Management of Raynaud's phenomenon and digital ischemia

Successful management of ulceration associated with diffuse dermal angiomatosis of the breasts with topical glyceryl trinitrate spray

We report the successful use of topical glyceryl trinitrate spray in managing ulceration associated with diffuse dermal angiomatosis of the breasts.

Evaluation of Clinical Recovery After Surgical Treatment for Hand Ischemia From Vasospastic and Occlusive Disease Using PROMIS

BACKGROUND

There is a paucity of literature describing the recovery trajectory after surgery for upper extremity ischemia. Using Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function (PF), Upper Extremity (UE), Pain Interference (PI), and Depression domains, we aimed to describe the postoperative recovery of such patients.

METHODS

We queried our PROMIS database for patients undergoing surgery for vasospastic or occlusive disease over a 4.5-year period. Inclusion criteria were preoperative, early (average 3 weeks) and late (average 6 months) postoperative PROMIS PF and/or UE, PI, and Depression scores. The change in PROMIS scores was calculated for each time point. Changes in PROMIS scores were compared with minimal clinically important difference estimates.

RESULTS

We identified 13 patients undergoing 13 surgical interventions that met inclusion criteria. More than one-half of our patients were men (n = 7 [54%]), and more than one-half of the surgeries (n = 7 [54%]) were for isolated occlusive diagnoses, with the remainder for vasospastic disease. At short-term postoperative follow-up, the change in PROMIS PF, UE, PI, and Depression scores was -6.34 (SD: 9.13), -6.81 (SD: 9.61), 3.16 (SD: 5.78), and -3.05 (SD: 8.37), respectively. At mid-term postoperative follow-up, the change in PROMIS PF, UE, PI, and Depression scores was 4.45 (SD: 10.33), 8.04 (SD: 13.84), -7.03 (SD: 7.06), and -12.27 (SD: 10.85), respectively.

CONCLUSIONS

Our findings suggest patients undergoing surgical treatment for upper extremity ischemia experience a worsening of functional symptoms initially, as expected, followed by notable improvement.

Study Protocol: A Randomized Controlled Prospective Single-Center Feasibility Study of Rheopheresis for Raynaud’s Syndrome and Digital Ulcers in Systemic Sclerosis (RHEACT Study)

Introduction

Raynaud’s phenomenon (RP) and digital ulcers (DU) are frequent manifestations of Systemic Sclerosis (SSc). Despite being very common in SSc patients, both conditions have proven to be notoriously difficult to study. There are very few available approved drugs with varying efficacy. It has been shown that the presence of DU is associated with increased whole blood viscosity (WBV). Rheopheresis (RheoP) is an extracorporeal apheresis technique used to treat microcirculatory disorders by improving blood viscosity. Improved blood flow and wound healing after RheoP treatments have been reported in single case reports.

Methods and Analysis

We report the clinical trial protocol of “A randomized controlled prospective single-center feasibility study of Rheopheresis for Raynaud’s syndrome and Digital Ulcers in Systemic Sclerosis (RHEACT).” RHEACT aims to investigate the efficacy of RheoP on the Raynaud Condition Score (RCS) as the primary efficacy outcome measure after 16 weeks from baseline. Thirty patients will be randomized in a 1:1:1 ratio to one of two RheoP treatment groups or assigned to the standard of care (SoC) control group (intravenous iloprost). Secondary endpoints include changes in DU, changes in nailfold video capillaroscopy and patient-reported-outcomes (Scleroderma Health Assessment Questionnaire, FACIT-Fatigue, and the Disability of Arm, Shoulder, and Hand, quick version).

Discussion

Apheresis techniques have been investigated in SSc but mainly in observational, retrospective studies, or single case reports. RheoP is a pathophysiologically driven potential new therapy for heavily burdened patients with SSc-associated secondary RP with or without DU.

Ethics and Dissemination

The study was registered at clinicaltrials.gov (Identifier: NCT05204784). Furthermore, the study is made publicly available on the website of the German network of Systemic Sclerosis “Deutsches Netzwerk Systemische Sklerodermie (DNSS).”

