A. Del Rosso

Nerve growth factor and neuropeptides circulating levels in systemic sclerosis (scleroderma).

OBJECTIVE To determine the circulating levels of nerve growth factor (NGF), neuropeptide Y (NPY), and vasoactive intestinal peptide (VIP) in systemic sclerosis (SSc), and to correlate these levels with clinical and laboratory features. METHODS Forty four patients with SSc were evaluated for circulating NGF (immunoenzymatic assay), NPY and VIP (radioimmunoassay), anticentromere and antitopoisomerase I autoantibodies, lung disease (pulmonary function tests with carbon monoxide transfer factor (Tlco), ventilation scintiscan with 99mTc DTPA radioaerosol, high resolution computed tomography (HRCT), pulmonary pressure (echo colour Doppler)), heart disease (standard and 24 ECG, echocardiography), cutaneous involvement (skin score), joint involvement (evidence of tender or swollen joints, or both), peripheral nervous system (PNS) involvement (electromyography), rheumatoid factor, angiotensin converting enzyme (fluorimetric method), von Willebrand factor (ELISA), and erythrocyte sedimentation rate (ESR) (Westergren). RESULTS Circulating NGF levels in SSc were significantly increased compared with controls (p<0.00001) and significantly higher in the diffuse than in the limited subset of patients (p<0.01). Patients with articular disease had significantly higher levels of NGF. A significant indirect correlation between NGF levels and Tlco was detected (p<0.01), but no correlation was found between NGF and HRCT, DTPA, skin score, PNS involvement and angiotensin converting enzyme and von Willebrand factor levels, antitopoisomerase or anticentromere antibodies, and ESR. NGF levels increased progressively as the disease worsened. Similarly, VIP circulating levels were significantly increased in patients with SSc (p<0.001), whereas the increase of NPY levels did not reach statistical significance. However, both neuropeptides, following the same trend as NGF, increased as the disease worsened (skin score and lung disease). CONCLUSIONS The increase of NGF and VIP in patients with SSc, the former in the diffuse subset of the disease, and in patients with prominent articular disease, may suggest a link between neurotransmitters and the disease pathogenesis. Neuropeptide circulating levels seem to increase only in patients with the most severe disease.

Systemic sclerosis fibroblasts inhibit in vitro angiogenesis by MMP-12-dependent cleavage of the endothelial cell urokinase receptor

Failure of endothelial cells to develop new vessels in response to hypoxia is a distinctive feature of systemic sclerosis (SSc) in the avascular phase. We have previously shown that SSc endothelial cells over‐express matrix metalloproteinase‐12 (MMP‐12), which blocks angiogenesis by cleavage of the endothelial urokinase‐type plasminogen activator receptor (uPAR). In the present study, we have investigated whether over‐expression of MMP‐12 and of angiostatic factors, or hypo‐expression of angiogenic factors by SSc fibroblasts, contributes to impaired angiogenesis in SSc. Dermal fibroblasts were isolated from healthy subjects (N‐Fb) and patients with diffuse SSc (SSc‐Fb). Angiogenesis of target normal human microvascular endothelial cells (H‐MVECs) was assayed by Matrigel invasion, cell proliferation, and capillary morphogenesis. uPAR cleavage and MMP‐12 activity were evaluated by western blotting. We show that the over‐expression of MMP‐12 by SSc‐Fb determines uPAR cleavage in H‐MVECs. Conditioned medium from SSc‐Fb impaired H‐MVEC proliferation, invasion, and capillary morphogenesis. Anti‐MMP‐12 antibodies restored such impairment. Altered expression of angiostatic/angiogenic factors, including transforming growth factor β1, did not account for SSc‐Fb‐dependent impairment of angiogenesis. The over‐expression of MMP‐12 by both SSc‐Fb and SSc endothelial cells indicates that MMP‐12 over‐production may have a critical pathogenic role in SSc‐associated vascular alterations. Copyright

Ultrastructural study of the muscle coat of the gastric wall in a case of systemic sclerosis

