Raynaud's Phenomenon Research Articles

Long-term survival analysis of free flap reconstruction in patients with collagen vascular disorders.

Collagen vascular disorders (CVD) are inflammatory diseases that can affect the blood vessels and soft tissues. Patients with CVD are often immunosuppressed, prone to hyper-coagulation, and represent a challenging patient cohort for free tissue transfer. A retrospective review of patients with CVD who underwent free flap reconstructions from 2000-2020 was performed at our institution. Inclusion criteria were patients 18 years old or older with the clinical diagnosis of CVD, including rheumatoid arthritis, Raynaud phenomenon, systemic lupus erythematosus, scleroderma, and sarcoidosis. A time-to-event analysis was performed to identify predictors of surgical complications. A total of 78 patients and 96 free flaps were included. The most common CVD were rheumatoid arthritis (n=36) and Raynaud's phenomenon (n=9). Type of flap included abdominal-based flap (26%), trunk-based flaps (32.3%), and extremity-based flaps (19.8%). The mean age was 56.7±14.6 years, and the mean BMI was 27.5±5.9 kg/m2. Antibody positivity was present in 25.6% of patients; 59% were on chronic steroids, 6.4% were on chronic anticoagulation, 35.9% had radiation therapy, and 29.5% had chemotherapy. Nine percent of patients had a history of prior flap loss, and 11.5% had a history of DVT or arterial thrombosis. The flap loss rate was 3.8%. Steroid treatment was associated with an increased risk of major complications after adjusting for the type of flap HR 2.5(1.3-4.9), p= 0.01. Specifically associated with a higher risk of cellulitis, OR 5.1 (1.1-24.5), p=0.02, and abscess, OR 5.7 (1.2-27.1), p=0.01. Free flap reconstruction can be safely performed in patients with CVD. Perioperative optimization of steroids is important to promote wound healing and stabilize disease activity.

Anti-Jo1 Syndrome: Understanding a Rare Cause of Interstitial Lung Disease.

Anti-Jo1 syndrome is one of the most common amongst the various anti synthetase syndromes (ASS), which forms a subgroup of the idiopathic inflammatory myositis (IIM). It is characterised by myositis, interstitial lung disease (ILD), fever, Raynaud's phenomenon, and mechanic's hands; associated with the presence of anti-Jo1 antibodies in serum. Being an orphan disease, the clinical diagnosis is often delayed. In this retrospective study, all patients diagnosed as Anti-Jo1 syndrome, from two tertiary care hospitals in Western Maharashtra, between 01 January 2019 - 31 December 2020, were enrolled. The parameters studied included demographic data, clinical features at presentation, laboratory parameters, spirometry, and radiographic findings, along with treatment instituted. A total of 17 patients (8 males, 9 females) qualified for inclusion in the study. The mean age of diagnosis was 40 (±13) years with mean time to diagnosis being 2 years (± 0.6 years), from first clinical presentation. The most common presenting symptoms encountered were arthritis (n = 12, 70.5%), fever (n = 16, 70.5%), myositis (n=11, 64.7%) and breathlessness (n=10, 58.8%).10 patients had ILD at presentation on high resolution computerised tomography of chest (n=10, 58.8%) with restrictive lung defect on spirometry. Six patients required induction of immunosuppression using pulse methylprednisolone (n=6) and Rituximab (n=6), while 11 were managed with oral steroids. Mycophenolate mofetil (n=10) and Azathioprine (n=7) were used as maintenance immunosuppression. Anti-Jo1 syndrome is a myositis syndrome, presenting with a multitude of clinical features. Steroids and disease modifying anti rheumatic drugs form mainstay of therapy.

External clinical validation of automated software to identify structural abnormalities and microhaemorrhages in nailfold videocapillaroscopy images.

Automated systems to analyse nailfold videocapillaroscopy (NVC) images are needed to promptly and comprehensively characterise patients with systemic sclerosis (SSc) or Raynaud's phenomenon (RP). We previously developed, and validated in-house, a deep convolutional neural network-based algorithm to classify NVC-captured images according to the presence/absence of structural abnormalities and/or microhaemorrhages. We present its external clinical validation. A total of 1,164 NVC images of RP patients were annotated by 5 trained capillaroscopists according to the following categories: normal capillary; dilation; giant capillary; abnormal shape; tortuosity; microhaemorrhage. The images were also presented to the algorithm. Matches and discrepancies between algorithm predictions and those annotations obtained by consensus of ≥3 or ≥4 interobservers were analysed. Consensus among ≥3 capillaroscopists was achieved in 86.9% of images, 75.8% of which were correctly predicted by the algorithm. Consensus among ≥4 experts occurred in 52.0% of cases, in which 87.1% of the algorithm's results matched with those of the expert panel. The algorithm's positive predictive value was >80% for microhaemorrhages and unaltered, giant or abnormal capillaries. Sensitivity was >75% for dilations and tortuosities. Negative predictive value and specificity were >89% for all categories. This external clinical validation suggests that this algorithm is useful to assist in the diagnosis and follow-up of SSc or RP patients in a timely manner. It may also be helpful in the management of patients with any pathology presenting with microvascular changes, as the algorithm has been designed to also be useful for research aiming at extending the usage of nailfold capillaroscopy to more conditions.

