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Radic M, Thomas J, McMillan S, Frech T. Does sublingual microscopy correlate with nailfold videocapillaroscopy in systemic sclerosis? Clin Rheumatol 2021; 40:2263-2266. [PMID: 33415452 DOI: 10.1007/s10067-020-05495-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/29/2020] [Accepted: 11/02/2020] [Indexed: 11/24/2022]
Abstract
In this study, we examine sublingual videomicroscopy and nailfold videocapillaroscopy (NVC) features in systemic sclerosis (SSc) patients presenting for routine care. Consented participants met classification criteria for SSc. Sublingual videomicroscopy testing was performed in each subject, followed by a NVC assessment. Sublingual assessment provided a density measurement, red blood cell fraction (RBC fract), and perfused boundary region (PBR) score. NVC evaluator defined nailfold findings as normal; specific changes for "early," "active," and "late" scleroderma pattern; or "non-specific" changes. Microangiopathy evolution score was calculated for each participant. Statistical evaluation was performed by non-parametric tests to assess the correlation of the two tools. Thirty-nine SSc patients with limited cutaneous disease participated in this study. Most participants had late pattern NVC. There was a highly significant association between the total sublingual microvascular density and number of capillaries measured by NVC (r = 0.569, P = 0.0002), and statistically significant negative correlation between sublingual total microvascular density and microangiopathy evolution score (r = 0.532, P = 0.0006). There was significant, negative correlation between the total sublingual microvascular density and disorganization of vascular array and capillary ramification (r = 0.461, P = 0.003) and degree of giant capillaries (r = 0.387, P = 0.01). There was no correlation between RBC fract and PBR with NVC parameters. This study showed a significant correlation between sublingual videomicroscopy and NVC in terms of sublingual total microvascular density and microangiopathy evolution score. These preliminary results further support the serial use of a non-invasive and automated sublingual microvascular function testing and glycocalyx measurement in the clinical setting. KEY POINTS: • Tools that longitudinally assess microvascular function and morphologic features are important for monitoring SSc vasculopathy. • Nailfold and sublingual microscopy can identify a loss of capillary density in SSc patients.
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Affiliation(s)
- Mislav Radic
- Department of Internal Medicine, Division of Rheumatology, University of Utah, 1900 E 30N, SOM 4b200, Salt Lake City, UT, 84132, USA.,Division of Rheumatology and Clinical Immunology, Centre of excellence for Systemic Sclerosis in Croatia, University Hospital Split and University of Split School of Medicine, Split, Croatia
| | - Julie Thomas
- Department of Internal Medicine, Division of Rheumatology, University of Utah, 1900 E 30N, SOM 4b200, Salt Lake City, UT, 84132, USA
| | - Sean McMillan
- Department of Internal Medicine, Division of Rheumatology, University of Utah, 1900 E 30N, SOM 4b200, Salt Lake City, UT, 84132, USA
| | - Tracy Frech
- Department of Internal Medicine, Division of Rheumatology, University of Utah, 1900 E 30N, SOM 4b200, Salt Lake City, UT, 84132, USA. .,Utah Vascular Research Laboratory, Salt Lake Veterans Affair Medical Center, Salt Lake City, UT, USA.
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Machin DR, Gates PE, Vink H, Frech TM, Donato AJ. Automated Measurement of Microvascular Function Reveals Dysfunction in Systemic Sclerosis: A Cross-sectional Study. J Rheumatol 2017; 44:1603-1611. [PMID: 28916547 DOI: 10.3899/jrheum.170120] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of our study was to determine whether an automated capture and analysis system could detect differences in structure and function of sublingual microvessels in patients with systemic sclerosis (SSc) compared to healthy controls. METHODS Intravital microscopy of the sublingual microcirculation was automatically captured and analyzed in 40 patients with SSc and 10 age-matched healthy controls. RESULTS Total and perfused microvascular density were lower in patients with SSc compared with controls (total microvascular density: 2471 ± 134 µm/mm2 vs 3067 ± 197 µm/mm2, p = 0.020; perfused microvascular density: 1708 ± 92 µm/mm2 vs 2192 ± 144 µm/mm2, p = 0.009). However, the relative percentage of perfused to total microvascular density was similar between SSc and controls (72 ± 2% vs 71 ± 2%, respectively, p = 0.429). Mean red blood cell (RBC) fraction, which indicates the longitudinal tube hematocrit of microvessel segments, was lower in patients with SSc compared with controls (69 ± 1% vs 77 ± 1%, respectively, p < 0.001). Perfused boundary region (PBR), a marker of endothelial glycocalyx barrier properties, was higher in patients with SSc compared with controls (2.1 ± 0.0 µm vs 1.9 ± 0.0 µm, respectively, p = 0.012), suggestive of a dysfunctional glycocalyx. There was an inverse association of PBR with perfused microvascular density (r = -0.40, p = 0.004) and RBC fraction (r = -0.80, p < 0.001). CONCLUSION Our results indicate that automated capture and analysis of sublingual microvessel segments produces detailed, objective microvascular structural and functional data that have allowed us to distinguish patients with SSc from controls. These data suggest that microvascular structural and functional abnormalities present in patients with SSc could be at least partly due to a dysfunctional glycocalyx.
