Joint MRI

A traditional method of monitoring the joint disease of patients with rheumatoid arthritis is "x-rays," whereby images are produced by exposing photographic film (radiographs). This technique has proven useful for doctors to follow the course of joint destruction. The early development of discrete bony destruction (erosions) is associated with more severe rheumatoid disease. While standard x-ray radiographs contribute substantially to the clinical evaluation of rheumatoid arthritis, they do lack some sensitivity early in the course of disease. This means that substantial joint destruction must happen before changes on the standard x-ray test become apparent. Modern treatment for rheumatoid arthritis is frequently directed at early disease. Accordingly, there efforts to establish methods for early diagnosis of the disease have increased. Several radiographic imaging modalities have been explored including magnetic resonance imaging (MRI) and ultrasonography. MRI scanning has been found to be sensitive as an indicator of early rheumatoid joint destruction, but it is very expensive and not widely available. Ultrasonography is an attractive method of imaging because of its low cost, absence of harmful radiation, and rapidity of imaging. Recent advances in ultrasound image technology have allowed the development of sonographic equipment for imaging inflamed joints in patients with rheumatoid arthritis. In a recent study published in Arthritis & Rheumatism (1) ultrasound imaging was compared with standard x-ray imaging and shown to be superior at detecting bone erosions early in the course of rheumatoid arthritis. In this study, 100 patients with rheumatoid arthritis underwent ultrasound and x-ray imaging of their hands. Twenty control patients were included in the ultrasound (but not x-ray) analysis for comparison. In the group of 100 RA patients, 127 abnormalities were detected in 56 patients by ultrasound, compared with 32 abnormalities in 17 patients detected by x-ray analysis. When patients with early rheumatoid arthritis were analyzed, 6.5 fold more abnormalities were detected by ultrasonography than by x-ray films. There were erosions detected by x-ray that were missed by ultrasound; the correlation between erosions seen by x-ray and those seen by ultrasound was 86%. From these results, the authors conclude that ultrasound is a reliable technique with greater sensitivity than standard x-ray radiography. They note that the ultrasound technique is influenced and limited by technical performance, requiring appropriate use of the sonographic equipment. (I would add that ultrasound technique and interpretation are both delicate matters. And, for this test to prove out useful, many more studies and standardizations will be required.) Other, limitations of this study include the technique used for analysis (only one x-ray view was obtained) and patient selection (patients with severe deformities were excluded). Overall, these results hold out the potential for a rapid, safe, and sensitive alternative to traditional x-ray analysis of joints in RA patients. We await further studies that will be necessary to correlate ultrasound findings with clinical outcomes in rheumatoid arthritis such as disease progression, joint destruction, and response to therapy. For now, X-ray testing remains the standard monitoring test for joint destruction.

Synovial Fluid Analysis

Synovial fluid analysis is a group of tests that examine your joint (synovial) fluid. The tests help diagnose and treat joint-related problems.

How the test is performed

A sample of synovial fluid is needed for this test. Synovial fluid is normally a thick, straw-colored liquid found in small amounts in joints, bursae (fluid-filled sacs in the joints), and tendon sheaths. After the area is cleaned, the health care provider will insert a sterile needle through the skin and into the joint space. Once the needle is in the joint, fluid is drawn through it into a sterile syringe. The fluid sample is sent to the laboratory. The laboratory technician will: Check the sample's color and clarity Place it under a microscope, count the number of red and white blood cells, and then look for crystals (in the case of gout) or bacteria Measure glucose, proteins, uric acid, and lactic dehydrogenase (LDH) Culture the fluid to see if any bacteria grow

How to prepare for the test

Normally, no special preparation is needed. Tell your health care provider if you are taking blood thinners, because they can affect test results or your ability to take the test.

How the test will feel

Sometimes, the health care provider will first inject numbing medicine into the skin with a small needle, which will sting. A larger needle will be used to draw out the joint fluid or synovial fluid. This test may also cause some pain if the tip of the needle touches bone. The procedure usually lasts less than 1 to 2 minutes.

Why the test is performed

The test can help diagnose the cause of pain, redness, or swelling in joints. Sometimes, removing the fluid can also help relieve joint pain. This test may be used when your doctor suspects: Bleeding in the joint after a joint injury Gout and other types of arthritis Infection in a joint

What abnormal results mean

Abnormal joint fluid may look cloudy or abnormally thick. Blood in the joint fluid may be a sign of injury inside the joint or a body-wide bleeding problem. An excess amount of normal synovial fluid can also be a sign of osteoarthritis.

What the risks are

Infection of the joint -- unusual but more common with repeated aspirations Bleeding into the joint space

Special considerations
Ice or cold packs may be applied to the joint for 24 to 36 hours after the test to reduce the swelling and joint pain. Depending on the exact problem, you can probably resume your normal activities after the procedure. Talk to your health care provider to determine what activity is most appropriate for you.

What is Anti-CCP antibody?

