Drop the Likelihood Ratio. A Novel Non-electronic Tool for Interpreting Diagnostic Test Results

OBJECTIVE

To present a geometric ruler to determine predictive values of binary diagnostic test results from prevalence, sensitivity and specificity without calculation.

METHODS

On logarithmic scale the relationships between pre-/post-test odds and the likelihood ratio as well as sensitivity, specificity and the likelihood ratio appear as simple linear (additive) equations.

RESULTS

Each of these additive equations can be solved geometrically in form of a ruler with three scales. By amalgamation we devise a novel non-electronic tool which omits the intermediate step of likelihood ratio determination.

CONCLUSIONS

We propose a simple geometric method to aid in interpretation of diagnostic test results for both practical and educational purposes.

Indirect comparison of lixisenatide versus neutral protamine Hagedorn insulin as add-on to metformin and sulphonylurea in patients with type 2 diabetes mellitus

Objective: There is currently a lack of evidence from direct comparisons of treatment outcomes with lixisenatide versus neutral protamine Hagedorn (NPH)-insulin in type 2 diabetes mellitus (T2DM) patients with suboptimal glycaemic control with oral antidiabetic drugs (OADs). Hence, the current analysis indirectly compared available evidence on the risk of hypoglycaemia and weight change between lixisenatide and NPH-insulin based on randomized controlled trial (RCT) data with exenatide, insulin glargine and placebo as common references.

Methods: A systematic search of PubMed, Embase, the Cochrane database and clinical registries identified English- and German-language articles published from January 1980 to October 2012 reporting data from RCTs. Only publications of trials that reported outcomes from 24 to 30 weeks comparing glucagon-like peptide-1 receptor agonists or basal insulin versus another antidiabetic agent or placebo were included. Hypoglycaemia, patients at glycated haemoglobin (HbA_1c) target and discontinuations due to adverse events (AEs) were treated as binary variables, with risk ratios and odds ratios (ORs) calculated. HbA_1c and body weight were treated as continuous variables with difference in mean change from baseline (MD) calculated. Meta-analyses were performed with random effects models and indirect comparisons were performed according to Bucher’s method.

Results: Seven RCTs (n=3,301 patients) comparing the efficacy and safety of lixisenatide, exenatide, insulin glargine and NPH-insulin with different antidiabetic treatments in adult patients with T2DM were included in the final analysis. In the adjusted indirect comparison, there was a significant difference in symptomatic hypoglycaemia (OR = 0.38; 95% CI = [0.17, 0.85]) and in confirmed hypoglycaemia (OR = 0.46; 95% CI = [0.22, 0.96]) favouring lixisenatide over NPH-insulin and comparable changes in HbA_1c from baseline (MD = 0.07%; 95% CI = [–0.26%, 0.41%]). In contrast to NPH-insulin, there was a significant reduction in body weight with lixisenatide (MD = –3.62 kg; 95% CI = [–5.86 kg, –1.38 kg]) at study completion. The number of discontinuations due to AEs numerically favoured NPH-insulin over lixisenatide (OR = 2.64; 95% CI = [0.25, 27.96]), with a broad confidence interval.

Conclusions: Lixisenatide treatment was associated with a lower risk of hypoglycaemia and a greater weight loss compared with NPH-insulin. Glycaemic control with lixisenatide treatment was comparable with NPH-insulin. These data suggest that lixisenatide is a beneficial treatment option for T2DM patients with inadequate glycaemic control on OADs, and is associated with reduced risk of hypoglycaemia and weight gain.

