Non-rheumatic Patients Research Articles

Ankle fusion after failed ankle replacement in rheumatic and non-rheumatic patients

BackgroundWith longer follow-up, survival rate of total ankle replacements (TAR) diminishes. It is therefore important to have a reliable fall-back option in case of failed TAR. Revision arthroplasty is often impossible because of loss of bonestock or infection. Conversion to ankle fusion is then indicated. We investigated the clinical, radiographic and patient reported results for fusion after failed TAR in a consecutive group of patients. We concentrated on the influence of inflammatory joint disease (IJD) on union rate. MethodsPatient files and radiographic images of 46 consecutive patients (47 ankles) were reviewed. There were 22 patients with IJD. Fixation methods included; anterior plating, blade plate fixation, intramedullary nailing, compression screws and external fixation. Foot and Ankle Outcome Score (FAOS) and Foot and Ankle Ability Measure (FAAM) were used to determine patient related outcomes. ResultsForty out of 47 ankles (85%) Fused. Union rate in the non-IJD group (96%) was significantly higher compared to the IJD-group (73%, p=0.04). Revisions and complications were more frequent in the IJD group, but numbers were too small to detect a significant difference. Mean PROM scores were: FAOS-symptoms; 68.5, FAOS-pain; 70.3, FAOS-QoL; 43.7, FAOS-ADL; 68.1 and FAAM-ADL; 52.1, with no significant difference between IJD and non-IJD patients. ConclusionsIJD-patients have a higher nonunion rate after ankle fusion for failed TAR. However, patient reported outcome is not significantly different between the two groups. Level of evidenceIV, retrospective cohort.

Long-term results after concomitant mitral and aortic valve surgery: repair or replacement?

The reported superiority of mitral valve (MV) repair for isolated MV regurgitation has not been confirmed in mitroaortic valve surgery. Our goals were to evaluate the feasibility of repair in patients undergoing mitral and aortic valve surgery and to identify factors predisposing to MV replacement, to compare long-term outcomes (survival and MV reoperation) of repair and replacement and to perform a subgroup analysis in patients with rheumatic MV disease. From January 1992 through December 2016, 1122 consecutive patients were submitted to concomitant aortic and MV surgery in 2 different centres (Coimbra and Santiago). Of these, 837 patients underwent MV repair (74.6%) and 285 patients had MV replacement (25.4%). Rheumatic aetiology was predominant (666 patients; 59.4%). Cumulative follow-up was 9522.6 patient-years (25th-75th percentile 2.6-13.2 years) and was complete for 95.6% of patients. Propensity score matching (1:1) was performed in 232 patients for comparing each treatment option (MV repair and MV replacement). Previous MV intervention, rheumatic aetiology, chronic obstructive pulmonary disease, higher degrees of tricuspid and mitral regurgitation and pulmonary hypertension were independently correlated with MV replacement. The 30-day mortality rate was higher in patients with MV replacement (4.2% vs 1.8%, P = 0.021) and was confirmed in the propensity score matching (4.7% vs 1.7%, P = 0.06). Late survival was lower in the MV replacement group (53.3 ± 4.5% vs 61.7 ± 2.0% at 12 years; P = 0.026) and was confirmed in the propensity score matching (54.6 ± 4.9% vs 63.2 ± 3.8%, P = 0.062) and rheumatic subgroup (57.9 ± 4.8% vs 68.0 ± 2.5%, P = 0.018). Freedom from MV reoperation at 12 years was higher in the MV repair group (94.7 ± 1.1% vs 89.0 ± 3.1%, P = 0.004) but similar in patients with rheumatic MV disease. MV repair can be performed in most patients undergoing aortic valve replacement. It should be the procedure of choice whenever feasible, because it is associated with lower early and late mortality rates and with freedom from reoperation in non-rheumatic patients.

