[6] and Ingegnoli et al. 1 for examples). 2015;34(2):27984. This pattern is also found in other connective tissue diseases, such as dermatomyositis and mixed connective tissue disease, and less frequently in systemic lupus erythematosus and undifferentiated connective tissue disease. Semin Arthritis Rheum. Int J Rheum Dis. Ingegnoli F, Gualtierotti R, Lubatti C, Bertolazzi C, Gutierrez M, Boracchi P, et al. Capillaroscopy in vasculitis. Adv Rheumatol 59, 5 (2019). Rev Bras Reumatol. There are several reasons why quantitative nailfold capillaroscopy analysis, for which videocapillaroscopy paved the way, is important, including the following. SLE is a multisystem, chronic inflammatory autoimmune disease that might be accompanied by microvascular damage. Silva I, Loureiro T, Teixeira A, Almeida I, Mansilha A, Vasconcelos C, et al. However, quantitative analysis complements and augments qualitative analysis, and is the way forwards to improve diagnostic accuracy and for capillaroscopy to become a long-awaited, non-invasive biomarker of disease progression and of treatment response. , Garg MK Article An evaluation of image enhancement techniques for capillary imaging. Doshi NP Sulli A 2004;18(1):628. Primary RP manifests usually in young individuals (14years of age, on average) and presents as symmetric and milder episodes, without necrosis, ulceration, or gangrene, in addition to the absence of any definite cause [1, 12]. Tiev KP, Cabane J. Digestive tract involvement in systemic sclerosis. 2001;30(6):397402. Over the past 20years various investigators have reported studies aiming to automate or semi-automate the analysis of nailfold capillaroscopic images in patients with different diseases including diabetes, hypertension and SSc. Microvasc Res. In SSc and scleroderma spectrum disorders, microhemorrhages usually exhibit a diffuse distribution and are close to dilated capillaries, which tend to become broken more easily. J Rheumatol. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Different investigators have measured this differently, and the literature refers to arterial, apical, and venous. Karbalaie A Finally, a study of adults with a history of isolated RP demonstrated, by means of a prognostic model, a correlation between abnormalities on NFC (microhemorrhages, giant loops, and number of capillaries) and progression into SSc spectrum disorders (B) [19]. Kayser C, Sekiyama JY, Prspero LC, Camargo CZ, Andrade LE. , Murray A Google Scholar. Berks DG The findings on NFC have poor specificity for early diagnosis and prognostic assessment, as no specific pattern has been identified for this disease (B) [77, 78]. Arch Intern Med. In a multicenter study, CSURI exhibited 92.9 and 81.4% sensitivity and specificity, respectively, for the development of DU within three months of videocapillaroscopy, with an area under the receiver operating characteristic (ROC) curve of 0.884 (B) [104]. Linnemann B, Erbe M. Raynauds phenomenon - assessment and differential diagnoses. , Taylor C Sebastiani M, Manfredi A, Colaci M, Giuggioli D, La Sala R, Elkhaldi N, Antonelli A, Ferri C. Correlation of a quantitative videocapillaroscopic score with the development of digital skin ulcers in scleroderma patients. All these techniques are examiner-dependent, and they do not point, alone, to the diagnosis of disease. 4C), thus creating the ability to track change over time [60, 61]. Only the morphological aspects of the distal row capillaries are evaluated using NFC. Wildt M, Wuttge DM, Hesselstrand R, Scheja A. , Secchi ME Measurement of red blood cell velocity is described briefly. Nailfold capillaroscopy plays a relevant role in the diagnosis of systemic sclerosis, as microvascular damage is an early marker of disease. Some capillaroscopy studies state that only clearly seen capillaries or images were included, and so this will influence results. , Moore T PPV and NPV for SSc was 68 and 94%, respectively (B) [2]. [42, 43] included capillaries at different levels in the distal row, i.e. Clin Rev Allergy Immunol. , Lubatti C Luggen M, Belhorn L, Evans T, Fitzgerald O, Spencer-Green G. The evolution of Raynaud's phenomenon: a longterm prospective study. The sensitivity and specificity for the diagnosis of SSc was 89.4 and 80%, respectively, when the SD pattern was found on NFC. , Boss C Capillaroscopy evaluation of individuals with RP might contribute to the identification of an underlying disease, as well as to the assessment of disease progression [2,3,4,5]. Globally, this is not currently happening. , The TH. a giant capillary or marked avascularity [34]. This has implications for quantitative analysis including capillary density. Office capillaroscopy in systemic sclerosis. 