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We aimed to apply and compare the QRISK3 and the adjusted Global AntiPhospholipid Syndrome (APS) Score (aGAPSS) in a cohort of systemic lupus erythematosus (SLE) patients, with and without a concomitant diagnosis of APS, in order to assess their augmented risk of developing cardiovascular diseases (CVDs).Patients (25-85 yo) with a diagnosis of SLE and/or of Secondary APS (SAPS) were included. QRISK3 was calculated using the official online calculator; aGAPSS using the validated point-values based on aPL-profile and independent risk factors.The cohort included 142 SLE patients: 34 SAPS (23.9%) and 108 SLE patients without APS (76.1%).When considering all the cohort, patients with cerebrovascular/coronary events showed higher values of aGAPSS (10.1 ± 6.2 vs. 5.8 ± 6.1; p = 0.007), but not of the QRISK3. Furthermore, a significant association was observed between the occurrence of these events and high-risk aGAPSS: p = 0.03 for aGAPSS≥8, p = 0.01 for aGAPSS ≥9, p = 0.008 for aGAPSS ≥10. aGAPSS strongly correlated with the occurrence of any thrombotic event, both at the uni- and multivariate analysis (p = 0.012 and p = 0.009). Male gender also resulted to positively correlate with the occurrence of any thrombotic event at both uni- and multivariate analysis (p = 0.017 and p = 0.03). Focusing on aPL-profile, regardless the diagnosis, we found a statistical significance only for aGAPSS (aPL+ =9.6 ± 6.3 vs. aPL- = 4.1 ± 5.1; p 0.001).Despite QRISK3 being more accurate than traditional risk score in predicting CVD risk in SLE patients, aGAPSS appears to be the most valuable tool for this purpose.

Background Patients on B-cell depleting agents may have a suboptimal response to vaccination, placing them at a higher risk of contracting SARS-CoV-2 or suffering from a more severe prognosis. Indeed, available data on pre-exposure prophylaxis with tixagevimab/cilgavimab (Evusheld) in subjects with glomerular diseases (GD) who received rituximab is limited. Methods We conducted a prospective study analyzing the safety and efficacy of tixagevimab/cilgavimab for pre-exposure prophylaxis in patients with GD who received rituximab in the previous 12 months. Rate of symptomatic infections and hospitalizations were compared to patients with GD treated with rituximab who refused to receive tixagevimab/cilgavimab. Results Tixagevimab/cilgavimab was administered to 22 patients (12 females, mean age 58,4 ± 19,6 years) with GD diagnoses including membranous nephropathy, lupus nephritis, ANCA-associated vasculitis and focal segmental glomerulosclerosis. No patient treated with tixagevimab/cilgavimab experienced symptomatic infection with SARS-CoV-2 during the follow-up (mean observation time follow-up was 112 ± 23 days), while 11 out 28 controls (39,3%) reported a symptomatic infection (p = 0001), requiring hospitalization in 2 cases. Reported adverse events were mild, namely self-limiting headache (4), discomfort at the injection site (3), flu-like symptoms/myalgia (3), and fever (1). No serious adverse event, (e.g. cardiac events, anaphylaxis) was reported. Conclusion Pre-exposure prophylaxis with tixagevimab/cilgavimab (Evusheld) seems safe and lowering of about 40% the risk of symptomatic SARS-CoV-2 infection in vaccinated subjects with GD who received anti-CD20 therapy. Possible applications in the subset of patients who need immunosuppressive therapy, especially with Rituximab, in a pandemic setting might be envisaged.

To investigate the rate of disease evolution in a cohort of patients with undifferentiated connective tissue disease (UCTD) and to determine clinical and immunological features more frequently associated with disease progression.This retrospective single-centre long-term follow-up cohort study included patients with UCTD diagnosis, ANA positive, with a follow-up of at least 2 years.A total of 100 UCTD patients were recruited. During the follow-up (6.2±2.1 years), 44 patients (44%) developed novel clinical and/or laboratory features (rate of development patient/year of 7%), and 21 patients (21%) evolved into a definite connective tissue disease (CTD) after a mean time of 7±5.5 years with a rate of disease evolution (patient/year) of 3%. New clinical manifestations (39 patients) included: joints (36%), haematological (30%), cutaneous (13%), pulmonary (10%) and renal (10%) involvement. New laboratory findings (17 patients (17%)) included: 2 anti-ENA positivity, 3 anti-dsDNA antibodies positivity and 6 low complement levels. At follow-up, 13 patients (61.9%) met the classification criteria for systemic lupus erythematosus, 1 patient (4.8%) for mixed CTD, 5 patients (23.8%) for systemic sclerosis and 2 patients (9.5%) for Sjögren's syndrome. Patients evolving towards a new diagnosis had longer disease duration (15.2±9.7 years vs. 10±5.8 years; respectively, p0.005), had a higher prevalence of anti-Ro/SSA antibodies (63.2% vs. 28.4%; respectively, p0.05) and anti-RNP antibodies (21.1% vs. 7.4%; respectively, p0.05). The statistical difference was also confirmed after the multivariate analysis.Up to 45% of UCTD patients might develop novel clinical and/or laboratory features during the follow-up, leading to evolution into a definite CTD in 1 out 5 cases.

Background The rate of antiphospholipid antibody (aPL) negativization in antiphospholipid syndrome (APS) patients is uncertain, but it is estimated to be as high as 8%. Currently, a consensus definition of aPL negativization is lacking, as well as international recommendations on how to approach treatment in patients with a persistent aPL-negative seroconversion. Aim The aim of the Delphi survey was to evaluate the clinical approach and level of consensus among experts from the APS Study Group of the Italian Society for Rheumatology (SIR-APS) in different clinical scenarios. Methods Experts of SIR-APS were contacted using a survey methodology. Results A structured survey was circulated among 30 experts. Up to 90% of the interviewed experts agreed on defining aPL negativization as the presence of two negative determinations, 1 year apart (90%). Almost full consensus exists among experts in some clinical settings, including: (1) the role of aPL negativization in the management of a thrombotic event determined by concomitant presence of cardiovascular risk factors, both modifiable and not modifiable (90%); (2) approach to young patients with triple aPL positivity who experienced pulmonary arterial thrombotic events and tested negative for aPL detection after 5 years of vitamin K antagonist (VKA) treatment (90%); (3) the use of “extra criteria” aPL antibody testing before pondering VKA suspension (93%). Conclusion A substantial agreement exists among experts on how to define aPL negativization. VKA suspension should be embraced with extreme caution, particularly in case of previous thrombotic events and/or triple aPL positivity. Nevertheless, VKA cessation might be considered when risk factors are carefully monitored/treated and the presence of “extra criteria” aPL is ruled out.

We aimed to investigate the epidemiology, the clinical and laboratory characteristics of the pediatric involvement of antiphospholipid syndrome (APS), by performing a review of the current evidence and reviewing local experience in the Northwest Italy. To achieve this, we performed a detailed literature search to identify articles describing clinical and laboratory characteristics of pediatric APS. In concomitance, we conducted a registry-based study collecting data from the Piedmont and Aosta Valley Rare Disease Registry including pediatric patients diagnosed with APS in the last 11 years. The literature review led to inclusion of six articles with a total of 386 pediatric patients (65% females, 50% with systemic lupus erythematosus (SLE) as concomitant diagnosis). Rates of venous and arterial thrombosis were 57 and 35%, respectively. “Extra-criteria manifestations” included mostly hematologic and neurologic involvement. Almost one-quarter of patients (19%) reported recurrent events and 13% manifested as catastrophic APS. A total of 17 pediatric patients (mean age 15.1 ± 2.8, 76% female) developed APS in the Northwest of Italy. In 29% of cases, SLE was a concomitant diagnosis. Deep vein thrombosis was the most frequent manifestation (28%) followed by catastrophic APS (6%). The estimated prevalence of pediatric APS in Piedmont and Aosta Valley Region is 2.5/100,000 people, whereas the estimated annual incidence is 0.2/100,000 inhabitants. In conclusion, clinical manifestations of pediatric APS seem to be more severe and with a high prevalence of noncriteria manifestations. International efforts are needed to better characterize this condition and to develop new specific diagnostic criteria to avoid missed/delayed diagnosis in children with APS.

