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Background: Belimumab (Benlysta) is currently approved for the treatment of active Lupus despite standard therapy. Few data are available on the efficacy of this drug in lupus nephritis (LN). Methods: 17 LN female followed in two Nephrology Italian Unit received belimumab for a median period of 36 months (range 6–42 months). The indications were: arthralgia in 3 patients, cutaneous manifestations in 2, residual proteinuria in 8, and the need to reduce steroids for severe side effects in 4. Of interest, 1 patient started therapy during Peritoneal Dialysis and continued after kidney transplantation due to non-responsive arthralgias. Results: Arthralgia and skin manifestations resolved in all patients. Proteinuria normalized in three patients and stabilized in all but one of the others. Steroids were indefinitely stopped in six patients (35%) and reduced to around 40% of the basal dosage in the other patients. During belimumab therapy, three extrarenal and one renal SLE flares were diagnosed accounting for a rate of renal flares of 0.02/patient/year. No major adverse events leading to therapy withdrawal occurred. Clinical case: Arthralgia resolved, immunological parameters improved and prednisone could be reduced within few months in the patient who started belimumab during peritoneal dialysis. After kidney transplantation belimumab was stopped but due to arthralgias unresponsive to standard immunosuppressive therapy it was restarted with success. Conclusions: Belimumab allows the achievement of complete response together with the withdrawal or the reduction of corticosteroids in almost all our patients. Of interest its satisfactory use in a patient in peritoneal dialysis and after kidney transplantation.

The outcome of patients with COVID‐19 improved over the pandemic, including patients with systemic rheumatic diseases. However, data on patients with systemic sclerosis (SSc) are lacking. This study aimed to assess the outcome of patients with both SSc and COVID‐19 over several waves. Patients with both SSc and COVID‐19 who were registered in the European Scleroderma Trials and Research group (EUSTAR) were collected between April 2020 and April 2021. Patients were assigned to waves 1, 2, or 3 depending on the date of their COVID‐19 diagnosis. Primary endpoints were death, intensive care unit stay, or ventilatory support (severe outcome). Subgroup analyses of patients who were hospitalized or died were conducted. General and SSc‐specific characteristics and treatment were compared over the waves. Descriptive statistics and multivariate logistic regression were applied. A total of 333 patients were included; 57 patients (17%) had a severe outcome, and 30 patients (9%) died. Compared to wave 1, significantly fewer patients with SSc suffered from severe COVID‐19 in waves 2 and 3 (28.2% vs 9.8% and 12.7%; P< 0.001), fewer patients required hospitalization (46.7% vs 19.6% and 25.5%; P< 0.001) or ventilatory support (24.0% vs 8.7% and 10.9%; P =0.001), and fewer patients died (15.7% vs 5.0% and 7.5%; P =0.011). Patients were significantly younger, more often men, had less frequent arterial hypertension, and less SSc cardiac involvement over waves 1 to 3. Patients received significantly less medium to high doses of corticosteroids as they did SSc treatment. The outcome of patients with both SSc and COVID‐19 improved significantly over time because of intrinsic and extrinsic factors.

Coronavirus disease-19 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), represents one of the biggest challenges of 21st century, threatening public health around the globe. Increasing age and presence of co-morbidities are reported risk factors for severe disease and mortality, along with autoimmune diseases (ADs) and immunosuppressive treatments such as haematopoietic stem cell transplantation (HSCT), which are also associated with adverse outcomes. We review the impact of the pandemic on specific groups of patients with neurological, rheumatological, and gastroenterological indications, along with the challenges delivering HSCT in adult and pediatric populations. Moving forward, we developed consensus-based guidelines and recommendations for best practice and quality of patient care in order to support clinicians, scientists, and their multidisciplinary teams, as well as patients and their carers. These guidelines aim to support national and international organizations related to autoimmune diseases and local clinical teams delivering HSCT. Areas of unmet need and future research questions are also highlighted. The waves of the COVID-19 pandemic are predicted to be followed by an “endemic” phase and therefore an ongoing risk within a “new normality”. These recommendations reflect currently available evidence, coupled with expert opinion, and will be revised according to necessary modifications in practice.

A randomized controlled trial (RCT) was performed to confirm preliminary uncontrolled data indicating that regional adipose tissue (AT) grafting (G) is effective in inducing ischemic digital ulcer (IDU) healing in patients with systemic sclerosis (SSc). SSc patients with IDUs were randomized to be blindly treated with AT-G or a sham procedure (SP). AT-G consisted of injection, at the base of the finger with the IDU, of 0.5–1 ml AT after centrifugation of fat aspirate. The SP consisted of false liposuction and local injection of saline solution. The primary endpoint was to compare the cumulative prevalence of healed IDUs in the two groups within the following 8 weeks. AT-G and the SP were carried out in 25 and 13 patients, respectively. The two groups were comparable for age, gender, disease duration, and SSc subtypes. IDU healing was observed in 23/25 and 1/13 patients treated with AT-G and the SP, respectively (p< 0.0001). The 12 patients who received the unsuccessful SP underwent a rescue AT-G. In all of them, IDU healing was observed after 8 weeks of observation. It was noticeable that in the AT-G-treated patients a significant reduction of pain intensity (measured by visual analogue scale) was recorded after 4 and 8 weeks (p< 0.0001 in all cases). Similarly, a significant increase of capillary numbers in the affected finger was recorded by nailfold videocapillaroscopy after 4 and 8 weeks (p< 0.0001 in both cases). This RCT strongly confirms that AT-G is effective in inducing IDU healing in SSc patients. ClinicalTrials.gov, NCT03406988. Registered retrospectively on 25 January 2018.

