2013 classification criteria for systemic sclerosis: an American college of rheumatology/European league against rheumatism collaborative initiative

Associations Between Soluble Cell Adhesion Molecules and Cardiovascular Comorbidities in Systemic Sclerosis: Implications for Insulin Resistance

Background: Soluble cell adhesion molecules such as sICAM-1 (soluble intercellular adhesion molecule-1), sVCAM-1 (soluble vascular cell adhesion molecule-1), and P-selectin have been implicated in cardiovascular disease pathogenesis in the general population. Cardiovascular disease is prevalent among patients with systemic sclerosis (SSc). This study aims to investigate potential associations between the serum levels of these adhesion molecules and specific cardiovascular comorbidities in SSc patients. Methods: This cross-sectional study encompassed 81 individuals with SSc. All SSc patients underwent a complete clinical evaluation. Serum sICAM-1, sVCAM-1, and P-selectin levels, lipid profiles and insulin resistance indices, and carotid ultrasound were assessed. Multivariable linear regression analyses were employed to investigate potential associations between adhesion molecule levels (sICAM, sVCAM, and P-selectin) and both SSc-specific manifestations and cardiometabolic parameters. Results: The associations of disease-related parameters with sICAM-1, sVCAM-1, and P-selectin levels were limited. Notably, only the modified Rodnan skin score exhibited a significant positive association with sVCAM-1 levels, while no such associations were observed for sICAM-1 and P-selectin. Regarding cardiovascular disease-related data, sVCAM-1 significantly correlated with higher values of insulin resistance and beta-cell function indices. In the case of P-selectin, although a trend was observed, statistical significance was not reached. Conclusions: In patients with SSc, serum values of sVCAM-1 independently correlate with insulin resistance. The assessment of CAMs in patients with SSc could serve as a valuable clinical tool for identifying individuals with increased insulin resistance and a higher risk of cardiovascular disease.

Distinct metabolic profiles of circulating plasmacytoid dendritic cells in systemic sclerosis patients stratified by clinical phenotypes

BACKGROUND

Plasmacytoid dendritic cells (pDCs) play a key role in systemic sclerosis (SSc) pathophysiology. However, despite the recognised importance of metabolic reprogramming for pDC function, their metabolic profile in SSc remains to be elucidated. Thus, our study aimed to explore the metabolic profile of pDCs in SSc and their potential contribution to the disease.

METHODS

Peripheral blood mononuclear cells (PBMCs) were isolated from the blood of healthy donors and SSc patients. SCENITH™, a single-cell flow cytometry-based method, was applied to infer the metabolic profile of circulating pDCs from patients with SSc. pDCs (CD304+ Lin-) at steady-state or stimulated with CpG A were analysed. Toll-like receptor (TLR)9 activation was confirmed by ribosomal protein S6 phosphorylation.

RESULTS

Circulating pDCs from ten healthy donors and fourteen SSc patients were analysed. pDCs from anti-centromere antibody-positive (ACA+) patients displayed higher mitochondrial dependence and lower glycolytic capacity than those from anti-topoisomerase I antibody-positive (ATA+) patients. Furthermore, cells from both ACA+ patients and limited cutaneous SSc (lcSSc) patients showed a stronger response towards TLR9 activation than cells from ATA+, anti-RNA polymerase III antibody-positive (ARA+) or diffuse cutaneous SSc (dcSSc) patients.

CONCLUSIONS

An innovative single cell flow cytometry-based methodology was applied to analyse the metabolic profile of pDCs from SSc patients. Our results suggest that pDCs from ACA+ patients rely more on oxidative phosphorylation (OXPHOS) and are more responsive to external stimuli, whereas pDCs from ATA+ patients may exhibit a more activated or exhausted profile.

Transthoracic Lung Ultrasound in Systemic Sclerosis-Associated Interstitial Lung Disease: Capacity to Differentiate Chest Computed-Tomographic Characteristic Patterns

Background/Objectives: Even today, interstitial lung disease (ILD) is diagnosed by chest high-resolution computed tomography (lung HR-CT). Large amounts of data are available about the usefulness of transthoracic lung ultrasound (LUS) in ILD. This study aimed to evaluate the transthoracic LUS capacity to discriminate different ILD patterns in systemic sclerosis (SSc) patients, such as usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP) with ground glass opacification/opacity (GGO), and NSIP with GGO and reticulations, as well as the possibility of identifying progressive fibrosing ILD. Methods: We enrolled SSc-patients attending the outpatient Clinic of the Rheumatology Unit of Policlinico of Foggia and the Rheumatology Unit of Policlinico of Bari who satisfied these inclusion criteria: age older than 18 years; the satisfaction of ACR/EULAR 2013 classification criteria for SSc; chest HR-CT scan within three months before or three months after transthoracic LUS evaluation; and availability of recent and complete pulmonary function test. The exclusion criteria were as follows: history or recent reactivation of chronic obstructive pulmonary disease, lung cancer, lung infection, heart failure, pulmonary oedema, pulmonary arterial hypertension, acute respiratory distress syndrome and diffuse alveolar haemorrhage and thoracic surgery. All enrolled SSc-patients underwent transthoracic LUS, performed by an experienced sonographer. The ILD diagnosis and the respective patterns were assessed by chest HR-CT, which still represents the best diagnostic tool. Results: ILD was observed in 99 (63.5%) patients. Of these, 25% had the UIP pattern and 75% the NSIP pattern (46 with GGO, 28 with GGO and reticulations). By receiver operating characteristic (ROC) curve analysis, higher values of accuracy, sensitivity, specificity, and negative clinical utility index (CUI) were found for pleural line irregularity (0.84 (95% CI: 0.75-0.91), 96%, and 73.6%, p = 0.0001; 0.72), and pleural line thickness (0.84 (95% CI: 0.74-0.91), 72%, and 96.4%, p = 0.0001; 0.85) for detecting the UIP pattern. The best performance among transthoracic LUS signs for NSIP with the GGO pattern was observed for B-lines (accuracy: 0.88 (95% CI: 0.80-0.93), sensitivity: 93.4% and specificity: 82.4, p = 0.0001; CUI+: 0.75, CUI-: 0.77). LUS signs with higher accuracy, sensitivity, and specificity for NSIP with GGO and reticulations were pleural line irregularity (0.89 (95% CI: 0.80-0.95), 96.4%, and 82.4%, p = 0.0001) with CUI-: 0.72, and B-lines (0.89 (95% CI: 0.80-0.95), 96.4%, 82.4%, p = 0.0001), with CUI+: 0.80 and CUI-: 0.70. Furthermore, a total number of B-lines > 10 maximises LUS performance with 92.3% sensitivity, and an accuracy of 0.83 (p = 0.0001) for detecting the NSIP pattern, particularly GGO. A sample-restricted analysis (66 SSc patients) evidenced the presence of progressive fibrosing ILD in 77% of these patients. By binary regression analysis, the unique LUS sign associated with progressive fibrosing ILD was the presence of pleural line irregularity (OR: 3.6; 95% CI 1.08-11.9; p = 0.036). Conclusions: Our study demonstrated that transthoracic LUS presented a high capacity to discriminate the different patterns of SSc-ILD. Therefore, the hypothesis that transthoracic LUS is an effective screening method for the evaluation of the presence of SSc-ILD and establishing the correct timing of chest HR-CT, in order to avoid patients receiving excessive exposure to ionising radiation, is supported.

Are the clinical phenotypes of systemic sclerosis determinant for osteoporosis and fragility fractures?

AIM

Systemic sclerosis (SSc) is associated with an increased risk of osteoporosis and fractures. The aim of this single-center cross-sectional study was to evaluate whether clinical phenotype and nailfold videocapillaroscopy (NVC) pattern could influence bone mineral density (BMD) values and fragility fractures in patients with SSc.

METHODS

A cohort of 84 consecutive outpatients (age 63.7 ± 13.7 years) diagnosed with SSc, 43 classified as diffuse cutaneus SSc (dSSc) and 41 as limited cutaneus SSc (lSSc), were enrolled in the study. All patients underwent BMD by Dual Energy X-ray Absorptiometry (DX, pulmonary function tests for diffusing capacity of carbon monoxide (DLCO), and NVC to be assigned to an "early," "active," or "late" pattern.

RESULTS

Patients with dSSc exhibited significantly lower BMD values compared to those with lSSc; moreover, the prevalence of osteoporosis and major osteoporotic fractures were higher in dSSc than in lcSSc (39,6% and 41,9% vs. 29,2% and 34,1%, respectively). Patients with a "late" or "active" NVC pattern had a more marked reduction in BMD with respect to those with a "early" pattern (p < 0.05). Moreover, patients with dSSc showed a greater reduction in DLCO values compared to those with lSSc in all three capillaroscopic patterns (p < 0.05). DLCO reduction and history of previous fracture were independent predictors of total hip BMD in dSSc patients.

CONCLUSION

Patients with SSc, and particularly those with a "diffuse" phenotype, have a high prevalence of osteoporosis and major osteoporotic fractures. Furthermore, in both SSc phenotypes, the presence of an "active" or "late" capillaroscopic pattern was associated with reduced BMD and DLCO values.

Natural killer cells are decreased in systemic sclerosis and have diagnostic value for pulmonary arterial hypertension incorporation

The aim of this study was to investigate lymphocyte subsets, especially natural killer (NK) cells, in patients with systemic sclerosis (SSc) and evaluate the diagnostic value of NK cells in secondary pulmonary arterial hypertension (PAH). A total of 115 SSc patients and 100 age- and sex-matched health controls (HCs) were enrolled in this study. Flow cytometry was employed to quantify NK cells, while the association between NK cells and disease activity as well as PAH was investigated to further elucidate its diagnostic potential. The absolute count of NK (CD3-CD56+) cells significantly decreased in SSc patients. There was a negative correlation between the mRSS score and the injury index. The levels of cytokine exhibited significant elevation among SSc patients. Conversely, SSc-PAH patients demonstrated significantly elevated levels of CRP, UA, and BNP. Additionally, there was a significant reduction in the absolute level of NK cells. ROC curve analysis revealed that the optimal cut-off point for NK cells was 185 cells/µL, while for BNP it was 70.50 pg/mL and for UA it was 323.00 µmol/L. Our study revealed a significant inverse correlation between peripheral blood NK cell levels and the incidence of complicated PAH in patients with SSc.

