Disease severity of 100 patients with systemic sclerosis over a period of 14 years: using a modified Medsger scale

Agreement Between Physician Evaluation and the Composite Response Index in Diffuse Cutaneous Systemic Sclerosis

OBJECTIVE

Diffuse cutaneous systemic sclerosis (SSc) is a highly heterogeneous disease. A provisionally approved Composite Response Index in diffuse cutaneous SSc (CRISS) was developed as a 1-year outcome measure for clinical trials. Our goal was to further validate the CRISS by examining agreement between CRISS definitions for improved/non-improved with physicians' evaluation of disease.

METHODS

Patient profiles from a large observational cohort were created for 50 random diffuse cutaneous SSc patients of <5 years disease duration with improved CRISS scores after 1 year and 50 with non-improved CRISS scores. Profiles described disease features used during the initial CRISS development at baseline and at 1 year. Each profile was independently rated by 3 expert physicians. Majority opinion determined whether a patient was improved or not improved, and kappa agreement with the CRISS cutoff of 0.6 was calculated.

RESULTS

Patients had mean ± SD disease duration of 2.2 ± 1.3 years. There was substantial agreement between the physician majority opinion about each case and the CRISS (κ = 0.76 [95% confidence interval (95% CI) 0.64-0.88]). The agreement between each individual physician opinion and the CRISS was also substantial (κ = 0.70 [95% CI 0.62-0.78]). All CRISS non-improvers were also rated as non-improved by physician majority; however, 12 CRISS improvers were rated as non-improved by physicians.

CONCLUSION

There was substantial agreement between the dichotomous CRISS rating and physician assessment of diffuse cutaneous SSc patients after 1 year. This supports the use of a CRISS cutoff at 0.6 for improvement versus non-improvement, although the CRISS tended to rate more patients as improved than did physicians.

Ultrasound evaluation of bowel vasculopathy in systemic sclerosis

BACKGROUND

Gastrointestinal (GI) manifestations are frequent in systemic sclerosis (SSc) with an impact on quality of life and morbidity. Bowel vasculopathy is a key pathogenetic factor responsible for GI involvement.

OBJECTIVES

To compare abdominal ultrasound (US) and Color Doppler Ultrasonography (CDU) features of splanchnic vessels of SSc patients with healthy controls.

METHODS

The charts of SSc patients who underwent an abdominal US and CDU study were retrospectively analyzed. For Superior Mesenteric Artery (SMA) and Inferior Mesenteric Artery (IMA) caliber, Peak Systolic Velocity (PSV), Reverse Velocity (RV), End-Diastolic Velocity (EDV), Mean Velocity (mV), Blood-flow, Resistive Index (RI) and Pulsatility Index (PI) were recorded.

RESULTS

28 SSc patients and 28 controls were enrolled. In SSc, caliber of SMA was significantly smaller than in controls (5.75 ± 0.62 mm vs. 6.45 ± 0.60 mm, p < 0.0001 - p adj =0.0002). The flow study of SMA and IMA showed a significant reduction of RV (SMA: 7.25 ± 6.37 cm/s vs. 18.52 ± 6.16 cm/s, p < 0.0001 - p adj <0.0001; IMA: 2.69 ± 6.10 cm/s vs. 17.06 ± 5.75 cm/s, p < 0.0001 - p adj <0.0001) and PI (SMA: 3.33 ± 0.75 vs. 4.53 ± 1.03, p < 0.0001 - p adj =0.0002; IMA: 3.54 ± 0.95 vs. 6.08 ± 1.53, p < 0.0001 - p adj <0.0001) in SSc patients than controls.

CONCLUSION

involvement of splanchnic vessels in SSc may be non-invasively investigated with abdominal US and CDU. Morphological and functional changes of Doppler parameters observed in SMA and IMA clearly demonstrate that these vessels are affected by SSc vasculopathy.

A Narrative Review of Pathogenetic and Histopathologic Aspects, Epidemiology, Classification Systems, and Disease Outcome Measures in Systemic Sclerosis

Systemic sclerosis (SSc) is a rare systemic autoimmune disease, characterized by the presence of three main actors: vasculopathy, immune activation, and fibrosis. This pathologic process is then translated in a clinical picture with great variability among different patients in terms of type of organ involvement, disease severity and prognosis. This heterogeneity is a main feature of SSc, which, in addition to the presence of early phases of the disease characterized by mild symptoms, can explain the high difficulty in establishing classification criteria, and in defining patients' subsets and disease outcomes. The definition of disease outcomes is particularly relevant in the setting of clinical trials, where the aim is to provide reliable endpoints, able to measure the magnitude of the efficacy of a certain drug or intervention. For this reason, in the last years, increasing efforts have been done to design measures of disease activity, damage, severity, and response to treatment, often in the context of composite indexes. When considering disease outcomes, the experience of the patient represents a relevant and complementary aspect. The tools able to capture this experience, the patient-reported outcomes, have been increasingly used in the last years in clinical practice and in clinical trials, both as primary and secondary endpoints. This comprehensive narrative review on SSc will therefore cover pathogenetic and histopathologic aspects, epidemiology, classification systems, and disease outcome measures, in order to focus on issues that are relevant for clinical research and design of clinical trials.

Gender differences in clinical features and outcomes of a Portuguese systemic sclerosis cohort

Evidence for the role of sex in the clinical manifestations of systemic sclerosis (SSc) patients is emerging. Some multicenter cohorts have shown that male SSc patients have more severe disease and worse survival. To assess the differences in clinical manifestations and survival in Portuguese SSc patients according to gender. Data from male and female adult SSc patients included in the Rheumatic Diseases Portuguese Register (Reuma.pt) were analysed and compared. Survival was calculated for patients included in Reuma.pt. within the first two years of diagnosis (inception cohort). In total, 1054 adult patients with SSc were included, 12.5% males. No differences in demographic features and comorbidities were found between the sexes, except for a higher rate of cigarette smokers among men. Diffuse cutaneous SSc and anti-topoisomerase antibodies were more prevalent in males than females. Additionally, male patients presented significantly more myositis, interstitial lung disease and gastric involvement. There were no differences in the patterns of drug use between the sexes. During follow-up, more deaths were reported in men than women (12.1% vs 7.3%, p = 0.04). The overall 1-, 3-, and 5-year survivals from diagnosis of the inception cohort (N = 469) for men vs women were 96.4% vs 98.2%, 93% vs 95.9%, and 75.8% vs 93.2%, respectively, with statistically significant differences (p < 0.01). This study confirms the existence of gender differences in clinical and immunological SSc features. Although SSc is less common in men than women, men have a more severe expression of skin and internal organ involvement and worse survival. Key Points • There are differences in SSc disease manifestations between sexes. • Males more commonly have diffuse cutaneous SSc, anti-topoisomerase antibodies, pulmonary and musculoskeletal involvement. • In the inception cohort, men had worse survival rates than women.