Comparison of two- and three-dimensional transthoracic echocardiography to cardiac magnetic resonance imaging for assessment of paravalvular regurgitation after transcatheter aortic valve implantation

This study evaluated 2-dimensional (2D) transthoracic echocardiography (TTE) using Valve Academic Research Consortium-2 (VARC-2) criteria and 3-dimensional (3D) TTE for assessment of aortic regurgitation (AR) after transcatheter aortic valve implantation (TAVI) in comparison with cardiac magnetic resonance (CMR) imaging. In 71 patients, 2D TTE, 3D TTE, and CMR imaging were performed to assess AR severity after TAVI. Using 2D TTE, AR severity was graded according to VARC-2 criteria and regurgitant volume (RVol) was determined. Three-dimensional color Doppler TTE allowed direct planimetry of the vena contracta area of the paravalvular regurgitation jet and calculation of the RVol as product with the velocity-time integral. RVol by CMR imaging was measured by phase-contrast velocity mapping in the ascending aorta. After TAVI, mean RVol determined by CMR imaging was 9.2 ± 9.6 ml/beat and mean regurgitant fraction was 13.3 ± 10.3%. AR was assessed as none or mild in 58 patients (82%) by CMR imaging. Correlation of 3D TTE and CMR imaging on RVol was better than correlation of 2D TTE and CMR imaging (r = 0.895 vs 0.558, p <0.001). There was good agreement between RVol by CMR imaging and by 3D TTE (mean bias = 2.4 ml/beat). Kappa on grading of AR severity was 0.357 between VARC-2 and CMR imaging versus 0.446 between 3D TTE and CMR imaging. Intraobserver variability for analysis of RVol of AR after TAVI was 73.5 ± 52.2% by 2D TTE, 16.7 ± 21.9% by 3D TTE, and 2.2 ± 2.0% by CMR imaging. In conclusion, 2D TTE considering VARC-2 criteria has limitations in the grading of AR severity after TAVI when CMR imaging is used for comparison. Three-dimensional TTE allows quantification of AR with greater accuracy than 2D TTE. Observer variability on RVol after TAVI is considerable using 2D TTE, significantly less using 3D TTE, and very low using CMR imaging.

Lipoprotein Apheresis in Patients With Maximally Tolerated Lipid-Lowering Therapy, Lipoprotein(a)-Hyperlipoproteinemia, and Progressive Cardiovascular Disease

Background—

Lipoprotein(a) (Lp(a)) hyperlipoproteinemia is a major risk factor for cardiovascular disease, which is not affected by treatment of other cardiovascular risk factors. This study sought to assess the effect of chronic lipoprotein apheresis (LA) on the incidence of cardiovascular events in patients with progressive cardiovascular disease receiving maximally tolerated lipid-lowering treatment.

Methods and Results—

In a prospective observational multicenter study, 170 patients were investigated who commenced LA because of Lp(a)-hyperlipoproteinemia and progressive cardiovascular disease. Patients were characterized regarding plasma lipid status, lipid-lowering drug treatment, and variants at the LPA gene locus. The incidence rates of cardiovascular events 2 years before (y-2 and y-1) and prospectively 2 years during LA treatment (y+1, y+2) were compared. The mean age of patients was 51 years at the first cardiovascular event and 57 years at the first LA. Before LA, mean low-density lipoprotein cholesterol and Lp(a) were 2.56±1.04 mmol·L −1 (99.0±40.1 mg·dL −1 ) and Lp(a) 3.74±1.63 µmol·L −1 (104.9±45.7 mg·dL −1 ), respectively. Mean annual rates for major adverse coronary events declined from 0.41 for 2 years before LA to 0.09 for 2 years during LA ( P <0.0001). Event rates including all vascular beds declined from 0.61 to 0.16 ( P <0.0001). Analysis of single years revealed increasing major adverse coronary event rates from 0.30 to 0.54 ( P =0.001) for y-2 to y-1 before LA, decline to 0.14 from y-1 to y+1 ( P <0.0001) and to 0.05 from y+1 to y+2 ( P =0.014).

Conclusions—

In patients with Lp(a)-hyperlipoproteinemia, progressive cardiovascular disease, and maximally tolerated lipid-lowering medication, LA effectively lowered the incidence rate of cardiovascular events.

Clinical Trial Registration—

URL: https://drks-neu.uniklinik-freiburg.de . Unique identifier: DRKS00003119.