Cardiac Morpho-Functional Changes, Inflammation and Fibrosis in Systemic Sclerosis-A Pilot Study of a Tertiary Center Cohort

Background: Cardiac involvement (CI) in systemic sclerosis (SSc) is frequently subclinical and it can be identified in up to 80% of autopsied hearts. If present, symptoms are related to adverse prognosis, and CI represents one of the predominant causes of SSc-related mortality. Methods: A total of 20 patients with a diagnosis of SSc were included and followed up, and 37 volunteers were included and subsequently scanned on a 1.5T MR system. Results: Overall, thirteen (65%) patients had one or more abnormal cardiac findings in CMR (defined as CI[+]), of which in seven (35%), baseline ECGs and standard echocardiograms were normal or unspecific. Compared to healthy volunteers, SSc patients had a lower LVEF% (56.6% vs. 61.6%; p = 0.0131), longer T1 (1028.3 ms vs. 993.1 ms; p = 0.0049) and T2 relaxation times (48.24 ms vs. 43 ms p = 0.0011), and higher extracellular volume (ECV, 27.9% vs. 26.0%; p = 0.0112). However, no difference in CMR-derived, feature-tracking GLS values between patients and healthy controls was found (-15.5[2,8] vs. -16.3[1,1], respectively, p = 0.11). Over 3.4 (1.9-5.5) years, three patients (15%) died, and two others (10%) sustained major cardiac complications. Conclusions: Cardiac magnetic resonance with modern quantitative techniques reveals subtle morpho-functional alterations and thus allows for early diagnosis of myocardial involvement in systemic sclerosis. Our findings emphasize the need for extended diagnostic workup in these patients and demonstrate the ability of cardiac MR to select patients requiring closer follow-up and/or treatment decisions.

The predictive value of anti-IFI16 antibodies for the development or persistence of digital ulcers in systemic sclerosis

To evaluate the association of anti-IFI16 antibodies with peripheral vasculopathy and the predictive value of anti-IFI16 antibodies for the development or persistence of digital ulcers (DPDU) in SSc. A total of 42 SSc patients and 42 age- and sex-matched healthy controls were enrolled. Anti-IFI16 antibodies were examined by ELISA. Nailfold videocapillaroscopy (NVC) and power Doppler ultrasound (PDUS) were used to assess the micro- and macro-vascular involvement in SSc. All patients were followed up for 6 months to evaluate DPDU. Potential risk factors for DPDU were analyzed by a Firth's penalized logistic regression model. Of the 42 SSc patients enrolled, 19.05% patients were positive for anti-IFI16 antibodies, compared to a significantly low positivity rate of 4.76% in healthy controls (p < 0.001). SSc patients who were positive for anti-IFI16 antibodies manifested higher ulnar artery resistance index than anti-IFI16 negative patients (p = 0.018). Within a 6-month follow-up, 14 (33.3%) patients suffered from DPDU, and the prevalence of anti-IFI16 antibodies in patients with DPDU was 42.9%, remarkably higher than 7.1% in those without DPDU (p = 0.012). Additionally, patients with DPDU were more likely to have digital ulcers (DUs) at enrollment and manifest lower finger pulp blood flow, lower ulnar artery (UA) flow velocity, lower UA resistance index, and higher UA resistance index at baseline in comparison to patients without DPDU. Multivariate analysis further identified DUs at enrollment (OR 5.81; 95% CI 1.09-30.86; p = 0.046) and the positivity of anti-IFI16 antibody (OR 8.64; 95% CI 1.05-70.87; p = 0.045) as independent risk factors for DPDU. Presence of anti-IFI16 antibody is associated with higher UA resistance index in SSc. Multivariate analysis further identified anti-IFI16 antibody as a predictive marker for DPDU in SSc. Key Points • SSc patients who were positive for anti-IFI16 antibodies manifested higher ulnar artery resistance at baseline. • The prevalence of anti-IFI16 antibodies in patients with DPDU during the 6-month follow-up was remarkably higher than those without DPDU. • Multivariate analysis identified DUs at enrollment and anti-IFI16 antibody positivity as independent risk factors for DPDU. • Anti-IFI16 antibody is associated with peripheral vasculopathy in SSc. Multivariate analysis further identified anti-IFI16 as a predictive biomarker for the development of DUs.

Comparison of Three Physician Global Assessment Instruments in Systemic Sclerosis

OBJECTIVE

Physician global assessments (PhyGAs) are variably applied in systemic sclerosis (SSc) clinical trials. The comparability of different PhyGA results is unknown. We sought to assess the comparability of results from three different PhyGA instruments simultaneously applied in the Australian Scleroderma Cohort Study (ASCS).

METHODS

Using data from 1,965 ASCS participants, we assessed the correlation between results of three PhyGA assessments: (1) overall health, (2) activity, and (3) damage. We evaluated the concordance of change in each PhyGA between study visits. Ordered logistic regression analysis was used to evaluate the clinical associations of each PhyGA.

RESULTS

The absolute scores of each PhyGA were strongly correlated at individual study visits. Concordant changes of the PhyGA scores occurred between 50% of study visits. Only patient-reported breathlessness was associated with all three PhyGA scores (overall health: odds ratio [OR] 1.67, P < 0.01; activity: OR 1.44, P < 0.01; damage: OR 1.32, P < 0.01). Changes in physician-assessed activity scores were also associated with patient-reported worsening skin disease (OR 1.25, P = 0.03) and fecal incontinence (OR 1.23, P = 0.01), whereas damage scores were associated with respiratory disease (pulmonary arterial hypertension: OR 1.25, P = 0.03; chronic obstructive pulmonary disease: OR 1.37, P = 0.04), as well as skin scores (OR 1.02, P < 0.01) and fecal incontinence (OR 1.21, P = 0.02).

CONCLUSION

PhyGAs of overall health, activity, and damage are each associated with different SSc features, and changes in different PhyGA scores are discordant 50% of the time. Our findings suggest results of variably worded PhyGAs are not directly interchangeable and support the development of a standardized PhyGA.

Preliminary nomogram model for predicting irreversible organ damage of patients with systemic sclerosis

OBJECTIVE

To investigate predictive factors for irreversible organ damage in systemic sclerosis (SSc) and establish a nomogram model.

METHODS

This retrospective study included patients with SSc who were treated at our hospital between March 2013 and March 2023. Irreversible organ damage included heart failure, respiratory failure, renal failure, and gangrene of the hands and feet. Cox and LASSO regression analyses were performed to determine the predictive factors. Based on the results, a nomogram model was developed. The model was evaluated using the C-indices, calibration plots and DCA.

RESULTS

A total of 361 patients with systemic sclerosis were randomly divided into the development (n = 181) and validation (n = 180) groups. Multivariate Cox regression analysis showed that age ≥65 years, weight loss, digital ulcers, mRSS ≥16, elevated creatinine, elevated myoglobin, elevated C-reactive protein, renal involvement and cardiac involvement were independent risk factors. Based on the LASSO analysis, a nomogram model of irreversible organ damage was established. The C-indices of the development group at 24, 60 and 96 m were 96.7, 84.5 and 85.7, whereas those of the validation group at 24, 60 and 96 m were 86.6, 79.1 and 78.5, respectively. The results of the DCA showed that the nomogram can be used as a valuable tool to predict irreversible organ damage in patients with SSc.

CONCLUSION

We included commonly used clinical indicators. According to the nomogram, the probability of irreversible organ damage can be calculated and high-risk patients can be identified.

Well-Being Therapy in systemic sclerosis outpatients: a randomized controlled trial

OBJECTIVES

Systemic sclerosis (SSc) patients have psychological distress and poor well-being and need a tailored treatment. Psychological interventions, rarely tested for efficacy, showed poor benefits. The present randomized controlled trial tested the efficacy of Well-Being Therapy (WBT) in SSc patients.

METHODS

Thirty-two outpatients were randomized (1:1) to WBT (n = 16) or Treatment As Usual (i.e. routine medical check-ups) (TAU) (n = 16). Primary outcome was well-being. Secondary outcomes included functional ability related to SSc, psychological distress, mental pain, suffering. All participants were assessed at baseline (T0). The WBT group was assessed after two months (end of WBT session 4) (T1), after four months (end of WBT session 8) (T2), after seven months (3-month follow-up) (T3) and after 10 months (6-month follow-up) (T4). The TAU group was assessed two (T1), four (T2), seven (T3) and ten (T4) months after baseline.

RESULTS

WBT produced a significant improvement in subjective well-being (P ≤ 0.001), personal growth (P = 0.006), self-acceptance (P = 0.003) compared with TAU, maintained at T3 as what concerns subjective well-being (P = 0.012). WBT produced a greater decrease in psychological distress (P = 0.010), mental pain (P = 0.010), suffering (P ≤ 0.001) compared with TAU, maintained at T4 as what concerns suffering (P ≤ 0.001). Participants reported high satisfaction with WBT.

CONCLUSION

The study provides preliminary evidence on the benefits of WBT as short-term approach for in- and out-patient SSc healthcare paths. Studies with larger samples are needed to have the evidence for recommending WBT to SSc patients.

Phenotype of diffuse cutaneous systemic sclerosis patients with positive anticentromere antibodies: A systematic literature review and meta-analysis

OBJECTIVES

Anticentromere antibodies (ACA) are typically found in limited cutaneous systemic sclerosis (lcSSc), whereas patients with anti-topoisomerase I antibodies (ATA) usually exhibit diffuse cutaneous involvement (dcSSc). We aimed to investigate the clinical phenotype and outcome of ACA-dcSSc.

METHODS

A systematic literature review was conducted (January 1970 to April 2023) across MEDLINE, Scopus and OVID, to define whether SSc patients (population) within the ACA-dcSSc subset (exposure) had higher/lower risk for major organ involvement (interstitial lung disease-ILD, pulmonary hypertension-PH, primary myocardial involvement-PMI, scleroderma renal crisis-SRC) and mortality (outcomes) compared to ACA-lcSSc and ATA-dcSSc. Inclusion criteria were: 1) adult SSc patients with identifiable demographic and clinical features by subtype; 2) observational studies. The quality of the studies was evaluated by the Newcastle-Ottawa Scale. Random-effects meta-analysis was performed to compare odds ratios (OR) for major organ involvement, and the 5- and 10-year mortality of ACA-dcSSc with the other subsets.

RESULTS

Out of 1570 hits, six articles were included, identifying 177 ACA-dcSSc patients. In ACA-dcSSc, ILD was more frequent than in ACA-lcSSc (OR 2.60; 95 %CI 1.39-4.87) but less frequent compared to ATA-dcSSc (OR 0.17; 95 %CI 0.10-0.29). ACA-dcSSc patients had a higher prevalence of PH vs. both conventional subsets; PMI and SRC were more frequent in ACA-dcSSc compared to ACA-lcSSc, and similar to ATA-dcSSc. While 5-year survival rates were comparable among the subsets, ACA-dcSSc patients exhibited a lower 10-year mortality than ATA-dcSSc (OR 0.42; 95 %CI 0.2-0.85).