The Correlation between Helicobacter Pylori Infection and Disease Severity in Patients with Systemic Sclerosis

BACKGROUND Systemic sclerosis (SSc) is a relatively common connective tissue disease, which is characterized by inflammation, progressive skin fibrosis, and injuries of small vessels, particularly in the lung and kidney. It seems that Helicobacter pylori (H. pylori) might contribute to the development of SSc as an extra-gastrointestinal autoimmune disease. We investigated the association between H. pylori infections and disease severity in patients with SSc. METHODS This is a cross-sectional study. Sampling method in this study was census method in such a way that all patients with SSc referred to Imam Reza Education and Research University Medical Center from May 2015 to August 2016 were included in the study. Finally, 74 patients were selected based on the inclusion criteria. Inclusion criteria were: 1. Definitive SSc based on American College of Rheumatology/ European League Against Rheumatism 2010 (ACR/EULAR) classification for scleroderma, which was diagnosed within the last two years. 2. Not taking any proton pump inhibitors. 3. Not taking any H. pylori treatment with a standard regimen within the recent 2 months. Disease severity was assessed and determined by two rheumatologists based on the Medsger's Disease Severity Scale (MDSS). H. pylori stool antigen was evaluated based on the test which sensitivity and specificity was proven. All obtained data were statistically analyzed by SPSS 16 using Fisher's exact test Spearman correlation test (RSpearman). RESULTS Forty one (55.4%) of the 74 patients had positive stool antigens. We found a significant positive association between the severity of disease based on MDSS and titer of H. pylori stool antigen (p ≤ 0.001). CONCLUSION This study reveals that H. pylori infection may play a significant role in the severity of organ involvement in SSc.

Skin improvement is a surrogate for favourable changes in other organ systems in early diffuse cutaneous systemic sclerosis

OBJECTIVES

Skin improvement in diffuse cutaneous SSc (dcSSc), measured with modified Rodnan skin score (mRSS), is frequently used as a primary outcome in clinical trials, but it is uncertain whether mRSS changes reflect changes in other organ systems. This aim of this study was to explore if skin changes in early dcSSc over 1 and 2 years are associated with changes in severity of other organ involvement.

METHODS

Canadian Scleroderma Research Group database patients with dcSSc, disease duration of ≤5 years, no evidence of initial end-stage organ damage and/or significant comorbidity who had 1 year (n = 154) and 2 years (n = 128) of follow-up data were included. mRSS changes of 25% and/or ≥5 points were considered significant. Organ involvement was assessed by Medsger Disease Severity Score and Canadian Scleroderma Research Group definitions using bivariate, chi-square, ANOVA, adjusted regression and longitudinal mixed effect model analyses.

RESULTS

Improvement in mRSS was found in 41% of patients at 1 year and in 50% at 2 years. Improved patients showed less forced vital capacity decline (P = 0.012) and less frequent new cardiac involvement (P = 0.02) over 1 year, as well as better lung (by both Disease Severity Score, P = 0.006, and Δforced vital capacity%, P = 0.026), peripheral vascular (P = 0.006) and joint/tendon (P = 0.002) involvement over 2 years. mRSS worsening was consistently linked to less favourable lung outcomes at both 1- and 2-year follow-up visits, and more severe gastrointestinal disease at 2 years.

CONCLUSION

Changes in lung function in early dcSSc closely parallel skin changes. mRSS improvement reflects better prognosis for visceral disease and may be a reliable outcome measure in clinical trials.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Immunosuppressive treatment in diffuse cutaneous systemic sclerosis is associated with an improved composite response index (CRISS)

Background

Outcomes of therapeutic studies in diffuse cutaneous systemic sclerosis (dcSSc) have mainly been measured for specific organs, particularly the skin and lungs. A new composite response index in dcSSc (CRISS) has been developed for clinical trials. The goal of this study was to determine whether, in an observational dcSSc cohort, immunosuppression was associated with global disease improvement measured with the CRISS.

Methods

We conducted a retrospective cohort study in a multi-centered SSc registry comparing 47 patients newly exposed to immunosuppression for ≥ 1 year to 254 unexposed patients. Inverse probability of treatment weighting (IPTW) was performed to create comparable exposed and unexposed groups by balancing for age, sex, disease duration, modified Rodnan skin score (mRSS), forced vital capacity, patient and physician global assessments, and Health Assessment Questionnaire score. A CRISS score ≥ 0.6 at 1 year was defined as improvement.

Results

Exposed patients had shorter disease duration (5.5 versus 11.7 years, p < 0.01), more interstitial lung disease (67.4% versus 40.3%, p < 0.01), and worse physician global severity scores (4.2 versus 2.5 points, p < 0.01) compared to unexposed patients. Improvement in CRISS scores was more common in exposed patients after IPTW (odds ratio 1.85, 95% confidence interval 1.11, 3.09). Of the individual CRISS variables, only mean patient global assessment scores were significantly better among exposed than unexposed patients (− 0.4 versus 0 points, p = 0.03) while other variables including mRSS were similar.

Conclusion

Using a composite response measure, immunosuppression was associated with better outcomes at 1 year in a dcSSc cohort. These results provide real-world data that align with clinical trials to support our current use of immunosuppression.

Distinct mortality profile in systemic sclerosis: a death certificate study in Rio de Janeiro, Brazil (2006-2015) using a multiple causes of death analysis

The objective of this study was to assess the mortality profile related to SSc in the state of Rio de Janeiro, Brazil. We retrospectively examined all registered deaths in the region (2006-2015 period) in which the diagnosis of SSc was mentioned on any line of the death certificates (underlying cause of death [UCD], n = 223; non-UCD, n = 151). Besides the analysis of gender, age, and the causes of death, we also compared the mortality from UCDs between individuals whose death causes included SSc (cases) and those whose death causes did not include SSc (deceased controls). For the latter comparison, we used the mortality odds ratio to approximate the cause-specific standardized mortality ratio. We identified 1495 death causes among the 374 SSc cases. The mean age at death of the SSc cases (85% women) was significantly lower than that of the controls (n = 1,294,117) (58.7 vs. 65.5 years, respectively). The main death causes were circulatory system diseases, infections, and respiratory diseases (36%, 34%, and 21% of SSc cases, respectively). Compared to the deceased controls, there were proportionally more deaths among the SSc cases from pulmonary arterial hypertension, lung fibrosis, septicemia, gastrointestinal hemorrhage, other systemic connective tissue diseases, and heart failure (for death age < 50 years). We confirmed the high burden of cardiovascular, respiratory, and infectious causes in this predominantly non-Caucasian sample of SSc patients. Of interest, the percentage of infection-related deaths in our report was about three times higher than that in SSc studies with predominantly Caucasian populations.

Measurement of Serum Klotho in Systemic Sclerosis

Background

The aim of our study was to evaluate the serum concentration of klotho in a cohort of systemic sclerosis (SSc) patients compared to that of healthy controls and to correlate its levels with the degree and the kind of organ involvement.

Methods

Blood samples obtained from both patients and controls were collected and analysed by an ELISA test for the determination of human soluble klotho. Scleroderma patients were evaluated for disease activity through clinical, laboratory, and instrumental assessment.

