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ObjectivesTo decipher the phenotype of endothelial cells (ECs) derived from circulating progenitors issued from patients with rheumatoid arthritis (RA).MethodsRA and control ECs were compared according to their proliferative capacities, apoptotic profile, response to tumour necrosis factor (TNF)-α stimulation and angiogenic properties. Microarray experiments were performed to identify gene candidates relevant to pathological angiogenesis. Identified candidates were detected by RT-PCR and western blot analysis in ECs and by immunohistochemistry in the synovium. Their functional relevance was then evaluated in vitro after gene invalidation by small interfering RNA and adenoviral gene overexpression, and in vivo in the mouse model of methyl-bovine serum albumin-(mBSA)-induced arthritis.ResultsRA ECs displayed higher proliferation rate, greater sensitisation to TNF-α and enhanced in vitro and in vivo angiogenic capacities. Microarray analyses identified the NAD-dependent protein deacetylase sirtuin-1 (SIRT1) as a relevant gene candidate. Decreased SIRT1 expression was detected in RA ECs and synovial vessels. Deficient endothelial SIRT1 expression promoted a proliferative, proapoptotic and activated state of ECs through the acetylation of p53 and p65, and lead the development of proangiogenic capacities through the upregulation of the matricellular protein cysteine-rich angiogenic protein-61. Conditional deletion of SIRT1 in ECs delayed the resolution of experimental methyl-bovine serum albumin-(mBSA)-induced arthritis. Conversely, SIRT1 activation reversed the pathological phenotype of RA ECs and alleviates signs of experimental mBSA-induced arthritis.ConclusionsThese results support a role of SIRT1 in RA and may have therapeutic implications, since targeting angiogenesis, and especially SIRT1, might be used as a complementary therapeutic approach in RA.

ObjectiveTo investigate baseline use of biologic or targeted synthetic (b/ts) disease-modifying antirheumatic drugs (DMARDs) and COVID-19 outcomes in rheumatoid arthritis (RA).MethodsWe analysed the COVID-19 Global Rheumatology Alliance physician registry (from 24 March 2020 to 12 April 2021). We investigated b/tsDMARD use for RA at the clinical onset of COVID-19 (baseline): abatacept (ABA), rituximab (RTX), Janus kinase inhibitors (JAKi), interleukin 6 inhibitors (IL-6i) or tumour necrosis factor inhibitors (TNFi, reference group). The ordinal COVID-19 severity outcome was (1) no hospitalisation, (2) hospitalisation without oxygen, (3) hospitalisation with oxygen/ventilation or (4) death. We used ordinal logistic regression to estimate the OR (odds of being one level higher on the ordinal outcome) for each drug class compared with TNFi, adjusting for potential baseline confounders.ResultsOf 2869 people with RA (mean age 56.7 years, 80.8% female) on b/tsDMARD at the onset of COVID-19, there were 237 on ABA, 364 on RTX, 317 on IL-6i, 563 on JAKi and 1388 on TNFi. Overall, 613 (21%) were hospitalised and 157 (5.5%) died. RTX (OR 4.15, 95% CI 3.16 to 5.44) and JAKi (OR 2.06, 95% CI 1.60 to 2.65) were each associated with worse COVID-19 severity compared with TNFi. There were no associations between ABA or IL6i and COVID-19 severity.ConclusionsPeople with RA treated with RTX or JAKi had worse COVID-19 severity than those on TNFi. The strong association of RTX and JAKi use with poor COVID-19 outcomes highlights prioritisation of risk mitigation strategies for these people.

The case reported by Guilpain et al attracted our attention. This case of granulomatosis with polyangiitis on immunosuppressants, including recent maintenance therapy with rituximab (RTX), developed a severe and life-threatening coronavirus-2 (SARS-CoV-2) disease 2019 (COVID-19). The particularity of this observation was the occurrence of a more progressive worsening than observed in most series.1 Herein, we report the observation of three patients with systemic sclerosis (SSc) routinely treated with RTX who were affected by COVID-19 and who also experienced a late clinical worsening to severe pneumonia. RTX is often used off-label in patients with SSc mainly for refractory skin, musculoskeletal or interstitial lung disease. Observational studies reported a safety profile similar to that reported in rheumatoid arthritis.2 Their main disease characteristics are presented in table 1. Patient 1 had early diffuse cutaneous SSc, with positive RNA polymerase-3 antibodies, and severe cutaneous involvement (peak modified Rodnan Skin Score at 32/51) as the main clinical involvement. Patient 2 had long-lasting limited cutaneous SSc with recurrent digital ulcers and inflammatory arthritis as the main disease manifestations. Patient 3 had a limited cutaneous subset evolving from 2 years, with positive RNA polymerase-3 antibodies and persisting arthritis. None of these patients had interstitial lung disease and primary or secondary heart involvement. Regarding the main comorbidities, patient 1 was treated for high blood pressure by perindopril, furosemide and lercanidipine, and patient 2 had chronic renal insufficiency and history …

Background:The bioequivalence between rituximab (RTX) originator and its biosimilar GP2013 has been demonstrated in rheumatoid arthritis (RA) (1). A recent randomized controlled trial suggested in a selected population a very low immunogenicity of GP2013 in RA (Objectives:To study in daily practice the risk of immunogenicity of patients treated with GP2013 for their chronic inflammatory rheumatic disorder.Methods:Prospective routine care study carried out between September 2018 and August 2020 in the Rheumatology department of Cochin Hospital. We consecutively included patients treated with the biosimilar RTX GP2013, systematically used in the department since March 2018. Samples were taken before each infusion in order to detect anti-RTX antibodies (Ab) and RTX residual concentrations by ELISA (Lisa Tracker Duo Rituximab, LTR005, Theradiag).Results:We included 159 consecutive patients treated with GP2013 (124 women, 78%) with a mean age of 59±13 years and a mean disease duration of 18±11 years. Among these 159 patients, 108 (68%) had RA and 51 had another disease (16 systemic sclerosis (SSc), 15 mixed connective tissue disease (MCTD), 5 systemic lupus (SLE), 5 inflammatory myopathies (MI), 5 undifferentiated polyarthritis, 2 juvenile idiopathic arthritis (JIA) and 3 primary Sjögren’s syndromes). 137 patients (86%) were receiving associated disease-modifying therapy (DMARD), mainly methotrexate (111/137 patients, 81%). 120 patients (75%) were in maintenance therapy with originator RTX (cumulative dose of RTX: 3.5±6g) before the switch to GP2013 in March 2018. Originator RTX was not re-established during the entire treatment period. The other 39 patients (25%) treated with GP2013 were naïve of originator RTX.The analysis of the first sample, performed before the second GP2013 infusion, identified 8 patients (5 RA, 1 SLE, 1 MCTD and 1 SSc) with positive anti-RTX antibodies (prevalence 5%), with rates varying between 6 and >100ng/mL and undetectable residual RTX concentrations. Among these 8 patients, 6 had previously received originator RTX and 2 were RTX-naïve patients. There was a trend for higher body mass index in patients with positive anti-RTX antibodies (28±7 vs. 25±6 kg/m2, p=0.12), and no association was observed between anti-RTX immunization and age, disease duration, combination with conventional DMARD, mean interval between infusions or cumulative RTX dose.Among the 8 immunized patients, two groups could be isolated: i) a group of 5 patients (3 RA, 1 SLE, 1 SSc) with low antibody levels (6-22 ng/mL) and no significant clinical consequences (absence of treatment discontinuation and loss of efficacy after 13±4 months of follow-up, only one minor allergic reaction) and ii) a group of 3 patients (2 RA, 1 MCTD) with a high antibody levels (≥100ng/mL) and meaningful clinical consequences: one severe allergic reaction during the second GP2013 infusion leading to treatment discontinuation, and a loss of efficacy with incomplete B depletion in 2 patients leading to RTX dose escalation from 500 mg to 1 g. Among the 151 patients not immunized at the time of the first sample, no severe allergic reaction and 6 minor allergic reactions were noted under GP2013.Conclusion:The immunogenicity of patients treated with RTX is a rare event with possible clinical and biological consequences, especially in patients with high antibody levels.References:[1]Smolen et al, Ann Rheum Dis 2017[2]Tony et al, Arthritis Care Res 2019Disclosure of Interests:None declared

ObjectiveTo evaluate the antifibrotic effects of the pan-peroxisome proliferator-activated receptor (PPAR) agonist IVA337 in preclinical mouse models of pulmonary fibrosis and related pulmonary hypertension (PH).MethodsIVA337 has been evaluated in the mouse model of bleomycin-induced pulmonary fibrosis and in Fra-2 transgenic mice, this latter being characterised by non-specific interstitial pneumonia and severe vascular remodelling of pulmonary arteries leading to PH. Mice received two doses of IVA337 (30 mg/kg or 100 mg/kg) or vehicle administered by daily oral gavage up to 4 weeks.ResultsIVA337 demonstrated at a dose of 100 mg/kg a marked protection from the development of lung fibrosis in both mouse models compared with mice receiving 30 mg/kg of IVA337 or vehicle. Histological score was markedly reduced by 61% in the bleomycin model and by 50% in Fra-2 transgenic mice, and total lung hydroxyproline concentrations decreased by 28% and 48%, respectively, as compared with vehicle-treated mice. IVA337 at 100 mg/kg also significantly decreased levels of fibrogenic markers in lesional lungs of both mouse models. In addition, IVA337 substantially alleviated PH in Fra-2 transgenic mice by improving haemodynamic measurements and vascular remodelling. In primary human lung fibroblasts, IVA337 inhibited in a dose-dependent manner fibroblast to myofibroblasts transition induced by TGF-β and fibroblast proliferation mediated by PDGF.ConclusionWe demonstrate that treatment with 100 mg/kg IVA337 prevents lung fibrosis in two complementary animal models and substantially attenuates PH in the Fra-2 mouse model. These findings confirm that the pan-PPAR agonist IVA337 is an appealing therapeutic candidate for these cardiopulmonary involvements.

Background:Methotrexate (MTX) holds a unique place in the management of rheumatoid arthritis (RA) given its favorable balance between efficacy and safety. However, conflicting data still suggest a potential risk of MTX-induced long-term liver fibrosis. The fibrosis-4 (FIB-4) index was originally proposed as a simple and non-invasive marker of liver fibrosis in HIV/HCV co-infection. In patients with RA, FIB-4 values have been correlated to the amount of histologic liver lesions, suggesting that this index may be a valuable marker to diagnose liver disease in RA patients (1).Objectives:To estimate the amount of scarring in the liver with the FIB-4 index in RA patients on maintenance therapy with MTX.Methods:We performed a cross-sectional study including successive RA patients hospitalized in the Rheumatology department of Cochin Hospital for a 12-month period. Data on liver function, disease activity, hepatotoxic and cardiovascular risk factors were systematically collected. The FIB-4 index was calculated according the following formula: (age(years) × AST(U/L)/platelet (PLT) (109/L) × √ALT(U/L)). Using a lower cutoff value of 1.45, a FIB-4 score 3.25 had a 97% specificity and a positive predictive value of 65% for advanced fibrosis (2).Results:We included 170 patients with established RA: 141 (83%) were women, the mean age was 59+/-12 years and the mean disease duration was 15+/-11 years. Positive rheumatoid factors and anti-CCP antibodies were detected in 134 patients (79%). 102 patients (60%) were treated with methotrexate, with a mean dose of 10.0+/-8.4 mg/week, a mean treatment duration of 9.5+/-10.3 years and a cumulative dose of 5.3+/-5.1g. 23 patients (13.5%) received conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) other than MTX, 112 (66%) corticosteroids (99 with a dose < 10 mg/day) and 85 targeted biologic DMARDs (bDMARDs) (50%). The mean FIB-4 value was 1.24+/-0.57, with 120 patients (71%) with value 3.25. The FIB-4 was low and not significantly different between patients receiving MTX, patients previously treated with MTX and patients never treated with MTX (median 1.1, 1.25 and 1.18, respectively, p=0.709). This result was not modified after adjustment on treatments with other csDMARDs, corticosteroids, and bDMARDs. No correlation was observed between FIB-4 values and the cumulative dose of MTX (r=0.09, p=0.271). The FIB-4 index was low and similar between patients receiving cumulative MTX doses 1.45 (median cumulative MTX dose 5.5g vs. 3.5g, p=0.302). No association was detected between the FIB-4 index and parameters of disease activity (DAS28, ESR and CRP levels), the body mass index, traditional cardiovascular risk factors and metabolic syndrome.Figure 1.Fibrosis-4 index according to the cumulative dose of methotrexate in patients with rheumatoid arthritisConclusion:RA patients with long-term maintenance MTX therapy have low FIB-4 values suggesting that MTX is not associated with an increased risk of advanced liver fibrosis.References:[1]Miyata et al, Mod Rheumatol 2019[2]Sterling et al, Hepatology 2006Disclosure of Interests:Jérôme Avouac Grant/research support from: Pfizer, Bristol Myers Squibb, Consultant of: Sanofi, Bristol Myers Squibb, Abbvie, Boerhinger, Nordic Pharma, Speakers bureau: Sanofi, Bristol Myers Squibb Abbvie, MSD, Pfizer, Nordic Pharma, Raphael Degrave: None declared, Hélène Vergneault: None declared, Yannick Allanore Shareholder of: Sanofi, Roche, Consultant of: Actelion, Bayer, BMS, Boehringer Ingelheim, Inventiva, Sanofi

BackgroundThe European Scleroderma Trials and Research Group (EUSTAR) recently developed a preliminarily revised activity index (AI) that performed better than the European Scleroderma Study Group Activity Index (EScSG-AI) in systemic sclerosis (SSc).ObjectiveTo assess the predictive value for short-term disease severity accrual of the EUSTAR-AI, as compared with those of the EScSG-AI and of known adverse prognostic factors.MethodsPatients with SSc from the EUSTAR database with a disease duration from the onset of the first non-Raynaud sign/symptom ≤5 years and a baseline visit between 2003 and 2014 were first extracted. To capture the disease activity variations over time, EUSTAR-AI and EScSG-AI adjusted means were calculated. The primary outcome was disease progression defined as a Δ≥1 in the Medsger’s severity score and in distinct items at the 2-year follow-up visit. Logistic regression analysis was carried out to identify predictive factors.Results549 patients were enrolled. At multivariate analysis, the EUSTAR-AI adjusted mean was the only predictor of any severity accrual and of that of lung and heart, skin and peripheral vascular disease over 2 years.ConclusionThe adjusted mean EUSTAR-AI has the best predictive value for disease progression and development of severe organ involvement over time in SSc.