2010;57(2):11920. Isolated microhemorrhages might occur in healthy individuals due to microtrauma [45]. These are easily visible dark areas on the nailfold capillary bed, and they occur due to rupture of the capillary wall. Which capillaries should be included in the distal row? The capillary has more than one apex, although this can be difficult to gauge if the feeder arteriole is not well seen. Bhakuni DS 2015;25(5):44451. 1995;22(12):222632. Silva I, Almeida C, Teixeira A, Oliveira J, Vasconcelos C. Impaired angiogenesis as a feature of digital ulcers in systemic sclerosis. Bukhari M Barth et al. Cutolo M, Sulli A, Pizzorni C, Accardo S. Nailfold videocapillaroscopy assessment of microvascular damage in systemic sclerosis. 2012;30(2 Suppl 71):S504. Skin capillary abnormalities as indicators of organ involvement in scleroderma (systemic sclerosis), Raynaud's syndrome and dermatomyositis. Videocapillaroscopy allows the storage of images and uses magnification up to 600 times, thus enabling exact measurements of individual capillaries using specific softwares [38]. An Med Interna. Another observational study conducted with patients with isolated RP and SSc analyzed the association between antinuclear antibodies, capillaroscopic patterns, and clinical findings. Although gross abnormalities may be identifiable in low-quality images, high-quality images are fundamental for meaningful quantitative analysis. , Vanhaecke A And (between-finger heterogeneity), appearances in the left index finger are very different from in the right ring finger. The hands to be examined should be clean, and the examination performed after acclimatization at a standard temperature [7]. Trombetta AC Tolosa-Vilella C, Morera-Morales ML, Simen-Aznar CP, Mar-Alfonso B, Colunga-Arguelles D, Callejas Rubio JL, et al. A prospective study found that 20% of patients initially diagnosed with primary RP exhibited a transition to suspected or definite secondary RP during a 10-year follow-up (B) [16]. Examination is done with a dermatoscope and the practice of doing this is simply referred to as nail fold capillaroscopy. Normal Nailfold Capillary Arrangement (by dermoscopy) This photo above shows the normal arrangement of these nail fold capillaries. Springer Nature. Angiology. nailfold Therefore, optimization of diagnosis in early stages of disease, including identification of milder structural abnormalities, might provide an opportunity to prevent the progression of systemic sclerosis. SSc is an autoimmune disease of unknown origin characterized by progressive vascular involvement, with subsequent chronic damage of several organs and systems, such as the gastrointestinal tract, lungs, heart, kidneys, and skin [20,21,22]. In this review article we shall first outline the rationale for quantitative analysis and then discuss, in turn, image acquisition, the key features (and challenges) of image interpretation and of monitoring disease over time, semi-quantitative analysis, then automated and semi-automated analysis. Nailfold capillary density is associated with the presence and severity of pulmonary arterial hypertension in systemic sclerosis. It is unlikely that more than a minority of general rheumatologists are ever likely to have access to videocapillaroscopy. , Taylor CJ PubMed Central , Muret P Nat Rev Rheumatol. Figure parts (A), (B) and (C) reproduced with permission from the relevant publishers. The development of high magnification nailfold videocapillaroscopy heralded a new surge of interest in capillaroscopy from the 1990s [6, 11]. Its major role in rheumatology is to facilitate the differential diagnosis of Raynauds phenomenon. 1992;10(5):4858. 1980;23(2):1839. Evidence was collected according to an evidence-based medicine approach, which integrates clinical experience with the ability to critically analyze and rationally apply scientific information, thus improving the quality of medical care. , Wuttge DM Diagnostic significance of nailfold capillary patterns in patients with Raynaud's phenomenon. , Sanchez-Camperos E Candela M, Pansoni A, De Carolis ST, Pomponio G, Corvetta A, Gabrielli A, Danieli G. Nailfold capillary microscopy in patients with antiphospholipid syndrome. et al. Clin Exp Rheumatol. With NVC, images can be assessed qualitatively or (semi-) quantitatively. One score, the Capillaroscopic Skin Ulcer Risk Index (CSURI) is calculated by means of the equation DxM/N2, in which D is the maximum diameter of giant