Evening Primrose Oil (Efamol) in the Treatment of Raynaud’s Phenomenon: A Double Blind Study

Prostaglandin E1 (PGE1) and prostacyclin have been used in Raynaud’s phenomenon (RP) but are unstable and require intravenous administration. An alternative approach is to stimulate the body’s own PGE1 production via administration of the precursor essential fatty acid. We studied the effect of 12 capsules/day of evening primrose oil (EPO) on the manifestations of RP. 21 patients received a two week course of placebo, thereafter 11 received EPO for 8 weeks and 10 patients received placebo. As the weather worsened the placebo group experienced significantly more attacks than the EPO group. Visual analogue scales assessing the severity of attacks and coldness of hands improved in the EPO group. No changes were seen in either group in hand temperatures and cold challenge plethysmography. Blood tests showed some antiplatelet effects of the drug. In conclusion patients receiving EPO benefited symptomatically. This was not matched however by any change in objective assessment of blood flow, although changes in platelet behaviour and blood prostanoids were observed.

The British Society for Rheumatology Biologics Registers in Ankylosing Spondylitis (BSRBR-AS) study: Protocol for a prospective cohort study of the long-term safety and quality of life outcomes of biologic treatment

BACKGROUND

Axial spondyloarthropathy typically has its onset in early adulthood and can impact significantly on quality of life. In the UK, biologic anti-tumour necrosis factor therapy is recommended for patients who are unresponsive to non-steroidal anti-inflammatory drugs. There remain several unresolved issues about the long-term safety and quality of life outcomes of biologic treatment in axial spondyloarthropathy. Long-term "real-world" surveillance data are required to complement data from randomised controlled trials.

METHODS/DESIGN

We are conducting a UK-wide prospective cohort study of patients with axial spondyloarthropathy who are naïve to biologic therapy at the time of recruitment. Those about to commence anti-tumour necrosis factor biologic therapy will enter a "biologic" sub-cohort with other patients assigned to a "non-biologic" sub-cohort. The primary objective is to determine whether the use of biologic therapy is associated with an increased risk of serious infection, while secondary objectives are to assess differences in malignancy, serious comorbidity, all-cause mortality but also assess impact on specific clinical domains (physical health, mental health and quality of life) including work outcomes between biologic and non-biologic patient cohorts. Patients will be followed-up for up to 5 years. Data are obtained at baseline and at standard clinical follow-up visits - at 3, 6 and 12 months and then annually for the biologic cohort and annually for the non-biologic cohort. This study will also collect biological samples for genetic analysis.

DISCUSSION

Although biologic therapy is widely used for ankylosing spondylitis patients who are unresponsive to non-steroidal anti-inflammatory drugs, the majority of the available safety information comes from rheumatoid arthritis, where increased infection risk has consistently been shown. However, given the typical demographic differences between rheumatoid arthritis and axial spondyloarthropathy patients, it is important to develop an epidemiologically rigorous cohort of patients receiving biologic therapy to effectively evaluate outcomes with regard not only to safety but also to quantify benefits across clinical, psychosocial and work outcomes.

CLINICAL TRIAL REGISTRATION

This is an observational cohort study and clinical trial registration was not required or obtained.

Global prevalence of ankylosing spondylitis

OBJECTIVES

For effective health care provision, knowledge of disease prevalence is paramount. There has been no systematic endeavour to establish continent-based AS estimates, however, prevalence is thought to vary by country and background HLA-B27 prevalence. This study aimed to estimate AS prevalence worldwide and to calculate the expected number of cases.

METHODS

A systematic literature search was conducted. Prevalence data were extracted and used to calculate the mean prevalence by continent and the expected number of cases based on country-specific prevalence (or, if missing, the prevalence from neighbouring countries). A second estimate was made using the prevalence from countries with similar HLA-B27 prevalences if a country-specific prevalence estimate was not available.

RESULTS

The mean AS prevalence per 10,000 (from 36 eligible studies) was 23.8 in Europe, 16.7 in Asia, 31.9 in North America, 10.2 in Latin America and 7.4 in Africa. Additional estimates, weighted by study size, were calculated as 18.6, 18.0 and 12.2 for Europe, Asia and Latin America, respectively. There were sufficient studies to estimate the number of cases in Europe and Asia, calculated to be 1.30-1.56 million and 4.63-4.98 million, respectively.

CONCLUSION

This study represents the first systematic attempt to collate estimates of AS prevalence into a single continent-based estimate. In addition, the number of expected cases in Europe and Asia was estimated. Through reviewing the current literature, it is apparent that the continuing conduct of epidemiological studies of AS prevalence is of great importance, particularly as diagnostic capabilities improve and with the recent development of the criteria for axial SpA.

Kinematic, kinetic and electromyographic response to customized foot orthoses in patients with tibialis posterior tenosynovitis, pes plano valgus and rheumatoid arthritis

Objective. To describe the effect of customized foot orthoses (FOs) on the kinematic, kinetic and EMG features in patients with RA, tibialis posterior (TP) tenosynovitis and associated pes plano valgus.

Methods. Patients with RA and US-confirmed tenosynovitis of TP underwent gait analysis, including three-dimensional (3D) kinematics, kinetics, intramuscular EMG of TP and surface EMG of tibialis anterior, peroneus longus, soleus and medial gastrocnemius. Findings were compared between barefoot and shod with customized FO conditions.

