Review on Effectiveness of Primary Prophylaxis in aPLs with and without Risk Factors for Thrombosis: Efficacy and Safety

Context. Antiphospholipid antibodies syndrome is an autoimmune disorder that is characterized by the association between presence of antiphospholipid antibodies and risk of thrombosis and/or pregnancy morbidity. Objectives. To systematically review the evidence for primary prophylaxis in patients with antiphospholipids antibodies syndrome or APS with or without other traditional risk factors of thrombosis when they did not have any thrombotic event yet. Methods. PubMed, the Cochrane Library, and Allied Health Literature were searched for studies that examined the efficacy and safety of primary prophylaxis in aPL patients from 1990 to February 2013. We examined literature looking at patients with aPLs with other risk factors for thrombosis and aPLs with no additional risk factors for thrombosis. Conclusion. We concluded that, in patients with aPLs, primary prophylaxes with HCQ and aspirin have been observed to reduce the frequency of thrombotic events in the case of asymptomatic aPL-positive patients with SLE. We also in this study concluded that LDA was effective in patients with autoimmune diseases. Independent cardiovascular risk factors include autoimmune defects such as SLE, rheumatoid arthritis, and atherosclerosis, where overall venous thrombosis will be induced by systemic inflammation. This review concludes that HCQ is an effective primary approach when compared to aspirin.

Anxiety, Automatic Negative Thoughts, and Unconditional Self-Acceptance in Rheumatoid Arthritis: A Preliminary Study

Objectives. This research was carried out in two stages: the objectives of the first stage were (1) to identify the existing relationships between the level of anxiety, the frequency of automatic negative thoughts, and unconditional self-acceptance and (2) to capture the existing differences regarding these variables between people diagnosed with rheumatoid arthritis and those with no such medical history. Methods. The sample made up of 50 subjects filled out the following three questionnaires: the Hamilton Anxiety Scale, the Automatic Thoughts Questionnaire, and the Unconditional Self-Acceptance Questionnaire. Results. Psychological anxiety is positively correlated with automatic negative thoughts, while unconditional self-acceptance is negatively correlated with both psychological anxiety and somatic anxiety as well as with automatic negative thoughts. All studied variables were significantly different in rheumatoid arthritis as compared to the control population. Conclusions. The results showed the presence to a greater extent of anxiety and automatic negative thoughts, along with reduced unconditional self-acceptance among people with rheumatoid arthritis. Intervention on these variables through support and counseling can lead to reducing anxiety and depression, to altering the coping styles, and, implicitly, to improving the patients’ quality of life.

Can HLA-DRB4 Help to Identify Asthmatic Patients at Risk of Churg-Strauss Syndrome?

HLA-DRB4 gene is associated with Churg-Strauss syndrome (CSS), a systemic eosinophilic vasculitis with a prodromal phase characterized by severe asthma, eosinophilia, nasal polyposis, and sinusitis. Aim of this study was to evaluate if the presence of HLA-DRB4 in asthmatic patients is associated with a clinical picture resembling that of the prodromal phase of CSS. HLA-DRB1 was determined in a cohort of 159 asthmatic patients and its frequency was compared with that of 1808 blood donors. HLA-DRB4 presence/absence was correlated with clinical features, including sinusitis, nasal polyposis, eosinophils, antiasthmatic drugs, asthma severity, and pulmonary function tests. HLA-DRB4 gene was associated with severe persistent asthma before treatment (P<0.02), near fatal or severe hypoxemic asthma (P<0.01), sinusitis (P<0.01), nasal polyposis (P<0.01), number of patients with eosinophils >1000/μl: (P<0.05), need of beclomethasone >1000–2000 μg/daily (P<0.001), use of a third controller (P<0.05), and oral prednisone (P<0.02). HLA-DRB4 gene is associated in asthmatic patients with a clinical picture characterized by asthma severity, sinusitis, nasal polyposis, and eosinophilia closely resembling that of the prodromal phase of CSS and might be useful to suspect corticosteroids-masked cases of CSS.

