Raynaud's phenomenon

Raynaud's Phenomenon of the Nipple: Epidemiological, Clinical, Pathophysiological, and Therapeutic Characterization

Raynaud's phenomenon of the nipple is a possible cause of pain and breastfeeding cessation in lactating women. However, there are still few studies on the characterization of this manifestation. Thus, we aim to develop a systematic review of the literature carried out between January 1992 and January 2024 in PubMed, Scopus, Web of Science, Virtual Health Library (VHL), and Portal de Periódicos da CAPES. Of the 438 articles, 19 met the eligibility criteria. The findings were divided by heuristic questions into two groups: "Epidemiological, pathophysiological, and clinical characterization of Raynaud's Phenomenon of the nipple" and "Treatment of Raynaud's Phenomenon of the nipple". Raynaud's phenomenon of the nipple is commonly primary, being more prevalent in the postpartum period, in women with a mean age of 32 years. The main triggers appear to be stress and temperature change. Generally, it is associated with a change in color and pain during breastfeeding. A calcium channel blocker was the most used medication with or without non-pharmacological measures.

Identification of novel signal of Raynaud's phenomenon with Calcitonin Gene-Related Peptide(CGRP) antagonists using data mining algorithms and network pharmacological approaches

BACKGROUND

Calcitonin gene-related peptide (CGRP) antagonists are recently approved for the treatment of migraine.

AIM

The main aim of the current study was to find out the association of CGRP antagonists with RP using data mining algorithms integrated with network pharmacological approaches.

RESEARCH DESIGN AND METHODS

The individual case safety reports were extracted using OpenVigil2.1-MedDRA-V17 (2004Q1-2022Q3), the United States Adverse Event Reporting System (US FAERS). The data mining algorithms i.e. reporting odds ratio (ROR) with 95% confidence and proportionality reporting ratio (PRR) with associated chi-square value were calculated along with a minimum of three ICSRs to identify the signal. Further, the network was constructed using Cytoscape 3.7.2. Finally, molecular docking was performed using Glide, Schrodinger Inc.

RESULTS

The PRR ≥2 with a linked chi-square value ≥4, add up of co-occurrence ≥3, and a lower limit of 95% confidence interval of ROR exceeding 2 indicates a positive signal of RP. Further, the network pharmacological and molecular docking results have shown the involvement of insulin-like growth factor 1-receptor (IGF1R) pathways.

CONCLUSION

The RP is recognized as a novel signal with all CGRP antagonists.

Near-wall hemodynamic parameters of finger arteries altered by hand-transmitted vibration

BACKGROUND

Sustained exposure to high-level hand-transmitted vibrations may result in angioneurotic disorders, which partly originate from vibration-altered hemodynamics in the finger arteries when repeating these disturbances throughout working life. Hence, the aim of this study is to assess the most relevant hemodynamic descriptors in the digital arteries, determine the relationship between the latter and vibration features, and gain better understanding of the physiological mechanisms involved.

METHODS

An experimental setup, mainly comprised of an ultra-high frequency ultrasound scanner and a vibration shaker, was used to image the digital proper volar arteries of the forefinger. Raw ultrasound data were post-processed by custom-made numerical routines to supply a pulsatile fluid mechanics model for computing the hemodynamic descriptors. Twenty-four healthy volunteers participated in the measurement campaign. Classical statistical methods were then applied to the dataset and also the wavelet transform for calculating the signal power in the frequency bands matching cardiac, respiratory, myogenic and neurogenic activities.

RESULTS

The artery diameter, the wall shear stress - WSS - and the WSS temporal gradient - WSSTG - were found to be the most relevant descriptors. Vibration-induced WSS was divided by three compared to its basal value whatever the vibration frequency and it was proportional to log2 of the acceleration level. Marked increases in WSSTG when stopping vibration might also lead to adverse health effects. Vibration caused a drop in WSS power for the frequency band associated with the neurogenic activity of the sympathetic nervous system.

