Disease-modifying anti-rheumatic drug usage, prescribing patterns and disease activity in rheumatoid arthritis patients in community-based practice

AIMS

Our aim was to examine the spectrum of disease activity and usage of disease-modifying anti-rheumatic drugs (DMARD) in rheumatoid arthritis (RA) patients seen over a period of 12 months in community-based rheumatology practice.

METHODS

Data were prospectively collected on 1059 consecutive RA patients who attended two private, community-based rheumatology clinics from 1 May 2007 to 1 May 2008. Information on patient demographics, medication history and disease activity was collected. Life table graphs were developed to track medication retention over time. Statistical significance was determined by log-rank tests.

RESULTS

One thousand and fifty-nine patients with RA were entered into the database over a 12-month period. Eight hundred and twenty-six patients (85%) were treated with single or combination conventional DMARD compared with 159 patients (15%) on a biologic DMARD either alone or in combination. Methotrexate monotherapy was the most commonly prescribed DMARD, used in 41% of patients studied. Almost half (47%) were on combination DMARD therapy. Methotrexate and tumour necrosis factor inhibitors had the highest retention rate over 12 and 30 months since first prescription. A large proportion of patients (47%) had moderate disease activity.

CONCLUSION

Rates of biologic DMARD usage were similar to other studies and the predominance of methotrexate use was also in keeping with current recommendations for management of RA. There appears to be a significant unmet need for improved disease control among RA patients with moderate disease activity, which requires further investigation.

Red flags in scleroderma

BACKGROUND

Scleroderma (systemic sclerosis) is an uncommon connective tissue disease characterised by vascular, inflammatory and fibrotic dysfunction of multiple organ systems. Systemic sclerosis is often recognised late in the course of the disease.

OBJECTIVE

This article outlines the clinical features of systemic sclerosis, in particular 'red flags' that indicate the presence of significant organ disease.

DISCUSSION

Common clinical features include Raynaud phenomenon and skin thickening, often with calcinosis and telangiectasia. These features should alert the physician to look for red flag features. In the general practice setting, early recognition of scleroderma will enable timely referral to specialist centres for regular screening and effective management of its many serious visceral complications.

Regional pain syndrome: clinical characteristics, mechanisms and management

Regional soft-tissue complaints are commonplace, and they usually relate to a disease process, such as strain, inflammation or degeneration of a muscle, tendon or related muscle-tendon unit. The clinical features and investigations of the causative processes of these complaints are characteristic, and outcomes to treatments are usually predictable and satisfactory. Regional pain syndromes are different: these syndromes present with regional pain and tenderness, and other sensory symptoms unaccounted for by a simple musculoskeletal mechanistic explanation. Approved classification criteria for regional pain syndromes are lacking, and these syndromes are poorly understood and frequently misdiagnosed. Regional pain syndromes often occur after injury and overlap extensively with other musculoskeletal pain syndromes, in terms of clinical signs and symptoms. The clinician and patient are often confused about the nature of the problem and routine treatments directed to putative tissue damage will fail. Review of the epidemiology of regional pain syndromes combined with knowledge of other similar pain syndromes has enabled an evolving understanding of the condition. The musculoskeletal and central nervous systems both contribute to regional pain syndromes, through spine-related pain mechanisms and central sensitization, respectively. The patient's emotional state, particularly the effect on pain modulation, links these two systems.

Fibromyalgia syndrome

The fibromyalgia syndrome (FM) workshop at OMERACT 8 continued the work initiated in the first FM workshop at OMERACT 7 in 2004. The principal objectives were to work toward consensus on core domains for assessment in FM studies, evaluate the performance quality of outcome measures used in a review of recent trials in FM, and discuss the research agenda of the FM working group. An initiative to include the patient perspective on identification and prioritization of domains, consisting of focus groups and a patient Delphi exercise, was completed prior to OMERACT 8. Patient-identified domains were, for the most part, similar to those identified by clinician-investigators in terms of symptoms and relative importance. However, patients identified certain domains, such as stiffness, that were not included by physicians, and emphasized the importance of domains such as dyscognition and impaired motivation. Many of the principal domains agreed upon by the clinician-investigators, patients, and OMERACT participants, including pain, fatigue, sleep, mood, and global measures, have been used in clinical trials and performed well when viewed through the OMERACT filter. The research agenda items reviewed and approved for continued study included development of objective "biomarkers" in FM, development of a responder index for FM, and coordination with the WHO's International Classification of Functioning Disability and Health (ICF) Research Branch and the US National Institutes of Health's Patient Reported Outcome Measures Information System network (PROMIS) to develop improved measures of function, quality of life, and participation. The OMERACT process has provided a framework for identification of key domains to be assessed and a path toward validation and standardization of outcome measures for clinical trials in FM.

