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Kuwahara Y, Hara T, Kurahashi T, Takeshige H, Urata S, Oguchi T. Comparing Clinical and Aesthetic Outcomes of Digital Artery Flap Using Nail Bed Graft for Fingertip Amputation with Replantation. Plast Reconstr Surg 2024; 153:1086-1092. [PMID: 37253041 DOI: 10.1097/prs.0000000000010760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Digital artery flap (DAF) with nail bed graft is a simple method to preserve finger length for fingertip amputations. This study compared the clinical and aesthetic outcomes between replantation and DAF. METHODS Patients who underwent replantation or DAF for a single fingertip amputation (Ishikawa subzone II or III) at the authors' hospital from 2013 to 2021 were retrospectively evaluated. The aesthetic and functional outcomes were finger length and nail deformity at the final follow-up, total active motion, grip strength, Semmes-Weinstein monofilament test, Fingertip Injuries Outcome Score, and Hand20 score. RESULTS Overall, in 74 analyzed cases (40 replantation, 34 DAF), the median operative time and the median length of hospital stay were longer with replantation than with DAF (188 versus 126 minutes; P < 0.01; 15 versus 4 days; P < 0.01). The success rates of replantation and DAF were 82.5% and 94.1%, respectively. The rate of finger shortening with replantation was significantly lower than with DAF (42.5% versus 82.4%; P < 0.01). There were fewer nail deformities with replantation than with DAF (45.0% versus 67.6%; P = 0.06). The proportion of patients who achieved excellent or good Fingertip Injuries Outcome Score and median Hand20 score were not significantly different between the groups (89.5% versus 85.3%, P = 0.61; 8.0 versus 13.5, P = 0.42, respectively). Median postoperative Semmes-Weinstein monofilament test values were similar between the groups (3.61 versus 3.61; P = 0.23). CONCLUSION In this retrospective study, compared with replantation, DAF for fingertip amputations achieved equivalent postoperative functional outcomes and shorter intraoperative time and hospital stays, but resulted in inferior cosmetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.
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Affiliation(s)
| | | | | | | | - Shiro Urata
- From Orthopedic Surgery, Anjo Kosei Hospital
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Elumalai S, Krishnamoorthi N, Periyasamy N, Farazullah M, Raj K, Mahadevan S. Analysis of microvascular pattern in diabetes mellitus condition using the nailfold capillaroscopy images. Proc Inst Mech Eng H 2024; 238:340-347. [PMID: 38279673 DOI: 10.1177/09544119231224510] [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] [Indexed: 01/28/2024]
Abstract
Diabetes is often considered a vascular disease due to its impact on blood vessels, it is a complex condition with various metabolic and autoimmune factors involved. One of the long term comorbidities of diabetes includes microvascular complications. The microvascular complications can be analyzed using the Nailfold capillaroscopy, a non-invasive technique that allows for the visualization and analysis of capillaries in the proximal nailfold area. Using advanced video capillaroscopy with high magnification, capillary images can be captured from and processed to analyze their morphology. The capillary images of normal group and diabetic group are acquired from 118 participants using nailfold capillaroscopy and the obtained images are preprocessed using image processing filters. The identification and segmentation of the capillaries are the challenges to be addressed in the processing of the images. Hence segmentation of capillaries is done using morphological operations, thresholding and convolutional neural networks. The performance of the filters and segmentation methods are evaluated using Mean Square Error (MSE), Peak signal to Noise Ratio (PSNR), Structural Similarity Index Measure (SSIM), Jaccard Index and Sorensen coefficient. By analyzing the morphological features namely the capillary diameter, density, distribution, presence of hemorrhage and the shape of the capillaries from both the groups, the capillary changes associated with diabetic condition were studied. It was found that the non diabetic participants considered in this study has capillary diameter in the range of 8-14 µm and the capillary density in the range of 10-30 capillaries per mm2 whereas the diabetic participants has capillary diameter greater than 30 µm and the capillary density is less than 10 capillaries per mm2. In addition to capillary density and diameter, the presence of hemorrhage, the orientation and distribution of the capillaries are also considered to differentiate the diabetic group from the non diabetic group. The classification of the participants are validated with the clinical history of the participants.
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Affiliation(s)
- Sowmiya Elumalai
- Department of Biomedical Engineering, Sri Sivasubramaniya Nadar College of Engineering, Chennai, Tamil Nadu, India
| | - Nirmala Krishnamoorthi
- Department of Biomedical Engineering, Sri Sivasubramaniya Nadar College of Engineering, Chennai, Tamil Nadu, India
| | - Naveen Periyasamy
- Department of Biomedical Engineering, Sri Sivasubramaniya Nadar College of Engineering, Chennai, Tamil Nadu, India
| | - Mohamed Farazullah
- Department of Biomedical Engineering, Sri Sivasubramaniya Nadar College of Engineering, Chennai, Tamil Nadu, India
| | - Kiran Raj
- Department of Biomedical Engineering, Sri Sivasubramaniya Nadar College of Engineering, Chennai, Tamil Nadu, India
| | - Shriraam Mahadevan
- Department of Endocrinology, Sri Ramachandra Medical College and Hospital, Chennai, Tamil Nadu, India
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Reddy Konda VV, Jindal AK, Nadig PL, Banday AZ, Vinay K, Singh S. Microvascular changes on nailfold capillaroscopy in acute stage of Kawasaki disease: a new diagnostic paradigm for an enigmatic condition. Rheumatology (Oxford) 2024; 63:392-398. [PMID: 37202349 DOI: 10.1093/rheumatology/kead213] [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: 12/22/2022] [Revised: 04/01/2023] [Accepted: 04/30/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVES Kawasaki disease (KD) is a medium vessel vasculitis with a predilection to involve coronary arteries. However, there is a paucity of literature on microvascular changes in patients with KD. METHODS Children diagnosed with KD based on American Heart Association guidelines 2017 were enrolled prospectively. Demographic details and echocardiographic changes in coronaries were recorded. Nailfold capillaries were assessed using Optilia Video capillaroscopy and data were analysed using Optilia Optiflix Capillaroscopy software at acute (prior to IVIG administration) and subacute/convalescent phase. RESULTS We enrolled 32 children with KD (17 boys) with a median age of 3 years. Nailfold capillaroscopy (NFC) was performed in 32 patients in the acute phase (compared with 32 controls) and in 17 during the subacute/convalescent phase at a median follow-up of 15 (15-90) days after IVIG treatment. The following findings were seen in NFC in the acute phase of KD: reduced capillary density (n = 12, 38.6%), dilated capillaries (n = 3, 9.3%), ramifications (n = 3, 9.3%) and capillary haemorrhages (n = 2, 6.2%). Capillary density was reduced significantly in the acute phase of KD (38.6%) as compared with the subacute/convalescent phase (25.4%) (P-value <0.001) and controls (0%) (P-value = 0.03). We observed no correlation between coronary artery involvement and mean capillary density (P = 0.870). CONCLUSION Results show that patients with KD have significant nailfold capillary changes in the acute phase. These findings may provide a new diagnostic paradigm for KD and a window to predict coronary artery abnormalities.
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Affiliation(s)
- Vishnu Vardhan Reddy Konda
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Kumar Jindal
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pallavi L Nadig
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aaqib Zaffar Banday
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Keshavamurthy Vinay
- Department of Dermatology, Venerology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surjit Singh
- Pediatric Allergy Immunology Unit, Department of Pediatrics, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Torres-Ruiz J, Pinal-Fernandez I, Selva-O'Callaghan A, Campbell B, Muñoz-Braceras S, Mejía-Domínguez NR, Núñez-Álvarez C, Milisenda J, Casal-Domínguez M, Pak K, Guillén-Del-Castillo A, Trallero-Araguas E, Gil-Vila A, Mammen AL. Nailfold capillaroscopy findings of a multicentric multi-ethnic cohort of patients with idiopathic inflammatory myopathies. Clin Exp Rheumatol 2024; 42:367-376. [PMID: 38488092 DOI: 10.55563/clinexprheumatol/l9gudh] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/01/2024] [Indexed: 03/18/2024]
Abstract
OBJECTIVES To assess nailfold video capillaroscopic (NVC) abnormalities and their association with clinical features, myositis-specific autoantibodies (MSA), and myositis-associated antibodies (MAA) in a large multi-ethnic cohort of patients with idiopathic inflammatory myopathies (IIM). METHODS We recruited 155 IIM patients from three centres in Mexico, Spain, and the USA. We evaluated the clinical and laboratory features of the patients and performed semiquantitative and quantitative analyses of the NVC. Each NVC study was defined as having a normal, non-specific, early systemic sclerosis (SSc), active SSc, or late SSc pattern. Twenty-three patients had at least one follow-up NVC when disease control was achieved. Quantitative variables were expressed as medians and interquartile range (IQR) and were compared with the Kruskal-Wallis, the Mann-Whitney U-test, and the Wilcoxon test for paired medians. Associations between qualitative variables were assessed with the χ2 test. RESULTS Most patients were women (68.3%), Hispanic (73.5%), and had dermatomyositis (DM) (61.2%). Fourteen patients (9%) had a normal NVC. A non-specific abnormality pattern was the most frequent (53.9%), and was associated with joint involvement, interstitial lung disease, Jo1 autoantibodies, anti-synthetase syndrome, and immune-mediated necrotising myopathy. The SSc pattern was observed mostly in DM and overlap myositis and was associated with cutaneous features and anti-TIF-1g autoantibodies. After treatment, there was a decrease in the capillaroscopic score, the capillary diameter, and the number of avascular areas, and an increase in capillary density and bushy capillary number. CONCLUSIONS NVC abnormalities are related to the diagnosis, clinical features, disease activity, and autoantibodies of patients with IIM.
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Affiliation(s)
- Jiram Torres-Ruiz
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico, and Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulations, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Iago Pinal-Fernandez
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulations, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, and Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Albert Selva-O'Callaghan
- Systemic Autoimmune Disease Unit, Vall d'Hebron Research Institute, Barcelona, and Universitat Autonoma de Barcelona, Spain
| | - Bianca Campbell
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulations, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, and Howard University College of Medicine, Washington DC, USA
| | - Sandra Muñoz-Braceras
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulations, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Nancy R Mejía-Domínguez
- Red de Apoyo a la Investigación, Coordinación de Investigación Científica, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Carlos Núñez-Álvarez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - José Milisenda
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulations, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA, and Muscle Research Unit, Internal Medicine Service, Hospital Clínic de Barcelona, Universidad de Barcelona and CIBERER, Barcelona, Spain
| | - Maria Casal-Domínguez
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulations, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Katherine Pak
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulations, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | | | | | - Albert Gil-Vila
- Systemic Autoimmune Disease Unit, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Andrew Lee Mammen
- Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulations, National Institute of Arthritis, Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore; and Department of Medicine, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Wildt M, Andréasson K, Hamberg V, Hesselstrand R, Wuttge DM. Treatment with mycophenolate mofetil is associated with improved nailfold vasculature in systemic sclerosis. Rheumatology (Oxford) 2024; 63:385-391. [PMID: 37158586 PMCID: PMC10836996 DOI: 10.1093/rheumatology/kead207] [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: 10/13/2022] [Revised: 03/27/2023] [Accepted: 04/19/2023] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVE To investigate the evolution of nailfold capillary density in patients with SSc in relation to immunosuppressive treatment and autoantibodies. METHODS This was a prospective study cohort. Consecutive newly diagnosed SSc patients were included into this study who, in a retrospective review, had at least two nailfold capillary microscopy measurements performed during the first 48 months of follow-up. Capillary density per 3 mm was measured with widefield nailfold capillary microscopy. Improvement of capillary density per finger and mean capillary density were analysed. Longitudinal measurements of mean capillary density were analysed by generalized estimating equation. RESULTS Eighty patients (68 women, 12 men) met the inclusion criteria. The median follow-up time was 27 months. Twenty-eight patients had an improved capillary density in per-finger analysis. MMF was associated with fewer numbers of fingers that had worsened in capillary density. Anti-topoisomerase antibodies were associated with low mean capillary density. Anti-RNA polymerase III antibodies were associated with improvement and anti-centromere antibodies with worsening of capillary density in per-finger analysis. MMF treatment was associated with less steep capillary density decline in a moderated generalized estimating equation model including presence of anti-topoisomerase antibodies and the interaction of MMF with follow-up time. CONCLUSION Nailfold capillary density improved over time in a substantial proportion of SSc patients. MMF treatment had a positive impact on the evolution of capillary density in these patients. SSc autoantibody phenotype may affect the capillary density development. The data support previous hypotheses that early immunosuppression may favourably affect vascular regeneration in SSc.
