- Email: [email protected]
International publications of interest from India (June—August 2011)
Indian Journal of Rheumatology 2011 September Volume 6, Number 3; pp. 144–147
PG Forum
International publications of interest from India (June–August 2011) Vivek Arya
1. Mathew AJ, Chopra A, Thekkemuriyil DV, George E, Goyal V, Nair JB. On behalf of the Trivandrum COPCORD Study Group. Impact of musculoskeletal pain on physical function and health-related quality of life in a rural community in south India: A WHOILAR-COPCORD-BJD India Study. Clin Rheumatol 2011 Aug 19. [Epub ahead of print] The aim of this study was to determine the prevalence of MSK pain and its relationship with the health-related quality of life (HRQL) in a rural community. Individuals (> 15 years) with MSK pain were identified by househouse survey from a population of 6763 individuals. HRQL was assessed using the validated ‘Modified Indian HAQ (CRD—Pune)’, translated into regional language. Moderate and severe health assessment questionnaire disability index (HAQ-DI) scores were considered significant. Details regarding the impact of pain on their personal, family and social life were also studied. All individuals with MSK pain were evaluated clinically by a medical team and HAQ-DI was compared in different groups of disorders. Prevalence of MSK pain in the community (mean age, 52 ± 15.8 years) was 26.08% (95% CI 25.03–27.13). About 8% of the respondents reporting MSK pain had to stop work and 4% had chronic depression. A significant HAQ-DI was scored by 31% subjects. Level of education and intensity of work had significant associations with HRQL. Among the clinical diagnoses, non-specific MSK pain also scored a high HAQ-DI. MSK pain, both due to specific and non-specific disorders, showed an important impact on HRQL in this community study. Studies like this provide important information on the community based prevalence and impact of musculoskeletal disorders. This information is vital for planning and implementing health care at the community level. 2. Dhaon P, Das S, Saran R, Parihar A. Is aorto arteritis a manifestation of primary antiphospholipid antibody syndrome? Lupus 2011 Aug 16. [Epub ahead of print] The authors report the unusual case of a 23-year-old female who presented with dyspnoea on exertion and absent pulses in the left upper limb. She had prior history of two first trimester abortions and pre-eclampsia doi: 10.1016/S0973-3698(11)60078-2
with premature delivery. A Doppler examination had revealed left subclavian and axillary artery thrombosis for which she had been given warfarin 6 months previously. She was admitted and investigated. She had low positive aCL IgG antibody, positive anti-beta2 gp1 antibody, negative lupus anticoagulant and negative ANA. She also had cardiomegaly and her echocardiography showed severe aortic regurgitation, moderate mitral regurgitation and moderate pulmonary artery hypertension with poor ejection fraction with normal aortic root. A diagnosis of primary antiphospholipid antibody syndrome with valvular involvement with dilated cardiomyopathy was made. A CT angiogram of the aorta revealed narrowing and irregularity of the aorta and its multiple branches suggestive of type III Takayasu’s arteritis. 3. Sharma D, Singh S, Suri D, Rawat A, Shava U, Sodhi KS. Anasarca as the initial presentation of juvenile polymyositis: an uncommon occurrence. Rheumatol Int 2011 Jul 31. [Epub ahead of print] This is a case report of an unusual presentation of juvenile polymyositis in an 8-year-old boy who presented with anasarca. Such a presentation has rarely been reported before in the paediatric literature. 4. Singh U, Verma PK, Bhagat P, Singh S, Singh S, Singh NK. IgG RF and anti-CCP2 antibody can be positive in undifferentiated arthritis due to streptococcal infection, hepatitis B virus, tuberculosis, trauma and hypothyroidism: a preliminary study. Rheumatol Int 2011 Jul 26. [Epub ahead of print] The authors studied 33 patients with undifferentiated arthritis in whom features of RA were not present, but anti-CCP2 antibodies were found. Of these patients, 19 had a diagnosis of a specific disease which included hyperthyroidism, hypothyroidism, tubercular arthritis, traumatic arthritis, pnaeumonia with arthritis, varicose vein with pain in legs, cervical spondylitis and SSA. The duration of disease was more than 1 year in 67.86% of cases. The knee was the commonest joint involved (20 cases). Most patients (78.78%) had involvement of one or two joints. CRP positivity was seen in 23.07%. Morning stiffness was present in 36.36%, while swelling
