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\begin{document}

\title{The Evaluation of Flow Mediated Dilatation and Blood Parameters in
Raynaud Phenomenon}



\author[1]{Suheyla UZUN}%
\author[2]{Ilker KAYA}%
\affil[1]{Tokat Gaziosmanpaşa University}%
\affil[2]{Tokat State Hospital}%


\vspace{-1em}



  
  \date{May 29, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Introduction: Raynaud phenomenon (RP) is a multifactorial disorder. If
any underlying disease cannot be detected responsible for RP then it
considered as primary RP (pRP). We aimed to investigate the differences
between laboratory markers and impaired endothelial function in pRP.
Material and Methods: Forty-two pRP patients included as study and
control groups were created from 30 healthy individuals. The endothelial
function was evaluated with flow-mediated dilatation (FMD) of the
brachial artery. The blood samples were obtained both groups and white
blood cell {[}WBC{]}, hemoglobin, platelet, mean platelet volume
{[}MPV{]}, creatinine, alanine aminotransferase {[}ALT{]}, aspartate
aminotransferase{[}AST{]}, D-dimer, fibrinogen, albumin, fibrinogen to
albumin ratio {[}FAR{]}, Neutrophil to Lymphocyte ratio {[}NLR{]},
D-dimer to albumin ratio {[}DDAR{]} and monocyte chemo-attractant
protein-1 {[}MCP-1{]}. Obtained blood parameters and FMD values were
compared between groups. Results: The groups were found as similar in
regards to age, gender, smoking history (p\textless{}0.05). There was no
difference between the two groups in regards to hemoglobin, platelet,
MPV, creatinine, ALT, D-dimer, albumin, FAR, NLR, DDAR levels
(p\textless{}0.05). AST levels were slightly higher in pRP group
(p=0.027). Markedly increased WBC, fibrinogen, MPV and MCP-1 values were
detected in pRP group (p=0.000). Additionally, higher abnormal FMD
responses were detected in pRP group (p=0.000). There was a direct
correlation between abnormal FMD response and serum MCP-1 values in
patients with pRP (R: 0.308, R2: 0.095, p: 0.044). Conclusion: It seems
to be that MCP-1 levels are higher in patients with pRP and increased
values of MCP-1 levels seem to be related to impaired endothelial
functions%
\end{abstract}%



\sloppy


\textbf{The Evaluation of Flow Mediated Dilatation and Blood Parameters
in Raynaud Phenomenon}

\textbf{Running Title: Possible Predictors of Raynaud Disease}

\textbf{ABSTRACT}

\textbf{Introduction: Raynaud phenomenon (RP) is a multifactorial
disorder. If any underlying disease cannot be detected responsible for
RP then it considered as primary RP (pRP). We aimed to investigate the
differences between laboratory markers and impaired endothelial function
in pRP.}

\textbf{Material and Methods: Forty-two pRP patients included as study
and control groups were created from 30 healthy individuals. The
endothelial function was evaluated with flow-mediated dilatation (FMD)
of the brachial artery. The blood samples were obtained both groups and
white blood cell {[}WBC{]}, hemoglobin, platelet, mean platelet volume
{[}MPV{]}, creatinine, alanine aminotransferase {[}ALT{]}, aspartate
aminotransferase{[}AST{]}, D-dimer, fibrinogen, albumin, fibrinogen to
albumin ratio {[}FAR{]}, Neutrophil to Lymphocyte ratio {[}NLR{]},
D-dimer to albumin ratio {[}DDAR{]} and monocyte chemo-attractant
protein-1 {[}MCP-1{]}. Obtained blood parameters and FMD values were
compared between groups.}

\textbf{Results: The groups were found as similar in regards to age,
gender, smoking history (p\textless{}0.05). There was no difference
between the two groups in regards to hemoglobin, platelet, MPV,
creatinine, ALT, D-dimer, albumin, FAR, NLR, DDAR levels
(p\textless{}0.05). AST levels were slightly higher in pRP group
(p=0.027). Markedly increased WBC, fibrinogen, MPV and MCP-1 values were
detected in pRP group (p=0.000). Additionally, higher abnormal FMD
responses were detected in pRP group (p=0.000). There was a direct
correlation between abnormal FMD response and serum MCP-1 values in
patients with pRP (R: 0.308, R2: 0.095, p: 0.044).}

