Search

Background The goal in treating RA has changed from clinical remission to structural remission with the increased use of biological agents (Bio) which target the pro-inflammatory cytokines interleukin (IL)-6 and tumor necrosis factor (TNF)-α. PCT, a useful marker of infection, has been shown to increase in mRNA expression in peripheral blood mononuclear cells by stimulated by pro-inflammatory cytokine, IL-6 or TNF-α. Objectives This study investigates whether the levels of following parameters (PCT, modified HAQ (mHAQ), MMP-3, RF, ESR, CRP and ACPA) at baseline (BL) of TCZ treatment can be used to predict clinical remission (DAS28-ESR, CDAI) at 52 weeks after the start of TCZ treatment. Methods Bio naive RA patients who can be observed at Week 52 were analyzed in this study. PCT (n=34), mHAQ (n=48), matrix metalloproteinase (MMP)-3 (n=54), RF (n=54), ESR (n=53), CRP (n=56) and ACPA (n=52) were assessed at BL. The patients were divided into 2 groups, based on DAS28-ESR remission (DAS28-ESR Results The variables with a significant difference between the remission and non-remission groups were PCT (p=0.001), mHAQ (p=0.014), RF (p=0.003), ESR (p=0.001) and CRP (p=0.041). The COVs were 0.027 ng/ml for PCT, 100U/ml for RF, 0.38 for mHAQ, 18 mm/hr for ESR, 1.96 mg/dl for CRP. For each variable, the DAS28-ESR remission rate in U group (PCT: 100%, mHAQ: 70.8%, RF: 77.8%, ESR: 87.5% and CRP: 64.3%) was significantly higher than in O group. Additionally, the CDAI remission rate in U group (PCT: 50.0% (p=0.040) and RF: 32.1% (p=0.026)) was significantly higher than in O group, but not others. For PCT at BL, DAS28-ESR or CDAI were no different between the U group and O group and no correlation with DAS28-ESR or CDAI were observed. BL DAS28-ESR was significantly lower in U groups for all other variables. Furthermore, BL PCT had correlation with DAS28-ESR and CDAI at Week 52. Conclusions BL PCT level is a useful predictive marker for clinical remission (DAS28-ESR, CDAI) at week 52 in Bio naive RA treated by TCZ. Moreover, unlike other variables, it is not affected by the BL disease activity level. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2437

Background The majority of SLE patients show evidence of excess type I interferon (IFN-I) production, a phenotype associated with renal disease and certain autoantibodies. However, detection of IFN-I proteins in serum is expensive examination and time consuming. Research in the past few years has demonstrated that their relative expression on circulating monocytes/macrophages may be modified by cytokines, including interferon (IFN)-α 1 . Little data exist on the in vivo expression of specific FcγRI, CD64 in SLE. However, the quantitative expression of CD64 on monocytes has not been reported. For the treatment early intervention, more rapid disease activity assessment is required in SLE. Objectives To determine whether quantitative expression of CD64 on circulating monocytes (mCD64) is associated with systemic exacerbation in SLE patients. Methods In this study, 10 SLE patients with high disease activity (aSLE), 20 SLE patients with quiescent activity (qSLE) and 20 healthy controls (HC) were enrolled. We measured the expression level of CD64 per monocyte quantitatively by flow cytometry. Comparisons of levels within each group were analyzed, and levels of respective measurements at both pre- and post-treatment in aSLE were analyzed. The expression level of mCD64 was compared with SLE disease activity index (SLEDAI) and SLE disease activity biomarkers (anti DNA antibody and compliments titer). Results aSLE had a mean SLEDAI of 12.1±7, and qSLE SLEDAI was 3.0±1.6. In aSLE and qSLE, mean expression level of mCD64 was 39800±16609 and 21759±7423 molecules/cell (p Conclusions Our results suggest that quantitative measurement of CD64 expression on monocytes can be useful to detect disease exacerbation in SLE. Flow cytometry analysis of CD64 expression on circulating monocytes is a convenient and rapid approach for estimating IFN-α levels in SLE. Quantitative mCD64 could become a novel biomarker to replace the SLE disease activity marker from that found a correlation with markers of disease activity, and reduced by treatment advantage. Further quantitative measurement of CD64 on flow cytometry will be necessary to obtain consistency of result between facilities. References Li, Y. et al. Monocyte surface expression of FCγreceptor RI (CD64), a biomarker reflecting type-I interferon levels in systemic lupus erythematosus. Arthritis Research & Therapy 2010, 12:R90. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2432

Background In rheumatoid arthritis (RA), pulmonary involvement is one of the important complication.Both organizing pneumonia (OP) and bacterial pneumonia (BP) can be evident during the course of RA. However, we often have difficulties with differentiating OP from BP clinically, because both present similar infiltrations in chest computed tomography (CT). Corticosteroid is the standard therapy for OP, on the other hand, antibiotics is necessary for BP.CD64 on neutrophils (nCD64) is FcγRI known to be upregulated as a response to infection. Objectives To evaluate the usefulness of nCD64 for differentiating OP from BP. Methods Eleven RA patients diagnosed as pneumonia with infiltrative shadows in their chest CT were enrolled in this study. Five patients were successfully treated only with predonisolone (PSL). Three of them were pathologically confirmed the tissue of lung lesions by transbronchial lung biopsy (TBLB). They were diagnosed as OP. Nine patients were successfully treated with only broad-spectrum antibiotics (ABx), diagnosed as BP. All patients received blood examinations before treatment and following parameters were examined. The expression level of CD64 per neutrophil (nCD64) was quantitatively measured by using flow cytometery. C-reactive protein (CRP) and procalcitonin (PCT) were also measured. Comparisons of levels within each group were analyzed using the Mann-Whitney9s U-test. Results nCD64 levels in OP were significantly lower than those in BP (p=0.0164). On the other hand, in CRP and PCT, there were no differences between OP and BP. Among these biomarkers, only nCD64 can distinguish OP from BP, indicating the efficacy of nCD64 for diagnosis of OP. Conclusions nCD64 is an effective diagnostic marker for differentiating OP from BP in RA patients. This novel marker would be contribute to both early diagnosis and suitable treatment. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2901

