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Chen SH, Lien PH, Lee CH, Huang RW, Hsu CC, Lin CH, Lin YT, Tsai CH, Tsai HI, Liu YC. Neurectomy of the Nerve of Henle Associated with Periarterial Sympathectomy for Management of Intractable Raynaud Phenomenon. Plast Reconstr Surg 2024; 153:1333-1344. [PMID: 37384892 DOI: 10.1097/prs.0000000000010902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
BACKGROUND In periarterial sympathectomy for intractable Raynaud phenomenon, the extent of adventitectomy and postoperative outcomes and hand perfusion assessment tools remain debatable. The authors evaluated the outcome of neurectomy of the nerve of Henle combined with ulnar tunnel release and periarterial adventitectomy in the treatment of refractory Raynaud phenomenon using objective measurements and patient-reported outcomes. METHODS Nineteen patients with 20 affected hands were prospectively enrolled and underwent the proposed procedures from 2015 to 2021. Relevant data, including Michigan Hand Outcomes Questionnaire and 36-Item Short Form health questionnaire scores, were documented for analysis during a 3-year follow-up. RESULTS The average ingress value of the three measured fingers (index, long, and ring) on indocyanine green angiography increased after surgery ( P = 0.02). The median number of ulcers decreased ( P < 0.001), and the median digital skin temperature increased ( P < 0.001). Questionnaire scores showed improvement in physical aspects, such as overall hand function ( P ≤ 0.001), activities of daily living ( P = 0.001), work performance ( P = 0.02), pain ( P < 0.001), physical function ( P = 0.053), and general health ( P = 0.048), and mental aspects, such as patient satisfaction ( P < 0.001) and mental health ( P = 0.001). The average indocyanine green ingress value of the three measured fingers significantly correlated with the patient-reported outcomes, including overall hand function ( r = 0.46, P = 0.04), work performance ( r = 0.68, P = 0.001), physical function ( r = 0.51, P = 0.02), and patient satisfaction ( r = 0.35, P= 0.03). CONCLUSIONS The proposed surgical procedures provided satisfactory outcomes, both subjectively and objectively, over a follow-up period of up to 3 years. Indocyanine green angiography may provide rapid and quantitative measurements for perioperative hand perfusion assessment. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Shih-Heng Chen
- From the Departments of Plastic and Reconstructive Surgery
| | - Po-Hao Lien
- Chang-Gung Memorial Hospital, Keelung Branch, Chang-Gung University and Medical College
| | - Che-Hsiung Lee
- From the Departments of Plastic and Reconstructive Surgery
| | - Ren-Wen Huang
- From the Departments of Plastic and Reconstructive Surgery
| | | | - Cheng-Hung Lin
- From the Departments of Plastic and Reconstructive Surgery
| | - Yu-Te Lin
- From the Departments of Plastic and Reconstructive Surgery
| | | | | | - Yuan-Chang Liu
- Medical Imaging and Intervention, Institute for Radiologic Research, Chang-Gung Memorial Hospital, Linkou Branch
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2
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Yu F, Liu Y, Zhang C, Pang B, Zhang D, Zhao W, Li X, Yang W. Efficacy analysis of minimally invasive surgery for Raynaud's syndrome. BMC Surg 2023; 23:313. [PMID: 37838733 PMCID: PMC10576400 DOI: 10.1186/s12893-023-02225-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 10/08/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND Raynaud's syndrome (RS), also referred to as Raynaud's phenomenon, is a vasospastic disorder causing episodic color changes in extremities upon exposure to cold or stress. These manifestations, either primary Raynaud's phenomenon (PRP) or associated with connective tissue diseases like systemic sclerosis (SSc) as secondary Raynaud's phenomenon (SRP), affect the quality of life. Current treatments range from calcium channel blockers to innovative surgical interventions, with evolving efficacy and safety profiles. METHODS In this retrospective study, patients diagnosed with RS were selected based on complete medical records, ensuring homogeneity between groups. Surgeries involved microscopic excision of sympathetic nerve fibers and stripping of the digital artery's adventitia. Postoperative care included antibiotics, analgesia, oral nifedipine, and heat therapies. Evaluation metrics such as the VAS pain score and RCS score were collected bi-weekly. Data analysis was conducted using SPSS 26.0, with significance set at p < 0.05. RESULTS In total, 15 patients formed the experimental group, with five presenting fingertip soft tissue necrosis and ten showing RS symptoms. Comparative analysis of demographic data between experimental and control groups, both containing 15 participants, demonstrated no significant age and gender difference. However, the "Mean Duration of RP attack" in the experimental group was notably shorter (9.47 min ± 0.31) than the control group (19.33 min ± 1.79). The RS Severity Score also indicated milder severity for the experimental cohort (score: 8.55) compared to the control (score: 11.23). Postoperative assessments at 2, 4, and 6 weeks revealed improved VAS pain scores, RCS scores, and other measures for the experimental group, showing significant differences (p < 0.05). One distinctive case showcased a variation in the common digital nerve and artery course in an RS patient. CONCLUSION Our retrospective analysis on RS patients indicates that microsurgical techniques are safe and effective in the short term. As surgical practices lean towards minimally invasive methods, our data supports this shift. However, extensive, prospective studies are essential for conclusive insights.
