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INTRODUCTION Like other autoimmune diseases, systemic sclerosis (SSc) has been described to be associated with accelerated atherosclerosis (ATS). Before clinical manifestations of cardiovascular disease (CVD) occur, subclinical ATS can be investigated in different ways. AIM To evaluate the presence of subclinical ATS in a group of patients with SSc, and to identify different risk profiles among patients. METHODS Subclinical ATS was reviewed in 43 SSc patients and 27 healthy controls, using 2 methods: carotid ultrasound and flow mediated dilation (FMD) of the brachial artery. RESULTS Plaques were statistically more frequent in SSc patients than in controls (65% vs 30%, P = .006); intima-media thickness of common carotid artery (CCA-IMT) resulted in statistically higher (median value 0.8 mm vs 0.55 mm; P

The concern about the offspring’s health is one of the reasons for a reduced family size of women with rheumatic diseases (RD). Increased risk of autoimmune diseases (AD) and neurodevelopmental disorders (ND) has been reported in children born to patients with RD. Within a nationwide survey about reproductive issues of women with RD, we aimed at exploring the long-term outcome of their children. By surveying 398 patients who received their diagnosis of RD during childbearing age (before the age of 45), information about the offspring were obtained from 230 women who declared to have had children. A total of 148 (64.3%) patients were affected by connective tissue diseases (CTD) and 82 (35.7%) by chronic arthritis. Data on 299 children (156 males, 52.1%; mean age at the time of interview 17.1 ± 9.7 years) were collected. Twelve children (4.0%), who were born to patients with CTD in 75% of the cases, were affected by AD (8 cases of celiac disease). Eleven children had a certified diagnosis of ND (3.6%; 6 cases of learning disabilities); 9 of them were born to mothers with CTD (5 after maternal diagnosis). No association was found between ND and prenatal exposure to either maternal autoantibodies or anti-rheumatic drugs. Absolute numbers of offspring affected by AD and ND were low in a multicentre cohort of Italian women with RD. This information can be helpful for the counselling about reproductive issues, as the health outcomes of the offspring might not be an issue which discourage women with RD from having children.

To explore the pathogenic association between periodontal disease and rheumatoid arthritis focusing on the role of Porphyromonas gingivalis.In the last decades our knowledge about the pathogenesis of rheumatoid arthritis substantially changed. Several evidences demonstrated that the initial production of autoantibodies is not localized in the joint, rather in other immunological-active sites. A central role seems to be played by periodontal disease, in particular because of the ability of P. gingivalis to induce citrullination, the posttranslational modification leading to the production of anticitrullinated protein/peptide antibodies, the most sensitive and specific rheumatoid arthritis biomarker.The pathogenic role of P. gingivalis has been demonstrated in mouse models in which arthritis was either triggered or worsened in infected animals. P. gingivalis showed its detrimental role not only by inducing citrullination but also by means of other key mechanisms including induction of NETosis, osteoclastogenesis, and Th17 proinflammatory response leading to bone damage and systemic inflammation.

Background Thrombocytopenia is a manifestation associated with primary antiphospholipid syndrome (PAPS), and many studies have stressed the leading role played by platelets in the pathogenesis of antiphospholipid syndrome (APS). Platelets are highly specialized cells, and their activation involves a series of rapid rearrangements of the actin cytoskeleton. Recently, we described the presence of autoantibodies against D4GDI (Rho GDP dissociation inhibitor beta, ARHGDIB) in the serum of a large subset of SLE patients, and we observed that anti-D4GDI antibodies activated the cytoskeleton remodeling of lymphocytes by inhibiting D4GDI and allowing the upregulation of Rho GTPases, such as Rac1. Proteomic and transcriptomic studies indicate that D4GDI is very abundant in platelets, and small GTPases of the RHO family are critical regulators of actin dynamics in platelets. Methods We enrolled 38 PAPS patients, 15 patients carrying only antiphospholipid antibodies without clinical criteria of APS (aPL carriers) and 20 normal healthy subjects. Sera were stored at − 20 °C to perform an ELISA test to evaluate the presence of anti-D4GDI antibodies. Then, we purified autoantibodies anti-D4GDI from patient sera. These antibodies were used to conduct in vitro studies on platelet activation. Results We identified anti-D4GDI antibodies in sera from 18/38 (47%) patients with PAPS, in sera from 2/15(13%) aPL carriers, but in no sera from normal healthy subjects. Our in vitro results showed a significant 30% increase in the activation of integrin αIIbβ3 upon stimulation of platelets from healthy donors preincubated with the antibody anti-D4GDI purified from the serum of APS patients. Conclusions In conclusion, we show here that antibodies anti-D4GDI are present in the sera of PAPS patients and can prime platelet activation, explaining, at least in part, the pro-thrombotic state and the thrombocytopenia of PAPS patients. These findings may lead to improved diagnosis and treatment of APS.

BackgroundAdhesion molecule CD44 contributes to T cell migration into target organs. A higher expression of CD44v3 and v6 isoforms has been identified on T cells from systemic lupus erythematosus (SLE) patients. The aim of this study was to investigate the expression of CD44v3/v6 on T cells of SLE patients in order to evaluate their correlation with clinical features.MethodsSixteen healthy subjects (HSs) and 33 SLE female patients were enrolled. Fifteen patients were in remission (Systemic Lupus Erythematosus Disease Activity Index-2000 (SLEDAI-2K) = 0) and 18 patients had an active disease (SLEDAI-2K ≥ 4). Experiments were conducted by flow cytometry.ResultsExpression of CD44v3 on CD4+and CD8+T cells was higher in active patients compared to HSs ( p = 0.0097 and p = 0.0096). CD44v3 on CD8+T cells was also higher in active patients compared to patients in remission ( p = 0.038). CD44v6 was higher on CD4+and CD8+T cells from active patients compared to HSs ( p = 0.003 and p = 0.0036) and to patients in remission ( p = 0.01 and p = 0.02). In active patients the ratio CD44v3/v6 was unbalanced towards isoform v6 on both T cell populations. In a receiver operating characteristic curve analysis, CD44v6 on CD4+T cells was the most sensitive and specific one (specificity of 81.8%, sensitivity of 75%). Expression of CD44v6 on CD4+and CD8+T cells correlated with the SLEDAI-2K ( p = 0.03, r = 0.38 and p = 0.02, r = 0.39). CD44v6 and CD44v3 on CD8+T cells associated with nephritis and arthritis ( p = 0.047 and p = 0.023).ConclusionsCD44v3/v6 can be used as biomarkers of disease activity and phenotypes; isoform v6 on CD4+T cells can be useful as a diagnostic biomarker.

Specific indices are not available to evaluate systemic lupus erythematosus (SLE) joint involvement; indeed, the application of indices validated for rheumatoid arthritis has been suggested. We evaluated the usefulness of organ specific composite indices, i.e. the Disease Activity Score on 28 joints (DAS28), Simplified Disease Activity Index (SDAI), Clinical Disease Activity Index (CDAI), and the ratio of swollen to tender joints (STR), to assess SLE joint activity by analyzing the correlation between these indices and ultrasonography (US) inflammatory status. We evaluated SLE patients with arthralgia and/or arthritis: the above-mentioned indices were calculated and the SLE Disease Activity Index 2000 (SLEDAI-2k) was applied to assess global disease activity. US of I–V metacarpophalangeal, I–V proximal interphalangeal, wrist, and knee bilateral was performed. Synovial effusion/hypertrophy and power Doppler findings were scored according to a semi-quantitative scale (0–3) to obtain an inflammatory total score (0–216). One hundred and six patients (M/F 7/99, median age 49.5 years (IQR 17.0), median disease duration 8.5 years (IQR 17.0)) were enrolled. We identified a positive correlation between US score and DAS28-CRP ( r = 0.3, p = 0.007), STR ( r = 0.42, p = 0.0005), SDAI ( r = 0.33, p = 0.02), CDAI ( r = 0.29, p = 0.03); US score reflected different levels of clinimetric joint activity. In conclusion, we suggest the ability of composite indices in detecting SLE joint inflammation and their possible real-life use.

Objective We investigated the genetic diversity, molecular epidemiology and evolutionary dynamics of Staphylococcus aureus (SA) isolated from SLE patients by means of phylogenetic analysis. Methods Consecutive SLE patients (ACR 1997 criteria) were enrolled: clinical/laboratory data were collected and nasal swab for SA identification was performed. On the basis of the translation elongation factor (tuf) gene, a phylogenetic analysis was performed to investigate relationships and to assess significant clades. Selective pressure analysis was used to investigate the evolution of the SA tuf gene. The gene sequences from non-SLE individuals, downloaded from the GenBank database, were compared through phylogenetic analysis with the tuf gene from SLE patients. Results We enrolled 118 patients [M/F 10/108; median (interquartile range (IQR)) age 45.5 (13.2) years; median (IQR) disease duration 120 (144) months]. Twenty-four patients (20.3%) were SA carriers (SA+), three of them MRSA. SA+ SLE showed significantly higher SLEDAI-2k values [SA+: median (IQR) 2 (3.75); SA−: 0 (2); P = 0.04]. The phylogenetic analysis, restricted to 21 non-MRSA SA+, revealed a statistically supported larger clade (A, n = 17) and a smaller one (B, n = 4). Patients located in clade A showed a significantly higher prevalence of joint involvement (88.2%) in comparison with clade B (50.0%, P Conclusion We suggest a possible role of SA nasal carriage status in SLE disease activity. Moreover, our findings support the hypothesis that bacterial genetic variants may be associated with specific disease features.

Objective SLE is an autoimmune disease, mainly affecting women of childbearing age, with possible impact on pregnancy. In this study, we evaluated pregnancy outcomes in all pregnant patients affected by SLE, followed in the context of a rheumatology/gynaecology multi-disciplinary team. Methods Since 2008, we evaluated 70 consecutive pregnancies occurring in 50 SLE patients referring to the Lupus Clinic of Sapienza University of Rome; as controls we evaluated 100 consecutive pregnancies in 100 women without autoimmune diseases. Results By comparing SLE patients and controls, we did not find differences in terms of pregnancy outcomes, except for the occurrence of small for gestational age, which was significantly higher in the SLE group (22.8% vs 11%, P =0.003). Small for gestational age was associated with the positivity for anti-dsDNA, anti-Sm and anti-RNP (P =0.009, P =0.02, P =0.002, respectively). A disease flare was reported in 28 pregnancies (40%) and in 31 puerperium periods (44.3%). Flare during pregnancy was associated with anti-SSA (P =0.02), while puerperium relapse with previous MMF treatment (P =0.01) and haematological flare during pregnancy (P =0.03). Conclusion The present study confirms how pre-gestational counselling and a multi-disciplinary approach could result in positive pregnancy outcomes for SLE patients. The high percentage of disease relapse justifies even more the need for multi-disciplinary management.

Background ICIs have strongly improved the outcome of NSCLC patients. However, primary and secondary resistance occur during treatment in most of the patients, with several of them developing fast progressions. Autoantibodies can be related with a dysfunctional immune system, although their association with immune-based anti-cancer therapies has never been investigated. Moreover, so far no reliable predictive factor is currently available to aid in treatment selection. CD137+T-cells are largely known to be the anti-tumor activated effector cells, but they have never been associated with the response to immunotherapies. Methods Forty-two patients with metastatic NSCLC receiving anti-PD-1 ICIs at Sant'Andrea Hospital and Policlinico Umberto I, from June 2016 to September 2018 were enrolled. Circulating levels of IgM-Rheumatoid Factor were evaluated at baseline and correlated with patients clinical response following the anti-PD-1 treatment. IgM-RF interaction and effect on T-cells in vivo and in vitro were investigated. Findings IgM-RF in NSCLC patient sera strongly predicted the development of early progression to ICIs. Also, a significant reduction of progression-free survival rate in anti-PD-1 treated patients could be identified when patients were stratified based on IgM-RF positivity and titers. IgM-RF bound preferentially circulating naive and central memory T-cells and a significant reduction of CD137+ anti-tumor T effector cells was found in IgM-RF positive patients. In addition, a higher percentage of CD137+T-cells in peripheral blood of NSCLC patients at baseline resulted as a strong independent prognostic factor for a better outcome in terms of PFS and OS after the anti-PD-1 treatment. Furthermore, T-cells exposed to IgM-RF showed a robust defect in their migratory ability in response to CCL19 chemokine. Interpretation In this study we showed that serum IgM-RF can be regarded as predictive factor for the development of early progression and prognostic factor of a reduced progression-free survival and overall-survival in anti-PD-1 treated NSCLC patients. The ability of IgM-RF to bind naive and central memory T-cells and impair their migration could make account for the reduction of the tumor-reactive CD137+ T-cells population that may cause a non-effectiveness of these T-cells targeting drugs. Fundings AIRC, MIUR and Sapienza University of Rome.

