ObjectiveTo explore development of a screening test for rheumatoid arthritis (RA) patients most likely to develop radiographic damage in the next year. The test is a simple, objective measurement of elevated dermal temperature over an inflamed joint in this observational, prospective cohort study.MethodsSeropositive RA patients were sequentially enrolled into cohorts with hot or cool joints, as determined by a dermal thermometer. Patients naive to biologic therapy were maintained on a stable dosage of methotrexate (20–25 mg/week). The hot‐joint cohort had a joint skin temperature greater than their body temperature on vital signs. Hand/wrist radiographs obtained at baseline and 1 year later were read and scored using modified Sharp/van der Heijde scores (SHS) by a single reader without sequence order or identifiers.ResultsEach cohort consisted of 104 patients enrolled into observation between 2009 and 2014. Patients in the cohort with hot joints had a mean ± SD joint temperature of 1.06 ± 0.69°F above central body temperature and a nearly 4‐fold higher risk of new radiographic damage than those with cool joints (SHS score 8.7 ± 6.2 versus 2.5 ± 1.4; P < 0.001). Sensitivity and specificity for joint temperature to predict radiographic damage in the next year were 92% and 78%, respectively, in the hot‐joint cohort. As expected, this cohort at baseline was younger, had more recent onset RA, and had higher Westergren erythrocyte sedimentation rate levels than the cool‐joint cohort (P < 0.001 for each).ConclusionDermal joint temperature may become a screening test to quickly and accurately identify individual RA patients at high risk for radiographic damage and those who may benefit most from biologic therapy.

Citrullinated Immunoglobulin Binding Protein (BiP) is a newly described autoimmune target in rheumatoid arthritis (RA), one of many cyclic citrullinated peptides(CCP or ACPA). BiP is over-expressed in RA patients causing T cell expansion and increased interferon levels during incubation for the QuantiFERON-Gold tuberculosis test (QFT-G TB). The QFT-G TB has never been validated where interferon is increased by underlying disease, as for example RA.Of ACPA-positive RA patients (n = 126), we found a 13% false-positive TB test rate by QFT-G TB. Despite subsequent biologic therapy for 3 years of all 126 RA patients, none showed evidence of TB without INH. Most of the false-positive RA patients after treatment with biologic therapy reverted to a negative QFT-G test. False TB tests correlated with ACPA level (p < 0.02).Three healthy women without arthritis or TB exposure had negative QFT-G TB. In vitro, all three tested positive every time for TB correlating to the dose of BiP or anti-BiP added, at 2 ug/ml, 5 ug/ml, 10 ug/ml, and 20 ug/ml.BiP naturally found in the majority of ACPA-positive RA patients can result in a false positive QFT-G TB. Subsequent undertreatment of RA, if biologic therapy is withheld, and overtreatment of presumed latent TB may harm patients.

No abstract

No abstract

No abstract

Background There is great debate regarding which patients to treat with expensive effective therapies for rheumatoid arthritis (RA). Objectives To identify RA patients rapidly and easily who are destined to have progressive destructive disease in the next year. Methods A digital dermal thermometer was used to record vital signs, on the skin of the forehead for a core temperature and then placed over the most painful peripheral joint (according to the patient) to record the temperature over the painful joint. This process adds less than a minute to the vital signs. Patients were sequentially entered into the program who were sero-positive and treated over the next year with methotrexate 20-25 mg/week. Corticosteroid therapy and Nsaids were allowed over the year but no other biologic or DMARD. Hand/wrist xrays were obtained initially and repeated 1 year later. A modified van der Heijde total Sharp score (mTSS) was read in December 2013 without sequence order or identifiers by a single reader (MG). The minimum meaningful change in mTSS was 5. Laboratory tests WESR and CRP were done on the day of the first xray and labs evaluated for prognostic value compared to the xray results. Medical history was reviewed for sex and years since diagnosis. A small group of subjects without RA (n=25) were used as controls to evaluate the usual range of joint temperature. Results 208 patients were evaluated. One group had hot joints (n=104) with the joint temperature exceeding the core temperature by an average of +1.06 degrees. The other group (n=104) had joints with a lower temperature than the core temperature by an average of -4.4 degrees. The control group of normal individuals (n=25) documented a – 6.3 temperature at the wrist and -12.0 temperature at the 2nd MCP, compared to the core temperature. There was a strong statistically significant difference in mTSS in 12 months change in mTSS between the hot joint group (8.7±6.2, CI 2.1) and the cool joint group (2.5±1.4, CI 0.5). In the hot joint group, 27 patients did not have meaningful progressive erosive destructive disease, and 77 had a change in mTSS ≥5, clear xray evidence of new damage (false positive identification for one year 26%). In the cool joint group, 97 did not have new xray damage and 7 did have bone or cartilage damage (false negative 7%). Therefore, 74% of the hot joint group had new xray damage in the next one year. If the 208 patients were combined, 40% had new xray damage in one year. There was a lower age and more recent onset of RA disease in the hot joint group (p<0.05) and a higher WESR. However, the sed rates between the hot and cool joint groups had a large overlap and sed rate does not work well on an individual case basis to determine who will have new destructive disease. There was no difference between groups in sex (83% female in each group) nor a difference in CRP between groups. Conclusions Joint temperature can be ascertained along with vital signs in less than a minute. This information can enrich the pool of active RA patients lik...

