causes of false positive anti ccp antibodies

As a result, we found significant effect on developing RA (OR Inf (95% CI 0.7-Inf), p value 0.048). 2006;65(8):11102. Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, Japan, Takeshi Iwasaki,Shuichiro Nakabo,Kosaku Murakami,Ran Nakashima,Hajime Yoshifuji,Takao Fujii,Tsuneyo Mimori&Koichiro Ohmura, Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan, Clinical Research Center, Shizuoka General Hospital, Shizuoka, Japan, The Department of Applied Genetics, The School of Pharmaceutical Sciences, University of Shizuoka, Shizuoka, Japan, Department of Advanced Medicine for Rheumatic Diseases, Graduate School of Medicine, Kyoto University, Kyoto, Japan, Department of Clinical Immunology and Rheumatology, Tazuke Kofukai Medical Research Institute, Kitano Hospital, Osaka, Japan, Department of Transfusion Medicine & Cell Therapy, Kyoto University Hospital, Kyoto, Japan, Yasuo Miura,Kimiko Yurugi&Taira Maekawa, Department of Rheumatology, Leiden University Medical Center, Leiden, The Netherlands, Myrthe A. M. van Delft&Leendert A. Trouw, Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands, Department of Clinical Immunology and Rheumatology, Wakayama Medical University, Wakayama, Japan, Ijinkai Takeda General Hospital, Kyoto, Japan, You can also search for this author in A positive result for cyclic citrullinated peptide (CCP) antibodies may be suggestive of rheumatoid arthritis (RA) if compatible clinical features of disease are present. Kakumanu P, Sobel ES, Narain S, Li Y, Akaogi J, Yamasaki Y, et al. Verheul MK, Bohringer S, van Delft MAM, et al: Triple positivity for anti-citrullinated protein autoantibodies, rheumatoid factor, and anti-carbamylated protein antibodies conferring high specificity for rheumatoid arthritis: Implications for very early identification of at-risk individuals. Anti-CCP Test - Anti-Cyclic Citrullinated Peptide - FactDr However, we found citrullination dependency was not associated with the risk of developing RA. X-rays of the hands and feet were taken for all patients in groups 1 and 2, and in 25 out of 31 patients in group 3. About 70% of RA patients test positive for anti-CCP antibodies [4, 23]. Anti-histone antibodies - Wikipedia Even patients with Rheumatoid arthritis can have a positive ANA. Irigoyen P, Lee AT, Wener MH, Li W, Kern M, Batliwalla F, et al. Interpretation in the clinical context is important. (2-4) Delayed diagnosis of RA is associated with joint erosion, destruction or deformities, poor response to treatment with ultimate increase in morbidity, and mortality.(3,4). Refining the complex rheumatoid arthritis phenotype based on specificity of the HLA-DRB1 shared epitope for antibodies to citrullinated proteins. Arthritis Rheum. California Privacy Statement, During the mean follow-up period of 8.9years, only 2 out of 33 patients fulfilled the 1987 revised ACR criteria (Fig. Kasukawa R TT, Miyawaki S, Yoshida H, Tanimoto K, Nobunaga M, Suzuki T, Takasaki Y, Tamura T. Preliminary diagnostic criteria for classification of mixed connective tissue disease: In: Kasukawa R, Sharp GC (Eds) Mixed Connective Tissue Disease and Antinuclear Antibodies. The higher the levels of anti-CCP antibody, the more likely it is to suggest RA. The anti-double stranded DNA (anti-dsDNA) tests are used to help diagnose and monitor lupus, also called systemic lupus erythematosus or SLE, a chronic inflammatory autoimmune disorder in which the immune system mistakenly targets the body's own cells and tissues. To assess whether anti-CCP-positive CTD patients had suffered from arthritis during this time frame, the attending physicians of patients completed a questionnaire survey in September 2020. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. RA and Anti-CCP: What is the Purpose of an Anti-CCP Test? A negative result by itself does not rule out the disease. Performance characteristics were verified by Mayo Clinic in a manner consistent with CLIA requirements. Although all 60 samples tested positive for the anti-CCP antibody using a commercial ELISA kit, 5 out of 33 RA-overlapping CTD and 6 out of 27 non-RA CTD serum samples tested negative using our in-house CCP ELISA. About 20% of RA patients are seronegative, meaning that their RF and anti-CCP lab results both continue to come back . However, the anti-CCP antibody test is the most widely-used ACPA test in clinical practice due to its accuracy [5]. SelfDecode does not treat, diagnose or cure any conditions, The wells are then washed to remove unbound serum constituents, and horse radish peroxidase-labeled goat anti-human IgG antibody is added. 