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Dundar HA, Adrovic A, Demir S, Demir F, Cakmak F, Ayaz NA, Sözeri B, Bilginer Y, Kasapçopur O, Unsal E. Description of the characteristics of the nailfold capillary structure in healthy children: a multi-centric study. Rheumatology (Oxford) 2024; 63:SI152-SI159. [PMID: 38775407 DOI: 10.1093/rheumatology/keae296] [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: 02/22/2024] [Accepted: 05/13/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND Nailfold videocapillaroscopy (NVC) is the primary diagnostic tool for the assessment of microcirculation in the pediatric population. OBJECTIVE To define and standardize age-specific normal NVC patterns in healthy children and adolescents. METHODS A cross-sectional observational multicentric study was conducted in 564 participants aged 5-17 years. Dino-Lite CapillaryScope 200 Pro Model MEDL4N Pro was performed at 200× magnification. Quantitative and qualitative NVC parameters were analysed separately for each age group and divided into four groups based on age categories. RESULTS Of the 564 healthy participants, 54.9% were female. A total of 1184 images and 3384 capillaries were analysed. Positive correlations were observed between age and capillary density (P < 0.001, R = 0.450, CI95% 0.398-0.503). There was also a positive correlation between age and arterial/venous, loop diameter and capillary length, whereas there was a weak negative correlation between intercapillary distance. However, no correlation was found between age and capillary width. In addition, capillary density was significantly lower in the 5-7 age group compared with the other patient groups. Arterial limb diameter was lower in the 5-7 age group, while venous limb diameter was significantly wider in the 15-17 age group compared with the other patient groups. Dilated capillaries (8.7%), capillary tortuosity (14.4%), crossed capillaries (43.1%), micro-haemorrhages (2.7%) and avascular area (4.8%) were present in all age groups. Excellent intra- and interobserver ICC values were obtained for all parameters. CONCLUSION These findings hold potential significance for future studies, aiding in the analysis and differentiation of children suspected of rheumatological diseases with potential microangiopathy.
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Affiliation(s)
- Hatice Adıgüzel Dundar
- Division of Pediatric Rheumatology, Dokuz Eylül University Faculty of Medicine, Izmir, Türkiye
| | - Amra Adrovic
- Division of Pediatric Rheumatology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Türkiye
| | - Selcan Demir
- Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Ferhat Demir
- Division of Pediatric Rheumatology, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Türkiye
| | - Figen Cakmak
- Division of Pediatric Rheumatology, Istanbul University Çapa Faculty of Medicine, Istanbul, Türkiye
| | - Nuray Aktay Ayaz
- Division of Pediatric Rheumatology, Istanbul University Çapa Faculty of Medicine, Istanbul, Türkiye
| | - Betul Sözeri
- Division of Pediatric Rheumatology, Health Sciences University, Ümraniye Training and Research Hospital, Istanbul, Türkiye
| | - Yelda Bilginer
- Division of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Türkiye
| | - Ozgur Kasapçopur
- Division of Pediatric Rheumatology, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Türkiye
| | - Erbil Unsal
- Division of Pediatric Rheumatology, Dokuz Eylül University Faculty of Medicine, Izmir, Türkiye
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Zhang R, Li X, Balasundaram G, Li B, Qi Y, Santosa A, Tan TC, Olivo M, Bi R. Hybrid Photoacoustic Ultrasound Imaging System for Cold-Induced Vasoconstriction and Vasodilation Monitoring. IEEE Trans Biomed Eng 2024; 71:712-716. [PMID: 37531313 DOI: 10.1109/tbme.2023.3301013] [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: 08/04/2023]
Abstract
Lewis hunting reaction refers to the alternating cold-induced vasoconstriction and dilation in extremities, whose underlying mechanism is complex. While numerous studies reported this intriguing phenomenon by measuring cutaneous temperature fluctuation under cold exposure, few of them tracked peripheral vascular responses in real-time, lacking a non-invasive and quantitative imaging tool. To better monitor hunting reaction and diagnose relevant diseases, we developed a hybrid photoacoustic ultrasound (PAUS) tomography system to monitor finger vessels' dynamic response to cold, together with simultaneous temperature measurement. We also came out a standard workflow for image analysis with self-defined indices. In the small cohort observational study, vascular changes in the first cycle of hunting reaction were successfully captured by the image series and quantified. Time difference between vasodilation and temperature recovery was noticed and reported for the first time, thanks to the unique capability of the PAUS imaging system in real-time and continuous vascular monitoring. The developed imaging system and indices enabled more objective and quantitative monitoring of peripheral vascular activities, indicating its great potential in numerous clinical applications.
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Kadian-Dodov D. Cold Hands or Feet: Is It Raynaud's or Not? Med Clin North Am 2023; 107:829-844. [PMID: 37541711 DOI: 10.1016/j.mcna.2023.04.005] [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: 08/06/2023]
Abstract
Raynaud's phenomenon is an exaggerated response to cold stimuli that may be primary or secondary. The diagnosis relies on patient history and physical examination to distinguish RP from other vasomotor dysfunction (e.g. acrocyanosis, pernio, small fiber neuropathy with vasomotor symptoms, and complex regional pain syndrome). Achenbach syndrome, or spontaneous venous hemorrhage, may also be mistaken for RP but is a self-limiting phenomenon. Laboratory evaluation and vascular diagnostic testing may identify SRP causes. Regardless of etiology, treatment includes warming with trigger avoidance, and consideration of vasodilators (eg. calcium channel, alpha-1 blockers). SRP with digital ulceration may require PDE5i, endothelin-1 receptor blockers, and prostanoids. Refractory cases may require pneumatic arterial pumps, botulinum toxin administration, or surgical sympathectomy.
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Affiliation(s)
- Daniella Kadian-Dodov
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1190 Fifth Avenue, Box 1030, New York, NY 10029, USA.
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Gualtierotti R, Fox SE, Da Silva Lameira F, Giachi A, Valenti L, Borghi MO, Meroni PL, Cugno M, Peyvandi F. Nailfold Videocapillaroscopic Alterations as Markers of Microangiopathy in COVID-19 Patients. J Clin Med 2023; 12:jcm12113727. [PMID: 37297922 DOI: 10.3390/jcm12113727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
Nailfold videocapillaroscopic alterations have been described in COVID-19, but their correlations with biomarkers of inflammation, coagulation and endothelial perturbation are still unclear, and no information is available on nailfold histopathology. Nailfold videocapillaroscopy was performed on fifteen patients with COVID-19 in Milan, Italy and the signs of microangiopathy were correlated with plasma biomarkers of inflammation (C reactive protein [CRP], ferritin), coagulation (D-dimer, fibrinogen), endothelial perturbation (Von Willebrand factor [VWF]) and angiogenesis (vascular endothelial growth factor [VEGF]) along with genetic drivers of COVID-19 susceptibility. Histopathological analysis of autoptic nailfold excisions was performed on fifteen patients who died for COVID-19 in New Orleans, United States. All COVID-19 patients studied with videocapillaroscopy showed alterations rarely seen in healthy individuals consistent with microangiopathy, such as hemosiderin deposits (sign of microthrombosis and microhemorrhages) and enlarged loops (sign of endotheliopathy). The number of hemosiderin deposits correlated both with ferritin and CRP levels (r = 0.67, p = 0.008 for both) and the number of enlarged loops significantly correlated with the levels of VWF (r = 0.67, p = 0.006). Ferritin levels were higher in non-O groups, determined by the rs657152 C > A cluster, (median 619, min-max 551-3266 mg/dL) than in the O group (373, 44-581 mg/dL, p = 0.006). Nailfold histology revealed microvascular damage, i.e., mild perivascular lymphocyte and macrophage infiltration and microvascular ectasia in the dermal vessels of all cases, and microthrombi within vessels in five cases. Alterations in nailfold videocapillaroscopy and elevated biomarkers of endothelial perturbation that match histopathologic findings open new perspectives in the possibility of non-invasively demonstrating microangiopathy in COVID-19.
