Specialist treatment for persistent depression in secondary care: Sustained effects from a multicentre UK study at 24 and 36 months

BACKGROUND

Despite the known health costs of persistent depression, there is no established service framework for the treatment of this disorder and a lack of long-term outcome data to inform commissioning. To address this gap, we report the long-term clinical effectiveness of a randomised controlled trial (RCT) testing a specialist, collaborative model of care for people with persistent moderate to severe unipolar depression.

METHODS

A multicentre, pragmatic, single-blind, parallel-group randomised controlled trial comparing outcomes from a Specialist Depression Service (SDS) offering collaborative treatment with cognitive behavioural therapy (CBT) and pharmacotherapy for 12 months with treatment as usual (TAU) for persistent, moderate-severe depression in UK secondary care. Participants were initially assessed at baseline, 3, 6, 9, 12, and 18 months, with primary endpoints (17-item Hamilton Depression Rating Scale [HDRS17], and a Global Assessment of Functioning [GAF]) reported elsewhere (Morriss et al., 2016). Additional long-term, post-treatment, follow-up was made at 24 and 36 months with outcomes presented here.

CLINICALTRIALS

gov (NCT01047124) and ISRCTN registration (ISRCTN 10963342).

RESULTS

At 24 months there remained a statistically significant between-group difference in HDRS17-2.69 (-5.14, -0.23) and a non-significant improvement in GAF 2.85 (-1.23, 6.94), both favouring the SDS. Simple statistics are presented at 36 months, due to attrition, showing higher continued response and remission vs TAU across all measures.

LIMITATIONS

Potential bias through loss to follow-up, particularly beyond 24 months.

CONCLUSIONS

Compared with standard secondary care, SDS management of persistent moderate-severe depression, produced long-term clinical benefits, sustained following treatment completion, suggesting a model for future specialist care.

A randomised controlled trial investigating the clinical and cost-effectiveness of Alpha-Stim AID cranial electrotherapy stimulation (CES) in patients seeking treatment for moderate severity depression in primary care (Alpha-Stim-D Trial)

Background

Major depression is the second leading cause of years lost to disability worldwide and is a leading contributor to suicide. However, first-line antidepressants are only fully effective for 33%, and only 40% of those offered psychological treatment attend for two sessions or more. Views gained from patients and primary care professionals are that greater treatment uptake might be achieved if people with depression could be offered alternative and more accessible treatment options. Although there is evidence that the Alpha-Stim Anxiety Insomnia and Depression (AID) device is safe and effective for anxiety and depression symptoms in people with anxiety disorders, there is much less evidence of efficacy in major depression without anxiety. This study investigates the effectiveness of the Alpha-Stim AID device, a cranial electrotherapy stimulation (CES) treatment that people can safely use independently at home. The device provides CES which has been shown to increase alpha oscillatory brain activity, associated with relaxation.

Methods

The aim of this study is to investigate the clinical and cost-effectiveness of Alpha-Stim AID in treatment-seeking patients (aged 16 years upwards) with moderate to moderately severe depressive symptoms in primary care. The study is a multi-centre parallel-group, double-blind, non-commercial, randomised controlled superiority trial. The primary objective of the study is to examine the clinical efficacy of active daily use of 8 weeks of Alpha-Stim AID versus sham Alpha-Stim AID on depression symptoms at 16 weeks (8 weeks after the end of treatment) in people with moderate severity depression. The primary outcome is the 17-item Hamilton Depression Rating Scale at 16 weeks. All trial and treatment procedures are carried out remotely using videoconferencing, telephone and postal delivery considering the COVID-19 pandemic restrictions.

Discussion

This study is investigating whether participants using the Alpha-Stim AID device display a reduction in depressive symptoms that can be maintained over 8 weeks post-treatment. The findings will help to determine whether Alpha-Stim AID should be recommended, including being made available in the NHS for patients with depressive symptoms.