CONCLUSION

Although uncommon, the ACA-dcSSc subset appears to have a distinct clinical phenotype, with a better prognosis than ATA-dcSSc.

Accrual of organ damage and one-year mortality in systemic sclerosis: A prospective observational study

OBJECTIVE

To determine cumulative organ damage in patients with systemic sclerosis (SSc) according to the Scleroderma Clinical Trials Consortium Damage Index (SCTC-DI), assess 1-year mortality risk, and identify associated factors.

METHODS

A prospective, single-center study was conducted in a cohort of patients with SSc. A cross-sectional study and a 12-month longitudinal follow-up were carried out. The main outcomes were SCTC-DI and all-cause mortality at 12 months. Other variables included clinical-laboratory data, modified Rodnan Skin Score (mRSS), EuroQoL 5-D (EQ-5D), and Steinbrocker functional status. Multivariate models were used to study factors associated with SCTC-DI and mortality.

RESULTS

The study population comprised 75 patients (97.3% females) with a mean age of 59.6 years. The median (IQR) of the SCTC-DI was 4(6), and only 4 (5.3%) patients had severe SCTC-DI (≥13). The factors associated with SCTC-DI were disease duration (β=0.276), mRSS (β=0.287), C-reactive protein (CRP) concentration (β=0.311), and EQ-5D (β= -0.207). After 1 year of follow-up, 4 patients had died. The factors associated with mortality at 12 months (OR [95% CI]) were baseline SCTC-DI ≥13 (44.5 [1.6-1237.9]; p = 0.025) and visual analog scale (VAS) of the EQ-5D (0.9 [0.8-0.9]; p = 0.018).

CONCLUSIONS

The SCTC DI can prove useful in clinical practice for assessing disease progression and short-term mortality risk. Cumulative damage was associated with disease duration, mRSS, CRP concentration, and a decline in EQ-5D, while the risk of death at 12 months was primarily associated with high SCTC-DI and low EQ-5D VAS. New studies are needed to improve assessment tools in patients with SSc.

Evaluating the safety and efficacy of plasma therapy/plasmapheresis for systemic sclerosis - A comprehensive systematic review

INTRODUCTION

Systemic sclerosis (SSc) is an autoimmune disorder with fibrosis in multiple organs, autoantibodies, and microvascular abnormalities. Its origin is unclear, but it may result from circulatory damage, collagen metabolism disruption, and modifications in immunoregulation. The disease affects various organs and has high morbidity and mortality rates. SSc-related complications are managed using immunosuppressive medications that target autoantibodies. The main objective of this study was to assess the safety and efficacy of plasma therapy/plasmapheresis in managing SSc.

METHODS

This systematic review followed PRISMA and IMRAD guidelines, using PICO framework for study selection based on MeSH terms and Boolean operators. It included cross-sectional, randomized control trials, and clinical studies on plasma therapy for SSc. Standardized protocols were used for data extraction and risk of bias assessment.

DISCUSSION

Plasma therapy is a growing treatment option for managing SSc with reported benefits, especially in early stages and specific organ complications. However, further investigation and standardized protocols are needed. This review explores the potential of plasma therapy in improving the quality of life for SSc patients and in combination with other treatments.

RESULT

The review analyzed 15 articles, including research papers, controlled trials, and case reports. Plasma therapy, involving Plasmapheresis and therapeutic plasma exchange (TPE), improved symptoms of SSc like Raynaud phenomenon, vasculitis, muscle dysfunction, and digital ulcers. However, outcomes varied among studies, and some advanced cases showed limited benefits.

CONCLUSION

Plasma therapy can be an effective way of managing the symptoms of systemic sclerosis with low incidence of adverse events. However, the exact mechanism behind this treatment is still unclear. Therefore, additional studies are required.

Aberrant Chitinase 3-Like 1 Expression in Basal Cells Contributes to Systemic Sclerosis Fibrosis

Systemic sclerosis (SSc) is an autoimmune disease characterized by extensive skin and internal organ fibrosis. However, the mechanism underlying fibrosis remains unclear, and effective treatments for halting or reversing fibrosis are lacking. In this study, single-cell RNA sequencing is used to obtain a comprehensive overview of skin cells from patients with SSc and healthy controls. A subset of basal cells with high chitinase 3-like 1 (Chi3L1) expression, which potentially plays an important role in fibroblast activation, is identified in SSc. Subsequently, patients with SSc are present with increased expression of Chi3L1 in the skin and serum, and elevated serum levels are associated with skin induration and pulmonary function. Furthermore, Chi3L1 promoted the differentiation of SSc dermal fibroblasts into myofibroblasts, and Chi3L1-deficient (Chi3L1-/-) mice showed amelioration of fibrosis in a bleomycin-induced SSc (BLM-SSc) model. Mechanistically, Chi3L1 mediates fibroblast activation primarily by interacting with interleukin-17 receptor A (IL-17RA), thereby initiating downstream nuclear factor kappa B and mitogen-activated protein kinases signaling pathways. Moreover, the anti-fibrotic effect of IL-17RA antagonists in BLM-SSc mice is demonstrated. In conclusion, Chi3L1 is a potential biomarker for the degree of fibrosis in SSc. Chi3L1 and its receptor, IL-17RA, are promising therapeutic targets for patients with SSc.

Prevalence and Intriguing Clinical Profiles of Autoimmune Inner Ear Diseases in Sudden Sensorineural Hearing Loss

INTRODUCTION

Sudden sensorineural hearing loss (SSNHL) is idiopathic in 70-90% of cases with 10-30% linked to vascular injuries, viral infections, or autoimmune inner ear disease (AIED). AIED contributes to less than 1% of all hearing losses, categorized into primary, affecting only the inner ear, and secondary, associated with systemic autoimmune diseases (SAID). This study examines the prevalence and features of AIED in SSNHL in a tertiary referral center.

MATERIALS AND METHODS

We conducted a prospective study from November 2021 to December 2022 including SSNHL patients who exhibited symptoms like hearing loss or tinnitus. Evaluations included tympanometry, pure tone audiometry, and blood tests, with suspected AIED cases further assessed by rheumatologists using Lobo's diagnostic criteria. Treatment responses were monitored through regular audiometry updates.

RESULTS

Out of 694 SSNHL patients, 43 (6.2%) were diagnosed with AIED, of which 36 (83.7%) had primary AIED and 7 (16.3%) had secondary AIED linked to conditions like Sjögren's syndrome and systemic lupus erythematosus. Treatment response was seen in 19.4% of primary and 42.9% of secondary AIED cases.

CONCLUSION

The prevalence of AIED in SSNHL patients was found to be 6.2%, with a notable fraction also suffering from SAID. Responses to treatment were positive in about a third of these cases, highlighting the importance of interdisciplinary management for this rare yet significant cause of SSNHL.

Inadequate sleep hygiene as a key factor in poor sleep quality in systemic sclerosis: an observational, cross-sectional study

This study aims to investigate the relationship between sleep hygiene and sleep quality in patients with systemic sclerosis (SSc) and to compare the sleep hygiene and sleep quality outcomes across three distinct groups: SSc patients, rheumatoid arthritis (RA) patients, and healthy controls (HC). This study employed an observational, cross-sectional, and parallel group design. SSc-related and RA-related variables, depression and anxiety were assessed. Physical function and quality of life, pain and fatigue of SSc patients were also evaluated. Sleep quality using the Pittsburg Sleep Quality Index (PSQI) and sleep hygiene using the Sleep Hygiene Index (SHI) were evaluated for all participants. Linear regression analysis was performed to show the relationship between the SHI scores and the other variables. Total PSQI and SHI scores were found to be significantly higher in SSc patients than in RA patients and HC. Fatigue, smoking, all SF-36 domains, depression and anxiety scores were associated with SHI scores in SSc patients. In the univariate logistic regression analysis, SSc patients exhibited 4.50 times higher odds (95% CI 2.165-9.353, p < 0.001) of experiencing poor sleep than RA patients and HC. In SSc patients, for every incremental increase in SHI score, the odds of poor sleep quality were 1.15 times higher (95% CI 1.093-1.220, p < 0.001). Sleep hygiene and sleep quality exhibit a more pronounced deterioration in SSc patients. Inadequate sleep hygiene is associated with compromised sleep quality in SSc. Therefore, improving sleep hygiene practices may be a key strategy to enhance the overall sleep quality in this population.

TEMPORARY REMOVAL: EULAR/ACR classification criteria for paediatric chronic nonbacterial osteomyelitis (CNO)

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Neutrophil extracellular traps as a potential marker of systemic lupus erythematosus activity

BACKGROUND

The heterogeneity of systemic lupus erythematosus (SLE) poses a significant challenge in identifying biomarkers for assessing disease activity. Currently, there is a paucity of established biomarkers capable of evaluating SLE flares. This study aimed to identify novel biomarkers that exhibit improved diagnostic accuracy in assessing SLE activity.

METHODS

A cross-sectional study was conducted at Zhongshan Hospital Xiamen University from August 2021 to April 2024,enrolling 118 patients with SLE, including 81 cases of active SLE, 50 cases of active lupus nephritis (LN) and 30 cases of active non-LN. The objective was to evaluate the diagnostic accuracy of novel biomarker called Neutrophil Extracellular Traps(NETs) for SLE activity and analyze its correlations with conventional biomarkers such as complement C3, C4, and anti-dsDNA.

RESULTS

Serum NETs levels were significantly elevated in patients with active SLE and active LN(P < 0.001). Furthermore, positive correlations were observed between NETs levels and disease activity score based on Systemic Lupus Erythematosus Disease Activity Index-2 K (SLEDAI-2 K) (r = 0.64, P < 0.001), as well as anti-dsDNA antibody (r = 0.54, P < 0.001).Conversely, the NETs levels were negativity correlated with complement C3 concentration (r = -0.50, P < 0.001), as well as C4 concentration (r = -0.34,P < 0.001). Univariate and multivariate analysis revealed two biomarkers performed statistical significance: NETs (OR = 6.802, 95 %CI: 2.414-19.167,P < 0.001) and anti-dsDN A(OR = 3.95,95 %CI:1.582-9.864, P = 0.003). NETs had the highest AUC of 0.82(P < 0.001), with a cut-off at 515.47 ng/L demonstrating 61.63 % sensitivity and 96.87 % specificity. For the active LN group, the AUC was found to be 0.97 (P < 0.001), with a cutoff value of 515.47 ng/L, sensitivity of 100 %, and specificity of 59.76 %. Moreover, the active non-LN group had AUC of 0.70 (P = 0.007), with the same cutoff value, sensitivity of 89.61 %, and specificity of 51.61 %.

