Emily Hallinan
email: eshallinan@ualg.pt

Omry Barzilai

Orcid

Amir Beshkani

João Cascalheira

Yuri E Demidenko

Mae Goder-Goldberger

Yamandú H Hilbert

Erella Hovers

Anthony E Marks

Andreas Nymark

Deborah I Olszewski

Maya Oron

Jeffrey I Rose

Matthew Shaw

Vitaly I Usik

The Nature of Nubian: developing current global perspectives on Nubian Levallois technology and the Nubian Complex 1. INTRODUCTION

Nubian Levallois technology has recently risen to the forefront of debates surrounding Late Pleistocene human technological behaviour, cultural traditions and demographic histories. Named after the region where it was first identified, Nubian Levallois describes a specific method of lithic point production that occurs in Middle Palaeolithic (or Middle Stone Age) assemblages across arid North Africa, the Levant and Arabia. [START_REF] Guichard | The Early and Middle Palaeolithic of Nubia: preliminary results[END_REF][START_REF] Marks | The Mousterian industries of Nubia[END_REF][START_REF] Van Peer | The Nile Corridor and the Out-of-Africa model: an examination of the archaeological record[END_REF][START_REF] Olszewski | Nubian Complex strategies in the Egyptian high desert[END_REF][START_REF] Rose | The Nubian Complex of Dhofar, Oman: an African Middle Stone Age industry in southern Arabia[END_REF][START_REF] Goder-Goldberger | Diffusion with modifications": Nubian assemblages in the central Negev highlands of Israel and their implications for Middle Paleolithic inter-regional interactions[END_REF][START_REF] Beshkani | The first evidence of Middle Palaeolithic Nubian technology in north-central Oman[END_REF][START_REF] Crassard | Middle Palaeolithic occupations in central Saudi Arabia during MIS 5 and MIS 7: new insights o the origins of the peopling of Arabia[END_REF][START_REF] Barzilai | Expansion of eastern Mediterranean Middle Paleolithic into the desert region in early marine isotopic stage 5[END_REF] However, the recent identification of Nubian technology in separate, disconnected regions, such as South Africa [START_REF] Hallinan | A new Middle Stone Age industry in the Tankwa Karoo, Northern Cape Province, South Africa[END_REF][START_REF] Hallinan | Nubian Levallois reduction strategies in the Tankwa Karoo, South Africa[END_REF][START_REF] Will | Implications of Nubian-Like core reduction systems in southern Africa for the identification of early modern human dispersals[END_REF] and possibly India [START_REF] Blinkhorn | Middle Palaeolithic occupation in the Thar Desert during the Upper Pleistocene: the signature of a modern human exit out of Africa?[END_REF][START_REF] Blinkhorn | Middle Palaeolithic point technologies in the Thar Desert, India[END_REF] suggests there are more diverse scenarios of its emergence and spread than the original model of a broad Nubian technocomplex related to a single, expanding population from its north-east African heartland. [START_REF] Van Peer | The Nile Corridor and the Out-of-Africa model: an examination of the archaeological record[END_REF] While few assemblages containing Nubian technology are directly dated, its proposed MIS 5 timing coincides with early modern human dispersals out of Africa, adding a further dimension of whether certain lithic technologies can be linked to specific geographic populations.

Currently, advancing this debate is hindered by having neither an accepted definition of what constitutes Nubian technology, nor a consensus on its role in modern human cultural evolution and population dynamics. [START_REF] Groucutt | Culture and convergence: the curious case of the Nubian Complex[END_REF][START_REF] Blinkhorn | Nubian Levallois technology associated with southernmost Neanderthals[END_REF][START_REF] Hallinan | No direct evidence for the presence of Nubian Levallois technology and its association with Neanderthals at Shukbah Cave[END_REF][START_REF] Blinkhorn | Reply to: 'No direct evidence for the presence of Nubian Levallois technology and its association with Neanderthals at Shukbah Cave[END_REF] To address this, 22 archaeologists (Table 1) met for an international workshop with two aims: (1) refining the definition of the Nubian technological method and how it can be identified in assemblages; and (2) re-evaluating the relationship between Nubian technology as a reduction strategy and the Nubian Complex as a cultural entity in the context of current evidence. The specialist group of lithic analysts brought expertise in relevant assemblagesparticularly those where Nubian technology forms a prominent component -from across Africa, the Levant and Arabia (Figure 1), contributing a diverse range of approaches and perspectives to this salient debate.

WORKSHOP OVERVIEW

The workshop was held at the Interdisciplinary Center for Archaeology and Human Evolution (ICArEHB), at the University of Algarve in Faro, Portugal, 24-26 February 2022. On the first day, presentations from workshop participants established the landscape of current knowledge about Nubian Levallois technology (Table 1). These were geographically wide-ranging, covering recent work in Israel's Negev Desert (Barzilai, Goder-Goldberger, Oron), extensive surveys in the Egyptian High Desert (Olszewski), the Combined Prehistoric Expedition campaign that originally defined Nubian cores in Sudan (Marks), and assemblages that contain especially high numbers of Nubian cores from the Arabian peninsula (Hilbert, Rose) and South Africa (Hallinan, Shaw). Complementary talks presented lithic studies from Syria (Demidenko), the Zagros (Nymark) and Morocco (Djellal). Additional perspectives tackled epistemological issues driving Nubian debates (Hovers) and encouraged new ways of conceptualising Nubian technology, drawing on geometry (Beshkani) and controlled knapping experiments (Rezek). The format for the second and third days took a discursive approach, with discussions guided by presentations on the following themes: (1) What? Defining Nubian Levallois technology; (2) Where? The origins and distribution of Nubian technology; (3) Why? Reasons behind Nubian technology.

What? A refined definition of Nubian Levallois reduction

Specialists in the field of Nubian Levallois technology have previously identified the need for a clear and unified definition if we are to advance our understanding of the nature of Nubian in technological and taxonomic terms; 17 therefore, this was a major focus of the workshop's first discussion session. The attribute list developed by Usik et al. [START_REF] Usik | Nubian Complex reduction strategies in Dhofar, southern Oman[END_REF] has been employed in numerous studies to assess whether Nubian Levallois technology in its strictest sense is present in an assemblage. [START_REF] Goder-Goldberger | Diffusion with modifications": Nubian assemblages in the central Negev highlands of Israel and their implications for Middle Paleolithic inter-regional interactions[END_REF][START_REF] Hallinan | Nubian Levallois reduction strategies in the Tankwa Karoo, South Africa[END_REF][START_REF] Will | Implications of Nubian-Like core reduction systems in southern Africa for the identification of early modern human dispersals[END_REF][START_REF] Hilbert | Technological analysis of the Al-Jawf Middle Paleolithic assemblages[END_REF] However, disagreement over the identification of certain cores [START_REF] Blinkhorn | Nubian Levallois technology associated with southernmost Neanderthals[END_REF][START_REF] Hallinan | No direct evidence for the presence of Nubian Levallois technology and its association with Neanderthals at Shukbah Cave[END_REF] and the ambiguous affinities of others [START_REF] Yellen | The archaeology of Aduma Middle Stone Age sites in the Awash Valley, Ethiopia[END_REF][START_REF] Wahida | A Middle Paleolithic assemblage from Jebel Barakah, Coastal Abu Dhabi Emirate[END_REF][START_REF] Groucutt | Skhul lithic technology and the dispersal of Homo sapiens into Southwest Asia[END_REF][START_REF] Masojć | Saharan green corridors and Middle Pleistocene hominin dispersals across the Eastern Desert, Sudan[END_REF] emphasise the need for a refined definition to serve as a solid foundation for subsequent behavioural interpretations.