Results. Ten patients with RA with a median (range) disease duration of 3 (1–18) years were recruited. Moderate levels of foot pain and foot-related impairment and disability were present with moderately active disease states. Altered timing of the soleus (P = 0.05) and medial gastrocnemius (P = 0.02) and increased magnitude of tibialis anterior (P = 0.03) were noted when barefoot was compared with shod with FO. Trends were noted for reduced TP activity in the contact period (P = 0.09), but this did not achieve statistical significance. Differences in foot motion characteristics were recorded for peak rearfoot eversion (P = 0.01), peak rearfoot plantarflexion (P < 0.001) and peak forefoot abduction (P = 0.02) in the shod with FOs compared with barefoot conditions. No differences in kinetic variables were recorded.

Conclusion. This study has demonstrated, for the first time, alterations in muscle activation profiles and foot motion characteristics in patients with RA, pes plano valgus and US-confirmed TP tenosynovitis in response to customized FOs. Complex adaptations were evident in this cohort and further work is required to determine whether these functional alterations lead to improvements in patient symptoms.

Tibialis posterior tenosynovitis and associated pes plano valgus in rheumatoid arthritis: electromyography, multisegment foot kinematics, and ultrasound features

Objective

To compare electromyographic (EMG), kinematic, kinetic, and ultrasound (US) features of pes plano valgus associated with US-confirmed tibialis posterior (TP) tenosynovitis in rheumatoid arthritis (RA) and healthy control subjects.

Methods

In this cross-sectional study, patients with RA and US-confirmed tenosynovitis of TP underwent gait analysis, including 3-dimensional kinematics, kinetics, and intramuscular EMG of TP, and findings were compared with a group of healthy individuals. The RA group also underwent B mode and power Doppler US scanning of the TP tendon to assess and score levels of pathology.

Results

Ten patients with RA, median (range) disease duration of 3 years (1–18 years), and 5 control subjects were recruited. Compared to control subjects, the RA patients walked slower and presented with moderate levels of foot-related disability. The mean ± SD Disease Activity Score in 28 joints was 4.6 ± 1.6. Increased magnitude of TP activity was recorded in the RA group compared to controls in the contact period of stance (P = 0.007), in conjunction with reduced ankle joint power (P = 0.005), reduced navicular height in the medial arch (P = 0.023), and increased forefoot dorsiflexion (P = 0.027). TP tendon thickening, fluid, and power Doppler signal were observed in the majority of patients.

Conclusion

This study has demonstrated, for the first time, increased TP EMG activity in the presence of US-confirmed TP tenosynovitis in RA. Altered muscle function occurred in conjunction with suboptimal mechanics, moderate levels of tendon pathology, and active disease. Targeted therapy may be warranted to reduce inflammation and mechanically off-load diseased tendon states.

The clinical significance of indomethacin-probenecid interaction

1 The effect of the addition of probenecid to oral and rectal regimes of indomethacin was studied in three groups of rheumatoid arthritic patients. 2 The addition of probenecid increases plasma levels of indomethacin given both orally and rectally and significantly reduces the clinical parameters of joint inflammation. 3 The use of probenecid with indomethacin at night may be useful in reducing morning stiffness and pain. 4 Though indomethacin plasma levels are markedly raised during concurrent probenecid therapy remarkably few side effects were observed.

Elucidating the chromosome 9 association with AS; CARD9 is a candidate gene

Ankylosing spondylitis (AS) is polygenic with contributions from the immunologically relevant genes HLA-B*27, ERAP1 and IL23R. A recent genome-wide association study (GWAS) identified associations (p~0.005) with the non-synonymous single nucleotide polymorphisms (nsSNPs), rs4077515 and rs3812571, in CARD9 and SNAPC4 on chromosome 9q that had previously been linked to AS. We replicated these associations in a study of 730 AS patients compared to 2879 historic disease controls, (rs4077515 p = 0.0004 odds ratio (OR) (95% confidence interval) = 1.2 (1.1-1.4); rs3812571 p = 0.0003 OR = 1.2 (1.1-1.4)). Meta-analysis revealed strong associations of both SNPs with AS, rs4077515 p = 0.000005 OR = 1.2 (1.1-1.3) and rs3812571 p = 0.000006 OR = 1.2 (1.1-1.3). We then typed 1604 AS cases and 1020 controls for 13 tagging SNPs; 6 showed at least nominal association, 5 of which were in CARD9. We imputed genotypes for 13 additional SNPs but none was more strongly associated with AS than the tagging SNPs. Finally, interrogation of an mRNA expression database revealed that the SNPs most strongly associated AS (or in strong linkage disequilibrium) were those most associated with CARD9 expression. CARD9 is a plausible candidate for AS given its central role in the innate immune response.

Clinical utility of ultrasonography in spondyloarthropathies

Since the introduction of ultrasonography by Professor Ian Donald in Glasgow as a tool for imaging in medicine, it has become an important technology for imaging the musculoskeletal system. Musculoskeletal ultrasonography is a powerful adjunct to clinical examination that can detect subclinical abnormalities of soft tissues, tendons, and ligaments; it is also an important tool for the objective assessment of synovitis and bone erosion. Enthesitis, the hallmark of spondyloarthropathies, can be readily imaged using ultrasound. Furthermore, the characteristic soft tissue abnormalities and bone erosions seen in psoriatic arthritis, for example, are easily detected. The axial skeleton is a complex structure that currently is not very amenable to ultrasound imaging, but advances have been made in its use to image sacroiliac joints and semiquantify active sacroiliitis. Technological advances currently being made in ultrasonography will provide exciting new possibilities for the application of this imaging modality to the spondyloarthropathies.