The aim of the study was to investigate the presence of subclinical vascular damage in polymyalgia rheumatica (PMR). We enrolled PMR patients having major cardiovascular risk factors (MCVRF) and, as controls, patients with MCVRF. All underwent: color Doppler ultrasound to evaluate the common carotid intima-media thickness (IMT), the anterior–posterior abdominal aortic diameter (APAD), and the prevalence of carotid artery stenosis; the cardio-ankle vascular index (CAVI) to measure arterial stiffness together with the ankle-brachial index (ABI) to investigate the presence of lower-extremity peripheral arterial disease. Finally, we measured the serum levels of adipocytokines implicated in vascular dysfunction. As a result, 48 PMR and 56 MCVRF patients were included. An increase of IMT (1.07/0.8–1.2 vs 0.8/0.8–1.05; p = 0.0001), CAVI (8.7/7.8–9.3 vs 7.6/6.9–7.8; p 2 = 0.845 and r2 = 0.556, respectively; p

Backgrounds The organization of minor salivary glands (MSG) infiltrates, in patients with Sjögren’s syndrome (SS), associates with disease severity and progression. Aberrant regulation of lymphocyte autophagy is involved in autoimmunity, and in previous work, we provided the first evidence of upregulated autophagy in CD4+ T cells infiltrating SS MSG. The aim of this study was to further explore autophagy in SS infiltrating and circulating lymphocytes and to investigate its role in disease histopathological progression. Methods After collection of 20 SS MSG, the presence of lymphocyte aggregates (foci) and the formation of germinal center (GC)-like structures were observed by H&E and confirmed by immunohistochemistry. The expression of autophagy-related genes, Atg5 and MAP1LC3A, was detected by RT-PCR on microdissected salivary gland tissue and control tonsils. In MSG and tonsils, autophagic lymphocytes were identified by the detection of the autophagosome protein LC3B visualized as LC3 puncta staining by immunofluorescence. Peripheral blood autophagy was assessed by flow cytometry in SS and healthy controls (HC). Results Real-time PCR demonstrated higher expression in the autophagy genes Atg5 and MAP1LC3A in MSG GCs as compared to both small foci (p = 0.0075, p = 0.0002) and GCs from tonsils (p = 0.0001, p = 0.0037). In MSG, LC3 puncta staining was detectable on both CD3+ and CD20+ lymphocytes; in tonsils, LC3 puncta was almost undetectable on all lymphocytes. Compared to HC (n = 20), flow cytometry did not reveal any increase of autophagy in SS circulating lymphocytes (n = 30). Conclusions In SS MSG, lymphocytes’ autophagy is a feature of infiltrating T and B cells and is associated with histological severity. Interestingly, in MSG aberrant regulation of autophagy is detectable in GC-like structures possibly indicating its involvement in the development and persistence of the autoimmune process within the lesions.

Background: Aim of this study was to search for any difference in the outcome of patients with adult onset Still's disease (AOSD) treated with anakinra (ANK) in relation with the interval between disease onset and the start of anti-interleukin(IL)-1 treatment and according with the different lines of ANK treatment. Patients and Methods: One hundred and forty-one AOSD patients treated with ANK have been retrospectively assessed. Statistically significant differences (p < 0.05) were analyzed in the frequency of ANK effectiveness, primary or secondary inefficacy to ANK and rate of resolution of clinical and laboratory AOSD manifestations after 3, 6, and 12 months since ANK treatment according with different lines of treatment and different times between AOSD onset and start of ANK. Results: No significant differences were identified in the ANK effectiveness and frequency of primary or secondary inefficacy for patients starting ANK within 6 months (p = 0.19, p = 0.14, and p = 0.81, respectively) or 12 months (p = 0.37, p = 0.23, and p = 0.81, respectively) since AOSD onset compared with patients starting ANK thereafter; no significant differences were identified in ANK effectiveness and primary or secondary inefficacy according with different lines of ANK treatment (p = 0.06, p = 0.19, and p = 0.13, respectively). Patients starting ANK within 6 and 12 months since AOSD onset showed a significantly quicker decrease of erythrocyte sedimentation rate and C-reactive protein than observed among patients undergoing ANK treatment after 6 and 12 months. The number of swollen joints at the 3 month follow-up visit was significantly lower among patients undergoing ANK within 6 months since AOSD onset (p = 0.01), while no significance was identified at the 6 and 12 month assessments (p = 0.23 and p = 0.45, respectively). At the 3 and 6 month visits, the number of swollen joints was significantly higher among patients previously treated with conventional and biological disease modifying anti-rheumatic drugs (DMARDs) compared with those formerly treated only with conventional DMARDs (p < 0.017). Conclusions: Clinical and therapeutic outcomes are substantially independent of how early ANK treatment is started in AOSD patients. However, a faster ANK effectiveness in controlling systemic inflammation and resolving articular manifestations may be observed in patients benefiting from IL-1 inhibition as soon as after disease onset.

Objective Caffeine, one of the most widely consumed products in the world, seems to interact with multiple components of the immune system by acting as a non-specific phosphodiesterase inhibitor. In vitro dose-dependent treatment with caffeine down-regulates mRNA levels of key inflammation-related genes in peripheral blood mononuclear cells. So far, no robust data are available about the possible contribution of caffeine in systemic lupus erythematosus (SLE). The aim of this study was to evaluate the impact of caffeine consumption on SLE-related disease phenotype and activity, in terms of clinimetric assessment and cytokine serum levels. Methods We performed a cross-sectional study, enrolling consecutive patients and reporting their clinical and laboratory data. Disease activity was assessed by SLE Disease Activity Index 2000 (SLEDAI-2K). Caffeine intake was evaluated by a 7-day food frequency questionnaire, including all the main sources of caffeine. As previously reported, patients were divided into four groups according to the daily caffeine intake: 376.6 mg/day (group 4). At the end of questionnaire filling, blood samples were collected from each patient to assess cytokine levels. These were assessed by using a panel by Bio-Plex assays to measure the levels of IL-6, IL-10, IL-17, IL-27, IFNγ, IFNα and BLyS. Results We enrolled 89 consecutive SLE patients. We observed a negative correlation between caffeine consumption and disease activity, measured with SLEDAI-2K. A significantly higher prevalence of lupus nephritis, neuropsychiatric involvement, haematological manifestations, hypocomplementaemia and anti-dsDNA positivity was observed in patients with a low intake of caffeine. Furthermore, patients with a low intake of caffeine were more frequently treated with glucocorticoids. Regarding cytokine analysis, a negative correlation between daily caffeine consumption and serum level of IFNγ was found ( p = 0.03, r = –0.2); furthermore, patients with a high intake of caffeine showed lower serum levels of IFNα ( p = 0.02), IL-17 ( p = 0.01) and IL-6 ( p = 0.003). Conclusions In this report we demonstrated the impact of caffeine on SLE disease activity status, as confirmed by the inverse correlation between its intake and both SLEDAI-2K values and cytokine levels. Moreover, patients with a low caffeine consumption seem to have a more severe disease phenotype.

Background:Systemic Lupus Erythematosus (SLE) related arthritis has been traditionally defined non-erosive and then considered a minor manifestation. Thanks to the application of more sensitive imaging techniques, such as ultrasonography (US), erosive damage has been identified in up to 40% of SLE patients with joint involvement, suggesting the need for more appropriate treatment (1). Antibodies directed against citrullinated and carbamilated proteins (ACPA and anti-CarP, respectively) have been associated with erosive damage and then proposed as biomarkers for this more aggressive phenotype (2).Objectives:Here, we evaluated a large SLE cohort with joint involvement by using cluster analysis, in order to identify the disease phenotype associated with erosive arthritis.Methods:For this analysis, we enrolled consecutive SLE patients (ACR 1997 criteria) with a clinical history of joint involvement (arthritis/arthralgia). Clinical and laboratory data were collected in a standardized computerized electronically filled form, including demographics, past medical history with the date of diagnosis, co-morbidities, previous and concomitant treatments, serological status. The presence of rheumatoid factor (RF), ACPA and anti-CarP was investigated by ELISA test. Erosive damage was assessed by ultrasonography at level of metacarpophalangeal, proximal interphalangeal and metatarsophalangeal joints (MyLab Eight Exp, Esaote, Florence, Italy). Data have been analysed by hierarchic cluster analysis (SPSS program, IBM).Results:We enrolled 203 patients [M/F 12/191, median age 46.0 years (IQR 18); median disease duration 120.0 months (IQR 108)]. Erosive damage was identified in 53 patients (26.1%), all of them referring at least one episode of arthritis during disease course. Moving on autoantibodies status, RF was positive in 29.5%, anti-CarP in 28.5% and ACPA in 11.2%. The univariate analysis demonstrated a significant association between US-detected erosive damage and anti-CarP (p=0.01), ACPA (p=0.03), and renal manifestations (p=0.03). In Figure 1 we reported the dendrogram obtained from cluster analysis, allowing the identification of four cluster. Positivity for ACPA, anti-CarP, erosive damage, Jaccoud’s arthropathy and renal manifestations were allocated in the same cluster. Interestingly, RF resulted allocated in a different cluster, including ENA, anti-SSA and anti-SSB antibodies.Conclusion:The application of cluster analysis allowed the identification of a specific SLE phenotype, characterized by erosive damage, renal manifestations and positivity for anti-CarP and ACPA. We could speculate about the presence of a shared pathogenic mechanism, involving NETosis, contributing to nephritis and erosive arthritis.References:[1]Ceccarelli F et al. Semin Arthritis Rheum 2017[2]Ceccarelli F et al. Arthritis Res Ther 2018Disclosure of Interests:Fulvia Ceccarelli: None declared, Francesco Natalucci: None declared, Carlo Perricone: None declared, enrica cipriano: None declared, Carmelo Pirone: None declared, Giulio Olivieri: None declared, Tania Colasanti: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Rheumatoid arthritis (RA) is a chronic inflammatory disease with increased risk of cardiovascular events and mortality that can be attributed to accelerated atherosclerosis. This pilot study aimed to investigate if changes in blood parameters were compatible with atherosclerotic events in RA patients. To this aim, 45 RA women (aged more than 18 years), and 25 age and gender-matched healthy donors (HD) were included. Biomarkers of oxidative stress, platelet activation and platelet aggregation were analysed in RA patients at baseline and after six months of treatment with disease modifying anti-rheumatic drugs (DMARDs). Flow cytometry analysis revealed that ca. 4% of platelets was in activated state (evaluated in term of Annexin V and PAC-1 positivity) in RA patients at baseline, and that the 76% of platelets displayed mitochondrial hyperpolarization. Moreover, platelets from RA patients at baseline aggregated more than those from HD after whole blood treatment with adenosine diphosphate. Interestingly, platelet aggregation in patients at baseline positively correlated with disease activity measured by DAS28 score. After six months of treatment with DMARDs, platelet activation and platelet aggregation reached values comparable to those of HD. Our preliminary data suggest that platelets might play an active role in the atherosclerosis occurring in RA patients.

Objective To establish clinical consensus for the optimal placement of TNF inhibitor (TNFi) in DMARDs-naive RA patients. Methods The steering group was composed of 15 Italian rheumatologists expert in the field of RA, who proposed and selected by consensus the clinically relevant questions on the role of TNFi treatment in DMARDs-naive RA patients. The question was rephrased according to the population, intervention, comparison and outcome statement. The available scientific evidence on this topic were collected by updating the systematic literature reviews used for the EULAR 2013 recommendations up to January 2016. The aspects evaluated in the studies concerned clinical efficacy, radiographic structural damage and safety. After the systematic literature review the expert panel formulated a consensus statement, and a modified Delphi panel evaluated the level of agreement between panellists (strength of recommendation). Results From a total of 1080 records we have included 6 studies, 2 randomized clinical trials and 4 open-label extension trials. Evidence from publications generated three statements for the final consensus document. The systematic literature review and the consensus statements developed showed that, for patients with early RA and in the presence of a treat-to-target strategy, the immediate use of anti-TNFi compared with an early (within 12 weeks) step-up to anti-TNF therapy did not confer a significant advantage regarding clinical, functional and radiographic outcomes. Conclusion The most appropriate placement of the TNFi therapy in the treatment algorithm of early RA still remains a challenging clinical question that needs to be further addressed.

Rheumatoid arthritis (RA) is a chronic autoimmune disease and rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) are the most frequently detected autoantibodies (autoAbs). To date, more than 20% of RA cases are still defined as seronegative forms (seronegative RA, SN-RA). The aim of this study was to identify new antigenic targets of autoAbs in RA patients, which can also be recognized in SN-RA. Using a proteomic approach, we tested sera from SN-RA patients by analyzing synovial fluid (SF) proteins from these patients. Sera from SN-RA patients revealed a strong reactive spot, corresponding to alpha 1 antitrypsin (A1AT). Reverse-phase nanoliquid chromatography and tandem mass spectrometry (Matrix Assisted Laser Desorption/Ionization-Time Of Flight, MALDI-TOF/TOF) confirmed the presence of A1AT in SF and showed that homocysteinylation was one of the post-translational modifications of A1AT. Homocysteinylated (Hcy)-A1AT immunoprecipitated from SN-RA patients' SFs and in vitro modified Hcy-A1AT were used as antigens by Enzyme-Linked ImmunoSorbent Assay (ELISA) to test the presence of specific autoAbs in sera from 111 SN-RA patients, 132 seropositive (SP)-RA patients, and from 95 patients with psoriatic arthritis, 40 patients with osteoarthritis, and 41 healthy subjects as control populations. We observed that a large portion of SN-RA patients (75.7%), and also most of SP-RA patients' sera (87.1%) displayed anti-Hcy-A1AT autoAbs (anti-HATA). Native A1AT was targeted at a lower rate by SP-RA patients autoAbs, while virtually no SN-RA patients' sera showed the presence of anti-native A1AT autoAbs. In conclusion, anti-HATA can be considered potential biomarkers for RA, also in the SN forms. The discovery of novel autoAbs targeting specific autoantigens can represent higher clinic significance for all RA patients' population.

In a previous report of two married cohabiting couples affected by polymyalgia rheumatica (PMR), we noticed that the wife of one couple and both members of the other couple suffered from symptomatic diverticular disease (DD), whose diagnosis was made before the onset of PMR. We investigated whether DD might be a risk factor for the development of PMR. We conducted a case-control study informed on a database containing the prospectively collected medical records of consecutive PMR patients. Among comorbidities, attention was focused on symptomatic DD, provided that the diagnosis had been made by colonoscopy and/or computed tomography scan. As controls, we identified one control per case at random among those matched by age and sex attending the ophthalmic and orthopedic outpatient clinics, as long as a PMR diagnosis had been excluded. A logistic regression model was used, following a multiplicative model, and results were presented as odds ratio (OR) and 95% confidence intervals (95% CI). The most frequent comorbidities in the two groups of patients (121 cases and 121 controls) were chronic coronary artery disease, atrial fibrillation, diabetes mellitus, hypertension, DD, hypercholesterolemia, osteoporosis, chronic obstructive pulmonary disease, gastroesophageal reflux disease, and cholelithiasis. The association between PMR and DD (OR = 4.06; 95% CI: 1.76-9.35) was by far stronger than that found comparing PMR with the other comorbidities. The chronic bowel inflammation induced by dysbiosis in patients with symptomatic DD could be a critical immunopathological mechanism supporting the development or exacerbation of PMR in susceptible individuals.