\textbf{Conclusion: It seems to be that MCP-1 levels are higher in
patients with pRP and increased values of MCP-1 levels seem to be
related to impaired endothelial functions}

\textbf{Key Words:} Primary Raynaud phenomenon, blood parameters,
monocyte chemoattractant protein-1, endothelial function, flow mediated
dilatation

\textbf{What's already known about this topic?}

Raynaud's phenomenon (RP) is a reversible vasospastic disorder that may
be provoked by cold or emotional stress. This phenomenon can be occur
without underlying disease or unknown etiology which named as primary RP
(pRP). The essential finding of pRP is aggravation of symptoms by
exposure cold and the detection of color changes (turn white, blue, or
both). The diagnosis is clarified after exclusion of possible underlying
diseases with checking nail capillaroscopy and laboratory panel such as
complete blood counting, inflammatory parameters, metabolic panel,
antibodies, enzymes etc. However, any specific laboratory marker was not
determined for diagnosing pRP. Therefore, researchers tried to determine
an objective laboratory marker that is highly specific and scientific
for pRP.

\textbf{What does this article add?}

To best of our knowledge this is the first study about relationship
between FMD response (impaired endothelial response) and blood
parameters in patients with pRP. On the other hand this is the first
report about relationship between impaired endothelial response and
MCP-1 levels in pRP. Our results indicated that patients with pRP have
higher impaired endothelial to ischemia. The incremental levels of serum
WBC, MPV, MCP-1 and fibrinogen values were detected in pRP group.
Moreover, moderate direct correlation was found between abnormal FMD
response and serum MCP-1 values.

\textbf{INTRODUCTION}

Raynaud's phenomenon (RP) is a reversible vasospastic disorder that may
be provoked by cold or emotional stress. RP involves extremity arteries
and presented with ischemic symptoms of extremities \textsuperscript{1}.
RP can be preliminary finding of some diseases and called as secondary
RP (sRP). This disorder can be related with traumas or micro-traumas
(prolonged usage of vibratory tools), exposure of some chemicals and
auto immune rheumatic or connective tissue diseases (such as systemic
sclerosis). If it is progressed it can be resulted with digital ulcers
or micro-amputations \textsuperscript{1-3} . However, RP can be occur
without underlying disease or unknown etiology which named as primary RP
(pRP). This sort of pRP commonly littered with atmospheric condition and
therefore the symptoms reliefs dramatically when exposure to the cause
is removed \textsuperscript{4,5} . In primary type, there is no
autoimmunity associated marker or reaction. Therefore, a comprehensive
anamnesis should be taken and physical and laboratory examination should
be made in every case with RP and after excluding suspected pathologies
the RP are often classified as primary type \textsuperscript{1,5} .

The essential finding of pRP is aggravation of symptoms by exposure cold
and the detection of color changes (turn white, blue, or both). The
diagnosis is clarified after exclusion of possible underlying diseases
with checking nail capillaroscopy and laboratory panel such as complete
blood counting, inflammatory parameters, metabolic panel, antibodies,
enzymes etc. Avoiding contact with cold and stress is suggested for
these patients. Lifestyle changes such as reducing smoking and caffeine
use are important. Additionally, some medications can be
applied\textsuperscript{1-5} . However, some patients have borderline
symptoms without physical findings like sort of a feeling of cold within
the extremities. In this patient group, management is harder because no
finding apart from anamnesis has been determined, and no parameter has
been defined for possible suspicion \textsuperscript{6,7} . Especially,
an abnormal capillaroscopic finding for differentiation of RP is
discriminative for secondary RP. Thus, nailfold capillaroscopy is losing
potential predictor role for pRP.

The aim of this study was to investigate the possible predictors for
pRP. Therefore, flow-mediated dilatation (FMD), routine blood markers,
and monocyte chemoattractant protein-1 (MCP1) levels were compared
between pRP patients and healthy individuals.

\textbf{MATERIAL AND METHOD}

The study steps were designed according to the Declaration of Helsinki
and ethical approval was obtained from the Local Ethics Committee of the
University. The signed informed consent was obtained from all
participants. This study was designed as a prospective, case-control
study.

Patients over 50 years of age (because of increased risk of
atherosclerotic occlusive arterial diseases), with past medical history
with trauma, thoracic outlet syndrome, secondary RP (malignity,
vasculitis, systemic inflammatory disease, auto-immune diseases, etc.),
anti-inflammatory or corticosteroid usage history, and patients with
accompanying diabetes, hypertension, familial hyperlipidemia were
excluded from the study.