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Affiliation(s)
- Marie Wildt
- Department of Clinical Sciences, Lund, Section of Rheumatology, Lund University and Skåne University Hospital, Lund, Sweden
| | - Kristofer Andréasson
- Department of Clinical Sciences, Lund, Section of Rheumatology, Lund University and Skåne University Hospital, Lund, Sweden
| | - Viggo Hamberg
- Department of Clinical Sciences, Lund, Section of Rheumatology, Lund University and Skåne University Hospital, Lund, Sweden
| | - Roger Hesselstrand
- Department of Clinical Sciences, Lund, Section of Rheumatology, Lund University and Skåne University Hospital, Lund, Sweden
| | - Dirk M Wuttge
- Department of Clinical Sciences, Lund, Section of Rheumatology, Lund University and Skåne University Hospital, Lund, Sweden
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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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Yin H, Wu Z, Huang A, Luo J, Liang J, Lin J, Ye Q, Xie M, Ye C, Li X, Wu Y. Automated nailfold capillary density measurement method based on improved YOLOv5. Microvasc Res 2023; 150:104593. [PMID: 37582460 DOI: 10.1016/j.mvr.2023.104593] [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: 05/25/2023] [Revised: 08/07/2023] [Accepted: 08/09/2023] [Indexed: 08/17/2023]
Abstract
Nailfold capillary density is an essential physiological parameter for analyzing nailfold health; however, clinical images of the nailfold are taken in many situations, and most clinicians subjectively analyze nailfold images. Therefore, based on the improved "you only look once v5" (YOLOv5) algorithm, this study proposes an automated method for measuring nailfold capillary density. The improved technique can effectively and rapidly detect distal capillaries by incorporating methods or structures such as 9mosaic, spatial pyramid pooling cross-stage partial construction, bilinear interpolation, and efficient intersection over union. First, the modified YOLOv5 algorithm was used to detect nailfold capillaries. Subsequently, the number of distal capillaries was filtered using the 90° method. Finally, the capillary density was calculated. The results showed that the Average Precision (AP)@0.5 value of the proposed approach reached 85.2 %, which was an improvement of 4.93 %, 5.24 %, and 107 % compared with the original YOLOv5, YOLOv6, and simple-faster rapid-region convolutional network (R-CNN), respectively. For different nailfold images, using the density calculated by nailfold experts as a benchmark, the calculated results of the proposed method were consistent with the manually calculated results and superior to those of the original YOLOv5.
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Affiliation(s)
- Hao Yin
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - Zhiwei Wu
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - An Huang
- School of Mechatronic Engineering and Automation, Foshan University, Foshan 528000, China
| | - Jiaxiong Luo
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - Junzhao Liang
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - Jianan Lin
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - Qianyao Ye
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - Mugui Xie
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - Cong Ye
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - Xiaosong Li
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China
| | - Yanxiong Wu
- School of Physics and Optoelectronic Engineering, Foshan University, Foshan 528000, China; Ji Hua Laboratory, Foshan, Guangdong 528200, China.
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9
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Bogusz-Górna K, Polańska A, Dańczak-Pazdrowska A, Żaba R, Sumińska M, Fichna P, Kędzia A. Non-invasive detection of early microvascular changes in juveniles with type 1 diabetes. Cardiovasc Diabetol 2023; 22:285. [PMID: 37865774 PMCID: PMC10590527 DOI: 10.1186/s12933-023-02031-y] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 10/12/2023] [Indexed: 10/23/2023] Open
Abstract
AIMS/HYPOTHESIS The study aimed to assess the usefulness of capillaroscopy and photoplethysmography in the search for early vascular anomalies in children with type 1 diabetes. METHODS One hundred sixty children and adolescents aged 6-18, 125 patients with type 1 diabetes, and 35 healthy volunteers were enrolled in the study. We performed a detailed clinical evaluation, anthropometric measurements, nailfold capillaroscopy, and photoplethysmography. RESULTS Patients with diabetes had more often abnormal morphology in capillaroscopy (68.60%, p = 0.019), enlarged capillaries (32.6%, p = 0.006), and more often more over five meandering capillaries (20.90%, p = 0.026) compared to healthy controls. Meandering capillaries correlated with higher parameters of nutritional status. In a photoplethysmography, patients with diagnosed neuropathy had a higher percentage of flow disturbance curves (p < 0.001) with a reduced frequency of normal curves (p = 0.050). CONCLUSIONS Capillaroscopic and photoplethysmographic examinations are non-invasive, painless, fast, and inexpensive. They are devoid of side effects, and there are no limitations in the frequency of their use and repetition. The usefulness of capillaroscopy and photoplethysmography in the study of microcirculation in diabetic patients indicates the vast application possibilities of these methods in clinical practice.
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Affiliation(s)
- Klaudia Bogusz-Górna
- Department of Pediatric Diabetes, Auxology, and Obesity, Poznan University of Medical Sciences, Poznan, Poland.
| | - Adriana Polańska
- Department of Dermatology and Venereology, Poznan University of Medical Sciences, Poznan, Poland
| | | | - Ryszard Żaba
- Department of Dermatology and Venereology, Poznan University of Medical Sciences, Poznan, Poland
| | - Marta Sumińska
- Department of Pediatric Diabetes, Auxology, and Obesity, Poznan University of Medical Sciences, Poznan, Poland
| | - Piotr Fichna
- Department of Pediatric Diabetes, Auxology, and Obesity, Poznan University of Medical Sciences, Poznan, Poland
| | - Andrzej Kędzia
- Department of Pediatric Diabetes, Auxology, and Obesity, Poznan University of Medical Sciences, Poznan, Poland
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10
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Yin H, Lin W, Lu L. Puffy fingers and abnormal nail fold capillaries. CMAJ 2023; 195:E1350. [PMID: 37816528 PMCID: PMC10610952 DOI: 10.1503/cmaj.230834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Affiliation(s)
- Hanlin Yin
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wanyi Lin
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liangjing Lu
- Department of Rheumatology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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11
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Kouwenberg CV, Spierings J, de Groot EL, de Boer JH, Kalinina Ayuso V. Involvement of the systemic microcirculation in pediatric uveitis. Pediatr Rheumatol Online J 2023; 21:109. [PMID: 37784087 PMCID: PMC10544362 DOI: 10.1186/s12969-023-00896-7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 09/14/2023] [Indexed: 10/04/2023] Open
Abstract
BACKGROUND Pediatric uveitis is a severe inflammatory ocular condition that can lead to sight-threatening complications and can negatively impact quality of life. The retinal microcirculation is often affected in intermediate uveitis and panuveitis. Here, we examined the extraocular (i.e., systemic) microcirculation in pediatric uveitis cases and healthy controls using nailfold capillaroscopy (NFC). METHODS We performed NFC in 119 children with noninfectious uveitis and 25 healthy pediatric controls, and assessed the following parameters: capillary density (number of capillaries/mm), dilated capillaries (apex > 20 µm), avascular area, the presence of microhemorrhages, and capillary morphology. Differences in NFC parameters between cases and controls were calculated using regression analysis after adjusting for age and sex. RESULTS The mean (± SD) age of the patient group was 13.7 (± 3) years, with 56% females; 46%, 18%, and 36% of cases presented as anterior uveitis, intermediate uveitis, and panuveitis, respectively, with an overall mean disease duration of 4.7 (± 4.0) years. Compared to the control group, the pediatric uveitis cases had a significantly higher number of dilated capillaries/mm and a higher prevalence of ramified capillaries. Moreover, compared to the control group the intermediate uveitis cases had a significantly higher number of dilated capillaries, whereas the anterior uveitis cases had a lower capillary density and a higher prevalence of ramified capillaries. CONCLUSIONS Children with uveitis without systemic disease can present with changes in systemic microcirculation. These changes vary amongst the subtypes of uveitis.
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Affiliation(s)
- Carlyn V Kouwenberg
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands.
| | - Julia Spierings
- Department of Rheumatology & Clinical Immunology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Evianne L de Groot
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Joke H de Boer
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
| | - Viera Kalinina Ayuso
- Department of Ophthalmology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht, 3584 CX, The Netherlands
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12
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林 卓, 蔡 如, 孙 洋, 穆 荣, 崔 立. [Methodology and clinical use of superb microvascular imaging in assessing micro-circulation changes of fingertips in systemic sclerosis]. Beijing Da Xue Xue Bao Yi Xue Ban 2023; 55:636-640. [PMID: 37534644 PMCID: PMC10398755] [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] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Indexed: 08/04/2023]
Abstract
OBJECTIVE To explore the feasibility of superb microvascular imaging (SMI) in evaluating microcirculation damage of the finger of systemic sclerosis (SSc), and determining the optimal scanning method by assessing the effect of scanning position (finger pulp or nail bed), plane (transverse or sagittal) and Doppler gain on the results. METHODS In the study, 32 SSc patients and 32 non-SSc volunteers admitted to Peking University Third Hospital from February to October 2022 were included. The SMI image under different gain set (40 dB or 35 dB) of the third fingertip (sagittal scans or transverse scan of nail bed or pulp) of both hands were collected while vascular index (VI) was measured. RESULTS Non-SSc volunteer presented abundant SMI signal distributed in the third fingertip. Arteriole of nail bed was observed on the dorsal side of the distal phalanx under SMI and gave off multiple vertical branches towards the nail. The arteriole of finger pulp ran parallel to the skin and gave off vertical branches towards the skin distributing subcutaneously as a network. In SSc group, the SMI signal in nail bed and finger pulp was reduced. The arteriole of nail bed and finger pulp was discontinuous and presented as sporadic dots and short rod-like color signal under SMI. The vascular index of the SSc patients was significantly lower than that of the non-SSc controls (P < 0.001). Among different positions and sections, the area under the receiver operating characteristic curve (AUC) of the sagittal plane of nail bed was the highest. Under low gain, the AUC of sagittal plane of nail bed was 0.871, the cut-off value was 5.4%, the sensitivity was 90.6%, and the specificity was 74.2%. Under high gain, the AUC was 0.893, the cut-off value was 14.0%, the sensitivity was 75.0%, and the specificity was 93.6%. Multivariate analysis showed that there was statistical significance on the diagnostic impact of the sagittal plane of nail bed (P < 0.005 for high gain condition; P < 0.05 for low gain condition). CONCLUSION SMI can be used to evaluate the abnormal changes of vascular in patients with SSc. Using the sagittal scan of nail bed with high gain can evaluate the vascular loss of the fingertip in SSc patient accurately and specifically.
