1
|
Opriș-Belinski D, Cobilinschi CO, Caraiola S, Ungureanu R, Cotae AM, Grințescu IM, Cobilinschi C, Andrei AC, Țincu R, Ene R, Mirea L. Trace Element Deficiency in Systemic Sclerosis-Too Much Effort for Some Traces? Nutrients 2024; 16:2053. [PMID: 38999801 PMCID: PMC11242991 DOI: 10.3390/nu16132053] [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: 04/21/2024] [Revised: 06/06/2024] [Accepted: 06/25/2024] [Indexed: 07/14/2024] Open
Abstract
Trace elements are essential for several physiological processes. To date, various data have suggested that inadequate levels of trace elements may be involved in the pathogenesis of different chronic diseases, including immune-mediated ones, or may develop during their course. Systemic sclerosis (SSc) is a complex autoimmune multisystemic disease, primarily characterized by microvascular dysregulation, the widespread activation of the immune system and tissue fibrosis. According to the latest reports regarding the pathogenesis of SSc, the main pathophysiological processes-inflammation, vasculopathy and fibrosis-may include various trace element derangements. The present literature review aims to update the available data regarding iron, zinc, copper and selenium status in SSc as well as to underline the possible implications of these trace elements in the complexity of the pathogenic process of the disease. We observe that the status of trace elements in SSc plays a crucial role in numerous pathogenic processes, emphasizing the necessity for proper monitoring and supplementation. The reported data are heterogenous and scarce, and future studies are needed in order to draw clearer conclusions about their complete spectrum.
Collapse
Affiliation(s)
- Daniela Opriș-Belinski
- Department of Internal Medicine Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Rheumatology and Internal Medicine, Sfânta Maria Clinical Hospital, 011172 Bucharest, Romania
| | - Claudia Oana Cobilinschi
- Department of Internal Medicine Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Rheumatology and Internal Medicine, Sfânta Maria Clinical Hospital, 011172 Bucharest, Romania
| | - Simona Caraiola
- Department of Internal Medicine Rheumatology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Rheumatology and Internal Medicine, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Raluca Ungureanu
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
| | - Ana-Maria Cotae
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
| | - Ioana Marina Grințescu
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
| | - Cristian Cobilinschi
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
| | - Andrei Cosmin Andrei
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
| | - Radu Țincu
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
- Department of Clinical Toxicology, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Răzvan Ene
- Department of Orthopedics, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Liliana Mirea
- Department of Anesthesiology and Intensive Care II, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Anesthesiology and Intensive Care, Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania
| |
Collapse
|
2
|
Alkhowaiter S, Al Rasheed MM, Alammar N, Alotaibi A, Altuwaijri M, Alshankiti S, Omair MA, Alsahafi M. Safety of prolonged use of metoclopramide and domperidone as treatment for chronic gastrointestinal dysmotility disorders in patients with systemic sclerosis. Saudi Pharm J 2024; 32:102039. [PMID: 38558884 PMCID: PMC10981152 DOI: 10.1016/j.jsps.2024.102039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
Background Metoclopramide and domperidone are prokinetic agents commonly used to treat gastrointestinal dysmotility disorders. This study aimed to evaluate the safety and associated side effects of prolonged-use metoclopramide and domperidone as treatment for chronic gastrointestinal dysmotility disorders in patients with systemic sclerosis (SSc). Methods A quantitative observational survey was conducted by interview questionnaire in rheumatology outpatients at a tertiary teaching hospital in Riyadh, Saudi Arabia. The study included all patients aged 25-80 years diagnosed with SSc. All patients were on metoclopramide or domperidone for the treatment of chronic gastrointestinal dysmotility symptoms over at least 12 weeks. Results Eighteen eligible patients were included. Most study participants were diagnosed with SSc complicated by interstitial lung disease (n = 13; 72.2 %). The most frequently reported side effect that occurred while taking prokinetic drugs was shortness of breath (n = 12; 66.7 %). None of the participants reported experiencing depression, galactorrhea, or syncope. CNS side effects were reported in 5.6 %. There were no differences in side effects based on the type and dosage of prokinetic drug used. Conclusions Use of metoclopramide and domperidone for the treatment of chronic gastrointestinal dysmotility in SSc patients for 12 weeks or longer was not associated with any troublesome side effects. Further studies with more participants are needed to confirm our findings.
Collapse
Affiliation(s)
- Saad Alkhowaiter
- College of Medicine, Department of Medicine, Division of Gastroenterology, King Saud University, Riyadh, Saudi Arabia
| | - Maha M. Al Rasheed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Nuha Alammar
- College of Medicine, Department of Medicine, Division of Gastroenterology, King Saud University, Riyadh, Saudi Arabia
| | - Ammar Alotaibi
- College of Medicine, Department of Medicine, Division of Gastroenterology, King Saud University, Riyadh, Saudi Arabia
| | - Mansour Altuwaijri
- College of Medicine, Department of Medicine, Division of Gastroenterology, King Saud University, Riyadh, Saudi Arabia
| | - Suliman Alshankiti
- College of Medicine, Department of Medicine, Division of Gastroenterology, King Saud University, Riyadh, Saudi Arabia
| | | | - Majid Alsahafi
- Division of Gastroenterology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| |
Collapse
|
3
|
Pătrîntașu DE, Sárközi HK, Lupușor E, Vlangăr IE, Rotariu GM, Rența IA, Nan AN, Budin CE. A Multidisciplinary Approach as a Goal for the Management of Complications in Systemic Scleroderma: A Literature Review and Case Scenario. Diagnostics (Basel) 2023; 13:3332. [PMID: 37958228 PMCID: PMC10648338 DOI: 10.3390/diagnostics13213332] [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: 10/12/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/15/2023] Open
Abstract
Systemic sclerosis (also known as scleroderma) is a chronic fibrosing autoimmune disease with both skin and multisystem organ involvement. Scleroderma has the highest mortality among all rheumatic diseases. The pathophysiology mechanism of systemic sclerosis is a progressive self-amplifying process, which involves widespread microvascular damage, followed by a dysregulation of innate and adaptive immunity and inflammation and diffuse fibrosis of the skin and visceral organs. Fibrosis of internal organs is a hint for systemic sclerosis, moreover associated with interstitial lung disease (SSc-ILD) is a complex process. In order to correlate scientific data from the literature with clinical experience, we present the case of a 56-year-old woman who was diagnosed with systemic sclerosis 16 years ago. The association of numerous comorbidities characterized by a considerable level of seriousness characterizes this case: the highly extensive systemic damage, the cardiovascular impact of the illness, and the existence of severe pulmonary arterial hypertension. The systemic and clinical manifestations, respiratory functional tests, radiological features, and specific therapy are discussed.
Collapse
Affiliation(s)
- Dariana-Elena Pătrîntașu
- Pneumology Department, Mures Clinical County Hospital, 540142 Targu Mures, Romania; (D.-E.P.); (H.K.S.); (E.L.); (I.-A.R.); (C.E.B.)
| | - Hédi Katalin Sárközi
- Pneumology Department, Mures Clinical County Hospital, 540142 Targu Mures, Romania; (D.-E.P.); (H.K.S.); (E.L.); (I.-A.R.); (C.E.B.)