Background Since the introduction of biological disease-modifying antirheumatic drugs (bDMARDs), treatment of rheumatoid arthritis (RA) has changed. Remission is a feasible treatment target for many patients. As a result, there is an increased interest in appropriate treatment strategies after achieving disease control, such as bDMARD discontinuation while in remission. However, its adoption in typical clinical practice has not been widely studied. Objectives We conducted a cross-national longitudinal observational study of bDMARD to describe the proportions of RA patients in remission who discontinued these agents, and to assess the potential predictors of discontinuation. Methods We utilized data from US CORRONA and Japanese NinJa registries. Patients who used bDMARDs on at least two consecutive visits and experienced remission defined by the Clinical Disease Activity Index (CDAI) ≤2.8 at least once were included. The outcome of interest was bDMARD discontinuation while in remission. Discontinuation was described with the Kaplan-Meier method as well as the cumulative incidence function method to account for competing risk events, i.e., loss of remission and switch to another bDMARD. The baseline predictors of discontinuation were assessed in the Cox regression models. Results The numbers of eligible patients were 4,382 in the CORRONA (34.4% of 12,721 bDMARD users among 22,684 total patients) and 413 in the NinJa (18.4% of 2,243 bDMARD users among 11,205 total patients). In the Kaplan-Meier analysis, discontinuation at 5 years among patient who remained in remission was observed in 28.1% in CORRONA and 22.7% in NinJa (p=0.002, log-rank test; Figure Panels A and B). In the cumulative incidence function analysis, the proportions of discontinuation at 5 years among patients who were initially in remission were 11.3% in CORRONA and 12.2% in NinJa (Figure Panels C and D). It was not significantly different (p=0.782, Gray's test) due to greater attrition to loss of remission in CORRONA (83.9%) compared to NinJa (77.2%). In Cox regression, reduced CDAI (hazard ratio for 1 point decrease: 1.49 [1.37,1.61] in CORRONA and 1.79 [1.33,2.38] in NinJa) and use of glucocorticoids (HR: 1.59 [1.19,2.12] in CORRONA and 2.11 [1.03, 4.31] in NinJa) predicted higher rates of bDMARD discontinuation in both cohorts. The overall R2 for the full models including sex, race, age, RA duration, biologic class, methotrexate use, duration of bDMARD use, and index year, was 0.074 in CORRONA and 0.168 in NinJa. ![Figure][1] Conclusions We found a slightly higher rate of bDMARD discontinuation in CORRONA than NinJa. Possible contributors to the discrepancy may include health care system differences (e.g. out of pocket cost) as well as cultural differences (e.g. patient preference vs doctor recommendation). While several variables were associated with more frequent discontinuation, they did not provide robust explanation of the variability in practice. Acknowledgements We would like to thank all CORRONA and NinJa contributors (patients, clinicians, and investigators) for maintaining such valuable sources of information. The CORRONA RA registry has been supported through contracted subscriptions in the last two years by Abbvie, Amgen, AstraZeneca, Genentech, Horizon Pharma, Eli Lilly, Novartis, Pfizer, Vertex and UCB. All non-pharmaceutically-initiated CORRONA research activities are conducted entirely independent of any pharmaceutical input. NinJa was supported in part by a Health and Labor Sciences Research Grant from the Ministry of Health, Labor, and Welfare of Japan. Disclosure of Interest : K. Yoshida Paid instructor for: Abbott Japan, H. Radner: None declared, M. Mjaavatten: None declared, J. Greenberg Shareholder of: CORRONA, Consultant for: AstraZeneca, Pfizer, Employee of: CORRONA, A. Kavanaugh Grant/research support: Abbott, Janssen, Amgen, BMS, Roche, UCBM, M. Kishimoto Speakers bureau: Santen, Mitsubishi-Tanabe, Pfizer, Abbott Japan, K. Matsui: None declared, M. Okada Speakers bureau: Santen, Mitsubishi-Tanabe, Pfizer, Abbott Japan, G. Reed Employee of: CORRONA, Y. Saeki Grant/research support: Tanabe-Mitsubishi, Chugai, Janssen, Nippon-Kayaku, Nichi-Iko, S. Tohma Grant/research support: Pfizer Japan, Eisai, Chugai, J. Kremer Shareholder of: CORRONA, Grant/research support: Abbott, Amgen, BMS, Genetech, Novo- Nordisk, Pfizer, Novartis, Eli Lilly, Employee of: CORRONA, D. Solomon Grant/research support: Eli Lilly, Amgen, CORRONA, Consultant for: Pfizer, Novartis, Eli Lilly DOI 10.1136/annrheumdis-2014-eular.1367 [1]: pending:yes

Background Infection is a critical complication that occurs during the management of RA patients. High levels of serum C-reactive protein (CRP), is not easily distinguishable between the exacerbations of RA from infections. PTX3 is a novel biomarker which responds to local inflammation. The following study evaluates the diagnostic use of PTX3 in RA patients with high levels of CRP. Objectives To evaluate the diagnostic use of PTX3 in RA patients with high levels of CRP. Methods 18 RA patients with infections (infection RA: iRA), 20 with high disease activity of RA (flare RA: fRA) and 23 healthy controls (HC) were enrolled in this study. Patients whom pathogens were identified were designated as iRA (15 bacterial, 2 viral and 1 mycosis). We measured PTX3, CRP, procalcitonin (PCT) and neutrophil CD64 (nCD64), pre- and post-treatments (iRA and fRA) and at any time (HC). PTX3 levels were measured using an enzyme-linked immunoabsorbent assay (ELISA). mCD64 was measured by a quantitative flow cytometry using fluorescene microbeads. Levels of respective measurements at both pre- and post-treatment were analyzed using the Wilcoxon signed-rank test, and comparisons of levels within each group were analyzed using the Mann-Whitney9s U-test. Results At pre-treatment, levels of PTX3 in iRA (15.1±20.7 ng/ml) are significantly higher compared with those in fRA (3.6±4.2 ng/ml). Both levels for iRA and fRA were significantly higher compared with those in HC (0.89±0.91 ng/ml). Additionally, levels of PCT (0.048±0.042 ng/ml) and nCD64 (1488±470 molecules per cell) at pre-treatment in fRA were After treatment, levels of PTX3 (p Conclusions Plasma PTX3 levels may be a helpful tool in distinguishing worsening of RA from complications due to infection. References Nature 1994; 367:338-45 Clin Exp Immunol 2000; 119:196–202 J Rheumatol. 2006; 33:2416-24 J Rheumatol. 2012; 39:1517-23 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.3761

Background Esophageal achalasia is a rare disease characterized by degeneration of Auerbach9s plexus. Although its presumed etiologies include autoimmune process, its precise mechanisms remain uncertain. Recently, it has reported that patients with achalasia are more likely to have autoimmune diseases. Objectives To elucidate the significance of achalasia in patients with autoimmune diseases Methods The computerized medical records system of our medical center were screened for patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc), polymyositis (PM)/dermatomyositis (DM), and achalasia for recent 30 years (between 1982 and 2012). Then the details of picked up patients were investigated. Results Twelve patients with achalasia were identified. Among them, 1 patient was also with SLE and 2 patients with SSc (table). All of them experienced nocturnal coughing with regurgitation of ingested food without gastric acid and suffered from aspiration pneumonia. Interestingly, all these 3 patients had autoantibodies relating to SSc (scl-70 or centromere), although patient 1 had no sign indicating SSc. The prevalence of such autoimmune diseases in achalasia patients was 25% (3/12). Inversely, the prevalence of achalasia in SLE patients was estimated at 0.19% (1/539), while that in SSc patients 0.67% (2/297). These patients are 19 times and 67 times more likely to suffer from achalasia compared with general population (1/10000), respectively. None of the 98 patients with PM and of 55 patients with DM had achalasia. The onset of achalasia could be before, at the same time as, or after that of autoimmune diseases. Conclusions The prevalence of achalasia among patients with autoimmune diseases (especially SSc) is much higher than that in general population. When patients with autoimmune diseases present recurrent regurgitation of food without gastric acid, esophageal achalasia must be ruled out, considering it might be underdiagnosed. Patients with SSc can exhibit similar symptoms, having reflux esophagitis.However, their regurgitations are usually with gastric acid. This is an important point for differential diagnosis. Further study is required to reveal its nature and clinical significance. References Booy JD. Et al. Dis Esophagus. 2012;25:209-13. Katada N. et al. Ann Thorac Cardiovasc Surg 2012; 18: 420–428. Gockel I. et al. Dtsch Arztebl Int. 2012;109:209-14. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4910

