Rheumatoid Arthritis: Abu-Shakra M

Avnon LS, Abu-Shakra M, Flusser D, Heimer D, Sion-Vardy N. · Pulmonary Clinic, Soroka University Medical Center, and Faculty of Health Sciences at Ben Gurion University of the Negev, Beer Sheva, Israel. · Rheumatol Int. · Pubmed #17294192 No free full text.

Abstract: Pleural involvement is the most frequent manifestation of rheumatoid arthritis (RA) in the chest. We report here two patients who presented with large exudative pleural effusions and subsequently developed sero-positive RA. In both cases, the differential cell count of the pleural effusion suggested empyema. A literature review identified that RA-associated pleural effusion afflicts more men than women and 95% of the patients have high titers of rheumatoid factor (RF). In 46% of cases, RA-associated pleural effusion is diagnosed in close temporal relationship with the diagnosis of RA. The effusion is an exudate and is characterized by low pH and glucose level, and high lactic dehydrogenase (LDH) and cell count. At diagnosis there is a tendency for predominant neutrophils to occur consistent with an empyema and 7-11 days later, the cells in the pleural effusion are replaced by lymphocytes. Pleural effusion with predominant eosinophilia is rare. RA patients with acidic effusion and low glucose content with neutrophils predominance should be treated with thoracic drainage and antibiotics until an infection is ruled out. The histo-pathologic findings in pleural fluid of tadpole cells and multinucleated giant cells and the replacement of the mesothelial cells on the parietal pleural surface with a palisade of macrophage derived cells are described as pathogonomic for RA. Treatment with systemic steroids and intra-pleural steroids are effective in most cases.

Tsumi E, Lifshitz T, Abu-Shakra M. · Department of Ophthalmology, Soroka University Medical Center and Ben-Gurion University of the Negev Beer Sheva, Israel. · Harefuah. · Pubmed #16838903 No free full text.

Abstract: Rheumatoid arthritis (RA) and juvenile rheumatoid arthritis (JRA) are systemic autoimmune diseases characterized by synovitis and a wide range of extraarticular manifestations. Ocular involvement occurs frequently in both diseases and it may affect all layers of the eyes. This review summarizes the clinical manifestations, the diagnostic tools and the therapeutic modalities of the various ocular features of patients with juvenile and adult rheumatoid arthritis.

Abu-Shakra M, Buskila D, Shoenfeld Y. · Autoimmune Rheumatic Diseases Unit and Departments of Medicine B & D, Soroka Medical Center, Beer-Sheva, Israel. · Clin Rev Allergy Immunol. · Pubmed #12794257 No free full text.

Abstract: Osteonecrosis is a clinical entity characterized by death of bone marrow and trabecular bone as a result of disruption of blood supply to the bone (1,2). Other aspects of this condition include avascular necrosis, aseptic necrosis, and osseous ischemic necrosis of bones. Osteonecrosis is classified into two main forms; post-traumatic and nontraumatic. The post-traumatic form of osteonecrosis usually develops as a result of traumatic displacement of bone fragments, which leads to impaired blood supply and ischemia to the affected bone. Osteonecrosis of the femoral head is common following fracture of the femoral neck. A variety of systemic diseases and clinical conditions are associated with nontraumatic osteonecrosis. These include autoimmune rheumatic diseases, alcoholism, pregnancy, Gaucher's disease, thrombophilia, corticosteroid therapy, Sickle-cell anemia, pancreatitis, inflammatory bowel diseases, and use of cytotoxic drugs and others. Idiopathic forms of osteonecrosis have also been reported (2-4). Among the rheumatic diseases, osteonecrosis is strongly associated with systemic lupus erythematosus (SLE) (5). However, osteonecrosis has been diagnosed in patients with primary antiphospholipid syndrome (APS) (6), rheumatoid arthritis (7), and systemic vasculitis (8). This article reviews the causes, clinical and epidemiological features, diagnosis, and treatment options for osteonecrosis among patients with SLE.

Ehrenfeld M, Abu-Shakra M, Buskila D, Shoenfeld Y. · Research Centre for Autoimmune Diseases, Sheba Medical Centre, Tel-Hashomer, Sackler Faculty of Medicine, Tel-Aviv University, Israel. · Blood Cells Mol Dis. · Pubmed #11778659 No free full text.