- Pneumology Department, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mures, 540139 Targu Mures, Romania
| | - Eugeniu Lupușor
- Pneumology Department, Mures Clinical County Hospital, 540142 Targu Mures, Romania; (D.-E.P.); (H.K.S.); (E.L.); (I.-A.R.); (C.E.B.)
| | - Irina Elena Vlangăr
- Cardiology Department, Elias University Emergency Hospital, 011461 Bucharest, Romania;
| | - Gheorghe-Marian Rotariu
- Faculty of Medicine, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mures, 540139 Targu Mures, Romania;
| | - Ionuț-Alexandru Rența
- Pneumology Department, Mures Clinical County Hospital, 540142 Targu Mures, Romania; (D.-E.P.); (H.K.S.); (E.L.); (I.-A.R.); (C.E.B.)
| | - Anda-Nicoleta Nan
- Pneumology Department, Mures Clinical County Hospital, 540142 Targu Mures, Romania; (D.-E.P.); (H.K.S.); (E.L.); (I.-A.R.); (C.E.B.)
| | - Corina Eugenia Budin
- Pneumology Department, Mures Clinical County Hospital, 540142 Targu Mures, Romania; (D.-E.P.); (H.K.S.); (E.L.); (I.-A.R.); (C.E.B.)
- Pathophysiology Department, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Târgu Mures, 540139 Targu Mures, Romania
| |
Collapse
|
4
|
Abstract
The upper gastrointestinal (GI) tract is frequently involved in systemic sclerosis (SSc) and may impact quality of life, physical function and survival. Although we are currently very proactive in terms of screening for heart and lung involvement, patients with SSc are not routinely screened for GI involvement. This review details the available investigations for common upper GI symptoms in SSc, including dysphagia, reflux and bloating and provides advice as to how to integrate these investigations into current clinical care.
Collapse
|
5
|
Nassar M, Ghernautan V, Nso N, Nyabera A, Castillo FC, Tu W, Medina L, Ciobanu C, Alfishawy M, Rizzo V, Eskaros S, Mahdi M, Khalifa M, El-Kassas M. Gastrointestinal involvement in systemic sclerosis: An updated review. Medicine (Baltimore) 2022; 101:e31780. [PMID: 36397401 PMCID: PMC9666124 DOI: 10.1097/md.0000000000031780] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
The gastrointestinal tract (GI) is the second most affected organ system in individuals suffering from systemic/localized scleroderma (SSc) or localized scleroderma. SSc can affect any part of the GI, between the oral cavity and anorectum. The annual incidence of SSc in the United States is estimated to be 19.3 cases per million adults, with the highest incidence reported in people aged 44 to 55. Females are 5 times more likely than males to suffer from SSc. Morbidity and mortality rates associated with SSc are predominantly elevated among patients with GI manifestations. Esophageal and intestinal manifestations impact 90% and 40% to 70% of patients with systemic scleroderma, respectively. SSc patients are known to suffer from small bowel hypomotility and small intestinal bacterial overgrowth, which cause malabsorption and malnutrition, ultimately contributing to the 50% mortality rate. Fecal incontinence is a common symptom of SSc that can lead to depression. SSc patients may suffer from gastrointestinal complications that can negatively impact their quality of life on a daily basis. Multidisciplinary approaches are necessary for systematically managing gastrointestinal complications associated with SSc. A prospective study should focus on developing targeted therapies to improve recovery patterns and prognosis in cases of SSc. This article summarizes the epidemiology, commonly reported clinical manifestations, complications, and available treatments for treating GI pathology in SSc patients.
Collapse
Affiliation(s)
- Mahmoud Nassar
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Victoria Ghernautan
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Nso Nso
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Akwe Nyabera
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Francisco Cuevas Castillo
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Wan Tu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Luis Medina
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | | | - Mostafa Alfishawy
- Internal Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Vincent Rizzo
- Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Saphwat Eskaros
- Division of Gastroenterology, Department of Medicine, Icahn School of Medicine at Mount Sinai, NYC Health+Hospitals, Queens, NY, USA
| | - Mamdouh Mahdi
- Internal Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
| | - Mohamed Khalifa
- Hospital Management Department, Helwan University, Cairo, Egypt
| | - Mohamed El-Kassas
- Endemic Medicine Department, Faculty of Medicine, Helwan University, Cairo, Egypt
- * Correspondence: Mohamed El-Kassas, Endemic Medicine Department, Faculty of Medicine, Helwan University, Ain Helwan 11795 Cairo, Egypt (e-mail: )
| |
Collapse
|
6
|
Banait S, Burriwar C, Jain J, Verma PG, Banait T, Joshi M. Cirrhosis of the Liver: A Case Report and Literature Review of a Rare Case Presentation of Autoimmune Hepatitis With Systemic Sclerosis. Cureus 2022; 14:e31147. [DOI: 10.7759/cureus.31147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 10/30/2022] [Indexed: 11/08/2022] Open
|
7
|
Bratoiu I, Burlui AM, Cardoneanu A, Macovei LA, Richter P, Rusu-Zota G, Rezus C, Badescu MC, Szalontay A, Rezus E. The Involvement of Smooth Muscle, Striated Muscle, and the Myocardium in Scleroderma: A Review. Int J Mol Sci 2022; 23:ijms231912011. [PMID: 36233313 PMCID: PMC9569846 DOI: 10.3390/ijms231912011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/24/2022] [Accepted: 10/07/2022] [Indexed: 11/09/2022] Open
Abstract
Systemic sclerosis (SSc) is a complex autoimmune disease characterized by heterogeneous changes involving numerous organs and systems. The currently available data indicate that muscle injury (both smooth and striated muscles) is widespread and leads to significant morbidity, either directly or indirectly. From the consequences of smooth muscle involvement in the tunica media of blood vessels or at the level of the digestive tract, to skeletal myopathy (which may be interpreted strictly in the context of SSc, or as an overlap with idiopathic inflammatory myopathies), muscular injury in scleroderma translates to a number of notable clinical manifestations. Heart involvement in SSc is heterogenous depending on the definition used in the various studies. The majority of SSc patients experience a silent form of cardiac disease. The present review summarizes certain important features of myocardial, as well as smooth and skeletal muscle involvement in SSc. Further research is needed to fully describe and understand the pathogenic pathways and the implications of muscle involvement in scleroderma.