The Fibromyalgia Bladder Index

The aim of this study was to determine whether an existing outcome measure, the Interstitial Cystitis Symptom and Problem Index (ICSI/ICPI), is a valid, reliable, and clinically relevant instrument to assess the sensory urinary symptoms in women with fibromyalgia syndrome (FM). Ninety women with American College of Rheumatology 90 FM and who had at least two sensory bladder symptoms participated in the study. All underwent urological screening to exclude lower urinary tract pathology. All participants completed the following: ICSI/ICPI, Fibromyalgia Impact Questionnaire (FIQ), Medical Outcome Study Short Form 36, King's Health Questionnaire (KHQ), and Vulval Symptom Assessment Scale. Assessment was made for internal consistency reliability, test-retest reliability, and concurrent validity. Factor analysis was used to assess the internal structure of the scale. Factor analysis displayed two separate components of symptom and problem combinations as distinct from the original ICSI/ICPI developed for the interstitial cystitis population. The eight items of the index configured differently and formed two subscales of a newly developed Fibromyalgia Bladder Index. The two subscales of this index include the Bladder Urgency and Pain Subscale and the Bladder Frequency and Nocturia Subscale. This index has high internal consistency reliability (Cronbach's alpha coefficient of 0.81), test-retest reliability showing intraclass correlation of 0.85, and high concurrent validity through correlations between the Fibromyalgia Bladder Index and the KHQ (0.735, p = 0.000) and the FIQ (0.433, p = 0.000). This more specific configuration of the ICSI/ICPI better reflects FM bladder symptomatology. The Fibromyalgia Bladder Index is a validated FM-specific instrument that captures information about the sensory bladder symptoms and their impact in this fibromyalgia population. This instrument should allow for better understanding and management of this important fibromyalgia-associated problem.

Fibrosing alveolitis in systemic sclerosis: the need for early screening and treatment

Abnormalities in lung function occur in 70% of patients with systemic sclerosis (SSc). Fibrosing alveolitis in SSc (FASSc) is more commonly seen in the diffuse cutaneous form of SSc, particularly in the presence of antitopoisomerase antibodies (Scl70), and with the decreasing incidence of scleroderma renal crisis it is now the major cause of mortality in this patient population. Screening of patients recently diagnosed with SSc by pulmonary function tests and the performance of high resolution computed tomography when physiological abnormalities are identified has resulted in the identification of significant numbers of patients with early, asymptomatic FASSc. Whether these patients should be further investigated with a surgical lung biopsy or receive immunosuppression is unclear, because it cannot yet be reliably predicted who will develop progressive disease and the evidence to support the efficacy of treatment is not strong. The objective of the present article was to review the evidence to support the use of immunosuppressive therapy in FASSc and, based on these data, to propose an algorithm for the investigation and management of this difficult clinical problem.

Towards epidemiological criteria for soft-tissue disorders of the arm

BACKGROUND

The lack of universally agreed criteria has hampered population studies of the prevalence and causation of soft-tissue disorders of the upper limb.

OBJECTIVES

To establish core variables for classification of the commonest disorders seen in population samples.

METHODS

Consecutive new cases seen in clinical practice in five different centres were evaluated with respect to 30 variables shown to have discriminatory value in univariate analysis. Multivariate analysis using logistic regression modelling was carried out with these as the independent variables and with the clinical diagnosis as the dependent variable.

RESULTS

A total of 1382 cases of soft-tissue disorder were recorded and only those diagnostic groups with 50 or more cases were included. In multivariate logistic regression, significant variables positively discriminating for each disorder were identified for carpal tunnel syndrome (n = 56), lateral epicondylitis (n = 87), tenosynovitis (n = 63), shoulder tendonitis (n = 157), non-specific upper limb disorder (n = 458), fibromyalgia (n = 124) and inflammatory arthritis (n = 100), which was used for comparison purposes. Significant discrimination for each model was demonstrated by the construction of receiver operating characteristic (ROC) curves and appropriate area under the curve statistics.