Алгоритмы лечения системной склеродермии при преимущественном поражении кожи и суставов, при синдроме Рейно и дигитальных язвах согласно современным рекомендациям

Системная склеродермия (ССД) (системный склероз) является уникальным заболеванием среди ревматических болезней, поскольку представляет проблему менеджмента хронической мультисистемной аутоиммунной патологии с широко распространенной облитерирующей васкулопатией малых артерий, связанной с разной степенью фиброза тканей. В патологический процесс могут вовлекаться все органы, так или иначе связанные с соединительной тканью и имеющие кровеносные сосуды. Прогрессирующее течение ССД приводит к развитию необратимых фиброзных изменений, в результате которых происходит нарушение функции пораженных органов. Отличительной чертой ССД является клиническая неоднородность подгрупп больных, которые различаются в зависимости от степени тяжести заболевания, вовлечения тех или иных органов и систем и дальнейшего прогноза. Врач должен тщательно обследовать каждого пациента с ССД для определения конкретных проявлений и уровня активности заболевания для назначения соответствующего лечения. В настоящее время использование алгоритмов лечения является современной стратегией ведения пациентов, особенно после неудачного использования препаратов первой линии. При ранней активной диффузной склеродермии с преимущественным поражением кожи следует отдать предпочтение метотрексату (МТХ) в качестве препарата первой линии, а при его неэффективности или непереносимости препаратом второй линии является мофетила микофенолат (ММФ), при неэффективности последнего препаратом третьей линии является внутривенный циклофосфамид. Следует заметить, что при тяжелом поражении кожи препаратом первой линии является ММФ, а МТХ — вторым, при неэффективности ММФ. На сегодняшний день блокаторы кальциевых каналов (БКК), главным образом нифедипин, остаются препаратами первой линии для терапии синдрома Рейно при ССД. При неэффективности этих лекарственных средств следует добавить ингибиторы фосфодиэстеразы-5 (иФДЕ-5), следующим шагом терапии является назначение ингибиторов ангиотензинпревращающего фермента или блокаторов рецепторов ангиотензина. При неэффективности комбинированной терапии БКК и иФДЕ-5, при тяжелом течении синдрома Рейно следует использовать простаноиды. Препаратом первой линии для лечения артрита, как и для поражения кожи, является МТХ, при его неэффективности или высокой воспалительной активности следует добавить глюкокортикоиды и нестероидные противовоспалительные препараты. Гидроксихинолон является препаратом третьей линии, его добавляют к терапии при неэффективности вышеперечисленных агентов. Биологические агенты (ритуксимаб и тоцилизумаб) являются препаратами четвертой линии лечения артрита, ассоциированного с ССД.

The Effect of Very Low Concentrations of Ethanol on Microvascular Artery and Vein Anastomosis: An Experimental Study

OBJECTIVES

This study investigated the effect of very low concentrations of ethanol on artery and vein anastomosis. Also, it was aimed to determine the appropriate ethanol concentration to be used in vasospasm.

METHODS

Rats were divided into five groups of eight rats, each group, as follows: Group i: saline; Group ii: 2.5% ethanol; Group iii: 5% ethanol; Group IV: 7.5% ethanol; and Group V: 10% ethanol. During the femoral artery and vein anastomosis, 1ml of the agent was used for irrigation in each group. Vessel diameters were measured before the anastomosis, at the fifth and 15th minutes, and the third week after the anastomosis. Histopathological samples were taken in the third week.

RESULTS

In Groups ii and iii, the mean vessel diameters were found to increase 15th minute. Also observed was an increase in mean vessel diameter that continued in the third week. Although acute vasodilation was detected in Groups IV and V, arterial and venous thrombosis was observed in the third week. Intima and media thickness decreased in Group ii, while it increased in Group iii. Perivascular inflammation and fibrosis increased as the ethanol concentration increased.

CONCLUSION

2.5% ethanol causes acute and prolonged vasodilation and does not cause endothelial cell damage, perivascular inflammation, and fibrosis. 2.5% ethanol will be a powerful alternative use in many situations that occur with vasospasm.

