non-RA Group Research Articles

Brain Natriuretic Peptides in Atherosclerotic Renal Artery Stenosis and Effects of Renal Angioplasty

Background: We hypothesized that plasma levels of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) would be elevated, and adiponectin concentrations reduced, in patients with atherosclerotic renal artery stenosis (ARAS) and that BNPs might be used to identify patients who would benefit from percutaneous transluminal renal angioplasty (PTRA). Methods: Data were collected before renal angiography in 91 patients with hypertension and suspected ARAS (significant ARAS; n=47, and non-RAS; n=44) and in 20 healthy controls (C). In ARAS patients analyses were repeated four weeks after PTRA. Results: Ambulatory systolic blood pressure (ASBP) was significantly elevated in the ARAS group vs. both C and non-RAS groups. Baseline plasma BNP and NT-proBNP levels were significantly elevated, and adiponectin concentrations reduced, in the ARAS group vs. C but not vs. the non-RAS group. One month after PTRA, ASBP was reduced vs. baseline (149±16 to 139±15 mm p<0.01). Brain natriuretic peptides were not significantly affected by PTRA. Conclusions: Patients with ARAS showed elevated of BNP and NT-proBNP concentrations, and reduced levels of adiponectin, compared to healthy controls but not vs. hypertensive individuals without RAS. Our data do no support the use of BNP analyses in the identification of ARAS patients who will have a beneficial blood pressure response to PTRA.

Assessment of foot and ankle muscle strength using hand held dynamometry in patients with established rheumatoid arthritis

BackgroundThe foot and ankle are frequently affected in patients with rheumatoid arthritis (RA). One of the negative consequences of RA on the physical function of patients is a decrease in muscle strength. However, little is known about foot and muscle strength in this population. The aim of the study was to evaluate significant differences in foot and ankle muscle strength between patients with established RA against age and sex-matched controls using hand-held dynamometry.MethodsThe maximal muscle strength of ankle plantarflexion, dorsiflexion, eversion and inversion was assessed in 14 patients with RA, mean (SD) disease duration of 22 (14.1) years, and 20 age and sex-matched control participants using hand-held dynamometry.ResultsSignificant differences were observed in muscle strength between the two groups in plantarflexion (p = 0.00), eversion (p = 0.04) and inversion (p = 0.01). No significant difference was found in dorsiflexion (p > 0.05). The patients with RA displayed a significantly lower plantarflexion-dorsiflexion ratio than the control participants (p = 0.03).ConclusionsThe results from this study showed that the RA patients displayed a significant decrease in ankle dorsiflexion, eversion and inversion when compared to the non-RA control group suggesting that foot and ankle muscle strength may be affected by the pathological processes in RA. This study is a preliminary step for the measurement of muscle impairments within the RA population.

Abstract 209: Time Intervals and Rearrest After Out-of-Hospital Cardiac Arrest

Background: Re-arrest (RA) occurs when a patient loses pulses following return of spontaneous circulation (ROSC) after out-of-hospital cardiac arrest (OHCA), but the exact causes of RA are not fully understood. Time-to-treatment intervals may affect patient outcome and could be a plausible contributor to RA. Objectives: To compare emergency medical services (EMS) time intervals between cases with and without RA. We hypothesized that RA cases will have significantly longer time intervals than no-RA cases. Methods: The Institutional Review Board of the University of Pittsburgh approved this study. Cases of EMS-treated, non-traumatic OHCA from 2006 to 2011 with at least one instance of prehospital ROSC were retrospectively gathered from the Pittsburgh site of the Resuscitation Outcomes Consortium. Prehospital event times were derived from computer assisted dispatch records. We calculated time intervals to the nearest minute, including 911 call to EMS arrival, arrival to first EMS CPR, EMS CPR to ROSC, and 911 call to arrival at the emergency department (ED). RA status was determined from electronic defibrillator downloads and patient care reports. We used logistic regression to examine the association between RA and each time interval while controlling for patient demographic and clinical variables with alpha = 0.05. Results: Two-hundred and thirty-five cases were analyzed, and 79 (34%) cases had an instance of RA. Mean time intervals and patient demographics are in Table 1. The RA group had a significantly higher proportion of males and shocked cases than the non-RA group. Odds ratios for the outcome of RA by time interval are as follows: 911 to arrival: 1.09 (CI: .98 - 1.21, p = 0.10); arrival to CPR: 1.02 (CI: 0.89 - 1.19, p = 0.74); CPR to ROSC: 0.99 (CI: 0.96 - 1.02, p = 0.86); 911 to ED: 0.99 (CI: 0.96 - 1.01, p = 0.35). Conclusion: EMS time intervals for OHCA were not predictive of RA.