Plaque vulnerability of coronary artery lesions is related to left ventricular dilatation as determined by optical coherence tomography and cardiac magnetic resonance imaging in patients with type 2 diabetes

Background

Patients with type 2 diabetes are at increased risk for both, left ventricular (LV)-dilatation and myocardial infarction (MI) following the rupture of a vulnerable plaque. This study investigated the to date incompletely understood relationship between plaque vulnerability and LV-dilatation using optical coherence tomography (OCT) and cardiac magnetic resonance imaging (CMR) in patients with type 2 diabetes and stable coronary artery disease.

Methods

CMR was performed in 58 patients with type 2 diabetes, in which 81 coronary lesions were investigated using OCT.

Results

A decreased minimal fibrous cap thickness (FCT) of coronary lesions was associated with an increase of several CMR-derived parameters including LV-end diastolic volume (LVEDV, r = 0.521, p < 0.001), LV-end diastolic diameter (r = 0.502, p < 0.001) and LV-end systolic volume (r = 0.467, p = 0.001). Similar results were obtained for mean FCT.

Furthermore, patients with dilated versus non-dilated LV differed significantly in several cardiovascular risk factors including previous MI (47.1% vs. 14.6%, p = 0.009), HDL-cholesterol (40.35 ± 5.57 mg/dl vs. 45.20 ± 10.79 mg/dl, p = 0.029) and smoking (82.4% vs. 51.2%, p = 0.027). However, minimal FCT is associated to LV-dilatation independent of previous MIs (odds ratio 0.679, p = 0.022).

Receiver-operating curve analysis demonstrated that CMR-derived LVEDV predicts plaque vulnerability with low-moderate diagnostic efficiency (area under the curve 0.699) and considerate specificity (83.3%) at the optimal cut-off value (159.0 ml).

Conclusion

These data suggest that vulnerability of coronary lesions is associated with LV-dilatation in high risk patients with type 2 diabetes. CMR may be a useful adjunct to the risk-stratification in this population. Future studies are warranted to investigate potential mechanisms linking plaque vulnerability and LV-dilatation.

Propofol sedation for colonoscopy with a new ultrathin or a standard endoscope: a prospective randomized controlled study

BACKGROUND AND STUDY AIMS

The majority of colonoscopies in Germany are performed under conscious sedation. Previous studies reported that pediatric colonoscopes reduce the demand for sedative drugs and may improve cecal intubation. The aim of this study was to compare a new ultrathin and a standard colonoscope in terms of propofol demand during colonoscopy.

PATIENTS AND METHODS

A total of 203 patients were prospectively randomized to undergo colonoscopy with either a 9.5-mm ultrathin (UTC) colonoscope or a standard colonoscope of variable stiffness. Initially, 40 or 60 mg of propofol were administered according to body weight, followed by bolus injections of 20 mg as deemed necessary. Propofol was administered by a separate physician who was blinded to the endoscope used. Sedation levels were defined according to guidelines; pain and complaints were recorded on a numeric rating scale.

RESULTS

Significantly less propofol was required to reach the cecum with the UTC (adjusted mean 94.9 mg [95 % confidence interval (CI) 85.7 - 105.0] vs. 115.3 mg [95 %CI 105.8 - 124.7]; P = 0.003). The level of sedation and pain score were lower with the UTC (sedation level 1 76 % vs. 61 %; P = 0.003; pain score adjusted mean 2.0 [95 %CI 1.7 - 2.4] vs. 2.8 [95 %CI 2.5 - 3.1]; P = 0.001). The rate of ileal and cecal intubation, time to reach the cecum, number of external compressions, withdrawal time, polyp and adenoma detection rate, and patient satisfaction were not different between the two colonoscopes. The time to intubate the ileum was longer with the UTC (1.73 minutes [95 %CI 1.42 - 2.04] vs. 1.22 minutes [95 %CI 0.91 - 1.52]; P = 0.020).

CONCLUSIONS

Use of a new ultrathin colonoscope was associated with reduced propofol consumption, lower patient sedation levels, and less pain than the standard colonoscope, but ileal intubation time was longer.

