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Gracia Tello BC, Sáez Comet L, Lledó G, Freire Dapena M, Mesa MA, Martín-Cascón M, Guillén Del Castillo A, Martínez Robles E, Simeón-Aznar CP, Todolí Parra JA, Varela DC, Maldonado Vélez G, Marín Ballvé A, Aramburu Llorente J, Pérez Abad L, Ramos Ibáñez E. Capi-score: a quantitative algorithm for identifying disease patterns in nailfold videocapillaroscopy. Rheumatology (Oxford) 2024:keae197. [PMID: 38530791 DOI: 10.1093/rheumatology/keae197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 02/22/2024] [Accepted: 03/17/2024] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVES The European Alliance of Associations for Rheumatology (EULAR) supports the use of nailfold videocapillaroscopy (NVC) to identify disease patterns (DPs) associated with systemic sclerosis (SSc) and Raynaud's phenomenon (RP). Recently, EULAR proposed an easy-to-manage procedure, a so-called Fast Track algorithm, to differentiate SSc from non-SSc patterns in NVC specimens. However, subjectivity among capillaroscopists remains a limitation. Our aim was to perform a software-based analysis of NVC peculiarities in a cohort of samples from SSc and RP patients and, subsequently, build a Fast Track-inspired algorithm to identify DPs without the constraint of interobserver variability. METHODS NVCs were examined by 9 capillaroscopists. Those NVCs whose DPs were consensually agreed (≥2 out of 3 interobservers) were subsequently analysed with an in-house developed software. Each variable's results were grouped according to the consensually agreed DPs in order to identify useful hallmarks to categorise them. RESULTS Eight-hundred and fifty-one NVCs (21 957 images) whose DPs had been consensually agreed were software-analysed. Appropriate cut-offs set in capillary density and percentage of abnormal and giant capillaries, tortuosities and hemorrhages allowed DP categorization and the development of the CAPI-Score algorithm. This consisted of 4 rules: Rule 1, SSc vs non-SSc, accuracy 0.88; Rules 2 and 3, SSc-early vs SSc-active vs SSc-late, accuracy 0.82; Rule 4, non-SSc normal vs non-SSc non-specific, accuracy 0.73. Accuracy improved when the analysis was limited to NVCs whose DPs had achieved full consensus among interobservers. CONCLUSIONS The CAPI-Score algorithm may become a useful tool to assign DPs by overcoming the limitations of subjectivity.
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Affiliation(s)
- B C Gracia Tello
- Internal Medicine, Zaragoza, Hospital Clínico Universitario Lozano Blesa, Zaragoza, ES
- Instituto de Investigación Sanitaria Aragón Zaragoza, ES
| | - L Sáez Comet
- Department of Internal Medicine Zaragoza, Hospital Universitario Miguel Servet
| | - G Lledó
- Department of Autoimmune Diseases Barcelona, Hospital Clinic de Barcelona, Catalunya, ES
| | - M Freire Dapena
- Complejo Hospitalario Universitario of Vigo, Thrombosis and Vasculitis Unit Vigo (Pontevedra), ES
| | - M A Mesa
- Clinica El Rosario, Sección Reumatología Medellin, Antioquia, CO
| | - M Martín-Cascón
- Internal Medicine Murcia, Hospital General Universitario José M Morales Meseguer, Murcia, ES
| | | | - E Martínez Robles
- Department of Internal Medicine Madrid, Hospital General Universitario La Paz, ES
| | - C P Simeón-Aznar
- Hospital Vall d'Hebron, Autoimmune Unit Barcelona, Catalunya, ES
| | - J A Todolí Parra
- Internal Medicine Valencia, Hospital Universitario y Politécnico La Fe, ES
| | - D C Varela
- Rheumatology Department Medellin, Hospital General de Medellín Luz Castro de Gutiérrez, CO
| | - G Maldonado Vélez
- Rheumatology Department Nashville, Vanderbilt University Medical Center, TN, US
| | - A Marín Ballvé
- Internal Medicine, Zaragoza, Hospital Clínico Universitario Lozano Blesa, Zaragoza, ES
- Instituto de Investigación Sanitaria Aragón Zaragoza, ES
| | - J Aramburu Llorente
- Internal Medicine, Zaragoza, Hospital Clínico Universitario Lozano Blesa, Zaragoza, ES
| | - L Pérez Abad
- Internal Medicine, Zaragoza, Hospital Clínico Universitario Lozano Blesa, Zaragoza, ES
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Lercara A, Malattia C, Hysa E, Gattorno M, Cere A, Lavarello C, Vojinovic T, Gotelli E, Paolino S, Sulli A, Pizzorni C, Smith V, Cutolo M. Microvascular status in juvenile Sjögren's disease: the first nailfold videocapillaroscopy investigation. Clin Rheumatol 2024; 43:733-741. [PMID: 38190091 PMCID: PMC10834566 DOI: 10.1007/s10067-023-06857-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Juvenile Sjögren's disease (jSjD) is a rare autoimmune disease characterized by exocrine gland involvement and systemic manifestations, including small vessel vasculitis and Raynaud's phenomenon (RP). We aimed to investigate the microvascular status in jSjD patients by nailfold videocapillaroscopy (NVC) and the potential correlations with clinical and serological features. METHODS Clinical data from thirteen consecutive jSjD patients (11 females and 2 males), with a mean age of 16 ± 4 years, diagnosed before 16 years of age (mean age at diagnosis 12 ± 3) according to the 2016 American College of Rheumatology/EULAR criteria for adult SjD, were collected including age- and sex-matched healthy controls (HCs). Clinical, laboratory, and instrumental data were collected, together with NVC examination. Non-specific and specific NVC parameters were investigated, such as capillary density, capillary dilations, giant capillaries, microhaemorrhages and abnormal shapes. Associations between NVC findings and clinical/serological features were explored and analysed using parametrical and non-parametrical tests. RESULTS Capillary density reduction correlated significantly with articular involvement (arthralgias) (p = 0.024). Microhaemorrhages correlated with lower C3 levels (p = 0.034). No specific NVC pattern for jSjD was identified, whereas abnormal capillary shapes were significantly higher in jSjD patients than HCs (p = 0.005). NVC abnormalities were not associated with SjD-specific instrumental tests (biopsy, imaging, Schirmer's test). RP was present in 8% of jSjD patients. CONCLUSIONS The reduction of capillary density, as well as microhaemorrhages at NVC analysis, are significantly associated with some clinical aspects like articular involvement and serum biomarkers (C3 reduction). The NVC is suggested as safe and further analysis in jSjD patients.
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Affiliation(s)
- Adriano Lercara
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Clara Malattia
- Clinica Pediatrica E Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetic and Maternal Infantile Sciences (DINOGMI), University of Genova, Genova, Italy
| | - Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Marco Gattorno
- Clinica Pediatrica E Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
- Autoinflammatory Diseases and Immunodeficiencies Center, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Andrea Cere
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Claudio Lavarello
- Clinica Pediatrica E Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Tamara Vojinovic
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Emanuele Gotelli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Sabrina Paolino
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carmen Pizzorni
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University Hospital, University of Ghent, Ghent, Belgium
- Department of Rheumatology, Ghent University Hospital, University of Ghent, Ghent, Belgium
- Unit for Molecular Immunology and Inflammation, Flemish Institute for Biotechnology, Inflammation Research Center, Ghent, Belgium
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine and Specialties (DIMI), University of Genova, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 6, 16132, Genova, Italy.
- IRCCS Ospedale Policlinico San Martino, Genova, Italy.
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Angeloudi E, Anyfanti P, Dara A, Pagkopoulou E, Bekiari E, Sgouropoulou V, Garyfallos A, Doumas M, Kitas GD, Dimitroulas T. Peripheral nailfold capillary microscopic abnormalities in rheumatoid arthritis are associated with arterial stiffness: Results from a cross-sectional study. Microvasc Res 2023; 150:104576. [PMID: 37414357 DOI: 10.1016/j.mvr.2023.104576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 07/08/2023]
Abstract
Vascular injury eventually resulting in the establishment of cardiovascular disease is a serious complication in rheumatoid arthritis (RA). Nailfold videocapillaroscopy (NVC) is a non-invasive imaging modality that enables the quantitative and qualitative assessment of the peripheral microvasculature. Nevertheless, capillaroscopic patterns remain inadequately defined in RA, especially regarding their clinical significance as potential markers of systemic vascular impairment. Consecutive RA patients underwent NVC using a standardized protocol, to assess the following parameters: capillary density, avascular areas, capillary dimensions, microhemorrhages, subpapillary venous plexus, and presence of ramified, bushy, crossed and tortuous capillaries. Carotid-femoral pulse wave velocity (PWV) and pulse pressure were measured as well-acknowledged markers of large artery stiffening. The vast majority of our cohort (n = 44) presented a combination of non-specific and abnormal capillaroscopic parameters. Capillary ramification was associated with both PWV and pulse pressure, even after adjustment for cardiovascular risk factors and systemic inflammation. Our study highlights the high prevalence of a wide range of capillaroscopic deviations from the normal patterns in RA. Furthermore, it provides for the first time evidence of an association between structural disorders of the microcirculation and markers of macrovascular dysfunction, suggesting that NVC might have a role as an index of generalised vascular impairment in RA.
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Affiliation(s)
- Elena Angeloudi
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiota Anyfanti
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasia Dara
- Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Pagkopoulou
- Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bekiari
- Second Medical Department, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Vasiliki Sgouropoulou
- 1st Department of Paediatrics, Hippokration Hospital, Aristotle University of Thessaloniki, Greece
| | - Alexandros Garyfallos
- Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michael Doumas
- 2nd Propedeutic Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George D Kitas
- Department of Rheumatology, Russells Hall Hospital, Dudley Group NHS Foundation Trust, Dudley, UK; School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, UK
| | - Theodoros Dimitroulas
- Fourth Department of Internal Medicine, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Pellicano C, Colalillo A, Rosato E. Serum kynurenic acid is lower in systemic sclerosis patients with microvascular damage of hands. Microvasc Res 2023; 148:104537. [PMID: 37030527 DOI: 10.1016/j.mvr.2023.104537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/10/2023]
Abstract
BACKGROUND Endothelial dysfunction occurs early in systemic sclerosis (SSc), leading to tissue hypoxia, vasoconstriction and fibrosis. It has been demonstrated that endothelial cells (ECs) are able to produce kynurenic acid (KYNA) in response to vascular inflammation, due to its anti-inflammatory and anti-oxidants activity. In SSc patients, blood perfusion of hands, assessed by laser speckle contrast analysis (LASCA), correlated negatively with the extent of the nailfold microvascular damage, scored according to nailfold videocapillaroscopy (NVC) classification. Aim of this study was to evaluate the difference of serum KYNA in SSc patients with different stages of microvascular damage. METHODS Serum KYNA was assessed in 40 SSc patients at the enrolment. NVC was performed to evaluate capillaroscopic patterns (early, active and late). LASCA was performed to evaluate mean peripheral blood perfusion (PBP) of both hands and to evaluate the proximal-distal gradient (PDG). RESULTS Median PDG was significantly lower in SSc patients with late NVC pattern compared to SSc patients with early and active NVC pattern [3.79 pU (IQR -8.55-18.16) vs 23.55 pU (IQR 14.92-43.80), p < 0.01]. Serum KYNA was significantly lower in SSc patients with late NVC pattern compared to SSc patient with early and active NVC pattern [45.19 ng/mL (IQR 42.70-54.74) vs 52.65 ng/mL (IQR 49.99-60.29), p < 0.05]. Moreover, SSc patients without PDG had significantly lower serum KYNA than in SSc patients with PDG [48.03 ng/mL (IQR 43.87-53.68) vs 59.27 ng/mL (IQR 49.15-71.00), p < 0.05]. CONCLUSION KYNA is lower in SSc patients with late NCV pattern and without PDG. KYNA may be associated with early endothelial dysfunction.
