C. Pizzorni

Correlations between nailfold microangiopathy severity, finger dermal thickness and fingertip blood perfusion in systemic sclerosis patients

Objective The aim of this study was to identify possible correlations between nailfold microangiopathy severity, finger dermal thickness (DT) and fingertip blood perfusion (FBP) in systemic sclerosis (SSc) patients. Methods Fifty-seven SSc patients and 37 healthy subjects were enrolled. All patients were evaluated by nailfold videocapillaroscopy (NVC) to classify and score the severity of microangiopathy. Both modified Rodnan skin score (mRss) and skin high-frequency ultrasound were used to detect finger DT. Laser Doppler flowmetry (LDF) was employed to detect FBP. Results A positive correlation was found between nailfold microvascular damage severity and both ultrasound-DT (p=0.028) and mRss values (p<0.0001). In particular, both ultrasound-DT and mRss were found progressively higher in patients with ‘Early’, ‘Active’ or ‘Late’ NVC pattern of microangiopathy. A negative correlation was observed between nailfold microvascular damage severity and FBP (p<0.0001), showing the lowest FBP of the patients with more advanced NVC patterns. A negative correlation was observed between FBP, and both ultrasound-DT (p=0.007) and mRss values (p=0.0002). SSc patients showed a higher ultrasound-DT at the level of the fingers, as well as a lower FBP than healthy subjects (p<0.0001). Conclusions This study demonstrates a relationship between nailfold microangiopathy severity, DT and FBP in SSc patients.

Correlations between skin blood perfusion values and nailfold capillaroscopy scores in systemic sclerosis patients.

OBJECTIVESnTo correlate blood perfusion (BP) values assessed by laser speckle contrast analysis (LASCA) in selected skin areas of hands and face with nailfold capillary damage scores in systemic sclerosis (SSc) patients.nnnMETHODSnSeventy SSc patients (mean SSc duration 6 ± 5 years) and 70 volunteer healthy subjects were enrolled after informed consent. LASCA was performed at different areas of the face (forehead, tip of nose, zygomas and perioral region) and at dorsal and volar regions of hands. Microvascular damage was assessed and scored by nailfold videocapillaroscopy (NVC) and the microangiopathy evolution score (MES) was calculated.nnnRESULTSnSSc patients showed a significantly lower BP than healthy subjects at fingertips, periungual areas and palm of hands (p<0.0001), but not at the level of face and dorsum of hands. A gradual decrease of BP at fingertips, periungual and palm areas, was found in SSc patients with progressive severity of NVC patterns of microangiopathy (early, active, or late) (p<0.01). A negative correlation was observed between MES and BP values, as well as between loss of capillaries and BP, at the same areas (p<0.001 and p<0.01, respectively). Patients with diffuse cutaneous SSc (dcSSc) showed lower BP than those with limited cutaneous SSc (p<0.04).nnnCONCLUSIONSnLASCA detects a significant reduction of BP only in those areas usually affected by Raynauds phenomenon (fingertips, periungual and palm areas), especially in dcSSc patients, and BP values significantly correlate with the nailfold capillaroscopy scores of microangiopathy.

Advances in nailfold capillaroscopic analysis in systemic sclerosis

Systemic sclerosis is an autoimmune connective tissue disease characterized by early and persistent microvascular impairment which leads to functional and organic manifestations, with progressive fibrosis of the skin and internal organs. Morphological and functional assessment of the peripheral microvasculature is a must, not only for diagnosis but also for the prognosis and therapeutical follow-up of systemic sclerosis patients, as reported in recent studies. Nailfold videocapillaroscopy is the validated technique for the study of scleroderma microangiopathy as it is able to detect peripheral microvascular morphology and both classify and score the capillary abnormalities into different microangiopathy patterns (‘Early’, ‘Active’ and ‘Late’). Indeed, the possibility to early diagnose and follow the microvascular changes and the safety of the technique have made nailfold videocapillaroscopy a mandatory tool for patient evaluation and included its assessment in the new systemic sclerosis classification criteria. Important links between nailfold videocapillaroscopy patterns and systemic sclerosis clinical manifestations have been described.