Clinical utility of nailfold capillaroscopy.

Nailfold capillaroscopy (NFC) is a simple noninvasive microscopic technique used to identify characteristic morphological abnormalities in the nailfold capillaries. The presence of this microvasculopathy appears to be of fundamental importance in the pathological processes that underlie the scleroderma spectrum disorders (including dermatomyositis and antisynthetase myositis). This review discusses the different methodologies and techniques in performing NFC and stresses the diagnostic utility achieved with simple 'bedside' techniques utilising the ophthalmoscope, dermatoscope or smart phone. Recent advances in reporting abnormal microvascular patterns and vascular metrics (e.g. capillary density and dropout) are discussed. The aetiopathogenesis of the microvasculopathy is currently unknown but its close association with Raynaud Phenomena and specific autoantibodies together with recent observations from sequential NFC allows speculations on its possible mechanism. Finally, future developments in the use of NFC as a possible biomarker in the management of the scleroderma spectrum disorders are discussed, with a recommendation that NFC becomes more widely available, particularly in rheumatological, immunological and dermatological practice. NFC provides a clinically accessible window on the pathologic process fundamental to scleroderma-related disease.

Role of kinurenic acid in the systemic sclerosis renal involvement.

Systemic sclerosis (SSc) subclinical renal vasculopathy is characterized by progressive increase of intrarenal stiffness and reduction of parenchymal thickness due to post ischemic fibrosis secondary to the renal Raynaud phenomenon. Aims of this study were to evaluate kinurenic acid (KYNA) serum level in SSc patients and healthy controls (HC) and to assess the role of KYNA in SSc subclinical nephropathy. Serum level of KYNA was evaluated in 52 SSc patients and 20 HC, matched for sex and age. Renal function was calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation to estimate glomerular filtration rate (eGFR) and renal doppler ultrasound was performed to evaluate kidneys' morphology and indices of intrarenal stiffness. The parameters registered were renal longitudinal length, atrophy index (AI), renal sinus, parenchymal thickness, renal resistive index (RRI), pulsatile index (PI) and systolic/diastolic ratio (S/D). SSc patients had lower median value of KYNA than HC [54.43ng/ml (IQR 44.44-63.64) vs 61.94ng/ml (IQR 55.23-88.75), p < 0.001]. SSc patients with AI ≥ 0.70 had lower KYNA than SSc patients with AI < 0.70 [47.85ng/ml (IQR 41.16-59.91) vs 55.5ng/ml (IQR 49.99-67.33), p < 0.05] and a slightly significant negative linear correlation was found between KYNA and AI (r = - 0.249, p < 0.05). SSc patient with RRI ≥ 0.70 had higher KYNA than SSc patients with RRI < 0.70 [58.25ng/ml (IQR 50.49-69.68) vs 50.07ng/ml (IQR 42.70-56.31), p < 0.05] and a significant positive correlation was found between KYNA and RRI (r = 0.318, p < 0.05). KYNA may be used as a marker to evaluate the renal involvement in SSc patients.

Is heart-type fatty acid binding protein (H-FABP) a valid marker of arterial stiffness in patients with systemic sclerosis?

Background/Aim: Both micro- and macro-vascular involvement has been researched in systemic sclerosis (SSc) for many years. In this study, the relationship of arterial stiffness with heart-type fatty acid binding protein (h-FABP), which is well-accepted as a cardiac marker, was investigated for the first time.&#x0D; Methods: In this case-control study, 40 patients diagnosed with SSc between the ages of 18 and 65 were included. Thirty healthy individuals of similar age and gender were included as the control group. Patients were excluded from the study if they had cardiovascular risk factors, active infections, and/or malignancies. Along with detecting biochemical markers in the blood, results from methods, such as 24-h blood pressure Holter recordings, pulse-wave velocities (PWV), and echocardiograms (ECHO) were obtained from patients.&#x0D; Results: The homocysteine mean level was higher in the patient group than in the control group (P &lt; 0.001). H-FABP and asymmetric dimethylarginine (ADMA) means were similar between the two groups (P = 0.286 and P = 0.340, respectively). Vascular parameters, including mean arterial pressure (MAP), augmentation index normalized to the 75 /min heart rate (AIx @ 75), and PWV were also similar between the two groups (P = 0.498, P = 0.382 and P = 0.180, respectively).&#x0D; Conclusion: It can be concluded that no ongoing myocardial damage occurs based on normotensive Holter findings, normal h-FABP levels, and ECHO findings in our patients. It is suggested that vasodilatory treatments, such as pentoxifylline and calcium channel blockers, which the patients receive for SSc treatment due to Raynaud Syndrome, may protect them from hypertension and therefore offer protection from myocardial damage.

