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Tayer-Shifman OE, Bingham KS, Touma Z. Neuropsychiatric Systemic Lupus Erythematosus in Older Adults: Diagnosis and Management. Drugs Aging 2021; 39:129-142. [PMID: 34913146 DOI: 10.1007/s40266-021-00911-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2021] [Indexed: 11/29/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multisystem chronic autoimmune disease with variable clinical manifestations. Neuropsychiatric systemic lupus erythematosus (NPSLE) includes the neurologic syndromes of the central, peripheral and autonomic nervous system and the psychiatric syndromes observed in patients with SLE. Neuropsychiatric systemic lupus erythematosus events may present as an initial manifestation of SLE or may be diagnosed later in the course of the disease. Older adults with NPLSE include those who are ageing with known SLE and those with late-onset SLE. The diagnosis of NPSLE across the lifespan continues to be hampered by the lack of sensitive and specific laboratory and imaging biomarkers. In this review, we discuss the particular complexity of NPSLE diagnosis and management in older adults. We first discuss the epidemiology of late-onset NPSLE, then review principles of diagnosis of NPSLE, highlighting issues that are pertinent to older adults and that make diagnosis and attribution more challenging, such as atypical disease presentation, higher medical comorbidity, and differences in neuroimaging and autoantibody investigations. We also discuss clinical issues that are of particular relevance to older adults that have a high degree of overlap with SLE, including drug-induced lupus, cerebrovascular disease and neurocognitive disorders. Finally, we review the management of NPSLE, mainly moderate to high- dose glucocorticoids and immunosuppressants, again highlighting considerations for older adults, such as increased medication (especially glucocorticoids) adverse effects, ageing-related pharmacokinetic changes that can affect SLE medication management, medication dosing and attention to medical comorbidities affecting brain health.
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Affiliation(s)
- Oshrat E Tayer-Shifman
- Rheumatology Unit, Meir Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Kfar Saba, Israel
| | - Kathleen S Bingham
- University Health Network Centre for Mental Health, Toronto General Hospital, Toronto, ON, Canada
| | - Zahi Touma
- Division of Rheumatology, Department of Medicine, Centre for Prognosis Studies in Rheumatic Diseases, Toronto Western Hospital-Lupus Clinic, University of Toronto, EW, 1-412, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.
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2
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Gadeholt O, Feuchtenberger M, Wech T, Schwaneck EC. Power-Doppler perfusion phenotype in RA patients is dependent on anti-citrullinated peptide antibody status, not on rheumatoid factor. Rheumatol Int 2019; 39:1019-1025. [PMID: 30806731 DOI: 10.1007/s00296-019-04256-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/14/2019] [Indexed: 11/26/2022]
Abstract
It is not known whether there are any consistent non-serological differences between seropositive and seronegative rheumatoid arthritis, and if any, whether they depend upon rheumatoid factor (RF), anti-citrullinated peptide antibodies (ACPA), or both. In a pilot study, we showed that the two forms could be differentiated using power-Doppler sonography (PDS), and that the difference is ACPA dependent. This extended study explored whether the previous findings could be confirmed. 103 patients 51 ACPA positive (ACPA +), 52 ACPA negative (ACPA -) with active wrist arthritis were examined using PDS. By means of a temporal image series, pulsatility was evaluated over a 3-5-s period, maximum and minimum perfusion signal were determined using a computer program counting the number of coloured pixels for each frame. Maxima (Pmax) and minima (Pmin) were determined, and the standardized peak-to-peak amplitude sA was calculated (sA = (Pmax - Pmin)/Pmax). This parameter was then compared for ACPA + and ACPA- patients. In addition, a multivariate regression was performed, to determine which factors influence sA. sA differed significantly between ACPA + and ACPA- patients [20% (13-26) vs. 41% (32-57), p < 0. 0001]. In the multivariate analysis, age (t = 2.5, p = 0.02) and ACPA status (t = - 4.8, p < 0.0001) were independent predictors of sA. PDS perfusion patterns are different in seropositive and seronegative RA. The difference appears to be ACPA, not RF dependent. This suggests that the underlying pathophysiological process is different in ACPA-positive and ACPA-negative RA.
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Affiliation(s)
- O Gadeholt
- Department of Rheumatology, Medical Clinic II, University Clinic Würzburg, Oberduerrbacher Str. 6, 97080, Würzburg, Germany.