The potential value of mesenchymal stromal/stem cell therapy in treating skin fibrosis in scleroderma (systemic sclerosis) and of the caveolin-1 scaffolding domain peptide in treating lung, skin, and heart fibrosis is known. To understand how these observations may relate to differences between mesenchymal stromal/stem cells from healthy subjects and subjects with fibrosis, we have characterized the fibrogenic and adipogenic potential of adipose-derived mesenchymal stromal/stem cells from systemic sclerosis patients, from mice with fibrotic lung and skin disease induced by systemic bleomycin treatment, and from healthy controls. Early passage systemic sclerosis adipose-derived mesenchymal stromal/stem cells have a profibrotic/anti-adipogenic phenotype compared to healthy adipose-derived mesenchymal stromal/stem cells (low caveolin-1, high α-smooth muscle actin, high HSP47, low pAKT, low capacity for adipogenic differentiation). This phenotype is mimicked by treating healthy adipose-derived mesenchymal stromal/stem cells with transforming growth factor beta or caveolin-1 small interfering RNA and is reversed in systemic sclerosis adipose-derived mesenchymal stromal/stem cells by treatment with caveolin-1 scaffolding domain peptide, but not scrambled caveolin-1 scaffolding domain peptide. Similar results were obtained with adipose-derived mesenchymal stromal/stem cells from systemic sclerosis patients and from bleomycin-treated mice, indicating the central role of caveolin-1 in mesenchymal stromal/stem cell differentiation in fibrotic disease.

For many years primary Sjögren’s syndrome (pSS) has been considered an orphan disease, since no specific therapies were recognized as being capable of contrasting the development and progression of this disorder. The treatment of oral and ocular features, as well as of the systemic organ involvement, has been entrusted to the joint management of different subspecialty physicians, like ophthalmologists, otolaryngologists, dentists and rheumatologists. These latter subspecialty doctors are usually more involved in the treatment of systemic extraglandular involvement and, to do it, they have long been using the conventional therapies borrowed by the treatment schedules adopted in other systemic autoimmune diseases. The increasing knowledge of the biological pathways that are operative in patients with pSS, and the parallel development of molecular biology technology, have allowed the production and availability of a number of biological agents able to positively act on different disease mechanisms, and thus are candidates for testing in therapeutic trials. Meanwhile, the scientific community has made a great effort to develop new accurate and validated classification criteria and outcome measures to be applied in the selection of patients to be included and monitored in therapeutic studies.Some of the new-generation biotechnological agents have been tested in a number of open-label and randomized controlled trials that have produced in many cases inconclusive or contradictory results. Behind the differences in trial protocols, adopted outcome measures and predefined endpoints, reasons for such unsatisfactory results can be found in the large heterogeneity of clinical subtypes in the examined cohorts. The future challenge for a substantial advancement in the therapeutic approach to pSS could be to identify the pathologic mechanisms, outcome tools and biomarkers that characterize the different subsets of the disease in order to test carefully selected target therapies with the highest probability of success in each different clinical phenotype.

Some abnormalities in nailfold videocapillaroscopy (NVC), such as the presence of micro-haemorrhages (MHEs), micro-thromboses (MTs), giant capillaries (GCs) and reduction in the number of capillaries (nCs), suggest a disease activity (DA) phase in systemic sclerosis (SSc). In a previous paper, we showed that the number of micro-haemorrhages and micro-thromboses (the so-called NEMO score) was the NVC feature more closely associated with DA. The present study was aimed at validating the NEMO score as a measure of DA in patients with SSc. Two cohorts of 122 and 97 patients with SSc who were referred to two different rheumatology units, one in Milan and one in Naples, respectively, constituted the validation cohorts. The NEMO score, the total number of GCs and the mean nCs per digit were the parameters defined in each patient by eight-finger NVC. An expert operator analysed the NVCs in each of the participating units. The European Scleroderma Study Group (ESSG) index was used to define the DA level in each patient at the time of NVC examination. The NEMO score was the NVC parameter more strictly correlated with the ESSG score in both the Milan and Naples cohorts (p< 0.0001), and it was the only one among the NVC variables that gave a significant contribution in a logistic model where the ESSG score represented the dependent variable. ROC curve analysis confirmed that the NEMO score had the best performance in measuring DA. The AUC of the NEMO score was significantly greater than the AUCs obtained by plotting the sensitivity and specificity of the number of GCs and the mean nCs (p< 0.0001 in all cases). The NEMO score values that showed the best sensitivity-specificity balance in capturing patients with a relevant DA level were slightly higher in the Naples cohort than in the Milan cohort. This study confirms that the presence of a certain number of MHEs and MTs in NVC may be considered a strong warning signal of a current phase of DA in patients with SSc.

Mesenchymal stromal cells (MSCs) have received attention as an ideal source of regenerative cells because of their multipotent differentiation potential. Adipose tissue is an attractive source of MSCs. Recent studies have shown that autologous fat grafting may be effective in the treatment of systemic sclerosis (SSc), but no specific study exists that aimed at investigating whether adipose tissue-derived stromal cells (ADSCs) from SSc patients maintain normal phenotypic and functional characteristics. The purpose of the current study was to investigate whether ADSCs from patients with SSc (SSc-ADSCs) are phenotypically and functionally identical to those from healthy controls (HC-ADSCs). Adipose tissue samples were obtained from 10 patients with SSc and from 8 HCs. Both MSC populations were evaluated for their capacity to (a) express specific MSC surface antigens by flow cytometry analysis, (b) proliferate, (c) differentiate along the adipogenic and osteogenic lineages, (d) suppress in vitro lymphocyte proliferation induced by a mitogenic stimulus, and (e) support endothelial cell (EC) tube formation. ADSCs from SSc patients and HCs showed similar surface phenotype and multilineage differentiation capabilities. In PBMC proliferation inhibition assays, no significant differences were observed between SSc- and HC-ADSCs. Using ADSC/EC cocultures, both SSc- and HC-ADSCs improved tube formation by both HC- and SSc-ECs. This effect was enhanced under hypoxic conditions in all of the cocultures. SSc-ADSCs exhibited the same phenotypic pattern, proliferation and differentiation potentials, and immunosuppressive properties as those from HCs. The proangiogenic activity shown by SSc-ADSCs, namely, under hypoxic conditions, suggests that autologous ADSC grafting may represent a possible therapeutic option for SSc.