Anticentromere antibody positive patients with primary Sjögren's syndrome have distinctive clinical and immunological characteristics.

To investigate the clinical manifestations, immunological characteristics, circulating lymphocyte subsets and risk factors of anticentromere antibody (ACA) positive patients with primary Sjögren's syndrome (pSS). Data of 333 patients with newly diagnosed pSS were collected and analysed retrospectively. The demographic features, glandular dysfunction, extraglandular manifestations, laboratory data, peripheral blood lymphocyte profiles and serum cytokines were compared between ACA-positive and ACA-negative pSS patients. Logistic regression analysis was used to evaluate the association between ACA and pSS characteristics. The prevalence of ACA among pSS patients was 13.5%. ACA-positive pSS patients were older at diagnosis and had longer disease duration. Xerostomia, xerophthalmia, parotid enlargement, Raynaud's phenomenon (RP), lung and digestive system involvement were more common in ACA-positive group, whereas haematological involvement such as leukopenia was more common in the ACA-negative group. Less frequency of rheumatoid factor, hypergammaglobulinaemia, anti-SSA and anti-SSB positivity, as well as higher positivity rate of ANA were observed in ACA-positive pSS patients, who exhibited a lower ESSDAI. In addition, decreased B cells and elevated NK cells were found in ACA-positive patients. Multivariate analysis identified that disease duration longer than 5 years, parotid enlargement, normal immunoglobulin and the absence of anti-SSA antibody were risk factors of ACA-positive pSS. ACA positive pSS patients have distinctive clinical manifestations and less severe immunological features, present a lower disease activity and lower activation of the humoral immune system. Physicians should pay attention to RP, lung and liver involvement in this subset of pSS.

Effectiveness of unilateral sequential video-assisted sympathetic chain blockage for primary palmar hyperidrosis in children and adolescents.

Primary palmar hyperhidrosis (PPH) is a severely debilitating condition that can affect patients of any age. Thoracoscopic sympathectomy provides a definitive treatment for PPH. Aim of this study is to investigate the effectiveness of unilateral sequential video-assisted thoracic sympathetic chain clamping (VATSCC) by clips application in pediatric population. The surgical procedure was done in the semi-sitting position, under general anesthesia with orotracheal intubation. Mean operation time was 23 ± 6 min (range 12-45). Two 5 mm ports were inserted at the level of the middle axillary line in the second and fourth intercostal space respectively. The sympathetic chain was identified, and two clips were applied, the first one at the level of the third and the second one, at the level of the fourth rib. No chest tube was used. Resolution of symptoms, complications, recurrence rate, onset and duration of compensatory hyperhidrosis were analyzed. From August 2017 to September 2021, 58 patients (male:female ratio 32:26), mean age 16.5 years (range 14-19), with PPH underwent unilateral sequential VATSCC by clips application, starting on the dominant hand. The contralateral side was operated 2 months after. All patients except one (transient pneumothorax) were discharged on the first post-op day. No immediate or late complications have been recorded. Mean follow-up was 32 months (range 6-41). All patients except one (1,7%), affected by Raynaud's disease, showed a complete resolution of the symptom. Seven patients (12%) developed transient moderate compensative hyperhidrosis (CH) that spontaneously disappeared in the postoperative period. Unilateral sequential thoracoscopic sympathetic chain clamping for PPH in pediatric patients is a safe and very effective procedure with a low complication rate and low incidence of postoperative CH that, in our experience, resolved spontaneously in the postoperative period, after the second surgery leading to an improvement in the quality of life.

Factors determining the quality of life in patients with Raynaud's syndrome

Raynaud's disease is a vasospastic phenomenon affecting acral areas, which manifests itself in characteristic color changes. Symptoms are affected by mundane things like stress or temperature. There are also differences in the presence and progression of the disease in terms of gender, age, health-damaging behaviors (e.g., smoking) and occupation. The aim of our study was to examine how the risk factors assumed in the literature affect the quality of life of patients with Raynaud's disease. 110 people diagnosed with Raynaud's disease completed a questionnaire on disease-specific quality of life and risk factors. There was a significant difference between the groups with good and less good quality of life in terms of age (p<0.001), education (p<0.01), type of diagnosis (p<0.001), duration of illness (p<0.001), headache frequency (p<0.01), the influence of cold (p<0.05) and emotions (p<0.01). The groups currently working (p<0.01), drinking coffee more often (p<0.05), attributing less influence to emotions (p<0.001) and cold (p<0.01) had a better quality of life. According to the regression analysis, the type of diagnosis, the duration of the disease, the influencing role of emotions and cold are the most important predictors of Raynaud-specific quality of life. Our results draw attention to the role of factors that potentially affect the long-term development of the quality of life, thereby identifying the possible focuses of prevention. Orv Hetil. 2022; 163(47): 1880-1885.

