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Background: Patients with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease (CVD) including heart failure. The role of autoimmunity and especially citrullination in the pathogenesis of the increased risk of CVD and the time-course of left ventricular (LV) dysfunction is unknown. Objectives: To assess the LV function according to the amount of inflammation during a 2-year follow-up period in a cohort of treatment naive RA patients without known CVD. Methods: Thirty-nine patients (21 women) with mean age 59+/-10.7 years and steroid- and disease-modifying antirheumatic drug (DMARD)-naive early RA were included and followed for 2 years. All patients were treated with methotrexate and followed the National treatment algoritm. Disease activity was assessed at baseline and at 2-year follow-up by the use of the Danish national DANBIO registry. IgM rheumafactor (IgM-RF) and anti-CCP titers were evaluated by standardized techniques at baseline and 2-year follow-up. We performed a novel advanced echocardiography by speckle tracking in means of global LV systolic deformation (GLS) imaging. One experienced senior rheumatologist and one experienced cardiologist performed all the clinical assessments as well as all the echocardiography including the LV deformation analysis at baseline and by 2-year follow-up. Results: Disease activity scores before treatment at baseline and at 2-year follow-up were respectively: number of swollen joints (28): 7.1+/-2.9 (SD) and 0.4+/-0.3, number of tender joints (28): 8.4+/-3.6 and 1.08+/-0.5, CRP: 10.4+/-9 and 4.4+/-8.8 mmol/l, HAQ: 0.67+/-0.64 and 0.24+/-0.13, pain VAS: 54.7+/-13.5 and 20.2+/-17.5, fatigue VAS: 51.2+/-23.5 and 26.4+/-20.9, physician global assessment: 54.7+/-13.5 and 11.4+/-14.6 and finally DAS28-CRP: 4.8+/-0.8 and 2.1+/-1. At baseline 46.2% patients were IgM-RF positive compared to 48.7% at 2-year follow-up. Twenty-six patients (66.7%) were anti-CCP positive at baseline and 26 (66.7%) at 2-year follow-up. At baseline 15 patients (38.5%) had an anti-CCP titer higher than 7 and lower than 340. Eleven patients (28.2%) were high titer anti-CCP positive (anti-CCP >340) at baseline and 12 patients (30.8%) at 2-year follow-up. We found global LV systolic deformation (GLS) assessed by speckle tracking similar at baseline and after 2-year follow-up (GLSBASELINE: -16.56+/-3.1% vs. GLS2 YEAR: -16.27+/-2.8%; p=0.66). However in patients with anti-CCP >340 at baseline and patients who persistently had an anti-CCP >340 at 2-year follow-up (n=10) we saw a significant decrease in deformation compared to patients who did not (n=29); (2.9+/-3.2% vs. -0.6+/-2.7%; p=0.002). Furthermore we observed a significant correlation between the changes in GLS over 2 years (GLSDELTA: 0.27+/-3.21%) and anti-CCP (r=0.63; p

Baggrund 50 % af den voksne befolkning oplever hvert år smerter i nakke, lænd, torakale afsnit eller måske i flere af ryggens regioner samtidigt. Rygsymptomer er altså et særdeles hyppigt fænomen, som i hovedparten af tilfældene er af uspecifik oprindelse, og som i de fleste tilfælde har ganske god prognose. Hos 10-20% af patienterne fortsætter smerterne imidlertid i måneder eller år trods relevante behandlingsforsøg. Udredning af såvel akutte (varighed < 3 mdr.) som kroniske (varighed > 3 mdr.) tilstande foregår gennem en diagnostisk triage: • Først afklares det, om der er red flags til stede, som kræver hurtig indsats. • Herefter vurderes om smerterne skyldes mulige specifikke diagnoser. • Er patienten i restgruppen, foretages en bredere udredning for at afdække eventuelle behandlingsmuligheder og prognose. Væsentlige kliniske karakteristika RED FLAGS Enhver førstegangsudredning af patienten med rygsmerter indledes ved klinisk at udpege de få alvorlige diagnoser, som kræver akut eller hurtig indsats: Sphinctersymptomer eller abnorme sensibilitets-/refleksforhold af perineum giver mistanke om cauda equina-syndrom. Progredierende parese af over- eller underekstremiteter eller paralyse er ofte tegn på truende incarceration af nerverod. L’Hermittes tegn, bilaterale UE-symptomer, hyperrefleksi eller Babinskis tåfænomen. Tænk begyndende medullært tværsnitssyndrom. Almensymptomer med fx vægttab, træthed og feber, tidligere cancersygdom, +50 år. Tænk andre red flags som infektion, systemsygdom eller cancer. Background Every year, 50% of the adult population experiences pain in the neck, low back pain, thoracic pain. Low Back pain is a very frequent phenomenon, which in most cases is of non-specific origin and which in most cases has a good prognosis. However, in 10-20% of patients, the pain persists for months or years despite relevant treatment trials. Both acute (duration 3 months) conditions are investigated through a diagnostic triage: • First, it is clarified whether red flags are present that require prompt action. • Thereafter, we assess whether the pain is due to possible specific diagnoses. • If the patient is in the residual group, a broader assessment is made to identify any treatment options and prognosis. Essential clinical characteristics RED FLAGS Any initial assessment of the patient with back pain is initiated by clinically identifying the few serious diagnoses that require urgent or urgent action: Sphincter symptoms or abnormal sensitivity / reflex conditions of the perineum cause cauda equina syndrome. Progressive palsy of upper or lower extremities or paralysis is often indicative of threatening nerve root incarceration. L’Hermitte’s signs, bilateral UE symptoms, hyper-reflex or Babinski’s toe phenomenon. Think incipient medullary cross-sectional syndrome. Common symptoms with eg weight loss, fatigue and fever, previous cancer disease, +50 years. Think of other red flags like infection, system disease or cancer.