Taking advantage of a PCR technique that allows amplification of all variable region genes with equal efficiency, we defined three novel waves of TCR δ-chain transcription during thymic ontogeny. The canonical DV101-D2-J2 rearrangement was confined to a narrow window from days 14 to 18 of gestation, indicating that the postulated two consecutive γδ precursor waves bearing this canonical DV101 rearrangement will coincide on day 16. Neonatal δ-chain transcripts used a second wave of diverse Vα gene segments that are exclusively located in the δ locus-proximal gene cluster of intermingled single members of different Vα subfamilies. In the adult, only expression of a clan of three homologous subfamilies, ADV7, DV104, and ADV17, persists. The members of the ADV7 subfamily are also scattered across the α locus, but their usage does not show the position-dependent bias of the other Vα-to-δ rearrangements.

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Background:Autoinflammatory periodic fever syndromes characterized by excessive interleukin(IL)-1b release and severe systemic and organ inflammation have been successfully treated with the anti-IL-1 inhibitor canakinumab (CAN). In clinical trial situations and real life, rapid remission of symptoms and normalization of laboratory parameters were observed in most patients.1-3Objectives:The present study explores long-term effectiveness and safety of CAN under routine clinical practice conditions in pediatric and adult patients with CAPS (cryopyrin-associated periodic syndromes), FMF (familial Mediterranean fever), TRAPS (tumor necrosis factor receptor-associated periodic syndrome) and HIDS/MKD (hyperimmunoglobulinemia D syndrome/mevalonate kinase deficiency).Methods:RELIANCE is a prospective, non-interventional, multi-center, observational study based in Germany with a 3-year follow-up period. Pediatric (age ≥2 years) and adult patients with clinically confirmed diagnoses of CAPS, FMF, TRAPS and HIDS/MKD that routinely receive CAN are enrolled in order to evaluate effectiveness and safety of CAN in clinical routine.Results:This first interim analysis of patient subgroups diagnosed with FMF, HIDS and TRAPS includes baseline data of 41 patients (10 TRAPS, 2 HIDS, 29 FMF), including preliminary 6-month data of a FMF-subset (N=16).Evaluation of disease activity and fatigue by patients’ assessment, days absent from school/work, inflammatory markers and physician global assessment (PGA) was performed at baseline and will be further assessed at 6-monthly intervals within the 3-year observation period. Preliminary results of a first subset of 16 patients diagnosed with FMF are available and indicate stable remission and disease control upon long-term CAN treatment: within the first study interval, no major changes were observed regarding the analyzed parameters (table 1).Table 1.Baseline characteristics of the TRAPS/HIDS/FMF-subgroups and preliminary 6-month data of FMF subset.TRAPSHIDSFMFBaselineBaselineBaselineall FMF patientsBaselineFMF subset6 monthsFMF subsetNumber of patients, N102291616Mean age, years (SD)22 (4; 43)11 (5; 18)26 (5; 56)16 (5; 47)16 (5; 47)Female (%), N=9 (1 missing)5 (56)1 (50)15 (52)7 (44)7 (44)Mean duration of prior canakinumab treatment, years (min; max)1 (0; 2)3 (2; 4)n. a.2.2 (0; 6)2.2 (0; 6)Patient’s assessment of disease activity 0-10, mean (min; max)2.1 (0; 5)0 (0; 0)3 (0; 10)2.8 (0; 8)2.2 (0; 7)Patient’s assessment of fatigue 0-103.4 (0; 8)0 (0; 0)4.4 (0; 9)4.6 (0; 9)3.9 (0; 8)Number (%) of patients with days absent from school/work due to study indication during last 6 months4 (44)2 (100)5 (17)2 (13)5 (31)Inflammatory markers, CRP/SAA, mean (mg/dL)2.07.90.10.60.95.30.52.40.62.4PGA of disease activity: no/mild to moderate/severe; N (%)*1 (11)6 (67)0 (0)2 (100)0 (0)0 (0)10 (35)8 (28)2 (7)5 (31)7 (44)1 (6)6 (38)7 (44)0 (0)SAE, N (%)0 (0)0 (0)2 (6.9)n. a.2 (12.5)Conclusion:Baseline characteristics of all subgroups and first interim data of FMF patients are available from the RELIANCE study, the longest running real-life CAN registry. Further interval data will be analyzed to assess efficacy and safety of long-term CAN-treatment in patients with autoinflammatory periodic fever syndromes.References:[1]Lachmann et al. N Engl J Med. 2009;360(23):2416-25[2]Kuemmerle-Deschner et al. Rheumatology (Oxford). 