“Remotion” Total Wrist Arthroplasty: Preliminary Results of a Prospective International Multicenter Study of 215 Cases

This study reports the current results of an international multicenter study of one last generation total wrist arthroplasty (TWA) ("ReMotion," Small Bone Innovation, Morristown, PA). The two first authors (G.H. and M.B.) built a Web-based prospective database including clinical and radiological preoperative and postoperative reports of "ReMotion" TWA at regular intervals. The cases of 7 centers with more than 15 inclusions were considered for this article. A total of 215 wrists were included. In the rheumatoid arthritis (RA; 129 wrists) and nonrheumatoid arthritis (non-RA; 86 wrists) groups, there were respectively 5 and 6% complications requiring implant revision with a survival rate of 96 and 92%, respectively, at an average follow-up of 4 years. Within the whole series, only one dislocation was observed in one non-RA wrist. A total of 112 wrists (75 rheumatoid and 37 nonrheumatoid) had more than 2 years of follow-up (minimum: 2 years, maximum: 8 years). In rheumatoid and non-RA group, visual analog scale (VAS) pain score improved by 48 and 54 points, respectively, and QuickDASH score improved by 20 and 21 points, respectively, with no statistical differences. Average postoperative arc of wrist flexion-extension was 58 degrees in rheumatoid wrists (loss of 1 degree) compared with 63 degrees in non-RA wrists (loss of 9 degrees) with no statistical differences. Grip strength improved respectively by 40 and 19% in rheumatoid and non-RA groups (p = 0.033). Implant loosening was observed in 4% of the rheumatoid wrists and 3% of the non-RA wrists with no statistical differences. A Web-based TWA international registry was presented. Our results suggest that the use of the "ReMotion" TWA is feasible in the midterm both for rheumatoid and non-RA patients. This is a significant improvement compared with the previous generation TWA. The level of evidence for this study is IV.

Rheumatoid Arthritis Is an Independent Risk Factor for an Increased Augmentation Index Regardless of the Coexistence of Traditional Cardiovascular Risk Factors

Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity. It was previously shown that the augmentation index (AIx), a marker of vascular dysfunction, is higher in RA patients without traditional cardiovascular risk factors than in healthy controls. In this study we determined whether the impact of RA on the AIx is diminished in the context of coexisting, strong cardiovascular risk factors. A total of 411 participants were included [203 with RA; 208 in the non-RA (n-RA) group]. Pulse-wave analysis was performed on the radial artery using applanation tonometry. The impact of RA on the AIx was determined in a single and in a multiple linear regression model. The mean unadjusted AIx was 30.5 ± 9.0% for RA patients and 24.0 ± 11.0% for the n-RA group (P < 0.001). In the regression model, the following variables are statistically significant at approximately the same level (P < 0.001); the order of impact of these variables is age > diastolic blood pressure > sex > RA > height > smoking status. RA, height, and smoking had a nearly equal impact on the AIx. The AIx is increased in RA patients regardless of the coexistence of traditional cardiovascular risk factors, thereby reflecting vascular dysfunction in this population. The impact of RA on the vascular system is comparable to that of smoking.

