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BackgroundNo immunomodulatory drug has ever demonstrated its efficacy in primary Sjögren’s Syndrome (pSS). Drug repurposing, or drug repositioning, refers to the use in another disease of an existing drug, originally approved or evaluated in a different disease.ObjectivesThe objective of our study was to repurpose existing therapeutic drugs in pSS using a transcriptomic approach.MethodsWe generated pSS transcriptomic signatures from peripheral blood samples of patients with pSS compared to healthy controls in two cohorts (ASSESS and a Norwegian cohort) and data mined available pSS transcriptomic signatures in public databases. We compared each disease signature to transcriptomic signatures, obtained from the biological action of 2837 drugs, 2160 knock-in and 3799 knock-down genes, available in the Connectivity Map database. A median similarity score with regard to disease signatures was computed for each candidate drug/gene. Drugs and genes were selected if p│80│. If this score is sufficiently high and statistically significant (>80, pFigure 1.Methods of drug-repurposing transcriptomic analysis (adapted from Toro-Dominguez et al, Arthritis Res Ther 2017;19:54)Results1091 peripheral blood transcriptomes were analyzed from 6 independent studies (906 patients with pSS and 185 healthy controls). Our analysis identified 11 transcriptomic drug signatures significantly associated with pSS signature. We identified 72 transcriptomic knock-in (11) or knock-down (61) gene signatures significantly associated with that of pSS, including 21 with a negative similarity score (Table 1).Table 1.Knock-down and knock-in genes significantly associated with the pSS transcriptomic signaturesType ofexperimentSimilarity scoreGenesNumber of genesKnock-in+IFNG, DUSP28, IFNB1, LYN, BCL2L2, TNFRSF1A, CD40, BCL10, NLK, ZNF39810-SLC52A2111Knock-down+SLC25A14, GOLIM4, DTYMK, DCXR, RRM2, IMPA1, CLTB, F12, CAB39, ID1, ISOC1, UBAP1, HIGD2A, UFD1L, SOD2, BTG1, PRKCI, HIST2H2BE, NISCH, TEAD4, MTX2, TYK2, GTF2B, NDUFS7, NNT, ACADSB, GSTP1, HOMER2, SORBS3, PCK2, PHB2, PDXK, TES, TM9SF2, TBX2, HOXA6, KIF2C, MED1, NR2F6, CD14, BECN141-TM9SF3, E2F3, PRMT3, KD, PKN2, SUCLA2, CD44, GRN, SP3, ATP5S, MYCBP2, TRAF7, POLA2, ADRB2, PSMG1, PPP2R3C, PMAIP1, ETFA, ANKRD37, SPECC1L2061Type I and II interferons were highly ranked (similarity score >99), and their overexpression mimicked the disease signature. CD40 appeared also as a very relevant target (similarity score = 98.8). Three drugs had a significant negative similarity score: ampicillin (-88.69, p=0.0019), amylocaine (-88.28, p=0.0026), and droxinostat (-85.42, p=0.0027). Droxinostat is a HDAC inhibitor. HDAC activity has been shown to be an essential element of the coactivation system for IFN-induced gene regulation and the IFN-induced innate immune response.ConclusionThis first drug repositioning transcriptomic approach in Sjögren’s syndrome confirms the interest of targeting interferons and identifies histone deacetylases as potential therapeutic targets.AcknowledgementsInvestigators of the ASSESS cohort: Emmanuelle Dernis, Valerie Devauchelle-Pensec, Philippe Dieude, Jean-Jacques Dubost, Anne-Laure Fauchais, Vincent Goeb, Eric Hachulla, Pierre Yves Hatron, Claire Larroche, Véronique Le Guern, Jacques Morel, Aleth Perdriger, Carinne Salliot, Stephanie Rist, Alain Saraux, Jean Sibilia, Olivier Vittecoq, Gaétane Nocturne, Philippe Ravaud, Raphaèle SerorCentre de Ressources Biologiques de l’Hôpital Bichat: Sarah TubianaJohan G. Brun for contributing to the Norwegian cohort.Funding SourcesThis work was supported by the Innovative Medicines Initiative 2 Joint Undertaking (IMI 2 JU) (NECESSITY grant 806975). The Joint Undertaking received support from the European Union’s Horizon 2020 Research and Innovation Program and from the European Federation of Pharmaceutical Industries and Associations. This work was also supported by R01 AR065953 Beth the NIH, United States. The contents are the sole responsibility of the authors and do not necessarily the official views of the NIH.JEG received an unrestricted grant from Bristol-Myer-Squibbs to do the transcriptomic analysis of the ASSESS and Norwegian cohorts. JEG received a grant from Geneviève Garnier (Association Française du Syndrome de Gougerot-Sjögren et des syndromes secs).The ASSESS cohort is promoted by the French Society of Rheumatology and received two research grants from the French Society of Rheumatology.The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.Disclosure of InterestsRenaud FELTEN: None declared, Tao Ye: None declared, Cédric Schleiss: None declared, Benno Schwikowski: None declared, Jean Sibilia: None declared, Fanny Monneaux: None declared, Hélène Dumortier: None declared, Roland Jonsson: None declared, Christopher Lessard: None declared, Wan Fai Ng: None declared, Tsutomu Takeuchi: None declared, Xavier Mariette: None declared, Jacques-Eric Gottenberg Grant/research support from: JEG received an unrestricted grant from Bristol-Myer-Squibbs to do the transcriptomic analysis of the ASSESS and Norwegian cohorts.

BackgroundThe TRial for Anti-B-Cell Therapy In patients with pSS (TRACTISS) is the largest multi-centre, placebo-controlled, phase-III trial with the administration of 2 cycles of Rituximab (RTX) or placebo at week 0 and 24, with trial clinical endpoints at week 48. Despite the primary endpoints (30% reduction in fatigue or oral dryness) were not met, RTX treated patients showed an improvement in secondary endpoints, such as unstimulated whole salivary flow (UWSF), and salivary gland (SG) total ultrasound score1,2. Additionally, recent post-hoc analysis of TRACTISS using novel CRESS composite endpoints3, highlighted a significantly increased response rate in the RTX vs placebo arm.ObjectivesTo perform the first longitudinal analysis of matched transcriptomic and histological data of SG biopsies of pSS patients treated with RTX vs placebo at 3 time points, over 48 weeks, from the TRACTISS cohort, in order to identify mechanisms of response/resistance to B cell depletion.Methods29 pSS patients randomised to RTX or placebo arm consented for labial SG biopsies at week 0, 16 and 48. Patients received two 1000mg cycles of RTX or placebo at week 0 and 24. SG focus score, inflammatory aggregate area fraction, B-cells (CD20+), T-cells (CD3+), follicular dendritic cells (FDCs) (CD21+) and plasma cells (CD138+) density were assessed using quantitative digital image analysis. RNA sequencing with deconvolution and pathway analysis was performed to identify genes signatures and consensus gene modules as biomarkers of disease evolution and response/resistance to therapy.ResultsPlacebo-treated SGs showed worsening of SG inflammation highlighted by the increment of aggregate size, B-cell density, development of new FDC networks, and a higher ectopic GC prevalence over 48 weeks, compared to RTX-treated patients. No difference in focus score, total T-cell and plasma cell infiltration was observed. RTX downregulated genes involved in immune cell recruitment and inflammatory aggregate organisation (e.g. CXCL13, CCR7 and PDCD1). Gene signature-based analysis of 35 immune cell types using XCell highlighted how RTX blocked class-switched and memory-B-cells accumulation in SGs over 48 weeks. Pathway analyses confirmed the downregulation of leukocyte migration, MHC-II antigen presentation, and T-cell co-stimulation immunological pathways, such as the CD40 receptor complex pathway. Among RTX-treated patients, only CRESS-responders demonstrated prevention of worsening B cell-driven molecular pathology signatures over time and a significant improvement in UWSF, in parallel with the upregulation of molecular pathways associated to SG restoration of the glandular epithelium. None of the above effects were observed at week 16 after the first RTX cycle.ConclusionTwo RTX infusions repeated at week 24 exerted beneficial effects on labial SG inflammatory infiltration in pSS by downregulating genes involved in immune cell recruitment, activation and organisation in ectopic GCs. Conversely, all the above parameters showed significant evolution in placebo treated patients over 48 weeks demonstrating progression of SG immunopathology. Clinical responders to RTX based on CRESS response criteria were characterised by preservation of exocrine function which appear driven by SG epithelial restoration.References[1]Fisher, B. A. et al. Effect of rituximab on a salivary gland ultrasound score in primary Sjögren’s syndrome: results of the TRACTISS randomised double-blind multicentre substudy. Ann. Rheum. Dis.77, 412–416 (2018).[2]Bowman, S. J. et al. Randomized Controlled Trial of Rituximab and Cost-Effectiveness Analysis in Treating Fatigue and Oral Dryness in Primary Sjögren’s Syndrome. Arthritis Rheumatol.69, 1440–1450 (2017).[3]Arends, S. et al. Composite of Relevant Endpoints for Sjögren’s Syndrome (CRESS): development and validation of a novel outcome measure. Lancet Rheumatol.3, e553–e562 (2021).Disclosure of InterestsNone declared

BackgroundSjogren’s disease (SjD) is an autoimmune disease characterized by reduced function of exocrine glands (i.e., salivary and lacrimal glands). Epithelial cell damage resulting from lymphocytic infiltration has been implicated in SjD etiology [1]. How genetic and epigenetic changes influence epithelial-immune cell interactions in SjD pathogenesis remain understudied.ObjectivesEvaluate the role of SjD risk loci in salivary gland tissue to gain insights into the potential genes involved in salivary gland dysfunction.MethodsSNPs from 16 regions with SNP-SjD associations (PResultsIn total, 5884 genome-wide significant SNPs from 16 SjD risk loci were identified as potential minor salivary gland eQTLs using two discovery thresholds: p(FDR)0.05 and pIRF5 and TNPO3 on chromosome 7 at 128Mb; however, this locus had 12 additional genes that were eQTLs in minor salivary gland. In contrast, other loci had no reported eQTLs for the index gene, but several reported eQTLs for other genes, such TYK2 on chromosome 19 at 10Mb that showed no change in TYK2 expression but eQTLs for 8 distant genes, including ICAM1. Pathway enrichment analysis revealed an enrichment in Butyrophilin (BTN) family interactions (R-HSA-8851) (PAdj=1.564x10-5), including the BTN2A1, BTN2A2, BTN3A1, BTN3A2 and BTN3A3 gene cluster in the MHC region. In further support, TWAS of the minor salivary gland and the SjD GWAS summary statistics (after Bonferroni correction) showed association between SjD and BTN3A2 (p=1.24x10-42), as well as many other loci in the MHC region. In addition, several long non-coding (lnc) RNAs on chromosome 17 were significant, peaking at RP11-259G18.1 (p=4.43x10-10).ConclusionThis study shows that SjD-associated risk alleles influence disease by altering gene expression in immune cells and minor salivary glands. Further, our analysis suggests that altered gene expression in the minor salivary gland expands beyond effects on the index gene to several genes on each locus. Interestingly, we observed minor salivary gland eQTLs for several BTN family genes, which act as cell-surface binding partners to regulate cell-cell interactions, including interactions between epithelial cells and activated T cells [3]. Future work will assess chromatin-chromatin-interactions within the 10 SjD risk loci in salivary gland cells and tissues to map local chromatin regulatory networks that regulate gene expression. Additional transcriptional studies of SjD minor salivary gland tissues will provide further insights into how altered gene expression in the salivary gland influences SjD pathology.References[1]Verstappen. Nat Rev Rheumatol 2021;17(6):333-348.[2]Khatri, et al. Annals of Rheumatic Diseases 2020;79:30-31.[3]Arnett HA, Viney JL. Nature Reviews Immunology 2014;14:559-569.Disclosure of InterestsFarhang Aghakhanian: None declared, Mandi M Wiley: None declared, Bhuwan Khatri: None declared, Kandice L Tessneer: None declared, Astrid Rasmussen: None declared, Simon J. Bowman Consultant of: Abbvie, Galapagos, and Novartis in 2020-2021., Lida Radfar: None declared, Roald Omdal: None declared, Marie Wahren-Herlenius: None declared, Blake M Warner: None declared, Torsten Witte: None declared, Roland Jonsson: None declared, Maureen Rischmueller: None declared, Patrick M Gaffney: None declared, Judith A. James: None declared, Lars Ronnblom: None declared, R Hal Scofield: None declared, Xavier Mariette: None declared, Marta Alarcon-Riquelme: None declared, Wan Fai Ng: None declared, Kathy Sivils Employee of: Current employee of Janssen, Gunnel Nordmark: None declared, Umesh Deshmukh: None declared, A Darise Farris: None declared, Christopher Lessard: None declared