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Affiliation(s)
- Roberta Gualtierotti
- S.C. Medicina-Emostasi e Trombosi, Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Sharon E Fox
- Department of Pathology, Louisiana State University Health Sciences Center, New Orleans, LA 70802, USA
- Pathology and Laboratory Medicine Service, Southeast Louisiana Veterans Healthcare System, New Orleans, LA 70119, USA
| | - Fernanda Da Silva Lameira
- Department of Pathology, Louisiana State University Health Sciences Center, New Orleans, LA 70802, USA
| | - Andrea Giachi
- S.C. Medicina-Emostasi e Trombosi, Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Luca Valenti
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milan, Italy
- Omic Science and Precision Medicine Laboratory, Biological Resource Center, Transfusion Medicine, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Maria Orietta Borghi
- Department of Clinical Sciences and Community Health, Università Degli Studi di Milano, 20122 Milan, Italy
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, 20095 Milan, Italy
| | - Pier Luigi Meroni
- Immunorheumatology Research Laboratory, IRCCS Istituto Auxologico Italiano, 20095 Milan, Italy
| | - Massimo Cugno
- S.C. Medicina-Emostasi e Trombosi, Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milan, Italy
| | - Flora Peyvandi
- S.C. Medicina-Emostasi e Trombosi, Centro Emofilia e Trombosi Angelo Bianchi Bonomi, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico di Milano, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milan, Italy
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Wang L, Chen H, Ding Z, Ma L, Sun Y, Jiang L. Associations of microcirculation damage on nailfold capillaroscopy with supra-aortic severe ischemic events in patients with Takayasu arteritis. Clin Rheumatol 2023; 42:1625-1634. [PMID: 36787036 DOI: 10.1007/s10067-023-06527-6] [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: 10/31/2022] [Revised: 12/19/2022] [Accepted: 01/27/2023] [Indexed: 02/15/2023]
Abstract
OBJECTIVE To evaluate the clinical characteristics and nailfold microcirculation and explore the associations with severe ischemic events (SIEs) in Takayasu arteritis (TA) with supra-aortic involvement. METHODS Eighty-one patients with supra-aortic artery involvement who underwent nailfold video-capillaroscopy (NVC) of their hands were enrolled from the East China TA (ECTA) cohort between August and December 2021. Clinical features and capillaroscopy variables associated with supra-aortic SIEs were analyzed by multivariate logistic regression. RESULTS Overall, 71 patients were female, and 42 experienced supra-aortic SIEs, among whom there was a higher prevalence of hypertension and the number of supra-aortic artery stenosis (P = 0.005, and 0.003, respectively). Furthermore, intergroup differences in capillary density (P < 0.001) and minor morphology abnormalities (P < 0.001) were significant. After adjustment for all confounders, multivariate logistic regression revealed hypertension (odds ratio [OR]: 7.3, 95% confidence interval [CI]: 1.6-33.7, P = 0.011), the number of supra-aortic arteries stenosis (≥4, OR: 6.8, 95% CI: 1.4-34.6, P = 0.020), capillary density (≤7.2/mm, OR: 43.0, 95% CI: 7.0-264.6, P < 0.001) and minor abnormalities (OR: 34.2, 95% CI: 3.6-325.1; P = 0.002) were independent risk factors for supra-aortic SIEs. capillary density (≤7.2/mm) and minor abnormalities or combined with at least two of the three items in the matrix model showed the probability of supra-aortic SIEs was 61.2-87.6%. CONCLUSION Decreased capillary density and morphologic abnormalities indicated that hypoperfusion was more likely to be observed in supra-aortic SIEs patients. Combined NVC indicators could be instrumental for early identification of supra-aortic SIEs. Key Points • Minor morphological abnormalities and hemorrhages were only observed in supra-aortic SIEs patients. • Capillaroscopic density and minor morphological abnormalities or combined with at least two of the three items in the matrix model showed the probability occurrence of supra-aortic SIEs was 61.2-87.6%.
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Affiliation(s)
- Li Wang
- Department of Rheumatology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Huiyong Chen
- Department of Rheumatology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Zhenqi Ding
- Department of Rheumatology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Lingying Ma
- Department of Rheumatology, Zhongshan Hospital Fudan University, Shanghai, 200032, China
| | - Ying Sun
- Department of Rheumatology, Zhongshan Hospital Fudan University, Shanghai, 200032, China.
- Evidence-based Medicine Center, Zhongshan Hospital Fudan University, Shanghai, China.
| | - Lindi Jiang
- Department of Rheumatology, Zhongshan Hospital Fudan University, Shanghai, 200032, China.
- Evidence-based Medicine Center, Zhongshan Hospital Fudan University, Shanghai, China.
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Nam K, Mendoza FA, Wessner CE, Allawh TC, Forsberg F. Ultrasound quantitative assessment of ventral finger microvasculopathy in systemic sclerosis with Raynaud's phenomena: a comparative study. RMD Open 2023; 9:rmdopen-2022-002954. [PMID: 36787926 PMCID: PMC9930605 DOI: 10.1136/rmdopen-2022-002954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/01/2023] [Indexed: 02/16/2023] Open
Abstract
OBJECTIVE To assess the finger vascularity of systemic sclerosis patients with Raynaud's phenomenon (RP-SSc) using various ultrasound techniques. METHODS All fingers (except thumbs) of 18 RP-SSc patients and 18 controls were imaged at room temperature using four ultrasound vascular imaging techniques. The percent vascular area was quantified by counting blood flow pixels in a 25 mm2 square centred at the nail fold for the dorsal side and in 25 mm2 and 100 mm2 square from the fingertip for the ventral side. The mean vascular intensity was calculated from the corresponding areas for dorsal and ventral sides. RESULTS The percent vascular areas and mean vascular intensities in RP-SSc were significantly lower than those in controls for both dorsal and ventral sides (p<0.01). The mean vascular intensities showed slightly higher area under the curve (AUC) than the percent vascular areas (0.53-0.91 vs 0.53-0.90) regardless of imaging technique and assessment side. For each imaging technique, the ventral side vascularity showed a higher AUC (0.74-0.91) compared with the dorsal side (0.53-0.81). Moreover, ventral side abnormalities were associated with a history of digital ulcers. CONCLUSIONS Ultrasound demonstrated potential to quantify finger vascularity of RP-SSc. The ventral side of the fingers showed a higher accuracy in detecting RP-SSc than the dorsal side.
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Affiliation(s)
- Kibo Nam
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fabian A Mendoza
- Department of Medicine, Division of Rheumatology and Jefferson Scleroderma Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Corinne E Wessner
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Tanya C Allawh
- Department of Medicine, Division of Rheumatology and Jefferson Scleroderma Center, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Pacini G, Pogna A, Pendolino M, Pizzorni C, Carmisciano L, Gotelli E, Sulli A, Paolino S, Schenone C, Smith V, Cutolo M. Understanding the value of non-specific abnormal capillary dilations in presence of Raynaud's phenomenon: a detailed capillaroscopic analysis. RMD Open 2022; 8:rmdopen-2022-002449. [PMID: 36197673 PMCID: PMC9462093 DOI: 10.1136/rmdopen-2022-002449] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/22/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Nailfold videocapillaroscopy (NVC) non-specific abnormalities may be present in subjects with isolated Raynaud's phenomenon (RP) before the potential transition to systemic sclerosis (SSc) specific microvascular alterations ('scleroderma pattern'). This study aims to investigate NVC non-specific abnormalities, notably capillary dilations, in RP patients, as possible forerunners of the 'scleroderma pattern'. METHODS A 10-year retrospective NVC-based investigation evaluated 55 RP patients sorted into 3 sex-matched and age-matched groups according to clinical evolution: 18 later developing SSc (cases), 19 later developing other connective tissue disease and 18 maintaining primary RP at long-term follow-up (controls). All patients had a basal NVC showing non-specific abnormalities, namely non-specific >30 µm dilated capillaries (30-50 μm diameter). Sequential NVCs were longitudinally evaluated using current standardised approach. Statistical analysis assessed the risk for developing a 'scleroderma pattern'. RESULTS Significantly larger capillary diameters were observed in cases versus controls both at basal NVC and during follow-up NVC (p=<0.05 to <0.001). Interestingly, controls showed stable NVC non-specific abnormalities over the study follow-up. The number of >30 µm dilated capillaries/mm at basal NVC was the strongest single predictor of 'scleroderma pattern' evolution with 24% increased risk per each dilated capillary (OR 1.24, 95% CI 1.17,1.32). Additionally, a tree-based analysis suggested the efferent (venous) diameter of the most dilated capillary on basal NVCas a variable of interest to identify patients maintaining primary RP. CONCLUSION This is the first study to describe an NVC 'prescleroderma signature' to potentially identify RP patients later developing a 'scleroderma pattern'.
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Affiliation(s)
- Greta Pacini
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Andrea Pogna
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Monica Pendolino
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carmen Pizzorni
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Luca Carmisciano
- Biostatistics Unit, Department of Health Sciences, University of Genoa, Genova, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carlotta Schenone
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Department of Rheumatology, University Hospital Ghent, Gent, Belgium
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Rheumatology, Postgraduate School of Rheumatology, Department of Internal Medicine and Specialties, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Kobayashi S, Nagafuchi Y, Shoda H, Fujio K. The Pathophysiological Roles of Regulatory T Cells in the Early Phase of Systemic Sclerosis. Front Immunol 2022; 13:900638. [PMID: 35686127 PMCID: PMC9172592 DOI: 10.3389/fimmu.2022.900638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Systemic sclerosis (SSc) is an autoimmune disease that is characterized by vascular damage and fibrosis. Both clinical manifestations and immunological disturbances are diverse according to the disease duration. Particularly, changes in immunological processes are prominent in the early phase of SSc. The orchestration of several subsets of immune cells promotes autoimmune responses and inflammation, and eventually stimulates pro-fibrotic processes. Many reports have indicated that CD4+ T cells play pivotal roles in pathogenesis in the early phase of SSc. In particular, the pathogenic roles of regulatory T (Treg) cells have been investigated. Although the results were controversial, recent reports suggested an increase of Treg cells in the early phase of SSc patients. Treg cells secrete transforming growth factor-β (TGF-β), which promotes myofibroblast activation and fibrosis. In addition, the dysfunction of Treg cells in the early phase of SSc was reported, which results in the development of autoimmunity and inflammation. Notably, Treg cells have the plasticity to convert to T-helper17 (Th17) cells under pro-inflammatory conditions. Th17 cells secrete IL-17A, which could also promote myofibroblast transformation and fibrosis and contributes to vasculopathy, although the issue is still controversial. Our recent transcriptomic comparison between the early and late phases of SSc revealed a clear difference of gene expression patterns only in Treg cells. The gene signature of an activated Treg cell subpopulation was expanded in the early phase of SSc and the oxidative phosphorylation pathway was enhanced, which can promote Th17 differentiation. And this result was accompanied by the increase in Th17 cells frequency. Therefore, an imbalance between Treg and Th17 cells could also have an important role in the pathogenesis of the early phase of SSc. In this review, we outlined the roles of Treg cells in the early phase of SSc, summarizing the data of both human and mouse models. The contributions of Treg cells to autoimmunity, vasculopathy, and fibrosis were revealed, based on the dysfunction and imbalance of Treg cells. We also referred to the potential development in treatment strategies in SSc.
