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Sambataro D, Sambataro G, Pignataro F, Zanframundo G, Codullo V, Fagone E, Martorana E, Ferro F, Orlandi M, Del Papa N, Cavagna L, Malatino L, Colaci M, Vancheri C. Patients with Interstitial Lung Disease Secondary to Autoimmune Diseases: How to Recognize Them? Diagnostics (Basel) 2020; 10:E208. [PMID: 32283744 PMCID: PMC7235942 DOI: 10.3390/diagnostics10040208] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/04/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023] Open
Abstract
The diagnostic assessment of patients with Interstitial Lung Disease (ILD) can be challenging due to the large number of possible causes. Moreover, the diagnostic approach can be limited by the severity of the disease, which may not allow invasive exams. To overcome this issue, the referral centers for ILD organized Multidisciplinary Teams (MDTs), including physicians and experts in complementary discipline, to discuss the management of doubtful cases of ILD. MDT is currently considered the gold standard for ILD diagnosis, but it is not often simple to organize and, furthermore, rheumatologists are still not always included. In fact, even if rheumatologic conditions represent a common cause of ILD, they are sometimes difficult to recognize, considering the variegated clinical features and their association with all possible radiographic patterns of ILD. The first objective of this review is to describe the clinical, laboratory, and instrumental tests that can drive a diagnosis toward a possible rheumatic disease. The secondary objective is to propose a set of first-line tests to perform in all patients in order to recognize any possible rheumatic conditions underlying ILD.
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Affiliation(s)
- Domenico Sambataro
- Artroreuma S.R.L., Outpatient clinic of Rheumatology associated with the National Health System Corso S. Vito 53, 95030 Catania, Italy
- Department of Clinical and Experimental Medicine, Internal Medicine Unit, Cannizzaro Hospital, University of Catania, via Messina 829, 95100 Catania, Italy; (L.M.); (M.C.)
| | - Gianluca Sambataro
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, via S. Sofia 68, pavillon 3 floor 1, 95123 Catania, Italy; (E.F.); (E.M.); (C.V.)
| | - Francesca Pignataro
- Scleroderma clinic, Department of Rheumatology, ASST G. Pini, 20122 Milan, Italy; (F.P.); (N.D.P.)
| | - Giovanni Zanframundo
- Division of Rheumatology, Hospital IRCCS Policlinico S. Matteo Foundation of Pavia, 27100 Pavia, Italy; (G.Z.); (V.C.); (L.C.)
| | - Veronica Codullo
- Division of Rheumatology, Hospital IRCCS Policlinico S. Matteo Foundation of Pavia, 27100 Pavia, Italy; (G.Z.); (V.C.); (L.C.)
| | - Evelina Fagone
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, via S. Sofia 68, pavillon 3 floor 1, 95123 Catania, Italy; (E.F.); (E.M.); (C.V.)
| | - Emanuele Martorana
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, via S. Sofia 68, pavillon 3 floor 1, 95123 Catania, Italy; (E.F.); (E.M.); (C.V.)
| | - Francesco Ferro
- Rheumatology Unit, Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy;
| | - Martina Orlandi
- Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, 50139 Florence, Italy;
| | - Nicoletta Del Papa
- Scleroderma clinic, Department of Rheumatology, ASST G. Pini, 20122 Milan, Italy; (F.P.); (N.D.P.)
| | - Lorenzo Cavagna
- Division of Rheumatology, Hospital IRCCS Policlinico S. Matteo Foundation of Pavia, 27100 Pavia, Italy; (G.Z.); (V.C.); (L.C.)
| | - Lorenzo Malatino
- Department of Clinical and Experimental Medicine, Internal Medicine Unit, Cannizzaro Hospital, University of Catania, via Messina 829, 95100 Catania, Italy; (L.M.); (M.C.)
| | - Michele Colaci
- Department of Clinical and Experimental Medicine, Internal Medicine Unit, Cannizzaro Hospital, University of Catania, via Messina 829, 95100 Catania, Italy; (L.M.); (M.C.)
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases, A. O. U. “Policlinico-Vittorio Emanuele” Dept. of Clinical and Experimental Medicine, University of Catania, via S. Sofia 68, pavillon 3 floor 1, 95123 Catania, Italy; (E.F.); (E.M.); (C.V.)
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Raynaud phenomenon and digital ulcers in systemic sclerosis. Nat Rev Rheumatol 2020; 16:208-221. [PMID: 32099191 DOI: 10.1038/s41584-020-0386-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2020] [Indexed: 01/21/2023]
Abstract
Raynaud phenomenon is a symptom complex caused by impaired digital perfusion and can occur as a primary phenomenon or secondary to a wide range of underlying causes. Raynaud phenomenon occurs in virtually all patients with systemic sclerosis (SSc) and is often the earliest clinical manifestation to occur. Careful assessment is required in patients with Raynaud phenomenon to avoid missing secondary causes such as SSc. Digital ulcers are a painful and disabling visible manifestation of digital vascular injury in patients with SSc. Progress has been made in the classification and assessment of digital ulcers and in understanding ulcer pathogenesis, and there are a wide range of treatments available to both prevent and heal digital ulcers, some of which are also used in Raynaud phenomenon management. In this Review, the assessment of patients with Raynaud phenomenon is discussed, including 'red flags' that are suggestive of SSc. The pathogenesis, classification and assessment of SSc-associated digital ulcers are also covered, alongside an overview of management approaches for SSc-associated Raynaud phenomenon and digital ulcers. Finally, unmet needs are discussed and the concept of a unified vascular phenotype in which therapies that affect the vasculature to support disease modification strategies is introduced.
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Hughes M, Pauling JD, Jones J, Denton CP, Domsic RT, Frech TM, Herrick AL, Khanna D, Matucci-Cerinic M, McKenzie L, Saketkoo LA, Gooberman-Hill R, Moore A. Patient experiences of digital ulcer development and evolution in systemic sclerosis. Rheumatology (Oxford) 2020; 59:2156-2158. [DOI: 10.1093/rheumatology/keaa037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - John D Pauling
- Royal National Hospital for Rheumatic Diseases, Royal United Hospitals, Bath, UK
- Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - Jennifer Jones
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK
| | - Christopher P Denton
- Department of Rheumatology, Royal Free Hospital, University College London, London, UK
| | - Robyn T Domsic
- Department of Rheumatology, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Tracy M Frech
- Department of Rheumatology, University of Utah and Salt Lake Veterans Affair Medical Center, Salt Lake City, UT, USA
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Manchester, UK
| | - Dinesh Khanna
- Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | | | - Lorraine McKenzie
- Patient representative, Contact via Professor Herrick, The University of Manchester, Manchester, UK
| | - Lesley Ann Saketkoo
- Tulane University School of Medicine, New Orleans Scleroderma & Sarcoidosis Patient Care & Research Center, UMC Comprehensive Pulmonary Hypertension Center, New Orleans, LA, USA
| | - Rachael Gooberman-Hill
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Moore
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Bristol, UK
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Ngcozana T, Ong VH, Denton CP. Improving access to digital ulcer care through nurse-led clinic: a service evaluation. Musculoskeletal Care 2020; 18:92-97. [PMID: 31961999 DOI: 10.1002/msc.1433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 09/15/2019] [Accepted: 09/16/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Digital ulcers (DU) remain one of the most burdensome co-morbidities in systemic sclerosis. The objectives of the study were to describe patient-level stratification and to evaluate a nurse-led DU clinic service development. METHODS A nurse-led digital ulcer clinic was established to identify patients with DU and manage them. Patients were recruited through scleroderma clinics, GP referrals, and self-referrals. The clinic involved patients being treated with appropriate treatment. Patients were stratified according to their DU risk level based on number and severity of ulcers. Among these, 22 patients were asked to complete a patient satisfaction survey. Data were analyzed descriptively. RESULTS Seventy-five patients were seen in the clinic, 46 (61%) were 56 years of age and above. Patients were identified as high (23%), medium (51%) or low risk (26%) for development of DU. The duration of DU history was from 7 months to 40 years. Prior to attending the nurse-led DU clinic, 90% of patients had received up to six courses of antibiotics for their DU, 76% had attended A&E, and 90% had unscheduled appointments. 90% had been seen by the GP due to DU and subsequently required hospital admissions. During the nurse-led clinic follow-up, only two patients had emergency admission. All patients reported that their needs in personal care of DU were met. CONCLUSION There are a significant number of people with SSc who have DUs affecting their quality of life as well as needing more healthcare services. A dedicated specialist nurse-led DU clinic may improve overall care of patients.
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Affiliation(s)
- Tanaka Ngcozana
- Rheumatology Department, Royal Free NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Voon H Ong
- Rheumatology Department, Royal Free NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Christopher P Denton
- Rheumatology Department, Royal Free NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
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Digital ulcer debridement in systemic sclerosis: a systematic literature review. Clin Rheumatol 2020; 39:805-811. [PMID: 31955323 DOI: 10.1007/s10067-019-04924-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 12/15/2019] [Accepted: 12/29/2019] [Indexed: 10/25/2022]
Abstract
Optimal wound care is an essential component in the management of systemic sclerosis (SSc) digital ulcers (DUs). DU debridement has been suggested to reduce ulcer-related pain and improve tissue healing. However, only a minority of rheumatologists perform DU debridement, and there is no standard of care/protocol. Our objectives were to (i) evaluate the current evidence for the use of debridement in DU management and (ii) assess whether there are any specific protocols. A systematic literature review was performed searching the PubMed database (between 01/01/1950-01/03/2019) in accordance with PRISMA guidelines. Two independent reviewers screened and extracted the abstracts/full manuscripts. Articles in English, which focussed on SSc-DU debridement/curettage, were included. Exclusion criteria included studies of juvenile/paediatric patients and basic/non-clinical research. Our search identified 1497 studies of which 4 studies were included in our final analysis. Three studies used scalpel debridement, and one study used this in combination with autolytic debridement. No studies specifically reported the effect on DU healing from debridement. Autolytic debridement with hyaluronate-based products was associated with significant ulcer pain and inflammation. Local anaesthetic significantly reduces pain both during and after debridement. Combined local and oral analgesia is often required for more severe or infected DUs. DU (scalpel and autolytic) debridement is being used by some clinicians in rheumatology; however, there are no standardised protocols. To improve wound care for SSc-DUs, future research should focus on developing a standardised protocol for SSc-DU debridement, with a view to facilitate randomised controlled trials to demonstrate safety and treatment efficacy.Key Points• Optimal wound care is an essential component in the management of systemic sclerosis-digital ulcers.• 'Sharp' debridement uses a scalpel, whereas 'autolytic' debridement uses dressings to optimize endogenous tissue lysis.• There is significant variation in the use of digital ulcer debridement in systemic sclerosis.• A standardized protocol and randomized controlled trials are needed to demonstrate debridement the safety and efficacy of digital ulcer debridement in systemic sclerosis.
