Cardiovascular risk management in rheumatoid arthritis: are we still waiting for the first step?

Rheumatoid arthritis (RA) is associated with a similar cardiovascular risk to that in diabetes, and therefore cardiovascular risk management (CV-RM) - that is, identification and treatment of cardiovascular risk factors (CRFs) - is mandatory. However, whether and to what extent this is done in daily clinical practice is unknown. In a retrospective cohort investigation, CV-RM was therefore compared between rheumatologists and primary care physicians (PCPs). Remarkably, CRFs in RA were less frequently identified and managed by rheumatologists in comparison with PCPs. In addition, PCPs assessed CRFs less frequently in RA than in diabetes. Obviously, there is a clear need for improvement of CV-RM in RA and this should be a joint effort from the rheumatologist and the PCP.Patients with rheumatoid arthritis (RA) have an increased cardiovascular (CV) risk that appears similar to that in diabetes. This observation highlights the significant CV burden in RA. In 1999, the American Diabetes Association and the American Heart Association published a statement for prevention of CV disease in diabetes. Since then, the CV risk in diabetes has been substantially lower than in earlier decades. Given the increased CV risk in RA, screening, identification of cardiovascular risk factors (CRFs) and cardiovascular risk management (CV-RM) are also highly needed as recommended by the European League Against Rheumatism (EULAR). The increased risk in RA is attributed to systemic inflammation as well as increased prevalence of CRFs. Hence, we should aim for tight disease control and control of CRFs.Presently unknown is whether and to what extent CV-RM is translated into clinical practice. In a retrospective cohort-comprising 251 patients with RA, 251 patients with diabetes, and 251 general population individuals-Desai and colleagues therefore investigated the identification and management of CRFs by rheumatologists and primary care physicians (PCPs) [1]. RA patients had to be registered at the University of Michigan Health System for at least 12 months between June 2007 and April 2012 and had been evaluated both by their rheumatologist as well as the PCP. CRFs of interest were smoking, exercise, weight, blood pressure, lipid profile, and fasting blood glucose.In RA, PCPs identified and managed most CRFs more frequently than rheumatologists. Secondly, identification of CRFs by rheumatologists in RA patients with elevated C-reactive protein levels was not different as compared with those with normal C-reactive protein levels. A third important observation was that PCPs identified and managed CRFs more frequently in patients with diabetes, followed by general population individuals and least often in RA patients. These striking results raise several issues.First, it is hard to believe that the largely absent CV-RM by rheumatologists is explained by under-recognition because the increased CV risk in RA must presently be well known among rheumatologists. A large amount of literature on this topic has been published over the last decade. Additionally, the necessity to screen, identify, and manage CRFs is incorporated into training programmes for rheumatology residents [2]. Against this background, it is important to realise that there is a lag time between the publication of the EULAR guideline and its actual implementation (that is, the guideline was published in 2010 [3] while the current study started in 2007). In other words, CV-RM in today''s clinical practice might have been improved, but not yet recognised.Second, that the CV risk in RA is related to the inflammatory burden is well known. Nevertheless, the present study did not indicate that there is more attention for CV-RM by rheumatologists in patients with a higher inflammatory load.Third, undertreatment of the increased CV risk in RA by PCPs might be explained by under-recognition because CRFs were assessed more frequently in diabetes in comparison with RA.The EULAR guidelines recommend screening and identification of CRFs in all RA patients, and, if indicated according to CV risk-prediction charts, adequate management. As accurate assessment of CV risk depends on RA characteristics, the EULAR favoured individualising risk assessment. Hence, a risk multiplication factor of 1.5 should be used in the presence of two of the following criteria: disease duration >10 years, rheumatoid factor, and/or anti-cyclic citrullinated peptide positivity or the presence of extra-articular manifestations. However, alternative approaches have been suggested - for example, increasing the age of an RA patient by 10 years to obtain a more precise CV risk estimate or to use other risk scores. Perhaps this lack of an RA-specific CV risk-prediction model hampers CV-RM implementation. Obviously, this discussion can only be solved by developing a RA-specific CV risk-prediction model, but this will take several years to complete.One may obviously argue that, due to its retrospective design, the strength of the conclusions of Desai and colleagues may be limited; however, they are in line with other recently published literature and thus confirm extending evidence that CV-RM is poorly conducted in RA, both by rheumatologists and PCPs. Another argument against CV-RM in RA is that we should wait until trials have been conducted that demonstrate the efficacy of statins and antihypertensive agents in RA. However, it will be (many) years before specific risk models are available and withholding cardiopreventive drugs that are very likely to work also in our high-risk population is unethical. Moreover, it is important to realise that, due to the decreased incidence of CV events in the last decades, CV prevention trials are nowadays very difficult to conduct. For instance, the TRACE-RA study [4] - a large placebo-controlled double-blind primary CV prevention trial in RA with atorvastatin - was stopped prematurely owing to the very low number of CV events that occurred.Altogether, the study from Desai and colleagues provides three important clues for improvement of CV-RM in RA. First, more education is urgently needed for both rheumatologists and PCPs. Second, it is important to realise that the contribution of higher prevalence CRFs in RA is one side of the coin, but the other side is effective suppression of the inflammation. The latter is a clear task for the rheumatologist. Third, CV care of a RA patient should be a joint effort by the rheumatologist and the PCP, and they should collaborate and agree on who performs the screening, identification, and, if required, management of CRFs.     

