Anti-tumor necrosis factor (TNF) therapy for the management of rheumatic diseases has been reimbursed in Australia progressively per agent and disease indication since 2003. Initial projections of uptake were grossly overestimated. In this article the anti-TNF experience in Australia is reviewed, including results of an eligibility study, Australian Rheumatology Association guidelines, anti-TNF registry, and a report of adverse effects. These observations may assist APLAR countries currently coming to terms with anti-TNF drug registration and funding.
The Bone and Joint Decade (2000–2010) provides a catalyst for the further development of musculoskeletal medicine. The Bone and Joint Decade (BJD) provides an opportunity to bring together industry, governments, health professionals and patients to further research education and services in musculoskeletal diseases.
The challenges for musculoskeletal medicine include an ageing population suffering increasingly from chronic multisystem disease, new technologies including pharmaceuticals, biomaterials and prostheses which come at increasing cost, and a health system which is increasingly required to focus on cost-effectiveness, patient outcomes and patient involvement.
All those involved in providing services in the area of musculoskeletal medicine have an opportunity to work together and create new systems of healthcare delivery. This is likely to involve a blurring of the barriers between the specialties and the health professions themselves to create a more sustainable, outcomes-orientated health delivery system. It may lead to task substitution within the musculoskeletal health professionals, the emergence of new forms of ‘generic’ musculoskeletal health professionals and significant changes in the way we delivery education and research. The new ‘musculoskeletal medicine’ will depend much more on inter-professional training, multidisciplinary research and team management with a patient outcome focus.
Abstract Despite the improvement in survival of patients with systemic lupus erythematosus (SLE) in the past few decades, manifestations that are refractory to conventional therapies, and complications as a result of treatment, are still major concerns in SLE management. Novel therapeutic modalities for SLE should aim at enhancing treatment efficacy, reducing the risk of disease flares, as well as decreasing the incidence of short-term and long-term toxicities. This article summarizes the newer therapeutic modalities that have been used in patients with SLE and those which are undergoing clinical trials.
Introduction: 1. A major long-term determinant of anterior cruciate ligament (ACL) graft strength is the biological remodeling process to which the ACL graft collagen matrix is subjected immediately after surgical implantation. The collagen matrix provides the tensile strength of ligaments. Previous quantitative ultrastructural studies have shown that both human and goat anterior cruciate ligament patellar tendon (ACL-PT) autografts contain mainly small diameter collagen fibrils (< 100 nm) at 3–20 years post-surgery irrespective of the tissue of origin of the graft. Similar observations have recently been reported for human ACL allografts over an 8 year period.¹ 2. Parry and Craig (1988) suggested there was a strong correlation between large collagen fibrils and the ultimate tensile strength and modulus of ligaments/tendons. This part of the study was designed to test the hypothesis that there was a positive correlation between large collagen fibrils and the tensile modulus and the area-normalized ultimate load of patella tendon preparations subjected to loading and unloading conditions.
Abstract Ultrasonography is a useful imaging modality for the diagnosis of pathologic conditions in the biceps tendon. We describe a 64-year old man with rheumatoid arthritis (RA) who suddenly developed a painless lump in the antecubital region of the right arm. The bulging was prominent when he flexed his forearm. Proximal loss of the long head in biceps tendon could be demonstrated by ultrasonography. The ultrasonographic features of spontaneous isolated biceps tendon rupture occurring in a patient with RA are described.
Abstract This report describes a 60-year-old woman with chronic active rheumatoid arthritis (RA) with rheumatoid heart disease treated successfully with infliximab. The patient had a history of rheumatoid heart disease, presented with cardiac failure and also had active polyarthritis. Two-dimensional echocardiogram (2-DE) showed ejection fraction (EF) of 35%. Infliximab therapy at 3 mg/kg was given to the patient, at weeks 0, 2, and 6 and then 8-weekly. There was complete remission of her joint symptoms and the EF improved to 55%. Patients with active arthritis and rheumatoid heart disease can benefit from infliximab.
Abstract Informed consent is today of paramount importance to the dental and medical professions because of modern ethical issues and medico-legal consequences. This paper looks at the risk communication by medical and dental practitioners as the patient's right to know constitutes the basis of modern medical ethics. The paper discusses informed consent for both clinical practices as well as for clinical research study.
