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BACKGROUND: Although targeted biological treatments have transformed the outlook for patients with rheumatoid arthritis, 40% of patients show poor clinical response, which is mechanistically still unexplained. Because more than 50% of patients with rheumatoid arthritis have low or absent CD20 B cells-the target for rituximab-in the main disease tissue (joint synovium), we hypothesised that, in these patients, the IL-6 receptor inhibitor tocilizumab would be more effective. The aim of this trial was to compare the effect of tocilizumab with rituximab in patients with rheumatoid arthritis who had an inadequate response to anti-tumour necrosis factor (TNF) stratified for synovial B-cell status. METHODS: This study was a 48-week, biopsy-driven, multicentre, open-label, phase 4 randomised controlled trial (rituximab vs tocilizumab in anti-TNF inadequate responder patients with rheumatoid arthritis; R4RA) done in 19 centres across five European countries (the UK, Belgium, Italy, Portugal, and Spain). Patients aged 18 years or older who fulfilled the 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for rheumatoid arthritis and were eligible for treatment with rituximab therapy according to UK National Institute for Health and Care Excellence guidelines were eligible for inclusion in the trial. To inform balanced stratification, following a baseline synovial biopsy, patients were classified histologically as B-cell poor or rich. Patients were then randomly assigned (1:1) centrally in block sizes of six and four to receive two 1000 mg rituximab infusions at an interval of 2 weeks (rituximab group) or 8 mg/kg tocilizumab infusions at 4-week intervals (tocilizumab group). To enhance the accuracy of the stratification of B-cell poor and B-cell rich patients, baseline synovial biopsies from all participants were subjected to RNA sequencing and reclassified by B-cell molecular signature. The study was powered to test the superiority of tocilizumab over rituximab in the B-cell poor population at 16 weeks. The primary endpoint was defined as a 50% improvement in Clinical Disease Activity Index (CDAI50%) from baseline. The trial is registered on the ISRCTN database, ISRCTN97443826, and EudraCT, 2012-002535-28. FINDINGS: Between Feb 28, 2013, and Jan 17, 2019, 164 patients were classified histologically and were randomly assigned to the rituximab group (83 [51%]) or the tocilizumab group (81 [49%]). In patients histologically classified as B-cell poor, there was no statistically significant difference in CDAI50% between the rituximab group (17 [45%] of 38 patients) and the tocilizumab group (23 [56%] of 41 patients; difference 11% [95% CI -11 to 33], p=0·31). However, in the synovial biopsies classified as B-cell poor with RNA sequencing the tocilizumab group had a significantly higher response rate compared with the rituximab group for CDAI50% (rituximab group 12 [36%] of 33 patients vs tocilizumab group 20 [63%] of 32 patients; difference 26% [2 to 50], p=0·035). Occurrence of adverse events (rituximab group 76 [70%] of 108 patients vs tocilizumab group 94 [80%] of 117 patients; difference 10% [-1 to 21) and serious adverse events (rituximab group 8 [7%] of 108 vs tocilizumab group 12 [10%] of 117; difference 3% [-5 to 10]) were not significantly different between treatment groups. INTERPRETATION: The results suggest that RNA sequencing-based stratification of rheumatoid arthritis synovial tissue showed stronger associations with clinical responses compared with histopathological classification. Additionally, for patients with low or absent B-cell lineage expression signature in synovial tissue tocilizumab is more effective than rituximab. Replication of the results and validation of the RNA sequencing-based classification in independent cohorts is required before making treatment recommendations for clinical practice. FUNDING: Efficacy and Mechanism Evaluation programme from the UK National Institute for Health Research. ispartof: LANCET vol:397 issue:10271 pages:305-317 ispartof: location:England status: published

PsA is characterized by a high prevalence of cardiovascular (CV) comorbidities. Recognizing these comorbidities is critical due to their influence on the quality of life and the choice of therapy. Imaging techniques also play an important role in the evaluation of the CV risk in psoriatic disease, improving the prediction of CV events when combined with clinical scores as a predictive tool. Meta-analyses point to a significant reduction in the incidence of CV events associated with the suppression of inflammatory activity when using systemic therapies. Consequently, the mortality rate in PsA patients has fallen in the last 40 years and is now similar to that of the general population, including cardiovascular causes. Obesity is an especially relevant CV comorbidity in patients with psoriatic disease, most of whom are overweight/obese. Body mass index (BMI) is a risk factor for PsA and a causal relationship with psoriasis has been demonstrated by Mendelian randomized studies. The study of fat distribution shows that patients with psoriasis are characterized by visceral fat accumulation, which correlates with CV risk measurements. These findings suggest that approaches to the prevention and treatment of psoriatic disease might come from targeting adiposity levels, in addition to the immune pathways. Weight loss treatment with low energy diets in patients with PsA has been associated with significant improvements in disease activity. Novel strategies using a multimorbidity approach, focused more on patients outcomes, are necessary to better address comorbidities, improve clinical outcomes and the quality of life of patients with psoriatic disease.

Objective: Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease that mainly targets joints. Monocytes and macrophages are critical in RA pathogenesis and contribute to inflammatory lesions. These extremely plastic cells respond to extracellular signals which cause epigenomic changes that define their pathogenic phenotype. Here, we interrogated how DNA methylation alterations in RA monocytes are determined by extracellular signals. Methods: High-throughput DNA methylation analyses of patients with RA and controls and in vitro cytokine stimulation were used to investigate the underlying mechanisms behind DNA methylation alterations in RA as well as their relationship with clinical parameters, including RA disease activity. Results: The DNA methylomes of peripheral blood monocytes displayed significant changes and increased variability in patients with RA with respect to healthy controls. Changes in the monocyte methylome correlate with DAS28, in which high-activity patients are divergent from healthy controls in contrast to remission patients whose methylome is virtually identical to healthy controls. Indeed, the notion of a changing monocyte methylome is supported after comparing the profiles of same individuals at different stages of activity. We show how these changes are mediated by an increase in disease activity-associated cytokines, such as tumour necrosis factor alpha and interferons, as they recapitulate the DNA methylation changes observed in patients in vitro. Conclusion: We demonstrate a direct link between RA disease activity and the monocyte methylome through the action of inflammation-associated cytokines. Finally, we have obtained a DNA methylation-based mathematical formula that predicts inflammation-mediated disease activity for RA and other chronic immune-mediated inflammatory diseases., We thank CERCA Programme/Generalitat de Catalunya for institutional support. EB was funded by the Spanish Ministry of Economy and Competitiveness (MINECO; grant numbers SAF2014-55942-R and SAF2017-88086-R). JDC was funded by FIS grant (PI17/00993) from Institute of Health Carlos III (ISCIII). JDC, JM and EB are supported by RETICS network grant from ISCIII (RIER, RD16/0012/0013), FEDER 'Una manera de hacer Europa'