capillaries, M the number of giant capillaries, and N the number of capillaries in the distal row (B) [103,104,105]. Some authors quantify the extension of devascularization by means of a semiquantitative scale ranging from 0 to 3: 0absence of avascular areas; 1discrete devascularization (one or two avascular areas); 2moderate devascularization (more than two avascular areas); 3extensive and confluent devascularization areas (D) [56], (B) [39, 45]. Rheumatology (Oxford). Clinical applicability of quantitative nailfold capillaroscopy in differential diagnosis of connective tissue diseases with Raynaud's phenomenon. Mugii N, Hasegawa M, Matsushita T, Hamaguchi Y, Horie S, Yahata T, et al. , Roussin A 2013;9(4):2458. Markov chain based edge detection algorithm for evaluation of capillary microscopic images. Progress has been made in standardizing the terminology/reporting of capillaroscopic analysis (as well as image acquisition and interpretation) as recently described by Smith et al. , Abtahi F Hirschl M, Hirschl K, Lenz M, Katzenschlager R, Hutter HP, Kundi M. Transition from primary Raynaud's phenomenon to secondary Raynaud's phenomenon identified by diagnosis of an associated disease: results of ten years of prospective surveillance. 2013;90:905. Nailfold Capillaroscopy in rheumatic diseases: which parameters should be evaluated? 3, and so selecting only (say) a 1mm section may be unrepresentative. Quantitative nailfold capillaroscopy findings in a population with connective tissue disease and in normal healthy controls. Prognostic model based on nailfold capillaroscopy for identifying Raynaud's phenomenon patients at high risk for the development of a scleroderma spectrum disorder: PRINCE (prognostic index for nailfold capillaroscopic examination). A large number of studies have focused on NC pattern description, classification, and scoring system validation, but minimal information has been published on the [7]. Nailfold capillaroscopy : a comprehensive review on Dinsdale G Population-based studies, which included several ethnic groups, estimated its prevalence as 3 to 20% as a function of the geographical location and local climate [7,8,9,10,11]. 2004;44(1):1930. Cutolo M, Sulli A, Smith V. Assessing microvascular changes in systemic sclerosis diagnosis and management. It is outwith the scope of this review to discuss in detail the different microscope systems available [6, 23]. Among them, NFC exhibits considerable predictive value regarding the development of autoimmune rheumatic disease and, thus, it should be performed in all individuals with Raynauds phenomenon. Avascular areas may be variably defined and can be focal or diffuse. Digital ulcers in scleroderma: staging, characteristics and sub-setting through observation of 1614 digital lesions. PubMed 1990;20(1):2131. The present guidelines followed the criteria developed for systematic reviews. J Evid Based Med. Nailfold capillaroscopy has the advantage of being a non-invasive technique that provides a window into the digital microcirculation. Some authors have suggested quantitative risk scores for prognostic purposes of DU development (A) [102], (B) [103]. Karbalaie et al. Nailfold capillary microscopy can suggest pulmonary disease activity in systemic sclerosis. Van den Hombergh WM In addition to the aforementioned morphological abnormalities on NFC, the SD pattern includes histopathological and functional changes, such as endothelial edema, inflammatory infiltrates, and slower blood flow [49, 62]. Image analysis of nailfold capillary patterns from video sequences. issues in assessing nailfold capillaroscopic images: a Arthritis Care Res (Hoboken). 2008;60(3):199205. WebAbstract. Automated analysis should circumvent these problems. Different observers vary in their opinions of evaluability, and this depends also on the nailfold capillary parameter being evaluated [17]. Using green light illumination provides high contrast images of the blood vessels and may be preferable to white light [26]. Raynaud's phenomenon and the role of capillaroscopy. Capillaroscopic parameters have already been proposed as primary outcome measures in clinical trials [18], but for these to be meaningful they must be reliable. For example, when calculating the Capillaroscopic Skin Ulcer Index (CSURI), which includes density, Sebastiani et al. 1996;55(8):50712. (B) The full composite frame (red box shows location of featured capillary). A retrospective study was conducted with 67 patients to analyze the sensitivity, specificity, positive (PPV), and negative (NPV) predictive value of capillaroscopy for the diagnosis of connective tissue diseases (B) [2]. Eight fingers (thumbs excluded) were examined in each patient. , Hasegawa M Therefore, NFC might be used for the assessment of disease severity and to predict the occurrence of systemic complications among patients with SSc. NailFold 2010;6(10):57887. We mimicked the image interpretation strategies of SSc experts, using deep learning networks to detect each capillary in the distal row of vessels and make morphological measurements. [5], have been used to predict development of a SSc-spectrum disorder in patients with RP [40, 41, 57] and digital trophic lesions in patients with SSc [58]. 