Prevalence and clinical significance of extra-articular manifestations at diagnosis in the ESPOIR cohort with recent-onset arthritis.

OBJECTIVES: The aim of this study was to determine the prevalence and clinical significance of extra-articular manifestations (EAMs) at inclusion into a cohort of patients with recent-onset arthritis consistent with rheumatoid arthritis (RA). METHODS: The ESPOIR cohort included patients aged 18 to 70 years who had a definitive or probable diagnosis of RA. Symptoms consistent with EAMs were collected at baseline. We divided the patients into two groups, with vs. without baseline EAMs. We looked for associations linking the presence of EAMs at baseline to patient and disease characteristics at baseline and 5 years later, as well as to diagnostic certainty after 2 years. The analyses were adjusted for multiple comparisons using the Benjamini-Hochberg procedure to control the false discovery rate. RESULTS: Of 798 patients, 330 (41.4%) had at least one symptom consistent with EAM at baseline, with the most common being sicca syndrome (28.4%) and Raynaud's phenomenon (17.3%). The EAM+ group had a higher mean baseline DAS-28 value (5.3 ± 1.3 versus 5.0 ± 1.3; corrected p value = 0.005) compared to the EAM- group. The final diagnosis did not differ between the two groups. After 5 years, the EAM+ group had significantly higher values for the tender joint count (3.9 ± 6.4 versus 1.8 ± 3.3, corrected p value = 0.005) and swollen joint count (1.3 ± 2.8 versus 1.1 ± 2.3, corrected p value =0.0005) compared to the EAM- group. CONCLUSION: EAMs, particularly sicca syndrome and Raynaud's phenomenon, are very common in patients with early arthritis consistent with RA. In this population, several parameters reflecting disease activity were higher among patients with EAMs, at baseline and after 5 years.

Low body mass index in long standing rheumatoid arthritis: relation to RA disease activity and functional indices.

The aim of the work was to study the relationship between the body mass index (BMI) in longstanding rheumatoid arthritis (RA) and RA disease activity and functional indices. This study included 105 RA patients. For all patients, we recorded the presence of erosions on radiographs, the presence of subcutaneous nodules (SCN), the 28-tender joint count (TJC), 28-swollen joint count (SJC) scores, the visual analogue scale (VAS), physicians' global assessments (PhGA), the erythrocyte sedimentation rate (ESR), and the rheumatoid factor (RF). The disease activity index (DAS28) and BMI were calculated and current treatment was recorded. Patients were divided into two groups: group I: BMI 25. Group I included 32 (30.5%) patients, whereas group II included 73 (69.5%) patients. There were statistically significant differences between the two groups regarding each of the following: SJC (p=0.006), erosions (p=0.006), DAS28 (p=0.016) and PhGA (p=0.007). All were higher in group I (underweight and normal) than in group II (overweight and obese). No statistically significant differences emerged regarding age (p=0.11), smoking (p=0.69), disease duration (p=0.46), TJC (p=0.14), SCN (p=1.00), HAQ (p=0.26), VAS (p=0.16), ESR (p=0.25), RF (p=0.54) and steroid cumulative dose (p=0.08). Low BMI in longstanding RA patients may indicate more active and erosive disease and it may be considered as a poor prognostic factor.

Incidence and classification of cutaneous manifestations in rheumatoid arthritis.