Background and AimsGM-CSF-dependent macrophage polarization has been demonstrated in rheumatoid arthritis (RA). Our aim was to seek diagnostic/prognostic biomarkers for undifferentiated arthritis (UA) by analyzing GM-CSF expression and source, macrophage polarization and density in joints of patients with UA evolving to RA or PsA compared with established RA or PsA, respectively.MethodsSynovial tissue (ST) from patients with UA evolving to RA (UA>RA, n=8), PsA (UA>PsA, n=9), persistent UA (UA, n=16), established RA (n=12) and PsA (n=10), and healthy controls (n=6), were analyzed. Cell source and quantitative expression of GM-CSF and proteins associated with pro-inflammatory (GM-CSF-driven) and anti-inflammatory (M-CSF-driven) macrophage polarization (activin A, TNFα, MMP12, and CD209, respectively) were assessed in ST CD163+ macrophages by multicolor immunofluorescence. GM-CSF and activin A levels were also quantified in paired synovial fluid samples. CD163+ macrophage density was determined in all groups by immunofluorescence.ResultsSynovial stromal cells (FAP+ CD90+ fibroblast, CD90+ endothelial cells) and CD163+ sublining macrophages were the sources of GM-CSF. ST CD163+ macrophages from all groups expressed pro-inflammatory polarization markers (activin A, TNFα, and MMP12). Expression of the M-CSF-dependent anti-inflammatory marker CD209 identified two macrophage subsets (CD163+ CD209high and CD163+ CD209low/-). CD209+ macrophages were more abundant in ST from healthy controls and PsA patients, although both macrophage subtypes showed similar levels of pro-inflammatory markers in all groups. In paired synovial fluid samples, activin A was detected in all patients, with higher levels in UA>RA and RA, while GM-CSF was infrequently detected. ST CD163+ macrophage density was comparable between UA>RA and UA>PsA patients, but significantly higher than in persistent UA.ConclusionsGM-CSF is highly expressed by sublining CD90+ FAP+ synovial fibroblasts, CD90+ activated endothelium and CD163+ macrophages in different types of arthritis. The polarization state of ST macrophages was similar in all UA and established arthritis groups, with a predominance of pro-inflammatory GM-CSF-associated markers. CD163+ macrophage density was significantly higher in the UA phases of RA and PsA compared with persistent UA. Taken together, our findings support the idea that GM-CSF is a strong driver of macrophage polarization and a potential therapeutic target not only in RA but also in PsA and all types of UA.

To analyse ultrasound (US) differences between rheumatoid arthritis (RA) patients according to autoantibody status and characterise the clinical and radiological features associated with the US pattern of seropositive patients.We collected demographic and clinical data and bilateral hand US images of RA patients. We defined an extreme proliferative US pattern, encompassing synovial hypertrophy grade II-III with Power Doppler signal, which we called US proliferative synovitis (US PS). To better characterise US PS, MRI of the dominant hand and immunostaining of synovial biopsies were made in subgroups of 42 and 23 patients, respectively.We included 205 RA patients (84.8% seropositive). No significant differences in disease activity were found according to autoantibody status. US PS was found in 55.5% of seropositive and 16.1% of seronegative patients (p=0.0001). In the multivariate analysis, erosions [OR 4.90 95% CI (2.17-11.07), p=0.0001] and ACPA [OR 3.5 95% CI (1.39-10.7), p=0.009] but not RF status [OR 0.74 95% CI (0.31-1.71), p=0.483] were independently associated with US PS. After a mean follow-up of 46 months, US PS was independently associated with changes in therapy (OR 2.63, 95% CI 1.20-5.77, p=0.016). Ninety-four per cent of joints with US PS had RAMRIS synovitis sub-index grade 2-3. US PS was significantly associated with higher synovial vessel density (p=0.042).In RA patients, US PS was associated with ACPA status, erosive disease and an enhanced need to change disease-modifying anti-rheumatic drug therapy in the long-term. At synovial level, this US pattern was characterised by higher vessel density.

To compare long-term clinical, immunological, and radiographic outcomes between five sets of remission criteria (four clinical and one ultrasound (US)-based) in a cohort of RA patients in a clinical care setting.RA patients in remission (DAS28-ESR2.6) were selected. Hand US assessments were made, and serum levels of inflammation/angiogenesis biomarkers were determined at baseline. Changes in baseline treatment and radiographic progression, defined as the variation in the modified Sharp van der Heijde score (mSHS) at 5 years, were analyzed. Five concepts were used to define remission: DAS28-ESR2.6, SDAI3.3, CDAI2.8, Boolean criteria and Power Doppler score (PD)=0.Eighty-seven patients with DAS28-ESR2.6 were included. One-third fulfilled SDAI (33.3%), CDAI (31%), and Boolean (35.6%) remission criteria, and 25.3% had no PD signal in the US evaluation. 26 patients (29.9%) changed therapy, ranging from 13.6% (PD remission) to 33.3% (CDAI remission) (p=0.11). Serum levels of ANG (p=0.015) and TNFa (p=0.025) were significantly lower in patients with Boolean remission, whereas IL-18 levels were significantly lower in those with PD remission (p=0.049). Patients without PD in the US assessment had significantly-lower mSHS erosion progression (p=0.014) at 5 years.Patients with established RA in DAS28-ESR remission had comparable clinical and radiographic outcomes in SDAI, CDAI, and Boolean definitions in a clinical care setting. US remission remained the closest to structural damage abrogation. Key Points • This study provides real world data on long-term outcomes of five clinical and imaging remission criteria in rheumatoid arthritis. • DAS28-ESR remission criteria had comparable radiographic progression and clinical prognosis than more stringent criteria in clinical practice. • US-based remission was closest to structural damage abolishment.

BackgroundThe mechanisms by which only some rheumatoid arthritis (RA) patients respond favorably to TNF blockade are still poorly characterized. The goal of this study was to identify biological features that explain this differential response using a multilevel transcriptome analysis of the synovial membrane.MethodsSynovial samples from 11 patients on anti-TNF therapy were obtained by arthroscopy at baseline and week 20. Analysis of the synovial transcriptome was performed at the gene, pathway, and cell-type levels. Newly characterized pathogenic cell types in RA, peripheral helper T cells (TPH), and CD34-THY1+ fibroblasts were estimated using a cell-type deconvolution approach. TPHassociation was validated using immunofluorescence. External validation was performed on an independent dataset.ResultsAfter multiple-test correction, 16 and 4 genes were differentially expressed at baseline and week 20, respectively. At the pathway level, 86 and 17 biological processes were significantly enriched at baseline and week 20, respectively. Longitudinal expression changes were associated with a drastic decrease of innate immune activity (P P PHcells at baseline and a better response (P = 0.026). Lower TPHcells were maintained in good responders up to week 20 (P = 0.032). Immunofluorescent analyses confirmed the accuracy of the cell-type estimation (r2 = 0.58,P = 0.005) and an association with response. TPHassociation with anti-TNF response was validated in an independent sample of RA patients (P = 0.0040).ConclusionsA lower abundance in the synovial membrane of the pathogenic T cell type newly associated with RA, peripheral helper T lymphocyte, is associated with a good response to anti-TNF therapy. Major changes in the myeloid cell compartment were also observed in response to therapy. The results of this study could help develop more effective therapies aimed at treating the pathogenic mechanisms in RA that are currently not well targeted by anti-TNF agents.