Background Mycophenolate mofetil (MMF) is an immunosuppressive drug currently used to treat Systemic Lupus Erythematosus (SLE). In addition to clinical efficacy, MMF use is also supported by a favorable profile of tolerance, with main side effects being nausea, diarrhea, headache, and, less frequently, leucopoenia. Acne is a relatively frequent adverse reaction to MMF that requires specific treatment and drug suspension. Investigations Herein, we describe four cases of MMF-induced acne, none reporting past medical history of acne. The patients were diagnosed with SLE and lupus nephritis and treated with MMF. They developed papulo-pustular and nodular skin lesions consistent with acne. The lesions occasionally showed the appearance of macrocomedones or of unusual, nodular, oedematous lesions in gluteal region, or they had abscess-like features. Culture test demonstrated the presence of Staphylococcus Aureus. They resolved after MMF withdrawal and therapy with tetracycline and local pseudomonic-acid. Conclusions Staphylococcus Aureus skin-localized infections inducing inflammatory/infectious acne may be a relatively frequent side-effect of MMF therapy in SLE. As soon as generalized, severe infections, due to Staphylococcus Aureus, may also occur in patients treated with MMF and even if antibiotics therapy is usually relatively effective, at least temporary MMF suspension may be suggested.

The therapeutic approach to CNS demyelination associated to ankylosing spondylitis is a complex issue due to the contraindication of TNF inhibitors in demyelinating diseases. Secukinumab, a human IgG1κ monoclonal antibody that binds and inhibits IL-17A, was recently approved for the treatment of ankylosing spondylitis. We report the clinical cases of two patients affected by a CNS demyelinating disease and ankylosing spondylitis who were successfully treated with secukinumab, providing additional evidence of the feasibility of this therapeutic option when the use of TNF inhibitors is discouraged by challenging comorbidities.

Anti-synthetase syndrome is an autoimmune disease characterized by autoantibodies toward amino acyl-tRNA synthetases (ARS), anti-Jo 1 being the most commonly detected. Muscle damage develops in up to 90% of ARS-positive patients, characterized by a necrotizing myositis restricted to the perifascicular region. This topographic distribution of muscle damage may lead to a misdiagnosis of dermatomyositis (DM) at muscle biopsy. We compared morphological, immunohistochemical, and histoenzymatic features of muscle from ARS-positive patients (n = 11) with those of DM (n = 7) providing clues for their differential diagnosis. In addition, we evaluated markers of mitochondrial damage to provide a further distinction between these two entities. Necrosis occurred in the majority of ARS patients, mainly located in the perifascicular region. It was often limited to small foci of fibers, always associated with myocyte regeneration. This last often overwhelmed necrosis, representing occasionally the main finding. In DM, necrosis/regeneration was scarce while the peculiar feature was a diffuse atrophy of perifascicular fibers. These last showed decreased cytochrome c oxidase (COX) stain and mitochondrial DNA depletion, consistent with mitochondrial dysfunction. In contrast to DM, ARS displayed scattered COX-deficient fibers, not restricted to the perifascicular region. This feature occurred in up to 91% of patients, being prominent only in two.

Objective In the present review, the different phenotypes, clinimetric and imaging tools able to assess joint involvement in patients affected by Systemic Lupus Erythematosus (SLE) have been described and summarized. Furthermore, the current knowledge about the pathogenic mechanism and the potential biomarkers of this feature is reported. Methods A literature search was done in PubMed, accessed via the National Library of Medicine PubMed interface ( http://www.ncbi.nlm.nih.gov/pubmed ). Firstly, PubMed was searched using the term “systemic lupus erythematosus” OR “lupus” in combination with (AND) “joint” OR “articular”.Secondly, the same PubMed research was combined with other terms, such as “pathogenesis” OR “genetic” OR “antibodies” OR “biomarkers” OR “cytokines” OR “imaging” OR “ultrasonography” OR “magnetic resonance” OR “clinimetry”. Results After a stringent selection, we evaluated in the present review 13 papers concerning clinical phenotypes of SLE joint involvement, 14 concerning clinimetric assessment, 20 concerning imaging, and finally, 28 concerning pathogenesis and biomarkers. Further relevant data were obtained from the reference lists of articles returned using these search terms and from authors own experience and knowledge of the literature. Conclusion Despite the prevalence and severity of SLE joint involvement, more awareness and a deeper evaluation of the clinical heterogeneity of this manifestation are mandatory. Moreover, longitudinal studies are needed to assess the progression of this manifestation and to provide standard definitions and examination/recording protocols.

Author(s): Clowse, Megan EB; Wallace, Daniel J; Furie, Richard A; Petri, Michelle A; Pike, Marilyn C; Leszczynski, Piotr; Neuwelt, C Michael; Hobbs, Kathryn; Keiserman, Mauro; Duca, Liliana; Kalunian, Kenneth C; Galateanu, Catrinel; Bongardt, Sabine; Stach, Christian; Beaudot, Carolyn; Kilgallen, Brian; Gordon, Caroline; EMBODY Investigator Group | Abstract: ObjectiveEpratuzumab, a monoclonal antibody that targets CD22, modulates B cell signaling without substantial reductions in the number of B cells. The aim of this study was to report the results of 2 phase III multicenter randomized, double-blind, placebo-controlled trials, the EMBODY 1 and EMBODY 2 trials, assessing the efficacy and safety of epratuzumab in patients with moderately to severely active systemic lupus erythematosus (SLE).MethodsPatients met ≥4 of the American College of Rheumatology revised classification criteria for SLE, were positive for antinuclear antibodies and/or anti-double-stranded DNA antibodies, had an SLE Disease Activity Index 2000 (SLEDAI-2K) score of ≥6 (increased disease activity), had British Isles Lupus Assessment Group 2004 index (BILAG-2004) scores of grade A (severe disease activity) in ≥1 body system or grade B (moderate disease activity) in ≥2 body systems (in the mucocutaneous, musculoskeletal, or cardiorespiratory domains), and were receiving standard therapy, including mandatory treatment with corticosteroids (5-60 mg/day). BILAG-2004 grade A scores in the renal and central nervous system domains were excluded. Patients were randomized 1:1:1 to receive either placebo, epratuzumab 600 mg every week, or epratuzumab 1,200 mg every other week, with infusions delivered for the first 4 weeks of each 12-week dosing cycle, for 4 cycles. Patients across all 3 treatment groups also continued with their standard therapy. The primary end point was the response rate at week 48 according to the BILAG-based Combined Lupus Assessment (BICLA) definition, requiring improvement in the BILAG-2004 score, no worsening in the BILAG-2004 score, SLEDAI-2K score, or physician's global assessment of disease activity, and no disallowed changes in concomitant medications. Patients who discontinued the study medication were classified as nonresponders.ResultsIn the EMBODY 1 and EMBODY 2 trials of epratuzumab, 793 patients and 791 patients, respectively, were randomized, 786 (99.1%) and 788 (99.6%), respectively, received study medication, and 528 (66.6%) and 533 (67.4%), respectively, completed the study. There was no statistically significant difference in the primary end point between the groups, with the week 48 BICLA response rates being similar between the epratuzumab groups and the placebo group (response rates ranging from 33.5% to 39.8%). No new safety signals were identified.ConclusionIn patients with moderate or severely active SLE, treatment with epratuzumab + standard therapy did not result in improvements in response rates over that observed in the placebo + standard therapy group.

Pregnancy problems are common in patients with rheumatic disease; indeed, autoimmune disorders and autoantibodies can affect pregnancy progress and lead to maternal complications. Recent studies have highlighted a close association between HMGB1, chronic inflammation, and autoimmune diseases. Thus, in this investigation, we analyzed serum levels of HMGB1, an alarmin which plays a pivotal role in inducing and enhancing immune cell function. Sera from 30 patients with antiphospholipid syndrome (11 primary and 19 secondary APS), 35 subjects with pregnancy morbidity, and 30 healthy women were analysed for HMGB1 and its putative receptor RAGE (sRAGE) by Western blot and for TNF-α by ELISA. Results revealed that APS patients showed significantly increased serum levels of HMGB1, sRAGE, and the proinflammatory cytokine TNF-α, as compared to healthy women. However, also, the pregnancy morbidity subjects showed significantly increased levels of HMGB1 and sRAGE as well as TNF-α compared to healthy women. Our findings suggest that in subjects with pregnancy morbidity, including obstetric APS, elevated levels of HMGB1/sRAGE may represent an alarm signal, indicating an increase of proinflammatory triggers. Further studies are needed to evaluate the role of HMGB1/sRAGE as a possible tool to evaluate the risk stratification of adverse pregnancy outcomes.

Background:Few studies have examined the correlation between clinical demographic and laboratory parameters with peripherical radiological erosive disease in PsA pts.Objectives:To examine the association between clinical, demographical and laboratory data and the presence of radiographic erosions (RE) in the peripheral joints of psoriatic arthritis (PsA) pts.Methods:A cross-sectional study was conducted in consecutive patients with PsA afferring 7 rheumatological italian tertiary care centers. Demographical, clinical, laboratory and imaging data were collected according to a standardized protocol. A patient was considered as affected by erosive disease (ED) if at least one joint presented radiographic erosions at hand and/or feet rx examination. Patients with ED at early rx examination (before 5 y from disease diagnosis) were considered as early ED (EED) pts and pts without ED at 6 y or more rx examination from disease diagnosis were considered as not EED (NEED).The association between the presence of joint erosions and demographical, clinical and laboratory data was assessed using logistic regression analysis. The results were expressed in terms odds ratios (OR), and 95% confidence intervals (CI).Results:Rx hand and feet examination were available for analysis in 492/794 (39.9 % females, mean age 53.3 ± 13.2 y, mean PsA duration 16.9 ± 16.8 y, ED 171 pts). 48 pts had EED and 133 pts had NEED. At univariate analyses factors significantly associated with EED (p < 0.20) were PsA duration (OR=0.979,95%CI 0.953-1.006, p = 0.119), diagnostic delay (OR=1.077, 95%CI 1.018-1.138, p = 0.009), history of peripheral enthesitis (OR=2.308,95%CI 0.904-5.888, p= 0.080), hypertrigliceridemia (OR=2.756,95%CI 0.997-7.618, p = 0.0.051), hypercholesterolemia (OR=1.687, 95%CI 0.777-3.661, p = 0.186), hyperuricemia (OR=0.450, 95%CI 0.174-1.166, p = 0.10), use of biological agents (OR=1.712, 95%CI 0.873-3.355, p=0.118). Factors significantly associated with EED at multivariate regression analyses were diagnostic delay (OR = 1.11, 95% CI: 1.01, 1.22), history of enthesitis (OR = 3.15, 95% CI: 1.23, 8.22), use of therapy with biological agents (OR = 3.60, 95% CI: 1.31, 9.85) with protective effect of hyperuricemia (OR = 0.25, 95% CI: 0.07, 0.90).Conclusion:The presence of EED in a group of consecutive PsA patients is correlated to diagnostic delay and history of enthesitis. Longitudinal study may confirm these associations.Disclosure of Interests:Maria Grazia Catanoso: None declared, Pierluigi Macchioni: None declared, Antonio Marchesoni Speakers bureau: Abbvie, Pfizer, UCB, Novartis, Celgene, Eli Lilly, Salvatore D’Angelo Speakers bureau: AbbVie, Biogen, BMS, Celgene, Janssen, Lilly, MSD, Novartis, Pfizer, Sanofi, and UCB, Roberta Ramonda Speakers bureau: Novartis, Celgene, Janssen, Pfizer, Abbvie, Lilly, Alberto Cauli: None declared, fabio perrotta: None declared, Roberto Bortolotti: None declared, mariana lofrano: None declared, laura rotunno: None declared, maria grazia lorenzin: None declared, Guido Valesini: None declared, giovanni mathieu: None declared, Giuseppe Paolazzi: None declared, Carlo Salvarani Grant/research support from: consulting and investigator fees from Abbvie, Pfizer, MSD, Roche, Celgene, Novartis, Consultant of: consulting and investigator fees from Abbvie, Pfizer, MSD, Roche, Celgene, Novartis