Systemic sclerosis (SSc) is one of the most complex connective tissue diseases. Although significant progress in the knowledge of pathogenic mechanisms and timely diagnosis, therapeutic options remain limited. The attempt to find new treatments for SSc has led researchers to investigate the potential of cellular therapies using autologous and allogeneic stem cells. Multipotent mesenchymal stromal cells (MSCs) are considered an attractive candidate for cell-based therapies. MSCs comprise a heterogeneous population of cells with multilineage differentiation potential that are preferentially able to home to the sites of damage, and secrete various cytokines and growth factors that can have immunomodulatory, angiogenic, anti-inflammatory and anti-apoptotic effects. MSCs from bone-marrow have been first extensively characterized. Adipose tissue represents an additional abundant and accessible source of stem cells. Compared with BM-MSCs, adipose-derived stromal/stem cells (ASCs) offer several advantages, including ease of isolation, less donor morbidity, relative abundance, and rapidity of expansion. For all these reasons, at present ASCs are one of the most attractive and promising sources of adult stem cells for cell therapy, finding a field of application in the treatment of SSc, too. This review will focus on the current applications and possible future perspectives of adipose tissue-cell therapies in SSc.

Systemic sclerosis (SSc) is one of the most complex connective tissue diseases. Although the pathogenesis of SSc still remains elusive, it is generally accepted that initial vascular injury due to autoimmunity might result in the constitutive activation of fibroblasts and fibrosis. All of these three processes interact and affect one another resulting in a polymorphous spectrum of clinical and pathologic manifestations of SSc. The disease pleomorphism poses numerous difficulties in defining the ideal outcomes to be used in clinical trials. Despite significant progress over the past decades, the clinical management of patients with SSc remains a challenge. Novel therapies are currently being tested in the treatment of SSc and have the potential for modifying the disease process and improving the clinical outcomes. However, the evaluation of the studies is still difficult, due to either the small size of included patients or the different types and phases of the scleroderma disease under scrutiny.

Digital ulcers (DUs) are a rather frequent and invalidating complication in systemic sclerosis (SSc), often showing a very slow or null tendency to heal, in spite of the commonly used systemic and local therapeutic procedures. Recently, stem cell therapy has emerged as a new approach to accelerate wound healing. In the present study, we have tentatively treated long-lasting and poorly responsive to traditional therapy SSc-related DUs by implantation of autologous adipose tissue-derived cell (ATDC) fractions. Fifteen patients with SSc having a long-lasting DU in only one fingertip who were unresponsive to intensive systemic and local treatment were enrolled in the study. The grafting procedure consisted of the injection, at the basis of the corresponding finger, of 0.5-1 ml of autologous ATDC fractions, separated by centrifugation of adipose tissue collected through liposuction from subcutaneous abdominal fat. Time to heal after the procedure was the primary end point of the study, while reduction of pain intensity and of analgesic consumption represented a secondary end point. Furthermore, the posttherapy variation of the number of capillaries, observed in the nailfold video capillaroscopy (NVC) exam and of the resistivity in the digit arteries, measured by high-resolution echocolor-Doppler, were also taken into account. A rather fast healing of the DUs was reached in all of the enrolled patients (mean time to healing 4.23 weeks; range 2-7 weeks). A significant reduction of pain intensity was observed after a few weeks (p< 0.001), while the number of capillaries was significantly increased at 3- and 6-month NVC assessment (p< 0.0001 in both cases). Finally, a significant after-treatment reduction of digit artery resistivity was also recorded (p< 0.0001). Even with the limitations related to the small number of patients included and to the open-label design of the study, the observed strongly favorable outcome suggests that local grafting with ATDCs could represent a promising option for the treatment of SSc-related DUs unresponsive to more consolidated therapies.

Joint and muscle pain are commonly observed in patients with primary Sjögren's syndrome (pSS). Different types of pain can be distinguished, that is, articular pain, neuropathic pain and widespread pain. Articular pain is due to more or less evident synovitis, usually involving peripheral joints such as hand joints, wrists, knees and ankles. Drugs used to treat rheumatoid arthritis, or lupus synovitis, are also employed for articular involvement in pSS.

Autologous fat tissue grafting (AFTG) has been successfully used in the treatment of different sclerotic conditions, including localized scleroderma. Patients with advanced systemic sclerosis (SSc)-related perioral thickening and mouth opening limitation are candidates for this therapeutic approach. AFTG of the lips was performed to improve mouth opening in patients with SSc. We enrolled in the study 20 female patients with diffuse SSc (median age 35 ± 15 years and 11 ± 10 years of disease duration). Two-milliliter fractions of autologous fat drawn from trochanteric or periumbilical areas were injected in eight different sites around the mouth. Baseline and after-treatment mouth opening changes were assessed by measuring interincisal distance and oral perimeter, while skin hardness was tested by digital durometer. Pre- and posttreatment modifications of microvascular architecture were assessed by counting capillaries in the inferior lip videocapillaroscopy (VC) images and by scoring the microvascular density (MVD) in anti-CD34/CD31 immunohistochemical (IH) stained perioral skin biopsy sections. Similarly, histological sections were examined to evaluate dermoepidermic junction (DEJ) modifications. Three months after treatment, both the interincisal distance and oral perimeter significantly increased (p< 0.001). At the same time, a significant skin neovascularization became evident, both considering the VC images (p< 0.001) and MVD scores in IH sections (p< 0.0001). Finally, some skin histological aspects also improved, as shown by the significant changes in DEJ flattening scores (p< 0.0001). The present study suggests that, in patients with SSc, AFTG can improve mouth opening and function, induce a neovascularization, and partially restore the skin structure.