CONCLUSION

This study may pave the way for a new framework to prevent vibration-induced vascular risk.

A Multiscale Approach for Predicting Certain Effects of Hand-Transmitted Vibration on Finger Arteries

Prolonged exposure to strong hand-arm vibrations can lead to vascular disorders such as Vibration White Finger (VWF). We modeled the onset of this peripheral vascular disease in two steps. The first consists in assessing the reduction in shearing forces exerted by the blood on the walls of the arteries (Wall Shear Stress—WSS) during exposure to vibrations. An acute but repeated reduction in WSS can lead to arterial stenosis characteristic of VWF. The second step is devoted to using a numerical mechano-biological model to predict this stenosis as a function of WSS. WSS is reduced by a factor of 3 during exposure to vibration of 40 m·s−2. This reduction is independent of the frequency of excitation between 31 Hz and 400 Hz. WSS decreases logarithmically when the amplitude of the vibration increases. The mechano-biological model simulated arterial stenosis of 30% for an employee exposed for 4 h a day for 10 years. This model also highlighted the chronic accumulation of matrix metalloproteinase 2. By considering daily exposure and the vibratory level, we can calculate the degree of stenosis, thus that of the disease for chronic exposure to vibrations.

Raynaud's Phenomenon: Reviewing the Pathophysiology and Management Strategies

Raynaud's phenomenon (RP) is a multifactorial vasospastic disorder characterized by a transient, recurrent, and reversible constriction of peripheral blood vessels. RP is documented to affect up to 5% of the general population, but variation in its prevalence is commonly recognized owing to many factors, including varied definitions, gender, genetics, hormones, and region. Furthermore, RP may be idiopathic or be a clinical manifestation of an underlying illness. Patients with RP classically describe a triphasic discoloration of the affected area, beginning with pallor, followed by cyanosis, and finally ending with erythema. This change in color spares the thumb and is often associated with pain. Each attack may persist from several minutes to hours. Moreover, the transient cessation of blood flow in RP is postulated to be mediated by neural and vascular mechanisms. Both structural and functional alterations observed in the blood vessels contribute to the vascular abnormalities documented in RP. However, functional impairment serves as a primary contributor to the pathophysiology of primary Raynaud's. Substances like endothelin-1, angiotensin, and angiopoietin-2 play a significant role in the vessel-mediated pathophysiology of RP. The role of nitric oxide in the development of this phenomenon is still complex. Neural abnormalities resulting in RP are recognized as either being concerned with central mechanisms or peripheral mechanisms. CNS involvement in RP may be suggested by the fact that emotional distress and low temperature serve as major triggers for an attack, but recent observations have highlighted the importance of locally produced factors in this regard as well. Impaired vasodilation, increased vasoconstriction, and several intravascular abnormalities have been documented as potential contributors to the development of this disorder. RP has also been observed to occur as a side effect of various drugs. Recent advances in understanding the mechanism of RP have yielded better pharmacological therapies. However, general lifestyle modifications along with other nonpharmacological interventions remain first-line in the management of these patients. Calcium channel blockers, alpha-1 adrenoreceptor antagonists, angiotensin-converting enzyme inhibitors, nitric oxide, prostaglandin analogs, and phosphodiesterase inhibitors are some of the common classes of drugs that have been found to be therapeutically significant in the management of RP. Additionally, anxiety management, measures to avoid colder temperatures, and smoking cessation, along with other simple modifications, have proven to be effective non-drug strategies in patients experiencing milder symptoms.