Abstract: Autoimmune rheumatic diseases and lymphocytic malignancies are related and this association is bidirectional. Lymphomas occur more frequently in the course of autoimmune disease and autoimmune rheumatic manifestations occur in the course of lymphocytic malignancies. An increased incidence of malignant lymphocytic diseases is present in patients with rheumatoid arthritis, systemic lupus erythematosus, Sjögren's syndrome, and autoimmune thyroid disease. Descriptions of lymphocytic malignancies among other autoimmune rheumatic disease have been published. In some patients, the malignant disease is diagnosed months or years before the appearance of the rheumatic disease.

Abu-Shakra M, Polychuck I, Szendro G, Bolotin A, Jonathan BS, Flusser D, Buskila D, Sukenik S. · Soroka University Medical Center and The Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel. · Semin Arthritis Rheum. · Pubmed #16084220 No free full text.

Abstract: BACKGROUND: "Ultrasonic biopsy" (U-B) is a noninvasive screening technique to detect early atherosclerotic plaques and arterial wall changes. AIM: To identify atherosclerosis (AS) in the common carotid artery (CCA) and common femoral artery (CFA) of patients with rheumatoid arthritis (RA) and their matched controls. METHODS: Fifty-seven consecutive RA patients were enrolled in the study. Controls were matched by age, sex, ethnicity, and AS risk factors. All patients and controls underwent U-B study of the CCA and CFA. The U-B features were classified and scored as follows: Class A, normal (score 0); Class B, interface disruption (score 2); class C, intima-media (I-M) granulation (score 4); Class D, plaque without hemodynamic disturbance (score 6); Class E, stenotic plaque (score 8); and Class F, plaque with symptoms (score 10). Total score per patient was calculated. Classes A-B indicate an intact media or minimal interphase changes; classes D-F point to a significant medial involvement. Class C signifies a borderline lesion, with a potential for regression to normal, being unchanged, or progression to a plaque. RESULTS: Mean ages were 52.1 years for RA and 51.4 years for controls (P = 0.81). Eighty-six percent of the patients and 85% of controls were women. The mean disease duration of RA was 12.8 years. Frequencies of risk factors among the RA patients compared with controls were hypertension (28% versus 32%), smoking (37% versus 29%), dyslipidemia (23% versus 25%), diabetes mellitus (DM) (14% versus 14%), and family history of cardiovascular disease (CVD) (4% versus 7%). Forty-five percent of the RA patients had at least a single Classes D-F lesion (plaque) in 1 of the 4 vessels tested, compared with 40% in the control group (P = 0.19). The mean total U-B scores of the RA patients and controls were not significantly different (8.87 versus 9.49, P = 0.7). Univariate analyses have shown that the development of plaques in RA patients was associated with age >50 years, disease duration, hypertension, dyslipidemia, and smoking. Multivariate analysis found plaques to be strongly associated with age above 50 years and dyslipidemia. CONCLUSION: In unselected RA patients, besides classic AS risk factors, older age and longstanding disease may help predict the development of a severe morphological expression of AS.

Codish S, Abu-Shakra M, Flusser D, Friger M, Sukenik S. · Faculty of Health Sciences, Ben Gurion University of the Negev, Beer-Sheva, Israel. · Rheumatol Int. · Pubmed #14618372 No free full text.

Abstract: OBJECTIVE: The aim of this study was to evaluate the efficacy of home treatment with mud compresses for the hands of patients with rheumatoid arthritis (RA). METHODS: Forty-five patients suffering from RA were enrolled in a double-blind, randomized, controlled study. Twenty-two were treated with true mud compresses (treatment group) and 23 were treated with attenuated mud compresses (control group). The compresses were applied in the patients' homes five times a week during a 3-week period. Patients were assessed four times: at baseline, upon completion of the 3-week treatment period, 1 month after the treatment, and 3 months after conclusion of the treatment period. Positive response was defined as reductions of 30% or more in the number of tender and swollen joints, 20% or more in physician global assessment of disease activity, and 20% or more in patient global assessment of the severity of joint pain. RESULTS: In the treatment group, significant reductions in the number of swollen and tender joints and patients' global assessments of pain severity was observed at all post-treatment assessments. Significant improvement in the scores of physician global assessment was seen at the end of therapy and 1 month later. In the control group, no improvement in the number of swollen and tender joints or physician global assessment was found in any post-treatment evaluation. However, a significant reduction in patient global assessment of joint pain severity was reported at the end of therapy and 3 months after concluding treatment. CONCLUSION: Treatment with mud compresses relieves pain affecting the hands and reduces the number of swollen and tender joints in the hands of patients suffering from RA. This treatment can augment conventional medical therapy in these patients.