Results

Our cohort consisted of 81 SSc patients (74 females, mean age 63.9 ± 13.1 years) and 136 healthy controls (78 females, mean age 50.5 ± 10.7 years). When matched for age, serum klotho concentration significantly differed between controls and patients (p < 0.001). However, in SSc patients, we did not find any significant association between serum klotho and clinical, laboratory, and instrumental findings. Lower serum levels of klotho were detected in 4 patients who were anticitrullinated peptide antibody (ACPA) positive (p = 0.005).

Conclusions

Our data show a lower concentration of klotho in the serum of SSc patients compared to that of healthy controls, without any significant association with clinical manifestations and laboratory and instrumental findings. The association between serum klotho and ACPA positivity requires further investigation.

Early Accrual of Organ Damage in Systemic Sclerosis: Rationale for Development of a Disease Damage Index

Introduction

Systemic sclerosis (SSc) is characterized by irreversible organ damage rather than fluctuating disease activity. However, there is no validated measure of damage in SSc. We aimed to quantify the accrual of organ damage in patients with early SSc.

Methods

Patients enrolled in the Australian Scleroderma Cohort Study with less than 2 years of SSc since the onset of the first non-Raynaud's symptom were included. Organ damage was defined by a group of six experts as substantial and permanent loss of organ function due to SSc.

Results

We identified 278 patients with early SSc. Among these, 38% had diffuse SSc. Damage was more common in the diffuse than in the limited disease subtype in the skin/musculoskeletal (75% vs. 25.2%, p<0.001) and lung (31.4% vs. 19.9%, p = 0.035) domains at year seven. The rates of damage accrual were highest in the skin/musculoskeletal, gastrointestinal and respiratory systems at year two (29.1%, 18.7%, 14.4%), increasing at year five (41.4%, 30.6%, 21.2%) and declining thereafter to year seven (43.9%, 32.7%, 23.0%). In particular, there was early accrual of damage due to joint contracture (22.3%), gastrointestinal dysmotility (11.5%) and pulmonary fibrosis with forced vital capacity <70% predicted (9.7%) at year two. The highest accrual rate of organ-specific damage from years two to seven was seen in fecal incontinence followed by proximal muscle weakness and pulmonary fibrosis.

Conclusions

Substantial accrual of organ damage occurs early in the course of disease, particularly in diffuse SSc. This provides the rationale for the development of a SSc damage index.

Acro-osteolysis as an indicator of severity in systemic sclerosis

INTRODUCTION

Systemic sclerosis is a rare disease that predominantly affects women. The Medsger severity scale has been used to assess the severity, but it requires expensive and poorly accessible studies and it does not include complications such acrosteolysis, calcinosis, pericardial disease or hypothyroidism that occur on a relatively frequent basis in this disease. There is no study that considers if comorbidities, such as primary biliary cirrhosis, are related to gravity.

OBJECTIVES

To determine the correlation between severity and the presence of such complications.

METHODS

40 patients with systemic sclerosis, dividing them into tertiles according to severity were studied. Dichotomous variables were described using percentages, while dimensional by averages+SD. Statistical inference was performed using chi square test or Kruskal-Wallis test with Dunn post-test, as appropriate. A significance at P<.05 was set.

RESULTS

Of all the complications studied there were only differences in severity with acrosteolysis. Within comorbidities, primary biliary cirrhosis is not associated with gravity.

Measures of disease status in systemic sclerosis: A systematic review

OBJECTIVES

To identify and appraise measures of disease status in systemic sclerosis (SSc).

METHODS

A systematic review of Medline (1966-2015), EMBASE (1974-2015), and Cochrane Library (inception-2015) was undertaken to identify indices of disease status in SSc. We focused on objective measures and excluded non-English articles. Measures were reviewed for content, whether they measured activity, damage and/or severity and whether they were validated according to the OMERACT filter.

RESULTS

Of the 4558 articles retrieved through the search, we identified 58 articles for review. We found a further 44 articles through a search of the bibliography of relevant articles. We identified the following 10 "composite" (multi-organ) indices: two disease activity indices, six disease severity scales, and two combined response indices. There was no disease damage index for SSc.

CONCLUSIONS

We identified a number of composite and organ-specific indices in SSc, incorporating mostly objective measures, developed to quantify disease activity, severity, and response in clinical trials. However, none of the indices was developed to exclusively quantify organ damage. Most of the existing indices require further validation according to the OMERACT filter. There is a need to develop and validate a disease damage index in SSc.

A gender gap in primary and secondary heart dysfunctions in systemic sclerosis: a EUSTAR prospective study

OBJECTIVES

In agreement with other autoimmune diseases, systemic sclerosis (SSc) is associated with a strong sex bias. However, unlike lupus, the effects of sex on disease phenotype and prognosis are poorly known. Therefore, we aimed to determine sex effects on outcomes.

METHOD

We performed a prospective observational study using the latest 2013 data extract from the EULAR scleroderma trials and research (EUSTAR) cohort. We looked at (i) sex influence on disease characteristics at baseline and (ii) then focused on patients with at least 2 years of follow-up to estimate the effects of sex on disease progression and survival.

RESULTS

9182 patients with SSc were available (1321 men) for the baseline analyses. In multivariate analysis, male sex was independently associated with a higher risk of diffuse cutaneous subtype (OR: 1.68, (1.45 to 1.94); p<0.001), a higher frequency of digital ulcers (OR: 1.28 (1.11 to 1.47); p<0.001) and pulmonary hypertension (OR: 3.01 (1.47 to 6.20); p<0.003). In the longitudinal analysis (n=4499), after a mean follow-up of 4.9 (±2.7) years, male sex was predictive of new onset of pulmonary hypertension (HR: 2.66 (1.32 to 5.36); p=0.006) and heart failure (HR: 2.22 (1.06 to 4.63); p=0.035). 908 deaths were recorded, male sex predicted deaths of all origins (HR: 1.48 (1.19 to 1.84); p<0.001), but did not significantly account for SSc-related deaths.

CONCLUSIONS

Although more common in women, SSc appears as strikingly more severe in men. Our results obtained through the largest worldwide database demonstrate a higher risk of severe cardiovascular involvement in men. These results raise the point of including sex in the management and the decision-making process.

The Effect of Male Sex on Survival in Systemic Sclerosis

Objective.

Systemic sclerosis (SSc) has a female predominance, however, little is understood about the effect of sex on SSc manifestations and survival. The objectives of our study were to evaluate differences in disease manifestations, and survival rates between males and females with SSc.

Methods.

A retrospective cohort study of the Toronto Scleroderma Program was conducted to evaluate sex-based differences in disease manifestations and survival. A relative survival analysis compared SSc survival to the general population.

Results.

