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Curtiss P, Svigos K, Schwager Z, Lo Sicco K, Franks AG. Part I: Epidemiology, pathophysiology, and clinical considerations of primary and secondary Raynaud's phenomenon. J Am Acad Dermatol 2024; 90:223-234. [PMID: 35809798 DOI: 10.1016/j.jaad.2022.06.1199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 11/24/2022]
Abstract
Raynaud's phenomenon (RP) is a relatively common disease with both primary and secondary forms. It is well understood as a vasospastic condition affecting the acral and digital arteries, resulting in characteristic, well-demarcated color changes typically in the hands and feet in response to cold or stress. Secondary RP (SRP) has been described in association with a variety of rheumatologic and nonrheumatologic diseases, environmental exposures, and/or medications. While both primary RP and SRP may impact the quality of life, SRP may lead to permanent and potentially devastating tissue destruction when undiagnosed and untreated. It is therefore crucial for dermatologists to distinguish between primary and secondary disease forms early in clinical evaluation, investigate potential underlying causes, and risk stratify SRP patients for the development of associated autoimmune connective tissue disease. The epidemiology, pathogenesis, and clinical presentation and diagnosis of both forms of RP are described in detail in this review article.
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Affiliation(s)
- Paul Curtiss
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Katerina Svigos
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York
| | - Zachary Schwager
- Department of Dermatology, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Kristen Lo Sicco
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York.
| | - Andrew G Franks
- The Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, New York, New York; Department of Internal Medicine, Division of Rheumatology, New York University School of Medicine, New York, New York
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2
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Markousis-Mavrogenis G, Bournia VK, Sfikakis PP, Mavrogeni SI. Raynaud phenomenon and microvasculopathy in systemic sclerosis: multi-modality imaging for diagnosis and evaluation. Curr Opin Rheumatol 2023; 35:324-333. [PMID: 37582056 DOI: 10.1097/bor.0000000000000965] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW To describe the clinical significance of and the diagnostic approach to Raynaud phenomenon (RP) in the peripheral extremities and the heart. RECENT FINDINGS Nailfold capillaroscopy has recently been standardized in an expert consensus paper. Abnormal capillaroscopy in combination with specific autoantibody profiles and clinical signs are highly predictive of progression of RP to systemic sclerosis (SSc). Magnetic resonance imaging (MRI) can also perform tissue characterization of both the extremities and the heart. Microvascular wall abnormalities detected using nailfold capillaroscopy in patients with SSc may lead to deposition of erythrocyte-derived iron, due to microhemorrhages, which may predispose to fibrosis. MRI can assess the presence of iron using T2∗ measurements. SUMMARY RP is a hallmark of the microvasculopathy in SSc and can affect both the peripheral extremities and the heart. Nailfold capillaroscopy is the current gold standard for the evaluation of the peripheral microvasculature. Other imaging modalities include thermography, laser Doppler-derived methods, 99m Tc-pertechnetate hand perfusion scintigraphy, power Doppler ultrasonography, dynamic optical coherence tomography, MRI, and photoacoustic imaging, but these are currently not widely used. Cardiac RP can be investigated with positron emission tomography or cardiovascular magnetic resonance, with the latter offering the additional possibility of tissue characterization and iron content quantification secondary to microhemorrhages.
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Affiliation(s)
- George Markousis-Mavrogenis
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Health Care, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital
| | | | - Petros P Sfikakis
- Joint Academic Rheumatology Program, National and Kapodistrian University of Athens Medical School
| | - Sophie I Mavrogeni
- University Research Institute of Maternal and Child Health and Precision Medicine and UNESCO Chair in Adolescent Health Care, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children's Hospital
- Onassis Cardiac Surgery Hospital, Athens, Greece
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3
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Amor-Dorado JC, Martín-Sanz E, Franco-Gutiérrez V, Urruticoechea-Arana A, García-Arumí AM, Racines-Álava E, Alemán-López O, Simeón-Aznar CP, González-Gay MÁ. Audiovestibular Manifestations in Patients with Primary Raynaud's Phenomenon and Raynaud's Phenomenon Secondary to Systemic Sclerosis. J Clin Med 2023; 12:jcm12093232. [PMID: 37176671 PMCID: PMC10179300 DOI: 10.3390/jcm12093232] [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: 04/11/2023] [Revised: 04/24/2023] [Accepted: 04/27/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVES To address the prevalence of audiovestibular disorders in patients with primary Raynaud's Phenomenon (RP). A series of patients with primary RP and secondary RP in the context of systemic sclerosis (SSc) were compared with healthy controls. METHODS A prospective multicenter observational cross-sectional study was conducted in several Otolaryngology and Rheumatology Divisions of tertiary referral hospitals, recruiting 57 patients with RP and 57 age- and gender-matched controls. Twenty patients were classified as primary RP when unrelated to any other conditions and 37 patients who met the 2013 ACR/EULAR classification criteria for SSc were classified as having secondary RP associated with SSc. Audiometric and vestibular testing (vHIT), clinical sensory integration and balance testing (CTSIB), and Computerized Dynamic Posturography (CDP) were performed. RESULTS As significant differences were found in the age of the two study groups, primary and secondary RP, no comparisons were made between both groups of RP but only with their control groups. No sensorineural hearing loss (SNHL) was recorded in any of our patients with primary RP and no differences were found in the voice audiometry tests with respect to controls. Four of 37 (10.8%) secondary RP patients presented SNHL. Those with SNHL were 7.03 times more likely to have a secondary RP than controls (p < 0.001). The audiometric curve revealed high-frequency hearing loss in 4 patients with RP secondary to SSc, and statistically significant differences were achieved when RP secondary was compared to controls in vHIT gain, caloric test, CTSIB, and CDP. CONCLUSIONS Unlike patients with RP secondary to SSc, patients with primary RP do not show audiovestibular abnormalities. Regarding audiovestibular manifestations, primary RP can be considered a different condition than secondary RP.
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Affiliation(s)
| | - Eduardo Martín-Sanz
- Department of Otolaryngology, University Hospital of Getafe, Carretera Toledo km 12,500, 28905 Madrid, Spain
- Department of Medicine, School of Biomedical Sciences and Health, European University of Madrid, C. Tajo, s/n, 28670 Madrid, Spain
| | | | | | | | | | - Oscar Alemán-López
- Rheumatology Division, General University Hospital of Alicante, 03203 Elche, Spain
| | | | - Miguel Á González-Gay
- Rheumatology Division, IIS-Fundación Jiménez Díaz, 28015 Madrid, Spain
- Department of Medicine, School of Medicine, University of Cantabria, 39011 Santander, Spain
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Mueller M, Gschwandtner ME, Emminger W, Kiener H, Schnaubelt S, Giurgea GA, Ristl R, Perkmann T, Koppensteiner R, Schlager O. Associations between nailfold capillary aberrations and autoantibodies in children and adults with Raynaud's phenomenon. RMD Open 2023; 9:rmdopen-2023-003077. [PMID: 36972928 PMCID: PMC10069575 DOI: 10.1136/rmdopen-2023-003077] [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: 02/16/2023] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
OBJECTIVE To characterise associations between individual nailfold capillary aberrations with autoantibodies in a cross-sectional study on children and adults with Raynaud's phenomenon (RP). METHODS Consecutive children and adults with RP and without previously known connective tissue disease (CTD) systemically underwent nailfold capillaroscopy and laboratory tests for the presence of antinuclear antibodies (ANA). The prevalence of individual nailfold capillary aberrations and ANA was assessed, and the associations between individual nailfold capillary aberrations and ANA were analysed separately in children and adolescents. RESULTS In total, 113 children (median age 15 years) and 2858 adults (median age 48 years) with RP and without previously known CTD were assessed. At least one nailfold capillary aberration was detected in 72 (64%) of included children and in 2154 (75%) of included adults with RP (children vs adults p<0.05). An ANA titre ≥1:80, ≥1:160 or≥1:320 was observed in 29%, 21% or 16% of included children, and in 37%, 27% or 24% of screened adults, respectively. While the occurrence of individual nailfold capillary aberrations was related to the presence of an ANA titre of ≥1:80 in adults (reduced capillary density, avascular fields, haemorrhages, oedema, ramifications, dilations and giant capillaries: each p<0.001), no comparable association between nailfold capillary aberrations and ANA was observed in children with RP without previously known CTD. CONCLUSION In contrast to adults, the association between nailfold capillary aberrations and ANA might be less pronounced in children. Further studies are warranted to validate these observations in children with RP.
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Affiliation(s)
- Markus Mueller
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria, Medical University of Vienna, Vienna, Austria
| | - Michael E Gschwandtner
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Emminger
- Department of Pediatrics, University Children's Hospital, Wien, Austria
| | - Hans Kiener
- Division of Rheumatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Georgiana-Aura Giurgea
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria, Medical University of Vienna, Vienna, Austria
| | - Robin Ristl
- Center of Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Thomas Perkmann
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Renate Koppensteiner
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria, Medical University of Vienna, Vienna, Austria
| | - Oliver Schlager
- Division of Angiology, Department of Medicine II, Medical University of Vienna, Austria, Medical University of Vienna, Vienna, Austria
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İncekalan TK, Ekinci RMK, Naz Şimdivar GH, Celik Ü. Cold-induced Vascular Changes in the Macula, Optic Disc and Choroid in Children with Raynaud's Phenomena. Ocul Immunol Inflamm 2023; 31:277-285. [PMID: 35081004 DOI: 10.1080/09273948.2022.2026411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
AIM To investigate changes in retinal and choroidal vessels in children with primary and secondary raynaud's phenomena(RP). METHODS Measurements were performed by optic coherence tomography angiography before as well as during and 10 minutes after the immersion of one hand in ice water. RESULTS Primary RP patients exhibited enlargement of the foveal avascular region and decrease in vessel density in the parafoveal superficial capillary plexus (SCP) during cold exposure, but values returned to normal when the hands were removed from the cold water. In children with secondary RP, there were decreases in choroidal thickness and vessel density in the SCP and radial peripapillary capillary plexus (RPCP) during cold exposure. Changes in choroid and peripapillary RPCP were still significant 10 minutes after removal from cold water. CONCLUSION Ocular arteriolar vasospasm seems to be more pronounced in patients with secondary RP, particularly in the choroid and the peripapillary area of the RPCP. CLINICAL TRIAL REGISTRATION NUMBER AND DATE: DECISION NUMBER 76/1315 - 10.03.2021.