The chromosome 16q region associated with ankylosing spondylitis includes the candidate gene tumour necrosis factor receptor type 1-associated death domain (TRADD)

OBJECTIVE

To replicate and refine the reported association of ankylosing spondylitis (AS) with two non-synonymous single nucleotide polymorphisms (nsSNPs) on chromosome 16q22.1.

METHODS

Firstly, 730 independent UK patients with AS were genotyped for rs9939768 and rs6979 and allele frequencies were compared with 2879 previously typed historic disease controls. Secondly, the two data sets were combined in meta-analyses. Finally, 5 tagging SNPs, located between rs9939768 and rs6979, were analysed in 1604 cases and 1020 controls.

RESULTS

The association of rs6979 with AS was replicated, p=0.03, OR=1.14 (95% CI 1.01 to 1.28), and a trend for association with rs9939768 detected, p=0.06, OR=1.25 (95% CI 0.99 to 1.57). Meta-analyses revealed association of both SNPs with AS, p=0.0008, OR=1.31 (95% CI 1.12 to 1.54) and p=0.0009, OR=1.15 (95% CI 1.06 to 1.23) for rs9939768 and rs6979, respectively. New associations with rs9033 and rs868213 (p=0.00002, OR=1.23 (95% CI 1.12 to 1.36) and p=0.00002 OR=1.45 (95% CI 1.22 to 1.72), respectively, were identified.

CONCLUSIONS

The region on chromosome 16 that has been replicated in the present work is interesting as the highly plausible candidate gene, tumour necrosis factor receptor type 1 (TNFR1)-associated death domain (TRADD), is located between rs9033 and rs868213. It will require additional work to identify the primary genetic association(s) with AS.

Investigating the genetic association between ERAP1 and ankylosing spondylitis

A strong association between ERAP1 and ankylosing spondylitis (AS) was recently identified by the Wellcome Trust Case Control Consortium and the Australo-Anglo-American Spondylitis Consortium (WTCCC-TASC) study. ERAP1 is highly polymorphic with strong linkage disequilibrium evident across the gene. We therefore conducted a series of experiments to try to identify the primary genetic association(s) with ERAP1. We replicated the original associations in an independent set of 730 patients and 1021 controls, resequenced ERAP1 to define the full extent of coding polymorphisms and tested all variants in additional association studies. The genetic association with ERAP1 was independently confirmed; the strongest association was with rs30187 in the replication set (P = 3.4 × 10⁻³). When the data were combined with the original WTCCC-TASC study the strongest association was with rs27044 (P = 1.1 × 10⁻⁹). We identified 33 sequence polymorphisms in ERAP1, including three novel and eight known non-synonymous polymorphisms. We report several new associations between AS and polymorphisms distributed across ERAP1 from the extended case–control study, the most significant of which was with rs27434 (P = 4.7 × 10⁻⁷). Regression analysis failed to identify a primary association clearly; we therefore used data from HapMap to impute genotypes for an additional 205 non-coding SNPs located within and adjacent to ERAP1. A number of highly significant associations (P < 5 × 10⁻⁹) were identified in regulatory sequences which are good candidates for causing susceptibility to AS, possibly by regulating ERAP1 expression.

Comparison of cardiovascular risk in ankylosing spondylitis and rheumatoid arthritis

Cardiovascular co-morbidity is now a recognised complication of chronic inflammation and an elevated acute phase response predisposes to hypertension, stroke and myocardial infarction. Dyslipidaemia is a feature of inflammatory joint diseases and is closely related to elevated CRP and Il-6 levels. Rheumatoid arthritis (RA) has an increased standardised mortality ratio largely attributable to cardiovascular risk. An increased although lesser, cardiovascular morbidity has also been observed in ankylosing spondylitis (AS) which has a similar abnormal lipid profile to that seen in RA. There is some evidence that therapeutic agents such as anti-tumour necrosis factor-alpha (TNF-alpha) drugs that down-regulate the acute phase response, also have an effect in reducing cardiovascular complications in RA and AS.

Protocol for the Foot in Juvenile Idiopathic Arthritis trial (FiJIA): a randomised controlled trial of an integrated foot care programme for foot problems in JIA

BACKGROUND

Foot and ankle problems are a common but relatively neglected manifestation of juvenile idiopathic arthritis. Studies of medical and non-medical interventions have shown that clinical outcome measures can be improved. However existing data has been drawn from small non-randomised clinical studies of single interventions that appear to under-represent the adult population suffering from juvenile idiopathic arthritis. To date, no evidence of combined therapies or integrated care for juvenile idiopathic arthritis patients with foot and ankle problems exists.