Role of short courses on nailfold capillaroscopy in obtaining abilities for the identification of microvasculopathy in patients with Raynaud's phenomenon.

An early distinction between "normal" and "abnormal" capillaroscopic pattern during the first visit to a dermatologist has a crucial significance for a diagnostic management of Raynaud's phenomenon (RP). There exists a question about the level of expertise sufficient to evaluate the microcirculation. To evaluate the utility of short courses on NFC among dermatologists and medical students in obtaining sufficient abilities for the identification of microvasculopathy in patients with RP using videocapillaroscope and handheld dermoscope. Both groups participated in 1-h course on NFC. Before the course, participants were asked to classify 20 videocapillaroscopic and 10 dermoscopic capillaroscopic pictures into "normal" or "abnormal" pattern. Each picture was displayed on a separate slide MS PowerPoint for 10 s. The evaluation was repeated soon after the course. A total of 36 dermatologists and 49 medical students were enrolled. The rate of properly classified dermoscopic and videodermoscopic pictures increased after the course in both groups, but students improved the accuracy of classification on dermoscopic pictures to the greater extent than dermatologists. The rate of correctly recognized pictures with "abnormal" pattern was significantly greater than ones with "normal" pattern at the baseline and after the course, independently of imagining tool. Short courses on NFC may improve the classification of capillaroscopic images, even in medical staff with no previous experience in NFC. The recognition of capillaroscopic abnormalities seems to be easier than obtaining the confidence that evaluated picture has "normal pattern."

Final Results of Ruxopeg, a Phase 1/2 Adaptive Randomized Trial of Ruxolitinib (Rux) and Pegylated Interferon Alpha (IFNa) 2a in Patients with Myelofibrosis (MF)

Background MF is characterized by splenomegaly, anemia, debilitating symptoms and bone marrow (BM) fibrosis. Rux is the current standard of care improving symptoms and splenomegaly but with little impact on the malignant clone and BM fibrosis. IFNa can reduce mutant allele burden and fibrosis but is poorly tolerated in highly symptomatic patients (pts). The RUXOPEG study was designed to assess the efficacy and safety of different doses combinations of Rux + pegylated IFNa 2a in both JAK inhibitor and IFNa-naïve MF pts (NCT02742324). Methods RUXOPEG is a multi-center Bayesian Phase 1/2 adaptive trial. Phase 1 (P1) evaluated 9 possible combinations of doses of Rux, and IFNa (10, 15 and 20 mg BID, and 45, 90 and 135 mcg/week, respectively) and included 6 cohorts of 3 pts. Phase 2 (P2) randomized the 2 best dose combinations selected from P1. Primary tolerance criterion was the occurrence of dose limiting toxicities (DLT) within 45 days in P1. Primary efficacy criterion was >50% reduction in spleen length (SL) by palpation within 24 weeks (W). Secondary objectives included molecular response, quality of life and symptoms evolution, reduction of BM fibrosis, event-free and overall survival. Key inclusion criteria: diagnosis of MF (WHO), Intermediate (Int) or high risk (HR) (IPSS), need of active therapy. Key exclusion criteria: prior treatment with Rux or IFNa, eligibility for stem cell transplantation, autoimmune disease, history of depression. Enrolment in P1 was completed in Nov 2018 and in P2 in Nov 2020. We report the data collected after last pt last visit after 12 months in the study (Nov 2021). Results A total of 37 pts (18 in P1, 19 in P2) were included from 6 centers. Median (range) age was 63.5 years (37-71), 21 had primary MF, 16 post ET or post PV MF. Median (range) SL was 9 cm (0-20) by palpation and 19.5 cm (10.6-30) by imaging. Mean (range) hemoglobin was 12.2 g/dL (7.8-16.2), WBC 12.2 G/L (3.5- 36.1), platelets 372 G/L (150-1304). IPSS at inclusion: Int-1 in 23, Int-2 or HR in 14 pts. Mean number of mutations (mut) per pt was 3.4.; 21 pts had JAK2V617F, 11 CALR and 4 MPL mut; NGS identified 90 additional mut in 17 genes in 33 pts, including mut in HR genes: ASXL1 (n= 21), EZH2 (5), SRSF2 (2), IDH1 (1), and TP53 (5). Safety: No DLT occurred among the 18 pts included in 6 cohorts of P1 (primary safety criterion), and 19 pts were randomized between the 2 dose combinations selected for P2: IFNa 135 mcg/w + Rux 15 (level 6, 9 pts) or 20 (level 9, 10 pts) mg BID. Over 24W, a total of 363 AEs (59% gr1, 33% gr2, 7.5% gr3, 0.5% gr4) including 6 SAE (2 skin cancers, 2 anemias, 1 urinary infection, 1 Raynaud's phenomenon) were reported. Only 2.5% of them resulted in treatment interruption. Most frequent AEs were anemia (18.7%), thrombocytopenia (13.7%), GI (7%), musculoskeletal (6.8%) and asthenia (6.6%). During the 12-month period of the study, 1 patient died of AML transformation after 10.4 months. Efficacy: Primary efficacy endpoint (reduction by at least 50% of SL within 24 W) was reached in 70% (IC95%: 53;84) of pts (26/37 pts in ITT, 67% in P1, 74% in P2) with a clear decrease in SL at W24 (median 3.5 cm by palpation, range 0-12) (Fig 1), maintained at 12 months (median SL of 3 cm, range 0-12) (Fig 2) including complete resolution of palpable splenomegaly in 38% of pts. The best response rate (83%) was seen in patients receiving dose level 6. JAK2V617F allele burden decreased from a median (range) of 84% (23-96) at baseline to 65% (16-95), and 53% (16-92) after 6, and 12 months. Genotyping of progenitor-derived colonies performed in 10 patients showed that the combination of drugs clearly targets in 12 months committed (CD34+CD38+), immature (CD34+CD38-) and HSC-enriched progenitors (CD90+CD34+CD38-) carrying homozygous or heterozygous JAK2V617F. BM biopsies at inclusion and after 12 months are currently centrally reviewed (preliminary results show reduction of BM cellularity and grade of fibrosis in selected pts), and results of additional exploratory endpoints including evolution of clonal architecture with single cell and NGS sequencing, cytokine array and changes in immune effector cells will be presented. Conclusion RUXOPEG is the first study to formally assess the safety and efficacy of Rux + pegylated IFNa 2a combination in patients with MF never exposed to either drug before. Final results show that the combination provided high rates of important reductions in SL and JAK2V617F allele burden due to selective targeting of mutated progenitors. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Resolvins Modulate Netosis and Autoimmunity in Sickle Cell Disease

