Systemic sclerosis

Bibliometric insights into systemic sclerosis with renal involvement: trends, contributions, and future directions

BACKGROUND

Renal involvement is not uncommon in patients with systemic sclerosis (SSc) and presents in various forms, particularly progressing to scleroderma renal crisis (SRC), which is associated with poor prognosis. Therefore, understanding the research trends in this field is critical for advancing clinical management and therapeutic strategies.

METHODS

A bibliometric analysis was conducted using the Web of Science Core Collection, examining publications related to SSc and renal involvement from January 2000 to November 2024. We analyzed publication trends, key contributors, institutions, and countries.

RESULTS

A total of 1,339 publications were identified in the field of SSc and renal involvement, demonstrating an upward trend in publication volume from 2000 to 2024. These articles have been cited a total of 61,234 times, with the majority of contributions coming from the United States, Italy, and East Asian countries. The University of Michigan and University College London were particularly prominent in terms of both publication volume and collaboration networks. Keyword analysis revealed a shift in research focus, with increasing attention on clinical aspects, pathophysiological mechanisms, and vascular complications.

CONCLUSIONS

This study provides a comprehensive overview of the research landscape on SSc with renal involvement, highlighting the key contributors and emerging trends.

Beyond circulating B cells: Characteristics and role of tissue-infiltrating B cells in systemic sclerosis

B cells play a key role in the pathophysiology of systemic sclerosis (SSc). While they are less characterized than their circulating counterparts, tissue-infiltrating B cells may have a more direct pathological role in tissues. In this review, we decipher the multiple evidence of B cells infiltration in the skin and lungs of SSc patients and animal models of SSc but also of other chronic fibrotic diseases with similar pathological mechanisms such as chronic graft versus host disease, idiopathic pulmonary fibrosis or morphea. We also recapitulate the current knowledge about mechanisms of B cells infiltration and their functions in tissues. Finally, we discuss B cell targeted therapies, and their specific impact on infiltrated B cells. Understanding the local consequences of infiltrating B cells is an important step for a better management of patients and the improvement of therapies in SSc.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

CONCLUSION

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

Efficacy of cyclophosphamide for skin fibrosis in systemic sclerosis: a systematic review and single-arm meta-analysis

PURPOSE

Systemic sclerosis (SSc) is a chronic connective tissue disorder characterized by skin thickening with vascular and visceral involvements. The efficacy of cyclophosphamide for SSc-related skin fibrosis remains controversial. The aim of this study was to evaluate the effectiveness of cyclophosphamide for skin fibrosis in SSc.

METHODS

PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov databases were systematically searched for all published clinical trials on the treatment of SSc with cyclophosphamide until January 15, 2025.The outcome of interest was the extent of skin fibrosis, measured by the modified Rodnan skin score (mRSS). Two authors independently screened studies, extracted data, and evaluated the risk of bias. Meta-analysis was conducted with Stata/SE software.

RESULTS

A total of 20 articles involving 869 patients met the inclusion criteria. Cyclophosphamide reduced mRSS score by 2.30 (95% CI 0.72-3.88), 4.53 (95% CI 2.91-6.14), 6.72 (95% CI 2.74-10.70), 5.70 (95% CI 4.04-7.36), and 4.60 (95% CI 3.18-6.02) at 6-, 12-, 18-, 24- and 36-month, respectively. The estimated effect size, obtained by pooling mRSS from all studies at the follow-up endpoint, decreased by 4.71 (95% CI 2.72-6.70). In diffuse cutaneous SSc (dcSSc) subtype, the pooled mRSS decreased by 3.02 (95% CI 1.46-4.58), 6.45 (95% CI 5.02-7.87), 8.03 (95% CI 5.26-10.80), and 6.34 (95% CI 6.00-6.68) at 6-, 12-, 18-, and 24-month, respectively. And the overall reduction in mRSS at the end of follow-up in dcSSc was 7.30 (95% CI 5.61-8.99) across 11 studies. Significant heterogeneity was observed among these studies, and subgroup analysis revealed that study size and disease subtype partially explained the heterogeneity. Sensitivity analysis indicated good study stability.

CONCLUSION

Cyclophosphamide effectively reduced mRSS scores in SSc, particularly in dcSSc. While skin thickness improvement diminishes after 24 months, it remains a viable option for patients with worsening skin fibrosis.

TRIAL REGISTRATION

PROSPERO registration number: CRD42024502283. Registered on 25 January 2024.

Antifibrotic therapeutic strategies in systemic sclerosis: Critical role of the Wnt/β-catenin and TGF-β signal transduction pathways as potential targets

Systemic sclerosis (SSc) is a prototypic fibrosing disorder characterized by widespread fibrosis and immune dysregulation. Current evidence highlights the intricate cross-talk between the canonical Wnt/β-catenin signaling pathway and transforming growth factor-beta (TGF-β) signaling, both of which play fundamental roles in the pathogenesis of fibrosis. This review aims to elucidate the central role of the Wnt/β-catenin-TGF-β pathway and TGF-β signal transduction pathway in fibrotic diseases, focusing on SSc. We summarized evidence from cellular biology studies, animal model investigations, and clinical observations to provide a comprehensive view of the mechanisms by which these pathways cause pathological fibrosis. In addition, we explore the possibilities of antifibrotic therapeutic strategies against Wnt/β-catenin-TGF-β signaling to counteract fibrosis. We aim to delineate approaches towards effectively treating fibrosis in SSc by targeting these interconnected signaling pathways.

Mortality and associated factors in patients with systemic sclerosis-associated pulmonary hypertension with and without interstitial lung disease: A long-term follow-up study

OBJECTIVES

We aimed to investigate mortality and prognostic factors in systemic sclerosis (SSc) patients with pulmonary hypertension (PH) with or without interstitial lung disease (ILD).

METHODS

The associations between mortality and demographics, transthoracic echocardiography, right heart catheterization (RHC), pulmonary functional parameters at baseline, and treatment modalities were evaluated.

RESULTS

Survival rates for PH-SSc patients (42 female, mean age 56.6 ± 13.5, median follow-up 45 months) were 91% at the first year, 75% at 2 years, and 43.1% at 5 years. The majority of the deceased patients had PH + ILD (P = .007). The PH + ILD group had more diffuse skin involvement, anti-Scl-70, high C-reactive protein, low FVC, and lower DLCO. The deceased patients had higher estimated pulmonary arterial systolic pressure (PASP), low cardiac output, and FVC values. Median survival time was significantly better in patients on combined therapy. Mortality-related factors in the PH + ILD group were decreased initial FVC, high estimated PASP, low cardiac output, deteriorated functional class, and monotherapy.

CONCLUSION

This is the first reported SSc-PH cohort from Turkey by a multidisciplinary team. PH is a severe complication of SSc with high mortality especially in patients with accompanying severe ILD.