Vitamin D, Autoimmune Diseases, and Systemic Lupus Erythematosus

Vitamin D is a steroid hormone that influences glucocorticoids and gonadal hormones, interfering with the immune system and estrogen-modulated cells. Therefore vitamin D deficiency is thought as a risk factor for several chronic inflammatory and autoimmune conditions.

AB0683 Treatment with statins in patients studied by fdg-pet/ct for possible large vessel vasculitis is associated with a low vascular score

Background Polymyalgia rheumatica (PMR), giant cell arteritis (GCA), and fever of unknown origin (FUO) may show large vessel vasculitis (LVV) when studied with FDG-PET/CT. Statins, widely used to lower cholesterol concentrations, have shown anti-inflammatory activity in both the atherosclerotic plaque and in rheumatoid arthritis. Objectives To test the hypothesis that the concomitant treatment with statins induces a low uptake of the vessels in patients with PMR, FUO and GCA. Methods Consecutive patients with a diagnosis of PMR, GCA or FUO underwent a thorough clinical examination, including drug history, and a PET/CT scan. Arterial uptake of FDG was scored relative to liver uptake as 0=nou2009uptake present, 1=lower than liver uptake, 2=similaru2009to liver uptake, 3=higher than liver uptake. The values of each district were summed to obtain a total vascular score (TVS). A further semi-quantitative analysis of FDG uptake was carried out, drawing regions of interest (ROIs) on the theoretical arterial wall and within the left ventricular chamber (blood-pool, BP). Arterial FDG uptake was quantified by calculating the mean standardised uptake value (SUV) within each ROI and the results expressed as the ratio between mean SUV value of each ROI and BP ROI (SUV/BP). Results 129 patients were included, 87 women, with median age of 74 years (range 50–92). 95 patients were diagnosed with PMR, 13 with GCA, 16 with both PMR and GCA and 5 patients presented with FUO. 37/129 patients (28.7%) were assuming glucocorticoids (GC) at the time of examination. The mean interval between onset of symptoms and PET/CT was 85 days (range 4–1957 days). LVV was present in 75 patients (58.2%) when a cut-off ≥2 was used and 32 patients (24.8%) had a score of 3. Twenty/129 patients (15.5%) were treated with statins for hypercholesterolemia. The median TVS was significantly lower in these patients when compared with those not treated with statins (8 [range 1–27] vs. 12 [range 0–42], p=0.02). This difference was present at the ascending aorta (p=0.017), the aortic arch (p=0.023), and the femoral arteries (p=0.025). The analysis of SUV was not significant (p=0.45). As expected, the arterial calcium load, corresponding to the extent of vessel calcification, was higher in patients treated with statins (14 [range 2–35] vs. 8 [range 0–35]; p=0.012). However, calcium load did not correlate with the TVS, whereas it inversely correlated with SUVs (p=0.03). At multiple regression, assumption of statins was not predicted by sex, type of diagnosis, GC treatment or presence of LVV at PET/CT. Only age predicted statin therapy (p=0.04), but age was not associated with LVV (p=0.23). Among clinical features, only fever was significantly less frequent in patients treated with statins (p=0.03). Conclusions With the limits of an observational retrospective study, our data suggest that treatment with statins may lower arterial uptake in patients studied for LVV. This finding was seen using the theoretically more subjective TVS but not with SUV analysis. We feel that the latter is more easily influenced by the presence of calcific plaques, as suggested by its inverse correlation with arterial calcium load. The role of statins in tempering arterial inflammation deserves further studies. Disclosure of Interest None declared

AB0539 Correlation between morphological and functional microvascular damage in systemic lupus erythematosuspatients