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Affiliation(s)
- Fengwei Yu
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Yongtao Liu
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China.
| | - Chengnian Zhang
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Botao Pang
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Daijie Zhang
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Wei Zhao
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Xuecheng Li
- Hand Microsurgery, Binzhou Medical University Hospital, Binzhou, 256600, China
| | - Weiqiang Yang
- The First Clinical School of Binzhou Medical University, Binzhou, 256600, China
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3
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Budge J, Azhar B, Desai M. Is there any role for surgical management of primary Raynaud's disease? Eur J Vasc Endovasc Surg 2023; 66:291. [PMID: 37169136 DOI: 10.1016/j.ejvs.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 05/03/2023] [Indexed: 05/13/2023]
Affiliation(s)
- James Budge
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; St George's University of London, London, UK.
| | - Bilal Azhar
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; St George's University of London, London, UK
| | - Mital Desai
- St George's Vascular Institute, St George's University Hospitals NHS Foundation Trust, London, UK; St George's University of London, London, UK
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4
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Pope JE, Denton CP, Johnson SR, Fernandez-Codina A, Hudson M, Nevskaya T. State-of-the-art evidence in the treatment of systemic sclerosis. Nat Rev Rheumatol 2023; 19:212-226. [PMID: 36849541 PMCID: PMC9970138 DOI: 10.1038/s41584-023-00909-5] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2023] [Indexed: 03/01/2023]
Abstract
Systemic sclerosis (SSc) is a rare autoimmune connective tissue disease with multi-organ involvement, fibrosis and vasculopathy. Treatment in SSc, including early diffuse cutaneous SSc (dcSSc) and the use of organ-specific therapies, has improved, as evident from randomized clinical trials. Treatments for early dcSSc include immunosuppressive agents such as mycophenolate mofetil, methotrexate, cyclophosphamide, rituximab and tocilizumab. Patients with rapidly progressive early dcSSc might be eligible for autologous haematopoietic stem cell transplantation, which can improve survival. Morbidity from interstitial lung disease and pulmonary arterial hypertension is improving with the use of proven therapies. Mycophenolate mofetil has surpassed cyclophosphamide as the initial treatment for SSc-interstitial lung disease. Nintedanib and possibly perfinidone can be considered in SSc pulmonary fibrosis. Pulmonary arterial hypertension is frequently treated with initial combination therapy (for example, with phosphodiesterase 5 inhibitors and endothelin receptor antagonists) and, if necessary, the addition of a prostacyclin analogue. Raynaud phenomenon and digital ulcers are treated with dihydropyridine calcium channel blockers (especially nifedipine), then phosphodiesterase 5 inhibitors or intravenous iloprost. Bosentan can reduce the development of new digital ulcers. Trial data for other manifestations are mostly lacking. Research is needed to develop targeted and highly effective treatments, best practices for organ-specific screening and early intervention, and sensitive outcome measurements.