Pulmonary involvement represents a major cause of death of systemic sclerosis (SSc) patients. Recent data suggest that tyrosine kinase inhibitors, such as imatinib, may be a therapeutic option for SSc patients. However, preliminary published clinical trials were inconclusive about imatinib efficacy and showed side effects. The purpose of this study was to verify efficacy and tolerability of low-dose imatinib on interstitial lung disease in a cohort of SSc patients unresponsive to cyclophosphamide therapy. Thirty consecutive SSc patients with active pulmonary involvement, unresponsive to cyclophosphamide, were treated with imatinib 200 mg/day for 6 months followed by a 6-month follow-up. A “good response” was defined as an increase of forced vital capacity (FVC) by more of 15% and/or increase of diffusing capacity of carbon monoxide (DLCO)>15% and PaO2> 90% of initial value and high-resolution computed tomography (HRCT)-scan pattern unchanged or improved. Twenty-six patients completed the study. Three patients died and one patient was lost to follow-up. Four patients (15.32%) had a good response, 7 worsened and 15 had a stabilized lung disease. Overall, 19 (73.07%) patients had an improved or stabilized lung disease. After a 6-month follow-up, 12 (54.5%) of the 22 patients showed an improved or stabilized lung disease. Lung function was stabilized in a large proportion of patients unresponsive to cyclophosphamide therapy and a beneficial outcome emerged from the analysis of HRCT lung scans. There was no significant improvement of skin involvement, and the low dose was well tolerated. These data provide useful suggestions to design future randomized clinical trials for SSc therapeutics. ClinicalTrials.gov NCT00573326. Registered 13 December 2007.

OBJECTIVE: Patients with systemic sclerosis (SSc) have significantly fewer and functionally impaired endothelial progenitor cells (EPC) in peripheral blood and bone marrow; further, endothelial apoptosis seems to play a primary role in the pathogenesis of vascular damage. We investigated whether the failure of bone marrow EPC is related to their apoptotic phenotype and analyzed the possible mechanisms inducing apoptosis. METHODS: The presence of apoptotic cells was investigated in bone marrow aspirates taken from patients with SSc; microvessel density (MVD) and the immunohistochemical expression of vascular endothelial growth factor (VEGF) were also measured in bone marrow biopsies. A correlation between EPC apoptosis and the presence of antiendothelial cell antibodies (AECA) was also investigated. RESULTS: We confirmed the presence of bone marrow EPC dysfunction in SSc, while hematopoiesis was not impaired. Bone marrow studies showed a high percentage of apoptotic progenitors, no signs of fibrosis or an altered MVD, and an increased VEGF index. The patients’ bone marrow plasma showed significant titers of AECA, and their presence correlated with that of apoptotic progenitors. These findings were further confirmed by an in vitro assay in which the apoptosis of normal progenitors was induced by the addition of AECA+ purified IgG. CONCLUSION: Our results showed that apoptosis in patients with SSc involves the source compartment of endothelial progenitors and correlates with AECA activity. These findings support the hypothesis that AECA may play a pathogenetic role by affecting the bone marrow EPC machinery that should repair the peripheral vascular lesions.

The antiphospholipid syndrome (APS) is an autoimmune disorder presenting with tissue injury in various organs related to large- or small-vessel thrombosis associated with antiphospholipid and antiprotein/phospholipid complex antibodies. Although the pathophysiology, diagnosis, and clinical scenario may seem clear and straightforward, a more detailed examination reveals a more complex and uncertain picture related to the management of APS. This article reviews the current situation relating to APS therapy by evaluating the different clinical features of the syndrome ranging from thrombosis to pregnancy complications together with new strategies and pharmacological approaches.

OBJECTIVE: To investigate whether statins may improve endothelial function in systemic sclerosis (SSc) by evaluating the effects of simvastatin on vasculogenesis [indicated by the expansion of circulating endothelial progenitor cells (EPC)] and the markers of vascular injury in the peripheral blood of patients with SSc. METHODS: Twenty SSc patients with normal cholesterol concentrations and 20 hypercholesterolemic subjects were allocated to receive 20 mg/day simvastatin for 12 weeks. Peripheral blood samples were collected before and 12 weeks after initiation of treatment, and 4 weeks after discontinuation. Five-parameter, 3-color flow cytometry was performed with a FacScan to enumerate EPC and mature circulating endothelial cells (CEC). Levels of soluble E-selectin, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, interleukin 6, and endothelin-1 were assessed by commercial ELISA. RESULTS: Simvastatin treatment significantly increased EPC in the hypercholesterolemic group, but failed to improve the EPC levels in the SSc patients, mainly in patients with late disease. Baseline levels of CEC were significantly higher in SSc patients compared with controls and at the end of the treatment they were significantly decreased. Regarding other markers of endothelial activation, we found that all the cytokine levels decreased in a statistically significant manner in the treated patients. CONCLUSION: Treatment with simvastatin results in rapid and significant improvement of measures of endothelial activation, suggesting a potential role of statins in the treatment of peripheral vascular disease in SSc. The lack of effect on increase of EPC confirms our previous findings of a defective endothelial stem cell recruitment in the bone marrow of SSc patients. This could indicate that the potential effectiveness of statins in SSc could mainly be ascribed to their effectiveness in modulating endothelial activation mechanisms.