Background Interferon (IFN)-α has been largely implicated in the ethiopathogenesis of SLE. The activation of IFN-α might be important in the prognosis and activity assessment of the disease. CD64 (FcγRI) is upregulated on monocytes as a response to IFN-I 1 . Flow cytometry analysis of mCD64 expression (Mean Fluorescence Intensity) is a convenient and rapid approach for estimating IFN-α levels in SLE patients. Additionally, macrophage colony-stimulating factor (M-CSF), which is involved in the differentiation of monocyte/macrophage, affects CD64 expression on monocyte 2 has been reported to increase in levels in SLE patients, 3 and is also involved in SLE disease activity 4 . mCD64 can be the quantified easily and the measurement is consistent among the respective facilities. However, the quantitative mCD64 of SLE patients has not been reported. Objectives We investigated the levels of mCD64 by quantitative flow cytometry to assess the usefulness of it as a SLE disease activity biomarker. Methods 30 SLE patients (10 active SLE, 20 inactive SLE) and 20 healthy controls (HC) were in this study. SLE disease activity was evaluated using by SLE-Disease Activity Index (SLEDAI) score. mCD64, SLE activity biomarkers (anti-DNA antibody and complement titer (CH50)), IFN-α and M-CSF were measured in SLE patients. mCD64 was measured by a quantitative flow cytometry using fluorescene microbeads. INF-α and M-CSF levels were measured using an enzyme-linked immunoabsorbent assay (ELISA). Correlational analysis between levels of mCD64, SLEDAI, SLE activity biomarkers, INF-α and M-CSF in each group were evaluated. Results Disease activity markers are shown Table 1. The variables with significant difference between active SLE and inactive SLE were SLEDAI (p Conclusions This study suggests that quantitative CD64 molecules expressed on monocytes can be a useful disease activity biomarker in SLE patients. References Li, Y. et al. Arthritis Research & Therapy 2010, 12:R90 Ji XH et al. Acta Pharmacol Sin. 2004; 25(10): 1361-5 Yang PT et al. Ann Rheum Dis. 2008, 67(3): 429-30 Tsuji S. et al. The Journal of Tokyo Medical University vol.70, No.1: 151-8 Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.2824

To assess the efficacy of a nonpharmacologic, noninvasive static magnetic device as adjunctive therapy for knee pain in patients with rheumatoid arthritis (RA).Randomized, double-blind, controlled, multisite clinical trial.An American and a Japanese academic medical center as well as 4 community rheumatology and orthopedics practices.Cohort of 64 patients over age 18 years with rheumatoid arthritis and persistent knee pain, rated greater than 40/100mm, despite appropriate use of medications.Four blinded MagnaBloc (with 4 steep field gradients) or control devices (with 1 steep field gradient) were taped to a knee of each subject for 1 week.The American College of Rheumatology recommended core set of disease activity measures for RA clinical trials and subjects' assessment of treatment outcome.Subjects randomly assigned to the MagnaBloc (n = 38) and control treatment groups (n = 26) reported baseline pain levels of 63/100mm and 61/100mm, respectively. A greater reduction in reported pain in the MagnaBloc group was sustained through the 1-week follow-up (40.4% vs 25.9%) and corroborated by twice daily pain diary results (p.0001 for each vs baseline). However, comparison between the 2 groups demonstrated a statistically insignificant difference (p.23). Subjects in the MagnaBloc group reported an average decrease in their global assessment of disease activity of 33% over 1 week, as compared with a 2% decline in the control group (p.01). After 1 week, 68% of the MagnaBloc treatment group reported feeling better or much better, compared with 27% of the control group, and 29% and 65%, respectively, reported feeling the same as before treatment (p.01).Both devices demonstrated statistically significant pain reduction in comparison to baseline, with concordance across multiple indices. However, a significant difference was not observed between the 2 treatment groups (p.23). In future studies, the MagnaBloc treatment should be compared with a nonmagnetic placebo treatment to characterize further its therapeutic potential for treating RA. This study did elucidate methods for conducting clinical trials with magnetic devices.

We report the case of a young female patient with primary Sjogren's syndrome (SS). In addition to sicca symptoms she also suffered from progressive renal insufficiency and renal tubular acidosis (RTA). She was treated with three sets of pulse high-dose corticosteroid infusion and subsequent low-dose corticosteroid oral administration. When the efficacy was evaluated about 6 months after the start of the therapy, dramatic improvements were seen with no adverse effects, not only in laboratory tests but also histopathologically, as indicated by the repeat kidney biopsy. This suggests that renal involvements of SS might be reversible in some cases, and that there might be a clinical benefit of pulse high-dose corticosteroid infusion therapy in SS with progressive renal involvement.

Functional roles of interleukin (IL-)6 in T cell response were investigated. Mice deficient in IL-6 and wild mice were immunized with antigens (myelin oligodendrocyte glycoprotein or methylated BSA) and production of IL-4 and interferon (IFN)-gamma by regional lymph nodes was measured. IL-6 deficiency led to an enhancement of IL-4 and an inhibition of IFN-gamma production. Moreover, polyclonal stimulation of spleen T cells from unimmunized IL-6-deficient mice with anti-CD3 plus anti-CD28 antibodies (Abs) demonstrated an enhancement of T helper (Th)(2)responses. The presence of IL-6, however, augmented IL-4 production but it inhibited IFN-gamma expression by spleen T cells in response to polyclonal stimulation and by antigen-primed spleen T cells in response to re-challenge with the antigen. In contrast, the induction of spleen CD4-positive T cells into Th(2)cells in vitro by the anti-CD3 plus IL-4 was completely suppressed by exogenously added IL-6, whereas Th(1)differentiation of T cells by the anti-CD3 plus IL-12 was not inhibited by the presence of IL-6. Thus, these results indicate that IL-6 physiologically could modulate qualitative T cell response and suggest that it augments Th(1)responses partly through its inhibitory capability of IL-4-induced Th(2)differentiation of naive T cells.

