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<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_439"
                     title="Heart Often Affected in Churg-Strauss (CME/CE)"
                     score="0.014"
                     href="http://www.medpagetoday.com/Rheumatology/GeneralRheumatology/tb/18353?impressionId=1265759404225"
                     
      &lt;p&gt;Cardiac involvement is common in patients with Churg-Strauss syndrome, even when their vasculitis is in clinical remission, a Dutch study found.&lt;/p&gt;
&lt;p&gt;Cardiac MRI detected abnormalities in 62% of patients with this rare, systemic disorder but in only 3% of matched controls (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), according to Robert M. Dennert, MD, of Maastricht University in the Netherlands, and colleagues.&lt;/p&gt;
&lt;p&gt;Yet only 26% of the patients had clinical symptoms suggesting cardiac involvement, the researchers reported in February&apos;s &lt;em&gt;Arthritis &amp;amp; Rheumatism.&lt;/em&gt;&lt;/p&gt;
&lt;p&gt;Cardiac involvement is an important predictor of poor outcome in Churg-Strauss syndrome, with approximately half of the associated mortality being heart-related. Myocardial damage typically results from eosinophilic infiltration and granuloma formation.&lt;/p&gt;
&lt;p&gt;However, the cardiac manifestations are often subclinical. They remain undiagnosed, and the exact incidence is unclear.&lt;/p&gt;
&lt;p&gt;So Dennert and colleagues enrolled 32 patients with confirmed Churg-Strauss syndrome who were in complete clinical remission, performing detailed imaging assessments to determine the frequency and extent of heart involvement.&lt;/p&gt;
&lt;p&gt;About two-thirds were men. The mean age was 61 years, and disease duration was slightly over six years.&lt;/p&gt;
&lt;p&gt;A total of 41% had antineutrophil cytoplasmic antibodies (ANCA), and most were on maintenance steroids or immunosuppressants.&lt;/p&gt;
&lt;p&gt;On EKG, major abnormalities (atrial fibrillation and conduction disturbances) were detected in only 13% of patients. Minor abnormalities such as T wave abnormalities were seen in 50% of patients and in one control subject.&lt;/p&gt;
&lt;p&gt;Echocardiography identified abnormalities in 50% of patients and in 3% of controls (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001). These included wall motion and valvular abnormalities, pericardial effusion, and pulmonary hypertension.&lt;/p&gt;
&lt;p&gt;In the 62% of patients whose MRIs revealed abnormalities, findings included fibrosis, inflammation, wall motion and valvular abnormalities, pericardial effusion, and obliterated right ventricle.&lt;/p&gt;
&lt;p&gt;Previous reports had suggested that ANCA positivity in Churg-Strauss syndrome was more often associated with renal disease and peripheral neuropathy, while ANCA negativity was associated with fever and heart involvement.&lt;/p&gt;
&lt;p&gt;In this cohort, 74% of ANCA-negative patients had cardiac involvement, and in 64%, these were wall motion disturbances.&lt;/p&gt;
&lt;p&gt;In comparison, only 23% of ANCA-positive patients had heart involvement.&lt;/p&gt;
&lt;p&gt;Defects were identified with echocardiography or MRI in 88% of patients who had clinical symptoms, and in all who had major EKG abnormalities.&lt;/p&gt;
&lt;p&gt;But in the absence of symptoms and even with a normal EKG, abnormalities could still be detected on echocardiography or MRI in almost 40% of patients, according to the investigators.&lt;/p&gt;
&lt;p&gt;&quot;We therefore recommend that the evaluation for cardiac involvement in patients with [Churg-Strauss syndrome] should include not only detailed history of cardiac symptoms and EKG, but also imaging with echocardiography or cardiac MRI,&quot; they stated.&lt;/p&gt;
&lt;p&gt;The high prevalence of heart abnormalities could not be attributed to concomitant heart disease such as coronary artery disease or hypertension, because the prevalence of these diseases among patients was comparable to that in controls.&lt;/p&gt;
&lt;p&gt;Churg-Strauss syndrome typically develops in three phases, beginning with asthma, followed by peripheral and tissue eosinophilia accompanied by pulmonary infiltrates, and finally the systemic small-vessel vasculitis.&lt;/p&gt;
&lt;p&gt;During this late phase the vasculitic lesions in the coronary vessels and myocardium can lead to myocardial infarction, heart failure, and cardiac tamponade.&lt;/p&gt;