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Affiliation(s)
- 卓华 林
- 北京大学第三医院超声医学科,北京 100191Department of Medical Ultrasound, Peking University Third Hospital, Beijing 100191, China
| | - 如意 蔡
- 北京大学第三医院风湿免疫科,北京 100191Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing 100191, China
| | - 洋 孙
- 北京大学第三医院超声医学科,北京 100191Department of Medical Ultrasound, Peking University Third Hospital, Beijing 100191, China
| | - 荣 穆
- 北京大学第三医院风湿免疫科,北京 100191Department of Rheumatology and Immunology, Peking University Third Hospital, Beijing 100191, China
| | - 立刚 崔
- 北京大学第三医院超声医学科,北京 100191Department of Medical Ultrasound, Peking University Third Hospital, Beijing 100191, China
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13
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Makol A, Karn A. Nailfold Capillaroscopy in Rheumatic Disease. N Engl J Med 2023; 389:262. [PMID: 37470249 DOI: 10.1056/nejmicm2213508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
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14
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Fukasawa T, Toyama S, Enomoto A, Yoshizaki-Ogawa A, Norimatsu Y, Tateishi S, Kanda H, Miyagawa K, Sato S, Yoshizaki A. Utility of nailfold capillary assessment for predicting psoriatic arthritis based on a prospective observational cohort study. Rheumatology (Oxford) 2023; 62:2418-2425. [PMID: 36440919 DOI: 10.1093/rheumatology/keac664] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 06/01/2022] [Accepted: 11/19/2022] [Indexed: 07/20/2023] Open
Abstract
OBJECTIVES PsA is one of the most serious comorbidities associated with psoriasis. While the early intervention in PsA is demanded, risk factors of PsA development are not well-known. This is the first prospective study to evaluate the clinical significance of nailfold capillary (NFC) changes in patients with psoriasis. METHODS We conducted a prospective cohort study in a population of 449 psoriasis patients who had not been treated with systemic therapy or topical finger therapy. NFCs were observed by dermoscopy and capillaroscopy, and the correlation of NFC abnormalities, including nailfold bleeding (NFB) and enlarged capillaries, with the prevalence of PsA, incidence of new PsA, and serum levels of TNF-a, IL-17A and IL-23 were analysed. RESULTS Detailed examination at the time of inclusion revealed that of 449 patients, 236 had Psoriasis vulgaris (PsV) and 213 had PsA. Both NFB and enlarged capillaries were significantly more frequent in patients with PsA (34.7% vs 84.5%, P < 0.0001; 25.4% vs 100%, P < 0.0001). In addition, PsV patients were prospectively observed before they developed PsA (mean 21 months, 95% CI 2, 77 months). Multivariate analysis suggested that the appearance of NFB and enlarged capillaries was a predictor of PsA development (HR 2.75, 95% CI 1.38, 5.47 and HR 4.49, 95% CI 2.25, 8.96, respectively). The degree of NFC abnormalities also correlated with the severity of PsA and serum cytokine levels. CONCLUSIONS NFC abnormalities were suggested to be a predictor of PsA in psoriasis patients, and at the same time, its degree could be an indicator of disease severity.
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Affiliation(s)
- Takemichi Fukasawa
- Department of Dermatology, Psoriasis Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Satoshi Toyama
- Department of Dermatology, Psoriasis Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Atsushi Enomoto
- Laboratory of Molecular Radiology, Center for Disease Biology and Integrative Medicine, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Asako Yoshizaki-Ogawa
- Department of Dermatology, Psoriasis Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Yuta Norimatsu
- Department of Dermatology, Psoriasis Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shoko Tateishi
- Immune-Mediated Diseases Therapy Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Hiroko Kanda
- Immune-Mediated Diseases Therapy Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Kiyoshi Miyagawa
- Laboratory of Molecular Radiology, Center for Disease Biology and Integrative Medicine, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Shinichi Sato
- Department of Dermatology, Psoriasis Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
| | - Ayumi Yoshizaki
- Department of Dermatology, Psoriasis Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
- Immune-Mediated Diseases Therapy Center, The University of Tokyo Graduate School of Medicine, Tokyo, Japan
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15
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Garaiman A, Nooralahzadeh F, Mihai C, Gonzalez NP, Gkikopoulos N, Becker MO, Distler O, Krauthammer M, Maurer B. Vision transformer assisting rheumatologists in screening for capillaroscopy changes in systemic sclerosis: an artificial intelligence model. Rheumatology (Oxford) 2023; 62:2492-2500. [PMID: 36347487 PMCID: PMC10321092 DOI: 10.1093/rheumatology/keac541] [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: 04/12/2022] [Accepted: 09/14/2022] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES The first objective of this study was to implement and assess the performance and reliability of a vision transformer (ViT)-based deep-learning model, an 'off-the-shelf' artificial intelligence solution, for identifying distinct signs of microangiopathy in nailfold capilloroscopy (NFC) images of patients with SSc. The second objective was to compare the ViT's analysis performance with that of practising rheumatologists. METHODS NFC images of patients prospectively enrolled in our European Scleroderma Trials and Research group (EUSTAR) and Very Early Diagnosis of Systemic Sclerosis (VEDOSS) local registries were used. The primary outcome investigated was the ViT's classification performance for identifying disease-associated changes (enlarged capillaries, giant capillaries, capillary loss, microhaemorrhages) and the presence of the scleroderma pattern in these images using a cross-fold validation setting. The secondary outcome involved a comparison of the ViT's performance vs that of rheumatologists on a reliability set, consisting of a subset of 464 NFC images with majority vote-derived ground-truth labels. RESULTS We analysed 17 126 NFC images derived from 234 EUSTAR and 55 VEDOSS patients. The ViT had good performance in identifying the various microangiopathic changes in capillaries by NFC [area under the curve (AUC) from 81.8% to 84.5%]. In the reliability set, the rheumatologists reached a higher average accuracy, as well as a better trade-off between sensitivity and specificity compared with the ViT. However, the annotators' performance was variable, and one out of four rheumatologists showed equal or lower classification measures compared with the ViT. CONCLUSIONS The ViT is a modern, well-performing and readily available tool for assessing patterns of microangiopathy on NFC images, and it may assist rheumatologists in generating consistent and high-quality NFC reports; however, the final diagnosis of a scleroderma pattern in any individual case needs the judgement of an experienced observer.
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Affiliation(s)
- Alexandru Garaiman
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Farhad Nooralahzadeh
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Carina Mihai
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | | | - Nikitas Gkikopoulos
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Mike Oliver Becker
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Michael Krauthammer
- Department of Quantitative Biomedicine, University of Zurich, Zurich, Switzerland
| | - Britta Maurer
- Department of Rheumatology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Rheumatology and Immunology, University Hospital Bern, University of Bern, Bern, Switzerland
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16
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Abstract
Nailfold capillaroscopy is a safe and well-established method for the assessment of structural alterations of the microcirculation. It is a crucial tool in the investigation and monitoring of patients presenting with Raynaud's phenomenon. Detection of the characteristic "scleroderma pattern" on capillaroscopy may indicate an underlying rheumatic disease, particularly systemic sclerosis (SSc). Herein, we highlight the practical aspects of videocapillaroscopy, including image acquisition and analysis, with mention of dermoscopy. Special emphasis is placed on standardized use of terminology to describe capillary characteristics. Systematic evaluation of images in discerning the normal from the abnormal using the validated European Alliance of Associations for Rheumatology (EULAR) Study Group consensus reporting framework is paramount. In addition to the relevance of capillaroscopy in the (very) early diagnosis of SSc, its emerging predictive value (especially capillary loss) for new organ involvement and disease progression is underscored. We further provide capillaroscopic findings in selected other rheumatic diseases.
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Affiliation(s)
- Vanessa Smith
- Department of Internal Medicine, Ghent University, Ghent, Belgium; Department of Rheumatology, Ghent University Hospital, Ghent, Belgium; Unit for Molecular Immunology and Inflammation, VIB Inflammation Research Center (IRC), Ghent, Belgium.
| | - Claudia Ickinger
- Division of Rheumatology, Chris Hani Baragwanath Academic Hospital, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Elvis Hysa
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
| | - Marcus Snow
- Department of Internal Medicine, Division of Rheumatology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Tracy Frech
- Internal Medicine, Vanderbilt University Medical Center and Tennessee Valley Healthcare System Nashville, TN, USA
| | - Alberto Sulli
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
| | - Maurizio Cutolo
- Laboratory of Experimental Rheumatology and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Italy - IRCCS San Martino Polyclinic, Genoa, Italy
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17
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Shah R, Petch J, Nelson W, Roth K, Noseworthy MD, Ghassemi M, Gerstein HC. Nailfold capillaroscopy and deep learning in diabetes. J Diabetes 2023; 15:145-151. [PMID: 36641812 PMCID: PMC9934957 DOI: 10.1111/1753-0407.13354] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 10/27/2022] [Accepted: 12/21/2022] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE To determine whether nailfold capillary images, acquired using video capillaroscopy, can provide diagnostic information about diabetes and its complications. RESEARCH DESIGN AND METHODS Nailfold video capillaroscopy was performed in 120 adult patients with and without type 1 or type 2 diabetes, and with and without cardiovascular disease. Nailfold images were analyzed using convolutional neural networks, a deep learning technique. Cross-validation was used to develop and test the ability of models to predict five5 prespecified states (diabetes, high glycosylated hemoglobin, cardiovascular event, retinopathy, albuminuria, and hypertension). The performance of each model for a particular state was assessed by estimating areas under the receiver operating characteristics curves (AUROC) and precision recall curves (AUPR). RESULTS A total of 5236 nailfold images were acquired from 120 participants (mean 44 images per participant) and were all available for analysis. Models were able to accurately identify the presence of diabetes, with AUROC 0.84 (95% confidence interval [CI] 0.76, 0.91) and AUPR 0.84 (95% CI 0.78, 0.93), respectively. Models were also able to predict a history of cardiovascular events in patients with diabetes, with AUROC 0.65 (95% CI 0.51, 0.78) and AUPR 0.72 (95% CI 0.62, 0.88) respectively. CONCLUSIONS This proof-of-concept study demonstrates the potential of machine learning for identifying people with microvascular capillary changes from diabetes based on nailfold images, and for possibly identifying those most likely to have diabetes-related complications.
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Affiliation(s)
- Reema Shah
- Population Health Research Institute, McMaster University and Hamilton Health SciencesHamiltonOntarioCanada
| | - Jeremy Petch
- Population Health Research Institute, McMaster University and Hamilton Health SciencesHamiltonOntarioCanada
- Centre for Data Science and Digital HealthHamilton Health SciencesHamiltonOntarioCanada
- Institute for Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
- Division of CardiologyMcMaster UniversityHamiltonOntarioCanada
| | - Walter Nelson
- Centre for Data Science and Digital HealthHamilton Health SciencesHamiltonOntarioCanada
- Department of Statistical SciencesUniversity of TorontoTorontoOntarioCanada
| | - Karsten Roth
- Cluster of Excellence Machine LearningUniversity of TübingenTübingenGermany
| | - Michael D. Noseworthy
- Electrical and Computer EngineeringMcMaster UniversityHamiltonOntarioCanada
- McMaster School of Biomedical EngineeringHamiltonOntarioCanada
- Department of RadiologyMcMaster UniversityHamiltonOntarioCanada
| | | | - Hertzel C. Gerstein
- Population Health Research Institute, McMaster University and Hamilton Health SciencesHamiltonOntarioCanada
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18
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Suma KV, Dinesh PA, Rao B. Multivariate Parametric Study of Nailfold Capillary Images for Disease Detection. Crit Rev Biomed Eng 2023; 51:1-19. [PMID: 37560877 DOI: 10.1615/critrevbiomedeng.2023047066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
Nailfold capillaroscopy is a tool which is non-invasive in nature and can be useful for diagnosis, research, therapeutic study and prognosis. Research shows that specific capillary morphology patterns are identified for diabetic subjects, hypertensive subjects and normal controls. In this study, we have proposed RATHEW approach of classifying these three classes of subjects. RATHEW approach employs a three step process for classifying nailfold images: one, identify six abnormality parameters from the image dataset; two, score these abnormality parameters based on the defined scoring rules; and three, combine them mathematically to segregate them into three classes. This technique can be further enhanced to grade the severity of disease and organ involvement. This can bring in a paradigm shift to the disease detection and therapeutic study mechanism.