2016;55(4):689-96[3]De Benedetti et al. N Engl J Med. 2018;378(20):1908-1919Disclosure of Interests:Jörg Henes Grant/research support from: Novartis, Roche-Chugai, Consultant of: Novartis, Roche, Celgene, Pfizer, Abbvie, Sanofi, Boehringer-Ingelheim,, J. B. Kuemmerle-Deschner Grant/research support from: Novartis, AbbVie, Sobi, Consultant of: Novartis, AbbVie, Sobi, Michael Borte Grant/research support from: Pfizer, Shire, Ivan Foeldvari Consultant of: Novartis, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Tilmann Kallinich Grant/research support from: Novartis, Consultant of: Sobi, Roche, Novartis, Birgit Kortus-Goetze Consultant of: Novartis, Frank Weller-Heinemann: None declared, Julia Weber-Arden Employee of: I am employed by Novartis, Norbert Blank Grant/research support from: Novartis, Sobi, Consultant of: Novartis, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Actelion, UCB, Boehringer-Ingelheim, Roche

Background:Familial Mediterranean Fever (FMF) is characterized by recurrent attacks of fever and serositis as well as elevated inflammatory markers. FMF treatment goals according to EULAR are to control acute attacks and subclinical inflammation and to improve patients´ quality of life1. In a phase 3 pivotal study (CLUSTER study), FMF patients treated with the interleukin-1β inhibitor canakinumab met all these goals2.Objectives:The present study explores the long-term efficacy and safety of canakinumab (CAN) in routine clinical practice in pediatric (age ≥2 years) and adult FMF patients.Methods:RELIANCE is a prospective, non-interventional, multi-center, observational study based in Germany with a three-year follow-up period. Patients with clinically confirmed diagnosis of FMF who routinely receive CAN were enrolled in order to evaluate effectiveness and safety of CAN under standard clinical practice conditions. Disease activity and remission by physicians´ assessment, disease activity, fatigue and impact on social life by patients’ assessment, inflammatory markers and AIDAI (Auto-Inflammatory Diseases Activity Index) score were recorded at baseline and were assessed at 6-monthly intervals within the three-year observation period of the study.Results:This interim analysis of FMF patients (N=54) enrolled by December 2020 includes baseline as well as 6-, 12- and 18-month data. Mean age in this cohort was 25 years (4−56 years) and the proportion of female patients was 46 % (N=25). At baseline, median duration of prior CAN treatment was 2.0 years (0−6 years).While physician ratings report around 62% of patients in disease remission, 52% with absent and 34% with mild-moderate disease activity, patient-reported disease activity decreased from moderate (PPA 3.0) to low (PPA 2.0) during the observation period. A decrease was observed regarding disease activity parameters, in particular in patients without prior CAN therapy (Table 1, Figure 1). A total of 11 serious adverse events was reported, of which one case of tonsillectomy was classified as drug-related.Conclusion:Interim data of FMF patients from the RELIANCE study, the longest running real-life CAN registry, confirm efficacy and safety of long-term CAN treatment.References:[1]Ozen S, et al. EULAR recommendations for the management of familial Mediterranean fever. Ann Rheum Dis 2016;75:644–651. doi:10.1136/annrheumdis-2015-208690[2]De Benedetti F, et al. Canakinumab for