To investigate the mechanism of rheumatoid synovial hyperplasia (RASH), the influence of tumour necrosis factor alpha (TNF-alpha) on Fas-mediated apoptotic cell death (Fas-ACD) was examined on cultured rheumatoid synovial cells (RASCs). RASCs were obtained from the synovial tissues of eight patients with rheumatoid arthritis (RA) and SCs from eight patients with osteoarthritis (OA) were used as a control. To examine the influence of TNF-alpha on Fas-ACD, SCs were cultured with anti-Fas antibody (CH11) for 16 h in the absence or presence of different doses of recombinant TNF-alpha. ACD was determined by electron microscopic analysis and the percentage of apoptotic cells was calculated by trypan blue staining. In addition, the expression of Fas and Bcl-2 on RASCs was examined by flow cytometry. As a result, RASCs were more susceptible to Fas-ACD in vitro than OASCs. TNF-alpha interfered with Fas-ACD on RASCs in a dose-dependent manner. Moreover, removal of TNF-alpha activity by a neutralizing anti-TNF-alpha antibody (cA2) restored Fas-ACD. Flow cytometric analysis showed no significant changes in either Fas or Bcl-2 expression on RASCs after the culture with TNFalpha. These results suggest the following: (1) Fas-ACD might be diminished in vivo by local excessive TNF-alpha and this might contribute in part to RASH. (2) The inhibition of Fas-ACD on RASCs by TNF-alpha might not be associated with changes in the expression of Fas or Bcl-2. (3) In addition, considering a magnetic resonance imaging (MRI) finding of marked reduction in the RASH after cA2 treatment, blockade of TNF-alpha activity could restore Fas-ACD in RA synovium, implicating a clinical benefit of anti-TNF-alpha therapy for RA.

The role of IL-6 in experimental autoimmune encephalomyelitis (EAE) provoked by myelin oligodendrocyte glycoprotein (MOG) was investigated using IL-6-deficient mice. We show here that IL-6-deficient mice were resistant to the MOG-induced EAE as compared to wild-type mice (one out of 18 versus 17 out of 20). The delayed-type hypersensitivity response, lymphocyte proliferation response and antibody reactivity to MOG in IL-6-deficient mice were significantly lower than those in wild-type mice. Furthermore, the histological examination revealed that no infiltration of inflammatory cells was observed in the central nervous system of IL-6-deficient mice. These results indicate that IL-6 may play a crucial role in the induction phase of EAE. Given the potential relevance of this animal model for multiple sclerosis (MS), it is possible that anti-IL-6 therapy may be useful in the prevention of relapses of MS.

Background Due to the introduction of biological agents that inhibit the pro-inflammatory cytokines, IL-6 and TNF-α, remission has become a goal in the treatment of RA. Rheumatoid factor (RF) and the Health Assessment Questionnaire (HAQ) have both been investigated as indicators of poor treatment response and poor prognosis. PCT is used for the diagnosis of infections. Although it has been reported that PCT is expressed from peripheral blood mononuclear cells induced by a pro inflammatory cytokine and that it is expressed in the tissues of many human organs, it has rarely been investigated in relation to noninfectious complication of RA. Objectives To investigate whether the levels of PCT and other RA diagnostic and disease activity indicators before the start of TCZ treatment (pre-TCZ) can be used to predict remission at 24 weeks after the start of TCZ treatment (Week 24). Methods Of the 216 patients who started TCZ treatment until September 2012 at our center, those who were observed at Week 24 were analyzed in this study. PCT (n=30), erythrocyte sedimentation rate (ESR) (n=164), RF (n=154), matrix metalloproteinase (MMP)-3 (n=166) and modified HAQ (mHAQ) (n=123) were found pre-TCZ, and the Disease Activity Score (DAS)28-ESR was found as a measure of disease activity. The patients were divided into 2 groups, based on DAS28-ESR remission at TCZ Week 24: the remission (R) group (DAS28-ESR

Background Inflammation, glucocorticoid use and functional disability are major contributors to bone loss or fragility in patient with rheumatoid arthritis (RA).The serum proteins sclerostin and Dickkopf-1(dkk-1) inhibits bone formation by suppression of Wnt-β-catenin signaling. Recently it is reported that the serum levels of sclerostin and dkk-1 increase in patient with RA (1-3) and TNF-alpha contribute to their increase (2,4), however, other possible contributors to the increase in these two Wnt antagonists, such as glucocorticoid use, functional disability or clinically evaluated inflammation level remains to be elucidated. Objectives The present clinical study aimed to investigate the association between serum level of sclerostin and dkk-1 with inflammatory marker, daily glucocorticoid dose and functional class in patients with RA. Methods Ambulatory female RA patients (n=83) with normal renal function (inclusion criteria Cre≤1.0) enrolled in this cross-sectional study. Mean age was 62.5±12.6 (average ± SD) years old. Level of sclerostin and dkk-1 were measured using a commercially available ELISA (Biomedica, Vienna, Austria, and R&D Systems, Mineapolis, MN, respectively). Correlation with serum sclerostin or dkk-1 levels and inflammatory markers, such as CRP, MMP3, RF, Hb, WBC, age, anthropometric factor, Steinblocker’s functional class and daily dose of prednisolone was analyzed using PASW statistics 18 (SPSS An IBM COMPANY, Illinois USA). Results Mean serum level of sclerostin was 36.8±18.4 (average ± SD) ranged from 5.0 to 119.0 pmol/L and dkk-1 was 3084±970 ranged from 1130 to 6490 pg/mL. Daily dose of prednisolone was 2.98±3.28 ranged from 0 to 13.0 mg. There was no correlation between serum level of sclerostin and dkk-1. Both Wnt antagonists were not correlated with any of age, body weight and height. Serum sclerostin level was negatively correlated with CRP (Spearman’s correlation coefficient and p-value, -0.289, 0.009) and positively correlated with Hb (0.221, 0.047), while it was not correlated with MMP-3 and RF. The daily dose of prednisolone was negatively correlated with the sclerostin level (-0.275, 0.024). On the other hand, serum level of dkk-1 was positively correlated with WBC count (0.320, 0.003) but not with CRP, MMP-3, RF, Hb and daily dose of prednisolone. There was no difference in sclerostin and dkk-1 level between functional class 1 and 2. Conclusions Although two Wnt antagonist sclerostin and dkk-1 could contribute to bone loss in patients with RA, discrete association of them with inflammation markers and prednisolone dose was revealed. Serum level of sclerostin was negatively correlated with CRP and daily dose of prednisolone, whereas dkk-1 level was positively correlated with WBC count. These data suggested the different role of these two Wnt antagonists in pathogenesis of bone loss occurred in patients with RA. References Terpos E et al. Clin Exp Rheumatol 2011 Epub ahead of print. Diarra D et al. Nat Med 2007;13:156-63. Garnero P et al. J Rheumatol 2008; 35:2313-15. Vincent C et al. J Bone Miner Res 2009; 24:1434-49. Disclosure of Interest None Declared

Background Long-term use of corticosteroid is often required in rheumatoid arthritis(RA), but it is suggested that dose dependent relationship between prednisone treatment and the risk of pneumonia in RA patients1. Therefore, reducing corticosteroid use may improve the safety profile. Moreover, because long term use of corticosteroid increases adverse events such as osteoporosis, diabetes mellitus, hyperlipidemia, it is better to taper corticosteroid dose as rapidly as clinically feasible. Objectives To evaluate the steroid-sparing efficacy of tocilizumab(TCZ) compared with infliximab(IFX) in RA. Methods Ninety-five RA patients (TCZ n=55; IFX n=40) were enrolled this study from our medical center between 2005 and 2011.The disease activity assessed by DAS28ESR, and prednisolone(PSL) dose were monitored at baseline and after 26, 54weeks. In addition, we evaluated total cholesterol, several bone biochemical markers such as serum crosslinked N-telopeptide of type I collagen (NTx), urinary NTx, and serum osteocalcin(OC) at the same time. Results Baseline characteristics were similar in the 2 groups. Mean age was 59.9±13.5, 58.2±12.5 y, and the mean duration of disease was 11.4±10.1, 9.8±10.0 y in the TCZ and IFX groups, respectively. Disease activity was significantly reduced at week26, week54 compared with baseline in both groups (P