OBJECTIVE We aimed to investigate the impact of applying the 2019 European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) classification criteria for systemic lupus erythematosus (SLE) in a previously described cohort of women with undifferentiated connective tissue disease (UCTD). METHODS This study included 133 women with UCTD. At the time of inclusion into the study, none of the patients met any classification criteria for other defined systemic connective tissue disease. RESULTS When applying the 2019 EULAR/ACR classification criteria to the cohort, 22 patients (17%) fulfilled the classification criteria for SLE. Patients classified as having SLE had significantly higher frequencies of mucocutaneous manifestations (23% versus 5%; P = 0.007), arthritis (59% versus 17%; P < 0.001), isolated urine abnormalities (18% versus 1%; P < 0.001), and highly specific antibodies (50% versus 15%; P < 0.001) compared to the other patients with UCTD. At follow-up, these patients were statistically significantly more likely to also meet the 1997 ACR revised SLE criteria and the Systemic Lupus International Collaborating Clinics (SLICC) criteria (18.2% versus 1.8%; P < 0.001) compared to the other UCTD patients. Patients who were diagnosed as having SLE according to the ACR 1997 update of the SLE revised criteria and the SLICC criteria during the follow-up scored higher on outcome measures when classified as having SLE according to the new 2019 EULAR/ACR classification criteria when compared to the other patients with UCTD (mean ± SD score 8.3 ± 3.7 versus 4.5 ± 4; P < 0.05). CONCLUSION When applying the 2019 EULAR/ACR criteria for SLE in a cohort of patients with UCTD, we observed that in up to 17% of cases the original classification could be challenged. New implementation will help to identify earlier patients at higher risk of developing more severe CTD manifestations.

The interest of extra-criteria antiphospholipid antibodies is growing, especially in patients negative for conventional antibodies. In this study we aimed to assess the clinical utility of anti-phosphatidyl-serine/prothrombin antibodies (aPS/PT) testing in patients negative for Beta2-Glycoprotein 1(β2GPI)-dependent tests, for identifying antiphospholipid syndrome (APS) patients that developed cerebrovascular events (CVE). When screening APS patients attending our center, out of 119 aPS/PT IgG/IgM-positive patients, thus patients negative for aβ2GPI and aCL, 42 patients (35%) tested negative for β2GPI-dependent tests and were tested with thrombin generation assay (TGA). Ten patients (24%), with isolated aPS/PT IgG/IgM, had a history of CVE. Lupus anticoagulant (LA)-positive test was more frequently observed in patients with CVE (8/22 vs. 2/20; p = 0.045). Out of the 10 patients who experienced CVE, 3 patients were aPS/PT IgG positive (all LA positive), and 8 patients were aPS/PT IgM positive (6/8 LA positive). One patient was positive for both aPS/PT IgG and IgM. LA-positive patients had only high titers of aPS/PT IgG/IgM, all of them being ≥ 80 U/ml, while the 2 LA-negative patients were aPS/PT IgM positive with medium titers [40–60 U/ml]. LA-positive patients had significantly altered TGA profile when compared to those who were LA negative, considering all TGA parameters. LA-positive patients had significantly higher tLag (8.4 ± 3.3 min vs. 6.6 ± 1.8 min; p = 0.046), higher tPeak (14 ± 4.3 min vs. 11 ± 2.7 min; p = 0.015) and lower Peak (207 ± 152 nM vs. 356.3 ± 104.7 nM; p p = 0.033). The use of aPS/PT might be of help in identifying patients with CVE and APS, as also confirmed by TGA testing.

(1) Background: Immunological laboratory testing is known to be complex, and it is usually performed in tertiary referral centers. Many criticalities affect diagnostic immunological testing, such as limited availability, the need for specifically trained laboratory staff, and potential difficulties in collecting blood samples, especially in the most vulnerable patients, i.e., the elderly and children. For this reason, the identification of a new feasible and reliable methodology for autoantibody detection is urgently needed. (2) Methods: We designed a systematic review to investigate the available literature on the utilization of saliva samples for immunological testing. (3) Results: A total of 170 articles were identified. Eighteen studies met the inclusion criteria, accounting for 1059 patients and 671 controls. The saliva collection method was mostly represented by passive drooling (11/18, 61%), and the most frequently described methodology for antibody detection was ELISA (12/18, 67%). The analysis included 392 patients with rheumatoid arthritis, 161 with systemic lupus erythematosus, 131 with type 1 diabetes mellitus, 116 with primary biliary cholangitis, 100 with pemphigus vulgaris, 50 with bullous pemphigoids, 49 with Sjogren syndrome, 39 with celiac disease, 10 with primary antiphospholipid syndromes, 8 with undifferentiated connective tissue disease, 2 with systemic sclerosis, and 1 with autoimmune thyroiditis. The majority of the reviewed studies involved adequate controls, and saliva testing allowed for a clear distinction of patients (10/12 studies, 83%). More than half of the papers showed a correlation between saliva and serum results (10/18, 55%) for autoantibody detection, with varying rates of correlation, sensitivity, and specificity. Interestingly, many papers showed a correlation between saliva antibody results and clinical manifestations. (4) Conclusions: Saliva testing might represent an appealing alternative to serum-based testing for autoantibody detection, considering the correspondence with serum testing results and the correlation with clinical manifestations. Nonetheless, standardization of sample collection processing, maintenance, and detection methodology has yet to be fully addressed.

To assess predicting factors that might influence systemic lupus erythematosus (SLE) disease activity in women in an extended follow-up period of two years after giving birth with clinical assessments every three months.The study was design as an international retrospective study, enrolling 119 women with a first birth and with a two years follow-up.Joint involvement was present in 80% of patients, acute cutaneous in 64%, haematological in 54%, renal in 41% and 75% of patients were positive for anti-dsDNA. The mean SLE disease activity index 2000 (SLEDAI-2K) at diagnosis was 13.5±6.8 and at first birth was 2.8±4.4. At follow-up, 51.3% of patients had at least one flare after a mean time after birth of 9±6.3 months (mean flare per patient 0.94±1.1). The most frequent flare manifestations were joint involvement (48%), renal (33%), cutaneous (28%) and haematologic (20%). Patients with remission of disease (SLEDAI-2K=0; no clinical or laboratory manifestations of SLE) at conception had significantly lower rates of flares (18/49-37% vs. 43/70-61%; p=0.008). Patients who experienced a flare during pregnancy (17 patients) had higher rates of flares during follow-up (76% vs. 47%; p=0.019), lower time for first flare (4.4±2.3 months vs. 10.3±6.5; p0.001), lower rate of remission of disease at conception (12% vs. 46%; p0.001), lower rates of SLEDAI-2K at conception (5.9±5.6 vs. 2.3±4; p0.001) and lower rates of exclusive breastfeeding (24% vs. 57%: p=0.009). Results were confirmed after performing multivariate analysis.Remission at conception can influence SLE disease positively, even at long-term. Planned pregnancy counseling is fundamental when managing SLE patients.

