[Angiogenesis and its association with inflammation and fibrosis in course of the development of scleroderma systematica].

Scleroderma systematica (SDS) is a chronic autoimmune disease characterized by severe fibrosis of the skin and visceral organs. Vascular disorders are an important component of the disease, but the mechanisms of vascular injury and their prevention are unknown. Angiogenesis in SDS is accompanied by the apparent expression of angiogenic factors, such as vascular endothelial growth factor and basal or fibroblast growth factor. Imbalance of these markers with endostatin expression is noted. This disease is characterized by inflammation and the intensity of neoangiogenesis correlates with its activity. The fact that there may be a pathogenic relationship between the processes of angiogenesis and the intensity of further fibrosis is shown. There is a vicious circle of the induction and maintenance of the processes of angiogenesis, inflammation, and fibrosis in SDS.

[Efficacy and safety of sildenafil in patients with systemic scleroderma].

AIM: To retrospectively analyze the efficacy and safety of sildenafil (Sf) in patients with systemic sclerosis (SS). SUBJECTS AND RESULTS: Sf was used in 16 patients (including 14 women) aged 20-66 years (mean 48.6 +/- 14.6 years; median 51.5 years) with SS of a duration of 2 months to 27 years (mean 8.8 +/- 7.3 years; median 6.5 years). The indications for Sf treatment were significant Raynaud's phenomenon (RP) in 3 patients, digital ulcers (DU) and/or necroses (N) in 9, pulmonary hypertension (PH) in 5 (2 patients had PH concurrent with DU/N), and critical ischemia of the left fingers in 1 patient. RP was seen in all the patients and so the effect of Sf on the course of RP was evaluated in the whole patient group. RESULTS: There was a significant decrease in the frequency and intensity of Raynaud's attacks in 11 (73%) of the 15 patients treated with Sf. This effect was obvious just in the first days of Sf treatment and remained stable throughout the treatment. No RP changes were seen in 3 patients. All 7 patients with DUs showed a decrease in their sizes just within the first two weeks of treatment. Complete DU healing was observed within 4-12 weeks of treatment. During a month, the necrotic area reduced and the signs of reparation appeared in 4 of the 6 patients. Pain ceased just within the first 5-7 days of treatment. Sf resulted in a rapid reduction in systolic pulmonary artery pressure (sPAP); in one case the latter diminished from 60 to 40 mm Hg just 90 min after the first intake of Sf 50 mg and remained unchanged during all 6 months during which the female patient was taking the drug. Doppler echocardiography showed that sPAP decreased from 103 to 85 mm Hg in another female taking Sf 100 mg for a month. The two cases showed clinical improvement as alleviated dyspnea and increased physical activity. In another case, Sf was discontinued because of dizziness after its first intake in a dose of 12.5 mg. The initial drug intake of the drug was not followed by adverse reactions in 12 (75%) of the 16 patients. Four patients had Sf-induced complaints, including headache (1), dizziness (2), and more severe angina pectoris (1). In different periods after treatment initiation, four more patients developed complications, such as fatal myocardial infarction after 6-week treatment, atrial fibrillation at 8 weeks, more severe angina at 6 months, and congestive heart failure after 5-year treatment. These complications were observed in patients with severe ECG changes, such as myocardial focal fibrosis or blood supply impairment. CONCLUSION: Sf is an effective drug to treat the manifestations of scleroderma vasculopathy, such as RP, DU/N, and PH. Sf is well tolerated in most cases. The SS patients with pronounced ECG changes have an increased risk of severe cardiac events and they need careful ECG monitoring.

[Pleiotropic effects of statins in systemic sclerosis].

AIM: To study anti-inflammatory and angioprotective properties of statins in patients with systemic sclerosis (SS). MATERIAL AND METHODS: Fifty SS patients enrolled in the trial were divided into two groups: the study group included 30 patients who received standard therapy and atorvastatin in a dose 10-40 mg/day, the control group (n = 20) received standard therapy alone. The blood of the patients was studied with enzyme immunoassay for concentrations of highly sensitive C-reactive protein (hs-CRP), IL-6, VCAM-1, E-selectin, WF antigen, VEGF-A, VEGF-R2. The tests were made before the treatment and after 12 months of the treatment. RESULTS: The levels of hs-CRP, IL-6, VCAM-1, E-selectin, WF antigen, VEGF-A and VEGF-R2 were significantly higher in the study group than in healthy donors. The controls also had elevated levels of the above substances except IL-6 and VEGF-A which elevated but not significantly. A 12-month treatment in the study group resulted in a significant lowering of hs-CRP, IL-6, WF antigen, E-selectin, VEGF-A and VEGF-R2, the number of patients with elevated IL-6, WF antigen, VEGF-R2 also reduced while in the controls the parameters did not change. CONCLUSION: Atorvastatin has anti-inflammatory and angioprotective effects in SS patients.