Laser Doppler imaging evaluation of nitroglycerin patch application in systemic sclerosis patients

Recent studies suggest the use of topical nitroglycerin (NTG) application in systemic sclerosis (SSc)-associated Raynaud phenomenon (RP). With the current study, we aimed to characterize for the first time the microvascular response to a NTG patch (Trinipatch^® 5 mg/24 h) applied to the hand dorsum in patients with SSc using Laser Doppler imaging (LDI) at baseline and following a cold challenge. The study included 21 patients with SSc and 13 controls. Blood flow was evaluated by LDI at the level of the fingertips and metacarpus. Microvascular morphology was evaluated by nailfold capillaroscopy (NC). LDI revealed decreased fingertip baseline perfusion and a stronger vasoconstrictor response to a cold challenge in patients with SSc versus control. Metacarpal application of a NTG patch led to an increase in blood flow and hand temperature in patients with SSc. Furthermore, NTG administration led to a faster reperfusion after cold challenge. Correlation analyses revealed that the magnitude of the vasodilatory response was inversely related to baseline fingertip perfusion and hand temperature, but unrelated to the number of capillaries/mm assessed using NC. In conclusion, we provide evidence of a vasodilatory reaction following NTG patch application in patients with SSc using LDI and a protective effect against cold challenge. The magnitude of the response to NTG was related to functional, but not structural features. Our results support a further evaluation of the NTG patch as a possible therapeutic agent in SSc-associated RP.

Effect of perivascular low dose ethanol on rat femoral vessels: Preliminary study

Vasospasm is one of the important causes of morbidity in free flap and replantation surgery. In secondary Raynaud's phenomenon, nearly half of the patients experience digital ulceration, pain and loss of function at least once in their lifetime. The aim of this study is to investigate the vasodilation effect of ethanol-mediated chemical denervation on peripheral vessels by topical administration. In this study, 27 Wistar albino male rats weighing 250-300 grams were used. The rats were randomly divided into three groups: saline (group S, n = 8), lidocaine (group L, n = 9) and 96% ethanol (group E, n = 9). According to group, 0.1 mL saline, 0.1 mL lidocaine and 0.1 mL ethanol were applied around the rat femoral neurovascular bundle. After the application, on the 0th day and 3th weeks, femoral artery and vein diameters were measured. After 3. weeks, histopathological samples from femoral artery, vein and nerve were evaluated. On the 0th day, the mean diameter of the femoral artery and vein was similar in group E and L and higher than group S. After three weeks, the vasodilatation effect of ethanol was increased in group E. In Group L and S, the vasodilatation effect was lost. Histopathological examination showed that ethanol significantly caused perivascular inflammation and nerve degeneration compared to other agents and did not cause endothelial damage. Vasodilatation obtained by ethanol is a rapid onset and long-lasting effect. It is also inexpensive and effective for peripheral vasodilatation.

Botulinum Toxin A Salvage of Ischemic Hand Trauma

Posttraumatic hand injuries from crush injury, infusion, or iatrogenic vascular cannulation can cause ischemic finger damage that can progress to necrosis and digital amputation. Botulinum toxin type A (Botox) improves blood flow in chronic vasospastic disorders of the hand. Botox's efficacy in salvaging ischemic loss in digits in acute traumatic and iatrogenic injury has not been previously reported. From February of 2015 to December of 2016, 11 patients at a Level I trauma center (West Virginia University) presented to the hand surgery service with early ischemic injury and vascular compromise to hand and fingers as a result of crush, direct drug injection, or proximal arterial injury from drug injection or catheterization. Before 2015, all patients with vascular compromise were treated with standard protocol. After January of 2016, patients were treated with additional injection of 80 to 100 U of Botox into the palm and wrist. Before administration of Botox, six patients with vascular compromise of one or more fingers were treated with a conservative protocol and 83 percent had amputation of necrotic digits. After January of 2016, five patients with ischemia were treated with Botox into the palm and proximal arteries. All Botox-treated digits were preserved (100 percent salvage). Pain scores were lower in Botox-treated fingers. We conclude that (1) in the acute traumatic vascular hand injury, early Botox injection markedly increases digital salvage; (2) direct nerve effects after Botox injections improve postinjury pain scores; and (3) early use of Botox in finger injuries is our standard approach to impending ischemia in the hand.

