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Introduction Endothelin antagonist receptors (ERAs) and phosphodiesterase-5 inhibitors (PDE5i) are beneficial in pulmonary arterial hypertension (PAH) and digital ulcers (DU) and prevent from DU recurrences. Our study aimed to determine the difference in the incidence rate of PAH and scleroderma renal crisis (SRC) in patients with SSc and DU (SSc-DU) under ERAs/PDE5i or without treatment. Methods We conducted a retrospective cohort study including SSc-DU patients from the Spanish Scleroderma Registry (RESCLE). The primary outcome was the incidence rate of PAH and SRC in patients under ERAs/PDE5i or not. Results Some 544 patients out of 1817 (29.9%) in the RESCLE database had DU, 221 (40.6%) under ERAs/PDE5i and 323 (59.4%) not. The incidence rate (95% CI) difference between patients under treatment or not under did not reach statistical significance in PAH [−0.1 (−4.8, 4.69), P = 0.988] or in SRC [0.7 (−2.2, 3.7), P = 0.620]. However, the time from the first DU to the diagnosis of SRC was delayed in treated patients [mean (s.d.) 7.6 (5.8) years vs 2.9 (5.3); P = 0.021]. The dcSSc subset was more prevalent in the treatment group (36 vs 26%; P = 0.018), along with anti-topoisomerase I antibodies (34 vs 18%; P Conclusion There was no difference in the incidence rate of PAH and SRC between groups. However, treatment with ERAs and/or PDE5i appeared to delay the occurrence of SRC.

Background:A nailfold capillaroscopy procedure is a non-invasive, low-cost, and well-established examination that can be used to diagnose several rheumatic autoimmune diseases and support the necessary follow-up of patients. While the clinical implications of the technique are known, a rigorous and in-depth examination of nailfold capillaries remains as one of the major challenges to produce new advances in research and diagnosis, due to practical limitations for analysing the whole nailfold area of each patient. The difference between the different patterns established by Maricq and Cutolo makes it possible to predict the evolution that the patient will present. We introduce Capillary.io, an automatic image reading system able to recognize capillaries in images obtained with any microscope, generate automatic measurements of each capillary and take advantage of this information to report capillary morphology and patterns.Objectives:to determine the ability to detect active and early scerodermiform patterns of Capillary.io.Methods:Forty-nine complete capillaroscopies, reported by expert capillaroscopists according to the different patterns manually (gold standard), were compared with the pattern detection capability of Capillary.io. A scoring system based on the algorithm of the Spanish Capillaroscopy Study Group (GREC) was performed and interpreted by capillary.io for the global interpretation of each of the capillaroscopies analyzed.Results:Overall, 37 of the 49 capillaroscopies reported agreed with the diagnosed pattern (75.51%). Separately, the early pattern presented a concordance of 77.27% and the active pattern of 74.07%. In reference to the findings detected by the Capillary.io system, the mean overall density was 5.01 capillaries/mm in the group with the active pattern compared to 6.46 capillaries/mm in the early pattern. The density of dilations and megacapillaries was 2.81/mm and 1.21/mm in the active pattern group versus 4.69/mm and 0.4/mm in the early pattern group. Global diameters were greater in the active pattern group with an apical mean of 37.3 μm compared to 28.5 μm in the early pattern subgroup.Conclusion:Capillary.io is a simple, easy-to-learn web system for interpreting capillaroscopic images of nail folds. It can be a very useful tool to standardize the interpretation of capillaroscopic images, not only individually for each capillary, but also jointly through the detection of different patterns.References:[1]Chen K, Wang J, Pang J, Cao Y, Xiong Y, Li X, et al. MMDetection: Open MMLab Detection Toolbox and Benchmark. arXiv preprint arXiv:190607155 2019;.[2]Cutolo M, Pizzorni C, Sulli A. Nailfold videocapillaroscopy assessment of microvascular damage in systemic sclerosis - Reply. The Journal of Rheumatology 2000 11;27:2722–2723.