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

Classification method for nailfold capillary images using an optimized sugeno fuzzy ensemble of convolutional neural networks

This study developed a novel binary classification method for analyzing nailfold capillary images associated with the risk of developing sclerosis. The proposed approach combined a Sugeno fuzzy integral inference system with an ensemble of convolutional neural networks (CNNs), including GoogLeNet, ResNet, and DenseNet. Nailfold capillary images are highly valuable for diagnosing and monitoring various systemic diseases. They can reveal early indicators of systemic sclerosis, such as capillary enlargement, loss, or hemorrhages. The study obtained nailfold capillary images from a hospital in Taiwan, with 80 % allocated for model training and the remaining 20 % reserved for testing purposes. The proposed method achieved a high performance with an accuracy of 85 %, a recall of 81.82 %, a precision of 90 %, and an F1 score of 85.17 %. In comparison, individual CNN models (GoogLeNet, ResNet, and DenseNet) achieved accuracies of 73.33 %, 67.96 %, and 70.83 %, respectively. These results demonstrate that the proposed integrated method outperforms single-model approaches in classifying nailfold capillary images more accurately and efficiency. Using CNN models as a novel application opens new avenues for research in related image analysis fields.

Imaging the microvasculature using nailfold capillaroscopy in patients with coronavirus disease-2019; A cross-sectional study

OBJECTIVES

It is understood that microvascular dysfunction plays a key role in the pathogenesis of SARS-CoV-2 coronavirus disease (COVID-19). The aim of this study was to evaluate the usefulness of an automated, quantitative nailfold capillaroscopy system in identifying microvascular changes in those confirmed with or having had COVID-19.

METHODS

Ninety-seven participants were enrolled into this study and grouped as follows: 52 participants with acute COVID-19 (further grouped by disease severity) and 45 participants with convalescent COVID-19 (further grouped into long COVID i.e. symptoms beyond 12 weeks, and fully recovered). Nailfold capillaroscopy images were obtained from the bilateral ring fingers using a Dino-Lite CapillaryScope 200 Pro, a small USB handheld microscope. Images were assessed quantitatively using bespoke automated measurement software and the number of haemorrhages noted for each participant.

RESULTS

Capillaries were predominantly 'normal' in appearance with narrow capillary loops and evenly distributed, but with an increased number of haemorrhages (40 % in the convalescent group and 17 % in the acute group, p = 0.007). There was no statistically significant difference in the mean width of capillaries (20.9-21.8 μm) or vessel density (9.6-9.9 caps/mm; acute and convalescent group, respectively).

CONCLUSIONS

This study has demonstrated the feasibility of nailfold capillaroscopy at the critical care bedside. Capillary structure appeared normal across all groups of individuals affected by COVID-19. Although the small differences in the microvasculature in recovered patients compared to in acutely unwell patients may suggest delayed structural change due to COVID-19, these differences are unlikely to be clinically relevant. Longitudinal studies would be required to explore this in more detail.

A systematic review of prevalence and predictors of depression in systemic sclerosis based on the CES-D, BDI, and PHQ- 9 self-assessment questionnaires

OBJECTIVES

This study aimed to investigate the prevalence of depression in Systemic Sclerosis (SSc) patients using depression self-assessment tools such as the Beck Depression Inventory (BDI), the Centre for Epidemiologic Studies Depression Scale (CES-D), and the Patient Health Questionnaire (PHQ-9) and to explore the clinical characteristics of SSc patients with depression and identify potential risk factors for depression.

METHODS

Based on PRISMA guidelines, an electronic search was conducted in PubMed, Embase, PsycINFO, and Google Scholar to collect studies assessing systemic sclerosis and depression up to April 2024. Original research studies in SSc patients and depression using BDI > 10, CES-D > 16, and PHQ-9 > 10 that met our inclusion criteria were included and appraised using the Joanna Briggs Institute (JBI) instrument, then data extraction was performed.

RESULTS

We identified 497 articles, of which 22 were included in this systematic review. Among the 4,165 patients who completed the self-assessment questionnaires, 1486 (35.6%) met the criteria for depression where 564 (31.9%) of patients were identified based on the CES-D, 410 (55.1%) from the BDI, and 512 (30.8%) from the PHQ-9 group. Gastrointestinal involvement was the most identified predictor for depression, while pain, disease activity, and pulmonary and joint symptoms of SSc were also commonly associated with depression. Non-SSc-related predictors of depression included unemployment, low educational level, and unmarried status.

CONCLUSION

Higher prevalence of depression is seen among patients with SSc. Although the prevalence varies according to the assessment tool used, we found correlation of depression estimates in SSc-patients between the CES-D and PHQ-9 scores. Moreover, this review identifies the significant predictors of depression in SSc patients and highlights the need of mental healthcare professionals to engage in the care of SSc patients.

CONCLUSION

HB level was significantly related to disease activity and structural damage in RA patients. Key Points • There is significant variability in estimates of depression among different self-assessment questionnaires in patients with SSc. • We found correlation of depression estimates in SSc-patients between the CES-D and PHQ9 scores. • Among the studies reviewed strong predictors of depression in SSc-patients were identified. These were significant GI and arthritic manifestations, increased pain and disease severity, and a lower educational level. • Importance in engaging mental healthcare professionals in the care of SSc- patients as per our study up to a third of patients may benefit from this.

Neural network analysis as a novel skin outcome in a trial of belumosudil in patients with systemic sclerosis

BACKGROUND

The modified Rodnan skin score (mRSS), a measure of systemic sclerosis (SSc) skin thickness, is agnostic to inflammation and vasculopathy. Previously, we demonstrated the potential of neural network-based digital pathology applied to SSc skin biopsies as a quantitative outcome. Here, we leverage deep learning and histologic analyses of clinical trial biopsies to decipher SSc skin features 'seen' by artificial intelligence (AI).

METHODS

Adults with diffuse cutaneous SSc ≤ 6 years were enrolled in an open-label trial of belumosudil [a Rho-associated coiled-coil containing protein kinase 2 (ROCK2) inhibitor]. Participants underwent serial mRSS and arm biopsies at week (W) 0, 24 and 52. Two blinded dermatopathologists scored stained sections (e.g., Masson's trichrome, hematoxylin and eosin, CD3, α-smooth muscle actin) for 16 published SSc dermal pathological parameters. We applied our deep learning model to generate QIF signatures/biopsy and obtain 'Fibrosis Scores'. Associations between Fibrosis Score and mRSS (Spearman correlation), and between Fibrosis Score and mRSS versus histologic parameters [odds ratios (OR)], were determined.

RESULTS

Only ten patients were enrolled due to early study termination, and of those, five had available biopsies due to fixation issues. Median, interquartile range (IQR) for mRSS change (0-52 W) for the ten participants was -2 (-9-7.5) and for the five with biopsies was -2.5 (-11-7.5). The correlation between Fibrosis Score and mRSS was R = 0.3; p = 0.674. Per 1-unit mRSS change (0-52 W), histologic parameters with the greatest associated changes were (OR, 95% CI, p-value): telangiectasia (2.01, [(1.31-3.07], 0.001), perivascular CD3 + (0.99, [0.97-1.02], 0.015), and % of CD8 + among CD3 + (0.95, [0.89-1.01], 0.031). Likewise, per 1-unit Fibrosis Score change, parameters with greatest changes were (OR, p-value): hyalinized collagen (1.1, [1.04 - 1.16], < 0.001), subcutaneous (SC) fat loss (1.47, [1.19-1.81], < 0.001), thickened intima (1.21, [1.06-1.38], 0.005), and eccrine entrapment (1.14, [1-1.31], 0.046).

CONCLUSIONS

Belumosudil was associated with non-clinically meaningful mRSS improvement. The histologic features that significantly correlated with Fibrosis Score changes (e.g., hyalinized collagen, SC fat loss) were distinct from those associated with mRSS changes (e.g., telangiectasia and perivascular CD3 +). These data suggest that AI applied to SSc biopsies may be useful for quantifying pathologic features of SSc beyond skin thickness.

Analysis of clinical features and risk factors of pulmonary hypertension associated with interstitial lung disease

Pulmonary hypertension (PH) can significantly impact the prognosis of interstitial lung disease (ILD). There are limited studies on the clinical characteristics and risk factors of PH associated with ILD (PH-ILD). The present study aimed to analyze the clinical characteristics of patients with PH-ILD and explore the correlation and predictive value of the easily obtainable indicators with respect to the severity of PH in patients with ILD. The results indicated that the red blood cell distribution width (RDW) and mean platelet volume (MPV) of patients with ILD with the moderate-to-severe PH (Ms-PH) were significantly higher compared with those of patients with ILD without PH and those with Mild-PH (P<0.05). Age, RDW, MPV and immunoglobulin G levels were emerged as independent risk factors for Ms-PH in patients with ILD. Receiver operating characteristic curve analysis demonstrated that the combination of RDW and MPV enhances the diagnostic efficiency for Ms-PH in patients with ILD. Consequently, the present study demonstrated that RDW and MPV are predictive factors for Ms-PH in patients with ILD.

Post hoc comparison of the effectiveness of tocilizumab, rituximab, mycophenolate mofetil, and cyclophosphamide in patients with SSc-ILD from the EUSTAR database

OBJECTIVES

Tocilizumab (TCZ), rituximab (RTX), mycophenolate mofetil (MMF), and cyclophosphamide (CYC) are the immunosuppressants (IS) most frequently used for systemic sclerosis-associated interstitial lung disease (SSc-ILD). This post hoc study aimed to compare their effectiveness in patients with SSc-ILD from the European Scleroderma Trials and Research (EUSTAR) database.

METHODS

We included radiologically confirmed SSc-ILD patients with treatment records for TCZ, RTX, MMF, or CYC. The primary endpoint was the change in forced vital capacity (FVC) percent predicted from baseline to follow-up. Analyses were adjusted for clinical and demographic characteristics, cotreatments, and follow-up duration using propensity score-based inverse probability of treatment weighting (IPTW).

