Yap drives the development of cardiovascular disease in patients with rheumatoid arthritis

Background

To assess the influence of serum level of YAP on laboratory examination findings, imaging findings and disease activity of rheumatoid arthritis patients combined cardiovascular disease (RA-CVD).

Methods

RA-CVD patients (n=60), RA-nCVD patients (n=60) and healthy subjects (n=60) were recruited. Serum levels of YAP in them were detected by qRT-PCR. Their baseline characteristics were analyzed and compared. Disease activity, CVD risk factors and imaging findings in RA-CVD and RA-nCVD patients were evaluated and compared. In addition, potential influences of YAP on disease activity, CVD risk factors and imaging findings in RA-CVD patients were assessed.

Results

RA-CVD patients had higher levels of ERS, anti-CCP, RF, HDL-C, CRP, FRS, BNP, LA, LVs, LVd and cIMT, and lower level of EF in comparison to RA-nCVD patients. Serum level of YAP was higher in RA-CVD patients than that of RA-nCVD patients and healthy subjects. YAP level was positively correlated to DAS28, TG, CRP, PLT, FRS, BNP and cIMT in RA-CVD patients.

Conclusions

Serum level of YAP increases in RA-CVD patients. YAP is a potential factor driving the development of CVD in RA patients through regulating inflammatory response, lipid metabolism, glycometabolism and thrombosis.

Chronic intermittent hypobaric hypoxia ameliorates vascular reactivity through upregulating adiponectin expression of PVAT in metabolic syndrome rats

Cumulating evidence demonstrated that chronic intermittent hypobaric hypoxia (CIHH) had beneficial effects on the body. This study investigated the role of perivascular adipose tissue (PVAT) in ameliorating effect of CIHH on vascular reactivity by adiponectin in mesenteric artery of metabolic syndrome (MS) rats. Main methods: 6-week-old male Sprague-Dawley rats were randomly divided into four groups: control (CON), MS model, CIHH treatment, and MS + CIHH treatment group. The size of adipocytes in PVAT was measured by scanning electron microscopy. Serum adiponectin was measured. The microvessel recording technique was used to observe the effect of CIHH on contraction and relaxation in mesenteric artery rings. Also, the expressions of interleukin-1β, tumor necrosis factor-α, adiponectin, AdipoR1, AdipoR2, APPL1, and endothelial nitric oxide synthase (eNOS) were assayed by Western blotting. Key findings: in MS rats, adipocyte size increased, serum adiponectin decreased, contraction reaction increased while relaxation reaction decreased, the expression of pro-inflammatory cytokines was upregulated, while adiponectin was downregulated in PVAT, and the expressions of AdipoR1, AdipoR2, APPL, and phosphorylated-eNOS were downregulated in mesenteric artery. All aforementioned abnormalities of MS were ameliorated in MS + CIHH rats. We concluded that CIHH treatment improves vascular reactivity through upregulating adiponectin expression and downregulating pro-inflammatory cytokine expression of PVAT in MS rats.

Ischemic Heart Disease and Rheumatoid Arthritis-Two Conditions, the Same Background

Rheumatoid arthritis (RA) is one of the most frequent inflammatory rheumatic diseases, having a considerably increased prevalence of mortality and morbidity due to cardiovascular disease (CVD). RA patients have an augmented risk for ischemic and non-ischemic heart disease. Increased cardiovascular (CV) risk is related to disease activity and chronic inflammation. Traditional risk factors and RA-related characteristics participate in vascular involvement, inducing subclinical changes in coronary microcirculation. RA is considered an independent risk factor for coronary artery disease (CAD). Endothelial dysfunction is a precocious marker of atherosclerosis (ATS). Pro-inflammatory cytokines (such as TNFα, IL-1, and IL-6) play an important role in synovial inflammation and ATS progression. Therefore, targeting inflammation is essential to controlling RA and preventing CVD. Present guidelines emphasize the importance of disease control, but studies show that RA- treatment has a different influence on CV risk. Based on the excessive risk for CV events in RA, permanent evaluation of CVD in these patients is critical. CVD risk calculators, designed for the general population, do not use RA-related predictive determinants; also, new scores that take into account RA-derived factors have restricted validity, with none of them encompassing imaging modalities or specific biomarkers involved in RA activity.

Specialized Pro-Resolving Lipid Mediators: The Future of Chronic Pain Therapy?

Chronic pain (CP) is a severe clinical entity with devastating physical and emotional consequences for patients, which can occur in a myriad of diseases. Often, conventional treatment approaches appear to be insufficient for its management. Moreover, considering the adverse effects of traditional analgesic treatments, specialized pro-resolving lipid mediators (SPMs) have emerged as a promising alternative for CP. These include various bioactive molecules such as resolvins, maresins, and protectins, derived from ω-3 polyunsaturated fatty acids (PUFAs); and lipoxins, produced from ω-6 PUFAs. Indeed, SPMs have been demonstrated to play a central role in the regulation and resolution of the inflammation associated with CP. Furthermore, these molecules can modulate neuroinflammation and thus inhibit central and peripheral sensitizations, as well as long-term potentiation, via immunomodulation and regulation of nociceptor activity and neuronal pathways. In this context, preclinical and clinical studies have evidenced that the use of SPMs is beneficial in CP-related disorders, including rheumatic diseases, migraine, neuropathies, and others. This review integrates current preclinical and clinical knowledge on the role of SPMs as a potential therapeutic tool for the management of patients with CP.

Mitogen and Stress-Activated Kinases 1 and 2 Mediate Endothelial Dysfunction

Inflammation promotes endothelial dysfunction, but the underlying mechanisms remain poorly defined in vivo. Using translational vascular function testing in myocardial infarction patients, a situation where inflammation is prevalent, and knock-out (KO) mouse models we demonstrate a role for mitogen-activated-protein-kinases (MAPKs) in endothelial dysfunction. Myocardial infarction significantly lowers mitogen and stress kinase 1/2 (MSK1/2) expression in peripheral blood mononuclear cells and diminished endothelial function. To further understand the role of MSK1/2 in vascular function we developed in vivo animal models to assess vascular responses to vasoactive drugs using laser Doppler imaging. Genetic deficiency of MSK1/2 in mice increased plasma levels of pro-inflammatory cytokines and promoted endothelial dysfunction, through attenuated production of nitric oxide (NO), which were further exacerbated by cholesterol feeding. MSK1/2 are activated by toll-like receptors through MyD88. MyD88 KO mice showed preserved endothelial function and reduced plasma cytokine expression, despite significant hypercholesterolemia. MSK1/2 kinases interact with MAPK-activated proteins 2/3 (MAPKAP2/3), which limit cytokine synthesis. Cholesterol-fed MAPKAP2/3 KO mice showed reduced plasma cytokine expression and preservation of endothelial function. MSK1/2 plays a significant role in the development of endothelial dysfunction and may provide a novel target for intervention to reduce vascular inflammation. Activation of MSK1/2 could reduce pro-inflammatory responses and preserve endothelial vasodilator function before development of significant vascular disease.