Background:Therapeutic approach of rheumatoid arthritis (RA) patients has been enriched by the introduction of small molecules. In particular Jak inhibitors (JAKi), baricitinib and tofacitinib, demonstrated their efficacy in patients naïve or resistant to biological treatments in randomized controlled trials. Moreover, these drugs seem to be able to prevent radiographic progression. To date few data are available from the real life context. Ultrasonographic (US) assessment has became a valid imaging tool in the management of RA patients in clinical practice, allowing the evaluation of joint inflammatory status. Together with clinimetric assessment, US could provide a comprehensive assessment of drug response.Objectives:In the present study we aimed at assessing the early response to JAKi treatment by using musculoskeletal US.Methods:In this prospective longitudinal study, we collected data about all consecutive active RA patients starting treatment with JAKi. RA was diagnosed according to the 2010 ACR/EULAR criteria. At each visit, clinical and laboratory data were collected in a standardized and computerized form, including demographics, past medical history, co-morbidities, previous and concomitant treatments. According with study protocol, all patients underwent clinical and US assessment at the following time-points: baseline (T0), 4 weeks (T1) and 12 weeks (T2). Clinical evaluation included tender and swollen joint counts (0-28), patients global health assessment. C-reactive protein (CRP) levels were registered and disease activity was calculated by disease activity score (DAS) in 28 joints by using CRP (DAS28-CRP). A systematic multiplanar grey-scale and power Doppler (pD) US examination was performed by using MyLab Eight Exp Machine (Esaote, Florence, Italy) at level of 22 joints (bilateral I-V metacarpophalangeal, I-V proximal interphalangeal, wrist). According with OMERACT definitions (1) we assessed the presence of synovial effusion, hypertrophy and pD, that were scored according to a semi-quantitative scale (0-3). A total US inflammatory score (0-198) was obtained by their sum.Results:We enrolled 91 patients [F/M 77/14; median age 60.0 years (IQR 15.5); median disease duration 144 months (IQR 126)]. Of these patients, 54 (59.3%) were treated by baricitinib and the remaining 37 by tofacitinib. At baseline we found a median US inflammatory score of 20 (IQR 18.7) and a median DAS28-CRP of 5.0 (IQR 1.56). US assessment demonstrated significant reduction in the median values of inflammatory score already at T1 [median 13 (IQR 14.7), pConclusion:In the present study, specifically designed to evaluate the US-detected efficacy of JAKi in RA patients, we demonstrated in a real life setting a significant, early and sustained improvement of inflammatory joint status.References:[1]Wakefield et al, J Rheumatol 2005Disclosure of Interests:enrica cipriano: None declared, Fulvia Ceccarelli: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Cristina Garufi: None declared, Ilaria Duca: None declared, Silvia Mancuso: None declared, cristiano alessandri Grant/research support from: Pfizer, Manuela Di Franco: None declared, Roberta Priori: None declared, Valeria Riccieri: None declared, Rossana Scrivo: None declared, Carlo Perricone: None declared, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Background:Joint involvement is one of the most common features observed in Systemic Lupus Erythematosus (SLE), potentially involving up to 90% of patients [1]. Several patients’ reported outcomes (PROs) have been employed to measure Quality of life (QoL) in SLE patients, but frequently not specifically developed for SLE patients. More recently, the LupusQoL has been validated, a disease specific questionnaire[2,3].Objectives:We focused at assessing the relationship between musculoskeletal manifestations and QoL in a large SLE cohort, by using the LupusQoL.Methods:SLE patients with a clinical history of joint involvement (arthralgia/arthritis – group A) were enrolled in the present study. SLE diagnosis was performed according to the revised 1997 ACR criteria. As a control group, we enrolled SLE patients without history of joint involvement (group B).Disease activity was assessed by the SLE Disease Activity Index-2000 (SLEDAI-2k). The activity of joint involvement was assessed by using the disease activity score on 28 joints (DAS28ESR). The LupusQoL was administered to the enrolled patients (Group A and Group B). It consists of 34 items referring to eight domains: physical health (PH), pain (P), planning (PL), intimate relationships (IR), burden to others (BO), emotional health (EH), body image (BI) and fatigue (F).Results:Group A included 110 patients [M/F 8/102; median age 49 years (IQR 13), median disease duration 156 months (IQR 216)], while group B included 58 patients [M/F 11/47; median age 40 years (IQR 15), median disease duration 84 months (IQR 108)]. Group A showed a significantly lower disease duration and mean age in comparison with group B (P< 0.001 for both comparisons). As represented in figure 1, group A showed significantly lower values in all LupusQoL domains except for “burden to others” domain. Moreover, we observed an inverse correlation between DAS28ESRand all the LupusQoL domains in group A patients [PH (r=-0.5, P>0.0001), P (r=-0.5, PFigure 1.Conclusion:In the present study, by using a disease specific PRO, we found a poorer QoL in SLE patients with joint involvement in comparison with those without this manifestation. Moreover,DAS28ESRsignificantly correlated with all LupusQol domains, differently from SLEDAI-2k, suggesting the need to evaluate joint involvement with a specific activity index.References:[1]Cervera R et al. Medicine 1993[2]McElhone K. et al. Arthritis Rheum 2007.[3]Conti F et al. Lupus 2014Group (A)Group (B)pPH80,38 ± 21,4362,88 ± 23.28< 0.0001P82,36 ± 25.0862,30± 26.02< 0.0001PL83,04 ± 27.8270,58± 29.450.001IR84,49± 25.9965,36± 36.330.0005BO69,58 ± 28.4663,45± 28.950.129EH71,98 ± 24.6964,69± 23.050.0169F73,69 ± 24.2959,78±26.060.0004B78,14 ± 24.6156,28±30.14Disclosure of Interests:Francesco Natalucci: None declared, Fulvia Ceccarelli: None declared, enrica cipriano: None declared, Giulio Olivieri: None declared, Carlo Perricone: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, Simona Truglia: None declared, Francesca Miranda: None declared, cristiano alessandri Grant/research support from: Pfizer, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi, Guido Valesini: None declared

Background:Rheumatoid arthritis (AR) is an autoimmune systemic inflammatory disease characterized by chronic synovial inflammation resulting in bone damage and erosions, with consequently functional disability. Currently, attempts for regenerative therapies for osteo-cartilage pathologies have proved unsuccessful. Recently, a “pool” of skeletal stem cells (hSSCs: human skeletal stem cells) able to generating bone cells, has been identified in human bone (1).Objectives:In light of these observations, we aim at characterizing skeletal stem cells in peripheral blood from RA patients candidate to Tofacitinib treatment.Methods:In this pilot study 4 RA patients [4F; mean age 65 years; mean disease duration 19 years] candidate to Tofacitinib treatment and 4 healthy donors (HD), matched by gender and age, were enrolled. Blood samples were collected from each subject of the study, at baseline (T0) and for RA patients, after 1 month of Tofacitinib (T1), to evaluatinghSSC(CD45-, CD146-, CD73+, PDPN+, CD164+) by flow cytometry. For this purpose, we performed on whole blood a negative magnetic selection for CD45 cells. Then, the eluate was labeled with antibodies anti CD146-PE, anti CD73-APC, anti CD164 - FITC and anti-Podoplanin (PDPN) PerCP/Cyanine5.5. The acquisition was performed using a FACS Calibur, which included 100,000 events per sample (Figure 1).Results:ThehSSCspercentage was significantly lower in RA patients than in HD (p = 0.0286). At T1, after treatment with Tofacitinib, meanhSSCspercentage significantly increased from 1.8% to 4.2 % (p = 0.016 vs RA T0) (Figure 2A). Correlation analysis showed a significant indirect relation between the percentage ofhSSCand disease activity measured by DAS28ESR, SDAI and CDAI (Figure 2B).Conclusion:The results of this study demonstrate, for the first time, circulating skeletal stem cells and their reduced expression in active RA patients. Tofacitinib treatment leads to a significant increase inhSSCspercentage. This evidence opens up new perspectives on bone repair mechanisms and on deepening of current therapeutic strategies.References:[1]Chan CKF, Gulati GS, Sinha R, Tompkins JV, Lopez M, Carter AC, Ransom RC, Reinisch A, Wearda T, Murphy M, Brewer RE, Koepke LS, Marecic O, Manjunath A, Seo EY, Leavitt T, Lu WJ, Nguyen A, Conley SD, Salhotra A, Ambrosi TH, Borrelli MR, Siebel T, Chan K, Schallmoser K, Seita J, Sahoo D, Goodnough H, Bishop J, Gardner M, Majeti R, Wan DC, Goodman S, Weissman IL, Chang HY, Longaker MT.Identification of the Human Skeletal Stem Cell.Cell. 2018 Sep 20;175(1):43-56.e21. doi: 10.1016/j.cell.2018.07.029.Acknowledgments:noneDisclosure of Interests:cristiana barbati: None declared, Francesca Romana Spinelli Grant/research support from: Pfizer, Consultant of: Novartis, Gilead, Lilly, Sanofi, Celgene, Speakers bureau: Lilly, cristina garufi: None declared, Ilaria Duca: None declared, fulvia ceccarelli: None declared, Tania Colasanti: None declared, Marta Vomero: None declared, cristiano alessandri Grant/research support from: Pfizer, Guido Valesini: None declared, fabrizio conti Speakers bureau: BMS, Lilly, Abbvie, Pfizer, Sanofi

Background Circulating endothelial progenitor cells (EPCs) are biologic markers of endothelial function. In patients with systemic lupus erythematosus (SLE), the numerical reduction and functional impairment of EPCs contribute to the endothelial dysfunction. Through ex vivo and in vitro studies, we aimed at evaluating the effects of B lymphocyte stimulator (BLyS) on EPC colonies and endothelial cells and also investigating BLyS receptor expression on these cells. Methods EPCs were isolated from peripheral blood mononuclear cells (PBMC). In order to evaluate their ability to form colonies, EPCs were cultured on fibronectin-coated dishes and incubated with BlyS alone or BlyS and belimumab. Apoptosis of EPCs and endothelial cell line EA.hy926 was evaluated after 6, 12, and 24 h of incubation with BLyS and after 6 h with BLyS and belimumab. The expression of B cell activating factor-receptor (BAFF-R), B cell maturation antigen (BCMA), and transmembrane activator and calcium modulator and cyclophilin ligand (CAML) interactor (TACI) on EPCs and EA.hy926 was analyzed by cytofluorimetry. Results The number of EPC colonies was lower in patients than in controls. Moreover, the colonies from SLE patients were poorly organized compared to controls; the addition of belimumab restored the colony structure. Incubation with BLyS induced apoptosis of EPCs and EA.hy926 that was inhibited by the co-incubation with belimumab. BAFF-R and BCMA were expressed on both EPCs and EA.hy926, while TACI was expressed only on EPCs. Conclusions EPCs and endothelial cells preferentially express BAFF-R which could be involved in the pro-apoptotic effect of BlyS. Belimumab administration seems to restore the quantitative and qualitative changes of EPC colonies both ex vivo and in vitro.

Background Endothelial-to-mesenchymal transition (EndoMT), a newly recognized type of cellular transdifferentiation, seems to be involved in Systemic Sclerosis (SSc) pathogenesis. In this process endothelial cells lose their specific markers, and acquire a mesenchymal phenotype, thus expressing cell products such as alpha smooth muscle actin (α-SMA) (1,2). Circulating endothelial progenitors cells (EPCs) derive from bone marrow stem cells and contribute to de novo vessels formation. Several studies, although with conflicting results, have shown that EPCs in the peripheral blood of patients with SSc are impaired in their number and function (3). Objectives to assess the expression of α-SMA, possibly associated with a pro-mesenchymal switch (EndoMT) of the circulating Early (CD34+KDR+CD 133+) and Late (CD34+KDR+) EPCs in the peripheral blood of SSc patients and of patients with Very Early Diagnosis of SSc (VEDOSS) compared with healthy controls (HC) using flow cytometry. Methods we enrolled 11 patients (7 SSc and 4 VEDOSS), classified according to the classification criteria for SSc (4) and for VEDOSS not fulfilling SSc criteria (5), and 10 HC. Phenotypic characterization was performed as previously described by Vasa et al. using a FACS Calibur (BD Immunocytometry Systems). EPCs number was expressed as a percentage of cells within the lymphocyte gate. Results we found a significantly higher percentage of α-SMA positive Early EPCs (CD34+KDR+CD 133+αSMA+) in all patients respect to HC (0,06% ±0,03 vs 0,03% ± 0,01; p=0,0149) particularly in VEDOSS patients (0,07%±0,01 vs 0,03±0,01 p=0,008). Moreover, in VEDOSS patients, also the percentage of Early EPCs (CD34+KDR+CD 133+), Late EPCs (CD34+KDR+)and α-SMA positive Late EPCs (CD34+KDR+αSMA+) were significantly higher than in HC (0,05%±0,01 vs 0,03%±0,01 p=0,05; 0,07%±0,01 vs 0,04%±002 p=0,04; 0,06%±0,01 vs 0,04%±0,02 p=0,05). Besides Early EPCs and α-SMA positive Early EPCs percentages seem to be significantly reduced in patients taking iloprost (p=0,05 and p=0,01 respectively), calcium channel blockers (CCB) (p=0,05 and p=0,03) and DMARDs (p=0,017 and p=0,013). Conclusion EndoMT seems to be involved in the pathogenesis of SSc and circulating EPCs seem to be impaired in number and function in SSc patients. In our study we found higher levels of EPCs, in particular α-SMA positive Early EPCs in both groups of patients (SSc and VEDOSS) respect to HC. Thus we can hypothesize a predominant pro-mesenchymal phenotype of this kind of EPCs. This could be considered the expression of the involvement of EPCs in EndoMT process and could better explain the controversial role of EPCs in SSc pathogenesis. Very interesting is the finding of a lower percentage of Early EPCs, and in particular of α-SMA positive Early EPCs, in those patients taking iloprost, CCB and DMARDs, suggesting a potential effect of these drugs on this subgroup of EPCs. References [1] Corallo C, et al. Arthritis Res Ther2016; [2] Manetti M, et al. Ann Rheum Dis2017; [3] Del Papa N, et al. Front. Immunol2018; [4] Van den Hoogen F, et al. Ann Rheum Dis2013; [5] Avouac J, et al. Ann Rheum Dis2011. Disclosure of Interests Katia Stefanantoni Consultant for: Only 1 scientific advice for Italfarmaco in 2016, cristiana barbati: None declared, Carlotta Angelelli: None declared, Greta Pellegrino: None declared, cristiano alessandri: None declared, Guido Valesini: None declared, Valeria Riccieri: None declared