Predictors and incidence of stent edge dissections in patients with type 2 diabetes as determined by optical coherence tomography

Patients with type 2 diabetes are at increased risk for post-PCI complications including stent thrombosis and restenosis. Stent edge dissections (SEDs) have been associated with these complications. This study assessed incidence and predictors of SEDs in patients with type 2 diabetes using optical coherence tomography (OCT). Intravascular lesion parameters and plaque morphology were investigated pre- and post-PCI using OCT in 73 type 2 diabetic patients with 90 lesions and 166 visible stent edges. We detected 42 (25.3 %) SEDs in 166 stent edges and 37 (41.1 %) SEDs in 90 lesions. More SEDs occurred if the border of the stent had been placed within diseased vessel segments with predominantly fibrous (42.9 %) and fibrocalcific (40.5 %) plaques compared to healthy vessel wall morphology (p < 0.001). Furthermore, the lumen eccentricity of the stent at its edges (SAE) (16.00 ± 6.07 vs. 13.11 ± 5.22 %, p < 0.003) and the stent-edge-to-lumen-area-ratio (1.26 ± 0.27 vs. 0.99 ± 0.20, p < 0.001) were both significantly larger in the presence of SEDs. All of the above parameters were significant predictors for SEDs on uni- and multivariate logistic regression analysis (all p < 0.01), suggesting that the lumen eccentricity of the SAE, the stent-edge-to-lumen-area-ratio and diseased vessel wall morphology of the reference segment adjacent to the stent edge are independent risk factors for the presence of SEDs. These results suggest that diseased vessel wall morphology at the stent edges may promote the occurrence of SEDs and that avoidance of longitudinal and transverse mismatch between stent and vessel could be important to reduce SEDs in cardiovascular high-risk patients with type 2 diabetes.

Effects of noise in primary schools on health facets in German teachers

Empirical research indicates that children and teachers are exposed to mean sound levels between 65 and 87 dB (A) and peak sound levels of 100 dB (A) in schools, which may lead to hearing loss and mental health problems. A questionnaire containing 13 targeted questions about noise and sensitivity to noise was distributed to 43 teachers aged between 25 and 64 years at five different primary schools in the Cologne municipal area. The small number of interrogated teachers leads to a wide range of deviation and little significance in the results. Thus, several results are reported following tendencies. Significant results are obtained when comparing younger and older teachers and part- and full-time occupation. Teachers experience highest sound levels in the schoolyard, corridors and classrooms, and 68% of the teachers are annoyed by the noise. Specially, teachers older than 45 years of age suffer from sleep disturbances (44%), and 90% of the full-time employees are tired and exhausted in the evening. Work is judged as physical and mental strain by 51% of the whole sample, and 81% of the older teachers report a significant increase of complaints with increasing years of professional activity. Work-related noise may contribute to physical and mental health problems in teachers. Measures to prevent disease, such as early sensitization of the children to the work-related stressor noise by adequate education with noise lights and dosimeters in the classroom and/or equipping rooms with sound-absorbing materials, have to be discussed.

Analysis of procedural effects of percutaneous edge-to-edge mitral valve repair by 2D and 3D echocardiography

BACKGROUND

Analysis of procedural effects in patients undergoing percutaneous mitral valve repair (PMVR) using the edge-to-edge technique is complex, and common methods to define mitral regurgitation severity based on 2-dimensional (2D) echocardiography are not validated for postprocedural double-orifice mitral valve. This study used 3D transesophageal echocardiography (TEE) to determine the functional and morphological effects of PMVR.