Rheumatoid arthritis: Extra-articular manifestations and comorbidities

Although synovitis is the pathological hallmark of rheumatoid arthritis (RA), many extra-articular manifestations (EMs) and comorbidities likely occur due to the complex, chronic, inflammatory, and autoimmune features of RA. Cardiovascular (CV) disease is the most common cause of death in patients with RA. Compared to the general population, patients with RA have twice the risk of myocardial infarction and up to 50% increased CV mortality risk. Severe and prolonged disease activity, genetics, and inflammation (e.g. CRP, ACPA, cytokines, matrix-degrading enzymes) play important roles in CV disease and atheroscleroticdamage. The second major cause of death in patients with RA is respiratory disease, which occurs in 30-40% of patients. RA may affect the lung interstitium, airways, and pleurae, while pulmonary vascular involvement is less frequent. Central and peripheral nervous system involvement is usually due to small vessel vasculitis, joint damage, or drug toxicity. There is also evidence that microvascular cerebral damage caused by systemic inflammation is associated with the development of Alzheimer's disease and vascular dementia. Some observational studies have hinted how Disease Modified Anti-Rheumatic Drugs and biologics could reduce the incidence of dementia. Primary gastrointestinal and renal involvements are rare and often relate to drug therapy. To minimize morbidity and mortality, physicians must manage RA disease activity (treat-to-target) and monitor risk factors and concomitant conditions (e.g. smoking cessation; weight regulation; monitoring blood pressure, lipids, thyroid hormone, folic acid and homocysteine; screening for depression, anxiety, atlantoaxial instability, and atherosclerosis). This article aims to provide an overview of the most prevalent and important EMs and comorbidities associated with RA.

Assessment of Serum Lipid Profiles and High-sensitivity C-reactive Protein Among Patients Suffering from Rheumatoid Arthritis at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia: A Cross-Sectional Study

Background

Rheumatoid arthritis (RA) is a chronic inflammatory disease characterized by severe joint pain, swelling, damage, and disability which leads to joint destruction and loss of function. The complication of RA is associated with cardiovascular diseases, particularly due to systemic inflammation and dyslipidemia. The purpose of this study was to assess the development of atherosclerosis, which acts as a major risk factor for cardiovascular complications in RA patients.

Methods

A hospital-based cross-sectional study was conducted at the Rheumatology Clinic of Tikur Anbessa Specialized Hospital. The study made a comparison of risk factors (dyslipidemia and inflammatory status) between individuals having RA as a case group and apparently healthy individuals as a control group. Simple descriptive statistics, one-way ANOVA, independent sample t-test and multivariate analysis were utilized for statistical analysis. p-value of <0.05 at the 95% confidence level was considered as statistically significant.

Results

The result of this study demonstrated that there was a significant elevation of mean ±SD of TC, TC/HDL, LDL/HDL, and lowered value of HDL-C was seen among RA patients than controls (P-value <0.05). The mean ±SD of inflammatory marker, high-sensitivity C-reactive protein (hsCRP), was significantly higher among RA patients compared to controls (P<0.05). HDL-C had a significant negative correlation with a hsCRP whereas TC/HDL-C and LDL/HDL-C had a significant positive correlation with hsCRP (P<0.05).

Conclusion

In this study, RA patients had lipid abnormalities and elevated systemic inflammation than controls. An increase in hsCRP and dyslipidemia status among RA patients indicates the possible development of an atherosclerotic event. Therefore, assessment of lipid profiles and hsCRP in early RA patients may be helpful to assess the possible development of cardiovascular complications.

[Clinicopatological variants and risk factors for chronic kidney disease in rheumatoid arthritis]

Recent studies have shown a high risk of chronic kidney disease and associated cardiovascular complications in patients with rheumatoid arthritis (RA), which determines the prognosis. However, the prevalence of chronic kidney disease (CKD) in RA has not been established in the Russians.

AIM

Study was to examine the prevalence, risk factors and histological variants of CKD in RA.

MATERIALS AND METHODS

180 patients with rheumatoid arthritis were observed in the Tareev clinic of nephrology, for the period from 2014 to 2019 years. Age, gender, duration of RA, drug therapy, ESR, CRP, DAS28, renal function, proteinuria, histological variants were analyzed. Of the common population risk factors for CKD arterial hypertension, weight index, serum lipids and glucose levels were also assessed.

RESULTS

The prevalence of CKD in RA was 19.7%. Age, presence and stage of arterial hypertension, an increase in body mass index, as well as high rates of disease activity ESR, CRP, DAS28 score and duration of RA were risk factors of CKD in RA. Age, duration of the disease, stage of AH and hypercholesterolemia were risk factors in multifactorial regression analysis. Amyloidosis was the most common histologic pattern (50.0%), followed by chronic glomerulonephritis (30.4%) and tubulo-interstitial nephritis (19.6%). Among chronic glomerulonephritis mesangial glomerulonephritis was the most frequent. Renal amyloidosis was associated with a duration of RA, presence of systemic symptoms and CRP level. An isolated decrease in GFR of less than 60 ml/min was detected in 31 (36.0%) out of 86 patients. Сonclusion. The risk factors for CKD in patients with RA are activity and duration of the disease In addition to common population factors. Amyloidosis was the most common histologic pattern associated with duration of RA and inflammatory proteins levels.

A prospective, longitudinal monocentric study on laser Doppler imaging of microcirculation: comparison with macrovascular pathophysiology and effect of adalimumab treatment in early rheumatoid arthritis

Increased cardiovascular (CV) morbidity and mortality have been found in rheumatoid arthritis (RA). Tumour necrosis factor α (TNF-α) inhibitors may improve vascular function. In the first part of this study, we determined microcirculation during postoocclusive reactive hyperemia (PORH) representing endothelial function. In a nonselected population (n = 46) we measured flow-mediated vasodilation (FMD) of the brachial artery and laser Doppler flow (LDF) by ultrasound. Among LDF parameters, we determined TH1 (time to half before hyperemia), TH2 (time to half after hyperemia), Tmax (time to maximum) and total hyperemic area (AH). We measured von Willebrand antigen (vWF:Ag) by ELISA. In the second part of the study, we assessed the effects of adalimumab treatment on microcirculatory parameters in 8 early RA patients at 0, 2, 4, 8 and 12 weeks. We found significant positive correlations between FMD and LDF Tmax (R = 0.456, p = 0.002), FMD and TH2 (R = 0.435, p = 0.004), and negative correlation between vWF:Ag and Tmax (R = - 0.4, p = 0.009) and between vWF:Ag and TH2 (R = - 0.446, p = 0.003). Upon adalimumab therapy in early RA, TH2 times improved in comparison to baseline (TH2_baseline = 26.9 s vs. TH2_4weeks = 34.7 s, p = 0,032), and this effect prolonged until the end of treatment (TH2_8weeks = 40.5, p = 0.026; TH2_12weeks = 32.1, p = 0.013). After 8 weeks of treatment, significant improvement was found in AHa (AH_baseline = 1599 Perfusion Units [PU] vs. AH_8weeks = 2724 PU, p = 0.045). The PORH test carried out with LDF is a sensitive option to measure endothelial dysfunction. TH1 and TH2 may be acceptable and reproducible markers. In our pilot study, treatment with adalimumab exerted favorable effects on disease activity, endothelial dysfunction and microcirculation in early RA patients.

Specialized pro-resolving lipid mediators: A new class of non-immunosuppressive and non-opioid analgesic drugs

We now appreciate that the mechanism of resolution depends on an active and time-dependent biosynthetic shift from pro-inflammatory to pro-resolution mediators, the so-called specialized pro-resolving lipid mediators (SPMs). These SPMs are biosynthesized from the omega-3 fatty acids arachidonic acid (AA), eicosapentaenoic acid (EPA), docosapentaenoic acid (DPA), or docosahexaenoic acid (DHA). Despite effective for a fraction of patients with rheumatic diseases and neuropathic pain, current analgesic therapies such as biological agents, opioids, corticoids, and gabapentinoids cause unwanted side effects, such as immunosuppression, addiction, or induce analgesic tolerance. A growing body of evidence demonstrates that isolated SPMs show efficacy at very low doses and have been successively used as therapeutic drugs to treat pain and infection in experimental models showing no side effects. Moreover, SPMs work as immunoresolvents and some of them present long-lasting analgesic and anti-inflammatory effects (i.e. block pain without immunosuppressive effects). In this review, we focus on how SPMs block pain, infection and neuro-immune interactions and, therefore, emerge as a new class of non-immunosuppressive and non-opioid analgesic drugs.

