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Background Bone damage in rheumatoid arthritis (RA) typically emerges at certain anatomical hotspots corresponding to the so-called “bare area”, an intra-articular region between the cartilage and the insertion site of the joint capsule (1,2). We hypothesized that this region exhibits certain micro-anatomical properties, which facilitates the emergence of bone erosions. Objectives To find the micro-structural correlate of the origin of bone erosions in the bare area of the human joint Methods Bare areas of human joints were analyzed for early microstructural changes by in-vivo high-resolution peripheral computed tomography (HR-pQCT). First, bare areas were exactly defined by scanning 6 cadaveric hands for localization of the bare area in the human metacarpal head. Bone lesions found in the cadaveric hand by HR-pQCT were additionally by super-resolution ex vivo micro-CT (μCT40). Then, number and distribution of the type of bare area bone lesion found in cadaveric study were analyzed in a cohort of 105 healthy individuals and 107 anti-citrullinated peptide (ACPA) positive RA patients with similar sex and age distribution. Results HR-pQCT combined with adaptive thresholding allowed the definition of a new type of bone lesions in the bare areas of the human joint termed “COMIC” standing for “cortical micro-channel”. Their existence in the bare area was additionally validated by microCT (Figure 1). RA patients showed significantly (p Conclusions CoMiCs represent a new structural feature of the joint, which is characteristic for the bone of the bare area. COMICS at low level are also found in young healthy individuals but they significantly increase with age and particularly with RA. COMICs develop much earlier and much more pronounced in RA patients than in healthy individuals and therefore represent an interesting new early indicator for erosion development in ACPA positive RA patients. References Stach CM, Bauerle M, Englbrecht M, Kronke G, Engelke K, Manger B, et al. Periarticular bone structure in rheumatoid arthritis patients and healthy individuals assessed by high-resolution computed tomography. Arthritis & Rheumatism. 2010;62(2):330–9. Simon D, Kleyer A, Stemmler F, Simon C, Berlin A, Hueber AJ,Haschka J, Renner N, Figueiredo C, Neuhuber W, Buder T, Englbrecht M, Rech J, Engelke K, Schett G. Age- and Sex-Dependent Changes of Intra-articular Cortical and Trabecular Bone Structure and the Effects of Rheumatoid Arthritis. J Bone Miner Res. 2016 Oct 27. doi: 10.1002/jbmr.3025. [Epub ahead of print]. Disclosure of Interest None declared

Background Achieving remission is the ultimate treatment goal in patients with rheumatoid arthritis (RA). With the development and wider use of highly effective disease modifying anti-rheumatic drugs (DMARD) about half of RA patients reach the disease remission state (1), raising the question about tapering or stopping anti-rheumatic treatment and appropriate predictors (2). Objectives To analyse the effect of a risk-stratified DMARD tapering algorithm based on multiple-biomarker disease activity (MBDA) score and anti-citrullinated protein (ACPA) status for successful DMARD tapering and treatment cost reduction in RA patients in sustained remission enrolled in the prospective randomized controlled RETRO study (3,4). Methods MBDA scores and ACPA status were determined in the baseline samples of 146 patients in sustained remission. Patients either continued DMARDs (arm1), tapered dose by 50% (arm 2) or stopped DMARDs after tapering (arm 3) for one year according to the RETRO study protocol. Direct treatment costs (including testing costs at baseline) were evaluated every three months. MBDA and ACPA status were used as predictors creating a risk-stratified tapering algorithm based on relapse rates. Results RA patients with a low MBDA score ( Conclusions Combining MBDA score and ACPA status allows risk stratification for successful DMARD tapering and cost-effective use of biologic DMARD. Given that previous data of the RETRO have shown that patients relapsing after tapering their DMARDs respond well to their reintroduction, a stratified tapering and stopping of DMARDs is not only a cost economic but also clinically feasible strategy. References Aga AB et al. Ann Rheum Dis. 2013;74:381–8. Schett G et al. Ann Rheum Dis. 2016 Aug;75(8):1428–373. Haschka J et al, Ann Rheum Dis. 2016;75:45–51. Rech J et al, Ann Rheum Dis. 2015; Oct. 19. Disclosure of Interest None declared

The comparison between different techniques to quantify the 3-dimensional size of inflammatory bone erosions in rheumatoid arthritis(RA) patients.Anti-cyclic citrullinated peptide antibody(ACPA) positive RA patients received high-resolution peripheral quantitative computed tomography (HR-pQCT) scans of the metacarpophalangeal joints (MCP). Erosions were measured by three different segmentation techniques: (1) manual method with calculation by half-ellipsoid formula, (2) semi-automated modified Evaluation Script for Erosions (mESE), and (3) semi-automated Medical Image Analysis Framework (MIAF) software. BlandAltman plots were used to describe agreement between methods. Furthermore, shape of erosions was classified as regular or irregular and then compared to the sphericity obtained by MIAF.A total of 76 erosions from 65 RA patients (46 females/19 males), median age 57 years, median disease duration 6.1 years and median disease activity score 28 of 2.8 units were analyzed. While mESE and MIAF showed good agreement in the measurement of erosion size, the manual method with calculation by half-ellipsoid formula underestimated erosions size, particularly with larger erosions. Accurate segmentation is particularly important in larger erosions, which are irregularly shaped. In all three segmentation techniques irregular erosions were larger in size than regular erosions (MIAF: 19.7 vs. 3.4mmMIAF and mESE allow segmentation of inflammatory bone erosions in RA patients with excellent inter reader reliability. They allow calculating erosion volume independent of erosion shape and therefore provide an attractive tool to quantify structural damage in individual joints of RA patients.

Introduction: Many anti-tumor therapies induce apoptotic cell death in order to cause tumor regression. Paradoxically, apoptotic cells are also known to promote wound healing, cell proliferation, and tumor cell repopulation in multicellular organisms. We aimed to characterize the nature of the regenerative signals concentrated in the micro milieu of dead and dying cells. Methods: Cultures of viable melanoma B16F10 cells, mouse fibroblasts and primary human fibroblast-like synoviocytes(FLS) in the presence of dead and dying cells,its supernatants or purified agonists and antagonists were used to evaluate the stimulation of proliferation. Viable cell quantification was performed by either flow cytometry of harvested cells or by crystal violet staining of adherent cells. High-performance liquid chromatography (HPLC) and liquid chromatography coupled with mass spectrometry (LC-MS) of cell supernatants were deployed to identify the nature of growth promoting factors.Co-implantation of living cells in the presence of supernatants collected from dead and dying cells and specific agonists was used to evaluate tumor growth in vivo. Results: The stimulation of proliferation of few surviving cells by bystander dead cells was confirmed for melanomacells,mouse fibroblasts and primary FLS. We found that small soluble molecules present in the protein free fraction of supernatants of dead and dying cells were responsible for the promotion of proliferation. The nucleoside inosine released by dead and dying cells acting via adenosine receptors was identified as putative inducer of proliferation of surviving tumor cells after irradiation and heat treatment. Conclusion: Inosine released by dead and dying cells mediates tumor cell proliferation via purinergic receptors. Therapeutic strategies surmountingthis pathwaymay help to reduce the rate of recurrence after radio- and chemotherapy.

Background The polarisation of macrophages leads to diverse populations, which are associated to a complex regulatory network of transcription factors. The activator protein (AP)−1 transcription factor family, specifically FOS proteins can regulate macrophage cytokines production. Because of the production of diverse pro-inflammatory and destructive molecules, macrophages are central players in chronic inflammation and bone destruction of rheumatoid arthritis (RA). Here, we delineate the diverse functions of Fra-1 and Fra-2 in the complex network of macrophage activations during RA development. Material and methods To determine Fra-1 and Fra-2 roles during macrophage activation, Fra-1 or Fra-2 deficient peritoneal macrophages were used for microarray and quantitative real-time PCR analysis. In addition, promoter from genes found differentially expressed were analysed by chromatin immunoprecipitation (ChIP) analysis to discover directs targets of Fra-1 or Fra-2 in macrophages. To address the physiological roles of Fra-1 and Fra-2 in macrophages, the serum induced arthritis (K/BxN) model was applied to Fra-1ΔMx or Fra-2ΔLysM deficient mice. Results Microarray analysis and subsequent gene ontology cluster enrichment highlight the specific role of Fra-1 during macrophages activation, whereas Fra-2 seems less essential for macrophage activated pathways. Additionally, the KEGG cluster analysis links Fra-1 expression to autoimmune diseases, such as RA. Applying the K/BxN serum transfer to Fra-2ΔLysM or Fra-1ΔMx mice, we could show that only Fra-1 deficient mice have a decreased arthritis severity, which was accompanied with a strong increased Arginase-1 (Arg1) expression in mice joints. Mechanistically, ChIP analysis confirmed that Fra-1 but not Fra-2 directly regulates Nos2 and Arg1 promoters in macrophages. Furthermore, the inhibition of Arg1 by Nω-hydroxy-nor-Arginine (NOHA) rescued the phenotype of Fra-1 mutant mice. Suggesting that Fra-1 promotes arthritic joint inflammation by inhibiting Arg1 expression, this probably leads to an increased resolution of inflammation in RA. Conclusion We showed that Fra-1 defines the activation status of macrophages. Physiologically, Fra-1 regulates the Arg1/iNos axis thus promoting inflammation and bone destruction in RA. The role of Fra-1 in macrophages is unique, since Fra-2 cannot recapitulate Fra-1 functions. In conclusion, our data describe a new role of Fra-1 in macrophages activation in the maintenance of inflammation and joint destruction during acute RA.