BackgroundFatigue is one of the most disabling symptoms in primary Sjogren’s syndrome (pSS) and it significantly impacts patient’s quality of life[1]. However, the cause of this symptom remains unclear.Lactate dehydrogenase (LDH), is an enzyme of the anaerobic respiratory pathway. High lactate levels are a marker of inflammation and create a pro-inflammatory microenvironment[2]. LDH levels can be raised in myositis, haemolysis and lymphoma. For this reason, serum LDH is routinely monitored in patients with pSS. However given its role in metabolic pathways, we hypothesize that serum levels of LDH may also be a biomarker of fatigue in pSS.Objectives1. To investigate the bivariate relationship between LDH and fatigue severity, hypothesizing a positive correlation between them.2. To incorporate factors such as depression, anxiety, serum creatinine and haemoglobin levels as covariates, as these factors may also contribute to fatigueMethodsWe used routinely collected clinical and laboratory data from 512 pSS patients from the Newcastle Sjogren’s syndrome cohort. The participants consented for their linked anonymised data to be used in pSS-related research. Severity of fatigue was measured using fatigue subscale of EULAR Sjogren’s Syndrome Reported Patient Index (ESSPRI)– a Likert scale of 0-10. Fatigue severity was also categorised into 4 categories: 0-2 being minimal, 3-5 mild, 6-7 moderate and 8-10 severe. Hospital Anxiety and Depression Score was used to measure patients’ anxiety and depression levels. Blood parameters including haemoglobin, full blood count, ESR, CRP, serum creatinine, alanine aminotransferase (ALT), alkaline phosphatase (ALP) and LDH were checked during each visit. Dryness was measured using ESSPRI dryness subscale.Statistical analysis of the relationship between the continuous blood parameters and categorical fatigue groups was performed using Kruskal-Wallis for categorical fatigue groups and linear regression for continuous fatigue measures.ResultsThe majority of the patients were female (87%) and Caucasian. Baseline measurements of pain, anxiety, depression, abnormal fatigue, mental fatigue and overall ESSPRI score increased with increasing fatigue severity.This is seen most prominently in serum LDH levels. LDH levels increased with increasing fatigue scores. We identified significant differences in baseline LDH levels across the four fatigue groups (p = 0.002). Within groups comparisons showed significant differences between mild and minimal, severe and minimal and moderate and minimal fatigue groups only (p-values: 0.026, 0.019 and 0.032 respectively). A baseline linear regression model for fatigue using LDH, CPK, age and gender was performed and showed LDH has a significant relationship with fatigue p=0.007.Findings were also determined using ANOVA where significant difference (p= 0.0023) of LDH between fatigue groups were identified using Kruskal-Walis test. A supplementary Tukey-Kramer test was carried out to determine if LDH was significant between two-groups of fatigue severity score, where significant difference was seen between three different sets of fatigue categories: mild-minimal, severe-minimal and moderate-minimal. The test ensured that a relationship between the enzyme and fatigue was present especially between the groups of fatigue severity stated above.The actual-by-predicted and leverage plot further supporting our findings by showing the unique effect of LDH in the models.ConclusionThe study concludes that a relationship between enzyme lactate dehydrogenase and fatigue exist; however, further study will be required to examine its role as a predictor of fatigue severity in pSS. The complex interconnection between inflammation, disease activity, psychological factors and LDH will have to be further investigated to advance the current understanding of chronic fatigue in Sjogrens syndrome.References[1]Fatigue and immune activity in sjogren’s syndrome[2]Lactate at the crossroad of metabolism, inflammation, and autoimmunityDisclosure of InterestsNone declared

BackgroundSjögren’s Disease (SjD) and Systemic Lupus Erythematosus (SLE) are autoimmune diseases with several shared characteristics and similar genome-wide significant associations with the DDX6-CXCR5 locus. DDX6 suppresses interferon-stimulated gene expression and CXCR5 regulates T cell functions implicated in autoimmunity.ObjectivesTo identify and characterize functional SNPs in the DDX6-CXCR5 interval.MethodsImmunoChip data from European populations (3785 SLE cases; 1916 SjD cases; 6893 controls) were imputed and SNP-trait associations tested. Bayesian statistics defined a credible SNP set that was refined using bioinformatic analyses (RegulomeDB, Haploreg, ENCODE, promoter capture Hi-C, eQTLs, etc.). Electrophoretic mobility shift assays (EMSAs) and luciferase expression assays were used to test allele-specific SNP function in EBV-transformed B (EBV B) cells, Daudi B cells, Jurkat T cells, THP1 monocytes, and A253 salivary gland cell lines. Chromatin conformation capture with quantitative PCR (3C-qPCR) was used to assess long-range chromatin interactions.ResultsFine mapping of the SjD and SLE associations found similar SNP associations. Bioinformatic analyses identified 5 common SNPs with strong evidence of functionality in immune cell types: rs57494551 in an intron of DDX6, and rs4938572, rs4936443, rs7117261, and rs4938573 in the promoter/enhancer region of DDX6 and CXCR5. EMSAs and luciferase experiments showed cell type-specific differences in protein binding and promoter or enhancer activity, respectively, at each SNP. Risk allele of rs57494551 increased enhancer activity in B cells and A253 cells (pDDX6 in T cells, and the risk allele significantly increased protein binding, promoter and enhancer activity in T cells (pDDX6 and CXCR5, rs57494551 and/or rs4938572 are reported eQTLs for several other genes of interest in the local chromatin regulatory network: IL10RA in T cells, TRAPPC4 in salivary gland and activated macrophages, and long non-coding (lnc)RNA AP002954.1 in T cells and whole blood. 3C-qPCR in EBV B and A253 cells showed that the two regulatory regions carrying rs4938572 or rs57494551 interacted with a region upstream of DDX6 that includes AP002954.1. Hi-C data showed looping between AP002954.1 and the regulatory region carrying rs4938572 and rs57494551 in T cells.ConclusionSjD and SLE share similar genomic architecture across the DDX6-CXCR5 risk interval with several common SNPs showing immune and salivary gland cell type-specific allelic effects on protein binding and/or enhancer/promoter activity. Extensive bioinformatic analyses suggest that the SNPs likely work within the local chromatin regulatory network to regulate cell type-specific expression of several genes on the interval. Ongoing studies will use 3C-qPCR to assess allele-specific chromatin interactions between the SNPs and these genes in different cells types, and CRISPR to determine how the risk alleles alters expression.Disclosure of InterestsMandi M Wiley: None declared, Bhuwan Khatri: None declared, Kandice L Tessneer: None declared, Michelle L Joachims: None declared, Anna M Stolarczyk: None declared, Anna Nagel: None declared, Astrid Rasmussen: None declared, Simon J. Bowman Consultant of: Abbvie, Galapagos, and Novartis in 2020-2021, Lida Radfar: None declared, Roald Omdal: None declared, Marie Wahren-Herlenius: None declared, Blake M Warner: None declared, Torsten Witte: None declared, Roland Jonsson: None declared, Maureen Rischmueller: None declared, Patrick M Gaffney: None declared, Judith A. James: None declared, Lars Ronnblom: None declared, R Hal Scofield: None declared, Xavier Mariette: None declared, Wan Fai Ng: None declared, Kathy Sivils Employee of: current employee of Janssen., Gunnel Nordmark: None declared, Betty Tsao: None declared, Christopher Lessard: None declared

Background:The pathogenic role of B-cells in primary Sjögren’s Syndrome (pSS) is well established and B cell abnormalities. Because of the substantial role of B-cells, rituximab (RTX), a chimeric anti-CD20 monoclonal antibody, has been considered as a potential biologic disease modifying drug to reduce disease activity in pSS. To date, the TRial for Anti-B-Cell Therapy In patients with pSS (TRACTISS) is the largest multi-centre, placebo-controlled trial with RTX. Despite the unmet primary endpoints (30% reduction in fatigue or oral dryness, measured by visual analogue scale), RTX treated patients showed an improvement in unstimulated whole salivary flow (Bowman et al. Arthritis Rheumatol 2017;69:1440–1450).Objectives:To provide the first longitudinal transcriptomic and histological analysis at 3 time points over 48 weeks of labial SGs of pSS patients treated with RTX, in comparison to placebo, from the TRACTISS cohort.Methods:26 pSS patients randomised to RTX or placebo arm consented for labial SG biopsies at baseline, weeks 16 and 48. Patients received two 1000mg cycles of RTX or placebo at baseline and week 24. SG focus score, inflammatory aggregate area fraction, B-cells (CD20+), T-cells (CD3+), follicular dendritic cells (FDCs) (CD21+) and plasma cells (CD138+) density were assessed by H&E and immunofluorescence staining. The histological analysis was performed by digital imaging using QuPath software. RNA was extracted from matched labial SG lobules and sequenced with Illumina platform. A Principal Component Analysis (PCA) and features driving the PCA were investigated along with the most influential gene loadings. The limma-voom R pipeline was used to extract Differential Expressed Genes (DEGs) between placebo and RTX group at week 48, and gene ontology (GO) enrichment analysis performed through EnrichR to derive GO terms and pathways associated with DEGs.Results:Placebo-treated labial SGs showed a worsening of inflammation highlighted by the increment of B-cell density, development of new FDC networks, and a higher ectopic GC prevalence at week 48, compared to RTX-treated patients. No difference in total T-cells and plasma cell infiltration was observed. RTX downregulated genes involved in immune cell recruitment and inflammatory aggregate organisation (e.g. CCR7, CCL19, CD52, and PDCD1) and gene signature-based analysis of 64 immune cell types highlighted how RTX preferentially blocked class-switched- and memory-B-cells infiltration in SGs at week 48. Pathway analyses confirmed the downregulation of leukocyte migration, MHC class II antigen presentation, and T-cell co-stimulation immunological pathways, such as the CD40 receptor complex pathway. The analysis of placebo SGs transcriptomic at week 48 showed a higher expression of genes linked to ectopic GC organisation, such as CXCL13, CCL19, LTβ, in female compared to male subjects. Gender was confirmed as a key co-variate responsible for most of the variation in the PCA, together with the SG focus score and the foci area fraction.Conclusion:Treatment with RTX showed beneficial effects on labial SG inflammatory infiltration in pSS, by downregulating genes involved in immune cell recruitment, activation and organisation in ectopic GCs. Class-switched-B-cells, memory-B-cells and FDC network development were primarily affected appearing to be responsible for the lack of progression in SG B cell infiltration in the RTX compared to the placebo arm in which clear worsening of SG immunopathology over 48 weeks was detected in female patients. Although a clear association with the clinical improvement in unstimulated salivary flow observed at week 48 in RTX-treated patients could not be established given the low number of patients consenting to 3 longitudinal biopsies it is conceivable that RTX is responsible for preserving exocrine function.Acknowledgements:SJB receives a salary contribution from the NIHR Birmingham Biomedical Research Centre.Disclosure of Interests:Elena Pontarini: None declared, Farzana Chowdhury: None declared, Elisabetta Sciacca: None declared, Sofia Grigoriadou: None declared, Felice Rivellese: None declared, Davide Lucchesi: None declared, Katriona Goldmann: None declared, Liliane Fossati-Jimack: None declared, Paul Emery: None declared, Wan Fai Ng: None declared, Nurhan Sutcliffe: None declared, Colin Everett: None declared, Catherine Fernandez: None declared, Anwar Tappuni: None declared, Myles Lewis: None declared, Costantino Pitzalis: None declared, Simon J. Bowman Consultant of: SJB In 2020 I have received consultancy fees from Novartis, Abbvie and Galapagos., Michele Bombardieri: None declared

International audience; The therapeutic management of Sjögren syndrome (SjS) has not changed substantially in recent decades: treatment decisions remain challenging in clinical practice, without a specific therapeutic target beyond the relief of symptoms as the most important goal. In view of this scenario, the European League Against Rheumatism (EULAR) promoted and supported an international collaborative study (EULAR SS Task Force) aimed at developing the first EULAR evidence and consensus-based recommendations for the management of patients with SjS with topical and systemic medications. The aim was to develop a rational therapeutic approach to SjS patients useful for healthcare professionals, physicians undergoing specialist training, medical students, the pharmaceutical industry and drug regulatory organisations following the 2014 EULAR standardised operating procedures. The Task Force (TF) included specialists in rheumatology, internal medicine, oral health, ophthalmology, gynaecology, dermatology and epidemiology, statisticians, general practitioners, nurses and patient representatives from 30 countries of the 5 continents. Evidence was collected from studies including primary SjS patients fulfilling the 2002/2016 criteria; when no evidence was available, evidence from studies including associated SjS or patients fulfilling previous sets of criteria was considered and extrapolated. The TF endorsed the presentation of general principles for the management of patients with SjS as three overarching, general consensus-based recommendations and 12 specific recommendations that form a logical sequence, starting with the management of the central triplet of symptoms (dryness, fatigue and pain) followed by the management of systemic disease. The recommendations address the use of topical oral (saliva substitutes) and ocular (artificial tear drops, topical non-steroidal anti-inflammatory drugs, topical corticosteroids, topical CyA, serum tear drops) therapies, oral muscarinic agonists (pilocarpine, cevimeline), hydroxychloroquine, oral glucocorticoids, synthetic immunosuppressive agents (cyclophosphamide, azathioprine, methotrexate, leflunomide and mycophenolate), and biological therapies (rituximab, abatacept and belimumab). For each recommendation, levels of evidence (mostly modest) and TF agreement (mostly very high) are provided. The 2019 EULAR recommendations are based on the evidence collected in the last 16 years in the management of primary 2002 SjS patients and on discussions between a large and broadly international TF. The recommendations synthesise current thinking on SjS treatment in a set of overarching principles and recommendations. We hope that the current recommendations will be broadly applied in clinical practice and/or serve as a template for national societies to develop local recommendations.

