We discovered a Sjögren's disease (SjD)-like state in the programmed cell death 1+ (PD-1⁺) niches of the spleen and submandibular glands of 36-week-old female Nishiura (NI) mice, characterized by the formation of tertiary lymphoid structures (TLS) by senescence-associated (SA) immune cells, production of anti-α-amylase autoantibodies, and reduced saliva secretion. Co-culturing B220⁺/PD-1⁺ cells derived from the spleens of NI mice with CD4+/PD-1+/CD153+ (SA-Tfh) cells for 48 h enhanced IgG and senescence-associated secretion phenotype production in both cell types. Conversely, transplantation of spleen-derived SA-Tfh cells from NI mice expanded TLS in the submandibular glands of recipient mice. Meanwhile, a retrospective histopathological cohort study of seven SjD patients aged 50-70 revealed that the fibrogenic capacity per SA-Tfh cell significantly increased with age. Collectively, these data suggest that TLS formation associated with SA immune cells in the submandibular glands is a key mechanism in SjD.

INTRODUCTION:Early identification of synovial hypertrophy is critical for preventing irreversible changes in haemophilic arthropathy (HA). Although prophylaxis has improved joint outcomes, it remains unclear which patients and joints in early HA should be prioritised for musculoskeletal ultrasound (MSKUS) screening. AIM:To identify the predictors of synovial hypertrophy at the patient and joint levels in early HA. METHODS:We enrolled patients with haemophilia aged 6-49 years with mild joint damage (Arnold-Hilgartner grades I-III). Elbows, knees and ankles were examined using MSKUS. Patient-level factors included age, body mass index, haemophilia characteristics, adherence and activity. Joint-level factors included symptoms, recent bleeding, physical findings and radiographic scores. Logistic regression was applied to patient-level predictors and mixed-effects models to joint-level predictors. RESULTS:In total, 203 joints from 40 patients were evaluated; synovial hypertrophy was identified in 82 joints (34 patients), most frequently in the knees (54.5%), followed by the elbows (38.9%) and ankles (22.2%). Adult age was the only significant patient-level predictor of synovial hypertrophy (odds ratio, 5.2; p = 0.001). At the joint level, no examined factors were significantly associated with synovial hypertrophy. Among asymptomatic joints, 37.9% demonstrated synovial hypertrophy (23.7% in paediatric patients vs. 56.9% in adults), with elbow involvement showing no significant age-related differences (34.4% vs. 40.7%, p = 0.79). CONCLUSIONS:Patient- and joint-specific findings alone are insufficient to predict synovial hypertrophy. MSKUS may be used routinely to enhance early detection in patients with HA on prophylaxis. Elbow synovial hypertrophy warrants attention from paediatric patients as one of the earliest stages of the disease.

Granulomatosis with polyangiitis (GPA) is traditionally regarded as a neutrophil-driven necrotizing vasculitis. However, the potential involvement of eosinophilic inflammation has not been fully elucidated. We investigated the contribution of eosinophilic inflammation to the pathogenesis of GPA, with a particular focus on eosinophil extracellular trap formation (EETosis). This retrospective study included 52 patients, including 25 with active GPA and 27 in remission. We recorded enzyme-linked immunosorbent assay-based serum concentrations of eosinophil-derived proteins (galectin-10, eosinophil cationic protein, and eosinophil-derived neurotoxin), neutrophil-derived proteins (myeloperoxidase), and a marker for extracellular traps (citrullinated histone H3) for these patients. EETosis in tissue samples of patients was examined by immunofluorescence staining. Serum-induced EETosis was evaluated in vitro. Serum concentrations of galectin-10, eosinophil cationic protein, eosinophil-derived neurotoxin, citrullinated histone H3, and C-reactive protein and antineutrophil cytoplasmic antibody titre of patients with active GPA were significantly higher than those in remission. Galectin-10 had the strongest correlation with the Birmingham Vasculitis Activity Score (r = 0.778, P < 0.001). Increased galectin-10 levels were identified to be associated with the active stage after adjustment for glucocorticoid dose and eosinophil count. Receiver operating characteristic analyses of galectin-10 to discriminate between the active and remission phases revealed an area under the curve of 0.923, with 85.2% sensitivity and 91.1% specificity. GPA lung tissue showed lytic eosinophils and EETosis. Additionally, serum from active GPA patients induced EETosis in vitro whereas that from remission patients did not. Eosinophil activation and EETosis may contribute to the disease activity of GPA, highlighting a previously underrecognized component of its pathogenesis.

