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BackgroundVascular involvement in Systemic Sclerosis (SSc) is known to start even before clinical diagnosis, to drive Digital Ulcer disease and later in the disease natural history to cause Pulmonary Artery Hypertension, among other manifestations. Despite the proven immune origin of Scleroderma, vascular involvement is not currently targeted by immune driven interventions. Similarly, little data is available on immune or inflammatory biomarkers and outcome measures of vascular disease in SSc. Digital Artery Volume Index (DAVIX) has been recently proposed as imaging surrogate outcome measure of vascular disease activity in SSc [1].ObjectivesHere we aimed to determine the value of DAVIX as overall biomarker of vascular involvement and its correlation with Type I IFN activation in patients with SSc.MethodsEighty-six patients attending our Scleroderma Program were consecutively enrolled for the evaluation of serum IFN score as previously described [2]. Clinical features including presence or history of Digital Ulcers, Presence of Pulmonary Artery Hypertension (PAH) and DLCO, were recorded. Digital Artery Vascular Index (DAVIX) of the dominant hand’s fingers was calculated using time of flight magnetic resonance images analysed through IAG proprietary algorithm, as previously described [1]. Medians were compared by Mann-Whitney-Wilcoxon test, correlation with clinical parameters was performed using Spearman’s or Pearson test, as appropriate (R).ResultsSixty-two patients fulfilled the 2013 ACR/EULAR classification criteria for SSc (diffuse cutaneous 24.6%, limited cutaneous 75.4%) whereas 23 were classified as Very Early Diagnosis of Scleroderma (Criteria score between 6 and 8). Twenty-three patients had DU disease (History of DUs in the previous 24 weeks, presence of DUs at baseline assessment, or onset of new DUs during the following 24 weeks). Eighteen patients had reduced DLCO (1.8 (suspected PAH). DAVIX showed a negative correlation with disease duration (r=-0.33 and p=.003) and with FVC/DLCO ratio (r=-0.34 and p=.009). Patients with DU disease presented lower DAVIX than patients without (p=.018).DAVIX showed a significant correlation with Serum IFN score (r=-0.24, pConclusionDAVIX correlated both with presence of Digital Ulcer disease, DLCO and disease duration. The correlation of DAVIX and Serum IFN score does support the notion of innate immune involvement in vascular disease manifestations of SSc. Prospective testing in the context of Randomised controlled trial will determine the value of DAVIX as surrogate outcome measure of vascular disease severity in SSc.References[1]Gjeloshi K, et al. Arthritis Rheumatol. 2020.[2]Hinchcliff M et al. Arthritis Rheumatol. 2021.Disclosure of InterestsStefano Di Donato: None declared, Mike Hughes: None declared, Giuseppina Abignano: None declared, Giovanni Lettieri: None declared, Rebecca Ross: None declared, Enrico De Lorenzis: None declared, Philip O’Connor: None declared, Olga Kubassova Shareholder of: IAG Image Analysis Group, CEO, Francesco Del Galdo: None declared

BackgroundLinking novel therapeutic targets for diffuse cutaneous Systemic Sclerosis (dcSSc) to markers of disease severity and clinical outcome will enable directing the right therapeutic agents to the appropriate patient populations. Such correlation will also support patient stratification in clinical trials, increasing their informative value and success rates.CCL24 is a chemokine within the Eotaxin family, that has been shown to have a dual pro-inflammatory and pro-fibrotic role in SSc. CCL24 and its receptor, CCR3, were found to be over-expressed in SSc skin and serum samples. In-vivo CCL24 blockage was associated with reduction of bleomycin induced skin and lung injury.ObjectivesWe aimed to study the role of CCL24 in dcSSc using patient cohorts, by correlating its serum levels to disease activity markers and disease progression.MethodsRetrospective and longitudinal dSSc patients’ cohorts were analyzed for CCL24 circulating levels, clinical measurement and disease related bio-markers.ResultsIn a retrospective cohort of 56 dcSSC patients, CCL24 serum levels were significantly higher in patients that had positive anti topoisomerase antibody (ATA) compared to patients with negative ATA. In addition, within the ATA positive patients, ones that had high serum CCL24 levels (≥1500 pg/ml) also presented significantly higher fibrotic activity reflected by a higher enhanced liver fibrosis (ELF) score compared to ATA positive patients with low CCL24 (In a second longitudinal cohort of 66 patient, baseline CCL24 levels positively correlated with ELF score (r=0.42, p≤0.0005). Patients with high baseline CCL24 serum levels were also more likely to experience lung disease progression, measured by reduction in forced vital capacity (FVC) during 12 months(7 out of 17 patients with CCL24 ≥ 1500 pg/ml had at least -5% reduction of FVC). Consistent with these data, patients with normal FVC at baseline (>80% predicted) which experienced worsening in the next 12 months (at least 7%) had a statistically significant higher baseline serum CCL24 (Average 2,275 pg/ml) compared to patients that had no worsening in FVC over time (average 962 pg/ml, p≤0.001). Interestingly, the same group showed an even steeper reduction in DLCO % predicted (-6.8% vs -0.2%, p≤0.05).ConclusionWe show here using two dcSSc patient cohorts, that CCL24 serum levels are correlated with disease activity and worse prognosis reflected by high fibrotic activity and deterioration of lung function over time. This reverse translational study supports the role of CCL24 as a therapeutic target for dcSSc and it has informed a phase 2 study testing CM-101, a CCL24 neutralizing antibody, in dcSSc patients to be started in 2022.Disclosure of InterestsMichal Segal Salto Employee of: Chemomab Therapeutic Ltd., Adi Mor Employee of: Chemomab Therapeutics Ltd., Francesco Del Galdo Consultant of: Chemomab Therapeutic Ltd., Grant/research support from: Chemomab Therapeutic Ltd.

BackgroundRisk-stratification is key in a heterogeneous disease like systemic sclerosis (SSc). Until now, SSc patients are stratified according to the extent of skin involvement into limited cutaneous, diffuse cutaneous and sine scleroderma subtypes. However, this classification remains inaccurate to capture disease heterogeneity. Autoantibodies are found in more than 90% of the patients and can be detected before onset of the disease. Among them, three predominant and specific antibodies are used: anti-centromere, anti-Scl70 and RNA polymerase III antibodies.ObjectivesTo compare the performances of stratification into LeRoy’s cutaneous subtypes versus autoantibody status in SSc versus combination of cutaneous subtypes and autoantibodies status.MethodsPatients from the EUSTAR database were classified either as (i) limited cutaneous, diffuse cutaneous or sine scleroderma (based on the recording made by the treating physician) or (ii) according to autoantibodies with the following subclassifications: (1) no specific autoantibodies, (2) isolated ANA, (3) anti-centromere antibodies, (4) anti-Scl70 antibodies and (5) anti-RNA polymerase III antibodies or (iii) according to combination of cutaneous subset and auto-antibodies. The respective performance of each model to predict overall survival (OS), progression-free survival (PFS), disease progression and different organ involvements was assessed and the three models were compared by the area under the receiver operating characteristic curve (AUC 95%CI) and the net reclassification improvement (NRI). Missing data were imputed through multiple imputation using chain equations.ResultsIn all, 10’711 patients were included: 84.6% females, mean age: 54.4±13.8 years, mean disease duration: 7.9±8.2 years. In the prospective analysis (n= 6’467 to 7’829 according to the outcome), after a mean follow-up of 56 months and a mean of three visits per patient, we did not identify any difference in AUC between the cutaneous-based model and the antibody-based model for prediction of OS and disease progression. However, the NRI showed a significant improvement in prediction of OS (0.57 [0.46-0.71] vs. 0.29 [0.19-0.39]) and disease progression (0.36 [0.29-0.46] vs. 0.21 [0.14-0.28]) at 4 years using the antibody-based model. Regarding prediction of each organ involvement in longitudinal analyses, the antibody-based model showed better performance than the cutaneous-one for renal crisis (AUC: 0.719 [0.696-0.742] vs. 0.664 [0.643-0.685]), with the highest association observed with anti-RNA polymerase III (OR: 7.47 [1.63-34.24], p= 0.010). Similarly, the antibody-based model was better than the cutaneous model in predicting lung fibrosis (AUC 0.719 [0.715-724] vs. 0.653 [0.647-0.659]) and restrictive lung fibrosis (AUC 0.759 [0.749-0.766] vs. 0.711 [0.701-0.721]) which were both associated with anti-Scl70 antibodies (OR: 9.29 [8.17-10.55] and 7.92 [5.37-11.69], respectively, pConclusionAuto-antibody status outperforms the common cutaneous subsetting to risk-stratify SSc patients in the EUSTAR cohort. This easily performed subclassification using autoantibodies specific status can be used by the clinicians to risk-stratify their patients and to adapt disease monitoring in routine practice.Disclosure of InterestsMuriel Elhai Speakers bureau: BMS outside of the submitted work, Marouane Boubaya: None declared, Nanthara Sritharan: None declared, Alexandra Balbir-Gurman: None declared, Elise Siegert: None declared, Eric Hachulla: None declared, Jeska de Vries-Bouwstra: None declared, Gabriela Riemekasten: None declared, Jörg H.W. Distler: None declared, Douglas Veale: None declared, Edoardo Rosato: None declared, Francesco Del Galdo: None declared, Fabian A Mendoza: None declared, Daniel Furst Consultant of: Abbvie, Novartis, Pfizer, R-Pharm, Grant/research support from: Emerald, Kadmon, PICORI, Pfizer,Prometheus, Talaris, Mitsubishi, Carlos De la Puente Bujidos: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Armando Gabrielli: None declared, Oliver Distler Speakers bureau: Bayer, Boehringer Ingelheim, Janssen, Medscape, Consultant of: Abbvie, Acceleron, Alcimed, Amgen, AnaMar, Arxx, AstraZeneca, Baecon, Blade, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, 4P Science, Galapagos, Glenmark, Horizon, Inventiva, Kymera, Lupin, Miltenyi Biotec, Mitsubishi Tanabe, MSD, Novartis, Prometheus, Roivant, Sanofi and Topadur, Grant/research support from: Kymera, Mitsubishi Tanabe, Boehringer Ingelheim, Coralie Bloch-Queyrat: None declared, Yannick Allanore Consultant of: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis, Grant/research support from: Actelion, Bayer, BMS, Boehringer-Ingelheim, Inventiva, Roche, Sanofi-Aventis

BackgroundLeRoy’s classification defines two main subsets of Systemic Sclerosis (SSc) based on the extent of skin fibrosis: limited cutaneous SSc (lcSSc) with skin thickening sparing the trunk and distal to the elbow and knees, and diffuse cutaneous SSc (dcSSc) with proximal and distal skin thickening. These two subsets notably differ in terms of survival and frequency of visceral involvement, dcSSc being less prevalent but having a higher mortality rate with more frequent visceral manifestations. SSc sine scleroderma (ssSSc) is a third subset initially described by Rodnan et al. and characterized by the absence of skin fibrosis but with the existence of SSc-associated visceral manifestations.ObjectivesThis study aimed to characterise the main clinical features of patients with ssSSc in comparison with the lcSSc and dcSSc subsets within the international EUSTAR database.MethodsAll patients from the EUSTAR database fulfilling the ACR2013 or 1980 classification criteria for SSc assessed by the modified Rodnan Skin score (mRSS) at inclusion and with at least one follow-up visit were eligible. Sine scleroderma (ssSSc) was defined by the absence of skin thickening (mRSS=0 and no sclerodactyly) at all available visits. The clinical characteristics of these ssSSc patients were compared to those of patients with lcSSc and dcSSc with similar disease duration at last follow-up visit. Descriptive statistics were applied.ResultsAmong the 4263 patients fulfilling the inclusion criteria, 376 (8.8%) were classified as ssSSc. Among them, 40.3% had puffy fingers, 39.4% had interstitial lung disease (ILD), 1.6% had a history of scleroderma renal crisis at inclusion visit. At last available visit, in comparison with 708 lcSSc and 708 dcSSc with the same disease duration, ssSSc patients had a lower prevalence of previous or current digital ulcers (28.2% versus 53.1% in lcSSc (PConclusionThis study highlights that ssSSc patients account for almost 10% of SSc patients with milder disease severity compared to both lcSSc and dcSSc.AcknowledgementsThe authors thank all EUSTAR collaboratorsDisclosure of InterestsAlain LESCOAT: None declared, Suiyuan Huang: None declared, Patricia Carreira: None declared, Elise Siegert: None declared, Jeska de Vries-Bouwstra: None declared, Jörg H.W. Distler: None declared, Vanessa Smith: None declared, Francesco Del Galdo: None declared, Branimir Anic: None declared, Nemanja Damjanov: None declared, Simona Rednic: None declared, Camillo Ribi: None declared, DOMNIQUE FARGE: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: Actelion, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Consultant of: Actelion, ARXX, Bayer, Boehringer Ingelheim, Jansen, Lilly, Medscape, Merck Sharp & Dohme, Roche, Grant/research support from: Boehringer Ingelheim, Armando Gabrielli: None declared, Oliver Distler: None declared, Dinesh Khanna: None declared, Yannick Allanore: None declared

BackgroundActivation of melanocortin 1 receptor (MC1R) is known to have broad anti-inflammatory and anti-fibrotic effects. The bleomycin (BLM)-induced skin fibrosis murine model is well-established for systemic sclerosis (SSc). α-melanocyte-stimulating hormone, an endogenous ligand of MC1R, inhibits skin fibrosis and MC1R knock-out enhances skin fibrosis in this model. These pieces of evidence suggest that MC1R agonism has potential in the treatment of SSc.ObjectivesDersimelagon phosphate (MT-7117) is an investigational small molecule that is an orally administered, selective agonist for MC1R. The purpose of this study is to investigate the potential of MT-7117 as a therapeutic agent for SSc by evaluating its efficacy and mechanism of action in complementary preclinical models. The expression and distribution of MC1R in the skin of SSc patients was investigated.MethodsThe effects of MT-7117 on skin fibrosis and lung inflammation were evaluated in BLM-induced SSc murine models that were optimized for prophylactic and therapeutic evaluation. Microarray-based gene expression analysis and serum protein profiling were performed to investigate the mechanism of action of MT-7117 in the BLM-induced SSc models. The effect of MT-7117 on TGF-β-induced activation of human dermal fibroblasts was evaluated in vitro. Immunohistochemical analyses of MC1R expression in skin samples from SSc patients were performed.ResultsProphylactic treatment with MT-7117 (≥0.3 mg/kg/day p.o.) significantly inhibited the increase in collagen content of the skin, the serum level of surfactant protein D, and the weight of the lungs from BLM-induced skin fibrosis and lung inflammation model. Therapeutic treatment with MT-7117 (≥3 mg/kg/day p.o.) significantly suppressed skin thickening and the numbers of myofibroblasts in pre-established BLM-induced skin fibrosis model. Gene array analysis using the BLM-induced SSc model demonstrated changes in numerous categories related to macrophages, monocytes, and neutrophils, followed by endothelial cell-related categories after treatment with MT-7117. In the analysis that focused on biological functions, categories of inflammatory response, activation of antigen-presenting cells, angiogenesis, atherosclerosis, vasculogenesis, and vaso-occlusion were suppressed by MT-7117. In the analysis that focused on molecular signaling pathways, triggering receptor expressed on myeloid cells-1, IL-6, and oncostatin M involved in inflammation, and peroxisome proliferator-activated receptor that is related to fibrosis were all affected by MT-7117. Serum protein profiling using BLM-induced SSc model revealed that multiple SSc-related biomarkers including P-selectin, osteoprotegerin, cystatin C, growth and differentiation factor-15 and S100A9 were suppressed by MT-7117. MT-7117 inhibited the activation of human dermal fibroblasts by suppressing TGF-β-induced ACTA2 (encoding α-smooth muscle actin) mRNA elevation in vitro. Immunohistochemical analyses showed that MC1R positivity was observed in 40 of 50 diffuse cutaneous SSc patients. MC1R was expressed by monocytes/macrophages, neutrophils, blood vessels (endothelial cells), fibroblasts, and epidermis (keratinocytes) in the skin of SSc patients.ConclusionMT-7117 demonstrates disease-modifying effects in preclinical models of SSc. Investigations of its mechanism of action and target expression analyses indicate that MT-7117 exerts its positive effects by affecting the pathologies of inflammation, vascular dysfunction, and fibrosis through inflammatory cells, endothelial cells, and fibroblasts. In view of its potent beneficial impact on all these three main pathologies of SSc, MT-7117 is a potential therapeutic agent for the treatment of clinically challenging SSc, which has diverse and difficult to treat symptoms. A phase 2 clinical trial investigating the efficacy and tolerability of MT-7117 in patients with early, progressive diffuse cutaneous SSc is currently in progress.Disclosure of InterestsMasahiro Kondo Employee of: Mitsubishi Tanabe Pharma Corporation, Tsuyoshi Suzuki Employee of: Mitsubishi Tanabe Pharma Corporation, Yuko Kawano Employee of: Mitsubishi Tanabe Pharma Corporation, Shinji Kojima Employee of: Mitsubishi Tanabe Pharma Corporation, Masahiko Miyashiro Employee of: Mitsubishi Tanabe Pharma Corporation, Atsuhiro Matsumoto Employee of: Mitsubishi Tanabe Pharma Corporation, Gabriela Kania: None declared, Przemyslaw Blyszczuk: None declared, rebecca ross: None declared, Panji Mulipa: None declared, Francesco Del Galdo Grant/research support from: Prof. F. Del Galdo received fees and research support from Abbvie, AstraZeneca, Boehringer-Ingelheim, Capella, Chemomab, Kymab, Janssen and Mitsubishi-Tanabe., Yun Zhang: None declared, Jörg H.W. Distler Grant/research support from: Prof. J.H.W. Distler received consulting fees, lecture fees, and/or honoraria from Actelion, Active Biotech, Anamar, ARXX, aTyr, Bayer Pharma, Boehringer Ingelheim, Celgene, Galapagos, GSK, Inventiva, JB Therapeutics, Medac, Pfizer, Sanofi-Aventis, RedX, RuiYi and UCB. J. H. W. Distler is stock owner of 4D Science and Scientific head of FibroCure.