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Affiliation(s)
- Satomi Kobayashi
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Itabashi-ku, Japan
| | - Yasuo Nagafuchi
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan
- Department of Functional Genomics and Immunological Diseases, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan
| | - Hirofumi Shoda
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan
| | - Keishi Fujio
- Department of Allergy and Rheumatology, Graduate School of Medicine, The University of Tokyo, Bunkyo-ku, Japan
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9
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Wang-Evers M, Casper MJ, Glahn J, Luo T, Doyle AE, Karasik D, Kim AC, Phothong W, Nathan NR, Heesakker T, Kositratna G, Manstein D. Assessing the impact of aging and blood pressure on dermal microvasculature by reactive hyperemia optical coherence tomography angiography. Sci Rep 2021; 11:13411. [PMID: 34183707 PMCID: PMC8238964 DOI: 10.1038/s41598-021-92712-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/14/2021] [Indexed: 12/12/2022] Open
Abstract
Visualization and quantification of the skin microvasculature are important for studying the health of the human microcirculation. We correlated structural and pathophysiological changes of the dermal capillary-level microvasculature with age and blood pressure by using the reactive hyperemia optical coherence tomography angiography (RH-OCT-A) technique and evaluated both conventional OCT-A and the RH-OCT-A method as non-invasive imaging alternatives to histopathology. This observational pilot study acquired OCT-A and RH-OCT-A images of the dermal microvasculature of 13 young and 12 old healthy Caucasian female subjects. Two skin biopsies were collected per subject for histological analysis. The dermal microvasculature in OCT-A, RH-OCT-A, and histological images were automatically quantified and significant indications of vessel rarefaction in both old subjects and subjects with high blood pressure were observed by RH-OCT-A and histopathology. We showed that an increase in dermal microvasculature perfusion in response to reactive hyperemia was significantly lower in high blood pressure subjects compared to normal blood pressure subjects (117% vs. 229%). These results demonstrate that RH-OCT-A imaging holds functional information of the microvasculature with respect to physiological factors such as age and blood pressure that may help to monitor early disease progression and assess overall vascular health. Additionally, our results suggest that RH-OCT-A images may serve as a non-invasive alternative to histopathology for vascular analysis.
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Affiliation(s)
- Michael Wang-Evers
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Malte J Casper
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Laboratory for Functional Optical Imaging, Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Joshua Glahn
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Yale School of Medicine, New Haven, CT, USA
| | - Tuanlian Luo
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Abigail E Doyle
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel Karasik
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anne C Kim
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Weeranut Phothong
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Department of Dermatology, Siriraj Hospital, Mahidol University, BKK, Thailand
| | - Neera R Nathan
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Tammy Heesakker
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Garuna Kositratna
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Dieter Manstein
- Cutaneous Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Radić M, Overbury RS. Capillaroscopy as a diagnostic tool in the diagnosis of mixed connective tissue disease (MCTD): a case report. BMC Rheumatol 2021; 5:9. [PMID: 33736700 PMCID: PMC7977576 DOI: 10.1186/s41927-021-00179-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 01/28/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The concept of mixed connective tissue disease (MCTD) as a unique connective tissue disease has endured for half a century. Disease onset can be in adulthood (MCTD) or of juvenile onset (jMCTD) and is characterized by overlapping features of systemic lupus erythematosus (SLE), polymyositis or dermatomyositis (PM/DM) and systemic sclerosis (SSc). No universally accepted classification criteria for MCTD exists, however agreed upon overlapping disease features include the presence of high titers of U1 small nuclear ribonucleoprotein particle antibodies (U1snRNP) in the peripheral blood, Raynaud's phenomenon, synovitis, myositis and swollen hands or fingers. Characteristic capillaroscopy findings are commonly seen in MCTD and jMCTD, which may represent a crucial and key clue for classification as well as prognosis in these patients. CASE PRESENTATION We present a young male patient, with symptom onset as early as age 13, who was diagnosed with MCTD at age 16 and found to have high titers of anti-U1snRNP antibodies, Raynaud's phenomenon, synovitis, and swollen hands and fingers. Most interestingly, his video capillaroscopy at diagnosis was abnormal and revealed an active SSc-like pattern. His presentation and course are described. CONCLUSIONS We conclude that based on existing data, and as highlighted by this case presentation, nailfold video capillaroscopy should be included as an early screening tool for the detection of microangiopathy in patients with the diagnosis MCTD and jMCTD. Additionally, given its prevalence in this population at disease diagnosis, we recommend consideration be given to nailfold video capillaroscopy as a potentially important classification criteria and prognostic tool for jMCTD and MCTD.
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Affiliation(s)
- Mislav Radić
- Department of Rheumatology and Clınıcal Immunollogy, University of Split, Split, Croatia
| | - Rebecca S Overbury
- Department of Internal Medicine, Division of Rheumatology, University of Utah, 30 N 1900 E, Ste 4B200, UT, 84132, Salt Lake City, USA.
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11
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Sulli A, Paolino S, Pizzorni C, Ferrari G, Pacini G, Pesce G, Carmisciano L, Smith V, Cutolo M. Progression of nailfold capillaroscopic patterns and correlation with organ involvement in systemic sclerosis: a 12 year study. Rheumatology (Oxford) 2020; 59:1051-1058. [PMID: 31750929 DOI: 10.1093/rheumatology/kez374] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/18/2019] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE The aim of this observational study was to investigate the evolution of scleroderma microangiopathy throughout different nailfold videocapillaroscopy (NVC) patterns ('early', 'active', 'late') as well as the prevalence of organ involvement in SSc patients during a 12-year follow-up. METHODS Thirty-four SSc patients showing at baseline (first capillaroscopic analysis) the 'early' NVC pattern of microangiopathy were enrolled and followed for 12 years (s.d. 2). Complete NVC analysis and clinical and serological findings were collected. Patients were in a standard therapeutic care setting. Statistical analysis was carried out by non-parametric tests. RESULTS After a 12-year follow-up, the 'early' NVC pattern changed from baseline in 76% of the patients. The NVC pattern was found to be 'active' in 9 patients (26%), 'late' in 13 (38%) and characterized by non-specific capillary abnormalities in 4 (12%). In the subgroup whose microangiopathy progressed from the 'early' to the 'late' NVC pattern, the median time of progression from the 'early' to the 'active' pattern was significantly shorter (11 months) when compared with patients who progressed from the 'early' to the 'active' NVC pattern (55 months) (P = 0.002). The median time of progression between NVC patterns was significantly shorter in SSc patients showing either a nucleolar ANA pattern or Scl70 autoantibodies (P = 0.048). Organ involvement was progressively greater in SSc patients with 'early', 'active' and 'late' NVC patterns, respectively. CONCLUSIONS This longitudinal study confirms over a 12-year follow-up the evolution of specific NVC patterns associated with the progressive severity of organ involvement in SSc patients in a standard clinical care setting.
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Affiliation(s)
- A Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - S Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - C Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - G Ferrari
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - G Pacini
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
| | - G Pesce
- Laboratory for Autoimmunity, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova
| | - L Carmisciano
- Biostatistics Section, Department of Health Sciences, University of Genova, Genova, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Department of Internal Medicine, VIB Inflammation Research Centre - Ghent University, Ghent, Belgium
| | - M Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine
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12
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Nailfold Videocapillaroscopy Changes Are Associated With the Presence and Severity of Systemic Sclerosis-Related Interstitial Lung Disease. J Clin Rheumatol 2019; 25:e12-e15. [PMID: 29782426 DOI: 10.1097/rhu.0000000000000815] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the association of nailfold videocapillaroscopy (NVC) changes and the presence and severity of interstitial lung disease (ILD) in systemic sclerosis. METHODS This was a cross-sectional analysis of 48 systemic sclerosis patients (21 patients with ILD). The NVC characteristics considered were capillary organization, capillary loss (CL), avascular areas, enlarged and giant capillaries, hemorrhages, abnormally shaped capillaries, edema, and intermittent flux.We analyzed the association between NVC findings and (1) presence and extension of ILD and (2) percent predicted of forced vital capacity (FVC) and the carbon monoxide diffusing capacity (DLCO). RESULTS Capillary loss and avascular areas showed a significant association with the presence of ILD (odds ratio, 18.57; 95% confidence interval [CI], 2.17-158.72 [p = 0.008]; and odds ratio, 4.64; 95% CI, 1.35-15.91 [p = 0.015], respectively). Receiver operating characteristic (ROC) curve analysis confirmed the association between CL and ILD (area under the ROC curve, 90.1%; 95% CI, 81.8-91.4). Avascular areas and CL were associated with a worse pulmonary function (FVC -18.1% [p = 0.034], DLCO -14.0% [p = 0.013]; and FVC -15.3% [p = 0.086], DLCO -12.3% [p = 0.049], respectively). No association was found between other NVC findings and ILD or lung function. CONCLUSIONS Capillary loss and avascular area showed a significant association with the presence of ILD, supported by ROC curve analysis. These results may reinforce a prognostic role for NVC and a physiopathology mechanism for ILD based on vascular damage.
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13
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Wermuth PJ, Piera-Velazquez S, Rosenbloom J, Jimenez SA. Existing and novel biomarkers for precision medicine in systemic sclerosis. Nat Rev Rheumatol 2019; 14:421-432. [PMID: 29789665 DOI: 10.1038/s41584-018-0021-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The discovery and validation of biomarkers resulting from technological advances in the analysis of genomic, transcriptomic, lipidomic and metabolomic pathways involved in the pathogenesis of complex human diseases have led to the development of personalized and rationally designed approaches for the clinical management of such disorders. Although some of these approaches have been applied to systemic sclerosis (SSc), an unmet need remains for validated, non-invasive biomarkers to aid in the diagnosis of SSc, as well as in the assessment of disease progression and response to therapeutic interventions. Advances in global transcriptomic technology over the past 15 years have enabled the assessment of microRNAs that circulate in the blood of patients and the analysis of the macromolecular content of a diverse group of lipid bilayer membrane-enclosed extracellular vesicles, such as exosomes and other microvesicles, which are released by all cells into the extracellular space and circulation. Such advances have provided new opportunities for the discovery of biomarkers in SSc that could potentially be used to improve the design and evaluation of clinical trials and that will undoubtedly enable the development of personalized and individualized medicine for patients with SSc.