Background Numerous articles have investigated peripheral microcirculation in primary Raynaud’s phenomenon (PRP).1–3 However, reports that analyse peripheral microcirculation in systemic lupus erythematosus (SLE) are scanty.4 5 Objectives The aim of this study was to investigate possible correlations between morphological and functional aspects of microcirculation in different skin areas of the hands and face in SLE patients and to compare the results with PRP patients and healthy subjects (HS). Methods A total of 14 SLE patients without RP (ACR criteria)6 (mean age 53±14u2009SD years, mean disease duration 7±4 years), 14 PRP patients (LeRoy and ACR/EULAR 2013 criteria)7 8 (mean age 53±17 years, mean RP duration 6±5 years) and 14 HS (mean age 50±17 years) were enrolled during the winter period. Nailfold videocapillaroscopy (NVC) and laser speckle contrast analysis (LASCA) were performed in the three groups of patients. The absolute nailfold capillary number (CN) per linear millimetre at first distal row was assessed by NVC. Blood perfusion (BP) was detected by LASCA at the level of fingertips, periungual areas, dorsum and palm of both hands and face. The average BP was calculated as perfusion units (PU).2 Patients were not taking vasodilator drugs since at least one month. Statistical analysis was performed by non parametric tests. Results SLE patients showed a positive correlation between BP and nailfold CN in all areas of hands (p<0.0001), but no statistically significant correlation was observed between BP and nailfold CN at the level of face (p=0.10). In both PRP and HS no statistically significant correlation was observed between BP and nailfold CN in all examined areas (p=0.70u2009and p=0.20, respectively). SLE patients showed a statistically significant lower nailfold CN than both PRP and HS (median 9.1 vs 10.3 vs 11.0, respectively, p<0.0005). Conversely, no statistically significant difference of nailfold CN was observed between PRP and HS. PRP patients showed a statistically significant lower BP than both SLE and HS at the level of fingertip (median 90, 114, 187 PU, respectively; p<0.0001), periungual (median 74, 100, 141 PU, respectively, p<0.0001), dorsal (median 61, 72, 128 PU, respectively, p<0.0001), and palm areas (median 76, 96, 124 PU, respectively, p<0.0001). Conversely, PRP, SLE and HS patients showed similar BP values at the level of face (median 141, 139, 137 PU, respectively, p=0.30). Conclusions This study demonstrates a correlation between morphological and functional microvascular features in SLE patients. SLE patients without RP have a subclinical microangiopathy, showing lower nailfold CN and BP than HS. Conversely, PRP patients show only a functional dysfunction, having a lower peripheral skin BP than both SLE patients and HS. The clinical value of this new finding is undergoing further analysis. References [1] Cutolo M, et al. J Rheumatol2010;37:1174–80. [2] Ruaro B, et al. Ann Rheum Dis2014;73:1181–5. [3] Rosato E, et al. Rheumatology2009;36:2257–63. [4] Anania C, et al. Lupus2012;21:815–20. [5] de Leeuw K, et al. Lupus2008;17:1010–1017. [6] Petri M, et al. Arthritis Rheum. 2012;64:2677–86. [7] van den Hoogen F, et al. Ann Rheum Dis2013;72:1747–55. [8] LeRoy EC, et al. Clin Ex Rheumatol1992;10:485–8. Disclosure of Interest None declared

OP0037 Evaluation of skin involvement in systemic sclerosis patients by using two ultrasound transducers with different frequency