The value of different antibodies detection in diagnosis of rheumatism with uveitis

Objective: To investigate the value of HLA-B27 antigen, antinuclear antibody (ANA), anti-dsDNA and Anti-Neutrophil Cytoplasmic Antibodies (ANCA) detection in diagnosis of rheumatism with uveitis. Methods: Seven hundred and twenty four newly diagnosed patients with non-infection uveitis in Beijing Tongren Hospital from March 2012 to March 2016 who long-term lived in Beijing and its surrounding areas were continuously enrolled. HLA-B27 antigen expressions in peripheral blood lymphocytes and ANA, anti-dsDNA and ANCA levels in serum were tested. The detailed clinical data, imaging examinations and pathological examinations were recorded to define whether the patients had rheumatism and the types of rheumatism. Results: There were 285 patients were diagnosed with rheumatism in 724 patients (39.4%), with 135 male (47.4%) and 150 female (52.6%). The mean age of male (41±14) was lower than that of female (44±14), with statistically significant (t=2.18, P<0.05). There were 176 patients with Spondyloarthropathies, 48 patients with primary systemic vasculitis, 22 patients with systemic lupus erythematosus, 18 patients with primary Sjogren's syndrome, 16 patients with rheumatoid arthritis and 5 patients with juvenile idiopathic arthritis in 285 rheumatism patients. The positive rate of HLA-B27(57.2%), ANA(15.8%), anti-dsDNA (5.3%) and ANCA(9.1%) in rheumatic uveitis patients were obviously higher than those of non-rheumatic uveitis patients [HLA-B27(1.1%), ANA(1.6%), anti-dsDNA (0.0%) and ANCA(0.9%)], with statistically significant (Fisher's exact test, P<0.01). The HLA-B27 positive antigen were mainly in patients with Spondyloarthropathies, rate was 92.1%; the positive ANA were mainly in patients with systemic lupus erythematosus, rate was 95.5%; the positive anti-dsDNA were mainly in patients with systemic lupus erythematosus, rate was 59.1%; the positive ANCA were mainly in patients with primary systemic vasculitis (besides Behcet disease), rate was 57.1%. Conclusions: The detections of HLA-B27 antigen, ANA, anti-dsDNA and ANCA are valuable for primary screening of some rheumatic uveitis. There fore, clinicians should select targeted laboratory examination combine with the patients' clinical manifestations. This will be helpful in the auxiliary diagnosis of some types of rheumatic uveitis.

PM176 Effect of Mitral Regurgitation in Non-Rheumatic Atrial Fibrillation Patients Taking and not Taking Warfarin on Stroke and Bleeding

PM176 Effect of Mitral Regurgitation in Non-Rheumatic Atrial Fibrillation Patients Taking and not Taking Warfarin on Stroke and Bleeding

Reduced expression of TRIM21/Ro52 predicts poor prognosis in diffuse large B-cell lymphoma patients with and without rheumatic disease.

TRIM21 (also known as Ro52) is an autoantigen in rheumatic disease and is predominantly expressed in leucocytes. Overexpression is associated with decreased proliferation, and the TRIM21 gene maps to a tumour suppressor locus. We therefore investigated the expression of TRIM21 in patients with diffuse large B-cell lymphoma (DLBCL) and its potential usefulness as a prognostic biomarker. TRIM21 expression levels were assessed by immunohistochemistry in lymphoma biopsies from three cohorts of patients with DLBCL: 42 patients with rheumatic disease treated with a cyclophosphamide, vincristine, doxorubicin and prednisone (CHOP)-like regimen, 76 CHOP-treated and 196 rituximab-CHOP-treated nonrheumatic patients. Expression was correlated with clinical and biomedical parameters. TRIM21 expression was assessed in relation to lymphocyte proliferation by quantitative PCR and correlated with (3) H-thymidine incorporation and propidium iodine staining. TRIM21 expression levels differed in the lymphomas compared to normal lymphoid tissue, with reduced expression correlating with shorter overall survival in all three cohorts. In the two larger cohorts, progression-free survival was assessed and was also found to correlate with TRIM21 expression. The association was independent of commonly used clinical prognostic scores, lymphoma subtype and several previously reported prognostic biomarkers. In agreement with this clinical observation, we noted an inverse correlation between TRIM21 expression and proliferation of leucocytes invitro. We show that loss of TRIM21 expression is associated with more aggressive lymphoma and increased proliferation, whereas maintenance of TRIM21 expression is associated with better prognosis in patients with DLBCL. Based on our findings, we suggest that TRIM21 should be considered as a novel biomarker for lymphoma characterization and for predicting patient survival.

