The Detrimental Effect of RA Pacing on LA Function and Clinical Outcome in Cardiac Resynchronization Therapy

ObjectivesThis study assessed the impact of right-atrial (RA) pacing on left-atrial (LA) physiology and clinical outcome.BackgroundData for the effects of RA pacing on LA synchronicity, function, and structure after cardiac resynchronization therapy (CRT) are scarce.MethodsThe effect of RA pacing on LA function, morphology, and synchronicity was assessed in a prospective imaging cohort of heart failure (HF) patients in sinus rhythm with a guideline-based indication for CRT. Additionally, in a retrospective outcome cohort of consecutive HF patients undergoing CRT implantation, the relationship to RA pacing was assessed using various outcome endpoints. High versus low atrial pacing burden was defined as atrial pacing above or below 50% in both cohorts.ResultsA total of 36 patients were included in the imaging cohort (68 ± 11 years of age). Six months after CRT, patients with high RA pacing burden showed less improvement in LA maximum and minimum volumes and total emptying fraction (p < 0.05). Peak atrial longitudinal strain and reservoir and booster strain rates but not conduit strain rate improved after CRT in patients with low RA pacing burden but worsened in patients with high RA pacing burden (p < 0.05 for all). A high RA pacing burden induced significant intra-atrial dyssynchrony (maximum opposing wall delay: 44 ± 13 ms vs. 97 ± 17 ms, respectively; p = 0.022). A total of 569 patients were included in the outcome cohort. After covariate adjustments were made, a high RA pacing burden was associated with reduced LV reverse remodeling (β = 8.738; 95% confidence interval [CI]: 3.101 to 14.374; p = 0.002) and new-onset or recurrent atrial fibrillation (41% vs. 22%, respectively, at a median of 31 months [range 22 to 44 months follow-up]; p < 0.001). There were no differences in time to first HF hospitalization or all-cause mortality (p = 0.185) after covariate adjustment. However, in a recurrent event analysis, HF readmissions were more common in patients exposed to a high RA pacing burden (p = 0.003).ConclusionsRA pacing in CRT patients negatively influences LA morphology, function, and synchronicity, which is associated with worse clinical outcome, including diminished LV reverse remodeling, increased risk for new-onset or recurrent AF and heart failure readmission. Strategies reducing RA pacing burden may be warranted.     

Strain patterns in primary mitral regurgitation due to rheumatic heart disease and mitral valve prolapse

ObjectiveLeft atrial (LA) and left ventricular (LV) remodelling are the adaptive changes that occur in primary mitral regurgitation (MR) and are related to its clinical outcomes. Despite the pathophysiological differences in MR in rheumatic heart disease (RHD) and mitral valve prolapse (MVP), whether the pattern of LV and LA remodelling is different between the two conditions remains unknown. Hence, we compared the LA and LV strain pattern in MR due to RHD, the predominant etiology in developing countries topatients with MVP and age and sex-matched controls.MethodsA total of 50 patients of severe MR which included 30 MVP MR and 20 RHD MR were assessed by strain imaging by speckle tracking echocardiography (STE) and were compared with age and sex-matched controls. 2D STE was used for LA and 3D STE was used for LV strain analysis. LA and LV strain parameters were compared between MVP MR and RHD MR groups.Results30 patients with MVP and 20 with RHD were studied. 60% (n = 30) were symptomatic. Mean GLS was ?17.2 ± 4.4% compared to ?20 ± 3.2% among controls and mean LA strain was 17.35 ± 10.3% compared to 51.34 ± 11.5% among controls which were significantly lower (both p < 0.01). No significant difference in LA strain and GLS was found between MVP and RHD subgroups (LA strain 20.45 ± 11.9% and 14.63 ± 8.85%; p = 0.08; GLS - 18.25 ± 4.3% and-16.2 ± 4.6%; p = 0.12). PALS in the RHD group was lower compared to MVP(p = 0.08) which showed a trend towards significance. LV strain parameters showed no significant difference among the MVP and RHD groups.ConclusionLA and LV strain parameters showed no significant difference in MR due to either RHD or MVP. There was a trend towards lower LA strain in RHD which needs validation with large multicentric studies. The current strain parameters from MVP with the prognostic value may be applied to MR of RHD etiology, pending confirmation of our results by other groups.     