RESULTS

Nine hundred fifty-five patients with 997 treatment observations were included in the study. The median follow-up time was 11 months (IQR, 8-14 months). After IPTW, the changes in FVC percent predicted were not significantly different in the multigroup comparison (P = .101). Paired comparisons showed no significant difference. CYC was associated with stable FVC in logistic regression. For subgroup analysis, the treatment differences in change of FVC percent predicted among the 4 groups were not significant in patients with combination IS or previous exposure to TCZ, RTX, or conventional IS, as well as in current smokers or nonsmokers, and regardless of whether observations started either at the initiating or noninitiating stage of the treatment.

CONCLUSIONS

In this first large real-world study, the effectiveness of TCZ, RTX, MMF, and CYC on FVC change in SSc-ILD patients was not statistically different.

Do functionality, strength, vascularization, inflammatory and biopsychosocial status improve by biopsychosocial model-based exercise in SSc?

OBJECTIVES

This study aimed to investigation of the effects of the Cognitive Exercise Therapy Approach [Bilişsel Egzersiz Terapi Yaklaşımı (BETY)], a supervised biopsychosocial model-based exercise intervention, on functionality, muscle strength, vascularization, anti-inflammatory and biopsychosocial status in SSc patients.

METHODS

Thirty-seven SSc patients were included. Twenty of them were recruited into the study group (SG) undergoing BETY group exercise sessions three times a week for 3 months and seventeen were in the control group (CG) following a home exercise program. Assessment tools were the Modified Rodnan Skin Score (mRSS), Scleroderma HAQ (SHAQ), Modified Hand Mobility in Scleroderma (mHAMIS), Duruoz Hand Index (DHI), Six-Min Walk Test (6-MWT), skeletal muscle strength measurements using an isokinetic dynamometer (Biodex System 3 Pro), Shear Wave Elastography, ELISA kits (for tumour necrosis factor-alpha, Interleukin-6, IL-10, serum irisin level), BETY-Biopsychosocial Questionnaire (BETY-BQ), Hospital Anxiety and Depression Scale (HADS) and Short Form-36 (SF-36).

RESULTS

The SG demonstrated improvements in SHAQ, mHAMIS, 6-MWT, BETY-BQ, HADS and SF-36 values, excluding the DHI scores (P < 0.05). In contrast, CG showed worsening in SHAQ-general scleroderma symptoms and HADS scores compared with SG (P < 0.05). IL-10 and TNF-alpha increased in both groups, also various vascular parameters were significantly different changed in SG than CG (P < 0.05). Muscle strength values improved in the SG but decreased in the CG, however, this was statistically not significant (P > 0.05).

CONCLUSION

BETY can be recommended as a non-pharmacological approach to the disease management of SSc patients.

Semi-quantitatively scored apical extent of disease predicts change in total lung capacity in patients with systemic sclerosis and early interstitial lung disease

BACKGROUND

Pulmonary function tests (PFTs) and extent of ILD on HRCT predict mortality in systemic sclerosis associated interstitial lung disease (SSc-ILD). It is not known whether location and type in addition to extent of affected lung parenchyma are associated with PFTs changes.

METHODS

SSc patients from a targeted healthcare program were included when PFTs and visually scored concomitant chest HRCT and PFTs at one year follow-up were available. Lung parenchyma of SSc patients was semi-quantitatively scored by visual assessment (reticulation, ground glass opacities, emphysema and disease extent) at five levels from apex to base. Regression analysis after linearity check and excluding multicollinearity was used to predict changes in PFT parameters (TLC, total lung capacity; FVC, forced vital capacity; DLCO, diffusion capacity for carbon monoxide).

RESULTS

A total of 185 patients were included (85% female, mean age at first symptoms 40 years). All HRCT variables correlated with PFT parameters cross-sectionally. Disease extent and reticulation at the apices (level 1), reticulation at level 2, disease extent and reticulation at level 3 all correlated significantly with TLC (r 0.151-0.17, p < 0.05). Of these HRCT variables disease extent at level 1 predicted change in TLC (adjusted R2 0.024, p 0.021) and when excluding patients with emphysema or pulmonary hypertension, reticulation at level 3 predicted change in TLC (adjusted R2 0.026, p 0.020).

CONCLUSIONS

In patients with systemic sclerosis and lung involvement, disease extent and reticulation at the mid-upper zones predicted change in TLC which may be of clinical importance.

Immunosuppressive therapy to treat newly diagnosed primary heart involvement in patients with systemic sclerosis: An Italian cardiac magnetic resonance based study

BACKGROUND

Primary heart involvement (pHI) is frequent in systemic sclerosis (SSc), and is associated with a poor prognosis. Therapeutic strategies to treat SSc-pHI are not yet defined.

OBJECTIVES

To evaluate the efficacy of immunosuppressive therapy on cardiac magnetic resonance (CMR) features in patients with CMR-proven SSc-pHI.

METHODS

The data from SSc patients with CMR-proven pHI who start or modify immunosuppressive therapy as indication for the newly diagnosed pHI and who had a follow-up CMR with parametric mapping after 6 to 18 months were analyzed. All patients underwent a comprehensive baseline evaluation of disease characteristics and organ involvement. In all patients, cardiac involvement was investigated at baseline and at follow up with CMR, evaluating: myocardial edema at STIR images, native-T1 and T2-mapping, extracellular volume fraction (ECV), and late gadoliunum enhancement (LGE). A p value <0.05 was considered as statistically significant.

RESULTS

Out of a cohort of 684 SSc patients, 35 (5.1 %) with SSc-pHI (females 77.1 %; median age 59 [46-64] years; anti-topoisomerase-I positivity 48.6 %; diffuse disease 34.3 %) were selected. In the majority of patients (74.3 %) at baseline CMR, signs of active myocardial inflammation (edema at STIR and/or increased T2-mapping) were found. Mycophenolate mofetil (MMF) was started in 15 (42.9 %) or increased in 7 (20.0 %) cases; 7 patients (20.0 %) received rituximab, 3 (8.6 %) azathioprine, while 3 patients were treated each one with cyclophosphamide (with pulse steroids), tocilizumab and hydroxychloroquine (with steroids). The median duration of immunosuppression was 12.0 [6.0-15.5] months. At follow-up CMR (performed after a median time 12.0 [6.5-16.0] months), increased T2-mapping suggestive for active myocardial inflammation was present in only 14 patients (40 %) (p = 0.003), and edema at STIR was present in 5 cases only (14.3 %) (p = 0.002). A significant reduction of T2-mapping (from 53.0 [49.0-55.0] to 51.0 [50.0-54.0] ms, p < 0.001), native-T1-mapping (from 1050.0 [1007.0-1084.0] to 1039.0 [1020.5-1080.5] ms, p = 0.022) and ECV (from 34.0 [31.0-36.75] to 33.0 [29.0-34.25] %, p = 0.041) was observed, especially in those with baseline increased mapping (T2-mapping from 53.0 [53.0-56.0] to 52.0 [50.0-57.0] ms; T1-mapping from 1066.0 [1050.0-1089.0] to 1057.0 [1027.5-1090.0] ms, p < 0.0001 for both]. The amelioration of the CMR features was paralleled by significant reduction of NT-proBNP (p = 0.008), high-sensitive troponin T (p = 0.003) and C-reactive protein (p = 0.010). No treatment-related adverse events were recorded.

CONCLUSIONS

Our data show that immunosuppression is a therapeutic strategy which has the potentiality to treat newly diagnosed SSc-pHI, by curbing signs of myocardial inflammation at CMR, and by significantly reducing cardiac enzymes, inflammatory markers and overall clinical burden. Larger prospective randomized studies are needed to confirm these data.

The effect of hydroxychloroquine on activities of daily living and hand function in systemic sclerosis: results from an analysis of the EUSTAR cohort

BACKGROUND

To evaluate the use of hydroxychloroquine (HCQ) and its impact on the Health Assessment Questionnaire disability index(HAQ-DI) and the Cochin Hand Function Status(CHFS) in a large Systemic Sclerosis (SSc) cohort.

METHODS

SSc patients from the European Scleroderma Trials and Research (EUSTAR) database treated with HCQ for at least 6 months were evaluated and compared to a matched group of SSc patients not using HCQ. Demographic and clinical data, concomitant drugs, HAQ-DI and CHFS (at least 2 evaluations) were recorded and were the outcome variables of interest. Statistical analysis was performed using propensity score matching for age, gender, disease duration, corticosteroids, immunosuppressives, vasoactive drugs in a 3:1 control: HCQ ratio. Standard descriptive statistics and Student's t-test and Chi-square test were used to assess the propensity-matched groups.

RESULTS

Out of 17,805 SSc patients evaluated, 468 (2.6%) used HCQ and constituted the HCQ group. Among them, 50 (10.7%) had at least a baseline and follow-up HAQ-DI evaluation and 44 (9.4%) had at least a baseline and follow-up CHFS evaluation. Propensity matching assured that patients were matched for female gender (HCQ vs. control 92.0% vs. 85.3%), mean age (49.8 vs. 50.0 years) disease duration (8.3 vs. 9.1 years), limited disease (55.3 vs. 62.6%) as well as background medications (all P > 0.1). We did not find any significant differences among the two groups in the change of HAQ-DI or CHFS, over up to 365 days (all P > 0.05).

CONCLUSIONS

Results from the EUSTAR registry showed that HCQ was used by 2.6% of SSc patients. HCQ use did not improve the HAQ-DI, or CHFS when comparing HCQ users to non-HCQ users.

Neuropsychiatric manifestations in systemic lupus erythematosus and Sjogren's disease

INTRODUCTION

Autoimmune diseases often present in a systemic manner, affecting various organs and tissues. Involvement of the central and peripheral nervous system is not uncommon in these conditions and is associated with high morbidity and mortality. Therefore, early recognition of the neuropsychiatric manifestations associated with rheumatologic diseases is essential for the introduction of appropriate therapies with the objective of providing a better quality of life for individuals.

OBJECTIVE

To provide a literature review of the neuropsychiatric manifestations related to Systemic Lupus Erythematosus (SLE) and primary Sjögren's Disease (pSD), through the description of signs, symptoms, and immunological variables associated with these conditions.