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Affiliation(s)
- Janet E Pope
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada.
- Department of Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada.
| | | | - Sindhu R Johnson
- Toronto Scleroderma Program, Toronto Western Hospital, Mount Sinai Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Andreu Fernandez-Codina
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
- General Internal Medicine, Windsor Regional Hospital, Windsor, ON, Canada
- Critical Care, Emergency and Systemic Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - Marie Hudson
- Department of Medicine, McGill University, Montreal, QC, Canada
- Division of Rheumatology and Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada
| | - Tatiana Nevskaya
- Division of Rheumatology, St Joseph's Health Care, London, ON, Canada
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5
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Hakami LM, Forster GL, Jones MK, DeGeorge BR. Scleroderma and Raynaud Phenomenon: The Cold Truth Regarding the Use of Operative Management. Plast Reconstr Surg 2022; 150:105e-114e. [PMID: 35544320 DOI: 10.1097/prs.0000000000009187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Raynaud phenomenon, with and without scleroderma, is a common vasospastic condition that manifests with extremity pain and skin discoloration. When conservative management fails, complications such as ischemia, ulceration, and gangrene may warrant surgical intervention. The purpose of this study was to determine the risk factors and use of surgical intervention in this population. METHODS A national insurance claims-based database with patient records from the Centers for Medicare and Medicaid Services was used for data collection. Patients with first diagnoses of Raynaud phenomenon, scleroderma, or both between 2005 and 2014 were identified. Primary outcomes included the presence of upper extremity amputation or vascular procedure, and history of amputation within 5 years of a vascular procedure. Secondary outcomes included hospital admissions, upper extremity wounds, and amputation within 1 year of diagnosis. RESULTS The Raynaud phenomenon, scleroderma, and Raynaud phenomenon with scleroderma cohorts consisted of 161,300, 117,564, and 25,096 patients, respectively. A diagnosis of both Raynaud phenomenon and scleroderma increased the odds of upper extremity amputation by 5.4-fold, vascular procedure by 4.8-fold, and amputation within 5 years of a vascular procedure by 1.5-fold. Patients with Raynaud phenomenon or scleroderma alone were 3.1 and 5.6 times less likely to undergo amputation within 5 years of a vascular procedure, respectively. CONCLUSIONS Patients with both Raynaud phenomenon and scleroderma have higher likelihoods of having upper extremity amputations, vascular procedures, and amputations following vascular procedures compared to each diagnosis alone. Vascular procedures are rarely being performed. Further research is necessary to establish a standard of care and determine whether early and more frequent intervention with vascular procedures can decrease amputation rates in this patient population. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Affiliation(s)
- Lee M Hakami
- From the Department of Plastic Surgery, the School of Medicine, and the Claude Moore Health Sciences Library, University of Virginia
| | - Grace L Forster
- From the Department of Plastic Surgery, the School of Medicine, and the Claude Moore Health Sciences Library, University of Virginia
| | - Marieke K Jones
- From the Department of Plastic Surgery, the School of Medicine, and the Claude Moore Health Sciences Library, University of Virginia
| | - Brent R DeGeorge
- From the Department of Plastic Surgery, the School of Medicine, and the Claude Moore Health Sciences Library, University of Virginia
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6
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Vegas DH, Fabiani MA, Gonzalez-Urquijo M, Bignotti A, Seré I, Salvadores P. Novel Combined Approach for Digital Necrosis Secondary to Raynaud's Phenomenon. Vasc Endovascular Surg 2021; 55:766-771. [PMID: 33866879 DOI: 10.1177/15385744211005663] [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: 11/16/2022]
Abstract
The presence of severe Raynaud's Phenomenon (RP), with permanent pain or digital necrosis is a rare condition. Cervical sympathectomy or distal sympathectomy or A botulinum toxin have demonstrated efficacy after medical treatment failure. We report the case of a 38-year-old female patient with an acute onset of severe RP in both hands secondary to systemic sclerosis. Medical treatment failed, so a novel approach by a combination of a modified distal sympathectomy and injection of A botulinum toxin on digital neuromuscular bundles was performed. Remission of the pain occurred immediately after the procedure and 45 days later she had complete healing of the digital wounds and recovered full mobilization of both hands. The patient remained asymptomatic 6 month after the procedure, and a Doppler ultrasound showed tri-phasic flows distal to the surgical site. This novel technique is described, and a brief review of the literature is performed.
