A. Lo Gullo

Circulating progenitor cells in rheumatoid arthritis: association with inflammation and oxidative stress

Objectives: To evaluate the association between inflammation, oxidative stress, and circulating progenitor cell (CPC) number and redox equilibrium, vascular lesions and accelerated atherosclerosis in rheumatoid arthritis (RA). Method: Circulating CD34+ cells were isolated from 33 RA patients and 33 controls. Reactive oxygen species (ROS) levels and mRNA expression of manganese superoxide dismutase (MnSOD), catalase (CAT), glutathione peroxidase type 1 (GPx-1) antioxidant enzymes, and the gp91phox-containing nicotinamide adenine dinucleotide phosphate (NADPH) oxidase NOX2 were measured in CD34+ cells. C-reactive protein (CRP), fibrinogen, erythrocyte sedimentation rate (ESR), carotid intima–media thickness (cIMT), and arterial stiffness (AS) were also evaluated. We investigated the relationships between inflammatory markers, vascular parameters, cell number, and antioxidant enzymes. Results: CD34+ cell number was lower in RA patients than in controls. In CD34+ cells from RA patients, ROS levels, MnSOD mRNA, and NOX2 mRNA were higher, while mRNA expression of GPx-1 and CAT was significantly lower. The AS, pulse wave velocity (PWV), and augmentation index (AIx) were higher, as was cIMT. CD34+ cell number was inversely correlated with CRP, ROS, PWV, and AIx, and with the CAT/MnSOD and GPx-1/MnSOD ratios. CRP was correlated with MnSOD mRNA, PWV, and AIx but not with CAT and GPx-1 mRNA. Conclusions: Our data show a link between inflammation, oxidative stress, and the impairment of the antioxidant system of CPCs and their number, and with arterial stiffness in RA subjects. This could suggest a perspective on the accelerated development of vascular damage and atherosclerosis in RA.

Biglycan expression in current cigarette smokers: A possible link between active smoking and atherogenesis

OBJECTIVE Cigarette smokers present early signs of vascular damage and systemic inflammation. Biglycan (BGN), an ubiquitous component of extracellular matrix orchestrating several physiological functions, has recently been indicated as a major source of low-density lipoprotein retention in the normal arterial intima-media layer. We evaluated whether BGN-mRNA expression was enhanced in peripheral monocytes of smokers with no additional cardiovascular risk factors (CVRFs), and if it was associated with altered carotid arterial stiffness (AS) or intima media thickness (cIMT). We also evaluated plasma markers of systemic and vascular inflammation, and correlation with BGN-mRNA. METHODS Two-hundred-fifty-one young smokers were enrolled, with no additional CVRFs, and 60 controls. Plasma lipids, fibrinogen, C-reactive protein (CRP), interleukin-6 (IL-6), AS and cIMT were assessed. A smoke exposure index (SEIx) was calculated. RESULTS Fibrinogen, CRP, AS indices, cIMT, and BGN-mRNA were higher in smokers compared to controls; HDL-C levels were lower, no difference was detected in IL-6 levels. After stratification of smokers in quartiles based on SEIx values, smokers in the highest quartiles presented highest fibrinogen, CRP, AS, cIMT, BGN, and also IL-6 values, and lowest HDL-C. CONCLUSION BGN-mRNA was enhanced in young smokers, compared to controls, and appears associated to a proatherogenic profile, characterized by increased fibrinogen, CRP, and IL-6, lower HDL-C, altered AS and cIMT values, particularly in those with higher SEIx: the more cigarettes smoked over years, the more marked the alterations. Although we cannot state whether BGN have a direct causal role in inducing, maintaining and developing vascular damage, including intima-media wall thickening and arterial stiffening, our data could suggest that it may represent a link between proatherogenic status induced by cigarette smoking, and the development and progression of vascular damage.

Evaluation of the threshold value for the Modified Early Warning Score (MEWS) in medical septic patients: a secondary analysis of an Italian multicentric prospective cohort (SNOOPII study).

