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Primary Sjögren's syndrome (pSS) is a rare disease in paediatric patients. Presenting symptoms differ from those in adult patients. The aim of this study was to evaluate presenting symptoms, classification criteria and clinical assessments, including salivary gland ultrasonography (SGUS), at disease onset in paediatric and adult patients with pSS.Data of 23 paediatric- and 33 adult-onset patients with pSS were obtained from our standardised multidisciplinary REpSULT and RESULT cohorts, respectively. Clinical, patient-reported, serological, functional, biopsy and SGUS parameters were compared.In paediatric-onset pSS (pedSS) patients, recurrent parotid gland swelling (91% vs. 49%, p0.001) and fever (30% vs. 3%, p=0.006) were more often present than in adult-onset patients. In contrast, sicca symptoms of mouth (52% vs. 79%, p=0.046) and eyes (26% vs. 73%, p0.001) were less common in pedSS patients. In paediatric patients, the entry criteria of the ACR/EULAR classification were most often met due to activity in the glandular domain of the ESSDAI. When applying the ACR/EULAR classification criteria, only 78% of pedSS fulfilled these criteria compared to 100% of adult patients. Abnormal glandular function tests had a greater contribution to fulfilling the criteria in adults, while the biopsy had a greater contribution in paediatric patients. Anti-SSA/Ro serology had similar contribution for both cohorts. SGUS Hocevar score was significantly higher in paediatric compared to adult patients (median 25 vs. 18, p=0.004).PedSS has a different presentation than adult-onset pSS. Recurrent parotid gland swelling in paediatric patients should alert clinicians to the potential presence of pSS.

OBJECTIVES: To explore Patient Acceptable Symptom State (PASS) in a standard of care cohort of patients with primary Sjögren's syndrome (pSS) and to compare patient characteristics including EULAR Sjögren's Syndrome Patient Reported Index (ESSPRI) between PASS and non-PASS groups.METHODS: All pSS patients fulfilling ACR/EULAR classification criteria from the Registry of Sjögren's Syndrome LongiTudinal (RESULT) cohort, who had available PASS data at baseline were included. Patient-reported outcomes included the PASS question: "Considering all the different ways your disease is affecting you, if you were to stay in this state for the next few months, do you consider your current state satisfactory?"; yes: PASS / no: non-PASS.RESULTS: Of the 278 included pSS patients, 199 (72%) had an acceptable symptom state according to the PASS question, and median ESSPRI was 6 (IQR 4-7). In the PASS group, 118 (59%) patients had an unacceptable symptom state according to ESSPRI (score ≥5). In multivariable regression analyses, ESSPRI and disease duration were independently associated with presence of PASS. The accuracy of ESSPRI to predict PASS was fair (AUC of 0.78). The cut-off point of ESSPRI for presence of PASS with the highest Youden's index was 7.2 (sensitivity 85%, specificity 56%), followed by 5.2 (sensitivity 48%, specificity 90%).CONCLUSIONS: The majority of pSS patients reported being in an acceptable symptom state according to the PASS question, despite high ESSPRI scores. In our standard of care cohort, the optimal cut-off point of ESSPRI to predict PASS is different when focusing on sensitivity (±7) or specificity (±5).

ObjectiveTo investigate salivary gland ultrasound (SGUS) abnormalities in relation to clinical phenotype and patient characteristics, disease activity, and disease damage in patients with primary Sjögren syndrome (pSS).MethodsConsecutive outpatients included in our REgistry of Sjögren Syndrome LongiTudinal (RESULT) cohort were selected. Patients with pSS who were included were classified according to the American College of Rheumatology/European League Against Rheumatism (EULAR) criteria and underwent full ultrasonographic examination (Hocevar score 0–48) at baseline. Total SGUS scores of ≥ 15 were considered positive. Patient characteristics, disease activity, and disease damage were compared between the different SGUS groups.ResultsIn total, 172 of 186 patients with pSS were eligible, of whom 136 (79%) were SGUS positive. Compared with patients who were SGUS negative, SGUS-positive patients had significantly longer disease duration, higher EULAR Sjögren Syndrome Disease Activity Index, higher Sjögren Syndrome Disease Damage Index, and were more likely to have a positive parotid gland biopsy, anti-SSA/SSB antibodies, and abnormal unstimulated whole saliva (UWS) and ocular staining score (OSS), and higher levels of IgG and rheumatoid factor. Regarding patient-reported outcome measurements (PROM), patients who were SGUS positive scored significantly lower on the EULAR Sjögren Syndrome Patient-Reported Index for fatigue and pain, and more often found their disease state acceptable compared with patients who were SGUS negative. SGUS total score showed significant associations with various clinical and serological variables, and with PROM. Highest associations were found for UWS (ρ = –0.551) and OSS (ρ = 0.532).ConclusionPatients who were SGUS positive show a distinct clinical phenotype in all aspects of the disease compared with patients who were SGUS negative: clinical, functional, serological, and PROM. SGUS could be a helpful tool in selecting patients for clinical trials and estimating treatment need.

Objective: Follow-up of patients with treatment-resistant Raynaud's phenomenon (RP) one-year after single-port thoracoscopic sympathicotomy (SPTS).Methods: Eight patients (six males, two females, median age of 45 years) with treatment-resistant RP underwent left-sided SPTS at the third rib (R3), unilaterally. Questionnaires were taken, and number and duration of RP attacks were reported over a 2-week period. Perfusion was assessed with a cooling and recovery procedure at baseline and one year after SPTS. Furthermore, laser speckle contrast analysis, pulse wave velocity, heart rate variability and nailfold capillary microscopy were performed.Results: One year after SPTS the duration of the attacks of was reduced with 1.9 h in the left hand versus 0.3 h in the right hand. Furthermore, three aspects of the questionnaire showed a significant improvement (role limitations due to physical health (p = 0.017), pain (p = 0.027) and physical functioning (p = 0.025)). The total area under the curve of the total cooling and recovery procedure of the left hand was larger one year after surgery (101 (75–140) at baseline versus 118 (95–190) one year post-operatively, p = 0.012), implying a better perfusion in the fingers. This was mainly due to the improvement during the recovery phase (21 (1–41) at baseline versus 38 (24–43) one year post-operatively, p = 0.028).Conclusion: One year after unilateral R3 SPTS the benefit with regard to the majority of outcome variables persisted, though some effects seem to attenuate. Long-term effects and long-term follow-up results will be investigated in an on-going study.Clinical trial registration number: NCT02680509.