1, 7.6%). Interpretation. Early detection of anti-CCP antibodies is crucial to properly treat the disease and stop its progression [10]. Once a patient develops a positive anti-CCP, it will usually remain positive, despite remission. Rheumatologic Tests: A Primer for Family Physicians | AAFP Anti-CCP-positive non-RA CTD patients rarely developed RA. Springer Nature. However, the presence of immunoglobulins causing pan-agglutination can cause false-positive results. Links with this icon indicate that you are leaving the CDC website.. Anti-CCP antibody and other autoantibody markers can be helpful in determining which patients with rheumatoid arthritis may have benefit from treatments such as anti-tumor necrosis factor-alfa (TNFa) monoclonal antibodies. Arthritis Rheum. Furthermore, the 2010 ACR/EULAR criteria were used to diagnose RA [26]. Ann Rheum Dis. 19952023 Mayo Foundation for Medical Education and Research. Aletaha D, Neogi T, Silman AJ, et al: 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. (3,4,8,9), Compared to early serologic tests for RA including RF, several studies have demonstrated that ACPA have much improved specificity for RA. The Centers for Disease Control and Prevention (CDC) cannot attest to the accuracy of a non-federal website. Bone erosions on the hands and feet were assessed by X-ray. Arthritis Rheum. Privacy Anti-citrullinated protein antibodies (ACPAs) are autoantibodies (antibodies to an individual's own proteins) that are directed against peptides and proteins that are citrullinated.They are present in the majority of patients with rheumatoid arthritis.Clinically, cyclic citrullinated peptides (CCP) are frequently used to detect these antibodies in patient serum or plasma (then referred to as . Vannini A, Cheung K, Fusconi M, Stammen-Vogelzangs J, Drenth JP, Dall'Aglio AC, et al. 2015;74(2):37580. For assistance, contact. a Comparison of citrullination dependency between rheumatoid arthritis (RA)-overlapping connective tissue diseases (CTD) and non-RA CTD patients. SI Abnormal Reports. Seronegative Rheumatoid Arthritis | Orlando | UCF Health During the first incubation, serum antibodies bind to adsorbed, solid phase CCP. contrary to popular belief anti ccp is not 100% specific for RA. 2010;62(9):256981. Semin Immunopathol. Anti-RNP. Knowing the symptoms of autoimmune joint disease is of utmost importance as well. CAS These antibodies are made as a direct attack of specific proteins found naturally in the body. The concentration of CCP antibodies is determined by comparison to a 5-point standard curve (15.6-250 U). The HLA-DRB1 allele was typed using the WAKFlow system (Wakunaga Pharmaceutical, Akitakata, Japan) and the following were classified as HLA-DRB1 SE: *01:01, *01:02, *04:01, *04:04, *04:05, *04:08, *04:10, *04:13, *04:16, *10:01, *13:03, *14:02, and *14:06, as reported previously [29]. Based on his own health success, he went on to found SelfDecode, the worlds first direct-to-consumer DNA analyzer & precision health tool that utilizes AI-driven polygenic risk scoring to produce accurate insights and health recommendations. Background Systemic lupus erythematosus (SLE) is a complex and challenging autoimmune disease. (sensitivity) versus the false positive rate (1 - specificity) for various possible cutpoints of a diagnostic test. 2017 Jun;39(4):437-446, 8. Two conditions that mimic celiac disease, but are different RF can also be found in patients that don't have rheumatoid arthritis at all. Use. Arthritis Rheum 1980;23(5):581590. INOVA Diagnostics; 02/2020). In contrast, antinuclear antibodies often attack your body's own tissues specifically targeting each cell's nucleus. An asterisk denotes the accuracy of the diagnosis was reconfirmed by a questionnaire completed by each attending physician, which asked whether the patient fulfilled the 1987 revised ACR criteria for the classification of RA. Clinical false positives resulting from recent intravenous Sensitivity/specificity of citrullination dependency for predicting RA development in the population of anti-CCP