In systemic sclerosis (SSc), which affects the microcirculation and leads to fibrosis of skin and internal organs,1 the oesophagus and the colon are the gastrointestinal (GI) segments most commonly affected, even though other tracts can be impaired.2,3 In SSc, a few ultrastructural examinations of the oesophageal and rectal wall have been made,4,5 but no study has been carried out on the stomach. This prompted us to examine the gastric wall of a patient with SSc by transmission electron microscopy (TEM) in order to investigate the components of the muscle coat. In 1997 a 52 year old woman, with limited SSc (lSSc) since 1979, came to our attention. She had Raynauds phenomenon, sclerodactyly, anticentromere antibodies, and Sjof-grens syndrome, but no lung, heart, and kidney disease. From the onset of her SSc, the patient had severe involvement of the distal oesophagus, which was confirmed by oesophagogastroscopy. In May 1998 the gastro-oesophageal symptoms worsened despite treatment (ranitidine and, later, omeprazole and cisapride) and the patient underwent a Nissen-Rossetti laparoscopic fundoplication. Eight months later, as she became progressively unable to eat, she underwent a total gastrectomy with a Roux-en-Y oesophagojejunal anastomosis operation. Samples of gastric anterior wall near the …

Piascledine modulates the production of VEGF and TIMP‐1 and reduces the invasiveness of rheumatoid arthritis synoviocytes

Background: In rheumatoid arthritis (RA), hypertrophy of the synovial membrane generates a tumour‐like pannus that invades the joint cavity and erodes cartilage and bone. Invasion of the extracellular matrix (ECM) is accompanied by angiogenesis, in which vascular endothelial growth factor (VEGF) and tissue inhibitors of metalloproteinases (TIMPs), produced by synoviocytes lining the pannus, have a primary role. Piascledine (PSD) is used in the treatment of osteoarthritis and has anti‐inflammatory effects in vitro. Objective: To study the effects of PSD on levels of VEGF and TIMP‐1 and chemoinvasion in RA synoviocytes and healthy controls. Methods: The effects of PSD 5, 10, and 20 µg/mL were evaluated, with/without interleukin‐1β (IL‐1β) and tumour necrosis factor‐α (TNFα) 20 ng/mL, on synoviocytes. The levels of VEGF and TIMP‐1 were assayed in the culture medium by enzyme‐linked immunosorbent assay (ELISA). Chemoinvasion was measured by the Boyden chamber invasion assay. Results: RA synoviocytes treated with PSD showed, compared to basal, lower levels of VEGF (41080±830 vs. 79210±920 pg/106 cells, p<0.001) and increased levels of TIMP‐1 (23540±93.2 vs. 12860±42.9 ng/106 cells, p<0.001). PSD decreased dose‐dependently IL‐1β and TNFα induced migration. Conclusions: In RA synoviocytes, and also to a lesser extent in control cells, PSD modulates VEGF and TIMP‐1 and decreases chemoinvasion. PSD might have a role in the treatment of RA synovitis controlling invasiveness.

Raloxifene reduces urokinase-type plasminogen activator-dependent proliferation of synoviocytes from patients with rheumatoid arthritis.

Extracellular fibrinolysis, controlled by the membrane-bound fibrinolytic system, is involved in cartilage damage and rheumatoid arthritis (RA) synovitis. Estrogen status and metabolism seem to be impaired in RA, and synoviocytes show receptors for estrogens. Our aims in this study were to evaluate in healthy and RA synoviocytes the effects of Raloxifene (RAL), a selective estrogen receptor modulator (SERM), on: proliferation; the components of the fibrinolytic system; and chemoinvasion. The effects of RAL were studied in vitro on synoviocytes from four RA patients and four controls. Proliferation was evaluated as cell number increase, and synoviocytes were treated with 0.5 μM and 1 μM RAL with and without urokinase-plasminogen activator (u-PA) and anti-u-PA/anti-u-PA receptor (u-PAR) antibodies. Fibrinolytic system components (u-PA, u-PAR and plasminogen activator inhibitor (PAI)-1) were assayed by ELISA with cells treated with 0.5 μM and 1 μM RAL for 48 h. u-PA activity was evaluated by zymography and a direct fibrinolytic assay. U-PAR/cell and its saturation were studied by radioiodination of u-PA and a u-PA binding assay. Chemoinvasion was measured using the Boyden chamber invasion assay. u-PA induced proliferation of RA synoviocytes was blocked by RAL (p < 0.05) and antagonized by antibodies alone. The inhibitory effect of RAL was not additive with u-PA/u-PAR antagonism. RA synoviocytes treated with RAL showed, compared to basal, higher levels of PAI-1 (10.75 ± 0.26 versus 5.5 ± 0.1 μg/106 cells, respectively; p < 0.01), lower levels of u-PA (1.04 ± 0.05 versus 3.1 ± 0.4 ng/106 cells, respectively; p < 0.001), and lower levels of u-PAR (11.28 ± 0.22 versus 23.6 ± 0.1 ng/106 cells, respectively; p < 0.001). RAL also significantly inhibited u-PA-induced migration. Similar effects were also shown, at least partially, in controls. RAL exerts anti-proliferative and anti-invasive effects on synoviocytes, mainly modulating u-PAR and, to a lesser extent, u-PA and PAI-1 levels, and inhibiting cell migration and proliferation.