Trial registration

ISRTCN ISRCTN11853110. Registered on 14 August 2020

Provider perspectives on telemental health implementation: Lessons learned during the COVID-19 pandemic and paths forward

After years of slow and fragmented implementation of telemental health (TMH), the coronavirus disease (COVID-19) pandemic necessitated widespread adoption. With the initial state of public health emergency behind us, we are at a decision point on whether to continue with TMH or return to a largely in-person care model. In this qualitative study, we investigated clinicians' perspectives on advantages and disadvantages of TMH in outpatient mental healthcare as well as considerations for future implementation. We conducted 29 semistructured interviews with outpatient mental health providers. Data were analyzed using rapid qualitative analysis methodology. Advantages included increased utilization of services, improved therapeutic processes, and improved provider wellbeing. Providers, however, also noted that TMH has some disadvantages in terms of therapeutic processes and provider wellbeing, and they reported technology issues as an additional disadvantage. Overall providers reported they can provide high quality care via TMH, but indicated some patient populations and appointment types are a better fit for in-person services. Most providers preferred a hybrid model of care moving forward with reimbursement discrepancies and out-of-state licensure restrictions as barriers. They indicated that, as TMH becomes a mainstay in psychiatric care, training and professional guidelines will be important. Continued implementation of TMH alongside in-person care is likely to offer improved access and enhanced service quality when applied to the right patient populations and appointment types. Effective implementation may require policy and systems level support on equitable reimbursement rates, out-of-state licensure restrictions and professional guidelines for delivering TMH. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Changes in daily mental health service use and mortality at the commencement and lifting of COVID-19 'lockdown' policy in 10 UK sites: a regression discontinuity in time design

OBJECTIVES

To investigate changes in daily mental health (MH) service use and mortality in response to the introduction and the lifting of the COVID-19 'lockdown' policy in Spring 2020.

DESIGN

A regression discontinuity in time (RDiT) analysis of daily service-level activity.

SETTING AND PARTICIPANTS

Mental healthcare data were extracted from 10 UK providers.

OUTCOME MEASURES

Daily (weekly for one site) deaths from all causes, referrals and discharges, inpatient care (admissions, discharges, caseloads) and community services (face-to-face (f2f)/non-f2f contacts, caseloads): Adult, older adult and child/adolescent mental health; early intervention in psychosis; home treatment teams and liaison/Accident and Emergency (A&E). Data were extracted from 1 Jan 2019 to 31 May 2020 for all sites, supplemented to 31 July 2020 for four sites. Changes around the commencement and lifting of COVID-19 'lockdown' policy (23 March and 10 May, respectively) were estimated using a RDiT design with a difference-in-difference approach generating incidence rate ratios (IRRs), meta-analysed across sites.

RESULTS

Pooled estimates for the lockdown transition showed increased daily deaths (IRR 2.31, 95% CI 1.86 to 2.87), reduced referrals (IRR 0.62, 95% CI 0.55 to 0.70) and reduced inpatient admissions (IRR 0.75, 95% CI 0.67 to 0.83) and caseloads (IRR 0.85, 95% CI 0.79 to 0.91) compared with the pre lockdown period. All community services saw shifts from f2f to non-f2f contacts, but varied in caseload changes. Lift of lockdown was associated with reduced deaths (IRR 0.42, 95% CI 0.27 to 0.66), increased referrals (IRR 1.36, 95% CI 1.15 to 1.60) and increased inpatient admissions (IRR 1.21, 95% CI 1.04 to 1.42) and caseloads (IRR 1.06, 95% CI 1.00 to 1.12) compared with the lockdown period. Site-wide activity, inpatient care and community services did not return to pre lockdown levels after lift of lockdown, while number of deaths did. Between-site heterogeneity most often indicated variation in size rather than direction of effect.

CONCLUSIONS

MH service delivery underwent sizeable changes during the first national lockdown, with as-yet unknown and unevaluated consequences.

The bi-factor structure of the 17-item Hamilton Depression Rating Scale in persistent major depression; dimensional measurement of outcome

BACKGROUND

The 17-item Hamilton Depression Rating Scale (HDRS17) is used world-wide as an observer-rated measure of depression in randomised controlled trials (RCTs) despite continued uncertainty regarding its factor structure. This study investigated the dimensionality of HDRS17 for patients undergoing treatment in UK mental health settings with moderate to severe persistent major depressive disorder (PMDD).

METHODS

Exploratory Structural Equational Modelling (ESEM) was performed to examine the HDRS17 factor structure for adult PMDD patients with HDRS17 score ≥16. Participants (n = 187) were drawn from a multicentre RCT conducted in UK community mental health settings evaluating the outcomes of a depression service comprising CBT and psychopharmacology within a collaborative care model, against treatment as usual (TAU). The construct stability across a 12-month follow-up was examined through a measurement equivalence/invariance (ME/I) procedure via ESEM.