Emerging roles of mechanically activated ion channels in autoimmune disease

Mechanically activated (MA) ion channels have rapidly gained prominence as vital conduits bridging aberrant mechanical cues in tissues with the dysregulated immune responses at the core of autoimmune diseases. Once regarded as peripheral players in inflammation, these channels, exemplified by PIEZO1, TRPV4, and specific K2P family members, now play a central role in modulating T-cell effector functions, B- cell activation and the activity of macrophages and dendritic cells. Their gating is intimately tied to physical distortions such as increased tissue stiffness, osmotic imbalances, or fluid shear, triggering a cascade of ionic fluxes that elevate proinflammatory signaling and drive tissue-destructive loops. Recognition of these channels as central mediators of mechanical stress-induced inflammation responses in autoimmune pathogenesis is rapidly expanding. In parallel, the emerging therapeutic strategies aim to restrain overactive mechanosensors or selectively harness them in affected tissues. Small molecules, peptide blockers, and gene-targeting approaches show preclinical promise, although off-target effects and the broader homeostatic roles of these channels warrant caution. This review explores how integrating mechanobiological concepts with established immunological paradigms enables a more detailed understanding of autoimmune pathogenesis. By elucidating how mechanical forces potentiate or dampen pathological immunity, we propose innovative strategies that exploit mechanosensitivity to recalibrate immune responses across a spectrum of autoimmune conditions.

Cerebrovascular Involvement in Systemic Sclerosis

Systemic sclerosis (SSc) is a chronic autoimmune rheumatic disease characterized by vascular damage, immune system dysregulation and fibrosis. The hallmark features include microvascular alterations and progressive tissue fibrosis, affecting skin, internal organs as well central and peripheral nervous system, adding to the disease's complexity and influencing overall outcomes. Of note, SSc has also been linked to macrovascular and cardiovascular involvement, including cerebrovascular damage as observed in stroke. Indeed, advanced neuroimaging is highly recommended for assessing cerebrovascular status in overt SSc to evaluate the complex interactions between cerebrovascular dysfunction and brain tissue damage and/or inflammation. Cerebral vasospasm detected by angiography, as well as an increase in subclinical cerebrovascular atherosclerosis observed by ultrasonography (carotid intimal medial thickness), are predictive for elevated stroke risk. Furthermore, a significant brain hypoperfusion detected by magnetic resonance imaging, along with white matter focal and/or diffuse signal abnormalities in SSc, have been found associated with concomitant peripheral microvascular damage detectable by "Active" and "Late" nail fold video capillaroscopy scleroderma patterns. Finally, the presence of calcifications in small arteries and arterioles found postmortem in the brain of SSc patients reinforces the hypothesis that SSc is associated with brain vascular remodeling. Furthermore, the current state of art shows an increased risk of cerebrovascular events in the SSc, confirmed by neuroimaging. Given the lack of updated comprehensive reviews on cerebrovascular involvement in SSc, we gathered the most relevant evidence on central nervous system damage, highlighting the underlying mechanisms, clinical implications, and potential advantages that neuroimaging may provide for its early detection.

Stimulation of endothelin-1 production by autoantibodies present in patients with scleroderma renal crisis

Here, we investigate how autoantibodies against G protein-coupled receptors (GPCRs) on endothelial cells, which are present in patients with scleroderma renal crisis (SRC) impact on endothelin-1 (ET-1) production in human microvascular endothelial cells (HMECs). To this end, serum IgG fraction was isolated from SRC patients and applied to HMECs in culture. Compared to cells treated with either plain control medium or serum IgG from healthy individuals, exposure of HMECs to SRC-IgG resulted in a time- and concentration-dependent increase in ET-1 expression and release. This effect could be blocked by the protease activated receptor 1 (PAR1) inhibitor and mimicked by thrombin, the PAR1 activator. Transcription factor C-FOS/AP-1 and tissue factor (TF) were identified as mediators of these responses. Thus, it can be concluded that serum IgG fraction from SRC patients stimulates endothelial cells to produce ET-1, acting through PAR1 in cooperation with TF.

Systemic sclerosis-related fecal incontinence: a scoping review focusing on a neglected manifestation

OBJECTIVES

This scoping review sought to summarize the current knowledge on the epidemiology, pathogenesis and clinical presentation of, and the investigations that may help characterize faecal incontinence (FI) in patients with SSc.

METHODS

The planned scoping review was based on the methodological framework proposed by Arksey and O'Malley. Two databases were screened: PubMed (Medline), (Web of Science), and data extraction was performed using a predefined template.

RESULTS

A total of 454 abstracts were screened and 61 articles were finally included, comprising 32 original articles. The prevalence of FI was 0.4% to 77% in original articles that did not use FI among the mandatory inclusion criteria. Internal anal sphincter was reported as more impacted than external sphincter and vasculopathy of arterioles and extracellular matrix deposition with fibrous replacement of the internal sphincter were the key underlaying pathogenic events. The most represented patient-reported outcome in original articles was the Wexner FI score (22% of original articles) followed by the UCLA SCTC-GIT 2.0 (16% of original articles). Although there is no validated diagnostic approach for FI in SSc, 47% of original articles used anorectal manometry to assess rectal physiology in SSc patients. Conservative measures to treat either liquid or hard stool including anti-diarrhoeal medications and dietary adjustments were the first step of proposed FI management in included narrative reviews and guidelines.

CONCLUSION

This is the first scoping review exploring FI in SSc. We propose a new research agenda which may help improve treatment strategies and foster research focusing on a neglected manifestation of SSc.

Anti-RNApol3-Associated myocarditis: an emerging disease linking autoimmunity and infection

BACKGROUND

Fulminant myocarditis (FM) is a severe condition primarily triggered by viruses. Anti-RNA polymerase III autoantibodies (RNApol3) which are typically found in patients with severe systemic sclerosis, have been reported in patients with influenza-related FM. Our objective is to provide additional insight into RNApol3-associated FM.

METHODS

We retrospectively included all patients admitted to our institution between January 2013 and June 2023 with acute myocarditis and positive serum RNApol3. We compared their characteristics, etiologies, and outcomes with those of a cohort of RNApol3 negative acute myocarditis.

RESULTS

Twenty-nine RNApol3-positive patients, comprising 83% females with a mean age of 39 ± 12 years, were included in this study. Each patient was admitted to the intensive care unit at least once and 11 (38%) relapsed. Triggers included influenza virus in 55% and SARS-CoV-2 virus in 48% of cases. The lowest left ventricular ejection fraction was 10 [5-10] % and the highest troponin value was 82 [22-360] times the ULN. Patients required dobutamine (94%), veno-arterial extracorporeal membrane oxygenation (85%) and pericardiocentesis (38%). At the last follow-up, 76% of patients were still alive, while 7% had undergone cardiac transplantation, and 3% required a left ventricular assist device. Compared to RNApol3-negative cases, RNApol3-positive myocarditis was associated with female gender, fulminant evolution, tamponade, a higher likelihood of being caused by a proven viral infection, and a higher rate of relapse.

CONCLUSION

RNApol3-associated myocarditis is an emerging disease linking autoimmunity and infection and a unique cause of acquired, pathogen-specific, organ-specific immunodeficiency. RNApol3 should be screened in all cases of FM, especially in young women infected by RNA viruses. The risk of FM in RNApol3-positive systemic sclerosis needs further investigation.