The intervertebral disc (IVD) is the largest predominantly avascular, aneural, alymphatic structure of the human body. It provides articulation between adjoining vertebral bodies and also acts as a weight-bearing cushion dissipating axially applied spinal loads. The IVD is composed of an outer collagen-rich annulus fibrosus (AF) and a central proteoglycan (PG)-rich nucleus pulposus (NP). Superior and inferior cartilaginous endplates (CEPs), thin layers of hyaline-like cartilage, cover the ends of the vertebral bodies. The AF is composed of concentric layers (lamellae) which contain variable proportions of type I and II collagen, this tissue has high tensile strength. The NP in contrast is a gelatinous PG-rich tissue which provides weight-bearing properties to the composite disc structure. With the onset of age, cells in the NP progressively die as this tissue becomes depleted of PGs, less hydrated and more fibrous as the disc undergoes an age-dependent fibrocartilaginous transformation. Such age-dependent cellular and matrix changes can decrease the discs’ biomechanical competence and trauma can further lead to failure of structural components of the disc. Annular defects are fairly common and include vertebral rim-lesions, concentric (circumferential) annular tears (separation of adjacent annular lamellae) and radial annular tears (clefts which initiate within the NP). While vascular in-growth around annular tears has been noted, evidence from human post-mortem studies indicate they have a limited ability to undergo repair. Several experimental approaches are currently under evaluation for their ability to promote the repair of such annular lesions. These include growth of AF fibrochondrocytes on a resorbable polycaprolactone (PCL) bio-membrane.1 Sheets of fibrochondrocytes lay down type-I collagen and actin stress fibres on PCL. These matrix components are important for the spatial assembly of the collagenous lamella during annular development and correct phenotypic expression of cells in biomatrices.1 An alternative approach employs preparation of tissue engineered IVDs where AF and NP cells are separately cultured in polyglycolic acid and sodium alginate biomatrices, either separately or within a manifold designed to reproduce the required IVD dimensions for its use as a prospective implant device.2 AF and NP cells have also been grown on tissue culture inserts after their recovery from alginate bead culture to form plugs of tissue engineered cartilage.3 A key component in this latter strategy was the stimulation of the high density disc cell cultures with osteogenic protein-1 (OP-1) 200 ng/mL.3 This resulted in the production of tissue engineered AF and NP plugs with compositions, histochemical characteristics and biomechanical properties approaching those of the native disc tissues.2,3 Such materials hold great promise in future applications as disc or annular implants. The introduction of appropriate genes into disc cells by gene transduction methodology using adenoviral vectors or ‘gene-gun’ delivery systems also holds considerable promise for the promotion of disc repair processes.4 Such an approach with the OP-1 gene is particularly appealing.5 The anchoring of discal implants to vertebral bodies has also been evaluated by several approaches. A 3D fabric based polyethylene biocomposite holds much promise as one such anchorage device6 while biological glues used to seal fibrocartilaginous structures such as the AF and meniscus8 following surgical intervention, also hold promise in this area. Several very promising new experimental approaches and strategies are therefore currently under evaluation for the improvement of discal repair. The aforementioned IVD defects are a common cause of disc failure and sites of increased nerve in-growth in symptomatic IVDs in man and are thus often sources of sciatic-type pain. Annular defects such as those described above have formerly been considered incapable of undergoing spontaneous repair thus a clear need exists for interventions which might improve on their repair. Based on the rapid rate of progress and the examples outlined above one may optimistically suggest that a successful remedy to this troublesome clinical entity will be developed in the not so distant future.
1Johnson WEB et al. (2001) Directed cytoskeletal orientation and intervertebral disc cell growth: towards the development of annular repair techniques. Trans Orthop Res Soc 26, 894.
2Mizuno H et al. (2001) Tissue engineering of a composite intervertebral disc. Trans Orthop Res Soc 26, 78.
3Matsumoto T et al. (2001) Formation of transplantable disc shaped tissues by nucleus pulposus and annulus fibrosus cells: biochemical and biomechanical properties. Trans Orthop Res Soc 26, 897.
4Nishida K et al. (2000) Potential applications of gene therapy to the treatment of intervertebral disc disorders. Clin Orthop Rel Res 379 (Suppl), S234–S241.
