Comprehensive dietary education in treated gout patients does not further improve serum urate.

BACKGROUND/AIM: This study aims to investigate the influence of dietary education in patients with gout on a stable dose of urate-lowering therapy (ULT). METHODS: Males and females aged >18 years with a history of gout, receiving an appropriate and stable dose of ULT, were recruited from two tertiary hospitals and randomised into two groups. The control group received basic advice regarding the importance of compliance with therapy and the benefit of weight loss. The intervention group received comprehensive dietary advice based on the British Society of Rheumatology Guidelines. Both groups received education at baseline and 3 months. Serum urate was measured at baseline, 3 months and 6 months, and a questionnaire was completed at baseline and at 6 months. The primary outcome of the study was to compare the change in serum urate between groups. RESULTS: Thirty patients were recruited into the study. There was no difference in serum urate between the control and intervention group at 6 months (0.29 mmol/L vs 0.29 mmol/L at baseline and 0.27 mmol/L vs 0.30 mmol/L at 6 months). The intervention group showed a statistically significant improvement in knowledge (8/13 in control group at baseline to 9/13 at 6 months vs 8/13 in intervention group at baseline to 12/13 at 6 months, P < 0.05) and self-reported dietary modification (1 in control vs 7 in intervention P < 0.05) at 6 months. CONCLUSION: This randomised controlled trial shows that in patients on ULT, providing education on diet does not lead to any clinically significant difference in serum urate at 6 months.

Management of gout: beyond allopurinol.

The basic concepts of the pathogenesis and management of gout have not altered for many years. Monosodium urate monohydrate crystals drive the disease and identification of these crystals is required for certain diagnosis. In contrast, our understanding of the mediators of gouty inflammation, the appropriate target serum urate concentration during treatment, the drugs available and the best ways to use those drugs have all advanced in recent years and will be the focus of this review.

Autologous stem cell transplantation in diffuse scleroderma: impact on hand structure and function.

BACKGROUND: The aim of the study was to assess the structural and functional effects of autologous stem cell transplantation (ASCT) on scleroderma finger clawing. METHODS: Using photocopies of hands of five scleroderma patients who underwent ASCT using photocopies of hands. Functional assessments used a standardized questionnaire. RESULTS: Pre-ASCT, synovitis and tenosynovitis were present in five and four patients, respectively. Modified Rodnan hand skin scores ranged from 6-12/12. Following pulsed chemotherapy, synovitis resolved. Tenosynovitis often did not. Post-ASCT, skin scores fell in four patients (range 0-6/12). Hand tenosynovitis resolved. With disease remission hand function globally improved. Functional improvement, noted early (+3 months) and continuously (+12 months) in disease remitters, occurred in all areas of function. Greatest hand-functional improvement related to paid employment, followed by self-care and hygiene, home-care activities and least by hobbies/sports. The second to fifth metacarpophalangeal width was reproducible and independent of ASCT therapy. In contrast, hand length and measures of abducted finger span (first to fifth fingertip and second to fifth fingertip distance) improved. Finger abduction (abducted first to fifth fingertips/second to fifth metacarpophalangeal width) was a more sensitive discriminator of finger clawing than hand length or hand length/second to fifth metacarpophalangeal width. CONCLUSION: ASCT improved hand scleroderma over 12 months and resolved previously refractory tenosynovitis. ASCT was unnecessary to treat scleroderma synovitis. ASCT secondarily improved hand function (paid employment, followed by self-care, home care, then by sport/hobbies). Loss of finger abduction was a more sensitive measure of finger clawing than apparent loss of hand length.

Effect of leflunomide on the peripheral nerves in rheumatoid arthritis.

BACKGROUND: The objective of this study was to determine the neurophysiological effects of leflunomide on peripheral nerves in rheumatoid arthritis. METHODS: We conducted a prospective cohort trial of 32 patients with rheumatoid arthritis with 16 patients receiving leflunomide treatment and 16 receiving other disease-modifying anti-rheumatic drug therapies. Clinical, laboratory and neurophysiological measurements were used to determine the presence of a peripheral neuropathy in these patients at study entry and then after a further 3 and 6 months. RESULTS: Fifty-four per cent of the leflunomide group and 8% of the control group had an increase in their neuropathy symptom score 6 months into the study (P = 0.01). No correlation was found between the electrophysiological findings and the clinical symptoms. There was no significant difference between the two groups in upper and lower limb sensory and motor amplitudes and conduction velocities recorded at 3 and 6 months. One patient developed both clinical and neurophysiological evidence of a peripheral neuropathy 5 months into the study that improved after cessation of leflunomide therapy and cholestyramine washout. CONCLUSION: After 6 months of exposure we found that leflunomide was associated with an apparent increase in the clinical symptoms of peripheral neuropathy in patients with rheumatoid arthritis. These symptoms did not correlate with neurophysiological studies.

MLYCD mutation analysis: evidence for protein mistargeting as a cause of MLYCD deficiency.