Mechanism of left a trial enlargement related to ventricular diastolic impairment in hypertension

Background and hypothesis: Systemic hypertension is the leading cause of left ventricular (LV) hypertrophy. The present study aimed to investigate the mechanism of left atrial (LA) enlargement in patients with hypertensive heart disease during cardiac catheterization. Methods: Data were obtained from eight control subjects and seven patients with hypertensive heart disease. Left atrial and LV pressures from catheter-tip micromanometer, and LA and LV volumes from biplane cineangiograms were analyzed during the same cardiac cycle. Results: Left atrial maximal volume were 93 ± 26 ml in patients with hypertensive heart disease and 63 ± 12 ml in control subjects (p<0.05). In patients with hypertensive heart disease, time constant of LV relaxation was significantly greater than that in controls (54 ± 18 vs. 31 ± 16 ms, respectively p<0.01). Left atrial maximal volume correlated with time constant of LV relaxation (r = 0.86, p<0.01). The ratio of LV filling volume before LA contraction to LV stroke volume in patients with hypertensive heart disease was significantly lower than that in control subjects (65 ± 13 vs. 76 ± 7%, respectively p<0.05). On the other hand, the ratio of LV filling volume during LA contraction to stroke volume in patients with hypertensive heart disease was significantly higher than that in controls (35 ± 13 vs. 24± 7%, respectively p<0.05). Left atrial volume before LA contraction in patients with hypertensive heart disease was significantly larger than that in controls (74 ± 22 vs. 47 ± 10 ml, respectively, p<0.01). During LA contraction, LA work was significantly increased in patients with hypertensive heart disease compared with that in controls (274 ± 101 vs. 94 ± 42 mmHg. ml, respectively p<0.001). Left atrial work showed significant correlation with LA volume before LA contraction (r = 0.75, p <0.01). Conclusion: Left ventricular diastolic filling was impaired in patients with hypertensive heart disease. Enlargement of left atrium might be attributed to the impairment of blood flow from left atrium to left ventricle due to the increased LV stiffness.     

Galectin-3 and interleukin-7 as potential serologic markers in rheumatoid arthritis patients

Aim of the workTo assess the level of serum galectin-3 and interleukin-7 (Il-7) in rheumatoid arthritis (RA) patients and to study their association with disease activity as well as other disease parameters.Patients and methodsSerum samples from 66 RA patients and 20 matched controls were tested for galectin-3 and IL-7 using enzyme-linked immunosorbent assay (ELISA). Disease activity was assessed using disease activity score (DAS28).ResultsThe mean age of the patients was 46.6 ± 12.02 years, mean disease duration was 7.5 ± 7.6 years and they were 61 females and 5 males. The mean DAS28 of the patients was 4.72 ± 1.77. Serum galectin-3 and IL-7 were higher in RA patients (7.7 ± 5.7 ng/ml and 9.03 ± 5.97 pg/ml) than the control (1.5 ± 0.8 ng/ml and 1.6 ± 1.1 pg/ml) (p < 0.001). Serum galectin-3 and IL-7 significantly correlated with age (r = 0.27, p = 0.03 and r = 25, p = 0.04), DAS28 (r = 0.64, p < 0.001 and r = 39, p = 0.001), as well as to each other (r = 0.48, p < 0.001). Serum galectin-3 significantly correlated with ESR (r = 0.29, p = 0.018) and significantly higher in those with fever (p = 0.017). At a cutoff of 2.94 ng/ml, serum galectin-3 showed 84.8% sensitivity and 100% specificity (p < 0.001) and at 2.71 pg/ml, serum IL7 showed a sensitivity of 92.4% and a specificity of 95% (p < 0.001) to diagnose RA.ConclusionSerum galectin-3 and IL-7 were higher in patients than in controls and were increased with high disease activity making them promising biomarkers for RA. Both of them showed high diagnostic power for RA. This may provide further understanding of RA pathogenesis and suggest new therapeutic interventions.     

Right atrium enlargement is related to increased heart damage and mortality in well-controlled hypertension

Background and aimLeft heart remodeling is a well-known pathophysiological effect of arterial hypertension. Right Heart status is not considered in its evaluation. No data are available on right atrium (RA) and its impact on the outcome in hypertension.We wondering to understand whether RA may play a role as a marker of an increased risk for organ damage in well-controlled hypertensives, to probe the clinical significance and whether it could indicate an increased risk.Methods and resultsWe studied well-controlled hypertensive patients. Heart damage was assessed by echocardiography. Patients were subdivided into those with RA area ≤18 cm² (normal RA - Group 1) (554 pts, 227 M, aged 60.35 ± 10.48 years) and those >18 cm² (Increased RA - Group 2) (101 pts, 71 M, age 61.65 ± 9.46 years). Group 2 had a higher left ventricle mass (LVM) and left atrium volume (LAV) both as absolute value (both p < 0.0001) and indexed for body surface area (LVMi p < 0.013; LAVi p = 0.0013). Group 2 showed an increased vascular stiffness (p < 0.0001) and carotid stenosis percentage (p = 0.011). TAPSE (p < 0.0001) resulted significantly increased. In The RA area was significantly correlated directly to LVM and LAV in both groups, but these correlations persisted in indexed values only in Group 2. Moreover, in this group there was a significant direct correlation between RA area and Tricuspid s'wave at echocardiography TDI analysis. Finally, Group 2 had an increased mortality rate compared to Group 1 (Log-Rank p = 0.0006).ConclusionGroup 2 hypertensive patients showed more alterations in dimensional and volumetric left heart parameters, and an increased mortality.     