There were 959 patients (791 females, 168 males) identified, with a female:male ratio of 4.7:1. Males more frequently had diffuse SSc [45% vs 30%, relative risk (RR) 1.44, 95% CI 1.18–1.75] and interstitial lung disease (ILD; 41% vs 33%, RR 1.24, 95% CI 1.01–1.52). There were 324 deaths (65 males, 259 females). Males had increased unadjusted mortality compared to females (HR 1.57, 95% CI 1.19–2.06). In an adjusted model including immunosuppressive use, male sex (HR 1.40, 95% CI 1.06–1.85), ILD (HR 1.58, 95% CI 1.26–1.98), and older age at diagnosis (HR 1.05, 95% CI 1.04–1.06) were independently associated with increased mortality, whereas the limited subtype (HR 0.70, 95% CI 0.49–0.77) and anticentromere antibodies (HR 0.70, 95% CI 0.49–0.98) were independently associated with decreased mortality. Male sex was associated with increased risk of mortality (HR 1.16, p = 0.003) in patients with SSc above that observed for males in the general population.

Conclusion.

The differential effect of disease between sexes is small, yet males have decreased survival compared to females with SSc.

Mortality and survival in systemic sclerosis: systematic review and meta-analysis

OBJECTIVE

To determine the mortality, survival, and causes of death in patients with systemic sclerosis (SSc) through a meta-analysis of the observational studies published up to 2013.

METHODS

We performed a systematic review and meta-analysis of the observational studies in patients with SSc and mortality data from entire cohorts published in MEDLINE and SCOPUS up to July 2013.

RESULTS

A total of 17 studies were included in the mortality meta-analysis from 1964 to 2005 (mid-cohort years), with data from 9239 patients. The overall SMR was 2.72 (95% CI: 1.93-3.83). A total of 43 studies have been included in the survival meta-analysis, reporting data from 13,529 patients. Cumulative survival from onset (first Raynaud's symptom) has been estimated at 87.6% at 5 years and 74.2% at 10 years, from onset (non-Raynaud's first symptom) 84.1% at 5 years and 75.5% at 10 years, and from diagnosis 74.9% at 5 years and 62.5% at 10 years. Pulmonary involvement represented the main cause of death.

CONCLUSIONS

SSc presents a larger mortality than general population (SMR = 2.72). Cumulative survival from diagnosis has been estimated at 74.9% at 5 years and 62.5% at 10 years. Pulmonary involvement represented the main cause of death.

Ultrasound assessment of ex vivo lung tissue properties using a fluid-filled negative pressure bath

A relationship between tendon stress and strain and ultrasonic echo intensity has previously been defined in tendons, demonstrating a correlation between tissue stiffness and echo intensity. An analogous relationship between volume-dependent pressure changes and echo intensity changes in inflating lungs would indicate a correlation between lung compliance and echo intensity. Lung compliance is an important metric to diagnose pathologies which affect lung tissue mechanics, such as emphysema and cystic fibrosis. The goal of this study is to demonstrate a correlation between ultrasound echo intensity and lung tissue mechanics in an ex vivo model using a fluid-filled negative pressure bath design which provides a controlled environment for ultrasonic and mechanical measurements. Lungs from 4 male Sprague-Dawley rats were removed and mechanically tested via inflation and deflation in a negative pressure chamber filled with hetastarch. Specific volumes (1, 2, 3, and 4 mL) were removed from the chamber using a syringe to create negative pressure, which resulted in lung inflation. A pressure transducer recorded the pressure around the lungs. From these data, lung compliance was calculated. Ultrasound images were captured through the chamber wall to determine echo intensity (grayscale brightness in the ultrasound image), which was then related to mechanical parameters. Ultrasound images of the lung were successfully captured through the chamber wall with sufficient resolution to deduce echo intensity changes in the lung tissue. Echo intensity (0-255 scale) increased with volumetric changes (18.4 ± 5.5, 22.6 ± 5.1, 26.1 ± 7.5, and 42.9 ± 19.5 for volumetric changes of 1, 2, 3, and 4 mL) in a pattern similar to pressure (-6.8 ± 1.7, -6.8 ± 1.4, -9.4 ± 0.7, and -16.9 ± 6.8 cm H2O for 1, 2, 3, and 4 mL), reflecting changes in lung compliance. Measured rat lung tissue compliance was comparable to reported values from ex vivo lungs (0.178 ± 0.067, 0.378 ± 0.051, 0.427 ± 0.062, and 0.350 ± 0.160 mL/cm H20 for 1, 2, 3, and 4 mL), supporting proof of concept for the experimental method. Changes in echo intensity reflected changes in lung compliance in this ex vivo model, thus, supporting our hypothesis that the stiffness-related changes in echo intensity originally seen in tendon can be similarly detected in lung tissue. The presented ultrasound-based methods allowed measurement of local lung tissue compliance in a controlled environment, however, the methods could be expanded to facilitate both ex vivo and in vivo studies.

Mortality in systemic sclerosis-a single centre study from the UK

This study aims to determine the cause and predictors of mortality in a cohort of patients with systemic sclerosis (SSc) and assess whether the mortality rate differs significantly from the general population. Patients enrolled onto the Royal National Hospital for Rheumatic Diseases Connective Tissue Disease database between 1999 and 2010 were included in this study. The NHS Strategic Tracing Service and UK Registry of Births, Marriages and Deaths were used to establish date and cause of deaths. A retrospective case note review collected information on clinical phenotype and serology. A standardised mortality ratio (SMR) was calculated and survival was determined using Kaplan-Meier estimates. Univariate and multivariate predictors of survival were assessed using proportional hazards regression modelling. Amongst this cohort of 204 patients (25 males, 40 diffuse SSc), the mean age at diagnosis was 51.6 years (SD13.7) and the mean duration of follow-up was 12.5 years (SD 8.8 years). In the deceased group (53 patients), the mean age of death was 72.0 years (SD 12.3 years). The mean disease duration at death was 14.2 years (SD 8.5 years). The overall SMR was 1.34 (95 % confidence interval (CI) 1.00-1.75). The SMR was higher in males (1.54 [95 % CI 0.67-3.04] vs. 1.30 [95 % CI 0.95-1.74]). The leading causes of death in this cohort were infection, respiratory disease and malignancy. The most common cause of SSc-related mortality was pulmonary complications. Factors adversely affecting survival were older age at diagnosis, male gender, interstitial lung disease (ILD) and anti-RNA polymerase III antibody. The mortality rate of our cohort, who had predominantly limited disease, was higher than that of the general population; although not as high as reported in previous retrospective studies.

Survival and causes of death in an unselected and complete cohort of Norwegian patients with systemic sclerosis

OBJECTIVE

To determine survival and causes of death in an unselected and complete cohort of Norwegian patients with systemic sclerosis (SSc) compared to the background population.

METHODS

Multiple methods were used to identify every patient with SSc living in southeast Norway, with a denominator population of 2,707,012, between 1999 and 2009. All patients who met either the American College of Rheumatology criteria or the Medsger and LeRoy criteria for SSc were included. Every patient was matched for sex and age with 15 healthy controls drawn from the national population registry. Vital status at January 1, 2010, was provided for patients and controls by the national population registry. Causes of death were obtained from death certificates and by chart review.