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Affiliation(s)
- K V Suma
- Department of Electronics and Communication, M S Ramaiah Institute of Technology, Bangalore, Karnataka 560054, India
| | - P A Dinesh
- Department of Mathematics, Ramaiah Institute of Technology, MSRIT Nagar, Bangalore 560 054, India
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El Miedany Y, Ismail S, Wadie M, Hassan M. Nailfold capillaroscopy: tips and challenges. Clin Rheumatol 2022; 41:3629-3640. [PMID: 36040673 DOI: 10.1007/s10067-022-06354-1] [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: 06/07/2022] [Revised: 08/22/2022] [Accepted: 08/23/2022] [Indexed: 11/03/2022]
Abstract
Although nailfold capillaroscopy (NFC) appears to have a bright future in clinical practice, the lack of familiarity with the technique and how to interpret its outcomes is major barriers which have made nailfold capillaroscopy an underutilized method in standard clinical practice. Traditional methods for assessment and measurement of capillary patterns, density, and blood flow are falling behind and face some challenges. In fact, there have been calls for improvement, hence the recent publication of the standardization of NFC by the EULAR Study Group on Microcirculation in Rheumatic Diseases. Nailfold capillaroscopy has the advantage of being a non-invasive technique that provides a window into the digital microcirculation. This paved the way for a rapidly growing interest in using capillaroscopy parameters as outcome measures in research. In standard clinical practice, whilst its main application is in the identification of an underlying systemic sclerosis spectrum disorder in patients presenting with Raynaud's phenomenon, its use has expanded to include other clinical features possibly suggestive of an underlying connective tissue disease. This article presents the challenges, provides tips, and highlights the exciting potential of nailfold capillaroscopy in standard practice.
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Affiliation(s)
- Yasser El Miedany
- Canterbury Christ Church University, Institute of Medical Sciences, Canterbury, England, UK.
| | - Sherif Ismail
- Rheumatology and Rehabilitation, Internal Medicine Department, National Research Center, Cairo, Egypt
| | - Mary Wadie
- Internal Medicine Cairo University, Cairo, Egypt
| | - Mohammed Hassan
- Rheumatology and Rehabilitation, Tanta University, Tanta, Egypt
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Rosei CA, Gaggero A, Famà F, Malerba P, Chiarini G, Nardin M, Brami V, Rossini C, Coschignano MA, Porteri E, Salvetti M, Muiesan ML, Rizzoni D, De Ciuceis C. Skin capillary alterations in patients with acute SarsCoV2 infection. J Hypertens 2022; 40:2385-2393. [PMID: 35983856 PMCID: PMC9640263 DOI: 10.1097/hjh.0000000000003271] [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: 12/09/2021] [Revised: 07/12/2022] [Accepted: 07/12/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acute SarsCov2 infection is associated with endothelial dysfunction and 'endothelitis', which might explain systemic microvascular impairment. The presence of endothelial damage may promote vasoconstriction with organ ischemia, inflammation, tissue oedema and a procoagulant state resulting in an increase in the incidence of cardiovascular and cerebrovascular events. Microvascular thrombosis has been demonstrated in postmortem autopsy of COVID-19 patients; however, few data are available about skin capillary alterations in these patients. MATERIALS AND METHODS We evaluated skin microvascular alteration in 22 patients admitted to our hospital with SarsCov2 infection. Capillary density was evaluated by capillaroscopy in the nailfold and the dorsum of the finger in the acute phase of the disease. Capillaroscopy was repeated after 3 months (recovery phase). In addition, blood chemistry parameters and inflammatory markers were obtained during acute infection and at the recovery after 3 months. RESULTS Patients with COVID-19 showed skin microvascular complications, such as thrombosis, microhaemorrhages and neoangiogenesis, which were not detected after 3 months from the discharge. A significant reduction of capillary density in the dorsum was observed after 3 months from the acute infection (97.2 ± 5.3 vs. 75.81 ± 3.9 n/mm 2P < 0.05). A significant inverse correlation between C-reactive protein and capillary density was observed in patients with acute SarsCov2 infection ( r = 0.44, P < 0.05). Conversely a direct correlation between capillary density during the acute phase and lymphocyte number was detected ( r = 0.49, P < 0.05). CONCLUSION This is the first in-vivo evidence of skin capillary thrombosis, microhaemorrhages and angiogenesis in patients with acute SarsCov2 infection, which disappeared after 3 months, supporting the presence of endothelial dysfunction and inflammation. Capillary alterations might reflect systemic vascular effects of viral infection.
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Affiliation(s)
- Claudia Agabiti Rosei
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Andrea Gaggero
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Francesca Famà
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Paolo Malerba
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Giulia Chiarini
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Matteo Nardin
- Third Division of Medicine, ASST Spedali Civili, Brescia
| | - Valeria Brami
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Claudia Rossini
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | | | - Enzo Porteri
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Massimo Salvetti
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Maria Lorenza Muiesan
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
| | - Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
- Division of Medicine, ASST Spedali Civili di Brescia, Montichiari, Italy
| | - Carolina De Ciuceis
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia
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21
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Boonstra M, Ciaffi J, Noordhoek DC, Liem SIE, Beaart-van de Voorde LJJ, van Bijnen STA, Huizinga TWJ, Vonk MC, de Vries-Bouwstra JK. Improvement of microangiopathy after haematopoietic stem cell transplantation in systemic sclerosis. Clin Exp Rheumatol 2022; 40:1993-1998. [PMID: 36259604 DOI: 10.55563/clinexprheumatol/5rjvkc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 10/10/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Haematopoietic stem cell transplantation (HSCT) is a treatment option for patients with severe systemic sclerosis (SSc), but the efficacy of the procedure in remodelling the nailfold microvascular array is largely unknown. Therefore, this study aimed to evaluate the effect of HSCT on microangiopathy assessed through nailfold capillaroscopy (NC) and to compare the results with findings in patients receiving conventional immunosuppression. METHODS We included SSc patients with severe SSc and whose pre- and post-treatment NC images were available. Findings in patients treated with HSCT were compared with patients not treated with HSCT. Images were scored by two independent observers blinded for clinical data and treatment history. Capillary pattern was determined and semiquantitative scores from 0 (no changes) to 3 (>66% alterations per millimetre) were used to quantify the degree of specific microvascular characteristics. Changes in severity of microangiopathy between baseline and post-treatment were compared between groups. RESULTS Images of 18 HSCT patients and 21 controls were scored. From baseline to follow-up, 33% of HSCT patients showed improvement from scleroderma pattern to normal NC, compared to 6% of controls (p=0.15). Pre- to post-treatment differences in semiquantitative scores showed significant improvement in HSCT patients compared to controls regarding capillary loss (-0.5 vs. 0.0, p<0.05) and disorganisation (-0.8 vs. 0.0, p<0.05). CONCLUSIONS The degree of microangiopathy improved significantly in severe SSc patients treated with HSCT compared with patients receiving conventional immunosuppressive therapy.
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Affiliation(s)
- Maaike Boonstra
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacopo Ciaffi
- Medicine and Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - D Christine Noordhoek
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Sophie I E Liem
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | | | | | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Madelon C Vonk
- Department of Rheumatology, Radboudumc, Nijmegen, The Netherlands
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22
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Abstract
Nailfold capillaroscopy is a rapid and easily applicable differential diagnostic technique that allows direct visualization of the microcirculation. Abnormal findings in nailfold capillaroscopy are closely associated with connective tissue diseases, such as systemic sclerosis. The clinical manifestation of impaired microcirculation is Raynaud's phenomenon, which is a classical symptom of connective tissue diseases. Nailfold capillaroscopy is increasingly used in various fields of medicine, therefore it is important to define methods for the acquisition and analysis of the results of nailfold capillary and to have a uniform definition of abnormal capillaries. This article discusses image acquisition and analysis, various capillaroscopic techniques, normal and abnormal capillaroscopic features and their significance, scoring systems and reliability of image acquisition and interpretation.
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Affiliation(s)
- R Hasseli-Fräbel
- Medizinische Klinik und Poliklinik II, Universitätsklinikum Gießen, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | - W Hermann
- Abteilung für Rheumatologie und Klinische Immunologie, Kerckhoff-Klinik GmbH, Benekestr. 2-8, 61231, Bad Nauheim, Deutschland.
| | - O Sander
- Poliklinik und Funktionsbereich für Rheumatologie, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
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23
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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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24
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Fernandez-Somoza JM, Ginarte M, Otero E, Tomé S, Soutullo C, Martínez-Ulloa A, Gonzalez-Quintela A. Clinical and capillaroscopic findings in patients with liver disease and proximal apparent leukonychia (Terry nails and its variants). Medicine (Baltimore) 2021; 100:e26207. [PMID: 34087892 PMCID: PMC8183706 DOI: 10.1097/md.0000000000026207] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 05/10/2021] [Indexed: 01/04/2023] Open
Abstract
Terry nails and Lindsay nails are similar forms of proximal apparent leukonychia (PAL). A change in nail bed vascularity is thought to be responsible for PAL. The study was aimed at investigating the frequency of PAL in patients attending a liver disease clinic, the factors associated with its presence, its value for detecting cirrhosis, its prognostic value for mortality, and associated capillaroscopic findings.A total of 521 patients were included (age range, 18-94 years; 69% men). Systematic nail photographs were evaluated by 2 independent investigators. Disease-related data were obtained from the medical records. Mortality was evaluated after 7 years of follow-up. Nailfold capillaroscopy was performed on a subset of 80 patients.PAL was present in 228 patients (43.8%; Terry nails in 205, Lindsay nails in 20, and both in 3). The kappa-coefficient of interobserver agreement was 0.82. The presence of PAL was associated with cirrhosis and, accordingly, with portal hypertension and hepatocellular dysfunction. The positive likelihood ratio of PAL for the diagnosis of cirrhosis was 1.6 (95% CI 1.3-1.92). PAL was independently associated with chronic alcohol abuse and was not a significant predictor of mortality. Venous loop dilatation and prominence of the venous plexus were observed on capillaroscopy in patients with cirrhosis but were not significantly associated with PAL.In summary, PAL is a common finding in patients from a liver clinic; it is associated with liver cirrhosis and with alcohol abuse. PAL is not associated with specific capillaroscopic findings. We propose the generic term proximal apparent leukonychia instead of classic eponymous titles to avoid confusion in the literature.