Senescence-associated follicular helper T (SA-Tfh) cells contribute to tertiary lymphoid structure (TLS) formation in autoimmune diseases, yet the mechanisms guiding their localization to glandular niches remain unclear. In the Nishiura (NI) Sjögren’s disease (SjD) mouse model, we demonstrated that mouse SA-Tfh (mSA-Tfh; CD4+/PD-1+/CD153+) cells form TLSs specifically within the submandibular gland niche. We identified integrin α7 (ITGα7) expression in mSA-Tfh cells and examined its functional role. Adhesion of mSA-Tfh cells to laminin (LAM) α2/α3/α4 was inhibited by anti-ITGα7 IgG (E-2), and ITGα7-deficient mSA-Tfh cells had reduced adhesion to LAMα1/α2 compared with LAMα3/α4/α5. Osteopontin production by mSA-Tfh cells, either alone or via interactions with mB220+/PD-1+ cells, was suppressed by E-2, anti-LAMα4 IgG, and ITGα7 deficiency. In female NI mice, E-2 administration at 24 weeks reduced Greenspan grade 4 TLSs at 28 weeks by decreasing ITGα7+/CD153+ cell accumulation. mSA-Tfh infiltration into aged C57BL/6 mice was similarly diminished by ITGα7 or LAMα4 deficiency. In human SjD cohorts, ITGα7 expression positively correlated with CD153 expression (R2 = 0.41) in peripheral lymphocytes and with LAMα4 expression (R2 = 0.35) in salivary gland vasculature and ducts. These findings suggest that circulating ITGα7+ SA-Tfh cells adhere to the LAMα4+ glandular niche to promote TLS formation in SjD.

OBJECTIVES:To assess the oral health-related quality of life (OHRQoL) in Sjögren's disease (SjD) patients with unstimulated whole salivary flow (UWSF) ≥0.1 ml/min for whom no preferred therapeutic approaches are provided in the European League Against Rheumatism recommendations. METHODS:Thirty-four SjD patients and 23 controls were enrolled in this study. The UWSF was measured using the spitting method. OHRQoL was quantitatively evaluated using the short-form Oral Health Impact Profile (OHIP-14). RESULTS:In SjD patients, 26 (76.5%) had a UWSF <0.1 ml/min, and 8 (23.5%) had ≥0.1 ml/min. The OHIP-14 scores were significantly higher in both the ≥0.1 and <0.1 ml/min groups than in the non-SjD group. Among the OHIP-14 questions, the ≥0.1 ml/min group scored significantly higher than the non-SjD group for 'uncomfortable to eat foods', 'self-conscious', 'diet unsatisfactory', 'difficult to relax', 'felt life less satisfying', and 'unable to function'. CONCLUSIONS:Even with UWSF ≥0.1 ml/min, SjD patients had lower OHRQoL. The normal range of salivary flow rates is wide, exhibiting high interindividual variability. Even if the salivary flow rate is preserved in a single measurement, the possibility of having oral dryness due to a decrease in the salivary flow rate from the normal value for that patient should be considered.

Inflammatory cytokine levels exhibit a circadian rhythm in sera, peaking from late night to early morning in patients with rheumatoid arthritis (RA). This cytokine kinetics is a recognized therapeutic target. This clinical study aimed to evaluate the effectiveness of night-time baricitinib administration based on cytokine secretion. In this 52-week multicenter non-randomized controlled study, 122 patients with RA were assigned to four groups: baricitinib 2 mg morning (BAR2MORN), 2 mg evening (BAR2EVE), 4 mg morning (BAR4MORN), or 4 mg evening (BAR4EVE). The primary endpoint was assessed using the 20

Introduction and objectives Ultrasound (US) remission in rheumatoid arthritis (RA) targets synovitis absence. Tenosynovitis triggers flares. Despite increased ultrasound use, flare patterns among patients with low disease activity (LDA) and ultrasound remission, especially in real-world settings, are poorly understood. This study examined flare rates and predictors of US remission in patients without synovitis or tenosynovitis. Materials and methods In a study of 88 patients achieving US remission and LDA, the focus was on the time to the first flare over a 2-year follow-up. US remission, indicated by the absence of active synovitis and tenosynovitis based on a power Doppler (US-PD) score of 0, was assessed on various joints. Flares are defined by the need for additional medication or encountering a US-PD flare. They were monitored at the baseline, 1-year, and 2-year visits with further US evaluation at clinical flare-ups. Baseline factors linked to a shorter time to flare were analyzed. Results At 1 year, LDA and US remission rates were 75% and 92%, respectively, and at 2 years, 73% and 87% respectively. Over the 2 years, 40% experienced flare, occurring on average at 11.7±7.0 months. Notably, 5.7% have US-PD flares without clinical signs. Analysis revealed Stage III disease and CRP as factors linked to a shorter time to flare. Discussion and conclusions In patients with RA achieving LDA and US remission, frequent flares were observed with US remission over 2 years, but most maintained sustained remission. Baseline factors are essential for predicting flares, emphasizing continuous monitoring and personalized treatment to sustain remission and minimize flare risks in RA management.