The role of musculoskeletal ultrasound in assessment of disease activity in rheumatoid arthritis patients with fibromyalgia

IntroductionFibromyalgia (FM) is frequently present in rheumatoid arthritis (RA) patients and this can lead to an overestimation of disease activity and consequently overtreatment. Musculoskeletal ultrasound (MSUS) can aid in evaluating synovitis for assessment of disease activity with more precision.Aim of the workTo verify the potential role of MSUS in the assessment of disease activity in RA patients with and without FM.Patients and methodsThis study was conducted on 100 active RA patients. Disease activity score (DAS28) and clinical disease activity index (CDAI) were assessed. MSUS was assessed using the 12 joint simplified score.ResultsThe 100 patients were 88 females and 12 male (F:M 7.3:1) with a mean age of 44.82 ± 11.4 years and disease duration of 6.88 ± 5.77 years. 67 RA patients had associated secondary FM and 33 did not. DAS-28 and CDAI were significantly higher in those with FM (4.99 ± 0.82 and 30.49 ± 10.59) compared to those without (4.22 ± 0.96 and 18 ± 10.68)(p < 0.001). Regarding ultrasonographic finding, no significant difference was found between those with and without FMS. DAS28 and CDAI significantly correlated (p = 0.006, p = 0.002 respectively) with grey scale ultrasound (GS-US12) in patients without FMS while DAS28 only significantly correlated with GS-US12 in those with FMS (r = 0.28, p = 0.022).ConclusionSecondary FM is common in RA patients and associated with a higher disease activity making it a potential influencer on the treatment strategy. MSUS can complement physical examination in the assessment of disease activity but had a limited role to delineate RA patients with FM from those without.     

Collagen triple helix repeat containing 1 (CTHRC1) protein: A promising biomarker for evaluation of rheumatoid arthritis patients

Aim of the workTo assess serum collagen triple helix repeat containing 1 (CTHRC1) protein level in rheumatoid arthritis (RA) patients and compare it with healthy controls. In addition, to evaluate the relation of its level with RA activity and severityPatients and methodsThe study included 60 adult RA patients and 60 matched controls. Disease activity score (DAS28), modified health assessment questionnaire (MHAQ) and RA medical records-based index of severity (RARBIS) were assessed in RA patients. Serum CTHRC1 levels were measured in patients and controls by enzyme linked immunosorbent assay (ELISA)ResultsThey were 49 females and 11 males patients with a mean age of 43.6 ± 10.8 years and disease duration of 8.8 ± 0.9 years. The mean of DAS28 was 4.9 ± 2 (1.95–8.6). Serum CTHRC1 levels were significantly higher in patients than controls (1009.5 ± 79.4 vs. 470.7 ± 8.2 ng/ml, p < 0.001).The optimum cut-off value of CTHRC1 to discriminate patients from control was > 583.5 ng/ml with sensitivity of 98.3% and specificity of 100%. CTHRC1 significantly correlated with DAS28 (r = 0.81, p < 0.001), MHAQ (r = 0.14, p = 0.002), RARBIS (r = 0.41, p = 0.006), erythrocyte sedimentation rate (ESR) (r = 0.57, p < 0.001), C-reactive protein (CRP) (r = 0.41, p = 0.002), rheumatoid factor (RF) (r = 0.31, p = 0.037) and anti-cyclic citrullinated peptide (anti-CCP) (r = 0.27, p = 0.036). The significant predictors of increase CTHRC1 among patients were elevation in DAS28 (ß=287.6; p = 0.007, CI = 83.4–491.9) and MHAQ (ß=369.7; p = 0.042, CI = 14.5–724.9)ConclusionSerum CTHRC1 is a promising biomarker for evaluation of RA patients. It can be used as a marker for RA diagnosis and in monitoring the disease activity and severity.     

