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The Relationship between Toe Brachial Pressure Index, Ankle Brachial Pressure Index, Arterial Calcification and Foot Ulceration in Patients with Rheumatoid Arthritis.

The Relationship between Toe Brachial Pressure Index, Ankle Brachial Pressure Index, Arterial Calcification and Foot Ulceration in Patients with Rheumatoid Arthritis.

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An essay for the 2012 Undergraduate Awards Competition by Molly Smith. Originally submitted for Bsc Podiatry , with lecturer Elaine Hyslop in the category of Medical Sciences
An essay for the 2012 Undergraduate Awards Competition by Molly Smith. Originally submitted for Bsc Podiatry , with lecturer Elaine Hyslop in the category of Medical Sciences

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Published by: Undergraduate Awards on Aug 30, 2012
Copyright:Attribution Non-commercial

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02/17/2014

 
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Research Dissertation Proposal
1.Title of project2.Keywords3.Abstract
LL
The Relationship between Toe Brachial Pressure Index, Ankle Brachial Pressure Index, ArterialCalcification and Foot Ulceration in Patients with Rheumatoid Arthritis.Rheumatoid Arthritis, Ulceration, Calcification.
 
Rheumatoid Arthritis (RA) is an autoimmune inflammatory disease progressing to joint destructionand impaired physical ability. Accelerated atherosclerosis is the main factor leading to the increasedcardiovascular events in this patient group.Recent research has highlighted that over half of RA patients with foot ulceration have anabnormally high Ankle Brachial Pressure Index (ABPI) > 1.3 indicating falsely elevated readings dueto incompressible calcified vessels.Toe Brachial Pressure Index (TBPI) may be used to determine a more accurate vascular statuswhere abnormal ABPI readings signify calcification. In this study one hundred participants will berecruited subsequent to a mail questionnaire. Participants will undergo an assessment at aspecialist rheumatology clinic consisting of TBPI, ABPI and foot ulceration measurement. Theseresults will be analysed in conjunction with Framingham Risk Index, calcification levels and patientrecords.
 
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4.Introduction (literature review citing key references)
 
Rheumatoid Arthritis (RA) is a common inflammatory disease affecting 0.5-1% of the population andis associated with increased mortality (Chung et al 2005). Cardiovascular (CV) disease is theleading cause of death in this group with a 50% increased risk of death (Pieringer and Pichler 2011). Although less publicised in RA, research indicates that atherosclerosis, a precursor to CV disease,occurs to the same frequency and severity in both RA and Diabetes Mellitus of similar diseaseduration (Stamatelopouos et al 2009).Chronic inflammation in RA is thought to play a significant role in the development of atherosclerosisand CV risk. Accumulated inflammatory cells, released cytokines and collagen-breaking enzymes,an increased expression of adhesion molecules and activated T-cells are all found in delicateatherosclerotic plaques. Joint synovitis in RA has been linked with the release of a number of proinflammatory mediators cytokines. These cytokines can gain access to the vascular systemaffecting organs and the endothelium resulting in a ‘proatherogenic’ state. Another contributor tothe accelerated atherothrombotic disease is the elevated levels of pro-thrombotic factors includingfibrinogen, von Willebrand factor, tissue plasminogen activator of D-dimer (Pieringer and Pichler 2011).C-Reactive Proteins (CRP) has been shown to inversely correlate to endothelial dysfunction in RApatients (De Groot et al 2010). Erythrocyte Sedimentation Rate (ESR) is also linked with theamount of endothelial dysfunction. A peak in ESR levels may be seen immediately prior to new-onset heart failure in RA patients confirming the involvement of inflammatory stimuli in CV disease(Gerli et al 2007).It is important to consider that common drugs used to treat RA may negatively or positively impactthe progression of atherosclerosis by favouring traditional CV risk factors or by reducing diseaseactivity (Gerli et al 2007). Research highlights that methotrexate and Tumor Necrosing Factor-α(TNFα) blocking agents may reduce the amount of cardiovascular events however diseasemodifying drugs such as leflunomide, cyclosporine, cyclo-oxygenase-2 inhibitors and non-steroidalanti-inflammatory drugs may worsen cardiovascular prognosis (Pieringer and Pichler 2011). Additonally, vascular complications play an important role in development of atherosclerosis and CVdisease. Compared to controls, RA patients exhibit a higher level of arterial stiffness against pulsewave velocity which explains the need for higher levels of pulse pressure. RA patients also showhigher levels of coronary artery calcifications and intima-media thickness which independentlyassociated with higher levels of CV morbidity (Pieringer and Pichler 2011).
 
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The Framingham risk score is a measure of CV risk factors including age, hypertension, smokingand dyslipidemia (Hee Rho et al 2009). A higher risk score is seen in RA patients with long standingdisease associated with coronary calcification according to research carried out by Gerli et al 2007on a total of 81 patients where age was equal to 63 with a standard deviation of ± 10 years .Furthermore patients with RA have a lower level of circulating Endothelial Progenitor Cells (EPCs)when compared with healthy subjects which are involved in development and maintenance of theendothelium. The number of circulating EPCs has been found to inversely correlate with theFramingham risk factor (Pieringer and Pichler 2011). It is important to remember that theFramingham risk factor score should be used in combination with many other factors whenconsidering RA-associated atherosclerosis (Szekanecz et al 2007).Vascular abnormalities and foot ulceration are closely linked in RA with estimates showing 10-13%of patients with RA are affected by previous/ current ulceration. A third of these patients experiencemultiple ulceration and the rate of recurrence is high at 47%. In a study involving 37 ulcerated limbs,the ankle brachial pressure index (ABPI) was > 1.3 in 60% of cases suggesting arterial calcification(Siddle et al 2011).Typically arterial ulcers occur on the toes and feet whereas venous ulcers are situated above themedial malleolus are are often associated with oedema, vasculitis and lipodermatosclerosis in RA(McRorie et al 1994; 1998).There is a lack of research investigating Toe Brachial Pressure Index (TBPI) in patients with RA. Abnormal TBPI and ABPI measurements are highly linked with ulceration in Diabetes (Khonalkar 2008). The presence of calcification may invalidate ABPI measurements as the arterial wall whichresists compression gives a falsely high systolic pressure. It must be kept in mind that in extremecases of calcification, digital arteries may be affected. In diabetic patients, studies have found that itis useful to calculate TBPI for a truer reflection of arterial status (Brooks et al 2000).One study by Muro et al (2009) investigated the efficacy of TBPIs in patients with systemic sclerosis,systemic lupus erthemathosus, sjögren’s syndrome and dermatomyosis compared with healthycontrols. The mean ABPI and frequency of reduced ABPI values (<1.0) did not differ significantlybetween the disease groups however TBPI differed significantly. TBPI values in patients withsystemic sclerosis and systemic lupus erythematosus were significantly lower than in those withsjogren’s syndrome and dermatomyosis. The presence of ulcers and/or RA among subjects wasassociated with reduced TBPI.In conclusion both RA and atherosclerosis are inflammatory disorders that share comparableinflammatory characteristics within the synovium and the endothelium which can lead to decreasedphysical ability, increased risk of atherosclerosis, CV disease and foot ulceration. Foot ulceration isperceived to be a common problem in RA which may lead to a negative impact on quality of lifehowever there is a limited evidence base in this area. Additional research is required to establishwhether TBPI measurements should be established as part of routine assessments in RA patientsexhibiting signs of calcification in conjunction with other assessments to determine CV risk andulceration status.

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