positive patients with arthritis (n=39) was 96%/18%, and PPV/negative predictive value (NPV) of that was 75%/67%. (1) Clinically, RA is typified by progressive damage of synovial joints, inflammation, production of diverse autoantibodies, and variable extra-articular manifestations. Primary Biliary cirrhosis, an autoimmune disease of the biliary ducts in the liver. There were no significant differences between the two groups (p=0.15). Your email address will not be published. Anti-CCP antibody titers were obtained from a retrospective chart review for 445 patients or were measured using the stored sera of 397 patients. Lets look at how doctors use this test as an auto-immune marker. You might be able to help lower your inflammatory joint symptoms by maintaining adequate vitamin D levels, addressing any gum disease you may have, and quitting smoking. Arthritis Rheumatol. Antinuclear Antibodies (ANA) Test: Results, Positive vs - WebMD (3-5) To facilitate early diagnosis, the American College of Rheumatology/European League Against Rheumatism 2010 RA classification criteria recommend testing for rheumatoid factor (RF) and anticitrullinated protein antibodies (ACPA). False positives are more common with RF than anti-CCP. 2017;76(1):11925. A plus sign next to the number [1+, 2+, etc] means that the information is found within the full scientific study rather than the abstract. Anti-RNP (anti-U1 ribonucleoprotein) is a non-specific antibody that occurs in many patients with lupus and other rheumatic diseases. Anti-CCP antibodies, also called CCP antibodies, are a type of antibody called autoantibodies. These antibodies are commonly found in rheumatoid arthritis patients. The entire, 55-min procedure for the detection of RF and anti-CCP using a dual-target ELISA assay is shown schematically in Fig. Arthritis Rheumatol. (Package insert: Quanta Lite CCP3 IgG ELISA. (4,6,10) A systemic review and meta-analysis of 33 studies including patients with RA and healthy or disease controls demonstrated the sensitivity of anti-mutated citrullinated vimentin, anticyclic citrullinated peptide, and RF of 71%, 71%, 77%, with the specificity of 89%, 95%, 73%, and the area under the curve of the summary receiver operating characteristic of 89%, 95%, 82%, respectively. Autoimmune hepatitis, an autoimmune disease of the liver. Our science team must pass long technical science tests, difficult logical reasoning and reading comprehension tests. 2a). Arnett FC, Edworthy SM, Bloch DA, McShane DJ, Fries JF, Cooper NS, et al. Anti-cyclic citrullinated peptide positivity in non-rheumatoid arthritis disease samples: citrulline-dependent or not? 2008;67(4):46670. American College of Rheumatology classification criteria for Sjgrens syndrome: a data-driven, expert consensus approach in the Sjgrens International Collaborative Clinical Alliance cohort. We are dedicated to providing the most scientifically valid, unbiased, and comprehensive information on any given topic. 2011;63(11):322633. Anti-Sm antibody binds to a protein that is attached to DNA. Google Scholar. Rheumatoid arthritis (RA) is a chronic, systemic inflammatory . Frontiers | False Positive Results in SARS-CoV-2 Serological Tests for Methods . The test is also not used to screen for RA patients because it can frequently miss individuals who have the disease [14]. Ann Rheum Dis. All authors approved the final manuscript. Highest rates of false-positive RF tests were found in patients with SLE (18.3% vs. 12.7% CCP), Sjgren's syndrome (73.3% vs. 3.3% CCP), and a control group with chronic hepatitis (24.7% vs. 1.3% CCP). Duration of preclinical rheumatoid arthritis-related autoantibody positivity increases in subjects with older age at time of disease diagnosis. These include [15]: A rheumatoid factor (RF) test is commonly ordered alongside an anti-CCP test to help make a diagnosis. One other test that can help is the anti-CCP antibody test. In a systematic review from 2010, it was found that false positivity can also occur in chronic . Although we considered an anti-CCP titer 100 to be 100, the relationship between the anti-CCP antibody titer and the risk of developing RA is supported by patients with a high ACPA level having a high score in the 2010 ACR/EULAR classification criteria of RA [26] as well as a high anti-CCP antibody titer being more strongly associated