Anxiety and depression in rheumatoid arthritis: an epidemiologic survey and investigation of clinical correlates in Iranian population

Psychiatric disorders occur in a considerable proportion of patients with rheumatoid arthritis (RA). This study was conducted in order to evaluate the prevalence of anxiety and depression in Iranian RA patients. In the cross sectional study, 414 RA patients were enrolled prospectively during a period of 6 months from RA clinic of Rheumatology Research Center. Beck’s and Cattell’s inventories were applied to investigate depression and anxiety in RA patients. RA activity was measured by Disease Activity Score and patients’ disability was assessed by Health Assessment Questionnaire. Levels of pain perception were stratified based on Visual Analog Scale. The prevalence of depression was 63.6 % and anxiety was in 84.1 % among RA patients. Mixed anxiety and depression was detected in 60.2 % of the study population. Functional disability was significantly associated with severity of depressive and anxiety symptoms (p < 0.001); however there was no association between disease activity and depression or anxiety (p = 0.420). There was weak correlation between disease activity score and functional disability (Spearman’s rho = 0.33; p < 0.01). Severe levels of depression and anxiety were associated with higher levels of pain perception (p < 0.001). Our study stressed the impact of depressive and anxiety symptoms in functional disability and pain perception of RA patients. Our results point out the multidisciplinary management of RA.     

Health-related quality of life and its associations with mood condition in familial Mediterranean fever patients

The aim of the present study was to investigate the health-related quality of life (HRQOL) and mood conditions in familial Mediterranean fever (FMF) patients. Ninety FMF patients (F/M 60/30, median age 29) and 67 control subjects (F/M 46/21, median age 30) were included in this study. HRQOL was assessed with short form-36 (SF-36) and mood conditions were assessed with hospital anxiety depression scale (HADS). FMF patients had significantly lower mean scores on SF-36 physical components compared to the control group. However, mental components were comparable between groups. FMF patients were significantly more likely to have depression and anxiety compared to the control group [30 (33%) vs. 8 (12%), respectively, χ ² = 9.58, OR (95% CI) = 3.7 (1.5–8.7), p < 0.01 for depression and 48 (53%) and 11 (16%), respectively, χ ² = 22.31, OR (95% CI) = 5.8 (2.7–12.5), p < 0.001 for anxiety]. When frequency of anxious subjects was adjusted for the presence of concomitant depressive status as a confounding factor, the difference between the groups remained statistically significant [χ ² = 11.86, OR (95% CI) = 5.4 (2.1–13.7), p < 0.01]. However, the difference of depression status between groups was not statistically significant when adjusted for the presence of concomitant anxiety status [χ ² = 0.08, OR (95% CI) = 1.3 (0.5–3.8), p = 0.78] and FMF was found to be independently associated with only anxiety [OR (95% CI) = 7.1 (2.3–20.3)]. In addition, pure anxious FMF subgroup had significantly lower scores of mental health and mental component summary when compared to normal mood subgroup. In conclusion, FMF might adversely affect HRQOL. Depression and anxiety are more frequent in FMF patients than healthy subjects.     

Predictive value of antibodies to cyclic citrullinated peptide in patients with early arthritis