Relationship between lower limb vascular characteristics, peripheral arterial disease and gait in rheumatoid arthritis

OBJECTIVES

Rheumatoid arthritis (RA) is associated with higher risk of atherosclerotic vascular disease, including peripheral arterial disease (PAD). The aim of this study was to measure lower limb vascular characteristics (indicative of PAD), using non-invasive chairside testing methods, in people with RA compared to matched controls, and to determine the association between vascular characteristics and gait velocity as a measure of functional capacity in people with RA.

METHODS

This was a cross-sectional pilot study which measured lower limb vascular characteristics (bilateral continuous wave Doppler, toe brachial index [TBI] and ankle brachial index [ABI]) and gait velocity (6-m walk test) in people with RA and controls. Differences in vascular characteristics between groups were determined using linear regression models, and associations between vascular characteristics and gait were determined using logistic regression models.

RESULTS

Seventy-two participants were included: 34 participants with RA mean disease duration 26.2 (SD 12.1) and 38 age- and sex-matched controls. The control group contained 30 females (79%), and the RA group had 28 females (82%). There were no significant differences between the RA and control groups for lower limb vascular characteristics. People with RA walked significantly slower compared to controls (1.10 m/s vs 0.91 m/s, P < .001). People with RA who had abnormal TBI, or abnormal qualitative Doppler walked significantly slower compared to those with normal TBI (0.86 m/s vs 0.95 m/s, P = .043 and 0.81 m/s, vs 0.93 m/s, P = .028). There was no significant association between ABI and gait velocity.

CONCLUSION

This study did not identify different lower limb vascular characteristics in people with RA compared to matched controls. However, in people with RA, abnormal Doppler and TBI results are associated with slower walking velocity.

Microvascular endothelial dysfunction in rheumatoid arthritis

The systemic autoimmune disease rheumatoid arthritis (RA) is characterized by increased cardiovascular mortality and morbidity and is an independent cardiovascular risk factor. Cardiovascular diseases (CVDs) result from accelerated atherogenesis, which is a consequence of endothelial dysfunction in the early stages of the disease. Endothelial dysfunction is a functional and reversible alteration of endothelial cells and leads to a shift in the properties of the endothelium towards reduced vasodilation, a pro-inflammatory state, and proliferative and prothrombotic properties. In RA, endothelial dysfunction can occur in the large vessels (such as the conduit arteries) and in the small vessels of the microvasculature, which supply oxygen and nutrients to the tissue and control inflammation, repair and fluid exchange with the surrounding tissues. Growing evidence suggests that microvascular endothelial dysfunction contributes to CVD development, as it precedes and predicts the development of conduit artery atherosclerosis and associated risk factors. As such, numerous studies have investigated microvascular endothelial dysfunction in RA, including its link with disease activity, disease duration and inflammation, the effect of treatments on endothelial function, and possible circulating biomarkers of microvascular endothelial dysfunction. Such findings could have important implications in the cardiovascular risk management of patients with RA.

Chronic kidney disease in rheumatoid arthritis patients: prevalence, risks factors, histopathological variants

The present review is focused on risk factors of chronic kidney disease in rheumatoid arthritis (RA). According to recent data, the chronic kidney disease (CKD) in RA patients is more often than at patients without RA. It is closely associated with risk of cardiovascular disease and high mortality. Besides of general population risk factors of CKD, the activity of the disease is independent predictors of reduction in glomerular filtration rate less than 60 ml/min/1.73 m2. In the review, histopathological variants and mechanisms of CKD on basis of international experience are also considered. Suppression of inflammation by basic therapy of RA and biological therapy have changed outcomes RA, prevalence, and structure of kidney involvement in recent years.

Values and Correlations between C-Reactive Protein and Apolipoprotein B after Treatment with Methotrexate at Patients with Rheumatoid Arthritis

BACKGROUND:

Patients with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease (CVD). Lipid changes related to inflammation have been described in RA. Methotrexate (MTX) treatment is effective in controlling inflammation and decreasing the CRP (C-reactive protein) values.

AIM:

To examine the disease activity, CRP and Apo B values in the detection of new patients with active and untreated RA, and impact of MTX therapy on their levels after 6 months and one year of treatment, and the correlation between their values in this period.

METHODS:

80 patients with active and newly discovered RA patients who meet the American Rheumatology Association (ARA) 1987 revised criteria were treated with disease-modifying anti-inflammatory drugs (DMARDs) according to the protocol for treatment.

RESULTS:

After a year of therapy RA patients achieved significant decrease in the DAS28 (disease activity score) (p < 0.01 and p < 0.001), and CRP values (p < 0.001). Levels of Apo B values at the 12 months were nonsignificantly higher compared to the results obtained at the beginning of the study (p < 0.001). After 6 and 12 months there was a weak nonsignificant negative correlation about the values of CRP and Apo B at baseline and after 12 months (r = –0.15 and r = -0.12 p > 0.05).

CONCLUSION:

Use of MTX therapy at RA patients had a reduced effect on disease activity and inflammation, but the nonsignificance effect on the values of Apo B lipoproteins.

Retinal Vessel Diameters and Physical Activity in Patients With Mild to Moderate Rheumatic Disease Without Cardiovascular Comorbidities

Objectives: Low-grade systemic inflammation is responsible for atherosclerotic lesions in patients with rheumatic diseases. Vascular dysfunction is a precursor of atherosclerosis and can be improved by physical activity (PA). Our aim was to asses micro- and macrovascular function as well as PA and cardiorespiratory fitness (CRF) in patients with rheumatic diseases in the absence of cardiovascular (CV) comorbidities compared to controls. Methods: Fifty-one patients without CV comorbidities were compared to 35 controls. Retinal microvascular diameters were assessed using a Retinal Vessel Analyzer. Arterial stiffness (AST) was measured by applanation tonometry. CRF was assessed as peak oxygen consumption and PA was assessed with a questionnaire. Results: Retinal venular diameters were significantly wider in patients [median 221 μm (interquartile range (IQR) 211, 231)] compared to controls [median 215 μm (IQR 196, 223); p = 0.01]. One hour increase of PA per week led to a venular constriction of -0.56 μm (95%CI -1.09, -0.03; p = 0.04). In our patients with low disease activity (median DAS28 1.9; median BASDAI 2.8), no differences in AST were evident compared to controls. The association of PA and CRF with AST was not independent of blood pressure. Conclusions: Patients with rheumatic disease and mild-to-moderate disease activity show an impairment of the retinal microvasculature but not of large artery stiffness. Retinal vessel analysis seems to be a sensitive biomarker to unmask vascular impairments even in the absence of classic CV risk factors. PA may have the potential to counteract the development of small artery disease at early stages of rheumatic disease.

Effects of supervised exercise training on lower-limb cutaneous microvascular reactivity in adults with venous ulcers

Purpose

To investigate the effects of a 12-week supervised exercise programme on lower-limb cutaneous microvascular reactivity in adults with venous leg ulceration.