Drawing on our combined experience of relevant assemblages in nearly all regions where Nubian technology is found, the workshop group identified the following features as key requirements for a Levallois core to be described as 'Nubian'. First, Nubian cores are expected to follow the widely accepted criteria of preferential Levallois reduction schemes more broadly: (1) the volume of the core is formed of two surfaces meeting at a plane of intersection, (2) these are hierarchically related with defined roles as preparation and production surface, and (3) the aim of reduction is to produce a predetermined product, achieved through the management of lateral and distal convexities. [START_REF] Boëda | Le concept Levallois et évaluation de son champ d'application[END_REF][START_REF] Van Peer | The Levallois Reduction Strategy[END_REF] Second, they show a specific sequence of reduction [START_REF] Usik | Nubian Complex reduction strategies in Dhofar, southern Oman[END_REF][START_REF] Van Peer | The Levallois Reduction Strategy[END_REF] that results in the following technological and morphological characteristics (Figure 2):

(1) Possession of a steep ridge at the distal end of the core (the distal median ridge), of 90 degrees or less, formed by two or more intersecting scars. (2) The presence of a distal platform for preparation removals, serving an alternate role to the proximal platform from which preferential removals are struck. (3) The distal portion of the core is the focus of preparation of the distal ridge, with removals from the distal platform and/or steep lateral preparation focused on the distal half to third of the core. (4) The overall morphology of the core is pointed, occurring in a variety of convergent shapes. (5) Reduction is aimed at producing pointed end-products.

In our discussions, an important distinction was drawn between two analytical goals: identifying whether an artefact is a Nubian core, and characterising variability within an assemblage containing Nubian Levallois technology. Our revised criteria directly address the first issue. The second issue, quantifying intra-assemblage variability of Nubian reduction, is captured in the attributes defined by Usik et al. [START_REF] Usik | Nubian Complex reduction strategies in Dhofar, southern Oman[END_REF] ; for example, exploring the range of distal median ridge steepness, which is expected to be between 60 and 120 degrees. Under our modified approach, this accommodates for reworked or exhausted cores that have a flatter distal ridge (greater than 90 and sometimes exceeding 120 degrees) but otherwise fall within a Nubian reduction system. Other attributes, such as the angle of the distal platform and core morphology, are suited to intra-assemblage analyses but are not diagnostic criteria alone.

A further point of discourse concerned the terms 'Type 1', 'Type 2' and 'Type 1/2' to describe dorsal scar preparation patterns on Nubian cores. The workshop participants agreed that Nubian 'Types' are only useful in so far as they describe preparation methods within an assemblage, representing the extremes of a spectrum of distal (Type 1) and lateral (Type 2) preparation strategies. Therefore, more clarity in characterising this variability in future work will come from describing cores explicitly in terms of their pattern of distal ridge preparation, thereby removing the blurred boundaries of Types and focusing instead on describing technology.

Where? Re-aligning the 'Nubian Complex' debate

Since the original applications of the term 'Nubian', [START_REF] Guichard | The Early and Middle Palaeolithic of Nubia: preliminary results[END_REF][START_REF] Marks | The Mousterian industries of Nubia[END_REF][START_REF] Van Peer | The Nile Corridor and the Out-of-Africa model: an examination of the archaeological record[END_REF] our knowledge of the geographic distribution of Nubian technology has widened, particularly in the last 10 years, resulting in more complex implications for how it is understood in cultural terms. However, it is increasingly evident that the quantitative occurrence of Nubian technology is not the same in time and space. It is to be expected that occasional cores that fall within our strict revised definition of Nubian cores may occur in other assemblages with Levallois reduction; however, the significance (or not) of these depend entirely on the assemblage context. Arguments focusing on the existence of the Nubian Complex [START_REF] Groucutt | Culture and convergence: the curious case of the Nubian Complex[END_REF] are doing little to aid our understanding of the nature of Nubian technology as a cultural behaviour in regions where it is a prominent reduction strategy. [START_REF] Olszewski | Nubian Complex strategies in the Egyptian high desert[END_REF][START_REF] Rose | The Nubian Complex of Dhofar, Oman: an African Middle Stone Age industry in southern Arabia[END_REF][START_REF] Goder-Goldberger | Diffusion with modifications": Nubian assemblages in the central Negev highlands of Israel and their implications for Middle Paleolithic inter-regional interactions[END_REF][START_REF] Barzilai | Expansion of eastern Mediterranean Middle Paleolithic into the desert region in early marine isotopic stage 5[END_REF] The conclusion arising from the workshop supported a move towards restricting the use of "Complex" or equivalent cultural designations until further comparative studies and explicit tests of dispersal, diffusion and convergence scenarios have been carried out. We propose a reorientation in approach towards a 'bottom up' understanding of the shared building blocks that may represent common cultural elements in a revised notion of a Nubian cultural entity.

Why Nubian?

