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Luo Y, Gordon JK, Xu J, Kolstad KD, Chung L, Steen VD, Bernstein EJ. Prognostic significance of pericardial effusion in systemic sclerosis-associated pulmonary hypertension: analysis from the PHAROS Registry. Rheumatology (Oxford) 2024; 63:1251-1258. [PMID: 37478347 PMCID: PMC11065440 DOI: 10.1093/rheumatology/kead368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 06/07/2023] [Accepted: 07/03/2023] [Indexed: 07/23/2023] Open
Abstract
OBJECTIVES Pulmonary hypertension (PH) is a leading cause of death in patients with SSc. The purpose of this study was to determine the prognostic significance of pericardial effusion in patients with SSc-PH. METHODS Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma (PHAROS) is a prospective multicentre registry which enrolled patients with newly diagnosed SSc-PH from 2005 to 2016. The prognostic impact of pericardial effusion status, including those who ever or never had pericardial effusion, and those who had persistent or intermittent pericardial effusion, was analysed. Kaplan-Meier survival analyses, log-rank test, and multivariable Cox proportional hazards regression were performed. RESULTS Of the 335 patients with SSc-PH diagnosed by right heart catheterization and documentation of pericardial effusion presence or absence on echocardiogram, 166 (50%) ever had pericardial effusion. Ever having pericardial effusion was not predictive of survival (log-rank test P = 0.49). Of the 245 SSc-PH patients who had at least two echocardiograms, 44% had a change in pericardial effusion status over an average of 4.3 years of follow up. Having a persistent pericardial effusion was an independent predictor of survival [adjusted hazard ratio (aHR)=2.34, 95% CI 1.20, 4.64, P = 0.002], while intermittent pericardial effusion was not a predictor of survival (aHR = 0.89, 95% CI 0.52, 1.56, P = 0.68), in a multivariable-adjusted analysis. CONCLUSION Persistent pericardial effusion, but not ever having had pericardial effusion or intermittent pericardial effusion, was independently associated with poorer survival. Incorporating information from serial echocardiograms may help clinicians better prognosticate survival in their SSc-PH patients.
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Affiliation(s)
- Yiming Luo
- Division of Rheumatology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Jessica K Gordon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Jiehui Xu
- Division of Biostatistics, Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Kathleen D Kolstad
- Division of Rheumatology, Department of Medicine, University of California, Los Angeles School of Medicine, Los Angeles, CA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine and Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Virginia D Steen
- Division of Rheumatology, Georgetown University Medical Center, Washington, DC, USA
| | - Elana J Bernstein
- Division of Rheumatology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
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Own M, Bloostein A, Spiera R, Berman JR, Moline J, Gordon JK, Lakin KS. Systemic Sclerosis in Individuals With Exposure to World Trade Center Ground Zero Rescue and Recovery Efforts: A Case Series. J Rheumatol 2024; 51:390-395. [PMID: 38224979 DOI: 10.3899/jrheum.2023-0821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/17/2024]
Abstract
OBJECTIVE The World Trade Center (WTC) attack in New York resulted in a dust plume containing silica, hydrocarbons, and asbestos. Autoimmune disorders have been reported among those with WTC site exposure. The characteristics of individuals developing systemic sclerosis (SSc) have not been previously described. The purpose of this study was to describe the features of patients with SSc with WTC exposure. METHODS Data were collected from 11 patients with SSc or SSc spectrum conditions who reported exposure to the WTC site. Seven patients completed an exposure assessment. RESULTS Of the 11 patients, the majority (n = 8) were female. The median (range) for age at diagnosis was 46 (36-75) years, time between exposure and first non-Raynaud phenomenon SSc symptom was 8 (1-19) years, and time between exposure and diagnosis was 11 (2-18) years. Fifty-five percent had SSc onset > 5 years from WTC exposure. Five patients had limited cutaneous SSc, 3 patients had diffuse cutaneous SSc, 1 patient with SSc features met criteria for mixed connective tissue disease (CTD), and 2 patients had undifferentiated CTD with features of SSc. Four patients had overlapping features with other CTDs. Interstitial lung disease (ILD) was present in 10 patients. Five of 11 patients had a history of tobacco use. Seven of 7 patients who completed the questionnaire reported other hazardous exposures outside of WTC. Of these, only 2 patients reported personal protective equipment use. CONCLUSION A high frequency of ILD and overlap features were observed among patients with SSc with WTC exposure. Future studies are needed to characterize this association.
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Affiliation(s)
- Maryam Own
- M. Own, MD, Weill Cornell Medicine, Department of Medicine, New York;
| | - Aliza Bloostein
- A. Bloostein, BA, Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, New York
| | - Robert Spiera
- R. Spiera, MD, J.R. Berman, MD, J.K. Gordon, MD, MS, K.S. Lakin, MD, MS, Weill Cornell Medicine, Department of Medicine, and Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, New York
| | - Jessica R Berman
- R. Spiera, MD, J.R. Berman, MD, J.K. Gordon, MD, MS, K.S. Lakin, MD, MS, Weill Cornell Medicine, Department of Medicine, and Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, New York
| | - Jacqueline Moline
- J. Moline, MD, MSc, Northwell Health, Department of Occupational Medicine, Epidemiology and Prevention, Great Neck, New York, USA
| | - Jessica K Gordon
- R. Spiera, MD, J.R. Berman, MD, J.K. Gordon, MD, MS, K.S. Lakin, MD, MS, Weill Cornell Medicine, Department of Medicine, and Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, New York
| | - Kimberly S Lakin
- R. Spiera, MD, J.R. Berman, MD, J.K. Gordon, MD, MS, K.S. Lakin, MD, MS, Weill Cornell Medicine, Department of Medicine, and Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, New York
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Luebker S, Frech TM, Assassi S, Skaug B, Gordon JK, Lakin K, Bernstein EJ, Luo Y, Steen VD, Shah AA, Hummers LK, Richardson C, Moore DF, Khanna D, Castelino FV, Chung L, Kapoor P, Hant FN, Shanmugam VK, VanBuren JM, Alvey J, Harding M, Shah A, Makol A, Lebiedz-Odrobina D, Thomas JK, Volkmann ER, Molitor JA, Sandorfi N. CONQUER Scleroderma: association of gastrointestinal tract symptoms in early disease with resource utilization. Rheumatology (Oxford) 2023; 62:3433-3438. [PMID: 37079727 PMCID: PMC10547507 DOI: 10.1093/rheumatology/kead176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/17/2023] [Accepted: 04/13/2023] [Indexed: 04/22/2023] Open
Abstract
OBJECTIVES SSc is associated with increased health-care resource utilization and economic burden. The Collaborative National Quality and Efficacy Registry (CONQUER) is a US-based collaborative that collects longitudinal follow-up data on SSc patients with <5 years of disease duration enrolled at scleroderma centres in the USA. The objective of this study was to investigate the relationship between gastrointestinal tract symptoms and self-reported resource utilization in CONQUER participants. METHODS CONQUER participants who had completed a baseline and 12-month Gastrointestinal Tract Questionnaire (GIT 2.0) and a Resource Utilization Questionnaire (RUQ) were included in this analysis. Patients were categorized by total GIT 2.0 severity: none-to-mild (0-0.49); moderate (0.50-1.00), and severe-to-very severe (1.01-3.00). Clinical features and medication exposures were examined in each of these categories. The 12-month RUQ responses were summarized by GIT 2.0 score categories at 12 months. RESULTS Among the 211 CONQUER participants who met the inclusion criteria, most (64%) had mild GIT symptoms, 26% had moderate symptoms, and 10% severe GIT symptoms at 12 months. The categorization of GIT total severity score by RUQ showed that more upper endoscopy procedures and inpatient hospitalization occurred in the CONQUER participants with severe GIT symptoms. These patients with severe GIT symptoms also reported the use of more adaptive equipment. CONCLUSION This report from the CONQUER cohort suggests that severe GIT symptoms result in more resource utilization. It is especially important to understand resource utilization in early disease cohorts when disease activity, rather than damage, primarily contributes to health-related costs of SSc.
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Affiliation(s)
- Sarah Luebker
- Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Tennessee Valley Health Care System, Veterans Affair Medical Center, Nashville, TN, USA
| | - Tracy M Frech
- Division of Rheumatology and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Tennessee Valley Health Care System, Veterans Affair Medical Center, Nashville, TN, USA
| | - Shervin Assassi
- Division of Rheumatology, Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Brian Skaug
- Division of Rheumatology, Department of Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jessica K Gordon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York City, NY, USA
| | - Kimberly Lakin
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York City, NY, USA
| | - Elana J Bernstein
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Yiming Luo
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Virginia D Steen
- Department of Medicine, Georgetown University Medical Center, Washington, DC, USA
| | - Ami A Shah
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Laura K Hummers
- Division of Rheumatology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Carrie Richardson
- Division of Rheumatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Duncan F Moore
- Division of Rheumatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Dinesh Khanna
- Division of Rheumatology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Flavia V Castelino
- Division of Rheumatology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University and Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Puneet Kapoor
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University and Palo Alto VA Health Care System, Palo Alto, CA, USA
| | - Faye N Hant
- Division of Rheumatology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Victoria K Shanmugam
- Department of Anatomy, George Washington University, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - John M VanBuren
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jessica Alvey
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Monica Harding
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ankoor Shah
- Division of Rheumatology and Immunology, Department of Medicine, Duke University, Durham, NC, USA
| | - Ashima Makol
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Dorota Lebiedz-Odrobina
- Division of Rheumatology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Julie K Thomas
- Division of Rheumatology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Elizabeth R Volkmann
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Jerry A Molitor
- Division of Rheumatic and Autoimmune Diseases, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Nora Sandorfi
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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4
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Luebker S, Frech TM, Assassi S, Gordon JK, Bernstein EJ, Steen VD, Shah AA, Hummers LK, Richardson C, Khanna D, Castelino F, Chung L, Hant FN, Shanmugam VK, VanBuren JM, Alvey J, Harding M, Sandorfi N. The Collaborative National Quality and Efficacy Registry for Scleroderma: association of medication use on gastrointestinal tract symptoms in early disease and the importance of tobacco cessation. Clin Exp Rheumatol 2023:19407. [PMID: 37497718 DOI: 10.55563/clinexprheumatol/04rauu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/17/2023] [Indexed: 07/28/2023]
Abstract
OBJECTIVES Systemic Sclerosis (SSc) is frequently associated with gastrointestinal tract (GIT) involvement. The Collaborative National Quality and Efficacy Registry (CONQUER) is a US-based collaborative study collecting longitudinal follow up data on SSc patients with less than 5-years disease duration enrolled at Scleroderma centres of excellence. This manuscript presents the GIT natural history and outcomes in relation to other scleroderma manifestations and medication exposures. METHODS CONQUER participants that had completed a minimum of two serial Scleroderma Clinical Trials Consortium GIT Questionnaires (GIT 2.0) were included in this analysis. Patients were categorised by total GIT 2.0 severity at baseline, and by category change: none-to-mild (0.49); moderate (0.50-1.00), and severe-to-very severe (1.01-3.00) at the subsequent visit. Based on this data, four groups were identified: none-to-mild with no change, moderate-to-severe with no change, improvement, or worsening. Clinical features and medications, categorised as gastrointestinal tract targeted therapy, anti-fibrotic, i, or immunomodulatory drugs, were recorded. Analysis included a proportional odds model accounting for linear and mixed effects of described variables. RESULTS 415 enrolled CONQUER participants met project inclusion criteria. Most participants had stable mild GIT symptoms at baseline and were on immunomodulatory and anti-reflux therapy. In most patients, anti-reflux medication and immunosuppression initiation preceded the baseline visit, whereas anti-fibrotic initiation occurred at or after the baseline visit. In the proportional odds model, worsening GIT score at the follow-up visit was associated with current tobacco use (odds ratio: 3.48 (1.22, 9.98, p 0.020). CONCLUSIONS This report from the CONQUER cohort, suggests that most patients with early SSc have stable and mild GIT disease. Closer follow-up was associated with milder, stable GIT symptoms. There was no clear association between immunosuppression or anti-fibrotic use and severity of GIT symptoms. However, active tobacco use was associated with worse GIT symptoms, highlighting the importance of smoking cessation counselling in this population.
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Affiliation(s)
- Sarah Luebker
- Vanderbilt University Medical Center, Division of Rheumatology and Immunology, Nashville, TN; and Tennessee Valley Health Care System, Veterans Affair Medical Center, Nashville, TN, USA
| | - Tracy M Frech
- Vanderbilt University Medical Center, Division of Rheumatology and Immunology, Nashville, TN; and Tennessee Valley Health Care System, Veterans Affair Medical Center, Nashville, TN, USA
| | - Shervin Assassi
- University of Texas Houston, Division of Rheumatology, Houston, TX, USA
| | - Jessica K Gordon
- Hospital for Special Surgery, Division of Rheumatology, New York City, NY, USA
| | - Elana J Bernstein
- Division of Rheumatology, Department of Medicine, Columbia University Irving Medical Center, Vagelos College of Physicians and Surgeons, New York, NY, USA
| | | | - Ami A Shah
- Johns Hopkins University, Division of Rheumatology, Baltimore, MD, USA
| | - Laura K Hummers
- Johns Hopkins University, Division of Rheumatology, Baltimore, MD, USA
| | | | - Dinesh Khanna
- University of Michigan, Division of Rheumatology, Ann Arbor, MI, USA
| | | | - Lorinda Chung
- Stanford University, Division of Rheumatology, Palo Alto, CA, USA
| | - Faye N Hant
- Medical University of South Carolina, Division of Rheumatology, Charleston, SC, USA
| | | | - John M VanBuren
- University of Utah, Division of Paediatric Critical Care, Department of Paediatrics, Salt Lake City, UT, USA
| | - Jessica Alvey
- University of Utah, Division of Paediatric Critical Care, Department of Paediatrics, Salt Lake City, UT, USA
| | - Monica Harding
- University of Utah, Division of Paediatric Critical Care, Department of Paediatrics, Salt Lake City, UT, USA
| | - Nora Sandorfi
- University of Pennsylvania, Division of Rheumatology, Philadelphia, PA, USA.
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5
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Saketkoo LA, Gordon JK, Fligelstone K, Mawdsley A, Chaudhry HA, Valenzuela A, Christensen A, Khalique SM, Jensen K, Weinmann SC, Busman E, Chung L, Hsu VM, Russell AM, Steen VD. Patient Experience of Systemic Sclerosis-Related Calcinosis: An International Study Informing Clinical Trials, Practice, and the Development of the Mawdsley Calcinosis Questionnaire. Rheum Dis Clin North Am 2023; 49:463-481. [PMID: 37028847 DOI: 10.1016/j.rdc.2023.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
Systemic sclerosis (SSc) -related calcinosis can be a debilitating, constantly painful, poorly understood vascular complication of calcium hydroxyapatite deposition in soft tissue structures that affects approximately 40% of both limited and diffuse cutaneous SSc subtypes. This publication describes the iterative and multitiered international qualitative investigations that yielded remarkable insights into natural history, daily experience, and complications of SSc-calcinosis providing pivotal information for health management. Patient-driven question development and field testing, according to Food and Drug Administration guidance, propelled the development of a patient-reported outcome measure for SSc-calcinosis, the Mawdsley Calcinosis Questionnaire.
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Affiliation(s)
- Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, LA, USA; University Medical Center-Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, LA, USA; Section of Pulmonary Medicine, Louisiana State University School of Medicine, New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA.
| | - Jessica K Gordon
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Kim Fligelstone
- Scleroderma & Raynaud Society, UK (SRUK); Federation of European Scleroderma Associations, UK
| | - Anne Mawdsley
- Raynaud's & Scleroderma Association-Care and Support, London, UK
| | - Humza A Chaudhry
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA
| | - Antonia Valenzuela
- Department of Rheumatology and Clinical Immunology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Samara M Khalique
- Department of Rheumatology, Virginia Tech Carilion Clinic School of Medicine, Roanoke, VA, USA
| | - Kelly Jensen
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, LA, USA; Tulane University School of Medicine, New Orleans, LA, USA; University of Colorado School of Medicine, Denver, CO, USA
| | - Sophia C Weinmann
- Department of Medicine, Division of Rheumatology and Immunology, Duke University Hospital, Durham, NC, USA
| | - Evan Busman
- Healthcare Patient Advocate, Atlanta, GA, USA
| | - Lorinda Chung
- Department of Medicine, Division of Immunology and Rheumatology, Stanford University School of Medicine and Palo Alto VA Healthcare System, Palo Alto, CA, USA; Department of Dermatology, Division of Immunology and Rheumatology, Stanford University School of Medicine and Palo Alto VA Healthcare System, Palo Alto, CA, USA
| | - Vivien M Hsu
- RWJ-Scleroderma Program, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Anne-Marie Russell
- Respiratory Institute, University of Exeter, Exeter, UK; Respiratory Medicine, Royal Devon University Healthcare NHS Foundation Trust, UK
| | - Virginia D Steen
- Division of Rheumatology, Department of Medicine, Georgetown University, Washington, DC, USA
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Showalter K, Magro C, Zhang Y, Spiera R, Orange DE, Gordon JK. Response to: 'Correspondence on 'Machine learning integration of scleroderma histology and gene expression identifies fibroblast polarisation as a hallmark of clinical severity and improvement'' by Manetti. Ann Rheum Dis 2023; 82:e22. [PMID: 33158883 DOI: 10.1136/annrheumdis-2020-219292] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 10/22/2020] [Indexed: 02/03/2023]
Affiliation(s)
- Kimberly Showalter
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Cynthia Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Yaxia Zhang
- Department of Pathology and Clinical Laboratory Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Robert Spiera
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Dana E Orange
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA.,Center for Clinical and Translational Science, Laboratory of Molecular Neuro-Oncology, The Rockefeller University, New York, New York, USA
| | - Jessica K Gordon
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
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Franks JM, Toledo DM, Martyanov V, Wang Y, Huang S, Wood TA, Spino C, Chung L, Denton CP, Derrett-Smith E, Gordon JK, Spiera R, Domsic R, Hinchcliff M, Khanna D, Whitfield ML. A genomic meta-analysis of clinical variables and their association with intrinsic molecular subsets in systemic sclerosis. Rheumatology (Oxford) 2022; 62:19-28. [PMID: 35751592 PMCID: PMC9788818 DOI: 10.1093/rheumatology/keac344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 05/19/2022] [Accepted: 06/06/2022] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVES Four intrinsic molecular subsets (inflammatory, fibroproliferative, limited, normal-like) have previously been identified in SSc and are characterized by unique gene expression signatures and pathways. The intrinsic subsets have been linked to improvement with specific therapies. Here, we investigated associations between baseline demographics and intrinsic molecular subsets in a meta-analysis of published datasets. METHODS Publicly available gene expression data from skin biopsies of 311 SSc patients measured by DNA microarray were classified into the intrinsic molecular subsets. RNA-sequencing data from 84 participants from the ASSET trial were used as a validation cohort. Baseline clinical demographics and intrinsic molecular subsets were tested for statistically significant associations. RESULTS Males were more likely to be classified in the fibroproliferative subset (P = 0.0046). SSc patients who identified as African American/Black were 2.5 times more likely to be classified as fibroproliferative compared with White/Caucasian patients (P = 0.0378). ASSET participants sera positive for anti-RNA pol I and RNA pol III autoantibodies were enriched in the inflammatory subset (P = 5.8 × 10-5, P = 9.3 × 10-5, respectively), while anti-Scl-70 was enriched in the fibroproliferative subset. Mean modified Rodnan Skin Score (mRSS) was statistically higher in the inflammatory and fibroproliferative subsets compared with normal-like (P = 0.0027). The average disease duration for inflammatory subset was less than fibroproliferative and normal-like intrinsic subsets (P = 8.8 × 10-4). CONCLUSIONS We identified multiple statistically significant differences in baseline demographics between the intrinsic subsets that may represent underlying features of disease pathogenesis (e.g. chronological stages of fibrosis) and have implications for treatments that are more likely to work in certain SSc populations.