Background: Thrombocytopenia is a manifestation associated with Primary Antiphospholipid Syndrome (PAPS) and many studies have stressed the leading role played by platelets in the pathogenesis of Antiphospholipid Syndrome (APS) (1). Platelets are highly specialized cells and their activation involves a series of rapid rearrangements of the actin cytoskeleton (2). Recently, we described the presence of autoantibodies against D4GDI (Rho GDP Dissociation Inhibitor Beta, ARHGDIB) in the serum of a large subset of SLE patients and we observed that anti-D4GDI antibodies activated the cytoskeleton remodeling of lymphocytes by inhibiting D4GDI and allowing the upregulation of Rho GTPases, such as Rac1(3). Proteomic and transcriptomic studies indicate that D4GDI is very abundant in platelets and small GTPases of the RHO family are critical regulators of actin dynamics in platelets (4). Objectives: The aim of the present study was to evaluate the presence of anti-D4GDI antibodies in PAPS sera and whether they can affect platelet activation, contributing to the thrombotic events and the thrombocytopenia of PAPS patients. Methods: 38 PAPS patients diagnosed according to the 2006 Sydney classification criteria were enrolled from the Lupus Clinic of the Sapienza University of Rome. 20 normal healthy subjects (NHS) served as controls. Sera were stored at −20 °C to performed an ELISA test using commercial D4GDI protein. Anti-D4GDI antibodies were purified from PAPS sera and used for in vitro treatment of platelets purified from NHS. Flow cytometry analysis was performed to determination of integrin αIIbβ3 activation, a well-established marker of platelet activation and adhesion. Results: We identified anti-D4GDI antibodies in sera from 18/38 (47%) patients with PAPS, but in no sera from NHS. Dividing the patients with PAPS according to the presence or absence of thrombocytopenia, we found a significant association between this hematologic manifestation and a higher titer of anti-D4GDI antibodies. Our in vitro results show a significant 30% increase in the activation of integrin αIIbβ3 upon stimulation of platelets from healthy donors preincubated with the antibody anti-D4GDI purified from the serum of APS patients. Interestingly the antibody does not only increase the overall integrin activation but also the rate/speed of integrin activation. Conclusion: We demonstrated that antibodies anti-D4GDI are present in the sera of PAPS patients and can prime platelet activation. Thus, explaining, at least in part, the pro-thrombotic state and the thrombocytopenia of PAPS patients. These findings may lead to improved diagnosis and treatment of APS. References: [1] Shechter Y, Tal Y, Greenberg A, Brenner B. Platelet activation in patients with antiphospholipid syndrome. Blood Coagul Fibrinolysis. 1998 Oct;9(7):653-7. [2] Seong-Hoon Yun, Eun-Hye Sim, Ri-Young Goh, Joo-In Park, and Jin-Yeong Han. Platelet Activation: The Mechanisms and Potential Biomarkers. BioMed Research International,Volume 2016, Article ID 9060143. Review [3] Barbati C, Alessandri C, Vomero M, Vona R, Colasanti T, Vacirca D, Camerini S, Crescenzi M, Pendolino M, Truglia S, Conti F, Garofalo T, Sorice M, Pierdominici M, Valesini G, Malorni W, Ortona E.Autoantibodies specific to D4GDI modulate Rho GTPase mediated cytoskeleton remodeling and induce autophagy in T lymphocytes. J Autoimmun. 2015 Apr;58:78-89. [4] Rowley JW, et al. Genome-wide RNA-seq analysis of human and mouse platelet transcriptomes. Blood. 2011;118(14). Disclosure of Interests: None declared

Background: Lupus nephritis (LN) occurs up to 50% of patients affected by Systemic Lupus Erythematosus (SLE) representing one of the major causes of morbidity and mortality in lupus population (1). Kidney biopsy is a fundamental tool for the diagnosis and management of lupus nephritis. The presence of pathological changes such as inflammatory infiltrate in glomeruli and/or in tubulo-interstitium are relevant in terms of prognosis and response to therapy (2). Objectives: The aim of the study was to correlate the clinical and laboratory findings and the response to therapy with presence of glomerular and/or interstitial infiltrate in kidney section of patients with a biopsy-proven LN. Methods: Kidney sections of patients with SLE undergoing a renal biopsy for diagnostically purpose were studied; samples were classified according to the 2004 International Society of Nephrology/Renal Pathology Society classification criteria (3). Clinical, laboratory and histological data were collected in a standardized, computerized and electronically filled form, including demographics, past medical history, autoantibody profile, previous and concomitant treatments. We assessed the disease activity by using SLEDAI-2K and remission in response to therapy was defined as the absence of renal impairment and as a score 0 of renal SLEDAI (proteinuria Results: We evaluated 53 kidney samples from patients with LN (F:M = 51:2, mean age at biopsy 35±7.7 years; mean disease duration at date of biopsy 8±8.3 years). Class IV (46%) was the most common class followed by class III (29%), class II (13%), class V (11.5%) and class VI (0,5%). Tubulo-interstitial infiltrate was found in 33 kidney specimens, with germinal centres (GC)-like features in 13 renal samples (Figure 1). During the follow up (6±3.8 years) the tubulo-insterstitial infiltrate, either diffuse or with GC-like feature, was negatively correlated with renal remission (P=0.03). Conclusion: Assessment and management of patients with LN are greatly facilitated by information obtained by renal biopsy. In the present study we demonstrate that the presence of tubulo-interstital infiltrate is associated with a worse outcome in response to therapy. Our data highlight the importance of tubulo-interstitium damage, scarcely considered in the current classification criteria, since it represents a key point to predict long-term prognosis. References: [1] Schwartz N, et al. Curr Opin Rheumatol. (2014) [2] Giannakakis K, et al. Clinic Rev Allerg Immunol (2011) [3] Weening JJ, et al. J Am Soc Nephrol (2004) [4] Gladman DD, et al. J Rheumatol (2002) [5] Houssiau FA, et al. Arthritis Rheum (2002) [6] Hahn BH, et al. Arthritis Care & Research (2012) Disclosure of Interests: None declared

Background Data on T regulatory (T reg) cells number and functions in patients with Systemic Lupus Erythematosus (SLE) are conflicting (1). Type I interferon (IFN) decreases Treg proliferation and induces Treg apoptosis (2). IFN stimulated gene 15 (ISG15) is an IFN-induced protein with a negative effect on IFN pathway. Objectives Aim of the study was to evaluate the effect of IFN alpha and ISG15 on Treg number and on STAT1 phosphorilation in patients with SLE. Methods We recruited patients with SLE classified according to 1997 ACR criteria. We collected demographic and clinical data including disease duration, disease activity scored according to Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) 2K. Peripheral blood mononuclear cells (PBMC) were isolated from whole blood samples. Intracellular phosphorilated STAT1 (pSTAT) levels were evaluated in Treg (CD4+FOXP3+CD127 low cells) and conventional T cell (Tconv, CD4+FOXP3- cells) by multiparametric flow cytometry, ex vivo or after stimulation with recombinant IFN alpha. PBMC were cultured for 48 hours with anti-CD3 or anti-CD3 and IFN alpha; the frequency of Treg was analysed by multiparametric flow cytometry. ISG15 mRNA expression was evaluated by RT-PCR on PBMC from SLE patients. Data were expressed as mean ± standard deviation or median (interquartile range(according) to the distribution; Mann-Whitney and Spearman tests were applied. P value Results We enrolled 21 SLE patients [F:M 20:1; mean age 45.2 ± 12.9 years; mean disease duration 157.5± 103 months; median SLEDAI 2(4)] Overall, median baseline ISG15 mRNA expression was 0.06 (IQR 0.16); patients were divided into ISG15-high (n=9) and ISG15-low (n=12), according to the mean mRNA expression. Ex vivo, after short-term treatment with IFN alpha (15 and 25 minutes), we observed a significant increase in STAT1 phosphorilation compared to baseline both in Treg and Tconv (p 4 vs SLEDAI Conclusion ISG15 protects T conventional cells from STAT1 phosphorilation and induces resistance to T regulatory cells depletion. The results of the study suggest that ISG15, a protein induced by IFN in the acute phase of the disease, exerts a negative feedback, allowing the recovery of T reg. References [1] Zhang SX, et al. J Immunol res. 2018 [2] Piconese S, et al. Cytokine Growth Factor rev. 2014 Disclosure of Interests None declared

Background: Cognitive impairment (CI) in Systemic Lupus Erythematosus (SLE) is a frequent neuropsychiatric manifestation affecting several domains, even in apparently asymptomatic patients. Current research revealed that the typical CI pattern affects frontal-subcortical circuit and thus executive functions. The impairment of non-literal language or Pragmatic Language (PL), including metaphors, idioms, inferences or irony has been well described in several conditions such as autism disorders, Parkinson’s disease, brain injury and even in earlier phases of neurodegenerative processes. Even if PL neuro-anatomy remains controversial, correlation between executive dysfunctions and non-literal language involvement has been reported both in traumatic injury and mild cognitive impairment patients. Nonetheless, no specific study has been performed to evaluate PL impairment in SLE patients so far. Objectives: We aimed at assessing the PL domain in a monocentric SLE cohort in comparison to healthy controls, matched to age and education, through a specific battery, BLED [1]. Secondly, we focused attention on possible correlations between CI and clinical and laboratory SLE-related features. Methods: Forty adult patients affected by SLE, according to the ACR criteria, and thirty healthy subjects were enrolled consecutively in this cross-sectional study. The protocol included complete physical examination, extensive clinical and laboratory data collection (comprehensive of demographics, past medical history, co-morbidities, disease activity, chronic damage evaluation, previous and concomitant treatments) and cognitive assessment for five different domains: memory, attention, pragmatic language, executive and visuospatial functions. Self-reported scale for anxiety and depression were performed to exclude the influence of mood disorders on cognitive dysfunction. Results: We enrolled forty Caucasian SLE patients (M/F 3/37; mean±SD age 45.9±10.1 years, mean±SD disease duration 120.8±81.2 months) and thirty healthy subjects (M/F 9/21; mean±SD age 41.3±13 years). According to the low level of disease activity and damage (mean±SD SLEDAI-2K of 1.3±2.3, mean±SD SDI of 0.2±0.5), only 30% of patients was on glucocorticoid treatment at the study entry. PL was the most compromised domain in terms of Mean Domain Z scores (Fig. 1). As regards the Domain Cognitive Dysfunction score, a deficit of PL was observed in 45% of patients and resulted significantly more prevalent than memory, executive and visuospatial functions impairment (P=0.0002, P=0.0002 and P Conclusion: We evaluated for the first time PL in a single center SLE cohort finding a dysfunction in almost half of patients enrolled, significantly more frequent than the other assessed domains. Reference: [1] Rinaldi C, Marangolo P, Lauriola M. “BLED Santa Lucia: Batteria sul Linguaggio dell’Emisfero Destro Santa Lucia” Giunti O.S., 2006. Disclosure of Interests: Carmelo Pirone: None declared, Fulvia Ceccarelli: None declared, Concetta Mina: None declared, Alfredo Mascolo: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Barbara Mazzotta: None declared, Laura Massaro: None declared, francesca spinelli: None declared, cristiano alessandri: None declared, Guido Valesini: None declared, fabrizio conti: None declared

Background: Baricitinib, a newly approved drug for the treatment of patients with moderate to severe rheumatoid arthritis (RA), is a selective inhibitor of Janus kinase 1 and 2. In a patient-centered care, patient-reported outcomes (PROs) are really helpful to better evaluate the disease activity and the response to therapy. Between them, Patient Acceptable Symptom State (PASS) is defined as the highest level of symptoms beyond which patients consider themselves well [1], and consists of a single question with dichotomized answer (yes or no): “Considering all the different ways your disease is affecting you, if you would stay in this state for the next months, do you consider that your current state is satisfactory?”. In randomized controlled trials baricitinib showed significant improvement of pain, fatigue, tiredness and assessment of disease [2]. Objectives: The aim of the present study was to investigate the effect of baricitinib on PASS one month from the beginning of therapy. Further aim was to quantify the time patients needed to reach an acceptable state of health and determine the clinical variables associated with PASS. Methods: Patients affected by RA according to 2010 ACR criteria, starting treatment with baricitinib as clinically indicated, were consecutively enrolled; PASS was determined after 1 month of treatment (T1); days to achieve PASS were estimated at T1; activity indices were calculated after 1 month of therapy and correlated with PASS. Results: Thirty-four RA patients were enrolled (age median-IQR 58-16 years; disease duration median-IQR 144-138 months; DAS-28 median-IQR 5.09-1.92). After 1 month of therapy, 30 of 34 patients achieved PASS, of which 73% in the first 2 weeks of treatment (days to achieve PASS median-IQR 12-22) (figure). At T1, patients achieving PASS, compared to those who did not, reported less pain (median VAS 30/100 vs 72/100, p= 0.025), a better global assessment of disease (median 40/100 vs 72/100, p=0.023), lower CDAI (median 12 vs 31, p= 0.048), SDAI (median 12.8 vs 33.95, p=0.011) and DAS-28 (median 3.67 vs 5.54, p= 0.082). 10 out of 30 PASS positive patients (33%) achieved a DAS-28 low-disease activity or remission at T1 vs 0% of the PASS negative cohort (p= 0.169). Age, disease duration and number of previous bDMARDs did not significantly differ between the two subgroups. Conclusion: Baricitinib was able to induce an acceptable state of health in about 90% of patients after the first month of therapy. The prompt effect of baricitinib on pain and fatigue could partially explain the rapid achievement of PASS, as shown by the decrease of VAS and improvement of the global assessment of disease. References [1] Maksymowych WP, et al. Evaluation and validation of the patient acceptable symptom state (PASS) in patients with ankylosing spondylitis. Arthritis Rheum 2007 [2] Schiff, et al. Patient-reported outcomes of baricitinib in patients with rheumatoid arthritis and no or limited prior disease-modifying antirheumatic drug treatment. Arthritis Res Ther. 2017 Disclosure of Interests: None declared