A key -though at this stage in our research, abstract -question is why the Nubian reduction strategy might have been employed. While debates usually centre on the Nubian core since this is the more abundant and recognisable artefact type in most assemblages, fresh perspectives offered by workshop participants working in other Palaeolithic contexts served as a reminder that tool function is an important and often neglected aspect. However, a widespread problem in tackling this is that very few assemblages with Nubian Levallois reduction contain high numbers of end-products (points or pointed flakes). Considerations related to point shape, robusticity and aerodynamics were discussed but further investigation is needed to test these hypotheses. [START_REF] Yaroshevich | Weapons in transition: reappraisal of the origin of complex projectiles in the Levant based on the Boker Tachtit stratigraphic sequence[END_REF] The relationship between Nubian technology and the present-day desert environments in which it occurs might also offer insights into arid behavioural adaptations, [START_REF] Hallinan | Nubian Levallois reduction strategies in the Tankwa Karoo, South Africa[END_REF] or a shared cultural 'contextual area'. [START_REF] Goder-Goldberger | Diffusion with modifications": Nubian assemblages in the central Negev highlands of Israel and their implications for Middle Paleolithic inter-regional interactions[END_REF][START_REF] Barzilai | Expansion of eastern Mediterranean Middle Paleolithic into the desert region in early marine isotopic stage 5[END_REF][START_REF] Hilbert | Technological analysis of the Al-Jawf Middle Paleolithic assemblages[END_REF][START_REF] Richter | Contextual areas" of early Homo sapiens and their significance for human dispersal from Africa into Eurasia between 200 ka and 70 ka[END_REF] 3. FUTURE DIRECTIONS Several areas were identified as priorities in our future research and plans to implement these were formed. First, the creation of experimentally knapped assemblages will provide a foundation for testing various hypotheses about the Nubian reduction method. While there are some extensively refitted archaeological assemblages (e.g. Makhadma 6, [START_REF] Van Peer | Makhadma 6, a Nubian Complex site[END_REF] Abydos 4011, [START_REF] Chiotti | Middle Palaeolithic lithic technology from the Western High Desert of Egypt[END_REF] TH.383c [START_REF] Usik | Nubian Complex reduction strategies in Dhofar, southern Oman[END_REF] ) these are in the minority and the problem of 'missing' Nubian end-products hinders many of the questions surrounding why Nubian reduction was used over other methods of point production. Second, the application of 3D methods to the measurement and analysis of the key attributes that define Nubian cores will aid the quantification and replicability of our data. Preliminary results of 3D geometric morphometric analyses showed the potential of these tools for comparing the shapes of Nubian cores and end-products, and various methods for digital angle measurements were discussed. The value of generating 3D models of artefacts was further demonstrated by the use of 3D printed Nubian cores to aid workshop discussions and compare specimens from different regions side-by-side. Third, the comparison of relevant assemblages where Nubian reduction is prominent will allow us to develop models that explicitly test the archaeological evidence against the expected signatures of dispersal, diffusion or convergence at an inter-regional scale. Applying Tostevin's [START_REF] Tostevin | Seeing lithics: A middle-range theory for testing cultural transmission in the Pleistocene[END_REF][START_REF] Tostevin | Content matters: the materiality of cultural transmission and the intersection of Paleolithic archaeology with cultural evolution theory[END_REF] attribute-based framework for measuring cultural transmission and social intimacy was proposed as one pathway for achieving this.

Given recent published debates on the nature of Nubian, our workshop was a necessary and timely contribution to the study of the 'Nubian' phenomenon. Adopting the revised approach set out in this paper will provide the necessary vocabulary and scientific rigour to advance these discussions. Our definition draws a clear distinction between identifying Nubian cores in an assemblage and interpreting the Nubian Levallois reduction strategy at an intra-and inter-assemblage scale. Building on the need for archaeological interpretations of lithic assemblages to be rooted in quantitative, reproducible data [START_REF] Will | Comparative analysis of Middle Stone Age artifacts in Africa (CoMSAfrica)[END_REF] , our workshop has both established a framework to facilitate this, and laid the groundwork for comparative studies. Future research arising from these outcomes promises significant new insights to constructively explore technological, behavioural and cultural dimensions of the Nubian debate.

Figure 1 .

 1 Figure 1. Map showing assemblages containing Nubian cores studied by workshop participants (red circles). Sites with Nubian cores reported (grey circles) after Hallinan and Shaw 2020.

Figure 2 .

 2 Figure 2. Schematic illustration of the characteristics of Nubian Levallois technology

ACKNOWLEDGMENTS

The 'Nature of Nubian' workshop was supported by funding from the FCT (Fundação para a Ciência e Technologia, Portugal) awarded to ICArEHB, FLAD (Luso-American Development Foundation) and the Algarve Archaeological Association. The workshop took place in the frame of Emily Hallinan's project TANKwA funded by the European Union Horizon 2020 Framework under the Marie Skłodowska-Curie Grant Agreement No. 891917.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analysed in this study.

EVOLUTIONARY ANTHROPOLOGY: NEWS The Nature of Nubian: developing current global perspectives on Nubian Levallois technology and the Nubian Complex

CONFLICT OF INTEREST

The authors declare no potential conflict of interest. Regrettably, due to global circumstances beyond our control, Yuri Demidenko, Vitaly Usik and Mirosław Masojć were unable to travel to the workshop. Anthony Marks participated over Zoom.


Miceli-Richard

Xavier Pr

Mariette

A single tumor necrosis factor α α α α haplotype influences response to adalimumab in rheumatoid arthritis

Keywords: TNFα, adalimumab, rheumatoid arthritis, genetic polymorphism, haplotype

Objective. To determine whether tumor necrosis factor (TNF) gene polymorphisms and/or the shared epitope are genetic predictors of response to adalimumab (ADA) in rheumatoid arthritis (RA). Methods. This ancillary study to the Research in Active Rheumatoid Arthritis (ReAct) Phase IIIb study included a large cohort of Caucasian patients with RA from France (N=380) treated with ADA plus methotrexate (MTX) (n=182), ADA plus any other DMARD (N=96) or ADA alone (N=102). The primary outcome was ACR50 at 12 weeks. Patients underwent genotyping for HLA-DRB1 and 3 TNFα gene polymorphisms (-238A/G, -308A/G and -857C/T). Extended haplotypes involving HLA-DRB1 and TNFα loci were reconstructed by use of the PHASE program. Results. A total of 152 patients (40%) had an ACR50 response at week 12. Neither the number of HLA-DRB1 SE copies nor presence of the 3 TNFα polymorphisms tested separately was significantly associated with ACR50 response at week 12. However, haplotype reconstruction of the TNFα locus revealed the GGC haplotype (-238G/-308G/-857C) in a homozygous form, present in more than half of the patients, significantly associated with a lower ACR50 response at 12 weeks (34% vs. 50% in patients without the haplotype) on treatment with ADA concomitant with MTX (P=0.0041; Pc=0.02). This effect was restricted to the subgroup of patients concomitantly treated with MTX. Conclusion. This large pharmacogenetic study provides robust data indicating that a single TNFα locus haplotype (-238G/-308G/-857C), present on both chromosomes is associated with a lower response to ADA and MTX therapy in RA patients homozygous for this haplotype.