- Rheumatologische Schwerpunktpraxis Würzburg, Haugerpfarrgasse 7, 97070, Würzburg, Germany.
| | | | - T Wech
- Department of Experimental Radiology, University Clinic Würzburg, Würzburg, Germany
| | - E C Schwaneck
- Department of Rheumatology, Medical Clinic II, University Clinic Würzburg, Oberduerrbacher Str. 6, 97080, Würzburg, Germany
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Hwang J, Ahn JK, Lee J, Koh EM, Cha HS. Rheumatoid Factor Positivity is Associated with Lower Bone Mass in Korean Male Health Examinees without Clinically Apparent Arthritis. JOURNAL OF RHEUMATIC DISEASES 2019. [DOI: 10.4078/jrd.2019.26.1.31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Jiwon Hwang
- Department of Internal Medicine, National Police Hospital, Seoul, Korea
| | - Joong Kyong Ahn
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaejoon Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Mi Koh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hoon-Suk Cha
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Abstract
Psoriasis, psoriatic arthritis, and rheumatoid arthritis are prevalent conditions that often require a team of primary care and specialist healthcare professionals for the most optimum patient outcomes. Primary care providers can facilitate referrals to dermatology and rheumatology specialists by obtaining the needed screening workup for patients who need treatment with immunosuppressive therapies. This article reviews tuberculosis screening, hepatitis screening, and vaccinations to be administered before patients begin biologic medications.
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Andersson ML, Forslind K, Hafström I. Patients with Early Rheumatoid Arthritis in the 2000s Have Equal Disability and Pain Despite Less Disease Activity Compared with the 1990s: Data from the BARFOT Study over 8 Years. J Rheumatol 2017; 44:723-731. [DOI: 10.3899/jrheum.161235] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/03/2017] [Indexed: 11/22/2022]
Abstract
Objective.To compare outcomes over the first 8 years in patients with early rheumatoid arthritis (RA) recruited in the 1990s and the 2000s, with a special focus on functional disability and its possible predictors.Methods.Data were acquired from 1938 patients with early RA (American College of Rheumatology 1987 criteria) included in the BARFOT study, who had completed the 8-year followup. The patients were divided into 2 cohorts: cohort 1 (n = 928, 68% women) included from 1992 to 1999 and cohort 2 (n = 1010, 70% women) included from 2000 to 2006. Health Assessment Questionnaire (HAQ), 28-joint Disease Activity Score (DAS28), visual analog scale pain, and radiographs of hands and feet scored by the van der Heijde modified Sharp method were assessed during the 8 years. Longitudinal data analyses were performed using a generalized linear model.Results.Despite more active medical treatment during the 2000s, the courses of HAQ and pain showed no difference between the cohorts during followup, in either women or in men, with significantly higher levels in women compared with men. However, as expected, disease activity decreased more over time in cohort 2 compared with cohort 1, for both sexes, and women in cohort 2 had less radiographic progression compared with cohort 1. HAQ was associated with DAS28, pain, radiological scores, and sex in both cohorts, and in cohort 2 also with age and smoking.Conclusion.Patients included in the 2000s had lower disease activity, but not less activity limitation and pain over 8 years of followup despite more active treatment. Pain, aging, and smoking might explain why patients included in the 2000s still had the same disability levels as those included in the 1990s.
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Anti-CCP status determines the power Doppler oscillation pattern in rheumatoid arthritis: a prospective study. Rheumatol Int 2016; 36:1671-1675. [PMID: 27507259 DOI: 10.1007/s00296-016-3548-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 08/02/2016] [Indexed: 10/21/2022]
Abstract
Rheumatoid arthritis (RA) is a chronic inflammatory disease leading to joint destruction. Serologically, it can be differentiated according to rheumatoid factor (RF), anti-cyclic citrullinated peptide antibodies (anti-CCP), or both. This differentiation is prognostically and therapeutically relevant. No method has been described to separate the two forms phenotypically. We hypothesize that a differentiation is possible by evaluating oscillation patterns in power Doppler sonography (PDS). In a prospective study, 20 patients with anti-CCP-positive RA and 20 patients with anti-CCP-negative RA with active wrist synovitis were examined. A PDS scan was performed, and perfusion maxima (P max) and minima (P min) as well as the amplitude (ΔP) were determined by a blinded study member. The amplitude was standardized (sΔP) by dividing by P max, and the anti-CCP-positive and anti-CCP-negative patients as well as the RF-positive and RF-negative were compared to each other. In the ultrasonographic evaluation, we found a highly significant difference in sΔP between CCPp and CCPn patients (median 19.0 vs. 42.9 %, p < 0.0001). sΔP is independent of disease activity. The absolute amplitude ΔP did not differ between the groups. Also, in anti-CCP-positive patients there was a completely linear correlation between P max and P min, and this was far less marked in anti-CCP-negative patients. Anti-CCP-positive and anti-CCP-negative RA display different PDS oscillation patterns. This constitutes a nonserological parameter to differentiate between the two forms. The difference in PDS oscillation patterns suggests that the underlying pathological process differs between the forms.
