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AlOmair M, AlMalki H, AlShamrani N, Habtar G, AlAsmari M, Mobasher W, AlQahtani H, Rahman A, Asiri A. Patterns of Response to Different Treatment Strategies in Seropositive Rheumatoid Arthritis Patients in a Tertiary Hospital in South-Western Saudi Arabia: A Retrospective Study. Open Access Rheumatol 2021; 13:239-246. [PMID: 34429668 PMCID: PMC8374534 DOI: 10.2147/oarrr.s322833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/03/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To study the pattern of response to different treatment strategies in seropositive rheumatoid arthritis (RA) patients and to describe our clinical practice in RA management. Patients and Methods Over a period of two years from April 2018 to April 2020, we conducted a retrospective analysis of data for 288 consecutive seropositive RA patients attending rheumatology clinics and the daycare unit at Aseer Central Hospital. Data were collected on patient demographics, disease duration, extraarticular manifestations, comorbidities and treatment. Disease activity was assessed using the clinical disease activity index (CDAI). Results Out of the total 288 patients, 42% (120) are on csDMRADs, while 54% (162) are on bDMRADs and 4% (6) are on tsDMARDs. Of the patients on csDMARDS, 51%, 43% and 7% of them were on remission, low and moderate disease activity, respectively. However, of the patients on non-csDMARDS, 36.3%, 49.4% and 14.3% of them were on remission, low and moderate disease activity, respectively. Failure of csDMARDs was affected by the presence of high disease activity at baseline, extraarticular lung manifestations and coexistent fibromyalgia, with a significant effect of the latter on remission rate. Among patients on non-csDMARDs, 42 (25%) showed one or more therapy changes. Tumor necrosis factor inhibitors were the predominant first-line agents in biologically naive patients (65%) followed by abatacept (18%). Abatacept was the most frequently prescribed second biologic in 52% of cases followed by tocilizumab in 19%. Conclusion The current clinical practice in our hospital is consistent with the latest American College of Rheumatology (ACR)/The European League Against Rheumatism (EULAR) guidelines. Treat-to-target strategy was achieved in the vast majority of our patients, while remission was observed in almost half of the patients.
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Affiliation(s)
- Mohammed AlOmair
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Hanan AlMalki
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Nouf AlShamrani
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Ghadah Habtar
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Maram AlAsmari
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Wejdan Mobasher
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Hanan AlQahtani
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Aydah Rahman
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
| | - Alhussain Asiri
- Division of Rheumatology, Department of Medicine, Aseer Central Hospital, Abha, Saudi Arabia
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Almoallim H, Hassan R, Cheikh M, Faruqui H, Alquraa R, Eissa A, Alhazmi A, Alsolaimani R, Janoudi N. Rheumatoid Arthritis Saudi Database (RASD): Disease Characteristics and Remission Rates in a Tertiary Care Center. Open Access Rheumatol 2020; 12:139-145. [PMID: 32821181 PMCID: PMC7418157 DOI: 10.2147/oarrr.s260426] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/27/2020] [Indexed: 11/23/2022] Open
Abstract
Background National Registries are essential to direct current practice. Rheumatoid arthritis (RA) registries in the middle east and North Africa remain scarcely represented. Objective To describe a population of Saudi RA patients and to compare the findings to internationally reported data. Methods This is an observational study that was conducted at Doctor Soliman Fakeeh Hospital (DSFH) in Saudi Arabia. The study ran from 2014 to 2018 using a pool of 433 patients. Inclusion criteria included adults older than 18 years of age who fulfilled the 2010 American College of Rheumatology criteria for the diagnosis of RA and who were also regular visitors in our rheumatology clinics. Data were collected directly from patients and entered in a specially designed program. Results At initial presentation, 45.5% had demonstrated active disease (moderate or high disease activity) based on DAS-28-CRP scores, while 54.5% were in low disease activity or remission. The remission rates after 1 year had increased to 79.6% (345 patients), while 9.7% (42 patients) and 10.6% (46 patients) had low disease activity and moderate disease activity, respectively. It was also found that the female gender, higher Health Assessment Questionnaire-Disability Index (HAQ-DI) and longer lag1/lag2 periods were associated with higher disease activity in our population. Conclusion We detected higher remission rates at 1 year of follow-up. This could be attributed to many factors, including good referral systems with easier access to biologics. We aim to expand this registry to the national level.
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Affiliation(s)
- Hani Almoallim
- Department of Medicine, Faculty of Medicine, Umm Alqura University, Makkah, Saudi Arabia.,Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia.,Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi Arabia
| | - Rola Hassan
- Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia.,Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi Arabia
| | - Mohamed Cheikh
- Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia.,Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi Arabia
| | - Hanan Faruqui
- Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Reem Alquraa
- Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Ayman Eissa
- Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
| | - Aous Alhazmi
- Alzaidi Chair of Research in Rheumatic Diseases, Umm Alqura University, Makkah, Saudi Arabia
| | - Roaa Alsolaimani
- Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia.,Department of Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Nahed Janoudi
- Internal Medicine Department, Doctor Soliman Fakeeh Hospital, Jeddah, Saudi Arabia
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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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Julià A, Blanco F, Fernández-Gutierrez B, González A, Cañete JD, Maymó J, Alperi-López M, Olivè A, Corominas H, Martínez-Taboada V, González-Álvaro I, Fernandez-Nebro A, Erra A, Sánchez-Fernández S, Alonso A, López-Lasanta M, Tortosa R, Codó L, Lluis Gelpi J, García-Montero AC, Bertranpetit J, Absher D, Myers RM, Tornero J, Marsal S. Identification of IRX1 as a Risk Locus for Rheumatoid Factor Positivity in Rheumatoid Arthritis in a Genome-Wide Association Study. Arthritis Rheumatol 2017; 68:1384-91. [PMID: 26815016 DOI: 10.1002/art.39591] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Accepted: 01/07/2016] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Rheumatoid factor (RF) is a well-established diagnostic and prognostic biomarker in rheumatoid arthritis (RA). However, ∼20% of RA patients are negative for this anti-IgG antibody. To date, only variation at the HLA-DRB1 gene has been associated with the presence of RF. This study was undertaken to identify additional genetic variants associated with RF positivity. METHODS A genome-wide association study (GWAS) for RF positivity was performed using an Illumina Quad610 genotyping platform. A total of 937 RF-positive and 323 RF-negative RA patients were genotyped for >550,000 single-nucleotide polymorphisms (SNPs). Association testing was performed using an allelic chi-square test implemented in Plink software. An independent cohort of 472 RF-positive and 190 RF-negative RA patients was used to validate the most significant findings. RESULTS In the discovery stage, a SNP in the IRX1 locus on chromosome 5p15.3 (SNP rs1502644) showed a genome-wide significant association with RF positivity (P = 4.13 × 10(-8) , odds ratio [OR] 0.37 [95% confidence interval (95% CI) 0.26-0.53]). In the validation stage, the association of IRX1 with RF was replicated in an independent group of RA patients (P = 0.034, OR 0.58 [95% CI 0.35-0.97] and combined P = 1.14 × 10(-8) , OR 0.43 [95% CI 0.32-0.58]). CONCLUSION To our knowledge, this is the first GWAS of RF positivity in RA. Variation at the IRX1 locus on chromosome 5p15.3 is associated with the presence of RF. Our findings indicate that IRX1 and HLA-DRB1 are the strongest genetic factors for RF production in RA.
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Affiliation(s)
- Antonio Julià
- Vall d'Hebron Hospital Research Institute, Barcelona, Spain
| | - Francisco Blanco
- Instituto de Investigación Biomédica de A Coruña-Hospital Universitario A Coruña, A Coruña, Spain
| | | | - Antonio González
- Instituto de Investigación Sanitaria and Hospital Clinico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - Joan Maymó
- Hospital del Mar, Barcelona, Barcelona, Spain
| | | | - Alex Olivè
- Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | | | | | | | - Antonio Fernandez-Nebro
- Instituto de Investigación Biomédica de Málaga, Hospital Regional Universitario de Málaga, and Universidad de Málaga, Málaga, Spain
| | - Alba Erra
- Hospital Sant Rafael, Barcelona, Spain
| | | | - Arnald Alonso
- Vall d'Hebron Hospital Research Institute, Barcelona, Spain
| | | | - Raül Tortosa
- Vall d'Hebron Hospital Research Institute, Barcelona, Spain
| | - Laia Codó
- Barcelona Supercomputing Center, Barcelona, Spain
| | | | | | - Jaume Bertranpetit
- National Genotyping Center and Pompeu Fabra University, Barcelona, Spain
| | - Devin Absher
- HudsonAlpha Institute for Biotechnology, Huntsville, Alabama
| | - Richard M Myers
- HudsonAlpha Institute for Biotechnology, Huntsville, Alabama
| | - Jesús Tornero
- Hospital Universitario de Guadalajara, Guadalajara, Spain
| | - Sara Marsal
- Vall d'Hebron Hospital Research Institute, Barcelona, Spain
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Cellular and molecular perspectives in rheumatoid arthritis. Semin Immunopathol 2017; 39:343-354. [PMID: 28508153 DOI: 10.1007/s00281-017-0633-1] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Accepted: 04/17/2017] [Indexed: 12/13/2022]
Abstract
Synovial immunopathology in rheumatoid arthritis is complex involving both resident and infiltrating cells. The synovial tissue undergoes significant neovascularization, facilitating an influx of lymphocytes and monocytes that transform a typically acellular loose areolar membrane into an invasive tumour-like pannus. The microvasculature proliferates to form straight regularly-branching vessels; however, they are highly dysfunctional resulting in reduced oxygen supply and a hypoxic microenvironment. Autoantibodies such as rheumatoid factor and anti-citrullinated protein antibodies are found at an early stage, often before arthritis has developed, and they have been implicated in the pathogenesis of RA. Abnormal cellular metabolism and mitochondrial dysfunction thus ensue and, in turn, through the increased production of reactive oxygen species actively induce inflammation. Key pro-inflammatory cytokines, chemokines and growth factors and their signalling pathways, including nuclear factor κB, Janus kinase-signal transducer, are highly activated when immune cells are exposed to hypoxia in the inflamed rheumatoid joint show adaptive survival reactions by activating. This review attempts to highlight those aberrations in the innate and adaptive immune systems including the role of genetic and environmental factors, autoantibodies, cellular alterations, signalling pathways and metabolism that are implicated in the pathogenesis of RA and may therefore provide an opportunity for therapeutic intervention.