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Affiliation(s)
| | - Diana M Toledo
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | | | - Yue Wang
- Department of Biomedical Data Science
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Suiyuan Huang
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Tammara A Wood
- Department of Biomedical Data Science
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Lebanon, NH
| | - Cathie Spino
- Department of Biostatistics, University of Michigan, Ann Arbor, MI
| | - Lorinda Chung
- Palo Alto Health Care System, Palo Alto, Stanford, CA, USA
| | | | | | | | | | | | | | - Dinesh Khanna
- Correspondence to: Michael L. Whitfield, Department of Biomedical Data Science, Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, HB 7261, 1 Medical Center Drive, Lebanon, NH 03756, USA. E-mail: ; Dinesh Khanna, Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, Suite 7C27, 300 North Ingalls Street, SP C 5422, Ann Arbor, MI 48109, USA. E-mail:
| | - Michael L Whitfield
- Correspondence to: Michael L. Whitfield, Department of Biomedical Data Science, Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, HB 7261, 1 Medical Center Drive, Lebanon, NH 03756, USA. E-mail: ; Dinesh Khanna, Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, Suite 7C27, 300 North Ingalls Street, SP C 5422, Ann Arbor, MI 48109, USA. E-mail:
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8
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Chaudhary V, Ah Kioon MD, Hwang SM, Mishra B, Lakin K, Kirou KA, Zhang-Sun J, Wiseman RL, Spiera RF, Crow MK, Gordon JK, Cubillos-Ruiz JR, Barrat FJ. Chronic activation of pDCs in autoimmunity is linked to dysregulated ER stress and metabolic responses. J Exp Med 2022; 219:e20221085. [PMID: 36053251 PMCID: PMC9441715 DOI: 10.1084/jem.20221085] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/04/2022] Open
Abstract
Plasmacytoid dendritic cells (pDCs) chronically produce type I interferon (IFN-I) in autoimmune diseases, including systemic sclerosis (SSc) and systemic lupus erythematosus (SLE). We report that the IRE1α-XBP1 branch of the unfolded protein response (UPR) inhibits IFN-α production by TLR7- or TLR9-activated pDCs. In SSc patients, UPR gene expression was reduced in pDCs, which inversely correlated with IFN-I-stimulated gene expression. CXCL4, a chemokine highly secreted in SSc patients, downregulated IRE1α-XBP1-controlled genes and promoted IFN-α production by pDCs. Mechanistically, IRE1α-XBP1 activation rewired glycolysis to serine biosynthesis by inducing phosphoglycerate dehydrogenase (PHGDH) expression. This process reduced pyruvate access to the tricarboxylic acid (TCA) cycle and blunted mitochondrial ATP generation, which are essential for pDC IFN-I responses. Notably, PHGDH expression was reduced in pDCs from patients with SSc and SLE, and pharmacological blockade of TCA cycle reactions inhibited IFN-I responses in pDCs from these patients. Hence, modulating the IRE1α-XBP1-PHGDH axis may represent a hitherto unexplored strategy for alleviating chronic pDC activation in autoimmune disorders.
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Affiliation(s)
- Vidyanath Chaudhary
- HSS Research Institute and David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY
- Department of Microbiology and Immunology, Weill Cornell Medical College of Cornell University, New York, NY
| | - Marie Dominique Ah Kioon
- HSS Research Institute and David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY
| | - Sung-Min Hwang
- Sandra and Edward Meyer Cancer Center and Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY
| | - Bikash Mishra
- HSS Research Institute and David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY
- Immunology and Microbial Pathogenesis Program, Graduate School of Medical Sciences, Weill Cornell Medicine, New York, NY
| | - Kimberly Lakin
- Department of Medicine, Division of Rheumatology and Scleroderma and Vasculitis Center, Hospital for Special Surgery, New York, NY
| | - Kyriakos A. Kirou
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY
| | - Jeffrey Zhang-Sun
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY
| | - R. Luke Wiseman
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA
| | - Robert F. Spiera
- Department of Medicine, Division of Rheumatology and Scleroderma and Vasculitis Center, Hospital for Special Surgery, New York, NY
| | - Mary K. Crow
- HSS Research Institute and David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Jessica K. Gordon
- Department of Medicine, Division of Rheumatology and Scleroderma and Vasculitis Center, Hospital for Special Surgery, New York, NY
| | - Juan R. Cubillos-Ruiz
- Sandra and Edward Meyer Cancer Center and Department of Obstetrics and Gynecology, Weill Cornell Medicine, New York, NY
- Immunology and Microbial Pathogenesis Program, Graduate School of Medical Sciences, Weill Cornell Medicine, New York, NY
| | - Franck J. Barrat
- HSS Research Institute and David Z. Rosensweig Genomics Research Center, Hospital for Special Surgery, New York, NY
- Immunology and Microbial Pathogenesis Program, Graduate School of Medical Sciences, Weill Cornell Medicine, New York, NY
- Department of Microbiology and Immunology, Weill Cornell Medical College of Cornell University, New York, NY
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9
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Bernstein EJ, Assassi S, Castelino FV, Chung L, Correia C, Evnin LB, Frech TM, Gordon JK, Skaug BA, Hant FN, Hummers LK, Sandorfi N, Shah AA, Shanmugam VK, Steen VD, Khanna D. Computed Tomography of the Chest to Screen for Interstitial Lung Disease in Patients With Systemic Sclerosis at Expert Scleroderma Centers in the United States. ACR Open Rheumatol 2022; 4:596-602. [PMID: 35460213 PMCID: PMC9274361 DOI: 10.1002/acr2.11434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Although a high-resolution computed tomography (HRCT) scan of the chest is the gold standard test for the detection of interstitial lung disease (ILD), there is no consensus among rheumatologists regarding the use of HRCT to screen for ILD in their patients with systemic sclerosis (SSc). The aims of this study were to describe the HRCT ordering practices at SSc centers in the United States and to determine which patient characteristics are associated with HRCT performance. METHODS We performed a prospective cohort study of patients with SSc enrolled in the US-based Collaborative National Quality and Efficacy Registry (CONQUER). We performed univariate logistic regression followed by multivariable logistic regression to determine which patient characteristics were associated with HRCT performance. RESULTS Of the 356 patients with SSc enrolled in CONQUER, 286 (80.3%) underwent HRCT at some point during their disease course. On multivariable analyses, missing total lung capacity percent predicted (odds ratio [OR] 3.26, 95% confidence interval [CI]: 1.53-7.41, P = 0.007) was positively associated with ever having undergone HRCT, whereas a positive anti-centromere antibody (OR 0.27, 95% CI: 0.12-0.61, P = 0.008) and missing forced vital capacity percent predicted (OR 0.29, 95% CI: 0.10-0.80, P = 0.005) were negatively associated with ever having undergone HRCT. There was a trend toward a positive association between crackles on pulmonary exam and ever having undergone HRCT (OR 2.28, 95% CI: 0.97-6.05, P = 0.058), although this relationship did not reach statistical significance. CONCLUSION The majority of patients with SSc enrolled in CONQUER underwent HRCT. A positive anti-centromere antibody was the key clinical variable inversely associated with performance of HRCT.
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Affiliation(s)
- Elana J Bernstein
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Shervin Assassi
- University of Texas Health Science Center at Houston, Houston, Texas
| | | | - Lorinda Chung
- Stanford University and Palo Alto VA Healthcare System, Palo Alto, California
| | - Chase Correia
- Northwestern University, Chicago, Illinois.,Riverside Rheumatology Specialists, Hampton, Virginia
| | - Luke B Evnin
- Scleroderma Research Foundation, San Francisco, California
| | - Tracy M Frech
- University of Utah, Salt Lake City, and Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Brian A Skaug
- University of Texas Health Science Center at Houston, Houston, Texas
| | - Faye N Hant
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Nora Sandorfi
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ami A Shah
- Johns Hopkins University, Baltimore, Maryland
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10
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Becetti K, Nguyen JT, Kwakkenbos L, Carrier ME, Tao L, Gordon JK, Mancuso CA, Welling J, Mouthon L, Bartlett SJ, Malcarne VL, Thombs BD, Spiera RF. Mental Health Care Use and Associated Factors in Systemic Sclerosis: A Scleroderma Patient-Centered Intervention Network Cohort Study. ACR Open Rheumatol 2022; 4:647-657. [PMID: 35603782 PMCID: PMC9374049 DOI: 10.1002/acr2.11439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 02/28/2022] [Indexed: 11/15/2022] Open
Abstract
Objective Systemic sclerosis (SSc) has significant psychosocial implications. We aimed to evaluate the proportion of participants in a large international SSc cohort who used mental health services in a 3‐month period and to evaluate demographic, psychological, and disease‐specific factors associated with use. Methods Baseline data of participants enrolled in the Scleroderma Patient‐Centered Intervention Network Cohort were analyzed. We determined the proportion that used mental health services and the source of services in the 3 months prior to enrollment. Multivariable logistic regression was used to identify variables associated with service use. Results Of the 2319 participants included in the analysis, 417 (18%) used mental health services in the 3 months prior to enrollment. General practitioners were the most common mental health service providers (59%), followed by psychologists (25%) and psychiatrists (19%). In multivariable analysis, mental health service use was independently associated with higher education (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.03‐1.11), smoking (OR 1.06, 95% CI 1.02‐1.11), being retired (OR 0.60, 95% CI 0.38‐0.93), having limited SSc (OR 1.39, 95% CI 1.02‐1.89), and having higher anxiety symptom scores (OR 1.04, 95% CI 1.03‐1.06) and lower self‐efficacy scores (OR 0.90, 95% CI 0.83‐0.97). Variables not significantly associated included age, race, disease manifestations, depression symptom scores, and body image distress. Conclusion About 18% of participants in a large international cohort received mental health services in a 3‐month period, of whom the majority received these services from a general practitioner.
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Affiliation(s)
| | | | - Linda Kwakkenbos
- Behavioural Science Institute, Radboud University, Nijmegen, the Netherlands
| | - Marie-Eve Carrier
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | - Lydia Tao
- Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada
| | | | | | - Joep Welling
- Dutch Patient Organization for Systemic Autoimmune Diseases, Utrecht, the Netherlands, and Federation of European Scleroderma Associations, Brussels, Belgium
| | - Luc Mouthon
- Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, and Hôpital Cochin, Paris, France
| | - Susan J Bartlett
- McGill University and McGill University Health Center Research Institute, Montreal, Quebec, Canada
| | | | - Brett D Thombs
- Lady Davis Institute for Medical Research, Jewish General Hospital and McGill University, Montreal, Quebec, Canada
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11
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Gordon JK, Showalter K, Wu Y, Kwakkenbos L, Carrier ME, Henry RS, Østbø N, Nordlund J, Bourgeault A, Cañedo-Ayala M, Carboni-Jiménez A, Denton CP, Mouthon L, Thombs BD, Spiera RF. Systemic sclerosis and COVID-19 vaccines: a SPIN Cohort study. The Lancet Rheumatology 2022; 4:e243-e246. [PMID: 35072109 PMCID: PMC8765760 DOI: 10.1016/s2665-9913(21)00416-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
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12
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Castelino FV, VanBuren JM, Startup E, Assassi S, Bernstein EJ, Chung L, Correia C, Evnin LB, Frech TM, Gordon JK, Hant FN, Hummers LK, Khanna D, Sandorfi N, Shah AA, Shanmugam VK, Steen V. Baseline characteristics of systemic sclerosis patients with restrictive lung disease in a multi-center US-based longitudinal registry. Int J Rheum Dis 2022; 25:163-174. [PMID: 34841681 DOI: 10.1111/1756-185x.14253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/12/2021] [Accepted: 11/12/2021] [Indexed: 11/29/2022]
Abstract
AIM Interstitial lung disease (ILD) is the leading cause of disease-related death in systemic sclerosis (SSc). Here, we assess baseline characteristics of SSc subjects with and without restrictive lung disease (RLD) in a multi-center, US-based registry. METHODS SSc patients within 5 years of disease onset were enrolled in the Collaborative National Quality and Efficacy Registry (CONQUER), a multi-center US-based registry of SSc study participants (age ≥ 18 years) enrolled at 13 expert centers. All subjects met 2013 American College of Rheumatology / European League Against Rheumatism criteria. Subjects with a pulmonary function test (PFT) at baseline before April 1, 2020 were included. High-resolution computed tomography scan of the chest was not available to characterize ILD for all subjects. RLD was defined as forced vital capacity (FVC) <80% or total lung capacity (TLC) <80% predicted. RESULTS There were 160 (45%) SSc subjects characterized as having RLD. There was no significant difference in age, gender or disease duration. RLD subjects had a mean disease duration from date of first non-Raynaud's symptom of 2.6 years and a mean FVC% predicted of 67% at baseline. In multivariable analysis, non-White race, higher physician global health assessment and modified Medical Research Council (mMRC) dyspnea scores, were independently associated with RLD. In the subgroup of RLD subjects with ILD, ILD had a negative correlation with RNA polymerase III antibody. CONCLUSION CONQUER is the largest, multi-center, prospective cohort of early SSc patients in the US. Non-White race was independently associated with RLD. In addition, 45% of CONQUER subjects already had RLD, highlighting the importance of screening for SSc-ILD at initial diagnosis.
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Affiliation(s)
- Flavia V Castelino
- Division of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John M VanBuren
- Department or Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Emily Startup
- Department or Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Shervin Assassi
- The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Elana J Bernstein
- Division of Rheumatology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York, USA
| | - Lorinda Chung
- Division of Rheumatology, Department of Medicine and Dermatology, Stanford University and Palo Alto Veterans Affairs Health Care System, Stanford, California, USA
| | - Chase Correia
- Division of Rheumatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Luke B Evnin
- Scleroderma Research Foundation, San Francisco, California, USA
| | - Tracy M Frech
- Division of Rheumatology, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affair Medical Center, Salt Lake City, Utah, USA
| | | | - Faye N Hant
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Laura K Hummers
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Dinesh Khanna
- University of Michigan Scleroderma Program, Ann Arbor, Michigan, USA
| | - Nora Sandorfi
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ami A Shah
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Victoria K Shanmugam
- Division of Rheumatology, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Virginia Steen
- Georgetown University School of Medicine, Washington, District of Columbia, USA
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13
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Asadourian PA, Chen AZ, Aristega Almeida B, Gordon JK, Burge AJ, Fufa DT. Magnetic Resonance Angiography of the Hand Vasculature in Patients With Systemic Sclerosis and Systemic Lupus Erythematosus. Hand (N Y) 2021; 18:553-561. [PMID: 34963371 DOI: 10.1177/15589447211064358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND When patients with systemic sclerosis (SSc) and systemic lupus erythematosus (SLE) develop digital ischemia, conventional angiography (CA) is traditionally used to assess hand vasculature. Recently, Chang et al described an angiographic classification system for patients with SSc. Conventional angiography uses intravascular contrast agents that are nephrotoxic and vasoconstrictive. Owing to these limitations, this study assesses the use of contrast-enhanced magnetic resonance angiography (MRA) as an alternative to CA to evaluate hand vasculature in patients with digital ischemia. METHODS This retrospective case series reports on 38 contrast-enhanced MRAs of hand vasculature from 30 symptomatic patients with SSc (N = 21) or SLE (N = 9). The radial and ulnar arteries (RA, UA) and the superficial and deep palmar arches were evaluated at standard reference points both quantitatively and qualitatively for their diameter, patency, and Chang classification. RESULTS In SSc MRAs (n = 26), the UA was significantly smaller than the RA and was occluded in 46%. In SLE MRAs (n = 12), the UA and RA had no difference in diameter and the UA was occluded in 25%. In SSc, the most common Chang classification was type 2 (UA involvement) in 44%. In SLE, the most common Chang classification was type 4 (UA and RA involvement) in 45%, with 18% classified as type 2. CONCLUSIONS Contrast-enhanced MRA used to assess hand vasculature in SSc patients with digital ischemia shows similar patterns of vascular involvement as previously demonstrated by CA. While vascular involvement in SSc predominantly involves the UA, the RA is also frequently involved in SLE.
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14
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Saketkoo LA, Frech T, Varjú C, Domsic R, Farrell J, Gordon JK, Mihai C, Sandorfi N, Shapiro L, Poole J, Volkmann ER, Lammi M, McAnally K, Alexanderson H, Pettersson H, Hant F, Kuwana M, Shah AA, Smith V, Hsu V, Kowal-Bielecka O, Assassi S, Cutolo M, Kayser C, Shanmugam VK, Vonk MC, Fligelstone K, Baldwin N, Connolly K, Ronnow A, Toth B, Suave M, Farrington S, Bernstein EJ, Crofford LJ, Czirják L, Jensen K, Hinchclif M, Hudson M, Lammi MR, Mansour J, Morgan ND, Mendoza F, Nikpour M, Pauling J, Riemekasten G, Russell AM, Scholand MB, Seigart E, Rodriguez-Reyna TS, Hummers L, Walker U, Steen V. A comprehensive framework for navigating patient care in systemic sclerosis: A global response to the need for improving the practice of diagnostic and preventive strategies in SSc. Best Pract Res Clin Rheumatol 2021; 35:101707. [PMID: 34538573 PMCID: PMC8670736 DOI: 10.1016/j.berh.2021.101707] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Systemic sclerosis (SSc), the most lethal of rheumatologic conditions, is the cause of death in >50% of SSc cases, led by pulmonary fibrosis followed by pulmonary hypertension and then scleroderma renal crisis (SRC). Multiple other preventable and treatable SSc-related vascular, cardiac, gastrointestinal, nutritional and musculoskeletal complications can lead to disability and death. Vascular injury with subsequent inflammation transforming to irreversible fibrosis and permanent damage characterizes SSc. Organ involvement is often present early in the disease course of SSc, but requires careful history-taking and vigilance in screening to detect. Inflammation is potentially reversible provided that treatment intensity quells inflammation and other immune mechanisms. In any SSc phenotype, opportunities for early treatment are prone to be under-utilized, especially in slowly progressive phenotypes that, in contrast to severe progressive ILD, indolently accrue irreversible organ damage resulting in later-stage life-limiting complications such as pulmonary hypertension, cardiac involvement, and malnutrition. A single SSc patient visit often requires much more physician and staff time, organization, vigilance, and direct management for multiple organ systems compared to other rheumatic or pulmonary diseases. Efficiency and efficacy of comprehensive SSc care enlists trending of symptoms and bio-data. Financial sustainability of SSc care benefits from understanding insurance reimbursement and health system allocation policies for complex patients. Sharing care between recognised SSc centers and local cardiology/pulmonary/rheumatology/gastroenterology colleagues may prevent complications and poor outcomes, while providing support to local specialists. As scleroderma specialists, we offer a practical framework with tools to facilitate an optimal, comprehensive and sustainable approach to SSc care. Improved health outcomes in SSc relies upon recogntion, management and, to the extent possible, prevention of SSc and treatment-related complications.