AimTo apply thrombin generation assay (TGA) in a large cohort of antiphospholipid antibodies (aPL)-positive patients.Material and methods108 patients were tested with TGA and lupus anticoagulant (LA) testing and divided according to their aPL profile. Briefly, 21 patients were positive for anti-phosphatidylserine (aPS)/prothrombin (PT) IgG/IgM (group1), 29 for anti-ß2-glycoprotein-I (aβ2GPI) and anti-cardiolipin (aCL) IgG/IgM (group2), 31 for aPS/PT, aβ2GPI and aCL IgG/IgM (group3), 27 for aPS/PT and/or aβ2GPI+aCL IgM at low-titres (group4). 31 healthy donors (HDs) and 24 controls treated with vitamin K antagonists (VKA) were included.ResultsThe most deranged TGA and LA profiles were observed in tetra-positive patients (group3) that differed significantly to the other groups, thus those with isolated, double or triple aPL-positivity. Moreover, when comparing the TGA profile of all antiphospholipid syndrome (APS) patients, aPL-carriers, HDs and VKA controls, we observed that the aPL+ patients (especially APS) showed a distinctive profile that allowed to distinguish them from the other groups with significantly higher tLag and tPeak, and lower Peak and area under the curve.When focusing on APS clinical manifestations, patients with a high-risk profile (group3) showed significant differences from those presenting low-titres aPL (group 4) regarding the number of venous events (p=0.04), recurrence of any thrombotic event (p=0.01), of arterial events (5 vs 0, p=0.02), the occurrence of TIA (p=0.04), DVT (p=0.02) and, when analysing extracriteria manifestations, of peripheral artery disease (p=0.04).ConclusionsTGA seems a valuable approach to stratify aPL+ patients according to their risk profile. The differences among different populations of autoantibodies specificities could be considered a translational validation of the increased thrombotic risk of patients with triple or tetra aPL-positivity.

Antiphospholipid syndrome (APS) is an autoimmune condition characterized by thrombosis (arterial, venous, and microvascular) and/or pregnancy morbidity occurring in subjects persistently positive for antiphospholipid antibodies (aPL). While the APS classification criteria are being currently updated to improve homogeneity in clinical research, patients who seek medical treatment often have a variety of laboratory and clinical characteristics that may not completely fulfill the classification criteria for overt APS. Those cases might represent a challenge in terms of treatment and overall management. We aim to present a collection of challenging scenarios of patients who tested positive for aPL and to discuss available literature to guide the therapeutic strategies.

Urinary and serological markers play an essential role in the diagnostic process of autoimmune diseases. However, to date, specific and reliable biomarkers for diagnosing Behçet’s disease (BD) are still lacking, negatively affecting the management of these patients. To analyze the currently available literature on serological and urinary BD biomarkers investigated in the last 25 years, we performed a systematic literature review using the Population, Intervention, Comparison, and Outcomes (PICO) strategy. One hundred eleven studies met the eligibility criteria (6301 BD patients, 5163 controls). Most of them were retrospective, while five (5%) were prospective. One hundred ten studies (99%) investigated serological biomarkers and only two (2%) focused on urinary biomarkers. One hundred three studies (93%) explored the diagnostic potential of the biomolecules, whereas sixty-two (56%) tested their effect on disease activity monitoring. Most articles reported an increase in inflammatory markers and pro-oxidant molecules, with a decrease in antioxidants. Promising results have been shown by the omics sciences, offering a more holistic approach. Despite the vast number of investigated markers, existing evidence indicates a persistent gap in BD diagnostic/prognostic indices. While new steps have been taken in the direction of pathogenesis and disease monitoring, international efforts for the search of a diagnostic marker for BD are still needed.

Objective The aim of the study is to perform a systematic review on the recent available evidence on antiphosphatidylserine/prothrombin (aPS/PT) antibodies and their association with clinical manifestations of the antiphospholipid syndrome (APS). Methods A detailed literature search was applied a priori to Ovid MEDLINE, In-Process and Other Non-Indexed Citation 2012 to present and to abstract from EULAR and ACR/ARHP Annual Meetings (2012–2019). Results Data from 2,901 patients, 587 diseases controls and 559 healthy controls included in 15 retrieved studies was analyzed. The patient population included 1,219 patients classified as APS according to the Sidney criteria, 285 patients with isolated persistently positive antiphospholipid antibodies (aPL) and 1,397 patients with a clinical suspicion of APS. Twelve studies, including 1,888 patients, analyzed the association between aPS/PT antibodies and thrombosis. We observed a statistically significant association between aPS/PT IgG/IgM positivity and thrombotic events (mean odds ratio [OR]: 6.8 [95% CI: 3.18–16.4], p Conclusion Our results highlight the strong association between aPS/PT and the clinical manifestations of APS. With the available level of evidence, aPS/PT testing can be considered as a robust test applicable in the investigation of patients suspected for APS, also beyond the research settings.

Chronic kidney disease (CKD) is a widely diffuse pathological condition which deeply impacts upon an affected patient’s quality of life and its worldwide rate is predicted to further rise. The main biological mechanism underlying CKD is renal fibrosis, a non-reversible process representing, for the affected system, a point of no return of tissue damage and dysfunction, deeply reducing the possible therapeutic strategies at the disposal of physicians. The best tool clinicians can use to address the extent of renal fibrosis at any level (glomeruli, tubule-interstitium, vasculature) is kidney biopsy that, despite its overall safety, remains an invasive procedure showing some shortcomings. Thus, the identification of novel non-invasive renal fibrosis biomarkers would be of fundamental importance. Here, when systematically reviewing the available evidence on serological biomarkers associated with renal fibrosis evaluated in patients suffering from CKD in the last five years, we found that despite the presence of several promising biomarkers, the level of observed evidence is still very scattered. Probably, the use of multiple measures capable of addressing different aspects involved in this condition would be the most suitable way to capture the high complexity characterizing the renal fibrotic process, having consequently a great impact on clinical practice by maximizing prevention, diagnosis, and management.

The clinical spectrum of the antiphospholipid syndrome (APS) encompasses additional manifestations other than thrombosis and pregnancy morbidity, which may potentially affect every organ and system. The pathophysiology of APS indeed cannot be explained exclusively by a prothrombotic state and the “extra-criteria” manifestations of the syndrome should be attributed to other mechanisms, such as inflammation, complement and platelet activation. In this case-series, we report patients with uncommon clinical APS presentations, to highlight relevant peculiarities of the syndrome, potentially paving the way for a further update of clinical as well as laboratory manifestations of this complex immunological condition.

Objective: This study aimed to prospectively investigate the incidence of first thromboembolic events (TEs) in a cohort of systemic lupus erythematosus (SLE) patients. The patients were positive for anti-phosphatidylserine/prothrombin (aPS/PT) antibodies and tested negative for anticardiolipin (aCL) and anti-β2–glycoprotein I (aβ2GPI) antibodies [regardless of their Lupus Anticoagulant (LA) status].Methods: Inclusion criteria included: (a) SLE with no previous TEs; (b) no concomitant anti-thrombotic therapy; (c) isolated confirmed positive test for aPS/PT.Results: From the total of 52 SLE patients (42, 80.8% women), 18 patients (34.6%) were found to be positive for aPS/PT (IgG/IgM). During a mean follow-up (3.9 ± 1.1 years), 3 TEs occurred (1.3%/year). The overall cumulative incidence of TEs was 5.8% after 2 years, and up to 16.7% when focusing on aPS/PT positive patients. All the TEs events (two cerebrovascular events and one thrombotic kidney microangiopathy) occurred in the aPS/PT positive group. When focusing on IgG aPS/PT, we found that patients who tested positive were at a significantly higher risk for TEs (crude HR 19.6, 95%; CI 1.1 to 357.6; p < 0.05) compared to patients with negative aPS/PT.Conclusion: This study observed a rate of TEs of 1.3%/year, in aPS/PT positive only patients. Our prospective data suggest that aPS/PT might confer an increased risk for the development of TEs in SLE patients.

Background Antiphospholipid Syndrome (APS) is a rare autoimmune disorder with an estimated prevalence of 40–50 cases per 100.000 persons. Patients suffering from low prevalence diseases are more likely to face diagnostic challenges, given the limited knowledge of most clinicians. The main aim of this study was to investigate the time between symptoms occurrence and the diagnosis of APS patients using the Piedmont and Aosta Valley Rare Disease Registry. Secondly, to evaluate the individual impact of the diagnostic gap by gathering patients’ personal experiences through a self-administered questionnaire. Results Data from the Piedmont and Aosta Valley Rare Disease Registry was used. In addition, personal experiences were analyzed through a self-administered questionnaire. A total of 740 APS patients included in the Piedmont and Aosta Valley Rare Disease Registry were analyzed. Diagnostic delay (as defined by time between symptoms’ occurrence and the diagnosis of APS) was significantly reduced over time. In particular, when comparing the diagnostic delay between patients diagnosed between 1983 and 1999 and patients diagnosed between 2000 and 2015, we found a significant statistical difference (Mann-Whithey U Test; mean rank 1216.6 vs. 1066.9, respectively; p Conclusions While the diagnostic delay of APS has been reduced during the last years, the time between symptoms occurrence and the diagnosis of rare diseases still represents a critical issue to be addressed in order to prevent major complications.