It is still uncertain which, if any, immunologic parameters may help diagnose a renal flare of lupus nephritis. Anti-C1q antibody (Ab) titers have been elevated in patients with lupus with renal involvement, but little information is available on whether the titers are different in quiescent and active phases of lupus nephritis. In this study, we compared anti-C1q Ab titers with other serological test results in 48 patients with biopsy-proven lupus nephritis to assess which parameter could offer the best reliability for differentiating between quiescent and active phases of lupus nephritis. Serum C3 and C4 levels, as well as anti–double-stranded DNA, antiendothelial cell, anti-C1q, and antiphospholipid Ab titers, were evaluated in patients with quiescent renal disease (38 samples) and those with clinical evidence of renal activity (23 samples). Only anti-C1q Ab titers correlated with active renal disease in both univariate (P< 0.0001) and multivariate analysis (P< 0.0001), with a sensitivity of 87% and a specificity of 92%. In six patients, immunologic parameters were measured serially. In all patients, the high anti-C1q Ab titers returned to normal values after treatment-induced remission. The other serological parameters did not show a significant association with renal disease activity. In patients with biopsy-proven lupus nephritis, anti-C1q Ab titers appear to be strongly related to renal disease activity. Their measurement may be useful for confirming the diagnosis of renal flares of lupus nephritis.

Anticardiolipin (aCL) and anti-beta2-glycoprotein I(antiβ2GPI) antibodies have been shown in animal models as not cross-reacting antibody populations. This observation prompted us to prove if anti-β2GPI exist in human sera by using a reliable method and then to investigate if these are independent from aCl antibodies. We have developed a new ELISA for the detection of anti-β2GPI antibodies employing the coating of the protein in carbonate buffer to irradiated microtitre plates and the filtration of serum samples, that makes irrelevant the binding to the uncoated wells. IgG F(ab)2fragments from IgG positive sera were shown bind β2GPI, providing that the binding was a specific antibody binding, mediated by the antigen binding site of the antibody molecule; moreover the antibodies were not able to differentiate native and delipidated β2GPI coated plates, making a possible role of a phospholipid contaminant unlikely. On the other hand, the phosphorus content of native as well as delipitated β2GPI was undetectable. IgG, but not IgM, anti-β2GPI antibodies were classically inhibited by the addition of soluble β2GPI, while cardiolipin liposomes appear to modify the reaction in a completely different way, possibly by the described interaction between cardiolipin and β2GPI. The application of the new ELISA to the study of patients has shown that: (1) the presence of anti-β2GPI is statistically associated with the presence of aCL antibodies (P < 0.0001), (2) anti-β2GPI antibodies are related to the classical features of antiphospholipid syndrome (thrombosis: P < 0.001; fetal loss: P < 0.001) while, in this series of patients, aCl antibodies are not (thrombosis: P < 0.126; fetal loss: P < 0.061).

Patients with severe rapidly progressive systemic sclerosis (SSc) have a poor prognosis.

Background: Nailfold videocapillaroscopy (NVC) is a feasible method that allows the observation of the microvascular changes that mark the course of systemic sclerosis (SSc). In previous studies, we demonstrated that the NEMO score, i.e. the cumulative number of microhaemorrhages and microthromboses, is a good indicator of the steady-state level and overtime changes of disease activity (DA) in SSc. Objectives: To verify whether high NEMO scores, which mirror a very active microvascular derangement in the fingers, may be associated with the subsequent development of ischaemic digital ulcers (IDUs). Methods: The NEMO score was assessed at baseline (T0) in 98 patients with SSc, all classified according to the ACR-EULAR criteria. Of them, 90 were females, 48 had the limited and 50 had the diffuse cutaneous variant of SSc. Afterwards, the patients were closely followed up for 2 years, and the appearance of new IDUs recorded at any time of the follow-up. The T0-NEMO score values of patients who developed IDUs were compared to those of patients who did not. A receiver operating curve (ROC) was constructed, and the area under the curve (AUC) calculated by plotting the sensitivity and 1-specificity of the different NEMO score values in predicting the subsequent development of IDUs. Results: During the follow-up, 38 out of 98 patients developed one or more IDUs. The NEMO score at T0 was significantly higher in those who developed IDUs with respect to those who did not [median 14.5 (95% CI 11.0–21.5) and 4.5 (95% CI 4.0–6.0), respectively, p&lt; 0.0001]. The ROC curve derived from different T0-NEMO score values had an AUC of 0.79 (95% CI 0.69–0.86, p&lt; 0.0001). A NEMO score of ≥ 12 had a sensitivity of 83.3% (95% CI 71.5–91.7) and a specificity of 63.2% (95% CI 46.0–78.2), with positive (P) and negative (N) predictive (PV) values of 58.9% (95% CI 44.7–72.2) and 85.6% (71.8–94.4), respectively. A NEMO score of ≥ 16 had a sensitivity of 95.0% (95% CI 86.1–99.0) and a NPV of 93.4% (77.5–99.2). Conclusions: Being a valid tool to measure DA levels in SSc, the NEMO score also appears to be closely related to the subsequent development of IDUs in this disease.