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Zeidler H. Drug-free sustained remission or spontaneous remission by natural history in rheumatoid arthritis? An unsolved question: comment on the article of Ajeganova et al. Ann Rheum Dis 2016; 76:e16. [PMID: 28007758 DOI: 10.1136/annrheumdis-2016-210887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2016] [Indexed: 11/03/2022]
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Hecht C, Englbrecht M, Rech J, Schmidt S, Araujo E, Engelke K, Finzel S, Schett G. Additive effect of anti-citrullinated protein antibodies and rheumatoid factor on bone erosions in patients with RA. Ann Rheum Dis 2014; 74:2151-6. [PMID: 25115448 DOI: 10.1136/annrheumdis-2014-205428] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 07/20/2014] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To determine whether there is an additive effect of anticitrullinated protein antibodies (ACPA) and rheumatoid factor (RF) on the number and size of bone erosions in patients with rheumatoid arthritis (RA) METHODS: 242 patients with RA received high-resolution peripheral quantitative CT (HR-pQCT) scans of the metacarpophalangeal joints. Demographic and disease-specific parameters including ACPA and RF levels were recorded from all patients. Erosion numbers and their size were assessed in 238 patients at 714 individual joints (MCP 2, 3 and 4) and 5712 sites (each 4 quadrants in metacarpal heads and phalangeal bases). The volume of erosions was calculated by a semiellipsoid formula. RESULTS Of the 238 patients, 112 patients showed RF and ACPAs (ACPAs+RF+), 28 only RF (RF+), 29 only ACPAs (ACPA+) and 69 were antibody negative (NEG). Erosion number and size were highest in RF+ACPAs+ patient group with significant differences compared with NEG patients with respect to erosion number (p=0.001) and to ACPA-negative patients with respect to erosion size (p<0.001). Results maintained significance in a linear mixed model showing ACPAs+RF+ status and disease duration being associated with higher number (p=0.017 and p=0.005, respectively), and larger size (p=0.014 and p=0.013, respectively) of bone erosions. Furthermore, erosion size was influenced by the presence and titre of RF only in ACPA-positive patients with RA but not in ACPA-negative patients. CONCLUSIONS ACPAs and RF show an additive effect on erosion number and erosion size. Concomitant presence of ACPAs and RF is associated with higher erosive disease burden in patients with RA. Furthermore, RF influences erosion size only in ACPA-positive but not in ACPA-negative patients.
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Affiliation(s)
- Carolin Hecht
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Matthias Englbrecht
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jürgen Rech
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sarah Schmidt
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Elizabeth Araujo
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Klaus Engelke
- Institute of Medical Physics, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stephanie Finzel
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Georg Schett
- Department of Internal Medicine 3, University of Erlangen-Nuremberg, Erlangen, Germany
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Suzuki T, Tohda E, Ishihara K. Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor. Mod Rheumatol 2014. [DOI: 10.3109/s10165-009-0150-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Peschken CA, Hitchon CA, Robinson DB, Smolik I, Barnabe CR, Prematilake S, El-Gabalawy HS. Rheumatoid arthritis in a north american native population: longitudinal followup and comparison with a white population. J Rheumatol 2010; 37:1589-95. [PMID: 20551109 DOI: 10.3899/jrheum.091452] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To describe differences in phenotype and outcomes in North American Native (NAN) patients with rheumatoid arthritis (RA) followed prospectively and compared to white patients with RA. METHODS Patients from a single academic center were followed over 20 years using a custom database. Data included diagnoses, year of disease onset, ethnicity, modified Health Assessment Questionnaire (mHAQ) score, patient and physician global scores, tender and swollen joint counts, treatment, serology, and erythrocyte sedimentation rate (ESR). Records of all white (n = 1315) and NAN (n = 481) patients with RA were abstracted. Cumulative treatment data and clinical measures were compared. RESULTS Disease duration was longer in white patients compared to NAN patients (16 +/- 11 vs 14 +/- 10 years, respectively; p = 0.03). Onset age was 34 years for NAN patients and 43 years for white patients (p < 0.001). NAN patients were more frequently positive for rheumatoid factor (89% vs 74%; p < 0.001) and antinuclear antibody (57% vs 21%; p < 0.001). Although mean tender joint counts and swollen joint counts were similar, NAN patients had higher Lansbury scores (weighted joint count; 66.5 vs 49.7; p < 0.001), mHAQ scores (1.1 vs 0.9; p = 0.001), and ESR (31 vs 25 mm/h; p < 0.012). NAN patients had more frequent knee (53% vs 34%; p < 0.001) and elbow (62% vs 48%; p = 0.007) involvement. Compared to white patients, NAN patients took a higher lifetime number of disease-modifying antirheumatic drugs (3.2 +/- 1.9 vs 2.2 +/- 1.7; p < 0.001), had more combination therapy (38% vs 29%; p = 0.002), and had more frequent prednisone use (55% vs 39%; p < 0.001). CONCLUSION Compared to white patients, NAN patients with RA develop disease earlier, are more frequently seropositive, have greater large joint involvement, and greater disease burden, although treatment is more aggressive. These differences are present early and persist throughout the disease course.
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Affiliation(s)
- Christine A Peschken
- Department of Medicine, Immunology, and the Section of Rheumatology, University of Manitoba, Winnipeg, Manitoba, Canada.
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Wu T, Sajitharan D, Mohan C. Biomarkers of rheumatoid arthritis: recent progress. ACTA ACUST UNITED AC 2010; 4:293-305. [DOI: 10.1517/17530059.2010.492828] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Nikolaisen C, Rekvig OP, Nossent HC. Rheumatoid factor by laser nephelometry and Waaler–Rose assay: prognostic value in patients with recent‐onset rheumatoid arthritis. Scand J Rheumatol 2009; 34:269-76. [PMID: 16195159 DOI: 10.1080/03009740510018606] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the prognostic value of rheumatoid factor (RF), detected in the Waaler-Rose agglutination assay and by nephelometry, in patients with recent-onset rheumatoid arthritis (RA). METHODS Consecutive patients with new-onset RA between 1993 and 1997 were followed for a median period of 4.7 years. Clinical data at baseline and drug use during the disease course were recorded. Outcome parameters studied were disease process, damage (erosions, joint surgery, extra-articular manifestations, and new co-morbidity), and death. Cut-off levels for RF were >40 IU/mL (nephelometry) and titres 1:160 (Waaler-Rose haemagglutination). RESULTS RF tests were negative by both methods in 22% of RA patients (RF- group), while 33% were RF positive by nephelometry only (RF+ group) and 45% were positive by Waaler-Rose and nephelometry (RF++ group). Baseline clinical and laboratory findings as well as the number of subsequently used disease-modifying anti-rheumatic drugs (DMARDs), the number of patients starting and the time spent on steroid therapy were similar in the three RF groups. Odd ratios for death (n = 23), erosions (n = 62), and serious extra-articular disease manifestations (EAMs) (n = 13) as well as patient survival, erosion-free or surgery-free survival rates did not differ between the RF groups. Only rheumatoid nodules were more frequent in RF++ patients. CONCLUSION The baseline presence of RF by either Waaler-Rose or nephelometry was not associated with differences in drug therapy, morbidity other than rheumatoid nodules, or mortality in RA patients in the first 5 years of disease. Being immunoglobulin M (IgM) RF positive thus had little impact on RA patient outcome.
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Affiliation(s)
- C Nikolaisen
- Department of Rheumatology, Institute of Clinical Medicine, University of Tromsø, Norway.
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Suzuki T, Tohda E, Ishihara K. Power Doppler ultrasonography of symptomatic rheumatoid arthritis ankles revealed a positive association between tenosynovitis and rheumatoid factor. Mod Rheumatol 2009; 19:235-44. [PMID: 19214653 DOI: 10.1007/s10165-009-0150-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2008] [Accepted: 12/15/2008] [Indexed: 12/21/2022]
Abstract
The aim of this study was to characterize the pathological conditions of symptomatic ankles in patients with rheumatoid arthritis (RA) using power Doppler sonography (PDS). We analyzed 17 consecutive ultrasonography (US) records of RA patients with symptomatic ankles who underwent B-mode ultrasonography (BUS) combined with PDS of their ankles in our department because of clinical need. Correlations between US findings and clinical and serological data were assessed. The diagnostic capabilities of BUS and PDS were also compared. Common US findings were talocrural synovitis (76%), subtalar synovitis (71%), and talonavicular synovitis (59%). Tenosynovitis around the ankle was detected in ten patients (59%), including several cases of tenosynovitis of tibialis posterior (41%) and tenosynovitis of peroneus longus and brevis (35%). Achilles tendon enthesitis was detected in six patients, and retrocalcaneal bursitis was detected in five. Compared with BUS, PDS offers demonstrably superior diagnostic capability for the detection of rheumatoid ankle diseases, especially subtalar joint synovitis and peroneal tenosynovitis. Rheumatoid factor (RF) levels were significantly higher in patients with tenosynovitis than in patients without tenosynovitis. PDS is an excellent modality for diagnosing both intra- and extracapsular synovitis in rheumatoid ankles. Using PDS, we found positive association between ankle tenosynovitis and RF levels in RA patients.
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Affiliation(s)
- Takeshi Suzuki
- Division of Rheumatology, Mitsui Memorial Hospital, Chiyoda-ku, Tokyo, Japan.
