Correlation between capillaroscopic classifications and severity in systemic sclerosis: results from SCLEROCAP study at inclusion

OBJECTIVES

We assessed the correlation between severity of systemic sclerosis (SSc) and current staging systems based on nailfold capillaroscopy.

METHODS

SCLEROCAP is a multicenter prospective study including consecutive scleroderma patients who have a yearly routine follow-up with capillaroscopy and digital blood pressure measurement. Capillaroscopy images were read by two observers blinded from each other, then by a third one in the case of discordance. A follow-up of 3 years is planned. The present study assessed the correlation between severity of systemic sclerosis (SSc) and current staging systems based on nail fold capillaroscopy at enrollment in the SCLEROCAP study. Univariate and multivariate logistic regression analysis was performed for both the Maricq and Cutolo classifications.

RESULTS

SCLEROCAP included 387 patients in one year. Maricq's active and Cutolo's late classifications were very similar. In multivariate analysis, the number of digital ulcers (OR for 2 ulcers or more, respectively 2.023 [1.074-3.81] and 2.596 [1.434-4.699]) and Rodnan's skin score >15 (OR respectively 32.007 [6.457-158.658] and 18.390 [5.380-62.865]) correlated with Maricq's active and Cutolo's late stages. Haemoglobin rate correlated with Cutolo's late stage (hemoglobin<100 vs. >120 g/dl: OR 0.223 [0.051-0.980]), and total lung capacity with Maricq's active one: increase in 10%: OR0.833 [0.717-0.969].

CONCLUSIONS

The correlations found between capillaroscopy and severity of SSc are promising before the ongoing prospective study definitively assesses whether capillaroscopy staging predicts complications of SSc. Only two capillaroscopic patterns seem useful: one involving many giant capillaries and haemorrhages and the other with severe capillary loss.

Lower-limb Ulcers in Systemic Sclerosis: A Multicentre Retrospective Case-control Study

Lower-limb ulcers in systemic sclerosis patients are rarely reported. The aim of this study was to describe the main causes and outcomes of lower-limb ulcers in systemic sclerosis patients and to assess factors associated with ischaemic causes (arterial disease and/or microvascular impairment). A retrospective, multicentre, case-control study was conducted in 2013 and 2014, including 45 systemic sclerosis patients presenting lower-limb ulcers between 2008 and 2013. The estimated prevalence of lower-limb ulcers among systemic sclerosis patients was 12.8%. Ulcers were related to venous insufficiency in 22 cases (49%), ischaemic causes in 21 (47%) and other causes in 2 (4%). Complete healing was observed in 60% of cases in a mean time of 10.3 months; 59% relapsed during a mean follow-up of 22 months. Ischaemic lower-limb ulcer outcomes were poor, with a 28.6% amputation rate. Logistic-regression multivariate analyses between ischaemic lower-limb ulcer cases and matched systemic sclerosis-controls identified past or concomitant digital ulcer and cutaneous sclerosis of the feet as independent risk factors associated with ischaemic lower-limb ulcers.

Reproducibility of capillaroscopic classifications of systemic sclerosis: results from the SCLEROCAP study

Objectives

Subgroups of capillaroscopic scleroderma landscape have been correlated with stages of SSc: two groups for Maricq's classification (slow and active), and three for Cutolo's classification (early, active and late). We report inter- and intra-observer agreement for these classifications as a preliminary step in the multicentre prospective SCLEROCAP study, which aims to assess the classification and single capillaroscopic items as prognostic tools for SSc.

Methods

SCLEROCAP included 385 patients. Agreement was studied in the first 100 patients, who were independently rated twice by two observers, blind to patients' characteristics; 30 of the patients were rated once by six observers. After consensus meetings, these ratings were held again. Kappa and intraclass correlation coefficients were used to assess agreement.