Sukenik S, Flusser D, Codish S, Abu-Shakra M. · Department of Rheumatology, Soroka Medical Center, Beer Sheva, Israel. · Isr Med Assoc J. · Pubmed #10731301 No free full text.

Abstract: BACKGROUND: Balneotherapy at the Dead Sea area has been applied in various inflammatory rheumatic diseases such as rheumatoid arthritis and psoriatic arthritis. The efficacy of balneotherapy at the Dead Sea area for the treatment of degenerative rheumatic diseases has not yet been formally evaluated. OBJECTIVE: To evaluate the efficacy of balneotherapy at the Dead Sea area in patients suffering from osteoarthritis of the knees. METHODS: Forty patients were randomly allocated into four groups of 10 patients. Group I was treated by bathing in a sulphur pool, group 2 by bathing in the Dead Sea, group 3 by a combination of sulphur pool and bathing in the Dead Sea, and group 4 served as the control group receiving no balneotherapy. The duration of balneotherapy was 2 weeks. RESULTS: Significant improvement as measured by the Lequesne index of severity of osteoarthritis was observed in all three treatment groups, but not in the control group. This improvement lasted up to 3 months of follow-up in patients in all three treatment groups. CONCLUSION: Balneotherapy at the Dead Sea area has a beneficial effect on patients with osteoarthritis of the knees, an effect that lastas at least 3 months.

Avnon LS, Manzur F, Bolotin A, Heimer D, Flusser D, Buskila D, Sukenik S, Abu-Shakra M. · Pulmonary Clinic, Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel. · Isr Med Assoc J. · Pubmed #19432035 links to  free full text

Abstract: BACKGROUND: A high incidence of abnormal pulmonary function tests has been reported in cross-sectional studies among patients with rheumatoid arthritis. Few patients have been enrolled in longitudinal studies. OBJECTIVES: To perform PFT in rheumatoid arthritic patients without pulmonary involvement and to identify variables related to changes in PFT over 5 years of follow-up. METHODS: Consecutive RA patients underwent PFT according to recommendations of the American Thoracic Society. All surviving patients were advised to repeat the examination 5 years later. RESULTS: PFT was performed in 82 patients (21 men, 61 women). Their mean age was 55.7 (15.9) years and the mean RA duration was 11.1 (10) years. Five years later 15 patients (18.3%) had died. Among the 67 surviving patients, 38 (56.7%) agreed to participate in a follow-up study. The initial PFT revealed normal PFT in only 30 patients (36.6%); an obstructive ventilatory defect in 2 (2.4%), a small airway defect in 12 (17%), a restrictive ventilatory defect in 21 (25.6%), and reduced DLco in 17 (20.7%). Among the 38 patients participating in the 5 year follow-up study, 8 developed respiratory symptoms, one patient had a new obstructive ventilatory defect, one patient developed a restrictive ventilatory defect, and 5 patients had a newly developed small airway defect. The DLco had improved in 7 of the 8 patients who initially had reduced DLco, reaching normal values in 5 patients. Over the study period a new reduction in DLco was observed in 7 patients. Linear regression analyses failed to identify any patient or disease-specific characteristics that could predict a worsening in PFT. The absolute yearly decline in forced expiratory volume in 1 sec among our RA patients was 47 ml/year, a decline similar to that seen among current smokers. CONCLUSIONS: Serial PFT among patients with RA is indicated and allows for earlier identification of various ventilatory defects. Small airways disturbance was a common finding in our RA patients.

Fuchs I, Avnon L, Freud T, Abu-Shakra M. · Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University, Beer-Sheva, Israel. · Clin Rheumatol. · Pubmed #18795393 No free full text.