BACKGROUND AND OBJECTIVE: There have only been few studies examining rheumatoid arthritis (RA)-related skin manifestations in larger patient populations. Herein, we present current data on the prevalence and spectrum of cutaneous lesions in RA, addressing disease activity scores, anti-CCP antibodies as well as novel pharmacological approaches. PATIENTS AND METHODS: Between November 2006 and July 2007, 214 patients with RA treated at the Division of Rheumatology, University Hospital Jena, Germany, were prospectively examined. RESULTS: 27.5 % of patients exhibited RA-related skin manifestations, almost all of which were rheumatoid nodules. These lesions occurred significantly more frequently in patients with longstanding disease, those testing positive for rheumatoid factor and anti-CCP-antibodies, as well as individuals on leflunomide and TNF-alpha antagonists. Comparatively lower prevalence rates were observed for palisading neutrophilic and granulomatous dermatitis and rheumatoid vasculitis. CONCLUSIONS: Despite increasingly early treatment of RA and use of novel pharmacological agents, there is a high prevalence of rheumatoid nodules, which represent the most common cutaneous manifestation in RA. The higher prevalence of rheumatoid nodules in patients on leflunomide and TNF-alpha antagonists might be an indication that pharmacological treatment has only limited effects on their formation, possibly due to pathogenetic pathways that are only inadequately affected by drug therapies. By contrast, palisading neutrophilic and granulomatous dermatitis and rheumatoid vasculitis appear to respond better to novel pharmacological agents.

Relationship of EQ-5D quality of life with the presence of co-morbidity and extra-articular features in patients with rheumatoid arthritis.

PURPOSE: Rheumatoid arthritis (RA) is associated with extra-articular features (ExRA) and other co-morbidities. The aim of this study is to quantify their relative contribution to quality of life (QOL) in patients with RA. METHODS: A consecutive series of 114 ambulatory RA patients aged between 40 and 65 years were assessed by a research nurse on a single occasion. Assessment included a patient questionnaire (including EQ-5D), medication review and fasting venous blood sample. Medical records were reviewed by a rheumatologist for co-existing conditions. Multiple linear regression was used to adjust mean differences in EQ-5D in the presence/absence of co-existing conditions for age, sex, university education, arthritis duration, rheumatoid factor, erythrocyte sedimentation rate, current disease-modifying drug therapy, previous hand joint erosions and joint surgery. RESULTS: Mean age was 54 years (82% female) and median arthritis duration 10 years. Unadjusted EQ-5D was -0.09 (95% CI -0.18 to -0.01) lower in patients with any co-existing condition. EQ-5D scores were inversely correlated with the overall number of co-existing conditions (Spearman's ρ -0.31, p = 0.001), number of co-morbidities (ρ -0.22, p = 0.02) and number of ExRA features (ρ -0.22, p = 0.02). There was a linear trend of lower EQ-5D with increasing number of co-existing conditions (p = 0.003). EQ-5D was -0.18 (95% CI -0.33 to -0.02) lower in the presence of more than two co-existing conditions compared to none. Co-morbidity and ExRA features were associated with comparable adjusted reductions (-0.05 vs. -0.06) in EQ-5D scores. CONCLUSION: A wide range of co-existing conditions are associated with poorer QOL in patients with RA.

Pulmonary rheumatoid nodules: presentation, methods, diagnosis and progression in reference to 5 cases.

Rheumatoid nodules are a rare manifestation of lung disease associated with rheumatoid arthritis (RA). Their emergence and evolution in the course of the disease is variable. The diagnosis of pulmonary rheumatoid nodules may be suggested if they have a typical appearance in an appropriate clinical context, but an accurate diagnosis cannot be made based only on imaging tests. It is recommended to follow nodules and may be necessary to histologically differentiate them from tumors.

Association of anticyclic citrullinated peptide antibodies with extra-articular manifestations, gender, and tabagism in rheumatoid arthritis patients from southern Brazil.