Is there a link between choroidal and retinal parameters in patients with systemic sclerosis? A prospective study

PURPOSE

Systemic sclerosis (SSc) is an autoimmune connective tissue disease. It affects choroid causing reduction in its thickness and volume. The aim of this study has been to get a better insight into the pathogenesis of retinal and choroidal involvement in SSc.

METHODS

This prospective single-center cross-sectional study included 33 patients with SSc and 40 controls. A full ophthalmological and rheumatological assessment was performed. The patients underwent the spectral-domain optical coherence tomography. The thickness of the inner retinal and outer retinal layer (ORL), outer nuclear layer (ONL), retinal pigment epithelium (RPE) was evaluated, as well as the central macular choroidal thickness and choroidal vascularity index (CVI).

RESULTS

The inner retinal thickness did not differ. In the outer retina, slight differences were observed in the thickness of the RPE and ORL within the inner temporal subfield, that were thinner in SSc patients, p<0.05. Choroidal parameters differed between the groups (luminal, stromal, and total choroidal areas; central choroidal thickness, p<0.05 for all). Correlations were found in the SSc patients (diffuse cutaneous systemic sclerosis group: the central macular ORL with the CVI rho=0.47, p=0.042; limited cutaneous systemic sclerosis group: the central macular RPE thickness with the total choroidal area rho=-0,7, p=0038, and with the luminal area: rho=-0,7, p=0036). The univariate regression analyses revealed only few significant associations with low fit of models to the data of the central macular ORL, ONL, RPE with the tested ocular and clinical parameters in the SSc and the controls.

CONCLUSION

It is plausible to assume that, although reduced in the SSc patients, the choroidal blood supply to the outer retina may still be sufficient to maintain its thickness.

A Comprehensive Exploration of the Biological Effects of Adipose-Derived Stem Cells in the Treatment of Systemic Sclerosis

Systemic sclerosis (SSc) is a complex autoimmune disease characterized by vasculopathy and tissue fibrosis affecting the skin and internal organs. Genetic and environmental factors influence susceptibility, severity, and onset. Current treatments are limited and not always effective, leading researchers to investigate new approaches, such as the use of adipose-derived mesenchymal stem cells (ADSCs) through fat grafting. This review seeks to understand how ADSCs may impact the development and progression of SSc, with a particular focus on how these cells could alter immune responses and reduce fibrosis. ADSCs have been found to affect various immune cells, including T cells, B cells, macrophages, and dendritic cells, by releasing cytokines, chemokines, and growth factors. These interactions generally suppress inflammation and promote a regulatory immune environment. Additionally, ADSCs can influence the extracellular matrix, helping to prevent fibrosis through signaling molecules like exosomes. ADSCs show promise as a treatment for SSc due to their ability to modulate the immune system and reduce fibrosis. Early clinical studies are encouraging, but more research is needed to fully understand how they work and to develop effective treatment protocols.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Lymphomonocytic Extracellular Vesicles Influence Fibroblast Proliferation and Collagen Production in Systemic Sclerosis

Systemic sclerosis (SSc) is a chronic autoimmune disorder characterized by fibrosis, immune dysregulation, and vascular abnormalities. Extracellular vesicles (EVs), secreted by immune cells, have been implicated in modulating fibroblast activity and are actively involved in SSc pathogenesis. This study aims to determine whether lymphomonocytic-derived EVs influence fibroblast proliferation and collagen synthesis in SSc. Fibroblasts from healthy donors (HDFs) and SSc patients (SScHDFs) were exposed to EVs derived from Jurkat and U937 cell lines stimulated under pro-inflammatory conditions using tumor necrosis factor-α (TNFα) or phorbol 12-myristate 13-acetate + ionomycin (PMA + IONO). Proliferation was assessed using CCK-8 assays, while collagen production was quantified via ELISA. Our findings demonstrate that EVs derived from PMA + IONO-stimulated Jurkat and U937 cells significantly reduced fibroblast proliferation in a dose-dependent manner. Notably, SScHDFs exhibited lower baseline proliferation and a diminished overall response to EV treatment. Collagen production was markedly reduced in both fibroblast types following exposure to PMA + IONO-stimulated EVs, whereas TNFα-stimulated EVs affected only HDFs. These findings suggest that EVs from activated immune cells modulate fibroblast function in SSc, potentially contributing to disease pathogenesis. Further research is warranted to elucidate the molecular mechanisms underlying these effects and to explore the therapeutic potential of targeting EV-mediated signaling in SSc.

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

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

The Role of CXCL4 in Systemic Sclerosis: DAMP, Auto-Antigen and Biomarker

Systemic sclerosis (SSc) is an autoimmune disease characterized by specific autoantibodies, vasculopathy and fibrosis of the skin and internal organs. In SSc, chronic activation of the immune system is largely sustained by endogenous inflammatory mediators that act as damage-associated molecular patterns (DAMPs), which activate Toll-like receptors (TLRs). Major autoantigens are nucleic acids or molecules that are able to bind nucleic acids. It is important to identify solid and predictive biomarkers of both disease activity and disease subtype. CXCL4 has been regarded as a new biomarker for early SSc in recent years, and here, we discuss its modulation over the course of a disease and after pharmacological interventions. Moreover, we provide evidence that CXCL4, in addition to being a biomarker of SSc subtypes and a prognostic marker of disease severity, has a dual pathogenic role in SSc: on the one hand, in complex with self-nucleic acids, CXCL4 acts as a DAMP for IFN-I and pro-inflammatory cytokines' release by innate immune cells (such as dendritic cells); on the other hand, CXCL4 is a target of both antibodies and T cells, functioning as an autoantigen. CXCL4 is certainly an interesting molecule in inflammation and autoimmunity, not only in SSc, and it may also be considered as a therapy target.

Ultrasound Beyond Joints: A Review of Extra-Articular Applications in Rheumatology

PURPOSE OF REVIEW

This review highlights key ultrasound applications for evaluating extra-articular involvement in rheumatic diseases, including the lungs, vessels, salivary glands, muscles, nerves, skin, and nails. It explores recent advances, emerging areas of assessment, and future research directions. Additionally, the review examines current limitations in the routine use of ultrasound for these purposes and considers the potential of new technologies, such as shear-wave elastography, contrast-enhanced ultrasound, and artificial intelligence, to enhance the early detection and monitoring of extra-articular manifestations in rheumatic diseases.

RECENT FINDINGS

Extra-articular manifestations in patients with rheumatic diseases are crucial for diagnosis, management (including treatment strategies), and prognosis, making accurate assessment essential. Growing evidence supports the role of ultrasound in assessing these manifestations for diagnosis, monitoring, and gaining insights into disease pathogenesis. Recent studies emphasize the significant utility of ultrasound in evaluating extra-articular involvement across various organ systems, including the lungs, vessels, salivary glands, muscles, nerves, skin, and nails. Technological advances, such as shear-wave elastography, contrast-enhanced ultrasound, and artificial intelligence, are expanding the scope and precision of ultrasound applications. Despite its potential, challenges such as operator dependency, lack of standardized protocols, and the need for specialized training hinder its widespread adoption. Ultrasound is a non-invasive, cost-effective, and radiation-free imaging modality with high diagnostic accuracy, making it a valuable tool for assessing extra-articular manifestations in rheumatic diseases. Emerging technologies may further enhance its clinical utility. However, efforts to standardize techniques and improve accessibility are necessary to optimize its integration into routine practice.