Long-term impact of radial artery harvest on forearm function and symptoms: A comparison with leg vein

The radial artery (RA) has gained popularity as a conduit for coronary artery bypass surgery despite a paucity of patient-centered analysis of long-term quality of life after its removal. We sought to characterize forearm function and symptoms after RA harvest and compare these with those associated with saphenous vein (SV) removal. A total of 408 patients from an RA trial completed a questionnaire up to 14 years after primary coronary artery bypass surgery. The survey included 7 statements concerning hand and forearm symptoms or limitations in daily life and 4 questions on concerns associated with arm or leg scars. A total of 230 patients had received an RA graft (RA group). Responses were graded in order of severity from 0 to 7, with greater than 3 (mild concern) being regarded as a significant symptom. Mean response to each question and total scores were compared with the non-RA harvest group. Comparisons were also made with responses to the same questionnaire completed preoperatively and 3 months postoperatively. In patients who had both RA and SV removal, we compared the impact of a forearm scar on quality of life with that of a leg scar. The mean duration of follow-up was 9.3 years (range, 4-14 years), and the response rate was 83%. In the RA group, 92% to 99% reported no significant symptoms, with the most frequent concerns relating to pain and numbness (8% each), but this was not significantly higher than in those who had not had an RA harvested. In the RA group, the mean scores for scar appearance and discomfort were 0.95 and 0.93, respectively (where 1 = no concern), suggesting satisfactory cosmesis and no impact on function. Symptom severity was significantly worse in 6 of 7 questions when compared with preoperative responses and in 4 of 7 items compared with 3-month follow-up, indicating a general deterioration in function over long-term follow-up. In those who had both the RA and SV harvested, patients reported more scar discomfort associated with SV harvest at 3 months (1.69 vs 1.34, P < .001) and in the present questionnaire (1.21 vs 0.97, P = .002). Concerns with scar appearance were no different between the arm and leg. RA harvesting is associated with high patient satisfaction and less scar discomfort than SV removal. Overall, functionality declines with time, and a small proportion of patients seem to experience forearm pain and numbness. However, this is not different than in those without artery removal and may therefore be unrelated to the effects of surgery.

Aliskiren for the treatment of essential hypertension under real-life practice conditions: design and baseline data of the prospective 3A registry

The renin-angiotensin system (RAS) is a key target for blood pressure control and for cardiovascular and renal protection. Aliskiren is the first-in-class direct oral inhibitor of renin that controls the rate-limiting step in the RAS cascade. So far little is known about the use and efficacy of aliskiren in the treatment of essential hypertension under clinical practice conditions. The 3A registry was an open, prospective cohort study (observational registry) of 14,988 patients in 899 offices throughout Germany. Consecutive patients were eligible for inclusion if their physician had decided to modify their antihypertensive therapy. This included treatment with aliskiren or an angiotensin converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB) or agents not blocking the RAS, alone or on top of an existing drug regimen. Mean age of patients was 65 years, their mean body mass index was 28.2 kg/m(2) 53.5% were men, 36% working, 90% in statutory health insurance and 26% in any disease management programme. Patients in the aliskiren and the RAS groups compared with the non-RAS group were older, more often men, had a longer history of hypertension, and had a higher prevalence of comorbidities (diabetes, chronic heart failure, ischaemic heart disease, renal disease). Mean systolic, but not diastolic blood pressure was substantially higher in the aliskiren group (158/91 mmHg vs. 154/89 mmHg in ACE-I/ARB vs. 152/89 mmHg in non-RAS). Mean number of antihypertensive drugs was higher in the aliskiren group compared with the other groups (3.0 drugs vs. 2.5 in ACE-I/ARB vs. 1.6 in non-RAS; p < 0.0001). In this large cohort of outpatients with hypertension, aliskiren was used mainly in patients with more severe stages of hypertension and those with concomitant diseases such as diabetes mellitus and impaired renal function. The 3A registry will provide important information about the use and efficacy of aliskiren in a real-life setting.