METHODS

A literature review was conducted by searching for national and international articles available in the SciELO and PubMed databases related to the description of neurological and psychiatric manifestations in patients with the rheumatologic diseases of interest in this study.

RESULTS

The main NP manifestations presented in SLE and pSD are discussed, focusing on clinical presentation and etiology. Treatment option are, however, mainly based on expert opinion, since a few randomized controlled trials have been done.

CONCLUSIONS

There is a high prevalence of neuropsychiatric manifestations associated with SLE and pSD. The variety of physiopathology pathways may explain the variety of symptoms, however pathological findings are rare. Multicenter studies on attribution protocols and treatment are necessary to address the current gaps.

Prospective SARS-CoV-2 Booster Vaccination in Immunosuppressant-Treated Systemic Autoimmune Disease Patients in a Randomized Controlled Trial

Background

Autoimmune disease patients on immunosuppressants exhibit reduced humoral responses to primary COVID-19 vaccination. Booster vaccine responses and the effects of holding immunosuppression around vaccination are less studied. We evaluated the efficacy and safety of additional vaccination in mycophenolate mofetil/mycophenolic acid (MMF/MPA)-, methotrexate (MTX)-, and B cell-depleting therapy (BCDT)-treated autoimmune disease patients, including the impact of withholding MMF/MPA and MTX.

Methods

In this open-label, multicenter, randomized trial, 22 MMF/MPA-, 26 MTX-, and 93 BCDT-treated autoimmune disease patients with negative or suboptimal antibody responses to initial COVID-19 vaccines (BNT162b2, mRNA-1273, or AD26.COV2.S) received a homologous booster. MMF/MPA and MTX participants were randomized (1:1) to continue or withhold treatment around vaccination. The primary outcome was the change in anti-Wuhan-Hu-1 receptor-binding domain (RBD) concentrations at 4 weeks post-additional vaccination. Secondary outcomes included adverse events, COVID-19 infections, and autoimmune disease activity through 48 weeks.

Results

Additional vaccination increased anti-RBD concentrations in MMF/MPA and MTX patients, irrespective of whether immunosuppression was continued or withheld. BCDT-treated patients also demonstrated increased anti-RBD concentrations, albeit lower than MMF/MPA- and MTX-treated cohorts. COVID-19 infections occurred in 30-46% of participants, were predominantly mild, and included only two non-fatal hospitalizations. Additional vaccination was well-tolerated, with low frequencies of severe disease flares and adverse events.

Conclusion

Additional COVID-19 vaccination is effective and safe in immunosuppressant-treated autoimmune disease patients, regardless of whether MMF/MPA or MTX is withheld. Trial Registration. ClinicalTrials.gov (NCT#05000216).

The minimal clinically important difference of the scleroderma clinical trials consortium damage index

Objective

The Scleroderma Clinical Trials Consortium Damage Index is an index of global damage in systemic sclerosis. The objective of this study is to determine the minimal clinically important difference of the Scleroderma Clinical Trials Consortium Damage Index.

Methods

Patients in the Canadian Scleroderma Research Group registry and the Australian Scleroderma Cohort Study who completed Scleroderma Clinical Trials Consortium Damage Index scores and the SF36v2 at baseline and the first full follow-up visit were studied. To calculate the minimal clinically important difference, an anchor question came from SF36v2: "Compared to one year ago, how would you rate your health in general?." Options were: much better, somewhat better, about the same, somewhat worse and much worse. We use the "somewhat worse" or "much worse" categories to indicate those with any worsening. We used four anchor methods: receiver operating characteristic curve, change difference, regression analysis, and average change.

Results

We studied 1672 patients. Mean disease duration was 11.4 ± 10.0 years; 62.5% had diffuse cutaneous systemic sclerosis. Baseline mean Damage Index was 5.3 ± 4.2; mean change of Damage Index over 1 year was 0.9 ± 1.8 units. The calculated minimal clinically important difference values were 1 for receiver operating characteristic method, 0.625 for change difference, 0.1879 for regression analysis, and 1.37 for average change. Omitting the regression analysis method as an outlier, the mean of the other methods was 1.

Conclusion

The most appropriate minimal clinically important difference for the Scleroderma Clinical Trials Consortium Damage Index is a change of ⩾ 1.0 units in the Scleroderma Clinical Trials Consortium Damage Index as is already recognized by patients as a significant change after 1 year. This can be applied to group means as well as to individuals where an ordinal change is required.

Controlling nutritional status score as a sensitive instrument for malnutrition screening in systemic sclerosis - a retrospective study

Despite the high prevalence of malnutrition in Systemic Sclerosis (SSc), it often remains overlooked in daily routine. The study aimed to assess the nutritional status of SSc patients using two different tools, concerning their clinical presentation and laboratory results. This retrospective study included 44 SSc patients. We assessed malnutrition with the Malnutrition Universal Screening Tool (MUST) and the Controlling Nutritional Status (CONUT) score. Systemic involvement and laboratory parameters were analysed. Statistical analysis was performed using ANOVA Kruscal-Wallis with post-hoc tests for continuous variables and Chi2 tests for dichotomous variables. The CONUT revealed a substantial proportion of malnourished patients (n = 27; 61,4%), which was higher compared to the assessment with MUST (n = 14; 34,1%). CONUT-undernourished patients had higher C-reactive-protein (28,84 ± 31,72 versus 2,91 ± 2,18, p = 0,0126), higher red-cell-distribution-width (moderate-16,46 ± 2,52 versus normal-13,90 ± 1,03, p = 0,0150), lower hemoglobin (moderate-11,45 ± 2,28 versus normal-13,49 ± 1,28, p = 0,0426), higher N-terminal pro-B-type-natriuretic-peptide (moderate-3790,53 ± 6810,00 versus normal-193,87 ± 265,16, p = 0,0406). However, these observations were not confirmed for MUST-assessed malnutrition. The prevalence of malnutrition in our study was similar to other described cohorts. The CONUT score appeared to be a more sensitive screening tool for malnutrition, however, in patients with cardiological involvement, it may give false-positive results. This study is the first to evaluate SSc patients with the CONUT score, highlighting the need for further research to assess its effectiveness thoroughly.

Cardiac Involvement and Heart Failure Staging in Patients with Systemic Sclerosis Without Pulmonary Arterial Hypertension

Background/Objectives: Systemic sclerosis (SSc) is an autoimmune connective tissue disease characterized by fibrosis and vascular damage, significantly increasing the risk of heart failure (HF). Methods: This cross-sectional study included 61 SSc patients (92% female, mean age 63 ± 13 years), excluding those with pulmonary arterial hypertension, referred to a tertiary pulmonary hypertension center. HF stages were classified according to updated guidelines. Clinical, echocardiographic, hemodynamic, and functional capacity data were analyzed in relation to HF stages. Results: A total of 48% of patients had pre-symptomatic HF (5% stage A, 43% stage B), while 38% had symptomatic HF (stage C). Advanced HF stages were significantly associated with older age (p = 0.02) and multiorgan involvement (p = 0.045) but not with SSc subtype or autoantibodies. Structural and functional echocardiographic abnormalities were prevalent (77% and 10%, respectively). Markers of elevated ventricular filling pressure such as left atrial volume (p = 0.011) and E/e' ratio (p = 0.03) correlated with HF severity. Functional impairment was observed with lower 6 min walk test (6MWT) distance (p = 0.017), reduced VO2 peak (p = 0.015), and increased VE/VCO2 slope (p = 0.002). Resting pulmonary artery wedge pressure did not correlate with HF stage (p = 0.93). VE/VCO2 slope and 6MWT were independently associated with HF severity. Conclusions: Preclinical and symptomatic HF are highly prevalent in SSc patients. HF staging was linked to disease severity, age, and cardiovascular risk factors. Functional capacity tests (6MWT and CPET) serve as valuable tools for HF risk stratification. These findings highlight the critical need for comprehensive cardiovascular assessment and targeted management strategies to mitigate HF progression in SSc patients.

Lasso-derived model for early prediction of systemic sclerosis based on vasculopathy assessment: a population-based cohort study

OBJECTIVE

Vasculopathy is a key feature of systemic sclerosis (SSc) and is critical for its diagnosis and prognosis. We aimed to comprehensively analyze vascular lesions in patients with SSc and establish an early diagnostic model based on these lesions.

METHODS

We recruited 111 participants (45 healthy participants and 66 patients with SSc, mean age 49.75 ± 12.902 years). Age, sex, blood pressure, hand grip strength, skin thickness, proper palmar digital artery vascular index, skin blood flow index, and nailfold microcirculation were compared between the two groups. Applying Lasso regression for variable selection, we further developed a binary logistic regression model to analyze the diagnostic differences in disease occurrence based on the vascular injury status. We assessed the performance of the model using receiver operating characteristic (ROC) and calibration curve analyses to evaluate its diagnostic ability and determine the optimal cutoff value.

RESULTS

Using Lasso regression analysis, we identified 10 key variables from 37 microcirculation parameters, including age, left hand grip strength, left peak systolic velocity (PSV), right PSV, right resistance index (RI), ischemic perfusion (IPU), ischemic reperfusion perfusion (IRPU), post-occlusive reactive hyperemia baseline (PORH BL), loop top length, and nailfold video-capillaroscopy (NVC) score. Among these, the NVC score (Cut-off point = 5.35, AUC = 0.845, SEN = 0.74, SPE = 0.87), PSV (Cut-off point = 11.38, AUC = 0.838, SEN = 0.82, SPE = 0.73), IRPU (Cut-off point = 111.3, AUC = 0.831, SEN = 0.61, SPE = 0.91), and Grip (Cut-off point = 22.8, AUC = 0.781, SEN = 0.79, SPE = 0.62) demonstrated high diagnostic value in predicting SSc. The binary logistic regression model based on these variables provides better interpretability for advanced diagnosis of microcirculation multidimensional integration. Compared to the scleroderma pattern model, this model exhibited superior performance, with an area under the curve of 0.929 (95% CI: 0.883-0.974).

CONCLUSION

Our results highlight the key role of the nailfold video-capillaroscopy score, grip strength, and peak systolic flow velocity of the proper palmar digital artery in predicting systemic sclerosis events.

