Health-related quality of life in patients with systemic sclerosis: evolution over time and main determinants

Advancing Gastrointestinal Microbiota Research in Systemic Sclerosis: Lessons Learned from Prior Research and Opportunities to Accelerate Discovery

Dysbiosis is a feature of patients with systemic sclerosis (SSc). While a causal relationship between the gastrointestinal (GI) microbiota and SSc pathogenesis has not been established, alterations in the GI microbiota are appreciated early in the SSc disease course. Moreover, recent research has illuminated specific microbial signatures that define SSc phenotypes. This review summarizes new research on the GI microbiome in SSc with a focus on technical advancements and the emerging study of the GI metabolome. This review also addresses diverse modalities for manipulating the GI microbiome with the hope of developing preventative treatment strategies to avert progression of SSc.

Hand function impairment in Systemic sclerosis: Outcomes, Mechanisms and Experience (HANDSOME) - a longitudinal observational multicentre study protocol

INTRODUCTION

The majority of all patients with systemic sclerosis (SSc) experience hand function impairment. The exact cause for this impairment is yet unknown. As impaired hand function hugely impacts daily functioning and quality of life, there is a high unmet need for effective treatments. With the availability of new imaging modalities, biomarkers and laboratory techniques, opportunities arise to increase insights into the factors contributing to hand function impairment. The objective of this study is to identify risk factors and underlying mechanisms leading to hand function impairment in SSc.

METHODS AND ANALYSIS

This is a longitudinal observational multicentre study in patients with very early diagnosis of systemic sclerosis and SSc under care of the Department of Rheumatology and Clinical Immunology of the University Medical Centre Utrecht (UMCU), St Antonius Hospital Nieuwegein, UMC Groningen (UMCG), Leiden UMC (LUMC), Radboudumc or Royal Free Hospital (RFH) London. Patients will be followed for 2 years. Medical history, clinical status, nailfold capillaroscopy, skin assessments, serum biomarker analysis, ultrasound, elastography and MRI will be performed, and results related to hand function measurements will be analysed.

ETHICS AND DISSEMINATION

This study was approved by the Medical Research Ethics Committee NedMec (MREC NedMec) in the Netherlands and by HRA and Health and Care Research Wales in the UK. Results will be published in scientific journals and presented at scientific congresses and patient meetings.

TRIAL REGISTRATION NUMBER

NCT06133244.

PROTOCOL VERSION

V1.3 6-06-2024.

Quality of life in scleroderma-related interstitial lung disease and its association with respiratory clinical parameters

Objectives

Interstitial lung disease in systemic sclerosis has a significant impact in the quality of life. This prospective study was designed to determine the correlation between quality of life in systemic sclerosis-interstitial lung disease patients using patient-reported outcome measures and the lung function test parameters, with assessment done at baseline and 1 year.

Methods

In total, 63 consecutive systemic sclerosis-interstitial lung disease patients underwent lung function test, 6-minute walk distance, and quality of life-validated questionnaires (King's Brief Interstitial Lung Disease and Functional Assessment of Chronic Illness Therapy dyspnea). King's Brief Interstitial Lung Disease covers three components, namely chest, breathlessness, and psychological symptoms. The Functional Assessment of Chronic Illness Therapy dyspnea score has Part I (breathlessness symptoms) and Part II (physical limitation due to breathlessness). All assessments except for 6-minute walk distance were done both at baseline and at 12 months.

Results

Both forced vital capacity predicted percentage at baseline and 12 months had significant negative correlation with the Functional Assessment of Chronic Illness Therapy dyspnea score Part I (p values: 0.038 and <0.001, respectively). Both forced vital capacity and diffuse capacity for carbon monoxide predicted percentage at 12 months were also negatively correlated with Functional Assessment of Chronic Illness Therapy dyspnea score Part II (p values: 0.001 and 0.010, respectively). There was no significant correlation between King's Brief Interstitial Lung Disease score and the lung function parameters, at both baseline and at 1-year interval. Positive significant correlation was observed between forced vital capacity predicted percentage at baseline and 6-minute walk distance (p = 0.001).

Conclusion

Systemic sclerosis-interstitial lung disease affects quality of life, which is best assessed using the Functional Assessment of Chronic Illness Therapy dyspnea score as it correlates significantly with the lung function test parameters.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence and Outcomes of Gastrointestinal Manifestations in an Australian Scleroderma Cohort

OBJECTIVE

The gastrointestinal tract (GIT) is the most commonly affected internal organ in systemic sclerosis (SSc). We sought to determine the prevalence and impact of GIT symptoms on survival and patient-reported outcomes.

METHODS

A total of 907 consecutive patients from the Australian Scleroderma Cohort Study who had prospectively completed the University of California, Los Angeles, Scleroderma Clinical Trials Consortium Gastrointestinal Tract 2.0 Questionnaire (UCLA GIT) between 2015 and 2021 were included. The associations between UCLA GIT scores and physical function (Scleroderma Health Assessment Questionnaire), quality of life (QoL; Short Form 36), mood (Patient-Reported Outcomes Measurement Information System [PROMIS] anxiety and depression domains), fatigue (Functional Assessment of Chronic Illness Therapy-Fatigue score), and employment were investigated using multivariable population-averaged panel models using generalized estimating equations (GEEs). Kaplan-Meier curves and multivariable Cox proportional hazard regression models were used to evaluate survival according to total UCLA GIT scores.

RESULTS

GIT symptoms were reported in 87% of participants, with 46% to 52% reporting moderate to very severe symptoms of reflux, distension, diarrhea, and constipation. Higher total UCLA GIT scores were associated with worse QoL, physical function, fatigue, anxiety, and depression (P < 0.001). In the multivariable GEE analysis, moderate and severe to very severe total scores, reflux scores, and distension scores were associated with worse physical function, QoL, fatigue, anxiety, and depression compared to mild scores (P < 0.05). Patients with severe total scores and diarrhea scores were more likely to be unemployed compared to those with mild scores (P < 0.05). UCLA GIT total scores were not independently associated with death in our cohort.