Radix astragali injection enhances recovery from sudden deafness

ObjectivesAn acute interruption of the blood supply to the inner ear is one of the most likely causative factors for sudden deafness (SD). Reactive oxygen species (ROS) have been suggested to be important mediators of the tissue injury during cochlear ischemia and reperfusion. Radix astragali (RA) is natural antioxidant. The aim of this study was to investigate the efficacy of RA in patients with SD. Patients and methodsWe compared the hearing gains from hearing impairment in 46 ears treated with RA with 46 ears treated with non-RA. RA was given intravenously daily for 10 days. There were no significant differences in clinical or audiological data between RA and non-RA groups. ResultsThe hearing gain at 250, 500, 1000, 2000, and 4000 Hz in RA group was much higher than that of non-RA group correspondingly (P < .01). Also, the hearing gain at PTA (pure-tone average of 250, 500, 1000, 2000, and 4000 Hz) in RA group was significantly higher than that of non-RA group (P < .01). ConclusionThe recovery of hearing was significantly better after treatment of RA than non-treatment of RA. RA can be valuable concurrent therapy for patients with SD.

Myocardial citrullination in rheumatoid arthritis: a correlative histopathologic study

IntroductionThe aim of this study was to explore the presence and localization of myocardial citrullination in samples from rheumatoid arthritis (RA) patients compared to rheumatic and non-rheumatic disease control groups.MethodsArchived myocardial samples obtained during autopsy from 1995 to 2009 were assembled into four groups: RA; scleroderma; fatal myocarditis; and non-rheumatic disease controls. Samples were examined by immunohistochemistry (IHC) for the presence and localization of citrullination and peptidyl arginine deiminase enzymes (PADs) by a single cardiovascular pathologist blinded to disease group and clinical characteristics.ResultsMyocardial samples from seventeen RA patients were compared with those from fourteen controls, five fatal myocarditis patients, and ten scleroderma patients. Strong citrullination staining was detected exclusively in the myocardial interstitium in each of the groups. However, average and peak anti-citrulline staining was 59% and 44% higher, respectively, for the RA group compared to the combined non-RA groups (P < 0.05 for both comparisons). Myocardial fibrosis did not differ between the groups. In contrast to citrullination, PADs 1 to 3 and 6 were detected in cardiomyocytes (primarily PADs 1 and 3), resident inflammatory cells (primarily PADs 2 and 4), and, to a smaller extent, in endothelial cells and vascular smooth muscle cells. PAD staining did not co-localize with anti-citrulline staining in the interstitium and did not vary by disease state.ConclusionsStaining for citrullination was higher in the myocardial interstitium of RA compared to other disease states, a finding that could link autoimmunity to the known increase in myocardial dysfunction and heart failure in RA.

Effects of Valsartan on Fibrinolysis in Hypertensive Patients With Metabolic Syndrome

The purpose of this study was to analyze the effect of valsartan on abnormal adipocyte metabolism and prothrombotic state in hypertensive patients with metabolic syndrome (MetS). We conducted a multicenter, prospective, randomized, parallel-group controlled trial in 150 hypertensive patients with MetS. They were randomly assigned to receive either 80-160 mg valsartan per day (valsartan group, n=79) or other conventional treatment without a renin-angiotensin system (RAS) inhibitor (non-RAS inhibitor group, n=71). After 1 year, there were no significant differences between the 2 groups in the changes in systolic and diastolic blood pressures (valsartan: 153±15/86±15 to 138±16/77±12 mmHg; non-RAS inhibitor: 150±14/82±15 to 137±15/76±10 mmHg). There was a significant difference in the change in the levels of plasminogen activator inhibitor-1 (PAI-1) between the 2 groups after 1 year (valsartan: 3.7±3.2 ng/ml; non-RAS inhibitor: 5.8±3.3 ng/ml, P=0.04). There was no significant difference between groups in the change in the concentration of adiponectin after 1 year (valsartan: 0.3±0.4 µg/ml; non-RAS inhibitor: 0.9±0.4 µg/ml, P=0.22). The animal study showed aortic PAI-1 protein expression was reduced in double knockout mice of angiotensin II type 1a receptor and apolipoprotein E (apoE) compared with the apoE knockout mice. Valsartan reduced plasma PAI-1 levels compared to non-RAS inhibitor in hypertensive patients with MetS, which suggests it may be useful for improving fibrinolytic function.