Neuropathic pain remains underrecognised and ineffectively treated in chronic pain sufferers. Consequently, their quality of life is considerably reduced, and substantial healthcare costs are incurred. The anatomical location of pain must be identified for definitive diagnosis, but current neuropsychological tools cannot do so. Matrix metalloproteinases (MMP) are thought to maintain peripheral neuroinflammation, and MMP-12 is elevated particularly in such pathological conditions. Magnetic resonance imaging (MRI) of the peripheral nervous system has made headway, owing to its high-contrast resolution and multiplanar features. We sought to improve MRI specificity of neural lesions, by constructing an MMP-12-targeted magnetic iron oxide nanoparticle (IONP). Its in vivo efficiency was evaluated in a rodent model of neuropathic pain, where the left lumbar 5 (L5) spinal nerve was tightly ligated. Spinal nerve ligation (SNL) successfully induced mechanical allodynia, and thermal hyperalgesia, in the left hind paw throughout the study duration. These neuropathy characteristics were absent in animals that underwent sham surgery. MMP-12 upregulation with concomitant macrophage infiltration, demyelination, and elastin fibre loss was observed at the site of ligation. This was not observed in spinal nerves contralateral and ipsilateral to the ligated spinal nerve or uninjured left L5 spinal nerves. The synthesised MMP-12-targeted magnetic IONP was stable and nontoxic in vitro. It was administered onto the left L5 spinal nerve by intrathecal injection, and decreased magnetic resonance (MR) signal was observed at the site of ligation. Histology analysis confirmed the presence of iron in ligated spinal nerves, whereas iron was not detected in uninjured left L5 spinal nerves. Therefore, MMP-12 is a potential biomarker of neuropathic pain. Its detection in vivo, using IONP-enhanced MRI, may be further developed as a tool for neuropathic pain diagnosis and management.

Background:Fatigue is reported as a common symptom among autoimmune and other chronic diseases such as fibromyalgia (FM), a long-term condition with uncertain pathophysiology. Previous studies from our group suggest that non-invasive vagus nerve stimulation (nVNS) may contribute to the improvement of patient reported outcome measures (PROMs) of fatigue in patients with primary Sjögren’s Syndrome (1).Objectives:This follow-up study uses the gammaCore device (electroCore) to assess the effect of nVNS on PROMs of fatigue and immune responses in chronic fatigue syndrome (CFS), FM and rheumatoid arthritis (RA).Methods:The study included thirteen CFS, fourteen FM and fifteen RA patients who used the gammaCore nVNS device twice daily over a 26-day period. Pre- and post- nVNS bloods were drawn at baseline and final visits. Whole blood samples were stimulated with 2 ng/mL lipopolysaccharide (LPS) and the IL-6 and TNF-α cytokine concentrations were quantified at 24 hours. In addition, the epidermal growth factor (EGF), IFN-γ, IL-6, IP-10, MIP-1α, and TNF-α levels were measured in ‘pre-nVNS’ serum and flow cytometric profiles of whole blood immune cells were analysed. The patient reported outcome measures (PROMs) recorded at each visit were the Visual Analogue Scale (VAS) (0-100 cm) of abnormal fatigue, Hospital Anxiety and Depression (HAD) Scale, Orthostatic Grading Scale, Epworth Sleepiness Scale (daytime sleepiness), and Profile of fatigue (PRO-F) for Physical and Mental fatigue. Paired t-tests were performed to assess for changes in PROMs, cytokine levels, and cell subset distribution and associations of cytokine response with PROMs were investigated by correlation analyses.Results:Eleven CFS, twelve FM and fourteen RA patients completed the study. There was a significant reduction in daytime sleepiness in CFS (p =0.0321) and FM (p =0.0294) patients between the final and baseline visits and a significant reduction in HAD depression (p =0.0413) in FM (Fig.1). Improvement in VAS for abnormal fatigue, HAD-Anxiety, HAD-Depression, PRO-F Physical and Mental fatigue was observed in all three groups over the study period with a reduction in VAS fatigue in 64% of CFS, 67% of FM and 62% of RA patients. There were no significant changes in the immune cell subsets or in cytokine response. Finally, higher baseline pre-nVNS supernatant IL-6 levels were predictive of an improvement in VAS fatigue (p =0.0006), Daytime Sleepiness (p =0.0466) and PRO-F Physical fatigue (p =0.0196) in RA, while higher baseline TNF-α levels were predictive of an improvement in VAS fatigue (p =0.0003), Daytime Sleepiness (p =0.0380), Orthostatic (p =0.0281) and PRO-F Physical fatigue (p =0.0007) in FM.Conclusion:Our findings suggest that nVNS may contribute to the improvement of PROMs of fatigue in CFS, FM and RA. NVNS led to significant reductions in daytime sleepiness in CFS and FM, and depression in FM. Further studies and a larger sample size are needed to investigate the potential effects of nVNS on diseases characterised by persistent fatigue.References:[1]Tarn J, Legg S, Mitchell S, Simon B, Ng WF. The Effects of Noninvasive Vagus Nerve Stimulation on Fatigue and Immune Responses in Patients With Primary Sjögren’s Syndrome. Neuromodulation Technol Neural Interface. 2018;22(5):580–5.Figure 1.VAS for abnormal fatigue and PROMs recorded at baseline and final visits in patients with chronic fatigue syndrome (CFS), fibromyalgia (FM) and rheumatoid arthritis (RA). Boxplots show the median, upper, and lower quartiles for PROMs at visit 1 and visit 3 in each disease group. Paired-t tests revealed a significant reduction in daytime sleepiness in CFS and FM (B), and a significant reduction in HAD depression in FM (E). Improvement trends were observed in VAS for abnormal fatigue, HAD-Anxiety, HAD-Depression, PRO-F Physical fatigue and PRO-F Mental fatigue in all three groups over the 26-day study period.Acknowledgements:This study received infrastructural support from the National Institute of Health Research (NIHR) Newcastle Biomedical Research Centre at Newcastle Hospitals Foundation Trust and Newcastle University.Disclosure of Interests:Emmanuella Traianos: None declared, Bethany Dibnah: None declared, Dennis Lendrem: None declared, Yasmin Clark: None declared, Victoria Macrae: None declared, Victoria Slater: None declared, Karl Wood: None declared, David Storey: None declared, Bruce Simon Shareholder of: Bruce Simon is an employee and shareholder of electroCore., Employee of: electroCore, Inc., Justyna Blake Shareholder of: Justyna Blake is an employee of electroCore, and receives stock ownership., Employee of: electroCore, Inc., Jessica Tarn: None declared, Wan Fai Ng: None declared

Background:Sjögren’s Syndrome (SS) and Systemic Lupus Erythematosus (SLE) are distinct chronic, complex autoimmune diseases with shared characteristics such as autoantibodies, heightened interferons, and polyarthritis. SS and SLE genome-wide association studies (GWAS) report strong associations with theDDX6-CXCR5risk interval. DDX6 suppresses interferon stimulated gene expression and CXCR5 regulates T cell functions implicated in autoimmunity.Objectives:To identify functional variants that impact regulation in theDDX6-CXCR5interval.Methods:Fine-mapping was done using ImmunoChip data from 3785 SLE, 1916 SS cases and 6893 population controls of European ancestry that were imputed and tested for SNP-trait association. Bayesian statistics assigned posterior probabilities to SNPs and defined a credible set of risk variants. Bioinformatic analyses further prioritized variants with predicted functionality. Electrophoretic mobility shift assays (EMSAs) and luciferase expression were used to validate predicted SNPs in EBV transformed B (EBV B) cells.Results:While some differences were observed, the overall SS and SLE association signals were similar. SNP-SS rs9736016 nearCXCR5and SNP-SLE rs76409436 nearDDX6were the most significant but did not show evidence of functionality. Bayesian statistics defined credible sets of variants in strong D’ in common between both SS and SLE. Bioinformatics analyses (Haploreg, RegulomeDB, ENCODE data, etc) further refined the credible set and identified 5 common SNPs with strong evidence of functionality in immune cell types: rs4938572, rs4936443, rs57494551, rs7117261 and rs4938573. EMSAs showed a significant increase in protein binding to the risk allele of rs57494551 (p=0.0001), rs7117261 (p=0.0001) and rs4938573 (p=0.0003), but not the others, using nuclear lysates from EBV B cells. Luciferase vectors with a minimal promoter or no promoter were used to test for enhancer or promoter activity, respectively. To this end, the rs57494551 risk allele exhibited a significant increase in enhancer activity (p=0.0001). In contrast, the rs7117261 risk allele decreased enhancer activity (p=0.018). The rs4938573 risk allele decreased enhancer (p=0.043) and promoter (p=0.024) activity. While rs7117261 or rs4938573 were not reported in eQTL databases, GTex data reported rs57494551 as an eQTL that altersDDX6expression in whole blood (p=1.8E-7). Additionally, these functional SNPs have been associated with looping events to several proximal promoters in nearby genes in immune cells.Conclusion:SS and SLE have similar genomic architecture across theDDX6-CXCR5risk interval. Multiple variants in the credible set exhibited allele specific changes in protein binding, as well as modified enhancer activity, promoter activity or both. Ongoing studies will use Cas9 in EBV B cells to determine which other loci are within the local regulatory network.Disclosure of Interests:Mandi M Wiley: None declared, Bhuwan Khatri: None declared, Kandice L Tessneer: None declared, Michelle L Joachims: None declared, Anna M Stolarczyk: None declared, Astrid Rasmussen Speakers bureau: Novartis, ThermoFischer, Simon J. Bowman Consultant of: Astrazeneca, Biogen, BMS, Celgene, Medimmune, MTPharma, Novartis, Ono, UCB, xtlbio, Glapagos, Speakers bureau: Novartis, Lida Radfar: None declared, Roald Omdal: None declared, Marie Wahren-Herlenius: None declared, Blake M Warner: None declared, Torsten Witte: None declared, Roland Jonsson: None declared, Maureen Rischmueller: None declared, Patrick M Gaffney: None declared, Judith A. James Grant/research support from: Progentec Diagnostics, Inc, Consultant of: Abbvie, Novartis, Jannsen, Lars Ronnblom Grant/research support from: AZ, Speakers bureau: AZ, R Hal Scofield Grant/research support from: Pfizer, Xavier Mariette: None declared, Wan-fai Ng: None declared, Kathy L Sivils: None declared, Gunnel Nordmark: None declared, Betty Tsao: None declared, Christopher Lessard: None declared