[3]Cutolo M, Trombetta AC, Melsens K, Pizzorni C, Sulli A, Ruaro B, et al. Automated assessment of absolute nailfold capillary number on videocapillaroscopic images: Proof of principle and validation in systemic sclerosis. Microcirculation 2018 May;25(4):e12447.[4]Smith V, Vanhaecke A, Herrick AL, Distler O, Guerra MG, Denton CP, et al. Fast track algorithm: How to differentiate a “scleroderma pattern” from a “non-scleroderma pattern”. Autoimmu- nity Reviews 2019 nov;18(11):102394.[5]Tavakol ME, Fatemi A, Karbalaie A, Emrani Z, Erlandsson BE. Nailfold Capillaroscopy in Rheumatic Diseases: Which Parameters Should Be Evaluated? BioMed Research International 2015;2015:1–17.Disclosure of Interests:Eduardo Ramos Shareholder of: Co-founder and shareholder of Capillary.io, Alfredo Guillén-Del-Castillo: None declared, Carmen Pilar Simeón-Aznar: None declared, Borja Gracia Tello Shareholder of: Co-founder and shareholder of Capillary.io, Vicent Fonollosa Pla: None declared, Albert Selva-O’Callaghan: None declared, Luis Sáez-Comet: None declared, Elena Martínez Robles: None declared, Juan José Rios: None declared, Gerard Espinosa: None declared, Jose Antonio Todolí Parra: None declared, Jose Luis Callejas-Rubio: None declared, Norberto Ortego: None declared, Begoña Marí-Alfonso: None declared, Mayka Freire: None declared, Patricia Fanlo: None declared

Background:Nailfold Capillaroscopy is a simple, inexpensive and non-invasive technique that allows microvascular damage to be observed, gaining recent importance in the diagnosis, monitoring and prognosis of many diseases with microangiopathy. However, the variability in the results interpretation has led to the development of new computerized systems that allow the automatic analysis of capillaroscopic images.Objectives:to compare the degree of agreement between the automatic system Capillary.io and a gold standard obtained from the agreement of 9 expert capillaroscopists and to know the degree of the interobserver reliability To demonstrate the validity of the system to detect normal and enlarged capillaries, hemorrhages, megacapillaries, ramifications and tortuosities.Methods:a cross-sectional study was performed in which 300 random and anonymous nailfold capillaroscopic images (1165 capillaries) were analyzed by 9 experienced observers. The degree of interobserver agreement was calculated from the 5 users. Likewise, the system performed an automatic assessment of the images and their agreement with the gold standard was calculated (interobserver agreement greater than 5, 6, 7, 8 and 9 successively). The validity of the program for each variable was also analyzed using sensitivity and specificity, positive and negative predictive values, and likelihood ratios, as well as their degree of agreement using the weighted kappa statistic (95% CI, p Results:the degree of interobserver agreement was 76.5% for the agreement of 5 or more observers, progressively decreasing to 15.4% for the 9 observers. Capillary.io obtained higher levels of agreement, reaching 97.7% for the 9 observers. Statistically significant results were obtained in the automated detection of all the morphological alterations analyzed Capillary.io presented a sensitivity (S) of 79.82% and a specificity (E) of 82% in the recognition of normal capillaries. The automatized system was able to recognize enlarged capillaries with a sensitivity of 86.97% and a specificity of 81.38%. Megacapillaries were detected with 89.41% sensitivity and 78.75% specificity. Similarly, the system was able to detect tortuosities (S 66.94%; E 67.71%), ramifications (S 54.34%; E 58.61%) and hemorrhages (S 71.36; E 73.97%).Conclusion:Capillary.io demonstrated a high degree of agreement with the gold standard, stronger with greater consensus among observers. It was able to detect with great sensitivity and specificity hemorrhages and megacapillaries, very relevant alterations in microangiopathies.References:[1]Roldán LMC, Franco CJV, Navas MAM. Capillaroscopy in systemic sclerosis: A narrative literature review. Rev Colomb Reumatol; 2016; 23: 250-8.