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Affiliation(s)
- Diego Herrera Vegas
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Mario Alejandro Fabiani
- Tecnologico de Monterrey, School of Medicine and Health Sciences, Monterrey, Nuevo León, México
| | | | - Agustín Bignotti
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Ignacio Seré
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
| | - Pablo Salvadores
- Centro de Estudios Médicos e Investigaciones Clínicas (C.E.M.I.C.), Buenos Aires, Argentina
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Hughes M, Bruni C, Ruaro B, Confalonieri M, Matucci-Cerinic M, Bellando-Randone S. Digital Ulcers in Systemic Sclerosis. Presse Med 2021; 50:104064. [PMID: 33548375 DOI: 10.1016/j.lpm.2021.104064] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 01/29/2021] [Indexed: 12/28/2022] Open
Abstract
Digital ulcers (DU) are one of the most common complication of Systemic Sclerosis (SSc)-related vasculopathy and represent an important burden for the patients as well as for the society. Still today there is no agreement on the definition, classification and cathegorization of DU even if they are of pivotal importance in clinical practice, for treatment choice and prognostic outcomes, as well as for clinical trials. DU management requires a dedicated multidisciplinary team, that must remain ever vigilant for the development of infective complications and gangrene throughout their disease course, as well as patient education that is crucial to obtain the best compliance to assure the success of the treatment. Currently several drugs are available for DU treatment but in the future, more investigations will be needed to ameliorate the approach and the systemic and local therapies.
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Affiliation(s)
- Michael Hughes
- Department of Rheumatology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Cosimo Bruni
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Firenze, & Department of Geriatric Medicine, Division of Rheumatology AOUC, Firenze, Italy
| | - Barbara Ruaro
- Pulmonology Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Marco Confalonieri
- Pulmonology Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Marco Matucci-Cerinic
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Firenze, & Department of Geriatric Medicine, Division of Rheumatology AOUC, Firenze, Italy
| | - Silvia Bellando-Randone
- Department of Experimental and Clinical Medicine, Division of Rheumatology, University of Firenze, & Department of Geriatric Medicine, Division of Rheumatology AOUC, Firenze, Italy.
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8
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Bello RJ, Cooney CM, Melamed E, Follmar K, Yenokyan G, Leatherman G, Shah AA, Wigley FM, Hummers LK, Lifchez SD. The Therapeutic Efficacy of Botulinum Toxin in Treating Scleroderma-Associated Raynaud's Phenomenon: A Randomized, Double-Blind, Placebo-Controlled Clinical Trial. Arthritis Rheumatol 2017; 69:1661-1669. [PMID: 28426903 DOI: 10.1002/art.40123] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 04/06/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the therapeutic efficacy of local injections of botulinum toxin type A (Btx-A) in improving blood flow to the hands of patients with Raynaud's phenomenon (RP) secondary to scleroderma. METHODS In this randomized, double-blind, placebo-controlled clinical trial, patients with scleroderma-associated RP received Btx-A (50 units in 2.5 ml sterile saline) in one randomly selected hand and sterile saline (2.5 ml) in the opposite hand. Follow-up at 1 and 4 months postinjection included laser Doppler imaging of hands, patient-reported outcomes, and physical examination. We compared outcomes using paired t-tests and population-average generalized models with generalized estimating equations. RESULTS Of 40 patients enrolled, 25 had limited scleroderma and 15 had diffuse scleroderma. From baseline to 1-month follow-up, there was a greater reduction in average blood flow in Btx-A-treated hands compared to placebo-treated hands. The model estimated that this difference was statistically significant (average difference -30.08 flux units [95% confidence interval -56.19, -3.98], P for interaction = 0.024). This difference was mainly influenced by patients with longstanding RP and diffuse scleroderma. Change in blood flow at 4-month follow-up was not significantly different between groups. Clinical measures (QuickDASH, McCabe Cold Sensitivity Score, pain on a visual analog scale, and Raynaud's Condition Score) improved slightly for Btx-A-treated hands. CONCLUSION Our laboratory-based laser Doppler imaging flow data do not support using Btx-A to treat RP in all scleroderma patients. The secondary clinical outcomes suggest some positive effect, but its clinical meaningfulness is questionable. The role of Btx-A in treating RP should be further studied with more homogeneous patient populations and in unique clinical situations such as acute digital ischemia.