Collapse
Affiliation(s)
- Ioana Bratoiu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
| | - Alexandra Maria Burlui
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
- Correspondence: (A.M.B.); (C.R.)
| | - Anca Cardoneanu
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
| | - Luana Andreea Macovei
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
| | - Patricia Richter
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
| | - Gabriela Rusu-Zota
- Department of Pharmacology, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
| | - Ciprian Rezus
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
- Correspondence: (A.M.B.); (C.R.)
| | - Minerva Codruta Badescu
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 16 Universitatii Street, 700115 Iasi, Romania
| | - Andreea Szalontay
- Department of Psychiatry, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
| | - Elena Rezus
- Department of Rheumatology and Physiotherapy, “Grigore T. Popa” University of Medicine and Pharmacy, 16 University Street, 700115 Iasi, Romania
| |
Collapse
|
8
|
Lee SG, Moon KW. Epidemiology and Treatment of Systemic Sclerosis in Korea. JOURNAL OF RHEUMATIC DISEASES 2022; 29:200-214. [PMID: 37476430 PMCID: PMC10351407 DOI: 10.4078/jrd.22.0029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 09/16/2022] [Accepted: 09/19/2022] [Indexed: 07/22/2023]
Abstract
Systemic sclerosis (SSc), a rare, chronic progressive systemic autoimmune disease of unknown etiology, is characterized by autoimmunity, tissue fibrosis, and obliterative vasculopathy. SSc can affect all major organs including the skin, blood vessels, lung, heart, kidneys, and gastrointestinal tract. Our understanding of its pathogenesis has increased over the past few decades, leading to improved diagnosis and treatment. However, the mortality rate of SSc remains considerable, mainly due to cardiopulmonary causes. A growing body of evidence suggests that geographical, regional, and ethnic differences could affect the epidemiology, clinical characteristics and prognosis of SSc. Although Korean data of this issue are lacking, a considerable amount of research has been published by many Korean researchers. To establish treatment strategies for Korean patients, extensive Korean research data are needed. This review summarizes the prevalence, incidence, mortality, and clinical and laboratory manifestations of Korean patients with SSc and discusses the current trends in evidence-based treatment and recommendations.
Collapse
Affiliation(s)
- Seung-Geun Lee
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Ki Won Moon
- Division of Rheumatology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| |
Collapse
|
9
|
Miller RC, Lipner SR. Treatment of Fingernail Onychomycosis with Efinaconazole 10% Solution in a Patient with Scleroderma: A Case Report. Skin Appendage Disord 2022; 8:350-353. [PMID: 35979526 PMCID: PMC9274809 DOI: 10.1159/000522407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/01/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Oral antifungals are typically preferred over topicals for moderate to severe onychomycosis due to efficacy and shorter treatment courses. However, systemics are contraindicated or cautioned in patients with liver dysfunction and with some autoimmune diseases, and in those taking interacting medications. Efinaconazole 10% solution is a topical antifungal therapy, but application for fingernail onychomycosis has not been adequately studied. Case Presentation We present a case of a 78-year-old female with scleroderma and moderate onychomycosis of the right 4th fingernail successfully treated with topical efinaconazole 10% solution. Conclusion We review the literature on contraindications to oral antifungals for onychomycosis, precautions with terbinafine in patients with some autoimmune diseases, and topical onychomycosis therapies. Topical efinaconazole may represent an effective alternative for patients with fingernail onychomycosis who have contraindications to oral medications.
Collapse
|
10
|
Iio S, Oka S, Sumioka A, Tsuboi A, Tanaka H, Yamashita K, Hiyama Y, Kotachi T, Takigawa H, Hayashi R, Yuge R, Urabe Y, Tanaka S. Characteristics and Treatment Outcomes of Small-bowel Angioectasia in Systemic Sclerosis Patients: A Retrospective Observational Study. Intern Med 2022; 61:615-622. [PMID: 34433725 PMCID: PMC8943382 DOI: 10.2169/internalmedicine.8034-21] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective Systemic sclerosis (SSc) is defined as an autoimmune disease presenting with fibrosis of various organs and vascular endothelial damage. Vascular lesions, including small-bowel angioectasias, are also frequently detected in SSc patients. Polidocanol injection (PDI) is a safe and effective hemostatic treatment for gastrointestinal bleeding. We evaluated the outcomes of PDI for small-bowel angioectasia in SSc patients. Methods We retrospectively evaluated 65 consecutive SSc patients (61 women; mean age, 64.3 years old) who underwent capsule endoscopy (CE) and/or double-balloon endoscopy at Hiroshima University Hospital between April 2012 and December 2019. Patients Patients were stratified according to the presence of small-bowel angioectasia. Among patients who underwent CE during the same period, those with small-bowel angioectasia without concomitant diseases were compared with SSc patients with small-bowel angioectasia. Clinical and endoscopic characteristics, treatment outcomes, and the incidence of metachronous small-bowel angioectasia after PDI were evaluated. Results SSc patients with small-bowel angioectasia exhibited significantly lower hemoglobin levels and a significantly higher incidence of skin telangiectasia than those without small-bowel angioectasia. On a multivariate analysis of the presence of small-bowel angioectasia, anemia and skin telangiectasia were significant independent factors. SSc patients with small-bowel angioectasia included a higher proportion of women and exhibited a significantly higher incidence of metachronous small-bowel angioectasia than X. The characteristics of small-bowel angioectasia and outcomes of PDI were not significantly different between the two groups. No post-treatment rebleeding cases or adverse events were noted. Conclusion CE should be performed for SSc patients with anemia and/or skin telangiectasia. PDI is effective for SSc patients with small-bowel angioectasia.
Collapse
Affiliation(s)
- Sumio Iio
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Japan
| | - Akiyoshi Tsuboi
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | - Hidenori Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | - Ken Yamashita
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | - Yuichi Hiyama
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | | | | | - Ryohei Hayashi
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | - Ryo Yuge
- Department of Endoscopy, Hiroshima University Hospital, Japan
| | - Yuji Urabe
- Department of Regeneration and Medicine Center for Translational and Clinical Research, Hiroshima University Hospital, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Japan
| |
Collapse
|
11
|
Skoumalová A, Horák P, Heřmanová Z, Videman J, Smržová A, Palla V. Early diagnosis of systemic scleroderma. VNITRNI LEKARSTVI 2022; 68:285-289. [PMID: 36283818 DOI: 10.36290/vnl.2022.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Systemic scleroderma (SSc) is a systemic immune-mediated connective tissue disease characterized by fibroproductive changes in connective tissue and microvascular disorders. The disease affects the skin, musculoskeletal system and internal organs. It is a disease with a significant rate of morbidity and mortality, significantly worsening the quality of life of patients. Early initiation of therapy is necessary to prevent disease progression. This review article discusses the current possibilities of early diagnosis of systemic scleroderma.
Collapse
|
12
|
Burlui AM, Cardoneanu A, Macovei LA, Rezus C, Boiculese LV, Graur M, Rezus E. Diet in Scleroderma: Is There a Need for Intervention? Diagnostics (Basel) 2021; 11:2118. [PMID: 34829464 PMCID: PMC8620611 DOI: 10.3390/diagnostics11112118] [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: 10/22/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 01/10/2023] Open
Abstract
Systemic sclerosis (SSc) patients exhibit a plethora of risk factors for nutritional decline, including the presence of chronic inflammation and the progressive nature of disease-related multisystem involvement. The prevalence and consequences of nutritional decline in scleroderma are frequently underestimated, its management currently remaining a subject of debate. The main objective of the present study was to perform a detailed assessment of scleroderma patients' diet as well as their eating habits and to describe the relationships with weight loss and malnutrition risk in the absence of professional nutritional counseling. METHODS We used a translated and validated version of the EPIC-Norfolk FFQ (European Prospective Investigation into Cancer and Nutrition Norfolk Food Frequency Questionnaire) to evaluate the patients' diet and MUST (Malnutrition Universal Screening Tool) to investigate the risk of malnutrition. Disease activity was estimated using the EUSTAR-AI (European Scleroderma Trials and Research group Activity Index). RESULTS We included 69 patients with SSc, of which 42 underwent a detailed dietary assessment. Dietary factors were connected to body composition and digestive symptoms. We found high sodium intake and frequent suboptimal energy consumption in our study group, including patients with cardiopulmonary involvement. Liver transaminases were inversely correlated with the consumption of nuts and seeds. Malnutrition and weight loss were significantly associated with pulmonary hypertension, heart failure, albumin levels, and the extent of skin fibrosis, but not advanced age. Although the patients with EUSTAR-AI ≥ 2.5 were more frequently included in the moderate and high malnutrition risk categories, these results did not reach statistical significance. CONCLUSIONS Currently, there is an unmet need for longitudinal and interventional research focusing on the long-term significance, ramifications, and management of nutritional impairment in SSc patients with various clinical manifestations. Our results indicate that scleroderma patients could benefit from personalized nutritional counseling in an interdisciplinary setting.