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Giuggioli D, Lumetti F, Spinella A, Cocchiara E, Sighinolfi G, Citriniti G, Colaci M, Salvarani C, Ferri C. Use of Neem oil and Hypericum perforatum for treatment of calcinosis-related skin ulcers in systemic sclerosis. J Int Med Res 2019; 48:300060519882176. [PMID: 31875751 PMCID: PMC7607053 DOI: 10.1177/0300060519882176] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Objective This study evaluated Neem oil and Hypericum perforatum (Holoil®) for treatment of scleroderma skin ulcers related to calcinosis (SU-calc). Procedure: We retrospectively analyzed 21 consecutive systemic sclerosis (SSc) patients with a total of 33 SU-calcs treated daily with Holoil® cream compared with a control group of 20 patients with 26 SU-calcs. Holoil® was directly applied to skin lesions, while the control group received only standard medication. Results Application of Holoil® either resulted in crushing and complete resolution of calcium deposits or facilitated sharp excision of calcinosis during wound care sessions in 27/33 cases (81.8%). Complete healing of SU-calc occurred in 15/33 (45%) of cases within a time period of 40.1 ± 16.3 (mean ± SD) days, while 18/33 (55%) of lesions improved in terms of size, erythema, fibrin and calcium deposits. Patients reported a reduction of pain (mean numeric rating scale 7.3 ± 1.9 at baseline versus 2.9 ± 1.4 at follow-up) The control group had longer healing times and a higher percentage of infections. Conclusions The efficacy of local treatment with neem oil and Hypericum perforatum suggest that Holoil® could be a promising tool in the management of SSc SU-calc.
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Affiliation(s)
- Dilia Giuggioli
- Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy
| | - Federica Lumetti
- Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy
| | - Amelia Spinella
- Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy
| | - Emanuele Cocchiara
- Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy
| | - Gianluca Sighinolfi
- Department of Life Sciences, University of Modena and Reggio Emilia, Via G. Campi 103/287, Modena, Italy
| | - Giorgia Citriniti
- Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy
| | - Michele Colaci
- Rheumatology Unit, University of Catania, Medical School, AOE Cannizzaro, Catania, Italy
| | - Carlo Salvarani
- Head of department, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy
| | - Clodoveo Ferri
- Rheumatology Unit, University of Modena and Reggio Emilia, Medical School, Azienda Ospedaliero-Universitaria, Policlinico di Modena, Modena, Italy
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Abstract
Digital ulcers are one of the earliest and most disabling manifestations of systemic sclerosis (SSc). We report the clinical case of a female patient with SSc and severe digital ulcers, recurrent and refractory to the classic treatments to whom it was prescribed off-label macitentan with complete resolution of the condition.
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Affiliation(s)
- Tatiana Gonçalves
- Internal Medicine Service, Coimbra Hospital and University Centre, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Lèlita Santos
- Internal Medicine Service, Coimbra Hospital and University Centre, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal.,CIMAGO Research Centre, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Is there a role for laser speckle contrast analysis (LASCA) in predicting the outcome of digital ulcers in patients with systemic sclerosis? Clin Rheumatol 2019; 39:69-75. [DOI: 10.1007/s10067-019-04662-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/19/2019] [Accepted: 06/25/2019] [Indexed: 12/16/2022]
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Zumstein Camargo C, Kayser C. Capillaroscopy changes are associated with disease progression in patients with early systemic sclerosis: A prospective study. Int J Rheum Dis 2019; 22:1319-1326. [PMID: 31050209 DOI: 10.1111/1756-185x.13592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 02/12/2019] [Accepted: 04/07/2019] [Indexed: 12/15/2022]
Abstract
AIM After the development of the 2013 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for systemic sclerosis (SSc), there are still a group of patients affected by early SSc who do not meet the new criteria. This study aimed to evaluate capillaroscopy changes and to identify predictors of progression to definite SSc in patients with early SSc over a 3-year follow-up. METHODS In this prospective study, 44 patients with early SSc (LeRoy and Medsger 2001 criteria) were included. Clinical evaluation and widefield nailfold capillaroscopy were performed at baseline and after 3 years of follow-up. At the end of follow-up, the fulfilment of the 2013 ACR/EULAR criteria was also assessed. RESULTS After 3 years, 34 patients with early SSc were re-evaluated. Of these, eight patients (23.5%) developed definite SSc. Worsening of capillaroscopy parameters was observed in 55.9% of patients. An increase in the number of giant capillaries and worsening of the avascular score were more frequent in patients who developed SSc than in those who did not (P = 0.02; P = 0.002, respectively). By multivariate analysis, an active or a late pattern at baseline on capillaroscopy was an independent predictor for the development of definite SSc (odds ratio = 30.0, 95% CI 2.1-421.1). CONCLUSIONS In this prospective study, worsening in capillaroscopy parameters was observed in early SSc patients. An active or a late pattern on capillaroscopy was an independent predictive risk factor for the development of SSc, suggesting that capillaroscopy might be a useful tool to identify patients with early SSc at risk of disease progression.
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Affiliation(s)
| | - Cristiane Kayser
- Rheumatology Division, Universidade Federal de São Paulo, São Paulo, Brazil
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Use of vasoactive/vasodilating drugs for systemic sclerosis (SSc)-related digital ulcers (DUs) in expert tertiary centres: results from the analysis of the observational real-life DeSScipher study. Clin Rheumatol 2019; 39:27-36. [PMID: 31111363 DOI: 10.1007/s10067-019-04564-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 04/10/2019] [Accepted: 04/15/2019] [Indexed: 12/16/2022]
Abstract
INTRODUCTION DeSScipher is the first European multicentre study on management of systemic sclerosis (SSc), and its observational trial 1 (OT1) evaluated the efficacy of different drugs for digital ulcer (DU) prevention and healing. The aim of this study was to assess current use of vasoactive/vasodilating agents for SSc-related DU in the expert centres by analysing the baseline data of the DeSScipher OT1. METHOD Baseline characteristics of patients enrolled in the OT1 and data regarding DU were analysed. RESULTS The most commonly used drugs, in both patients with and without DU, were calcium channel blockers (CCBs) (71.6%), followed by intravenous iloprost (20.8%), endothelin receptor antagonists (ERAs) (20.4%) and phosphodiesterase 5 (PDE-5) inhibitors (16.5%). Of patients, 32.6% with DU and 12.8% without DU received two drugs (p < 0.001), while 11.5% with DU and 1.9% without DU were treated with a combination of three or more agents (p < 0.001). Sixty-five percent of the patients with recurrent DU were treated with bosentan and/or sildenafil. However, 64 out of 277 patients with current DU (23.1%) and 101 (23.6%) patients with recurrent DU were on CCBs alone. CONCLUSIONS Our study shows that CCBs are still the most commonly used agents for DU management in SSc. The proportion of patients on combination therapy was low, even in patients with recurrent DU: almost one out of four patients with current and recurrent DU was on CCBs alone. Prospective analysis is planned to investigate the efficacy of different drugs/drug combinations on DU healing and prevention. Key Points • The analysis of DeSScipher, the first European multicentre study on management of SSc, has shown that the most commonly used vasoactive/vasodilating drugs for DU were CCBs, followed by intravenous Iloprost, ERAs and PDE-5 inhibitors. • More than half of the patients with recurrent DU received bosentan and/or sildenafil. • However, the proportion of patients on combination therapy of more than one vasoactive/vasodilating drug was low and almost one out of four patients with current and recurrent DU was on CCBs alone.
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Exploring the patient experience of digital ulcers in systemic sclerosis. Semin Arthritis Rheum 2019; 48:888-894. [DOI: 10.1016/j.semarthrit.2018.08.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 07/23/2018] [Accepted: 08/07/2018] [Indexed: 12/11/2022]
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Ferdowsi N, Huq M, Stevens W, Hudson M, Wang M, Tay T, Burchell JL, Mancuso S, Rabusa C, Sundararajan V, Prior D, Proudman SM, Baron M, Nikpour M. Development and validation of the Scleroderma Clinical Trials Consortium Damage Index (SCTC-DI): a novel instrument to quantify organ damage in systemic sclerosis. Ann Rheum Dis 2019; 78:807-816. [DOI: 10.1136/annrheumdis-2018-214764] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 03/11/2019] [Accepted: 03/12/2019] [Indexed: 01/31/2023]
Abstract
ObjectiveWe sought to develop the first Damage Index (DI) in systemic sclerosis (SSc).MethodsThe conceptual definition of ‘damage’ in SSc was determined through consensus by a working group of the Scleroderma Clinical Trials Consortium (SCTC). Systematic literature review and consultation with patient partners and non-rheumatologist experts produced a list of potential items for inclusion in the DI. These steps were used to reduce the items: (1) Expert members of the SCTC (n=331) were invited to rate the appropriateness of each item for inclusion, using a web-based survey. Items with >60% consensus were retained; (2) Using a prospectively acquired Australian cohort data set of 1568 patients, the univariable relationships between the remaining items and the endpoints of mortality and morbidity (Physical Component Summary score of the Short Form 36) were analysed, and items with p<0.10 were retained; (3) using multivariable regression analysis, coefficients were used to determine a weighted score for each item. The DI was externally validated in a Canadian cohort.ResultsNinety-three (28.1%) complete survey responses were analysed; 58 of 83 items were retained. The univariable relationships with death and/or morbidity endpoints were statistically significant for 22 items, with one additional item forced into the multivariable model by experts due to clinical importance, to create a 23-item weighted SCTC DI (SCTC-DI). The SCTC-DI was predictive of morbidity and mortality in the external cohort.ConclusionsThrough the combined use of consensus and data-driven methods, a 23-item SCTC-DI was developed and retrospectively validated.