The appearance of a small thrombus in the pulmonary vein indicates the existence of a smaller pulmonary vein

Stroke is a leading cause of serious long-term disability and the third-leading cause of death [1]. Acute ischemic stroke accounts for approximately 70% of all strokes, and cardiac embolism accounts for approximately 15% of embolic strokes. Atrial fibrillation (AF), which is responsible for 10% of all ischemic strokes and half of all cardioembolic strokes, increases the risk of stroke by 4to 5-fold in nonrheumatic patients. The left atrial appendage (LAA) is the most common location in which a thrombus forms in the left atrium (LA). Transesophageal echocardiography is a routine clinical procedure that is frequently used prior to cardioversion to detect an LA thrombus. Pulmonary vein thrombosis is a potentially life threatening condition that can lead to thromboembolic stroke, but the occurrence of this type of thrombosis is believed to be rare and often goes undiagnosed and untreated. The primary causes of pulmonary vein thrombi formation are thought to be lung surgery [2], lung transplantation [3,4], and increased expansion of lung cancer [5]. The signs and symptoms of this condition are generally atypical, thus resulting in its underdiagnosis. Since 2012, I have publishedmany cases of pulmonary vein thromboses in elderly patients who present without traditional clinical conditions. In 2014, I reported that 35 (61%) of 57 elderly patients with chest pain had a pulmonary vein thrombus [6], indicating that pulmonary vein thromboses are more common in elderly populations. In 2015, I reported that a small thrombus in the visible small pulmonary

Determinants of prolonged length of hospital stay after cardiac surgery: impact of rheumatic heart disease

BACKGROUND: Rheumatic heart disease remains a major health problem in developing countries. Several factors contribute to valve-related morbidity after cardiac surgery, but the role of rheumatic etiology of valve disease is not well defined. This study was designed to determine the additional value of rheumatic valve disease in predicting morbidity after cardiac surgery in the current era of heart valve disease treatment. METHOD: This study prospectively included 164 patients for cardiac surgery from June 2010 to June 2011. The outcome was prolonged length of stay, defined as a length of stay greater than or equal to the 75th percentile for length of stay for each operation, including the day of discharge. RESULTS: Rheumatic heart disease was present in 32 patients (20%) and all rheumatic patients underwent valve replacement. Rheumatic heart disease patients were younger with less comorbidities compared to non-rheumatic patients, with most (63%) having had previous surgery. Forty-one patients were classified as having a prolonged hospital length of stay; 11 (34%) patients with rheumatic and 30 (23%) non-rheumatic fever. Rheumatic heart disease was not associated with prolonged hospital stay in the univariate analysis; however, after adjustment for other factors including infectious endocarditis, surgery duration, mechanical ventilation time, EuroSCORE, and postoperative pneumonia, it was found to be a predictor of prolonged hospitalization. CONCLUSION: This study demonstrates that rheumatic heart disease was an important factor associated with prolonged hospital, after adjustment for well-known risk factors of morbidity after cardiac surgery. Rheumatic fever is still prevalent among the patients who underwent to cardiac surgery in the current age, contributing to increase the postoperative morbidity.

THU0112 Rosuvastatin and Olmesartan Improve Inflammation and Endothelial Dysfunction in Rheumatoid Arthritis

BackgroundCardiovascular disease remains the leading cause of excessive morbidity and mortality in rheumatoid arthritis (RA). Atherosclerosis and RA share similar pathogenetic mechanisms1. Rosuvastatin and olmesartan improve inflammation and endothelial dysfunction...

Low level tumor necrosis factor-alpha protects cardiomyocytes against high level tumor necrosis factor-alpha: brief insight into a beneficial paradox.