METHODS/DESIGN

An exploratory phase II non-pharmacological randomised controlled trial where patients including young children, adolescents and adults with juvenile idiopathic arthritis and associated foot/ankle problems will be randomised to receive integrated podiatric care via a new foot care programme, or to receive standard podiatry care. Sixty patients (30 in each arm) including children, adolescents and adults diagnosed with juvenile idiopathic arthritis who satisfy the inclusion and exclusion criteria will be recruited from 2 outpatient centres of paediatric and adult rheumatology respectively. Participants will be randomised by process of minimisation using the Minim software package. The primary outcome measure is the foot related impairment measured by the Juvenile Arthritis Disability Index questionnaire's impairment domain at 6 and 12 months, with secondary outcomes including disease activity score, foot deformity score, active/limited foot joint counts, spatio-temporal and plantar-pressure gait parameters, health related quality of life and semi-quantitative ultrasonography score for inflammatory foot lesions. The new foot care programme will comprise rapid assessment and investigation, targeted treatment, with detailed outcome assessment and follow-up at minimum intervals of 3 months. Data will be collected at baseline, 6 months and 12 months from baseline. Intention to treat data analysis will be conducted.A full health economic evaluation will be conducted alongside the trial and will evaluate the cost effectiveness of the intervention. This will consider the cost per improvement in Juvenile Arthritis Disability Index, and cost per quality adjusted life year gained. In addition, a discrete choice experiment will elicit willingness to pay values and a cost benefit analysis will also be undertaken.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

UKCRN5045.

Unintended benefits of immunosupression on autoimmune disease due to chemoradiation therapy for head and neck cancer

The immune system is an important factor in the host's defenses against cancer. Immunosupression by radiation and/or chemotherapy is often associated with systemic and hematologic complications, opportunistic infections, and the development of malignancies, but immunosupression can also have beneficial effects, which are sometimes incidental. We report 2 patients with autoimmune diseases where immunosupression had beneficial effects. The first case is about a patient with carcinoma of the tonsil, with severe rheumatoid arthritis, who was treated with chemoradiation, which resulted in remission of his arthritis. The second case is about a patient with severe atopic eczema who was on long-term treatment with psoralen and ultraviolet A radiation and azathioprine; the patient developed metastatic carcinoma of the lip, which was treated with surgery and radiation that resulted in complete remission of his eczema.

Angiotensin II type 1 receptor as a novel therapeutic target in rheumatoid arthritis: in vivo analyses in rodent models of arthritis and ex vivo analyses in human inflammatory synovitis

OBJECTIVE

Angiotensin II (Ang II) is known to have proinflammatory actions, and Ang II type 1 (AT(1)) receptors are up-regulated in the rheumatoid synovium, suggesting that this receptor could be a therapeutic target. The purpose of this study was to investigate the antiinflammatory potential of the selective AT(1) receptor antagonist losartan, which is currently used for the treatment of cardiovascular disease.

METHODS

Dose-ranging studies of losartan (1-50 mg/kg) were initially conducted in a rat model of acute (carrageenan/kaolin) arthritis, with subsequent evaluation in a rat model of adjuvant-induced arthritis (Freund's complete adjuvant). Losartan (10(-10) to 10(-6)M) was further tested ex vivo in human inflammatory synovitis, using collagenase-digested synovium.

RESULTS

Western blot and immunohistochemical analyses both revealed a substantial increase in AT(1) receptor protein content in synovium from acutely and chronically inflamed rat knee joints. Similarly, synovial Ang I/II protein content was elevated during inflammation. Losartan inhibited acute joint inflammation in a dose-dependent manner, with 15 mg/kg being the optimal dose (and used in subsequent studies). Both prophylactic and therapeutic administration of 15 mg/kg of losartan substantially reduced knee joint swelling in rats with adjuvant monarthritis (> or =50%; P < 0.0001). Losartan also suppressed tumor necrosis factor alpha generation from inflamed human synovium in a dose-dependent manner (P < 0.05).

CONCLUSION

Targeting the angiotensin pathway, particularly AT(1) receptors, could have significant therapeutic potential. Randomized placebo-controlled trials are now warranted to establish the extent to which angiotensin receptor blockers may provide antiinflammatory benefits.

Enumeration and phenotypical analysis of distinct dendritic cell subsets in psoriatic arthritis and rheumatoid arthritis

Dendritic cells (DCs) comprise heterogeneous subsets of professional antigen-presenting cells, linking innate and adaptive immunity. Analysis of DC subsets has been hampered by a lack of specific DC markers and reliable quantitation assays. We characterised the immunophenotype and functional characteristics of psoriatic arthritis (PsA)-derived and rheumatoid arthritis (RA)-derived myeloid DCs (mDCs) and plasmacytoid DCs (pDCs) to evaluate their potential role in arthritis. Circulating peripheral blood (PB) pDC numbers were significantly reduced in PsA patients (P = 0.0098) and RA patients (P = 0.0194), and mDCs were significantly reduced in RA patients (P = 0.0086) compared with healthy controls. The number of circulating mDCs in RA PB was significantly inversely correlated to C-reactive protein (P = 0.021). The phenotype of both DC subsets in PsA PB and RA PB was immature as compared with healthy controls. Moreover, CD62L expression was significantly decreased on both mDCs (PsA, P = 0.0122; RA, P = 0.0371) and pDCs (PsA, P = 0.0373; RA, P = 0.0367) in PB. Both mDCs and pDCs were present in PsA synovial fluid (SF) and RA SF, with the mDC:pDC ratio significantly exceeding that in matched PB (PsA SF, P = 0.0453; RA SF, P = 0.0082). pDCs isolated from RA SF and PsA SF displayed an immature phenotype comparable with PB pDCs. RA and PsA SF mDCs, however, displayed a more mature phenotype (increased expression of CD80, CD83 and CD86) compared with PB mDCs. Functional analysis revealed that both SF DC subsets matured following toll-like receptor stimulation. pDCs from PB and SF produced interferon alpha and tumour necrosis factor alpha on TLR9 stimulation, but only SF pDCs produced IL-10. Similarly, mDCs from PB and SF produced similar tumour necrosis factor alpha levels to TLR2 agonism, whereas SF mDCs produced more IL-10 than PB controls. Circulating DC subset numbers are reduced in RA PB and PsA PB with reduced CD62L expression. Maturation is incomplete in the inflamed synovial compartment. Immature DCs in SF may contribute to the perpetuation of inflammation via sampling of the inflamed synovial environment, and in situ presentation of arthritogenic antigen.