Collapse
Affiliation(s)
- Alexandra Maria Burlui
- Department of Rheumatology and Rehabilitation, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (L.A.M.); (E.R.)
| | - Anca Cardoneanu
- Department of Rheumatology and Rehabilitation, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (L.A.M.); (E.R.)
| | - Luana Andreea Macovei
- Department of Rheumatology and Rehabilitation, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (L.A.M.); (E.R.)
| | - Ciprian Rezus
- Department of Internal Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Lucian Vasile Boiculese
- Department of Preventive Medicine and Interdisciplinarity, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Mariana Graur
- Department of Diabetes, Nutrition and Metabolic Diseases, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Elena Rezus
- Department of Rheumatology and Rehabilitation, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.C.); (L.A.M.); (E.R.)
| |
Collapse
|
13
|
Lee TH, Lee JS, Park S, Lee KA, Kim HS. Reliability and validity of the Korean version of the University of California-Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract instrument in patients with systemic sclerosis. Korean J Intern Med 2021; 36:1504-1514. [PMID: 33561335 PMCID: PMC8588985 DOI: 10.3904/kjim.2020.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/08/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND/AIMS Systemic sclerosis (SSc) is associated with a wide range of gastrointestinal (GI) changes. The University of California-Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA SCTC GIT 2.0) instrument is a self-administered GI assessment instrument for patients with SSc. We developed a Korean version of the UCLA SCTC GIT 2.0 instrument and evaluated its reliability and internal consistency. METHODS The participants were 37 Korean patients with SSc. Translation and cross-cultural adaptation of the UCLA SCTC GIT 2.0 were performed according to international standardized guidelines. We evaluated reproducibility by calculating the intraclass correlation coefficients and assessed the internal consistency of the Korean version of the UCLA SCTC GIT 2.0. We assessed its construct validity by evaluating its correlations with the Short Form Health Survey version 2 and EQ-5D scores by means of Spearman correlation analyses. RESULTS Patients with SSc were mostly women (89.19%) with a mean age of 52.2 years, median disease duration of 24 months, and median modified Rodnan total skin score of 4. The median total GIT score on the UCLA SCTC GIT 2.0 was 0.3. The UCLA SCTC GIT 2.0 Korean version showed excellent internal consistency (Cronbach's α of total GIT score = 0.863). Most domains of the ULCA SCTC GIT 2.0 were correlated with those of the EuroQol (EQ)-5D score. CONCLUSION The Korean version of the UCLA SCTC GIT 2.0 has acceptable internal consistency, reliability, and validity. Therefore, it can be used to assess GIT involvement in Korean patients with SSc.
Collapse
Affiliation(s)
- Tae Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Joon Seong Lee
- Division of Gastroenterology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Suyeon Park
- Department of Biostatistics, Soonchunhyang University Seoul Hospital, Seoul, Korea
- Department of Applied Statistics, Chung-Ang University, Seoul, Korea
| | - Kyung-Ann Lee
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyun-Sook Kim
- Division of Rheumatology, Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| |
Collapse
|
14
|
Kahana N, Freund MR, Koslowsky B, Blich O, Reissman P, Yellinek S. High Failure Rate Following Restorative Surgery for Rectal Prolapse in Systemic Sclerosis Patients. Am Surg 2021:31348211047487. [PMID: 34670433 DOI: 10.1177/00031348211047487] [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: 11/17/2022]
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare autoimmune connective tissue disorder. Colonic disorders are reported in 70% of patients. Only a few cases of rectal prolapse surgical repair in SSc patients were published, demonstrating high recurrence rate following any restorative surgery. The aim of this study is to present our surgical experience combined with the reported cases of SSc patients who underwent surgical interventions for rectal prolapse. METHODS We reviewed our data and the published reports in the English literature of patients with SSc who underwent surgery for rectal prolapse. We located 6 case reports, in addition to 3 patients who were operated in our center. RESULTS A total of 19 procedures (9 patients) were included, among them 17 restorative surgeries and 2 low anterior resections (LAR) with end-colostomy. All patients were female (mean age 70.3). Index surgery was perineal rectosigmoidectomy in 5, abdominal resection rectopexy in 3, and LAR with colostomy in 1 patient. All patients following restorative surgery suffered from fecal incontinence. 5 patients (62.5%) who underwent restorative surgery required at least 1 re-operation. The 2 patients who underwent LAR and colostomy reported a complete resolution of anorectal symptoms with a major improvement in their quality of life. CONCLUSION High recurrence rate is expected in SSc patients with rectal prolapse who undergo a restorative procedure. Low anterior resection and permanent colostomy provide an alternative surgical option to patients with SSc and prolapse in contrast to restorative surgery. We believe that this surgical approach should be offered for these patients.