CONCLUSION

GIT manifestations are common in SSc and negatively impact QoL, physical function, and employment but are not directly associated with increased death.

Impact of gastrointestinal symptoms and psychological distress on quality of life in systemic sclerosis: a cross-sectional study

BACKGROUND

Systemic sclerosis (SSc) is a chronic autoimmune disease characterised by microvascular damage and fibrosis. Mortality in patients with SSc has significantly decreased. Consequently, patients with SSc have longer life expectancy, and health-related quality of life (HrQoL) has become more relevant in the comprehensive management of the disease.

OBJECTIVE

To evaluate the impact between gastrointestinal (GI) symptom burden and psychological well-being on HrQoL in patients with SSc.

DESIGN

Nested cross-sectional study conducted between January and July 2022.

PARTICIPANTS

A single-centre cohort of 166 patients with SSc, including 103 (55%) with limited cutaneous SSc, 43 (24%) with diffuse SSc and 37 (21%) with sine-sclerosis SSc.

MAIN MEASURES

GI symptom burden was assessed using the University of California Los Angeles Scleroderma Clinical Trial Consortium gastrointestinal tract 2.0 (UCLA SCTC GIT 2.0) questionnaire, psychological well-being was measured with the Hospital Anxiety and Depression Scale (HADS), and HrQoL was evaluated using the Short Form 36 (SF-36) questionnaire. Demographic, clinical and immunological data were collected from a prospectively maintained database.

KEY RESULTS

Patients with moderate to severe GI symptoms (UCLA SCTC GIT 2.0 score >0.5, n=95, 57%) reported decreased HrQoL in all subdomains except vitality by SF-36, and higher anxiety and depression scores by HADS (all p<0.05). The severity of GI symptom burden and depression were independently associated with a decline in the physical component of QoL (β=-0.273 and β=-0.411, respectively, p<0.01 for both). Only the severity of depression and anxiety (β=-0.482 and β=-0.213, respectively, p<0.05), but not GI symptom burden, were independently associated with a decline in the mental component of QoL.

CONCLUSIONS

Our data suggest that in patients with SSc, GI and psychological burden negatively influence quality of life independently, highlighting the need for a holistic approach to patient's care.

Microstomia is associated with functional impairment and is a poor prognostic factor in systemic sclerosis - a single center observational study with survival analysis

BACKGROUND

Objectives were to assess the mouth opening ability (MOA) among patients with systemic sclerosis (SSc) in comparison to a healthy control population. The impact of microstomia (decrease in any of the MOA parameters) on physical performance and long-term survival was also investigated.

METHODS

Interincisal (ID), interlabial (LD), the intercommissural distances at both opened mouth and closed mouth (OW, CW) and the oral area (OA) and circumference (OC) all were assessed in 131 SSc patients. Microstomia was defined based on the oral aperture values of a healthy control group (n = 63) with similar median age and sex distribution. Tests evaluating functional performance were performed. Survival analysis by univariate and multivariate Cox regression analysis was performed.

RESULTS

Microstomia was present in 56.5% of the entire SSc cohort. Patients with microstomia had higher number of contractures compared to those with preserved oral aperture parameters (median 10 vs. 7, p < 0.01). LD, OA and OC correlated negatively with the number of joint contractures, both in the entire SSc cohort and separately in the diffuse (dcSSc) and limited cutaneous subsets (lcSSc), (rho: between - 0.267 and - 0.516, p < 0.05). Reduced ID was associated with worse Health Assessment Questionnaire Disability Index (HAQ-DI) only in dcSSc while reduced LD was linked to increased HAQ-DI scores in both SSc subsets. Decreased OA upon enrollment was associated with an increased risk in mortality by multivariate Cox regression analysis (HR: 2.74; 95% CI, 1.15-6.53).

CONCLUSIONS

Microstomia was associated with joint damage, and higher overall disability based on HAQ-DI. Interlabial distance was a beneficial, convenient measurable parameter to characterize oral aperture. Oral area was an independent poor prognostic factor regarding long-term survival.

Peer mentoring program through a digital platform for people with systemic sclerosis: A feasibility study

Objective

People with systemic sclerosis (SSc or scleroderma), a rare chronic autoimmune disease, often face significant physical and emotional challenges. Peer mentoring, where someone with similar lived experiences offers guidance and support, shows promise in enhancing the well-being of recipients and may benefit individuals with systemic sclerosis. This study aims to evaluate the feasibility and potential health effects of peer mentoring through a digital platform for people with systemic sclerosis.

Methods

We conducted a one-group study to evaluate a 16-week peer mentoring program for people with systemic sclerosis. Mentors and mentees were matched by demographics and systemic sclerosis characteristics. Feasibility was evaluated using Orsmond and Cohn criteria: recruitment, data collection, acceptability, available resources, and participant responses to the program. Perceptions and usability of the peer mentoring program through a digital platform were assessed at week 16 (post-program). The health effects of peer mentoring were measured at baseline, week 8, and week 16.

Results

Five trained mentors and 15 mentees were enrolled. Each mentor was paired with 2-4 mentees. We found that peer mentoring through a digital platform was feasible, acceptable, and had good usability for both mentors and mentees. Mentees reported significantly less anxiety at week 16 (p < 0.001). Other improvements in fatigue, pain interference, depressed mood, and resilience were observed, but did not reach statistical significance.

Conclusion

The peer mentoring program through a digital platform was well-received. Results provided preliminary support for the feasibility and potential health benefits of peer mentoring to enhance well-being in people with systemic sclerosis. Findings lay the groundwork for future peer mentoring research in systemic sclerosis.