ObjectivesTo investigate the influence of vasodilator drugs on the occurrence of features depending on myocardial ischaemia/fibrosis (ventricular arrhythmias, Q waves, cardiac blocks, pacemaker implantation, left ventricular ejection fraction (LVEF) Methods601 patients with SSc were enrolled from 1 December 2012 to 30 November 2015 and had a second visit 0.5–4 years apart. 153 received no vasodilators; 448 received vasodilator therapy (ie, calcium channel blockers and/or ACE inhibitors or angiotensin II receptor blockers or combinations of them), 89 of them being also treated with either endothelin receptor antagonists or PDE5 inhibitors or prostanoids. Associations between the occurrence of myocardial disease manifestations and any demographic, disease and therapeutic aspect were investigated by Cox regression analysis. A Cox frailty survival model with centre of enrolment as random effect was performed.ResultsDuring 914 follow-up patient-years, 12 ventricular arrhythmias, 5 Q waves, 40 cardiac blocks, 6 pacemaker implantations and 19 reduced LVEF and/or congestive heart failure (CHF) occurred. In multivariate Cox regression analysis, vasodilator therapy was associated with a lower incidence of ventricular arrhythmias (p=0.03); low-dose acetylsalicylic acid (ASA) with a lower incidence of cardiac blocks and/or Q waves and/or pacemaker implantation (p=0.02); active disease with a higher incidence of LVEF ConclusionsThe present study might suggest a preventative effect on the occurrence of distinct myocardial manifestations by vasodilator therapy and low-dose ASA.

Background:In 2017, TOCILIZUMAB (TCZ) obtained marketing authorization for treatment of giant cell arteritis (GCA); however, this doesn’t extend to polymyalgia rheumatica (PMR) therapy. Based on efficacy data for TCZ in GCA, TCZ is sometimes used as a glucocorticoid (GC) sparing agent when PMR is GC dependent or when a rapid steroid withdraw is needed. Currently, there are no available recommendations on the use of this therapeutic class in for this particular indication.Objectives:Here, we present the results of an observational French multicentric study of patients with PMR treated with TCZ.Methods:Thirteen medical centers were included in this study. The data was collected retrospectively between 2015 and 2020. The minimum duration of treatment was 3 months. Patients were included when receiving TCZ for isolated PMR or associated with a non-active GCA (asymptomatic, no vascular fixation on PET scanner).Results:Overall, 34 patients were included (24 women; mean age 70.1 years (+/-10.3)). At TCZ introduction, patients had been treated with GC for a mean duration of 27,9 months (+/-25.9) and the mean GC dose was 16,8mg/d (+/-10). Fifteen patients (44%) had one or more complications from GC therapy. Another immunosuppressant was added before TCZ treatment for 25 (74%); mostly METHOTREXATE (24/25).TCZ was initiated intravenously at 8mg/kg every 4 weeks for 27 patients (79%) and subcutaneously at 162mg/week for 7 patients (21%).The reasons for TCZ introduction included GC dependence (n=30, 88%), and necessity of quick GC sparing (n=4 patients,12%).Of all patients, 76% (26 patients) had stopped GC treatment definitively, with a mean time of 9,4 (0-32) months.The mean TCZ treatment period was 19,2 months (3-66). Fifteen patients (44%) permanently stopped TCZ at the end of the observation period (8 prolonged remissions;1 myocardial infarction; 1 cutaneous lymphoma; 1 primary failure, 3 lost to follow up).Eighteen patients (60%) benefited from an attempted tapering of TCZ (infusion spacing or dose reduction), 6 attempts (1/3) led to a relapse. 1/2 patients had side effects mostly benign (cytopenia n=6, infections n=5).Conclusion:This is the largest cohort presenting results of the use of TCZ in PMR. Despite the small number of participants, our study suggests TCZ is effective as a GC sparing agent in PMR. As there are no official recommendations of use, indications for TCZ use within this population are no defined. Randomized Controlled Trial would be beneficial to validate these first results.References:[1]Toussirot, « Biothérapies, pseudo- polyarthrite rhizomélique et artérite à cellules géantes État des lieux en 2018 ».[2]Devauchelle-Pensec et al., « Efficacy of First-Line Tocilizumab Therapy in Early Polymyalgia Rheumatica ».[3]Genovese et al., « Longterm Safety and Efficacy of Tocilizumab in Patients with Rheumatoid Arthritis ».[4]Stone et al., « Trial of Tocilizumab in Giant-Cell Arteritis ».Disclosure of Interests:None declared

Background:Inhibiting a specific JAK may impede more than one pathway, explaining both the efficacy and adverse effects observed with JAK inhibitors (JAKi). Among those, there have been recent concerns about potential thromboembolic risks with these drugs. As patients enrolled are not representative of all patients who may receive JAKi, data from trials are unlikely to provide definitive answers. Real impact of JAKi in real life on major cardiovascular events is not known.Objectives:To evaluate the risk of venous and arterial thromboembolic events with the use of JAKi in a real-world setting.Methods:A self-controlled case series analysis (method in which individuals act as their own control) was performed using data from the French national healthcare insurance system SNDS (“Système National des Données de Santé”), which included all anonymized individual level data about sociodemographic data, outpatient healthcare dispensed, hospital discharge summaries, and registration status for a list of 30 long term diseases. All patients treated by JAKi (baricitinib or tofacitinib) for rheumatoid arthritis, psoriasis arthritis and/or inflammatory bowel disease, and with at least one thromboembolic event (venous (VTE): deep vein thrombosis (DVT), pulmonary embolism (PE), arterial (ATE): acute coronary syndrome (ACS), myocardial infarction (MI), transient ischemic attack (TIA) and stroke) between 2017/11/01 and 2019/06/30 were included in the study. Associations were evaluated by incidence rate ratios (IRR), which compare the rate of events during exposed periods with rate of event during all other observed time periods. Exposed periods were defined as i) exposure to JAKi, ii) the month following exposure (post-exposure 1-30 days), and iii) long-term post-exposure (31 to 60 days). A pre-exposure period of 7 days was individualized to identify event-dependent probabilities of exposure and potential reverse causality bias, and all other periods were considered as non-exposed periods.Results:Among the 5,870 patients treated with JAKi between 2017/11/01 and 2019/06/30, 94 presented an incident thromboembolic event and were included. Almost two thirds were female (n=61, 64.9%), and median age was 65.4 [IQR: 55.5; 75.8] years. Most of patients have a rheumatoid arthritis (n=91, 96.8%), 62 (66.0%) were treated by baricitinib, and 32 (34.0%) by tofacitinib. Almost half (n=42, 44.7%) presented a venous thromboembolism, mainly DVT (n=31, 33.0%), and 52 (55.3%) presented an arterial thromboembolism, mainly MI (n=16, 17.0%) and stroke (n=14, 14.9%). Eleven patients (11.7%) died during the study period. The median time of occurrence of VTE was 4.3 [IQR: 2.5; 8.9] months, and 6.1 [IQR: 3.3; 9.2] months for ATE.The median duration of exposure was 6.0 [IQR: 3.3; 10.1] months for VTE, and 12.0 [IQR: 4.8; 15.3] months for ATE. The IRR for VTE and ATE were increased during exposure, and during the 30 days following exposure (Table 1). The IRR for VTE was only increased during exposure and in the early post-exposure phase contrary to the IRR for ATE that was also increased in the pre-exposure 7-Day period. Analysis conducted on survival patients confirmed results.Table 1.NPatient-yearsIRR95%CIVenous thromboembolic eventsNon-exposure (reference)83975.01-Pre-exposure to JAK-i1135.24.70.6-38.0Exposure to JAK-i272090.59.84.1-23.3Post-exposure 1-30 d5369.06.21.9-19.9Post-exposure 31-60 d1139.01.50.2-12.6Arterial thromboembolic eventsNon-exposure (reference)74076.81-Pre-exposure to JAK-i3344.111.52.8-46.8Exposure to JAK-i326363.87.42.9-18.7Post-exposure 1-30 d8659.211.53.8-34.6Post-exposure 31-60 d2132.24.30.8-22.0Conclusion:The present study found an increased risk of VTE and ATE for baricitinib and tofacitinib. The risk persists in the month following the discontinuation of treatment but disappears after day 30 post-exposure.Disclosure of Interests:Amandine Gouverneur: None declared, Jérôme Avouac Consultant of: JA has/had consultancy relationship and/or has received research funding in the area of potential treatments for rheumatoid arthritis from (last three years): Abbvie, Galapagos, Pfizer, Bristol Myers Squibb, Sanofi, Nordic Pharma, Chugai and MSD., Grant/research support from: JA has/had consultancy relationship and/or has received research funding in the area of potential treatments for rheumatoid arthritis from (last three years): Abbvie, Galapagos, Pfizer, Bristol Myers Squibb, Sanofi, Nordic Pharma, Chugai and MSD., Clément Prati: None declared, Jean-Luc Cracowski: None declared, Thierry Schaeverbeke Consultant of: TS consultancy and/or research fundings: Abbvie, Lilly, Pfizer, Galapagos, Novartis, BMS, Medac, NordicPharma, Biogen, Mylan, Janssen., Grant/research support from: TS consultancy and/or research fundings: Abbvie, Lilly, Pfizer, Galapagos, Novartis, BMS, Medac, NordicPharma, Biogen, Mylan, Janssen., Antoine Pariente Grant/research support from: AP reports acting as an independant expert towards the French Medicines Agency (Agence Nationale de Securité du Médicament et des Produits de Santé, ANSM) and the European Medicines Agency (EMA). AP coordinates the DRUGS Systematised Assessment in real-liFe EnviRonment (DRUGS-SAFER) programme funded by the Agence Nationale de Sécurité du Médicament et des Produits de Santé (ANSM)., Marie-Elise Truchetet Consultant of: has/had consultancy relationship and/or has received research funding in the area of potential treatments for rheumatoid arthritis and spondyloarthritis and their complications from (last three years): Abbvie, Galapagos, Lilly, Medac, Novartis, Pfizer, and Roche., Grant/research support from: has/had consultancy relationship and/or has received research funding in the area of potential treatments for rheumatoid arthritis and spondyloarthritis and their complications from (last three years): Abbvie, Galapagos, Lilly, Medac, Novartis, Pfizer, and Roche.