The objective of this study was to determine the diagnostic value for rheumatoid arthritis (RA) of antibodies to cyclic citrullinated peptides (anti-CCP) in patients with early arthritis and vasculitis. Sixty-four adult patients with early arthritis and disease duration of less than 4 months were clinically diagnosed by an experienced rheumatologist as having RA (n=27), spondyloarthropathy (n=11), and undifferentiated arthritis (n=26). Eighteen patients with vasculitis were also included in the study. The patients with early arthritis were followed up for 9 months. After the follow-up period, five of 26 patients with undifferentiated arthritis were diagnosed as having RA. All serum samples were tested for anti-CCP and IgM rheumatoid factor (IgM-RF). The anti-CCP positivity in RA patients (44.4%) was significantly more frequent than in patients with undifferentiated arthritis (3.8%), spondyloarthropathy (0%), and vasculitis (5.6%) (p=0.001, p<0.01, and p<0.01, respectively). The frequency of IgM-RF positivity was 40.7% in RA, 7.7% in undifferentiated arthritis, 0% in spondyloarthropathy, and 22.2% in vasculitis groups. The respective specificity of anti-CCP and IgM-RF tests for early RA were 97.3 and 94.6%, and the respective sensitivity of them were 44.4 and 40.7%, respectively. The combination of anti-CCP and IgM-RF positivity had a very high specificity and positive predictive value (100%) but a rather low sensitivity (33.3%). When either anti-CCP or IgM-RF positivity combined into one criterion, the sensitivity became high (51.9%) but the specificity decreased to 91.9%. Overall performance of anti-CCP test alone for the early RA was higher than IgM-RF and the combination of anti-CCP and IgM-RF (p<0.05), and was similar to the combination of anti-CCP or IgM-RF. The specificity of positive anti-CCP test for diagnosis of established RA reached up to 100%. In conclusion, the anti-CCP test is a new diagnostic test with extremely high specificity for RA. Anti-CCP antibody testing combined with IgM-RF testing has additional value over IgM-RF testing alone in patients with early arthritis.     

EORTC QLQ-C30 assessment in Turkish patients with hematological malignancies

We aimed to evaluate the prevalences of self-reported anxiety and depression symptoms in hematological malignancy patients and to determine the association between the presence of these disorders and the results of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-30 (EORTC QLQ-C30). One hundred and forty patients with a diagnosis of a hematological malignancy completed the Hospital Anxiety and Depression Scale (HADS) and the General Health Questionnaire. Patients with higher anxiety scores were more frequently inpatients, had higher EORTC general symptom scores, and they had lower cognitive, emotional, social functioning and global quality of life (QoL) scores (all p values <0.05). Patients with higher depression scores had more frequently active disease and were inpatients; they had higher mean Eastern Cooperative Oncology Group performance scores, EORTC gastrointestinal system and general symptom scores, and significantly lower physical, role, emotional, social and cognitive functioning and global QoL scores (all p values <0.01). During follow-up, it was observed that survival curves of patients with active disease who had higher HADS depression scores tended to be shorter than those with lower scores (p = 0.1). Anxiety and depression are frequent in hematological malignancy patients and associated with poor QoL and performance status. In addition, the presence of self-reported depression might have a predictive value for poor prognosis.     

The psychosocial status of the family members of rheumatoid arthritis patients in Korea

To investigate the psychosocial aspect of the family members of the patients with rheumatoid arthritis (RA), we conducted a population-based analysis to examine the psychosocial characteristics of family members of RA patients in comparison with the general population. From the Fifth Korea National Health and Nutrition Examination Survey dataset (KNHANES V) (2010–2012), we identified 363 RA patients and selected family members of these patients who were aged 20 years or older (n = 367). The control group was randomly sampled from members of families without RA patients and matched for sex and age (n = 1101). We compared the psychosocial characteristics of family members of RA patients with the control group. Additionally, serial conditional logistic regression models were performed to evaluate the factors that affect psychosocial status of the RA family members, after adjusting for covariates. No significant differences were found in socioeconomic status between the two groups. For psychological factors, stress (85.8 vs 74.7 %, p < 0.001) and depression (7.9 vs 3.3 %, p < 0.001) were more common in the family members of RA patients. The presence of a RA patient in the family showed a positive association with stress [odds ratio (OR) 2.07; 95 % confidence interval (CI) 1.48–2.88, p < 0.001] and depression (OR 2.59, CI 1.55–4.32, p < 0.001), after adjusting for socioeconomic status. Our data show that the family members of RA patients have an increased prevalence of stress and depression. Physicians who treat RA patients should also consider the needs and the burden of family members.     