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Affiliation(s)
- Chiara Pellicano
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Amalia Colalillo
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University, Rome, Italy.
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Piette Y, Reynaert V, Vanhaecke A, Bonroy C, Gutermuth J, Sulli A, Cutolo M, Smith V. Standardised interpretation of capillaroscopy in autoimmune idiopathic inflammatory myopathies: A structured review on behalf of the EULAR study group on microcirculation in Rheumatic Diseases. Clin Exp Rheumatol 2022; 21:103087. [PMID: 35421608 DOI: 10.1016/j.autrev.2022.103087] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/05/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We conducted a systematic review, on behalf of the EULAR Study Group on Microcirculation in Rheumatic Diseases (EULAR SG MC/RD), to investigate the value of nailfold videocapillaroscopy (NVC) in idiopathic inflammatory myopathies (IIM). METHODS Three electronic databases were systematically searched to find all relevant manuscripts reporting NVC outcomes in IIM patients. Articles were assessed based on study design, population, NVC methodology and description of NVC results. To allow comparison between the articles, all NVC results were interpreted according to standardised capillaroscopic terminology, as previously consented by the EULAR SG MC/RD and the Scleroderma Clinical Trials Consortium (SCTC) Group on Capillaroscopy. RESULTS Of the 653 identified records; five were retained after critical appraisal on title, abstract and manuscript level. A marked difference in NVC was observed between (juvenile) dermatomyositis [(j)DM] versus polymyositis, healthy controls and systemic sclerosis patients. In addition, reduced capillary density and scleroderma pattern seem to be associated with active disease in (j)DM, while immunosuppressive treatment appears to reduce NVC abnormalities. CONCLUSION This is the first systematic review investigating NVC in IIM, interpreting the results according to an international consented standardised manner, as proposed by the EULAR SG MC/RD and SCTC Group on Capillaroscopy. We can conclude that NVC presents a promising asset in the diagnosis of (j)DM. Moreover, NVC could be a biomarker for organ involvement and follow-up. Large multicentre prospective standardised studies are further needed to definitely describe associations with clinical and laboratory parameters in the different IIM subtypes.
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Affiliation(s)
- Yves Piette
- Department of Rheumatology, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Valerie Reynaert
- Department of Rheumatology, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Department of Dermatology, SKIN research group, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Amber Vanhaecke
- Department of Rheumatology, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Carolien Bonroy
- Department of Laboratory Medicine, Ghent University Hospital, Department of Diagnostic Sciences, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Jan Gutermuth
- Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZ Brussel), Department of Dermatology, SKIN research group, Laarbeeklaan 101, 1090, Brussels, Belgium
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino Polyclinic Hospital, Genoa, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Internal Medicine, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium; Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Technologiepark-Zwijnaarde 71, 9052, Ghent, Belgium.
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Sirufo MM, Magnanimi LM, Ginaldi L, De Martinis M. Primary Raynaud's phenomenon, very early and early scleroderma tips for a timely diagnosis. Eur J Intern Med 2022; 98:111-112. [PMID: 35120748 DOI: 10.1016/j.ejim.2022.01.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 01/21/2022] [Indexed: 11/20/2022]
Affiliation(s)
- Maria Maddalena Sirufo
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy; Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Italy
| | - Lina Maria Magnanimi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy
| | - Lia Ginaldi
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy; Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Italy
| | - Massimo De Martinis
- Department of Life, Health and Environmental Sciences, University of L'Aquila, Italy; Allergy and Clinical Immunology Unit, Center for the Diagnosis and Treatment of Osteoporosis, AUSL 04 Teramo, Italy.
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Pellicano C, Iannazzo F, Romaggioli L, Rosato E. IL33 and sST2 serum level in systemic sclerosis microvascular involvement. Microvasc Res 2022; 142:104344. [PMID: 35182578 DOI: 10.1016/j.mvr.2022.104344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 10/19/2022]
Abstract
AIM Endothelial dysfunction and microvascular damage are hallmarks of systemic sclerosis (SSc). Objective of this study was to evaluate IL33 and ST2 serum levels in SSc patients and healthy controls (HC). Secondary aim was to evaluate the IL33 axis in the SSc microvascular manifestation. METHODS IL33 and sST2 have been assessed in 46 SSc patients and 24 HC matched for sex and age. Main clinimetric indexes were assessed. Skin perfusion of hands was evaluated by Laser Speckle Contrast Analysis (LASCA) and echocolordoppler ultrasound of renal arteries was performed to evaluate subclinical renal involvement. RESULTS SSc patients had higher serum level of IL33 and sST2 than HC. IL33 and sST2 were significantly higher in SSc patient with digital ulcers (DUs) compared to SSc patients without DUs. SSc patients with late nailfold videocapillaroscopy (NVC) pattern had higher serum levels of sST2 than SSc patients with active NVC pattern. SSc patients without proximal-distal gradient (PDG) at LASCA had significantly higher sST2 serum level compared to SSc patients with PDG. SSc patients with renal resistive index (RRI) ≥ 0.70 had higher serum levels of sST2 than SSc patients with RRI < 0.70. A positive linear correlation was shown between sST2 and RRI, between sST2 and intrarenal S/D and between sST2 and PI. Kaplan-Meier curves show a significantly reduced free survival from DUs in patients with increased sST2 (p = 0.025). In multivariate analysis, sST2 is associated with the development of new DUs. CONCLUSION IL33 and sST2 are increased in SSc patients and ST2 might be a marker of microvascular damage.
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Affiliation(s)
- Chiara Pellicano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesco Iannazzo
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Laura Romaggioli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy.
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Çakmak F, Demirbuga A, Demirkol D, Gümüş S, Torun SH, Kayaalp GK, Ömeroglu RE, Somer A, Uysalol M, Yıldız R, Ayaz NA. Nailfold capillaroscopy: A sensitive method for evaluating microvascular involvement in children with SARS-CoV-2 infection. Microvasc Res 2021; 138:104196. [PMID: 34097919 PMCID: PMC8190529 DOI: 10.1016/j.mvr.2021.104196] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/06/2021] [Accepted: 06/01/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The hyperinflammatory state and the viral invasion may result in endothelial dysfunction in SARS-CoV-2 infection. Although a method foreseeing microvascular dysfunction has not been defined yet, studies conducted in patients diagnosed with COVID-19 have demonstrated the presence of endotheliitis. With this study, we aimed to investigate the microvascular circulation in patients diagnosed with COVID-19 and multisystem inflammatory syndrome in children (MIS-C) by nailfold videocapillaroscopy (NVC). METHODS Thirty-one patients with SARS-CoV-2 infection, 25 of whom were diagnosed with COVID-19 and 6 with MIS-C and 58 healthy peers were included in the study. NVC was performed in eight fingers with 2 images per finger and 16 images were examined for the morphology of capillaries, presence of pericapillary edema, microhemorrhage, avascular area, and neoangiogenesis. Capillary length, capillary width, apical loop, arterial and venous width, and intercapillary distance were measured from three consecutive capillaries from the ring finger of the non-dominant hand. RESULTS COVID-19 patients showed significantly more capillary ramification (p < 0.001), capillary meandering (p = 0.04), microhemorrhage (p < 0.001), neoangiogenesis (p < 0.001), capillary tortuosity (p = 0.003). Capillary density (p = 0.002) and capillary length (p = 0.002) were significantly lower in the patient group while intercapillary distance (p = 0.01) was significantly longer compared with healthy volunteers. Morphologically, patients with MIS-C had a higher frequency of capillary ramification and neoangiogenesis compared with COVID-19 patients (p = 0.04). CONCLUSION Abnormal capillary alterations seen in COVID-19 and MIS-C patients indicate both similar and different aspects of these two spectra of SARS-CoV-2 infection and NVC appears to be a simple and non-invasive method for evaluation of microvascular involvement.
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Affiliation(s)
- Figen Çakmak
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Asuman Demirbuga
- Department of Pediatric Infectious Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Demet Demirkol
- Department of Pediatric Intensive Care Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Süheyla Gümüş
- Department of Pediatric Emergency Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Selda Hancerli Torun
- Department of Pediatric Infectious Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Gülşah Kavrul Kayaalp
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Rukiye Eker Ömeroglu
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Ayper Somer
- Department of Pediatric Infectious Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Metin Uysalol
- Department of Pediatric Emergency Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
| | - Raif Yıldız
- Department of Pediatric Emergency Unit, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey.