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Affiliation(s)
- Tuğba Kurumoğlu İncekalan
- Department of Opthalmology, University of Health Sciences Adana City Training and Research Hospital, Adana, Turkey
| | - Rabia Miray Kisla Ekinci
- Pediatric Rheumatology, University of Health Sciences Adana City Training and Research Hospital, Adana, Turkey
| | - Göksu Hande Naz Şimdivar
- Department of Opthalmology, University of Health Sciences Adana City Training and Research Hospital, Adana, Turkey
| | - Ümit Celik
- Pediatric Infectious Diseases, University of Health Sciences Adana City Training and Research Hospital, Adana, Turkey
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Andraos R, Ahmad A, Eriksson P, Dahlström Ö, Wirestam L, Dahle C, Hesselstrand R, Bengtsson AA, Jönsen A, Andréasson K, Sjöwall C. Autoantibodies associated with systemic sclerosis in three autoimmune diseases imprinted by type I interferon gene dysregulation: a comparison across SLE, primary Sjögren's syndrome and systemic sclerosis. Lupus Sci Med 2022; 9:9/1/e000732. [PMID: 36581379 PMCID: PMC9806068 DOI: 10.1136/lupus-2022-000732] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 12/22/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE SLE, primary Sjögren's syndrome (pSS) and systemic sclerosis (SSc) are heterogeneous autoimmune diseases with a dysregulated type I interferon (IFN) system. The diseases often show overlapping clinical manifestations, which may result in diagnostic challenges. We asked to which extent SSc-associated autoantibodies are present in SLE and pSS, and whether these link to serum IFN-α, clinical phenotypes and sex. Samples with clinical data from patients with SSc and healthy blood donors (HBDs) served as controls. Finally, the diagnostic performance of SSc-associated autoantibodies was evaluated. METHODS Samples from well-characterised subjects with SLE (n=510), pSS (n=116), SSc (n=57) and HBDs (n=236) were analysed using a commercially available immunoassay (EuroLine Systemic Sclerosis Profile (IgG)). IFN-α was quantified by ELISA. Self-reported data on Raynaud's phenomenon (RP) were available. RESULTS With exceptions for anti-Ro52/SSA and anti-Th/To, SSc-associated autoantibodies were more frequent in SSc than in SLE, pSS and HBDs regardless of sex. IFN-α levels correlated with the number of positive SSc-associated autoantibodies (r=0.29, p<0.0001) and associated with Ro52/SSA positivity (p<0.0001). By using data from SLE, SSc and HBDs, RP was significantly associated with topoisomerase I, centromere protein (CENP)-B, RNA polymerase III 11 kDa, RNA polymerase III 155 kDa and PM-Scl100 whereas Ro52/SSA associated inversely with RP. In SLE, CENP-A was associated with immunological disorder, CENP-B with serositis and Ku with lupus nephritis. By combining analysis of ANA (immunofluorescence) with SSc-associated autoantibodies, the diagnostic sensitivity reached 98% and the specificity 33%. CONCLUSIONS The 13 specificities included in the EuroLine immunoassay are commonly detected in SSc, but they are also frequent among individuals with other diseases imprinted by type I IFNs. These findings are valuable when interpreting serological data on patients with suspected SSc, especially as patients may present with disease manifestations overlapping different rheumatological diseases. In SLE, we observed associations between manifestations and SSc-associated autoantibodies which have not previously been reported.
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Affiliation(s)
- Rama Andraos
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, Linköping, Sweden
| | - Awais Ahmad
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Clinical Immunology, Linköping University, Linköping, Sweden
| | - Per Eriksson
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, Linköping, Sweden
| | - Örjan Dahlström
- Department of Behavioural Sciences and Learning, Swedish Institute for Disability Research, Linköping University, Linköping, Sweden
| | - Lina Wirestam
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, Linköping, Sweden
| | - Charlotte Dahle
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Clinical Immunology, Linköping University, Linköping, Sweden
| | - Roger Hesselstrand
- Department of Clinical Sciences, Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Anders A Bengtsson
- Department of Clinical Sciences, Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Andreas Jönsen
- Department of Clinical Sciences, Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Kristofer Andréasson
- Department of Clinical Sciences, Rheumatology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Christopher Sjöwall
- Department of Biomedical and Clinical Sciences, Division of Inflammation and Infection/Rheumatology, Linköping University, Linköping, Sweden
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Anyfanti P, Angeloudi E, Dara A, Arvanitaki A, Bekiari E, Kitas GD, Dimitroulas T. Nailfold Videocapillaroscopy for the Evaluation of Peripheral Microangiopathy in Rheumatoid Arthritis. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081167. [PMID: 36013346 PMCID: PMC9410266 DOI: 10.3390/life12081167] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/28/2022] [Accepted: 07/25/2022] [Indexed: 11/21/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic and refractory autoimmune joint disease that affects multiple organs. Several methods have been applied for the study of microvascular endothelial dysfunction, which is considered an important component of vascular disease in RA. Implementation of nailfold videocapillaroscopy (NVC) represents a viable choice, as the skin is an easily accessible window for the non-invasive, real-time assessment of subtle microcirculation abnormalities. Although NVC is routinely used in the rheumatology field, especially for the diagnostic workout of Raynaud’s phenomenon, accumulating evidence suggests a role in the evaluation of systemic vasculopathy associated with autoimmune rheumatic disorders. The current paper aims to provide an overview of NVC as a valuable clinical aid for the assessment of peripheral microcirculation in RA. Previous studies characterizing the capillaroscopic pattern in RA are summarized, along with associations with disease-related characteristics. Most available reports have mainly focused on the descriptions of non-specific morphological alterations that may reflect endothelial injury over the course of the disease. Still, the exact pattern of structural and functional capillaroscopic alterations and their clinical significance in RA remains a subject of ongoing research.
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Affiliation(s)
- Panagiota Anyfanti
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (E.A.); (E.B.)
- Correspondence:
| | - Elena Angeloudi
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (E.A.); (E.B.)
| | - Athanasia Dara
- Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.D.); (A.A.); (T.D.)
| | - Alexandra Arvanitaki
- Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.D.); (A.A.); (T.D.)
- First Department of Cardiology, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54621 Thessaloniki, Greece
| | - Eleni Bekiari
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (E.A.); (E.B.)
| | - George D. Kitas
- Department of Rheumatology, Russells Hall Hospital, Dudley Group NHS Foundation Trust, Dudley DY1 2HQ, UK;
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece; (A.D.); (A.A.); (T.D.)
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Hong C, Xiang L, Saffari SE, Low AHL. Nailfold capillaroscopy for the early diagnosis of the scleroderma spectrum of diseases in patients without Raynaud's phenomenon. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2022; 7:144-150. [PMID: 35585956 PMCID: PMC9109506 DOI: 10.1177/23971983221088460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/01/2022] [Indexed: 09/05/2023]
Abstract
BACKGROUND The utility of nailfold capillaroscopy in the evaluation of patients without Raynaud's phenomenon is unclear. OBJECTIVE This study aims to compare the utility of nailfold capillaroscopy for the early diagnosis of the scleroderma-spectrum of diseases in patients who present with Raynaud's phenomenon, undifferentiated non-Raynaud's phenomenon features and positive systemic sclerosis-associated antibodies without scleroderma-spectrum of disease features. METHODS Eligible patients were divided into three referral criteria groups: (I) Raynaud's phenomenon; (II) Undifferentiated non-Raynaud's phenomenon features and (III) Positive systemic sclerosis-associated autoantibodies without features to suggest scleroderma-spectrum of diseases. This includes systemic sclerosis, mixed connective tissue disease and dermatomyositis. The association between baseline scleroderma pattern on nailfold capillaroscopy (systemic sclerosis-nailfold capillaroscopy) and final diagnosis at follow-up was determined using logistic regression analysis. Test characteristics of nailfold capillaroscopy were compared and stratified by referral groups. RESULTS Of 95 patients followed-up for a mean of 1.6 years, 28 (29.5%) patients developed scleroderma-spectrum of diseases, 36 (37.9%) patients had suspected/other connective tissue disease and 27 (28.4%) patients had no connective tissue disease. Baseline systemic sclerosis-nailfold capillaroscopy was significantly associated with the development of scleroderma-spectrum of diseases in patients from Group I (odds ratio, 7.1, p = 0.01) and Group II (odds ratio 7.3, p = 0.005). In Group II patients, nailfold capillaroscopy had a sensitivity, specificity, positive and negative predictive values of 71.4%, 76.5%, 55.6% and 86.7%, respectively. Specificity (81.8%) and PPV (69.2%) were the highest in Group I patients. Nailfold capillaroscopy had the highest negative predictive value in Group III (100%), followed by Group II (86.7%) and Group I (78.3%) patients. CONCLUSION In addition to evaluating patients with Raynaud's phenomenon, nailfold capillaroscopy was useful in the evaluation and exclusion of scleroderma-spectrum of diseases in patients with undifferentiated non-Raynaud phenomenon features and those with systemic sclerosis-associated antibodies without features to suggest scleroderma-spectrum of diseases.
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Affiliation(s)
- Cassandra Hong
- Department of Rheumatology and
Immunology, Singapore General Hospital, Singapore
- Yong Loo Lin School of Medicine,
National University of Singapore, Singapore
- Duke-NUS Medical School, National
University of Singapore, Singapore
| | - Ling Xiang
- Department of Rheumatology and
Immunology, Singapore General Hospital, Singapore
- Yong Loo Lin School of Medicine,
National University of Singapore, Singapore
| | - Seyed Ehsan Saffari
- Centre for Quantitative Medicine,
Duke-NUS Medical School, National University of Singapore, Singapore
| | - Andrea HL Low
- Department of Rheumatology and
Immunology, Singapore General Hospital, Singapore
- Yong Loo Lin School of Medicine,
National University of Singapore, Singapore
- Duke-NUS Medical School, National
University of Singapore, Singapore
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9
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Sirufo MM, Magnanimi LM, Ginaldi L, De Martinis M. The shadow zone of capillaroscopy in the classification of the Raynaud's phenomenon. Curr Med Res Opin 2022; 38:637-639. [PMID: 35227144 DOI: 10.1080/03007995.2022.2047538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Raynaud's phenomenon (RP) is a frequent clinical finding in the general population that can be observed across multiple medical specialties and nailfold videocapillaroscopy is a first line imaging tool to early differenziate primitive and secondary forms of RP. According to the criteria of LeRoy and Medsger normal nailfold capillaries characterize a primary RP. The recognition of vascular alterations at capillaroscopy is the key to a correct framing of the phenomenon. Capillaroscopy is of significant practical value as it allows a reliable predictive assessment of the developmental risk of the disorder. However, to date, the variety of nomenclature for subjects affected by RP generates uncertainty in patient management and in the possibility of comparing studies. The capillaroscopic findings have a very broad range of normality and a significant presence of non specific microvascular abnormalities are reported also in patients with primary RP. The presence of these non specific vascular changes can make it difficult to differenziate primary and secondary RP. Here we highlight some critical points in the capillaroscopic distinction of primary and secondary RP and relaunch the debate on the classification of the RP because it is likely that what we identify today as the primary RP (pRP) collects different clinical entities with different prognostic significance and different therapeutic needs.