Assessing mechanical vibration-altered wall shear stress in digital arteries

The aim of this study is to implement and validate a method for assessing acute vibration-altered Wall Shear Stress (WSS) in the proper volar digital artery of the non-exposed left forefinger when subjecting the right hand to mechanical vibration. These changes of WSS may be involved in Vibration White Finger. Hence, an experimental device was set-up to link a vibration shaker and an ultra-high frequency ultrasound scanner. The Womersley-based WSS was computed by picking up the maximum velocity from pulse Wave Doppler measurements and extracting the artery diameter from B-mode images through an in-house image processing technique. The parameters of the former method were optimised on numerical ultrasound phantoms of cylindrical and lifelike arteries. These phantoms were computed with the FIELD II and FOCUS platforms which mimicked our true ultrasound device. The Womersley-based WSS were compared to full Fluid Structure Interaction (FSI) and rigid wall models built from resonance magnetic images of a volunteer-specific forefinger artery. Our FSI model took into account the artery's surrounding tissues. The diameter computing procedure led to a bias of 4%. The Womersley-based WSS resulted in misestimating the FSI model by roughly 10% to 20%. No difference was found between the rigid wall computational model and FSI simulations. Regarding the WSS measured on a group of 20 volunteers, the group-averaged basal value was 3 Pa, while the vibration-altered WSS was reduced to 1 Pa, possibly triggering intimal hyperplasia mechanisms and leading to the arterial stenoses encountered in patients suffering from vibration-induced Raynaud's syndrome.

A three-dimensional visco-hyperelastic FE model for simulating the mechanical dynamic response of preloaded phalanges

This study lays the groundwork for a multi-scale strategy that will lead to a better understanding and prediction of the effects of vibration on the digital arterial network. This is accomplished by modelling the mechanical and biological factors that could disturb the basal vasoconstriction balance in the fingertip. The first stage of this novel approach involved building and validating an original dissipative constitutive law for the fingertip soft tissue for the purpose of finite element modelling of the mechanical response of preloaded phalanges in vibration. This visco-hyperelastic constitutive law was established by means of a two-stage procedure for combining a classical pure static nonlinear law with an original dissipative model. First, the parameters of an Ogden-Hill pure static nonlinear constitutive law were identified using a constrained optimisation algorithm. Second, an original viscous dissipation model was proposed in the spectral domain. This model is based on the linearization of the nonlinear quasi-linear viscoelasticity law and the use of a viscoelastic relaxation modulus, expressed as a continuous distribution of relaxation spectra suitable for living tissues. The experimental data used to fit this model were the static and dynamic stiffnesses of preloaded fingertips acquired from a group of 20 subjects. The relative errors between the measured and simulated stiffnesses were less than 5% in the static procedure and approximately 8% using dynamic analysis. The computed mechanical pressure and maximal tangential stress within the fingertip were high in the soft tissues close to the vibration excitation and also in the bones and interphalangeal cartilages far from the vibration source. Mechanical power was only dissipated significantly in the immediate vicinity of the contact area between the probe and the finger. The main contribution of this study was to implement and identify the parameters of a new spectral dissipative law for fingertip soft tissues. This work may apply in occupational health for modifying the vibration dose assessment or for the follow-up and screening of connective tissue diseases.

Raynaud's phenomenon in Northern Sweden: a population-based nested case-control study

The aim of this study was to determine the association between individual and external exposure factors, and the reporting of Raynaud's phenomenon, with or without concomitant cold sensitivity. In a population-based nested case-control study, cases with Raynaud's phenomenon (N = 578), and matched controls (N = 1156), were asked to respond to a questionnaire focusing on different risk factors. Univariate and multiple conditional logistic regression were performed. Analyses were stratified according to whether the cases reported cold sensitivity or not. In total, 1400 out of 1734 study subjects answered the questionnaire (response rate 80.7%). In the final multiple model, the factor with the strongest association to Raynaud's phenomenon, with and without cold sensitivity, was previous frostbite affecting the hands (OR 12.44; 95% CI 5.84-26.52 and OR 4.01; 95% CI 1.78-9.01, respectively). Upper extremity nerve injury was associated to reporting Raynaud's phenomenon and cold sensitivity (OR 2.23; 95% CI 1.29-3.85), but not Raynaud's phenomenon alone. Reporting any exposure to hand-arm vibration or cumulative cold exposure was significant in univariate analyses for cases with both Raynaud's phenomenon and cold sensitivity, but not in the multiple model. Raynaud's phenomenon is strongly associated to previous cold injury, with a larger effect size among those who also report cold sensitivity. The fact that only upper extremity nerve injury differed significantly between case groups in our multiple model offers additional support to the neural basis for cold sensitivity.