Significance of vascular endothelial growth factor (VEGFA)-1154 G/A gene polymorphism (rs1570360) in rheumatoid arthritis patients

Aim of the workTo evaluate the association of the vascular endothelial growth factor (VEGF) 1154G/A single nucleotide polymorphism (SNP) with the risk of RA and its possible relation to different disease parameters.Patients and methodsFifty RA patients and 50 matched healthy controls were enrolled in the study. Disease activity score (DAS28) was assessed. VEGF 1154G/A was measured byreal time polymerized chain reaction (RT-PCR) for patients and controls.ResultsThe patients mean age was 44.2 ± 12.1 years (25–64 years) and they were 41 females and 9 males with a disease duration of 5 ± 3.6 years and DAS28 of 5.88 ± 1.06. None of the patients were in remission or had low disease activity. The VEGF-1154 AA genotype and A allele were significantly higher in controls (54%, 56%) compared to the patients (10%, 23%)(p < 0.001). The GG, GA genotypes and G allele tended to be higher in patients (64%, 26% and 77%) compared to the control (42%, 4% and 44% respectively (p < 0.001). As regards anti-cyclic citrullinated peptide (anti-CCP) and rheumatoid factor (RF), AA genotype was significantly higher in seronegative (93.1% and 96.5%) patients compared to seropositive (6.9% and 3.5%; p = 0.002 and p = 0.005 respectively). There was no significant difference in the genotype according to gender (p = 0.45) or DAS28 (p = 0.78). No significant association was found between the SNP with the age (p = 0.48), disease duration (p = 0.58), ESR (p = 0.97) and CRP (p = 1).ConclusionsThe minor A allele of VEGFA1154G/A might act as a protective factor against RA and might also be related to a better disease prognosis.     

Subclinical entheseal involvement in patients with rheumatoid arthritis

BackgroundEnthesopathy is a common feature of Spondyloarthritis (SpA) but can also be found in rheumatoid Arthritis (RA). Recognizing enthesopathy could be challenging because of low sensitivity and specific clinical testing. To detect enthesopathy, The European League Against Rheumatism (EULAR) recommends magnetic resonance imaging (MRI) or ultrasonography (US).Aim of the workTo investigate the frequency and distribution of entheseal involvement in RA patients and its relation to disease activity.Patients and methods100 RA patients with any symptom in foot and ankle were enrolled. Disease activity score (DAS28), Visual analogue scale (VAS), Health assessment questionnaire-Disability index (HAQ-DI) and Glasgow Ultrasound Enthesitis Scoring System (GUESS) were assessed.ResultsThe mean age of patients was 44.1 ± 12.2 years, disease duration was 7 ± 5.8 years and 86% were females. The mean DAS28 score was 4.3 ± 1.2 and GUESS score was 7.2 ± 4.2; all patients had variable degrees of enthesitis: 30% of patients had mild enthesitis, 42% had moderate enthesitis and 28% had marked enthesitis. GUESS was significantly higher in patients with moderate (7.8 ± 4.9) and high (7.2 ± 3.2) disease activity than in patients with low disease activity (5.2 ± 3.9) and those in remission (6.5 ± 1.9) (p = 0.015). HAQ, Age and ESR significantly correlated with GUESS score (r = 0.19, p = 0.049; r = 0.23, p = 0.023; r = 0.33, p = 0.001 respectively).ConclusionSubclinical enthesitis is remarkable in RA patients. Quadriceps tendon enthesis was mostly affected. Enthesitis is significantly related to age, ESR and HAQ. The presence of enthesitis in RA may represent a potential marker for disease activity.     

Detection of hearing loss in rheumatoid arthritis patients using extended high frequency audiometry: Is it related to disease activity and severity?

Aim of the workTo evaluate audiological characteristics in rheumatoid arthritis (RA) patients compared with controls using extended high frequency audiometry and analyze their correlations with RA activity and severity to identify patients at higher risk of hearing loss.Patients and methodsThe study was carried out on 95 RA patients and 100 controls. Every subject underwent pure tone audiometry (PTA) from 250 through 8000 Hz, speech audiometry and extended high frequency audiometry (EHFA) from 10,000 to 20000 Hz. Disease activity score (DAS28) and RA medical records-based index of severity (RARBIS) were assessed.ResultsPatients were 85 females and 10 males with age mean 46.5 ± 1.1 years and disease duration of 9.57 ± 0.61 years. The hearing thresholds (HT) of patients were significantly higher than those of controls at all PTA (p < 0.001) and EHFA frequencies (p < 0.001). Hearing loss (HL) was detected in 68.4% and 64.2% by using PTA, while EHFA revealed it in 100% and 97.9% of right and left ears of RA patients respectively. Hearing loss was bilateral, symmetrical and sensorineural in all cases. HT of EHFA significantly correlated with age (r = 0.63, p < 0.001), age at onset (r = 0.51, p < 0.001), disease duration (r = 0.3, p = 0.03), DAS28 (r = 0.31, p = 0.01) and RARBIS (r = 0.21, p = 0.03).ConclusionBilateral symmetrical sensorineural hearing loss (SNHL) is significantly more frequent in RA patients compared to control. EHFA is valuable test to detect HL in patients with RA. Older age, longer disease duration, higher disease activity and severity are important factors for the development of HL in RA.     