Deep medullary veins: a promising neuroimaging marker for neurodegeneration in multiple sclerosis

Background

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system (CNS). Recent studies have shown that different forms of vascular abnormalities may be related to the pathogenesis of MS. Susceptibility-weighted imaging (SWI) can directly image intracranial venules. The aim of this study was to investigate the association between deep medullary veins (DMVs) and the degree of neurodegeneration in patients with MS.

Methods

In this prospective cross-sectional study, 34 patients with MS and 30 age-matched healthy controls (HCs) were recruited. The count and score of DMVs, which can reflect the visibility and continuity of DMVs were evaluated based on SWI. The differences between the group with a high DMV score (DMV >10) and the group with a low DMV score (DMV ≤10) were assessed. The association of DMV change with neurodegeneration neuroimaging markers [including amount and volume of white matter lesion (WML), degree of cortical atrophy, whole-brain atrophy, and deep gray matter (DGM) atrophy] and clinical Expanded Disability Status Scale (EDSS) were observed in patients with MS.

Results

It was found that compared with controls, patients with MS (n=34) had a significantly lower DMV count (P<0.001) and a significantly higher DMV score (P<0.001). The low- and high-DMV score groups differed significantly in terms of EDSS (P=0.048) and neurodegeneration neuroimaging indicators, including WML volume (P=0.015), brain parenchymal fraction (BPF) (P=0.047), thalamic fraction (P=0.036), and caudate fraction (P=0.015). In the correlation analysis of the MS group, DMV count was negatively correlated with the number of WMLs (r=-0.535; P=0.001) and the WML volume (r=-0.416; P=0.014) but positively correlated with the neuroimaging measurements reflecting the degree of whole-brain atrophy and DGM atrophy. Furthermore, the DMV score was positively correlated with EDSS (r=0.450; P=0.008), number of WMLs (r=0.490; P=0.003), and WML volumes (r=0.635; P=0.001) but negatively correlated with the neuroimaging measurements reflecting the degree of whole-brain atrophy and DGM atrophy.

Conclusions

Reduced DMV visibility and continuity could reflect the severity of neurodegeneration in patients with MS. DMV count and score may be imaging indicators for assessing the severity of MS.

Soluble oncostatin M receptor (sOSMR): A potential biomarker in systemic sclerosis diagnosis

BACKGROUND

Systemic sclerosis (SSc) is a complex disease whose diagnosis is based on clinical manifestations, serological testing for autoantibodies, and nailfold capillaroscopy. Although some proteins have been proposed as biomarkers, the diagnosis of SSc remains a challenge for clinicians. The soluble oncostatin M receptor (sOSMR) is a potential biomarker for the diagnosis of SSc, as it appears to act as an antagonist of oncostatin M (OSM)-mediated signaling, which is involved in biological and inflammatory processes, including tissue injury and fibrosis. Therefore, this study aimed to evaluate the diagnostic performance of sOSMR in systemic sclerosis.

METHODOLOGY

Serum samples were collected from 105 patients with SSc, 50 with rheumatoid arthritis (RA), 64 with systemic lupus erythematosus (SLE), and 130 healthy controls (HC). The sOSMR levels were measured using an ELISA kit, and a receiver operating characteristic (ROC) curve was used to analyze the biomarker's potential for diagnosing SSc.

RESULTS

sOSMR levels are significantly elevated in the serum of patients with SSc when compared to patients with RA and SLE, as well as healthy controls (p < 0.0001 for all comparisons). The area under the curve (AUC) of ROC curve analysis revealed the ability of sOSMR serum levels to distinguish patients with SSc from those with RA (0.901 [95 % CI 0.842-0.943]; p < 0.0001), with a sensitivity of 89.52 % and specificity of 78.00 %, and from patients with SLE (0.897 [95 % CI 0.841-0.938]; p < 0.0001), with a sensitivity of 81.90 % and specificity of 89.06 %, as well as from healthy controls (0.876 [95 % CI 0.827 - 0.916]; p < 0.0001), with a sensitivity of 82.86 % and specificity of 81.54 %. When comparing patients with SSc to patients with other diseases (RA and SLE combined), an AUC of 0.898 ([95 % CI 0.851-0.935]; p < 0.0001) was found, with a sensitivity of 82.86 % and specificity of 85.09 %.

CONCLUSION

Serum sOSMR levels are elevated in patients with SSc and have shown a good ability to distinguish between SSc patients, patients with other autoimmune rheumatologic diseases (RA and SLE), and healthy controls. Thus, sOSMR is a promising marker for diagnosing SSc.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Galapagos and Boehringer Ingelheim.

Barriers to CAR T-cell therapy in rheumatology

Chimeric antigen receptor (CAR) T cells have recently shown remarkable promise in treating rheumatic diseases, including systemic lupus erythematosus (SLE), idiopathic inflammatory myopathies, and systemic sclerosis. Currently, there are 37 clinical trials registered for CAR T-cell therapy in rheumatic diseases and many more are being planned. Much of this enthusiasm is justifiable, but widespread adoption of CAR T-cell therapy in rheumatology faces several barriers. The trajectory of autoimmune diseases differs from malignancies and a surprisingly narrow population could be eligible for CAR T-cell therapy. Current CAR T-cell approaches rely on B-cell depletion, which has a mixed record of success for many diseases. The high cost of CAR T-cell therapy and potential safety concerns, such as cytokine release syndrome and long-term infection risks, also pose substantial challenges. Moving forward, more targeted CAR T-cell approaches, such as antigen-specific chimeric autoantibody receptors or chimeric autoantigen T-cell receptors, could offer greater efficacy and safety in treating rheumatic diseases.

An international perspective on the future of systemic sclerosis research

Systemic sclerosis (SSc) remains a challenging and enigmatic systemic autoimmune disease, owing to its complex pathogenesis, clinical and molecular heterogeneity, and the lack of effective disease-modifying treatments. Despite a century of research in SSc, the interconnections among microvascular dysfunction, autoimmune phenomena and tissue fibrosis in SSc remain unclear. The absence of validated biomarkers and reliable animal models complicates diagnosis and treatment, contributing to high morbidity and mortality. Advances in the past 5 years, such as single-cell RNA sequencing, next-generation sequencing, spatial biology, transcriptomics, genomics, proteomics, metabolomics, microbiome profiling and artificial intelligence, offer new avenues for identifying the early pathogenetic events that, once treated, could change the clinical history of SSc. Collaborative global efforts to integrate these approaches are crucial to developing a comprehensive, mechanistic understanding and enabling personalized therapies. Challenges include disease classification, clinical heterogeneity and the establishment of robust biomarkers for disease activity and progression. Innovative clinical trial designs and patient-centred approaches are essential for developing effective treatments. Emerging therapies, including cell-based and fibroblast-targeting treatments, show promise. Global cooperation, standardized protocols and interdisciplinary research are vital for advancing SSc research and improving patient outcomes. The integration of advanced research techniques holds the potential for important breakthroughs in the diagnosis, treatment and care of individuals with SSc.