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Affiliation(s)
- Maria Maddalena Sirufo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the diagnosis and treatment of Osteoporosis, AUSL 04, Teramo, Italy
| | - Lina Maria Magnanimi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
| | - Lia Ginaldi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the diagnosis and treatment of Osteoporosis, AUSL 04, Teramo, Italy
| | - Massimo De Martinis
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
- Allergy and Clinical Immunology Unit, Center for the diagnosis and treatment of Osteoporosis, AUSL 04, Teramo, Italy
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10
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Pizzorni C, Ferrari G, Schenone C, Hysa E, Carmisciano L, Gotelli E, Pacini G, Sulli A, Paolino S, Smith V, Cutolo M. Capillaroscopic analysis of the microvascular status in mixed versus undifferentiated connective tissue disease. Microvasc Res 2022; 142:104367. [DOI: 10.1016/j.mvr.2022.104367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/25/2022] [Accepted: 03/25/2022] [Indexed: 02/02/2023]
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11
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Shenavandeh S S, Ajri M, Hamidi S. Causes of Raynaud's phenomenon and the predictive laboratory and capillaroscopy features for the evolution to a definite connective tissue disease. Rheumatology (Oxford) 2021; 61:1975-1985. [PMID: 34463711 DOI: 10.1093/rheumatology/keab668] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 08/18/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE In patients with Raynaud's phenomenon (RP), capillaroscopy is useful for discriminating primary from secondary causes. There are certain capillaroscopy and lab values as predictive factors leading to a known connective tissue disease (CTD). We conducted the present study to evaluate the causes of RP in our area and followed the studied subjects to find prognostic factors of becoming a definite CTD or remaining undifferentiated connective tissue disease (UCTD). METHODS In this retrospective cohort study, we included all adult patients with RP who were referred for capillaroscopy from 2010 to 2019. All the patients with primary and secondary RP with follow-up were evaluated for demography, laboratory, and capillaroscopy to find the risk factors of their progression to a CTD. RESULTS 760 out of 776 patients were included with 679 being female (89.3%) and 81 (10.7%) male. There were 660 subjects (90.8%) with secondary RP [mostly UCTD (48.2%) and then systemic sclerosis (SSc) (16.4%)] and 67 (9.2%) with primary RP; 109 patients were followed up and 42 (42%) of those with secondary RP developed a definite CTD. Scleroderma pattern and some capillary changes in capillaroscopy and/or positive Anti-Nuclear Antibody (ANA) had statistically significant differences for CTD transition. CONCLUSION We had a low number of patients with primary RP. The most prevalent causes of secondary RP in our patients were UCTD and SSc. Some capillaroscopy and laboratory results alone or in combination could be used as a predictive marker for the transition of the patients with UCTD to a CTD.
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Affiliation(s)
- Saeedeh Shenavandeh S
- Shiraz University of Medical Sciences, Departments of Internal Medicine, Division of Rheumatology, Shiraz, Iran
| | - Mehrnoush Ajri
- Shiraz University of Medical Sciences, Departments of Internal Medicine, Shiraz, Iran
| | - Sahand Hamidi
- Shiraz University of Medical Sciences, Department of Cardiology, Shiraz, Iran
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12
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Coşkun Benlidayı İ, Kayacan Erdoğan E, Sarıyıldız A. Response to: Comment on “The evaluation of nailfold capillaroscopy pattern in patients with fibromyalgia’’. Arch Rheumatol 2021; 36:628-629. [PMID: 35382364 PMCID: PMC8957760 DOI: 10.46497/archrheumatol.2021.8933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- İlke Coşkun Benlidayı
- Department of Physical Medicine and Rehabilitation, Çukurova University Faculty of Medicine, Adana, Turkey
| | - Esra Kayacan Erdoğan
- Department of Rheumatology, University of Health Sciences, Adana City Training and Research Hospital, Adana, Turkey
| | - Aylin Sarıyıldız
- Department of Physical Medicine and Rehabilitation, Silopi State Hospital, Şırnak, Turkey
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13
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Klein-Weigel P, Sander O, Reinhold S, Nielitz J, Steindl J, G. Richter J. Raynaud's Phenomenon: A Vascular Acrosyndrome That Requires Long-Term Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0023. [PMID: 33632387 PMCID: PMC8287761 DOI: 10.3238/arztebl.m2021.0023] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 11/24/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Some 5-10% of the German population are affected by Raynaud's phenomenon (RP). In around 10-20% of cases RP arises from an underlying disease, most commonly a connective tissue disease. This review encompasses the diagnosis and differential diagnosis of RP and examines the efficacy of the currently available pharmaceutical and non-pharmaceutical treatment options. METHODS We conducted a selective literature search in PubMed using the search terms "Raynaud's phenomenon", "Raynaud's syndrome," "vasospasm," "vascular acrosyndrome," and "systemic sclerosis," together with a search of the Cochrane Database of Systematic Reviews up to April 2020. RESULTS Raynaud's phenomenon mainly affects the fingers or toes and is typically triggered by cold or emotional stressors. The most important diagnostic steps are demonstration of a tendency towards digital vasospasm, exclusion of occlusions in the afferent arteries and acral vessels, nail-fold capillaroscopy, and determination of autoantibody status. Tumor screening should be arranged in the presence of B symptoms or first manifestation of RP in old age. The onset of RP in childhood is a rare occurrence and points to a secondary origin. The principal options for treatment are protection against cold and administration of calcium antagonists, which reduces the occurrence of RP by around 20-40 %. The treatment of RP in patients with systemic sclerosis is described in the recommendations of the European League Against Rheumatism (EULAR). CONCLUSION At onset or after years of latency, patients with Raynaud phenomenon may have an underlying disease (most commonly a connective tissue disease). Long-term specialist care is necessary for asymptomatic patients with risk factors and for those with clinically manifest symptoms of an underlying condition alike.
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Affiliation(s)
- Peter Klein-Weigel
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Oliver Sander
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Düsseldorf University Hospital, Faculty of Medicinet, Heinrich Heine University Düsseldorf: Dr. med. Oliver Sander, Prof. Dr. med. Jutta G. Richter
| | - Simone Reinhold
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Jessica Nielitz
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Julia Steindl
- Department of Angiology, Klinikum Ernst von Bergmann, Potsdam: Dr. med Peter Klein-Weigel, Dr. med Simone Reinhold, Jessica Nielitz, Dr. med. Julia Steindl
| | - Jutta G. Richter
- Policlinic of Rheumatology and Hiller Research Unit Rheumatology, Düsseldorf University Hospital, Faculty of Medicinet, Heinrich Heine University Düsseldorf: Dr. med. Oliver Sander, Prof. Dr. med. Jutta G. Richter
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14
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Di Pino L, Bilancini S, Peruzzi M, Lucchi M. Capillaroscopy: a useful tool in the early diagnosis of connective tissue disease and nonscleroderma spectrum disorders. Minerva Cardiol Angiol 2021; 70:476-483. [PMID: 33823574 DOI: 10.23736/s2724-5683.21.05513-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Detection of early capillaroscopic alterations in the preclinical phase may prove useful in patients with non-scleroderma connective tissue disease (CTD). We aimed to verify whether certain capillaroscopic alterations, alone or in combination, might be predictive of CTD. METHODS We retrospectively collected data on patients with Raynaud's phenomenon who underwent capillaroscopy conducted by highly expert examiners with a degree in vascular medicine at our institutions. Included subjects were divided in two groups: those developing rheumatic disease during follow-up, and those without subsequent diagnosis of CTD. Notably, we excluded subjects who presented with an evident scleroderma pattern or rheumatic disease during their initial examination. RESULTS We included a total of 76 patients, 60 who developed CTD during follow-up, which spanned in this group 23±7 months, and 16 who did not develop CTD during follow-up, which spanned 23±9 months. The following features were significantly associated with Raynaud's phenomenon: 1) angiotectonic disorder (p<0.001), 2) nonhomogeneous loop morphology (p<0.001), 3) avascular areas (p<0.001), 4) pseudo-avascular areas (p<0.001), and, albeit to a lesser degree, 5) ectasias (p=0.050). Notably, the initial capillaroscopic pattern did not undergo any changes in subsequent tests. CONCLUSIONS Although certain pathological characteristics of the capillaroscopic pattern are nonspecific and not diagnostic if considered individually, they can be significantly suggestive for latent CTD when found in combination. At the very least, they warrant an in-depth diagnostic analysis and a lengthy follow-up.
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Affiliation(s)
- Luigi Di Pino
- Dipartimento Chirurgia e Specialità Medico-Chirurgiche Sezione Angiologia, Università di Catania, Catania, Italy
| | | | - Mariangela Peruzzi
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy.,Mediterranea Cardiocentro, Naples, Italy
| | - Massimo Lucchi
- Centro Studi Malattie Vascolari J.F. Merlen, Frosinone, Italy
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15
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Abstract
Raynaud's phenomenon, which is characterized by episodic digital pallor, cyanosis and rubor upon exposure to cold environment or to stress, is relatively common, although the prevalence depends on the climate. Still, it is under-diagnosed, under-treated, and often confused with other conditions. Primary Raynaud's phenomenon (i.e., Raynaud disease) must be distinguished from secondary Raynaud's phenomenon (i.e., Raynaud syndrome) as long-term morbidity and outcomes differ vastly between the two conditions. Additionally, the practitioner must differentiate between Raynaud's phenomenon and related vascular disorders, such as acrocyanosis, pernio, and livedo reticularis. In this article, we review differences between the conditions and suggest an approach to diagnosis and treatment strategy for these disorders.
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Affiliation(s)
- Eunjung Choi
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Stanislav Henkin
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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16
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Chong A. Perfusion Scintigraphy for the Evaluation of Patients with Raynaud's Phenomenon. Nucl Med Mol Imaging 2020; 54:269-273. [PMID: 33281997 DOI: 10.1007/s13139-020-00671-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 10/06/2020] [Accepted: 10/16/2020] [Indexed: 10/23/2022] Open
Abstract
Raynaud's phenomenon (RP) is a functional vascular disorder, which can be defined as transient vasospasm of the peripheral arteries and arterioles in the affected areas exposed to the cold or other stress. The diagnosis of RP is mainly based on symptoms. Perfusion scintigraphy, with or without cold stimulation, can be used to evaluate RP. Studies with perfusion scintigraphy for RP have shown that patients with RP showed lower finger-to-palm ratio than patients without RP. Responses after cold stimulation were also different in patients with RP. Not only decreased perfusion or blood pool after cold stimulation but also paradoxically increased perfusion can be shown in patients with RP. Some studies have shown that primary and secondary RP can be differentiated by perfusion scintigraphy. Correlation between duration of disease and findings on perfusion scintigraphy was reported. Perfusion scintigraphy can show differences before and after treatment as well. However, the protocols for perfusion scintigraphy for PR vary among studies. The standard protocol of perfusion scintigraphy for RP should be established.
