CD4+ T helper (TH)-17 cells play a pivotal role in mucosal immune defense and are implicated in autoimmune diseases and cancer. Although Th17 cell plasticity is well-studied in mice, the factors driving their transition between pro-inflammatory and immunomodulatory states in humans remain less understood. Our study explored the transcriptional and epigenetic landscapes of single-cell cultures of human memory TH17 cells, focusing on clones that produce either immunomodulatory IL-10 or pro-inflammatory IFNγ and IL-22. We found that IL-10+ TH17 cells exhibit a T cell exhaustion-like profile with increased CTLA-4 expression and reduced IL-2 levels, while Ikaros zinc finger (IkZF) transcription factors, Aiolos and Eos, are differentially expressed in IL-10+ and IL-22+ TH17 cells, respectively. While exogenous IL-2 promotes IL-10 production in TH17 cells, lenalidomide induces IL-2 and promotes inflammatory TH17 cells, shifting TH17 cells towards a pro-inflammatory phenotype by reducing IL-10 and increasing IL-22 and IFNγ levels. Conversely, upregulation of Eos enhanced pro-inflammatory cytokine production. These findings highlight the crucial role of IkZF transcription factors in regulating human TH17 cell functions. Moreover, single-cell RNA sequencing of PBMCs from lenalidomide-treated patients confirmed an enrichment of inflammatory signatures, including interferon and IL-2/STAT5 pathways in TH17 cells. The ability to modulate this axis through targeted interventions, such as lenalidomide-induced Aiolos degradation or enforced Eos expression, presents new therapeutic opportunities for managing TH17 cell states in cancer and autoimmune diseases.

OBJECTIVES:People with systemic lupus erythematosus (SLE) experience high levels of pain and fatigue with poor overall health, which persist in those with low disease activity. By performing epigenome-wide DNA methylation analysis, this study aims to identify epigenetic alterations associated with self-reported scores for pain, fatigue and health in women with SLE. METHODS:Forty-eight women with SLE from the SLEGOT cohort were included. Study participants exhibited low disease activity (median SLEDAI-2K = 0) and minimal damage (median SLICC damage index = 0). An epigenome-wide DNA methylation analysis in whole blood identified 704 237 CpG loci, with 511 673 annotated to known genes. RESULTS:We identified 485, 591 and 577 differentially methylated CpGs linked to pain, fatigue and poor health, respectively. The association of reported pain with CpGs in GPR107, SPHK2, HBA1 and RERE genes suggested a potential role for neuromodulation in pain perception in SLE. For fatigue, enrichment analysis highlighted pathways related to neuronal development, morphogenesis and synaptic signalling. Nine genes, including BDNF and TGIF1, showed strong correlations with all three scores, suggesting a shared epigenetic influence that may underlie pain, fatigue and poor health in SLE. Specific microRNA genes were differentially methylated in relation to pain and fatigue. CONCLUSION:By studying a cohort of women with well-controlled SLE, we identified several CpGs and genes associated with pain, fatigue and general health. Our findings suggest that epigenetic changes in genes involved in neuronal modulation, rather than inflammatory pathways, could be involved in the development of these symptoms in patients with SLE.

Introduction:Programmed cell death protein 1 (PD-1) inhibitors improve survival in advanced melanoma but can induce immune-related adverse events (irAEs). IrAEs have been linked to better outcomes. However, it remains unclear whether specific irAE types drive this effect and how corticosteroid treatment of irAEs influences survival. Materials and methods:A seven-year retrospective cohort study of 301 patients with advanced cutaneous melanoma treated with single-agent PD-1 inhibition at Sahlgrenska University Hospital. irAEs were identified using CTCAE v4.0/v5.0, and irAEs requiring systemic corticosteroids or endocrine replacement therapy were included. Corticosteroid therapy was categorized as low dose (≤0.5 mg/kg prednisolone equivalent) or high dose (>0.5 mg/kg). Overall survival (OS) was assessed using Kaplan-Meier and Cox models, including time-dependent analyses to address immortal time bias. Results:Patients with irAE (109 of 301 patients) had longer OS than those without irAEs. Of the eight most common irAEs, four were associated with superior survival, one was borderline significant, and three were non-significant. Rheumatic irAEs and late-onset thyroid irAEs remained associated with improved OS after adjustment for negative prognostic factors and immoral time bias. Colitis irAE were borderline significant in univariate analysis. Sarcoidosis-like and hypophysitis irAEs were rare but conferred excellent outcomes. Hepatitis, nephritis, and pneumonitis were not associated with better survival. Most survival-associated irAEs were treated with a lower start dose of corticosteroids but duration and time to onset were similar to non-survival-associated irAEs. Conclusion:Rheumatic, endocrine, and sarcoidosis-like irAEs are markers of superior survival and suggest that lower initial corticosteroid doses may preserve PD-1 inhibitor efficacy.