Objective The involvement of salivary glands in primary SS (pSS) can be assessed in different ways: histopathology, salivary flow and ultrasonography. To understand the relative value of these different approaches, it is crucial to understand the relationship between them. As we routinely perform these three modalities in the parotid gland for disease evaluation, our aim was to investigate the construct validity between these modalities in one and the same gland. Methods Consecutive sicca patients underwent a multidisciplinary diagnostic workup including parotid gland biopsy, collection of parotid gland–specific saliva and parotid gland ultrasonography. Patients who were classified as pSS according to the ACR-EULAR criteria were included. Construct validity was assessed using Spearman’s correlation coefficients. Results The 41 included pSS patients completed a full workup within a mean time interval of 2.6 months. Correlations between histopathological features and stimulated parotid salivary flow were fair (ρ = −0.123 for focus score and ρ = −0.259 for percentage of CD45+ infiltrate). Likewise, poor correlations were observed between stimulated parotid salivary flow and parotid ultrasonography (ρ = −0.196). Moderate to good associations were found between the histopathological items focus score and the percentage of CD45+ infiltrate, with parotid US scores (total US score: ρ = 0.510 and ρ = 0.560; highest for homogeneity: ρ = 0.574 and ρ = 0.633). Conclusion Although pSS-associated ultrasonographic findings did correlate with histopathological features, the three modalities that evaluate salivary gland involvement assess different (or at best partly related) constructs. Therefore histopathology, salivary flow and ultrasonography are complementary measurements and cannot directly replace each other in the workup of pSS.

Raynaud's phenomenon (RP) is a disorder of the microvasculature which causes poor blood flow to the digits. This disorder is common in young females and may be associated with several underlying connective tissue diseases including systemic sclerosis. Although RP may have a tremendous impact on quality of life, treatment options are limited. Conventional medical treatment mainly consists of vasodilatory drugs, which are not effective in all patients and may induce undesired side effects. The current clinical lesson describes three patients with severe RP who all underwent a novel, minimally invasive, single-port thoracoscopic sympathicotomy (SPTS). Although this procedure seems promising in patients with treatment-resistant RP, as shown with patients A and B, future research has yet to show what the long-term effects are.

Objective: Systemic features influence disease prognosis and choice of treatment in primary Sjogren's syndrome (pSS). Our aim was to investigate the prevalence of pulmonary involvement in pSS patients and to classify patients according to the pulmonary domain of the EULAR Sjogren's Syndrome Disease Activity Index (ESSDAI). Methods: This retrospective cohort study included consecutive pSS patients, fulfilling American-European Consensus Group/American College of Rheumatology classification criteria, who visited the Department of Rheumatology and Clinical Immunology, University Medical Center Groningen, in 2015. Data on pulmonary complaints and pulmonary tests were obtained from electronic patient records. Pulmonary involvement was recorded if therapy was needed or follow-up was recommended, and when it was possibly or assumed to be related to pSS instead of coincidental factors. Results: Of the 262 included pSS patients, 88 (34%) had pulmonary complaints, mostly cough or dyspnoea on exertion. Pulmonary diagnostics were performed in 225 patients (86%). Pulmonary involvement was present and assumed to be related to pSS in 25 patients (10%) and possibly related to pSS in 14 (5%). Interstitial lung disease (ILD, n = 15), especially non-specific interstitial pneumonia (n = 7), was present most commonly. In total, 16 patients (6%) were scored as low (n = 4), moderate (n = 11), or high activity (n = 1) on the ESSDAI pulmonary domain. Conclusion: In this cross-sectional study in daily clinical practice, pulmonary involvement was present in 10-15% of pSS patients, of which ILD was most common. Of all pSS patients, 6% were scored as active on the pulmonary domain of the ESSDAI.

Objective: To investigate treatment efficacy of long-term abatacept treatment in pSS patients.Methods: The single-centre ASAP-III trial consisted of two phases: the randomised, double-blind, placebo-controlled phase (1:1 randomisation) from baseline to week 24, of which results have been published previously, and the open-label extension phase from week 24 to 48, in which all patients received abatacept. Main inclusion criteria were fulfilment of the AECG criteria, positive gland biopsy, disease duration = 5. Long-term treatment effects of abatacept on clinical, patient-reported, glandular and laboratory outcome measures were assessed in patients treated with abatacept from baseline to week 48. Furthermore, Composite of Relevant Endpoints for Sj_ogren's Syndrome (CRESS) response (response on >= 3 of 5 items) was analysed.Results: In patients on abatacept treatment for 48 weeks (n = 40), median ESSDAI improved from baseline 14.0 (IQR 9.0 - 16.8) to 4.0 (2.0 - 8.0) at week 48 (p < 0.001), with 50% of patients reaching low disease activity (ESSDAI < 5) at week 48. Median ESSPRI improved from 7.0 (IQR 5.4-7.7) to 5.0 (3.7-6.7) (p < 0.001). Significant improvement was also seen in dry eye and laboratory tests. Combining response at multiple clinically relevant items, 73% of patients were CRESS responders at week 48. Additional improvement was seen between week 24 and week 48 of abatacept treatment.Conclusion: In the open-label extension phase of the ASAP-III trial, improvement was seen up to 48 weeks of abatacept treatment in clinical, patient-reported, dry eye and laboratory outcomes. The majority of patients were CRESS responders at week 48. (c) 2022 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)

Objective.To assess the presence of a systemic sclerosis (SSc) pattern on nailfold capillary microscopy (NCM) in patients with Raynaud phenomenon (RP) and to explore its association with abnormal pulmonary function tests (PFT).Methods.NCM patterns were assessed in 759 consecutive patients with RP. Patterns were classified as normal (n = 354), nonspecific (n = 159), or SSc pattern (n = 246). Abnormal PFT was defined as forced vital or diffusion capacity < 70%. Patients were classified as primary RP (n = 245), or secondary: no definite diagnosis (n = 391), SSc (n = 40), primary Sjögren syndrome (pSS; n = 30), systemic lupus erythematosus (SLE; n = 30), mixed connective tissue disease (MCTD; n = 7), rheumatoid arthritis (RA; n = 15).Results.An SSc pattern on NCM was frequently observed in most patients with a definite diagnosis: SSc (88%), pSS (33%), SLE (17%), MCTD (71%), and RA (13%). In patients without definite diagnosis, 17% had a normal NCM pattern, 35% nonspecific, and 48% SSc pattern. Abnormal PFT was more frequent in patients with an SSc pattern (35.9% vs 19.5%, p = 0.002), even when corrected for SSc diagnosis (p = 0.003). Absence of an SSc pattern had high negative predictive value (88%); positive predictive values were low.Conclusion.SSc pattern on NCM is common in patients with RP, and in those with connective tissue diseases other than SSc. It is associated with a higher prevalence of abnormal PFT, independent of the presence of an SSc diagnosis. Although these data need validation in a prospective setting, they underline the importance of NCM in RP and putative value to stratify the risk of pulmonary involvement in early stages of disease.