Abstract: To determine the rate of true tuberculin skin test (TST) response in a cohort of patients with rheumatic disease treated with tumor necrosis factor inhibitors (TNFi). The study population included consecutive patients with rheumatoid arthritis (RA), ankylosing spondylitis (AS), and psoriatic arthritis (PsA) treated with TNFi for at least 3 months. Patients with a positive TST at screening who began Tb prophylaxis before the beginning of TNFi therapy were excluded. All patients underwent a second TST. True TST response was defined as an increase of 6 mm of induration between the screening test and the second test. Forty patients (12 men and 28 women) were included. Mean age was 51.2 years. Of them, 27 (67.5%) had RA, eight (20%) had PsA, and five patients (12.5%) had AS. At pre-treatment TST, 15 patients had a TST > or = 5 mm. A significantly higher percent of patients with TST > or = 5 mm was seen among men compared with women (75% vs. 21%, p = 0.012) and patients with PsA compared with patients with RA (75% vs. 22%, p = 0.014). At the second test, eight (20%) had an increase of 6 mm between readings with four having an increase of 10 mm or more. Four patients received infliximab and the other four were treated with etanercept. Seven of these eight patients had RA and one was a patient with PsA. Patients with true TST response were significantly older and non-smokers with elevated sedimentation rate and a higher rate of anemia. Nationality, comorbid conditions, treatment with immunosuppressives, and BCG vaccination status had no significant influence on the TST response. Serial TST testing in patients receiving TNFi is indicated to identify patients with reactivation of latent tuberculosis infection or those exposed to mycobacterium.

Sukenik S, Abu-Shakra M, Kudish S, Flusser D. · Department of Medicine 'D' Soroka University Medical Center, Faculty of Health Sciences, Ben Gurion University of Negev, Beer Sheva. · Harefuah. · Pubmed #16509416 No free full text.

Abstract: In the last two decades balneotherapy and climatotherapy have been shown to be effective in cases of inflammatory arthritis such as rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis and non-inflammatory arthritis such as osteoarthritis and fibromyalgia. This review presents different modalities of balneotherapy, their mechanism of action, side-effects and major contraindications. The article also summarizes all the publications on clinical trials conducted in the Dead Sea and Tiberias.

Gilburd B, Abu-Shakra M, Shoenfeld Y, Giordano A, Bocci EB, delle Monache F, Gerli R. · Department of Medicine B, Center for Autoimmune Diseases, Sheba Medical Center, Sackler Faculty of Medicine, Tel-Aviv University, Tel-Hashomer, Israel. · Clin Dev Immunol. · Pubmed #15154612 links to  free full text

Abstract: BACKGROUND: Flow-based, multiplex bead arrays (MBA) have been developed for a variety of applications including the detection of antibodies to extractable nuclear antigens (ENA). It offers a rapid and sensitive method to assess multiple analyses in a single tube/well. PURPOSE: To evaluate the Athena Multi-Lyte ANA Test System utilizes Luminex Corporation's MBA technology for the detection of antinuclear antibodies (ANA) and ENA antibodies in the sera of patients with Sjogren's syndrome (SS). METHODS: MBA assay was used to detect ANA and ENA antibodies in the sera of 37 patients with SS and 96 sera from healthy subjects. RESULTS: All patients were women. Their mean age was 48.7 years and the mean disease duration was 7.27 years. ANA was found in 3 (3%) sera of healthy subjects by the AtheNA system and in 2 (2%) sera by the ELISA kit. A 99% concordance between the 2 assays was found. A 94.6% concordance between the 2 assays was found by testing the sera of patients with SS for ANA. By the AtheNA system, none of the sera of 37 patients with SS had autoantibodies reacting with Sm, Jo-1, dsDNA or histones. Anti-RNP antibody was found in 5.4% of the sera and 2.7% of the sera reacted with Scl-70 and histones. Anti-SS/A and anti-SS/B were identified in 84 and 76% of the sera, respectively. CONCLUSION: The AtheNa Multi-Lyte ANA Test System offers a sensitive and specific result for the detection of ANA and ENA antibodies in the sera of patients with SS.