Determinants of sexual disability and dissatisfaction in female patients with rheumatoid arthritis

Previous research has identified two main problems of sexuality in female rheumatoid arthritis (RA) patients: difficulties in sexual performance and diminution of sexual desire and satisfaction. This study attempts to determine the clinical and psychological factors significantly contributing to sexual disability and dissatisfaction in female RA patients. Ninety consecutive female RA outpatients were assessed by a gynecologist. After excluding patients who were not sexually active and those with genital tract abnormalities, 52 patients were examined and investigated rheumatologically and given questionnaires assessing sexual performance, desire, and satisfaction, as well as demographic variables, pain, disability, anxiety, and depression. Following a correlation analysis, the contributions of demographic, disease, and psychological variables to sexual disability and dissatisfaction were explored by hierarchical and stepwise regression. Thirty-two patients (62%) had difficulties in sexual performance including nine patients (17%) who were totally unable to engage in sexual intercourse because of arthritis. Sexual desire or satisfaction were diminished in 24 patients (46%) and completely lost in 24 patients (46%). Sexual disability was not significantly correlated with any psychodemographic variables, but with parameters of disease activity (p<0.001), Health Assessment Questionnaire (HAQ)-disability (p<0.001), hip (p<0.001) but not knee joint disease, seropositivity (p<0.05), and diminished desire (p<0.05). However, HAQ-disability and hip joint disease were the only independent and significant determinants of sexual disability in the regression model after controlling for the effects of age and disease duration. These variables together explained 64% of the variance of sexual disability. On the other hand, pain (p<0.001), age (p<0.05), and depression (p<0.05) were the significant determinants in the regression model for sexual dissatisfaction, all together contributing 36% of its variance. More than 60% of female RA patients experience variable degrees of sexual disability and diminished sexual desire and satisfaction. Difficulties in sexual performance are related more to overall disability and hip involvement, while diminished desire and satisfaction are influenced more by perceived pain, age, and depression.     

The relationship between disease activity and depression in patients with Behcet disease and rheumatoid arthritis

Disease activity may be questioned as a possible related factor to depression in patients with rheumatoid arthritis (RA) and Behcet disease (BD). Our aims were to determine and compare the depression levels of patients with RA and BD and to investigate a possible association between disease activity and depression scores of the patients. A total of 30 RA and 30 BD patients were included in this study. In RA patients; pain, morning stiffness duration, systemic involvement, tender–swollen joints, the physician–patient global assessments and DAS28 scores were determined. In patients with BD, the BD Current Activity Form was assessed for disease activity. Beck depression inventory (BDI) was used for the evaluation of patient groups. BDI score above 13 was considered as cut-off point for depression. Pearson’s correlation and Mann–Whitney U tests were used for statistical analysis. In RA patients, in spite of no correlation between disease activity and depression, a significant correlation between BDI scores and pain was determined (p < 0.000; r = 0.615). In BD group; positive correlations between BDI scores and patient’s impression of disease activity and arthralgia were determined (p < 0.014 and p < 0.001, respectively). Number of BD patients with higher BDI scores than cut-off point was significantly more than those in RA group (p < 0.039). Pain in RA patients, and patient’s impression of disease activity and joint involvement in BD patients were found as related factors to the depression scores. The greater ratio of BD patients with higher depression score than those in RA indicates the need for increased awareness of depressive symptoms in patients with BD.     

Prevalence and characteristics of anxiety in patients with unconfirmed pulmonary nodules

This study focuses on the prevalence and characteristics of anxiety in patients with pulmonary nodules that was assessed by Hamilton Anxiety Scale (HAMA) scores. A total of 890 patients were enrolled in this study, including incidence of absence of anxiety n = 343 (38.54%), mild or probable anxiety n = 459 (51.57%) and moderate or definite anxiety n = 79 (8.88%) and obvious anxiety n = 9 (1.01%), respectively. According to the definition of anxiety, 88 (9.89%) patients were enrolled in anxiety group. The incidence of anxiety in females was significantly higher than male (11.98% vs. 7.20%, p = 0.018), patients with respiratory symptoms were significantly higher than without respiratory symptoms (13.33% vs. 8.50%, p = 0.029) and diameter of pulmonary nodules >8 mm is significantly higher than ≤8 mm (13.35% vs. 7.10%, p = 0.002). Regression analysis showed that female (OR = 0.548, 95% CI: 0.340–0.884), family history of malignant tumour (OR = 1.691, 95% CI: 1.067–2.678), respiratory symptoms (OR = 1.713, 95% CI: 1.073–2.733) and diameter >8 mm (OR = 2.135, 95% CI: 1.350–3.375) were independent risk factors of anxiety. Further analysis of 88 patients with anxiety showed the sum of psychic anxiety was significantly higher than somatic anxiety (16.66 ± 2.46 vs. 0.97 ± 1.10, p < 0.0001). Hence, vast majority of patients with unconfirmed pulmonary nodules suffered various severity of anxiety and manifested as psychic anxiety. And gender, respiratory symptoms, family history of malignant tumour and diameter of pulmonary nodules were independent influencing factors of anxiety. Effective strategies urgently need exploring and providing for improving the mental health.     