[Significance of bone marrow endothelial progenitor cells in disturbance of angiogenesis and endothelial dysfunction in systemic scleroderma].

The study is aimed to investigate the process of endothelial repair related to endothelial progenitor cells (EPC) in systemic sclerosis (SS), and analyze the role of EPC abnormalities in endothelial dysfunction and impaired angiogenesis. Correlation between EPC circulating levels, measured by flowcytometry, and peripheral vascular manifestations, cardiac involvement, carotid artery disease, Framingham risk factor score, endothelial function and morphological signs of microangiopathy is explored. Our data demonstrate, that EPC reduction with disease progression is closely linked with endothelial dysfunction and destructive microangiopathy, and significantly contribute into development of severe cardiac disease and pulmonary hypertension in SS patients.

[Clinical associations of C-reactive protein in systemic sclerosis].

AIM: To evaluate incidence of C-reactive protein (CRP) rise and CRP associations with clinical manifestations in systemic sclerosis (SS). MATERIAL AND METHODS: CRP concentrations in blood serum were estimated with solid phase enzyme immunoassay in 21 SS patients (8 patients with diffuse SS--dSS and 13 patients with limited SS--lSS). Two patients with ISS had documented rheumatoid arthritis (RA)--SS/RA. Forty two healthy donors with normal levels of CRP served control. RESULTS: CRP was elevated in 10 (48%) of 21 SS patients. Mean CRP content was 9.87 +/- 7.73 mg/l (about 3 times higher than in the control group, p < 0.0001) in 20 eligible patients. A mean CRP level did not differ between ISS and dSS patients. RA patients had higher levels of CRP (p = 0.001). CRP was elevated in 4 of 5 (80%) patients with digital ulcers and only in 5 (27%) of 15 patients without ulcers, but the difference was insignificant as well as those in mean CRP in these subgroups. Content of von Willebrand factor antigen (Ag:vW) was high in 7 (33%) patients (mean 1.70 +/- 0.84 IU/ml) this being significantly higher than in the control group (p < 0.0001). CPR concentration closely correlated with that of Ag:vW (r = 0.52; p = 0.017). Close association was found between CRP level and ESR (r = 0.75; p < 0.001) and titer of antinuclear factor (r = 0.52; p = 0.035). CONCLUSION: A moderate rise of CRP level in about 50% cases of SS is associated with arthritis and cutaneous ulcers. A positive correlation between CRP content and Ag:vW in blood suggests that CPB concentrations may reflect severity of vascular damage in SS.

[Classification of microangiopathy in systemic sclerosis].

AIM: To classify main types of morphological changes of nailfold capillaries in systemic sclerosis (SSc). MATERIAL AND METHODS: Nailfold videocapillaroscopy (NCS) was performed in 103 patients with SSc (34 patients with dSSc and 69 patients with ISSc) with a median age of 47.9 +/- 13.3 years and mean disease duration of 8.1 +/- 7.1 years. The control group consisted of 35 healthy persons. RESULTS: On the basis of a quantitative estimation of changes the main capillaroscopic patterns of structural changes of capillaries in SSc were distinguished. The first (early) type is characterized by changes mainly of sizes of capillaries and a rather moderate decrease of their amount. In the second (transitive) type simultaneously with change of the sizes of capillaries an appreciable decrease of the amount of capillaries with formation of avascular sites is observed. The third (late) type of changes is characterized by marked reduction of capillaries and plenty of avascular sites in the absence or presence of few dilated capillaries. NCS enables to reveal destruction and new growth of capillaries. The statistical analysis has shown authentic distinctions of NCS parameters between main types of changes and close association of these types with activity of the disease. CONCLUSION: Definition of a type of capillaroscopic changes can serve a reliable and objective criterion of a stage and activity of microangiopathy in SSc which reflects duration of illness as a whole.

[Level of soluble tumor necrosis factor receptor type I in patients with systemic scleroderma]. / Uroven' rastvorimogo retseptora I tipa faktora nekroza opukholi u bol'nykh sistemnoi sklerodermiei.

