Adalimumab for sight-threatening uveitis in Behçet's disease.

AIMS: To describe the clinical outcome of three patients with Behçet's disease maintained on infliximab who were switched to adalimumab therapy. METHODS: Case note review. Main outcome measure was recurrence of uveitis. RESULTS: All patients remained free of recurrence with stable visual acuities. CONCLUSIONS: Adalimumab appears to maintain disease remission in Behçet's disease.

Prevalence of incontinence in women with benign joint hypermobility syndrome.

The objective of this study was to determine whether the prevalence of urinary and anal incontinence in women with benign joint hypermobility syndrome (BJHS) was more than in a control group without this condition. The International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) and the Manchester Health Questionnaire were sent to 30 patients with benign joint hypermobility syndrome and 30 healthy women without this condition and results were compared. It was found out that the prevalence of urinary incontinence in the study group we surveyed was 18/30 and in the control group was 9/30 (60 vs 30%; p=0.037). Twenty-three percent (7/30) of the women with BJHS had a problem with anal incontinence but none of the controls had problems with anal incontinence (23 vs 0%; p=0.01). Therefore, the prevalence of both urinary and anal incontinence appears to be significantly higher in women with BJHS when compared to women without this condition.

Ultrasound guidance allows accurate needle placement and aspiration from small joints in patients with early inflammatory arthritis.

OBJECTIVES: To compare the accuracy of palpation-guided and high frequency ultrasound-guided needle placement in small joints and to develop a technique to obtain synovial fluid from these joints for diagnosis and research. METHODS: The accuracy of needle placement during palpation-guided proximal interphalangeal (PIP) or metacarpophalangeal (MCP) joint injection was assessed. This was compared with the accuracy of ultrasound-guided needle placement. A joint lavage technique was developed to obtain synovial fluid from these joints. RESULTS: Needle positioning was intra-articular in 59% of palpation-guided injections (6/12 PIP and 4/5 MCP joints). No fluid could be aspirated prior to injection. With ultrasound guidance, initial needle placement was intra-articular in 96% of cases (24/26 PIP and 27/27 MCP joints). Synovial fluid cells were lavaged from 63% of joints (19/25 PIP and 14/27 MCP joints). In only one case was a large effusion seen and this was aspirated directly. CONCLUSIONS: The use of high frequency ultrasound to guide needle placement within a small joint allows for significantly greater accuracy than a palpation-guided approach. When followed by lavage, synovial fluid cells and diluted synovial fluid can be obtained from the majority of small joints. This has important clinical and research implications.

A regional audit of the prevention and treatment of corticosteroid-induced osteoporosis in patients with rheumatic diseases in the West Midlands.

BACKGROUND: Audit is an important tool in clinical governance. Combining resources from across a region may facilitate data collection and allow variation in practice between individual units to be analysed. This audit is the first such regional audit to be carried out in rheumatology in the West Midlands and the organization and value of regional audit is discussed. This audit assessed the prevention and management of corticosteroid-induced osteoporosis (CIOP). METHODS: Adult patients attending rheumatology follow-up clinics in 10 units, during a 2-week period were assessed using the 1998 National Osteoporosis Society (NOS) guidance on the prevention and management of CIOP. The audit standard adopted was that 80% of eligible patients should be on appropriate therapy. RESULTS: Data was collected on 1766 (95.2%) of 1855 patients during the audit period. Two hundred and thirty-five (13.3%) were currently being prescribed or about to commence >or=7.5 mg daily of oral prednisolone for >or=6 months. Dual X-ray absorptiometry scans were performed in 102 patients (43.4%). Of these, 53 (52%) had a T score of -1.5 or below at the hip or spine. Of the 235 patients, 202 (86%) were receiving osteoporosis treatment. One hundred and forty-eight patients (63%) were receiving appropriate osteoporosis medication according to the NOS 1998 guidelines and 87 (37%) were inappropriately treated. Of these, 71 (81.6%) were under-treated and 16 (18.4%) were over-treated. CONCLUSIONS: Overall, the Region failed to meet the audit standard. The audit highlighted a number of differences and potential problems in the West Midlands with regard to CIOP which are currently being addressed by individual units and the West Midlands Rheumatology Services and Training Committee (WMRSTC). The Committee plan to re-audit in 2 yr.