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Horimoto AMC, de Souza AS, Rodrigues SH, Kayser C. Risk of digital ulcers occurrence in systemic sclerosis: a cross-sectional study. Adv Rheumatol 2019; 59:14. [DOI: 10.1186/s42358-019-0057-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 03/14/2019] [Indexed: 11/10/2022] Open
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Blagojevic J, Bellando-Randone S, Abignano G, Avouac J, Cometi L, Czirják L, Denton CP, Distler O, Frerix M, Guiducci S, Huscher D, Jaeger VK, Lóránd V, Maurer B, Nihtyanova S, Riemekasten G, Siegert E, Tarner IH, Vettori S, Walker UA, Allanore Y, Müller-Ladner U, Del Galdo F, Matucci-Cerinic M. Classification, categorization and essential items for digital ulcer evaluation in systemic sclerosis: a DeSScipher/European Scleroderma Trials and Research group (EUSTAR) survey. Arthritis Res Ther 2019; 21:35. [PMID: 30678703 PMCID: PMC6346551 DOI: 10.1186/s13075-019-1822-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 01/11/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND A consensus on digital ulcer (DU) definition in systemic sclerosis (SSc) has been recently reached (Suliman et al., J Scleroderma Relat Disord 2:115-20, 2017), while for their evaluation, classification and categorisation, it is still missing. The aims of this study were to identify a set of essential items for digital ulcer (DU) evaluation, to assess if the existing DU classification was useful and feasible in clinical practice and to investigate if the new categorisation was preferred to the simple distinction of DU in recurrent and not recurrent, in patients with systemic sclerosis (SSc). METHODS DeSScipher is the largest European multicentre study on SSc. It consists of five observational trials (OTs), and one of them, OT1, is focused on DU management. The DeSScipher OT1 items on DU that reached ≥ 60% of completion rate were administered to EUSTAR (European Scleroderma Trials and Research group) centres via online survey. Questions about feasibility and usefulness of the existing DU classification (DU due to digital pitting scars, to loss of tissue, derived from calcinosis and gangrene) and newly proposed categorisation (episodic, recurrent and chronic) were also asked. RESULTS A total of 84/148 (56.8%) EUSTAR centres completed the questionnaire. DeSScipher items scored by ≥ 70% of the participants as essential and feasible for DU evaluation were the number of DU defined as a loss of tissue (level of agreement 92%), recurrent DU (84%) and number of new DU (74%). For 65% of the centres, the proposed classification of DU was considered useful and feasible in clinical practice. Moreover, 80% of the centres preferred the categorisation of DU in episodic, recurrent and chronic to simple distinction in recurrent/not recurrent DU. CONCLUSIONS For clinical practice, EUSTAR centres identified only three essential items for DU evaluation and considered the proposed classification and categorisation as useful and feasible. The set of items needs to be validated while further implementation of DU classification and categorisation is warranted. TRIAL REGISTRATION Observational trial on DU (OT1) is one of the five trials of the DeSScipher project (ClinicalTrials.gov; OT1 Identifier: NCT01836263 , posted on April 19, 2013).
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Affiliation(s)
- J. Blagojevic
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - S. Bellando-Randone
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - G. Abignano
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Rheumatology Institute of Lucania (IReL), Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy
| | - J. Avouac
- Department of Rheumatology, University of Paris Descartes, Paris, France
| | - L. Cometi
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - L. Czirják
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - C. P. Denton
- Department of Rheumatology, University College London, Royal Free Hospital, London, UK
| | - O. Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - M. Frerix
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Campus of the Justus-Liebig University Giessen, Bad Nauheim, Germany
| | - S. Guiducci
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - D. Huscher
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - V. K. Jaeger
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | - V. Lóránd
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - B. Maurer
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - S. Nihtyanova
- Department of Rheumatology, University College London, Royal Free Hospital, London, UK
| | - G. Riemekasten
- Clinic of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
| | - E. Siegert
- Department of Rheumatology and Clinical Immunology, Charité – Universitaetsmedizin Berlin, Corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - I. H. Tarner
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Campus of the Justus-Liebig University Giessen, Bad Nauheim, Germany
| | - S. Vettori
- Rheumatology Section, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
| | - U. A. Walker
- Department of Rheumatology, University of Basel, Basel, Switzerland
| | - Y. Allanore
- Department of Rheumatology, University of Paris Descartes, Paris, France
| | - U. Müller-Ladner
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Campus of the Justus-Liebig University Giessen, Bad Nauheim, Germany
| | - F. Del Galdo
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
| | - M. Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
| | - EUSTAR co-workers
- Department of Experimental and Clinical Medicine, University of Florence, and Department of Geriatric Medicine, Division of Rheumatology and Scleroderma Unit AOUC, Villa Monna Tessa, viale Pieraccini 18, 50139 Florence, Italy
- NIHR Leeds Biomedical Research Centre, Leeds Teaching Hospitals NHS Trust and Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
- Rheumatology Institute of Lucania (IReL), Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza, Italy
- Department of Rheumatology, University of Paris Descartes, Paris, France
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
- Department of Rheumatology, University College London, Royal Free Hospital, London, UK
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
- Department of Rheumatology and Clinical Immunology, Kerckhoff-Klinik GmbH, Campus of the Justus-Liebig University Giessen, Bad Nauheim, Germany
- Institute of Biometry and Clinical Epidemiology, Charité – Universitätsmedizin Berlin, Corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Department of Rheumatology, University of Basel, Basel, Switzerland
- Clinic of Rheumatology and Clinical Immunology, University of Lübeck, Lübeck, Germany
- Department of Rheumatology and Clinical Immunology, Charité – Universitaetsmedizin Berlin, Corporate member of Freie Universitaet Berlin, Humboldt-Universitaet zu Berlin, and Berlin Institute of Health, Berlin, Germany
- Rheumatology Section, Department of Precision Medicine, University of Campania “Luigi Vanvitelli”, Naples, Italy
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Kayser C, Bredemeier M, Caleiro MT, Capobianco K, Fernandes TM, de Araújo Fontenele SM, Freire E, Lonzetti L, Miossi R, Sekiyama J, de Souza Müller C. Position article and guidelines 2018 recommendations of the Brazilian Society of Rheumatology for the indication, interpretation and performance of nailfold capillaroscopy. Adv Rheumatol 2019; 59:5. [PMID: 30670098 DOI: 10.1186/s42358-018-0046-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/20/2018] [Indexed: 12/22/2022] Open
Abstract
Nailfold capillaroscopy (NFC) is a reproducible, simple, low-cost, and safe imaging technique used for morphological analysis of nail bed capillaries. It is considered to be extremely useful for the investigation of Raynaud's phenomenon and for the early diagnosis of systemic sclerosis (SSc). The capillaroscopic pattern typically associated with SSc, scleroderma ("SD") pattern, is characterized by dilated capillaries, microhemorrhages, avascular areas and/or capillary loss, and distortion of the capillary architecture. The aim of these recommendations is to provide orientation regarding the relevance of NFC, and to establish a consensus on the indications, nomenclature, the interpretation of NFC findings and the technical equipments that should be used. These recommendations were formulated based on a systematic literature review of studies included in the database MEDLINE (PubMed) without any time restriction.
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Affiliation(s)
- Cristiane Kayser
- Rheumatology Division, Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), Rua Botucatu 740, 3° andar, São Paulo, SP, 04023-062, Brazil.
| | - Markus Bredemeier
- Rheumatology Service, Hospital Nossa Senhora da Conceição, Grupo Hospitalar Conceição, Porto Alegre, RS, Brazil
| | - Maria Teresa Caleiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Karina Capobianco
- Rheumatology Service, Moinhos de Vento Hospital, Porto Alegre, Brazil
| | | | | | - Eutilia Freire
- Rheumatology Service, Universidade Federal da Paraíba, João Pessoa, Brazil
| | - Lilian Lonzetti
- Rheumatology Service, Complexo Hospitalar da Santa Casa de Misericórdia de Porto Alegre, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | - Renata Miossi
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Juliana Sekiyama
- Faculdade de Ciências Médicas, Universidade Estadual de Campinas (UNICAMP), Campinas, SP, Brazil
| | - Carolina de Souza Müller
- Rheumatology Division, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, Brazil
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66
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Kim E, Lee HN, Kim YK, Kim GT, So MW, Ahn E, Sohn DH, Lee SG. Increased serum uric acid levels are associated with digital ulcers in patients with systemic sclerosis. Rheumatol Int 2019; 39:255-263. [DOI: 10.1007/s00296-019-04240-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
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67
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Bruni C, Ngcozana T, Braschi F, Pucci T, Piemonte G, Benelli L, Poli M, Suliman YA, Guiducci S, Bellando-Randone S, Balduzzi S, Grotts J, Denton CP, Rasero L, Montecucco C, Furst DE, Matucci-Cerinic M. Preliminary Validation of the Digital Ulcer Clinical Assessment Score in Systemic Sclerosis. J Rheumatol 2018; 46:603-608. [DOI: 10.3899/jrheum.171486] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2018] [Indexed: 12/20/2022]
Abstract
Objective.To date, “healed/non-healed” and clinical judgment are the only available assessment tools for digital ulcers (DU) in patients with systemic sclerosis (SSc). The aim of our study is to examine a preliminary composite DU clinical assessment score (DUCAS) for SSc for face, content, and construct validity.Methods.Patients with SSc presenting at least 1 finger DU were enrolled and assessed with the Health Assessment Questionnaire–Disability Index, Cochin scale, visual analog scale (VAS) for DU-related pain, patient global DU status, and global assessment as patient-reported outcomes (PRO), and physician VAS for DU status (phyGDU) as an SSc-DU expert physician/nurse measure. The DUCAS included 7 DU-related variables selected by a committee of SSc DU experts and weighted on a clinical basis. Face validity was examined by consensus and partial construct validity was tested through convergent correlation with other measures of hand function, using Spearman’s correlations. A range of patients with SSc was examined. A linear regression model with backward stepwise analysis was used to determine the relationship of individual variables with the primary clinical parameter, phyGDU.Results.Forty-four patients with SSc (9 males, mean age 55 ± 15 yrs, mean disease duration 9.9 ± 5.8 yrs) were enrolled in the study. Overall DUCAS showed significant positive correlations with all abovementioned PRO (r > 0.4, p < 0.01). When all scores and scales were modeled, only DUCAS significantly predicted phyGDU (r = 0.59, R2 = 0.354, Akaike information criterion = 385.4).Conclusion.Preliminarily, we suggest that the DUCAS may be a new clinical score for SSc-related DU, having face and content validity and convergent/divergent correlations (construct validity). These early data suggest that this score deserves further evaluation.
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Odyakmaz Demirsoy E, Çatal C, Yazıcı A, Bayramgurler D. A Rare Cause of Leg Ulcer: Calcinosis Cutis as a Part of CREST Syndrome. INT J LOW EXTR WOUND 2018; 17:282-284. [PMID: 30270692 DOI: 10.1177/1534734618799576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Leg ulcers are not a disease themselves, they are a symptom of a disease. To manage them properly, finding the correct diagnosis of the disease is mandatory. Our case is a model to underline that leg ulcers are a significant burden for the patient, because leg ulcer got ahead of the patient's other serious complaints such as Raynaud's phenomenon or sclerodactyly. Furthermore, our patient is also a model, and an attentive clinical evaluation is inevitable to find the correct diagnosis. We present our case aiming to underline the significance of full dermatologic examination in each ulceration to discover underlying disease.