Gender and environmental factors are known to influence the clinical heterogeneity and outcome of rheumatoid arthritis (RA). Some variables have been suggested to be associated with the severity of the disease, which can be of great value in the correct management of RA patients. The purpose of this study was to investigate the associations among anticyclic citrullinated antibody (anti-CCP2) positivity, extra-articular manifestations (EAM), gender, and tobacco exposure in a Brazilian RA population. We performed a transversal study comprising 156 RA patients which were investigated for EAM, functional class, presence of anti-CCP2, and IgM rheumatoid factor (IgM-RF). The determination of anti-CCP2 was performed using enzyme immunoassay (ELISA) kits and IgM-RF by latex agglutination test. Clinical and demographical data were obtained through review of charts. Anti-CCP positivity intensity was directly correlated with tobacco smoking, sex, and the development of rheumatoid nodules. Intense anti-CCP2 reaction was 19.8-fold higher in females vs. males, 2.7-fold higher in tobacco vs. non-tobacco users, 7.7-fold higher in female vs. male tobacco users, and 5.15-fold higher in patients with rheumatoid nodules. Tobacco smoking, gender, and rheumatoid nodules are significantly correlated with anti-CCP2 positivity in Brazilian RA patients.

Skin manifestations of rheumatoid arthritis: a study of 215 Turkish patients.

OBJECTIVE: To investigate the frequency and clinicopathological features of skin involvement in rheumatoid arthritis (RA), to find out whether early and aggressive disease-modifying treatment is changing the spectrum towards a milder disease pattern. METHODS: Two hundred and fifteen consecutive RA patients were enrolled. Main outcome measures were the frequency of cutaneous features and their relation to disease severity and treatment modality, ultrasound (USG) examination of nodules, histopathological examination of nodules and papules. RESULTS: Mean age and disease duration were 55.3 years and 138.1 months, respectively. Sixty-six percent of the patients had erosive disease, 70% were rheumatoid factor (RF) positive and 44% had Classes III and IV functional index. Among 43 patients having nodules, 20 were diagnosed as rheumatoid nodules (RNs) and the others as synovitis, bursitis, and so on, on clinical basis and by ultrasound. In 7 of 20 RNs, diagnosis was confirmed by histopathological examination. When clinical, histopathological, and USG data were analyzed collectively, sensitivity, and specificity of USG were found as 100 and 75%, respectively. Sixteen patients had relevant papular lesions. Fourteen of these were diagnosed as palisading neutrophilic granulomatous dermatitis (PNGD) and two as rheumatoid neutrophilic dermatitis (RND) on histopathological examination. Accelerated nodulosis was seen in one, and vasculitis in two of the patients. CONCLUSIONS: We observed a milder disease pattern compared to Anglo-Saxon countries with lower RN and vasculitis frequency. This cannot be explained by early and aggressive treatment as disease onset to treatment interval was long in our patient group. PNGD resembles RN in terms of frequency and association with severe disease.

Smoking is a strong risk factor for rheumatoid nodules in early rheumatoid arthritis.

OBJECTIVE: To examine whether smoking is a risk factor for rheumatoid nodules in early rheumatoid arthritis, and if so to determine the quantitative effect of smoking. METHODS: From a cohort (n = 1589) in a structured programme for follow up of newly diagnosed cases of rheumatoid arthritis (symptoms of swollen joints < or =12 months), 112 individuals with rheumatoid nodules at inclusion were identified. Nodular patients were each compared with two age and sex matched controls without nodules from the same cohort. A detailed self administered tobacco use questionnaire was answered by 210 patients (63%). RESULTS: Seventy patients were current smokers, 71 former smokers, and 69 had never smoked. Current smoking and former smoking were more common in patients with rheumatoid nodules compared with controls (86% v 59%) in both sexes. Positive rheumatoid factor (RF) was found more often among cases with nodules than controls (78% v 64%). Using detailed information from the questionnaires with conditional logistic regression analyses, ever having smoked was associated with an increased risk of the presence of rheumatoid nodules (odds ratio (OR) = 7.3 (95% confidence interval, 2.3 to 23.6); p = 0.001). The risk of having nodules was not obviously dose dependent when smoking duration as well as smoking amount were examined. A stratified analysis showed that only RF positive smokers had an increased risk of rheumatoid nodules. Smoking was associated with rheumatoid nodules among both men (p = 0.006) and women (p = 0.001). Tobacco use other than smoking (n = 31) was not associated with an increased risk of nodules (OR = 0.8 (0.2 to 3.4); p = 0.813). CONCLUSIONS: There is a strong association between smoking and rheumatoid nodules in early seropositive rheumatoid arthritis.