After exclusion of secondary RP, a total of 43 patients was included in
the study who admitted to the cardiovascular surgery clinic with RP
symptoms (bruising and cold hands/f provoked by cold) and diagnosed as
primary RP (Figure 1). The control group was formed from healthy
individuals who admitted to the hospital for a routine checkup without
cardiovascular symptoms.

\emph{Evaluation of flow-mediated dilatation (FMD)}

The FMD evaluation was made in each participant in early morning after
overnight fasting period in a standard ultrasound room by expert
sonographer before starting other steps of study (blood sampling) as
described in previous literature \textsuperscript{8,9} . An android
compatible linear transducer (Philips Lumify L12-4 {[}12--4 mHz{]};
Philips Ultrasound Inc., Bothell, WA) was used to evaluation of vessel
diameter. The normal diameter of the brachial artery was measured over
about 5 cm of the antecubital fossa and therefore the evaluation point
was marked. Thereafter the sphygmomanometer cuff was placed to proximal
site of evaluation point and inflated to above 50 mmHg of normal blood
pressure for five minutes as explained in previous
literature\textsuperscript{8,9} . After 5 minutes of ischemia period
cuff was deflated and the ultrasound probe was placed to marked point
for measurement of post-ischemic diameter of brachial artery. The
enlargement of diameter equal or over than 5\% was accepted as normal
response and lower than 5\% was accepted as abnormal vascular response
to ischemia which indicates abnormal endothelial
function\textsuperscript{8,9} .

\emph{Blood Sampling}

After evaluation of the FMD response the routine 10 ml venous blood
samples were obtained from each participant. After centrifugation,
routine laboratory parameters (white blood cell {[}WBC{]}
(10\textsuperscript{-3}/uL), hemoglobin (g/dL), platelet
(10\textsuperscript{-3}/uL), mean platelet volume {[}MPV{]} (fL),
creatinine (mg/dL), alanine aminotransferase {[}ALT{]} (IU/L), aspartate
aminotransferase{[}AST{]} (IU/L), D-dimer (ng/L), fibrinogen (\selectlanguage{greek}μ\selectlanguage{english}g/ml),
albumin (g/dL), fibrinogen to albumin ratio {[}FAR{]} (\%), Neutrophil
to Lymphocyte ratio {[}NLR{]} (\%), D-dimer to albumin ratio {[}DDAR{]}
(\%)) and monocyte chemo-attractant protein-1 {[}MCP-1{]} (pg/ml) levels
were studied from obtained serum samples. The commercially available
human MCP1 ELISA kit (SUNLONG, Sun Long Biotech Co., LTD) was used for
determining MCP-1 levels (SUNLONG, Sun Long Biotech Co., LTD) as
described in previous reports \textsuperscript{10} .

\emph{Statistical Analyze}

The nominal data analysis was made by using Yates- corrected chi-square
test. A comparison of parametric data between the two groups was made by
using student tests. Pearson correlation coefficients were used to
compare the relation of parameters with FMD. SPSS 17.0 (SPSS Inc.,
Chicago, IL, USA) statistical software program was used for all
statistical analyses. A p-value less than 0.05 was considered
significant.

\textbf{RESULTS}

The groups were found as similar (p\textgreater{}0.05) in regards of
demographical variables (age, gender, smoking) and markedly higher
abnormal FMD responses rates detected in primary RP patient group (p=
0.000). The comparison of demographical, clinical (FMD) and laboratory
variables between control and pRP patients was demonstrated in Table 1.

Serum hemoglobin, platelet, creatinine, ALT, D-Dimer, FAR, NLR, albumin,
DDAR values were found as similar between groups (p\textgreater{}0.05).
Slightly higher AST values (p= 0.027) were detected in pRP group
(25.60\selectlanguage{ngerman}±9.77 IU/L) when compare with healthy subjects (21.20±5.14 IU/L).
Serum WBC, MPV, fibrinogen and MCP-1 values were significantly higher in
pRP group (Table 1) when compare with healthy control group
(p\textless{}0.05).

Higher MCP-1 values (Figure 2) were detected in participants with
abnormal FMD response (p=0.001). The significant correlation was
detected between abnormal FMD response and MCP-1 levels (R: 0.308, R2:
0.095, p: 0.044). Additionally, the low level of relationship was found
between FMD response and MPV, MCP-1 and fibrinogen values (Table 2).