Collapse
Affiliation(s)
- Noam Kahana
- Department of General Surgery, Shaare Zedek Medical Center, 26743The Hebrew University School of Medicine, Jerusalem, Israel
| | - Michael R Freund
- Department of General Surgery, Shaare Zedek Medical Center, 26743The Hebrew University School of Medicine, Jerusalem, Israel
| | - Benjamin Koslowsky
- Department of Gastroenterology, Shaare Zedek Medical Center, 26743The Hebrew University School of Medicine
| | - Ori Blich
- Department of General Surgery, Shaare Zedek Medical Center, 26743The Hebrew University School of Medicine, Jerusalem, Israel
| | - Petachia Reissman
- Department of General Surgery, Shaare Zedek Medical Center, 26743The Hebrew University School of Medicine, Jerusalem, Israel
| | - Shlomo Yellinek
- Department of General Surgery, Shaare Zedek Medical Center, 26743The Hebrew University School of Medicine, Jerusalem, Israel
| |
Collapse
|
15
|
Iio S, Oka S, Tanaka S, Sumioka A, Tsuboi A, Nojima T, Hirata S, Matsuo Y, Sugiyama E, Hide M, Arihiro K, Chayama K. Capsule endoscopy findings reflect the gastrointestinal conditions of patients with systemic sclerosis. Sci Rep 2021; 11:20163. [PMID: 34635790 PMCID: PMC8505447 DOI: 10.1038/s41598-021-99775-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 10/01/2021] [Indexed: 11/23/2022] Open
Abstract
Systemic sclerosis (SSc) is characterized by fibrosis of the skin and various internal organs. However, there is limited knowledge concerning small-bowel lesions. We evaluated the clinical state of patients with SSc according to the capsule endoscopy (CE) findings. Sixty-five consecutive patients with SSc (61 females; mean age, 64.3 years) underwent CE at Hiroshima University Hospital between April 2012 and December 2019. SSc was subclassified into diffuse and limited cutaneous SSc. Among the 65 patients, 55 (51 females; mean age, 64.5 years; diffuse cutaneous SSc, 27 patients) were evaluated for the presence of fibrosis in the gastrointestinal tract by biopsy. Small-bowel lesions were detected in 27 (42%) patients with SSc. Type 1b angioectasia (Yano-Yamamoto classification) was more frequent in limited cutaneous SSc patients (p = 0.0071). The average capsule transit time of the esophagus was significantly longer in diffuse cutaneous SSc patients (p = 0.0418). There were more cases of Type 1a angioectasia in SSc patients without fibrosis. The average capsule transit time of the esophagus was significantly longer in SSc patients with fibrosis. Thus, this study revealed that the frequency of small-bowel angioectasia and gastrointestinal motility in patients with SSc differed depending on SSc subclassification and the presence of fibrosis.
Collapse
Affiliation(s)
- Sumio Iio
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Shiro Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Akihiko Sumioka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Akiyoshi Tsuboi
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Takaki Nojima
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shintaro Hirata
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Yoshimi Matsuo
- Department of Dermatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Eiji Sugiyama
- Department of Clinical Immunology and Rheumatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Michihiro Hide
- Department of Dermatology, Hiroshima University Hospital, Hiroshima, Japan
| | - Koji Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| |
Collapse
|
16
|
Kadakuntla A, Juneja A, Sattler S, Agarwal A, Panse D, Zakhary N, Pasumarthi A, Shapiro L, Tadros M. Dysphagia, reflux and related sequelae due to altered physiology in scleroderma. World J Gastroenterol 2021; 27:5201-5218. [PMID: 34497445 PMCID: PMC8384755 DOI: 10.3748/wjg.v27.i31.5201] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/13/2021] [Accepted: 07/30/2021] [Indexed: 02/06/2023] Open
Abstract
Systemic sclerosis is a connective tissue disease that presents with significant gastrointestinal involvement, commonly in the esophagus. Dysphagia is a common clinical manifestation of systemic sclerosis and is strongly related to esophageal dysmotility. However, there are multiple other contributing factors in each step in the physiology of swallowing that may contribute to development of severe dysphagia. The oral phase of swallowing may be disrupted by poor mastication due to microstomia and poor dentition, as well as by xerostomia. In the pharyngeal phase of swallowing, pharyngeal muscle weakness due to concurrent myositis or cricopharyngeal muscle tightening due to acid reflux can cause disturbance. The esophageal phase of swallowing is most commonly disturbed by decreased peristalsis and esophageal dysmotility. However, it can also be affected by obstruction from chronic reflux changes, pill-induced esophagitis, or Candida esophagitis. Other contributing factors to dysphagia include difficulties in food preparation and gastroparesis. Understanding the anatomy and physiology of swallowing and evaluating systemic sclerosis patients presenting with dysphagia for disturbances in each step can allow for development of better treatment plans to improve dysphagia and overall quality of life.
Collapse
Affiliation(s)
| | - Ankit Juneja
- Albany Medical College, Albany, NY 12208, United States
| | | | | | - Drishti Panse
- Albany Medical College, Albany, NY 12208, United States
| | - Nardin Zakhary
- Department of Dentistry, Ministry of Health, Alexandria 21500, Egypt
| | | | - Lee Shapiro
- Division of Rheumatology, Albany Medical Center, Albany, NY 12208, United States
| | - Micheal Tadros
- Division of Gastroenterology, Albany Medical Center, Albany, NY 12208, United States
| |
Collapse
|
17
|
Vitton V, Bazin C, Luciano L, Granel B, Alessandrini M, Harle JR. Oesophageal motor disorders and oesophageal endoscopic involvement in patients with systemic sclerosis: a systematic association? Scand J Gastroenterol 2021; 56:508-513. [PMID: 33689560 DOI: 10.1080/00365521.2021.1881813] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Although oesophageal motor disorders (OMDs) are frequent in systemic sclerosis (SSc), the frequency of associated endoscopic lesions is unknown. We aimed at assessing the presence of endoscopic lesions in SSc patients with OMD. The secondary objective was to identify the clinical and serological profile of such patients. METHODS This retrospective study included SSc patients suffering from OMD diagnosed by oesophageal high-resolution manometry (OHRM) and with recent upper gastro-intestinal endoscopy (UGIE). Clinical data collected were age, gender, body mass index, SSc disease duration, tobacco, SSc cutaneous type, non-digestive SSc visceral disorders, oesophageal symptoms, serological profile (autoantibodies), proton pump inhibitor use, time between SSc diagnosis and UGIE. RESULTS 53 selected patients from 210 SSc patients investigated by OHRM in our department were included. Among these patients, 25 (47.2%) had endoscopic lesions: 18 (34.6%) had oesophagitis and 7 (13.5%) had Barrett's oesophagus. The only two parameters significantly associated with endoscopic lesions were a shorter disease duration (6 vs. 11 years; p = .002) and a shorter delay between SSc diagnosis and UGIE (3 vs. 8.5 years; p = .002). No other clinical or biological parameters could help identify the patients at risk of endoscopic lesion. CONCLUSION In our study, only a shorter disease duration and a shorter delay between SSc diagnosis and UGIE were significantly associated with the presence of endoscopic lesions in patients with OMD, but no other parameters were identified. This study highlights the need to perform UGIE in SSc patients with OMD whatever their clinical symptoms.