Effects of diabetes mellitus on left atrial volume and functions in normotensive patients without symptomatic cardiovascular disease

PurposeLeft atrial (LA) size has been shown to be a predictor of adverse cardiovascular outcomes. The aim of the study was to evaluate the direct effect of diabetes mellitus (DM) on left atrial volume and phasic functions by using real-time three-dimensional echocardiography (RT3DE) in a population of patients free of symptomatic cardiovascular disease and hypertension.MethodsComprehensive transthoracic echocardiographic examination was performed on 40 consecutive patients with DM (20 male, age: 50.5 ± 7.3 years) and 40 healthy controls (20 male, age: 48.4 ± 6.7 years). In addition to conventional 2D echocardiographic measurements RT3DE was performed to assess LA volumes and phasic functions.ResultsThere were no significant difference between groups regarding parameters reflecting LV systolic function as LV diameters and ejection fraction. However, regarding parameters reflecting LV diastolic function; transmitral deceleration time and E/E′ ratio values were significantly higher and majority of early diastolic tissue Doppler velocity values were significantly lower in diabetic patients compared with controls. RT3DE demonstrated significantly higher LA maximum and minimum volumes for diabetic patients compared with controls (40.9 ± 11.9 vs 34.6 ± 9.3 mL, p: 0.009 and 15.6 ± 5.9 vs 11.9 ± 4.6 mL, p: 0.002, consecutively). LA total emptying fraction (TEF), expansion index (EI) and active emptying fraction (AEF) were found to be significantly lower in diabetics reflecting depressed LA reservoir and pump functions. There was no significant difference between groups regarding passive emptying fraction (PEF) which is assumed to be a marker of left atrial conduit function.ConclusionPatients with type 2 diabetes mellitus were found to have increased LA volume and impaired atrial compliance and contractility. Evaluation of asymptomatic diabetic patients by using RT3DE atrial volume analysis may facilitate recognition of subtle myocardial alterations related with type 2 diabetes.     

Evaluation of serum calprotectin level as a biomarker of disease activity in rheumatoid arthritis and osteoarthritis patients

Aim of the workTo measure the levels of serum calprotectin (CLP) in rheumatoid arthritis (RA) and osteoarthritis (OA) patients and to assess its association with disease activity, severity and functional status.Patients and methodsA total of 30 RA and30 OA patients and 30 controlswere included. Rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP), Disease activity score (DAS28), health assessment questionnaire (HAQ) and RA medical records-based index of severity (RARBIS) were assessed in RA patients. Western Ontario and McMaster Osteoarthritis index (WOMAC) and Kellgren-Lawrence (KL) grading scale were assessed in OA patients and serum CLP levels were measured.ResultsThe mean age of RA and OA patients was 48.6 ± 8.6 and 50.8 ± 9.3 years respectively andthe majority of studied groups were females. CLP was significantly higher in RA patients in comparison to OA patients and healthy control (2.70 ± 2.08 vs. 1.18 ± 0.35 vs 1.11 ± 0.24 μg/ml); p < 0.0001). Serum CLP correlated with swollen joint count (SJC) (r = 0.7, p < 0.0001), tender joint count (TJC) (r = 0.73, p < 0.0001), patient global assessment (PGA) (r = 0.51, p = 0.004), Physician global assessment (PhGA) (r = 0.58, p = 0.001), HAQ (r = 0.6,p < 0.0001), erythrocyte sedimentation rate (ESR) (r = 0.5, p = 0.005), DAS28 (r = 0.69, p < 0.0001), RARBIS (r = 0.66, p < 0.0001). At a cut-off value of 2.5 µg/ml CLP can significantly differentiate active RA patients from those in remission (AUC 0.896; p < 0.0001) at a sensitivity of 83.3%, specificity of 88.9%, and accuracy of 86.7%.CLP was significant predictor for RA activity.ConclusionThe serum CLP levels were significantly high in RA patients compared to OA patients and controls and these high levels were associated with disease activity, severity, and functional status.     

