The Disability Index of the Health Assessment Questionnaire is a predictor and correlate of outcome in the high-dose versus low-dose penicillamine in systemic sclerosis trial

Characteristics of ScleroID highlighting musculoskeletal and internal organ implications in patients afflicted with systemic sclerosis

BACKGROUND

Systemic sclerosis (SSc) is a multi-organ disease with impaired health-related quality of life (HRQoL). The EULAR SSc Impact of Disease (ScleroID) is a newly introduced SSc-specific patient-reported outcome to evaluate HRQoL in SSc.

OBJECTIVE

To investigate the correlation between the ScleroID and the involvement of organ systems as well as disease activity/damage in a SSc cohort from a large tertiary care centre.

PATIENTS AND METHODS

The ScleroID and clinical characteristics including internal organ involvement and hand function were investigated in 160 consecutive patients with SSc (median age 46 (43;56) years; diffuse cutaneous SSc 55%).

RESULTS

A strong correlation was found between the ScleroID and articular disease activity scores (DAS28-CRP, DAS28-ESR, CDAI, SDAI), a hand function performance test, the Hand Anatomy Index and muscle strength tests. Additionally, a strong significant correlation was discovered using instruments representing hand function and musculoskeletal disability including the Cochin Hand Function Scale, the Quick Questionnaire of the Disability of the Hands, Arms and the Shoulders and the Health Assessment Questionnaire Disability Index. A significant negative correlation was found between the ScleroID score and the 6-min walking test (6MWT) (rho - 0.444, p < 0.001). Clinically mild lung/heart disease did not show increased ScleroID values. The Mouth Handicap in the Scleroderma Scale and the University of California Los Angeles Scleroderma Clinical Trials Consortium gastrointestinal tract 2.0 also showed significant positive correlations to the ScleroID score (rho: 0.626, p < 0.001; rho: 0.646, p < 0.001, respectively). Patients experiencing oesophageal difficulties bore a significantly higher score compared to individuals with a normal functioning oesophagus (3.2/1.5;4.5/ vs. 2.2/1.0;3.2/, p = 0.011). Moreover, the ScleroID showed a significant positive correlation to the revised EUSTAR disease activity index and modified activity index.

CONCLUSION

In a large single-centre cohort, the previously described ScleroID-related findings were confirmed. Furthermore, several organ involvement-related functional and performance tests showed a good correlation to the ScleroID including the 6MWT and gastrointestinal-related complaints. Many aspects of musculoskeletal damage, overall disease activity, pain and fatigue were also well represented in the ScleroID, which efficiently reflects the impact of organ involvement, disease activity and functional damage.

Functional Disability Among Systemic Sclerosis Patients: Relation to Disease Characteristics and Quality of Life Parameters

BACKGROUND

Disability in patients with scleroderma (SSc) has been associated with poor health-related quality of life (HRQoL) in all dimensions, including physical, psychological, and social dimensions.

OBJECTIVE

This study was conducted to examine different factors that may be associated with functional disability and poor HRQoL, with the aim of targeting these factors in the future to improve physical activity, functional outcomes, and HRQoL.

METHODS

A single-center cross-sectional study was conducted on 38 patients with SSc to compare characteristics between patients with and without disability using the Health Assessment Questionnaire Disability Index (HAQ-DI). Quality of life was assessed using the Short Form-36 (SF-36). Linear regressions were performed to examine variables contributing to functional disability.

RESULTS

Almost 65.78% (n = 25) of patients in the study group reported functional disability. The presence of functional disability was associated with reduced HRQoL, as reflected by physical function (P = 0.0001), physical role (P = 0.016), bodily pain (P = 0.001), general health (P = 0.002), social functional (P = 0.002), emotional role (P = 0.042), and mental health (P = 0.025) domains of the SF-36 score. Multiple linear regression indicated that the main predictive factors associated with HAQ-DI were the modified Hand Mobility in Scleroderma; modified Rodnan skin score; DIstance walked in 6 minutes, BOrg dyspnea index, and SAturation of oxygen at 6 minutes (DIBOSA); and Fatigue Severity Scale among patients with SSc.

CONCLUSION

In patients with SSc, recognizing the relationships between clinical findings and functional disability will allow the development of further management strategies to minimize disease severity and enhance HRQoL.

New risk model is able to identify patients with a low risk of progression in systemic sclerosis

Objectives

To develop a prediction model to guide annual assessment of systemic sclerosis (SSc) patients tailored in accordance to disease activity.

Methods

A machine learning approach was used to develop a model that can identify patients without disease progression. SSc patients included in the prospective Leiden SSc cohort and fulfilling the ACR/EULAR 2013 criteria were included. Disease progression was defined as progression in ≥1 organ system, and/or start of immunosuppression or death. Using elastic-net-regularisation, and including 90 independent clinical variables (100% complete), we trained the model on 75% and validated it on 25% of the patients, optimising on negative predictive value (NPV) to minimise the likelihood of missing progression. Probability cutoffs were identified for low and high risk for disease progression by expert assessment.

Results

Of the 492 SSc patients (follow-up range: 2–10 years), disease progression during follow-up was observed in 52% (median time 4.9 years). Performance of the model in the test set showed an AUC-ROC of 0.66. Probability score cutoffs were defined: low risk for disease progression (<0.197, NPV:1.0; 29% of patients), intermediate risk (0.197–0.223, NPV:0.82; 27%) and high risk (>0.223, NPV:0.78; 44%). The relevant variables for the model were: previous use of cyclophosphamide or corticosteroids, start with immunosuppressive drugs, previous gastrointestinal progression, previous cardiovascular event, pulmonary arterial hypertension, modified Rodnan Skin Score, creatine kinase and diffusing capacity for carbon monoxide.

Conclusion

Our machine-learning-assisted model for progression enabled us to classify 29% of SSc patients as ‘low risk’. In this group, annual assessment programmes could be less extensive than indicated by international guidelines.

Fatigue and its relationship with disease-related factors in patients with systemic sclerosis: A cross-sectional study

Background/aim

Fatigue is very common symptom in patients with systemic sclerosis (SSc) and adversely affects health-related quality of life and the ability to perform daily living activities. This study aimed to determine the severity of fatigue, and its related factors, in patients with SSc.

Materials and methods

A total of 35 patients with SSc (6 males and 29 females, mean age of 50.71 ± 10.09 years) and 35 healthy control subjects (8 males and 27 females, mean age of 54.14 ± 9.51 years) were included in this study. The Fatigue Impact Scale for fatigue, Modified Medical Research Council Scale for dyspnea severity, 6-Minute Walking Test for functional capacity, Health Assessment Questionnaire Disability Index, Scleroderma Health Assessment Questionnaire and Short Form-36 Quality of Life Questionnaire for health-related quality of life were used in the evaluation of the subjects. Furthermore, pulmonary functions, diffusion capacity, and respiratory and peripheral muscle strength were evaluated.