Background Rheumatoid arthritis (RA) is an inflammatory autoimmune disease that is characterised by the infiltration of activated immune cells in the synovial joint, followed by progressive destruction of cartilage and bone. Even though there are many effective drug-based treatment options available not all patients do respond satisfactorily. In those cases treatment with low dose radiotherapy (LD-RT) might be an option as previous studies demonstrated that LD-RT attenuates inflammation and pain. In previous experiments using the hTNF-α tg mouse model we discovered that fibroblast-like synoviocytes (FLS) can be altered into an anti-inflammatory phenotype and numbers of differentiated osteoclasts are being reduced by LD-RT. Our in vivo experiments further showed reduced inflammation and bone loss in locally irradiated (1 × 0.5Gy) paws. As factors secreted by inflammatory FLS modulate other immune cells, we now aimed to investigate their impact on macrophages (MPHs) that are key players in inflammation and also major producers of inflammatory cytokines. Further, as bone turnover is a tightly linked process between bone resorption and build-up, we subsequently aimed to investigate whether and how LD-RT impacts on osteoblasts. Material and methods Bone marrow-derived MPHs of hTNF-α tg mice were differentiated using M-CSF and supernatants of X-ray treated FLS. Consecutively, MPH phenotypes were analysed by flow cytometry and ELISA. hTNF-α tg-derived osteoblasts were irradiated with various doses of X-rays and the impact of radiation was analysed using alizarin-red, qPCR and ELISA. Results Treatment of MPHs with supernatants of irradiated FLS lead to decreased CD86 (0.5-2Gy) and MHCII (0.1–0.5Gy) surface expression, while secreted IL-10 levels were increased at 0.5Gy. LD-RT of osteoblasts led to increased mineralization at a dose of 0.5Gy, a dose dependent increase in expression levels of osteoblast maturation markers, and reduced Rank-L expression, alongside with increased secretion of osteoprotegerin. Conclusion We conclude that LD-RT is able to positively modulate bone-turnover and exerts anti-inflammatory effects on FLS and MPHs. In accordance with our previous results, these modulations might contribute to improvements in TNF-driven RA. In the future, placebo controlled studies are desirable in order to investigate the effects of LD-RT in RA and osteoimmunological events in the clinics. Acknowledgement Supported by the German Federal Ministry of Education and Research (GREWIS, 02NUK017G).

Background Checkpoints and mechanisms regulating the onset of rheumatoid arthritis (RA) remain largely elusive. Apart from B cells and auto-antibodies, Th17 cells were shown to critically contribute to disease development. Mice lacking IL-23, a cytokine controlling the pathogenicity of Th17 cells, are completely protected against arthritis. Yet, the exact role of the IL-23/Th17 axis during this autoantibody-driven disease remain incompletely understood. Material and methods IL23A-/- mice and mice receiving an IL23 blocking antibody were analysed during active and passive arthritis models including collagen-induced arthritis (CIA), the K/BxN arthritis model, collagen-antibody induced arthritis (CAIA) and K/BxN-serum transfer arthritis. Both clinical, histological and immunological parameters of arthritis were assessed. IgG glycosylation was analysed using the MALDI-TOF technique. IgG activity was determined by measuring the cytokine release of immune-complex-stimulated myeloid cells. To study the crosstalk between B cells and Th17 cells, co-culture experiments were performed. Results Here we report, that the IL-23/Th17 axis did not directly contribute to auto-antibody induced inflammation within inflamed joints, but controlled the glycosylation profile and inflammatory activity of auto-antibodies during the prodromal phase of disease. Th17 cells were found to accumulate in germinal centres auf secondary lymphatic organs prior to onset of experimental arthritis, where they suppressed the expression of β-glactoside α2,6-sialyltransferase 1 (St6gal1) in differentiating plasmablasts. The consecutive change in the immunoglobulin G (IgG) glycosylation profile provoked a shift towards a pro-inflammatory autoantibody repertoire and triggered the inflammatory phase of arthritis. Plasmablasts of RA patients similarly displayed a decreased St6gal1 activity, while IgG from these individuals showed corresponding changes in its glycosylation profile as well as an increased inflammatory activity, suggesting that related pathways might contribute to onset and progression of autoantibody-mediated diseases in humans. Conclusion Our current findings identify a novel IL-23/Th17-dependent checkpoint that controls autoantibody activity, unmasks a preexisting breach in humoral tolerance, and initiates the transition from a stage of asymptomatic autoimmunity into inflammatory autoimmune disease.

Background Rheumatoid arthritis (RA) and psoriatic arthritis (PsA) result in severe joint destruction and functional disability if left untreated. We aim to develop tools that help patients with RA and PsA to understand and experience the impact of inflammatory joint disease on the integrity of their (juxta-articular) bone and increase adherence to medical treatment. In this study, we used high-resolution peripheral quantitative computed tomography (HR-pQCT) to develop 3D prototypes of patients’ finger joints. Methods HR-pQCT (XtremeCT, Scanco) measurements were performed in healthy individuals and patients with inflammatory joint disease, followed by a 3D print using the objet30 printer. Healthy participants (n = 10), and patients (n = 15 with RA and 15 with PsA) underwent a detailed, standardized interview with demonstration of printed joints. Results Utilizing HR-pQCT images of metacarpophalangeal (MCP) heads, high quality and exact 3D prints as prototypes were created. Erosions in different sizes and the trabecular network printed in detail were visualized, demonstrating structural reduction in arthritic vs. healthy bone. After demonstration of 3D prints (healthy vs. erosive joint, visual and haptic) 26/39 (66%) participants (including healthy volunteers) were deeply affected, often quoting “shock”. Of the patients with RA and PsA, 13/15 (86%) and 11/15 (73%), respectively, stated that they would rethink their attitude to medication adherence. More importantly, 21/24 patients with RA or PsA (87.5%) expressed that they would have wished to see such 3D prints during their first disease-specific conversations. Conclusion Using arthro-haptic 3D printed prototypes of joints may help to better understand the impact of inflammatory arthritides on bone integrity and long-term damage. Electronic supplementary material The online version of this article (doi:10.1186/s13075-017-1234-z) contains supplementary material, which is available to authorized users.

Objective Rheumatoid arthritis therapies that are based on inhibition of a single cytokine, e.g., tumor necrosis factor α (TNFα) or interleukin-6 (IL-6), produce clinically meaningful responses in only about half of the treated patients. This study was undertaken to investigate whether combined inhibition of TNFα and IL-17 has additive or synergistic effects in the suppression of mesenchymal cell activation in vitro and inflammation and tissue destruction in arthritis in vivo. Methods Cultures of human fibroblast-like synoviocytes (FLS) were stimulated with TNFα, IL-17, or a combination of both. Single/combined neutralizing antibodies against TNFα and IL-17 were used to examine in vitro cytokine responses and in vivo development of arthritis and bone and cartilage destruction in TNFα-transgenic mice. Bispecific anti–TNFα/IL-17 antibodies were designed, and their potential to block cytokine responses in human FLS was tested. Results TNFα and IL-17 had additive/synergistic effects in promoting production of IL-6, IL-8, and granulocyte colony-stimulating factor, as well as matrix metalloproteinases, in FLS. Bispecific anti–TNFα/IL-17 antibodies showed superior efficacy in blocking cytokine and chemokine responses in vitro. Furthermore, dual versus single inhibition of both cytokines using neutralizing antibodies was more effective in inhibiting the development of inflammation and bone and cartilage destruction in arthritic mice. Conclusion Combined blockade of TNFα and IL-17 was more effective than single blockade in inhibiting cytokine, chemokine, and matrix enzyme responses from human mesenchymal cells and in blocking tissue destruction associated with arthritis, and additionally showed a positive impact on rebalance of bone homeostasis. Bispecific anti–TNFα/IL-17 antibodies may have superior efficacy in the treatment of arthritis and may overcome the limited therapeutic responses obtained with single cytokine neutralization.