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Affiliation(s)
- Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Tulane University School of Medicine, New Orleans, USA; Louisiana State University School of Medicine, Section of Pulmonary Medicine, New Orleans, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, USA.
| | - Tracy Frech
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cecília Varjú
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Pécs, Hungary
| | | | - Jessica Farrell
- Albany College of Pharmacy and Health Sciences, Albany, NY, USA; Steffens Scleroderma Foundation, Albany, NY, USA
| | - Jessica K Gordon
- Department of Rheumatology at Hospital for Special Surgery, New York, NY, USA
| | - Carina Mihai
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Department of Internal Medicine and Rheumatology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | | | - Lee Shapiro
- Steffens Scleroderma Foundation, Albany, NY, USA; Division of Rheumatology, Albany Medical Center, Albany, NY, USA
| | - Janet Poole
- Occupational Therapy Graduate Program, University of New Mexico, Albuquerque, NM, USA
| | - Elizabeth R Volkmann
- University of California, David Geffen School of Medicine, UCLA Scleroderma Program and UCLA CTD-ILD Program, Division of Rheumatology, Department of Medicine, Los Angeles, CA, USA
| | | | - Kendra McAnally
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Centre, Phoenix, AZ, USA
| | - Helene Alexanderson
- Function Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Department of Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Pettersson
- Function Allied Health Professionals, Medical Unit Occupational Therapy and Physiotherapy, Karolinska University Hospital, Stockholm, Sweden; Department of Medicin, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Faye Hant
- Division of Rheumatology, Medical University of South Caroline, SC, USA
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Ami A Shah
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University, and Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Vivien Hsu
- Rutgers- RWJ Scleroderma Program, New Brunswick, NJ, USA
| | - Otylia Kowal-Bielecka
- Department of Rheumatology and Internal Medicine, Medical University of Bialystok, Bialystok, Poland
| | - Shervin Assassi
- Rheumatology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Polyclinic San Martino Hospital, Genova, Italy
| | - Cristiane Kayser
- Escola Paulista de Medicina, Federal University of São Paulo (UNIFESP) São Paulo, SP, Brazil
| | - Victoria K Shanmugam
- Department of Rheumatology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA
| | - Madelon C Vonk
- Department of the rheumatic diseases, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Kim Fligelstone
- Patient Research Partner, Scleroderma & Raynaud Society UK (SRUK), London, UK; Royal Free Hospital, London, UK
| | - Nancy Baldwin
- Patient Research Partner, Scleroderma Foundation, Chicago, IL, USA
| | | | - Anneliese Ronnow
- Federation of European Scleroderma Associations, Copenhagen, Denmark; Federation of European Scleroderma Associations, Budapest, Hungary; Federation of European Scleroderma Associations, London, UK
| | - Beata Toth
- Federation of European Scleroderma Associations, Copenhagen, Denmark; Federation of European Scleroderma Associations, Budapest, Hungary; Federation of European Scleroderma Associations, London, UK
| | | | - Sue Farrington
- Patient Research Partner, Scleroderma & Raynaud Society UK (SRUK), London, UK; Federation of European Scleroderma Associations, Copenhagen, Denmark; Federation of European Scleroderma Associations, Budapest, Hungary; Federation of European Scleroderma Associations, London, UK
| | - Elana J Bernstein
- Columbia University/New York-Presbyterian Scleroderma Program, Division of Rheumatology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | | | - László Czirják
- Department of Rheumatology and Immunology, Medical School, University of Pécs, Pécs, Hungary
| | - Kelly Jensen
- Tulane University School of Medicine, New Orleans, USA; Oregon Health and Science University, Portland, OR, USA
| | - Monique Hinchclif
- Yale School of Medicine, Department of Internal Medicine, Section of Rheumatology, Allergy & Immunology, USA
| | - Marie Hudson
- Division of heumatology and Department of Medicine, Jewish General Hospital and McGill University, Montreal, QC, Canada
| | - Matthew R Lammi
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, USA; Louisiana State University School of Medicine, Section of Pulmonary Medicine, New Orleans, USA; University Medical Center - Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, USA
| | | | - Nadia D Morgan
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Fabian Mendoza
- Rheumatology Division, Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Mandana Nikpour
- Jefferson Institute of Molecular Medicine and Scleroderma Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - John Pauling
- University of Melbourne, Melbourne at St. Vincent's Hospital Melbourne, Victoria, Australia
| | - Gabriela Riemekasten
- Royal National Hospital for Rheumatic Diseases, Bath, UK; University of Lübeck, University Clinic of Schleswig-Holstein, Dept Rheumatology and Clinical Immunology, Lübeck, Germany
| | | | - Mary Beth Scholand
- University of Utah, Division of Pulmonary Medicine, Pulmonary Fibrosis Center, Salt Lake City, UT, USA
| | - Elise Seigart
- Department of Rheumatology and Clinical Immunology Charité - Universitätsmedizin Berlin and Berlin Institute of Health, Berlin, Germany
| | | | - Laura Hummers
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ulrich Walker
- Dept. of Rheumatology, Basel University Hospital, Basel, Switzerland
| | - Virginia Steen
- Division of Rheumatology, Department of Medicine, Georgetown University, Washington, DC, USA
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15
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Showalter K, Pinheiro LC, Jannat-Khah D, Sobol I, Szymonifka J, Finik J, Steen VD, Gordon JK. Hospital readmission in systemic sclerosis associated pulmonary hypertension: Results from the PHAROS registry. Rheumatology (Oxford) 2021; 61:1510-1517. [PMID: 34273167 DOI: 10.1093/rheumatology/keab569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 07/09/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To identify individual-level factors associated with hospital readmission among individuals with systemic sclerosis associated pulmonary hypertension (SSc-PH). METHODS Individuals enrolled in the Pulmonary Hypertension Assessment and Recognition of Outcomes in Scleroderma (PHAROS) registry contributed clinical data related to SSc-PH disease severity and hospital admissions. Readmission was defined as a subsequent hospitalization within 12 months of any hospital discharge. Characteristics were compared between individuals with and without readmissions using Fisher's exact test, Wilcoxon rank-sum test, or Kruskal Wallis test. Logistic regression was used to estimate associations between clinical predictors and likelihood of readmission. RESULTS Of 572 individuals with SSc-PH enrolled in PHAROS, 54% had ≥1 hospitalizations between 2005 and 2016. Among individuals ever-hospitalized, 34% had ≥1 readmission. Individuals with vs without readmissions had shorter median (IQR) time between index hospitalization date and next PHAROS visit (37 (3, 80) vs 81 (42, 136) days, p< 0.001). Index admissions related to PH or SSc (vs non-PH/SSc related) were associated with an increased odds of 12-month readmission (aOR 6.6 (95% CI 3.2, 13.6) and aOR 2.2 (95% CI 1.1, 4.5), respectively). Readmission was less likely among home oxygen users (vs non-users) (aOR 0.44; 95% CI 0.22, 0.89). Race, age, sex, disease duration, and disease subtype were not associated with readmission. CONCLUSION The strongest predictor for 12-month readmission was an index hospitalization reason related to PH. Home oxygen use was associated with lower odds of readmission. Future studies should determine whether testing for the need for home oxygen mediates the risk of readmission in SSc-PH.
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Affiliation(s)
- Kimberly Showalter
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street
- New York, NY 10021
| | - Laura C Pinheiro
- Department of Medicine, Division of General Internal Medicine, Weill Cornell Medicine, 525 East 68th Street, New York, F-2011
- , NY 10065
| | - Deanna Jannat-Khah
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street
- New York, NY 10021
| | - Irina Sobol
- Department of Medicine, Division of Cardiology, Weill Cornell Medicine, 520 East 70th street
- New York, NY 10021
| | - Jackie Szymonifka
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street
- New York, NY 10021
| | - Jackie Finik
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street
- New York, NY 10021
| | - Virginia D Steen
- Department of Medicine, Division of Rheumatology, MedStar Georgetown University Hospital, 3800 Reservoir Road, Washington, DC NW
- , 20007
| | - Jessica K Gordon
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street
- New York, NY 10021
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16
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Assassi S, Li N, Volkmann ER, Mayes MD, Rünger D, Ying J, Roth MD, Hinchcliff M, Khanna D, Frech T, Clements PJ, Furst DE, Goldin J, Bernstein EJ, Castelino FV, Domsic RT, Gordon JK, Hant FN, Shah AA, Shanmugam VK, Steen VD, Elashoff RM, Tashkin DP. Predictive Significance of Serum Interferon-Inducible Protein Score for Response to Treatment in Systemic Sclerosis-Related Interstitial Lung Disease. Arthritis Rheumatol 2021; 73:1005-1013. [PMID: 33350170 DOI: 10.1002/art.41627] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/15/2020] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Response to immunosuppression is highly variable in systemic sclerosis (SSc)-related interstitial lung disease (ILD). This study was undertaken to determine whether a composite serum interferon (IFN)-inducible protein score exhibits predictive significance for the response to immunosuppression in SSc-ILD. METHODS Serum samples collected in the Scleroderma Lung Study II, a randomized controlled trial of mycophenolate mofetil (MMF) versus cyclophosphamide (CYC), were examined. Results were validated in an independent observational cohort receiving active treatment. A composite score of 6 IFN-inducible proteins IFNγ-inducible 10-kd protein, monokine induced by IFNγ, monocyte chemotactic protein 2, β2 -microglobulin, tumor necrosis factor receptor type II, and macrophage inflammatory protein 3β) was calculated, and its predictive significance for longitudinal forced vital capacity percent predicted measurements was evaluated. RESULTS Higher baseline IFN-inducible protein score predicted better response over 3 to 12 months in the MMF arm (point estimate = 0.41, P = 0.001) and CYC arm (point estimate = 0.91, P = 0.009). In contrast, higher baseline C-reactive protein (CRP) levels were predictive of a worse ILD course in both treatment arms. The predictive significance of the IFN-inducible protein score and CRP levels remained after adjustment for baseline demographic and clinical predictors. During the second year of treatment, in which patients in the CYC arm were switched to placebo, a higher IFN-inducible protein score at 12 months showed a trend toward predicting a worse ILD course (point estimate = -0.61, P = 0.068), while it remained predictive of better response to active immunosuppression in the MMF arm (point estimate = 0.28, P = 0.029). The predictive significance of baseline IFN-inducible protein score was replicated in the independent cohort (rs = 0.43, P = 0.028). CONCLUSION A higher IFN-inducible protein score in SSc-ILD is predictive of better response to immunosuppression and could potentially be used to identify patients who may derive the most benefit from MMF or CYC.
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Affiliation(s)
| | - Ning Li
- University of California, Los Angeles
| | | | | | | | - Jun Ying
- University of Texas Health Science Center at Houston
| | | | | | | | | | | | | | | | | | - Flavia V Castelino
- Massachusetts General Hospital and Harvard University, Boston, Massachusetts
| | | | | | - Faye N Hant
- Medical University of South Carolina, Charleston
| | - Ami A Shah
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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17
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Frech TM, VanBuren JM, Startup E, Assassi S, Bernstein EJ, Castelino FV, Chung L, Correia C, Gordon JK, Hant FN, Hummers L, Khanna D, Sandorfi N, Shah AA, Shanmugam VK, Steen V, Evnin L. Does hand involvement in systemic sclerosis limit completion of patient-reported outcome measures? Clin Rheumatol 2021; 40:965-971. [PMID: 33094395 PMCID: PMC7897231 DOI: 10.1007/s10067-020-05467-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 10/09/2020] [Accepted: 10/13/2020] [Indexed: 01/08/2023]
Abstract
The objective of this analysis is to examine whether the severity of systemic sclerosis (SSc)-hand involvement influences patient-reported outcome measure (PROM) completion rate in a US cohort of early disease. Participants included SSc patients with less than 5 years disease duration consented and enrolled in the Collaborative, National, Quality, and Efficacy Registry (CONQUER) between June 2018 and December 2019. Participants' socio-demographics, hand clinical features (severe modified Rodnan skin score, presence of small joint contractures, acro-osteolysis, calcinosis, and digital ulcers), and completion rates of seven PROMs including a Resource Use Questionnaire were analyzed. Cohort characteristics and baseline PROM completion were evaluated. Multivariable logistic regression assessed the relationship between hand limitations and PROM incompletion at several time points using generalized estimating equations. At the time of data lock, 339 CONQUER subjects had a total of 600 visits available for analysis. Calcinosis (odds ratio [OR] 6.35, confidence interval [CI] 2.41-16.73 and acro-osteolysis OR 3.88 (1.57-9.55) were significantly associated with incomplete PROM. The Resource Use Questionnaire was the PROM most commonly not completed. Increasing age was correlated with resource use questionnaire incompletion rate. Acro-osteolysis and calcinosis were associated with lower PROM completion rates in a US SSc cohort, independent of the length of the questionnaires or the modality of administration (electronic or paper). Resource Use Questionnaires are important for understanding the economic impact and burden of chronic disease; however, in this study, it had lower completion rates than PROMs devoted to clinical variables. Key points •Multiple strategies are needed to ensure optimal completion of PROM in longitudinal cohort studies. Even if patients request electronic surveys, we have found it is important to follow up incomplete surveys with paper forms provided at the time of a clinical visit. •The Resource Utilization Questionnaire was lengthy and prone to non-completion in the younger population. •Acro-osteolysis and calcinosis were associated with reduced PROM completion rates.
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Affiliation(s)
- Tracy M Frech
- Department of Internal Medicine, Division of Rheumatology, University of Utah and Salt Lake Veterans Affair Medical Center, 1900 E 30 N, SOM 4b200, Salt Lake City, UT, 84132, USA.
| | - John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Shervin Assassi
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Elana J Bernstein
- Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Flavia V Castelino
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Lorinda Chung
- Department of Medicine and Dermatology, Division of Rheumatology, Stanford University and Palo Alto Veterans Affairs Health Care System, Stanford, CA, USA
| | - Chase Correia
- Department of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Faye N Hant
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA
| | - Laura Hummers
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dinesh Khanna
- University of Michigan Scleroderma Program, Ann Arbor, MI, USA
| | - Nora Sandorfi
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ami A Shah
- Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Victoria K Shanmugam
- Division of Rheumatology, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Virginia Steen
- Georgetown University School of Medicine, Washington, DC, USA
| | - Luke Evnin
- Scleroderma Research Foundation, San Francisco, CA, USA
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18
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Showalter K, Spiera R, Magro C, Agius P, Martyanov V, Franks JM, Sharma R, Geiger H, Wood TA, Zhang Y, Hale CR, Finik J, Whitfield ML, Orange DE, Gordon JK. Machine learning integration of scleroderma histology and gene expression identifies fibroblast polarisation as a hallmark of clinical severity and improvement. Ann Rheum Dis 2021; 80:228-237. [PMID: 33028580 PMCID: PMC8600653 DOI: 10.1136/annrheumdis-2020-217840] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 08/27/2020] [Accepted: 08/30/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We sought to determine histologic and gene expression features of clinical improvement in early diffuse cutaneous systemic sclerosis (dcSSc; scleroderma). METHODS Fifty-eight forearm biopsies were evaluated from 26 individuals with dcSSc in two clinical trials. Histologic/immunophenotypic assessments of global severity, alpha-smooth muscle actin (aSMA), CD34, collagen, inflammatory infiltrate, follicles and thickness were compared with gene expression and clinical data. Support vector machine learning was performed using scleroderma gene expression subset (normal-like, fibroproliferative, inflammatory) as classifiers and histology scores as inputs. Comparison of w-vector mean absolute weights was used to identify histologic features most predictive of gene expression subset. We then tested for differential gene expression according to histologic severity and compared those with clinical improvement (according to the Combined Response Index in Systemic Sclerosis). RESULTS aSMA was highest and CD34 lowest in samples with highest local Modified Rodnan Skin Score. CD34 and aSMA changed significantly from baseline to 52 weeks in clinical improvers. CD34 and aSMA were the strongest predictors of gene expression subset, with highest CD34 staining in the normal-like subset (p<0.001) and highest aSMA staining in the inflammatory subset (p=0.016). Analysis of gene expression according to CD34 and aSMA binarised scores identified a 47-gene fibroblast polarisation signature that decreases over time only in improvers (vs non-improvers). Pathway analysis of these genes identified gene expression signatures of inflammatory fibroblasts. CONCLUSION CD34 and aSMA stains describe distinct fibroblast polarisation states, are associated with gene expression subsets and clinical assessments, and may be useful biomarkers of clinical severity and improvement in dcSSc.
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Affiliation(s)
- Kimberly Showalter
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Robert Spiera
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Cynthia Magro
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York, USA
| | | | - Viktor Martyanov
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Jennifer M Franks
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | | | | | - Tammara A Wood
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Yaxia Zhang
- Department of Pathology, Hospital for Special Surgery, New York, New York, USA
| | - Caryn R Hale
- Laboratory of Molecular Neuro-Oncology, The Rockefeller University, New York, New York, USA
| | - Jackie Finik
- Department of Medicine, Hospital for Special Surgery, New York, New York, USA
| | - Michael L Whitfield
- Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
- Biomedical Data Science, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Dana E Orange
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
- Laboratory of Molecular Neuro-Oncology, The Rockefeller University, New York, New York, USA
| | - Jessica K Gordon
- Department of Medicine, Division of Rheumatology, Hospital for Special Surgery, New York, New York, USA
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19
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Showalter K, Ma X, Pinheiro L, Sobol I, Gordon JK, Mehta B. Thirty-day hospital readmission in systemic sclerosis associated pulmonary hypertension: A nationwide study. Semin Arthritis Rheum 2021; 51:324-330. [PMID: 33465591 DOI: 10.1016/j.semarthrit.2021.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 12/22/2020] [Accepted: 01/05/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To identify risk-factors for 30-day hospital readmission in systemic sclerosis pulmonary hypertension (SSc-PH) and to compare trends and characteristics of 30-day readmissions in SSc-PH versus non-SSc pulmonary arterial hypertension (non-SSc PAH). METHODS In this retrospective study, we identified SSc-PH and non-SSc PAH hospitalizations using ICD-9 codes within the Healthcare Cost and Utilization Project-National Readmission Database. Thirty-day readmission rates were calculated between 2010 and 2015. Characteristics were compared using chi-square, Wilcoxon rank-sum, or two-sample t-tests between (A) SSc-PH patients with versus without readmission and (B) patients with ≥1 readmission with SSc-PH versus non-SSc PAH. Adjusted logistic regression models were generated for readmission in SSc-PH. RESULTS 4,846 of 22,420 (22%) with SSc-PH and 10,573 of 49,254 (21%) with non-SSc PAH had ≥1 30-day readmission. Between 2010-2015, readmission rate decreased in non-SSc PAH (23% to 20%; p<0.001) and was unchanged in SSc-PH (23% to 23%; p = 0.77). In SSc-PH, independent predictors of 30-day readmission include male sex, age <60, Medicare or Medicaid, higher Charlson/Deyo comorbidity index, and congestive heart failure (CHF). A higher proportion of patients with SSc-PH (vs. non-SSc PAH) died during index hospitalizations (p = 0.001) and readmissions (p <0.001). Readmitted patients with SSc-PH (vs. non-SSc PAH) were younger and less often had CHF. In SSc-PH, the most common readmission primary diagnosis was infection, followed by respiratory and heart failure. CONCLUSION In SSc-PH, 30-day readmission is frequent, and in-hospital deaths occur at a higher rate compared to those with non-SSc PAH. This study identifies factors that may characterize those with SSc-PH at highest risk for readmission.
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Affiliation(s)
- Kimberly Showalter
- Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, 535 East 70th Street, New York, NY 10021, United States.
| | - Xiaoyue Ma
- Weill Cornell Medicine, Department of Healthcare Policy and Research, 402 East 67th Street, New York, NY 10065, United States.
| | - Laura Pinheiro
- Weill Cornell Medicine, Department of Medicine, Division of General Internal Medicine, 420 East 70th Street, 3rd Floor, New York, NY 10065, United States.
| | - Irina Sobol
- Weill Cornell Medicine, Department of Medicine, Division of Cardiology, 520 East 70th Street, New York, NY 10021, United States.
| | - Jessica K Gordon
- Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, 535 East 70th Street, New York, NY 10021, United States.
| | - Bella Mehta
- Hospital for Special Surgery, Department of Medicine, Division of Rheumatology, 535 East 70th Street, New York, NY 10021, United States.