RESULTS

Forty-three (14%) of 312 patients with SSc died during the study period. The standardized mortality rate (SMR) was estimated to be 2.03 for the entire cohort and 5.33 for the subgroup with diffuse cutaneous (dc) SSc. The 5- and 10-year survival rates were 91% and 70%, respectively, for dcSSc and 98% and 93% for limited cutaneous (lc) SSc. Causes of death were related to SSc in 24/43 (56%) patients, mostly cardiopulmonary diseases (n = 13), including pulmonary hypertension (n = 8). Factors associated with fatal outcome included male sex, dcSSc, pulmonary hypertension, and interstitial lung disease.

CONCLUSION

Compared to the Norwegian background population, our cohort of 312 unselected patients with SSc had decreased survival. The survival rates observed were, however, better than those previously reported from SSc referral centers.

Hematopoietic stem cell transplantation for systemic sclerosis: history and current status

PURPOSE OF REVIEW

Systemic sclerosis (SSc) remains one of the last severe autoimmune disease with a poor prognosis and modest response to immunosuppressive therapy. Mortality in severe diffuse disease with internal organ involvement is elevated. Autologous hematopoietic transplantation (HSCT) has emerged in the last decade as a promising disease-modifying treatment.

RECENT FINDINGS

In phase I/II trials, HSCT has demonstrated to induce impressive reversal of skin fibrosis, neoangiogenesis, improved functionality and quality of life, and stabilization of internal organ function. Treatment-related mortality was reduced over time by better pretransplant evaluation and by treating patients earlier in disease.

SUMMARY

Two out of three randomized trials of autologous HSCT for SSc have been concluded: the nonmyeloablative American Systemic Sclerosis Immune Suppression versus Transplant, and Autologous Stem cell Transplantation International Scleroderma. The myeloablative Scleroderma Cyclophosphamide versus Transplant instead is still recruiting patients. The soon expected results from these trials should clarify the role of autologous HSCT in the challenging management of severe SSc.

Trends in mortality in patients with systemic sclerosis over 40 years: a systematic review and meta-analysis of cohort studies

OBJECTIVE

SSc is known as the most severe connective tissue disorder, and to be associated with a high mortality risk. Some improvements in therapy for SSc have been achieved in recent years and some preliminary data have suggested an improvement in patient survival. Thus, we set out to determine whether mortality rate in SSc patients has decreased over the past 40 years through a meta-analysis of cohort studies.

METHODS

We performed a systematic review and a meta-analysis of literature in MEDLINE and Embase databases from January 1960 to June 2010. All cohort studies reporting on SSc mortality were analysed. We then calculated pooled standardized mortality ratios (SMRs) of SSc mortality and calculated their changes over time using meta-regression analysis.

RESULTS

Nine studies were included, corresponding to a total of 2691 SSc patients. The pooled SMR was 3.53 [95% CI 3.03, 4.11, P < 0.0001; I(2 )= 93%, P(het) = 0.001]. Mid-cohort year ranged from 1977 to 1995 (before 1980: two studies; 1980-90: five studies; and after 1990: two studies): adjusted meta-regression analysis did not show significant change in SMR over time (P = 0.523). Among 732 deaths, heart involvement was the most frequent cause of deaths (29%) followed by lung involvement.

CONCLUSION

Our results confirm that SSc is a devastating condition as reflected by a pooled SMR of 3.5. Additionally, SMR has not significantly changed over the past 40 years. Further studies are needed to assess the effect of the most recent available therapies on mortality in SSc.

Preliminary study of cardiovascular manifestations and cardiac severity scale in 58 patients with systemic sclerosis in iran using the medsger scale

BACKGROUND

Cardiac involvement in systemic sclerosis (SSc) is more prevalent than previously thought. In this study, the frequency and severity of cardiovascular involvement were assessed in SSc patients referred to Firouzgar Hospital.

METHODS

Fifty-eight patients with SSc, selected from the data bank of SSc patients, were reviewed for the frequency and severity of 8 organ involvements in this case series. The preliminary severity scale, published by international SSc study groups, was employed for the determination of the severity grade in the cardiovascular system. In the cardiac scoring scale, grade 0 represents normal heart (no cardiac involvement), grade 1 denotes mild involvement [electrocardiography (ECG) conduction defect and a left ventricular ejection fraction (LVEF) of 45-49%)], grade 2 signifies moderate involvement (arrhythmia, LVEF = 40-44%), grade 3 indicates severe involvement (LVEF <40%)], and grade 4 stands for end stage (congestive heart failure and arrhythmia requiring treatment).

RESULTS

In this study, 24 (41.4%) patients were in the diffuse cutaneous (dcSSc) subset. The female to male ratio was 10.5:1, and the mean duration from symptom onset to diagnosis was 7.35 years for the dcSSc subset and 8.41 years for the limited cutaneous (lcSSc) subset of disease, there being no significant difference. Cardiac involvement in this series was seen in 13 (22.4%) cases; and there was no significant difference in terms of frequency and severity between the two disease subgroups (p value = 0.96 and p value = 0.46 respectively).

CONCLUSION

Our findings showed that the cardiac involvement in this series was infrequent and that there was no significant difference in the severity of cardiovascular involvement between the two subtypes of SSc in the late stage of the disease.

Prevalence of scleroderma in Spain: an approach for estimating rare disease prevalence using a disease model

PURPOSE

To estimate scleroderma prevalence in Spain.

METHODS

As no data were available for Spain we used reported scleroderma incidence (Silman's study on UK and Alamanos' on Greece), scleroderma cause-specific mortality, obtained through the National Institute of Statistics (codes included in M34 of the International Classification of Diseases, 10th revision) in Spain and remission data. Estimates were applied to the Spanish population and to all-cause mortality for 2004, broken down by age group and gender. Estimators were assumed to follow a Poisson distribution. DisMod-II software was used for this purpose.

RESULTS

Estimated prevalence was 0.23 and 0.71 cases per 10,000 people for men and women, respectively, based on UK incidence, and 0.28 and 2.58 cases per 10,000 people, respectively, based on Greek incidence. Estimated age at disease onset ranged from 50 to 58 years among men and from 52 to 55 among women, according to UK and Greek data, respectively. Mean duration of the disease was estimated to be in the range of 17-20 years for men and 19-20 for women.

CONCLUSIONS

DisMod-II is useful for obtaining, modelling and confirming variability ranges of prevalence found in literature. It also provides information for orphan drug designation and for supporting public health decisions regarding rare diseases.