2006;25(2):1538. ; EULAR Study Group on Microcirculation in RheumaticDiseases. Bissell LA, Abignano G, Emery P, Del Galdo F, Buch MH. Arch Dermatol. Nailfold capillaroscopy is increasingly being used among rheumatologists. , Melsens K Barth Z , Armstong SK. , Colaci M Barth Z Capillaroscopy may be performed with lenses with low (20) and with high magnification (200 up to 600). Reumatologia. PubMed Typical microangiopathy in SSc includes dilated loops, giant loops, a reduced number of loops and avascular areas, microhemorrhages, neoangiogenesis and disorganization of the nailfold capillary architecture, which together are known as the SD (scleroderma) pattern (B) [24], (C) [25]. Dermatoscopy is widely used in dermatology to investigate skin lesions, but the images have less magnification and poorer resolution. An EULAR study group pilot study on reliability of simple capillaroscopic definitions to describe capillary morphology in rheumatic diseases. , Herrick AL. , Seshadri R 2006;54(6):197481. , Dinsdale G First, the wide spectrum of nailfold capillary normality [1416] often makes it difficult to separate out normal and abnormal (Fig. A six-year follow-up study. Several studies have found that the presence of abnormalities in the nailfold microcirculation on NFC is an independent risk factor for the development of autoimmune rheumatic disease (B) [14, 15]. , Moore T. Among this latter group of patients, the capillaroscopic abnormalities corresponded to the active pattern (giant capillaries, microhemorrhages, and discrete avascular areas) (B) [89]. The structural measurements are as follows: capillary density, mean capillary width (the mean of the individual capillary widths), maximum capillary width (the largest of the individual capillary widths), shape score (the mean vessel tortuosity) and derangement score (the angular dispersion of the capillaries). Relationship between nailfold capillary abnormalities and organ involvement in systemic sclerosis. 2000;27(3):797800. 2015;49(2):24052. For example Maricq's size scale was I (same range as healthy subjects), II (definitely enlarged) and III (extremely enlarged) with avascularity rated as none, slight', moderate or extensive [9]. Technique and rating scale for abnormalities seen in scleroderma and related disorders, Comparison of quantitative and semiquantitative estimates of nailfold capillary abnormalities in scleroderma spectrum disorders, How to perform and interpret capillaroscopy, Computerised nailfold video capillaroscopy a new tool for assessment of Raynaud's phenomenon, Quantitative alterations of capillary diameter have a predictive value for development of the capillaroscopic systemic sclerosis pattern, Panoramic nailfold capillaroscopy: a new reading method and normal range, Quantitative nailfold capillaroscopy findings in a population with connective tissue disease and in normal healthy controls, Nailfold capillary patterns in healthy subjects: a real issue in capillaroscopy, Intra- and inter-observer reliability of nailfold videocapillaroscopy A possible outcome measure for systemic sclerosis-related microangiopathy, Hit hard and early: analysing the effects of high-dose methylprednisolone on nailfold capillary changes and biomarkers in very early systemic sclerosis: study protocol for a 12-week randomised controlled trial, A multicentre study on the reliability of qualitative and quantitative nailfold videocapillaroscopy assessment, Quantitative videocapillaroscopy correlates with functional respiratory parameters: a clue for vasculopathy as a pathogenic mechanism for lung injury in systemic sclerosis, Association between nailfold capillary density and pulmonary and cardiac involvement in medium to longstanding juvenile dermatomyositis, Does nailfold capillaroscopy help predict future outcomes in systemic sclerosis? It is time to cut the Gordian knot and develop a prevention or rescue strategy, Preliminary criteria