Whether tumor necrosis factor-alpha (TNFα) caused beneficial or detrimental cardiovascular effects remains poorly defined. Anti-TNFα agents improved cardiac end points in chronic rheumatic diseases characterized by progressive deterioration of cardiac function. In contrast, anti-TNFα agents did not always improve but actually worsened cardiac function in non-rheumatic patients with heart failure (HF), in spite of that HF usually accompanies with high circulating levels of TNFα. To shed light on these mixed findings, we characterized the effects of TNFα in H9c2 cardiomyocytes. Cells were incubated for 24h with increasing concentrations of TNFα, hydrogen peroxide, aminotriazole, or etoposide. Posttreatment cell viability was assessed by antimycin A-inhibitable reduction of 3-(4,dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide, and the IC50 value of each test compound was defined. H9c2 cells were also preconditioned with a low non-toxic concentration of TNFα and then re-challenged with increasing concentrations of TNFα and other stressor agents. In re-challenge experiments, all of the IC50 values increased significantly, with the IC50 value of TNFα increasing approximately 16-fold. TNFα preconditioning increased cardiomyocytes shedding of the external portion of transmembrane type 1 and type 2 TNFα receptors [(soluble TNFα receptors (sTNFR)]. Levels of survival-oriented soluble TNFR2 (sTNFR2) always exceeded those of death-oriented sTNFR1. When exposed to TNFα at its IC50 value, preconditioned cardiomyocytes showed an increased release of sTNFR2 but not sTNFR1. These results denoted that preconditioning by "low TNFα" helped cardiomyocyte to withstand toxicity from "high TNFα" or other agents. These results also suggested that beneficial or detrimental effects of anti-TNFα agents might well depend on whether these agents spared or intercepted discrete amounts of TNFα that preconditioned cardiomyocytes and made them more resistant to high concentrations of TNFα.

Risk Factors of Rheumatic Heart Disease in Bangladesh: A Case-Control Study

Not all cases of rheumatic fever (RF) end up as rheumatic heart disease (RHD). The fact raises the possibility of existence of a subgroup with characteristics that prevent RF patients from developing the RHD. The present study aimed at exploring the risk factors among patients with RHD. The study assessed the risk of RHD among people both with and without RF. In total, 103 consecutive RHD patients were recruited as cases who reported to the National Centre for Control of Rheumatic Fever and Heart Disease, Dhaka, Bangladesh. Of 309 controls, 103 were RF patients selected from the same centre, and the remaining 206 controls were selected from Shaheed Suhrawardy Medical College Hospital, who got admitted for other non-cardiac ailments. RHD was confirmed by auscultation and colour Doppler echocardiography. RF was diagnosed based on the modified Jones criteria. An unadjusted odds ratio was generated for each variable, with 95% confidence interval (CI), and only significant factors were considered candidate for multivariate analysis. Three separate binary logistic regression models were generated to assess the risk factors of RF, risk factors of RHD compared to non-rheumatic control patients, and risk factors of RHD compared to control with RF. RF and RHD shared almost a similar set of risk factors in the population. In general, age over 19 years was found to be protective of RF; however, age of the majority (62.1%) of the RHD cases was over 19 years. Women [odds ratio (OR) = 2.2, 95% CI 1.1-4.3], urban resident (OR = 3.1, 95% CI 1.2-8.4), dwellers in brick-built house (OR = 3.6, 95% CI 1.6-8.1), having > 2 siblings (OR = 3.1, 95% CI 1.5- 6.3), offspring of working mothers (OR = 7.6, 95% CI 2.0-24.2), illiterate mother (OR = 2.6, 95% CI 1.2-5.8), and those who did not brush after taking meals (OR = 2.5, 95% CI 1.0-6.3) were more likely to develop RF. However, more than 5 members in a family showed a reduced risk of RF. RHD shared almost a similar set of factors in general. More than three people sharing a room also showed an increased risk of RHD (OR = 1.9, 95% CI 1.0-3.4), in addition to the risk factors of RF. Multivariate model also assessed the factors that may perpetuate RHD among RF patients. Overcrowding (OR = 2.4, 95% CI 1.2-4.7) and illiteracy (OR = 2.4, 95% CI 1.1-5.2) posed the risk of RHD in the RF patients. The study did not find new factors that might pose an increased risk, rather looked for the documented risk factors and how these operate in the population of Bangladesh.