Among &ldquo, extra-criteria&rdquo, antiphospholipid antibodies (aPL), anti-phosphatidylserine/prothrombin (aPS/PT) antibodies, are considered a part of risk assessment strategies when investigating patients suspected of having antiphospholipid syndrome (APS). aPL detection is currently performed by solid-phase assays to identify anti-cardiolipin (aCL), anti-&beta, 2glycoprotein I (a&beta, 2GPI) and aPS/PT antibodies, but new techniques are emerging. Among these, particle-based multi-analyte technology (PMAT), which allows the full automation and simultaneous digital detection of autoantibodies and proteins, including IgG, IgA and IgM isotypes of aCL, a&beta, 2GPI and aPS/PT. The aim of this study was to investigate the agreement of aPS/PT testing between enzyme-linked immunosorbent assay (ELISA) and the PMAT platform. A total of 94 patients were enrolled in the study, including 71 patients with confirmed APS and 23 &ldquo, aPL carriers&rdquo, aPS/PT IgG showed a moderate binomial agreement between ELISA and PMAT (k = 0.57, 95% CI 0.45&ndash, 0.75), and aPS/PT IgM showed a moderate agreement (k = 0.60, 95% CI 0.45&ndash, 0.75). Moreover, when considering the continuous agreement, both aPS/PT IgG and IgM showed a statistically significant correlation between ELISA and PMAT (Spearman&rsquo, s correlation = 0.69, p &lt, 0.001 and 0.72, p &lt, 0.001, respectively). This study demonstrates that PMAT technology is a reliable method for aPS/PT IgG and IgM testing when compared to the available commercial ELISA kit.

Background:Type I Interferons (IFN) play a key role in the pathogenesis and development of various autoimmune conditions. Among them, a solid amount of data demonstrates that the expression of various IFN regulated genes (IRGs), the so-called “IFN signature”, has been linked to disease activity and disease progression in systemic lupus erythematosus (SLE) patients. Nevertheless, to date, a limited number of studies have analysed the IFN signature in antiphospholipid syndrome (APS) setting.Objectives:This study aims to describe the activation and structure of the type I IFN signature among different subsets of APS, including primary APS (PAPS) and when associated with other autoimmune conditions (secondary APS - SAPS), and antiphospholipid antibodies positive individuals (“aPL carriers”).Methods:A total of 116 patients were enrolled, including 19 PAPS patients, 13 SAPS, 75 SLE patients, and 9 aPL carriers [1,2]. Thirty-two subjects were also recruited as healthy controls (HCs). IFI44, IFI44L, IFI6, MX1 and IRF4 gene expression was determined in whole blood in the entire cohort. Expression levels were normalized to Z-scores and averaged into a global IFN signature. Differences were measured by Kruskal-Wallis tests and associations among genes were studied by cluster and correspondence analyses. Correlations were plotted by network analyses.Results:A global activation of the type I IFN signature was observed (HCs: -0.44±0.08, aPL carriers: -0.38±0.12, PAPS: -0.31±0.80, SAPS: -0.17±0.39, SLE: 0.09±0.80; p(Kruskal-Wallis)< 0.001). A certain degree of heterogeneity was observed among IRGs: MX1 being increased in all patient groups (all p< 0.001), whereas IFI44 was only increased in SLE (p< 0.001) and PAPS (p< 0.001), and both IFI44L and IFI6 were increased in SLE (both, p< 0.001) and a trend was observed in SAPS (p=0.060 and p=0.080) (Figure 1). By means of an unsupervised analysis, 3 clusters (I to III) were identified, which correlated with clinical status of the patients by correspondence analysis (p< 0.0001, Figure 2a). Network analyses revealed different structures of the IRGs networks among groups, from weaker networks in HCs and aPL carriers to stronger degree of correlations among IRGs in SAPS and SLE, thus pointing to diverse expression programs (Figure 2b). Among APS patients (both SAPS and PAPS), the IFN signature was positively associated with anti-phosphatidylserine/prothrombin antibodies IgG levels (r=0.478, p=0.003), but no associations were observed for the IgM isotype nor with other autoantibodies specificities (all p >0.050). No associations were observed with traditional cardiovascular risk factors or current treatments (all p >0.050).Conclusion:In line with other autoimmune conditions, APS is associated with a broad type I IFN activation, with distinct profiles of the IFN signature structure among different clinical subsets, suggesting that different pathogenic pathways are involved in the pathogenesis of these conditions.References:[1]Miyakis S, et al. J Thromb Haemost (2006); [2] Aringer M, et al. Arthritis Rheumatol (2019).Acknowledgments:NoneDisclosure of Interests:None declared

Patients with antiphospholipid syndrome (APS) present with clinical features of recurrent thrombosis and pregnancy morbidity and persistently test positive for the presence of antiphospholipid antibodies (aPL). At least one clinical (vascular thrombosis or pregnancy morbidity) and one lab-based (positive test result for lupus anticoagulant, anticardiolipin antibodies and/or anti-β2-glycoprotein 1 antibodies) criterion have to be met for a patient to be classified as having APS. Nevertheless, the clinical variety of APS encompasses additional signs and symptoms, potentially affecting any organ, that cannot be explained exclusively by a prothrombotic state. Those manifestations, also known as extra-criteria manifestations, include haematologic (thrombocytopenia and haemolytic anaemia), neurologic (chorea, myelitis and migraine) manifestations as well as the presence of livedo reticularis, nephropathy and valvular heart disease. The growing body of evidence describing the clinical aspect of the syndrome has been paralleled over the years by emerging research interest focusing on the development of novel biomarkers that might improve the diagnostic accuracy for APS when compared to the current aPL tests. This review will focus on the clinical utility of extra-criteria aPL specificities. Besides, the promising role of a new technology using particle based multi-analyte testing that supports aPL panel algorithm testing will be discussed. Diagnostic approaches to difficult cases, including real-world case studies investigating the diagnostic added value of extra criteria aPL, particularly anti-phosphatidylserine/prothrombin, will also be examined.

Antiphospholipid syndrome (APS) is the most common acquired thrombophilia. The clinical manifestations of APS are mainly vascular thrombosis (venous and/or arterial) and/or recurrent pregnancy morbidity with the concomitant persistent presence of antiphospholipid antibodies (aPL). Therefore, the goals of the treatment of patients with APS are reducing the pregnancy morbidity and/or the prevention of thrombotic events during the follow-up. Optimal treatment of APS has long been discussed, due to the heterogeneity of the clinical manifestations and the consequent plurality in the medical specialties involved in managing this condition. This review summarizes the available evidence on primary thromboprophylaxis in aPL-positive individuals with no prior thrombotic events, secondary prophylaxis in patients with positive history for thrombotic events, the management of refractory or difficult cases and the current strategies for the management of APS during pregnancy.