Sickle cell disease (SCD) is a genetically determined hematological disease which is characterized by anemia, chronic hemolysis, and multi-organ chronic inflammatory vasculopathy with acute vaso-occlusive painful crises and chronic organ damage. The pathophysiology of SCD is complex and involves several other cell types and metabolic pathways than erythrocytes, including neutrophils and soluble factors such as cytokines or alternative complement pathway which affect the function of vascular endothelium. An inflammatory vasculopathy with chronically activated neutrophils releasing Neutrophil Extracellular Traps (NETs) is a key component of the pathophysiology of sickle cell disease (SCD). Chiang et al. have recently shown that resolvins (Rv) reduce NETS and improve NETs clearance in a model of sepsis by Staphylococus aureus, a known trigger of NETosis (Chiang N et al. Blood 139 (8): 1222, 2022). We previously reported that targeting pro-resolution mechanisms with Rv improves SCD vasculopathy and organ damage in humanized sickle mice. Here, we studied 23 adult patients with SCD, followed by the Comprehensive center for hemoglobinopathies and rare anemias, University of Verona and AOUI Verona from January 2019 to December 2021. For each patient the presence/absence of concomitant rheumatological condition such as rheumatoid arthritis, other inflammatory arthropathies, immune-mediated dermatological conditions, Sicca syndrome and Raynaud's phenomenon, were assessed. Eight age, and ethnicity matched healthy controls were analyzed. Blood was collected for hematological and biochemical assay as part of the standard clinical care for these patients. Additional blood was collected for research studies on whole blood and on plasma cytokines. SCD patients display significant increase in tumor- necrosis-factor (TNF)- α (p = 0.011) and interleukin (IL)-10, suggesting both active inflammatory state and an upregulated counterregulatory mechanism to limit inflammation. We observed that antinuclear antibodies (ANA), but not extractable nuclear antibodies (ENA), were significantly increased in SCD patients (provide specific data here). Previous reports have reported the presence of this type of autoantibodies in the absence of autoimmune clinical manifestations in patients with SCD (Toly-Ndour C et al J Rheumatol 38: 302, 2011). ANA+ SCDsubjects (defined by a cell nuclei homogenous pattern, and positive dilution in the 1:80 to 1: 160 range) had a higher inflammatory and hemolytic status, as demonstrated by increased WBC and neutrophil counts and LDH values compared to ANA- subjects. NETosis plays a key role in modification and externalization of autoantigens involved in production of autoantibodies such as ANA. Here, we found basal NETosis was higher, though not significant, in ANA+ SCD subjects compared to ANA-SCD patients. This was associated with lower expression of receptors for RvD1 and D2, namely ALX, GPR32/DRV1, and GPR18/DRV2 on PMN, monocytes, and lymphocytes from ANA+ SCD patients when compared to ANA- SCD subjects, who were also characterized by relatively low LDH compared to ANA+ SCD patients. Exogenous treatment of SCD neutrophils with RvD1 and D4 significantly dampened NETs release and enhanced NETs clearance by macrophages. RvD4 along with other pro-resolving mediators also stimulated ex vivo clearance of P. aeruginosa and S. aureus by SCD neutrophils. Our findings provide a novel link between autoimmunity and neutrophil-mediated vasculopathy in SCD and highlight the importance of Rv and their immune-pro-resolution effects in limiting disease progression in SCD but also to modulate the host response to infections and sepsis, which is altered in SCD.