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Andersson MLE, Forslind K, Hafström I. Comparing Five Year Out-Come in Two Cohorts of Patients with Early Rheumatoid Arthritis - A BARFOT Study. Open Rheumatol J 2015; 9:8-15. [PMID: 25674182 PMCID: PMC4319195 DOI: 10.2174/1874312901409010008] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/11/2014] [Accepted: 12/17/2014] [Indexed: 01/11/2023] Open
Abstract
The objective of the study was to compare disease characteristics over the first 5 years of disease in patients with RA, with disease onset in 1990s and 2000s, respectively.
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Affiliation(s)
- Maria L E Andersson
- Spenshult Research and Development Centre, Halmstad, Sweden ; Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden
| | - Kristina Forslind
- Department of Clinical Sciences, Section of Rheumatology, Lund University, Lund, Sweden ; Section of Rheumatology, Department of Internal Medicine, Helsingborgs Lasarett, Helsingborg, Sweden
| | - Ingiäld Hafström
- Department of Rheumatology, Karolinska Institutet at Karolinska University Hospital, Huddinge, Sweden
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Kim S, Hwang J, Xuan J, Jung YH, Cha HS, Kim KH. Global metabolite profiling of synovial fluid for the specific diagnosis of rheumatoid arthritis from other inflammatory arthritis. PLoS One 2014; 9:e97501. [PMID: 24887281 PMCID: PMC4041724 DOI: 10.1371/journal.pone.0097501] [Citation(s) in RCA: 103] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 04/17/2014] [Indexed: 11/18/2022] Open
Abstract
Currently, reliable biomarkers that can be used to distinguish rheumatoid arthritis (RA) from other inflammatory diseases are unavailable. To find possible distinctive metabolic patterns and biomarker candidates for RA, we performed global metabolite profiling of synovial fluid samples. Synovial fluid samples from 38 patients with RA, ankylosing spondylitis, Behçet's disease, and gout were analyzed by gas chromatography/time-of-flight mass spectrometry (GC/TOF MS). Orthogonal partial least-squares discriminant and hierarchical clustering analyses were performed for the discrimination of RA and non-RA groups. Variable importance for projection values were determined, and the Wilcoxon-Mann-Whitney test and the breakdown and one-way analysis of variance were conducted to identify potential biomarkers for RA. A total of 105 metabolites were identified from synovial fluid samples. The score plot of orthogonal partial least squares discriminant analysis showed significant discrimination between the RA and non-RA groups. The 20 metabolites, including citrulline, succinate, glutamine, octadecanol, isopalmitic acid, and glycerol, were identified as potential biomarkers for RA. These metabolites were found to be associated with the urea and TCA cycles as well as fatty acid and amino acid metabolism. The metabolomic analysis results demonstrated that global metabolite profiling by GC/TOF MS might be a useful tool for the effective diagnosis and further understanding of RA.