TLR4 mutations (Asp299Gly and Thr399Ile) are not associated with ankylosing spondylitis

BACKGROUND

Immunoregulatory genes and Gram negative gut bacteria are thought to be important in disease expression in ankylosing spondylitis (AS).

OBJECTIVE

To compare the frequency of two common and functional TLR4 mutations (Asp299Gly, and Thr399Ile) between patients with AS and HLA-B27 healthy controls.

METHODS

The TLR4 genotypes of patients and healthy HLA-B27 controls were determined using allele-specific PCR and restriction fragment length polymorphism analysis. Asp299Gly genotype was determined in 193 patients and 125 HLA-B27 positive controls and Thr399Ile genotype in 184 patients and 113 HLA-B27 controls. Allele frequencies were compared using a chi(2) test of association.

RESULTS

29/193 (15%) patients with AS had a polymorphism in the Asp299 site compared with 18/125 (14.4%) healthy HLA-B27 controls. Of the patients genotyped for the Thr399Ile allele, 29/184 (15.8%) carried the polymorphism compared with 19/113 (16.8%) HLA-B27 controls. No significant difference between the frequencies of the Asp299Gly genotype or the Thr399Ile genotype between patients with AS and healthy HLA-B27 controls was found. No significant difference in allele frequency was found at either site.

CONCLUSION

Two common TLR4 polymorphisms, which cause a functional deficiency in host immune response to Gram negative bacteria, are not overrepresented in patients with AS.

Inflammatory suppression rapidly attenuates microvascular dysfunction in rheumatoid arthritis

Rheumatoid arthritis (RA) is associated with greater risk of cardiovascular morbidity and mortality, the inflammatory component of RA being strongly linked to this excess risk. Endothelial dysfunction is linked to atherosclerosis and has been demonstrated in larger vessels in RA. In this pilot study, we determined for the first time whether skin microvascular function was impaired in patients with active RA and also determined its response to anti-inflammatory treatment. This was assessed non-invasively using laser Doppler imaging combined with iontophoresis of the vasodilators acetylcholine (ACh, endothelium dependent) and sodium nitroprusside (SNP, endothelium independent) to the forearm. Eight RA patients admitted for acute flare-ups were assessed before and following anti-inflammatory treatment. Standard laboratory indices were obtained along with pain perception (VAS). A control group of eight subjects was included for baseline comparison. Compared to this group, vascular function was substantially and significantly (P<0.00001) lower in RA patients. Following treatment, as CRP and VAS decreased, vascular function improved for both ACh (P<0.00001) and SNP (P=0.001), this improvement being significantly greater for ACh (P<0.001). Vascular dysfunction is evident in RA patients, even at the level of the cutaneous microcirculation, but improves as inflammation regresses. Assessment of cutaneous vascular function may be a useful, non-invasive surrogate indicator of vascular risk in RA, inclusive of myocardial microvascular abnormalities.

ASAS/EULAR recommendations for the management of ankylosing spondylitis

OBJECTIVE

To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the 'ASsessment in AS' international working group and the European League Against Rheumatism.

METHODS

Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise.

RESULTS

The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I-IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion.

CONCLUSION

Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.

Amelioration of symptoms by enhancement of proprioception in patients with joint hypermobility syndrome

OBJECTIVE

Joint hypermobility syndrome (JHS) is characterized by an association between joint hypermobility and musculoskeletal pains, the latter occurring in the absence of any objective indicator of rheumatic disease. The lack of a recognizable disease marker makes this condition difficult to identify and manage. We previously observed that patients with JHS have impaired proprioception compared with that of a matched control group. The purpose of this study was to investigate whether a home-based exercise program could produce objective enhancement of proprioception as well as alleviate symptoms in JHS.

METHODS

A threshold detection paradigm was used to assess knee joint proprioception, balance was assessed using a balance board, and quadriceps and hamstring strength were measured by an isokinetic dynamometer. A visual analog scale was used to assess musculoskeletal pain, and quality of life was evaluated by a Short Form 36 questionnaire. Assessments were performed before and after an 8-week program of progressive closed kinetic chain exercises.