BackgroundPatient Reported Outcomes (PROs) are central to measure how patients feel and function especially when determining the effect of disease modifying agents. In patients with Systemic Sclerosis associated Interstitial Lung Disease (SSc-ILD), dyspnea is the main driver of HAQ decline but the effect of reduced lung function on both generic and specific measures of functional impairment is not well defined, and there are many potential confounding biases that could distort the apparent extent and direction of this relationship. Moreover, collider biases potentially induced by selection into the cohort and in clinical trials can also play a role.ObjectivesTo define within the EUSTAR database, the correlation of Forced Vital Capacity (FVC) and functional impairment PROs and identify potential confounders to be considered in casual inference studies.MethodsA cross-sectional analysis included for each patient with SSc-ILD (by X-ray and/or HRCT) in the EUSTAR registry the last visit with at least one PRO (Health Assessment Questionnaire Disability Index [HAQ-DI], Cochin hand function scale [CHFS] and/or dyspnoea visual analogue scale [VAS]) and % predicted FVC (%pFVC), if available. Patients with LVEF≤50% or pulmonary arterial hypertension at RHC were excluded. SSc-ILD with restricted lung volume was defined as %pFVC≤70 [1]. Spearman’s correlation analysis was performed. Results of this analysis and literature review were integrated to design a directed acyclic graph (DAG) and identify the appropriate confounder adjustment set for the total causal effect of FVC on functional impairment PROs.ResultsAmong 17.338 SSc patients in the EUSTAR registry (extracted in November 2019), 727 SSc-ILD patients fulfilled the inclusion criteria (median %pFVC 90 (IQR 74-104), median %pDLCO 60 (IQR 47-52)). Patients with %pFVCTable 1.Results are reported as number/number available (%) for dichotomic variables, or as median (IQR) (n available) for continuous variables.%pFVC≥70 (n=578)%pFVC)Age at disease onset (years)60.6 (52.3-69.3) (546)52.5 (45.6-63-7) (137)Disease duration (months)134.4 (77.5-212.2) (546)110.3 (66.3-199.7) (137)Male sex84/578 (14.5)32/149 (21.5)Anti-Scl70+231/468 (40.7)81/122 (66.4)Smoker ever52/389 (13.4)17/107 (15.9)Caucasian ethnicity545/569 (95.8)131/145 (90.3)dcSSc167/559 (29.9)74/147 (50.3)Oesophageal symptoms319/571 (55.9)93/147 (63.3)Muscle weakness78/565 (13.8)37/149 (24.8)CRP elevation141/540 (26.1)53/134 (39.6)Elevated sPAP (ECHO)45/456 (9.9)21/121 (17.2)Pericardial effusion2/448 (0.4)4/110 (3.6)Diastolic function abnormality151/431 (35.0)31/102 (30.4)Conduction blocks78/480 (16.3)35/120 (29.2)%pDLCO62 (52-74) (527)42 (35-53) (118)CHFS7 (1-23) (493)16 (2-34.8) (114)HAQ-DI0.63 (0.13-1.13) (578)1.25 (0.38-2) (139)VAS dyspnoea (0-100)15 (10-45) (391)40 (20-70) (109)NYHA stage 3/447/561 (8.4)37/143 (25.9)Subsequently, we created a DAG showing the proposed causal pathway considered relevant to the relationship between FVC and HAQ (Figure 1).ConclusionLung function as measured by FVC appears to correlate with worse patient-reported function in our unadjusted analysis of the large multicentre EUSTAR dataset. However, to estimate the total causal effect we must consider a multitude of potentially confounding factors, which need to be integrated and analysed in a causal inference framework. The proposed DAG will inform the development of simulations of the potential impact of bias (confounding, collider and omitted variable) on effect estimates we could obtain from EUSTAR cohort.References[1]Goh NS, et al. Am J Respir Crit Care Med, 2008.Disclosure of InterestsMaria Grazia Lazzaroni Grant/research support from: Research grant from Boehringer-Ingelheim, Michelle Wilson Grant/research support from: Research grant from Boehringer-Ingelheim, Elizabeth Hensor: None declared, Jörg H.W. Distler: None declared, Giovanna Cuomo: None declared, Elise Siegert: None declared, Ulf Müller-Ladner: None declared, Yannick Allanore: None declared, Maria Joao Salvador: None declared, Branimir Anic: None declared, Ulrich Walker: None declared, László Czirják: None declared, Camillo Ribi: None declared, Cristina-Mihaela Tanaseanu: None declared, Armando Gabrielli: None declared, Anna-Maria Hoffmann-Vold: None declared, Oliver Distler: None declared, Francesco Del Galdo: None declared

Background:In SSc, ILD is a major cause of morbidity and mortality. High resolution computed tomography (HRCT) is the gold standard for the diagnosis. Predictors of ILD onset are eagerly awaited to improve SSc-ILD management. Pulmonary function test (PFTs) are routinely performed to measure lung function changes.Objectives:Our aim was to investigate the performance of DLCO (diffusing capacity of lung carbon monoxide) and FVC (forced vital capacity) in predicting the development of SSc-ILD.Methods:The longitudinal data of DLCO, FVC and ILD on HRCT of SSc patients from the EUSTAR database were evaluated at baseline (t0), after 12 (±4) (t1) and 24 (±4) (t2) months. Patients with negative HRCT for any sign of ILD both at t0 and t1 were included. Patients who presented or developed pulmonary hypertension during the study period were excluded. At baseline, demographic data, disease duration from Raynaud’s onset, disease subsets, autoantibodies and other laboratory and instrumental data were recorded.Results:474/17805 patients were eligible for the study (403 females, 71 males): 26.0% dcSSc, 58.3% lcSSc, 220 (48.0%) patients with positive anticentromere antibodies (ACA) and 117 (25.4%) with positive antitopoisomerase I antibodies (Topo-I abs). Among all enrolled patients, 46 (9.7%) developed HRCT signs of ILD at t2. Patients with Topo-I abs showed an association with ILD development at t2 (16.7% vs 7.8%, p=0.0031), contrarily ACA positive patients were negatively associated with ILD appearance after 2 years of follow-up (4.4% vs 14.4%, p=0.0001). Positive t2 HRCT patients had a significant lower value of DLCO and FVC at all three assessments when compared to patients with a negative HRCT at t2 (Table 1) and both t0 DLCO and FVC values negatively correlated with ILD development (Table 1). The mean t0 to t1 change (Δ) of DLCO in patients with negative t2 HRTC and positive t2 HRCT were -0.5 (±12.6) and -1.0 (±15.1), respectively. The mean t0 to t1 ΔFVC in patients with negative t2 HRTC and positive t2 HRCT were -0.2 (±10.6) and 0.1 (±11.5), respectively. None of them predicted the appearance of ILD at t2 (ΔDLCO: OR (IC) 0.997 (0.97-1.02), p=0.8024; ΔFVC OR (IC) 1.002 (0.97-1.03), p=0.8664). The data showed an association between t0 DLCO value0 FVC value0 DLCOConclusion:Our data suggest that an impaired baseline DLCO (Table 1.DLCO and FVC values at t0, t1 and t2 values in patients with positive or negative HRCT for ILD at t2 and their statistical differences.Patients without ILD at t2 (mean±SD)Patients with ILD at t2 (mean±SD)OR (95%CL)p-valueDLCO at t079.0 ± 16.669.9 ± 17.40.97 (0.95 - 0.99)0.0006DLCO at t178.4 ± 16.868.9 ± 18.60.97 (0.95 - 0.98)0.0005DLCO at t278.0 ± 17.065.1 ± 19.10.95 (0.93 - 0.97)FVC at t0102.2 ± 17.394.6 ± 16.20.97 (0.96 - 0.99)0.0052FVC at t1101.9 ± 17.994.7 ± 16.50.98 (0.96 - 0.99)0.0092FVC at t2101.6 ± 17.694.5 ± 20.00.98 (0.96 - 1)0.0126Disclosure of Interests:Gemma Lepri: None declared, Cosimo Bruni Speakers bureau: CB reports personal fees from Actelion, personal fees from Eli Lilly, Grant/research support from: CB reports personal fees from Actelion, personal fees from Eli Lilly, grants from European Scleroderma Trial and Research (EUSTAR) group, grants from New Horizon Fellowship, grants from Foundation for Research in Rheumatology (FOREUM), grants from Fondazione Italiana per la Ricerca sull’Artrite (FIRA), outside the submitted work, Lorenzo Tofani: None declared, Alberto Moggi Pignone: None declared, Martina Orlandi: None declared, Tomasetti Sara Speakers bureau: Speaker’s fees for Roche and Boehringer Ingelheim, Mike Hughes: None declared, Francesco Del Galdo: None declared, Rosaria Irace: None declared, Oliver Distler Grant/research support from: OD (last three years) has/had consultancy relationship and/or has received research funding in the area of potential treatments for systemic sclerosis and its complications from (last three years): Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB. Patent issued “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143)., Valeria Riccieri: None declared, Yannick Allanore Speakers bureau: YA received personal fees from Boehringer, Sanofi, Menarini and Medsenic and grants from Alpine with regards to the management of systemic sclerosis, Grant/research support from: YA received personal fees from Boehringer, Sanofi, Menarini and Medsenic and grants from Alpine with regards to the management of systemic sclerosis, Ana Maria Gheorghiu: None declared, Elise Siegert: None declared, Jeska de Vries-Bouwstra: None declared, Eric Hachulla: None declared, Mohammed Tikly: None declared, Nemanja Damjanov: None declared, Francois Spertini: None declared, Luc Mouthon: None declared, Anna-Maria Hoffmann-Vold Speakers bureau: AMHV: received consulting fees from Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme and Roche; and grants from Boehringer Ingelheim., Consultant of: AMHV: received consulting fees from Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme and Roche; and grants from Boehringer Ingelheim., Grant/research support from: AMHV: received consulting fees from Actelion, ARXX, Bayer, Boehringer Ingelheim, Lilly, Medscape, Merck Sharp & Dohme and Roche; and grants from Boehringer Ingelheim., Armando Gabrielli: None declared, Serena Guiducci: None declared, Marco Matucci-Cerinic Speakers bureau: has received consulting fees or honorarium from Actelion, Janssen, Inventiva, Bayer, Biogen, Boehringer, CSL Behring, Corbus, Galapagos, Mitsubishi, Samsung, Regeneron, Acceleron, MSD, Chemomab, Lilly, Pfizer, Roche, Grant/research support from: has received consulting fees or honorarium from Actelion, Janssen, Inventiva, Bayer, Biogen, Boehringer, CSL Behring, Corbus, Galapagos, Mitsubishi, Samsung, Regeneron, Acceleron, MSD, Chemomab, Lilly, Pfizer, Roche, Daniel Furst: None declared, Silvia Bellando Randone: None declared

Background:Patient Reported Outcomes (PROs) are used to capture disease impact on patients’ Health Related Quality of Life (HRQoL) and they have been increasingly used as endpoints in clinical trials for Systemic Sclerosis (SSc). The DeSScipher project within the EUSTAR group highlighted dyspnea as one of the factors more strongly related with the highest SHAQ scores (1). Nevertheless, the SENSCIS trial in SSc-ILD (2) showed the efficacy of Nintedanib in reducing the annual rate of FVC loss, as compared to placebo, without significant changes in the PROs used as secondary endpoints (St. George’s Respiratory Questionnaire and the FACIT-Dyspnoea questionnaire). Since patient’s perspective is a crucial determinant to define the overall relevance of an intervention, the performance of PROs in reflecting different lung functional stages is a relevant issue in SSc.Objectives:To analyse in a prospective SSc cohort the inference of reduced lung function as measured by FVC on median PRO scores and the correlation among distinct commonly used PROs.Methods:A cross-sectional study was performed on data exported from the STRIKE database regarding SSc patients followed in Leeds Scleroderma Programme for SSc. Data included records of periodical visits with scores of different PROs commonly used in SSc (Scleroderma-Health Assessment Questionnaire (SHAQ), Cochin Hand Function Scale (CHFS) and Borg dyspnoea scale) and FVC%-predicted (%pFVC) and DLCO%-predicted (%pDLCO). SHAQ score was calculated as the mean value of HAQ (0-3) with the average of the 7-VAS scores divided by 3.33. The 7-VAS (score 1-10) were 1: pain, 2: general function, 3: arthritis, 4: gastro-intestinal, 5: dyspnoea, 6: Raynaud Phenomena; 7: digital ulcers. The correlation of FVC with distinct PROs, and the inter-PRO correlation, were analysed through the non-parametric Spearman test.Results:Complete data were available from 182 visits of 87 SSc patients (41 with diffuse and 46 with limited cutaneous involvement). Mean %pFVC was 95.16 ±24.93 (median 95) and mean %pDLCO was 59.31±16.51 (median 59). Overall, FVC and DLCO showed a moderate correlation with SHAQ (r=-0.36, pInter PROs analysis showed that CHFS score had a stronger correlation with SHAQ than Borg dyspnoea score in the overall population (r:0.86 vs. r:0.57, both pConclusion:The analysis of a single centre prospective cohort of SSc patients, suggests a small inference of lung function in the overall SHAQ. The stronger correlation of SHAQ with CHFS, than with Borg score, suggests a higher weight of hand function on SHAQ in this population with relatively conserved lung function. In patients with %pFVC 70%, suggesting that mild reductions in FVC might not be perceived by the patients, or at least they might not modify HrQoL as measured by SHAQ.References:[1]Jaeger VK, et al. Rheumatology 2017;57(3):441-50.[2]Distler O, et al. N Engl J Med 2019; 380:2518-2528.Disclosure of Interests:Maria Grazia Lazzaroni Grant/research support from: Boehringer-Ingelheim, Giuseppina Abignano: None declared, Michelle Wilson: None declared, Vishal Kakkar: None declared, Francesco Del Galdo Consultant of: Astra-Zeneca, Boehringer-Ingelheim, Mitsubishi-Tanabe, Capella Biosciences, Kymab, Actelion, Grant/research support from: Astra-Zeneca, Boehringer-Ingelheim, Mitsubishi-Tanabe, Capella Biosciences, Kymab, Actelion

Background:Interstitial lung disease (ILD) is the leading cause of mortality in patients with Systemic Sclerosis (SSc). Forced Vital Capacity (FVC) is a major indicator of severity in SSc ILD. The ELF serum test and its constituent biomarkers (HA, PIIINP and TIMP-1) have shown to correlate with FVC in two large, independent multicentre cohorts of 457 patients, but also showed a correlation with age.Objectives:Here we aimed to investigate the relationship of the ELF biomarkers and age in a large population of healthy controls and to identify a combined clinical and biomarkers model to stratify for risk of ILD progression in a multicentre longitudinal cohort of patients with SSc.Methods:ELF score was measured in sera from 925 healthy controls in one centre and 869 longitudinal samples from 254 SSc patients from 6 centres across 4 European countries. Clinical data were recorded according to EUSTAR Minimal Essential dataset. FVC% change over time was estimated by Mixed-effects modelling. Patients were then divided in two groups: progressors, with a %FVC drop > 3%/year (according to published MCID) and a group of patients with stable or improving FVC. Lasso penalised regression was carried out with biomarkers and the available clinical and demographic variables at patient’s first visit as potential predictors. The resulting linear predictor was used to derive two thresholds, one for optimal sensitivity (rule-out) and one for optimal specificity (rule-in). Patients within thresholds were further selected according to the ratio of TIMP-1: PIIINP (Figure 1).Results:HA was the only ELF biomarker that correlated significantly with age in the healthy control cohort. Therefore, we defined by linear regression a “residual HA” which accounted for age. TIMP1, PIIINP and residual HA were then considered as distinct biomarkers in the analysis of the SSc cohort. 189 SSc patients with 785 time-points had complete datasets and were included in the analysis. Median follow up was 33 months (IQR 18-48). One-hundred and forty patients (74%) were classified as non progressors, 94 (50%) with no change or improving FVC and 46 (24%) with FVC drop Conclusion:Building on the face and content validity of the biomarkers included in the ELF score, here we identify an easy to assess combined clinical and biomarker model to stratify patients for their risk of ILD progression. Despite its derivation from a large multicentre cohort, independent validation will determine the clinical value of Scleroscore as a stratification tool for risk of progression of SSc ILD.Disclosure of Interests:Michelle Hutchinson: None declared, Giuseppina Abignano: None declared, Jelena Blagojevic: None declared, Silvia Laura Bosello: None declared, Yannick Allanore Grant/research support from: Alpine, Boehringer Ingelheim, Genentech/Roche, Medsenic, and Sanofi, Christopher Denton Consultant of: Corbus, Actelion, GlaxoSmithKline, Bayer, Sanofi, Galapagos, Inventiva, Boehringer Ingelheim, Roche, CSL Behring, Acceleron, Horizon, Arxx Therapeutics, Grant/research support from: Corbus, Actelion, GlaxoSmithKline, Bayer, Sanofi, Galapagos, Inventiva, Boehringer Ingelheim, Roche, CSL Behring, Acceleron, Horizon, Arxx Therapeutics, Oliver Distler Consultant of: Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB, Grant/research support from: Abbvie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Blade Therapeutics, Bayer, Boehringer Ingelheim, ChemomAb, Corbus Pharmaceuticals, CSL Behring, Galapagos NV, Glenmark Pharmaceuticals, GSK, Horizon (Curzion) Pharmaceuticals, Inventiva, iQvia, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Topadur, Target Bioscience and UCB, Paul Emery Consultant of: Lilly, Abbvie, Roche, Grant/research support from: Lilly, Marco Matucci-Cerinic Consultant of: Chemomab, Lilly, Abbvie, Actelion, Francesco Del Galdo Speakers bureau: Astra-Zeneca, Boehringer Ingelheim, Actelion, Consultant of: Astra-Zeneca, Mitsubishi-Tanabe, Capella Biosciences, Chemomab, Actelion, Boehringer-Ingelheim, Grant/research support from: Capella Biosciences, Chemomab, Kymab, Mitsubishi-Tanabe