Background Ultrasonography enables to assess the progression of inflammatory joint in patients with rheumatoid arthritis (RA) and the grey-scale and Doppler mode has become an established method for the diagnosis and measurement of response to treatment as part of the follow-up of RA patients. It is quite useful to investigate expansion of synovium and vascularization in the synovium. However, the reliability and limitations of ultrasonography remain a concern. Objectives In this study, we investigated the differences between the findings of ultrasonography in inflamed joints and histopathological investigation in RA patients. Methods 13 RA patients (11 female, 2 men) were enrolled in the study. At the time of joint surgery, the patients had a mean age of 62±11 years and a mean disease duration was 13±7.7 years. All surgery was arthroplasty included as follows; 5 for elbow, 2 for wrist, 1 for finger and 5 for knee. Ultrasound examinations were performed before joint surgery and Power Doppler (PD) signals graded from 0 to 3 were scored semiquantitatively. Synovial tissues were extracted from these patients at the time of operation and histopathological examination was performed using hematoxylin and eosin to evaluate differences. Clinical laboratory data including C-reactive protein (CRP), matrix metalloproteinase-3 (MMP-3), and disease activity scores including a 28-joint count (DAS28), methotrexate (MTX) dose, glucocorticoid dose and use of biologics were also assessed before surgery. Results The US preoperatively showed synovial proliferation in all patients. The PD Grade0 was 6, Grade1 was 4, and Grade2 was 3 patients. The results of histopathological examination showed inflammatory cell infiltration and vascularization in all cases of Grade1 and Grade2. However, inflammatory cell infiltration was revealed even in all 6 cases of Grade0. Moreover, vascularization was revealed even in two cases of Grade0. Conclusions In this study, the results of PD Grade1 and 2 scored by ultrasonography were consistent with histopathological findings. However, it was also revealed that inflammatory cell infiltration and vascularization was observed even if PD showed Grade0. Although further studies are necessary, this study may suggest the possibility that subclinical inflammation are continued even if PD shows Grade0. References Analysis of the histologic variation of synovitis in rheumatoid arthritis. Rooney M, Condell D, Quinlan W, Daly L, Whelan A, Feighery C, Bresnihan B. Arthritis Rheum. 1988 Aug;31(8):956-63. Relationship between histological findings and clinical findings in rheumatoid arthritis. Matsuno H, Yudoh K, Nakazawa F, Koizumi F.Pathol Int. 2002 Aug;52(8):527-33. Synovial membrane immunohistology in early untreated juvenile idiopathic arthritis: differences between clinical subgroups.Finnegan S, Clarke S, Gibson D, McAllister C, Rooney M.Ann Rheum Dis. 2011 Oct;70(10):1842-50. Disclosure of Interest None Declared

Background Gut microbiota have long been thought to contribute to inflammatory disease, and some have considered the bacterial flora as one of the environmental factors causing rhumatoid arthritis (RA). Recently, two gnotobiotic experiments have shown that only one indigenous microflora is critical for the development of arthritis.Wu, et al. have demonstrated that Segmented Filamentous Bacteria induce the differentiation of Th17 cells and cause arthritis in K/BxN mice. Furthermore, Abdollahi-Roodsaz et al. showed the induction of arthritis in IL-1 receptor antagonist-knockout mice by oral administration of Lactobacillus sp. under germ-free condition. In humans, gut microbiota might regulate the host immune systems. Some changes of bacterial flora may cause autoimmune arthritis.On the other hand, new culture-independent genomic analysis techniques of the human microbiome have advanced and make us possible to clarify and quantify in-cultured commensal bacteria. Objectives To explore the differences of fecal microbiota between RA patients and healthy volunteers, employing the newly developed the Yakult Intestinal Flora-SCAN (YIF-SCAN®), based on reverse transcription–quantitative PCR (RT-qPCR) using specific primers that target bacterial rRNA molecules. Methods Fecal samples were collected from 37 RA patients and 59 healthy volunteers in NHO Osaka Minami Medical Center between January and November, 2011. YIF-SCAN® was performed to quantify the bacterial count with 16S or 23S rRNA-targeted group-specific primers. Results Clinical characteristics of both groups are shown in Table 1. There were no statistically significant difference in the bacterial counts and the prevalence of obligate anaerobic bactrerial groups ( Clostridium coccoides group, C. leptum subgroup, Bacteroides fragilis group, Bifidobacterium , Atopobium cluster, Prevotella ) and C. difficile, C. perfringens between RA and healthy volunteers. Interestingly, Table 2 showed that in facultative anaerobic groups, total bacterial population levels of Lactobacillus (especially L. gasseri, L. reuteri, L. plantarum, L. fermentum subgroup ) and Enterococcus were significantly higher in RA. The prevalence of L. reuteri, L. ruminis, L. fermentum subgroup was significantly higher in RA. Conclusions We obviously found the differences of fecal microbiota between RA patients and healthy volunteers. Clinical significance of these observations is still unknown.For further understanding of these results, samples of RA patients who have been treated with biologics for 6 months and attained clinical remission are being re-examined for analysis. References H-J Wu et al., Immunity 32: 815-827, (2010) S. Abdollahi-Roodsaz et al., J Clin Invest 118: 205-216, (2008) J. U. Scher et al., Nat. Rev. Rheumatol. 7: 569-578, (2011) Disclosure of Interest None Declared

Background Oxidative stress induced by reactive oxygen species (ROS) is also an important mechanism that underlies destructive and proliferative synovitis in rheumatoid arthritis (RA). Abundant amounts of reactive oxygen species have been detected in the synovial fluid of inflamed rheumatoid joints. It is reported that drugs that block tumor necrosis factor (TNF) reduce the oxidative stress marker levels in patients with RA [1,2]. Then, it is plausible to consider that interleukin-6 (IL-6)-blocking drug also reduce ROS levels in RA cases. Objectives The influence of not only TNF-blocking drug, but also IL-6-blocking drug on the serum level of oxidative stress marker were evaluated. Methods In this study, we measured reactive oxygen species (ROM: reactive oxygen metabolites) using a free radical analytical system (FRAS4, Wismarl, Italy) in 140 patients with RA treated with disease-modifying anti rheumatic drugs (DMARDs) (n=91), TNF-blocking drugs (infliximab, etanercept) (n=8), and an interleukin-6 (IL-6)-blocking drug (tocilizumab) (n=26). As a control, patients suffering from osteoarthritis (OA) were selected (n=15). Of these 26 patients treated with tocilizumab, 3 cases were followed longitudinally. Serum level of ROM was measured before administration of tocilizumab, 1 week after administration, 3 and 4 months after administration. Inflammatory makers (CRP: C-reactive protein, WBC: white blood cell) and matrix metalloproteinase-3 (MMP-3) were also measured. Results Patients with OA showed 375.5 ± 72.5 Carr U of ROM, which is significantly lower (p Conclusions Serum level of oxidative stress markers is dramatically low and smoothly reduced in patients with RA treated with tocilizumab, suggesting that IL-6 blocking therapy reduces not only joint damage, but also extra-articular manifestations caused by oxidative stress, including vascular degeneration in patients with RA. We believe that this drastic effect may reduce the incidence of cardiovascular events and mortality in patients with RA. References Kageyama Y, Takahashi M, Nagano A et al. Clin Exp Rheumatol. 2008 Kageyama Y, Takahashi M, Nagano A et al. Rheumatol Int. 2008 Hirao M, Yamasaki N, Hashimoto J et al. Rheumatol Int. 2012 Disclosure of Interest None Declared