The last ten years have seen a better understanding of the pathogenesis of rheumatoid arthritis (RA). Studies have led to the recognition of TNFα as one of the cornerstone cytokines involved in the synovial inflammatory process. Such results have provided the basis for the development of TNF blockers for treating RA. Three TNF blockers are currently used for RA treatment, one corresponding to a recombinant soluble form of TNF receptor, TNFRSF1B (etanercept), and two others corresponding an anti-TNFα monoclonal antibody (infliximab and adalimumab [ADA]). These TNF blockers act by inhibiting the binding of TNFs to TNF receptors on the cell surface and therefore interfere with TNF-driven signal transduction pathways. Etanercept binds to both TNFα and TNFβ (or lymphotoxine α [LTA]) and infliximab and adalimumab to TNFα only. TNF blockers are efficient in about 70% of patients, but 30% are resistant. Taking into account the cost of these treatments in RA, the persisting questions about potential long-term adverse events (infections and cancers) and the availability of other efficient biotherapies, the identification of predictive factors of response to treatment is a key issue. In this field, pharmacogenetic approaches give promising hope. Nevertheless, few studies have been performed to date and some have led to contradictory results, especially those concerning the role of the shared epitope (SE) and/or TNF -308A/G polymorphism [START_REF] Padyukov | Genetic markers for the efficacy of tumour necrosis factor blocking therapy in rheumatoid arthritis[END_REF][START_REF] Criswell | The influence of genetic variation in the HLA-DRB1 and LTA-TNF regions on the response to treatment of early rheumatoid arthritis with methotrexate or etanercept[END_REF][START_REF] Mascheretti | Pharmacogenetic investigation of the TNF/TNF-receptor system in patients with chronic active Crohn's disease treated with infliximab[END_REF][START_REF] Mugnier | Polymorphism at position -308 of the tumor necrosis factor alpha gene influences outcome of infliximab therapy in rheumatoid arthritis[END_REF][START_REF] Cuchacovich | Tumour necrosis factor-alpha (TNF-alpha) levels and influence of -308 TNF-alpha promoter polymorphism on the responsiveness to infliximab in patients with rheumatoid arthritis[END_REF][START_REF] Martinez | Association of the major histocompatibility complex with response to infliximab therapy in rheumatoid arthritis patients[END_REF][START_REF] Mugnier | Tumor necrosis factor alpha haplotypes versus tumor necrosis factor alpha -308 G/A polymorphism in the prediction of infliximab treatment efficacy in rheumatoid arthritis[END_REF][START_REF] Fonseca | Polymorphism at position -308 of the tumour necrosis factor alpha gene and rheumatoid arthritis pharmacogenetics[END_REF][START_REF] Kang | The influence of a polymorphism at position -857 of the tumour necrosis factor alpha gene on clinical response to etanercept therapy in rheumatoid arthritis[END_REF][START_REF] Lee | Association of TNF-alpha -308 G/A polymorphism with responsiveness to TNF-alpha-blockers in rheumatoid arthritis: a metaanalysis[END_REF][START_REF] Marotte | The shared epitope is a marker of severity associated with selection for, but not with response to, infliximab in a large rheumatoid arthritis population[END_REF][START_REF] Seitz | The -308 tumour necrosis factor-{alpha} gene polymorphism predicts therapeutic response to TNF{alpha}-blockers in rheumatoid arthritis and spondyloarthritis patients[END_REF] (Table 1). The aim of this study was to determine whether the SE and/or TNFα gene polymorphisms, analyzed separately or after haplotype reconstruction, are genetic predictors of response to ADA in patients with RA.

METHODS

Patients

This pharmacogenetic study was ancillary to the Research in Active Rheumatoid Arthritis (ReAct) protocol performed at various sites in Europe and Australia. In the parent ReAct study, 6610 patients were included to assess the safety and effectiveness of ADA, a fully human IgG 1 anti-TNF monoclonal antibody. The objectives of the ReAct study were to evaluate patients for efficacy and tolerance of ADA in combination with a variety of disease-modifying antirheumatic drugs (DMARDs), including those previously treated with etanercept or infliximab. Briefly, patients enrolled in the ReAct study were men and women ≥ 18 years of age with active, adult-onset RA as defined by the 1987 revised criteria of the American College of Rheumatology (ACR) [START_REF] Arnett | The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis[END_REF]. Inclusion criteria required a disease duration ≥ 3 months; a disease activity score based on erythrocyte sedimentation rate and an evaluation of 28 joints (DAS28) [START_REF] Prevoo | Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis[END_REF] ≥3.2, indicating at least moderate disease activity; and failure of treatment with at least 1 traditional DMARD. Previous therapy with biologic response modifiers including other TNF antagonists was allowed if the medication was discontinued at least 2 months before enrolment. The pharmacogenetic study we describe here concerns a large cohort of 398 French patients included in the ReAct study. All the patients provided written informed consent. The study was approved by the local ethics committee. Eight patients were excluded owing to their Asian or African descent (Figure 1). Ten other patients were excluded from the main statistical analysis because of missing ACR50 response data at 12 weeks. Thus, 380 patients from the original population were eligible for the study and underwent treatment with ADA plus MTX (n=182), ADA plus any other DMARD (n=96) or ADA alone (n=102).

Collection of clinical and biological data and outcome measures

The clinical and biological data were from the original ReAct protocol. At baseline and weeks 2, 6, and 12, scores for variables necessary to assess DAS 28 and ACR response were recorded, as were scores on the Health Assessment Questionnaire-Disability Index (HAQ). Outcomes were measured after 12 weeks of treatment. The primary outcome for the genetic study was ACR50 response, secondary outcomes were ACR20 and ACR70 responses.

Genetic polymorphisms in TNF and HLA genes

We chose to analyze the TNF gene polymorphisms on the basis of a previous report showing four main haplotypes consisting of TNF +488, -238 and -308 singlenucleotide polymorphisms (SNPs) among a Caucasian population [START_REF] Mullighan | TNF and lymphotoxin-alpha polymorphisms associated with common variable immunodeficiency: role in the pathogenesis of granulomatous disease[END_REF]. However, TNF+488 has been reported to have strong linkage disequilibrium (LD) with TNF-857 (LD value, Somer's D=0.92 in a Caucasian population [START_REF] Simmonds | A systematic approach to the assessment of known TNF-alpha polymorphisms in Graves' disease[END_REF]). Moreover, TNF -857 was recently reported to influence clinical response to etanercept [START_REF] Kang | The influence of a polymorphism at position -857 of the tumour necrosis factor alpha gene on clinical response to etanercept therapy in rheumatoid arthritis[END_REF], so we chose to genotype TNF-857 instead of TNF+488. The three studied SNPs encompasse the entire TNF promoter locus, leading hence, as expected, to obtain the four main haplotypes cited below in our Caucasian population of RA patients. Because definite HLA-DRB1 alleles have been previously reported to play an important role in RA susceptibility --the SE hypothesis [START_REF] Gregersen | The shared epitope hypothesis. An approach to understanding the molecular genetics of susceptibility to rheumatoid arthritis[END_REF] --and severity [START_REF] Gorman | Impact of shared epitope genotype and ethnicity on erosive disease: a meta-analysis of 3,240 rheumatoid arthritis patients[END_REF], we genotyped our RA patients for HLA-DRB1 alleles by direct sequencing. The alleles considered to have the SE were HLA-DRB1*0101, *0102, *0401, *0404, *0405, *0408, *0413, *1001, and *1402 [START_REF] Gregersen | The shared epitope hypothesis. An approach to understanding the molecular genetics of susceptibility to rheumatoid arthritis[END_REF]. To analyze the SE contribution in response to ADA treatment, patients were classified as having 0, 1 or 2 copies of the SE, or as being SE carriers or not. Extended haplotypes comprising HLA-DRB1 alleles and TNF SNPs were reconstructed as well.