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Affiliation(s)
| | | | | | | | | | | | - Ami A Shah
- Johns Hopkins University, Baltimore, Maryland
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9
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Hughes M, Herrick AL. Digital ulcers in systemic sclerosis. Rheumatology (Oxford) 2016; 56:14-25. [PMID: 27094599 DOI: 10.1093/rheumatology/kew047] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 02/15/2016] [Indexed: 11/14/2022] Open
Abstract
Digital ulcers (DUs) are a common visible manifestation of the progressive vascular disease that characterizes the SSc disease process. DUs not only impact significantly on patients' quality of life and hand function, but are also a biomarker of internal organ involvement and of disease severity. The aetiology of (digital) vascular disease in SSc is multifactorial, and many of these factors are potentially amenable to therapeutic intervention. The management of DU disease in SSc is multifaceted. Patient education and non-pharmacological interventions (e.g. smoking cessation) should not be neglected. There are a number of drug therapies available to prevent (e.g. phosphodiesterase type-5 inhibitors and ET receptor-1 antagonists) and treat (e.g. i.v. iloprost) DUs. DUs are also important for two other reasons: firstly, as a primary end point in SSc-related clinical trials; and secondly, DUs are included in the ACR/EULAR SSc classification criteria. However, the reliability of rheumatologists to grade DUs is poor to moderate at best, and this poses challenges in both clinical practice and research. The purpose of this review is to provide the reader with a description of the spectrum of DU disease in SSc including pathophysiology, epidemiology and clinical burden, all of which inform the multifaceted approach to management.
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Affiliation(s)
- Michael Hughes
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester
| | - Ariane L Herrick
- Centre for Musculoskeletal Research, The University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester.,NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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10
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Gunnarsson R, Hetlevik SO, Lilleby V, Molberg Ø. Mixed connective tissue disease. Best Pract Res Clin Rheumatol 2016; 30:95-111. [DOI: 10.1016/j.berh.2016.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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11
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Letamendia A, López-Román J, Bustamante-Munguira J, Herreros J. Digital periarterial sympathectomy in the management of post-traumatic Raynaud syndrome. J Vasc Surg 2016; 63:459-65. [DOI: 10.1016/j.jvs.2015.08.102] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 08/25/2015] [Indexed: 11/28/2022]
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12
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Abstract
Raynaud’s phenomenon and digital ulcerations are two common clinical features seen in patients with systemic sclerosis. They are painful and lead to significant morbidity and altered hand function within this patient population. While currently there are no US Food and Drug Administration (FDA)-approved medications for the treatment of digital ulcerations in the United States, clinical trials have supported the use of pharmacologic and nonpharmacologic modalities in facilitating healing of existing digital ulcers and preventing formation of new ulcers. This article reviews the published data on these therapeutic options.
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Affiliation(s)
- Shawn Abraham
- Division of Rheumatology, immunology, and Allergy, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Virginia Steen
- Division of Rheumatology, immunology, and Allergy, MedStar Georgetown University Hospital, Washington, DC, USA
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13
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Volkmann ER, Furst DE. Management of Systemic Sclerosis-Related Skin Disease: A Review of Existing and Experimental Therapeutic Approaches. Rheum Dis Clin North Am 2015. [PMID: 26210126 DOI: 10.1016/j.rdc.2015.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The skin is the most common organ system involved in patients with systemic sclerosis (SSc). Nearly all patients experience cutaneous symptoms, including sclerosis, Raynaud's phenomenon, digital ulcers, telangiectasias, and calcinosis. In addition to posing functional challenges, cutaneous symptoms are often a major cause of pain, psychological distress, and body image dissatisfaction. The present article reviews the main features of SSc-related cutaneous manifestations and highlights an evidence-based treatment approach for treating each manifestation. This article also describes novel treatment approaches and opportunities for further research in managing this important clinical dimension of SSc.