Background In recent years, we have to evaluate the disease activity more precisely and more complexly in a tight schedule. Therefore we need the convenient system both for inputting the information and viewing the sufficient data. We developed an original computerized touch-panel type screening system for assessment of HAQ and visual analog scale (VAS). This is connecting to our original medical database for RA patients, called “MIRAI”, MIRAI works as a supporting system for the electronic health record. It is possible to show the record of prescription for RA, DAS28, SDAI, CDAI, RAPID3, CRP, HAQ, map of swollen/tender joints and physician’s VAS on the same screen. Objectives We assessed the usefulness of our original touch-panel method for the evaluation of functional ability in RA. Methods 300 RA patients visiting Osaka-Minami medical center were asked their opinion about their experience filling in the HAQ, their willingness for future registration on the touch-panel, and their opinion on usefulness of the HAQ in the survey questionnaire. Results The average age was 62.7 years (range 18-85) and 79% were female. The mean time patients needed to fill in their HAQ was 0.8 minutes (range 0.1-19.2). Inputting with touch-panel method was not time-consuming since it is easy to input and includes only a small number of actions. Result of survey questionnaires are presented in table 1. 96% of patients could fill out on the touch panel easily, and did not feel necessity of assistance at the next visit. 98.7% of patients were willing to fill in the HAQ at the next visit. All patients except one (99.7%) felt discussing problems in daily functioning is important, however it is not always discussed with the doctors (45.7%). 10.3% of patients felt HAQ did not give accurate representation of functional abilities. Conclusions This touch-panel method is very useful and feasible for assessing both the functional status quality of life and disease activity with rheumatoid arthritis. It might contribute to shortening the time of medical examination. In addition, MIRAI would be promising system for supporting the electronic health record. Furthermore, this system would develop the network efficiency among hospitals and consequently our clinical research collaboration as well. Disclosure of Interest None Declared

Background With recent astonishing advances in drug therapy, “remission” has become a realistic therapeutic goal in RA. Among them the most powerful driving force might be the advent of “biologics (Bio)” targeting cytokines and lymphocytes. In fact, they have shown outstanding efficacy and become a master of drug. However, some issues remain to be addressed and resolved, including adverse effects such as serious infections, therapeutic failure and high cost. Objectives To examine the causes of discontinuation of Bio in 2,274 Japanese RA patients treated with Bio under practical circumstances. Methods The causes of discontinuation of Bio-use were analyzed by using the data from the “NinJa”, one of the largest Japanese RA patient registry established since 2002 and now consists of the clinical data of 10,368 patients from more than 30 hospitals. Results 2,274 (22.1%) of the total registered patients were treated with some Bio. Among them, 352 (15.5%), 940 (41.3%), 258 (11.3%), 63 (2.8%), 459 (20.2%), and 206 (9.1%) of the patients were treated with IFX, ETN, ADA, TCZ and ABT respectively. The cases (percentages) of discontinuation of Bio-use were 62 (17.6%), 71 (7.6%), 55 (21.3%), 39 (8.5%), and 20 (9.7%) in IFX, ETN, ADA, TCZ and ABT respectively. The causes of discontinuation were analyzed and shown in the following Table. Regarding “Failure”, the discontinuation rate was significantly higher ADA. In “Adverse effects”, there was no significant difference among all Bio, although a tendency of higher rate was observed in IFX and ADA. In contrast, it was relatively low in ABT. In addition, the discontinuation due to “Remission” was significantly higher in IFX compared to other Bio. Conclusions There were some characteristics in the causes of discontinuation among Bio. It seems to be feasible to achieve Bio-free remission in some Bio. With further investigations, these findings might provide us a clue to know how and which cases can be achieved Bio-free remission. Acknowledgements This study was supported by both the grants of NHO (National Hospital Organization) and the Ministry of Health, Welfare and Labor. Disclosure of Interest None Declared

Background Recent cumulative evidence suggests that early therapeutic intervention by DMARDs including MTX could prevent progression of RA. However, it is not clarified how early and which population of the patients should be taken early therapeutic intervention by DMARDs. Previously we reported that the patients with early-onset UA (EUA) showing high-titer anti-citrullinated peptide antibodies (ACPA) (>15 U/ml) developed RA within a year at high-rate (>80%) (ref.1). Objectives To examine whether very early therapeutic intervention of MTX could prevent development of RA in the patients with EUA showing high-titer of ACPA. Methods A prospective controlled study was conducted. The total number of 48 patients with UA showing high-titer of ACPA (>15 U/ml) who have never treated with any non-biologic DMARDs or biologics. All patients were fulfilled with 1994 JCR classification criteria for early RA (ref.2) but not 1987 ACR classification for RA. They participated in this study with given written informed consents and divided into two groups according to their decision. One group was treated with MTX concomitant with corticosteroid (PSL Results As shown in Figure 1(Kaplan-Meier), 5 of the 30 patients (16.7%) in the MTX+ Group developed RA compared with 14 of the 18 patients (77.8%) in the MTX- Group (HR 0.214 [95% CI 0.093-0.495], p p = 0.312), the number of patients without obvious radiographical progression was relatively more in MTX+ (18 /23, 78.3%) compared to in MTX- (6 /11, 54.5%). In addition, there were no particular findings regarding to adverse events. Image/graph Conclusions Although short-term observation, very early therapeutic intervention of MTX might prevent development of RA in some populations of EUA. References Kudo-Tanaka E et al. Clin Rheumatol 2007.26:1627-33. Yamamoto S. Ryumachi 1994.34:1013-8. Disclosure of Interest None Declared