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Affiliation(s)
- Sooah Kim
- Department of Biotechnology, Korea University Graduate School, Seoul, Republic of Korea
| | - Jiwon Hwang
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jinhua Xuan
- Department of Biotechnology, Korea University Graduate School, Seoul, Republic of Korea
| | - Young Hoon Jung
- Department of Biotechnology, Korea University Graduate School, Seoul, Republic of Korea
| | - Hoon-Suk Cha
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyoung Heon Kim
- Department of Biotechnology, Korea University Graduate School, Seoul, Republic of Korea
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Shim CN, Hwang JW, Lee J, Koh EM, Cha HS, Ahn JK. Prevalence of rheumatoid factor and parameters associated with rheumatoid factor positivity in Korean health screening subjects and subjects with hepatitis B surface antigen. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0603-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Choong-Nam Shim
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, #108, Chongro-ku, Pyung-dong, Seoul, Republic of Korea
| | - Ji-Won Hwang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jaejoon Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Mi Koh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Hoon-Suk Cha
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Joong Kyong Ahn
- Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, #108, Chongro-ku, Pyung-dong, Seoul, Republic of Korea
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ARAI J, ITO T, MIYASHITA M, SHIMODUMA Y, UCHIKOSHI M, MORIKAWA K, EGUCHI J, HAYASHI E, NOZAWA H, YOSHIDA H. High Level of Rheumatoid Factor is Associated with Hepatitis B Viremia in Patients with Chronic Hepatitis B. ACTA ACUST UNITED AC 2014. [DOI: 10.15369/sujms.26.75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Jun ARAI
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Takayoshi ITO
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Miyuki MIYASHITA
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Yuu SHIMODUMA
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Manabu UCHIKOSHI
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Kenichi MORIKAWA
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Junichi EGUCHI
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Eiichi HAYASHI
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Hisako NOZAWA
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
| | - Hitoshi YOSHIDA
- Division of Gastroenterology, Department of Medicine, Showa University School of Medicine
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Kang BH, Park JK, Roh JH, Song JW, Lee CK, Kim M, Jang SJ, Colby TV, Kim DS. Clinical significance of serum autoantibodies in idiopathic interstitial pneumonia. J Korean Med Sci 2013; 28:731-7. [PMID: 23678265 PMCID: PMC3653086 DOI: 10.3346/jkms.2013.28.5.731] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2012] [Accepted: 02/28/2013] [Indexed: 11/20/2022] Open
Abstract
Although autoantibodies are routinely screened in patients with idiopathic interstitial pneumonia, there are no reliable data on their clinical usefulness. The aim of this study was to investigate the prognostic value of autoantibodies for predicting the development of new connective tissue disease in these patients and also mortality. We conducted retrospective analysis of the baseline, and follow-up data for 688 patients with idiopathic interstitial pneumonia (526 with idiopathic pulmonary fibrosis, 85 with nonspecific interstitial pneumonia, and 77 with cryptogenic organizing pneumonia) at one single tertiary referral center. The median follow-up period was 33.6 months. Antinuclear antibody was positive in 34.5% of all subjects, rheumatoid factor in 13.2%, and other specific autoantibodies were positive between 0.7%-6.8% of the cases. No significant difference in patient survival was found between the autoantibody-positive and -negative groups. However, the presence of autoantibodies, especially antinuclear antibody with a titer higher than 1:320, was a significant predictor for the future development of new connective tissue diseases (relative risk, 6.4), although the incidence was low (3.8% of all subjects during follow-up). In conclusion, autoantibodies are significant predictors for new connective tissue disease development, although they have no prognostic value.
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Affiliation(s)
- Bo Hyoung Kang
- Department of Pulmonary and Critical Care Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Kyeong Park
- Department of Pulmonary and Critical Care Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jae Hyung Roh
- Department of Pulmonary and Critical Care Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin Woo Song
- Department of Pulmonary and Critical Care Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Chang Keun Lee
- Department of Rheumatology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Miyoung Kim
- Department of Radiology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Se Jin Jang
- Department of Pathology, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
| | - Thomas V Colby
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ, USA
| | - Dong Soon Kim
- Department of Pulmonary and Critical Care Medicine, University of Ulsan, College of Medicine, Asan Medical Center, Seoul, Korea
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Prevalence of rheumatoid factor and parameters associated with rheumatoid factor positivity in Korean health screening subjects and subjects with hepatitis B surface antigen. Mod Rheumatol 2012; 22:885-91. [PMID: 22327743 DOI: 10.1007/s10165-012-0603-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 01/19/2012] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The purpose of this study is to assess the prevalence and titer of rheumatoid factor (RF) in Korean health screening subjects and consecutive subjects with hepatitis B surface antigen (HBsAg) and to examine the factors influencing RF positivity. METHODS This study was performed in 37,660 patients (23,269 men, 14,391 women) without arthralgia, who participated in a health checkup program in 2009. RESULTS Approximately 3.7% of health screening subjects (3.3% of males and 4.4% of females) were positive for RF. Among subjects with HBsAg (n = 1,494) and antibody for hepatitis C virus (HCV) (n = 132), 11.8 and 10.6% were RF positive, respectively. There was a significant difference in the RF-positive rate between males and females. The RF-positive rate had a significant linear-by-linear association with aging, but there was no significant relationship between RF positivity and aging among subjects with HBsAg or anti-HCV antibody. Presence of HBsAg and anti-HCV antibody, positive C-reactive protein (CRP), and female sex were factors strongly associated with RF positivity. CONCLUSIONS The rate of RF positivity in health screening adults and subjects with HBsAg in Korea can be estimated to be 3.7 and 11.8%, respectively. Clinicians should consider hepatitis B or C virus infection status, CRP positivity, and sex when interpreting RF-positive results.