[Etiological profile of secondary Raynaud's phenomenon in an internal medicine department. About 121 patients]

INTRODUCTION

Raynaud's phenomenon is a reversible episodic vasospastic disorder triggered by cold or emotion. Two types of Raynaud's phenomenon were distinguished: Raynaud's disease and secondary Raynaud's phenomenon. The purpose of this study was to determine the etiologic profile of secondary Raynaud's phenomenon in an internal medicine department.

METHODS

A descriptive retrospective study including patients with secondary Raynaud's phenomenon followed in a tertiary internal medicine department between 2000 and 2013.

RESULTS

We included 121 patients. The sex ratio M/F was 0.16. The mean age at the onset of Raynaud's phenomenon was 41.7 years. The average age of patients at the time of the etiologic diagnosis was 47.3 years. The mean delay between Raynaud's phenomenon onset and the first consultation was 41.33 months. Raynaud's phenomenon involved hands in all cases and feet in 16.10% of cases with a typical form in most cases (41.4%). Complications (digital ulcers and scars) were noted in 32.23% of cases. Nail fold capillaroscopy showed scleroderma pattern in 49.52% of patients. Antinuclear antibodies were positive in 88.49% of patients. Interstitial lung disease was reported in 54.04% of cases. Connective tissue diseases were diagnosed in 86.77% of patients. Other secondary Raynaud's phenomenon causes were vasculitis (6.61%), atherosclerosis (1.65%) and medical or professional causes (1.65%). The most frequent one cause systemic sclerosis (n=61, 98%) followed by systemic lupus erythematosus (11.57%) and primary Sjögren syndrome (6.61%).

CONCLUSION

In our study, the Raynaud's phenomenon was most frequently secondary to connective tissue diseases. This may be a selection bias because our department is a third-line unit where patients are often referred for systemic disease suspicion.

Nailfold Capillaroscopy in Rheumatic Diseases: Which Parameters Should Be Evaluated?

Video nailfold capillaroscopy (NFC), considered as an extension of the widefield technique, allows a more accurate measuring and storing of capillary data and a better defining, analyzing, and quantifying of capillary abnormalities. Capillaroscopic study is often performed on the patients suspected of having microcirculation problems such as Raynaud's phenomenon as the main indication for nailfold capillaroscopy. Capillaroscopic findings based on microcirculation studies can provide useful information in the fields of pathophysiology, differential diagnosis, and monitoring therapy. Nailfold capillaroscopy provides a vital assessment in clinical practices and research; for example, its reputation in the early diagnosis of systemic sclerosis is well established and it is also used as a classification criterion in this regard. This review focuses on the manner of performing video nailfold capillaroscopy and on a common approach for measuring capillary dimensions in fingers and toes.

Prevalence of Raynaud phenomenon and nailfold capillaroscopic abnormalities in Fabry disease: a cross-sectional study

Fabry disease (FD) is a lysosomal disorder leading to progressive systemic involvement, including microvascular damage that leads to neurological and cardiovascular disorders. We hypothesize that the latter could be documented at an early stage by performing a microcirculation study with nailfold capillaroscopy and evaluation of Raynaud phenomenon.The objective was to measure the prevalence of Raynaud phenomenon and nailfold capillaroscopic abnormalities in FD.This cross-sectional study included a standardized questionnaire and a nailfold capillaroscopy that assessed previously reported patterns in FD (dystrophic and giant capillaries, avascular fields, irregular architecture, dilatation and density of capillaries, hemorrhage), and was conducted on 32 Fabry patients and 39 controls. Capillaroscopic photographs were reviewed by 2 independent blinded investigators.Twelve Fabry patients (38%) suffered from Raynaud phenomenon, 5 were males (ie, 50% of male Fabry patients), compared with 2 controls (13%) (P < 0.001), of whom none were males (P < 0.001). Raynaud phenomenon was concomitant or before the occurrence of pain in the extremities in 42% of Fabry patients.More ramified capillaries were significantly observed in Fabry patients (12/32, 38%) than in controls (5/39, 13%, P = 0.016).Secondary Raynaud phenomenon should lead to screening for FD, especially in men. By extension, in high-risk populations for FD, the presence of Raynaud phenomenon and ramified capillaries should be assessed.