Clinical and Hemodynamic Effects of Renin–Angiotensin System Blockade in Cardiac Transplant Recipients

Chronic kidney disease continues to be a major limiting factor for long-term survival of heart transplant recipients. Little is known about the early use of renin-angiotensin system (RAS) blocking agents and their impact on renal function and hemodynamics in heart transplant recipients. In this cohort study all eligible recipients of orthotopic heart transplants at the UTAH cardiac transplantation program from 2001 through 2007 were divided into 2 groups-patients who were started on angiotensin-converting enzyme inhibitors or angiotensin receptor blockers within the first 4 weeks of transplantation and continued on these for ≥4 weeks during the first 3 months (RAS blockade group, n = 75) and those who were not (non-RAS blockade group, n = 52). All patients were followed for 1 year after transplantation. There were no significant differences at baseline between the 2 groups. Estimated glomerular filtration rate at 12 months was significantly higher in the RAS blockade group compared to the non-RAS blockade group (mean ± SD, 56.3 ± 22.4 vs 47.3 ± 18.1 ml/min/1.73 m(2), p = 0.036). At 12 months pulmonary artery systolic pressure was significantly lower in the RAS blockade group compared to the non-RAS blockade group (30.2 ± 7.4 vs 32.9 ± 9.3 mm Hg, p = 0.023). Left ventricular ejection fraction and pulmonary capillary wedge pressure were similar between the 2 groups. In conclusion, early RAS blockade after heart transplantation is safe, well tolerated, and associated with better renal function and hemodynamic profile at 1 year after transplantation.

Radix Astragali injection enhances recovery from acute acoustic trauma

Conclusion. The average recovery of hearing and cessation of tinnitus was significantly better after treatment with Radix Astragali (RA) than after non-treatment with RA. RA can be valuable adjuvant therapy for patients with acute acoustic trauma (AAT). Objectives. AAT is one of the early indications for the use of RA. The reasons for administering RA to patients with AAT are based on experimental studies showing that noise exposure results in the formation of reactive oxygen species (ROS), which trigger metabolic damage to the organ of Corti. RA is a natural antioxidant. The aim of this study was to investigate the efficacy of RA in patients with AAT. Methods: We compared the recovery from hearing impairment and tinnitus in 40 ears treated with RA with 40 ears treated with non-RA. RA was given intravenously daily for 10 days. There were no significant differences in clinical or audiological data between RA and non-RA groups. Results: The average recovery of hearing at both high and speech frequencies was significantly better and tinnitus persisted less commonly in the RA group than in the non-RA group. Normal hearing at the end of the follow-up period was regained in 27 ears in the RA group and in 21 ears in the non-RA group (p < 0.01).

Preventive effect of renin-angiotensin system inhibitor on left atrial remodelling in patients with chronic atrial fibrillation: long-term echocardiographic study

Left atrium (LA) gradually enlarges with the time course of atrial fibrillation (AF). The aim of this study was to examine whether the renin-angiotensin system (RAS) inhibitor could prevent LA remodelling in patients with chronic AF. Forty-one patients with chronic non-valvular AF were enrolled and divided into the following two groups: the RAS group taking an RAS inhibitor and the non-RAS group not taking it. We compared echocardiographic parameters including LA volume at the beginning and the end of follow-up. Percent change of these parameters was calculated from the value at the end of follow-up divided by the value at the beginning of follow-up. An enlargement of LA volume index and a decrease in LA expansion fraction was significantly prevented in the RAS group. Administration of RAS inhibitors was significantly associated with the prevention of increasing LA volume in multivariate analysis. RAS inhibitors may prevent structural and functional degradation of LA in chronic non-valvular AF.