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Arvanitaki A, Giannakoulas G, Triantafyllidou E, Pagkopoulou E, Boutou A, Garyfallos A, Karvounis H, Dimitroulas T. Nailfold videocapillaroscopic changes in patients with pulmonary arterial hypertension associated with connective tissue diseases. Rheumatol Int 2021; 41:1289-98. [PMID: 33978819 DOI: 10.1007/s00296-021-04839-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/06/2021] [Indexed: 01/05/2023]
Abstract
Pulmonary arterial hypertension (PAH) represents one of the most devastating complications in connective tissue diseases (CTDs). The aim of this study was to investigate the presence of peripheral microangiopathy in patients with PAH associated with CTDs (CTD-PAH) by exploring nailfold videocapillaroscopic (NVC) changes and identify possible associations of NVC characteristics with markers of disease severity. Α cross-sectional study was performed in 18 CTD-PAH patients [13 PAH due to systemic sclerosis (SSc-PAH) and 5 with other types of CTD-PAH], 14 patients with SSc without PAH (SSc-non-PAH) and 20 healthy controls. NVC quantitative and qualitative parameters were evaluated using Optilia Digital Capillaroscope. To ensure inter-observer repeatability, capillaroscopic images were reviewed by two independent investigators. When compared to healthy controls, patients with CTD-PAH (77.8% women, mean age 65.9 years) presented reduced capillary density (6.5 ± 1.6 loops/mm vs. 9.7 ± 0.7 loops/mm, p < 0.001) and increased capillary loop width (23.3 ± 10.1 μm vs. 11.2 ± 2.5 μm, p < 0.001). SSc-PAH patients presented lower capillary density in comparison with other CTD-PAH patients and SSc-non-PAH subjects and abnormal and disorganized capillaries compared to controls. Patients with other CTD-PAH had also reduced capillary density and increased loop diameter compared to controls. A significant linear correlation was identified between capillary density and estimated glomerular filtration rate in the total CTD-PAH population (r = 0.63, p = 0.007). In SSc-PAH group, capillary loop diameter was positively correlated to cardiac index (r = 0.61, p = 0.02). Significant NVC microvascular changes were detected in patients with various types of CTD-PAH, suggesting an impaired peripheral microcirculation parallel to pulmonary vasculopathy.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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11
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Del Papa N, Pignataro F, Maglione W, Minniti A, Sambataro D, Sambataro G, Valentini G, Caporali R, Vitali C. High NEMO score values in nailfold videocapillaroscopy are associated with the subsequent development of ischaemic digital ulcers in patients with systemic sclerosis. Arthritis Res Ther 2020; 22:237. [PMID: 33050944 PMCID: PMC7556978 DOI: 10.1186/s13075-020-02342-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 10/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nailfold videocapillaroscopy (NVC) is a feasible method that allows the observation of the microvascular changes that mark the course of systemic sclerosis (SSc). In previous studies, we demonstrated that the NEMO score, i.e. the cumulative number of microhaemorrhages and microthromboses, is a good indicator of the steady-state level and overtime changes of disease activity (DA) in SSc. OBJECTIVES To verify whether high NEMO scores, which mirror a very active microvascular derangement in the fingers, may be associated with the subsequent development of ischaemic digital ulcers (IDUs). METHODS The NEMO score was assessed at baseline (T0) in 98 patients with SSc, all classified according to the ACR-EULAR criteria. Of them, 90 were females, 48 had the limited and 50 had the diffuse cutaneous variant of SSc. Afterwards, the patients were closely followed up for 2 years, and the appearance of new IDUs recorded at any time of the follow-up. The T0-NEMO score values of patients who developed IDUs were compared to those of patients who did not. A receiver operating curve (ROC) was constructed, and the area under the curve (AUC) calculated by plotting the sensitivity and 1-specificity of the different NEMO score values in predicting the subsequent development of IDUs. RESULTS During the follow-up, 38 out of 98 patients developed one or more IDUs. The NEMO score at T0 was significantly higher in those who developed IDUs with respect to those who did not [median 14.5 (95% CI 11.0-21.5) and 4.5 (95% CI 4.0-6.0), respectively, p < 0.0001]. The ROC curve derived from different T0-NEMO score values had an AUC of 0.79 (95% CI 0.69-0.86, p < 0.0001). A NEMO score of ≥ 12 had a sensitivity of 83.3% (95% CI 71.5-91.7) and a specificity of 63.2% (95% CI 46.0-78.2), with positive (P) and negative (N) predictive (PV) values of 58.9% (95% CI 44.7-72.2) and 85.6% (71.8-94.4), respectively. A NEMO score of ≥ 16 had a sensitivity of 95.0% (95% CI 86.1-99.0) and a NPV of 93.4% (77.5-99.2). CONCLUSIONS Being a valid tool to measure DA levels in SSc, the NEMO score also appears to be closely related to the subsequent development of IDUs in this disease.
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Affiliation(s)
- Nicoletta Del Papa
- Department of Rheumatology, UOC Day Hospital of Rheumatology, ASST G.Pini-CTO, 20122, Milan, Italy.
| | - Francesca Pignataro
- Department of Rheumatology, UOC Day Hospital of Rheumatology, ASST G.Pini-CTO, 20122, Milan, Italy
| | - Wanda Maglione
- Department of Rheumatology, UOC Day Hospital of Rheumatology, ASST G.Pini-CTO, 20122, Milan, Italy
| | - Antonina Minniti
- Department of Rheumatology, UOC Day Hospital of Rheumatology, ASST G.Pini-CTO, 20122, Milan, Italy
| | - Domenico Sambataro
- Department of Clinical and Experimental Medicine, Internal Medicine Unit, Section of Rheumatology, University of Catania, Catania, Italy
| | - Gianluca Sambataro
- Department of Clinical and Experimental Medicine, Regional Referral Center for Rare Lung Disease, University of Catania, Catania, Italy
| | - Gabriele Valentini
- Department of Internal Medicine, Rheumatology Unit, 2nd University of Naples, Naples, Italy
| | - Roberto Caporali
- Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, University of Milan, Milan, Italy
| | - Claudio Vitali
- Rheumatology Outpatient Clinics, 'Mater Domini' Humanitas Hospital, Castellanza, Italy
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Natalello G, De Luca G, Gigante L, Campochiaro C, De Lorenzis E, Verardi L, Paglionico A, Petricca L, Martone AM, Calvisi S, Ripa M, Cavalli G, Della-Torre E, Tresoldi M, Landi F, Bosello SL, Gremese E, Dagna L. Nailfold capillaroscopy findings in patients with coronavirus disease 2019: Broadening the spectrum of COVID-19 microvascular involvement. Microvasc Res 2020; 133:104071. [PMID: 32949574 PMCID: PMC7494493 DOI: 10.1016/j.mvr.2020.104071] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/04/2020] [Accepted: 09/04/2020] [Indexed: 01/01/2023]
Abstract
Objective Increasing evidence points to endothelial dysfunction as a key pathophysiological factor in coronavirus disease-2019 (COVID-19). No specific methods have been identified to predict, detect and quantify the microvascular alterations during COVID-19. Our aim was to assess microvasculature through nailfold videocapillaroscopy (NVC) in COVID-19 patients. Methods We performed NVC in patients with a confirmed diagnosis of COVID-19 pneumonia. Elementary alterations were reported for each finger according to a semi-quantitative score. Capillary density, number of enlarged and giant capillaries, number of micro-hemorrhages and micro-thrombosis (NEMO score) were registered. Results We enrolled 82 patients (mean age 58.8 ± 13.2 years, male 68.3%) of whom 28 during the hospitalization and 54 after recovery and hospital discharge. At NVC examination we found abnormalities classifiable as non-specific pattern in 53 patients (64.6%). Common abnormalities were pericapillary edema (80.5%), enlarged capillaries (61.0%), sludge flow (53.7%), meandering capillaries and reduced capillary density (50.0%). No pictures suggestive of scleroderma pattern have been observed. Acute COVID-19 patients, compared to recovered patients, showed a higher prevalence of hemosiderin deposits as a result of micro-hemorrhages (P = .027) and micro-thrombosis (P < .016), sludge flow (P = .001), and pericapillary edema (P < .001), while recovered patients showed a higher prevalence of enlarged capillaries (P < .001), loss of capillaries (P = .002), meandering capillaries (P < .001), and empty dermal papillae (P = .006). Conclusion COVID-19 patients present microvascular abnormalities at NVC. Currently ill and recovered subjects are characterized by a different distribution of elementary capillaroscopic alterations, resembling acute and post-acute microvascular damage. Further studies are needed to assess the clinical relevance of NVC in COVID-19. We assessed and accurately described peripheral microvasculature in COVID-19 patients through nailfold videocapillaroscopy. Capillary alterations at the nailfold bed suggest a broad COVID-related microvascular involvement. Different alterations in acutely-ill and recovered patients resemble a transition from acute to post-acute injury.
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Affiliation(s)
- Gerlando Natalello
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy.
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Laura Gigante
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Enrico De Lorenzis
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy; PhD program in Biomolecular Medicine - cycle XXXV, University of Verona, Italy
| | - Lucrezia Verardi
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Annamaria Paglionico
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Luca Petricca
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Anna Maria Martone
- Department of Geriatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Stefania Calvisi
- General Medicine and Advanced Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Ripa
- Department of Infectious Diseases, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio Cavalli
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Emanuel Della-Torre
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Moreno Tresoldi
- General Medicine and Advanced Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Landi
- Department of Geriatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Silvia Laura Bosello
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Elisa Gremese
- Division of Rheumatology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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13
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Pignataro F, Maglione W, Minniti A, Sambataro D, Sambataro G, Campanaro F, Valentini G, Vitali C, Del Papa N. NEMO score in nailfold videocapillaroscopy is a good tool to assess both steady state levels and overtime changes of disease activity in patients with systemic sclerosis: a comparison with the proposed composite indices for this disease status entity. Arthritis Res Ther 2019; 21:258. [PMID: 31783890 DOI: 10.1186/s13075-019-2032-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/14/2019] [Indexed: 11/30/2022] Open
Abstract
Background In previous studies, we demonstrated that the NEMO score, i.e. the cumulative number of microhaemorrhages (MHEs) and microthromboses (MTs), observed in nailfold videocapillaroscopy was a good indicator of the steady state level of disease activity (DA) in patients with systemic sclerosis (SSc) when the European Scleroderma Study Group (EScSG) index was considered the gold standard. Aim of the study To verify whether the NEMO score could be (i) a valid tool to assess DA, even when the modified European Scleroderma Trials and Research (EUSTAR) index was considered to be the comparator, and (ii) a sensitive method to capture the DA overtime changes. Patients and methods The NEMO score and the EScSG and EUSTAR indices were contemporarily assessed at baseline (T0) and after a follow-up of 4–56 months (T1) in 98 patients with SSc. The differences (Δ) between the T1 and T0 values of the NEMO score and the EScSG and EUSTAR indices were calculated and compared to each other. Results NEMO score values were very closely correlated with the corresponding values of the EScSG and EUSTAR indices both at T0 and T1 observations (p < 0.0001 in all cases with the exception of the correlation with EScSG values at T1 (p < 0.03)). The values of the two composite DA indices were also strictly related to each other in both T0 and T1 observations (p < 0.0001). Receiver operating characteristic (ROC) curve analysis showed the NEMO score had a good sensitivity and specificity in classifying patients with a predefined level of DA (scores ≥ 3.0 and ≥ 2.5 for the EScSG and EUSTAR indices, respectively, p < 0.0001 in both cases). Δ values of the NEMO score were significantly correlated with the corresponding values of both the EScSG and EUSTAR indices. Weighted Cohen’s k level of agreement between Δ values of the NEMO score and those of the EScSG and EUSTAR indices was moderate (0.55 and 0.59, respectively). Conclusions NEMO score proves to be a feasible, non-invasive, and valid tool to assess steady state levels and changes over time of DA in patients with SSc. Thus, it can represent an alternative or complementary method to measure this disease status entity in this disorder.