BACKGROUND Antiphospholipid antibodies (aPL) are known to increase the risk of obstetrical complications. However, aPL significance and prevalence in women with late-onset pregnancy complications (LO-PC) need further clarification. OBJECTIVES To investigate the prevalence of aPL in a cohort of women who experienced LO-PC and to compare it with a cohort of uneventful pregnancies. METHODS One hundred pregnant women who experienced LO-PC, had a low risk for chromosomal abnormalities, and absence of fetal abnormalities were recruited from August 2018 to August 2019. One hundred women with uneventful pregnancy were included as controls. aPL testing was performed on serum samples derived from prenatal screening test and included both criteria and "extra criteria" aPL. RESULTS Patients with LO-PC had significantly higher aPL prevalence when compared with controls (31/100 [31%] vs 10/100 [10%]; P

Objectives To investigate fetal/perinatal and maternal outcomes from a large multicentre cohort of women diagnosed with UCTD. Methods This multicentre retrospective cohort study describes the outcomes of 224 pregnancies in 133 consecutive women with a diagnosis of UCTD, positive for ANA and aged Results Of the 224 pregnancies analysed, 177 (79%) resulted in live births, 45 (20.1%) in miscarriages (defined as pregnancy loss before 12 weeks’ gestation), 2 (0.9%) in stillbirths (pregnancy loss after 20 weeks’ gestation) and 6 (2.7%) cases showed intrauterine growth restriction. Miscarriages and stillbirths were strongly associated with the presence of aPL and ENA antibodies (P Conclusion In our multicentre cohort, women with UCTD had a live birth rate of 79%. Women with UCTD should be referred to specialist follow-up when planning a pregnancy. ENA profiling and aPL testing should be mandatory in this setting, and further therapeutic approaches and management should be planned accordingly.

Background: Skin lesions represent the leading feature of systemic sclerosis (SSc), with Raynaud’s phenomenon (RP) the most frequent and early clinical manifestation of the disease. Digital vasculopathy severely affects SSc patients, lowering their quality of life and negatively impacting on their daily functions. Digital ulcers is associated with poor cardiovascular prognosis and decreased survival rate [1]. Nevertheless, standardized treatment strategies and non-invasive tools for the management of RP and SSc skin manifestations are badly needed. Objectives: The aim of this study was a) to evaluate the efficacy of infrared thermography in the assessment of peripheral vasculopathy in a cohort of SSc patients treated with cyclic intravenous infusions with synthetic prostanoids b) to identify those patients who might benefit from an intensified infusional treatment protocol with prostanoids. Methods: Twenty-six SSc patients [2], attending our Department for their routinely 28-days apart intravenous therapy with prostanoids (Iloprost) based on the presence of severe secondary RP and/or digital ulcers, were enrolled in this study. Thermographic evaluation of both hands was made at baseline (T0), and at days 14 and 28 after the first prostanoid infusion (named T1 and T2, respectively). Statistical analyses have been performed and a p-value Results: A total of 26 SSc patients, 24 (92.3%) female, mean age 65.3±12.6 yrs, mean disease duration at time of data collection 12.4±6.6 years, were prospectively enrolled in the study. Among them, 15 patients (57.7%) presented with limited cutaneous SSc, while 11 patients (42.3%) showed an extra-cutaneous form of the disease. Demographic, clinical, and laboratory characteristics of the patients included in the study are detailed in Table 1. The thermographic assessment showed a substantial stability of the temperature values when comparing T0 and T1 (mean differences of the right hands 0.4 ±5.6; mean differences of the left hands 1.2 ±4.5), while they are significantly reduced when comparing T1 and T2 (mean differences of the right hands -3.1 ± 9.3, p=0.049; mean differences of the left hands -3.4 ±8.5, p=0.012 respectively) (Figure 1A). When stratifying according to clinical manifestation, a higher differences in temperature variations were observed between T1 and T2 in SSc patients with systemic involvement, when compared to those with limited cutaneous SSc (mean of the differences of the right hands -5.0 ±11; mean of left-hands differences -4.9 ±11.5 Vs. mean right-hands differences -2.5 ±11; mean left-hands differences -3±8.6; p=0..035 respectively) (Figure 1B). Conclusion: Thermography could represent a reliable, non-invasive, manageable and cost-effective method for the assessment and monitoring of peripheral vasculopathy in patients with SSc. These data also show that SSc patients with systemic involvement could benefit more from an intensified infusion protocol with prostanoids compared to SSc patients with a limited skin form of the disease. Thermography has shown excellent potential to be a reliable and objective outcome measures to facilitate clinical trials of novel treatments SSc-related RP. References: [1] Mihai C, et al. Digital ulcers predict a worse disease course in patients with systemic sclerosis. Ann Rheum Dis2016;75:681–6. [2] van den Hoogen F, et al. 2013classification criteria for systemic sclerosis: an ACR/EULAR collaborative initiative.Arthritis Rheum. 2013 Nov;65(11):2737-47. Disclosure of Interests: None declared

Background: Systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) are two systemic chronic autoimmune diseases characterised by a wide spectrum of clinical and immune-pathological features. In clinical practice, the concept of Overlap Syndrome is defined when the two diseases coexist in the same patient. Rhupus syndrome is a rare clinical condition, characterized by overlap of SLE and RA. However, it is still subject to debate whether the syndrome should be considered a distinctive entity or an aggressive form of SLE. To date, the estimated prevalence of rhupus is unknown. Objectives: To evaluate the prevalence of patients with rhupus syndrome in our tertiary care center. Methods: We chart-reviewed all patients with a diagnosis of SLE[1] or RA[2], based on the current ACR classification criteria, who presented to our outpatient clinic rheumatology unit. Clinical and laboratory data were retrospectively collected from patient notes. Diagnosis were systematically analyzed by two independent reviewers (SGF and ER). Disagreements were resolved by consensus; if consensus could not be achieved, a third party (SS) would provide an assessment of eligibility. Results: One-hundred eighty-two patients with a diagnosis of SLE and 253 patients of RA, were identified. Out of 182 SLE and 253 RA cases analysed, only 2 patients fulfilled rhupus criteria. The estimated prevalence in our cohort was 0.46% (2/437). In Figure 1 are illustrated the clinical manifestations of SLE (Panel A; Malar rash) and RA (radiograph-documented erosive polyarthritis) of the two patients. Additionally, we identified 7 patients (1.61% of the total cohort) that only partially fulfilled both criteria for SLE and RA. In detail, 1 patient (0.23%) manifested with an overlap of clinical manifestations of SLE and RA, while 1 patient had an overlap of both laboratory criteria. Two patients (0.46%) presented with clinical criteria of RA and laboratory criteria for SLE and RA and 3 patients (0.69%) with clinical criteria of SLE and laboratory criteria for SLE and RA. Patient’s selection is resumed in Figure 2. Conclusion: The prevalence of rhupus observed in our study was relatively low (0.46%). However, we identified up to 1.6% of patients partially fulfilling a diagnosis of rhupus. Rhupus syndrome is a rare and aggressive clinical condition and further prospective studies and an harmonization of classification criteria are highly needed. References [1] Hochberg MC. Updating the ACR revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997 Sep;40(9):1725. [2] Aletaha D, et al. 2010 rheumatoid arthritis classification criteria: an ACR/EULAR collaborative initiative. Ann Rheum Dis. 2010 Sep 1;69(9):1580–8. Disclosure of Interests: None declared