Psychological impact of autologous hematopoietic stem cell transplantation in systemic sclerosis patients and influence of resilience

Objective

In severe cases of systemic sclerosis (SSc), autologous hematopoietic stem cell transplantation (aHSCT) is superior compared to cyclophosphamide. But treatment related morbidity and mortality have to be considered. To date, data on major physical and psychological impacts of aHSCT are scarce. Therefore, subjectively experienced physical and psychological impact of aHSCT and exploration of internal and external factors helping to cope with aHSCT was assessed.

Methods

Retrospective assessment of physical and psychological variables in an SSc cohort after aHSCT to describe: Health-related quality of life (HRQL), SSc-associated impairment, coping strategies, body image, and resilience. Additionally, semi-structured interviews were conducted and analyzed via mixed methods qualitative content analysis.

Results

Thirty-two patients were included. HRQL correlated with impairment due to SSc and with depressive coping. An unfavorable body image correlated with reduced HRQL and increased impairment but improves after aHSCT. Patients with good resilience had a better HRQL, less depressive coping, and less SSc-associated impairment. The semi-structured interviews revealed that resilience is important for a successful disease management as patients with higher resilience were more satisfied with aHSCT, patients with lower resilience would have wished for more psychological support. Thirty-one patients would recommend aHSCT to other patients.

Conclusion

A transient negative impact of aHSCT on mental well-being is present but can be relieved by a team specialized to aHSCT. Psychological support seems to be an unmet need, particularly in patients with low resilience. Patients with higher resilience described a lower negative impact caused by aHSCT and higher satisfaction after therapy.

Factors associated with physical function among people with systemic sclerosis: a SPIN cohort cross-sectional study

OBJECTIVES

To compare physical function in systemic sclerosis (SSc, scleroderma) to general population normative data and identify associated factors.

METHODS

Scleroderma Patient-centered Intervention Network Cohort participants completed the Physical Function domain of the Patient-Reported Outcomes Measurement Information System Version 2 upon enrolment. Multivariable linear regression was used to assess associations of sociodemographic, lifestyle, and disease-related variables.

RESULTS

Among 2385 participants, the mean physical function T-score (43.7, SD = 8.9) was ∼2/3 of a standard deviation (SD) below the US general population (mean = 50, SD = 10). Factors associated in the multivariable analysis included older age (-0.74 points per SD years, 95% CI -0.78 to -1.08), female sex (-1.35, -2.37 to -0.34), fewer years of education (-0.41 points per SD in years, -0.75 to -0.07), being single, divorced, or widowed (-0.76, -1.48 to -0.03), smoking (-3.14, -4.42 to -1.85), alcohol consumption (0.79 points per SD drinks per week, 0.45-1.14), BMI (-1.41 points per SD, -1.75 to -1.07), diffuse subtype (-1.43, -2.23 to -0.62), gastrointestinal involvement (-2.58, -3.53 to -1.62), digital ulcers (-1.96, -2.94 to -0.98), moderate (-1.94, -2.94 to -0.93) and severe (-1.76, -3.24 to -0.28) small joint contractures, moderate (-2.10, -3.44 to -0.76) and severe (-2.54, -4.64 to -0.44) large joint contractures, interstitial lung disease (-1.52, -2.27 to -0.77), pulmonary arterial hypertension (-3.72, -4.91 to -2.52), rheumatoid arthritis (-2.10, -3.64 to -0.56) and idiopathic inflammatory myositis (-2.10, -3.63 to -0.56).

CONCLUSION

Physical function is impaired for many individuals with SSc and is associated with multiple disease factors.

A Phase 1a Study to Evaluate Safety, Tolerability, Pharmacokinetics, and Pharmacodynamics of RO7303509, an Anti-TGFβ3 Antibody, in Healthy Volunteers

INTRODUCTION

Transforming growth factor beta (TGFβ) cytokines (TGFβ1, TGFβ2, and TGFβ3) play critical roles in tissue fibrosis. However, treatment with systemic pan-TGFβ inhibitors have demonstrated unacceptable toxicities. In this study, we evaluated the safety, tolerability, pharmacokinetics, and pharmacodynamics of RO7303509, a high-affinity, TGFβ3-specific, humanized immunoglobulin G1 monoclonal antibody, in healthy adult volunteers (HVs).

METHODS

This phase 1a, randomized, double-blind trial included six cohorts for evaluation, with each cohort receiving single doses of placebo or RO7303509, administered intravenously (IV; 50 mg, 150 mg, 240 mg) or subcutaneously (SC; 240 mg, 675 mg, 1200 mg). The frequency and severity of adverse events (AEs) and RO7303509 serum concentrations were monitored throughout the study. We also measured serum periostin and cartilage oligomeric matrix protein (COMP) by immunoassay and developed a population pharmacokinetics model to characterize RO7303509 serum concentrations.

RESULTS

The study enrolled 49 HVs, with a median age of 39 (range 18-73) years. Ten (27.8%) RO7303509-treated subjects reported 24 AEs, and six (30.8%) placebo-treated subjects reported six AEs. The most frequent AEs related to the study drug were injection site reactions and infusion-related reactions. Maximum serum concentrations (Cmax) and area under the concentration-time curve from time 0 to infinity (AUC0-inf) values for RO7303509 appeared to increase dose-proportionally across all doses tested. Serum concentrations across cohorts were best characterized by a two-compartment model plus a depot compartment with first-order SC absorption kinetics. No subjects tested positive for anti-drug antibodies (ADAs) at baseline; one subject (2.8%; 50 mg IV) tested positive for ADAs at a single time point (day 15). No clear pharmacodynamic effects were observed for periostin or COMP upon TGFβ3 inhibition.

CONCLUSION

RO7303509 was well tolerated at single SC doses up to 1200 mg in HVs with favorable pharmacokinetic data that appeared to increase dose-proportionally. TGFβ3-specific inhibition may be suitable for development as a chronic antifibrotic therapy.