Background The PDE4-inhibitor apremilast has been recently introduced in the treatment of Psoriatic Arthritis (PsA). It acts by down-regulating intracellular inflammatory mediators synthesis by elevating cAMP levels. Tregs, a subset of FOXP3+ CD4 T cells, play a key role in preventing immune responses and could exert their suppressive function via cAMP (1). Reduced frequencies of circulating Tregs have been observed in inflammatory disorders, nonetheless very few data are available on PsA patients. Objectives We evaluated peripheral Tregs in a cohort of PsA patients treated by apremilast. Methods Seventeen PsA patients (M/F 3/14; median age 56.0 years, IQR 20.0; median disease duration 15.0 years, IQR 11.0) with polyarticular subset treated by apremilast, were evaluated at baseline (T0) and after 6 (T1) and 12 weeks (T1). Clinimetric evaluation included DAS28, DAPSA, CDAI, and SDAI. Moreover, US assessment was performed at wrists, metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints: synovial effusion/hypertrophy and power Doppler were scored by a semi-quantitative scale (0-3), obtaining a total score (0-198). Treg frequency was assessed in peripheral blood mononuclear cells by flow cytometry, as the percentage of CD127low FOXP3+ in live CD4+ T cells (%Treg). Results At baseline we identified a median%Tregs of 4.6 (IQR 1.1), inversely correlating with DAS28 (r=-0.5, p=0.02), DAPSA (r=-0.7, p=0.003), CDAI (r=-0.6, p=0.01), SDAI (r=-0.6, p=0.003 and US inflammatory score (r=-0.6, p=0.01) (Figure 1). Treatment with apremilast was able to induce a significant improvement in all activity indices at T1 (DAS28, P=0.009; DAPSA, P=0.01; CDAI, P=0.005; SDAI, P=0.006; US score, P Conclusion The results of our study demonstrate that%Treg is a marker of disease activity in PsA patients. Moreover, the baseline value of Tregs could predict the response to apremilast after 12 weeks of treatment. Reference: [1] Chavele KMet al, FEBS Lett2011. Disclosure of Interests Fulvia Ceccarelli: None declared, Ilenia Pacella: None declared, Ramona Lucchetti: None declared, Arianna Forniti: None declared, francesca spinelli: None declared, enrica cipriano: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Simona Truglia: None declared, Francesca Miranda: None declared, Rossana Scrivo: None declared, cristiano alessandri: None declared, Vincenzo Barnaba: None declared, Guido Valesini: None declared, Silvia Piconese: None declared, fabrizio conti: None declared

Background The introduction of TNF inhibitors have revolutionized the outcome of patients affected by Rheumatoid Arthritis (RA). In the last years, pharmaco-economic implications determined the introduction of biosimilar as alternative to originator biological drugs. Phase I and head-to-head phase III clinical studies demonstrated pharmacokinetic equivalence and comparability in terms of efficacy, safety, immunogenicity and tolerability. However, biosimilar drugs demonstrated some differences related to charge and glycosylation, not influencing the function and the ability to bind the soluble TNF. To date, very few data are available concerning the use of biosimilar drugs in a real-life setting. Results from DANBIO registry suggested a lower retention rate in RA patients switchers from Etanercept originator (ETA) to biosimilar (SB4) versus the historic ETA cohort and higher in comparison with historic SB4 patients (1). Objectives To compare the efficacy of ETA versus SB4 in a cohort of RA patients in a real life setting. Methods In this monocentric case-control prospective study, we consecutively enrolled RA patients starting ETA or SB4 treatment from 2015. RA diagnosis was made according with ACR/EULAR 2010 criteria (2). Data were collected and entered into a standardized, computerized, electronically filled-in form. We included patient demographics, date of diagnosis, comorbidities and previous and concomitant medications. The clinical evaluation included the count of swollen and tender joints and the patient‘s and physician’s global disease assessment based on a visual analogue scale (VAS; range, 0 to 100 mm). Disease activity was measured according to the disease activity score in 28 joints (DAS28ESR) (3). The patients were asked to fill in the Health Assessment Questionnaire (HAQ). All the patients were evaluated at the beginning of treatment (T0) and after 4 (T1) and 12 months (T2). Clinical response to treatment was evaluated by using EULAR criteria (4). Results We evaluated 35 RA patients treated with SB4 (M/F 2/33; median age 63 years, IQR 21; median disease duration 108 months, IQR 138) and 40 with ETA (M/F 5/35; median age 60.5 years, IQR 20; median disease duration 102 months, IQR 141). Biologic drug was prescribed as first-line biological treatment in 71.4% of SB4 cohort and in 80.0% of ETA. At T0 no significant differences were observed among the two groups in terms of DAS28ESR [SB4 median 4.6 (IQR 1.8), ETA 4.3 (IQR 1.9), p=ns] and HAQ [SB4: median 1 (IQR 1.05), ETA median 1 (IQR 0.85), p=ns]. In both groups we observed a significant reduction of DAS28 values at T1 (BS4 p=0.01; ETA p Conclusion The results of our study confirmed in a real-life setting the efficacy of SB4 in RA patients, as demonstrated by the significant reduction of DAS28ESR values after 4 and 12 months of treatment, similarly to ETA. Nonetheless, ETA seems to be able to induce a remission status earlier than SB4. References [1] Glintborg B, et al. Ann Rheum Dis. 2018 [2] Aletaha D, et al. Arthritis Rheum. 2010 [3] Anderson JK, et al. Arthritis Care Res. 2011 [4] van Gestel AM, et al. Arthritis Rheum. 1996 Disclosure of Interests Ramona Lucchetti: None declared, Fulvia Ceccarelli: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Simona Truglia: None declared, Francesca Miranda: None declared, Manuela Di Franco: None declared, Valeria Riccieri: None declared, Rossana Scrivo: None declared, Antonio Sili Scavalli: None declared, francesca spinelli: None declared, cristiano alessandri: None declared, Guido Valesini: None declared, Roberta Priori: None declared, fabrizio conti: None declared

Background: The pathway of Janus tyrosine kinases (JAKs) has a central role in the pathogenesis of rheumatoid arthritis (RA) by regulating multiple immune functions and cytokine production. The orally available JAK inhibitor CP-690,550, named tofacitinib, is able to inhibit Jak1, Jak2 and Jak3 and it showed a great clinical efficacy in RA patients not responding to methotrexate or TNF-inhibitors (1). Autophagy, a highly conserved mechanism involved in the degradation of intracellular components, was found to be dysregulated in several autoimmune diseases including RA (2). In fact, fibroblasts like synoviocytes (FLS) from RA patients showed a resistance to apoptosis associated with the induction of autophagy (3). Maeshima and colleagues recently demonstrated that tofacitinib suppressed proliferation, but not apoptosis, of CD4+ T cells derived from the synovium (4), but to date there are no data on the effect of inhibition of JAK pathway on autophagy. Objectives: Since hyperactive autophagy has been associated with impaired apoptosis of RA FLS, the aim of the study was to investigate the role of tofacitinib in modulating autophagy and apoptosis in FLS from RA patients. Methods: Primary RA FLS isolated from RA biopsies (Figure 1A) were cultured in presence of autophagy inducer rapamycin (as control condition) and tofacitinib (1μM). After 24h of culture, autophagy was evaluated both by flow cytometry and western blot analysis. Apoptosis was analyzing by annexin V (AV) and propidium iodide (PI) apoptosis detection kit by flow cytometry. Results: As expected tofacitinib inhibited the expression of the phosphorylated form of STAT3 (p Conclusion: The results of this study elucidated a new mechanism of action of tofacitinib related to autophagy modulation and led to a better understanding of the role of autophagy in RA. This study was supported by an unconditioned Research grant from Pfizer Inc. References [1] Burmester GR, Blanco R, Charles-Schoeman C, et al. Tofacitinib (CP-690,550) in combination with methotrexate in patients with active rheumatoid arthritis with an inadequate response to tumour necrosis factor inhibitors: a randomised phase 3 trial. Lancet2013; 381: 451-60. [2] Vomero M, Barbati C, Colasanti T, et al. Autophagy and Rheumatoid Arthritis: Current Knowledges and Future Perspectives. Front Immunol. 2018;9:1577. [3] Shin YJ, Han SH, Kim DS, et al. Autophagy induction and CHOP under-expression promotes survival of fibroblasts from rheumatoid arthritis patients under endoplasmic reticulum stress. Arthritis Res Ther. 2010; 12:R19. [4] Maeshima K, Yamaoka K, Kubo S, et al. The JAK inhibitor tofacitinib regulates synovitis through inhibition of interferon-γ and interleukin-17 production by human CD4+ T cells. Arthritis Rheum. 2012;64:1790-8. Disclosure of Interests: Marta Vomero: None declared, Mattia Caliste : None declared, cristiana barbati: None declared, Tania Colasanti: None declared, francesca spinelli: None declared, Fulvia Ceccarelli: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Annacarla Finucci: None declared, Mariangela Speziali: None declared, Alessandra Ida Celia: None declared, Michele Bombardieri Grant/research support from: Celgene, Consultant for: Medimmune, fabrizio conti: None declared, Guido Valesini: None declared, cristiano alessandri: None declared

Background: Autophagy is a lysosome mediated catabolic process that promotes cell survival during stress conditions. Aberrant regulation of autophagy is involved in the pathogenesis of a widening spectrum of autoimmune disorders: in particular, activation of autophagy pathway is implicated in aberrant survival of activated T cells. We recently demonstrated that autophagy is up-regulated in CD4+ T lymphocytes from patients with Sjogren’s Syndrome (SS) both in peripheral blood and tissue. Moreover, aberrant autophagy correlates with systemic disease activity. Little is known on the role of autophagy in B cells homeostasis in SS. Objectives: To investigate the activation of the autophagy pathway in lymphocytes infiltrating salivary gland in SS and peripheral blood from patients with SS. Methods: Frozen SS minor salivary glands (MSG) from 20 patients were sectioned and evaluated with immunohistochemistry (IHC) by staining for CD3+, CD20+, and CD21+. MSG sections, sequential to IHC, were stained by Cresyl Violet and microdissected (Laser Capture Microdissection) in order to isolate and collect small infiltrates, large CD21- infiltrates, and large CD21+ infiltrates (GC-like structures). Microdissected GC from frozen human tonsils were used as control. The expression of autophagy genes Atg5 and MAP1LC3II (expressed as 2^deltaCT normalized to GADPH) was determined by qPCR on microdissected tissue. For studies on peripheral blood, 19 SS patients and 11 healthy controls were enrolled, and autophagy, expressed as the ratio between Mean Fluorescence Intensity and the isotopic control (rMFI), was evaluated by Cyto-ID® Autophagy detection kit in T lymphocytes (CD4+ and CD8+) and B lymphocytes (CD19+) using a FACSCalibur cytometer. Results: Expression of the autophagy genes Atg5 and MAP1LC3 was significantly higher in the GCs from SS salivary glands compared to control tonsils (p Immunophenotyping studies revealed activation of the autophagy pathway in both circulating CD19+ and CD4+ lymphocytes from SS (p=0.04 and p=0.03 compared to HC); conversely, no pathway activation was detected in CD8+ cells. Of note, in patients with SS activation of autophagy was most marked in circulating CD19+ B cells compared the other subsets [(CD19+ vs CD4+ (p Conclusion: Our findings revealed that the autophagy pathway is aberrantly activated in lymphocytes infiltrating salivary glands of SS patients. Of note, progressively higher expression levels of autophagy genes mirrored the severity and extension of inflammatory infiltrates. Immunophenotyping studies revealed that activation of autophagy is preeminent in B cells. Thus, activation of autophagy emerges as a feature of both infiltrating and circulating SS lymphocytes, and as mechanism possibly implicated in the activation and survival o?f autoreactive cells. Disclosure of Interests: Serena Colafrancesco: None declared, Antonina Minniti: None declared, Roberta Priori: None declared, Marta Vomero: None declared, cristiana barbati: None declared, Francesca Arienzo: None declared, Valentina Iannizzotto: None declared, Elena Pipi: None declared, Joana Campos: None declared, Saba Nayar: None declared, Francesco Ciccia Grant/research support from: CELGENE, PFIZER, Consultant for: UCB, NOVARTIS, CELGENE, PFIZER, LILLY, Paid instructor for: UCB, NOVARTIS, CELGENE, PFIZER, LILLY, JANSSEN, Speakers bureau: UCB, NOVARTIS, CELGENE, PFIZER, LILLY, JANSSEN, MSD, ROCHE, AMGEN, Francesca Barone Grant/research support from: GlaxoSmithKline, Roche, UCB Pharma, Actelion, ONO Pharmaceutical, Consultant for: GlaxoSmithKline, Roche, Actelion, ONO Pharmaceutical, Guido Valesini: None declared, cristiano alessandri: None declared

Background: an increased risk of malignancies (1.5-5 times) was found in Systemic Sclerosis (SSc). Well recognized risk factors are the diffuse form, advanced age and (1), more recently, the positivity for anti-RNA Polimerase III antibodies (aRNAP3) has assumed considerable importance (2). Objectives: the aim of this study was to evaluate the frequency of neoplasms and precancerous conditions, as well as the main risk factors, in our cohort of patients with SSc. Methods: we enrolled 312 consecutive patients (288/92% females and 24/8% males, mean age 62.3 years, average disease duration 108 months) afferent at our department from 2000 to 2018, with a diagnosis of SSc confirmed according to the 2013 aCR/EULAR criteria (3). All patients underwent clinical, instrumental and laboratory evaluation. In 93 patients, negative for anti-topoisomerase I antibodies (aScl70) and anti-centromere antibodies (ACA), the presence of aRNAP3 antibodies was evaluated by an ELISA method (QUANTA LiteTM RNA Pol III). Results: we found a limited form of disease in 229 patients (73.4%) and a diffuse form in 83 (26.6%). Eighty eight (28.2%) patients were positive for aScl70, 112 (35.9%) for aCA and 17 (5.4%) for aRNAP3. In the whole group, 44 (14%) patients had a positive familiar history for neoplasm while 105 (33.65%) had a history of neoplasms and/or precancerous conditions. Among these 105 cases, 44 (41.9%) were malignant, 50 (47.6%) benign and 11 (10.5%) had precancerous conditions. The most frequent neoplasms were breast carcinomas (14 cases/14.9%), thyroid (7 cases/7.4%), lung and kidney (3 cases/3.1%), melanomas (5 cases/5.3%). The most frequent precancerous condition was Barrett’s esophagus (7 cases/63.3%). Regarding the antibody profile, 5 (4.8%) patients were positive for anti-RNAP3 and only 2 (1.9%) of these patients presented a malignant neoplasm, breast cancer in both cases. In 30 cases (28.6%) these neoplastic/precancerous conditions had arisen in the close period (± 36 months) at the SSc diagnosis and only 3 of them were anti-RNAP3 positive. Among the evaluated risk factors. Only familiarity was significantly associated with the development of neoplasia (p = 0.003), confirmed at the multivariate analysis (OR 2.9, IC95% [1,5-5,7]; p=0,002). Conclusion: our study evaluated not only malignant neoplasms, but also benign neoplasms and precancerous conditions and identified familiarity as the only significant risk factor. In our cohort we did’nt find any relationship between the presence of anti-RNAP3 antibodies and the development of neoplasms, not even stratifying for the type of neoplasm. However, to better define our data, we should analyze anti-RNAP3 also in the double negative (antiScl70 and aCA) cases, in light of the recent evidence of double antibody positivity, as well as other newly investigated rare autoantibodies, associated with neoplasm in many connective tissue diseases, including SSc. References [1] Szekanecz E, et al. (2012) autoimmun Rev11, 852; [2] Shaha aAet al(2017) J Scleroderma Relat Disord. 2, 153; [3] Van den Hoogen F, et al. (2013) ann Rheum Dis72, 1747–55. Disclosure of interests: Katia Stefanantoni Consultant for: only 1 scientific advice for Italfarmaco in 2016, Natalia Di Tommaso: None declared, Nicoletta Iannace: None declared, Iliana Sciarra: None declared, Carlotta angelelli: None declared, Elena Marafioti: None declared, Greta Pellegrino: None declared, massimiliano vasile: None declared, Guido Valesini: None declared, Valeria Riccieri: None declared