Results

Interobserver agreement on 100 patients was moderate for Maricq and Cutolo classifications [κ 0.47 (0.28, 0.66) and 0.49 (0.33, 0.65), respectively], and became substantial after consensus meetings [0.64 (0.50, 0.77) and 0.69 (0.56, 0.81)]. Intra-observer agreement between two observers was moderate to substantial: κ 0.54 (0.33, 0.75) and 0.70 (0.57, 0.83) for Maricq's classification; 0.57 (0.38, 0.77) and 0.76 (0.65, 0.87) for Cutolo's. Thirty patients were rated once by each of six observers, and agreement was moderate to substantial: κ 0.57 ± 0.10 (Maricq) and 0.61 ± 0.12 (Cutolo). Agreement was substantial for bushy, giant capillaries and microhaemorrhages, moderate for capillary density and low for oedema, disorganization and avascular areas.

Conclusion

The moderate reproducibility of Maricq and Cutolo classifications might hamper their prognostic value in SSc patients. Consensus meetings improve reliability, a prerequisite for better prognostic performances. A focus on giant capillaries, haemorrhages and capillary density might be more reliable.

Ambulatory Venous Pressure and Leg Volume Measurements before and after Surgery for Primary Varicose Veins

Objective:

To compare clinical disability, ambulatory venous pressure (AVP) and leg volume before and after venous surgery, and to relate the changes to those observed after one night preoperative in-hospital rest.

Design:

Prospective study.

Setting:

Department of Vascular Surgery, University Hospital, Paris, France.

Subjects:

Nineteen patients with primary varicose veins and mild chronic venous insufficiency (CVI), scheduled for venous surgery.

Main outcome measures:

Clinical disability recorded by the analogue scale method, and leg volume and AVP measurements. These evaluations were repeated three times: on the day before surgery, in the afternoon; in the early morning on the day of surgery; and 2 months after surgery, in the afternoon.

Results:

Varicose vein surgery improved disability ( p = 0.001) and two AVP parameters: recovery time (RT, p = 0.0049) and the calf muscle pump index (CMPI), which rose by 345% (95% confidence intervals: 29, 659). Preoperative supine rest for one night improved disability ( p = 0.0016) and reduced leg volume ( p = 0.0002). The improvements induced by surgery correlated with the changes induced by rest, for disability ( p = 0.016), RT ( p = 0.006) and CMPI ( p = 0.033).

Conclusion:

Surgery improves venous function in patients with primary varicose veins. AVP remains a standard method of evaluating CVI. Combined with volumetry, it allows sensitive comparisons between different treatments. Because venous function varies greatly with daily activity, it is imperative to standardize the times at which venous function is evaluated.

Malignancy and chronic leg ulcers: the value of systematic wound biopsies: a prospective, multicenter, cross-sectional study

OBJECTIVE

To determine the frequency of skin cancers associated with chronic leg ulcers (CLUs) presumably of vascular origin and failing to heal (ie, increased wound area or depth) despite 3 months or more of appropriate treatment.

DESIGN

Prospective cross-sectional study.

SETTING

Ambulatory or hospitalized patients from 17 dermatology departments.

PATIENTS

Between January 1, 2006, and May 31, 2008, a total of 144 patients consulted for CLUs, attributed to venous and/or peripheral arterial disease(s), increasing in wound size, that is, larger area and/or depth, despite appropriate standard treatment for at least 3 months.

MAIN OUTCOME MEASURES

At inclusion, at least two 6-mm punch biopsies, 1 at the wound edge and 1 in the wound bed, in the most clinically suspicious areas, were systematically performed. The primary end point was the skin cancer frequency diagnosed in at least 1 wound biopsy specimen obtained at inclusion.

RESULTS

The 144 patients included had 154 CLUs. The overall skin cancer frequency in the CLUs was 10.4%: 9 squamous cell and 5 basal cell carcinomas, 1 melanoma, and 1 leiomyosarcoma; 56.3% had persisted for at least 3 years. Univariate analyses retained older age, abnormal excessive granulation tissue at wound edges, high clinical suspicion of cancer, and number of biopsies, but not wound area or duration, as being significantly associated with skin cancer in 1 or more biopsy specimens.

CONCLUSIONS

The combined primary ulcerated cancer or malignant transformation frequency was sufficiently high in CLUs referred to tertiary care centers to consider systematic biopsy of a wound refractory to 3 months or more of appropriate treatment.