the treatment of autoinflammatory recurrent fever syndromes. N Engl J Med 2018;378:1908–19.Table 1.Baseline characteristics and third interim analysis data of patients with FMFBaseline6 months12 months18 monthsAll patients | patients without prior CAN therapyNumber of patients, N5411357275163Number (%*) of patients in disease remission (physician assessment)18 (48.6)1 (20.0)19 (73.1)3 (75.0)13 (65.0)1 (50.0)8 (61.5)1 (100.0)Physician Global Assessment, percentage* of absent/mild-moderate/severe rating43/38/110/40/6065/27/050/50/055/35/00/50/046/46/00/100/0Patient assessment of current disease activity; 0–10, median (min; max)3.0 (0; 10)7.0 (0; 10)2.5 (0; 7)2.0 (0; 5)2.0 (0; 7)2.0 (0; 2)2.0 (0; 6)0.5 (0; 1)Patient assessment of current fatigue; 0–10, median (min; max)5.0 (0; 10)5.0 (0; 9)3.5 (0; 10)3.0 (1; 6)3.0 (0; 10)0.0 (0; 4)3.0 (0; 7)0.5 (0; 1)Number (%*) of patients without impairment of social life by the disease19 (46.3)3 (37.5)18 (66.7)3 (75.0)14 (66.7)4 (80.0)5 (55.6)2 (66.7)CRP, median (mg/dl)0.21.10.20.10.20.00.10.5SAA, median (mg/dl)0.76.80.80.40.80.60.60.7ESR, median (mm/h)9.018.56.05.05.54.08.05.0SAENumber of eventsIncidence rate per 100 patient yearsTotal1116.23Arthritis57.38SARS-CoV-2 infection22.95Familial Mediterranean Fever11.48Intestinal Hemorrhage11.48Pyrexia11.48Tonsillectomy (SADR)11.48*not reported for all patientsCRP, c-reactive protein; ESR, erythrocyte sedimentation rate; n. a., not annotated; SAA, serum amyloid A; SADR, serious adverse drug reaction; SAE, serious adverse eventDisclosure of Interests:Jörg Henes Consultant of: Novartis, AbbVie, Sobi, Roche, Janssen, Boehringer-Ingelheim, Grant/research support from: Novartis, Roche, J. B. Kuemmerle-Deschner Consultant of: Novartis, AbbVie, Sobi, Grant/research support from: Novartis, AbbVie, Sobi, Tilmann Kallinich Consultant of: Sobi, Novartis, Roche, Grant/research support from: Novartis, Frank Dressler Consultant of: Abbvie, Mylan, Novartis, Pfizer, Grant/research support from: Novartis, Frank Weller-Heinemann: None declared, Birgit Kortus-Goetze Consultant of: Novartis, Ivan Foeldvari Consultant of: Novartis, Gerd Horneff Speakers bureau: bbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Markus Hufnagel Grant/research support from: Novartis, Florian Meier Speakers bureau: Novartis, Julia Weber-Arden Employee of: Novartis, Norbert Blank Consultant of: Novartis, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Actelion, UCB, Boehringer-Ingelheim, Roche, Grant/research support from: Novartis, Sobi

Background:In the treatment of monogenic autoinflammatory diseases (AID), a heterogeneous group of diseases with excessive interleukin (IL)-1β release and severe systemic and organ inflammation, the anti-IL-1 inhibitor canakinumab (CAN) has been associated with rapid remission of symptoms in clinical trials as well as in real-life.1-3Objectives:The aim of the RELIANCE registry is to explore long-term effectiveness and safety of CAN under routine clinical practice conditions in pediatric and adult patients with CAPS (cryopyrin-associated periodic syndromes, including Muckle-Wells syndrome [MWS], familial cold autoinflammatory syndrome [FCAS], neonatal onset multisystem inflammatory disease [NOMID]/chronic infantile neurological cutaneous and articular syndrome [CINCA]), FMF (familial Mediterranean fever), TRAPS (tumor necrosis factor receptor-associated periodic syndrome) and HIDS/MKD (hyperimmunoglobulinemia D syndrome/mevalonate kinase deficiency).Methods:This prospective, non-interventional, observational study is based in Germany with a 3-year follow-up and enrolls pediatric ≥2 years and adult patients with clinically confirmed diagnoses of CAPS, FMF, TRAPS and HIDS/MKD routinely receiving CAN. In 6-monthly visits, clinical data and patient-reported outcomes are assessed. Study endpoints are long-term effectiveness and safety of CAN. Here, the CAPS cohort was analyzed.Results:This 18-month interim-analysis includes 78 CAPS patients (49% females) enrolled by September 2019. Mean age at baseline was 25 years and mean duration of prior CAN treatment was 5.7 years. 