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Affiliation(s)
- Elizabeth R Volkmann
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Suite 32-59, Los Angeles, CA 90095, USA.
| | - Daniel E Furst
- Division of Rheumatology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, 1000 Veteran Avenue, Suite 32-59, Los Angeles, CA 90095, USA
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14
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Moaveni D, Cohn J, Brodt J, Hoctor K, Ranasinghe J. Scleroderma and pulmonary hypertension complicating two pregnancies: use of neuraxial anesthesia, general anesthesia, epoprostenol and a multidisciplinary approach for cesarean delivery. Int J Obstet Anesth 2015; 24:375-82. [PMID: 26119257 DOI: 10.1016/j.ijoa.2015.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 05/01/2015] [Accepted: 05/03/2015] [Indexed: 10/23/2022]
Abstract
Literature regarding the anesthetic care of patients with scleroderma during labor and delivery is limited to remote case reports. No recent publications provide information on the anesthetic management of patients with coexisting pulmonary hypertension. This report describes the anesthetic and multidisciplinary management of two pregnant patients with concomitant scleroderma and pulmonary hypertension undergoing cesarean delivery; one with neuraxial anesthesia and one with general anesthesia. Considerations for neuraxial and general anesthesia in patients with concurrent scleroderma and pulmonary hypertension are discussed.
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Affiliation(s)
- D Moaveni
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
| | - J Cohn
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - J Brodt
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - K Hoctor
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - J Ranasinghe
- University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
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15
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Momeni A, Sorice SC, Valenzuela A, Fiorentino DF, Chung L, Chang J. Surgical treatment of systemic sclerosis-is it justified to offer peripheral sympathectomy earlier in the disease process? Microsurgery 2015; 35:441-6. [DOI: 10.1002/micr.22379] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 12/22/2014] [Accepted: 12/26/2014] [Indexed: 11/07/2022]
Affiliation(s)
- Arash Momeni
- Division of Plastic and Reconstructive Surgery; Stanford University Medical Center; Palo Alto CA
| | - Sarah C. Sorice
- Division of Plastic and Reconstructive Surgery; Stanford University Medical Center; Palo Alto CA
| | - Antonia Valenzuela
- Division of Immunology and Rheumatology; Stanford University Medical Center; Palo Alto CA
| | - David F. Fiorentino
- Division of Immunology and Rheumatology; Stanford University Medical Center; Palo Alto CA
- Department of Dermatology; Stanford University Medical Center; Palo Alto CA
| | - Lorinda Chung
- Division of Immunology and Rheumatology; Stanford University Medical Center; Palo Alto CA
- Department of Dermatology; Stanford University Medical Center; Palo Alto CA
| | - James Chang
- Division of Plastic and Reconstructive Surgery; Stanford University Medical Center; Palo Alto CA
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16
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Moran ME. Scleroderma and evidence based non-pharmaceutical treatment modalities for digital ulcers: a systematic review. J Wound Care 2014; 23:510-6. [PMID: 25296352 DOI: 10.12968/jowc.2014.23.10.510] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Digital ulcers are difficult to heal, increasing the chance of infection, gangrene, amputation and limited functional use of hands. They are a complication in scleroderma or systematic sclerosis (SSc) and occur in approximately 50% of patients. This is a systematic review of the evidence supporting the use of non-pharmaceutical therapeutic modalities and their effectiveness to facilitate the healing of chronic digital ulcers in patients with scleroderma. METHOD A comprehensive review of computerised databases from 2000-2013: PubMed/MEDLINE, CINAHL, Pedro, OT Seeker, OT Search, OVID, and Proquest as well as manual review of other resources was completed using the following search terms scleroderma or systemic sclerosis and/or digital ulcers, specific modalities (low level laser therapy, electrical stimulation, intermittent compression, ultrasound, vitamin E, myofascial release, wound dressings, iontophoresis, negative pressure therapy, and exercise), chronic wounds, and wound care. English language studies, from 2000 to January 2013, which used therapeutic modalities to facilitate healing of digital ulcers and use healing of the digital ulcer as an outcome measure were reviewed. RESULTS Of the 403 identified articles, only 11 studies addressed non-pharmaceutical treatment modalities to facilitate healing for digital ulcers. Exercise had no direct effect on healing ulcers. The following studies were positive but have limitations in design and sample size:: hyperbaric oxygen therapy (n=2), negative pressure therapy (n=1), intermittent compression (n=27) and acoustic pressure wound healing (n=1). Vitamin E gel showed a significant difference compared to a control group (n=27). Iontophoresis studies have shown that the modality increases blood flow but the results in five different studies are mixed and the application and intensity were inconsistent. CONCLUSION No one modality was proven to be the most effective. Larger efficacy studies on treating digital ulcers are needed in order to develop appropriate care guidelines to improve outcomes, promote function and lower health-care costs.
