represents an antiviral mechanism in the context of the infectious synapse that could account for the delayed appearance of X4 viruses.

Evidence links aryl hydrocarbon receptor (AHR) activation to rheumatoid arthritis (RA) pathogenesis, although results are inconsistent. AHR agonists inhibit pro-inflammatory cytokine expression in macrophages, pivotal cells in RA aetiopathogenesis, which hints at specific circuits that regulate the AHR pathway in RA macrophages. We compared microRNA (miR) expression in CD14(+) cells from patients with active RA or with osteoarthritis (OA). Seven miR were downregulated and one (miR-223) upregulated in RA compared to OA cells. miR-223 upregulation correlated with reduced Notch3 and Notch effector expression in RA patients. Overexpression of the Notch-induced repressor HEY-1 and co-culture of healthy donor monocytes with Notch ligand-expressing cells showed direct Notch-mediated downregulation of miR-223. Bioinformatics predicted the AHR regulator ARNT (AHR nuclear translocator) as a miR-223 target. Pre-miR-223 overexpression silenced ARNT 3'UTR-driven reporter expression, reduced ARNT (but not AHR) protein levels and prevented AHR/ARNT-mediated inhibition of pro-inflammatory cytokine expression. miR-223 counteracted AHR/ARNT-induced Notch3 upregulation in monocytes. Levels of ARNT and of CYP1B1, an AHR/ARNT signalling effector, were reduced in RA compared to OA synovial tissue, which correlated with miR-223 levels. Our results associate Notch signalling to miR-223 downregulation in RA macrophages, and identify miR-223 as a negative regulator of the AHR/ARNT pathway through ARNT targeting., Spanish Ministry Economy and Competitiveness (SAF2011-24453 and SAF2014-54475-R to SM; SAF2010-15106 and SAF2013-44857-R to MLT), the Comunidad de Madrid (INMUNOTHERCAN; S2010/BMD-2326 to SM and RAPHYME S2010/BMD-2350 to JLP), the Instituto de Salud Carlos III (ISCIII) (Inflammation and Rheumatic Diseases Network, co-financed by FEDER, RD12/0009; and FIS PI12/00439 to JLP).

Objective CXCL12γ is an alternative splicing isoform of CXCL12 with enhanced affinity for heparan sulfate (HS) proteoglycans. This study was undertaken to investigate the distribution and potential function of CXCL12γ in rheumatoid arthritis (RA) synovium and normal lymphoid tissue, where its immobilization to HS may be relevant in pathologic or homeostatic immune cell migration and activation. Methods Expression of CXCL12 or CXCL12γ was immunodetected in RA and normal synovium, lymphoid tissue, and cultured cells with anti–pan-CXCL12 or anti-CXCL12γ–specific monoclonal antibodies. CXCL12α and CXCL12γ messenger RNA expression was analyzed by quantitative reverse transcription–polymerase chain reaction. Binding of wild-type CXCL12 isoforms or their HS binding–defective mutants to monocyte-derived dendritic cells (DCs) was analyzed by flow cytometry. The effect of DC-bound CXCL12α and CXCL12γ on T cell activation was analyzed in DC/T cell allogeneic cultures. Results CXCL12γ expression was increased in RA compared to normal synovium and preferentially located in endothelia and DC-SIGN–positive cells. This distribution was also observed in lymphoid organs. Surface-bound CXCL12γ was detected in a fraction of freshly isolated DCs. Monocyte-derived DCs, but not monocytes, showed a high capacity to bind CXCL12γ in an HS-dependent manner. Surface-bound CXCL12α and CXCL12γ on monocyte-derived DCs were potent inhibitors of allogeneic T cell activation, in contrast to the T cell–stimulatory effects of soluble CXCL12 proteins. Conclusion CXCL12γ shows a specific and similar distribution in RA synovium and lymphoid tissue, consistent with its higher HS binding affinity. Presentation of CXCL12 to T cells on membrane HS in DCs can play a distinct regulatory role in T cell activation.

Objective Changes in rheumatoid arthritis synovial fibroblast (RASF) gene expression are usually defined by a comparison to osteoarthritis synovial fibroblasts (OASFs). This study was undertaken to analyse the transcriptome of OASFs as compared to RASFs and healthy synovial fibroblasts (HSFs). Methods The authors used microarray messenger RNA expression profiling of synovial fibroblasts cultured from osteoarthritis (OA), rheumatoid arthritis and normal synovial tissues. Quantitative real-time PCR of selected genes was performed to validate microarray data. Analysis of variance, Student t test and the Benjamini–Hochberg multiple testing correction method for multiple testing correction were used to determine the statistical significance of the changes between the three groups. Results Larger numbers of transcripts showed a differential expression in OASFs versus the other groups, rather than in RASFs versus HSFs. Cluster analysis confirmed that the differences between the three groups were mostly due to the differences between OA and the other groups. Functional classification identified a significant number of genes related to growth factor activities, cell adhesion, neurotransmission and Ras signalling that are differentially expressed in OASFs. Classical proinflammatory factors or proteases involved in cartilage degradation were not found to be overexpressed in OASFs. Conclusion Cultured OASFs display a more homogeneous transcriptomic profile than RASFs when compared to HSFs. This supports the participation of synovial fibroblasts in the pathogenesis of OA and may reflect global defects in the mesenchyma-derived lineages of the different tissues in OA joints. These data support individual heterogeneity among RASFs and advise against the use of OASFs as controls.