TRIAL REGISTRATION

ISRCTN13175485.

Scleroderma: oral, maxillofacial and radiographic manifestations for dental practitioners

Scleroderma is an autoimmune condition of unknown aetiology with a range of manifestations, which can be limited to the skin or can extend to be multisystemic. It is characterised by fibrosis, microangiopathy and dysregulation of the immune system and commonly affects the oral cavity. Frequent oral and maxillofacial features include fibrosis of the face, circumoral furrows and reduced oral aperture. Radiographic findings are often incidental, including uniform, asymptomatic periodontal ligament space widening of teeth and osteolysis of bone at muscular attachments. The oral and maxillofacial manifestations significantly contribute to its disease burden and are often overlooked and undertreated as their treatment can be limited due to their challenging rheumatological care. Given the complexity of the condition and its multisystemic impacts, better co-operation between dentists and rheumatologists may help improve this patient cohort's quality of life. This clinical article aims to better equip dentists to identify features of scleroderma and manage the day-to-day oro-facial manifestations.

Orofacial Manifestation of Systemic Sclerosis: A Cross-Sectional Study and Future Prospects of Oral Capillaroscopy

BACKGROUND AND OBJECTIVES

oral alterations in Systemic Sclerosis (SSc) patients are widespread and include microstomia, periodontitis, telangiectasias, mandibular resorption, bone lesions, and xerostomia. This cross-sectional study aims to evaluate the differences between SSc patients (cases) and healthy subjects (controls) regarding oral manifestations, quality of life (QoL), and microcirculation alterations.

METHODS

plaque index (PCR), periodontal index (PSR), DMFT, salivary flow rate, and buccal opening were measured by expert clinicians. S-HAQ test, the Self-Rating Anxiety State (SAS), the Self-Rating Depression Scale (SDS), and the WHOQOL-BREF test were administered to patients to evaluate their QoL. Microvascular alterations were assessed by oral videocapillaroscopy, performed on gingival and labial mucosa. A statistical analysis was conducted to find significant differences between healthy people and SSc patients.

RESULTS

59 patients were enrolled in this study. Standard salivary flow is significantly more frequent in controls, while xerostomia, reduced flow, microstomia, lip retraction, and periodontitis are significantly more frequent in the cases. Gingival capillaroscopy showed differences concerning loop visibility, thickening of the gum, tortuosity of gingival loops, and reduced gingival density. Labial capillaroscopy demonstrates that visibility of the labial loops, the labial ectasias, and the tortuosity of the loops are significantly associated with the presence of scleroderma. Hand and facial deformities, hypomobility of the tongue, cheeks, lips, microstomia, and xerostomia significantly compromised the quality of life of SSc patients, which was significantly worse among them. Moreover, oral videocapillaroscopy could be a proper diagnostic method to detect oral microcirculation alterations. SSc patients often present ectasias, rarefaction of the reticulum, microhemorrhages, and megacapillaries, which negatively impact their oral health.

CONCLUSIONS

periodontitis, reduced salivary flow, and microstomia could be considered SSc oral manifestations. Joint deformities, facial appearance, and comorbidities significantly reduce the QoL of SSc patients compared to healthy subjects. Oral videocapillaroscopy could be an innovative and reliable technique to detect oral microcirculation anomalies.

Performance of myotonometer in the assessment of skin involvement in systemic sclerosis

OBJECTIVES

A clinically practical tool to assess skin biomechanical properties rapidly and accurately is still lacking. Our aim was to examine the intra- and inter-observer reproducibility of a myotonometer for objective skin property assessment in systemic sclerosis (SSc), comparing it with the modified Rodnan skin score (mRSS), and distinguishing patients from healthy controls.

METHOD

Thirty-four patients (21 limited and 13 diffuse SSc), and 31 age and gender-matched healthy controls were enrolled. Skin tone and stiffness were measured at four different anatomical sites (the forearm, hand, leg, and foot) using a myotonometer. The correlation between the mRSS and skin properties was assessed. Also, hand functionality was evaluated for possible correlations between the variables. The differences in skin properties between dcSSc and lcSSc patients, and healthy controls were assessed using variance analysis.

RESULTS

Intra- and inter-examiner reproducibility were excellent (ICC = 0.70 to 0.98) for tone and stiffness except for non-dominant hand tone, which showed good reliability (ICC = 0.64 to 0.74). Stiffness and tone values of the hands, forearms, and feet significantly correlated with mRSS total score (r = 0.40 to 0.71, p < 0.05). Additionally, tone and stiffness of the hands and forearms moderately correlated with hand function (p < 0.05). Tone and stiffness values increased in patients with dcSSc compared to healthy controls, or patients with lcSSc, at the hands, forearms, and legs (p < 0.05).

CONCLUSIONS

Our findings emphasize the potential utility of the myotonometer for assessing skin properties and differentiating SSc patients from controls, demonstrating its promise as a valuable clinical evaluation tool in this context. Key Points •The myotonometer displayed excellent intra- and inter-examiner reproducibility for assessing skin properties. •Skin tone and stiffness parameters well correlated with the mRSS scores. •The myotonometer can distinguish patients with diffuse cutaneous SSc from healthy controls.

The long-term course of the Health Assessment Questionnaire in patients with systemic sclerosis

Objective

The Health Assessment Questionnaire-Disability Index is an important outcome measure reflecting functional disability, but knowledge on its course over time in patients with systemic sclerosis is scarce. Therefore, we investigated the long-term course of the Health Assessment Questionnaire-Disability Index and its association with baseline characteristics in systemic sclerosis patients.