International publications of interest from India
of the joint was present in 33.33%. In 16 cases, a serum sample was available for further analysis. 62.5% cases showed IgG RF positivity. Antitubercular IgM and IgG were detected in 18.75% of cases; ASO was elevated in 12.5%, and HBs Ag was positive in 6.25%. None of the controls (n = 30) were positive for these infections, antiCCP2 antibody or RF. This study highlights an important caveat to the use of anti-CCP antibody positivity in the diagnosis of RA in patients with undifferentiated arthritis. It is of concern that these antibodies and rheumatoid factor were detectable in patients without RA who had a wide variety of underlying diseases. However, these patients presented with mono/oligo-arthritis, a clinical presentation that is less commonly seen in RA. It must be kept in mind that it is important to exclude other causes of arthritis before diagnosing RA in a patient with undifferentiated arthritis. 5. Chopra M, Jadhav S, Venugopalan A, Hegde V, Chopra A. Salivary immunoglobulin A in rheumatoid arthritis (RA) with focus on dental caries: a cross-sectional study. Clin Rheumatol 2011 Jul 20. [Epub ahead of print] Salivary secretory immunoglobulin A (sIgA) is postulated to protect against dental caries. The authors tested the hypothesis that there is a higher salivary sIgA in cariesfree subjects and a higher extent of caries in RA. A cross-sectional pilot study was carried out to determine salivary sIgA in 48 patients with RA and 102 non-RA, healthy controls. A decay, missing teeth, filled teeth (DMFT) index was used to classify caries. Whole unstimulated saliva was collected to assay sIgA using a commercial ELISA kit. Dental caries was diagnosed in 67% and 86% of the RA and healthy subjects, respectively. Eight percent of RA patients had visited a dental surgeon. Neither the rate of caries, nor the levels of sIGA were statistically significantly different in the two groups. RA patients have often been reported to have poor dental care and a higher incidence of caries. The findings from this study have questioned the validity of this assumption. 6. Chopra A, Saluja M, Tillu G, Venugopalan A, Narsimulu G, Handa R, Bichile L, Raut A, Sarmukaddam S, Patwardhan B. Comparable efficacy of standardized Ayurveda formulation and hydroxychloroquine sulfate (HCQS) in the treatment of rheumatoid arthritis (RA): a randomized investigator-blind controlled study. Clin Rheumatol 2011 Jul 20. [Epub ahead of print] The authors carried out this study to compare standardized Ayurvedic formulations and HCQS in the treatment of RA. One hundred twenty-one patients with active moderately severe RA (ACR 1988 classified) were randomized into a 24-week investigator-blind, parallel
PG Forum
145
efficacy, three-arm (two Ayurvedic and one HCQS) multicenter drug trial study; polyherb (Tinospora cordifolia and Zingiber officinale based) and monoherb (Semecarpus anacardium). Study measures included joint counts (pain/tenderness and swelling), pain visual analogue scale, global disease assessments, and health assessment questionnaire. All groups matched well at baseline. An intent-to-treat analysis (ANOVA, significance P < 0.05) did not show significant differences by treatment groups. In the polyherb, monoherb, and HCQS arms, 44%, 36%, and 51%, respectively, showed ACR 20 index improvement. Only mild adverse events (gut and skin, and none withdrew) were reported with no differences between the groups. Forty-two patients dropped out. This study has assessed the effectiveness and safety of an ayurvedic preparation for RA in a single blind, randomized fashion. Given the extensive use of alternative and complementary medicine by Indian patients, it is worthwhile finding out if such therapy is effective and safe. The authors found the ayurvedic drug to be as effective and as safe as HCQS. It would be interesting to see a similar trial using methotrexate in place of HCQS (see below). 