Background Due to aging and resources limitation, septic patients are often admitted to medical wards (MWs). Early warning deterioration is a relevant issue in this setting. Unfortunately, a suitable prognostic score has not been identified, yet. Aim To explore the ability of Modified Early Warning Score (MEWS) to predict the in-hospital mortality in septic patients admitted to MWs. Design Secondary analysis of a multicentric prospective study. Methods Consecutive septic patients with positive blood culture admitted to 31 Italian MWs were included. Baseline characteristics, clinics, isolates, rate of transfer to ICU, MEWS was collected on admission according to the study protocol. The accuracy of MEWS in predicting the in-hospital mortality was assessed with the area under the receiver-operating characteristic curves. Sensitivity, specificity, positive and negative predictive value (PPV and NPV), likelihood ratio (LR) were calculated for different MEWS cut-offs and age/comorbidities subgroups. Results In total 526 patients were included in this analysis. Median MEWS was (range 0-11). In-hospital mortality was 14.8% and transfer to ICU 1.3%. Mortality progressively increased according to MEWS (3% in MEWS 0 vs. 27% in MEWS >5; Chi square for trend P < 0.05). The AUC of MEWS in predicting in-hospital mortality was 0.596 (95% CI, 0.524, 0.669). MEWS did not appear to have an adequate sensitivity, sensibility, PPV, NPV and LR both in the whole population and in the pre-specified subgroups. Conclusions Our findings do not seem to support the use of MEWS to predict the in-hospital mortality risk of sepsis in MWs.

Coronary vasculitis in granulomatosis with polyangiitis

Granulomatosis with polyangiitis (GPA), formerly known as Wegeners granulomatosis, is a granulomatous disorder usually associated with vasculitis involving the small and medium-sized blood vessels. It most commonly affects the upper and lower respiratory tracts and the kidneys, but almost any organ can be involved [1,2]. Cardiac involvement in GPA is rare and different manifestations are described such as pericarditis, valvular lesions, coronary arteritis, myocarditis and cardiac rhythm disorders [3,4]. We described a young woman, with a previous diagnosis of GPA, who has been subjected to coronography after a positive cardiac stress test. A 35-year old woman was admitted to our outpatient clinic for a recent history of dyspnea onmoderate exertion, fever and cough. She denied a familiar history of cardiac disease. She was no smoker. The patient was diagnosed a year earlier with GPA with upper and lower respiratory tract involvement, renal failure at second stage, positive for antineutrophil cytoplasmic antibodies, anti-proteinase 3 (cANCA). No renal biopsy was performed. Moreover a previous brain MRI showed a brain involvement with microvascular inflammatory lesions in various stages of development. She also had arterial hypertension for 2 years before admission, for which she was taking 20 mg of olmesartan with normal blood pressure values and she had a hypothyroidism secondary to thyroidectomy for multinodular goiter. She was on therapy with prednisone at 25 mg/day, esomeprazole and in the weeks prior our hospitalization she had a bronchiolitis with resolution after antibiotic therapy. On admission, she complained of constrictive chest pain during moderate effort; blood pressure was 130/70 mm Hg, heart rate was 72/min, clinical examination was unremarkable, with no respiratory or cardiac pathological findings on auscultation. The chest radiograph was normal. The ECG looks almost normal (Fig. 1A). Laboratory showed an elevated sedimentation rate (73 mm/h) and C-reactive protein levels (5.93 mg/dl). Troponin I and myoglobin were normal; c-ANCA was 63 (normal value 0.0–2.0 UI/ml). Creatinine was 1.5 mg/dl, hemoglobin was 12.9 mg/dl, white blood cell was 9700 mm. Echocardiogram showed: mild concentric hypertrophy of the left ventricle, hypokinesia of the distal segment of the anterolateral wall with preserved global pump function, sclerosis and calcification of mitral and aortic valves; small pericardial effusion rear right atrium and systolic pericardial dissection of the free wall of the right ventricle (Fig. 1B and C); I degree diastolic dysfunction. For further diagnostic evaluation the patient undergone to dobutamine stress echocardiography [5,6], early stopped (20 γ/kg/ min) for the onset of constrictive retrosternal pain associated with electrocardiographic changes suggestive of ischemia in the absence of new mechanical alterations (Fig. 2). The following coronary angiography showed a diffuse coronary artery disease without hemodynamically significant stenosis with the exception of a 90% stenosis of the proximal portion of the left anterior descending artery, engaging the emergence of the first diagonal branch (Fig. 3A and B), treatedwith percutaneous transluminal coronary angioplasty (PTCA) with position of stent (Fig. 3C). Cardiac involvement in GPA has been reported to range between 6% and 44% [3,4] with coronary artery disease reported in the 50% of all cases of heart involvement in GPA [7]. Accelerated atherogenesis, one of the most important mechanisms triggering coronary disease, is well documented in GPA and patients affected by Wegeners granulomatosis are at a significantly increased risk of cardiovascular morbidity and mortality [8,9]. Moreover the GPA patients were found to have a 3.6-fold increased risk of acute MI occurring 5.0 years after the date of the GPA diagnosis [10,11].