Interstitial lung disease in anti-U1RNP systemic sclerosis patients: A European Scleroderma Trials and Research analysis

Background

Interstitial lung disease is the leading cause of morbidity and mortality in systemic sclerosis, but it is characterized by significant heterogeneity in patient outcomes. So far, little is known about the influence of anti-U1RNP antibodies on lung outcomes in systemic sclerosis-associated interstitial lung disease patients.

Methods

European Scleroderma Trials and Research group systemic sclerosis patients with radiological-confirmed interstitial lung disease, available %predicted forced vital capacity, and autoantibody status were included. Baseline demographic and disease features were compared between anti-U1RNP positive and anti-U1RNP negative patients. Moreover, longitudinal analyses were done measuring relative change in %predicted forced vital capacity over 12 ± 6, 24 ± 6, and 36 ± 6 months, and changes were classified into stable (⩽ 4%), mild (5%-9%), and major progression (⩾ 10%). Predictors associated with death of any cause or major interstitial lung disease progression were evaluated in systemic sclerosis-associated interstitial lung disease patients with or without anti-U1RNP antibodies. Logistic regression analyses and Cox proportional hazards models adjusted for age and FVC were applied.

Results

A total of 6043 systemic sclerosis-associated interstitial lung disease patients were included for the analysis, among which 327 (5.4%) were positive for anti-U1RNP antibodies. Mean age was 56.8 ± 13.2 years and 4971 (82.3%) were women. Anti-U1RNP + systemic sclerosis-associated interstitial lung disease patients had more frequently limited cutaneous systemic sclerosis (63.5.5% vs 53.3%, p < 0.001), higher frequency of joint synovitis (18.1% vs 13.9%, p = 0.039), and myositis (24.0% vs 19.5%, p = 0.048). Anti-U1RNP + patients had a baseline lower mean forced vital capacity (82.0% vs 86.0%, p < 0.001) and lower mean %predicted diffusing capacity for carbon monoxide (57.0% vs 60.5%, p = 0.003). Periods of mild or major FVC decline and mortality rates were not statistically different between the groups.

Conclusion

Systemic sclerosis-associated interstitial lung disease patients positive for anti-U1RNP antibodies have more impaired baseline lung function but similar trajectories of forced vital capacity changes and mortality during the first 3 years of follow-up.

Markers of Endotoxemia and Inflammation are Associated with Digital Ulcers in Systemic Sclerosis Patients

BACKGROUND

The aim of this study was to evaluate the possible role of lipopolysaccharide-binding protein (LBP) and interleukin 6 (IL-6) in the development of digital ulcers (DUs) in Systemic sclerosis (SSc).

METHODS

60 SSc patients were enrolled and tested for serum levels of LBP and IL-6. The development of DUs was assessed in a 12-month follow-up period.

RESULTS

Median LBP and IL-6 were 107.445 ng/mL and 10.8 pg/mL whilst 33.3% patients had LBP ≥ 11995 ng/mL and 51.7% patients had IL-6 ≥ 12.5 pg/mL. DUs history were present in 41.7% SSc patients and at follow-up 23.3% patients developed new DUs. Baseline LBP (14105 ng/mL vs 10355 ng/mL, p < .001) and IL-6 (195 pg/mL vs 9.4 ng/mL, p < .001) were higher in SSc patients with new DUs. The ROC curves showed a good diagnostic accuracy for a cut-off of LBP ≥ 11995 ng/mL [AUC = 0.804 (95% CI = 0.656-0.951), p < .001] and for a cut-off of IL-6 ≥ 12.5 pg/mL [AUC = 0.897 (95% CI = 0.783-1.000), p < .001]. Free survival from new DUs was shorter in SSc patients with increased LBP (p < .001) or IL-6 (p = .003).

CONCLUSIONS

LPB or IL-6 could play a role in digital microvascular damage of SSc patients.

Serum Proteomic Markers in Patients with Systemic Sclerosis in Relation to Silica Exposure

Background: Systemic sclerosis (SSc) is a multisystem autoimmune disease characterised by fibrosis, vasculopathy, and immune dysfunction. Silica exposure has been associated with a more aggressive phenotype of the disease, including diffuse cutaneous involvement and interstitial lung disease. This study aims to identify proteomic differences between SSc patients exposed to silica and those not exposed to silica. Methods: An observational study of 32 SSc patients (11 silica-exposed and 21 non-exposed) was performed, with occupational history and quantitative proteomic analysis using SWATH-MS mass spectrometry. Differentially expressed proteins were analysed, and functional pathway enrichment was performed. Results: Eight proteins showed significant differences between groups, all with reduced levels in silica-exposed patients: adiponectin, immunoglobulins (IGLV3-19, IGLV2-18), complement C2, alpha-2-macroglobulin, vitronectin, cytoplasmic actin 2, and pigment epithelium-derived factor. Alterations in pathways related to fibrinolysis, complement activation, and inflammation were highlighted, suggesting that silica exposure may influence the pathogenesis of SSc and worsen its clinical course. Conclusions: This study supports the hypothesis that silica exposure is not only a triggering factor for SSc, but is also modulating its progression through inflammatory, procoagulant, and fibrotic pathways. The identification of proteomic biomarkers could contribute to the phenotypic classification of patients and the development of personalised therapies. Future studies should expand the cohort and further investigate the functional mechanisms of these proteins in 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.

Characteristics and management of systemic sclerosis-related osteomyelitis: a retrospective cohort study

Digital ulcers in patients with systemic sclerosis (SSc) can be complicated by SSc-related osteomyelitis (SRO). The microbiological data and optimal management of SRO remain unclear. This single-center retrospective study involved patients with SSc aged 18 or older from April 2005 to March 2022. Diagnosis of SRO was based on clinical presentation and MRI findings. The accuracy of the superficial swab culture results was estimated using the bone culture as a reference. Temporal changes in local signs for up to a year were collected, and their association with (1) duration of antimicrobial therapy (> 6 weeks) or (2) surgical interventions was assessed using univariable analyses. Among the 2,126 patients, 46 (2.2%) were diagnosed with SRO. In seven patients whose swab and bone cultures were both available, two (28.6%) had swab cultures identifying all the organisms detected in bone cultures. Resolution of local inflammatory signs consistently preceded wound closure. Three months after therapy initiation, prolonged antimicrobial therapy was not significantly associated with the resolution of local inflammatory signs (16/19 [84.2%] vs. 12/14 [85.7%]; P = 1.00), and surgical intervention was not significantly associated with wound dehiscence (6/9 [66.7%] vs. 20/24 [83.3%]; P = 0.36). Superficial swab cultures may not reliably reflect the true causative organism of SRO. Prolonging antimicrobial therapy beyond six weeks may be of little benefit for patients with SRO when local inflammatory signs improve. Surgical intervention may be a safe and effective option for selected patients with SRO.

Precision Medicine in Rheumatology: The Role of Biomarkers in Diagnosis and Treatment Optimization

Rheumatic diseases encompass a wide range of autoimmune and inflammatory disorders, including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), psoriatic arthritis (PsA), and systemic sclerosis (SSc). These conditions often result in chronic pain, disability, and reduced quality of life, with unpredictable disease courses that may lead to joint destruction, organ damage, or systemic complications. Biomarkers, defined as measurable indicators of biological processes or conditions, have the potential to transform clinical practice by improving disease diagnosis, monitoring, prognosis, and treatment decisions. While significant strides have been made in identifying and validating biomarkers in rheumatic diseases, challenges remain in their standardization, clinical utility, and integration into routine practice. This review provides an overview of the current state of biomarkers in rheumatic diseases, their roles in clinical settings, and the emerging advancements in the field.

Respiratory tract lining fluid copper content contributes to pulmonary oxidative stress in patients with systemic sclerosis

Background

Systemic sclerosis (SSc) is an autoimmune disease characterized by fibrosis of the skin and internal organs, mostly affecting young and middle-aged women. Significant questions remain as to its pathogenesis, especially the triggers for the associated interstitial lung disease (SSc-ILD). We examined the extent to which SSc and SSc-ILD were related to oxidative stress and altered metal homeostasis at the air-lung interface.

Methods

In this case-control study, we recruited 20 SSc patients, of which 11 had SSc-ILD. Eighteen healthy individuals were recruited as age-matched healthy controls, for a total of 38 study participants. Low molecular weight antioxidants (ascorbate, urate and glutathione), metal transport and chelation proteins (transferrin and ferritin) and metals (Fe and Cu) concentrations, including a measure of the catalytically active metal pool, were determined in respiratory tract lining fluid (RTLF) collected by bronchoalveolar lavage from the SSc group and compared with healthy controls.

Results

In the SSc group, 14 individuals were of female sex (70%) and the median age was 57 years (range 35-75). We observed evidence of oxidative stress in the RTLFs of SSc patients, characterised by increased concentrations of glutathione disulphide (GSSG, P<0.01), dehydroascorbate (DHA, P<0.05) and urate (P<0.01). This was associated with elevated RTLF Fe (P=0.07) and Cu (P<0.001), and evidence of a catalytic metal pool, demonstrated by an enhanced rate of ascorbate oxidation in the recovered lavage fluid (p<0.01). Cu concentrations were significantly associated with the ascorbate depletion rate (r=0.76, P<0.001), and GSSG (r=0.38, P<0.05) and protein carbonyl (r=0.44, P<0.01) concentrations. Whilst these markers were all increased in SSc patients, we found no evidence for an association with SSc-ILD.

Conclusions

These data confirm the presence of oxidative stress in the airways of SSc patients and, for the first time, suggest that an underlying defect in metal homeostasis at the air-lung interface may play a role in disease progression.

Disease Safety, Immunogenicity, and Efficacy of Recombinant Herpes Zoster Vaccine (RZV or Shingrix) in Autoimmune Rheumatic Diseases: Launching a Randomized Phase 4 Study

BACKGROUND

Patients with autoimmune rheumatic diseases (ARDs) are at an increased risk for herpes zoster (HZ). Vaccination is recommended for this population.

OBJECTIVE

The aim of this study was to evaluate the safety of vaccination with the recombinant zoster vaccine (Shingrix) in ARD patients, humoral immunogenicity (HI), cellular immunogenicity (CI), and the incidence of HZ.