Results

Of the SSc patients, 80% experienced fatigue and presented with higher total and cognitive, physical, and psychosocial subscale fatigue scores than the healthy control subjects (P < 0.05). Moreover, the SSc patients exhibited significantly increased dyspnea severity, impaired pulmonary function-diffusion capacity, decreased respiratory-peripheral muscle strength, reduced functional capacity, and worsened health-related quality of life when compared to the control group (P < 0.05). Fatigue in the SSc group was significantly associated with age, dyspnea severity, diffusion capacity, respiratory and peripheral muscle strength, functional capacity, and health-related quality of life (P < 0.05).

Conclusions

Along with the decrease in diffusion capacity, increase dyspnea, a decrease in both peripheral and respiratory muscle strength, and worsening functional capacity may have an effect on increased fatigue in SSc patients. Increased fatigue can also affect the life quality and daily life activities of a patient. Therefore, multidisciplinary approaches are recommended to evaluate and improve these parameters in the treatment of fatigue from the early period in SSc patients.

Association of Anti-Topoisomerase I Antibodies of the IgM Isotype With Disease Progression in Anti-Topoisomerase I-Positive Systemic Sclerosis

Objective

Anti–topoisomerase I (anti–topo I) autoantibodies in systemic sclerosis (SSc) are associated with diffuse skin involvement and interstitial lung fibrosis. Thus far, however, the relationship between anti–topo I antibody response and disease course has not yet been fully evaluated. This study was undertaken to gain insight into the association between characteristics of the anti–topo I antibody response and clinical disease course in SSc patients positive for anti–topo I antibodies.

Methods

Levels of anti–topo I IgG, anti–topo I IgM, and anti–topo I IgA were assessed in consecutive serum samples obtained from patients at baseline who were positive for anti–topo I IgG in the Leiden Combined Care In Systemic Sclerosis (CCISS) cohort. One‐year disease progression was defined by a relevant increase in modified Rodnan skin thickness score (MRSS), decline in pulmonary function, development of digital ulcers, renal crisis, and pulmonary hypertension, and/or mortality. Validation was performed in SSc patients who were positive for anti–topo I from the Oslo University Hospital and University Hospital Zurich.

Results

Of the 103 patients with anti–topo I IgG in the CCISS cohort, clinical data were available to assess 1‐year disease progression in 81 patients. Of these 81 patients, 23 (28%) had disease progression. At baseline, patients with disease progression were significantly more often anti–topo I IgM–positive than those who did not experience disease progression (21 [91%] of 23 versus 33 [57%] of 58; P < 0.01). This finding was confirmed in the independent validation samples.

Conclusion

In SSc patients who were anti–topo I IgG–positive, presence of anti–topo I IgM, which might be considered as a surrogate for an ongoing autoreactive B cell immune response, is associated with disease progression.

Changes in skin score in early diffuse cutaneous systemic sclerosis are associated with changes in global disease severity

OBJECTIVE

To determine whether skin score changes are associated with changes in overall disease severity, function and quality of life in early dcSSc patients.

METHODS

A total of 154 and 128 dcSSc patients from the Canadian Scleroderma Research Group database with 1 and 2 year follow-up and a disease duration ⩽5 years without end-stage organ damage and/or significant comorbidity at the initial visit were included. Skin was assessed using the modified Rodnan skin score (mRSS) and disease severity by the summed Medsger disease severity score (DSS) (without skin domain), physician and patient global assessments, function [HAQ disability index (HAQ-DI)] and quality of life [36-item Short Form Health Survey (SF-36) physical component summary (PCS)]. Analyses were repeated in patients with a disease duration ⩽3 years.

RESULTS

At 2 years, 64 (50%) patients had improved skin (mRSS decrease of ⩾5 points and/or ⩾25%). Skin improvers had improved summed DSS (P = 0.002); better physician global assessments of disease activity, severity and damage (all P ⩽ 0.003); better HAQ-DI (P = 0.001) and SF-36 PCS (P = 0.005). Changes in the mRSS were positively correlated with changes in summed DSS (P = 0.006) and other disease outcomes. In the 26 (20.3%) patients with worsened skin (mRSS increase of ⩾5 points and/or ⩾25%), the summed DSS and physician global assessments were worse (P = 0.01 and P ⩽ 0.009, respectively). In the subgroup with a disease duration ⩽3 years, similar associations were found.

CONCLUSION

At 1 and 2 years, overall disease improvement parallels skin improvement in early dcSSc. This is important for prognosis and reflects the value of mRSS as an outcome measure in trials with these patients.

Patient-reported outcome instruments in clinical trials of systemic sclerosis

Patient-reported outcome instruments provide valuable insight into disease-related morbidity known only to the patient and complement more objective outcome tools in the clinical trial setting. They are of particular importance in systemic sclerosis owing to the challenges around defining disease activity, the episodic nature of many disease-specific manifestations and the paucity of validated objective surrogate outcome measures for use in clinical trials. Early clinical trials of systemic sclerosis often incorporated legacy patient-reported outcome instruments, but the last 20 years has witnessed the emergence of several scleroderma-specific instruments that are now being routinely used alongside other outcomes in systemic sclerosis clinical trials. More recently, the value of patient-reported outcomes has been highlighted by their prominence in the American College of Rheumatology Combined Response Index for Systemic Sclerosis that has been utilized as the primary endpoint of recent clinical trials of early diffuse systemic sclerosis. This review considers the role and performance of the various patient-reported outcome instruments utilized in systemic sclerosis clinical trials, the current positioning of patient-reported outcome instruments within clinical trial endpoint models across the range of systemic sclerosis disease manifestations and, where applicable, we shall highlight areas for future research.

Current and Future Outlook on Disease Modification and Defining Low Disease Activity in Systemic Sclerosis

Systemic sclerosis (SSc) is an autoimmune rheumatic disease with heterogeneous clinical manifestations and a variable course in which the severity of the pathology dictates the disease prognosis and course. Among autoimmune rheumatic diseases, SSc has the highest mortality rate among all rheumatic diseases, though there are exciting new therapeutic targets that appear to halt the progression of SSc manifestations such as skin or lung fibrosis. In selected patients, high-intensity regimens with autologous stem cell transplantation can favorably modify the course. In what was once thought to be an untreatable disease, targeted therapies have now changed the outlook of SSc to a treatable disorder. Herein, we discuss the targeted therapies modifying the outlook on selected organ involvement and creating opportunities for future treatment. We also present a framework for defining low disease activity in SSc.

Skin thickness score as a surrogate marker of organ involvements in systemic sclerosis: a retrospective observational study

Background

Previous studies have shown the relationship between higher skin thickness score and the existence of organ involvements in systemic sclerosis (SSc). Here, we firstly investigated the correlation between skin thickness score and quantitative measurements of each organ involvement in Japanese patients with SSc.

Methods

All Japanese SSc patients hospitalized to our clinic for initial evaluation of SSc were selected. Skin thickness was evaluated by modified Rodnan total skin thickness score (mRSS). Relationship between mRSS and prevalence or incidence of organ involvements was examined by logistic analyses. Correlation between mRSS and quantitative measurements of organ involvements was examined by correlation analyses and regression analyses.