Fcgamma receptor type IIIA is associated with rheumatoid arthritis in two distinct ethnic groups.

OBJECTIVE: To investigate a possible association between a functional polymorphism in the intermediate-affinity receptor for IgG called Fc-gamma receptor type IIIA (FcgammaRIIIA [CD16]) and rheumatoid arthritis (RA). METHODS: This was an allelic association study in which a single nucleotide polymorphism in FcgammaRIIIA was examined as a susceptibility and/or severity factor for RA. The FcgammaRIIIA-158V/F polymorphism was genotyped by direct sequencing in 2 well-characterized ethnic groups, UK Caucasians (141 RA patients and 124 controls) and North Indians and Pakistanis (108 RA patients and 113 controls). RESULTS: The FcgammaRIIIA-158V/F polymorphism was associated with RA in both ethnic groups (P = 0.028 for UK Caucasians, P = 0.050 for North Indians and Pakistanis, and P = 0.003 for both groups combined). FcgammaRIIIA-158VF and -158W individuals had an increased risk of developing RA in both populations (UK Caucasians odds ratio [OR] 1.6, P = 0.050; North Indians and Pakistanis OR 1.9, P = 0.023; and combined groups OR 1.7, P = 0.003). In the UK Caucasian group, the highest risk was for nodular RA, a more severe disease subset, associated with homozygosity for the FcgammaRIIIA-158V allele (OR 4.4, P = 0.004). There was also evidence for an interaction between the RA-associated HLA-DRB1 allele and the presence of at least 1 FcgammaRIIIA-158V allele in predicting susceptibility to RA (OR 5.5, P = 0.000). CONCLUSION: We have demonstrated that the FcgammaRIIIA-158V/F polymorphism is a susceptibility and/or severity marker for RA in 2 distinct ethnic groups. This finding may ultimately provide additional insights into the pathogenesis of RA and other autoantibody/immune complex-driven autoimmune diseases.

Racial origin and its effect on disease expression and HLA-DRB1 types in patients with rheumatoid arthritis: a matched cross-sectional study.

OBJECTIVE: There are a significant number of patients with rheumatoid arthritis (RA) of North Indian or Pakistani origin (Asian) now living in the UK. RA has been poorly studied in this racial group. The aim of this study was to compare RA in this Asian group with RA in the indigenous northern European (European) population. It was hypothesized that these two racial groups would have different disease expressions and immunogenetics that could be relevant to pathogenesis, prognosis and therapy. METHODS: One hundred and seven Asian RA patients, who fulfilled the 1987 American College of Rheumatology criteria, were stringently matched for age, sex and disease duration with 107 European RA patients, and were fully assessed. RESULTS: The Asian RA patients had significantly fewer bony erosions [median Larsen score 58.5 (interquartile range 45.5-77.8) vs 68 (52-93) for European patients; P: = 0.0066, Mann-Whitney U:-test] and rarely had nodules (5.7 vs 20%, P: = 0. 0019, Fisher's exact test). The two groups had the same prevalence of rheumatoid factor positivity, number of swollen joints and level of inflammation (C-reactive protein). The Asian RA patients had a reduced prevalence of the conserved third allelic hypervariable region (3AHVR) (45 vs 82%, P: < 0.0001, Fisher's exact test), particularly DRB1*0401 (4.5 vs 55%). However, the prevalence of the conserved 3AHVR was significantly increased in the Asian RA patients compared with Asian controls. By contrast, the Asian patients had more tender joints [13.5 (7-22) vs 5.5 (2-11.8); P: < 0.0001 Mann-Whitney U:-test]. The Health Assessment Questionnaire score was also significantly worse in the Asians compared with the Europeans [median 2.0 (1.13-2.63) vs 1.25 (0.5-2.13), P: = 0.0001). CONCLUSIONS: The Asian patients had similar levels of inflammation and less damage but more pain and disability than the matched European RA patients. Of the known prognostic factors for erosions (rheumatoid factor, conserved 3AHVR, swollen joints and C-reactive protein), only the conserved 3AHVR was reduced in the Asian RA patients, and this was consistent with their less erosive disease. These data also indicate the importance of pain as well as erosive damage in determining disability in Asian patients and stress the importance of adequate pain relief, in addition to disease suppression, when treating Asian RA patients.