Background: Mortality rate in patients infected by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) can be related to the presence of comorbidities like diabetes, cardiovascular and pulmonary diseases. On the contrary, few data exist on the impact of CoronaVirus Disease 2019 (COVID-19) on patients with rheumatic disorders, namely in those having pulmonary involvement and treated with immunosuppressive agents. The present survey is aimed at knowing the impact of COVID-19 in a cohort of patients with systemic sclerosis (SSc).Methods: Telephone interviews were carried out during the COVID-19 outbreak in patients with SSc followed in a Rheumatic Disease Unit in Italy. Patients were asked for confirmed SARS-CoV-2 infection, symptoms suggestive of COVID-19, and modification of their therapy.Results: A total number of 526 patients with SSc were contacted and interviewed. Of them, 270 and 256 had limited cutaneous and diffuse cutaneous SSc, respectively. Interstitial lung disease (ILD) was present in 45% of patients and most of them (68.2%) were treated with immunosuppressive therapy. Only two patients were hospitalized for COVID-19-related pneumonia, and one of them died despite invasive ventilator support. An additional 11 patients reported flu-like symptoms compatible with a mild form of COVID-19. Nobody modified the therapy during the COVID-19 outbreak.Conclusion: Despite the large prevalence of ILD and immunosuppressive therapies, which can be considered risk factors for the occurrence and severity of incidental viral infections, the impact of COVID-19, in terms of mortality rate and morbidity, does not appear particularly severe in this large cohort of patients with SSc. Possible mechanisms influencing this figure are discussed.

Background: In previous studies, we demonstrated that the NEMO score, i.e. the cumulative number of microhaemorrhages (MHEs) and microthromboses (MTs), observed in nailfold videocapillaroscopy was a good indicator of the steady state level of disease activity (DA) in patients with systemic sclerosis (SSc) when the European Scleroderma Study Group (EScSG) index was considered the gold standard. Aim of the study: To verify whether the NEMO score could be (i) a valid tool to assess DA, even when the modified European Scleroderma Trials and Research (EUSTAR) index was considered to be the comparator, and (ii) a sensitive method to capture the DA overtime changes. Patients and methods: The NEMO score and the EScSG and EUSTAR indices were contemporarily assessed at baseline (T0) and after a follow-up of 4–56 months (T1) in 98 patients with SSc. The differences (Δ) between the T1 and T0 values of the NEMO score and the EScSG and EUSTAR indices were calculated and compared to each other. Results: NEMO score values were very closely correlated with the corresponding values of the EScSG and EUSTAR indices both at T0 and T1 observations (p&lt; 0.0001 in all cases with the exception of the correlation with EScSG values at T1 (p&lt; 0.03)). The values of the two composite DA indices were also strictly related to each other in both T0 and T1 observations (p&lt; 0.0001). Conclusions: NEMO score proves to be a feasible, non-invasive, and valid tool to assess steady state levels and changes over time of DA in patients with SSc. Thus, it can represent an alternative or complementary method to measure this disease status entity in this disorder.

No relevant conflicts of interest to declare.

Introduction:Systemic sclerosis (SSc) is a chronic autoimmune disease with ongoing high disease related mortality. Three randomized controlled trials proofed efficacy of autologous stem cell transplantation (aHSCT) in patients with severe SSc and superiority over the standard cyclophosphamide pulse therapy. Treatment related mortality is a major point of criticism and different treatment regimen are used in different centers.

No relevant conflicts of interest to declare.

Introduction

High dose immunosuppressive therapy and hematopoietic stem cell transplantation (HSCT) has shown efficacy in severe or rapidly progressive systemic sclerosis (SSc) in phase 1 and 2 trials with durable responses in two thirds of patients (pts), while a recent phase 2 randomised trial in 19 SSc pts showed superior benefit of HSCT over iv pulse cyclophosphamide (Cy) on skin score and lung function.The ASTIS-trial (Autologous Stem cell Transplantation International Scleroderma trial) is a multinational prospective randomized controlled phase 3 trial, comparing safety and efficacy of HSCT versus Cy in early progressive dcSSc pts with disease duration of a) 4 years or less and evidence of organ involvement or b) of 2 years or less and evidence of systemic inflammation with or without major organ involvement. Major exclusion criteria were: concomitant severe SSc disease (mean PAP > 50 mmHg, DLCO < 40% predicted, creatinine clearance (CCl) <40 ml/min, LVEF <45%, uncontrolled arythmia, infection, previous Cy (>5gr iv or >3months oral) treatment), liver failure. Pts randomized to the transplant arm underwent mobilization with Cy 2×2 g/m2 + G-CSF 10mcg/kg/d, conditioning with Cy 200 mg/kg, rbATG 7.5 mg/kg, followed by reinfusion of CD34+ autologous HSCT. Controls were treated with 12× monthly iv pulse Cy 750 mg/m2. Crossing over was allowed after 2 years. The primary endpoint was event-free survival (EFS), defined as survival until death or development of major organ failure at 2 yrs. Toxicity according to WHO criteria and progression free survival (defined as worsening of modified Rodnan skin score, functional ability, major organ function) were the main secondary endpoints. The effects of treatment were analyzed on an ITT basis and by comparing EFS using the KM survival curves (using log-rank test) and Cox models.156 pts (female 59%), from 27 centers were enrolled in 10 countries from March 2001 until October 2009 and randomized to HSCT (n=79) or iv pulse Cy (n=77). Seventy-five pts in each arm started treatment, 70 pts in HSCT and 58 pts in control groups completed treatment. The median time (Interquartile Range (IR)) from randomization to completion of treatment was 93 (43.0) days in the HSCT and 338 (41.75) days in the control groups respectively. Baseline characteristics (mean (SD)) of the pts were: age 44 (11.2) yrs, SSc duration 1.4 (1.3) yrs, BMI 24 (14.4), Rodnan skin score 25 (8), HAQ 1.35 (0.8), prior Cy therapy 22%, creat cl 116 (39.5) ml/min, LVEF 65% (8.5), DLCO 59% (14), with no significant differences between the 2 arms.With data cut at 1 May 2012, median follow-up (IR) are 33 (42.0) and 27 (34.0) months in the HSCT and control groups respectively. Forty two events occurred : 18 in the HSCT group (16 deaths and 2 irreversible renal failures) and 24 in the control group (24 deaths). Event-free survival was time-dependent with a hazard ratio at 84 months of 0.22 (95% CI 0.08–0.58, P= 0.002). Eight deaths (including 1 during mobilization and 1 after conditioning) in the HSCT group were deemed treatment-related by the independent data monitoring committee with heart failure (3), ARDS (2), multiple organ failure (2) and pulmonary oedema (1) as the causes of death. In the control group, none died from treatment causes and most deaths were due to progressive disease. Eight pts in the control arm received rescue HSCT treatment, one of whom later died from secondary acute myeloid leukaemia. Two HSCT pts received rescue iv Cy therapy.The ASTIS-trial is the first international, investigator-initiated, phase 3 HSCT trial in early diffuse cutaneous systemic sclerosis. The data show that despite 10% treatment-related mortality, long term event-free survival and overall survival were better in the HSCT group than in the group treated with iv pulse cyclophosphamide.(Funded by the European Group for Blood and Marrow Transplantation, European League Against Rheumatism, AP-HP, NIHR, DIGR, Imtix-Sangstat, Miltenyi-Biotec, Amgen Europe; Current Controlled Trials number, ISRCTN 54371254).No relevant conflicts of interest to declare.