CONCLUSION

In contrast to conventional laboratory markers, serum NETs represent a novel diagnostic marker for assessing disease activity in SLE, demonstrating promising potential for clinical application.

Serum KL-6 and SP-D: Markers of Lung Function in Autoimmune-Related Interstitial Lung Diseases

This study evaluates the usefulness of serum KL-6, SP-D and TGF-β1 levels in assessing lung impairment and predicting interstitial lung disease (ILD) short-term progression in patients with interstitial pneumonia with autoimmune features (IPAF). A total of 24 patients with IPAF, 21 with connective tissue disease-associated ILD (CTD-ILD) and 23 with CTD without ILD were followed for 1 year. Serum levels of KL-6, SP-D and TGF-β1 were measured and their associations with disease severity and progression were analysed. KL-6, SP-D and TGF-β1 levels were significantly higher in IPAF and CTD-ILD patients compared to CTD without ILD (p < 0.0001, p = 0.0005 and p = 0.0001, respectively). KL-6 (r = 0.45, p = 0.002) and SP-D (r = 0.35, p = 0.02) levels correlated with lung involvement in HRCT in the ILD group. In IPAF, KL-6 levels correlated with pulmonary function tests (FVC%, TLCO%, and 6MWD) and SpO2, while SP-D correlated with 6MWD and SpO2. In CTD-ILD, KL-6 and SP-D levels were positively correlated with BAL cell count (KL-6: r = 0.58, p = 0.04; SP-D: r = 0.63, and p = 0.02). KL-6 also showed a negative correlation with the time since symptom onset (r = -0.51, p = 0.02). No significant associations were found between the baseline biomarker levels and ILD progression risk. KL-6 and SP-D may serve as potential biomarkers for assessing lung impairment in IPAF, though their predictive value for short-term prognosis remains uncertain.

Automated AI-based image analysis for quantification and prediction of interstitial lung disease in systemic sclerosis patients

BACKGROUND

Systemic sclerosis (SSc) is a rare connective tissue disease associated with rapidly evolving interstitial lung disease (ILD), driving its mortality. Specific imaging-based biomarkers associated with the evolution of lung disease are needed to help predict and quantify ILD.

METHODS

We evaluated the potential of an automated ILD quantification system (icolung®) from chest CT scans, to help in quantification and prediction of ILD progression in SSc-ILD. We used a retrospective cohort of 75 SSc-ILD patients to evaluate the potential of the AI-based quantification tool and to correlate image-based quantification with pulmonary function tests and their evolution over time.

RESULTS

We evaluated a group of 75 patients suffering from SSc-ILD, either limited or diffuse, of whom 30 presented progressive pulmonary fibrosis (PPF). The patients presenting PPF exhibited more extensive lesions (in % of total lung volume (TLV)) based on image analysis than those without PPF: 3.93 (0.36-8.12)* vs. 0.59 (0.09-3.53) respectively, whereas pulmonary functional test showed a reduction in Force Vital Capacity (FVC)(pred%) in patients with PPF compared to the others : 77 ± 20% vs. 87 ± 19% (p < 0.05). Modifications of FVC and diffusing capacity of the lungs for carbon monoxide (DLCO) over time were correlated with longitudinal radiological ILD modifications (r=-0.40, p < 0.01; r=-0.40, p < 0.01 respectively).

CONCLUSION

AI-based automatic quantification of lesions from chest-CT images in SSc-ILD is correlated with physiological parameters and can help in disease evaluation. Further clinical multicentric validation is necessary in order to confirm its potential in the prediction of patient's outcome and in treatment management.

The B-cells paradigm in systemic sclerosis: an update on pathophysiology and B-cell-targeted therapies

Systemic sclerosis (SSc) is considered a rare autoimmune disease in which there are alterations of both the innate and adaptive immune response resulting in the production of autoantibodies. Abnormalities of the immune system compromise the normal function of blood vessels leading to a vasculopathy manifested by Raynaud's phenomenon, an early sign of SSc . As a consequence of this reactive picture, the disease can evolve leading to tissue fibrosis. Several SSc-specific autoantibodies are currently known and are associated with specific clinical manifestations and prognosis. Although the pathogenetic role of these autoantibodies is still unclear, their production by B cells and plasma cells suggests the importance of these cells in the development of SSc. This review narratively examines B-cell dysfunctions and their role in the pathogenesis of SSc and discusses B-cell-targeted therapies currently used or potentially useful for the management of end-organ complications.

Predictive Value of the DETECT Algorithm for Pulmonary Arterial Hypertension in Systemic Sclerosis: Findings from an Italian Observational Study

Background/Objectives: Pulmonary arterial hypertension (PAH) is a complication of systemic sclerosis (SSc), and several screening algorithms have been proposed for the early detection of PAH in SSc. This study aimed to evaluate the predicting values of the DETECT algorithm for SSc-PAH screening in patients with SSc undergoing right heart catheterization (RHC) based on 2015 ESC/ERS echocardiographic criteria in a real-life setting. Methods: Patients fulfilling the 2013 ACR/EULAR classification criteria for SSc and with available data for PAH screening with the DETECT algorithm and the 2015 ESC/ERS echocardiographic criteria were retrospectively enrolled from January to June 2017 and then followed for 5 years. Baseline and annual clinical, laboratory, and instrumental data were collected. Results: A total of 33 out of 131 (25%) patients were selected based upon the ESC/ERS echocardiographic criteria, but 30 (23%) underwent RHC, while 51 (39%) patients with SSc were positive based on the DETECT algorithm. PAH diagnosis was confirmed in 28/30 cases (93.3%). The DETECT algorithm showed lower specificity and positive predictive value (PPV) (p < 0.0001) but higher sensitivity and negative predictive value (NPV) (p < 0.0001) than ESC/ERS criteria. Notably, patients with SSc with a negative DETECT screening at baseline had a low probability of developing PAH during a 5-year follow-up (OR 0.15, 95% CI 0.10-0.60-p < 0.0001). Conclusions: The DETECT algorithm has proven to be an easy, fast, and inexpensive tool for screening PAH in patients with SSc. Overall, a low probability of PAH using DETECT is highly predictive of a good prognosis.

Assessment of interocular symmetry of choroidal vascularity index and thickness in patients with systemic sclerosis: a prospective study

Purpose

Systemic sclerosis (SSc) affects blood vessels, internal organs, and skin. In ophthalmology, SSc impacts the choroid. The choroidal vascularity index (CVI) measures the vascular component of the choroid and may serve as a biomarker for the disease staging and prognosis. Studies have reported reduced choroidal thickness and altered CVI in SSc, which supports the theory of vascular damage. This study aimed to examine interocular symmetry in choroidal parameters among SSc patients. It has provided the insight into the disease symmetry and assessed the representativeness of examining one eye.

Methods

This prospective single-center cross-sectional study included 33 patients with SSc and 40 healthy controls. The patients underwent ophthalmological examination (including refraction, visual acuity, IOP, biometry, slit-lamp biomicroscopy, dilated fundus examination, and spectral-domain optical coherence tomography) and rheumatological evaluation. Various parameters of the choroid in the macular and peripapillary regions were analyzed, including choroidal thickness, choroidal volume, and CVI. The interocular asymmetry in the choroidal parameters was quantified using signed and absolute differences. The correlation analysis between the left and right eyes was based on the intraclass correlation coefficient (ICC), Spearman's correlation coefficient, and paired Wilcoxon test.

Results

There were no significant differences in the macular and peripapillary choroidal parameters between fellow eyes in both SSc patients and controls (p > 0.05). The parameter that showed the lowest correlation among those examined was CVI-in both groups, as well as in both examined areas. The interocular correlation of choroidal parameters was stronger in the peripapillary area than in the macular area in both groups. In general, the results were confirmed in subgroup analyses stratified according to sex, SSc subtype, Scl70 antibody positivity and previous and/or active digital ulcers.

Conclusion

There is interocular symmetry of the choroidal parameters in patients with SSc and controls included in our study. The parameters from one eye are representative of the fellow eye of a given patient. This conclusion may contribute to the design and interpretation of future studies. It also broadens our knowledge of SSc pathophysiology.

Association of nutritional status indices with gastrointestinal symptoms in systemic sclerosis: a cross-sectional study

Gastrointestinal (GI) involvement is highly prevalent in systemic sclerosis (SSc) and significantly affects patient quality of life and clinical outcomes. This study investigates the potential of undernutrition scores, namely the Control of Nutritional Status (CONUT) score and the Prognostic Nutrition Index (PNI), in predicting GI involvement in patients with SSc. A total of 82 patients diagnosed with SSc were enrolled in this cross-sectional study. Participants were evaluated using the UCLA Scleroderma Clinical Research Consortium Gastrointestinal Tract 2.0 (UCLA GIT 2.0) tool, which assesses the severity of GI symptoms and their impact on health-related quality of life. Malnutrition was assessed using CONUT and PNI scores derived from routine laboratory parameters. The correlation between these malnutrition indices and the UCLA GIT 2.0 scores was analyzed to determine the predictive value of malnutrition in GI involvement. The study found that patients with higher CONUT scores, indicating malnutrition, had significantly higher total UCLA GIT 2.0 scores. A moderate positive correlation was observed between CONUT scores and total UCLA GIT 2.0 scores (r =.539; p <.01), while a negative correlation was found between CONUT scores and PNI (r = -.513; p <.01). These findings suggest that malnutrition, as measured by CONUT and PNI, is associated with greater GI involvement in SSc. This study shows that malnutrition indices such as CONUT and PNI in SSc patients, together with the UCLA GIT 2.0 score, may serve as usefull predictors of GI involvment in routine clinical practice.

Longitudinal association between nailfold capillaroscopy and incident interstitial lung disease: A EUSTAR database analysis

Objectives

To evaluate (1) the association between nailfold capillaroscopy pattern and 5-year risk for incident interstitial lung disease and (2) the association between transition in nailfold capillaroscopy pattern and risk of incident interstitial lung disease.

Methods

Data of adult patients from the EUSTAR database fulfilling the ACR-EULAR criteria with a disease duration ⩽5 years, having a scleroderma pattern at nailfold capillaroscopy with high-resolution computed tomography confirmed absence of interstitial lung disease (i.e. baseline) was used. Interstitial lung disease-free survival was assessed for up to 5 years of follow-up with a Cox proportional hazards model stratified on nailfold capillaroscopy pattern at baseline. The association of annual transition in nailfold capillaroscopy pattern on the risk to develop interstitial lung disease was assessed with a mixed logistic regression analysis.