\textbf{DISCUSSION}

To best of our knowledge this is the first study about relationship
between FMD response (impaired endothelial response) and blood
parameters in patients with pRP. On the other hand this is the first
report about relationship between impaired endothelial response and
MCP-1 levels in pRP. Our results indicated that patients with pRP have
higher impaired endothelial to ischemia. The incremental levels of serum
WBC, MPV, MCP-1 and fibrinogen values were detected in pRP group.
Moreover, moderate direct correlation was found between abnormal FMD
response and serum MCP-1 values.

The impaired endothelial dysfunction demonstrated in both primary and
secondary RP in previous studies. Furthermore it was shown that
microvascular derangement was found as associated with endothelial
dysfunction in RP patients \textsuperscript{11,12} . The endothelium has
an important role in the regulation of vascular response against blood
flow\selectlanguage{english}-associated shear stress and ischemia-reperfusion events.
Insufficient flow-mediated vasorelaxation response is an indicator for
increased vascular disease \textsuperscript{13} . The dilation response
of the brachial artery after a 4-5 minutes ischemic period is a reliable
non-invasive assessment method for the evaluation of endothelium
functions. The post-ischemic brachial artery dilatation with equal to or
more than 5\% of normal diameter is accepted as normal endothelial
functions. Additionally, dilatation with lower than 5\% of diameter is
accepted as impaired endothelial functions \textsuperscript{9,14} . The
FMD response was studied in patients with RP. Flavahan indicated as FMD
response is normal in pRP and it was added that cold induced disruption
of arteriovenous connections in RP cases, can lead to digital artery
spasm \textsuperscript{15} . Mavrikakis et al. studied FMD in patients
with sRP and they detected abnormal FMD response in these patients.
Additionally, they found that ascorbic acid does not reverse endothelial
vasomotor dysfunction in their study \textsuperscript{16} . Klein-Weigel
et al. investigate the seasonal variations in patients with RP and they
did not show abnormal FMD response in pRP \textsuperscript{17} . However
most of the previous reports were conducted with mall RP populations.
Although our results indicated that abnormal FMD response can detected 5
(17\%) of 30 healthy individuals, the abnormal FMD was detected at 30
(70\%) of 43 pRP patients.

The routine blood parameters were investigated for several kinds of
vascular diseases \textsuperscript{18} . Platelet indices were
investigated in vasospastic disorders detected with cold stimulation
test by Kadan et al. \textsuperscript{19} . They found that the
relationship between severity of disease and MPV. Shemirani et al. found
independent relationship between pRP and higher serum MPV
levels\textsuperscript{20} . Another study higher MPV was suggested as
triggering factor for pRP \textsuperscript{21} . In same study WBC
levels were found as insignificant predictor in same study. Lau et al.
was found increased white blood cell activation in patients with
RP\textsuperscript{22} . Our findings supported that MPV and WBC levels
in patients with pRP. Plasma fibrinogen is another laboratory parameter
that investigated in vasospatic disorders. Splenger et al. concluded as
increased plasma fibrinogen levels in patients with RP are related with
disrupted distal microcirculation \textsuperscript{23} . Similarly,
higher fibrinogen levels found as associated with plasma fibrin clots
displaying impaired lysability and increased endothelial damage in pRP
by \selectlanguage{polish}Ż\selectlanguage{english}uk et al. \textsuperscript{24} . In our study higher fibrinogen
levels were detected in pRP patients.

MCP-1 is an important potent regulatory chemokine that is responsible
for the migration and the infiltration of monocytes. The ischemia,
oxidative stress, released cytokines, or growth factors triggers the
biological activity of MCP-1 and leads to infiltration of
monocytes/macrophages. Rajagopalan et al. investigated to MCP-1 levels
in sRP and pRP and they found that MCP-1 levels were higher in sRP when
compared with primary type. However, they did not compare the MCP-1
levels with healthy controls and did not investigate the relation with
endothelial response \textsuperscript{25} . MCP-1 was suspected to
pathogenesis of vasospastic outcomes of diseases that presented with
sRP\textsuperscript{26,27} . However, the literature includes
insufficient reports about the relationship between impaired endothelial
function and MCP-1 levels in pRP. Furthermore, another insufficiency is
about the differences between pRP and normal population in regards to
MCP-1 levels. Our results indicated that MCP-1 levels are higher in
patients with pRP and these results revealed a relation between impaired
endothelial functions and serum MCP-1 levels.