Objective Anticitrullinated protein antibodies (ACPA) are a major risk factor for bone loss in rheumatoid arthritis (RA). We have recently shown that ACPA directly induce bone loss by stimulating osteoclast differentiation. As ACPA precede the clinical onset of RA by years, we hypothesised that ACPA positive healthy individuals may already show skeletal changes. Methods We performed a comparative micro-CT analysis of the bone microstructure in the metacarpophalangeal joints of ACPA positive and ACPA negative healthy individuals without clinical signs of arthritis. Results ACPA positive (n=15) and negative (n=15) healthy individuals were not different in age (48.2±4.1 vs 51.4±3.8 years, p=0.57) or gender (eight women and two men in both groups). Bone mineral density was significantly reduced in ACPA positive individuals (mean±SEM 280±11 mg/cm 3 ) compared with controls (327±6). Bone loss was based on cortical bone changes, with significant (p=0.044) reduction in cortical thickness in the ACPA positive group (mean±SEM 0.22±0.03 mm) compared with controls (0.32±0.03 mm). Areas of cortical porosity were significantly (p=0.0005) more widespread in ACPA positive (mean±SEM 7.4±1.4%) than in ACPA negative individuals (1.0±0.3%). Discussion Structural bone damage starts before the clinical onset of arthritis in subjects with ACPA. These findings revise the concept that bone damage is an exclusive consequence of synovitis in patients with RA.

This review provides an update on the new interleukin-1 (IL-1) cytokine family members in inflammatory diseases with focus on recent findings concerning the family members IL-36, IL-37, and IL-38 and their different expression patterns.The IL-1 cytokines are known to be involved in many different inflammatory and autoimmune diseases. The latest IL-1 family members, IL-36, IL-37, and IL-38 have been shown to be differently regulated during course of disease. Studies of patients suffering from inflammatory diseases revealed that those cytokines are upregulated in the serum as well as in inflamed tissue. Both, epithelial cells and infiltrating peripheral mononuclear blood cells serve as source of the cytokines IL-36, IL-37, and IL-38 triggering different outcomes. These results could be confirmed in different mouse models and in-vitro and ex-vivo studies.IL-36, IL-37, and IL-38 are involved in the pathogenesis of the inflammatory diseases psoriasis, rheumatoid arthritis, gout, systemic lupus erythematosus as well as Crohn's disease. Thereby IL-36 acts proinflammatory triggering further inflammatory mediators. In contrast, IL-37 and IL-38 are upregulated to counteract. Understanding the imbalance of the IL-1 family is crucial for future therapeutics.

To characterize the specific structural properties of the erosion-prone bare area of the human joint, and to search for early microstructural changes in this region during rheumatoid arthritis (RA).In the initial part of the study, human cadaveric hand joints were examined for exact localization of the bare area of the metacarpal heads, followed by detection of cortical micro-channels (CoMiCs) in this region by high-resolution peripheral quantitative computed tomography (HR-pQCT) and, after anatomic dissection, validation of the presence of CoMiCs by micro-computed tomography (micro-CT). In the second part of the study, the number and distribution of CoMiCs were analyzed in 107 RA patients compared to 105 healthy individuals of similar age and sex distribution.Investigation by HR-pQCT combined with adaptive thresholding allowed the detection of CoMiCs in the bare area of human cadaveric joints. The existence of CoMiCs in the bare area was additionally validated by micro-CT. In healthy individuals, the number of CoMiCs increased with age. RA patients showed significantly more CoMiCs compared to healthy individuals (mean ± SD 112.9 ± 54.7/joint versus 75.2 ± 41.9/joint; P 0.001), with 20-49-year-old RA patients exhibiting similar numbers of CoMiCs as observed in healthy individuals older than age 65 years. Importantly, CoMiCs were already found in RA patients very early in their disease course, with enrichment in the erosion-prone radial side of the joint.CoMiCs represent a new form of structural change in the joints of patients with RA. Although the number of CoMiCs increases with age, RA patients develop CoMiCs much earlier in life, and such changes can even occur at the onset of the disease. CoMiCs therefore represent an interesting new opportunity to assess structural changes in RA.

The objective of this cross-sectional study was to define normal sex- and age-dependent values of intra-articular bone mass and microstructures in the metacarpal heads of healthy individuals by high-resolution peripheral quantitative computed tomography (HR-pQCT) and test the effect of rheumatoid arthritis (RA) on these parameters. Human cadaveric metacarpal heads were used to exactly define intra-articular bone. Healthy individuals of different sex and age categories and RA patients with similar age and sex distribution received HR-pQCT scans of the second metacarpal head and the radius. Total, cortical, and trabecular bone densities as well as microstructural parameters were compared between 1) the different ages and sexes in healthy individuals; 2) between metacarpal heads and the radius; and 3) between healthy individuals and RA patients. The cadaveric study allowed exact definition of the intra-articular (intracapsular) bone margins. These data were applied in measuring intra-articular and radial bone parameters in 214 women and men (108 healthy individuals, 106 RA patients). Correlations between intra-articular and radial bone parameters were good (r = 0.51 to 0.62, p 0.001). In contrast to radial bone, intra-articular bone remained stable until age 60 years (between 297 and 312 mg HA/cm

Objective To define the anatomic distribution of the earliest inflammatory and structural changes in individuals with anti-citrullinated protein antibody (ACPA+) positivity but no signs of arthritis. Methods ACPA+ individuals ( N = 20) and healthy controls ( N = 13) received simultaneous gadolinium-enhanced magnetic resonance imaging (MRI) and high-resolution peripheral quantitative computed tomography (HR-pQCT) of the hands. MRI sequences were scored for synovitis, osteitis, and bone erosions according to the RAMRIS method as well as for presence, localization, and extent of tenosynovitis. Bone erosions were validated by HR-pQCT scanning and related to the inflammatory changes found in the MRI. Results Tenosynovitis was the most prevalent inflammatory pathology, affecting 80% of ACPA+ individuals but none of the controls. Tenosynovitis at two or more anatomical sites was associated with later development of RA. Synovitis (65%) and osteitis (35%) were present in ACPA+ individuals as well, but at a lower frequency than tenosynovitis. MRI bone erosions were found in 65% of the individuals and additionally confirmed by HR-pQCT. Presence of MRI osteitis was the inflammatory pathology most strongly associated with bone erosions. Conclusion Tenosynovitis is highly prevalent in ACPA+ individuals without arthritis and associated with later development of RA. Small erosions, often linked to osteitis, are also found in ACPA+ individuals without arthritis.

ObjectiveTo perform a detailed analysis of the autoantibody response against post-translationally modified proteins in patients with rheumatoid arthritis (RA) in sustained remission and to explore whether its composition influences the risk for disease relapse when tapering disease modifying antirheumatic drug (DMARD) therapy.MethodsImmune responses against 10 citrullinated, homocitrullinated/carbamylated and acetylated peptides, as well as unmodified vimentin (control) and cyclic citrullinated peptide 2 (CCP2) were tested in baseline serum samples from 94 patients of the RETRO study. Patients were classified according to the number of autoantibody reactivities (0–1/10, 2–5/10 and >5/10) or specificity groups (citrullination, carbamylation and acetylation; 0–3) and tested for their risk to develop relapses after DMARD tapering. Demographic and disease-specific parameters were included in multivariate logistic regression analysis for defining the role of autoantibodies in predicting relapse.ResultsPatients varied in their antimodified protein antibody response with the extremes from recognition of no (0/10) to all antigens (10/10). Antibodies against citrullinated vimentin (51%), acetylated ornithine (46%) and acetylated lysine (37%) were the most frequently observed subspecificities. Relapse risk significantly (p=0.011) increased from 18% (0–1/10 reactivities) to 34% (2–5/10) and 55% (>5/10). With respect to specificity groups (0–3), relapse risk significantly (p=0.021) increased from 18% (no reactivity) to 28%, 36% and finally to 52% with one, two or three antibody specificity groups, respectively.ConclusionsThe data suggest that the pattern of antimodified protein antibody response determines the risk of disease relapse in patients with RA tapering DMARD therapy.Trial registration number2009-015740-42; Results.