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

Objective To compare long-term clinical and radiographic outcomes among five sets of remission criteria [four clinical and one Ultrasound (US)-based] in a cohort of RA patients in a clinical care setting. Methods RA patients in remission (DAS28-ESR

Background: The mechanisms by which only some rheumatoid arthritis (RA) patients respond favorably to TNF blockade are still poorly characterized. The goal of this study was to identify biological features that explain this differential response using a multilevel transcriptome analysis of the synovial membrane.Methods: Synovial samples from 11 patients starting anti-TNF therapy were obtained by arthroscopy at baseline and week 20. Analysis of the synovial transcriptome was performed at the gene, pathway and cell-type levels. Newly characterized pathogenic cell types in RA, peripheral helper T cells (TPH) and CD34-THY1+ fibroblasts, were estimated using a cell-type deconvolution approach. TPH association was validated using immunofluorescence. External validation was performed on an independent dataset. Results: After multiple test correction, 16 and 4 genes were differentially expressed at baseline and week 20, respectively. At the pathway level, 86 and 17 biological processes were significantly enriched at baseline and week 20, respectively. Longitudinal expression changes were associated with a drastic decrease of innate immune activity (PPH cells at baseline and a better response (P=0.026). Lower TPH cells were maintained in good responders up to week 20 (P=0.032). Immunofluorescent analyses confirmed the accuracy of the cell-type estimation (r2=0.58, P=0.005) and the association with response. TPH association with anti-TNF response was validated in an independent sample of RA patients (P=0.0040). Conclusions: A lower abundance in the synovial membrane of the new pathogenic T cell type associated to RA, peripheral helper T lymphocyte, is associated to a good response to anti-TNF therapy. Major changes in the myeloid cell compartment are also seen in response to therapy. The results of this study could help develop more effective therapies aimed at treating the pathogenic mechanisms in RA that are currently not well targeted by anti-TNF agents.

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

Las poblaciones de frijol silvestres (Phaseolus vulgaris L.) actualmente son usadas incipientemente por los humanos; muchas de ellas son tolerantes a ambientes inductores de estrés y sus características nutricionales y de calidad pueden ser excepcionales, por ello representan un recurso desaprovechado. El objetivo del estudio fue describir la reacción del frijol silvestre a la profundidad de siembra y contrastarla con la de cultivares. La hipótesis fue que, ya que en su hábitat las semillas de frijol silvestre germinan cerca de la superficie del suelo, donde se depositan después de la dehiscencia espontánea de las vainas, la mayor profundidad de siembra afecta negativamente la emergencia de las plántulas. Se empleó un diseño experimental completamente al azar con arreglo factorial de tratamientos (15 x 4) en condiciones de invernadero. Los factores estudiados fueron: material vegetal (seis genotipos silvestres, tres cultivares tradicionales y seis cultivares mejorados) y profundidad de siembra (2.5, 5.0, 7.5 y 10 cm). Se evaluó la biomasa de las semillas, tiempo para la emergencia inicial y final (total o máxima), y porcentaje de emergencia inicial y máxima. La emergencia acumulada de los frijoles silvestres mostró tendencia logística (y = k/l + [k-n/ne-rx]) como los domesticados. Los frijoles silvestres en profundidad de 2.5 y 10 cm tardaron 1 d más (p≤ 0.05) para iniciar la emergencia (7.67 y 9.93 d) en comparación con los domesticados (6.43 y 9.02 d), pero el porcentaje de emergencia inicial no fue diferente (p> 0.05). La emergencia máxima fue diferente (p≤ 0.05) únicamente con 10 cm, en la que los frijoles silvestres emergieron en proporción mayor (72.78 %) que los domesticados (59.02 %). La profundidad de siembra no representa desventaja para la emergencia del frijol silvestre.

Background:Seronegative (sero-) and seropositive (sero+) Rheumatoid Arthritis (RA) have different genetic, immunopathological and vascular morphology features, but no previous studies have analyzed if US characteristics differ between sero+ or sero- RA. Our preliminary studies suggest that sero+ RA is associated with an expansive synovitis pattern that we have called “proliferative synovitis” (PS)Objectives:To analyze potential differences between patients with RA according to their autoantibody status by using ultrasonography (US). We aimed to assess whether PS is associated with ACPA+ ptsMethods:We collected clinical, epidemiological data and bilateral carpal and hand US images of pts with RA. Synovial hypertrophy (SH), Power Doppler signal (PD) and total score (sum of scores of SH and PD) in wrist and hand (1-5 metacarpophalangeal) were assessed. We evaluated the presence of PS, defined as expansive synovial growth encompassing the concepts of synovial SH grade II and III. We performed synovial biopsies of a subgroup of pts using arthroscopy or US guided in order to see immunohistochemistry differences between “proliferative” and “flat” (non-proliferative) synovitis. Serum levels of angiogenic and inflammatory biomarkers were performedResults:Two hundred and five RA patients were collected. Overall, 173 (84.8%) pts were sero+ for RF (68.7%) or ACPA (74.6%), general characteristics are summarized in Table. No significant differences between sero+ and sero- pts in terms of disease activity or therapy were found. PS was present in 55.5% of sero+ pts (55.3% in RF+ and 58.2% in ACPA+ pts) and 16.1% of sero- pts (p=0.0001). Globally, 101 pts (49.2%) had PS. Ninety-six (95.0%) were RF or ACPA positive. Only 5 pts with sero- RA had PS (p=0.001). In the univariate analysis, significantly more pts with PS had erosive disease (72.3% vs 35.0% p=0.0001), higher US scores (p=0.0001) and more of them were taking conventional synthetic Disease-modifying anti-rheumatic drugs (csDMARD) (81.8% vs 69.6% p=0.05). No differences regarding disease activity were found.In the multivariate analysis erosions [OR 4.90 CI 95% (2.17-11.07) p=0.0001] and ACPA [OR 3.5 CI 95% (1.39-10.7) p=0.09] but not RF status [OR 0.74 CI 95% (0.31-1.71) p=0.483] were independently associated with the presence of PS.We immunostained synovial biopsies from 23 pts with PS (13 pts) or non-PS (10 pts). PS was significantly associated with higher density of vessels (p=0.042) and a strong trend to a higher density of B, T, Mast cells and macrophages (figure 1). Significantly higher serum levels of angiogenic (Activin A, bFGF, IL18, IL20, PIGF, SDF-1 and VEGF-D) and pro-inflammatory (IL23) cytokines were found in patients with PS (figure 2).Conclusion:The presence of “proliferative Synovitis” was significantly associated with ACPA and erosive disease in patients with RA. PS pattern also was associated with higher density of synovial vessels and higher serum levels of angiogenic and inflammatory mediatorsTable .Total US pattern p valueN=205Proliferative (N=101)Non proliferative (N=104)Female, n (%)162 (79.4)79 (78.2)83 (80.6)0.57Age, mean (SD) years57.1 (± 14,1)56.3 (± 12.0)58.0 (± 15.9)0.40Current Smoker, n (%)47 (26.9)22 (25.6)25 (28.1)0.73Disease duration, mean (SD) months113.3 (± 105.7)127.7 (± 111.1)99.3 (± 99.3)0.05Erosion, n (%)108 (53.7)73 (72.3)35 (35.0)0.00ACPA, n (%)153 (75.4)89 (89)64 (62.1)0.00RF, n (%)99 (68.3)78 (78)63 (61.2)0.01DAS 28–CRP, mean (SD)2.55 (±1.03)2.66 (±1.04)2.44 (±1.02)0.17GC, n (%)99 (49.3)45 (45.5)54 (52.9)0.32cDMARDs, n (%)152 (75.6)81 (81.8)71 (69.6)0.05bDMARD, n (%)69 (34.3)35 (35.4)34 (33.3)0.76Total US score14.9 (± 11.5)18.8 (± 11.8)11.1 (± 9.9)0.00*ACPA anti-citrullinated protein antibodies, RF rheumatoid factor, DAS28-CRP Disease Activity Score 28-joint count, CRP C-reactive protein, GC glucocorticoids, bDMARD biological disease-modifying antirheumatic drugsDisclosure of Interests:Ana Belén Azuaga-Piñango: None declared, Beatriz Frade-Sosa: None declared, Roberto Gumucio: None declared, Katherine Cajiao: None declared, Andrea Cuervo: None declared, Raquel Celis: None declared, Jose A. Gómez-Puerta Speakers bureau: Abbvie, BMS, GSK, Lilly, Pfizer, Roche, Raimón Sanmartí Speakers bureau: Abbvie, Eli Lilly, BMS, Roche and Pfizer, Juan de Dios Cañete: None declared, Julio Ramirez: None declared