for the very early diagnosis of systemic sclerosis: results of Fa Delphi Consensus Study from EULAR Scleroderma Trials and Research Group, Nailfold capillaroscopy by digital microscope in an Indian population with systemic sclerosis, A study comparing videocapillaroscopy and dermoscopy in the assessment of nailfold capillaries in patients with systemic sclerosis-spectrum disorders, The assessment of nailfold capillaries: comparison of dermoscopy and nailfold videocapillaroscopy (letter), Consensus-based evaluation of dermatoscopy versus nailfold videocapillaroscopy in Raynaud's phenomenon linking USA and Europe: a European League against Rheumatism study group on microcirculation in rheumatic diseases project, The Author(s) 2021. Nailfold images from a patient presenting with Raynaud's phenomenon. Nailfold capillary patterns in healthy subjects: a real issue in capillaroscopy. Future studies of associates, and also studies examining the degree of nailfold capillary abnormality as a predictor of (for example) digital ulceration (reviewed in [22]) would benefit from reliable and fast quantitative assessments. These images are stitched together automatically to generate a high-quality static whole-nailfold capillary image mosaic, from which fully automated measurements of capillary structure and (as described in the next section) flow are derived (Fig. Kim SH, Kim HO, Jeong YG, Lee SY, Yoo WH, Choi TH, Lee SI. This definition/algorithm (which had high reliability when raters were asked to grade 1mm images [34]) is likely to be specific but insensitive, given that other investigators have reported densities higher than 3/mm in most patients with SSc [4, 3537] and patients with an early scleroderma pattern are generally considered as having densities higher than 7/mm [6]. 2011;11(1):6873. For example (within-finger heterogeneity) in the left little finger, capillaries on the left side of the image are within normal limits whereas those in the middle are very abnormal. Levels of Evidence and Grades of Recommendations - Oxford Centre for Evidence Based Medicine. quantitative) rating of abnormality (on a continuous scale) is required. Wells G, Shea B, OConnell D, Robertson J, Peterson J, Welch V, et al. For this to be achievable a numerical (i.e. NFC abnormalities are more frequent among patients with SLE and RP (B) [35]. Clin Dermatol. The funding body had no role in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. Clin Rheumatol. , Scheja A. Berks M Angiology. Smith V USB microscopy, dermoscopy) are likely to increase in popularity: a survey of 42 United States SSc specialists suggested these low cost systems are favoured by US clinicans [25]. Br J Rheumatol. In: Taylor C An abnormality score was obtained for each finger by summing the mean values of three of the parameters (loss of capillaries, disorganization, ramifications), and a patient microangiopathy evolution score (score 09) score was obtained by taking the mean of this score over the eight fingers. 1986;13(3):55663. It can sometimes be difficult to decide whether this is true avascularity or due to difficulties in visualising (sections of) the distal row. Geographic variation in the prevalence of Raynaud's phenomenon: a 5 region comparison. The main abnormal findings are increased capillary tortuosity, which occurs in more than 40% of patients, and an increased capillary length. Maverakis E, Patel F, Kronenberg DG, Chung L, Fiorentino D, Allanore Y, et al. Dr. Herrick explains, At the nailfold, capillaries run parallel, rather than perpendicular, to the skin surface, and they can, therefore, be visualized noninvasively when magnified. , Trombetta AC et al. 2008;27(6):7836. , Freyschuss A. Martina B If there are multiple apical loops fed by a single arteriole (which might be difficult to see) is this counted as one capillary, or as more? Clin Rheum Dis. Maricq HR, Maize JC. 2016;17(1):342. From a clinical perspective, increased uptake of nailfold capillaroscopy by general rheumatologists could be achieved via low-cost hand-held devices with cloud-based automated analysis. Your privacy choices/Manage cookies we use in the preference centre. et al. et al. Part of 2007;26(8):126874. ; EUSTAR Group. Increased RBC velocity has been reported in response to vasoactive treatment in other conditions [86, 87]. Ingegnoli F, Boracchi P, Gualtierotti R, Biganzoli EM, Zeni S, Lubatti C, Fantini F. Improving outcome prediction of systemic sclerosis from isolated Raynaud's phenomenon: role of autoantibodies and nail-fold capillaroscopy. 