METHODS

This randomized, double-blind, placebo-controlled phase 4 study involves 1180 ARD patients and a control group (CG) of 393 balanced healthy individuals, aged ≥50 years. ARD patients will be randomly assigned in a blinded manner (1:1 ratio) to 2 groups: vaccine or placebo (on days 0 and 42), administered intramuscularly. Outcomes will be assessed at baseline, 6 weeks, and 12 weeks after vaccination, including disease activity (using specific disease activity scores), HI, and CI. Adverse events will be assessed using a standardized questionnaire after each vaccine dose. Incident HZ cases will be monitored throughout the study. One year following the second dose, the persistence of HI and CI will be evaluated in both ARD patients and CG. HI and CI will be assessed using serum concentrations of anti-gE antibodies and the frequencies of gE-specific CD4+ T cells, respectively. Comparisons of anti-gE titers between ARD patients and CG at different time points will be analyzed using 2-way repeated-measures analysis of variance. Multiple regression analysis will be conducted, with a positive immune response as the dependent variable, and variables with p < 0.2 from univariate analysis as independent variables.

CONCLUSIONS

This large trial addresses a critical gap by examining disease safety, efficacy, adverse effects, and immunogenicity, considering the impact of diverse therapies following recombinant zoster vaccine administration in ARD patients.

Is Myopenia or Myosteatosis Clinically Relevant in Systemic Sclerosis? Skeletal Muscle Assessment Using Computed Tomography

OBJECTIVES

Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by fibrosis, vascular damage, and immune dysregulation, often leading to muscle abnormalities. This study aimed to evaluate the prevalence of myopenia and myosteatosis in SSc patients using computed tomography (CT) and their associations with clinical features, including lung disease and esophageal dilatation.

MATERIALS AND METHODS

SSc patients followed at Gazi University Rheumatology Clinic (2000-2024) who had thoracic CT imaging were included. Muscle mass and density were assessed at the L1 vertebral level. Skeletal muscle area (SMA) and skeletal muscle radiation attenuation (SMRA) were measured to identify myopenia and myosteatosis. Lung disease involvement and widest esophageal diameter (WED) were assessed via CT. Statistical analyses explored correlations between muscle metrics and clinical variables, with multiple linear regression identifying predictors.

RESULTS

Among 95 patients (54.7% diffuse SSc, 45.3% limited SSc; mean age 57.04 ± 13.65 years; female-to-male ratio 8.5:1), myopenia and myosteatosis prevalence were 27.3% and 41.1%, respectively. Myosteatosis was associated with female sex (p = 0.001), older age (p = 0.001), higher BMI (p = 0.043), and inflammation markers (CRP, ESR). Myopenia correlated with BMI (p = 0.001) but not clinical outcomes. Higher WED correlated with lower SMRA (p = 0.001). BMI predicted muscle mass (R² = 0.42), while age, gender, and BMI determined SMRA (R² = 0.67, p < 0.001).

CONCLUSIONS

Myosteatosis was more prevalent and strongly associated with clinical features, including lung disease and esophageal dilatation, than myopenia, underscoring the importance of muscle quality.

Frequency and implications of malnutrition in systemic sclerosis

OBJECTIVES

To quantify the frequency and impact of malnutrition in systemic sclerosis (SSc), as diagnosed by the Global Leadership Initiative on Malnutrition (GLIM) criteria, based on weight loss, BMI and muscle atrophy.

METHODS

Australian Scleroderma Cohort Study participants meeting ACR/EULAR criteria for SSc with ≥1 concurrent weight and height measurement were included. The chi-squared test, two-sample t-test or Wilcoxon's rank-sum test was used for between-group comparison as appropriate. Multivariable logistic regression models were used to establish the determinants of malnutrition diagnosis. Kaplan-Meier and Cox proportional hazard models were used for survival analyses, based on malnutrition diagnosis, and individual GLIM criteria (percentage weight loss, BMI thresholds and presence of muscle atrophy).

RESULTS

In this study of 1903 participants, 43% were diagnosed with malnutrition according to GLIM criteria, of whom 33% had severe malnutrition. Participants diagnosed with malnutrition were older, and more likely to have diffuse cutaneous SSc (dcSSc), higher SSc severity scores and RNA polymerase-3 positivity. Gastrointestinal (GI) involvement, multimorbidity, cardiopulmonary disease, raised inflammatory markers, hypoalbuminaemia and anaemia were more common in malnourished participants (P < 0.01). Multimorbidity (odds ratio [OR] 1.6; 95% CI: 1.2, 2.0; P < 0.01), pulmonary arterial hypertension (OR 2.1; 95% CI: 1.4, 2.0; P < 0.01) and upper GI symptoms (OR 1.6; 95% CI: 1.3, 2.0; P < 0.01) were all associated with malnutrition. Health-related quality-of-life (HRQoL) and physical function were poorer in malnourished participants. Survival was worse in those with malnutrition after adjusting for age, sex and dcSSc (hazard ratio 1.4; 95% CI: 1.1, 1.7; P < 0.01).

CONCLUSION

Malnutrition is common in SSc and confers poorer survival, HRQoL and physical function.

Systemic Sclerosis Dermal Fibroblast Exosomes Trigger Type 1 Interferon Responses in Keratinocytes via a TBK/JAK/STAT Signaling Axis

OBJECTIVE

Activation of type I interferon (IFN) response has been shown to correlate with disease activity in systemic sclerosis (SSc). It is currently unknown whether the tissue-specific type I IFN activation is a consequence of the response observed in blood or rather its source. Exosomes from SSc fibroblasts were recently shown to activate macrophages in vitro. Here, we aimed to determine the source of type I IFN signature in SSc skin biopsies and the potential role of exosomes from SSc dermal fibroblasts in the process.

METHODS

Skin biopsies were obtained from the forearms of healthy patients and of those with SSc and processed for dermal fibroblasts and keratinocytes. Exosomes were isolated from healthy and SSc dermal fibroblast supernatants by ultracentrifugation and added to human skin keratinocytes. Keratinocyte transcriptome was analyzed by RNA sequencing (RNA-seq) analysis. TANK-binding kinase (TBK) and JAK were inhibited using a small molecule inhibitor (GSK8612) and tofacitinib, respectively.

RESULTS

SSc skin biopsies showed the highest levels of type I IFN response in the epidermal layer. RNA-seq analysis of keratinocytes transcriptome following exposure to dermal fibroblast exosomes showed strong up-regulation of IFN signature genes induced by SSc exosomes compared to healthy control. Inhibition of TBK or JAK activity suppressed the up-regulation of the IFN signature induced by SSc exosomes.

CONCLUSION

IFN activation of SSc keratinocytes is dependent on their crosstalk with dermal fibroblasts and inducible by extracellular exosomes. Our data indicate that SSc fibroblast exosomes contribute to the type I IFN activation in SSc skin through activation of pattern recognition receptors upstream of TBK.

Rituximab retention rate in systemic sclerosis: a long term real-life multicentre study

OBJECTIVES

To report real-life data on rituximab retention rate as an indicator of safety and efficacy in a multicentric national cohort of systemic sclerosis patients.

METHODS

SSc patients treated with rituximab and followed for at least 36 months were included, clinically characterized and longitudinally monitored. A competing risk analysis with sub-hazard ratio (sHR) definition was performed to explore the clinical variables linked to specific cause of rituximab discontinuation.

RESULTS

One-hundred and fifty-two SSc-patients [mean age 47.3 (12.3) years; females 79.6%; diffuse disease 77.6%; anti-topoisomerase-I positivity 63.2%] were evaluated over a median (interquartile range) time of 3.3 (1.7-5.0) years. The primary indications for rituximab were interstitial lung disease (38.8%), worsening skin fibrosis (36.8%) and arthritis (13.8%); 138 patients (90.8%) received more than one rituximab course. The 5-year rituximab retention rate was 59.9% (44.6-64.7%). Clinical response was the most common reason for rituximab discontinuation [5.7; 95% CI: (3.7-8.4) per 100 patient-years] and was associated with a shorter disease duration (sHR 0.8; 95% CI: 0.7, 0.9), anti-topoisomerase-I negativity (sHR 0.4; 95% CI: 0.2, 0.9), previous digital ulcers (sHR 2.6; 95% CI: 1.1, 6.2) and no history of arthritis (sHR 0.3; 95% CI: 0.1, 0.8). Treatment failure was the second cause of rituximab discontinuation [3.7 (95% CI: 2.2, 6.0) per 100 patient-years] and was associated with anti-centromere antibody positivity (sHR 2.8; 95% CI: 1.1, 7.4) and anti-topoisomerase-I negativity (sHR 0.2; 95% CI: 0.1, 0.6). Adverse events (AEs) were the less common cause of discontinuation [3.1 (95% CI: 1.7, 5.2) per 100 patient-years], associated with limited cutaneous subset (sHR 3.4; 95% CI: 1.2, 9.7) and previous mycophenolate mofetil treatment (sHR 4.5; 95% CI: 1.2, 16.3).

CONCLUSION

Rituximab is a safe and effective treatment in SSc: clinical response emerged as the primary reason for rituximab discontinuation, and AEs had a limited impact on treatment persistence. The identification of specific disease features associated with a response to rituximab will be useful in the management of SSc-patients.

Detection of decline in pulmonary function in patients with systemic sclerosis-associated interstitial lung disease using home monitoring in the Netherlands (DecreaSSc): a prospective, observational study

BACKGROUND

In patients with systemic sclerosis, interstitial lung disease (ILD) is the leading cause of mortality. Early detection of progressive ILD associated with systemic sclerosis is warranted for timely adjustment of management strategies and improved prognosis. We aimed to investigate the validity of home spirometry to detect a decline in pulmonary function in patients with systemic sclerosis-associated ILD.