Background: Patients with Rheumatoid Arthritis (RA) in remission will present flares during the evolution of the disease.Definitive biomarkers have not been identified to predict flares and radiographic progression (RP) in this kind of patients Objectives: To search biomarkers of clinical relapse and RP in patients with RA in clinical remission Methods: RA patients in clinical remission (DAS28-ESR 6 months) were selected.Clinical,epidemiological and serological data were analyzed.MRI of dominant hand,ultrasound assessment of knees and hands and serum levels of inflammation and angiogenesis biomarkers were evaluated at 0 and 48 weeks.Synovial biopsy was performed in patients with subclinical synovitis.Patients were follow-up for 5 years.Radiological data were collected.Clinical relapse was defined as the loss of remission status involving a therapeutic intervention.RP was defined as the change in the Sharp van der Heijde (SvH) index at 5 years >10.47 [SDD (minimum detectable change)]. Results: 60 patients in DAS28 remission. 1/3 also met remission criteria for SDAI(33.3%),CDAI(31.6%) and ACR(35%).78% were women,mean age 53 years. 82% were ACPA+.26% were taking oral prednisone,76% DMARDs and 45% biological therapies.48% met criteria for subclinical synovitis(UdAS:SH>2+PD)1. After 5 years of follow-up, 44(73%), 11(18%), 9(15%) and 10(17%) patients remained in remission according to DAS28,SDAI, DAI and ACR criteria,respectively. 29 patients (48%) had flares at any time during the 5 years. In the multivariate analysis, the variables that were related to clinical relapse were the BMI (OR 1.6 CI 95% 1.1-2.3), bone edema at baseline (OR 1.2,CI 95% 1-1.5), PD signal at 48w (OR 9.2,CI 95% 1.2-66.7) and the change in levels of CXCL16 (OR 1.04 CI 95% 0.9-1) and ESR (OR 3.6,CI 95% 1.1-12.2) between the first and latest evaluation (Rate). In the subgroup of 23 patients undergoing synovial biopsy, the number of mast cells was higher in those patients (n=10) who flared (p=0.02). 20 patients (33%) changed DMARDs or biological therapy. In the logistic regression analysis, BMI (OR 1.3 CI 95% 1-1.6), biological therapy (OR 17.8 CI 95% 2-167.1),progression of erosions measured by MRI (OR 1.1, CI 95% 1-1.3) and the rate of progression of calprotectin levels during the first year (OR 4.4,CI 95% 1.1-17.2) were the main factors that predicted the change in baseline therapy after 5 years of follow-up. Finally, only 6 patients (10%) had RP according to the SvH index and 7 (12%) had erosion progression.This small number of “progressors” did not allowed more exhaustive analysis of factors predicting RP.However,the number of macrophages and T cells at sinovial tissue (ST) was much higher in patients with RP.Likewise,the first-year rate of bone edema was significantly higher in patients suffering structural progression (p=0.04). Conclusion: 27% of RA patients lost clinical remission (DAS28) after 5 years of follow-up.BMI,baseline bone edema,PD signal at 12m and first-year rate of CXCL16 and VSG levels were predictors of joint flares. Baseline BMI, use of biological therapy,MRI erosions and calprotectin levels predicted the change of baseline therapy for RA. Only 10% of patients had RP along the study.Sinovial mast cells were associated with disease flares. Macrophages and T cells in ST were higher in patients with RP in an exploratory analysis. Reference [1] Ramirez J, Ruiz-Esquide V, Pomes I, Celis R, Cuervo A, Hernandez MV, et al. Patients with rheumatoid arthritis in clinical remission and ultrasound-defined active synovitis exhibit higher disease activity and increased serum levels of angiogenic biomarkers. Arthritis Res Ther. 2014;16:R5. Disclosure of Interests: Julio Ramirez: None declared, Andrea Cuervo: None declared, Raquel Celis: None declared, Raul Castellanos-Moreira Speakers bureau: MSD, Lilly, Sebastian C Rodriguez-Garcia: None declared, Virginia Ruiz-Esquide: None declared, Jose Gomez Puerta Speakers bureau: BMS, Pfizer, Amgen, Raimon Sanmarti Speakers bureau: PFIZER, SANOFI, LILLY, MSD, UCB, NOVARTIS, JANSSEN, Juan D. Canete: None declared

Psoriatic arthritis (PsA) is an immuno-inflammatory disease with a heterogeneous clinical presentation as affects musculoskeletal tissues (arthritis, enthesitis, spondylitis), skin (psoriasis) and, less frequently, eye (uveitis) and bowel (inflammatory bowel disease). It has been suggested that distinct affected tissues could exhibit different immune-inflammatory pathways so complicating the understanding of the physiopathology of psoriatic disease as well as its treatment. Despite of the key pathogenic and clinical relevance that enthesitis has in PsA, peripheral arthritis is more easily perceived. At the macroscopic level, PsA synovitis has predominantly tortuous, bushy vessels, whereas rheumatoid arthritis (RA) is characterized by mainly straight, branching vessels so reflecting prominent neo-angiogenesis in PsA. Synovial biopsies have demonstrated a similar cellular and molecular picture in PsA and RA, although some differences have been reported at the group level, as higher density of vessels, CD163+ macrophages, neutrophils and mast cells in PsA. In fact, synovial IL-17+ mast cells are significantly increased in PsA and produce more IL-17A compared with RA, and a proof of concept study supports its relevant role in the synovitis of SpA, included PsA. As firstly reported in RA, synovial lymphoid neogenesis is found also in the same proportion of PsA as in RA patients, despite the lack of autoantibodies in PsA. These lymphoid structures are associated with activation of the IL-23/Th17 pathway in RA and seemly in PsA, which could be useful to stratify RA patients. Immunohistochemical and transcriptomic methodologies have still not found synovial biomarkers useful to distinguish psoriatic from rheumatoid synovitis at the patient level. However, modern methodologies, as MALDI-Mass Spectrometry Imaging, applied to the study of synovial tissue have revealed metabolic and lipid signatures which could support clinical decision-making in the diagnosis of PsA and RA and to go further toward the personalized medicine.

