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Blagojevic J, AlOdhaibi KA, Aly AM, Bellando-Randone S, Lepri G, Bruni C, Moggi-Pignone A, Guiducci S, Mecacci F, Matucci-Cerinic M, Furst DE. Pregnancy in Systemic Sclerosis: Results of a Systematic Review and Metaanalysis. J Rheumatol 2019; 47:881-887. [PMID: 31474594 DOI: 10.3899/jrheum.181460] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2019] [Indexed: 01/02/2023]
Abstract
OBJECTIVE Through a systematic literature search (SLR) and metaanalysis, to determine maternal and fetal outcomes in pregnancies involving systemic sclerosis (SSc), to analyze the effect of pregnancy on disease activity, and to examine predictors of fetal and maternal outcomes. METHODS An SLR was performed for articles on SSc and pregnancy published between 1950 and February 1, 2018. Reviewers double-extracted articles to obtain agreement on > 95% of predefined critical outcomes. RESULTS Out of 461 publications identified, 16 were included in the metaanalysis. The metaanalysis showed that pregnancies involving SSc were at higher risk of miscarriage (OR 1.6, 95% CI 1.22-2.22), fetuses with intrauterine growth retardation (IUGR; OR 3.2, 95% CI 2.21-4.53), preterm births (OR 2.4, 95% CI 1.14-4.86), and newborns with low birth weight (OR 3.8, 95% CI 2.16-6.56). Patients with SSc had a 2.8 times higher chance of developing gestational hypertension (HTN; OR 2.8, 95% CI 2.28-3.39) and a 2.3 times higher chance of cesarean delivery compared to controls (OR 2.3, 95% CI 1.37-3.8). The definitions of disease worsening/new visceral organ involvement were too inexact to have any confidence in the results, although worsening or new disease manifestations during pregnancy in 44/307 cases (14.3%) and 6 months postpartum in 32/306 cases (10.5%) were reported. The data did not permit definition of predictors of disease progression and of maternal and fetal outcomes. CONCLUSION Pregnancies involving SSc have increased frequency of miscarriages, IUGR, preterm deliveries, and newborns with low birth weight compared to healthy controls. Women with SSc were more prone to develop gestational HTN and to undergo cesarean delivery. Disease manifestations seem to remain stable or improve in most patients.
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Affiliation(s)
- Jelena Blagojevic
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy. .,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington.
| | - Khitam Abdullah AlOdhaibi
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Aly M Aly
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Silvia Bellando-Randone
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Gemma Lepri
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Cosimo Bruni
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Alberto Moggi-Pignone
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Serena Guiducci
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Federico Mecacci
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Marco Matucci-Cerinic
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
| | - Daniel E Furst
- From the Department of Experimental and Clinical Medicine, University of Florence, and the Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, Azienda Ospedaliero Universitaria Careggi (AOUC), Florence, Italy; Department of Family Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Faculty of Medicine, Alexandria University, Alexandria, Egypt; Department of Emergency Medicine, Division of Medicine IV AOUC; Department of Maternal-Neonatal Caref, Careggi University Hospital, Florence, Italy; University of California at Los Angeles, Los Angeles, California; University of Washington, Seattle, Washington, USA; University of Florence, Florence, Italy.,J. Blagojevic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; K.A. AlOdhaibi, MD, Department of Family Medicine, King Faisal Specialist Hospital and Research Centre; A.M. Aly, MBBch, Faculty of Medicine, Alexandria University; S. Bellando-Randone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; G. Lepri, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; C. Bruni, MD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; A. Moggi-Pignone, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Emergency Medicine, Division of Medicine IV, AOUC; S. Guiducci, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; F. Mecacci, MD, PhD, Department of Maternal-Neonatal Care, Careggi University Hospital; M. Matucci-Cerinic, MD, PhD, Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit, AOUC; D.E. Furst, MD, UCLA (Emeritus), and University of Washington
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