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Affiliation(s)
- Peter J Wermuth
- Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,The Joan and Joel Rosenbloom Center for Fibrosis Research, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sonsoles Piera-Velazquez
- Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,The Joan and Joel Rosenbloom Center for Fibrosis Research, Thomas Jefferson University, Philadelphia, PA, USA
| | - Joel Rosenbloom
- Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,The Joan and Joel Rosenbloom Center for Fibrosis Research, Thomas Jefferson University, Philadelphia, PA, USA
| | - Sergio A Jimenez
- Jefferson Institute of Molecular Medicine, Thomas Jefferson University, Philadelphia, PA, USA. .,The Joan and Joel Rosenbloom Center for Fibrosis Research, Thomas Jefferson University, Philadelphia, PA, USA. .,The Scleroderma Center, Thomas Jefferson University, Philadelphia, PA, USA.
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14
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Nailfold capillaroscopy in rheumatology: ready for the daily use but with care in terminology. Clin Rheumatol 2019; 38:2293-2297. [DOI: 10.1007/s10067-019-04716-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/24/2019] [Indexed: 10/26/2022]
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15
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Karbalaie A, Emrani Z, Fatemi A, Etehadtavakol M, Erlandsson BE. Practical issues in assessing nailfold capillaroscopic images: a summary. Clin Rheumatol 2019; 38:2343-2354. [PMID: 31278512 DOI: 10.1007/s10067-019-04644-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 11/30/2022]
Abstract
Nailfold capillaroscopy (NC) is a highly sensitive, safe, and non-invasive technique to assess involvement rate of microvascularity in dermatomyositis and systemic sclerosis. A large number of studies have focused on NC pattern description, classification, and scoring system validation, but minimal information has been published on the accuracy and precision of the measurement. The objective of this review article is to identify different factors affecting the reliability and validity of the assessment in NC. Several factors can affect the reliability of the examination, e.g., physiological artifacts, the nailfold imaging instrument, human factors, and the assessment rules and standards. It is impossible to avoid all artifacts, e.g., skin transparency, physically injured fingers, and skin pigmentation. However, minimization of the impact of some of these artifacts by considering some protocols before the examination and by using specialized tools, training, guidelines, and software can help to reduce errors in the measurement and assessment of NC images. Establishing guidelines and instructions for automatic characterization and measurement based on machine learning techniques also may reduce ambiguities and the assessment time.
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Affiliation(s)
- Abdolamir Karbalaie
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Zahra Emrani
- Medical Image and Signal Processing Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Alimohammad Fatemi
- Rheumatology Section, Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahnaz Etehadtavakol
- Department of Medical Physics, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Björn-Erik Erlandsson
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
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16
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Unmet Needs in Systemic Sclerosis Understanding and Treatment: the Knowledge Gaps from a Scientist's, Clinician's, and Patient's Perspective. Clin Rev Allergy Immunol 2019; 55:312-331. [PMID: 28866756 PMCID: PMC6244948 DOI: 10.1007/s12016-017-8636-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Systemic sclerosis (SSc) is a highly heterogeneous disease caused by a complex molecular circuitry. For decades, clinical and molecular research focused on understanding the primary process of fibrosis. More recently, the inflammatory, immunological and vascular components that precede the actual onset of fibrosis, have become a matter of increasing scientific scrutiny. As a consequence, the field has started to realize that the early identification of this syndrome is crucial for optimal clinical care as well as for understanding its pathology. The cause of SSc cannot be appointed to a single molecular pathway but to a multitude of molecular aberrances in a spatial and temporal matter and on the backbone of the patient's genetic predisposition. These alterations underlie the plethora of signs and symptoms which patients experience and clinicians look for, ultimately culminating in fibrotic features. To solve this complexity, a close interaction among the patient throughout its "journey," the clinician through its clinical assessments and the researcher with its experimental design, seems to be required. In this review, we aimed to highlight the features of SSc through the eyes of these three professionals, all with their own expertise and opinions. With this unique setup, we underscore the importance of investigating the role of environmental factors in the onset and perpetuation of SSc, of focusing on the earliest signs and symptoms preceding fibrosis and on the application of holistic research approaches that include a multitude of potential molecular alterations in time in an unbiased fashion, in the search for a patient-tailored cure.
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17
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Dinsdale G, Roberts C, Moore T, Manning J, Berks M, Allen J, Anderson ME, Cutolo M, Hesselstrand R, Howell K, Pizzorni C, Smith V, Sulli A, Wildt M, Taylor C, Murray A, Herrick AL. Nailfold capillaroscopy-how many fingers should be examined to detect abnormality? Rheumatology (Oxford) 2019; 58:284-288. [PMID: 30247696 DOI: 10.1093/rheumatology/key293] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Indexed: 11/08/2023] Open
Abstract
Objectives Nailfold capillaroscopy is being increasingly used by rheumatologists in the diagnosis of SSc. However, assessment of all nailfolds can be time-consuming in a busy outpatient clinic. Our aim was to answer the question as to how many (and which) fingers a clinician should routinely assess to capture accurately the true state. Methods A total of 2994 assessments (by an international panel of expert observers) of 1600 images from 173 participants (101 with SSc, 22 with primary RP and 50 healthy controls) were included in this analysis. Seven single-finger or finger combinations (derived from the middle and ring fingers) were then tested for sensitivity for the presence of two markers of capillary abnormality [presence of giant capillaries and an SSc grade (early, active or late)] compared with assessment of all eight fingers. Results For the eight-finger gold standard, sensitivity against the diagnostic criteria was 74.6% (53.0% for the presence of giants alone and 73.1% for image grade alone). Examining only one finger gave low sensitivity (ranging from right middle 31.7% to left ring 46.6%). Examining both ring fingers gave a sensitivity of 59.8%, whereas examining the four-finger combination of both ring and both middle fingers gave a sensitivity of 66.7%. Conclusion During routine capillaroscopic examination, ideally all eight nailbeds (excluding thumbs) should be examined, otherwise some abnormalities will be missed. Examining only four fingers reduces capillaroscopy sensitivity.
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Affiliation(s)
- Graham Dinsdale
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Tonia Moore
- Rheumatology Department, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Joanne Manning
- Rheumatology Department, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - John Allen
- Microvascular Diagnostics, Northern Medical Physics and Clinical Engineering, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marina E Anderson
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Roger Hesselstrand
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Kevin Howell
- Institute of Immunity and Transplantation, University College London, Royal Free Campus, London, UK
| | - Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Marie Wildt
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Christopher Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Andrea Murray
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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18
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Zanatta E, Famoso G, Boscain F, Montisci R, Pigatto E, Polito P, Schiavon F, Iliceto S, Cozzi F, Doria A, Tona F. Nailfold avascular score and coronary microvascular dysfunction in systemic sclerosis: A newsworthy association. Autoimmun Rev 2018; 18:177-183. [PMID: 30572139 DOI: 10.1016/j.autrev.2018.09.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS We aimed to assess the relationship between nailfold videocapillaroscopy (NVC) abnormalities and coronary flow reserve (CFR), a marker of coronary microvascular dysfunction (CMD) in patients with systemic sclerosis (SSc). METHODS We studied 39 SSc patients (33 females, mean ± SD age 54 ± 12 years, median disease duration 11 years, range 6-22) and 22 controls (matched for age and sex) without any evidence of cardiovascular disease. Clinical assessment was performed by modified Rodnan skin score (mRss) and EUSTAR score. Coronary flow velocities in the left anterior descending coronary artery were measured by transthoracic echocardiography. Average peak flow velocities, CFR and microvascular resistance at baseline (BMR) and in hyperaemic (HMR) condition were assessed. CFR ≤2.5 was considered marker of CMD. Six NVC-abnormalities were evaluated by a semi quantitative scoring system: enlarged and giant capillaries (diameter > 20 μm and >50 μm, respectively), hemorrhages, disarray, capillary ramifications and loss of capillaries (avascular score). Statistic was performed using SPSS. RESULTS CFR was lower in SSc patients than in controls (2.6 ± 0.5 vs 3.3 ± 0.5). CMD was detected in 24 patients (61.5%) vs 0 controls (p < .0001). CFR was inversely correlated with NVC-avascular score (rho =-0.750, p < .0001). Avascular and capillary ramifications scores (p = .001 and p = .03, respectively), mRss (p = .003) and EUSTAR score (p = .01) were higher in patients with CMD than in those without. At multivariable analysis, avascular score was independently associated with CMD (p = .01). HMR was directly correlated with avascular score (rho = 0.416, p = .008). CONCLUSIONS In our SSc patients NVC-avascular score was associated with CMD which seems to be the result of a structural microvascular remodeling.