Background Early diagnosis in psoriatic arthritis (PsA) is mandatory in order to initiate early therapy and prevent disability. Around 20% of patients with Psoriasis (PsO) routinely visited in Dermatology departments have PsA previously undiagnosed. Objectives The aim of this study is to evaluate the presence of inflammation by clinical examination and ultrasound in joints and enthesis of patients with PsO without musculoskeletal symptoms. Methods Patients with PsO under topic or PUVA therapy without musculoskeletal symptoms were referred to our Arhritis Unit. Clinical and demographic data were collected. The patients were evaluated for Body Surface Area (BSA), Swollen Joint Count (SJC) (66 joints), Tender Joint Count (TJC) (68 joints) and enthesis (MASES). Psoriatic Arthritis Impact of Disease tool questionnaire (PsAID) and Psoriasis Epidemiology Screening tool questionnaire (PEST) were used to assess the impact of the disease. A comprehensive ultrasound evaluation of 46 joints and 12 enthesis was made (ESAOTE MylabTwice, 12–18 Mhz probe). Enthesis score was calculated using the Madrid Sonographic Enthesis Index (MASEI) and a total score for synovitis (synovial hypertrophy and Power Doppler) was also calculated. Results 42 patients were included. 20 patients were female (48%), mean age (SD) was 48.3 y (14.6) and disease duration was 17.9 y (15.9). Mean BMI was 24.6 (5.2) and BSA 5 (8.7). 13 out of 42 (31%) had severe PsO (systemic treatment or BSA >10% at any time of evolution). 4 patients (9.5%) had Power Doppler signal and 2 (4.8%) fulfilled criteria for ultrasound-defined active synovitis (SH ≥2 + PD) despite no signs or symptoms of musculoskeletal disease. However, although structural alterations such as calcifications and enthesophytes were frequent, no PD was found at any enthesis. In the univariate analysis, higher BMI (p=0.013), weight (p=0.010), waist (p=0.033) and hip (p=0.014) circumferences were significantly associated with severe PsO. In the same way, CRP serum levels were also significantly higher in patients with severe PsO (p=0.027). A strong trend was found between higher MASEI scores and onycopathy (p=0.09). pan> Conclusions Patients with PsO under topic or PUVA therapy without musculoskeletal sympoms have a low prevalence of findings in the joints and enthesis ultrasound evaluation. Of note, 9.5% of PsO patients had subclinical synovitis defined as PD. No changes in those finding were found in a short follow-up (6 months) in these patients. A higher number of patients would be necessary to have strong results. These patients will be followed in order to confirm if they develop Psoriatic Arthritis. Acknowledgements This work was partially financed by Pfizer-Spain Disclosure of Interest None declared

Background The ideal definition of remission in RA remains to be agreed. Angiogenic factors and proinflammatory cytokines are key in RA pathogenesis. Objectives The aim of this study was to analyse serum levels differences of angiogenic and inflammatory biomarkers between SDAI, CDAI, ACR, DAS28 and sonographic remission in patients with (RA). Methods We selected patients with RA in clinical remission (DAS28-ESR 6 months). PDUS of knees and hands was performed. Serum levels of biomarkers of inflammation/angiogenesis were determined by Quantibody® Human Array. Patients were classified according to 6 sets of remission criteria: SDAI ( Results 60 patients with RA were collected. 76% female, aged (mean) 53 years; disease duration 110 months. 47 (76%) csDMARDs, and 27 (45%) biological therapies. At baseline, 67% of patients had PD signal and 48% fulfilled criteria for previously defined UdAS. Although patients in sonographic remission had lower levels of inflammatory biomarkers such as IL-6, IL-17 or IL-23, no significant differences were found between the 6 sets of remission criteria. Angiogenic biomarkers such as CXCL6 (0.039), ENA78 (0.007), SDF1 (0.047) and VEGF-R1 (0.025) were significantly lower in patients fulfilling CDAI remission. Patients with no PD signal (0.009) and no UdAS (0.006) had significantly lower levels of bFGF. Conclusions RA patients in CDAI remission had significantly-lower levels of angiogenic cytokines. However, no differences in serum levels of proinflammatory cytokines were found between the 6 sets of remission criteria. Disclosure of Interest None declared

Background Undifferentiated Arthritis (UA) is defined as an inflammatory oligo/poly arthritis that does not fulfil criteria for a definitive diagnosis.Delay in diagnosis and treatment leads to poor prognosis. Previous studies have found differences in the cellular infiltrate between the synovitis of Rheumatoid Arthritis (RA) and Spondyloarthritis, including psoriatic arthritis (PsA) Objectives To identify synovial biomarkers that may be useful to diagnose patients with early UA Methods Retrospective longitudinal study.Patients with UA followed in our Arthritis Unit,who underwent arthroscopy between 2000 and 2014.Synovial biopsy were stained by immunohistochemistry with the following antibodies:CD3 for T cells,CD20 for B cells,CD79 for B cells,CD138 for plasma cells,CD31 for vessels,CD68 for macrophages,CD15 for neutrophils,CD117 for mast cells and hsp47 for fibroblasts, and quantified by Digital Image Analysis (Olympus).The same antibodies were evaluated in RA and PsA control groups Results 55 UA and 78 controls were included.Table 1 shows the clinical, serological and demographic characteristics.Among patients with UA, 23 (42%) patients met criteria for RA and 32 (58%) for PsA during follow-up.Synovitis of patients with UA had higher macrophage (CD68+) density in total tissue (p=0.008) and sublining (SL) (p=0.012) than the control group.The UA that evolved to RA had a higher density of CD3 T lymphocytes than the control RA group (p=0.014). No differences were observed in cells of adaptive immunity (CD20 B lymphocytes, CD138 plasma cells), innate immunity (CD117 mast cells, CD15 neutrophils), vessels (CD31) between the 4 groups.The area (%) stained by anti-hsp47 (synovial fibroblasts) in SL was higher in the RA control group than in the PsA (p=0.003) Conclusions This is the first immunohistological study of synovitis in a significant group of patients with UA who developed AR or PsA during follow-up. Although there are some differences between the UA and control groups in the density of CD68+ macrophages and lymphocytes T CD3+, these do not appear to be useful for an early diagnosis of UA. On the other hand, unlike the results of some previous studies, we not found differences between the cellular infiltrate (adaptive immunity, innate immunity or vessels) in patients with RA and PsA. The fact that some patients with UA were undergoing treatment prior to synovial biopsy and its retrospective character limit the results of this study Acknowledgements Financed: “Fondo de Investigaciόn Sanitaria” (PI14/00785. JD Canete) del Instituto de Salud Carlos III (ISCIII). Co-financed by BECA FER-2015. Premis “Emili Letang”, Hospital Clinic. BECA MSD-Sociedad Catalana de Reumatologia Disclosure of Interest None declared

Objectives As the role of polymorphisms in death receptors (DRs) such as Tumor Necrosis Factor–related Apoptosis-inducing Ligand Receptor 1 (TRAIL-R1) and Tumor Necrosis Factor Receptor 1A (TNF-R1A) on the response to anti-TNF therapy remains unknown, we evaluated the association between TRAILR1 and TNFR1A gene polymorphisms (rs20575/C626G and rs767455/G36A) and the pharmacogenetics of patients with rheumatoid arthritis (RA) and psoriatic arthritis (PsA) treated with TNFα blockers. Methods One hundred and forty-five patients (90 RA and 55 PsA) treated with anti-TNFα therapy (RA: 75 infliximab, 8 etanercept, 7 adalimumab. PsA: 27 infliximab, 19 etanercept, 9 adalimumab) were genotyped for TRAILR1 and TNFR1A polymorphisms by allelic discrimination. The response to anti-TNFα was assessed by EULAR criteria. Results In RA, the TRAILR1 CC genotype was associated with a better response after 3 and 6 months of anti-TNFα treatment (CC: 91.7% vs. CG/GG: 62.2%; P = 0.019, and CC: 82.6% vs. CG/GG: 56.1%; P = 0.019, respectively). Similar results were observed in only infliximab-treated RA patients. With respect to the TNFR1A polymorphism, there was an association between the AA genotype and a poorer response at 3 months in RA patients (AA: 39.3% vs. AG/GG: 19.0%; P = 0.04). In PsA, TRAILR1 CC genotype was only associated with EULAR response to infliximab at 6 months (CC: 71.4% vs CG/GG: 50%P = 0.048). In contrast to RA, the TNFR1 polymorphism in PsA was associated with a better response at 3 months (AA 88% vs AG/GG 58.9%; P = 0.04). Conclusions This study provides the first evidence that a polymorphism in TRAILR1 influences the response to anti-TNFα therapy in RA and also suggests that TNFR1A polymorphism may have opposing effects on the response to anti-TNFα in RA and PsA.