RESULTS

Following the exercise program, proprioceptive acuity increased in 16 of 18 subjects and was very significantly improved overall (P < 0.001). There was a comparable improvement in performance on the balance board (P < 0.001), and quadriceps and hamstring strength also increased significantly. Symptomatic improvement also occurred, in terms of both pain (P = 0.003) and quality-of-life (P = 0.029 for physical functioning; P = 0.008 for mental health) scores.

CONCLUSION

Appropriate exercises lead not only to symptomatic improvement, but also to demonstrable enhancement of objective parameters such as proprioception.

Ultrasonography is superior to clinical examination in the detection and localization of knee joint effusion in rheumatoid arthritis

OBJECTIVE

Musculoskeletal ultrasonography allows real-time imaging of joint structures and may be used to complement clinical examination in rheumatological practice. We compared ultrasonography (US) with clinical examination (CE) in the detection of effusion, suprapatellar bursitis, and Baker's cyst of the knee in rheumatoid arthritis (RA) in order to determine whether US provided additional clinical information.

METHODS

A total of 22 patients with RA (ACR criteria) underwent independent clinical and US examination of both knees for suprapatellar bursitis, knee effusion, and presence of Baker's cyst. US was performed using an ATL HDI 3000 machine with L7-4 MHz and CL10-5 MHz probes. Clinical examination was performed using standard techniques by an experienced rheumatologist. Patients with previous knee surgery were excluded from the study.

RESULTS

A total of 44 knees were examined at a total of 130 sites (one patient was unable to lie prone for US of popliteal fossae). US detected soft tissue abnormality (suprapatellar bursitis, knee effusion, or Baker's cyst) at 54/130 (42%) sites, while CE detected soft tissue abnormality at 36/130 (28%) sites. US detected 17 (39%) cases of suprapatellar bursitis in 44 knees, 7 (16%) of which were detected on CE. US detected 27 (61%) knee joint effusions in 44 knees, 16 (36.36%) of which were detected on CE. US detected 10 (23.81%) Baker's cysts in 42 knees, 2 (4.76%) of which were detected on CE. Taking US of the knee as the gold standard, CE was specific but not sensitive in the detection of soft tissue abnormality of the knee in RA.

CONCLUSION

US is more sensitive than CE in the detection of suprapatellar bursitis, knee effusion, and Baker's cyst in RA. CE underestimates knee inflammation in RA. This has implications for the use of CE as a component of standardized disease activity scores and in guiding knee joint aspiration.

Prospective comparative study of patients with culture proven and high suspicion of adult onset septic arthritis

OBJECTIVE

To investigate whether patients with acute septic arthritis (SA) diagnosed by positive synovial fluid (SF) culture (Newman grade A) have different clinical and serological features from those with sterile SF in whom there is nonetheless a high suspicion of SA (Newman grades B and C).

PATIENTS AND METHODS

A prospective 12 month multicentre hospital based study of adult patients with SA recruited 47 patients with culture positive SA and 35 patients with clinically suspected SA but sterile SF.

RESULTS

Patient demography, clinical and laboratory features at presentation were similar irrespective of the underlying diagnosis, SF culture, and the presence of prosthetic joints. Medical and surgical treatment and outcome were comparable in the two patient groups. Patients with both suspected and proven SA were more likely to be from the more socially deprived areas of our community (p<0.0001).

CONCLUSION

Patients in whom there is a high clinical suspicion of SA are comparable to those patients with SA with a positive SF culture and have similar morbidity and mortality on follow up. Therefore, if clinical suspicion of SA is high then it is correct to treat as SA in the absence of bacterial proof.

A clinical procedure to predict the value of temporary occlusion therapy in keratoconjunctivitis sicca

PURPOSE

To evaluate the effects of dissolvable collagen punctal plugs on the symptoms, tear stability and volume in aqueous deficient dry eyes.

METHODS

Sixty-two aqueous deficient dry eye patients of mixed aetiology underwent lacrimal punctal occlusion with dissolvable collagen plugs. The subjects were randomly allocated to one of two treatment groups: group I (n = 36) had their lower puncta occluded and group II (n = 26) had both their upper and lower puncta occluded. The effectiveness of this treatment was clinically assessed by (1). scoring subject symptoms and (2). measuring the tear parameters of tear thinning time (TTT) and tear meniscus height (TMH) as indicators of tear stability and volume, respectively. Following baseline measurements, patients were reviewed at time intervals of 5 and 12 days post-occlusion. A group of age- and gender-matched normals (n = 45) was recruited for comparison (group III).

RESULTS

Tear volume and stability were significantly higher in group III compared with I and II at baseline. In the treated groups on both days 5 and 12: (1). symptom score reduced significantly from a median value of 7 to 3 (p = <0.001); (2). tear stability increased significantly from a median value of 3 to 5 s by day 5 (p <or= 0.001); reduced between days 5 and 12 (p < 0.05) and remained below the stability in group III at all times; (c). tear volume increased significantly by day 5 in both treatment groups from a median value of 0.13 to 0.20 mm (p<or=0.001), remained stable by day 12 in group II but reduced in group I (p < 0.05); (d). the increase in tear volume was negatively correlated with pre-treatment tear volume; (e). symptom score correlated with both baseline tear volume and stability.

CONCLUSION

Collagen plugs improved tear status in the aqueous deficient dry eyes. Occluding both upper and lower puncta with temporary collagen plugs offers no practical beneficial gain compared with occluding just the lower punctum.