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Affiliation(s)
| | - Cansu Çatal
- 1 Department of Dermatology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Ayten Yazıcı
- 2 Department of Rheumatology, Kocaeli University School of Medicine, Kocaeli, Turkey
| | - Dilek Bayramgurler
- 1 Department of Dermatology, Kocaeli University School of Medicine, Kocaeli, Turkey
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69
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Ascherman DP, Zang Y, Fernandez I, Clark ES, Khan WN, Martinez L, Greidinger EL. An Autoimmune Basis for Raynaud's Phenomenon: Murine Model and Human Disease. Arthritis Rheumatol 2018; 70:1489-1499. [PMID: 29569858 DOI: 10.1002/art.40505] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 03/15/2018] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Raynaud's phenomenon (RP) is common in anti-RNP-positive patients with rheumatic diseases but is not itself known to be caused by autoimmunity. The aim of this study was to assess autoantibodies that could mediate this process. METHODS Antibodies derived from patient sera and from murine models of anti-RNP autoimmunity were screened for the ability to induce RP-like tissue ischemia and endothelial cell apoptosis in murine models and in vitro systems. RESULTS RNP-positive sera from RP patients and murine sera from RNP-positive B cell adoptive transfer recipients induced RP-like tissue ischemia and endothelial cell apoptosis. Proteomic analysis identified cytokeratin 10 (K10) as a candidate autoantigen in RP. Monoclonal anti-K10 antibodies reproduced patterns of ischemic tissue loss and endothelial cell apoptosis; K10 knockout or depletion of anti-K10 activity in serum was protective. Cold exposure enhanced K10 expression and in vivo tissue loss. CONCLUSION Anti-K10 antibodies are sufficient to mediate RP-like ischemia in murine models and are implicated in the pathogenesis of RP in patients with anti-RNP autoimmunity.
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Affiliation(s)
- D P Ascherman
- Miami VA Medical Center and University of Miami Miller School of Medicine, Miami, Florida
| | - Y Zang
- University of Miami Miller School of Medicine, Miami, Florida
| | - I Fernandez
- University of Miami Miller School of Medicine, Miami, Florida
| | - E S Clark
- University of Miami Miller School of Medicine, Miami, Florida
| | - W N Khan
- University of Miami Miller School of Medicine, Miami, Florida
| | | | - E L Greidinger
- Miami VA Medical Center and University of Miami Miller School of Medicine, Miami, Florida
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70
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Hughes M, Murray A, Denton CP, Herrick AL. Should all digital ulcers be included in future clinical trials of systemic sclerosis-related digital vasculopathy? Med Hypotheses 2018; 116:101-104. [PMID: 29857890 DOI: 10.1016/j.mehy.2018.04.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/25/2018] [Accepted: 04/30/2018] [Indexed: 11/24/2022]
Abstract
Digital ulcers (DU) are a common manifestation of systemic sclerosis (SSc) and occur at a variety of locations including the fingertips and over the extensor aspects of the hands. However, most recent clinical trials have included only fingertip DUs as these are believed to be ischaemic in aetiology, and therefore likely to benefit from treatment with vasoactive drug therapies. There is an emerging evidence base to suggest that all DUs in SSc could share an ischaemic component which is potentially responsive to vascular therapy. Our hypothesis is that is that DUs occurring at sites other than the fingertips, in particular, those overlying the extensor aspect of the hands, may also have a potentially reversible ischaemic component. We review the evidence under the headings: 'microvascular imaging', 'structural microvascular' and, 'functional vascular disease', 'macrovascular involvement' and 'vascular associates'. Based upon the current evidence, we would encourage the expert SSc community to reconsider the rationale for including only fingertip DUs in future SSc clinical trials, and suggest an agenda for future research.
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Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
| | - Andrea Murray
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; Photon Science Institute, The University of Manchester, UK
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK; NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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71
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Ingegnoli F, Schioppo T, Allanore Y, Caporali R, Colaci M, Distler O, Furst DE, Hunzelmann N, Iannone F, Khanna D, Matucci-Cerinic M. Practical suggestions on intravenous iloprost in Raynaud's phenomenon and digital ulcer secondary to systemic sclerosis: Systematic literature review and expert consensus. Semin Arthritis Rheum 2018; 48:686-693. [PMID: 29706243 DOI: 10.1016/j.semarthrit.2018.03.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/27/2018] [Accepted: 03/29/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Systemic sclerosis (SSc) is an autoimmune chronic disease characterized by vascular impairment, immune dysfunction and collagen deposition. Raynaud's phenomenon (RP) and digital ulcers (DU) are prominent features of SSc. Intravenous (IV) iloprost (ILO), according to the recently updated EULAR recommendations, is indicated for RP after failure of oral therapy. Moreover, IV ILO could be useful in DU healing. IV ILO is currently available mainly on the European market approved for RP secondary to SSc with 3-5 days infusion cycle. Unfortunately, data published varies regarding regimen (dosage, duration and frequency). Up to now, ILO has been studied in small cohorts of patients and in few randomized controlled trials. METHODS A systematic review of studies on IV ILO in patients with SSc complicated by DU and RP was performed. Insufficient data were available to perform a meta-analysis according to the GRADE system. We performed a three-stage internet-based Delphi consensus exercise. RESULTS Three major indications were identified for IV ILO usage in SSc: RP non-responsive to oral therapy, DU healing, and DU prevention. IV ILO should be administered between 0.5 and 2.0ng/kg/min according to patient tolerability with a frequency depending on the indication. CONCLUSIONS Although these suggestions are supported by this expert group to be used in clinical setting, it will be necessary to formally validate the present suggestions in future clinical trials.
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Affiliation(s)
- Francesca Ingegnoli
- Division of Clinical Rheumatology, ASST Pini-CTO, Milano, Italy; Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milano, Italy.
| | | | - Yannick Allanore
- Paris Descartes University, Cochin Hospital, Rheumatology A department, INSERM U1016, Paris, France
| | - Roberto Caporali
- Division of Rheumatology, University of Pavia, IRCCS S. Matteo Foundation, Pavia, Italy
| | - Michele Colaci
- Rheumatology Unit, University of Modena and Reggio Emilia, Modena, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Switzerland
| | - Daniel E Furst
- Los Angeles, USA UCLA (emeritus); University of Washington, Seattle Wash; University of Florence, Florence, Italy
| | | | | | - Dinesh Khanna
- Ann Arbor, University of Michigan, Ann Arbor, Michigan
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence & Department of Geriatric Medicine, Division of Rheumatology AOUC, Florence, Italy
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Gigante A, Margiotta D, Navarini L, Barbano B, Gasperini ML, D'Agostino C, Amoroso A, Afeltra A, Rosato E. Serum level of endostatin and digital ulcers in systemic sclerosis patients. Int Wound J 2018; 15:424-428. [PMID: 29600562 DOI: 10.1111/iwj.12882] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 11/20/2017] [Indexed: 11/29/2022] Open
Abstract
Patients with systemic sclerosis (SSc) are at a high risk of the development of ischaemic digital ulcers (DUs) that can be complicated with infections, gangrene, and osteomyelitis. The aim of this study is to evaluate the role of endostatin in scleroderma DUs.In total, 90 SSc patients were enrolled in this study. Serum endostatin levels and DU assessment were determined in all SSc patients. The serum levels of endostatin significantly increased with progression of capillaroscopic damage (P < .01). The serum levels of endostatin are significantly (P < .05) higher in SSc patients with new DUs than in SSc patients without new DUs (127 ± 31.1 ng/mL vs 116.3 ± 39.7 ng/mL). The Receiver Operating Characteristic (ROC) curves demonstrated good accuracy of new DU prediction for the serum level of endostatin (0.70, P < .01 [95% confidence interval (CI) 0.59-0.81]). Using a cut-off value of 116 ng/mL, the odds ratio was 2.609 (CI 1.075-6.330, P < .05). The serum levels of endostatin are significantly (P < .01) higher in SSc patients with infected DUs than in SSc patients without infected DUs (139.2 [114.6-340.91] ng/mL vs 117.5 [64.3-163.9] ng/mL). Serum levels of endostatin are higher in patients with DUs, especially in those with infected DUs.
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Affiliation(s)
- Antonietta Gigante
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Domenico Margiotta
- Unit of Allergology, Immunology, Rheumatology, Campus Bio-Medico University, Rome, Italy
| | - Luca Navarini
- Unit of Allergology, Immunology, Rheumatology, Campus Bio-Medico University, Rome, Italy
| | - Biagio Barbano
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Maria L Gasperini
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Claudia D'Agostino
- Department of Public Health and Infectious Diseases, Sapienza University, Rome, Italy
| | - Antonio Amoroso
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Antonella Afeltra
- Unit of Allergology, Immunology, Rheumatology, Campus Bio-Medico University, Rome, Italy
| | - Edoardo Rosato
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
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Simpson V, Hughes M, Wilkinson J, Herrick AL, Dinsdale G. Quantifying Digital Ulcers in Systemic Sclerosis: Reliability of Computer-Assisted Planimetry in Measuring Lesion Size. Arthritis Care Res (Hoboken) 2018; 70:486-490. [DOI: 10.1002/acr.23300] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/01/2017] [Indexed: 11/06/2022]
Affiliation(s)
| | - M. Hughes
- University of Manchester; Manchester UK
| | | | - A. L. Herrick
- University of Manchester and Central Manchester University Hospitals NHS Foundation Trust; Manchester UK
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Dinsdale G, Moore TL, Manning JB, Murray AK, Atkinson R, Ousey K, Dickinson MR, Taylor C, Herrick AL. Tracking digital ulcers in systemic sclerosis: a feasibility study assessing lesion area in patient-recorded smartphone photographs. Ann Rheum Dis 2018; 77:1382-1384. [DOI: 10.1136/annrheumdis-2017-212829] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/15/2018] [Accepted: 01/24/2018] [Indexed: 11/03/2022]
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Scleroderma skin ulcers definition, classification and treatment strategies our experience and review of the literature. Autoimmun Rev 2017; 17:155-164. [PMID: 29196241 DOI: 10.1016/j.autrev.2017.11.020] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Skin ulcers (SU) are one of the most frequent manifestations of systemic sclerosis (SSc). SSc-SU are very painful, often persistent and recurrent; they may lead to marked impairment of patient's activities and quality of life. Despite their severe impact on the whole SSc patient's management, the proposed definition, classification criteria, and therapeutic strategies of SSc-SU are still controversial. OBJECTIVE The present study aimed to elaborate a comprehensive proposal of definition, classification, and therapeutic strategy of SSc-SU on the basis of our long-term single center experience along with a careful revision of the world literature on the same topic. METHODS A series of 282 SSc patients (254 females and 28 males; 84% with limited and 16% diffuse cutaneous SSc; mean age of 51.5±13.9SD at SSc onset; mean follow-up 5.8±4.6SDyears) enrolled during the last decade at our Rheumatology Unit were retrospectively evaluated with specific attention to SSc-SU. The SSc-SU were classified in 5 subtypes according to prominent pathogenetic mechanism(s) and localization, namely 1. digital ulcers (DU) of the hands or feet, 2. SU on bony prominence, 3. SU on calcinosis, 4. SU of lower limbs, and 5. DU presenting with gangrene. This latter is a very harmful evolution of both DU of the hands and feet needing a differential diagnosis with critical limb ischemia. RESULTS During the follow up period, one or more episodes of SSc-SU were recorded in over half patients (156/282, 55%); skin lesions were often recurrent and difficult-to-heal because of local complications, mainly infections (67.3%), in some cases associated to osteomyelitis (19.2%), gangrene (16%), and/or amputation (11.5%). SSc-SU were significantly associated with lower patients' mean age at the disease onset (p=0.024), male gender (p=0.03), diffuse cutaneous subset (p=0.015), calcinosis (p=0.002), telangiectasia (p=0.008), melanodermia (p<0.001), abnormal PAPs (p=0.036), and/or altered inflammation reactant (CRP, p=0.001). Therapeutic strategy of SSc-SU included both systemic and local pharmacological treatments with particular attention to complicating infections and chronic/procedural pain, as well as a number of non-pharmacological measures. Integrated local treatments were often decisive for the SSc-SU healing; they were mainly based on the wound bed preparation principles that are summarized in the acronym TIME (necrotic Tissue, Infection/Inflammation, Moisture balance, and Epithelization). The updated review of the literature focusing on this challenging issue was analyzed in comparison with our experience. CONCLUSIONS The recent advancement of knowledge and management strategies of SSc-SU achieved during the last years lead to the clear-cut improvement of patients' quality of life and reduced long-term disability.