&lt;p&gt;Studies have shown that long-term treatment with immunosuppressive drugs can improve survival and resolve the cardiac abnormalities, so early diagnosis is needed.&lt;/p&gt;
&lt;p&gt;The authors acknowledged that their study was cross-sectional, and that a longitudinal study could have provided more detailed data.&lt;/p&gt;
&lt;p&gt;Nonetheless, the study revealed a high incidence of cardiac involvement, which was often unrecognized, and they concluded that a multidisciplinary approach to management therefore should include a cardiologist.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by the Netherlands Heart Foundation and the Dutch Organization for Scientific Research.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_283"
                     title="Antibodies Predict Response to Biologics in RA (CME/CE)"
                     score="0.005"
                     href="http://www.medpagetoday.com/Rheumatology/Arthritis/tb/18141?impressionId=1265759404225"
                     
      &lt;p&gt;Patients with rheumatoid arthritis who develop antibodies against the tumor necrosis factor (TNF) antagonist infliximab (Remicade) are also likely to develop antibodies against adalimumab (Humira), a Dutch cohort study found.&lt;/p&gt;
&lt;p&gt;During 28 weeks of follow-up, 33% of patients with anti-infliximab antibodies also developed anti-adalimumab antibodies, compared with only 18% of patients who had never received a TNF blocker (&lt;em&gt;P&lt;/em&gt;=0.039), according to Geertje M. Bartelds, MD, of the Jan van Breemen Institute in Amsterdam, and colleagues.&lt;/p&gt;
&lt;p&gt;Patients who developed antibodies to both TNF blockers also had a smaller decrease in their disease activity score compared with TNF-naive patients (1.1 versus 1.7 points, &lt;em&gt;P&lt;/em&gt;=0.007), a difference that persisted after adjustment for baseline disease activity (95% CI &amp;#8722;1.166 to &amp;#8722;0.351, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001), the researchers reported online in the &lt;em&gt;Annals of the Rheumatic Diseases&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Some 30% to 40% of patients with rheumatoid arthritis fail to respond to anti-TNF therapy. Some, though not all of this failure can be explained by immunogenic antibody responses to the drugs.&lt;/p&gt;
&lt;p&gt;When patients don&apos;t respond to one TNF antagonist, doctors frequently switch to another, the researchers noted, but the choice of drug is generally not evidence-based, and there is considerable variability in subsequent response.&lt;/p&gt;
&lt;p&gt;To investigate factors determining response after switching, Bartelds and colleagues prospectively followed a consecutive cohort of 235 patients with rheumatoid arthritis being treated with adalimumab.&lt;/p&gt;
&lt;p&gt;Mean age was 53 years and disease duration was about 10 years. About 80% were women. They had previously received a mean of four disease-modifying, anti-rheumatic drugs, and more than 80% also were receiving methotrexate.&lt;/p&gt;
&lt;p&gt;Baseline erythrocyte sedimentation rate (ESR) was approximately 30 mm/hour, and the mean disease activity score (DAS28) was 5.3. (A DAS28 of 3.2 or higher reflects active disease.)&lt;/p&gt;
&lt;p&gt;A total of 52 had previously received infliximab.&lt;/p&gt;
&lt;p&gt;In the overall cohort the mean DAS28 fell by 1.6 points during 28 weeks of follow-up.&lt;/p&gt;
&lt;p&gt;When responses were assessed according to the criteria used by the European League Against Rheumatism (EULAR), 24% were nonresponders, 43% were moderate responders, and 33% were good responders at 28 weeks.&lt;/p&gt;
&lt;p&gt;Among the TNF-naive patients, there were: &lt;ul&gt; &lt;li&gt;38% good responders&lt;/li&gt; &lt;li&gt;39% moderate responders &lt;/li&gt; &lt;li&gt;23% nonresponders&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;In contrast, among patients who had previously received infliximab, there were: &lt;ul&gt; &lt;li&gt;15% good responders&lt;/li&gt; &lt;li&gt;54% moderate responders&lt;/li&gt; &lt;li&gt;31% nonresponders&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Post-hoc analysis determined that only the percentage of good responders differed significantly between the TNF-naive patients and the infliximab switchers (&lt;em&gt;P&lt;/em&gt;=0.002).&lt;/p&gt;