Background:We have previously shown that decreased expression of the deacetylase sirtuin-1 (SIRT1) contributes to the proliferative, activated and proangiogenic profile of endothelial cells (EC) in rheumatoid arthritis (RA) (1). The matricellular protein CCN1, characterized by proangiogenic and immunomodulatory properties, may be directly implicated in these processes, since its expression is negatively regulated by SIRT1 (1).Objectives:To study the implication of CCN1 in RA pathogenesis.Methods:CCN1 expression was assessed in ECs (25 RA and 10 controls) by quantitative RT-PCR, western blot and ELISA, in the synovial tissue (5 RA and 5 controls) by immunohistochemistry and immunofluorescence, and in the serum (205 RA and 20 controls) by ELISA. Invalidation of CCN1 in RA ECs was achieved through the use of shRNA and neutralizing monoclonal antibodies. The functional consequences of CCN1 invalidation in RA ECs were studied i) in vitro by the analysis of proliferation (cell impedance), tube formation in Matrigel and migration in Boyden chambers; and ii) in vivo in the murine model of tumor neoangiogenesis.Results:CCN1 mRNA and protein expression were increased by 1.72- (p = 0.012) and 7.2-fold (p=0.008) in RA ECs compared to controls, respectively. CCN1 concentrations were significantly increased in RA EC culture supernatants (930±153 vs. 359±199 pg/mL, p=0.007). CCN1 was overexpressed in the synovial tissue of RA patients (Figure 1A) and confocal microscopy analyses revealed a prominent CCN1 expression in the vascular endothelium (CD31 +) and T cells (CD3 +) (Figure 1B).In vitro, recombinant TNF-α and IL-17 induced the mRNA and protein expression of CCN1 in RA ECs. CCN1 invalidation was associated with reduced proliferative capacities, delayed capillary tube formation and decreased migration of RA ECs (Figure 1E). In vivo, subcutaneous transplantation of CT26 tumor cells combined with RA ECs transfected with CCN1 shRNA to CB17 SCID mice was associated with a 51% reduction in tumor volume (p=0.008) and a 27% reduction in tumoral vascular density (p=0.032) compared with mice transplanted with MOCK transfected RA-ECs (Figure 1F).Serum concentrations of CCN1 were significantly reduced in the serum of RA patients compared to controls (233±118 vs. 279±75 pg/mL, p=0.045) (Figure 1C). However, serum CCN1 concentrations were significantly higher in the presence of bone erosions (253±139 vs. 202±7 pg/mL, p=0.002) (Figure 1D) and correlated with radiographic Larsen score (r=0.3, p=0.001) and HAQ (r=0.25, p=0.012).Conclusion:CCN1 is overexpressed in ECs and the synovial tissue of patients with RA. CCN1 also regulate the functional properties of RA ECs and their angiogenic potential in vivo. CCN1 could represent a new therapeutic target, which is being evaluated in experimental models of erosive arthritis.CCN1 may be a reliable biomarker of structural damages given the association between its serum concentrations and the extent of radiographic lesions. The performance of CCN1 serum levels to predict structural progression is under investigation.References:[1]Leblond et a, Ann Rheum Dis 2020.Figure 1.Implication of CCN1 in the pathogenesis of rheumatoid arthritis (RA). A, Representative immunohistochemistry staining for CCN1. B, Representative confocal microscopy analyses. C-D, CCN1 serum concentrations; statistical test: Student t test, ** pE, Representative images of RA endothelial cell (EC) migration; Y-axis shows the number of migrated cells, statistical test: Wilcoxon test, * pF, Representative subcutaneous tumors, Y-axis shows the fluorescence area in %, statistical test: Wilcoxon test, * pDisclosure of Interests:None declared

Background The pathogenesis of systemic sclerosis (SSc) involves a distinctive triad of autoimmune, vascular and inflammatory alterations resulting in fibrosis. Evidence suggests that peroxisome proliferator-activated receptors (PPARs) play an important role in SSc-related fibrosis and their agonists may become effective therapeutic targets. Objective To determine the expression of PPARs in human fibrotic skin and investigate the effects of IVA337, a pan PPAR agonist, in in vitro and in vivo models of fibrosis. Methods The antifibrotic effects of IVA337 were studied using a bleomycin-induced mouse model of dermal fibrosis. The in vivo effect of IVA337 on wound closure and inflammation were studied using an excisional model of wound healing. Results Low levels of PPARα and PPARγ were detected in the skin of patients with SSc compared with controls. In mice, IVA337 was associated with decreased extracellular matrix (ECM) deposition and reduced expression of phosphorylated SMAD2/3—intracellular effector of transforming growth factor (TGF)-β1. Although the antifibrotic effect of pan PPAR was similar to that of PPARγ agonist alone, a significant downregulation of several markers of inflammation was associated with IVA337. Despite its anti-inflammatory and antifibrotic properties, IVA337 did not interfere with wound closure. In vitro effects of IVA337 included attenuation of transcription of ECM genes and alteration of canonical and non-canonical TGF-β signalling pathways. Conclusions These findings indicate that simultaneous activation of all three PPAR isoforms exerts a dampening effect on inflammation and fibrosis, making IVA337 a potentially effective therapeutic candidate in the treatment of fibrotic diseases including SSc.

Objectives S100A4 is a calcium binding protein with regulatory functions in cell homeostasis, proliferation and differentiation that has been shown to promote cancer progression and metastasis. In the present study, we evaluated the role of S100A4 in fibroblast activation in systemic sclerosis (SSc). Methods The expression of S100A4 was analysed in human samples, murine models of SSc and in cultured fibroblasts by real-time PCR, immunohistochemistry and western blot. The functional role of S100A4 was evaluated using siRNA, overexpression, recombinant protein and S100A4 knockout (S100A4 −/− ) mice. Transforming growth factor β (TGF-β) signalling was assessed by reporter assays, staining for phosphorylated Smad2/3 and analyses of target genes. Results The expression of S100A4 was increased in SSc skin and in experimental fibrosis in a TGF-β/Smad-dependent manner. Overexpression of S100A4 or stimulation with recombinant S100A4 induced an activated phenotype in resting normal fibroblasts. In contrast, knockdown of S100A4 reduced the pro-fibrotic effects of TGF-β and decreased the release of collagen. S100A4 −/− mice were protected from bleomycin-induced skin fibrosis with reduced dermal thickening, decreased hydroxyproline content and lower myofibroblast counts. Deficiency of S100A4 also ameliorated fibrosis in the tight-skin-1 (Tsk-1) mouse model. Conclusions We characterised S100A4 as a downstream mediator of the stimulatory effects of TGF-β on fibroblasts in SSc. TGF-β induces the expression of S100A4 to stimulate the release of collagen in SSc fibroblasts and induce fibrosis. Since S100A4 is essentially required for the pro-fibrotic effects of TGF-β and neutralising antibodies against S100A4 are currently evaluated, S100A4 might be a candidate for novel antifibrotic therapies.

Objectives Transforming growth factor β (TGFβ) has been identified as a key player in fibrotic diseases. However, the molecular mechanisms by which TGFβ activates fibroblasts are incompletely understood. Here, the role of JunD, a member of the activator protein 1 (AP-1) family of transcription factors, as a downstream mediator of TGFβ signalling in systemic sclerosis (SSc), was investigated. Methods The expression of JunD was analysed by real-time PCR, immunofluorescence, western blotting and immunohistochemistry. The canonical Smad pathway was specifically targeted by small interfering (si)RNA. The expression of extracellular matrix proteins in JunD deficient (JunD −/− ) fibroblasts was analysed by real-time PCR and hydroxyproline assays. The mouse model of bleomycin-induced dermal fibrosis was used to assess the role of JunD in experimental fibrosis. Results JunD was overexpressed in SSc skin and in cultured fibroblasts in a TGFβ dependent manner. The expression of JunD colocalised with pSmad 3 in fibrotic skin and silencing of Smad 3 or Smad 4 by siRNA prevented the induction of JunD by TGFβ. JunD −/− fibroblasts were less responsive to TGFβ and released less collagen upon stimulation with TGFβ. Moreover, JunD −/− mice were protected from bleomycin-induced fibrosis with reduced dermal thickening, decreased myofibroblast counts and lower collagen content of lesional skin. Conclusions These data demonstrate that JunD is overexpressed in SSc and that JunD is a mediator of the profibrotic effects of TGFβ. Considering that inhibitors of AP-1 signalling have recently been developed and are available for clinical trials in SSc, these findings may have translational implications.

ObjectiveTo examine the outcomes of hand radiographic x-rays in patients with systemic sclerosis (SSc) and to identify risk factors for the progression of hand radiographic lesions in a prospective cohort.MethodsDual time-point x-rays were systematically performed after a median interval of 5 years (range 4–7 years) in 103 consecutively recruited patients with SSc. Univariate and multivariate Cox proportional hazards models evaluated predictors of progression of hand radiographic lesions.ResultsRadiographic progression of erosive arthritis, acro-osteolysis, calcinosis and flexion contracture occurred in 24, 22, 27 and 18 patients, respectively. Multivariate Cox regression analysis did not identify any predictor of the progression of erosive arthritis. Digital ulcers were shown independently to predict the progression of acro-osteolysis and calcinosis (HR 12.43, 95% CI 1.97 to 88.40 and 3.16, 95% CI 1.22% to 9.43%, respectively). The diffuse cutaneous subset was shown to be an independent predictor of the progression of flexion contracture (HR 7.52, 95% CI 1.21 to 43.93).ConclusionThe results highlight the striking level of hand radiographic lesions in SSc and suggest close monitoring of patients with the diffuse cutaneous subset for the occurrence or worsening of this complication. The results also show that severe peripheral vascular involvement predicts both acro-osteolysis and calcinosis, highlighting their vascular background.

Background: Heterogeneous data have been reported regarding the detection and number of circulating endothelial progenitor cells (EPCs) in systemic sclerosis (SSc). Objective: We investigated the number of circulating EPCs using recent recommendations and we quantified their late outgrowth in patients with SSc and healthy controls. Patients and methods: EPCs, defined as Lin–/7AAD–/CD34+/CD133+/VEGFR-2+ cells, were quantified in 50 patients with SSc (mean age: 55 (16) years, disease duration: 9 (9) years) and 26 controls (mean age: 53 (19) years) by cell sorting/flow cytometry and by counting late outgrowth colony-forming units (CFU). Results: Patients with SSc displayed higher circulating EPC counts than controls (median 86 (5–282) vs 49 (5–275)) EPCs for 1 million Lin– mononuclear cells; p = 0.01). Lower EPC counts were associated with the higher Medsger’s severity score (p = 0.01) and with the presence of past and/or current digital ulcers (p = 0.026). There was no difference for the number of late outgrowth EPC-CFUs between patients with SSc and controls in cell culture evaluation. The formation of colonies was associated with higher levels of circulating EPCs (p = 0.02) and the number of colonies correlated with levels of EPCs (R = 0.73, p = 0.0004), validating our combination of fluorescence-activated cell sorter surface markers. Conclusions: We quantified circulating EPCs with an accurate combination of markers herein validated. Our data demonstrate increased circulating EPC levels in SSc, supporting their mobilisation from bone marrow. Furthermore, the subset of patients with digital vascular lesions and high severity score displayed low EPC counts, suggesting increased homing at this stage. The predictive value of this biomarker now warrants further evaluation.

Systemic sclerosis (SSc) is characterised by a progressive microangiopathy that contributes significantly to the morbidity of patients with SSc. Besides insufficient angiogenesis, defective vasculogenesis with altered numbers of endothelial precursor cells (EPCs) might also contribute to the vascular pathogenesis of SSc. However, different protocols for isolation, enrichment, culture and quantification of EPCs are currently used, which complicate comparison and interpretation of the results from different studies.The aim of the European League Against Rheumatism Scleroderma Trials and Research (EUSTAR) group expert panel was to provide recommendations for standardisation of future research on EPCs. Consensus statements and recommendations were developed in a face to face meeting by an expert panel of the basic science working group of EUSTAR.The findings were: cardiovascular risk factors and medications such as statins should be described in detail. A detailed description of methods considering isolation, culture, enrichment and detection of EPCs should be given. For in vitro culture of EPCs, no protocol has been shown to be superior to another, but coating with laminin and type IV collagen would resemble most closely the situation in vivo. The endothelial phenotype should be confirmed in all in vitro cultures at the end of the culture period. We recommend using CD133, vascular endothelial growth factor type 2 receptor (VEGFR2) and CD34 in combination with a viability marker for quantification of EPCs in the blood. Finally, exact standard operating procedures for fluorescence-activated cell sorting (FACS) analysis are given that should be strictly followed.In summary, the EUSTAR recommendations will help to unify EPC research and allow better comparison between the results of different studies.

Objective: To determine the effects of recently available oral therapies, ie, endothelin receptor antagonists (ERAs) and phosphodiesterase-5 inhibitors (PDEIs), in patients with pulmonary arterial hypertension related to connective tissue disease (CTD), mostly systemic sclerosis (SSc). Method: A systematic literature search was conducted up to April 2007. All randomised controlled trials evaluating the efficacy of bosentan, sitaxsentan and sildenafil vs placebo on exercise capacity were selected. Effect size was calculated in each study to assess the magnitude of treatment effect. Results: In all, 10 studies were analysed, giving a total of 613 participants (186 with CTD) who received the active treatment and 272 (72 with CTD) who received placebo. The effect sizes of bosentan, sitaxsentan and sildenafil for exercise capacity in the CTD subset of patients were non-significant; 0.31 (95% confidence interval (CI) −0.22 to 0.83), 0.26 (95% CI −0.06 to 0.57) and 0.53 (95% CI −0.02 to 0.89), respectively. In the whole PAH population, these values were significant; 0.61 (95% CI 0.38 to 0.84), 0.33 (95% CI 0.15 to 0.51) and 0.58 (95% CI 0.38 to 0.79), respectively. Conclusion: This meta-analysis suggests an absence of clinically relevant improvement on exercise capacity in patients with CTD/SSc after 12 to 18 weeks of treatment. A poor therapeutic response, insufficient power of studies or poor sensitivity to change of the 6-min walk test may explain these results. The promising preliminary data on survival of ERAs and the confounding effects of other comorbidities associated with CTD and SSc may support the latter hypothesis.

Objective Activated T cells are the main component of the inflammatory skin infiltrates that characterise systemic sclerosis (SSc). Our aim was to investigate the efficacy of abatacept, which tempers T-cell activation, in reducing skin fibrosis in complementary mouse models of SSc. Methods The antifibrotic properties of abatacept were evaluated in the mouse models of bleomycin-induced dermal fibrosis and sclerodermatous chronic graft-versus-host disease, reflecting early and inflammatory stages of SSc. Thereafter, we studied the efficacy of abatacept in tight skin (Tsk-1) mice, an inflammation-independent mouse model of skin fibrosis. Results Abatacept efficiently prevented bleomycin-induced skin fibrosis and was also effective in the treatment of established fibrosis. In this model, abatacept decreased total and activated T-cell, B-cell and monocyte infiltration in the lesional skin. Abatacept did not protect CB17-SCID mice from the development of bleomycin-induced dermal fibrosis, which supports that T cells are necessary to drive the antifibrotic effects of abatacept. Upon bleomycin injections, skin interleukin (IL) 6 and IL-10 levels were significantly reduced upon abatacept treatment. Moreover, treatment with abatacept ameliorated fibrosis in the chronic graft-versus-host disease model, but demonstrated no efficacy in Tsk-1 mice. The tolerance of abatacept was excellent in the three mouse models. Conclusions Using complementary models, we demonstrate that inhibition of T-cell activation by abatacept can prevent and induce the regression of inflammation-driven dermal fibrosis. Translation to human disease is now required, and targeting early and inflammatory stages of SSc sounds the most appropriate for positioning abatacept in SSc.