Objectives. To validate the ACR-EULAR classification criteria for primary SS (pSS), and compare them to the American-European Consensus Group (AECG) and ACR criteria in a Dutch prospective diagnostic cohort.Methods. Consecutive patients (n = 129) referred for suspicion of pSS underwent a multidisciplinary evaluation, including a labial and/or parotid gland biopsy. Patients with an incomplete work-up (n= 8) or associated systemic auto-immune disease (n= 7) were excluded. The ACR-EULAR classification was compared with expert classification, AECG and ACR classification. Additionally, the accuracy of individual ACR-EULAR items in discriminating pSS from non-pSS was evaluated. The validity of criteria sets was described separately using parotid or labial gland biopsy results for classification.Results. Of the 114 evaluated patients, the expert panel classified 34 (30%) as pSS and 80 (70%) as non-pSS. Using labial gland biopsy results, ACR-EULAR classification showed 87% absolute agreement (kappa = 0.73) with expert classification, with a sensitivity of 97% and specificity of 83%. Using the parotid gland biopsy results, the ACR-EULAR criteria performed excellently as well. Focus score, anti-SSA titre and ocular staining score showed good to excellent accuracy, whereas unstimulated whole saliva and Schirmer's test had poor accuracy. The ACR-EULAR and AECG criteria had equal validity. Compared with ACR classification, ACR-EULAR classification showed higher sensitivity but lower specificity.Conclusion. The ACR-EULAR criteria showed good agreement with expert classification, but some patients may be misclassified as pSS. Unstimulated whole saliva and Schirmer's test showed poor discriminative value. The ACR-EULAR criteria performed equally to the AECG criteria, and had higher sensitivity but lower specificity than the ACR criteria.

ObjectiveTo assess the validity of ultrasound of major salivary glands (sUS) compared with parotid and labial gland biopsies, sialometry, anti-SSA/Ro antibody status and classification criteria in patients clinically suspected with primary Sjögren’s syndrome (pSS).Methods103 consecutive outpatients with clinically suspected pSS underwent sUS. Parenchymal echogenicity, homogeneity, hypoechogenic areas, hyperechogenic reflections and clearness of salivary gland border were scored according to the Hocevar scoring system. Total ultrasound score was calculated as the sum of these domains (range 0–48).ResultsAbsolute agreement between sUS and parotid (83%) and labial (79%) gland biopsy outcome was good. Negative sUS predicts negative parotid gland biopsy, and positive sUS predicts positive labial gland biopsy. Compared with the American European Consensus Group (AECG) classification, sUS showed an absolute agreement of 82%, sensitivity of 71% and specificity of 92%. Compared with the American College of Rheumatology (ACR) classification, absolute agreement was 86%, sensitivity was 77% and specificity was 92%. Compared with the ACR-European League Against Rheumatism (EULAR) classification, absolute agreement was 80%, sensitivity was 67% and specificity was 94%. Positive sUS predicts classification, but negative sUS does not exclude classification. The combination of positive sUS with presence of anti-SSA/Ro antibodies or negative sUS with absence of anti-SSA/Ro antibodies showed a high predictive value for classification as pSS or non-pSS.ConclusionIn our prospective inception cohort study derived from daily clinical practice, absolute agreement between sUS and salivary gland biopsies was slightly higher for parotid compared with labial gland biopsies. The combination of positive sUS and presence of anti-SSA/Ro antibodies highly predicts classification according to the AECG, ACR and ACR-EULAR classification criteria.

Background Distinguishing primary Raynaud’s phenomenon (PRP) from Raynaud’s phenomenon secondary to systemic sclerosis (SSc) is crucial in the early detection of SSc. Recently we reported that patients with more severe vasculopathy suffer from a prolonged ischemia time during Raynaud’s attack. [1] additionally, it appears that the thumb is more frequently involved in SSc, where it seems to be spared in PRP. [2] these two characteristics are easily recognized by patients and physicians, and can help rising awareness for SSc. Objectives The aim was to study if the recovery of a Raynaud’s attack and involvement of the thumb are differentiators for SSc in patients with Raynaud’s phenomenon (RP). Methods A stepwise cooling and recovery procedure was performed, provoking an RP attack, in patients with PRP and SSc. One hand was submerged up till the radiocarpal joint in water. The water temperature was lowered in steps of 3 degrees Celsius every four minutes, from 33 until at least 9 degrees Celsius. Afterwards ten minutes of recovery in room air of 23 degrees Celsius was observed. During the procedure perfusion of the fingertips was assessed by photo-electric plethysmography. Results In total 18 patients with SSc and 68 patients with PRP underwent the procedure. Seventeen (94%) SSc patients had no restoration of perfusion after ten minutes in one or more fingers, compared to 28 (41%) PRP patients (figure 1), with a negative predictive value of 98%. During cooling, 17 (94%) SSc patients developed abnormal perfusion in the thumb compared to 48 (71%) PRP patients (p=0.036), with a negative predictive value of 95%. There was no difference in involvement of the other fingers during cooling (all p>0.05). Positive predictive values were low. Conclusion In patients with RP, when there is restoration of perfusion in all fingers after ten minutes or when the thumb is spared, the presence of an underlying SSc is very unlikely. Although this objective measurement needs to be verified with patient’s reports, these results suggest that these simple signs can help physicians to assess if the patient needs to be referred for additional tests. References [1] van Roon aM, Smit aJ, van Roon aM, Bootsma H, Mulder DJ. Digital ischaemia during cooling is independently related to nailfold capillaroscopic pattern in patients with Raynaud’s phenomenon. Rheumatology (Oxford)2016;55:1083-1090. [2] Chikura B, Moore T, Manning J, Vail a, Herrick aL. Thumb involvement in Raynaud’s phenomenon as an indicator of underlying connective tissue disease. J Rheumatol2010;37:783-786. Disclosure of interests Anniek van Roon: None declared, arie Van Roon: None declared, alja J. Stel: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant for: Roche, Bristol-Myers Squibb, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Bristol-Myers Squibb, Novartis, andries Smit Shareholder of: Has been co-founder, and is still shareholder of Diagnoptics Technologies, the company which developed the aGE reader., Douwe J Mulder Grant/research support from: My University has received research grants for my research from: Boehringer ingelheim and actelion, Speakers bureau: My University has received speakers fee from: Sanofi