Methods

Systemic sclerosis patients, fulfilling the European League Against Rheumatism and the American College of Rheumatology 2013 criteria, were included from the Leiden Combined Care in Systemic Sclerosis cohort with annual assessments including the Scleroderma Health Assessment Questionnaire-Disability Index (range = 0-3). The course of the Health Assessment Questionnaire-Disability Index was evaluated over the total follow-up (baseline to last available Health Assessment Questionnaire-Disability Index) and between yearly visits. Based on a minimal clinical important difference of 0.22, courses were categorized into worsening, stable or improvement. The course of the Health Assessment Questionnaire-Disability Index over time was evaluated with linear mixed models. Baseline characteristics were compared between patients with a worsening or improvement of the Health Assessment Questionnaire-Disability Index over the total follow-up period with logistic regression analyses.

Results

A total of 517 systemic sclerosis patients were included, with a median follow-up of 7 years (interquartile range = 4-9; 2649 visits) and a baseline Health Assessment Questionnaire-Disability Index of 0.625 (interquartile range = 0.125-1.25). On group level, the Health Assessment Questionnaire-Disability Index is stable with an annual increase of 0.019 (95% confidence interval = 0.011 to 0.027). Looking at subgroups, patients >65 years or who died/were physically unable to come during follow-up had a worse mean Health Assessment Questionnaire-Disability Index. In individual courses from baseline to the last follow-up, the proportions of patients with a clinically meaningful worsening, stable or improved Health Assessment Questionnaire-Disability Index were 35%, 42% and 23%, respectively. Patients with immunosuppressants (odds ratio = 0.5, 95% confidence interval = 0.3 to 0.9) or gastrointestinal involvement (odds ratio = 0.6, 95% confidence interval = 0.4 to 0.9) at baseline showed a reduced chance of worsening of the Health Assessment Questionnaire-Disability Index over the total follow-up period.

Conclusion

Over time, the average course of the Health Assessment Questionnaire-Disability Index was stable in systemic sclerosis patients. However, individual courses vary, with worsening occurring in one-third. Worsening occurred less often in individuals using immunosuppressants or with gastrointestinal involvement at baseline.

Experiences of Exergaming for Upper Extremity Exercises in People With Systemic Sclerosis

Impaired upper extremity (UE) function has limited activities of daily living in people with systemic sclerosis (SSc). Exergaming, a combination of gaming and exercises, could be a novel way to improve UE exercise engagement. The objective of this study was to examine the usability of exergaming and to investigate participant experiences after exergaming among people with SSc. Both quantitative and qualitative data were collected. Participants completed questionnaires regarding the usability of exergaming. Semi-structured interviews were conducted directly after exergaming. Descriptive statistics and thematic content analysis were performed. Twenty participants with SSc participated. Exergaming was highly acceptable with a good System Usability Scale score (M = 71.6 ± 9.9). Participants described exergaming as motivating with potential physical and nonphysical benefits. Although results were generally positive, participants expressed some barriers and temporary side effects of using exergaming and needs for improvement. This work stands to inform future exergaming interventions in people with SSc.

Determinants of Depressive Symptoms, Quality of Life, Subjective Health Status and Physical Limitation in Patients with Systemic Sclerosis

Systemic sclerosis is a progressive connective tissue disease for which there is limited knowledge about physical limitations, quality of life and depression. The aim of this study was to assess these parameters during the disease process of systemic sclerosis, in a cross- sectional study of 79 patients and a longitudinal study of 33 patients over 10 years. Medical data were collected by physicians' questionnaires and sociodemographic data, pain, physical limitation, quality of life, subjective health status, risk of depressive symptoms by patients' questionnaires. Data analysis was descriptive and exploratory. Cross-tabulations, χ2 test and Student's t-test were used for calculations, Pearson's correlation to measure dependencies, and logistic regression analyses for categorized parameters. The cross-sectional analysis of 79 patients with systemic sclerosis (81% female, mean ± standard deviation age 61.5 ± 12.6 years) demonstrated a higher rate of patients with risk of depressive symptoms (42.3%) higher physical limitations, lower quality of life, and subjective health status than reference values for the general German population. Moderate to strong correlations between disease-related physical limitation, quality of life, subjective health status, risk of depressive symptoms and pain were detected (correlation according to Pearson -0.459 to -0.638, p < 0.001). Longitudinal analysis revealed a significant increase in disease activity, pain, physical limitation and risk of depressive symptoms (p < 0.001) during the disease process. This study demonstrates that nearly half of patients with systemic sclerosis probably experience depressive symptoms. The rate of patients with risk of depressive symptoms, pain and physical limitations increased during the systemic sclerosis disease process. Health-related quality of life and state of health declined, indicating the need for better interdisciplinary care for patients with systemic sclerosis.

In Systemic Sclerosis Patients, Peripheral Blood CD21low B Cells and Serum IL-4 and IL-21 Influence Joint Involvement

Systemic sclerosis (SSc) patients have an increased frequency of CD21low B cells and of serum interleukin-4 (IL-4) and IL-21, each possible markers of joint involvement in inflammatory arthritis. The aim of this study was to investigate the possible influence of CD21low B cells, IL-4, and IL-21 on joint involvement in a cohort of 52 SSc patients. The DAS28-ESR was correlated with CD21low B cells (r = 0.452, p < 0.001), IL-4 (r = 0.478, p < 0.001), and IL-21 (r = 0.415, p < 0.001). SSc patients with a DAS28-ESR > 3.2 had more CD21low B cells (12.65% (IQR: 7.11-13.79) vs. 5.08% (IQR: 3.76-7.45), p < 0.01), higher IL-4 levels (132.98 pg/mL (IQR: 99.12-164.12) vs. 100.80 pg/mL (IQR: 62.78-121.13), p < 0.05), and higher IL-21 levels (200.77 pg/mL (IQR: 130.13-302.41) vs. 98.83 pg/mL (IQR: 35.70-231.55), p < 0.01) than patients with a DAS28-ESR ≤ 3.2. The logistic regression analysis models showed that the DAI (OR: 2.158 (95% CI: 1.120; 4.156), p < 0.05) and CD21low B cells (OR: 1.301 (95% CI: 1.099; 1.540), p < 0.01), the DAI (OR: 2.060 (95% CI: 1.082; 3.919), p < 0.05) and IL-4 level (OR: 1.026 (95% CI: 1.006; 1.045), p < 0.01), and the DAI (OR: 1.743 (95% CI: 1.022; 2.975), p < 0.05) and IL-21 level (OR: 1.006 (95% CI: 1.000; 1.011), p < 0.05) were independently associated with a DAS28-ESR > 3.2. An elevated CD21low B cell percentage, IL-4 level, and IL-21 level was associated with higher articular disease activity in patients, suggesting a possible role in the pathogenesis of SSc joint involvement.