7. Raju R, Balakrishnan L, Nanjappa V, Bhattacharjee M, Getnet D, Muthusamy B, Kurian Thomas J, Sharma J, Rahiman BA, Harsha HC, Shankar S, Prasad TS, Mohan SS, Bader GD, Wani MR, Pandey A. A comprehensive manually curated reaction map of RANKL/ RANK-signaling pathway. Database (Oxford) 2011 Jul 8. Receptor activator of nuclear factor-kappa B ligand (RANKL) is a member of tumour necrosis factor (TNF) superfamily that plays a key role in the regulation of differentiation, activation and survival of osteoclasts and also in tumour cell migration and bone metastasis. The authors have attempted a systematic cataloguing of the molecular events induced by RANKL/RANK interaction. They present a comprehensive reaction map of the RANKL/RANK-signalling pathway based on an extensive manual curation of the published literature. This work could enable new biomedical discoveries, which can provide novel insights into disease processes and development of novel therapeutic interventions. 8. Myles A, Viswanath V, Singh YP, Aggarwal A. Soluble receptor for advanced glycation endproducts is decreased in patients with juvenile idiopathic arthritis (era category) and inversely correlates with disease activity and s100a12 levels. J Rheumatol 2011 Jul 1. [Epub ahead of print] The authors studied soluble receptor for advanced glycation endproducts (sRAGE) levels in patients with JIA
146
Indian Journal of Rheumatology 2011 September; Vol. 6, No. 3
[enthesitis-related arthritis (ERA) category]. sRAGE levels were estimated in the serum of patients with ERA JIA (n = 101), systemic onset JIA and polyarticular JIA (n = 10 each), and healthy controls (n = 45). Synovial fluid (SF) sRAGE was measured in patients with ERA, rheumatoid arthritis, reactive arthritis, and osteoarthritis (n = 10). Levels of S100A12 were also measured. Twenty-four patients with ERA were followed for 4 months. Disease activity was assessed by swollen joint count (SJC), tender joint count (TJC), and erythrocyte sedimentation rate (ESR). The serum sRAGE (pg/mL) level was significantly lower in patients compared to healthy controls. In paired samples, SF had lower levels compared to corresponding plasma level. The level of S100A12 was higher in SF than in serum. Serum sRAGE correlated negatively with S100A12 levels, ESR, and SJC, but not with TJC. The levels of sRAGE remained stable over time in patients with stable disease. The authors conclude that the levels of sRAGE are reduced in patients with ERA and correlate negatively with disease activity and S100A12 levels. sRAGE may be a modulator of inflammation in these patients. 9. Ravindran V, Anoop P. Rheumatologic manifestations of benign and malignant haematological disorders. Clin Rheumatol 2011 Jun 23. [Epub ahead of print] This detailed review focuses on the well-described rheumatologic features, other occasionally reported rheumatologic manifestations and unusual musculoskeletal complications related to the treatment in patients with underlying haematological conditions. Useful for both haematologists and rheumatologists. 10. Chattopadhyay P, Dhua D, Philips CA, Saha S. Acute cerebellar ataxia in lupus. Lupus 2011 Jun 13. [Epub ahead of print] This is a report of a patient with an unusual manifestation of SLE—acute cerebellar ataxia. The patient recovered completely with intravenous high-dose steroid therapy. 11. Mishra R, Singh A, Chandra V, Negi MP, Tripathy BC, Prakash J, Gupta V. A comparative analysis of serological parameters and oxidative stress in osteoarthritis and rheumatoid arthritis. Rheumatol Int 2011 Jun 5. [Epub ahead of print] The authors recruited 36 asymptomatic controls (25 women), 28 patients with OA (20 women) and 36 patients with RA (22 women). Patients with OA were screened according to radiological and clinical finding of Kellgren and Lawrence grade and ACR criteria and assessed by VAS and WOMAC score. Patients with RA fulfilled 4/5 symptoms of ACR criteria, and their DAS28-CRP, VAS score, and RF positivity were evaluated. Participants of the groups were matched for sex, age, weight, and height