OBJECTIVES:To investigate the association between joint involvement pattern (JIP) subgroups and treatment responses to conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) and biological disease-modifying antirheumatic drugs (bDMARDs), and to compare the impact of JIP subgroups with other clinical parameters in treatment-naïve patients with early rheumatoid arthritis (RA). METHODS:An individual patient data meta-analysis was conducted using 2 randomised controlled trials, NOrdic Rheumatic Diseases Strategy Trials And Registries (NORD-STAR) and Behandel-Strategieën (BeSt), including 1250 treatment-naïve patients with early RA. JIP subgroup assignment was based on 4 previously identified subgroups defined by baseline clinical characteristics, primarily joint involvement in the 66/68 joint scheme. Treatment outcomes were measured using the longitudinal Clinical Disease Activity Index (CDAI) and other disease activity indices through week 48. Associations of the JIP subgroups and other clinical predictors were evaluated using a mixed-model analysis. RESULTS:Patients with a hand-dominant JIP (JIP-Hand) showed significantly better CDAI scores after treatment (Beta for CDAI = -1.4 [95% CI, -2.3 to -0.55]; p = .0016), whereas those with a polyarthritis pattern (JIP-Poly) exhibited worse outcomes (Beta = 0.95 [95% CI, 0.064-1.8]; p = .035). Female sex was also associated with worse CDAI scores (Beta = 1.2 [95% CI, 0.40-2.0]; p = .0031), whereas anticitrullinated protein antibodies did not show a significant association (Beta = 0.19 [95% CI, -0.69 to 1.1]; p = .67). When compared across groups, csDMARDs and combined bDMARDs were similarly effective in the respective JIP subgroups (interaction p > .10). CONCLUSIONS:In early RA, csDMARD and bDMARD treatments resulted in the greatest improvement in disease activity in JIP-Hand and the least improvement in JIP-Poly.

Abstract Background Dysfunctional programmed cell death-1 (PD1) signalling may contribute to persistent immune activation in rheumatoid arthritis (RA). However, co-inhibitory molecule interactions between T cells and fibroblast-like synoviocytes (FLS) remain insufficiently understood. This study aimed to determine whether T cell activation and subset-associated cytokines differentially regulate the expression of PD-ligand 1 (PD-L1) and PD-L2 on FLS from RA patients compared with non-inflammatory (NI) controls, and whether PD1 engagement induces distinct transcriptional downstream responses in RA-FLS versus NI-FLS. Methods Primary FLS cell lines were cultured from synovial tissue of patients with established RA or NI controls undergoing arthroscopy due to previous injury. Cells were cultured with CD3+ T cells or stimulated with TNF, IFNγ, IL-4, or TGF-β, and PD-L1 and PD-L2 expression was analysed by flow cytometry. PD-L1 and PD-L2 knockout FLS were generated using CRISPR/Cas9. TNF-primed knockout or mock-transfected RA- and NI-FLS were treated with soluble PD1, and transcriptomic responses were analysed by total mRNA sequencing. Results Analysis of publicly available RNA-sequencing datasets showed that, in early RA, PD-L1 and PD-L2 expression were significantly higher in lymphoid compared to myeloid and fibroid synovial tissue pathotypes. In established RA, PD-L1 and PD-L2 expression in FLS showed a trend towards higher levels in lymphocyte-rich compared to lymphocyte-poor tissue. In vitro, activated but not resting T cells upregulated both PD-L1 and PD-L2 on FLS. Further, TNF and IFNγ induced PD-L1 expression up to fourfold compared with unstimulated FLS, whereas IL-4 and TGF-β had no effect. PD-L2 was induced by TNF, IFNγ, and IL-4 to similar levels. PD-L1 and PD-L2 expression did not differ between RA- and NI-FLS either in co-culture with T cells or under cytokine stimulation. Finally, soluble PD1-induced reverse signalling in FLS altered the expression of threefold more genes in NI-FLS compared to RA-FLS, indicating that RA-FLS might be less responsive to PD1 signalling. PD-L1 or PD-L2 knockout further showed that reverse signalling through each ligand modulates distinct gene sets in FLS. Conclusions Cytokine-induced PD-L1 and PD-L2 expression is preserved in FLS from established RA but PD1-ligand signalling is altered, potentially contributing to the loss of immune regulation in RA.