&lt;p&gt;Among the 20% of patients who developed anti-adalimumab antibodies, the mean decrease in DAS28 was 0.6 points, compared with 1.8 points in those without the antibodies (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001). That difference remained significant after adjustment for baseline ESR (95% CI &amp;#8722;1.797 to &amp;#8722;0.908, &lt;em&gt;P&lt;/em&gt;&amp;lt;0.0001).&lt;/p&gt;
&lt;p&gt;Previous studies have suggested that there may be differences between patients who are primary nonresponders and secondary nonresponders (who initially improve with treatment).&lt;/p&gt;
&lt;p&gt;In primary nonresponders, who never responded to anti-TNF therapy, TNF may not be the crucial cytokine responsible for the initiating events in rheumatoid arthritis, the investigators hypothesized.&lt;/p&gt;
&lt;p&gt;The findings of this study suggest that nonresponders could be treated according to their antibody status, with antibody-positive patients likely deriving greater benefit from switching to a less immunogenic drug acting on the same principle, or from optimizing concomitant methotrexate therapy.&lt;/p&gt;
&lt;p&gt;In nonresponders without antibodies, it may be more useful and cost-effective to try a drug with a different mechanism of action, they suggested.&lt;/p&gt;
&lt;p&gt;The study was limited by the small number of patients and the observational cohort design. The patient population also had severe, longstanding rheumatoid arthritis, which might have made it difficult to detect treatment effects.&lt;/p&gt;
&lt;p&gt;&quot;To our knowledge, this is the first study providing more information on the underlying mechanisms contributing to the possible success of switching,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;More research will be needed, however, to provide conclusive data on how immunogenicity could aid in clinical decision-making for individual patients.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by Abbott, Wyeth, and the Netherlands Organization for Health Research and Development.&lt;/p&gt;&lt;p&gt;One co-author has served as consultant to Abbott, Amgen, Centocor, Schering-Plough, UCB, and Wyeth, and several others also are members of the advisory board of Abbott and have received honoraria for lectures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_268"
                     title="No Meds Needed for Two Effective OA Regimens (CME/CE)"
                     score="0.004"
                     href="http://www.medpagetoday.com/Rheumatology/GeneralRheumatology/tb/18119?impressionId=1265759404225"
                     
      &lt;p&gt;Middle-aged patients with early knee osteoarthritis can benefit from either a self-managment program or strength training, but a combination of the two did not provide additional gains, a study found.&lt;/p&gt;
&lt;p&gt;During a two-year trial, roughly two-thirds of participants randomized to one of three groups achieved clinically meaningful improvements in functioning, defined as a 26% change from baseline, according to a new report in the Jan. 15 &lt;em&gt;Arthritis Care &amp;amp; Research&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Patients also achieved clinically meaningful improvements in pain -- defined as a 40% change from baseline -- regardless of treatment group, wrote Patrick E. McKnight, PhD, of George Mason University in Fairfax, Va., and colleagues.&lt;/p&gt;
&lt;p&gt;The functional improvements were 70% for patients in the strength training group, 64% for those in the self-management group, and a 66% improvement in the combined treatment group. For pain, the breakdown was as follows: &lt;ul&gt; &lt;li&gt;Strength training, 65%&lt;/li&gt; &lt;li&gt;Self-management, 56%&lt;/li&gt; &lt;li&gt;Combined treatment, 65%&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;McKnight and colleagues wrote that studies in older patients have reported positive changes for both strength training and self-management.&lt;/p&gt;
&lt;p&gt;To see if these modalities also could benefit younger patients with milder disease, and whether combining the two would lead to additional benefits, the investigators recruited 273 subjects ages 35 to 64 years.&lt;/p&gt;
&lt;p&gt;Participants all had pain on most days in at least one knee, had symptoms for less than five years, had radiographic evidence of osteoarthritis, and had self-reported disability.&lt;/p&gt;