Systemic Sclerosis Quality of Life Questionnaire (SScQoL): translation into Turkish and assessing its psychometric properties

BACKGROUND

Systemic sclerosis (SSc) is a chronic autoimmune disease that affects the connective tissues and leads to physical, emotional, and social challenges for patients. Evaluating health-related quality of life (HRQoL) with a disease-specific tool may be preferable for improving patient care and treatment outcomes. The aim of this study was to translate the Systemic Sclerosis Quality of Life Questionnaire (SScQoL) into Turkish and to investigate its psychometric properties.

METHODS

Eighty-six patients with SSc (mean age 51.8 ± 11.7 years, 80 females) participated in the study. Convergent validity was explored by correlation analyses between Turkish SScQoL and Short-Form 36 (SF-36), European Quality of Life Survey-5 Dimensions (EQ-5D), EQ-5D Visual Analog Scale (EQ-VAS), and Scleroderma Health Assessment Questionnaire (SHAQ). Cronbach's alpha was calculated to test internal consistency. Turkish SScQoL was readministered after 7-14 days to fifty-eight patients for determining test re-test reliability. Intraclass correlation coefficients in 95% confidence interval (ICCs [95%CI]) were calculated to examine the agreement between two assessments. Values greater than 15% and an absolute skewness value < 1 were recognized as the presence of a floor or ceiling effect.

RESULTS

SScQoL correlated significantly with SF-36 subdomains (r = -0.347 to -0.618, p < 0.01), EQ-5D (r = -0.535, p < 0.01), EQ-VAS (r = -0.636, p < 0.01), and SHAQ global score (r = 0.521, p < 0.01). SScQoL demonstrated excellent internal consistency (Cronbach's alpha = 0.917), and good to excellent test-retest reliability (ICC [95%CI] = 0.85 [0.76-0.91]). No floor/ceiling effects were observed.

CONCLUSION

The Turkish version of SScQoL seems to have adequate psychometric properties and can be used to evaluate HRQoL in clinical and research settings. Key points • Turkish version of SScQoL is a valid and reliable tool for measuring health-related quality of life of patients with systemic sclerosis. • SScQoL is the only diseases-specific quality of life measurement for systemic sclerosis available in Turkish. • Patients with limited and diffuse SSc seem to be similar in terms of self-reported health-related quality of life.

Clinical characteristics and survival of pulmonary arterial hypertension with or without interstitial lung disease in systemic sclerosis

OBJECTIVES

To describe the clinical phenotype and prognosis of people in the Australian Scleroderma (SSc) Cohort Study with pulmonary arterial hypertension (PAH) with or without interstitial lung disease (ILD).

METHODS

Participants meeting ACR/EULAR criteria for SSc were divided into four mutually exclusive groups: those meeting criteria for PAH (PAH-only), ILD (ILD-only), concurrent PAH and ILD (PAH-ILD) or neither PAH nor ILD (SSc-only). Logistic or linear regression analyses were used for associations between clinical features, health-related quality of life (HRQoL) and physical function. Survival analysis was performed using Kaplan-Meier estimates and Cox-regression modelling.

RESULTS

Of 1561 participants, 7% fulfilled criteria for PAH-only, 24% ILD-only, 7% PAH-ILD and 62% SSc-only. People with PAH-ILD were more frequently male, with diffuse skin involvement, higher inflammatory markers, older age of SSc onset and higher frequency of extensive ILD than the cohort overall (p < 0.001). People of Asian race more frequently developed PAH-ILD (p < 0.001). People with PAH-ILD or PAH-only had worse WHO functional class and 6-min-walk-distance than ILD-only (p < 0.001). HRQoL scores were worst in those with PAH-ILD (p < 0.001). Survival was reduced in the PAH-only and PAH-ILD groups (p < 0.01). Multivariable hazard modelling demonstrated the worst prognosis in extensive ILD and PAH (HR = 5.65 95% CI 3.50-9.12 p < 0.01), followed by PAH-only (HR = 4.21 95% CI 2.89-6.13 p < 0.01) and PAH with limited ILD (HR = 2.46 95% CI 1.52-3.99 p < 0.01).

CONCLUSIONS

The prevalence of concurrent PAH-ILD in the ASCS is 7%, with poorer survival in those patients with PAH-ILD compared to ILD or SSc alone. The presence of PAH confers a poorer overall prognosis than even extensive ILD; however, further data are required to better understand the clinical outcomes of this high-risk patient group.