OBJECTIVE:To examine B cell-activating factor (BAFF) and type I interferon (IFN) activity at the transcriptional and protein levels in blood and placental tissue in SLE compared with healthy pregnancies to assess their relationship and to determine whether BAFF levels are associated with pregnancy outcomes in SLE. METHODS:In the SLE-Placenta study, we followed women with SLE (n=83) and healthy controls (n=67) throughout pregnancy. Blood samples were collected in all trimesters and at delivery from peripheral blood, placental intervillous blood and cord blood. Postpartum blood samples were obtained from a subset of women with SLE. Bulk messenger RNA (mRNA) sequencing was performed on peripheral blood mononuclear cells (PBMCs) and placental tissue from a subgroup of women with SLE and healthy controls. BAFF concentrations were measured by ELISA and IFNα protein levels by single-molecule array (Simoa). RESULTS:Women with SLE had upregulated BAFF (TNFSF13B) and IFN-stimulated gene expression in PBMCs and placenta compared with controls. BAFF blood levels were consistently and significantly higher in SLE throughout pregnancy and inversely correlated with circulating B cell numbers. SLE pregnancies with IF-ANA or anti-dsDNA positivity displayed higher BAFF levels than antibody-negative pregnancies but BAFF showed no association with disease activity. Both BAFF and IFNα concentrations were higher in placental than peripheral blood in SLE, whereas only BAFF showed additional accumulation in cord blood. Finally, elevated BAFF levels were associated with shorter pregnancy duration in SLE but not in healthy pregnancy. CONCLUSIONS:Pregnant women with SLE exhibited persistently elevated BAFF levels, which were associated with lower B cell numbers, SLE-related autoantibody positivity and shorter pregnancy duration. Together with a disease-specific placental enrichment of IFNα, these findings support the presence of an inflammatory and potentially pathogenic IFN-BAFF signature in SLE pregnancy. Further studies are needed to determine the functional consequences of these immunological alterations on maternal-fetal health in SLE.

OBJECTIVES:To investigate, in early rheumatoid arthritis, whether bridging with glucocorticoids (GCs) is associated with an increased risk of flare following GC tapering and withdrawal. METHODS:A total of 810 NOrdic Rheumatic Diseases Strategy Trials And Registries (NORD-STAR) patients were included in this post hoc analysis: all received methotrexate (MTX), in addition to which 135 patients received oral GC bridging therapy ('oral GC group'); 80 received intra-articular (IA) GC bridging therapy, sulfasalazine and hydroxychloroquine ('injection GC group'); and 595 received one of three (certolizumab pegol, abatacept and tocilizumab) biologic disease-modifying antirheumatic drugs (bDMARDs), hereafter the ('bDMARD group'). Clinical disease activity index (CDAI) flares (≥4.5 increase in CDAI score) were assessed longitudinally. RESULTS:Up to 48 weeks, flare occurred at least once in 43% of oral GC, 24% of injection GC and 28% of bDMARD patients. Over-time relative risk (RR) was higher with oral GC bridging (adjusted RR, 1.54; 95% CI, 1.16-2.03) but similar with injection GC bridging (adjusted RR 0.93; 95% CI, 0.54-1.55) versus bDMARD. Flare rates were numerically higher in the oral GC versus bDMARD group at all time points (12, 24, 32, 40 and 48 weeks), with a significant difference at w.40, the visit after protocol-defined GC discontinuation; at this visit 27% of patients who discontinued GC experienced flare; 29% among those in remission; 33% remained on low-dose prednisolone at 48 weeks. CONCLUSION:Discontinuation of oral GC bridging therapy on background MTX is associated with increased flare risk, even among patients in remission. Flare rates with IA GC bridging plus triple therapy did not differ from the bDMARD group. TRIAL REGISTRATION NUMBER:EudraCT 2011-004720-35; ClinicalTrials.gov NCT01491815.