Cutaneous microvascular blood flow and reactivity in patients with homozygous sickle cell anaemia

Homozygous sickle cell anaemia (SS disease) involves a high prevalence of skin ulcerations, and background experience concerning the cutaneous microcirculatory flux and reactivity in this disease is very limited. We investigated, by laser-Doppler velocimetry, the microcirculatory cutaneous blood flow and vasoreactivity in 17 patients with SS disease but no cutaneous trophic changes, vs. the corresponding values in 18 normal matched controls. The laser-Doppler probe was placed on the foot dorsum, and recordings were made in the supine and dependent positions, and after post-ischaemic hyperaemia. The venoarteriolar reflex was calculated as the difference between the fluxes in the supine and dependent positions. In both positions, patients with SS disease exhibited clear vasodilation, with larger cutaneous fluxes than those of the controls (P=0.024 and 0.0009, respectively). The venoarteriolar reflex, expressed as a percentage of the resting supine flux, was lower in the patients (P=0.0004). These impairments of the microcirculatory fluxes, which combine a vasodilated state with abnormal vasoreactivity, resemble those observed in patients with chronic venous insufficiency and might be crucial in determining the pathogenesis of the skin ulcerations that occur in SS disease. Laser-Doppler velocimetry seems a suitable non-invasive technique for investigating such cutaneous microangiopathy.

Leg ulcers and hydroxyurea: forty-one cases

BACKGROUND

Hydroxyurea is an antitumor agent used to treat chronic myeloproliferative disorders. Leg ulcerations have been reported in patients undergoing long-term hydroxyurea therapy for myeloproliferative diseases. To better define this dermatological adverse effect of hydroxyurea therapy and to try to understand the pathophysiological process of this disease, we collected medical information for such patients in a multicenter retrospective study.

OBSERVATIONS

Forty-one patients (mean age, 67 years) developed leg ulcerations while undergoing hydroxyurea therapy (mean therapy duration, 5 years). The sex ratio was 1, and there was no underlying vascular disease. Hematologic abnormalities were identified. Complete recovery from the ulcerations occurred quickly after withdrawal of treatment in 33 (80%) of the cases.

CONCLUSIONS

This longest-reported series of patients confirms the role of hydroxyurea therapy in the onset of leg ulcerations. Healing or improvement requires cessation of treatment. Cutaneous atrophy and impaired wound healing may explain the relationship between hydroxyurea and leg ulcers. In addition, the megaloblastic erythrocytes resulting from the presence of hydroxyurea may circulate poorly through the capillary network. A prospective study in hematologic centers would be valuable.

Abnormal IgG cardiolipin antibody titers in patients with Raynaud's phenomenon and/or related disorders: prevalence and clinical significance

BACKGROUND

The prevalence of antibodies to cardiolipin (a-CL) in patients with Raynaud's phenomenon (RP) and/or related disorders (rD) is not known.

OBJECTIVE

The purpose of this study was to determine the prevalence of these antibodies.

METHODS

We assayed IgG a-CL in 230 consecutive patients with RP/rD and compared the results with those in a series of 230 control blood donors.

RESULTS

Sixteen percent of patients were a-CL positive versus 7.8% of the control donors (p = 0.014). The prevalence of a-CL positivity was 8.7% for primary RP, 10.5% for secondary RP, 8% for chilblains, 25% for essential acrocyanosis, 20% for connective tissue diseases, and 17% for undifferentiated connective tissue diseases. Among patients with digital necrosis, 24% were a-CL positive.

CONCLUSION

The prevalence of abnormal a-CL titers is higher in patients with RP/rD than in control donors, especially in patients with a connective tissue disease.

Importance of cutaneous postural reflex vasoconstriction in patients with atherosclerotic occlusive disease of the lower extremities

OBJECTIVE

The present study was designed to measure the cutaneous postural vasoconstrictive reflex (PVR) in normal controls and patients with atherosclerotic occlusive disease of the lower extremities, and to determine its diagnostic and prognostic relevance.

EXPERIMENTAL DESIGN

The postural vasoconstrictive reflex was recorded in 34 patients with atherosclerotic occlusive disease of the lower limbs and 27 normal controls, using laser-Doppler flowmetry. Patients also had ankle and toe pressure measurements and transcutaneous oximetry (TcPO2).

