Rheumatoid Arthritis Laboratory Testing Proposal

Running head: RHEUMATOID ARTHRITIS LABORATORY TESTING PROPOSAL 1

RheumatoidArthritis Laboratory Testing Proposal

Acknowledgement

Ihereby acknowledge my parents and relatives who have offered me thesupport financial and mental throughout this exercise. I am gratefulfor my tutor who besides offering me direct lectures, availedessential pieces of advice on the best topic to select and itsrelevance with the course objectives. I pay special tribute to theprominent researchers who had studied the topic previously andoffered critical information as well. I would also recognize theUniversity for offering me the special laboratory instruments neededfor the experiments, the laboratory assistants together with mycolleagues who assisted me directly or indirectly. I would dedicatethis research proposal to the institution since through theinstitution, and I have obtained the skills necessary for outstandingcompetence in the medical profession.

Abstract

Rheumatoidarthritis (RA) constitutes the most prevalent autoimmune rheumaticcondition, nevertheless particular and realistic examinations for itsdiagnosis are missing (Isozaki et al., 2013). There was anexamination of the diagnostic precision of the latest commercialELISA in identifying anti-cyclic citrullinated peptide (CCP)antibodies for the analysis of the condition. Serum samples will becollected from 260 people after which they will be tested for theanti-CPP antibodies as well as the IgM rheumatoid factor (IgM RF)using the conventional Enzyme-Linked Immunosorbent Assay (ELISA). TheACR criteria will be used to evaluate the specificity and sensitivityof the tests. The ELISA method will be based on the second-generationELISA technique developed by the INOVA Diagnostics Corporation of SanDiego, California. Observations from the ELISA method will berecorded for each test. The standard Mann-Whiteney U test will be thegold standard for testing the subgroups, where the variables will beexpressed as the median, interquartile range in the graph.

Variableswill also be expressed in percentages. The SPSS statistical tool willbe used to compare the specificity and sensitivity of the tests basedon the chi-square test. In addition, the study will determine otheraspects such as negative predictive values, specificity andsensitivity of the diagnosis and the area ‘under the curve’ usingthe SPSS statistical tool. All the tests will be two-tailed andtested at the significant level of 0.05 (Niewold et al., 2007).Tables will be used to describe the demographic data and the clinicalcharacteristics of the participants for the samples of the twocategories (RA and non-RA samples).

Rheumatoidarthritis (RA) incorporates an autoimmune condition in the broaderfamily of the lupus. It has never been understood why in rheumatoidarthritis the body defense system becomes disorganized and begins toattack uninvolved tissues, particularly the cartilage situated withinthe joints (Isozaki et al., 2013). Many joints develop red color,become hot, and inflamed due to the offensive attack. Theconfiguration of inflammation is normally regular, happening on bothsections of the body. Alternate symptoms entail swelling of the eyes,nodes or protuberances below the skin, and an overall feeling ofillness. The rheumatoid arthritis is most prevalent in women ascompared to men and characteristically begins amid 30 and 60 years.The diagnosis of the disease is performed through matching thepattern of signs with certain distinguishing laboratory results.

Medicaltreatment comprises mainly of two classifications of drugs: theanti-inflammatory medicines in the nonsteroidal anti-inflammatorydrugs (NSAIDs) together with drugs that might be capable of puttingrheumatoid arthritis into complete or else half- remission, alsoreferred to as the disease-modifying antirheumatic drugs (DMARDs).Anti-inflammatory medications relieve signs of rheumatoid arthritisbut then again do not alter the general advancement of the disease,while the DMARDs appear to affect the actual disease (Isozaki et al.,2013). A proper correspondence may be the numerous choices present toremedy the condition from serious advancements.

Inrheumatoid arthritis as a condition, the medications believed tochange the direction of the condition entail D-penicillamine,sulfasalazine, the gold compounds, and interleukin-one receptorantagonists amongst others. The drugs outlined are different butperform a similar role.