BACKGROUND:Pain, fatigue, and impaired health-related quality of life are common manifestations of rheumatoid arthritis. The aim of this study was to compare the effects of active conventional treatment with three different biological disease-modifying antirheumatic drugs (DMARDs) on patient-reported outcomes after 48 weeks, in patients with early rheumatoid arthritis using data from the NORD-STAR trial. METHODS:NORD-STAR was an investigator-initiated open-label randomised controlled trial done at 29 rheumatology centres across Denmark, Finland, Iceland, Norway, Sweden, and the Netherlands. Newly diagnosed patients aged 18 years or older, with rheumatoid arthritis (according to the 2010 American College of Rheumatology-European Allience of Associations for Rheumatology classification criteria for rheumatoid arthritis), symptom duration less than 24 months and who were naïve to DMARDs were randomly assigned (1:1:1:1) to receive active conventional treatment, certolizumab pegol, abatacept, or tocilizumab. The patient-reported outcomes assessed at baseline and weeks 4, 8, 12, 16, 24, 32, 40, and 48 included pain, patient's global assessment of disease activity, Health Assessment Questionnaire Disability Index, Fatigue, Short Form-36 (reflecting health-related quality of life, morning stiffness, and patient's acceptable symptom state). Linear mixed regression and logistic regression analyses were adjusted for sex, country, baseline patient-reported outcomes values, anti-citrullinated protein antibody status, and treatment group. Proportions of patients reporting improvements greater than or equal to the minimal clinically important difference (MCID) were assessed. There was lived experience involvement in the design and implementation of the study. This trial was registered with ClinicalTrials.gov, NCT01491815, and EudraCT, 2011-004720-35. FINDINGS:Between Dec 14, 2012, and Dec 11, 2018, 812 patients were enrolled and randomly assigned; after exclusion of 17 patients not receiving tocilizumab due to administrative issues, the intention-to-treat population consisted of 795 patients (200 [25%] received active conventional treatment, 203 [26%] received certolizumab pegol plus methotrexate, 204 [26%] received abatacept plus methotrexate, and 188 [24%] received tocilizumab plus methotrexate). 547 (69%) of 795 patients were female, 248 (31%) were male, the mean age was 54 years (SD 15). Between baseline and week 48 large and clinically relevant improvements in patient-reported outcomes were observed in all treatment groups. At 48 weeks the biological DMARD groups had larger improvements in pain, fatigue, physical component score, and bodily pain of SF-36 compared with the active conventional treatment group. For pain, improvement exceeding MCID was reported by 155 (76%) of 203 patients with certolizumab pegol plus methotrexate and 162 (79%) of 204 patients with abatacept plus methotrexate compared with 136 (68%) of 200 patients in the active conventional treatment group. In the group of patients with tocilizumab and methotrexate 132 (70%) of 188 patients reported pain improvement exceeding MCID. The absolute differences between the biological DMARD groups and the active conventional treatment group were otherwise generally marginal. INTERPRETATION:All treatment groups showed substantial improvements in patient-reported outcomes over time. Biological DMARDs produced somewhat greater gains in pain, fatigue, and physical quality of life measures than conventional treatments, though overall differences between groups were small. The results highlight that early treatment and effective disease control in rheumatoid arthritis lead to strong patient-reported benefits regardless of therapy type. FUNDING:Stockholm County Council, Swedish Medical Research Council, Swedish Rheumatism Association, Academy of Finland, Finska Läkaresällskapet, South-Eastern Health Region Norway, HUS Institutional grant, Icelandic Society for Rheumatology, Interregional grant from all health regions in Norway, NordForsk, Regionernes Medicinpulje, The Research Fund of University Hospital Reykjavik, UCB, Bristol Myers Squibb.