5Matsumoto T et al. (2001) Transfer of osteogenic protein-1 gene by gene gun system promotes matrix synthesis in bovine intervertebral disc and articular cartilage cells. Trans Orthop Res Soc 26, 30.
6Shikinami Y , Kawarada (1998) Potential application of a triaxial three-dimensional fabric (3-DF) as an implant. Biomaterials 19, 617–35.
Abstract Children born from mothers positive for autoantibodies against SSA/Ro and/or anti-SSB/La ribonucleoproteins may develop heart conduction tissue damage resulting in atrioventricular block and/or transient skin rash, liver enzyme abnormalities and anaemia/thrombocytopenia. Additional transient electrocardiographic abnormalities (sinus bradycardia, QT interval prolongation) have been reported. Such clinical and laboratory manifestations are included in the so-called neonatal lupus syndromes, independently whether the mother is suffering from a systemic autoimmune disease or is totally asymptomatic. The prevalence of the congenital heart block is around 2%, of neonatal rash around 20%, while laboratory abnormalities in asymptomatic babies can be detected in up to 40% of cases. The risk of recurrence of complete heart block is almost 10 times higher in the following pregnancies. Most of the mothers are asymptomatic at delivery and are identified only by the birth of an affected child. Their long-term outcome is generally more reassuring than previously assumed and arthralgias and xerophtalmia are the most common symptoms. A standard therapy for heart blocks detected in uterus is still a matter of investigation, although fluorinated corticosteroids have been reported to be effective on myocarditic signs when present. Serial echocardiograms and obstetric sonograms, performed at least every two weeks, starting from the 16 weeks gestation, are recommended in anti-Ro/SSA positive pregnant women: the goal is to detect early fetal abnormalities, that might precede complete atrioventricular block and that might be a target of preventive therapy. Transplacental passage of maternal anti-SSA/Ro -SSB/La IgG is thought to be pivotal in inducing tissue damage. However, the discordant appearance of the syndrome in twins does suggest a role also for fetal or environmental factors.
Skeletal growth factors participate in the formation of the bones and joints during development, as well as bone modelling during growth and bone remodeling in maturity. Bone morphogenetic proteins and their antagonists collaborate during skeletal morphogenesis. These and other growth factors also regulate the differentiation of mesenchymal stem cells into mature osteoblasts, and control the production of bone matrix during bone formation. They also regulate, in complex ways, the turnover of bone initiated by osteoclastic resorption of bone. Factors such as TGFβ, sequestered in the bone matrix, are released during bone resorption and are likely to be important in promoting the synthesis of new replacement bone. An understanding of the biology of agents that are anabolic in bone is enabling pharmaceutical approaches to providing better quality bone in osteoporosis and osteopenia, as well as the repair and regeneration of bone. Particular examples are the increased bone mass that can be achieved by intermittent injection of parathyroid hormone, and the enhanced repair of fracture and regeneration of bone defects that administration of BMP2 or BMP7 enables. Thus, newly available anabolic agents are enabling exciting new treatment paradigms for metabolic bone diseases, such as osteoporosis and for orthopedic procedures such as fracture repair.
Aim: To investigate the feasibility, efficacy and safety of high-dose immunosuppressive therapy and autologous peripheral blood stem cell transplantation (PBSCT) with CD34+ cell selection in patients with refractory and severe autoimmune diseases.
Methods: Eighteen patients with persistent systemic lupus erythematosus refractory to conventional treatment were enrolled into the study of peripheral blood stem cell transplantation in Peking Union Medical College Hospital from 1999 to 2005. After mobilization and conditioning, the enriched CD34+ cells were reinfused. Disease activity, adverse effects, haematopoietic and immunologic reconstitution were monitored and followed up for at least 6 months.
Results: Overall treatment-related mortality was 5.6% with one patient dying of cytomegalovirus infection. The overall remission rate was 95.8% in the first year after PBSCT. Relapse occurred in three patients (17.6%) in 37, 26, and 19 months post-transplantation, respectively. Disease Activity Index scores of systemic lupus erythematosus survivors were decreased significantly (P < 0.001).
Conclusions: Short-term effect of autologous peripheral blood stem cell transplantation is promising although treatment-related mortality and relapses are observed in a subset of patients. High-dose immunosuppressive therapy followed by autologous peripheral blood stem cell transplantation with CD34+ cell selection is feasible and relatively safe in the treatment of severe and refractory autoimmune diseases. The long-term effect needs further evaluation and multicentre study.