Resume Objectifs Puisque le role des polymorphismes des recepteurs de mort (TNFR) tels que le recepteur tumor necrosis factor-related apoptosis-inducing ligand receptor 1 (TRAILR1) et le recepteur tumor necrosis factor receptor 1A (TNFR1A) joues dans la reponse au traitement anti-TNF reste inconnu, nous avons evalue l’association entre les polymorphismes des genes TRAILR1 et TNFR1A (rs20575/C626G et rs767455/G36A) et la pharmacogenetique des patients atteints de polyarthrite rhumatoide (PR) et de rhumatisme psoriasique (RP) traites par anti-TNFα. Methodes Cent quarante-cinq patients (90 PR et 55 RP) traites par anti-TNFα (PR : 75 infliximab, huit etanercept, sept adalimumab ; RP : 27 infliximab, 19 etanercept, neuf adalimumab) ont ete genotypes pour les polymorphismes de TRAILR1 et de TNFR1A par discrimination allelique. La reponse aux anti-TNFα etait evaluee selon les criteres de l’European League Against Rheumatism (EULAR). Resultats Dans la PR, le genotype CC de TRAILR1 etait associe a une meilleure reponse apres trois a six mois de traitement par anti-TNFα (CC : 91,7 % versus CG/GG : 62,2 % ; p = 0,019, et CC : 82,6 % versus CG/GG : 56,1 % ; p = 0,019, respectivement). Des resultats similaires ont ete observes uniquement chez les patients traites par infliximab. En ce qui concerne le polymorphisme de TNFR1A, une association entre le genotype AA et une plus mauvaise reponse a trois mois a ete observee chez les patients atteints de PR (AA : 39,3 % versus AG/GG : 19,0 % ; p = 0,04). Dans le RP, le genotype CC de TRAILR1 etait associe uniquement a une reponse EULAR a l’infliximab apres six mois (CC : 71,4 % versus CG/GG : 50 % p = 0,048). Compare a la PR, le polymorphisme de TNFR1 dans le RP etait associe a une meilleure reponse a trois mois (AA 88 % versus AG/GG 58,9 % ; p = 0,04). Conclusions Cette etude apporte les premieres preuves qu’un polymorphisme de TRAILR1 influe sur la reponse au traitement par anti-TNFα chez les patients atteints de PR et suggere aussi que le polymorphisme TNFR1A peut avoir des effets opposes sur la reponse aux anti-TNFα chez les patients atteints de PR ou de RP.

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

Introduction The functional relevance of synovial ectopic lymphoid neogenesis (ELN) in rheumatoid arthritis (RA) remains unknown. As ELN correlates with the degree of tissue inflammation, we investigated whether ELN was associated with specific cytokine profiles. Methods Synovial ELN was determined by immunohistology and long CD21 isoform (CD21L) expression. Cytokine expression was determined by multiplex enzyme-linked immunosorbent assay (ELISA) and quantitative polymerase chain reaction (PCR) as well as immunohistology in synovial fluid (SF) (n = 44) and tissue (ST) (n = 108), respectively. Production of ELN-associated chemokines by fibroblast-like synoviocytes (FLS) was studied in vitro. Results Screening analysis of SF by multiplex ELISA showed higher protein levels of interleukin (IL)-23 (p = 0.018) and IL-17F (p = 0.028) in ELN+ versus ELN- samples. Other cytokines, including IL-17A, IL-6, and tumor necrosis factor (TNF)-α, were not different. The association between IL-23 and ELN was not biased by disease activity or other clinical features and was confirmed by higher IL-23 mRNA expression in ELN+ versus ELN- ST samples (p = 0.030), a correlation between IL-23 and CD21L expression in the same samples (r = 0.70 p

Introduction Comparative data on synovial cell infiltrate and cytokine levels in anti citrullinated peptide/protein antibody (ACPA)-positive and ACPA negative rheumatoid arthritis (RA) patients are scarce. Our aim was to analyze synovial cell infiltrate and synovial fluid (SF) levels of cytokines in patients with RA according to the presence or absence of ACPA in serum. Methods A cross-sectional study in a single center including consecutive RA patients was performed. Patients were defined as 'ACPA negative' if serum was negative to two different ACPAs [second generation commercial anti-cyclic citrullinated peptide antibodies (CCP2) and chimeric fibrin/filaggrin citrullinated antibodies]. Parallel synovial tissue (ST) biopsies and SF were obtained by knee arthroscopy. Synovial cell infiltrate and endothelial cells were analyzed by immunohistochemistry and SF levels of Th1, Th2, Th17 and pro-inflammatory cytokines by Quantibody(R) Human Array. Results A total of 83 patients underwent arthroscopy, with a mean age of 55.9 ± 12 years, and mean disease duration of 45 months (interquartile range, IQR 10.8 to 122). 62% were female and 77% were ACPA positive. No significant differences were found in clinical variables, acute phase reactants, synovial cell infiltrate or lymphoid neogenesis (LN) between ACPA positive and negative patients. However ACPA positive patients had significantly higher levels of IL-1β, IL-10, IL-17 F and CC chemokine ligand 20 (CCL-20) than ACPA negative patients. Conclusions In our cohort of patients with RA no significant differences were found in synovial cell infiltrate or synovial LN according to ACPA status. However, ACPA positive patients had higher levels of T-cell derived and pro-inflammatory cytokines than ACPA negative patients. As systemic and local inflammation was similar in the two groups, these findings support a distinct synovial physiopathology., This study was supported by a public grant from Fondo de Investigación Sanitaria (FIS: PI 080207) of the Ministerio de Sanidad y Consumo, Instituto Carlos III, Spain).