Background: The osteoarticular and soft tissue structures of the hand may be involved in systemic sclerosis (SSc), causing functional disability. Objective: To assess radiological hand features in a cross sectional study of SSc patients and in controls. Methods: Hand radiology was done systematically in patients with SSc seen over a two year period and in unselected controls with rheumatoid arthritis or digital trauma. Two independent investigators blind to the diagnosis carried out the radiological assessment. Results: 120 consecutive SSc patients (median (range) age, 56.5 (20 to 90) years; disease duration, 6 (0 to 42) years) and 42 controls (22 with rheumatoid arthritis and 20 with digital trauma) were studied. Radiological abnormalities in SSc patients included erosion (21%), joint space narrowing (28%), arthritis (defined by concomitant erosion and joint space narrowing) (18%), radiological demineralisation (23%), acro-osteolysis (22%), flexion contracture (27%), and calcinosis (23%). In univariate and multivariate analysis, the resorption of distal phalanges was significantly associated with digital ulcers, extra-articular calcification, and pulmonary arterial hypertension; flexion contracture was associated with the diffuse cutaneous form and high HAQ (Health Assessment Questionnaire) disability score. Calcinosis was most often seen in patients with digital ulcers, but was similarly observed in patients with the diffuse or limited cutaneous subtypes. Conclusions: Flexion contracture was associated with disability and occurred in patients with the diffuse cutaneous subtype of SSc, consistent with the tendency towards fibrosis and functional impairment of this subtype. Calcinosis and acro-osteolysis were both associated with vascular complications, highlighting a potential role of vascular injury in such lesions.

Objective: To evaluate the two generations of anti-cyclic citrullinated protein (CCP) antibodies as a diagnostic marker of rheumatoid arthritis (RA) and as a predictor of future development of RA in healthy subjects and in patients with early undifferentiated arthritis. Methods: A systematic analysis of the literature published between 1999 and February 2006 was conducted. Data were collected on the sensitivity and specificity of the two generations of anti-CCP antibodies for diagnosing RA and predicting future development of the disease. Results: Among 107 studies initially identified, 68 had interpretable data and were analysed. Diagnostic properties were assessed in 58 studies: mean (SD) sensitivity was 53 (10)% (range 41–68) and 68 (15)% (range 39–94) for anti-CCP1 and anti-CCP2, respectively; mean (SD) specificity was 96 (3)% (range 90–99) and 95 (5)% (range 81–100) for anti-CCP1 and anti-CCP2, respectively. Predictive properties were assessed in 14 studies; odds ratio (95% confidence interval) of anti-CCP1 and anti-CCP2 for the future development of RA were 20 (14 to 31) and 25 (18 to 35), respectively, among patients with early undifferentiated arthritis and 64.5 (8.5 to 489) and 28 (8 to 95), respectively, among healthy subjects. Conclusion: Sensitivity of the second generation of anti-CCP is close to that of rheumatoid factor, with a higher specificity, for distinguishing RA from other rheumatic diseases. Moreover, anti-CCP antibodies appear to be highly predictive of the future development of RA in both healthy subjects and patients with undifferentiated arthritis.

Objectives In systemic sclerosis (SSc), vascular involvement is characterised by vascular endothelial growth factor (VEGF)-A/VEGF receptor (VEGFR) system disturbances. Neuropilin-1 (NRP1), a receptor for both class-3 semaphorins (Sema3s) and VEGF-A, is required for optimal VEGF-A/VEGFR-2 signalling. Here, we investigated the possible involvement of Sema3A/NRP1 axis in SSc. Methods Circulating Sema3A and soluble NRP1 (sNRP1) were measured in patients with SSc and controls. NRP1 and Sema3A expression in skin biopsies was evaluated by immunofluorescence and western blotting. NRP1 expression was assessed in SSc and healthy dermal microvascular endothelial cells (SSc-MVECs and H-MVECs), and in SSc and control endothelial progenitor cell (EPC)-derived endothelial cells (ECs). The possible impact of transcription factor Friend leukaemia integration 1 (Fli1) deficiency on endothelial NRP1 expression was investigated by gene silencing. The binding of Fli1 to NRP1 gene promoter was evaluated using chromatin immunoprecipitation. Capillary morphogenesis was performed on Matrigel. Results Decreased sNRP1 levels in SSc were associated with active and late nailfold videocapillaroscopy patterns and digital ulcers. No difference in Sema3A was found between patients and controls. NRP1 was significantly decreased in SSc-MVECs both ex vivo and in vitro. NRP1 and Fli1 significantly decreased in H-MVECs challenged with SSc sera, while they were not different in SSc and control EPC-derived ECs. Fli1 occupied the NRP1 gene promoter and Fli1 gene silencing reduced NRP1 expression in H-MVECs. NRP1 gene silencing in H-MVECs resulted in a significantly impaired angiogenic capacity comparable to that of cells treated with SSc sera. Conclusion In SSc, NRP1 deficiency may be an additional factor in the perturbed VEGF-A/VEGFR-2 system contributing to peripheral microvasculopathy and defective angiogenesis.

ObjectiveTo assess the effect of sildenafil, a phosphodiesterase type 5 inhibitor, on digital ulcer (DU) healing in systemic sclerosis (SSc).MethodsRandomised, placebo-controlled study in patients with SSc to assess the effect of sildenafil 20 mg or placebo, three times daily for 12 weeks, on ischaemic DU healing. The primary end point was the time to healing for each DU. Time to healing was compared between groups using Cox models for clustered data (two-sided tests, p=0.05).ResultsIntention-to-treat analysis involved 83 patients with a total of 192 DUs (89 in the sildenafil group and 103 in the placebo group). The HR for DU healing was 1.33 (0.88 to 2.00) (p=0.18) and 1.27 (0.85 to 1.89) (p=0.25) when adjusted for the number of DUs at entry, in favour of sildenafil. In the per protocol population, the HRs were 1.49 (0.98 to 2.28) (p=0.06) and 1.43 (0.93 to 2.19) p=0.10. The mean number of DUs per patient was lower in the sildenafil group compared with the placebo group at week (W) 8 (1.23±1.61 vs 1.79±2.40 p=0.04) and W12 (0.86±1.62 vs 1.51±2.68, p=0.01) resulting from a greater healing rate (p=0.01 at W8 and p=0.03 at W12).ConclusionsThe primary end point was not reached in intention-to-treat, partly because of an unexpectedly high healing rate in the placebo group. We found a significant decrease in the number of DUs in favour of sildenafil compared with placebo at W8 and W12, confirming a sildenafil benefit.Trial registration numberNCT01295736.

OBJECTIVES: In agreement with other autoimmune diseases, systemic sclerosis (SSc) is associated with a strong sex bias. However, unlike lupus, the effects of sex on disease phenotype and prognosis are poorly known. Therefore, we aimed to determine sex effects on outcomes. METHOD: We performed a prospective observational study using the latest 2013 data extract from the EULAR scleroderma trials and research (EUSTAR) cohort. We looked at (i) sex influence on disease characteristics at baseline and (ii) then focused on patients with at least 2 years of follow-up to estimate the effects of sex on disease progression and survival. RESULTS: 9182 patients with SSc were available (1321 men) for the baseline analyses. In multivariate analysis, male sex was independently associated with a higher risk of diffuse cutaneous subtype (OR: 1.68, (1.45 to 1.94); p

Objectives Targeted therapies for systemic sclerosis (SSc) and other fibrotic diseases are not yet available. We evaluated the efficacy of heat shock protein 90 (Hsp90) inhibition as a novel approach to inhibition of aberrant transforming growth factor (TGF)-β signalling and for the treatment of fibrosis in preclinical models of SSc. Methods Expression of Hsp90 was quantified by quantitative PCR, western blot and immunohistochemistry. The effects of Hsp90 inhibition were analysed in cultured fibroblasts, in bleomycin-induced dermal fibrosis, in tight-skin (Tsk-1) mice and in mice overexpressing a constitutively active TGF-β receptor I (TβRI). Results Expression of Hsp90β was increased in SSc skin and in murine models of SSc in a TGF-β-dependent manner. Inhibition of Hsp90 by 17-dimethylaminoethylamino-17-demethoxy-geldanamycin (17-DMAG) inhibited canonical TGF-β signalling and completely prevented the stimulatory effects of TGF-β on collagen synthesis and myofibroblast differentiation. Treatment with 17-DMAG decreased the activation of canonical TGF-β signalling in murine models of SSc and exerted potent antifibrotic effects in bleomycin-induced dermal fibrosis, in Tsk-1 mice and in mice overexpressing a constitutively active TβRI. Dermal thickness, number of myofibroblasts and hydroxyproline content were all significantly reduced on treatment with 17-DMAG. No toxic effects were observed with 17-DMAG at antifibrotic doses. Conclusions Hsp90 is upregulated in SSc and is critical for TGF-β signalling. Pharmacological inhibition of Hsp90 effectively blocks the profibrotic effects of TGF-β in cultured fibroblasts and in different preclinical models of SSc. These results have translational implications, as several Hsp90 inhibitors are in clinical trials for other indications.

Background NailfoldCapillaroscopy (NC) is a diagnostic and sensitive tool in order to investigate Raynaud9s phenomenon (RF) that is the hallmark of both Systemic Sclerosis (SSc) and Very Early Diagnosis Of ScS (VEDOSS) patients. Thus NC is largely used in patients with these conditions and NC specific abnormalities have become a minor criteria in ACR/EULAR SSc Criteria in 2013. Objectives Aim of our study was to monitor NC changes in a group of 66 VEDOSS patients, enrolled in two EUSTAR center. Methods We selected those patients who developed SSc at the follow-up. Moreover, we compared the NC features of these patients with NC of those VEDOSS patients who did not move to SSc, in order to find out NC features, if any, suitable as predictive risk factor for SSc at the time of VEDOSS diagnosis. Results In our 66 VEDOSS patients, 21 of them (19 females, mean age 55 yrs) shifted to SSc in a mean follow-up time of 31 months (range 6–60 months). Table 1 shows the main features of matched VEDOSS patients: Group A with unchanging diagnosis and Group B progressing into SSc. Table 2 shows the progression of NC abnormalities from VEDOSS to established SSc diagnosis in Group B patients. When we compared basal NC of Group A and Group B patients, in former VEDOSS developing SScwe found a significantly higher NC score (>1), 13 versus 5 cases (p Conclusions Our study describes a progression of NC changes during the evolution of early SSc. Moreover we identified some NC features, such as higher NC score and larger apex width, whose presence at the very early diagnosis of SSc may suggests its development in an established disease, thus underlying the relevance of specific NC abnormalities as possible predictive risk factors. Disclosure of Interest None declared

Background Systemic sclerosis (SSc) can greatly impact the patients9 quality of life due to the multisystem manifestations. The health assessment questionnaire (HAQ) is one of the most commonly used measures of disability in musculoskeletal disorders and was extended to form the scleroderma HAQ (SHAQ), a more disease-specific disability scale that incorporates the HAQ and the 5 SHAQ-visual analogue scales (VAS) into one score. Objectives This study aims to identify predictors of disability in SSc by means of the SHAQ. Methods Patients from the DeSScipher cohort were included in the analysis if they had at least one complete SHAQ recorded, fulfilled either the 1980 ACR or the 2013 ACR/EULAR criteria for SSc and were above 18 years of age. Multiple linear regression analysis was used to assess the combined effect of factors possibly associated with disability. Variables included in the model were defined a priori. Results 813 patients had one complete SHAQ recorded between June 2013 and January 2016 (34.1% of all patients followed in the DeSScipher cohort). Of these, 12% fulfilled only the 2013 ACR/EULAR criteria, 2% fulfilled only the 1980 ACR criteria and 86% fulfilled both, the median age was 58 years (IQR 49–67) and 15% were male. 26% of the patients were in the diffuse SSc subset, 56% in the limited and 18% had SSc sine sclerosis. The patients had a median SHAQ score of 0.79 (IQR 0.28–1.31) and a median HAQ score of 0.88 (IQR 0.25–1.5). The medians of the five VASs included in the SHAQ were (in order of the VAS magnitude): overall disease severity (30, IQR 10–51), Raynaud9s phenomenon (21, IQR 3–50), pulmonary symptoms (10, IQR 1–40), gastrointestinal symptoms (6, IQR 1–31) and digital ulcers (2, IQR 1–30). 60% of the patients were in the lowest SHAQ category (score of 0 to 1) which is regarded as “mild to moderate difficulty”, 34% in the category regarded as “moderate to severe disability” (score of 1 to 2) and 6% in the category regarded as “severe to very severe disability” (score of 2 to 3). In multiple linear regression, the main factors associated with high SHAQ scores were dyspnoea (NYHA-stage 4 (β=0.67), 3 (β=0.59) and 2 (β=0.18; all vs. stage 1), fibromyalgia (β=0.42), muscle weakness (β=0.25), current digital ulcers (β=0.20) and gastrointestinal symptoms (oesophageal symptoms, β=0.18; stomach symptoms, β=0.14; intestinal symptoms, β=0.14; figure). Conclusions Patients perceive dyspnoea, pain, digital ulcers, muscle weakness and gastrointestinal symptoms as the main factors driving their level of disability. Acknowledgement The DeSScipher project was funded by the European Community9s Framework Programme 7 (FP7-HEALTH-2012.2.4.4–2-Observational trials in rare diseases) under grant agreement N° 305495. We acknowledge the contribution of the following EUSTAR centres: Moscow(78), Padova(31), Istanbul(133), Wuppertal(192), Monserrato(142), Roma(94), Cologne(44), Cluj-Napoca(16), Ancona(34), Iasi(162), Frankfurt(124). Disclosure of Interest None declared