In conclusion, our findings demonstrated that MPV, WBC, fibrinogen, and
MCP-1 levels were higher in pRP patients when compare with healthy
control. It seems to be that increased MCP-1 values were related to
abnormal FMD response in pRP group. These results might be helpful for
the establishment of the pathophysiology of the RP.

Limitations of Study

The main limitation of the study is concerning about small sample size.
Although previous literature has present findings with smaller patient
groups, the comprehensive cohorts are necessary for obtaining powerful
and exact results. The second limitation is concerning the determination
of endothelial response with a single method (FMD). The endothelial
response should be confirmed with other techniques to present more
clarified findings. The third limitation is related to the nature of the
disease. If any underlying disease cannot be detected responsible for RP
then it called primary RP. However, there is multifactorial etiology for
RP and it is possible to skip diagnosis.

Acknowledgement

Funding: This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.

Competing Interest: The authors declare no conflict of interest.

\textbf{REFERENCES}

1. Ingegnoli F, Ughi N, Crotti C, Mosca M, Tani C. Outcomes, rates and
predictors of transition of isolated Raynaud's phenomenon: a systematic
review and meta-analysis. Swiss Med Wkly. 2017;147:w14506. doi:
10.4414/smw.2017.14506.

2. Hughes M, Allanore Y, Chung L, Pauling JD, Denton CP, Matucci-Cerinic
M. Raynaud phenomenon and digital ulcers in systemic sclerosis. Nat Rev
Rheumatol. 2020;16(4):208-221. doi: 10.1038/s41584-020-0386-4.

3. Galluccio F, Matucci-Cerinic M. Two faces of the same coin: Raynaud
phenomenon and digital ulcers in systemic sclerosis. Autoimmun Rev.
2011;10(5):241-3. doi: 10.1016/j.autrev.2010.09.008.

4. Carlsson D, Wahlstr\selectlanguage{ngerman}öm J, Burström L, Hagberg M, Lundström R,
Pettersson H, et al. Can sensation of cold hands predict Raynaud's
phenomenon or paraesthesia? Occup Med (Lond). 2018;68(5):314-319. doi:
10.1093/occmed/kqy053. PMID: 29750280;

5. Temprano KK. A Review of Raynaud's Disease. Mo Med.
2016;113(2):123-6. PMID: 27311222;

6. Lambova SN, Müller-Ladner U. The role of capillaroscopy in
differentiation of primary and secondary Raynaud's phenomenon in
rheumatic diseases: a review of the literature and two case reports.
Rheumatol Int. 2009;29(11):1263-71. doi: 10.1007/s00296-009-1019-z.

7. Latuskiewicz-Potemska J, Chmura-Skirlinska A, Gurbiel RJ, Smolewska
E. Nailfold capillaroscopy assessment of microcirculation abnormalities
and endothelial dysfunction in children with primary or secondary
Raynaud syndrome. Clin Rheumatol. 2016;35(8):1993-2001. doi:
10.1007/s10067-016-3340-8.

8. Corretti MC, Anderson TJ, Benjamin EJ, Celermajer D, Charbonneau F,
Creager MA, et al. International Brachial Artery Reactivity Task Force.
Guidelines for the ultrasound assessment of endothelial-dependent
flow-mediated vasodilation of the brachial artery: a report of the
International Brachial Artery Reactivity Task Force. J Am Coll Cardiol.
2002;39(2):257-65.

9. Karahan O, Manduz S, Bektasoglu G, Zorlu A, Turkdogan KA, Bozok S. A
high oxidative stress index predicts endothelial dysfunction in young
male smokers. Bratisl Lek Listy. 2013;114(12):721-5. doi:
10.4149/bll\_2013\_152.

10. Duman A, Turkdogan KA, Avcil M, Yenisey C, Ture M, Akoz A, et al.
The predictive value of the inflammatory markers P-selectin and MCP1 in
determining the length of stay and 30-day survival in the
differentiation of sepsis patients. J Pak Med Assoc.
2018;68(9):1321-1326.

11. Le JH, Cho KI. Association between endothelial function and
microvascular changes in patients with secondary Raynaud's phenomenon.
Clin Rheumatol. 2014;33(11):1627-33. doi: 10.1007/s10067-014-2553-y.