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Affiliation(s)
- Ari Chong
- Department of Nuclear Medicine, Chosun University Hospital, Chosun University School of Medicine, 365, Pilmun-daero, Dong-gu, Gwangju Metropolitan City, 61453 Republic of Korea
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17
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Valentini G, Pope JE. Undifferentiated connective tissue disease at risk for systemic sclerosis: Which patients might be labeled prescleroderma? Autoimmun Rev 2020; 19:102659. [PMID: 32942034 DOI: 10.1016/j.autrev.2020.102659] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/12/2020] [Indexed: 02/06/2023]
Abstract
Undifferentiated Connective Tissue Disease at risk for Systemic Sclerosis (UCTD-risk-SSc), otherwise referred to as very early-early SSc (very early-early diagnosis of systemic sclerosis VEDOSS), is a condition characterized by Raynaud's phenomenon (RP) and either SSc serum marker autoantibodies or a capillaroscopic scleroderma pattern or both, but without satisfying classification criteria for SSc neither features consistent with SSc sine scleroderma. Approximately half the UCTD-risk-SSc patients develop definite SSc over 5-10 years of follow-up. Identifying patients who will undergo such evolution is an unmet need. Predicting at onset which patients with RP are going to develop SSc over time has long been a research objective and still is an unaccomplished task. The present review is devoted to the critical analysis of the nosographic boundaries of the condition and of items predictive of evolution including serological, capillaroscopic and circulating markers. A weighted score, based on serum antinuclear antibody titre, serum marker antibodies positivity and avascular areas has been developed and may identify in the meanwhile patients to be labeled prescleroderma i.e. those probably developing SSc over time. Future research should be directed to investigate unexplored features, validate and improve the performance of the score and highlight the involved pathways to be contrasted in order to identify a targeted therapy hampering the development of overt SSc.
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Affiliation(s)
- Gabriele Valentini
- Università degli Studi della Campania "Luigi Vanvitelli", Department of Precision Medicine, Section of Rheumatology, Italy.
| | - Janet E Pope
- Università degli Studi della Campania "Luigi Vanvitelli", Department of Precision Medicine, Section of Rheumatology, Italy; Schulich School of Medicine and Dentistry, University of Western Ontario, Division of Rheumatology, St. Joseph's Health Care, London, Ontario, Canada
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18
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Wang Y, Zhang H, Zheng Q, Tang K, Sun Q. Public interest in Raynaud's phenomenon: A Google Trends analysis. Dermatol Ther 2020; 33:e14017. [PMID: 32672856 DOI: 10.1111/dth.14017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/26/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
Abstract
Raynaud's phenomenon is a common disorder affecting body extremities and other vascular beds. As infodemiological methods have developed, online search tools could be used to explore the public interest of the disease. The study aimed to determine the annual trend, seasonal pattern, and associated topics of Raynaud's phenomenon. Google Trends was used to collect the data. "Raynaud syndrome" was selected as the search term. Data on monthly relative search volume (RSV) were collected from four selected countries (United States, United Kingdom, Australia, and New Zealand) and globally. Related topics were obtained, and annual-related topics were also collected for analysis. The maximum RSV appeared in January 2019, and the minimum value was observed in August 2011. The peak for RSV occurred in winter, and the bottom appeared in summer. In top related topics, "Maurice Raynaud" was the most related. In rising related topics, disease manifestations and autoimmune connective diseases were highly concerned. For annual-related topics, associated diseases were attracting more attention over time. The population is interested in related diseases, pathogenesis, and treatment. There was a peak in winter for searching and supported the importance of season variation on the impact of Raynaud's phenomenon.
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Affiliation(s)
- Yuanzhuo Wang
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, China.,Eight-Year MD Program, Peking Union Medical College, Beijing, China
| | - Hanlin Zhang
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, China.,Eight-Year MD Program, Peking Union Medical College, Beijing, China
| | - Qingyue Zheng
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, China.,Eight-Year MD Program, Peking Union Medical College, Beijing, China
| | - Keyun Tang
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, China.,Eight-Year MD Program, Peking Union Medical College, Beijing, China
| | - Qiuning Sun
- Department of Dermatology, Peking Union Medical College Hospital, Beijing, China
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19
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Sobolewski P, Maślińska M, Wieczorek M, Łagun Z, Malewska A, Roszkiewicz M, Nitskovich R, Szymańska E, Walecka I. Systemic sclerosis - multidisciplinary disease: clinical features and treatment. Reumatologia 2019; 57:221-233. [PMID: 31548749 PMCID: PMC6753596 DOI: 10.5114/reum.2019.87619] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 08/19/2019] [Indexed: 12/17/2022] Open
Abstract
Systemic sclerosis is a chronic autoimmune disease of still not fully understood pathogenesis. Fibrosis, vascular wall damage, and disturbances of innate and acquired immune responses with autoantibody production are prominent features. Systemic sclerosis has specific subsets with different autoantibodies, and differences in the affected skin areas. The suspicion of systemic sclerosis and establishing the diagnosis will be facilitated by the criteria created by EULAR/ACR experts. The treatment of this autoimmune disease remains a challenge for clinicians and new therapeutic options are constantly sought. The occurrence of various symptoms and the involvement of many organs and systems make systemic sclerosis a multidisciplinary disease and require a holistic approach. The present article summarizes different clinical features of systemic sclerosis and the profile of autoantibodies and discusses recent rules and future perspectives in disease management.
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Affiliation(s)
- Piotr Sobolewski
- Clinic of Dermatology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
| | - Maria Maślińska
- Clinic of Early Arthritis, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Marta Wieczorek
- Clinic of Dermatology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
| | - Zuzanna Łagun
- Clinic of Dermatology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
| | - Aleksandra Malewska
- Clinic of Dermatology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
| | - Marek Roszkiewicz
- Clinic of Dermatology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
| | | | - Elżbieta Szymańska
- Clinic of Dermatology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
| | - Irena Walecka
- Clinic of Dermatology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior, Warsaw, Poland
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20
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Evans RW. Raynaud's Phenomenon Associated With Calcitonin Gene‐Related Peptide Monoclonal Antibody Antagonists. Headache 2019; 59:1360-1364. [DOI: 10.1111/head.13596] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2019] [Indexed: 11/30/2022]
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21
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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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22
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Vounotrypidis P, Pyrpasopoulou A, Sakellariou GT, Zisopoulos D, Kefala N, Oikonomou DI, Stefanis C, Aslanidis S, Bermperidis C, Pappas P. Vascular acrosyndromes in young adult population. Definition of clinical symptoms and connections to joint hypermobility. Clin Rheumatol 2019; 38:2925-2932. [PMID: 31177398 DOI: 10.1007/s10067-019-04627-w] [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: 02/24/2019] [Revised: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Clinical recognition of vascular acrosyndromes is often challenging. The term Raynaud's phenomenon (RP) is commonly overused to describe any form of cold-related disorder. This study aims to formally evaluate peripheral vascular symptoms affecting the population, aged ≤ 40 years, and identify any correlations to joint hypermobility (JH). PATIENTS AND METHODS Fifty patients (31 males, 19 females) with vasomotor symptoms enrolled in this five-year prospective observational study. Clinical examination by a rheumatologist and a vascular surgeon was performed along with cardiology, echocardiographic and Doppler evaluation. Patients underwent blood cell count, biochemistry, thyroid and selectively immunologic testing. Twenty-four (48%) of them performed nailfold capillaroscopy. The SPSS for Windows, v.17.0, Chicago, USA, was used for the statistical analyses. RESULTS Twenty-eight patients (56%) presented with erythromelalgia (EM), 6 (12%) with acrocyanosis (AC) and 9 (18%) as a combination of the above disorder. RP diagnosed in five (10%) while two patients (4%) presented as a mix of EM-RP. There was no correlation with abnormal laboratory tests. Increased incidence of JH was found in EM and AC patients. Among those who were tested with nailfold capillaroscopy, 75% had abnormalities ranged from mild to autoimmune-like diseases. CONCLUSIONS Erythromelalgia is the commonest functional vasculopathy in young population followed by acrocyanosis and a combination of these conditions. Joint hypermobility is markedly increased, indicating that dysautonomy may be considered the causative factor following a trigger event. Overall, RP was observed in 14% of patients. Clinical recognition of these disorders avoids unnecessary investigation. Key Points • Vascular acrosyndromes in young adults are commonly functional disorders resembling vascular algodystrophy induced by thermic stress. • Dysautonomy of joint hypermobility is the co-factor influencing the appearance of the vascular disorders. • Raynaud's phenomenon accounts to approximately 14% of vascular acrosyndromes presented in the young adult population.
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Affiliation(s)
- Periklis Vounotrypidis
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece.
| | - Athina Pyrpasopoulou
- 2nd Propaedeutic Clinic, Department of Internal Medicine, "Ippokration" Hospital, Thessaloniki, Greece
| | - Grigorios T Sakellariou
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece
| | - Dimitrios Zisopoulos
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece
| | - Nikoleta Kefala
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece
| | - Dimitrios I Oikonomou
- Department of Immunology and Microbiology, 424 General Military Hospital, Thessaloniki, Greece
| | | | - Spyros Aslanidis
- 2nd Propaedeutic Clinic, Department of Internal Medicine, "Ippokration" Hospital, Thessaloniki, Greece
| | - Charalambos Bermperidis
- Rheumatology Department, 424 General Military Hospital, Nea Efkarpia, 56249, Thessaloniki, Greece
| | - Periklis Pappas
- Vascular Surgery Department, 424 General Military Hospital, Thessaloniki, Greece
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Gorski S, Bartnicka M, Citko A, Żelazowska-Rutkowska B, Jablonski K, Gorska A. Microangiopathy in Naifold Videocapillaroscopy and Its Relations to sE- Selectin, Endothelin-1, and hsCRP as Putative Endothelium Dysfunction Markers among Adolescents with Raynaud's Phenomenon. J Clin Med 2019; 8:jcm8050567. [PMID: 31027378 PMCID: PMC6572411 DOI: 10.3390/jcm8050567] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 04/19/2019] [Accepted: 04/23/2019] [Indexed: 02/03/2023] Open
Abstract
The aim of this study was to analyze the relationship between the qualitative abnormalities on nailfold videocapillaroscopy (NVC), and the concentrations of selected biomarkers (sE-selectin, endothelin-1, high-sensitivity c-reactive protein (hsCRP)) and lipid metabolism parameters in children and adolescents with Raynaud’s phenomenon (RP). Raynaud’s phenomenon, to assess whether nailfold capillary changes may reflect the degree of systemic blood vessel abnormalities. The study group included 66 patients (34 undifferentiated—uRP and 32 secondary—sRP) aged 6–19 years and the control group. In both groups, NVC was performed and the selected biomarkers were measured (sE-selectin, endothelin-1, hsCRP) and lipid profile. Endothelin-1, sE-selectin and hsCRP concentrations in patients from both RP groups were significantly higher; concentration of HDL fraction was significantly lower compared with the control group. The analysis of multiple linear regression demonstrated that megacapillaries most strongly determine the sE-selectin value (p = 0.04) and hsCRP (p = 0.03). Both the total cholesterol and low-density lipoprotein (LDL) fraction concentrations were determined by the presence of avascular areas (p = 0.02). In conclusion, specific pathologic NVC changes were associated with higher endothelial damage biomarkers concentration and adverse changes in the lipid profile.