Background Effective systemic treatment is not yet available for primary Sjogren syndrome (pSS). Abatacept (CTLA-4-Ig) targets the CD80/CD86:CD28 co-stimulatory pathway required for full T-cell activation and T-cell dependent activation of B-cells. IV abatacept was shown to be safe, well tolerated, and to decrease disease activity in an open-label study of 15 pSS patients.1 Objectives To assess the efficacy and safety of subcutaneous (SC) abatacept vs. placebo in patients with early active pSS. Methods The Abatacept Sjogren Active Patients phase III (ASAP-III) study is a monocenter, investigator-initiated, double-blind, placebo-controlled trial (NCT02067910). ASAP-III included 80 adult patients with biopsy-proven pSS, fulfilling the AECG and ACR/EULAR criteria, with a disease duration of ≤7 years and moderate to high EULAR Sjogren’s syndrome disease activity score (ESSDAI ≥5). Patients were randomized in a 1:1 ratio to receive weekly SC abatacept (125 mg) or placebo for 24 weeks (figure 1). After the double-blind phase, all patients were treated with abatacept in a 24-week open label phase. Concomitant use of other DMARDs was not permitted, with the exception of a stable dose of prednisone (≤10mg). Rescue therapy with prednisone or cyclophosphamide was permitted after week 12. Participants visited our pSS tertiary referral center nine times, to be evaluated by a multidisciplinary team of rheumatologists, ophthalmologists, and oral and maxillofacial surgeons. The primary endpoint is ESSDAI at 24 weeks. Secondary outcomes over 24 and 48 weeks include clinical, patient reported, functional, histological, laboratory, ultrasound, and microbiome parameters, and the occurrence of (serious) adverse events and treatment discontinuation. Results Baseline characteristics of participants are shown in table 1. Database lock for the blinded stage is planned in March 2019. Subsequently, the first intention-to-treat analyses will be performed, focusing on the ESSDAI and EULAR Sjogren Syndrome Patient Reported Index (ESSPRI), quality of life (EQ-5D), unstimulated and stimulated whole salivary flow (UWS, SWS), Schirmer test, Ocular Staining Score (OSS), serological parameters (RF, IgG), and safety parameters. Conclusion The ASAP-III trial was designed to assess the clinical efficacy and safety of SC abatacept in pSS patients with short disease duration and active disease. The 24-week results will be available during the EULAR congress 2019. Reference [1] Meiners, et al. Ann Rheum Dis2014;73:1393-6. Disclosure of Interests Jolien F. van Nimwegen Speakers bureau: Bristol-Myers Squibb, Greetje S. van Zuiden Speakers bureau: Roche, Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Esther Mossel: None declared, Robin F. Wijnsma: None declared, Alja J. Stel: None declared, Konstantina Delli: None declared, Bert van der Vegt: None declared, Erlin A. Haacke: None declared, Lisette Olie: None declared, Leonie I. Los: None declared, Janita Bulthuis-Kuiper: None declared, Gwenny M. Verstappen: None declared, Sarah A. Pringle: None declared, Fred K.L. Spijkervet: None declared, Frans G.M. Kroese Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant for: Bristol-Myers Squibb, Speakers bureau: Bristol-Myers Squibb, Roche, Janssen-Cilag, Arjan Vissink: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant for: Roche, Bristol-Myers Squibb, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Bristol-Myers Squibb, Novartis

With great interest we have read the recent publication by Fisher et al ,1 entitled ‘Effect of rituximab on a salivary gland ultrasound score in primary Sjogren’s syndrome: results of the TRACTISS randomised double-blind multicenter substudy’ in which the authors demonstrated a significant improvement in total ultrasound score (TUS) after rituximab treatment compared with placebo at weeks 16 and 48 in 52 patients with primary Sjogren’s syndrome (pSS). We and others have shown that treatment with rituximab, a chimeric anti-CD20 monoclonal antibody, affects the histopathology of the salivary glands and results in a decrease in area of lymphocytic infiltrate in the labial and parotid glands.2–5 This reduction in infiltrated area, that is, up to 50%, is mainly caused by B cell depletion.2 Rituximab treatment also causes a significant loss of germinal centres.2 Interestingly, rituximab treatment also leads to a significant restoration of the ductal epithelium glandular tissue itself. This is illustrated by a significant decrease in number and severity of lymphoepithelial lesions (LELs) in parotid gland tissue 12 weeks after rituximab treatment.2 6 The normalisation of the epithelium appears to be a direct consequence of depletion of intraepithelial B cells.7 Significant improvement of the parotid gland ultrasound score of patients with pSS has been observed before in another randomised controlled trial (RCT) with rituximab, the Tolerance and Efficacy of Rituximab in Primary Sjogren’s Syndrome (TEARS) study.8 This is an RCT with rituximab versus placebo, performed by a French group. Together with the improvement of the histopathology of the gland, it might not be a surprise that Fisher et al 1 also observed a significant improvement in TUS. This newly …

Objective: To assess whether the addition of salivary gland ultrasonography (SGUS) or replacement of current criteria items by SGUS influences the performance of the American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) criteria for primary Sjögren's syndrome. Methods: Included were consecutive patients with complete data on all ACR/EULAR items (n = 243) who underwent SGUS in our primary Sjögren's syndrome expertise center. Clinical diagnosis by the treating physician was used as the gold standard. Separate analyses were performed for patients who underwent labial or parotid gland biopsies. The average score for hypoechogenic areas in 1 parotid and 1 submandibular gland was determined (range 0–3). Next, performance of the ACR/EULAR criteria was evaluated after addition of SGUS or replacement of current items by SGUS. Results: Receiver operating characteristic analysis showed an optimal cutoff value of ≥1.5 for SGUS. The optimal weight for SGUS positivity was 1. Cutoff for ACR/EULAR fulfilment remained ≥4. In patients who underwent a labial gland biopsy (n = 124), the original criteria showed an area under the curve (AUC) of 0.965, sensitivity of 95.9%, and specificity of 92.2%. After the addition of SGUS, the AUC was 0.966, with a sensitivity of 97.3% and specificity of 90.2%. In patients who underwent a parotid gland biopsy (n = 198), similar results were found. Sensitivity of the criteria decreased substantially when SGUS replaced salivary gland biopsy or anti-SSA antibodies, while performance remained equal when SGUS replaced the ocular staining score, Schirmer's test, or unstimulated whole saliva flow. Conclusion: Validity of the ACR/EULAR criteria remains high after incorporation of SGUS. With SGUS, clinicians are offered a larger array of tests to evaluate fulfillment of the ACR/EULAR criteria.