Aim: To study the prevalence of rheumatic disorders in two Aboriginal populations on the western coast of Cape York Peninsula.
Methods: Physical and radiological examination of 217 adult Aborigines at Aurukun Aboriginal Mission and 71 Aboriginal adults at Weipa Mission. The study was performed in October 1965.
Results: Mild to moderate degenerative arthritis was not uncommon in the populations examined. However, generalised or nodal osteoarthritis was not seen. One young woman had definite sero-positive rheumatoid arthritis. This woman's appearance suggested some Torres Strait Islander influence. No case of gouty arthritis or classical ankylosing spondylitis was encountered. An incidental finding of retrospective interest was that the calculated body mass index showed that the majority of adults were underweight by Caucasian standards.
Conclusions: These findings are of historic interest given the health impacts of social, cultural and environmental circumstances of Aborigines currently reported.
Abstract In some patients with psoriatic arthritis, arthritis may precede psoriatic skin lesions. In fact, psoriatic skin lesions may not develop for more than 10 years after the onset of arthritis. Making diagnostic and therapeutic decisions in such patients is therefore challenging. We describe a case with classic features of psoriatic arthritis without psoriatic skin or nail lesions for 21 years. We suggest that recognition of psoriatic arthritis sine psoriasis is important for selecting appropriate therapy to prevent joint damage.
Abstract We describe a 48-year-old woman with dermatomyositis complicated with interstitial pneumonia. The pulmonary lesion was refractory; however, several therapeutic regimens such as steriod pulse therapy or gamma globulin and cyclophosphamide, resolved the situation. Later she developed multiple brain abscesses thought to be responsible for immune depression; prolonged antimycotic therapy brought dramatic improvement. Brain abscess is a rare complication in such immuno-compromised cases; attention should be given to the possibility of deep mycosis, especially brain abscess.
Abstract Acinar cell carcinoma of the pancreas is rare and can occur with the unusual presentation of arthritis and panniculitis that mimic erythema nodosum. We report a case and review the available literature regarding this rare condition of erythema nodosum and panniculitis associated with bilateral ankle and feet pain, which has rendered the patient virtually wheelchair-bound.
Abstract Angioedema has different causes and different clinical presentations that has two forms: acquired angioedema (types I and II) and hereditary angioedema. However, acquired angioedema type-II is a very rare disorder and there is no significant treatment. So, in this paper, we propose to report the successful use of combination therapy of deflazacort and danazol for two such cases.
Abstract The use of haematopoietic stem cell transplantation (HSCT) has now expanded beyond the domain of haematological diseases. Increasingly, the benefits of intense immunosuppression in the management of severe autoimmune diseases are being recognized. In diffuse systemic sclerosis (SSc), there has been increasing evidence of the efficacy of HSCT in improving morbidity and mortality. We present the first Australian patient to undergo autologous HSCT for SSc and review the current literature in the use of HSCT in SSc. Remarkably, the patient had complete resolution of skin disease (modified Rodnan skin score 27/51–0/51), tenosynovitis, synovitis and myositis.
Aim: This study examined the frequency of secondary amyloidosis in Iranian patients with rheumatoid arthritis (RA) in order to determine its clinical significance.
Methods: A total of 220 RA patients (167 female, 53 male), with minimum disease duration of 5 years, were included in this prospective study over a period of about 2 years. Abdominal subcutaneous fat-pad aspiration (ASFA) method was used in obtaining specimens from all subjects. All of the specimens were examined for apple-green birefringence under polarized light microscope. Amyloid deposits were graded from 1+ to 3+. Clinical, radiological, and laboratory characteristics of the patients were assessed and recorded.
Results: Amyloid deposition was detected in 11 (5%) of the fat smears stained with Congo red stain. All of the samples had minimal (1+) amyloid deposits. In this study, amyloid-positive cases showed clinically significant symptoms; six of the patients (55%) presented with proteinuria, and seven other cases (64%) presented with severe constipation.
Conclusion: Abdominal fat amyloid deposition was found to be uncommon in adult Iranian RA patients. In up to half of the patients the deposits were subclinical. A longer follow-up and larger multicentric collaborative study is needed to determine the significance of subclinical amyloid deposits.