Background Rheumatoid arthritis (RA) is a chronic, inflammatory, autoimmune disorder that primarily affects joints. Beside the well-known rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) have been reported to be a very useful diagnostic and prognostic marker of RA, recently antibodies against carbamylated proteins (anti-CarP) have been described also in ACPA negative RA patients. However, more than 20% of RA cases are still defined as seronegative forms. Therefore, the individuation of new antibody specificities in RA could be helpful for diagnostic and prognostic purposes. Objectives The goals of this study were the identification and the immunologic characterization of post-translational modified synovial fluid (SF) autoantigens, specifically targeted by autoantibodies from sera of seronegative RA patients. Methods SFs from 5 seronegative RA patients were collected, pooled and treated with hyaluronidase. After removal of both albumin and IgG, the sample was washed and cleansed, concentrated, separated by 2-dimensional electrophoresis (2-DE) and then transferred by Western blotting to nitrocellulose membrane, for autoantigen detection by immunoassay, using a pool of sera from 5 seronegative RA patients. The antigenic protein spots were identified by peptide mass fingerprint, using a Matrix-Assisted Laser Desorption/Ionization-Time Of Flight (MALDI-TOF) mass spectrometer. This approach revealed Alpha 1 Anti-Trypsin (A1AT) as a target of RA patients autoantibodies. Pooled SFs were also analyzed by reverse-phase nanoliquid chromatography and tandem mass spectrometry, to confirm the presence of A1AT and for the identification of A1AT post-translational modifications. Homocysteinylated A1AT was immunoprecipitated from pooled SFs of RA seronegative patients and, after a diafiltration and concentration process, was used as an antigen to detect anti-homocysteinylated A1AT antibodies by Enzyme-Linked ImmunoSorbent Assay (ELISA). In order to this, consecutive patients with RA, osteoarthritis (OA), psoriatic arthritis (PsA), and healthy donors were enrolled and sera were collected. Results Homocysteinylated A1AT was identified as a potential antigenic target not only in ACPA and RF positive RA patients but, more importantly, also in RA seronegative patients. Antibodies anti-homocysteinylated A1AT were found in 66.7% (44/66) RA patients seronegative for ACPA and RF, 88.6% (39/44) RA patients, 15% (3/20) OA patients, 26.3% (5/19) PsA patients and in none (0/41) of healthy donors. Conclusion Homocysteinylated A1AT was identified as a new possible antigenic target of autoantibodies in sera from RA patients, including RA seronegative patients. This tool may be useful in diagnosis and monitoring of the disease and may contribute to understand the immunopathogenic mechanisms of RA in future studies. Disclosure of Interests Tania Colasanti: None declared, Danilo Sabatinelli: None declared, Carmine Mancone: None declared, Arbi Pecani: None declared, Mariangela Speziali: None declared, Marta Vomero: None declared, cristiana barbati: None declared, Alessandra Ida Celia: None declared, Annacarla Finucci: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Fulvia Ceccarelli: None declared, francesca spinelli: None declared, Vincenzo Barnaba: None declared, fabrizio conti: None declared, Guido Valesini: None declared, cristiano alessandri: None declared

Background: Rheumatoid arthritis (RA) is associated with high incidence of cardiovascular events, mainly due to accelerated atherosclerosis and endothelial dysfunction (1). Apoptosis in endothelial cells has been associated with vascular wall damage, contributing to atherosclerotic plaque formation (2). At the contrary, autophagy may play a protective role in preventing development of atherosclerosis. However, the exact mechanism which controls the autophagy of endothelial cells is still unknown. Tumor necrosis factor alpha (TNF-α) is one of the leading cytokines involved in the pathogenesis of RA. Several evidences suggest a pro-atherogenic effect of TNF-α in patients with RA. Etanercept (ETA) and other TNF-α inhibitors are effective treatments for joint inflammation in RA, but their effect on endothelial dysfunction is still not well understood. Objectives: The aim of this study was to investigate in vitro, the effects of ETA treatment on endothelial cells exposed to TNF-α, with particular attention on apoptosis levels and autophagy pathway. Methods: In vitro effects of ETA and TNF-α on endothelium were evaluated using human umbilical vein cell line EA.hy926. Cells were treated with ETA (15μg), TNF-α (10 ng/ml), alone or in combination. An untreated control cell culture was also performed. After 24 hours, apoptosis levels and autophagy have been evaluated. Apoptosis was analyzed by flow cytometry using a FITC-conjugated annexin V and propidium iodide apoptosis detection kit (3); autophagy was analyzed by western blot for the expression level of the autophagic markers LC3-II and p-62 (4). Results: TNF-α treatment significantly increased apoptosis in endothelial cells compared both to untreated and ETA-treated cells (p= 0.0067 and p= 0.00187 respectively) [Figure 1]. The co-treatment with TNF-α and ETA significantly reverted the increase of apoptosis levels (p= 0.001 versus TNFα alone). Both ETA and TNFα treatments significantly increased the expression level of LC3II in treated cells when compared to untreated cells (p=.18 and p=.3 respectively). The co-treatment induced an additive effect on autophagy levels (p Conclusion: Our results show that treatment with Etanercept have a protective effect on endothelial cells in vitro, reversing the apoptosis induced by TNF-α. Moreover, this is the first study that supports a possible effect of Etanercept in increasing autophagy level in endothelial cells. Reducing TNFα-induced apoptosis, Etanercept treatment may lead to an improvement of endothelial function and to a reduction of accelerated atherosclerosis. References: [1] Hurlimann D, Forster A, Noll G, Enseleit F, Chenevard R, Distler O, et al. Anti-tumor necrosis factor-a treatment improves endothelial function in patients with rheumatoid arthritis. Circulation. 2002;106:2184–2187 [2] Fukuo K, Nakahashi T, Nomura S, Hata S, Suhara T, Shimizu M, et al. Possible participation of Fas-mediated apoptosis in the mechanism of atherosclerosis. Gerontology. 1997;1:35–42. [3] Alessandri C, Barbati C, Vacirca D, Piscopo P, Confaloni A, Sanchez M, et al. T lymphocytes from patients with systemic lupus erythematosus are resistant to induction of autophagy. FASEB J. 2012;26:4722–4732. [4] Barbati C, Alessandri C, Vomero M, Vona R, Colasanti T, Vacirca D, et al. Autoantibodies specific to D4GDI modulate Rho GTPase mediated cytoskeleton remodeling and induce autophagy in T lymphocytes. J Autoimmun. 2015;58:78–89. Disclosure of Interests: None declared

Background: Frailty is a condition characterized by the reduction of the individual’s homeostatic reserves, leading to an increased vulnerability to stressors and an increased risk of unfavourable events. The aging of the population and the consequent need to implement new paradigms of care and assistance, have given this tool a growing interest in many medical disciplines1. In rheumatology, however, the interest is still limited2. The Frailty Index (FI), developed on an arithmetical model of deficit accumulation, is an accurate tool for assessing frailty, providing an estimate of the biological aging. Objectives: Creation of a FI to be used in clinical practice in patients with Sjogren’s syndrome (SS) and evaluation of the correlations with patient‘s age, duration of illness, activity and disease damage at baseline and in the following 5 years. Methods: The FI is composed by a checklist of non-predefined variables (deficits) constituted by symptoms, signs, diseases, disabilities, and laboratory findings. The deficits must meet these criteria: age-related; associated with negative outcomes; multidimensional (referring to different domains of the health status); present in at least 1%, but not more than 80% of the sample. To each variable is assigned the value of 0 (= no deficit) or 1 (= deficit). The FI is the ratio between deficits presented by the individual and the total number of deficits considered, thus providing a measure of frailty ranging between 0 (no frailty) and 1 (maximum of frailty)3. A FI was developed for patients with SS consisting of 43 items (17 comorbidities, 14 signs and symptoms, 5 disabilities and 7 laboratory findings). Statistical analysis was performed with Spearman’s test for correlation assessment, the Mann Whitney test for comparing non-parametric variables was used. Results: FI was administered to a first small group of 30 female consecutive patients recruited as outpatients at the clinic dedicated to SS. The average age was 57.2 yrs, mean age at diagnosis 52.7 yrs and average disease duration 4.7 yrs. At the time of completing the FI, the average disease activity (ESSDAI) was 3.4, the mean value of the damage (SjSDDI) 1.6 and the average score of FI equal to 0.21. A statistically significant correlation between FI and age has been reported (p = 0.017). No significant correlations between frailty and duration, activity and disease damage have been highlighted at the moment. Conclusion: For the first time a FI was developed for patients with SS consisting of 43 items. The data shows a relationship between age andFI. The correlation is statistically significant, similarly to what is reported in the literature for other conditions. This confirms that FI is indeed an objective marker of aging and even though the sample population is young (average age = 57.2 years), FI maintains its main properties. This tool can be used to assess the health status of patients, making it possible to identify those at greater risk of trajectories or unfavourable outcomes. It is currently being administered the FI to patients with SS whose clinical course will be evaluated in the next 5 years (complications, mortality, hospitalization, institutionalization and disability). References [1] Canevelli M, et al, Promoting the Assessment of Frailty in the Clinical Approach to Cognitive Disorders, Front. Aging Neurosc 2017 [2] Rockwood MR, et al, FI to Measure Health Status in People with SSc, J Rheum 2014 [3] Searle SD, et al, A standard procedure for creating a FI, BMC Geriatrics2008 Disclosure of Interests: None declared

Background: Immune checkpoint inhibitors (ICIs) has radically changed the oncology field: the blockade of co-stimulatory molecules on T cells, antigen presenting cells and tumor cells induces unchecked T cell activation with subsequent immune response targeting malignant cells. In the last years, different ICIs have been approved for the treatment of several malignancies. The stimulation of the immune response could be associated with the development of immune-related adverse events (irAEs), potentially involving every organ/system (1). Musculo-skeletal manifestations represent one of the most common irAEs developing during ICIs treatment: up to 40% of treated patients could experience arthralgia or arthritis. Moving from these evidences, the role of the rheumatologist became very important in the management of ICIs treated patients (2). Objectives: To determine the frequency of musculo-skeletal manifestations in patients treated with ICIs in a combined rheumatology/oncology outpatient clinic. Methods: From January 2015 we organised a rheumatology/oncology combined outpatient clinic: all patients starting an ICIs treatment were referred from oncologist to rheumatologist. Data from patients, including demographic features, date of diagnosis, comorbidities and previous and concomitant medications, smoke habit, were collected and registered into a standardized, computerized, electronically filled-in form. All the patients underwent to a physical and laboratory evaluation in order to assess the presence of tender and swollen joints. In case of joint involvement, we assessed disease activity by clinimetric evaluation (DAS28) and ultrasonographic assessment of involved joints (presence of active synovitis as for presence of power Doppler). Moreover, a laboratory evaluation including, ESR, CRP, and autoantibodies (ANA, ACPA, RF) was performed. Results: Seventy-two patients were evaluated (M/F 48/24, median age 66.0 years, IQR 13.0; median disease duration 7 months, IQR 13.0). Concerning malignant disease, 75.1% were affected by non-small cell lung cancer, 15.3% by renal cell carcinoma, 6.9% by melanoma, 2.7% by other malignancies; all patients were treated with anti-PD-1, 67 (93.1%) with nivolumab and 5 (6.9%) with pembrolizumab. During ICIs treatment, 7 patients (9.7%) developed clinically evident synovitis (absolute risk: 0.1; incidence rate 0.01 patients/month): table 1 reports the main features of these 7 patients. According with ACR/EULAR 2010 criteria, two patients could be classified as affected by rheumatoid arthritis (RA). Six patients (85.7%) were treated by prednisone (dosage range 10-12.5mg/daily) or NSAIDs, experiencing a rapid, complete and persistent response. Patient 2, due to resistance to prednisone, was treated by methotrexate 10mg/weekly achieving remission after 6 weeks. Conclusion: The present study represents the first attempt to apply a multidisciplinary approach involving rheumatologists and oncologists in the evaluation of patients treated with ICIs. We found a high absolute risk (10%) to develop synovitis in patients treated by ICIs. Interestingly, the majority of these patients experienced a clinically evident synovitis promptly responding to glucocorticoids and not requiring further DMARDs treatment. This could suggest a peculiar pathogenesis of such ICIs-induced arthritis. References: [1] Calabrese L & Velcheti V, Ann Rheum Diseases 2016; 2. Mooradian MJ et al, Semin Arthritis Rheum 2018 Disclosure of Interests: Fulvia Ceccarelli: None declared, Andrea Botticelli: None declared, Alain Gelibter: None declared, Ilaria Leccese: None declared, Ilaria Zizzari: None declared, Grazia Sirgiovanni: None declared, Francesca Romana Di Pietro: None declared, Ramona Lucchetti: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Enrico Cortesi: None declared, Marianna Nuti: None declared, fabrizio conti: None declared, Paolo Marchetti: None declared, Guido Valesini: None declared