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Lambrecht S, Tilleman K, Elewaut D, Deforce D. Proteomics in rheumatology: The beginning of a fairy tale? Proteomics Clin Appl 2008; 2:411-9. [DOI: 10.1002/prca.200780084] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Indexed: 11/11/2022]
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14
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Bukhari M, Thomson W, Naseem H, Bunn D, Silman A, Symmons D, Barton A. The performance of anti-cyclic citrullinated peptide antibodies in predicting the severity of radiologic damage in inflammatory polyarthritis: results from the Norfolk Arthritis Register. ACTA ACUST UNITED AC 2007; 56:2929-35. [PMID: 17763407 PMCID: PMC2435419 DOI: 10.1002/art.22868] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective Anti–cyclic citrullinated peptide (anti-CCP) antibodies are a stronger predictor of the severity of rheumatoid arthritis than is rheumatoid factor (RF). Their role in predicting outcome in unselected patients with new-onset inflammatory polyarthritis (IP) has not been examined. The aims of this study were to examine the role of baseline RF and anti-CCP antibodies in determining the likelihood of patients having erosions at presentation or in predicting future radiologic damage, and to determine whether anti-CCP antibodies or RF is sufficiently robust to be clinically useful in guiding treatment decisions in early IP. Methods Patients were recruited from the Norfolk Arthritis Register. Logistic regression models were fitted to test the ability of anti-CCP antibodies and RF to predict erosions. Further models were investigated to examine the role of anti-CCP antibodies in patients stratified by RF status. Results The presence of anti-CCP antibodies at baseline was strongly associated with both prevalent erosions (odds ratio [OR] 2.53 [95% confidence interval (95% CI) 1.48–4.30]) and developing erosions at 5 years (OR 10.2 [95% CI 6.2–16.9]). These ORs were higher than those for RF (OR 1.63 [95% CI 0.94–2.82] and OR 3.4 [95% CI 2.2–5.2], respectively). The likelihood ratio (LR) for the prediction of prevalent erosions and erosions at 5 years was highest in the RF−subgroup (LR 2.2 and 5.8, respectively). However, 27% of anti-CCP−patients had developed erosions by 5 years. Conclusion Despite their strong association with the presence, development, and extent of erosions, anti-CCP antibodies alone are not a sufficiently accurate measure upon which to base clinical treatment decisions. Knowledge of anti-CCP antibody status is most informative in RF−negative patients.
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Affiliation(s)
- M Bukhari
- University of Manchester, Manchester, UK
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El Miedany Y, Youssef S, Mehanna AN, El Gaafary M. Development of a scoring system for assessment of outcome of early undifferentiated inflammatory synovitis. Joint Bone Spine 2007; 75:155-62. [PMID: 17980637 DOI: 10.1016/j.jbspin.2007.04.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Accepted: 04/26/2007] [Indexed: 11/19/2022]
Abstract
BACKGROUND The current paradigm for early undifferentiated arthritis suggests that persistent synovitis leads to erosive joint damage, which results in functional disability. Discriminating between different forms of early arthritis outcome is relevant for therapeutic decision-making and prevents the occurrence of circularity in diagnostic studies. Implementation of a prognostic model into clinical practice is highly required. OBJECTIVE To identify the prognostic factors at entry for the persistence of early inflammatory arthritis and to develop a scoring system to assess the outcome in patients presenting with early inflammatory arthritis. METHODS A cohort of 173 patients with early inflammatory arthritis, were assessed in a special early arthritis clinic. Case definition of synovitis was assessed clinically by the number of tender joint and swollen joint counts as well as symmetry of the affected joints and data were recorded. Baseline HAQ score, serum rheumatoid factor and anti-CCP titre were monitored. Patients satisfying the American College of Rheumatology classification criteria for RA and the European Spondyloarthropathy Study Group criteria for spondylo-arthropathry were excluded, as well as those with a specific rheumatic diagnosis. All the patients were reviewed every 3 months for 24 months period. Ultrasonography for both MCP and PIP joints, both hands, were performed at day of entry and 6 months after initial assessment. All patients had MRI both hands and wrist joints. The arthritis outcome recorded at 1-year follow up represented the gold standard for the diagnosis. Logistic regression analysis was performed to identify the independent factors (predictors) of persistent arthritis and accordingly a scoring system was invented that involved the predictors revealed from the analysis. A ROC curve was set to display the performance of the scoring system and a cut off point was selected taking into consideration a higher sensitivity than specificity, as this model will be mainly used as a screening tool. RESULTS During the follow up period, 93 patients showed evidence of self-limiting arthritis while 80 showed persistent arthritis. Duration of morning stiffness in minutes, percentage change in HAQ score after 3 months duration and anti-CCP positivity were the predictors of persistent arthritis. ROC curve analysis identified a cut off point of 121 above which the early arthritis patient would be more at risk of developing persistent arthritis. CONCLUSION Application of a model (scoring system) to stratify patients presenting with early persistent inflammatory arthritis from those with self-limiting disease can be attained. The developed model was found to be valid on the studied cohort. This model is important for standard clinical practice as the value of prediction of persistent arthritis has its great impact not only for identifying the patients but also on the therapeutic outcome as well.
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Mewar D, Coote A, Moore DJ, Marinou I, Keyworth J, Dickson MC, Montgomery DS, Binks MH, Wilson AG. Independent associations of anti-cyclic citrullinated peptide antibodies and rheumatoid factor with radiographic severity of rheumatoid arthritis. Arthritis Res Ther 2007; 8:R128. [PMID: 16859535 PMCID: PMC1779371 DOI: 10.1186/ar2017] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2006] [Revised: 07/07/2006] [Accepted: 07/20/2006] [Indexed: 11/10/2022] Open
Abstract
Several recent publications have established a strong association between anti-cyclic citrullinated peptide antibody (anti-CCP)-positive rheumatoid arthritis (RA) and carriage of shared epitope (SE) alleles. Although anti-CCP have also been associated with more severe RA, the issue of whether this is independent of rheumatoid factor (RF) has not been addressed. To identify associations between RF, anti-CCP, SE status and radiological damage, we studied a large cross-sectional cohort with longstanding RA. Individuals (n = 872) enrolled in the study all fulfilled the American College of Rheumatology criteria for RA, had a minimum disease duration of 3 years, and at least one definite radiographic erosion was present in hands or feet. Radiographs were scored blind at study entry by a single musculoskeletal radiologist using a modified Larsen's score. Anti-CCP and RF levels were determined using enzyme-linked immunosorbent assay, and DRB1 typing was performed using polymerase chain reaction based methodology. Both anti-CCP and RF levels were strongly associated with radiographic severity (P < 0.0001). In subgroups stratified for both anti-CCP and RF status, evidence of independent associations of both antibodies with radiographic outcome was found (P < 0.0001). An association of SE alleles with radiographic severity was present only in RF-negative individuals. Anti-CCP positivity was associated with SE status with evidence of a gene-dose effect, most markedly in RF-negative individuals (P < 0.01). Anti-CCP and RF status are independent severity factors for RA, with SE alleles playing at most a secondary role. Our data support the view that previously described associations between SE and radiological severity, especially in RF-negative patients, may be indirect and due to an association with anti-CCP.
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Affiliation(s)
- Devesh Mewar
- Division of Genomic Medicine, University of Sheffield, Sheffield, UK
| | - Annabel Coote
- Division of Genomic Medicine, University of Sheffield, Sheffield, UK
| | - David J Moore
- Division of Genomic Medicine, University of Sheffield, Sheffield, UK
| | - Ioanna Marinou
- Division of Genomic Medicine, University of Sheffield, Sheffield, UK
| | - Jodie Keyworth
- Division of Genomic Medicine, University of Sheffield, Sheffield, UK
| | | | | | | | - Anthony G Wilson
- Division of Genomic Medicine, University of Sheffield, Sheffield, UK
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Mewar D, Wilson AG. Autoantibodies in rheumatoid arthritis: a review. Biomed Pharmacother 2006; 60:648-55. [PMID: 17064873 DOI: 10.1016/j.biopha.2006.09.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 09/21/2006] [Indexed: 12/24/2022] Open
Abstract
Emerging insights into the importance of B cells in the pathogenesis of rheumatoid arthritis (RA) as highlighted by the efficacy of B cell depletion is one factor that has contributed to the upsurge of interest in the potential role of autoantibodies both as disease markers and with respect to a pathogenic role. Since the initial description of rheumatoid factor (RF), a large number of both disease-specific and non-specific autoantibodies have been described in patients with RA including antibodies to type II collagen (CII), immunoglobulin binding protein (BiP) and antibodies directed at citrullinated peptides (anti-CCP) and other citrullinated proteins such as vimentin (anti-Sa) . Despite some overlap the serological profile of RA does appear to be distinct from other diseases such as SLE . Although the precise mechanisms responsible for the formation of these antibodies have not been well defined their presence must reflect the interaction between T and B cells believed to be relevant to the pathogenesis of RA. The specificity of the association of such factors as anti-CCP and anti-BiP with RA may reflect unique pathogenic events leading to the processing and presentation of the "cryptic self" . Ease of measurement and stability make autoantibodies attractive diagnostic and prognostic markers particularly in early disease when it may be difficult to distinguish self-limiting synovitis from persistent disease . The purpose of this article is to provide an overview of the current state of knowledge of the spectrum of autoantibodies thus far characterised in individuals with rheumatoid arthritis, and discuss their diagnostic, prognostic and pathogenetic relevance.
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Affiliation(s)
- D Mewar
- School of Medicine and Biomedical Sciences, Beech Hill Rd, Sheffield S10 2RX, UK.