Predictors of chronicity and the discriminative value of the new ACR/EULAR rheumatoid arthritis classification criteria in an untreated polyarthritis cohort with less than 6 weeks of disease duration

Thirty-seven patients were included. During the follow up most of the patients evolved into RA (57%). The median age of the patients of the RA-group was similar to the median age of the non-RA group (median (IQR) 47 (31-58.5) vs 43 (34-69) years, p=0.74). At the initial visit the DAS 28 in the RA group was significantly higher than in the non-RA group, as well as the VAS and the number of swollen joints. The ESR values did not differ significantly between RA and non-RA groups (Table 1).

Utility of modified transarticular screw in the middle and lower cervical spine as intermediate fixation in posterior long fusion surgery

The use of a pedicle screw (PS) in the cervical spine ensures strong fixation. However, 6.7-29% of such screws appear to be malpositioned using manual insertion techniques, especially at C-3 to C-6 where the pedicle diameter is smaller, potentially causing catastrophic complications such as vertebral artery (VA) and spinal cord or nerve root injuries. To optimize safety, the authors use a new technique: cephalad and/or caudad ends at C-2 and C-7/T-1, respectively, are fixed with PSs, and intermediate points around C3-6 are fixed using a modified transarticular screw technique that captures 3 dorsal cortices and preserves the ventral cortex of the facet in posterior long fusion surgery involving occipitospinal fixation. The purpose of the present study was to demonstrate this technique and evaluate the clinical and radiological outcomes. Thirty-nine patients, 8 men and 31 women, with a mean age of 61.7 +/- 11.0 years at surgery, were included in the study. Twenty-eight occipitospinal fusions and 11 posterior long fusions were performed. Patients were divided into 2 groups: a rheumatoid arthritis (RA) group consisting of 26 patients and a non-RA group of 13 patients including 7 with athetoid cerebral palsy. Clinical outcomes were evaluated according to the Japanese Orthopaedic Association (JOA) score. For radiological evaluation, the Cobb angle on lateral radiographs was measured preoperatively, postoperatively, and at the final follow-up, and the degree of realignment from pre- to postoperation and the loss of correction from postoperation to the follow-up were compared between the 2 patient groups. The recovery rate of the JOA score was 50.6 +/- 20.7% in the RA group and 37.3 +/- 24.3% in the non-RA group. Neither VA injury nor spinal cord or nerve root injury occurred among this series. The degree of realignment was greater in the non-RA group (9.2 +/- 13.9 degrees ) than the RA group (1.4 +/- 12.7 degrees ) as the Cobb angle was more kyphotic preoperatively in the non-RA group (2.9 +/- 18.6 degrees ) than in the RA group (17.4 +/- 15.7 degrees ). However, 38.5% of patients in the non-RA group had a correction loss > 10% compared with 7.7% in the RA group; this difference was statistically significant. The featured transarticular screw technique, which preserves the ventral cortex of the facet, as intermediate fixation in long fusion is a safe and easy procedure with few complications. It ensures acceptable clinical and radiological outcomes, especially in patients with RA.

Significance of anti-CCP antibodies in modification of 1987 ACR classification criteria in diagnosis of rheumatoid arthritis