Background Infection is one of the serious complications seen in the management of RA patients. The acute inflammatory marker C-reactive protein (CRP) is elevated both during infection and during high disease activity of RA, and this often poses a problem when distinguishing the two. The soluble CD14 subtype, presepsin has been reported to be a novel effective marker for the diagnosis of sepsis but has not been evaluated in RA patients. Objectives To evaluate the use of presepsin in RA patients during an infectious event. Methods 25 RA patients with infections, 21 RA patients with high disease activity, 23 healthy controls (HC) were enrolled in this study. RA patients in whom the pathogens were identified (22 bacterias, 2 viruses, and 1 M. tuberculosis) were designated as the infection RA group (iRA), high disease activity RA patients without infection were designated as the flare RA group (fRA). Presepsin was measured using a chemiluminescent enzyme immunoassay. CRP and procalcitonin (PCT) were also measured. RA disease activity was evaluated using DAS28-CRP. Levels of respective measurements at both pre- and post-treatment were analyzed using the Wilcoxon signed-rank test, and comparisons of levels within each group were analyzed using the Mann-Whitney’s U-test. Additionally, Spearman’s rank correlation coefficient was used to analyze the correlation of levels of presepsin, CRP, and PCT in iRA and correlation of presepsin, DAS28-CRP, and CRP in fRA. Further, AUC was obtained from the ROC analysis. Treatment for iRA included antibiotics, antivirals, and treatment for fRA included corticosteroids, DMARDs, and biologics. Results In fRA, average level of CRP was 2.4±2.1mg/dl, DAS28-CRP was 4.2±1.31. At pre-treatment, levels of presepsin in iRA (2088.4±4243.7pg/ml) was significantly higher compared to in fRA (319.3±321.8pg/ml, p Conclusions Presepsin is an effective diagnostic marker for infection in RA patients. References Y. Yaegashi, et al., J Infect Chemother 2005;11:234-238 T. Shozushima, et al., J Infect Chemother 2011;17:764-769 Disclosure of Interest None Declared

Background New insights from DNA sequence-based analyses of gut microbial communities and the renewed interest in mucosal immunology suggest that the microbiome is an important environmental factor influencing autoimmune disease manifestations. Objectives To investigate the fecal microbiota of rheumatoid arthritis (RA) patients and healthy volunteers (HVs), we used the Yakult Intestinal Flora-SCAN (YIF-SCAN®), based on reverse transcription–quantitative polymerase chain reaction, with primers specific for target bacterial rRNA. We also investigated whether the fecal microbiota changed in RA patients due to biologic (Bio) treatment. Methods Fecal samples were collected from 55 RA patients and 77 HVs in NHO Osaka Minami Medical Center during 2011–2012. YIF-SCAN® was performed to quantify the bacterial count with 16S or 23S rRNA-targeted group-specific primers. 25 RA patients were re-examined after they underwent Bio treatment (tocilizumab, 10; infliximab, 9; etanercept, 3; adalimumab, 1; abatacept, 2) for 6 mo. Patients who had received antibiotic therapy were excluded. Results The mean age was 57.8 ± 14.5 and 36.3 ± 10.7 years; mean body weight, 54.5 ± 10.0 and 57.0 ± 9.0 kg; and the proportion of women, 72.7% and 90.9%, for the RA patients and HVs, respectively. From the facultative anaerobic groups, the total population levels of Lactobacillus (especially the Lactobacillus gasseri, L. reuteri, and L. fermentum subgroups) and Enterococcus, Enterobacteriaceae were significantly higher in RA. These results support those of our 2012 study [1]. The background of the 25 RA patients reanalyzed after treatment is shown in [Table 1][1]. The DAS28CRP was 4.1 ± 1.1 at baseline and 2.5 ± 1.1 at 6 mo. 12 patients (48%)achieved remission (DAS28CRP < 2.3) at 6 mo. The total bacterial count and total population levels of the Clostridium. coccoides group, Bifidobacterium, and the L. gasseri and L. plantarum subgroups significantly decreased at 6 mo ([Table 2][1]). ![Figure][2] Conclusions We confirmed the difference in the fecal microbiota of RA patients and HVs. Bio treatment considerably reduced commensal bacteria in RA patients. To our knowledge, this is the first study describing changes in fecal microbiota due to Bio treatment. Further studies are required to elucidate the clinical significance of these results. References Y.maeda, et al. Ann Rheum Dis 2012;71(Suppl3):496 Disclosure of Interest None Declared [1]: #F1 [2]: pending:yes

Background While the emphasis in rheumatoid arthritis (RA) treatment is on early diagnosis and intervention, we cannot provide the certain strategies for diagnosis. It is well known that serum immunoglobulin G (IgG) from RA patient exhibit decreased galactosylation of conservative N-glycans in CH2 domains of the heavy chains. Kondo et al. developed novel high-performance liquid chromatography (HPLC) method for precise analysis of oligosaccharides of IgG 1) . Objectives To evaluate both diagnostic and predictive value of agalactosyl IgG in RA, we analyze serum IgG oligosaccharide structures using HPLC both in established RA, and in early undifferentiated arthritis as a diagnostic marker for future development ofRA. Methods Firstly, serum samples were collected from 94 patients with RA fulfilled the 1987-ACR-criteria, 16 with OA, 18 with SLE, and 24 with healthy subjects (HS). The percentage agalactosyl IgG oligosaccharides (%G0) were analyzed in serum samples by high performance HPLC method. Secondly, we analyzed %G0 in 144 patients with recent-onset undifferentiated arthritis (UA) defined as not fulfilling existing classification criteria. They were studied for whether UA progressed to RA after 2 year. Results In the first study, serum levels of %G0 were significantly higher in established RA (41.5±9.1) than in HS (21.1±4.4; p Conclusions In conclusion, this novel method for analyzing agalactosyl IgG revealed excellent diagnostic value inRA. %G0 as well as ACPA would contribute to prediction of RA, allowing early therapeutic decisions. Furthermore, agalactosyl IgG may be involved in pathogenesis of RA. References Kondo A, et al. Separation of pyridylamino oligosaccharides by high-performance liquid chromatography on an amine-bearing silica column. Anal Biochem 1994, 219, (1), 21-5. Disclosure of Interest None Declared

Background Therapy for rheumatoid arthritis (RA) has made rapid progress in recent years. The use of biologics makes it possible to achieve both bio-free remission and drug-free remission. However, biologics are known to increase the risk of infection, and discontinuance rates of biologics are on the rise. Objectives To evaluate the use of biologics, to compare different biologics, and to investigate the reason why interruption in biologics occurs by Ninja. The Ninja is the largest registry database of Japanese patients with RA. This database consists of data in real world. Methods We analyzed the use of biologics among 7574 RA patients enrolled in the Ninja during 2010. Characteristics (age, duration of RA, steroid dosage, duration of biologics and rate of remission) of these patients were evaluated. Cases of discontinuation or change in biologics during 2009∼2010, were evaluated. Furthermore, in the cases of discontinuation due to remission we sent out questionnaires to every institution. Results Among the 7574 RA patients, 1350 (18%) were on biologics, including infliximab (IFX), 306 patients (23%), tocilizumab (TCZ) 220 (16%), etanercept (ETN) 607 (45%), adalimumab (ADA) 171 (13%), abatacept (ABT) 34 (2%), and golimumab (GOL), 10 (1%). There were no significant differences in age, duration of RA, duration of biologic use and steroid dosages. However, MTX dosages were different in each group. The IFX group had the highest number of MTX use (99%), and TCZ group had the least number of patients (35%) (Table 1). During the period 2009∼2010, there were 192 cases that discontinued biologics. The reasons for discontinuing biologics were, (1) ineffectiveness (92 cases/48%), (2) adverse events (66/34%), (3) remission (13/6%),(4) others (21/10%) (Fig. 1). The results showed that IFX and TCZ might be more effective for inducing bio-free remission than other biologics. No cases of bio-free remission were seen with ETN, suggesting that bio-free remission may be difficult to achieve with ETN. When we analyzed the 13 cases of bio-free remission, we found no difference in patient characteristics compared with all case of biologic use. It was also shown that the bio-free remission can be achieved in patients with long history of RA. Conclusions ETN was the most commonly used, followed by IFX, and TCZ. IFX and TCZ may achieve bio-free remission more effectively compared with other biologics. In contrast, it may be difficult to achieve bio-free remission with ETN. This might be, however, dependent on the dosage of MTX, as the MTX dosage was less in the ETN group compared to the others. In the TCZ group the cases that maintained the bio-free remission had no MTX use, indicating the potential of TCZ to achieve the bio-free remission without MTX. Disclosure of Interest None Declared