1994;45(1):3742. Beltrn E, Toll A, Pros A, Carbonell J, Pujol RM. Normally, the distal row of capillaries are orderly distributed in horizontal lines or palisade array on the periungueal region. Le JH, Cho KI. Redisch W, Messina EJ, Hughes G, McEwen C. Capillaroscopic observations in rheumatic diseases. The sample included 288 patients with primary RP, 11.8% of whom exhibited a transition from isolated RP to SSc, and 42 patients to other connective tissue diseases (B) [67]. PubMed Meli M, Gitzelmann G, Koppensteiner R, Amann-Vesti BR. The authors compared results for manual annotation with and without automatic correction using their elliptical broken line method and found improved inter- and intra-observer reliability with automatic correction [46]. Article , Sponagel L Investigators performed a systematic review of studies focused on different capillaroscopic techniques, capillaroscopic characteristics and definitions, scoring systems, and reliability of image acquisition and interpretation. Rheum Dis Clin N Am. The abstracts of all the retrieved studies were analyzed. , Etehadtavakol M Smith V J Rheumatol. Ferri C, Valentini G, Cozzi F, Sebastiani M, Michelassi C, La Montagna G, et al. 1999;38(9):82630. et al. Geographic variation in the prevalence of Raynaud's phenomenon: Charleston, SC, USA, vs Tarentaise, Savoie, France. As a rule, they are defined based on the number of capillaries per millimeter; diffuse devascularization is present when the number of capillaries per millimeter is 7. The influence of age on nailfold capillary dimensions in childhood. Normal capillaries have an inverted U shape with a thinner arterial (afferent) side. Semin Arthritis Rheum. , Dinsdale G The thumb nailfold is often difficult to visualize and so thumbs are usually excluded. Wildt M Google Scholar. Sebastiani M Vasa. Rheumatology (Oxford). Association between endothelial function and microvascular changes in patients with secondary Raynaud's phenomenon. [37] suggested that in a study of 140 patients with SSc, capillary loss over a 3-year period was a marker of disease/organ progression. Z Rheumatol. Methodological details, expanded results and rationale of the formulated questions for the present recommendations [114,115,116,117]. Diagnostic potential of in vivo capillary microscopy in scleroderma and related disorders. By means of an optical magnification device and incident light, NFC enables direct evaluation of peripheral microcirculation structures. SaucedbySally on Twitter: "RT @HarrySpoelstra: COVID-19 is a , Moore T , Herrick AL , Merla A. 2001;357(9273):20428. CAS de Holanda Mafaldo Digenes A, Bonf E, Fuller R, Correia Caleiro MT. et al. Allen PD et al. Filaci G, Cutolo M, Scudeletti M, Castagneto C, Derchi L, Gianrossi R, Ropolo F, Zentilin P, Sulli A, Murdaca G, Ghio M, Indiveri F, Puppo F. Cyclosporin a and iloprost treatment of systemic sclerosis: clinical results and interleukin-6 serum changes after 12 months of therapy. ramified, bushy or bizarre capillaries) by fitting an ellipse around the capillary, defining the apex as the most distant vertex from the centre of the ellipse. nailfold capillaroscopy J Rheumatol. , Dinsdale G The handheld dermatoscope as a nail-fold capillaroscopic instrument. et al. For quantitative measurements, ideally the whole nailfold should be examined. Improved diagnosis of systemic sclerosis using nailfold capillary flow. Comput Biol Med. Reproducibility of capillaroscopic classifications of systemic sclerosis: results from the SCLEROCAP study. 2008;58(12):390212. Finally we give a personal view on next steps. Ann Rheum Dis. Following the application of eligibility (inclusion/exclusion) criteria, articles were selected to answer the questions, which led to the evidence forming the basis of the present guidelines. In longitudinal studies, it is imperative that the same section of the nailfold is examined each time, otherwise different results may be obtained irrespective of any change in the clinical status of the patient [12, 48]. 2013;31(2 Suppl 76):1038. Abnormalities of renal physiology in systemic sclerosis. Assessment of capillary density in systemic sclerosis with three different capillaroscopic methods. But counting capillaries is more complex than it might seem. , Herrick AL Capobianco KG, Xavier RM, Bredemeier M, Restelli VG, Brenol JC. The frequency of such transitions might vary depending on the analyzed population (C) [17,18,19]. et al. et al. , Unal G Rheumatology (Oxford). , Cornelissen BM Several microcirculation abnormalities have been described among patients with MCTD, such as microhemorrhages and capillary disorganization.