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Affiliation(s)
- Daniel R Machin
- From the University of Utah, Department of Internal Medicine, and the Department of Exercise and Sport Science, and the Department of Biochemistry; VA Salt Lake City, Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, Utah, USA; Maastricht University, Department of Physiology, Maastricht, the Netherlands; MicroVascular Health Solutions LLC, Alpine, Utah, USA.,D.R. Machin, PhD, University of Utah, Department of Internal Medicine, and VA Salt Lake City, GRECC; P.E. Gates, PhD, University of Utah, Department of Internal Medicine; H. Vink, PhD, Maastricht University, Department of Physiology, and MicroVascular Health Solutions LLC; T.M. Frech, MD, University of Utah, Department of Internal Medicine; A.J. Donato, PhD, University of Utah, Department of Internal Medicine, Department of Exercise and Sport Science, Department of Biochemistry, and VA Salt Lake City, GRECC
| | - Phillip E Gates
- From the University of Utah, Department of Internal Medicine, and the Department of Exercise and Sport Science, and the Department of Biochemistry; VA Salt Lake City, Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, Utah, USA; Maastricht University, Department of Physiology, Maastricht, the Netherlands; MicroVascular Health Solutions LLC, Alpine, Utah, USA.,D.R. Machin, PhD, University of Utah, Department of Internal Medicine, and VA Salt Lake City, GRECC; P.E. Gates, PhD, University of Utah, Department of Internal Medicine; H. Vink, PhD, Maastricht University, Department of Physiology, and MicroVascular Health Solutions LLC; T.M. Frech, MD, University of Utah, Department of Internal Medicine; A.J. Donato, PhD, University of Utah, Department of Internal Medicine, Department of Exercise and Sport Science, Department of Biochemistry, and VA Salt Lake City, GRECC
| | - Hans Vink
- From the University of Utah, Department of Internal Medicine, and the Department of Exercise and Sport Science, and the Department of Biochemistry; VA Salt Lake City, Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, Utah, USA; Maastricht University, Department of Physiology, Maastricht, the Netherlands; MicroVascular Health Solutions LLC, Alpine, Utah, USA.,D.R. Machin, PhD, University of Utah, Department of Internal Medicine, and VA Salt Lake City, GRECC; P.E. Gates, PhD, University of Utah, Department of Internal Medicine; H. Vink, PhD, Maastricht University, Department of Physiology, and MicroVascular Health Solutions LLC; T.M. Frech, MD, University of Utah, Department of Internal Medicine; A.J. Donato, PhD, University of Utah, Department of Internal Medicine, Department of Exercise and Sport Science, Department of Biochemistry, and VA Salt Lake City, GRECC
| | - Tracy M Frech
- From the University of Utah, Department of Internal Medicine, and the Department of Exercise and Sport Science, and the Department of Biochemistry; VA Salt Lake City, Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, Utah, USA; Maastricht University, Department of Physiology, Maastricht, the Netherlands; MicroVascular Health Solutions LLC, Alpine, Utah, USA.,D.R. Machin, PhD, University of Utah, Department of Internal Medicine, and VA Salt Lake City, GRECC; P.E. Gates, PhD, University of Utah, Department of Internal Medicine; H. Vink, PhD, Maastricht University, Department of Physiology, and MicroVascular Health Solutions LLC; T.M. Frech, MD, University of Utah, Department of Internal Medicine; A.J. Donato, PhD, University of Utah, Department of Internal Medicine, Department of Exercise and Sport Science, Department of Biochemistry, and VA Salt Lake City, GRECC
| | - Anthony J Donato
- From the University of Utah, Department of Internal Medicine, and the Department of Exercise and Sport Science, and the Department of Biochemistry; VA Salt Lake City, Geriatric Research, Education, and Clinical Center (GRECC), Salt Lake City, Utah, USA; Maastricht University, Department of Physiology, Maastricht, the Netherlands; MicroVascular Health Solutions LLC, Alpine, Utah, USA. .,D.R. Machin, PhD, University of Utah, Department of Internal Medicine, and VA Salt Lake City, GRECC; P.E. Gates, PhD, University of Utah, Department of Internal Medicine; H. Vink, PhD, Maastricht University, Department of Physiology, and MicroVascular Health Solutions LLC; T.M. Frech, MD, University of Utah, Department of Internal Medicine; A.J. Donato, PhD, University of Utah, Department of Internal Medicine, Department of Exercise and Sport Science, Department of Biochemistry, and VA Salt Lake City, GRECC.