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20
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Chung L, Spino C, McLain R, Johnson SR, Denton CP, Molitor JA, Steen VD, Lafyatis R, Simms RW, Kafaja S, Frech TM, Hsu V, Domsic RT, Pope JE, Gordon JK, Mayes MD, Sandorfi N, Hant FN, Bernstein EJ, Chatterjee S, Castelino FV, Ajam A, Allanore Y, Matucci-Cerinic M, Whitfield ML, Distler O, Singer O, Young A, Nagaraja V, Fox DA, Furst DE, Khanna D. Safety and efficacy of abatacept in early diffuse cutaneous systemic sclerosis (ASSET): open-label extension of a phase 2, double-blind randomised trial. Lancet Rheumatol 2020; 2:e743-e753. [PMID: 34966900 PMCID: PMC8713509 DOI: 10.1016/s2665-9913(20)30237-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Abatacept was well tolerated by patients with early diffuse cutaneous systemic sclerosis in a phase 2, double-blind randomised trial, with potential efficacy at 12 months. We report here the results of an open-label extension for 6 months. METHODS Patients (aged ≥18 years) with diffuse cutaneous systemic sclerosis of less than 3 years' duration from their first non-Raynaud's symptom were enrolled into the ASSET trial (A Study of Subcutaneous Abatacept to Treat DiffuseCutaneous Systemic Sclerosis), which is a double-blind trial at 22 sites in Canada, the UK, and the USA. Aftercompletion of 12 months of treatment with either abatacept or placebo, patients received a further 6 months ofabatacept (125 mg subcutaneous every week) in an open-label extension. The primary endpoint of the double-blind trial was modified Rodnan Skin Score (mRSS) at 12 months, which was reassessed at 18 months in the open-label extension. The primary analysis included all participants who completed the double-blind trial and received at least one dose of open-label treatment (modified intention to treat). This trial is registered with ClinicalTrials.gov, NCT02161406. FINDINGS Between Sept 22, 2014, and March 15, 2017, 88 participants were randomly allocated in the double-blind trial either abatacept (n=44) or placebo (44); 32 patients from each treatment group completed the 6-month open-labelextension. Among patients assigned abatacept, a mean improvement from baseline in mRSS was noted at 12 months (-6·6 [SD 6·4]), with further improvement seen during the open-label extension period (-9·8 [8·1] at month 18). Participants assigned placebo had a mean improvement from baseline in mRSS at 12 months (-3·7 [SD 7·6]), with a further improvement at month 18 (-6·3 [9·3]). Infections during the open-label extension phase occurred in nine patients in the placebo-abatacept group (12 adverse events, one serious adverse event) and in 11 patients in theabatacept-abatacept group (14 adverse events, one serious adverse event). Two deaths occurred during the 12-month double-blind period in the abatacept group, which were related to scleroderma renal crisis; no deaths were recorded during the open-label extension. INTERPRETATION During the 6-month open-label extension, no new safety signals for abatacept were identified in the treatment of diffuse cutaneous systemic sclerosis. Clinically meaningful improvements in mRSS and other outcome measures were observed in both the abatacept and placebo groups when patients transitioned to open-label treatment. These data support further studies of abatacept in diffuse cutaneous systemic sclerosis. FUNDING Bristol-Myers Squibb and National Institutes of Health.
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Affiliation(s)
- Lorinda Chung
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Cathie Spino
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Richard McLain
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Sindhu R Johnson
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Christopher P Denton
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Jerry A Molitor
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Virginia D Steen
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Robert Lafyatis
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Robert W Simms
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Suzanne Kafaja
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Tracy M Frech
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Vivien Hsu
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Robyn T Domsic
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Janet E Pope
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Jessica K Gordon
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Maureen D Mayes
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Nora Sandorfi
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Faye N Hant
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Elana J Bernstein
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Soumya Chatterjee
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Flavia V Castelino
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Ali Ajam
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Yannick Allanore
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Marco Matucci-Cerinic
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Michael L Whitfield
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Oliver Distler
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Ora Singer
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Amber Young
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Vivek Nagaraja
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - David A Fox
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Daniel E Furst
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
| | - Dinesh Khanna
- Stanford University School of Medicine, Stanford, CA, USA (Prof L Chung MD); Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA (Prof C Spino ScD, R McLain MS); Division of Rheumatology, Mount Sinai Hospital and University Health Network, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (S R Johnson MD); University College London, Division of Medicine, London, UK (Prof C P Denton MD); Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN, USA (J A Molitor MD); Rheumatology, Georgetown University Medical Center, Washington, DC, USA (ProfV D Steen MD); Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA, USA (Prof R Lafyatis MD); Rheumatology, Boston University School of Medicine, Boston, MA, USA (Prof R W Simms MD); Rheumatology, Geisel School of Medicine, Dartmouth, Lebanon, NH, USA (Prof R W Simms); Department of Internal Medicine, University of Californiaat Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA, USA (S Kafaja MD, Prof D E Furst MD); Division of Rheumatology, University of Utah, Salt Lake City, UT, USA (T M Frech MD); Rutgers-Robert Wood Johnson Medical School, Department of Medicine, Rheumatology Division, New Brunswick, NJ, USA (VHsu MD); Medicine-Rheumatology, University of Pittsburgh, Pittsburgh, PA, USA (R T Domsic MD); Department of Medicine, University of Western Ontario, London, ON, Canada (Prof J E Pope MD); Rheumatology, Hospital for Special Surgery, NewYork, NY, USA (J K Gordon MD); McGovern Medical School, University of Texas, Houston, TX, USA (Prof MD Mayes MD); Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA, USA (N Sandorfi MD); Medicine-Rheumatology and Immunology, Medical University of South Carolina, Charleston, SC, USA (F N Hant DO); Rheumatology, Columbia University, New York, NY, USA (E J Bernstein MD); Rheumatic and Immunologic Diseases, Cleveland Clinic, Cleveland, OH, USA (S Chatterjee MD); Rheumatology, Harvard Medical School, Boston, MA, USA (F V Castelino MD); Division of Rheumatology-Immunology, Ohio State University Wexner Medical Center, Columbus, OH, USA (A Ajam MBBS); Paris Descartes University, Institut National de la Santé et de la Recherche Médicale U1016, Université Sorbonne Paris Cité, and Cochin Hospital, Paris, France (Prof Y Allanore MD); Department of Experimental and Clinical Medicine, University of Florence, and Division of Rheumatology Azienda Ospedaliero Universitaria Careggi, Florence, Italy (Prof M Matucci-Cerinic MD); Geisel School of Medicine at Dartmouth, Hanover, NH, USA (Prof M L Whitfield PhD); Department of Rheumatology, University Hospital, Zurich, Switzerland (Prof O Distler MD); and Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA (O Singer MD, A Young MD, V Nagaraja MD, Prof D A Fox MD, Prof D Khanna MD)
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21
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Showalter K, Merkel PA, Khanna D, Gordon JK. Assessment of skin disease in scleroderma: Practices and opinions of investigators studying scleroderma. J Scleroderma Relat Disord 2020; 5:167-171. [PMID: 35382518 PMCID: PMC8922616 DOI: 10.1177/2397198320921044] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Accepted: 03/31/2020] [Indexed: 10/28/2023]
Abstract
BACKGROUND The modified Rodnan skin score is a common primary outcome measurement tool in clinical trials of systemic sclerosis (scleroderma). However, it is unknown how often physicians perform the modified Rodnan skin score in clinical practice or what precise approach is most often used when assessing each of the 17 sites included in the modified Rodnan skin score (i.e. "maximizing," "averaging," "representative area"). This study assessed the experiences, perceptions, training, and practices of individuals studying scleroderma with regard to modified Rodnan skin score. METHODS An invitation with an online survey link was sent electronically to 282 individuals who are part of the Scleroderma Clinical Trials Consortium. The 46-item survey included three sections: participant demographics, modified Rodnan skin score background/training, and modified Rodnan skin score assessment practices. The survey was accessible for 5 weeks (October-November 2019). RESULTS The response rate was 41% (116 of 282 individuals). The majority of participants perform the modified Rodnan skin score in clinical care (>99%) and practice at academic institutions (90%) in North America (41%) or Europe (40%). Nearly all participants felt that the modified Rodnan skin score is either "somewhat important" (43%) or "essential" (56%) to the care of patients with systemic sclerosis. In total, 91% of participants reported having received modified Rodnan skin score training. The majority (60%) of those who had not received training were interested in receiving modified Rodnan skin score training, and 39% of participants felt either "uncomfortable" or only "somewhat comfortable" performing the modified Rodnan skin score. The modified Rodnan skin score approach varied: 44% used "maximizing," 28% used "averaging," and 18% used "representative area." CONCLUSION A majority of participants feel that the modified Rodnan skin score is "essential" to the care of patients with systemic sclerosis; however, the method used to measure modified Rodnan skin score varies greatly among systemic sclerosis investigators. These results indicate a continued role of modified Rodnan skin score for care and research in systemic sclerosis, support ongoing efforts to increase opportunities for modified Rodnan skin score training, and highlight a potential need to harmonize the technical approach to measuring the modified Rodnan skin score.
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Affiliation(s)
- Kimberly Showalter
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Peter A Merkel
- Division of Rheumatology, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Division of Clinical Epidemiology, Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, PA, USA
| | - Dinesh Khanna
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jessica K Gordon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery, New York, NY, USA
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22
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Bernstein EJ, Jaafar S, Assassi S, Domsic RT, Frech TM, Gordon JK, Broderick RJ, Hant FN, Hinchcliff ME, Shah AA, Shanmugam VK, Steen VD, Khanna D. Performance Characteristics of Pulmonary Function Tests for the Detection of Interstitial Lung Disease in Adults With Early Diffuse Cutaneous Systemic Sclerosis. Arthritis Rheumatol 2020; 72:1892-1896. [PMID: 32583956 DOI: 10.1002/art.41415] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 06/16/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Interstitial lung disease (ILD) is the leading cause of death in patients with systemic sclerosis (SSc). Although pulmonary function tests (PFTs) are commonly used to screen for ILD in patients with SSc, studies have shown that they lack sensitivity for the detection of ILD in general SSc cohorts. This study was undertaken to assess the performance characteristics of PFTs for the detection of ILD in patients with early diffuse cutaneous SSc (dcSSc), a population at high risk for the development of ILD. METHODS We performed a retrospective cohort study of patients enrolled in the Prospective Registry of Early Systemic Sclerosis at 11 sites in the US between April 2012 and January 2019. Patients were included if they underwent spirometry and high-resolution computed tomography (HRCT) of the chest. We calculated the performance characteristics of PFTs for the detection of ILD on HRCT. RESULTS The study included 212 patients, 54% of whom had radiographic ILD. For the detection of ILD on HRCT imaging, a forced vital capacity (FVC) <80% predicted had a sensitivity of 63%. The combination of FVC <80% predicted or diffusing capacity for carbon monoxide (DLco) <80% predicted improved the sensitivity to 85%. An FVC <80% predicted had a negative predictive value (NPV) of 61%, while the combination of FVC <80% predicted or DLco <80% predicted had an NPV of 70%. CONCLUSION PFTs alone are an inadequate screening tool for the diagnosis of ILD in patients with early dcSSc. HRCT should be part of the ILD screening algorithm in patients with dcSSc.
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Affiliation(s)
| | | | | | - Robyn T Domsic
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | | | | | - Faye N Hant
- Medical University of South Carolina, Charleston
| | | | - Ami A Shah
- Johns Hopkins University, Baltimore, Maryland
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23
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Khanna D, Spino C, Johnson S, Chung L, Whitfield M, Denton CP, Berrocal V, Jennifer F, Mehta B, Molitor J, Steen VD, Lafyatis R, Simms RW, Gill A, Kafaja S, Frech TM, Hsu V, Domsic RT, Pope JE, Gordon JK, Mayes MD, Schiopu E, Young A, Sandorfi N, Park J, Hant FN, Bernstein EJ, Chatterjee S, Castelino FV, Ajam A, Wang Y, Wood T, Allanore Y, Matucci-Cerinic M, Distler O, Singer O, Bush E, Fox D, Furst DE. Abatacept in Early Diffuse Cutaneous Systemic Sclerosis: Results of a Phase II Investigator-Initiated, Multicenter, Double-Blind, Randomized, Placebo-Controlled Trial. Arthritis Rheumatol 2020; 72:125-136. [PMID: 31342624 PMCID: PMC6935399 DOI: 10.1002/art.41055] [Citation(s) in RCA: 143] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 07/18/2019] [Indexed: 12/14/2022]
Abstract
OBJECTIVE T cells play a key role in the pathogenesis of early systemic sclerosis. This study was undertaken to assess the safety and efficacy of abatacept in patients with diffuse cutaneous systemic sclerosis (dcSSc). METHODS In this 12-month, randomized, double-blind, placebo-controlled trial, participants were randomized 1:1 to receive either subcutaneous abatacept 125 mg or matching placebo, stratified by duration of dcSSc. Escape therapy was allowed at 6 months for worsening disease. The coprimary end points were change in the modified Rodnan skin thickness score (MRSS) compared to baseline and safety over 12 months. Differences in longitudinal outcomes were assessed according to treatment using linear mixed models, with outcomes censored after initiation of escape therapy. Skin tissue obtained from participants at baseline was classified into intrinsic gene expression subsets. RESULTS Among 88 participants, the adjusted mean change in the MRSS at 12 months was -6.24 units for those receiving abatacept and -4.49 units for those receiving placebo, with an adjusted mean treatment difference of -1.75 units (P = 0.28). Outcomes for 2 secondary measures (Health Assessment Questionnaire disability index and a composite measure) were clinically and statistically significantly better with abatacept. The proportion of subjects in whom escape therapy was needed was higher in the placebo group relative to the abatacept group (36% versus 16%). In the inflammatory and normal-like skin gene expression subsets, decline in the MRSS over 12 months was clinically and significantly greater in the abatacept group versus the placebo group (P < 0.001 and P = 0.03, respectively). In the abatacept group, adverse events occurred in 35 participants versus 40 participants in the placebo group, including 2 deaths and 1 death, respectively. CONCLUSION In this phase II trial, abatacept was well-tolerated, but change in the MRSS was not statistically significant. Secondary outcome measures, including gene expression subsets, showed evidence in support of abatacept. These data should be confirmed in a phase III trial.
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Affiliation(s)
- Dinesh Khanna
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - Cathie Spino
- Biostatistics, University of Michigan, Ann Arbor, MI
| | - Sindhu Johnson
- Rheumatology, Mount Sinai Hospital and University Health Network, Toronto, ON, Canada
| | - Lorinda Chung
- Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA
| | - Michael Whitfield
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | | | | | - Franks Jennifer
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | - Bhaven Mehta
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | - Jerry Molitor
- Rheumatic & Autoimmune Diseases, University of Minnesota, Minneapolis, MN
| | - Virginia D. Steen
- Rheumatology, MedStar Georgetown University Hospital, Washington, DC
| | - Robert Lafyatis
- Medicine/Division of Rheumatology, Pittsburgh University Medical Center, Pittsburgh, PA
| | - Robert W. Simms
- Rheumatology, Boston University School of Medicine, Boston, MA
| | - Anna Gill
- UCL Division of Medicine, Royal Free Campus, London, United Kingdom
| | - Suzanne Kafaja
- Department of Internal Medicine, University of California Los Angeles, David Geffen School of Medicine, Division of Rheumatology, Los Angeles, CA
| | - Tracy M. Frech
- Division of Rheumatology, University of Utah, Salt Lake City, UT
| | - Vivien Hsu
- Rheumatology, Robert Wood Johnson University Scleroderma Program, New Brunswick, NJ
| | - Robyn T. Domsic
- Medicine - Rheumatology, University of Pittsburgh, Pittsburgh, PA
| | - Janet E. Pope
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | | | - Maureen D. Mayes
- Rheumatology, University of Texas McGovern Medical School, Houston, TX
| | - Elena Schiopu
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - Amber Young
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - Nora Sandorfi
- Perelman School of Medicine, University of Pennsylvania, Pittsburgh, PA
| | - Jane Park
- Seattle Rheumatology Associates, Seattle, WA
| | - Faye N. Hant
- Medicine/Rheumatology & Immunology, Medical University of South Carolina, Charleston, SC
| | | | | | | | - Ali Ajam
- Division of Rheumatology-Immunology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Yue Wang
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | - Tammara Wood
- Department of Molecular and Systems Biology, Geisel School of Medicine at Dartmouth, Hanover
| | | | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Ora Singer
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - Erica Bush
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
| | - David Fox
- Division of Rheumatology, Department of Internal Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI
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24
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Shanmugam VK, Frech TM, Steen VD, Hummers LK, Shah AA, Bernstein EJ, Khanna D, Gordon JK, Castelino FV, Chung L, Hant FN, Startup E, VanBuren JM, Evnin LB, Assassi S. Collaborative National Quality and Efficacy Registry (CONQUER) for Scleroderma: outcomes from a multicenter US-based systemic sclerosis registry. Clin Rheumatol 2020; 39:93-102. [PMID: 31667644 PMCID: PMC7280746 DOI: 10.1007/s10067-019-04792-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 09/15/2019] [Accepted: 09/21/2019] [Indexed: 01/06/2023]
Abstract
The Collaborative National Quality and Efficacy Registry (CONQUER) for Scleroderma is a multicenter US-based longitudinal study of patients with systemic sclerosis (SSc) within 5 years of first non-Raynaud's symptom. The data collection methodology incorporates successful models from other SSc registries. The cohort is designed to provide linked bio-specimen and clinical outcomes data on a longitudinal cohort of SSc patients for validation of hypothesis-driven research and to provide a platform for studying patient-reported outcomes in scleroderma. The CONQUER registry was developed using the guidelines of the International Society for Biological Repositories, and was an iterative process between physicians with an expertise in SSc, patient stakeholders, and information technology experts. Enrollment commenced in June 2018. During the first 6 months of the CONQUER Scleroderma study, 151 SSc patients with less than 5 years of disease duration (from first non-Raynaud's symptom) have been recruited. The mean age is 51 ± 14 years, 83% are female, and 60% of patients have diffuse disease. Survey completion rates are above 88% for all patient-reported outcome surveys. Bio-specimen collection rates are over 97%, and disease severity score completion rates are over 98%. Pulmonary function test data is available on 91% of patients, and echocardiography is available 80%. The CONQUER scleroderma study provides a unique and growing resource for studying scleroderma in a longitudinal, US-based population. KEY POINTS : • The Collaborative National Quality and Efficacy Registry (CONQUER) for Scleroderma is a multicenter US-based longitudinal study of patients with systemic sclerosis (SSc) within 5 years of first non-Raynaud's symptom. • The CONQUER scleroderma study provides a unique and growing resource for studying scleroderma in a longitudinal, US-based population. • CONQUER is innovative in its design in that it is focused on prospective collection of paired clinical and patient outcome data with bio-specimens.
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Affiliation(s)
- Victoria K Shanmugam
- Division of Rheumatology, The George Washington University School of Medicine and Health Sciences, 2300 M Street, NW, Room 307, Washington, DC, 20007, USA.
| | - Tracy M Frech
- Division of Rheumatology, Department of Internal Medicine, University of Utah and Salt Lake Veterans Affair Medical Center, Salt Lake City, UT, USA
| | - Virginia D Steen
- Division of Rheumatology, Georgetown University Medical Center, Washington, DC, USA
| | - Laura K Hummers
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elana J Bernstein
- Division of Rheumatology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, NY, USA
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Jessica K Gordon
- Division of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Flavia V Castelino
- Division of Rheumatology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lorinda Chung
- Division of Immunology and Rheumatology, Department of Medicine, Stanford University School of Medicine and Palo Alto Veterans Affairs Health Care System, Palo Alto, CA, USA
| | - Faye N Hant
- Division of Rheumatology and Immunology, Medical University of South Carolina, Charleson, SC, USA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Luke B Evnin
- Scleroderma Research Foundation, San Francisco, CA, USA
| | - Shervin Assassi
- Division of Rheumatology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
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25
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Skaug B, Khanna D, Swindell WR, Hinchcliff ME, Frech TM, Steen VD, Hant FN, Gordon JK, Shah AA, Zhu L, Zheng WJ, Browning JL, Barron AMS, Wu M, Visvanathan S, Baum P, Franks JM, Whitfield ML, Shanmugam VK, Domsic RT, Castelino FV, Bernstein EJ, Wareing N, Lyons MA, Ying J, Charles J, Mayes MD, Assassi S. Global skin gene expression analysis of early diffuse cutaneous systemic sclerosis shows a prominent innate and adaptive inflammatory profile. Ann Rheum Dis 2019; 79:379-386. [PMID: 31767698 DOI: 10.1136/annrheumdis-2019-215894] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVES Determine global skin transcriptome patterns of early diffuse systemic sclerosis (SSc) and how they differ from later disease. METHODS Skin biopsy RNA from 48 patients in the Prospective Registry for Early Systemic Sclerosis (PRESS) cohort (mean disease duration 1.3 years) and 33 matched healthy controls was examined by next-generation RNA sequencing. Data were analysed for cell type-specific signatures and compared with similarly obtained data from 55 previously biopsied patients in Genetics versus Environment in Scleroderma Outcomes Study cohort with longer disease duration (mean 7.4 years) and their matched controls. Correlations with histological features and clinical course were also evaluated. RESULTS SSc patients in PRESS had a high prevalence of M2 (96%) and M1 (94%) macrophage and CD8 T cell (65%), CD4 T cell (60%) and B cell (69%) signatures. Immunohistochemical staining of immune cell markers correlated with the gene expression-based immune cell signatures. The prevalence of immune cell signatures in early diffuse SSc patients was higher than in patients with longer disease duration. In the multivariable model, adaptive immune cell signatures were significantly associated with shorter disease duration, while fibroblast and macrophage cell type signatures were associated with higher modified Rodnan Skin Score (mRSS). Immune cell signatures also correlated with skin thickness progression rate prior to biopsy, but did not predict subsequent mRSS progression. CONCLUSIONS Skin in early diffuse SSc has prominent innate and adaptive immune cell signatures. As a prominently affected end organ, these signatures reflect the preceding rate of disease progression. These findings could have implications in understanding SSc pathogenesis and clinical trial design.