Overthe recent few years, studies have found that serious jointdestructions ensures very prematurely in rheumatoid arthritis. Theevidence has resulted into most authorities to propose initial,hostile cure with the condition-modifying drugs to thwart jointdestruction. Nevertheless, this methodology has never beencollectively approved. Some medics still recommend NSAIDs for initialphases of the rheumatoid arthritis.

Thestudy will be conducted because specific, reliable and predictablediagnostic tests for Rheumatoid Arthritis (RA) are lacking (Niewold,Harrison &amp Paget, 2007). Yet, studies have shown that RA is themost common form of autoimmune rheumatoid illness and affects severalof persons in the United States and millions in the world (Dollah,Yaacob, Ismail &amp Hussin, 2011). However, the recently developedELISA technique based on the Anti-cyclic citrullinated peptide(anti-CPP) antibodies against RA proteins in the human serum is areliable diagnostic tool for RA (Dollah et al., 2011).

Theresearch will be performed after endorsement by the interior reviewboard of the institutional hospital. Determination of theeffectiveness of anti-cyclic citrullinated peptide (Anti-CPP)antibodies in the diagnosis of rheumatoid arthritis will take placein the study (Dollah et al., 2011). In particular, the effectivenessof the antibodies will be examined and tested to establish itsspecificity and sensitivity based. American College of Rheumatologycriteria as the gold standard will provide the basis for the testwill be (Niewold et al., 2007). It will be conducted between January2015 and March 2015 using 260 participants with arthritis (140 withrheumatoid arthritis and 120 with arthralgia or other forms ofarthritis that does not meet the American College of RheumatologyCriteria for rheumatoid arthritis).

Peptidylargininedeiminases (PADs) perform an essential function in producingautoantigens in rheumatoid arthritis (RA), but then again the systemprocesses fundamental to their dysregulation in this condition havenever been determined (Nicassio et al., 2012). Even though PADs needsupraphysiologic concentrations of calcium to be active in vitro, theenzymes are always vigorous in vivo (for instance, in RA synovialfluid) in which calcium quantities are significantly lower. There hasbeen a discovery of a subsection of anti-PAD4 autoantibodies(recognized through their cross-reactivity with PAD3) which,evidently enhance the catalytic effectiveness of PAD4 by lowering theenzyme’s necessity for calcium into the physiologic array. Patientswhose bodies contain these PAD3/PAD4 cross-reactive autoantibodiespossessed higher baseline radiographic impairment levels and agreater likelihood of radiographic advancement compared to peoplewithout such antibodies. The capacity of the autoantibodies tostimulate an enzyme which, in itself releases citrullinatedautoantigens to determine an essential feed-forward loop that mighttrigger the erosive result manifested in RA victims with theautoantibodies. PAD3 autoantibodies might thus recognize RA victimswho would gain from initial aggressive treatment or else the therapyinvolving the augmentation of the PAD inhibitor. The research willendeavor to prove the notion outlining that Erosive RheumatoidArthritis Is Associated with Antibodies That Activate PAD4 byIncreasing Calcium Sensitivity (Nicassio et al., 2012).

LiteratureReview

Leeb,B. W. (1998). Rheumatoid Arthritis Diagnosis and Screening. DisManage Health Outcomes, 315-324.

Leeof 1998 emphasizes on the management of RA and highlights criticalissues such as means to avert the condition in all situations.Rheumatoid Arthritis has affected a minimum of at least 52.5 millionpersons in America solely as per the statistics of 2010 (NHIS, 2011).Considering the situation, this article was selected so as to attainan overview of the diagnostic evaluations and methodologies formerlyemployed in medicine. This will allow an adequate contrast of theapproaches involved then together with assessment of the criteriathat are applied presently.

Thearticle explains various means that Rheumatoid Arthritis (RA) isdiagnosed depending on clinical aspects such as laboratoryexaminations, as well as imaging education.

Inaddition to the above outlines, genetic sensors have been manifestedto be important paraumeters for condition advancement, but then againhave never been included as a section of the medical course.