RESULTS

ESEM showed HDRS17 had a bi-factor structure for PMDD patients (baseline mean (sd) HDRS17 22.6 (5.2); 87% PMDD >1 year) with an overall depression factor and two group factors: vegetative-worry and retardation-agitation, further complicated by negative item loading. This bi-factor structure was stable over 12 months follow up. Analysis of the HDRS6 showed it had a unidimensional structure, with positive item loading also stable over 12 months.

CONCLUSIONS

In this cohort of moderate-severe PMDD the HDRS17 had a bi-factor structure stable across 12 months with negative item loading on domain specific factors, indicating that it may be more appropriate to multidimensional assessment of settled clinical states, with shorter unidimensional subscales such as the HDRS6 used as measures of change.

Synthesis of C-14 labeled Rac-(3R,2S)-glycopyrronium bromide

In an effort to better understand the drug metabolism and pharmacokinetics (DMPK) properties of glycopyrronium bromide (1), a muscarinic acetylcholine receptor antagonist, a C-14 labeled isotopologue was required. The compound was prepared in five synthetic steps and 5% overall radiochemical yield from Cu¹⁴ CN. During the synthesis, an unexpected decarboxylation of phenylglyoxylate resulted in the loss of much of the radiolabeled compound. Chiral chromatography was utilized to isolate and deliver the proper pair of enantiomers as [¹⁴ C]-1.

Abstract P5-19-07: Defining priorities for research: Interim results of the Canadian metastatic breast cancer priority setting partnership

Background: Research priorities are generally determined by funders and researchers without direct involvement and input from patients and caregivers. Certain disease areas have incorporated the patient voice to determine patient driven priorities. In this study, this approach was employed to better understand the needs and priorities of metastatic breast cancer patients and their caregivers.

Methods: This study was conducted using methodology outlined by the James Lind Alliance. A steering committee of patients, physicians, patient advocates, and allied health care professionals was assembled to oversee the research study. The initial survey collected unanswered research questions from patients, caregivers, and clinicians. Responses were collected and categorized by consensus of the steering committee. Here we present the results from the national survey.

Results: Between November 2016 and April 2017, 733 responses from 311 individuals were collected (62% patients, 11% physicians, 9% caregivers or relatives, 5% nurses/allied health professionals, 2% patient organization representatives, and 10% other). The main themes for key patient priorities are: 136 (19%) related to treatment and monitoring, 78 (11%) linked lifestyle and alternative therapy, 58 (8%) regarded tumour biology, 53 (7%) regarded psychosocial aspects, 46 (6%) to diagnosis, 35 (5%) to toxicity, 24 (3%) to prevention, and 17 (2%) to young or pre-menopausal population. Two hundred and eighty-six (39%) were considered out of scope. The most frequently identified priorities included the role of alternative therapies for improving survival, the role of immune therapy for treating metastatic breast cancer, and the potential for improving outcomes with early detection/surveillance with modern treatment and diagnostic modalities.

Conclusion: Patient derived research priorities in advanced breast cancer point to an improved understanding of alternative therapies, integration of immune therapy and a focus on early detection of relapse. These priorities should be addressed by the research community to meet the needs of our patients with advanced breast cancer.

Citation Format: Nixon N, Simmons C, Lemieux J, Verma S. Defining priorities for research: Interim results of the Canadian metastatic breast cancer priority setting partnership [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-19-07.

Factor structure and longitudinal measurement invariance of PHQ-9 for specialist mental health care patients with persistent major depressive disorder: Exploratory Structural Equation Modelling

BACKGROUND

The Patient Health Questionnaire-9 (PHQ-9) is a widely used instrument for measuring levels of depression in patients in clinical practice and academic research; its factor structure has been investigated in various samples, with limited evidence of measurement equivalence/invariance (ME/I) but not in patients with more severe depression of long duration. This study aims to explore the factor structure of the PHQ-9 and the ME/I between treatment groups over time for these patients.

METHODS

187 secondary care patients with persistent major depressive disorder (PMDD) were recruited to a randomised controlled trial (RCT) with allocation to either a specialist depression team arm or a general mental health arm; their PHQ-9 score was measured at baseline, 3, 6, 9 and 12 months. Exploratory Structural Equational Modelling (ESEM) was performed to examine the factor structure for this specific patient group. ME/I between treatment arm at and across follow-up time were further explored by means of multiple-group ESEM approach using the best-fitted factor structure.