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Affiliation(s)
- Brian Skaug
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Dinesh Khanna
- Scleroderma Program, Department of Internal Medicine, Division of Rheumatology, University of Michigan, Ann Arbor, Michigan, USA
| | - William R Swindell
- Ohio University Heritage College of Osteopathic Medicine, Athens, Ohio, USA.,Department of Internal Medicine, The Jewish Hospital, Cincinnati, Ohio, USA
| | - Monique E Hinchcliff
- Department of Medicine, Section of Allergy, Rheumatology, and Immunology, Yale University, New Haven, Connecticut, USA
| | - Tracy M Frech
- Division of Rheumatology, Department of Internal Medicine, University of Utah and Salt Lake Regional Veterans Affairs Medical Center, Salt Lake City, Utah, USA
| | - Virginia D Steen
- Division of Rheumatology, Department of Medicine, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Faye N Hant
- Division of Rheumatology and Immunology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jessica K Gordon
- Department of Rheumatology, Hospital for Special Surgery, New York City, New York, USA
| | - Ami A Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lisha Zhu
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - W Jim Zheng
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jeffrey L Browning
- Department of Microbiology, Section of Rheumatology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Alexander M S Barron
- Department of Microbiology, Section of Rheumatology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Minghua Wu
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Sudha Visvanathan
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, Connecticut, USA
| | - Patrick Baum
- Boehringer Ingelheim International GmbH, Biberach, Germany
| | - Jennifer M Franks
- Department of Biomedical Data Science, Dartmouth College Geisel School of Medicine, Lebanon, New Hampshire, USA.,Department of Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Michael L Whitfield
- Department of Biomedical Data Science, Dartmouth College Geisel School of Medicine, Lebanon, New Hampshire, USA.,Department of Molecular and Systems Biology, Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Victoria K Shanmugam
- Division of Rheumatology, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Flavia V Castelino
- Division of Rheumatology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elana J Bernstein
- Division of Rheumatology, Vagelos College of Physicians and Surgeons, New York City, New York, USA
| | - Nancy Wareing
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Marka A Lyons
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jun Ying
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Julio Charles
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Maureen D Mayes
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Shervin Assassi
- Division of Rheumatology and Clinical Immunogenetics, University of Texas Health Science Center at Houston, Houston, Texas, USA
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Nagaraja V, Spino C, Bush E, Tsou PS, Domsic RT, Lafyatis R, Frech T, Gordon JK, Steen VD, Khanna D. A multicenter randomized, double-blind, placebo-controlled pilot study to assess the efficacy and safety of riociguat in systemic sclerosis-associated digital ulcers. Arthritis Res Ther 2019; 21:202. [PMID: 31481106 PMCID: PMC6724329 DOI: 10.1186/s13075-019-1979-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 08/16/2019] [Indexed: 11/10/2022] Open
Abstract
Background To determine the effect of riociguat, an oral, selective soluble guanylate cyclase stimulator, on the net digital ulcer (DU) burden in systemic sclerosis (SSc). Methods Participants with SSc-related active or painful indeterminate DUs were recruited in a multicenter, double-blind, randomized, placebo-controlled, proof-of-concept trial. Eligible participants were required to have at least one visible, active ischemic DU or painful indeterminate DU at screening, located at or distal to the proximal interphalangeal joint and that developed or worsened within 8 weeks prior to screening. Participants were randomized 1:1 to placebo or riociguat in individualized doses (maximum of 2.5 mg three times daily) during an 8-week titration period, followed by an 8-week stable dosing period. This was followed by an optional 16-week open-label extension phase for participants with active DU/reoccurrence of DUs within 1 month of the end of the main treatment phase. The primary endpoint was the change from baseline to week 16 in net ulcer burden (NUB), analyzed using ANCOVA. Other endpoints included plasma biomarkers and proportion of participants with treatment-emergent adverse events (AEs). Results Seventeen participants (eight placebo, nine riociguat) were randomized at five centers. Six participants in each group transitioned to the open-label extension. Baseline characteristics were comparable between the treatment groups, except participants randomized to placebo were older and had longer disease duration (p < 0.05). At baseline, the mean (SD) NUB was 2.5 (2.0) in the placebo and 2.4 (1.4) in the riociguat. No significant treatment difference was observed in the change from baseline to 16 weeks in NUB (adjusted mean treatment difference − 0.24, 95% CI (− 1.46, 0.99), p = 0.70). Four participants experienced five serious AE (four in riociguat and one in placebo); none was considered related to study medication. Statistically significant elevation of cGMP was observed at 16 weeks in the riociguat group (p = 0.05); no other biomarkers showed significant changes. In the open-label extension, participants in the riociguat-riociguat arm had complete healing of their DUs. Conclusion In participants with SSc-DU, treatment with riociguat did not reduce the number of DU net burden compared with placebo at 16 weeks. Open-label extension suggests that longer duration is needed to promote DU healing, which needs to be confirmed in a new trial. Trial registration ClinicalTrials.gov, NCT02915835. Registered on September 27, 2016. Electronic supplementary material The online version of this article (10.1186/s13075-019-1979-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Vivek Nagaraja
- Division of Rheumatology/Department of Internal Medicine, University of Michigan Scleroderma Program, Suite 7C27, 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA
| | - Cathie Spino
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Erica Bush
- Division of Rheumatology/Department of Internal Medicine, University of Michigan Scleroderma Program, Suite 7C27, 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA
| | - Pei-Suen Tsou
- Division of Rheumatology/Department of Internal Medicine, University of Michigan Scleroderma Program, Suite 7C27, 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA
| | - Robyn T Domsic
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert Lafyatis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tracy Frech
- Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | - Jessica K Gordon
- Division of Rheumatology, Hospital of Special Surgery, New York, NY, USA
| | - Virginia D Steen
- Division of Rheumatology, Georgetown University Medical Center, Washington, DC, USA
| | - Dinesh Khanna
- Division of Rheumatology/Department of Internal Medicine, University of Michigan Scleroderma Program, Suite 7C27, 300 North Ingalls Street, SPC 5422, Ann Arbor, MI, 48109, USA.
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27
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Becetti K, Kwakkenbos L, Carrier ME, Gordon JK, Nguyen JT, Mancuso CA, Mouthon L, Nguyen C, Rannou F, Welling J, Thombs BD, Spiera RF. Physical or Occupational Therapy Use in Systemic Sclerosis: A Scleroderma Patient-centered Intervention Network Cohort Study. J Rheumatol 2019; 46:1605-1613. [PMID: 31043542 DOI: 10.3899/jrheum.181130] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Systemic sclerosis (SSc) is characterized by significant disability because of musculoskeletal involvement. Physical and occupational therapy (PT/OT) have been suggested to improve function. However, the rate of PT/OT use has been shown to be low in SSc. We aimed to identify demographic, medical, and psychological variables associated with PT/OT use in SSc. METHODS Participants were patients with SSc enrolled in the Scleroderma Patient-centered Intervention Network (SPIN) Cohort. We determined the rate and indication of PT/OT use in the 3 months prior to enrollment. Multivariable logistic regression was used to identify variables independently associated with PT/OT use. RESULTS Of the 1627 patients with SSc included in the analysis, 23% used PT/OT in the preceding 3 months. PT/OT use was independently associated with higher education (OR 1.08, 95% CI 1.04-1.12), having moderately severe small joint contractures (OR 2.09, 95% CI 1.45-3.03), severe large joint contractures (OR 2.33, 95% CI 1.14-4.74), fewer digital ulcerations (OR 0.70, 95% CI 0.51-0.95), and higher disability (OR 1.54, 95% CI 1.18-2.02) and pain scores (OR 1.04, 95% CI 1.02-1.06). The highest rate of PT/OT use was reported in France (43%) and the lowest, in the United States (17%). CONCLUSION Despite the potential of PT/OT interventions to improve function, < 1 in 4 patients with SSc enrolled in a large international cohort used PT/OT services in the last 3 months. Patients who used PT/OT had more severe musculoskeletal manifestations and higher pain and disability.
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Gourh P, Remmers EF, Boyden SE, Alexander T, Morgan ND, Shah AA, Mayes MD, Doumatey A, Bentley AR, Shriner D, Domsic RT, Medsger TA, Steen VD, Ramos PS, Silver RM, Korman B, Varga J, Schiopu E, Khanna D, Hsu V, Gordon JK, Saketkoo LA, Gladue H, Kron B, Criswell LA, Derk CT, Bridges SL, Shanmugam VK, Kolstad KD, Chung L, Jan R, Bernstein EJ, Goldberg A, Trojanowski M, Kafaja S, Maksimowicz-McKinnon KM, Mullikin JC, Adeyemo A, Rotimi C, Boin F, Kastner DL, Wigley FM. Brief Report: Whole-Exome Sequencing to Identify Rare Variants and Gene Networks That Increase Susceptibility to Scleroderma in African Americans. Arthritis Rheumatol 2018; 70:1654-1660. [PMID: 29732714 DOI: 10.1002/art.40541] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 04/26/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Whole-exome sequencing (WES) studies in systemic sclerosis (SSc) patients of European American (EA) ancestry have identified variants in the ATP8B4 gene and enrichment of variants in genes in the extracellular matrix (ECM)-related pathway that increase SSc susceptibility. This study was undertaken to evaluate the association of the ATP8B4 gene and the ECM-related pathway with SSc in a cohort of African American (AA) patients. METHODS SSc patients of AA ancestry were enrolled from 23 academic centers across the US under the Genome Research in African American Scleroderma Patients consortium. Unrelated AA individuals without serologic evidence of autoimmunity who were enrolled in the Howard University Family Study were used as unaffected controls. Functional variants in genes reported in the 2 WES studies in EA patients with SSc were selected for gene association testing using the optimized sequence kernel association test (SKAT-O) and pathway analysis by Ingenuity Pathway Analysis in 379 patients and 411 controls. RESULTS Principal components analysis demonstrated that the patients and controls had similar ancestral backgrounds, with roughly equal proportions of mean European admixture. Using SKAT-O, we examined the association of individual genes that were previously reported in EA patients and none remained significant, including ATP8B4 (P = 0.98). However, we confirmed the previously reported association of the ECM-related pathway with enrichment of variants within the COL13A1, COL18A1, COL22A1, COL4A3, COL4A4, COL5A2, PROK1, and SERPINE1 genes (corrected P = 1.95 × 10-4 ). CONCLUSION In the largest genetic study in AA patients with SSc to date, our findings corroborate the role of functional variants that aggregate in a fibrotic pathway and increase SSc susceptibility.
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Affiliation(s)
- Pravitt Gourh
- NIAMS and National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Elaine F Remmers
- National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Steven E Boyden
- National Human Genome Research Institute, NIH, Bethesda, Maryland
| | | | - Nadia D Morgan
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ami A Shah
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Ayo Doumatey
- National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Amy R Bentley
- National Human Genome Research Institute, NIH, Bethesda, Maryland
| | - Daniel Shriner
- National Human Genome Research Institute, NIH, Bethesda, Maryland
| | | | | | | | | | | | - Benjamin Korman
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | - John Varga
- Northwestern University, Feinberg School of Medicine, Chicago, Illinois
| | | | | | - Vivien Hsu
- Robert Wood Johnson University, New Brunswick, New Jersey
| | | | | | - Heather Gladue
- Arthritis and Osteoporosis Consultants of the Carolinas, Charlotte, North Carolina
| | | | | | | | | | | | | | - Lorinda Chung
- Stanford University School of Medicine, Stanford, California, and Palo Alto VA Health Care System, Palo Alto, California
| | - Reem Jan
- University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Elana J Bernstein
- New York Presbyterian Hospital, Columbia University, New York, New York
| | - Avram Goldberg
- New York University Langone Medical Center, New York, New York
| | | | - Suzanne Kafaja
- David Geffen School of Medicine, University of California, Los Angeles
| | | | - James C Mullikin
- National Human Genome Research Institute, NIH Intramural Sequencing Center, Rockville, Maryland
| | | | - Charles Rotimi
- National Human Genome Research Institute, NIH, Bethesda, Maryland
| | | | - Daniel L Kastner
- National Human Genome Research Institute, NIH, Bethesda, Maryland
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Baron M, Kahaleh B, Bernstein EJ, Chung L, Clements PJ, Denton C, Domsic RT, Ferdowsi N, Foeldvari I, Frech T, Gordon JK, Hudson M, Johnson SR, Khanna D, McMahan Z, Merkel PA, Narain S, Nikpour M, Pauling JD, Ross L, Valenzuela Vergara AM, Vacca A. An Interim Report of the Scleroderma Clinical Trials Consortium Working Groups. J Scleroderma Relat Disord 2018; 4:17-27. [PMID: 30906878 DOI: 10.1177/2397198318783926] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The Scleroderma Clinical Trials Consortium (SCTC) represents many of the clinical researchers in the world who are interested in improving the efficiency of clinical trials in Systemic Sclerosis (SSc). The SCTC has established 11 working groups (WGs) to develop and validate better ways of measuring and recording multiple aspects of this heterogeneous disease. These include groups working on arthritis, disease damage, disease activity, cardiac disease, juvenile SSc, the gastrointestinal tract, vascular component, calcinosis, scleroderma renal crisis, interstitial lung disease, and skin measurement. Members of the SCTC may join any one or more of these groups. Some of the WGs have only recently started their work, some are nearing completion of their mandated tasks and others are in the midst of their projects. All these projects, which are described in this paper, will help to improve clinical trials and observational studies by improving or developing better, more sensitive ways of measuring various aspects of the disease. As Lord Kelvin stated, "To measure is to know. If you cannot measure it you cannot improve it." The SCTC is dedicated to improving the lives of patients with SSc and it is our hope that the contributions of the WGs will be one important step in this process.
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Affiliation(s)
- Murray Baron
- Division of Rheumatology, Jewish General Hospital, Montreal, Canada
| | - Bashar Kahaleh
- Faculty of Rheumatology, University of Toledo Medical Center, Toledo, OH, USA
| | - Elana J Bernstein
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Lorinda Chung
- Department of Immunology and Rheumatology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Philip J Clements
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA; University College London, London, United Kingdom
| | - Christopher Denton
- Insitute of Immunity and Transplantation, University College London, London, United Kingdom
| | - Robyn T Domsic
- Arthritis and Autoimmunity Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Nava Ferdowsi
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - Ivan Foeldvari
- Hamburg Centre for Pediatric Rheumatology, Hamburg, Germany
| | - Tracy Frech
- Department of Rheumatology, University of Utah, UT, USA
| | - Jessica K Gordon
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA
| | - Marie Hudson
- Division of Rheumatology, Jewish General Hospital, Montreal, Canada
| | - Sindhu R Johnson
- Department of Rheumatology, Toronto Western Hospital, Toronto, Canada
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, MI, USA
| | | | - Peter A Merkel
- Department of Medicine, University of Pennsylvania, PA, USA
| | - Sonali Narain
- Department of Rheumatology, Hosfra Northwell School of Medicine
| | - Mandana Nikpour
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
| | - John D Pauling
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases University of Bath
| | - Laura Ross
- Division of Rheumatology, St. Vincent's Hospital, Melbourne, Australia
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30
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Mantero JC, Kishore N, Ziemek J, Stifano G, Zammitti C, Khanna D, Gordon JK, Spiera R, Zhang Y, Simms RW, Lafyatis R. Randomised, double-blind, placebo-controlled trial of IL1-trap, rilonacept, in systemic sclerosis. A phase I/II biomarker trial. Clin Exp Rheumatol 2018; 36 Suppl 113:146-149. [PMID: 30277862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 07/23/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES This clinical trial was designed to study the safety and efficacy of blocking IL-1 in skin fibrosis of patients with diffuse cutaneous systemic sclerosis (dcSSc), and to test the hypothesis that inhibition of IL-1 by rilonacept will downregulate expression of the 2G SSc gene biomarker as a surrogate for the modified Rodnan skin score (MRSS). METHODS 19 dcSSc patients were randomised 2:1 active treatment:placebo in this double blinded trial. Study patients received weekly treatments with either subcutaneous rilanocept 320 mg loading dose at day 0 and then 160 mg for each of the 5 subsequent weekly doses, or placebo. Skin biopsies were taken to test 2G SSc biomarker gene expression at day 0 before treatment and one week after the final study drug dose, comparing gene expression changes between rilonacept- and placebo-treated patients, as well as the change in gene expression at week 6 compared to baseline in rilonacept-treated patients. Safety assessments extended to 6 weeks after the final dose of study drug or placebo. Other secondary outcome measures included global and IL-1-regulated gene expression, serum biomarkers and the MRSS. RESULTS Rilonacept compared to placebo-treated patients did not show any treatment-related effect on the 2G SSc biomarker. Rilonacept treatment also failed to alter IL-6 expression in skin, serum IL-6, C-reactive protein, or CCL18, a marker of IL-6 activity in SSc. CONCLUSIONS In this small trial we did not observe any effect of blocking IL-1 on clinical skin disease or biomarkers of IL-1 activity.
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Affiliation(s)
- Julio C Mantero
- Department of Rheumatology, Boston University Medical Center, Boston, MA, USA
| | - Nina Kishore
- Department of Rheumatology, Boston University Medical Center, Boston, MA, USA
| | - Jessica Ziemek
- Department of Rheumatology, Boston University Medical Center, Boston, MA, USA
| | - Giuseppina Stifano
- Department of Rheumatology, Boston University Medical Center, Boston, MA, USA
| | | | - Dinesh Khanna
- Department of Rheumatology, University of Michigan Medical Center, Ann Arbor, MI, USA
| | - Jessica K Gordon
- Department of Rheumatology, Hospital of Special Surgery, New York, NY, USA
| | - Robert Spiera
- Department of Rheumatology, Hospital of Special Surgery, New York, NY, USA
| | - Yuqing Zhang
- Division of Epidemiology, Massachusetts General Hospital, Boston, MA, USA
| | - Robert W Simms
- Department of Rheumatology, Boston University Medical Center, Boston, MA, USA
| | - Robert Lafyatis
- Division of Rheumatology and Clinical Immunology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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31
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Blank RB, Nwawka OK, Yusov AA, Gordon JK. Inflammatory arthritis in systemic sclerosis: What to do? Journal of Scleroderma and Related Disorders 2018; 4:3-16. [DOI: 10.1177/2397198318779532] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 05/08/2018] [Indexed: 01/16/2023]
Abstract
Musculoskeletal involvement, including arthritis and tendinopathy, is a common and important determinant of disability and impaired quality of life in systemic sclerosis. However, the treatment of arthritis in systemic sclerosis has not been studied as a primary outcome in randomized controlled trials, and arthritis-specific outcome measures for systemic sclerosis have not been sufficiently validated to date. Rheumatologists caring for patients with systemic sclerosis must address these complaints regularly despite the fact that the level of evidence for the treatment of systemic sclerosis–related inflammatory arthritis is limited. Consensus statements, based on treatments for related musculoskeletal aspects of rheumatoid arthritis, systemic lupus erythematosus, and other autoimmune diseases, support the use of methotrexate and hydroxychloroquine. Newer biologics, which have efficacy in the treatment of other autoimmune conditions, may show promise in the treatment of arthritis in systemic sclerosis. In this article, we review the current literature on the assessment and treatment of systemic sclerosis arthritis in order to address management considerations.