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Affiliation(s)
- Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Francesca Boscain
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, San Giovanni di Dio Hospital, University of Cagliari, Cagliari, Italy
| | - Erika Pigatto
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Pamela Polito
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Franco Schiavon
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Franco Cozzi
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy.
| | - Francesco Tona
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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19
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Nešković JS, Ristić A, Petronijević M, Zeljković A, Grdinić A, Gudelj O, Đurović B, Nešković B. B-type Natriuretic Peptide as a Marker of Different Forms of Systemic Sclerosis. J Med Biochem 2018; 37:406-414. [PMID: 30584399 PMCID: PMC6298475 DOI: 10.1515/jomb-2017-0058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 12/09/2017] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is an autoimmune connective tissue disease which affects various tissues and organs, including skin, lungs, kidneys, gastrointestinal tract and cardiovascular system. Cardiac involvement is the most commonly recognized problem and a significant cause of morbidity. The brain natriuretic peptide (BNP) is a previously known marker of elevated cardiovascular risk in SSc, but the levels of BNP in various forms of SSc have not been investigated so far. AIM The aim of our study was to evaluate the influence of SSc on the function of the right ventricle and the right atrium using the echocardiographic parameters. Moreover, we examined the levels of BNP in different forms of SSc as well as the association of disease severity with the plasma concentrations of BNP. METHODS We included 42 patients with newly diagnosed SSc and patients whose disease had been diagnosed earlier. SSc patients and non-SSc control patients were examined by using echocardiography and the concentrations of BNP were determined. RESULTS We analyzed differences in the parameters of right ventricle (RV) function and right atrium (RA) function between SSc patients and healthy controls. The two groups had similar distribution of gender, but SSc patients were significantly older than controls. RV wall thickness was increased in SSc patients (p<0.001), while right ventricular end-systolic area (RVESA; p=0.408) and right ventricular end-diastolic area (RVEDA; p=0.368) did not differ among the examinees. In contrast, RA minor-axis dimension (p=0.001) and the tricuspid annular plane systolic excursion (TAPSE) (p=0.001) were significantly higher in SSc patients. Also, we analyzed differences in brain natriuretic peptide (BNP) concentrations between diffuse cutaneous systemic sclerosis (DSSc) and limited cutaneous systemic sclerosis (LSSc) patients. DSSc patients had significantly higher concentrations of BNP. We found that levels of BNP were in significant positive correlations with age (p=0.007), disease duration (p=0.023), C reactive protein (CRP) (p=0.032), right ventricle fractional area change (FAC) (p=0.022), pulmonary vascular resistance (PVR) and Rodnan score (p=0.019). CONCLUSIONS Given the obtained results, the laboratory determination of BNP could be useful in differentiating different forms of systemic sclerosis as well as in predicting the severity of the disease and future cardiovascular complications.
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Affiliation(s)
| | - Anđelka Ristić
- Clinic for Emergency and Internal Medicine, Military Medical Academy, Belgrade, Serbia
| | | | - Aleksandra Zeljković
- Department of Medical Biochemistry, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | | | - Ognjen Gudelj
- Clinic for Cardiology, Military Medical Academy, Belgrade, Serbia
| | - Branka Đurović
- Institute of Occupational Medicine, Medical Academy, Belgrade, Serbia
| | - Branimir Nešković
- Clinic for General Surgery, Military Medical Academy, Belgrade, Serbia
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20
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Ruaro B, Sulli A, Smith V, Pizzorni C, Paolino S, Alessandri E, Trombetta AC, Cutolo M. Advances in nailfold capillaroscopic analysis in systemic sclerosis. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:122-131. [PMID: 35382238 PMCID: PMC8892861 DOI: 10.1177/2397198318757699] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 01/03/2018] [Indexed: 09/26/2023]
Abstract
Systemic sclerosis is an autoimmune connective tissue disease characterized by early and persistent microvascular impairment which leads to functional and organic manifestations, with progressive fibrosis of the skin and internal organs. Morphological and functional assessment of the peripheral microvasculature is a must, not only for diagnosis but also for the prognosis and therapeutical follow-up of systemic sclerosis patients, as reported in recent studies. Nailfold videocapillaroscopy is the validated technique for the study of scleroderma microangiopathy as it is able to detect peripheral microvascular morphology and both classify and score the capillary abnormalities into different microangiopathy patterns ('Early', 'Active' and 'Late'). Indeed, the possibility to early diagnose and follow the microvascular changes and the safety of the technique have made nailfold videocapillaroscopy a mandatory tool for patient evaluation and included its assessment in the new systemic sclerosis classification criteria. Important links between nailfold videocapillaroscopy patterns and systemic sclerosis clinical manifestations have been described.
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Affiliation(s)
- Barbara Ruaro
- Research Laboratory and Academic
Division of Clinical Rheumatology, Department of Internal Medicine, University of
Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alberto Sulli
- Research Laboratory and Academic
Division of Clinical Rheumatology, Department of Internal Medicine, University of
Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent
University Hospital, Department of Internal Medicine, Ghent University, Ghent,
Belgium
| | - Carmen Pizzorni
- Research Laboratory and Academic
Division of Clinical Rheumatology, Department of Internal Medicine, University of
Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Sabrina Paolino
- Research Laboratory and Academic
Division of Clinical Rheumatology, Department of Internal Medicine, University of
Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Elisa Alessandri
- Research Laboratory and Academic
Division of Clinical Rheumatology, Department of Internal Medicine, University of
Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Amelia Chiara Trombetta
- Research Laboratory and Academic
Division of Clinical Rheumatology, Department of Internal Medicine, University of
Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Maurizio Cutolo
- Research Laboratory and Academic
Division of Clinical Rheumatology, Department of Internal Medicine, University of
Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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21
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Berks M, Dinsdale G, Murray A, Moore T, Manning J, Taylor C, Herrick AL. Automated structure and flow measurement - a promising tool in nailfold capillaroscopy. Microvasc Res 2018; 118:173-177. [PMID: 29605552 PMCID: PMC5956308 DOI: 10.1016/j.mvr.2018.03.016] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 03/08/2018] [Accepted: 03/28/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Despite increasing interest in nailfold capillaroscopy, objective measures of capillary structure and blood flow have been little studied. We aimed to test the hypothesis that structural measurements, capillary flow, and a combined measure have the predictive power to separate patients with systemic sclerosis (SSc) from those with primary Raynaud's phenomenon (PRP) and healthy controls (HC). METHODS 50 patients with SSc, 12 with PRP, and 50 HC were imaged using a novel capillaroscopy system that generates high-quality nailfold images and provides fully-automated measurements of capillary structure and blood flow (capillary density, mean width, maximum width, shape score, derangement and mean flow velocity). Population statistics summarise the differences between the three groups. Areas under ROC curves (AZ) were used to measure classification accuracy when assigning individuals to SSc and HC/PRP groups. RESULTS Statistically significant differences in group means were found between patients with SSc and both HC and patients with PRP, for all measurements, e.g. mean width (μm) ± SE: 15.0 ± 0.71, 12.7 ± 0.74 and 11.8 ± 0.23 for SSc, PRP and HC respectively. Combining the five structural measurements gave better classification (AZ = 0.919 ± 0.026) than the best single measurement (mean width, AZ = 0.874 ± 0.043), whilst adding flow further improved classification (AZ = 0.930 ± 0.024). CONCLUSIONS Structural and blood flow measurements are both able to distinguish patients with SSc from those with PRP/HC. Importantly, these hold promise as clinical trial outcome measures for treatments aimed at improving finger blood flow or microvascular remodelling.
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Affiliation(s)
- Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
| | - Graham Dinsdale
- Division of Musculoskeletal & Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Andrea Murray
- Division of Musculoskeletal & Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Tonia Moore
- Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Chris Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, The University of Manchester, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal & Dermatological Sciences, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; NIHR Manchester Musculoskeletal Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK.
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Deegan AJ, Talebi-Liasi F, Song S, Li Y, Xu J, Men S, Shinohara MM, Flowers ME, Lee SJ, Wang RK. Optical coherence tomography angiography of normal skin and inflammatory dermatologic conditions. Lasers Surg Med 2018; 50:183-193. [PMID: 29356051 DOI: 10.1002/lsm.22788] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2017] [Indexed: 11/09/2022]
Abstract
BACKGROUND In clinical dermatology, the identification of subsurface vascular and structural features known to be associated with numerous cutaneous pathologies remains challenging without the use of invasive diagnostic tools. OBJECTIVE To present an advanced optical coherence tomography angiography (OCTA) method to directly visualize capillary-level vascular and structural features within skin in vivo. METHODS An advanced OCTA system with a 1310 nm wavelength was used to image the microvascular and structural features of various skin conditions. Subjects were enrolled and OCTA imaging was performed with a field of view of approximately 10 × 10 mm. Skin blood flow was identified using an optical microangiography (OMAG) algorithm. Depth-resolved microvascular networks and structural features were derived from segmented volume scans, representing tissue slabs of 0-132, 132-330, and 330-924 μm, measured from the surface of the skin. RESULTS Subjects with both healthy and pathological conditions, such as benign skin lesions, psoriasis, chronic graft-versus-host-disease (cGvHD), and scleroderma, were OCTA scanned. Our OCTA results detailed variations in vascularization and local anatomical characteristics, for example, depth-dependent vascular, and structural alterations in psoriatic skin, alongside their resolve over time; vascular density changes and distribution irregularities, together with corresponding structural depositions in the skin of cGvHD patients; and vascular abnormalities in the nail folds of a patient with scleroderma. CONCLUSION OCTA can image capillary blood flow and structural features within skin in vivo, which has the potential to provide new insights into the pathophysiology, as well as dynamic changes of skin diseases, valuable for diagnoses, and non-invasive monitoring of disease progression and treatment. Lasers Surg. Med. 50:183-193, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Anthony J Deegan
- Department of Bioengineering, University of Washington, 3720 15th Ave. N.E., Seattle, Washington 98195
| | - Faezeh Talebi-Liasi
- School of Medicine, University of Washington, 1959 N.E. Pacific St., Seattle, Washington 98195
| | - Shaozhen Song
- Department of Bioengineering, University of Washington, 3720 15th Ave. N.E., Seattle, Washington 98195
| | - Yuandong Li
- Department of Bioengineering, University of Washington, 3720 15th Ave. N.E., Seattle, Washington 98195
| | - Jingjiang Xu
- Department of Bioengineering, University of Washington, 3720 15th Ave. N.E., Seattle, Washington 98195
| | - Shaojie Men
- Department of Bioengineering, University of Washington, 3720 15th Ave. N.E., Seattle, Washington 98195
| | - Michi M Shinohara
- Division of Dermatology and Dermatopathology, University of Washington, 1959 N.E. Pacific St., Seattle, Washington 98195
| | - Mary E Flowers
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Seattle, Washington 98109
| | - Stephanie J Lee
- Clinical Research Division, Fred Hutchinson Cancer Research Center, 1100 Fairview Ave. N., Seattle, Washington 98109
| | - Ruikang K Wang
- Department of Bioengineering, University of Washington, 3720 15th Ave. N.E., Seattle, Washington 98195
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Herrick AL. Evidence-based management of Raynaud's phenomenon. Ther Adv Musculoskelet Dis 2017; 9:317-329. [PMID: 29201156 PMCID: PMC5700788 DOI: 10.1177/1759720x17740074] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 09/07/2017] [Indexed: 12/18/2022] Open
Abstract
Raynaud's phenomenon (RP) is relevant to the rheumatologist because it may signify an underlying connective tissue disease and also because it can be very challenging to treat, especially when it has progressed to digital ulceration or critical ischaemia. This review article discusses diagnosis (does this patient have an underlying connective tissue disease?), including the role for nailfold capillaroscopy, and treatment. Management of 'uncomplicated' RP is first described and then treatment of RP complicated by progression to digital ulceration or critical ischaemia, highlighting recent advances (including phosphodiesterase type 5 inhibition, and endothelin 1 receptor antagonism) and the evidence base underpinning these. Possible future therapies are briefly discussed.