HIF-1 mediated upregulation of VEGF and VEGF-R in systemic sclerosis (SSc): Imbalance with angiostatic factors suggests VEGF as a novel option for the treatment of ischemia in patients with SSc

Vascular changes are consistent early findings in patients with SSc and often precede the development of fibrosis. Despite a significant reduction in the capillary density, there is paradoxically no sufficient angiogenesis in the skin of SSc patients. By using a pO2 histograph, we showed that low pO2 values are overt in involved skin of patients with SSc. In vitro, real-time PCR revealed a 3.7-fold upregulation of the potent angiogenic growth factor VEGF in SSc fibroblasts after hypoxic exposure compared to normoxic controls. In situ hybridization for VEGF in skin biopsies of patients with SSc showed an overexpression of VEGF mRNA by fibroblasts and mononuclear infiltrates, whereas its expression was limited to keratinocytes in healthy control biopsies. In contrast to the SSc skin, HIF-1 alpha protein was found to be coexpressed with VEGF in healthy skin samples, indicating that the constitutive VEGF synthesis in the skin is driven by this transcription factor. Additionally, we showed that the lack of angiogenesis in SSc is not due to a reduced bioavailability of the overexpressed VEGF, since the VEGF receptors Flk-1 and Flt-1 were found to be expressed on endothelial cells of patients with SSc, but not in healthy controls, and since SSc patients had severely elevated serum levels of VEGF compared to healthy controls. Despite the enhanced levels of VEGF, serum samples of SSc patients did not induce angiogen-esis in the vivo chorion allantois membrane assay, indicating that the proangiogenic effects of VEGF may be outweighed by angiostatic factors. The hypothesis that VEGF synthesis has to be above an individual threshold in SSc patients to induce angiogenesis was further strengthened by the finding that patients without fingertip ulcers had significantly higher levels than patients with fingertip ulcers. Interestingly, the angiostatic factor endostatin was elevated in a subset of patients and thus may counteract directly the biologic effects of VEGF in SSc patients. Serum levels of VEGF were also correlated significantly with disease severity parameters including antitopoisomerase antibodies. These results suggest that therapeutic application of VEGF by either gene transfer or as a recombinant protein might be a novel option in SSc.

The renal excretory activity of atrial natriuretic factor is independent of renal prostaglandins in humans

Since renal prostaglandins may contribute to natriuresis induced by endogenous atrial natriuretic factor (ANF), acute volume expansion (AVL), a known stimulus of ANF and prostaglandins, was induced in 8 healthy women in order to test whether the consequent sodium and water diuresis is altered by prostaglandin inhibition. AVL (i.v. infusion of a 2 liter 5% glucose solution in 1 h) was infused after placebo and after inhibition of prostaglandins with diclofenac (200 mg/day orally for 4 days), in a double blind randomized cross-over fashion. Urinary eicosanoids (PGE2, PGF2 alpha, 6-ketoPGF1 alpha, TXB2--RIA), plasma ANF (RIA) and urinary electrolytes were determined before, during and after AVL under both placebo and diclofenac regimes. During placebo, AVL induced sustained increases in plasma ANF (174% at peak, p less than 0.001 ANOVA), excretion of the four eicosanoids (149%-1172%, p less than 0.005-0.001), urinary volume (UV, 815%, p less than 0.001), natriuresis (UNa, 98%, p less than 0.005) and in kaliuresis (UK, 90%, p less than 0.001). Cyclooxygenase inhibition resulted in a reduction of over 70% in both baseline values and AVL-induced increase of eicosanoids. It did not alter either baseline levels or AVL-stimulated ANF, UV, UNa and UK in relation to placebo. The present results suggest that the diuretic and natriuretic activity of ANF is not mediated by renal PGs in humans.