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Affiliation(s)
- Rebecca B Blank
- NewYork-Presbyterian/Weill Cornell Medicine Center, New York, NY, USA
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32
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Pauling JD, Frech TM, Hughes M, Gordon JK, Domsic RT, Anderson ME, Ingegnoli F, McHugh NJ, Johnson SR, Hudson M, Boin F, Ong VH, Matucci-Cerinic M, Altorok N, Scolnik M, Nikpour M, Shah A, Pope JE, Khanna D, Herrick AL. Patient-reported outcome instruments for assessing Raynaud's phenomenon in systemic sclerosis: A SCTC Vascular Working Group Report. J Scleroderma Relat Disord 2018; 3:249-252. [PMID: 30705970 DOI: 10.1177/2397198318774307] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The episodic nature of Raynaud's phenomenon (RP) in systemic sclerosis (SSc) has led to a reliance on patient-reported outcome (PRO) instruments such as the Raynaud's Condition Score (RCS) diary. Little is known about the utilisation in routine clinical practice and health professional attitudes towards existing PRO instruments for assessing SSc-RP. Members of the Scleroderma Clinical Trials Consortium Vascular Working Group (SCTC-VWG, n=28) were invited to participate in a survey gauging attitudes towards the RCS diary and the perceived need for novel PRO instruments for assessing SSc-RP. Nineteen SCTC-VWG members (68% response rate) from academic units based in North America (n=9), Europe (n=8), South America (n=1) and Australasia (n=1) took part in the survey. There was broad consensus that RCS diary returns could be influenced by factors including seasonal variation in weather, efforts made by patients to avoid or ameliorate attacks of RP, habituation to RP symptoms, evolution of RP symptom characteristics with progressive obliterative microangiopathy, patient coping strategies, respondent burden and placebo effect. There was consensus that limitations of the RCS diary might be a barrier to drug development (79% of respondents agree/strongly agree) and that a novel PRO instrument for assessing SSc-RP should be developed with the input of both clinicians and patients (84% agree/strongly agree). Perceived potential limitations of the RCS diary have been identified along with concerns that such factors might impede drug development programs for SSc-RP. There is support within the systemic sclerosis community for the development of a novel PRO instrument for assessing SSc-RP.
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Affiliation(s)
- John D Pauling
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Tracy M Frech
- University of Utah and Salt Lake Regional Veterans Affair Medical Center, Salt Lake City, UT
| | - Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | | | | | - Marina E Anderson
- Institute of Ageing and Chronic Disease, Faculty of Health and Life Sciences, University of Liverpool & Aintree University Hospital
| | - Francesca Ingegnoli
- Division of Rheumatology, Dept. of Clinical Sciences and Community Health, University of Milano, Milan, Italy
| | - Neil J McHugh
- Royal National Hospital for Rheumatic Diseases (at Royal United Hospitals), Bath, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Sindhu R Johnson
- Toronto Scleroderma Program, Toronto Western Hospital, Mount Sinai Hospital; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Marie Hudson
- Jewish General Hospital, Lady Davis Institute and McGill University, Montreal, Canada
| | - Francesco Boin
- UCSF Scleroderma Center, University of California San Francisco, San Francisco, CA
| | - Voon H Ong
- University College London Medical School, Royal Free Hospital, London, UK
| | | | | | - Marina Scolnik
- Rheumatology Section, Hospital Italiano de Buenos Aires, Argentina
| | - Mandana Nikpour
- The University of Melbourne at St. Vincent's Hospital, Melbourne, Victoria, Australia
| | | | | | - Dinesh Khanna
- University of Michigan Scleroderma Program, Ann Arbor, MI
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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Lammi MR, Saketkoo LA, Gordon JK, Steen VD. Changes in hemodynamic classification over time are common in systemic sclerosis-associated pulmonary hypertension: insights from the PHAROS cohort. Pulm Circ 2018; 8:2045893218757404. [PMID: 29468935 PMCID: PMC5826006 DOI: 10.1177/2045893218757404] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Group classification of pulmonary hypertension (PH) is based on pulmonary artery wedge pressure (PAWP) on right heart catheterization (RHC). How hemodynamics, particularly PAWP, change over time in systemic sclerosis (SSc)-PH patients is unknown. SSc-PH patients enrolled in the prospective observational PHAROS registry who had > 1 RHC (n = 120) were included in this analysis. Patients were considered to have a “PAWP class change” if they had a PAWP ≤ 15 mmHg on RHC-1 and then a PAWP > 15 on RHC-2 or had a PAWP > 15 on RHC-1 and then PAWP ≤ 15 on RHC-2. There was a median time of 1.4 years between RHC-1 and RHC-2 and 75% of patients had a PH medication added after their initial RHC. PAWP increased significantly (11 ± 5 versus 13 ± 6 mmHg, P = 0.01) between RHC-1 and RHC-2, particularly for patients who were started on PH medications. Overall, 30% of patients who had a repeat RHC experienced a PAWP class change between their initial and follow-up RHC, independent of whether a PH medication was added. Patients initially classified as World Health Organization group 2 PH were most likely to change PAWP class over time. In conclusion, PAWP values commonly change to a significant degree in SSc-PH, which highlights the challenges in using a single time-point PAWP to define clinical classification groups.
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Affiliation(s)
- Matthew R Lammi
- 1 Lousiana State University Health Sciences Center, New Orleans, LA, USA.,2 12255 Comprehensive Pulmonary Hypertension Center-University Medical Center New Orleans, New Orleans, LA, USA
| | - Lesley Ann Saketkoo
- 2 12255 Comprehensive Pulmonary Hypertension Center-University Medical Center New Orleans, New Orleans, LA, USA.,3 New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center; Tulane University School of Medicine, New Orleans, LA, USA
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Gordon JK, Martyanov V, Franks JM, Bernstein EJ, Szymonifka J, Magro C, Wildman HF, Wood TA, Whitfield ML, Spiera RF. Belimumab for the Treatment of Early Diffuse Systemic Sclerosis: Results of a Randomized, Double-Blind, Placebo-Controlled, Pilot Trial. Arthritis Rheumatol 2018; 70:308-316. [PMID: 29073351 PMCID: PMC6590997 DOI: 10.1002/art.40358] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/19/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of treatment with belimumab in patients with early diffuse cutaneous systemic sclerosis (dcSSc) treated with background mycophenolate mofetil (MMF). METHODS In this 52-week, investigator-initiated, single-center, double-blind, placebo-controlled, pilot study, 20 patients with dcSSc recently started on MMF were randomized 1:1 to additionally receive belimumab at 10 mg/kg intravenously or placebo. We assessed safety, efficacy, and differential gene expression. RESULTS In the belimumab group, the median modified Rodnan skin thickness score (MRSS) decreased from 27 (interquartile range [IQR] 26.5, 31) to 18 (IQR 11, 23) (P = 0.039). In the placebo group, the median MRSS decreased from 28 (IQR 22, 28) to 21 (IQR 14, 25) (P = 0.023). The median change in MRSS was -10 (IQR -13, -9) in the belimumab group and -3.0 (IQR -15, -1) in the placebo group (P = 0.411). There were no significant differences between the groups in the number of adverse events (AEs). A significant decrease in expression of B cell signaling and profibrotic genes and pathways was observed in patients with improved MRSS in the belimumab group but not in the placebo group. CONCLUSION Patients in both treatment groups experienced significant improvements in MRSS. The median difference was greater in the belimumab group but did not achieve statistical significance in this small pilot study. AEs were similar between the groups. Changes in gene expression were consistent with mechanism of action and showed that clinical response to treatment with belimumab is associated with a significant decrease in profibrotic genes and pathways. Additional studies are needed to determine the role of belimumab in the treatment of dcSSc.
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Affiliation(s)
- Jessica K. Gordon
- Jessica K. Gordon, MD, MSc, Robert F. Spiera, MD: Hospital for Special Surgery, New York, New York
| | - Viktor Martyanov
- Viktor Martyanov, PhD, Jennifer M. Franks, BS, Tammara A. Wood, MS, Michael L. Whitfield, PhD: Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Jennifer M. Franks
- Viktor Martyanov, PhD, Jennifer M. Franks, BS, Tammara A. Wood, MS, Michael L. Whitfield, PhD: Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Elana J. Bernstein
- Elana J. Bernstein, MD, MSc, Jackie Szymonifka, MA: New York Presbyterian Hospital, Columbia University, New York, New York
| | - Jackie Szymonifka
- Elana J. Bernstein, MD, MSc, Jackie Szymonifka, MA: New York Presbyterian Hospital, Columbia University, New York, New York
| | - Cynthia Magro
- Cynthia Magro, MD, Horatio F. Wildman, MD: Weill Cornell Medical College, New York, New York
| | - Horatio F. Wildman
- Cynthia Magro, MD, Horatio F. Wildman, MD: Weill Cornell Medical College, New York, New York
| | - Tammara A. Wood
- Viktor Martyanov, PhD, Jennifer M. Franks, BS, Tammara A. Wood, MS, Michael L. Whitfield, PhD: Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Michael L. Whitfield
- Viktor Martyanov, PhD, Jennifer M. Franks, BS, Tammara A. Wood, MS, Michael L. Whitfield, PhD: Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Robert F. Spiera
- Jessica K. Gordon, MD, MSc, Robert F. Spiera, MD: Hospital for Special Surgery, New York, New York
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Ah Kioon MD, Tripodo C, Fernandez D, Kirou KA, Spiera RF, Crow MK, Gordon JK, Barrat FJ. Plasmacytoid dendritic cells promote systemic sclerosis with a key role for TLR8. Sci Transl Med 2018; 10:10/423/eaam8458. [PMID: 29321259 PMCID: PMC9865429 DOI: 10.1126/scitranslmed.aam8458] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 07/17/2017] [Accepted: 11/14/2017] [Indexed: 01/25/2023]
Abstract
Systemic sclerosis (SSc) is a multisystem life-threatening fibrosing disorder that lacks effective treatment. The link between the inflammation observed in organs such as the skin and profibrotic mechanisms is not well understood. The plasmacytoid dendritic cell (pDC) is a key cell type mediating Toll-like receptor (TLR)-induced inflammation in autoimmune disease patients, including lupus and skin diseases with interface dermatitis. However, the role of pDCs in fibrosis is less clear. We show that pDCs infiltrate the skin of SSc patients and are chronically activated, leading to secretion of interferon-α (IFN-α) and CXCL4, which are both hallmarks of the disease. We demonstrate that the secretion of CXCL4 is under the control of phosphatidylinositol 3-kinase δ and is due to the aberrant presence of TLR8 on pDCs of SSc patients, which is not seen in healthy donors or in lupus pDCs, and that CXCL4 primarily acts by potentiating TLR8- but also TLR9-induced IFN production by pDCs. Depleting pDCs prevented disease in a mouse model of scleroderma and could revert fibrosis in mice with established disease. In contrast, the disease was exacerbated in mice transgenic for TLR8 with recruitment of pDCs to the fibrotic skin, whereas TLR7 only partially contributed to the inflammatory response, indicating that TLR8 is the key RNA-sensing TLR involved in the establishment of fibrosis. We conclude that the pDC is an essential cell type involved in the pathogenesis of SSc and its removal using depleting antibodies or attenuating pDC function could be a novel approach to treat SSc patients.
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Affiliation(s)
- Marie Dominique Ah Kioon
- Autoimmunity and Inflammation Program, HSS Research Institute, Hospital for Special Surgery, New York, NY 10021, USA
| | - Claudio Tripodo
- Tumor Immunology Unit, Department of Health Science, Human Pathology Section, University of Palermo School of Medicine, Palermo, Italy
| | - David Fernandez
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY 10021, USA
| | - Kyriakos A. Kirou
- Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY 10021, USA
| | - Robert F. Spiera
- Scleroderma and Vasculitis Center, Hospital for Special Surgery, New York, NY 10021, USA
| | - Mary K. Crow
- Autoimmunity and Inflammation Program, HSS Research Institute, Hospital for Special Surgery, New York, NY 10021, USA.,Mary Kirkland Center for Lupus Research, Hospital for Special Surgery, New York, NY 10021, USA
| | - Jessica K. Gordon
- Scleroderma and Vasculitis Center, Hospital for Special Surgery, New York, NY 10021, USA
| | - Franck J. Barrat
- Autoimmunity and Inflammation Program, HSS Research Institute, Hospital for Special Surgery, New York, NY 10021, USA.,Corresponding author.
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Morgan ND, Shah AA, Mayes MD, Domsic RT, Medsger TA, Steen VD, Varga J, Carns M, Ramos PS, Silver RM, Schiopu E, Khanna D, Hsu V, Gordon JK, Gladue H, Saketkoo LA, Criswell LA, Derk CT, Trojanowski MA, Shanmugam VK, Chung L, Valenzuela A, Jan R, Goldberg A, Remmers EF, Kastner DL, Wigley FM, Gourh P, Boin F. Clinical and serological features of systemic sclerosis in a multicenter African American cohort: Analysis of the genome research in African American scleroderma patients clinical database. Medicine (Baltimore) 2017; 96:e8980. [PMID: 29390428 PMCID: PMC5758130 DOI: 10.1097/md.0000000000008980] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Racial differences exist in the severity of systemic sclerosis (SSc). To enhance our knowledge about SSc in African Americans, we established a comprehensive clinical database from the largest multicenter cohort of African American SSc patients assembled to date (the Genome Research in African American Scleroderma Patients (GRASP) cohort).African American SSc patients were enrolled retrospectively and prospectively over a 30-year period (1987-2016), from 18 academic centers throughout the United States. The cross-sectional prevalence of sociodemographic, clinical, and serological features was evaluated. Factors associated with clinically significant manifestations of SSc were assessed using multivariate logistic regression analyses.The study population included a total of 1009 African American SSc patients, comprised of 84% women. In total, 945 (94%) patients met the 2013 American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria for SSc, with the remaining 64 (6%) meeting the 1980 ACR or CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia) criteria. While 43% were actively employed, 33% required disability support. The majority (57%) had the more severe diffuse subtype and a young age at symptom onset (39.1 ± 13.7 years), in marked contrast to that reported in cohorts of predominantly European ancestry. Also, 1 in 10 patients had a severe Medsger cardiac score of 4. Pulmonary fibrosis evident on computed tomography (CT) chest was present in 43% of patients and was significantly associated with anti-topoisomerase I positivity. 38% of patients with CT evidence of pulmonary fibrosis had a severe restrictive ventilator defect, forced vital capacity (FVC) ≤50% predicted. A significant association was noted between longer disease duration and higher odds of pulmonary hypertension, telangiectasia, and calcinosis. The prevalence of potentially fatal scleroderma renal crisis was 7%, 3.5 times higher than the 2% prevalence reported in the European League Against Rheumatism Scleroderma Trials and Research (EUSTAR) cohort.Our study emphasizes the unique and severe disease burden of SSc in African Americans compared to those of European ancestry.
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Affiliation(s)
- Nadia D. Morgan
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ami A. Shah
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Maureen D. Mayes
- Division of Rheumatology, University of Texas-McGovern Medical School, Houston, TX
| | | | | | - Virginia D. Steen
- Division of Rheumatology, Georgetown University School of Medicine, Washington, DC
| | - John Varga
- Division of Rheumatology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Mary Carns
- Division of Rheumatology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Paula S. Ramos
- Division of Rheumatology, Medical University of South Carolina, Charleston, SC
| | - Richard M. Silver
- Division of Rheumatology, Medical University of South Carolina, Charleston, SC
| | - Elena Schiopu
- Division of Rheumatology, University of Michigan, Ann Arbor, MI
| | - Dinesh Khanna
- Division of Rheumatology, University of Michigan, Ann Arbor, MI
| | - Vivien Hsu
- Division of Rheumatology, Robert Wood Johnson University, New Brunswick, NJ
| | - Jessica K. Gordon
- Division of Rheumatology, Hospital for Special Surgery, New York, NY
| | - Heather Gladue
- Department of Rheumatology, Arthritis and Osteoporosis Consultants of the Carolinas, Charlotte, NC
| | - Lesley A. Saketkoo
- Division of Rheumatology, Tulane University School of Medicine, New Orleans, LA
| | | | - Chris T. Derk
- Division of Rheumatology, University of Pennsylvania, Philadelphia, PA
| | | | | | - Lorinda Chung
- Division of Rheumatology, Stanford University School of Medicine, Stanford, CA
| | - Antonia Valenzuela
- Division of Rheumatology, Stanford University School of Medicine, Stanford, CA
| | - Reem Jan
- Division of Rheumatology, University of Chicago Pritzker School of Medicine, Chicago, IL
| | - Avram Goldberg
- Division of Rheumatology, New York University Langone Medical Center, New York, NY
| | | | | | - Fredrick M. Wigley
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Pravitt Gourh
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Francesco Boin
- Division of Rheumatology, University of California San Francisco, CA
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Chung L, Fairchild RM, Furst DE, Li S, Alkassab F, Bolster MB, Csuka ME, Derk CT, Domsic RT, Fischer A, Frech TM, Gomberg-Maitland M, Gordon JK, Hinchcliff M, Hsu V, Hummers LK, Khanna D, Medsger TAJ, Molitor JA, Preston IR, Schiopu E, Shapiro L, Hant F, Silver R, Simms R, Varga J, Steen VD, Zamanian RT. Utility of B-type natriuretic peptides in the assessment of patients with systemic sclerosis-associated pulmonary hypertension in the PHAROS registry. Clin Exp Rheumatol 2017; 35 Suppl 106:106-113. [PMID: 27908301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 09/28/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To assess the utility of B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) in detecting and monitoring pulmonary hypertension (PH) in systemic sclerosis (SSc). METHODS PHAROS is a multicenter prospective cohort of SSc patients at high risk for developing pulmonary arterial hypertension (SSc-AR-PAH) or with a definitive diagnosis of SSc-PH. We evaluated 1) the sensitivity and specificity of BNP≥64 and NT-proBNP≥210 pg/mL for the detection of SSc-PAH and/ or SSc-PH in the SSc-AR-PAH population; 2) baseline and longitudinal BNP and NT-proBNP levels as predictors of progression to SSc-PAH and/or SSc-PH; 3) baseline BNP≥180, NT-proBNP≥553 pg/mL, and longitudinal changes in BNP and NT-proBNP as predictors of mortality in SSc-PH diagnosed patients. RESULTS 172 SSc-PH and 157 SSc-AR- PAH patients had natriuretic peptide levels available. Median BNP and NT-proBNP were significantly higher in the SSc-PH versus SSc-AR-PAH group. The sensitivity and specificity for SSc-PAH detection using baseline BNP≥64 pg/mL was 71% and 59%; and for NT-proBNP≥210 pg/mL, 73% and 78%. NT-proBNP showed stronger correlations with haemodynamic indicators of right ventricular dysfunction than BNP. Baseline creatinine, RVSP > 40 mmHg, and FVC%:DLco% ratio ≥1.8 were associated with progression from SSc-AR-PAH to SSc-PH but no association with individual or combined baseline BNP and NT-proBNP levels was observed. Baseline and follow-up BNP or NT-proBNP levels were not predictive of death, however, a composite BNP/NT-proBNP group predicted mortality (HR 3.81 (2.08-6.99), p<.0001). CONCLUSIONS NT-proBNP may be more useful than BNP in the detection and monitoring of PAH in SSc patients, but additional studies are necessary.