Abstract 964This icon denotes a clinically relevant abstract

Aim: Idiopathic myelofibrosis (IMF) is associated with an increased risk of pulmonary arterial hypertension (PAH). We investigated the prevalence of PAH in a large cohort of IMF patients and its possible association with some mechanisms known to be involved in PAH generation. Materials and methods: Systolic pulmonary arterial pressure (sPAP) was evaluated by transthoracic doppler echocardiography in 37 IMF patients (20 males and 17 females; median age 65.1 years, range 37–83). The patients with sPAP ≥35 mmHg were further evaluated by high-resolution lung CT, lung perfusion scintigraphy, arterial blood gas analysis and pulmonary function tests (PFT), including lung carbon monoxide diffusing capacity. The patients’ circulating endothelial cells (CECs: CD45−, CD146+, CD31+) and endothelial progenitor cells (EPCs: CD45−, CD133+, CD34+) were evaluated using 4-parameter 3-colour flow cytometry and compared with those of 11 age-matched healthy controls. Serum VEGF, ET-1, TGFβ, PDGF-AB and sE-selectin levels were also determined. Results: PAH (sPAP ≥35 mmHg) was documented in 13 patients (35%), six of whom (16% of the whole series) had mild PAH (sPAP ≥45 mmHg); three of the patients with PAH were symptomatic. No case of pulmonary hypertension was due to cardiac or lung disease, or thromboembolic events. Median EPC levels were higher in the IMF patients than controls (0.78/μL [range 0–4.3] vs 0.32/μL [range 0.11–0.65]; p=0.003), and lower in the IMF patients with PAH than in those with sPAP <35 mmHg (0.44/μL [range 0–2.73] vs 0.94/μL [range 0.13–4.3]; p=0.02). Additionally, EPC levels in the patients with PAH inversely correlated with SPAP (p=0.02). There were no significant differences in cytokine (ET1, PDGF-AB, TGFβ, sE-selectin) or CEC levels between the IMF patients and controls, or between the IMF patients with or without PAH. Median VEGF levels were higher in the IMF patients than in controls (1449 pg/L [range 266.9–2369.4] vs 281.2 pg/L [range 68.8–1151.7]; p=0.008) and higher in the patients with PAH than in those without (1782.8 pg/L [range 406.8–2306] vs 1037.6 pg/L [range 266.9–2369.4]; p<0.05). Conclusion: This study shows that PAH is frequent in IMF patients without any known pulmonary or heart complications, being moderate in a subset in whom close follow-up is advisable. IMF and PAH have abnormal angiogenesis in common, and the patients with IMF complicated by PAH had markedly high VEGF levels together with relatively low EPC levels. Our findings suggest that PAH in this setting is associated with abnormalities in angiogenic status rather than the direct endothelial damage expressed by the increased CEC shedding found in other diseases associated with PAH. These results support the hypothesis that common mechanism(s) may be involved in the pathogenesis of IMF and PAH, thus warranting studies of CEP clonality.

Aim: Idiopathic myelofibrosis (IMF) is associated with an increased risk of pulmonary arterial hypertension (PAH). We investigated the prevalence of PAH in a large cohort of IMF patients and its possible association with some mechanisms known to be involved in PAH generation.