Collapse
Affiliation(s)
- Véronique Vitton
- Department of Gastroenterology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - Camille Bazin
- Department of Gastroenterology, North Hospital, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - Laure Luciano
- Department of Gastroenterology, Instruction Hospital of French Army Laveran, Marseille, France
| | - Brigitte Granel
- Internal Medicine Department, CHU Nord, Assistance Publique Hôpitaux de Marseille (AP-HM), Aix-Marseille University, Vascular Research Center of Marseille, INSERM UMRS-1076, Aix-Marseille University, Marseille, France
| | - Marine Alessandrini
- EA 3279 - Public Health, Chronic Diseases and Quality of Life - Research Unit, Aix-Marseille University, Marseille, France
| | - Jean-Robert Harle
- Internal Medicine Department, CHU La Timone, Assistance Publique Hôpitaux de Marseille (AP-HM), Aix-Marseille University, Marseille, France
| |
Collapse
|
18
|
Bering J, Griffing WL, Crowell M, Umar SB. Progression of gastrointestinal symptoms over time in patients with systemic sclerosis. Rheumatol Int 2021; 41:1281-1287. [PMID: 33630144 DOI: 10.1007/s00296-021-04806-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
Up to 90% of patients with systemic sclerosis (SSc) develop gastrointestinal (GI) symptoms. To evaluate whether GI symptoms and quality of life in patients with SSc demonstrate longitudinal stability. Consecutive patients with SSc (n = 100) completed the validated university of California at Los Angeles scleroderma clinical trial consortium gastrointestinal tract 2.0 (GIT) instrument and completed the same instrument approximately 5 years later. Comparison was made between patients with diffuse (dcSSc) and limited (lcSSc) subtypes and duration of disease of less than or greater than 5 years. GIT scores were calculated and analyzed for differences. 37 patients with dcSSc and 63 patients with lcSSc were included. Social functioning score significantly improved over time [0.44 (0.59)-0.31 (0.47); P = 0.003]. Total GIT scores were lower in patients with diffuse [0.51 (0.41)] compared with limited [(0.72 (0.53); P = 0.029] disease at both baseline and follow-up. Social functioning improved similarly in both dcSSc and lcSSc over time (P = 0.004). GIT Total scores increased in 27% (27/100) of patients and did not change or improved in 73% (73/100). Patients with worsening GI status had significantly increased scores on all GIT subscales. A lower body-mass index at baseline was significantly associated with worsening GIT Total score (OR 1.22; 95% CI 1.07-1.39; P < 0.001). Patients with SSc generally demonstrate longitudinal stability or improvement in their GI symptoms, but a subset of patients experience worsening of GI symptoms and negative impacts on GI-related quality of life.
Collapse
Affiliation(s)
- Jamie Bering
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - W Leroy Griffing
- Division of Rheumatology Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Michael Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA
| | - Sarah B Umar
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA.
| |
Collapse
|
19
|
Hoffmann-Vold AM, Volkmann ER. Gastrointestinal involvement in systemic sclerosis: Effects on morbidity and mortality and new therapeutic approaches. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2021; 6:37-43. [PMID: 35382247 PMCID: PMC8922632 DOI: 10.1177/2397198319891282] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 11/01/2019] [Indexed: 08/22/2023]
Abstract
The majority of research studies in systemic sclerosis focus largely on addressing skin and cardiopulmonary manifestations. Fewer studies assess the pathogenesis and treatment of gastrointestinal tract involvement in systemic sclerosis, despite the fact that the majority of patients with systemic sclerosis have gastrointestinal manifestations and these manifestations are a leading cause of death in systemic sclerosis. The present review provides a comprehensive update on morbidity and mortality outcomes related to gastrointestinal involvement in systemic sclerosis. This review also describes conventional and emerging approaches to managing gastrointestinal symptoms in systemic sclerosis. Recent developments in systemic sclerosis-gastrointestinal research efforts have revealed promising treatment targets, including specific auto-antibodies and microbiota alterations. This review will conclude with an overview of future research directions that may improve our understanding of systemic sclerosis-gastrointestinal involvement and ultimately help to alleviate suffering from this devastating dimension of systemic sclerosis.
Collapse
Affiliation(s)
- Anna-Maria Hoffmann-Vold
- Department of Rheumatology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Elizabeth R Volkmann
- Division of Rheumatology, Department of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
| |
Collapse
|
20
|
Feng X, Li XQ, Jiang Z. Prevalence and predictors of small intestinal bacterial overgrowth in systemic sclerosis: a systematic review and meta-analysis. Clin Rheumatol 2021; 40:3039-3051. [PMID: 33426631 DOI: 10.1007/s10067-020-05549-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/08/2020] [Accepted: 12/13/2020] [Indexed: 12/11/2022]
Abstract
The reported prevalence of small intestinal bacterial overgrowth (SIBO) among patients with systemic sclerosis (SSc) is highly variable. We conducted this systematic review and meta-analysis to estimate the prevalence and identify predictors of SIBO in SSc by summarizing all of the available data. A comprehensive literature search of the PubMed, Cochrane Library, and EMBASE databases from inception to July 2020 was conducted for studies correlating SIBO with SSc. Studies were screened, and relevant data were extracted and analyzed. The pooled prevalence of SIBO among SSc patients and the odds ratio (OR) of SIBO among SSc patients compared with healthy controls were calculated. Furthermore, predictors of SIBO in SSc were evaluated. Fourteen studies containing 700 SSc patients and 217 healthy controls met the inclusion criteria. The pooled prevalence of SIBO in SSc was 34% (95% CI 27-42%). The OR of SIBO in SSc patients was 12.51 (95% CI 6.51-24.03) compared with the healthy controls. Subgroup analyses showed that the prevalence of SIBO in SSc was higher in studies using the lactulose hydrogen breath test (LHBT) for diagnosis (56%, 95% CI 46-67%) compared with those that used the glucose hydrogen breath test (GHBT) (27%, 95%CI 20-35%) and a jejunal aspirated culture (JAC) (35%, 95%CI 25-51%). The prevalence of SIBO in SSc was higher in studies conducted in Western countries (38%, 95% CI 31-47%) than those conducted in Asian countries (15%, 95%CI 10-23%), and the prevalence of SIBO in the SSc population defined by ACR-EULAR 2013 (50%, 95% CI 0.21-0.79) was higher than the prevalence defined by ACR 1980 (30%, 95% CI 0.17-0.42) or other criteria (32%, 95% CI 0.16-0.48) Moreover, the risk of diarrhea was higher in SSc patients with SIBO than those without SIBO (OR 8.82, 95% CI 4.09-19, P < 0.00001); gender, SSc subset, digital ulcer, and pulmonary fibrosis do not seem to be associated with SIBO in SSc. Antibiotic therapy seems to be effective with SIBO in SSc patients. Approximately one-third of SSc patients tested positive for SIBO with a significantly increased risk over the controls. The prevalence of SIBO in SSc varied according to the SIBO diagnostic test performed, geographic area, and SSc diagnostic criteria. The presence of diarrhea may be a predictor of SIBO in SSc. Antibiotic treatment can lead to eradication of SIBO and gastrointestinal symptomatic improvement in SSc patients. Key Points • The pooled prevalence of SIBO in SSc patients was 34%, which varied according to the SIBO diagnostic test performed, geographic area and SSc diagnostic criteria. • The risk of SIBO in SSc was increased by nearly thirteenfold compared to the healthy controls. • Diarrhoea, but not gender, SSc subset, digital ulcer and pulmonary fibrosis, was associated with SIBO in SSc patients. • For SSc patients with SIBO, antibiotic treatment can lead to eradication of SIBO and gastrointestinal symptomatic improvement.
Collapse
Affiliation(s)
- Xin Feng
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiao-Qing Li
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Zheng Jiang
- Department of Gastroenterology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| |
Collapse
|
21
|
Abstract
PURPOSE OF REVIEW In this review, the authors discuss systemic sclerosis-associated interstitial lung disease (SSc-ILD) with a focus on recent developments in diagnosis, surveillance, and management. RECENT FINDINGS With advances in the management of SSc, the importance of ILD has been increasingly recognized and is the leading cause of mortality. Early detection is essential, and a combination of lung function testing and chest imaging are key tools in diagnosis and surveillance. The foundation of treatment is immunomodulation with recent studies identifying several potential new agents. The use of therapies targeting pro-fibrotic pathways have demonstrated significant effects on lung function decline and represent the latest advance in therapy for SSc-ILD. SUMMARY Recent studies support the use of newer therapies in SSc-ILD including antifibrotic agents. The identification and management of comorbidities is important, and lung transplantation is a viable option for patients with advanced disease.