RESULTS

A two-factor structure was evidenced (somatic and affective factor). This two-factor structure had strong factorial invariance between the treatment groups at and across follow up times.

LIMITATIONS

Participants were largely white British in a RCT with 40% attrition potentially limiting the study's generalisability. Not all two-factor modelling criteria were met at every time-point.

CONCLUSION

PHQ-9 has a two-factor structure for PMDD patients, with strong measurement invariance between treatment groups at and across follow-up time, demonstrating its validity for RCTs and prospective longitudinal studies in chronic moderate to severe depression.

Efficacy and cost-effectiveness of a specialist depression service versus usual specialist mental health care to manage persistent depression: a randomised controlled trial

BACKGROUND

Persistent moderate or severe unipolar depression is common and expensive to treat. Clinical guidelines recommend combined pharmacotherapy and psychotherapy. Such treatments can take up to 1 year to show an effect, but no trials of suitable duration have been done. We investigated the efficacy and cost-effectiveness of outpatient-based, specialist depression services (SDS) versus treatment as usual (TAU) on depression symptoms and function.

METHODS

We did a multicentre, single-blind, patient-level, parallel, randomised controlled trial (RCT), as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) study, in three mental health outpatient settings in England. Eligible participants were in secondary care, were older than 18 years, had unipolar depression (with a current major depressive episode, a 17-item Hamilton Depression Rating Scale [HDRS17] score of ≥16, and a Global Assessment of Function [GAF] score of ≤60), and had not responded to 6 months or more of treatment for depression. Randomisation was stratified by site with allocation conveyed to a trial administrator, with research assessors masked to outcome. Patients were randomised (1:1) using a computer-generated pseudo-random code with random permuted blocks of varying sizes of two, four, or six to either SDS (collaborative care approach between psychiatrists and cognitive behavioural therapists for 12 months, followed by graduated transfer of care up to 15 months) or to the TAU group. Intention-to-treat primary outcome measures were changes in HDRS17 and GAF scores between baseline and 6, 12, and 18 months' follow-up. We will separately publish follow-up outcomes for months 24 and 36. Clinical efficacy and cost-effectiveness were examined from health and social care persp ectives at 18 months, as recommended by the National Institute for Health and Care Excellence. This trial is registered at ClinicalTrials.gov (NCT01047124) and the ISRCTN registry (ISRCTN10963342); the trial has ended.

FINDINGS

307 patients were assessed for eligibility between Dec 21, 2009, and Oct 31, 2012. 94 patients were assigned to TAU and 93 patients to SDS, and were included in intention-to-treat analyses. The changes from baseline to 6 months in HDRS17 and GAF scores did not significantly differ between treatment groups (mean change difference in HDRS17 score -1·01 [95% CI -3·30 to 1·28], p=0·385; and in GAF score 1·33 [-2·92 to 5·57], p=0·538). Primary outcome data were available for 134 (72%) patients at 12 months. We noted no differences at 12 months' follow-up between SDS and TAU for mean HDRS17 score (14·8 [SD 7·9] in the SDS group vs 17·2 [7·3] in the TAU group, p=0·056) or GAF score (60·4 [11·7] vs 55·8 [12·7], p=0·064), and the changes from baseline to 12 months in HDRS17 and GAF scores did not significantly differ between treatment groups (mean change difference in HDRS17 score -2·45 [95% CI -5·04 to 0·14], p=0·064; and in GAF score 4·12 [-0·11 to 8·35], p=0·056). The mean change in HDRS17 score from baseline to 18 months was significantly improved in the SDS group compared with the TAU group (13·6 [SD 8·8] in the SDS group vs 16·1 [6·6] in the TAU group; mean change difference -2·96 [95% CI -5·33 to -0·59], p=0·015), but the GAF scores showed no significant differences between the groups (61·2 [SD 13·0] vs 57·7 [11·9]; mean change difference 3·82 [-9·3 to 8·57], p=0·113). We reported no deaths, but one (1%) patient was admitted to hospital for myocardial infarction, and three episodes of self-harm were reported in three (2%) patients (two receiving TAU, one receiving SDS care). The incremental cost-effectiveness ratio of SDS versus TAU was £43 603 per quality-adjusted life-year.

INTERPRETATION

Compared with usual specialist mental health secondary care, SDS might improve depression symptoms for patients with persistent moderate to severe depression, but functional outcomes and economic benefits are equivocal.