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Review of local wound management for scleroderma-associated digital ulcers. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 3:66-70. [PMID: 32099902 DOI: 10.5301/jsrd.5000268] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Digital ulcers (DU) are a common clinical problem in systemic sclerosis (SSc); however, there is no standardization of local wound care protocols for management of these lesions. There is a well-recognized need to develop and standardize non-pharmacological management of DU in patients with SSc, and to adopt these protocols in future clinical trials that focus on DU healing. The purpose of this review is to outline the types of DU that occur in SSc, and provide an update on the principles of wound management for these lesions based on the current literature and expert opinion.
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77
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Cutolo M, Smith V, Furst DE, Khanna D, Herrick AL. Points to consider-Raynaud's phenomenon in systemic sclerosis. Rheumatology (Oxford) 2017; 56:v45-v48. [PMID: 28992170 DOI: 10.1093/rheumatology/kex199] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 11/13/2022] Open
Abstract
RP is an exaggerated vasospastic response to cold or emotion. Randomized, double-blind, placebo-controlled trials with either parallel group or cross-over trials should be mainly considered. Cross-over design, which is good for early phase trials of immediate or very short-term outcomes, is important in a condition as heterogeneous as RP: a wash-out period between treatment arms should always be included to minimize the possibility of a period (carry-over) effect. Duration of RP trials is usually constrained by the need to complete these over a single season, usually winter when the weather is colder. For cross-over trials, each treatment arm tends to be 4 weeks or less. Frequency and duration of attacks, and the Raynaud's Condition Score are widely used outcome measures. There is increasing interest in physiological laboratory endpoints, for example laser Doppler imaging at least for early phase trials.
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Affiliation(s)
- Maurizio Cutolo
- Research Laboratories and Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS, University of Genova, Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital.,Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Daniel E Furst
- Department of Rheumatology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Dinesh Khanna
- Department of Medicine University of Michigan, University of Michigan Scleroderma Program, Ann Arbor, MI
| | - Ariane L Herrick
- The University of Manchester, Salford Royal NHS Foundation Trust, Manchester and NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, UK
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Galluccio F, Allanore Y, Czirjak L, Furst DE, Khanna D, Matucci-Cerinic M. Points to consider for skin ulcers in systemic sclerosis. Rheumatology (Oxford) 2017; 56:v67-v71. [PMID: 28992171 DOI: 10.1093/rheumatology/kex200] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Indexed: 12/22/2022] Open
Abstract
This article discusses points to consider when undertaking a clinical trial to test therapy for skin ulcers in SSc. A validated definition of skin ulcers should be used if available. Defining a uniform SSc patient population, including consideration of disease duration, history of digital ulcers and capillaroscopic patterns, is important. Excluding confounding factors such as infection, calcinosis and trauma should be strongly considered, or at least accounted for, in defining patients. Outcome measures such as time to healing, prevention of new ulcers, function, pain and objective measures such as US, laser Doppler and thermography can be considered as outcome measures, although their validation has not yet been achieved and efforts may be needed to validate them before use. Likewise, biomarkers should be considered or consideration should be given to storing serum, plasma or cells for possible future analysis. A pre-planned analysis is important and should include consideration of missing data.
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Affiliation(s)
- Felice Galluccio
- Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence, AOU Careggi, Florence, Italy
| | - Yannick Allanore
- Department of Rheumatology A, Cochin Hospital and Cochin Institute, Assistance Publique-Hôpitaux de Paris, Paris-Descartes University, Paris, France
| | - Lázló Czirjak
- Department of Rheumatology and Immunology, University of Pécs, Pécs, Hungary
| | - Daniel E Furst
- Department of Rheumatology, David Geffen School of Medicine, University of California. Los Angeles, Los Angeles, CA
| | - Dinesh Khanna
- Department of Medicine, University of Michigan Scleroderma Program, University of Michigan, Ann Arbor, MI, USA
| | - Marco Matucci-Cerinic
- Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence, AOU Careggi, Florence, Italy
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Abstract
The abstract book contains the abstracts of keynote lectures, focus sessions, symposia, workshops, AIUC annual meeting, AISLEC annual meeting, EPUAP annual meeting, ETRS special session, sponsor symposia, oral presentations, poster presentations and the subject index.
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The critical need for accurately defining digital ulcers in scleroderma. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 2:69-71. [PMID: 32090169 DOI: 10.5301/jsrd.5000238] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Digital ulcers are one of the key predictors of disease progression and quality of life in patients with systemic sclerosis. Choosing the right treatment for the individual patient begins at developing a consensus among clinicians of what constitutes a digital ulcer. The aim of this editorial is to describe the high unmet need for a standardized method of defining digital ulcers, which is a major challenge not only for treatment, but also for development of new therapies. We discuss the potential role of ultrasound in the development of a validated definition of digital ulcers in systemic sclerosis.
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81
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Defining Skin Ulcers in Systemic Sclerosis: Systematic Literature Review and Proposed World Scleroderma Foundation (WSF) definition. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017; 2:115-120. [PMID: 30569018 DOI: 10.5301/jsrd.5000236] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose There is a lack of a valid, definition for skin ulcers in SSc to be used in clinical trials. Our aim was to develop a consensus definition for SSc-skin ulcers based on the results of a systematic literature review (SLR) for skin ulcer definitions and expert opinion; and to evaluate its face validity, reliability and feasibility. Methods SLR for skin ulcer definitions was conducted using PubMed, Web of Science, and Cochrane library for articles published from inception to January 1st, 2016. SSc experts were to discuss the definitions' categories and vote for the relevant terms. Reliability of the definition were tested in a second expert meeting, seven SSc experts evaluated 7 SSc pts with skin lesions twice. Face validity and feasibility evaluated by sending out case report forms(CRFs) to 4 SSc experts, they were asked to use the definition in 5 pts each. Results A total of 3464 abstracts and titles were screened, and 446 articles were fully evaluated. Of these, 66 met eligibility criteria and skin ulcer definitions were extracted. SSc experts discussed, refined and voted on the consensus definition using nominal process. Kappa for inter-, intra-rater rater agreement was 0.51, 0.90 respectively. The mean time to decide if the lesion is an ulcer was 7.4 sec. All investigators endorsed the face validity of the new definition in the CRFs. Conclusion Using a SLR and a nominal technique, we developed a preliminary consensus-based definition of SSc-skin ulcers. Face validity, feasibility and reliability were demonstrated for the developed definition.
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82
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Taniguchi T, Asano Y, Nakamura K, Yamashita T, Saigusa R, Ichimura Y, Takahashi T, Toyama T, Yoshizaki A, Sato S. Fli1 Deficiency Induces CXCL6 Expression in Dermal Fibroblasts and Endothelial Cells, Contributing to the Development of Fibrosis and Vasculopathy in Systemic Sclerosis. J Rheumatol 2017; 44:1198-1205. [DOI: 10.3899/jrheum.161092] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/17/2017] [Indexed: 02/02/2023]
Abstract
Objective.CXCL6, a chemokine with proangiogenic property, is reported to be involved in vasculopathy associated with systemic sclerosis (SSc). We investigated the contribution of CXCL6 to SSc development by focusing on the association of friend leukemia virus integration 1 (Fli1) deficiency, a potential predisposing factor of SSc, with CXCL6 expression and clinical correlation of serum CXCL6 levels.Methods.mRNA levels of target genes and the binding of Fli1 to the CXCL6 promoter were evaluated by quantitative reverse transcription-PCR and chromatin immunoprecipitation, respectively. Serum CXCL6 levels were determined by ELISA.Results.FLI1 siRNA significantly enhanced CXCL6 mRNA expression in human dermal fibroblasts and human dermal microvascular endothelial cells, while Fli1 haploinsufficiency significantly suppressed CXCL6 mRNA expression in murine peritoneal macrophages stimulated with lipopolysaccharide. Supporting a critical role of Fli1 deficiency to induce SSc-like phenotypes, CXCL6 mRNA expression was higher in SSc dermal fibroblasts than in normal dermal fibroblasts. Importantly, Fli1 bound to the CXCL6 promoter in dermal fibroblasts, endothelial cells, and THP-1 cells. In patients with SSc, serum CXCL6 levels correlated positively with the severity of dermal and pulmonary fibrosis and were elevated in association with cardiac and pulmonary vascular involvement and cutaneous vascular symptoms, including Raynaud phenomenon, digital ulcers (DU)/pitting scars, and telangiectasia. Especially, serum CXCL6 levels were associated with DU/pitting scars and heart involvement by multiple regression analysis.Conclusion.CXCL6 expression is upregulated by Fli1 deficiency in fibroblasts and endothelial cells, potentially contributing to the development of fibrosis and vasculopathy in the skin, lung, and heart of SSc.