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Chatfield SM, Wicks IP, Sturgess AD, Roberts LJ. Anti-citrullinated peptide antibody: death of the rheumatoid factor? Med J Aust 2009; 190:693-5. [PMID: 19527206 DOI: 10.5694/j.1326-5377.2009.tb02640.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2008] [Accepted: 12/10/2008] [Indexed: 11/17/2022]
Abstract
Early diagnosis and treatment of rheumatoid arthritis (RA) is necessary to prevent joint damage and long-term disability. High rates of false-negative and false-positive results of the rheumatoid factor (RF) test make it generally unhelpful in the early diagnosis of RA. A new clinical test for RA--the anti-citrullinated peptide antibody (ACPA) test--is now widely available in Australia. Owing to its high specificity (95%), a positive ACPA test result usually confirms a diagnosis of RA in a patient with undifferentiated inflammatory arthritis. The superior specificity of the ACPA test provides an argument for it to replace the RF test in the primary care setting. Performing both tests adds little to the use of the ACPA test alone. An early diagnostic opinion from a rheumatologist is still recommended, as the ACPA and RF tests frequently return negative results in early RA.
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Affiliation(s)
- Simon M Chatfield
- Rheumatology Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
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Abstract
The differentiation of articular from nonarticular complaints and inflammatory from noninflammatory disorders can usually be made by clinical evaluation. Laboratory and radiographic studies serve as adjuncts in the evaluation of musculoskeletal complaints; however, before ordering these studies, it is important to consider how the findings will affect diagnosis, prognosis, and treatment. An effective clinical evaluation is frequently sufficient to establish a differential diagnosis, focus further confirmatory testing, and consider appropriate treatment.
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Affiliation(s)
- A C Phillips
- Harvard Medical School and The Arthritis Unit of the Medical Service, Massachusetts General Hospital, Boston 02114, USA
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15
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Abstract
The rheumatoid factor (RF) is a frequently ordered diagnostic test, yet it possesses significant limitations in sensitivity, specificity, and predictive value. Recognition of these limitations could improve the test's utility by encouraging more selective test ordering and more circumspect interpretation of test results. An analysis of 563 requests for RF from a teaching hospital revealed a positive predictive value of only 24% to 34%. The RF performs best under conditions of moderate pretest likelihood of rheumatoid arthritis, and otherwise has rather limited clinical utility.
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Affiliation(s)
- R H Shmerling
- Division of General Medicine and Primary Care, Beth Israel Hospital, Boston, Massachusetts
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16
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Abstract
Rheumatic diseases in the elderly are common and may be more difficult to diagnose than in younger patients. Treatment must be tailored to the patients' needs and functional reserve. Elderly patients need to be monitored even more closely for toxicity than younger adults.