Serum-soluble ST2 and systemic sclerosis arthropathy

Interleukin (IL)33 and its receptor ST2 have been involved in the pathogenesis of several conditions, including arthritis. The aim of the study was to evaluate the association between IL33 or soluble ST2 (sST2) serum levels and systemic sclerosis (SSc) articular involvement. IL33 and sST2 serum levels were measured in 64 SSc patients and 24 HC matched for sex and age. Articular involvement assessed by using Disease Activity Score 28 based on erythrocyte sedimentation rate (DAS28-ESR), presence of tendon friction rubs (TFRs) and finger-to-palm (FTP) distance. sST2 serum levels were significantly higher in SSc patients with DAS28-ESR > 3.2 than in SSc patients with DAS28-ESR⩽3.2 [9726.1 (IQR 7746.5 - 14,953.5) pg/mL vs 7611.7 (IQR 5162.6 -11,036.7) pg/mL; p < 0.05]. sST2 serum levels were significantly higher in SSc patients with TFRs compared to SSc patients without TFRs [9726.1 (IQR 7746.5 - 14,953.5) pg/mL vs 7426.4 (IQR 5145.9 - 10,593.5) pg/mL; p < 0.01] and in SSc patients with FTP ≥ 1 cm compared to SSc patients with FTP < 1 cm [9683.7 (IQR 8067.2 - 16,387.6) pg/mL vs 7679.1 (IQR 5246.1 - 11,472.2) pg/mL; p < 0.05]. No significant association was observed between IL33 and DAS28-ESR, TFRs and FTP. A slightly positive linear correlation was found between sST2 and Disease Activity Index (r = 0.294, p < 0.05) and Disease Severity Scale (r = 0.265, p < 0.05). sST2 serum levels were positively correlated with DAS28-ESR (r = 0.371, p < 0.01). Elevated sST2 serum levels were associated with higher articular disease activity, TFRs and hand dysfunction, suggesting that sST2 might have a role in the pathogenesis of SSc articular involvement. Key Points • In SSc patients elevated serum levels of sST2 were associated with higher articular disease activity • High serum levels of sST2 were reported in SSc patients with TFRs and hand dysfunction • sST2 might have a role in the pathogenesis of SSc articular involvement.

Mental Health Considerations in Chronic Disease

Each person who presents for scleroderma-focused care not only has their own psychosocial stressors in their day-to-day life but they also have scleroderma symptom-specific stressors as well as their own mental health reactions throughout their journey with this disease course. There are many actions patients can take to help and support themselves when they are faced with any of the mental health and social determinants of health stressors associated with this rare, chronic illness. Using the scleroderma specialty providers to inform, discuss, and address these areas with their patients can assist with more effective symptom and disease self-management.

Mouth opening in systemic sclerosis: Its course over time, determinants and impact on mouth handicap

Objective

Decreased maximal mouth opening is a common and disabling manifestation in systemic sclerosis patients. We aimed to study the course of maximal mouth opening, determinants of smaller maximal mouth opening over time and the burden of smaller maximal mouth opening on mouth handicap.

Methods

Consecutive systemic sclerosis patients participating in the prospective Leiden Combined Care in systemic sclerosis cohort were included. Annual clinical assessment included maximal mouth opening measurement and mouth handicap evaluation (Mouth Handicap in Systemic Sclerosis scale). Presence of microstomia (maximal mouth opening < 30 mm) was studied. Maximal mouth opening over time was assessed on group level and for all patients individually. Baseline characteristics were analysed for their association with smaller maximal mouth opening over time (linear mixed-effects models). Furthermore, cross-sectional association between maximal mouth opening with Mouth Handicap in Systemic Sclerosis scale was assessed (linear regression analysis).

Results

A total of 382 systemic sclerosis patients were studied with median follow-up time of 2.0 years (interquartile range = 0.0-3.0). At baseline, mean maximal mouth opening was 42.2 ± 8.0 mm and 7% suffered from microstomia. Annual decrease of > 5.0 mm in maximal mouth opening during follow-up occurred in 63 patients and was accompanied by increase in disease severity. Disease characteristics at baseline independently predictive for smaller maximal mouth opening over time were: more extended skin subtype; peripheral vasculopathy; pulmonary, renal and gastrointestinal involvement. Smaller maximal mouth opening was significantly associated with more reported mouth handicap.

Conclusion

The course of maximal mouth opening is stable in a majority of systemic sclerosis patients. Still, maximal mouth opening over time was smaller in patients with more severe organ involvement. Although microstomia was infrequent, a smaller maximal mouth opening was significantly associated with more mouth handicap, indicating the importance to address maximal mouth opening in routine care of systemic sclerosis patients.

Patient Assessment Chronic Illness Care (PACIC) and its associations with quality of life among Swiss patients with systemic sclerosis: a mixed methods study

BACKGROUND

The Chronic Care Model (CCM) is a longstanding and widely adopted model guiding chronic illness management. Little is known about how CCM elements are implemented in rare disease care or how patients' care experiences relate to health-related quality of life (HRQoL). We engaged patients living with systemic sclerosis (SSc) to assess current care according to the CCM from the patient perspective and their HRQoL.

METHODS

We employed an explanatory sequential mixed methods design. First, we conducted a cross-sectional quantitative survey (n = 101) using the Patient Assessment of Chronic Illness Care (PACIC) and Systemic Sclerosis Quality of Life (SScQoL) questionnaires. Next, we used data from individual patient interviews (n = 4) and one patient focus group (n = 4) to further explore care experiences of people living with SSc with a focus on the PACIC dimensions.

RESULTS

The mean overall PACIC score was 3.0/5.0 (95% CI 2.8-3.2, n = 100), indicating care was 'never' to 'generally not' aligned with the CCM. Lowest PACIC subscale scores related to 'goal setting/tailoring' (mean = 2.5, 95% CI 2.2-2.7) and 'problem solving/contextual counselling' (mean = 2.9, 95% CI 2.7-3.2). No significant correlations were identified between the mean PACIC and SScQoL scores. Interviews revealed patients frequently encounter major shortcomings in care including 'experiencing organized care with limited participation', 'not knowing which strategies are effective or harmful' and 'feeling left alone with disease and psychosocial consequences'. Patients often responded to challenges by 'dealing with the illness in tailored measure', 'taking over complex coordination of care' and 'relying on an accessible and trustworthy team'.

CONCLUSIONS

The low PACIC mean overall score is comparable to findings in patients with common chronic diseases. Key elements of the CCM have yet to be systematically implemented in Swiss SSc management. Identified gaps in care related to lack of shared decision-making, goal-setting and individual counselling-aspects that are essential for supporting patient self-management skills. Furthermore, there appears to be a lack of complex care coordination tailored to individual patient needs.