Results

We recruited 198 patients into our study. The mean disease duration was 7.3 years with the mean follow-up duration of 3.2 years. Multivariate logistic regression analyses revealed that higher mRSS is related to higher prevalence of interstitial lung disease (P < 0.05), restrictive impairment (P < 0.01), and diffusion impairment (P < 0.05) of the lung. Correlation analyses revealed mRSS negatively correlates with forced vital capacity (P < 0.001) and diffusing capacity (P < 0.001) of the lung. Correlation between longitudinal change of mRSS and that of forced vital capacity (P < 0.05) or diffusing capacity (P < 0.001) of the lung was also demonstrated.

Conclusions

Skin thickness score significantly correlates with quantitative measurements of lung involvement in Japanese patients with SSc.

Assessment of skin involvement in systemic sclerosis

Skin involvement in SSc is an important marker of disease activity, severity and prognosis, making the assessment of skin a key issue in SSc clinical research. We reviewed the published data assessing skin involvement in clinical trials and summarized the major conclusions important in SSc clinical research. A systematic literature review identified randomized controlled trials using skin outcomes in SSc. Analysis examined the validity of the different skin measures based on literature findings. Twenty-two randomized controlled trials were found. The average study duration was 10.2 (s.d. 4.5) months, mean (s.d.) sample size 32.4 (32.6) and 26.7 (27.8) in intervention and control arms, respectively. The 17-site modified Rodnan skin score is a fully validated primary outcome measure in diffuse cutaneous SSc. Skin histology seems to be an appropriate method for evaluation of skin thickness. These findings have important implications for clinical trial design targeting skin involvement in SSc.

Muscle function in women with systemic sclerosis: Association with fatigue and general physical function

BACKGROUND

Individuals with systemic sclerosis have muscle functions with varying degrees of muscle weakness and atrophy, which in turn can have a negative impact on functional and health-related quality of life. This study aimed to evaluate peripheral muscle performance using isokinetic dynamometry of the knee in women with systemic sclerosis and to correlate peripheral muscle dysfunction with disability levels and general fatigue.

METHODS

Twenty-six women with systemic sclerosis and a matched control group with an equal number of women underwent knee isokinetic dynamometry at angular speeds of 75°/s and 240°/s, isometric handgrip strength, the Health Assessment Questionnaire Disability Index, the Functional Assessment of Chronic Illness Therapy-Fatigue scale, and the Fatigue Impact Scale.

FINDINGS

Women with systemic sclerosis showed significant reductions in almost all isokinetic parameters for the two angular velocities tested compared with the controls. An agonist/antagonist ratio with values <40% was observed in approximately one-third of the patients. These patients had lower isometric handgrip strength. These patients also performed worse on the two general fatigue scales evaluated. Significant correlations were observed between the isokinetic parameters and the measured isometric handgrip strength, and the Health Assessment Questionnaire Disability Index.

INTERPRETATION

Systemic sclerosis patients have reduced strength and endurance as well as a muscle imbalance between the quadriceps and hamstrings. In these patients, lower muscle dysfunction of the knee joint is associated with lower handgrip strength and physical incapacity.

Rituximab in early systemic sclerosis

OBJECTIVES

(1) Hypothesis testing of the potency of rituximab (RTX) in preventing fibrotic complications and (2) assessing acceptability and feasibility of RTX in early systemic sclerosis (SSc).

METHODS

A small, 24-month, randomised, double-blind, placebo-controlled, single-centre trial in patients with SSc diagnosed <2 years was conducted. Patients received RTX or placebo infusions at t=0, t=15 days and t=6 months. Patients were clinically evaluated every 3 months, with lung function tests and high-resolution CT every other visit. Skin biopsies were taken at baseline and month 3. Immunophenotyping of peripheral blood mononuclear cells was performed at every visit, except at months 9 and 18. Adverse events, course of skin and pulmonary involvement and B cell populations in skin and peripheral blood were evaluated.

RESULTS

In total 16, patients (rituximab n=8, placebo n=8) were included. Twelve patients had diffuse cutaneous SSc. Eighty-eight adverse events (RTX n=53, placebo n=35, p=0.22) and 11 serious adverse events (RTX n=7, placebo n=4, p=0.36) occurred. No unexpected RTX-related events were observed. Mean skin score over time did not differ between the groups. Over time, forced vital capacity and extent of lung involvement slightly improved with RTX, but this difference was insignificant. In peripheral blood B cells depletion was demonstrated.

CONCLUSIONS

No unexpected safety issues were observed with RTX in early SSc. Although this small trial could not confirm or reject potential efficacy of RTX in these patients, future placebo-controlled trials are warranted, specifically in the subgroup of patients with pulmonary involvement.

TRIAL REGISTRATION NUMBER

EudraCT 2008-07180-16; Results.

Standardization of the modified Rodnan skin score for use in clinical trials of systemic sclerosis

The modified Rodnan skin score (mRSS) is a measure of skin thickness and is used as a primary or secondary outcome measure in clinical trials of systemic sclerosis (scleroderma). This state-of-art review provides a historical perspective of the development of the mRSS, summarizes the performance of mRSS as an outcome measure, provides guidance on assessing mRSS, and makes recommendations for incorporation of the mRSS into clinical trials.

Musculoskeletal Involvement in Systemic Sclerosis: An Unexplored Aspect of the Disease

Musculoskeletal (MSK) symptoms in patients with systemic sclerosis (SSc) include articular involvement (arthralgia, synovitis, contractures), which is often an early phenomenon and significantly contributes to the disability. Predominantly the hands are affected. Consensus in outcome measures of articular involvement is missing. Health Assessment Questionnaire Disability Index (HAQ-DI), Cochin Hand Function Scale (CHFS), Hand Mobility Index in Scleroderma (HAMIS), and Disease Activity Score of 28 Joints (DAS28) may be used for the assessment of different aspects of joint involvement. There is an unmet need for therapies confirmed by randomized controlled clinical trials (RCTs) to treat both synovitis and non-inflammatory joint involvement. The few rehabilitation studies that have been conducted have shown some promising efficacy.

Muscle involvement may be an early symptom. The presence of clinically meaningful muscle involvement often heralds an unfavourable prognosis. The histology of muscle biopsy shows a variable picture including inflammation and necrosis. Besides, signs of acute neurogenic atrophy have been recently described as a previously underestimated contributor to muscle weakness. Similar to articular involvement, the lack of classification criteria on inflammatory and non-inflammatory SSc-associated myopathies, and the lack of validated core set of outcome measures makes it difficult to perform RCTs.

The SSc-specific fibrinous tenosynovitis (tendon-friction rubs /TFRs/) is a frequent finding in SSc. Patients with TFR are at increased risk of developing renal, vascular, cardiac and gastrointestinal involvement and have reduced survival rates. Changes of fibrinous tenosynovitis can be objectively detected by ultrasound and may be used as an outcome measure in the treatment of MSK involvement.

Independent Association of Severity of Muscle Weakness With Disability as Measured by the Health Assessment Questionnaire Disability Index in Scleroderma

OBJECTIVE

To determine whether the presence and degree of muscle weakness in scleroderma is associated with disability.