Malonyl-CoA decarboxylase (MLYCD) deficiency is an autosomal recessive disorder characterized by malonic aciduria, developmental delay, seizure disorder, hypoglycemia, and cardiomyopathy. Genomic sequencing of MLYCD in nine unrelated patients identified 16 of 18 pathogenic alleles, which are documented in the newly created Human MLYCD Allelic Variant Database (http://mlycd.hgu.mrc.ac.uk/). Fibroblast cell lines were available from eight of these patients and two previously reported patients with homozygous MLYCD mutations. Western blot analysis using antisera raised to a C-terminal peptide detected a 66-kDa band that was absent in six patients and substantially reduced in three patients. One patient showed an increase in protein levels with a prominent smeary 68-l83-kDa band. Immunocytochemical analysis of MLYCD-expressing patient cell lines showed apparent intracellular mislocalization. An extreme N-terminal mutation c.8G>A (p.G3D) mislocalized to the plasma membrane, suggesting that a novel targeting signal may reside in a four-amino acid conserved N-terminal motif. A 25-base deletion between the putative mitochondrial and peroxisomal initiating codons (M1 and M40) and a point mutation ablating the second of these (c.119T>C, p.M40T) both showed punctate perinuclear staining. As none of the three mislocalizing mutations are predicted to alter the catalytic function of the peptide, it seems likely that correct subcellular localization of MLYCD is critical for it to function normally.

Stable gene expression from a mammalian artificial chromosome.

We have investigated the potential of PAC-based vectors as a route to the incorporation of a gene in a mammalian artificial chromosome (MAC). Previously we demonstrated that a PAC (PAC7c5) containing alpha-satellite DNA generated mitotically stable MACs in human cells. To determine whether a functional HPRT gene could be assembled in a MAC, PAC7c5 was co-transfected with a second PAC containing a 140 kb human HPRT gene into HPRT-deficient HT1080 cells. Lines were isolated containing a MAC hybridizing with both alpha-satellite and HPRT probes. The MACs segregated efficiently, associated with kinetochore proteins and stably expressed HPRT message after 60 days without selection. Complementation of the parental HPRT deficiency was confirmed phenotypically by growth on HAT selection. These results suggest that MACs could be further developed for delivering a range of genomic copies of genes into cells and that stable transgene expression can be achieved.

Women's health after plastic surgery.

BACKGROUND: Allegations that exposure to endogenous silicone, especially related to breast implants, might be causally related to connective tissue disease originated from case studies. More recent comparative studies have implied no such increased risk. The aims of the present study were to compare the prevalence and/or incidence of autoimmune and connective tissue disorders in a population-based cohort of female Sydney residents stratified by augmentation mammoplasty status. METHODS: In this population-based retrospective cohort study, the health status of female Sydney residents who had augmentation mammoplasty for cosmetic reasons between 1979 and 1983 was compared with that of female Sydney residents who had non-silicone-associated plastic surgery over the same period. Both groups were matched for age (+/- 5 years), year of plastic surgery (+/- 2 years), plastic surgeon, anaesthetist and mode of anaesthesia. Outcome measures comprised rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, sicca symptoms polymyositis/ dermatomyositis, connective tissue disease overlap, digital vasospasm, abnormal nailfold capillaroscopy, elevated antinuclear antibody titre, carpal tunnel syndrome, tendonitis, osteoarthritis, psoriatic arthritis, livedo reticularis, thyroid disease, multiple sclerosis, axillary lymphadenopathy, fibromyalgia and breast carcinoma. RESULTS: There was no difference in the occurrence of connective tissue diseases or connective tissue disease-related parameters, thyroid disorders, fibromyalgia or multiple sclerosis between cohorts. However, axillary adenopathy and low titre positive antinuclear antibody (ANA) occurred with a significantly greater frequency in the exposed cohort (odds ratio (OR) = 3.50, 95% confidence interval (CI) = 2.10-5.84 and OR = 1.29, 95% CI = 1.03-1.62, respectively). Axillary adenopathy correlated with capsular contracture (relative risk (RR) = 2.07, 95% CI = 1.22-3.51) and also the self-reported development of digital vasospasm (RR = 3.20, 95% CI = 1.46-7.03) after breast augmentation. CONCLUSIONS: No association was found between augmentation mammoplasty exposure and various connective tissue diseases and/or their related features. However, axillary adenopathy and low titre ANA were detected more frequently in the exposed cohort. Women with axillary adenopathy were more likely to have breast capsular contracture and report digital vasospasm post-dating surgery. Given comparable frequencies of higher titre ANA of both cohorts, the finding of elevations of low titre ANA is of dubious clinical significance.

Gout and other crystal-associated arthropathies.