[Systemic sclerosis and the gastrointestinal tract. Diagnostic and therapeutic approach]

In systemic sclerosis esophagus is affected in 90% followed by anal and rectal involvement (50-70%), stomach (40-70%), colon (10-50%) and small bowel (40%). The main clinical findings are esophagic: dysphagia and sign of gastroesophageal reflux and its complications. Gastric symptomatology is a consequence of gastroparesis (postprandial fullness, nausea). Intestinal affection produces hypomotility (abdominal distention, deficient intestinal absorption, bacterial overgrowth). In colon there are diverticula, intestinal constipation, and fecal incontinence. For the diagnosis of GIT involvement the following are useful: studies of digestive tract with contrast media, endoscopy of upper GIT; gastric emptying; pH metry; esophageal and rectal manometry, as well as test to investigate deficient intestinal absorption syndrome. The prokinetic are a cornerstone for the treatment of hypomotility of GIT, along with pump proton inhibitors for the esophageal alteration and antibiotics for bacterial overgrowth.

High-resolution CT scan findings in patients with symptomatic scleroderma-related interstitial lung disease

BACKGROUND

Lung disease has become the leading cause of mortality and morbidity in scleroderma (SSc) patients. The frequency, nature, and progression of interstitial lung disease seen on high-resolution CT (HRCT) scans in patients with diffuse SSc (dcSSc) compared with those with limited SSc (lcSSc) has not been well characterized.

METHODS

Baseline HRCT scan images of 162 participants randomized into a National Institutes of Health-funded clinical trial were compared to clinical features, pulmonary function test measures, and BAL fluid cellularity. The extent and distribution of interstitial lung disease HRCT findings, including pure ground-glass opacity (pGGO), pulmonary fibrosis (PF), and honeycomb cysts (HCs), were recorded in the upper, middle, and lower lung zones on baseline and follow-up CT scan studies.

RESULTS

HRCT scan findings included 92.9% PF, 49.4% pGGO, and 37.2% HCs. There was a significantly higher incidence of HCs in the three zones in lcSSc patients compared to dcSSc patients (p = 0.034, p = 0.048, and p = 0.0007, respectively). The extent of PF seen on HRCT scans was significantly negatively correlated with FVC (r = - 0.22), diffusing capacity of the lung for carbon monoxide (r = - 0.44), and total lung capacity (r = - 0.36). A positive correlation was found between pGGO and the increased number of acute inflammatory cells found in BAL fluid (r = 0.28). In the placebo group, disease progression was assessed as 30% in the upper and middle lung zones, and 45% in the lower lung zones. No difference in the progression rate was seen between lcSSc and dcSSc patients.

CONCLUSIONS

PF and GGO were the most common HRCT scan findings in symptomatic SSc patients. HCs were seen in more than one third of cases, being more common in lcSSc vs dcSSc. There was no relationship between progression and baseline PF extent or lcSSc vs dcSSc.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00004563.

Update on Indices of Disease Activity in Systemic Sclerosis

OBJECTIVE

An important barrier in the study of systemic sclerosis (SSc) is the difficulty in measuring disease activity. We reviewed the literature on currently available global measures of disease activity in SSc.

METHODS

The PubMed database (1950-2006) was searched for the key words "scleroderma" in conjunction with "disease activity" and then "disease severity." All relevant original and review articles in English and French were reviewed. Textbooks in rheumatology and pertinent secondary references were also reviewed.

RESULTS

There are currently 3 tools that are used to measure disease activity globally in SSc. Physician global assessments have been commonly used but have not been formally evaluated. The Valentini Disease Activity Index is a new measure that consists of 10 variables and a resulting score ranging from 0 to 10. It appears easy to use but lacks some face and content validity and responsiveness to change has yet to be demonstrated. The Medsger Disease Severity Scale measures disease severity in 9 organ systems. However, it assesses mostly damage and is difficult to score.

CONCLUSIONS

There is currently no gold standard measure of disease activity in SSc. Given the need to measure disease activity in SSc and the limitations of the currently available instruments, efforts are ongoing to develop new ones. This represents a major challenge but one that remains particularly important to undertake.

Bronchoalveolar lavage and response to cyclophosphamide in scleroderma interstitial lung disease

RATIONALE

The presence of inflammatory cells on bronchoalveolar lavage is often used to predict disease activity and the need for therapy in systemic sclerosis-associated interstitial lung disease.

OBJECTIVES

To evaluate whether lavage cellularity identifies distinct subsets of disease and/or predicts cyclophosphamide responsiveness.

METHODS

Patients underwent baseline lavage and/or high-resolution computed tomography as part of a randomized placebo-controlled trial of cyclophosphamide versus placebo (Scleroderma Lung Study) to determine the effect of therapy on forced vital capacity. Patients with 3% or greater polymorphonuclear and/or 2% or greater eosinophilic leukocytes on lavage and/or ground-glass opacification on computed tomography were eligible for enrollment.

MEASUREMENTS AND MAIN RESULTS

Lavage was performed in 201 individuals, including 141 of the 158 randomized patients. Abnormal cellularity was present in 101 of these cases (71.6%) and defined a population with a higher percentage of men (P = 0.04), more severe lung function, including a worse forced vital capacity (P = 0.003), worse total lung capacity (P = 0.005) and diffusing capacity of the lung for carbon monoxide (P = 0.004), more extensive ground-glass opacity (P = 0.005), and more extensive fibrosis in the right middle lobe (P = 0.005). Despite these relationships, the presence or absence of an abnormal cell differential was not an independent predictor of disease progression or response to cyclophosphamide at 1 year (P = not significant).

CONCLUSIONS

The presence of an abnormal lavage in the Scleroderma Lung Study defined patients with more advanced interstitial lung disease but added no additional value to physiologic and computed tomography findings as a predictor of progression or treatment response. Clinical trial registered with www.clinicaltrials.gov (NCT 000004563).

Six-Minute Walk Test for the Evaluation of Pulmonary Disease Severity in Scleroderma Patients

BACKGROUND

Pulmonary involvement is the leading cause of systemic sclerosis (SSc)-related deaths. A simple test to evaluate exercise capacity is the 6-min walk test (6MWT), and the walk distance is used as a primary outcome in clinical trials. Hemoglobin desaturation during a 6MWT is predictive of mortality in patients with primary pulmonary hypertension. Our objectives were to evaluate the walk distance and resting oxygen saturation - oxygen saturation after the 6-min period (DeltaSat) during the 6MWT in patients with SSc, and to establish correlations between the 6MWT results and other clinical variables.

METHODS

We analyzed 110 SSc patients. DeltaSat was defined as a fall of end-of-test saturation >or= 4%. Clinical and demographic data were collected. All the patients were submitted to chest radiographs and high-resolution CT (HRCT) and underwent pulmonary function testing and echocardiography, and the presence of autoantibodies was determined.

RESULTS

The variables associated with a walk distance < 400 m (p < 0.05) were age, dyspnea index, fibrosis on radiography, pulmonary arterial systolic pressure (PASP) >or= 30 mm Hg, and desaturation. The variables associated with DeltaSat (p < 0.05) were age, positive anti-Scl-70 autoantibody, dyspnea index, fibrosis on radiography, FVC < 80% of predicted, PASP >or= 30 mm Hg, and ground-glass or reticular opacities on HRCT. In the multivariate logistic regression analysis, three variables were significant when tested with walk distance: age, race, and dyspnea index; four variables were significant when tested with DeltaSat: age, dyspnea index, positive anti-Scl-70 autoantibody, and FVC < 80% of predicted.