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Affiliation(s)
- Lorinda Chung
- Stanford University, Stanford, CA and VA Palo Alto Health Care System, Palo Alto, CA, USA.
| | | | | | | | - Firas Alkassab
- University of Massachusetts Medical School, Worcester, MA/University of North Carolina-Chapel Hill, Charlotte, NC, USA
| | | | | | - Chris T Derk
- University of Pennsylvania, Philadelphia, PA, USA
| | | | - Aryeh Fischer
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | | | | | | | - Vivien Hsu
- Rutgers-RWJ Medical School, New Brunswick, NJ, USA
| | | | | | | | | | | | | | | | - Faye Hant
- Medical University of South Carolina, Charleston, SC, USA
| | - Richard Silver
- Medical University of South Carolina, Charleston, SC, USA
| | | | - John Varga
- Northwestern University, Chicago, IL, USA
| | | | - Roham T Zamanian
- Stanford University, Stanford, CA, and Vera Moulton Wall Center for Pulmonary Vascular Disease, USA
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38
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Lammi MR, Saketkoo LA, Gordon JK, Lauto P, Fagan K, Steen VD. Clinical characteristics and survival of systemic sclerosis patients with pulmonary hypertension and elevated wedge pressure: Observations from the PHAROS cohort. Respirology 2017; 22:1386-1392. [PMID: 28500695 DOI: 10.1111/resp.13067] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 01/18/2017] [Accepted: 03/03/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND OBJECTIVE Systemic sclerosis (SSc) is a complex autoimmune disease commonly associated with pulmonary hypertension (PH). When associated with elevated pulmonary artery wedge pressure (PAWP), pulmonary artery pressure (PAP) is either in-proportion (post-capillary PH) or higher than expected (combined PH) relative to the increased PAWP. METHODS Patients from the PHAROS registry (a prospective observational cohort of SSc-PH patients) who had mean PAP ≥ 25 and PAWP > 15 on right heart catheterization were stratified based on diastolic pressure gradient (DPG). Kaplan-Meier analysis was performed to compare survival and PH-related hospitalization. Baseline factors were compared between patients dying and those who survived using Cox regression analysis. RESULTS A total of 59 patients were included, of whom 21 (36%) patients were classified as combined PH and 38 (64%) had post-capillary PH. No baseline characteristics were significantly different between the two groups. There were no differences in survival or PH-related hospitalization between the groups. The only baseline factor independently associated with death was lower 6-min walk distance (6MWD) (hazard ratio (HR): 1.33 per 25 m decrease, 95% CI: 1.11-1.59, P = 0.002). PH-specific medications were started during follow-up in significantly more patients in the combined PH group compared with the post-capillary group (86% vs 50%, P = 0.01). CONCLUSION Outcomes were similar between SSc patients with post-capillary PH and combined pre- and post-capillary PH. 6MWD at baseline can predict risk for death in SSc patients with PH and an elevated PAWP. More patients with combined PH were started on PH-specific medications, and the clinical benefit of treating this subgroup specifically in SSc patients needs further exploration.
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Affiliation(s)
- Matthew R Lammi
- Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Lesley A Saketkoo
- Section of Pulmonary Diseases, Critical Care and Environmental Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Jessica K Gordon
- Department of Rheumatology, Hospital for Special Surgery, New York, New York, USA
| | - Paula Lauto
- Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Karen Fagan
- Pulmonary and Critical Care, University of South Alabama, Mobile, Alabama, USA
| | - Virginia D Steen
- Division of Rheumatology, Georgetown University, Washington, DC, USA
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Haddon DJ, Wand HE, Jarrell JA, Spiera RF, Utz PJ, Gordon JK, Chung LS. Proteomic Analysis of Sera from Individuals with Diffuse Cutaneous Systemic Sclerosis Reveals a Multianalyte Signature Associated with Clinical Improvement during Imatinib Mesylate Treatment. J Rheumatol 2017; 44:631-638. [PMID: 28298564 PMCID: PMC5860882 DOI: 10.3899/jrheum.160833] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2017] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Imatinib has been investigated for the treatment of systemic sclerosis (SSc) because of its ability to inhibit the platelet-derived growth factor receptor and transforming growth factor-β signaling pathways, which have been implicated in SSc pathogenesis. In a 12-month open-label clinical trial assessing the safety and efficacy of imatinib in the treatment of diffuse cutaneous SSc (dcSSc), significant improvements in skin thickening were observed. Here, we report our analysis of sera collected during the clinical trial. METHODS We measured the levels of 46 cytokines, chemokines, and growth factors in the sera of individuals with dcSSc using Luminex and ELISA. Autoantigen microarrays were used to measure immunoglobulin G reactivity to 28 autoantigens. Elastic net regularization was used to identify a signature that was predictive of clinical improvement (reduction in the modified Rodnan skin score ≥ 5) during treatment with imatinib. The signature was also tested using sera from a clinical trial of nilotinib, a tyrosine kinase inhibitor that is structurally related to imatinib, in dcSSc. RESULTS The elastic net algorithm identified a signature, based on levels of CD40 ligand, chemokine (C-X-C motif) ligand 4 (CXCL4), and anti-PM/Scl-100, that was significantly higher in individuals who experienced clinical improvement than in those who did not (p = 0.0011). The signature was validated using samples from a clinical trial of nilotinib. CONCLUSION Identification of patients with SSc with the greatest probability of benefit from treatment with imatinib has the potential to guide individualized treatment. Validation of the signature will require testing in randomized, placebo-controlled studies. Clinicaltrials.gov NCT00555581 and NCT01166139.
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Affiliation(s)
- D James Haddon
- From the Division of Immunology and Rheumatology, Stanford University School of Medicine; Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford; Department of Rheumatology, Palo Alto VA Health Care System, Palo Alto, California; Department of Rheumatology, Hospital for Special Surgery, New York, New York, USA
- D.J. Haddon, PhD, Research Associate, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine; H.E. Wand, BS, Genetic Counseling Candidate, Division of Immunology and Rheumatology, Stanford University School of Medicine; J.A. Jarrell, PhD Candidate, Immunology, Division of Immunology and Rheumatology, Stanford University School of Medicine; R.F. Spiera, MD, Professor of Clinical Medicine, Rheumatology and Director, Vasculitis and Scleroderma Program, Department of Rheumatology, Hospital for Special Surgery; P.J. Utz, MD, Professor of Medicine, Immunology and Rheumatology, Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine; J.K. Gordon, MD, Assistant Professor of Medicine, Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York; L.S. Chung, MD, MS, Associate Professor of Medicine, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine, and Department of Rheumatology, Palo Alto VA Health Care System
| | - Hannah E Wand
- From the Division of Immunology and Rheumatology, Stanford University School of Medicine; Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford; Department of Rheumatology, Palo Alto VA Health Care System, Palo Alto, California; Department of Rheumatology, Hospital for Special Surgery, New York, New York, USA
- D.J. Haddon, PhD, Research Associate, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine; H.E. Wand, BS, Genetic Counseling Candidate, Division of Immunology and Rheumatology, Stanford University School of Medicine; J.A. Jarrell, PhD Candidate, Immunology, Division of Immunology and Rheumatology, Stanford University School of Medicine; R.F. Spiera, MD, Professor of Clinical Medicine, Rheumatology and Director, Vasculitis and Scleroderma Program, Department of Rheumatology, Hospital for Special Surgery; P.J. Utz, MD, Professor of Medicine, Immunology and Rheumatology, Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine; J.K. Gordon, MD, Assistant Professor of Medicine, Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York; L.S. Chung, MD, MS, Associate Professor of Medicine, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine, and Department of Rheumatology, Palo Alto VA Health Care System
| | - Justin A Jarrell
- From the Division of Immunology and Rheumatology, Stanford University School of Medicine; Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford; Department of Rheumatology, Palo Alto VA Health Care System, Palo Alto, California; Department of Rheumatology, Hospital for Special Surgery, New York, New York, USA
- D.J. Haddon, PhD, Research Associate, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine; H.E. Wand, BS, Genetic Counseling Candidate, Division of Immunology and Rheumatology, Stanford University School of Medicine; J.A. Jarrell, PhD Candidate, Immunology, Division of Immunology and Rheumatology, Stanford University School of Medicine; R.F. Spiera, MD, Professor of Clinical Medicine, Rheumatology and Director, Vasculitis and Scleroderma Program, Department of Rheumatology, Hospital for Special Surgery; P.J. Utz, MD, Professor of Medicine, Immunology and Rheumatology, Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine; J.K. Gordon, MD, Assistant Professor of Medicine, Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York; L.S. Chung, MD, MS, Associate Professor of Medicine, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine, and Department of Rheumatology, Palo Alto VA Health Care System
| | - Robert F Spiera
- From the Division of Immunology and Rheumatology, Stanford University School of Medicine; Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford; Department of Rheumatology, Palo Alto VA Health Care System, Palo Alto, California; Department of Rheumatology, Hospital for Special Surgery, New York, New York, USA
- D.J. Haddon, PhD, Research Associate, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine; H.E. Wand, BS, Genetic Counseling Candidate, Division of Immunology and Rheumatology, Stanford University School of Medicine; J.A. Jarrell, PhD Candidate, Immunology, Division of Immunology and Rheumatology, Stanford University School of Medicine; R.F. Spiera, MD, Professor of Clinical Medicine, Rheumatology and Director, Vasculitis and Scleroderma Program, Department of Rheumatology, Hospital for Special Surgery; P.J. Utz, MD, Professor of Medicine, Immunology and Rheumatology, Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine; J.K. Gordon, MD, Assistant Professor of Medicine, Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York; L.S. Chung, MD, MS, Associate Professor of Medicine, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine, and Department of Rheumatology, Palo Alto VA Health Care System
| | - Paul J Utz
- From the Division of Immunology and Rheumatology, Stanford University School of Medicine; Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford; Department of Rheumatology, Palo Alto VA Health Care System, Palo Alto, California; Department of Rheumatology, Hospital for Special Surgery, New York, New York, USA
- D.J. Haddon, PhD, Research Associate, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine; H.E. Wand, BS, Genetic Counseling Candidate, Division of Immunology and Rheumatology, Stanford University School of Medicine; J.A. Jarrell, PhD Candidate, Immunology, Division of Immunology and Rheumatology, Stanford University School of Medicine; R.F. Spiera, MD, Professor of Clinical Medicine, Rheumatology and Director, Vasculitis and Scleroderma Program, Department of Rheumatology, Hospital for Special Surgery; P.J. Utz, MD, Professor of Medicine, Immunology and Rheumatology, Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine; J.K. Gordon, MD, Assistant Professor of Medicine, Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York; L.S. Chung, MD, MS, Associate Professor of Medicine, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine, and Department of Rheumatology, Palo Alto VA Health Care System
| | - Jessica K Gordon
- From the Division of Immunology and Rheumatology, Stanford University School of Medicine; Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford; Department of Rheumatology, Palo Alto VA Health Care System, Palo Alto, California; Department of Rheumatology, Hospital for Special Surgery, New York, New York, USA
- D.J. Haddon, PhD, Research Associate, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine; H.E. Wand, BS, Genetic Counseling Candidate, Division of Immunology and Rheumatology, Stanford University School of Medicine; J.A. Jarrell, PhD Candidate, Immunology, Division of Immunology and Rheumatology, Stanford University School of Medicine; R.F. Spiera, MD, Professor of Clinical Medicine, Rheumatology and Director, Vasculitis and Scleroderma Program, Department of Rheumatology, Hospital for Special Surgery; P.J. Utz, MD, Professor of Medicine, Immunology and Rheumatology, Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine; J.K. Gordon, MD, Assistant Professor of Medicine, Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York; L.S. Chung, MD, MS, Associate Professor of Medicine, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine, and Department of Rheumatology, Palo Alto VA Health Care System
| | - Lorinda S Chung
- From the Division of Immunology and Rheumatology, Stanford University School of Medicine; Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine, Stanford; Department of Rheumatology, Palo Alto VA Health Care System, Palo Alto, California; Department of Rheumatology, Hospital for Special Surgery, New York, New York, USA.
- D.J. Haddon, PhD, Research Associate, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine; H.E. Wand, BS, Genetic Counseling Candidate, Division of Immunology and Rheumatology, Stanford University School of Medicine; J.A. Jarrell, PhD Candidate, Immunology, Division of Immunology and Rheumatology, Stanford University School of Medicine; R.F. Spiera, MD, Professor of Clinical Medicine, Rheumatology and Director, Vasculitis and Scleroderma Program, Department of Rheumatology, Hospital for Special Surgery; P.J. Utz, MD, Professor of Medicine, Immunology and Rheumatology, Institute for Immunity, Transplantation and Infection, Stanford University School of Medicine; J.K. Gordon, MD, Assistant Professor of Medicine, Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York; L.S. Chung, MD, MS, Associate Professor of Medicine, Immunology and Rheumatology, Division of Immunology and Rheumatology, Stanford University School of Medicine, and Department of Rheumatology, Palo Alto VA Health Care System.
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Gordon JK, Girish G, Berrocal VJ, Zhang M, Hatzis C, Assassi S, Bernstein EJ, Domsic RT, Hant FN, Hinchcliff M, Schiopu E, Steen VD, Frech TM, Khanna D. Reliability and Validity of the Tender and Swollen Joint Counts and the Modified Rodnan Skin Score in Early Diffuse Cutaneous Systemic Sclerosis: Analysis from the Prospective Registry of Early Systemic Sclerosis Cohort. J Rheumatol 2017; 44:791-794. [PMID: 28298560 DOI: 10.3899/jrheum.160654] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2017] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the inter/intraobserver reliability of the tender and swollen joint counts (TJC, SJC) and the modified Rodnan Skin Score (mRSS) in diffuse cutaneous systemic sclerosis (dcSSc) and to assess content validity of the TJC/SJC. METHODS Ten rheumatologists completed the SJC, TJC, and mRSS on 7 patients. Musculoskeletal ultrasound (MSUS) was performed. RESULTS Interobserver and intraobserver reliability for the TJC was 0.97 and 0.99, for the SJC was 0.24 and 0.71, and for the mRSS was 0.81 and 0.94, respectively. MSUS abnormalities did not correspond with SJC/TJC. CONCLUSION We demonstrate excellent inter- and intraobserver reliability for the mRSS and TJC in dcSSc. However, the SJC and TJC did not correspond to MSUS.
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Affiliation(s)
- Jessica K Gordon
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA. .,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program.
| | - Gandikota Girish
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Veronica J Berrocal
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Meng Zhang
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Christopher Hatzis
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Shervin Assassi
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Elana J Bernstein
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Robyn T Domsic
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Faye N Hant
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Monique Hinchcliff
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Elena Schiopu
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Virginia D Steen
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Tracy M Frech
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
| | - Dinesh Khanna
- From the Department of Rheumatology, and Department of Epidemiology and Biostatistics, Hospital for Special Surgery; Department of Rheumatology, Columbia University, New York, New York; Department of Radiology, and Department of Biostatistics, University of Michigan; University of Michigan Scleroderma Program, Ann Arbor, Michigan; Department of Rheumatology, University of Texas, Houston, Texas; Department of Rheumatology, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Rheumatology, Medical University of South Carolina, Charleston, South Carolina; Department of Rheumatology, Northwestern University, Chicago, Illinois; Department of Rheumatology, Georgetown University, Washington, DC; Department of Rheumatology, University of Utah, Salt Lake City, Utah, USA.,J.K. Gordon, MD, MSc, Department of Rheumatology, Hospital for Special Surgery; G. Girish, MBBS, Department of Radiology, University of Michigan; V.J. Berrocal, MSc, PhD, Department of Biostatistics, University of Michigan; M. Zhang, PhD, Department of Epidemiology and Biostatistics, Hospital for Special Surgery; C. Hatzis, BA, Department of Rheumatology, Hospital for Special Surgery; S. Assassi, MD, MS, Department of Rheumatology, University of Texas; E.J. Bernstein, MD, MSc, Department of Rheumatology, Columbia University; R.T. Domsic, MD, MPH, Department of Rheumatology, University of Pittsburgh; F.N. Hant, DO, Department of Rheumatology, Medical University of South Carolina; M. Hinchcliff, MD, MS, Department of Rheumatology, Northwestern University; E. Schiopu, MD, University of Michigan Scleroderma Program; V.D. Steen, MD, Department of Rheumatology, Georgetown University; T.M. Frech, MD, MS, Department of Rheumatology, University of Utah; D. Khanna, MD, MS, University of Michigan Scleroderma Program
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Bernstein EJ, Gordon JK, Spiera RF, Huang WT, Horn EM, Mandl LA. Comparison of change in end tidal carbon dioxide after three minutes of step exercise between systemic sclerosis patients with and without pulmonary hypertension. Rheumatology (Oxford) 2016; 56:87-94. [PMID: 28028158 DOI: 10.1093/rheumatology/kew365] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 09/06/2016] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Pulmonary hypertension (PH) is an important cause of morbidity and mortality in patients with SSc. The submaximal heart and pulmonary evaluation (step test) is a non-invasive, submaximal stress test that could be used to identify SSc patients with PH. Our aims were to determine whether change in end tidal carbon dioxide ([Formula: see text]) from rest to end-exercise, and the minute ventilation to carbon dioxide production ratio ([Formula: see text]), both as measured by the step test, differ between SSc patients with and without PH. We also examined differences in validated self-report questionnaires and potential PH biomarkers between SSc patients with and without PH. METHODS We performed a cross-sectional study of 27 patients with limited or dcSSc who underwent a right heart catheterization within 24 months prior to study entry. The study visit consisted of questionnaire completion; history; physical examination; step test performance; and phlebotomy. [Formula: see text], [Formula: see text], self-report data and biomarkers were compared between patients with and without PH. RESULTS SSc patients with PH had a statistically significantly lower median (interquartile range) [Formula: see text] than SSc patients without PH [-2.1 (-5.1 to 0.7) vs 1.2 (-0.7 to 5.4) mmHg, P = 0.035], and a statistically significantly higher median (interquartile range) [Formula: see text] [53.4 (39-64.1) vs 36.4 (31.9-41.1), P = 0.035]. There were no statistically significant differences in self-report data or biomarkers between groups. CONCLUSION [Formula: see text] and [Formula: see text] as measured by the step test are statistically significantly different between SSc patients with and without PH. [Formula: see text] and [Formula: see text] may be useful screening tools for PH in the SSc population.
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Affiliation(s)
- Elana J Bernstein
- Division of Rheumatology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York-Presbyterian Hospital
| | - Jessica K Gordon
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery
| | - Robert F Spiera
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery
| | - Wei-Ti Huang
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery
| | - Evelyn M Horn
- Division of Cardiology, Department of Medicine, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Lisa A Mandl
- Division of Rheumatology, Department of Medicine, Hospital for Special Surgery
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Chia JJ, Zhu T, Chyou S, Dasoveanu DC, Carballo C, Tian S, Magro CM, Rodeo S, Spiera RF, Ruddle NH, McGraw TE, Browning JL, Lafyatis R, Gordon JK, Lu TT. Dendritic cells maintain dermal adipose-derived stromal cells in skin fibrosis. J Clin Invest 2016; 126:4331-4345. [PMID: 27721238 DOI: 10.1172/jci85740] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 08/30/2016] [Indexed: 12/14/2022] Open
Abstract
Scleroderma is a group of skin-fibrosing diseases for which there are no effective treatments. A feature of the skin fibrosis typical of scleroderma is atrophy of the dermal white adipose tissue (DWAT). Adipose tissue contains adipose-derived mesenchymal stromal cells (ADSCs) that have regenerative and reparative functions; however, whether DWAT atrophy in fibrosis is accompanied by ADSC loss is poorly understood, as are the mechanisms that might maintain ADSC survival in fibrotic skin. Here, we have shown that DWAT ADSC numbers were reduced, likely because of cell death, in 2 murine models of scleroderma skin fibrosis. The remaining ADSCs showed a partial dependence on dendritic cells (DCs) for survival. Lymphotoxin β (LTβ) expression in DCs maintained ADSC survival in fibrotic skin by activating an LTβ receptor/β1 integrin (LTβR/β1 integrin) pathway on ADSCs. Stimulation of LTβR augmented the engraftment of therapeutically injected ADSCs, which was associated with reductions in skin fibrosis and improved skin function. These findings provide insight into the effects of skin fibrosis on DWAT ADSCs, identify a DC-ADSC survival axis in fibrotic skin, and suggest an approach for improving mesenchymal stromal cell therapy in scleroderma and other diseases.