AIM: To study content and clinical correlations of sTNF-RI in patients with systemic sclerosis (SS). MATERIAL AND METHODS: Thirty nine SS patients were examined with enzyme immunoassay for serum levels of sTNF-RI and soluble adhesion molecules (sSAM) sVSAM-1, sISAM-1 and sR-selectine using R&D System kits (USA). The control group consisted of 14 healthy subjects (donors). Content of sTNF-RI and sSAM was considered as elevated if it exceeded relevant mean values by 1SD. RESULTS: sTNF-RI content was significantly higher in the patients than in the controls (p = 0.0001) and was similar in patients with diffuse and limited forms of the disease. A rise in sTNF-RI correlated with a rise in pulmonary artery pressure. In patients with pulmonary hypertension or restrictive pulmonary affection sTNF-RI was higher than in patients free of pulmonary hypertension or impaired external respiration function. A marked correlation was found between sTNF-RI and sVSAM-1. Patients with high CRP had significantly higher sTNF-RI level than patients with normal CRP. CONCLUSION: SS is characterized by elevated content of sTNF-RI. This content may serve a diagnostic marker of the disease progression.

[Morphological characteristics of sclerodermic angiopathy]. / Morfologicheskaia kharakteristika sklerodermicheskoi angiopatii.

Capillaroscopic study of the nail bed of patients with scleroderma systematica (SS) detects avascular regions and neoangiogenesis signs, but the data on the morphological substrate of these changes are lacking. Positive correlation is established between the degree of inflammation and fibroblast number in the skin biopsies on the one hand and expression of the avascular foci, their total surface and sclerodermic processes activity, on the other. Vascular lesions in SS manifested with sclerodermic vasculopathy which in some patients is comorbid with vasculitis of microcirculatory vessels. A wide spectrum of morphological vascular lesions reflects clinical heterogeneity of SS. Vascular lesions is an obligatory component, are manifest at early stages of SS and their transformation reflects the disease evolution.

[Clinical value of soluble adhesion molecules in systemic scleroderma]. / Klinicheskoe znachenie rastvorimykh molekul adgezii pri sistemnoi sklerodermii.

The aim of the trial was to study clinical significance of estimation of cell adhesion soluble molecules (CASM) in scleroderma systematica (SS). Quantitation of CASM VCAM-1, ICAM-1 and R-selectin was made with enzyme-immunoassay (R&D System kits, USA) in 38 patients with SS (11 with limited SS and 27 with diffuse SS). The levels of VCAM-1, ICAM-1 and R-selectin was elevated in 30 (79%), 17 (45%) and 20 (53%) patients, respectively. Mean values of VCAM-1 and ICAM-1 in patients were significantly higher than in healthy donors. R-selectin was also higher but insignificantly. A mean CASM level and a relative number of patients with elevated count of CASM in patients with diffuse and limited forms of SS did not differ. In 15 patients with active (progressive) course of the disease the level of VCAM-1 was significantly higher than in patients with chronic (non-progressive) course of SS while concentrations of ICAM-1 and R-selectine were almost the same. Thus, SS patients have elevated levels of CASM. CASM VCAM-1 concentration is the most sensitive marker of SS activity compared to other CASM.

[Vascular pathology in systemic scleroderma]. / Patologiia sosudov pri sistemnoi sklerodermii.

The mechanisms of vascular lesions in systemic scleroderma (SSC) are still little studied with the current comprehensive investigations being focused on this issue. The results of a study dealing with the structural-and-morphological and molecular reasons of sclerodermic micro-angiopathy as compared with the variations and pattern of the clinical disease course are summarized in the article. The structural capillary changes were evaluated on the basis of the results of a wide-field video-capillaroscopy of the nail bed (CNB). The level of soluble adhesion molecules VCAN-1, ICAM-1 and P-selectine determined by the quantitative immune-enzyme assay described the vascular endothelium condition. Morphological examinations of dermal samplings included an identification of the lymphocytic composition of infiltrates by applying the mononuclear antibodies to markers T (CD3, CD4, CD8) and B (CD20) of lymphocytes and detection of the endothelial activation by applying the mononuclear antibodies to intercellular adhesion-1 molecule (ICAM-1). The conducted investigations revealed the structural capillary changes in all SSC patients; the nature of such changes is closely related with a clinical variation and course of the disease. The morphological signs of micro-angiopathy were detected in 98% of patients including at the early disease stage. A more pronounced perivascular infiltration with predominance of CD4+ T-lymphocytes was observed and expression of ICAM-1 to the endothelial cells was registered more often in an active disease course. Higher levels of VCAM-1, ICAM-1 and P-selective in blood were found in 80%, 45% and 48% of patients, respectively. Correlations of VCAM-1 with an activity and a progressing disease course were established. Therefore, the serological and morphological signs of vascular lesions reflect an intensity degree of sclerodermic micro-angiopathy and correlate with an SSC clinical course.