Background:Oxidative stress associated with vascular damage represents one the major contributor in the pathogenesis of systemic sclerosis (SSc) [1]. Indeed, different studies demonstrated that excessive free radicals production can contribute to the activation of fibrotic process in the skin and visceral organs [1]. CXCL10 and CXCL11, together with their receptor CXCR3, are involved in vascular damage and in fibrosis [2]. Furthermore, these chemokines have been proposed as biomarkers of vascular damage progression and severe SSc prognosis [3].Emerging evidences highlight the beneficial effects of the phosphodiesterase type 5 (PDE5) inhibitor, sildenafil, to protect different cell types from reactive oxygen species (ROS)-induced DNA damage, in vitro [3]. This effect has been linked to modulation of CXCL10 concentration in different pathological conditions [4,5].Objectives:Here we set out to investigate the effects of sildenafil, in modulating the CXCR3/CXCL10, -11 inflammatory axis in dermal fibroblasts exposed to oxidative stress, in vitro.Methods:Human dermal fibroblasts isolated by SSc skin biopsies were treated for 24h with 100µM of hydrogen peroxide (H2O2), in the presence or not of sildenafil (1µM). Dermal fibrobalsts from healthy skin were used as controls. CXCL10 and CXCL11 were evaluated in cell medium by luminex technology assay; expression of chemokine receptor (CXCR)3 and peroxisome proliferator-activated receptor (PPARγ) (a regulator of CXCL10,-11 mRNA) was evaluated by western blot assay.Results:As showed in figure 1, SSc fibroblasts (grey bar) showed similar basal levels of CXCL10 (A) and CXCL11 (B) to healthy controls (black bar). H2O2 induced a significant increase of both chemokines only in SSc fibroblasts (by 4.6 fold for CXCL10 and by 4.2 fold for CXCL11) (*Pvs. c; #Pvs. healthy controls). Sildenal pre-incubation reduced by approximatively 50% the effects of H2O2 on chemokines release (Figure 1A and B) (§P2O2), and reduced the expression of CXCR3 and PPARγ induced by hydrogen peroxyde exposure (data not shown).Conclusion:In vitro study on dermal fibroblasts support clinical studies to determine the efficacy of sildenafil in the preventing tissue damage and fibrosis in SSc, by reducing the pro-inflammatory activation induced by oxidative stress.References:[1]Di Luigi L, Sgrò P, Duranti G, Sabatini S, Caporossi D, Del Galdo F, Dimauro I, Antinozzi C. Sildenafil Reduces Expression and Release of IL-6 and IL-8 Induced by Reactive Oxygen Species in Systemic Sclerosis Fibroblasts. Int J Mol Sci. 2020 Apr 30;21(9):3161. doi: 10.3390/ijms21093161. PMID: 32365773; PMCID: PMC7246497.[2]Koper OM, Kamińska J, Sawicki K, Kemona H. CXCL9, CXCL10, CXCL11, and their receptor (CXCR3) in neuroinflammation and neurodegeneration. Adv Clin Exp Med. 2018 Jun;27(6):849-856. doi: 10.17219/acem/68846. PMID: 29893515.[3]Crescioli C, Corinaldesi C, Riccieri V, Raparelli V, Vasile M, Del Galdo F, Valesini G, Lenzi A, Basili S, Antinozzi C. Association of circulating CXCL10 and CXCL11 with systemic sclerosis. Ann Rheum Dis. 2018 Dec;77(12):1845-1846. doi: 10.1136/annrheumdis-2018-213257. Epub 2018 May 14. PMID: 29760155; PMCID: PMC6241615.[4]Giannattasio S, Corinaldesi C, Colletti M, Di Luigi L, Antinozzi C, Filardi T, Scolletta S, Basili S, Lenzi A, Morano S, Crescioli C. The phosphodiesterase 5 inhibitor sildenafil decreases the proinflammatory chemokine IL-8 in diabetic cardiomyopathy: in vivo and in vitro evidence. J Endocrinol Invest. 2019 Jun;42(6):715-725. doi: 10.1007/s40618-018-0977-y. Epub 2018 Nov 10. PMID: 30415310; PMCID: PMC6531405.[5]You N, Li J, Huang X, Wu K, Tang Y, Wang L, Li H, Mi N, Zheng L. COMMD7 activates CXCL10 production by regulating NF-κB and the production of reactive oxygen species. Mol Med Rep. 2018 May;17(5):6784-6788. doi: 10.3892/mmr.2018.8706. Epub 2018 Mar 8. PMID: 29532873.Disclosure of Interests:None declared

Background:The ACR Composite Response Index in diffuse cutaneous Systemic Sclerosis (CRISS) was developed to measure the probability of improvement in response to treatment in patients with early diffuse cutaneous SSc (dcSSc), accounting for new/worsening cardiopulmonary involvement and/or renal crisis, and changes in modified Rodnan skin score, forced vital capacity, health assessment questionnaire disability index, and patient’s and physician’s global impressions. In patients with SSc-ILD, treatment response may be reflected as slower progression, stabilisation or improvement.Objectives:Using data from patients with dcSSc and ILD in the placebo group of the SENSCIS trial, we analysed the probability of improvement using the ACR CRISS score at week 52. We also evaluated whether the CRISS numerator could provide information on the spectrum of responses in this patient population.Methods:The SENSCIS trial enrolled subjects with SSc-ILD with onset of first non-Raynaud symptom ≤7 years before screening, FVC ≥40% predicted, and fibrotic ILD ≥10% extent on an HRCT scan. Subjects on prednisone ≤10 mg/day (or equivalent) and/or stable therapy with mycophenolate or methotrexate were allowed to participate. Subjects were randomised to receive nintedanib or placebo. Subjects were not randomised by use of mycophenolate. In patients randomised to receive placebo who had dcSSc and/or mRSS >15 at baseline, we analysed the ACR CRISS and its numerator at week 52 in subgroups by use of mycophenolate at baseline. Analyses were exploratory and descriptive.Results:Of 117 analysed subjects in the placebo group who had dcSSc and/or mRSS >15 at baseline, 60 (51.3%) were taking mycophenolate at baseline. Compared with patients not taking mycophenolate at baseline, those taking mycophenolate had a lower mean age (48.4 [SD 11.8] vs 53.1 [13.4] years), lower mean FVC % predicted (68.8 [17.0] vs 73.0 [14.6]), and a greater proportion were female (76.7% vs 71.9%); median time since first onset of non-Raynaud symptom was similar (3.9 vs 4.5 years, respectively) as was mean (SD) mRSS (16.5 [7.7] vs 15.9 [8.0], respectively). One patient (taking mycophenolate at baseline) had limited cutaneous SSc. At week 52, median (Q1, Q3) ACR CRISS score was 0.036 (0.001, 0.601) in subjects taking mycophenolate and 0.002 (0.000, 0.112) in subjects not taking mycophenolate at baseline, and mean (SD) ACR CRISS score was 0.28 (0.37) in subjects taking mycophenolate and 0.16 (0.31) in subjects not taking mycophenolate at baseline (Figure 1). In these groups, respectively, 25.0% and 14.0% of subjects had CRISS score >0.6 (considered improved) at week 52. The CRISS numerator provided a broader distribution of response values, but was not informative in this patient population.Conclusion:In exploratory analyses, among subjects with dcSSc and ILD who received placebo in the SENSCIS trial, the proportion considered improved at week 52 based on ACR CRISS score was numerically greater in patients taking than not taking mycophenolate at baseline. There remains a need for composite scores that provide better interpretation of the magnitude of response in patients with SSc.Acknowledgements:The SENSCIS trial was funded by Boehringer Ingelheim. Medical writing support was provided by FleishmanHillard Fishburn, London, UK. The authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors (ICMJE).Disclosure of Interests:Francesco Del Galdo Speakers bureau: Actelion and AstraZeneca, Consultant of: Actelion, AstraZeneca, Boehringer Ingelheim, Capella BioScience, ChemomAb and Mitsubishi Tanabe Pharma, Grant/research support from: Capella BioScience, Kymab and Mitsubishi Tanabe Pharma, Oliver Distler Consultant of: AbbVie, Acceleron Pharma, Amgen, AnaMar, Arxx Therapeutics, Baecon Discovery, Bayer, Blade Therapeutics, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos NV, GlaxoSmithKline, Glenmark Pharmaceuticals, Horizon (Curzion) Pharmaceuticals, Inventiva, IQVIA, Italfarmaco, iQone, Kymera Therapeutics, Lilly, Medac, Medscape, Merck Sharp & Dohme, Mitsubishi Tanabe Pharma, Novartis, Pfizer, Roche, Sanofi, Serodapharm, Target Bioscience, Topadur Pharma and UCB, Grant/research support from: Kymera Therapeutics and Mitsubishi Tanabe Pharma, Christopher Denton Speakers bureau: Boehringer Ingelheim, Corbus, Janssen, and Mallinckrodt Pharmaceuticals, Consultant of: Acceleron Pharma, Arxx Therapeutics, Bayer, Boehringer Ingelheim, Corbus, CSL Behring, Galapagos NV, GlaxoSmithKline, Horizon Therapeutics, Janssen, Mallinckrodt Pharmaceuticals, Roche, Sanofi and UCB, Grant/research support from: Arxx Therapeutics, GlaxoSmithKline and Servier, Yannick Allanore Consultant of: Boehringer Ingelheim, Medsenic, Menarini and Sanofi, Grant/research support from: Alpine Pharmaceuticals, Daniel Wachtlin Employee of: Currently an employee of Boehringer Ingelheim, Margarida Alves Employee of: Currently an employee of Boehringer Ingelheim, Dinesh Khanna Shareholder of: Eicos Sciences, Inc. (less than 5%), Consultant of: Acceleron Pharma, Actelion, AbbVie, Amgen, Bayer, Boehringer Ingelheim, CSL Behring, Corbus, Gilead Sciences, Galapagos NV, Genentech/Roche, GlaxoSmithKline, Horizon Therapeutics, Merck, Mitsubishi Tanabe Pharma, Sanofi-Aventis and United Therapeutics, Grant/research support from: Bayer, Bristol-Myers Squibb, Horizon Therapeutics, Immune Tolerance Network, National Institutes of Health and Pfizer, Employee of: Chief Medical Officer- CiviBioPharma/Eicos Sciences, Inc.

Background:Skin fibrosis is the hallmark fibrotic manifestation of systemic sclerosis (SSc). Despite a key role of tissue fibroblasts, skin changes extend to the keratinocyte layer, which contribute to the loss of skin function. RNA seq. analysis of SSc patient forearm skin showed that palmoplantar specific Keratin 9 (CK9) was highly expressed (1). SSc affected skin shares several features with palmoplantar skin including increased keratinocyte layer thickness and lack of hair. Seminal work of last decade has shown that long noncoding RNA in the HOX loci play a crucial role in skin keratinocyte differentiation (2), with the lncRNA HOTAIR being one of the HOX lncRNA mostly expressed in the palmoplantar region.Objectives:Following recent data suggesting a role of HOTAIR in the profibrotic phenotype of dermal fibroblasts in SSc (3), here we set out to determine if HOTAIR expressed in SSc dermal fibroblasts was a contributing factor to the high levels of CK9 found in SSc patient skinMethods:Full-thickness skin biopsies were surgically obtained from the forearms of patients with SSc of recent onset. Fibroblasts were isolated and cultured in monolayers. HOX transcript antisense RNA (HOTAIR) was expressed in healthy dermal fibroblasts by lentiviral induction employing a vector containing the specific sequence. Exosomes were isolated from dermal fibroblast media using the Total exosome isolation reagent (Thermo Fisher). Enhancer of zeste 2 (EZH2) was blocked with GSK126 inhibitor. Skin equivalents were created using scramble and HOTAIR expressing fibroblasts with primary keratinocytesResults:Media from both SSc patient fibroblasts and HOTAIR expressing fibroblasts induced CK9 expression in healthy keratinocytes in vitro. In addition, HOTAIR expressing fibroblasts induces CK9 expression in keratinocytes in 3D skin equivalent models. Media fractionation studies indicated that HOTAIR was present in fibroblasts exosomes and found at a higher concentration (2.7 fold p=0.01) in exosomes from SSc fibroblasts. Importantly, transfection of Exosomal RNAs from SSc fibroblasts could reproduce the increase in CK9 in keratinocytes. Mechanistically, CK9 induction was mediated by changes to the histone methylation profile in the keratinocytes through EZH2.Conclusion:Pro-fibrotic dermal fibroblasts in systemic sclerosis contribute to the overall skin loss of function by inducing CK9 in adjacent keratinocytes through transfer of the long non-coding RNA HOTAIR. Unraveling the crosstalk of activated fibroblasts with adjacent cells may lead to identify therapeutic targets to re-establish tissue homeostasis and function during fibrosis.References:[1]Assassi S et.al Arthritis and Rheumatology 2015[2]Rinn JL et.al Cell 2007[3]Wasson CW et.al Annals of Rheumatic Disease 2020Disclosure of Interests:Chris Wasson: None declared, rebecca ross: None declared, Jessica Bryon: None declared, Francesco Del Galdo Speakers bureau: Speakers bureau: Astra-Zeneca, Boehringer Ingelheim, Actelion, Consultant of: Astra-Zeneca, Mitsubishi-Tanabe, Capella Biosciences, Chemomab, Actelion, Boehringer-Ingelheim, Grant/research support from: Grant/research support from: Capella Biosciences, Chemomab, Kymab, Mitsubishi-Tanabe

Background:Primary systemic sclerosis heart involvement (pSSc-HI) is described in the majority of SSc patients when sensitive methods such as cardiovascular magnetic resonance (CMR) are used1. The natural history of these subclinical findings are unknown.Objectives:To evaluate for interval change in subclinical pSSc-HI, the association between change in CMR abnormalities and disease phenotype and whether disease modifying antirheumatic (DMARD) and/or vasodilator treatment influence the CMR course.Methods:SSc patients, fulfilling the 2013 ACR/EULAR criteria, with no cardiovascular (CV) disease, diabetes and no more than 2 CV risk factors had two CMRs performed (V1 & V2; minimum 1 year apart). A 3T CMR with late gadolinium enhancement (LGE), T1 mapping for extracellular volume (ECV of diffuse fibrosis) quantification and stress perfusion was undertaken.Results:31 SSc patients were evaluated, with median (IQR) follow up (between the 2 CMR scans) of 33 (17, 37) months. Median (IQR) age was 52 (47,60), 32% had diffuse cutaneous SSc, 52% interstitial lung disease (ILD), 29% Scl70+.4/31 patients had a non-ischaemic LGE pattern suggesting focal fibrosis at V1, with no change in the pattern, distribution, or median (IQR) LGE scar mass between V1 and V2 [1.88 (1.01, 6.34) vs 1.70 (1.21, 4.18)]. At V2, 2 additional patients showed focal fibrosis, of which one had an episode of clinically diagnosed myocarditis. No significant change in ECV, T1 native, myocardial perfusion reserve (MPR) or left ventricle (LV) volumes and function were noted at V2 compared with V1 (p>0.01).SSc patients with either increase in pre-existing LGE scar mass (n=1) or new fibrosis were all dcSSc, with ILD, 2 Scl70+. A reduction in forced vital capacity and total lung capacity associated with a reduction in LV ejection fraction (LVEF) (rho=0.413, p=0.021; rho-0.335, p=0.07) and MPR (rho=0.543, p=0.007; rho=0.627, p=0.002).Patients receiving DMARD treatment had higher baseline LV end-diastolic volume compared to those with no DMARD treatment [mean (SD) 78 (19) vs 69 (10), p=0.167]. A decrease in LV stroke volume and an increase in T1 native at V1 vs V2 was noted for those on DMARD [mean (SD) 49 (8) vs 46 (8), p =0.023; 1208 (65) vs 1265 (56), p=0.008 respectively] (Figure 1). No significant change in CMR measures in those receiving vasodilator or angiotensin-converting-enzyme inhibitor treatment was noted (p>0.01).Figure 1.Mean (SD) of T1 native, LVSV/BSA, LVEF, and LVEDV/BSA at V1 compared to V2 in those with and without DMARD treatment. BSA, body surface area; DMARD, disease modifying antirheumatic drugs; EDV, end-diastolic volume; SV, stroke volume; LV left ventricular; EF, ejection fraction.Conclusion:This first, pilot longitudinal study of CMR-defined subclinical pSSc-HI suggests largely stable appearances with follow-up. Progression of new focal fibrosis and decline in LV function and MPR, where observed, associated with poor prognostic factors of SSc and ILD progression. Consistent with this, individuals on DMARD appeared to show interval decline. Larger longitudinal studies are warranted to confirm these findings and inform on utility of CMR monitoring of subclinical pSSc-HI in poor prognosis SSc.References:[1]Ntusi NA et al, J Cardiovasc Magn Reson. 2014Disclosure of Interests:Raluca-Bianca Dumitru: None declared, Lesley Anne Bissell: None declared, Bara Erhayiem: None declared, Graham Fent: None declared, Ananth Kidambi: None declared, Giuseppina Abignano: None declared, John Greenwood: None declared, John Biglands: None declared, Francesco Del Galdo: None declared, Sven Plein: None declared, Maya H Buch Grant/research support from: Pfizer, Roche, and UCB, Consultant of: Pfizer; AbbVie; Eli Lilly; Gilead Sciences, Inc.; Merck-Serono; Sandoz; and Sanofi