Increased frequencies of hysterectomy and early menopause in fibromyalgia patients: a comparative study

The objective was to determine the relationship between symptoms of fibromyalgia (FM) and early menopause and hysterectomy. We included 115 postmenopausal patients with FM (mean age 54.6 ± 7.6) and 67 rheumatoid arthritis (RA) patients (mean age 55.5 ± 9) into our study. All patients were questioned about the severity of their symptoms of FM, anxiety, and depression by using a visual analog scale and FM impact questionnaire. Patients’ history of menopause and hysterectomy were recorded. Menopause (≤45 years) was accepted to be early. The frequencies of early menopause (38.3% vs. 13.4%, p = 0.001) and hysterectomy (16.5% vs. 6%, p = 0.039) in FM patients were significantly higher than in RA patients. While chronic widespread pain and other FM-related symptoms started after menopause in 58.3% of FM patients, the disease started after menopause in 64.2% of RA patients (p > 0.05). FM-related symptoms started in 30 patients (26.1%) with FM with menopause or within the first postmenopausal year. When the clinical features of FM patients whose symptoms started within the first menopausal year were compared to other FM patients; it was observed that the frequency of early menopause was higher in the former group (p = 0.048). Duke anxiety and depression score was higher in patients with hysterectomy whose FM symptoms started within the first year of post-hysterectomy than other FM patients (9.1 ± 2.7 vs. 6.7 ± 2.7, p = 0.022). Early menopause and hysterectomy may be one of the factors contributing to the development of FM.     

A prospective study of psychiatric and psychological aspects of Cushing's syndrome

OBJECTIVE Cushing's syndrome is associated with psychiatric and psychological disturbances. The aim of this study was to ascertain the extent of mental illness in patients before and after treatment for Cushing's syndrome. DESIGN AND PATIENTS Patients with Cushing's syndrome were identified for a prospective study. Control patients were selected with pituitary adenomas secreting GH or PRL. The aim was to reassess patients after Cushing's syndrome had been treated. MEASUREMENTS Psychiatric symptoms were measured and classified using the Present State Examination (PSE), and analysed on the Catego Programme. The Hamilton Rating Scale (HRS) was used to measure depression. The Crown-Crisp Experiential Index was used to measure common psychoneurotic symptoms (anxiety, phobia, obsession, somatic, depression and hysteria scales). The Eysenck Personality Inventory was used to assess extroversion and neuroticism. Cortisol, ACTH, and other hormones were measured by conventional methods. Parametric and non-parametric tests were used where appropriate. RESULTS Catego analysis of psychiatric ratings showed only 8 patients of 43 with active Cushing's syndrome (19%) were normal. Psychiatric diagnoses were obtained as follows: neurotic depression in 20 (46%), possible neurotic depression in 1 (2%), reactive depression in 6 (14%), and non-specific neurotic symptoms in 8 (19%). Additional Catego ratings of suspected other psychoses were made for 3 patients who were also depressed. None of these 43 patients with active Cushing's syndrome had ratings of schizophrenia or mania, obsessional neurosis or pathological anxiety. In the control group 13 (87%) were normal, 1 patient with acromegaly had an anxiety state and one patient with a prolactinoma had neurotic depression. It was possible to reassess the Present State Examination after treatment in 25 patients, when cortisol levels had been substantially reduced (to normal in 88%), the percentage rated as psychiatrically normal increased from 19 to 68 (χ²=11.7, 1 d.f., P<0.01). Hamilton Rating Scale scores for depression showed significant improvements after treatment for Cushing's syndrome (mean decrease from 9.2 to 2.4, n=36, P<0.001). Crown-Crisp experiential index data showed significant improvements in anxiety, somatic symptoms, and depression (n=25, P<0.05). Eysenck Personality Inventory assessments showed a significant improvement in neuroticism score (n=26 P=0.016), but no significant change in extroversion (P=0.5) or lie score (P=0.6). CONCLUSIONS Most patients with Cushing's syndrome had significant psychiatric pathology, usually depressive illness. As cortisol levels were returned to normal there were significant improvements in scores for depression and anxiety. Management of patients with Cushing's syndrome should include careful assessment of psychological and psychiatric illness.     