Autonomic imbalance assessed by time-domain heart rate variability indices in primary Raynaud's phenomenon

Objectives

The pathogenesis of primary Raynaud’s phenomenon (RP) seems to be multifactorial and autonomic nervous dysfunction is one factor. Heart rate variability (HRV) is one of the most reliable parameters to demonstrate autonomic dysfunction. Our aim was to evaluate the time-domain HRV in patients with primary RP.

Methods

A time analysis of HRV was performed in patients with primary RP and age- and gender-matched healthy controls. The results of the study and control group were compared.

Results

Thirty patients with primary RP [all men, median (IQR) age: 21 (2) years) and 31 age- and gender-matched healthy controls (median (IQR): 21(3) years) were enrolled in the study. We found a statistically significant difference between the primary RP patients and control subjects in terms of time-domain HRV parameters (p < 0.05 for all).

Conclusion

Our study showed the presence of autonomic nervous dysfunction of heart function in patients with primary RP.

The association between vibration and vascular injury in rheumatic diseases: a review of the literature

Vascular manifestations can be seen early in the pathogenesis of inflammatory rheumatic diseases. Animal experiments, laboratory and clinical findings indicated that acute or long-term vibration exposure can induce vascular abnormalities. Recent years, in addition to Raynaud's phenomenon (RP), vibration as a risk factor for other rheumatic diseases has also received corresponding considered. This review is concentrated upon the role of vibration in the disease of systemic sclerosis (SSc). In this review, we are going to discuss the main mechanisms which are thought to be important in pathophysiology of vascular injury under the three broad headings of "vascular", "neural" and "intravascular". Aspects on the vibration and vascular inflammation are briefly discussed. And the epidemiological studies related to vibration studies in SSc and other rheumatic diseases are taken into account.

Digital ischemia associated with cancer: results from a cohort study

Digital ischemia associated with cancer (DIAC) is increasing in frequency and recent reports have suggested the concept of paraneoplastic manifestation. The aims of this study were to characterize the clinical presentation of DIAC and identify clinical features that could lead physicians to diagnose underlying cancer.From January 2004 to December 2011, 100 patients were hospitalized in the Department of Internal Medicine at Rouen University Hospital, France for a first episode of DI. Fifteen (15%) exhibited symptomatic or asymptomatic cancer during the year preceding or following vascular episode and constituted the DIAC group. Other patients without cancer made up the digital ischemia (DI) group.Median time between diagnosis of cancer and episode of digital necrosis was 2 months [0.25-9]. Diagnosis of DI and concomitant cancer was made in 7 of the 15 patients, while DI preceded the malignant disorder in 2 cases and followed it in 6 cases. Histological types were adenocarcinoma for 7 (46.7%), squamous cell carcinoma for 4 (26.7%), and lymphoid neoplasia for 3 patients (20%). Six patients (40%) had extensive cancer. Three patients were lost to follow-up and 5 patients died <1 year after diagnosis of cancer. Cancer treatment improved vascular symptoms in 6 patients (40%). Patients with DIAC, compared to patients with DI, were significantly older (56 years [33-79] vs 46 [17-83] P =0.005), and had significantly lower hemoglobin and hematocrit levels (12.7 g/dl vs 13.9 g/dl; P =0.003 and 38% vs 42%; P =0.003, respectively). Patients with DIAC had a higher platelet rate (420 vs 300 G/L P =0.01), and 6 patients with DIAC (40%) had thrombocytosis. There was no difference between groups either in C-reactive protein level (12 mg/L vs 5 mg/L; P =0.08) or regarding cardiovascular risk factors, presence of autoimmunity, or monoclonal protein.This retrospective study suggests that DIAC may be more prevalent than previously reported. Outcomes of the 2 diseases were not strictly chronologically parallel. However, in the majority of cases, treatment of the tumor resolved vascular involvement. Our findings suggest that age >50 years and thrombocytosis should alert physicians to consider a possible occult malignancy when digital necrosis occurs.