Genotyping methods

Patients were genotyped for HLA-DRB1 and 3 TNFα gene polymorphisms (-857C/T, -308A/G and -238A/G). HLA-DRB1 alleles were determined by polymerase chain reaction (PCR) amplification and DNA sequencing by use of an ABI 3700 sequencer (PE Applied Biosystems, Courtaboeuf, France). TNF -238A/G PCR gene polymorphisms was genotyped by mismatch polymerase chain reaction (PCR) -restriction fragment full length polymorphism (RFLP) using the MspI restriction enzyme. Primers used for PCR amplification were: forward 5'ATCTGGAGGAAGCGGTAGTG3' and reverse 5'AGAAGACCCCCCTCGGAACC3'. Forward primer contained a purposeful 3' mismatch, so that when incorporated into the PCR products they create a MspI restriction site with the G allele but not with the A allele.

TNF -308A/G polymorphism was genotyped by allelic discriminating TaqMan PCR by use of the PreDeveloped TaqMan assay kit C_7514879 (PE Applied Biosystems). Amplifications involved use of a 7900HT Applied Biosystems real-time thermal cycler (PE Applied Biosystems). TNFα -857C/T genotyping was performed by a TaqMan® 5'-nuclease assay (PE Applied Biosystems) with allele-specific fluorogenic oligonucleotide probes (5'CCCTGTCTTCATTAAG and 5'CCCTGTCTTCGTTAAG) using an ABI 7000 sequence detection system (PE Applied Biosysytem).

Statistical analysis

All quantitative data are expressed as the mean +/-SD and all qualitative data as frequencies and percentages. All genotyped SNPs were in Hardy-Weinberg equilibrium. Within the TNF gene, a measure of the LD between the different SNPs was estimated using Somer's D'. Since the LD was significantly different among all TNF SNPs and between TNF SNPs and HLA-DRB1 alleles, we also considered the haplotypes for TNF and extended haplotypes comprising HLA DRB1 alleles and TNF. We used the software PHASE (version 2.1) to perform haplotype reconstructions. This Bayesian algorithm provides the most-likely pairs of haplotypes carried by each subject [START_REF] Stephens | Haplotype variation and linkage disequilibrium in 313 human genes[END_REF][START_REF] Stephens | A comparison of bayesian methods for haplotype reconstruction from population genotype data[END_REF]. The average probability of PHASE certainty in haplotype inference was 99% for TNF haplotypes and 83% for SE-TNF extended haplotypes. For each gene, genotypes and haplotypes were tested for association with ACR50 response to ADA at week 12. Differences in genotype distribution for efficacy were tested using contingency tables (3 X 2 crosstabs for each genotype and 2 X 2 crosstabs for each possible combination of homozygote and heterozygote genotypes) with the 2-sided chi-square test. A Bonferroni correction was applied for multiple comparisons. Both adjusted and unadjusted P values are presented. P values less than 0.05 were considered significant. The factors influencing the probability of achieving an ACR50 response at week 12 were studied through multivariate logistic regression. In addition to the SNPs and to the haplotypes described above, we considered the following covariates: gender, age, weight, clinical variables measured at baseline, duration of disease, presence of rheumatoid factor (RF) and concomitant treatment. First, univariate logistic regressions were performed to screen covariates. The models with and without a given covariate were compared using a log-likelihood ratio test, that is, by comparing twice the difference in log-likelihoods of the two model to the critical values of the χ 2 statistic. We kept all the covariates for which the p-value of this test was less than 0.15. A multivariate regression model was then built including all candidate covariates selected in the previous step, and the final model was selected through backward selection, using log-likelihood ratio tests as previously. At this stage, covariates were kept in the model if the p-value of the test was less than 0.05.

RESULTS

Description of the cohort

The baseline characteristics of patients are presented in Table 2. The profile of clinical response of the 380 patients included in this pharmacogenetic study was the same as that of the entire ReAct population (6610 patients). At 12 weeks, 40% of the patients (n=151) showed an ACR50 response, 71% (n=263) an ACR20 response and 16% (n=59) an ACR70 response. MTX adjunction to ADA therapy was significantly associated with a better ACR50 response both in univariate (P=0.005) and multivariate analyses (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.07-2.66; P=0.026). In the subgroup of patients not receiving methotrexate, there was a non significant trend for a better response when other DMARDs were administered in addition to ADA (38% of ACR50 responders versus 29% in patients given only ADA, NS). Genotype distributions were as follows: for TNF-238 G>A (N=364), 94% GG, 5% AG, and one patient had the rare AA genotype; for TNF-308 G>A (N=373), 71% GG, 26% AG, and 3% had the AA genotype; for TNF-857 C>T (N=361), 82.7% CC, 17% CT, and one patient had the rare TT genotype. These distributions were consistent with data from public databases for Caucasians (http://www.ncbi.nlm.nih.gov/projects/SNP). SE could be determined in 326 patients. The distribution of the SE among patients was as follows: 25.4% had no copies, 47.6% 1 copy, and 27% 2 copies, for a total of 74.6% carriers. In 346 patients in whom we determined the 3 SNPs of the TNFα promoter (-238A/G, -308A/G and -857C/T), we identified four main haplotypes (e.g., the haplotype GGC consisted of -238G, -308G and -857C). These most frequent haplotypes (GGC, GAC, GGT and AGC) accounted for more than 99% of the total number of haplotypes, with frequencies of occurrence of 74%, 14%, 8% and 3%, respectively. The rare AAC haplotype was found in only one patient.

Univariate and multivariate analysis of factors influencing ACR50 response to ADA We used binary logistic regression to study the probability of achieving the ACR50 response to ADA therapy at 12 weeks. Univariate regression to screen for variables (with P < 0.15) to enter in the model in the second step revealed weight, body mass index (BMI), height, associated therapy with MTX, associated therapy with other DMARDs, presence of rheumatoid factor (RF), TNF polymorphisms -857 and -238, TNF haplotype (-238G, -308G and -857C), number of swollen joints and HAQ score at baseline. These covariates were retained as candidate covariates to build a multivariate model.