CONCLUSIONS

This approach to classification criteria is based on multivariate modelling rather than on a consensus statement. This includes the effects of negative as well as positive associations. Further work is required on both the reproducibility of the clinical signs and the application of the criteria to other datasets.

Fibromyalgia. What is it and how do we treat it?

BACKGROUND

Fibromyalgia is a chronic musculoskeletal disorder that is characterised by widespread pain, tenderness at multiple anatomical sites and other clinical manifestations such as fatigue and sleep disturbance. It occurs predominantly in women and affects approximately 2-4% of people in industrialised societies.

OBJECTIVE

To discuss the syndrome of fibromyalgia and effective management strategies.

DISCUSSION

Fibromyalgia is a disorder of pain amplification due to increased sensitivity of the pain system. Management of simple fibromyalgia involves education regarding the nature of the problem, an exercise program and advice on stress management. However, management needs to be flexible and holistic and may involve relaxation programs, physical therapies, cognitive behavioural therapy and analgesic medication.

The value of clinical signs in rheumatology

BACKGROUND

Eliciting and interpreting clinical signs is essential in diagnosing many rheumatic disorders but the sensitivity and specificity of many of these signs for any given disorder remains poorly categorised.

OBJECTIVE

To discuss important clinical signs in rheumatological disease and to assess their clinical significance.

DISCUSSION

Physical examination forms a vital part of the assessment of musculoskeletal and rheumatic disorders but there remains a need for studies to assess the clinical usefulness of a number of the clinical signs elicited. The patterns of presentation of groups of clinical signs are of more diagnostic significance than individual clinical signs.

Clinical experience with combination disease-modifying antirheumatic drug therapy with cyclosporine

OBJECTIVES

We previously reported on the clinical use of cyclosporine (Neoral), alone or in combination with methotrexate (MTX), in the first 46 refractory rheumatoid arthritis (RA) patients treated at our centre between March 1996 and November 1997. Thirty of the 46 patients remained on cyclosporine at study completion (mean dose 2.98 mg/kg/day) with efficacy inferred by significant reductions in the prednisolone and MTX doses and creatinine maintained in an acceptable range. Early discontinuation was primarily related to non-serious side effects.

METHODS

The 30 patients continuing cyclosporine were reviewed 12 months later in November 1998. Analysis included life-table techniques.

RESULTS

21 of the original 46 patients (46%) continued at a mean dose of 2.59 mg/kg/day after a mean of 23.4 months. Nine patients discontinued cyclosporine during this 12-month period: 3 due to inactive disease, 2 due to hypertension, 2 due to elevated creatinine, and 1 due to mononeuritis multiplex secondary to rheumatoid vasculitis, and 1 due to inefficacy. Patients continuing cyclosporine had a shorter disease duration (9.85 versus 15.5 years [P = 0.05]). The prednisolone dose decreased from a baseline value of 10.57 mg/day to 6.78 mg/day (P = 0.007) and the MTX dose from 15.6 mg/week to 13.1 mg/week (P = 0.02). The mean serum creatinine level increased from a baseline of 73.86 mumol/l to 85.8 mumol/l (16%). 21/30 patients on combination therapy with MTX showed no difference in discontinuation rates compared with those on cyclosporine alone. Life-table analysis showed a bimodal distribution with significantly increased cyclosporine discontinuation in the first 12 months (principally due to non-renal/hypertensive causes) versus the subsequent period.

CONCLUSION

This follow-up study indicates that the use of cyclosporine in refractory RA allows a reduction in the prednisolone and MTX doses. Utilization is longer in earlier disease and is unaffected by combination with MTX. Renal function is maintained within an acceptable range. The bimodal discontinuation curve reflects early patient/physician concern about minor side effects, while renal/hypertension changes resulted in later discontinuation.