Intra-articular crystals (monosodium urate monohydrate, calcium pyrophosphate dihydrate, basic calcium phosphates) can cause acute and chronic inflammation and joint damage. Identification of the crystals by polarized microscopy is the key step in diagnosis but improved reliability of synovial examination is required. Treatment of disorders associated with gout or calcium pyrophosphate deposition may reduce non-joint morbidity and assist treatment of the arthritis. Various forms of anti-inflammatory therapy work for acute crystal-induced arthritis; prompt commencement is usually more important than which option is used. In gout, recurrent attacks are usual, but hypouricaemic therapy is almost never urgent, is life-long, and is too often negated by poor compliance. In most patients, allopurinol or any of the potent uricosuric drugs will allow maintenance of normouricaemia but renal failure, renal calculi, transplantation, and allopurinol allergy narrow the options and complicate management.

Mammalian artificial chromosome formation from circular alphoid input DNA does not require telomere repeats.

Mammalian artificial chromosomes (MACs) form in HT1080 cells after transfecting linear yeast artificial chromosome constructs minimally containing competent alphoid arrays, a selectable marker and terminal human telomere repeats. Restrictions on the structure of input DNA in MAC formation were investigated by transfecting circular or linear alphoid constructs with or without human telomere arrays and by varying the position and orientation of the telomere arrays on input linear constructs. Circular input DNA efficiently produced MACs. Absence of telomere arrays from circular input molecules did not significantly alter MAC formation rates. Linear constructs capped with telomere arrays generated MACs effectively, but a severe reduction in MAC formation was observed from linear constructs lacking telomere arrays. Human telomere arrays positioned 1-5 kb from linear construct ends and in either orientation were able to promote MAC formation with similar efficiencies. Both circular and linear input constructs generated artificial chromosomes that efficiently segregated in the absence of selection. Telomeres were not detected on the MACs, regardless of the inclusion of telomere arrays on input DNA, suggesting that circular chromosomes were formed. We found no evidence for acquisition of host cell DNA, which is consistent with de novo chromosome assembly.

A human DAZ transgene confers partial rescue of the mouse Dazl null phenotype.

In a subset of infertile men, a spectrum of spermatogenic defects ranging from a complete absence of germ cells (sertoli cell only) to oligozoospermia is associated with microdeletions of the DAZ (deleted in azoospermia) gene cluster on human distal Yq. DAZ encodes a testis-specific protein with RNA-binding potential recently derived from a single-copy gene DAZL1 (DAZ-like) on chromosome 3. Y chromosomal DAZ homologues are confined to humans and higher primates. It remains unclear which function unique to higher primate spermatogenesis DAZ may serve, and the functional status of the gene recently has been questioned. To assess the extent of functional conservation we have tested the capacity of a human DAZ gene contained in a 225-kb yeast artificial chromosome to complement the sterile phenotype of the Dazl null mouse (Dazl-/-), which is characterized by severe germ-cell depletion and meiotic failure. Although Dazl-/- mice remained infertile when the DAZ transgene was introduced, histological examination revealed a partial and variable rescue of the mutant phenotype, manifest as a pronounced increase in the germ cell population of the seminiferous tubules and survival to the pachytene stage of meiosis. As well as constituting definitive proof of the spermatogenic role of the DAZ gene product, these findings confirm the high degree of functional conservation between the DAZ and DAZL1 genes, suggesting they may constitute a single target for contraceptive intervention and raising the possibility of therapeutic up-regulation of the DAZL1 gene in infertile men.

Construction of YAC-based mammalian artificial chromosomes.

To construct a mammalian artificial chromosome (MAC), telomere repeats and selectable markers were introduced into a 100 kb yeast artificial chromosome (YAC) containing human centromeric DNA. This YAC, which has a regular repeat structure of alpha-satellite DNA and centromere protein B (CENP-B) boxes, efficiently formed MACs that segregated accurately and bound CENP-B, CENP-C, and CENP-E. The MACs appear to be about 1-5 Mb in size and contain YAC multimers. Structural analyses suggest that the MACs have not acquired host sequences and were formed by a de novo mechanism. The accurate segregation of the MACs suggests they have potential as vectors for introducing genes into mammals.

Quality assurance for synovial fluid examination for crystals: an improved method.

OBJECTIVE: To determine the best method of preparing synovial fluid specimens for use in quality assurance (QA) surveys designed to assess accuracy of crystal identification. METHODS: A previously published method (A) was compared with a new method (B) in the setting of a QA survey. Ten Australian, one New Zealand, and one Hong Kong hospital laboratories took part in the survey. Each laboratory examined six different synovial fluid specimens prepared using method A (first round) and a separate six specimens using method B (second round). In method A, a drop of synovial fluid on a glass slide was surrounded by a rim of Ultramount, sealed with a coverslip, and distributed. The participating laboratory did not need to perform any processing of the specimen before examination. In method B, a capillary tip was filled with synovial fluid, heat sealed, and distributed. The fluid was expelled onto a glass slide in preparation for examination after arrival in the participating laboratory. RESULTS: Using method A 36 of 71 (51%) of the specimens were rated as satisfactory, compared with 53 of 61 (87%) of the specimens using method B (Fisher's exact test, p < 0.001). CONCLUSIONS: An improved method of preparation of synovial fluid specimens for QA surveys is described. Using the new method it is feasible to perform a synovial fluid QA survey covering a large area (Australasia).