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Affiliation(s)
- L C Corman
- Division of General Medicine, University of Florida College of Medicine, Gainesville
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17
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Menzel EJ, Zlabinger GJ, Dunky A, Steffen C. Autoimmunity and T-cell subpopulations in old age. Arch Gerontol Geriatr 1988; 7:249-60. [PMID: 2976265 DOI: 10.1016/0167-4943(88)90008-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/1987] [Revised: 12/30/1987] [Accepted: 01/11/1988] [Indexed: 01/03/2023]
Abstract
To investigate the interrelationship between T-cell-dependent immune functions and autoimmune phenomena in old age we determined T-cell subpopulations in 20 aged healthy individuals (80-96 years old) using monoclonal antibodies. These persons were also investigated as to humoral parameters such as antinuclear antibodies, rheumatoid factors (IgG-, IgA-, IgM-RF), antibodies to collagen types I-IV as well as autoantibodies to organ-specific antigens. In addition, immune complexes were determined. We found that aged individuals have an increased frequency of autoantibodies as compared to a young control population, each aged subject presenting with at least one autoantibody species. Immune complexes, however, were only rarely detected. Three individuals showed a slightly increased T-helper/T-suppressor cell ratio, four had a decreased ratio. An increased number of T-suppressor cells was significantly correlated with a lowered incidence of anticollagen antibodies. Other parameters tested by us: fibronectin, laminin, procollagen type III, C3 and C4 complement components, immunoglobulins and acid alpha 1-glycoprotein. Aged individuals have significantly higher serum levels of fibronectin, while laminin and procollagen concentrations are in the normal range. A large percentage of old individuals had increased serum levels of C3 and/or C4. The acute phase protein orosomucoid, however, was in the normal range.
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Affiliation(s)
- E J Menzel
- Institute of Immunology, University of Vienna, Austria
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Abstract
An extensive literature survey was performed and hospital records were reviewed in order to identify cases of fever of undetermined origin in patients aged 65 or older. Analysis of the 111 cases discovered demonstrates a characteristic but not unique spectrum of underlying disorders. Potentially curable entities such as abdominal abscess, bacterial endocarditis, tuberculosis and giant-cell arteritis account for more than half of the serious illnesses presenting with prolonged pyrexia in elderly subjects. A diagnostic approach to the management of the persistently febrile geriatric patient is discussed.
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Masi AT, Maldonado-Cocco JA, Kaplan SB, Feigenbaum SL, Chandler RW. Prospective study of the early course of rheumatoid arthritis in young adults: comparison of patients with and without rheumatoid factor positivity at entry and identification of variables correlating with outcome. Semin Arthritis Rheum 1976; 4:299-326. [PMID: 1273600 DOI: 10.1016/0049-0172(76)90013-5] [Citation(s) in RCA: 106] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The early course of newly diagnosed RA among young adult patients (16-44 yr) is described from results of an ongoing study with a mean follow-up of 3.4 yr. Study diagnosis was based on the judgement of experienced rheumatologists, and data on several hundred variables were obtained on entry and annually for the purpose of defining patterns of onset and course of disease. Race and sex factors, as well as certain entry manifestations, e.g., RF, were found to correlate with onset and course patterns. Females, and especially white females, had significantly greater numbers of swollen upper extremity joints than males at entry and at last observation, with increased likelihood of developing bone erosions. At entry, RF positive patients differed only on few articular manifestations from RF negative patients, but had a higher frequency of positive ANA at entry and more subcutaneous nodules and bone erosions during follow-up. Seropositive white females at entry had significantly more swollen upper joints than their seronegative counterparts, but with no difference found at last follow-up. White females of each serogroup had more joint involvement at last examination than patients of other race-sex groups. Males had more acute onset, especially under age 30, with significantly greater improvement in arthritis and in ESR than did females. The majority (55%) of patients entered as seropositive, converted to seronegative during follow-up, and no correlation of either joint swelling or erosions was noted with this phenomenon. At last visit, RF positively did not correlate with bone erosions, but patients developing bone erosions had higher frequency of ANA and higher mean serum complement levels at last examination. The following entry factors were found to correlate significantly with a better outcome: maleness, acute onset under age 30, less swollen upper joints, and negative RF. Type of drug therapy tended to reflect severity of arthritis, rather than vice versa, and functional capacity improved significantly from entry to last evaluation in both males and females, even though the latter had stable or progressive arthritis. Further study is necessary over long intervals and in wider age range to more adequately interpret the biologic implications of findings of this ongoing study. A better understanding of the pathogenesis of RA may be derived from critical studies of the contribution of host factors, e.g., sex, and other variables predisposing to the development of RF positivity (and ANA), subcutaneous nodules, and bone erosions, particularly in systematic ongoing studies of patients with early diagnosed disease.