Primary care and specialist management options

Fibromyalgia syndrome varies from being a mild intermittent disorder to one that is severe and protracted. Much of the management of the more common milder type is best done at the primary care level with the expectancy of improvement in key symptoms and a generally good prognosis. Careful appraisal of the dimensions of fibromyalgia is needed with an individualized management strategy. Critical to good outcome is the need for an understandable explanation of the mechanism of fibromyalgia and introduction to self-management skills that include exercise and techniques that minimize aberrant responses to psychosocial stressors. The primary care practitioner is well placed to identify risk factors that associate with fibromyalgia in order to minimize emotional distress accompanying illness or psychosocial predicaments. Little formal research has been done on these important areas. In contrast, there is much information on management of fibromyalgia when it presents to specialist practice. More complex and expensive approaches result in variable changes in the outcome of fibromyalgia.

Three year followup of bone mineral density change in premenopausal women with systemic lupus erythematosus

OBJECTIVE

To measure the change in bone mineral density (BMD, g/cm2) in a female population with systemic lupus erythematosus (SLE) over 3 years, to identify factors predictive of bone loss, including the role of corticosteroid and disease related variables, and to determine the predictive value of urinary collagen crosslinks for bone loss.

METHODS

All premenopausal women with SLE who participated in a cross sectional study of BMD in 1994 were invited to undergo a standardized interview, examination, medical record review, and BMD measurement of the lumbar spine and femoral neck by dual energy x-ray absorptiometry.

RESULTS

Thirty-two women participated with a mean (SEM) age of 35.2 (1.5) years, duration of SLE of 7.0 (0.8) years, and mean (range) time to followup of 3.2 (2.9-3.4) years. Twenty-one subjects were exposed to corticosteroids during the study period with a mean (range) daily dose of prednisolone of 11.1 (2.8-22.9) mg. There was no significant change over the 3 years in BMD at the lumbar spine (1.161+/-0.122 vs. 1.169+/-0.022; p = 0.39) or femoral neck (0.944+/-0.023 vs. 0.955+/-0.020; p = 0.47) for the group as a whole, or when subjects were divided according to corticosteroid exposure. However, in the corticosteroid exposed subgroup, patients treated with > or = 7.5 mg/day (n = 14) lost lumbar spine BMD (-0.50%/yr) in contrast to those receiving <7.5 mg/day, who gained 1.06%/yr (p = 0.02). Furthermore, no participant receiving <7.5 mg/day lost lumbar spine BMD, while 57% of patients receiving > or =7.5 mg/day lost lumbar spine BMD (p = 0.01). In the corticosteroid exposed subgroup only, subjects who did not exercise regularly lost femoral neck BMD, while those who did gained femoral neck BMD (-0.54%/yr vs. 1.39%/yr; p = 0.02). Disease related variables (disease severity, activity, duration, functional capacity) and baseline urinary collagen crosslink levels were not predictive of BMD change.

CONCLUSION

Loss of lumbar spine and femoral neck BMD in this premenopausal female SLE population was minimal for the group as a whole; however, a daily dose of prednisolone of > or =7.5 mg was associated with loss of lumbar spine BMD. In corticosteroid exposed patients, regular exercise was protective of femoral neck BMD loss. A single baseline measurement of urinary collagen crosslinks was not predictive of bone loss.

Gastrointestinal tolerability of meloxicam compared to diclofenac in osteoarthritis patients. International MELISSA Study Group. Meloxicam Large-scale International Study Safety Assessment