Methods

Thirty-eight adults with unilateral venous ulceration who were being treated with lower-limb compression therapy (58% male; mean age 65 years; median ulcer size 5 cm²) were randomly allocated to exercise or control groups. Exercise participants (n = 18) were invited to attend thrice weekly sessions of lower-limb aerobic and resistance exercise for 12 weeks. Cutaneous microvascular reactivity was assessed in the gaiter region of ulcerated and non-ulcerated legs at baseline and 3 months using laser Doppler fluxmetry coupled with iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP). Cutaneous vascular conductance (CVC) was calculated as laser Doppler flux (AU)/mean arterial pressure (mmHg).

Results

Thirty-seven participants completed follow-up assessments. Median session attendance was 36 (range 2–36). Analyses of covariance revealed greater peak CVC responses to ACh in the exercise group at 3 months in both the ulcerated (adjusted difference = 0.944 AU/mmHg; 95% CI 0.504–1.384) and non-ulcerated (adjusted difference = 0.596 AU/mmHg; 95% CI 0.028–1.164) legs. Peak CVC responses to SNP were also greater in the exercise group at 3 months in the ulcerated leg (adjusted difference = 0.882 AU/mmHg; 95% CI 0.274–1.491), but not the non-ulcerated leg (adjusted difference = 0.392 AU/mmHg; 95% CI − 0.377 to 1.161).

Conclusion

Supervised exercise training improves lower-limb cutaneous microvascular reactivity in adults with venous leg ulceration.

The "Choosing Wisely" initiative in infectious diseases

OBJECTIVE

"Choosing Wisely" is a growing international campaign aiming at practice changes to improve patient health and safety by both, conduct of essential and avoidance of unnecessary diagnostic, preventive and therapeutic procedures. The goal is to create an easily recognizable and distributable list ("Choosing Wisely items") that addresses common over- and underuse in the management of infectious diseases.

METHODS

The German Society of Infectious Diseases (DGI) participates in the campaign "Klug Entscheiden" by the German Society of Internal Medicine. Committee members of the (DGI) listed potential 'Choosing Wisely items'. Topics were subjected to systematic evidence review and top ten items were selected for appropriateness. Five positive and negative recommendations were approved via individual member vote.

RESULTS

The final recommendations are: (1) Imperatively start antimicrobial treatment and remove the focus in Staphylococcus aureus bloodstream infection. (2) Critically ill patients with signs of infection need early appropriate antibiotic therapy. (3) Annual influenza vaccination should be given to individuals with age >60 years, patients with specific co-morbidities and to contact persons who may spread influenza to others. (4) All children should receive measles vaccine. (5) Prefer oral formulations of highly bioavailable antimicrobials whenever possible. (6) Avoid prescribing antibiotics for uncomplicated upper respiratory tract infections. (7) Do not treat asymptomatic bacteriuria with antibiotics. (8) Do not treat Candida detected in respiratory or gastrointestinal tract specimens. (9) Do not prolong prophylactic administration of antibiotics in patients after they have left the operating room. (10) Do not treat an elevated C-reactive protein (CRP) or procalcitonin with antibiotics for patients without signs of infection.

CONCLUSIONS

Physicians will reduce potential harm to patients and increase the value of health care when implementing these recommendations.

Infliximab equivalently suppresses oxidative stress compared to tocilizumab among well-controlled patients with rheumatoid arthritis

AIM

This study was designed to investigate which biological agent, infliximab or tocilizumab, would more intensively keep suppressing oxidative stress among well-controlled patients as C-reactive protein (CRP) levels normalized in rheumatoid arthritis (RA). In addition, it was intended to clarify indicative factors of oxidative stress among well-controlled patients with RA.

METHODS

We recruited 61 well-controlled (CRP < 0.3 mg/dL within normal ranges) patients with RA using biological agents (infliximab n = 33; tocilizumab n = 28), active RA patients with CRP > 1.0 mg/dL (n = 10) and healthy subjects (n = 10) and examined the fraction of oxidized albumin (oxidized-albumin [%]) as a marker of oxidative stress in addition to inflammatory measures and disease activity scores such as CRP, erythrocyte sedimentation rate (ESR), matrix metalloproteinase 3 (MMP-3), serum amyloid A (SAA), Clinical Disease Activity Index, Simplified Disease Activity Index, visual analog scale (VAS), Disease Activity Index of 28 joints (DAS28)-CRP, DAS28-ESR and renal function (creatinine clearance [CCr]).

RESULTS

Oxidized-albumin (%) was significantly elevated among active RA patients (33.83 ± 5.31%) as compared with healthy subjects (23.00 ± 2.56%). Although oxidized-albumin (%) among well-controlled RA patients also increased, there was no difference with oxidized-albumin (%) between infliximab and tocilizumab groups (26.40 ± 5.44% in infliximab; 26.62 ± 4.53% in tocilizumab). In Pearson's correlation, oxidized-albumin (%) had significant correlations with CRP, MMP-3, ESR, SAA, age, CCr, VAS, DAS28-CRP and DAS28-ESR. With those variables, multiple stepwise forward regression analysis was conducted and revealed that CCr, DAS28-ESR and CRP are the statistically significant explanatory variables on oxidized-albumin (%) among well-controlled RA patients.

CONCLUSIONS

We demonstrated that there was no difference with infliximab and tocilizumab on oxidative stress and we clarified that CCr, DAS28-ESR and CRP become indicative factors of oxidative stress among well-controlled RA patients.

Inflammation as a Risk of Developing Chronic Kidney Disease in Rheumatoid Arthritis

Objective

The relationship between chronic inflammation and the incidence of chronic kidney disease (CKD) remained not-clear in patients with rheumatoid arthritis (RA). This study aims to examine the relationship between persistently high C-reactive protein (CRP), a marker of inflammation, and the incidence of CKD in RA.

Methods

We retrospectively examined the relationship between the levels of CRP and incidence of CKD in 345 RA patients. The outcome of interest was incidence of CKD, defined as an estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² and/or positive dipstick testing for proteinuria for ≥3 months. We defined high CRP, as >3.0 mg/L. On the basis of three measurements of CRP for 6-months period, patients were divided into three groups: group 1, including patients with no high CRP values; group 2, patients with transient high CRP values (once or twice) and group 3, patients with persistently high CRP values.

Results

During a median follow-up period of 89 months, 14% of all patients developed CKD. The cumulative incidence of CKD was 7% in group 1, 14% in group 2 and 22% in group 3 (P = 0.008, log-rank test). In a multivariate analysis, including classical risk factors for CKD, persistently high CRP was an independent predictor of the incidence of CKD (hazard ratio, 3.00; 95% confidence interval, 1.23–8.53; P = 0.01).

Conclusions

Persistently high CRP was a significant risk factor for the incidence of CKD. Results suggest that persistent inflammation is a marker for the high risk of CKD in RA.

Cardiovascular and autoimmune diseases in females: The role of microvasculature and dysfunctional endothelium

Cardiovascular (CV) diseases are becoming increasingly frequent and associated with a high incidence of CV events, disability and death. It is known that there is a relationship between CV burden and systemic autoimmune diseases (SADs) that is mainly due to inflammation and autoimmunity, but the other mechanisms underlying the high CV risk of SAD patients have not yet been fully clarified. The aim of this review article is to discuss some of the specific factors associated with the accelerated atherosclerosis (ATS) characterising SADs (female sex, the microcirculation and the endothelium) in order to highlight the importance of an early diagnosis and the prompt implementation of preventive measures, as well as the possible role of new therapeutic strategies such as vaccine immunomodulation. Finally, as the natural history of ATS begins with endothelial injury (a potentially reversible process that is influenced by various factors) and microvascular damage plays a central role in the etiopathogenesis of SADs, it underlines the crucial need for the development of reliable means of detecting sub-clinical abnormalities in the microcirculation, particularly coronary microcirculation dysfunction.