Aim. The aim of this study was to investigate whether cytokines associated with tumour necrosis factor- (TNF-) α and interleukin- (IL-) 6 signalling could predict rheumatoid arthritis (RA) clinical remission (CR) with Janus kinase inhibitor (JAKinib) treatment using the Simplified Disease Activity Index (SDAI). Methods. Eighty-nine patients with RA treated with JAKinibs were enrolled, and their clinical data were collected retrospectively. CR was defined as an SDAI≤3.3 after 6 months of treatment with JAKinib. The serum samples of 89 patients were analysed for IL-6, soluble IL-6 receptor (sIL-6R), soluble gp130 (spg130), and soluble TNF receptor- (sTNFR-) I and sTNFR-II titres. Results. There were no significant differences in the baseline clinical parameters between the CR and non-CR groups. Serum levels of IL-6, sIL-6R, and sgp130 were not significantly different; whereas, the serum sTNFR-I and sTNFR-II levels were significantly lower in the CR group. Univariate and multivariate logistic regression analysis showed that the baseline log sTNFR II values (OR: 0.002; p=0.034) were predictors of CR. Conclusions. Patients with RA can be stratified prior to JAKinib administration using serum sTNFR-I and sTNFR-II levels but not serum IL-6 axis cytokine levels (IL-6, sIL-6R, and sgp130).

YKL-40 is implicated in inflammation and tissue repair, but no reports have investigated its involvement in myositis in polymyositis (PM) and dermatomyositis (DM). Therefore, we aimed to investigate the relationship between YKL-40 and PM/DM. We retrospectively enrolled 35 patients diagnosed with PM/DM along with 26 healthy controls (HCs). Both PM and DM were diagnosed according to Bohan and Peter’s criteria. Serum YKL-40 levels were measured, age-corrected to YKL-40 percentile values, and compared to HCs. Patients with myositis without interstitial lung disease were also enrolled and compared to HCs. Immunofluorescence staining was performed to identify YKL-40-positive inflammatory cells in muscle biopsy samples from two patients each with PM and DM. Age-corrected serum YKL-40 levels were significantly higher in patients with PM/DM compared to HCs with and without lung disease; however, these levels decreased significantly after treatment. Immunohistochemical analysis showed infiltration of YKL-40-positive inflammatory cells into the intramuscular sheath and perimuscular membrane. Immunofluorescence staining showed CD68 expression in YKL-40-positive inflammatory cells, suggesting that these cells were macrophages. To the best of our knowledge, this is the first study to demonstrate that YKL-40-positive macrophages are present in PM and DM, indicating that YKL-40 may be involved in PM/DM.

Reactivity to an anisakis allergen component was examined in three patients with a history of an anisakiasis anaphylaxis. Case 1, a 38-year-old man, allergic symptoms appeared 0.5 hours after ingestion, and the component Ani s 1 and 3 were positive. Case 2, a 44-year-old woman, allergic symptoms appeared 4 hours after ingestion, and components Ani s 3 and 12 were positive. Case 3, a 36-year-old woman, developed allergic symptoms 7 hours after ingestion of fish and shellfish, and tested positive for Ani s 1, 4, and 12. Case 3 reacted strongly to both heated and unheated Anisakis extract, while cases 1 and 2 reacted weakly to heated Anisakis extract. The most common allergen was Ani s 12, followed by Ani s 1, when analyzed in conjunction with existing reports on 10 cases. Anisakis IgE was class 3 or higher in all cases. Analysis of 13 cases showed 2 cases sensitized to Ani s 4 and moderate or higher anaphylaxis, while Ani s 4-sensitized patients were reported to be more likely to develop severe disease. It is possible that the patients sensitized to Ani s 4 need to be careful about the severity of their allergic symptoms.

Endogenous DNA is released into the bloodstream as cell-free DNA (cfDNA) following cell death and is associated with various pathological conditions. However, their association with therapeutic drugs against rheumatoid arthritis (RA) remains unknown. Therefore, we investigated the significance of cfDNA in RA treated with tocilizumab and tumour necrosis factor inhibitor (TNF-I). Biological DMARDs (bDMARDs), including tocilizumab and TNF-I, were administered to 77 and 59 RA patients, respectively. Plasma cfDNA levels were measured at weeks 0, 4, and 12 by quantitative polymerase chain reaction. Disease activity was evaluated at the same time point using DAS28ESR. cfDNA levels from RA synovial cells treated with tocilizumab or etanercept for 24 h were measured. Human toll-like receptor 9 (hTLR9)-expressing HEK293 cells, which release secreted embryonic alkaline phosphatase (SEAP) upon NF-κB activation, were stimulated by cfDNA from RA patients, and subsequently, SEAP levels were determined. NF-κB translocation was evaluated by immunofluorescence staining with or without tocilizumab. The DAS28ESR significantly improved in both bDMARD groups at week 12. However, plasma cfDNA levels significantly decreased in the tocilizumab group at week 12 compared to that in week 0. cfDNA levels correlated with DAS28ESR in biological treatment-naïve patients administered tocilizumab. cfDNA levels in synovial cells were significantly suppressed by tocilizumab treatment and unaltered with etanercept. HEK293 cells released SEAP upon cfDNA stimulation, and the observed NF-κB nuclear translocation was suppressed by tocilizumab. Tocilizumab suppressed inflammation via the TLR9 pathway by decreasing cfDNA levels. Regulation of cfDNA may be a therapeutic target for RA.