Although widely used, non-steroidal anti-inflammatory drugs (NSAIDs) are associated with a high incidence of gastrointestinal (GI) side-effects. Inhibition of the cyclooxygenase (COX) enzyme is the basis for both the efficacy and toxicity of NSAIDs. The discovery of two COX isoforms, constitutive COX-1 and inducible COX-2, has led to the hypothesis that selective inhibition of COX-2 will minimize the potential for GI toxicity without compromising efficacy. The Meloxicam Large-scale International Study Safety Assessment (MELISSA) trial reported here was therefore set up to investigate the tolerability of meloxicam, a preferential inhibitor of COX-2, compared to diclofenac. MELISSA was a large-scale, double-blind, randomized, international, prospective trial, conducted over 28 days in patients with symptomatic osteoarthritis. Patients received either meloxicam 7.5 mg or diclofenac 100 mg slow release, the recommended doses for the treatment of osteoarthritis. Evaluation of the profile of adverse events was the main aim of the trial, together with assessment of efficacy. A total of 9323 patients received treatment (4635 and 4688 in the meloxicam and diclofenac groups, respectively). Significantly fewer adverse events were reported by patients receiving meloxicam. This was attributable to fewer GI adverse events (13%) compared to diclofenac (19%; P < 0.001). Of the most common GI adverse events, there was significantly less dyspepsia (P < 0.001), nausea and vomiting (P < 0.05), abdominal pain (P < 0.001) and diarrhoea (P < 0.001) with meloxicam compared to diclofenac. Five patients on meloxicam experienced a perforation, ulcer or bleed vs seven on diclofenac (not significant). No endoscopically verified ulcer complication was detected in the meloxicam group compared to four with diclofenac. There were five patient days of hospitalization in patients on meloxicam compared to 121 with diclofenac. Adverse events caused withdrawal from the study in 254 patients receiving meloxicam (5.48%) compared to 373 (7.96%) on diclofenac (P < 0.001). These differences were attributable to differences in reported GI adverse events (3.02% on meloxicam vs 6.14% on diclofenac; P < 0.001). Differences in efficacy, as assessed by visual analogue scales, consistently favoured diclofenac. In all instances, 95% confidence intervals did not cross zero, suggesting a statistically significant effect. However, differences were small (4.5-9.01% difference) and did not reach pre-determined levels of clinical significance. Nevertheless, significantly more patients discontinued meloxicam because of lack of efficacy (80 out of 4635 vs 49 out of 4688; P < 0.01). The MELISSA trial confirms earlier studies suggesting that meloxicam has a significantly improved GI tolerability profile in comparison with other NSAIDs, including diclofenac. These results may in part reflect the preferential COX-2 selectivity of meloxicam, although the dose and other aspects of tolerability may be important. These results may provide support for the hypothesis that selective inhibition of COX-2 relative to COX-1 might be an effective approach towards improved NSAID therapy.

Improvement in gastrointestinal tolerability of the selective cyclooxygenase (COX)-2 inhibitor, meloxicam, compared with piroxicam: results of the Safety and Efficacy Large-scale Evaluation of COX-inhibiting Therapies (SELECT) trial in osteoarthritis

SELECT is a large-scale, prospective, international, multicentre, double-blind, double-dummy, randomized, parallel-group trial. Patients with exacerbation of osteoarthritis were treated with the recommended dose of meloxicam (7.5 mg) or piroxicam (20 mg) once daily for 28 days; 4320 patients were administered meloxicam and 4336 piroxicam. The incidence of adverse events was significantly lower in the meloxicam group (22.5%) compared with the piroxicam group (27.9%; P < 0.001), mainly due to the significantly lower incidence of gastrointestinal (GI) adverse events in the meloxicam than in the piroxicam group (10.3% vs 15.4%,; P < 0.001), while the efficacy of both drugs was equivalent. Individual GI events occurred significantly less often with meloxicam than piroxicam: dyspepsia (3.4% vs 5.8%; P < 0.001), nausea/vomiting (2.5% vs 3.4%; P < 0.05) and abdominal pain (2.1% vs 3.6%; P < 0.001). There were 16 patients with perforations, ulcerations or bleeding (PUBs) of the upper GI tract in the piroxicam group compared with seven in the meloxicam group (relative risk piroxicam:meloxicam = 1.4). Four PUBs were complicated (perforations or bleedings); none of these occurred in the meloxicam group (relative risk piroxicam:meloxicam = 1.9). The outcome of SELECT is consistent with that of the large-scale clinical trial of similar design and size which compared 7.5 mg meloxicam with 100 mg diclofenac in patients with osteoarthritis, and with a previous global analysis of the safety of meloxicam. It adds further data to the proposed relationship between selective inhibition of cyclooxygenase-2 and improved GI tolerability of non-steroidal anti-inflammatory drugs.

Prevalence of reduced bone mineral density in systemic lupus erythematosus and the role of steroids

OBJECTIVE

To determine the prevalence of reduced bone mineral density (BMD) in a large female cohort of systemic lupus erythematosus (SLE) and to determine the role of steroids and disease related variables.

METHODS

All females with SLE managed by rheumatologists affiliated with a single center were invited to undergo BMD measurement of the lumbar spine and left femoral neck by dual energy X-ray absorptiometry (DEXA), standardized examination, and medical record review.