An important role for A20-binding inhibitor of nuclear factor-kB-1 (ABIN1) in inflammation-mediated endothelial dysfunction: an in vivo study in ABIN1 (D485N) mice

Introduction

The link between cardiovascular disease (CVD) and patients with chronic inflammation is not clearly understood. We examined a knock-in mouse expressing a poly-ubiquitin-binding-defective mutant of the protein ABIN1 (ABIN1(D485N)), which develops a systemic lupus erythematosus-like autoimmune disease because of the hyperactivation of IκB kinases (IκKs) and mitogen-activated protein kinases (MAPKs). These mice were used to determine the potential role of these signaling pathways in inflammation-mediated CVD development.

Methods

Laser Doppler imaging in combination with the iontophoresis of vasoactive chemicals were used to assess endothelium-dependent vasodilatation in vivo in ABIN1 (D485N)) mutant defective (n = 29) and wild-type (WT) control (n = 26) mice. Measurements were made at baseline, and animals were subdivided to receive either chow or a proatherogenic diet for 4 weeks, after which, follow-up assessments were made. Paired and unpaired t tests, and ANOVA with post hoc Bonferroni correction were used for statistical significance at P <0.05.

Results

Endothelium-dependent vasodilatation to acetylcholine was attenuated at 4 weeks in ABIN1(D485N)-chow-fed mice compared with age-matched WT-chow-fed mice (P <0.05). The magnitude of attenuation was similar to that observed in WT-cholesterol-fed animals (versus WT-chow, P <0.01). ABIN1(D485N)-cholesterol-fed mice had the poorest endothelium-dependent responses compared with other groups (P <0.001). ABIN1(D485N)-chow-fed mice had increased plasma interleukin-6 (IL-6) levels (versus WT-chow, P <0.001), and this was further elevated in ABIN1(D485N)-cholesterol-fed mice (versus ABIN1(D485N)-chow; P <0.05). IL-1α was significantly greater in all groups compared with WT-chow (P <0.01). ABIN1(D485N) mice showed significant cardiac hypertrophy (P <0.05).

Conclusions

The ABIN(D485N) mice display endothelial dysfunction and cardiac hypertrophy, which is possibly mediated through IL-6 and, to a lesser degree, IL-1α. These results suggest that the ABIN1-mediated hyperactivation of IKKs and MAPKs might mediate chronic inflammation and CVD development.

Sleep quality and duration are related to microvascular function: the Amsterdam Growth and Health Longitudinal Study

Sleep and sleep disorders are related to cardiovascular disease, and microvascular function is an early cardiovascular disease marker. Therefore, the relationship of sleep (measured in sleep quality and duration) with microvascular function was examined in healthy adults. Sleep quality was assessed with the validated Sleep Wake Experience List (SWEL) questionnaire. Duration of sleep was self-reported in an additional question. Microvascular function was measured using nailfold capillaroscopy. Linear regression analyses were used to examine the relationship between sleep and microvascular function. Potential confounders included physical activity, smoking, blood pressure, body mass index and several biochemical parameters. Analyses were performed in 259 participants (116 men). For women reporting insufficient (<7 h) sleep duration, microvascular function (post-ischaemic capillary recruitment) was significantly lower (b = -11.17; P = 0.04) compared to women reporting sufficient sleep duration. There was no relationship between sleep quality and microvascular function in females. In males, a trend towards lower capillary recruitment was found in those reporting a combination of poor sleep quality and insufficient duration (b = -7.54; P = 0.09), compared to those reporting good sleep quality as well as sufficient duration. This study suggests an association between sleep and microvascular function. Which aspects of sleep exactly affect microvascular function, and if indeed the association is different between males and females in other samples, needs further research.

Cardiovascular involvement in autoimmune diseases

Autoimmune diseases (AD) represent a broad spectrum of chronic conditions that may afflict specific target organs or multiple systems with a significant burden on quality of life. These conditions have common mechanisms including genetic and epigenetics factors, gender disparity, environmental triggers, pathophysiological abnormalities, and certain subphenotypes. Atherosclerosis (AT) was once considered to be a degenerative disease that was an inevitable consequence of aging. However, research in the last three decades has shown that AT is not degenerative or inevitable. It is an autoimmune-inflammatory disease associated with infectious and inflammatory factors characterized by lipoprotein metabolism alteration that leads to immune system activation with the consequent proliferation of smooth muscle cells, narrowing arteries, and atheroma formation. Both humoral and cellular immune mechanisms have been proposed to participate in the onset and progression of AT. Several risk factors, known as classic risk factors, have been described. Interestingly, the excessive cardiovascular events observed in patients with ADs are not fully explained by these factors. Several novel risk factors contribute to the development of premature vascular damage. In this review, we discuss our current understanding of how traditional and nontraditional risk factors contribute to pathogenesis of CVD in AD.

Chronic arthritis and cardiovascular disease: altered blood parameters give rise to a prothrombotic propensity

OBJECTIVE

Rheumatoid arthritis, and to a lesser extent ankylosing spondylitis and psoriatic arthritis, associates with increased morbidity and mortality due to cardiovascular complications. We hypothesized that the increased risk of cardiovascular disease is reflected by changes in blood parameters that are compatible with a prothrombotic propensity. To substantiate this notion, we performed an extensive literature search identifying such parameters.

METHODS

A search through PubMed (1970-2013) was done to find primary articles with the following search terms: rheumatoid arthritis, ankylosing spondylitis, psoriatic arthritis or synovial fluid. These were combined with keywords reflecting processes of atherothrombosis: atherosclerosis, cardiovascular disease, coagulation, endothelial, fibrinolysis, mean platelet volume, microparticle, platelet, platelet count and mass, thrombosis, and thrombus.

RESULTS

The published studies point to a multitude of blood-related processes that can contribute to a prothrombotic propensity in chronic inflammatory diseases. These include an increase in platelet mass; low-level platelet activation, enforced by interaction with leukocytes and the formation of proinflammatory cytokines; a locally activated endothelium; and an increased coagulant activity. Patient treatment with methotrexate or TNF-α blockers appears to result in normalization of several of these prothrombotic parameters.

CONCLUSION

This analysis provides a first identification of the mechanisms by which inflammatory arthritis can aggravate cardiovascular disease.

Endothelial dysfunction in chronic inflammatory diseases

Chronic inflammatory diseases are associated with accelerated atherosclerosis and increased risk of cardiovascular diseases (CVD). As the pathogenesis of atherosclerosis is increasingly recognized as an inflammatory process, similarities between atherosclerosis and systemic inflammatory diseases such as rheumatoid arthritis, inflammatory bowel diseases, lupus, psoriasis, spondyloarthritis and others have become a topic of interest. Endothelial dysfunction represents a key step in the initiation and maintenance of atherosclerosis and may serve as a marker for future risk of cardiovascular events. Patients with chronic inflammatory diseases manifest endothelial dysfunction, often early in the course of the disease. Therefore, mechanisms linking systemic inflammatory diseases and atherosclerosis may be best understood at the level of the endothelium. Multiple factors, including circulating inflammatory cytokines, TNF-α (tumor necrosis factor-α), reactive oxygen species, oxidized LDL (low density lipoprotein), autoantibodies and traditional risk factors directly and indirectly activate endothelial cells, leading to impaired vascular relaxation, increased leukocyte adhesion, increased endothelial permeability and generation of a pro-thrombotic state. Pharmacologic agents directed against TNF-α-mediated inflammation may decrease the risk of endothelial dysfunction and cardiovascular disease in these patients. Understanding the precise mechanisms driving endothelial dysfunction in patients with systemic inflammatory diseases may help elucidate the pathogenesis of atherosclerosis in the general population.