Imagingknowledge has cnstituted an alternative main diagnostic approachwhich permits visualization of the anatomical information. Trheapplication of Magnetic Resonance Imaging (MRI) and Radiography havebeen in place for more than a decade ago and have superior results ascompared to plain X-rays. The Ultrasound evaluations incorporatingthe use of Power Doppler avails a better summary of iswelling and isinexpensive and convenient with regards to time consusumption ascompared to MRI scans. Scintigraphy is constitutes an alternativetechnique which allows conception of the involvement of joint, yet itdoes not permit quantification of soreness.

Screeningas well as prompt diagnosis of RA have been a technical task as aresult of the benign charasteristic of the condition. Number ofenflamed, soft joints as well as movement functional ability and therheumatoid factor are preliminary examinations to recognize thebeginning of rheumatoid arthritis.

Discrepancydiagnosis is fundamentally essential to recognize RA from other typesof joint illnesses for example reactive arthritis among other formssuch as the psoriatic arthritis as well as various seronegativespondylarthropathies. In an attempt to distinguish amid collageninfections and RA, serological sensors in consort with clinicalcharacteristics for instance photosensitivity as well as theRaynaud’s syndrome. There are other research reports outlining thesame concept – Psychoneuroimmunology:1.(2007). Amsterdam: Elsevier and Tugwell, P., Boers, M., &ampBrookes, P. (2003). Evidence-BasedRheumatology.Oxford: Blackwell Pub. The two articles outlined the most currentstudies on the examination of RA through the use of symptoms inblood.

Latestresearch studies performed by the American College of Rheumatologythrough a relative analysis of blood mockups of persons sufferingfrom RA and individuals manifesting no symptoms of RA. The outcomeoutlined that a big incidence of cytokines showed formation ofdisease, thus concenting analysis of RA even prior to the appearanceof the symptoms. The article however never cited the future workdone by the author. Conversely, there was an explicit and crediblefactual presentations with a clear conclusion.

Thearticle by Cutulculer of 2011 will be essential in this study as itoutlines the ability of immunoglobulin light chain levéis to beemployed in the determination of the condition of the stage amongstchildren infected with Juvenile idiopathic Arthritis. The articleoffers the effect of Immunoglobulin chains for definition of illnesslevel of RA in the young, that explicitly identifies its importance.The sedimentation of red blood, acute phase reactants (ARPs) togetherwith Serum amyloid evaluations (SAA) are presently employed asinflammation detectors. Swelling as well as auto immune infectionsare accompanied by high amounts of oligoclonal delocalized lightchains in the body (Reid &amp Miller, 2008). The conditionincorporates the purpose of many immunoglobulins. This researchintended to assess the effectiveness of immunoglobulin quantities asswelling marker and associate it with presently applied markers ofthe disease.

Applicationof immunoglobulin light chain kappa quantities as as RA conditionmarkers was examined in the article, and the efficacy of thisapproach was gauged against other examinations for instance, ESR,CRP, as well as SAA. therefopre, in order to have ultimate results,Familial Mediterranean fever (FMF) was included in the experiment asa control experiment in association with serum assortmrnts fromuninfected individuals.

Numerousconclusions were obtained from the article. First of all, Ig lightchain quantities were realized to be very little in FMF individualsthis undoubtedly marked the distinguishing factor between JIA inaddition to FMF since both are seditious diseases. In order tocontrol disease level, K chains manifested to be appropriate markersfor realization of condition phase in JIA (Reid &amp Miller, 2008).

Thisarticle (Corcione A, 2009) portrayed much evidence in support of the hypothesis which triggered and consequently improved hike in IgG afact which has been infered among JIA patients. The growth inactivated B memory cells, as well as IgG plasma blasts in synovialfluid samples of JIA patients, was put into realization by this pieceof writing. IgG plasmablasts is a booster of immune inspiration,which in turn brings about an increase in IgG levels in JIA patients.

Thispaper goes ahead to give an investigative insight on differentiationof T helper (Th) cells and cytokine levels in RA patients. This is ofmuch imminent on the role of immune cells in the gradual diseasematurity, which is a vital source of information into how diseaseprogresses and how the levels of Th1, Th2, Th17 and Treg cellsfluctuate with progressing stages of disease.