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Affiliation(s)
| | - Manuel Ginarte
- Department of Dermatology, Hospital Clínico Universitario, Santiago de Compostela, Spain
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25
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Shikama M, Sonoda N, Morimoto A, Suga S, Tajima T, Kozawa J, Maeda N, Otsuki M, Matsuoka T, Shimomura I, Ohno Y. Association of crossing capillaries in the finger nailfold with diabetic retinopathy in type 2 diabetes mellitus. J Diabetes Investig 2021; 12:1007-1014. [PMID: 33070436 PMCID: PMC8169354 DOI: 10.1111/jdi.13444] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Revised: 10/09/2020] [Accepted: 10/14/2020] [Indexed: 12/19/2022] Open
Abstract
AIMS/INTRODUCTION Crossing capillaries in the finger nailfold might potentially be a novel diabetic retinopathy (DR) biomarker that could be assessed non-invasively in the clinical setting. However, the association between crossing capillaries and DR is controversial. This study aimed to investigate the association between the percentage of crossing capillaries in the finger nailfold and DR in patients with type 2 diabetes mellitus. MATERIALS AND METHODS This cross-sectional study enrolled 108 type 2 diabetes mellitus patients (aged 40-75 years) who visited the outpatient diabetic clinic at Osaka University Hospital, Osaka, Japan, between May and October 2019. Capillary morphology was assessed using nailfold capillaroscopy based on the simple capillaroscopic definitions of the European League Against Rheumatism Study Group. Details of DR and other laboratory data were obtained from medical records. The association between the tertile of the percentage of the crossing capillary and DR was analyzed using multivariable logistic regression. RESULTS After adjusting for age, sex, diabetes duration, glycated hemoglobin, systolic blood pressure, body mass index, and use of renin-angiotensin system inhibitor and antihyperlipidemic medication, the percentage of crossing capillaries was significantly associated with DR (multivariable-adjusted odds ratios for increasing tertiles of the percentage of crossing capillary: 1 [reference], 2.05 [95% confidence interval 0.53-7.94], and 4.33 [95% confidence interval 1.16-16.21]; P-trend = 0.028). CONCLUSIONS A higher percentage of crossing capillaries in the nailfold was associated with a higher risk of DR, independent of traditional risk and inhibiting factors, in patients with type 2 diabetes mellitus.
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Affiliation(s)
- Maiko Shikama
- Department of Mathematical Health ScienceGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Nao Sonoda
- Department of Fundamental NursingGraduate School of NursingOsaka Prefecture UniversityHabikinoJapan
| | - Akiko Morimoto
- Department of Fundamental NursingGraduate School of NursingOsaka Prefecture UniversityHabikinoJapan
| | - Sayaka Suga
- Department of Mathematical Health ScienceGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Tetsuya Tajima
- Department of Mathematical Health ScienceGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Junji Kozawa
- Department of Metabolic MedicineOsaka University Graduate School of MedicineSuitaJapan
- Department of Diabetes Care MedicineGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Norikazu Maeda
- Department of Metabolic MedicineOsaka University Graduate School of MedicineSuitaJapan
- Department of Metabolism and AtherosclerosisGraduate School of MedicineOsaka UniversitySuitaJapan
| | - Michio Otsuki
- Department of Metabolic MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Taka‐Aki Matsuoka
- Department of Metabolic MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Iichiro Shimomura
- Department of Metabolic MedicineOsaka University Graduate School of MedicineSuitaJapan
| | - Yuko Ohno
- Department of Mathematical Health ScienceGraduate School of MedicineOsaka UniversitySuitaJapan
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26
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Kim B, Hariyani YS, Cho YH, Park C. Automated White Blood Cell Counting in Nailfold Capillary Using Deep Learning Segmentation and Video Stabilization. Sensors (Basel) 2020; 20:E7101. [PMID: 33322435 PMCID: PMC7763965 DOI: 10.3390/s20247101] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
White blood cells (WBCs) are essential components of the immune system in the human body. Various invasive and noninvasive methods to monitor the condition of the WBCs have been developed. Among them, a noninvasive method exploits an optical characteristic of WBCs in a nailfold capillary image, as they appear as visual gaps. This method is inexpensive and could possibly be implemented on a portable device. However, recent studies on this method use a manual or semimanual image segmentation, which depends on recognizable features and the intervention of experts, hindering its scalability and applicability. We address and solve this problem with proposing an automated method for detecting and counting WBCs that appear as visual gaps on nailfold capillary images. The proposed method consists of an automatic capillary segmentation method using deep learning, video stabilization, and WBC event detection algorithms. Performances of the three segmentation algorithms (manual, conventional, and deep learning) with/without video stabilization were benchmarks. Experimental results demonstrate that the proposed method improves the performance of the WBC event counting and outperforms conventional approaches.
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Affiliation(s)
- Byeonghwi Kim
- Department of Computer Engineering, Kwangwoon University, Seoul 01897, Korea; (B.K.); (Y.-S.H.)
| | - Yuli-Sun Hariyani
- Department of Computer Engineering, Kwangwoon University, Seoul 01897, Korea; (B.K.); (Y.-S.H.)
- School of Applied Science, Telkom University, Bandung 40257, Indonesia
| | - Young-Ho Cho
- Department of Electrical Communication, Daelim University, Anyang-Si 13916, Korea
| | - Cheolsoo Park
- Department of Computer Engineering, Kwangwoon University, Seoul 01897, Korea; (B.K.); (Y.-S.H.)
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27
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ELMAS ÖF, OKÇU M, DEMİRBAŞ A, AKDENİZ N. Handheld dermatoscopy as an easy-to-use capillaroscopic instrument in rheumatoid arthritis: a cross-sectional study. Turk J Med Sci 2020; 50:1540-1545. [PMID: 32718130 PMCID: PMC7605092 DOI: 10.3906/sag-2006-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 06/01/2020] [Accepted: 07/27/2020] [Indexed: 12/29/2022] Open
Abstract
Background/aim Nailfold video capillaroscopy is considered as a reliable method for evaluating peripheral microangiopathy in rheumatologic diseases. In this study, we aimed to demonstrate the utility of handheld dermatoscopy as an easy-to-use nailfold capillaroscopic instrument in patients with rheumatoid arthritis. Materials and methods This cross-sectional study included patients with rheumatoid arthritis and healthy subjects. A handheld dermatoscopic examination of proximal nail fold was performed in each subject. The possible correlation of capillaroscopic findings with disease activity was evaluated using the disease activity score 28 (DAS28). Results A total of 59 patients with rheumatoid arthritis and 60 healthy subjects were enrolled in the study. The presence of capillaryenlargement, avascular areas, capillary deformities, and capillary vascular anomalies in the group of patients showed a statistically significant difference when compared with the healthy subjects. No correlation was found between the nail fold capillaroscopic findings and DAS28 score. Conclusion Hand-held dermatoscopy seems to be a useful technique in the evaluation of nail fold capillary changes. We suggest that in patients with rheumatoid arthritis, when capillaroscopic examination is needed, it can be evaluated using handheld dermatoscopy. Selected patients who showed findings using this method can be further examined with classical capillaroscopy to obtain more quantitative data.
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Affiliation(s)
- Ömer Faruk ELMAS
- Department of Dermatology and Veneorology, Faculty of Medicine, Ahi Evran University, KırşehirTurkey
| | - Mehmet OKÇU
- Department of Physical Therapy and Rehabilitation, Faculty of Medicine Ahi Evran University, KırşehirTurkey
| | - Abdullah DEMİRBAŞ
- Department of Dermatology and Veneorology, Konya Numune State Hospital, KonyaTurkey
| | - Necmettin AKDENİZ
- Department of Dermatology and Veneorology, Faculty of Medicine, İstanbul Medeniyet University, İstanbulTurkey
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28
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Affiliation(s)
- Jose W Ricardo
- Department of Dermatology, Weill Cornell Medicine, New York, New York
| | - Shari R Lipner
- Department of Dermatology, Weill Cornell Medicine, New York, New York.
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29
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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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30
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Fassio A, Giovannini I, Idolazzi L, Zabotti A, Iagnocco A, Sakellariou G. Nail ultrasonography for psoriatic arthritis and psoriasis patients: a systematic literature review. Clin Rheumatol 2019; 39:1391-1404. [PMID: 31440917 DOI: 10.1007/s10067-019-04748-2] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/23/2019] [Accepted: 08/12/2019] [Indexed: 01/11/2023]
Abstract
To systematically review the role of ultrasound (US) in the assessment of the joint-enthesial-nail apparatus in patients with psoriatic arthritis (PsA) or psoriasis (PSO) in terms of prevalence, diagnosis, prognosis, monitoring and treatment. A systematic literature review was conducted through medical databases (PubMed, Embase) and the grey literature up to February 2018. The main areas of application of nail US were first identified, allowing the development of research questions, which were rephrased following the PICOs methodology to develop inclusion criteria. Of the 585 studies produced by PubMed and Embase searches, 17 studies met the criteria for inclusion. Five additional studies were included: 1 from the hand search and 4 from the 2016-2017 ACR and EULAR congresses. The prevalence of nail plate changes varied from < 10 to 97%, for power Doppler signal from 20-30 to 96% and distal interphalangeal joint (DIJ) involvement from 8.9 to 100%. The performance of US nail/DIJ abnormalities in the diagnosis of PsA and PSO elementary lesions was analysed by five studies, with a wide heterogeneity. Reproducibility and reliability of US nil/DIJ were assessed by interclass correlation coefficient or Cohen's k and their values ranged from 0.6 to 0.9. The value of US nail/DIJ in the monitoring of the lesions was analysed only by a single study. The analysis revealed applications for US nail/DIJ in PsA and PSO and highlights limitations. Validation is strongly needed to demonstrate its appropriateness in the clinical practice and to define its diagnostic and prognostic role.
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Affiliation(s)
- A Fassio
- Rheumatology Unit, University of Verona, Piazzale A. Stefani 1, 137126, Verona, Italy
| | - I Giovannini
- Department of Medical and Biological Sciences, Rheumatology Clinic, University of Udine, Udine, Italy
| | - L Idolazzi
- Rheumatology Unit, University of Verona, Piazzale A. Stefani 1, 137126, Verona, Italy.
| | - A Zabotti
- Department of Medical and Biological Sciences, Rheumatology Clinic, University of Udine, Udine, Italy
| | - A Iagnocco
- Academic Rheumatology Centre, Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Turin, Italy
| | - G Sakellariou
- Division of Rheumatology, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
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Karbalaie A, Emrani Z, Fatemi A, Etehadtavakol M, Erlandsson BE. Practical issues in assessing nailfold capillaroscopic images: a summary. Clin Rheumatol 2019; 38:2343-2354. [PMID: 31278512 DOI: 10.1007/s10067-019-04644-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 03/19/2019] [Revised: 06/10/2019] [Accepted: 06/14/2019] [Indexed: 11/30/2022]
Abstract
Nailfold capillaroscopy (NC) is a highly sensitive, safe, and non-invasive technique to assess involvement rate of microvascularity in dermatomyositis and systemic sclerosis. A large number of studies have focused on NC pattern description, classification, and scoring system validation, but minimal information has been published on the accuracy and precision of the measurement. The objective of this review article is to identify different factors affecting the reliability and validity of the assessment in NC. Several factors can affect the reliability of the examination, e.g., physiological artifacts, the nailfold imaging instrument, human factors, and the assessment rules and standards. It is impossible to avoid all artifacts, e.g., skin transparency, physically injured fingers, and skin pigmentation. However, minimization of the impact of some of these artifacts by considering some protocols before the examination and by using specialized tools, training, guidelines, and software can help to reduce errors in the measurement and assessment of NC images. Establishing guidelines and instructions for automatic characterization and measurement based on machine learning techniques also may reduce ambiguities and the assessment time.