Subcutaneous administration of tocilizumab is effective in myointimal hyperplasia remodelling in refractory Takayasu arteritis

Takayasu arteritis (TA) is a chronic inflammatory disease of unknown origin that involves large and mediumsized arteries, primarily the aorta and its major branches. TA is a therapeutic challenge because corticosteroids and conventional immunosuppressive agents are not always effective or safe. Interleukin 6 (IL-6) has emerged as a key cytokine in the pathogenesis of TA and its serum levels have been shown to well correlate with disease activity. We report a 19 years old female patient with TA refractory to conventional immunosuppressive agents, successfully treated with subcutaneous tocilizumab, a humanized monoclonal antibody against IL-6 receptor, in which ultrasonography (US) was used as imaging tool to follow up the patient. Currently, clinical indices of disease activity, inflammatory markers, carotid intima media thickness (cIMT) as well as carotid pulse wave velocity (cPWV) normalised, while the prednisone dosage has been tapered. Tocilizumab appears to be a good option in refractory TA, with a remarkable steroid-sparing effect. In addition, it seems to have a favourable effect on endothelial function, as it improved cIMT and PWV.

FRI0447 Temporomandibular Joint and Chewing Features in Systemic Sclerosis Patients: A Clinical and Magnetic Resonance Imaging Analysis

Background The pathogenesis of Systemic Sclerosis (SSc) remains unknown, but increasing evidence suggests that activation of lesional fibroblasts contributes to the fibrotic process. SSc is characterized by symmetric, erosive synovitis, which may result in joint irregularity and disability. Objectives The purpose of this clinical study was to assess the prevalence and characteristics of Temporomandibular joint (TMJ) symptoms, clinical and Magnetic Resonance Imaging (MRI) findings in a cohort of patients with SSc. Methods 27 patients with SSc (12 Diffuse, 15 Limited, mean age 53.9, SD ±1.2) and 28 healthy subjects (mean age 54.8, SD ±4.2) were enrolled in this cohort study. Oro-facial clinical examination for assessing the presence of TMJ sounds, pain in the TMJ area, tenderness of masticatory muscles, limited mouth opening, pain assessment, MRI scan and Anamnestic and Dysfunctional Index were achieved in all of patients. Results The test groups presented more clinical and MRI TMJ symptoms and dysfunction than Control group. The distributions of symptoms were significantly different (P<0.05), in the Test groups for TMJ sounds, pain during mandibular movement and difficulty in the maximum mouth opening. There was also a significant decrease (P<0.001), in the Test groups, in the mean of leftward, rightward laterotrusion and protrusion. Correlation analysis showed that maximum opening leftward laterotrusion, protrusion and click were significantly correlated to Modified Rodnan Skin Score. The mean duration of disease was significantly correlated, ever in Total SSc group, only for the maximum mouth opening value. Conclusions This study proves that TMJ dysfunction is a common feature in SSc patients and it is correlated with a extent and involvement of disease and supports the notion that TMJ examination should be encouraged in rheumatology and clinicians should provide a patient support and a right pain management. References Jelaska A, Arakawa M, Broketa G, Korn JH. Heterogeneity of collagen synthesis in normal and systemic sclerosis skin fibroblasts: increased proportion of high collagen–producing cells in systemic sclerosis fibroblasts. Arthritis Rheum 1996;39:1338–46. Schieir O, Thombs BD, Hudson M, Boivin JF, Steele R, Bernatsky S, et al. Canadian Scleroderma Research Group. Prevalence, severity, and clinical correlates of pain in patients with systemic sclerosis. Arthritis Care Res (Hoboken). 2010;62:409-17. Disclosure of Interest None declared