Background:Sjögren’s syndrome (SS) is a complex autoimmune disease with exocrine gland dysfunction leading to substantial morbidity. There are 10 published genetic susceptibility loci.Objectives:Our genome-wide association study (GWAS) aimed to identify additional risk loci of genome-wide significance (GWS; pMethods:A total of 3232 cases and 17481 controls genotyped on GWAS arrays and 619 cases and 6171 controls genotyped on ImmunoChip (IC) arrays were imputed after quality control. Logistic regression was calculated adjusting for ancestry using the first 4 principal components to identify SS-associated SNPs. GWAS and IC results were meta-analyzed using weighted Z-scores. Bayesian statistics were used to assign posterior probabilities and define credible SNP sets for each locus. Bioinformatic analyses were used to predict functionality.Results:Seven novel loci exceeded GWS in the GWAS analysis:NAB1,MIR146A-PTTG1,XKR6,MAPT-CRHR1,RPTOR-CHMP6-BAIAP2,TYK2andSYNGR1. Meta-analysis with IC data identified three more novel loci exceeding GWS:CD247,PRDM1-ATG5andTNFAIP3. Several additional loci with suggestive association (pADAMTSL2,CGNL1andPHRF1.Several identified loci have reported functional implications in immune regulation and autoimmune disease. In lupus, rs2431697 correlated with rs2431098, which was shown to alterMIR146Aexpression, resulting in type I interferon pathway imbalance. Similarly,TYK2risk association reportedly drives interferon, IL10 and RET signaling pathways.PRDM1encodes Blimp-1, a master regulator of immune cell differentiation.CD247encodes the zeta subunit of the T cell receptor complex.XKR6is implicated in apoptotic cell ingestion.ATG5is also involved in apoptosis, as well as autophagy and antigen presentation.Additional bioinformatics analyses (Haploreg, Regulome DB, ENCODE, etc.) revealed immune-relevant functional implications for each risk locus. The SS-associated credible set included variants downstream ofTNFAIP3in a region reported to abolish looping between an enhancer and theTNFAIP3promoter in lupus and a coding variant that has been shown to alter NF-kB activity and neutrophil extra-cellular traps. The rs2293765 in the 5’ UTR ofNAB1showed evidence of enhancer/promoter activities. The rs2069235 in theSYNGR1locus showed enhancer and transcription start site activities in B and T cells. The rs7210219 in theMAPT-CRHR1locus showed enhancer/promotor activities in various tissues.Conclusion:We have identified ten novel genetic susceptibility loci associated with SS pathology. Our finding increases the current number of GWS regions in SS patients of European origin, from 10 to 20. Future work is needed to identify and characterize the functional variants in each region.Disclosure of Interests:Bhuwan Khatri: None declared, Tove Ragna Reksten: None declared, Kandice L Tessneer: None declared, Astrid Rasmussen Speakers bureau: Novartis, ThermoFischer, R Hal Scofield Grant/research support from: Pfizer, Simon J. Bowman Consultant of: Astrazeneca, Biogen, BMS, Celgene, Medimmune, MTPharma, Novartis, Ono, UCB, xtlbio, Glapagos, Speakers bureau: Novartis, Joel Guthridge Grant/research support from: Xencor, Bristol Myers Squibb, DXterity, Judith A. James Grant/research support from: Progentec Diagnostics, Inc, Consultant of: Abbvie, Novartis, Jannsen, Lars Ronnblom Grant/research support from: AZ, Speakers bureau: AZ, Blake M Warner: None declared, Xavier Mariette: None declared, Roald Omdal: None declared, Javier Martin Ibanez: None declared, Maria Teruel: None declared, Janicke Liaaen Jensen: None declared, Lara A Aqrawi: None declared, Øyvind Palm: None declared, Marie Wahren-Herlenius: None declared, Torsten Witte: None declared, Roland Jonsson: None declared, Maureen Rischmueller: None declared, A Darise Farris Speakers bureau: Biogen, Marta Alarcon-Riquelme: None declared, Wan-fai Ng: None declared, Kathy L Sivils: None declared, Gunnel Nordmark: None declared, Christopher Lessard: None declared

Background:Current rheumatoid arthritis (RA) therapeutics target immune inflammation and are subject to ceiling effects, with non-response observed in a third of recipients together with low remission rates. Synovial fibroblasts (SFs) are stromal cells not yet targeted in RA, whose hyperplastic and proliferative properties drive inflammation and tissue destruction. Seliciclib (R-roscovitine) is an orally available cyclin-dependent kinase (CDK) inhibitor that suppresses SF proliferation and ameliorates inflammatory arthritis in rodents.Objectives:To determine the maximum tolerated dose (MTD) of seliciclib in patients with active RA despite anti-TNF, with or without background conventional disease modifying anti-rheumatic drugs (cDMARDs). Safety and pharmacokinetics (PK) were also evaluated.Methods:A restricted, one-stage Bayesian continual reassessment method (CRM) determined MTD based on a target dose-limiting toxicity (DLT) probability of 35%. RA patients (DAS28 ≥3.2) were recruited sequentially to cohorts of 3 subjects each. Cohort 1 received 400mg seliciclib daily for 4 consecutive days each week for 4 weeks, added to existing therapy. Each subsequent cohort received a dose determined by the toxicity-based CRM algorithm, calculated upon conclusion of the previous cohort. Safety was assessed through adverse event (AE) monitoring. Associations with relevant PK parameters were sought.Results:15 anti-TNF recipients were enrolled, 10 of whom were also taking cDMARDs (median DAS28 4.9). Application of the CRM algorithm prompted one dose increment during the study (to 600mg for cohort 2), but reversion to 400mg for subsequent cohorts (Figure 1A). After treatment of 5 cohorts, 400mg was determined the MTD, with a DLT probability of 0.35 (CI 0.18-0.52; Figure 1B). 6 patients experienced DLTs, of which two were classified as serious AEs (SAEs) in keeping with the safety profile of seliciclib; these are summarised in Table 1. Of 43/65 total AEs reported at any dose that didnotcontribute to a DLT, 26 were possibly, probably or definitely related to seliciclib; 19 of these 26 were mild, 7 moderate and none severe. The most frequent AE was mild nausea. No relationship of safety and/or tolerability with concomitant cDMARD use or PK was seen.Table 1.Characteristics of patients who developed HZ at initiation of baricitinibDLTSeliciclib dose (mg)Doses receivedContributing AEsContributing SAEsDescriptionOutcomeA1400830Constipation, N+V, liver injury; fatigue.Resolved2600430Constipation, N+V.Resolved3600101BFever, N+V, renal injury.Resolved4400831BConstipation, N+V, jaundice, liver injury.Resolved5400840Fever, dizziness, liver injury.Resolved6400890Dizziness, N+V, liver injury, bilirubin rise.Persistent AST riseConclusion:The MTD of seliciclib has been defined for RA. No unexpected safety concerns were identified to preclude ongoing evaluation in patients, which focuses on clinical, radiological and biological indicators of efficacy.Disclosure of Interests:Arthur Pratt Grant/research support from: Pfizer, GlaxoSmithKlein, Stefan Siebert Grant/research support from: BMS, Boehringer Ingelheim, Celgene, GlaxoSmithKline, Janssen, Novartis, Pfizer, UCB, Consultant of: AbbVie, Boehringer Ingelheim, Janssen, Novartis, Pfizer, UCB, Speakers bureau: AbbVie, Celgene, Janssen, Novartis, Michael Cole: None declared, Deborah Stocken: None declared, Stephen Kelly: None declared, Muddassir Shaikh: None declared, Amy Cranston: None declared, Miranda Morton: None declared, Jennifer Walker: None declared, Sheelagh Frame Employee of: Cyclacel Ltd., Wan-fai Ng: None declared, Chris Buckley Consultant of: Janssen, Pfizer, GSK, Galapagos, Gillead, Iain McInnes Grant/research support from: Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Janssen, and UCB, Consultant of: AbbVie, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Gilead, Janssen, Novartis, Pfizer, and UCB, Andrew Filer: None declared, John D Isaacs Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, Gilead, Janssen, Merck, Pfizer, Roche

Background:Sjögren’s Syndrome is a chronic autoimmune disease affecting the exocrine glands accompanied by variable extra-glandular manifestations. Symptom flares, including dry eyes, dry mouth, dry skin, fatigue, myalgia and arthralgia, are frequent. Many of these symptoms have a considerable impact on quality of life, but are variable, sensitive to external factors, and difficult to measure objectively.Clinical research on Sjögren’s Syndrome is advancing with the help of patient registries: an array of clinical data is collected and available for approved studies. However, many of these registries focus on collecting clinical information and often fail to capture the diverse patient experience adequately. Thus, there is an unmet need for an online ‘patient portal’, secure and encrypted with the capability of interacting with existing registries, while also patient-facing to encourage active involvement in research and personal healthcare. Patient demand for this resource was highlighted in 2017 when the Cambridgeshire regional support group of the British Sjögren’s Syndrome Association (BSSA) contacted the Patient Led Research Hub (PLRH). The PLRH provides research expertise to co-produce research ideas with patient organisations1; the PLRH and Cambridgeshire group have since secured funding and initiated work on this project with the Cambridge Clinical Trials Unit.Objectives:Develop ‘My Sjögren’s Diary’ a cross-platform patient portal to:1.Act as an interactive tool to help patients manage their healthcare needs and aid communication with healthcare providers.2.Function as a research platform, enabling patients to consent to contact, as well as support home-based data entry, allowing real-time capture of symptom scores and ensuring ease of participation for patients. Link with the UK Primary Sjögren’s Syndrome Registry and NHS Digital to provide complementary clinical datasets.Methods:The PLRH has coordinated a team of rheumatologists, database programmers, patients and family members to develop My Sjögren’s Diary. Regular meetings, national surveys and correspondence with patients ensures the project remains relevant to patient needs, while collaborating with rheumatologists ensures the database is reliable, valid and of benefit to clinical care. Workshops hosted at key stages of database development have allowed both patients and rheumatologists to direct and refine My Sjögren’s Diary. A prototype was presented at the 2019 BSSA Annual Conference before further improvements and beta release.Results:A beta version of My Sjögren’s Diary enabling BSSA members to track their medication and symptoms is now active. Feedback will be incorporated into the final version before it is publicly available to Sjögren’s Syndrome patients. Further funding is required to develop the research platform.Conclusion:My Sjögren’s Diary encourages equal partnership between patients, clinicians and researchers. It presents a unique opportunity for comprehensive analysis of Sjögren’s Syndrome and associated health utilities. Research participation is not mandatory, encouraging all patients to have an active role in personal healthcare management.References:[1]Mader LB, Harris T, Kläger S, Wilkinson IB, Hiemstra TF. Inverting the patient involvement paradigm: defining patient led research.Research Involvement and Engagement4, 21 (2018).Acknowledgments:Thank you to Cambridgeshire and North Eastern BSSA regional support groups for ongoing review of the portal’s usability, function and design. Thank you to BSSA for project funding, and to the Cambridge Clinical Trials Unit and University of Cambridge Medical Library for providing workshop facilities.Disclosure of Interests:None declared

Introduction Newborn screening is important for early diagnosis and effective treatment of inborn errors of metabolism (IEM). In response to a 2008 coroners' report of a 14-year-old boy who died of an undiagnosed IEM, the OPathPaed service model was proposed. In the present study, we investigated the feasibility of the OPathPaed model for delivering expanded newborn screening in Hong Kong. In addition, health care professionals were surveyed on their knowledge and opinions of newborn screening for IEM. Methods The present prospective study involving three regional hospitals was conducted in phases, from 1 October 2012 to 31 August 2014. The 10 steps of the OPathPaed model were evaluated: parental education, consent, sampling, sample dispatch, dried blood spot preparation and testing, reporting, recall and counselling, confirmation test, treatment and monitoring, and cost-benefit analysis. A fully automated online extraction system for dried blood spot analysis was also evaluated. A questionnaire was distributed to 430 health care professionals by convenience sampling. Results In total, 2440 neonates were recruited for newborn screening; no true-positive cases were found. Completed questionnaires were received from 210 respondents. Health care professionals supported implementation of an expanded newborn screening for IEM. In addition, there is a substantial need of more education for health care professionals. The majority of respondents supported implementing the expanded newborn screening for IEM immediately or within 3 years. Conclusion The feasibility of OPathPaed model has been confirmed. It is significant and timely that when this pilot study was completed, a government-led initiative to study the feasibility of newborn screening for IEM in the public health care system on a larger scale was announced in the Hong Kong Special Administrative Region Chief Executive Policy Address of 2015.