Background Systemic sclerosis (SSc) is a severe fibrotic disease with no effective treatment. The OX40-OX40L axis is emerging as a new potential target in autoimmune diseases offering the advantage of a targeted approach on co-stimulatory signals with limited impact on the whole immune response and very preliminary data suggested its involvement in SSc. Objectives To investigate the contribution of OX40L in SSc Methods We assessed the expression of OX40L in fibrotic skin and in the serum of SSc-patients. The efficacy of a targeted therapy against OX40L in vivo was evaluated using complementary experimental mouse models. Results Expression of OX40L protein was higher in fibrotic skin of SSc-patients as compared to healthy controls (p=0.003), particularly in diffuse cutaneous forms. Soluble OX40 levels were significantly higher in SSc-patients (n=177) than in healthy controls (n=100). Longitudinal analyses of our cohort showed that high level of serum OX40L at baseline was highly predictive of worsening of dermal and lung fibrosis during the follow-up (HR: 8.28 [2.11–32.50] and 4.60 [1.52–12.18], P Invalidation of OX40L prevented dermal fibrosis in the bleomycin mouse model with a decrease in dermal thickness, hydroxyprolin content and myofibroblasts count. OX40L invalidation was associated with a decrease in T cell, B cell and macrophage infiltrates and in cytokine release (IL-6, TNF-α) in lesional skin of mice. A transcriptomic approach identified two main pathways regulated by OX40L blockade: NF kappa B and AP 1 signaling. Then pharmacologic approaches, using a monoclonal anti-OX40L antibody, demonstrated that the blockade of OX40L not only prevented dermal fibrosis, but also induced regression of established fibrosis. Thereafter, the use of this monoclonal antibody demonstrated in the fra-2 transgenic mouse model marked protection from fibrosing alveolitis (measured by CT-scan (Figure) and histology) and vessel remodeling leading to pulmonary arterial hypertension. Conclusions Altogether, our results show that OX40L is as an attractive target in inflammation-driven fibrosis. OX40L appears as a very promising biomarker in SSc and an appealing potential therapy to reduce both skin and lung fibrosis. Disclosure of Interest None declared

Background Rheumatoid arthritis (RA) is associated with an excess of mortality. This risk depends on disease activity, severity and associated comorbidities. Objectives Our objective was to study the mortality profile of RA patients in France using multiple-cause-of-death analysis. Methods Data were collected between 2000 and 2011 in the French Epidemiological Center for the Medical Causes of Death database, and death certificates issued upon the death of an adult for whom RA was an underlying cause of death (UCD) or a non-underlying cause of death (NUCD) were evaluated using multiple-cause-of-death analysis. Sex, age, sex ratio, standardized mortality rates, as well as frequency of the various causes of death were assessed. For the main causes of death, the observed number of deaths in relation to the expected number of deaths (O:E ratio) was calculated. Results During the study period, 13,208 deaths related to RA were identified. RA was identified as the UCD in 4597 (35%) certificates. The number of certificates mentioning RA as the UCD decreased from 38 to 27% between 2000 and 2011. The mean±SD age at death was 79 ± 9 years (51% with ≥80 years). The female: male ratio was 3.2 and remained stable during the follow-up period. This ratio was significantly higher in the population where RA was the UCD (4.1 vs. 2.8 p 1 for infectious (3.56), respiratory (1.40) and cardiovascular diseases (1.24), but was Conclusions This is the first national study using a multiple-cause-of-death analysis to study the mortality profile of patients with RA. Our results show that cardiovascular diseases are the most common UCD and NUCD associated with RA in France. These data strengthen the need to develop specific strategies for cardiovascular prevention to improve survival of patients with RA. Disclosure of Interest None declared

Background In SSc, the management of DU is a problem in clinical practice, therefore their prevention is highly warranted. Sildenafil, iloprost, calcium channel blockers (CCB), ACE inhibitors (ACEi) and bosentan, alone or in combination, are used for DU prevention without unanimous agreement. Objectives DeSScipher (“to decipher the optimal management of SSc”) is an EC-funded FP7 research project that consists of five observational trials (OT) addressing different aspects of SSc. The aim of OT1 was to evaluate the efficacy of vasoactive and vasodilating drugs or a combination therapy for the management of DU in SSc. Methods Longitudinal data were collected for up to 24 months by 28 DeSScipher centres. In SSc patients, the efficacy of sildenafil, bosentan, sildenafil+bosentan, iloprost or CCB /ACEi for the prevention of new DU was evaluated. Clinical features, ulcer type and other drugs were also recorded. Time without new DU, proportion of patients without new DU, risk of developing new DU and the mean number of new DU per patient were evaluated at 6 months follow-up. Results In OT1, 1394 patients were enrolled. The history of DU was a significant risk factor for developing new DU (OR=3.146; (95%CI:1.19–8.31), p=0.021), therefore analysis was focused on secondary prevention (prevention of new DU in patients with DU history). 473/1394 (33.9%) had a history of DU and 268/473 (56.7%) had follow up data (58.2% limited and 41.8% diffuse SSc subset). 47/268 (17.5%) were on Bosentan, 33/268 (12.3%) on Sildenafil, 40/268 (14.9%) on Iloprost, 31/268 (11.6%) on Sildenafil and Bosentan combination and 117/268 (43.7%) on CCB/ACEi alone. In patients with history of DU in the last 24 weeks, the treatment with CCB/ACEi alone was associated with 7 fold increased risk of developing new DU compared to all other treatment arms (OR =7.313; 95%CI:1.248–42.85, p=0.027). Patients on concomitant immunosuppressive treatment had a trend towards faster DU recurrence. Conclusions History of DU in the past 24 weeks should prompt a more aggressive preventive strategy other than therapy with CCB/ACEi alone due to its lower efficacy to prevent DU recurrence compared to the other treatment options. Acknowledgement The DeSScipher project was funded by the European Community9s Framework Programme 7 (FP7-HEALTH-2012.2.4.4–2 - Observational trials in rare diseases) under grant agreement N° 305495. We acknowledge the contribution of the following EUSTAR centers: Ancona (member N°34), Assiut (168), Bad Bramstedt (187), Belgrade (55), Bucharest (100), Cluj-Napoca (16), Erlangen (106), Frankfurt (124), Hamburg (64), Iasi (162), Istanbul (21), Istanbul (133), Koln (44), Monserrato (142), Moscow (78), Moscow (190), Padua (31), Rome (94), Salford/Manchester (80), Tubingen (56), Wuppertal (192). Disclosure of Interest None declared

Background Systemic sclerosis (SSc) primarily affects postmenopausal women. This sex bias could partly be explained by the action of estrogens on the immune system and/or fibrogenesis. Since little is known about their direct role in fibrogenesis. Objectives Our aim was to evaluate the effects of estrogens i) on the pathological activation of dermal fibroblasts induced by transforming growth factor-b (TGF-β) and ii) in the development of experimental dermal fibrosis. Methods Effects on estrogen inhibition by gene inactivation (knockout mice for the estrogen receptor-α, ERKOα) or targeted molecular strategy (tamoxifen, a selective estrogen receptor modulator that display anti-estrogenic properties) were evaluated in the mouse model of bleomycin-induced dermal fibrosis and in the tight skin (Tsk-1) mouse model. SSc dermal fibroblasts were stimulated with TGF-β and incubated with different concentrations of 17-β-estradiol and/or tamoxifen. Collagen release from fibroblasts was evaluated by mRNA levels of col1a1 and col1a2 and by measuring the concentrations of collagen in cell culture supernatants with the SirCol collagen assay. Differentiation of fibroblasts into myofibroblasts was assessed by the expression of alpha smooth muscle actin (α-SMA). Activation of the TGF-β pathway was evaluated by the expression of phospho-smad-2/3. Results Estrogen inhibition increased the activation of canonical TGF-β signaling and exacerbated skin fibrosis both in the bleomycin model and in Tsk-1 mice. Upon bleomycin injections, ERKO-α mice treated with tamoxifen had a significant increase of dermal thickness (17%, p=0.03 and 20%, p=0.04), hydroxyproline content mice (16%, p=0.02 and 36%, p=0.003, respectively) and number of myofibroblasts (22%, p=0.01 and 20%, p=0.04 respectively) compared to control mice. In Tsk-1 mice, treatment with tamoxifen led to significantly enhanced skin fibrosis, with a 31±8% increase of hypodermal thickening (p=0.03) and a 17% increase of hydroxyproline content (p=0.01) compared to control mice. In SSc dermal fibroblasts, treatment with 17-β-estradiol significantly decreased the stimulatory effects of TGF-β on collagen synthesis and myofibroblast differentiation, decreased activation of canonical TGF-β signaling, and markedly reduced the expression of TGF-β target genes. Tamoxifen reversed the inhibitory effects of estrogens by restoring Smad2/3 phosphorylation and TGF-β-induced collagen synthesis. Conclusions Our results demonstrate a beneficial effect of estrogen in experimental dermal fibrosis. Estrogens reduce TGF-β dependent activation of SSc dermal fibroblasts and estrogen inhibition leads to a more severe experimental dermal fibrosis. These findings may partly contribute to the occurrence of SSc in postmenopausal women and the greater severity of the disease in men and open avenue to potential hormonal therapies. Disclosure of Interest None declared

Background Nailfold videocapillaroscopy (NVC) is a simple, non-invasive and inexpensive imaging technique that allows a detailed assessment of skin microcirculation. Although NVC has face and content validity for the detection of microvascular damages related to systemic sclerosis (SSc), its sensitivity to change has not been assessed in detail. Objectives Our aim was to determine in a prospective cohort the merit of NVC to detect meaningful changes over time and whether these changes are associated with disease progression. Methods A prospective cohort of 140 SSc patients was recruited over a 12-month period and was followed up on an annual basis for 3 years. NVC was performed at inclusion and repeated once a year by four investigators (ET, GL, CH and AV) according to a standardized procedure. NVC pictures were analysed by one investigator (JA) and classified as early, active and late patterns. Organ progression was defined according to validated definitions. The worsening of the Medsger severity scale (from category 1–2 to category 3–4) was considered as a marker of disease progression. Results 140 SSc patients were included (111 women, 56±11 year-old, disease duration of 9±8 years). A change of NVC pattern was observed in 29 SSc patients (21%) during the follow-up period.At least 3 annual NVC evaluations were available for each patient. A progression from a normal or early NVC pattern to an active NVC pattern was detected in 15 patients (10%). Patients who progressed to the active NVC pattern were significantly less at risk to develop ischemic digital ulcers (DU) during follow-up (hazard ratio, HR: 0.78, 95% Confidence Interval, CI 0.17–0.95). A progression to a late NVC pattern was observed in 14 patients (10%). Progression to a late NVC pattern was associated with the occurrence of new ischemic DU (HR: 4.51, 95% CI 1.68–12.14), lung vascular progression (HR: 5.12 95% CI 1.23–21.27), progression of skin fibrosis (HR: 3.70, 95% CI 1.14–11.94) and the worsening of Medsger disease severity scale (HR: 4.47, 95% CI 1.63–12.26). Conclusions Change of the NVC pattern was observed in 21% of patient with SSc during a follow-up of 3 years. NVC has the ability to detect meaningful changes over time associated with markers of disease progression. Our results support the use of NVC for the routine follow-up of SSc patients in order to improve their risk stratification. NVC might be used in the future to select high-risk patients and change to a late NVC pattern might be regarded as potential surrogate marker for disease severity. Disclosure of Interest None declared

ObjectiveTo investigate the contribution of the adhesion receptor DNAX accessory molecule-1 (DNAM-1) in the development of dermal fibrosis on gene inactivation and targeted molecular strategies.MethodsHuman skin expression of DNAM-1 was determined by immunohistochemistry. Mice deficient for DNAM-1 (dnam1−/−) and wild-type controls (dnam1+/+) were injected with bleomycin or NaCl. Infiltrating leucocytes, T cells, B cells and monocytes were quantified and inflammatory cytokines were measured in lesional skin of dnam1−/−and dnam1+/+mice. The anti-fibrotic potential of a DNAM-1 neutralising monoclonal antibody (mAb) was evaluated in the mouse model of bleomycin-induced dermal fibrosis.ResultsOverexpression of DNAM-1 was detected in the skin of patients with SSc (systemic sclerosis). Dnam1−/−mice were protected from bleomycin-induced dermal fibrosis with reduction of dermal thickening (75±5%, p=0.03), hydroxyproline content (46±8%, p=0.04) and myofibroblast counts (39±5%, p=0.01). Moreover, the number of T cells was significantly decreased in lesional skin of dnam1−/−mice (69±15%, p=0.0007). Dnam1−/−mice also displayed decreased levels of TNF-α and IL-6 in lesional skin. Consistent with the gene inactivation strategy, treatment of mice with DNAM-1 neutralising mAb prevented dermal fibrosis induced by bleomycin with reduction of dermal thickness (64±6%, p=0.002), hydroxyproline content (61±8%, p=0.004) and myofibroblast counts (83±12%, p=0.002).ConclusionsAn inactivation gene strategy showed that DNAM-1 exerts profibrotic effects by controlling T cell activation and cytokine release. A molecular targeted strategy confirmed that DNAM-1 neutralising mAb has potent antifibrotic properties, supporting the hypothesis that inhibition of DNAM-1 might be a promising new approach for the treatment of SSc and potentially other related fibrotic diseases.