Background The modified Rodnan skin score (mRSS) is the validated method to evaluate the extension of skin involvement in systemic sclerosis (SSc) and to distinguish between patients with limited cutaneous skin involvement (lcSSc, skin involvement is confined to the extremities) or diffuse (dcSSc) (1,2). Recently several studies have demonstrated that skin high frequency ultrasound (US) is a valid and reproducible technique to measure dermal thickness (DT) in patients with SSc (3–6). Objectives To compare the values of DT obtained by two ultrasound transducers with different frequency (18 MHz and 22 MHz) in evaluating the DT in lcSSc patients and healthy controls. Methods Thirty-seven lcSSc patients (mean age 62±13SD years, mean disease duration 5±5SD years) and 37 healthy controls (CNT) sex and age matched were enrolled after informed consent. Both US transducers of 18 and 22 MHz (Esaote, Genova) were used to evaluate DT in the seventeen areas of the skin (zygoma, fingers, dorsum of hands, forearms, arms, chest, abdomen, thighs, legs, feet) of SSc patients where Rodnan skin score (mRSS) is usually assessed. Skin US was also performed in the same seventeen areas of CNT, looking for DT differences in comparison with lcSSc patients. Statistical analysis was carried out by non parametric tests. Results DT evaluated with the 22 MHz probe was found significantly higher in all body areas in comparison with the 18 MHz transducer, both in lcSSc patients (p<0.01) and in CNT (p=0.05). The median difference of DT values between the two probes was of 0.11 millimetres in lcSSc patients (minimum 0.0023, maximum 0.28 mm) and 0.01 millimetres in CNT (minimum 0.0029, maximum 0.03 mm). Of interest, in lcSSc DT evaluated by 18 MHz transducer was recognized significantly higher (p<0.001) also in four out of six skin areas where the mRSS was found normal (score=0) (upper-arms, chest and abdomen), with exclusion of thighs (p=0.08), in contrast with the classification of lcSSc. However, by using the 22 MHz transducer a statistically significantly higher median DT was showed in all skin areas, included thighs (p<0.01). Finally, a positive statistically significant correlation was observed between the two transducers in the evaluation of DT (p<0.0001), as well as between both probes and mRSS (p<0.0001 for both). Conclusions This study suggests that subclinical dermal involvement may be detectable by skin high frequency US already in patients with limited cutaneous SSc. This study confirms that DT can be better assessed in SSc patients by using a 22 MHz US probe, and suggests that DT might be underestimated by using US probes of lower frequency (18 MHz). However, the DT values obtained using both probes resulted significantly correlated together and with the mRSS. References Clements PJ, et al. Arthritis Rheum 2000;43:2445–54. Moore TL, et al. Rheumatology 2003;42:1559–63. Sulli A, et al. Ann Rheum Dis. 2014;73:247–51. Czirják L, et al. Ann Rheum Dis. 2007;66:966–9. Hesselstrand R, et al. Rheumatology 2008;47:84–7. Kaloudi O, et al. AnnRheum Dis.2010;69:1140–3. Disclosure of Interest None declared

OP0212 Endothelin-1 induces a profibrotic phenotype in cultured human microvascular endothelial and circulating monocyte/macrophage cells