METHODS

DecreaSSc was a prospective, observational study done in two tertiary referral centres in the Netherlands. Eligible patients were aged 18 years or older, fulfilled the American College of Rheumatology-European Alliance of Associations for Rheumatology criteria for systemic sclerosis, had a disease duration from first non-Raynaud phenomenon symptom of 5 years or less, had high-resolution CT-confirmed diagnosis of ILD, and had a maximum immunosuppressive treatment duration of 8 weeks at baseline. Patients took weekly home spirometry measurements using a handheld spirometer for 1 year. At baseline and at semi-annual study visits, patients pulmonary function testing was done in the hospital and patients completed questionnaires on patient-reported outcome measurements. The primary outcome was the κ agreement between home and hospital measurements after 1 year to detect a decline in force vital capacity (FVC) of 5% or more, estimated using separate linear regression analyses for home-based and hospital-based FVC% predicted in individual patients. The sensitivity and specificity of home spirometry to detect an absolute decline in FVC% predicted of 5% or more was assessed using the hospital pulmonary function test as the gold standard. The longitudinal correlation between hospital and home measurements was assessed with regression analysis, whereas the cross-sectional correlation was assessed with the intraclass coefficient. People with lived experience were involved at several stages of the study.

FINDINGS

Between Jan 26, 2021, and Feb 27, 2023, 43 patients were enrolled, 35 of whom completed 6 months of follow-up and 31 of whom completed 12 months of follow-up. The last follow-up visit took place on March 28, 2024. 20 (57%) of patients were women and 15 (43%) were men; 32 (91%) were White. Mean age was 57·7 years (SD 10·7). The agreement between hospital and home measurements had a κ value of 0·40 (95% CI 0·01-0·79). The sensitivity of home spirometry to detect a decline in FVC% predicted of 5% or more was 60% (95% CI 44-76) and specificity was 87% (75-98). Regression analysis showed that the course of pulmonary function was not different between hospital and home assessment as the interaction term was not significant (-0·0003 [95% CI -0·0006 to 0·000008]; p=0·057) with a longitudinal correlation of 0·55 (95% CI 0·26-0·74; p=0·0070). The intraclass coefficient between both measurements was 0·85 (95% CI 0·73-0·92; p<0·0001) at baseline, 0·84 (0·71-0·92; p<0·0001) at 6 months, and 0·72 (0·50-0·86; p<0·0001) at 12 months.

INTERPRETATION

Home spirometry has the potential to detect a decline in pulmonary function in patients with systemic sclerosis-associated ILD earlier when used in addition to regular health care management. Future research could reveal whether home spirometry can contribute to improved outcomes of patients with systemic sclerosis-associated ILD.

FUNDING

Galapagos and Boehringer Ingelheim.

Efficacy of methylprednisolone in very early systemic sclerosis: results of the 'Hit Hard and Early' randomized controlled trial

OBJECTIVE

We hypothesized that glucocorticoids would induce remission in very early systemic sclerosis (SSc) patients by inhibition of inflammation driving the disease. We examined the efficacy and safety of methylprednisolone in very early SSc.

METHODS

In this trial adults with puffy fingers for less than 3 years, specific auto-antibodies and meeting the Very Early Diagnosis of Systemic Sclerosis criteria were randomly assigned (2:1) to methylprednisolone 1000 mg i.v. or placebo for three consecutive days three times with monthly intervals. The primary end point was nailfold capillary density at week 12. Capillary density at 52 weeks, number of megacapillaries and patient-reported outcomes were secondary outcomes. In addition, we assessed disease progression and lung function decline over 52 weeks. We used linear regression analyses adjusted for baseline values and stratification variables to estimate differences between groups.

RESULTS

Between February 2017 and February 2021, 87 patients were screened, of whom 30 (70% female, median [interquartile range, IQR] age 52.9 [40.8-60.8] years, median [IQR] disease duration 11.4 [4.6-18.6] months) were randomly assigned to methylprednisolone (n = 21) or placebo (n = 9). We found no difference in nailfold capillary density at 12 weeks (-0.5 [95% CI: -1.1, 0.2]) nor in any of the secondary outcomes. Eleven (37%) patients showed disease progression during 1 year follow-up, and seven (23%) patients had a relevant pulmonary function decline. No serious adverse events were reported.

CONCLUSION

No clinically relevant effect of short-term methylprednisolone in patients with very early SSc was observed. A substantial proportion of patients showed disease progression.

TRIAL REGISTRATION

clinicaltrials.gov, NCT03059979.

Secondary cryofibrinogenemia is related to more severe microangiopathic involvement in systemic sclerosis: results from a retrospective observational study

The aims of this study were to investigate the prevalence of cryofibrinogenemia in a cohort of patients with systemic sclerosis (SSc) regardless of clinical manifestations, who were admitted to our hospital and determine the associations among CF positivity, disease features and ongoing therapies. This was a monocentric and retrospective study. The inclusion criteria were a diagnosis of SSc (according to the ACR/EULAR 2013 classification criteria), regular administration of i.v. prostanoids, and CF testing between February 2020 and February 2022. Data on demographic, clinical, and immunological features and ongoing treatments were retrospectively collected. Categorical data were compared with the chi-square test or Fisher's exact test, while quantitative variables comparisons were carried out with Student's t test or Mann‒Whitney test. In total, 101 SSc patients were ultimately enrolled. The majority of patients were female (92.1%) and had the limited cutaneous form of SSc (81.2%). CF positivity was observed in 69.3% of the patients, whereas only 9% presented cryoglobulins and CF. CF positivity was negatively associated to RNAP3 antibodies (p = 0.027). No direct associations with specific clinical phenotypes were observed. No associations with immunosuppressive treatments were identified, however a positive association with nifedipine administration (p = 0.040), and a negative association with endothelin receptor antagonists (ERAs) plus phosphodiesterase-5 (PDE5) inhibitors regimen (p = 0.031) were observed. Macitentan administration was also associated to CF cryocrit ≥ 1% (p = 0.045). Among patients who were not treated with ERAs, an estimated pulmonary artery systolic pressure ≥ 30 mmHg was significantly associated with CF positivity (p = 0.025). Moreover, a cryocrit ≥3% was associated with a relative risk of 3.44 (95% CI 1.26-9.39, p = 0.016) for digital amputation and 5.17 (95% CI 1.18-22.6, p = 0.029) for death. Isolated CF is a frequent phenomenon observed in SSc patients and is associated with a higher administration of vasoactive drugs, probably identifying a SSc clinical phenotype with a more severe microvascular involvement. Moreover, a higher cryocrit is associated with an increased risk of death and digital amputations. Screening SSc patients for CF would represent an opportunity to provide better therapeutic approaches by anticipating ERA administration in an earlier phase, thereby preventing the manifestation of severe microvascular involvement. Key Points • Cryofibrinogen is a cryoprotein that can cause microangiopathic damage. • Isolated cryofibrinogenemia is common in patients with systemic sclerosis. • SSc patients should be tested for cryofibrinogen because a high cryocrit (≥ 3%) is associated with death and/or digital amputation due to necrosis. • Cryofibrinogen is associated with indirect markers of pulmonary arterial hypertension in patients not treated with endothelin receptor agonists (ERAs). • ERAs could play a role in preventing cryofibrinogen damage.

Functional Capacity Incorporating Dynamic Ventilation in Systemic Sclerosis: Agreement Analysis Between Performance on the 6-Minute Walk Test and Glittre-ADL Test

BackgroundFunctional capacity at submaximal exercise levels has become more popular as an outcome measure in systemic sclerosis (SSc). However, it is necessary to know the ventilatory requirements of the different field tests.ObjectivesTo verify the agreement of the ventilatory dynamics measured at submaximal exercise between the the Glittre-ADL test (TGlittre) and the 6-min walk test (6MWT) and, secondarily, to evaluate the correlations of these measurements with clinical and functional variables in women with SSc (wwSSc).MethodsThis was a cross-sectional study in which 30 wwSSc underwent the 6MWT and TGlittre while hooked to a device reading their ventilatory demand. Physical function was assessed on the Health Assessment Questionnaire Disability Index (HAQ-DI), and lung function was assessed by spirometry.ResultsThe median 6-min walking distance (6MWD) was 344 (282-410) metres, and 25 (83.3%) participants did not reach 80% of the predicted distance. The median TGlittre time was 147 (107-188) seconds, and 18 (60%) participants exceeded 120% of the predicted time. There was agreement between the two tests on the following variables: heart rate (ICC = 0.883, P < 0.0001), breathing reserve (ICC = 0.816, P < 0.0001), peripheral oxygen saturation (ICC = 0.752, P = 0.0009), inspiratory capacity (ICC = 0.690, P < 0.0001), and peak minute ventilation (ICC = 0.433, P = 0.007). There was a weak correlation between 6MWD and TGlittre time (rs=-0.353, P = 0.05). 6MWD correlated significantly with the HAQ-DI score (rs=-0.606, P = 0.0004) and forced vital capacity (FVC, rs = 0.427, P = 0.018). TGlittre time correlated significantly with HAQ-DI (rs = 0.440, P = 0.015) and FVC (rs=-0.404, P = 0.026).ConclusionIn wwSSc, the 6MWT and TGlittre have almost the same ventilatory requirements, although these patients perform worse in the 6MWT. 6MWD and TGlittre time are weakly correlated. Both 6MWD and TGlittre time are associated with physical function and lung function. Therefore, both tests should be used in clinical practice for the monitoring of these patients as they are complementary.

Psychometric Evaluation of the Scleroderma Skin Questionnaire: A Novel Patient-Reported Outcome for Skin Disease in Patients With Systemic Sclerosis

OBJECTIVE

We aimed to evaluate the psychometric properties of the Scleroderma Skin Questionnaire (SSQ), a novel patient-reported outcome (PRO) to assess systemic sclerosis (SSc)-related skin symptoms.

METHODS

Participants were recruited from the SSc Collaborative National Quality and Efficacy Registry (CONQUER). Internal consistency was determined using Cronbach α and McDonald ω total (ωt). The correlation of the SSQ was assessed with the modified Rodnan skin score (mRSS), physician global assessment (PGA), Scleroderma Health Assessment Questionnaire, 29-item Patient-Reported Outcomes Measurement Information System (PROMIS-29), and patient global assessment to assess criterion, convergent, and divergent validity. Correlations were also assessed between patients' self-reported recall of skin changes over the past 6 months ("SSQ 6-Month") and 6-month change in mRSS.