Results

Out of 771 eligible patients, 283 (37%) had an early pattern, 377 (49%) had an active pattern, and 111 (14%) had a late pattern. The Cox proportional hazard model including the identified confounders did not show an association between severity of nailfold capillaroscopy pattern at baseline and increased risk for interstitial lung disease during 5-year follow-up (hazard ratio (95 confidence interval; p value): 1.09 (0.86-1.39; 0.47)). The mixed logistic regression analysis revealed an increased annual risk for incident interstitial lung disease with increasing severity of capillaroscopic pattern (odds ratio (95% confidence interval); p value 3.76 (1.99-7.11; <0.01)).

Conclusion

Our study shows that worsening of nailfold capillaroscopy has a strong association with an increased annual risk to develop interstitial lung disease. Of note, a worse scleroderma pattern at nailfold capillaroscopy is not associated with the long-term risk to develop interstitial lung disease.

Patient perspectives on educational needs in scleroderma-interstitial lung disease

Background

Systemic sclerosis is a chronic and rare connective tissue disease with multiorgan effects, including interstitial lung disease (ILD). Navigating systemic sclerosis-interstitial lung disease presents a challenge for patients due to the gaps in patient education, which can impact patient health and quality of life. This study utilized the nominal group technique to identify priority knowledge gaps among patients with systemic sclerosis-interstitial lung disease and inform future educational interventions and research.

Methods

We conducted four structured group sessions using the nominal group technique. Patients with systemic sclerosis-interstitial lung disease were presented with two questions that aimed to identify knowledge gaps. Following participant ranking, investigators performed a thematic analysis of the patients' responses to categorize the generated knowledge gaps.

Results

Twenty-one patients were interviewed and ranked the top three themes for the first question (What questions about your scleroderma-lung disease that you have keep you awake at night?), based on total points, as: (1) Understanding progression, its impacts on the body, and managing health changes (39.7%); (2) anticipating future symptoms and implementing strategies for management and coping (19.8%); and (3) employing and understanding non-pharmacological interventions and self-management strategies (17.5%). The top three themes for the second question (What information do you want about your scleroderma-lung disease that you cannot find?) ranked by total points were: (1) understanding progression, its impacts on the body, and managing health changes (41.3%); (2) navigating health system barriers (16.7%); and (3) research efforts toward treating scleroderma (10.3%).

Conclusions

Our study underscores the importance of understanding the educational needs of patients with systemic sclerosis-interstitial lung disease. Patient responses emphasize the need to comprehensively address concerns about disease management, coping with impacts on social life, and navigating the healthcare system. By addressing these multifaceted concerns, we can design and implement patient-centered education to empower patients through increased support.

External and internal exposome as triggers of biological signalling in systemic sclerosis - A narrative synthesis

Systemic sclerosis (SSc) is an autoimmune chronic connective tissue disorder with a complex pathogenesis and a strong gene-environment interaction. Despite the low prevalence of SSc, with around 100-250 cases per million, the morbidity and mortality are high and disproportionately affecting women. In this context, we review the influence of the external and internal exposome on the "immunome" in SSc. While several studies have addressed aspects of exposure-induced autoimmunity in general, very few have focused on SSc-specific phenotypes. In epidemiological studies, targeted characterization of the external exposome component in relation to SSc has often been limited to a single exposure. Despite the selective characterization of exposure, such studies play an important role in providing evidence that can be used towards reduction of exposure of modifiable factors, and can lead to proper management and prevention of SSc. Additionally, there is an effort towards integration of external exposome data with health data (health records, medical imaging, diagnostic results, etc.), to significantly improve our understanding of the environmental and occupational causes of SSc. A limited number of studies have identified biological processes related to the vascular homeostasis, fibrotic processes and the immune system. The key findings of the current review show advances in our understanding of the SSc disease phenotype and associated biomarkers in relation to specific pathophysiological features, however most often such studies are not supplemented with external exposome data.

Targeting CD13/Aminopeptidase N as a Novel Therapeutic Approach for Scleroderma Fibrosis

OBJECTIVE

Systemic sclerosis (SSc) is an autoimmune multisystem disease with poorly understood pathogenesis and ineffective treatment options. Soluble CD13 (sCD13), generated by the cleavage of cell surface CD13 via matrix metalloproteinase 14 (MMP14), signals through the bradykinin receptor B1 (B1R) to elicit pro-inflammatory, pro-arthritic, and pro-angiogenic responses. In this study, we explored the antifibrotic potential of targeting the sCD13-B1R axis in SSc.

METHODS

The expression of CD13, B1R, and MMP14 was examined in SSc skin and explanted dermal fibroblasts. The efficacy of B1R antagonists in the inhibition on fibrosis was determined in vitro and in vivo.

RESULTS

Expression of the genes for CD13, B1R, and MMP14 was elevated in skin biopsies from patients with diffuse cutaneous (dc) SSc. Notably, single-cell analysis of SSc skin biopsies revealed the highest BDKRB1 expression in COL8A1-positive myofibroblasts, a population exclusively seen in SSc. Transforming growth factor beta (TGFβ) induced the expression of BDKRB1 and production of sCD13 by dcSSc skin fibroblasts. Treatment of dcSSc fibroblasts with sCD13 promoted fibrotic gene expression, signaling, cell proliferation, migration, and gel contraction. The pro-fibrotic responses of sCD13 or TGFβ were prevented by a B1R antagonist. Mice lacking Cd13 or Bdkrb1 were resistant to bleomycin-induced skin fibrosis and inflammation. Pharmacological B1R inhibition had a comparable antifibrotic effect.

CONCLUSION

These results are the first to demonstrate a key role for sCD13 in SSc skin fibrosis and suggest that targeting the sCD13-B1R signaling axis is a promising novel therapeutic approach for SSc.

Assessment of foot impairment in systemic sclerosis: a cross-sectional study

OBJECTIVES

To assess foot function in SSc and its association with socio-demographic and clinical factors. To evaluate mobility, foot alterations, foot pain, and foot care in these patients.

METHODS

Consecutive SSc patients underwent structured interviews and physical examinations. Disability was assessed using the HAQ disability index (HAQ-DI) and the Scleroderma HAQ (SHAQ). Foot function was measured using the Foot Function Index (FFI), foot pain using a numeric pain scale (NPS), and mobility using the Timed-Up-and-Go test (TUG).

RESULTS

A total of 101 patients were included. Forefoot pain was observed in 50.5%, hindfoot pain in 31.7%, foot ulcers in 6.9%, foot plantar callosities in 38.6%, foot arthritis in 2.97%, hallux valgus in 9.9%, claw toes in 5%, and valgus ankle in 3% of patients. The mean FFI was 3.54 (±2.6), the mean NPS was 6.08 (±3.58), and the mean TUG test result was 10.52 (±6.5) seconds. Higher FFI scores, increased NPS, and prolonged TUG were associated with RP severity, SHAQ and HAQ-DI. Of the 101 patients, 36.6% of patients reported never having had their feet examined, and only 32.7% had had their feet examined within the past year.

CONCLUSION

Foot dysfunction and pain are common in SSc. Higher FFI scores, increased pain, and prolonged TUG duration were linked to disability (HAQ-DI and SHAQ). These analyses should be considered exploratory and require confirmation in external cohorts. Routine foot examinations were lacking in clinical practice. Improved attention for evaluating and caring for the feet in SSc patients is needed.

Analysis of nailfold capillaroscopy images with artificial intelligence: Data from literature and performance of machine learning and deep learning from images acquired in the SCLEROCAP study

OBJECTIVE

To evaluate the performance of machine learning and then deep learning to detect a systemic scleroderma (SSc) landscape from the same set of nailfold capillaroscopy (NC) images from the French prospective multicenter observational study SCLEROCAP.

METHODS

NC images from the first 100 SCLEROCAP patients were analyzed to assess the performance of machine learning and then deep learning in identifying the SSc landscape, the NC images having previously been independently and consensually labeled by expert clinicians. Images were divided into a training set (70 %) and a validation set (30 %). After features extraction from the NC images, we tested six classifiers (random forests (RF), support vector machine (SVM), logistic regression (LR), light gradient boosting (LGB), extreme gradient boosting (XGB), K-nearest neighbors (KNN)) on the training set with five different combinations of the images. The performance of each classifier was evaluated by the F1 score. In the deep learning section, we tested three pre-trained models from the TIMM library (ResNet-18, DenseNet-121 and VGG-16) on raw NC images after applying image augmentation methods.

RESULTS

With machine learning, performance ranged from 0.60 to 0.73 for each variable, with Hu and Haralick moments being the most discriminating. Performance was highest with the RF, LGB and XGB models (F1 scores: 0.75-0.79). The highest score was obtained by combining all variables and using the LGB model (F1 score: 0.79 ± 0.05, p < 0.01). With deep learning, performance reached a minimum accuracy of 0.87. The best results were obtained with the DenseNet-121 model (accuracy 0.94 ± 0.02, F1 score 0.94 ± 0.02, AUC 0.95 ± 0.03) as compared to ResNet-18 (accuracy 0.87 ± 0.04, F1 score 0.85 ± 0.03, AUC 0.87 ± 0.04) and VGG-16 (accuracy 0.90 ± 0.03, F1 score 0.91 ± 0.02, AUC 0.91 ± 0.04).

CONCLUSION

By using machine learning and then deep learning on the same set of labeled NC images from the SCLEROCAP study, the highest performances to detect SSc landscape were obtained with deep learning and in particular DenseNet-121. This pre-trained model could therefore be used to automatically interpret NC images in case of suspected SSc. This result nevertheless needs to be confirmed on a larger number of NC images.

Toll-Like Receptor 8 is Expressed in Monocytes in Contrast to Plasmacytoid Dendritic Cells and Mediates Aberrant Interleukin-10 Responses in Patients With Systemic Sclerosis

OBJECTIVE

Systemic sclerosis (SSc) is a severe rheumatic disease causing fibrotic tissue rearrangement. Aberrant toll-like receptor (TLR) 8 transcripts in plasmacytoid dendritic cells (pDCs) were recently linked to SSc pathogenesis, which is at least partially mediated by increased type I interferon (IFN-I) responses. Here, we addressed the functional role of TLR8 signaling in different immune cell subsets of patients with SSc.

METHODS

Monocytes, conventional dendritic cells (cDCs), and pDCs from the blood and skin of patients with SSc were analyzed for TLR8 protein expression. To assess TLR function, cytokine responses upon TLR7 and TLR8 stimulation were studied. To identify relevant alterations specific for patients with SSc (n = 16), patients with primary Sjögren disease (pSS; n = 10) and healthy controls (HCs; n = 13) were included into the study.