Relation of some clinical composite indices of disease activity in rheumatoid arthritis to a simplified 12 joint power Doppler ultrasound activity index

Aim of the workTo assess the association of some clinical composite disease activity indices with a simplified 12 joint power Doppler ultrasound (PDUS) activity index in rheumatoid arthritis (RA).Patients and methodsOne hundred RA patients who fulfilled the 2010 European league against rheumatism/American college of Rheumatology (EULAR/ACR) classification criteria for RA were recruited from the Rheumatology outpatient clinic, Cairo University Hospitals. Disease activity score (DAS28), the simplified disease activity index (SDAI), clinical disease activity index (CDAI) as well as mean overall index for RA (MOI-RA) were assessed. Grey Scale Ultrasonography (GSUS) and PDUS activity assessment was performed using a simplified 12-joint score.ResultsThe 100 patients were 80 females and 20 males (F:M 4:1). Their mean age was 44.4 ± 10.8 years with disease duration of 6.3 ± 4.7 years. Rheumatoid factor was positive in 77 %. DAS28 was 4.5 ± 1.3, SDAI 27.7 ± 22.7, CDAI 17.5 ± 13.2 and MOI-RA 86.8 ± 25.1. On US, tenosynovitis was present in 10 %, irregularity in 23 % and erosion in 62 %. The mean 12-point PDUS was 3.53 ± 4.16 and the overall US score 10.34 ± 9.3. A significant correlation was found between the US findings of overall synovitis, degree of PD and US score with DAS28 (r = 0.3, p < 0.0001; r = 0.4, p < 0.0001 and r = 0.3, p < 0.0001) with SDAI (r = 0.3, p < 0.0001; r = 0.4,p < 0.0001; r = 0.4, p < 0.0001) and with MOI-RA score (r = 0.3, p < 0.0001; r = 0.4, p < 0.0001 and r = 0.4, p < 0.0001 respectively) but the highest correlations was with CDAI (r = 0.4, p < 0.0001; r = 0.5, p < 0.0001 and r = 0.4, p < 0.0001 respectively).ConclusionSimplified 12 -joint PDUS score is well correlated with activity indices in RA patients.     

Risk of cervical myelopathy in rheumatoid arthritis patients with neck pain

BackgroundCervical spine (CS) evaluation in rheumatoid arthritis (RA) is challenging since subtle neurological insult is usually masked by the severe peripheral joint affection or muscle atrophy. Neglected CS lesions could end up with cervical myelopathy. Magnetic resonance imaging (MRI) has been the modality of choice in assessing CS in RA.Aim of the workTo evaluate CS in RA using MRI and detect the risk factors for its involvement.Patients and methodsForty RA patients with neck pain were assessed using disease activity score (DAS28), Ranawat classification of rheumatoid myelopathy, simple erosion narrowing score (SENS), bilateral hand and wrist musculoskeletal ultrasound (MSKUS) for early erosion detection and CS MRI.ResultsThe mean age of patients was 44.3 ± 10.1 years, disease duration 7.9 ± 6.6 years and the DAS28 was 4.8 ± 1.6. 70% of patients were in Ranawat class I, 30% in class II, and none in class III. 70% of patients had CS lesions where synovitis occurred in 67.5% of patients, odontoid erosions in 15%, atlanto-axial marrow edema in 5%, atlanto-occipital marrow edema in 5% and none had atlanto-axial subluxation (AAS), subaxial subluxation (SAS), spinal cord/brain stem compression. CS involvement was significantly related to peripheral joint erosion, high SENS and positive RF (p = 0.01, p < 0.0001, p < 0.0001 respectively).ConclusionCS involvement is remarkable in RA especially in those with peripheral joint erosions, high SENS and positive RF. RA patients with persistent neck pain, even in absence of objective neurological deficit should be evaluated early for detection and management of CS lesions before irreversible neurological damage takes place.     

The early cardiac involvement in patients with β-thalassemia major

BackgroundCardiac complications, heart failure and arrhythmias remain the major causes of death in thalassemia major.AimTo detect the early cardiac involvement in β-thalassemic patients.Patients and methods56 Patients (pts) with β-thalassemia major and transfusion burden ?12 times/year (age 6–16 years) were included in our study, classified into three groups according to serum ferritin, group I: 21 pts with ferritin level <2500 ng/ml, group II: 23 pts with ferritin level 2500–5000 and group III: 12 pts with ferritin level >5000 ng/ml. They were subjected to detailed clinical evaluation, routine laboratory investigations, serum ferritin level, ECG {corrected QT intervals (QTc) and QT dispersion(QTd)}, echocardiography for measurement of left atrial (LA) active emptying fraction, Systolic (peak systolic wave, Q–S peak duration) and diastolic functions of left ventricle using standard and tissue Doppler imaging (TDI).ResultsGroups III and II showed a significant increase in LV septal and posterior wall thickness than group I while QTc and QTd were increased significantly only in group III compared to group I (P = 0.00, 0.01). LV diastolic function and LA active emptying fraction were significantly impaired in group III and II compared to group I while LV systolic function parameters by TDI were impaired significantly in group III compared to group I with insignificant difference by standard echocardiography.ConclusionThe increase in LV septal and posterior wall thickness precedes ECG changes. Also LV diastolic dysfunction and impaired LA active emptying fraction precede LV systolic dysfunction.     