Arya
(body mass index). The BMI of all three groups was also found to be the same (P > 0.05). The mean level of LDL, Cholesterol, MDA, CRP, and Triglyceride was significantly (P < 0.05 or P < 0.01) higher in both OA and RA as compared to control. The mean level of total lipid, cholesterol, MDA, CRP, and triglyceride was found to be significantly (P < 0.05 or P < 0.01) higher in RA as compared to OA. The pre-treatment CRP level of both groups of patients showed significant and direct relation with total lipid (r = 0.27, P < 0.05) and cholesterol (r = 0.66, P < 0.01). This study found results for biochemical parameters in RA and OA similar to those reported in previous studies. 12. Furst DE, Venkatraman MM, McGann M, Manohar PR, Booth-Laforce C, Sarin R, Sekar PG, Raveendran KG, Mahapatra A, Gopinath J, Kumar PR. Double-blind, randomized, controlled, pilot study comparing classic ayurvedic medicine, methotrexate, and their combination in rheumatoid arthritis. J Clin Rheumatol 2011; 17: 185–92. This study consisted of 43 seropositive RA patients diagnosed by American College of Rheumatology (ACR) criteria with disease duration of less than 7 years. The patients were assigned to the following treatment groups: MTX plus Ayurvedic placebo (n = 14), Ayurveda plus MTX placebo (n = 12), or Ayurveda plus MTX (n = 17). Outcomes included the Disease Activity Score (DAS28-CRP), ACR20/50/70, and Health Assessment Questionnaire—Disability Index. All measures were obtained every 12 weeks for 36 weeks. All groups were comparable at baseline in demographics and disease characteristics. There were no statistically significant differences among the 3 groups on the efficacy measures. ACR20 results were MTX 86%, Ayurveda 100%, and combination 82%, and DAS28-CRP response were MTX—2.4, Ayurveda—1.7, and combination—2.4. Differences in adverse events among groups were also not statistically significant, although the MTX groups experienced more adverse event (MTX 174, Ayurveda 112, combination 176). No deaths occurred. The results of this study, along with those from the study by Chopra et al., suggest that Ayruvedic remedies may be safe and effective in the treatment of RA when compared to traditional DMARDs. However, the number of patients in these studies is small and larger trials are needed before definite conclusions can be drawn. 13. Singh U, Singh S, Singh NK, Verma PK, Singh S. Anticyclic citrullinated peptide autoantibodies in systemic lupus erythematosus. Rheumatol Int 2011; 31: 765–7. The authors evaluated anti-CCP2 Ab positivity in patients with lupus arthritis. Anti-CCP Ab, ANA, ds DNA, and
International publications of interest from India
APLA were estimated by ELISA. Fifty eight patients with SLE were studied. A total of 44 (75.86%) patients with SLE had arthritis. In 29 (50.00%) cases, arthritis resembled RA along with classical features of SLE, while 15 cases (25.86%) had nonspecific lupus arthritis. Anti-CCP2 Ab was positive in 22 cases (37.93%) of SLE. In 13 cases (44.82%) of RA type lupus arthritis, anti-CCP2 Ab was positive, while only three (20%) nonspecific lupus arthritis cases had elevated anti-CCP.
PG Forum
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In 14 (24.13) patients with SLE, there was no arthritis, but in this group also (6/14) 42.85% cases had elevated anti-CCP. This study and the one by Singh et al. raise questions about the specificity of anti-CCP antibody testing in RA. It is prudent to keep in mind that clinical evaluation remains the most important parameter in assessing arthritis and anti-CCP may be detectable in patients with SLE and also those with thyroid dysfunction, tuberculosis and several other non-rheumatological disorders.