Background Sjogren’s syndrome (SS) is a chronic, heterogeneous disease with hallmark features of auto-inflammation and autoantibody production. We previously identified association between the DDX6-CXCR5 locus and SS surpassing genome-wide significance. Objectives This study aims to determine the mechanism by which this association contributes to disease. Methods Fine mapping and imputation allowed enrichment of existing genetic datasets from a total of 1916 SS cases and 3684 controls with 971 testable variants in the DDX6-CXCR5 interval. Candidate variants were prioritized using statistical and bioinformatics approaches. Electromobility shift assays (EMSAs) and pull-downs (PDs) followed by mass spectrometry (MS) were used to determine allelic-specific differences in binding using lysates from HSB-2 (T), Jurkat (T), Reh (B), Ramos (B), Daudi (B), THP-1 (monocyte), and HEK 293T (epithelial) cells. Results Bioinformatic analysis of the top associated variants after imputation (rs7125066 and rs7119038) in the DDX6-CXCR5 region did not yield evidence of regional functionality. However, 46 other candidates that span the region of association were identified through imputation. Chromatin methylation pattern data from the Roadmap database showed several variants in this region were within transcription start sites or enhancer elements depending on the cell type and state. Using RegulomeDB, Haploreg, and other databases, rs4938572, rs12365699, rs57494551, and rs10892294 showed strong evidence affecting binding and/or expression of one or more target genes in the region and were selected for further study. Using EMSAs, statistically significant increase in binding for the risk allele as compared to the non-risk allele was found for rs4938572 (p Conclusions The genetic variants in the DDX6-CXCR5 locus that were selected based on bioinformatics data resulted in a difference in the direction of binding, with the risk allele all residing on the same risk haplotype. The change in binding of protein.to each associated variant likely would alter expression of both protein coding genes in a cell/context specific manner. Ongoing studies will assess the regulatory role of these sequences using luciferase assays and CRISPR/Cas9 based genetic modification of target SNPs in various cell types. Disclosure of Interest None declared

The clinical manifestations of primary Sjogren’s syndrome (PSS) vary considerably between individual patients. The pathogenesis of PSS is not fully understood and although many aberrant biological pathways have been identified, the relationships between these pathways and clinical manifestations remain unclear. Furthermore, there is substantial heterogeneity in long-term outcomes and in health economic cost among patients with PSS. Stratification of PSS into more homogeneous subsets will facilitate better understanding of the pathogenesis of the disease, development of more cost-effective management strategies and accelerate therapeutic development programmes of targeted therapies in PSS. The establishment of several large cohorts of clinically well characterised PSS cohorts with associated biobanked materials has provided a rich resource for stratified medicine research in PSS. The growing number of datasets from clinical trials in PSS provide an excellent opportunity to evaluate the potential impact of stratified approach to therapy development in PSS. In this presentation, different approaches to identify clinically and biologically meaningful PSS subsets will be considered. In addition, the key challenges and potential future directions in Stratified Medicine in PSS will be discussed. Disclosure of Interest W.-F. Ng Grant/research support from: ElectroCore, Resolve Therapeutics, Nascient, Consultant for: GlaxoSmithKline, Novartis, Abbvie, MedImmune

Mycoplasma pneumoniae infection usually presents with upper and lower respiratory tract infection. Extrapulmonary involvement is not uncommon, however. We report two cases of predominantly extrapulmonary manifestations of Mycoplasma pneumoniae infection without significant pulmonary involvement. Both cases were diagnosed by serology. These cases illustrate the diversity of clinical presentations of Mycoplasma pneumoniae infection. Clinicians should maintain a high index of suspicion.

Background: Inflammatory back pain (IBP) is an early feature of ankylosing spondylitis (AS) and its detection offers the prospect of early diagnosis of AS. However, since back pain is very common but only a very small minority of back pain sufferers have ASpA or AS, screening of back pain sufferers for AS is problematic. In early disease radiographs are often normal so that fulfilment of diagnostic criteria for AS is impossible though a diagnosis of axial SpA can be made if MRI evidence of sacroiliitis is present. This pilot study was designed to indicate whether a cost-effective pick up rate for ASpA/early AS could be achieved by identifying adults with IBP stratified on the basis of age. Methods: Patients aged between 18 and 45 years who were referred to a hospital physiotherapy service with back pain of more than 3 months duration were assessed for IBP. All were asked to complete a questionnaire based on the Berlin IBP criteria. Those who fulfilled IBP criteria were also asked to complete a second short questionnaire enquiring about SpA comorbidities, to have a blood test for HLA-B27 and CRP level and to undergo an MRI scan of the sacroiliac joints. This was a limited scan, using STIR, diffusion-weighted, T1 and T2 sequences of the sacroiliac joints to minimize time in the scanner and cost. The study was funded by a research grant from Abbott Laboratories Ltd. Results: 50 sequential patients agreed to participate in the study and completed the IBP questionnaire. Of these 27 (54%) fulfilled criteria for IBP. Of these, 2 patients reported a history of an SpA comorbidity - 1 psoriasis; 1 ulcerative colitis - and 3 reported a family history of an SpA comorbidity - 2 psoriasis; 1 Crohn's disease. 4 were HLA-B27 positive, though results were not available for 7. Two patients had marginally raised CRP levels (6, 10 -NR ≤ 5). 19 agreed to undergo MRI scanning of the sacroiliac joints and lumbar spine; 4 scans were abnormal, showing evidence of bilateral sacroiliitis on STIR sequences. In all cases the changes met ASAS criteria but were limited. Of these 4 patients 3 were HLA-B27 positive but none gave a personal or family history of an SpA-associated comorbidity and all had normal CRP levels. Conclusions: This was a pilot study yielding only limited conclusions. However, it is clear that: Screening of patients referred for physiotherapy for IBP is straightforward, inexpensive and quick. It appears that IBP is more prevalent in young adults than overall population data suggest so that targeting this population may be efficient. IBP questionnaires could be administered routinely during a physiotherapy assessment. HLA-B27 testing in this group of patients with IBP is a suitable screening tool. The sacroiliac joint changes identified were mild and their prognostic significance is not yet clear so that the value of early screening needs further evaluation. Disclosure statement: C.H. received research funding for this study from Abbott. A.K. received research funding for this study, and speaker and consultancy fees, from Abbott. All other authors have declared no conflicts of interest

Background B lymphocytes are important in the pathogenesis of primary Sjogren9s syndrome (PSS), but two phase III trials (TEARS and TRACTISS) of the B cell depleting agent rituximab (RTX) failed to show an effect on their primary endpoints in PSS. Whilst RTX may lack efficacy in a non-stratified PSS population, other possible explanations for these negative results include the choice and timing of primary outcome. In a small single-site salivary gland ultrasound (SGUS) substudy in TEARS, more subjects in the RTX arm demonstrated improvement in parotid gland echostructure. Importantly, SGUS is an operator-dependent technique. Objectives To compare the effects of RTX versus placebo on SGUS in PSS, in a multicentre, multiobserver substudy of TRACTISS. Methods Subjects consenting to SGUS were randomised to 1000mg RTX or placebo given at weeks 0, 2, 24 and 26, and scanned at baseline and weeks 16 and 48. Sonographers completed a 0–11 total ultrasound score (TUS) comprising domains of echogenicity, homogeneity, glandular definition, glands involved, and size of hypoechoic foci. Baseline-adjusted values of TUS were analysed over time, modelling change from baseline at each time point. For each TUS domain we fitted a repeated measures logistic regression model to model the odds of a response in the RTX arm (defined as a 1 point improvement) as a function of the baseline score, age category, disease duration and time point. Results 66 patients (49.6% of the total study population) consented to SGUS, and 52 (39.1%; n=26 RTX and n=26 placebo) completed the baseline and at least one follow-up visit. Estimated baseline-adjusted TUS at week 16 was 6.2 (95% CI 5.4–7.0) for placebo and 5.0 (95% CI 4.4–5.6) for RTX, and at week 48, 6.1 (95% CI 5.5–6.6) and 4.8 (95% CI 4.2–5.4) respectively. Estimated between group differences (RTX-placebo) in baseline adjusted TUS were -1.2 (95% CI -2.1 to -0.3; p=0.0099) and -1.2 (95% CI -2.0 to –0.5; p=0.0023) at weeks 16 and 48. Glandular definition was the only domain to show statistically significant improvement with an OR of 6.8 (95% CI 1.1–43.0; p=0.043) at week 16 and 10.3 (95% CI 1.0–105.9; p=0.050) at week 48. Improvement of ≥1 point in TUS was associated with improvement in oral dryness VAS at week 16 (diff=15.9; CI 1.5 to 30.3; p=0.030) but not week 48 in the RTX arm. Conclusions TUS differed between study arms, favouring RTX. This encourages further research into SGUS as an imaging biomarker in PSS clinical trials. Acknowledgements Funded by Arthritis Research UK. Roche provided RTX. Disclosure of Interest B. Fisher Paid instructor for: Novartis, Roche, Virtualscopics, C. Everett: None declared, J. Rout: None declared, J. O9Dywer: None declared, P. Emery: None declared, C. Pitzalis: None declared, W.-F. Ng Consultant for: Pfizer, UCB, MedImmune, Takeda and Sanofi, A. Carr: None declared, C. Pease: None declared, E. Price: None declared, N. Sutcliffe: None declared, J. Makdissi: None declared, N. Gendi: None declared, F. Hall: None declared, S. Ruddock: None declared, C. Fernandez: None declared, C. Hulme: None declared, K. Davies: None declared, C. Edwards: None declared, P. Lanyon: None declared, R. Moots: None declared, E. Roussou: None declared, L. Sharples: None declared, M. Bombardieri Consultant for: GSK, Amgen/MedImmune and UCB, S. Bowman Consultant for: Cellgene, Glenmark, GSK, Eli Lilly, Novartis, Roche, Takeda, UCB

Background Lymphoma development is a serious complication of Primary Sjogren9s syndrome (pSS). To date, the biological processes that may be involved in pSS-associated lymphoma are not fully understood. Objectives The aim of our study is to use microarray gene expression data from a well-defined cohort of pSS patients to identify biological processes that may be relevant to pSS-associated lymphoma. Methods pSS patients and healthy controls from the UK primary Sjogren9s syndrome registry (UKPSSR) were used in this study. All patients fulfilled the AECG criteria. Whole genome gene expression data from whole blood RNA samples (n=144) stratified into five clinical subsets (pSS=61, pSS with lymphoma=16, pSS with other cancers=21, pSS with paraproteinemia=23 and healthy controls=23) were used for the pathway analysis. A list of 68 differentially expressed genes in pSS-associated lymphoma compared with pSS (non lymphoma) were uploaded into the Ingenuity Pathway Analysis (IPA) analytic tool. Similar approach was also used for comparison between the lymphoma and other pSS subject groups. Finally, we also examined the regulators and pathways involved in the genes from the gene expression signature in pSS-associated lymphoma we have previously described (BMS1, NUDT14 and MGST3) [1]. Results In pSS-associated lymphoma the top canonical pathway was “Aryl Hydrocarbon Receptor (AHR) signaling,” which includes MGST3. Several other canonical pathways also included the genes of the 3-gene biosignature of pSS-associated lymphoma. The downstream effects and gene-gene interactions were explored through molecular networks analysis. Furthermore, important upstream regulators of the 3 biosignature genes include NFE2L2, PPARA and TOCF1 were identified. The pathway analyses of the other pSS subgroups showed 67 common canonical pathways showed among all the pSS subgroups. Focusing on pSS-associated lymphoma versus healthy controls, 94.9% of the canonical pathways in this comparison were in common with the canonical pathways identified when comparing pSS-associated lymphoma with pSS. The “Interferon Signaling pathway” was the top pathway for all pSS subgroups comparing with healthy controls. In addition, all the non-lymphoma pSS subgroups showed similar patterns in the downstream analysis which differ from the pSS-associated lymphoma group. Conclusions The pathway analysis revealed different possible pathways that might be involved in lymphoma development in pSS and indicates a unique gene expression signature exist in pSS-associated lymphoma. These results might provide a deeper understanding and a direction for future studies to investigate lymphoma development in pSS patients. References Al-Ali S, et al. Whole blood transcriptomic signature of primary Sjogren9s syndrome associated lymphoma. Biomarkers and Targeted Therapeutics in Sjogren9s (BATTS) Conference, 2016. Disclosure of Interest None declared