Association of serum osteoprotegerin and osteoprotegerin gene polymorphism with subclinical carotid artery atherosclerosis and disease activity in rheumatoid arthritis patients

Aim of the workTo investigate the association of single nucleotide polymorphism (SNP) (rs2073618) of the OPG gene and of serum OPG with subclinical carotid atherosclerosis in RA patients.Patients and methodsEighty RA patients with no previous history of a cardiovascular disease were studied and forty healthy controls were enrolled in the study. Carotid atherosclerosis was evaluated by high-resolution B-mode ultrasound and the carotid intimal medial thickness (CIMT) measured. rs2073618 OPG genotyping was performed by polymerized chain reaction (PCR) and serum OPG concentrations were measured. The high sensitive C reactive protein (hs-CRP), rheumatoid factor (RF) titer and anti-cyclic citrullinated peptide (anti-CCP) were assessed. The disease activity score (DAS28) was evaluated.ResultsThe patients mean age was54.1 ± 6.2 years, disease duration of 12.5 ± 8.5 years and were 72 females and 8 males. Increased IMT was found in 38 patients, 40 age and sex matched controls were included. Patients with atherosclerosis (n = 38) had longer disease duration, higherDAS28, hs-CRP, RF titer and anti-CCP. The serum OPG levels were higher in patients with atherosclerosis (1106.4 ± 1157.1 ng/l) compared to those without (658.3 ± 151.1 ng/l)(p = 0.001). Serum OPG significantly correlated with disease duration (r = 0.42, p = 0.005), DAS28 (r = 0.53, p = 0.001), hs-CRP (r = 0.41, p = 0.007), anti-CCP (r = 0.47, p = 0.003) and mean CIMT (r = 0.37, p = 0.02). The frequencies of CC, CG and GG genotypes were comparable between those with and without atherosclerosis (39.5%, 50%, 10.4% vs 42.9%, 47.6% and 9.5% respectively).Conclusionrs2073618 OPG gene may not be associated with subclinical atherosclerosis, although the serum level could be a reliable marker for disease activity and for early detection of carotid artery atherosclerosis in RA.     

MicroRNA146a gene polymorphism in patients with rheumatoid arthritis and the relevant value with disease activity and extra-articular manifestations

Aim of the workTo analyze the relationship between miRNA-146a rs2910164 and rheumatoid arthritis (RA) susceptibility and clarifying its association with disease activity and extra-articular involvement.Patients and methodsThe study enrolled 50 RA patients and 40 controls. DNA extraction from whole blood was done. Genotyping was performed by real-time polymerase chain reaction. The selected single nucleotide polymorphism was rs2910164 in the miRNA-146a gene. Genotyping was performed on genomic DNA samples by allelic discrimination assay. Disease activity score (DAS28) and health assessment questionnaire-disability index (HAQ-DI) were assessed.ResultsThe mean age of patients was 44.8 ± 9.9 years while age at onset was 37.2 ± 9.8 years. Female:male was 5.3 vs 1. Females had significantly higher DAS28, visual analogue scale and rheumatoid factor (RF) than males (p = 0.04, p = 0.009, p = 0.03). The frequency of GC genotype was more in both males and females (62.5 vs 47.6%). GC genotype and G allele were the most frequent in patients. No significant difference in the frequency distribution of genotypes and alleles was observed between patients and controls. There was a significant difference in the number of swollen joints (p = 0.04) and sicca symptoms (p = 0.01) being higher in those with CC genotype with a tendency of increased DAS28, HAQ-DI, deformities and rheumatoid nodules with CC genotype and interstitial pulmonary fibrosis and RF with GG genotype.ConclusionsCC genotype was associated with sicca symptoms and swollen joints, deformities, disease activity and functional disability. miRNA-146a may be a potential biomarker for extra-articular manifestations of RA that need more attention and warrant aggressive therapy.     

