Article
A new score to predict digital ulcers combining clinical data, imaging and patient history in systemic sclerosis
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Authors
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Stefanie Friedrich
- Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Charité – Universitätsmedizin Berlin, Berlin
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Susanne Lüders
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Gastroenterologie, Infektiologie, Rheumatologie, Berlin
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Gerd-Rüdiger Burmester
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Berlin
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Gabriela Riemekasten
- Universität zu Lübeck, Klinik für Rheumatologie und Klinische Immunologie, Lübeck
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Sarah Ohrndorf
- Charité – Universitätsmedizin Berlin, Medizinische Klinik mit Schwerpunkt Rheumatologie und Klinische Immunologie, Berlin
| Published: | February 5, 2019 |
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Outline
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Background: Ischemic complications such as digital ulcers (DU) are a common complication in systemic sclerosis (SSc) patients. The aim of this study was to combine clinical characteristics and imaging methods to a composite predictive score.
Methods: Seventy-nine SSc patients received clinical examination and their patient history was taken. Furthermore, we performed nailfold capillaroscopy (NC), colour Doppler ultrasonography (CDUS) and fluorescence optical imaging (FOI) of the hands at baseline. Newly developed digital ulcers over a period of approximately 12 months were registered. We used criteria with significant (p<0.5) OR values above 3.5 in regard to the development of these new DU to create the score (CIP-DUS, clinical features, imaging, patient history – digital ulcer score).
Results: Twenty-nine percent of the patients developed new DU during follow-up (48.1% diffuse SSc, 18.4% limited SSc). The following criteria were used: SSc diffuse subtype (OR 4.127, p=0.0087), modified Rodnan skin score > 8 (OR 9.429 [95%CI: 3.0-29.2], p<0.0001), pulmonary arterial hypertension (OR 6.854 [95%CI: 1.6-9.7], p=0.0088), present digital ulcers or pitting scars at baseline (OR 15.71 [95%CI: 3.3-74.3], p<0.0001), history of digital ulcer or pitting scars (OR 36.15 [95%CI: 2.1-626.9], p<0.0001), NC pattern (OR 18.6 [95%CI: 1.1-326.4], p=0.0035), reduced capillary density (n<7/mm) in digit III of the right hand in NC (OR 9.0 [95%CI: 1.1-73.6], p=0.0266), missing initial enhancement in FOI in digit III of the right hand (OR 3.857 [95%CI: 1.2-12.8], p=0.0323), percentage of pathologic (i. e. narrowed or occluded) vessels > 35% in CDUS (OR 4.286 [95%CI: 1.5-12.4], p=0.0099). Criteria with greater OR should impact the score to a higher degree so we appointed three points to dichotomous criteria with OR >10, two points for criteria with OR between 5-10, and one point for criteria with OR <5. Regarding the NC pattern, 3 points were given to patients with late pattern, 2 points for active and 1 point for early pattern.
Best results were found for a cut-off of >10 points with obtained sensitivity levels of 95% and specificity levels of 74% in regard to new DU (AUC=0.8687, p<0.0001). In the absence of CDUS and FOI data, specificity levels dropped slightly to 72% with unchanged sensitivity values of 95%.
Conclusion: A new score was introduced with the aim to predict digital ulcers. If applied correctly and with the new imaging techniques proposed, 95% of patients at risk of digital ulcers throughout 12 months could be identified.