RESULTS

In all individuals, TLR8 was expressed in monocytes and cDCs but not in pDCs. The TLR8 expression levels were overall similar in patients with SSc and pSS and HCs. Additionally, in all study participants, TLR8 stimulation of pDCs did not induce IFN-I expression. In contrast, monocytes from patients with SSc revealed increased interleukin (IL)-10 responses upon TLR8 (patients with SSc vs HCs, P = 0.0126) and TLR7/8 stimulation (patients with SSc vs HCs, P = 0.0170).

CONCLUSION

TLR8 protein is not expressed in pDCs of patients with SSc. Accordingly, they do not respond to TLR8 stimulation. In contrast, monocytes of patients with SSc respond to TLR8 stimulation with increased IL-10 responses. Therefore, TLR8 signaling in monocytes participates in SSc pathogenesis by conferring aberrant IL-10 expression.

Mutual Amplification of GLI2/Hedgehog and Transcription Factor JUN/AP-1 Signaling in Fibroblasts in Systemic Sclerosis: Potential Implications for Combined Therapies

OBJECTIVE

Deregulation of the cJUN/AP-1 and hedgehog/GLI2 signaling pathways has been implicated in fibroblast activation in systemic sclerosis (SSc). However, the consequences of their concomitant up-regulation are unknown. Here, we tested the hypothesis that mutual amplification of both pathways might drive persistent fibroblast activation.

METHODS

Cultured fibroblasts and skin sections of patients with diffuse SSc and healthy volunteers were analyzed. cJUN/AP-1 signaling and hedgehog/GLI2 signaling were inhibited using knockdown and pharmacologic approaches. Hedgehog signaling was activated in mice by fibroblast-specific overexpression of constitutively active Smoothened.

RESULTS

cJUN and GLI2 are concomitantly up-regulated and colocalize in fibroblasts of patients with SSc compared to healthy controls. Activation of hedgehog/GLI2 signaling induces the expression of cJUN in vitro and in vivo, whereas inactivation of GLI2 inhibits cJUN expression. Likewise, inactivation of cJUN impairs the expression of GLI2. This mutual regulation occurs at the level of transcription with binding of cJUN and GLI2 to specific binding motifs. Interference with this mutual amplification of cJUN signaling and GLI2 signaling inhibits fibroblast activation and collagen release: Inhibition of cJUN/AP-1 signaling ameliorates hedgehog-induced fibroblast activation and skin fibrosis in SmoACT mice with a reduction of skin thickness of 103% (P = 0.0043) in the treatment group compared to the fibrotic control group. Moreover, combined pharmacologic inhibition of cJUN/AP-1 and hedgehog/GLI2 exerts additive antifibrotic effects in a model of TGFβ-driven experimental fibrosis (TBRACT mice).

CONCLUSION

The transcription factors cJUN and GLI2 reinforce each other's activity to promote fibroblast activation in SSc. Interruption of this crosstalk by combined inhibition of both pathways exerts additive antifibrotic effects at well-tolerated doses.

Steroid hormones in systemic sclerosis: associations with disease characteristics and modifications during scleroderma renal crisis

OBJECTIVE

The renin-angiotensin-aldosterone system (RAAS) and glucocorticoids (GCs) are involved in vascular remodeling and fibrosis but have not been extensively studied in systemic sclerosis (SSc). Our aim was to investigate the RAAS and GC hormones in SSc patients.

METHODS

Serum levels of renin (dosage and activity), aldosterone and its precursors (DOC, B, 18-OH-DOC, 18-OH-B), and GCs (cortisol, cortisone, 11-deoxycortisol, 18-OH-F) were assessed in 122 SSc patients and 52 healthy controls. After applying stringent inclusion criteria aimed at ensuring accurate hormone assessments (exclusion of interfering drugs, strict sampling conditions), we analysed RAAS hormones in 61 patients, and GCs in 96 patients. Hormone levels were compared between patients and controls; and associations with disease characteristics were assessed in patients.

RESULTS

Regarding RAAS hormones, SSc patients displayed significantly lower aldosterone levels (although within normal range), similar renin levels, and higher B levels than controls. Abnormal RAAS hormone levels were associated with a more severe SSc phenotype (lung and skin fibrosis, heart and pulmonary vascular involvements, inflammation). Regarding GC hormones, SSc patients had higher levels of cortisol, 11-desoxycortisol (precursor) and 18-OH-F (metabolite) but lower levels of cortisone (inactive counterpart) than controls. RAAS hormone levels were assessed in five SSc patients before and during scleroderma renal crisis (SRC): concentrations varied considerably between patients, but consistently included normal/increased aldosterone levels and elevated renin levels.

CONCLUSION

RAAS and GC hormones are abnormally produced in SSc patients, especially in patients with severe SSc and during SRC. This could suggest a participation of these hormonal systems in SSc pathogenesis.

Multi-centre modified Delphi exercise to identify candidate items for classifying early-stage symptomatic knee osteoarthritis

OBJECTIVE

To generate a list of candidate items potentially useful for discriminating individuals with Early-stage Symptomatic Knee Osteoarthritis (EsSKOA) from those with other conditions and from established osteoarthritis (OA), and to reduce this list based on expert consensus.

DESIGN

We conducted a three-round online international modified Delphi exercise with OA clinicians and researchers ("OA experts"). In Round 1, participants reviewed 84 candidate items and nominated additional item(s) potentially useful for EsSKOA classification; those nominated by ≥3 participants were added. In Round 2, participants rated perceived usefulness of 108 items (1 [not at all useful] to 9 [extremely useful]). In Round 3, participants could revise their ratings after reviewing Round 2 group median and quartiles. Following Round 3, we retained items with a median usefulness score >5 and ≥33.3% of participants categorised the item as useful (7 to 9), overall and in subgroup analysis by clinician field.

RESULTS

There were 128 participants in Round 1 and 113 (88%) completed all rounds. We retained 77 items that spanned multiple domains (demographics, symptoms, physical exam, performance-based measures, imaging, laboratory investigations, and gross inspection/arthroscopy). Highly rated items included (median usefulness score): prior knee joint injury (8), diagnosis of OA in a different joint (7), and activity-related knee pain (7). The interquartile range was most often 3.

CONCLUSION

We identified 77 items that OA experts consider potentially useful for EsSKOA classification. The results highlight experts' uncertainty around item usefulness. Next, candidate items will be further assessed and reduced using data-driven and multicriteria decision analysis methods.

Barnidipine as a potential alternative treatment for Raynaud's phenomenon secondary to systemic sclerosis: a retrospective pilot study

OBJECTIVES

To assess short-term barnidipine efficacy and tolerability on Systemic Sclerosis (SSc)-Raynaud's phenomenon (RP).

METHODS

We retrospectively evaluated patients with SSc starting barnidipine 10 mg/day. Raynaud's Condition Score (RCS) and mean blood pressure (MBP) were assessed at baseline and 6-month follow-up. Discontinuation rates and adverse events (AEs) were compared with retrospectively evaluated patients who started MR-nifedipine 20 mg/day at our centre.

RESULTS

Sixty-four patients (29 barnidipine, 35 MR-nifedipine) were evaluated. Most patients starting barnidipine had a previous CCB exposure (69%; 57.9% of these were withdrawn for AEs). During follow-up, RCS decreased significantly (6.6 ± 1.8 vs 4.4 ± 1.8, p < 0.001), while the MBP did not change significantly (86.4 ± 8.4 vs 85 ± 7.3 mmHg; p = 0.36). Nine patients (31%) discontinued barnidipine during the follow-up (AEs 6/9, inefficacy 3/9). Previous CCB failure did not predict barnidipine withdrawal (OR = 0.188 95%CI [0.02-1.8]; p = 0.147). No predictors of barnidipine withdrawal were found, and no clinical or demographic differences were found between patients withdrawing and continuing barnidipine. The 6-month retention rates of barnidipine and MR-nifedipine did not differ significantly (69 vs 80%; log-rank p = 0.23), and the two groups had a similar incidence of AEs leading to discontinuation (20.1 vs 17%; p = 0.48).

CONCLUSIONS

Barnidipine could be an effective and well-tolerated therapeutic option to treat SSc-RP, even in patients previously failing other CCBs. Key Points • Calcium channel blockers (CCBs) currently represent the first-line treatment for Raynaud's phenomenon secondary to Systemic Sclerosis (SSc-RP). However, little data exists about using novel CCBs, such as barnidipine, in this condition. • This study retrospectively evaluated patients with SSc-RP treated with barnidipine to assess its short-term efficacy. To serve as a control group for tolerability, we retrospectively compared these patients with others starting modified release-nifedipine (MR-nifedipine). • In patients treated with barnidipine, we observed a significant decrease in Raynaud's condition score at the 6-month follow-up without substantial changes in mean blood pressure. • The proportion of adverse events and drug withdrawal rate between patients starting barnidipine and MR-nifedipine did not differ significantly, even in patients starting barnidipine after previously failing other CCBs.

Progression and clinical implications of frailty in patients with systemic sclerosis

INTRODUCTION/OBJECTIVES

To identify the frequency, correlates and progression of frailty in systemic sclerosis (SSc).

METHOD

All Australian Scleroderma Cohort Study participants meeting ACR/EULAR criteria with a calculable FRAIL Scale score were included. FRAIL Scale scores were calculated annually and were used to group participants as 'robust', 'pre-frail' or 'frail'. Progression of frailty over time was examined by comparing first-recorded, highest-recorded and last-recorded FRAIL Scale scores for each participant. Determinants of frailty at each visit were evaluated with ordinal logistic regression. Survival was analysed using Cox hazard modelling.

RESULTS

Of 1703 participants, 14% and 53% met criteria for frailty or pre-frailty respectively, with 33% consistently robust. Among initially frail participants, 40% remained frail and 60% improved to pre-frailty/robustness. Of pre-frail participants, 15% became frail while 32% improved to robustness. One-third of initially robust participants progressed to pre-frailty/frailty. SSc-specific determinants of frailty included diffuse SSc (odds ratio (OR) 1.4, 95% confidence interval (CI) 1.1-1.8, p < 0.01), pulmonary arterial hypertension (OR 7.1, 95% CI 5.1-9.9, p < 0.01), interstitial lung disease (OR 1.6, 95% CI 1.3-2.0, p < 0.01), proximal weakness (OR 1.5, 95% CI 1.2-2.0, p < 0.01) and lower-tract gastrointestinal symptoms (OR 1.5, 95% CI 1.3-1.8, p < 0.01). Older age (OR 1.1, 95% CI 1.1-1.2, p < 0.01), raised CRP (OR 1.7, 95% CI 1.4-2.0, p < 0.01) and anaemia (OR 1.4, 95% CI 1.2-1.7, p < 0.01) were also significantly associated with frailty. A graded risk of death was observed with the diagnosis of pre-frailty and frailty states (hazard ratio (HR) 3.5, 95% CI 2.6-4.8, p < 0.01; and HR 9.8, 95% CI 6.8-14.1, p < 0.01 respectively). Frailty and pre-frailty were associated with reduced health-related quality-of-life and physical function (p < 0.05).