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El Miedany Y, Palmer D, El Gaafary M. Diagnosis of early arthritis: outcomes of a nurse-led clinic. ACTA ACUST UNITED AC 2006; 15:394-9. [PMID: 16723942 DOI: 10.12968/bjon.2006.15.7.20904] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Recent data suggest that early treatment of inflammatory arthritis can improve patient outcomes. While rheumatologists recognized this need for early evaluation and treatment, the current load on the rheumatology service nationwide may limit the capacity for timely evaluation. The authors developed a protocol to be applied through a specialized early arthritis clinic that is able to discriminate between different categories of early arthritis, to shortening the time taken to reach the correct diagnosis and provide the appropriate management. A total of 108 patients have been reviewed in the early arthritis clinic over 12 months. It took 3 weeks for the patients to be fully assessed in the rheumatology clinic instead of 16 weeks. Completing the clinic proforma helped the assessor to cover all causes of arthritis/arthralgia. Disease-modifying antirheumatic drug (DMARD) therapy was initiated within a few weeks (2 to 5 weeks) once diagnosis was confirmed, instead of 8 to 10 months previously. This early arthritis clinic model helped to shorten the referral lag time (duration between symptoms onset and first rheumatologist assessment) as well as lag time to DMARD therapy (duration between symptom onset and the institution of DMARD therapy).
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Affiliation(s)
- Y El Miedany
- Rheumatology Department, Darent Valley Hospital, Dartford, Kent
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Abstract
The treatment of rheumatoid arthritis (RA) has changed dramatically in the past decade as advancements in the understanding of the pathobiology of the disease have led to novel therapeutic agents. The recognition that early diagnosis and treatment leads to improvements in morbidity and mortality has altered the therapeutic strategy such that early therapy is now considered the standard of care. This review focuses on the challenges in making the diagnosis of early RA, including a broad differential diagnosis for inflammatory polyarthritis, poor performance of the standard classification criteria, difficulty in clinical assessment of synovitis, absence of absolute laboratory tests, inability of conventional radiography to detect bony changes early, and barriers to rheumatology care. Additionally, the pathogenesis of RA is highlighted, with particular emphasis on cytokine biology as it relates to therapeutic regimens. Relevant clinical trials in early RA are reviewed and discussed, including trials of combination disease-modifying antirheumatic drugs and biological therapy. The role of induction therapy as a novel therapeutic approach is highlighted. The search for predictors of response is reviewed and the external validity of the trials is analysed. Finally, the trials in early RA therapy suggest that swift intervention with combinations of medications is required for patients with severe RA. However, further research is needed to determine which regimen is appropriate for the individual patient with RA.
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Affiliation(s)
- Amy C Cannella
- University of Nebraska Medical Center, Omaha, Nebraska 68198-3025, USA.
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Shin YS, Choi JH, Nahm DH, Park HS, Cho JH, Suh CH. Rheumatoid factor is a marker of disease severity in Korean rheumatoid arthritis. Yonsei Med J 2005; 46:464-70. [PMID: 16127769 PMCID: PMC2815829 DOI: 10.3349/ymj.2005.46.4.464] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2004] [Accepted: 03/28/2005] [Indexed: 12/01/2022] Open
Abstract
Serum rheumatoid factor (RF) is important in the diagnosis and prognosis of rheumatoid arthritis (RA). The purpose of this study is to compare the clinical characteristics and treatment patterns of RA according to the presence of RF in Korean patients. A retrospective analysis was performed on the records of 109 patients who were followed for at least 2 years, among 230 RA patients who visited at the rheumatology clinic in Ajou University Hospital and who fulfilled the 1987 revised American College of Rheumatology criteria for RA. Sixty-four patients were RF positive (58.7%) and 91 patients were female (83.5%). There was no significant difference in demographic characteristics, joint involvements, or percentage of morning stiffness between seropositive and seronegative groups. Antinuclear antibody was detected more frequently in the seropositive group (p < 0.05). At initial diagnosis, the seropositive group had higher white blood cell and platelet counts than the seronegative group (p < 0.01). However, the difference was disappeared at the last follow-up. Inflammatory markers such as ESR and CRP were also higher at diagnosis in the seropositive group (p < 0.01). These inflammatory markers were still greater than the seronegative group at the last follow-up (p < 0.01). There was no significant difference in the use of disease modifying antirheumatic drug (DMARD) and steroid dosage between groups. However, DMARD combination therapy was more commonly used in the seropositive group (p < 0.05), especially triple DMARD combination. These results suggest that disease activity is more severe in the seropositive than the seronegative group, and more aggressive treatments are needed in the seropositive group.
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Affiliation(s)
- Yoo-Seob Shin
- Department of Allergy and Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Jeong-Hee Choi
- Department of Allergy and Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Dong-Ho Nahm
- Department of Allergy and Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Hae-Sim Park
- Department of Allergy and Rheumatology, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Hyun Cho
- Department of Radiology, Ajou University School of Medicine, Suwon, Korea
| | - Chang-Hee Suh
- Department of Allergy and Rheumatology, Ajou University School of Medicine, Suwon, Korea
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Rönnelid J, Wick MC, Lampa J, Lindblad S, Nordmark B, Klareskog L, van Vollenhoven RF. Longitudinal analysis of citrullinated protein/peptide antibodies (anti-CP) during 5 year follow up in early rheumatoid arthritis: anti-CP status predicts worse disease activity and greater radiological progression. Ann Rheum Dis 2005; 64:1744-9. [PMID: 15843452 PMCID: PMC1755292 DOI: 10.1136/ard.2004.033571] [Citation(s) in RCA: 240] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To study serum levels of citrullinated protein/peptide antibodies (anti-CP) during up to 5 years' follow up of patients with early rheumatoid arthritis (RA), and to relate serum levels to disease course and to treatments in clinical practice. METHODS 279 patients with early RA were followed up with clinical investigations, radiographs, and measurement of anti-CP at baseline and after 3 months, 1, 2, 3, and 5 years. RESULTS 160/279 (57.3%) patients were anti-CP positive at the first visit (mean 5 months after first symptoms). During follow up only 11/279 (3.9%) of the patients changed their anti-CP status. Anti-CP levels fell significantly during the first year, and this drop correlated with the extent of sulfasalazine treatment but not with other drugs or clinical indices. Anti-CP positive and negative patients had similar disease activities at baseline, but during follow up the anti-CP positive patients had worse clinical disease and greater radiological progression, despite at least equally intensive antirheumatic treatment. CONCLUSIONS Anti-CP are stable during the first 5 years of RA, suggesting that events before rather than after onset of clinical manifestations of disease determine this phenotype. The presence of anti-CP at diagnosis predicts a less favourable disease course and greater radiological progression despite antirheumatic treatment, but subsequent changes in antibody levels do not reflect changes in disease activity. Taken together, these observations suggest that anti-CP positive RA is a distinct clinical and pathophysiological entity.
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Affiliation(s)
- J Rönnelid
- Unit of Clinical Immunology, Rudbeck Laboratory C5, SE-75185 Uppsala, Sweden.
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22
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Mewar D, Moore DJ, Young-Min S, Bertolaccini ML, Khamashta MA, Watson PF, Wilson AG. Antiferritin antibodies discovered by phage display expression cloning are associated with radiographic damage in rheumatoid arthritis. ACTA ACUST UNITED AC 2005; 52:3868-72. [PMID: 16320334 DOI: 10.1002/art.21483] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Several autoantibodies have been described in individuals with rheumatoid arthritis (RA), leading to interest in the use of such antibodies as diagnostic or prognostic markers in RA as well as in their relevance to disease pathology. The objective of this study was to use a phage display expression cloning system to identify novel autoantibody targets in RA. METHODS We used immunoscreening of a phage-displayed complementary DNA (cDNA) library to isolate a cDNA clone encoding the ferritin heavy chain polypeptide. Antiferritin antibody levels in patients with early and established RA, healthy controls, and disease controls were measured by enzyme-linked immunosorbent assay. Antibody-positive and antibody-negative individuals were compared with respect to disease severity as measured by the modified Larsen score, demographic variables, rheumatoid factor status, and carriage of HLA-DRB1 shared epitope alleles. RESULTS Antiferritin antibodies were present in 60 (16%) of 366 patients with established RA, 23 (19%) of 118 patients with early RA, 2 (2.7%) of 73 healthy blood donors, 2 (2.1%) of 94 individuals with osteoarthritis, and 2 (2.1%) of 97 patients with systemic lupus erythematosus (P < 0.01, RA patients versus healthy and disease controls). Antiferritin antibodies were more common in men than in women (28.4% versus 12.2%; P < 0.001), and antiferritin levels were associated with the severity of joint damage (P = 0.01). CONCLUSION Antiferritin antibodies are observed in a subset of patients with RA, are present early in the disease course, and are associated with the severity of radiographic damage. Further studies are required to explore their potential as diagnostic and prognostic markers in RA.
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Affiliation(s)
- D Mewar
- Division of Genomic Medicine, University of Sheffield, Sheffield, UK.
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23
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Wernhoff P, Olofsson P, Holmdahl R. The genetic control of rheumatoid factor production in a rat model of rheumatoid arthritis. ACTA ACUST UNITED AC 2003; 48:3584-96. [PMID: 14674011 DOI: 10.1002/art.11342] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate the genetic regulation of rheumatoid factor (RF) in a rat model of rheumatoid arthritis, in order to gain understanding of the enigmatic role of RF in the disease. METHODS IgM-RF and IgG-RF, as well as total levels of immunoglobulins of different subclasses, were measured in sera from rats with pristane-induced arthritis (PIA). The major gene regions were identified by linkage analysis of genetically segregating crosses. RESULTS The production of RF was found to correlate with development of arthritis and to be higher in females than in males. Surprisingly, the relatively arthritis-resistant E3 strain had higher levels of RF than the arthritis-susceptible DA strain. In an (E3 x DA)F(2) cohort a major locus controlling the levels of IgM-RF in serum was identified on chromosome 11 (Rf1) and another on chromosome 16 (Rf3), and these were not related to arthritis susceptibility. However, the Rf2 locus on chromosome 4 controlled IgG-RF levels, IgG2a levels, and chronic arthritis in males (Pia5). Some previously defined arthritis loci (Pia4, Pia6, Pia7, and Pia8) were found to also control immunoglobulin levels in serum. CONCLUSION RFs are produced in the rat PIA model and correlate with development of arthritis. Gene regions controlling RF and serum immunoglobulin levels were identified, of which some cosegregated with arthritis. This suggests a new focus of study to elucidate the role of RF in the pathogenesis of arthritis.