SETTING

University hospital.

RESULTS

The PVR on the pulp of the big toe was 20+/-7 arbitrary perfusion units in normal controls, 9.4+/-12 in patients with claudication, and -19 +/- 5 in patients with rest pain and/or gangrene, who differed from the claudicant and control groups (p=0.001 and 0.0001 respectively). The sensitivity of negative PVR in the big toe was 89% for the diagnosis of rest pain and/or gangrene, and its specificity, 83%. The severity of foot ischaemia and PVR values exhibited a significant inverse correlation (r=-0.56, p<0.0001). All patients with a poor outcome, ie. death and/or major amputation within 100 days of follow-up, had a negative PVR, and all patients with a positive PVR had a good 100-day prognosis without even a minor amputation.

CONCLUSIONS

Laser-Doppler provides useful additional information in the assessment of foot ischaemia severity by showing that postural vasoconstriction is impaired in patients with severe atherosclerotic occlusive disease of the lower limbs, resulting in increased skin microcirculatory flow during leg dependency.

Haemodynamics of patients with severe lower limb arterial disease: the critical aspects of critical ischaemia

OBJECTIVES

To compare the value of ankle and toe pressures as regards the diagnosis of critical ischaemia, its prognosis, and the need for vascular surgery.

DESIGN

University hospital-based retrospective study.

MATERIALS AND METHODS

Fifty-seven patients (23 women and 34 men) with gangrene or rest pain had a haemodynamic evaluation combining ankle systolic pressure, toe pressure and cutaneous oximetry (tcPO2) with long-term follow-up (until death, for 44%).

RESULTS

After 2 years of follow-up, actuarial rates were 49 and 79% for survival and limb salvage, respectively. Ankle and toe pressures gave rise to different subsets of patients, p < 0.001, mainly because of the existence of a group of patients with very distal foot arterial disease. Low ankle pressure was linked to the risk of major amputation. Low toe pressure was linked to a great need for vascular surgery. Diabetes increased the risk of minor amputation.

CONCLUSIONS

The concept of critical ischaemia remains clinically relevant. Haemodynamic quantitative data strengthen this concept, but ankle and toe pressures are not interchangeable parameters. For these reasons, toe pressures should be changed from a recommended to a mandatory haemodynamic parameter in the definition of critical ischaemia.

Nailfold capillary microscopy in patients with anticardiolipin antibodies: a case-control study

BACKGROUND AND DESIGN

This case-control study was undertaken to determine whether anticardiolipin antibodies (ACA) are responsible for particular abnormalities in nailfold capillary microscopy (NCM). Cases comprised 33 consecutive patients positive for ACA (24 women and 7 men). Controls comprised the same number of ACA-negative patients, with the same sex ratio, the same diagnosis and the most similar duration of disease possible. Clinical data, serum samples and NCM recordings were obtained from all patients and controls.

RESULTS

In each group, 22 patients had connective-tissue-related disorders and 11 various other diseases. In ACA-positive patients, the mean IgG ACA titre was 39 +/- 58 IgG phospholipid units. Cases and controls displayed various cutaneous manifestations. In ACA-positive patients, there were Raynaud's phenomenon (54%), cutaneous vasculitis (24%), scleroderma changes (18%), photosensitivity (9%), a history of digital gangrene (6%), malar rash (6%), acrocyanosis (6%), chilblains (3%), livedo reticularis (3%) and purpura (3%). Cases and controls exhibited numerous NCM abnormalities. In ACA-positive patients, they included haemorrhages (54%), oedema (24%), bushy capillaries (21%), disordered capillaries (18%), capillary bed disorganization (12%), capillary rarefaction (9%), giant capillaries (6%) and 'desert areas' (3%). There were no correlations between the ACA titres on the one hand and the number of cutaneous manifestations or NCM abnormalities on the other.

CONCLUSIONS

ACA-positive patients frequently exhibit clinical skin lesions and abnormal NCM. In this study, these lesions and NCM abnormalities resembled those of the matched ACA-negative controls.