Background The alteration of microvascular endothelial cell (EC) functions and the presence of macrophages in the immune inflammatory infiltrate, followed by the transition of these cell types into a profibrotic phenotype, represent early and crucial pathological features of the fibrotic process in systemic sclerosis (SSc) (1). The alternatively activated macrophage subset M2a was found in several diseases characterized by extensive fibrosis (1). M2a macrophages express specific phenotype markers, CD206 (mannose receptor), CD204 and CD163 (scavenger receptors) as well as profibrotic molecules, primarily transforming growth factor-β1 (TGFβ1) (1). Endothelin-1 (ET1) and/or TGFβ1 are known to induce the transition of fibroblasts into profibrotic myofibroblasts, which are key mediators of fibrosis in SSc. Objectives To investigate the effects of ET1 in inducing a profibrotic phenotype in cultured human microvascular ECs (HMVECs) and macrophages. Methods HMVECs, at 3rd culture passage, were grown in endothelial cell medium (EGM2MV) and treated for 6 days with ET1 (100nM) or treated for 1 hr with ET1 receptor antagonist (ETA/BRA, bosentan 10μM) before stimulation with ET1. Human monocytes were isolated from peripheral blood mononuclear cells of healthy subjects using a monocyte isolation kit. The cells were maintained in RPMI growth medium for 24 hrs and then treated for 6 days with ET1 or treated for 1 hr with bosentan before stimulation with ET1. Cultured HMVECs and monocytes maintained in EGM2MV and RPMI growth medium, respectively, were used as untreated cells. Gene and protein expression of profibrotic myofibroblast markers –α-smooth muscle actin (α-SMA), fibroblast specific protein-1 (S100A4), type 1 collagen (COL1) and fibronectin (FN) – were evaluated by quantitative real time polymerase chain reaction (qRT-PCR), Western blotting (WB) and immunocytochemistry (ICC) in cultured HMVECs. Gene and protein expression of M2a phenotype markers (CD206, CD204, CD163) and TGFβ1 were investigated by qRT-PCR and WB in cultured human macrophages. Statistical analysis was carried out by Mann-Whitney non-parametric test. Results In cultured HMVECs, ET1 induced the significant upregulation of the gene expression of α-SMA, S100A4 (myofibroblast markers), COL1 and FN, compared to untreated cells (p<0.001;p<0.001;p<0.05;p<0.01). ETA/BRA significantly contrasted the ET1 mediated transition of HMVECs into a profibrotic phenotype (p<0.05 for α-SMA, COL1 and FN; p<0.01 for S100A4 vs. ET1-treated cells). In cultured human macrophages, ET1 induced the significant overexpression of M2a markers (p<0.05 for CD204 and CD163;p<0.01 for CD206) and TGFβ1 (p<0.01) compared to untreated cells. ETA/BRA significantly contrasted the ET1-mediated transition of cultured macrophages into profibrotic M2a (p<0.05 vs. ET1-treated cells, for all investigated proteins). Data were confirmed by WB and ICC on both cultured cell types. Conclusions ET1 seems to be involved in the early phases of the fibrotic process by inducing the transition of both cultured HMVECs and macrophages into a profibrotic phenotype, myofibroblast and M2a respectively (observed in SSc), a process which is apparently contrasted by ETA/BRA treatment. References Wynn TA et al. Immunity. 2016;44:450–62. Disclosure of Interest S. Soldano: None declared, P. Montagna: None declared, R. Brizzolara: None declared, A. Trombetta: None declared, A. Sulli: None declared, C. Pizzorni: None declared, M. Ghio: None declared, S. Paolino: None declared, V. Smith: None declared, M. Cutolo Grant/research support from: Actelion

SAT0381 Correlation between three different methods to assess dermal thickness in systemic sclerosis patients with different patterns of nailfold microangiopathy

Background Systemic sclerosis (SSc) is characterized by the increase of dermal thickness (DT) (1). The modified Rodnan skin score (mRss) is the validated method to evaluate the severity of skin impairment (2,3). Several studies have reported the capability of high frequency skin ultrasound (US) to reflect the overall severity of the skin damage in SSc patients (4–5). The plicometer skin test (PST) is another method to evaluated cutaneous involvement in SSc patients (6). Objectives The aim of this study was to identify possible correlations between US, mRss and PST to evaluate DT in SSc patients with different patterns of nailfold microangiopathy. Methods Sixty-three SSc patients (mean age 64±11SD years, mean disease duration 7±6 years, 43 lcSSc and 20 dcSSc) and 63 sex and age matched healthy subjects were enrolled after written informed consent. All subjects were assessed by mRss, US and PST to evaluate the DT in the seventeen skin areas of the body usually evaluated by mRss (zygoma, fingers, hands, dorsum of hands, forearms, arms, chest, abdomen, thighs, legs, feet) (1–6). Nailfold videocapillaroscopy (NVC) was used to assess the proper pattern of microangiopathy and to calculate the microangiopathy evolution score (MES) (7–8). Statistical evaluation was performed by non-parametric tests. Results As expected, the group of SSc patients had a statistically significant higher DT, as evaluated by the three methods, at level of all areas when compared to the control group (p=0.0001). All methods demonstrated a progressively higher DT in patients with “Early”, vs. “Active” and vs “Late” pattern of nailfold microangiopathy (p<0.005), and a positive correlation was observed with MES (r=0.71 p<0.001). A positive correlation was observed in SSc patients between the three method to evaluate DT (PST vs mRss r=0.98, p<0.0001; PST vs US r=0.53, p<0.0001; US vs mRss r=0.53, p<0.0001). Conclusions This study demonstrates a relationship between different methods to assess DT (US, mRss and PST) in SSc patients and a relationship between skin damage and microangiopathy impairment. References Moore TL, et al. Rheumatology 2003;42:1559–63. Sulli A, et al. Ann Rheum Dis. 2014;69:1140–3. Kaldas M, et al. Rheumatology 2009;48:1143–6. Hesselstrand R, et al. Rheumatology 2008;47:84–7. Kaloudi O, et al. Ann Rheum Dis. 2010;69:1140–3. Parodi MN, et al. Br JRheumatol. 1997;36:244–50. Sulli A, et al. Ann Rheum Dis 2008;67:885–7. Cutolo et al. J Rheumatol 2000; 27;155.60. Disclosure of Interest None declared