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Affiliation(s)
- Ariane L. Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester UK, M13 9PT and NIHR Manchester Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester, UK
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24
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Cutolo M, Herrick AL, Distler O, Becker MO, Beltran E, Carpentier P, Ferri C, Inanç M, Vlachoyiannopoulos P, Chadha-Boreham H, Cottreel E, Pfister T, Rosenberg D, Torres JV, Smith V. Nailfold Videocapillaroscopic Features and Other Clinical Risk Factors for Digital Ulcers in Systemic Sclerosis: A Multicenter, Prospective Cohort Study. Arthritis Rheumatol 2017; 68:2527-39. [PMID: 27111549 PMCID: PMC5129545 DOI: 10.1002/art.39718] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Accepted: 04/07/2016] [Indexed: 12/22/2022]
Abstract
Objective To identify nailfold videocapillaroscopic features and other clinical risk factors for new digital ulcers (DUs) during a 6‐month period in patients with systemic sclerosis (SSc). Methods In this multicenter, prospective, observational cohort study, the videoCAPillaroscopy (CAP) study, we evaluated 623 patients with SSc from 59 centers (14 countries). Patients were stratified into 2 groups: a DU history group and a no DU history group. At enrollment, patients underwent detailed nailfold videocapillaroscopic evaluation and assessment of demographic characteristics, DU status, and clinical and SSc characteristics. Risk factors for developing new DUs were assessed using univariable and multivariable logistic regression (MLR) analyses. Results Of the 468 patients in the DU history group (mean ± SD age 54.0 ± 13.7 years), 79.5% were female, 59.8% had limited cutaneous SSc, and 22% developed a new DU during follow‐up. The strongest risk factors for new DUs identified by MLR in the DU history group included the mean number of capillaries per millimeter in the middle finger of the dominant hand, the number of DUs (categorized as 0, 1, 2, or ≥3), and the presence of critical digital ischemia. The receiver operating characteristic (ROC) of the area under the curve (AUC) of the final MLR model was 0.738 (95% confidence interval [95% CI] 0.681–0.795). Internal validation through bootstrap generated a ROC AUC of 0.633 (95% CI 0.510–0.756). Conclusion This international prospective study, which included detailed nailfold videocapillaroscopic evaluation and extensive clinical characterization of patients with SSc, identified the mean number of capillaries per millimeter in the middle finger of the dominant hand, the number of DUs at enrollment, and the presence of critical digital ischemia at enrollment as risk factors for the development of new DUs.
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Affiliation(s)
- Maurizio Cutolo
- University of Genoa and IRCCS Azienda Ospedaliera Universitaria San Martino, Genoa, Italy.
| | - Ariane L Herrick
- University of Manchester, Salford Royal NHS Foundation Trust, NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust and Manchester Academic Health Science Centre, Manchester, UK
| | | | - Mike O Becker
- University Hospital, Zurich, Switzerland, and Charité University Hospital, Berlin, Germany
| | - Emma Beltran
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | | | | | | | | | | | | | | | | | - Vanessa Smith
- Ghent University Hospital and Ghent University, Ghent, Belgium.
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Dinsdale G, Moore T, O'Leary N, Tresadern P, Berks M, Roberts C, Manning J, Allen J, Anderson M, Cutolo M, Hesselstrand R, Howell K, Pizzorni C, Smith V, Sulli A, Wildt M, Taylor C, Murray A, Herrick AL. Intra-and inter-observer reliability of nailfold videocapillaroscopy - A possible outcome measure for systemic sclerosis-related microangiopathy. Microvasc Res 2017; 112:1-6. [PMID: 28163035 DOI: 10.1016/j.mvr.2017.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/12/2017] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Our aim was to assess the reliability of nailfold capillary assessment in terms of image evaluability, image severity grade ('normal', 'early', 'active', 'late'), capillary density, capillary (apex) width, and presence of giant capillaries, and also to gain further insight into differences in these parameters between patients with systemic sclerosis (SSc), patients with primary Raynaud's phenomenon (PRP) and healthy control subjects. METHODS Videocapillaroscopy images (magnification 300×) were acquired from all 10 digits from 173 participants: 101 patients with SSc, 22 with PRP and 50 healthy controls. Ten capillaroscopy experts from 7 European centres evaluated the images. Custom image mark-up software allowed extraction of the following outcome measures: overall grade ('normal', 'early', 'active', 'late', 'non-specific', or 'ungradeable'), capillary density (vessels/mm), mean vessel apical width, and presence of giant capillaries. RESULTS Observers analysed a median of 129 images each. Evaluability (i.e. the availability of measures) varied across outcome measures (e.g. 73.0% for density and 46.2% for overall grade in patients with SSc). Intra-observer reliability for evaluability was consistently higher than inter- (e.g. for density, intra-class correlation coefficient [ICC] was 0.71 within and 0.14 between observers). Conditional on evaluability, both intra- and inter-observer reliability were high for grade (ICC 0.93 and 0.78 respectively), density (0.91 and 0.64) and width (0.91 and 0.85). CONCLUSIONS Evaluability is one of the major challenges in assessing nailfold capillaries. However, when images are evaluable, the high intra- and inter-reliabilities suggest that overall image grade, capillary density and apex width have potential as outcome measures in longitudinal studies.
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Affiliation(s)
- Graham Dinsdale
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - Tonia Moore
- Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Neil O'Leary
- Centre for Biostatistics, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Philip Tresadern
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Christopher Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Joanne Manning
- Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - John Allen
- Microvascular Diagnostics, Northern Medical Physics and Clinical Engineering, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marina Anderson
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Roger Hesselstrand
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Kevin Howell
- Institute of Immunity and Transplantation, University College London, Royal Free Campus, London, UK
| | - Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Marie Wildt
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Christopher Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Andrea Murray
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, 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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Romanowska-Próchnicka K, Walczyk M, Olesińska M. Recognizing systemic sclerosis: comparative analysis of various sets of classification criteria. Reumatologia 2016; 54:296-305. [PMID: 28115780 PMCID: PMC5241366 DOI: 10.5114/reum.2016.64906] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/16/2016] [Indexed: 01/30/2023] Open
Abstract
Systemic sclerosis is a complex disease characterized by autoimmunity, vasculopathy and tissue fibrosis. Although most patients present with some degree of skin sclerosis, which is a distinguishing hallmark, the clinical presentation vary greatly complicating the diagnosis. In this regard, new classification criteria were jointly published in 2013 by American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR). A recent major development in the classification criteria is improved sensitivity, particularly for detecting early disease. The new criteria allow more cases to be classified as having systemic sclerosis (SSc), which leads to earlier treatment. Moreover it is clinically beneficial in preventing the disease progression with its irreversible fibrosis and organ damage. The aim of this review is to give insight into new classification criteria and current trends in the diagnosis of systemic sclerosis.
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Affiliation(s)
- Katarzyna Romanowska-Próchnicka
- Department of General and Experimental Pathology, 2 Faculty of Medicine, Medical University of Warsaw, Poland
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Marcela Walczyk
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
| | - Marzena Olesińska
- Department of Systemic Connective Tissue Diseases, National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
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27
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Capillaroscopic findings and vascular biomarkers in systemic sclerosis: Association of low CD40L levels with late scleroderma pattern. Microvasc Res 2016; 108:17-21. [DOI: 10.1016/j.mvr.2016.07.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 07/02/2016] [Indexed: 11/21/2022]
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28
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Pavlov-Dolijanovic S, Petrovic N, Vujasinovic Stupar N, Damjanov N, Radunovic G, Babic D, Sobic-Saranovic D, Artiko V. Diagnosis of Raynaud’s phenomenon by 99mTc-pertechnetate hand perfusion scintigraphy: a pilot study. Rheumatol Int 2016; 36:1683-1688. [DOI: 10.1007/s00296-016-3584-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 10/19/2016] [Indexed: 11/25/2022]
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Abstract
Capillaroscopy is a non-invasive, easy and safe diagnostic technique designed to evaluate small vessels of the microcirculation in the nailfold. It can reveal both the general architecture of capillary rows and fine details of particular vessels. The most important indications for performing capillaroscopy include differential diagnosis of primary and secondary Raynaud's phenomenon, as well as assessment of scleroderma spectrum disorders. In systemic sclerosis capillary abnormalities appear and evolve in a clearly defined sequence called the scleroderma pattern, which correlates with internal organ involvement. Capillaroscopy is also listed as a systemic sclerosis classification criterion recognized by the European League Against Rheumatism (EULAR). With digitized equipment, capillaroscopy allows for precise qualitative and quantitative evaluation of the microcirculation and is a valuable tool in the rheumatologists’ daily practice.