with RA in the general population [32]. Anti-citrullinated peptide antibody assays and their role in the diagnosis of rheumatoid arthritis. Hensvold AH, Magnusson PK, Joshua V, Hansson M, Israelsson L, Ferreira R, et al. Tests with lower rates of sensitivity will produce more false negative results. As shown in Table2, the incidence of arthritis, prevalence of rheumatoid factor (RF), titer of the anti-CCP antibody, and usage of disease-modifying antirheumatic drugs (DMARDs) were all significantly lower in non-RA CTD patients. Rheumatoid arthritis (RA) is a chronic systemic autoimmune disease characterized by interactions between the environment, specific genetic risk factors, and the human immune system. 1). Rantapaa-Dahlqvist S, de Jong BA, Berglin E, Hallmans G, Wadell G, Stenlund H, et al. Unlike anti-dsDNA, the Sm antibody does not change in titer during a lupus flare or in response to treatment so need not be monitored. 2007;66(4):5116. Association between SARSCoV2 and SLE is not clear. In most cases, a positive ANA test indicates that your immune system has launched a . 2010 Rheumatoid arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Antiphospholipid Antibodies : Johns Hopkins Lupus Center Anti-cyclic citrullinated peptide (anti-CCP) antibodies are commonly found in patients with rheumatoid arthritis (RA), an autoimmune disorder that destroys the joints throughout the body [1]. Thirty-nine out of the 62 RA-overlapping CTD patients tested positive for the anti-CCP antibody (62.9%). 2012;64(8):267786. Part of A rough guide to the disease associations of ENAs is provided in Table 1. Different patterns of associations with anti-citrullinated protein antibody-positive and anti-citrullinated protein antibody-negative rheumatoid arthritis in the extended major histocompatibility complex region. antibodies are routinely tested for by ELISA at Clinipath. A Mayo Clinic prospective clinical evaluation of the CCP antibody test showed a diagnostic sensitivity for RA of 78% with fewer than 5% false positive results in healthy controls (see Cautions). Arthritis Rheum. CAP, the arginine version of CCP (the citrulline residues of CCP were converted to arginine), and CCP were coated on the same plate, and reactivities against CAP and CCP were compared. Arthritis Rheum. Objective: We sought to characterize a novel cohort of patients with lung disease, anti-cyclic citrullinated peptide (CCP) antibody positivity, without rheumatoid arthritis (RA) or other connective tissue disease (CTD). Positive results for cyclic citrullinated peptide (CCP) antibodies may occur in some patients with systemic lupus erythematosus or other autoimmune, connective tissue diseases. 1), and the mean CTD duration period at anti-CCP testing was 10.19.4years. Lung disease with anti-CCP antibodies but not rheumatoid - PubMed Therefore, SE has potential as a genetic marker to distinguish RA from non-RA in the ACPA-positive population. What is anti-CCP lab test? - Vidque.com Sixty-two patients were diagnosed with RA-overlapping CTD before the anti-CCP test was performed. False-positive tests also occur in . What Is the Anti-Cyclic Citrullinated Peptides (Anti-CCP) Blood Test? Testing is performed on the Agility instrument by Dynex. Systemic lupus erythematosus (SLE): when active, usually a homogenous pattern on ANA or less commonly speckled, rim, or nucleolar when present in high enough titer to be . PDF Autoantibodies related to systemic autoimmune with COVID-19 The anti-CCP antibody becoming negative over time was more frequently observed in non-RA CTD patients than in RA-overlapping CTD patients, although there was no statistical difference. Antirheumatic therapy should not be initiated based solely on a positive test for CCP antibodies, and changes in treatment should not be based upon the levels of CCP antibodies. Since the emergence of the anti-CCP antibody may have preceded the onset of RA in these patients, anti-CCP-positive non-RA CTD patients may be more susceptible to developing RA than indicated by the present results. 