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Michalska-Jakubus M, Cutolo M, Smith V, Krasowska D. Imbalanced serum levels of Ang1, Ang2 and VEGF in systemic sclerosis: Integrated effects on microvascular reactivity. Microvasc Res 2019. [PMID: 31075243 DOI: 10.1016/j.mvr2019.103881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
INTRODUCTION AND AIM Microangiopathy is a hallmark of systemic sclerosis (SSc). It is a progressive process from an early inflammatory and proangiogenic environment to insufficient microvascular repair with loss of microvessels. The exact underlying mechanisms remain ill-defined. Aim of the study was to investigate whether imbalanced angiopoietins/VEGF serum profile should be related in SSc to the altered microvascular reactivity characterized by aberrant angiogenesis and avascularity. MATERIALS AND METHODS Serum levels of Angiopoietin-1 (Ang1), Angiopoietin-2 (Ang2) and VEGF were measured by ELISA in 47 SSc patients and 27 healthy controls. Microvascular alterations were assessed by nailfold videocapillaroscopy (NVC). RESULTS Serum concentrations of Ang1 were significantly lower [mean (S.D.): 21516.04 (11,441.035) pg/ml], and Ang2 significantly increased [25,89.55 (934.225) pg/ml] in SSc as compared with the control group [Ang1: 28,457.08 (10,431.905) pg/ml; Ang2: 1556.23 (481.255) pg/ml, p < 0.01, respectively], whereas VEGF did not differ significantly. The ratios of Ang1/Ang2 and Ang1/VEGF were significantly lower in SSc patients (8.346 ± 4.523 and 95.17 ± 75.0, respectively) than in healthy subjects (17.612 ± 6.731 p < 0.000001 and 183.11 ± 137.73; p = 0.004]. Formation of giant capillaries with vascular leakage and collapse was associated with significant increase in VEGF and concomitant Ang1 deficiency. Capillary loss was related to significant increase in VEGF with respect to those with preserved capillary number (395.12 ± 256.27 pg/mL vs. 254.80 ± 213.61 pg/mL) whereas elevated Ang2 levels induced more advanced capillary damage as indicated by the presence of the "Late" NVC pattern. CONCLUSIONS We found that serum levels of Ang1, Ang2 and VEGF are differentially expressed in SSc and altered Ang1/Ang2 profile might underlay the aberrant angiogenesis in SSc despite increase in VEGF. For the first time we identified that significant deficiency of Ang1 might be involved in early capillary enlargement, followed by collapse and lack of stable newly-formed vessels in VEGF-enriched environment, whereas Ang2 levels seem to increase later in disease progression and advanced microvascular damage ("Late" NVC pattern).
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Affiliation(s)
- Małgorzata Michalska-Jakubus
- Department of Dermatology, Venereology and Paediatric Dermatology, Medical University of Lublin, Lublin, Poland.
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| | - Vanessa Smith
- Faculty of Internal Medicine, Ghent University, Belgium.
| | - Dorota Krasowska
- Department of Dermatology, Venereology and Paediatric Dermatology, Medical University of Lublin, Lublin, Poland.
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15
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Michalska-Jakubus M, Cutolo M, Smith V, Krasowska D. Imbalanced serum levels of Ang1, Ang2 and VEGF in systemic sclerosis: Integrated effects on microvascular reactivity. Microvasc Res 2019; 125:103881. [PMID: 31075243 DOI: 10.1016/j.mvr.2019.103881] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 02/03/2019] [Accepted: 05/04/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND AIM Microangiopathy is a hallmark of systemic sclerosis (SSc). It is a progressive process from an early inflammatory and proangiogenic environment to insufficient microvascular repair with loss of microvessels. The exact underlying mechanisms remain ill-defined. Aim of the study was to investigate whether imbalanced angiopoietins/VEGF serum profile should be related in SSc to the altered microvascular reactivity characterized by aberrant angiogenesis and avascularity. MATERIALS AND METHODS Serum levels of Angiopoietin-1 (Ang1), Angiopoietin-2 (Ang2) and VEGF were measured by ELISA in 47 SSc patients and 27 healthy controls. Microvascular alterations were assessed by nailfold videocapillaroscopy (NVC). RESULTS Serum concentrations of Ang1 were significantly lower [mean (S.D.): 21516.04 (11,441.035) pg/ml], and Ang2 significantly increased [25,89.55 (934.225) pg/ml] in SSc as compared with the control group [Ang1: 28,457.08 (10,431.905) pg/ml; Ang2: 1556.23 (481.255) pg/ml, p < 0.01, respectively], whereas VEGF did not differ significantly. The ratios of Ang1/Ang2 and Ang1/VEGF were significantly lower in SSc patients (8.346 ± 4.523 and 95.17 ± 75.0, respectively) than in healthy subjects (17.612 ± 6.731 p < 0.000001 and 183.11 ± 137.73; p = 0.004]. Formation of giant capillaries with vascular leakage and collapse was associated with significant increase in VEGF and concomitant Ang1 deficiency. Capillary loss was related to significant increase in VEGF with respect to those with preserved capillary number (395.12 ± 256.27 pg/mL vs. 254.80 ± 213.61 pg/mL) whereas elevated Ang2 levels induced more advanced capillary damage as indicated by the presence of the "Late" NVC pattern. CONCLUSIONS We found that serum levels of Ang1, Ang2 and VEGF are differentially expressed in SSc and altered Ang1/Ang2 profile might underlay the aberrant angiogenesis in SSc despite increase in VEGF. For the first time we identified that significant deficiency of Ang1 might be involved in early capillary enlargement, followed by collapse and lack of stable newly-formed vessels in VEGF-enriched environment, whereas Ang2 levels seem to increase later in disease progression and advanced microvascular damage ("Late" NVC pattern).
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Affiliation(s)
- Małgorzata Michalska-Jakubus
- Department of Dermatology, Venereology and Paediatric Dermatology, Medical University of Lublin, Lublin, Poland.
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, Italy.
| | - Vanessa Smith
- Faculty of Internal Medicine, Ghent University, Belgium.
| | - Dorota Krasowska
- Department of Dermatology, Venereology and Paediatric Dermatology, Medical University of Lublin, Lublin, Poland.
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Kreps EO, Carton C, Cutolo M, Cutolo CA, Vanhaecke A, Leroy BP, Smith V. Ocular involvement in systemic sclerosis: A systematic literature review, it's not all scleroderma that meets the eye. Semin Arthritis Rheum 2018; 49:119-125. [PMID: 30660382 DOI: 10.1016/j.semarthrit.2018.12.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 12/02/2018] [Accepted: 12/21/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Systemic sclerosis (SSc) is a rare and complex autoimmune disorder characterized by microvascular damage and progressive fibrosis which affects the skin and multiple other organs. Much of the published data concerning SSc and the eye consists of single case reports or small case studies. This systematic review aims to provide an overview of the current level of evidence for SSc-related ocular changes. MATERIALS AND METHODS A systematic literature review was conducted using 3 electronic databases, according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. A combination of following keywords was used: "Systemic Sclerosis" and ophthalmology-related search terms, including the keywords "Eye", "Ocular" and "Ophthalmic". All articles were screened by 2 independent reviewers at title, abstract and full text level. We solely included case-control studies that investigated specific ocular findings in SSc patients compared to healthy controls. RESULTS Nine of 270 articles were retained. Dry eye symptoms are associated with SSc, whereas objective signs (Schirmer I testing) show conflicting results. There is insufficient evidence of SSc-related changes to the central corneal thickness. In terms of posterior segment involvement, choroidal vasculature appears to be affected to greater extent than the retinal microcirculation. However, the limited number of patients included in the studies renders it hazardous to draw overall conclusions. CONCLUSIONS There is a paucity of well-designed case-control studies investigating possible ocular involvement in SSc. Our systematic review demonstrates limited proven associations between SSc and ocular abnormalities, mainly in terms of dry eye symptoms and choroidal thickness. Future standardized prospective studies are needed to clarify the impact of the disease on the eye.
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Affiliation(s)
- Elke O Kreps
- Department of Ophthalmology, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Charlotte Carton
- Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium.
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, IRCCS San Martino Polyclinic Hospital, Viale Benedetto XV, 616132 Genoa, Italy.
| | - Carlo Alberto Cutolo
- Clinica Oculistica, DiNOGMI, University of Genoa, IRCCS Ospedale Policlinico San Martino, Viale Benedetto XV, 616132 Genoa, Italy.
| | - Amber Vanhaecke
- Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium.
| | - Bart P Leroy
- Department of Ophthalmology & Center for Medical Genetics, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Division of Ophthalmology & Center for Molecular & Cellular Therapeutics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Vanessa Smith
- Department of Internal Medicine, Ghent University, Corneel Heymanslaan 10, 9000 Ghent, Belgium; Department of Rheumatology, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium; Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Corneel Heymanslaan 10, 9000 Ghent, Belgium.
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Guillén-Del-Castillo A, Simeón-Aznar CP, Callejas-Moraga EL, Tolosa-Vilella C, Alonso-Vila S, Fonollosa-Pla V, Selva-O'Callaghan A. Quantitative videocapillaroscopy correlates with functional respiratory parameters: a clue for vasculopathy as a pathogenic mechanism for lung injury in systemic sclerosis. Arthritis Res Ther 2018; 20:281. [PMID: 30567570 PMCID: PMC6299957 DOI: 10.1186/s13075-018-1775-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 11/25/2018] [Indexed: 01/21/2023] Open
Abstract
Background To determine whether lung involvement is related to microvascular perturbations, nailfold videocapillaroscopy (NVC) was performed in patients with systemic sclerosis (SSc). Methods A cross-sectional study was consecutively accomplished in 152 SSc patients. NVC, a pulmonary function test and echocardiography were undergone within a 3-month period. Finally, 134 patients with at least eight NVC (200× magnification) images were selected for quantitative and qualitative examinations. Results Patients with interstitial lung disease presented lower median capillary density (4.86/mm vs 5.88/mm, p = 0.005) and higher median of neoangiogenesis (0.56/mm vs 0.31/mm, p = 0.005). A higher quantity of neoangiogenesis capillaries was found in patients with pulmonary arterial hypertension (0.70/mm vs 0.33/mm, p = 0.008). Multivariate linear regression analysis established a correlation between neoangiogenesis and decreased forced vital capacity (FVC) (p < 0.001): for each capillary with neoangiogenesis visualized on average per 1 mm, FVC was 7.3% reduced. In qualitative NVC, a late pattern as defined by Cutolo was also associated with lower FVC (p = 0.018). The number of giant capillaries was associated with reduced diffusion capacity of the lung for carbon monoxide (DLCO) (p = 0.016); for each giant capillary per 1 mm, DLCO was 11.8% diminished. Conclusions A good correlation was observed between distinctive quantitative and qualitative NVC features with lung functional parameters such as FVC and DLCO. It is suggested that vasculopathy could play a role in SSc lung involvement.