Heart Valve Lesions Due to the Formation of a Beta-Hemolytic Streptococ Role of Adhesion Molecules

Objectives: A rise in the levels of adhesion molecules such as VCAM-1, ICAM-1and E-selectin in valve disease patients has been reported lately. In our study, by detecting the presence of adhesion molecule expression in the valve endothelium we will try to show the level of adhesion molecules in peripheral blood leucocytes. Materials and Methods: Valve samples were obtained from patients having undergone aortic and mitral valve replacement due to symptomatic aortic stenosis/aortic insufficiency and/or mitral stenosis/mitral insufficiency. The clinical preoperative diagnosis was made using two-dimensional echocardiography and Doppler echocardiography. Rheumatic valves were in group B (n = 20). Group A (n = 8) constituted the control group. Immunohistochemical staining was performed using CD4, CD8, CD54/ICAM-1, and CD106/VCAM-1. Flow cytometric analysis was performed. The Kolmogorov-Smirnov test and Fisher’s exact test were used for the comparison of categorical variables. Results: Group A (non-rheumatic) patients were found to be older than group B (rheumatic) patients (59.8 ± 11.4 years vs. 45.3 ± 11.8 years, p = 0.008). In group B VCAM-1 level was higher than that of group A (296.6 ± 21.2 vs. 258.5 ± 42.1, p = 0.004). CD11b monocyte in group B was higher than in group A (98.8 ± 0.5 vs. 92.9 ± 9.7, p = 0.003). CD11b granulocyte was higher in group B than in group A (99.96 ± 0.05 vs. 93.79 ± 13.26, p = 0.33). Significant differences were not determined in the other parameters. Conclusion: The fact that increases in serum VCAM-1 and CD-11b only occurred in patients with rheumatic valvular disease in our study suggests that inflammation in patients with the same hemodynamic disorder is higher in rheumatic valvular disease than in the ones with non-rheumatic valvular disease.

Antithrombotic Strategy in the Three First Months following Bioprosthetic Heart Valve Implantation

Heart valve prosthesis unquestionably improve quality of life and survival of patients with severe valvular heart disease, but the need for antithrombotic therapy to prevent thromboembolic complications is a major challenge to clinicians and their patients. Of the articles analyzed, most were retrospective series of cases or historical cohorts obtained from the database. The few published randomized trials showed no statistical power to assess the primary outcome of death or thromboembolic event. In this article, we decided to perform a systematic literature review, in an attempt to answer the following question: what is the best antithrombotic strategy in the first three months after bioprosthetic heart valve implantation (mitral and aortic)?After two reviewers applying the extraction criteria, we found 1968 references, selecting 31 references (excluding papers truncated, which combined bioprosthesis with mechanical prosthesis, or without follow-up).Based on this literature review, there was a low level of evidence for any antithrombotic therapeutic strategy evaluated. It´s therefore interesting to use aspirin 75 to 100 mg / day as antithrombotic strategy after bioprosthesis replacement in the aortic position, regardless of etiology, for patients without other risk factors such as atrial fibrillation or previous thromboembolic event. In the mitral position, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts comprised mostly of elderly non-rheumatic patients.The current evidence is limited to have a consistent and safe level of evidence regarding the best therapeutic strategy. Based on these studies, 75 to 100 mg/day of aspirin is interesting as antithrombotic strategy after implantation of aortic bioprosthesis, regardless of etiology, for patients with no other risk factors such as atrial fibrillation or previous thromboembolic event. As for mitral bioprosthesis, the risk of embolism, although low, is more relevant than in the aortic position, according to published series and retrospective cohorts - usually elderly non rheumatic patients.