Ultrasound guided versus conventional joint and soft tissue fluid aspiration in rheumatology practice: a pilot study

OBJECTIVE

To compare joint and soft tissue aspiration using a conventional technique with an ultrasound (US) guided technique.

METHODS

In the conventional group, 32 joints in 30 consecutive patients referred for joint aspiration and injection to an experienced consultant rheumatologist were aspirated. In the US guided group, 31 consecutive patients were examined by US to confirm the presence and location of fluid. Following US examination, aspiration was performed by a second rheumatologist based on the US localization of fluid or under direct US guidance.

RESULTS

In the conventional group, successful aspiration was achieved in 10 (32%) joints. In the US guided group, successful aspiration was achieved in 31 (97%) joints. The mean volume of fluid obtained from successful aspirations was similar in both groups (11.7 ml in the US group and 14 ml in the conventional group).

CONCLUSION

The use of US to localize joint and soft tissue fluid collection greatly improves the rate of diagnostic synovial fluid aspiration, particularly in small joints. This has important implications for accurate administration of local steroid therapy and emphasizes the importance of US as a useful tool in clinical rheumatological practice.

Ultrasonography of entheseal insertions in the lower limb in spondyloarthropathy

OBJECTIVE

To compare ultrasonography (US) with clinical examination in the detection of entheseal abnormality of the lower limb in patients with spondyloarthropathy (SpA).

METHODS

35 patients with SpA (ankylosing spondylitis 27; psoriatic arthritis 7; reactive arthritis 1) underwent independent clinical and ultrasonographic examination of both lower limbs at five entheseal sites-superior pole and inferior pole of patella, tibial tuberosity, Achilles tendon, and plantar aponeurosis. US was performed using an ATL (Advanced Technology Laboratories, Bothell, Washington, USA) high definition imaging 3000 machine with linear 7-4 MHz and compact linear 10-5 MHz probes to detect bursitis, structure thickness, bony erosion, and enthesophyte (bony spur). An enthesitis score was formulated from these US findings giving a possible maximum total score of 36.

RESULTS

On clinical examination 75/348 (22%) entheseal sites were abnormal and on US examination 195/348 (56%) sites were abnormal. In 19 entheseal sites with bursitis on US, only five were detected by clinical examination. Compared with US, clinical examination had a low sensitivity (22.6%) and moderate specificity (79.7%) for the detection of enthesitis of the lower limbs. There was no significant correlation between the US score of enthesitis and acute phase parameters such as erythrocyte sedimentation rate (ESR) or C reactive protein (CRP). The intraobserver kappa value for analysis of all sites was 0.9.

CONCLUSIONS

Most entheseal abnormality in SpA is not detected at clinical examination. US is better than clinical examination in the detection of entheseal abnormality of the lower limbs in SpA. A quantitative US score of lower limb enthesitis is proposed but further studies are required to validate it in SpA.

Erythroblast iron metabolism and serum soluble transferrin receptor values in the anemia of rheumatoid arthritis

OBJECTIVES

We have investigated in vitro erythroblast iron metabolism in the anemia of rheumatoid arthritis (RA). We also have examined the results in relation to bone marrow iron status in an attempt to explain the reported difference between serum soluble transferrin receptor (sTfR) values in anemia of chronic disease (ACD) and iron deficiency anemia (IDA) in patients with RA.

METHODS

Bone marrow was examined in 29 anemic patients with RA, 9 healthy volunteers, and 6 patients with simple IDA. High purity erythroblast fractions were prepared from these bone marrow samples. Erythroblast surface TfR expression and iron uptake was assessed in vitro using (125)I-transferrin (Tf) and (59)Fe-Tf, respectively. The efficiency of erythroblast surface TfR function for Tf-iron uptake was determined by relating total iron uptake at 4 hours to surface TfR number. Serum sTfR values were measured for the RA anemia group, which was subdivided as RA-ACD (marrow iron present) or RA-IDA (marrow iron absent) on the basis of visible reticuloendothelial (RE) marrow iron stores.

RESULTS

High purity (87 +/- 5%) erythroblast fractions were obtained from 35 of the 44 marrow samples. Erythroblasts obtained from patients with simple IDA showed a significant increase in surface TfR expression (P = 0.0003) and Tf-iron uptake (P = 0.001). RA anemia also led to a significant increase in erythroblast Tf-iron uptake (P = 0.016). This increase was not associated with an increase in surface TfR expression (P = 0.5), but was seen to occur as a result of a significant increase in the efficiency of surface TfR for Tf-iron uptake (P = 0.027). Within the RA anemia group, the increase in erythroblast Tf- iron uptake at 4 hours was more evident for RA-IDA (3.96 +/- 1.73 versus 1.66 +/- 0.66; P = 0.03) than for RA-ACD (2.69 +/- 1.18 versus 1.66 +/- 0.66; P = 0.057). This additional erythroblast response to absent RE iron stores led to a highly significant difference in serum sTfR values between RA-IDA and RA-ACD (40.2 +/- 14.0 versus 23.9 +/- 5.3 nmoles/liter; P = 0.001)

CONCLUSIONS

An increase in erythroblast surface TfR efficiency for Tf-iron uptake compensates for the low plasma iron levels associated with anemia in RA and helps to maintain RA erythroblast iron uptake. With adequate RE iron stores, this increased efficiency limits intracellular iron deprivation and consequently reduces the need to increase surface TfR expression. As a result, serum sTfR levels in RA-ACD remain within the normal range. RA erythroblasts, however, are still able to respond to any additional worsening of the iron supply caused by absent RE iron stores. This additional response causes the highly significant increase in serum sTfR values seen between RA-IDA and RA-ACD.