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Affiliation(s)
- Stanislaw Gorski
- Department of Medical Education, Jagiellonian University Medical College, 31-530 Krakow, Poland.
| | - Marta Bartnicka
- Department of Family Medicine, Medical University of Bialystok, 15-054 Bialystok, Poland.
| | - Anna Citko
- Outpatient Clinic, Bialystok Children's Clinical Hospital of L. Zamenhof, Medical University of Bialystok, 15-274 Bialystok, Poland.
| | - Beata Żelazowska-Rutkowska
- Department of Pediatric Laboratory Diagnostics, Medical University of Bialystok, 15-276 Bialystok, Poland.
| | - Konrad Jablonski
- Department of Medical Education, Jagiellonian University Medical College, 31-530 Krakow, Poland.
| | - Anna Gorska
- Department of Family Medicine, Medical University of Bialystok, 15-054 Bialystok, Poland.
- Department of Pediatrics, Rheumatology, Immunology, and Metabolic Bone Diseases, Rheumatology Outpatient Clinic, Medical University of Bialystok, 15-276 Bialystok, Poland.
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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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Sinha P, Grewal R, Shanmuganandan K, Chatterjee M, Yadav A, Bhattacharjee S. A study of dermatological manifestations in patients attending the rheumatology outpatient department at a tertiary care hospital. JOURNAL OF MARINE MEDICAL SOCIETY 2019. [DOI: 10.4103/jmms.jmms_72_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Fábián B, Fábián AK, Bugán A, Csiki Z. Comparison of mental and physical health between patients with primary and secondary Raynaud's phenomenon Category: Article. J Psychosom Res 2019; 116:6-9. [PMID: 30654995 DOI: 10.1016/j.jpsychores.2018.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 11/03/2018] [Accepted: 11/04/2018] [Indexed: 01/09/2023]
Abstract
OBJECTIVE To compare anxiety, depression, physical health and quality of life in patients with primary Raynaud's phenomenon (PRP) and patients with secondary Raynaud's phenomenon (SRP). METHOD Adult patients with Raynaud's phenomenon (RP) were assessed for the severity of anxiety and depressive symptoms, physical health and quality of life by using the General Anxiety Disorder Scale (GAD-7), the Beck Depression Inventory (BDI), the 12-item Short Form Health Survey: Physical Component Scale (PCS-12), and the Raynaud Specific Quality of Life Questionnaire (RQLQ), respectively. Patients with PRP and SRP were recruited for comparison at a single clinical center in Debrecen, Hungary from September to December 2017. RESULTS In total, 60 primary and 41 secondary patients with RP were studied. Gender distribution, family status, employment status and smoking were similar in the two groups. Significantly more patients with SRP had anxiety and depressive symptoms than patients with PRP. Patients with SRP had significantly higher GAD-7 and BDI; and lower overall PCS-12 and RQLQ scores than patients with PRP. CONCLUSION Anxiety and depression is more common in patients with SRP than in patients with PRP. Patients with SRP have a lower physical health condition and RP specific quality of life than patients with PRP. Anxiety, depression and quality of life impairments should be taken into account when managing all patients with RP. Further study is needed to assess whether appropriately designed interventions have the potential to reduce the mental and physical health burdens of RP on quality of life (QOL), especially in patients with SRP.
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Affiliation(s)
- Balázs Fábián
- Department of Behavioural Sciences, Faculty of Public Health, University of Debrecen, Debrecen, Hungary.
| | - Anna Klaudia Fábián
- Department of Behavioural Sciences, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Antal Bugán
- Department of Behavioural Sciences, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
| | - Zoltán Csiki
- Department of Internal Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Abstract
Raynaud's phenomenon (RP) is a transient, acral, vasospastic phenomenon that manifests with characteristic color changes. This vasospasm, classically triggered by cold temperatures, may also be driven by shifts in temperature, climate, or emotional state. Primary RP (PRP) is a common condition without severe sequelae. Secondary RP (SRP), which may be driven by vascular, autoimmune, hematologic, or endocrine etiologies, can result in digital ulceration, irreversible ischemia and necrosis, and secondary infection. This review delineates the clinical manifestations of both primary and secondary RP, as well as the current understanding of RP epidemiology and pathogenesis. Proper examination, including nailfold capillary microscopy, and laboratory workup for secondary causes of RP are also discussed. The traditional armamentarium of therapies used for RP, as well as newer medical and surgical options, is also summarized with particular regard to the clinical evidence for their efficacy.
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Affiliation(s)
- Thomas Stringer
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA
| | - Alisa N Femia
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, New York, New York, USA.
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Mosdósi B, Bölcskei K, Helyes Z. Impairment of microcirculation and vascular responsiveness in adolescents with primary Raynaud phenomenon. Pediatr Rheumatol Online J 2018; 16:20. [PMID: 29566759 PMCID: PMC5865297 DOI: 10.1186/s12969-018-0237-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/12/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Raynaud's phenomenon (RP) is a functional vascular disease, presenting with recurrent episodes of ischemia of extremities in response to cold and emotional stress. Investigating cutaneous microcirculation is an important tool in understanding the complex neuro-immuno-vascular interactions in its pathophysiological mechanisms. Since there is no available data on vascular responsiveness in RP in the paediatric population, we investigated skin perfusion and heat-induced hyperaemia in comparison with clinical severity and laboratory parameters of the disease. METHODS Fifty two adolescents (27 patients with primary RP and 25 age-matched healthy controls) were investigated in the study. Patients were divided into two groups according to the symptoms existing within the previous 2 months. Following baseline microcirculation measurement with Laser Doppler flowmetry (Periflux 5000 system), all subjects underwent local heating test at 42 °C and 44 °C. Besides routine laboratory parameters, immune-serological tests and the vasoactive sensory neuropeptides somatostatin and pituitary adenylate-cyclase activating polypeptide (PACAP) were measured. RESULTS Baseline perfusion measured in perfusion units (PU) at 32 °C was significantly lower in symptomatic RP patients (97.6 ± 22.4 PU) compared with both healthy volunteers (248.3 ± 23.5 PU, p < 0.001) and RP patients without symptoms (187.4 ± 24.9 PU, p < 0.05). After local heating to 42 °C maximum blood flow was significantly reduced in primary RP participants with current symptoms (358.6 ± 43.9 PU, p < 0.001), but not in asymptomatic ones (482.3 ± 28.7 PU, p > 0.05) when compared with healthy subjects (555.9 ± 28.2 PU). Both the area under the response curve and the latency to reach the maximum flow were significantly increased in both RP groups (symptomatic 164.6 ± 7.4 s, p < 0.001, asymptomatic 236.4 ± 17.4 s, p < 0.001) when compared with the control group (101.9 ± 4.7 s). The heat-induced percentage increase from baseline to maximal blood flow was significantly greater in symptomatic RP adolescents in comparison with healthy ones. Laboratory parameters and neuropeptide plasma levels were not altered in any groups. CONCLUSION To our knowledge this is the first study in paediatric population to show altered heat-induced cutaneous hyperaemia responses in relation with the clinical severity and symptomatology.
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Affiliation(s)
- Bernadett Mosdósi
- Clinical Center, Department of Pediatrics, University of Pécs, József Attila u. 7, Pécs, H-7623, Hungary.
| | - Kata Bölcskei
- 0000 0001 0663 9479grid.9679.1János Szentágothai Research Centre & Centre for Neuroscience, University of Pécs, Ifjúság útja 20, Pécs, H-7624 Hungary ,0000 0001 0663 9479grid.9679.1Medical School, Department of Pharmacology and Pharmacotherapy, University of Pécs, Szigeti út 12, Pécs, H-7624 Hungary
| | - Zsuzsanna Helyes
- 0000 0001 0663 9479grid.9679.1János Szentágothai Research Centre & Centre for Neuroscience, University of Pécs, Ifjúság útja 20, Pécs, H-7624 Hungary ,0000 0001 0663 9479grid.9679.1Medical School, Department of Pharmacology and Pharmacotherapy, University of Pécs, Szigeti út 12, Pécs, H-7624 Hungary
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Trapiella-Martínez L, Díaz-López JB, Caminal-Montero L, Tolosa-Vilella C, Guillén-Del Castillo A, Colunga-Argüelles D, Rubio-Rivas M, Iniesta-Arandia N, Castillo-Palma MJ, Sáez-Comet L, Egurbide-Arberas MV, Ortego-Centeno N, Freire M, Vargas-Hitos JA, Ríos-Blanco JJ, Todolí-Parra JA, Rodríguez-Carballeira M, Marín-Ballvé A, Chamorro-Fernández AJ, Pla-Salas X, Madroñero-Vuelta AB, Ruiz-Muñóz M, Fonollosa-Pla V, Simeón-Aznar CP. Very early and early systemic sclerosis in the Spanish scleroderma Registry (RESCLE) cohort. Autoimmun Rev 2017; 16:796-802. [DOI: 10.1016/j.autrev.2017.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 05/12/2017] [Indexed: 12/29/2022]
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Moreau J, Dupond AS, Dan N, Untereiner T, Vidal C, Aubin F. [Comparative evaluation of dermoscopy and capillaroscopy in Raynaud's phenomenon]. Ann Dermatol Venereol 2017; 144:333-340. [PMID: 28343718 DOI: 10.1016/j.annder.2017.02.004] [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: 08/23/2015] [Revised: 01/15/2017] [Accepted: 02/20/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Raynaud's phenomenon (RP) is a common cause for consultation. Capillaroscopy is a well-established technique to detect capillary abnormalities suggestive of a connective tissue disease, but it is sometimes unavailable. The aim of this study was to compare dermoscopy and capillaroscopy in the assessment of RP. METHODS This was a prospective single-centre observational study in adult patients consulting for RP at the Hôpital Nord Franche-Comté between January 2014 and June 2015. Dermoscopy was performed at dermatological consultations and capillaroscopy was prescribed. For each capillaroscopy and dermoscopy, the following parameters were examined: normal appearance, giant capillaries, avascular areas, dystrophic capillaries or tortuosity and haemorrhages. Kappa coefficients were calculated. RESULTS Twenty-six patients participated in this study. The kappa coefficient was 0.76 for "normal" status, 0.78 for tortuosity, 0.70 for giant capillaries, 0.48 for haemorrhage and 0.62 for avascular areas. The global kappa coefficient was 0.33. Detection of these abnormalities with capillaroscopy was significantly associated with abnormal dermoscopic status (P<0.05). The sensitivity of dermoscopy for the detection of "abnormal" capillaroscopic status was 0.87. CONCLUSION The correlation coefficients were good. Despite poor global concordance, 80% of patients had the same status, normal or abnormal, for both capillaroscopy and dermoscopy, which resulted in the same clinical management. Dermoscopy is thus a valuable tool screening for periungual anomalies and provides support for clinical examination by the dermatologist, although the reference method continues to be capillaroscopy.
