Rosuvastatin might have an effect on C-reactive protein but not on rheumatoid disease activity: Tayside randomized controlled study.

The aim of this study was to study the effects of rosuvastatin in patients with rheumatoid arthritis (RA) looking at the C-reactive protein (CRP), interleukin-6 (IL-6) and joint disease activity. Fifty RA patients were randomized in a double-blind placebo-controlled trial to receive either 10 mg of rosuvastatin or placebo as an adjunct to existing disease-modifying antirheumatic therapy. Patients were followed up for a six-month period. Measurements were done at baseline and six months. CRP and IL-6 were measured in the blood. RA disease activity was measured using disease activity score based on 28 joint counts (DAS 28). When analysing from baseline to six months there was no difference between the rosuvastatin and placebo groups in rheumatoid disease activity (-0.01; standard deviation [SD], 1.08; and +0.18; SD, 0.95; respectively; P value 0.509). There was a trend towards improvement in CRP in the rosuvastatin group (-3.23; SD, 18.18) compared with the placebo group (+17.43; SD, 38.03); P value, 0.161. IL-6 showed a trend towards worsening in the rosuvastatin group (+0.15; SD, 1.09) compared with placebo (-0.73; SD, 1.4); P value, 0.054. These data show that rosuvastatin with might decrease the CRP independent to IL-6 in patients with RA but does not improve the overall rheumatoid disease activity.

C-reactive protein: the underlying cause of microvascular dysfunction in rheumatoid arthritis.

OBJECTIVE: RA is a chronic autoimmune inflammatory condition associated with increased cardiovascular morbidity and mortality. Endothelial dysfunction, a marker of early atherosclerotic disease, occurs in some inflammatory diseases but this relationship has not been previously explored within the microvasculature of patients with RA. We therefore assessed forearm microvascular endothelial function in patients with RA and determined its relationship to RA disease activity and inflammation. METHODS: A total of 128 RA patients with no previous history of cardiovascular disease were evaluated. Endothelium-dependent and -independent forearm skin microvascular function was measured using laser Doppler imaging after iontophoretic delivery of acetylcholine (ACh) and sodium nitroprusside (SNP), respectively. Parameters of RA disease activity and inflammation were also checked. RESULTS: There was a significant negative correlation between the level of inflammation measured by log(10)CRP and maximum vasodilatation measured by peak ACh response (r(2) = -0.209, P = 0.018, Pearson correlation test). In a multiple regression model, age (beta = -0.449, P < 0.0001) and log(10)CRP (beta = -0.193, P = 0.026) were independently negatively associated with ACh responses. When RA patients were sub-divided according to their systemic inflammatory status (CRP > 10 mg/l vs CRP

Bone health in patients with fibromyalgia.

OBJECTIVES: To determine whether women with fibromyalgia are at increased risk of developing osteoporosis or osteomalacia. METHODS: Forty premenopausal women with fibromyalgia and 37 age-matched female controls were studied. Broadband ultrasound attenuation (BUA) and velocity of sound (VOS) were measured at the calcaneum and bone mineral density was measured at the forearm and lumbar spine using dual-energy X-ray absorptiometry. Serum calcium, alkaline phosphatase, gamma-glutamyl transferase, 25-hydroxyvitamin D and plasma viscosity were measured in all subjects and parathyroid hormone was measured in subjects recruited in the latter part of the study. RESULTS: Seventeen patients with fibromyalgia syndrome and seven controls had 25-hydroxyvitamin D concentrations <20 nmol/l (P < 0.015) and in three FMS patients serum parathyroid hormone was raised. Bone density in fibromyalgia patients was slightly lower at the mid-distal forearm but comparable to that in controls at other sites. CONCLUSIONS: There is no reason to recommend routine bone densitometry in fibromyalgia patients. However, vitamin D subnutrition is common in these patients and this should be sought.

Rheumatoid arthritis and macrovascular disease.

OBJECTIVE: To measure the extent of subclinical atherosclerosis in patients with rheumatoid arthritis (RA) compared with controls, and to evaluate any potential vascular risk factors. METHODS: Forty RA patients were compared with an age- and sex-matched control group. Non-invasive vascular tests, i.e. carotid duplex scanning [measuring common carotid artery intima-media thickness (IMT)], ankle-brachial blood pressure index (ABPI) and QT dispersion on ECG (QTD), were performed. Traditional risk factors such as high blood pressure, blood sugar, lipids and steroid usage were assessed. RESULTS: The average IMT (S.E.) in RA patients was 0.73 (0.03) mm, compared with 0.62 (0.03) mm in the control group (P=0.01, Mann-Whitney). Ten out of 40 RA patients (25%) had an ABPI < 1.0 compared with 1/40 (2.5%) in the control group (P=0.007, Fisher's). QTD was higher in RA patients; mean (S.E.) 55 (2.70) ms compared with 40 (2.50) ms in the control group (P < 0.001, t-test). There were no significant differences in the prevalence of high blood pressure, diabetes or lipid profiles. However, patients on steroids had a higher mean QTD (S.E.): 63.5 (4) compared with 48 (2.7) ms in those patients who had not received long-term steroids (P=0.003, t-test). CONCLUSION: RA patients have an increased risk of subclinical vascular disease as was shown by a higher prevalence of carotid disease, peripheral arterial disease and increased QTD. Among traditional risk factors we found a history of steroid usage to be one of the potential risk factors.