Rheumatoid necroses in the forefoot.

BACKGROUND: The incidence and morphological features of rheumatoid necroses (RN) in the forefoot are unknown. METHODS: Biopsy material from 223 patients with seropositive rheumatoid arthritis (RA) was examined morphologically. The incidence and morphological features of RN in the forefoot were evaluated. RESULTS: RN was found in 65% of cases, which had not been suspected clinically. It was correlated with pain in 69% of cases. CONCLUSIONS: Rheumatoid necrosis contributes to the development of pain and foot deformation. It can be a significant factor worsening the clinical behavior in seropositive RA patients.

Rheumatoid arthritis in Spain: occurrence of extra-articular manifestations and estimates of disease severity.

OBJECTIVES: To characterise RA in a sample of Spanish patients by estimating mean clinical activity, functional ability, and radiological damage, and current and cumulative prevalence of extra-articular manifestations. METHODS: Cross sectional analysis of a cohort of patients with RA randomly selected from the clinical databases of 34 centres. Standard definitions and measurements were used, and radiographs read centrally. Estimates and confidence intervals were adjusted to sampling. RESULTS: Data were available for 788 patients. Extra-articular RA was present in 285 (36.2%) patients. Cumulative prevalence and 95% confidence intervals of extra-articular manifestations were estimated: nodules 24.5% (21.5 to 27.5), Sjögren's syndrome 17.0% (14.4 to 19.6), atlantoaxial subluxation 12.1% (9.8 to 14.4), carpal tunnel syndrome 10.7% (7.8 to 13.6), interstitial lung disease 3.7% (2.4 to 5.0), serositis 2.5% (1.4 to 3.5), eye disease 2.5% (1.1 to 3.9), vasculitis 1.3% (0.5 to 2.1), amyloidosis 0.6% (0.1 to 1.2), and Felty's syndrome 0.3% (<0.6). Mean (SD) activity/progression indexes were: DAS28-3 3.4 (1.2), HAQ 1.6 (0.4), Larsen score 54.7 (26.4). Less than 5% of the patients were in remission. 205 (72%) patients were receiving disease modifying antirheumatic drugs (DMARDs). CONCLUSION: Spanish patients with RA ever seen by a rheumatologist have, on average, a moderate degree of activity, despite widespread use of DMARDs. Measures of the degree of progression do not show a benign disease. The proportion of extra-articular manifestations in Spanish patients with RA is similar to that found in other Mediterranean populations, and lower than that reported in Anglo Saxon countries.

Extra-articular disease manifestations in rheumatoid arthritis: incidence trends and risk factors over 46 years.

OBJECTIVE: To investigate the trends in incidence of extra-articular rheumatoid arthritis (ExRA) in a well defined community based cohort of patients with rheumatoid arthritis (RA), and to examine possible predictors of ExRA occurrence. METHODS: Using the resources of the Rochester Epidemiology Project, a retrospective medical record review was conducted of a cohort of 609 cases of RA in Olmsted County, MN, diagnosed during 1955-94. These cases had been previously classified using the ACR 1987 criteria for RA. Patients were followed up from 1955 to 2000 (median follow up 11.8 years; range 0.1-42.8), and incident ExRA manifestations were recorded according to predefined criteria. Time to first presentation of ExRA was compared in patients with RA by decade of diagnosis. Possible ExRA risk factors were identified in case record reviews. RESULTS: ExRA occurred in 247 patients (40.6%). A subgroup of 78 patients (12.8%) had ExRA manifestations considered to be severe in a previous study from Malmö, Sweden. The incidence of severe ExRA did not change significantly over the decades (p=0.165). In a multivariate analysis the main predictors of severe ExRA were smoking at RA diagnosis (risk ratio (RR)=2.94; 95% confidence interval (95% CI) 1.68 to 5.13) and early disability (Steinbrocker class III-IV at diagnosis) (RR=2.45; 95% CI 1.51 to 4.00). The effect of smoking overwhelmed the weaker effect of rheumatoid factor seropositivity. CONCLUSION: There was no decrease in the incidence of extra-articular manifestations in patients with RA diagnosed up to 1995. Smoking and early disability are independent risk factors for extra-articular RA.