CONCLUSIONS

Desaturation during a 6MWT provides additional information regarding severity of disease in scleroderma patients with pulmonary manifestations.

Clinical features and prognosis of primary biliary cirrhosis associated with systemic sclerosis

BACKGROUNDS AND AIMS

To evaluate the prognosis of primary biliary cirrhosis (PBC) together with systemic sclerosis (SSc), as this is unknown.

METHODS AND RESULTS

A PBC database of 580 patients identified 43 with PBC and SSc: two patients with PBC alone were matched to each PBC-SSc patient for serum bilirubin concentration at the initial visit. Forty (93%) patients had limited cutaneous SSc. At diagnosis of PBC, median values were: 49.7 years, bilirubin 17 micromol/l, and albumin 40.5 g/l. Liver diagnosis occurred a median 4.9 years after SSc in 24 (56%) patients. In matched patients, median values at diagnosis were: 53.2 years, bilirubin 12 micromol/l, and albumin 41 g/l. Median follow up was similar: 3.16 years (PBC-SSc) and 4.8 years (PBC alone). The risk of transplantation or death from diagnosis, adjusting for sex, age, log bilirubin, and alkaline phosphatase was significantly lower in PBC-SSc (hazard ratio 0.116, p=0.01) due to less transplantation (hazard ratio 0.068, p=0.006). The rate of bilirubin increase was less in PBC-SSc (p=0.04). Overall survival was similar (hazard ratio 1.11, p=0.948); there were nine deaths (21%) in PBC-SSc (six SSc related and two liver related) and nine (11%) in PBC alone (six liver related).

CONCLUSIONS

Liver disease has a slower progression in PBC-SSc compared with matched patients with PBC alone.

Prevalência de achados cutâneos em portadores de esclerose sistêmica: experiência de um hospital universitário

FUNDAMENTOS: A esclerose sistêmica é colagenose pouco comum e muito rica em manifestações cutâneas. OBJETIVO: Estudar a prevalência das manifestações cutâneas na esclerose sistêmica em geral e nos seus diferentes subtipos (formas limitada, generalizada e mista). MÉTODOS: Analisaram-se 32 pacientes de esclerose sistêmica (20 com forma limitada, oito com generalizada e quatro com forma mista) quanto à esclerose de pele, fenômeno de Raynaud, cicatrizes estelares, telangiectasias, leucomelanodermia, microstomia, calcinose e prurido. RESULTADOS: Encontraram-se esclerose de pele e fenômeno de Raynaud em 100% dos pacientes; cicatrizes estelares em 65,6%; telangiectasias em 43,7%; leucomelanodermia em 43,7%; microstomia em 31,25%; prurido em 28,1% e calcinose em 12,5%. Não se observaram diferenças entre as formas localizada e difusa da doença, sendo p = 1 para cicatrizes estelares; p = 0,69 para telangiectasias; p = 0,22 para microstomia, p = 1 para calcinose e prurido. A forma mista de doença não diferiu das formas isoladas (limitada e difusa) quanto aos mesmos achados. CONCLUSÕES: As manifestações mais comuns na esclerose sistêmica são a esclerose de pele e o fenômeno de Raynaud, e a mais rara é a calcinose. As três formas apresentam freqüências semelhantes de Raynaud, cicatrizes estelares, microstomia, telangiectasia, calcinose e prurido.

Severe gastrointestinal involvement in systemic sclerosis: report of five cases and review of the literature

OBJECTIVE

To review current literature on the gastrointestinal tract (GIT) manifestations of systemic sclerosis (SSc) and to report on 5 patients with severe gastrointestinal SSc.

MATERIALS AND METHODS

The clinical course and histopathology of 5 patients are described. A review of the medical literature registered in MedLine and PreMedLine databases from 1996 through mid-2004 was performed using the keywords systemic sclerosis and scleroderma and combining them with text words such as gastric, gastrointestinal, anorectal, colonic, and hepatic.

RESULTS

All 5 patients had severe GIT involvement: 4 with diffuse cutaneous SSc (dcSSc) and 1 with limited cutaneous SSc (lcSSc). Autopsy results of 2 patients who died from severe malnutrition and aspiration pneumonia are presented. Literature review includes involvement from oral cavity to anus with varying degrees of severity. Most GIT manifestations result from dysmotility secondary to infiltration of the gastrointestinal wall with fibrous tissue and can cause life-threatening malabsorption and malnutrition. Diagnostic tests, pathology, and treatments of GIT SSc are reviewed.

CONCLUSIONS

GIT involvement in SSc can be severely debilitating and even life-threatening. Although morbidity is inevitable, appropriate supportive treatment can prolong survival.

RELEVANCE

GI complications of SSc cause significant morbidity and mortality.

Juvenile Systemic Sclerosis: A Follow-up Study of Eight Patients

Juvenile systemic sclerosis (jSSc) is a rare form of systemic sclerosis (also known as scleroderma). Fewer than 10% of SSc cases have their onset before age 20 and fewer than 2% before the age of 10. Few case reports and cohort studies on jSSc have been published. Our objective was to assess the clinical and laboratory characteristics of eight cases of juvenile-onset SSc followed up at our institution. Clinical manifestations of SSc were recorded, and immunologic laboratory tests including antinuclear antibodies (ANAs), anti-centromere antibodies (ACAs), and anti-Scl-70 antibodies were assessed. The female-to-male ratio was 7:1, and age at onset ranged from 3-17 years. At the time of analysis, 2 of 8 patients were still under 18 years of age, and 6 of 8 patients were adults. The mean follow-up period from the onset of disease was 19.1 years. Raynaud's phenomenon was present in all cases. Only 2 of 8 patients had diffuse SSc. During follow-up, pulmonary fibrosis developed in only 2 of 8 patients and cardiovascular manifestations in 3 of 8 patients. Secondary sicca syndrome was present in 2 of 8 cases. Regarding immunologic laboratory markers, 7 of 8 patients were ANA positive. However, none of these patients ever carried anti-Scl-70 antibodies, and only 2 of 8 patients had ever had ACA seropositivity. Our results suggest that in jSSc, Raynaud's phenomenon is more severe, whereas internal organ manifestations and the frequency of autoantibodies are far less pronounced than in adult-onset SSc. Also, the survival rate and final outcome of patients with jSSc appear to be better than those in patients with adult-onset SSc.

Mortality in systemic sclerosis: an international meta-analysis of individual patient data

PURPOSE

Studies on mortality associated with systemic sclerosis have been limited by small sample sizes. We aimed to obtain large-scale evidence on survival outcomes and predictors for this disease.

METHODS

We performed a meta-analysis of individual patient data from cohorts recruited from seven medical centers in the United States, Europe, and Japan, using standardized definitions for disease subtype and organ system involvement. The primary outcome was all-cause mortality. Standardized mortality ratios and predictors of mortality were estimated. The main analysis was based only on patients enrolled at each center within 6 months of diagnosis (incident cases).