Effect of Korean red ginseng on cold hypersensitivity in the hands and feet: study protocol for a randomized controlled trial

Background

Cold hypersensitivity in the hands and feet (CHHF) is one of the most common complaints among Asians, especially in women. Korean red ginseng (KRG), which is a steamed form of Panax ginseng, has vasodilating action in the peripheral vessels and increases blood flow under cold stress. However, few studies have evaluated the effect of KRG on cold hypersensitivity.

Methods/Design

This trial is a randomized, double-blind, placebo-controlled trial in 80 CHHF patients. The trial will be implemented at Kyung Hee University Hospital at Gangdong in Seoul, Korea. The participants will take KRG or a placebo for eight weeks, after which they will be followed-up for four weeks. During the administration period, six capsules of 500 mg KRG or placebo will be provided twice a day. The primary outcome is change of skin temperature in the hands between baseline and after treatment. The secondary outcomes include the visual analogue scale scores of cold hypersensitivity in the hands, change of skin temperature and the VAS scores of cold hypersensitivity in the feet, the recovery rate of the skin temperature by the cold stress test of the hands, the distal-dorsal difference of the hands, power variables of heart rate variability, and the 36-item short form health survey.

Discussion

This study is the first trial to evaluate the efficacy of KRG on CHHF by using infrared thermography. Our study will provide basic evidence regarding CHHF.

Trial registration

CliniacalTrials.gov NCT01664156

Chemometrics-Assisted UV Spectrophotometric and RP-HPLC Methods for the Simultaneous Determination of Tolperisone Hydrochloride and Diclofenac Sodium in their Combined Pharmaceutical Formulation

Chemometrics-assisted UV spectrophotometric and RP-HPLC methods are presented for the simultaneous determination of tolperisone hydrochloride (TOL) and diclofenac sodium (DIC) from their combined pharmaceutical dosage form. Chemometric methods are based on principal component regression and partial least-square regression models. Two sets of standard mixtures, calibration sets, and validation sets were prepared. Both models were optimized to quantify each drug in the mixture using the information included in the UV absorption spectra of the appropriate solution in the range 241-290 nm with the intervals λ = 1 nm at 50 wavelengths. The optimized models were successfully applied to the simultaneous determination of these drugs in synthetic mixture and pharmaceutical formulation. In addition, an HPLC method was developed using a reversed-phase C18 column at ambient temperature with a mobile phase consisting of methanol:acetonitrile:water (60:30:10 v/v/v), pH-adjusted to 3.0, with UV detection at 275 nm. The methods were validated in terms of linearity, accuracy, precision, sensitivity, specificity, and robustness in the range of 3-30 μg/mL for TOL and 1-10 μg/mL for DIC. The robustness of the HPLC method was tested using an experimental design approach. The developed HPLC method, and the PCR and PLS models were used to determine the amount of TOL and DIC in tablets. The data obtained from the PCR and PLS models were not significantly different from those obtained from the HPLC method at 95% confidence limit.