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30
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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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Scolnik M, Vasta B, Hart DJ, Shipley JA, McHugh NJ, Pauling JD. Symptoms of Raynaud's phenomenon (RP) in fibromyalgia syndrome are similar to those reported in primary RP despite differences in objective assessment of digital microvascular function and morphology. Rheumatol Int 2016; 36:1371-7. [PMID: 27136918 PMCID: PMC5020104 DOI: 10.1007/s00296-016-3483-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 04/16/2016] [Indexed: 11/25/2022]
Abstract
Symptoms of Raynaud’s phenomenon (RP) are common in fibromyalgia syndrome (FMS). We compared symptom characteristics and objective assessment of digital microvascular function using infrared thermography (and nailfold capillaroscopy where available) in patients with FMS (reporting RP symptoms) and primary RP. We retrospectively reviewed the outcome of microvascular imaging studies and RP symptom characteristics (captured using patient-completed questionnaire at the time of assessment) for patients with FMS (reporting RP symptoms) and patients with primary RP referred for thermographic assessment of RP symptoms over a 2-year period. Of 257 patients referred for thermographic assessment of RP symptoms between 2010 and 2012, we identified 85 patients with primary RP and 43 patients with FMS. There were no differences in RP symptom characteristics between FMS and primary RP (p > 0.05 for all comparisons). In contrast, patients with FMS had higher baseline temperature of the digits (32.1 vs. 29.0 °C, p = 0.004), dorsum (31.9 vs. 30.2 °C, p = 0.005) and thermal gradient (temperature of digits minus temperature of dorsum; +0.0 vs. −0.9 °C, p = 0.03) compared with primary RP. Significant differences between groups persisted following local cold challenge. In primary RP, patient reporting “blue” digits, bi-phasic and tri-phasic RP was associated with lower digital perfusion. In contrast, no associations between skin temperature and RP digital colour changes/phases were identified in FMS. Our findings suggest that symptoms of RP in FMS may have a different aetiology to those seen in primary RP. These findings have potential implications for both the classification of RP symptoms and the management of RP symptoms in the context of FMS. Digital colour changes reported by patients might reflect the degree of digital microvascular compromise in primary RP.
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Affiliation(s)
- M Scolnik
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK.,Sección Reumatología, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - B Vasta
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
| | - D J Hart
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
| | - J A Shipley
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK
| | - N J McHugh
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK.,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK
| | - J D Pauling
- Department of Rheumatology, Royal National Hospital for Rheumatic Diseases, Upper Borough Walls, Bath, BA1 1RL, UK. .,Department of Pharmacy and Pharmacology, University of Bath, Bath, UK.
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Hughes M, Ong VH, Anderson ME, Hall F, Moinzadeh P, Griffiths B, Baildam E, Denton CP, Herrick AL. Consensus best practice pathway of the UK Scleroderma Study Group: digital vasculopathy in systemic sclerosis. Rheumatology (Oxford) 2015; 54:2015-24. [DOI: 10.1093/rheumatology/kev201] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2014] [Indexed: 01/02/2023] Open
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Raynaud's phenomenon: new aspects of pathogenesis and the role of nailfold videocapillaroscopy. Reumatologia 2015; 53:87-93. [PMID: 27407233 PMCID: PMC4847279 DOI: 10.5114/reum.2015.51508] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/04/2015] [Indexed: 11/21/2022] Open
Abstract
Raynaud's phenomenon (RP) refers to paroxysmal pallor or cyanosis of the digits of the hands or feet and, infrequently, the tips of the nose or ears (acral parts) owing to cold-induced vasoconstriction of the digital arteries, precapillary arterioles, and cutaneous arteriovenous shunts. Raynaud's phenomenon reflects an exaggeration of normal central and local vasomotor responses to cold or emotion. Raynaud's phenomenon has been classified as primary or secondary, depending on whether it occurs as an isolated condition or is associated mainly with a connective tissue disease. Dysregulation of autonomic and sensitive nerve fibers, functional and structural vessel changes, and intravascular alterations can be observed in the pathogenesis of RP. Nailfold videocapillaroscopy (NVC) is the best non-invasive and repetitive diagnostic technique for detecting morpho-functional changes in the microcirculation. Nailfold videocapillaroscopy is accepted in early diagnosis and monitoring of primary and secondary RP.
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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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Park JS, Park MC, Song JJ, Park YB, Lee SK, Lee SW. Application of the 2013 ACR/EULAR classification criteria for systemic sclerosis to patients with Raynaud's phenomenon. Arthritis Res Ther 2015; 17:77. [PMID: 25889905 PMCID: PMC4384278 DOI: 10.1186/s13075-015-0594-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2014] [Accepted: 03/11/2015] [Indexed: 11/10/2022] Open
Abstract
Introduction We investigated how many patients, who presented with Raynaud’s phenomenon (RP) and who had not been classified as systemic sclerosis (SSc), would be reclassified as SSc, if the 2013 American College of Rheumatology (ACR)/the European League Against Rheumatism (EULAR) classification criteria were used. We also analyzed the predictive values of the reclassification as SSc in those patients. Methods We consecutively enrolled 64 patients with RP and 60 patients with SSc. We applied the new classification criteria to them, reclassified them, and compared variables between those who were newly classified as SSc and those who were not or previously classified as SSc. Results Seventeen of 64 patients (26.5%), who presented with RP, but did not fulfill the 1980 ACR classification criteria, were newly classified as SSc by the 2013 ACR/EULAR classification criteria. The newly classified patients as SSc showed increased frequencies of sclerodactyly, digital tip ulcer, telangiectasia, abnormal nailfold capillaries and the presence of anti-centromere antibody, compared to those not and telangiectasia and anti-centromere antibody, compared to the previously classified patients. For the reclassification as SSc, the variables with independent predictive value were sclerodactyly (odds ratio (OR) 60.025), telangiectasia (OR 13.353) and the presence of anti-centromere antibody (OR 11.168). Conclusions Overall, 26.5% of the patients, who presented with RP, but who did not fulfill the 1980 ACR classification criteria, were newly classified as SSc according to the 2013 ACR/EULAR classification criteria. Sclerodactyly, telangiectasia, and the presence of anti-centromere antibody had independent predictive value for reclassifying patients with RP as SSc.
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Affiliation(s)
- Jin-Su Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Min-Chan Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Jason Jungsik Song
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Yong-Beom Park
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Soo-Kon Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
| | - Sang-Won Lee
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, South Korea.
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36
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Hughes M, Moore T, O’Leary N, Tracey A, Ennis H, Dinsdale G, Murray A, Roberts C, Herrick AL. A study comparing videocapillaroscopy and dermoscopy in the assessment of nailfold capillaries in patients with systemic sclerosis–spectrum disorders. Rheumatology (Oxford) 2015; 54:1435-42. [DOI: 10.1093/rheumatology/keu533] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Indexed: 11/13/2022] Open
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38
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Camargo CZ, Sekiyama JY, Arismendi MI, Kayser C. Microvascular abnormalities in patients with early systemic sclerosis: less severe morphological changes than in patients with definite disease. Scand J Rheumatol 2014; 44:48-55. [DOI: 10.3109/03009742.2014.926566] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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39
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Kuryliszyn-Moskal A, Kita J, Dakowicz A, Chwieśko-Minarowska S, Moskal D, Kosztyła-Hojna B, Jabłońska E, Klimiuk PA. The influence of Multiwave Locked System (MLS) laser therapy on clinical features, microcirculatory abnormalities and selected modulators of angiogenesis in patients with Raynaud's phenomenon. Clin Rheumatol 2014; 34:489-96. [PMID: 24820143 PMCID: PMC4348551 DOI: 10.1007/s10067-014-2637-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 03/20/2014] [Accepted: 04/15/2014] [Indexed: 11/25/2022]
Abstract
The aim of this study was to investigate the influence of the Multiwave Locked System (MLS) laser therapy on clinical features, microvascular changes in nailfold videocapillaroscopy (NVC) and circulating modulators releasing as a consequence of vascular endothelium injury such as vascular endothelial growth factor (VEGF) and angiopoietin 2 (Ang-2) in patients with primary and secondary Raynaud’s phenomenon. Seventy-eight RP patients and 30 healthy volunteers were recruited into the study. All patients with RP received MLS laser irradiation for 3 weeks. Clinical, NVC and laboratory investigations were performed before and after the MLS laser therapy. The serum concentration of VEGF and Ang-2 were determined by an enzyme-linked immunosorbent assay (ELISA). After 3 weeks of MLS laser therapy, the clinical improvement manifested by decreasing of the number of RP attacks, mean duration of Raynaud’s attack and pain intensity in RP patients was observed. After MLS laser therapy in 65 % of patients with primary and in 35 % with secondary RP, an increase in the loop number and/or a reduction in avascular areas in NVC were observed. In comparison with a control group, higher serum concentration of VEGF and Ang-2 in RP patients was demonstrated. After MLS laser therapy, a reduction of Ang-2 in both groups of RP patients was found. Our results suggest that NVC may reflect microvascular changes associated with clinical improvement after MLS laser therapy in patients with primary and secondary RP. Ang-2 serum levels may be a useful marker of microvascular abnormalities in RP patients treated with MLS laser therapy.