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Affiliation(s)
- M E Moran
- Assistant Professor; Department of Occupational Therapy Kean University 1000 Morris Avenue Union, New Jersey 0708
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Frerix M, Meier F, Hermann W, Müller-Ladner U. Therapeutische Strategien im Frühstadium der systemischen Sklerose. Z Rheumatol 2013; 72:960-9. [DOI: 10.1007/s00393-013-1270-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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In vivo reduction or blockade of interleukin-1β in primary osteoarthritis influences expression of mediators implicated in pathogenesis. Osteoarthritis Cartilage 2012; 20:1610-8. [PMID: 22935786 PMCID: PMC3478416 DOI: 10.1016/j.joca.2012.08.011] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Revised: 08/10/2012] [Accepted: 08/18/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Diminish interleukin-1β (IL-1β) signaling in a model of primary osteoarthritis by RNA interference-based transcript reduction or receptor blockade, and quantify changes incurred on transcript expression of additional mediators. METHODS Knees of Hartley guinea pigs were collected at 120 and 180 days of age following injection with viral vectors (N = 4/treatment group/date) at 60 days. Two groups received either adeno-associated viral serotype 5 vector containing a knockdown sequence (TV), or adenoviral vector encoding for IL-1 receptor antagonist protein (Ad-IRAP); treatments were contrasted with opposite knees administered corresponding vector controls. A third group evaluated TV relative to saline-only injected knees. Chondropathy and immunohistochemistry findings were compared to untreated guinea pigs. Transcript expression levels in cartilage were calculated using the comparative CT (2(-ΔΔCT)) method and analyzed by one-way analysis of variance (ANOVA) with pairwise comparisons using Tukey 95% confidence intervals. RESULTS Vector transduction was confirmed at both harvest dates. TV and Ad-IRAP, relative to vector controls, significantly decreased IL-1β. Inflammatory mediators [tumor necrosis factor-α (TNF-α), IL-8, interferon-γ (IFN-γ)], and catabolic matrix metalloproteinase 13 (MMP13) were also decreased, while anabolic transforming growth factor-β1 (TGF-β1) was increased. IL-1β was also decreased by TV vs saline, with a decrease in MMP13 and increase TGF-β1; TNF-α, IL-8, and IFN-γ were transiently increased. CONCLUSIONS This work confirmed that a reduction in IL-1β signaling was accomplished by either method, resulting in decreased expression of three inflammatory mediators and one catabolic agent, and increased expression of an anabolic molecule. Thus, evidence is provided that IL-1β serves a role in vivo in spontaneous osteoarthritis and that these translational tools may provide beneficial disease modification.
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Current world literature. Curr Opin Rheumatol 2011; 23:620-5. [PMID: 21960037 DOI: 10.1097/bor.0b013e32834ccef6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Botzoris V, Drosos AA. Management of Raynaud's phenomenon and digital ulcers in systemic sclerosis. Joint Bone Spine 2011; 78:341-6. [DOI: 10.1016/j.jbspin.2010.11.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 11/05/2010] [Indexed: 11/30/2022]
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