Implications of isolation and low genetic diversity in peripheral populations of an amphi-Atlantic coral

Limited dispersal and connectivity in marine organisms can have negative fitness effects in populations that are small and isolated, but reduced genetic exchange may also promote the potential for local adaptation. Here, we compare the levels of genetic diversity and connectivity in the coral Montastraea cavernosa among both central and peripheral populations throughout its range in the Atlantic. Genetic data from one mitochondrial and two nuclear loci in 191 individuals show that M. cavernosa is subdivided into three genetically distinct regions in the Atlantic: Caribbean-North Atlantic, Western South Atlantic (Brazil) and Eastern Tropical Atlantic (West Africa). Within each region, populations have similar allele frequencies and levels of genetic diversity; indeed, no significant differentiation was found between populations separated by as much as 3000 km, suggesting that this coral species has the ability to disperse over large distances. Gene flow within regions does not, however, translate into connectivity across the entire Atlantic. Instead, substantial differences in allele frequencies across regions suggest that genetic exchange is infrequent between the Caribbean, Brazil and West Africa. Furthermore, markedly lower levels of genetic diversity are observed in the Brazilian and West African populations. Genetic diversity and connectivity may contribute to the resilience of a coral population to disturbance. Isolated peripheral populations may be more vulnerable to human impacts, disease or climate change relative to those in the genetically diverse Caribbean-North Atlantic region.     

Effect of humic acids from Leonardite on the stability of soil aggregates and melon roots under greenhouse conditions

Leonardite is an oxidized form of lignite carbon, which is obtained from fossilized organic materials. Such materials are used for the extraction of humic acids (HA). The result of the addition of HA of organic origin on soil structure is known; however, the effects of adding HA of Leonardite on soil structure have been scarcely investigated. The objectives of this research were (1) to determine the influence of humic acids derived from Leonardite in increasing the aggregate stability of an Aridisol under greenhouse conditions, and (2) evaluate the morphology of the root xylem during the phenological development of melon plants (Cucumis melo L.). Three treatments of HA solution application to the soil were used: soil without solution application (HA0), and application of HA solution to the soil with pH 6 (HA6) or (HA7). Aggregate stability (As) and bulk density (Da) were evaluated as soil variables. Development and quantification of xylem area were studied on plants. There were significant differences in aggregate stability. Also, there was an increase in the root xylem area, and the best treatment was when AH7 solution was applied. Humic acids derived from Leonardite increased the stability of soil aggregates when plants grew under greenhouse conditions, and fostered the development of xylem conduits during the fruiting stage.     

Breeding success of Spotted Flycatchers Muscicapa striata in southern England – is woodland a good habitat for this species?

The UK population of the Spotted Flycatcher Muscicapa striata has declined markedly in the last 30 years but there have been few recent studies of the species. This study examined the relationship between nest success and the predominant habitat type around Spotted Flycatcher nests in two contrasting areas of England. A breeding population in eastern England, a region where numbers of Spotted Flycatchers are known to have decreased dramatically in recent decades, was compared with another in southwest England, where numbers have remained stable or even increased. Whilst there was no difference in breeding success between the two study areas, there were significant differences between habitats, with garden nests more successful than those in farmland or woodland, at both egg and chick stages. Estimates of productivity per nesting attempt were also lower in farmland and woodland, with nests in gardens fledging twice as many chicks as those in either woodland or farmland. The proximate cause of lower success in farmland and woodland was higher nest predation rates during both egg and chick stages. In terms of nesting success, farmland and woodland appear to be similar in quality for this species, but both appear to be suboptimal habitats when compared with gardens, providing evidence of a problem on the breeding grounds for this species, in at least these two habitats.     

Hon-yaku: a biology-driven Bayesian methodology for identifying translation initiation sites in prokaryotes

Background  

Computational prediction methods are currently used to identify genes in prokaryote genomes. However, identification of the correct translation initiation sites remains a difficult task. Accurate translation initiation sites (TISs) are important not only for the annotation of unknown proteins but also for the prediction of operons, promoters, and small non-coding RNA genes, as this typically makes use of the intergenic distance. A further problem is that most existing methods are optimized for Escherichia coli data sets; applying these methods to newly sequenced bacterial genomes may not result in an equivalent level of accuracy.     

Changes in the composition of the auditory bulla in southern Solomon Islands populations of the grey cuscus, Phalanger orientalis breviceps (Marsupialia, Phalangeridae)

The auditory bulla is a much-scrutinized taxonomic character of mammals, which is generally regarded as showing a high degree of structural consistency within higher taxa. Observations of bulla variability in populations of the marsupial Phalanger orientalis from the Solomon Islands demonstrate considerable flexibility in bulla makeup, with variable incorporation of the squamosal into the tympanic floor. Studies of the ontogeny of the bulla in Phalanger show the presence of three ossification centres, including an entotympanic. Squamosal invasion of one of these ossificiation centres is seen as a possible result of inbreeding, arising from the mode of colonization of the Solomon Islands by this species. This suggests that, under certain conditions, considerable morphological plasticity may be induced within the selective constraints of bulla function.