The registry of the German Network for Systemic Scleroderma: frequency of disease subsets and patterns of organ involvement

Objective. Systemic sclerosis (SSc) is a rare, heterogeneous disease, which affects different organs and therefore requires interdisciplinary diagnostic and therapeutic management. To improve the detection and follow-up of patients presenting with different disease manifestations, an interdisciplinary registry was founded with contributions from different subspecialties involved in the care of patients with SSc.

Methods. A questionnaire was developed to collect a core set of clinical data to determine the current disease status. Patients were grouped into five descriptive disease subsets, i.e. lcSSc, dcSSc, SSc sine scleroderma, overlap-syndrome and UCTD with scleroderma features.

Results. Of the 1483 patients, 45.5% of patients had lcSSc and 32.7% dcSSc. Overlap syndrome was diagnosed in 10.9% of patients, while 8.8% had an undifferentiated form. SSc sine scleroderma was present in 1.5% of patients. Organ involvement was markedly different between subsets; pulmonary fibrosis for instance was significantly more frequent in dcSSc (56.1%) than in overlap syndrome (30.6%) or lcSSc (20.8%). Pulmonary hypertension was more common in dcSSc (18.5%) compared with lcSSc (14.9%), overlap syndrome (8.2%) and undifferentiated disease (4.1%). Musculoskeletal involvement was typical for overlap syndromes (67.6%). A family history of rheumatic disease was reported in 17.2% of patients and was associated with early disease onset (P < 0.005).

Conclusion. In this nationwide register, a descriptive classification of patients with disease manifestations characteristic of SSc in five groups allows to include a broader spectrum of patients with features of SSc.

[Use of computer-assisted Doppler sonography and rheography in acral vascular diagnosis in progressive systemic sclerosis]

For the quantitative characterization of the blood flow of patients with progressive systemic sclerosis a combined computer-assisted Doppler sonographic as well as rheographic measuring place was established. An aimed examination of the peripheral situation of the blood supply was performed in 15 patients with progressive systemic sclerosis in comparison to a control group of patients with healthy vessels. The demonstration of the corresponding parameters of time and form of the curves resulted in significant differences for the two examination groups, particularly of the pulsation index (PI) and the index of the peripheral resistance (PWI) in the Doppler flow curves as well as for the maximum increase (A) and the peak time (GZ) in the rheogrammes. The computer-assisted functional-diagnostic investigation methods in the peripheral vascular region offer themselves for the objectivation and the assessment of the course of the participation of the vessels in the collagenoses.

[Ultrasound-controlled fine-needle puncture with a specially prepared puncture needle]

The described puncture needle with dual amplified point has been successfully applied at the Medical Clinic of the County Hospital Halle for more than half a year now. Better reflecting capacity in both vitro and vivo results from preparation of the needle point's surface. The more clear visibility of the needle point in the ultrasonic sectional view results in a better display during the whole process of puncture and makes possible a better locating also under difficult sonographic conditions. By the application of the described puncture needle the safety of the ultrasonic directed fine-needle puncture increases for both patient and examiner.

[Studies of protein clearance in detecting early renal involvement of lupus erythematosus]

By means of protein clearance investigations the differentiation of the damage degree of the kidneys is to be described in a certain extent also with lupus nephritis. The in 1982 stated proteinuria elimination of 0.5 g/24 hour as a criterion for a renal participation could be the cause for the often relatively late stated kidney participation in the LE. The determination of selective and nonselective excreted proteins in connection with the detection of the double strain-DNS antibodies might be more proper to indicate a kidney participation.

[Cardiac involvement in rheumatic diseases]

In the enclosed paper cardial changes of different rheumatic diseases are concerned. It refers to the change concerning the cardial symptoms of the single diseases and differential diagnostic considerations are made. Essential cardial symptoms and important symptoms and therapeutic possibilities are named.

[Fulminant course of streptococcal-meningococcal infection--the OPSI syndrome (overwhelming postsplenectomy infection syndrome)]

On the basis of the foudroyant course of a streptococci-meningococci-sepsis in a 19-year-old splenectomized patient the importance of the spleen as an organ of important defence functions is described and the organ-preserving surgical treatment as prophylaxis of the OPSI-syndrome is demanded.

[Basic drug therapy of rheumatoid arthritis]

At first the term of basic therapeutic preparations is explained. Then the essential representatives of the basic medicaments are described, in which cases the author particularly pays attention to their therapeutic mechanisms, the clinical efficiency and their dosage. Out of the number of the possible basic drugs preparations with guaranteed efficacy are particularly described.

[Studies of protein clearance in patients treated with and without gold preparations in rheumatoid arthritis]

It is reported on investigations of protein clearance in rheumatics treated with Tauredon in comparison to non-treated patients suffering from rheumatoid arthritis. In that way no significant differences concerning the secretion of selective and unselective proteins could be found between the observed groups of patients. Secondary effects of the gold therapy in the form of a relevant proteinuria as elaborated by some authors cannot be confirmed in our patients. On the other hand investigations of protein clearance allow the premature recognition of renal failure and thus they can contribute to the increasing of the patients' security in the application of this therapy.