Innovations in the Assessment of Primary and Secondary Raynaud's Phenomenon

Objectives: Raynaud's phenomenon (RP) is characterized by intense vasospasm of the digital arteries that causes characteristic color changes in fingers. There are two main types of RP: Primary RP (PRP) and Secondary RP (SRP). PRP is a benign condition. Whilst SRP is associated with several connective tissue diseases (CTD), in particular systemic sclerosis (SSc). The objectives of this report were: to present a short review on morphological (nailfold videocapillaroscopy, NVC) and functional techniques (laser tools and thermography) that allow for a correct diagnosis and treatment of RP and to investigate blood perfusion (BP) by laser speckle contrast analysis (LASCA) in different skin areas of hands and face in PRP, SRP to SSc, and healthy subjects (CNT). Methods: 31 PRP patients (LeRoy criteria), 70 SRP to SSc (ACR/EULAR criteria) and 68 CNT were enrolled. BP was assessed by LASCA at the level different areas of hands and face. NVC was performed to distinguish between PRP and SRP, and to detect the proper pattern of nailfold microangiopathy in SSc patients. Results: Both PRP and SRP showed a statistically significant lower BP than CNT at the level of fingertips (p < 0.0001), periungual (p < 0.0001), palmar aspect of 3rd finger (p < 0.0001), and palm areas (p < 0.0001). Moreover, BP was significantly lower in PRP than in SRP to SSc with the "Early" pattern of microangiopathy in the same areas as above (p < 0.04). Conclusion: By considering a small cohort of patients, BP of hands was found lower in PRP than in SSc patients with the "Early" NVC pattern of microangiopathy.

Aminaphtone Efficacy in Primary and Secondary Raynaud's Phenomenon: A Feasibility Study

Objectives

The aim of this six-month open feasibility study was to evaluate skin blood perfusion and clinical symptom changes during aminaphtone treatment in patients with either primary or secondary Raynaud’s phenomenon to systemic sclerosis.

Methods

Ninety-two patients referring for Raynaud’s phenomenon have been enrolled in November during routine clinical assessment, after informed consent. Aminaphtone was administered 75 mg twice daily in addition to current treatments to forty-six patients. Skin blood perfusion was measured by Laser Speckle Contrast Analysis (LASCA) at the level of fingertips, periungual areas, dorsum and palm of hands, and face at baseline (W0), after one (W1), four (W4), twelve (W12) and twenty-four (W24) weeks of treatment. Raynaud’s condition score (RCS) and both frequency and duration of Raynaud’s attacks were assessed at the same time.

Results

Compared with the control group, despite colder period of the year, aminaphtone treated patients showed a progressive statistically significant increase of blood perfusion, as well as a decrease of RCS, frequency of Raynaud’s attacks/day and their duration, from W0 to W12 in all skin areas. From W12 to W24 no further increase of blood perfusion was observed. The results were similar in both primary and secondary Raynaud’s phenomenon patients. Five weeks after aminaphtone discontinuation blood perfusion values were significantly higher than those at baseline in the majority of skin areas.

Conclusion

This study demonstrates that aminaphtone treatment increases skin blood perfusion and improves Raynaud’s phenomenon clinical symptoms, with sustained efficacy up to 6 months, even in patients with systemic sclerosis. A randomized, blind, controlled, clinical trial including a larger number of subjects is advisable to confirm these early results.

A randomised placebo-controlled double-blind trial to assess the safety of intramuscular administration of allogeneic mesenchymal stromal cells for digital ulcers in systemic sclerosis: the MANUS Trial protocol

INTRODUCTION

Systemic sclerosis (SSc) is an autoimmune disease characterised by inflammation, fibrosis and vasculopathy. Digital ulcers (DUs) are a frequent manifestation of vasculopathy in patients with SSc. Despite recent advances in pharmacological treatments, DU still have major health and economic implications. As there is currently no proven therapeutic strategy to promote DU healing, new treatments are urgently needed. Mesenchymal stem or stromal cells (MSCs) may provide a novel therapy for DU in SSc, because of their immunomodulatory and vasculoregenerative properties. Allogeneic MSC therapy involves functionally competent MSCs from healthy donors and may be used as 'off-the-shelf' available treatment. This study will evaluate whether allogeneic MSC therapy is a safe and potentially efficacious treatment for DU of SSc.