Renal dysfunction increases cardiovascular (CV) risk. We compared cystatin C-based estimated glomerular filtration rate (eGFRcys), creatinine-based eGFR (eGFRcr), and their ratio (eGFRcys/eGFRcr) in relation to major adverse cardiovascular events (MACE) and all-cause mortality in chronic coronary syndrome, assessing the added prognostic value of the eGFRratio. In this post hoc analysis of 14,513 Stabilization of Atherosclerotic Plaque by Initiation of Darapladib Therapy trial patients, we investigated associations between baseline eGFRcys, eGFRcr, their ratio, and MACE and all-cause death using Cox regression models, unadjusted and adjusted for eGFRcys, eGFRcr, and their combination. Discrimination was assessed using Harrell's C -index; added value by the fraction of new information (FNI). Median age was 65 years; 82% were male. Median eGFRcys was 77 (interquartile range [IQR]: 61–94) and eGFRcr 79 (IQR: 65–91) mL/min/1.73 m 2 . Over 3.7 years, 1449 MACE and 1063 deaths occurred. Lower eGFR values and eGFRratio were associated with increased MACE risk, primarily driven by CV death. For eGFRcys 60 versus 90, the hazard ratio (HR) for MACE adjusted for eGFRcr was 1.77 (95% CI: 1.49–2.09, FNI 54%). In contrast, eGFRcr adjusted for eGFRcys showed no positive association (HR 0.82, 95% CI: 0.68–0.97, FNI 3%). A lower eGFRratio was linked to higher MACE risk (HR 1.99, 95% CI: 1.80–2.21), which remained after eGFRcr adjustment (HR 1.89, 95% CI: 1.70–2.10, FNI 54%) but was attenuated after eGFRcys adjustment (HR 1.29, 95% CI: 1.13–1.46, FNI 5%). In chronic coronary syndrome, lower eGFRcys, eGFRcr, and eGFRratio were associated with higher MACE and mortality risk. eGFRcys had the strongest association; eGFRcr and eGFRratio added limited incremental value.

Systemic lupus erythematosus (SLE) is a complex autoimmune disease with fluctuating disease activity and heterogeneous clinical manifestations. While DNA methylation changes have been implicated in SLE pathogenesis, their relationship to disease activity remains unclear. This study aimed to identify epigenetic correlates of disease activity in women with SLE using genome-wide DNA methylation profiling. Whole blood DNA from 48 women with established SLE was analyzed using Illumina EPIC arrays. Disease activity was assessed using the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K). Differentially methylated positions (DMPs) and regions (DMRs) associated with disease activity were identified using linear modeling and region-level analyses, adjusting for age, ethnicity, smoking status, body mass index (BMI), and cell composition. Gene ontology enrichment and motif analyses were also performed. No individual CpGs reached FDR-corrected significance, therefore, a hypothesis-generating approach using a raw p-value < 0.01 was applied. Over 4,500 suggestive DMPs (p < 0.01) were identified and further analyzed for DMRs and pathway mapping. Thirty-six significant DMRs (at 1% false discovery rate) were detected, with several genes involved in neuroimmune regulation and systemic inflammation. Motif analysis identified REST, a transcriptional repressor that silences neuronal genes in non-neuronal tissues, as a common motif among several DMRs. Semantic analysis of the affected loci revealed five major biological domains relevant to SLE: immune signaling, neuroimmune and neural processes, organ developmental morphogenesis, metabolic regulation, and epigenetic control. This exploratory study identified potential epigenome-wide methylation changes linked to disease activity in a well-controlled cohort of women with SLE. Region-level analysis revealed DMRs mapping to immune and neuroimmune pathways and showed enrichment of the REST binding motif. Although these findings are preliminary and require independent validation, they suggest subtle epigenetic alterations that may be associated with SLE activity and points to candidate pathways for further investigation.