12. Mosdósi B, Bölcskei K, Helyes Z. Impairment of microcirculation and
vascular responsiveness in adolescents with primary Raynaud phenomenon.
Pediatr Rheumatol Online J. 2018;16(1):20. doi:
10.1186/s12969-018-0237-x.

13. Pyke KE, Tschakovsky ME. The relationship between shear stress and
flow-mediated dilatation: implications for the assessment of endothelial
function. J Physiol. 2005;568(Pt 2):357-69. doi:
10.1113/jphysiol.2005.089755.

14. Charakida M, Masi S, Lüscher TF, Kastelein JJ, Deanfield JE.
Assessment of atherosclerosis: the role of flow-mediated dilatation. Eur
Heart J. 2010;31(23):2854-61. doi: 10.1093/eurheartj/ehq340.

15. Flavahan NA. A vascular mechanistic approach to understanding
Raynaud phenomenon. Nat Rev Rheumatol. 2015;11(3):146-58. doi:
10.1038/nrrheum.2014.195.

16. Mavrikakis ME, Lekakis JP, Papamichael CM, Stamatelopoulos KS,
Kostopoulos ChC, Stamatelopoulos SF. Ascorbic acid does not improve
endothelium-dependent flow-mediated dilatation of the brachial artery in
patients with Raynaud's phenomenon secondary to systemic sclerosis. Int
J Vitam Nutr Res. 2003;73(1):3-7. doi: 10.1024/0300-9831.73.1.3.

17. Klein-Weigel P, Krall K, Falkensammer J, Heinz-Erian P, Ulmer H,
Fraedrich G. Lack of seasonal variation in flow-mediated dilatation of
the brachial artery in women with primary Raynaud's phenomenon and
healthy controls. Vasa. 2003;32(2):69-73. doi:
10.1024/0301-1526.32.2.69. 18. Karahan O, Yavuz C, Kankilic N, Demirtas
S, Tezcan O, Caliskan A, et al. Simple blood tests as predictive markers
of disease severity and clinical condition in patients with venous
insufficiency. Blood Coagul Fibrinolysis. 2016;27(6):684-90. doi:
10.1097/MBC.0000000000000478.

19. Kadan M, Karabacak K, Kaya E, Arslan G, Erol G, Do\selectlanguage{polish}ğ\selectlanguage{english}anc\selectlanguage{polish}ı \selectlanguage{english}S, et al.
Platelet indices may be correlated with severity of vasospastic
disorders. Med Sci Monit Basic Res. 2015;21:63-7. doi:
10.12659/MSMBR.893999.

20. Shemirani AH, Nagy B Jr, Tak\selectlanguage{ngerman}áts AT, Zsóri KS, András C, Kappelmayer
J, et al. Increased mean platelet volume in primary Raynaud's
phenomenon. Platelets. 2012;23(4):312-6. doi:
10.3109/09537104.2011.618563.

21. Turan E, Kilic SS. Retrospective view of primary Raynaud's
phenomenon in childhood. Reumatol Clin. 2019;15(6):e92-e95.doi:
10.1016/j.reuma.2017.12.012.

22. Lau CS, O'Dowd A, Belch JJ. White blood cell activation in Raynaud's
phenomenon of systemic sclerosis and vibration induced white finger
syndrome. Ann Rheum Dis. 1992;51(2):249-52. doi: 10.1136/ard.51.2.249.

23. Spengler MI, Svetaz MJ, Leroux MB, Leiva ML, Bottai HM. Association
between capillaroscopy, haemorheological variables and plasma proteins
in patients bearing Raynaud's phenomenon. Clin Hemorheol Microcirc.
2004;30(1):17-24.

24. \selectlanguage{polish}Ż\selectlanguage{english}uk J, Snarska-Drygalska A, Malinowski KP, Papuga-Szela E, Natorska
J, Undas A. Unfavourably altered plasma clot properties in patients with
primary Raynaud's phenomenon: association with venous thromboembolism. J
Thromb Thrombolysis. 2019;47(2):248-254. doi:
10.1007/s11239-019-01805-0.

25. Deshmane SL, Kremlev S, Amini S, Sawaya BE. Monocyte chemoattractant
protein-1 (MCP-1): an overview. J Interferon Cytokine Res.
2009;29(6):313-26. doi: 10.1089/jir.2008.0027.