[2]Ingegnoli F, Gualtierotti R, Lubatti C, Bertolazzi C, Gutierrez M, Boracchi P, et al. Nailfold capillary patterns in healthy subjects: A real issue in capillaroscopy. Microvasc Res. 2013;90:90-5.[3]Cutolo M, Pizzorni C, Secchi ME, Sulli A. Capillaroscopy. Best Pract Res Clin Rheumatol. 2008; 22:1093-108.[4]Tavakol ME, Fatemi A, Karbalaie A, Emrani Z, Erlandsson BE. Nailfold Capillaroscopy in Rheumatic Diseases: Which Parameters Should Be Evaluated? BioMed Res Int. 2015; 2015: 974530.[5]Smith V, Herrick AL, Ingegnoli F, Damjanov N, De Angelis R, Denton CP, et al. Standardisation of nailfold capillaroscopy for the assessment of patients with Raynaud’s phenomenon and systemic sclerosis. Autoimmunity Reviews. 2020; 19: 102458.Disclosure of Interests:Borja Gracia Tello Shareholder of: Co-founder and shareholder of Capillary.io., Eduardo Ramos Shareholder of: Co-founder and shareholder of Capillary.io., Carmen Pilar Simeón-Aznar: None declared, Vicent Fonollosa Pla: None declared, Alfredo Guillén-Del-Castillo: None declared, Albert Selva-O’Callaghan: None declared, Luis Sáez-Comet: None declared, Elena Martínez Robles: None declared, Juan José Rios: None declared, Gerard Espinosa: None declared, Jose Antonio Todolí Parra: None declared, Jose Luis Callejas-Rubio: None declared, Norberto Ortego: None declared, Begoña Marí-Alfonso: None declared, Mayka Freire: None declared, Patricia Fanlo: None declared

Primary biliary cirrhosis (PBC) is associated to any systemic autoimmune disease (SAD), in particular systemic sclerosis (SSc). To investigate the prevalence of SAD in a cohort of patients with PBC, specifically the prevalence of SSc and its clinical subtypes, and determining the clinical and biological profile of patients with associated PBC and SSc.Observational study of 62 patients with PBC following a protocol that included an anamnesis and physical examination to detect the presence of SAD as well as a nailfold capillaroscopy and an immunological study with specific SSc autoantibodies. A comparative analysis was conducted between patients with isolated PBC and patients with PBC and an associated SAD.SAD was associated to PBC in 22 patients (35,4%), and SSc was the most frequent illness, identified in 13 cases (21%). Five patients (8%) without previous diagnosis of SAD fulfilled pre-scleroderma criteria, according to LeRoy and Medsger criteria. The presence of anticentromere antibodies (54,5% vs. 5%, P.001) was the unique immunological determination identified more frequently in patients with PBC-SAD. The SSc suggestive capillary pattern was visualized in 11 patients (20,4%), mainly the slow pattern. No factors associated with greater morbi-mortality were identified in the PBC-SAD group.It does exist a subgroup of patients with PBC and clinical-biological features suggestive of an SAD, which advise a protocolized study to detect early the association to an SAD.

Resumen Introduccion y objetivos La cirrosis biliar primaria (CBP) se asocia a algunas enfermedades autoinmunes sistemicas (EAS), en particular a la esclerosis sistemica (ES. Determinar la prevalencia de EAS en una cohorte de pacientes con CBP, especificamente la ES y sus diferentes subtipos clinicos, y establecer el perfil clinico-biologico propio de estos pacientes. Metodos Estudio observacional de 62 pacientes con CBP, con un protocolo que incluia una anamnesis y exploracion fisica dirigidas a detectar una EAS, la realizacion de una capilaroscopia ungueal microscopica y un amplio estudio de autoinmunidad, incluido el perfil de anticuerpos especificos de ES. Se realizo un analisis comparativo entre el grupo de pacientes con CBP aislada y los pacientes con CBP y una EAS asociada. Resultados Se asocio una EAS en 22 pacientes (35,4%), y la ES fue la entidad mas frecuente (21%), del subtipo cutaneo limitado (11%). Cinco pacientes (8%) sin EAS previa cumplian criterios de preesclerodermia, segun los criterios de LeRoy y Medsger. Los anticuerpos anticentromero (54,5 vs. 5%, p Conclusiones Existe un subgrupo de pacientes con CBP con caracteristicas clinico-biologicas que sugieren la asociacion con una EAS, con elevada probabilidad, y que recomiendan el estudio protocolizado de estos pacientes con CBP para detectar de forma precoz EAS.