Collapse
|
22
|
Zhang S, Lv J, Ren X, Hao X, Zhou P, Wang Y. The efficacy and safety of fecal microbiota transplantation in the treatment of systemic sclerosis: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2020; 99:e21267. [PMID: 32664182 PMCID: PMC7360200 DOI: 10.1097/md.0000000000021267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Systemic sclerosis (SSc) is 1 of the most complex systemic autoimmune diseases.Accumulating evidence suggests that gut microbiota affect the development and function of the immune system and may play a role in the pathogenesis of autoimmune diseases. This new paradigm raises the possibility that many diseases result, at least partially, from microbiota-related dysfunction. This understanding invites the investigation of fecal microbiota transplantation (FMT) in the treatment of SSc. However, no study has specifically and systematically investigated the efficacy and safety of FMT in the treatment of SSc. Thus, this study will systematically and comprehensively appraise the efficacy and safety of FMT in the treatment of SSc. METHODS We will search the following sources without restrictions for date, language, or publication status: PubMed, Web of Science,Cochrane Central Register of Controlled Trials (CENTRAL) Cochrane Library, EMBASE and China National Knowledge Infrastructure. We will apply a combination of Medical Subject Heading (MeSH) and free-text terms incorporating database-specific controlled vocabularies and text words to implement search strategies. We will also search the ongoing trials registered in the World Health Organization's International Clinical Trials Registry Platform. Besides, the previous relevant reviews conducted on FMT for SSc and reference lists of included studies will also be searched. RESULTS This study will provide a reliable basis for the treatment of SSc with FMT. CONCLUSIONS The findings will be an available reference to evaluate the efficacy and safety of FMT in the treatment of SSc. REGISTRATION NUMBER INPLASY202060019.
Collapse
Affiliation(s)
| | - Jingjing Lv
- Hebei Province Hospital of Chinese Medicine, Shijiazhuang City, Hebei
| | | | - Xinyu Hao
- Hebei University of Chinese Medicine
| | | | - Yangang Wang
- Hebei Province Hospital of Chinese Medicine, Shijiazhuang City, Hebei
| |
Collapse
|
23
|
Effects of Nintedanib in an Animal Model of Liver Fibrosis. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3867198. [PMID: 32337244 PMCID: PMC7150695 DOI: 10.1155/2020/3867198] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 03/03/2020] [Indexed: 02/08/2023]
Abstract
Systemic sclerosis can affect multiple internal organs, including the liver and lungs. Nintedanib, an antifibrotic approved for treatment of interstitial lung disease associated with systemic sclerosis, may have activity outside of the lungs. This study explored the effect of preventive and therapeutic nintedanib treatment in a 3-week carbon tetrachloride (CCL4)-induced (500 mg/kg/day twice weekly for 3 weeks) model of hepatic inflammation and fibrosis in C57Bl/6 mice (aged 8 weeks, n = 5 per group). Mice also received nintedanib (30 or 60 mg/kg/day) either each day for 21 days (preventive treatment) or from day 7 or day 14 (therapeutic treatment). Preventive nintedanib treatment at both doses significantly reduced CCL4-induced increases in myeloperoxidase (p < 0.01), hepatic collagen (p < 0.001), and interleukin (IL)-6 (p < 0.01) in the liver. Nintedanib also significantly reduced hepatic necrosis (p < 0.01 and p < 0.05), inflammation (p < 0.001 and p < 0.05), fibrosis (p < 0.001 and p < 0.05) and IL-1β (p < 0.05 and p < 0.001) at both 30 and 60 mg/kg/day, respectively. Therapeutic treatment with nintedanib at 30 and 60 mg/kg/day significantly reduced CCL4-induced serum alanine aminotransferase from day 7 (p < 0.05 and p < 0.001) and day 14 (p < 0.01 and p < 0.05), respectively. Increases in tissue inhibitor of metalloproteinase-1 were significantly reduced by nintedanib at 60 mg/kg/day from day 7 only (p < 0.001), and nintedanib completely blocked elevation of IL-6 and IL-1β levels regardless of dose or start of treatment (p < 0.05-p < 0.001). In both the preventive and therapeutic treatment schedules of the study, nintedanib treatment was beneficial in attenuating CCL4-induced pathology and reducing hepatic injury, inflammation, and fibrosis, demonstrating that nintedanib has antifibrotic and anti-inflammatory activity outside of the lungs.
Collapse
|
24
|
Richard N, Hudson M, Wang M, Gyger G, Proudman S, Stevens W, Nikpour M, Baron M. Severe gastrointestinal disease in very early systemic sclerosis is associated with early mortality. Rheumatology (Oxford) 2020; 58:636-644. [PMID: 30517716 DOI: 10.1093/rheumatology/key350] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 09/23/2018] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To examine the incidence, predictors and outcomes associated with severe gastrointestinal (GI) disease in a large inception SSc cohort. METHODS SSc subjects with <2 years of disease duration were identified from two multicentre cohorts. Severe GI disease was defined as: malabsorption, hyperalimentation, pseudo-obstruction and/or ⩾10% weight loss in association with the use of antibiotics for bacterial overgrowth or oesophageal stricture. Kaplan-Meier, multivariate logistic regression and Cox proportional hazard analyses were performed to determine the cumulative incidence rate, independent clinical correlates and mortality rate associated with severe GI disease. A longitudinal mixed model was used to assess the impact of severe GI disease on the Short Form Health Survey. RESULTS In this inception SSc cohort, the probability of developing severe GI disease was estimated at 9.1% at 2 years and 16.0% at 4 years. In multivariate analysis, severe GI disease was associated with inflammatory myositis (odds ratio 4.68, 95% CI 1.65, 13.24), telangiectasias (odds ratio 2.45, 95% CI 1.19, 5.04) and modified Rodnan skin score (odds ratio 1.03, 95% CI 1.01, 1.07). Severe GI disease was associated with a >2-fold increase in the risk of death (hazard ratio 2.27, 95% CI 1.27, 4.09) and worse health-related quality of life [Short Form Health Survey physical (β = -2.37, P = 0.02) and mental (β = -2.86, P = 0.01) component summary scores]. CONCLUSION Severe GI disease is common in early SSc and is associated with significant morbidity and increased mortality. More research is needed to understand, prevent and mitigate severe GI disease in SSc.