Background Fatigue is a very common symptom of primary Sjogren9s syndrome (pSS), being reported by up to 70% of patients [1]. It is more pronounced when compared to healthy individuals [2] and patients often report that it is their greatest problem and the most difficult to cope with [3]. There is only one non-randomized controlled study on aerobic exercise in pSS with a small sample size suggesting improvement in fatigue, aerobic capacity, depression and physical function [4]. Objectives To evaluate the safety and effectiveness of a supervised walking program in women with pSS. Methods Forty five sedentary women fulfilling the American European Consensus Criteria for pSS were randomized to a Training Group (TG, n=23) or Control Group (CG, n=22). Patients in the TG were submitted to supervised walking, 3 times a week, for 16 weeks. The patients of the CG were instructed to not perform any kind of regular physical exercise. Outcomes measured were aerobic capacity, fatigue, disease activity, depression, perception of pSS9s symptoms and quality of life. An intent-to-treat analysis was performed. Results The mean change after 16 weeks of VO2max (ml.kg-1.min-1), distance and FACIT-fatigue were higher in the TG than in the CG (p=0.016, p=0.043 and p=0.030, respectively) (Figure 1). Improved aerobic capacity was associated with improvements in fatigue scores and physical components of quality of life measured using SF-36. Furthermore, improved fatigue scores were associated with reduced depression and improvements in the physical and mental components of the quality of life measures. Overall, 95.4% of patients in the TG rated themselves as clinically improved versus 62% of the patients in the CG (p=0.049). There was no flare in disease activity and no serious adverse events with exercise. Conclusions This supervised walking program was demonstrated to be feasible and safe with improvements in the aerobic capacity, exercise tolerance, fatigue and patient perception of improvement in pSS patients. References Ng W-F, Bowman SJ. Primary Sjogren9s syndrome: too dry and too tired. Rheumatology 2010;49(5):844–53. Strombeck B, Ekdahl C, Manthorpe R, et al. Physical capacity in women with primary Sjogren9s syndrome: a controlled study. Arthritis Rheum 2003;49(5):681–8. Meijer JM, Meiners PM, Huddleston Slater JJR, et al. Health-related quality of life, employment and disability in patients with Sjogren9s syndrome. Rheumatology 2009;48(9):1077–82. Strombeck BE, Theander E, Jacobsson LTH. Effects of exercise on aerobic capacity and fatigue in women with primary Sjogren9s syndrome. Rheumatology 2007;46(5):868–71. Acknowledgements This work was supported by the Coordenacao de Aperfeicoamento de Pessoal de Nivel Superior - CAPES Foundation [BEX 8831/14–9 to S.T.M]. Disclosure of Interest None declared

Background We have previously described a model of fatigue in patients with primary Sjogren9s syndrome (PSS) based on the levels of serum cytokines, pain and depression scores. Importantly, removal of cytokines from this model substantially reduced the accuracy suggesting that cytokines may have a key role in the biological basis of fatigue [1]. However, interpreting the model is complicated by the complexity of the immune system and the likely multiple interactions between numerous cytokines and other variables [2]. Structural equation modelling (SEM) is a statistical technique that allows for analysis of one or multiple independent variables with one or multiple dependent variables. SEM consists of two components – the structural model, which represents the relationships between the theoretical variables, and the measurement model, which are the relationships between the latent variables and their measures [3]. Objectives To use SEM to test our hypothesis that the balance between pro-inflammatory and anti-inflammatory cytokines play an important role in determining severity of fatigue in patients with PSS. Methods We used Canonical Correpondence Analysis (CCA) to investigate the variation in cytokine expression across our spectrum of fatigue patietns to explore interactions and dependencies between cytokines. We then built a conceptual model based on the literature representing the likely relationships between fatigue and various proinflammatory and anti-inflammatory cytokines and other soluble molecules in the serum. This conceptual model was then challenged using serum data and fatigue scores of 161 PSS patients from the UK primary Sjogren9s syndrome registry. Model fit was assessed using the Confirmatory Factor Index, the Root Mean Square Error of Association and the Standardised Root Mean Square Residual. We also analysed changes in fatigue scores over a period between 1–4 years. Results CCA revealed the first axis of ordination (CCA1) broadly correlates with fatigue, consists of many pro-inflammatory cytokines including TNFα, LTα and IFNγ, IL17, which were negatively correlated with fatigue while IL-6 and MCP1, which were positively associated with increased fatigue severity. The second axis (CCA2) reflects a trend in cytokines which appear to relate to patients9 age. Fatigue scores were largely stable over time and therefore data were not included in the SEM analysis. The main pro-inflammatory SEM model showed fatigue was negatively associated with pro-inflammatory cytokine activity (p=0.019); IL-10 drove IP-10 (p=0.000); and IL-10 was driven by IL-6 (p=0.006) (Fig. 1) Conclusions Chronic fatigue in PSS is negatively associated with many pro-inflammatory cytokines. We hypothesize that it reflects adaptive biological processes, which occurs after chronic exposure to inflammation in conditions such as PSS. References Howard-Tripp N, et al. RMD Open. 2016;2:e000282. Genser B, et al. BMC immunology. 2007;8:1. Beran TN & Violato C. BMC Research Notes. 2010;3:267. Acknowledgements All UKPSSR participants. Disclosure of Interest D. Gardiner: None declared, W. Reid: None declared, J. Tarn: None declared, D. Lendrem: None declared, N. Howard-Tripp: None declared, S. Bowman Consultant for: Cellgene, Glenmark, GSK, Eli Lilly, Novartis, Roche, Takeda, UCB, B. Griffiths: None declared, S. Rushton: None declared, W.-F. Ng Consultant for: Pfizer, UCB, MedImmune, Takeda and Sanofi

Background The recent classification criteria sets for primary Sjogren9s syndrome (AECG 2002 and ACR/EULAR 2017) did not include major salivary glands ultrasononography (SGUS). Objectives The UTOPIA study was undertaken to determine if and how SGUS may improve the ACR/EULAR criteria. Methods Twenty four international experts in pSS evaluated on an internet-secure relational database 512 randomly realistic vignettes derived from 150 patients with suspected pSS included in the french DiapSS cohort. Each vignette contained sections on “history” (duration of the symptoms, gender, age), clinical symptoms (dry mouth, dry eyes and systemic manifestations), results of the SGUS evaluation (score > ou Results Univariate and multivariate analyses confirmed that ACR/EULAR criteria and SGUS were independently associated with the diagnosis of pSS. Disease duration, OSS and ocular dryness were not associated with the diagnosis of pSS. Only 6 variables were selected by logistic regression analysis: presence of anti-SSA (weight:4), focus score (weight:3), SGUS (weight:2), Schirmer9s test (weight:1), dry mouth (weight:1) and salivary flow rate (weight:1). According to ROC curve analysis, a score of ≥5 had 96% Se and 84% Sp, compared with 90% Se and 84% Sp for the ACR/EULAR criteria. The corrected C statistic (AUC) for the new weighted score was 0.98. Conclusions Inclusion of the SGUS item in the ACR/EULAR criteria improves their diagnostic performance. Disclosure of Interest S. Jousse-Joulin: None declared, F. Gatineau: None declared, C. Baldini: None declared, S. Arends: None declared, F. Barone: None declared, A. Baer: None declared, H. Bootsma: None declared, S. Bowman: None declared, P. Brito-Zeron: None declared, D. Cornec: None declared, T. Dorner: None declared, S. De Vita: None declared, B. Fisher: None declared, D. Hammenfors: None declared, M. Jonsson: None declared, X. Mariette: None declared, V. Milic: None declared, T. Nakamura: None declared, W.-F. Ng: None declared, E. Nowak: None declared, A. Rasmussen: None declared, R. Seror: None declared, C. Shiboski: None declared, T. Nakamura: None declared, M. Ramos-Casals: None declared, A. Vissink: None declared, A. saraux: None declared, V. Devauchelle-Pensec Grant/research support from: ROCHE-CHUGAI

Mesenteric Panniculitis is a benign fibro-inflammatory process involving adipose tissue of the mesentery. It is characterised by fat necrosis, chronic inflammation and fibrosis, causing thickening and shortening of the mesentery. Patients may present with localised abdominal pain, abdominal mass, intestinal obstruction and ischaemic colitis. We report a case of mesenteric panniculitis causing abdominal pain in a patient with active Primary Sjogren’s Syndrome. The rarity of this case makes it of interest. We review the current literature on mesenteric panniculitis and its association with connective tissue disease and inflammatory conditions. A 64-year-old Caucasian male presented in 1994 with dry mouth. A diagnosis of Primary Sjogren’s Syndrome (PSS) was made on salivary gland biopsy. In 2010 he presented with an exacerbation of his eye symptoms, muscle pain and fatigue. He complained of abdominal pain and night sweating, but denied any weight loss or change in bowel habit. There was no significant past medical history other than PSS. On examination he had a small right submandibular node and mild synovitis at the right proximal interphalangeal joint and carpometacarpal joint. Examination of the abdomen showed marked umbilical tenderness but no organomegally. Blood tests at this time showed an active inflammation: CRP of 61 (NR 5 mg/L), ESR 39 (NR 20 mm/s), strongly positive ENA Ro and La. IgG was elevated at 18.6 (NR 5.8-15.4), Complement was low at 0.17 (NR 0.18-0.6). An abdominal ultrasound scan demonstrated a 6 × 3 ×3 cmarea of diffuse homogenous fat encasing some mesenteric vessels in the area of focal tenderness. CT abdomen and pelvis showed oedematous mesenteric fat and lymph nodes in the jejunal small bowel mesentery, consistent with mesenteric panniculitis. Laparoscopic biopsy was discussed with the surgical team, but was felt not indicated as risk outweighed potential benefit. The patient was treated with a 9-week reducing course of oral steroids. His abdominal symptoms resolved although CT abdomen showed little improvement in mesenteric panniculitis. A review of the literature suggests that currently there is no standard treatment and management should be guided by patient symptoms. Mesenteric Panniculitis is rare; as a result evidence for treatment is limited to individual case reports. There is no clear link between symptom improvement and radiological resolution of mesenteric panniculitis. It has, therefore been suggested that follow-up imaging should be limited to those with persistent symptoms. Overall the prognosis for mesenteric panniculitis is good, up to half of patients do not require treatment, and recurrence of symptoms is uncommon.

Objective. Ultrasonography (US) is a sensitive tool in the diagnosis of major salivary gland abnormalities in primary Sjogren's syndrome (pSS). The aim of this systematic review was to assess the metric properties of this technique. Methods. PUBMED and EMBASE databases were searched. All publications between January 1988 and January 2013 were considered. Data were extracted from the articles meeting the inclusion criteria according to US definition of salivary gland scoring system and metric properties studied. The type and number of glands tested, study design and metric properties according to OMERACT filter (truth, discrimination, feasibility) were assessed. Results. Of 167 publications identified initially with PUBMED and EMBASE, 31 met the inclusion criteria. The number of pSS patients varied among the studies from 16 to 140. The diagnosis of pSS was in line in most of the cases with the American-European Consensus Group (AECG) classification criteria for Sjogren's syndrome. The US examination was performed in suspected pSS only in studies in which the sensitivity ranged from 45.8 to 91.6% and specificity from 73 to 98.1%. There was heterogeneity in regard to the definition of US in B-mode and few studies used US in colour Doppler. Few studies reported reliability of US and sensitivity to change in pSS. Conclusion. US is a valuable tool for detecting salivary gland abnormalities in pSS. Its reliability has been poorly investigated and there is considerable variation in the definition of US abnormalities. Further studies are required to validate and standardize the US definition of salivary gland in pSS.

When gas turbine engines operate in environments where the intake air has some concentration of particles, the engine will experience degradation. Very few studies of such microparticles approaching their melting temperatures are available in open literature. The coefficient of restitution (COR), a measure of the particles' impact characteristics, was measured in this study of microparticles using a particle tracking technique. Part II of this study presents data taken using the Virginia Tech Aerothermal Rig and Arizona road dust (ARD) of 20–40 μm size range. Data were taken at temperatures up to and including 1323 K, where significant deposition of the sand particles was observed. The velocity at which the particles impact the surface was held at a constant 70 m/s for all of the temperature cases. The target on which the particles impacted was made of a nickel alloy, Hastelloy X. The particle angle of impact was also varied between 30 deg and 80 deg. Deposition of particles was observed as some particles approach their glass transition point and became molten. Other particles, which do not become molten due to different particle composition, rebounded and maintained a relatively high COR. Images were taken using a microscope to examine the particle deposition that occurs at various angles. A rebound ratio was formulated to give a measure of the number of particles which deposited on the surface. The results show an increase in deposition as the temperature approaches the melting temperature of sand.