METHODS

The study included a cohort of 1,718 scleroderma patients who had available data on muscle strength and disability. The primary independent variable was muscle weakness as defined by the maximum Medsger muscle severity score and the outcome was disability as measured by the last recorded Health Assessment Questionnaire disability index (HAQ DI) score. Univariate regression analyses were performed to assess the association of HAQ DI scores with the Medsger muscle severity score and other scleroderma characteristics. A multivariate regression analysis was performed to determine whether an association existed between the degree of muscle weakness and disability, while controlling for confounders.

RESULTS

In 1,718 patients with scleroderma, 22.8% (392 of 1,718) had muscle weakness, as defined by a Medsger muscle severity score of ≥1. This subset was more likely than those without weakness to have diffuse cutaneous scleroderma (55.6% versus 35.1%; P < 0.0001), higher modified Rodnan skin thickness scores (mean ± SD 16.3 ± 13.7 versus 10.3 ± 10.6; P < 0.00001), shorter disease duration (mean ± SD 5.21 ± 6.75 versus 6.22 ± 7.67 years; P = 0.02), synovitis (17.7% versus 11.4%; P = 0.001), forced vital capacity <70% (46.2% versus 30.6%; P = 0.0001), and higher creatine kinase values (mean ± SD 441 ± 1,211 versus 151 ± 255; P = 0.00001). Both univariate and multivariate analyses revealed that for every unit of increase in the Medsger muscle severity score, there was a clinically significant (minimum clinically important difference ± 0.14) increase in the mean HAQ DI score at last followup visit.

CONCLUSION

The presence of muscle weakness associates with several features of worse disease burden and independently associates with disability as measured by the HAQ DI.

Calcinosis is associated with digital ischaemia in systemic sclerosis-a longitudinal study

OBJECTIVE

To determine if ischaemia is a causal factor in the development of calcinosis in SSc.

METHODS

Patients with SSc were assessed yearly. Physicians reported the presence of calcinosis, digital ischaemia (digital ulcers, digital necrosis/gangrene, loss of digital pulp on any digits and/or auto- or surgical digital amputation) and nailfold capillary dropout assessed using a dermatoscope. The number of digits with digital ischaemia was used as an assessment of the severity of digital ischaemia. SSc specific antibodies were detected with a line immunoassay. Multiple logistic regression and Cox proportional hazards models were generated to determine associations between calcinosis, digital ischaemia and capillary dropout.

RESULTS

One thousand three hundred and five patients were included in this study, of whom 300 (23.0%) had calcinosis at study entry. In a cross-sectional multivariate analysis, at baseline, calcinosis was associated with digital ischaemia (odds ratio (OR) = 2.37, 95% CI: 1.66, 3.39), severity of ischaemia (OR = 1.12, 95% CI: 1.06, 1.18), capillary dropout (OR = 1.41, 95% CI: 1.05, 1.89), ACAs (OR = 1.68, 95% CI: 1.17, 2.43) and anti-RNA polymerase III antibodies (OR = 1.77, 95% CI: 1.08, 2.89). Current use of calcium channel blockers was inversely associated with the presence of calcinosis (OR = 0.70, 95% CI: 0.52, 0.96). Of the 805 patients with no calcinosis at study entry and at least one follow-up visit, 215 (26.7%) developed calcinosis during follow-up. Significant baseline predictors of the development of calcinosis in follow-up were digital ischaemia (hazard ratio (HR) = 1.82, 95% CI: 1.30, 2.54), capillary dropout (HR = 1.46, 95% CI: 1.08, 1.99), dcSSc (HR = 1.57, 95% CI: 1.11, 2.21), ACA (HR = 2.18, 95% CI: 1.50, 3.17) and anti-RNA polymerase III antibodies (HR = 2.58, 95% CI: 1.65, 4.04).

CONCLUSION

Ischaemia may play a role in the development of calcinosis in SSc.

Management of Widespread Skin Thickening in Diffuse Systemic Sclerosis

Skin thickening is one of the early organ manifestations of systemic sclerosis (SSc) and has a great impact on quality of life (QOL) as well as overall daily living in patients with SSc. The dynamic changes that occur as the disease progresses and as other organs become further involved present the treating physician with therapeutic challenges. Hence, when considering drug therapy for skin disease, the treating physician should consider a number of factors including disease duration, the rate of skin thickening, the extent of disease progression, organ involvements, and patient-related outcome measures, all of which impact the type of treatments considered. For early diffuse skin disease, we prefer the use of methotrexate (MTX). And when there is evidence of lung involvement or tendon friction rubs (given its association with ILD development), we tend to shift to the use of mycophenolate or cyclophosphamide because these agents have been shown efficacious for the specific indication of lung disease in SSc. We have managed joint disease, on the other hand when present, with MTX or other DMARDs, as well as the use of biologics when there is evidence of inflammatory polyarthritis or rheumatoid arthritis overlap. While the treatment of myositis in the setting of SSc can present a therapeutic dilemma, reluctantly, we may use steroids along with MTX, mycophenolate, intravenous immunoglobulin (IV-Ig), or rituximab. Ongoing clinical trials investigating the use of tocilizumab, abatacept, and other agents offer promising potential therapies. Great strides have been made in treating skin disease in SSc. And with recent trials focusing on early SSc disease, this will allow for a greater insight into the mechanisms underlying SSc especially as it relates to skin, and the expansion of future treatment options in this field.

Outcome of a glucocorticoid discontinuation regimen in patients with inactive systemic sclerosis

Glucocorticoids (GC) are widely used to treat systemic sclerosis (SSc). The lack of efficacy data and patient/physician concerns may prompt therapy discontinuation. The aim of this study is to identify factors hampering GC discontinuation in patients with stable disease on oral GC for longer than 12 months. Consecutive patients fulfilling the 2013 ACR/EULAR criteria for SSc and with stable disease were prescribed a slow tapering GC regimen to achieve discontinuation. At study entry and 6 months later (T6), patients were assessed for disease activity and severity. Moreover, the Short-Form-36; the Health Assessment Questionnaire Disability Index (HAQ-DI); and visual analog scales for fatigue, pain, and general health were completed. Reasons for stopping the discontinuation regimen were recorded. Forty-eight patients (46 females, 9 diffuse SSc), with a mean ± SD age of 56±14 years and a median disease duration of 10 years (range 2-22), were enrolled. The median daily GC dose was 5 mg (range 5-10; all patients treated with prednisone). At T6, 33 (68.7 %) patients had discontinued GC. The remaining 15 patients could not discontinue GC because of arthralgia in eight, arthritis in two, puffy fingers in two, increased creatine-kinase in two, and bursitis in one patient. At multiple logistic analysis, a higher baseline HAQ-DI was the only independent factor associated with GC need (OR 2.98, 95 % CI 1.20-7.41; p = 0.01). About one third of SSc patients did not achieve a GC-free regimen. Disability as assessed by HAQ-DI was the leading factor hindering GC discontinuation. A low HAQ-DI score can identify candidates for GC discontinuation.