ObjectivesThe hallmark of systemic sclerosis (SSc) is the accumulation of extracellular matrix proteins by pathologically activated fibroblasts. This study analysed the antifibrotic effects of the selective c-Jun N-terminal kinase (JNK) inhibitor, CC-930, which recently entered first clinical trials as a novel antifibrotic approach.MethodsPhosphorylated c-Jun was detected by western blot and immunohistochemistry. The model of bleomycin-induced dermal fibrosis and the tight skin 1 (TSK1) mouse model were used to investigate the effects of CC-930 on the prevention of experimental fibrosis. The potential of CC-930 to induce regression of fibrosis was assessed in a modified model of established fibrosis.ResultsTransforming growth factor beta (TGFβ) and platelet-derived growth factor (PDGF) activate JNK and stimulate the phosphorylation of its downstream target c-Jun. Incubation with CC-930 prevented the phosphorylation of c-Jun and reduced the stimulatory levels of these cytokines on the release of collagen. Inhibition of JNK prevented dermal thickening, myofibroblast differentiation and the accumulation of collagen in a dose-dependent manner in mice challenged with bleomycin and in TSK1 mice. In addition to the prevention of fibrosis, treatment with pharmacologically relevant doses of CC-930 also induced regression of established experimental fibrosis.ConclusionsThese data identify JNK as a downstream mediator of the pro-fibrotic effects of of TGFβ and PDGF in SSc fibroblasts. Selective inhibition of JNK by CC-930 exerted potent antifibrotic effects in vitro and in different models in vivo. JNK might thus be a novel molecular target for the treatment of fibrosis in SSc.

The European League Against Rheumatism Scleroderma Trials and Research Group (EUSTAR) has established an online database with clinical data of currently more than 8200 patients with systemic sclerosis (SSc). In addition to clinical research, EUSTAR fosters biomolecular studies to develop novel biomarkers and therapies for SSc. High-quality biospecimens are the basis for successful biomolecular studies. The EUSTAR biobanking group has therefore developed recommendations to standardise the collection, storage and distribution of SSc biospecimens at EUSTAR centres. These recommendations consider the scientific challenges associated with biomolecular research in SSc and the organisational requirements of EUSTAR. They were approved by the EUSTAR executive committee as well as the EUSTAR board. Once they become effective, these recommendations will be the basis for international EUSTAR studies with large numbers of SSc biospecimens. These recommendations might also be followed by other SSc consortia to enable exchange of biosamples between different SSc initiatives and might serve as a template for biobanking initiatives in other rheumatic diseases.

ObjectiveTo identify a core set of preliminary items considered as important for the very early diagnosis of systemic sclerosis (SSc).MethodsA list of items provided by European League Against Rheumatism (EULAR) Scleroderma Trial and Research(EUSTAR) centres were subjected to a Delphi exercise among 110 experts in the field of SSc. In round 1, experts were asked to choose the items they considered as the most important for the very early diagnosis of SSc. In round 2, experts were asked to reconsider the items accepted after the first stage. In round 3, the clinical relevance of selected items and their importance as measures that would lead to an early referral process were rated using appropriateness scores.ResultsPhysicians from 85 EUSTAR centres participated in the study and provided an initial list of 121 items. After three Delphi rounds, the steering committee, with input from external experts, collapsed the 121 items into three domains containing seven items, developed as follows: skin domain (puffy fingers/puffy swollen digits turning into sclerodactily); vascular domain (Raynaud's phenomenon, abnormal capillaroscopy with scleroderma pattern) and laboratory domain (antinuclear, anticentromere and antitopoisomerase-I antibodies). Finally, the whole assembly of EUSTAR centres ratified with a majority vote the results in a final face-to-face meeting.ConclusionThe three Delphi rounds allowed us to identify the items considered by experts as necessary for the very early diagnosis of SSc. The validation of these items to establish diagnostic criteria is currently ongoing in a prospective observational cohort.

Systemic sclerosis (SSc) is an orphan and incurable connective tissue disease that affects particularly the skin. The characteristic features of SSc include extensive fibrosis, fibroproliferative vasculopathy, systemic autoimmunity and inflammation. Skin involvement is crucial in the disease process and skin thickening provides a surrogate measure of disease severity and has prognostic value. In patients with SSc, an abnormal accumulation of extracellular matrix constituents is the most prominent pathological manifestation of the disease in skin. Two stages can be described based on histopathology of the lesional skin: an early cellular stage and a later fibrotic stage. Early skin lesions are characterized by the presence of i) thickened collagen bundles within the reticular dermis that run parallel to the skin surface, and ii) inflammatory cell infiltrates composed mainly of activated T cells. Later stages are characterized by an excessive accumulation of extracellular matrix components leading to increased skin thickness. In contrast to early lesions, late skin lesions have few if any inflammatory cells. Increased myofibroblast counts are also observed in the dermis of SSc patients throughout the different disease stages, which participate to the upregulated synthesis of collagen and other extracellular matrix proteins. Skin biopsies taken from patients with SSc have shown nearly indistinguishable patterns of gene expression in clinically affected and clinically unaffected tissue, even though these were clearly distinguishable from the patterns found in similar tissue from healthy controls. Thus, histopathology changes observed in the skin occur relatively early in the disease course and can be measured in what is considered, healthy clinically unaffected skin. Histopathology of the skin is not requested for the diagnosis of SSc. Skin biopsy is recommended for the diagnosis of SSc by French health authorities only in the case of diagnostic doubt with other scleroderma like disorders (nephrogenic systemic fibrosis, eosinophilic fasciitis, scleromyxedema…). Conversely, skin biopsy is usually performed during the evaluation process of new drugs, in parallel of the evaluation of the modified Rodnan skin score (mRSS). Indeed, a large number of biomarkers reflecting the different aspects of the disease are differentially expressed in the skin of patients with SSc and thus may be modulated by new therapies. These biomarkers can reflect SSc-related vasculopathy (in particular increased levels of vascular endothelial growth factor), inflammatory processes (increased levels of IL-6, TNF-a…) or fibrosis (transforming growth factor-b, thrombospondin-1, cartilage oligomeric matrix protein…). Some of these markers have been shown to correlate with the mRSS. Skin biopsy is also often performed for research purposes. Indeed, the first step analysis of new candidates or pathways that may contribute to the disease pathogenesis requires the evaluation of their dermal expression or activation in the skin of SSc patients compared to healthy controls. Finally, skin biopsy may also have a prognostic value: patterns of gene expression that readily distinguish normal from scleroderma skin, and possibly specific overexpression or underexpression of specific molecular markers may correlate with disease progression and prognosis. However, this aspect is not considered yet in clinical practice. Histological analysis of lung, heart and kidney is not performed in routine because of the limited access of these tissues. In addition the cell analysis of bronchoalveolar lavage fluid is not performed anymore for decision-making, which is based on the results of high-resolution chest CT scan and pulmonary function tests. Disclosure of Interest None declared

Background Early stages of systemic sclerosis (SSc) are characterized by inflammatory skin infiltrates mainly composed of activated T cells. Cytotoxic T-lymphocyte associated molecule-4 (CTLA-4) is a key regulator of T cell activation and preliminary data have suggested that it might contribute to SSc. Objectives Our aim was to investigate the efficacy of the CTLA-4-Ig abatacept, an inhibitor of T cell activation, in reducing skin fibrosis in complementary mouse models of SSc. Methods We first evaluated the antifibrotic properties of abatacept in the mouse model of bleomycin-induced dermal fibrosis, reflecting early and inflammatory stages of SSc. To assess whether abatacept might prevent the development of dermal fibrosis, six-week-old C57BL/6 mice received in parallel subcutaneous injections bleomycin (0.5 mg/ml) and intraperitoneal (i.p) injections of abatacept or purified human IgG1 at a dose of 100 mg every other day for three weeks. To assess whether abatacept might induce the regression of established dermal fibrosis, six-week-old C57BL/6 mice were challenged with bleomycin for 6 weeks and received i.p injections of 100 mg of abatacept or control IgG1 every other day during the last 3 weeks. Then, we investigated abatacept in the tight skin (Tsk-1) mice, an inflammation-independent mouse model of skin fibrosis. To this end, five-week-old Tsk-1 mice received i.p injections of 100 mg of abatacept or control IgG1 every other day for 5 weeks. Infiltrating leukocytes and T cells were quantified in lesional skin by immunohistochemistry. Results Treatment with abatacept prevented the induction of bleomycin-induced dermal fibrosis: dermal thickness was significantly reduced by 48±5% in mice treated with abatacept compared to mice receiving the control IgG1 (p=0.03). Consistent with decreased dermal thickness, hydroxyproline content and myofibroblast counts were reduced upon treatment with abatacept by 63±4% (p=0.02) and 41±6% (p=0.04) respectively, compared to mice receiving the control antibody. In addition, treatment with abatacept led to decreased leukocyte and T cell infiltrates in the lesional skin of mice challenged with bleomycin. Abatacept also induced the regression of established bleomycin-induced dermal fibrosis: dermal thickness, hydroxyproline content and myofibroblast counts were reduced by 15±2% (p Conclusions Using complementary mouse models of SSc, we demonstrate that abatacept can prevent and induce the regression of inflammation-driven experimental dermal fibrosis. Translation to human disease is now required, and targeting early and inflammatory stages of SSc sounds the most appropriate. This strategy is currently under investigation in a phase-3 clinical trial assessing the efficacy of abatacept to improve skin involvement in patients with early diffuse SSc. Disclosure of Interest None declared

Background Systemic sclerosis (SSc) is known as one of the most fatal rheumatic diseases, but it also promotes many detrimental effects on health-related quality of life (HRQOL). However, the data provided so far on HRQOL in SSc suffer from a weak power related to the difficulty to recruit large sample. Furthermore, previous works mostly reported the outcome of early diffuse cutaneous SSc (DcSSc) subset. Objectives To assess HRQOL and disease perception in a large and international cohort of SSc patients using validated questionnaires. Methods We conducted an international cross-sectional survey supported by EUSTAR, FESCA and Scleroderma US Foundation, from December 2013 to April 2014. We built a standardized questionnaire translated by patient associations and available on a website, including: Socio-demographic information, disease characteristics and self-assessment questionnaires namely Short Form 36 (SF-36) and Revised Illness Perception Questionnaire (IPQ-R). Results 1902 SSc patients from 60 countries were included with a mean ± standard deviation (SD) age of 54±16 years and a mean ± SD disease duration of 13±12 years. 712 (34.4%) patients had DcSSc, 853 (44.8%) limited cutaneous SSc (LcSSc) and 122 (6.4%) sine scleroderma SSc. HRQOL appeared to be strongly impaired in SSc patients; in physical health (PCS, mean ± SD 43.4±23.4; 100=best health) but also in mental health (MCS, mean ± SD 52.3±23.1; 100=best health). SSc patients also held strong perceptions of the chronicity and negative consequence of the disease, and experienced negative emotions due to SSc. Compared to LcSSc, patients with DcSSc had poorer HRQOL both in physical (PCS, mean ± SD 46.6±23.7 vs 39.8±22.3; p Patients ranked organ involvements having the most severe impact on daily life and on illness severity perception: Raynaud phenomenon (6.6 and 6.5/10), gastrointestinal complications (5.4 and 5.5/10), musculoskeletal (4.9 and 5/10) and skin lesion (4.5 and 4.6/10) were the top rated involvements. Non-European SSc patients had a greater impact on their QOL, mainly in physical health (PCS, mean ± SD 39.9±22.6 vs 46.0±23.7; p Conclusions This study provides unique information about patient perception of the disease and impact on QOL according to disease subset, disease duration and various geographical origins. The key message overall is the major impact on QOL and rather negative perception of their disease by SSc patients. Nevertheless, illness perception tends to improve with disease duration suggesting effective coping strategies. These results will have to be taken into consideration for patient management and also future trials. Disclosure of Interest None declared