Rheumatologic rehabilitation: towards recommendations

Rheumatic patients are highly complex and often affected by chronic diseases. Rehabilitation is generally needed for proper management of the underlying disease. This article describes the characteristics of an effective rheumatologic rehabilitation, takes into account data published in international literature, suggests recommendations based on scientific evidence to develop a correct rehabilitation plan for rheumatic patients and proposes the basis to draw up guidelines in the field of rheumatologic rehabilitation.

THU0592 Efficacy of Rehabilitation with TAI JI Quan on Disability, Quality of Life, Pain, Psychological Distress, Sleep in an Italian Cohort of Patients with Fibromyalgia Syndrome

Background Fibromyalgia syndrome (FMS) is characterized by chronic widespread musculoskeletal pain, and muscle tenderness leading to disability, impaired quality of life (QoL), fatigue, and it is accompanied by sleep disorders and psychological distress. The Tai Ji Quan is a Chinese martial art that, integrating meditation, slow movements, deep breathing and relaxation, contributes to the distribution of Qi (vital breath) throughout the body. Some studies showed that Tai Ji Quan, in patients with rheumatic diseases and FMS, improved QoL, disability, and psychological distress (1-2). Objectives To evaluate the efficacy of Tai Ji Quan on disability, QoL, fatigue, sleep and psychological distress in an Italian cohort of FMS patients. Methods We enrolled 22 FMS patients (16 women and 6 men; age: 52,24±12,19 years; symptom onset: 8,2±5,39 years; diagnosis: 3,25±2,97 years). Eleven patients (Experimental Group) participated to a course of Tai Ji Quan Yang style of 17 lessons (1/week, 60 minutes each); 11 patients (Control Group) participated to an educational course about FMS (17 lessons; 1/week, 60 minutes each). At the enrollment (T0) and at the end of treatment (T1), all FMS patients were evaluated for disability, [Fibromyalgia Impact Questionnaire (FIQ) Health Assessment Questionnaire (HAQ)], QoL [Short-Form 36 (SF36)], fatigue [Functional Assessment of Chronic Illness-Fatigue (FACIT-F)], pain [Widespread Pain Index (WPI)], tenderness [Tender Points (TP)], Sleep Quality [Pittsburgh Sleep Quality Index (PSQI] and mood disorders [Hospital Anxiety and Depression Scale (HADS)]. Results At T0, parameters of FMS patients were similar in the 2 groups. A T1 versus T0, patients of the Experimental Group improved significantly in FIQ (P=0.019), SF36 Summary Physical Index (P=0.016), WPI (P=0.037), tender points (P=0.0035), PSQI total (P=0.044) and PSQI sleep duration (P=0.025) HADS (total score: P=0.015; anxiety subscale: P=0.028) (Table). Patients in the Control Group did not improve in any parameter. Conclusions In our FMS patients, Tai Ji Quan improved disability, QoL, psychological distress, sleep quality and pain. So. it may be regarded as an effective rehabilitation method for treating FMS patients. However, our results should be confirmed by further long-term studies, with follow-up evaluations, in larger populations. References Wang C.C, et al. Rheum Dis Clin North Am, 2011. Wang C.C, et al. N Engl J Med. 2010. Disclosure of Interest None declared

AB1120 Rehabilitation of Temporomandibular Joint (TMJ) in Patients with Systemic Sclerosis (SSC). A Comparison between Two Protocols: Preliminary Results