Collapse
Affiliation(s)
- Nicolas Richard
- Division of Rheumatology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada.,Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, Quebec, Canada.,Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Mianbo Wang
- Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| | - Geneviève Gyger
- Department of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, Quebec, Canada
| | - Susanna Proudman
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Medicine, University of Adelaide, Adelaide, South Australia
| | - Wendy Stevens
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Mandana Nikpour
- Department of Rheumatology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Department of Medicine, University of Melbourne at St Vincent's Hospital, Melbourne, Victoria, Australia
| | | | | | - Murray Baron
- Department of Medicine, McGill University, Montreal, Quebec, Canada.,Division of Rheumatology, Jewish General Hospital, Montreal, Quebec, Canada.,Lady Davis Institute, Jewish General Hospital, Montreal, Quebec, Canada
| |
Collapse
|
25
|
Iudici M, Bafeta A, Atal I, Ravaud P. Ten Years of Interventional Research in Systemic Sclerosis: A Systematic Mapping of Trial Registries. Arthritis Care Res (Hoboken) 2019; 72:140-148. [DOI: 10.1002/acr.23817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 11/20/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Michele Iudici
- INSERMUMR 1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center Paris France
| | - Aïda Bafeta
- INSERMUMR 1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center Paris France
| | - Ignacio Atal
- INSERMUMR 1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center Paris France
| | - Philippe Ravaud
- INSERMUMR 1153, Epidemiology and Biostatistics Sorbonne Paris Cité Research CenterHôpital Hôtel‐DieuAssistance Publique des Hôpitaux de Paris, and Cochrane France, Paris, France, and Columbia University, Mailman School of Public Health New York New York
| |
Collapse
|
26
|
Abstract
Rheumatological diseases (RDs) represent a diverse group of diseases that are inherited or related to environmental factors. RDs frequently affect the gastrointestinal (GI) tract, and gastroenterologists are often asked to evaluate patients with symptoms thought to represent an underlying or coexisting RD. GI manifestations of RDs vary based on the organ involved as well as the extent and duration of involvement. Although most manifestations of RD are nonspecific and not life-threatening, the chronicity and severity of symptoms can be debilitating and may lead to serious injury. This narrative review discusses the most common RD encountered by gastroenterologists: systemic lupus erythematosus, systemic sclerosis (scleroderma), dermatomyositis/polymyositis, rheumatoid arthritis, Sjögren syndrome, overlap syndromes, mixed connective tissue disease, Ehlers-Danlos syndromes, and other vasculitides. Each section begins with a brief overview of the condition, followed by a discussion of the etiopathophysiology, physical examination findings, GI manifestations, diagnostic tools (i.e., serologic, imaging, endoscopic, and functional), and treatment options.
Collapse
|
27
|
Systemische Sklerose – klinisches Bild, Diagnostik und Therapie. Hautarzt 2019; 70:723-741. [DOI: 10.1007/s00105-019-4454-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
28
|
Smith E, Pauling JD. The efficacy of dietary intervention on gastrointestinal involvement in systemic sclerosis: A systematic literature review. Semin Arthritis Rheum 2019; 49:112-118. [DOI: 10.1016/j.semarthrit.2018.12.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 12/03/2018] [Indexed: 12/19/2022]
|
29
|
Systemische Sklerose – klinisches Bild, Diagnostik und Therapie. Z Rheumatol 2019; 78:439-457. [DOI: 10.1007/s00393-019-0639-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
|
30
|
Chatzinikolaou SL, Quirk B, Murray C, Planche K. Radiological findings in gastrointestinal scleroderma. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 5:21-32. [DOI: 10.1177/2397198319848550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022]
Abstract
Gastrointestinal involvement is the most common visceral organ manifestation in systemic sclerosis. Symptoms from the gastrointestinal tract are very frequent among scleroderma patients and in many cases present a therapeutic challenge. However, gastrointestinal involvement may also be asymptomatic, presenting with complications later in the disease course. Early recognition of gastrointestinal scleroderma is therefore important both for symptomatic control and prevention of complications. Gastrointestinal imaging alongside clinical assessment forms the mainstay of diagnosis. Radiological investigations, traditionally plain radiographs and barium studies, with the more recent advances in computed tomography, magnetic resonance imaging and ultrasound, provide means for accurate evaluation of visceral organ involvement and more effective patient care. Awareness of the characteristic images is important not only for radiologists but also for the treating physicians and gastroenterologists.
Collapse
Affiliation(s)
- Stamatia-Lydia Chatzinikolaou
- Department of Gastroenterology, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, Royal Free London NHS Foundation Trust, London, UK
| | - Bernadine Quirk
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| | - Charles Murray
- Department of Gastroenterology, The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, Royal Free London NHS Foundation Trust, London, UK
| | - Katie Planche
- Department of Radiology, Royal Free London NHS Foundation Trust, London, UK
| |
Collapse
|
31
|
Abstract
A variety of rheumatologic disorders may affect the liver. There is a significant epidemiologic, genetic, and immunologic overlap between immune-mediated rheumatologic disorders and autoimmune liver diseases. There is an increased frequency of autoimmune liver diseases, such as primary biliary cholangitis, autoimmune hepatitis, primary sclerosing cholangitis, or overlap syndrome, in patients with systemic lupus erythematosus, rheumatoid arthritis, Sjögren syndrome, systemic sclerosis, vasculitis, and other immune-related diseases. Non-immune-mediated rheumatologic diseases such as gouty arthritis may also have hepatic manifestations. Furthermore, medications used to treat rheumatologic diseases occasionally cause liver dysfunction. Conversely, primary immune-mediated and non-immune-mediated liver disorders may present with rheumatologic manifestations.
Collapse
Affiliation(s)
- Agazi Gebreselassie
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Howard University Hospital, 2041 Georgia Avenue Northwest, Suite 4J19, Washington, DC 20060, USA
| | - Farshad Aduli
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Howard University Hospital and College of Medicine, 2041 Georgia Avenue Northwest, Suite 5C22, Washington, DC 20060, USA
| | - Charles D Howell
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Howard University Hospital and College of Medicine, 2041 Georgia Avenue Northwest, Suite 5C02, Washington, DC 20060, USA.
| |
Collapse
|
32
|
Abstract
INTRODUCTION Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease characterized by vascular dysfunction, fibrosis, inflammation and autoantibodies. The pathophysiology of SSc is not completely understood, and many patients acquire organ or tissue damage despite advances in treatment. Current treatments target affected organs with modest improvements. Areas covered: This review evaluates several treatment strategies for SSc based on involved organs including skin, pulmonary, cardiac, renal, musculoskeletal, and gastrointestinal. Currently, pulmonary hypertension and interstitial lung disease are the primary causes of increased mortality. We will outline an approach to treatment of SSc based on disease manifestations and current evidence. Expert commentary: This complex disease is currently treated with therapies developed for similar indications such as for vascular manifestations of SSc using idiopathic pulmonary arterial hypertension treatments. Future directions in this field may include combination and maintenance therapy that is currently used in other autoimmune diseases, and tailoring these treatments according to the patients' phenotype. This will hopefully increase the efficacy of available treatments and decrease mortality from SSc.
Collapse
Affiliation(s)
- Maysoon Eldoma
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,b Rheumatologist, Connective Tissue Disease Fellow , University of Western Ontario , Ontario , Canada.,c Division of Rheumatology, Department of Medicine , University of Calgary , Calgary , Alberta , Canada
| | - Janet Pope
- a Division of Rheumatology, St. Joseph's Health Care, Department of Medicine , University of Western Ontario , Ontario , Canada.,d Division Head Rheumatology and Professor of Medicine , University of Western Ontario , Ontario , Canada
| |
Collapse
|