Anti CCP antibody stands for anti-cyclic citrullinated peptide antibody. It is a protein produced as part of the process that leads to joint inflammation in rheumatoid arthritis. It is a test used to confirm the diagnosis of rheumatoid arthritis. At present, anti- CCP antibody is the most specific marker for Rheumatoid arthritis. With a specificity of about 98%, it is a reliable marker to confirm the diagnosis of Rheumatoid arthritis. Schellekens, G.A was the first to show that patients suffering from rheumatoid arthritis produce antibodies to peptides or proteins containing citrulline in 1998.

What is the utility of anti-CCP antibody test?

Anti CCP is a very useful blood test in the diagnosis of Rheumatoid arthritis. It scores over the routine rheumatoid factor test for early &spcific diagnosis of rheumatoid arthritis* Anti CCP antibody is also of prognostic significance in Rheumatoid arthritis. High levels of the antibody indicate a more aggressive RA & higher risk of joint damage as compared to a patient with low levels** Interestingly, anti CCP antibodies predate the diagnosis of RA & may be found years before symptoms of RA develop. They are believed to have a pathogenic role in development of RA, but are not obligatory for the same.

Is anti CCP antiboy test better than Rheumatoid factor test?

Yes. Anti CCP antibody is more reliabkle than Rheumatoid factor in diagnosing Rheumatoid arthritis. Anti CCP test can accurately diagnose Rheumatoid Arthritis at a very early stage as compared to rheumatoid factor. An earlier diagnosis would mean early institution of DMARDs & higher chances of remission.

Does a negative anti CCP rule out Rheumatoid Arthritis?

No. A negative anti CCP does not completely rule out Rheumatoid Arthritis.

How reliable is Anti CCP antibody in the diagnosis of Rheumatoid arthritis?

Anti CCP antibody is a very reliable marker for RA. The specificity of 1st generation anti CCP assay for RA was 65-70%. With further research & refinement of the processes involved in anti CCP antibody detection, 2nd generation anti CCP kits evolved. The specificity of the 2nd generation anti CCP assay, is almost 96-98%.

C-Reactive Protein: Indicator of Arthritis & Heart Disease

When the body has any sort of inflammation, levels of C-reactive protein in the blood increase usually within 2 to 6 hours. The liver produces C-reactive protein (CRP) when there is inflammation somewhere in the body. In an arthritis panel, physicians check the C-reactive protein levels to determine any significant changes. The normal range of C-reactive protein should be 0-1.0 milligrams per deciliter (mg/dL) or less than 10 mg/L (SI units). A C-reactive protein test is used to indicate inflammation: however, it cannot determine the cause and location of the inflammation. The arthritis panel includes several other tests since different factors can interfere with the accuracy of

the results. Patients using hormone replacement therapy (HRT) or oral contraceptives may have inaccurate results. Use of nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin, or corticosteroids also interfere with the results. Other factors may include pregnancy, obesity, vigorous exercise, and medication to lower cholesterol. A C-reactive protein (CRP) test may be done to help determine:

Rheumatoid arthritis Lupus Gout Reiter's Syndrome Crohn's Disease Acute Pacreatitis Hodgkin's Lymphoma Lymphoma Tuberculosis Burns Temporal Arteritis Inflammatory Bowel Disease Polymyalgia Rheumatica Sepsis Pelvic Inflammatory Disease Bacterial Meningitis Urinary Tract Infection

Recent research conducted at Duke University Medical Center has shown, "healthy people who are prone to anger, hostility and mild to moderate depressive symptoms produce higher levels of Creactive protein which promotes cardiovascular disease and stroke." Increase levels of stress hormones activate the production of C-reactive protein, according to Edward Suaraz, Ph. D., associate professor in the Duke University Department of Psychiatry and Behavioral Sciences. A growing number of studies have suggested C-reactive protein tests can predict cardiovascular disease. Evidence of inflammation is important in atherosclerosis because diseased arteries typically contain inflammatory cells. Atherosclerosis is the process in which fatty substances; cholesterol, cellular waste products, calcium, and other substances build up in the lining of the arteries. Studies have shown the higher the levels of C-reactive protein, the higher the risk of developing heart attacks.

itamin B6 (Pyridoxine)
Overview:

Vitamin B6, also called pyridoxine, is one of 8 B vitamins. All B vitamins help the body convert food (carbohydrates) into fuel (glucose), which is used to produce energy. These B vitamins, often referred to as B complex vitamins, also help the body metabolize fats and protein. B complex vitamins are

needed for healthy skin, hair, eyes, and liver. They also help the nervous system function properly. All B vitamins are water-soluble, meaning that the body does not store them. Vitamin B6 helps the body make several neurotransmitters, chemicals that carry signals from one nerve cell to another. It is needed for normal brain development and function, and helps the body make the hormones serotonin and norepinephrine, which influence mood, and melatonin, which helps regulate the body clock. Along with vitamins B12 and B9 (folic acid), B6 helps control levels of homocysteine in the blood. Homocysteine is an amino acid that may be associated with heart disease. Your body needs B6 in order to absorb vitamin B12 and to make red blood cells and cells of the immune system. It is rare to have a significant deficiency of B6, although studies indicate many people may be mildly deficient, especially children and the elderly. Certain medications can also cause low levels of B6 in the body. Symptoms of serious deficiency include muscle weakness, nervousness, irritability, depression, difficulty concentrating, and short-term memory loss.