1
|
Andreoli L, Chighizola CB, Iaccarino L, Botta A, Gerosa M, Ramoni V, Tani C, Bermas B, Brucato A, Buyon J, Cetin I, Chambers CD, Clowse MEB, Costedoat-Chalumeau N, Cutolo M, De Carolis S, Dolhain R, Fazzi EM, Förger F, Giles I, Haase I, Khamashta M, Levy RA, Meroni PL, Mosca M, Nelson-Piercy C, Raio L, Salmon J, Villiger P, Wahren-Herlenius M, Wallenius M, Zanardini C, Shoenfeld Y, Tincani A. Immunology of pregnancy and reproductive health in autoimmune rheumatic diseases. Update from the 11 th International Conference on Reproduction, Pregnancy and Rheumatic Diseases. Autoimmun Rev 2023; 22:103259. [PMID: 36549355 DOI: 10.1016/j.autrev.2022.103259] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022]
Abstract
Autoimmune rheumatic diseases (ARD) can affect women and men during fertile age, therefore reproductive health is a priority issue in rheumatology. Many topics need to be considered during preconception counselling: fertility, the impact of disease-related factors on pregnancy outcomes, the influence of pregnancy on disease activity, the compatibility of medications with pregnancy and breastfeeding. Risk stratification and individualized treatment approach elaborated by a multidisciplinary team minimize the risk of adverse pregnancy outcomes (APO). Research has been focused on identifying biomarkers that can be predictive of APO. Specifically, preeclampsia and hypertensive disorders of pregnancy tend to develop more frequently in women with ARD. Placental insufficiency can lead to intrauterine growth restriction and small-for-gestational age newborns. Such APO have been shown to be associated with maternal disease activity in different ARD. Therefore, a key message to be addressed to the woman wishing for a pregnancy and to her family is that treatment with compatible drugs is the best way to ensure maternal and fetal wellbeing. An increasing number of medications have entered the management of ARD, but data about their use in pregnancy and lactation are scarce. More information is needed for most biologic drugs and their biosimilars, and for the so-called small molecules, while there is sufficient evidence to recommend the use of TNF inhibitors if needed for keeping maternal disease under control. Other issues related to the reproductive journey have emerged as "unmet needs", such as sexual dysfunction, contraception, medically assisted reproduction techniques, long-term outcome of children, and they will be addressed in this review paper. Collaborative research has been instrumental to reach current knowledge and the future will bring novel insights thanks to pregnancy registries and prospective studies that have been established in several Countries and to their joint efforts in merging data.
Collapse
Affiliation(s)
- Laura Andreoli
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Cecilia B Chighizola
- Paediatric Rheumatology Unit, ASST G. Pini & CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Luca Iaccarino
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Angela Botta
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Maria Gerosa
- Division of Clinical Rheumatology, ASST Gaetano Pini-CTO, Research Center for Adult and Pediatric Rheumatic Diseases, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Véronique Ramoni
- Medicina Generale Lodi, ASST Lodi-Ospedale Maggiore, Lodi, Italy
| | - Chiara Tani
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milan, Italy; Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Jill Buyon
- Division of Rheumatology, New York University Grossman School of Medicine, New York, NY, USA
| | - Irene Cetin
- Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy; Department of Woman, Mother and Child, Luigi Sacco and Vittore Buzzi Children Hospitals, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Christina D Chambers
- Department of Pediatrics, University of California, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, La Jolla, CA, USA
| | - Megan E B Clowse
- Division of Rheumatology & Immunology, Duke University School of Medicine, Durham, NC, USA
| | - Nathalie Costedoat-Chalumeau
- Internal Medicine Department, Cochin Hospital, Referral center for rare autoimmune and systemic diseases, Université de Paris, CRESS, INSERM, INRA, Paris, France
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal M edicine, University of Genoa, IRCSS San Martino Polyclinic, Genoa, Italy
| | - Sara De Carolis
- Department of Obstetrics, Gynaecology and Pediatrics, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Radboud Dolhain
- Department of Rheumatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Elisa M Fazzi
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy; Child Neurology and Psychiatry Unit, ASST Spedali Civili, Brescia, Italy
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Ian Giles
- Centre for Rheumatology, Department of Inflammation, Division of Medicine, University College London, Department of rheumatology, University College London Hospital, London, UK
| | - Isabell Haase
- Department for Rheumatology and Hiller Research Institute, Heinrich-Heine-University, Düsseldorf, Germany