RESULTS

Among 1645 incident cases, 578 deaths occurred over 11,521 person-years of follow-up. Standardized mortality ratios varied by cohort (1.5 to 7.2). In multivariate analyses that adjusted for age and sex, renal (hazard ratio [HR] = 1.9; 95% confidence interval [CI]: 1.4 to 2.5), cardiac (HR = 2.8; 95% CI: 2.1 to 3.8), and pulmonary (HR = 1.6; 95% CI: 1.3 to 2.2) involvement, and anti-topoisomerase I antibodies (HR = 1.3; 95% CI: 1.0 to 1.6), increased mortality risk. Renal, cardiac, and pulmonary involvement tended to occur together (P <0.001). For patients without adverse predictors for 3 years after enrollment, the subsequent risk of death was not significantly different from that for the general population in three cohorts, but was significantly increased in three cohorts that comprised mostly referred patients. Analyses that included all cases in each center (n = 3311; total follow-up: 19,990 person-years) yielded largely similar results.

CONCLUSION

Systemic sclerosis confers a high mortality risk, but there is considerable heterogeneity across settings. Internal organ involvement and anti-topoisomerase I antibodies are important determinants of mortality.

Resting and exercise physiology in interstitial lung diseases

Interstitial lung diseases (ILDs) are a heterogeneous group of parenchymal pulmonary disorders with varying histologic appearances. Pulmonary function tests have gained a prominent role in the diagnosis and management of patients with these disorders. Although their role in the differential diagnosis of the various ILDs is limited, physiologic measurements are pivotal studies providing clues regarding disease severity, prognosis,and response to therapy.

Scleroderma epidemiology

Evidence from multiple sources indicates that SSc does not occur randomly in the population; there are particular groups who are at greater risk. The overall incidence rate of SSc in the adult population of the United States is approximately 20 per million per year; this rate has increased from 1944 to 1973, but has been relatively stable since that time. The prevalence of SSc in the United States also seems to be stable over the past two decades with a prevalence estimate for adults of 240 per million. Recent population studies suggest that SSc occurs more frequently in the United States than in continental Europe, the United Kingdom, and in some areas in Asia. Overall survival has improved over the past few decades; mean survival is approximately 12 years from diagnosis. Renal disease accounts for some of the early mortality, but pulmonary disease has emerged as a major cause of death. Cardiac disease is also correlated with a poorer prognosis. Gastrointestinal involvement contributes to morbidity and, indirectly, to mortality, but the magnitude of this contribution is difficult to assess. Women are affected more frequently than men but the factors that are responsible for this are not apparent. Studies of reproductive history have provided conflicting data; some studies suggested that the number of pregnancies may influence later disease expression, whereas other studies found no correlation. Racial factors seem to play a role in disease susceptibility, as well as disease expression. Age-specific incidence rates are higher in black women than in white women; the greatest difference occurs in the young to middle adult age group (less than 54 years of age). Diffuse disease also seems to occur more commonly in the black population than in the white. Age at onset of diffuse disease is younger, on average, than the age at onset of limited disease; age-adjusted survival is worse in black women than in white women because of their predilection for diffuse disease. Reports of geographic clustering are intriguing; the reported clusters in London and Italy have not resulted in the identification of potential causal factors. The Choctaw Native American cluster suggests that genetic factors that have not been identified may play an important role. Familial clustering of SSc has been demonstrated in the United States and in Australia, which provides additional evidence of a genetic component. It is likely that there is a strong interplay among genetic factors, hormonal or reproductive-related events, and an external trigger that must interact to result in clinical disease.

Predictors and outcomes of scleroderma renal crisis: the high-dose versus low-dose D-penicillamine in early diffuse systemic sclerosis trial

OBJECTIVE

The reported frequency of scleroderma M01-R renal crisis (SRC) in diffuse systemic sclerosis (SSc; scleroderma) is 15-20%. Early use of angiotensin-converting enzyme (ACE) inhibitors has markedly improved outcome. The present analysis reexamines the prognostic factors for and outcome of SRC in a prospective cohort of patients with early diffuse SSc.

METHODS

We retrospectively evaluated the cohort of SSc patients who participated in the High-Dose Versus Low-Dose D-Penicillamine in Early Diffuse SSc trial. Patients with diffuse cutaneous scleroderma were enrolled if their disease duration was <18 months. Because the trial failed to show a difference between treatment groups, the data were pooled.

RESULTS

One hundred thirty-four SSc patients entered the observation period a mean +/- SD of 0.8 +/- 0.3 years after onset of SSc. SRC occurred in 18 patients a mean +/- SD of 0.9 +/- 1.1 years after entry. During a mean +/- SD 4.0 +/- 1.1 years of followup after entry, 9 of the 18 patients died (mean +/- SD 0.6 +/- 0.9 years after SRC onset). Baseline characteristics that predicted SRC included a modified Rodnan skin thickness score of >or=20 (P < 0.01), enlarged cardiac silhouette on radiograph (P = 0.04), large joint contractures (wrist, elbow, knee) (P = 0.008), and prednisone use at entry (P = 0.01). Baseline characteristics that did not predict SRC included age, sex, race, Health Assessment Questionnaire score, fist closure, handspread, lung involvement, muscle weakness, erythrocyte sedimentation rate, and platelet count. In 5 of 10 subjects for whom at least 2 sequential skin scores were available, skin scores increased significantly (P = 0.012) in the 6 months before onset of SRC.

CONCLUSION

SRC occurred in 13% of patients soon (mean 11 months) after entry into the cohort. Predictors of SRC identified in this study included higher than average skin score, prednisone use at study entry, large joint contractures, and heart enlargement. Our data suggest, however, that low-dose prednisone alone was not associated with the onset of SRC, except in the appropriate clinical setting. Although ACE inhibitors and dialysis are now readily available, SRC continues to be associated with poor survival (in this study, 50% of patients with SRC died).

Scleroderma in children

Juvenile systemic scleroderma (jSSc) is a rare childhood disease. In the review period covered within this article, there were few reports devoted exclusively to it. In the past year, there was no breakthrough regarding pathogenesis, classification, or treatment. In the pediatric field, the proposed classification system for jSSc shows significant progress toward a definition of the pediatric population. It should allow better evaluation of this patient group. In adult systemic scleroderma, European efforts to establish indices for disease activity have been published. They should help to assess the disease activity in a standardized way and therefore enable earlier adequate treatment for patients. Biologic markers and new assessment methods for particular organ involvement help to determine disease activity/severity as well. There is still no effective disease-modifying treatment for systemic scleroderma and jSSc. The summarized data of the phase I/II autologous stem cell transplantation trial have been published. The first guidelines for autologous stem cell transplantation for jSSc are proposed. In organ-specific treatment, the introduction of bosentan, a dual endothelin receptor antagonist, to control pulmonary hypertension is a real gain in the therapeutic options. New methods to assess prognosis are evolving and need to be validated in a larger patient population.