Aim: We performed a small study to examine the efficacy of caudal epidural analgesia in our patients with lumbosacral radicular pain, to assess the patient's tolerance of the procedure and to assess the willingness of patients to have the procedure repeated in future if offered.
Method: Patients with low back pain/sciatica being examined by rheumatology consultants were selected for caudal epidural injection. The procedure was done in the rheumatology ward as a day procedure. Bupivacaine 0.25% (15–25 mL) and triamcinolone (40 mg) were used.
Results: The majority of patients found improvement in pain. We did not come across any major side effects. A majority of patients were willing to have further injections.
Conclusion: Caudal epidural analgesia for sciatica and low back pain is a relatively safe and straightforward procedure.
Objective: This study was designed to search for a possible pathological involvement of renal arteries among patients with systemic sclerosis (SSc) and to correlate the findings with renal functions.
Patients and methods: Fourteen female patients with SSc were recruited for this study. The diagnosis and classification of SSc was based on the 1980 American College of Rheumatology criteria for classification of SSc. Nine patients had diffuse-type SSc, and the remaining five belonged to the limited type of the disease. All patients were evaluated by history-taking, clinical examination, laboratory investigations and renal angiography.
Results: Three out of the nine patients (33.3%) with diffuse SSc had tortuous renal arteries, but there were none in the limited type. Two patients (22.2%) with diffuse SSc had ectatic renal arteries and three (33.3%) had osteal renal artery stenosis. Tortuous abdominal aorta was detected in one patient (11.1%) with diffuse SSc and congenital double renal artery in another (11.1%). Two out of the five patients with limited-type disease (40%) had osteal renal artery stenosis that was bilateral in one case. Bilateral renal artery affection was observed in 3/14 studied patients (21.42%), and two of these had diffuse disease and one had limited disease. Three patients had hypertension (two had diffuse pattern and one had limited pattern).
Conclusion: We consider that renal artery stenosis is the most important among all the findings detected and should be considered in SSc patients presenting with renal crisis because use of angiotensin converting enzyme (ACE) inhibitors in this situation may be deleterious rather than beneficial.
Aim: The aim of this study is to evaluate pulmonary manifestations of ankylosing spondylitis on high-resolution computed tomography (CT) scan and to correlate these findings with clinical assessment, plain chest X-ray and pulmonary function tests.
Methods: The study comprised 32 patients (26 males [81.3%], 6 females [18.8%]) who met the modified New York criteria for diagnosis of idiopathic ankylosing spondylitis; in addition 10 normal subjects not complaining of any respiratory symptoms and matched for age and sex served as a control group. All patients were subjected to full history-taking, full clinical examination, chest X-ray, high-resolution computed tomography (HRCT) chest and pulmonary function tests.
Results: The abnormalities on HRCT included evidence of apical lung fibrosis in two patients (6.3%), interstitial lung disease in six (18.8%), minor interstitial abnormalities in eight (25%), bronchiectasis in four (12.5%), lung nodules in three (6.3%) and pleural thickening in five patients (6.3%). Nine patients (28.1%) showed negative findings by chest X-ray which revealed positive findings on HRCT. Five patients (15.6%) showed positive findings on both HRCT and plain chest X-ray, and 18 patients (56.3%) showed no findings on both HRCT and chest X-ray. Four patients (12.5%) showed normal pulmonary function tests, 25 (78.13%) showed restrictive pattern, 17 (53.13%) had obstructive pattern and 26 patients (81.3%) had diffusion defects.
Conclsuion: The identification of non-apical minor basal interstitial lung disease in our study which was previously reported in other studies, raises a possible association to ankylosing spondylitis. High-resolution CT scan is more sensitive than chest X-rays in detection of such minor interstitial lung disease (ILD), and other parenchymal lung changes.
Objectives: The aim of this study was to assess B-mode and power Doppler ultrasound findings of long head of biceps tendon in patients with ankylosing spondylitis (AS).
Methods: Anthropometric measurements were carried out and disease activity and functional status were evaluated with BASDAI, BASFI, Dougados Functional Index (DFI) and Articular Index (DAI) in 30 patients with AS. The Shoulder Disability Questionnaire (SDQ) was performed. Pressure pain threshold (PPT) was measured on bilateral long head of biceps tendon and B-mode and power Doppler ultrasound were carried out. Focal changes (hypoechogenic areas within the tendon), calcification of the tendon, and fluid collection inside or outside the tendon sheath at bicipital groove (peritendinous hypoechoic rim) and vascularity of the peritendinous region were assessed. A cumulative ultrasound score (CUSS) was obtained.