In the multivariate analysis, we found the following variables associated with ACR50 response: associated therapy with MTX (OR, 1.68; 95% CI, 1.07-2.66; P=0.026), presence of RF (OR, 1.91; 95% CI, 1.13-3.21; P=0.015), BMI (OR, 1.06; 95% CI, 1.01-1.11; P=0.01), baseline HAQ score (OR, 0.55; 95% CI, 0.37-0.82; P=0.003), and presence of TNF haplotypes other than the GGC homozygous haplotype (OR, 1.92; 95% CI, 1.21-3.02; P=0.005).

Influence of the SE and individual TNFα α α

α genotypes on ADA response

The SE was not identified in uni-or multivariate analysis as a factor influencing ACR50 response to ADA therapy at week 12. In fact, we found no association between ACR50 response to ADA and SE copy number or carrier status (Figure 2A and 2B) or any of the 3 TNFα gene polymorphisms -238A/G, -308A/G and -857C/T genotypes (Figure 2C, 2D and 2E) tested individually. However, we found a trend of an association between a lower response to ADA therapy at 12 weeks and -238GG, -308GG and -857CC genotypes (Figure 2C, 2D and 2E).

Influence of the TNFα α α α haplotype on ADA response

In analyzing the influence of TNFα haplotype on response to ADA therapy, GGC haplotype carrier status showed significant results (Figure 3A). In the first analysis, we discarded rare haplotype combinations (N=27) represented fewer than 10 times: AGC/AAC (N=1), GAC/AGC (N=2), GAC/GAC (N=9), GGT/AGC (N=3), GGT/GAC (N=9), GGT/GGT (N=3). For subjects with the remaining four main haplotype combinations, those homozygous for the GGC haplotype (N=184) had a significantly lower ACR50 response rate (34%) than subjects with the three other main combined haplotypes: GGC/GAC (47%; N=77), GGC/GGT (53%; N=45), and GGC/AGC (71%; N=14) (P=0.0041, P c =0.02) (Figure 3A). This observation highly suggested a recessive effect of the GGC haplotype on response to treatment. In fact, the response rate for homozygous GGC haplotype carriers (34%; N=184) was significantly lower than the response rate observed when pooling all other haplotype combinations, including the rare ones (50%; N=162) (P=0.003, after Bonferroni correction P c =0.015) (Figure 3B). A similar but non significant trend was observed for ACR20 and ACR70 responses to ADA therapy at week 12: The GGC/GGC group showed a 69% ACR20 response versus 76% for the other haplotype carriers (P=0.14) and a 15% ACR70 response versus 19% for the other haplotype carriers (P=0.3). The lack of significant difference regarding ACR20 and ACR70 responses can be explained by a lack of statistical power since responders and non responders are unbalanced with these criteria. Conversely, ACR50 response at week 12 provides the best statistical power to demonstrate an effect with a distribution of responders and nonresponders approaching 50% of the whole population.

As well as our finding of the homozygous effect of the GGC haplotype, we noted a "trans" effect of certain haplotypes present on the opposite chromosome. Alone, the "trans" association of the AGC haplotype with the GGC haplotype appeared to be associated with a better response to ADA therapy: 71% for the GGC/AGC combination (Figure 3A) versus 40% for all the other haplotype combinations, including the rare ones. The difference between those groups was not significant after Bonferroni correction (P=0.019; Pc=0.095). Nevertheless, few patients were AGT haplotype carriers (10 ACR50 responders and 4 ACR50 nonresponders), so this analysis was therefore underpowered.

Baseline characteristics did not significantly differ between GGC homozygous patients and other haplotype carriers, especially in DAS28 RA disease-activity criteria (Table 2). Since about half of our sample received MTX therapy with ADA, we further analyzed the GGC homozygosity effect according to treatment: ADA plus MTX, ADA plus any other DMARD, and ADA alone. Surprisingly, the lower ACR50 response rate was present mainly in the group of patients receiving ADA plus MTX (n=182): 38% ACR50 response versus 60% for the other haplotype carriers (P=0.006; P c =0.03) (Figure 3C). For the ADA plus other DMARD group (n=96), we observed a similar, although not significant, trend: 32% ACR50 response versus 48% for the other haplotype carriers (Figure 3C). For the ADA-alone group (n=102), the GGC homozygous haplotype had no significant effect (29% versus 32% for the other haplotype carriers) (Figure 3C).

In analyzing the time-course evolution of ACR50 response among treatment groups, for patients receiving ADA plus MTX, the response differed between GGC haplotype homozygous and other haplotype carriers as soon as week 2 after treatment initiation and increased until week 12 (Figure 4A). For patients receiving ADA plus any other DMARD, the response showed a trend in favor of a difference between haplotype groups over time, which might have become significant with longer follow-up, which was not available in the ReAct protocol (Figure 4B). For patients receiving ADA alone, the response did not significantly differ between haplotype groups over time (Figure 4C).

Influence of the SE on the negative effect of GGC homozygosity on ADA response

The TNFα locus is located near HLA DRB1, so we analyzed the extent to which the GGC haplotype was in LD with the SE. Although some alleles belonging to the SE were in LD with the some TNF gene alleles, the overall LD between the GGC haplotype and the SE alleles was weak, with a Somers D' equal to 0.24.

Our extended haplotype reconstructions resulted in 82 SE-TNF haplotype combinations. Careful examination of these haplotypes showed the GGC haplotype mainly associated with HLA DRB1*0101 and *0401 alleles of the SE, which is not surprising because GGC is the most frequent TNFα haplotype and DRB1*0101 and *0401 are the most frequent HLA DRB1 alleles among Caucasians. Most of these extended haplotypes were associated with an approximate 40% ACR50 response (range 36-42%), except for the 0701-GGC haplotype (n=29; 24% ACR50 response) and the 0405-GGC haplotype (n=23; 30% ACR50 response). The rate of ACR50 responders among the GGC haplotype carriers was independent of the number of SE copies (40% with 2 SE copies; 41% with 0 or 1 SE copies). Thus, SE does not play a role in the lower response rate to ADA at week 12 observed in patients carrying the TNFα homozygous GGC haplotype.

DISCUSSION

This large pharmacogenetic study has investigated the effect of TNFα gene polymorphisms on response to ADA in RA patients. Although the presence of individual TNFα SNPs was not associated with a specific pattern of response to ADA, haplotype analysis provided convincing data suggesting that the ancestral haplotype of the TNFα promoter, GGC, the most frequent among Caucasians [START_REF] Mullighan | TNF and lymphotoxin-alpha polymorphisms associated with common variable immunodeficiency: role in the pathogenesis of granulomatous disease[END_REF], was associated with a lower response to ADA when present in the homozygous form.