64 patients (82%) had MWS, 2 FCAS, 7 NOMID/CINCA, 3 atypical CAPS and 2 lacked subtype diagnosis. Disease activity, fatigue and social impairment by patients’ assessment, days absent from school/work, inflammatory markers, and remission by physician assessment were evaluated at 6-monthly intervals starting at baseline with last update at 18 months of follow-up (table 1). The results demonstrate sustained remission and disease control as evaluated parameters remained stable over time. Serious adverse events were reported for 9 patients including papillitis, pyrexia, tonsillitis (n=2), appendicitis, chest pain, circulatory collapse, skin disorders, and preterm delivery.Table 1.Patient and physician assessment of clinical CAPS disease activity and laboratory markers over timeBaseline6 months12 months18 monthsNumber of patients, N78514229Mean age, years (SD)25 (4; 79)22 (4; 79)20 (4; 58)22 (4; 54)Patient’s assessment of disease activity 0-10, mean (min; max)2.2 (0; 7)1.8 (0; 7)2.4 (0; 7)2.8 (0; 8)Patient’s assessment of fatigue 0-102.9 (0; 9)2.4 (0; 8)2.8 (0; 8)1.7 (0; 7)Number (%) of patients without impairment of social life by disease16 (49)29 (76)20 (61)14 (67)Number (%) of patients with days absent from school/work25 (32.5)11 (22)14 (34)15 (52)Inflammatory markers, CRP/SAA, mean (mg/dL)0.43.20.42.10.30.80.20.5Number (%) of patients in disease remission (physician assessment)55 (72)38 (76)29 (71)22 (76)Conclusion:The 18-month interim analysis of the RELIANCE study, the longest running real-life CAN registry, demonstrates that long-term CAN treatment is safe and effective in CAPS patients.References:[1]Lachmann et al. N Engl J Med. 2009;360(23):2416-25[2]Kuemmerle-Deschner et al. Rheumatology (Oxford). 2016;55(4):689-96[3]De Benedetti et al. N Engl. J Med. 2018;378(20):1908-1919Disclosure of Interests:Norbert Blank Grant/research support from: Novartis, Sobi, Consultant of: Novartis, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Actelion, UCB, Boehringer-Ingelheim, Roche, Michael Borte Grant/research support from: Pfizer, Shire, Ivan Foeldvari Consultant of: Novartis, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Tilmann Kallinich Grant/research support from: Novartis, Consultant of: Sobi, Roche, Novartis, Birgit Kortus-Goetze Consultant of: Novartis, Prasad Oommen Consultant of: Novartis, Catharina Schuetz: None declared, Frank Weller-Heinemann: None declared, Julia Weber-Arden Employee of: I am employed by Novartis, J. B. Kuemmerle-Deschner Grant/research support from: Novartis, AbbVie, Sobi, Consultant of: Novartis, AbbVie, Sobi

TCR delta-chain gene rearrangements were analyzed at different stages of thymic ontogeny. The VDJ delta junctional sequences of the dominantly expressed TCR delta-chain V7 subfamily are highly conserved in fetal and neonatal thymocytes. They are equally conserved in C delta-targeted mice lacking cell surface expression of gamma delta receptors, indicating evolutionary selection acting at the level of DNA rearrangement. Yet, in C delta-mutant mice, the frequency of in-frame transcripts is reduced to 61%, from 88% in wild-type mice, suggesting cellular selection of this DV7-overexpressing gamma delta thymocyte subset. In contrast, in genomic DNA rearrangements, no difference was found in the frequency of productive rearrangements between mutant (26%) and wild-type mice (31%). This in-frame rate, characteristic of random rearrangements, indicates that positive selection is not required for thymic maturation of gamma delta T cells. The results are discussed with regard to models of alpha beta/gamma delta lineage commitment.