RESULTS

Ninety-seven females with a mean (SD) age of 44.2 (14.9) years were studied. Low bone mass [defined as BMD > 1 standard deviation (SD) below young adult mean] was present in 44.3 and 42.1% at the lumbar spine and femoral neck, respectively. Osteoporosis (defined as BMD > 2.5 SD below young adult mean) was present in 13.4 and 6.3% at the lumbar spine and femoral neck, respectively. Steroid usage showed a strong inverse relationship with BMD in the lumbar spine, but a less strong relationship in the femoral neck.

CONCLUSION

The findings of high prevalence of reduced BMD and association with steroid therapy have important implications for the routine management of SLE.

Fibromyalgia and disability. Report of the Moss International Working Group on medico-legal aspects of chronic widespread musculoskeletal pain complaints and fibromyalgia

The present article is the result of a working group conference held in Moss, Norway, in June 1993, financed by the Royal Norwegian Ministry of Health and Social Affairs. Its purpose was to review and focus upon problems and needs related to the medico-legal aspects of fibromyalgia and chronic widespread musculoskeletal complaints: thus to define directions for future work on issues which have generally not been addressed within the medical community. Our report describes specific problems in this area in regard to definition, evaluation and recommendation, and in currently available work and disability statistics. We have recommended international efforts to establish research programs through organizations such as the International Social Security Association and the World Health Organization. While our recommendations call for research into medico-legal interactions, causes and pathogenic mechanisms, prevention and treatment are also key and relevant concerns in the medico-legal setting.

Pressure pain threshold in pain-free subjects, in patients with chronic regional pain syndromes, and in patients with fibromyalgia syndrome

OBJECTIVE

We hypothesized that change in pain threshold to pressure reflects a generalized change in the pain system affecting both tender and control points.

METHODS

We assessed 18 tender points and 4 control points using an algometer in 60 patients with generalized fibromyalgia/fibrositis syndrome, 60 patients with localized chronic pain syndromes, and in 60 pain-free subjects.

RESULTS

A significant correlation was found between myalgia scores at tender points and control points in these subjects.

CONCLUSION

These results suggest that there is a diffuse change in pain modulation in fibromyalgia, as hypothesized, but the tender point is still clinically useful.

A unique presentation of multicentric reticulohistiocytosis in pregnancy

We describe a patient with multicentric reticulohistiocytosis who presented, during the second trimester of pregnancy, with symmetric polyarthritis, marked erythematous, pulsatile synovial swelling of the distal interphalangeal joints of both hands, and widespread telangiectasias. She did not have the typical skin manifestations of multicentric reticulohistiocytosis. The erythema and pulsatility of the synovial swellings of the distal interphalangeal joints resolved after delivery, but she continued to have widespread active synovitis, which did not resolve until treatment with low-dose oral methotrexate was instituted.

Identifying subclasses of patients with rheumatoid arthritis through cluster analysis

Nonhierarchical cluster analysis was used to classify 92 patients with rheumatoid arthritis drawn from a community rheumatology practice into 5 groups on the basis of biochemical measures and disease indices. The major differentiating variables were the number of active joints, number of damaged joints, overall disease activity, extraarticular complications, and history of joint surgery. Although the 5 subclasses were equivalent on measures of psychological functioning, they differed systematically on such health outcome measures as mobility, physical activity, and dexterity. Relationships between the taxonomy produced through cluster analysis and conventional classifications are discussed, and directions for further investigation are noted.

Paget's disease of the thoracic spine. A case report

A case of cord compression, secondary to Paget's disease, and responding to medical therapy is presented. The role of current imaging techniques in this condition is discussed.

The radiographic changes of scleroderma in the hands

Hand radiographs from 160 patients with scleroderma were reviewed. The presence of calcinosis distal to the metacarpophalangeal joints was significantly associated with the female sex, disease duration over 10 years, digital ulceration, telangiectasia, tuft erosion and the presence of anticentromere antibodies. The presence of calcinosis proximal to the metacarpophalangeal joints was significantly associated with tuft erosions and erosions involving all joints. The lack of distal calcinosis was significantly associated with anti Scl 70 and antinucleolar antibodies. The prevalence of other radiological manifestations of scleroderma such as osteoarthritis, erosions and dorsal tuft modelling was documented. Specific radiological findings correlate with certain clinical and serological characteristics in scleroderma.