Background: Thrombin generation assay (TGA) is a simple and reproducible technique, that could potentially be used in coagulation laboratories, that measures the concentration of generated thrombin after plasma recalcification. The clinical usefulness of TGAs in assessing thrombotic risk has been a matter of growing interest, however, it has not been applied on a large scale to a large cohort of patients with antiphospholipid syndrome (APS). Objectives: The aim of our study was to assess the potential use of TGA in monitoring the pro-coagulant state in APS patients and its role in predicting the relative risk score in developing APS clinical manifestations, by comparing its parameters to the validated global antiphospholipid score (GAPSS). Methods: After chart-reviewing all APS patients that presented at San Giovanni Bosco Hospital in the last 5 years, we enrolled 4 groups of patients for the sake of this study, matched for age and sex. Clinical and laboratory characteristics were retrospectively collected. Inclusion criteria were as follows: Group A) Fulfilled the diagnosis of Thrombotic APS defined as per Sidney criteria [1]: 60. Group B) Patients with aPL positivity, but with no clinical manifestations of APS defined as per Sidney criteria [1]: 30. Group C) Patients treated with Warfarin (target INR 2-3), negative for aPL and other autoimmune conditions: 60. Group D) Healthy Controls: 60. Results: Figure 1 resumes the representative TGA profiles between groups. Healthy controls and patients with aPL positivity, but no APS clinical manifestations, had similar TGA profiles [mean tLag (min) 9.6 ±2.9 v.s. 8.6 ±3.2; mean tPeak (min) 16.2 ±4.7 v.s. 13.7 ±5.8; mean Peak (nM) 209.2 ±103.8 v.s. 265.4 ±106.2; mean AUC (nM) 2023 ±489.2 v.s. 2057.1 ±571.8, respectively]. When analyzing the TGA profile curve of the patient with APS compared with healthy controls and aPL positive patients with no clinical manifestations of APS, we observed a statistically significant higher tLag (13.3 ±5.9 min; p= 0.003; p= 0.008, respectively) and tPeak (21.3 ±9.2 min; p= 0.006; p= 0.014, respectively) with lower Peak (99.1 ±71.8 nM; p Furthermore, also when analyzing the TGA profile of APS patients compared to patients treated with warfarin and no APS, APS patients had significant higher tLag (13.3 ±5.9 min v.s. 8.2 ±2.1; p When analyzing a correlation model between GAPSS and TGA parameters, we observed a statistically significant correlation for tLag (Pearson 0.444; p= 0.002), tPeak (Pearson 0.464; p= 0.001) and Peak (Pearson -0.382; p= 0.008). AUC showed no statistical significant correlation (Pearson -0.255; p= 0.083). Correlation analysis between GAPSS and TGA parameters is resumed in Figure 2. When stratifying the patients for clinical manifestations, patients with a more aggressive clinical profile, who experienced both arterial and venous thrombosis, when compared with patients who had an history of either arterial or venous thrombosis, had significant different levels of GAPSS (mean GAPSS 17.5 ± 2.1 v.s. 12.4± 5.5, respectively; p= 0.001) and had a significant higher tLag (16.5 ± 7.4 v.s. 11.9± 4.5, respectively; p= 0.048) and tPeak (27.4 ± 13.5 v.s. 19± 6.3, respectively; p= 0.027). Conclusion: TGA might represent a valuable tool to stratify the risk of developing clinical manifestations in APS patients. References [1] Miyakis S, Lockshin MD, Atsumi T, Branch DW, Brey RL, Cervera R, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost [Internet]. 2006 Feb Disclosure of Interests: None declared

Background:Antiphospholipid Syndrome (APS) is an autoimmune disease whose precise aetiology is still unknown, but the high heterogeneity of its manifestations and clinical course is presumably due to the occurrence of different mechanisms and alterations at different levels and pathways [1]. The first genetic studies in APS focused primarily on the human leukocytes antigen system region, but more recent data highlighted a role of other genes in APS susceptibility, primarily those involved in the immune response and in the haemostatic process.Objectives:We aimed to deepen the investigation of APS genetic background starting from a case of familial APS, analysing two siblings with thrombotic APS (Table 1), both triple positive for antiphospholipid antibodies (aPL).Table 1.Main clinical and laboratory characteristics of the patients included in the study.PatientAgeaPL ProfileRelevant Clinical History1 (F)51Triple positive (LA, aCL IgG, aβ2GPI IgG)Two episodes of ischemic stroke, one episode of CAPS (renal thrombotic microangiopathy, visual impairment, ischemic stroke)2 (M)47Triple positive (LA, aCL IgG, aβ2GPI IgG)Three episodes of deep vein thrombosis, regardless ongoing well conducted therapy vitamin k antagonist and additional retinal vein thrombosisLA: lupus anticoagulant; aCL: anti-cardiolipin antibodies; aβ2GPI: anti- β2 glycoprotein I antibodies; CAPS: catastrophic APS.Methods:Genomic DNA was extracted from peripheral blood and the samples underwent Whole Exome Sequencing (WES). Sequencing was done on a 100X coverage, and reads have been aligned to the human reference genome (GRCh37/hg19 assembly) using the Burrows–Wheeler Alignment tool (BWA). The mean sequencing depth on target regions was 170X for patient 1, 205X for patient 2, moreover, 99.50% of the targeted bases had at least 10X coverage for all the three donors. The resulting single nucleotide polymorphisms (SNPs) have been analysed through a step-by-step process based on their frequency population (using Genome Aggregation Database), their predicted effects on the protein (using VarSome) and a literature research about the genes carrying them. Moreover, genes previously associated with a pro-thrombotic tendency and with APS have been analysed in the two patients.Results:Starting from more than 120000 SNPs for each patients, the analysis led to reduce the list of SNPs of interest to 27 missense mutations. The complete literature research regarding the genes carrying these mutations allowed to further reduce the number of selected genes, focusing on those that exert a role potentially involved in APS pathogenesis and development. In particular, these genes (PLA2G6, HSPG2, BCL3, ZFAT, ATP2B2, CRTC3 and ADCY3) take part in the immune response and the vascular homeostasis. The list of the DNA missense variants of interest found in our cases of familial APS is resumed in Figure 2.Figure 2.List of DNA missense variants of interest found in patient 1 and 2. Genes potentially involved in APS pathogenesis and development are highlighted in bold.No mutations on genes known to be associated with a pro-thrombotic state (F5, F2, MTHFR, F13A1, PROC, PROS1, FGB and SERPINE1), or on genes previously associated with APS (B2GPI, PF4V1, SELP, TLR2, TLR4, GP Ia, GP1BA, F2R, F2RL1, TFPI, F3, VEGFA, FLT1, and TNF) have been found in the WES analysis.Conclusion:To some extent, this can be seen as a proof of concept of the complexity of APS. Efforts to interpret the genetic risk factors involved in the heterogeneous clinical features of the syndrome, for instance, the integration of WES and network-based approaches might help to identify and stratify patients at risk of developing APS.References:[1]Iuliano A, Galeazzi M, Sebastiani GD. Antiphospholipid syndrome’s genetic and epigenetic aspects. Autoimmun Rev. 2019;18(9).Disclosure of Interests:None declared

Background:Antiphospholipid syndrome (APS) is a rare autoimmune disorder that mainly affects young individuals. Due to the potentially devasting effects of some of its clinical manifestations, such as ischemic stroke and thrombotic microangiopathy, APS can have a deep negative impact on the quality of life (QoL) of the affected patients due to damage accrual (2).To capture the full consequences of the disease, including both thrombotic and extra-criteria APS specific features, the antiphospholipid syndrome (APS) damage index (DIAPS), a 37-item score, was conceived.Objectives:The aim of this study was to validate the DIAPS in a cohort of antiphospholipid antibodies (aPL) positive subjects, comparing it to the risk stratification score for the development of clinical manifestations of APS (Global APS Score -GAPSS) and QoL questionnaires filled out by APS patients.Methods:This retrospective study included a total of 84 consecutive persistent aPL positive patients who attended the San Giovanni Bosco Hospital (Turin, Italy). Patients were then divided based on their diagnosis in 3 groups: primary APS (PAPS), secondary APS (SAPS) and aPL positive patients without clinical manifestations of APS, according to Miyakis criteria (1). Demographic, clinical and laboratory characteristics, were retrieved from electronic medical records and are summarized in Table 1. DIAPS was calculated as previously reported by adding together all points corresponding to the clinical manifestations of the patients (3).Results:A total of consecutive 84 patients were enrolled in the study: 39 primary APS patients (PAPS), 28 secondary APS patients (SAPS) and 17 aPL positive patients without APS-related clinical manifestations. APS patients had significantly higher levels of DIAPS when compared to aPL asymptomatic patients (mean DIAPS 2.6 ±1.8 vs. 1.5 ±1.9, respectively; pConclusion:The DIAPS might be a valid score system for the assessment of APS-related damage and QoL.References:[1]Miyakis S, Lockshin MD, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006;4:295–306.[2]Grika EP, Ziakas PD, et al. Morbidity, mortality, and organ damage in patients with antiphospholipid syndrome. J Rheumatol 2012;39:516–523.[3]Amigo MC, Goycochea-Robles M V. et al. Development and initial validation of a damage index (DIAPS) in patients with thrombotic antiphospholipid syndrome (APS). Lupus 2015;24:927–934.Table 1.Clinical and laboratory characteristics of the patientsPAPS(n=39)SAPS(n=28)aPL asymptomatic(n=17)AnagraphicMean age (S.D.) at data collection50.6±13.747.4±12.148.6±11.3Sex (females), n29 (74.4%)29 (74.4%)29 (74.4%)Secondary diagnosis, nN/ASLE 24 (85.7%)SSJ 1 (3.6%)UCTD 1 (3.6%)MCTD 2 (7.1%)SLE 8 (45.1%)Clinical manifestations of APSThrombosis, n30 (76.9%)26 (92.9%)N/AArterial thrombosis, n20 (51.3%)14 (50%)N/AVenous thrombosis, n17 (43.6%)15 (53.6%)N/APregnancy morbidity, n11 (28.2%)4 (14.3%)N/AaPL profile at diagnosisLA, n31 (79.5%)23 (82.1%)12 (70.6%)aCL (IgG/M), n22 (56.4%)18 (64.3%)10 (58.9%)Anti-β2GPI (IgG/M), n18 (46.2.%)16 (57.1%)3 (17.6%)aPS/PT (IgG/M), n23 (59%)21 (75%)8 (47.1%)Figure 1.Relative involvement of the organ domains included in the DIAPS according to diagnosisDisclosure of Interests:None declared