We examined whether serum B cell activating factor (BAFF) is useful for predicting the remission of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) following rituximab treatment. We used the Birmingham Vasculitis Activity Score (BVAS) 2008 version 3 for the evaluation of 27 patients with AAV 6 months after rituximab treatment. Those with BVAS = 0 achieved remission, whereas those with BVAS score > 0 did not achieve remission. We considered changes in serum BAFF before rituximab treatment, 1 month after treatment, and 6 months after treatment. In the remission group, the serum BAFF increased consistently. In the non-achieved group, serum BAFF was within the normal range. In addition, there was no statistically significant difference between the two groups in terms of serum BAFF before and 1 month after rituximab treatment. However, the serum BAFF level at 6 months after rituximab treatment was significantly higher in the remission group than in the non-achieved group. If serum BAFF does not increase after 6 months of rituximab in AAV, it may be assumed that there are residual B cells and plasma cells in the tissues. Enhanced treatment targeting B cells, including re-administration of rituximab or the addition of other immunosuppressive drugs, should be considered.

Background Endogenous DNA derived from nuclei or mitochondria is released into the blood circulation as cell-free DNA (cfDNA) following cell damage or death. cfDNA is associated with various pathological conditions; however, its clinical significance in antineutrophil cytoplasmic antibody-associated vasculitis (AAV) remains unclear. This study aimed to evaluate the clinical significance of cfDNA in AAV. Methods We enrolled 35 patients with AAV, including 10 with eosinophilic granulomatosis with polyangiitis (EGPA), 13 with microscopic polyangiitis, and 12 with granulomatosis with polyangiitis. Serum cf-nuclear DNA (cf-nDNA) and cf-mitochondrial DNA (cf-mtDNA) levels were measured by quantitative polymerase chain reaction before and after the initiation of immunosuppressive therapy. Tissue samples from EGPA patients were examined by immunofluorescence and transmission electron microscopy. The structure of eosinophil extracellular traps (EETs) and neutrophil extracellular traps (NETs) and stability against DNase were assessed in vitro. Platelet adhesion of EETs were also assessed. Results Serum cf-nDNA and cf-mtDNA levels were significantly higher in AAV than in healthy controls, with the highest levels in EGPA; however, serum DNase activities were comparable among all groups. cf-nDNA and cf-mtDNA decreased after treatment and were associated with disease activity only in EGPA. Blood eosinophil count and plasma D-dimer levels were significantly correlated with cf-nDNA in EGPA and cf-mtDNA. EGPA tissue samples showed lytic eosinophils and EETs in small-vessel thrombi. The structure of EETs showed bolder net-like chromatin threads in vitro and EETs showed greater stability against DNase than NETs. EETs provided a scaffold for platelet adhesion. Conclusion cfDNA was increased in EGPA, associated with disease activity. The presence of DNase-resistant EETs in small-vessel thrombi might contribute to higher concentration of cfDNA and the occurrence of immunothrombosis in EGPA.

Endogenous DNA derived from the nuclei or mitochondria is released into the bloodstream following cell damage or death. Extracellular DNA, called cell-free DNA (cfDNA), is associated with various pathological conditions. Recently, multiple aspects of cfDNA have been assessed, including cfDNA levels, integrity, methylation, and mutations. Rheumatoid arthritis (RA) is the most common form of autoimmune arthritis, and treatment of RA has highly varied outcomes. cfDNA in patients with RA is elevated in peripheral blood and synovial fluid and is associated with disease activity. Profiling of cfDNA in patients with RA may then be utilized in various aspects of clinical practice, such as the prediction of prognosis and treatment responses; monitoring disease state; and as a diagnostic marker. In this review, we discuss cfDNA in patients with RA, particularly the sources of cfDNA and the correlation of cfDNA with RA pathogenesis. We also highlight the potential of analyzing cfDNA profiles to guide individualized treatment approaches for RA.

Table S1. Characteristics of autoimmune dyslipidemia patients previously reported. Appendix S1. Supplemental method. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.