Metacarpophalangeal joints in rheumatoid arthritis: laser Doppler imaging--initial experience

Laser Doppler imaging is a noninvasive method yielding a spatial perfusion map. With use of a near-infrared laser, elevated perfusion associated with the metacarpophalangeal joints was detectable in patients with active rheumatoid arthritis. Findings at laser Doppler imaging correlated with pain scores and synovitis detected at ultrasonography, whereas the power Doppler sign (red pixels inside the active green box) did not. Laser Doppler imaging has the potential to help assess soft-tissue inflammation.

A prospective 2-year study of 75 patients with adult-onset septic arthritis

AIMS AND METHODS

To assess the clinical features of septic arthritis and characterize therapeutic strategies and outcome in a prospective study of 75 patients selected by positive synovial fluid culture.

RESULTS

Underlying joint disease was present in 46 patients, 25 of whom had rheumatoid arthritis and 15 osteoarthritis. Eleven patients were i.v. drug abusers. Fifty-six per cent of cases involved the knee, 15% involved two or more joints, and staphylococci and streptococci were cultured in >90%. Seventy-eight per cent of patients lived in areas of high social deprivation. Fever was present in 64% and the white cell count (WCC) was normal in 38%. The C-reactive protein was elevated in 98%. Leg ulcers were present in 11% of all patients but in 38% of patients who died (P<0.006). Median duration of antibiotic therapy was 15 days i.v. with subsequent oral treatment for 21 days. Thirty-seven per cent of cases required surgical intervention. Mortality was 11%. A raised WCC at presentation (P<0.02) and the development of abnormal renal function (P<0.015) were predictors of poor prognosis.

B cell receptor-stimulated mitochondrial phospholipase A2 activation and resultant disruption of mitochondrial membrane potential correlate with the induction of apoptosis in WEHI-231 B cells

Cross-linking of the Ag receptors on the immature B cell lymphoma, WEHI-231, leads to growth arrest and apoptosis. We now show that although commitment to such B cell receptor (BCR)-mediated apoptosis correlates with mitochondrial phospholipase A(2) activation, disruption of mitochondrial function, and ATP depletion, it is executed independently of caspase activation. First, we demonstrate a pivotal role for mitochondrial function in determining B cell fate by showing up-regulation of cytosolic phospholipase A(2) expression, induction of mitochondrial phospholipase A(2) activity, arachidonic acid-mediated collapse of mitochondrial transmembrane inner potential (Delta psi(m)), and depletion of cellular ATP under conditions of apoptotic, but not proliferative, signaling via the BCR. Importantly, disruption of Delta psi(m), ATP depletion, and apoptosis can be prevented by rescue signals via CD40 or by Delta psi(m) stabilizers such as antimycin or oligomycin. Second, we show that commitment and postmitochondrial execution of BCR-mediated apoptosis are not dependent on caspase activation by demonstrating that such apoptotic signaling does not induce release of cytochrome c from the mitochondria or activation of effector caspases, as evidenced by poly(ADP-ribose) polymerase or Bcl-x(L) cleavage. Indeed, apoptotic signaling via the BCR in WEHI-231 B cells does not stimulate the activation of caspase-3 and, consistent with this, BCR-mediated disruption of Delta psi(m) and commitment to apoptosis take place in the presence of caspase inhibitors. In contrast, BCR signaling induces the postmitochondrial activation of cathepsin B, and resultant apoptosis is blocked by the cathepsin B inhibitor, (23,35)trans-epoxysuccinyl-L-leucylamindo-3-methylbutane ethyl ester (EST) suggesting a key role for this executioner protease in Ag receptor-driven apoptosis of WEHI-231 immature B cells.

Intraobserver repeatability and interobserver reproducibility in musculoskeletal ultrasound imaging measurements

OBJECTIVE

To assess the repeatability and reproducibility of ultrasonographic measurements at the anterior surface of the femoral neck and iliofemoral ligament and on a human tissue-mimicking phantom.

METHODS

Two independent investigators studied 22 consecutive hips. One investigator had previous experience in musculoskeletal ultrasonography (US). The other investigator had undergone a short course in hip sonography (only 3 hours). Both investigators were blinded to their own and each other's results. On the phantom both observers had taken 10 vertical measurements at 6 cm deep where two objects were placed at 2 cm from each other. Calculation of measurement errors, percent errors and the Bland-Altman graphic technique were used for analysis of data.

RESULTS

After 132 examinations the first investigator's within-subject standard deviation was 0.4 mm. The intraobserver error was 4.75%. The second investigator's within-subject standard deviation was 0.6 mm and his intraobserver error was 7.00%. The interobserver error was 10.91%. After 20 phantom examinations the first investigators's intraobserver error was 1.11% and the second investigator's intraobserver error was 1.47%.

CONCLUSION

An inexperienced musculoskeletal sonographer can achieve an acceptable performance if given appropriate training.