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83
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Vitamin D deficiency is associated with digital ulcer but not with atherosclerosis or arterial stiffness in patients with systemic sclerosis: a pilot study. Clin Rheumatol 2017; 36:1325-1333. [DOI: 10.1007/s10067-017-3622-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 03/22/2017] [Accepted: 03/28/2017] [Indexed: 12/12/2022]
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84
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Lescoat A, Coiffier G, Rouil A, Droitcourt C, Cazalets C, de Carlan M, Perdriger A, Jégo P. Vascular Evaluation of the Hand by Power Doppler Ultrasonography and New Predictive Markers of Ischemic Digital Ulcers in Systemic Sclerosis: Results of a Prospective Pilot Study. Arthritis Care Res (Hoboken) 2017; 69:543-551. [PMID: 27390194 DOI: 10.1002/acr.22965] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 05/24/2016] [Accepted: 06/21/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the relevance of power Doppler ultrasonography (PDUS) as a predictive tool of 1-year digital ulcer (DU) occurrence in systemic sclerosis (SSc). METHODS A total of 55 SSc patients and 19 controls underwent PDUS of both hands to evaluate the prevalence of ulnar artery occlusion (UAO) at baseline. Finger pulp blood flow (FPBF) of the third and fourth fingers was also assessed and considered as pathologic if a defect of the Doppler signal on a finger pulp was observed. All patients were clinically re-evaluated 6 and 12 months later and new ischemic DU occurrences in the meantime were retrospectively recorded. Patients were also asked to call if new DUs occurred between consultations. RESULTS PDUS parameters were normal in all controls. The prevalence of UAO was 36.4% and was bilateral in 70% of the SSc cases. A total of 56.4% of SSc patients had a pathologic FPBF. UAO and pathologic FPBF were associated with a history of multiple DU episodes (odds ratio [OR] 8.98 [95% confidence interval (95% CI) 2.52-32.01], P < 0.001, and OR 4.69 [95% CI 1.30-16.93], P = 0.014, respectively) and the occurrence of new DUs during the followup in the univariable model (OR 8.73 [95% CI 2.00-38.16], P = 0.005, and OR 12.65 [95% CI 1.50-106.77], P = 0.005, respectively). The association of UAO and pathologic FPBF in the same patient was a predictive factor of new DUs in the multivariable analysis (P = 0.015). CONCLUSION This study suggests that UAO and pathologic FPBF are associated with a history of multiple DUs and are predictors of new ischemic DUs. These parameters could be used as prognostic factors and considered in further studies evaluating DU treatment strategies.
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Affiliation(s)
| | | | - Alban Rouil
- CHU Rennes, University of Rennes, Rennes, France
| | | | | | | | | | - Patrick Jégo
- CHU Rennes, University of Rennes, Rennes, France
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85
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Souza EJR, Muller CS, Horimoto AMC, Rezende RA, Guimarães I, Mariz HA, Dantas AT, Da Costa IP, Del-Rio APT, Sekiyama J, Kahwage CB, Kayser C. Geographic variation as a risk factor for digital ulcers in systemic sclerosis patients: a multicentre registry. Scand J Rheumatol 2016; 46:288-295. [DOI: 10.1080/03009742.2016.1233994] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- EJR Souza
- Internal Medicine Service, Santa Casa Hospital, Belo Horizonte, Brazil
| | - CS Muller
- Rheumatology Division, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | - AMC Horimoto
- Rheumatology Division, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - RA Rezende
- Internal Medicine Service, Santa Casa Hospital, Belo Horizonte, Brazil
| | - I Guimarães
- Rheumatology Division, Clinics Hospital, Federal University of Paraná, Curitiba, Brazil
| | - HA Mariz
- Clinics Hospital, Federal University of Pernambuco, Recife, Brazil
| | - AT Dantas
- Clinics Hospital, Federal University of Pernambuco, Recife, Brazil
| | - IP Da Costa
- Rheumatology Division, Federal University of Mato Grosso do Sul, Campo Grande, Brazil
| | - APT Del-Rio
- School of Medical Sciences, State University of Campinas, Campinas, Brazil
| | - J Sekiyama
- School of Medical Sciences, State University of Campinas, Campinas, Brazil
| | - CB Kahwage
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - C Kayser
- Rheumatology Division, Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil
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86
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Bongi SM, Ravenni G, Ciampi B, Del Rosso A, El Aoufy K. Biomechanical podiatric evaluation in an Italian cohort of patients with systemic sclerosis: A pilot study. Eur J Rheumatol 2016; 3:169-174. [PMID: 28149661 DOI: 10.5152/eurjrheum.2016.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/16/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Foot problems are often present in Systemic Sclerosis (SSc) patients, however studies regarding podiatric problems related to SSc are lacking and there are no data evaluating the foot biomechanical changes. The aim of the present pilot study was to evaluate podiatric problems in an Italian cohort of SSc patients by assessing received podiatric services, foot pain and disability and biomechanical foot deformity. MATERIAL AND METHODS 25 consecutive SSc patients were enrolled from the Division of Rheumatology, University of Florence. All SSc patients were assessed by: Standards of Care for People with Foot Musculoskeletal Health problems: Audit Tool, Foot Function Index (FFI), Weight and non-weight bearing foot joint assessment, (Foot Posture Index (FPI) and Gait Cycle), Health Assessment Questionnaire (HAQ) and Medical Outcomes Survey Short Form 36 (SF-36). RESULTS Audit Tool - Only 7 (28%) out of the 25 patients with SSc had a specific podiatric assessment and treatment: no patient received a foot health assessment within the first 6 months of disease diagnosis and no patient received information about foot involvement. 1 patient (4%) received foot assessment every year; 1 patient (4%) received specific information about the disease and 5 patients (20%) received information about the benefits of using adapted footwear and insoles. FFI - Values of pain, disability and activity limitations, reported in FFI, are 4.7±5.1, 5.1±3.2 and 3.2±3.1 (M±DS), respectively. Non-weight bearing foot joint assessment shows a rearfoot varus deformity in 64% of patients, forefoot varus deformity in 42% and 6% forefoot valgus deformity. Weight bearing foot joint assessment, through FPI shows a pronated foot 20% of patients with and 34% with highly pronated overall foot posture. Gait analysis shows that 64% of patients has a contact of the calcaneus in invertion while 36% in eversion. In the midstance, 78% have the foot in pronation and 22% in supination, while in propulsion 12% presents a takeoff of the foot in supination and 88% in the pronation. HAQ result is 1.13±0.80, SFI and SMI scales of SF-36 have scores of 32.38±10.65 and 38.67±11.40, respectively. CONCLUSION Our results shows that podiatric problems in SSc patients are common, serious but foot assessment and health care are inadequate. Thus, foot health information should be improved in order to better empower patients to self-manage low risk problems and help identify high-risk problems, which require specialist care.
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Affiliation(s)
- Susanna Maddali Bongi
- Division of Rheumatology, Department Of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giovanni Ravenni
- Division of Rheumatology, Department Of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Benedetta Ciampi
- Division of Rheumatology, Department Of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Angela Del Rosso
- Division of Rheumatology, Department Of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Khadija El Aoufy
- Division of Rheumatology, Department Of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Plasma endothelial microparticles reflect the extent of capillaroscopic alterations and correlate with the severity of skin involvement in systemic sclerosis. Microvasc Res 2016; 110:24-31. [PMID: 27889559 DOI: 10.1016/j.mvr.2016.11.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 11/17/2016] [Accepted: 11/17/2016] [Indexed: 10/20/2022]
Abstract
INTRODUCTION AND AIM Endothelial microparticles (EMPs) are membrane-coated vesicles shed from endothelial cells and are considered markers of the endothelial state. It has been shown that total numbers of circulating EMPs are increased in patients with systemic sclerosis (SSc), but their clinical correlations have not yet been investigated in detail. We aimed to assess possible relationships between circulating EMPs and clinical as well as laboratory features among SSc patients with special attention to possible association with alteration in microvascular morphology objectified on nailfold videocapillaroscopy and clinical signs of microvascular complications. MATERIALS AND METHODS The study included 47 SSc patients and 27 age- and sex-matched healthy controls. EMPs were identified with flow cytometry after staining platelet-poor plasma with combinations of fluorescent cell-specific monoclonal antibodies (anti-CD31, -51, -42b, -62E and Annexin V). The following types of EMPs were evaluated: total EMPs (CD31+/CD42b-), activated EMPs (CD62E+/AnnV-,) and apoptotic EMPs (CD62E+/AnnV+ or CD51+). Clinical evaluation of patients was obtained, including nailfold videocapillaroscopy. RESULTS All types of EMPs were significantly elevated in SSc patients as compared with healthy controls. We found significant inverse correlation between severity of skin involvement and values of total EMPs (r=-0.32; p=0.02) and their levels tended to be lower in SSc patients with digital ulcers when compared to those without ischaemic skin lesions (p=0.09). Total EMPs and activated EMPs showed correlations with the number of ramified capillaries (r=-0.40 and r=0.37, respectively, p<0.05 for both). Moreover, total EMPs inversely correlated with the severity of capillary loss (r=-0.35, p<0.05) and their levels were significantly lower in patients with late NVC pattern with respect to those with early microangiopathy (p<0.05). On the other hand, active NVC pattern was characterized by strongly elevated levels of activated EMPs when compared to an early vascular alteration (p<0.05). CONCLUSIONS Our results suggest that quantity and phenotype of circulating EMPs might indicate on molecular vascular damage with endothelial dysfunction and to reflect progressive loss of capillaries consequencing in microvascular insufficiency in SSc patients.
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88
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Braschi F, Bartoli F, Bruni C, Fiori G, Fantauzzo C, Paganelli L, De Paulis A, Rasero L, Matucci-Cerinic M. Lidocaine controls pain and allows safe wound bed preparation and debridement of digital ulcers in systemic sclerosis: a retrospective study. Clin Rheumatol 2016; 36:209-212. [PMID: 27686661 DOI: 10.1007/s10067-016-3414-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 08/25/2016] [Accepted: 09/10/2016] [Indexed: 10/20/2022]
Abstract
In Systemic Sclerosis (SSc), digital ulcers (DU) are painful, difficult to heal, and frequently infected. To reduce the risk of bacterial infection and to prevent chronicity, it is essential to carefully remove necrotic tissue from DU, with maximum patient comfort. Debridement, although very efficacious, is invasive and causes local pain: lidocaine is a local anesthetic commonly used as to fight pain during debridement procedures. The aim of the study was to evaluate the efficacy of lidocaine 4 % in pain control during debridement procedure of DU in SSc. One hundred eight DU characterized by pain Numeric Rating Scale (NRS) >3/10 before starting the procedure were treated with lidocaine 4 % (lidocaine cloridrate 200 mg in 5 ml of injecting solution). Pain was measured with NRS (0-10) before starting debridement, after 15 min of lidocaine application and at the end of the procedure. In DU, in respect to baseline (mean NRS 6.74 ± 2.96), pain after application of lidocaine 4 % for 15 min was significantly lower (mean NRS 2.83 ± 2.73) (p < 0.001). At the end of the procedure, pain control was still maintained and significantly lower (mean NRS 2.88 ± 2.65) in respect to baseline (p < 0.001). No systemic adverse event due to topical lidocaine were observed. In SSc, topical application of lidocaine 4 % significantly reduces pain, allowing a safe debridement procedure, thus improving the management of DU.