Biallelic Deleterious Germline SH2B3 Variants Cause a Novel Clinical Syndrome of Myeloproliferation and Multi-Organ Autoimmunity

SH2B3 is a negative regulator of cytokine receptor signalling pathways in hematopoietic tissue. Acquired deleterious SH2B3 variants resulting in increased JAK/STAT signalling are observed in myeloproliferative neoplasms (MPN) however the clinical implications and phenotype of deleterious germline variants in SH2B3 are less clear. A single consanguineous kindred has been previously described with homozygous deleterious germline SH2B3 variants presenting with hepatosplenomegaly, autoimmune hepatitis, developmental delay, autoimmune thyroiditis and acute lymphoblastic leukemia (Perez-Garcia, A., et al, Blood, 2013), however a clinically valid gene-disease pair according to formal criteria has not been met to date for SH2B3. We identified two probands from unrelated kindred with germline homozygous deleterious SH2B3 variants. The first patient presented with splenomegaly, thrombocytosis, neutrophilia and a leukoerythroblastic blood film at 3 months old. He developed alopecia areata at 2 years and autoimmune hypothyroidism at 6 years. He was otherwise developmentally normal without any detected liver abnormalities or thrombotic episodes. Whilst his splenomegaly and neutrophil count gradually improved throughout life, his platelet count remained markedly elevated (~1000x109/L at 18 years of age). Targeted NGS identified a homozygous frameshift variant in SH2B3 (NM_005475.3:c.441_468del; p.(Arg148Profs*40)). Both parents were heterozygous carriers of this variant. The second patient was a male born to consanguineous parents and noted shortly after birth to have isolated splenomegaly. He was diagnosed with autoimmune hypothyroidism and Raynaud syndrome at 12 years and was noted to have a persistent thrombocytosis ranging from 550 - 780 x109/L. He developed autoimmune hepatitis and insulin dependent diabetes at 17 years and around the same time he also suffered a right-sided middle cerebral artery territory infarct with a right carotid artery thrombus. Whole genome sequencing detected a homozygous missense variant in SH2B3 (NM_005475.3:c.1204G>A; p.(Val402Met)) in the patient with both parents being heterozygous carriers. In order to understand these variants further we modelled the human p.(Arg148Profs*40) variant from patient 1 in zebrafish. CRISPR-Cas9 gene editing was targeted to the analogous region of zebrafish sh2b3 to create assorted carboxyl-truncating mutations in F0 crispants. On-target gene-editing was verified by Sanger sequencing and NGS. F0 crispants had a significantly increased number of macrophages and CD41-expressing cells (HSCs and thrombocytes), replicating the patient phenotype. Treatment of the sh2b3 crispant fish with the JAK inhibitor ruxolitinib intercepted the myeloproliferative phenotype. The myeloproliferative phenotype was not observed in stable deletion mutants, likely reflecting genetic compensation not present in crispants. Skin-derived fibroblasts from patient 2 who carried the Val402Met homozygous variant, showed increased phosphorylation of JAK2, STAT5 and STAT3 by immunoblotting after stimulation with IL3, GH, GM-CSF and EPO compared to healthy controls. In conclusion, these newly described kindreds showing striking phenotypic similarity to each other as well as the previously described kindred and in conjunction with our functional data provide sufficient evidence for biallelic homozygous deleterious variants in SH2B3 to be considered a valid gene-disease association with a clinical syndrome of bone marrow myeloproliferation and multi-organ autoimmune manifestations. Notably, neither of our patients had evidence of acute lymphoblastic leukemia or overt hematological malignancy and further affected individuals will need to be described in order to fully understand the breadth of the phenotype. Moreover, our data supports ruxolitinib as being a potential therapeutic option for patients with this rare novel immune dysregulatory syndrome.