26. Rajagopalan S, Pfenninger D, Kehrer C, Chakrabarti A, Somers E,
Pavlic R, et al. Increased asymmetric dimethylarginine and endothelin 1
levels in secondary Raynaud's phenomenon: implications for vascular
dysfunction and progression of disease. Arthritis Rheum.
2003;48(7):1992-2000. doi: 10.1002/art.11060.

27. Yamamoto T, Nishioka K. Role of monocyte chemoattractant protein-1
and its receptor,CCR-2, in the pathogenesis of bleomycin-induced
scleroderma. J Invest Dermatol. 2003;121(3):510-6. doi:
10.1046/j.1523-1747.2003.12408.x.

28. Bellando Randone S, George J, Mazzotta C, Guiducci S, Furst DE, Mor
A, et al. Angiostatic and Angiogenic Chemokines in Systemic Sclerosis:
An Overview. Journal of Scleroderma and Related Disorders.
2017;2(1):1-10. doi:10.5301/jsrd.5000226

Figure and Table Legends

Figure 1. The bruising on hand and foot in patients with pRP

Figure 2. The comparison of monocyte chemoattractant protein-1 (MCP1)
values in normal and abnormal flow-mediated dilatation (FMD) groups.

Table 1. The comparison of demographic and laboratory variables in pRP
and healthy control group

Table 2. The relation between laboratory parameters and abnormal
flow-mediated dilatation (FMD)