METHODS AND ANALYSIS

The MANUS (Mesenchymal stromal cells for Angiogenesis and Neovascularization in digital Ulcers of Systemic Sclerosis) Trial is a double-blind randomised placebo-controlled trial. 20 patients with SSc with refractory DU will be randomised to receive eight intramuscular injections with either placebo or 50*10⁶ MSCs. The primary outcome is the toxicity of the treatment at 12 weeks after administration. Secondary outcomes include (serious) adverse events, number and time to healing of DU, pain, reported hand function, quality of life and SSc disease activity. We will also evaluate changes in nailfold capillaroscopy pattern, as well as biochemical parameters and biomarkers in peripheral blood and skin biopsies. Follow-up visits will be scheduled at 48 hours and 2, 4, 8, 12, 24 and 52 weeks post-treatment. If the results confirm safety, feasibility and potential efficacy, a large multicentre randomised controlled trial with longer follow-up will be initiated focusing on efficacy.

ETHICS AND DISSEMINATION

The study has been approved by the Dutch Central Committee on Research Concerning Human Subjects (protocol no: NL51705.000.15). The results will be disseminated through patient associations and conventional scientific channels.

TRIAL REGISTRATION NUMBER

NCT03211793; Pre-results.

Diagnostic criteria, severity classification and guidelines of systemic sclerosis

Several effective drugs have been identified for the treatment of systemic sclerosis (SSc). However, in advanced cases, not only their effectiveness is reduced but they may be also harmful due to their side-effects. Therefore, early diagnosis and early treatment is most important for the treatment of SSc. We established diagnostic criteria for SSc in 2003 and early diagnostic criteria for SSc in 2011, for the purpose of developing evaluation of each organ in SSc. Moreover, in November 2013, the American College of Rheumatology and the European Rheumatology Association jointly developed new diagnostic criteria for increasing their sensitivity and specificity, so we revised our diagnostic criteria and severity classification of SSc. Furthermore, we have revised the clinical guideline based on the newest evidence. In particular, the clinical guideline was established by clinical questions based on evidence-based medicine according to the New Minds Clinical Practice Guideline Creation Manual (version 1.0). We aimed to make the guideline easy to use and reliable based on the newest evidence, and to present guidance as specific as possible for various clinical problems in treatment of SSc.

Evidence for increase in finger blood flow, evaluated by laser Doppler flowmetry, following iloprost infusion in patients with systemic sclerosis: a week-long observational longitudinal study

OBJECTIVES

Iloprost plays an important role in the treatment of Raynaud's phenomenon (RP), but has transient vasodilatory effects owing to its very short half-time. We aimed to evaluate short- and medium-term haemodynamic effects of iloprost by measuring dorsal finger microvessel blood flow using laser Doppler flowmetry (LDF), in patients with RP associated with systemic sclerosis (SSc).

METHOD

In 24 consecutive SSc patients with RP (disease duration 10.5 ± 1.3 years), LDF with heating probes was used to measure blood flow in four fingers by occlusive and heating tests, at baseline, after 3 consecutive days of iloprost infusion, and at 24 h and 7 days after last iloprost infusion. Nailfold videocapillaroscopy (NVC) patterns of microvascular damage were investigated. Sixteen healthy controls were studied to compare baseline flows.

RESULTS

Compared to controls, SSc patients showed significantly impaired axon reflex vasoregulation and nitric oxide responses at baseline (p = 0.001 and p = 0.03, respectively). After iloprost, a prompt but transient significant improvement in endothelial-dependent vasodilation (occlusive test) was seen only in SSc patients with an 'active' NVC pattern (p ≤ 0.05). The iloprost effects vanished within 7 days after the last infusion. No significant differences were found, in the whole study, between patients with and without digital ulcers.