Background Allergic sensitization to food can occur through skin exposure. We investigated anaphylactic cases due to carmine, a food additive extracted from Dactylopius coccus. Methods Screening all patients, who visited our department from January 2000 to December 2009, we identified 2 new such cases. Both had history of rash induced by certain cosmetics containig carmine. We further investigated previous case reports of carmine allergy, whether skin sensitization antedated food allergy or not. Results Case 1: A 26-year-old woman visited our hospital because of anaphylaxis occurred within 5 minutes after ingesting a Japanese YOKAN (sweetened and jellied bean paste). IgE antibodies against common food allergens including beans and wheat were all negative. As the paste contains carmine, we tested specific IgE antibody, which was positive. She had been avoiding using certain cheeks and lips for 2 years, since they cause erythema. These cosmetics emerged as containing carmine. Abstaining from the food additive made her free from anaphylaxis. Case 2: A 30-year-old woman came to our hospital for dyspnea, uriticaria, and bilateral blepharedema, immediately after drinking Campari soda. Her past history was prominent, as she had 4 episodes of anaphylaxis in 4 years, requiring emergency transport twice. All anaphylactic episodes occurred in Italian restaurants when she drank cocktails, which might contain carmine in Campari soda. She had been also sensitive to certain rouges since several years before the first onset of anaphylaxis. It became clear that the rouges contained carmine. In literatures, we found 22 cases with allergy to ingested carmine. It is surprising that all cases were women (aged 25 to 52), while occupationally sensitized patients are predominantly men. As far as we could know, 85.7 % of (6/7) mentioned cases had previous history of sensitization to cosmetics containing carmine. Conclusions In many cases with allergy against ingested carmine, the route of first sensitization was not via intestine but skin. This is similar to suspected peanut sensitization mechanism and might be a paradigm of food allergy. As allergic reaction to carmine mainly directed to impurities, using highly purified carmine is desired not only for foods but also for cosmetics.

To investigate the mode of the pathogenesis of multiple sclerosis (MS), we transferred cerebrospinal fluid (CSF) cells, predominantly mononuclear cells, from MS patients at both exacerbation and remission stages of the disease into severe combined immunodeficiency mice by intracisternal injection. As controls, (i) CSF cells from patients with cervical spondylosis and (ii) peripheral blood mononuclear cells from normal individuals were transferred. Four to 6 weeks after transfer, most mice transferred with CSF cells from MS patients at the exacerbation stage of the disease developed paralysis and ataxia. The histopathological examination on the sacrificed mice revealed multiple scattered, discrete lesions localized in the white matter of the brainstems and spinal cords. These lesions were characterized by various degrees of tissue necrosis, involving inflammatory-cell infiltration. Most infiltrating cells were macrophages, although a smaller number of granulocytes appeared in several foci. Reactive astrocytic gliosis was also seen around the necrotic foci. Furthermore, these lesions exhibited demyelination. These histopathological changes are similar to those seen in MS. In contrast, none of the severe combined immunodeficiency mice transferred with CSF cells from MS patients at the remission stage of the disease, or with CSF cells from the patients with cervical spondylosis, or with peripheral blood mononuclear cells from normal individuals showed any such histopathological changes. These observations provide convincing direct evidence of encephalitogenicity of mononuclear cells in CSF from MS patients at the exacerbation stage of the disease.

The tumor-specified cellular and humoral immunity induced by anti-idiotype antibodies (Ab2s) 2F10 and 3A4 has been studied. Ab2s were made against a monoclonal anti-L1210/GZL lymphoma, 11C1. They were screened for their ability to block 11C1 binding to tumor, induce tumor-specific DTH and CTL responses, and induce an anti-tumor humoral response. Two Ab2s, 2F10 and 3A4, which were found to have similar fine specificity and to induce similar cellular and humoral responses, were compared for their ability to elicit tumor-protective immunity. Interestingly, only preimmunization with the 2F10 Ab2 protected animals from live tumor challenge. The possible causes for this discriminatory biological effect induced by otherwise similar Ab2s are discussed.

Statistical analysis of serum immunoglobulin levels in 54 systemic lupus erythematosus (SLE) patients showed a decrease in serum IgM (normal 77 +/- 26 mg/dl; P less than 0.001) that was closely related to disease duration. The longer the duration of SLE, the more striking the decrease in serum levels of IgM (r = -0.74, P less than 0.01). Selective IgM deficiency (less than 47 mg/dl) occurred in SLE patients whose disease was clinically inactive or less active.

In an analysis of lymphocyte functions of systemic lupus erythematosus (SLE) patients, B cell abnormalities such as a lack of mitogen-responsive B cells and a predominance of spontaneous IgA-secreting cells (SC) were found. Lymphocyte functions of 20 SLE patients were studied. Impaired proliferative response to B cell mitogen, Staphylococcus aureus strain Cowan I (Cowan I), was observed, whereas the response to T cell mitogen phytohemagglutinin was normal. High levels of spontaneous IgA-SC were observed in SLE patients (greater than 10(2) cells/10(4) peripheral blood mononuclear cells [PBMC]), whereas spontaneous IgM-, IgG-, or IgE-SC were not proportionately increased. The number of spontaneous IgA-SC decreased with time in culture and became undetectable by day 5 of culture. In contrast, spontaneous immunoglobulin- (IgM, IgG, and IgA) SC were not observed in healthy volunteers (less than 10 cells/10(4) PBMC). Moreover, in SLE patients failure of induction of immunoglobulin-secreting cells (ISC) was observed when B cells were stimulated by Cowan I and B cell differentiation factor at any day tested, whereas ISC were induced in healthy volunteers on day 6 of culture. Depletion of T cells or macrophages did not affect the results obtained. These results suggest that the abnormalities observed in SLE B cells are not due to the in vitro direct effects of suppressor macrophages or suppressor T cells, and that the condition of the predominance of spontaneous IgA-SC and the unresponsiveness to exogenous stimulation may be emblematic of hyperactive B cells in SLE.