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Yuriev E, Ramsland PA, Edmundson AB. Recognition of IgG-derived peptides by a human IgM with an unusual combining site. Scand J Immunol 2002; 55:242-55. [PMID: 11940231 DOI: 10.1046/j.0300-9475.2002.01032.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
A monoclonal immunoglobulin (Ig)M cryoglobulin (Mez) with interesting binding behaviour was isolated from a Waldenström's macroglobulinemia (WM) patient. It demonstrated very strong binding to peptides derived from the sequences of human IgG. However, when tested for binding to intact IgG, this antibody (Ab) did not show any rheumatoid factor (RF) activity. We propose several nonexclusive structural interpretations of the Mez-binding propensities, based on the orientations and solvent accessibilities of ligand residues and the nature of the Ab-binding site. To further characterize the structural features of Mez-peptide binding, IgG-derived octapeptides were docked into the Mez fragment variable (Fv)-binding site, revealing additional reasons for Mez-binding selectivity based on the interactions of the docked peptides with the Mez Fv. The problem was also approached from an immunological perspective. Comparisons of Mez variable region of the light chain (VL)/variable region of the heavy chain (VH) sequences with those of human germlines and known IgM RFs allowed us to provide a possible outline tracing the structural and functional origins of the Mez IgM. Coupled with examinations of interactions in docked complexes, this analysis led us to propose that the potential for RF activity, demonstrated through Mez binding to IgG-derived peptides, was owing to the inherent sequence and structure of the Mez IgM, rather than to somatic mutations. Thus, Mez IgM may occupy an intermediate niche between IgMs with and without RF activity.
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Affiliation(s)
- E Yuriev
- Crystallography Program, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA
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25
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Rau R, Herborn G, Menninger H, Sangha O. Radiographic outcome after three years of patients with early erosive rheumatoid arthritis treated with intramuscular methotrexate or parenteral gold. Extension of a one-year double-blind study in 174 patients. Rheumatology (Oxford) 2002; 41:196-204. [PMID: 11886970 DOI: 10.1093/rheumatology/41.2.196] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To compare the radiographic outcomes after 36 months in patients with early erosive rheumatoid arthritis (RA) who were treated with methotrexate (MTX) or gold sodium thiomalate (GSTM). METHODS In a randomized, double-blind fashion, 174 patients from two centres were assigned to receive weekly intramuscular injections of either 15 mg MTX or 50 mg GSTM. After 12 months, the study was continued as an open prospective study for an additional 2 yr, administering the same amount of MTX and half of the GSTM dose. Radiographic outcomes were assessed by standardized methods in all patients at baseline and after 6, 12, 24 and 36 months. RESULTS Intention-to-treat analysis showed that patients treated with MTX had higher radiographic scores and more erosive joints at all follow-up points. However, there was no statistically significant difference between the two treatment groups. The progression rate was significantly slower during the second and third years of follow-up in both groups. Baseline and time-integrated (area under the curve over 6 months) disease activity parameters were good predictors of radiographic outcome after 3 yr. Seropositivity was not an independent predictor of progression. However, patients who were positive for rheumatoid factor had higher time-integrated disease activity (with less response to treatment) and thus their disease was significantly more progressive. CONCLUSION Both of the disease-modifying compounds used in this study, MTX and GSTM, were able to reduce the slope of radiographic progression during 3 yr of follow-up. There was some advantage for parenteral gold but no significant intergroup difference.
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Affiliation(s)
- R Rau
- Department of Rheumatology, Evangelisches Fachkrankenhaus, Ratingen, Germany
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Ollier WE, Harrison B, Symmons D. What is the natural history of rheumatoid arthritis? Best Pract Res Clin Rheumatol 2001; 15:27-48. [PMID: 11358413 DOI: 10.1053/berh.2000.0124] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Inflammatory polyarthritis can be a self-limiting disease, develop into rheumatoid arthritis (RA) or differentiate into another form of chronic arthritis. It remains a clinical and scientific challenge to understand the relationship between these phenotypes, determine their aetiologies and predict the course and outcome for individual patients. Even patients labelled as having RA show a wide spectrum of clinical phenotypes. Disease definition is a major problem in studying the aetiology of RA as currently used classification criteria were derived using patients with established disease. RA is thought to result from the combination of genetic susceptibility and exposure to an appropriate environmental trigger. The genetic component is probably oligogenic. The association with HLA has been known for over 25 years. RA is now thought to be associated with a conserved sequence of amino acids in a number of HLA-DRB1 alleles, called the RA shared epitope. However, the shared epitope appears to be associated with RA chronicity and severity more than with susceptibility. Other potential RA susceptibility genes include IL-1, aromatase, corticotropin-releasing hormone and a region on the X chromosome. Hormonal and reproductive factors also influence RA susceptibility and severity. RA is more common in women than men, especially before the menopause. Men may be protected by hormonal factors and require a stronger genetic component to develop disease. Although infectious triggers of RA have long been suspected, no definitive evidence has been obtained. Previous blood transfusion, smoking and obesity are also possible risk factors. Chronicity and remission are important aspects of the natural history of early RA. Although we can identify patients at risk of adverse prognosis with some accuracy, we remain unable to predict remission. Functional disability and radiological damage are the most studied outcomes in RA. Radiological damage often occurs early in the course of RA, but patients may show erosion for the first time several years after symptom onset. Many studies have demonstrated a relationship between HLA and features of severe RA in established patients. This appears to be related to gene dosage.
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Affiliation(s)
- W E Ollier
- ARC Epidemiology Unit, University of Manchester Medical School, Oxford Road, Manchester, M13 9PT, UK
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Harrison B, Symmons D. Early inflammatory polyarthritis: results from the Norfolk Arthritis Register with a review of the literature. II. Outcome at three years. Rheumatology (Oxford) 2000; 39:939-49. [PMID: 10986297 DOI: 10.1093/rheumatology/39.9.939] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
Circulating autoimmune complexes of IgM rheumatoid factors (RF) bound to the Fc portions of normal, polyclonal IgG antibodies are frequently present in humans with rheumatoid arthritis (RA). The sweet tasting methyl ester of L-Asp-L-Phe (aspartame or APM) was found to relieve pain and improve joint mobility in subjects with osteo- and mixed osteo/rheumatoid arthritis [Edmundson, A. B. and Manion, C. V. (1998). Clin. Pharmac. Ther. 63, 580-593]. These clinical observations prompted the testing of the inhibition by APM of the binding interactions of human IgM RFs with IgG Fc regions. The propensity of APM to inhibit IgM RF binding was assessed by competitive enzyme immunoassays with solid-phase human IgG. Ten RA serum samples and three purified monoclonal cryoglobulins, all of which had RF activity, were tested in this system. We found that the presence of APM significantly reduced the binding of IgM RFs. The inhibitory propensity of APM with monoclonal RF cryoglobulins was increased by the addition of CaCl(2) to the binding buffer. Similar inhibition of the binding of RA derived RFs to IgG was observed for Asp-Phe and its amidated derivative, indicating that the methyl ester is not required for APM's interaction with IgM antibodies. A human (Mez) IgM known to bind octameric peptides derived from the Fc portion of a human IgG(1) antibody was tested for binding of dipeptides by the Pepscan method of combinatorial chemistry. The relative binding constants of Asp-Phe and Phe-Asp were ranked among the highest values for 400 possible combinations of the 20 most common amino acids. Possible blocking interactions of APM were explored by computer-assisted docking studies with the model of a complex of an RF Fab with the Fc of a human IgG(4) antibody. Modeling of ternary immune complexes revealed a few key residues, which could act as molecular recognition sites for APM. A structural hypothesis is presented to explain the observed interference with RF reactivity by APM. Extrapolations of the current results suggest that APM may inhibit the binding of IgG in a substantial proportion of IgM RFs. Interference of RF reactivity, especially in RA patients, may alleviate the pain and immobility resulting from chronic inflammation of the joints.
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Affiliation(s)
- P A Ramsland
- Crystallography Program, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104, USA
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Bonagura VR, Kwong T, Kenny T, Robbins DL, Morrison SL. The specificity of synovial IgM rheumatoid factors (RF) for genetically engineered IgG antibodies is not affected by the method used to immortalize RF-producing B cells. Scand J Immunol 1999; 49:106-11. [PMID: 10023865 DOI: 10.1046/j.1365-3083.1999.00475.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Previously, we have shown that some rheumatoid factors (RFs) produced by Epstein-Barr virus (EBV)-transformed B cells from patients with rheumatoid arthritis (EBV-RA-RF) appear to be disease-specific autoantibodies that bind differently to defined epitopes on genetically engineered IgG antibodies, compared with RFs expressed by patients with Waldenstrom's macroglobulinaemia (Wmac-RFs) and healthy immunized donors (HID-RFs). To exclude the possibility that EBV transformation is responsible for these differences, we have now studied 15 other monoclonal IgM RFs from patients with RA that were produced by heterohybridoma-B-cell fusion (HRA-RFs). These HRA-RFs show the same gross specificity profiles for IgG as do their EBV-RA-RF counterparts. However, when the specificities of the HRA-RF and EBV-RA-RF panels were combined and compared with those RFs from patients with Wmac or HID, significant differences in binding specificity were again observed. Hybrid IgG3/4 antibodies made by exon shuffles between the IgG3 and IgG4 wild-type genes, and families of IgG variant antibodies made by site-directed mutagenesis, were used to map the fine specificity of HRA-RFs. The fine specificity of HRA-RFs were also similar to those of EBV-RA-RFs. These studies demonstrate that the method used for immortalizing IgM, RF-producing B cells from RA patients does not influence the specificity of the RFs obtained. Furthermore, some RFs expressed in RA have distinct and unique specificities, and may therefore represent disease-specific autoantibodies.