Diagnosis of occlusive lesions of upper extremity arteries in patients with thromboangiitis obliterans.

The study accrued 84 patients suffering from thromboangiitis obliterans (TO) examined and treated at the A.V. Vishnevsky Institute of Surgery, RAMS, over the period 1988 to 2002. Based on the complaints on the part of the upper extremities the patients were distributed into four groups. Sixteen (19.1%) TO patients did not make any complaints on the part of the arms (degree I ischemia). Thirty-eight (45.2%) patients complained of numbness and paresthesia, chiefly of the tips of the fingers on both hands (degree II ischemia). Six (7.1%) persons complained of pains in the hands at physical exercise (decree III ischemia). Ulcers and necroses of the fingers were present in 24 (28.6%) patients (degree IV ischemia). The diagnostic procedures for arterial lesion of the upper extremities included laboratory investigations, duplex scanning of the great arteries, of the arteries of the hands, fingers and nail matrix, wide-field capillaroscopy, oxygen tension measurements, and angiography as well. Comparison of the clinical manifestations of arterial lesion of the upper extremities in TO patients to the data supplied by different research methods has revealed a direct correlation between the degree of ischemia and the pathomorphological as well as functional changes which increased as the ischemic syndrome was aggravated. As a result of the present work, there have been studied and systematized the criteria for the diagnosis of the degree of arterial lesion of the upper extremities in TO patients, based on the data, supplied by duplex scanning, capillaroscopy, measurements of transcutaneous oxygen tension and angiography. In addition, there has been studied the role of the humoral component of immunity in the delineation of inflammatory activity in patients with TO.

[Tumor necrosis factor alpha in systemic scleroderma]. / Faktor nekroza opukholi-alpha pri sistemnoi sklerodermii.

The authors present the review of the literature on the role of tumor necrosis factor alpha (TNF alpha) in scleroderma systematica (SS). It is shown that TNF alpha participates in activation of vascular endothelium, regulation of immune response and metabolism of the connective tissue by modulation of fibroblastic function. SS patients exhibit a systemic and local rise of TNF alpha content. This rise contributes to SS progression, development of fibrosing alveolitis and skin fibrous alterations in Raynaud's syndrome.

[Alterations of rheological properties of blood in systemic sclerodermia]. / Narusheniia reologicheskikh svoistv krovi pri sistemnoi sklerodermii.

AIM: To study hemorheological status in systemic sclerosis (SS) patients. MATERIAL AND METHODS: Macro- and microrheology of blood were investigated in 70 SS patients. The rate of spontaneous aggregation of red blood cells [T1(s)], durability of the largest units [Ia2.5(%)], general hydrodynamic durability of units [beta(s-1)], limit of fluidity [tau 0 (mPa)], Casson viscosity K (mPa/s) were determined. RESULTS: The total severity of hemorheological disturbances was 1.90 +/- 0.07 with T1 = 4.98 +/- 1.52s, beta = 62.76 +/- 19.32s, Ia 2.5 = -0.78 +/- 12.83%, tau 0 = 7.00 +/- 0.45 mPa. The Casson viscosity did not differ from normal levels. Plasma viscosity was 1.71 +/- 0.18 rel units, viscosity of sera 1.55 +/- 0.14 rel.units. The severity of hemorheological disturbances did not differ in cute and chronic courses but the parameter beta (72.0 +/- 4.5) was significantly higher (p < 0.05) in the acute course. The severity of hemorheological disturbances was highest in SS patients with cardiac disease (p < 0.05) and in 10 year SS duration. CONCLUSION: The course of SS is complicated by progressive hyperaggregation syndrome promoting development of visceral pathology. Active correction of hemorheology is pathogenetically validated in SS.

[Autoantibodies to vasoactive peptides and angiotensin converting enzyme in patients with systemic diseases of the connective tissue]. / Autoantitela k vazoaktivnym peptidam in angiotenzinprevrashchaiushchemu fermentu u bol'nykh s sistemnymi zabolevaniiami soedinitel'noi tkani.