To examine the incorporation of anti-CCP antibodies into the American College of Rheumatology (ACR) classification criteria for rheumatoid arthritis (RA) and to evaluate the advantages of the revised anti-CCP criteria in diagnosing Chinese patients. Patients who suffered from arthritic problems during the recent 2 years were selected from the Department of Rheumatology and Immunology of Peking University People's Hospital. The patients were divided into RA group and non-RA group according to the clinical diagnosis by experienced rheumatologists. The ACR criteria were revised in three ways: (1) replacement of rheumatoid nodules and erosions as criteria with anti-CCP antibodies (RA-6 criteria); (2) replacement of rheumatoid nodules with anti-CCP antibodies as a criterion (RA-7 criteria); (3) addition of anti-CCP antibodies (RA-8 criteria). The diagnostic value of ACR criteria and anti-CCP revised criteria (RA-6, RA-7, and RA-8) were evaluated by comparing the sensitivity and specificity of all criteria, in all subjects and in subjects with arthritis symptoms within 2 years. There were 604 patients included in the study totally, among whom 312 patients were diagnosed as RA and 292 were diagnosed as other rheumatic diseases by rheumatologists. For all the RA patients, the sensitivity and specificity of anti-CCP antibodies were 76.2% and 96%, respectively. Its specificity was much higher than RF (85.2%). For the patients with a disease duration less than two years, the sensitivities were 82.0%, 91.0%, 87.0%, and 87.0%, while the specificities were 95.6%, 83.9%, 95.6%, and 95.6%, respectively, according to 1987 ACR criteria, RA-6, RA-7, and RA-8 criteria. Among all the RA patients, the corresponding sensitivities were 92.3%, 96.8%, 94.6%, and 94.6%, and the specificities were 92.8%, 83.6%, 92.8%, and 92.8%, respectively. The 1987 ACR criteria have high sensitivity and specificity in established RA, but are less sensitive in early RA. The RA-6 criteria improve the sensitivity by reducing its specificity. The RA-7 criteria with replacement of rheumatoid nodules by anti-CCP antibodies increase the sensitivity without losing specificity, which may serve as new classification criteria in routine clinical practice, especially in early RA patients.

Palindromic Rheumatism: Longterm Outcomes of 60 Patients Diagnosed in 1967–84

To study longterm outcomes of 60 patients with palindromic rheumatism (PR) diagnosed in 1967-1984. A cohort of patients with PR was identified in Jyväskylä Central Hospital in 1967-84, and reexamined in 1984-86. In 2006, medical records of the patients were reviewed to analyze the proportion of patients who had developed chronic rheumatoid arthritis (RA), had joint replacement surgery, or had died. Patients' health status was reviewed by mail questionnaires including functional status on the Health Assessment Questionnaire (HAQ), pain, and the number of painful joints. Forty patients developed chronic RA over the observation period of over 20 years, among whom 38 patients within 10 years and 2 patients after 10 years. Twenty-four patients had died by 2006, 17 (42%) in the RA group and 7 (35%) in the non-RA group. Nine patients, all in the RA group (23%), had received 1 or more joint replacements. The mean HAQ score was 0.57 in the non-RA survivors (mean age 70 yrs), compared to 0.89 in the RA group (mean age 66 yrs) (p = 0.020, adjusted for age). Pain scores and the number of painful joints were similar between the groups. Two-thirds of the patients with PR developed chronic arthritis. The risk to develop chronic arthritis remained over 10 years. The RA group was characterized with functional declines and having joint replacements as longterm outcomes of the disease.

The effect of pretreatment with renin-angiotensin-aldosterone system blockers on cardioversion success and acute recurrence of atrial fibrillation

Renin-angiotensin-aldosterone system (RAS) may be activated during atrial fibrillation (AF). It is unclear whether RAS inhibition may facilitate cardioversion from AF and may prevent acute recurrence of AF (ARAF). We thus investigated the effect of pretreatment with RAS blockers on cardioversion success and ARAF in patients with AF scheduled for elective cardioversion. This observational study included 356 patients with AF undergoing elective pharmacological or electrical cardioversion. Of these patients, 135 were not included based on exclusion criteria and the remaining 221 patients were divided into RAS group (n = 116, 69 male) or non-RAS group (n = 105, 58 male) based on precardioversion use of any RAS blocker. Hypertension, coronary heart disease and heart failure were more frequent in the RAS group. Cardioversion from AF was more successful in the RAS group than in the non-RAS group (%92 vs. %82, p = 0.026). The rate of ARAF was lower in RAS group compared with that in non-RAS group (17% vs. 31%, p = 0.026). In multivariate analysis, pretreatment with RAS blockers in addition to shock number and enlarged left atrium, independently predicted ARAF (OR: 0.33, 95% CI: 0.15-0.75, p = 0.008). Independent predictors of cardioversion success were shock number and left atrial dilatation, but not use of RAS blocker. Precardioversion use of RAS blockers may reduce ARAF following successful cardioversion of AF, but did not improve electrical cardioversion.