Therapeutic Effects of Acetone Extract of Saraca asoca Seeds on Rats with Adjuvant-Induced Arthritis via Attenuating Inflammatory Responses

Saraca asoca has been traditionally used in Indian system for treatment of uterine, genital, and other reproductive disorders in women, fever, pain, and inflammation. The hypothesis of this study is that acetone extract of Saraca asoca seeds is an effective anti-inflammatory treatment for arthritis in animal experiments. The antiarthritic effect of its oral administration on Freund’s adjuvant-induced arthritis has been studied in Wistar albino rats after acute and subacute toxicities. Phytochemical analysis revealed presence of high concentrations of phenolic compounds such as flavonoids and tannins, while no mortality or morbidity was observed up to 1000 mg/kg dose during acute and subacute toxicity assessments. Regular treatment up to 21 days of adjuvant-induced arthritic rats with Saraca asoca acetone extract (at 300 and 500 mg/kg doses) increases RBC and Hb, decreases WBC, ESR, and prostaglandin levels in blood, and restores body weight when compared with control (normal saline) and standard (Indomethacin) groups. Significant (P<0.05) inhibitory effect was observed especially at higher dose on paw edema, ankle joint inflammation, and hydroxyproline and glucosamine concentrations in urine. Normal radiological images of joint and histopathological analysis of joint, liver, stomach, and kidney also confirmed its significant nontoxic, antiarthritic, and anti-inflammatory effect.

Minimally Invasive Minor Salivary Gland Biopsy for the Diagnosis of Amyloidosis in a Rheumatology Clinic

Background. Systemic amyloidosis is a potentially fatal condition, unless diagnosed and treated before development of irreversible organ damage. Demonstration of amyloid deposits within tissue biopsies is only definitive diagnostic method, which makes appropriate selection of biopsy site essential. Herein, we evaluated efficacy of minimally invasive minor salivary gland biopsy (MSGB) for the diagnosis of amyloidosis. Methods. We analyzed 37 biopsies taken from 35 patients. Suggestive findings for amyloidosis were significant proteinuria, renal impairment, refractory diarrhea, neuropathy, and restrictive cardiomyopathy. Minor salivary gland was the initial biopsy site in all subjects. When MSGB was negative but there was a high suspicion for amyloidosis, a kidney, duodenum, or rectal biopsy was performed for further investigation. Results. Mean age of patients was 45.4 and 21 were female. In 11 patients amyloidosis was diagnosed with MSGB. In overall 18 patients were diagnosed with amyloidosis. Sixteen of them were identified as being of AA type and two were AL type amyloidosis. The sensitivity of minimally invasive MSGB is 61.1% for diagnosing amyloidosis in this study. Conclusion. MSGB is a safe and simple method for the diagnosis of amyloidosis which can be performed in an outpatient setting. We suggest extensive use of this minimally invasive method.

Review of Hyperuricemia as New Marker for Metabolic Syndrome

Hyperuricemia has long been established as the major etiologic factor in gout. In recent years, a large body of evidence has accumulated that suggests that hyperuricemia may play a role in the development and pathogenesis of a number of metabolic, hemodynamic, and systemic pathologic diseases, including metabolic syndrome, hypertension, stroke, and atherosclerosis. A number of epidemiologic studies have linked hyperuricemia with each of these disorders. In some studies, therapies that lower uric acid may prevent or improve certain components of the metabolic syndrome. There is an association between uric acid and the development of systemic lupus erythematosus; the connection between other rheumatic diseases such as rheumatoid arthritis and osteoarthritis is less clear. The mechanism for the role of uric acid in disorders other than gout is not well established but recent investigations point towards systemic inflammation induced by urate, as the major pathophysiological event common to systemic diseases, including atherosclerosis.

Correlation of Self-Reported Questionnaire (KOOS) with Some Objective Measures in Primary OA Knee Patients

Purpose. Objective of the present study was to see the correlation of subjectively measured KOOS questionnaire with objectively measured 6-minute walk test (6-MWT), age, height, weight, and BMI. Participants. 251 subjects with OA knee based on American College of Rheumatology criteria. Methods. After passing inclusion and exclusion criteria, the following parameters were recorded: age, height, weight, and BMI. Then subjects were asked to fill KOOS questionnaire; then all subjects were asked to do self-paced walk for 6 minutes. Analysis. Spearman rank test was done to see the correlation. Significant level was set at P<0.05. Results. 6-MWT had a weak correlation with KOOS-ADL (rho 0.461) and strong correlation with KOOS-symptom, KOOS-pain, and KOOS-sports and very strong correlation with KOOS-QOL. BMI had a strong correlation with KOOS-pain, KOOS-symptom, KOOS-ADL, and KOOS-sports and very strong correlation with KOOS-QOL. Weight had a weak correlation with KOOS-symptom, KOOS-ADL, and KOOS-sports and strong correlation with KOOS-pain and KOOS-QOL. All the above values were significant with P<0.001. Conclusion. KOOS is strongly positively correlated with 6-MWT and negatively correlated with BMI. Its correlation strength has decreased with weight.