AIM: To estimate the level of natural autoantibodies (NAAb) to angiotensin-converting enzyme (ACE) and endogenic mediators affecting vascular tone (bradykinin--BK, angiotensin II--AII, vasopressin--VP) as well as the activity of serum ACE in patients with systemic diseases of the connective tissue. MATERIAL AND METHODS: Levels of NAAb were measured by enzyme immunoassay in sera from 30 patients with SLE, 19 patients with rheumatoid arthritis (RA) and 36 patients with scleroderma systematica (SS). Serum from donors served control. IgM NAAb to ACE were measured by a new technique. Serum ACE activity was determined by the initial velocity of hydrolysis reaction using spectrofluometry. RESULTS: IgM NAAb were detected in the sera of both patients and donors. SS patients had the level of NAAb to ACE in diffuse form significantly higher than in limited (p < 0.05). In SLE and SS patients ACE activity was significantly lower (p < 0.05) than in healthy subjects and RA patients. Levels of NAAb to BK was significantly elevated (p < 0.01) in patients with SLE and RA vs donors while to AII in SS patients it was lowered (p < 0.001). Patients with diffuse SS had NAAb to BK higher than patients with SS limited form (p < 0.01). In SLE the lowest levels of NAAb to all the mediators studied were observed in patients with nephritis, for NAAb to VP the differences were significant (p < 0.05). In patients with urinary syndrome concentration of NAAb to BK was significantly higher (p < 0.01), differences between their levels in patients with nephritis and urinary syndrome were also significant (p < 0.05). CONCLUSION: Further studies are needed for specification of physiological or pathological role of NAAb to endogenic mediators.

[Effect of vazaprostan on microcirculation in patients with scleroderma systematic]. / Vliianie vazaprostana na mikrotsirkuliatsiiu u bol'nykh sistemnoi sklerodermiei.

AIM: To investigate the effect of vazaprostan (alprostadil) on skin blood flow in patients with sclerodermia systematica (SS). MATERIAL AND METHODS: A total of 51 patients with SS aged 33-70 years were included in the study. 33 of them received a 3-hour infusion of vazaprostan at the standard dose for 20 consecutive days. The rest 18 patients received low molecular dextran solution. Before and at the end of the treatment digital skin microcirculation was measured with a laser Doppler flowmeter. The laser probe was attached to the distal pad of the ring finger on the left hand. Baseline blood flow and vascular reactivity in the tests with sympathetic stimulation, local heating and during orthostasis were evaluated. RESULTS: Baseline blood flow and vascular response to functional tests were significantly reduced in all the patients. At the end of the treatment the flow increased only in patients treated with vazaprostan. Vascular reactivity was not changed after the treatment in both groups of patients. CONCLUSION: Vazaprostan increases baseline blood flow and contributes to the improvement of microcirculation in patients with SS.

Investigation of sialic acids and sialyltransferase activity in blood of patients with systemic scleroderma.

Systemic scleroderma (SSd) is a connective tissue disorder accompanied by generalized fibrosis. A disturbance of the synthesis and production of matrix glycoproteins, such as collagens, fibronectin, and proteoglycans, by connective tissue cells is typical for this disease. We previously demonstrated a decrease in the ganglioside content of cultured skin fibroblasts from patients with SSd. In this work the contents of sialoglycoproteins and sialoglycolipids in blood sera of patients with SSd were estimated. Simultaneously, the level of asialofetuin-sialyltransferase activity in blood plasma of three groups of patients--those with SSd, Raynaud's phenomenon, and with localized scleroderma--was investigated. CMP-5-acetamido-9-deoxy-9-fluoresceinylthioureidoneuraminic acid was used as a substrate for the enzyme assay. It was shown that the concentration of total sialic acid was increased and the concentration of lipid-bound sialic acid was slightly decreased in the blood sera of patients with SSd. A correlation between the lipid-bound sialic acid level and the severity of disease was observed; there was no correlation between severity of disease and total sialic acid. Sialyltransferase assay showed a decrease in the activity level in all three groups of patients. The greatest decrease (2-fold) of this activity was observed in patients with Raynaud's phenomenon. Our data suggest that in SSd and similar diseases the process of glycoconjugate sialylation is disturbed. These changes may considerably affect the mechanisms of regulation of metabolism and cellular interactions.