Serum C-reactive protein level but not its gene polymorphism is associated with Takayasu arteritis

Takayasu arteritis (TA) patients with active disease often have elevated serum C-reactive protein (CRP) levels, which usually decline with the disease remission. The serum CRP concentration has been showed to be related to CRP gene polymorphisms in previous studies. The present study aims to investigate the associations of serum level of CRP and CRP polymorphisms with TA. A total of 178 unrelated Chinese Han TA patients and 229 unrelated Chinese Han individuals without documented disease were enrolled in our studies. After a systemic search in the HapMap database, four single-nucleotide polymorphisms (SNPs) were selected, namely, rs1800947, rs3093077, rs1205, and rs2808630. The ligase detection reaction (LDR) was used in genotyping. CRP concentrations were determined using turbidimetric immunoassay. Genotype frequencies and allele frequencies of CRP variations were similar between TA patients and controls. CRP haplotype frequencies in patients were not significantly different from those of controls. No significant association between serum CRP concentrations and genotypes was found. Moreover, no association was found in CRP concentration between patients with types I, II, and III TA or between patients with or without pulmonary involvement. By contrast, serum CRP concentration was directly correlated with disease severity. In conclusion, CRP polymorphisms were not associated with TA susceptibility or serum CRP levels in the Chinese Han population. However, higher CRP level was correlated with a more serious disease status, which implies that CRP possibly contributes to the progression of TA.

Periodontal therapy in chronic periodontitis lowers gingival crevicular fluid interleukin-1beta and DAS28 in rheumatoid arthritis patients

To evaluate clinical outcomes and effects of non-surgical periodontal therapy on serum, gingival crevicular fluid (GCF) interleukin-1beta (IL-1β) and tumor necrosis factor-alpha (TNF-α) levels in chronic periodontitis patients with/without rheumatoid arthritis (RA), fifteen RA patients with chronic periodontitis (RA-P) and 15 systemically healthy non-RA chronic periodontitis patients (H-P) were recruited. Clinical periodontal recordings, GCF, and blood samples were obtained at baseline, 1, 3, and 6 months after periodontal treatment. GCF, serum IL-1β, TNF-α levels were analyzed by ELISA. Disease activity score 28 (DAS28) was used to assess RA clinical morbidity. Study groups were compared by Mann-Whitney U test. Wilcoxon test was used to compare the data at baseline, 1, 3, and 6 months after periodontal therapy within the same group. DAS28 decreased significantly after periodontal therapy in RA-P group (p < 0.01). Serum TNF-α concentrations of H-P group were significantly higher than those of RA-P group (p < 0.01), whereas IL-1β levels were similar. No significant change was observed in serum levels of these cytokines after periodontal therapy. GCF IL-1β amounts decreased significantly in both groups following treatment (p < 0.01). At 6-months, H-P GCF IL-1β concentrations were significantly lower than baseline. DAS28 and GCF IL-1β correlated with clinical periodontal indices (p < 0.01). Significant decreases in DAS28 and GCF IL-1β amounts after periodontal treatment suggest that periodontal therapy synergizes with systemic RA therapy to improve RA status.

Extreme sleep durations and increased C-reactive protein: effects of sex and ethnoracial group

STUDY OBJECTIVES

We hypothesize that extremes of sleep duration are associated with elevated C-reactive protein (CRP), a pro-inflammatory marker for cardiovascular disease risk.

DESIGN

Cross-sectional.

SETTING

Population-based research.

PARTICIPANTS

Nationally representative sample of 2007-2008 National Health and Nutrition Examination Survey participants (n = 5,587 adults).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Associations between CRP and self-reported total sleep time (TST) were examined. Explanatory models considered contributions of sex, age, race/ethnicity, body mass index (BMI), and BMI squared (BMI2). Models also explored the role of insomnia symptoms, sleep apnea, active medical illness, and antidiabetic/antihypertensive treatment. Differential patterns among race/ethnicity groups were examined using interactions and stratified analyses. Nonlinear relationships between CRP and TST were assessed using polynomial and multinomial regression models (< 5, 5, 6, 7, 8, 9, and > 9 h). Linear and squared terms were significant in all models in the complete sample, with notable differences by sex and ethnoracial group. Overall, in models adjusted for sociodemographics and BMI, different patterns were observed for non-Hispanic white (elevated CRP for < 5 h and > 9 h), black/African-American (elevated CRP for < 5 h and 8 h), Hispanic/Latino (elevated CRP for > 9 h), and Asian/ Other (higher in 9 and > 9 h and lower in 5 h and 6 h) groups. Ethnoracial groups also demonstrated patterning by sex.

CONCLUSION

In a representative sample of American adults, elevated CRP was associated with extreme sleep durations. Sex, race/ethnicity, sleep disorders, and medical comorbidity influenced these associations. Differences in CRP along these dimensions should be considered in future research on sleep related disparities influencing cardiometabolic disease risk.

The role of inflammation and cardiovascular disease risk on microvascular and macrovascular endothelial function in patients with rheumatoid arthritis: a cross-sectional and longitudinal study

Introduction

Rheumatoid arthritis (RA) is associated with an increased risk for cardiovascular disease (CVD), and it has been postulated that RA disease-related inflammation contributes to endothelial dysfunction. The aim of the present work was to examine predictors (RA-related and CVD risk factors) and anti-tumor necrosis factor-alpha (anti-TNF-α) treatment effects on endothelial function in different vascular beds.

Methods

Microvascular endothelial function (laser Doppler imaging with iontophoresis of acetylcholine and sodium-nitroprusside), and macrovascular endothelial function (flow-mediated dilatation and glyceryl-trinitrate-mediated dilatation) were analyzed in parallel with disease activity. Individual CVD risk factors and global CVD risk were assessed cross-sectionally in 99 unselected RA patients and longitudinally (baseline, 2 weeks, and 3 months) in 23 RA patients commencing anti-TNF-α therapy.

Results

In this cross-sectional study, regression analyses revealed that markers of RA disease-related inflammation were not associated with microvascular or macrovascular endothelium-dependent function (P > 0.05); global CVD risk inversely correlated with microvascular endothelium-dependent function (P < 0.01) and with macrovascular endothelium-independent function (P < 0.01). In the longitudinal study, only microvascular endothelium-dependent function showed an improvement after 2 weeks of anti-TNF-α treatment when compared with baseline (437% ± 247% versus 319% ± 217%; P = 0.001), but no association was evident between change in endothelial function and change in inflammatory markers.

Conclusions

Classical CVD risk may influence endothelial function more than disease-related markers of inflammation in RA. Classical CVD risk factors and anti-TNF-α medication have different effects on microvascular and macrovascular endothelial function, suggesting that combined CVD-prevention approaches may be necessary. Prospective studies examining whether assessments of vascular function are predictive of long-term CV outcomes in RA are required.