Background:Abatacept (CTLA-4-Ig) targets the CD80/CD86:CD28 co-stimulatory pathway required for full T-cell activation and T-cell dependent activation of B-cells. The Abatacept Sjögren Active Patients phase III (ASAPIII) trial is a mono-center, investigator-initiated, placebo controlled study with an open-label extension phase (NCT02067910), which assessed the efficacy and safety of weekly subcutaneous abatacept (125mg) in patients with early active primary Sjögren’s syndrome (pSS). Previous analyses of the double blind phase showed no significant effect of abatacept treatment compared to placebo on the primary endpoint, difference in EULAR Sjögren’s syndrome disease activity index (ESSDAI) at week 24.1Objectives:To evaluate the efficacy and safety of extended (48 weeks) open label abatacept treatment in pSS patients.Methods:Included patients had biopsy-proven pSS, fulfilled the AECG and ACR-EULAR criteria, had disease duration ≤7 years (median 2 years), ESSDAI ≥5, and 89% were anti–SSA positive. All 40 patients who received abatacept (ABA) in week 0-24 were subsequently treated with abatacept from week 24-48. Of the 40 patients who received placebo (PLB) in week 0-24, 2 were lost to follow up, and 38 were treated with abatacept from week 24-48. Systemic disease activity (ESSDAI), patient reported symptoms (ESSPRI), serological outcomes (RF and IgG), ocular staining score (OSS) and unstimulated whole salivary flow (UWS) were assessed. We evaluated whether outcomes improved within treatment groups, from week 0 to subsequent visits and from week 24 to subsequent visits:1.Within ABA→ABA treated patients:a. Week 0-48 to assess overall efficacy.b. Week 24-48 to assess additional efficacy of long term treatment.2.Within PLB→ABA treated patients:a. Week 0-24 to assess whether a placebo effect occurred.b. Week 24-48 to assess short-term efficacy of open label ABA.GEE modeling was used to test significance of changes over time. Missing data were not imputed.Results:ESSDAI and ESSPRI were improved within ABA/ABA patients between week 0-48 with additional efficacy after week 24, and within PLB/ABA patients after switching to ABA. Significant decreases in ESSDAI and ESSPRI were also seen within PLB treated patients between week 0-24 (Figure 1). IgG and RF were improved within ABA/ABA patients between week 0-48 with additional efficacy after week 24, and within PLB/ABA patients after switching to ABA. OSS was improved within ABA/ABA treated patients between week 0-48. UWS only showed significant improvement in week 36 within ABA/ABA treated patients. No changes in IgG, RF, OSS or UWS were seen within PLB treated patients. No deaths occurred. One serious adverse event possibly related to intervention occurred during ABA treatment.Conclusion:ESSDAI and ESSPRI improved significantly during 48-week treatment with abatacept. Placebo treated patients also showed significant improvement in both indices and further improvement occurred after switching to abatacept. Biological activity was decreased by abatacept treatment. 48-week abatacept treatment improved OSS, and might improve UWS. Abatacept was well tolerated by pSS patients.References:[1]van Nimwegen et al. Lancet Rheumatol.Published online 31-01-2020Acknowledgments:This study was funded by Bristol-Myers Squibb. We thank all patients for participation in the ASAP-III trial.Disclosure of Interests:Suzanne Arends Grant/research support from: Grant/research support from Pfizer, Jolien F. van Nimwegen Consultant of: Bristol-Myers Squibb, Speakers bureau: Bristol-Myers Squibb, Esther Mossel: None declared, Greetje S. van Zuiden Speakers bureau: Roche, Konstantina Delli: None declared, Alja J. Stel: None declared, Bert van der Vegt Consultant of: Advisory board member for Philips and Visiopharm., Erlin A. Haacke: None declared, Lisette Olie: None declared, Leoni Los: None declared, Gwenny M. Verstappen: None declared, Sarah A. Pringle: None declared, Fred K.L. Spijkervet: None declared, Frans G.M. Kroese Grant/research support from: Unrestricted grant from Bristol-Myers Squibb, Consultant of: Consultant for Bristol-Myers Squibb, Speakers bureau: Speaker for Bristol-Myers Squibb, Roche and Janssen-Cilag, Arjan Vissink: None declared, Hendrika Bootsma Grant/research support from: Unrestricted grants from Bristol-Myers Squibb and Roche, Consultant of: Consultant for Bristol-Myers Squibb, Roche, Novartis, Medimmune, Union Chimique Belge, Speakers bureau: Speaker for Bristol-Myers Squibb and Novartis.

Background Despite the extensive research on this subject, the exact pathogenesis of RP still remains incompletely understood. The current view on this rather complex phenomena is that the imbalance between vasoconstriction and vasodilatation is purely functional and that structural vascular changes do not occur in PRP patients Although RP is a frequently occurring problem in underweight patients, microvascular changes have never been (structurally) investigated. Objectives The aim of the current study was to investigate the relationship between microvascular abnormalities and body mass index (BMI) in subjects with Raynaud’s phenomenon (RP), without an underlying connective tissue disease. Methods Nailfold capillaroscopic patterns (NCP) were retrospectively assessed in 352 RP patients, without an underlying systemic disease (e.g. negative serology tests, and no signs of organ involvement). Patient characteristics were obtained and patients were divided by BMI category: underweight (BMI 3, or any giant capillaries were observed. Results Approximately 70% of the underweight patients showed an abnormal NCP. This was irrespective of age and smoking behaviour. Underweight RP patients had the highest mean count of dilated capillaries (5.14 for BMI Conclusions Our findings indicate NCP abnormalities are more frequently observed in underweight individuals, indicating that microvascular changes may occur independently of an underlying connective tissue disease. These findings may alert clinicians that (perivascular) adipose tissue may play a crucial role in the occurrence of Raynaud’s phenomenon. Disclosure of Interest None declared

Background Salivary gland ultrasound (SGUS) is cheap, non-invasive and easy to perform in an outpatient setting. The ACR-EULAR criteria were recently developed to reach international consensus regarding the classification of primary Sjogren’s syndrome (pSS), but SGUS is not yet included as a classification item. Objectives To assess the performance of the ACR-EULAR criteria when salivary gland ultrasound (SGUS) replaces current items, in a large cohort of patients clinically suspected or diagnosed with pSS in daily clinical practice. Methods Included were all consecutive outpatients who underwent SGUS between October 2014 and , July 2017 and had a complete data-set on all ACR-EULAR items. Classification according to the criteria was determined separately in patients who were subjected to a labial or parotid gland biopsy. For SGUS, the average score for hypoechogenic areas in the parotid and submandibular glands on one side was applied (range 0–3)1. The optimal cut-off value for our SGUS score was determined using ROC analysis. Clinical diagnosis by the treating physician was used as gold standard. Area under the curve (AUC), absolute agreement, sensitivity and specificity of the original and adjusted ACR-EULAR criteria sets were determined. Results Of the 363 consecutive patients, 243 patients had a complete data-set, of whom 147 patients were diagnosed with pSS. Accuracy of SGUS to predict clinical diagnosis was good, with an AUC of 0.860 and optimal cut-off value of ≥1.5. When applying a weight of 1 point for a positive SGUS, the cut-off value of the ACR-EULAR criteria to discriminate between pSS and non-pSS remained 4, irrespective of the type of biopsy used. In patients who underwent a labial gland biopsy (n=124), the original ACR-EULAR criteria showed an AUC of 0.965 (figure 1A). Absolute agreement with clinical diagnosis was 94.4%, sensitivity was 95.9% and specificity was 92.2%. When SGUS replaced the labial gland biopsy, absolute agreement was 87.9%, sensitivity was 82.2% and specificity was 96.1%. When SGUS replaced anti-SSA antibody status, absolute agreement was 89.5%, sensitivity was 86.3% and specificity was 94.1%. When SGUS replaced the ocular staining score (OSS), Schirmer’s test or unstimulated whole saliva flow (UWS), absolute agreement varied between 89.5%–93.5%, sensitivity varied between 90.4%–95.9% and specificity varied between 88.2%–92.2%. In patients who underwent a parotid gland biopsy (n=198), similar results were found (figure 1B). Conclusions SGUS cannot be used as a replacement for salivary gland biopsy or anti-SSA antibody status in the ACR-EULAR criteria because of a substantial reduction in sensitivity. For diagnostic purposes, a high sensitivity is preferred over a high specificity. Replacement of the OSS, Schirmer’s test or UWS by SGUS only resulted in negligible changes in accuracy of the ACR-EULAR criteria. With SGUS being able to replace one of these function tests, clinicians are offered more options that could lead to fulfilment of the ACR-EULAR criteria. Reference [1] Mossel, et al. Ann Rheum Dis2017: Published online first at December 12. Disclosure of Interest None declared