Background:Risk stratification in patients with antiphospholipid antibodies (aPL) remains a clinical challenge [1].Objectives:We aimed to evaluate the role of Thrombin Generation Assay (TGA) in distinguishing various populations of aPL positive patients (with and without lupus anticoagulant - LA) and its association with β2GPI-dependent and anti-phosphatidyl-serine/prothrombin(aPS/PT) antibodies.Methods:One-hundred-and-eight patients were tested with TGA and divided as follows: 21 patients with aPS/PT IgG/IgM (Group 1), 29 with aβ2GPI IgG/IgM (Group 2), 31 with aPS/PT and aβ2GPI IgG/IgM (Group 3), 27 with aPS/PT and/or aβ2GPI IgM low-titers (Group 4). Table 1 resumes the clinical characteristics of the APS patients (excluding aPL asymptomatic). Thirty-one healthy donors (HDs) and 24 controls treated with VKA were also included.Results:The most deranged TGA and LA profile was observed in patients with both aPS/PT and aβ2GPI when compared to those with an isolated positivity for aPS/PT or aβ2GPI and patients with aPS/PT and/or aβ2GPI IgM at low titres (Figure 1). Similarly, patients with aPS/PT and/or aβ2GPI at medium/high titres presented with the higher rate of clinical manifestations.When comparing the TGA curves of APS patients, asymptomatic aPL positive (aPL+) subjects, HDs and controls treated with VKA, we observed that aPL+ patients (particularly those with a confirmed diagnosis of APS) showed a characteristic profile.Differences among groups were confirmed also when comparing APS clinical manifestations. When comparing Group 1 and Group 4 we found significant differences with respect to the number of thrombotic events (21vs.15,pWhen analysing the cumulative frequency of extra-criteria APS manifestations, Group 1,2 and 3 were comparable, while comparing Group 3 and those positive for aβ2GPI and/or aPS/PT IgM at low titres (Group 4) we found a statistically significant difference (71%vs13%,pConclusion:TGA seems a valuable approach to stratify aPL+ patients according to their risk profile. The differences among groups and different populations of autoantibodies specificities obtained from this test can be considered a translational validation of the increased thrombotic risk of patients with triple or tetra aPL positivity.References:[1]Miyakis S et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J. Thromb. Haemost. 2006;4(2):295–306.Table 1.“Classical” and “Extra-criteria” APS clinical manifestations of each group (considering solely patients with a confirmed diagnosis of APS).Group 1: isolated aPS/PT+ IgG/IgM (16)Group 2: isolated aβ2GPI+ IgG/IgM(20)Group 3: aPS/PT+ and aβ2GPI+ IgG/IgM (24)Group 4: aPS/PT+ and/or aβ2GPI+ IgM low titres (15)APS clinical manifestationsThrombosis (Y/N), n (%)14 (87,5%)16 (80%)21 (87,5%)13 (86,6%)N of thrombotic events21233615Arterial thrombosis (Y/N), n (%)10 (62,5%)9 (45%)14 (58,3%)11 (73,3%)Arterial events, n13102112Venous thrombosis (Y/N), n (%)6 (37,5%)10 (50%)11 (45,8%)3 (20%)Venous events, n913153Pregnancy morbidity, n (%)3 (18,8%)4 (20%)3 (12,5%)2 (13,3%)Recurrent thrombosis (Y/N), n (%)3 (18,8%)3 (15%)7 (29,1%)0Livedo reticularis, n (%)1 (6,2%)1 (5%)4 (16,6%)0Thrombocytopenia, n (%)4 (25%)4 (20%)6 (25%)2 (13,3%)Valvular, n (%)1 (6,2%)02 (8,3%)0Peripheral artery disease, n (%)03 (15%)4 (16,6%)0Diffuse alveolar hemorrhage, n (%)001 (4,1%)0Figure 1.Graphical representation of the differences between TGA and LA profiles between groups.Disclosure of Interests:None declared

As in many autoimmune diseases, the pathogenesis of the antiphospholipid syndrome (APS) is the result of a complex interplay between predisposing genes and triggering environmental factors, leading to a loss of self-tolerance and immune-mediated tissue damage. While the first genetic studies in APS focused primarily on the human leukocytes antigen system (HLA) region, more recent data highlighted the role of other genes in APS susceptibility, including those involved in the immune response and in the hemostatic process. In order to join this intriguing debate, we analyzed the single-nucleotide polymorphisms (SNPs) derived from the whole exome sequencing (WES) of two siblings affected by APS and compared our findings with the available literature. We identified genes encoding proteins involved in the hemostatic process, the immune response, and the phospholipid metabolism (PLA2G6, HSPG2, BCL3, ZFAT, ATP2B2, CRTC3, and ADCY3) of potential interest when debating the pathogenesis of the syndrome. The study of the selected SNPs in a larger cohort of APS patients and the integration of WES results with the network-based approaches will help decipher the genetic risk factors involved in the diverse clinical features of APS.