Pharmacogenetic studies of the influence of TNF genes on response to TNF blocker treatment in RA have given discordant results (Table 1). Two studies reported an association of the TNFA-308GG genotype with better response to infliximab [START_REF] Mascheretti | Pharmacogenetic investigation of the TNF/TNF-receptor system in patients with chronic active Crohn's disease treated with infliximab[END_REF] or etanercept [START_REF] Fonseca | Polymorphism at position -308 of the tumour necrosis factor alpha gene and rheumatoid arthritis pharmacogenetics[END_REF] but concerned only a limited number of patients: 59 and 22, respectively. A recent study suggested that the TNFA -308GG genotype was associated with a better response to TNF blockers (ADA, infliximab or etanercept) at week 24, independent of rheumatic disease (i.e., RA, psoriatic arthritis or ankylosing spondylitis) [START_REF] Seitz | The -308 tumour necrosis factor-{alpha} gene polymorphism predicts therapeutic response to TNF{alpha}-blockers in rheumatoid arthritis and spondyloarthritis patients[END_REF]. Again, this study involved a limited number of patients (N=88), of whom only 54 had RA. Studies involving larger sample sizes [N=151 with etanercept (2) and N=198 with infliximab [START_REF] Marotte | The shared epitope is a marker of severity associated with selection for, but not with response to, infliximab in a large rheumatoid arthritis population[END_REF]] did not confirm these results, nor did ours, with 381 patients receiving ADA therapy. A study of 70 Asian patients did not find any association of TNF-308A/G with response to etanercept [START_REF] Kang | The influence of a polymorphism at position -857 of the tumour necrosis factor alpha gene on clinical response to etanercept therapy in rheumatoid arthritis[END_REF]. Many explanations may account for such discrepancies, but the small number (less than 80 patients) of subjects in the positive studies is the best probable explanation, since the 3 negative studies each included more than 150 patients. Moreover, parameters such as the response criteria chosen as primary endpoint (DAS28 decrease, ACR20 or ACR50 response) and the delay of efficacy for the primary endpoint (range from 6 to 24 months from baseline) differed among studies [START_REF] Criswell | The influence of genetic variation in the HLA-DRB1 and LTA-TNF regions on the response to treatment of early rheumatoid arthritis with methotrexate or etanercept[END_REF][START_REF] Mugnier | Polymorphism at position -308 of the tumor necrosis factor alpha gene influences outcome of infliximab therapy in rheumatoid arthritis[END_REF][START_REF] Mugnier | Tumor necrosis factor alpha haplotypes versus tumor necrosis factor alpha -308 G/A polymorphism in the prediction of infliximab treatment efficacy in rheumatoid arthritis[END_REF][START_REF] Fonseca | Polymorphism at position -308 of the tumour necrosis factor alpha gene and rheumatoid arthritis pharmacogenetics[END_REF][START_REF] Seitz | The -308 tumour necrosis factor-{alpha} gene polymorphism predicts therapeutic response to TNF{alpha}-blockers in rheumatoid arthritis and spondyloarthritis patients[END_REF]. Interestingly, few of these studies focused on TNF haplotypes as a factor that could influence response to TNF blockers. One study analyzed extended haplotypes comprising HLA DRB1 alleles, TNFα 488/-238/-308 polymorphisms and lymphotoxin α 720/365/249 polymorphisms. This study involved a US Caucasian population and reported an association of 2 extended haplotypes with better response to etanercept in RA [START_REF] Criswell | The influence of genetic variation in the HLA-DRB1 and LTA-TNF regions on the response to treatment of early rheumatoid arthritis with methotrexate or etanercept[END_REF]. Unfortunately, the authors did not analyze the effect of TNFα polymorphism haplotypes alone on response to etanercept, which precluded any comparison with our results. Another study analyzing the effect of TNFα haplotypes on response to TNF blockers involved an Asian population [START_REF] Kang | The influence of a polymorphism at position -857 of the tumour necrosis factor alpha gene on clinical response to etanercept therapy in rheumatoid arthritis[END_REF]. The different ethnic origin of the patients in this last report limits a comparison with our results. Nevertheless, extended haplotypes were inferred from five TNFα promoter polymorphisms (-1031, -863, -857, -308, -238). The frequency of haplotypes carrying -238G, -308G, and -857C alleles was 71% in the Asian population, very close to the 73% observed in our Caucasian population, which suggests a similar frequency of the TNF (-238G, -308G, and -857C) haplotype in both Caucasian and Asian populations. A TNF haplotypic effect on etanercept response was not evidenced in this study, but no study has investigated a homozygous effect of the main haplotypes with this treatment. Interestingly, patients homozygous for the -857C-allele were poor responders to etanercept. In fact, when ACR20 nonresponders were compared with ACR70 responders, the proportion of responders was higher in the TT-CT group than in the CC group (OR, 12; 95% CI, 1.2-120; P=0.033). The result was not significant after Bonferroni correction, but the sample size studied was low (N=70 patients). The result mirrored in part the effect of the (-238G, -308G, and -857C) homozygous haplotype associated with the lower response to ADA we observed. The functional effect of TNFα promoter haplotypes has not been reported to date. In fact, most of the functional studies of the TNFα promoter focused on separate analysis of SNPs and mainly on the -308A/G polymorphism. Most published studies reported high TNFα production, among various cell types and stimulation conditions, in the A allele carriers [START_REF] Bouma | Secretion of tumour necrosis factor alpha and lymphotoxin alpha in relation to polymorphisms in the TNF genes and HLA-DR alleles. Relevance for inflammatory bowel disease[END_REF][START_REF] Louis | Tumour necrosis factor (TNF) gene polymorphism influences TNF-alpha production in lipopolysaccharide (LPS)-stimulated whole blood cell culture in healthy humans[END_REF][START_REF] Tang | Tumor necrosis factor gene polymorphism and septic shock in surgical infection[END_REF][START_REF] Fernandes | Investigation of promoter polymorphisms in the tumor necrosis factor-alpha and interleukin-10 genes in liver transplant patients[END_REF]. These results, even if not confirmed by others [START_REF] Huizinga | TNF-alpha promoter polymorphisms, production and susceptibility to multiple sclerosis in different groups of patients[END_REF][START_REF] Kubota | Effects of tumor necrosis factor gene polymorphisms on patients with congestive heart failure. VEST Investigators for TNF Genotype Analysis. Vesnarinone Survival Trial[END_REF][START_REF] De Jong | Polymorphisms in or near tumour necrosis factor (TNF)-gene do not determine levels of endotoxin-induced TNF production[END_REF], are mainly accepted by the scientific community. We found that the TNF (-238G, -308G, and -857C) homozygous haplotype was associated with a lower response to ADA therapy than were other haplotypes. In agreement with a high TNFα production with presence of -308A alleles, poorer responders might be those who produce low levels of TNFα. In fact, recent studies suggest that subjects with high response to TNF blockers could also have high TNFα bioactivity [START_REF] Marotte | Circulating tumour necrosis factor-alpha bioactivity in rheumatoid arthritis patients treated with infliximab: link to clinical response[END_REF] or high TNFα synovial levels at baseline [START_REF] Wijbrandts | The Response To TNF-alpha Blockade In Rheumatoid Arthritis Is In Part Dependent On TNF-alpha Expression In The Synovium[END_REF].