Objective Hypoxia is a prominent feature in rheumatoid arthritis (RA) synovium. However, its contribution to the pathogenesis of RA remains unclear. We undertook this study to systematically characterize the changes in gene expression induced by hypoxia in synovial fibroblasts. Methods We used microarray expression profiling in paired normoxic and hypoxic cultures of healthy synovial fibroblasts (HSFs) and RA synovial fibroblasts (RASFs). We used Student's paired t-test with Benjamini and Hochberg multiple testing correction to determine statistical significance. Validation of microarray data was performed by quantitative real-time reverse transcription–polymerase chain reaction analysis of selected genes. Biologic pathways differentially modulated by hypoxia in RASFs or HSFs were identified using unsupervised Ingenuity Pathways Analysis. Results Hypoxia induced significant changes in the expression of a large group of genes in both HSFs and RASFs. In RASFs, we observed a lower number of hypoxia-regulated genes and partial differences in their functional categories. The number of differentially expressed genes in RASFs compared with HSFs was significantly increased by hypoxia. Multiple gene sets involved in energy metabolism, intracellular signal transduction, angiogenesis, and immune and inflammatory pathways were significantly modified, the last in both proinflammatory and antiinflammatory directions. Conclusion These data demonstrate that hypoxia induces significant changes in gene expression in HSFs and RASFs and identify differences between RASF and HSF profiles. The hypoxia-induced gene expression program in synovial fibroblasts identifies new factors and pathways relevant to understanding their contribution to the pathogenesis of chronic arthritis.

Objectives. To evaluate whether the use of platelet immunohistochemistry (IHC) markers improves the sensitivity of histological methods to detect microthrombosis in SLE nephritis and aPLs and to analyse the clinicopathological correlations of microthrombosis in this setting. Methods. Kidney biopsy specimens from 65 patients with SLE, including 36 with positive aPLs, were studied by IHC using antibodies against platelet glycoproteins CD41 and CD61. Clinical data at the time of kidney biopsy and during a mean follow-up of 7.5 years after biopsy were recorded and analysed with regard to histological or IHC data. Results. Histological lesions previously defined as APS nephropathy were found in 33% of the SLE kidney biopsies and were not associated with positive aPLs. Microthrombi detected as intravascular CD61 platelet deposits were present in 43% of the tissues and were significantly associated with positive aPLs, but not with histological APS nephropathy, nephritis manifestations nor with renal outcome. Histological APS lesions but not CD61 + microthrombi correlated with an older age at nephritis presentation, previous cardiovascular risk factors and worse renal outcome. Conclusions. Immunodetection of intravascular CD61 + platelet aggregates is more sensitive than histological evaluation to detect acute microthrombosis and provides a better correlation with aPLs in SLE patients. In contrast, histological lesions consistent with APS nephropathy were not associated with aPLs but with cardiovascular risk factors and worse renal outcome.

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease whose pathogenesis is not completely understood. Unbalanced Th1/Th2 T-cell polarization has been suggested to play a pathogenetic role and therefore, modulation of T-cell polarization is a potential therapeutic target. Vasoactive intestinal peptide (VIP) is a broadly distributed peptide that exerts anti-inflammatory and immunomodulatory effects, in the collagen-induced arthritis (CIA) murine model of RA, and ex vivo, in synovial cells from RA patients. In the present study, we have found that polyclonal stimulation of peripheral blood lymphocytes (PBL) from RA patients produces higher levels of inflammatory mediators and lower levels of Th1 cytokines than PBL from healthy controls; moreover, VIP has negligible effects on inflammatory mediators and Th1 cytokines produced by PBL from healthy controls but favours Th2 profile and enhanced IL-10 production after stimulation. VIP increases the levels of IL-10 and IL-4 in the supernatant of human CD4(+)CD45RA(+) cells cultured in a non-conditioned or a Th2-conditioned situation. In contrast, VIP does not modify the production of these cytokines in a Th1-conditioned medium. In summary, VIP can differentially modify the functional capacity of human lymphocytes by inducing Th2/Treg differentiation depending on their previous phenotype.