RESULTS

The SSQ was administered to 799 adults (mean age 52.7; 83% female) enrolled in CONQUER. Cronbach α was 0.90 and ωt was 0.92, indicating high internal consistency. The SSQ was moderately correlated with mRSS (r 0.56), with stronger correlations in diffuse (r 0.54) vs limited cutaneous subtypes (r 0.24; all P < 0.05). The SSQ was also moderately-to-strongly correlated with PROMIS-29 physical function (r -0.50) and pain interference subscales (r 0.61), strongly with Health Assessment Questionnaire score (r 0.63) and severity subscale (r 0.62), and moderately with PGA SSc activity score (r 0.48; all P < 0.05). SSQ 6-Month correlated weakly with the 6-month change in mRSS (r 0.26; P < 0.05).

CONCLUSION

SSQ demonstrated high reliability and moderate correlation with mRSS and legacy PROs. This study provides initial support for SSQ, but not SSQ 6-Month, to assess skin symptoms in patients with SSc.

Occupational dust and chemical exposures and the development of autoimmune rheumatic diseases

Although the association between certain occupational exposures and the development of autoimmune rheumatic disease was first described over a century ago, this association has only become more widely recognized in the past 10 years because of the use of high-silica-content engineered stone in construction and home renovation. There is now a substantial and growing body of evidence that occupational dust and chemical exposure, be it through mining, stonemasonry, building or other trades, increases the risk of various systemic autoimmune rheumatic diseases (SARDs) including rheumatoid arthritis and systemic sclerosis. Although the pathogenic mechanisms of silica-induced autoimmunity are not fully elucidated, it is thought that alveolar macrophage ingestion of silica and the ensuing phagosomal damage is an initiating event that ultimately leads to production of autoantibodies and immune-mediated tissue injury. The purportedly causal association between occupational exposure to chemicals, such as organic solvents, and an increased risk of SARDs is less frequently recognized compared with silica dust, and its immunopathogenesis is less well understood. An appreciation of the importance of occupational dust and chemical exposures in the development of SARDs has implications for workplace health and safety regulations and offers a unique opportunity to better understand autoimmune disease pathogenesis and implement preventative strategies.

ADAM17/PTGS2 Facilitates Pulmonary Fibrosis by Regulating Ferroptosis

Pulmonary fibrosis (PF) is a chronic and progressive interstitial lung disease characterised by excessive deposition of extracellular matrix (ECM), resulting in high mortality rates. In this study, we provide evidence that ADAM17/PTGS2 plays a crucial role in inducing ferroptosis in fibroblasts, promoting PF. Initially, an assessment was made of ADAM17 protein levels in patients diagnosed with connective tissue diseases-interstitial lung diseases (CTD-ILD), using ELISA assays. Confirmation of the relationship between ADAM17 and fibrosis was achieved by stimulating cells with PMA or TAPI-1 (the ADAM17 inhibitor), in conjunction with the fibrosis-inducing factor, TGFβ1. To further explore the major downstream proteins of ADAM17 contributing to altered PF, we employed mRNA transcriptomics. To further investigate the role of ADAM17/PTGS2 in promoting ferroptosis and fibrosis, we employed western blot assays, immunofluorescence and transmission electron microscopy (TEM). Furthermore, the effects of the ADAM17/PTGS2/ferroptosis pathway in PF were verified using Adeno-associated virus (AAV)-mediated ADAM17 gene knockdown in mice. In CTD-ILD patients, ADAM17 expression was significantly elevated. Upon PMA stimulation, lung fibroblasts exhibited increased fibrosis-related proteins, and the combined stimulation of PMA and TGFβ1 synergistically promoted cellular fibrosis. Conversely, TAPI-1 alleviated fibrotic stimulation induced by TGFβ1. Transcriptomic analysis of lung fibroblast specimens overexpressing ADAM17 revealed significantly elevated PTGS2 expression levels. Knockdown and ferroptosis inhibition assays demonstrated that ADAM17 regulates ferroptosis in lung fibroblasts via PTGS2, ultimately inducing fibrosis. Furthermore, the deficiency of ADAM17 alleviated bleomycin-induced PF and inflammation in mice. These findings first verified that ADAM17/PTGS2/ferroptosis is a novel mechanism for regulating PF; it provides a new theoretical basis for further exploring the treatment of PF.

Postural stability and fall risk in systemic sclerosis patients

Objectives

This study aims to objectively assess the fall risk and postural balance status of systemic sclerosis (SS) patients and investigate its association with various clinical findings.

Patients and methods

The cross-sectional study was conducted between July 2020 and September 2020. The study included 14 patients (12 females, 2 males; mean age: 48.4±12.3 years; range, 21 to 63 years) diagnosed with SS and a control group of 20 healthy volunteers (17 females, 3 males; mean age: 46.8±9.0 years; range, 25 to 60 years). Demographic and clinical data of the participants were noted. Results of anti-nuclear antibodies and anti-Scl-70 antibodies were recorded. The fall index, indicating fall risk, was determined using a posturography device, and postural stability measurements were performed. The Falls Efficacy Scale-International was used to evaluate fall activity. The modified Rodnan skin score was used to assess the degree of cutaneous involvement in SS.

Results

Fall index results were higher in the SS group (p<0.05). The rate of falls in the past year among SS patients was 7.1%. The SS group showed deviations from the normal population in the postural measurement when eyes closed on a solid surface in normal position with the stability index, eyes closed on a pillow with the stability index, and eyes closed on a solid surface with the head tilted 30° forward with the weight distribution index (p<0.05). Fear of falling scores were higher in diffuse-type SS compared to limited-type SS (p<0.01). No differences were observed in other parameters.

Conclusion

This study revealed impaired postural balance and increased fall risk in SS patients compared to the normal population. Evaluation of postural balance and fall risk in SS patients should be done in the early period, and necessary treatments should be applied.

Clinical significance of histological inflammation in systemic sclerosis-associated interstitial lung disease

BACKGROUND

Systemic sclerosis-associated interstitial lung disease (SSc-ILD) is known to have a poor prognosis and the relationships between histological findings and response to anti-inflammatory therapy or prognosis have not been well investigated.

METHODS

We examined SSc-ILD patients who underwent surgical lung biopsy at a single respiratory center between 2008 and 2021 and received anti-inflammatory therapy (corticosteroids and/or immunosuppressive drugs). These patients were classified into two groups: an inflammation group, where histological evidence of inflammation defined as "lymphoid aggregates with germinal centers" or "plasmacytosis" was observed, and a non-inflammation group, where these findings were not observed. The correlation of the histological conclusions of inflammation with treatment response and prognosis was retrospectively investigated.

RESULTS

Twenty-seven patients were included in the study; 15 (55.6%) were allocated to the inflammation group and 12 (44.4%) to the non-inflammation group. Patient backgrounds did not differ between the groups. The first annual increase in % predicted FVC was significantly larger in the inflammation group than in the non-inflammation one (from 74.3% to 85.9% vs. 75.0%-74.7%, respectively; p = 0.021). The inflammation group took significantly longer to reach end-stage lung disease, defined as an FVC <50%, needing continuous oxygen, or death (p = 0.011). They also had a trend towards longer overall survival compared to the non-inflammation group (median survival: not reached vs. 6.6 years, p = 0.083).

CONCLUSIONS

Approximately half of the SSc-ILD patients showed histological evidence of inflammation, which may influence treatment response and long-term disease progression.

Differential Item Functioning on the Cochin Hand Function Scale Among People With Systemic Sclerosis by Language, Sex, and Disease Subtype: A Scleroderma Patient-Centered Intervention Network (SPIN) Cohort Study

OBJECTIVE

To evaluate the degree that the Cochin Hand Function Scale (CHFS) generates scores that are comparable across language, sex, and disease subtype.

METHODS

We included participants enrolled in the Scleroderma Patient-centered Intervention Network (SPIN) Cohort who completed the CHFS at their baseline assessment between April 2014 and September 2020. Confirmatory factor analysis (CFA) was used to test unidimensionality, and multiple indicator multiple cause (MIMIC) models were used for differential item functioning (DIF) analysis based on language, sex, and disease subtype. Both intraclass correlation coefficient (ICC) and Pearson's correlation were calculated using factor scores obtained from unadjusted and DIF-adjusted MIMIC models to evaluate agreement and correlation between scores.

RESULTS

A total of 2,155 participants were included. CFA with covarying error terms supported a good fit of the model (χ2[127] = 1,754.671; P < 0.001; Tucker-Lewis index = 0.985; comparative fit index = 0.987; root mean square error of approximation = 0.077). Nine items displayed statistically significant DIF for language of administration, 10 items for sex, and 10 items for disease subtype. However, the overall impact of DIF was negligible when comparing factor scores that did and did not account for DIF (ICC = 0.999; r = 0.999).

CONCLUSION

The CHFS has score comparability in systemic sclerosis regardless of participants' language, sex, and disease subtype.

Validation of a semi-quantitative method to assess interstitial lung disease severity and progression in systemic sclerosis by standard and low-dose HRCT scans

BACKGROUND

While the presence of distinct imaging abnormalities by high-resolution CT (HRCT) defines interstitial lung disease (ILD), there is a relative lack of validated methods to quantify these abnormalities in clinical practice, limiting ILD severity and progression assessments. We aimed to validate a semi-quantitative method for lung fibrosis assessment in patients with systemic sclerosis associated ILD (SSc-ILD) by standard and low-dose HRCT, considering lung structure and function as integral components of ILD evaluation.

METHODS

SSc patients from Oslo and Zurich with HRCT images, pulmonary function tests, including forced vital capacity (FVC), diffusing capacity for carbon monoxide (DLCO) and the 6-minute walk test with oxygen (O2) desaturation were enrolled. We validated the semi-quantitative fibrosis extent method by HRCT using criteria for content and construct validity, discrimination, sensitivity to change and feasibility, as well as inter- and intra-rater variability.