Background:Antiphospholipid antibody (aPL) specificities are increasing, however the best accuracy for predicting the clinical manifestations of the diseases is still under debate.Objectives:To evaluate the clinical accuracy of aPL specificities both individually and/or in combination, to identify a panel of tests that may provide the best accuracy for predicting clinical manifestations of antiphospholipid syndrome (APS).Methods:We chart-reviewed patients that presented at San Giovanni Bosco Hospital in the last 5 years who tested persistently positive for at least one aPL[1]. Inclusion criteria comprehended: a)Primary APS(PAPS); b) Secondary APS(SAPS), c)aPL positive asymptomatic and d)Patients with clinical manifestations of APS and either inconsistent previous LA positivity and/or low-medium titers aPL(suspect APS).Results:A total of 122 patients were included in the study 38 PAPS, 31 SAPS, 23 aPL positive asymptomatic and 30 low titers APS patients). Table1 resumes the main clinical and laboratory characteristics of the patients included in the study. All patients were tested for five aPL: criteria aPL, anti-phosphatidylserine/prothrombin(aPS/PT) and anti-Beta2Glycoprotein I Domain I(β2GPI-D1).Among the single aPL positivity, β2GPI-D1 showed the best accuracy in predicting the clinical manifestations of APS (AUC 0.639,CI95% 0.539–0.74,p=0.011). Similarly, when investigating the possible combinations of aPL panels, the positivity for aPS/PT IgG/IgM and/or β2GPI-D1 showed the best accuracy in predicting the clinical manifestations of APS (AUC 0.698, CI95%0.604 –0.793, pFigure 1.When considering aPL asymptomatic patients and APS patients (both PAPS and SAPS), the only two aPL combinations that showed a statistically significant association with the APS group were aPS/PT IgG/IgM and/or β2GPI-D1 (OR 4.86,CI95%1.76-13.3,p11 (OR 2.87, CI95% 1.08-7.6, pConclusion:Combining anti-β2GPI D1 and aPS/PT improves the diagnostic power of aPL testing and might improve in risk stratification in patients with aPL positivity.References:[1] Miyakis S et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost [Internet]. 2006 Feb;4(2):295–306.Table 1.PAPS(n=38)SAPS (n=31)aPL+(n=23)Low titers (n=30)DemographicsAge at study inclusion; years (±SD)50,2 (±13,7)49,3 (±12,3)48,78 (±12,8)50,6 (±11,3)Clinical CharacteristicsThrombosis; n, (%)31 (82)30 (97)026 (87)Arterial; n, (%)21 (55)16 (52)014 (47)Venous; n, (%)15 (39)16 (52)013 (43)Pregnancy Morbidity*; n, (%)8 (21)3 (10)05 (17)Recurrences of APS clinical manifestations; n, (%)7 (18)5 (16)02 (7)Laboratory ProfileLA; n, (%)32 (84)26 (84)21 (91)16 (53)aCL (IgG/M); n, (%)25 (66)22 (71)15 (65)14** (47)ß2GPI (IgG/M); n, (%)26 (68)23 (74)15 (65)14** (47)Triple aPL (IgG/M); n, (%)23 (61)19 (61)13 (57)4** (13)Triple aPL (IgG); n, (%)17 (45)16 (52)10 (44)0**aPS/PT (IgG/M); n, (%)24 (63)20 (65)15 (65)6 (20)ß2GPI-D1; n, (%)13 (34)15 (48)3 (13)4 (13)Triple aPL and aPS/PT (IgG/M); n, (%)16 (42)14 (45)10 (44)0**Triple aPL and ß2GPI-D1; n, (%)12 (32)12 (39)3 (13)0**aPS/PT (IgG) and/or ß2GPI-D1; n, (%)22 (58)24 (77)7 (30)6 (20)Cardiovascular Risk FactorsHypertension; n, (%)15 (39)14 (45)5 (22)9 (30)Hyperlipidemia; n, (%)14 (37)11 (35)2 (9)7 (23)Smoking; n, (%)4 (11)7 (23)2 (9)4 (13)Diabetes; n, (%)4 (11)2 (6)1 (4)1 (3)GAPSS; value (±SD)13,8 (±6)14 (±5,5)12,6 (±5,3)7,3 (±4,8)GAPSS >9; n, (%)30 (79)22 (71)14 (61)7 (23)GAPSS >14; n, (%)17 (44)16 (52)11 (48)2 (7)Disclosure of Interests:None declared

Background:Current guidelines help defining correct pregnancy standard of care for patients with antiphospholipid syndrome (APS) and antiphospholipid antibodies (aPL) carriers, but little is known about the significance of aPL detection during pregnancy and their association with clinical manifestations of the syndrome [1].Objectives:Investigate the presence of aPL antibodies in a cohort of women who experienced late onset pregnancy complications (LO-PC) and low-risk for chromosomal abnormalities.Methods:We retrospectively collected clinical, demographic and laboratory data of women ever pregnant from August 2017 to August 2018, who attended the S. Anna University Clinic (Turin, Italy). Inclusion criteria were LO-PC, negative triple test and absence of US foetal abnormalities. 100 patients have been recruited and, as control, 100 women matched for age with normal pregnancy. aPL testing was performed on serum samples derived from pregnancy screening test collected between 15 and 18w of gestation. Criteria and “extra criteria” aPL were tested.Results:Number of aPL positivity (aPL+) was statistically different between patients and controls: 31 aPL+ vs 10 aPL+, respectively (p-value Patients’ population had a significant higher percentage of single aPL+ (p-value < 0.001; p < .05) and, among single isotypes, of ACA IgG (p-value 0.017; p < 0.05) and aPS/PT IgM (p-value 0.0378; p When comparing aPL+ and aPL negative (aPL-) patients for median age at conception, mode of delivery, foetal outcomes, maternal and foetal pregnancy complication, maternal and foetal post-partum complication and histology findings (see Table 1), we found that aPL+ patient had a significant higher presence of IUGR (PTable 1.Patient characteristicsPopulation charachteristicsAll patients (100)aPL positive (31)aPL negative (69)Chi square test (p value)Age at conception, mean (S.D.), years32.9 (5.3)33.6 (4.7)32.6 (5.6)N/AMode of deliveryCesarean52 (52)14 (45)38 (55)0.36Fetal outcomesLive births, n (%)93 (93)28 (90)65 (94)0.48Birthweight, mean (S.D.), grams2448(910)2505(877)2423(923)N/AGestational delivery, mean (S.D), weeks35.5(1.6)35.3(1.3)35.6(1.6)N/AMild pre-term birth (34-36 + 6 gestation w), n (%)181080.012Birthweight below 10 percentile (SGA), n (%)46 (46)11 (11)35 (51)0.157Maternal and fetal complicationsGestational hypertension, n (%)52 (52)13 (42)39 (56)0.18Preclamspia, n (%)47 (47)11 (35)36 (52)0.12HELLP, n (%)11 (11)4 (13)7 (10)0.68IUGR, n (%)16 (16)1 (3)15 (21)0.01Maternal and fetal postpartum complicationsHypertensive crisis, n (%)15 (15)4 (13)11 (16)0.69Hemorrhage, n (%)10 (10)4 (13)6 (9)0.51Placental histology findingsPlacental malperfusion, n (%)27 (27)8 (26)19 (27)0.85When comparing aPL+/aPL- in UD patients’ subgroub, we found no difference; instead, when comparing aPL+/aPL- in H patients’ subgroup we found that aPL+ had a significant higher percentage of pre-term birth (34-36w; paPS/PT IgM isotype, alone, allowed the detection 17 patients who tested negative for aPL criteria (Graph 1).Conclusion:Our results, even if preliminary, suggest a direct correlation between aPL positivity and risk of development of LO-PM. In conclusion, testing for both criteria and “extra criteria” aPL in women with previous LO-PM could improve the diagnostic accuracy identifying women at higher risk in case of future pregnancy.References:[1]Tektonidou, EULAR recommendations for the management of APS in adults. Ann Rheum Dis (2019)Figure 1.Graph 1. aPL positivity isotype among groupsDisclosure of Interests: :None declared

Objective: To create a mobile application able to help patients follow medical treatments properly. Methods: We designed and developed a custom Android/iOS App to remind patients of the pharmaceutical drugs to be taken, of the visits and exams to attend, and to detect their compliance with their personal therapeutic plan. In this paper we describe the App development, UX/UI design, Gamification. TuTOR is an Android and iOS application designed to remind patients of the drugs to be taken, giving them all the information related to their therapeutic plans in a simple and non-invasive way. Thanks to a dedicated back-office, specially designed to meet specific medical information needs, the App can also help physicians detect their patients’ compliance with their treatments and modify prescriptions in real time. The App also ensures a state-of-the-art approach to data security and privacy protection. The main feature of TuTOR is the smart therapy assistant, which features dedicated alarms to remind users of taking their prescription drugs. Thanks to the automatic synchronization with a local database, the alert system works even without connection to the Internet. Particular attention was paid during the App’s design process: we looked to create an intuitive interface to ensure absolute ease of use, with state-of-the-art visual design aimed at maximizing user experience. Other relevant features include the App’s ability to givevisual evidence of the most important drugs to be taken and its note-taking feature, which gives patients the possibility to note down indications on why a specific drug was skipped. The App also keeps track of upcoming medical exams, laboratory tests, and visits on a devoted calendar. It also helps patients by listing therapy contacts, such as physicians’ phone numbers, and indicates all medical references by showing, for example, locations of relevant clinics and pharmacies on a map. Thanks to specific visual progress indicators and an innovative gamification approach, the App encourages users to faithfully follow therapy guidelines. With TuTOR, assessing the therapy’s state of completion is quick and easy.Thanksto the privacy-by-design approach used, all data managed by the system is compliant with the European Privacy Regulation and it is not available to third parties. Expected results: A mobile App for medication adherence might increase objectively and subjectively measured adherence.