Safety and tolerability of conversion from stable Sandimmun maintenance treatment to Sandimmun Neoral in patients with rheumatoid arthritis.

OBJECTIVE: To assess the safety and tolerability of converting patients with rheumatoid arthritis (RA) taking a stable dose of cyclosporin A (CyA) maintenance treatment (Sandimmun, SIM) to a new microemulsion capsule formulation, Sandimmun Neoral (Neoral), at an initial dose of 2.5 mg/kg/day. METHODS: In this single arm, open multicenter study, 28 patients were recruited to enter a 6 week pre-conversion period; of these, 22 patients completed 12 weeks' treatment with Neoral. RESULTS: During the 12 week post-conversion period, 11 patients experienced adverse events considered to be drug related; most were mild to moderate in severity and reflected the known safety profile for CyA. Only slight differences in efficacy variables were observed after conversion. The mean Neoral dose at Week 12 (2.84 mg/kg/day) was lower than the mean SIM pre-conversion dose (3.38 mg/kg/day). The study showed that, in patients with RA undergoing stable SIM maintenance treatment, conversion to an initial Neoral dose of 2.5 mg/kg/day did not give rise to any clinically relevant safety and tolerability concerns, and efficacy of the treatment was maintained compared with SIM. CONCLUSION: This conversion strategy constitutes a clinically acceptable alternative to a 1:1 dose conversion.

Sjögren's syndrome in women presenting with chronic dyspareunia.

OBJECTIVE: To identify cases of Sjögren's syndrome among women with chronic dyspareunia who did not already have a diagnosed rheumatological disorder. DESIGN: Prospective recruitment over 12 months. SETTING: Tertiary referral service for the assessment of vulval disease. PARTICIPANTS: Women with chronic dyspareunia who had musculoskeletal symptoms, Raynaud's phenomenon or symptoms of ocular or oral dryness. METHODS: The women underwent a Schirmer tear test and a comprehensive auto-antibody screen including latex fixation test for rheumatoid factor, antinuclear, anti-Ro, anti-La and anti-salivary duct antibodies. A labial salivary gland biopsy and vaginal biopsy were taken for routine histological analysis. MAIN OUTCOME MEASURES: Cases of definite and probable Sjögren's syndrome were identified using the European criteria. RESULTS: Eleven women were assessed for features of Sjögren's syndrome. Four had definite primary Sjögren's syndrome, two had probable primary Sjögren's syndrome and one had probable secondary Sjögren's syndrome. Among these seven women the median duration of vaginal symptoms was seven years (range 0.25-20), of ocular symptoms was one year (range 0.25-2) and of oral symptoms was 1.5 years (range 0-6). In all but one woman dyspareunia presented before ocular or oral symptoms, often by many years. CONCLUSIONS: Although well-recognised as a feature of established Sjögren's syndrome, this study emphasises that chronic dyspareunia can be a presenting feature in these women, antedating the emergence of ocular or oral symptoms by many years. Symptoms of ocular or oral dryness, Raynaud's phenomenon or musculoskeletal symptoms should be sought in women with chronic dyspareunia to identify those who merit further investigation.

Do gold rings protect against articular erosion in rheumatoid arthritis?

OBJECTIVE: To examine the hypothesis that gold rings might delay articular erosion at the metacarpophalangeal (MCP) joint of the left ring finger in ring wearers with rheumatoid arthritis (RA). METHODS: Consecutive patients with RA were recruited. They were classified as ring wearers if they had worn a gold ring on the left ring finger throughout most of the time since disease onset, or as non-ring wearers if they had never worn a gold ring. Standard hand radiographs (with rings removed, where possible) were taken and articular erosion was quantified at the MCP and proximal interphalangeal joints. RESULTS: Thirty ring wearers (27 female) and 25 non-ring wearers (12 female) were included. The median (25th-75th centile) Larsen score in the left hand ring MCP joint of ring wearers was 1.0 (1.0-2.0), which was significantly less than in their equivalent right hand joint (1.0, 1.0-5.0, p = 0.01). It also tended to be less than the equivalent left hand joint of non-ring wearers (4.0, 1.0-5.0, p = 0.06), with a similar but significant difference observed at the adjacent middle finger MCP joint (p = 0.01). CONCLUSIONS: The results of this preliminary study suggest that there may be less articular erosion at the left hand ring, and perhaps adjacent, MCP joints observed in ring wearers with RA. These data support the hypothesis that gold could pass from a gold ring through skin and local lymphatics 'downstream' to nearby MCP joint in sufficient quantities to delay articular erosion.