Frequency Spectrum Analysis of Signals Used in Transcorneal Electrical Stimulation

The contribution of this research work focuses on understanding the biological behavior of time-varying electric fields, specifically in the eyeball, by proposing sensitive frequency ranges, specifically for primary open-angle glaucoma POAG and RP retinitis pigmentosa. These ranges were obtained from the analysis of the frequency spectrum of the signals used by other authors in transcorneal electrical stimulation TES therapies. This analysis was performed using an algorithm proposed in this work. The frequency spectra of the signals used in the TES were also compared with the frequency response of the cellular behavior evoked by genestein drug, in order to compare the frequency characteristics of the signals applied in the TES and the biological response of the drug. which causes the same effect in POAG.

G protein estrogen receptor as a potential therapeutic target in Raynaud's phenomenon.

Exaggerated cold-induced vasoconstriction can precipitate a pathogenesis called Raynaud's phenomenon (RP). Interestingly, RP is significantly more prevalent in females than age-matched men, highlighting the potential implication of 17β-estradiol (E2) in the etio-pathogenesis of this disease. Indeed, we have previously reported that E2 stimulates the expression of vascular alpha 2C-adrenoceptors (α2C-AR), the sole mediator of cold-induced constriction of cutaneous arterioles. This induced expression occurs through the cyclic adenosine monophosphate → exchange protein activated by cAMP→ Ras-related protein 1→ c-Jun N-terminal kinase→ activator protein-1 (cAMP/Epac/Rap/JNK/AP-1 pathway). On the basis that estrogen-induced rapid cAMP accumulation and JNK activation occurs so rapidly we hypothesized that a non-classic, plasma membrane estrogen receptor was the mediator. We then showed that an impermeable form of E2, namely E2:BSA, mimics E2 effects suggesting a role for the membranous G-protein coupled estrogen receptor (GPER) in E2-induced α2C-AR expression. Our current working hypothesis and unpublished observations further cement this finding, as G1, a GPER agonist, mimics while G15, a GPER antagonist, abrogates estrogen's effect on the expression of vascular α2C-AR. These, and other observations, highlight the potential of GPER as a tractable target in the management of RP, particularly in pre-menopausal women.

Comparison of the efficacy and safety of oligomeric proanthocyanidins and nifedipine in patients with primary Raynaud's phenomenon: An open-label, randomized, prospective pilot study.

Comparison of the efficacy and safety of oligomeric proanthocyanidins and nifedipine in patients with primary Raynaud's phenomenon: An open-label, randomized, prospective pilot study.

Raynaud's phenomenon associated with calcitonin gene-related peptide receptor antagonists case report.

Calcitonin gene-related peptide (CGRP) is a potent vasodilator that regulates the cerebrovascular and peripheral circulation. A new class of migraine therapies decreases CGRP through various mechanisms. One unknown off-target effect is the impact decreasing CGRP will have on the peripheral circulation. The following cases report new onset Raynaud's phenomenon (RP) following the use of CGRP receptor antagonists (-gepants) for both the acute and preventive treatment of migraine. These cases describe the development of RP in two individuals after using each of the currently available gepant medications. To our knowledge these are the first cases reported of RP associated with the use of gepants. RP has previously been reported in association with monoclonal antibodies to the CGRP ligand and CGRP receptor indicated in the prevention of migraine. One case involved oral CGRP receptor antagonists for acute treatment inducing RP. In this case, rimegepant and ubrogepant used separately for different migraine attacks each led to RP in the digits. The other case involved oral CGRP receptor antagonist, atogepant, used as a preventive treatment and induced RP in the digits. This patient had a prior history of areolar tissue RP while breastfeeding, but never in her fingers. In both cases, the offending medications were discontinued, and the patients reported no further episodes of RP. Two cases are reported of people with migraine with new onset digital RP while taking CGRP receptor antagonists (rimegepant, ubrogepant, atogepant) for acute and preventive treatment.

Cutaneous Features, Autoantibody Profile, and Nailfold Capillaroscopy of Systemic Sclerosis: A Study of 60 Cases.