Table 1. The comparison of demographic and laboratory variables in pRP
and healthy control group\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Variables\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Control N:30\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
Raynaud Phenomenon N:43\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
p\textsuperscript{\#}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Female n(\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
22 (73\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
34 (79\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.772\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Age (mean\selectlanguage{ngerman}±SD)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
27.17\selectlanguage{ngerman}±8.01\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
28.33\selectlanguage{ngerman}±8,71\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.565\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Smoking n(\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
8 (27\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
19 (44\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.201\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Abnormal FMD* n(\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
5 (17\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
30 (70\%)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
\textbf{0.000}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
WBC** (10\textsuperscript{-3}/uL)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
6.20\selectlanguage{ngerman}±1.43\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
7.64\selectlanguage{ngerman}±1.73\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{0.000}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Hemoglobin (g/dL)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
13.46\selectlanguage{ngerman}±1.06\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
12.93\selectlanguage{ngerman}± 1.78\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.148\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Platelet Count (10\textsuperscript{-3}/uL)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
225.50\selectlanguage{ngerman}±79.23\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
250.91\selectlanguage{ngerman}±74.67\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.167\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
MPV*** (fL)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
8.36\selectlanguage{ngerman}±0.96\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
10.47\selectlanguage{ngerman}±0.87\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{0.000}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Creatinine (mg/dL)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.85\selectlanguage{ngerman}±0.17\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.79\selectlanguage{ngerman}±0.21\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.232\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
AST\textsuperscript{+} (IU/L)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
21.20\selectlanguage{ngerman}±5.14\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
25.60\selectlanguage{ngerman}±9.77\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{0.027}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
ALT\textsuperscript{++} (IU/L)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
23.45\selectlanguage{ngerman}±7.36\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
26.12\selectlanguage{ngerman}±12.94\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.311\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
D-Dimer (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
1.25\selectlanguage{ngerman}±1.15\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
2.50\selectlanguage{ngerman}±5.049\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.185\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Fibrinogen (\selectlanguage{greek}μ\selectlanguage{english}g/ml)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
258.94\selectlanguage{ngerman}±89.74\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
375.57\selectlanguage{ngerman}±160.49\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{0.000}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
FAR\textsuperscript{+++} (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
88.38\selectlanguage{ngerman}±66.85\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
112.54\selectlanguage{ngerman}±45.49\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.090\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
NLR\textsuperscript{\&} (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
9.44\selectlanguage{ngerman}±11.26\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
8.07\selectlanguage{ngerman}±6.03\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.501\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
Albumin (g/dL)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3.3500 .38841\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
3.3279 .70561\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.579\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
DDAR\textsuperscript{\&\&} (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.3819\selectlanguage{ngerman}±0.37301\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.9210\selectlanguage{ngerman}±1.65428\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
0.877\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
MCP1\textsuperscript{@} (pg/ml)\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
264.4342\selectlanguage{ngerman}±71.12647\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
332.4933\selectlanguage{ngerman}±39.45015\strut
\end{minipage} & \begin{minipage}[t]{0.24\columnwidth}\raggedright\strut
\textbf{0.000}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
*FMD: flow mediated dilatation. **WBC: white blood cell. ***MPV: main
platelet volume. \textsuperscript{+}AST: aspartate aminotransferase.
\textsuperscript{++}ALT: alanine aminotransferase.
\textsuperscript{+++}FAR: fibrinogen to albumin ratio.
\textsuperscript{\&}NLR: Neutrophil to Lymphocyte ratio.
\textsuperscript{\&\&}DDAR: D-dimer to albumin ratio.
\textsuperscript{@}MCP1: monocyte chemo-attractant protein-1
\textsuperscript{\#}p\textless{}0.05 is considered as statistically
significant\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
*FMD: flow mediated dilatation. **WBC: white blood cell. ***MPV: main
platelet volume. \textsuperscript{+}AST: aspartate aminotransferase.
\textsuperscript{++}ALT: alanine aminotransferase.
\textsuperscript{+++}FAR: fibrinogen to albumin ratio.
\textsuperscript{\&}NLR: Neutrophil to Lymphocyte ratio.
\textsuperscript{\&\&}DDAR: D-dimer to albumin ratio.
\textsuperscript{@}MCP1: monocyte chemo-attractant protein-1
\textsuperscript{\#}p\textless{}0.05 is considered as statistically
significant\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
*FMD: flow mediated dilatation. **WBC: white blood cell. ***MPV: main
platelet volume. \textsuperscript{+}AST: aspartate aminotransferase.
\textsuperscript{++}ALT: alanine aminotransferase.
\textsuperscript{+++}FAR: fibrinogen to albumin ratio.
\textsuperscript{\&}NLR: Neutrophil to Lymphocyte ratio.
\textsuperscript{\&\&}DDAR: D-dimer to albumin ratio.
\textsuperscript{@}MCP1: monocyte chemo-attractant protein-1
\textsuperscript{\#}p\textless{}0.05 is considered as statistically
significant\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
*FMD: flow mediated dilatation. **WBC: white blood cell. ***MPV: main
platelet volume. \textsuperscript{+}AST: aspartate aminotransferase.
\textsuperscript{++}ALT: alanine aminotransferase.
\textsuperscript{+++}FAR: fibrinogen to albumin ratio.
\textsuperscript{\&}NLR: Neutrophil to Lymphocyte ratio.
\textsuperscript{\&\&}DDAR: D-dimer to albumin ratio.
\textsuperscript{@}MCP1: monocyte chemo-attractant protein-1
\textsuperscript{\#}p\textless{}0.05 is considered as statistically
significant\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 2. The relation between laboratory parameters and abnormal
flow-mediated dilatation (FMD)\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
& FMD\textsuperscript{@} & FMD\textsuperscript{@}\tabularnewline
\midrule
\endhead
MCP1* & R & \textbf{0.308}\tabularnewline
& R2 & 0.095\tabularnewline
& p\textsuperscript{\#} & \textbf{0.044}\tabularnewline
& N & 43\tabularnewline
WBC** & R & 0.036\tabularnewline
& R2 & 0.001\tabularnewline
& p\textsuperscript{\#} & 0.819\tabularnewline
& N & 43\tabularnewline
MPV*** & R & 0.171\tabularnewline
& R2 & 0.029\tabularnewline
& p\textsuperscript{\#} & 0.272\tabularnewline
& N & 43\tabularnewline
Fibrinogen & R & 0.101\tabularnewline
& R2 & 0.010\tabularnewline
& p\textsuperscript{\#} & 0.517\tabularnewline
& N & 43\tabularnewline
\textsuperscript{@}FMD: flow mediated dilatation. **WBC: white blood
cell. ***MPV: main platelet volume. \textsuperscript{\#}p: Correlation
is significant at the 0.05 level (2-tailed). & \textsuperscript{@}FMD:
flow mediated dilatation. **WBC: white blood cell. ***MPV: main platelet
volume. \textsuperscript{\#}p: Correlation is significant at the 0.05
level (2-tailed). & \textsuperscript{@}FMD: flow mediated dilatation.
**WBC: white blood cell. ***MPV: main platelet volume.
\textsuperscript{\#}p: Correlation is significant at the 0.05 level
(2-tailed).\tabularnewline
\bottomrule
\end{longtable}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure1300/figure1300}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/figure2300/figure2300}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