Background In SSc patients, microstomia is frequent and impairs mouth function. It may be due to fibrosis of skin face and to changes in TMJ, scarcely evaluated and treated with rehabilitation in SSc. Objectives To evaluate, in SSc patients (pts) with microstomia due to TMJ dysfunction, the efficacy of 2 rehabilitation protocol. Methods We enrolled 26 SSc pts (22 women, 4 men; age and disease duration: 59.08±10.31 and 13.65±5.71 years) with microstomia and TMJ dysfunction. Group 1 (13 pts) was treated by Protocol 1 (P1) (home exercises for mimic, masticatory and neck muscles; 20 minutes/day, 3 days/week) and group 2 (13 pts) was treated by Protocol 2 (exercises plus face and neck,connective tissue massage, Kabat technique for mimic muscles, manual techniques -intra- and extra-oral manipulation of TMJ, stretching and mobilization of cranio-cervical muscles-; 1 hour/week). Pts were evaluated at T0, at T1 (end of treatment; week 12) and at T2 (at 8 weeks of follow-up) by: Helkimo Index (Anamnestic -A-dysfunction -D- and occlusal-O- index), for TMJ dysfunction; mobility of cervical rachis (cm) and mouth (ROM) (mm); SSc face involvement (facial skin score; Mouth Handicap in SSc scale–MHISS-). Results At T1, both protocols improved Helkimo A index and Helkimo O Score, while only protocol 2 improved Helkimo D (p<0.05).Mouth left lateralization and protrusion were improved by both protocols while mouth opening and right lateralization were increased only by P2 (p<0.05). At T1, P1 improved cervical anterior flexion and left rotation (p<0.05), with the latter result confirmed at T2 versus (vs) T0 (p<0.01), P2 ameliorated cervical right lateralization, while both protocols improved cervical left lateralization, right rotation and extension (p<0.05), with the latter result confirmed at T2 vs T0 for P1 and P2 (p<0.05). Both protocols reduced facial skin score at T1 (p<0.01), with the results confirmed at T2 vs T0 for both treatments (p=NS). P2 also improves at T1 vs T0 values of MHISS (p<0.05). T0 T1 T2 PT0/T1 P T0/T2 PT1/T2 Helkimo A P1 1.42±0.51 1.08±0.67 1.25±0.62 <0.05 NS NS P2 10.57±4,58 5.64±2,17 9.28±5,73 <0.05 NS NS Helkimo D P1 11.17±4.63 9.08±5.64 10.42±5.35 NS NS NS P2 10.57±4,58 5.64±2,17 9.28±5,73 <0.05 NS NS Helkimo score O P1 2.68±0.49 2.33±0.78 2.50±0.67 <0.05 NS NS P2 2.50±0.65 1.78±0.42 2.36±0.63 <0.01 NS <0.05 Mouth opening P1 42.83±9.51 44.42±13.83 45.08±9.18 NS NS NS P2 44.79±9.17 51.57±8.8 50.57±9.06 <0.001 <0.01 NS Mouth protrusion P1 7.5±2.47 10.63±2.42 9.08±2.61 <0.001 <0.05 <0.05 P2 7.21±2.63 8.71±2.16 8.5±1.74 <0.05 NS NS Cervical anterior flexion P1 3.92±1.16 3.00±0.47 3.54±0.78 <0.05 NS NS P2 3.03±1.47 2.18±1.25 2.5±1.27 NS NS NS Cervical extension P1 18.50±2.81 21.58±2.94 22.46±1.96 <0.001 <0.001 NS P2 17.64±2.5 19.79±1.80 19.86±2.98 <0.05 <0.05 NS Facial Skin Score P1 6.33±2.74 3.83±1,90 4.33±2.01 <0.001 <0.01 NS P2 6.43±2.44 2.93±1.94 3.0±2.07 <0.001 <0.001 NS MHISS P1 22.92±10.73 21.58±9.24 18.42±9.43 NS NS NS P2 22.43±10.43 13.64±7.81 16.50±9.53 <0.05 NS NS Conclusions In SSc patients, both protocols improve TMJ and cervical mobilization, TMJ disability, and skin score. with some of the results confirmed at follow-up. P2, also improving SSc face disability, seems to ameliorate more items than P1 and to be more efficacious than P1. Disclosure of Interest None declared DOI 10.1136/annrheumdis-2014-eular.4505