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Affiliation(s)
- Abdolamir Karbalaie
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Zahra Emrani
- Medical Image and Signal Processing Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.
| | - Alimohammad Fatemi
- Rheumatology Section, Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mahnaz Etehadtavakol
- Department of Medical Physics, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Björn-Erik Erlandsson
- School of Engineering Sciences in Chemistry, Biotechnology and Health, KTH Royal Institute of Technology, Stockholm, Sweden
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Rossi D, Sciascia S, Roccatello D. Nailfold Capillaroscopy Patterns. Isr Med Assoc J 2019; 21:497-498. [PMID: 31507129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Daniela Rossi
- Center of Research of Immunopathology and Rare Diseases (CMID) - Division of Nephrology and Dialysis (ERK-net member), St. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases (CMID) - Division of Nephrology and Dialysis (ERK-net member), St. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases (CMID) - Division of Nephrology and Dialysis (ERK-net member), St. Giovanni Bosco Hospital and University of Turin, Turin, Italy
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Ciaffi J, van Leeuwen NM, Huizinga TWJ, de Vries-Bouwstra JK. Cumulative endogenous estrogen exposure is not associated with severity of peripheral microangiopathy in patients with systemic sclerosis. Clin Exp Rheumatol 2019; 37 Suppl 119:82-87. [PMID: 31587694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/09/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To determine whether cumulative endogenous estrogen exposure (CEEE) is associated with severity of microvascular damage or with presence of clinical characteristics in women with systemic sclerosis (SSc). METHODS The population was composed of female SSc patients from the Leiden CCISS (combined care in SSc) cohort. Reproductive life history was investigated through structured questionnaires and CEEE was calculated with a mathematical equation. Demographic, laboratory and clinical characteristics were available for all patients. The most recent nailfold videocapillaroscopy (NVC) was used to semiquantitatively score microangiopathy parameters. RESULTS We included 97 patients, with a mean age of 59.6±14 years and a mean CEEE of 9±5.5 years. Ordinal logistic regression using CEEE as independent variable failed to demonstrate an association with loss (OR 1.05, 95% CI 0.97-1.14), dilated capillaries (OR 1.05, 95% CI 0.96-1.14), giants (OR 1.03, 95% CI 0.95-1.12) and ramifications (OR 0.99, 95% CI 0.92-1.07). Binary logistic regression did not show an effect of CEEE on presence of scleroderma pattern vs. non-scleroderma pattern, (OR 0.99, 95% CI 0.89-1.1) or of late scleroderma pattern vs. non-late patterns (OR 0.96, 95% CI 0.88-1.05) at NVC. Furthermore, no association was found between CEEE and presence of interstitial lung involvement (OR 0.98, 95% CI 0.88-1.08) but a trend for occurrence of digital ulcers (OR 1.09, 95% CI 0.99-1.19) was observed. CONCLUSIONS In SSc patients, CEEE is not associated with the extent of microvascular derangement. No associations between CEEE and organ involvement were found.
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Affiliation(s)
- Jacopo Ciaffi
- Dept.of Rheumatology, Leiden University Medical Centre, the Netherlands; Rheumatology Unit, Azienda Policlinico of Modena, University of Modena and Reggio Emilia, Modena and Medicine and Rheumatology Unit, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy.
| | - Nina M van Leeuwen
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Tom W J Huizinga
- Department of Rheumatology, Leiden University Medical Centre, Leiden, The Netherlands
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Rimar D, Rimar O, Rosner I, Rozenbaum M, Kaly L, Boulman N, Slobodin G. Nailfold Video Capillaroscopy: Beyond Systemic Sclerosis. Isr Med Assoc J 2019; 21:499-502. [PMID: 31507130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Doron Rimar
- Rheumatology Unit, Bnai Zion Medical Center, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Ori Rimar
- Rheumatology Unit, Bnai Zion Medical Center, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Itzhak Rosner
- Rheumatology Unit, Bnai Zion Medical Center, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michael Rozenbaum
- Rheumatology Unit, Bnai Zion Medical Center, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Lisa Kaly
- Rheumatology Unit, Bnai Zion Medical Center, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nina Boulman
- Rheumatology Unit, Bnai Zion Medical Center, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gleb Slobodin
- Rheumatology Unit, Bnai Zion Medical Center, affiliated with Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Paolino S, Ferrari G, Pizzorni C, Patanè M, Smith V, Cutolo M, Sulli A. Long-term follow-up of nailfold videocapillaroscopic microvascular parameters in mixed connective tissue disease versus systemic sclerosis patients: a retrospective cohort study. Clin Exp Rheumatol 2019; 37 Suppl 119:102-107. [PMID: 31587695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/11/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To retrospectively study nailfold videocapillaroscopy (NVC) changes in mixed connective tissue disease (MCTD) patients and to compare the capillary morphological abnormalities between patients affected by MCTD and systemic sclerosis (SSc) over time. METHODS Ten MCTD patients on whom NVC had been performed, with a follow-up of three years, were selected. In addition, ten patients affected by SSc with similar age and disease duration of MCTD patients were enrolled to compare NVC abnormalities at baseline (T0). RESULTS Seven out of ten patients with MCTD showed a "scleroderma-like pattern" at first NVC. No statistically significant variation of the detected NVC parameters was observed during the 3-year follow-up, and no statistically significant correlation was observed between capillary parameters and MCTD clinical aspects at first visit and during the follow-up. The scores of enlarged capillaries, giant capillaries and microhaemorrhages were significantly lower (p<0.05) in MCTD versus SSc patients at T0, moreover, the absolute number of total capillaries and normal capillaries was found significantly higher (p<0.05) in MCTD versus SSc patients. CONCLUSIONS This study suggests that nailfold microvascular damage does not seem to be significantly progressive in MCTD patients during a three-year follow-up. MCTD patients show significantly lower number of enlarged/giant capillaries, but higher number of total and normal capillaries than SSc patients at first nailfold capillaroscopy. The identification of a specific NVC pattern in MCTD patients is not yet possible.
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Affiliation(s)
- Sabrina Paolino
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giorgia Ferrari
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Carmen Pizzorni
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Massimo Patanè
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Department of Internal Medicine and VIB Inflammation Research Centre, Ghent University, Ghent, Belgium
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy.
| | - Alberto Sulli
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Bernardino VR, Rodrigues AC, Panarra A. Raynaud's phenomenon and inflammatory bowel disease: The possible role of microcirculation. Eur J Intern Med 2019; 62:e16. [PMID: 30737060 DOI: 10.1016/j.ejim.2019.02.001] [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: 12/09/2018] [Accepted: 02/01/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Vera R Bernardino
- Unidade de Doenças Auto-Imunes, Internal Medicine Department 7.2, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal.
| | - Ana Catarina Rodrigues
- Unidade de Doenças Auto-Imunes, Internal Medicine Department 7.2, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
| | - António Panarra
- Unidade de Doenças Auto-Imunes, Internal Medicine Department 7.2, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
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Dinsdale G, Roberts C, Moore T, Manning J, Berks M, Allen J, Anderson ME, Cutolo M, Hesselstrand R, Howell K, Pizzorni C, Smith V, Sulli A, Wildt M, Taylor C, Murray A, Herrick AL. Nailfold capillaroscopy-how many fingers should be examined to detect abnormality? Rheumatology (Oxford) 2019; 58:284-288. [PMID: 30247696 DOI: 10.1093/rheumatology/key293] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Indexed: 11/08/2023] Open
Abstract
Objectives Nailfold capillaroscopy is being increasingly used by rheumatologists in the diagnosis of SSc. However, assessment of all nailfolds can be time-consuming in a busy outpatient clinic. Our aim was to answer the question as to how many (and which) fingers a clinician should routinely assess to capture accurately the true state. Methods A total of 2994 assessments (by an international panel of expert observers) of 1600 images from 173 participants (101 with SSc, 22 with primary RP and 50 healthy controls) were included in this analysis. Seven single-finger or finger combinations (derived from the middle and ring fingers) were then tested for sensitivity for the presence of two markers of capillary abnormality [presence of giant capillaries and an SSc grade (early, active or late)] compared with assessment of all eight fingers. Results For the eight-finger gold standard, sensitivity against the diagnostic criteria was 74.6% (53.0% for the presence of giants alone and 73.1% for image grade alone). Examining only one finger gave low sensitivity (ranging from right middle 31.7% to left ring 46.6%). Examining both ring fingers gave a sensitivity of 59.8%, whereas examining the four-finger combination of both ring and both middle fingers gave a sensitivity of 66.7%. Conclusion During routine capillaroscopic examination, ideally all eight nailbeds (excluding thumbs) should be examined, otherwise some abnormalities will be missed. Examining only four fingers reduces capillaroscopy sensitivity.
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Affiliation(s)
- Graham Dinsdale
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Roberts
- Centre for Biostatistics, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Tonia Moore
- Rheumatology Department, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Joanne Manning
- Rheumatology Department, Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - Michael Berks
- Centre for Imaging Sciences, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - John Allen
- Microvascular Diagnostics, Northern Medical Physics and Clinical Engineering, Freeman Hospital, Newcastle upon Tyne, UK
| | - Marina E Anderson
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genoa, Genoa, 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, Department of Internal Medicine, University of Genoa, Genoa, 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, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Marie Wildt
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Christopher Taylor
- Centre for Imaging Sciences, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Andrea Murray
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - Ariane L Herrick
- Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Salford Royal Hospital NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- NIHR Manchester Musculoskeletal Biomedical Research Centre, Central Manchester NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
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Halder A, Banerjee M, Singh S, Adhikari A, Sarkar PK, Bhattacharya AM, Chakrabarti P, Bhattacharyya D, Mallick AK, Pal SK. A Novel Whole Spectrum-Based Non-Invasive Screening Device for Neonatal Hyperbilirubinemia. IEEE J Biomed Health Inform 2019; 23:2347-2353. [PMID: 30640639 DOI: 10.1109/jbhi.2019.2892946] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Careful screening of bilirubin level in newborns is mandatory as per American Academy of Pediatrics (2004), to reduce incidents of kernicterus and acute bilirubin encephalopathy. Although, invasive capillary collection of blood and subsequent biochemical test is considered a gold standard for jaundice detection in neonates, transcutaneous bilirubin measurement using various non-invasive instruments is also used sporadically across the globe. The major aim of this study was to develop a non-invasive spectrometry-based technique for measurement of neonatal bilirubin level as an alternative of total serum bilirubin (TSB) test without limitations of other available bilirubinometers. METHODS The instrument comprises of a light source and a spectroscopic detector. A light beam from source incident on the neonatal nail plate through optical fibers. The retro reflected light is acquired using the detector. An indigenously developed software is used to acquire and analyze the optical signal and to calculate the bilirubin value. The instrument was calibrated and validated in reference to TSB on 1033 subjects. MAJOR RESULTS The result (r = 0.95 and P < 0.001) indicates a strong correlation between the bilirubin value obtained from our method and TSB. Time variant analysis of the subjects undergoing phototherapy provided a good correlation (r = 0.98). The repeatability test result shows the mean coefficient of variation is less than 5.0%. CONCLUSIONS The indigenously developed non-invasive technique successfully detects the bilirubin level in newborns under various physiological conditions with high accuracy and precision.