PTSD in Urban Primary Care: High Prevalence and Low Physician Recognition

BACKGROUND Posttraumatic stress disorder (PTSD) is associated with medical and psychological morbidity. The prevalence of PTSD in urban primary care has not been well described. OBJECTIVE To measure the prevalence of PTSD in primary care patients overall and among those with selected conditions (chronic pain, depression, anxiety, heavy drinking, substance dependence (SD), irritable bowel syndrome (IBS), and immigrant status). DESIGN Cross-sectional study. PARTICIPANTS English-speaking patients aged 18–65 years old, awaiting primary care appointments in an urban academic medical center, were eligible for enrollment to determine PTSD prevalence (N = 509). Additional eligible participants (n = 98) with IBS or SD were subsequently enrolled. MEASUREMENTS PTSD (past year) and trauma exposure were measured with Composite International Diagnostic Interview. We calculated the prevalence of PTSD associated with depression, anxiety, heavy drinking, SD, IBS, and chronic pain. Only the analyses on heavy drinking, SD, and IBS used all 607 participants. RESULTS Among the 509 adults in primary care, 23% (95% CI, 19–26%) had PTSD, of whom 11% had it noted in the medical record. The prevalence of PTSD, adjusted for age, gender, race, and marital and socioeconomic statuses, was higher in participants with, compared to those without, the following conditions: chronic pain (23 vs 12%, p = .003), major depression (35 vs 11%, p < .0001), anxiety disorders (42 vs 14%, p < .0001), and IBS (34 vs 18%, p = .01) and lower in immigrants (13 vs 21%, p = .05). CONCLUSIONS The prevalence of PTSD in the urban primary care setting, and particularly among certain high-risk conditions, compels a critical examination of optimal approaches for screening, intervention, and referral to PTSD treatment. Portions of this work were presented at the annual meeting of the Society of General Internal Medicine, May 2005, New Orleans, LA, at the annual meeting of the College on Problems of Drug Dependence, June 2005, Orlando, FL, and at the annual meeting of the American Public Health Association, November 2004, Washington, DC.     

Airway Inflammation and Hypothalamic-Pituitary-Adrenal Axis Activity in Asthmatic Adults with Depression

Objective. To investigate the features of airway inflammation and hypothalamic-pituitary-adrenal axis (HPAA) activity in patients with asthma accompanied by depression. Methods. Adult asthmatics were recruited and enrolled into one of the two groups based on scores on the Hamilton Depression Rating Scale (HAMD): asthmatics with depression (HAMD score ≥8, n = 23), and asthmatics without depression (HAMD score <8, n = 41). In addition, 27 healthy individuals and 21 adults with depression only were enrolled as controls. Induced sputum and blood samples were collected for measurement of cytokines and other inflammatory factors. The diurnal rhythm profiles of salivary cortisol and other hormones were obtained for assessment of the HPAA activity. Results. For the group of asthmatics with depression, the mean HAMD score was 19.0, and for the group of asthmatics without depression, the HAMD score averaged 4.9(p < .001). Serum and sputum tumor necrosis factor alpha (TNF-α) were significantly higher in asthmatics with depression than those in the other groups (p < .05) while serum interferon-gamma (IFN-γ) was lower in asthmatics with depression than that in the other groups (p < .05). Twenty-four-hour urinary cortisol, salivary cortisol at 8 a.m. and 4 p.m. were lower in asthmatics with depression compared to other groups (p < .05). Conclusions. As compared to healthy individuals and those with asthma or depression alone, individuals with comorbid depression and asthma showed the highest level of pro-inflammatory cytokines and the lowest level of anti-inflammatory cytokines and cortisol. These observations may serve as a valuable reference for diagnosis and clinic therapies of depression in asthmatics.     