PG Forum
International publications of interest from India (June–August 2011) Vivek Arya
1. Mathew AJ, Chopra A, Thekkemuriyil DV, George E, Goyal V, Nair JB. On behalf of the Trivandrum COPCORD Study Group. Impact of musculoskeletal pain on physical function and health-related quality of life in a rural community in south India: A WHOILAR-COPCORD-BJD India Study. Clin Rheumatol 2011 Aug 19. [Epub ahead of print] The aim of this study was to determine the prevalence of MSK pain and its relationship with the health-related quality of life (HRQL) in a rural community. Individuals (> 15 years) with MSK pain were identified by househouse survey from a population of 6763 individuals. HRQL was assessed using the validated ‘Modified Indian HAQ (CRD—Pune)’, translated into regional language. Moderate and severe health assessment questionnaire disability index (HAQ-DI) scores were considered significant. Details regarding the impact of pain on their personal, family and social life were also studied. All individuals with MSK pain were evaluated clinically by a medical team and HAQ-DI was compared in different groups of disorders. Prevalence of MSK pain in the community (mean age, 52 ± 15.8 years) was 26.08% (95% CI 25.03–27.13). About 8% of the respondents reporting MSK pain had to stop work and 4% had chronic depression. A significant HAQ-DI was scored by 31% subjects. Level of education and intensity of work had significant associations with HRQL. Among the clinical diagnoses, non-specific MSK pain also scored a high HAQ-DI. MSK pain, both due to specific and non-specific disorders, showed an important impact on HRQL in this community study. Studies like this provide important information on the community based prevalence and impact of musculoskeletal disorders. This information is vital for planning and implementing health care at the community level. 2. Dhaon P, Das S, Saran R, Parihar A. Is aorto arteritis a manifestation of primary antiphospholipid antibody syndrome? Lupus 2011 Aug 16. [Epub ahead of print] The authors report the unusual case of a 23-year-old female who presented with dyspnoea on exertion and absent pulses in the left upper limb. She had prior history of two first trimester abortions and pre-eclampsia doi: 10.1016/S0973-3698(11)60078-2
with premature delivery. A Doppler examination had revealed left subclavian and axillary artery thrombosis for which she had been given warfarin 6 months previously. She was admitted and investigated. She had low positive aCL IgG antibody, positive anti-beta2 gp1 antibody, negative lupus anticoagulant and negative ANA. She also had cardiomegaly and her echocardiography showed severe aortic regurgitation, moderate mitral regurgitation and moderate pulmonary artery hypertension with poor ejection fraction with normal aortic root. A diagnosis of primary antiphospholipid antibody syndrome with valvular involvement with dilated cardiomyopathy was made. A CT angiogram of the aorta revealed narrowing and irregularity of the aorta and its multiple branches suggestive of type III Takayasu’s arteritis. 3. Sharma D, Singh S, Suri D, Rawat A, Shava U, Sodhi KS. Anasarca as the initial presentation of juvenile polymyositis: an uncommon occurrence. Rheumatol Int 2011 Jul 31. [Epub ahead of print] This is a case report of an unusual presentation of juvenile polymyositis in an 8-year-old boy who presented with anasarca. Such a presentation has rarely been reported before in the paediatric literature. 4. Singh U, Verma PK, Bhagat P, Singh S, Singh S, Singh NK. IgG RF and anti-CCP2 antibody can be positive in undifferentiated arthritis due to streptococcal infection, hepatitis B virus, tuberculosis, trauma and hypothyroidism: a preliminary study. Rheumatol Int 2011 Jul 26. [Epub ahead of print] The authors studied 33 patients with undifferentiated arthritis in whom features of RA were not present, but anti-CCP2 antibodies were found. Of these patients, 19 had a diagnosis of a specific disease which included hyperthyroidism, hypothyroidism, tubercular arthritis, traumatic arthritis, pnaeumonia with arthritis, varicose vein with pain in legs, cervical spondylitis and SSA. The duration of disease was more than 1 year in 67.86% of cases. The knee was the commonest joint involved (20 cases). Most patients (78.78%) had involvement of one or two joints. CRP positivity was seen in 23.07%. Morning stiffness was present in 36.36%, while swelling