Effect of education on disease activity and functional status in rheumatoid arthritis patients

Aim of the workTo study the effect of education on rheumatoid disease in a cohort of Egyptian patients.Patients and methodsThis study included 1022 consecutive rheumatoid arthritis (RA) patients recruited from several rheumatology clinics of public and private sectors from Cairo, Kafr Elsheik and Fayoum governorates. Their mean age was 45.1 ± 12.4 years and mean disease duration was 85.9 ± 73 months. Patients were divided into groups according to their educational level (university degree/high school/illiterate) and were compared regarding their disease activity score (DAS28) and modified health assessment questionnaire (mHAQ) as a measure of the functional status.ResultsThe mean age of patients was 45.1 ± 12.4 years, they were 854 females and 168 males and disease duration of 85.9 ± 73 months. 106 (10.4%) were smokers and 333 (32.6%) were employed. 342 (33.5%) were illiterate, 455 (44.5%) were non-university-educated and 225 (22%) university educated. Educated patients showed significant lower disease activity (p = 0.001), swollen joint count (p = 0.044), tender joint count (p = 0.001), doctors global assessment (p = 0.001), erythrocyte sedimentation rate (p = 0.003) and visual analogue scale (p = 0.001). Educated patients had significantly received more biologic therapy (p = 0.001) and attended regular follow-up (p = 0.001). They showed better functional status with significantly lower MHAQ and had significant higher percentage of employment (p = 0.001). Rheumatoid patients with a university degree had significantly lower diseases activity and better functional indices compared to those without. Further regression analysis showed that university education is a predictor for low disease activity.ConclusionRheumatoid disease is influenced by education among Egyptians. Higher educated patients had lower disease activity and better functional outcome, and university education predicts low disease activity among Egyptian RA patients.     

Quality of sleep in rheumatoid arthritis patients: Relationship with disease activity,depression and functional status

Aim of the workTo assess sleep quality in Egyptian patients with rheumatoid arthritis (RA) and its relationship with disease activity, depression and functional status.Patients and methodsThis cross-sectional study included 133 RA patients and 76 age and sex matched controls. Sleep using the Pittsburg Sleep Quality Index (PSQI), Beck depression inventory (BDI), functional status using health assessment questionnaire (HAQ), visual analogue scale-pain (VAS), and disease activity score (DAS28) were assessed.ResultsPatients were 125 females and 8 males with a mean age of 42.5 ± 9.5 years and disease duration of 3.9 ± 1.3 years. 76 age and sex matched control were also included. Poor sleep quality was detected in 54.1% of patients. Patients had significantly higher scores in the subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, day-time dysfunction domains and in terms of the total PSQI score compared to the control (p < 0.05). A significant difference was found between RA patients with poor sleep quality and those with good sleep quality as regards marital status, HAQ, erythrocyte sedimentation rate (ESR), VAS, DAS28, morning stiffness duration, anti-cyclic citrullinated peptide (anti-CCP) (p < 0.05), and the BDI (p < 0.001). The multivariate regression analysis found that disease activity, functional disability and depression were predictors for poor sleep quality (p = 0.04, p = 0.01 and p < 0.001; respectively).ConclusionThe sleep quality is impaired in RA patients. The poor sleep quality is associated with disease activity, depression and functional disability. Systemic psychiatric screening, holistic assessment and targeted interventions are required to improve sleep quality and quality of life.     

Rheumatoid arthritis patients with interstitial lung disease: Clinical,radiological and laboratory characteristics

BackgroundRheumatoid arthritis associated interstitial lung disease (RA-ILD) has a significant burden of morbidity and mortality.Aim of the workTo analyze clinical, radiological and laboratory characteristics of RA-ILD in an Egyptian cohort.Patients and methodsThe study included 160 RA patients. Detailed medical history, disease activity score (DAS28) and joint damage (Sharp score) were carefully recorded. Chest x-ray, high-resolution computed tomography (HRCT) and pulmonary function tests (PFTs) were done and patients were sub-grouped as RA-ILD (HRCT or PFTs abnormalities) and RA without ILD.ResultsPatients were 136 (85%) females and 24 (15%) males with a mean age of 37.8 ± 11.3 years and disease duration of 4.98 ± 5.53 years. 50% of patients had chest manifestations suggestive of ILD. 60% demonstrated abnormalities in PFT and 63.75% in HRCT. The most common HRCT findings were reticulation (66.6%) and ground glass appearance (64.7%), followed by bronchiectasis (50.9%) and honey combing (46%). usual interstitial pneumonia (UIP) was the most common HRCT subtype (49%). RA-ILD patients were significantly older (p < 0.001), had longer disease duration (p < 0.001), more frequent arthritis (p = 0.002), higher DAS28 (p < 0.001) and Sharp score (p < 0.001), significantly positive rheumatoid factor (RF) (p = 0.007) and anti-citrullinated protein antibody (ACPA) (p < 0.001).ConclusionA high frequency of ILD among Egyptian patients is recorded due to careful evaluation of respiratory symptoms and valuable assessment by PFTs and HRCT chest. UIP is the most common radiologic pattern of RA-ILD. RA patients with ILD are significantly older with longer disease duration, delayed age at onset, high disease activity with arthritis and positive RF and ACPA.