Background Due to lack of adequate clinical research data, drug treatment of the rare disease systemic sclerosis (SSc) is commonly off-label. The international EC-funded research project DeSScipher (acronym for “to decipher the optimal management of systemic sclerosis”) was designed to increase the evidence-based treatment strategies for SSc patients and subsequently to improve their long-term quality-of-life. Objectives The primary objective is to compare the outcomes of different treatments with respect to efficacy and safety of currently used off-label drugs from the early to the advanced phases of the main SSc-associated organ dysfunctions in a routine rheumatology in- and outpatient setting. Methods Five prospective observational trials (OTs), carried out within the EULAR Scleroderma Trials and Research (EUSTAR) group, have been designed to analyze current treatment approaches of early functionally relevant manifestations such as digital ulcers (OT1) and hand arthritis (OT2) to the morbidity and mortality-driving manifestations such as interstitial lung disease (OT3), pulmonary hypertension (OT4) and severe heart disease (OT5). The study protocols are accessible at clinicaltrials.gov Identifiers NCT01836263, NCT01834157, NCT01858259, NCT01840748, NCT01829126. Results Between April 2013 and January 2015, 1781 SSc patients have been screened at 27 contributing EUSTAR centers. 1577 (89%) patients have been enrolled into at least one of the five OTs. In particular, 1179, 127, 981, 237 and 716 patients have been enrolled into OT1-5, respectively (3240 in total; a given patient could be enrolled into multiple OTs), which represents a baseline patient recruitment rate of 79% of the target number of 4098 patients (accordingly 226%, 79%, 59%, 25% and 91% of the required number of 522, 160, 1670, 960, 786 patients for OT1-5, respectively). The completion of 1-year (OT3, OT5) and 2-year follow-up visits (OT1, OT2, OT4) are pending. Conclusions DeSScipher is currently the largest prospective observational research project ever for SSc. While patient recruitment is still ongoing, preliminary results of the five OTs are expected in late 2015 and the final results depending on the completion of follow-up visits are expected between 2017 and 2018. Acknowledgements The DeSScipher project was funded by the European Community9s Framework Programme 7 (FP7-HEALTH-2012.2.4.4-2 - Observational trials in rare diseases) under grant agreement N° 305495. We acknowledge the contribution of the following EUSTAR centers: Wuppertal (member N°192), Lille (93), Bad Bramstedt (187), Moscow (78), Assiut (168), Moscow (190), Bucharest (100), Monserrato (142), Iasi (162), Cluj-Napoca (16), Frankfurt (124), Salford/Manchester (80), Tubingen (56), Ancona (34), Zagreb (51) and Roma (94). Disclosure of Interest None declared

Background The treatment of ILD remains a challenge for the rheumatologist. Recent studies suggested a potential short-term benefit of rituximab (RTX) on connective tissue diseases developing ILD. Objectives To compare RTX effects on ILD in patients with systemic sclerosis (SSc), mixed connective tissue disorder (MCTD) and anti-synthetase (SYN). Methods Multicentre retrospective assessment of the effects of RTX on ILD comparing three patient populations: SSc (n=23), MCTD (n=6) and SYN (n=15). All underwent high-resolution computed tomography (HRCT) at baseline and lung function tests (LFTs) at baseline and at 1 and 2 years of follow-up. The primary outcomes were the mean change in predicted forced vital capacity (FVC) value and the percentage of responders defined by an increase in FVC of 10% or greater. Results In SYN patients, although the change of FVC from baseline to 2 years was not statistically significant, a trend of improvement was observed (table 1). In SSc, discrepancies were observed with a trend of improvement at 1 year but a decline at 2 years. In MCTD, FVC remained table at 1 and 2 years of follow-up. In SYN patients, the percentage of responders for FVC was greater than in SSc (33.3% vs 9.5%) (p=0.1) and than in MCTD patients (33.3% vs 16.7%) (p=0.15). At baseline, SSc and MCTD patients had a higher FVC when compared to SYN population (table 1) and this finding may partially explain the major percentage of responders in SYN than in SSc. The percentage of responders in DLCO (gain ≥15%) was similar in SYN and SSc populations (27.3% and 23.8% respectively). Some patients received DMARDs and/or immunosuppressive treatment previously or/and concurrently to RTX; although this did not influence our findings, these treatments may influence the effects of RTX. RTX showed a satisfactory safety profile. Conclusions Our data obtained in routine care provide for the first time outcomes in LFTs after 2 years of follow-up. The main results show a good safety profile supporting future development. We also observed a promising trend of improvement in the SYN group and indicate that the drug may provide a stabilization of the involvement of the lung in SSc and MCTD. Future trials on homogenous groups of patients are warranted to determine how rituximab may be positioned in the treatment of CTD-ILD, but the SYN group should be prioritized. Acknowledgements EULAR scintific travel bursary Disclosure of Interest G. Lepri: None declared, J. Avouac: None declared, P. Airo: None declared, F. Anguita Santos: None declared, S. Bellando Randone: None declared, J. Blagojevic: None declared, O. Distler Grant/research support from: received research funding from, 4D Science, Actelion, Active Biotec, Bayer-Schering, Biogen, Biovitrium, BMS, Boehringer Ingelheim Pharma, EpiPharm, Ergonex, GSK, Inventiva, Medac, Novartis, Pfizer, Pharmacyclics, Roche/Genentech, Sanofi/Genzyme, Serodapharm, Sinoxa and United BioSource Corporation., F. J. Garcia Hernandez: None declared, J. A. Gonzalez Nieto: None declared, S. Guiducci: None declared, S. Jordan: None declared, V. Limaye: None declared, B. Maurer: None declared, V. Riccieri: None declared, A. Selva-O9Calaghan: None declared, M. Matucci Cerinic: None declared, Y. Allanore Grant/research support from: received research funding in relationship with the treatment of systemic sclerosis from Actelion, Bayer, Biogen Idec, BMS, Genentech/Roche, Inventive, Medac, Pfizer, Sanofi/Genzyme, Servier and UCB

Background Cutaneous telangiectasia (CT) are visible macular dilated superficial blood vessels. CT are an item of the new 2013 ACR/EULAR classification criteria for systemic sclerosis (SSc) (1) and are part of the newly established detection algorithm for SSc-related pulmonary arterial hypertension (2). These recent achievements highlight the importance of CT both for the diagnosis and prognosis of the disease. The number and size of CT can strongly vary from a patient to another according to the severity and progression of SSc-related vasculopathy. Nailfold videocapillaroscopy (NVC) is an accurate tool to evaluate microangiopathy allowing to discriminate vascular disease activity. Objectives The aim of our study was to determine whether the number and size of CT were associated with specific NVC features. Methods We performed a cross-sectional study including consecutive SSc patients over a 9-month period. We considered three subset of patients according to the number of hand or face CT: absence of CT, ≤10 hand or face CT (minor to moderate CT) or >10 CT (profuse CT). Pseudotumoral CT were also taken into account and were defined as CT with >5mm diameter. NVC was performed and classified as early, active and late patterns (3). Results 87 patients were included (69 females), with a median age of 58 years (range 19-89 years), and a median disease duration of 11 years (range 0-53 years). 75 patients (86%) had CT: 27 (36%) had profuse CT, and 19 (25%) pseudotumoral CT. In univariate analysis, patients with profuse and pseudotumoral CT were more likely to have the late NVC pattern (p=0.003 and p=0.001 respectively). Profuse and pseudotumoral CT were also associated with capillary loss (5.09±1.25 vs. 7.73±2.1 capillaries/digit, p 14 ng/L) (p In multivariate logistic regression analysis, we confirmed that pseudotumoral CT were independently associated with the late NVC pattern (odds ratio, OR: 5.22, 95% confidence interval, CI, 1.09-29.95, p=0.038) and especially with neoangiogenesis (OR: 7.77, 95% CI 1.30-46.36). Conclusions Our study reveals an independent association between pseudotumoral CT and the late NVC pattern. Our findings also show a relationship between pseudotumoral CT and neoangiogenesis, both characterized by ramified and bushy capillaries. These results support the development of a more accurate classification and staging of CT. This simple clinical finding might improve risk stratification of the vascular risk of SSc patients. References Van den Hoogen et al, Ann Rheum Dis 2013 Coghlan et al, Ann Rheum Dis 2014 Cutolo et al, J Rheumatol 2000 Disclosure of Interest None declared

Background Cardiac and peripheral microvascular alterations are key features of systemic sclerosis (SSc). We have previously reported that angiogenic markers can predict the cardiovascular outcomes in SSc [1]. In parallel, a cross-sectional study reported an association between severe cardiovascular complications and functional antibodies against angiotensin II type 1 receptor (AT 1 R) and Endothelin-1 type A receptor (ET A R) [2]. Objectives Our aim was to investigate the respective merit of all these markers in a prospective cohort. Methods Serum levels of anti-AT 1 R and anti-ET A R autoantibodies, placenta growth factor (PlGF) and soluble vascular adhesion molecule (sVCAM) were measured with sandwich ELISA in a prospective cohort of 75 SSc patients. Circulating endothelial progenitor cells (EPCs) were quantified in peripheral blood by flow cytometry after cell sorting. The occurrence of at least one cardiac/vascular event was assessed during a planed 3-year follow-up by a composite index defined by the occurrence of at least one of the following event: a) one or more new ischemic digital ulcer (DU), b) pre-capillary pulmonary hypertension (PH) confirmed by right heart catheterization, c) left ventricular (LV) dysfunction, defined by a LV ejection fraction (EF) Results The mean age of SSc patients (64 women) was 55±12 year old and the mean disease duration was 9±8 years at baseline. Twenty-eight patients developed at least one cardiac/vascular event (DU in 18, PH in 5, LV dysfunction in 4 and SRC in a single patient). By univariate analysis, high baseline serum levels of anti-ET A R were predictive of the occurrence of cardiac/vascular events (p=0.002), together with low EPC counts (p=0.003) and increased levels of PlGF (p=0.0005) and sVCAM (p=0.009). No predictive value of anti-AT 1 R antibodies was identified. Multivariate analysis confirmed high serum levels of anti-ET A R antibodies (hazard ratio, HR: 3.71, 95%CI 1.44-9.52, p=0.03) and PlGF (HR: 5.22, 95%CI 1.96-15.87) as independent predictors of further development of cardiac/vascular events. The combination of high serum levels of anti-ET A R antibodies and PlGF was highly predictive of cardiac and vascular events occurrence during follow-up (HR 7.27 95%CI 2.49-23.51, P=0.0002). Conclusions This study identifies for the first time anti-ET A R antibodies as an independent predictor of cardiac and vascular events in SSc. This functional antibody, together with other angiogenic markers and in particular PlGF, may serve as biomarkers to improve cardiovascular risk stratification and therefore allow earlier therapeutic intervention. References Avouac et al, Ann Rheum Dis 2012. Riemekasten et al, Ann Rheum Dis 2011. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3482

Background Microangiopathy is a cardinal feature of systemic sclerosis (SSc), which plays a critical role in the development of primary myocardial involvement and pulmonary hypertension, two major causes of death in SSc. Objectives Our aim was to measure plasma concentrations of two cardiac biomarkers, high sensitive Cardiac troponin T (HS-cTnT), a marker of myocyte necrosis and/or ischemia, and N-terminal fragment of pro-BNP (NT-proBNP), a marker of cardiac strain, in two large cohorts of SSc patients and controls. Methods 161 SSc patients (135 women, 84%) with a mean ± SD age of 57±17 years were included and were compared to 213 healthy controls (170 women, 80%, mean ± SD age of 55±11 years). The plasma HS-cTnT concentrations were measured using an electrochemiluminescence immunoassay (Roche Diagnostic, Meylan, France). The 99th percentile, with a CV ≤10% was achieved for 14 ng/L. Plasma NT-proBNP levels were assessed by an immunoenzymatic assay (Roche Diagnostic). Results Among the SSc cohort, mean disease duration was 9±8 years, 65 patients (40%) had the diffuse cutaneous subset. HS-cTnT and NT-proBNP plasma levels were significantly increased in SSc patients versus controls (p=0.0001 and p 14 ng/L) and NT-proBNP than controls (30/161 patients (19%) with HS-cTnT >14 ng/l vs. 4/213 controls (2%), p Multivariate logistic regression analysis confirmed diabetes mellitus (p=0.006), high blood pressure (p=0.02), precapillary pulmonary hypertension (PH) (p=0.04), ESR >28 mm/H1 (p=0.007) and the diffuse cutaneous subset (p=0.004) as factors independently associated with HS-cTnT >14 ng/L. Increased NT-proBNP concentrations were only associated with the presence of precapillary PH (p=0.0001). The combination of increased HS-cTNT and NT-proBNP levels had the highest positive predictive value for the diagnosis of precapillary PH (67%) compared to HS-cTnT (20%) or NT-proBNP (35%) alone. Conclusions Plasma levels of HS-cTnT and NT-proBNP are increased in SSc patients. Associated factors with increased HS-cTnT include the diffuse cutaneous subset and precapillary PH, which reflect the severity of the disease. In addition, the combination of increased HS-cTnT and NT-proBNP plasma concentrations display higher positive predictive value for the diagnosis of precapillary PH than each marker alone. Given the prognostic significance of these biomarkers, they might be helpful to select the patients that justify further examinations in case of suspicion of cardiac complication. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4011