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Fink C, Kilian S, Bertlich I, Hoxha E, Bardehle F, Enk A, Haenssle HA. Evaluation of capillary pathologies by nailfold capillaroscopy in patients with psoriasis vulgaris: study protocol for a prospective, controlled exploratory study. BMJ Open 2018; 8:e021595. [PMID: 30099394 PMCID: PMC6089272 DOI: 10.1136/bmjopen-2018-021595] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Psoriasis vulgaris was shown to be an independent factor increasing the risk of several comorbidities such as obesity, diabetes and dyslipidaemia with an increased risk of stroke and myocardial infarction. We hypothesise that early endothelial dysfunction, which plays a crucial role in the pathogenesis of atherosclerosis, may be detected by digital video nailfold capillaroscopy (DVNC) at the level of the dermal capillary microvasculature as a surrogate parameter. Nailfolds represent the only body site allowing for a non-invasive assessment of the capillary microvasculature at a horizontal plane. DVNC is a well-established diagnostic tool for in vivo assessment of the peripheral microcirculation by evaluating the morphology of dermal papillary capillaries. To date, reports on morphological changes of the non-lesional nailfold capillaries in patients with psoriasis vulgaris are scarce and the existing data are not conclusive. METHODS AND ANALYSIS This is a prospective, single-centre, non-randomised, controlled, exploratory study assessing the capillary patterns in 100 subjects affected by psoriasis vulgaris. Non-lesional nailfold capillaries will be imaged by means of DVNC (Optilia Digital Capillaroscopy System, Optilia Instruments AB, Sollentuna, Sweden) in 50 patients affected by psoriasis vulgaris and 50 healthy controls. Assessments will include a qualitative, descriptive analysis of the nailfold capillaries' morphology, as well as a quantitative investigation (frequency, extent) of changes in capillary patterns. Moreover, patients' characteristics associated with the manifestation of nailfold capillaries' pathologies including well-known cardiovascular risk markers will be studied. ETHICS AND DISSEMINATION Ethical approval was provided by the ethic committee of the medical faculty of the University of Heidelberg (Ethics approval number S-447/2017). The design and the final results of the study will be published and made available to the public. TRIAL REGISTRATION NUMBER DRKS00012856.
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Affiliation(s)
- Christine Fink
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Samuel Kilian
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Ines Bertlich
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Elti Hoxha
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Felicitas Bardehle
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Alexander Enk
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
| | - Holger A Haenssle
- Department of Dermatology, University of Heidelberg, Heidelberg, Germany
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Vasile M, Avouac J, Sciarra I, Stefanantoni K, Iannace N, Cravotto E, Valesini G, Allanore Y, Riccieri V. From VEDOSS to established systemic sclerosis diagnosis according to ACR/EULAR 2013 classification criteria: a French-Italian capillaroscopic survey. Clin Exp Rheumatol 2018; 36 Suppl 113:82-87. [PMID: 30183599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 05/07/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Nailfold capillaroscopy (NC) shows microcirculatory abnormalities in systemic sclerosis (SSc). The inclusion of NC specific abnormalities increases the sensitivity of both 2013 ACR/EULAR and VEDOSS (Very Early Diagnosis of Systemic Sclerosis) classification criteria. We aimed to detect NC features able to predict progression toward established SSc in VEDOSS patients. METHODS Sixty-six VEDOSS patients were enrolled. They had a clinical follow-up and underwent NC once a year, considering morphological parameters, appropriate pattern and semi- quantitative rating scale. RESULTS In a mean follow-up time of 31 months, 21 patients progressed into SSc (P = Progressors), while 45 were "Non Progressor" (NP). Comparing NC basal features of both groups, significantly larger loop diameter and apex width, higher haemorrhage and NC scores were found in P respect to NP patients. When comparing NC features of P patients who progressed within one year (FP = Fast progressor), loop diameter and apex width were significantly higher compared to all VEDOSS subjects. Each unit increase of apex width was associated with an increasing risk of 1% for developing SSc and the cut-off value of 103 μm showed a positive predictive value of 56% and a negative predictive value of 71%. CONCLUSIONS We describe NC findings in VEDOSS patients, identifying those suggesting a progression into established disease. These findings must be regarded as possible predictive risk factor to develop SSc and can also be of relevance in the detection of those cases with a faster development. Thus NC seems to have a diagnostic and prognostic role in VEDOSS cases.
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Affiliation(s)
- Massimiliano Vasile
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Jerome Avouac
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Iliana Sciarra
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Katia Stefanantoni
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Nicoletta Iannace
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Elena Cravotto
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Guido Valesini
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy
| | - Yannick Allanore
- Rheumatology A Department, Cochin Hospital, Paris Descartes University, Paris, France
| | - Valeria Riccieri
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Italy.
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Bakirci Ureyen S, Kara RO, Erturk Z, Yaldiz M. The microvascular and morphostructural changes of nails in psoriatic patients with nail disease; a link between ultrasound and videocapillaroscopy findings in the nailfold. Med Ultrason 2018; 20:185-191. [PMID: 29730685 DOI: 10.11152/mu-1274] [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] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVE The objective of this study is to evaluate the link between nail fold vessel resistive index (NVRI) measured by ultrasound (US) and capillary loops diameters measured using nailfold videocapillarascopy (NVC), and to assess the morphological appearance of the nail bed in patients with psoriatic nail disease (PND) as compared with healthy controls (HCs). MATERIAL AND METHODS This study was conducted in patients with PND and HCs. General demographic data were collected and clinical assessments were performed for all subjects. The nail plate thickness (NPT) was measured on gray scale using US. The NVRI was measured using color Doppler (CD) US. The measurements of the apical, arterial, venous limb diameters and morpho-structural changes (tortuous, cross-linked capillaries) were assessed using NVC. RESULTS Thirty-four patients with PND and 15 HCs were enrolled in this study. The two groups were matched for age and body mass index (BMI). Patients with PND had higher NPT and NVRI in comparison with HCs [(20 (17-23) vs 14 (14-15), p<0.001), (0.55 (0.51-0.61) vs 0.43 (0.38-0.49), p<0.001), respectively]. A higher proportion of patients with PND had tortuous capillaries than HCs (62% and 20% respectively, p=0.005). The mean NVRI was higher in patients with PND who had tortuous capillaries than patients who did not have tortuous capillaries (0.58 (0.7) and 0.52 (0.09), respectively p=0.033). CONCLUSION Microvascular changes can be detected easily using non-invasive methods such as US and NVC. These methods can provide an objective data to better assess PND.
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Affiliation(s)
- Sibel Bakirci Ureyen
- Sakarya Education and Research Hospital, Department of Internal Medicine, Division of Rheumatology, Sakarya, TURKEY.
| | - Rabia Oztas Kara
- Department of Dermatology, Sakarya Education and Research Hospital, Sakarya, Turkey
| | - Zeynep Erturk
- Department of Internal Medicine, Sakarya Education and Research Hospital, Sakarya, Turkey
| | - Mahizer Yaldiz
- Department of Dermatology, Sakarya Education and Research Hospital, Sakarya, Turkey
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Mihai C, Smith V, Dobrota R, Gheorghiu AM, Cutolo M, Distler O. The emerging application of semi-quantitative and quantitative capillaroscopy in systemic sclerosis. Microvasc Res 2018; 118:113-120. [PMID: 29544760 DOI: 10.1016/j.mvr.2018.03.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 03/10/2018] [Accepted: 03/11/2018] [Indexed: 12/23/2022]
Abstract
Systemic sclerosis (SSc) is a connective tissue disease with high morbidity and mortality, characterized by autoimmunity, obliterative vasculopathy involving mainly the microvasculature, and fibrosis. SSc-specific nailfold capillaroscopic changes have been defined, and nailfold capillaroscopy (NFC) is now unequivocally accepted to be a cornerstone for the early diagnosis of SSc. However, the use of NFC in patients already diagnosed with SSc is still not standardized. Several studies have shown that NFC abnormalities correlate with disease activity and severity and are predictive for disease worsening, such as occurrence of new digital ulcers. More importantly, successful treatment has been shown to diminish NFC abnormalities in severe SSc cases. These findings support the importance of NFC in monitoring patients with SSc and even its role as an outcome measure in SSc clinical trials. It is a matter of debate if Semi-quantitative and Quantitative NFC would be a more sensitive tool than qualitative NFC for meeting these objectives. This review is presenting the emerging application of Semi-quantitative and Quantitative NFC in SSc and its potential benefits.
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Affiliation(s)
- Carina Mihai
- Department of Internal Medicine and Rheumatology, Cantacuzino Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland.
| | - Vanessa Smith
- Department of Rheumatology, Ghent University Hospital, Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Rucsandra Dobrota
- Department of Internal Medicine and Rheumatology, Cantacuzino Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania; Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
| | - Ana Maria Gheorghiu
- Department of Internal Medicine and Rheumatology, Cantacuzino Hospital, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Maurizio Cutolo
- Research Laboratory and Academic Unit of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Genova, Italy
| | - Oliver Distler
- Department of Rheumatology, University Hospital Zurich, Zurich, Switzerland
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García-González M, Rodríguez-Lozano B, Bustabad S, Ferraz-Amaro I. Undifferentiated connective tissue disease: predictors of evolution into definite disease. Clin Exp Rheumatol 2017; 35:739-745. [PMID: 28770704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 12/20/2016] [Indexed: 06/07/2023]
Abstract
OBJECTIVES The natural evolution of undifferentiated connective tissue diseases (UCTD) has not yet been established. The aim of our study was to analyse the clinical outcomes of a cohort of UCTD patients followed in a routine outpatient setting and to establish which clinical, serological or capillaroscopy features are associated with an increased risk of evolution to definite connective tissue disease (CTD). METHODS Data for this study were collected by a retrospective review of 758 patients referred to our hospital, between 1999 and 2008, with suspected CTD. After selection criteria, 98 patients were considered eligible and their records, laboratory findings and nailfold-capillaroscopy pattern (NCP) were analysed until clinical outcome. Three groups of patient outcomes were established: remission, UCTD, and definite CTD. Logistic regression analysis was performed to study the association of baseline clinical features, including NCP progression during monitoring, with clinical outcomes. RESULTS After a mean follow-up of 11±3 years, 62% of the patients continued to suffer from UCTD, 24% regressed to a remission state and 14% developed definite CTD. Cytopenias (p=0.030), positivity for antibody specificities (ENA) (p=0.008), anti-Ro (p=0.036) and antiphospholipid antibodies (p=0.032), and the presence of an altered NCP (p=0.026) at baseline proved different between groups and were more frequently encountered in the group that evolved to definite CTD when compared with the others two groups. Specifically, cytopenias (odds ratio -OR- 4.20 [1.30-13.56] p=0.016), the presence of an antinuclear antibody (ANA) titre ≥1/640 (OR 7.00 [1.99-24.66], p=0.002) and anti-centromere positivity (OR 3.77 [1.03-13.79], p=0.045) at baseline and NCP progression (OR 6.63 [1.70-25.87], p=0.007) were associated with the future presence of definite CTD. CONCLUSIONS Most patients with UCTD remain in an undifferentiated state after routine outpatient clinic follow-up. High ANA titres or the presence of cytopenias at baseline, as well as progression of NCP during follow-up, are the leading factors associated with evolution to definite CTD.
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Affiliation(s)
| | | | - Sagrario Bustabad
- Division of Rheumatology, Hospital Universitario de Canarias, Tenerife, Spain
| | - Ivan Ferraz-Amaro
- Division of Rheumatology, Hospital Universitario de Canarias, Tenerife, Spain
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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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Hatzis C, Lerner D, Paget S, Cutolo M, Smith V, Spiera R, Gordon J. Integration of capillary microscopy and dermoscopy into the rheumatology fellow curriculum. Clin Exp Rheumatol 2017; 35:850-852. [PMID: 28229821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Accepted: 11/28/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVES This study evaluates a novel, three-part nailfold capillaroscopy training curriculum for adult and paediatric rheumatology fellows. METHODS All rheumatology fellows training at an academic medical centre took part in the three-part nailfold capillaroscopy curriculum. Tests of fellows' usage, interest, confidence, and ability in nailfold capillaroscopy were taken at multiple time-points throughout the curriculum. RESULTS Fellows self-reported high levels of interest, increased confidence in delineating normal and abnormal nailfold capillaries (p=0.03) and increased usage of nailfold capillaroscopy (p=0.09). The ability of fellows to identify normal nailfold capillaries (p=0.03) and systemic sclerosis-specific nailfold capillary changes, such as neoangiogenesis (p<0.001), also increased. CONCLUSIONS The curriculum was feasible and led to improved ability of learners to distinguish normal from abnormal and to recognise and describe systemic sclerosis-specific nailfold capillary changes. This curriculum also led to improved confidence in examining nailfold capillaries and increased usage of this skill in rheumatologic consultation.