Background:Left ventricular diastolic dysfunction (LVDD) is a very common finding in heart involvement in Systemic Sclerosis (SSc).Objectives:To determine the prevalence, risk factors and mortality associated with LVDD in a cohort of patients with SSc.Methods:A retrospective study was conducted with data from the multicentre Spanish Scleroderma Registry (RESCLE). A case-control study was performed to identify factors associated with LVDD.Results:Out of 1517 cases of SSc, 319 (21%) developed LVDD. Basal characteristics are shown in Table 1. In multivariate analysis, LVDD was associated to older age at diagnosis of SSc [54 vs 44 years, OR 1.05 (1,04-1.06)], presence of telangiectasia [67 vs 59%, OR 1.42 (1,88-1.08)], and treatment with calcium channel blockers [50 vs. 45%, OR 1.55 (1.16-1.96)], and inversely correlated to treatment with ACE inhibitors [74 vs. 83%, OR 0.59 (0.44-0.8)]. Mortality was increased in patients with LVDD (24 vs 17%, OR 1.4, p = 0.01). Kaplan–Meier cumulative survival for the SSc cohort, according to the presence or absence of LVDD showed significant differences in 30 years from the first SSc symptom (59 vs. 70%, p = 0.04).Table 1.Number of patients1517319 (21%)1198 (79%)PLimited SSc923 (61%)201 (63%)722 (60%)0.438Diffuse SSc304 (20%)51 (16%)253 (21%)0.041Sine Sclerodema SSc174 (11%)47 (15%)127 (11%)0.048Age at disease onset(years) med±SD46.4±16.554.1±15.944.5±16.1Arterial hypertensión491 (33%)148 (48%)343 (30%)Digital ulcers615 (41%)108 (34%)507 (42%)0.006Telangiectasia918 (61%)212 (67%)706 (59%)0.011Interstitial lung disease645 (43%)153 (48%)492 (41%)0.021Pulmonary hypertension139 (9.2%)34 (11%)105 (8.8%)0.325Capillaroscopy Slow pattern673 (51%)130 (46%)543 (53%)0.038Centromere Antibodies679 (49%)154 (55%)525 (48%)0.032Conclusion:In our cohort, LVDD is relative common in SSc patients, and it is associated with older age at diagnosis, treatment with calcium channel blockers and telangiectasia. ACE inhibitors could play a protective role against the development of LVDD. Mortality is higher in SSc patients with LVDD, and is more significative over time.References:[1]Tennøe AHet al. Left Ventricular Diastolic Dysfunction Predicts Mortality in Patients with Systemic Sclerosis. J Am Coll Cardiol. 2018;72:1804-13Disclosure of Interests:Andrés González: None declared, Jose Luis Patier: None declared, Mónica López-Rodríguez: None declared, Alfredo Guillén del Castillo: None declared, Manuel Rubio-Rivas: None declared, Ana Argibay: None declared, Begoña Marí-Alfonso: None declared, Antonio-J Chamorro: None declared, Ana Belén Madroñero-Vuelta: None declared, Eduardo L. Callejas-Moraga: None declared, Cristina González-Echávarri: None declared, Norberto Ortego: None declared, Vicent Fonollosa-Pla Consultant of: Actelion pharmaceuticals, GSK, MSD., Carmen Pilar Simeón-Aznar Consultant of: Actelion pharmaceuticals, GSK, MSD., on behalf of RESCLE Investigators, Autoimmune Diseases Study Group (GEAS): None declared

Background:Prior literature shows a global increase of cancer risk among patients with systemic sclerosis (SSc). Although breast cancer (BC) is one of the most frequent malignancies in SSc patients, the characteristics of this neoplasm among SSc patients is not well established and it is uncertain whether SSc significantly increases the risk of this cancer.Objectives:Describe the characteristics and risk factors for BC among Spanish patients with SSc.Methods:Ambispective and multicenter study of patients with a diagnosis of SSc according to ACR/EULAR criteria and/or LeRoy classification included in the Spanish Scleroderma Registry (RESCLE) from 2006 to 2018. Characteristics of patients with BC were described and incidence was compared with that