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Affiliation(s)
- V R Bonagura
- Department of Pediatrics, Schneider Children's Hospital, Long Island Jewish Medical Center, New Hyde Park, NY 11040, USA
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Jackson CG, Williams HJ. Disease-modifying antirheumatic drugs. Using their clinical pharmacological effects as a guide to their selection. Drugs 1998; 56:337-44. [PMID: 9777310 DOI: 10.2165/00003495-199856030-00003] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Rheumatoid arthritis is a disease of unknown aetiology characterised by persistent joint swelling, functional disability and increased mortality. No curative therapy exists at present but some therapeutic agents, commonly referred to as disease-modifying drugs, offer the potential for suppression of the inflammatory activity and attenuation of the disease process. Since the precise mechanism of action of most disease modifying drugs is uncertain, the selection of a particular therapy must at present be based on the pharmacologic properties of each available agent, appropriately individualised for each clinical setting. The toxicity of disease-modifying agents often limits the dose and/or duration of therapy and makes careful monitoring mandatory. No consensus exists as to the order in which disease-modifying agents should be employed. Less toxic disease-modifying drugs such as auranofin, hydroxychloroquine, minocycline, and sulfasalazine are usually used in early and mild disease. Azathioprine, penicillamine (D-penicillamine), methotrexate and parenteral gold are usually considered to be more toxic and are most often used in the setting of progressive disease while the most toxic agents, such as chlorambucil and cyclophosphamide, are reserved for life-threatening manifestations such as vasculitis. Newer therapeutic approaches presently under study include the use of existing drugs in combination and novel biologic agents which selectively inhibit lymphocyte and cytokine activity. These strategies offer the hope of more efficacious and less toxic therapy in the future.
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Affiliation(s)
- C G Jackson
- University of Utah School of Medicine, Salt Lake City Veterans Affairs Hospital, USA
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Möttönen T, Paimela L, Leirisalo-Repo M, Kautiainen H, Ilonen J, Hannonen P. Only high disease activity and positive rheumatoid factor indicate poor prognosis in patients with early rheumatoid arthritis treated with "sawtooth" strategy. Ann Rheum Dis 1998; 57:533-9. [PMID: 9849312 PMCID: PMC1752741 DOI: 10.1136/ard.57.9.533] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To investigate the prognostic significance of clinical and genetic markers on the outcome of patients with recent-onset rheumatoid arthritis (RA) treated actively with slow acting antirheumatic drugs (SAARDs). METHODS A total of 142 consecutive patients with early RA (median disease duration of 7 months) were treated according to the "sawtooth" strategy and prospectively followed up for an average of 6.2 years. Several clinical parameters at start as well as genetic markers were related to the functional outcome (ARA Functional class and HAQ disability score) and radiographic joint damage (Larsen's score) at the latest visit. RESULTS In logistic regression analysis only Mallya score (including morning stiffness, pain scale, grip strength, Ritchie's articular index, haemoglobin, and erythrocyte sedimentation rate) at baseline, and Mallya score and rheumatoid factor (RF) positivity at one year were found to be of significance with respect to the radiographic outcome of the patients. Furthermore, at the latest visit HAQ score was related to radiographic score. At baseline the mean ages of the DR4 positive patients and the patients with RA associated DR alleles were statistically significantly lower than those without the above mentioned risk factors (44 v 49, p = 0.03 and 41 v 53, p = 0.04, respectively). However, these genetic markers had no prognostic significance on the functional or radiographic outcome of the patients. CONCLUSION High clinical disease activity at baseline and RF positivity especially at one year after the institution of SAARD treatment are the best predictors of poor prognosis in early RA. However, from the clinical point of view, the disease outcome of an individual patient with early RA, cannot be predicted accurately enough by present means.
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Affiliation(s)
- T Möttönen
- Department of Medicine, Turku University Central Hospital, Finland
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32
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Bonagura VR, Agostino N, Børretzen M, Thompson KM, Natvig JB, Morrison SL. Mapping IgG Epitopes Bound by Rheumatoid Factors from Immunized Controls Identifies Disease-Specific Rheumatoid Factors Produced by Patients with Rheumatoid Arthritis. THE JOURNAL OF IMMUNOLOGY 1998. [DOI: 10.4049/jimmunol.160.5.2496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
We have mapped the specificity of 28 monoclonal IgM rheumatoid factors (RFs) produced by heterohybridomas derived from five healthy blood donors immunized with mismatched human red blood cells (HID). The HID-RFs did not differ in their binding specificity for IgG epitopes from RFs that we previously analyzed from patients with Waldenström’s macroglobulinemia. However, IgM RFs produced by HID differed in their specificity for IgG compared with RFs expressed by patients with rheumatoid arthritis (RA-RFs). Only 1 of 28 HID-RFs bound all IgG subclasses (pan binding pattern) compared with 7 of 19 RA-RFs (p = 0.006). Three HID-RFs bound IgG3 compared with 9 RA-RFs (p = 0.007). Fine specificity differences were also identified between HID- and RA-RFs. Therefore, some RA-RFs show novel specificities for IgG not found among RFs from HID or individuals with Waldenström’s macroglobulinemia who do not have joint disease. These Abs with unique specificities may represent disease-specific autoantibodies in patients with RA. Nine of the HID-RFs from the same individual were clonally related, and several contained somatic mutations. Even when the clonally related HID-RFs were considered as one RF for comparison, the reactivity of the HID-RFs differed significantly from RA-RFs in their inability to recognize all IgG subclasses (p = 0.044) and recognize IgG3 (p = 0.041). Interestingly, among the clonally related RFs, considerable differences in the specificity for IgG were also observed, with the RF containing the most somatic mutations in VH and VL showing the most distinctive specificity changes. Therefore, these studies also demonstrate a correlation between somatic mutation and binding specificity.
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Affiliation(s)
- Vincent R. Bonagura
- *Division of Allergy/Immunology, Department of Pediatrics, Schneider Children’s Hospital, Long Island Jewish Medical Center; and
- †Department of Microbiology and Immunology, Albert Einstein College of Medicine, New Hyde Park, NY 11040
| | - Nick Agostino
- *Division of Allergy/Immunology, Department of Pediatrics, Schneider Children’s Hospital, Long Island Jewish Medical Center; and
| | - Marie Børretzen
- ‡Institute of Immunology and Rheumatology, The National Hospital, University of Oslo, Oslo, Norway; and
| | - Keith M. Thompson
- ‡Institute of Immunology and Rheumatology, The National Hospital, University of Oslo, Oslo, Norway; and
| | - Jacob B. Natvig
- ‡Institute of Immunology and Rheumatology, The National Hospital, University of Oslo, Oslo, Norway; and
| | - Sherie L. Morrison
- §Department of Microbiology and Molecular Genetics, University of California, Los Angeles, CA 90024
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Abstract
Rheumatoid arthritis (RA), a chronic polyarticular disease affecting about 1% of the adult population of the world, produces significant joint destruction, physical impairment, work disability, and early mortality. Patients with RA may have a slowly or rapidly progressive disease or a self-limited one. To design a rational treatment program for all patients, the clinician must identify early on whether patients are destined to have a rapidly progressive disease. This article reviews socioeconomic, psychological, immunogenetic, and disease-related features that may help to identify such patients.
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Affiliation(s)
- G S Alarcón
- Division of Clinical Immunology and Rheumatology, The University of Alabama at Birmingham, 35294, USA
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Vinasco J, Beraún Y, Nieto A, Fraile A, Mataran L, Pareja E, Martín J. Polymorphism at the TNF loci in rheumatoid arthritis. TISSUE ANTIGENS 1997; 49:74-8. [PMID: 9027971 DOI: 10.1111/j.1399-0039.1997.tb02715.x] [Citation(s) in RCA: 89] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The purpose of this work was to analyze the possible influence of TNF loci polymorphism on the susceptibility and/or the disease profile of rheumatoid arthritis (RA). Tumor necrosis factor (alpha and beta) genotypes were determined in 60 patients with RA and 102 healthy subjects by a method based on PCR-RFLP with amplification-created restriction sites. The results obtained in the present study showed that there is not a significant association of either TNF alpha promoter variation (at positions -308 and -238) or TNF beta polymorphism with susceptibility to RA. However, a significant difference in the mean age at disease onset was found between -238 TNF alpha genotypes. In addition, a difference in the presence of nodular disease was observed between -308 TNF alpha genotype. The results of this study suggests that the TNF alpha gene may play a role in the disease profile of rheumatoid arthritis.