[Biochemical aspects of the pathogenesis of the late diabetic syndrome]

First of all the three essential patho-biochemical reactions of insulindependent tissues with glucose excess are being outlined especially in order to emphasize the non-enzymatic glycolysation as an essential factor for the development of the diabetic late syndrom. Within the glycolysation reactions of the glucose with albumins it is especially being referred to the connection with haemoglobin, fibrinogen, albumin, kristallin, myelin, the membrane proteins and apoproteins and it is shortly being reported on the clinical effects.

[Problems and observations on progressive systemic scleroderma]

At first the pathogenesis of sclerodermia is discussed. Disturbed immunological control mechanisms for the activity of fibroblasts with an increased humoral activity are mentioned as causes. Then relevant clinical changes in connection with own investigations are outlined and finally some therapeutic possibilities are mentioned. The pathobiochemical changes of the collagen metabolism of sclerodermia are analysed and own investigations about the laboratory parameters, hydroxyprolin and N-acetyl-neuraminic acid which summarizingly reflect the collagen metabolism in patients with sclerodermia follow. Finally diagnostic possibilities of a renal participation are shown with the help of a quantitative and qualitative protein analysis in the collective urine, in which case a particular point is to be made of the distinction of selectively and unselectively excreted proteins.

[Relation between glycohemoglobin, hypoxia parameters and diabetic microangiopathy]

In normal persons and in diabetics with and without tissue injuries was tried to find out a connection between the glycolyzed haemoglobin and the parameters of hypoxia. In a small number of cases no clearly evident correlation between the concentrations of the 2,3-diphosphoglycerate and the lactate to the glycohaemoglobins was found. In connection with this investigation pathobiochemical considerations of late diabetic injuries are carried out, which are the consequence of inconveniences in the usability of glucose of diabetics and the connected with this non-enzymatic glycosylation of various proteins.

[Proteinuria and protein clearance for the early diagnosis and monitoring of diabetic nephropathy]

The subtile comprehension of the proteinuria is applied to an early recognition of the diabetic microangiopathia in the sphere of the kidneys. A series of usual methods of the determination of urine protein is compared with different protein clearance results. From these examinations follows that qualitative determinations of protein are unsuitable and quantitative investigations of protein show only an orienting character for the estimation of a microangiopathia. The determination of proteins in urine selectively and non-selectively secreted shows direct relations to microangiopathia and thus could also be applied to the estimation of disturbances in microcirculations in the sphere of physiological proteinuria.

[Facts and problems of the structural clarification, determinative methods and clinical value of glycosylated hemoglobins]

First of all a report is given on the structural peculiarities of the glycohaemoglobins and an appreciation of the non-enzymatic glycosylation reactions with different hexoses is performed. Furthermore a critical judgment of the different methods for the determination of glycosylated haemoglobins follows with the results that in conformity with the international literature the smallest expense and the highest effectiveness must be ascribed to column chromatographic and photometrical methods. The importance of glycosylated haemoglobins for a long-range judgment of the situation of metabolism in diabetics is proved. According to this in particular clearly increased Hb A1 and Hb A1c values are identical with a bad situation of metabolism. Moreover its importance as an additional diagnostic criterion in the bordersphere of the pathological carbohydrate tolerance is emphasized. The effects of different influence factors, e.g. pregnancy, drugs, lipid metabolism and of certain affections on the concentration of glycohaemoglobins are also discussed.

[The dependence of Hb Al (glycohemoglobin) on age, pregnancy and glucose tolerance]

The dependence of Hb A1 on various factors was investigated. A dependence of age of Hb A1 in normal persons could be proved. Moreover, significant differences of Hb A1 in pregnant women in the pre- and postnatal phase were proved. but the analyses carried out did not show any significant correlation between the weight of birth and the substance of glycohaemoglobin of pregnant women who were healthy in metabolism. In the protodiabetic stages the Hb A1 can as a diagnostic means contribute to the comprehension of a glucose intolerance in the protodiabetic stages. During a longer period of observations the Hb A1 shows a dynamic reaction of its concentration dependent of the glycaemic condition.

[The clinical significance of HbA1c determination in diabetics]

It is reported on HbA1c as a suitable screening method for the estimation of a long-range situation of metabolism in diabetics. The relations of HbA1c-concentration to the level of blood glucose and to the secretion quantity of urine glucose are represented. The highest HbA1c-concentrations found out do not correlate with the level of the single concentration of blood glucose which as a rapid method are not representative for the whole position of glycaemia. Further investigations concerning the estimation of the temporal interval of the change of the HbA1c-concentration in dependence on blood glucose and urinary glucose concentration must be carried out.

[A method of hemoglobin A-lc determination]

It is reported on one for practice rational method for the determination of HbA1c. Methodical problems of its realization are pointed out. By the selection of suitable buffers short separating times can be achieved without any high expense of apparatuses. We have simplified the manufacture of haemolysates from venous blood to be separated chromatographically by the use of capillary blood. We did not find any significant differences between the values from venous and capillary blood. The valency of HbA1c for the purpose of estimation of the metabolic situation in diabetics during a longer period is explained with the help of literature, and the normal values in healthy test persons are represented.

[Possibilities of diagnostic standardization in the differential diagnosis of comatose conditions on the basis of the working methods of a grade IIb laboratory]

In the paper life-threatening diseases which may be accompanied by profound unconsciousness are explained from the laboratory-chemical point of view. It is referred to the significance of a laboratory-diagnostic programme for the differential diagnosis of comatous conditions. In this case the material and personal prerequisites and the laboratory capacity of a district hospital are taken into consideration.