Incidence of rheumatoid nodule in Dalmatia: similarities and differences among populations.

BACKGROUND: The specific aim of our study was neither prognosis nor long-term evaluation but focus on determining incidence of rheumatoid nodules (RN) in a large population of patients with rheumatoid arthritis (RA) on the coastline of Croatia (Dalmatia) within a certain range. We compared our data with those published previously in the literature. METHODS: Our study was focused on determining incidence of RN occurrence in patients with rheumatoid arthritis in Dalmatia, Croatia by comparing these figures with data reported elsewhere and evaluating its importance in the process of diagnosing RA. The duration of the study was 10 years (1991-2001). There were 421 patients (344 women and 77 men) with confirmed RA diagnosis. Median follow-up time was 2 years (range: 1.4-3.5 years). RESULTS: Existence of RN was established by clinical examination in 109 of 421 patients; incidence density was 17.3%. RN occurred somewhat more frequently in men (32%) as compared to women (24%) without statistically significant difference. In 38% of patients, RN occurred simultaneously in several sites, more frequently in men (64%) than in women (30%) (odds ratio [OR] 2.13, p <0.05). Correlation of seropositivity and RN appearance was very high: positive in 84% of patients with nodules as compared to 58% of patients without nodules (OR 1.45, p <0.05) with no statistically significant differences between sexes. CONCLUSIONS: Results obtained warrant the conclusion that RN incidence in our patients from Dalmatia is comparable with results of earlier Croatian studies as well as with Western European figures and Caucasian population data reported on other continents. RN incidence differs significantly for Asian and Arabian populations, i.e., is less frequent, and for the U.S. population, where it is more frequent.

A cross sectional study of the association between sex, smoking, and other lifestyle factors and osteoarthritis of the hand.

OBJECTIVE: To describe the association between sex, smoking, physical activity, occupation, and previous digit fracture and hand osteoarthritis (OA). METHODS: Cross sectional study of 522 subjects from 101 Tasmanian families (348 women, 174 men). Hand OA was assessed by 2 observers using the OARSI atlas for joint space narrowing and osteophytes at distal interphalangeal (DIP) and carpometacarpal joints as well as a score for Heberden's nodes based on hand photography. A structured questionnaire collected information regarding physical activity, sport participation, occupation, and smoking history. RESULTS: Women had a higher prevalence of hand OA and the increase with age was significantly higher for women at all sites (all p < 0.05). Ever smoking was associated with less frequent (OR 0.59, 95% CI 0.38, 0.92) and less severe Heberden's nodes (beta -0.60, 95% CI -1.03, -0.17), but not radiological disease. Recall of occupation, physical activity, and sport participation between the ages of 20 and 40 years had no association with the prevalence or severity of hand OA, while self-reported digital fracture was significantly associated with more common (OR 2.42, 95% CI 1.22, 4.83) and severe DIP joint disease (beta +3.92, 95% CI +1.50, +6.36). No factors were associated with carpometacarpal disease. CONCLUSION: In this sample, women had a higher prevalence of hand OA at all sites as well as greater severity and a steeper age gradient (implying higher incidence rates). Smoking may decrease the risk of Heberden's nodes while having no effect on radiological hand OA, suggesting a differential effect possibly at the time of disease onset. With the exception of digital fracture, these data do not support a causal role for occupation or activity in earlier life with regard to hand OA.

Extra-articular manifestations in 587 Italian patients with rheumatoid arthritis.