Polyarthropathy, orbital myositis and posterior scleritis: an unusual adverse reaction to influenza vaccine.

We report a patient who developed an acute symmetrical polyarthropathy, orbital myositis and posterior scleritis following inoculation with the 1993 Fluvirin (inactivated influenza vaccine: surface antigen) vaccine. We believe that this represents a hypersensitivity reaction to the vaccine as extensive investigations revealed no underlying infective, inflammatory or systemic cause. We review the current indications for vaccination against the influenza virus and the known adverse reactions to the vaccine.

Glutathione reductase activity, riboflavin status, and disease activity in rheumatoid arthritis.

OBJECTIVE: To measure erythrocyte glutathione reductase (EGR) activity and riboflavin status, and their relations to disease activity, in rheumatoid arthritis patients compared to healthy controls. METHODS: Patients with rheumatoid arthritis were classified as active if there were features of articular inflammation which required initiation or change of disease modifying therapy, and as inactive if they had little evidence of articular inflammation. EGR was measured in patients and healthy controls by a functional assay with or without the addition of flavin adenine dinucleotide (FAD). The ratio of stimulated EGR (with FAD added) to basal EGR (no added FAD), which measures riboflavin status, is known as the EGR activation coefficient (EGRAC). An EGRAC > or = 1.3 represents biochemical riboflavin deficiency. RESULTS: 91 patients with rheumatoid arthritis, including 57 with active disease, and 220 healthy controls were studied. Both basal and stimulated EGR were significantly higher in patients with rheumatoid arthritis (P = 0.0001) than in controls. Biochemical riboflavin deficiency was identified in 41% controls and 33% patients with active rheumatoid arthritis but was significantly less frequent (9%) in patients with inactive compared to active disease (P = 0.02) or healthy controls (P = 0.0006). Pain score, articular index, C reactive protein, and erythrocyte sedimentation rate were increased in patients with riboflavin deficiency (all P < 0.02). CONCLUSIONS: Higher basal and stimulated EGR might be expected in patients with rheumatoid arthritis in response to chronic oxidative stress due to synovial inflammation. The association of riboflavin deficiency with increased disease activity suggests that impaired EGR activity could facilitate continuing inflammation in these patients.

Irreversible visual loss in dermatomyositis.

Retinopathy has been described in dermatomyositis but visual loss is rare. We describe an unusual case of dermatomyositis where retinal complications resulted in permanent and profound central visual loss. Pulsed intravenous and oral methylprednisolone and cyclophosphamide therapy controlled the systemic disease but the macular and optic disc damage was irreversible. Early diagnosis and aggressive immunosuppressive therapy may help to prevent and control severe and potentially blinding intraocular inflammation. We emphasize the need for close co-operation between ophthalmologist and physician in the management of this condition.

Interleukin 1 beta, hand and foot bone mineral content and the development of joint erosions in rheumatoid arthritis.

OBJECTIVE: To assess the relationship between plasma levels of the cytokine interleukin-1 beta (IL-1 beta) and the progression of rheumatoid arthritis (RA). METHODS: Two subgroups of patients, one with persistently raised ESR (>/= 50 mm/hour, n = 16, group A) and one with persistently low ESR (

Sulfasalazine induced seizures and dysphasia.

We describe the case of a 46-year-old woman with rheumatoid arthritis who developed a severe reaction to sulfasalazine, characterized by dysphasia, seizures, rash and the development of strongly positive pANCA (perinuclear antineutrophil cytoplasmic antibodies). Her condition improved spontaneously upon withdrawal of sulfasalazine. Dysphasia has not been reported as a side effect of sulfasalazine.