Reversal of endotheual dysfunction after AF cardioversion

Flow abnormalities which occur in AF patient due to irregular heart rate which resultant turbulent flow both in left atrium and systemically may lead to endothelial dysfunction. To detect endothelial dysfunction in non rheumatic AF patient. And test the hypothesis that endothelial dysfunction is reversible upon restoration of normal sinus rhythm and correction of the blood flow dynamics. Endothelium-dependent (flow-mediated dilation) vasodilator function of brachial artery was measured using high resolution ultrasound in 30 patients with persistent non rheumatic AF who were scheduled for elective electrical cardioversion and in 10 control subjects. In patients who remained in sinus rhythm after cardioversion, these measurements were repeated after one month and two months. Compared with control subjects, patients showed lower FMD during AF (6.66 ± 1.62% vs 14.29 ± 2.93%, p < 0.001). In patients who remained in sinus rhythm, FMD increased at both one month (6.66 ± 1.62% vs 10.71 ± 2.81%, p < 0.001) and two months (6.66 ± 1.62% vs 14.28 ± 3.48%, p < 0.001). There is endothelial dysfunction associated with non-rheumatic persistent AF patients which is reversible upon restoration of normal sinus rhythm and correction of blood flow dynamics.

Increased C1q, C4 and C3 deposition on platelets in patients with systemic lupus erythematosus – a possible link to venous thrombosis?

Patients with systemic lupus erythematosus (SLE) have an increased risk of developing vascular diseases (VD) such as myocardial infarction, stroke and venous thrombosis, which can only partly be explained by traditional risk factors. The role of platelets in this process has not been extensively studied. Platelet activation supports complement binding to the platelet surface, and increased C4d has been seen on platelets in SLE patients as well as in non-rheumatic patients with stroke. In this study we investigated in vivo platelet deposition of the classical complement pathway components C1q, C4d and C3d in relation to VD in SLE patients. Furthermore, the ability of serum to support in vitro complement deposition on fixed heterologous platelets was analyzed. Blood from 69 SLE patients and age- and sex-matched healthy individuals was collected in sodium-citrate tubes and platelets isolated by centrifugation. Complement deposition on platelets was detected by flow cytometry. We could demonstrate that SLE patients had increased C1q, C3d and C4d deposition on platelets as compared to healthy controls (p < 0.0001). SLE patients with a history of venous thrombosis had increased complement deposition on platelets as compared to SLE patients without this manifestation (p < 0.05). In vitro studies demonstrated that serum from patients with lupus anticoagulant, venous thrombosis or antiphospholipid antibody syndrome supported increased platelet C4d deposition in vitro as compared to SLE patients without these manifestations (p < 0.05). Our data support the hypothesis that platelet activation and the subsequent complement deposition on platelets are central in the development of venous thrombosis in SLE. Altogether we suggest that complement deposition on platelets could reflect important pathogenetic events related to the development of venous thrombosis in SLE and might be used as a marker for venous thrombosis in SLE.

Septic Arthritis of the Knee Associated with Calf Abscess

Septic arthritis associated with extra-articular abscess is rare. We report on 2 non-rheumatic patients with septic arthritis of the knee associated with calf abscess. Magnetic resonance imaging showed a distinct leakage pathway from the knee joint in each patient. One was a ruptured popliteal cyst (posteromedial). Another was a pathologic popliteus hiatus (posterolateral). These patients underwent open drainage of the calf abscess via a small incision, followed by arthroscopic debridement of the knee. Careful palpation of the lower leg, followed by magnetic resonance imaging and needle aspiration, is important to exclude a possible extra-articular abscess regardless of the presence of a popliteal cyst.

Efficacy of Surgical Ablation of Atrial Fibrillation in Patients With Rheumatic Heart Disease