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Affiliation(s)
- J Moreau
- Service de dermatologie, CHU de Besançon, 3, boulevard Fleming, 25000 Besançon, France.
| | - A-S Dupond
- Service de dermatologie néphrologie, CH Montbéliard, 2, rue du Dr-Flamand, 25200 Montbéliard, France
| | - N Dan
- Service de dermatologie, hôpital de jour, CH Montbéliard, 2, rue du Dr-Flamand, 25200 Montbéliard, France
| | - T Untereiner
- Service de radiologie, CH Montbéliard, 2, rue du Dr-Flamand, 25200 Montbéliard, France
| | - C Vidal
- Centre d'investigation clinique, CHU de Besançon, 3, boulevard Fleming, 25000 Besançon, France
| | - F Aubin
- Service de dermatologie, CHU de Besançon, 3, boulevard Fleming, 25000 Besançon, France
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Severe Primary Raynaud's Disease Treated with Rituximab. Case Rep Rheumatol 2016; 2016:2053804. [PMID: 27651971 PMCID: PMC5019931 DOI: 10.1155/2016/2053804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 08/09/2016] [Indexed: 11/20/2022] Open
Abstract
Raynaud's phenomenon refers to reversible spasms of the peripheral arterioles that can be primary Raynaud's phenomenon (PRP) or secondary Raynaud's phenomenon (SRP) to underlying connective tissue disease, both of which are characterized by a triphasic color response triggered by cold exposure or stress. PRP is typically a benign disease, whereas SRP may progress into digital ulcers and/or gangrene. Here, we report a case of a 55-year-old female diagnosed with PRP 7 years ago. Treatment with first-line agents, including calcium channel blocker, aspirin, and phosphodiesterase inhibitor, did not control her symptoms, which progressed to digital ulceration and gangrene. There were no symptoms of underlying autoimmune disease or malignancy, and autoimmune, serology, and immunology test results were normal; a biopsy of her left little finger was negative for vasculitis. Development to critical digital ischemia necessitated treatment with intravenous iloprost and heparin infusion followed by angioplasty, which led to a partial improvement. Due to persistent symptoms, rituximab therapy was initiated and two cycles induced a complete resolution of symptoms.
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Bissell LA, Abignano G, Emery P, Del Galdo F, Buch MH. Absence of Scleroderma pattern at nail fold capillaroscopy valuable in the exclusion of Scleroderma in unselected patients with Raynaud's Phenomenon. BMC Musculoskelet Disord 2016; 17:342. [PMID: 27526772 PMCID: PMC4986250 DOI: 10.1186/s12891-016-1206-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 08/05/2016] [Indexed: 11/29/2022] Open
Abstract
Background To report the predictive value of nail-fold capillaroscopy (NFC) patterns of vasculopathy for systemic sclerosis (Scleroderma; SSc) in an unselected cohort of patients with Raynaud’s phenomenon (RP). Methods Patients referred to a tertiary SSc clinic with RP were evaluated by light/video-NFC. Clinical diagnosis, details and serology were recorded. Primary RP was defined as RP with no features of connective tissue disease (CTD)/antibody. NFC patterns were determined: normal, non-specific, ‘early’, ‘active’ or ‘late’ SSc patterns. Fulfilment of the VEDOSS or 2013 ACR/EULAR criteria for SSc was determined following NFC assessment. Results Three hundred forty-seven patients were referred: mean (SD) age 47 (15.2) years. On clinical review, 54 (16 %) did not have RP, 69 (20 %) had primary RP, 52 (15 %) had SSc and 172 (50 %) had secondary RP. NFC SSc pattern was detected in 80 (23 %) patients; 37/52 with SSc, 30/172 with secondary RP, 9/69 with primary RP and 4/54 with no RP. For identifying patients who met either the VEDOSS or 2013 ACR/EULAR criteria for SSc, detection of a SSc NFC pattern had a sensitivity of 71 %, specificity 95 %, positive predictive value 84 % and negative predictive value 90 %. Conclusions The absence of SSc NFC pattern in patients with RP or suspected CTD is very valuable in the exclusion of SSc.
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Affiliation(s)
- Lesley-Anne Bissell
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Giuseppina Abignano
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Paul Emery
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Francesco Del Galdo
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK.,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Maya H Buch
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, 2nd Floor, Chapel Allerton Hospital, Chapeltown Road, Leeds, LS7 4SA, UK. .,NIHR Leeds Musculoskeletal Biomedical Research Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
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Silva I, Teixeira A, Oliveira J, Almeida R, Vasconcelos C. Peripheral vasculopathy in Raynaud phenomenon: Vascular disease biomarkers. ANGIOLOGIA E CIRURGIA VASCULAR 2016. [DOI: 10.1016/j.ancv.2016.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Abstract
Raynaud's phenomenon (RP) is a major cause of pain and disability in patients with autoimmune connective tissue diseases (CTDs), particularly systemic sclerosis (SSc). The clinician must perform a comprehensive clinical assessment in patients with RP to differentiate between primary (idiopathic) and secondary RP, in particular (for rheumatologists), secondary to an autoimmune CTD, as both the prognosis and treatment may differ significantly. Key investigations are nailfold capillaroscopy and testing for autoantibodies (in particular, those associated with SSc). Patients with RP and either abnormal nailfold capillaroscopy or an SSc-specific antibody (and especially with both) have a high risk of transitioning to an autoimmune CTD. Both nailfold capillaroscopy and autoantibody specificity may help the clinician in predicting organ-based complications. The management of CTD-associated RP requires a multifaceted approach to treatment, including patient education and conservative ('non-drug') measures. Patients with CTD-associated RP often require pharmacological treatment, which in the first instance is usually a calcium channel blocker, although other agents can be used. There is an increasing tendency to use phosphodiesterase type 5 inhibitors early in the treatment of CTD-associated RP. Oral therapies are commonly associated with side effects (often due to systemic vasodilation) that may result in failure of dose escalation and/or permanent discontinuation. Intravenous prostanoid therapy and surgery (e.g., botulinum toxin injection and digital sympathectomy) can be considered in severe RP. Patients with CTD-associated RP can develop a number of ischaemic digital complications (primarily ulcers and critical ischaemia), which may be associated with significant tissue loss. Future research is required to increase the understanding of the pathogenesis and natural history of RP (to drive therapeutic advances), and to explore/develop drug therapies, including those that target the mechanisms mediating cold-induced vasoconstriction, and locally acting therapies free of systemic side effects.
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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
| | - 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 Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
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Ennis H, Hughes M, Anderson ME, Wilkinson J, Herrick AL. Calcium channel blockers for primary Raynaud's phenomenon. Cochrane Database Syst Rev 2016; 2:CD002069. [PMID: 26914257 PMCID: PMC7065590 DOI: 10.1002/14651858.cd002069.pub5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Calcium channel blockers are the most commonly prescribed drugs for people with primary Raynaud's phenomenon. Primary Raynaud's phenomenon is a common condition characterised by an exaggerated vasospastic response to cold or emotion: classically the digits (fingers and toes) turn white, then blue, then red. This is an update of the review first published in 2014. OBJECTIVES To assess the effects of different calcium channel blockers for primary Raynaud's phenomenon as determined by attack rates, severity scores, participant-preference scores and physiological measurements. SEARCH METHODS For this update the Cochrane Vascular Trial Search Co-ordinator searched the Specialised Register (last searched January 2016) and the Cochrane Register of Studies (CENTRAL) (2015, Issue 12). In addition the TSC searched clinical trials databases. SELECTION CRITERIA Randomised controlled trials evaluating the effects of oral calcium channel blockers for the treatment of primary Raynaud's phenomenon. DATA COLLECTION AND ANALYSIS Three review authors independently assessed the trials for inclusion and their quality, and extracted the data. Data extraction included adverse events. We contacted trial authors for missing data. MAIN RESULTS We included seven randomised trials with 296 participants. Four trials examined nifedipine and the remainder nicardipine. Comparisons were with placebo in six trials and with both dazoxiben and placebo in one trial (only the nifedipine versus placebo data were used within this review). Treatment with oral calcium channel blockers was minimally effective in primary Raynaud's phenomenon at decreasing the frequency of attacks (standardised mean difference of 0.23; 95% confidence interval (CI) 0.08 to 0.38, P = 0.003). This translates to 1.72 (95% CI 0.60 to 2.84) fewer attacks per week on calcium channel blockers compared to placebo. One trial provided details on duration of attacks reporting no statistically significant difference between the nicardipine and placebo groups (no P value reported). Only two trials provided any detail of statistical comparisons of (unvalidated) severity scores between treatment groups: one of these trials (60 participants) reported a mean severity score of 1.55 on placebo and 1.36 on nicardipine, difference 0.2 (95% CI of difference 0 to 0.4, no P value reported) and the other trial (three participants only with primary Raynaud's phenomenon) reported a median severity score of 2 on both nicardipine and placebo treatment (P > 0.999) suggesting little effect on severity. Participant-preference scores were included in four trials, but in only two were results specific to participants with primary Raynaud's phenomenon, and scoring systems differed between trials: scores differed between treatments in only one trial, in which 33% of participants on placebo and 73% on nifedipine reported improvement in symptoms (P < 0.001). Physiological measurements were included as outcome measures in five trials (different methodologies were used in each): none of these trials found any statistically significant between-treatment group differences. Treatment with calcium channel blockers appeared to be associated with a number of adverse reactions, including headaches, flushing and oedema (swelling). Overall, the trials were classed as being at low or unclear risk of bias; and the quality of the evidence presented was moderate for number of attacks, very low for duration of attacks, high for severity scores and low for patient preference scores. AUTHORS' CONCLUSIONS The randomised controlled trials included in this review provide moderate quality evidence that oral calcium channel blockers are minimally effective in the treatment of primary Raynaud's phenomenon as measured by the frequency of attacks and high-quality evidence that they have little effect on severity. We are unable to comment on duration of attacks or on patient preference due to the very low and low quality of evidence as a result of small sample sizes in the included studies and the variable data quality of outcome measures.