| | - Munther Khamashta
- Women & Children's Health, King's College, London, UK; GlaxoSmithKline Global Medical Expert, Dubai, United Arab Emirates
| | - Roger A Levy
- Universidade do Estado de Rio de Janeiro, Rio de Janeiro, Brazil; GlaxoSmithKline Global Medical Expert, Collegeville, PA, USA
| | - Pier Luigi Meroni
- IRCCS Istituto Auxologico Italiano, Immunorheumatology Research Laboratory, Milan, Italy
| | - Marta Mosca
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana and Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital (Inselspitaland University of Bern, Bern, Switzerland
| | - Jane Salmon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery and Weill Cornell Medicine, New York, NY, USA
| | - Peter Villiger
- Rheumatology and Clinical Immunology, Medical Center Monbijou, Bern, Switzerland
| | - Marie Wahren-Herlenius
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne Wallenius
- National Advisory Unit on Pregnancy and Rheumatic Diseases, St Olavs Hospital, Trondheim, University Hospital and Institute of Neuromedicine and Movement Science, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Cristina Zanardini
- Department of Obstetrics and Gynecology, ASST Spedali Civili, Brescia, Italy
| | - Yehuda Shoenfeld
- Sackler Faculty of Medicine, Ariel University, Ariel, Zabludowicz Center for Autoimmune Diseases, Sheba Medical Center, Tel-Hashomer, Israel
| | - Angela Tincani
- Rheumatology and Clinical Immunology Unit, ASST Spedali Civili, Brescia, Italy; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| |
Collapse
|
9
|
Hachulla E, Agard C, Allanore Y, Avouac J, Bader-Meunier B, Belot A, Berezne A, Bouthors AS, Condette-Wojtasik G, Constans J, De Groote P, Diot E, Dumas F, Jego P, Joly F, Launay D, Le Guern V, Le Quintrec JS, Lescaille G, Meune C, Moulin B, Nguyen C, Omeish N, Pene F, Richard MA, Rochefort J, Roren A, Sitbon O, Sobanski V, Truchetet ME, Mouthon L. French recommendations for the management of systemic sclerosis. Orphanet J Rare Dis 2021; 16:322. [PMID: 34304732 PMCID: PMC8310704 DOI: 10.1186/s13023-021-01844-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 12/13/2022] Open
Abstract
Systemic sclerosis (SSc) is a generalized disease of the connective tissue, arterioles, and microvessels, characterized by the appearance of fibrosis and vascular obliteration. There are two main phenotypical forms of SSc: a diffuse cutaneous form that extends towards the proximal region of the limbs and/or torso, and a limited cutaneous form where the cutaneous sclerosis only affects the extremities of the limbs (without passing beyond the elbows and knees). There also exists in less than 10% of cases forms that never involve the skin. This is called SSc sine scleroderma. The prognosis depends essentially on the occurrence of visceral damage and more particularly interstitial lung disease (which is sometimes severe), pulmonary arterial hypertension, or primary cardiac damage, which represent the three commonest causes of mortality in SSc. Another type of involvement with poor prognosis, scleroderma renal crisis, is rare (less than 5% of cases). Cutaneous extension is also an important parameter, with the diffuse cutaneous forms having less favorable prognosis.
Collapse
Affiliation(s)
- Eric Hachulla
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France.
| | - Christian Agard
- Internal Medicine, Nantes University Hospital, University of Nantes, Nantes, France
| | - Yannick Allanore
- Rheumatology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Jerome Avouac
- Rheumatology Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Brigitte Bader-Meunier
- Department of Pediatric Immunology and Rheumatology; Hospital Necker, APHP, Paris, France
| | - Alexandre Belot
- Pediatric Nephrology, Rheumatology, Dermatology, HFME, Hospices Civils de Lyon, Bron, France
| | - Alice Berezne
- Department of Internal Medicine, CHR Annecy-Genevois, Annecy, France
| | - Anne-Sophie Bouthors
- Anaesthesia Intensive Care Unit, Jeanne de Flandre Women Hospital, Academic Hospital, ULR 7365 - GRITA - Groupe de Recherche Sur Les Formes Injectables Et Les Technologies Associées, University Lille, Lille, France
| | - Geraldine Condette-Wojtasik
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | - Joël Constans
- Vascular Medicine Department, Bordeaux University Hospital Centre, Saint André Hospital, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists) PeripherAL Artery DIsease Network (PALADIN), Bordeaux, France
| | - Pascal De Groote
- Cardiology Department, Lung-Heart Institute, CHU de Lille, 59000, Lille, France
| | | | - Florence Dumas
- Emergency Department, Cochin Hospital, Paris University, Paris, France
| | - Patrick Jego
- Internal Medicine and Clinical Immunology Unit, CHU Rennes, Rennes, France
| | - Francisca Joly
- Department of Gastroenterology, IBD and Nutrition Support, Beaujon Hospital, INSERM UMRS-1149, Assistance Publique-Hôpitaux de Paris, University of Paris, Clichy, France
| | - David Launay
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | - Veronique Le Guern