Background:Previous studies have shown that Optical Coherence Tomography (OCT) is a reliable biomarker of skin fibrosis and significantly correlates with the severity of the skin involvement in Systemic Sclerosis (SSc)1,2.Objectives:Aim of this cross-sectional study was to evaluate the performance of skin OCT to discriminate between SSc and healthy controls (HC) and to compare results with the current gold standard, the modified Rodnan skin score (mRss), in a different SSc study cohort.Methods:Dorsal forearm skin of consecutive diffuse cutaneous SSc (dcSSc) patients and matched-HC was scanned by an investigator blinded to the clinical data using Vivosight scanner (Michelson Diagnostics, Kent, UK). Minimum Optical Density (MinOD), Maximum OD (MaxOD) and OD at 300 micron-depth (OD300) were measured. Clinical involvement was assessed by a blinded operator using the mRss and results were compared with imaging data. Statistical analysis was performed using GraphPad Prism software V.7.0.Results:A total of 88 OCT images were obtained from 22 dcSSc patients [20 Female, mean age 49 (±11) years, 12 with < 5 years disease duration) and 22 HC (20 Female, mean age 50.7 (±6.7) years]. All OCT measures (MinOD, MaxOD and OD300) were significantly lower in SSc patients than in HC (p=0.011, pConclusion:These results confirm in a cohort different from those of the previous studies that skin OCT is able to reflect the severity of skin involvement in SSc. Longitudinal studies are needed to validate its potential as surrogate outcome measure of skin fibrosis in SSc patients.References:[1]Abignano G et al. Ann Rheum Dis 2013; 2. Pires NSM et al. Ann Rheum Dis 2018.Disclosure of Interests:None declared

Background:In the SENSCIS trial in patients with SSc-ILD, nintedanib reduced the rate of decline in FVC over 52 weeks vs placebo, with no difference between groups in change in mRSS.Objectives:Analyse correlation between progression of skin fibrosis and progression of SSc-ILD in the SENSCIS trial.Methods:Patients with SSc-ILD were randomised to receive nintedanib or placebo until the last patient reached week 52 but for ≤100 weeks. We calculated Spearman correlation coefficients between FVC (mL) at baseline and change from baseline in mRSS, mRSS at baseline and change from baseline in FVC (mL), and changes from baseline in mRSS and FVC at weeks 52 and 100 in all patients. We analysed the rate of decline in FVC (mL/year) in patients who did and did not have progression of skin fibrosis (relative change from baseline in mRSS >25% and absolute change from baseline >5 points) at week 52.Results:In the nintedanib (n=288) and placebo (n=288) groups, respectively, mean (SD) baseline FVC (mL) was 2459 (736) and 2541 (816) and mRSS was 11.3 (9.2) and 10.9 (8.8); 53.1% and 50.7% had dcSSc;18.4% and 16.0% had progression of mRSS at week 52. No meaningful correlations were observed in analyses between mRSS and FVC (Table). The mean (SE) annual rate of decline in FVC in the placebo group was similar in patients who did and did not have progression of mRSS (-95.2 [27.1] and -91.4 [15.7] mL/year, respectively). The effect of nintedanib vs placebo on reducing the rate of decline in FVC was numerically more pronounced in patients who did not have progression of mRSS vs those who did (difference [95% CI] 44.3 mL/year [0.6, 88.1] vs 24.6 [-53.7, 102.9]), but the interaction p-value (0.66) did not indicate heterogeneity in treatment effect between subgroups.Conclusion:In the SENSCIS trial, the proportion of patients who had progression of skin fibrosis over 52 weeks was low, without significant differences between placebo and nintedanib. No meaningful correlations were observed between skin fibrosis at baseline or progression of skin fibrosis and progression of SSc-ILD. The rate of decline in FVC was similar between patients who did and did not have progression of mRSS. These findings suggest that in the overall patient population in the SENSCIS trial, progression of skin fibrosis and progression of ILD were distinct manifestations of disease progression.Table:FVC at baseline and change from baseline in mRSSmRSS at baseline and change from baseline in FVCChanges from baseline in mRSS and FVCNCorrelation*NCorrelation*NCorrelation*Week 52Nintedanib2470.11 (-0.01, 0.23)241-0.08 (-0.20, 0.05)238-0.07 (-0.19, 0.06)Placebo2540.12 (-0.00, 0.24)257-0.15 (-0.27, -0.03)2520.03 (-0.09, 0.15)Week 100Nintedanib730.21 (-0.02, 0.42)73-0.06 (-0.29, 0.17)700.06 (-0.17, 0.30)Placebo660.28 (0.04, 0.49)730.04 (-0.19, 0.27)66-0.14 (-0.37, 0.10)*Spearman correlation coefficient (95% CI)Disclosure of Interests:Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Kristin Highland Grant/research support from: Boehringer Ingelheim - PI for SENSCIS and SENSCIS-ON trials (paid to my institution), Consultant of: Kristin Highland has acted as a consultant to Boehringer Ingelheim. She was a member of the SENSCIS trial Steering Committee (Boehringer Ingelheim), Speakers bureau: Kristin Highland reports speaker fees from Boehringer Ingelheim, Anna-Maria Hoffmann-Vold Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Actelion, Bayer, GlaxoSmithKline, Speakers bureau: Boehringer Ingelheim, Actelion, Roche, Otylia Kowal-Bielecka Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Inventiva, MSD, Novartis, Speakers bureau: Boehringer Ingelheim, Medac, Novartis, Roche, Sandoz, Ulrich Walker Grant/research support from: Ulrich Walker has received an unrestricted research grant from Abbvie, Consultant of: Ulrich Walker has act as a consultant for Abbvie, Actelion, Boehringer Ingelheim, Bristol-Myers Squibb, Celgene, MSD, Novartis, Pfizer, Phadia, Roche, Sandoz, Sanofi, and ThermoFisher, Paid instructor for: Abbvie, Novartis, and Roche, Speakers bureau: Abbvie, Actelion, Bristol-Myers Squibb, Celgene, MSD, Novartis, Pfizer, Phadia, Roche, Sandoz, and ThermoFisher, Francesco Del Galdo: None declared, Madelon Vonk Grant/research support from: Janssen and Ferrer, Consultant of: Boehringer Ingelheim, Janssen and GSK, Speakers bureau: Boehringer Ingelheim, BMS and Roche, Laura Hummers Grant/research support from: Boehringer Ingleheim, Corbus pharmaceuticals, CSL Behring, Cumberland Pharmaceuticals, and GlaxoSmithKline, Consultant of: Boehringer Ingleheim, Corbus pharmaceuticals, and CSL Behring, Elvira Erhardt Employee of: Employee of Boehringer Ingelheim, Manuel Quaresma Employee of: Employee of Boehringer Ingelheim, Margarida Alves Employee of: Employee of Boehringer Ingelheim, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl

Background:The VEDOSS study has recently indicated that more than 80% of patients affected by Raynaud’s phenomenon (RP) with specific SSc auto-antibodies and capillaroscopy changes satisfied ACR/EULAR 2013 criteria within 5 years. These data suggest that there is a window of opportunity for early detection of SSc in these patients.Objectives:Here we aimed to determine whether sera, skin biopsies and skin fibroblasts cultured from these patients showed any biomarker sign of SSc.Methods:Fifty-nine at risk patients identified by having RP and SSc auto-antibodies or capillaroscopy pattern (or both) were enrolled in the Kennedy national inception cohort. Sera were tested for IFN inducible chemokines (CXCL-9,10 and 11 and CCL2, 8 and 19) and biomarker of extracellular matrix turnover (ELF test), all previously shown to be increased in SSc. Further, two 3mm skin biopsies were taken from the forearms from 3 ACA+ve (anti-centromere antibodies), 3 SCL70+ve patients. One biopsy was subjected to histology analysis, including haematoxylin and eosin staining and immunohistological staining for Collagen Type 1, alpha-SMA, Caveolin 1 and CD31 as endothelial marker. The other biopsy was used to explant fibroblasts cultures. mRNA and protein were isolated from primary fibroblasts and processed for RT-qPCR and western blotting analyses.Results:Sera from at risk patients showed overall higher IFN inducible chemokines and ELF test (Pcompared to healthy control fibroblasts. Furthermore, fibroblasts from ACA or SCL70+ve patients showed limited TGF-beta induced increase in collagen and SMA expression, similar to SSc fibroblasts.Conclusion:Although pilot in nature, this study suggests that patients “at risk” already show biomarker signs of SSc both in their sera, at skin biopsy and fibroblast level. Longitudinal studies on patients at this stage of pre-clinical disease may inform on the stratification strategies for imminent progression to clinical manifestations, and offer both insights on pathogenesis of clinical signs and a window of opportunity for delaying the onset clinical intervention trials.Disclosure of Interests:rebecca ross: None declared, Ioanna Georgiou: None declared, Antonio Carriero: None declared, Giuseppina Abignano: None declared, Chris Wasson: None declared, Gemma Migneco: None declared, Ariane Herrick: None declared, Christopher Denton Grant/research support from: GlaxoSmithKline, CSL Behring, and Inventiva, Consultant of: Medscape, Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Corbus Pharmaceuticals, Acceleron, Curzion and Bayer, Francesco Del Galdo: None declared

Background:Neointima proliferation is a key pathologic feature of Systemic Sclerosis (SSc), causing arterial vessel narrowing and being the recognised culprit pathological lesion in Digital Ulcers (DUs), pulmonary artery hypertension and renal crisis. Nevertheless, there are no validated imaging techniques to assess the severity of vascular involvement in SSc. Digital Artery Volume index (DAVIX ©) is an MRITime of flight angiographybased quantitative score of digital arteries flow, without the need to administer contrast.Objectives:To determine the value of DAVIX in predicting the onset of digital ulcers (DUs), the worsening of patient reported outcomes (PROs) and clinical parameters in SSc patients.Methods:We enrolled 91 consecutive patients affected by Raynaud’s phenomenon, 63 of which fulfilled the 2013 ACR/EULAR classification criteria for SSc and 28 had a score Results:78/91 patients were females and median disease duration was 4 years (IQR1.91-9). Complete historical and prospective follow-up data were available for 68 patients. DAVIX© correlated with mRSS (r=-0.258, p=0.017), DLCO% (r=0.338, p=0.008) and capillaroscopy pattern (r=-0.388, p=0.001). In patients with DUs, DAVIX© showed a stronger correlation with DLCO% (r=0.786, p=0.048). DAVIX© predicted the worsening of HAQ-DI (r=-0.295, p=0.029), sHAQ (r =-0.333, p=0.029) and VAS pain (r=-0.269, p=0.038) independently of the presence of DUs. In the context of DU, 7 patients had DUs at baseline (5 with a positive history for DUs). 12 patients developed DUs within 12 months, 3 of them had DUs at baseline. 38 patients did not have either previous or current DUs, neither did they develop new DUs within 12 months. DAVIX of patients with current DUs was 3-fold lower than DAVIX of patients without DUs (0.18 vs 0.63 p=0.0093). Further, DAVIX of patients with positive history of DUs was 50% lower than in patient with a negative history (median 0.34 vs 0.64, p=0.0052). In patients without current DUs, DAVIX of patients who developed new DUs within 12 months of follow-up was 3-fold lower than in patients who didn’t develop DU (0.21 vs 0.65, p=0.0156). ROC curve analysis indicated that DAVIX threshold Conclusion:Outcome measures of vascular involvement in SSc are scanty. We demonstrated that DAVIX© is a promising and feasible surrogate outcome measure of neointima proliferation in SSc and a useful imaging biomarker of vascular disease activity. The predictive value of DAVIX for the future onset of DU could be employed as a useful stratification tool in clinical trials. The value of DAVIX in predicting the worsening of PROs and clinical parameters in overall patients, may offer insights on the role of vascular disease activity in the overall progression of SSc.References:[1]Lettieri G, Abignano G, et al Digital artery volume index: the first objective, automated, non-invasive imaging diagnostic of macrovascular involvement in ssc.Annals Rheum Dis2018Disclosure of Interests:Klodian Gjeloshi: None declared, Fiammetta Danzo: None declared, Giovanni Lettieri: None declared, Giuseppina Abignano: None declared, Mark Hinton: None declared, Anne-Maree Dean: None declared, Giovanna CUOMO: None declared, Olga Kubassova Shareholder of: IAG, Image Analysis Group, Consultant of: Novartis, Takeda, Lilly, Employee of: IAG, Image Analysis Group, Francesco Del Galdo: None declared

Background:The main clinical associations of anti-PM/Scl in Systemic Sclerosis (SSc) so far reported include calcinosis, myositis and interstitial lung disease (ILD). Nevertheless, data regarding the long-term outcome of ILD in these patients are lacking. A single centre Spanish cohort reported a better functional outcome in 14 SSc-ILD patients anti-Pm/Scl+ as compared to 49 anti-Topo I after a mean follow-up of 7 years (1).Objectives:To analyze the long-term outcome of ILD in a large multicentre EUSTAR study dedicated to anti-Pm/Scl SSc patients.Methods:A case-control study within the EUSTAR cohort collected 165 anti-PM/Scl+ SSc cases and 257 anti-PM/Scl- SSc controls, matched for sex, cutaneous subset, disease duration, and age at onset. Data for ILD at HRCT were available for 162/165 cases and 249/257 controls. Data for pulmonary function tests (PFT) at the baseline (T0), 1 year after diagnosis (T1) and at the last visit (LV) were analyzed.Results:A significantly higher frequency of ILD was reported in anti-Pm/Scl+ cases vs anti-Pm/Scl- controls (62.3% vs 39.4%, p:In ILD cases, %pFVC tended to improve from T0 (85.1±18.3) to T1 (89.5±16.5, p:0.045) and to LV (87.9±16.9, p:0.057), while in ILD controls remained stable from T0 (90.4±18.5) to T1 (91.1±16.5, p:0.38) and significantly declined to LV (85.0±18.0, p:0.0002). %pDLCO remained stable from T0 (60.5±16.8) to T1 (60.1±17.6, p:0.87) and to LV (60.4±16.9, p:0.77) in ILD cases, while significantly declined from T0 (67.0±18.9) to T1 (62.7±18.2, p:0.0016) and to LV (59.6±18.4, pDelta %pFVC (LV-T0) was 2.85±11.3 for the anti-Pm/Scl+ group vs -5.42±13.4 in the control group (p:0.0004) with a significant smaller proportion of patients with FVC loss ≥10% from T0 to LV in the anti-PM/Scl group (12.3% vs. 39.7%, p:0.0001). Delta %pDLCO (LV-T0) was -0.13±10.8 for the anti-PM/Scl+ group vs -7.38±14.6 in the control group (p:0.0015), with a significant smaller proportion of patients with DLCO loss ≥10% from T0 to LV in the anti-PM/Scl+ group (13.6% vs. 42.3%, pConclusion:In this multicenter real-life study, the long-term pulmonary functional outcome in SSc-ILD patients with anti-Pm/Scl positivity seems to be more favorable than in patients without anti-Pm/Scl antibodies.References:[1]Guillen-Del Castillo A, Semin Arthritis Rheum 2014, 44 (3), 331-7.Disclosure of Interests: :Maria Grazia Lazzaroni: None declared, Corrado Campochiaro Speakers bureau: Novartis, Pfizer, Roche, GSK, SOBI, Emiliano Marasco: None declared, Jeska de Vries-Bouwstra: None declared, Franco Franceschini: None declared, Francesco Del Galdo: None declared, Christopher Denton Grant/research support from: GlaxoSmithKline, CSL Behring, and Inventiva, Consultant of: Medscape, Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Corbus Pharmaceuticals, Acceleron, Curzion and Bayer, Lorenzo Cavagna: None declared, Oliver Distler Grant/research support from: Grants/Research support from Actelion, Bayer, Boehringer Ingelheim, Competitive Drug Development International Ltd. and Mitsubishi Tanabe; he also holds the issued Patent on mir-29 for the treatment of systemic sclerosis (US8247389, EP2331143)., Consultant of: Consultancy fees from Actelion, Acceleron Pharma, AnaMar, Bayer, Baecon Discovery, Blade Therapeutics, Boehringer, CSL Behring, Catenion, ChemomAb, Curzion Pharmaceuticals, Ergonex, Galapagos NV, GSK, Glenmark Pharmaceuticals, Inventiva, Italfarmaco, iQvia, medac, Medscape, Mitsubishi Tanabe Pharma, MSD, Roche, Sanofi and UCB, Speakers bureau: Speaker fees from Actelion, Bayer, Boehringer Ingelheim, Medscape, Pfizer and Roche, Yannick Allanore Grant/research support from: BMS, Inventiva, Roche, Sanofi, Consultant of: Actelion, Bayer AG, BMS, BI, Paolo Airò: None declared