Single-cell RNA sequencing in autoimmune diseases: New insights and challenges

Autoimmune diseases involve a variety of cell types, yet the intricacies of their individual roles within molecular mechanisms and therapeutic strategies remain poorly understood. Single-cell RNA sequencing (scRNA-seq) offers detailed insights into transcriptional diversity at the single-cell level, significantly advancing research in autoimmune diseases. This article explores how scRNA-seq enhances the understanding of cellular heterogeneity and its potential applications in the etiology, diagnosis, treatment, and prognosis of autoimmune diseases. By revealing a comprehensive cellular landscape, scRNA-seq illuminates the functional regulation of different cell subtypes during disease progression. It aids in identifying diagnostic and prognostic markers, and analyzing cell communication networks to uncover potential therapeutic targets. Despite its valuable contributions, addressing the limitations of scRNA-seq is essential for making further advancements.

The role and mechanism of JAK2 inhibitor in endothelial mesenchymal transition in systemic sclerosis

BACKGROUND

Systemic sclerosis (SSc) is an autoimmune disease characterized by vascular endothelial dysfunction and damage, immune dysregulation and fibrosis. Endothelial mesenchymal transition (EndoMT) has been implicated in the skin fibrosis of SSc. Many studies have demonstrated that janus kinase type2 (JAK2) inhibitor can alleviate skin fibrosis in both SSc patients and bleomycin (BLM)-induced mouse models of SSc. However, the potential therapeutic effect of JAK2 inhibitor on EndoMT in SSc skin, along with the underlying molecular mechanisms, remains unexplored.

OBJECTIVE

To investigate the effects of JAK2 inhibitor on the EndoMT in SSc skin and to elucidate the associated molecular mechanisms.

METHODS

Wild-type female C57BL/6 mice were divided into several groups to assess the effects of JAK2 inhibitor on EndoMT through H&E staining, masson staining, immunofluorescence and single-cell RNA-sequencing (scRNA-seq). Cultured human umbilical vein endothelial cells (HUVECs) were used to explore the mechanism of action of JAK2 inhibitor on EndoMT using immunofluorescence, quantitative RT-PCR, RNA sequencing and western blot.

RESULTS

JAK2 inhibition improved skin fibrosis, reduced CD31/α-SMA co-localisation and the number of EndoMT-activated vascular endothelial cells in bleomycin-induced SSc mice. Treatment of HUVECs with TGF-β or BLM led to a myofibroblast-like morphology and markers, along with downregulation of endothelial cell features, which were reversed following JAK2 inhibition. The activation of the PI3K/Akt/mTOR pathway was involved in EndoMT in HUVECs induced by TGF-β/BLM, and this activation was attenuated by JAK2 inhibition.

CONCLUSIONS

JAK2 inhibitor may serve as an effective treatment for EndoMT in SSc, potentially through modulation of the PI3K/Akt/mTOR signaling pathway.

Exosomes carrying adipose mesenchymal stem cells function alleviate scleroderma skin fibrosis by inhibiting the TGF-β1/Smad3 axis

Systemic sclerosis (SSc) is a connective tissue disease characterized by progressive fibrosis of the skin and visceral organs, to date, skin fibrosis remains a clinical therapeutic challenge. Adipose-derived mesenchymal stem cells (AMSCs) have been considered extremely promising for the treatment of SSc, and the biological effects of MSCs are partly attributed to the secretion of exosomes (exos). Our aim was to determine whether exosomes derived from AMSCs have parental biological effects to AMSCs in the therapy of SSc skin fibrosis. In vitro cellular experiments, AMSCs and SSc skin fibroblasts were cocultured in direct contact and transwell indirect contact at a ratio of 1:5 and 1:10, respectively, then exosomes were extracted from the cell culture supernatant of AMSCs and identified, and the exosomes were cocultured with fibroblasts to investigate the effects of AMSCs and exosomes on fibroblast collagen synthesis. Repeated subcutaneous injections of bleomycin (BLM) to construct a model of SSc skin fibrosis in vivo experiments, then AMSCs and exosomes were injected subcutaneously to investigate their effects on skin fibrosis in the BLM mice. The results revealed that exosomes had similar biological functions to AMSCs, by inhibiting the TGF-β1/Smad3 axis, which alleviated collagen synthesis in skin fibroblasts from SSc patients and skin fibrosis in BLM models. In conclusion, AMSCs-derived exosomes may be "rising star candidates" for the treatment of SSc skin fibrosis.

Immunometabolic shifts in autoimmune disease: Mechanisms and pathophysiological implications

Autoimmune diseases occur when the immune system abnormally attacks the body's normal tissues, causing inflammation and damage. Each disease has unique immune and metabolic dysfunctions during pathogenesis. In rheumatoid arthritis (RA), immune cells have different metabolic patterns and mitochondrial/lysosomal dysfunctions at different disease stages. In systemic lupus erythematosus (SLE), type I interferon (IFN) causes immune cell metabolic dysregulation, linking activation to metabolic shifts that may worsen the disease. In systemic sclerosis (SSc), mitochondrial changes affect fibroblast metabolism and the immune response. Idiopathic inflammatory myopathies (IIMs) patients have mitochondrial and metabolic issues. In primary Sjögren's syndrome (pSS), immune cell metabolism is imbalanced and mitochondrial damage can lead to cell/tissue damage. Metabolic reprogramming links cellular energy needs and immune dysfunctions, causing inflammation, damage, and symptoms in these diseases. It also affects immune cell functions like differentiation, proliferation, and secretion. This review discusses the potential of targeting metabolic pathways to restore immune balance, offering directions for future autoimmune disease research and treatment.

Acute Coronary Syndrome and Rheumatic Disease

Patients with rheumatic disease and immune disorders have been noted to show an earlier development of atherosclerosis and to present with acute coronary syndrome. These diseases disproportionately affect women, and patients frequently have a higher number of comorbidities and other risk factors. Inflammation has long been known to play a role in the development of coronary artery disease. Early studies have shown some benefit in treatment targeting inflammation. While this has not been realized for all populations, there remains potential in treatment with targeted and individualized therapies. Especially since these diseases are associated with a worse prognosis, management benefits from the multidisciplinary expertise of cardiologists, rheumatologists, and other providers. However, the prevention and treatment of underlying rheumatic disease remains essential. This review will seek to highlight prior studies and future directions in the treatment of acute coronary syndrome in patients with rheumatologic disease.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Promoting ER stress in a plasmacytoid dendritic cell line drives fibroblast activation

BACKGROUND

Fibrosis remains a major complication in several chronic diseases, including systemic sclerosis (SSc). Plasmacytoid dendritic cells (pDCs) are innate immune cells that play a key role in the development of fibrosis in SSc patients, through still poorly defined mechanisms. Interestingly, endoplasmic reticulum (ER) stress signaling pathways are dysregulated in pDCs from patients with SSc, but their contribution to fibrosis remains unclear. Thus, this study aimed to unravel the mechanisms behind the involvement of pDCs and ER stress in fibrosis.