To assess the inter- and intraobserver reliability of ultrasound of major salivary glands in patients clinically suspected of having primary Sjögren's syndrome (pSS) as well as to assess sources of variation in outcomes of ultrasonographic evaluation. 80 consecutive outpatients with clinically suspected pSS underwent ultrasound evaluation. The following ultrasound variables of the parotid and submandibular salivary glands were assessed: echogenicity, parenchymal homogeneity, presence of hypoechogenic areas, hyperechogenic reflections and clearness of posterior glandular border, according to the scoring system of Hocevar et al. (total score range: 0 - 48). Images were scored independently by three blinded observers in two sessions. The intraobserver reliability of the total ultrasound score was excellent, with an intraclass correlation (ICC) ranging from 0.89 to 0.96. The interobserver reliability was good to excellent, with ICCs of 0.84 and 0.76 for the total ultrasound score in the two sessions. The kappa value ranged from 0.60 to 0.83 depending on the applied cut-offs (cut-off score ≥ 15 and ≥ 17). Hypoechogenic areas and homogeneity of parotid glands showed the highest interobserver reliability. The median kappa for echogenicity was low. The total ultrasound scores varied more between observers in patients with higher ultrasonographic scores (approximately scores ≥ 20). Ultrasound of major salivary glands is a reliable imaging technique for patients with clinically suspected pSS. Discrepancies between observers in assessing the severity of ultrasound findings may interfere with detecting 'true' changes over time. When monitoring the progression of pSS or treatment efficacy, it is advised that a particular patient be scored by the same ultrasonographer at every time point.ZIEL: Beurteilung der Inter- und Intraobserver-Reliabilität des Ultraschalls der großen Speicheldrüsen bei Patienten mit klinischem Verdacht auf primäres Sjögren-Syndrom (pSS) und Bewertung der Schwankungsquellen der Sonografie-Ergebnisse. 80 aufeinander folgende ambulante Patienten mit klinischem Verdacht auf pSS wurden sonografisch bewertet. In der Glandula parotidea und Glandula submandibularis wurden die folgenden Ultraschallvariablen untersucht: Echogenität, Homogenität des Parenchyms, Nachweis von echoarmen Reflexionen und deutliche Abgrenzung des posterioren Drüsenrands nach dem Scoring-System von Hocevar et al. (gesamter Score-Bereich: 0 – 48). Die Bilder wurden unabhängig voneinander durch drei verblindete Beobachter in zwei Sitzungen eingeteilt. Die Intraobserver-Reliabilität der Gesamt-Ultraschall-Scores war ausgezeichnet, mit einer Intraklasse-Korrelation (ICC) zwischen 0,89 und 0,96. Die Interobserver-Reliabilität war gut bis ausgezeichnet, mit ICCs von 0,84 und 0,76 für den Gesamt-Ultraschall-Score in den beiden Sitzungen. Der kappa-Wert war zwischen 0,60 und 0,83 je nach verwendetem Cut-off (Cut-off Score ≥ 15 und ≥ 17). Echoarme Bereiche und die Homogenität der Parotisdrüsen zeigten die höchste Interobserver-Reliabilität. Der mediane Kappawert für die Echogenität war gering. Bei Patienten mit höheren Ultraschall-Scores variierten die Gesamt-Ultraschall-Scores stärker zwischen den Beobachtern (Scores von etwa ≥ 20). Die Sonografie der großen Speicheldrüsen ist eine zuverlässige bildgebende Diagnostik bei Patienten mit klinischem Verdacht auf pSS. Widersprüchliche Bewertungen des Schweregrads von Ultraschall-Befunden zwischen Beobachtern können den Nachweis "echter" Veränderungen im Laufe der Zeit stören. Bei der Überwachung der Progression des pSS oder der Wirksamkeit der Therapie wird empfohlen, dass ein bestimmter Patient jedes Mal vom selben Ultraschalldiagnostiker beurteilt wird.

ObjectiveTo assess whether ultrasonographic scoring of (i) both parotid and submandibular salivary glands and (ii) all individual components of the Hocevar scoring system, is needed for classifying patients as primary Sjögren’s syndrome (pSS).MethodsUltrasound examination of the major salivary glands (sUS) was performed in 204 consecutive patients clinically suspected (n=171) or diagnosed (n=33) with pSS.Parenchymal echogenicity, homogeneity, hypoechogenic areas, hyperechogenic reflections and salivary gland posterior border were scored in left and right parotid and submandibular glands. Logistic regression analyses were performed to assess which glands and sUS components contributed significantly to classification as pSS or non-pSS according to the 2016 American College of Rheumatology-European League Against Rheumatism (ACR-EULAR) criteria.Results116 (57%) patients were classified as pSS, the remaining as non-pSS. Instead of scoring both sides (area under the curve; AUC=0.856, Nagelkerke R2=0.526), multivariate analysis showed that sUS scoring of only right (AUC=0.850; R2=0.518) or left (AUC=0.852; R2=0.511) parotid and submandibular glands is sufficient to predict ACR-EULAR classification. Moreover, all individual components of the Hocevar scoring system significantly predicted classification. Multivariate analysis showed that parenchymal echogenicity and hypoechogenic areas contributed independently to ACR-EULAR classification (AUC=0.857; R2=0.539). Scoring these components in one parotid and one submandibular gland highly predicted ACR-EULAR classification (AUC=0.855; R2=0.539). Scoring only hypoechogenic areas on one side showed almost similar results (AUC=0.846; R2=0.498).ConclusionsUS examination of parotid and submandibular glands on one side is sufficient to predict classification of patients according to the ACR-EULAR criteria. To further increase feasibility of sUS in outpatient clinics worldwide, only hypoechogenic areas can be scored.