The prevalence and significance of positive antinuclear antibodies in patients with fibromyalgia syndrome: 2-4 years' follow-up.

The aim of this study was to ascertain whether fibromyalgia patients with positive ANA develop other features of connective tissue disease over 2-4 years' follow-up. Patients attending our clinic with a diagnosis of fibromyalgia were identified. All ANA-positive patients (n = 12) were recruited and matched for age and sex with 12 ANA-negative FMS patients. As further control groups, patients with a diagnosis of osteoarthritis (OA) were included. A screening questionnaire for possible features of connective tissue disease was sent to all participants. Patients who had three or more positive criteria were invited for further assessment. The ANA-positive rate was 12/137 (8.8%) in FMS and 20/225 (8.9%) in OA patients. All ANA positivity was at a low titre. Fourteen out of 20 (70%) FMS patients and 17/30 (56.7%) OA patients had three or more criteria (P = 0.34). No significant differences in the number of the positive criteria were found between those who were ANA positive or negative in both groups. On full assessment we found one patient who fulfilled the criteria for SLE from the ANA-positive FMS group and one in the ANA-negative group who fulfilled the criteria for primary Sjögren's syndrome. Of the patients with OA, one who was ANA positive was diagnosed as having rheumatoid arthritis. The results from our study show that ANA (at least in low titre) is not a good predictor of the future development of connective tissue.

A non-infective cause of recurrent purulent arthritis.

We describe a case of recurrent attacks of acute sterile pyogenic arthritis in a 66-year old man. Seven years after the first presentation the diagnosis of acute disseminated fatty necrosis (DFN) was made.

A case-control study examining the role of physical trauma in the onset of fibromyalgia syndrome.

OBJECTIVE: To investigate whether physical trauma may precipitate the onset of fibromyalgia syndrome (FMS). DESIGN: A case-control study was carried out to compare fibromyalgia out-patients with controls attending non-rheumatology out-patient clinics. METHOD: One hundred and thirty-six FMS patients and 152 age- and sex-matched controls completed a postal questionnaire about any physical trauma in the 6 months before the onset of their symptoms. RESULTS: Fifty-three (39%) FMS patients reported significant physical trauma in the 6 months before the onset of their disease, compared with only 36 (24%) of controls (P<0.007). There was no significant difference between FMS patients who had a history of physical trauma and those who did not have physical trauma with regard to age, sex, disease duration, employment status and whether their job at onset was manual. CONCLUSION: Physical trauma in the preceding 6 months is significantly associated with the onset of FMS.

Investigation of cutaneous microvascular activity and flare response in patients with fibromyalgia syndrome.

OBJECTIVES: To assess microvascular activity in the skin of patients with fibromyalgia syndrome (FMS) as compared with normal controls. METHODS: Fifteen patients, who fulfilled the American College of Rheumatology criteria for FMS, and 15 age- and sex-matched healthy controls, were studied. The microvascular activity of the skin overlying the trapezius muscle was quantified using iontophoresis of acetylcholine as an endothelial-dependent vasodilator and sodium nitroprusside as an endothelial-independent vasodilator. We also studied the flare response by iontophoresing acetylcholine continuously for 10 min to stimulate a ring of nociceptor c-fibre endings in the skin. RESULTS: There was no significant difference in cutaneous vascular responses to short-duration iontophoresis of acetylcholine and sodium nitroprusside at the three different doses used. The area under the curve (AUC) (mean+/-s.e.m.) for acetylcholine baseline, 20, 40, and 80 s were 6+/-0.7, 23+/-6, 45+/-7 and 66+/-10 AU for patients and 11+/-4, 24+/-3, 49+/-7 and 62+/-12 AU for controls, respectively (P=0.2, 0.9, 0.7, 0.8, respectively). The corresponding figures for sodium nitroprusside were 5+/-1, 18+/-7, 51+/-14 and 68+/-14 AU for patients and 8+/-3, 13+/-2, 39+/-5 and 61+/-9 AU for controls, respectively (P=0.2, 0.5, 0.4, 0.7, respectively). There was also no significant difference in the flare response in patients with FMS as compared with control subjects (119+/-15 and 131+/-13 AU, respectively; P=0.57). CONCLUSION: There are no significant differences in cutaneous microvascular reactivity between patients with FMS and control subjects.

Chest wall tenderness is unhelpful in the diagnosis of recurrent chest pain.