Medicolegal aspects of fibrositis syndrome

The recent Australian epidemic of localized fibrositis syndrome is used to highlight the role of compensation and medicolegal systems on the clinical features and outcome of fibrositis syndrome. It is suggested that psychological factors are of great importance when this syndrome occurs after minor injury or de novo in the workplace. Current compensation and medicolegal systems usually negate appropriate management plans and thus lead to perseveration of fibrositis syndrome. It is suggested that public health policies in regard to fibrositis syndrome in this context need reappraisal.

Local radiotherapy for pedal manifestations of HLA-B27-related arthropathy

Four males with characteristic foot manifestations of HLA-B27-related arthropathy are reported. The severity of this problem and its recalcitrance to standard therapies led to the use of local radiotherapy. The beneficial outcome and minimal short-term side effects of this treatment are discussed in relation to previous experience with radiotherapy in ankylosing spondylitis.

Bilateral internuclear ophthalmoplegia in systemic lupus erythematosus

The case of a 25-year-old female with bilateral internuclear ophthalmoplegia as a presenting feature of systemic lupus erythematosus (SLE) is described. It is important to recognize that bilateral internuclear ophthalmoplegia may be an early manifestation of cerebral involvement in SLE in addition to its occurrence in multiple sclerosis.

The use of unproven remedies for rheumatoid arthritis in Australia

It is important for a medical practitioner to be aware of his or her patient's use of non-prescribed, unproven remedies. This is especially so in a chronic relapsing disease of unknown cause such as rheumatoid arthritis. We selected 90 consecutive patients with classic or definite rheumatoid arthritis who attended the rheumatology clinic of a teaching hospital in 1982. The patients were asked about their previous or current use of an unproven remedy; 82% had used more than one unproven remedy since the diagnosis was made and 52% were currently using an unproven remedy. In all, 352 separate unproven remedies were used, with a mean of 4 +/- 0.3 remedies per patient. Avoidance of a particular food substance or use of a copper bracelet were the most common of such remedies. Fourteen per cent of remedies were deemed to be useful and 3% were felt to have resulted in an adverse effect.

Spinal entheseal new bone formation: the early changes of spinal diffuse idiopathic skeletal hyperostosis

Diffuse idiopathic skeletal hyperostosis is characterized by new bone growth at the point of insertion of ligaments and tendons to bone. We examined retrospectively the anatomical morphologic changes discernible at the insertion of spinal longitudinal ligamentous fibrous tissue to vertebral bodies. The earliest evidence of bone formation was in the "waist" of the vertebral body away from the intervertebral disc area. New bone arose along the insertion of the fibrous tissue to the anterior cortical surface of the vertebral body and progressed along the fibres at an angle to the cortical surface distinct from it until the advanced stages. With disc degeneration the 2 processes were distinct and separate. Degenerative disc disease occurred at the margin of the endplate of the vertebral body with associated changes in the disc itself. Entheseal ossification occurred remote from the margin of the intervertebral disc and remained distinct from the subjacent vertebral body as it followed the ligamentous tissue; fusion with the cortical surface of the subjacent vertebral body was only seen in the most advanced cases of disseminated idiopathic systemic hyperostosis.

Steady-state plasma levels of salicylate in patients with rheumatoid arthritis: effects of dosing interval and tablet strength

Forty patients who were admitted to hospital with rheumatoid arthritis received a total of 3.9 g/d of enteric-coated acetylsalicylic acid (ASA) (Entrophen) according to one of four dosing schedules: group 1 (n = 13), three 325-mg tablets four times daily; group 2 (n = 11), two 650-mg tablets three times daily; group 3 (n = 10), three 650-mg tablets twice daily; and group 4 (n = 6), two 975-mg tablets twice daily. Five to seven days after the start of therapy, when steady-state plasma salicylate levels had been achieved, 10 blood samples, 1 per hour, were collected. Three healthy volunteers who received plain ASA formed a control group. There was little fluctuation in the salicylate levels over the sampling period, regardless of the dosing interval, and no significant difference in the fluctuations between the five groups. Likewise, there was no significant difference in the mean salicylate levels at each sampling time, regardless of the dosing interval or tablet strength. These results suggest that different tablet strengths of enteric-coated ASA and different dosing intervals produce comparable plasma salicylate levels. Less frequent dosing may improve patient acceptance of salicylate therapy in the treatment of arthritis.