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Larsen RA. Family studies in systemic lupus erythematosus (SLE). VI. Presence of rheumatoid factors in relatives and spouses. JOURNAL OF CHRONIC DISEASES 1972; 25:191-203. [PMID: 5064771 DOI: 10.1016/0021-9681(72)90130-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Larsen RA, Godal T. Family studies in systemic lupus erythematosus (SLE). IX. Thyroid diseases and antibodies. JOURNAL OF CHRONIC DISEASES 1972; 25:225-33. [PMID: 5040348 DOI: 10.1016/0021-9681(72)90133-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Waller M. Present status of the rheumatoid factor. CRC CRITICAL REVIEWS IN CLINICAL LABORATORY SCIENCES 1971; 2:173-209. [PMID: 4141951 DOI: 10.3109/10408367109151307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Dequeker J, Van Noyen R, Vandepitte J. Age-related rheumatoid factors. Incidence and characteristics. Ann Rheum Dis 1969; 28:431-6. [PMID: 5306143 PMCID: PMC1010513 DOI: 10.1136/ard.28.4.431] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Rhodes K, Scott A, Markham RL, Monk-Jones ME. Immunological sex differences. A study of patients with rheumatoid arthritis, their relatives, and controls. Ann Rheum Dis 1969; 28:104-20. [PMID: 4180579 PMCID: PMC1031119 DOI: 10.1136/ard.28.2.104] [Citation(s) in RCA: 49] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Rothfield NF, Rodnan GP. Serum antinuclear antibodies in progressive systemic sclerosis (scleroderma). ARTHRITIS AND RHEUMATISM 1968; 11:607-17. [PMID: 4176069 DOI: 10.1002/art.1780110502] [Citation(s) in RCA: 109] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Gabay P, Lille-Szyszkowicz I, Podliachouk L, Eygruem A, Bourdin JS, Saracino RT. Antiglobulin and anti-Gm antibodies in patients with malignant tumors. Vox Sang 1968; 14:233-5. [PMID: 5301808 DOI: 10.1111/j.1423-0410.1968.tb03411.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Lorber A, Cutler LS, Chang CC. Serum copper levels in rheumatoid arthritis: relationship of elevated copper to protein alterations. ARTHRITIS AND RHEUMATISM 1968; 11:65-71. [PMID: 5640612 DOI: 10.1002/art.1780110109] [Citation(s) in RCA: 44] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Svec KH, Veit BC. Age-related antinuclear factors: immunologic characteristics and associated clinical aspects. ARTHRITIS AND RHEUMATISM 1967; 10:509-16. [PMID: 4864484 DOI: 10.1002/art.1780100604] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Wilson ID, Williams RC, Tobian L. Renal tubular acidosis. Three cases with immunoglobulin abnormalities in the patients and their kindreds. Am J Med 1967; 43:356-70. [PMID: 4166917 DOI: 10.1016/0002-9343(67)90192-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Seligmann M, Danon F, Mihaesco C, Fudenberg HH. Immunoglobulin abnormalities in families of patients with Waldenström's macroglobulinemia. Am J Med 1967; 43:66-83. [PMID: 4143650 DOI: 10.1016/0002-9343(67)90149-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Willkens RF, Whitaker RR, Anderson RV, Berven D. Significance of antinuclear factors in older persons. Ann Rheum Dis 1967; 26:306-10. [PMID: 4951716 PMCID: PMC1031063 DOI: 10.1136/ard.26.4.306] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Moskowitz RW, Benedict KJ, Stauffer R. Serum antibodies to gamma globulin: inter-relationships of aging disease, and geography. JOURNAL OF CHRONIC DISEASES 1967; 20:291-302. [PMID: 5298008 DOI: 10.1016/0021-9681(67)90057-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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Tuffanelli DL, Wuepper KD, Bradford LL, Wood RM. Fluorescent treponemal-antibody absorption tests. Studies of false-positive reactions to tests for syphilis. N Engl J Med 1967; 276:258-62. [PMID: 4163092 DOI: 10.1056/nejm196702022760503] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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de Blécourt JJ, Boerma FW, Vorenkamp EO. Incidence of "rheumatoid factors" in aged serum. Ann Rheum Dis 1967; 26:47-9. [PMID: 6017059 PMCID: PMC1030998 DOI: 10.1136/ard.26.1.47] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Tönder O, Natvig JB. Detection of anti-gamma-globulin factors in human sera by simple screening methods. ACTA PATHOLOGICA ET MICROBIOLOGICA SCANDINAVICA 1966; 68:108-16. [PMID: 4162989 DOI: 10.1111/apm.1966.68.1.108] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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