Background:Peripheral myositis in systemic sclerosis (SSc) is associated with poor prognosis and myocarditis1but non-inflammatory myopathy, which also represents a significant cause of disability in SSc remains poorly understood. Cardiovascular magnetic resonance (CMR) T1 mapping studies in asymptomatic SSc patients show increased extracellular volume (ECV), suggestive of diffuse fibrosis in both the myocardium and thoracic muscle2.Objectives:To evaluate the feasibility of T1 mapping MRI and determine ECV in peripheral muscle of SSc patients with and without myopathy and explore the association between cardiac and peripheral muscle T1 mapping in SSc.Methods:This was a hypothesis-generating pilot and feasibility study. SSc patients, fulfilling the 2013 ACR/EULAR criteria, with no cardiovascular disease or myositis but either minimal muscle symptoms (non-inflammatory myopathy) or no muscle involvement and healthy volunteers (HV) underwent peripheral muscle T1 mapping-MRI for native T1 and extracellular volume (ECV) quantification of the dominant thigh. Patients also had T1 mapping CMR, and creatine-kinase (CK) measured. Non-inflammatory myopathy was defined as current/history of minimally raised CK (Results:12 SSc patients and 10 HV were recruited. SSc patients had a median (IQR) age of 52 (41,65) years, 9/12 had limited cutaneous SSc, 4/12 interstitial lung disease, 7/12 non-inflammatory myopathy. Higher skeletal muscle ECV was recorded in SSc patients compared to HV [mean (SD) 23(11)%, vs 11(4)% p=0.04]. Skeletal muscle native T1 values were comparable between the 2 groups although modestly higher in SSc patients [mean (SD) 1396ms (56) vs 1387ms (42)] (Figure 1A).Peripheral muscle ECV associated with CK (R2=0.307, rho=0.554, p=0.061) and was higher in SSc patients with evidence of myopathy compared to those with no myopathy [28 (10)% vs 15 (5)%, p=0.023] (Figure 1B). An ECV of 22% was determined to best identify myopathy with a sensitivity of 71% and a specificity of 80%.SSc patients had raised myocardial ECV and native T1 with means (SD) of 31 (3) % and 1287 (54) ms respectively (normal reference range ECV ≤29%, native T1 ≤1240ms). No clear association between myocardial and peripheral muscle ECV (rho=-0.485) or between myocardial ECV and peripheral muscle native T1 (rho=0.470) of SSc patients was observed.Conclusion:This pilot study to determine ECV-MRI of the peripheral muscle showed higher ECV in SSc patients compared to HV, suggesting the presence of diffuse fibrosis in the peripheral muscle of SSc patients. These data support further investigation to understand the pathophysiological involvement and relationship of peripheral and cardiac muscle in SSc.References:[1]Follansbee WP et al, Am Heart J. 1993[2]Barison A et al, Eur Heart J Cardiovasc Imaging. 2015Disclosure of Interests:Raluca-Bianca Dumitru: None declared, Alex Goodall: None declared, David Broadbent: None declared, Ananth Kidambi: None declared, Sven Plein: None declared, Francesco Del Galdo: None declared, Ai Lyn Tan: None declared, John Biglands: None declared, Maya H Buch Grant/research support from: Pfizer, Roche, and UCB, Consultant of: Pfizer; AbbVie; Eli Lilly; Gilead Sciences, Inc.; Merck-Serono; Sandoz; and Sanofi

Background:Lung involvement is very common is systemic sclerosis (SSc). Approximately one quarter of patients develops pulmonary problems within the first 3 years of diagnosis and still represents the leading cause of death in these patients. In a recent clinical trail, the reduction of FVC was not accompanied by a benefit with respect to health-related quality of life and patient-reported outcomes (PROs).Objectives:To assess how the change in Pulmonary Function Test (PFTs) parameters correlates with the Patient Reported Outcomes (PROs) in an observational cohort of patients with Systemic Sclerosis (SSc).Methods:We conducted a retrospective study of 330 clinic episodes from 121 unselected patients diagnosed with systemic sclerosis according to EULAR/ACR 2013 criteria, in annual follow-up (for a total of 165 patients/year) with PFTs, Health Assessment Questionnaire Disability Index (HAQ-DI), Scleroderma Health Assessment Questionnaire (sHAQ), Modified Borg Dyspnea Scale (Borg) and Cochin Hand Function Score (CHFS). We assessed the correlation between the HAQ and the Visual Analogical Scale 1-7 at baseline (VAS1 pain, VAS2 disease severity, VAS3 arthritis activity, VAS4 intestinal problems, VAS5 dyspnea, VAS6 Raynaud’s phenomenon, VAS7 digital ulcers). We evaluated the correlation of PFTs with PROs at every time period and the correlation between the change of PFTs parameters (δFVC, δDLCO) with the change of the PROs over a year of follow-up. Following analysis of distribution, Spearman or Pearson Test were used to determine correlation coefficients, as appropiate (Prism 7).Results:The median disease duration was 5 years (IQR 3-10). The median of 12 months δFVC% and δDLCO% were 0 (IQR -5.81 to 3.28) and -2.439 (IQR -8.76 to 5.98), respectively. The analysis evidenced a strong positive correlation between VAS1-7 and HAQ. We observed also significant correlation between FVC%, DLCO% and HAQ-DI (r= - 0.355 and -0.266, respectively; pConclusion:This analysis of a monocentric non-selected population evidenced that the current commonly used PROs in SSc while showing a good correlation with lung function are poorly sensitive to change or to reflect changes in lung function over 12 months. In this sense, prudent interpretation of the lack of correlation between FVC and patient-reported outcomes in studies of phase 3 is warranted.References:[1]Rahimi S., Nintedanib for systemic sclerosis-associated interstitial lung disease, Lancet Respiratory Medicine (2020)Disclosure of Interests:None declared

Background:Arthritic involvement in systemic sclerosis (SSc) is a common manifestation impacting on the quality of life. A wide range of articular involvement is recognised including from arthralgia to inflammatory joint and tendon disease.Objectives:To assess the weight of patient reported ‘’arthritis activity’’ in determining Patient Reported Outcome Measures (PROMs) in an observational cohort of SSc patients.Methods:We conducted a retrospective study of 330 clinic episodes from 121 unselected patients diagnosed with SSc according to EULAR/ACR 2013 classification criteria, in annual follow-up (for a total of 165 patients/year) with Pulmonary Function Tests (PFTs), Health Assessment Questionnaire - Disability Index (HAQ-DI), Scleroderma Health Assessment Questionnaire (sHAQ) and Cochin Hand Function Score (CHFS). Hand disability index was assessed by CHFS and global disability index was assessed by HAQ and sHAQ. Patient reported arthritis activity was assessed by Visual Analogical Scale for Arthritis Activity (VAS3). Based on the median of VAS3, patients were classified in two groups and the evaluation of global and hand disability index was performed for each group. Furthermore, we assessed the correlation between the change of VAS3 and the modification of disability scores (ΔHAQ, ΔSHAQ, ΔCHFS) over 12 months of follow-up. Following analysis of distribution, Spearman or Pearson Test were used to determine correlation coefficients, as appropriate (Prism 7).Results:The median disease duration was 5 years (IQR 3-10). The median of VAS3 was 35 (IQR 2 - 66). In patients with VAS3 Conclusion:This analysis of a monocentric non-selected population supports the key role of joint involvement in determining global patient reported functional and hand disability in SSc. Severity of musculoskeletal involvement should be carefully considered when interpreting PROs in patients with SSc.References:[1]Sandler RD, Matucci-Cerinic M, Hughes M. Musculoskeletal hand involvement in systemic sclerosis. Seminars in Arthritis and Rheumatism (2019)Disclosure of Interests:None declared

Contains fulltext : 181772.pdf (Publisher’s version ) (Closed access) OBJECTIVES: Systemic sclerosis (SSc) is heterogenous. The objectives of this study were to evaluate the purpose, strengths and limitations of existing SSc subset criteria, and identify ideas among experts about subsets. METHODS: We conducted semi-structured interviews with randomly sampled international SSc experts. The interview transcripts underwent an iterative process with text deconstructed to single thought units until a saturated conceptual framework with coding was achieved and respondent occurrence tabulated. Serial cross-referential analyses of clusters were developed. RESULTS: Thirty experts from 13 countries were included; 67% were male, 63% were from Europe and 37% from North America; median experience of 22.5 years, with a median of 55 new SSc patients annually. Three thematic clusters regarding subsetting were identified: research and communication; management; and prognosis (prediction of internal organ involvement, survival). The strength of the limited/diffuse system was its ease of use, however 10% stated this system had marginal value. Shortcomings of the diffuse/limited classification were the risk of misclassification, predictions/generalizations did not always hold true, and that the elbow or knee threshold was arbitrary. Eighty-seven percent use more than 2 subsets including: SSc sine scleroderma, overlap conditions, antibody-determined subsets, speed of progression, and age of onset (juvenile, elderly). CONCLUSIONS: We have synthesized an international view of the construct of SSc subsets in the modern era. We found a number of factors underlying the construct of SSc subsets. Considerations for the next phase include rate of change and hierarchal clustering (e.g. limited/diffuse, then by antibodies).

Background Bleomycin forms part of the chemotherapy regimen (“BEP”) for germ cell testicular cancer (1). The drug is known to cause Raynaud9s phenomenon (RP) in up to 25% of men who receive the BEP regime (2). RP is also a feature of systemic sclerosis (SSc), a connective tissue disease that is studied in a mouse model using bleomycin as the agent to induce pulmonary fibrosis (3,4). There have been isolated cases where patients, treated for lymphoma with bleomycin containing regimens, have developed SSc (5,6) thus evaluation of RP and SSc is warranted in testicular cancer patients. Objectives In men with germ cell testicular cancer who have received BEP in Leeds: 1) Evaluate the prevalence, nature, and onset of RP. 2) Compare the characteristics of those that developed RP with those that did not. 3) Determine whether those reporting RP have microvascular features of SSc. Methods A patient questionnaire completed retrospectively by men receiving follow up post BEP treatment was used to collect data on the prevalence, nature, and onset of RP. A subset of patients reporting RP then underwent capillaroscopy and thermography. Results 24 eligible men completed the questionnaire. RP was prevalent in 13 of the men (54% CI 0.34–0.74), usually bilaterally (92%) and accompanied by sensory disturbance (92%). Onset was most commonly reported to be following chemotherapy completion (77%). There was no association between RP and marital status, smoking status, tumour type or total bleomycin dose (p values >0.05). No evidence was found to suggest SSc in the patients who underwent capillaroscopy and thermography. Hallmark capillary changes indicative of SSc were absent at the nailbed. The mean (SD) recovery of the fingers back to baseline temperature was 93.8 (14.57)% at ten minutes post cold challenge and the mean (SD) re-warming rate of the fingers was 0.925 (0.17) °C/minute. Conclusions The prevalence of RP in this patient group was higher than expected. The absence of SSc vasculopathy was reassuring, however not all of the men reporting RP underwent Rheumatology assessment. The retrospective nature and small sample size of this study are key limitations but our findings justify further prospective evaluation of the prevalence and the basis for bleomycin-associated RP. References Horwich A, Nicol D, Huddart R. Testicular germ cell tumours. BMJ 2013; 347: f5526 doi: 10.1136/bmj.f5526. Bokemeyer C, Berger C C, Kuczyk M A, Schmoll H. Evaluation of Long-Term Toxicity After Chemotherapy for Testicular Cancer. Journal of Clinical Oncology 1996; 14: 2923–2932. Lakos G, Takagawa S, Varga J. Animal Models of Scleroderma. In: Perl A. Ed. Methods in Molecular Medicine, Vol. 102: Autoimunity: Methods and Protocols. 2004. Humana Press Inc., Totowa, NJ. 377–393. Matucci-Cerinic M, Kahaleh B, Wigley F M. Evidence That Systemic Sclerosis Is a Vascular Disease. Arthritis & Rheumatism 2013; 65(8): 1953–1962. Passiu G, Cauli A, Atzeni F, et al. Bleomycin-induced Scleroderma: Report of a Case with a Chronic Course Rather Than the Typical Acute/Subacute Self-Limiting Form. Clinical Rheumatology 1999; 18: 422–424. Kin K H, Yoon T J, Oh C W, Ko G H, Kim T H. A Case of Bleomyin-induced Scleroderma. Journal of Korean Medical Science 1996; 11(5): 454–456. Disclosure of Interest None declared

Background VEDOSS project relied on a specific set of inclusion criteria identifying patients in very early stage of systemic sclerosis (SSc) to be submitted to a tight follow up and unravel factors linked to the progression of the disease. The components of the ELF score (PIIINP, TIMP-1 and HA) have been shown to correlate with severity of skin and lung fibrosis in SSc. Objectives Our aim was to analyze the concentrations of ELF components in a subset of patients enrolled in the VEDOSS study and determine their potential diagnostic value. Methods Sera from 114 patients enrolled into the VEDOSS data base and 67 SSc controls fulfilling ACR/EULAR 2013 criteria (subsets: 33 diffuse; 34 limited) were obtained from 2 centres. Serum concentrations of ELF components were determined on Siemens Advia Centaur platform. Logistic regression analysis of the results was performed employing classification of SSc as state variable. Results Among the 114 patients enrolled from VEDOSS, 30 subjects had primary Raynaud9s phenomenon (PRP); 54 had Raynaud9s phenomenon (RP) and at least one of the following “red flags” (risk factors) for SSc: (Puffy fingers, ANA, SSc specific autoantibodies or SSc-specific capillaroscopic pattern) without fulfilling 2013 ACR/EULAR criteria (score 9) despite having no evidence of skin involvement nor interstitial lung disease at lung high resolution CT or pulmonary arterial hypertension, left ventricular systolic impairment or renal involvement. All serum biomarkers concentrations correlated with age (p Conclusions Our data indicate that the SSc score is a simple serum test based model that can be used in patients with RP to aid in the very early diagnosis of SSc. Furthermore, the identification of VEDOSS patients with a high SSc score test and already classified as SSc even in the absence of internal organ involvement can be used in intervention trials aimed to prevent further disease progression. Disclosure of Interest None declared

Background In SSc, the management of DU is a problem in clinical practice, therefore their prevention is highly warranted. Sildenafil, iloprost, calcium channel blockers (CCB), ACE inhibitors (ACEi) and bosentan, alone or in combination, are used for DU prevention without unanimous agreement. Objectives DeSScipher (“to decipher the optimal management of SSc”) is an EC-funded FP7 research project that consists of five observational trials (OT) addressing different aspects of SSc. The aim of OT1 was to evaluate the efficacy of vasoactive and vasodilating drugs or a combination therapy for the management of DU in SSc. Methods Longitudinal data were collected for up to 24 months by 28 DeSScipher centres. In SSc patients, the efficacy of sildenafil, bosentan, sildenafil+bosentan, iloprost or CCB /ACEi for the prevention of new DU was evaluated. Clinical features, ulcer type and other drugs were also recorded. Time without new DU, proportion of patients without new DU, risk of developing new DU and the mean number of new DU per patient were evaluated at 6 months follow-up. Results In OT1, 1394 patients were enrolled. The history of DU was a significant risk factor for developing new DU (OR=3.146; (95%CI:1.19–8.31), p=0.021), therefore analysis was focused on secondary prevention (prevention of new DU in patients with DU history). 473/1394 (33.9%) had a history of DU and 268/473 (56.7%) had follow up data (58.2% limited and 41.8% diffuse SSc subset). 47/268 (17.5%) were on Bosentan, 33/268 (12.3%) on Sildenafil, 40/268 (14.9%) on Iloprost, 31/268 (11.6%) on Sildenafil and Bosentan combination and 117/268 (43.7%) on CCB/ACEi alone. In patients with history of DU in the last 24 weeks, the treatment with CCB/ACEi alone was associated with 7 fold increased risk of developing new DU compared to all other treatment arms (OR =7.313; 95%CI:1.248–42.85, p=0.027). Patients on concomitant immunosuppressive treatment had a trend towards faster DU recurrence. Conclusions History of DU in the past 24 weeks should prompt a more aggressive preventive strategy other than therapy with CCB/ACEi alone due to its lower efficacy to prevent DU recurrence compared to the other treatment options. Acknowledgement The DeSScipher project was funded by the European Community9s Framework Programme 7 (FP7-HEALTH-2012.2.4.4–2 - Observational trials in rare diseases) under grant agreement N° 305495. We acknowledge the contribution of the following EUSTAR centers: Ancona (member N°34), Assiut (168), Bad Bramstedt (187), Belgrade (55), Bucharest (100), Cluj-Napoca (16), Erlangen (106), Frankfurt (124), Hamburg (64), Iasi (162), Istanbul (21), Istanbul (133), Koln (44), Monserrato (142), Moscow (78), Moscow (190), Padua (31), Rome (94), Salford/Manchester (80), Tubingen (56), Wuppertal (192). Disclosure of Interest None declared

Background While foot problems in patients with systemic sclerosis (SSc) have been described previously and the association with disability noted, the impact of such problems on the quality of life (QoL) in people living with SSc has yet to be quantified. Objectives To identify the factors, including those arising from foot pathology, that impact on QoL in SSc. Methods Structural equation modelling (SEM) was used to explore the multifactorial pathways impacting on QoL in a cross section cohort of people with SSc. Potential candidate factors were identified through: i) a literature review with expert consultation; and ii) a cross-sectional study capturing clinical features. QoL was measured using the disease-specific SScQoL questionnaire. Results One hundred and twenty one patients with SSc were recruited (106 female; median age 59, ranges 25 to 86 years) with a median disease duration of nine years (IQR:4,13) and a median modified Rodnan Skin Score of 2 (IQR:0, 5). The model that best explained the factors contributing to the SSc impact on QoL showed complex inter-relationships between 11 factors (Figure1) (c2=37.022, df=37, p=0.468, RMSEA=0.002, GFI=0.951, CFI=1.000). Combined, these factors explained 84% of the impact on QoL (R2 =0.84) in patients with SSc. General disease factors, including physical function (standardised total effect 0.64), breathing problems (standardised total effect 0.493), and depression (standardised total effect 0.428) had the greatest impact. Foot problems had a substantial but indirect effect on quality of life (foot function and foot pain standardised total effect 0.343 and 0.327). A summary of the effects of the factors included in the model is provided in the Table 1. Conclusions The impact of SSc on QoL is substantial and complex. While loss of physical function is the most influential factor on QoL, followed by breathing difficulty and depression, foot problems significantly contribute to this impact. Disclosure of Interest None declared