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Affiliation(s)
- Francesca Braschi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Francesca Bartoli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy. .,Department of Geriatric Medicine Division of Rheumatology AOUC, University of Florence, Florence, Italy.
| | - Cosimo Bruni
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Ginevra Fiori
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Claudia Fantauzzo
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Lucia Paganelli
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Amato De Paulis
- Department of Translational Medical Sciences and Center for Basic and Clinical Immunology Research (CISI), University of Naples Federico II, Naples, Italy
| | - Laura Rasero
- Department of Public Health AOUC, University of Florence, Florence, Italy
| | - M Matucci-Cerinic
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Geriatric Medicine Division of Rheumatology AOUC, University of Florence, Florence, Italy
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89
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Adya KA, Inamadar AC, Palit A. "Pitted" lesions in dermatology. Int J Dermatol 2016; 56:3-17. [PMID: 27613605 DOI: 10.1111/ijd.13358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 01/20/2016] [Accepted: 03/20/2016] [Indexed: 11/29/2022]
Abstract
Cutaneous pitting, dimpling, or depressions are frequently dealt with in clinical practice. Such lesions may be primary manifestations of a disorder or develop as secondary changes during the course of the disease. Cutaneous pitting may be a manifestation of certain genodermatoses and internal disorders when it serves as a marker of such conditions. This article describes various types of pitted lesions affecting the ectodermal structures (skin, nails, and teeth) and their clinical significance along with brief description of the associated conditions.
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Affiliation(s)
- Keshavmurthy A Adya
- Department of Dermatology, Venereology and Leprosy, SBMP Medical College, Hospital and Research Center, BLDE University, Vijayapur, Karnataka, India
| | - Arun C Inamadar
- Department of Dermatology, Venereology and Leprosy, SBMP Medical College, Hospital and Research Center, BLDE University, Vijayapur, Karnataka, India
| | - Aparna Palit
- Department of Dermatology, Venereology and Leprosy, SBMP Medical College, Hospital and Research Center, BLDE University, Vijayapur, Karnataka, India
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90
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Poirier E, Wind H, Cordel N. [Efficacy of hyperbaric oxygen therapy in the treatment of ischemic toe ulcer in a patient presenting systemic sclerosis]. Ann Dermatol Venereol 2016; 144:55-59. [PMID: 27476378 DOI: 10.1016/j.annder.2016.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Revised: 04/02/2016] [Accepted: 06/03/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The medical treatment of ischemic ulcers in patients with systemic sclerosis remains difficult. Despite the major help provided by vasodilator treatments, the risk of spontaneous or surgical amputation remains high. OBSERVATION A 48-year-old female patient from Guadeloupe was treated in our department for diffuse systemic sclerosis present for 15 years complicated by lung, joint and digestive involvement, and associated with severe Raynaud's phenomenon. The clinical course was marked by the occurrence of multiple ischemic ulcers, which were resistant to conventional medical treatment and resulted in two surgical amputations (to the 2nd and 3rd interphalangeal joints of the toes of the left foot). Treatment with an endothelin-receptor antagonist and a calcium inhibitor was then introduced for secondary prevention. Two years later, the patient consulted for a further ischemic ulcer of the left 4th toe. She refused the proposed treatment with iloprost. Because of the unfavorable outcome and the absence of therapeutic alternative to amputation, hyperbaric oxygen therapy was initiated. Thirty 90-minutes sessions of pure oxygen at 2.5 ATA were conducted over a 10-week period. Complete healing was obtained after 8 months. DISCUSSION We report herein a clinical case illustrating the efficacy of hyperbaric oxygen therapy for the treatment of ischemic ulcers of the toes in systemic sclerosis. It could offer an alternative therapeutic option, in particular for patients presenting resistant ischemic ulcers and a contraindication for or intolerance to the conventional medical treatment.
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Affiliation(s)
- E Poirier
- Unité de dermatologie-médecine interne, CHU de Pointe-à-Pitre/Abymes, route de Chauvel, 97110 Pointe-à-Pitre, Guadeloupe.
| | - H Wind
- Service d'accueil des urgences, CHU de Pointe-à-Pitre/Abymes, route de Chauvel, 97110 Pointe-à-Pitre, Guadeloupe
| | - N Cordel
- Unité de dermatologie-médecine interne, CHU de Pointe-à-Pitre/Abymes, route de Chauvel, 97110 Pointe-à-Pitre, Guadeloupe
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Allanore Y, Denton CP, Krieg T, Cornelisse P, Rosenberg D, Schwierin B, Matucci-Cerinic M. Clinical characteristics and predictors of gangrene in patients with systemic sclerosis and digital ulcers in the Digital Ulcer Outcome Registry: a prospective, observational cohort. Ann Rheum Dis 2016; 75:1736-40. [PMID: 27353738 PMCID: PMC5013077 DOI: 10.1136/annrheumdis-2016-209481] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 05/27/2016] [Indexed: 11/04/2022]
Affiliation(s)
- Yannick Allanore
- Department of Rheumatology A, Cochin Hospital, Paris Descartes University, Paris, France
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK
| | - Thomas Krieg
- Department of Dermatology, University of Cologne, Cologne, Germany
| | - Peter Cornelisse
- Department of Biostatistics, Actelion Pharmaceuticals, Allschwil, Switzerland
| | - Daniel Rosenberg
- Department of Epidemiology and Observational Studies, GCS & E, Actelion Pharmaceuticals, Allschwil, Switzerland
| | - Barbara Schwierin
- Department of Global Clinical Development and Epidemiology, Actelion Pharmaceuticals, Allschwil, Switzerland
| | - Marco Matucci-Cerinic
- Division of Rheumatology AOUC, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Bartoli F, Fiori G, Braschi F, Amanzi L, Bruni C, Blagojevic J, Bellando-Randone S, Cometi L, de Souza Mueller C, Guiducci S, Rasero L, Epifani F, Furst DE, Matucci-Cerinic M. Calcinosis in systemic sclerosis: subsets, distribution and complications. Rheumatology (Oxford) 2016; 55:1610-4. [PMID: 27241706 DOI: 10.1093/rheumatology/kew193] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To retrospectively analyse the features of calcinosis in a cohort of SSc patients. METHODS Charts of SSc patients attending the Ulcer Unit of the Rheumatology Department, University of Florence and presenting a clinical suspicion of calcinosis were considered in the study. Data on clinical history, including recent skin changes, and clinical examination of all areas with suspected calcinosis, radiological imaging of the calcinotic area, demographics and SSc-related organ involvement and pain measured by a visual analogue scale were recorded. RESULTS In 52 of 112 SSc patients, a total of 316 calcinoses were recorded and were divided into visible and palpable {154 [47.4%], clustered according to their macroscopic features as mousse [49 (31.8%)] and stone [: 105 (68.2%)]} and non-visible but palpable {: 162 [52.6%]: net [5 (3%)], plate [22 (13.8%)] and stone [135 (83.2%)]}. The X-ray-based classification of all calcinoses, both visible and non-visible, was as follows: stone, 289 (91.4%); net, 12 (3.8%) and plate, 15 (4.8%). Skin ulcers complicated 154 of 316 calcinoses (48.7%). Mousse calcinosis was associated with pulmonary arterial hypertension, the stone subset was suggestive of pulmonary involvement and justified further investigation and the net subset was the slowest to heal. CONCLUSION Our data indicate that calcinosis may be classified in SSc as mousse, stone, net and plate according to its clinical and X-ray features. This classification awaits validation for a possible use in clinical practice and to support early treatment and prevention of complications.
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Affiliation(s)
- Francesca Bartoli
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Ginevra Fiori
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Francesca Braschi
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Laura Amanzi
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Cosimo Bruni
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Jelena Blagojevic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Laura Cometi
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | - Carolina de Souza Mueller
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy Serviço de Reumatologia, University Hospital of Curitiba, Paraná, Brazil
| | - Serena Guiducci
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
| | | | - Francesco Epifani
- Interinstitutional Department of Didactic, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Florence, Italy
| | - Daniel E Furst
- Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Florence, Florence, Italy
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93
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Hughes M, Herrick AL. Digital ulcers in systemic sclerosis. Rheumatology (Oxford) 2016; 56:14-25. [PMID: 27094599 DOI: 10.1093/rheumatology/kew047] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/15/2016] [Indexed: 11/14/2022] Open
Abstract
Digital ulcers (DUs) are a common visible manifestation of the progressive vascular disease that characterizes the SSc disease process. DUs not only impact significantly on patients' quality of life and hand function, but are also a biomarker of internal organ involvement and of disease severity. The aetiology of (digital) vascular disease in SSc is multifactorial, and many of these factors are potentially amenable to therapeutic intervention. The management of DU disease in SSc is multifaceted. Patient education and non-pharmacological interventions (e.g. smoking cessation) should not be neglected. There are a number of drug therapies available to prevent (e.g. phosphodiesterase type-5 inhibitors and ET receptor-1 antagonists) and treat (e.g. i.v. iloprost) DUs. DUs are also important for two other reasons: firstly, as a primary end point in SSc-related clinical trials; and secondly, DUs are included in the ACR/EULAR SSc classification criteria. However, the reliability of rheumatologists to grade DUs is poor to moderate at best, and this poses challenges in both clinical practice and research. The purpose of this review is to provide the reader with a description of the spectrum of DU disease in SSc including pathophysiology, epidemiology and clinical burden, all of which inform the multifaceted approach to management.
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Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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94
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van Roon AM, Smit AJ, van Roon AM, Bootsma H, Mulder DJ. Digital ischaemia during cooling is independently related to nailfold capillaroscopic pattern in patients with Raynaud’s phenomenon. Rheumatology (Oxford) 2016; 55:1083-90. [DOI: 10.1093/rheumatology/kew028] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Indexed: 11/12/2022] Open
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95
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Silva I, Almeida C, Teixeira A, Oliveira J, Vasconcelos C. Impaired angiogenesis as a feature of digital ulcers in systemic sclerosis. Clin Rheumatol 2016; 35:1743-51. [PMID: 26920752 DOI: 10.1007/s10067-016-3219-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 07/27/2015] [Accepted: 02/16/2016] [Indexed: 12/20/2022]
Abstract
Impaired angiogenesis in systemic sclerosis has a major role in tissue injury pathogenesis. Our objective was to determine whether angiogenic biomarkers (vascular endothelial growth factor (VEGF), endoglin, and endostatin) are related to microvascular damage and to determine their predictive value for new digital ulcers (DU). The main outcome of the study was the occurrence of a new digital ulcer during 3-year follow-up. This prospective longitudinal study was performed between October 2011 and December 2014. Seventy-seven patients definitely diagnosed with systemic sclerosis where divided into two groups: those with active DU at baseline and those with no DU until enrollment. Patients were matched by sex and age with healthy controls. Serum levels of VEGF, endoglin, and endostatin were measured at enrollment, and several nailfold videocapillaroscopies were performed during the 3-year follow-up. Serum levels of VEGF were lower (245.06, 158.68-347.33; p < 0.001) and those of endoglin were higher (3.013, 1.463-7.023; p < 0.001) in patients with active DU than those with no DU history (339.49, 202.00-730.93/1.879, 0.840-3.280), and they were higher than those found in controls (178.030, 101.267-222.102)/0.277, 0.154-0.713), respectively. No differences in endostatin levels were found between groups (p = 0.450). Endoglin was the only biomarker significantly different (p = 0.031) between patients with diffuse versus limited systemic sclerosis and between early, active, and late patterns (p = 0.020). VEGF was identified as an independent predictor for the development of new DU. Our study confirmed the relationship between angiogenic vascular biomarkers and the occurrence of DU. Endoglin and VEGF serum levels are potential risk factors, and VEGF has a predictive value for the occurrence of new DU.