CONCLUSIONS

Microcirculatory blood flow increases following 3 days of iloprost infusion but fades shortly after treatment. Although iloprost is effective in reducing the severity of RP in SSc, the most suitable regimen and timing to obtain longer lasting vasodilatory benefits remain to be established.

Increased Whole Blood Viscosity Is Associated with the Presence of Digital Ulcers in Systemic Sclerosis: Results from a Cross-Sectional Pilot Study

Objective

To investigate the role of whole blood viscosity in digital ulcer (DU) development in patients with diffuse and limited Systemic sclerosis.

Methods

A convenience sample of patients with Systemic sclerosis (SSc) was selected from the adult Rheumatology clinic at the University of Chicago. The study group consisted of patients with SSc (with ulcers present, a history of ulcers, and no ulcers); the control group consisted of matched healthy Rheumatology clinic staff. WBV was measured using a scanning capillary viscometer at different shear rates (1–1000 1/s).

Results

Whole blood viscosity as measured by a scanning capillary viscometer was increased in patients with SSc compared to healthy controls (p < 0.0001). Additionally, patients with present DU had significantly higher whole blood viscosity when compared to patients with a history of DU and patients with no history of DU (p < 0.0001). These findings were most pronounced at lower shear rates between 1 and 10 1/s.

Conclusion

Whole blood viscosity might be a contributing factor in DU development in patients with SSc. Further studies with larger patient cohorts are required to fully evaluate how increased WBV contributes to the development of DU and whether the currently available treatment options improve the microcirculation by influencing WBV.

Innominate Artery Stenosis Presenting With Migratory Digital Ischemia

Background:

Atherosclerotic lesions of the supra-aortic trunk vessels, including the innominate artery, subclavian artery, or the common carotid artery, tend to present either as low-flow state distal to the lesion or as embolic events. The risk of embolic cerebrovascular event complicates the management of this condition via a pure endovascular approach. A combined operative–endovascular intervention may be a valuable approach in order to reduce the risk of intraoperative stroke and prevent future embolic events.

Case Presentation:

An 84-year-old female presented at the emergency department (ED) with a 4-month history of migratory digital cyanotic lesions across various fingers on her right hand. The lesion eventually progressed into dry gangrene on her right middle finger. Selective angiography of the aortic arch vessels demonstrated significant atherosclerotic plaque burden throughout her supra-aortic vessels and a segmental stenosis at the proximal innominate artery. A right carotid cut down was performed to allow clamping of the carotid artery so as to minimize the risk of intraoperative stroke from plaque manipulation. Retrograde balloon angioplasty was performed, and stent was placed across the stenotic segment. The patient tolerated the procedure well and had an uneventful postoperative course. She was discharged on postoperative day 3. At 2-week follow-up, she has had no progression of her digital ischemia nor other focal cranial nerve deficits.

Conclusion:

Migratory digital ischemia is a rare presentation of atherosclerotic disease of the supra-aortic vessels. It represents a challenging situation for endovascular intervention due to concern about plaque dislodgment during the procedure. A retrograde balloon-stent angioplasty following distal carotid control with an open approach may be safe and effective in selected patients.

Botulinum toxin A in the treatment of Raynaud's phenomenon: a systematic review

INTRODUCTION

The management of Raynaud's phenomenon in its most severe form is challenging, and current medical and surgical treatment methods frequently do not lead to optimal symptom control and prevention of ischemic complications. The aim of the study was to critically evaluate all existing evidence on the use of botulinum toxin A in the management of Raynaud's phenomenon.

MATERIAL AND METHODS

We adopted the PRISMA methodology and searched Cochrane Library, MEDLINE, SCOPUS, EULAR and ACR congresses abstract archives for Raynaud* AND botulinum toxin OR onabotulinum. All studies that contained reports of botulinum toxin A use and its outcome in Raynaud's phenomenon were included in the review.

RESULTS

Eleven studies met our inclusion criteria and involved a total of 125 patients. Two reviewers extracted data from the studies under review and achieved a consensus in their selection. The main outcomes measured were pain reduction and healing of digital ulcers. The level of evidence across studies was very low to moderate.