1997;40(9):1725. Despite this limitation, PPV for developing RA in non-RA CTD patients (2/33, 6.1%) was markedly lower than that in healthy individuals (8296%) [3, 4] and similar to the incidence of RA complications in CTD patients in the present study ((group 1 and group 2)/group 0 in Fig. Ryu YS, Park SH, Lee J, Kwok SK, Ju JH, Kim HY, et al. 2005;52(11):34338. They help your body recognize and fight infections. A sample was considered to be citrullination-dependent when the anti-CCP antibody titer was higher than the cut-off (25 arbitrary U/mL) and the absorbance values at 415nm value for CCP was 0.1 higher than that for CAP [28]. (PPTX 48 kb). Background: Anti-cyclic citrullinated peptide (anti-CCP) antibodies are considered highly specific markers of rheumatoid arthritis. b A similar analysis was performed by stratifying all samples for which HLA data were available based on positivity for the HLA-DR shared epitope (SE). Preliminary criteria for classification of adult Still's disease. An anti-CCP antibody test is ordered when a person is experiencing symptoms of joint. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. Fingerstick tests give you results within 10 minutes, allowing your doctor to give you immediate feedback [21]. These tests are slightly less accurate than tests that require blood draws that are then sent away to a lab for analysis. PDF A Basic Guide to Autoimmune Testing: Part I ANA, ENA and dsDNA Antibodies We simultaneously assessed anti-CAP and anti-CCP in 60 serum samples (33 RA-overlapping CTD and 27 non-RA CTD) and compared their reactivities. When we compared clinical, serological, and genetic features between non-RA CTD and RA-overlapping CTD patients, we found not only the presence of joint symptoms, bone erosion, and RF, which were all included in the 1987 revised ACR criteria [25], but also a higher anti-CCP titer and more prevalent HLA-DRB1 SE in RA-overlapping CTD patients (Table2). 1) (Table3). TI and SN analyzed the data. Anti CCP Antibody Assay: A Diagnostic Dilemma in Diagnosis of Thirty-three anti-CCP-positive non-RA CTD patients were retrospectively followed up for the development of RA. Your doctor may order an anti-dsDNA if you have a positive antinuclear antibody . The normal level of anti-CCP antibodies is less than 20 units/mL. Currently, they are not widely used in clinical practice [22]. 1 Introduction. Anti-cyclic citrullinated peptide antibodies in type 1 autoimmune hepatitis. Arthritis Rheum. It's also called an ANA or FANA (fluorescent antinuclear antibody) test. The dependency on citrullination was evaluated by subtracting absorbance values of anti-CAP from that of anti-CCP. 2008;1143:26885. The present study was supported in part by JSPS KAKENHI (grant no. This indicates that anti-CCP Abs may be a helpful tool in the differential diagnosis of EORA from PMR. Anti-CCP (Cyclic Citrullinated Peptide) Antibodies, IgG and - Labcorp Anti-CCP antibody, a marker for the early detection of rheumatoid arthritis. For more information see Connective Tissue Disease Cascade. Arthritis care & research. The development of Assessment of SpondyloArthritis international Society classification criteria for axial spondyloarthritis (part I): classification of paper patients by expert opinion including uncertainty appraisal. X-rays were examined in 27 out of the 33 patients, and only one (3.7%) showed bone erosions. 2a). After further incubation and washing to remove unbound conjugate, substrate (3,3',5,5' tetramethylbenzidine) is added and allowed to incubate. The immune system then produces antibodies to attack these . Anti-CCP antibody titers were obtained from a retrospective chart review or measured using stored sera. 2004;50(2):3806. Tagged: Mean. Beverley. While RA is a lifelong disease, diagnosing it early and treating it properly will give the best chance at controlling its progression and allowing you to live a healthy and active lifestyle. We do not aim to diagnose, treat, cure or prevent any illness or disease. Anti-CD38 Monoclonal Antibodies Interfere With Isoagglutinin Is it possible to have negative ANA and positive anti-DNA in SLE J Rheumatol. False positives are also known to happen in about 5% of tests when a person would be classified as healthy. Anti-cyclic citrullinated peptide (CCP) antibody and anti-cyclic arginine peptide (CAP) antibody titers. A CCP antibodies test measures the level of these autoantibodies. This might be partly due to strict criterion of threshold of citrullination dependency (absorbance difference between anti-CAP and anti-CCP 0.1) for low absorbance level samples. X-rays of the hands and feet were taken