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Affiliation(s)
- J Vinasco
- Instituto de Parasitología y Biomedicina López Neyra, CSIC, Granada, Spain
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35
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Alarcón GS, Willkens RF, Ward JR, Clegg DO, Morgan JG, Ma KN, Singer JZ, Steen VD, Paulus HE, Luggen ME, Polisson RP, Ziminski CM, Yarboro C, Williams HJ. Early undifferentiated connective tissue disease. IV.Musculoskeletal manifestations in a large cohort of patients with undifferentiated connective tissue diseases compared with cohorts of patients with well-established connective tissue diseases: followup analyses in patients with unexplained polyarthritis and patients with rheumatoid arthritis at baseline. ARTHRITIS AND RHEUMATISM 1996; 39:403-14. [PMID: 8607889 DOI: 10.1002/art.1780390308] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES To examine the musculoskeletal manifestations in a large cohort of patients (n = 410) diagnosed with either a well-established connective tissue disease (CTD) (n = 197) or an early undifferentiated CTD (n = 213) with a symptom duration of <1 year. This study was aimed at determining the predictive value of demographic, clinical, and laboratory features on outcome in patients with unexplained polyarthritis (UPA) (from the early undifferentiated CTD cohort; n = 67) or rheumatoid arthritis (RA) (from the well-established CTD cohort; n = 57), over a 5-year followup period. METHODS Patients from both cohorts were assessed at years 1, 3, and 5. At the study visits, clinical data were collected in a standardized manner, and sera were obtained and stored. A priori criteria were established for patient ascertainment and diagnosis over the duration of the study. Standard statistics were used for comparisons of baseline characteristics in patients diagnosed as having systemic lupus erythematosus, RA, undifferentiated CTD, and UPA at entry into the cohorts. Baseline features in patients with UPA were examined according to the different subsequent outcomes (RA, CTD, or undifferentiated CTD, remission [nonpersistent], or persistent or active UPA). Baseline features in patients with RA whose disease remained active versus those in whom remission was attained were also examined. Two multivariable analyses, classification trees and polychotomous logistic regression, were performed to predict disease outcomes over time. RESULTS The overall rate of ascertainment for the 410 patients ranged from 90 % at year 1 to 71 % at year 5. Patients with established CTDs showed a tendency for more stable diagnoses than those with early undifferentiated CTDs (90-100% versus 45-70%). Consistent baseline predictors of persistent active disease among patients with RA, in both univariate and multivariable analyses, were higher joint counts for pain and tenderness and higher erythrocyte sedimentation rate (ESR). In approximately 20% of patients who were classified as having RA when they originally entered the cohort, the disease was in remission at 5 years. Twenty percent of the patients originally classified as having UPA developed RA over the duration of the study. These patients tended to be older and to have swelling of small joints at baseline. However, a consistent pattern of predictive variables could not be identified in the multivariable analyses, other than at year 1 (higher small joint counts for swelling and higher ESR). CONCLUSION Baseline features (joint counts, and ESR) among RA patients were variously predictive of persistently active disease at years 1-5. Consistent baseline predictors of outcome among patients with UPA only emerged at year 1. Remission occurred in approximately 20% of RA patients, whereas a similar percentage of patients with UPA developed RA. These findings have implications with regard to treatment decisions in patients with early RA and/or UPA.
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Affiliation(s)
- G S Alarcón
- The University of Alabama at Birmingham, 34294, USA
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36
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Abstract
Rheumatoid arthritis (RA) and spondylarthropathies are the most frequent chronic inflammatory arthritides. RA is a potentially severe disease which causes a functional handicap in nearly half the patients 10 years after the first clinical symptoms. However RA is a heterogenous disorder characterized by wide variations in clinical manifestations, disease course and response to therapy. No prognosis factor has been identified and universally accepted and validated. Markers of prognosis would be highly appreciated by clinicians who could then more closely adapt their management decisions to the disease potential. Clinical and biological data collected to date have provided a limited amount of information. Nevertheless, ESR, CRP and rheumatoid factor titer appeared to be the most powerful available indicators of prognosis at the early stage of the disease. Recent progress in molecular biology strongly suggests that genetic markers (HLA-DRB1 alleles) could be correlated with disease severity and it would appear possible to distinguish immunogenetically homogeneous subpopulations of patients with RA. Serum concentrations of specific cartilage and bone molecules reflecting tissue turnover could correlate to rate of joint destruction. Finally a combination of the most pertinent markers could determine a "score of severity" of the disease. In spondylarthropathies, limited information is available at present. The variables which were usually correlated with disease severity are: onset before 16 years of age, hip arthritis, ESR, limitation of lumbar spine, sausage-like finger or toe, oligoarthritis, poor efficacy of nonsteroidal antiinflammatory drugs and rapid evolution during the first 2 years. Genetic factors could also have prognosis value that should be clarified.
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Affiliation(s)
- B Combe
- Fédération de rhumatologie, hôpital Lapeyronie, Montpellier, France
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37
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Abstract
Rheumatoid arthritis is a chronic, progressive disease with a long-term outcome characterized by significant morbidity, loss of functional capacity, and increased mortality. The cornerstone of therapy includes the appropriate melding of pharmacological, rehabilitative, and surgical treatments. New developments in the care of patients with rheumatoid arthritis have focused on aggressive pharmacological therapy early in the course of the illness, ongoing assessment of disease activity and patient function, and a better understanding of the role of rehabilitative techniques such as therapeutic exercise and behavioral approaches to education. This article synthesizes information from studies on recent advances in the management of rheumatoid arthritis outlining diagnosis and assessment, disability issues, outcome studies, current status of traditional and experimental pharmacological therapies, and new strategies of nonpharmacological treatments aimed at the clinician challenged by this fascinating disorder.
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Affiliation(s)
- E L Semble
- Department of Internal Medicine, Bowman Gray School of Medicine, Winston-Salem, NC 27157
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38
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Aho K, Palusuo T, Kurki P. Marker antibodies of rheumatoid arthritis: diagnostic and pathogenetic implications. Semin Arthritis Rheum 1994; 23:379-87. [PMID: 7524151 DOI: 10.1016/0049-0172(94)90088-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Rheumatoid arthritis (RA) is associated with several autoantibodies specific enough to serve as diagnostic and prognostic markers. These include rheumatoid factor (RF), antikeratin antibody (AKA), antiperinuclear factor (APF), and anti-RA33. The first three, and possibly also anti-RA33, may precede the onset of clinical RA. The prevalence of positive test reactions depends on the period between taking the specimen and onset of disease; when the period is short, the prevalence is nearly the same as in established disease. Thus, RA has a long asymptomatic period with broadening immunological activity. The assays for AKA and APF (and possibly also for anti-RA33), compared with RF testing, yielded greater specificity rather than the ability to define any subgroup with particularly severe disease. Used together, the above marker antibodies may form a new and more enlightened basis for defining seropositive RA. It is commonly believed that genetically mediated immune response plays an important role in the initiation of RA. However, the role of the major histocompatibility complex antigens may be in modulation of the inflammatory reaction in a later phase.
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Affiliation(s)
- K Aho
- National Public Health Institute, Helsinki, Finland
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39
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40
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Yanni G, Whelan A, Feighery C, Bresnihan B. Synovial tissue macrophages and joint erosion in rheumatoid arthritis. Ann Rheum Dis 1994; 53:39-44. [PMID: 8311554 PMCID: PMC1005241 DOI: 10.1136/ard.53.1.39] [Citation(s) in RCA: 142] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To analyse the mononuclear cell populations in synovial membrane biopsies obtained before treatment from patients with rheumatoid arthritis (RA) and to correlate the findings with the degree of joint damage occurring over one year. METHODS Multiple needle biopsy specimens were obtained from inflamed knee joints on entry to the study. The tissue samples were examined using immunohistochemical techniques. The degree of joint damage was estimated using the Larsen radiological index. RESULTS Twelve patients were studied. It was observed that there was a significant correlation between the number of synovial tissue macrophages and the degree of joint erosion over one year (r = 0.66; p = 0.04). The synovial lining layer contained large numbers of macrophages and the cellularity of the lining layer correlated significantly with the number of macrophages infiltrating the sublining areas (r = 0.65; p = 0.01). Finally, the cellularity of the lining layer correlated with the synovial fluid levels of interleukin-6 (r = 0.66; p = 0.04). The radiological course did not correlate with infiltrating T or B lymphocyte populations, but did correlate with other previously identified indicators of the clinical course, including a high index of disease activity and IgA rheumatoid factors levels. CONCLUSION This study suggests that synovial tissue macrophages play a critical role in the pathogenesis of joint erosion in RA.
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Affiliation(s)
- G Yanni
- Department of Rheumatology, University College, Dublin, Ireland
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41
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Goñi MA, Scheines EJ, Paira SO, Barceló HA, Maldonado Cocco JA. Rheumatoid nodulosis: a puzzling variant of rheumatoid arthritis. Clin Rheumatol 1992; 11:396-401. [PMID: 1458790 DOI: 10.1007/bf02207201] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Four patients with rheumatoid nodulosis are here described, together with a review of cases reported to date in the literature. This particular variant of rheumatoid arthritis (RA) is characterized by the presence of subcutaneous rheumatoid nodules, scanty or absent systemic manifestations and a clinically benign course. Joint involvement appears more commonly as palindromic rheumatism, although patients with arthralgia episodes alone and others with chronic polyarthritis have been described. Seldom reported up to now, a consideration of this entity may help to avoid diagnostic pitfalls and the use of aggressive therapy.
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Affiliation(s)
- M A Goñi
- Rheumatology Department, Instituto Nacional de Rehabilitación, Buenos Aires, Argentina
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42
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Deighton CM, Surtees D, Walker DJ. Influence of the severity of rheumatoid arthritis on sex differences in health assessment questionnaire scores. Ann Rheum Dis 1992; 51:473-5. [PMID: 1586243 PMCID: PMC1004694 DOI: 10.1136/ard.51.4.473] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In a study of 284 consecutive patients with rheumatoid arthritis attending hospital clinics a previous observation that female patients score higher on the Stanford Health Assessment Questionnaire (HAQ) than men was confirmed. A clinical disease severity score and the spread/severity index also showed that women had more severe disease. Although scores in some categories of the HAQ were higher in women, they were not disproportionately so, providing no evidence that domestic categories of the HAQ are biased against women. A multiple regression analysis showed that the spread/severity index score was the best predictor of HAQ scores, with sex making no significant contribution. The severity of the disease adequately explained the higher HAQ scores in female patients with rheumatoid arthritis.