CONCLUSIONS

There is insufficient evidence to assess the efficacy of botulinum toxin A in Raynaud's phenomenon. Despite many promising reports, further research in the form of randomized controlled trials is warranted in order to investigate this new treatment method for Raynaud's phenomenon.

Evidence for the Use of Epoprostenol to Treat Raynaud's Phenomenon With or Without Digital Ulcers

OBJECTIVE

To review the evidence for using intravenous (IV) epoprostenol to treat Raynaud's phenomenon (RP).

DATA SOURCES

The databases MEDLINE (1946 to March 2016), PubMed, and International Pharmaceutical Abstracts were searched using the terms epoprostenol, Flolan, Raynaud's disease, and CREST syndrome. Further literature sources were identified by reviewing article citations.

STUDY SELECTION AND DATA EXTRACTION

All English-language, clinical trials and case series evaluating IV epoprostenol for the management or treatment of RP were included. Lower-quality evidence were incorporated due to limited information.

DATA SYNTHESIS

Seven small uncontrolled studies/case series, 1 small placebo controlled study, and 1 larger randomized trial were identified and included. There was no consistent measurement of efficacy utilized, but improvements in hand temperature, RP attack duration and frequency were commonly associated with IV epoprostenol treatment (5 trials). There were conflicting data regarding effect sustainability, with 5 trials showing long-term effects and 3 showing immediate effects. Fewer ischemic ulcers developed during treatment with IV epoprostenol in 1 trial compared to conventional treatment. Ulcer healing ocurred in 2 trials. Common adverse effects included hypotension, headache, flushing, gastrointestinal symptoms, and jaw pain.

CONCLUSIONS

Available evidence supports the use of IV epoprostenol for treatment of severe RP in patients refractory or intolerant to standard therapies. The dose, titration schedule, and duration of IV epoprostenol utilized in studies varied, but a conservative approach to initiation should be considered. Patients who do not respond to intermittent infusions and have severe digital ischemia may require more aggressive regimens.

Impaired angiogenesis as a feature of digital ulcers in systemic sclerosis

Impaired angiogenesis in systemic sclerosis has a major role in tissue injury pathogenesis. Our objective was to determine whether angiogenic biomarkers (vascular endothelial growth factor (VEGF), endoglin, and endostatin) are related to microvascular damage and to determine their predictive value for new digital ulcers (DU). The main outcome of the study was the occurrence of a new digital ulcer during 3-year follow-up. This prospective longitudinal study was performed between October 2011 and December 2014. Seventy-seven patients definitely diagnosed with systemic sclerosis where divided into two groups: those with active DU at baseline and those with no DU until enrollment. Patients were matched by sex and age with healthy controls. Serum levels of VEGF, endoglin, and endostatin were measured at enrollment, and several nailfold videocapillaroscopies were performed during the 3-year follow-up. Serum levels of VEGF were lower (245.06, 158.68-347.33; p < 0.001) and those of endoglin were higher (3.013, 1.463-7.023; p < 0.001) in patients with active DU than those with no DU history (339.49, 202.00-730.93/1.879, 0.840-3.280), and they were higher than those found in controls (178.030, 101.267-222.102)/0.277, 0.154-0.713), respectively. No differences in endostatin levels were found between groups (p = 0.450). Endoglin was the only biomarker significantly different (p = 0.031) between patients with diffuse versus limited systemic sclerosis and between early, active, and late patterns (p = 0.020). VEGF was identified as an independent predictor for the development of new DU. Our study confirmed the relationship between angiogenic vascular biomarkers and the occurrence of DU. Endoglin and VEGF serum levels are potential risk factors, and VEGF has a predictive value for the occurrence of new DU.

The cardiac magnetic resonance in the diagnosis of cardiac Raynaud phenomenon in a patient with systemic sclerosis: case report and review of literature

Raynaud phenomenon (RP) is the hallmark of Systemic Sclerosis (SSc). Visceral RP has also been proposed in SSc patients. Cardiac Raynaud's phenomenon (C-RP) was evaluated in a few clinical studies both as cold-induced transient myocardial ischaemia and as presence of advanced myocardial fibrosis and contraction band necrosis in autopsied patients. Until today numerous techniques, such as scintigraphy and myocardial contrast echocardiography, have been used to evaluate C-RP. In this case report for the first time we have used Cardiac Magnetic Resonance (CMR) after cold test to demonstrate the presence of the C-RP. In addition we have shown that therapy with Iloprost can be used to reduce episodes of C-RP.