Objective Arthritis is a chronic inflammatory disease characterised by immune cell infiltration and mesenchymal cell expansion in the joints. Although the role of immune cells in arthritis is well characterised, the development of mesenchymal cell hyperplasia needs to be better defined. Here, we analysed the role of the ribosomal S6 kinase Rsk2, which we found to be highly activated in joints of patients with arthritis, in the development of mesenchymal cell hyperplasia. Methods We genetically inactivated Rsk2 in the tumour necrosis factor (TNF)-α transgenic ( TNF tg) mice, an animal model for human inflammatory arthritis. Clinical and histological signs of arthritis as well as molecular markers of inflammation and joint destruction were quantified. Fibroblast-like synoviocytes (FLS) were characterised in vitro and the effect of Rsk2 deletion on the pattern of gene expression was determined. Results Rsk2 deficiency in TNF tg mice results in earlier and exacerbated inflammation as well as increased bone and cartilage destruction. The production of inflammatory cytokines, matrix metalloproteinases and osteoclastogenic molecules was significantly increased in vivo upon Rsk2 inactivation. Bone marrow deficient in Rsk2 could not transfer this phenotype, indicating that Rsk2 expression in mesenchymal cells controls the course of arthritis. Indeed, Rsk2 deficiency was associated with a more activated phenotype and higher proliferative capacity of FLS, thereby increasing cytokines and production of matrix proteinases. Conclusions Rsk2 emerges as a key regulator of mesenchymal cell numbers in the joint and thereby could be targeted to control the inflammatory and tissue-destructive feature of joints in arthritis.

The checkpoints and mechanisms that contribute to autoantibody-driven disease are as yet incompletely understood. Here we identified the axis of interleukin 23 (IL-23) and the TH17 subset of helper T cells as a decisive factor that controlled the intrinsic inflammatory activity of autoantibodies and triggered the clinical onset of autoimmune arthritis. By instructing B cells in an IL-22- and IL-21-dependent manner, TH17 cells regulated the expression of β-galactoside α2,6-sialyltransferase 1 in newly differentiating antibody-producing cells and determined the glycosylation profile and activity of immunoglobulin G (IgG) produced by the plasma cells that subsequently emerged. Asymptomatic humans with rheumatoid arthritis (RA)-specific autoantibodies showed identical changes in the activity and glycosylation of autoreactive IgG antibodies before shifting to the inflammatory phase of RA; thus, our results identify an IL-23–TH17 cell–dependent pathway that controls autoantibody activity and unmasks a preexisting breach in immunotolerance.

Objectives The family members of patients with rheumatoid arthritis (RA) are at increased risk of developing RA and are potential candidates for predictive testing. This study explored the perceptions of first-degree relatives of people with RA about being at risk of RA and engaging in predictive testing. Methods# 34 first-degree relatives (siblings and offspring) of patients with RA from the UK, Germany and Austria participated in semistructured interviews about their perceptions of RA risk and the prospect of predictive testing. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Results First-degree relatives were aware of their susceptibility to RA, but were unsure of the extent of their risk. When considering their future risk, some relatives were concerned about the potential impact that RA would have on their lives. Relatives were concerned that knowing their actual risk would increase their anxiety and would affect decisions about their future. Also, relatives were concerned about the levels of uncertainty associated with predictive testing. Those in favour of knowing their future risk felt that they would need additional support to understand the risk information and cope with the emotional impact of this information. Conclusions# Identifying individuals at risk of RA may allow targeted interventions to reduce the risk and consequence of future disease; however, relatives have concerns about predictive testing and risk information. The development of strategies to quantify and communicate risk needs to take these views into account and incorporate approaches to mitigate concerns and minimise the psychological impact of risk information.

ObjectiveTo analyse the role of multibiomarker disease activity (MBDA) score in predicting disease relapses in patients with rheumatoid arthritis (RA) in sustained remission who tapered disease modifying antirheumatic drug (DMARD) therapy in RETRO, a prospective randomised controlled trial.MethodsMBDA scores (scale 1–100) were determined based on 12 inflammation markers in baseline serum samples from 94 patients of the RETRO study. MBDA scores were compared between patients relapsing or remaining in remission when tapering DMARDs. Demographic and disease-specific parameters were included in multivariate logistic regression analysis for defining predictors of relapse.ResultsModerate-to-high MBDA scores were found in 33% of patients with RA overall. Twice as many patients who relapsed (58%) had moderate/high MBDA compared with patients who remained in remission (21%). Baseline MBDA scores were significantly higher in patients with RA who were relapsing than those remaining in stable remission (N=94; p=0.0001) and those tapering/stopping (N=59; p=0.0001). Multivariate regression analysis identified MBDA scores as independent predictor for relapses in addition to anticitrullinated protein antibody (ACPA) status. Relapse rates were low (13%) in patients who were MBDA−/ACPA−, moderate in patients who were MBDA+/ACPA− (33.3%) and MBDA−ACPA+ (31.8%) and high in patients who were MBDA+/ACPA+ (76.4%).ConclusionsMBDA improved the prediction of relapses in patients with RA in stable remission undergoing DMARD tapering. If combined with ACPA testing, MBDA allowed prediction of relapse in more than 80% of the patients.Trial registration numberEudraCT 2009-015740-42.

Background: Interleukin (IL)-36α is a recently described member of the IL-1 cytokine family with pro-inflammatory and clearly pathogenic properties in psoriasis. Objective: To determine the IL-36α expression in psoriatic arthritis (PsA) compared to rheumatoid arthritis (RA) and osteoarthritis (OA). Methods: Synovial tissues obtained from arthritis patients were stained for IL-36α, IL-36 receptor (IL-36R) and IL-36R antagonist (IL-36Ra) by immunohistochemistry and immunofluorescence. Lysates were examined for IL-36α by western blot analysis. Synovial fibroblasts (FLS) cultured in the presence of IL-36α were assayed for cytokine expression by quantitative real time PCR and multiplex assay. IL-36α-induced signal transduction in FLS was analysed by immunoblotting. Results: Expression of IL-36R and its ligands IL-36α and IL-36Ra was detected in the synovial lining layer and cellular infiltrates of patients with inflammatory arthritis. IL-36α was expressed significantly higher in PsA and RA than in OA synovium. CD138-positive plasma cells were identified as the main cellular source of IL-36α. No differences were observed for the expression of IL-36R and IL-36Ra between PsA, RA and OA. Functionally, IL-36α induced the expression of IL-6 and IL-8 in FLS through p38/NFkB activation. Conclusions: IL-36α is up-regulated in PsA and RA synovium, expressed by tissue plasma cells and leads to IL-6 and IL-8 production by synovial fibroblasts. Hence, IL-36α links plasma cells to inflammatory cytokine production by FLS and may represent a key link between autoimmunity and the induction of synovitis.

Tumour necrosis factor alpha (TNF-α) is a major inducer for inflammation and bone loss. Here, we investigated whether interleukin (IL)-17 plays a role in TNF-α-mediated inflammation and bone resorption. Human TNF-α transgenic (hTNFtg) mice were treated with a neutralizing anti-IL-17A antibody and assessed for inflammation, cartilage and bone damage. T-cell transcription factors and lymphokine patterns were measured in the LNs. IL-17A inhibition in the absence of IL-1 was also evaluated by treating hTNFtg/IL-1−/− mice with an IL-17A neutralizing antibody. IL-17A neutralization had only minor effects on TNF-α-induced inflammation but effectively reduced local and systemic bone loss by blocking osteoclast differentiation in vivo. Effects were based on a shift to bone-protective T-cell responses such as enhanced Th2 differentiation, IL-4 and IL-12 expression and Treg cell numbers. Whereas inflammation in hTNFtg/IL-1−/− mice was highly sensitive to IL-17A blockade, no shift in the T-cell lineages and no additional benefit on bone mass were observed in response to IL-17A neutralization. We thus conclude that IL-17A is a key mediator of TNF-α-induced bone loss by closely interacting with IL-1 in blocking bone protective T-cell responses.

Psoriasis is a common chronic autoimmune condition of the skin characterized by hyperplasia of epidermal keratinocytes associated with pro-inflammatory cytokines. IL-33 is a new member of the IL-1 superfamily that signals through the ST2 receptor and was originally defined as an inducer of T helper 2 (Th2) cytokines. Recently, broader immune activatory potential has been defined for IL-33 particularly via mast cell activation and neutrophil migration. Here, we show that ST2(-/-) mice exhibit reduced cutaneous inflammatory responses compared with WT mice in a phorbol ester-induced model of skin inflammation. Furthermore, injections of IL-33 into the ears of mice induce an inflammatory skin lesion. This inflammatory response was partially dependent on mast cells as mast cell-deficient mice (Kit(W-sh/W-sh) ) showed delayed responses to IL-33. IL-33 also recruited neutrophils to the ear, an effect mediated in part by increased production of the chemokine KC (CXCL1). Finally, we show that IL-33 expression is up-regulated in the epidermis of clinical psoriatic lesions, compared with healthy skin. These results therefore demonstrate that IL-33 may play a role in psoriasis-like plaque inflammation. IL-33 targeting may provide a new treatment strategy for psoriasis.