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Affiliation(s)
- Anna Kuryliszyn-Moskal
- Department of Rehabilitation, Medical University of Bialystok, M. Sklodowskiej-Curie 24A, 15-276, Bialystok, Poland,
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40
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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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41
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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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42
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Keck AD, Foocharoen C, Rosato E, Smith V, Allanore Y, Distler O, Stamenkovic B, Pereira Da Silva JA, Hadj Khelifa S, Denisov LN, Hachulla E, Garcia de la Pena Lefebvre P, Sibilia J, Airo P, Caramaschi P, Muller-Ladner U, Wiland P, Walker UA. Nailfold capillary abnormalities in erectile dysfunction of systemic sclerosis: a EUSTAR group analysis. Rheumatology (Oxford) 2013; 53:639-43. [DOI: 10.1093/rheumatology/ket392] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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43
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Ingegnoli F, Gualtierotti R. A systematic overview on the use and relevance of capillaroscopy in systemic sclerosis. Expert Rev Clin Immunol 2013; 9:1091-7. [PMID: 24147535 DOI: 10.1586/1744666x.2013.849198] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Capillaroscopy is a non-invasive and safe technique that allows the detection and quantification of the early microvascular abnormalities that characterize secondary Raynaud's phenomenon. The well-established role of capillaroscopy for the early diagnosis of systemic sclerosis, its inclusion in the classification criteria, combined with its predictive value for clinical complications of the disease and its potential for monitoring disease progression and treatment response, makes nailfold capillaroscopy an important assessment in clinical practice and research. Capillaroscopy provides a unique window into the microcirculation and its application in diseases in which a microvascular component is suspected; it also may provide new insights into their pathophysiology and natural history.
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Affiliation(s)
- Francesca Ingegnoli
- Department of Clinical Sciences & Community Health, Division of Rheumatology, University of Milan, Piazza Cardinal Ferrari, 1, 20122 Milan, Italy
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44
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Hofstee HMA, de Waal TT, Zweegman S, Voskuyl AE, Smulders YM, Schoordijk MCE, Janssen JJWM, Serné EH. Nailfold capillary abnormalities in sclerodermatous chronic GVHD. Bone Marrow Transplant 2013; 48:1574-7. [PMID: 23892332 DOI: 10.1038/bmt.2013.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 06/20/2013] [Accepted: 06/21/2013] [Indexed: 11/09/2022]
Abstract
Chronic GVHD (cGVHD) complicating allo-SCT commonly presents as sclerotic skin changes resembling systemic sclerosis (SSc), suggesting a common pathophysiological pathway. Damage to capillaries is considered an early event in the pathogenesis of SSc, and is associated with characteristic nailfold capillary abnormalities. Whether such nailfold capillary abnormalities occur in sclerodermatous cGVHD is unknown. Nailfold videocapillaroscopy (NVC) was used to evaluate capillary morphology, density and loop dimensions in 14 patients with sclerodermatous cGVHD, 14 sex- and age-matched SSc patients, and 14 healthy controls. It was shown that none of the cGVHD patients and controls, whereas all SSc patients showed severe capillary abnormalities. cGVHD patients and controls showed no differences in capillary density (9.05 vs 9.16 loops/mm, respectively, P=0.84), and capillary loop dimensions (total loop width 44.36 vs 45.56 μm, respectively, P=0.84). Compared with cGVHD patients, SSc patients had a reduced capillary density (9.05 vs 5.25 loops/mm, respectively, P<0.001), and an increase in capillary loop dimensions (total loop width 44.36 vs 99.97 μm, respectively, P=<0.001). In conclusion sclerodermatous cGVHD patients do not show the characteristic microvascular abnormalities seen in SSc, suggesting that capillary damage does not contribute to the pathophysiology of sclerodermatous cGVHD, and making NVC unsuitable for early identification.
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Affiliation(s)
- H M A Hofstee
- Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
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45
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Ingegnoli F, Gualtierotti R, Lubatti C, Bertolazzi C, Gutierrez M, Boracchi P, Fornili M, De Angelis R. Nailfold capillary patterns in healthy subjects: a real issue in capillaroscopy. Microvasc Res 2013; 90:90-5. [PMID: 23880032 DOI: 10.1016/j.mvr.2013.07.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 06/10/2013] [Accepted: 07/04/2013] [Indexed: 12/22/2022]
Abstract
Nailfold capillaroscopy has been extensively applied in a broad spectrum of pathologic conditions, but very few data have been published in healthy individuals. The aim of this study was to describe the nailfold capillary findings on a large series of healthy subjects using the video-capillaroscopy technique. Nailfold capillaries were studied based on their morphology, dimensions and density. Then, to evaluate jointly the association between different capillary findings in groups of subjects which were homogeneous for their characteristics, cluster analysis was performed. The results (median) of capillary measurements were as follows: loop length 207μm, external diameter 39μm, internal diameter 17μm, apical diameter 17μm, and intercapillary distance 143μm. Based on the cluster analysis three major "normal" morphologic capillaroscopic patterns were depicted: 1) the "normal" pattern mainly with 2 to 5 U-shaped loops/mm and ≤2 tortuous loops/mm; 2) the "perfect normal" pattern with ≥5 U-shaped loops/mm and 3) the "unusual normal" with at least 1 meandering or bushy loop, or at least 1 microhemorrhage, or with >4 crossed loops/mm. Regarding the loop measurements, the majority of subjects had a median of 7capillaries/mm with a median length of 198μm.
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Affiliation(s)
- Francesca Ingegnoli
- Division of Rheumatology, Istituto Gaetano Pini, Department of Clinical Sciences and Community Health, University of Milan, Italy
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46
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Ingegnoli F, Ardoino I, Boracchi P, Cutolo M. Nailfold capillaroscopy in systemic sclerosis: data from the EULAR scleroderma trials and research (EUSTAR) database. Microvasc Res 2013; 89:122-8. [PMID: 23792167 DOI: 10.1016/j.mvr.2013.06.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The aims of this study were to obtain cross-sectional data on capillaroscopy in an international multi-center cohort of Systemic Sclerosis (SSc) and to investigate the frequency of the capillaroscopic patterns and their disease-phenotype associations. METHODS Data collected between June 2004 and October 2011 in the EULAR Scleroderma Trials and Research (EUSTAR) registry were examined. Patients' profiles based on clinical and laboratory data were obtained by cluster analysis and the association between profiles and capillaroscopy was investigated by multinomial logistic regression. RESULTS 62 of the 110 EUSTAR centers entered data on capillaroscopy in the EUSTAR database. 376 of the 2754 patients (13.65%) were classified as scleroderma pattern absent, but non-specific capillary abnormalities were noted in 55.48% of the cases. Four major patients' profiles were identified characterized by a progressive severity for skin involvement, as well as an increased number of systemic manifestations. The "early" and "active" scleroderma patterns were generally observed in patients with mild/moderate skin involvement and a low number of disease manifestations, while the "late" scleroderma pattern was found more frequently in the more severe forms of the disease. CONCLUSION These data indicate the importance of capillaroscopy in SSc management and that capillaroscopic patterns are directly related to the extent of organ involvement.
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Affiliation(s)
- Francesca Ingegnoli
- Division of Rheumatology, Istituto Gaetano Pini, Department of Clinical Sciences & Community Health, University of Milano, Milano, Italy.
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Abstract
This review focuses on new findings and developments relevant to the clinician caring for patients with primary and secondary [especially systemic sclerosis (SSc)-related] Raynaud phenomenon (RP). In the last 18 months, several clinical trials and observational studies of RP and of SSc-related digital ulceration have been published, reflecting increased awareness of disease burden and increased interest by pharmaceutical companies: new insights into pathophysiology are driving new approaches to treatment. Key developments are the increased use of phosphodiesterase type V inhibitors in severe RP, and of bosentan (an endothelin-1 receptor antagonist) for prevention of recurrent SSc-related digital ulcers. Other treatments being researched include topical glyceryl trinitrate (applied locally to the digits), botulinum toxin (for severe digital ischemia/ulceration), and several other drugs including oral prostanoids. Increased availability and interest in nailfold capillaroscopy, by facilitating early diagnosis of SSc, should pave the way for studies of early intervention and vascular protection.
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Affiliation(s)
- Ariane L Herrick
- Centre for Musculoskeletal Research, Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, University of Manchester, Salford M6 8HD, UK.
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48
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Cutolo M, Smith V. State of the art on nailfold capillaroscopy: a reliable diagnostic tool and putative biomarker in rheumatology? Rheumatology (Oxford) 2013; 52:1933-40. [DOI: 10.1093/rheumatology/ket153] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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49
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KUWANA M. Roles of aberrant endothelial progenitor cells in pathogenesis of systemic sclerosis. ACTA ACUST UNITED AC 2013; 36:17-26. [DOI: 10.2177/jsci.36.17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Masataka KUWANA
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine
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50
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Iglesias Otero M, Portela Romero M, Bugarín González R, Ventura Victoria MA. [Methylphenidate and secondary Raynaud's phenomenon]. Semergen 2012; 39:330-4. [PMID: 24034762 DOI: 10.1016/j.semerg.2012.07.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 07/26/2012] [Accepted: 07/30/2012] [Indexed: 10/27/2022]
Abstract
Raynaud's phenomenon is a clinical disease characterized by episodic attacks of vasoconstriction of the arteries and arterioles of the extremities such as fingers and toes, sometimes the ears and nose, in response to cold or emotional stimuli. A classic attack is the pallor of the distal extremity, followed by cyanosis and redness, accompanied by paresthesia, usually as heat. When it occurs without apparent cause is called primary Raynaud's phenomenon. When associated with other disease, is called secondary Raynaud's phenomenon. The secondary table is associated with increased frequency of rheumatic diseases of collagen. They can also present certain drugs that cause vasoconstriction, such as ergotamine, beta-adrenergic antagonists, contraception and sympathomimetic drugs. Regarding the latter, we present a case of Raynaud's phenomenon secondary to methylphenidate in a 14 years.
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Affiliation(s)
- M Iglesias Otero
- Medicina de Familia y Comunitaria, Centro de Salud de Padrón, Gerencia de Gestión Integrada de Santiago de Compostela, Servicio Gallego de Salud, España
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