Objectives: To investigate the effect of poly(ADP-ribose) polymerase (PARP) inhibition on the production of inflammatory mediators and proliferation in tumour necrosis factor (TNF)-stimulated fibroblast-like synoviocytes (FLS) from patients with rheumatoid arthritis (RA). Methods: Cultured FLS from patients with RA were treated with two PARP inhibitors, 3,4-dihydro-5-[4-1(1-piperidinyl)buthoxy]-1(2H)-isoquinolinona (DPQ) or 4-amino-1,8-naphthalimida (ANI) before TNF stimulation. PARP-1 expression was also suppressed in RA FLS by small interfering RNA (siRNA) transfection. Expression and secretion of inflammatory mediators were analysed by quantitative polymerase chain reaction and by enzyme-linked immunosorbent assay, respectively. Proliferation of RA FLS was also determined. Mitogen-activated protein kinase (MAPK) activity was analysed by western blot assay and activator protein (AP)-1 and nuclear factor (NF)κB binding by electrophoretic mobility shift assay. Results: We show, for the first time, that PARP inhibition either with specific inhibitors or by siRNA transfection significantly reduced TNF-induced cytokine and chemokine expression in FLS from patients with RA. PARP inhibitors also decreased TNF-induced RA FLS proliferation. PARP inhibition reduced TNF-induced JNK phosphorylation and AP-1 and NFκB binding activities were partially impaired by treatment with PARP inhibitors or by PARP-1 knockdown. Conclusion: PARP inhibition reduces the production of inflammatory mediators and the proliferation of RA FLS (in response to TNF), suggesting that PARP inhibitors could have therapeutic benefits in RA.

Background The immunosuppressive and anti-inflammatory properties of mesenchymal stromal cells (MSC) have prompted their therapeutic application in several autoimmune diseases, including rheumatoid arthritis. Adult MSC are finite and their clinical use is restricted by the need for long-term expansion protocols that can lead to genomic instability. Inhibition of Smad2/3 signaling in human pluripotent stem cells (hPSC) provides an infinite source of MSC that match the phenotype and functional properties of adult MSC. Here, we test the therapeutic potential of hPSC-MSC of embryonic origin (embryonic stem cell-derived mesenchymal stromal cells, hESC-MSC) in the experimental model of collagen-induced arthritis (CIA). Methods CIA was induced in DBA/1 mice by immunization with type II collagen (CII) in Complete Freund’s Adjuvant (CFA). Mice were treated with either a single dose (106 cells/mouse) of hESC-MSC on the day of immunization (prophylaxis) or with three doses of hESC-MSC every other day starting on the day of arthritis onset (therapy). Arthritis severity was evaluated daily for six weeks and ten days, respectively. Frequency of Treg (FoxP3+), Th1 (IFNγ+) and Th17 (IL17+) CD4+ T cells in inguinal lymph nodes (ILN) was quantified by flow cytometry. Serum levels of anti-CII antibodies were determined by ELISA. Detection of hESC-MSC and quantification of murine and human indoleamine 2,3 dioxygenase (IDO1) expression was performed by quantitative real-time PCR. Statistical differences were analyzed by ANOVA and the Mann-Whitney U test. Results Administration of hESC-MSC to mice with established arthritis reduced disease severity compared to control-treated mice. Analysis of CD4 T cell populations in treated mice showed an increase in FoxP3+ Treg and IFNγ+ Th1 cells but not in Th17 cells in the ILN. Anti-CII antibody levels were not affected by treatment. Migration of hESC-MSC to the ILN in treated mice was associated with the induction of murine IDO1. Conclusion Treatment with hESC-MSC ameliorates CIA by inducing IFNγ+ Th1 cells and IDO1 in the host. Thus, hESC-MSC can provide an infinite cellular source for treatment of rheumatoid arthritis.

Patients with rheumatoid arthritis (RA) in clinical remission may have ultrasound-defined synovitis according to the presence of power Doppler (PD) signal. The objective was to describe the immunopathologic characteristics of ultrasound-defined synovitis compared with synovitis in patients with clinically active RA.We included between 6 and 8 ultrasound-guided synovial biopsies per patient from 20 patients with RA in clinical remission (DAS28-ESR2.6) with PD signal, 22 synovial tissue samples (ST) from patients with clinically active RA (swollen joint with confirmed inflammatory synovial fluid) as inflammatory controls, and 10 ST from non-inflammatory controls. Immunostaining for CD3 (T lymphocytes), CD20 (B lymphocytes), CD68 (macrophages), CD117 (mast cells), hsp47 (fibroblasts), bFGF and CXCL12 (angiogenic factors) was made and quantified by digital image analysis. The number of CD31 vessels/mm(2) was quantified.RA patients in remission with PD signal had significantly reduced synovial T-cell, B-cell, mast cell and fibroblast density, but similar macrophage infiltration compared with patients with clinically active RA. Vascularity, bFGF and CXCL12 were partially reduced in RA patients in remission with PD signal compared to those with active RA, but were significantly higher compared with ST from non-inflammatory controls. During the 12-month follow up, 8/20 RA patients (40 %) lost remission: all had synovial hypertrophy grade ≥2 and significantly more synovial B cells and mast cells than patients maintaining remission.Asymptomatic ultrasound-defined synovitis and clinically active arthritis differ in the degree of infiltrating lymphoid, mast cells and fibroblast density, but are similar with respect to macrophage infiltration. Persistently increased angiogenic factor expression and vascularity may explain the persistence of a PD signal.