The neutrophil marker CD177 (NB1, HNA-2a) is expressed by 0-100% of circulating neutrophils in any given donor, dividing neutrophils into 2 distinct subpopulations (CD177pos and CD177neg). High proportions of CD177pos blood neutrophils have been linked to both systemic infections and a range of inflammatory pathologies, but whether this is a cause or a consequence of disease is not known. Many conditions displaying elevated CD177pos neutrophil proportions are also accompanied by the presence of circulating low-density granulocytes. Accordingly, it is tempting to speculate that these 2 events are connected (i.e. that proportions of CD177pos neutrophils increase as a result of an enlarged pool of circulating low-density granulocytes). A temporary increase in CD177pos neutrophils, in combination with the presence of low-density granulocytes, has been reported during pregnancy. The present study aimed to investigate whether elevated proportions of CD177pos neutrophils in peripheral blood from pregnant women can be attributed to the presence of low-density granulocytes. We found that low-density granulocytes were indeed present in pregnancy and included both immature and activated mature neutrophils. The proportion of CD177pos low-density granulocytes increased over time during pregnancy and correlated with a simultaneous increase in immature cells. However, most immature neutrophils were CD177neg, meaning that increased release of immature cells cannot explain the increased proportions of the CD177pos subtype. Therefore, although low-density granulocytes and CD177pos neutrophils are expanded simultaneously during pregnancy, these events occur independently from each other.

OBJECTIVES:In the NOrdic Rheumatic Diseases Strategy Trials And Registries (NORD-STAR) trial, the active conventional arm had 2 nonrandomised regimens: arm 1A (oral group; Sweden, Norway, Netherlands, and Iceland) and arm 1B (injection group; Denmark and Finland). We report clinical, patient-reported, safety, and radiographic outcomes after 48 weeks. METHODS:Oral group received methotrexate plus oral prednisolone (20.0 mg/d, tapered rapidly, discontinued week 36); Injection group received triple therapy (methotrexate, sulphasalazine, hydroxychloroquine) and mandatory intra-articular glucocorticoid injections. The primary end point was analysed by logistic regression with several approaches for handling missing outcomes. RESULTS:In total, 137 and 80 patients were included in the oral group and injection group; 78% vs. 89% completed, respectively. At 48 weeks, adjusted clinical disease activity index remission ≤2.8 rates (95% CI) were 36% (28-44) and 55% (42-68), respectively; the risk difference (primary outcome) was 19% (2-35). Similarly, key secondary clinical, patient-reported and safety outcomes showed numerically better results in the injection group vs oral group, for example, infections occurred in 53% vs 30%, respectively. Radiographic progression (Δtotal van der Heijde-modified Sharp Score) was low: oral group: adjusted mean, 0.26 (95% CI, 0.08-0.43); injection group: adjustedd mean, 0.80 (95% CI, 0.55-1.05). Cumulative dose of oral/intra-articular glucocorticoids (median) was 1905 mg prednisolone for the oral group and 165 mg for the injection group. CONCLUSIONS:In treatment-naïve patients with early rheumatoid arthritis, triple therapy and mandatory glucocorticoid joint injections had numerically better clinical outcomes, fewer withdrawals, fewer adverse events, and lower cumulative dose of glucocorticoids, but slightly worse radiographic outcomes than treatment with methotrexate and oral prednisolone. These findings, although nonrandomised, suggest a potential for optimising treatment strategy with conventional therapies in early rheumatoid arthritis.