Development and Validation of a Precise, Single HPLC Method for the Determination of Tolperisone Impurities in API and Pharmaceutical Dosage Forms

A novel, sensitive, stability-indicating HPLC method has been developed for the quantitative estimation of Tolperisone-related impurities in both bulk drugs and pharmaceutical dosage forms. Effective chromatographic separation was achieved on a C18 stationary phase with a simple mobile phase combination delivered in a simple gradient programme, and quantitation was by ultraviolet detection at 254 nm. The mobile phase consisted of a buffer and acetonitrile delivered at a flow rate 1.0 ml/min. The buffer consisted of 0.01 M potassium dihydrogen phosphate with the pH adjusted to 8.0 by using diethylamine. In the developed HPLC method, the resolution between Tolperisone and its four potential impurities was found to be greater than 2.0. Regression analysis showed an R value (correlation coefficient) of greater than 0.999 for the Tolperisone impurities. This method was capable of detecting all four impurities of Tolperisone at a level of 0.19 μg/mL with respect to the test concentration of 1000 μg/mL for a 10 µl injection volume. The tablets were subjected to the stress conditions of hydrolysis, oxidation, photolysis, and thermal degradation. Considerable degradation was found to occur in base hydrolysis, water hydrolysis, and oxidation. The stress samples were assayed against a qualified reference standard and the mass balance was found to be close to 100%. The established method was validated and found to be linear, accurate, precise, specific, robust, and rugged.

Sociodemographic and disease correlates of body image distress among patients with systemic sclerosis

Background

Body image concerns are infrequently studied in systemic sclerosis (SSc), even though significant visible disfigurement is common. The objective of this study was to identify sociodemographic and disease-related correlates of dissatisfaction with appearance and social discomfort among people with SSc.

Methods

SSc patients came from the 15-center Canadian Scleroderma Research Group Registry. Sociodemographic information was based on patient self-report. Disease characteristics were obtained via physician examinations. The Brief-SWAP was used to assess dissatisfaction with appearance and social discomfort. Structural equation models were conducted with MPlus to determine the relationship of dissatisfaction with appearance and social discomfort with age, sex, education, marital status, race/ethnicity, disease duration, skin involvement, telangiectasias, skin pigmentation changes, and hand contractures.

Results

A total of 489 SSc patients (432 female, 57 male) were included. Extent of skin involvement was significantly associated with both dissatisfaction with appearance and social discomfort (standardized regression coefficients = 0.02, p = 0.001; 0.02, p = 0.020, respectively), as was skin involvement in the face (0.18, p = 0.016; 0.23, p = 0.006, respectively). Greater social discomfort was robustly associated with younger age (−0.017, p<0.001) and upper-body telangiectasias (0.32, p = 0.021). Dissatisfaction with appearance was associated with hand contractures (0.07, p = 0.036).

Conclusion

This study found that dissatisfaction with appearance and social discomfort were associated with numerous disfiguring characteristics of SSc, in addition to age. These results underline that there are multiple factors contributing to body image distress in SSc, as well as the need to attend to both disease and social contexts in understanding the impact of disfigurement among patients.

The effect of metoprolol alone and combined metoprolol-felodipin on the digital microcirculation of patients with primary Raynaud's syndrome

OBJECTIVES

Calcium channel inhibitors have beneficial impact on microcirculation, but beta-blocker effect is controversial. Clinicians still do not agree on beta-blocker combination with other treatments in the management of impaired microcirculation. The aim of the present study was to describe the effects of beta-blocker metoprolol monotherapy and combined with calcium channel inhibitor felodipin on digital microcirculation in primary Raynaud's syndrome.

METHODS

We enrolled in this study 46 patients suffering from both hypertension and primary Raynaud's syndrome. Fifteen patients were treated with beta-blocker monotherapy (metoprolol), 13 received combined beta-blocker and calcium channel blocker therapy (felodipin and metoprolol), while 18 patients without any medications served as controls. Measurement of digital microcirculation was carried out with laser Doppler scanner.

RESULTS AND CONCLUSIONS

Our investigation concludes that the concurrent administration of beta-blockers with calcium channel inhibitors positively reduces symptoms in patients suffering from Raynaud's syndrome.

Asymptomatic lower extremity acrocyanosis: report of two cases and review of the literature

Vasospastic disorders affecting the lower extremities are unusual entities. Two cases of asymptomatic foot discoloration with lower extremity dependency are presented. In the first case, an elderly gentleman was admitted to the hospital with a contralateral foot infection. His physical exam revealed pulse examination within normal limits and his blood work failed to identify any known causes for vasospasm. His foot infection was successfully treated with sensitivity-directed antibiotics. The second case is that of a young man with a history of quadriplegia secondary to a remote diving accident, who presented with a three-month history of foot discoloration while sitting up in his wheelchair, which resolved with recumbent leg positioning. A review of the possible diagnoses for these patients' presentation is presented herein.