International publications of interest from India
of the joint was present in 33.33%. In 16 cases, a serum sample was available for further analysis. 62.5% cases showed IgG RF positivity. Antitubercular IgM and IgG were detected in 18.75% of cases; ASO was elevated in 12.5%, and HBs Ag was positive in 6.25%. None of the controls (n = 30) were positive for these infections, antiCCP2 antibody or RF. This study highlights an important caveat to the use of anti-CCP antibody positivity in the diagnosis of RA in patients with undifferentiated arthritis. It is of concern that these antibodies and rheumatoid factor were detectable in patients without RA who had a wide variety of underlying diseases. However, these patients presented with mono/oligo-arthritis, a clinical presentation that is less commonly seen in RA. It must be kept in mind that it is important to exclude other causes of arthritis before diagnosing RA in a patient with undifferentiated arthritis. 5. Chopra M, Jadhav S, Venugopalan A, Hegde V, Chopra A. Salivary immunoglobulin A in rheumatoid arthritis (RA) with focus on dental caries: a cross-sectional study. Clin Rheumatol 2011 Jul 20. [Epub ahead of print] Salivary secretory immunoglobulin A (sIgA) is postulated to protect against dental caries. The authors tested the hypothesis that there is a higher salivary sIgA in cariesfree subjects and a higher extent of caries in RA. A cross-sectional pilot study was carried out to determine salivary sIgA in 48 patients with RA and 102 non-RA, healthy controls. A decay, missing teeth, filled teeth (DMFT) index was used to classify caries. Whole unstimulated saliva was collected to assay sIgA using a commercial ELISA kit. Dental caries was diagnosed in 67% and 86% of the RA and healthy subjects, respectively. Eight percent of RA patients had visited a dental surgeon. Neither the rate of caries, nor the levels of sIGA were statistically significantly different in the two groups. RA patients have often been reported to have poor dental care and a higher incidence of caries. The findings from this study have questioned the validity of this assumption. 6. Chopra A, Saluja M, Tillu G, Venugopalan A, Narsimulu G, Handa R, Bichile L, Raut A, Sarmukaddam S, Patwardhan B. Comparable efficacy of standardized Ayurveda formulation and hydroxychloroquine sulfate (HCQS) in the treatment of rheumatoid arthritis (RA): a randomized investigator-blind controlled study. Clin Rheumatol 2011 Jul 20. [Epub ahead of print] The authors carried out this study to compare standardized Ayurvedic formulations and HCQS in the treatment of RA. One hundred twenty-one patients with active moderately severe RA (ACR 1988 classified) were randomized into a 24-week investigator-blind, parallel
PG Forum
145
efficacy, three-arm (two Ayurvedic and one HCQS) multicenter drug trial study; polyherb (Tinospora cordifolia and Zingiber officinale based) and monoherb (Semecarpus anacardium). Study measures included joint counts (pain/tenderness and swelling), pain visual analogue scale, global disease assessments, and health assessment questionnaire. All groups matched well at baseline. An intent-to-treat analysis (ANOVA, significance P < 0.05) did not show significant differences by treatment groups. In the polyherb, monoherb, and HCQS arms, 44%, 36%, and 51%, respectively, showed ACR 20 index improvement. Only mild adverse events (gut and skin, and none withdrew) were reported with no differences between the groups. Forty-two patients dropped out. This study has assessed the effectiveness and safety of an ayurvedic preparation for RA in a single blind, randomized fashion. Given the extensive use of alternative and complementary medicine by Indian patients, it is worthwhile finding out if such therapy is effective and safe. The authors found the ayurvedic drug to be as effective and as safe as HCQS. It would be interesting to see a similar trial using methotrexate in place of HCQS (see below). 