The aim of the study was to evaluate the frequency of extra-articular manifestations (EAMs) of rheumatoid arthritis (RA) in a series of patients from nine Italian rheumatology clinics. A total of 587 patients underwent direct questioning, complete physical evaluation, and review of medical records and laboratory data. The relationships between EAMs and the eosinophilic count, IgM rheumatoid factor (RF), and antinuclear antibodies (ANA) were studied. EAMs were present in 240/587 (40.9%) patients. The most common features were sicca syndrome (17.5%) and rheumatoid nodules (16.7%). EAMs were significantly more frequent in male patients (OR = 1.68), patients with ANA positivity (OR = 2.82), high anatomical class (OR = 2.3), and rheumatoid factor seropositivity (OR = 2.22). EAMs were more common in patients from southern Italy than in those from northern Italy (P < 0.001). EAMs seem to be rarer in Italy than in the Anglo-Saxon populations of northern Europe and the USA. Differences in prevalence of EAMs can exist even within the same country.

Identification and prevalence of rheumatoid nodules in the finger tendons using high frequency ultrasonography.

OBJECTIVE: Rheumatoid nodules are classical diagnostic feature of rheumatoid arthritis (RA). The prevalence of rheumatoid nodules in the finger tendons is not known. We determined the prevalence of rheumatoid nodules of finger tendons in patients with RA, using high frequency linear transducers with high resolution ultrasonography. METHODS: The study comprised 54 consecutive patients with RA and 20 controls. Dynamic ultrasound examination of various tendons was performed using real-time equipment, the Apogee 800 ATL, with an 11 MHz linear array transducer. RESULTS: RA nodules were identified in 9 patients (16.66%); their sizes ranged from 0.21 to 0.95 cm (mean 0.35+/-0.12 cm), in 4 cases (7.4%) the nodules were intratendinous. The flexor tendons were affected in the 9 patients. The finger tendon ultrasonography identified RA nodules that had escaped routine clinical detection. CONCLUSION: The ultrasonography technique was valuable in the confirmation of rheumatoid nodule involvement of the finger tendons. The prevalence of rheumatoid nodule in finger tendons was 16.66%. We believe that ultrasonography should be the screening procedure of choice for diagnosis of RA nodules of the fingers.

[Occurrence of subcutaneous rheumatoid nodules in patients with rheumatoid arthritis in Croatia]. / Ucestalost pojave potkoznih reumatoidnih cvorica u bolesnika s reumatoidnim artritisom u Hrvatskoj.

The subcutaneous rheumatoid nodules (RN) have been recognized by the American Rheumatism Association, both in 1958 and in 1987, as one of the diagnostic criteria (ARA criteria) among other rheumatoid arthritis (RA) symptoms. The aim of this research has been both to provide the incidence of occurrence of RN in patients with RA in Croatia and to determine its significance in making the RA diagnose. The test group comprised 233 patients (182 women and 51 men) with RA, their average age being 48.3 years in the range of 18 to 77. Both the anamnesis and the clinical examination have determined the occurrence of RN in 54 (23.2%) of 233 patients. The range of occurrences was more evident in men (31.4%) than in women (20.8%), though this difference was statistically irrelevant. The most common localization of benign rheumatoid nodules was the exterior side of elbow and PIP hand joints. The obtained results prove that the incidence of RN in our tested patients with RA can be compared with those of the earlier researches done in Croatia (18.1% Jajic, Vlak; 20-25% Jajic), as well as with those obtained in the western European countries (20% Doherty, George; 25% Ziff; 20-25% Miehle; 21% Wolf et al.).

Clinical, laboratory, and radiographic features of rheumatoid arthritis with and without nodules.