Results: Focal changes were present in five tendons of four patients. Calcification of the tendon was present in three tendons of three patients. Biceps tendon sheath effusion (peritendinous hypoechoic rim) was observed in 10 tendons of eight patients. Thirteen tendons of eight patients had discernible flow signals, six were inside the tendon sheath (within the hypoechoic rim) and seven were outside the tendon sheath. Cumulative US score correlated significantly with DFI and ESR. There was not a significant correlation between CUSS and total PPT.
Conclusion: Ultrasound examination of the long head of biceps tendon gives detailed information of the tendon and PDUS has the potential to be able to show inflammatory activity of the tendon.
Abstract A 30-year-old man with ankylosing spondylitis (AS) of 7 years duration consulted us for intractable neck pain of 2 months duration. Magnetic resonance imaging cervical spine showed inflammatory pannus around the dens and computed tomography scan showed fluffy periostitis at the attachment of the alar ligament. Cervical spine involvement in AS is reviewed.
Aim: The sex preference of ankylosis in collagen-induced arthritis is evaluated.
Method: Mice were immunized with bovine type II collagen emulsified with complete Freund's adjuvant H37Ra. The incidence of arthritis, arthritic score, number of paws with whole rear-paw swelling (WRPS), and number of paws with ankle ankylosis (Ankank) were monitored at various intervals after immunization.
Results: Arthritic score and number of paws with WRPS in each mouse were significantly higher in male than in female mice at 3, 5, and 8 weeks. On the other hand, there was no difference between male and female mice in arthritic score, number of paws with WRPS in each mouse, and number of paws with Ankank among ankles with WRPS at 10 and 15 weeks.
Conclusion: There was a suppressive effect on the development of arthritis in female mice. On the other hand, there was no sex difference in the incidence of ankylosis in arthritic ankles after arthritis was established.
Abstract Tumour necrosis factor-α is a pleiotropic cytokine which has a broad range of actions in inflammation, infection and immunity. TNF-α is supposed to play a crucial role in the pathogenesis of various autoimmune diseases. TNF-α blocking agents have been demonstrated to be highly effective in the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and juvenile rheumatoid arthritis. TNF-α inhibitors also have been tried with other rheumatic diseases and have emerged as promising treatments. We here review the current evidences of effectiveness of the anti-TNF-α therapy in various autoimmune diseases.
Aims: To assess the association between non-steroidal anti-inflammatory drug (NSAID) use and upper gastrointestinal (GI) tract-related hospitalizations and to evaluate inpatient healthcare resource utilization associated with these complications in Malaysia.
Methods: A retrospective case control study was performed using medical records of patients admitted to two Malaysian hospitals during 1999 and 2000. Cases were identified based on mode of presentation at hospital admission. One control was identified for each case, matched by age, sex and admission date. NSAID exposure was determined by drug use during one year prior to admission. Conditional logistic regression analysis was used to determine the association between NSAID use and upper GI complications, adjusting for predictors.
Results: The 273 cases were significantly more likely to have used NSAIDs in the year prior to hospitalization than controls (27.8%vs. 6.2% of patients; P < 0.0001). Conditional logistic regression analysis adjusting for other predictors showed that the odds of being hospitalized for upper GI tract complications were 4.1 times higher among NSAID users than non-users (95% CI = 1.88–9.12). Other risk factors for GI-related hospitalizations were a history of upper GI tract complications (OR = 5.8, 95% CI = 1.28–26.53), use of gastroprotective agents (OR = 5.3, 95% CI = 1.67–16.79), and use of antacids (OR = 5.0, 95% CI = 2.10–11.91) in the previous year.
Conclusion: This study demonstrated that NSAID exposure was significantly higher among patients hospitalized for GI-related complications than for other reasons, indicating that NSAID use is an independent risk factor for upper GI tract complications in this Malaysian sample.