Raynaud's phenomenon together with antinuclear antibodies: a common subset of incomplete connective tissue disease

BACKGROUND

The frequency of incomplete connective tissue disease (ICTD) is unknown.

OBJECTIVE

Our purpose was to determine the frequency of Raynaud's phenomenon (RP) and antinuclear antibodies (ANA) in patients without definite connective tissue disease.

METHODS

A series of 165 consecutive patients with RP was investigated.

RESULTS

Fifty-one patients had primary RP; 60 had secondary RP; 54 patients were classified as having ICTD, 35 of whom had ANA and 19 of whom did not. Of the 35 patients who had ICTD with ANA, 29 were women and six were men. Their clinical findings were as follows: 17 had nonerosive arthritis, 14 had a nailfold capillary scleroderma pattern, 12 had puffy fingers, 10 had anticentromere antibodies, nine had sicca syndrome, seven had pernio, seven had esophagitis, six had fingertip ulceration, five had telangiectasia, four had malar eruption, four had myalgia, four had weight loss, four had exertional dyspnea, and three had photo-sensitivity. No patient exhibited life-threatening visceral complications or antitopoisomerase antibodies.

CONCLUSION

In this series ICTD was more frequent than definite connective tissue disease. Many patients with RP have ICTD that is sometimes chronic.

Long-term follow-up study of 164 patients with definite systemic sclerosis: classification considerations

To evaluate the usefulness of recently proposed schemes of classification for systemic sclerosis an extensive cross-sectional study of a series of 164 consecutive patients with long-term systemic sclerosis was undertaken. There were 47 cases of proximal sclerosis, 93 of distal sclerosis and 24 of complete CREST syndrome. The study included clinical, visceral, immunological and follow-up data. In addition, a quantitative clinical score was calculated for each patient, thus providing indications for prognosis. Data were expressed according to three conventional systems of classification: The ARA system, the diffuse versus limited systemic sclerosis system and the early cutaneous involvement system. The most reliable indications of severe outcome were: proximal sclerosis, trunk skin involvement, presence of anti Scl 70 autoantibody, pulmonary and/or heart involvement and age. Diagnosis and prognosis were not generated by the same items. Prognosis indicators proved more accurate for groups than for individuals. Mortality was 1 death per 149 patient X years of follow-up from diagnosis. We conclude that the ARA criteria for classification should be recognized as a standard, but patients with complete CREST syndrome should be included in the distal group. Other systems of classification, principally 2-way versus 3-way criteria, allow different subsets of patients that correlate with prognosis and the severity of the disease, and could be used for therapeutic purposes.

Clinical correlations and prognosis based on hyaluronic acid serum levels in patients with progressive systemic sclerosis

The serum levels of hyaluronic acid (sHA) were measured using an affinoimmunoenzymatic assay in patients with distal (n = 16) and proximal (n = 15) progressive systemic sclerosis (PSS) and in 31 controls. The severity of PSS was evaluated using a standardized organ-involvement score. The mean sHA was significantly higher in the patients with PSS than in controls (mean +/- SD:80 +/- 43.4 micrograms/l vs. 42.3 +/- 19.1 micrograms/l, P less than 0.001). sHA was significantly higher in patients with proximal PSS than in patients with distal PSS (106.4 +/- 44.6 micrograms/l vs. 55.4 +/- 23.8 micrograms/l, P less than 0.001). A positive correlation was found between sHA and the disease score (r = 0.67, P less than 0.001). sHA was also correlated with lung diffusion capacity for carbon monoxide (r = 0.70, P less than 0.001), but only in the those patients who had abnormal lung function, and therefore presumably had lung PSS involvement. We suggest that sHA could be an indicator of the degree of systemic involvement in PSS. Its prognostic value and possible use in the follow up of patients with PSS remain to be clarified.