To determine the significance of nodules in rheumatoid arthritis, we reviewed the medical records of 420 patients who underwent standardized clinical, laboratory, and radiological investigations during a hospitalization for rheumatoid arthritis between January 1, 1981 and December 31, 1994. Sixty-six patients (16%) had nodules and 354 (84%) did not. Age and gender distributions were similar in the two groups. Disease duration was significantly longer in the nodular than in the nonnodular group (11.3 +/- 9.4 years versus 7.6 +/- 7.3 years; P = 0.0003). When patients were stratified into five-year disease duration groups, dryness of the eyes and mouth was found to be more common in the nodular group, with the difference being largest during the first five years. Patients with nodules were more likely to have vasculitis irrespective of disease duration (odds ratio, 6.08; P = 0.028). Lee's and Ritchie's indices and radiographic alterations were more severe in the nodular group, whereas tests for inflammation were not significantly different. Patients with rheumatoid factors accounted for a larger proportion of the nodular than of the nonnodular group (odds ratio 2.48; P = 0.017). When patients were dichotomized based on latex test results, nodules were not significantly associated with antiperinuclear factor or antikeratin antibodies, whereas patients with nodules were significantly more likely to have vasculitis (odds ratio 5.3; P = 0.035), antinuclear factors (odds ratio 1.82; P = 0.043), and cryoglobulinemia (odds ratio 4.86; P = 0.0029). As compared with nonnodular rheumatoid arthritis, nodular rheumatoid arthritis was associated with more severe extraarticular disease, faster radiographic progression and a greater likelihood of rheumatoid factor and antinuclear antibody production. Each of these characteristics was associated with the presence of nodules independently from disease duration and rheumatoid factor positivity.

Nodulosis reumatoidea: un subtipo de artritis reumatoidea

Ocurrence of subcutaneous nodules in rheumatic diseases is frequent, and occasionally may be source of diagnostic confusion. These nodules are also seen in other entities such as collagen vascular diseases, metabolic and storage diseases, infections, induced by chemicals, and sometimes of unkown etiology. Subcutaneous nodules are usually asociated to systemic diseases and given its charasteristic, location, and histopathology it is possible to make a specific diagnosis. This review discusses in a minute fashion the history, histopathology, and diagnosis of subcutaneous nodules. In addition several clinical cases are reported and discussed

Subcutaneous nodules in acute rheumatic fever--an analysis of age old dictums.

It is assumed that subcutaneous nodule (SCN), one of the major criteria in acute rheumatic fever (ARF), is rare and whenever these nodules appear, they are invariably associated with carditis. Further large number of nodules appear in crops and they are evanescent. This prospective study of 42 cases of ARF with SCN attempts to analyse the accuracy of such statements. The group comprised of 12.5% of 336 consecutive cases of ARF. Other major criteria associated with SCN were carditis in 38 (90.4%), arthritis in 33 (78.5%) and chorea in two (4.7%). No evidence of carditis could be found in 4 (9.5%). When a detailed study of SCN was done the average number of nodules found in the group was 18 (range 4-49). Thirteen (30.9%) had less than 10 nodules and 5 (11.9%) had only 4-5 nodules. With initiation of treatment SCN disappeared within 4 weeks in 29 (69%), within next 5-8 weeks in 8 (19%) and within 9-12 weeks in 3 (7.1%). In two cases (4.7%) multiple nodules were observed 12 weeks later when all other evidences of activity had disappeared. The study shows a comparative high incidence of SCN in ARF, not all being associated with carditis. Number of nodules appearing in ARF might be quite small and they could persist for long inspite treatment.

Nodules of the shoulder girdle in two Indonesian villages.

During a community survey of rheumatic complaints in a Javanese rural population, fibrous shoulder girdle nodules having a consistent form and position were observed in seven men. This was 2.3% of 303 men with complaints examined from a total population of 2184 men surveyed by house-to-house interviews (response rate 95.2%). Nodules were not seen in any of the 640 women examined with complaints from a total population of 2499, nor were they seen in 130 men and 159 women with complaints from an urban population of 481 men and 590 women over the age of 15 years. It was considered most likely that these shoulder nodules were the result of longstanding repetitive mechanical irritation due to carrying heavy loads by a resilient wooden pole balanced across the shoulder.