Early initiation of effective treatment is associated with positive long-term prognosis for patients with rheumatoid arthritis (RA). Currently, there are no biomarkers in clinical use to predict treatment response. A predictor of treatment response may be the B-cell compartment, as this is altered in RA patients, making it a potential candidate for predicting treatment response. In this study, we sought to identify B-cell subset(s) at diagnosis that might be associated with Clinical Disease Activity Index (CDAI) remission at 24-week follow-up. Seventy early RA patients from the NORD-STAR trial, recruited from two Swedish sites, and 28 matched healthy controls, were included in this spin-off study. In NORD-STAR, all patients were randomized to methotrexate (MTX) combined with 1) prednisolone, 2) anti-TNF (certolizumab-pegol), 3) CTLA4-Ig (abatacept), or 4) anti-IL-6R (tocilizumab). Circulating B-cell subsets at diagnosis were assessed by flow cytometry. The primary outcome measure was remission according to CDAI ≤ 2.8. A multivariate two-part discriminant analysis was performed to assess whether B-cell subpopulations at diagnosis could predict remission at 24 weeks. Subsequent univariable statistical analyses were performed using t-tests, Mann-Whitney U, or Kruskal-Wallis tests, as appropriate. Correlations were analyzed using Spearman or Pearson tests, depending on data type. The impact of specific B-cell populations on remission at week 24 was assessed using logistic regression models. The logistic regression model was also used to simultaneously visualize the sensitivity and specificity of the model for all possible values of the exposure (B-cell subpopulations) in predicting the outcome. Patients who achieved CDAI remission at 24 weeks had higher proportions of transitional (p < 0.01) and CD21− PD-1+ (p < 0.01) B cells at diagnosis compared to those who did not. When the two B-cell populations were combined, the sensitivity and specificity for remission, including all treatment arms, were 59

Combination CTLA-4 (ipilimumab) and PD-1 (nivolumab) checkpoint inhibition (dual-ICI) improves survival in patients with advanced melanoma. However, many patients also experience immune-related adverse events (irAE) that require systemic treatment with corticosteroids. Corticosteroids dampen the anti-tumoral response and may impair survival. Here, we investigated the association between irAE and overall survival as well as exposure to corticosteroids and second line immunosuppressants in dual ICI-treated patients with advanced melanoma (n = 205). Patients with irAE (n = 113) had superior OS compared to patients with no irAE (n = 92). The survival benefit persisted after adjusting for immortal time bias. Regarding specific irAE, patients with colitis, hepatitis, rheumatic irAE, hypophysitis, and skin-related irAE had improved OS after adjusting for negative baseline factors. A survival benefit persisted for hypophysitis (p = 0.03) and hepatitis (p = 0.04) after adjusting for immortal time bias, whereas rheumatic (p = 0.05) and skin-related irAE (p = 0.06) where borderline significant. Hepatitis and colitis required higher doses of corticosteroids for longer times and more often second-line immunosuppression compared to other irAE. In conclusion, irAE are associated with superior OS in patients with advanced melanoma treated with dual ICI. Hepatitis and hypophysitis were most strongly associated with better survival outcomes. Studies investigating the mechanisms underlying hepatitis and hypophysitis may identify important response mechanisms.

OBJECTIVES:To determine anticitrullinated protein antibody (ACPA) responses to novel peptides predicting the clinical outcomes of treatment-naïve early rheumatoid arthritis (RA) in the presymptomatic stage. METHODS:We analysed monoclonal ACPAs derived from RA patients, including a characterised protective ACPA (clone E4), along with plasma samples collected from 520 presymptomatic individuals, of whom 244 were also sampled at diagnosis of RA, and 530 population controls in Sweden. The validation cohort (The Nordic Rheumatic Diseases Strategy Trials and Registries, NORD-STAR) consisted of 690 treatment-naïve early RA patients. Responses to citrullinated or native alpha-enolase (ENO1) or peptidylarginine deiminase 4 (PAD4) peptides were analysed by bead-based multiplex flow immunoassay. Clinical outcomes included C-reactive protein (CRP) and the 28-joint disease activity score (DAS28) with its components: tender joint count (TJC), swollen joint count (SJC), and erythrocyte sedimentation rate (ESR). RESULTS:Monoclonal ACPAs displayed distinct binding patterns to ENO1 and PAD4 peptides. A time-dependent increase of ACPA response to citrullinated peptides was observed in the presymptomatic stage towards onset. In the presymptomatic (0.2-5 years before onset) and early RA stage, ACPA responses to several ENO1 and PAD4 peptides were associated with less severe RA, assessed as lower levels of CRP and DAS28 and its components. In early RA, the association was more pronounced in rheumatoid factor (RF)-negative patients based on lower SJC. In presymptomatic individuals, ACPA responses widely predicted lower disease activity in early RA and were more pronounced in 5 selected peptides. CONCLUSIONS:Antibody responses to certain citrullinated epitopes are associated with lower disease activity in treatment-naïve early RA and appear years before symptom onset of RA.