FRI0471 Negative Temporal Artery Biopsies: Pathologic Findings of Patients with Biopsy-Negative GIANT Cell Arteritis Compared to Those of Patients without Arteritis

Background Temporal artery biopsy (TAB) showing transmural inflammation is considered the gold standard for the diagnosis of giant cell arteritis (GCA). A negative TAB does not rule out GCA, and a diagnosis of biopsy-negative GCA was reported in 5-25% of patients. In the absence of active inflammation (negative TAB), other structural changes in the wall of TA are often present and some of those have been described as “healed” or quiescent arteritis, but if these histological changes are expression of GCA is still debated. Objectives To evaluate if there are histopathological features of negative TAB that allow to differentiate patients with GCA from those without. Methods 42 consecutive patients with negative TAB were retrospectively selected. All patients underwent TAB for suspected GCA between January 2009 and December 2012. Demographic, clinical and laboratory data at presentation and at each follow up visit were collected. A pathologist with expertise in vasculitis blinded to clinical data and final diagnosis reviewed all 42 negative TABs. Histopathologic features evaluated were: the presence of a focal medio-intimal scar with medial attenuation, intimal hyperplasia, fragmentation of inner elastic lamina (IEL), calcification, adventitial fibrosis and neoangiogenesis. Results After a median follow-up period of 177 days (interquartile range 38, 508), 20 of the 42 patients had a final diagnosis of GCA, while in the remaining 22 patients GCA was excluded (9 had polymyalgia rheumatica, 4 non arteritic anterior ischemic optic neuropathy, 3 fibromyalgia, 2 non-specific elevation of inflammatory markers, 1 fever of unknown origin, 1 rheumatoid arthritis, 1 ANCA associated vasculitis, 1 osteoarthitis). 1990 ACR classification criteria for GCA were satisfied in 13 of the 20 patients with GCA (65%) and in none of the 22 non-GCA patients. 12 patients (60%) with GCA and 14 patients (64%) with non-GCA were on steroid therapy when TAB was performed (p>0.05). The mean prednisone dose was (mg± SD) 23.75 ±12.95 for GCA patients and 13.57 ±11.67 for non-GCA patients (p=0.05). Mean duration of prednisone treatment was (days±SD) 30.58±44.23 for GCA patients and 144.36±162.24 for non GCA patients (p<0.05). A focal medio-intimal scar with medial attenuation was found in 15% of GCA vs 14% of non-GCA patients (p>0.05). Intimal hyperplasia was present in 45% vs 59%, fragmentation of IEL in 80% vs 91%, calcification in 30% vs 18%, adventitial fibrosis in 10% vs 5% and neoangiogenesis in 10% vs 9% of GCA vs non-GCA patients respectively (all p NS). 4 patients with GCA had visual loss. A focal medio-intimal scar with medial attenuation was not observed in these 4 patients, intimal hyperplasia was observed in 2, fragmentation of IEL in all 4, calcification in 2, adventitial fibrosis in 1 and neoangiogenesis in 1. Histological findings of GCA patients with visual loss were similar to those of patients with non-GCA. Conclusions The histological features of negative TAB evaluated in this study do not allow to differentiate between GCA and non-GCA patients. These data suggest that in the absence of mural active inflammation, other histological changes of the TA wall are not specific for GCA. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5633