Abstract Aim: The objective of this study was to investigate a possible association in rheumatoid arthritis (RA) of perinuclear antineutrophil cytoplasmic antibodies (pANCA) and joint failure requiring joint surgery as a well-defined functional end point. Methods: 188 patients with RA according to the American College of Rheumatology criteria, with a mean duration of disease of 18 years, were enrolled in a cross-sectional study. Patients were assessed for history of joint surgery, previous/current therapies, function according to the modified Health Assessment Questionnaire (mHAQ), rheumatoid factor (RF) and clinical and laboratory parameters of disease activity. ANCA were detected using indirect immunofluorescence. Results: Overall, 36.7% of patients were pANCA positive (including atypical pANCA) and 35.1% of patients had a history of joint surgery. There was no association between the presence of pANCA and joint surgery. No association was demonstrated between ANCA status and other prognostic markers such as RF, previous or current therapies and disease activity or function. Conclusion: No association between pANCA and joint surgery was demonstrated in this cohort of RA patients.
Background and method: This clinical experience involved the treatment of resistant systemic lupus erythematosus (SLE) patients with CD20 monoclonal antibody. Five patients failed conventional therapy, two developed complications and one needed rituximab as an emergency measure. Four patients had lupus nephritis, three had autoimmune hemolytic anemia, two had immune thrombocytopenia and one had lupoid hepatitis. The patients were aged 14–49 years, (mean 28.63). Three were Malays, two Chinese, two Indian and one Turkish; six were females. Mean disease duration was 63.25 months and mean total rituximab dose received was 2812.50 mL.
Results: Hemoglobin levels improved from 9.3 ± 5.7 to 13.1 ± 8.6 g/dL for two SLE patients with autoimmune hemolytic anemia after 34 weeks (P = 0.180). Platelet counts improved from 25 ± 17 to 198 ± 97 × 109/high powered field from 0 to 10 weeks for three SLE patients with immune thrombocytopenia (P = 0.109). In the lupus nephritis patients on rituximab, serum albumin improved from 24.5 ± 23.2 to 37.5 ± 31.8 mmol/L (n = 3) from week 0 to week 17 (P = 0.100). Urine protein creatinine ratio improved from 0.55 ± 0.23 to 0.08 ± 0.03 g/mmol creatinine (P = 0.068) from week 0 to week 13. C3 and C4 improved from 90.8 ± 36.5 to 120.7 ± 37.9 (P = 0.07) and 21.6 ± 10.1–27.3 ± 16.2 mg/dL (P = 0.27), respectively, and Systemic Lupus Erythematosus Activity Disease Index was reduced from 17.9 ± 11.2 to 6.3 ± 6.8 (P = 0.375) after 8 weeks. Two patients developed drug reactions to rituximab.
Conclusion: All of the patients responded to rituximab on top of their conventional therapy.
Abstract A 38-year-old female patient was diagnosed as a case of systemic lupus erythematosus (SLE) in 1994. Her initial presentation was nephritis which remitted on combination of steroid, azathioprine and pulse cyclophosphamide therapy. One year later the patient developed bilateral avascular necrosis (AVN) both hips and underwent bilateral hip replacement. In 2003 the patient developed bilateral AVN of both shoulders. In view of this uncommon presentation the patient screened for hidden secondary antiphospholipid syndrome and surprisingly investigations revealed negative anticardiolipin antibodies, weakly positive lupus anticoagulant test and positive reactivity against β2 glycoprotein 1. Although steroid is well know for its major role in AVN in patients with SLE, the presence of hidden secondary antiphospholipid syndrome augments the deleterious effects of steroid on bone and leads to AVN in uncommon sites. It is suggested that in SLE patients with positive lupus anticoagulant and negative antiphospholipid antibodies, testing for reactivity against β2 glycoprotein 1 is mandatory.
Abstract A 66-year-old woman developed firm, painless, slowly growing nodular masses over her elbows, fingers, toes, and left hip over four years. Aspiration of the elbow mass revealed a white chalky material that was shown to be carbonate apatite on infrared spectroscopy and energy dispersive X-ray spectroscopy. We discuss the classification of tumoral calcinosis and the nature of the calcium deposits. Tumoral calcinosis should be differentiated from tophaceous gout and calcium pyrophosphate dihydrate crystal deposition disease. Polarizing light microscopy and crystal analysis by X-ray and infrared spectroscopy, electron or X-ray diffraction will confirm the diagnosis. Secondary causes of tumoral calcinosis should also be excluded.