ObjectivesSystemic sclerosis (SSc) is characterised by vasculopathy, an aberrantly activated immune system and excessive extracellular matrix deposition. Inflammatory chemokines control migration of cells to sites of tissue damage; their removal from inflamed sites is essential for resolution of the inflammatory response. The atypical chemokine receptor D6 has a critical role in this physiological balance. To explore potential deregulation of this system in SSc, inflammatory chemokine and D6 expression were compared with that in healthy controls (HC).MethodsSerum levels of inflammatory mediators were assessed by luminex analysis. Peripheral blood mononuclear cells (PBMCs) were used in molecular and immunocytochemical analysis. Platelet-rich plasma was collected and assessed by western blotting for D6 expression levels. Sex-matched HC were used for comparison.Results72 patients with SSc and 30 HC were enrolled in the study. The chemokines MCP-1/CCL2, MIP-1α/CCL3, MIP-1β/CCL4 and IL-8/CXCL8 were significantly increased in patients with SSc, regardless of disease subtype and phase. Quantitative PCR analysis revealed a significant 10-fold upregulation of D6 transcripts in patients with SSc compared with controls, and this was paralleled by increased D6 protein expression in the PBMCs of patients with SSc. Platelet lysates also showed strong D6 expression in patients with SSc but not in controls. Importantly, high levels of D6 expression correlated with reduced levels of its ligands in serum.ConclusionsInflammatory chemokines and the regulatory receptor D6 are significantly upregulated in SSc and high D6 levels are associated with lower systemic chemokine levels, indicating that some patients control systemic chemokine levels using D6. These results suggest that chemokines may represent a therapeutic target in SSc.

Standard finger implants, manufactured by conventional techniques (e.g. machining), as they are used today for patients suffering from inflammatoryrheumatic diseases such as rheumatoid arthritis (RA) or degenerative diseases like osteoarthritis, are lacking of individuality and long-term stability. In this study here, a way to generate patient tailored finger implants based on XtremeCT technique is described. First finger implants are manufactured by Selective Laser Melting (SLM) and illustrate the feasibility of manufacturing patient tailored implants with additional functionalities. A technical abstraction of the original 3D-CAD file lead to major functional improvements by adjusting the stiffness of patient tailored implants to imitate bone. This results in less stress shielding and a better long-term stability of the implant as it needs to be reconfirmed in further clinical studies.

Interleukin-33 (IL-33) is a novel member of IL-1 cytokine family. It can act both as a nuclear factor and as a soluble mediator; however, the precise role of IL-33 within the nucleus is still not clear. As a cytokine, IL-33 is suggested to function as an alarmin that is released upon endothelial or epithelial cell damage. As such, IL-33 targets multiple cell types thereby alerting the immune system to endogenous trauma such as physical stress or infection. However, a dysregulated release of IL-33 has a potential to drive distinct pathologies. In this review, we discuss the contribution of IL-33 to the pathophysiology of asthma, arthritis, obesity and atherosclerosis as well as the potential of IL-33 for therapeutic intervention.

Current therapeutics for the treatment of rheumatoid arthritis (RA) offer limited efficacy in a restricted number of patients. There is, therefore, an unmet clinical need for the development of more efficacious therapeutics for the treatment of disease. Anti-TNFalpha therapy has provided proof of principle that cytokine blockade is an appropriate strategy by which to inhibit disease progression. In this review, we describe the basic biology of potential novel cytokine targets and the results of recent clinical trials, with particular focus on the cytokines related to Th17 biology, namely interleukin (IL)-12, IL-23 and IL-17, in addition to the TNF superfamily and the adipocytokines.

Background The cellular mechanisms of tendinopathy remain unclear particularly with respect to the role of inflammation in early disease. The authors previously identified increased levels of inflammatory cytokines in an early human model of tendinopathy and sought to extend these studies to the cellular analysis of tissue. Purpose To characterize inflammatory cell subtypes in early human tendinopathy, the authors explored the phenotype and quantification of inflammatory cells in torn and control tendon samples. Design Controlled laboratory study. Methods Torn supraspinatus tendon and matched intact subscapularis tendon samples were collected from 20 patients undergoing arthroscopic shoulder surgery. Control samples of subscapularis tendon were collected from 10 patients undergoing arthroscopic stabilization surgery. Tendon biopsy samples were evaluated immunohistochemically by quantifying the presence of macrophages (CD68 and CD206), T cells (CD3), mast cells (mast cell tryptase), and vascular endothelium (CD34). Results Subscapularis tendon samples obtained from patients with a torn supraspinatus tendon exhibited significantly greater macrophage, mast cell, and T-cell expression compared with either torn supraspinatus samples or control subscapularis-derived tissue (P < .01). Inflammatory cell infiltrate correlated inversely (r = .5; P < .01) with rotator cuff tear size, with larger tears correlating with a marked reduction in all cell lineages. There was a modest but significant correlation between mast cells and CD34 expression (r = .4; P < .01) in matched subscapularis tendons from shoulders with supraspinatus ruptures. Conclusion This study provides evidence for an inflammatory cell infiltrate in early mild/moderate human tendinopathy. In particular, the authors demonstrate significant infiltration of mast cells and macrophages, suggesting a role for innate immune pathways in the events that mediate early tendinopathy. Clinical Relevance Further mechanistic studies to evaluate the net contribution and hence therapeutic utility of these cellular lineages and their downstream processes may reveal novel therapeutic approaches to the management of early tendinopathy.

The proinflammatory cytokine IL-17A is considered a crucial player in rheumatoid arthritis (RA) pathogenesis. In experimental models of autoimmune arthritis, it has been suggested that the cellular source of IL-17A is CD4+ T cells (Th17 cells). However, little is known about the source of IL-17 in human inflamed RA tissue. We explored the cellular sources of IL-17A in human RA synovium. Surprisingly, only a small proportion of IL-17–expressing cells were T cells, and these were CCR6 negative. Unexpectedly, the majority of IL-17A expression colocalized within mast cells. Furthermore, we demonstrated in vitro that mast cells produced RORC-dependent IL-17A upon stimulation with TNF-α, IgG complexes, C5a, and LPS. These data are consistent with a crucial role for IL-17A in RA pathogenesis but suggest that in addition to T cells innate immune pathways particularly mediated via mast cells may be an important component of the effector IL-17A response.

A 32-year old male Caucasian patient presented with mild exertional dyspnea, pain and swelling of both ankles, and general malaise. On examination symmetrical arthritis of both ankles and a vivid nodular erythema with slight pain on pressure was detected on the sole of the right foot (A). A therapy with ibuprofen had not led to any improvement of symptoms. This article is protected by copyright. All rights reserved.

The detection of subclinical early inflammation in autoimmune diseases is an important but currently technically demanding approach to direct initial diagnosis and subsequent choice of therapy. Recent advances in imaging using NP provides the potential to detect cellular recruitment, vascular activation or leakage at a subclinically stage of disease and may provide predictive "biomarkers" of future pathogenesis. The NP used are either untargeted and taken up by phagocytic cells, or are linked to a ligand, targeting localisation to the site of inflammation. Techniques, varying from MRI and fluorescence to Raman spectroscopy are being employed. In this short review, we summarise many of the recent developments in the field of NP imaging related to inflammation.

Background: Despite recent advances, work disability in rheumatoid arthritis (RA) remains common. Work disability is frequently preceded by a period of work instability characterised by a mismatch between an individual’s functional abilities and job demands. This could raise the risk of work disability if not resolved. A work instability scale for RA (RA–WIS) has previously been developed to screen for this risk. The objective of this study was the adaptation of this scale into French, Dutch and German. Method: Different language versions of the RA–WIS were produced through a process of forward and back translations. The new scales were tested for face validity. English data from the original developmental study was pooled with data generated through postal surveys in each country. The internal construct and cross-cultural validity of the new scales were assessed using Rasch analysis, including differential item functioning (DIF) by culture. Results: The pooled data showed good fit to the Rasch model and demonstrated strict unidimensionality. DIF was found to be present for six items, but these appeared both to cancel out at the test level and have only a marginal effect on the test score itself. Conclusions: The RA–WIS was shown to be robust to adaptation into different languages. Data fitted Rasch model expectations and strict tests of unidimensionality. This project and the continuing work on further cross-cultural adaptations have the potential to help ensure clinicians across Europe are able to support RA patients to achieve their potential in work through early identification of those most at risk.