RESULTS

65 SSc patients from Zurich and 90 from Oslo were included. Significant correlations were observed between the extent of fibrosis on HRCT and FVC (r=-0.517, p<0.001), DLCO (r=-0.400, p<0.001) and O2 desaturation (r=-0.500, p<0.001), indicating content, construct and criterion validity. Discrimination and sensitivity to change assessments showed moderate correlation with DLCO (r=-0.377, p=0.003) but not with FVC or O2 desaturation. Inter- and intra-rater variability demonstrated excellent reliability (κ=0.891 and κ=0.996, respectively), with HRCT quantification averaging 9-15 min, indicating high feasibility.

CONCLUSION

This study confirms that semi-quantitative fibrosis assessment of HRCT for SSc-ILD meets most validation criteria, supporting its use in clinical practice and showing additive value of structural to functional ILD assessment.

Assessment of Factors Related to Sarcopenia in Patients with Systemic Sclerosis

Objectives: Systemic sclerosis (SSc) patients exhibit a heightened vulnerability to sarcopenia, a condition characterized by the loss of muscle mass and strength. This study aims to determine the prevalence of sarcopenia in patients with SSc and to investigate the associated factors contributing to this condition. Methods: Eighty patients with SSc were included in the study, and their demographic and clinical characteristics, body composition by bioelectrical impedance analysis, SARC-F score, chair-stand test performance, and 4 m walking speed were recorded. Results: Among the 80 participants, 91.3% were female, with a median age of 56.5 years (range 45-65). The majority (70%) had limited SSc, and 71.3% reported at least one comorbidity. According to the International Physical Activity Questionnaire, only 12.5% of participants met the criteria for an active lifestyle. The SARC-F questionnaire indicated that 20% of patients were at risk for sarcopenia. The prevalence of sarcopenia among patients showed considerable variability: 5% (95% CI 0.1-9) were identified through the appendicular skeletal muscle index (ASMI), 8.8% (95% CI 2.4-15) via the fat-free mass index (FFMI), and a concerning 20% (95% CI 11-29) according to the skeletal muscle mass index (SSMI). A multivariate logistic regression analysis identified age as the only factor significantly influencing the SARC-F score, with an odds ratio of 1.081 (95% CI 1.012-1.154, p = 0.020). Additionally, the older age group demonstrated a lower level of physical activity, poorer chair-stand test outcome, and slower 4 m gait speeds (p = 0.013, p = 0.008, p = 0.001, respectively), as well as a higher reported frequency of falls (p = 0.039). Conclusions: Sarcopenia is a prevalent issue among individuals with SSc, particularly in the older population. This study did not identify a direct correlation between sarcopenia and SSc subtype, disease activity, or other clinical parameters. However, the need for an improved cut-off value for diagnosing sarcopenia in this specific cohort is evident.

A cohort study in HigAshi-nippon of Pulmonary hyPertensIoN in systEmic SclerosiS (HAPPINESS study): protocol and baseline data for an observational study

BACKGROUND

Pulmonary hypertension (PH) is the leading cause of death among patients with systemic sclerosis (SSc). Recently, early therapeutic intervention to improve the prognosis was suggested, and the definition of PH was recently revised by lowering the cut-off value of mean pulmonary arterial pressure (mPAP) from ≥ 25 to > 20 mmHg. However, the optimal threshold for therapeutic intervention remains unclear. We aim to evaluate the prognosis of patients with SSc and its relationship with mPAP.

METHODS

For this non-interventional retrospective and prospective cohort study, we enrolled patients with SSc or scleroderma spectrum disorders accompanied by other connective tissue diseases who underwent right heart catheterization (RHC) for suspected PH from 2010 to 2023. The date of the first RHC was defined as the baseline. Enrolled patients were classified into three groups based on their mPAP at the first RHC (≤ 20, 21-24, and ≥ 25 mmHg) and are being observed from baseline up to three years. The primary endpoint is the time between the first RHC and the first hospitalisation or death due to worsening PH.

RESULTS

This study was approved by the Ethics Committee of Hokkaido University Hospital. A total of 229 patients were enrolled from 12 participating centres, with 41 prospectively followed up and 188 retrospectively followed up. The number of patients in each group (an mPAP of ≤ 20, 21-24, and ≥ 25 mmHg) is 79, 26, and 124, respectively. The observation is expected to be completed by December 2026. Findings will be disseminated at scientific conferences, peer-reviewed journals.

CONCLUSIONS

The findings of this study that we will obtain are expected to provide important information that will lead to improvements in the diagnosis of PH and the prognosis of patients.

TRIAL REGISTRATION

This study was approved by the Ethics Committee of Hokkaido University Hospital (approval number 022-0109). It has been registered in the Japan Registry of Clinical Trials as jRCT1010220025 since November 7, 2022.

The impact of systemic sclerosis on women's health evaluated with an ad hoc-developed patient-reported questionnaire

Objective

The impact of disease on women's health-related quality of life has become increasingly important in patients with rheumatic diseases (RDs). Systemic sclerosis (SSc) mostly affects women with a broad spectrum of clinical presentations and severity, and a variable impact on daily living. The objective of the present study was to specifically address "women's health" in systemic sclerosis patients through a dedicated questionnaire.

Methods

An anonymous self-reported questionnaire (only in Italian) was developed in collaboration with obstetricians and gynecologists and subsequently revised and approved by five patient representatives. The questionnaire was administered to SSc patients during scheduled visits in an outpatient Rheumatology SSc Clinic.

Results

Between April 2021 and March 2023, 168 patients accepted to participate; among them, 44.1% had received their SSc diagnosis during reproductive age (<45 years). The questionnaire was composed of 44 questions and included 5 sections encompassing different topics. A high rate of adherence to female cancer screening programs was recorded (86.9% for cervix and 93.6% for breast cancer), while a non-regular gynecological follow-up was observed in 36.4%, mostly in patients with more severe disease phenotype. Only 42.3% accepted to compile the Female Sexual Function Index (FSFI), which indicated a sexual dysfunction (score ⩽ 26.55) in 66.2% of patients. A worse sexual function was shown to be associated with different disease manifestations, including digital ulcers. More than 90% of patients who expressed a desire for pregnancy after diagnosis received medical pre-conception counseling and were satisfied with the information provided. In contrast, discussion about contraception occurred in 37.8% of patients who had been diagnosed during fertile age. Family planning still represents an unmet need, as 43.6% of patients did not achieve their desired family size, mainly due to concerns about their capacity to care for their children.

Conclusion

The newly developed questionnaire provides a unique opportunity to comprehensively assess the experience of women with SSc. Disease burden was shown to negatively impact sexual function and adherence to regular gynecological visits. Furthermore, receiving a diagnosis during reproductive age may increase the likelihood of a reduced family size. Clinicians who take care of women with SSc should implement these domains into routine management, thus improving the health literacy of their patients.

Lung Ultrasound for Assessment of Interstitial Lung Disease in Systemic Sclerosis: Relationship With High-Resolution Computed Tomography and Nailfold Capillaroscopy

Background

Lung ultrasound (LUS) has been recently proposed as a convenient and radiation-free imaging modality for the evaluation of systemic sclerosis-related interstitial lung disease.

Objectives

The current study evaluates the relation between LUS and both high-resolution computed tomography (HRCT) and capillaroscopy findings in patients with systemic sclerosis.

Design

This cross-sectional study included 32 patients with systemic sclerosis.

Methods

Besides clinical evaluation, all participants underwent LUS, HRCT, pulmonary function tests (PFT), and nailfold video-capillaroscopy (NVC). All participants' data were compared and correlated.

Results

There is an excellent agreement between number of B-lines and HRCT score (interclass correlation = 0.864, P-value < .001). A significant positive correlation exists between number of B-lines and disease duration (r = 0.459, P-value = .008). Conversely, the number of B-lines is negatively correlated with capillary density (r = -0.687, P-value < .001), forced expiratory volume in the first second (FEV1) (r = -0.886, P-value < .001), and forced vital capacity (FVC) (r = -0.898, P-value < .001). Patients with either neoangiogenesis or previous/current digital ulcers had significantly higher number of B-lines than those without (P-value < .001, .016, respectively).

Conclusion

The number of B-lines parallels the HRCT score and the extent of digital vascular damage as indicated by NVC and clinical digital ulcers. Lung ultrasound has proven to be a reliable radiation-free modality for screening of systemic sclerosis-related interstitial lung disease and detecting its extent.

Imaging findings of scleroderma-associated myopathy: A systematic literature review

AIMS

Systemic sclerosis (SSc) affects skeletal muscle directly, with SSc-associated myopathy (SSc-myopathy) increasingly recognised as a distinct immune-mediated myopathy. Manual muscle testing and creatine kinase (CK) are insensitive diagnostic tools for SSc-myopathy. We aimed to evaluate the role of imaging in SSc-myopathy diagnosis.

METHODS

A systematic search of MEDLINE(Ovid), Pubmed, and EMBASE databases was performed to identify studies of ≥10 SSc patients that reported skeletal muscle imaging results. Eligibility criteria were defined a priori. Risk of bias assessment was performed using the National Heart, Lung and Blood Institute (NHLBI) quality assessment tool. Descriptive summaries were used to present data owing to inter-study heterogeneity.

RESULTS

Of 2426 studies identified, 17 articles met the inclusion criteria. Imaging modalities varied, but magnetic resonance imaging (MRI) was the most commonly applied imaging technique (n = 9 studies). Abnormalities on MRI were reported in 38-100 % of patients and included muscle oedema, atrophy, and fatty infiltration. Changes were observed in skeletal muscles (n = 14 studies), axial muscles (n = 1), masseter muscle (n = 1), and accessory respiratory muscles (n = 2). Blood oxygenation level-dependent MRI, dynamic contrast-enhanced ultrasound, and scintigraphic evaluation have each been used to assess skeletal muscle perfusion. A lack of correlation between creatine kinase, clinical weakness, and imaging findings was consistently reported. We were unable to identify any distinct imaging patterns or relationship between imaging and histopathological skeletal muscle abnormalities owing to limited data available.

CONCLUSION

Imaging detects inflammatory, atrophic, and vasculopathic changes in the skeletal musculature of SSc patients. The discordance between clinical assessment and imaging findings underscores the potential role for muscle imaging to both screen and diagnose SSc-myopathy.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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