Although atrial fibrillation (AF) ablation is efficient in many patient cohorts, its effect on rheumatic heart disease remains controversial. We describe a retrospective comparison of surgical ablation using the same technique in rheumatic versus nonrheumatic patients. Between 2004 and 2009, we performed AF ablation as a part of another cardiac surgery in 192 patients with bipolar radiofrequency ablator and a cryoprobe. Patients were retrospectively allocated to a rheumatic heart disease group (76 patients, 40%) and a nonrheumatic heart disease group (116 patients, 60%). All demographic characteristics were similar in both groups, as well as in a number of patients with permanent and persistent AF and long-standing AF. Permanent AF was present in 37 patients (49%) and 51 patients (44%) in the rheumatic and nonrheumatic groups, respectively. Heart function and functional class were also similar, whereas more rheumatic patients had a severely enlarged left atrium (200 to 300 cc [p = 0.02]). There were 2 perioperative deaths. Postoperative complications were similar in both groups, with 51 rheumatic patients (67%) and 81 nonrheumatic patients (70%) in sinus rhythm at discharge. Total, mean follow-up was 16 months, after which 63 patients (83%) and 96 patients (84%) were in sinus in the rheumatic group and nonrheumatic group, respectively, of whom 72% were without antiarrhythmic medications. Ablation failure risk factors included AF duration of 10 years or longer before ablation (p < 0.05), and preoperative permanent AF (p = 0.03). The efficacy of AF ablation proved similar in rheumatic and nonrheumatic patients, providing preoperative AF type and duration were similar. Larger left atria in rheumatic patients did not influence ablation results.

Functional consequences of DECTIN-1early stop codon polymorphism Y238X in rheumatoid arthritis

IntroductionDectin-1, a pattern recognition receptor expressed by the innate immune system, is known to be a major receptor inducing Th17-type adaptive immune responses that have been demonstrated to mediate autoimmunity. In this study, dectin-1 mRNA and protein expression, as well as the recently characterized DECTIN-1 Y238X early stop codon polymorphism, were studied in relation to rheumatoid arthritis (RA) susceptibility and severity.MethodsDectin-1 mRNA expression was measured in synovial tissue specimens of RA, osteoarthritis (OA), and nonrheumatic patients. Dectin-1 protein expression and localization were assessed in RA synovial tissue specimens. Macrophages from individuals with different DECTIN-1 genotypes were examined for differences in cytokine responses on dectin-1 stimulation. Furthermore, clinical parameters of inflammation and bone destruction of 262 RA patients were correlated with the presence of the DECTIN-1 Y238X polymorphism.ResultsEvaluation of dectin-1 mRNA expression in synovial tissue biopsies revealed an increased expression in RA specimens, compared with biopsies from OA and nonrheumatic patients. Accordingly, dectin-1 protein expression in RA synovial tissue biopsies was moderate to high, especially on macrophage-like cells. Cytokine production capacity of macrophages bearing the DECTIN-1 Y238X polymorphism was demonstrated to be impaired on dectin-1 stimulation. However, the presence of the DECTIN-1 Y238X polymorphism was not associated with RA susceptibility or disease severity.ConclusionsAlthough expression of dectin-1 was high in synovial tissue of RA patients, and reduced cytokine production was observed in macrophages of individuals bearing the DECTIN-1 Y238X polymorphism, loss of one functional allele of DECTIN-1 is not associated with either susceptibility to or severity of RA.

Predictors of Stroke Risk in Native Chinese with Nonrheumatic Atrial Fibrillation: Retrospective Investigation of Hospitalized Patients

Data on stroke risk factor profiles and atrial fibrillation (AF) for the Chinese population are sparse. This study identified risk factors for stroke among native Chinese with nonrheumatic AF. In this retrospective investigation, patients diagnosed with nonrheumatic AF were identified from 18 hospitals in representative areas of the country, from January 2000 to April 2002, based on the medical records. All parameters relevant to AF were compared between AF patients with stroke and those without. The independent risk factors for stroke were assessed with a logistic regression analysis. Patients numbering 3,425 with AF were included, among whom 827 subjects were discharged on account of stroke. The prevalence of stroke in nonrheumatic AF patients was 24.15%. AF patients with stroke were significantly older than controls (73.31 +/- 9.18 versus 68.22 +/- 12.29 y, p < 0.001) and more likely to have a history of hypertension (71.0 versus 51.6%, p < 0.001) and diabetes (17.9 versus 11.1%, p = 0.001).Both, systolic and diastolic blood pressure, are significantly higher in patients with stroke. Of all the parameters of echocardiography, there was strong evidence that left atrial (LA) thrombi significantly increased risk of stroke. Patients with persistent AF were more likely to have stroke than paroxysmal AF patients, while lone AF is less in patients with stroke than in those without. The rate of anticoagulation treatment is only 9.27%, but there were no significant differences between the 2 groups. In multivariate analysis, age > or = 75 y (odds ratio [OR] 1.76; 95% confidence interval [CI] 1.08-2.98), history of hypertension (OR 1.52; 95% CI 1.28-1.80), diabetes (OR 1.39; 95% CI 1.11-1.76), high systolic blood pressure (OR 1.71; 95% CI 1.21-2.28), LA thrombi (OR 2.77; 95% CI 1.25-6.13) were independent predictors for stroke. The prevalence of stroke in hospitalized nonrheumatic AF patients was high. The population-specific risk factors for stroke were age > or = 75 y, diabetes, history of hypertension, high systolic blood pressure and LA thrombi by transesophageal echocardiography (TEE). These merit further evaluation.