Validated methods for assessment of subclinical atherosclerosis in rheumatology

Rheumatoid arthritis, as well as other types of arthritides and connective tissue diseases, is associated with accelerated atherosclerosis, and increased cardiovascular morbidity and mortality. The early signs of cardiovascular disease therefore need to be recognized in patients with these conditions so that effective cardiovascular protection can be introduced. This Review provides an overview of validated techniques that are currently available to determine subclinical atherosclerosis in patients with rheumatic conditions. Techniques for early assessment of endothelial dysfunction include brachial artery flow-mediated vasodilation and laser Doppler flowmetry. Coronary circulation can be assessed by measuring coronary flow reserve using CT, MRI or PET based techniques. The standard indicators of arterial stiffness are pulse-wave velocity and the augmentation index. Carotid atherosclerosis is determined by the common carotid intima-media thickness (ccIMT) measurement or by the assessment of plaques and plaque areas. The combination of ccIMT with plaque assessment is likely to increase the predictive value of this approach. The potential use of a multimarker approach to increase the diagnostic and prognostic value of these clinical assessments is also discussed.

Vascular function and morphology in rheumatoid arthritis: a systematic review

OBJECTIVES

RA associates with significantly increased morbidity and mortality from cardiovascular disease (CVD). This may be due to complex interactions between traditional CVD risk factors, systemic rheumatoid inflammation and the vasculature. We reviewed the current literature to answer: (i) whether there is sufficient evidence that patients with RA have altered vascular function and morphology compared with normal controls; (ii) whether there is sufficient evidence to determine if such changes relate predominantly to systemic inflammation; and (iii) whether any changes of vascular function and morphology in RA can be modified with therapy.

METHODS

The MEDLINE database was searched to identify publications from 1974 to 1 November 2010 pertaining to vascular function and morphology in RA. The total number of articles included in the present review was 93. This included 57 cross-sectional studies, 27 longitudinal studies without randomization and 9 longitudinal studies with randomization.

RESULTS

Vascular function and morphology was impaired in RA relative to healthy controls. The majority of studies reported no associations between systemic inflammation and vascular function. Treatment with anti-inflammatory medication resulted in both transient and long-term improvements in the vasculature, but only a few studies reported associations between change in inflammation and change in vascular function and morphology.

CONCLUSION

The link between systemic inflammation and vascular function and morphology is not wholly supported by the available literature. Long-term studies examining specific predictors (including CVD risk factors) on the vasculature in RA are needed.

Potential role for S100A4 in the disruption of the blood-brain barrier in collagen-induced arthritic mice, an animal model of rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune disease associated with chronic inflammation of the joints. RA has been shown to increase the morbidity of and mortality due to cardiovascular and cerebrovascular diseases. We recently reported that cerebrovascular permeability was increased in mice with collagen-induced arthritis (CIA), an animal model of RA. S100A4, a member of the S100 family, is up-regulated in synovial fluid and plasma from RA patients. This study was aimed at evaluating a role of S100A4 in the mediation of blood-brain barrier (BBB) dysfunction in CIA mice. CIA was induced by immunization with type II collagen in mice. Cerebrovascular permeability was assessed by measurement of sodium fluorescein (Na-F) levels in the brains of control and CIA mice. Serum S100A4 concentrations in control and CIA mice were measured by enzyme-linked immunosorbent assays (ELISA). Accumulation of Na-F in the brain and serum levels of S100A4 were increased in CIA mice. Increased S100A4 levels in the serum are closely correlated with hyperpermeability of the cerebrovascular endothelium to Na-F. We investigated whether S100A4 induces BBB dysfunction using mouse brain capillary endothelial cells (MBECs). S100A4 decreased the transendothelial electrical resistance and increased Na-F permeability in the MBECs. S100A4 reduced the expression of occludin, a tight junction protein, and stimulated p53 expression in MBECs. These findings suggest that S100A4 increases paracellular permeability of MBECs by decreasing expression levels of occludin, at least in part, via p53. The present study highlights a potential role for S100A4 in BBB dysfunction underlying cerebrovascular diseases in patients with RA.

Dynamic contrast-enhanced texture analysis of the liver: initial assessment in colorectal cancer

PURPOSE

To undertake an initial assessment of the potential utility of dynamic contrast-enhanced texture analysis (DCE-TA) of the liver in patients with colorectal cancer.

MATERIALS AND METHODS

TA comprised measurement of mean gray-level intensity, entropy, and uniformity with and without selective-scale filtration using a band-pass filter to highlight different spatial frequencies reflecting fine, medium, and coarse textures. An initial phantom study assessed the sensitivity of each texture qualifier to computed tomography (CT) acquisition parameters. Texture was analyzed in DCE-CT series from 27 colorectal cancer patients having apparently normal hepatic morphology (node-negative: n = 8, node-positive: n = 19). Averaged changes in hepatic texture induced by contrast material were assessed qualitatively and quantitatively by using kinetic modeling to calculate hepatic perfusion indices following fine, medium, and coarse image filtration.

RESULTS

All texture qualifiers were less sensitive to changes in CT acquisition parameters than measurement of CT attenuation. Temporal changes in hepatic texture were qualitatively different from changes in enhancement. Statistically significant differences between node-negative and node-positive patients were observed for at least 1 time period for measurements of hepatic enhancement and for all texture parameters. The differences were most statistically significant and occurred over the greatest number of time periods for fine texture quantified as mean gray-level intensity (5 time periods, minimum P value: 0.006) followed by fine texture quantified as entropy (4 time points, minimum P value: 0.006). There was no difference in hepatic perfusion indices for the 2 groups.

CONCLUSIONS

DCE-TA is a potentially useful adjunct to DCE-CT warranting further investigation.

Microvascular function is preserved in newly diagnosed rheumatoid arthritis and low systemic inflammatory activity

Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity and mortality. Microvascular function has been linked to several risk factors for cardiovascular disease and may be affected in RA. It is, however, presently unknown at what point in the disease course the abnormalities in microvascular function occur. We determined whether microvascular function is already disturbed in early disease-modifying antirheumatic drugs (DMARD)-naive RA patients with low systemic inflammation. Fifteen consecutive RA patients with a median symptom duration of 5 months, a C-reactive protein level of ≤20 mg/l and without a history of cardiovascular disease, and age 15 and sex-matched healthy controls were recruited. Endothelium-dependent and endothelium-independent vasodilatation in skin was evaluated with laser Doppler fluxmetry after iontophoresis of acetylcholine and sodium nitroprusside, respectively. Videomicroscopy was used to measure recruitment of skin capillaries after arterial occlusion. CRP and ESR levels were mildly, but significantly elevated in patients compared to controls. No differences in both endothelium-dependent vasodilatation and capillary recruitment were observed between groups [709% (95% CI, 457–961%) vs 797% (95% CI, 556–1,037%), P = 0.59 and 37% (95% CI, 26–47%) vs 41% (95% CI, 31–50%), P = 0.59, respectively]. Skin microvascular function is preserved in early, DMARD-naive RA patients with moderately active RA but low systemic inflammatory activity. Both the extent of the systemic inflammation and disease duration, therefore, may be important determinants of microvascular dysfunction and subsequent increased risk for cardiovascular disease.

Assessment of endothelial function as a marker of cardiovascular risk in patients with rheumatoid arthritis

The endothelium is a major regulator of cardiovascular function and maintains an atheroprotective role through several mechanisms, including vasodilatation, inhibition of platelet aggregation, having anticoagulant and profibrinolytic effects, and having an anti-inflammatory effect. Early changes in the normal functioning of the endothelium are key initiating factors in the development and progression of atherosclerosis. These changes are present well before the presentation of clinical symptoms. Thus, researchers have focused much attention on developing methods for reliable non-invasive testing of endothelial function to allow early detection and monitoring and progression of subclinical atherosclerosis. To date, there is a wide range of methods in use to assess endothelial function, each with its own advantages and limitations. Ideally, the tests should be non-invasive to allow repeated measurements and be applicable in normal healthy subjects and also in children. Given the wide range of regulatory functions of the endothelium, it is not surprising that there is no single measure of endothelial function that provides all the necessary information regarding vascular integrity in different vascular beds. Therefore, a combination of tests examining different components of the vascular system is more appropriate. Since patients with rheumatoid arthritis have increased mortality due to cardiovascular disease, assessment of endothelial function could prove to be useful tools in the identification and monitoring of cardiovascular risk. The purpose of this review is to give a brief overview of some of the commonly used techniques for assessment of endothelial function, and in particular on those that have been used in studies of patients with rheumatoid arthritis.