CONCLUSIONS

Frailty and pre-frailty are common in SSc and contribute to morbidity and mortality. Both SSc and non-SSc determinants of frailty exist. Frailty in SSc is a dynamic phenomenon with potential to deteriorate or improve over time.

Lung ultrasound in the assessment of interstitial lung disease in patients with connective tissue disease: Performance in comparison with high-resolution computed tomography

OBJECTIVE

To investigate clinical relevance of performing lung ultrasound (LUS) in patients with connective tissue disease (CTD)-associated interstitial lung disease (ILD) in comparison with high-resolution computed tomography (HRCT).

METHODS

This single-centre study enrolled eligible patients with CTD-ILD from the prospective LUS registry. Total B-lines were detected by assessment at 14 sites via LUS. Forced vital capacity, diffusing lung capacity for carbon monoxide (DLCO), DLCO/alveolar volume, 6-minute walking distance, and the ILD-GAP index were used as ILD prognostic parameters. Correlations were examined using single and multiple regression analyses.

RESULTS

Sixty-seven patients were enrolled, including 29 with idiopathic inflammatory myopathy or anti-synthetase syndrome, 25 with systemic sclerosis (SSc), 10 with rheumatoid arthritis, and 3 with mixed CTD. The total number of B-lines correlated with ILD extent on HRCT in patients with CTD-ILD (r = 0.66; P < .001), particularly in patients with SSc-ILD (r = 0.78; P < .001). Total B-lines and ILD extent on HRCT showed comparable correlations with prognostic parameters, while multiple regression analysis revealed the limited benefit of performing LUS in addition to HRCT in predicting correlations with prognostic factors.

CONCLUSIONS

LUS serves as an alternative tool for assessing the severity and prognosis of patients with CTD-ILD.

The Efficacy and Tolerability of Prostaglandin Analogues in Treating Systemic Sclerosis-Associated Raynaud Phenomenon: A Systematic Review and Meta-Analysis

Background: Systemic sclerosis-associated Raynaud phenomenon (SSc-RP) confers poor outcomes, including ulceration, gangrene, autoamputation, and hand disability. Prostaglandin analogues (PG) are a group of prostacyclin-derived drugs with properties that may address underlying complex mechanisms of SSc-RP. This systematic review and meta-analysis evaluated the efficacy and tolerability of PGs in SSc-RP. Methods: We systematically reviewed randomized control trials (RCTs) evaluating PG use in SSc-RP. The primary outcome was the severity of RP attacks. The secondary outcomes were the frequency and duration of RP attacks, healing of digital ulcers, development of new digital ulcers, change of capillary blood flow, patient health-reported outcome measure (PROM-VAS), and tolerability. Results: Eleven RCTs were included, reporting a total of n = 1081 individuals with SSc. PG confers a beneficial effect on RP severity in the short-term, weighted Mean difference (WMD) -0.63 (95% CI -0.99, -0.27, I 2 0%), with no difference in tolerability compared to placebo OR 1.88 (95% CI 1.00, 3.55, I 2 = 1%). PG has nonsignificant trends towards improvement in RP frequency WMD of -0.32 (95% CI -0.76, 0.13, I 2 = 0%), RP duration WMD -4.78 (95% CI -14.69, 5.14, I 2 = 1%), PROM-VAS WMD -4.81 (95% CI -11.31, 1.69, I 2 = 67%), and new or recurrent digital ulcers OR 0.92 (95% CI 0.48, 1.76, I 2 = 34%). Conclusion: PGs are beneficial in the short term to reduce the RP severity and are tolerable. Larger, adequately powered trials are needed for higher certainty evidence across SSc-RP outcomes.

Non-Invasive Cardiac and Vascular Monitoring in Systemic Sclerosis: Impact of Therapy on Subclinical Dysfunction

Background and objectives: Systemic sclerosis (SSc) causes myocardial and microvascular impairment, with subclinical dysfunction and eventually permanent cardio-vascular damage. The long-term influence of SSc therapies on subclinical cardiovascular dysfunction is insufficiently investigated. We aimed to assess 2D and 4D cardiac ultrasound parameters of heart function in patients with different forms of SSc versus controls and to determine the evolution of cardiac function and arterial stiffness parameters under therapy. Materials and methods: A total of 60 subjects with SSc were studied at baseline; 30 SSc patients were compared to 30 matched controls. A total of 52 SSc subjects were reassessed after 1 year and 30 after 2 years of treatment. Cardiac function was evaluated through 2D standard echocardiography, tissue Doppler, speckle tracking and 4D auto LV quantification echo. Arterial stiffness was determined via the cardio-ankle vascular index and ankle brachial index. Results: At baseline, the standard echo parameters were normal. The 4D and myocardial work parameters, although in normal limits, were significantly altered in the SSc group vs. controls (4D ejection fraction 54.5 ± 8.5% in SSc vs. 63.8 ± 3.1% in controls; 4D longitudinal strain -14.2 ± 2.4% in SSc vs. -22.0 ± 2.7% in controls; global constructive work 2124.2 ± 449.5 mmHg% in SSc vs. 3102.8 ± 337.5 mmHg% in controls, for all p ≤ 0.02). Both at 1 year and 2 years of treatment, all echo and arterial stiffness parameters were similar to baseline, with no correlation to treatment type. Conclusions: SSc determines subclinical systolic dysfunction. Non-invasive assessment methods do not detect a functional cardiovascular decline in patients on classical therapy. Complex cardiac follow-up should be implemented in cases at risk for complications.

Psychological features of systemic sclerosis: results from an observational study

Objectives

(a) Assessing mental disorders, psychological distress, psychological wellbeing in patients with systemic sclerosis (SSc); (b) identifying psychological features independently contributing to the status of having the diagnosis of SSc.

Methods

Two hundred SSc outpatients were compared with 100 healthy subjects. Mental disorders were assessed via the Mini International Neuropsychiatric Interview (MINI). Self-reported rating scales were administered: Health Assessment Questionnaire Disability Index (HAQ-DI), Symptom Checklist-90-Revised (SCL-90-R), Psychological Well Being scales (PWB). General linear models allowed to verify which psychological feature would individually make unique contributions to overall status of having the diagnosis of SSc.

Results

Major depressive episode/disorder, panic disorder were more prevalent among patients with SSc (p < 0.05); SCL-90-R somatization and depression were more severe (p < 0.05) in SSc; PWB personal growth, positive relationships with others, purposes in life were poorer (p < 0.05) in patients with SSc if compared to healthy controls. The final general linear model, accounting for 20.4% of variance, showed that having the diagnosis of SSc was associated to lower SCL-90-R paranoid ideation and poorer PWB relationships with others.

Conclusion

SSc showed to present psychological features in need of assessment since some of them individually made unique contributions to overall status of having the SSc diagnosis.

Patients with systemic sclerosis frequently use phytopharmaceuticals: a cross-sectional survey

The use of complementary and alternative medicine (CAM) has increased. Phytotherapy, also known as herbal medicine, is one of the CAM therapies that involves using medicinal plants and plant-derived substances. This study aims to evaluate the use of phytopharmaceuticals and the factors associated with their use in patients with Systemic sclerosis (SSc). Our study is designed as a survey and consists of two parts with 32 questions. The first part gathers demographic data with 14 questions, and the second part assesses participants' knowledge about phytotherapy with 18 questions. The questionnaire was administered face-to-face to patients with SSc who consented to participate. One hundred participants completed the survey. Fifty-two (52%) participants had diffuse sclerosis. Raynaud's phenomenon affected 97 (97%) participants; 53 (53%) participants suffered from lung involvement, and 64 (64%) had musculoskeletal system involvement. A total of 55 (55%) participants had used phytopharmaceuticals after SSc diagnosis. Phytotherapy users and non-users had similar demographic and clinical characteristics in terms of age, gender, disease duration, type of SSc, organ involvement, and education level. Participants mostly used the following phytopharmaceuticals: 23 participants used Camellia sinensis (green tea), 16 used Hypericum perforatum, and 12 used Curcuma longa (curcumin). The most improved symptoms with phytopharmaceuticals were musculoskeletal system findings and skin thickness, as stated by participants. A significant portion of SSc patients used phytopharmaceuticals in their disease duration. Although patients stated that they benefited from phytopharmaceuticals, studies on the effectiveness of these treatments are insufficient.

Evaluation of Progression From Preclinical to Systemic Autoimmune Rheumatic Disease: Novel Use of the European Alliance of Associations for Rheumatology/American College of Rheumatology Systemic Lupus Erythematosus Classification Criteria as an Outcome Measure

OBJECTIVE

Our objective was to evaluate the development of a systemic autoimmune rheumatic disease (SARD) in undifferentiated and asymptomatic individuals with antinuclear antibodies (ANAs). We comparatively evaluated those who did and did not develop a SARD and fulfillment of classification criteria.

METHODS

We conducted a cohort study of undifferentiated and asymptomatic patients with ANAs who were assessed for the development of a SARD. The primary outcome was a diagnosis of a SARD over a two-year period. We assessed fulfillment of classification criteria. Risk ratios (RRs) were used to evaluate differences among those who did and did not progress to a SARD.

RESULTS

We evaluated 207 asymptomatic ANA-positive or undifferentiated patients, of whom 23 (11%) progressed to a SARD, whereas 187 (89%) did not progress. Progressors developed systemic lupus erythematosus (SLE) (n = 11 [48%]), Sjögren disease (n = 5 [22%]), systemic sclerosis (n = 3 [13%]), rheumatoid arthritis (n = 1 [4%]), and from ANA-positive to undifferentiated connective tissue disease (n = 3 [13%]). Fever (RR 0.89, 95% confidence interval [CI] 0.8-0.93) and antiphospholipid antibodies (RR 0.89, 95% CI 0.87-0.93) occurred less frequently, whereas arthritis (RR 1.74, 95% CI 1.20-2.55) occurred more frequently in progressors. Progressors to SLE had arthritis (91%), whereas none developed delirium, psychosis, or nephritis. Among patients with SLE, 100% fulfilled the EULAR/American College of Rheumatology (ACR) SLE criteria (sensitivity 91.7%, specificity 100%), whereas 73% fulfilled the 1997 ACR SLE criteria (sensitivity 81.8%, specificity 98.9%).

CONCLUSION

Most undifferentiated/asymptomatic individuals with ANA do not progress to a SARD over a two-year period. SLE progressors appear to have mild disease in the short term. The EULAR/ACR SLE criteria have improved ability to identify those who develop SLE.