7. Raju R, Balakrishnan L, Nanjappa V, Bhattacharjee M, Getnet D, Muthusamy B, Kurian Thomas J, Sharma J, Rahiman BA, Harsha HC, Shankar S, Prasad TS, Mohan SS, Bader GD, Wani MR, Pandey A. A comprehensive manually curated reaction map of RANKL/ RANK-signaling pathway. Database (Oxford) 2011 Jul 8. Receptor activator of nuclear factor-kappa B ligand (RANKL) is a member of tumour necrosis factor (TNF) superfamily that plays a key role in the regulation of differentiation, activation and survival of osteoclasts and also in tumour cell migration and bone metastasis. The authors have attempted a systematic cataloguing of the molecular events induced by RANKL/RANK interaction. They present a comprehensive reaction map of the RANKL/RANK-signalling pathway based on an extensive manual curation of the published literature. This work could enable new biomedical discoveries, which can provide novel insights into disease processes and development of novel therapeutic interventions. 8. Myles A, Viswanath V, Singh YP, Aggarwal A. Soluble receptor for advanced glycation endproducts is decreased in patients with juvenile idiopathic arthritis (era category) and inversely correlates with disease activity and s100a12 levels. J Rheumatol 2011 Jul 1. [Epub ahead of print] The authors studied soluble receptor for advanced glycation endproducts (sRAGE) levels in patients with JIA
146
Indian Journal of Rheumatology 2011 September; Vol. 6, No. 3
[enthesitis-related arthritis (ERA) category]. sRAGE levels were estimated in the serum of patients with ERA JIA (n = 101), systemic onset JIA and polyarticular JIA (n = 10 each), and healthy controls (n = 45). Synovial fluid (SF) sRAGE was measured in patients with ERA, rheumatoid arthritis, reactive arthritis, and osteoarthritis (n = 10). Levels of S100A12 were also measured. Twenty-four patients with ERA were followed for 4 months. Disease activity was assessed by swollen joint count (SJC), tender joint count (TJC), and erythrocyte sedimentation rate (ESR). The serum sRAGE (pg/mL) level was significantly lower in patients compared to healthy controls. In paired samples, SF had lower levels compared to corresponding plasma level. The level of S100A12 was higher in SF than in serum. Serum sRAGE correlated negatively with S100A12 levels, ESR, and SJC, but not with TJC. The levels of sRAGE remained stable over time in patients with stable disease. The authors conclude that the levels of sRAGE are reduced in patients with ERA and correlate negatively with disease activity and S100A12 levels. sRAGE may be a modulator of inflammation in these patients. 9. Ravindran V, Anoop P. Rheumatologic manifestations of benign and malignant haematological disorders. Clin Rheumatol 2011 Jun 23. [Epub ahead of print] This detailed review focuses on the well-described rheumatologic features, other occasionally reported rheumatologic manifestations and unusual musculoskeletal complications related to the treatment in patients with underlying haematological conditions. Useful for both haematologists and rheumatologists. 10. Chattopadhyay P, Dhua D, Philips CA, Saha S. Acute cerebellar ataxia in lupus. Lupus 2011 Jun 13. [Epub ahead of print] This is a report of a patient with an unusual manifestation of SLE—acute cerebellar ataxia. The patient recovered completely with intravenous high-dose steroid therapy. 11. Mishra R, Singh A, Chandra V, Negi MP, Tripathy BC, Prakash J, Gupta V. A comparative analysis of serological parameters and oxidative stress in osteoarthritis and rheumatoid arthritis. Rheumatol Int 2011 Jun 5. [Epub ahead of print] The authors recruited 36 asymptomatic controls (25 women), 28 patients with OA (20 women) and 36 patients with RA (22 women). Patients with OA were screened according to radiological and clinical finding of Kellgren and Lawrence grade and ACR criteria and assessed by VAS and WOMAC score. Patients with RA fulfilled 4/5 symptoms of ACR criteria, and their DAS28-CRP, VAS score, and RF positivity were evaluated. Participants of the groups were matched for sex, age, weight, and height