&lt;p&gt;The strength training program consisted of two phases, the first being nine months focused on stretching and balance, range of motion and flexibility, and isotonic muscle strengthening in three sessions each week.&lt;/p&gt;
&lt;p&gt;Phase two involved the development of self-directed long-term exercising habits, following the guidance and advice of trainers.&lt;/p&gt;
&lt;p&gt;The self-management program also included two phases. During the first nine-month phase, participants attended 12 weekly 90-minute classroom sessions addressing coping and self-efficacy skills, promoting active adaptive strategies and increasing perception of control for physical function and pain management.&lt;/p&gt;
&lt;p&gt;Phase two consisted of telephone calls from instructors and problem-solving discussions.&lt;/p&gt;
&lt;p&gt;The combined treatment group concurrently participated in both strength training and self-management programs, adjusted to maintain equivalent contact time with the other two groups.&lt;/p&gt;
&lt;p&gt;Overall compliance was modest, with 55.8% of those in the strength training group completing the study, along with 69.1% and 59.6% of the self-management and combined groups, respectively.&lt;/p&gt;
&lt;p&gt;Objective measures of physical functioning consisted of five physical performance tests measured at baseline and at months nine and 24. Pain and disability were self-reported.&lt;/p&gt;
&lt;p&gt;All of these outcomes showed significant changes over time in all three treatment groups, with effect sizes computed using the standard Cohen&apos;s d units: &lt;ul&gt; &lt;li&gt;Leg press, d=0.85&lt;/li&gt; &lt;li&gt;Range of motion, d=1.00&lt;/li&gt; &lt;li&gt;Work capacity, d=0.60&lt;/li&gt; &lt;li&gt;Balance, d=0.59&lt;/li&gt; &lt;li&gt;Stair climbing, d=0.59&lt;/li&gt; &lt;li&gt;Pain, d= &amp;#8722;0.51&lt;/li&gt; &lt;li&gt;Disability, d= &amp;#8722;0.55&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Both men and women improved, although benefits were greater among men, who gained more large muscle mass strength. Study-related adverse effects included accident, injury, or increased pain with strength training.&lt;/p&gt;
&lt;p&gt;Within-group and between-group effect sizes were also computed. All within-group effect sizes differed significantly from zero, with the exception of the pain outcome in the strength training group, but none of the between-group effects were significant.&lt;/p&gt;
&lt;p&gt;&quot;The logic behind the combined treatment was that the different factors addressed in physical and psychological treatments might produce an additive effect if administered together. These results suggest otherwise,&quot; the investigators conceded.&lt;/p&gt;
&lt;p&gt;As to why there were no differences between the three treatment arms, the length of the study and the relative youth of the participants may have contributed.&lt;/p&gt;
&lt;p&gt;The sample was younger than are included in typical osteoarthritis studies and were higher functioning at baseline, which could mean that there was less opportunity to produce a significant effect, the investigators suggested.&lt;/p&gt;
&lt;p&gt;Also, the increased burden of the combined treatment may have diluted the effects of the two programs.&lt;/p&gt;
&lt;p&gt;Despite the fact that combined treatment in this study had negligible benefits beyond that seen with strength training and self-management, other long-term outcomes such as physical activity level might show a greater response. This remains speculative, but deserves further study, according to the investigators.&lt;/p&gt;
&lt;p&gt;Limitations of the study include the fact that the researchers did not assess effects of the treatment on articular cartilage or inflammation, and they did not include a no-treatment arm.&lt;/p&gt;
&lt;p&gt;Also, there may have been differences in self-medication practices between the groups.&lt;/p&gt;
&lt;p&gt;Nonetheless, the study findings suggest that the two nonpharmacologic approaches can produce gains in middle-age patients with osteoarthritis, and both can be recommended.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases.&lt;/p&gt;&lt;p&gt;One co-author is an employee of Bristol-Myers Squibb and holds stock and/or stock options in the company.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_9_963"
                     title="Early Carotid Atherosclerosis Found in Rheumatoid Arthritis Patients"
                     score="-0.005"
                     href="