Validity and responsiveness of the Michigan Hand Questionnaire in patients with systemic sclerosis

OBJECTIVE

The aim was to assess the validity and responsiveness of the Michigan Hand Questionnaire (MHQ) in patients with SSc.

METHODS

Data were gathered in connection with a randomized, controlled trial comparing the effectiveness of a 12-week multidisciplinary team care programme, including a hand function treatment module, with regular care. Hand function was evaluated by the MHQ (37 items, six domains: Function, Daily activities, Pain, Work, Aesthetics and Satisfaction) and other measurements, including the HAQ, Hand Mobility in Scleroderma, Sequential Occupational Dexterity Assessment (SODA), grip strength, pinch grip and modified Rodnan Skin Score. Fifty-three patients (28 intervention group and 25 control group) completed evaluation at baseline and after 12 weeks. Validity was determined by computing Spearman correlation coefficients between the baseline MHQ total score and subscales and other measures of (hand) disability. Responsiveness in the intervention group was evaluated by the standardized response mean and effect size (ES). In addition, the pooled ES for the difference between the two groups was computed.

RESULTS

Significant correlations were seen between the MHQ total score and the HAQ (r = -0.62), Hand Mobility in Scleroderma (r = -0.54), SODA (r = 0.47), SODA Pain (r = 0.32) and modified Rodnan Skin Score (r = 0.46). The ES of the MHQ total score within the intervention group was 0.49, which was larger than that of all other outcome measures. Similar results were obtained for the standardized response mean. The pooled ES of the difference between intervention and control groups for the MHQ total score was 0.86.

CONCLUSION

The MHQ demonstrated adequate validity and responsiveness in patients with SSc.

Therapeutic and diagnostic outcomes of a standardised, comprehensive care pathway for patients with systemic sclerosis

Objectives

To determine the outcomes, including number of medical interventions and initiation of immunosuppressive treatment of a standardised, comprehensive, diagnostic care pathway for patients with systemic sclerosis (SSc). Patient characteristics associated with need for medical interventions and with need for immunosuppressive treatment were determined.

Methods

Data were routinely gathered in connection with a 2-day care pathway combining multidisciplinary care and complete diagnostic work-up of organ involvement in SSc. The number of patients in whom the pathway resulted in medical interventions, and/or initiation of immunosuppressives was recorded. Patient characteristics and diagnostic tests results were compared between patients with and without medical interventions, and patients with and without initiation of immunosuppressives by means of multivariable logistic regression analyses.

Results

During a period of 44 months, 226 patients with SSc were referred to the care pathway. They included 186 (82%) women with mean age of 54 (SD 14.5) years, and median disease duration of 4 years (range 1–11); 73 (32%) of them had diffuse cutaneous SSc. Medical interventions were initiated in 191 (85%) patients, including initiation of immunosuppressive treatment in n=49 (22%). Presence of telangiectasias and higher erythrocyte sedimentation rate were associated with any medical intervention. Of commonly available variables, lower age, higher skin score and absence of anticentromere antibody were associated with initiation of immunosuppressives.

Conclusions

A standardised comprehensive 2-day care pathway for patients with SSc resulted in additional diagnostic or therapeutic interventions in 85% of the patients, regardless of SSc subtype and disease duration. In 22% of the patients, immunosuppressive treatment was initiated.

Computer-Aided Tomographic Analysis of Interstitial Lung Disease (ILD) in Patients with Systemic Sclerosis (SSc). Correlation with Pulmonary Physiologic Tests and Patient-Centred Measures of Perceived Dyspnea and Functional Disability

Objectives

This study was designed (a) to evaluate an improved quantitative lung fibrosis score based on a computer-aided diagnosis (CaM) system in patients with systemic sclerosis (SSc),—related interstitial lung disease (SSc-ILD), (b) to investigate the relationship between physiologic parameters (forced vital capacity [FVC] and single-breath diffusing capacity for carbon monoxide [DLCO]), patient-centred measures of dyspnea and functional disability and CaM and visual reader-based (CoVR) methods, and (c) to identify potential surrogate measures from quantitative and visual HRCT measurement.

Methods

126 patients with SSc underwent chest radiography, HRCT and PFTs. The following patient-centred measures were obtained: modified Borg Dyspnea Index (Borg score), VAS for breathing, and Health Assessment Questionnaire-Disability Index (HAQ-DI). HRCT abnormalities were scored according to the conventional visual reader-based score (CoVR) and by a CaM. The relationships among the HRCT scores, physiologic parameters (FVC and DLCO, % predicted) results and patient-centred measures, were calculated using linear regression analysis and Pearson’s correlation. Multivariate regression models were performed to identify the predictor variables on severity of pulmonary fibrosis.

Results

Subjects with limited cutaneous SSc had lower HAQ-DI scores than subjects with diffuse cutaneous SSc (p <0.001). CaM and CoVR scores were similar in the 2 groups. In univariate analysis, a strong correlation between CaM and CoVR was observed (p <0.0001). In multivariate analysis the CaM and CoVR scores were predicted by DLco, FVC, Borg score and HAQ-DI. Age, sex, disease duration, anti-topoisomerase antibodies and mRSS were not significantly associated with severity of pulmonary fibrosis on CaM- and CoVR methods.

Conclusions

Although a close correlation between CaM score results and CoVR total score was found, CaM analysis showed a more significant correlation with DLco (more so than the FVC), patient-centred measures of perceived dyspnea and functional disability. Computer-aided tomographic analysis is computationally efficient, and in combination with physiologic and patient-centred measures, it could allow a means for accurately assessing and monitoring the disease progression or response to therapy.

Correlates and responsiveness to change of measures of skin and musculoskeletal disease in early diffuse systemic sclerosis

OBJECTIVE

Skin and musculoskeletal involvement are frequently present early in diffuse cutaneous systemic sclerosis (dcSSc). The current study examined the correlates for skin and musculoskeletal measures in a 1-year longitudinal observational study.

METHODS

Patients with dcSSc were recruited at 4 US centers and enrolled in a 1-year study. Prespecified and standardized measures included physician and patient assessments of skin involvement, modified Rodnan skin score (MRSS), durometer score, Health Assessment Questionnaire disability index, serum creatine phosphokinase, tender joint counts, and presence/absence of tendon friction rubs, small joint contractures, and large joint contractures. Additionally, physician and patient global health assessments and health-related quality of life assessments were recorded. Correlations were computed among the baseline global assessments, skin variables, and musculoskeletal variables. Using the followup physician and patient anchors, effect sizes were calculated.

RESULTS

A total of 200 patients were studied: 75% were women, mean ± SD age was 50.0 ± 11.9 years, and mean ± SD disease duration from first non-Raynaud's phenomenon symptom was 1.6 ± 1.4 years. Physician global health assessment had large correlations with MRSS (r = 0.60) and physician-reported skin involvement visual analog scale in the last month (r = 0.74), whereas patient global assessment had large correlations with MRSS, the Short Form 36 health survey physical component scale, skin interference, and skin involvement in the last month (r = 0.37-0.72). Four of 9 skin variables had moderate to large effect sizes (0.51-1.09).

