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The distribution of the HLA-DR allele frequencies of 105 RA patients has been compared with the expected distribution under recessive and dominant modes of inheritance using control data from 2041 controls and the antigen genotype frequency among patients methodology. The observed distribution was compatible with a recessive mode of HLA-linked inheritance in RA, with a dominant mode rejected, whether HLA-DR4 was considered alone, or HLA-DR4 and HLADRI were combined as if they were behaving as a single predisposing gene. Mean sibship concordance rates (MSCRs) were calculated for categories of proband HLA-DR genotypes. The highest MSCR was seen for HLA-DR4 homozygous probands, and the lowest for HLA-DR2 or 7/non-4 genotypes. These combined observations suggest that interactions between both inherited HLA-haplotypes are important in the predisposition to RA. [ABSTRACT FROM PUBLISHER]

One hundred and forty-two RA patients and 121 of their healthy same-sexed siblings were tested for antibodies (Abs) to by indirect immunofluorescence. Eighty-five individuals had active RA (CRP>10 mg/l) and 57 inactive RA. The anti- Ab titre in the active RA group was significantly higher than in the inactive RA and non-RA group (<0.0001 in both cases). Anti- Abs were significantly elevated in 30 individuals with active RA compared with their healthy HLA-identical same-sexed siblings (>0.001). In 42 HLA-DR4 positive and 15 HLA-DR4 negative active RA patients, the Ab titre was non-significantly higher in the former group. Anti- Abs were not significantly elevated in any of the groups. Longitudinal data on 36 RA patients demonstrated a significant positive correlation between changes in CRP and changes in antibody titres (=0.52, <0.001). These observations require an explanation. [ABSTRACT FROM PUBLISHER]

We report a 6-yr follow-up study of an original population of 50 patients who had three or more major joints (hips and knees) replaced. Thirty-one of 32 surviving patients were still ambulant in the community, and all patients described significant pain relief. No RA patient was requiring permanent inpatient or residential care and the family remained the main social support. They remained a very disabled group with a median Health Assessment Questionnaire score of 2.75. Ten required revision surgery: three hips and seven knees; four patients required their fourth lower limb joint (hip/knee) replaced and seven patients required surgery to the upper limbs and nine feet during the follow-up period. The median 10-yr survival of hip and knee arthroplasties in multiple joint replacement (MJR) patients with RA was 90.5 and 78.6% respectively. There was an increased incidence of cervical myelopathy in MJR patients 16.9%. The mortality rate was higher than expected (standardized mortality ratio = 590) but the actual surgery was not implicated. MJR therefore appears to be a worthwhile policy, even at long-term follow-up. [ABSTRACT FROM PUBLISHER]

We have studied anti- antibodies (APA), isolation of , and their relation to various measures of RA disease activity. Seventy RA patients with a CRP>10 mg/l had higher APA titres than 17 RA patients with CRP≤10 mg/1 ( = 0.006), and 36 non-RA controls ( = 0.003). However, in a cross-sectional study of the RA group, there was no correlation between APA and a number of clinical and laboratory measures of disease activity, including the CRP and Stoke RA activity index. A longitudinal study showed no correlation between changes in these measures of disease activity and change in APA titre. We were unable to isolate in the urine or faeces of RA patients more frequently than controls, and the isolation of did not correlate with serum APA titres. Urinary APA was present in equal frequencies in RA and non-RA patients. NSAIDs, DMARDs and steroids did not appear to influence APA titres in the RA group. These results suggest that APA may act as an acute phase protein, distinct from CRP, but not correlating with RA disease activity in its broadest context. The fact that the antibody we are measuring binds to may be irrelevant, and the study does not support a role for in RA. [ABSTRACT FROM PUBLISHER]

Objectives. The NICE re-appraisal of anti-TNF requires demonstration of ongoing response, making the baseline 28-joint Disease Activity Score (DAS28) crucially important. A retrospective analysis of all RA patients on their first anti-TNF determined predictive factors for those classified as non-responders at 6 months according to current NICE guidelines. [ABSTRACT FROM PUBLISHER]

Objectives. A discrepancy exists between the National Institute for Health and Clinical Excellence (NICE) guidelines for continuation of TNF therapy in RA and EULAR response criteria. We performed a retrospective study of patients starting anti-TNF therapy to establish how many NICE non-responders would have met EULAR response criteria, and whether this may increase. [ABSTRACT FROM PUBLISHER]

The author tackles the issues about discharging patients with rheumatoid arthritis. The author describes the practice and research in inflammatory joint disease particularly rheumatoid arthritis (RA) in terms of quality of care, the cost, primary care physician (PCP), follow-up and clinical research. The author concludes that RA must be evaluated through a multidisciplinary specialist service. The author calls for agreed management protocols for the long-term management of inflammatory joint disease to avoid further inequality of specialist services.

Objectives. National Institute for Health and Clinical Excellence (NICE) guidelines for anti-tumour necrosis factor (TNF) in rheumatoid arthritis (RA) state that two pre-assessments of Disease Activity Score (DAS28) should be performed a month apart. We performed a retrospective audit of data from six centres to determine the stability of DAS28 between assessments, and the proportion of patients still satisfying eligibility criteria at baseline. [ABSTRACT FROM PUBLISHER]

In view of the variable and unpredictable efficacy and toxicity of non-steroidal anti-inflammatory and disease-modifying anti-rheumatic drugs, it is not surprising that some patients with rheumatoid arthritis elect to cope without recourse to these medications. We describe four of these patients, consider the lessons to be learnt, and identify further research that needs to be done on this aspect of illness behaviour. [ABSTRACT FROM PUBLISHER]

A letter to the editor about cases of neutropenia with etanercept is presented.

A letter to the editor is presented about the impact of the appraisal consultation document by the National Institute for Health and Clinical Excellence (NICE) on anti-tumor necrosis factor (TNF) therapy for ankylosing spondylitis.

A 28-year-old Nigerian woman presented with persistent pyrexia, marked pruritis, eosinophilia, myalgias, flitting arthralgias, serositis and massive splenomegaly. Intensive investigation for an infective or neoplastic aetiology proved negative. Empirical treatment for helminthic infections and tuberculosis was unhelpful. Although there were no specific clues to suggest an underlying connective tissue disease, a trial of steriods and azathioprine was introduced, with no obvious response. Her condition deteriorated to a point where it was decided that intravenous immunosuppressive therapy was needed and subsequently, her condition improved remarkably. This patient illustrates the problems in the diagnosis and management of complex disorders, particularly when classical tests for connective tissue diseases are absent. Also, we would like to report that marked pruritis can be associated with connective tissue disease. [ABSTRACT FROM PUBLISHER]