Clinical case of olokizumab treatment in a patient with diffuse systemic sclerosis

Treatment algorithms for systemic sclerosis have not been completely developed. Effectivity of medications are usually used in clinical practice has a low level of evidence. Therefore, it is necessary to find a new treatment approaches for this nosological form. In the paper described clinical case of olokizumab treatment in a patient with diffuse systemic sclerosis with interstitial lung disease, polyserositis, severe microcirculatory alterations.

Unmet Medical Needs in Chronic, Non-communicable Inflammatory Skin Diseases

An estimated 20-25% of the population is affected by chronic, non-communicable inflammatory skin diseases. Chronic skin inflammation has many causes. Among the most frequent chronic inflammatory skin diseases are atopic dermatitis, psoriasis, urticaria, lichen planus, and hidradenitis suppurativa, driven by a complex interplay of genetics and environmental factors. Autoimmunity is another important cause of chronic skin inflammation. The autoimmune response may be mainly T cell driven, such as in alopecia areata or vitiligo, or B cell driven in chronic spontaneous urticaria, pemphigus and pemphigoid diseases. Rare causes of chronic skin inflammation are autoinflammatory diseases, or rheumatic diseases, such as cutaneous lupus erythematosus or dermatomyositis. Whilst we have seen a significant improvement in diagnosis and treatment, several challenges remain. Especially for rarer causes of chronic skin inflammation, early diagnosis is often missed because of low awareness and lack of diagnostics. Systemic immunosuppression is the treatment of choice for almost all of these diseases. Adverse events due to immunosuppression, insufficient therapeutic responses and relapses remain a challenge. For atopic dermatitis and psoriasis, a broad spectrum of innovative treatments has been developed. However, treatment responses cannot be predicted so far. Hence, development of (bio)markers allowing selection of specific medications for individual patients is needed. Given the encouraging developments during the past years, we envision that many of these challenges in the diagnosis and treatment of chronic inflammatory skin diseases will be thoroughly addressed in the future.

The effect of silver fibre gloves on Raynaud's phenomenon in patients with systemic sclerosis: a double-blind randomized crossover trial

OBJECTIVES

Silver fibre gloves transport heat from the palm to the fingers, possibly reducing the burden of RP in SSc patients. We aim to evaluate the clinical efficiency of this intervention.

METHODS

A multicentre, double-blind, randomized trial was performed, accounting for interindividual differences and external factors using a crossover design. Patients were randomized in two groups: group 1 wore 8% silver fibre gloves in period 1 and normal gloves in period 2 and group 2 vice versa. Each period lasted 6 weeks. The primary outcome was the Raynaud Condition Score (RCS) over time (minimal clinical important difference 1.4), assessed three times per week using an online questionnaire. Secondary outcomes included vascular complications and Scleroderma-Health Assessment Questionnaire (SHAQ). Outcomes were evaluated before unblinding using linear mixed models.

RESULTS

A total of 85 SSc patients were included, with 76 completing the study. The mean RCS during 2 weeks before the study (i.e. without gloves) was 6.4 (s.d. 1.6). Both with silver fibre gloves and normal gloves the mean RCS decreased to 3.9 (s.d. 2.3) with a similar course over time. There was no difference in mean RCS over time between the type of gloves [β = 0.067 (95% CI -0.006, 0.19)]. Of secondary outcomes, total SHAQ [β = 0.036 (95% CI 0.026, 0.046)] was slightly higher with silver fibre gloves, which is clinically irrelevant. Three patients developed new digital ulcers with normal gloves vs one patient with silver fibre gloves [odds ratio 3.2 (95% CI 0.32, 31.1)].

CONCLUSIONS

Wearing gloves in SSc patients clearly decreases the RP burden. Our results do not support the hypothesis that increased heat transport of 8% silver fibre gloves is associated with less disease burden as measured in this study by the RCS compared with normal gloves.

CLINICAL TRIAL REGISTRATION NUMBER

Netherlands Trial register (https://www.trialregister.nl/) NL7904.

How do systemic sclerosis manifestations influence patients' lives? Results from a survey on patients and caregivers

OBJECTIVE

To investigate the patient- and caregiver-reported impact of systemic sclerosis (SSc) manifestations (hand/feet/joint involvement and pulmonary complications) on the diagnostic and therapeutic journey, working productivity, and social life.

METHODS

Two questionnaires (one for the patients, n = 260 and one for the caregivers, n = 47) were designed in collaboration with the patients' association Gruppo Italiano per la Lotta alla Sclerodermia (GILS). Validated questionnaires were combined with specific questions relevant to the Italian scenario.

RESULTS

Pulmonary fibrosis and hand/feet/joint involvement have a major impact on patient's working status: (85.3% of patients with pulmonary fibrosis and 72.6% with hand/feet/joint involvement report loss of job/job change due to SSc. Productivity was affected as well: 60.6% of the patients (75% of those with fibrosis) reported that working productivity in the previous 4 weeks was restricted by physical limitations. The disease has a significant impact on patients' life, limiting the ability to conduct common activities, especially those related to movement, such as object manipulation (61.1%), doing small manual jobs (44.0%), writing (38.9%), and an increased impact in case of pulmonary fibrosis and hands/feet/joints involvement. Half of the patients also present some difficulties in eating-related activities a Patients also experience poorer social life, personal relationships, and sexual life. Caregivers are also deeply influenced by the manifestations of SSc. Pulmonary fibrosis and hand/feet/joint involvement represent an additional challenge.

CONCLUSION

Pulmonary fibrosis and hand/feet/joint involvement are extremely burdensome complications for both SSc patients and caregivers, decreasing work productivity, limiting relationship and social life, and impacting psychological status and everyday activities.