CONCLUSION

Physician and patient global assessments have larger correlations with skin measures compared to musculoskeletal measures. From a clinical trial perspective, skin variables were more responsive to change than musculoskeletal variables over a 1-year period, although both provide complementary information.

Musculoskeletal involvement in systemic sclerosis

Musculoskeletal (MSK) involvement is a very frequent manifestation of patients with systemic sclerosis (SSc). There are several reports about clinical trials assessing musculoskeletal involvement in SSc. However, only few controlled studies have been conducted. The prevalence of musculoskeletal symptoms, clinical and radiographic findings has been assessed. The most important articular (arthralgia, synovitis, contractures), tendon (tendon friction rubs, tenosynovitis) and muscular manifestations (myalgia, muscle weakness, myositis) should be carefully evaluated during the assessment of SSc patients, because these are not only common, but substantially influence the quality of life and some of them also have predictive value concerning disease activity and severity.

Patterns and predictors of change in outcome measures in clinical trials in scleroderma: an individual patient meta-analysis of 629 subjects with diffuse cutaneous systemic sclerosis

OBJECTIVE

To examine the range and responsiveness to change of clinical outcome measures and study predictors of clinical response in patients with diffuse cutaneous systemic sclerosis (dcSSc) in the context of clinical trials.

METHODS

Data were combined from 629 patients with dcSSc who participated in 7 multicenter clinical therapeutic trials. Trials used common outcome measures: modified Rodnan skin thickness score (MRSS), Health Assessment Questionnaire disability index (HAQ DI), patient's global assessment of disease activity, pulmonary function tests (forced vital capacity, diffusing capacity for carbon monoxide), hand span, and oral aperture.

RESULTS

The combined database included 629 patients (82% women, mean ± SD age 46.5 ± 11.8 years, mean ± SD disease duration 19.4 ± 15.9 months). Outcomes tended to improve during trials for patients with more severe disease at study entry and to worsen for patients with less severe disease at entry. Disease duration was mildly negatively predictive of change in MRSS at 6 months (r = -0.27, P < 0.001), and substantial bidirectional variation in change in MRSS and HAQ DI score was seen across the spectrum of disease duration. Sixty-three percent of patients with "early" disease (disease duration <18 months) had a decline in MRSS, and 37% had an increase in MRSS. Eighty-one percent of patients with "late" disease (disease duration ≥ 18 months) had a decline in MRSS, and 19% had an increase in MRSS. Multivariate mixed models did not demonstrate that any baseline variables were strongly predictive of subsequent outcome.

CONCLUSION

Among patients with dcSSc enrolled in clinical trials, standard outcome measures tend to improve in those with more severe disease at study entry and to worsen in those with less severe disease at entry. Overall, the MRSS improves during trials, while HAQ DI scores and lung function are mostly static. None of these variables, including disease duration, reliably identifies groups of subjects whose MRSS will predictably increase or decrease in the course of a clinical trial. These findings have important implications for clinical trial design in scleroderma.

Predictors of health-related quality of life and fatigue in systemic sclerosis: evaluation of the EuroQol-5D and FACIT-F assessment tools

This study evaluates predictors of health-related quality of life (HRQoL) and fatigue in systemic sclerosis (SSc) using two novel self-report indices. A cross-sectional study of patients with SSc was undertaken using a postal questionnaire including the EuroQol-5Domain health questionnaire (EQ-5D™), Functional Assessment of Chronic Illness Therapy-Fatigue scale (FACIT-F) and the Scleroderma Health Assessment Questionnaire (SHAQ). The EQ-5D assesses five domains of health quality and is quantified as a time trade-off (TTO) value and patient global assessment (0-100 visual analogue scale [VAS]). The FACIT-F is a 13-item questionnaire (0-52 scale). Higher scores for both the EQ-5D and FACIT-F indicate better health. Case notes were scrutinised for patient demographics, disease duration, serology and clinical phenotype. Sixty-eight patients (60 females, mean age 62.6 years) completed the questionnaires. Fatigue correlated closely with HRQoL (r (s) = 0.78 and 0.77 for FACIT-F vs. EQ-5D VAS and TTO respectively, p < 0.01) and disability (r (s) = -0.74 for FACIT-F vs. HAQ-DI, p < 0.01). Pain was the most frequently reported health problem (80 %) in the EQ-5D. HRQoL also correlated closely with disability (r (s) = 0.83 for EQ-5D vs. HAQ-DI, p < 0.01). SHAQ-VAS scores correlated well with the FACIT-F, EQ-5D and HAQ-DI scores (p < 0.05 for all comparisons). Of the patient demographics and clinical disease associations, only the absence of upper gastrointestinal complications was associated with better levels of fatigue, HRQoL and function. There is a strong correlation between disability, fatigue and HRQoL measured using self-reports, possibly reflecting similarly perceived health beliefs amongst patients across outcomes. There was little association between self-report indices and patient demographics and/or clinical phenotype.

Analysis of the Validation Status of Quality of Life and Functional Disability Measures in Pulmonary Arterial Hypertension Related to Systemic Sclerosis: Results of a Systematic Literature Analysis by the Expert Panel on Outcomes Measures in Pulmonary Arterial Hypertension Related to Systemic Sclerosis (EPOSS)

Objective.

We aimed to assess the current validity status of the Health Assessment Questionnaire–Disability Index (HAQ-DI) and the 36-item Medical Outcomes Study Short Form Health Survey (SF-36).

Methods.

Studies using HAQ-DI and/or SF-36 in patients with pulmonary arterial hypertension (PAH) associated with systemic sclerosis (PAH-SSc) were identified through a systematic literature review and assessed according to the Outcome Measures in Rheumatology Clinical Trials (OMERACT) consensus group criteria.

Results.

Both HAQ-DI and SF-36 were considered credible (having face validity) and feasible. Based on expert opinion, neither HAQ-DI nor SF-36 was specific for PAH-SSc since their results may be influenced by other aspects of SSc (judged “unclear” with respect to the content validity criterion). In the overall SSc population, there was significant albeit weak correlation between physical component SF-36 scores and pulmonary artery systolic pressure (PASP) by echocardiography (Kendall tau b = −0.2, p < 0.01). Although HAQ-DI also correlated with PASP by echocardiography, there were no significant correlations in SSc patients with PAH proven by right heart catheterization between changes in HAQ-DI over time and changes in other PAH measures including 6-min walk distance (r = −0.04, p = 0.86), expert global assessment (r = 0.06, p = 0.97), and New York Heart Association functional class (r = 0.38, p = 0.39), indicating lack of construct validity for HAQ-DI in PAH-SSc. No studies enabling assessment of criterion validity or discrimination of HAQ-DI or SF-36 in PAH-SSc could be identified.

Conclusion.

Further validation of HAQ and SF-36 in PAH-SSc is needed. Alternatively, more specific assessments for functional disability or quality of life in PAH-SSc might be required.