Diagnostic algorithm for Raynaud’s phenomenon and vascular skin lesions in systemic lupus erythematosus

Skin discolorations and skin lesions due to vascular pathologies are common clinical features in systemic lupus erythematosus. A variety of clinical manifestations such as Raynaud’s phenomenon, acrocyanosis, livedo patterns, erythematous or violaceous macules and papules or necrosis are triggered by heterogeneous pathophysiological mechanisms such as vasospasm, vasculitis or thromboembolism. A standardized macro- and microvascular assessment is necessary to establish the correct diagnosis. We describe and illustrate common clinical features of vascular skin manifestations in systemic lupus erythematosus and present a diagnostic algorithm. Lupus (2010) 19, 1087—1095.

Current drug therapy for scleroderma and secondary Raynaud's phenomenon: evidence-based review

(1) Scleroderma and secondary Raynaud's phenomenon are frequently associated with increased morbidity for which no specific standardised treatment guidelines exist. (2) Current therapies for scleroderma target the immune system, with the goal of reducing inflammation and secondary tissue injury and fibrosis. Therapy targeting underlying vascular disease is designed to improve the symptoms of Raynaud's phenomenon and to reduce ischemic injury to involved organs. (3) Few controlled trials of therapy used for scleroderma are completed, and current treatments are largely based on organ-specific therapy and uncontrolled case series suggesting disease modification. (4) Recent randomised, controlled trials in scleroderma demonstrate promising results in the treatment of interstitial lung disease with cyclophosphamide, and vascular disease of the lungs and digits with endothelin receptor antagonists, the phosphodiesterase inhibitor sildenafil and prostacyclins, while trials with methotrexate show only modest benefit in controlling scleroderma-associated skin disease. (5) Prostacyclins are a therapeutic option in patients with secondary Raynaud's phenomenon. Modest benefits have also been shown with alpha1-antagonists and calcium channel blockers, while the effect of ACE inhibitors has been variable. Some data suggest some benefits to the use of the phosphodiesterase inhibitor sildenafil, the serotonin uptake inhibitor fluoxetine and the angiotensin receptor inhibitor losartan.

The endothelin system as a therapeutic target in cardiovascular disease: great expectations or bleak house?

There is considerable evidence that the potent vasoconstrictor endothelin-1 (ET-1) contributes to the pathogenesis of a variety of cardiovascular diseases. As such, pharmacological manipulation of the ET system might represent a promising therapeutic goal. Many clinical trials have assessed the potential of ET receptor antagonists in cardiovascular disease, the most positive of which have resulted in the licensing of the mixed ET receptor antagonist bosentan, and the selective ET(A) receptor antagonists, sitaxsentan and ambrisentan, for the treatment of pulmonary arterial hypertension (PAH). In contrast, despite encouraging data from in vitro and animal studies, outcomes in human heart failure have been disappointing, perhaps illustrating the risk of extrapolating preclinical work to man. Many further potential applications of these compounds, including resistant hypertension, chronic kidney disease, connective tissue disease and sub-arachnoid haemorrhage are currently being investigated in the clinic. Furthermore, experience from previous studies should enable improved trial design and scope remains for development of improved compounds and alternative therapeutic strategies. Although ET-converting enzyme inhibitors may represent one such alternative, there have been relatively few suitable compounds developed, and consequently, clinical experience with these agents remains extremely limited. Recent advances, together with an increased understanding of the biology of the ET system provided by improved experimental tools (including cell-specific transgenic deletion of ET receptors), should allow further targeting of clinical trials to diseases in which ET is involved and allow the therapeutic potential for targeting the ET system in cardiovascular disease to be fully realized.