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Kumar S, Singh J, Rattan S, DiMarino AJ, Cohen S, Jimenez SA. Review article: pathogenesis and clinical manifestations of gastrointestinal involvement in systemic sclerosis. Aliment Pharmacol Ther 2017; 45:883-898. [PMID: 28185291 PMCID: PMC5576448 DOI: 10.1111/apt.13963] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Revised: 11/18/2016] [Accepted: 01/11/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Gastrointestinal tract (GIT) involvement is a common cause of debilitating symptoms in patients with systemic sclerosis (SSc). There are no disease modifying therapies for this condition and the treatment remains symptomatic, largely owing to the lack of a clear understanding of its pathogenesis. AIMS To investigate novel aspects of the pathogenesis of gastrointestinal involvement in SSc. To summarise existing knowledge regarding the cardinal clinical gastrointestinal manifestations of SSc and its pathogenesis, emphasising recent investigations that may be valuable in identifying potentially novel therapeutic targets. METHODS Electronic (PubMed/Medline) and manual Google search. RESULTS The GIT is the most common internal organ involved in SSc. Any part of the GIT from the mouth to the anus can be affected. There is substantial variability in clinical manifestations and disease course and symptoms are nonspecific and overlapping for a particular anatomical site. Gastrointestinal involvement can occur in the absence of cutaneous disease. Up to 8% of SSc patients develop severe GIT symptoms. This subset of patients display increased mortality with only 15% survival at 9 years. Dysmotiity of the GIT causes the majority of symptoms. Recent investigations have identified a novel mechanism in the pathogenesis of GIT dysmotility mediated by functional anti-muscarinic receptor autoantibodies. CONCLUSIONS Despite extensive investigation, the pathogenesis of gastrointestinal involvement in systemic sclerosis remains elusive. Although treatment currently remains symptomatic, an improved understanding of novel pathogenic mechanisms may allow the development of potentially highly effective approaches including intravenous immunoglobulin and microRNA based therapeutic interventions.
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Affiliation(s)
- Sumit Kumar
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Jagmohan Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Satish Rattan
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Anthony J DiMarino
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Sidney Cohen
- Department of Medicine, Division of Gastroenterology and Hepatology, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
| | - Sergio A. Jimenez
- Jefferson Institute of Molecular Medicine and Scleroderma Center, Thomas Jefferson University, Sidney Kimmel Medical College, Philadelphia, PA
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Morrisroe K, Frech T, Schniering J, Maurer B, Nikpour M. Systemic sclerosis: The need for structured care. Best Pract Res Clin Rheumatol 2016; 30:3-21. [PMID: 27421213 DOI: 10.1016/j.berh.2016.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Autoimmune connective tissue diseases (CTDs) have a propensity to affect multiple organ systems as well as physical function, quality of life, and survival. Their clinical heterogeneity, multisystem involvement, and low worldwide prevalence present challenges for researchers to establish a study design to help better understand the course and outcomes of CTDs. Systemic sclerosis (SSc) is a notable example of a CTD, wherein longitudinal cohort studies (LCS) have enabled us to elucidate disease manifestations, disease course, and risk and prognostic factors for clinically important outcomes, by embedding research in clinical practice. Nevertheless, further efforts are needed to better understand SSc especially with regard to recognizing organ involvement early, developing new therapies, optimizing the use of existing therapies, and defining treatment targets. The heterogeneous multi-organ nature of SSc would lend itself well to a structured model of care, wherein step-up treatment algorithms are used with the goal of attaining a prespecified treatment target. In this chapter, we discuss the rationale for a structured treatment approach in SSc and propose possible treatment algorithms for three of the more common disease manifestations, namely skin involvement, digital ulcers and gastrointestinal tract involvement. We discuss possible strategies for evaluating and implementing these algorithms in the setting of LCS. We conclude by presenting a research agenda for the development of structured models of care in SSc.
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Affiliation(s)
- Kathleen Morrisroe
- Department of Medicine, The University of Melbourne at St. Vincent's Hospital, Melbourne, VIC, Australia; Department of Rheumatology, The University of Melbourne at St. Vincent's Hospital, Melbourne, VIC, Australia
| | - Tracy Frech
- Division of Rheumatology, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA; Salt Lake Regional Veterans Affair Medical Center, Salt Lake City, UT, USA
| | - Janine Schniering
- Division of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Britta Maurer
- Division of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Mandana Nikpour
- Department of Medicine, The University of Melbourne at St. Vincent's Hospital, Melbourne, VIC, Australia; Department of Rheumatology, The University of Melbourne at St. Vincent's Hospital, Melbourne, VIC, Australia.
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