Needs and preferences regarding health care delivery as perceived by patients with systemic sclerosis

This study aims to examine the needs and preferences regarding the delivery of health care services and information provision and their determinants in patients with systemic sclerosis (SSc). A questionnaire was sent to 77 SSc outpatients, comprising 27 items on health care needs within the domains physical, psychological, social support, employment/daily activities, or other health problems and 13 items on information needs. Moreover, the patients’ preferences regarding the provision of health care services and information were listed. Additional assessments included sociodemographic characteristics, physical functioning (SSc Health Assessment Questionnaire), and quality of life (SF-36). Sixty-four patients (83%) returned the questionnaire. Twenty-six patients (41%) reported one or more unmet health care needs, with the highest proportions of patients with unmet needs seen in the physical (28%) and psychological (20%) domain. The highest percentages of patients with information needs were observed for medical subjects (20–28%). A lower mental component summary scale score and younger age were associated with the presence of at least one health care need in the psychological domain. Worse physical functioning, a diagnosis of diffuse SSc and having a partner were associated with higher information need score. A yearly, standardized multidisciplinary assessment program was most frequently mentioned as a preferred, but not yet existing health care model (59%) and the rheumatologist as a preferred source of information supply (75%). Unmet health care and information needs are common among SSc patients. To improve SSc health care, more attention should be paid to health care services for specific physical and psychological problems and medical information supply by the rheumatologist. In addition, the development of new models of care, such as a yearly, standardized multidisciplinary diagnostic program seems warranted.

Impaired exercise performance in systemic sclerosis and its clinical correlations

OBJECTIVES

To investigate the prevalence of impaired exercise performance as assessed by a standardized cardiopulmonary exercise test (CPET) in systemic sclerosis (SSc) and to identify the associated disease features.

METHODS

Forty-six SSc patients were enrolled and evaluated for clinical and serological SSc subset, extent of skin and internal organ involvement, and disease activity and severity. Exercise performance was subsequently evaluated in these patients and in 23 healthy individuals matched for sex and age, using a standardized CPET.

RESULTS

Exercise performance, measured by maximum oxygen uptake (VO2 max < 80% of predicted value), was found to be impaired in 43/46 patients. Stepwise regression analysis showed that VO2 max adjusted for body weight VO2 max/kg) was independently correlated with the severity of heart (p = 0.001) and lung (p = 0.013) involvement, left ventricular diastolic dysfunction (p = 0.009), and the Health Assessment Questionnaire Disability Index (HAQ-DI) score (p = 0.016).

CONCLUSIONS

This study demonstrates that physical disability contributes significantly to the development of impaired exercise performance in SSc patients. Cardiopulmonary exercise testing may be included among the battery of tests used to determine the severity of SSc.

Tendon friction rubs in early diffuse systemic sclerosis: prevalence, characteristics and longitudinal changes in a randomized controlled trial

OBJECTIVES

To characterize the baseline tendon friction rubs (TFRs) in early dcSSc and to evaluate the association of change in TFR over 6 and 12 months with changes in modified Rodnan skin score (MRSS) and HAQ-Disability Index (HAQ-DI) over 12 and 24 months, respectively.

METHODS

We analysed data from the d-Pen study, a 2-year study in early dcSSc (< or =18 months from first non-Raynaud's symptom). TFR was scored as present/absent at seven anatomical sites at baseline and every 6 months thereafter. Multivariable linear regression models assessed associations between TFR and change in MRSS, and change in the HAQ-DI, over 12 and 24 months, respectively. Covariates included baseline TFR, change in the TFR over 6 and 12 months, age, sex, duration of SSc, MRSS, and tender joint count and swollen joint count (SJC).

RESULTS

Forty-nine (37%) of 134 patients had TFR at baseline, 50% had resolution of their TFR, whereas 21% developed new TFRs. Patients with baseline TFRs were likely to be Caucasian (86 vs 58%) and had a higher HAQ-DI score (P = 0.008). In regression analyses, change in TFR (P = 0.04) and baseline MRSS (P = 0.03) predicted change in MRSS over a 12-month period (Model R(2 )= 0.14). For the HAQ-DI model, independent predictors were change in TFR at 6 months (P = 0.008) and baseline SJC (P = 0.04, Model R(2 )= 0.19). Results were similar for 24-month models.

CONCLUSIONS

We document the presence of TFR very early in the course of dcSSc. Changes in TFR over 6 and 12 months predict changes in MRSS and HAQ-DI over 12 and 24 months, respectively.

Sensitivity to change in systemic sclerosis of the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR): shift in patient priorities over time

OBJECTIVE

To assess the sensitivity to change of the McMaster-Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR) in systemic sclerosis (SSc) and a shift in patient priorities over time.

METHODS

We assessed 49 patients with SSc (8 men) using the MACTAR in a prospective longitudinal study twice or more during annual meetings of the French patient association from 2004 to 2007. Patient-perceived improvement or worsening regarding health status was recorded. Sensitivity to change was assessed by the effect size (ES) and the standardized response mean (SRM) of the MACTAR.

RESULTS

The MACTAR global score was significantly increased at followup in the whole group of patients, and the ES and SRM values were -0.37 and -0.34, respectively. These values were similar to those observed for widely used outcome measures for SSc such as the Health Assessment Questionnaire. As defined by the International Classification of Functioning, Disability and Health, the 3 disability domains most often cited at baseline were mobility (7 activities, cited 17 times; 33.3% of patients), domestic life (4 activities, cited 17 times; 33.3% of patients), and community, social and civic life (3 activities, cited 10 times; 19.6% of patients). At followup, 40 patients had changed their first priority and 34 changed 3 priorities.

CONCLUSION

The evolution in MACTAR global score over time for patients with SSc reflects longterm general feelings of deterioration. However, shifts in patient priorities are common and may influence the sensitivity to change of the instrument.

Perceived functioning has ethnic-specific associations in systemic sclerosis: another dimension of personalized medicine

OBJECTIVE

To measure self-reported physical and mental functioning and associated clinical features at study entry in 3 ethnic groups with systemic sclerosis (SSc).

METHODS

Sixty Hispanic, 39 African American, and 104 Caucasian patients with recent-onset SSc (< 5 yrs) were assessed for perceived physical and mental functioning, using the Medical Outcomes Study Short Form-36 (SF-36) and Scleroderma-Health Assessment Questionnaire (Scleroderma-HAQ). Socioeconomic, demographic, clinical, immunologic, immunogenetic, behavioral, and psychological variables (Interpersonal Support Evaluation List, ISEL; Illness Behavior Questionnaire, IBQ; and Arthritis Helplessness Index, AHI) were analyzed by linear regression models for associations with SF-36 and mHAQ scores as dependent variables.

RESULTS

Perceived physical functioning scores had ethnic-specific associations with AHI > fatigue scores > IBQ > clinical variables (hypertension, skin score, and percentage predicted DLCO). Scleroderma-HAQ scores had ethnic-specific associations with IBQ > AHI scores > most clinical and laboratory variables. Decreased mental component summary (MCS) scores associated with AHI > ISEL. Ethnic-specific immunogenetic variables HLA-DQB1*0202 (Caucasian) and HLA-DRB 1*11 (African American), and HLA-DQA1*0501 (Hispanic) also associated with MCS. Antinuclear autoantibodies, anti-topoisomerase I, and RNA polymerases I and III also demonstrated associations with functioning in African American and Hispanic groups.