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Affiliation(s)
- Alfredo Guillén-Del-Castillo
- Department of Systemic Autoimmune Diseases, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Carmen Pilar Simeón-Aznar
- Department of Systemic Autoimmune Diseases, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain.
| | - Eduardo L Callejas-Moraga
- Department of Internal Medicine, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Carles Tolosa-Vilella
- Department of Internal Medicine, Corporació Sanitària Universitària Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Barcelona, Spain
| | - Serafín Alonso-Vila
- Department of Systemic Autoimmune Diseases, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Vicente Fonollosa-Pla
- Department of Systemic Autoimmune Diseases, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
| | - Albert Selva-O'Callaghan
- Department of Systemic Autoimmune Diseases, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Passeig Vall d'Hebron 119-129, 08035, Barcelona, Spain
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Zanatta E, Famoso G, Boscain F, Montisci R, Pigatto E, Polito P, Schiavon F, Iliceto S, Cozzi F, Doria A, Tona F. Nailfold avascular score and coronary microvascular dysfunction in systemic sclerosis: A newsworthy association. Autoimmun Rev 2018; 18:177-183. [PMID: 30572139 DOI: 10.1016/j.autrev.2018.09.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 09/01/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS We aimed to assess the relationship between nailfold videocapillaroscopy (NVC) abnormalities and coronary flow reserve (CFR), a marker of coronary microvascular dysfunction (CMD) in patients with systemic sclerosis (SSc). METHODS We studied 39 SSc patients (33 females, mean ± SD age 54 ± 12 years, median disease duration 11 years, range 6-22) and 22 controls (matched for age and sex) without any evidence of cardiovascular disease. Clinical assessment was performed by modified Rodnan skin score (mRss) and EUSTAR score. Coronary flow velocities in the left anterior descending coronary artery were measured by transthoracic echocardiography. Average peak flow velocities, CFR and microvascular resistance at baseline (BMR) and in hyperaemic (HMR) condition were assessed. CFR ≤2.5 was considered marker of CMD. Six NVC-abnormalities were evaluated by a semi quantitative scoring system: enlarged and giant capillaries (diameter > 20 μm and >50 μm, respectively), hemorrhages, disarray, capillary ramifications and loss of capillaries (avascular score). Statistic was performed using SPSS. RESULTS CFR was lower in SSc patients than in controls (2.6 ± 0.5 vs 3.3 ± 0.5). CMD was detected in 24 patients (61.5%) vs 0 controls (p < .0001). CFR was inversely correlated with NVC-avascular score (rho =-0.750, p < .0001). Avascular and capillary ramifications scores (p = .001 and p = .03, respectively), mRss (p = .003) and EUSTAR score (p = .01) were higher in patients with CMD than in those without. At multivariable analysis, avascular score was independently associated with CMD (p = .01). HMR was directly correlated with avascular score (rho = 0.416, p = .008). CONCLUSIONS In our SSc patients NVC-avascular score was associated with CMD which seems to be the result of a structural microvascular remodeling.
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Affiliation(s)
- Elisabetta Zanatta
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Francesca Boscain
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, San Giovanni di Dio Hospital, University of Cagliari, Cagliari, Italy
| | - Erika Pigatto
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Pamela Polito
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Franco Schiavon
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
| | - Franco Cozzi
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Andrea Doria
- Rheumatology Unit, Department of Medicine-DIMED, University of Padova, Padova, Italy.
| | - Francesco Tona
- Department of Cardiac, Thoracic and Vascular Sciences, University of Padova, Padova, Italy
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19
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Rodriguez-Reyna TS, Bertolazzi C, Vargas-Guerrero A, Gutiérrez M, Hernández-Molina G, Audisio M, Roverano S, González de Urizar M, Díaz Coto JF, Herrera Velasco BE, Cornejo Ortega MP, Sapag Durán AM, Villegas Guzmán JE, Medina Quintero LF, Sabelli M, Sapag Durán S, Cutolo M. Can nailfold videocapillaroscopy images be interpreted reliably by different observers? Results of an inter-reader and intra-reader exercise among rheumatologists with different experience in this field. Clin Rheumatol 2018; 38:205-210. [PMID: 29476351 DOI: 10.1007/s10067-018-4041-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 02/12/2018] [Accepted: 02/14/2018] [Indexed: 11/27/2022]
Abstract
Nailfold videocapillaroscopy (VCP) allows non-invasive assessment of the microcirculation. Adequate training in this field is relevant for rheumatologists. There is increasing evidence of the reliability of VCP findings among different readers. Objective: To evaluate inter- and intra-reader agreement of rheumatologists to identify normal images and systemic sclerosis (SSc) patterns on VCP ("early," "active," and "late" proposed by Cutolo et al.). Thirteen rheumatologists with different experience in nailfold VCP received training to standardize reading criteria. They rated 60 VCP images from healthy and SSc patients at baseline and 4 weeks later, using an electronic platform. The reading of an expert was considered the gold standard. Data were analyzed using Cohen's kappa for concordance and Student's t test and ANOVA to compare kappa means for inter-reader, intra-reader, and inter-pattern readings. Mean inter-reader and intra-reader kappa were 0.45 and 0.49, respectively, (moderate agreement). Kappa scores were higher among experienced vs inexperienced readers (inter-reader kappa 0.58 vs 0.34, p = 0.001, intra-reader kappa 0.65 vs 0.37, p = 0.01). Agreement was substantial (kappa = 0.61) for the identification of normal vs abnormal images and higher for the identification of active (0.48, p = 0.009) and late SSc patterns (0.56, p = 0.008) than for the early SSc pattern (0.35, p = 0.003). There is moderate agreement among rheumatologists for the identification of SSc videocapillaroscopy patterns (higher among experienced rheumatologists) and substantial agreement, regardless of previous experience in VCP, in the identification of normal and abnormal images. Agreement for the identification of active and late patterns is higher than for the early pattern.
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Affiliation(s)
- Tatiana Sofía Rodriguez-Reyna
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Calle Vasco de Quiroga 15, Col. Belisario Domínguez, Sección XVI, Del. Tlalpan, C.P. 14080, Mexico City, Mexico.
| | | | - Angélica Vargas-Guerrero
- Department of Rheumatology, Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | | | - Gabriela Hernández-Molina
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Calle Vasco de Quiroga 15, Col. Belisario Domínguez, Sección XVI, Del. Tlalpan, C.P. 14080, Mexico City, Mexico
| | - Marcelo Audisio
- Department of Rheumatology, Hospital Nacional de Clínicas de la Universidad Nacional de Córdoba, Córdoba, Argentina
| | - Susana Roverano
- Department of Rheumatology, Hospital J.M. Cullen, Santa Fe, Argentina
| | | | - José Francisco Díaz Coto
- Servicio de Reumatología, Hospital México-Caja Costarricense del Seguro Social, San Jose, Costa Rica
| | | | | | - Ana María Sapag Durán
- Department of Rheumatology, Hospital Universitario Japonés, Santa Cruz de la Sierra, Bolivia
| | | | | | - Mirtha Sabelli
- Hospital Italiano de Buenos Aires, Perón, 4190, CABA, Argentina
| | - Sandy Sapag Durán
- Rheumatologic Research Institue Sapag and Sapag, Santa Cruz de la Sierra, Bolivia
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS Polyclinic Hospital San Martino University of Genova, Genova, Italy
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20
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Dinsdale G, Moore T, O'Leary N, Berks M, Roberts C, Manning J, Allen J, Anderson M, Cutolo M, Hesselstrand R, Howell K, Pizzorni C, Smith V, Sulli A, Wildt M, Taylor C, Murray A, Herrick AL. Quantitative outcome measures for systemic sclerosis-related Microangiopathy - Reliability of image acquisition in Nailfold Capillaroscopy. Microvasc Res 2017; 113:56-59. [PMID: 28495471 DOI: 10.1016/j.mvr.2017.05.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/04/2017] [Accepted: 05/06/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Nailfold capillaroscopic parameters hold increasing promise as outcome measures for clinical trials in systemic sclerosis (SSc). Their inclusion as outcomes would often naturally require capillaroscopy images to be captured at several time points during any one study. Our objective was to assess repeatability of image acquisition (which has been little studied), as well as of measurement. METHOD 41 patients (26 with SSc, 15 with primary Raynaud's phenomenon) and 10 healthy controls returned for repeat high-magnification (300×) videocapillaroscopy mosaic imaging of 10 digits one week after initial imaging (as part of a larger study of reliability). Images were assessed in a random order by an expert blinded observer and 4 outcome measures extracted: (1) overall image grade and then (where possible) distal vessel locations were marked, allowing (2) vessel density (across the whole nailfold) to be calculated (3) apex width measurement and (4) giant vessel count. Intra-rater, intra-visit and intra-rater inter-visit (baseline vs. 1week) reliability were examined in 475 and 392 images respectively. A linear, mixed-effects model was used to estimate variance components, from which intra-class correlation coefficients (ICCs) were determined. RESULTS Intra-visit and inter-visit reliability estimates (ICCs) were (respectively): overall image grade, 0.97 and 0.90; vessel density, 0.92 and 0.65; mean vessel width, 0.91 and 0.79; presence of giant capillary, 0.68 and 0.56. These estimates were conditional on each parameter being measurable. CONCLUSION Within-operator image analysis and acquisition are reproducible. Quantitative nailfold capillaroscopy, at least with a single observer, provides reliable outcome measures for clinical studies including randomised controlled trials.
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Affiliation(s)
- Graham Dinsdale
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Manchester, UK.
| | - Tonia Moore
- Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Neil O'Leary
- Centre for Biostatistics, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Christopher Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Joanne Manning
- Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - John Allen
- Microvascular Diagnostics, Northern Medical Physics and Clinical Engineering, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marina Anderson
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Roger Hesselstrand
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Kevin Howell
- Institute of Immunity and Transplantation, University College London, Royal Free Campus, London, UK
| | - Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University, Hospital, Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Marie Wildt
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Christopher Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Andrea Murray
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Salford Royal Hospital, Stott Lane, Manchester, UK; NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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21
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Andracco R, Irace R, Zaccara E, Vettori S, Maglione W, Riccardi A, Pignataro F, Ferrara R, Sambataro D, Sambataro G, Vitali C, Valentini G, Del Papa N. The cumulative number of micro-haemorrhages and micro-thromboses in nailfold videocapillaroscopy is a good indicator of disease activity in systemic sclerosis: a validation study of the NEMO score. Arthritis Res Ther 2017; 19:133. [PMID: 28610600 PMCID: PMC5470283 DOI: 10.1186/s13075-017-1354-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 05/30/2017] [Indexed: 11/20/2022] Open
Abstract
Background Some abnormalities in nailfold videocapillaroscopy (NVC), such as the presence of micro-haemorrhages (MHEs), micro-thromboses (MTs), giant capillaries (GCs) and reduction in the number of capillaries (nCs), suggest a disease activity (DA) phase in systemic sclerosis (SSc). In a previous paper, we showed that the number of micro-haemorrhages and micro-thromboses (the so-called NEMO score) was the NVC feature more closely associated with DA. The present study was aimed at validating the NEMO score as a measure of DA in patients with SSc. Methods Two cohorts of 122 and 97 patients with SSc who were referred to two different rheumatology units, one in Milan and one in Naples, respectively, constituted the validation cohorts. The NEMO score, the total number of GCs and the mean nCs per digit were the parameters defined in each patient by eight-finger NVC. An expert operator analysed the NVCs in each of the participating units. The European Scleroderma Study Group (ESSG) index was used to define the DA level in each patient at the time of NVC examination. Results The NEMO score was the NVC parameter more strictly correlated with the ESSG score in both the Milan and Naples cohorts (p < 0.0001), and it was the only one among the NVC variables that gave a significant contribution in a logistic model where the ESSG score represented the dependent variable. ROC curve analysis confirmed that the NEMO score had the best performance in measuring DA. The AUC of the NEMO score was significantly greater than the AUCs obtained by plotting the sensitivity and specificity of the number of GCs and the mean nCs (p < 0.0001 in all cases). The NEMO score values that showed the best sensitivity-specificity balance in capturing patients with a relevant DA level were slightly higher in the Naples cohort than in the Milan cohort. Conclusions This study confirms that the presence of a certain number of MHEs and MTs in NVC may be considered a strong warning signal of a current phase of DA in patients with SSc.