Systemic sclerosis (SSc) is an autoimmune chronic multisystem disorder with a plethora of cutaneous manifestations. These manifestations often may be the only presenting complaint. Early identification of these help in diagnosing grievous systemic manifestations and their prompt and appropriate treatment. To study the clinical profile of SSc, modified Rodnan's skin scoring (mRSS), nailfold capillaroscopy (NFC) patterns, antibody profile in the western India population, and their association with cutaneous manifestations. Patients of SSc fulfilling the European League Against Rheumatism (EULAR) 2013 classification of SSc criteria, who attended dermatology outpatient department (OPD) between January 2017 and September 2018 were included in the study. The demographic data, cutaneous features, autoantibody profile, mRSS, and NFC pattern were noted Results: A total of 60 patients (57 females and 3 males; mean age years) of SSc were evaluated. Clinical subtypes were 40 diffuse cutaneous SSc and 20 limited cutaneous SSc. The most common presenting symptoms were Raynaud's phenomenon (RP) (95%) and skin tightening (90%). The common cutaneous findings were sclerodactyly (86.7%), stellate scars (78.3%), parrot-beaked nose (76.7%), mask-like facies (75%), microstomia (56.7%), salt and pepper pigmentation (55%), puffy finger (46.7%), telangiectasia (46.7%), digital ulcer (38.3%), fixed flexion deformity (33.3%), and calcinosis cutis (8.33%). Limited cutaneous systemic sclerosis (lcSSc) had mRSS score of 8.3 ± 4.1 and diffuse cutaneous systemic sclerosis (dcSSc) subset had a score of 28 ± 10.4. Antinuclear antibody (ANA), Anti-topoisomerase antibody (ATA), and anti-centromere antibody (ACA) were positive in 59, 49, and 7 patients, respectively. The NFC patterns were early (23.3%), active (45%), and late (18.3%). The sample size of the study was small. We were not able to determine the significance of other less common autoantibodies with scleroderma. The study highlights the importance of identifying early cutaneous findings and the role of a useful diagnostic and prognostic reproducible scoring system (mRSS) and NFC.

A RARE MANIFESTATION OF KIDNEY DISEASE IN COMMON VARIABLE IMMUNODEFICIENCY

<h3>Introduction</h3> Patients with Common Variable Immunodeficiency (CVID) are at risk for developing both infectious and non-infectious complications. An uncommon complication in patients with CVID is kidney disease. <h3>Case Description</h3> A 39 year old male with history of CVID, granulomatous and lymphocytic interstitial lung disease (GLILD), immune thrombocytopenia purpura, splenomegaly, Raynaud's phenomenon and autoimmune thyroiditis was found to have an asymptomatic elevated creatinine. He developed a gradual increase in creatinine starting in 2020 with a peak creatinine of 2.17 and blood urea nitrogen of 30 in 2022. His creatinine and blood urea nitrogen were 0.91 and 18 in 2019. CVID was originally diagnosed in 2016. He was managed on subcutaneous immunoglobulin replacement therapy for several years. He did not have a known family history of chronic kidney disease. Kidney biopsy demonstrated dense lymphocytic infiltration with B and T lymphocytes. He was started on slow prednisone taper, rituximab, and trimethoprim-sulfamethoxazole for <i>Pneumocystis</i> pneumonia prophylaxis. His kidney function improved and has remained stable with a creatinine and blood urea nitrogen of 1.68 and 27, respectively. <h3>Discussion</h3> This case serves as an example of a rare complication in a patient with CVID. The mechanism of kidney disease in CVID is not well known. Previous reported cases of kidney disease in CVID have demonstrated evidence of glomerulonephritis and tubulointerstitial nephritis. This case is also unique in that the patient was treated with rituximab. Further investigation is needed into the appropriate monitoring and treatment options for kidney disease with CVID.

POLYMYALGIA RHEUMATICA AFTER MRNA COVID-19 VACCINATION

<h3>Introduction</h3> Polymyalgia rheumatica (PMR) is an inflammatory disorder characterized by muscle pain and stiffness. We present a 67-year-old man who developed PMR after immunization with the mRNA COVID-19 vaccine. <h3>Case Description</h3> A 67-year-old male with a history of viral pericarditis, non-ischemic cardiomyopathy, Raynaud's phenomenon, and prostate cancer presented for evaluation of acute-onset proximal muscle pain and weakness, extreme fatigue, malaise, and weight loss. Symptoms developed 10 days after the first dose of the mRNA COVID-19 vaccine. No associated fever or skin rashes. No history of natural COVID-19 infection. A workup for malignancy was negative. CRP and ESR were elevated. ANA was positive (1:80, speckled pattern). ENAs were negative. CK and aldolase were normal. He had low IgG at 328 mg/dL with normal IgA and IgM. However, repeat IgG levels a week later were normal (1130 mg/dL), raising the possibility of a laboratory error. Lymphocyte subsets in peripheral blood were normal. IgG titers to the SARS-COV2 spike and nucleocapsid proteins were consistent with COVID-19 immunity from prior immunization. He was treated with low-dose oral prednisone with resolution of his symptoms and has been slowly tapering prednisone as tolerated. <h3>Discussion</h3> This case report raises the possibility that PMR may be triggered by an immune response to the mRNA COVID-19 vaccine in susceptible individuals. However, further studies involving a larger population are required to assess whether this association is causative or rather coincidental.