A new cold test for the diagnosis of Raynaud's phenomenon

An objective test for the diagnosis of Raynaud's phenomenon is useful for three reasons: 1. the phenomenon may not be evident at the time of the clinical examination, 2. proof of diagnosis is required by insurance companies when an occupational origin is suspected, and 3. to assess drug induced improvement. Most cold tests in the medical literature are either complex and expensive or unreliable for routine clinical use. We studied cold induced post-ischemic reactive hyperemia in 14 patients with Raynaud's disease and in 15 healthy controls. The hand was immersed in a stirred water bath at 13 degrees C, and ischemia was induced by placing an inflatable tourniquet around a finger for five minutes. Afterwards the tourniquet was deflated while the hand remained in the cold water bath. The temperature of the finger with the deflated tourniquet was compared with that of an adjacent finger serving as control. Hyperemia was the increase in differential temperature between these two fingers after tourniquet release minus the difference in temperature existing before deflating the tourniquet. With a normal lower limit of 0.7 degrees C for hyperemia, 13 of the 14 patients with Raynaud's phenomenon were abnormal (93% sensitivity), and 14 of the 15 controls were normal (93% specificity). All these 14 controls were also normal at a second examination done to assess test reproducibility. A false-positive healthy control was still positive at the second examination. This new, simple and inexpensive cold test can reliably diagnose Raynaud's phenomenon. Further studies are necessary to establish its reliability in monitoring the effectiveness of treatment in prospective trials.

trans-4-Hydroxytamoxifen concentration and metabolism after local percutaneous administration to human breast

trans-4-Hydroxytamoxifen (4-OHTAM), a very active metabolite of the antiestrogen tamoxifen, was percutaneously administered to the affected breast of nine patients before surgery for breast cancer in order to evaluate 4-OHTAM absorption through the skin and its subcellular localization and metabolism. After percutaneous administration of 80 muCi, [3H]-4-OHTAM was detected in breast tissue. It was especially concentrated in tumor tissue and nuclear and cytosolic fractions, in which it remained unmetabolized except for limited isomerization from the trans to the cis form. In contrast to breast tissue, concentrations of radioactivity remained low in plasma but with a high proportion of metabolites. In another experiment [3H]tamoxifen was percutaneously administered over the breast of 3 patients, resulting in tissue retention weaker and shorter than after [3H]-4-OHTAM. In addition [3H]-4-OHTAM was administered to either breast or abdominal skin; the appearance of radioactivity in plasma and urine was delayed after administration to the breast in comparison with administration to the abdomen. It therefore appears that 4-OHTAM passes through the skin and is concentrated in receptor structures of breast tissue, thus avoiding the hepatic metabolism subsequent to p.o. administration. We suggest that local percutaneous administration of this active antiestrogen could be useful in the treatment of hormone-dependent benign breast diseases.

Estradiol 17 beta-hydroxysteroid dehydrogenase activity in human breast fibroadenomas

In the human endometrium, the presence of the progesterone-dependent enzyme 17 beta-hydroxysteroid dehydrogenase (E2DH) permits the conversion of an active estrogen, estradiol, into a less active one, estrone. This E2DH activity contributes to the antiestrogenic properties of progesterone. In the present study, E2DH activity was assayed in 54 surgically removed fibroadenomas. This benign breast disease was chosen since it offers rather homogeneous epithelial concentrations and still remains close to normal breast tissue from a pathological and hormonal point of view. E2DH activity was highest in fibroadenomas with high epithelial cell density. In addition, in these high epithelial cell density fibroadenomas (n = 18), E2DH activity increased markedly throughout the luteal phase of the menstrual cycle. Thus, it was 3- to 4-fold higher in fibroadenomas removed at the end of the luteal phase (1520 +/- 166 fmol/mg protein.h) than in those obtained during the follicular phase (375 +/- 95 fmol/mg protein.h). In addition, a striking increase in E2DH activity was observed in fibroadenomas from 5 patients treated with oral progestins (4080 +/- 650 fmol/mg protein.h) and 3 patients receiving progesterone topically applied upon the breast (3830 +/- 475 fmol/mg protein.h). E2DH activity, therefore, appears to be an important mechanism involved in the control by progesterone of estradiol action in breast tissue, as it is in the endometrium. It is also a good index of cellular differentiation and progesterone action at the molecular level. It is hypothesized that E2DH activity might be a specific marker of progesterone receptor itself and could be proposed in the evaluation of the hormone dependence of human breast tissue.