METHODS

To address this question, we established an in vitro model designed to study the interactions between pDCs and fibroblasts. More specifically, IMR-90 fibroblasts were co-cultured with CAL-1, a pDC cell line. ER stress was then induced by the bacterial toxin SubAB. Extracellular matrix (ECM) production was assessed using immunoblotting, qPCR and confocal microscopy. The importance of cell-to-cell contact was investigated using conditioned media (CM) and transwell assays.

RESULTS

Direct contact of CAL-1 and IMR-90 cells under ER stress conditions led to increased expression of fibronectin and alpha-smooth muscle actin (α-SMA). This effect required expression of the ER stress signaling sensor protein kinase R-like ER kinase (PERK) in pDCs and was observed only upon direct contact between both cell types.

CONCLUSIONS

Overall, our data suggest that ER stress induction in pDCs promotes fibroblast activation, which may contribute to the development of fibrosis in SSc.

SOX9: a key transcriptional regulator in organ fibrosis

The SOX9 gene locus is not only extensive but also intricate, and it could promote fibrosis in different organs or tissues, including cardiac fibrosis, liver fibrosis, kidney fibrosis, pulmonary fibrosis, as well as other organ fibrosis. Many disorders are associated with the process of fibrosis; moreover, fibrosis is a common symptom of chronic inflammatory diseases, characterized by the accumulation of excessive components in the extracellular matrix through different signaling pathways. The advanced stage of the fibrotic process leads to organ dysfunction and, ultimately, death. In this review, we first give an overview of the original structure and functions of SOX9. Second, we will discuss the role of SOX9 in fibrosis in various organs or tissues. Third, we describe and reveal the possibility of SOX9 as an antifibrotic treatment target. Finally, we will focus on the application of novel technologies for SOX9 and the subsequent investigation of fibrosis.

Extracellular Matrix-Inspired Dendrimer Nanogels Encapsulating Cyclophosphamide for Systemic Sclerosis Treatment

Cyclophosphamide has a certain therapeutic effect on treating systemic sclerosis (SSc), while difficulties exist in controlling severe systematic side effects and enhancing targeting capacity. Here, inspired from the natural extracellular matrix composition, we propose a cyclophosphamide-encapsulated nanogel based on dendritic polymers polyamidoamine (PAMAM) for SSc treatment. We combine bovine serum albumin and generation 5 (G5) PAMAM dendrimers with polyphenol modification to obtain nanogels featured with antioxidant and anti-inflammatory effects. The nanogels can possess excellent biocompatibility and prevent fibroblasts from oxidative stress damage and TGF-β-mediated activation. Furthermore, in the bleomycin-induced SSc mouse model, dendrimer nanogels encapsulating cyclophosphamide also exhibit the ability to attenuate fibrosis by modulating immunity, suppressing inflammation, and reducing collagen synthesis. These findings underscore the value of this dendritic polymer nanogel in the treatment of chronic SSc, indicating its broader potential for clinical applications.

Quantification of coronary artery calcification in systemic sclerosis using visual ordinal and deep learning scoring: Association with systemic sclerosis clinical features

OBJECTIVE

To investigate the association between systemic sclerosis (SSc) clinical features and the extent and progression of coronary artery calcifications.

METHODS

We conducted a single-center retrospective cohort study of patients with SSc. In our primary aim, we investigated the association between SSc clinical features and the annual progression of coronary artery calcium (CAC) scores quantified using the visual ordinal scoring method. In our secondary aim, we utilized DeepCAC, a deep learning-based method, to quantify coronary artery calcifications ("deep learning CAC score"), and explored its association with SSc clinical features.

RESULTS

Eighty-six SSc patients were included in the primary aim and 171 in the secondary aim. SSc disease duration was inversely associated with annual ordinal CAC score progression in the demographics-adjusted model (coefficient = -0.004, 95 % CI -0.006 to -0.001, p-value = 0.01) and the demographics- and cardiovascular (CV) risk factor-adjusted model (coefficient = -0.004, 95 % CI -0.008 to -0.0004, p-value = 0.03). The presence of "fingertip ischemic ulcers or digital pitting scars" (demographics-adjusted model: coefficient = 1.07, 95 % CI 0.29 to 1.85, p < 0.01; demographics- and CV risk factor-adjusted model: coefficient = 1.39, 95 % CI 0.43 to 2.34, p < 0.01) and Group 1 pulmonary hypertension (demographics-adjusted model: coefficient = 1.34, 95 % CI 0.34 to 2.35, p < 0.01; demographics- and CV risk factor-adjusted model: coefficient = 1.52, 95 % CI 0.38 to 2.65, p < 0.01) were both associated with the deep learning CAC score.

CONCLUSION

Our results suggest that the progression of coronary artery calcification accelerates early during the SSc disease course and that severe microvasculopathy may be a risk factor for atherosclerotic CVD.

Generation of human induced pluripotent stem cell lines (iPSC) from adipose-derived mesenchymal stromal cells from two patients with systemic sclerosis

Systemic sclerosis (SSc) is a rare and complex connective tissue disease associated with high morbidity and mortality. SSc is characterized by ischemic vasculopathy, cutaneous and visceral fibrosis and a dysimmune state (Denton and Khanna, 2017; Volkmann et al., 2023; Barnes and Mayes, 2012). We have derived induced pluripotent stem cell (iPSC) lines from two SSc patients aged 38 and 67 years with severe vascular phenotype. These iPSC lines expressed pluripotent markers, exhibited normal and stable genome, and differentiated into trilineage embryonic layers in teratoma formation assays. These SSc-specific iPSC lines can be differentiated into endothelial cells, providing a valuable model to elucidate vascular dysfunction and develop personalized therapeutic approaches.

Comparison of Three Physician Global Assessment Instruments in Systemic Sclerosis

OBJECTIVE

Physician global assessments (PhyGAs) are variably applied in systemic sclerosis (SSc) clinical trials. The comparability of different PhyGA results is unknown. We sought to assess the comparability of results from three different PhyGA instruments simultaneously applied in the Australian Scleroderma Cohort Study (ASCS).

METHODS

Using data from 1,965 ASCS participants, we assessed the correlation between results of three PhyGA assessments: (1) overall health, (2) activity, and (3) damage. We evaluated the concordance of change in each PhyGA between study visits. Ordered logistic regression analysis was used to evaluate the clinical associations of each PhyGA.

RESULTS

The absolute scores of each PhyGA were strongly correlated at individual study visits. Concordant changes of the PhyGA scores occurred between 50% of study visits. Only patient-reported breathlessness was associated with all three PhyGA scores (overall health: odds ratio [OR] 1.67, P < 0.01; activity: OR 1.44, P < 0.01; damage: OR 1.32, P < 0.01). Changes in physician-assessed activity scores were also associated with patient-reported worsening skin disease (OR 1.25, P = 0.03) and fecal incontinence (OR 1.23, P = 0.01), whereas damage scores were associated with respiratory disease (pulmonary arterial hypertension: OR 1.25, P = 0.03; chronic obstructive pulmonary disease: OR 1.37, P = 0.04), as well as skin scores (OR 1.02, P < 0.01) and fecal incontinence (OR 1.21, P = 0.02).