Background The ELF test and its components (PIIINP, TIMP-1 and HA) have been shown to correlate with skin, lung and overall fibrosis and not with any vascular manifestation of Systemic Sclerosis (SSc) 1 . On the contrary, NT-proBNP has been suggested to be useful for stratification of SSc patients, especially to identify those at risk of pulmonary hypertension 2 . Objectives Aims of this study were: a) to validate ELF score and its single analytes on an independent cohort of scleroderma patients; b) to evaluate whether NT-proBNP could provide additional value to the development of an SSc-specific algorithm. Methods 250 sera from SSc patients from a single UK centre were analysed employing a high-throughput in vitro diagnostic of a routine NHS pathology lab to measure ELF score, its analytes and NT-proBNP levels. All patients fulfilled 2013 ACR/EULAR classification criteria for SSc. Clinical, laboratory and instrumental data were collected at time of sampling. Statistical analysis was performed using SPSS. P Results Multivariate analysis of ELF score (including the variables found statistically significant in univariate analysis) identified age, mRSS and DLCO% as independently associated with ELF score (p Conclusions Our findings validate the value of ELF score in a second independent cohort of 250 SSc sera and suggest that NT-proBNP has a complementary value correlating with other aspects of the disease such as PAH and heart severity. Longitudinal multicentres studies are warranted to determine the sensitivity to change and the predictive value of these biomarkers in SSc patients and to build up a new combined scleroderma specific algorithm including markers of fibrosis and vasculopathy. References Abignano G et al. Ann Rheum Dis 2014 Avouac J et al. Arthritis Care Res 2015 Disclosure of Interest None declared

Background Systemic sclerosis (SSc) can greatly impact the patients9 quality of life due to the multisystem manifestations. The health assessment questionnaire (HAQ) is one of the most commonly used measures of disability in musculoskeletal disorders and was extended to form the scleroderma HAQ (SHAQ), a more disease-specific disability scale that incorporates the HAQ and the 5 SHAQ-visual analogue scales (VAS) into one score. Objectives This study aims to identify predictors of disability in SSc by means of the SHAQ. Methods Patients from the DeSScipher cohort were included in the analysis if they had at least one complete SHAQ recorded, fulfilled either the 1980 ACR or the 2013 ACR/EULAR criteria for SSc and were above 18 years of age. Multiple linear regression analysis was used to assess the combined effect of factors possibly associated with disability. Variables included in the model were defined a priori. Results 813 patients had one complete SHAQ recorded between June 2013 and January 2016 (34.1% of all patients followed in the DeSScipher cohort). Of these, 12% fulfilled only the 2013 ACR/EULAR criteria, 2% fulfilled only the 1980 ACR criteria and 86% fulfilled both, the median age was 58 years (IQR 49–67) and 15% were male. 26% of the patients were in the diffuse SSc subset, 56% in the limited and 18% had SSc sine sclerosis. The patients had a median SHAQ score of 0.79 (IQR 0.28–1.31) and a median HAQ score of 0.88 (IQR 0.25–1.5). The medians of the five VASs included in the SHAQ were (in order of the VAS magnitude): overall disease severity (30, IQR 10–51), Raynaud9s phenomenon (21, IQR 3–50), pulmonary symptoms (10, IQR 1–40), gastrointestinal symptoms (6, IQR 1–31) and digital ulcers (2, IQR 1–30). 60% of the patients were in the lowest SHAQ category (score of 0 to 1) which is regarded as “mild to moderate difficulty”, 34% in the category regarded as “moderate to severe disability” (score of 1 to 2) and 6% in the category regarded as “severe to very severe disability” (score of 2 to 3). In multiple linear regression, the main factors associated with high SHAQ scores were dyspnoea (NYHA-stage 4 (β=0.67), 3 (β=0.59) and 2 (β=0.18; all vs. stage 1), fibromyalgia (β=0.42), muscle weakness (β=0.25), current digital ulcers (β=0.20) and gastrointestinal symptoms (oesophageal symptoms, β=0.18; stomach symptoms, β=0.14; intestinal symptoms, β=0.14; figure). Conclusions Patients perceive dyspnoea, pain, digital ulcers, muscle weakness and gastrointestinal symptoms as the main factors driving their level of disability. Acknowledgement The DeSScipher project was funded by the European Community9s Framework Programme 7 (FP7-HEALTH-2012.2.4.4–2-Observational trials in rare diseases) under grant agreement N° 305495. We acknowledge the contribution of the following EUSTAR centres: Moscow(78), Padova(31), Istanbul(133), Wuppertal(192), Monserrato(142), Roma(94), Cologne(44), Cluj-Napoca(16), Ancona(34), Iasi(162), Frankfurt(124). Disclosure of Interest None declared

Background The basis as to why chronic gout related tophi may be completely asymptomatic is not understood. In experimental settings coating of gouty crystals may be associated with the prevention of inflammatory responses (1). Objectives We used optical coherence tomography (OCT) in patients with gout to test the hypothesis that tophus related pain was due to the disruption of tophus capsule. Methods Eight consecutive patients with tophaceous gout were recruited. Each patient received detailed clinical assessment by a Rheumatologist including physical examination, history, current therapy, presence, number and site of tophi and whether or not each tophus was symptomatic. Tophi were photographed and scanned using Vivosight OCT scan (Michelson Diagnostics, Kent, UK). OCT of corresponding regions of the opposite side were undertaken for comparison and for subclinical tophi evaluation. One hundred slices OCT scans allowed post-processing 3D reconstructions of the visualized superficial tophus morphology (smooth or irregular) and presence or absence of tophus capsule were assessed. VAS pain scores for individual tophi were subsequently collected and correlated with imaging. Results Thirty seven tophi from eight patients with tophaceous gout were scanned. Four patients had tophi located at fingers, one at toes, two at both sites. Two patients of the third group had additional sites involved in form of multiple aggregates located at knees, heels, elbows. VAS score ranged from 0 to 9 (median=2). Eleven of the 37 tophi were symptomatic (VAS score range: 4–9), the remaining 26 were mildly or not symptomatic (VAS score 0–3). Most of the tophi (28/37) had a smooth border, 9 had an irregular aspect. Tophi with smooth border seemed to be surrounded by a “pseudo-capsule” (p Conclusions These findings suggest that non-painful tophi in patients with tophaceous gout have a different morphology and a capsule which provides support for the idea that a capsule prevents pain and inflammation. Capsular disruption is linked to flares and the hypothesis that initial serum urate lowering therapy may lead to capsule disruption should be further investigated. References Schauer C et al. Aggregated neutrophil extracellular traps limit inflammation by degrading cytokines and chemokines. Nat Med. 2014;20:511–7 Disclosure of Interest None declared

Background The Systemic Sclerosis Quality of Life (SScQoL) questionnaire is a 29-item tool developed in UK to measure needs-based patient-reported quality of life in people with systemic sclerosis (SSc). Objectives To undertake a cross-cultural adaptation and validation of the SScQoL in six European countries. Methods This was a cross-sectional study involving six European countries: Germany, France, Italy, Spain, Sweden and UK. Adult patients with a definite diagnosis of SSc, who were willing and able to complete the SScQoL were eligible. The English SScQoL was adapted into the five European languages using a forward-backward translation process. 1 The translated SScQoL was completed by patients and the data was analysed using Rasch models. Where local response dependency was evident, items were grouped into subscales (function, emotion, sleep, social and pain) and re-analysed to test the scaling properties and cross-cultural equivalence, thus allowing calibration of the SScQoL into an interval scale. Results The adaptation of the SScQoL into European languages was seamless except in Germany, where patients reported problems in deciding yes/no responses for some items. Cross-cultural validation included 849 patients (mean age =57.9 years, SD =13.9), 87% of whom were women. All country-specific data except Germany had good fit to the Rasch model after correcting for local dependency. See table 1. After excluding Germany from the analysis, the scale was validated and calibrated with cross-cultural adjustment for Italy in the social subscale. Conclusions The SScQoL translated versions can be used as a valid common measure in France, Spain, Sweden, UK and Italy; the latter with adjustments in the social subscale. The German version requires further work. References Beaton DE, et al. Guidelines for the process of cross-cultural adaptation of self-report measures. Spine. 2000;25(24):3186–91. Disclosure of Interest None declared

Pulmonary arterial hypertension (PAH) is a complex, multifactorial disease characterised by endothelial cells (EC) dysfunction and subsequent uncontrolled proliferation of vascular smooth muscle cells (VSMC), leading to a progressive increase in pulmonary vascular resistance and ultimately right heart failure. PAH is frequently associated with connective tissue diseases (CTD). The most common cause of CTD associated PAH is Systemic Sclerosis or Scleroderma (SSc), an autoimmune condition characterised by tissue fibrosis and endothelial cell dysfunction. While tissue fibrosis is the hallmark of SSc, EC dysfunction is a very early pathological manifestation and it causes PAH in 40% of patients during the course of the disease. The most important profibrotic growth factor involved in SSc is transforming growth factor (TGF)-β, however the putative link between aberrant TGF-β signalling and EC dysfunction is still not clear. Heme oxygenase 1 (HO-1) is an inducible enzyme (under hypoxia) with important antioxidant, anti-proliferative, and anti-inflammatory properties in VSMC and ECand its expression can be supressed by TGF-β. Here we explored whether inhibitory effect of TGF-β on HO-1 expression could be the link between aberrant TGF-β signalling and the endothelial dysfunction associated with the pathogenesis of PAH. Using immunohistochemistry we examined the expression of HO-1 in both skin and lung biopsies from healthy controls and patients with SSc. HO-1 expression was less dominant in the skin of SSc patients. By contrast, HO-1 was only detected in the infiltrated areas of SSc lung biopsies. Expression of HO-1 was assessed by western blotting (n = 4) and quantitative PCR (n = 3) in skin fibroblasts isolated from SSc patients and healthy subjects under Normoxia (control),chronic hypoxia (CH, in vitro model of PAH), TGF-β (5 ng/mL), and the combination of CH + TGF-β. Basal HO-1 expression was downregulated in SSc fibroblasts compared with healthy controls. HO-1 expression was upregulated by CH and not significantly affected by TGF-β. By contrast, TGF-β reversed the CH-dependent upregulation of HO-1 expression under CH. Importantly our results show that aberrant TGF-β signalling within SSc is responsible for the downregulation of HO-1, and might be responsible for the endothelial dysfunction associated with the pathogenesis of PAH.

Objective:To investigate the role of junctional adhesion molecule-A (JAM-A) in the pathogenesis of systemic sclerosis (SSc).Methods:Biopsy specimens from proximal and distal arm skin and serum were obtained from patients with SSc and normal volunteers. To determine the expression of JAM-A on SSc dermal fibroblasts and in SSc skin, cell surface ELISAs and immunohistology were performed. An ELISA was designed to determine the amount of soluble JAM-A (sJAM-A) in serum. Myeloid U937 cell–SSc dermal fibroblast and skin adhesion assays were performed to determine the role of JAM-A in myeloid cell adhesion.Results:The stratum granulosum and dermal endothelial cells (ECs) from distal arm SSc skin exhibited significantly decreased expression of JAM-A in comparison with normal volunteers. However, sJAM-A was increased in the serum of patients with SSc compared with normal volunteers. Conversely, JAM-A was increased on the surface of SSc compared with normal dermal fibroblasts. JAM-A accounted for a significant portion of U937 binding to SSc dermal fibroblasts. In addition, JAM-A contributed to U937 adhesion to both distal and proximal SSc skin.Conclusions:JAM-A expression is dysregulated in SSc skin. Decreased expression of JAM-A on SSc ECs may result in a reduced response to proangiogenic basic fibroblast growth factor. Increased JAM-A expression on SSc fibroblasts may serve to retain myeloid cells, which in turn secrete angiogenic factors.

Background Interstitial lung disease (ILD) represents one of the most frequent causes of death in systemic sclerosis (SSc) patients. Yet, there are no approved drugs for treatment of SSc-ILD, consensus of management is difficult, and evidence-based data facilitating a treatment algorithm for everyday practice are lacking. Objectives To describe immunosuppressive treatment and prescription patterns in patients with SSc-ILD. Methods The European League against Rheumatism – Scleroderma Trial and Research (EUSTAR) database was established in 2004 to collect annually data on specialized care of patients with SSc. Based on this database, the FP7 DeSScipher project consisting of several observational trials was initiated, of which one focuses on ILD. The EUSTAR database was analyzed with respect to immunosuppressive therapy. Results Out of a cohort of 11,496 SSc patients, we identified 3,778 adult patients fulfilling the ACR or according to available data the new ACR-EULAR criteria, additionally showing signs of ILD (either on plain X-ray or high resolution computed tomography) with at least one report on immunosuppressive treatment. Mean age was 55.5±13.4 years, with 83.6% females and a mean SSc disease duration of 8.5±7.9 years. Mean mRSS was 10.6±8.7, 44.4% had diffuse skin involvement, 46.9% the limited SSc subtype, and 7.5% sclerodactyly only. Compared to the 2,681 (71%) patients who had at least one episode of immunosuppressive therapy the 1,097 (29%) patients without use of immunosuppressants ever were on average 5 years older, had longer disease duration (3.2 years), more often limited skin involvement, higher DLCO and FVC values.The immunosuppressants most frequently used were prednisolone (pred) (58.8%), cyclophosphamide (cyc) (19.1%), azathioprine (aza) (15.0%), methotrexate (mtx) (14.7%), and mycophenolate mofetil (mmf) (13.1%), all others were prescribed in less than 3%. With regard to highest treatment intensity ever received, similar proportions of patients got monotherapies (34.0%) and combinations of two drugs (32.4%), while triple therapy was comparably rare with 4.1%. When comparing patient characteristics at treatment start of the most frequent regimens, differences compared to the “never IS” group and between treatment arms become apparent (table 1). Conclusions “Everyday” use of immunosuppressants is frequent in SSc-ILD patients showing a wide variety of single and combined substances with distinct patient patterns between treatment regimens. However, prospective studies are still necessary to define indications and outcomes. The EU-funded international FP7 DeSScipher research project was initiated to achieve this goal, comprising 5 prospective observational trials addressing the most frequent medical problems in SSc patients. Acknowledgements This study was supported by the Seventh Framework Program of European Commission as part of the DeSScipher Project (grant agreement No. 305495). Disclosure of Interest D. Huscher: None declared, S. Adler: None declared, E. Siegert: None declared, Y. Allanore: None declared, L. Czirjak: None declared, F. Del Galdo: None declared, C. P. Denton Grant/research support from: Actelion, CSL Behring, Novartis, Consultant for: Actelion, GSK, Bayer, Inventiva, Takeda, O. Distler Grant/research support from: or consultant fees: 4D Science, Actelion, Active Biotec, Bayer-Schering, Biogen, Biovitrium, BMS, Boehringer Ingelheim Pharma, EpiPharm, Ergonex, GSK, Inventiva, Medac, Novartis, Pfizer, Pharmacyclics, Roche/Genentech, Sanofi/Genzyme, Serodapharm, Sinoxa and United BioSource Corporation., I. Foeldvari: None declared, M. Frerix: None declared, M. Matucci-Cerinic: None declared, U. Mueller-Ladner: None declared, I. H. Tarner Grant/research support from: and speaker9s honoraria from Abbvie, Actelion, BMS, Chugai, Pfizer, Roche and UCB, G. Valentini: None declared, U. A. Walker Consultant for: manufacturer of Ilaris, G. Riemekasten: None declared

Background Due to lack of adequate clinical research data, drug treatment of the rare disease systemic sclerosis (SSc) is commonly off-label. The international EC-funded research project DeSScipher (acronym for “to decipher the optimal management of systemic sclerosis”) was designed to increase the evidence-based treatment strategies for SSc patients and subsequently to improve their long-term quality-of-life. Objectives The primary objective is to compare the outcomes of different treatments with respect to efficacy and safety of currently used off-label drugs from the early to the advanced phases of the main SSc-associated organ dysfunctions in a routine rheumatology in- and outpatient setting. Methods Five prospective observational trials (OTs), carried out within the EULAR Scleroderma Trials and Research (EUSTAR) group, have been designed to analyze current treatment approaches of early functionally relevant manifestations such as digital ulcers (OT1) and hand arthritis (OT2) to the morbidity and mortality-driving manifestations such as interstitial lung disease (OT3), pulmonary hypertension (OT4) and severe heart disease (OT5). The study protocols are accessible at clinicaltrials.gov Identifiers NCT01836263, NCT01834157, NCT01858259, NCT01840748, NCT01829126. Results Between April 2013 and January 2015, 1781 SSc patients have been screened at 27 contributing EUSTAR centers. 1577 (89%) patients have been enrolled into at least one of the five OTs. In particular, 1179, 127, 981, 237 and 716 patients have been enrolled into OT1-5, respectively (3240 in total; a given patient could be enrolled into multiple OTs), which represents a baseline patient recruitment rate of 79% of the target number of 4098 patients (accordingly 226%, 79%, 59%, 25% and 91% of the required number of 522, 160, 1670, 960, 786 patients for OT1-5, respectively). The completion of 1-year (OT3, OT5) and 2-year follow-up visits (OT1, OT2, OT4) are pending. Conclusions DeSScipher is currently the largest prospective observational research project ever for SSc. While patient recruitment is still ongoing, preliminary results of the five OTs are expected in late 2015 and the final results depending on the completion of follow-up visits are expected between 2017 and 2018. Acknowledgements The DeSScipher project was funded by the European Community9s Framework Programme 7 (FP7-HEALTH-2012.2.4.4-2 - Observational trials in rare diseases) under grant agreement N° 305495. We acknowledge the contribution of the following EUSTAR centers: Wuppertal (member N°192), Lille (93), Bad Bramstedt (187), Moscow (78), Assiut (168), Moscow (190), Bucharest (100), Monserrato (142), Iasi (162), Cluj-Napoca (16), Frankfurt (124), Salford/Manchester (80), Tubingen (56), Ancona (34), Zagreb (51) and Roma (94). Disclosure of Interest None declared