Rare copresent rheumatoid arthritis and gout: comparison with pure rheumatoid arthritis and a literature review

Copresent rheumatoid arthritis (RA) and gout is seldom reported. This study summarizes the findings of eight cases of copresent RA and gout and compares them with 31 pure RA cases. Additional reported cases were retrieved from the current literature by Medline search. Patients with copresent RA and gout were older (p = 0.014) and predominantly male (p < 0.01). Synovial fluid, positive for urate crystals, was aspirated most frequently from the knee (five out of eight), followed by the first metatarsophalangeal joint (three out of eight). Serum creatinine and urate levels in the copresent group were significantly higher (p < 0.01, both), and serum hemoglobin was lower (p = 0.04) than those with pure RA. Copresent subjects had much lower percentage of positive rheumatoid factor (RF) tests than patients with pure RA (37.5 vs 80.6%). Only one copresent subject had both RF and anti-cyclic citrullinated peptide antibody. Of copresent subjects, 75% had gouty arthritis before diagnosis of RA, which is consistent with earlier reports. Seven copresent subjects had gout attacks under disease-modifying antirheumatic drug use. This study revealed that polyarthritis negative for RF in a previously gouty patient may be RA and vice versa. This combination occurs more frequently in males. Moreover, anti-CCP antibody examination is not helpful for this diagnosis. Therefore, physicians must obtain synovial fluid for analysis in joints with intense swelling, especially in old RA subjects with renal insufficiency or involvement of lower extremities. Conversely, RA must be considered in gouty patients with polyarticular involvement.     

Urinary Thrombomodulin in Patients with Rheumatoid Arthritis: Relationship to Disease Subset

In 110 patients with rheumatoid arthritis (RA), the mean (± SD) urinary thrombomodulin (TM) concentration was 74.4 ± 19.5 ng/mg creatinine (Cre), which was significantly higher than the mean in age-matched healthy controls (49.9 ± 10.8 ng/mg Cre; p<0.0001). The mean urinary TM concentration in the RA subset with least erosive disease (LES) was 65.2 ± 12.4 ng/mg Cre (n= 41), with more erosive disease (MES) was 77.4 ± 20.4 ng/mg Cre (n= 58) and with mutilating disease (MUD) was 92.6 ± 20.2 ng/mg Cre (n= 11). TM in the MUD group was the highest of the three subsets (ANOVA, p<0.0001). By contrast, the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) in the MES and MUD groups were not significantly different. Urinary TM levels may allow differentiation of RA subsets, unlike markers of inflammation such as ESR and CRP. Received: 10 September 1998 / Accepted: 17 March 1999     

Difficulties with positive emotion regulation in anorexia nervosa

Individuals with anorexia nervosa (AN) have well-documented difficulties regulating negative emotions, but less is known about positive emotion regulation in this population. To address this gap, we compared responses on the Difficulties in Emotion Regulation Scale-Positive questionnaire and the traditional DERS questionnaire (measuring negative affect dysregulation) between females with AN (n = 30) and demographically-matched controls without an eating disorder history (NC; n = 30) and examined relations between positive emotion regulation and clinical symptoms. Results indicated that individuals with AN demonstrated greater difficulty regulating negative (p < 0.001, d = 2.75) and positive (p < 0.001, d = 1.08) emotions compared to NC participants. Specifically, the AN group reported heightened positive emotion nonacceptance (p = 0.004, d = 0.78) and impulsivity (p = 0.003, d = 0.81). Greater positive emotion nonacceptance was associated with higher anxiety (p = 0.015) and depression (p = 0.022) among individuals with AN. Unexpectedly, more positive emotion impulsivity was associated with less restrictive eating in AN (p < 0.001). Findings were largely maintained even after controlling for negative emotion dysregulation and psychotropic medication use. The results suggest that reducing shame related to positive emotions could improve mood in AN; alternatively, relinquishing control when experiencing positive emotion could reduce restriction. More research is warranted on positive emotion regulation as a treatment target for AN.     