METHODS AND RESULTS

In 39 high-risk surgical patients with moderate to severe functional mitral valve regurgitation, 3D TEE with and without color Doppler as well as 2D transthoracic and TEE was performed before and after PMVR (MitraClip device). Mitral valve regurgitant volume by color Doppler 3D TEE was determined as the product of vena contracta areas defined by direct planimetry and velocity time integral using continuous-wave Doppler. Regurgitant volume was reduced from 84.1±38.3 mL preintervention to 35.6±25.6 mL postintervention. Patients in whom vena contracta area could be reduced >50% had a smaller preprocedural mitral annulus area compared with patients with ≤50% reduction (11.9±3.9 versus 16.1±8.5 cm(2), respectively; P=0.036) and tended to have a smaller mitral annulus circumference (13.0±2.0 versus 14.8±4.1 cm, respectively; P=0.112). At 6 months follow-up, left atrial and left ventricular end-diastolic volumes were significantly more reduced in patients in whom regurgitant vena contracta area was reduced by >50% compared with those with less reduction (-11.4±5.2 versus -4.8±7.7%; P=0.005, and -11.0±7.2 versus -4.5±9.3%; P=0.028). The maximum diastolic mitral valve area decreased from 6.0±2.0 to 2.9±0.9 cm(2) (P<0.0001).

CONCLUSIONS

Three dimensional TEE demonstrates significant reduction of regurgitant volume after PMVR. The unique visualization of the mitral valve by 3D TEE allows improved understanding of the morphological and functional changes induced by PMVR.

Quantitative analysis of endocardial and epicardial left ventricular myocardial deformation-comparison of strain-encoded cardiac magnetic resonance imaging with two-dimensional speckle-tracking echocardiography

BACKGROUND

Quantitative analysis of segmental myocardial deformation of different myocardial layers has become possible using strain-encoded cardiac magnetic resonance imaging (SENC) and speckle-tracking echocardiography (STE). We evaluated and compared the quantitative analysis of myocardial deformation using SENC and STE.

METHODS

In 44 patients (age 61 ± 13 years, 34 men), SENC by cardiac magnetic resonance imaging using a 1.5-Tesla whole-body scanner and two-dimensional STE were performed prospectively. Quantitative layer-specific analysis of segmental left ventricular function was performed to determine the peak circumferential and peak longitudinal systolic strain values using SENC and STE of an endocardial and epicardial myocardial layer. In addition, segmental function was defined as normokinetic, hypokinetic, or akinetic by visual analysis of the magnetic resonance imaging cine sequences.

RESULTS

The endocardial and epicardial strain defined by SENC or STE differed significantly between the visually defined segmental function states. The correlation of the peak circumferential endocardial strain by SENC versus STE (intraclass correlation coefficient [ICC] 0.493, 95% CI 0.358-0.597) tended to be better than the correlation of the circumferential epicardial strain using both methods (ICC 0.321, 95% CI 0.238-0.399). The correlation of the peak longitudinal endocardial strain by SENC and STE was similar (ICC 0.472, 95% CI 0.398-0.541), in contrast to the longitudinal epicardial strain analysis by both techniques (ICC 0.554, 95% CI 0.417-0.655). Circumferential strain analysis by STE allowed better distinction of the hypokinetic or akinetic segments from the normokinetic segments than did the circumferential strain analysis by SENC of the endocardial layer (area under the receiver operating characteristic curve [AUC ROC] 0.946 vs 0.884; P < .001) or epicardial layer (AUC ROC 0.884 vs 0.782; P < .001). Longitudinal strain analysis using STE and SENC of the endocardial layer (AUC ROC 0.851 vs 0.839; P = .5838) and epicardial layer (AUC ROC 0.849 vs 0.833; P = .4321) had similar diagnostic value for identifying the presence of hypokinetic and akinetic segments.

CONCLUSIONS

Quantitative analysis of segmental deformation by SENC and STE allowed accurate distinction of myocardial segments with different functional states. Circumferential endocardial strain analysis by STE allowed the best distinction of segments with impaired function from the normokinetic segments.

Prevention through Activity in Kindergarten Trial (PAKT): a cluster randomised controlled trial to assess the effects of an activity intervention in preschool children

Background

Physical activity and motor skills acquisition are of high importance for health-related prevention and a normal development in childhood. However, few intervention studies exist in preschool children focussing on an increase in physical activity and motor skills. Proof of positive effects is available but not consistent.