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Affiliation(s)
- Holly Ennis
- University of EdinburghEdinburgh Clinical Trials UnitOPD Building Level 2Western General HospitalEdinburghUKEH4 2XU
| | - Michael Hughes
- University of Manchester, Manchester Academic Health Science CentreCentre for Musculoskeletal Research, Institute of Inflammation and RepairStopford BuildingOxford RoadManchesterUKM13 9PT
| | - Marina E Anderson
- University of LiverpoolInstitute of Ageing and Chronic DiseaseLiverpoolUK
| | - Jack Wilkinson
- University of Manchester, Manchester Academic Health Science CentreBiostatistics, Institute of Population HealthClinical Sciences Building Salford Royal NHS Foundation Trust HospitalStott Lane, SalfordManchesterUKM6 8HD
| | - Ariane L Herrick
- University of Manchester, Manchester Academic Health Science CentreCentre for Musculoskeletal Research, Institute of Inflammation and RepairStopford BuildingOxford RoadManchesterUKM13 9PT
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Mueller M, Gschwandtner ME, Gamper J, Giurgea GA, Charwat-Resl S, Kiener HP, Smolen JS, Perkmann T, Koppensteiner R, Schlager O. Relation of Nailfold Capillaries and Autoantibodies to Mortality in Patients With Raynaud Phenomenon. Circulation 2016; 133:509-17. [PMID: 26733605 DOI: 10.1161/circulationaha.115.017816] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 12/21/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND In incipient Raynaud phenomenon, nailfold capillaroscopy and autoantibody tests are obtained to screen for an emerging connective tissue disease. Whether the presence of abnormal nailfold capillaries and autoantibodies are related to mortality in patients with incipient Raynaud phenomenon is not known. METHODS AND RESULTS In 2958 consecutive patients (78% women, median age 45 years) with incipient Raynaud phenomenon without previously known connective tissue disease, nailfold capillaroscopy and laboratory tests for antinuclear antibodies (ANA) and ANA subsets were obtained at initial presentation. During a median follow-up period of 9.3 years, 227 women (9.9% of female patients) and 129 men (20% of male patients) with Raynaud phenomenon died. In comparison with a demographically matched standard population, survival was poorer in patients with Raynaud phenomenon (log-rank test P<0.0001). In patients with Raynaud phenomenon, mortality was higher in men than in women (P<0.0001, Cox proportional hazards model). In women, the presence of abnormal nailfold capillaries, ANA, and anti-Scl-70 antibodies were related to an increase in all-cause mortality. The conjoint presence of abnormal nailfold capillaries and autoantibodies was associated with the highest mortality rates. In men, abnormal nailfold capillaries, and ANA and ANA subsets, as well, were not related to survival. In both sexes, patients' age and serum creatinine were associated with mortality. CONCLUSIONS In Raynaud phenomenon, male sex, age, and serum creatinine are related to mortality. Abnormal nailfold capillaries and autoantibodies are associated with an increase in all-cause mortality in female patients, but not in male patients with Raynaud phenomenon.
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Affiliation(s)
- Markus Mueller
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Michael E Gschwandtner
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Jutta Gamper
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Georgiana-Aura Giurgea
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Silvia Charwat-Resl
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Hans P Kiener
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Josef S Smolen
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Thomas Perkmann
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Renate Koppensteiner
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria
| | - Oliver Schlager
- From Division of Angiology, Department of Medicine II (M.M., M.E.G., G.-A.G., S.C.R., R.K., O.S.), Center of Medical Statistics, Informatics and Intelligent Systems (J.G.), Division of Rheumatology, Department of Medicine III (H.P.K., J.S.S.), and Department of Laboratory Medicine (T.P.), Medical University of Vienna, Austria.
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Uniphasic Blanching of the Fingers, Abnormal Capillaroscopy in Nonsymptomatic Digits, and Autoantibodies: Expanding Options to Increase the Level of Suspicion of Connective Tissue Diseases beyond the Classification of Raynaud's Phenomenon. J Immunol Res 2015; 2015:371960. [PMID: 26075287 PMCID: PMC4449942 DOI: 10.1155/2015/371960] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/02/2015] [Accepted: 05/04/2015] [Indexed: 11/17/2022] Open
Abstract
In patients with Raynaud's phenomenon (RP), the role of medical history, capillaroscopy, and autoantibodies in order to provide an early diagnosis of connective tissue disease (CTD) were examined. 115 consecutive adults with uni-, bi-, or triphasic colour changes of the fingers were studied. RP was bilateral in 92.7% of patients. The middle finger was significantly more affected. A lack of association between fingers affected by RP and fingers with capillary abnormalities was observed OR = 0.75 (0.34–1.66). RP with the cyanotic phase had a higher risk at capillaroscopy to have hemorrhages OR = 4.46 (1.50–13.30) and giant capillaries OR = 24.85 (1.48–417.44). The thumb and triphasic involvement have an OR of 1.477 and 1.845, respectively. RP secondary to systemic sclerosis (SSc) had greater value of VAS pain (p = 0.011). The presence of anti-centromere antibodies was significantly associated with a higher risk of SSc (p < 0.001). 44.3% of subjects had uniphasic blanching of the fingers, and among these, 27% was diagnosed as having an overt or suspected CTD. Markers of a potential development of CTDs include severe RP symptoms, positive autoantibodies, and capillary abnormalities. These data support the proposal to not discharge patients with uniphasic blanching of the fingers to avoid missing the opportunity of an early diagnosis.
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Souza EJDRE, Kayser C. [Nailfold capillaroscopy: relevance to the practice of rheumatology]. REVISTA BRASILEIRA DE REUMATOLOGIA 2015; 55:264-71. [PMID: 25440704 DOI: 10.1016/j.rbr.2014.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2014] [Revised: 09/04/2014] [Accepted: 09/14/2014] [Indexed: 12/13/2022] Open
Abstract
Nailfold capillaroscopy is a simple, low-cost method, that is extremely important in the evaluation of patients with Raynaud's phenomenon and of patients with systemic sclerosis (SSc) spectrum diseases. Besides its importance for the early diagnosis of SSc, nailfold capillaroscopy is a useful tool to identify scleroderma patients with high risk for development of vascular and visceral complications and death. The inclusion of capillaroscopy in the new classification criteria for SSc of the American College of Rheumatology (ACR) and European League Against Rheumatism (Eular) gives a new impetus to the use and dissemination of the method. In this paper, we present a didactic, non-systematic review on the subject, with emphasis on advances recently described.
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Affiliation(s)
- Eduardo José do Rosário E Souza
- Disciplina de Reumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brasil; Santa Casa de Belo Horizonte, Belo Horizonte, MG, Brasil
| | - Cristiane Kayser
- Disciplina de Reumatologia, Universidade Federal de São Paulo, São Paulo, SP, Brasil.
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Kadan M, Erol G, Karabacak K, Kaya E, Arslan G, Doğancı S, Demirkılıç U. How can follow-up of patients with Raynaud phenomenon be optimized? Med Sci Monit Basic Res 2015; 21:47-52. [PMID: 25847811 PMCID: PMC4395022 DOI: 10.12659/msmbr.893998] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Raynaud phenomenon (RP) is common worldwide and presents diagnostic and therapeutic difficulties. We aimed to share our experience with optimizing of patient follow-up by using the cold-stimulation test (CST). Material/Methods Data of 81 patients admitted with RP symptomatology were collected. Demographic data and symptoms were recorded. A scale was used for determining the severity of disease at pre-treatment and post-treatment. CST was performed to all patients at pre-treatment and post-treatment for assessment of treatment efficiency in follow-up. Results were analyzed with the SPSS for Mac 20.0 program. Results All the patients were male. Mean age was 22.3±2.14 (19–29). Mean duration of symptoms from onset to present was 4.59±2.85 years. There were statistically significant differences between pre-treatment and post-treatment hand temperatures measured by CST (p<0.001). However, there were no statistically significant differences between pre-treatment and post-treatment severity scores of patients (p=0.135). Conclusions To quantitatively determine the treatment efficacy, CST may be used instead of asking simple questions of patients.
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Affiliation(s)
- Murat Kadan
- Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - Gökhan Erol
- Department of Cardiovascular Surgery, Maresal Cakmak Military Hospital, Erzurum, Turkey
| | - Kubilay Karabacak
- Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - Erkan Kaya
- Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - Gökhan Arslan
- Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - Suat Doğancı
- Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey
| | - Ufuk Demirkılıç
- Department of Cardiovascular Surgery, Gulhane Military Medical Academy, Ankara, Turkey
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Giurgea GA, Mlekusch W, Charwat-Resl S, Mueller M, Hammer A, Gschwandtner ME, Koppensteiner R, Schlager O. Relationship of age and body mass index to skin temperature and skin perfusion in primary Raynaud's phenomenon. Arthritis Rheumatol 2015; 67:238-42. [PMID: 25330753 DOI: 10.1002/art.38923] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 10/14/2014] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To assess the relationship of age and body mass index (BMI) to skin temperature and perfusion in patients with primary Raynaud's phenomenon (RP) compared with controls. METHODS Patients with RP as well as age- and sex-matched controls underwent external cold provocation by exposure to 20 °C water for 1 minute. Before and after cold provocation, skin temperature and skin perfusion were measured. RESULTS Twenty-six patients with RP (20 women and 6 men; median age 41.9 years) and 22 controls (17 women and 5 men; median age 42.9 years) were studied. In RP patients, cold exposure led to a median change in skin temperature of -7% (interquartile range [IQR] -13.1, -4.1) and to a median change in skin perfusion of -26.4% (IQR -36.2, 2.9). In controls, skin temperature changed by -15.7% (IQR -18.3, -11.6) and skin perfusion by -33% (IQR -53.3, -1.1) upon cold exposure. In patients with RP, age and BMI were related to skin temperature (for age, r = 0.683, P < 0.0001; for BMI r = 0.657, P < 0.0001) and skin perfusion (for age, r = 0.595, P = 0.002; for BMI, r = 0.653, P < 0.0001), while no association was found in controls. The cold-induced decrease in skin temperature was inversely related to age (r = -0.518, P = 0.003) and BMI (r = -0.662, P < 0.0001) in patients with RP; correlations were not observed in controls. The cold-induced change in skin perfusion was not related to age or BMI in either group. CONCLUSION The cold-induced decrease in skin temperature is related to age and BMI in patients with RP but not in controls. Further studies are needed to clarify the pathophysiology of digital ischemia in primary RP.