Inflammatory Cell Infiltrates in Vessels With Different Susceptibility to Atherosclerosis in Rheumatic and Non-Rheumatic Patients A Controlled Study of Biopsy Specimens Obtained at Coronary Artery Surgery

The main aim of the present study was to compare the occurrence of inflammatory cell infiltrates in the aorta, a vessel with a high occurrence of atherosclerosis, with that in the saphenous vein (SV) and internal mammary artery (IMA), which are protected from atherosclerosis. Samples from the aorta, SV, and IMA of 65 patients with inflammatory rheumatic diseases (IRD) and from 51 control patients undergoing coronary artery bypass graft surgery were examined for the presence and location of inflammatory cell infiltrates and atherosclerotic lesions. Mononuclear cell infiltrates (MCIs) in the media or adventitia were observed in 2% IMAs, 17% SVs, and 35% aortic specimens (SV vs IMA: p=0.006; SV vs aorta: p=0.001). Atherosclerotic lesions were present in none IMA, 3% SVs and 18% aortic specimens. IRD and smoking increased the odds of MCI in the aorta (odds ratio (OR)=3.6, 95% confidence interval (CI): 1.6-8.5 and OR=4.0, 95% CI: 1.5-10.9), but not in the SV or IMA. The occurrence of medial and adventitial MCI in the aorta, SV, and IMA paralleled each vessel's susceptibility to atherosclerosis: it was highest in the aorta and lowest in IMA. Local vascular inflammation may be involved in atherogenesis, and influence the patency of vascular grafts.

Initial Worldwide Experience With the WATCHMAN Left Atrial Appendage System for Stroke Prevention in Atrial Fibrillation

This study assessed the feasibility of implanting a device in the left atrial appendage (LAA) in patients with atrial fibrillation (AF) to prevent thromboembolic stroke. Meta-analyses confirmed that in cases of left atrial thrombus in nonrheumatic AF patients approximately 90% of them are in the LAA. The WATCHMAN Left Atrial Appendage System (Atritech Inc., Plymouth, Minnesota) is a nitinol device implanted percutaneously to seal the LAA. Patients were followed by clinical and transesophageal echocardiography at 45 days and 6 months with annual clinical follow-up thereafter. Sixty-six patients underwent device implantation. Mean follow-up was 740 +/- 341 days. At 45 days, 93% (54 of 58) devices showed successful sealing of LAA according to protocol. Two patients experienced device embolization, both successfully retrieved percutaneously. No embolizations occurred in 53 patients enrolled after modification of fixation barbs. There were 2 cardiac tamponades, 1 air embolism, and 1 delivery wire fracture (first generation) with surgical explantation but no long-term sequelae for the patient. Four patients developed a flat thrombus layer on the device at 6 months that resolved with additional anticoagulation. Two patients experienced transient ischemic attack, 1 without visible thrombus. There were 2 deaths, neither device related. Autopsy documented a stable, fully endothelialized device 9 months after implantation. No strokes occurred during follow-up despite >90% of patients with discontinuation of anticoagulation. Preliminary data suggest LAA occlusion with the WATCHMAN System to be safe and feasible. A randomized study is ongoing comparing oral anticoagulation with percutaneous closure.