AB0301 Vascular Markers in Woman and in Men with Rheumatoid Arthritis

Background Rheumatoid arthritis (RA) is associated with increased morbidity and mortality rates due to cardiovascular disease, and this occurs early in the disease process. In RA an impairment of the number and the activity of circulating progenitor cells, including CD34+ cells and endothelial progenitor cells, is involved in the development of endothelial damage and cardiovascular diseases (CVD). Objectives To evaluate CD34+ cell number and vascular markers in woman and men with RA. Methods We enrolled 48 patients (mean age 50.6±7.6), 22 men (mean age 51.1±7.9) and 26 women (mean age 50.2±7.4); patients were enrolled at the time of diagnosis, if they did not present with cardiovascular risk factors. CD34+, C-reactive protein (CRP), fibrinogen, carotid intima-media thickness (cIMT), Pulse wave velocity (PWV), were assessed at baseline. We investigated the relationships among cell number, inflammatory markers, and vascular parameters in woman and men. Results No differences in CD34+ cell number (1.79±1.34 vs 1.99±1.59), fibrinogen (361.9±64.2 vs 343.1±74.0), CRP (3.32±1.0 vs 3.12±0.96), PWV (7.77±2.3 vs 7.34±2.9), and cIMT (1.11±0.3 vs 1.14±0.1) between woman and men. In both groups was confirmed a correlation between CD34+ and Fibrinogen, CRP, PWV (all p<0.01). Conclusions Despite RA affects more woman than men, we found no differences in vascular parameters between men and woman at the onset of the disease. References Kuller LH et al. Determinants of mortality among postmenopausal woman who report rheumatoid arthritis in the Womans Health Initiative. Arthritis and Rheumatism 2013. (Epub ahead of Print). Lo Gullo A et al. Circulating progenitor cells in rheumatoid arthritis: association with inflammation and oxidative stress. Scand J Rheumatol 2013 (Epub ahead of Print). Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.5976

FRI0103 Vit d deficiency, depletion of circulating endothelial progenitor cells and impaired arterial stiffness in patients with ra

Background Vitamin D deficiency was recently acknowledged as an independent predictor of cardiovascular diseases and all-cause mortality in several clinical setting and its serum levels are commonly reduced in Rheumathoid Arthritis. (RA). Patients affected by RA present accelerated atherosclerosis and increased cardiovascular morbidity and mortality with respect to the general population. In RA an impairment of the number and the activity of circulating progenitor cells, including CD34+ cells and endothelial progenitor cells, appears to be involved in development of endothelial damage and cardiovascular diseases. Objectives This study investigates the association between vitamin D deficiency and circulating progenitor cell number (CPCs). Methods Circulating progenitor cells number and vitamin D levels were measured in 30 patients affected by RA and in 30 controls matched for age and gender. C-reactive protein (CRP), fibrinogen, erythrocyte sedimentation rate (ESR), carotid intima-media thickness (cIMT), augmentation index (AIx), pulse wave velocity (PWV) were also evaluated. We investigated the relationships among vitamin D and cell number, inflammatory markers, and vascular parameters. Results In RA patients the levels of vitamin D were reduced with respect to controls (21.5±6.9 vs 37.6±13.2 ng/ml, p <0.001); CPCs number (1.80±0.59 vs 2.32± 0.34 cells/µL, p <0.001) was also significantly reduced. PWV and AIx were higher in RA, while cIMT was not different between RA patients and controls. Vitamin D correlate inversely with CPCs number and PWV (rs -0.49 p < 0.005 and rs -0.56, p< 0.001 respectively). In RA we identify no association between vitamin D and cIMT, CRP, ESR, fibrinogen. CPCs number correlates with CRP (rs -0.50, p<0.005) and ESR (rs= -0.57, p<0.001). Conclusions Our findings suggest that Vitamin D deficiency is a common finding in RA and is associated with reduced CPCs counts. Future studies are needed to determine whether vitamin D supplementation could improve CPCs levels and arterial stiffness indices in patients affected by rheumathoid arthritis. References Semba RD et al. Relationship of 25-hydroxyvitamin D with all-cause and cardiovascular disease mortality in older community-dwelling adults. Eur J Clin Nutr. 2010 Feb;64(2):203-9. Cutolo M at al. Vitamin D in rheumatoid arthritis. Autoimmun Rev. 2007 Nov;7(1):59-64. Haque UJ et al. Association of vitamin D with cardiometabolic risk factors in rheumatoid arthritis. ArthritisCare Res (Hoboken). 2012 Oct;64(10):1497-504. Herbrig K et al. Endothelial dysfunction in patients with rheumatoid arthritis is associated with a reduced number and impaired function of endothelial progenitor cells. Ann Rheum Dis 2006;65(2):157-63. Reynolds JA et al. 25-Hydroxyvitamin D deficiency is associated with increased aortic stiffness in patients with systemic lupus erythematosus. Rheumatology (Oxford). 2012 Mar;51(3):544-51. Disclosure of Interest None Declared