CONCLUSION

PhyGAs of overall health, activity, and damage are each associated with different SSc features, and changes in different PhyGA scores are discordant 50% of the time. Our findings suggest results of variably worded PhyGAs are not directly interchangeable and support the development of a standardized PhyGA.

The predictive value of anti-IFI16 antibodies for the development or persistence of digital ulcers in systemic sclerosis

To evaluate the association of anti-IFI16 antibodies with peripheral vasculopathy and the predictive value of anti-IFI16 antibodies for the development or persistence of digital ulcers (DPDU) in SSc. A total of 42 SSc patients and 42 age- and sex-matched healthy controls were enrolled. Anti-IFI16 antibodies were examined by ELISA. Nailfold videocapillaroscopy (NVC) and power Doppler ultrasound (PDUS) were used to assess the micro- and macro-vascular involvement in SSc. All patients were followed up for 6 months to evaluate DPDU. Potential risk factors for DPDU were analyzed by a Firth's penalized logistic regression model. Of the 42 SSc patients enrolled, 19.05% patients were positive for anti-IFI16 antibodies, compared to a significantly low positivity rate of 4.76% in healthy controls (p < 0.001). SSc patients who were positive for anti-IFI16 antibodies manifested higher ulnar artery resistance index than anti-IFI16 negative patients (p = 0.018). Within a 6-month follow-up, 14 (33.3%) patients suffered from DPDU, and the prevalence of anti-IFI16 antibodies in patients with DPDU was 42.9%, remarkably higher than 7.1% in those without DPDU (p = 0.012). Additionally, patients with DPDU were more likely to have digital ulcers (DUs) at enrollment and manifest lower finger pulp blood flow, lower ulnar artery (UA) flow velocity, lower UA resistance index, and higher UA resistance index at baseline in comparison to patients without DPDU. Multivariate analysis further identified DUs at enrollment (OR 5.81; 95% CI 1.09-30.86; p = 0.046) and the positivity of anti-IFI16 antibody (OR 8.64; 95% CI 1.05-70.87; p = 0.045) as independent risk factors for DPDU. Presence of anti-IFI16 antibody is associated with higher UA resistance index in SSc. Multivariate analysis further identified anti-IFI16 antibody as a predictive marker for DPDU in SSc. Key Points • SSc patients who were positive for anti-IFI16 antibodies manifested higher ulnar artery resistance at baseline. • The prevalence of anti-IFI16 antibodies in patients with DPDU during the 6-month follow-up was remarkably higher than those without DPDU. • Multivariate analysis identified DUs at enrollment and anti-IFI16 antibody positivity as independent risk factors for DPDU. • Anti-IFI16 antibody is associated with peripheral vasculopathy in SSc. Multivariate analysis further identified anti-IFI16 as a predictive biomarker for the development of DUs.

Topical Application of Nitrate Ameliorates Skin Fibrosis by Regulating ST2+CD4+ T Cells in Systemic Sclerosis Mouse Model

Systemic sclerosis (SSc) is characterized by intractable multiorgan fibrosis caused by vascular and immune dysfunction. Currently, effective therapeutic options for patients with SSc are limited. Nitrate, an abundant nutrient in the diet, has been demonstrated to be preventative and therapeutic for several diseases. To determine whether nitrate can slow or reverse SSc progression, topical application of nitrate delivered by dissolving microneedles was used to treat a bleomycin-induced dermal fibrosis mouse model. In this study, nitrate considerably attenuated dermal thickness, stiffness, and collagen deposition. Bulk RNA sequencing of skin revealed that Cd4 was a key hub gene in SSc nitrate therapy. In addition, bleomycin-induced cytokines and chemokines were inhibited by nitrate, and CD4+ T cells infiltration markedly declined. Il4, Il6, Il13, and Tgfb expressions in CD4+ T cells isolated from skin biopsies also significantly decreased. Mechanistically, Il1rl1, a type 2 immune response inducer, was markedly repressed in isolated CD4+ T cells and dermal tissues after nitrate treatment. Remarkably, compared with wild-type mice, mice lacking Il1rl1 showed impaired transcriptional profiles after intradermal bleomycin injection. Adoptive transfer of ST2+CD4+ T cells promoted bleomycin-induced Rag2-/- mice dermal fibrosis. Collectively, these findings demonstrate that nitrate targeting ST2+CD4+ T cells is an effective therapeutic option for SSc.

Preliminary nomogram model for predicting irreversible organ damage of patients with systemic sclerosis

OBJECTIVE

To investigate predictive factors for irreversible organ damage in systemic sclerosis (SSc) and establish a nomogram model.

METHODS

This retrospective study included patients with SSc who were treated at our hospital between March 2013 and March 2023. Irreversible organ damage included heart failure, respiratory failure, renal failure, and gangrene of the hands and feet. Cox and LASSO regression analyses were performed to determine the predictive factors. Based on the results, a nomogram model was developed. The model was evaluated using the C-indices, calibration plots and DCA.

RESULTS

A total of 361 patients with systemic sclerosis were randomly divided into the development (n = 181) and validation (n = 180) groups. Multivariate Cox regression analysis showed that age ≥65 years, weight loss, digital ulcers, mRSS ≥16, elevated creatinine, elevated myoglobin, elevated C-reactive protein, renal involvement and cardiac involvement were independent risk factors. Based on the LASSO analysis, a nomogram model of irreversible organ damage was established. The C-indices of the development group at 24, 60 and 96 m were 96.7, 84.5 and 85.7, whereas those of the validation group at 24, 60 and 96 m were 86.6, 79.1 and 78.5, respectively. The results of the DCA showed that the nomogram can be used as a valuable tool to predict irreversible organ damage in patients with SSc.

CONCLUSION

We included commonly used clinical indicators. According to the nomogram, the probability of irreversible organ damage can be calculated and high-risk patients can be identified.

Well-Being Therapy in systemic sclerosis outpatients: a randomized controlled trial

OBJECTIVES

Systemic sclerosis (SSc) patients have psychological distress and poor well-being and need a tailored treatment. Psychological interventions, rarely tested for efficacy, showed poor benefits. The present randomized controlled trial tested the efficacy of Well-Being Therapy (WBT) in SSc patients.

METHODS

Thirty-two outpatients were randomized (1:1) to WBT (n = 16) or Treatment As Usual (i.e. routine medical check-ups) (TAU) (n = 16). Primary outcome was well-being. Secondary outcomes included functional ability related to SSc, psychological distress, mental pain, suffering. All participants were assessed at baseline (T0). The WBT group was assessed after two months (end of WBT session 4) (T1), after four months (end of WBT session 8) (T2), after seven months (3-month follow-up) (T3) and after 10 months (6-month follow-up) (T4). The TAU group was assessed two (T1), four (T2), seven (T3) and ten (T4) months after baseline.

RESULTS

WBT produced a significant improvement in subjective well-being (P ≤ 0.001), personal growth (P = 0.006), self-acceptance (P = 0.003) compared with TAU, maintained at T3 as what concerns subjective well-being (P = 0.012). WBT produced a greater decrease in psychological distress (P = 0.010), mental pain (P = 0.010), suffering (P ≤ 0.001) compared with TAU, maintained at T4 as what concerns suffering (P ≤ 0.001). Participants reported high satisfaction with WBT.