Methods/Design

The design, curriculum, and evaluation strategy of a cluster randomised intervention study in preschool children are described in this manuscript. In the Prevention through Activity in Kindergarten Trial (PAKT), 41 of 131 kindergartens of Wuerzburg and Kitzingen, Germany, were randomised into an intervention and a control group by a random number table stratified for the location of the kindergarten in an urban (more than 20.000 inhabitants) or rural area. The aims of the intervention were to increase physical activity and motor skills in the participating children, and to reduce health risk factors as well as media use. The intervention was designed to involve children, parents and teachers, and lasted one academic year. It contained daily 30-min sessions of physical education in kindergarten based on a holistic pedagogic approach termed the "early psychomotor education". The sessions were instructed by kindergarten teachers under regular supervision by the research team. Parents were actively involved by physical activity homework cards. The kindergarten teachers were trained in workshops and during the supervision. Assessments were performed at baseline, 3-5 months into the intervention, at the end of the intervention and 2-4 months after the intervention. The primary outcomes of the study are increases in physical activity (accelerometry) and in motor skills performance (composite score of obstacle course, standing long jump, balancing on one foot, jumping sidewise to and fro) between baseline and the two assessments during the intervention. Secondary outcomes include decreases in body adiposity (BMI, skin folds), media use (questionnaire), blood pressure, number of accidents and infections (questionnaire), increases in specific motor skills (throwing, balancing, complex motor performance, jumping) and in flexibility.

Discussion

If this trial proofs the effectiveness of the multilevel kindergarten based physical activity intervention on preschooler's activity levels and motor skills, the programme will be distributed nationwide in Germany.

Trial Registration

ClinicalTrials.gov Identifier: NCT00623844

Development and validation of a risk-score model for subjects with impaired glucose tolerance for the assessment of the risk of type 2 diabetes mellitus-The STOP-NIDDM risk-score

AIMS

To develop a risk-score model, based on available clinical data to assess absolute risk of type 2 diabetes among people with impaired glucose tolerance (IGT).

METHODS

Data from the study to prevent non-insulin dependent diabetes mellitus (STOP-NIDDM) investigating acarbose treatment in individuals with IGT were used to develop multivariable Cox proportional hazards model for the time to onset of diabetes. The final model equation was externally validated using data from the Finnish Cardiovascular Risk Factor (FINRISK) population.

RESULTS

The risk-score model included the variables acarbose treatment, gender, serum triglyceride level, waist circumference, fasting plasma glucose, height, history of cardiovascular disease (CVD) and hypertension. The final model yielded an area under the receiver-operating-characteristic curve (AUC(ROC)) of 0.64 when applied to people with IGT in the STOP-NIDDM, and 0.84 and 0.90 when applied to FINRISK population with IGT alone and IGT and normal glucose tolerance combined, respectively; AUC(ROC) is a measure of the discriminatory power of the model (1, perfect discrimination).

CONCLUSIONS

The STOP-NIDDM risk-score is a simple and validated tool that can identify high-risk individuals with IGT who would benefit most from type 2 diabetes or CVD prevention strategies, such as lifestyle management or early acarbose treatment.

Assessment of the antiobstructive effect of fexofenadine on nasal allergy challenge in patients with seasonal allergic rhinitis

The oral administration of fexofenadine 120 mg daily is a common treatment of seasonal allergic rhinitis (SAR). It reduces the H1 receptor-mediated symptoms, such as sneezing, pruritus, and nasal secretion as well as non-nasal symptoms such as conjunctivitis. The objective was to assess the effect of fexofenadine on nasal symptoms (such as nasal obstruction) in seasonal allergic rhinitis. A placebo-controlled, double-blind, randomized, cross-over study was performed which yielded evidence that two-week therapy with fexofenadine 120 mg daily in patients with SAR also relieves nasal obstruction and congestion. The parameters of nasal obstruction were evaluated by means of rhinoscopy, a subjective symptom score, and active anterior rhinomanometry. The subjective evaluation of nasal obstruction/congestion as recorded by the patient every 15 minutes for 4.5 hours after nasal allergen provocation showed a significant difference of the AUC (p = 0.025) between fexofenadine and placebo with a 12.8% lower obstruction after fexofenadine. The swelling of the nasal mucosa, which was assessed by rhinoscopy for 4.5 hours after nasal allergen provocation, was 21% lower after treatment with fexofenadine (p = 0.041). In this double-blind, placebo-controlled trial, subjective patient ratings as well as objective investigator assessments demonstrate the anti-obstructive effect of fexofenadine in nasal allergen challenge.