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Pelrine ER, Ah-Kioon MD, Zhang M, Barrat FJ, Spiera RF, Gordon JK. Musculoskeletal Involvement in SSc Is Associated with Worse Scores on Short Form-36 and Scleroderma Health Assessment Questionnaire and Lower Tumor Necrosis Factor-α Gene Expression in Peripheral Blood Mononuclear Cells. HSS J 2016; 12:255-260. [PMID: 27703420 PMCID: PMC5026664 DOI: 10.1007/s11420-016-9515-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/30/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND Systemic sclerosis (SSc) is characterized by a wide variety of symptoms and disease manifestations including joint pain, gastrointestinal dysfunction, interstitial lung disease, and cardiomyopathy. QUESTIONS/PURPOSES Using the Scleroderma Health Assessment Questionnaire (SHAQ) and Short Form-36 (SF-36) we explored how patient-reported physical health, mental health, and functional status related to these clinical characteristics and to cytokine levels utilizing the Hospital for Special Surgery Scleroderma Registry. METHODS In a cross-sectional study of 185 patients meeting the 2013 ACR/EULAR criteria for SSc, we compared disease features and patient-reported outcomes (PROs). Interleukin-6 (IL-6), interleukin-1β (IL1β), and tumor necrosis factor-α (TNFα) levels were assessed by luminex and ELISA assays in a subset of 32 patients. The Pearson correlation coefficient, Spearman correlation coefficient, two-sample t test or Wilcoxon rank sum test, ANOVA or Kuskal-Wallis test, and Pearson chi-squared or Fisher's exact test were performed as applicable to detect the association between disease manifestations, PROs, and blood biomarkers. RESULTS The modified Rodnan skin score (MRSS) was positively correlated with SHAQ scores. Patients who had musculoskeletal involvement scored worse on both the SHAQ and SF-36. Lower levels of TNFα expression in PBMCs were also correlated with musculoskeletal involvement. No other significant correlations were found between clinical factors, PROs, and cytokine data. CONCLUSION Musculoskeletal outcomes are a major determinant of quality of life and function in patients with SSc. These results emphasize the importance of musculoskeletal outcomes in clinical studies of SSc.
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Affiliation(s)
- Eliza R. Pelrine
- Department of Medicine, Hospital for Special Surgery, 535 East 70th Streret, New York, NY 10021 USA
| | | | - Meng Zhang
- Department of Biostatistics, Hospital for Special Surgery, New York, NY USA
| | - Franck J. Barrat
- Department of Research, Hospital for Special Surgery, New York, NY USA
| | - Robert F. Spiera
- Department of Medicine, Hospital for Special Surgery, 535 East 70th Streret, New York, NY 10021 USA
| | - Jessica K. Gordon
- Department of Medicine, Hospital for Special Surgery, 535 East 70th Streret, New York, NY 10021 USA
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Nusbaum JS, Gordon JK, Steen VD. African American race associated with body image dissatisfaction among patients with systemic sclerosis. Clin Exp Rheumatol 2016; 34 Suppl 100:70-73. [PMID: 27192123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 04/04/2016] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Studies have shown a high degree of body image dissatisfaction among patients with systemic sclerosis (SSc). We aimed to identify demographic and phenotypic characteristics that correlate with body image dissatisfaction. METHODS Ninety-eight patients with SSc were recruited from Georgetown University Medical Center 2003-2004. Anonymous surveys collected demographic information (age, race, gender, duration/type of SSc) and assessed degree of body image dissatisfaction on a scale of 0-3 in relation to phenotypic features of SSc (hand contractures, finger ulcers, pigmentation changes, lip wrinkling/thinning, telangiectasias). A composite total distress score was derived. Parametric and nonparametric T tests were used to compare groups. RESULTS Of 98 patients, 86 were female and 12 male. The majority of patients were 30-60 years old. The sample was 62% Caucasian, 27% African American, and the rest identified as "other". Twenty-seven percent had limited SSc, 48% diffuse, and 25% "other". African American patients had greater total body image dissatisfaction (p=0.002), specifically with respect to digital ulcers, pruritus, and pigmentation changes, than Caucasian participants. Patients with diffuse SSc had greater body image dissatisfaction than those with limited disease (p=0.002). CONCLUSIONS Our results suggest that African American patients with SSc and those with diffuse subtype suffer a higher degree of body image dissatisfaction. Screening for and addressing this issue in SSc patients is prudent. Further study is needed to understand racial differences in body image dissatisfaction among patients with SSc.
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MESH Headings
- Adult
- Black or African American/psychology
- Body Image/psychology
- Cost of Illness
- Female
- Health Knowledge, Attitudes, Practice/ethnology
- Humans
- Male
- Middle Aged
- Personal Satisfaction
- Quality of Life
- Risk Factors
- Scleroderma, Diffuse/diagnosis
- Scleroderma, Diffuse/ethnology
- Scleroderma, Diffuse/psychology
- Scleroderma, Systemic/diagnosis
- Scleroderma, Systemic/ethnology
- Scleroderma, Systemic/psychology
- Stress, Psychological/ethnology
- Stress, Psychological/psychology
- Surveys and Questionnaires
- White People/psychology
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Affiliation(s)
- Julie S Nusbaum
- New York Presbyterian/Weill Cornell Medical Center, New York, NY, USA
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Rice LM, Ziemek J, Stratton EA, McLaughlin SR, Padilla CM, Mathes AL, Christmann RB, Stifano G, Browning JL, Whitfield ML, Spiera RF, Gordon JK, Simms RW, Zhang Y, Lafyatis R. A longitudinal biomarker for the extent of skin disease in patients with diffuse cutaneous systemic sclerosis. Arthritis Rheumatol 2016; 67:3004-15. [PMID: 26240058 DOI: 10.1002/art.39287] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 07/14/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To define a pharmacodynamic biomarker based on gene expression in skin that would provide a biologic measure of the extent of disease in patients with diffuse cutaneous systemic sclerosis (dcSSc) and could be used to monitor skin disease longitudinally. METHODS Skin biopsy specimens obtained from a cohort of patients with dcSSc (including longitudinal specimens) were analyzed by microarray. Expression of genes correlating with the modified Rodnan skin thickness score (MRSS) were examined for change over time using a NanoString platform, and a generalized estimating equation (GEE) was used to define and validate longitudinally measured pharmacodynamic biomarkers composed of multiple genes. RESULTS Microarray analysis of genes parsed to include only those correlating with the MRSS revealed prominent clusters of profibrotic/transforming growth factor β-regulated, interferon-regulated/proteasome, macrophage, and vascular marker genes. Using genes changing longitudinally with the MRSS, we defined 2 multigene pharmacodynamic biomarkers. The first was defined mathematically by applying a GEE to longitudinal samples. This modeling method selected cross-sectional THBS1 and longitudinal THBS1 and MS4A4A. The second model was based on a weighted selection of genes, including additional genes that changed statistically significantly over time: CTGF, CD163, CCL2, and WIF1. In an independent validation data set, biomarker levels calculated using both models correlated highly with the MRSS. CONCLUSION Skin gene expression can be used effectively to monitor changes in SSc skin disease over time. We implemented 2 relatively simple models on a NanoString platform permitting highly reproducible assays that can be applied directly to samples from patients or collected as part of clinical trials.
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Affiliation(s)
- Lisa M Rice
- Boston University School of Medicine, Boston, Massachusetts
| | - Jessica Ziemek
- Boston University School of Medicine, Boston, Massachusetts
| | | | | | | | | | | | | | | | - Michael L Whitfield
- Geisel School of Medicine at Dartmouth University Medical School, Hanover, New Hampshire
| | | | | | - Robert W Simms
- Boston University School of Medicine, Boston, Massachusetts
| | - Yuqing Zhang
- Boston University School of Medicine, Boston, Massachusetts
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Johnson ME, Grassetti AV, Taroni JN, Lyons SM, Schweppe D, Gordon JK, Spiera RF, Lafyatis R, Anderson PJ, Gerber SA, Whitfield ML. Stress granules and RNA processing bodies are novel autoantibody targets in systemic sclerosis. Arthritis Res Ther 2016; 18:27. [PMID: 26801089 PMCID: PMC4724133 DOI: 10.1186/s13075-016-0914-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 01/03/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Autoantibody profiles represent important patient stratification markers in systemic sclerosis (SSc). Here, we performed serum-immunoprecipitations with patient antibodies followed by mass spectrometry (LC-MS/MS) to obtain an unbiased view of all possible autoantibody targets and their associated molecular complexes recognized by SSc. METHODS HeLa whole cell lysates were immunoprecipitated (IP) using sera of patients with SSc clinically positive for autoantibodies against RNA polymerase III (RNAP3), topoisomerase 1 (TOP1), and centromere proteins (CENP). IP eluates were then analyzed by LC-MS/MS to identify novel proteins and complexes targeted in SSc. Target proteins were examined using a functional interaction network to identify major macromolecular complexes, with direct targets validated by IP-Western blots and immunofluorescence. RESULTS A wide range of peptides were detected across patients in each clinical autoantibody group. Each group contained peptides representing a broad spectrum of proteins in large macromolecular complexes, with significant overlap between groups. Network analyses revealed significant enrichment for proteins in RNA processing bodies (PB) and cytosolic stress granules (SG) across all SSc subtypes, which were confirmed by both Western blot and immunofluorescence. CONCLUSIONS While strong reactivity was observed against major SSc autoantigens, such as RNAP3 and TOP1, there was overlap between groups with widespread reactivity seen against multiple proteins. Identification of PB and SG as major targets of the humoral immune response represents a novel SSc autoantigen and suggests a model in which a combination of chronic and acute cellular stresses result in aberrant cell death, leading to autoantibody generation directed against macromolecular nucleic acid-protein complexes.
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Affiliation(s)
- Michael E Johnson
- Department of Genetics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Andrew V Grassetti
- Department of Genetics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Jaclyn N Taroni
- Department of Genetics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Shawn M Lyons
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, MA, USA.
| | - Devin Schweppe
- Department of Genetics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Jessica K Gordon
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA.
| | - Robert F Spiera
- Department of Rheumatology, Hospital for Special Surgery, New York, NY, USA.
| | | | - Paul J Anderson
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, MA, USA.
| | - Scott A Gerber
- Department of Genetics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
| | - Michael L Whitfield
- Department of Genetics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
- Dartmouth Medical School, Hinman Box 7400, Hanover, NH, 03755, USA.
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Gordon JK, Martyanov V, Magro C, Wildman HF, Wood TA, Huang WT, Crow MK, Whitfield ML, Spiera RF. Nilotinib (Tasigna™) in the treatment of early diffuse systemic sclerosis: an open-label, pilot clinical trial. Arthritis Res Ther 2015; 17:213. [PMID: 26283632 PMCID: PMC4538758 DOI: 10.1186/s13075-015-0721-3] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Accepted: 07/20/2015] [Indexed: 01/06/2023] Open
Abstract
Introduction Tyrosine kinase inhibitors (TKI) are medications of interest in the treatment of Systemic Sclerosis (SSc) because of their ability to inhibit pathways involved in fibrosis. In this open-label pilot trial, our objectives were to assess the safety, efficacy, and molecular change associated with treatment of patients with diffuse cutaneous (dc)SSc with the TKI nilotinib (Tasigna™). Methods Ten adult patients with early dcSSc were treated with nilotinib. Primary endpoints were safety and change in modified Rodnan Skin Score (MRSS) after 6 months. Lesional skin biopsies at baseline, 6 and 12 months of treatment were assessed by histopathology, immunohistochemistry, and DNA microarray. Results Patients had early and active dcSSc with median disease duration of 0.7 years (range 0.5, 1.7) and increasing MRSS in the month prior to baseline (mean +2.9, p=0.02). Seven out of ten patients completed 6 and 12 months of treatment. Seventy-one adverse events (AEs) including 2 serious AEs were observed, and 92 % of AEs were grade 1-2. Two patients discontinued the medication due to mild QTc prolongation. MRSS improved by a mean of 4.2 points (16 %) at 6 months and by 6.3 points (23 %) at 12 months in the 7 completers, p=0.02 and 0.01, respectively. Patients with a decrease in MRSS >20 % from baseline at 12 months (classified as improvers) had significantly higher expression of transforming growth factor beta receptor (TGFBR) and platelet-derived growth factor receptor beta (PDGFRB) signaling genes at baseline than non-improvers, and the expression of these genes significantly decreased in improvers post-treatment. Conclusion Nilotinib was well tolerated by the majority of patients in this study, with tolerability limited primarily by mild QTc-prolongation. Significant MRSS improvement was observed in these early, active patients, but is not conclusive of treatment effect given the open-label study-design and small number of patients in this pilot study. Improvers had higher levels of expression of genes associated with TGFBR and PDGFRB signaling at baseline, and a significant decrease in the expression of these genes occurred only in patients with higher MRSS improvement. The findings of this pilot study warrant more conclusive evaluation. Trial registration Clinicaltrials.gov NCT01166139, July 1, 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13075-015-0721-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jessica K Gordon
- Department of Rheumatology, Hospital for Special Surgery, 535 East 70th St, New York, NY, 10021, USA.
| | - Viktor Martyanov
- Geisel School of Medicine at Dartmouth, Department of Genetics, Remsen 7400, Hanover, NH, 03755, USA.
| | - Cynthia Magro
- Weill Cornell Medical Center, Department of Dermatopathology, 525 East 68th St, New York, NY, 10065, USA.
| | - Horatio F Wildman
- Weill Cornell Medical Center, Department of Dermatology, 1305 York Ave, New York, NY, 10021, USA.
| | - Tammara A Wood
- Geisel School of Medicine at Dartmouth, Department of Genetics, Remsen 7400, Hanover, NH, 03755, USA.
| | - Wei-Ti Huang
- Department of Rheumatology, Hospital for Special Surgery, 535 East 70th St, New York, NY, 10021, USA.
| | - Mary K Crow
- Department of Rheumatology, Hospital for Special Surgery, 535 East 70th St, New York, NY, 10021, USA.
| | - Michael L Whitfield
- Geisel School of Medicine at Dartmouth, Department of Genetics, Remsen 7400, Hanover, NH, 03755, USA.
| | - Robert F Spiera
- Department of Rheumatology, Hospital for Special Surgery, 535 East 70th St, New York, NY, 10021, USA.
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Rice LM, Padilla CM, McLaughlin SR, Mathes A, Ziemek J, Goummih S, Nakerakanti S, York M, Farina G, Whitfield ML, Spiera RF, Christmann RB, Gordon JK, Weinberg J, Simms RW, Lafyatis R. Fresolimumab treatment decreases biomarkers and improves clinical symptoms in systemic sclerosis patients. J Clin Invest 2015; 125:2795-807. [PMID: 26098215 DOI: 10.1172/jci77958] [Citation(s) in RCA: 246] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Accepted: 05/14/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND TGF-β has potent profibrotic activity in vitro and has long been implicated in systemic sclerosis (SSc), as expression of TGF-β-regulated genes is increased in the skin and lungs of patients with SSc. Therefore, inhibition of TGF-β may benefit these patients. METHODS Patients with early, diffuse cutaneous SSc were enrolled in an open-label trial of fresolimumab, a high-affinity neutralizing antibody that targets all 3 TGF-β isoforms. Seven patients received two 1 mg/kg doses of fresolimumab, and eight patients received one 5 mg/kg dose of fresolimumab. Serial mid-forearm skin biopsies, performed before and after treatment, were analyzed for expression of the TGF-β-regulated biomarker genes thrombospondin-1 (THBS1) and cartilage oligomeric protein (COMP) and stained for myofibroblasts. Clinical skin disease was assessed using the modified Rodnan skin score (MRSS). RESULTS In patient skin, THBS1 expression rapidly declined after fresolimumab treatment in both groups (P = 0.0313 at 7 weeks and P = 0.0156 at 3 weeks), and skin expression of COMP exhibited a strong downward trend in both groups. Clinical skin disease dramatically and rapidly decreased (P < 0.001 at all time points). Expression levels of other TGF-β-regulated genes, including SERPINE1 and CTGF, declined (P = 0.049 and P = 0.012, respectively), and a 2-gene, longitudinal pharmacodynamic biomarker of SSc skin disease decreased after fresolimumab treatment (P = 0.0067). Dermal myofibroblast infiltration also declined in patient skin after fresolimumab (P < 0.05). Baseline levels of THBS1 were predictive of reduced THBS1 expression and improved MRSS after fresolimumab treatment. CONCLUSION The rapid inhibition of TGF-β-regulated gene expression in response to fresolimumab strongly implicates TGF-β in the pathogenesis of fibrosis in SSc. Parallel improvement in the MRSS indicates that fresolimumab rapidly reverses markers of skin fibrosis. TRIAL REGISTRATION Clinicaltrials.gov NCT01284322.
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Christensen A, Khalique S, Cenac S, Fligelstone K, Mawdsley A, French T, Gordon JK, Baron M, Busman E, Steen VD, Saketkoo LA. SYSTEMIC SCLEROSIS RELATED CALCINOSIS: PATIENTS PROVIDE WHAT SPECIALISTS WANT TO LEARN. J La State Med Soc 2015; 167:158-159. [PMID: 27159488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Calcinosis is a disabling, rarely discussed manifestation of systemic sclerosis (SSc) for which the natural history and management is understood poorly. OBJECTIVES To develop a calcinosis specific patient reported outcome measure (PROM) that can be used for future clinical research to test the effects of therapy on scleroderma related calcinosis. METHODS Patients were selected for participation by their scleroderma physicians. Four focus groups and individual interviews were recorded and transcribed verbatim. Patients were asked to frame questions to help a physician learn if calcinosis was better, worse or the same. Patient transcripts underwent an iterative inductive process (no preconceived coding, content drives coding and analysis) by at least five independent analysts including at least one research team member with SSc. Concepts were triangulated to identify a comprehensive set of meaningful concepts with occurrence quantified per participant. RESULTS Twenty-three patients (22/23 female, 19/23 white, with mean disease duration 14.8 years) consented and were interviewed. Responses included concepts of self-management strategies and recurrent hypotheses relating calcinosis development to trauma, Raynaud's and cold exposure. We identified discrete concepts such as the perceived association between cold exposure, Raynaud's and calcinosis severity. Calcinosis tended to present along with or soon after SSc diagnosis and remained throughout disease duration - though was not yet compared to report of first Raynaud experience. CONCLUSIONS Patient observations and self-management behavior provide opportunities for experts to learn from and to preemptively educate physicians and patients. Patients are eager for self-management guidance. These concepts are the groundwork for PROM development. However, patients suggested a composite of scales anchored in pain, size, frequency, number and related impairment may reasonably serve as an interim instrument for SSc calcinosis.
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Affiliation(s)
- A Christensen
- Tulane University School of Medicine, New Orleans, LA
| | - S Khalique
- Louisiana University Health Sciences Center, New Orleans, LA
| | - S Cenac
- Louisiana University Health Sciences Center, New Orleans
| | - K Fligelstone
- Royal Free Hospital, Scleroderma Unit and The Scleroderma Society UK, London, UK
| | - A Mawdsley
- Raynaud's and Scleroderma - Care and Support, UK
| | - T French
- University of Utah, Salt Lake City, UT
| | | | - M Baron
- Jewish General Hospital, McGill University, Montreal, Canada
| | - E Busman
- Atlanta Scleroderma Support Group, Atlanta, GA
| | - V D Steen
- Georgetown University Medical Center, Washington, DC
| | - L A Saketkoo
- University Medical Center Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans
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