Background Ultrasound of the major salivary glands (SGUS) has shown high diagnostic accuracy for primary Sjogren9s syndrome (pSS) [1,2]. None of the existing studies, however, included a control group of patients with sarcoidosis, amyloidosis, human immunodeficiency virus (HIV) or hepatitis C (HCV) infection [2]. These diseases are known to frequently affect the major salivary glands, cause dry mouth or may have histopathology similar to pSS. Objectives To assess the diagnostic accuracy of SGUS to differentiate pSS from systemic diseases with salivary gland involvement. Methods Twenty consecutive patients fulfilling the AECG criteria for pSS and 20 consecutive patients with well-established systemic diseases, i.e., 5 patients with sarcoidosis, 5 patients with amyloidosis, 5 patients with HIV infection and 5 patients with HCV infection, were included. Echogenicity, parenchymal homogeneity, presence of hypoechogenic areas and clearness of posterior glandular border of both parotid and submandibular salivary glands were scored independently by two blinded observers and rated according to the Hocevar et al scoring system (ultrasound total score (UTS), range: 0–48) [3]. The optimal cut-off point was determined by using ROC curve. The agreement between SGUS positivity and classification as pSS was assessed. Results The median age of patients with pSS and systemic diseases was 50 and 53 years, respectively. Daily complaints of dry mouth longer than 3 months, need of liquid to swallow food and recurrent or persistent swelling of the major salivary glands were reported by 95%, 85% and 70% of patients with pSS compared to 45%, 30% and 20% of patients with systemic diseases. The accuracy of SGUS to discriminate pSS was excellent, with an area under ROC of 0.91 and optimal cut off point of 15. The agreement between SGUS and diagnosis for pSS was good (κ=0.75, percentage of absolute agreement 87.5) with a sensitivity of 90%, specificity of 85%, positive predictive value of 86%, negative predictive value of 89% and diagnostic odds ratio of 51. UTS was positive in 2 patients with HIV infection and one patient with sarcoidosis. Patients with pSS had significantly higher UTS than patients with systemic diseases (median UTS 27 vs. 10, p Conclusions This pilot study indicates that SGUS has a high diagnostic accuracy to discriminate pSS from associated systemic diseases with salivary gland involvement. A minority of HIV and sarcoidosis patients, however, may show SGUS findings mimicking pSS. References Jousse-Joulin et al. Rheumatology (Oxford) 2016;55:789–800. Delli et al. Oral Dis 2015;21:792–800. Hocevar et al. Rheumatology (Oxford) 2005;44:768–72. Disclosure of Interest None declared

Objectives: The parotid glands are commonly involved in primary Sjogren syndrome (pSS). The aim of this study was to assess the diagnostic accuracy of ultrasound of the parotid glands (PSGUS) compared with parotid histopathology and parotid saliva production. Study Design: We included consecutive patients suspected to have pSS. All patients underwent a full diagnostic workup according to American College of Rheumatology– European League Against Rheumatism (ACR-EULAR) criteria, including PSGUS, parotid gland biopsy, and collection of stimulated parotid saliva. For PSGUS, the average score of hypoechogenic areas in both parotid glands was applied (range 0-3). On hematoxylin and eosin (HE P < .001) and percentage of lymphocytic infiltrate (ρ = 0.575; P < .001). There was a moderate to good absolute agreement between the PSGUS and focus scores (78.5%), plasma cell shift (79.8%), LELs (81.4%), and GCs (82.7%). “Presence of hypoechogenic areas” was not very sensitive to predict focus score (69.2%), plasma cell shift (45.8%), LELs (61.5%), or GCs (34.6%). Interestingly, almost all patients with less than 25% presence of hypoechogenic areas in glandular parenchyma were also negative for GCs (98.7%). A substantial number of these patients did not have a positive focus score (81.4%), plasma cell shift (90.7%), or LELs (87.8%). There was a fair reversed correlation between PSGUS and stimulated parotid saliva flow (ρ = −0.259; P = .07). Conclusions: This is the first study comparing the diagnostic accuracy of PSGUS with histopathology and salivary secretion in detail. PSGUS and histopathology have a stronger association compared with PSGUS and parotid secretion. The specificity of PSGUS increases when the results are compared with plasma cell shift, LELs, and GCs, rather than with the focus score.

The clinical efficacy of the CD20-specific chimeric monoclonal antibody rituximab is significantly hampered by intrinsic or acquired resistance to therapy. Rituximab activates antibody-dependent cellular cytotoxicity/complement-dependent cytotoxicity–dependent lysis but also induces apoptosis by cross-linking of its target antigen CD20. Recent reports indicate that this apoptotic activity of rituximab can be synergized by cotreatment with Fas agonists. Here, we report on a strategy designed to exploit and optimize the synergy between rituximab and Fas signaling by genetically fusing a rituximab-derived antibody fragment to soluble Fas ligand (sFasL). The resultant fusion protein, designated scFvRit:sFasL, potently induced CD20-restricted apoptosis in a panel of malignant B-cell lines (10 of 11) and primary patient-derived malignant B cells (two of two non–Hodgkin lymphoma and five of six B cell chronic lymphocytic leukemia). ScFvRit:sFasL efficiently activated CD20 and Fas apoptotic signaling, resulting in a far superior proapoptotic activity compared with cotreatment with rituximab and Fas agonists. ScFvRit:sFasL lacked activity toward normal human B cells and also lacked systemic toxicity in nude mice with no elevation of aspartate aminotransferase and alanine aminotransferase levels or liver caspase-3 activity. In conclusion, scFvRit:sFasL efficiently activates CD20 and Fas-apoptotic signaling and may be useful for the elimination of malignant B cells. [Cancer Res 2008;68(2):597–604]

ObjectiveTo perform a systematic review and meta-analysis on studies examining the properties of ultrasonography of major salivary glands for diagnosing Sjogren's syndrome.Materials and MethodsWe searched for the literature on eight databases. The quality of included articles was assessed with the QUADAS-2 tool. Publication bias, pooled sensitivity, specificity, diagnostic odds ratio, and 95% confidence intervals (95%CI) were calculated. Meta-regression analysis was performed.ResultsWe identified 37 studies and 33 ultrasonographic scoring systems. High risk of bias was observed in patient selection', conduct and interpretation of ultrasound', and flow of patients and timing of tests' in 78%, 70%, and 51% of the studies. We included 29 studies in the meta-analysis. Publication bias was highly probable. Pooled sensitivity was 0.69 (95%CI: 0.67-0.71), specificity 0.92 (95%CI: 0.91-0.93), and diagnostic odds ratio 33.89 (95%CI: 20.75-55.35). Significant heterogeneity was detected between studies. Meta-regression analysis showed that studies with high risk of bias in conduct and interpretation of ultrasound' and studies evaluating only parenchymal homogeneity had higher log diagnostic odds ratio (1.09 and 2.49, respectively, pConclusionsThe quality of current studies is low, thus not allowing to judge the likelihood of salivary gland ultrasonography as a reliable and practical tool in diagnosing Sjogren's syndrome.

In the present study, we investigated the relation between p21 expression and the sensitivity of testicular germ cell tumor (TGCT) cells to apoptotic stimuli. Despite similar cisplatin-induced wild-type p53 accumulation, the TGCT cell lines Tera and Scha expressed low p21 protein and mRNA levels in comparison to A2780 ovarian cancer cells. Inhibition of the proteasome complex with MG-132 increased p21 protein levels in TGCT cells but much more in A2780 cells, whereas cisplatin had no additional effect on p21 protein levels. Inhibition of caspase-3 activity in TGCT cells with the broad-spectrum caspase inhibitor zVAD-fmk had no effect on p21 levels and also not upon cisplatin treatment. A similar induction of p53 irradiation, in contrast to cisplatin, substantially increased both p21 mRNA and protein expression in Tera cells. Cisplatin-treated Tera cells expressing low p21 protein levels were Fas-sensitive, while irradiation-induced p21, which was mainly localized in the cytosol, rendered irradiated Tera cells resistant to Fas-induced apoptosis. Sensitivity of irradiated Tera cells to Fas-induced apoptosis was restored by short interfering RNA-specific suppression of p21 expression. These results strongly indicate that the low p21 protein levels are caused by reduced p21 gene transcription and sensitize cisplatin-treated TGCT cells to the Fas death pathway.