FUNDING

National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, UK Medical Research Council, Nottinghamshire Healthcare NHS Foundation Trust, Derbyshire Healthcare NHS Foundation Trust, Cambridgeshire and Peterborough NHS Foundation Trust, University of Nottingham.

Abstract P2-12-03: I-SPY 2 Clinical Trial: Telephone Support Provided by Peer Counselors

Background: I-SPY 2 is an innovative collaboration to assess 8-12 investigational agents and numerous biomarkers in an adaptive, neoadjuvant clinical trial for patients with locally advanced breast cancer and a high likelihood of recurrence. The first site opened in March 2010, and the trial will eventually open in up to 20 sites and enroll 800 patients. It is well known that patients who have recently been diagnosed with breast cancer are often overwhelmed, frightened and cognitively impaired. Making treatment decisions and dealing with the strain of treatment are among the most traumatic events patients are likely to experience. Nevertheless, they are often significantly helped by peer support. Methods: The Breast Cancer Network of Strength (formerly Y-ME) provides 24x7 peer support for callers seeking information and/or support related to breast cancer. All peer counselors are trained and certified breast cancer survivors. I-SPY 2 partnered with this organization to leverage their services in the I-SPY 2 trial. In particular, ten experienced peer counselors received a day of training to prepare them to counsel I-SPY 2 patients. They learned about the details of the trial, support materials available to patients (i.e., I-SPY 2 brochure, DVD and website), and specific challenges patients going through the trial are likely to face. Training included extensive role play exercises. When patients agree to treatment within the I-SPY 2 trial, they are offered the option of peer counseling. If they so choose, a counselor will call five times during their six months of treatment. Calls will be scheduled to meet the needs of individual patients, but are expected to take place: 1) shortly after enrollment; 2) a week after the first chemotherapy treatment; 3) shortly after completion of pacitaxel and any investigational agent; 4) shortly before surgery; and 5) shortly after surgery. The goals of providing peer support to I-SPY2 participants are to: 1) provide participants with an opportunity to discuss their diagnosis,treatment, and trial issues to validate emotions and provide support for dealing with the rigors of receiving breast cancer treatment; 2) help patients understand and anticipate upcoming aspects of their treatment; and 3) encourage patients to comply with trial requirements and raise concerns with their health care providers. Discussion: The I-SPY 2 trial initially planned to offer patients who were deciding whether to participate in the trial the option of speaking to a peer counselor. However, one IRB objected to this use of peer counselors despite demonstration of peer counselors being helpful and not coercive. For example, when this service was provided in CALGB 49907, a majority of patients who used the service expressed appreciation of counseling, but only about 50% who spoke to counselors enrolled in the trial. In the current study, use of peer counselors will initially be restricted to enrolled patients. However, it is likely that it be expanded to patients contemplating participation at sites where IRBs agree. Future research will clarify which patients request counselors and why, how they view their experience, and to what extent peer counseling influences patient enrollment, compliance and trial completion.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P2-12-03.

Randomised controlled trial of the clinical and cost effectiveness of a specialist team for managing refractory unipolar depressive disorder

BACKGROUND

Around 40 per cent of patients with unipolar depressive disorder who are treated in secondary care mental health services do not respond to first or second line treatments for depression. Such patients have 20 times the suicide rate of the general population and treatment response becomes harder to achieve and sustain the longer they remain depressed. Despite this there are no randomised controlled trials of community based service delivery interventions delivering both algorithm based pharmacotherapy and psychotherapy for patients with chronic depressive disorder in secondary care mental health services who remain moderately or severely depressed after six months treatment. Without such trials evidence based guidelines on services for such patients cannot be derived.

METHODS/DESIGN

Single blind individually randomised controlled trial of a specialist depression disorder team (psychiatrist and psychotherapist jointly assessing and providing algorithm based drug and psychological treatment) versus usual secondary care treatment. We will recruit 174 patients with unipolar depressive disorder in secondary mental health services with a Hamilton Depression Rating Scale (HDRS) score ≥ 16 and global assessment of function (GAF) ≤ 60 after ≥ 6 months treatment. The primary outcome measures will be the HDRS and GAF supplemented by economic analysis including the EQ5 D and analysis of barriers to care, implementation and the process of care. Audits to benchmark both treatment arms against national standards of care will aid the interpretation of the results of the study.

DISCUSSION

This trial will be the first to assess the effectiveness and implementation of a community based specialist depression disorder team. The study has been specially designed as part of the CLAHRC Nottinghamshire, Derbyshire and Lincolnshire joint collaboration between university, health and social care organisations to provide information of direct relevance to decisions on commissioning, service provision and implementation.