of the general population.Results:Among 1930 patients with SSc, 206 (10.7%) had cancer. BC was the most frequent tumor location (47 patients of 206 with cancer [22.8%]), followed by lung cancer (29, 14.1%). The risk of BC was increased in patients with SSc compared to the general population (standardized incidence ratio [SIR] 1.31; 95% CI 1.10-1.54;P= 0.003).The comparison of patients with BC and those without cancer showed that patients with BC had older age at diagnosis of SSc (50.9 vs 45.9 years, respectively;P=0.004), were more frequently diagnosed of interstitial lung disease (ILD) (30/47 [63.8%] vs 694/1714 [40.5];P= 0.002) and pulmonary hypertension (12/24 [50.0%] vs 262/917 [28.6%];P= 0.037), had higher frequency of puffy hands as the first manifestation of SSc (4/45 [8.9%] vs 38/1664 [2.3 %];P= 0.023) and had more frequently primary biliary colangitis (PBC) (7 /46 [15.2%] vs 72 /1708 [4.2%];P= 0.004). Regarding autoimmunity profile, patients with SSc and BC had a significantly higher presence of anti-Ro (11/44 [25.0%] vs 214/1528 [14.0%];P= 0.049) and anti-mitochondrial antibodies (7/28 [25.0%] vs 96/837 [11.5%];P= 0.039). Multivariable regression analysis showed an independent association between the puffy hands (OR = 6.40; 95% CI 1.73-23.60;P= 0.005), diagnosis of PBC (OR = 5.70; 95% CI 2.16-15.07;P= 0.001), presence of ILD (OR = 3.29, 95% CI 1.69-6.39;PP= 0.048) with the presence of BC.Conclusion:BC risk was increased in patients with SSc. The development of ILD, PBC, the presence of anti Ro and puffy hands as the first clinical manifestation of SSc were identified as independent factors associated with the development of BC in our cohort.References:Colaci M et al. Breast cancer in systemic sclerosis: results of a cross-linkage of an Italian Rheumatologic Center and a population-based Cancer Registry and review of the literaure. Autoimmun Rev. 2014;13(2):132-7.Zhang JQ et al. The risk of cancer development in systemic sclerosis: a meta-analysis. Cancer Epidemiol. 2013;37(5):523-7.Disclosure of Interests:Cristina Carbonell: None declared, Antonio-J Chamorro: None declared, Miguel Marcos: None declared, Alfredo Guillén del Castillo: None declared, Dolores Colunga Argüelles Consultant of: Actelion pharmaceuticals, GSK, MSD., Manuel Rubio-Rivas: None declared, Ana Argibay: None declared, Begoña Marí-Alfonso: None declared, Adela Marín Ballvé: None declared, Antoni Castro Consultant of: Actelion pharmaceuticals, GSK, MSD., Ana Belén Madroñero-Vuelta: None declared, Eduardo L. Callejas-Moraga: None declared, Vicent Fonollosa-Pla Consultant of: Actelion pharmaceuticals, GSK, MSD., Carmen Pilar Simeón-Aznar Consultant of: Actelion pharmaceuticals, GSK, MSD., on behalf of RESCLE Investigators, Autoimmune Diseases Study Group (GEAS): None declared

Background Monotherapy with endotelin antagonist receptors (ERA) an phosphodiesterase 5 (PDE5) inhibitors is a first choice treatment for PAH in functional class (FC) II-III, with the same grade of evidence and recommendation than combination therapy. Recently, studies have proven superiority of combination therapy against monotherapy in combined morbi-mortaliy endpoints. Objectives To demonstrate superiority of combination therapy against monotherapy in a single mortality endpoint in SSc-associated PAH. Methods Retrospective cohort study including patients from the Spanish Scleroderma Registry (RESCLE) diagnosed with SSc-associated-PAH by right heart catheterization (RHC). Patients were divided in 3 groups: monotherapy vs. sequential combination therapy (>12 weeks between first and second treatment) vs. upfront combination therapy ( Results Seventy-six patients with PAH out of 1817 participants were included. Thirty-four (45%)were receiving monotherapy [with ERA (22 patients, 29%) or PDE5 inhibitors (12 patients, 16%)], 25 patients (33%) sequential combination therapy and 17 patients (22%) upfront combination therapy. Baseline demographic, clinical and complementary tests were similar among groups. ILD (mainly moderate) was more frequent in both combination groups in 58% vs. 80% vs. 76.4%, without statistical significance. A worse FVC/DLco in the sequential combination group was reported (2.9±1.1 vs. 1.8±0.4 vs.2.3±0.8, global p=0.085 but p=0.043 comparing monotherapy with sequential combination) and also a worse mPAP in both sequential and upfront combination groups(37.2±8.7 mmHg vs. 40.8±8.8 vs. 46±15.9, p=0.026). The treatment regimen prescribed (p=0.017) and FC at baseline (p=0.007) were found predictors of mortality. Sequential combination therapy was found a protective factor [HR=0.11 (95%CI 0.03–0.51), p=0.004] and the upfront combination therapy showed a tendency of protection [HR=0.68 (95%CI 0.23–1.97), p=0.476]. Survival rates from diagnosis of PAH among groups were: 78% vs. 95.8% vs. 94.1% at 1 year, 40.7% vs. 81.5% vs. 51.8% at 3 years and 31.6% vs. 56.5% vs. 34.5% at 5 years (p=0.007). Side effects were not significantly different among groups. Conclusions Combined sequential therapy improves survival in SSc-PAH patients, even wtih moderate ILD. Upfront combination therapy may improve survival, but did not reach statistical significants due to study limitations. Treatment regimen and FC were found as prognostic factors for survival: sequential combination therapy was a protective factor and FC was a risk factor. Disclosure of Interest None declared

Objetive To assess the prevalence and causes of hepatobiliary involvement (HBI) in systemic sclerosis (SSc), to investigate the clinical characteristics and prognosis of SSc patients with HBI (SSc-HBI) and without HBI (SSc-non HBI), and to compare both groups according to the cutaneous SSc subsets. Methods 1572 SSc patients were collected in the RESCLE registry up to January 2015, and all hepatobiliary disturbances were recorded. We investigated the HBI related characteristics and survival from the entire SSc cohort and according to the following cutaneous subsets: diffuse cutaneous SSc (dcSSc), limited cutaneous SSc (lcSSc), and SSc sine scleroderma (ssSSc). Results Out of 1572, 118 (7.5%) patients had HBI. Primary biliary cholangitis (PBC) was largely the main cause (n = 67, 4.3%), followed by autoimmune hepatitis (n = 19, 1.2%), and anti-mitochondrial negative PBC (n = 6, 0.4%). Other causes of HBI were: secondary liver diseases (n = 11, 0.7%), SSc-related HBI (n = 7, 0.4%), nodular regenerative hyperplasia (n = 3, 0.2%), liver cirrhosis (n = 3, 0.2%), and HBI of unknown origin (n = 2, 0.1%). In multivariate analysis, HBI was independently associated to lesser risk of dcSSc (5.1% vs. 24.4%), and higher frequency of calcinosis (26% vs. 18%), left ventricular diastolic dysfunction (46% vs. 27%), sicca syndrome (51% vs. 29%), and anti-centromere antibodies (ACA, 73% vs. 44%). According to the cutaneous subsets, HBI was associated: (1) in lcSSc, to longer time from SSc onset to diagnosis (10.8±12.5 vs. 7.2±9.3 years), sicca syndrome (54% vs. 33%), and ACA (80% vs. 56%); (2) in ssSSc, to sicca syndrome (44% vs. 19%), and (3) in dcSSc, no associations were found. HBI was the cause of death in 2.3% patients but the cumulative survival according to the presence or absence of HBI showed no differences. Conclusions HBI prevalence in SSc is 7.5% and dcSSc is the least involved subset. PBC is the main cause of HBI. Patients with SSc-HBI exhibited specific clinical and immunologic profile. Survival is similar for SSc patients with HBI.