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Affiliation(s)
- Christopher Hatzis
- Department of Rheumatology, Hospital for Special Surgery, New York, USA.
| | - Daniele Lerner
- Department of Rheumatology, Hospital for Special Surgery, New York, USA
| | - Stephen Paget
- Department of Rheumatology, Hospital for Special Surgery, New York, USA
| | - Maurizio Cutolo
- Research Laboratory and Academic Division of Clinical Rheumatology, Department of Internal Medicine, University of Genova, Italy
| | - Vanessa Smith
- Department of Internal Medicine, Faculty of Medicine and Health Sciences, Ghent University, and Department of Rheumatology, Ghent University Hospital, Ghent, Belgium
| | - Robert Spiera
- Department of Rheumatology, Hospital for Special Surgery, New York, USA
| | - Jessica Gordon
- Department of Rheumatology, Hospital for Special Surgery, New York, USA
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Corrado A, Correale M, Mansueto N, Monaco I, Carriero A, Mele A, Colia R, Di Biase M, Cantatore FP. Nailfold capillaroscopic changes in patients with idiopathic pulmonary arterial hypertension and systemic sclerosis-related pulmonary arterial hypertension. Microvasc Res 2017; 114:46-51. [PMID: 28619664 DOI: 10.1016/j.mvr.2017.06.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [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: 04/07/2017] [Revised: 05/10/2017] [Accepted: 06/09/2017] [Indexed: 01/12/2023]
Abstract
Pulmonary arterial hypertension (PAH) represents one of the main clinical expressions of the vascular changes in systemic sclerosis (SSc). Lung microvascular changes can play a role in the pathogenesis of idiopathic PAH (IPAH) also. The aim of this study is to investigate the presence of capillaroscopic abnormalities in patients with IPAH and to evaluate the differences in capillary nailfold changes between patients with IPAH and patients with SSc with and without PAH. METHODS 39 SSc patients (19 with PAH - SSc-PAH and 20 without - SSc-noPAH), 21 subjects with IPAH and 20 healthy subjects were recruited. PAH was diagnosed by right heart catheterization. Nailfold videocapillaroscopy was performed (NVC) in all recruited subjects; capillary quantitative parameters (loops length and width, capillary density, neoangiogenesis) were evaluated and a semiquantitative scoring was used (normal, minor or major abnormalities for healthy controls and IPAH subjects and specific patterns - early, active and late - for SSc subjects) to define microvascular alterations. RESULTS The presence of capillaroscopic abnormalities was detected in 38,1% subjects with IPAH; particularly, compared to healthy controls, capillary density was significantly lower (7,5±1,65loops/mm vs 9±1,37loops/mm p<0,05) and mean capillary width was significantly higher (21±13μm vs 17±3μm p<0,05). A more severe NVC pattern (active/late) was described. SSc-PAH patients compared to SSc-noPAH patients (73,2% vs 50% respectively, p<0,05), with a significantly lower capillary density (5,64±1,9loops/mm vs 6,5±1,3loops/mm p<0,05) and a significantly higher capillary width (55±7μm vs 35±8μm - p<0,05) and mean number of neoangiogenesis (N/mm) (1±0,33 vs 0,2±0,22 respectively p<0,05). CONCLUSIONS These data, beyond to confirm the role of microvascular damage in SSc-related PAH, support the hypothesis of systemic microvascular involvement in IPAH also, which can be detected by NVC, although further studies are needed to establish whether the changes in the systemic microcirculation are causal or consequential to PAH.
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Affiliation(s)
- A Corrado
- Rheumatology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy
| | - M Correale
- Cardiology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy
| | - N Mansueto
- Rheumatology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy
| | - I Monaco
- Cardiology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy
| | - A Carriero
- Rheumatology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy
| | - A Mele
- Rheumatology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy
| | - R Colia
- Rheumatology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy
| | - M Di Biase
- Cardiology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy
| | - F P Cantatore
- Rheumatology Clinic, Department of Medical and Surgical Sciences - University of Foggia, Foggia, Italy.
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Chen C, Cheng KHY, Jakubovic R, Jivraj J, Ramjist J, Deorajh R, Gao W, Barnes E, Chin L, Yang VXD. High speed, wide velocity dynamic range Doppler optical coherence tomography (Part V): Optimal utilization of multi-beam scanning for Doppler and speckle variance microvascular imaging. Opt Express 2017; 25:7761-7777. [PMID: 28380895 DOI: 10.1364/oe.25.007761] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
In this paper, a multi-beam scanning technique is proposed to optimize the microvascular images of human skin obtained with Doppler effect based methods and speckle variance processing. Flow phantom experiments were performed to investigate the suitability for combining multi-beam data to achieve enhanced microvascular imaging. To our surprise, the highly variable spot sizes (ranging from 13 to 77 μm) encountered in high numerical aperture multi-beam OCT system imaging the same target provided reasonably uniform Doppler variance and speckle variance responses as functions of flow velocity, which formed the basis for combining them to obtain better microvascular imaging without scanning penalty. In vivo 2D and 3D imaging of human skin was then performed to further demonstrate the benefit of combining multi-beam scanning to obtain improved signal-to-noise ratio (SNR) in microvascular imaging. Such SNR improvement can be as high as 10 dB. To our knowledge, this is the first demonstration of combining different spot size, staggered multiple optical foci scanning, to achieve enhanced SNR for blood flow OCT imaging.
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He L, Wang C, Hu L, Hao F, Wu Z, Cai R, Wang J. [Impacts of mild moxibustion on immune indices and nailfold microcirculation in the subhealthy group]. Zhongguo Zhen Jiu 2017; 37:115-119. [PMID: 29231470 DOI: 10.13703/j.0255-2930.2017.02.001] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To compare the difference in the clinical therapeutic effects of the regulation of subhealthy condition between the mild moxibustion on alternate days and Chinese herbal medicine. METHODS Seventy-two participants of subhealthy condition were assigned into a mild moxibustion group (36 cases) and a medication group (36 cases) according to random number table. In the mild moxibustion group, the intervention of mild moxibustion with moxa stick was applied to Guanyuan (CV 4), Zusanli (ST 36) and Sanyinjiao (SP 6), once every other day. In the medication group, yupingfeng granules were prescribed for oral administration, three times a day. The treatment was continued for 2 months. Before and after treatment, the levels of IgA, IgM and IgG, SOD (superoxide dismutase), the total score of fatigue scale 14 (FS-14) and the score of nailfold microcirculation were observed separately. RESULTS Compared with the results before treatment, the immune indices, the total score of FS-14 and the scores of nailfold microcirculation were all improved after treatment in the two groups, indicating the significant differences (P<0.05, P<0.01). In comparison between the two groups after treatment, the levels of immune globulin, e.g. IgM, IgG and SOD in the mild moxibustion group were higher in tendency than those in the medication group, but without significant differences (all P>0.05). The total score of FS-14 after treatment in the mild moxibustion group was lower than that in the medication group (P<0.05). After treatment, in the mild moxibustion group, for the nailfold microcirculation, the flow state score, the periloop score and the total score were all reduced more apparently as compared with those in the medication group (P<0.01, P<0.05). CONCLUSIONS Mild moxibustion with moxa stick on alternate days apparently relieves fatigue state, immune dysfunction and microcirculatory impairment in the subhealthy group. The results are apparently superior to the treatment with yupingfeng granules.
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Affiliation(s)
- Lu He
- Clinical School of Acupuncture and Osteology, Anhui University of CM, Hefei 230038, China
- Institute of Acupuncture and Meridian, Anhui Academy of Chinese Medical Sciences, Hefei 230038, China
| | - Chunhua Wang
- Anhui Institute of International Business, Hefei 230038, China
| | - Ling Hu
- Clinical School of Acupuncture and Osteology, Anhui University of CM, Hefei 230038, China
- Institute of Acupuncture and Meridian, Anhui Academy of Chinese Medical Sciences, Hefei 230038, China.
| | - Feng Hao
- the Second Clinical Medical School, Nanjing University of CM, Hefei 230038, China
| | - Zijian Wu
- Institute of Acupuncture and Meridian, Anhui Academy of Chinese Medical Sciences, Hefei 230038, China
| | - Ronglin Cai
- Institute of Acupuncture and Meridian, Anhui Academy of Chinese Medical Sciences, Hefei 230038, China
| | - Jie Wang
- Clinical School of Acupuncture and Osteology, Anhui University of CM, Hefei 230038, China
- Institute of Acupuncture and Meridian, Anhui Academy of Chinese Medical Sciences, Hefei 230038, China
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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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Hsu PC, Liao PY, Chang HH, Chiang JY, Huang YC, Lo LC. Nailfold capillary abnormalities are associated with type 2 diabetes progression and correlated with peripheral neuropathy. Medicine (Baltimore) 2016; 95:e5714. [PMID: 28033273 PMCID: PMC5207569 DOI: 10.1097/md.0000000000005714] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [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] [Indexed: 11/26/2022] Open
Abstract
Diabetes mellitus (DM) is associated with a state of chronic hyperglycemia with a highly increased risk of vascular complications. The current study aimed to investigate microcirculation abnormalities in patients with type 2 DM and those with pre-DM using nailfold videocapillaroscopy (NVC) and evaluate the possible correlation with microvascular complications.A total of 115 patients with type 2 DM, 41 patients with pre-DM, and 37 healthy subjects without diabetes were enrolled. All subjects underwent NVC to evaluate capillary density, length, morphology, distribution, presence of enlarged loops or hemorrhages, and blood flow. NVC score was used to quantitate the aforementioned characteristics.Patients with type 2 DM showed significantly increased alterations including reduced capillary length (29.6%), irregular distribution (35.7%), and abnormal morphology (59.1%), while the corresponding NVC scores were comparable to those of control subjects. In addition, subjects with pre-DM had a significantly higher NVC score and greater alterations in distribution (26.8%) and morphology (48.8%) than control subjects. NVC score was positively correlated with diabetic peripheral neuropathy (DPN) and the number of microvascular complications.NVC identified a high frequency of microcirculation abnormalities in subjects with pre-DM or type 2 DM compared to those in the control group. NVC score was also capable of detecting microvascular complications in patients with type 2 DM and was correlated with DPN and the number of microvascular complications.
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Affiliation(s)
- Po-Chi Hsu
- Graduate Institute of Chinese Medicine, College of Chinese Medicine, China Medical University, Taichung
- Department of Chinese Medicine, Changhua Christian Hospital
| | - Pei-Yung Liao
- Department of Endocrinology, Changhua Christian Hospital
| | - Hen-Hong Chang
- School of Post-Baccalaureate Chinese Medicine, College of Chinese Medicine, and Research Center for Chinese Medicine and Acupuncture, China Medical University
- Department of Chinese Medicine, China Medical University Hospital, Taichung
| | - John Y. Chiang
- Department of Computer Science and Engineering, National Sun Yat-sen University
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung
| | - Yu-Chuen Huang
- School of Chinese Medicine, College of Chinese Medicine, China Medical University
- Department of Medical Research, China Medical University Hospital, Taichung
| | - Lun-Chien Lo
- Department of Chinese Medicine, Changhua Christian Hospital
- Graduate Institute of Statistical and informational Science, National Changhua University of Education, Changhua, Taiwan
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