Systemic Sclerosis (SSc) is a connective tissue disease characterized by early generalized microangiopathy and culminating in systemic fibrosis. Recent studies have provided evidence that SSc is associated with a reactive but ineffective angiogenesis, so that the disease finally leads to the irreversible loss of capillaries. Aim of the study was to investigate whether impaired vasculogenesis in SSc is due to defective characteristics in BM microenvironment. Peripheral blood (PB) samples were collected from 70 patients (pts): circulating endothelial progenitors (CEPs) were characterized as CD45−/CD133+ and evaluated by flow cytometry. BM samples were collected from 14 SSc pts and hematopoiesis evaluated by various assays. CD133+ cells were isolated by immunomagnetic sorting (IMS) and grown in order to induce endothelial differentiation. Long-term bone marrow cultures (LTBMC) were assessed and the number of stromal clonogenic precursors evaluated by a CFU-F (colony-forming unit fibroblast) assay. Mesenchymal stem cells (MSC) were separated by IMS for the expression of the nerve growth factor-receptor (NGF-R+) and grown in order to assess the clonogenic potential and the proliferative capacity, while their multipotential differentiation ability was determined after culture in different conditioned media. Phenotypic analysis of BM mononuclear cells showed a greater expression of the surface markers P1H12 and CD105 TGF-β receptor (1.2%±0.6 vs 0.5%±0.1 in normal controls, p=0.01 and 9.9%±5 vs 4.7%±3, p=0.02 respectively), but lower percentages of NGF-R+ stromal cell precursors (0.73±0.5 vs 1.61±0.6, p=0.02) and CD133+ cells (0.36%±0.4 vs 1.2%±0.8, p=0.05). On the contrary, the absolute number of CEPs in PB was higher in patients with SSc than in healthy controls (mean values 2.1 cells/μL vs 0.26 cells/μL, p=0.04). When BM CD133+ cells were grown in the presence of VEGF, only 3/12 cases gave endothelial differentiation, but always with a reduced proliferative ability. All pts showed a defective stromal compartment and a reduced number of BM stromal precursors, as detected by the LTBMC and by the lower CFU-F frequency (4%±3.2 vs 43%±19.8/1x10(e)6 LDMNCs, p=0.002 and 7±12.8 vs 69±61/1x10(e)5 NGF-R+ cells, p=0.01). Interestingly, NGF-R+ MSC overexpressed KDR and CD117 (26.4%±7.4 vs 4.6%±1.7, p=0.01 and 87.7%±5.1 vs 57.6%±11, p=0.03 respectively): when grown in the presence of VEGF they gave rise to endothelial colonies, only in 2/8 cases they formed a confluent layer with fibroblastic morphology but a reduced proliferative ability, while in the presence of adipogenic or osteogenic inductive media they failed to origin specific differentiation. Moreover, all “in vitro” differentiated endothelial cells even before activation showed high levels of CD62-E, VCAM-1 and CD105 expression, suggestive of the presence of increased levels of proangiogenic factors in BM. The results of this study provide evidence that patients with SSc have a stem cell defect involving both the hematopoietic and the stromal cells compartments. The higher expression of KDR on NGF-R+ cells suggests a role for VEGF in inducing endothelial differentiation of MSC, so resulting in a depletion of stromal precursors. The continuous recruitment of endothelial progenitors to sites of vascular injury, suggested by the high numbers of CEPs in PB, might lead to the irreversible BM damage we observed.

Systemic Sclerosis (SSc) is a connective tissue disease characterized by early generalized microangiopathy and culminating in systemic fibrosis. Recent studies have provided evidence that SSc is associated with a reactive but ineffective angiogenesis, so that the disease finally leads to the irreversible loss of capillaries. Aim of the study was to investigate whether impaired vasculogenesis in SSc is due to defective characteristics in BM microenvironment. Peripheral blood (PB) samples were collected from 70 patients (pts): circulating endothelial progenitors (CEPs) were characterized as CD45−/CD133+ and evaluated by flow cytometry. BM samples were collected from 14 SSc pts and hematopoiesis evaluated by various assays. CD133+ cells were isolated by immunomagnetic sorting (IMS) and grown in order to induce endothelial differentiation. Long-term bone marrow cultures (LTBMC) were assessed and the number of stromal clonogenic precursors evaluated by a CFU-F (colony-forming unit fibroblast) assay. Mesenchymal stem cells (MSC) were separated by IMS for the expression of the nerve growth factor-receptor (NGF-R+) and grown in order to assess the clonogenic potential and the proliferative capacity, while their multipotential differentiation ability was determined after culture in different conditioned media. Phenotypic analysis of BM mononuclear cells showed a greater expression of the surface markers P1H12 and CD105 TGF-β receptor (1.2%±0.6 vs 0.5%±0.1 in normal controls, p=0.01 and 9.9%±5 vs 4.7%±3, p=0.02 respectively), but lower percentages of NGF-R+ stromal cell precursors (0.73±0.5 vs 1.61±0.6, p=0.02) and CD133+ cells (0.36%±0.4 vs 1.2%±0.8, p=0.05). On the contrary, the absolute number of CEPs in PB was higher in patients with SSc than in healthy controls (mean values 2.1 cells/μL vs 0.26 cells/μL, p=0.04). When BM CD133+ cells were grown in the presence of VEGF, only 3/12 cases gave endothelial differentiation, but always with a reduced proliferative ability. All pts showed a defective stromal compartment and a reduced number of BM stromal precursors, as detected by the LTBMC and by the lower CFU-F frequency (4%±3.2 vs 43%±19.8/1x10(e)6 LDMNCs, p=0.002 and 7±12.8 vs 69±61/1x10(e)5 NGF-R+ cells, p=0.01). Interestingly, NGF-R+ MSC overexpressed KDR and CD117 (26.4%±7.4 vs 4.6%±1.7, p=0.01 and 87.7%±5.1 vs 57.6%±11, p=0.03 respectively): when grown in the presence of VEGF they gave rise to endothelial colonies, only in 2/8 cases they formed a confluent layer with fibroblastic morphology but a reduced proliferative ability, while in the presence of adipogenic or osteogenic inductive media they failed to origin specific differentiation. Moreover, all “in vitro” differentiated endothelial cells even before activation showed high levels of CD62-E, VCAM-1 and CD105 expression, suggestive of the presence of increased levels of proangiogenic factors in BM. The results of this study provide evidence that patients with SSc have a stem cell defect involving both the hematopoietic and the stromal cells compartments. The higher expression of KDR on NGF-R+ cells suggests a role for VEGF in inducing endothelial differentiation of MSC, so resulting in a depletion of stromal precursors. The continuous recruitment of endothelial progenitors to sites of vascular injury, suggested by the high numbers of CEPs in PB, might lead to the irreversible BM damage we observed.