for 27 out of the 33 anti-CCP-positive CTD patients, and only one showed bone erosions (Fig. All statistical analyses were conducted using R version 3.6.3. Anti-CCP or Anti-Cyclic Citrullinated Peptide is an autoantibody also known as ACPAs or anti-citrullinated protein antibodies. Regarding anti-CCP-positive non-RA CTD patients who dropped out of the follow-up and RA-overlapped patients, we retrospectively evaluated X-rays of their hands and feet, which had been taken after the anti-CCP antibody became positive. Elsevier, Amsterdam. it is found in Psoriatic arthritis, even leprosy, and as a false positive finding . The 1987 revised ACR criteria were used to diagnose RA; therefore, the potential effect of anti-CCP positivity on the RA or non-RA classification was excluded. To make a conclusive diagnosis, your doctor will take into account both of your antibody results in combination with CRP and ESR tests and any symptoms you have [25]. Anti-CCP antibodies target proteins in which the amino acid arginine has been converted (citrullinated) into another amino acid called citrulline. Antibodies and autoantibodies are proteins made by the immune system. Avouac J, Gossec L, Dougados M. Diagnostic and predictive value of anti-cyclic citrullinated protein antibodies in rheumatoid arthritis: a systematic literature review. (3,4,8,9) Compared to early serologic tests for RA including RF, several studies have demonstrated that ACPA have much improved specificity for RA. Rheumatoid arthritis is an autoimmune, inflammatory disorder caused by a person's immune system mistakenly attacking and destroying healthy cells within the body. Anti-citrullinated protein antibody - Wikipedia Epstein-Barr Virus Laboratory Testing - Centers for Disease Control and Anti-dsDNA Test - Testing.com Arthritis Res Ther. Approximately 70% of RA patients are positive for anti-CCP IgG, while only 2% of random blood donors and control subjects are positive. However, limited information is currently available on the long-term outcomes of anti-CCP-positive non-RA CTD patients. Our team comprises of trained MDs, PhDs, pharmacists, qualified scientists, and certified health and wellness specialists. An antinuclear antibody test is a blood test that looks for certain kinds of antibodies in your body. Autoimmune diseases are the most frequent cause of a positive ANA. Methods: The study sample included 74 subjects with respiratory symptoms, evaluated January 2008-January 2010 and found to have a positive anti-CCP antibody but no evidence for . Anti-CCP Antibody Test: Results and What They Mean Although late RA prognosis may be linked to adverse consequences, early diagnosis has been reported to improve outcomes; notably reduced joint destruction or deformity, delayed radiologic progression, and decreased functional disability. Cookies policy. Marked differences in fine specificity and isotype usage of the anti-citrullinated protein antibody in health and disease. Rheumatoid factors are proteins produced by your immune system that can attack healthy tissue in your body. Anti-CCP antibodies are found in most rheumatoid arthritis patients and likely play a key role in the development of the disease. The follow-up length of each patient was defined as the period from the day when serum was collected or the anti-CCP antibody test was ordered in the clinic to the last visit before January 2020 (see Supplementary Figure 1, Additionalfile1). HLA-DRB1 SE and anti-CCP antibody titers may facilitate the differentiation of RA-overlapping CTD from anti-CCP-positive non-RA CTD. Because rheumatoid factor antibody binds to normal antibodies, it can be generally referred to as an autoantibody. RA Diagnosis: What Criteria are used to Diagnose Rheumatoid Arthritis? Furthermore, the 100% positive predictive value of anti-CCP Abs confers a remarkable advantage on this serum marker in comparison with RF. If CCP antibodies are found in your blood, it can be a . However, the target population in the present study was pSS patients who were cross-sectionally evaluated, and RA-overlapping CTD patients were not excluded when anti-CCP antibody titers were measured.

Boles Apartments Waterville, Maine, What Is A Rite Of Passage Examples, Huntington Third Wave Of Democratization Pdf, What Beach Has Most Shark Attacks?, Michael Mcgrath Obituary New York, Articles C