The effect of the TNF (-238G, -308G, and -857C) homozygous haplotype on ADA response was restricted to patients also receiving MTX, with a trend to association with ADA plus any other DMARD treatment, and was absent in patients receiving ADA alone. The reason for such observation remains unclear. A specific effect of TNF promoter polymorphisms on response to MTX itself cannot be excluded. This point has never been addressed before in the literature. MTX plus ADA provided significantly higher response than ADA alone. Such results are markedly enhanced in GGC haplotype homozygous carriers and could help physicians in treatment management. In fact, the necessity for MTX treatment with ADA therapy appears critical in GGC haplotype homozygous carriers, to reach a good ACR50 response rate at week 12. Discrepancies among published results involve the implication of the SE in response to TNF blockers in RA (Table 1). One study reported increased response to etancercept in patients with 2 copies of the SE (OR, 4.3; 95% CI, 1.8-10.3) (N=151) [START_REF] Criswell | The influence of genetic variation in the HLA-DRB1 and LTA-TNF regions on the response to treatment of early rheumatoid arthritis with methotrexate or etanercept[END_REF] and a second did not replicate such results on a larger studied population (N=198) [START_REF] Marotte | The shared epitope is a marker of severity associated with selection for, but not with response to, infliximab in a large rheumatoid arthritis population[END_REF]. Regardless, our results among 322 patients do not show any effect of SE copy number on response to ADA.

In conclusion, this pharmacogenetic study is remarkable because of the size of the population studied as well as the quality of the clinical data recorded within the ReAct study. It provides robust data indicating that a single TNFα locus haplotype (-238G/-308G/-857C), when carried on both chromosomes, is associated with a lower response to ADA in RA patients treated with a combination of ADA and MTX than patients with other haplotypes. The mechanism of action of this genetic predisposition (a specific effect on response to MTX itself or an effect on TNFα bioactivity and/or TNFα serum levels) needs further investigations.

Table 2 :

 2 Baseline characteristics of 381 genotyped patients and comparisons for the main RA characteristics between patients homozygous for the TNF GGC haplotype and the other haplotypes carriers.

	Characteristics	Baseline value All patients (N=380)	TNF haplotype * GGC homozygous (N=189)	Others TNF haplotypes (N=164)	P-value* (*GGC homozygous versus other)
	Sex, % female/% male	78.2/21.8	79.4/20.6	76.8/23.2	0.66
	Age, mean +/-SD years	54.0 +/-11.2	54.5 +/-11.4	53.4 +/-11.1	0.34
	Disease duration, mean weeks	140.7	142.7	139.3	0.83
	MDAS, mean +/-SD (range)	5.9 +/-1.0 (3.2 -8.9) 5.9+/-1.0 (3.2 -8.9) 5.9+/-1.0 (3.2 -8.3) 0.87
	No. of tender joints (1-28) +/-SD	13.2 +/-6.5	13.2 +/-6.5	13.3 +/-6.4	0.93
	No. of swollen joints (1-28) +/-SD	9.8 +/-5.0	9.6+/-5.2	10.3+/-4.8	0.09
	RF positivity, %	70.9	71.3	70.8	0.99
	CRP, mean mg/liter (range)	26.5 (3.5 -167.0)	25.9 (3.5 -146.0)	28.3 (3.5 -167.0)	0.34
	ESR, mean mm/hour (range)	31.6 (2.0 -98.0)	32.2 (2.0 -95.0)	30.6 (2.0 -90.0)	0.50
	ADA + MTX +,%	47.9	43.4	51.2
	ADA + other DMARDs	25.3	27.0	25.0
	ADA alone	26.8	29.6	23.8
	ADA= adalimumab MDAS = Modified Disease Activity Score based on erythrocyte sedimentation rate and an evaluation of 28 joints ESR = erythrocyte sedimentation rate RF = rheumatoid factor CRP = C-reactive protein MTX = methotrexate treatment associated with DMARD=disease-modifying antirheumatic drug * TNF haplotype (-238G, -308G and -857C

Acknowledgement

We thank Axelle Belaube and Laura Contreras, Abbot France, for help in conduct of this pharmacogenomic study. We thank the following collaborators for their participation in DNA collection: Pr Pierre Bourgeois (Hôpital La Pitié-Salpétrière -Paris), Pr Alain Cantagrel (Hôpital Rangueil -Toulouse), Pr Bernard Combe (Hôpital Lapeyronie -Montpellier), Pr Thierry Schaeverbeke (Hôpital Pellegrin -Bordeaux), Pr Maxime Dougados (Hôpital Cochin -Paris), Dr Jean-Paul Eschard (Hôpital Sébastopol -Reims), Pr Liana Euller-Ziegler (Hôpital de L'Archet 1 -Nice), Pr Patrice Fardellone (Hôpital Nord -Amiens), Pr René-Marc Flipo (Hôpital B Roger Salengro -Lille), Pr Pascal Hilliquin (Centre Hospitalier Sud Francilien -Corbeil Essonnes), Pr Robert Juvin (Hôpital Albert Michallon -La Tronche), Pr André Kahan (Hôpital Cochin -Paris), Pr Pierre Lafforgue (Hôpital de la Conception -Marseille), Pr Christian Marcelli (Hôpital de la Côte de Nacre -Caen), Pr Isabelle Chary-Valckenaere (Hôpital du Brabois -Vandoeuvre les Nancy), Dr Xavier Puechal (Centre hospitalier -Le Mans), Pr Jean-Michel Ristori (Hôpital Gabriel Montpied -Clermont-Ferrand), Pr Jean Sibilia (Hôpital de Hautepierre -Strasbourg), Pr Philippe Goupille (Hôpital Trousseau -Tours), Pr Aleth Perdriger (Hôpital Sud Fontenoy -Rennes), Pr Eric Houvenagel (Centre hospitalier Saint-Philibert -Lomme), Pr Mis en forme

This work was promoted by the Club Rhumatismes et Inflammation with a grant from Abbott France.

Christian Alexandre (Hopital de Bellevue, Saint-Etienne), and Dr Alain Heraud (Centre hospitalier Robert Boulin -Libourne).