AB0075 Toll-like receptor 3 and interleukine 1b expression in circulating progenitor cells isolated from patients with rheumatoid arthritis.

Background Circulating progenitor cells (CPCs), including CD34+ cells and endothelial progenitor cells (EPCs), play a role in delaying atherosclerosis and cardiovascular disease. Toll-like receptor 3 (TLR3), a member of the pathogen recognition receptors that mediates immune response and activates inflammatory genes, is involved in the development of atherosclerosis. TLR3 has been recently detected in EPCs and its “in vitro” activation appears to induce cytokine expression and apoptosis. We measured the expression of TLR3 and Interleukine1β- mRNA in CPCs isolated from patients with rheumatoid arthritis. Objectives The aim was to evaluate whether systemic inflammation is associated with CPC number and CPC expression of TLR3 and IL-1β. Methods CD34+ cells were isolated from peripheral blood from 21 patients with rheumatoid arthritis (RA patients) and from 21 matched controls. TLR3 and IL-1β -RNA expression were measured in enriched sample of CD34+ cells. Plasma C-reactive protein (CRP) and fibrinogen levels were also measured. Results With respect to controls, CD34+ cell number was lower in RA patients. CRP and fibrinogen levels were higher in RA patients than in controls. TLR3-mRNA anf IL-1βexpression were significantly higher in RA patients with respect to controls. CRP and fibrinogen levels were associated with IL-1β e TLR3 expression; moreover, the increased expression of TLR3 and IL-1β were associated with lowering CPC number. Conclusions RA is associated to an increased expression of TLR3 and of IL-1β in CPCs, which appear to affect the decrease of CPC number. It is likely that this novel association may at least in part contribute to explain the increase of cardiovascular morbidity and mortality in patients suffering from RA. Further studies could clarify whether the modulation of TLR3 expression in CPCs may modify the CV risk in patients affected by RA. References Herbrig K et al. Endothelial dysfunction in patients with rheumatoid arthritis is associated with a reduced number and impaired function of endothelial progenitor cells. Ann Rheum Dis 2006;65(2):157-63. Yang M et al. The functional expression of TLR3 in EPCs impairs cell proliferation by induction of cell apoptosis and cell cycle progress inhibition. Int Immunopharmacol 2011, 11(12):2118-2124. Raicevic G et al. Inflammation modifies the pattern and the function of Toll-like receptors expressed by human mesenchymal stromal cells. Hum Immunol 2010, 71(3):235-244. Ito C et al. Cilostazol enhances IL-1beta-induced NO production and apoptosis in rat vascular smooth muscle via PKA-dependent pathway. Cell Signal 2002, 14(7):625-632. Zimmer S et al. Activation of endothelial toll-like receptor 3 impairs endothelial function. Circ Res 2011, 108(11):1358-1366. Disclosure of Interest None Declared