We investigated whether the presence of chest wall tenderness or fibromyalgia helped to distinguish between ischaemic and non-ischaemic chest pain. Seventy-one patients with recurrent chest pain, 36 with normal (group A) and 35 with abnormal coronary angiograms (group B), were assessed by investigator-administered questionnaires, and were examined for chest wall tenderness and fibromyalgia by a single blinded observer. Chest wall tenderness was greater in group A. However, it was much greater in women, who predominated in group A, than in men, who predominated in group B, and this explained the intergroup difference. Seven patients (25%) (six female, one male) in the group A and one patient (3%) (male) in group B (chi(2) p=0.027) fulfilled criteria for fibromyalgia. Patients with recurrent chest pain are more likely to have a ischaemic cause if they are male. Although our study suggests that chest wall tenderness alone in patients with recurrent chest pain has no value in excluding myocardial ischaemia as a cause, the confounding factor of gender prevents our study design from answering this question conclusively. Fibromyalgia is commoner in patients with chest pain and normal coronary angiograms, but may be related to the excess of females in this group. Its presence does not preclude the co-existence of ischaemic heart disease.

An observer-blinded comparison of supervised and unsupervised aerobic exercise regimens in fibromyalgia.

OBJECTIVE: To compare a supervised 12-week aerobic exercise class with unsupervised home aerobic exercises in the treatment of patients with fibromyalgia. METHODS: This was a 48-week randomized single (observer) blind study in a teaching hospital rheumatology and physiotherapy department. The subjects were 74 patients who fulfilled the American College of Rheumatology criteria for fibromyalgia. Results and conclusions. A 12-week exercise class programme with home exercises demonstrated no benefit over a single physiotherapy session with home exercises in the treatment of pain in patients with fibromyalgia. Neither group (nor the groups combined) showed an improvement in pain compared with baseline. There was some significant benefit in psychological well-being in the exercise class group and perhaps a slowing of functional deterioration in this group.

Acute non-purulent inflammatory arthropathy associated with Staphylococcus aureus abscess.

Case 1. A 20-year-old woman presented 4 weeks post-partum with widespread symmetrical inflammatory polyarthropathy with marked synovitis. Investigations revealed grossly raised CRP with negative immunology screen. A few days before presentation she saw her general practitioner with left-sided mastitis, which then developed into a Staphylococcus breast abscess. Surgical drainage of this led to almost immediate resolution of the joint complaints and return of CRP to normal. Case 2. A 27-year-old man developed widespread symmetrical inflammatory arthropathy. A few days prior to this he had developed folliculitis with a furuncle on his neck. Swab grew Staphylococcus aureus. His arthritis settled immediately following spontaneous drainage of his abscess and a full course of antibiotic. The pathogenic mechanism is unclear but could be toxin-mediated.

The risk of treatment. A study of rheumatoid arthritis patients' attitudes.

Despite its importance, there is no well-validated method of measuring patients' concept of 'acceptable' risk of medical treatment. Numerical methods give widely varying results depending on the methodology. We have attempted to assess 'acceptable' risk using relative comparisons. We administered a questionnaire to 67 patients with rheumatoid arthritis (RA). In general, patients' estimate of acceptable risk was less than the actual risk of treatment. Some illogical choices were made, showing poor understanding by patients of the concepts of risk and risk:benefit ratio. Patients appeared willing to accept higher levels of risk from procedures than from drug treatment. Willingness to accept risk in exchange for successful treatment of their RA did not correlate with disease severity, age, willingness to take non-medical risks or family responsibilities.

Low dose desensitisation does not reduce the toxicity of sulphasalazine in rheumatoid arthritis.

OBJECTIVE: To examine the proposal that pretreatment low dose desensitisation may reduce the incidence of toxicity of sulphasalazine in the treatment of rheumatoid arthritis (RA). METHODS: A double blind, placebo controlled trial was performed with 422 patients satisfying the American College of Rheumatology criteria for RA who required sulphasalazine treatment because of increased disease activity. Patients received either sulphasalazine desensitisation, or placebo, for three weeks before commencement of sulphasalazine treatment. The frequency and nature of adverse effects and changes in clinical and laboratory parameters of disease activity were measured after three and six months. RESULTS: Improvement in the efficacy of sulphalasazine (measured by clinical and laboratory parameters) was significant and similar in magnitude in both groups. There was no significant difference between actively and placebo desensitised patients as regards the incidence or profile of adverse effects (toxicity). CONCLUSION: Pretreatment low dose desensitisation is unhelpful in reducing the toxicity associated with sulphasalazine treatment of RA.

Assessment and referral patterns of patients admitted after deliberate self-poisoning.

The assessment and referral patterns of adult patients after deliberate self-poisoning in Dundee were examined. Questionnaires were completed by the admitting physicians and assessing psychiatrists over a 3 month period. Demographic data concerning the patients and the nature of self-harm were similar to previous studies. Initial referral rate was 95% but dropped to between 70% and 81% after the post receiving round. Up to 2 hours/day could be required for assessment and 75% of the cases required some form of psychiatric follow-up. Although both groups of doctors considered that the majority of patients required or would benefit from psychiatric referral, there was poor agreement when patients were independently categorised into high or low suicide risk (kappa = 0.04). Agreement was also low regarding whether referral was essential or not (kappa = 0.06). Although junior medical staff can play an important role in screening of patients, the psychiatric service, including trained nurses, may be best placed to provide a full assessment, where required.