Background TNF-a inhibitors have completely changed the prognosis of rheumatoid arthritis (RA). The number of molecules and the time of exposure have increased. However, few studies have compared i) the safety of the five now available TNF-a inhibitors between them, and ii) their medium term safety (after more than 6 months of use). Objectives The aim of our study was to compare the data regarding medium-term safety obtained from randomized controlled trials for the five TNF-a inhibitors used in the treatment of RA. We particularly aimed to focus on two serious events: death and severe infections. Methods A systematic review of articles published from January 2000 to January 2013 was performed using MEDLINE, EMBASE and COCHRANE databases. We included randomized, controlled, double blind and parallel-group trials, with a follow-up period of at least 6 months, comparing TNF-a inhibitors to placebo, with or without concomitant treatment with Methotrexate. The primary outcome measure was the occurrence of a serious adverse event, defined by the occurrence of death or of a serious infection (this latter defined in all studies by the requirement of hospitalization). Secondary outcome measures were the occurrence of death or serious infection. MedCalc software was used for the statistical analysis. Results Among the 396 articles initially identified, 22 were finally selected. These articles included 6682 patients in the TNF-a inhibitor group (Adalimumab: 2507, Golimumab: 575, Certolizumab: 1512, Infliximab: 1087 and Etanercept: 1001) and 3607 in the placebo group. The duration of patient follow-up ranged from 24 to 78 weeks. The analysis of our primary outcome showed no increased risk of serious adverse event (death or severe infection) in the TNF-a inhibitor group compared to the placebo group (Odds Ratio, OR: 1.14, 95% Confidence Interval, CI: 0.91-1.44). Sensitivity analysis with respect to each molecule did not change the main conclusion, except for Certolizumab, which showed an increased risk of serious adverse events (OR: 2.06, CI: 1.35-3.15). Regarding secondary outcomes, no increased risk of death in the TNF-a inhibitor group compared to the placebo group was observed (OR: 1.27, CI: 0.71-2.25). However, increased risk of severe infections in the TNF-a inhibitor group was observed compared to the placebo group (OR: 1.66, CI: 1.25-2.23). Sensibility analysis with respect to each molecule did not change the main conclusion regarding the risk of death, but revealed that adalimumab had an increased risk of severe infection (OR: 2.10, CI: 1.28-3.46). Conclusions This meta-analysis has been performed on a large number of patients and included the five TNF-a inhibitors currently available. It allowed an indirect comparison between the different molecules according to their medium-term safety. We did not find an increased risk of serious adverse events or deaths in patients treated with TNF-a inhibitors. However, we observed an increased risk of severe infections. Further studies aiming at the evaluation of the long-term safety are now needed to confirm these results. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3230

Background Calcinosis and acro-osteolysis are frequent in systemic sclerosis (SSc) and are easily detected by X-rays (1). Recent findings indicate that these lesions may be related to digital vasculopathy. Accumulating evidence support the input of nailfold videocapillaroscopy (NVC) as a marker of digital vasculopathy. Objectives To determine whether calcinosis and acro-osteolysis are associated with specific NVC features. Methods Consecutive SSc patients were consecutively included during a 24-month period. NVC was performed and analysed by one investigator (JA) blinded for the results of X-Rays and classified as early, active and late pattern (2). Two independent investigators carried out radiological assessment on standard anteroposterior views of the hands and wrists (LM, MS), followed by a consensus reading (AF and YA). Calcinosis was defined by the presence of at least one calcification in soft tissue and acro-osteolysis by the presence of the resorption of at least one digit tip. Both were classified on X-rays as mild, moderate or severe according to their extent. Results 155 patients were included, with a mean age of 57±13 years and a mean disease duration of 9±5 years; 65 (42%) had the diffuse cutaneous subset. 15 (10%) patients had a normal, 46 (30%) an early, 47 (30%) an active, and 47 (30%) a late NVC pattern. Regarding X-ray analysis, the kappa coefficient of inter-rater agreement was 0.75. 43 (28%) patients had calcinosis, of whom 26 (17%) had moderate or severe lesions; 25 (16%) patients had acro-osteolysis; of whom 13 (8%) had severe lesions. Patients with calcinosis were more likely to have acro-osteolysis (p=0.02), but Cramer9s V coefficient of association was 0.19, supporting low association between these variables. Patients with calcinosis and acro-osteolysis were more likely to have the late NVC pattern (p=0.04 and p 14 (p=0008) and positive antitopoisomerase-I antibodies (p=0.01). Conclusions We show for the first time an independent association between calcinosis/acro-osteolysis and the late NVC pattern, and in particular, with reduced number of capillaries. This result suggests that these lesions may be related to the severe capillary loss observed at this stage. Acro-osteolysis, but not calcinosis, was associated with neoangiogenesis, which may suggest an attempt to compensate bone resorption. Further studies are now needed to determine whether capillaroscopy may predict the further occurrence or worsening of these lesions. References Avouac J et al, Ann Rheum Dis 2006; (2) Cutolo M et al. J Rheumatol. 2000 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4427

Objectives To assess whether nailfold videocapillaroscopy (NVC) changes are associated with peripheral blood or serum levels of angiogenic biomarkers in systemic sclerosis (SSc). Methods Endothelial markers were first assessed in a discovery cohort of 60 SSc patients consecutively recruited. Circulating endothelial progenitor cells (EPCs) and circulating endothelial cells (CECs) were quantified in peripheral blood by flow cytometry after cell sorting, as previously described (1). Serum levels of vascular endothelial growth factor (VEGF), placenta growth factor (PlGF), soluble vascular adhesion molecule (sVCAM), endothelin-1 (ET1), angiopoietin-2, endoglin, endostatin and Tie-2, were measured by quantitative sandwich enzyme-linked immunosorbent assay (ELISA) technique (Quantikine kits, R&D systems). Serum levels of endothelial markers that were found associated with NVC patterns in the discovery cohort were then measured in a replication cohort of 43 SSc patients. NVC was performed by two independent examiners and images were analysed anonymously by four investigators blinded for the clinical and serum status of SSc patients and classified as early, active and late pattern (2). Results The mean ± standard deviation (SD) age of the 60 patients (46 women) was 56±13 year old and the mean ± SD disease duration was 9±8 years at baseline. Thirty-six patients had the diffuse cutaneous subset, and 24 the limited. 14 (23%) and 8 (18%) patients had an early, 22 (37%) and 20 (46%) an active, and 24 (40%) and 15 (35%) a late NVC pattern in the discovery and replication cohorts, respectively. By univariate analysis focused on biomarkers, patients with late NVC pattern exhibited significantly lower EPC levels and higher VEGF serum levels than patients with early and active patterns (p 14 (p Conclusions Our data revealed decreased EPC counts in patients with the late NVC pattern, suggesting that deficient vasculogenesis may contribute to the severe capillary loss observed at this stage. VEGF upregulation in the late pattern may appear as an attempt of compensatory mechanism to stimulate deficient vasculogenesis. Further studies are now needed to determine the role of VEGF and EPCs in endothelial injury and repair in SSc. References Avouac et al, Ann Rheum Dis 2008, Cutolo M et al. J Rheumatol. 2000 Disclosure of Interest J. Avouac Grant/research support from: Actelion, Pfizer, M. Vallucci: None Declared, V. Smith: None Declared, P. Senet: None Declared, B. Ruiz: None Declared, A. Sulli: None Declared, C. Pizzorni: None Declared, C. Frances: None Declared, G. Chiocchia: None Declared, M. Cutolo: None Declared, Y. Allanore Grant/research support from: Actelion, Pfizer

Background Tribbles Homolog 3 (TRB3), is a member of the family of pseudokinases called Tribbles which regulate activation of various intracellular signaling pathways with roles extending from mitosis and cell activation to apoptosis and modulation of gene expression. Objectives To investigate the role of TRB3 in the pathologic activation of fibroblasts in systemic sclerosis (SSc). Methods Activation of TRB3 was determined by real-time PCR, immunohistochemistry and immunofluorescence. Collagen synthesis was quantified by real-time PCR and SirCol collagen assay. A plasmid construct overexpressing TRB3 was designed. TRB3 expression was inhibited in cultured fibroblasts and murine models of fibrosis via siRNA. The mouse models of dermal fibrosis induced by bleomycin and attenuated adenovirus overexpressing a constitutively active TGF-β receptor I were used. Results Increased expression of TRB3 was detected in the upper layer of the dermis of SSc patients and colocalized with prolyl-4-hydroxylase, αSMA and phosphorylated Smad3 expression. The overexpression of TRB3 persisted in cultured SSc fibroblasts (4.1±0.4-fold increase, p Conclusions This is the first study on the key role of TRB3 in fibroblast activation and tissue fibrosis in SSc. TRB3 is upregulated in SSc and in experimental fibrosis in a TGF-β dependent manner. TRB3 is essential for the pro-fibrotic effects of TGF-β and inhibition of TRB3 completely prevents the stimulatory effect of TGF-β. In addition, knockdown of TRB3 protected from experimental dermal fibrosis in different mouse models. Considering the potent anti-fibrotic effects in this study, TRB3 might be a promising candidate for molecular targeted therapies of SSc. Acknowledgements This study was performed with support of CMH Research Projects No 00000023728. Disclosure of Interest None Declared

Background Watermelon stomach (WS) or Gastric Antral Vascular Ectasia (GAVE) is a very rare gastric complication of Systemic Sclerosis (SSc). It has a unique endoscopic appearance that is characterized by multiple longitudinal stripes of red vessels, which radiate in a spoke-like fashion from the pylorus to the antrum. The characteristics of patients with SSc-GAVE remain poorly described. Objectives The aim of this study was to determine the subgroup at risk together with the outcomes of SSc patients with GAVE. Methods We performed a retrospective, multicenter, international, case/control study. We collected cases of SSc-GAVE cases through EUSTAR network. Every case was matched with 2 SSc controls recruited from the same center, matched for age, sex, cutaneous subtype and disease duration. Disease characteristics were recorded at the time of GAVE occurrence and the last observation was used to defined the outcomes. Results We included 29 cases of SSc patients with GAVE, who were compared to 58 SSc controls. These 29 SSc patients (26 women, 89%) had a mean ± standard deviation (SD) age of 59±13 years and a mean ± SD disease duration of 7±3 years; 17 (59%) had the diffuse cutaneous subset and 12 (41%) the limited. Among these patients, 28 (97%) had anaemia, 13 (45%) needed red blood cell transfusion, and 18 (62%) required endoscopic treatment. In addition, SSc patients with GAVE were more likely to have positive anti-RNA polymerase-III antibodies (17/29, 60% vs. 8/58, 14%, p=0.0002), DLCO/AV Conclusions Presence of antibodies to RNA-Polymerase-III antibodies may be useful to identify the subset of SSc patients with increased risk for GAVE. Despite it was described as a late complication, SSc patients with GAVE had early disease duration in our cohort. GAVE appears as a cause of anaemia that clinicians should be aware of. This complication often requires local endoscopic therapy, which is usually efficient, despite frequent recurrent events. The inclusion of further cases in this ongoing project may help to better characterise the features of this rare complication. Disclosure of Interest None Declared

Background Gastro-Intestinal (GI) involvement is a well-known complication of Systemic Sclerosis (SSc). Small intestinal bacterial overgrowth (SIBO) is part of such involvement. It can compromise the patient quality of life and lead to severe outcomes (cachexia, high infectious risk). However, the prevalence of SIBO is not established and predictors remain unexplored. Objectives To estimate the prevalence of SIBO in patients with SSc exhibiting GI symptoms and identify subsets of patients at risk of SIBO regarding clinical and biological presentations and GI symptoms measured by standardised questionnaires. Methods Between 2011 and 2012, patients with SSc exhibiting GI complaints (pain, diarrhoea, bloating) underwent glucose hydrogen/methane breath tests (BT) and blood assays (CRP, ferritin, vitamins D, B9 and B12, albumin, calcium, phosphate, prothrombin and lipid profile). At the time of the BT, patients were asked to complete two questionnaires: the Short Form-36 (SF-36) and the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument (UCLA SCTC GTI).1 Results Among 120 consecutive SSc patients, 38 patients (30 women) were included, (median age: 59 years (30-80)). Fourteen patients (37%) had a positive BT and were diagnosed with SIBO giving a point prevalence of 12% (14/120) in SSc and 37% (14/38) in SSc patients with GI symptoms. Among the 38 patients included, 18 (48%) had the diffuse cutaneous subset. Median disease duration was 8.5 years (1-35). Patients with SIBO showed a longer disease duration (13.5 years (4-29) vs. 6.5 (1-35), p=0.007); a higher frequency of pulmonary arterial hypertension confirmed by right heart catheterization (3/14, 21% vs. 0/24, 0%, p=0.01) and a lower frequency of anti-topoisomerase-I antibodies (1/14, 7% vs. 10/24, 42%, p=0.04). Median age (60.5 vs. 59 years, p=0.5) and cutaneous subset (36% vs. 54% patients with the diffuse form, p=0.5) did not differ between patients with or without SIBO. Of the most interest, significant weight-loss within the past 6 months (>5% of total body weight) was observed in patients with BT+ (6/14, 43% vs. 2/24, 8%, p=0.03). Despite normal median values, calcium (p=0.04), phosphate (p=0.04) and triglycerid levels (p=0.04) were lower in patients with SIBO. Focusing on GI manifestations, it is of note that the total UCLA SCTC GTI score was higher in patients suffering from SIBO (0.85 (0.24-2.22) vs. 0.30 (0.04-1.24), p=0.02). The SF-36 assessment was comparable between the 2 groups. Two patients died due to intestinal involvement with severe chronic malabsorption. Conclusions In our series, the prevalence of SIBO was 37% of SSc patients displaying GI symptoms. To our knowledge, this is the first study using the UCLA SCTC GTI to identify patients at risk of SIBO in SSc. Higher UCLA SCTC GTI score and weight-loss appeared to be strongly associated with SIBO. These results support the systematic use of this score, together with a regular weight evaluation in SSc patients. Further studies are needed to confirm these results on a larger scale and to assess the evolution of the UCLA SCTC GTI score after SIBO optimal treatment, which is currently ongoing in our unit. References Khanna D, et al. Reliability and validity of the University of California, Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract Instrument. Arthritis Rheum 2009; 61: 1257-63. Disclosure of Interest None Declared