We would like to thank Alegria et al 1 for their letter to the editor commenting on our recent publication entitled ‘Ultrasonography of major salivary glands compared with parotid and labial gland biopsy and classification criteria in patients with clinically suspected primary Sjogren’s syndrome’.2 Our study was the first that directly compared the validity of ultrasound of major salivary glands (sUS) with parotid gland biopsy outcome. We showed that the agreement between sUS and parotid as well as labial gland biopsies was good but was slightly higher for the former. As noted by Alegria et al ,1 we found different results for the positive predictive value (PPV) and negative predictive value (NPV) between sUS versus parotid and sUS versus labial gland biopsies.2 Although these observations may indeed be caused by discordance between the parotid and labial gland biopsy outcome, there are other factors that may equally well contribute to this discrepancy. First, the parotid glands are assessed during the sUS examination and included in the scoring, whereas the labial glands are not.2 Second, in 6%–15% of the general population, the labial gland biopsy is positive, while in only 5% of the general population, the parotid gland biopsy is positive. …

Background Ultrasound of major salivary glands (sUS) is an upcoming diagnostic method to assess the involvement of major salivary glands in primary Sjogren9s syndrome (pSS). In the AECG, ACR and recently published ACR-EULAR criteria, a positive salivary gland biopsy and/or presence of anti-SSA antibodies are necessary to classify a patient as pSS, while sUS is not included as a diagnostic item. Objectives To assess whether combining anti-SSA antibody status with sUS outcome can predict classification of patients as pSS in our inception cohort study. Methods Consecutive outpatients clinically suspected with pSS underwent sUS of the parotid and submandibular glands. Parenchymal echogenicity, homogeneity, hypoechogenic areas, hyperechogenic reflections and clearness of salivary gland border were scored according to the Hocevar scoring system (total score 0–48). 1 Positive sUS was defined as total score ≥15. Patients underwent a diagnostic work up according to the AECG, ACR and ACR-EULAR criteria. We analyzed the predictive value of the combination of anti-SSA antibody status and sUS outcome for classification as pSS or non-pSS. Separate analyses were done considering either i) parotid gland biopsy or ii) labial gland biopsy as an item, when applying these classification criteria. Results Anti-SSA antibody status was positive in 53 (51%) patients and sUS was positive in 40 (39%) patients. When parotid gland biopsy outcome was considered as an item of the criteria, 45 of 97 patients were classified as pSS according to the AECG, 44 of 97 according to the ACR and 52 of 99 according to the ACR-EULAR criteria. The combination of presence of anti-SSA antibodies with positive sUS showed a very high positive predictive value for classification as pSS (94–97%) and the combination of absence of anti-SSA antibodies with negative sUS highly excludes classification (negative predictive value 98–100%). When labial gland biopsy outcome was considered as an item of the criteria, 49 of 96 patients were classified as pSS according to the AECG, 43 of 93 according to the ACR and 55 of 97 according to the ACR-EULAR criteria. The combination of presence of anti-SSA antibodies with positive sUS showed a high positive predictive value for classification as pSS (94–97%). However, the combination of absence of anti-SSA antibodies with negative sUS did not per se exclude classification (negative predictive value 89–93%). Conclusions In our prospective inception cohort study derived from daily clinical practice, the combination of presence of anti-SSA antibodies and positive sUS outcome highly predicts classification as pSS according to the AECG, ACR and ACR-EULAR classification criteria. References Hocevar et al. Rheumatology (Oxford) 2005;44:768–72. Disclosure of Interest None declared

This paper describes a bi-specific antibody, which was called BIS20x3. It retargets CD3ɛ-positive cells (T-cells) to CD20-positive cells and was obtained by hybrid–hybridoma fusion. BIS20x3 could be isolated readily from quadroma culture supernatant and retained all the signalling characteristics associated with both of its chains. Cross-linking of BIS20x3 on Ramos cells leads to DNA fragmentation percentages similar to those obtained after Rituximab-cross-linking. Cross-linking of BIS20x3 on T-cells using cross-linking F(ab′)2-fragments induced T-cell activation. Indirect cross-linking of T-cell-bound BIS20x3 via Ramos cells hyper-activated the T-cells. Furthermore, it was demonstrated that BIS20x3 effectively re-targets T-cells to B-cells, leading to high B-cell cytotoxicity. The results presented in this paper show that BIS20x3 is fully functional in retargeting T-cells to B-cells and suggest that B-cell lymphomas may represent ideal targets for T-cell retargeting bi-specific antibodies, because the retargeted T-cell is maximally stimulated in the presence of B-cells. Additionally, since B-cells may up-regulate CD95/ Fas expression upon binding of CD20-directed antibodies, B-cells will become even more sensitive for T-cell mediated killing via CD95L/ Fas L, and therefore supports the intention to use T-cell retargeting bi-specific antibodies recognizing CD20 on B-cell malignancies as a treatment modality for these diseases. © 2001 Cancer Research Campaign http://www.bjcancer.com

Ab binding to CD20 has been shown to induce apoptosis in B cells. In this study, we demonstrate that rituximab sensitizes lymphoma B cells to Fas-induced apoptosis in a caspase-8-dependent manner. To elucidate the mechanism by which Rituximab affects Fas-mediated cell death, we investigated rituximab-induced signaling and apoptosis pathways. Rituximab-induced apoptosis involved the death receptor pathway and proceeded in a caspase-8-dependent manner. Ectopic overexpression of FLIP (the physiological inhibitor of the death receptor pathway) or application of zIETD-fmk (specific inhibitor of caspase-8, the initiator-caspase of the death receptor pathway) both specifically reduced rituximab-induced apoptosis in Ramos B cells. Blocking the death receptor ligands Fas ligand or TRAIL, using neutralizing Abs, did not inhibit apoptosis, implying that a direct death receptor/ligand interaction is not involved in CD20-mediated cell death. Instead, we hypothesized that rituximab-induced apoptosis involves membrane clustering of Fas molecules that leads to formation of the death-inducing signaling complex (DISC) and downstream activation of the death receptor pathway. Indeed, Fas coimmune precipitation experiments showed that, upon CD20-cross-linking, Fas-associated death domain protein (FADD) and caspase-8 were recruited into the DISC. Additionally, rituximab induced CD20 and Fas translocation to raft-like domains on the cell surface. Further analysis revealed that, upon stimulation with rituximab, Fas, caspase-8, and FADD were found in sucrose-gradient raft fractions together with CD20. In conclusion, in this study, we present evidence for the involvement of the death receptor pathway in rituximab-induced apoptosis of Ramos B cells with concomitant sensitization of these cells to Fas-mediated apoptosis via Fas multimerization and recruitment of caspase-8 and FADD to the DISC.