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Valentini G, Marcoccia A, Cuomo G, Vettori S, Iudici M, Bondanini F, Santoriello C, Ciani A, Cozzolino D, De Matteis GM, Cappabianca S, Vitelli F, Spanò A. Early systemic sclerosis: analysis of the disease course in patients with marker autoantibody and/or capillaroscopic positivity. Arthritis Care Res (Hoboken) 2015; 66:1520-7. [PMID: 24515450 DOI: 10.1002/acr.22304] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Accepted: 02/04/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To investigate whether patients affected by 1 of the 3 subsets of early systemic sclerosis (SSc; scleroderma), i.e., subset I, Raynaud's phenomenon with SSc marker autoantibodies and typical capillaroscopic findings; subset II, autoantibody positive only; and subset III, capillaroscopy positive only and not satisfying the 2013 American College of Rheumatology (ACR)/European League Against Rheumatism (EULAR) classification criteria for SSc at admission, differ from each other in the time to satisfy the criteria. METHODS Early SSc patients subdivided into the 3 subsets indicated above consecutively admitted to a rheumatology/angiology center were monitored for 12-102 months (median 36 months). Patients were reevaluated twice yearly to assess whether and when each patient satisfied the new ACR/EULAR classification criteria for SSc. Patients with undifferentiated connective tissue disease (UCTD) served as the comparator group. RESULTS During followup, 11 (52.3%) of 21 subset I, 10 (66.6%) of 15 subset II, 0 of 24 subset III, and 0 of 44 UCTD patients satisfied the criteria (P = 0.0001). The difference was significant between early SSc and UCTD patients (P = 0.0001) and, within the group of early SSc patients, between each of the 2 autoantibody-positive subsets (subsets I and II) and the capillaroscopic-positive/autoantibody-negative subset (subset I versus III: P = 0.0001; subset II versus III: P = 0.0009). There was no difference between the 2 autoantibody-positive subsets (P = 0.454). In addition to marker autoantibody positivity, preclinical lung or heart involvement was associated with an increased risk to satisfy the criteria during followup. CONCLUSION Our data demonstrated faster progression of SSc in autoantibody-positive patients, particularly in those with preclinical internal organ involvement at baseline, than in autoantibody-negative patients.
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Geschlechtsspezifische Unterschiede bei Gesunden und Patienten mit entzündlich-rheumatischen Erkrankungen in der Kapillarmikroskopie. Z Rheumatol 2014; 73:615-22. [DOI: 10.1007/s00393-014-1359-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Abstract
BACKGROUND Calcium channel blockers are the most commonly prescribed drugs for people with primary Raynaud's phenomenon. Primary Raynaud's phenomenon is a common condition characterised by an exaggerated vasospastic response to cold or emotion: classically the digits (fingers and toes) turn white, then blue, then red. OBJECTIVES To assess the effects of different calcium channel blockers for primary Raynaud's phenomenon as determined by attack rates, severity scores, participant-preference scores and physiological measurements. SEARCH METHODS The Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator (TSC) searched the Specialised Register (last searched February 2013) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 1). In addition the TSC searched clinical trials databases. SELECTION CRITERIA Randomised controlled trials evaluating the effects of oral calcium channel blockers for the treatment of primary Raynaud's phenomenon. DATA COLLECTION AND ANALYSIS Three review authors independently assessed the trials for inclusion and their quality, and extracted the data. Data extraction included adverse events. We contacted trial authors for missing data. MAIN RESULTS We included seven randomised trials with 296 participants. Although overall all the trials were classed as being at low or unclear risk of bias, the sample size of the included trials was small and there was unclear reporting of outcomes. Four trials examined nifedipine and the remainder nicardipine. Comparisons were with placebo in six trials and with both dazoxiben and placebo in one trial (only the nifedipine versus placebo data were used within this review). Treatment with oral calcium channel blockers was minimally effective in primary Raynaud's phenomenon at decreasing the frequency of attacks (standardised mean difference of 0.23; 95% confidence interval (CI) 0.08 to 0.38, P = 0.003). This translates to 1.72 (95% CI 0.60 to 2.84) fewer attacks per week on calcium channel blockers compared to placebo. One trial provided details on duration of attacks reporting no statistically significant difference between the nicardipine and placebo groups (no P value reported). Only two trials provided any detail of statistical comparisons of (unvalidated) severity scores between treatment groups: one of these trials (60 participants) reported a mean severity score of 1.55 on placebo and 1.36 on nicardipine, difference 0.2 (95% CI of difference 0 to 0.4, no P value reported) and the other trial (three participants only with primary Raynaud's phenomenon) reported a median severity score of 2 on both nicardipine and placebo treatment (P > 0.999). Participant-preference scores were included in four trials, but in only two were results specific to participants with primary Raynaud's phenomenon, and scoring systems differed between trials: scores differed between treatments in only one trial, in which 33% of participants on placebo and 73% on nifedipine reported improvement in symptoms (P < 0.001). Physiological measurements were included as outcome measures in five trials (different methodologies were used in each): in none of these trials were any statistically significant between-treatment group differences found. Treatment with calcium channel blockers appeared to be associated with a number of adverse reactions, including headaches, flushing and oedema (swelling). AUTHORS' CONCLUSIONS The randomised controlled trials included in this review provide moderate-quality evidence that oral calcium channel blockers are minimally effective in the treatment of primary Raynaud's phenomenon as measured by the frequency of attacks. However, the results of this review were limited by small sample sizes in the included studies and by variable data quality, particularly with regard to outcome measures.
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Affiliation(s)
- Holly Ennis
- Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Stopford Building, Oxford Road, Manchester, UK, M13 9PT
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Prete M, Fatone MC, Favoino E, Perosa F. Raynaud's phenomenon: from molecular pathogenesis to therapy. Autoimmun Rev 2014; 13:655-67. [PMID: 24418302 DOI: 10.1016/j.autrev.2013.12.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 12/24/2013] [Indexed: 01/01/2023]
Abstract
Raynaud's phenomenon (RP) is a well defined clinical syndrome characterized by recurrent episodes of digital vasospasm triggered by exposure to physical/chemical or emotional stress. RP has been classified as primary or secondary, depending on whether it occurs as an isolated condition (pRP) or is associated to an underlying disease, mainly a connective tissue disease (CTD-RP). In both cases, it manifests with unique "triple" (pallor, cyanosis and erythema), or "double" color changes. pRP is usually a benign condition, while sRP can evolve and be complicated by acral digital ulcers and gangrene, which may require surgical treatment. The pathogenesis of RP has not yet been entirely clarified, nor is it known whether autoantibodies have a role in RP. Even so, recent advances in our understanding of the pathophysiology have highlighted novel potential therapeutic targets. The aim of this review is to discuss the etiology, epidemiology, risk factors, clinical manifestations, recently disclosed pathogenic mechanisms underlying RP and their correlation with the available therapeutic options, focusing primarily on pRP and CTD-RP.
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Affiliation(s)
- Marcella Prete
- Internal Medicine, University of Bari Medical School, I-70124 Bari, Italy
| | | | - Elvira Favoino
- Rheumatological and Autoimmune Systemic Diseases Units, University of Bari Medical School, I-70124 Bari, Italy
| | - Federico Perosa
- Rheumatological and Autoimmune Systemic Diseases Units, University of Bari Medical School, I-70124 Bari, Italy.
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Cutolo M. Disease modification in systemic sclerosis. Do integrated approaches offer new challenges? Z Rheumatol 2014; 72:326-8. [PMID: 23552981 DOI: 10.1007/s00393-013-1157-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- M Cutolo
- Research Laboratories and Academic Unit of Clinical Rheumatology, Department of Internal Medicine, University of Genova Italy, Viale Benedetto XV, 6, 16132 Genova, Italy.
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Saketkoo LA, Magnus JH, Doyle MK. The primary care physician in the early diagnosis of systemic sclerosis: the cornerstone of recognition and hope. Am J Med Sci 2014; 347:54-63. [PMID: 24366221 PMCID: PMC3872337 DOI: 10.1097/maj.0b013e3182a55d24] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Systemic sclerosis (SSc) is a disease of unknown causative factor that manifests as a heterogenous group of multiorgan system manifestations and is characterized by vasculopathy and fibrosis of the skin and internal organs, with mortality related to pulmonary, cardiac, renal or gastrointestinal involvement. The prevalence of SSc may be underestimated in the general population. Cases are often undiagnosed or misdiagnosed, particularly cases with mild or no skin manifestations. Because of late referrals to rheumatologic care, many moderate-to-severe cases progress to irreversible end-organ damage that might have been prevented by early diagnosis. Early diagnosis of SSc with initiation of appropriate treatment is essential, with great impact on morbidity and mortality. This review examines presenting features, ensuing complications and treatment providing a focus on SSc as a treatable disease. Primary care providers play a pivotal role in recognizing initial symptoms associated with SSc and securing early diagnosis through early referral to specialists.
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Affiliation(s)
- Lesley Ann Saketkoo
- Department of Medicine, Scleroderma and Sarcoidosis Patient Care and Research Center, Louisiana State University Health Sciences Center, New Orleans, Louisiana;
| | - Jeanette H. Magnus
- Institute for Health and Society Medical School, University of Oslo, Norway
- Tulane Xavier National Center of Excellence in Women’s Health, The Mary Amelia Douglas-Whited Community Women’s Health Education Center and Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
| | - Mittie K. Doyle
- Alexion Pharmaceuticals, Translational Medicine Group, Cambridge, MA
- Tulane Xavier National Center of Excellence in Women’s Health, The Mary Amelia Douglas-Whited Community Women’s Health Education Center and Tulane University School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA
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Frerix M, Meier F, Hermann W, Müller-Ladner U. Therapeutische Strategien im Frühstadium der systemischen Sklerose. Z Rheumatol 2013; 72:960-9. [DOI: 10.1007/s00393-013-1270-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Pistorius MA, Carpentier PH. Bilan étiologique minimal du phénomène de Raynaud : un consensus d’experts. Ann Dermatol Venereol 2013; 140:549-54. [DOI: 10.1016/j.annder.2013.02.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Accepted: 05/09/2012] [Indexed: 10/27/2022]
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Jung P, Trautinger F. Capillaroscopy. J Dtsch Dermatol Ges 2013; 11:731-6. [PMID: 23738531 DOI: 10.1111/ddg.12137] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Accepted: 04/23/2013] [Indexed: 11/28/2022]
Abstract
Microscopy of the nailfold capillaries has found increasing use in dermatology, rheumatology and angiology particularly as an important tool to distinguish between primary and secondary Raynaud disease. The best evidence is available in systemic sclerosis where specific capillaroscopic patterns have a high positive predictive value for the development of the disease. Conversely, a regular capillary pattern rules out systemic sclerosis with high degree of probability. PRINCE (prognostic index for nailfold capillaroscopic examination) was developed to identify patients at high risk of developing systemic sclerosis. CSURI (capillaroscopic skin ulcer risk index) should predict the risk of developing digital ulcers in patients with systemic sclerosis with high specificity and sensitivity. As a consequence of recent results a pathologic capillary pattern was integrated by the EULAR Scleroderma Trials and Research Group (EUSTAR) in the diagnostic algorithm of the VEDOSS-Project (very early diagnosis of systemic sclerosis). Capillary patterns may correlate with visceral involvement and capillaroscopy thus has the potential as a screening tool to enable early diagnosis of organ involvement in systemic sclerosis.
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Affiliation(s)
- Peter Jung
- Department of Dermatology, State Hospital St. Pölten, Austria.
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