Many gas turbine engines operate in harsh environments where the engines ingest solid particles. Ingested particles accelerate the deterioration of engine components and reduce the engine’s service life. Understanding particle impacts on materials used in gas turbines at representative engine conditions leads to improved designs for turbomachinery operating in particle-laden environments. Coefficient of Restitution (COR) is a measure of particle/wall interaction and is used to study erosion and deposition. In the current study, the effect of temperature (independent of velocity) on COR was investigated. Arizona Road Dust (ARD) of 20–40/μm size was injected into a flow field to measure the effects of temperature and velocity on particle rebound. Target coupon materials used were 304 stainless steel and Hastelloy X. Tests were performed at three different temperatures, 300 K (ambient), 873 K, and 1073 K while the velocity of the flow field was held constant at 28 m/s. The impingement angle of the bulk sand on the coupon was varied from 30 ° to 80 ° for each temperature tested. The COR was found to decrease substantially from the ambient case to the 873 K and 1073 K cases. This decrease is believed to be due to the changes in the surface of both materials due to oxide layer formation which occurs as the target material is heated. The Hastelloy X material exhibits a larger decrease in COR than the stainless steel 304 material. The results are also compared to previously published literature.

Objective To determine the prevalence of traditional cardiovascular risk factors using established definitions in a large cohort of clinically well-characterized primary Sjögren's syndrome (SS) patients and to compare them to healthy controls. Methods Data on cardiovascular risk factors in primary SS patients and controls were collected prospectively using a standardized pro forma. Cardiovascular risk factors were defined according to established definitions. The prevalence of cardiovascular risk factors in the primary SS group was determined and compared to that in the control group. Results Primary SS patients had a higher prevalence of hypertension (28–50% versus 15.5–25.6%; P < 0.01) and hypertriglyceridemia (21% versus 9.5%; P = 0.002) than age- and sex-matched healthy controls. Furthermore, a significant percentage (56%) of hypertensive patients expected to be on antihypertensive treatment according to best practice was not receiving it. Conclusion Primary SS patients are more than 2 times more likely to experience hypertension and hypertriglyceridemia than age- and sex-matched healthy controls. Additionally, hypertension is underdiagnosed and suboptimally treated in primary SS.

Spondylocostal dysostosis (SCD) is a rare congenital disorder that is characterized by vertebral segmentation and formation defects, and asymmetrical rib anomalies. We describe a case diagnosed during the second trimester of pregnancy with the sonographic features of abnormal alignment of the spine, hemivertebrae in the thoracic spine and kyphoscoliosis. Three-dimensional ultrasound demonstrated a 'fan-like' rib cage with fusion of the ribs. The postmortem findings confirmed the ultrasound findings and were consistent with SCD.

Large amounts of tiny microparticles are ingested into gas turbines over their operating life, resulting in unexpected wear and tear. Knowledge of such microparticle behavior at gas turbine operating temperatures is limited in published literature. In this study, Arizona Road Dust (ARD) is injected into a hot flow field to measure the effects of high temperature and velocity on particle rebound from a polished 304 Stainless Steel (SS) coupon. The results are compared with baseline (27m/s) measurements at ambient (300°K) temperature made in the Virginia Tech Aerothermal Rig, as well as previously published literature. Mean Coefficient of Restitution (COR) was shown to decrease with the increased temperature/velocity conditions in the VT Aerothermal Rig. The effects of increasing temperature and velocity led to a 12% average reduction in COR at 533°K (47m/s), 15% average reduction in COR at 866°K (77m/s), and 16% average reduction in COR at 1073°K (102m/s) compared with ambient results. The decrease in COR appeared to be almost entirely a result of increased velocity that resulted from heating the flow. Trends show that temperature plays a minor role in energy transfer between particle and impact surface below a critical temperature.

Aims - To evaluate the usefulness of a single-tube nested polymerase chain reaction (PCR) assay in the diagnosis of tuberculosis in 1497 pulmonary and 536 extrapulmonary specimens. Methods-A single-tube nested PCR, utilising two sets of primers with different melting temperatures (88°C for external primers; 70°C for internal primers) to augment sensitivity and specificity without increasing the risk of amplicon contamination, was evaluated. Specimens were initially tested for the repetitive IS6110 sequences and if negative, retested for the universal 38 kilodalton sequence and for inhibitors. dUTP/Uracil-N-glycosylase and Instagene treatment were used to minimise contamination and the effect of inhibitors, respectively. Results - Using culture as the gold standard, the overall sensitivity of the assay was 89% for pulmonary and 42% for extrapulmonary specimens. Sensitivity varied greatly with respect to sample type (92% for follow up specimens from a chest hospital and 70% for non-follow up specimens from a general hospital). The smear positivity rates were 15% for extrapulmonary specimens, and 69% and 45%, respectively, for follow up and non-follow up specimens from pulmonary sites. Specificity was 99.7%. Inhibitors were present more frequently in extrapulmonary than in pulmonary specimens (13.4% v 2.7%). Conclusion - Despite the high sensitivity of the PCR assay for the diagnosis of tuberculosis in pulmonary specimens, it was less effective in the extrapulmonary samples. This is probably because of the lower bacterial load in extrapulmonary specimens, the presence of more inhibitors adversely affecting the PCR assay and the higher volume of specimens used for culture., published_or_final_version

Background Primary Sjogren9s Syndrome (pSS) is a chronic multi-system disease causing a wide-range of symptoms including dryness, pain and fatigue. 1,2 Individual experiences of pSS differ considerably resulting in a heterogeneous patient population. 3 These differences in disease-manifestation have not yet been characterised and the biological basis of varied patient-reported outcomes remains unclear. Objectives We aim to identify distinct clinical phenotypes within pSS, using patient-reported symptoms and to determine whether such clinical subgroups display differences in healthy utility values, and biological measures of disease activity. Methods Symptoms of 608 patients on the United Kingdom Primary Sjogren9s Syndrome Registry (UKPSSR) were reviewed. 4 Phenotypes were identified using hierarchical cluster analysis of patient reported rating scales for pain, fatigue, dryness, anxiety and depression symptoms. Non-parametric analysis of variance was used to evaluate differences between clusters. Results Four phenotypic clusters were identified: High symptom burden (HSB), Low symptom burden (LSB), dryness dominant (DD) and Low Anxiety and Depression (LAD). Not surprisingly, there were significant differences between these groups in measures of health status and quality of life (EQ-5D p Conclusions Distinct biological differences may underlie pSS clinical phenotypes. The identification of these different clinical subsets of pSS could impact on the future study and management of the condition using a stratified approach. References R. I. Fox, Sjogren9s syndrome. Lancet 366,321–331 (2005) W. F. Ng, S. J. Bowman, Primary Sjogren9s syndrome: too dry and too tired. Rheumatology 49, 844–853 (2010) L. Robinson, K. Hackett, S.J. Bowman, B. Griffiths, W.F. Ng, P. Gallagher, Understanding the gap between subjective symptoms and objective illness markers in Primary Sjogren9s Syndrome. Annals of the Rheumatic Diseases 73, 188–189 (2014). W. F. Ng, S. J. Bowman, B. Griffiths, UK Sjogren9s Syndrome Group, United Kingdom Primary Sjogren9s Syndrome Registry-a united effort to tackle an orphan rheumatic disease. Rheumatology 50, 32–39 (2011) Acknowledgement We would like to thank all the patients and healthy volunteers who have participated in the UKPSSR. This study received grant support from the Medical Research Council, British Sjogren9s Syndrome Association and the Newcastle University. Disclosure of Interest None declared

Background There has been much research aimed at elucidating key biological and clinical features which predict severity of disease and development of lymphoma in patients with primary Sjogren9s syndrome (pSS). Key biological predictors identified include the presence of leukopenia or lymphopenia, hypocomplementaemia, cryoglobulinaemia, monoclonal gammopathy; key clinical predictors include younger age at time of symptom onset or diagnosis, peripheral neuropathy, salivary gland enlargement and skin involvement (particularly palpable purpura) [1–4]. The UK Primary Sjogren9s Syndrome Registry (UKPSSR) is a MRC funded patient cohort, devised to facilitate research into pSS to improve understanding of the condition. Objectives Ascertain the prevalence of putative clinical predictors amongst UKPSSR patients. Explore the relationship between demographics, clinical parameters, disease severity and lymphoma development. Methods Patients were identified on the UKPSSR (n=868), those with insufficient data were excluded from analysis (n=36). Frequency of the predictors was calculated for remaining 832 patients. Patients were assigned a value for each predictor: 1 for present, 0 for absent. These values were then added to provide the prevalence of each predictor within the cohort, and a cumulative score for each patient. Each patient had 2 cumulative scores: one for disease severity and risk of death, the other for risk of lymphoma. Patients with a recorded age of pSS symptom onset (n=739) were analysed to investigate the relationship between age of onset and development of lymphoma. SPSS used for statistical analysis. Results Pearson Chi-squared analysis found a statistically significant (p=0.004) increased incidence of lymphoma in patients presenting with symptoms of pSS before the age of 35. Predictors of lymphoma development were more common in patients whose symptoms started between age 20–34 (p=0.05). Patients with diagnosed lymphoma had a higher cumulative lymphoma risk score than patients who did not have lymphoma (p=0.05). Predictors of severe disease were found to be more common in patients whose symptoms began before age 35 (p=0.05). Conclusions This analysis corroborates the findings of previous research showing an increased lymphoma prevalence in patients presenting with pSS at a younger age [4]. It also finds a statistically significant link between poor prognostic features and development of lymphoma as described in the literature [2,3]. Further statistical analysis will aim to establish the link between each predictor and the development of systemic manifestations of pSS, baseline and cumulative ESSDAI scores and lymphoma. References Brito-Zeron, P., et al., Systemic activity and mortality in primary Sjogren syndrome. Ann Rheum Dis. Luciano, N., et al., One year in review 2015: Sjogren9s syndrome. Clin Exp Rheumatol. Nocturne, G. and X. Mariette, Sjogren syndrome-associated lymphomas. BJH. Ramos-Casals, M., et al., Systemic involvement in primary Sjogren9s syndrome evaluated by the EULAR-SS disease activity index. Rheumatology. Disclosure of Interest None declared

Background Sjogren9s syndrome (SS) is a complex autoimmune disease with both environmental and genetic factors playing important roles in its etiology. Objectives The goal of this study was to replicate 8 suggestive loci that failed to exceed the genome-wide significance (GWS) threshold of 5x10E-8 in our previously published work: TNFAIP3 , PTTG1 , PRDM1 , DGKQ , FCGR2A , IRAK1BP1 , ITSN2 , and PHIP . Methods Our previous study included 1638 SS cases and 6754 population controls. In the current study, we genotyped an additional 282 SS cases and 2576 population controls yielding a total of 1920 SS cases and 9330 controls. Analysis was done using logistic regression accounting for ancestry and gender. Results Two regions exceeded the GWS threshold. Association has been previously established with SS to a risk haplotype spanning the TNFAIP3 coding region described in lupus; however, we identified a novel independent effect ∼230kb 59 of TNFAIP3 (rs6933404 P meta =6.85x10E-9, OR=1.28) originally described in rheumatoid arthritis. Association was observed for the haplotype spanning the TNFAIP3 coding region peaking at rs58721818 (P=4.77x10E-4), which is not correlated with rs6933404 ( r 2 =0.02; D9=0.49). Bioinformatics data provided limited support that rs6933404 is the functional variant in this region; however, another variant on this haplotype also surpassing GWS, rs6927172, modifies 8 transcription factor binding sites, and is located within an enhancer element in CD4 + CD25 – IL17 + PMA-Ionomycin stimulated Th17 primary cells by the Epigenetics Road Map Project. A variant in the region of PRDM1 also surpassed the GWS threshold (rs526531 P meta =1.70x10E-8, OR=1.25). Two additional variants on this haplotype exceeded GWS, but no clear candidate functional variant has emerged based on bioinformatics data. Of the 6 remaining suggestive regions, PTTG1 , DGKQ , and FCGR2A continue trending towards GWS. Conclusions These data now establish 2 new SS risk loci, TNFAIP3 and PRDM1 . TNFAIP3 , which codes for the protein A20, is a negative regulator of NF-kB. PRDM1 , which codes for the protein BLIMP1, is a transcription factor that regulates interferon-beta locus and plasma cell differentiation. Additional studies are needed to determine how these association signals function in the human genome and contribute to SS etiology. Disclosure of Interest None declared

To investigate if two important epidemic viral encephalitis in children, Enterovirus 71 (EV71) encephalomyelitis and Japanese encephalitis (JE) whose clinical and pathological features may be nonspecific and overlapping, could be distinguished.Tissue sections from the central nervous system of infected cases were examined by light microscopy, immunohistochemistry and in situ hybridization.All 13 cases of EV71 encephalomyelitis collected from Asia and France invariably showed stereotyped distribution of inflammation in the spinal cord, brainstem, hypothalamus, cerebellar dentate nucleus and, to a lesser extent, cerebral cortex and meninges. Anterior pons, corpus striatum, thalamus, temporal lobe, hippocampus and cerebellar cortex were always uninflamed. In contrast, the eight JE cases studied showed inflammation involving most neuronal areas of the central nervous system, including the areas that were uninflamed in EV71 encephalomyelitis. Lesions in both infections were nonspecific, consisting of perivascular and parenchymal infiltration by inflammatory cells, oedematous/necrolytic areas, microglial nodules and neuronophagia. Viral inclusions were absent.Immunohistochemistry and in situ hybridization assays were useful to identify the causative virus, localizing viral antigens and RNA, respectively, almost exclusively to neurones. The stereotyped distribution of inflammatory lesions in EV71 encephalomyelitis appears to be very useful to help distinguish it from JE.