Disperitieswitnessed in the levels of Th1 and Th2 brought about by acutecytokine levels were main finding in most of the approved out studies. Using cytometric technique, the charge of Th1, Th2, Th17 andTreg cells were tested and infered in blood samples of RA patients.Th1 and Th17 levels were massive along with Th1/Th17 coupledcytokines.Th2 levels were low display high levels of cytokines asopposed to censored outcome.

Theresearch result that reported that Th1 and Th17 levels showdisproportion only in an higher stage of disease. Th2 cells areinvolved in cytokine emission, and Treg cells are concerned incell-cell communication in RA progression. But, the authors claimedthat additional study is needed to prove this result.

Theresearch conclusion were well-structured and clearly presented toillustrate a major result in how the immune cells are alarmed withdisease development. The conclusion first discussed Th1/Th2difference is a major feature that causes RA to progress onto furtherstages. The blood samples of RA patients had elevated Th1 and Th2levels in comparisson to hale and hearty persons. And the disparitiesin Th1/Th2 levels was due to manufacture of extreme cytokines.Analyzing the cytokine levels, the major cytokines produced by Th1were IL-2, IFN-γ, and TNF-α. The sera samples of RA patients hadbetter cytokine levels (TNF-α, serum IL-2, and IFN-γ). amongst allcytokines, IL-2, IFN- γ and TNF- α displayed copious increase amongRA patients at all disease stage.

Afterconsidering several alternate probable risk aspects, a replication ofrheumatoid factor amount was connected to a 3.3-fold elevated risk ofleading to rheumatoid arthritis. The greatest rheumatoid contributorlevel was connected to a 26-fold heightened risk of contracting thecondition.

Incomplete form, the greatest one decade threat of rheumatoid arthritisof about 35% was observed among 50 to 70 year old females who smokeand had developed rheumatoid factor quantities of 100 IU/mL or ahigher quantity.

Theleast complete one decade threat of rheumatoid arthritis of less than0.2% was observed among men venerable 70 years as well as over withrheumatoid component levels of lower than 25 IU/mL.

Theresearchers emphasize that their research activities can neverconfirm that rheumatoid factor performs a fundamental function in theadvancement of rheumatoid arthritis, yet they determine that theresults &quotmight result into modification of procedures forinitially recommended for a rheumatologist and initial arthritisdispensaries depending on a constructive rheumatoid factor evaluationeven in the nonappearance of the actual arthritic joint signs.&quot

Citrullinatedproteins are greatly particular of the immune reaction in the RA andare available at higher quantities in the synovial tissue as well asthick liquid of the affected, implying that dysregulated PAD actionmight be availablein this condition. Even though the anti-PAD4antibodies are recognized before to the beginning of illness and arelinked with serious erosive RA, a hazardous role for the antibodiesmaintain to be undefined. In this study, the realization of adistinctive composition of anti-PAD4 antibodies which interact withPAD3 has determined a RA subunit with the maximum erosive andenhansed arthritis. Such PAD3/PAD4 interactive antibodies contain thestriking capacity to improve the sensitivity of PAD4 to Ca,subsidiary to protein citrullination at calcium that is clinicallyrelevant concentrations. In this case there is a proposition thatthis characteristic to stimulate PAD4 enzymatic actions has in RAaccompanies pathogenic outcomes.