Disease Activity and Bone Mineral Density of MCP Joints in Patients with Rheumatoid and Psoriatic Arthritis: Is There a Correlation?—A Study in Patients Treated with Methotrexate and an Anti-TNFα Agent

Background. Bone damage in rheumatoid arthritis (RA) and in psoriatic arthritis (PsA) includes an accelerated bone mineral density (BMD) reduction. The objective was to evaluate BMD variations of the metacarpophalangeal joints (MCPs) in patients starting treatment with methotrexate (MTX) or etanercept. Methods. Patients affected by RA or PsA with hand joints involvement and with moderate or high disease activity, were enrolled in this study. All patients underwent clinical examination, laboratory exams, and a DXA scan of the most affected hand, as assessed with an ultrasound examination at the baseline, at the time of enrolment and after 1, 3, 6, and 12 months. Patients non-responders to MTX received combination therapy, while patients with no previous treatment initiated MTX. Results. 22 patients were enrolled. In both RA and PsA groups, BMD increased independently of the treatment. However, in the patients affected by RA, a slight BMD decrease was observed at the last checkup. Globally, the BMD variations of the MCPs were strongly correlated with the disease activity. At the reduction of DAS28, the scores corresponded an increase of BMD. Conclusions. MCPs BMD is inversely correlated to disease activity. BMD increase seems to be correlated with the response to treatment and not with the drug itself.

Aspirin Use in Rheumatoid Arthritis Patients with Increased Risk of Cardiovascular Disease

Objectives. To examine the patterns of low-dose aspirin use in rheumatoid arthritis (RA) patients with high risk for coronary artery disease (CAD). Methods. Cross-sectional study of 36 consecutive RA patients with a Framingham score ≥10% for CAD. Eligible RA patients were provided with a questionnaire on CAD risk factors and use of low-dose aspirin. For aspirin nonusers, the reason for nonuse was requested by both the patient and rheumatologist. Questions for patients included physician's advice, self-preference, history of gastrointestinal bleeding, allergy to aspirin, or concomitant use of other anti-inflammatory medications. Questions for rheumatologists included awareness of the increased CAD risk, attribution, patient preference, history of gastrointestinal bleeding, allergy to aspirin, and medication interactions. Results. Patients participated in the study; 8 patients reported using daily aspirin, while 23 patients did not. The main reason cited by patients for not taking aspirin was that they were not instructed by their primary care physician (PCP) to do so (n=16), which was also the main reason cited by rheumatologists (n=9). Conclusion. This study confirmed underutilization of aspirin in RA patients at high risk for CAD, largely due to the perception that this is an issue which should be handled by the PCP.

Role of Endothelial to Mesenchymal Transition in the Pathogenesis of the Vascular Alterations in Systemic Sclerosis

The pathogenesis of Systemic Sclerosis (SSc) is extremely complex, and despite extensive studies, the exact mechanisms involved are not well understood. Numerous recent studies of early events in SSc pathogenesis have suggested that unknown etiologic factors in a genetically receptive host trigger structural and functional microvascular endothelial cell abnormalities. These alterations result in the attraction, transmigration, and accumulation of immune and inflammatory cells in the perivascular tissues, which in turn induce the phenotypic conversion of endothelial cells and quiescent fibroblasts into activated myofibroblasts, a process known as endothelial to mesenchymal transition or EndoMT. The activated myofibroblasts are the effector cells responsible for the severe and frequently progressive fibrotic process and the fibroproliferative vasculopathy that are the hallmarks of SSc. Thus, according to this hypothesis the endothelial and vascular alterations, which include the phenotypic conversion of endothelial cells into activated myofibroblasts, play a crucial role in the development of the progressive fibrotic process affecting skin and multiple internal organs. The role of endothelial cell and vascular alterations, the potential contribution of endothelial to mesenchymal cell transition in the pathogenesis of the tissue fibrosis, and fibroproliferative vasculopathy in SSc will be reviewed here.