Ureteric tumours are rare and most of them are malignant. Of benign tumours, ureteral fibroepithelial polyps are the most common but are still considered clinical rarities. In the past, most benign ureteric tumours were only diagnosed after surgical removal. With technological advance, magnetic resonance imaging has become an effective means of assessing ureteric lesions. Non-contrast enhanced magnetic resonance urography can produce an image comparable to an intravenous urogram without use of intravenous water-soluble contrast. A polyp can be diagnosed on imaging if there is an elongated filling defect inside the ureter. Nevertheless, a definitive diagnosis relies on ureteroscopic examination with biopsy. When a non-obstructive polyp is being managed conservatively, imaging is helpful for monitoring. Equally, the information obtained from imaging can be used to plan operative treatment.

This paper experimentally investigates the effect of high freestream turbulence intensity, turbulence length scale, and exit Reynolds number on the surface heat transfer distribution of a turbine blade at realistic engine Mach numbers. Passive turbulence grids were used to generate freestream turbulence levels of 2%, 12%, and 14% at the cascade inlet. The turbulence grids produced length scales normalized by the blade pitch of 0.02, 0.26, and 0.41, respectively. Surface heat transfer measurements were made at the midspan of the blade using thin film gauges. Experiments were performed at exit Mach numbers of 0.55, 0.78 and 1.03 which represent flow conditions below, near, and above nominal conditions. The exit Mach numbers tested correspond to exit Reynolds numbers of 6 × 105, 8 × 105, and 11 × 105, based on true chord. The experimental results showed that the high freestream turbulence augmented the heat transfer on both the pressure and suction sides of the blade as compared to the low freestream turbulence case. At nominal conditions, exit Mach 0.78, average heat transfer augmentations of 23% and 35% were observed on the pressure side and suction side of the blade, respectively.

Background Aerobic capacity is a key biomarker of health and wellbeing, from risk of secondary disease to quality of life (QOL). Although anecdotally reported to be reduced in primary Sjogren9s syndrome (pSS)1, aerobic capacity has not been objectively assessed. The lack of data limits the ability to target aerobic capacity as a therapy for QOL and secondary disease. Objectives This pilot study defines the relationship between aerobic capacity with fatigue, disease activity, depression and QOL in pSS. Methods In a preliminary cross-sectional study, 20 pSS (AECG) sedentary women with a mean age of 53 (±7) performed a maximal progressive treadmill exercise test. Expired gas analysis was performed with a computerized metabolic system. They were evaluated through the questionnaires FACIT-Fatigue, ESSPRI, ESSDAI, BDI and SF-36. Pearson9s tests were used to correlate the variables. Multiple linear regressions were used to examine the effect of the variables on VO2max and VO2AT. Results ESSDAI, ESSPRI and FACIT-Fatigue scores mean were 1.55 (±1.43), 6.13 (±2.75) and 32 (±8.49), respectively. Mean of VO2max was 19 (±4) ml/kg-1/min-1 and VO2AT was 15 (±3) ml/kg-1/min-1. VO2max correlated with ESSPRI dryness (r=-0.53; p Conclusions In pSS, low aerobic capacity is associated with worse symptoms, higher levels of CK and lower QOL. The optimization of aerobic capacity should be explored as a way to modify clinical presentations and increase QOL in pSS. References Strombeck B et al. Physical capacity in women with primary Sjogren9s syndrome: a controlled study. Arthritis Rheum. 2003; 49:681–8. Acknowledgements CAPES Foundation Disclosure of Interest None declared

Background Sjogren9s syndrome (SS) is a common, autoimmune exocrinopathy characterized by symptoms of dry eyes and mouth present in 0.7% of the European American population. Gene expression profiling (GEP) has previously demonstrated overexpression of transcripts induced by interferons (IFN) in SS patients. Objectives In this study, we sought to identify and characterize underlying genetic contributions to dysregulation of IFN pathways in SS. Methods IFN signature genes of interest were selected from GEP studies performed in 115 anti-Ro positive SS cases and 73 controls using microarray data and evaluated for cis -expression quantitative trait loci (eQTL) in 178 subjects by integration with genome-wide association study (GWAS) data. Gene splicing patterns were evaluated using RNA-sequencing (RNA-seq) performed in 57 SS cases and 27 controls on the Illumina platform. Results GEP showed that OAS1 , an IFN-inducible gene involved in inhibition of virus replication, was significantly overexpressed in SS patients. Multiple cis -eQTL were identified in OAS1 with the most significant peaking at rs10774671, strengthening prior evidence of this variant for disease association (( p =8.47×10 -5 ) obtained in our large GWAS dataset consisting of 765 cases and 3825 controls. We further replicated this genetic association in an independent set of 514 cases and 3466 controls followed by meta-analysis ( p =2.59×10 -9 ; OR=0.75). The risk allele “A” of rs10774671 is a splice site consensus variant located at the junction between intron-5 and exon-6 of OAS1 , and thus may switch the primary isoform, p46, to various alternatives. Transcripts measured by RNA-seq were reconstructed and the abundance of isoforms was compared across samples according to the genotype of rs10774671. The risk allele “A”, which demolishes the splicing consensus sequence, was correlated with higher expression of p42, p48, and p44 isoforms, but a lower expression of the normally spiced OAS1 isoform, p46. Functional characterization of different OAS1 isoforms indicated that the alternatively spliced isoforms resulted in impaired protein expression and lack of response to type I IFNs. Conclusions We identified OAS1 as a novel candidate SS locus. The risk allele “A” has been reported to result in decreased Oas1 enzyme activity. These results suggest a mechanism in which alternatively spliced OAS1 transcripts lead to reduced viral clearance resulting in perpetuation of type I IFN signaling in SS. Disclosure of Interest None declared

The “What is New” in Sjogren9s Syndrome (SS) lecture will provide a comprehensive update on the new developments in SS research in the preceding 12 months. The update will include work that has been published in peer-review journals and selected abstracts from major conferences including the EULAR 2015. The lecture will be broadly divided into 3 main themes. 1. Scientific advances in our understanding of the pathogenesis of SS and SS-associated lymphoma. 2. Advances in clinical research in SS including outcome measures and registries. 3. Data from clinical trials of novel therapies in SS. Disclosure of Interest None declared

Background/Purpose Micro RNAs (miRNAs) are 18–25 nt non-coding RNAs that bind target/complementary sequences within the 3’UTR of RNA molecules steering them towards degradation or translational repression, and play a key role in the regulation of gene expression. Better understanding of the expression pattern of miRNAs in diseases may improve our understanding of the biological basis of the disease and identify potential biomarkers. The role of miRNAs in primary Sjogren’s syndrome (PSS) and PSS-related lymphoma remains poorly understood. The aim of this project is to identify a miRNA signature for PSS-related lymphoma. Methods We profiled the expression of miRNAs in whole blood (PaxGene) total RNA preparations using the Exiqon miRCURY LNA array which encompasses >1400 miRNAs and other small non-coding RNAs. A discovery cohort comprised of 36 samples from the United Kingdom Primary Sjogren’s Syndrome Registry (UKPSSR) (12 PSS patients with lymphoma, 12 PSS patients without lymphoma, 12 healthy controls) were used in the initial analysis. We also explored different normalisation strategies and developed an approach, which we considered most appropriate for analysing these data. Real-Time PCR was used to validate the most highly differentially expressed miRNAs between groups. A miRNA signature for PSS-related lymphoma was identified using cluster analysis followed by validation with a second independent cohort of 36 patients and controls. Results The initial miRNA array profiling revealed a clear clustering of the 3 subject groups. Between patient groups with and without lymphoma association, 44 miRNAs were differentially expressed. RT-PCR was used to validate 3 out of 9 of the most highly differentially expressed miRNAs. A 5-miRNA signature for pSS-associated lymphoma was identified using clustering analysis followed by validation with a second independent cohort of 36 patients and controls. The sensitivity and specificity of the signature is excellent with an area under the ROC curve of 0.92. Conclusion We have identified 5 miRNAs that are differentially expressed in peripheral blood between PSS patients with lymphoma and those without lymphoma. Identifying the mRNA targets of these miRNAs in PSS may improve our understanding of the pathogenesis of PSS-related lymphoma. Furthermore, miRNAs may be useful biomarkers for PSS-related lymphoma.

We assessed the accuracy of physician trainees in identifying different cardiac sounds and examined the factors influencing their cardiac auscultation proficiency.A total of 106 physicians in the Family Medicine Training Programme were asked to identify 10 cardiac sounds played sequentially on the Littmann electronic stethoscope, which functioned as a surrogate patient. Their auscultation accuracy was scored numerically out of a maximum of 10. Demographical data of the physicians was collected prospectively.The mean (+/-SD) auscultation proficiency score of the study population was 4.0 +/- 1.7. Physicians who graduated in 1994 or earlier fared significantly poorer than those who obtained their Bachelor of Medicine and Bachelor of Surgery degrees between 1995 and 2000 (p-value equals 0.02). Auscultation proficiency was not related to current practice, previous years of primary care, cardiology, internal medicine or paediatric medicine postings, or cumulative years of postings. Normal heart sounds were most accurately identified. Prosthetic cardiac sounds were better identified than other extra-cardiac sounds while systolic murmurs were more accurately identified than diastolic murmurs. Tachycardia had the lowest identification rate.Our data suggest that cardiac auscultation skill declined with time, being significantly impaired eight years after graduation. We suggest that there is a need for retraining in the form of continuing medical education to address not only new knowledge and skills, but also basic skill competency.

The influence of freestream turbulence representative of the flow downstream of a modern gas turbine combustor and first stage vane on turbine blade heat transfer has been measured and analytically modeled in a linear, transonic turbine cascade. High intensity, large length-scale freestream turbulence was generated using a passive turbulence-generating grid to simulate the turbulence generated in modern combustors after passing through the first stage vane row. The grid produced freestream turbulence with intensity of approximately 10–12% and an integral length scale of 2 cm (Λx/c = 0.15) near the entrance of the cascade passages. Mean heat transfer results with high turbulence showed an increase in heat transfer coefficient over the baseline low turbulence case of approximately 8% on the suction surface of the blade, with increases on the pressure surface of approximately 17%. Time-resolved surface heat transfer and passage velocity measurements demonstrate strong coherence in velocity and heat flux at a frequency correlating with the most energetic eddies in the turbulence flow field (the integral length-scale). An analytical model was developed to predict increases in surface heat transfer due to freestream turbulence based on local measurements of turbulent velocity fluctuations and length-scale. The model was shown to predict measured increases in heat flux on both blade surfaces in the current data. The model also successfully predicted the increases in heat transfer measured in other work in the literature, encompassing different geometries (flat plate, cylinder, turbine vane and turbine blade) and boundary layer conditions.