Background Definitive biomarkers have not been identified to predict flares in patients with RA in clinical remission. Objectives To determine clinical, serological and ultrasonografic variables predicting disease relapse at 12 months of follow-up in a cohort of RA patients in clinical remission. Methods We included consecutively RA patients in clinical remission defined as DAS28-ESR 6months evaluated by two independent rheumatologist from our Arthritis Clinic. Complete clinical and biological assessment, determination of serum levels of angiogenic and proinflamatory cytokines, and ultrasound scans of both hands were performed at baseline and after 12 months of follow-up. Risk factors odds ratio (OR) related with 12 months flare were adjusted with multivariate logistic models. Results Sixty patients with RA in remission were included; 78.3% were female. Median age was 53 years (range: 31–74), weight was 67 kg (47–108). Disease and remission mean duration were 111.9 ± 86.4 and 37 months, respectively. 71% of patients were RF positive and 81% were ACPA positive. Patients taking low-dose prednisone, csDMARDs and bDMARDs were 16 (26%), 47 (78%) and 28 (46.7%), respectively. At baseline, 66% had power-doppler (PD) signal and 48% also had synovial hyperplasia grade ≥2, so fulfilling the criteria previously defined of ultrasound defined active sinovitis (UdAS). Twenty-six (43%) patients had disease flare during the follow-up. In the univariate analysis, disease flares were more frequent in patients with PD signal (p=0.056) or UdAS (p=0.117), and significantly less frequent in patients with mild-moderate intake of alcohol. However, in the multivariate analysis, only higher ESR levels (OR: 1.1, 95%CI: 1–1.1), higher weight (OR: 3.1, 95%CI: 1.4–7) and low-dose prednisone treatment (OR: 1.8, 95%CI: 1.2–2.8) were independent risk factors at baseline for disease flares. This model has a sensitivity of 76.9% (95%CI: 56.4–91), a specificity of 76.5% (95%CI: 58.8–89.3), a predictive positive value of 71.40% (95%CI: 52.4–88.4), a predictive negative value of 81.3% (95%CI: 62.7–91.7) and a good predictive power (ROC: 0.849, IC 95%: 74.4–95.4%). We did not find differences between angiogenic or proinflammatory cytokine serum levels and not differences in RAMRIS between patients relapsing or maintaining the remission at baseline. Conclusions This prospective study suggests that higher ESR levels, higher weight and low-dose prednisone treatment are relevant independent risk factors for development of disease flares in patients with RA in clinical remission. However, imaging data (Ultrasound or MRI) or angiogenic/cytokine serum levels were no predictors of flare in this study. Disclosure of Interest None declared

Background A high proportion of patients with rheumatoid arthritis (RA) in clinical remission (CR) present subclinical synovitis when evaluated by sonography. Most prospective studies on baseline biomarkers of radiographic progression in this patients not include immunological biomarkers that could be of interest to better identify the residual inflammatory activity. Objectives To determine clinical, serological and ultrasonografic variables predicting progression of structural damage as evaluated by MRI at 12 months (mo.) of follow-up in a cohort of RA patients in CR. Methods We included 42 RA patients in CR defined as DAS28-ESR 6 mo. Complete clinical and biological assessment, ultrasonography of two hands and MRI of dominant hand were performed at baseline and after 12 mo. We analyzed risk factors related with RAMRIS progression with multivariate lineal models. Results 42 patients were included (76.7% female). Mean age was 53.5 years, body mass index (BMI) 26.7 kg/m 2 . Disease and remission median duration were 94 and 37 mo. respectively. 73.8% RF[+] patients and 85.7% ACPA [+]. RAMRIS 10.3 and erosion (RAMRIS) 18.8. At baseline, 66.7% had power-doppler (PD) signal and 45.2% also had synovial hyperplasia grade ≥2, so fulfilling the criteria of previously defined ultrasound defined active synovitis (UdAS) 1 . The risk factors more related with RAMRIS progression at 12 mo. were baseline RAMRIS, BMI, disease duration, low-dose prednisone treatment, absence of csDMARDs treatment and presence of UdAS. Synovitis as defined by only PD positive signal was no associated to erosions. We excluded the baseline RAMRIS in the multivariate model because it was the strongest predictor factor. We observed that higher serum levels of calprotectin and ENA78 at baseline were significant predictors. Absence of csDMARD treatment, disease duration and the presence of UdAS also remained as independent predictive factors (Table 1). Conclusions This prospective study confirms a high prevalence of UdAS in patients with RA in CR, which is an independent risk factor to develop structural damage progression at 12 months of follow-up. Baseline RAMRIS, BMI, disease duration, absence of csDMARDs therapy, UdAS, and baseline levels of calprotectin and ENA78, were independent predictors of RAMRIS progression. References Ramirez J, et al. Patients with rheumatoid arthritis in clinical remission and ultrasound-defined active synovitis exhibit higher disease activity and increased serum levels of angiogenic biomarkers. Arthritis Res Ther. 2014;16(1):R5 Disclosure of Interest None declared

Persistent viremia after clinical or subclinical hepatitis C virus (HCV) infection is believed to occur in patients with chronic hepatitis C, but little is known about the duration of HCV replication in patients with acute hepatitis who have recovered or the relation of HCV viremia with the kinetics of antibodies to HCV (antiHCV). We tested HCV-RNA and anti-HCV in serial serum samples from 41 patients with posttransfusion non-A, non-B hepatitis, followed for an average of 6 years after transfusion. Serum HCV-RNA was measured by nested polymerase chain reaction, which used primers from the 5′ untranslated region of the HCV genome. Anti-HCV were tested with first- and second-generation enzyme-linked immunosorbent assays (ELISA 1 and ELISA 2), and with a second-generation recombinant immunoblot assay. Of the 41 patients, 10 recovered and 31 progressed to chronic liver disease. HCV-RNA was detected in serum before or simultaneously with the onset of hepatitis in all cases, and lasted between 2 and 6 weeks in 5 of the 10 patients who recovered, whereas it persisted for the entire follow-up period in every case with chronic hepatitis and in the remaining 5 patients with self-limiting hepatitis. Anti-HCV were detected with ELISA 2 in the first serum sample, with raised serum transaminases in 57% of patients, but in only 6% with ELISA 1. In the sample obtained 1 month after the onset of hepatitis, anti-HCV were detected with ELISA 2 in 94% of patients, but in 34% with the ELISA 1. Anti-HCV (anti C-33 and anti-c22) were cleared in the five patients with transient hepatitis C viremia, but remained detectable in those with chronic viremia. In conclusion, serum HCV-RNA is detected at the onset of acute posttransfusion hepatitis C and persists in patients progressing to chronic hepatitis. Some patients with self-limiting hepatitis become HCV-RNA negative soon after the onset of hepatitis, whereas in others it persists throughout follow-up, suggesting the development of a silent carrier state.

Objective Synovial fibroblast (SF) hyperplasia contributes to the pathogenesis of rheumatoid arthritis (RA), but quantitative information on this process is scarce. This study was undertaken to evaluate the fibroblast-specific marker Hsp47 as a quantitative marker for SFs and to analyze its clinicopathologic correlates and evolution after anti–tumor necrosis factor α (anti-TNFα) therapy. Methods Synovial biopsy samples were obtained from 48 patients with RA and 20 controls who were healthy or had osteoarthritis (OA). Twenty-five RA patients who had active disease at the time of biopsy underwent a second biopsy after anti-TNFα therapy. Immunolabeling for Hsp47, inflammatory cells, and vascular cell markers was performed. Hsp47-positive lining and sublining fractional areas were quantified, and their correlation with clinicopathologic variables was analyzed. Results In normal and diseased synovial tissue, Hsp47 was specifically and uniformly expressed by lining, sublining, and perivascular fibroblasts. Lining SF area was significantly increased in both RA and late OA tissue compared to normal tissue. Sublining SF area was increased in RA tissue but not in late OA tissue compared to normal tissue. Lining SF area was positively correlated with macrophage density, Disease Activity Score in 28 joints, and RA disease duration. In contrast, sublining SF area was negatively correlated with RA disease duration and activity. A significant reduction in lining SF area but not sublining SF area was observed after anti-TNFα therapy. Conclusion Our findings indicate that Hsp47 is a reliable marker for quantifying SFs in human synovial tissue. Our data suggest that lining and sublining SFs undergo different dynamics during the course of the disease. Lining SF expansion parallels the activity and temporal progression of RA and can be partially reversed by anti-TNFα therapy.