CONCLUSION

The study provides preliminary evidence on the benefits of WBT as short-term approach for in- and out-patient SSc healthcare paths. Studies with larger samples are needed to have the evidence for recommending WBT to SSc patients.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Evaluating the safety and efficacy of plasma therapy/plasmapheresis for systemic sclerosis - A comprehensive systematic review

INTRODUCTION

Systemic sclerosis (SSc) is an autoimmune disorder with fibrosis in multiple organs, autoantibodies, and microvascular abnormalities. Its origin is unclear, but it may result from circulatory damage, collagen metabolism disruption, and modifications in immunoregulation. The disease affects various organs and has high morbidity and mortality rates. SSc-related complications are managed using immunosuppressive medications that target autoantibodies. The main objective of this study was to assess the safety and efficacy of plasma therapy/plasmapheresis in managing SSc.

METHODS

This systematic review followed PRISMA and IMRAD guidelines, using PICO framework for study selection based on MeSH terms and Boolean operators. It included cross-sectional, randomized control trials, and clinical studies on plasma therapy for SSc. Standardized protocols were used for data extraction and risk of bias assessment.

DISCUSSION

Plasma therapy is a growing treatment option for managing SSc with reported benefits, especially in early stages and specific organ complications. However, further investigation and standardized protocols are needed. This review explores the potential of plasma therapy in improving the quality of life for SSc patients and in combination with other treatments.

RESULT

The review analyzed 15 articles, including research papers, controlled trials, and case reports. Plasma therapy, involving Plasmapheresis and therapeutic plasma exchange (TPE), improved symptoms of SSc like Raynaud phenomenon, vasculitis, muscle dysfunction, and digital ulcers. However, outcomes varied among studies, and some advanced cases showed limited benefits.

CONCLUSION

Plasma therapy can be an effective way of managing the symptoms of systemic sclerosis with low incidence of adverse events. However, the exact mechanism behind this treatment is still unclear. Therefore, additional studies are required.

The pathogenesis, diagnostic utility and clinical relevance of cutaneous telangiectasia in systemic sclerosis

Cutaneous telangiectasia (Tel) are visible permanently dilated postcapillary dermal venules and are one of the most common disease-specific manifestations of systemic sclerosis (SSc). Telangiectasia have long been recognised for their utility in the diagnosis and classification of SSc, but the clinical and prognostic relevance of these aberrant cutaneous vascular manifestations has been somewhat neglected by clinicians. Similarly, the impact of SSc-Tel on body image dissatisfaction and social discomfort has been under-appreciated. The paucity of evidence-based approaches to management has limited access to potential effective treatments for SSc-Tel. The present review examines the pathogenesis, diagnostic value, impact and clinical relevance of telangiectasia in SSc. We highlight the potentially overlooked prognostic value and clinical utility of SSc-Tel, as part of a broader appraisal of areas of unmet research need.

Accelerated structural valve deterioration in systemic sclerosis patients following transcatheter aortic valve replacement: a case series

Background

Systemic sclerosis (SSc) is marked by an excessive systemic accumulation of collagen. Recent literature implies that aortic stenosis is more prevalent in patients with SSc than previously thought. While there are limited feasibility studies on transcatheter aortic valve replacement (TAVR) in this population, the long-term outcomes remain uncertain.

Case summary

We report two cases of patients with SSc who developed early structural valve deterioration following TAVR, necessitating successful redo-TAVR procedures. Both patients exhibited extensive soft tissue calcinosis as a manifestation of their underlying condition.

Discussion

The fibrotic and calcific processes inherent to certain SSc subtypes could potentially adversely impact the durability and functionality of transcatheter aortic valves. Our observation highlights the need for vigilant post-procedural surveillance and individualized management strategies in this unique patient population. Further investigation into the mechanisms underlying valve degeneration in this patient subset is warranted. Nevertheless, redo-TAVR procedure appears to be a viable option.

Aberrant Chitinase 3-Like 1 Expression in Basal Cells Contributes to Systemic Sclerosis Fibrosis

Systemic sclerosis (SSc) is an autoimmune disease characterized by extensive skin and internal organ fibrosis. However, the mechanism underlying fibrosis remains unclear, and effective treatments for halting or reversing fibrosis are lacking. In this study, single-cell RNA sequencing is used to obtain a comprehensive overview of skin cells from patients with SSc and healthy controls. A subset of basal cells with high chitinase 3-like 1 (Chi3L1) expression, which potentially plays an important role in fibroblast activation, is identified in SSc. Subsequently, patients with SSc are present with increased expression of Chi3L1 in the skin and serum, and elevated serum levels are associated with skin induration and pulmonary function. Furthermore, Chi3L1 promoted the differentiation of SSc dermal fibroblasts into myofibroblasts, and Chi3L1-deficient (Chi3L1-/-) mice showed amelioration of fibrosis in a bleomycin-induced SSc (BLM-SSc) model. Mechanistically, Chi3L1 mediates fibroblast activation primarily by interacting with interleukin-17 receptor A (IL-17RA), thereby initiating downstream nuclear factor kappa B and mitogen-activated protein kinases signaling pathways. Moreover, the anti-fibrotic effect of IL-17RA antagonists in BLM-SSc mice is demonstrated. In conclusion, Chi3L1 is a potential biomarker for the degree of fibrosis in SSc. Chi3L1 and its receptor, IL-17RA, are promising therapeutic targets for patients with SSc.

Inadequate sleep hygiene as a key factor in poor sleep quality in systemic sclerosis: an observational, cross-sectional study

This study aims to investigate the relationship between sleep hygiene and sleep quality in patients with systemic sclerosis (SSc) and to compare the sleep hygiene and sleep quality outcomes across three distinct groups: SSc patients, rheumatoid arthritis (RA) patients, and healthy controls (HC). This study employed an observational, cross-sectional, and parallel group design. SSc-related and RA-related variables, depression and anxiety were assessed. Physical function and quality of life, pain and fatigue of SSc patients were also evaluated. Sleep quality using the Pittsburg Sleep Quality Index (PSQI) and sleep hygiene using the Sleep Hygiene Index (SHI) were evaluated for all participants. Linear regression analysis was performed to show the relationship between the SHI scores and the other variables. Total PSQI and SHI scores were found to be significantly higher in SSc patients than in RA patients and HC. Fatigue, smoking, all SF-36 domains, depression and anxiety scores were associated with SHI scores in SSc patients. In the univariate logistic regression analysis, SSc patients exhibited 4.50 times higher odds (95% CI 2.165-9.353, p < 0.001) of experiencing poor sleep than RA patients and HC. In SSc patients, for every incremental increase in SHI score, the odds of poor sleep quality were 1.15 times higher (95% CI 1.093-1.220, p < 0.001). Sleep hygiene and sleep quality exhibit a more pronounced deterioration in SSc patients. Inadequate sleep hygiene is associated with compromised sleep quality in SSc. Therefore, improving sleep hygiene practices may be a key strategy to enhance the overall sleep quality in this population.