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Affiliation(s)
- Romina Andracco
- UOC Day Hospital of Rheumatology, Department of Rheumatology, ASST G. Pini-CTO, Milan, Italy
| | - Rosaria Irace
- Rheumatology Unit, Department of Internal Medicine, 2nd University of Naples, Naples, Italy
| | - Eleonora Zaccara
- UOC Day Hospital of Rheumatology, Department of Rheumatology, ASST G. Pini-CTO, Milan, Italy
| | - Serena Vettori
- Rheumatology Unit, Department of Internal Medicine, 2nd University of Naples, Naples, Italy
| | - Wanda Maglione
- UOC Day Hospital of Rheumatology, Department of Rheumatology, ASST G. Pini-CTO, Milan, Italy
| | - Antonella Riccardi
- Rheumatology Unit, Department of Internal Medicine, 2nd University of Naples, Naples, Italy
| | - Francesca Pignataro
- UOC Day Hospital of Rheumatology, Department of Rheumatology, ASST G. Pini-CTO, Milan, Italy
| | - Roberta Ferrara
- Rheumatology Unit, Department of Internal Medicine, 2nd University of Naples, Naples, Italy
| | - Domenico Sambataro
- UOC Day Hospital of Rheumatology, Department of Rheumatology, ASST G. Pini-CTO, Milan, Italy
| | - Gianluca Sambataro
- UOC Day Hospital of Rheumatology, Department of Rheumatology, ASST G. Pini-CTO, Milan, Italy
| | - Claudio Vitali
- Section of Rheumatology, Villa San Giuseppe, Istituto Santo Stefano, Como, Italy
| | - Gabriele Valentini
- Rheumatology Unit, Department of Internal Medicine, 2nd University of Naples, Naples, Italy
| | - Nicoletta Del Papa
- UOC Day Hospital of Rheumatology, Department of Rheumatology, ASST G. Pini-CTO, Milan, Italy.
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22
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Sulli A, Ruaro B, Smith V, Paolino S, Pizzorni C, Pesce G, Cutolo M. Subclinical dermal involvement is detectable by high frequency ultrasound even in patients with limited cutaneous systemic sclerosis. Arthritis Res Ther 2017; 19:61. [PMID: 28320447 PMCID: PMC5360023 DOI: 10.1186/s13075-017-1270-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2016] [Accepted: 02/21/2017] [Indexed: 11/24/2022] Open
Abstract
Background The aim of the study was to detect by skin high-frequency ultrasound (US) possible subclinical skin involvement in patients affected by limited cutaneous systemic sclerosis (lcSSc), in those skin areas apparently not affected by the disease on the basis of a normal modified Rodnan skin score (mRSS). Differences in dermal thickness (DT) in comparison with healthy subjects were investigated. Methods Fifty patients with lcSSc (age 62 ± 13 years (mean ± SD), disease duration 5 ± 5 years) and 50 sex-matched and age-matched healthy subjects (age 62 ± 11 years) were enrolled. DT was evaluated by both mRSS and US at the usual 17 skin areas (zygoma, fingers, dorsum of the hands, forearms, upper arms, chest, abdomen, thighs, lower legs and feet). Non-parametric tests were used for the statistical analysis. Results Subclinical dermal involvement was detected by US even in the skin areas in patients with lcSSc, who had a normal local mRSS. In addition, statistically significantly higher mean DT was found in almost all skin areas, when compared to healthy subjects (p < 0.0001 for all areas). In particular, DT was significantly greater in patients with lcSSc than in healthy subjects in four out of six skin areas with a normal mRSS (score = 0) (upper arm, chest and abdomen), despite the clinical classification of lcSSc. Conclusions This study strongly suggests that subclinical dermal involvement may be detectable by US even in skin areas with a normal mRSS in patients classified as having lcSSc. This should be taken into account during SSc subset classification in clinical studies/trials.
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Affiliation(s)
- A Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Viale Benedetto XV, n° 6, AOU IRCCS San Martino, 16132, Genova, Italy
| | - B Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Viale Benedetto XV, n° 6, AOU IRCCS San Martino, 16132, Genova, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - S Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Viale Benedetto XV, n° 6, AOU IRCCS San Martino, 16132, Genova, Italy
| | - C Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Viale Benedetto XV, n° 6, AOU IRCCS San Martino, 16132, Genova, Italy
| | - G Pesce
- Laboratory of Autoimmunity, Department of Internal Medicine, University of Genova, IRCCS A.O.U, San Martino, Genoa, Italy
| | - M Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Viale Benedetto XV, n° 6, AOU IRCCS San Martino, 16132, Genova, Italy.
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23
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Dinsdale G, Moore T, O'Leary N, Tresadern P, Berks M, Roberts C, Manning J, Allen J, Anderson M, Cutolo M, Hesselstrand R, Howell K, Pizzorni C, Smith V, Sulli A, Wildt M, Taylor C, Murray A, Herrick AL. Intra-and inter-observer reliability of nailfold videocapillaroscopy - A possible outcome measure for systemic sclerosis-related microangiopathy. Microvasc Res 2017; 112:1-6. [PMID: 28163035 DOI: 10.1016/j.mvr.2017.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 01/12/2017] [Accepted: 02/01/2017] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Our aim was to assess the reliability of nailfold capillary assessment in terms of image evaluability, image severity grade ('normal', 'early', 'active', 'late'), capillary density, capillary (apex) width, and presence of giant capillaries, and also to gain further insight into differences in these parameters between patients with systemic sclerosis (SSc), patients with primary Raynaud's phenomenon (PRP) and healthy control subjects. METHODS Videocapillaroscopy images (magnification 300×) were acquired from all 10 digits from 173 participants: 101 patients with SSc, 22 with PRP and 50 healthy controls. Ten capillaroscopy experts from 7 European centres evaluated the images. Custom image mark-up software allowed extraction of the following outcome measures: overall grade ('normal', 'early', 'active', 'late', 'non-specific', or 'ungradeable'), capillary density (vessels/mm), mean vessel apical width, and presence of giant capillaries. RESULTS Observers analysed a median of 129 images each. Evaluability (i.e. the availability of measures) varied across outcome measures (e.g. 73.0% for density and 46.2% for overall grade in patients with SSc). Intra-observer reliability for evaluability was consistently higher than inter- (e.g. for density, intra-class correlation coefficient [ICC] was 0.71 within and 0.14 between observers). Conditional on evaluability, both intra- and inter-observer reliability were high for grade (ICC 0.93 and 0.78 respectively), density (0.91 and 0.64) and width (0.91 and 0.85). CONCLUSIONS Evaluability is one of the major challenges in assessing nailfold capillaries. However, when images are evaluable, the high intra- and inter-reliabilities suggest that overall image grade, capillary density and apex width have potential as outcome measures in longitudinal studies.
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Affiliation(s)
- Graham Dinsdale
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK.
| | - Tonia Moore
- Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Neil O'Leary
- Centre for Biostatistics, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Philip Tresadern
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Christopher Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Joanne Manning
- Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - John Allen
- Microvascular Diagnostics, Northern Medical Physics and Clinical Engineering, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marina Anderson
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Roger Hesselstrand
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Kevin Howell
- Institute of Immunity and Transplantation, University College London, Royal Free Campus, London, UK
| | - Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Faculty of Internal Medicine, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Dept. Internal Medicine, University of Genova, Italy
| | - Marie Wildt
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Christopher Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging & Data Sciences, University of Manchester, Manchester, UK
| | - Andrea Murray
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal & Dermatological Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; NIHR Manchester Musculoskeletal Biomedical Research Unit, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Pizzorni C, Giampetruzzi AR, Mondino C, Facchiano A, Abeni D, Paolino S, Ruaro B, Smith V, Sulli A, Cutolo M. Nailfold capillaroscopic parameters and skin telangiectasia patterns in patients with systemic sclerosis. Microvasc Res 2016; 111:20-24. [PMID: 27989404 DOI: 10.1016/j.mvr.2016.12.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 12/07/2016] [Accepted: 12/09/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To correlate nailfold capillaroscopic parameters with the presence of skin telangiectases (TAs) in systemic sclerosis patients (SSc). METHODS Thirty-three consecutive patients (28 women and 5 men, mean age 59±21years) affected by SSc according to the ACR/EULAR criteria, 30 with limited (lcSSc) and 3 with diffuse (dcSSc) skin disease, displaying the presence of skin TAs on face, hands, forearms, neck, and décolleté were recruited. Nailfold videocapillaroscopy (NVC) was performed to classify the patients into one of the three main patterns of SSc microangiopathy ("early", "active", "late"), and to calculate the microangiopathy evolution score (MES). SSc patients underwent also dermoscopy (DS) for the analysis of the TA score and patterns (spot or reticular). Possible correlations between clinical findings, serum autoantibodies, TA patterns and both NVC patterns and MES were investigated. RESULTS The "late" NVC pattern was found associated with a highest total number of TAs (p=0.005): in particular both "spot" and "reticular" TA patterns were found equally distributed in SSc patients with the "late" pattern. High MES values were found associated with the highest total number of TAs (p=0.003), with the "reticular" but not with the "spot" DS pattern (p=0.003) and with the "late" pattern of microangiopathy (p=0.001). CONCLUSIONS The severity of nailfold microangiopathy seems to correlate in SSc patients with both progressive cutaneous microvascular abnormalities and Medsger's severity score, as evaluated by NVC analysis and DS. The assessment of the microvascular damage may be useful not only during the onset of SSc for the early diagnosis, but also to monitor its evolution.