International audience; This case study describes a 44-year-old chronically non-adherent HIV-infected male with relapsing, life threatening toxoplasmic encephalitis (TE) and other recurring opportunistic infections. Non-adherence resulted in critical illness, suppressed CD4 lymphocyte count and elevated viral load. In order to bypass the patient's complete psychological aversion to taking medication, and after exhausting various psychological interventions, a percutaneous endoscopic gastronomy (PEG) tube was inserted for delivery of indispensable medication. During the 15 month follow-up, the patient was adherent, exhibiting a consistently undetectable viral load, high CD4 count and a remission of the opportunistic infections. This is an interesting case study demonstrating life-saving and long-term benefit of PEG in an exceptional setting, which has implications for future research and treatment of non-adherent HIV-infected patients.

Demyelinating polyneuropathy with anti-myelin associated glycoprotein (anti-MAG) antibodies is an immune mediated disorder characterized by proximal and distal symmetric weakness. Electrophysiological measurements depict features characteristic for demyelination, including prolonged distal latency, retarded conduction velocity, delayed or absent F-waves, and, rarely, partial conduction block. We report on a 65-year-old patient who was diagnosed with demyelinating polyneuropathy and anti-MAG antibodies five years before admission. Despite immunosuppressive agents and extracorporeal therapy (plasmapheresis) the disease progressed as assessed by clinical symptoms and neurological tests. Laboratory results showed an increase of serum immunoglobulin M and anti-MAG antibodies over time. Because of progressive disease we decided to treat the patient with immunoadsorption followed by application of the anti-CD20 antibody, rituximab. Six cycles of selective immunoadsorption were performed over three-weekly intervals with a repetitively used column (Globaffin); each cycle consisted of four consecutive daily treatments. Starting at cycle 4 the anti-CD20 antibody rituximab was administered with 375 mg/m(2) after immunoadsorption. The pretreatment anti-MAG antibody level of 10,000 U/mL, indicating disease activity, initially increased during treatment to a maximum of 30,559 U/mL. However, after completion of the six cycles, the anti-MAG level had decreased to 2348 U/mL; 16 months after the last immunoadsorption cycle the anti-MAG level had increased to 4134 U/mL, while the conduction velocity and compound motor action potentials remained stabile. Immunoadsorption in combination with a monoclonal anti-CD20 antibody in patients with demyelinating polyneuropathy with anti-MAG is effective and can be used an alternative treatment option in patients with progressive disease.

Objectives To search for subclinical inflammatory joint disease in patients with psoriasis without psoriatic arthritis (PsA), and to determine whether such changes are associated with the later development of PsA. Methods Eighty-five subjects without arthritis (55 with psoriasis and 30 healthy controls) received high field MRI of the hand. MRI scans were scored for synovitis, osteitis, tenosynovitis and periarticular inflammation according to the PsAMRIS method. Patients with psoriasis additionally received complete clinical investigation, high-resolution peripheral quantitative CT for detecting erosions and enthesiophytes and were followed up for at least 1 year for the development of PsA. Results 47% of patients with psoriasis showed at least one inflammatory lesion on MRI. Synovitis was the most prevalent inflammatory lesion (38%), while osteitis (11%), tenosynovitis (4%) and periarticular inflammation (4%) were less frequent. The mean (±SD) PsAMRIS synovitis score was 3.0±2.5 units. Enthesiophytes and bone erosions were not different between patients with psoriasis with or without inflammatory MRI changes. The risk for developing PsA was as high as 60% if patients had subclinical synovitis and symptoms related to arthralgia, but only 13% if patients had normal MRIs and did not report arthralgia. Conclusions Prevalence of subclinical inflammatory lesions is high in patients with cutaneous psoriasis. Arthralgia in conjunction with MRI synovitis constitutes a high-risk constellation for the development of PsA.

Objective Interleukin (IL)-36R signalling plays a proinflammatory role in different organs including the skin, but the expression of IL-36R ligands and their molecular function in intestinal inflammation are largely unknown. Design We studied the characteristics of IL-36R ligand expression in IBDs and experimental colitis. The functional role of IL-36R signalling in the intestine was addressed in experimental colitis and wound healing models in vivo by using mice with defective IL-36R signalling ( IL-36R −/−) or Myd88, neutralising anti-IL-36R antibodies, recombinant IL-36R ligands and RNA-seq genome expression analysis. Results Expression of IL-36α and IL-36γ was significantly elevated in active human IBD and experimental colitis. While IL-36γ was predominantly detected in nuclei of the intestinal epithelium, IL-36α was mainly found in the cytoplasm of CD14 + inflammatory macrophages. Functional studies showed that defective IL-36R signalling causes high susceptibility to acute dextran sodium sulfate colitis and impairs wound healing. Mechanistically, IL-36R ligands released upon mucosal damage activated IL-36R + colonic fibroblasts via Myd88 thereby inducing expression of chemokines, granulocyte-macrophage colony-stimulating factor (GM-CSF) and IL-6. Moreover, they induced proliferation of intestinal epithelial cells (IECs) and expression of the antimicrobial protein lipocalin 2. Finally, treatment of experimental intestinal wounds with IL-36R ligands significantly accelerated mucosal healing in vivo. Conclusions IL-36R signalling is activated upon intestinal damage, stimulates IECs and fibroblasts and drives mucosal healing. Modulation of the IL-36R pathway emerges as a potential therapeutic strategy for induction of mucosal healing in IBD.

Objective To investigate the effect of intensive lowering of serum uric acid (SUA) levels by pegloticase on the resolution of tophi in patients with refractory gout. Methods Descriptive study in patients with refractory gout receiving pegloticase treatment. SUA levels were measured before and after each infusion. Dual-energy CT (DECT) scans were taken from all patients before the first infusion and after the last infusion. Computerised tophus volumes were calculated for the baseline and follow-up assessments and compared with each other. Results 10 patients with refractory gout and baseline mean SUA level of 8.1 mg/dL were enrolled. Patients were treated for a mean of 13.3 weeks. Pegloticase effectively reduced tophi in all patients showing a decrease in volume by 71.4%. Responders, showing reduction of SUA level below 6 mg/dL during at least 80% of the treatment time, were virtually cleared from tophi (−94.8%). Dependent on their anatomical localisation, resolution of tophi showed different dynamics, with articular tophi showing fast, and tendon tophi slow, resolution. Conclusions Tophi are highly sensitive to pegloticase treatment, particularly when located at articular sites. Debulking of disease and a tophus-free state can be reached within a few months of pegloticase treatment. DECT allows for comprehensively assessing tophus burden and monitoring treatment responses.

Objectives: To investigate remission rates in rheumatoid arthritis patients exposed to tocilizumab treatment in real life clinical practice and to test whether concomitant conventional and previous biological disease modifying anti-rheumatic drugs treatment affects the efficacy of tocilizumab to reach remission. Methods: Between January 2009 and December 2012 disease activity was analyzed in 272 rheumatoid arthritis patients exposed to tocilizumab at the onset of treatment and sequentially thereafter, i.e. every four weeks at the time of infusion. Aside from demographic and disease-specific variables, previous and concomitant conventional and biologic disease modifying anti-rheumatic drugs therapy was documented in all patients. Multivariate logistic regression analyses were conducted to identify factors influencing Disease Activity Score 28 remission and attrition to tocilizumab treatment. Results: 219 (80.5%) of all patients were female. Mean Age was 55.48 ± 13.23 years and our patients had mean disease duration of 12.48 ± 9.30 years. Disease Activity Score 28 significantly decreased from 5.00 ± 1.52 at baseline to 3.09 ± 1.49 at the latest infusion. Mean treatment period was 58.28 ± 43.95 weeks. A total of 101 patients (42.8%) achieved Disease Activity Score 28 remission, which was significantly associated to the length of tocilizumab exposure. Achievement of Disease Activity Score 28 remission was independent from the concomitant use of conventional disease modifying anti-rheumatic drugs. Previous exposure to tumour necrosis factor inhibitors but not rituximab significantly reduced the likelihood to achieve Disease Activity Score 28 remission. Two logistic regression analyses revealed baseline disease activity and duration of tocilizumab therapy as independent factors for Disease Activity Score 28 remission, whereas age and concomitant methotrexate therapy were linked to attrition to tocilizumab treatment. Conclusion: Remission rates found in this observational study are comparable to those of randomized controlled trials and those of big post-marketing surveillance studies. Remission rates of rheumatoid arthritis patients treated with tocilizumab in clinical practice are not influenced by concomitant disease modifying anti-rheumatic drugs use. Previous exposure to tumour necrosis factor inhibitors but not to rituximab decreases the chance to reach remission with tocilizumab.