FRI0569 Evaluation of bone microarchitecture in systemic sclerosis patients: relationships between trabecular bone score (TBS) and disease severity

Background Systemic sclerosis (SSc) is a rare connective tissue disorder characterized by an increased synthesis and deposition of extracellular matrix in the skin and internal organs (1). Several studies described SSc as potential risk factor for osteoporosis, however, to date the bone quality in SSc is unclear (2). Trabecular bone score (TBS) has been recently proposed as an indirect measure of bone microarchitecture (3). Objectives The aim of this study was to assess bone microarchitecture in SSc patients and possible association with disease severity and microangiopathy. Methods Twenty-three female SSc patients (mean age 63.2±12.8 SD years, mean disease duration 92.8±66 SD months, mean Raynauds Phenomenon duration 142.6±126.1 SD months) were enrolled after written informed consent. The assessment of disease severity was performed using the Medsgers severity scale (4). Bone Mineral Density (BMD) measurements at L1-L4, femoral neck and total hip, were performed using DXA Prodigy Densitometer (GE Lunar). TBS was derived for each spine DXA examination using the TBS index (TBS iNsight Medimaps). Nailfold videocapillaroscopy (NVC) was used to assess the microangiopathy based on nailfold video capillaroscopic pattern (NVC) analysis and the microangiopathy evolution score (MES) (5–6). Using the FRAX (Fracture Risk Assessment Tool) we also evaluate the 10-year risk of hip and major joints osteoporotic fracture. Results A positive correlation was observed between TBS and Medsgers general organ score (r=0.5; p=0.01); no other correlations were found between TBS and Medsgers score. Interestingly, TBS was positively and significantly correlated with modified Rodnam skin score (mRss) (p=0.01). When the patients were divided in two groups considering skin involvement by mRss, TBS was found significantly higher into the group with mRss >15 compared to the group with mRss <15 (1.255±0.08 vs 1.163±0.03; p=0.01) No correlations were found between NVC patterns/MES and bone quality assessment (TBS) or bone density assessment (BMD), only a significant correlation, as expected, was observed between MES and skin involvement (mRss) (p=0.05). On the other hands, FRAX, the major osteoporotic fracture risk, positively correlates with Medsgers kidney disease severity (p=0.04) and Medsgers lung disease severity (p=0.04); in addition, FRAX, for hip fracture risk, seems to correlate significantly with Medsgers lung involvement severity (p=0.04). Conclusions This study demonstrates in SSc patients a relationship between clinical disease severity (organ fibrosis/failure) and altered bone microarchitecture (TBS). In addition, skin involvement was found significantly correlated with altered quality of the trabecular bone architecture (TBS) and a significant increase of osteoporotic fracture risk (FRAX) was found correlated with kindey and lung involvement. References Varga J, Abraham D. J Clin Invest. 2007 Mar;117(3):557–67. Loucks J, Pope JE. Semin Arthritis Rheum. 2005 Feb;34(4):678–82. Silva BC et al. J Bone Miner Res. 2014 Mar;29(3):518–30. Medsger TA et al. Clin Exp Rheumatol. 2003;21(3 Suppl 29):S42–6. Sulli A, et al. Ann Rheum Dis 2008;67:885–7. Cutolo et al. J Rheumatol 2000; 27;155.60. Disclosure of Interest None declared