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Affiliation(s)
- Ivone Silva
- Angiology and Vascular Surgery Service and Clinical Immunology Unit, Centro Hospitalar do Porto, Porto, Portugal.
| | - Cristiana Almeida
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
| | - Andreia Teixeira
- Health Information and Decision Sciences Department, CINTESIS- Center for Research in Health Technologies and Information Systems, Universidade do Porto, Porto, Portugal
| | - José Oliveira
- Clinical Pathology Department, Clinical Chemistry, Centro Hospitalar do Porto, Porto, Portugal
| | - Carlos Vasconcelos
- Clinical Immunology Unit, Centro Hospitalar do Porto; Instituto de Ciências Biomédicas Abel Salazar, Multidisciplinar Unit of biomedical investigation, University of Porto, Porto, Portugal
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96
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Blagojevic J, Piemonte G, Benelli L, Braschi F, Fiori G, Bartoli F, Guiducci S, Bellando Randone S, Galluccio F, Cometi L, Castellani S, Boddi M, Moggi Pignone A, Rasero L, Epifani F, Matucci-Cerinic M. Assessment, Definition, and Classification of Lower Limb Ulcers in Systemic Sclerosis: A Challenge for the Rheumatologist. J Rheumatol 2016; 43:592-8. [PMID: 26834223 DOI: 10.3899/jrheum.150035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate pathogenesis and clinical features of lower limb ulcers in systemic sclerosis (SSc) and to propose a classification that could be used in clinical practice. METHODS Charts of 60 patients with SSc who had lower limb cutaneous lesions were reviewed. All patients had videocapillaroscopy and arterial and venous lower limb color Doppler ultrasonography (US). Arteriography was performed if occlusive peripheral arterial disease was suspected. RESULTS The 554 lesions were classified as hyperkeratosis, ulcers, and gangrenes. There were 341 (61.6%) hyperkeratoses, 208 (37.5%) ulcers, and 5 (0.9%) gangrenes. Ulcers were divided into pure ulcers, ulcers associated with hyperkeratosis, and ulcers secondary to calcinosis. Involvement of arterial and venous macrocirculation as determined by color Doppler US was observed in 17 (18.3%) and 18 (30%) patients, respectively. Seventeen out of 37 patients with pure ulcers (45.9%) presented neither venous insufficiency nor hemodynamically significant macrovascular arterial disease. In these patients, pure ulcers were most likely caused by isolated SSc-related microvascular involvement (pure microvascular ulcers). The only significant risk factor for development of pure microvascular ulcers in the multivariate analysis was the history of lower limb ulcers (OR 26.67, 95% CI 2.75-259.28; p < 0.001). CONCLUSION Results of our study indicate that lower limb ulcers in SSc often have a multifactorial pathogenesis that may be difficult to manage. Further studies are needed to validate the proposed classification and to assess the most appropriate management of lower limb ulcers in SSc.
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Affiliation(s)
- Jelena Blagojevic
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Guya Piemonte
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Laura Benelli
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Francesca Braschi
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Ginevra Fiori
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Francesca Bartoli
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Serena Guiducci
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Silvia Bellando Randone
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Felice Galluccio
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Laura Cometi
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Sergio Castellani
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Maria Boddi
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Alberto Moggi Pignone
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Laura Rasero
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Francesco Epifani
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
| | - Marco Matucci-Cerinic
- From the University of Florence: Department of Clinical and Experimental Medicine, Division of Rheumatology; Department of Internal Medicine; Interinstitutional Department of Didactics, Florence, Italy.J. Blagojevic, MD, Doctoral Candidate, University of Siena and University of Florence Joint Doctoral Program, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Piemonte, BSN, RN, Doctoral Candidate, University of Florence, Department of Clinical and Experimental Medicine, Division of Rheumatology; L. Benelli, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Braschi, BSN, RN, Registered Nurse, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; G. Fiori, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Bartoli, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Guiducci, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Bellando Randone, PhD, Researcher, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; F. Galluccio, MD, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; L. Cometi, MD, Rheumatology Resident, Department of Clinical and Experimental Medicine, Division of Rheumatology, University of Florence; S. Castellani, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; M. Boddi, PhD, Associate Professor, Department of Clinical and Experimental Medicine, University of Florence; A. Moggi Pignone, PhD, Associate Professor, Department of Internal Medicine, University of Florence; L. Rasero, BSN, RN, Associate Professor, Department of Clinical and Experimental Medicin
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Tag HS, Jun SM, Lee SG, Park EK, Koo DW, Kim GT. Successful Treatment of Newly Developed, Intractable Digital Ulcers and Gangrene with Bosentan in Systemic Sclerosis. JOURNAL OF RHEUMATIC DISEASES 2016. [DOI: 10.4078/jrd.2016.23.3.193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hee-Sang Tag
- Division of Rheumatology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sung-Min Jun
- Department of Nuclear Medicine, Kosin University College of Medicine, Busan, Korea
| | - Seung Geun Lee
- Department of Rheumatology, Pusan National University Hospital, Busan, Korea
| | - Eun Kyoung Park
- Department of Rheumatology, Pusan National University Hospital, Busan, Korea
| | - Dong-Wan Koo
- Department of Rheumatology, Pusan National University Hospital, Busan, Korea
| | - Geun Tae Kim
- Division of Rheumatology, Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
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98
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Matucci-Cerinic M, Krieg T, Guillevin L, Schwierin B, Rosenberg D, Cornelisse P, Denton CP. Elucidating the burden of recurrent and chronic digital ulcers in systemic sclerosis: long-term results from the DUO Registry. Ann Rheum Dis 2015; 75:1770-6. [PMID: 26612339 PMCID: PMC5036212 DOI: 10.1136/annrheumdis-2015-208121] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Accepted: 10/27/2015] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Digital ulcers (DUs) occur in up to half of patients with systemic sclerosis (SSc) and may lead to infection, gangrene and amputation with functional disability and reduced quality of life. This study has elucidated the burden of SSc-associated DUs through identification of four patient categories based on the pattern of DU recurrence over a 2-year observation period. METHODS Patients with SSc-associated DUs enrolled in the Digital Ulcers Outcome Registry between 1 April 2008 and 19 November 2013, and with ≥2 years of observation and ≥3 follow-up visits during the observation period were analysed. Incident DU-associated complications were recorded during follow-up. Work and daily activity impairment were measured using a functional assessment questionnaire completed by patients after the observation period. Potential factors that could predict incident complications were identified in patients with chronic DUs. RESULTS From 1459 patients, four DU occurrence categories were identified: 33.2% no-DU; 9.4% episodic; 46.2% recurrent; 11.2% chronic. During the observation period, patients from the chronic category had the highest rate of incident complications, highest work impairment and greatest need for help compared with the other categories. Independent factors associated with incident complications included gastrointestinal manifestations (OR 3.73, p=0.03) and previous soft tissue infection (OR 5.86, p=0.01). CONCLUSIONS This proposed novel categorisation of patients with SSc-associated DUs based on the occurrence of DUs over time may help to identify patients in the clinic with a heavier DU burden who could benefit from more complex management to improve their functioning and quality of life.
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Affiliation(s)
- Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Thomas Krieg
- Department of Dermatology, University of Cologne, Cologne, Germany
| | - Loic Guillevin
- Department of Internal Medicine, Centre de Référence pour les Vascularites Nécrosantes et la Sclérodermie Systémique, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | | | | | | | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, Royal Free Hospital, London, UK
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99
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Mahmood M, Wilkinson J, Manning J, Herrick AL. History of surgical debridement, anticentromere antibody, and disease duration are associated with calcinosis in patients with systemic sclerosis. Scand J Rheumatol 2015; 45:114-7. [DOI: 10.3109/03009742.2015.1086432] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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100
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Bălănescu P, Lădaru A, Bălănescu E, Voiosu T, Băicuş C, Dan GA. Endocan, Novel Potential Biomarker for Systemic Sclerosis: Results of a Pilot Study. J Clin Lab Anal 2015; 30:368-73. [PMID: 26331941 DOI: 10.1002/jcla.21864] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 06/27/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Systemic sclerosis (Ssc) is an autoimmune disease characterized by vascular alterations of small arteries and microvessels with subsequent tissue fibrosis. Endocan is expressed by endothelial cells and associated with endothelial dysfunction; therefore it could be a potential biomarker for Ssc patients. METHODS Twenty-one Ssc patients and 20 sex- and age-matched healthy controls were recruited for the study. Serum endocan levels were determined using ELISA method in all patients and controls. RESULTS Serum endocan levels were superior in Ssc patients (median 2.53 (1.10-7 ng/ml)) compared with controls (0.79 (0-2 ng/ml), P < 0.05). Higher serum endocan expression was seen in diffuse Ssc subset and associated with the presence of digital ulcers and daily Raynaud's phenomenon (P < 0.05). Higher serum endocan levels were associated with a modified Rodnan skin score >14 and longer disease duration (P < 0.05). Values of areas under the receiver operating curves showed that serum endocan had good discriminative power for Ssc diagnosis, differentiating diffuse from limited subset type and differentiating patients with modified Rodnan skin score above and under 14 (area under curve: 0.94, 0.81, 0.75, respectively). CONCLUSION The results of this pilot study suggest endocan as a potential biomarker for microvascular manifestations and complications in Ssc patients. These encouraging results could promote future prospective studies in order to determine the exact role played by endocan as a biomarker for Ssc.
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Affiliation(s)
- Paul Bălănescu
- CDPC Clinical Immunology Department, Colentina Clinical Hospital, Bucharest, Romania. .,Internal Medicine Chair, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania. .,Clinical Research Unit, RECIF (Réseau d' Epidémiologie Clinique International Francophone), Bucharest, Romania.
| | - Anca Lădaru
- Pediatrics Department, Institute for Mother and Child Protection "Alfred Rusescu," Bucharest, Romania
| | - Eugenia Bălănescu
- CDPC Clinical Immunology Department, Colentina Clinical Hospital, Bucharest, Romania
| | - Theodor Voiosu
- Internal Medicine Chair, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.,Clinical Research Unit, RECIF (Réseau d' Epidémiologie Clinique International Francophone), Bucharest, Romania
| | - Cristian Băicuş
- Internal Medicine Chair, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.,Clinical Research Unit, RECIF (Réseau d' Epidémiologie Clinique International Francophone), Bucharest, Romania.,Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
| | - Gheorghe Andrei Dan
- Internal Medicine Chair, University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.,Clinical Research Unit, RECIF (Réseau d' Epidémiologie Clinique International Francophone), Bucharest, Romania.,Department of Internal Medicine, Colentina Clinical Hospital, Bucharest, Romania
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