Optimal T-cell activation depends on the antigen-specific signal mediated by the TCR and engagement of costimulatory receptors such as CD28. CTLA-4, a homologous counterpart of CD28, is considered to be a crucial inhibitory receptor. To test its function separately from CD28 in an antigen-driven and ligand-specific model, we stably transfected the T-cell hybridomas A1.1 and DO11.10, which lack significant endogenous CD28 or CTLA-4 expression, with wild-type CTLA-4 (CTLA-4 WT) and a construct lacking the cytoplasmic tail (tailless [TL]). Functional studies were carried out by co-incubation with APC expressing the B7 ligands for CTLA-4 and appropriate MHC molecules loaded with their cognate antigens. IL-2 production on costimulation of CTLA-4WT and TCR did not differ significantly from untransfected controls. However, coligation of TCR and CTLA-4TL resulted in a vigorous IL-2 response specific for the interaction of CTLA-4 with B7. Thus, lack of the cytoplasmic tail converted CTLA-4 into a costimulatory receptor. This indicates that the CTLA-4 inhibitory function may not be attributable to sequestration of the common B7 ligands when competing with CD28. Rather, ligation of B7 by the CTLA-4 extracellular domain can enhance TCR activation, whereas in the full-length receptor, inhibitory signals mediated by the cytoplasmic domain may override this activation.

The immunoregulatory cytokine interleukin 10 (IL-10) modulates the function of diverse immune and non-immune cells. Here, we examine the chromatin structural changes associated with IL10 gene transcription by naive and differentiated murine T cells. Naive T cells lack DNase I hypersensitive (HS) sites in the vicinity of the IL10 gene, whereas differentiated T cells display a strong 3' constitutive HS site as well as several inducible sites. The majority of HS sites map to regions that are strongly conserved in sequence between mouse and human genomes. In committed Th1 cells, the mechanism of IL10 gene silencing is associated with the development of repressive histone modifications near the IL10 promoter and also near intronic hypersensitive regions of the IL10 gene. Our results constitute the first report of chromatin structural differences within the IL10 gene in differentiated Th1 and Th2 cells and emphasize the surprising diversity of mechanisms used to regulate cytokine gene expression at the chromatin level.

Introduction: Interleukin (IL)-36a is a newly described member of the IL-1 cytokine family with a known inflammatory and pathogenic function in psoriasis. Recently, we could demonstrate that the receptor (IL-36R), its ligand IL-36a and its antagonist IL-36Ra are expressed in synovial tissue of arthritis patients. Furthermore, IL-36a induces MAP-kinase and NFkB signaling in human synovial fibroblasts with subsequent expression and secretion of pro-inflammatory cytokines. Methods: To understand the pathomechanism of IL-36 dependent inflammation, we investigated the biological impact of IL-36a signaling in the hTNFtg mouse. Also the impact on osteoclastogenesis by IL-36a was tested in murine and human osteoclast assays. Results: Diseased mice showed an increased expression of IL-36R and IL-36a in inflamed knee joints compared to wildtype controls. However, preventively treating mice with an IL-36R blocking antibody led to no changes in clinical onset and pattern of disease. Furthermore, blockade of IL-36 signaling did not change histological signs of TNF-induced arthritis. Additionally, no alteration on bone homeostasis was observed in ex vivo murine and human osteoclast differentiation assays. Conclusion: Thus we conclude that IL-36a does not affect the development of inflammatory arthritis.

Objective: To prospectively analyse the risk for disease relapses in patients with rheumatoid arthritis (RA) in sustained remission, either continuing, tapering or stopping disease-modifying antirheumatic drugs (DMARDs) in a prospective randomised controlled trial. Methods: Reduction of Therapy in patients with Rheumatoid arthritis in Ongoing remission is a multicentre, randomised controlled, parallel-group phase 3 trial evaluating the effects of tapering and stopping all conventional and/or biological DMARDs in patients with RA in stable remission. Patients (disease activity score 28 (DAS28)

Rheumatoid arthritis therapies that are based on inhibition of a single cytokine, e.g., tumor necrosis factor α (TNFα) or interleukin-6 (IL-6), produce clinically meaningful responses in only about half of the treated patients. This study was undertaken to investigate whether combined inhibition of TNFα and IL-17 has additive or synergistic effects in the suppression of mesenchymal cell activation in vitro and inflammation and tissue destruction in arthritis in vivo.Cultures of human fibroblast-like synoviocytes (FLS) were stimulated with TNFα, IL-17, or a combination of both. Single/combined neutralizing antibodies against TNFα and IL-17 were used to examine in vitro cytokine responses and in vivo development of arthritis and bone and cartilage destruction in TNFα-transgenic mice. Bispecific anti-TNFα/IL-17 antibodies were designed, and their potential to block cytokine responses in human FLS was tested.TNFα and IL-17 had additive/synergistic effects in promoting production of IL-6, IL-8, and granulocyte colony-stimulating factor, as well as matrix metalloproteinases, in FLS. Bispecific anti-TNFα/IL-17 antibodies showed superior efficacy in blocking cytokine and chemokine responses in vitro. Furthermore, dual versus single inhibition of both cytokines using neutralizing antibodies was more effective in inhibiting the development of inflammation and bone and cartilage destruction in arthritic mice.Combined blockade of TNFα and IL-17 was more effective than single blockade in inhibiting cytokine, chemokine, and matrix enzyme responses from human mesenchymal cells and in blocking tissue destruction associated with arthritis, and additionally showed a positive impact on rebalance of bone homeostasis. Bispecific anti-TNFα/IL-17 antibodies may have superior efficacy in the treatment of arthritis and may overcome the limited therapeutic responses obtained with single cytokine neutralization.

Many different diseases have overlapping clinical symptoms. A major challenge in daily clinical practice is to differentiate between diseases associated with systemic inflammation, such as neoplasia, infection and autoimmune disease. We report on a 46-year-old Caucasian male with a 3-month history of rheumatoid arthritis presenting with dramatic weight loss and dysphagia. Computer tomography revealed multiple lesions in the liver and the spleen, strongly suggesting malignant disease of unknown origin. Surprisingly, on biopsy, the liver lesions drained pus. Workup revealed that the abscesses resulted from gastric perforation, which was the consequence of NSAR therapy for rheumatoid arthritis. Antibiotic therapy was initiated, abscesses diminished and dysfunctional deglutition improved. This unique case demonstrates in a dramatic way the difficulties in daily clinical practice to differentiate between paraneoplasia, infection and autoimmune disease and the potentially life-threatening consequences of their therapy.

Objective: To investigate the possibility of drug-free remission in patients with psoriatic arthritis (PsA) in continuous remission. Methods: Prospective observational study in disease-modifying antirheumatic drug (DMARD)-treated PsA patients in continuous disease remission (no musculoskeletal symptoms, no or minimal skin/nail disease) for at least 6 months. Demographic, disease-specific and ultrasound parameters were assessed at baseline. DMARDs (traditional or biologic) were discontinued at the initial visit, and patients were followed for a maximum of 6 months for recurrence of disease. Results: 26 patients (methotrexate monotherapy: N=14; tumour necrosis factor inhibitors: N=12) with a mean age of 55.2 years, absence of musculoskeletal symptoms and minimal skin disease (mean Psoriasis Area Severity Index (PASI): 0.21) were enrolled. Incidence of recurrence of disease was high (N=20, 76.9%) and occurred rapidly (74.50±51.72 days) after treatment discontinuation. Male PsA patients were significantly more likely to lose remission. Long disease duration, more severe skin involvement and the presence of synovial hypertrophy by ultrasonographic examination at baseline decreased the likelihood for drug-free remission. Reinitiation of DMARDs promptly restored remission in all PsA patients with recurrence of disease. Conclusions: This study shows that the chance to reach drug-free remission in PsA patients is low. Discontinuation of DMARD therapy cannot be recommended in patients with PsA.