Giant cell arteritis (GCA) is the most common form of vasculitis in individuals older than 50 years in Western countries. To shed light onto the genetic background influencing susceptibility for GCA, we performed a genome-wide association screening in a well-powered study cohort. After imputation, 1,844,133 genetic variants were analyzed in 2,134 case subjects and 9,125 unaffected individuals from ten independent populations of European ancestry. Our data confirmed HLA class II as the strongest associated region (independent signals: rs9268905, p = 1.94 × 10−54, per-allele OR = 1.79; and rs9275592, p = 1.14 × 10−40, OR = 2.08). Additionally, PLG and P4HA2 were identified as GCA risk genes at the genome-wide level of significance (rs4252134, p = 1.23 × 10−10, OR = 1.28; and rs128738, p = 4.60 × 10−9, OR = 1.32, respectively). Interestingly, we observed that the association peaks overlapped with different regulatory elements related to cell types and tissues involved in the pathophysiology of GCA. PLG and P4HA2 are involved in vascular remodelling and angiogenesis, suggesting a high relevance of these processes for the pathogenic mechanisms underlying this type of vasculitis.

Objective Digital ulcers (DU) are the most common vascular complication of systemic sclerosis (SSc). We compared the characteristics between patients with prior or current DU with those never affected and evaluated whether a history of DU may be a predictor of vascular, organ involvement, and/or death in patients with SSc. Methods Data from SSc patients with or without prior or current DU were collected by 19 referral centers in an ongoing registry of Spanish SSc patients, named Registro de ESCLErodermia (RESCLE). Demographics, organ involvement, autoimmunity features, nailfold capillary pattern, survival time, and causes of death were analyzed to identify DU related characteristics and survival of the entire series and according to the following cutaneous subsets—diffuse cutaneous SSc (dcSSc), limited cutaneous SSc (lcSSc), and SSc sine scleroderma (ssSSc). Results Out of 1326, 552 patients enrolled in the RESCLE registry had prior or current DU, 88% were women, the mean age was 50 ± 16 years, and the mean disease duration from first SSc symptom was 7.6 ± 9.6 years. Many significant differences were observed in the univariate analysis between patients with and without prior/current DU. Multivariate analysis identified that history of prior/current DU in patients with SSc was independently associated to younger age at SSc diagnosis, diffuse cutaneous SSc, peripheral vascular manifestations such Raynaud's phenomenon, telangiectasia, and acro-osteolysis but no other vascular features such as pulmonary arterial hypertension or scleroderma renal crisis. DU was also associated to calcinosis cutis, interstitial lung disease, as well as worse survival. Multivariate analysis performed in the cutaneous subsets showed that prior/current DU were independently associated: (1) in dcSSc, to younger age at SSc diagnosis, presence of telangiectasia and calcinosis and rarely a non-SSc pattern on nailfold capillaroscopy; (2) in lcSSc, to younger age at SSc diagnosis, presence of Raynaud's phenomenon as well as calcinosis cutis, interstitial lung disease, and higher incidence of death from all causes; and (3) in ssSSc, to younger age at first SSc symptom and greater incidence of death from all causes. Conclusions Digital ulcers develop in patients with SSc younger at diagnosis, mainly in patients with dcSSc and lcSSc, and they are associated to other peripheral vascular manifestations such as Raynaud's phenomenon, telangiectasia, and acro-osteolysis but also to calcinosis, and interstitial lung disease. History of DU in SSc leads to worse survival, also noticeable for lcSSc and ssSSc subsets but not for dcSSc patients.