CONCLUSION

Clinical, psychosocial, and immunogenetic variables had ethnic-specific associations with perceived physical and mental functioning. Consideration of ethnic-specific psychological and behavioral support in designing more personalized, relevant therapeutic interventions for the patient may improve therapeutic efficacy in SSc.

Long-term effects of bosentan on quality of life, survival, safety and tolerability in pulmonary arterial hypertension related to connective tissue diseases

OBJECTIVES

This study investigated the long-term effects of bosentan, an oral endothelin ET(A)/ET(B) receptor antagonist, in patients with pulmonary arterial hypertension (PAH) exclusively related to connective tissue diseases (CTD).

METHODS

A total of 53 patients with PAH related to connective tissue diseases (PAH-CTD) in World Health Organization (WHO) functional class III received bosentan 62.5 mg twice a day for 4 weeks and then 125 mg twice a day for 44 weeks in this open non-comparative study. Assessments at weeks 16 and 48 included WHO class, clinical worsening, quality of life (Short-Form Health Survey (SF-36) and health assessment questionnaire (HAQ) modified for scleroderma), and survival (week 48 only). Safety and tolerability were monitored throughout the study.

RESULTS

At week 48, WHO class improved in 27% of patients (95% CI 16-42%) and worsened in 16% (95% CI 7-29%). Kaplan-Meier estimates were 68% (95% CI 55-82%) for absence of clinical worsening and 92% (95% CI 85-100%) for survival. Overall changes in quality of life were minimal. There were no unexpected side effects observed during the study.

CONCLUSIONS

In most patients, bosentan was associated with improvement or stability of clinical status. The 92% estimate for survival at 48 weeks is a significant achievement in this patient population.

Effects of 1-year treatment with cyclophosphamide on outcomes at 2 years in scleroderma lung disease

RATIONALE

The Scleroderma Lung Study enrolled 158 patients with scleroderma-related interstitial lung disease in a placebo-controlled trial of oral cyclophosphamide (CYC). Although treatment-related benefits in pulmonary function, skin scores, and patient-centered outcomes were demonstrated after 1 year of therapy, the duration of benefit beyond 1 year was unclear.

OBJECTIVES

A second year of follow-up was performed to determine if these effects persisted after stopping treatment.

METHODS

A detailed analysis of data obtained over the two years of the study was performed.

MEASUREMENTS AND MAIN RESULTS

Using a longitudinal joint model, we analyzed FVC, total lung capacity, transitional dyspnea index, Rodnan skin scores, and the Health Assessment Questionnaire-Disability Index during the second year, after adjusting for baseline values, baseline fibrosis score, and nonignorable missing data. Evaluable subjects (72 CYC; 73 placebo) included 93 who completed all visits plus 52 who completed at least 6 months of therapy and returned at 24 month or had their 24-month data imputed. The beneficial effects of CYC on pulmonary function and health status continued to increase through 18 months, after which they dissipated, whereas skin improvements dissipated after 12 months. In contrast, the positive effect on dyspnea persisted through 24 months. Adverse events were uncommon.

CONCLUSIONS

One year of CYC improved lung function, skin scores, dyspnea, and health status/disability, effects which either persisted or increased further for several months after stopping therapy. However, except for a sustained impact on dyspnea, all of these effects waned and were no longer apparent at 24 months. Treatment strategies aimed at extending the positive therapeutic effects observed with CYC should be considered. Clinical trial registered with www.clinicaltrials.gov (NCT 000004563).

High-dose immunosuppressive therapy and autologous hematopoietic cell transplantation for severe systemic sclerosis: long-term follow-up of the US multicenter pilot study

More effective therapeutic strategies are required for patients with poor-prognosis systemic sclerosis (SSc). A phase 2 single-arm study of high-dose immunosuppressive therapy (HDIT) and autologous CD34-selected hematopoietic cell transplantation (HCT) was conducted in 34 patients with diffuse cutaneous SSc. HDIT included total body irradiation (800 cGy) with lung shielding, cyclophosphamide (120 mg/kg), and equine antithymocyte globulin (90 mg/kg). Neutrophil and platelet counts were recovered by 9 (range, 7 to 13) and 11 (range, 7 to 25) days after HCT, respectively. Seventeen of 27 (63%) evaluable patients who survived at least 1 year after HDIT had sustained responses at a median follow-up of 4 (range, 1 to 8) years. There was a major improvement in skin (modified Rodnan skin score, -22.08; P < .001) and overall function (modified Health Assessment Questionnaire Disability Index, -1.03; P < .001) at final evaluation. Importantly, for the first time, biopsies confirmed a statistically significant decrease of dermal fibrosis compared with baseline (P < .001). Lung, heart, and kidney function, in general, remained clinically stable. There were 12 deaths during the study (transplantation-related, 8; SSc-related, 4). The estimated progression-free survival was 64% at 5 years. Sustained responses including a decrease in dermal fibrosis were observed exceeding those previously reported with other therapies. HDIT and autologous HCT for SSc should be evaluated in a randomized clinical trial.

Reliability, validity, and minimally important differences of the SF-6D in systemic sclerosis

OBJECTIVES

To evaluate the reliability and validity and estimate the minimally important difference (MID) for the SF-6D in patients with systemic sclerosis (SSc). Subjects We used data from two clinical studies to analyze the SF-6D in patients with SSc: Study 1 was a cross-sectional observational study (N = 107) designed to assess three direct preference measures--the rating scale, time trade-off, and standard gamble (SG) in patients with diffuse SSc and limited SSc, and Study 2 was a 12-month randomized, placebo-controlled, clinical trial (N = 168) assessing oral bovine collagen versus placebo in diffuse SSc.

METHODS

We assessed the test-retest reliability of the SF-6D in Study 2 over a mean (SD) 4.8 (3.0)-week interval and the agreement between the SF-6D and direct preference measures in Study 1 using intraclass correlations (ICC). The MID was estimated using three different anchors--the SF-36 change in health item (patients who answered "somewhat better" formed the MID group), the Health Assessment Questionnaire-Disability Index (HAQ-DI; change of > or =0.14 and > or =0.22) and the skin score (change of > or =5.3). Results The mean (SD) SF-6D scores were 0.61 (0.12) in Study 1 and 0.64 (0.13) in Study 2. Test-retest reliability for the SF-6D was high (ICC = 0.82 [95% CI: 0.76, 0.87]). Agreement between the SF-6D and three direct preferences measures was poor to moderate (0.16-0.52). The MID estimate for the SF-6D using the change in SF-36 item -0.012 and this level of change was similar to the no change group. The mean MID estimate for the SF-6D improvement using the HAQ-DI and skin score as anchors was 0.035 (effect size of 0.27).

CONCLUSION

This is the first study to assess the SF-6D in SSc. The SF-6D is reliable and valid in patients with SSc. We provide MID estimates that can aid in calculating sample size for clinical trials involving patients with diffuse SSc.