[Postmarketing surveillance studies in community pharmacies]

Postmarketing surveillance of prescription medicines is a routine practice, yet similar evaluation of non-prescription medicines is uncommon. In order to get insights into the validity of pharmacy-based observational studies 22 postmarketing surveillance studies in the German community of pharmacies involving non-prescription medications have been investigated. The objective was to evaluate their contribution to the knowledge about drug use in self-medication. The results of the comparative evolution show that postmarketing surveillance studies with non-prescription medications deliver valid and meaningful findings about the usage, effectiveness and safety. Statements to the efficacy of the drug often serve marketing interests.

High frequency of corticosteroid and immunosuppressive therapy in patients with systemic sclerosis despite limited evidence for efficacy

Introduction

In systemic sclerosis (SSc) little evidence for the effectiveness of anti-inflammatory and immunosuppressive therapy exists. The objective of this study was to determine the extent to which SSc patients are treated with corticosteroids and immunosuppressive agents.

Methods

Data on duration and dosage of corticosteroids and on the type of immunosuppressive agent were analyzed from 1,729 patients who were registered in the German Network for Systemic Scleroderma (DNSS).

Results

A total 41.3% of all registered SSc patients was treated with corticosteroids. Corticosteroid use was reported in 49.1% of patients with diffuse cutaneous SSc and 31.3% of patients with limited cutaneous SSc (P < 0.0001). Among patients with overlap disease characteristics, 63.5% received corticosteroids (P < 0.0001 vs. limited cutaneous SSc). A total 16.1% of the patients received corticosteroids with a daily dose ≥ 15 mg prednisone equivalent. Immunosuppressive therapy was prescribed in 35.8% of patients. Again, among those patients with overlap symptoms, a much higher proportion (64.1%) was treated with immunosuppressive agents, compared with 46.4% of those with diffuse cutaneous SSc sclerosis and 22.2% of those with limited cutaneous SSc (P < 0.0001). The most commonly prescribed drugs were methotrexate (30.5%), cyclophosphamide (22.2%), azathioprine (21.8%) and (hydroxy)chloroquine (7.2%). The use of these compounds varied significantly between medical subspecialties.

Conclusions

Despite limited evidence for the effectiveness of corticosteroids and immunosuppressive agents in SSc, these potentially harmful drugs are frequently prescribed to patients with all forms of SSc. Therefore, this study indicates the need to develop and communicate adequate treatment recommendations.

Skin sclerosis is only of limited value to identify SSc patients with severe manifestations--an analysis of a distinct patient subgroup of the German Systemic Sclerosis Network (DNSS) Register

OBJECTIVES

In SSc, diagnosis and classification is based mainly on skin sclerosis. Herein, we investigated in a large multicentre cohort, to what extent skin sclerosis reflects organ involvement and additional clinical symptoms.

METHODS

A total of 1200 SSc patients from the register of the German Systemic Sclerosis Network (DNSS), classified as either lcSSc or dcSSc, were analysed for their serological characteristics, clinical symptoms and organ manifestations in relation to skin involvement measured by the modified Rodnan skin score (mRSS).

RESULTS

SSc patients with different mRSS did not differ significantly in their disease duration and in most of the clinical symptoms. They showed a similar distribution of most organ manifestations such as pulmonary arterial hypertension as well as cardiac, renal and nervous system involvement. More severe skin thickening was found to be associated with pulmonary fibrosis and gastrointestinal symptoms, as well as with digital ulcers and musculoskeletal involvement.

CONCLUSIONS

In patients with SSc, potentially life-threatening complications and clinical symptoms with high impact on the quality of life occur independently from the extent of skin sclerosis. The diagnosis in SSc patients with a low mRSS could be missed or they could be insufficiently treated.