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Affiliation(s)
- Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino-IST Genova, Italy
| | - Anna R Giampetruzzi
- Department of Dermatology, Dermoscopy and Nailfold Capillaroscopy Services, Istituto Dermopatico dell'Immacolata IDI-IRCCS FLMM, Rome, Italy
| | | | - Antonio Facchiano
- Research Laboratory, Istituto Dermopatico dell'Immacolata IDI-IRCCS FLMM, Rome, Italy
| | - Damiano Abeni
- Clinical Epidemiology Unit, Istituto Dermopatico dell'Immacolata IDI-IRCCS FLMM, Rome, Italy
| | - Sabrina Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino-IST Genova, Italy
| | - Barbara Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino-IST Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino-IST Genova, Italy
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS AOU San Martino-IST Genova, Italy.
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Pizzorni C, Sulli A, Smith V, Ruaro B, Trombetta AC, Cutolo M, Paolino S. Primary Raynaud's phenomenon and nailfold videocapillaroscopy: age-related changes in capillary morphology. Clin Rheumatol 2016; 36:1637-1642. [PMID: 27722973 DOI: 10.1007/s10067-016-3442-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 09/26/2016] [Accepted: 09/29/2016] [Indexed: 11/30/2022]
Abstract
This study aimed to detect by nailfold videocapillaroscopy (NVC) the presence of age-related capillary morphological patterns in a large cohort of subjects affected by primary Raynaud's phenomenon (PRP). NVC was performed in 877 patients affected by PRP, divided into three age groups: <35, 35-55 and >55 years. The following qualitative parameters were assessed and compared in the three groups of patients: apical dilations, irregular (non-homogeneous) dilations, venous branch dilations, microhaemorrhages, tortuosities and subpapillary venous plexus visibility. Patients with either irregular dilations or venous branch dilations were found significantly younger than those without (p < 0.0001). The presence of either irregular or venous branch dilations seems to exclude the presence of apical dilations. Patients with microhaemorrhages were found significantly younger than those without (p = 0.05), and 81 % of patients without microhaemorrhages did not show irregular and venous branch dilations. The subpapillary venous plexus seems more visible in subjects with age < 35, as well as in those with age > 55 years (p < 0.0001). A statistically significant negative correlation was found between presence of apical and irregular dilations (p < 0.0001), apical dilations and venous branch dilations (p = 0.02), apical dilations and tortuosities (p = 0.0005), microhaemorrhages and tortuosities (p < 0.0001) and venous branch dilations and tortuosities (p = 0.02). Finally, a statistically significant positive correlation was found between irregular and venous branch dilations (p < 0.0001), irregular dilations and microhaemorrhages (p < 0.0001) and venous branch dilations and microhaemorrhages (p < 0.0001). In conclusion, our study detected different age-related morphological capillary changes mainly in younger patients with PRP, as well as statistically significant correlations between the presence of different capillary variables.
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Affiliation(s)
- Carmen Pizzorni
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS A.O.U. San Martino, University of Genova, Viale Benedetto XV, no. 6, 16132, Genoa, Italy.
| | - Alberto Sulli
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS A.O.U. San Martino, University of Genova, Viale Benedetto XV, no. 6, 16132, Genoa, Italy
| | - Vanessa Smith
- Department of Rheumatology, Department of Internal Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Barbara Ruaro
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS A.O.U. San Martino, University of Genova, Viale Benedetto XV, no. 6, 16132, Genoa, Italy
| | - Amelia Chiara Trombetta
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS A.O.U. San Martino, University of Genova, Viale Benedetto XV, no. 6, 16132, Genoa, Italy
| | - Maurizio Cutolo
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS A.O.U. San Martino, University of Genova, Viale Benedetto XV, no. 6, 16132, Genoa, Italy
| | - Sabrina Paolino
- Research Laboratories and Academic Division of Clinical Rheumatology, Department of Internal Medicine, IRCCS A.O.U. San Martino, University of Genova, Viale Benedetto XV, no. 6, 16132, Genoa, Italy
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Abstract
Systemic sclerosis is a complex disease that involves “autoimmunity,” “inflammation,” “fibrosis,” and “vasculopathy.” Microvascular damage and dysfunction particularly represent the earliest morphological and functional markers of systemic sclerosis. These morphological changes and progressions can be detected by nailfold videocapillaroscopy (NVC). In 2013, the American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) proposed a new set of criteria for systemic sclerosis for the first time in 30 years. Items are given a weighted score, and a score more than 9 indicates systemic sclerosis. These classification criteria encompass a broader spectrum of systemic sclerosis patients including those with early stage and with excellent sensitivity and specificity. Notably, nailfold capillary abnormalities were one of the new items in the criteria. Moreover, these abnormalities are also markers of systemic sclerosis severity and progression, as reduced capillary density has been associated with a high risk of developing digital skin ulcers and pulmonary arterial hypertension. Since microvascular damage and dysfunction represent early markers of systemic sclerosis, qualitative and semi-quantitative assessment of videocapillaroscopy images is expected in clinical application and treatment outcome assessment. Despite the potential for targeted therapies in systemic sclerosis, there is no established therapy as yet. This may be due to several reasons. First, no fully validated outcome measures exist. Second, diagnosis of systemic sclerosis is often delayed and early intervention is difficult. Moreover, systemic sclerosis has clinical heterogeneity. Appropriate use of NVC helps to overcome these issues. Moreover, NVC may be useful in evaluating the pathogenesis of systemic sclerosis.
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Affiliation(s)
- Satoshi Kubo
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata-nishi-ku, Kitakyushu, Fukuoka 807-8555 Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahata-nishi-ku, Kitakyushu, Fukuoka 807-8555 Japan
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Erol MK, Balkarli A, Toslak D, Dogan B, Durmaz D, Süren E, Altun S, Bulut M, Cobankara V. Evaluation of nailfold videocapillaroscopy in central serous chorioretinopathy. Graefes Arch Clin Exp Ophthalmol 2016; 254:1889-1896. [PMID: 26995556 DOI: 10.1007/s00417-016-3322-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 02/08/2016] [Accepted: 03/09/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Nailfold videocapillaroscopy (NVC) is a diagnostic tool to evaluate micro-vasculature. The presence of choroidal vasculopathy is apparent in central serous chorioretinopathy (CSCR). OBJECTIVES This study was aimed at assessing capillaroscopic nailfold findings in patients with CSCR. To the best of our knowledge, there is no study assessing NVC findings in CSCR in the literature. METHOD Sixty-one patients with CSCR who met the inclusion criteria, and 82 age- and sex-matched healthy controls were included to the study. A videocapillaroscopy device with 200× magnification was used for capillaroscopic assessment. RESULTS The mean age was 48.79 ± 11.15 years in the patient group (13 female, 48 male) and 49.38 ± 9.02 years in the control group (17 female, 65 male). The age and gender were comparable in the patient and control groups (p = 0.727 and p = 0.933, respectively). The capillary count was found to be decreased in the patient group compared to control group. No significant correlation was found between capillary count and choroidal thickness (p = 0.551; r = -0.081). In the patient group, the frequencies of major capillaroscopic findings including capillary ectasia, aneurysm, micro-hemorrhage, avascular area, tortuosity, neo-formation, bizarre capillary, bushy capillary, meander capillary and extravasation were found to be increased in the patient group. However, no significant correlation was detected between capillaroscopic findings and disease type and presence of attacks. CONCLUSIONS This is first study in which nailfold capillary assessment was performed in patients with CSCR, and we detected major capillaroscopic changes. These findings suggest that CSCR can be a systemic microvasculopathy. Further studies are needed to clarify the diagnostic and prognostic value of capillaroscopy in CSCR.
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Affiliation(s)
- Muhammet Kazim Erol
- Department of Ophtholmology, Antalya Education and Research Hospital, Kazim Karabekir Avenue, 07720, Muratpaşa, Antalya, Turkey.
| | - Ayse Balkarli
- Department of Internal Medicine, Division of Rheumatology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Devrim Toslak
- Department of Ophtholmology, Antalya Education and Research Hospital, Kazim Karabekir Avenue, 07720, Muratpaşa, Antalya, Turkey
| | - Berna Dogan
- Department of Ophtholmology, Antalya Education and Research Hospital, Kazim Karabekir Avenue, 07720, Muratpaşa, Antalya, Turkey
| | - Dogan Durmaz
- Department of Ophtholmology, Antalya Education and Research Hospital, Kazim Karabekir Avenue, 07720, Muratpaşa, Antalya, Turkey
| | - Elçin Süren
- Department of Ophtholmology, Antalya Education and Research Hospital, Kazim Karabekir Avenue, 07720, Muratpaşa, Antalya, Turkey
| | - Salih Altun
- Department of Ophtholmology, Gulhane Military Medical Academy, Ankara, Turkey
| | - Mehmet Bulut
- Department of Ophtholmology, Antalya Education and Research Hospital, Kazim Karabekir Avenue, 07720, Muratpaşa, Antalya, Turkey
| | - Veli Cobankara
- Department of Internal Medicine, Division of Rheumatology, Pamukkale University Hospital, Denizli, Turkey
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Gigante A, Barbano B, Barilaro G, Quarta S, Gasperini ML, Di Mario F, Romaniello A, Amoroso A, Cianci R, Rosato E. Serum uric acid as a marker of microvascular damage in systemic sclerosis patients. Microvasc Res 2016; 106:39-43. [PMID: 27003713 DOI: 10.1016/j.mvr.2016.03.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 03/10/2016] [Accepted: 03/17/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Microvascular damage of skin and internal organs is a hallmark of systemic sclerosis (SSc). Serum uric acid (UA) represents a marker of inflammation and endothelial dysfunction. The aims of this study were to evaluate the correlation between serum UA and intrarenal arterial stiffness evaluated by Doppler ultrasound in SSc patients with normal renal function. We also evaluated the correlation between serum UA and other clinical variables of the disease. METHODS Forty-five SSc patients underwent clinical assessment, Doppler ultrasound of intrarenal arteries with evaluation of resistive index (RI), pulsatile index (PI), and systolic/diastolic ratio (S/D), echocardiography with systolic pulmonary artery pressure (PAPs), baseline pulmonary function tests, and nailfold videocapillaroscopy (NVC). In all patients serum UA was measured. RESULTS The serum UA showed a significant positive correlation with sCr (r=0.33, p<0.0001) and PAPs (r=0.38, p<0.01) >and negative correlation with CKD-EPI (r=-0.35, p<0.01). The mean value of serum UA increased with severity of NVC damage. Using this cut-off value of 4.7mg/dl, the mean value of Doppler indices of intrarenal stiffness is significantly different (p<0.05) in SSc patients with low normal or high normal serum UA. CONCLUSIONS Serum UA concentration is higher in patients with high microvascular damage than in patients with low microvascular damage. These preliminary data must be confirmed in large prospective studies.