Thecritical dissimilarity in attraction and calcium demands for BAEEtogether with histone H3 catalysis proposes that citrullination ofthe macromolecules necessitates protracted substrate-enzyme reactionsreliant on binding of extra calcium ions (Reid &amp Miller, 2008).Because binding of Ca1 together with Ca2 is adequate for generationof the vigorous site bifurcated and citrullination of BAEE (Reid &ampMiller, 2008), the minimum K0.5for the BAEE catalysis probably shows binding of the two calcium ions(Reid &amp Miller, 2008). Fusion of Ca3, 4, as well as Ca5 by theremains isolated from the energetic site, at the boundary of theNitrogen- and Ccarbon-terminal territories, possibly necessitatesgreater calcium quantities to initiate the structural modificationsdemanded for collaboration with macromolecular substrates. Theability of cross-reactive antibodies to shift the calciumrequirements for histone citrullination to a range epicted in smallmolecule substrates proposes that such antibodies can encourage aPAD4 arrangement that is the same as that usually achieved throughthe binding of Ca3 and Ca5. Furthermore, this is upheld by thethought that cross-reactive antibodies have the ability to sum up theimpact of 2 mM calcium as well as safeguard PAD4 from the breakdownof its proteins performed by GrB at D388,a deposit needed for the harmonization of Ca4 (Reid &amp Miller,2008). Therefore, such assessments outline a model whereby PAD3/PAD4interactive antibodies attach to the interface existing amid the N-and C-terminal spheres as well as locking PAD4 in to a calcium-boundorganization advantageous for the citrullination constituting themacromolecular fluids at the concentrations of physiologicconcentrations of calcium (`).

Inan supplementary journal, Dr Simard from Sweden’s the KarolinskaInstitutet propose that that even though the Nielsen researchoutlined persons with a rheumatoid factor confirmed outcome, thisdata might not up till now be such critical in medical practice asrheumatoid factor testing seldomly occurs in the without the signs.Other authors including Simad proposes that prospective studyresearch must emphasize on the connection amid rheumatoid factortogether with that of rheumatoid arthritis and spread such engagementto other critical autoantibodies for instance the anti-citrullinatedprotein a.

Method

Thestudy seeks to enroll 260 patients (170 males and 90 females) with amean age of 25- 65 years, randomly selected from a total studypopulation of 3644 patients presenting at the rheumatoid departmentof the university hospital between January 2012 and September 2014.Of the total 260 patients, it is expected that 140 (53.85%- 56females and 84 males) will be included in the AR group because theywill have satisfied the ACR criteria for AR. The non-RA patients willbe composed of the other 120 patients (46.15%- 76 males and 44females) because they will not have satisfied the ACR criteria forAR. In addition, it is expected that the non-AR group will includepatients with diverse types of arthritis (other than AR), includingspondyloarthropathy, systematic lupus erythromatosus, osteoarthritis,mixed connective tissue disease, primary Sjogren’s syndrome, adultonset Still’s disease, gouty arthritis and Behcet’s disease(Dollah et al., 2011).

Uponan inclusion in the study sample, each patient’s gender, age andclinical characteristics will be recorded. All the patients will berequired to provide serum within the first day of the study.Laboratory experts in the rheumatoid department will be assigned thetask of taking serum from each subject. The samples will be stored at-20oC while waiting for the start of the assay (Dollah et al., 2011).The use of the laboratory, human samples, and the criteria will beunder the approval of the university hospital as a clinical andacademic study and following all the ethical criteria set by theinstitution.

Initially,each serum sample will be tested for the anti-CPP antibodies as wellas the IgM rheumatoid factor (IgM RF) using the conventionalEnzyme-Linked Immunosorbent Assay (ELISA) (Niewold et al., 2007). TheACR criteria will be used to evaluate the specificity and sensitivityof the tests. The ELISA method will be based on the second-generationELISA technique developed by the INOVA Diagnostics Corporation of SanDiego, California. All the samples will be assayed in duplicate inorder to decrease the chances of errors. In addition, each samplewill be evaluated based on the upper limit of 20IU/mL in order tofollow the instructions given by the manufacturer (Dollah et al.,2011). The identification of the IgM Rheumatoid Factor (RF IgM) willbe accomplished using the nephelometry with a cut-off level of15IU/mL (Dollah et al., 2011).

Conclusion

RAis a complicated condition with several effects for the patienttogether with their lifestyle. Rheumatoid Arthritis affects on manyindividual and financial aspects for the victim together with theirfamily and is again connected to substantial direct costs to the NHS,as well as secondary cost to the country’s economy. Successfulcooperation between primary in addition to secondary care is criticalin case patients desire to receive the ultimate probable care. Nursesand other healthcare practitioners are crucial members of the MDT,who assist patients to control their RA and its effect on severalperspectives of their lives. Understanding RA and its repercussionsallow health experts to carry out responsibilities in a moreefficient manner and coordinate efficiently with the healthcarepersonnel.