Methods ST samples from the inflamed knee joint of 30 patients fulfilling the CASPAR criteria for PsA were immunostained with CD3 (T cell), CD20 (B-cell) and MECA-79 (high endothelial vessels). SLN was defined by lymphoid aggregates grade 2-3 (>6 radial of B and T cells), T-B cell segregation and MECA-79 positive vessels. mRNA was also extracted from ST samples of patients and 2 controls without synovial inflammation, and measured by TaqMan. Relative changes in gene expression were assessed by the delta-delta CT method using GAPDH as an endogenous control gene. The following cytokines and receptors were analyzed: CCR7, Lymphotoxin (LT)-beta (b), IL-7, IL-10, IL-1b, IL-6, TNF-a, IL-17 A, IL-21, IL-22 and IL-23. Clinical and biological data were collected at inclusion and at the end of follow-up.

Background Angiogenesis is considered an important factor in the pathogenesis of Rheumatoid Arthritis (RA) where it has been proposed as a therapeutic target. In other settings, active angiogenesis is characterized by pathologic, immature vessels that lack periendothelial cells. We searched for the presence of immature vessels in RA synovium and analyzed the dynamics of synovial vasculature along the course of the disease, particularly after therapeutic response to TNF antagonists. Methodology/principal findings Synovial arthroscopic biopsies from RA, osteoarthritis (OA) and normal controls were analyzed by double labeling of endothelium and pericytes/smooth muscle mural cells to identify and quantify mature/immature blood vessels. To analyze clinicopathological correlations, a cross-sectional study on 82 synovial biopsies from RA patients with variable disease duration and severity was performed. A longitudinal analysis was performed in 25 patients with active disease rebiopsied after anti-TNF-alpha therapy. We found that most RA synovial tissues contained a significant fraction of immature blood vessels lacking periendothelial coverage, whereas they were rare in OA, and inexistent in normal synovial tissues. Immature vessels were observed from the earliest phases of the disease but their presence or density was significantly increased in patients with longer disease duration, higher activity and severity, and stronger inflammatory cell infiltration. In patients that responded to anti-TNF-alpha therapy, immature vessels were selectively depleted. The mature vasculature was similarly expanded in early or late disease and unchanged by therapy. Conclusion/significance RA synovium contains a significant fraction of neoangiogenic, immature blood vessels. Progression of the disease increases the presence and density of immature but not mature vessels and only immature vessels are depleted in response to anti-TNFalpha therapy. The different dynamics of the mature and immature vascular fractions has important implications for the development of anti-angiogenic interventions in RA.

In a previous study, we found that synovial immunopathology differs between Behcet disease (BD) and psoriatic arthritis (PsA). The objective of this study is to describe the macroscopic features of early untreated knee synovitis in BD and PsA. Fourteen consecutive patients with active early knee synovitis (seven BD and seven PsA) undergoing rheumatologic arthroscopy were assessed. The following macroscopic synovial features were evaluated and scored by analyzing the video recordings of each procedure: capillary hyperaemia, morphology of synovitis, vascular pattern, fibrinoid membranes, and topographic distribution of these features. Video-recording of 35 early untreated arthritis patients with different diagnoses were also studied looking for BD-like macroscopic features. Six out of seven BD patients had extensive fibrinoid membranes and large areas of erythematous synovitis without villi or a distinctive vascular pattern, while PsA patients had diffuse erythematous villous synovitis with a tortuous vascular morphology. None of the 35 patients with early untreated arthritis exhibited all the characteristic features of BD synovitis. This exploratory study shows some distinctive features between BD and PsA knee synovitis that confirm macroscopic differences in patients with previously reported immunopathological differences.

Objective: Fcγ receptor (FcγR) polymorphism influences the affinity of the receptor for Ig, which may, in turn, affect the efficacy of Ig-based therapies. The relationship between functional single nucleotide polymorphisms (SNP) of the FCGR2A and FCGR3A genes and the response to anti-tumour necrosis factor (TNF)α therapy (infliximab) in patients with rheumatoid arthritis (RA) was assessed. Methods: A total of 91 patients with RA (89% female; 76.7% rheumatoid factor (RF) positive) starting therapy with infliximab were evaluated at 0, 6 and 30 weeks using the American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) response criteria and the 28-joint Disease Activity Score (DAS28) was evaluated using three parameters, including C-reactive protein (CRP) (DAS28 3v-CRP) changes during the follow-up. Genotyping of FCGR2A -R131H and FCGR3A -F158V polymorphisms was performed by allele-specific PCR and PCR sequence-based typing, respectively. The χ 2 and Fisher exact tests were used to show differences in the outcome variables, and analysis of variance (ANOVA) to analyse the evolution of DAS28 3v-CRP. A generalised linear models multivariable analysis was also performed. Results: At week 6 of follow-up, the proportion of patients achieving 50% improvement as per ACR criteria (ACR50) and EULAR good responses were significantly higher among homozygotes of the low affinity FCGR3A allele (FF: 24.1% and VV-VF:2.2%; p = 0.003 and FF: 44.8% and VV-VF: 22.9%; p = 0.040, respectively). At week 30, homozygotes of the low affinity FCGR2A allele had a better ACR20 response (RR: 60% and HH-RH: 33.3%; p = 0.035). Changes in DAS28 3v-CRP during follow-up were consistent with those observed in ACR and EULAR responses. Conclusions: The response to anti-TNFα treatment with infliximab in patients with RA is influenced by the FCGR2A and FCGR3A genotypes. This effect is observed at different times in the follow-up (6 and 30 weeks, respectively) indicating the dynamic nature of the FcγR versus Ig interaction.

Objective:To investigate the clinical significance of lymphoid neogenesis (LN) in rheumatoid arthritis (RA), the clinicopathological correlates of this process and its evolution after anti-tumour necrosis factor (TNF)α therapy in a large series of synovial tissues were analysed.Methods:Arthroscopic synovial biopsies from 86 patients with RA were analysed by immunohistochemistry. LN was defined as the presence of large aggregates of lymphocytes with T/B cell compartmentalisation and peripheral node addressin (PNAd) positive high endothelial venules. Clinical variables at baseline and after prospective follow-up were compared in LN positive and negative RA subsets. The evolution of LN and its correlation with the clinical course in a subgroup of 24 patients that underwent a second arthroscopic biopsy after anti-TNFα therapy was also analysed.Results:LN was present in 49% of RA synovial tissues. Patients with LN had a significantly higher disease duration and a higher previous use of anti-TNFα agents. During prospective follow-up, the proportion of patients achieving good or moderate European League Against Rheumatism (EULAR) 28-joint Disease Activity Score (DAS28) responses was significantly lower in patients who were LN positive despite a significantly higher use of anti-TNFα agents. By multivariate logistic regression analysis, LN remained as an independent negative predictor of response to therapy. In the subgroup of patients rebiopsied after anti-TNFα therapy, reversal of LN features occurred in 56% of the patients and correlated with good clinical responses.Conclusions:Synovial LN in RA predicts a lower response to therapy. LN features can be reversed after a short period of anti-TNFα therapy in parallel to good clinical responses.