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares D'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), APHP-CUP, Hôpital Cochin, Université de Paris, 75014, Paris, France
| | | | - Geraldine Lescaille
- Centre d'Immunologie et Maladies Infectieuses (CIMI-Paris), Department of Odontology, Paris Diderot/Paris 07, Sorbonne Paris Cité, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Christophe Meune
- Cardiology Department, Hôpital Avicenne, AP-HP, Université de Paris, Paris, France
| | - Bruno Moulin
- Department of Nephrology and Kidney Transplantation, Nouvel Hôpital Civil, University Hospitals of Strasbourg, Strasbourg, France
| | - Christelle Nguyen
- Physical Medicine and Rehabilitation Department, Hôpital Cochin, AP-HP, Université de Paris, Paris, France
| | - Nadine Omeish
- Oral and Dental Medicine, Hôpital Pitié-Salpêtrière, APHP, Université de Paris, Paris, France
| | - Frederic Pene
- Medical Intensive Care Unit, Hôpital Cochin, AP-HP. Centre & Université de Paris, Paris, France
| | - Marie-Aleth Richard
- Department of Dermatology, Timone Hospital, University Hospital of Marseille, Marseille, France
| | - Juliette Rochefort
- Oral and Dental Medicine, Hôpital Pitié-Salpêtrière, APHP, Université de Paris, Paris, France
| | - Alexandra Roren
- AP-HP Cochin Hospital, Université Paris Descartes Sorbonne Paris Cité, INSERM U1153, Paris, France
| | - Olivier Sitbon
- Assistance Publique-Hôpitaux de Paris, Service de Pneumologie, Hôpital Bicêtre, Laboratoire d'Excellence en Recherche Sur le Médicament et Innovation Thérapeutique, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Vincent Sobanski
- Service de Médecine Interne et Immunologie Clinique, Centre de Référence Des Maladies Autoimmunes Systémiques Rares du Nord et Nord-Ouest de France (CeRAINO), Univ. Lille, Inserm, CHU Lille, U1286 - INFINITE - Institute for Translational Research in Inflammation, 59000, Lille, France
| | | | - Luc Mouthon
- Service de Médecine Interne, Centre de Référence Maladies Autoimmunes Systémiques Rares D'Ile de France, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), APHP-CUP, Hôpital Cochin, Université de Paris, 75014, Paris, France.
| | | |
Collapse
|
11
|
Blagojevic J, AlOdhaibi KA, Aly AM, Bellando-Randone S, Lepri G, Bruni C, Moggi-Pignone A, Guiducci S, Mecacci F, Matucci-Cerinic M, Furst DE. Pregnancy in Systemic Sclerosis: Results of a Systematic Review and Metaanalysis. J Rheumatol 2019; 47:881-887. [PMID: 31474594 DOI: 10.3899/jrheum.181460] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Through a systematic literature search (SLR) and metaanalysis, to determine maternal and fetal outcomes in pregnancies involving systemic sclerosis (SSc), to analyze the effect of pregnancy on disease activity, and to examine predictors of fetal and maternal outcomes. METHODS An SLR was performed for articles on SSc and pregnancy published between 1950 and February 1, 2018. Reviewers double-extracted articles to obtain agreement on > 95% of predefined critical outcomes. RESULTS Out of 461 publications identified, 16 were included in the metaanalysis. The metaanalysis showed that pregnancies involving SSc were at higher risk of miscarriage (OR 1.6, 95% CI 1.22-2.22), fetuses with intrauterine growth retardation (IUGR; OR 3.2, 95% CI 2.21-4.53), preterm births (OR 2.4, 95% CI 1.14-4.86), and newborns with low birth weight (OR 3.8, 95% CI 2.16-6.56). Patients with SSc had a 2.8 times higher chance of developing gestational hypertension (HTN; OR 2.8, 95% CI 2.28-3.39) and a 2.3 times higher chance of cesarean delivery compared to controls (OR 2.3, 95% CI 1.37-3.8). The definitions of disease worsening/new visceral organ involvement were too inexact to have any confidence in the results, although worsening or new disease manifestations during pregnancy in 44/307 cases (14.3%) and 6 months postpartum in 32/306 cases (10.5%) were reported. The data did not permit definition of predictors of disease progression and of maternal and fetal outcomes. CONCLUSION Pregnancies involving SSc have increased frequency of miscarriages, IUGR, preterm deliveries, and newborns with low birth weight compared to healthy controls. Women with SSc were more prone to develop gestational HTN and to undergo cesarean delivery. Disease manifestations seem to remain stable or improve in most patients.
Collapse
Affiliation(s)
- Jelena Blagojevic
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy. .,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington.
| | - Khitam Abdullah AlOdhaibi
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Aly M Aly
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Silvia Bellando-Randone
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Gemma Lepri
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Cosimo Bruni
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Alberto Moggi-Pignone
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Serena Guiducci
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Federico Mecacci
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Marco Matucci-Cerinic
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Daniel E Furst
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| |
Collapse
|