Young age of onset is associated with increased prevalence of circulating IgM rheumatoid factor and antinuclear antibodies at presentation in women with rheumatoid arthritis

In 200 patients, 143 women and 57 men, with rheumatoid arthritis (RA), age at onset was related to the presence of IgM rheumatoid factor (RF) and antinuclear antibodies (ANA) in serum at presentation. The patients were stratified into bands of age at onset: <40 years, 40– 60 years, and >60 years. In women, the prevalences of ANA (1:160) were 63.0%, 45.5%, and 31.1% in the respective age bands (p=0.002), and the prevalences of IgM RF were 85.2%, 72.7% and 66.4%, respectively (p=0.03). The prevalences of ANA and IgM RF among men were, respectively, 35% and 86% with no association with age at onset. The findings may indicate interactive effects between gender and various pathogenetic factors.Abbreviations ANA Antinuclear antibodies - MBL Mannose-binding lectin - RA Rheumatoid arthritis - RF Rheumatoid factor     

Depression,anxiety, stress and stigma in informal caregivers of People Living with HIV (PLHIV)

Informal caregivers are unpaid individuals who help friends or family members who cannot fully care for themselves. However fulfilling the act of helping debilitated individuals, exposure to another person’s traumatic experiences often results in psychological distress. Caregiver’s stigma towards HIV worsens this. Hence, this study aims to assess the effect of stigma on the mental health of caregivers so that their needs for support can be determined. A cross sectional hospital based study was carried out in Mangalore, India on 150 informal caregivers of PLHIV. The HIV Stigma Scale was used to assess stigma and DASS-21 was used to assess depression, anxiety and stress. Of the 150 caregivers, 20% marked one or more items on the stigma scale. Frequency of depression, anxiety and stress was 46%, 27% and 8% respectively. Most caregivers who had stigma and anxiety were of those patients diagnosed for a shorter duration of time (≤5 years) n?=?20, p?=?0.05 and n?=?26, p?=?0.03 respectively. Spouses of PLHIV (n?=?31, p?=?0.005), sero-positive caregivers (n?=?25, p?=?0.03) and those living with patients (n?=?39, p?=?0.01) suffered most from anxiety. Stress was significantly associated with depression (83%, p?=?0.007) and anxiety (66.6%, p?=?0.001) in caregivers. In conclusion, more of depression and anxiety was observed among the participants than stress. Stigma was seen in 20% of the participants. Stigma was not significantly associated with depression anxiety and stress.     

A study on vascular endothelial growth factor and endothelin-1 in patients with extra-articular involvement of rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease associated with a wide range of extra-articular manifestations. Recent studies emphasise a key inflammatory role of the endothelial cells, either by overexpression of inflammatory mediators or by the proliferation of new blood vessels, in the disease process leading to the systemic organ involvement. To evaluate the relationship between internal organ manifestations and immunological markers of endothelial activation, serum levels of vascular endothelial growth factor (VEGF) and endothelin-1 (ET-1) were determined by an enzyme-linked immunosorbent assay in 64 RA patients and in 32 healthy controls. In comparison with a control group, higher serum concentrations of VEGF and ET-1 (p<0.001) in RA patients were demonstrated. A comparison between both RA groups with (20 patients) and without systemic involvement (44 patients) showed significantly higher concentrations of VEGF (p<0.05) and ET-1 (p<0.01) in the sera of patients with systemic manifestation. Moreover, a significant positive correlation between VEGF and ET-1 (r=0.475, p<0.001) in RA patients was found. A positive correlation between VEGF and Disease Activity Score (DAS) 28 index (r=0.39, p<0.005) as well as erythrocyte sedimentation rate (ESR) (r=0.564, p<0.0001) and C-reactive protein was found. ET-1 serum level correlated significantly with ESR (r=0.326, p<0.05) and DAS 28 index (r=0.307, p<0.05). These results suggest that the elevated serum levels of VEGF and ET-1 are associated with systemic organ involvement in RA patients and may play a key role in the pathogenesis of extra-articular manifestation of the disease.     