Disruption of the blood-brain barrier in collagen-induced arthritic mice

Patients with rheumatoid arthritis (RA) are at higher risk of developing pathological cardiovascular and cerebrovascular events than non-RA subjects. Vascular endothelial dysfunction is involved in the induction of cardiovascular events and this process is also observed in patients with RA. Endothelial dysfunction impairs the integrity of the blood-brain barrier (BBB); this phenomenon also underlies brain damage in cerebrovascular diseases. This study was aimed at evaluating the influence of a chronic inflammatory state on BBB integrity in RA using collagen-induced arthritis (CIA), an animal model of RA. CIA was induced by intradermal injection of type II collagen emulsified with Freund's complete adjuvant at the base of the tail of DBA/1 mice. Cerebrovascular permeability was assessed by measurement of sodium fluorescein (Na-F) content in the brains of CIA mice. The expression level of tight junction proteins was investigated by immunoblotting and immunofluorescence of occludin and zonula occludens-1 (ZO-1). Cerebrovascular permeability to Na-F in the brain was increased in CIA mice. This CIA-induced BBB hyperpermeability was more remarkable in the advanced stage than that in the persistent stage of the arthritis. The expression of occludin, but not that of ZO-1, was decreased by CIA. Our results indicate that the integrity of the BBB could be impaired in the inflammatory pathophysiology of RA.

Combination stem cell therapy for heart failure

Patients with congestive heart failure (CHF) that are not eligible for transplantation have limited therapeutic options. Stem cell therapy such as autologous bone marrow, mobilized peripheral blood, or purified cells thereof has been used clinically since 2001. To date over 1000 patients have received cellular therapy as part of randomized trials, with the general consensus being that a moderate but statistically significant benefit occurs. Therefore, one of the important next steps in the field is optimization. In this paper we discuss three ways to approach this issue: a) increasing stem cell migration to the heart; b) augmenting stem cell activity; and c) combining existing stem cell therapies to recapitulate a "therapeutic niche". We conclude by describing a case report of a heart failure patient treated with a combination stem cell protocol in an attempt to augment beneficial aspects of cord blood CD34 cells and mesenchymal-like stem cells.

The role of endothelial function and its assessment in rheumatoid arthritis

Patients with rheumatoid arthritis (RA) have a reduced life expectancy when compared with the general population, largely attributable to cardiovascular disease. Factors that contribute to this increased cardiovascular risk include traditional risk factors, which account for only part of the excess, along with manifestations of the disease itself. RA is characterized by inflammation, which also is a key component in the development of atherosclerosis. Inflammation leads to the activation of endothelial cells, which, through an increase in the expression of leukocyte adhesion molecules, promotes a pro-atherosclerotic environment. Endothelial dysfunction is an early preclinical marker of atherosclerosis, and is commonly found in patients with RA. Several methods are available for the assessment of endothelial function, such as flow-mediated dilatation and laser Doppler flowmetry combined with iontophoresis, each with its own advantages and limitations. Studies have shown that endothelial dysfunction in RA is closely associated with inflammation, and therapeutic reduction of inflammation leads to improvements in endothelial function. As such, assessments of endothelial function could prove to be useful tools in the identification and monitoring of cardiovascular risk in patients with RA. Given the increase in cardiovascular mortality associated with RA, effective management must involve prevention of cardiovascular risk, in addition to control of disease activity and inflammation.

Lower Healthy Eating Index-2005 dietary quality scores in older women with rheumatoid arthritis v. healthy controls

OBJECTIVE

To assess the dietary quality of older women with and without rheumatoid arthritis (RA) using the Healthy Eating Index-2005 (HEI-2005) to identify potential strategies to improve the nutritional status.

DESIGN

Cross-sectional. Diet was assessed using 7 d food records and analysed for nutrient composition (Food Processor v. 7.11). Diet quality was determined using the HEI-2005, a measure of compliance with 2005 US Dietary Guidelines. Individuals with RA completed a self-reported evaluation of arthritis (pain scale and disability index). Independent two-tailed t tests or Mann-Whitney tests compared the differences between groups and correlations were computed between HEI-2005 and measures of disease reactivity.

SETTING

Arizona, USA.

SUBJECTS

Older (> or = 55 years) women (n 108) with RA (n 52) and healthy controls (HC; n 56).

RESULTS

There were no differences between groups in age, weight, or BMI (kg/m2). HC participants had higher mean HEI-2005 scores for whole fruit (cups; P = 0.02), total fruit (cups; P = 0.05), whole grains (oz; P = 0.004), oil (g; P = 0.05) and total HEI score (P = 0.04) than the RA group. In the RA group, these same HEI components were inversely correlated with disability index (r = -0.20, P = 0.04). Participants with RA reported lower mean intakes of carbohydrate (g; P = 0.02), fibre (g; P = 0.01) and vitamin C (mg; P = 0.04).

CONCLUSIONS

This is the first study examining the dietary quality in older women with and without RA using the HEI-2005. Living with RA was associated with significantly lower dietary quality. Since even small changes in dietary quality can translate into better nutritional status, future interventions should focus on increasing dietary quality in this high-risk group.

Inflammation and Microvascular and Macrovascular Endothelial Dysfunction in Rheumatoid Arthritis: Effect of Treatment

Objective.

To determine whether abnormalities in microvascular and macrovascular function in rheumatoid arthritis (RA) are associated with plasma markers [von Willebrand factor (VWF)] of endothelial dysfunction and inflammation [C-reactive protein (CRP)] and whether the abnormalities would be altered by treatment. Endothelial dysfunction and inflammation in RA may contribute to adverse cardiovascular events. Although endothelial dysfunction in RA has been demonstrated by altered plasma markers, the relationships with macrovascular and microvascular function are relatively unexplored.

Methods.

We recruited 66 patients with chronic RA, 48 community controls (CC), and 25 patients with diabetes and hypertension as a disease control group (DC). Subjects had venous blood sampled for plasma markers, and underwent laser Doppler perfusion imaging of forearm skin (to assess microvascular circulation) following acetylcholine and sodium nitroprusside iontophoresis, to assess endothelium-dependent and endothelium-independent responses, respectively. Brachial artery flow-mediated dilatation assessed endothelial dysfunction in a macrovascular bed. A subgroup of 29 patients with RA were assessed pretherapy and after 2–4 weeks of antirheumatic therapy.

Results.

As expected, patients with RA had higher CRP, erythrocyte sedimentation rate (ESR), and VWF. Endothelium-independent vasoreactivity was abnormal in RA, and this correlated negatively with CRP. All aspects of microvascular function were abnormal in the DC compared to the CC. Macrovascular function was preserved in RA but was abnormal in the DC group. Four weeks of antiinflammatory therapy reduced CRP and ESR but had no effect on any vascular function index in the patients with RA.

Conclusion.

Patients with RA have abnormal endothelium-independent microvascular function that correlates with inflammation but is not altered by short-term antiinflammatory therapy.