Melanopsin mediates light-dependent relaxation in blood vessels

Melanopsin (opsin4; Opn4), a non-image-forming opsin, has been linked to a number of behavioral responses to light, including circadian photo-entrainment, light suppression of activity in nocturnal animals, and alertness in diurnal animals. We report a physiological role for Opn4 in regulating blood vessel function, particularly in the context of photorelaxation. Using PCR, we demonstrate that Opn4 (a classic G protein-coupled receptor) is expressed in blood vessels. Force-tension myography demonstrates that vessels from Opn4(-/-) mice fail to display photorelaxation, which is also inhibited by an Opn4-specific small-molecule inhibitor. The vasorelaxation is wavelength-specific, with a maximal response at ∼430-460 nm. Photorelaxation does not involve endothelial-, nitric oxide-, carbon monoxide-, or cytochrome p450-derived vasoactive prostanoid signaling but is associated with vascular hyperpolarization, as shown by intracellular membrane potential measurements. Signaling is both soluble guanylyl cyclase- and phosphodiesterase 6-dependent but protein kinase G-independent. β-Adrenergic receptor kinase 1 (βARK 1 or GRK2) mediates desensitization of photorelaxation, which is greatly reduced by GRK2 inhibitors. Blue light (455 nM) regulates tail artery vasoreactivity ex vivo and tail blood blood flow in vivo, supporting a potential physiological role for this signaling system. This endogenous opsin-mediated, light-activated molecular switch for vasorelaxation might be harnessed for therapy in diseases in which altered vasoreactivity is a significant pathophysiologic contributor.

A PRISMA-driven systematic review for predictive risk factors of digital ulcers in systemic sclerosis patients

Vasculopathy has a major role in the pathogenesis and tissue injury in systemic sclerosis (SSc). Raynaud's phenomenon (RP) is frequently the first clinical manifestation of SSc preceding by years other clinical manifestations. RP in SSc patients is frequent, often very severe and long lasting. The repeated bouts of RP lead to prolonged digital ischemia that may progress to digital ulceration or in extreme to critical digital ischemia with gangrene. Digital ulcers (DU) are a true burden for all patients. They are very painful, with a long and slow healing course, have high risk of infection and are extremely disabling. In adults, up to 40-50% of patients will experience at least one DU in the course of the disease and of these 31-71% will have recurrent ulcers. In order to try to identify predictive risk factors for DU in SSc patients, an extensive literature review was conducted, according to the guidelines proposed at the PRISMA statement. MEDLINE database (PubMed) and Thomson Reuters Web of Knowledge platform were searched for articles published in peer-reviewed journals since 1990 with the last search run on June 2014 and published in English language. The keyword search terms included: digital ulcer/s, systemic sclerosis, scleroderma, digital scars, ischemic complications, autoantibodies, biomarkers, endothelium dysfunction, endothelin-1, vascular endothelial growth factor (VEGF), endostatin, ADMA, endoglin, angiostatin, and capillaroscopy. The following criteria were included: (1) cohorts of SSc patients including patients with DU, (2) endothelium dysfunction and angiogenesis biomarkers compared with a healthy control group, (3) autoantibodies, capillary morphology and distribution, endothelium dysfunction and angiogenesis biomarkers compared between patients with and without digital ulcers, (4) detailed description of the statistical methods used to conclude for predictive factors, and (5) English language. Our search provided a total of 376 citations. Of these, 297 studies were discarded for not meeting the criteria proposed.

Minimally invasive treatment of Raynaud phenomenon: the role of botulinum type A

Although the mechanism is unknown, Btx-A injection may be an effective, localized, nonsurgical treatment option without addictive properties or systemic side effects for the treatment of ischemic digits. Clinical research supports the safety and efficacy of injection of Btx-A for the treatment of Raynaud phenomenon.