BackgroundMethotrexate (MTX) has long been known to improve the cardiovascular system. Myocardial infarction, strokes, and mortality are significantly reduced in patients compliant with long term MTX(.1 Hearing loss at middle age is an independent major risk factor for dementia,2 and sleep over 8 hours is associated with better health. MTX use may affect all of these risk factors.ObjectivesOur hypothesis is that the cardiovascular benefits of long term MTX treatment would translate into improved cognition, improved hearing, and better sleep patterns.MethodsCambridge Cognition (CamCog based in Cambridge)developed cognitive objective testing to study brain function. Camcog is widely used to assess cognitive function in atherosclerotic disease, dementia and ageing. The CamCog tests are computer based. Programs used in this trial included “PAL”, paired associates learning for new learning memory and “SWM”, spatial working memory along with new strategic thinking during the test. These tests provide 22 assessments per patient. In separate testing, each patient was scored on the mini-mental state examination, including serial 7’s, WORLD spelled backward, memory retention of 3 items, and drawn forms such as clock faces(.2 Sleep patterns were assessed by questionnaire.ResultsThere were 88 patients with RA between the ages of 80–101 years who had been treated with MTX a minimum of 20 years. The average PALFAM score for the group was 16.3 (sd 2.7) with a maximum score of 20. The SWMBE score for errors for the group was 2.2 (sd 4.4) with the best score 0 errors. In all 22 scoring categories of the CamCog tests, the 88 long term MTX users scored in the top quintile, and better than average for published results for healthy people at age 65. All scores were statistically significant (p<0.01) compared to healthy 65 year olds. It was not possible to compare age, sex matched normal individuals because the normative CamCog database only extends to age 90. All 88 subjects scored above 24 on the mini-mental testing (reflecting no cognitive impairment on that test). The audiometry testing was much better than expected for age, in the top tertile. Of the 88 patients on long term MTX, 3 had hearing aides. Sleep duration averaged 8.5 hours/pm which is considered excellent for maintaining cognition.3 ConclusionsThis is a subset of people with cardiovascular risk due to age and RA. The CV risk assessment tool* for our subgroup predicted 10 year risk for MI or CVA at 54%. We did not see MI or CVA over 20 years, despite RA. Expanding on that physiology, we found 88 RA patients on long term MTX had above average cognitive testing, completed mini-mental test, drawings, audiometry close to the scores expected for people 3 decades younger. One reason these preliminary results cannot be generalised to other populations is that only RA patients were studied with long term MTX. Also our group were 80–101 years old and there may be a survival advantage in this subgroup since all were healthy at age 65. A study in a larger general population given M...

Objectives: To correlate audiometry with atherosclerosis. Presbycusis is associated with age and atherosclerosis; a strong correlation might present opportunities to use audiometry to track atherosclerosis disease. Design: The authors tested 87 elderly patients with rheumatoid arthritis (age range: 80–101 years; median: 86 years) with a history of methotrexate use for over 20 years. After 50 years of age, hearing loss begins slowly and by the age of 90, the majority of the general population require hearing aids. In the 87 elderly participants, however, hearing was remarkably preserved. Results: The observed cohort of 87 individuals showed better hearing than predicted compared to audiometry historically documented in the elderly (p<0.001). The patients tested one to two decades younger than expected on audiometry and 44% of patients qualified for hearing aids instead of the expected 80%, based on age. Conclusion: The known reduction in atherosclerosis with methotrexate use in rheumatoid arthritis may account for this observed preservation of hearing.1,2 As hearing and atherosclerosis are related, the authors further postulated that routine audiometry may provide a cost-effective screening tool for other populations in future atherosclerosis studies.