Arya
(body mass index). The BMI of all three groups was also found to be the same (P > 0.05). The mean level of LDL, Cholesterol, MDA, CRP, and Triglyceride was significantly (P < 0.05 or P < 0.01) higher in both OA and RA as compared to control. The mean level of total lipid, cholesterol, MDA, CRP, and triglyceride was found to be significantly (P < 0.05 or P < 0.01) higher in RA as compared to OA. The pre-treatment CRP level of both groups of patients showed significant and direct relation with total lipid (r = 0.27, P < 0.05) and cholesterol (r = 0.66, P < 0.01). This study found results for biochemical parameters in RA and OA similar to those reported in previous studies. 12. Furst DE, Venkatraman MM, McGann M, Manohar PR, Booth-Laforce C, Sarin R, Sekar PG, Raveendran KG, Mahapatra A, Gopinath J, Kumar PR. Double-blind, randomized, controlled, pilot study comparing classic ayurvedic medicine, methotrexate, and their combination in rheumatoid arthritis. J Clin Rheumatol 2011; 17: 185–92. This study consisted of 43 seropositive RA patients diagnosed by American College of Rheumatology (ACR) criteria with disease duration of less than 7 years. The patients were assigned to the following treatment groups: MTX plus Ayurvedic placebo (n = 14), Ayurveda plus MTX placebo (n = 12), or Ayurveda plus MTX (n = 17). Outcomes included the Disease Activity Score (DAS28-CRP), ACR20/50/70, and Health Assessment Questionnaire—Disability Index. All measures were obtained every 12 weeks for 36 weeks. All groups were comparable at baseline in demographics and disease characteristics. There were no statistically significant differences among the 3 groups on the efficacy measures. ACR20 results were MTX 86%, Ayurveda 100%, and combination 82%, and DAS28-CRP response were MTX—2.4, Ayurveda—1.7, and combination—2.4. Differences in adverse events among groups were also not statistically significant, although the MTX groups experienced more adverse event (MTX 174, Ayurveda 112, combination 176). No deaths occurred. The results of this study, along with those from the study by Chopra et al., suggest that Ayruvedic remedies may be safe and effective in the treatment of RA when compared to traditional DMARDs. However, the number of patients in these studies is small and larger trials are needed before definite conclusions can be drawn. 13. Singh U, Singh S, Singh NK, Verma PK, Singh S. Anticyclic citrullinated peptide autoantibodies in systemic lupus erythematosus. Rheumatol Int 2011; 31: 765–7. The authors evaluated anti-CCP2 Ab positivity in patients with lupus arthritis. Anti-CCP Ab, ANA, ds DNA, and
International publications of interest from India
APLA were estimated by ELISA. Fifty eight patients with SLE were studied. A total of 44 (75.86%) patients with SLE had arthritis. In 29 (50.00%) cases, arthritis resembled RA along with classical features of SLE, while 15 cases (25.86%) had nonspecific lupus arthritis. Anti-CCP2 Ab was positive in 22 cases (37.93%) of SLE. In 13 cases (44.82%) of RA type lupus arthritis, anti-CCP2 Ab was positive, while only three (20%) nonspecific lupus arthritis cases had elevated anti-CCP.
PG Forum
147
In 14 (24.13) patients with SLE, there was no arthritis, but in this group also (6/14) 42.85% cases had elevated anti-CCP. This study and the one by Singh et al. raise questions about the specificity of anti-CCP antibody testing in RA. It is prudent to keep in mind that clinical evaluation remains the most important parameter in assessing arthritis and anti-CCP may be detectable in patients with SLE and also those with thyroid dysfunction, tuberculosis and several other non-rheumatological disorders.