Prevalence of positive ppd in a cohort of rheumatoid arthritis patients

The main objective of this study is to determine the prevalence of positive and anergic tuberculin skin test (ppd) in a rheumatoid arthritis cohort of patients (RA) and assess the association among ppd results and clinical and treatment variables. Patients with RA diagnosis were included. The ppd was done by Mantoux method. Positive result was considered when indurations were equal or greater than 5 mm. Anergic reaction was defined when the indurations was 0 mm. We included 105 patients (N = 105). The prevalence of positive ppd was 12.4% (n = 13), while the 87.6% (n = 92) presented a negative result. The 69.5% (n = 73) of the population were anergic to ppd. Patients with negative result received higher steroids dosages than patients with positive ppd (p < 0.04). In the multivariable model, the steroids dosage was a significant and independent predictor of negative ppd (p = 0.021, OR 0.72, 95% CI 0.55–0.95). Anergic and non-anergic patients were separated in groups, and a new analysis was done. The higher dosage of methotrexate was associated to tuberculine anergy (p = 0.025). In the multivariable model, the methotrexate dosage was a significant and independent predictor of tuberculine anergy (p = 0.005, OR 1.14, 95% CIs 1.04–1.24). In conclusion, in our cohort, the prevalence of positive ppd was lower than others studies. Among analyzed variables, the high steroid dose was a significant and independent predictor of negative ppd. The methotrexate treatment and dose were associated with ppd anergy.     

Is rheumatoid factor still a superior test for the diagnosis of rheumatoid arthritis?

The diagnosis of rheumatoid arthritis (RA) is based primarily on the 1987 revised American College of Rheumatology criteria for RA, which considers mainly the clinical symptoms. But typical clinical symptoms of RA are not manifested completely in early disease course. On the other hand, appreciable advantages have been made in the therapeutic strategy of RA in the last decade and highly effective disease-modifying anti-rheumatic drugs are available now for the control of RA. The treatment strategy for the control of early RA is aggressive. Thus, a highly specific and early diagnostic marker is needed for the detection of RA. Our study is an attempt to see the role of anti-CCP2 antibody (claimed to be highly specific and early diagnostic tool) in the diagnosis of RA. We studied 119 cases of RA in terms of clinical symptoms, disease duration and various autoantibody [including rheumatoid factor (RF), anti-CCP2 antibody, antinuclear antibody, anti-dsDNA] and C-reactive protein status. All the tests were also performed in 26 age and sex-matched healthy controls. Estimation of antibodies was done by quantitative ELISA. IgM RF was positive in 47.89% cases (p value = 0.000), followed by IgG RF (42.01%, p = 0.000) and IgA RF (36.97%, p = 0.000). RF was positive in 64.7% RA cases (p value = 0.000) when all three isotypes were tested together. RF was also detected in one healthy control. In 92 cases, anti-CCP2 Ab was done, hence other data were analyzed further in 92 cases only. Anti-CCP2 Ab was positive (cut-off = 15.0 U/ml) in only 50% RA patients but none of the healthy controls was positive for it. Swelling of joints was seen in 82.6% anti-CCP2 Ab positive cases (p value = 0.092) when compared with anti-CCP2 Ab negative cases (67.4%) while among RF positive cases, only 65.4% ((p value = 0.010) cases had swelling of joints. Out of 39 RA cases presenting with disease duration less than 1 year, only 48.71% patients were anti-CCP2 Ab positive while RF was positive in 61.53% patients. Utility of various combined autoantibody tests revealed that if one does all isotypes of RF (IgG, IgA and IgM) only, then 64.7% RA cases can be diagnosed and if anti-CCP2 Ab is added to it, the sensitivity increases to 75.56%. Thus, our study concludes that anti-CCP2 Ab is not a sensitive test for the diagnosis of RA neither it is useful in early diagnosis of RA, but it increases the sensitivity if added with all RF isotypes.