Background Post-translational-modifications (PTMs) are implicated in the pathogenesis of autoimmune diseases, leading to the break of self-tolerance, generation of new autoantigens and production of autoantibodies. Anti-citrullinated-proteins antibodies (ACPA) play a key role in the pathogenesis of rheumatoid arthritis (RA) and many evidences showed that they are related to bone loss in RA. Osteoclasts are the primary targets of ACPA in the joint site, displaying citrullinated antigens on their surface. Carbamylation is another PTM generating the production of anti-carbamylated proteins antibodies (anti-CarP), recently proposed as a new biomarker for RA. Anti-CarP have been also studied in patients with systemic lupus erythematosus (SLE) with predominant joint involvement, showing a prevalence of 46.1%. Moreover, in SLE patients these autoantibodies have been also associated to bone erosive damage. The pathogenic mechanism of these autoantibodies is not completely clarified so far. Objectives The aim of the present study was to investigate the possible pathogenic role of anti-CarP in the induction of osteoclastogenesis. Methods Peripheral blood mononuclear cells (PBMCs) were isolated from a buffy coat from healthy donors using a Ficoll Hypaque gradient. Cells were cultured for 14 days in α-MEM complete medium, supplemented with 25 ng/ml of macrophage-colony-stimulating-factor (MCSF) and 30 ng/ml of receptor activator of nuclear-factor-kappa-β-ligand (RANKL), for the differentiation of monocytes in osteoclasts. Simultaneously, PBMCs were co-cultured in presence of anti-carbamilated-vimentin autoantibodies (anti-Vim CarP) purified from sera of 3 patients with RA and 3 patients with SLE with a predominant joint involvement at 100 ng/ml and 1 μg/ml. As control, intravenous immunoglobulin (IVIg) were used at the same concentrations. After 14 days, osteoclast differentiation was evaluated by staining cells for tartrate-resistant acid phosphatase (TRAP), using leukocyte acid phosphatase kit. Results Anti-VimCarP purified from RA patients at 100 ng/ml were able to increase the median number of osteoclasts per well significantly more than untreated and IVIg at 100 ng/ml and 1 μg/ml (P=0.0008; P=0.0009 and P=0.0009, respectively). The same results were observed treating cells with 1 μg/ml of anti-VimCarP from RA patients (P=0.0008, P=0.002 and P=0.002, respectively). Similarly, anti-VimCarP purified from SLE patients at 100 ng/ml significantly increased the median number of osteoclasts than untreated and IVIg at 100 ng/ml and 1 μg/ml (P=0.002, P=0.004 and P=0.003, respectively). Analogously, we observed similar results co-culturing cells with 1 μg/ml of anti-VimCarP from SLE patients (P=0.002, P=0.02 and P=0.006, respectively). Conclusion For the first time, we demonstrated that anti-Vim CarP purified from RA and SLE patients are able to induce osteoclastogenesis, suggesting their potential role as a biomarker of joint erosiveness in these autoimmune diseases. Disclosure of Interests Laura Massaro: None declared, Tania Colasanti: None declared, francesca spinelli: None declared, Fulvia Ceccarelli: None declared, Riccardo Mancini: None declared, Arbi Pecani: None declared, enrica cipriano: None declared, Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Francesca Miranda: None declared, Simona Truglia: None declared, Francesco Natalucci: None declared, Martina Leopizzi: None declared, Valeria Di Maio: None declared, Carlo Della Rocca: None declared, cristiano alessandri: None declared, Guido Valesini: None declared, fabrizio conti: None declared

Background Rheumatoid arthritis (RA) is more prevalent in women than men (F:M=4:1), due to hormonal, genetic and environment factors. Women present higher disease activity markers as Disease Activity Score-28 (DAS28) and Health Assessment Questionnaire (HAQ), at the onset and after c-DMARDs therapy, without correlation with radiographic damage. Objectives The purpose of this study was to assess gender differences in RA patients after anti- tumor necrosis factor (TNF) α treatment. Methods Ninety-six patients were enrolled at the beginning of anti-TNF α therapy (etanercept and adalimumab). All patients satisfied 1987 and 2010 ACR criteria for RA. They underwent to clinical and clinimetric evaluation at baseline (T0) and after three (T3) and six (T6) months of therapy with: tender and swollen joints, Visual Analogic Scale (VAS) pain, VAS patient and physician, DAS28, Clinical/Simplified clinical disease activity index (CDAI/SDAI) and HAQ. The evaluation of erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), Rheumatoid Factor (RF) and anti-citrullinated protein antibody (ACPA) was performed in all patients. Results Among these patients, 70 were women and 26 men; 81 patients (58 female, 23 male) started etanercept and 15 adalimumab (12 female, 3 male). They presented a mean age of 56.4 ± 14.5 years (women 55.2 ± 15.4, men 60 ± 11.2) and mean disease duration of 11 ± 6.8 years (woman 11.51 ± 6.3, men 9.6 ± 8.1). Both women and men had a DAS28 reduction after 3 and 6 months therapy (p Conclusion In this study, both women and men had a good response to anti-TNF treatment but women presented worse clinical response. Female gender resulted the only variable associated with DAS28 reduction differences. We could hypothesize that beyond to biological factors, also social contest, daily life and work activity could explain a worse impact of disease on women. References [1] Neovius M, Ann Rheum Dis 2011; [2] O.L. Quintero, et al., Journal of Autoimmunity 2012. [3] M Ahlm aen, Ann Rheum Dis 2010. [4] Jawaheer, et al, The Journal of Rheumatology 2010. [5] Jawaheer, et al, The Journal of Rheumatology 2012. [6] Arnett FC, Arthritis Rheum 1988. [7] Aletaha D, Arthritis Rheum 2010. Disclosure of Interests None declared

Background Systemic sclerosis (SSc) is an autoimmune disease ending in multiorgan fibrosis. Vascular damage, responsible for the vascular alteration and disruption, has been suggested to play a key role in disease maintenance and progression [1]. Recent data demonstrated that high serum levels of the interferon (IFN)-γ-induced protein 10 (IP-10) in SSc patients correlated with peripheral vascular injure and increased in association with nailfold capillaroscopic pattern worsening and digital ulcers presence [2, 3]. Between the vasoactive drugs used for SSc treatment, the prostacyclin analogue iloprost (I) and PDE-5 inhibitor sildenafil (S) seem to have high vasodilatatory and immunomodulatory actions [4-6]. Objectives To investigate and compare the ability of S and I to modulate: IP-10 circulating levels in SSc patients under different treatments; IP-10 release by human endothelial (Hfaec) cells subjected to Th1-related inflammatory stimuli. Methods Sera of 28 patients satisfying ACR/EULAR 2013 classification criteria for SSc were analyzed by ELISA. IFNγ+TNFα-induced activation of NFkB, STAT1, JNK, ERK1/2 and AKT in Hfaec after S or I was tested by Western blot. Results The treatment with S significantly reduced IP-10 serum levels vs. treatment with (DMARDS) and corticosteroids (CCs) (184.1±65.10 vs. 880.9±339.0 pg/ml and vs. 426.5±101.7, respectively, P Conclusion In vivo results show that S and I have more effect in targeting serum IP-10 in SSc patients than other therapeutic treatments. In vitro data show different inhibitory drug-induced effects onto paths underlying IP-10 production, depending on intracellular targets. S could be a potential pharmacological tool as effective as I to control IP-10 in blood or at endothelial cell level in SSc. References [1] Varga J, et al., 2007. [2] Antonelli A, et al., 2008. [3] Crescioli C, et al., 2018. [4] Scorza R, et al., 2001. [5] Higuchi T, et al., 2015. [6] Hassoun PM, et al. 2015. Disclosure of Interests clara crescioli: None declared, Valeria Riccieri: None declared, Katia Stefanantoni Consultant for: Only 1 scientific advice for Italfarmaco in 2016, clarissa corinaldesi: None declared, massimiliano vasile: None declared, francesco marampon: None declared, Guido Valesini: None declared, andrea lenzi: None declared, luigi di luigi: None declared, cristina antinozzi: None declared

Background: (SLE) is a chronic autoimmune disease with a complex pathogenesis in which genes and environmental factors interact leading to a protean clinical picture. Joint involvement is one of the most common manifestations in SLE patients, with a prevalence ranging from 69 to 95%. This feature significantly influences the patients’ quality of life, possibly leading to disability and impaired functional performance in daily activities. Identification of prognostic biomarkers, able to identify patients at risk to develop this more aggressive phenotype, is mandatory. Autoantibodies associated with inflammatory arthritis, such as Rheumatoid Arthritis (RA), have been shown to play a role also in SLE arthritis. For instance, ACPA can be found in approximately 16% of SLE patients and, recently, it was demonstrated that anti-carbamylated proteins antibodies (anti-CarP) can be identified in up to 28.3% of SLE patients (1). Objectives: Thus, our aim was to analyze previously identified loci associated with SLE in a cohort of SLE patients to evaluate their influence on autoantibody production. Methods: We recruited 52 Italian SLE patients. A panel of 34 SNPs in 19 genes involved in immune response, autophagy and inflammation, was selected. SNPs genotyping was performed by allelic discrimination assay by TaqMan assays (Applied Biosystems, Foster City, CA, USA) and ABI PRISM 7000. The main clinical/laboratory features (including injury index and disease activity) were collected on an electronic platform. The presence of Rheumatoid Factor (RF), ACPA, and anti-CarP antibodies was investigated. All autoantibody assays were carried out in duplicate, commercial enzyme-linked immunosorbent assay (ELISA) kits were used and the results were evaluated according to the manufacturers’ instructions. Detailed methods are described in (1). A genotype/phenotype correlation analysis was performed. Results: Clinical and demographic data of patients are described in table 1. The variant allele of rs2910164 (MIR146a) (P=0.03) was significantly associated with presence of anti-CarP antibodies in SLE. Specifically, patients carrying the C allele of MIR146a were more likely to have anti-CarP antibodies (P=0.01, OR 5.018, 95% CI 1.414-17.811). Among the clinical and laboratory features, the same polymorphism was associated with presence of arthritis in clinical history (P=0.02), and with anti-dsDNA positivity (P=0.025). In a multinomial logistic regression analysis, MIR146A was independently associated with anti-CarP (P=0.017, Exp(B)=5.433, 95%CI 1.345-21.944). Conclusion: Carbamylation is a non-enzymatic process consisting in the addition of a cyanate group on self-proteins determining a modification in the tertiary structure. This change causes the generation of new epitopes and the consequent production of autoantibodies. This is the first report suggesting that anti-CarP production is genetically driven. Indeed, Mir146a expression is altered in SLE and has been linked with autoantibody production in lupus-prone mice models. Probably, the higher IFNa levels observed in patients carrying the C allele can be responsible for such higher autoantibody production. Reference [1] Massaro L, et al. Anti-carbamylated protein antibodies in systemic lupus erythematosus patients with articular involvement. Lupus. 2018;27:105-111. Disclosure of Interests: Carlo Perricone Speakers bureau: BMS; Lilly, Celgene, Sanofi, Cinzia Ciccacci: None declared, Fulvia Ceccarelli: None declared, Ilaria Leccese: None declared, Giuseppe Mettola: None declared, Sara Rufini: None declared, cristiano alessandri: None declared, francesca spinelli: None declared, Cristina Politi: None declared, Andrea Latini: None declared, Giuseppe Novelli: None declared, Guido Valesini: None declared, Paola Borgiani: None declared, fabrizio conti: None declared

Background: Patients with Rheumatoid Arthritis (RA) have an increased risk of cardiovascular diseases (CVD). Inflammation and autoantibodies indipendently promote endothelial dysfunction, which is the earliest, reversible stage of atherosclerosis. In vitro studies have demonstrated that antibodies against carbamylated proteins (anti-CarP), recently described in RA patients, can induce the production of proatherosclerotic molecules like Vascular Cell Adhesion Molecule (VCAM-1) and activate Interleukin-1 Receptor-Associated Kinase (IRAK-1), Nuclear Factor kB (NF-kB), inducible Nitric Oxide Synthase (iNOS) in endothelial cells (1,2). Moreover, anti-CarP are associated to endothelial dysfunction and subclinical atherosclerosis in RA patients (3). Objectives: Aims of the present study were: 1) to analyze the role of vimentin as a target of autoantibody response in the serum of patients with RA and 2) investigate the expression of vimentin and carbamylated proteins in endothelial cells. Methods: Consecutive RA patients were enrolled in this study. Vimentin was carbamylated and used as an antigen for the detection of anti-Vimentin Carbamylated antibodies (CarVim), through immunoenzymathic methods. Cells were incubated with anti-vimentin and carbamylated antibodies. The presence of vimentin and carbamylated proteins was investigated by immunofluorescence on the immortalized endothelial cell line EA.hy 926. Results: Eighty-eight (88) RA patients were enrolled in this study (F:M = 79:9, mean age = 56 ± 13 years). Anti-CarVim antibodies were present in 9% of the patients with a mean titre of di 442 aU/ML (IQR 303 aU/ml). Vimentin and carbamylated proteins were detected in the endothelial cells by immunofluorescence (Figure 1). Conclusion: The results of this study confirm that Vimentin is one of the antigenic targets of anti-CarP antibodies present in the serum of RA patients. The presence of carbamylated proteins and vimentin in endothelial cells suggests that anti-CarVim could bind the modified protein and determine endothelial activation and subsequent endothelial dysfunction. Reference [1] Pecani A & Alessandri C et al, Arthr Res Ther 2016 [2] Pecani A et al, Reumatismo 2017 [3] Spinelli FR & Pecani A et al, BMC Musculoskelet Disord 2017. Disclosure of Interests: None declared