Background Heart disease in patients with systemic sclerosis (SSc) can cause manifestations such as cardiac blocks (CBs), ventricular arrhythmias (VA), and congestive heart failure (CHF) which may require a pacemaker/defibrillator implant, are the cause of death or sudden death (SD) in about 20% of patients and can be referred to as severe heart disease (SHD). The European League against Rheumatism – Scleroderma Trial and Research (EUSTAR) database provides an unique opportunity to address this topic. The results of such analysis are instrumental for the DeSScipher project, an EU funded project devoted to decipher the optimal management of SSc . Objectives To investigate the prevalence of each SHD manifestation and their associations with demographic, serological, clinical and therapeutic aspects in a large series of adult SSc patients. Methods Seven EUSTAR-DeSScipher centers provided clinical charts at study entry including all the items of SHD. The prevalence of any and each SHD manifestation was calculated. The associations with demographic, serological, clinical features and treatment with vasodilators, i.e. calcium channel blockers (CCBs) and /or ACE inhibitors (ACEi), were investigated by univariate analysis and confirmed by multivariate logistic regression analysis. Results At July 6th 2012, 1119 SSc patients from the 7 EUSTAR centers had no missing data (995 females, 164 males; median age 53.6 years, range 14-86). Out of them, 211 patients (19%) had at least 1 SHD manifestation, 152 patients had CBs (14%), 71 had VA (6%), 132 had CHF (12%), and 27 received a pacemaker/defibrillator implant (2%). CBs were the only SHD manifestation in 100 patients, VA in 31, and CHF in 80. No association was found between SHD and clinical (diffuse or limited) and serological (ACA or anti-Scl-70) subset. No association was found between either CHF or pacemaker/defibrillator implant and any other disease feature. In multiple logistic regression analysis, CBs were associated with bibasilar lung fibrosis at chest X-Ray (OR=2.6; 95%CI=1-6.4; p=0.04), while VA were associated with increased CPK levels (OR=11; 95%CI=1-117; p=0.02) and, unexpectedly, current CCB use (OR 10; 95%CI 1.4-76.1; p=0.02). Conclusions This is the first study devoted to investigate SHD in a large series of carefully assessed SSc patients. SHD was detected in about 19% of the cases, CBs in 14%, VA in 6%, CHF in 12%. Pacemaker/defibrillator implant was needed in 2.4%. These data highlight the importance of an accurate heart assessment in SSc patients. Moreover, the associations between VA and CPK elevation and current CCB use should stimulate the clinician to avoid these drugs in patients with myositis/myocarditis. Acknowledgements The DeSScipher project was funded by the European Community9s Framework Programme 7 (FP7-HEALTH-2012.2.4.4-2 - Observational trials in rare diseases) under grant agreement N° 305495 Disclosure of Interest S. Vettori Grant/research support from: Roche, Consultant for: Phadia Thermofisher, Pfizer, Abbvie, G. Cuomo: None declared, V. Jaeger: None declared, M. Frerix: None declared, E. Siegert: None declared, V. Lorand: None declared, S. Jordan: None declared, G. Riemekasten: None declared, Y. Allanore: None declared, L. Czirjak: None declared, I. Tarner: None declared, O. Distler Grant/research support from: 4D Science, Actelion, Active Biotec, Bayer-Schering, Biogen, Biovitrium, BMS, Boehringer Ingelheim Pharma, EpiPharm, Ergonex, GSK, Inventiva, Medac, Novartis, Pfizer, Pharmacyclics, Roche/Genentech, Sanofi/Genzyme, Serodapharm, Sinoxa and United BioSource Corporation, Consultant for: 4D Science, Actelion, Active Biotec, Bayer-Schering, Biogen, Biovitrium, BMS, Boehringer Ingelheim Pharma, EpiPharm, Ergonex, GSK, Inventiva, Medac, Novartis, Pfizer, Pharmacyclics, Roche/Genentech, Sanofi/Genzyme, Serodapharm, Sinoxa and United BioSource Corporation, C. Denton: None declared, M. Matucci-Cerinic: None declared, F. Del Galdo: None declared, U. Walker: None declared, U. Mueller-Ladner: None declared, G. Valentini: None declared

Background Digital ulceration (DU) and reduction in hand function due to Raynaud9s phenomenon (RP) are more common and severe in Systemic Sclerosis (SSc) than in other Connective Tissue Diseases because of reduced capacity of the digital arteries, which in turn is caused by neointima proliferation. While the presence of DU and loss of hand function reflect the severity of the hand vasculopathy, to date there is no direct surrogate outcome measure of neointima proliferation in Scleroderma hands which could predict onset of SSc in patients with severe RP. Non-contrast Magnetic Resonance Angiography (MRA) employing Time Of Flight technique (TOF) has become more and more utilized for assessing vascular pathologic conditions with MRI. The TOF allows the visualization of the blood flow by different magnetization and therefore contrast resolution between the water nuclei flowing in the arteries and the stationary nuclei of the surrounding tissues in a definite volume. Objectives To determine the proof of concept, face and content validity of non-contrast hand MRA by TOF as imaging outcome measure of fibroproliferative vasculopathy in Scleroderma. Methods Twenty hands were scanned from 8 SSc patients (of which 4 with current DU) and 10 healthy volunteers (HV). MRI scans were performed on a 3T Magnetom Verio (Siemens Healthcare). A VIBE 3D T1 scan of 3 minutes and a 2D TOF sequence of 8 minutes were performed using Time of Echo of 5 milliseconds (ms) and repetition time (TR) ranging from 24 to 72 ms when needed. Post-processing analysis was undertaken with OsiriX software. Digital arterial flow index (DAFI) was calculated as % of the ratio of digital arteries flow volume and the respective finger volume. DAFI values were analysed by Graph prism software by two-way-ANOVA or unpaired two-tailed t-test as appropriate. Results Digital arteries were visualized at TR of 24 ms in 17/20 hands. Three HV required increased TR. Seventy native TOF images were post-processed to obtain the volume of the digital arteries by OsiriX segmentation. DAFI of HV was in average 1.21 (STDV 0.39) vs 0.37 (STDV 0.18) of SSc patients (p Conclusions Time of Flight MRA is a sensitive, non-invasive tool to assess arterial flow volume in SSc hands. While definite validation with tissue biopsies is poorly feasible, the correlation of the DAFI with functional score and presence of DU is strongly supporting the face and content validity of the test. Longitudinal evaluation of a large cohort of patients with SSc and secondary RP is warranted to determine the sensitivity to change, the specificity and the potential predictive value of the test in diagnosing fibroproliferative vasculopathy in the hands of patients affected by RP. Disclosure of Interest None declared

The pathogenesis of immunological and nonimmunological components that cause chronic kidney allograft nephropathy (CAN), is not yet completely understood. To explore the possible contribution of alloreactive cytotoxic T cells, we analyzed the transcription of cytotoxic molecules such as granzyme B and perforin using semiquantitative RT-PCR on surgically removed grafts obtained from two groups: group 1 (n = 10) were cases of CAN; group 2 (n = 3) had no CAN. Among group 1 kidneys, granzyme-B was expressed in 7 of 10, whereas perforin was detectable in 9 of 10 cases; their detection was not related to the presence of superimposed signs of acute graft lesions. Cytotoxic molecules were never found in group 2 kidneys. These results show that explanted chronically rejected grafts display cytotoxic molecule transcripts in addition to Th2 type cytokines, such as IL-10, IL-3, and IL-6, suggesting that both cellular and humoral alloreactive mechanisms may play important roles in CAN pathogenesis.

Background: The outcome of patients with nasopharyngeal carcinoma (NPC) presenting as advanced-stage disease or failing conventional radio-chemotherapy is poor. Thus, additional forms of effective, low-toxicity treatment are warranted to improve NPC prognosis. Since NPC is almost universally associated with Epstein– Barr virus (EBV), cellular immunotherapy with EBV-specific cytotoxic T lymphocytes (CTLs) may prove a successful treatment strategy. Patient and methods: A patient with relapsed NPC, refractory to conventional treatments, received salvage adoptive immunotherapy with EBV-specific CTLs reactivated ex vivo from a human leukocyte antigen-identical sibling. EBV-specific immunity, as well as T-cell repertoire in the tumor, before and after immunotherapy, was evaluated. Results: CTL transfer was well tolerated, and a temporary stabilization of disease was obtained. Moreover, notwithstanding the short in-vivo duration of allogeneic CTLs, immunotherapy induced a marked increase of endogenous tumor-infiltrating CD8+ T lymphocytes, and a long-term increase of latent membrane protein 2-specific immunity. Conclusions: Preliminary data obtained in this patient indicate that EBV-specific CTLs are safe, may exert specific killing of NPC tumor cells in vitro, and induce antitumor effect in vivo.

SUMMARYThe loss of CD4 lymphocytes in HIV disease associates with opportunistic infections. Since diverse CD4 T cell clones respond to an opportunistic pathogen, we asked whether CD4 depletion deletes selected clones in the repertoire (vertical depletion) or it affects all clones by reducing the cell number in each progeny without affecting the overall number of clones (horizontal depletion). Understanding this point may help explain the mode of CD4 depletion and the mode of immunoreconstitution after therapy. Therefore we examined the CD4 T cell repertoire specific for Pneumocystis carinii, a relevant opportunistic pathogen in AIDS, in HIV-infected, asymptomatic individuals. We identified two patients of 36 asymptomatics for lack of proliferation to P. carinii, suggesting selective depletion of specific CD4 cells. To investigate clonal heterogeneity of P. carinii-responsive CD4 lymphocytes, specific CD4 T cell lines were generated and studied by TCR BV gene family usage and CDR3 length analysis (spectratyping). Clonal heterogeneity was similar in antigen-specific CD4 lines generated from P. carinii non-responding HIV seropositives and from controls. Thus, despite undetectable response to the pathogen, residual specific cells probably prevent overt infection and, when expanded in vitro, exhibit a clonal diversity similar to normal controls. These findings suggest a horizontal, rather than vertical, depletion in these asymptomatic patients.

Background Systemic sclerosis is a chronic fibrotic disease highly heterogeneous in clinical outcome, involving autoimmune activation, fibroproliferative vasculopathy and tissue fibrosis of skin and multiple internal organs. The mechanisms linking immune activation and tissue fibrosis are still not fully characterised. A widely accepted model of immune-mediated skin fibrosis is chronic sclerodermoid graft versus host disease (Scl-GVHD), a form of chronic GVHD in patients receiving allogenic bone marrow transplant. Histopathologic studies of cGVHD skin biopsies confirmed the presence of both fibroproliferative vasculopathy and tissue fibrosis in Scl-GVHD. Objective To identify which genes are differentially expressed in SSc skin biopsies are similarly expressed in the transcriptome of Scl-GVHD skin biopsies and therefore of potential importance in linking immune activation and skin fibrosis. Methods Metanalysis of microarray data published in the literature identified a set of 80 genes whose differential expression is highly reproduced in our SSc skin biopsies signature. The mRNA expression level of these genes was then analysed in eight Scl-GVHD and three cGVHD skin biopsies, and compared to normal skin and their differential expression in SSc. Genes found to be significantly differentially expressed (p Results 46 genes were differentially expressed in cGVHD biopsies and 34 remained unique of SSc. 78.3% of the differentially expressed genes had a similar pattern of regulation in SSc. 25% were similarly expressed in both cGVHD variants, whereas 16.6% were specific of Scl-GVHD. Remarkably, this analysis identified several chemokines (CCL5, CXCL9-10-11) specifically involved in the fibrotic versus non-fibrotic response in GVHD and also increased expression of SFRP4, a potent angiogenesis inhibitor, in SSc and Scl-GVHD. Using confocal microscopy we identified as the source of increased SFRP4, cells in the basal layer of the epidermis which lost E-cadherin expression, co-expressed vimentin and specifically lacked Caveolin-1 expression. Conclusion Approximately 50% of SSc signature genes presented an altered expression in cGVHD. The further characterisation of the cells that play a role both in the fibrotic process, by undergoing EMT, and in the vasculopathy, by inhibiting angiogenesis through SFRP4 inhibition of WNT signalling, may pave the way to understand the link between these two processes in SSc.

Background Skin involvement is of major clinical and prognostic relevance in systemic sclerosis (SSc) and is often the primary outcome in clinical trials in SSc. Nevertheless, a fully validated, objective and sensitive measure of skin involvement is lacking. Shear-wave elastography in the form of Siemens9 proprietary, Virtual Touch and Imaging Quantification (VTIQ), is an emerging, operator-independent technique, which can obtain absolute quantitative stiffness values. Objectives To determine validity and reliability of VTIQ for evaluate skin stiffness as a measure of skin involvement in SSc. Methods Twenty-six SSc patients were included (mean age was 55.3±12.1, mean disease duration 12.5 years (range 0.5-36), and mean mRSS 11.8 (range 0-33). Seventeen age and gender matched controls were recruited. Ultrasound evaluation was performed with a Siemens ACUSON S3000 ultrasound system. Each participant underwent an ultrasound exam at 16 Rodnan sites (face was excluded). The images consist of translucent colour maps superimposed on B-mode images, indicating soft through stiffer tissue and supplemented by tabulated absolute values for shear wave velocity (as a measure of the skin stiffness). Mean shear-wave velocities (in m/s) were obtained at each site by averaging three measurements made per image. Intraobserver reliability was calculated in four SSc patients and two healthy controls, in two different scanning sessions, one week apart. Results The mean and SD absolute stiffness measures were (in m/s): chest –SSc 2.7±1.1 vs control 2.3±0.7, upperarm – SSc 2.9±1.0 vs control 2.2±0.3; forearm – SSc 3.1±1.1 vs control – 2.2±0.3; finger –SSc 4.3±2.0 vs control – 2.2±0.2; hand –SSc 4.0±1.5 vs control – 2.2±0.3; abdomen - SSc 2.4±0.8 vs control 2.0±0.4, thigh – SSc 2.6±0.4 vs control 2.1±0.2, leg – SSc 3,1±0.9 vs control 2,4±0,4 and foot – SSc 3.2±0.9 vs control 2.3±0.2. Average skin stiffness increased with increasing skin scores for all regions studied other than hands (Figure 1). Two-tailed t-tests were performed to investigate whether differences between the means of patients and controls differed systematically at each site. Statistical significance (p The technique showed very good intraobserver reliability in our small sample (intraclass correlation coefficients >0.8). Conclusions Shear-wave elastography represents a feasible and reproducible quantitative method for assessing stiffness of the skin in scleroderma. It adds sensitivity to clinical evaluation, as even apparently normal skin in SSc patients presents increased shear-wave velocities values. Further research is required, but this early study supports the clinical and scientific potential of this new measure of skin involvement in SSc. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1213

Background Optical coherence tomography (OCT) has been recently shown to be a novel quantitative reliable tool to assess skin involvement in Systemic Sclerosis (SSc) (1). However the sensitivity to change over-time has not been evaluated. Objectives The present study aimed to compare skin assessment by OCT over-time in patients with SSc. Methods We performed 52 OCT scans of dorsal forearms on 26 sites of analysis from 17 SSc patients (9 with diffuse, 8 with limited subset according to Le Roy et al; F/M =15:2; mean disease duration at baseline ± SD =6±4.5 years) at 0 and 24 months. Clinical skin involvement was assessed using the modified Rodnan skin score (mRss). Minimum and Maximum Optical Density (Min and Max OD) of the mean-A scans were calculated employing Matlab software as previously described (1). Comparison of the mRss at the site of analysis and Min and Max OD at the 2 time-points was performed by two-tailed paired t-test employing GraphPrism software. Results Fourteen sites of analysis with local mRss=0 did not change over 24 months. Accordingly, both Min and Max OD showed only an average +2.98% and -0.05% change, respectively (p>0.05). By contrast, at 6 sites of analysis mRss improved by 2 points (three sites with local score “2” improved to “0”, three sites with local score of “3” improved to “1”). At these sites Min OD showed an average increase of 23.92% (p=0.0084) and Max OD of 25.13% (p=0.008). At 4 sites of analysis mRss improved by 1 point (two sites with local score “3” improved to “2”, one site with local score of “2” improved to “1”, one site with local score of “1” improved to “0”). At these sites Min OD and Max OD showed no significant improvement (Min OD of 1.93% and Max OD of 8.15%; p>0.05 for both). Furthermore, both Min and Max OD showed a trend towards a decrease (-3.54%, -5.41% respectively) at the 2 sites of analysis with worsening mRSS (one point increase). Conclusions Although a low number of observations, this preliminary study provides the first evidence suggesting that OCT of the skin is sensitive to change over time and is consistent with mRss. The lack of improvement of OCT findings at sites with a mRSS of 1 deserves further evaluation to determine whether this is associated with poor accuracy of mRSS or room for improvement in OCT analysis. Studies including a larger number of patients and sites of analysis with different grades of skin involvement and improvement/deterioration of clinical score are needed for more definitive validation. References Abignano G, Aydin SZ, Castillo-Gallego C et al. Virtual Skin biopsy by Optical Coherence Tomography: the first quantitative imaging biomarker for Scleroderma. Ann Rheum Dis 2013;72:1845-51. Disclosure of Interest G. Abignano: None declared, L.-A. Bissell: None declared, J. Britton: None declared, G. Lettieri: None declared, D. Woods Employee of: Michelson Diagnostics, M. Buch: None declared, D. McGonagle: None declared, P. Emery: None declared, F. Del Galdo: None declared DOI 10.1136/annrheumdis-2014-eular.4697