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Affiliation(s)
- Antonietta Gigante
- Department of Clinical Medicine, Clinical Immunology Unit-Scleroderma Center, Sapienza University of Rome, Italy
| | - Biagio Barbano
- Department of Clinical Medicine, Clinical Immunology Unit-Scleroderma Center, Sapienza University of Rome, Italy
| | - Giuseppe Barilaro
- Department of Clinical Medicine, Clinical Immunology Unit-Scleroderma Center, Sapienza University of Rome, Italy
| | - Silvia Quarta
- Department of Clinical Medicine, Clinical Immunology Unit-Scleroderma Center, Sapienza University of Rome, Italy
| | - Maria Ludovica Gasperini
- Department of Clinical Medicine, Clinical Immunology Unit-Scleroderma Center, Sapienza University of Rome, Italy
| | - Francesca Di Mario
- Department of Nephrology and Dialysis Unit, Sapienza University of Rome, Italy
| | - Antonella Romaniello
- Department of Clinical and Molecular Medicine, Cardiology Unit, S'Andrea Hospital, Sapienza University of Rome, Italy
| | - Antonio Amoroso
- Department of Clinical Medicine, Clinical Immunology Unit-Scleroderma Center, Sapienza University of Rome, Italy
| | - Rosario Cianci
- Department of Clinical Medicine, Clinical Immunology Unit-Scleroderma Center, Sapienza University of Rome, Italy
| | - Edoardo Rosato
- Department of Clinical Medicine, Clinical Immunology Unit-Scleroderma Center, Sapienza University of Rome, Italy.
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Ruaro B, Sulli A, Pizzorni C, Paolino S, Smith V, Cutolo M. Correlations between skin blood perfusion values and nailfold capillaroscopy scores in systemic sclerosis patients. Microvasc Res 2016; 105:119-24. [PMID: 26907637 DOI: 10.1016/j.mvr.2016.02.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/17/2016] [Accepted: 02/17/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To correlate blood perfusion (BP) values assessed by laser speckle contrast analysis (LASCA) in selected skin areas of hands and face with nailfold capillary damage scores in systemic sclerosis (SSc) patients. METHODS Seventy SSc patients (mean SSc duration 6 ± 5 years) and 70 volunteer healthy subjects were enrolled after informed consent. LASCA was performed at different areas of the face (forehead, tip of nose, zygomas and perioral region) and at dorsal and volar regions of hands. Microvascular damage was assessed and scored by nailfold videocapillaroscopy (NVC) and the microangiopathy evolution score (MES) was calculated. RESULTS SSc patients showed a significantly lower BP than healthy subjects at fingertips, periungual areas and palm of hands (p<0.0001), but not at the level of face and dorsum of hands. A gradual decrease of BP at fingertips, periungual and palm areas, was found in SSc patients with progressive severity of NVC patterns of microangiopathy ("early", "active", or "late") (p<0.01). A negative correlation was observed between MES and BP values, as well as between loss of capillaries and BP, at the same areas (p<0.001 and p<0.01, respectively). Patients with diffuse cutaneous SSc (dcSSc) showed lower BP than those with limited cutaneous SSc (p<0.04). CONCLUSIONS LASCA detects a significant reduction of BP only in those areas usually affected by Raynaud's phenomenon (fingertips, periungual and palm areas), especially in dcSSc patients, and BP values significantly correlate with the nailfold capillaroscopy scores of microangiopathy.
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Affiliation(s)
- B Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy
| | - A Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy
| | - C Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy
| | - S Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, Ghent University, Belgium
| | - M Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS San Martino-IST, Genoa, Italy.
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Voilliot D, Magne J, Dulgheru R, Kou S, Henri C, Caballero L, De Sousa C, Sprynger M, Andre B, Pierard LA, Lancellotti P. Prediction of new onset of resting pulmonary arterial hypertension in systemic sclerosis. Arch Cardiovasc Dis 2016; 109:268-77. [PMID: 26898632 DOI: 10.1016/j.acvd.2015.11.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 11/13/2015] [Accepted: 11/18/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Early detection of pulmonary arterial hypertension (PH) is crucial in systemic scleroderma. However, predictors of new onset of resting PH during follow-up (FUPH) have been poorly explored. AIM To determine whether nailfold videocapillaroscopy (NVC) grade and exercise echocardiographic variables are predictors of FUPH. METHODS We prospectively enrolled 40 patients with systemic sclerosis (age 54±13 years; 68% women). All patients underwent graded semisupine exercise echocardiography and NVC. Baseline resting PH and FUPH were defined as systolic pulmonary arterial pressure (sPAP)>35 mmHg, and exercise-induced PH (EIPH) as exercise sPAP>50 mmHg. RESULTS Seventeen patients developed EIPH (43%). During follow-up (FU) (25±15 months), 11 patients without baseline PH developed FUPH (28%), all from the EIPH group. Patients with FUPH were significantly older (60±14 vs 50±12 years; P=0.04), had higher resting and exercise sPAP (30±4 vs 22±5 and 60±12 vs 40±11 mmHg, respectively; P<0.0001) and a higher exercise E/e' ratio (9.4±0.7 vs 5.8±0.4; P=0.0003) and presented more frequently NVC grade>2 (90% vs 35%; P=0.0009). After adjustment for age, resting sPAP, exercise sPAP and NVC grade>2 were associated with maximal resting sPAP during follow-up and FUPH (P<0.05). Patients with both EIPH and NVC grade>2 had a very high incidence of FUPH (82%), and both variables remained strongly associated with FUPH after adjustment for age (hazard ratio 11.6, 95% confidence interval 2.4-55.3; P=0.002). CONCLUSION Exercise echocardiography and NVC can identify a subgroup of patients with systemic sclerosis who are at risk of developing FUPH.
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Affiliation(s)
- Damien Voilliot
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Julien Magne
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Raluca Dulgheru
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Seisyou Kou
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Christine Henri
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Luis Caballero
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Carla De Sousa
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Muriel Sprynger
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Béatrice Andre
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium
| | - Luc A Pierard
- University of Liège Hospital, GIGA Cardiovascular Sciences, Department of Cardiology, Heart Valve Clinic, University Hospital Sart Tilman, Liège, Belgium.
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Ghizzoni C, Sebastiani M, Manfredi A, Campomori F, Colaci M, Giuggioli D, Ferri C. Prevalence and evolution of scleroderma pattern at nailfold videocapillaroscopy in systemic sclerosis patients: Clinical and prognostic implications. Microvasc Res 2015; 99:92-5. [PMID: 25842153 DOI: 10.1016/j.mvr.2015.03.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 03/21/2015] [Accepted: 03/25/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Microvascular involvement plays a decisive role in systemic sclerosis (SSc) pathogenesis occurring early in the course of the disease. Microangiopathy is responsible of important clinical manifestations, such as Raynaud's phenomenon, digital ulceration, and pulmonary arterial hypertension. Typical microvascular alterations, called scleroderma pattern, are detectable at nailfold capillaroscopy in a significant percentage of SSc patients; however its prevalence is highly variable in published studies. AIM The aims of this study are to evaluate the prevalence and the evolution of scleroderma pattern in SSc patients and analyze their demographic, clinical and prognostic characteristics according to capillaroscopic features. METHODS Two hundred and seventy-five SSc patients, underwent at least two nailfold videocapillaroscopy during follow-up, were retrospectively enrolled. RESULTS A scleroderma pattern was observed in 80% of patients at baseline and 87.1% during follow-up, and it was significantly associated to digital ulcers, interstitial lung disease, reduction of diffusion lung of carbon monoxide <75%, teleangectasias and melanodermia, while sicca syndrome and arthralgias were associated to normal/nonspecific pattern. Digital ulcers, teleangectasias, sicca syndrome, and arthralgias remained independently associated with scleroderma pattern on multivariate analysis. In conclusion, the main clinical manifestation correlated with scleroderma pattern is the occurrence of digital ulcers, and their appearance is strictly correlated with the variation of capillaroscopic feature during the time. Further studies should confirm the association between SSc pattern and lung fibrosis.
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Affiliation(s)
- Cecilia Ghizzoni
- Rheumatology Unit, University of Modena and Reggio Emilia, Italy
| | - Marco Sebastiani
- Rheumatology Unit, University of Modena and Reggio Emilia, Italy.
| | | | | | - Michele Colaci
- Rheumatology Unit, University of Modena and Reggio Emilia, Italy
| | - Dilia Giuggioli
- Rheumatology Unit, University of Modena and Reggio Emilia, Italy
| | - Clodoveo Ferri
- Rheumatology Unit, University of Modena and Reggio Emilia, Italy
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Ruaro B, Smith V, Sulli A, Decuman S, Pizzorni C, Cutolo M. Methods for the morphological and functional evaluation of microvascular damage in systemic sclerosis. Korean J Intern Med 2015; 30:1-5. [PMID: 25589827 PMCID: PMC4293547 DOI: 10.3904/kjim.2015.30.1.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 11/10/2014] [Indexed: 11/27/2022] Open
Abstract
Systemic sclerosis is a connective tissue disease characterized by alterations in microvascular structure and function. In these patients, numerous studies have demonstrated a relationship between capillary morphology and peripheral blood perfusion. Nailfold videocapillaroscopy reveals the peripheral microvascular morphology and thus allows classification and scoring of capillary abnormalities with respect to different microangiopathy patterns (early, active, and late). Laser Doppler flowmetry and laser speckle contrast analysis can be used to estimate cutaneous blood flow through microvessels and to assess and quantify blood perfusion at peripheral sites. These two methods are also used to identify changes in digital blood perfusion after the infusion of vasodilators.
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Affiliation(s)
- Barbara Ruaro
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Gent, Belgium
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Saskia Decuman
- Department of Rheumatology, Ghent University Hospital, Gent, Belgium
| | - Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genoa, Italy
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Valentini G. Undifferentiated Connective Tissue Disease at risk for systemic sclerosis (SSc) (so far referred to as very early/early SSc or pre-SSc). Autoimmun Rev 2014; 14:210-3. [PMID: 25461837 DOI: 10.1016/j.autrev.2014.11.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Accepted: 11/05/2014] [Indexed: 10/24/2022]
Abstract
In the last few years, a number of studies have been published on a condition characterized by Raynaud's phenomenon (RP) associated with systemic sclerosis (SSc) marker autoantibodies and/or scleroderma-type capillaroscopic abnormalities and referred to as very early/early SSc. The present review is devoted to analyze pathophysiologic, clinical, and evolutive aspects of the condition that would induce to label it as Undifferentiated Connective Tissue Disease at risk for SSc and to split it into 3 subsets (i.e. RP associated to marker autoantibodies and scleroderma-type capillaroscopic abnormalities; RP associated to marker autoantibodies in the absence of scleroderma-type capillaroscopic abnormalities; and RP associated to scleroderma-type capillaroscopic abnormalities without any detectable marker autoantibody), which have been shown to carry different degrees of risk, but not the certainty, to develop overt SSc over time. This nosographic approach is instrumental to plan future studies devoted to investigate validated biomarkers heralding the development of major vascular disease manifestations as well as skin and/or organ fibrosis in patients at risk.
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