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Affiliation(s)
- C M Deighton
- Department of Rheumatology, University of Newcastle upon Tyne, United Kingdom
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43
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Artandi SE, Calame KL, Morrison SL, Bonagura VR. Monoclonal IgM rheumatoid factors bind IgG at a discontinuous epitope comprised of amino acid loops from heavy-chain constant-region domains 2 and 3. Proc Natl Acad Sci U S A 1992; 89:94-8. [PMID: 1370358 PMCID: PMC48182 DOI: 10.1073/pnas.89.1.94] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
A combination of site-directed mutagenesis and exon exchange has been used to further define the structure on IgG recognized by monoclonal IgM rheumatoid factors (RFs) from patients with Waldenstrom macroglobulinemia. Most of these RFs bound IgG1, -2, and -4 but not IgG3. For these RFs, His-435 is a critical residue for binding and replacing it with arginine, the residue present in IgG3, destroys or reduces RF binding. However, additional polymorphic sequences in both the heavy-chain constant-region domains (CH) 2 and 3 are important for RF binding. Among the important residues in CH2 are amino acids 252-254 and 309-311, which are conserved among IgG isotypes and comprise two loops of amino acids on the surface of the domain. Therefore, at least three regions, two from CH2 and one from CH3, contribute significantly to the epitope recognized by the RFs. Although this epitope contains many of the same residues as the staphylococcal protein A binding site on IgG, the binding specificities of staphylococcal protein A and monoclonal RFs are not identical. Sera from patients with rheumatoid arthritis contain antibodies directed not only at this epitope but also at other sites on IgG.
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Affiliation(s)
- S E Artandi
- Department of Microbiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032
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44
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Abstract
Antirheumatic drugs fall into four categories: non-steroidal anti-inflammatory drugs (NSAIDs), slow-acting antirheumatic drugs (SAARDs), corticosteroids, and cytotoxic drugs. NSAIDs are useful in controlling the symptoms and signs of inflammation. They work within a few days but patients' response varies widely and is unpredictable. Hence there is a wide choice of agent. Anxiety about the side-effects of NSAIDs, particularly on the stomach and kidney, is growing and their use is likely to decline, especially in the elderly. SAARDs are being used increasingly early in the disease. It is realized that there is only a small window of opportunity (2 years) in which to get the disease into remission before irreversible damage is done to the joints. Thus, there is a growing tendency to use combinations of SAARDs together with steroids early in the disease. The most appropriate treatment for established RA (of more than 2 years duration) is less easy to discern. It is important to define realistic treatment goals on an individual basis and to tailor the medication accordingly. Cytotoxic drugs are still reserved for severe aggressive joint disease or for systemic manifestations. Once we are able to predict outcome more accurately, the stage will be set for a trial of combination chemotherapy in severe early RA.
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45
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Caruso I, Santandrea S, Sarzi Puttini P, Montrone F, Boccassini L, Azzolini V, Cazzola M, Dell'Acqua D. Prevention of appearance of radiological lesions in early rheumatoid arthritis: a randomized, single-blind study comparing intra-articular rifamycin with auranofin. J Int Med Res 1992; 20:61-77. [PMID: 1568521 DOI: 10.1177/030006059202000108] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
In a prospective, randomized, single-blind study of 116 patients with early rheumatoid arthritis (mean disease duration 7 months), therapeutic activity of intra-articular rifamycin SV (525 mg/week) infiltration into each peripheral joint over 10 weeks was compared with that of 3 mg auranofin given orally twice daily. The incidence of side-effects was lower in rifamycin-treated patients. At the end of follow-up, the clinical variables and erythrocyte sedimentation rate showed a significant and persistent improvement both in 16 patients who continued the auranofin treatment regularly and in 55 treated with rifamycin who had completed the therapeutic cycle 62.5 months before; the latex test decreased only in the rifamycin group. In patients treated with auranofin or who changed to other commonly used antirheumatic agents, 57% of those with an initially negative radiological picture developed new radiological lesions in at least one of the small joints compared with 9% in the rifamycin group. Although the number of patients treated with rifamycin was small and the follow-up relatively short, the results of the study indicated that treatment with intra-articular rifamycin SV may prevent the appearance of radiological lesions in patients with early rheumatoid arthritis and normal radiographs initially.
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Affiliation(s)
- I Caruso
- Rheumatology Unit, L. Sacco Hospital, Milan, Italy
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46
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Vlachoyiannopoulos PG, Moutsopoulos HM. Rheumatoid arthritis in south-east Europe. BAILLIERE'S CLINICAL RHEUMATOLOGY 1992; 6:221-33. [PMID: 1563037 DOI: 10.1016/s0950-3579(05)80345-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The clinical, serological and immunogenetic studies of RA in mediterranean countries and other small tribal groups have added some more information that is valuable in understanding the pathogenesis of RA. However, the immunogenetic studies seem to be more helpful in understanding the mechanisms of initiation of disease and its dissimilarities in different ethnic groups than in discovering its cause. It should also be stressed that, in addition to genetic factors, other factors may influence disease expression. This proposal was supported by a study from Africa which revealed an increasing incidence and severity of RA in rural compared with urbanized African populations (Brighton, 1987). Thus, the variability factor influencing disease expression may lie in the environment (Woodrow, 1988).
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47
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Soden M, Rooney M, Whelan A, Feighery C, Bresnihan B. Immunohistological analysis of the synovial membrane: search for predictors of the clinical course in rheumatoid arthritis. Ann Rheum Dis 1991; 50:673-6. [PMID: 1958087 PMCID: PMC1004527 DOI: 10.1136/ard.50.10.673] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Immunohistological features which might predict the clinical course and outcome of rheumatoid arthritis were sought by examining multiple synovial membrane samples obtained by needle biopsy from the knee joints of 57 patients who had not received disease modifying antirheumatic drugs. Clinical measurements, but not biopsies, were repeated one year and three years after starting treatment. A correlation between both the intensity of synovial lining layer thickening and mononuclear cell infiltration and the clinical status at the time of biopsy was seen. After three years of treatment the correlations were maintained in patients who had presented and persisted with milder disease but not in patients who had presented with more active disease.
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Affiliation(s)
- M Soden
- University College Dublin, Department of Rheumatology, St Vincent's Hospital, Ireland
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48
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Borque L, Rus A, Ruiz R. Automated turbidimetry of rheumatoid factor without heat inactivation of serum. EUROPEAN JOURNAL OF CLINICAL CHEMISTRY AND CLINICAL BIOCHEMISTRY : JOURNAL OF THE FORUM OF EUROPEAN CLINICAL CHEMISTRY SOCIETIES 1991; 29:521-7. [PMID: 1954306 DOI: 10.1515/cclm.1991.29.8.521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We describe an improved turbidimetric procedure for rheumatoid factor measurement in human serum. Heat-aggregated human IgG is used as antigen. Interference produced by the complement component C1q, which required a previous heat pretreatment of sera, is avoided by the addition of the chemical inhibitor, poly(vinyl sulphonic acid). This inhibitor eliminates C1q interference without affecting the attachment of rheumatoid factor to the Fc part of IgG, thus permitting full automation of the assay. After studying the reactivity of different heat-aggregated IgG preparations, we optimized the procedure for preparing the antigen in order to attain maximal reactivity: IgG was heated at 63 degrees C until the absorbance at 340 nm of a 1/10 dilution of the antigen lay between 0.65 and 0.95 absorbance units. The study of antigen stability showed a maximum aggregation two weeks after preparation. The antigen was then stable and could be used in the assay. The standard curve extends from 30 to 500 x 10(3) IU/l. Intra- and inter-assay CV were less than 5.5%. Relative analytical sensitivity and specificity were 98.3% and 95.2%, respectively. The results agreed well with those obtained by the non-improved turbidimetric procedure (r = 0.996) and with nephelometry values on the Behring nephelometer analyser (r = 0.964). The correlation with an enzyme immunoassay was also good (r = 0.923).
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Affiliation(s)
- L Borque
- Laboratorio de Bioquímica, Hospital San Millán, Logroño, Spain
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49
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Meenan RF, Kazis LE, Anthony JM, Wallin BA. The clinical and health status of patients with recent-onset rheumatoid arthritis. ARTHRITIS AND RHEUMATISM 1991; 34:761-5. [PMID: 2053922 DOI: 10.1002/art.1780340618] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
This study was designed to document the clinical and health status of patients with recent-onset rheumatoid arthritis (RA). Three groups were studied: 108 patients who had had RA for greater than 1 year (established RA group), 313 patients who had had RA for less than or equal to 1 year (recent-onset RA group), and 188 healthy friend of the patients with recent-onset RA (no RA group). Clinical status was measured using tender joint count, erythrocyte sedimentation rate, and overall physician assessment. Health status was measured using the physical, psychological, pain, and arthritis impact scores of the Arthritis Impact Measurement Scales. Scores on all clinical and health status measures indicated substantial disease effects in the group with recent-onset RA. For most of these measures, effect size analysis indicated that clinical and health status impacts in the recent-onset RA group were similar in magnitude to those found in the groups with more established disease, with scores in both groups being substantially different from those found in the no RA group. These results document the magnitude of the clinical and health status impacts in recent-onset RA. They lend support to recent arguments advocating aggressive therapy earlier in the course of this frequently disabling disease.
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Affiliation(s)
- R F Meenan
- Arthritis Center, Boston University, MA 02118
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Abstract
Rheumatoid arthritis continues to be recognised as a disorder with a variable prognosis, but recent studies have emphasised its potential for shortening life span. Epidemiological, genetic, and natural history studies have helped to identify patients who are at risk for the development of more aggressive disease earlier in their clinical course, and rheumatologists are willing to be more aggressive in their treatment now as their armamentarium expands. Earlier separation of drugs into anti-inflammatory and immunomodulatory agents becomes irrelevant as these concepts change and drugs fulfil both definitions. Sequences of therapy continue to be dictated by the potential of toxicity and generally follow rather than precede disease progression. The addition of several new agents to the algorithms of therapy against rheumatoid arthritis raises questions about their effects and place in therapeutic regimens, especially as concerns auranofin, sulphasalazine, methotrexate and cyclosporin. Combination therapy is currently at the end of the drug line, but the therapeutic horizon beckons with the potential of biological agents aimed at the restoration of immune balance.
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Affiliation(s)
- R F Willkens
- Harborview Medical Center, University of Washington, Seattle
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