Comparative Performance Analysis of 4 Different Anti-Citrullinated Protein Assays in the Diagnosis of Rheumatoid Arthritis

To evaluate the diagnostic performances of 2 recently developed assays, third-generation anti-cyclic citrullinated peptide (anti-CCP3) and anti-mutated citrullinated vimentin (anti-MCV), in comparison to conventional second-generation anti-cyclic citrullinated peptide (anti-CCP2) assay; and to assess a novel fully automated, random-access AxSYM anti-CCP assay for early diagnosis of rheumatoid arthritis (RA). A cohort of 176 patients was enrolled in our study; 93 were diagnosed as having RA. The non-RA group consisted of 83 patients including 38 with systemic lupus erythematosus, 17 with primary Sjögren's syndrome, 11 with osteoarthritis, and 17 healthy controls. All were tested for presence of anti-CCP2, anti-CCP3, AxSYM anti-CCP, anti-MCV, and rheumatoid factor (RF)-IgM according to the manufacturers' instructions. Diagnostic performance of the assays revealed the highest area under the curve for the novel AxSYM anti-CCP [89.1; 95% confidence interval (CI) 84.3-93.8], followed by anti-CCP3 (86.7; 95% CI 81.6-91.9), anti-CCP2 (82; 95% CI 75.8-88.3), and anti-MCV (71.9; 95% CI 64.4-79.5). The sensitivities and specificities were 60.2% and 98.8% for anti-CCP2, 61.3% and 97.6% for anti-CCP3, 80.6% and 84.3% for AxSYM anti-CCP, 49.8% and 91.6% for anti-MCV, and 67.8% and 91.6% for RF-IgM, respectively. At cutoff of 5 U/ml, AxSYM anti-CCP emerged as a highly sensitive first-line early diagnostic tool for RA, with the greatest discrimination power, above 16 U/ml, in case of positive result. Using a single easily performed automated assay at 2 determined decision limits we were able to diagnose 81% of cases of RA and missing only 1.2%.

Usefulness of anti -CCP antibodies in rheumatic diseases in Indian patients

The usefulness of anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies) to identify rheumatic arthritis (RA) from other rheumatic diseases presenting with joint pain is not well studied. We aimed to determine the sensitivity and specificity of anti-CCP antibodies in Indian RA patients with respect to non-RA rheumatic diseases and to study the relationship of anti-CCP antibodies and IgG, IgM and IgA rheumatoid factor in RA. Case-control cross-sectional study carried out in the rheumatology division of All India Institute of Medical Sciences. Sixty-three patients with rheumatoid arthritis (RA) and 51 patients with non-RA rheumatic diseases having joint pain were included in the study. Sera were tested for anti-CCP antibodies (IgG) and IgA, IgM, IgG rheumatoid factor, using a commercially available enzyme-linked immunosorbent assay. Statistical analysis was performed using SPSS statistical software version 11.5. Fifty-four of 63 RA patients (85.71%) were positive for anti-CCP antibodies. In the non-RA group, anti-CCP antibody was positive in only 5 of 51 patients (9.8%). Our study found a sensitivity of 85% and a specificity of 90.19% with regard to the use of anti-CCP antibodies assay in patients with joint pain to correctly identify RA. Anti-CCP antibodies positive patients did not have more erosive disease. IgM-RF-positive patients had more erosion when compared to the IgM-RF-negative group. Thirty-two of 57 (56.1%) IgM-RF-positive patients had erosions, while no patient (0/6 patients) had erosions in the IgM-RF-negative group (P=0.01) Anti-CCP antibodies have high sensitivity and specificity for diagnosis of RA, in Indian patients. Anti-CCP antibodies positive patients did not have more erosive disease in our study.