BackgroundHyper-IgD syndrome/mevalonate kinase deficiency (HIDS/MKD) is a rare autoinflammatory condition caused by a defect in the gene coding for mevalonate kinase. This periodic fever syndrome is characterized by severe systemic and organ inflammation. Treatment with interleukin-1β inhibitor canakinumab (CAN), approved and applied for treatment of HIDS/MKD patients since 2017 [1], resulted in rapid remission of symptoms and normalization of laboratory parameters in most patients in clinical trials [2] as well as in real-life.ObjectivesTo explore the long-term efficacy and safety of CAN under routine clinical practice conditions in pediatric (age ≥2 years) and adult HIDS/MKD patients.MethodsRELIANCE is a prospective, non-interventional, multi-center, observational study based in Germany with a 3-year follow-up period. Patients with clinically confirmed diagnoses of TRAPS, CAPS, FMF or HIDS/MKD who routinely receive CAN are enrolled in order to evaluate efficacy and safety of CAN under standard clinical practice conditions at baseline and at 6-monthly intervals.ResultsThe present interim analysis shows baseline data of 8 HIDS/MKD patients enrolled by December 2021 as well as preliminary 18-month data. Of these patients, 5 (63%) were females and median age at baseline was 8 years (2–39 years). The median duration of prior CAN treatment at baseline was 1.5 years (0–5 years). Standard, low, and high dose CAN treatment was evenly distributed at every interval.Preliminary results indicate stable remission and disease control by physicians´ and patients´ assessment as well as laboratory parameters (Table 1). In total, 4 patients were affected by adverse drug reactions, however, none of these events was classified as serious.Table 1.Baseline characteristics and interim analysis data of patients with HIDS.Baseline (N=8)6 months (N=7)12 months (N=6)18 months (N=4)Number (%) of patients in disease remission (physician assessment)4 (50)6 (86)4 (67)3 (75.0)Physician assessment of disease activity, percentage of absent/mild-moderate/severe rating37 / 50 / 1371 / 29 / 050 / 33 / 1750 / 50 / 0Patient´s assessment of current disease activity; 0–10, median (min; max)0 (0; 7)2.0 (0; 7)0.0 (0; 8)0.0 (0; 0)Patient´s assessment of current fatigue; 0–10, median (min; max)2.5 (0; 7)3.0 (0; 7)1.0 (0; 4)1.0 (0; 2)Number (%) of patients without impairment of social life by the disease3 (50)4 (67)4 (80)1 (33)Number (%) of patients with days absent from work/school during last 6 months2 (25)3 (43)0 (0)1 (25)CRP, median (mg/dl)0.20.50.32.1SAA, median (mg/dl)0.60.70.80.5ESR, median (mm/h)10.06.08.013.0CRP, c-reactive protein; SAA, serum amyloid A; ESR, erythrocyte sedimentation rateConclusionBaseline characteristics and preliminary data of HIDS/MKD patients from the RELIANCE study indicate good clinical and laboratory disease control and no unexpected safety concerns at the 18 months interim analysis.References[1]Ilaris, INN-canakinumab (europa.eu)[2]De Benedetti F, et al. Canakinumab for the treatment of autoinflammatory recurrent fever syndromes. N Engl J Med 2018;378:1908–19Disclosure of InterestsPrasad Oommen Grant/research support from: Novartis, Tilmann Kallinich Consultant of: Sobi, Novartis, Roche, Grant/research support from: Novartis, Jürgen Rech Speakers bureau: Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, MSD; Mylan, Novartis, Roche, Sanofi, Sobi, UCB, Consultant of: Abbvie, Biogen, BMS, Chugai, GSK, Janssen, Lilly, MSD, Mylan, Novartis, Roche, Sanofi, Sobi, UCB, Grant/research support from: Novartis, Sobi, Norbert Blank Consultant of: Novartis, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Actelion, UCB, Boehringer-Ingelheim, Roche, Grant/research support from: Novartis, Sobi, Julia Weber-Arden Employee of: Novartis, J. B. Kuemmerle-Deschner Consultant of: Novartis, AbbVie, Sobi, Grant/research support from: Novartis, AbbVie, Sobi