Changes of cerebral structure and perfusion in subtypes of systemic sclerosis: a brain magnetic resonance imaging study

OBJECTIVES

The characteristics of brain impairment in different subtypes of systemic sclerosis (SSc) (dcSSc, diffuse cutaneous SSc; lcSSc, limited cutaneous SSc) remain unclear. This study aimed to characterize cerebral structure and perfusion changes in different subtypes of SSc patients using magnetic resonance (MR) imaging.

METHODS

Seventy SSc patients (46.0 ± 11.7 years, 62 females) and 30 healthy volunteers (44.8 ± 13.7 years, 24 females) were recruited and underwent brain MR imaging and Montreal Cognitive Assessment (MoCA) test. Gray matter (GM) volumes were measured using voxel-based morphometry analysis on T1-weighted images. Voxel-based and regional cerebral blood flow (CBF) was calculated on arterial spin labelling images. The cerebral structural and perfusion measurements by MR imaging were compared among dcSSc, lcSSc and healthy subjects using one-way ANOVA. The correlations between clinical characteristics and MR imaging measurements were also analysed.

RESULTS

The dcSSc patients exhibited a significant reduction in GM volume in the para-hippocampal region (cluster P < 0.01, FWE corrected) compared with healthy volunteers. Whereas SSc patients, particularly lcSSc patients, showed elevated CBF in cerebellum, insula, cerebral cortex and subcortical structures (regional analyses: all P < 0.05; voxel-based analyses: cluster P < 0.01, FWE corrected). Furthermore, clinical characteristics of modified Rodnan skin score (mRSS) (r value ranged from -0.29 to -0.45), MoCA scores (r = 0.40) and anti-nuclear antibody (ANA) positivity (r = -0.33) were significantly associated with CBF in some regions (all P < 0.05).

CONCLUSION

The manifestations of brain involvement vary among different subtypes of SSc. In addition, severe skin sclerosis may indicate higher risk of brain involvement in SSc patients.

Outcomes and predictors of progression in progressive pulmonary fibrosis

BACKGROUND

Progressive pulmonary fibrosis (PPF) is a general term for a class of interstitial lung diseases (ILDs) characterized by a progressive fibrosing (PF) phenotype. Patients with PPF have decreased lung function, exercise ability, and quality of life. The purpose of this study was to investigate the clinical characteristics, potential associated factors for disease progression, and survival outcomes of patients in the PPF population.

METHODS

This study retrospectively reviewed the data of patients diagnosed with ILD between January 2011 and December 2022 at The First Affiliated Hospital of Ningbo University. A PF phenotype was defined based on the criteria that were used in the PPF clinical practice guidelines, which led to the identification of 92 patients with a PF phenotype among the 177 patients with fibrotic ILD. Baseline clinical information and laboratory parameters were collected and analysed in our cohort.

RESULTS

Patients in the PPF group had higher tumour marker levels and lower pulmonary function test results at baseline than did those in the non-PPF group. According to the multivariate logistic regression analysis, age >65 years (OR 2.71, 95% CI 1.26-5.89; p = 0.011), LDH >245 U/L (OR 3.07, 95% CI 1.39-6.78; p = 0.006), CA-153 > 35 U/mL (OR 3.16, 95% CI 1.25-7.97; p = 0.015), FVC <60% predicted (OR 4.82, 95% CI 1.60-14.51; p = 0.005), DLCO <50% predicted (OR 3.21, 95% CI 1.43-7.21; p = 0.005), and the UIP-like pattern on chest HRCT (OR 3.65, 95% CI 1.33-10.07; p = 0.012) were potentially associated with the progression of fibrotic interstitial lung diseases (f-ILDs) to PPF. Furthermore, the PPF group had a poorer survival rate than the non-PPF group (p = 0.0045). According to the multivariate Cox regression analysis, an SPAP ≥ 37 mmHg (HR 2.33, 95% CI 1.09-5.00; p = 0.030) and acute exacerbation (HR 2.88, 95% CI 1.26-6.59; p = 0.012) were identified as significant prognostic factors for mortality in patients with PPFs.

CONCLUSIONS

Patients who were older, had high CA-153 and LDH levels, had poor pulmonary function test results, or had a UIP-like pattern on chest HRCT were more likely to have indications for the progression of f-ILD to PPF. Increased SPAP and AE are independent risk factors for the prognosis of PPF patients, so additional attention should be given to such patients.

Evaluating the Associations Among Dysautonomia, Gastrointestinal Transit, and Clinical Phenotype in Patients With Systemic Sclerosis

OBJECTIVE

Our objective was to identify patients with systemic sclerosis (SSc) with a high burden of autonomic symptoms and to determine whether they have a distinct clinical phenotype, gastrointestinal (GI) transit, or extraintestinal features.

METHODS

In a prospective cohort of patients with SSc with GI disease, clinical data were systematically obtained at routine visits. Dysautonomia was identified by the Composite Autonomic Symptom Score (COMPASS)-31questionnaire. GI transit was measured by whole-gut scintigraphy. Associations between total COMPASS-31 scores and clinical features, GI symptoms, and transit were evaluated. Comparisons between patients with global autonomic dysfunction (GAD; ≥5 positive COMPASS-31 subdomains) and those with limited autonomic dysfunction (LAD; <5 positive subdomains) were also studied.

RESULTS

A total of 91 patients with SSc and GI involvement were included (mean age 57 years, 90% female, 74% limited cutaneous disease, 83% significant GI disease [Medsger score ≥2]). The mean COMPASS-31 score in patients with SSc was higher than controls (38.8 vs 7.2); 33% had GAD, and 67% had LAD. Patients with GAD were more likely to have limited SSc (93% vs 65%; P < 0.01) and have sicca symptoms (100% vs 77%; P = 0.01). Gastric and colonic transit were faster in patients with GAD (P < 0.05). Upper GI involvement (Medsger GI score of 1 or 2) was associated with higher total COMPASS-31 scores (P = 0.02).

CONCLUSION

Symptoms of global dysautonomia are seen in up to one-third of patients with SSc and GI involvement. Identifying specific clinical characteristics associated with GAD in SSc will help to identify a population that may benefit from therapies that modulate the autonomic nervous system.

Autoantibodies in systemic sclerosis overlap syndrome and their correlation with organ damage and survival

BACKGROUND

Systemic sclerosis (SSc) often overlaps with other autoimmune diseases. More complex autoantibody profiles may be observed in SSc overlap syndrome (SSc OS). To determine the clinical significance of autoantibodies in SSc OS and classify the patients more accurately for better disease assessments, we analysed the correlation between serological profiles, organ involvements and outcomes.

METHODS

A retrospective cohort study was conducted in Peking University People's Hospital. Chi-square tests and analysis of variance were used to analyse univariate comparisons of clinical symptoms, organ involvement and laboratory indicators. Survival was evaluated using Cox proportional hazards model.

RESULTS

Among 141 cases, anti-Ro-52 was the most common antibody, followed by anti-centromere antibody and anti-Scl-70 antibody. We analysed the correlation between autoantibodies and vital organ damage in SSc OS patients, and compared the differences across four SSc OS subgroups (SSc SLE, SSc RA, SSc PM/DM and SSc SS) to demonstrate the correlation between autoantibodies and clinical characteristics and organ damage. Cox regression analysis showed that scleroderma renal crisis (SRC) (p = .004) and pulmonary arterial hypertension (PH) (p = .010) were independent risk factors for survival.

CONCLUSIONS

Autoantibodies are associated with clinical features, organ involvement and prognosis in SSc OS patients. Anti-Scl-70 antibody is associated with interstitial lung disease (ILD) and SRC, while ACA is a protective factor of ILD. SRC and PH are risk factors associated with death.

Alternative splicing and intron retention: Their profiles and roles in cutaneous fibrosis of systemic sclerosis

BACKGROUND

Alternative splicing (AS) and intron retention (IR) implicated in multiple pathophysiological processes, have rarely been reported in systemic sclerosis (SSc).

METHODS

We integrated bulk RNA-seq and 4D label-free mass spectrometry to perform a multi-omics analysis of AS and IR in SSc skin tissue and fibroblasts. RMATS and iREAD were used to identify AS and IR, which were validated by real-time PCR. Spearman correlation and the LASSO method were employed to assess correlations among clinical features, introns, splicing factors (regulators of AS) and proteins.

FINDINGS

AS profiles showed distinct alterations in SSc skin tissue, with the most pronounced changes occurring in IR. AS and IR were associated with total modified Rodnan skin score (mRSS) and local skin score. Upon TGF-β stimulation, fibroblasts exhibited significant alterations in IR profiles, affecting genes related to fibroblast proliferation and collagen fibril organization. A comprehensive integrated analysis of introns, exons, and proteome profiles revealed that IR exerted a negative impact on protein expression, with certain changes being under intronic control. RT-PCR confirmed the presence of intron and exon-derived sequences of CTTN, OGA, MED16 and PHYKPL. Additionally, notable changes were observed in the regulatory network of splicing factors in SSc skin tissues. These factors are also involved in fibrosis pathways and correlated with clinical features.

CONCLUSION

Totally, abnormal AS, IR profiles and splicing factors were identified in SSc, altered IRs and splicing factors participated in fibrosis-related pathways. IR exerted a negative impact on protein expression in TGF-β-stimulated fibroblasts. Clarification of the IR mechanisms will provide new insights into the pathophysiology of SSc.

Breaking barriers: advancing cellular therapies in autoimmune disease management

Autoimmune diseases occur due to a dysregulation within the immune system, leading to an aberrant assault on the organism's own tissues. The pathogenesis of these conditions is multifactorial, encompassing intricate interplays among genetic predispositions, environmental determinants, and hormonal fluctuations. The spectrum of autoimmune diseases is broad, impacting a multitude of organ systems, with notable examples such as rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), multiple sclerosis (MS), psoriasis, and vitiligo. Despite substantial progress in therapeutic interventions over recent years, a definitive cure for autoimmune diseases has yet to be realized, with existing modalities largely providing palliative care. Cellular therapy is considered the fourth pillar in the management of oncological disorders subsequent to surgical resection, radiotherapy, and chemotherapy. Cellular therapies have shown potential in augmenting immune competence and eliminating of targeted neoplastic cells in a spectrum of cancers. As targeting specific molecules on the surface of autoreactive B and T cells, such as CD19, BCMA, CD20, and CTLA-4, cellular therapies are emerging as promising approaches for the treatment of autoimmune diseases. This review delineates the advancements in the application of cellular therapies applied recently for autoimmune diseases and proposes considerations for the advancement of novel therapeutic strategies.