Background: The occurrence of Hodgkin’s lymphoma (HL) as a second aggressive lymphoid malignancy (known as Hodgkin’s disease variant of Richter’s transformation) is rarely observed. Response rates, even with highly aggressive therapy such as stem cell transplantation, are limited, ranging from 4 to 43%, and the medium survival time ranges from 5 to 8 months. Case Report: A 72-year-old patient with a history of chronic lymphatic leukemia (CLL) was admitted with thoracic back pain and assumed progression of the CLL. The patient showed no fever, night sweats or weight loss. A computed tomography (CT) scan confirmed the progression of axillary and cervical lymph nodes. In addition, an intraspinal infiltration at the 8th thoracic vertebra (Th8) was detected. Surprisingly, histology of an extirpated lymph node demonstrated the existence of 2 tumors in the same lymph node. Infiltrates of small lymphocytes representing the pre-existing CLL (CD5-, CD20-, CD23-positive) coexisted with Reed-Sternberg Hodgkin’s cells (CD30-, CD15-positive). Chemotherapy was started, combined with palliative radiation of vertebrae Th7–Th10. 12 months after diagnosis of Richter’s transformation the patient is still alive without any progression of the underlying disease. Conclusion: We present a unique case of a Hodgkin’s disease variant of Richter’s transformation and CLL in the same lymph node, which was detected early because of spinal infiltration and was subsequently stabilized with reduced-dosage gemcitabine and local radiation. Additionally, we show unique pictures of 2 tumors coexisting in the same lymph node. Hintergrund: Das Auftreten eines Hodgkin-Lymphoms als zweite aggressive, bösartige, lymphoidzellige Erkankung (bezeichnet als Hodgkin-Variante einer Richter-Transformation) wird sehr selten beobachtet. Selbst mit Hochdosis- Regimen bewegen sich die Ansprechraten etwa zwischen 4 und 43%. Die mittlere Überlebenszeit beträgt 5–8 Monate. Case Report: Wir berichten über einen 72- jährigen Patienten, der bei bekannter chronischer lymphatischer Leukämie (CLL) aufgrund zunehmender Schmerzen im Bereich des Rückens unter der Annahme eines Progresses der CLL stationär aufgenommen wurde. Fragen nach Fieber, Nachtschweiß und Gewichtsverlust wurden verneint. Computertomogramm (CT)-Aufnahmen zeigten eine Größenzunahme axillärer und zervikaler Lymphknoten. Zudem zeigte sich eine intraspinale Raumforderung in Höhe des achten Brustwirbels (Th8). Histologisch konnten in der durchgeführten Lymphknotenbiospie 2 Tumore in ein und demselben Lymphknoten festgestellt werden. Es zeigten sich Infiltrate der vorbestehenden CLL (CD5-, CD20-, CD23-positiv) in Koexistenz mit Reed-Sternberg-Hodgkin-Zellen (CD30-, CD15-positiv). Eine Chemotherapie in Kombination mit lokaler Bestrahlung wurde begonnen. 12 Monate nach der Erstdiagnose einer Richter-Transformation ist der Patient am Leben ohne Zeichen von Progress. Schlussfolgerung: Wir präsentieren hier das Auftreten eines Morbus Hodgkin mit einer CLL als eine seltene Variante einer Richter-Transformation, die durch die frühe Diagnosestellung mit subtherapeutischer Dosis von Gemcitabin und lokaler Bestrahlung nun über 12 Monate stabilisiert werden konnte. Zudem können wir anhand dieses Falles ein Bild zweier Lymphome in ein und demselben Lymphknoten zeigen.

Objective: To determine whether erosions appearing in MRI in patients with rheumatoid arthritis (RA) represent true erosions. Methods: 50 RA patients received 1.5 T MRI and microCT (μCT) of the dominant hand. Erosion counts were assessed in coronal T1 weighted MRI sections and in coronal as well as axial μCT sections of the metacarpophalangeal (MCP) joints II–IV. Extent of erosions was assessed by RA MRI Score (RAMRIS) erosion score (MRI) and by three-dimensional assessment of erosion volume (μCT). Results: 111 of the 600 evaluated joint regions showed erosions in the MRI and 137 in the μCT. In only 28 regions false negative lesions (μCT positive, MRI negative) were found, all of which were very small lesions with a volume of less than 10 mm3. Only two results were false-positive (μCT negative, MRI positive). RAMRIS erosion scores were strongly correlated to erosion volumes in the μCT (Pearson's r=0.514, p

Background Periarticular bone loss is a typical finding in rheumatoid arthritis (RA) patients. However, this structural bone change is yet insufficiently characterized. Larger studies assessing periarticular bone composition in healthy controls (HC) and RA patients by high-resolution imaging have not been undertaken and have not been validated against standard measurement at the distal radius. Objectives To assess periarticular bone by high-resolution peripheral quantitative computed tomography (HR-pQCT) in the metacarpal heads and compare it with standard measurement in the distal radius in HC and anti-citrullinated peptide antibodies-positive (ACPA+) RA patients. Methods HR-pQCT (XtremeCT, Scanco, Switzerland) scans of the distal radius and of the metacarpal head 2 joints of HC and RA patients were performed. In contrast to previous studies the entire metacarpal head was assessed. After motion grading of the images by two independent readers, images with a motion grade more than 3 were excluded. A graphical objet (GOBJ) was generated and evaluated using the standard evaluation protocol for the radius provided by the manufacturer for both, the metacarpal head and the distal radius. In the last step, bone density values such as average bone density (D100 [mg HA/cm3]), bone volume/total volume (BV/TV), number of trabeculae (Tb N [1/mm])) were determined and compared between (i) the metacarpal head and the radius and (ii) between HC and RA patients. Results 222 subjects (110 HC and 112 RA) were analyzed. Sex and age distribution were balanced between HC (f/m: 58/52; 50.1±16.1 years) and RA patients (f/m: 53/59; 53.2±12.4 years; disease duration 9.2±8.7 years). Bone density in HC was 288.3±54.7 mg HA/cm3 in the distal radius and 294.4±43.3 mg HA/cm3 in the metacarpal head with significant correlation (ρ=0.583 (p Conclusions In this large study, we show that the assessment of periarticular bone structure in metacarpal heads is feasible and correlates well with standard measurement in the distal radius. Furthermore, we show significant bone loss in RA patients as compared to HC in both anatomical sites. Disclosure of Interest None declared

Background Psoriasis is a chronic inflammatory disease affecting 2–3% of the population [1,2]. Up to 30% of psoriasis patients develop psoriatic arthritis (PsA), and usually musculoskeletal symptoms start after the onset of skin disease. Psoriatic skin disease has a higher prevalence than arthritis what raises the question whether psoriasis patients without PsA are indeed spared from joint inflammation [3]. Detecting subclinical joint inflammation could help identify which patients with skin disease would benefit of treatment covering both skin and musculoskeletal inflammation. Objectives To search for subclinical inflammatory joint disease in psoriasis patients without arthritis, and to determine whether such changes are associated with the later development of PsA. Methods Eighty-five subjects without arthritis (55 with psoriasis and 30 healthy controls) received high field magnetic resonance imaging (MRI) of the hand. MRI scans were scored according to the PSAMRIS method [4]. Psoriasis patients received complete clinical investigation, high-resolution peripheral quantitative computed tomography (HR-pQCT) to detect erosions and enthesiophytes and were followed up for at least one year for the development of PsA. Results 47% of psoriasis patients showed at least one inflammatory lesion on MRI. Synovitis was the most prevalent inflammatory lesion (38%), while osteitis (11%), tenosynovitis (4%) and periarticular inflammation (4%) were less frequent. The mean (±SD) PSAMRIS synovitis score was 3.0±2.5 units. Enthesiophytes and bone erosions were not different between psoriasis patients with or without inflammatory MRI changes. The risk for developing PsA was as high as 55% if patients had subclinical synovitis and symptoms related to arthralgia, but only 15% of patients had normal MRIs and did not report of arthralgia. Conclusions Prevalence of subclinical inflammatory lesions is high in patients with cutaneous psoriasis. Arthralgia associated with MRI synovitis constitutes a high-risk constellation for the development of PsA. References Mease PJ, Gladman DD, Papp KA, et al. Prevalence of rheumatologist-diagnosed psoriatic arthritis in patients with psoriasis in European/North American dermatology clinics. J Am Acad Dermatol 2013;69:729–35. McGonagle D, Ash Z, Dickie L, et al. The early phase of psoriatic arthritis. Ann Rheum Dis 2011;70 Suppl 1:i71–6. Palazzi C, Lubrano E, D9Angelo S, et al. Beyond early diagnosis: occult psoriatic arthritis. J Rheumatol 2010;37:1556–8 Ostergaard M, McQueen F, Wiell C, et al. The OMERACT psoriatic arthritis magnetic resonance imaging scoring system (PsAMRIS): definitions of key pathologies, suggested MRI sequences, and preliminary scoring system for PsA Hands. J Rheumatol 2009;36:1816–24. Acknowledgement This study was supported by the Deutsche Forschungsgemeinschaft (SPP1468, CRC1181), the Marie Curie project OSTEOIMMUNE, the Metarthros project of the German Ministry of Science and Education, the IMI-funded project BTCure and the Pfizer Competitive Grant Award Germany. Disclosure of Interest None declared