Association of polymorphism in the transforming growth factor {beta}1 gene with disease outcome and mortality in rheumatoid arthritis

OBJECTIVE

To investigate whether polymorphism in the transforming growth factor beta1 (TGFbeta1) gene is associated with disease outcome in rheumatoid arthritis.

METHODS

208 patients with established rheumatoid arthritis were genotyped for the TGFbeta1 T869C polymorphism using an amplification refractory mutation system-polymerase chain reaction (ARMS-PCR) method. Disease severity was assessed by measuring radiographic damage by Larsen score and functional outcome by the health assessment questionnaire (HAQ). Patients were tracked on the NHS central register for notification of death, and the relation between TGFbeta1 polymorphism and mortality was analysed using Cox proportional hazards regression.

RESULTS

Patients carrying a TGFbeta1 T allele had a higher mean HAQ score than those without this allele (1.60 v 1.22, p = 0.04). The T allele was also associated with higher five year mean area under the curve (MAUC) erythrocyte sedimentation rate (ESR), and nodular disease. Larsen score was higher in patients with the TT genotype compared with CC + CT genotypes, although this was not significant after correction for disease duration. There was a trend of increasing mortality risk with T allele dose after adjustment for age, sex, and disease duration (hazard ratio = 1.6 (95% confidence interval, 1.1 to 2.4), p = 0.01).

CONCLUSIONS

TGFbeta1 T869C gene polymorphism is associated with disease outcome in rheumatoid arthritis. Carriage of the T allele (putatively associated with decreased TGFbeta1 production) was associated with increased inflammatory activity and poor functional outcome, while increasing T allele dose was associated with worse survival.

Demonstration of cytokeratin in endothelial cells of the synovial microvasculature in situ and in vitro

We have used a panel of anti-cytokeratin antibodies and immunofluorescence microscopy to examine synovial tissue from a variety of large and small joints in patients with various rheumatic conditions, including RA, OA, AS, pigmented villonodular synovitis (PVNS) and tenosynovitis (TS). In every case we regularly found blood vessels with endothelia which express cytokeratin. Positive staining was obtained with a guinea pig anti-keratin antibody, with monoclonal antibody 8.13 and with a monoclonal antibody specific for keratin 18. Staining of endothelial cells was confirmed by double labelling with antibodies to cytokeratin and factor VIII/von Willebrand factor. We also detected a polypeptide corresponding to cytokeratin 18 (MW 45,000) by Western blotting of synovial tissue. In addition we have isolated pure populations of synovial endothelial cells in culture and demonstrate an extensive cytokeratin intermediate filament network which co-localizes with vimentin filaments. An understanding of the role of the cytokeratin 18 network in synovial endothelium may be important for our understanding of endothelial changes in synovial disease.

Alpha, mu and pi class glutathione S-transferases in human synovium and cultured synovial fibroblasts: effects of interleukin-1 alpha, hydrogen peroxide and inhibition of eicosanoid synthesis

We describe expression of alpha, mu and pi class glutathione S-transferase (GST) and, CuZn- and Mn superoxide dismutase (SOD) in human synovium and cultured synovial fibroblasts. Immunohistochemical and immunoblotting studies showed synovium and cultured cells expressed pi GST and both isoforms of SOD. Cellular localisation was largely perinuclear. No expression of alpha or mu GST was detected even though polymerase chain reaction analysis showed 4/6 subjects had positive genotypes at the polymorphic, mu class GSTM1 locus. Incubation of cultured synovial fibroblasts with H2O2, IL-1 alpha and the cyclooxygenase and lipoxygenase inhibitor, Tenidap, did not induce expression of alpha, mu or pi GST though treatment with IL-1 alpha caused a marked increase in the expression of Mn SOD.

Rheumatoid arthritis and chronic lymphatic leukaemia

There is evidence for an increased incidence of lymphoproliferative disorders in patients with rheumatoid arthritis (RA). We present the clinical features of 4 patients with RA and chronic lymphatic leukaemia (CLL) which, occurring in a population of 1505 RA patients, represents a significantly increased prevalence of CLL (p less than 0.05) compared to the general population. These patients had significantly lower natural killer cell activity than matched rheumatoid controls (p less than 0.05) or normal controls (p less than 0.01) and we discuss this as a possible mechanism of association.