Rheumatoidarthritis has other effects and can impact the eyes negatively inmany ways. There can be swelling of the episclera. Can also result towhite of the eye, which is a prevalent complication of RheumatoidArthritis. The condition is normally mild, yet the eye can developred color that is painful. Scleritis is more severe and can resultinto loss of vision.

Rheumatoidarthritis often attacks between ages 30 and 60, the ages at whichmost people lives. Day-to-day life and future strategies rapidly haveto entail a chronic condition that has undesirable as it is random.Familiarizing family natural life, work, and relations to therealities of harassment and exhaustion is a factual occurrence oflife with the condition, RA. Even though effective remedies arepresent, there`s no absolute cure. Rheumatoid arthritis becomes thechallenge of a lifespan to the people affected.

Thisproposal will be applicable in several situations ranging from themedical to the economic. There are notions looming among people inthe social setup, and that mainly foster the plight of RA patients.Having the knowledge on RA, it will be possible to provide informedadvice to the members of the public to know how to live healthy withthe condition. The patients should understand that their condition isjust a state of life, and that does not mean the end of life.

Anyinvestor including the government can invest in this research becauseit will be viable. The research addresses several pertinent issues onRheumatoid Arthritis as have been outlined in the previous sectionsof this research proposal. Successful completion of this researchwill lead findings on RA, discussion part and recommendations. Thediscussion will provide the rationale for the findings includingfactors that attribute to such findings. From the discussion, theresearch will provide recommendations based on the inferences.Therefore, the proposal is essential, and the government should nothesitate to adopt its provisions.

References

Ader,R. (2007). Psychoneuroimmunology.Amsterdam: Elsevier/Academic Press.

Ciccone,C. (2007). Pharmacologyin Rehabilitation.Philadelphia: F.A. Davis Company.

Dollah,R., Yaacob, A., Ismail, A. H., &amp Hussin, C. M. (2011). Anti-CCPAntibodies: A Better Diagnostic Tool for Rheumatoid Arthritis.InternationalMedical Journal,18(1),216-233.

Goronzy,J. J., &amp Weyand, C. M. (2001). Rheumatoidarthritis.Basel [u.a.: Karger.

NationalConsortium for Physical Education and Recreation for Individuals withDisabilities (U.S.), &amp Kelly, L. (2006). Adaptedphysical education national standards. Champaign, Ill: Human Kinetics.

Isozaki,T., Rabquer, B. J., Ruth, J. H., Haines, G. K., &amp Koch, A. E.(2013). ADAM‐10is overexpressed in rheumatoid arthritis synovial tissue and mediatesangiogenesis. Arthritis &amp Rheumatism, 65(1), 98-108.

Kutulculer,N. K. (2011). immunoglobulin light chain levéis Can Be Used toDetermine Disease Stage in Chiidren with Juvenile idiopathicArthritis. RESEARCH AND REPORTS, 93-98.

MLO.(2010 ). New Studies. Nelson Thornes.

Nicassio,P. M., Ormseth, S. R., Custodio, M. K., Irwin, M. R., Olmstead, R., &ampWeisman, M. H. (2012). A multidimensional model of fatigue inpatients with rheumatoid arthritis. The Journal of rheumatology,39(9), 1807-1813.

Niewold,T. B., Harrison, M. J., &amp Paget, S. A. (2007). Anti-CCP antibodytesting as a diagnostic and prognostic tool in rheumatoid arthritis.Qjm,100(4),193-201.

Psychoneuroimmunology:1.(2007). Amsterdam: Elsevier [u.a..

Reid,D., &amp Miller, C. G. (2008). Clinicaltrials in rheumatoid arthritis and osteoarthritis. London: Springer.

Tugwell,P., Boers, M., &amp Brookes, P. (2003). Evidence-BasedRheumatology.Oxford: Blackwell Pub.