Background Nail-fold capillaroscopy (NFC) patterns of vasculopathy have been well described in systemic sclerosis (SSc) but few studies have reported their predictive value in an unselected cohort of patients with Raynaud9s Phenomenon (RP). Objectives To describe the association and predictive value of NFC patterns with a clinical diagnosis of SSc. Methods Patients (pts) referred to a tertiary Scleroderma clinic to aid in the diagnosis and management of RP were evaluated by light/video-NFC, performed by a fully trained physician. Data collected included clinical diagnosis, antibody (Ab) status, NFC findings and fulfilment of the VEDOSS or 2013 ACR/EULAR criteria for SSc. Primary RP (pRP) was defined as RP with no features of CTD/Ab. NFC patterns were determined: normal, non-specific, “early”, “active” or “late” SSc patterns as described. Results 347 pts were referred to the NFC service between Jan 2009 and Oct 2013; mean (SD) age was 47 (15.2) yrs, 83% were female, 26% smokers (Table 1). On clinical review, 54 (15%) did not have RP, 69 (20%) had primary RP, 52 had SSc (56% ACA+ve, 8% Scl70+ve; 67% lcSSc, 10% dcSSc, 11.5% undefined, 11.5% overlap; at referral, 29% met VEDOSS criteria, 60% met 2013 ACR/EULAR criteria), and 172 (39.5%) had secondary RP (sRP). NFC SSc pattern was detected in 80 (23%) pts: 43 with “early”, 31 with “active” and 6 with “late” pattern. 37 of the 52 patients with SSc had SSc pattern at NFC. Among the other patients with SSc pattern, 30 had sRP, 9 pRP and 4 no RP. Non-specific findings were detected in 8/52 patients with SSc, 62/172 patients with sRP, 33/69 patients with pRP and 21/54 patients with no RP. Of those without a clinical diagnosis of scleroderma (n=295), 41 (14%) met VEDOSS criteria following NFC and 4 (1.3%) the 2013 ACR/EULAR criteria for SSc. Of the 41 pts meeting VEDOSS, 28 (68%) were found to have a SSc NFC pattern. Considering the entire unselected cohort, the detection of SSc pattern on NFC had a sensitivity of 71%, specificity 95%, positive predictive value 84% and negative predictive value 90% for identifying pts who met the VEDOSS or 2013 ACR/EULAR criteria. Conclusions Our specialised NFC service improved the detection of SSc in an unselected cohort of pts with RP or suspected CTD. Pts meeting the new ACR/EULAR criteria are more likely to have a SSC NFC pattern than those meeting VEDOSS criteria. The absence of SSc NFC pattern in pts with RP or suspected CTD is very valuable in the exclusion of SSc. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.1577

Background Skin involvement in systemic sclerosis (SSc) is often primary outcome in clinical trials but it is still orphan of a quantitative imaging technique. Optical Coherence Tomography (OCT) is an emerging imaging technology for clinical examination employing a low-intensity infra-red laser beam and providing high-contrast 2 mm deep skin images with a 4 micron resolution. Objectives The aim of this study was to evaluate face validity and reliability of OCT in SSc. Methods Dorsal aspect of forearms was assessed employing topical probe “VivoSight” (Michelson Diagnostics) and optics of Swept-source Fourier-Domain type with a laser wavelength of 1305±15 nm. Clinical skin involvement was determined using the mRSS. The study included 8 foreams from 8 healthy controls (HC) and 5 forearms for each group scored from “0” to “3” from 13 SSc patients. Hematoxylin-Eosin (H&E) staining was performed from forearm skin biopsy, within 1 cm of OCT scanned region, in one HC and one SSc patient (mRSS=3 on the site of analysis). Matlab software was employed to calculate mean optical density (OD) of the scans. Signal changes within epidermis (ED), Dermal-Epidermal Junction (DEJ) and dermis of SSc patients and HC were analysed and collated to a unique graph. To investigate the intraobserver and interobserver reproducibility, intraclass correlation coefficient (ICC) and limits of agreement (LoA) were calculated for the minimum value after the first peak and the maximum value of the second peak of the averaged A-scans. Results OCT images collected in HC showed a regular hyper-reflective border of the skin surface and a homogeneous hypo-reflective epidermal layer. The papillary dermis (PD) was visualized as hyper-reflective area compared to the adjacent ED allowing the visualization of the DEJ. Mean OD data showed that DEJ was a OD nadir region between 60 and 70 micron from the surface, the PD a high density region (OD range:0.64-0.72; micron range:60-100) and the reticular dermis (RD) had a OD ranging from 0.72 and 0.4. In contrast SSc affected tissues (mRSS=3) showed no DEJ and no increase in OD in the PD which appeared with a range density of 0.61-0.56. Interestingly in SSc non-affected tissues (mRSS=0), the valley corresponding to DEJ was still visible with an almost normal OD range of the PD (OD=0.64-0.67) and an OD of the second peak lower than healthy subjects. In the remaining cases (mRSS=1 and 2) the valley after the entrance peak was still visible, however with a weaker second peak compared to healthy skin and SSc non-affected skin. Validation with HE LoA=0.94-0.99) in both parameters measured by the same clinician on the two separate occasions. The interobserver reliability was also excellent with ICC>0.89 (LoA=0.61-0.97) in both parameters assessed by two investigators. Conclusions This is a proof of concept validation of face validity of OCT as quantitative imaging technique of scleroderma skin. The potential of this tool is supported by an excellent reliability. Sensitivity to change ability of OCT is under evaluation to determine whether the technique could be used as outcome measure of skin involvement in SSc. Disclosure of Interest None Declared

Background Measurement of skin involvement is essential for diagnosis and assessment of prognosis in systemic sclerosis (SSc). The modified Rodnan Skin Score (mRSS) is the gold standard outcome measure for assessment of skin thickness by palpation. The mRSS has been criticised for being associated with high inter-observer variability and requiring a skilled trained investigator. There is a need therefore for a reliable and objective method to assess skin stiffness. Elastography Ultrasound (EUS) is a new, non-invasive method, which has allowed qualitative and quantitative measurements of relative skin stiffness. Recently, acoustic radiation force impulse (ARFI) with a new 3 rd generation technology, virtual touch quantification (VTQ), has added a new dimension, reporting absolute values for the wave propagation speed (absolute tissue stiffness). The use of VTQ technology has never before been reported in patients with SSc. Objectives To assess skin absolute stiffness in SSc using VTQ. Methods Skin absolute stiffness was measured by VTQ at 5 of the 17 anatomical sites of the mRSS (forearm, hand, phalanx, leg and foot, of the dominant limb). Eight patients and eight age and gender matched controls were included in the study. Ultrasound measurements of absolute skin stiffness were compared with mRSS. Absolute skin stiffness measurements are presented as median plus interquartile ranges. Spearman correlation tests were used to calculate associations between ultrasound measurements and mRSS. Results Absolute skin stiffness measurements were systematically higher in SSc patients vs controls in 4 out of 5 measurements sites: forearm [2.4 (0.5) vs 1.7 (0.3)], hand [3.0 (1.4) vs 2.0 (0.9)], phalanx [3.8 (3.0) vs 2.1 (0.5)] and dorsum of the foot [4.4 (3.3) vs 3.1 (1.9)]. Forearm absolute skin stiffness correlated with the total mRSS (r=0.707, p=0.002). Hand absolute skin stiffness correlated with the local mRSS for this site of analysis (r=0.609, p=0.012). figure 1 VTQ of the volar aspect of the forearm in a control (A) and in a patient with SSc (B). Skin absolute stiffness values (shear-wave velocities) are presented (m/s) (right side). Red indicates stiff tissue, green/yellow intermediate stiffness and blue low stiffness. Tissues with a higher shear-wave velocity have higher stiffness. Image/graph Conclusions VTQ is a novel and promising application of ARFI imaging. It provides a very precise quantification of absolute skin stiffness and has potential as an objective measure for skin assessment. Further studies are warranted to define the potential contribution of VTQ to the clinical evaluation and for its use as potential outcome measure of skin involvement in SSc. References Clements PJ, et al Arthritis Rheum.1990;Iagnocco A, et al J Rheumatol. 2010;Di Geso L, et al Clin Exp Rheumatol. 2011. Disclosure of Interest None Declared

Background A recent large multicenter study has identified an algorithm, known as Enhanced Liver Fibrosis (ELF), by combining the serum concentrations of amino-terminal propeptide of procollagen type III (PIIINP), tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) and hyaluronic acid (HA). The algorithm has been shown to predict liver related outcomes in patients with chronic liver diseases and recently it has been shown to correlate with several measures of fibrosis in Systemic Sclerosis (SSc). Objectives The aim of this study was to compare the ability of ELF and its single components in correlating with the different clinical and instrumental variables to determine whether any of the three biomarkers could have a specific role as surrogate outcome measure in SSc. Methods The serum concentrations of the three biomarkers were analysed in 210 SSc patients employing the same platform used to calculate the ELF score (Siemens, Advia Centaur). All patients were investigated for clinical features, skin and internal organs involvement, HAQ-DI, disease severity and activity. Statistical analysis was performed using GraphPrism software. Results Correlation coefficients are shown in the table. All three components of ELF showed a significant correlation with mRSS and were higher in patients with flexion contractures (p Conclusions Sub-analysis of the single serum markers included in the ELF score algorithm suggests that the different biomarkers may function as surrogate outcome measure of specific organ involvement in SSc. In this regard, longitudinal studies assessing the sensitivity to change over time of the single biomarkers may pave the way to develop specific algorithms tailored to carry the maximum predictive value on specific organ involvement in SSc. Disclosure of Interest None Declared

Background Elastography Ultrasound (EUS) is an ultrasound-based method, which allows the qualitative or quantitative measurements of the biomechanical properties of tissues. EUS can be performed using compression-wave or more recently, shear-wave propagation, using acoustic radiation force impulse (ARFI) imaging and associated new virtual touch imaging (VTI) and virtual touch quantification (VTQ) technologies. ARFI estimates tissue stiffness in real time and is quantitative and user independent. The use of VTQ technology has never before been reported in patients with systemic sclerosis (SSc). Objectives To compare the relative and absolute soft tissue stiffness in patients with SSc and healthy controls using compression EUS and ARFI. Methods Twenty-six patients with SSc and twenty-five age and gender matched healthy controls were included in the study. Relative and absolute stiffness of soft tissue were measured on the palmar aspect of the third metacarpophalangeal joint, plantar aspect of the third metatarsophalangeal joint and over the heel. All these sites have an anatomical features associated withbiomechanical stress. Results There was a trend towards greater tissues stiffness values in SSc patients and controls using all three technologies. VTQ was the most consistent measure and provided absolute outputs (Table 1). Conclusions Measurements of tissue stiffness by EUS add a new dimension to the assessment of soft tissues in SSc. The compression EUS and VTI technologies have some limitations for the real-world application in SSc. VTQ however, is a promising technique that provides absolute and objective quantification of tissue stiffness. In the longer term VTQ and similar technologies may offer an objective and quantitative alternative tools to clinical measures such as the modified Rodnan Skin Score. References -Clements PJ, et al Arthritis Rheum. 1990; 33:1256-63; -Drakonaki EE, et al. Br J Radiol. 2012; 85:1435-45; -Iagnocco A, et al J Rheumatol. 2010;37:1688-91; -Di Geso L, et al Clin Exp Rheumatol. 2011; 29:926-32; -Porta F, et al Rheumatology (Oxford). 2012;51:S7. Disclosure of Interest None Declared

Background The key cellular elements in the pathogenesis of tissue fibrosis are myofibroblasts. It is widely accepted that the number of myofibroblasts is increased in Scleroderma (SSc) and it correlates with the severity of tissue fibrosis. The mechanisms underlying their increased number in SSc are unknown. The heterogeneity in their frequency may explain the inconsistency of some in vitro studies published on SSc fibroblast biology and may mirror the clinical heterogeneity of SSc patients both in natural history and severity of skin fibrosis. Objectives The purpose of this study was to unravel the specific transcriptome of myofibroblasts derived from SSc skin biopsies. Methods Four patients with diffuse rapidly progressive SSc, within 18 months from skin involvement and before any immunosuppression, were enrolled in the study. Skin biopsy on forearm was performed and the fibroblasts subcultured for three passages. 250 acetone fixed alpha-SMA positive cells were isolated by laser capture microdissection (LCM) for mRNA analysis by Affymetrix Gene array. qRT-PCR and in situ hybridization were employed for validation of the results. Pathway analysis was conducted according to David-NIH software. Immunofluorescence (IF) followed by confocal laser scanning microscopy (CLSM) was conducted as well. Normal dermal fibroblasts were utilized to evaluate the effects of TGF-beta stimulation both at mRNA and protein level. Results qRT-PCR for alpha-SMA showed, in average, 3.7 fold increased expression in alpha-SMA in the LCM captured cells. Microarray analisis identified 269 genes upregulated more than 2 fold in the myofibroblasts. Of these, 24 were clearly reconducible to profibrotic activation, including alpha-SMA, Collagens I, VI and XI, Fibronectin, several Integrin genes, FGF7, CD36, IGF and Rho; 16 were ribosomial genes; 14 were mitochondrial genes involved in oxidative phosphorylation, including COX1,2, 3 and 6 ND1 to 6, CYT-b and F-type ATP-ase; 28 genes were involved in cell to cell adhesion including, JAM2, ERM, and MLC and 7 in antigen processing and presentation including RAB13, B2-microgrobiulin, cathepsin, HSPs, calnexin, and calreticulin. The remaining genes were not classifiable in any specific functional pathway. IF studies followed by CLSM confirmed the specific pattern of protein expression in myofibroblasts vs alpha-SMA negative fibroblasts from the same donor. Long non coding RNA tiling array of the same cells indicated that alpha-SMA positive fibroblasts had a specific up-regulation of HOX-A9 also known as HOTAIR, which is usually expressed mainly in the dermis of the palmo-plantar region. qRT-PCR and in situ hybridization confirmed the increased expression of HOTAIR in SSc skin. Consistently with these results, skin biopsies from the forearms of SSc patients showed an increased level of the palmo-plantar specific Keratin-9. Conclusions Myofibroblast secretome displayed, besides predictable genes involved in the increased ECM production and TGF-beta pathway activation, a specific gene expression non TGF-inducible and suggestive of a distinct and stable differentiation lineage usually present only in the palmo-plantar region. This distinct differentiation status may account for the dermal and epidermal changes in SSc. Disclosure of Interest None Declared

Background Calcium deposits (calcinosis) in Systemic Sclerosis (SSc) are clinically heterogeneous both for site and severity of involvement. Despite often leading to complications such as digital ulcers and driving poor hand function, little attention has been paid to the pathogenesis of calcinosis and the therapeutic options remain limited. The presence of calcinosis in limited cutaneous SSc as well as in the diffuse form suggests that the condition may be associated with vasculopathy rather than fibrosis, however to date, no formal studies have addressed this hypothesis. Objectives We performed video-capillaroscopy of peri-calcinotic skin and unaffected skin in the same but contra-lateral Region of Interest (ROI), to determine whether we could detect any calcinosis – specific change in the capillaroscopic pattern. Methods Eighteen calcinotic deposits and contra-lateral ROIs were analysed with an Optilia Digital video-capillaroscopy system equipped with 200x magnification lens. For each calcinotic deposit we captured images in the 4 surrounding quadrants within 3 millimetres of the lesion. Images from each quadrant were captured, indentified and stored and in an electronic database. Analysis of the images was performed by two rheumatologists fully trained in video-capillaroscopy and blinded to the clinical details. Presence of; enlarged capillaries, Giant capillaries, Haemorrhages, Drop-out, disorganisation and capillary ramifications were assessed independently. McNemars tests were employed for statistical analysis. Results Twelve of the 18 calcinotic deposits were located at the distal phalanx, 3 at the proximal phalanx, 1 at both the middle and proximal phalanx and two at the palmer metacarpal. Drop out areas were observed in at least 1 quadrant of all 18 calcinotic deposits vs 7 contra-lateral control ROIs (p=0.05). Enlarged capillaries were observed at 17 deposits vs 11 ROIs (p =0.05), giant capillaries, disorganisation and capillary ramifications were observed at 7, 9 and 5 deposits, respectively, while none were observed in any ROIs (P < 0.05 for all). Haemorrhages were observed at 5 deposits and 2 ROIs, (P = 0.05). Conclusions This pilot study suggests that specific features of severe vasculopathy such as drop out areas, giant capillaries and disorganisation of the vascular array are observable in plain skin video-capillaroscopy and may be specifically associated with calcinotic deposits in SSc. Further studies are warranted both to unravel the role of vasculopathy in the pathogenesis of calcinosis and to determine potential benefit of therapeutic options targeting peripheral vasculopathy. Disclosure of Interest None Declared