Correction to: Remarkable improvement in serum 25-hydroxyvitamin levels among hip fracture patients over a 12-year period: a prospective study in South-eastern Finland

The presentation of Table 4 was unclear in the original publication. The article has now been corrected in this respect.

Remarkable improvement in serum 25-hydroxyvitamin levels among hip fracture patients over a 12-year period: a prospective study in South-eastern Finland

Hypovitaminosis D is a problem among hip fracture patients. In a 1-year cohort study comprising 245 hip fracture patients (mean age of females 81 years and males 78 years) from south-eastern Finland, the mean 25-hydroxyvitamin D [S-25(OH)D] concentration was 73(SD 31) nmol/L. Vitamin D supplementation has been integrated into our current practice.

INTRODUCTION

The objectives of this study are to verify vitamin D levels among hip fracture patients and to compare the results with a similar study conducted in the same two hospitals covering the same geographic area 12 years ago.

METHODS

A prospective cohort comprising 245 Caucasian hip fracture patients was enrolled in the study in two acute hospitals in south-eastern Finland (61° N) over a 12-month period in 2015-2016. The S-25(OH)D was measured using 25-hydroxyvitamin D electrochemiluminescence binding assay. The S-25(OH)D concentrations were compared with the corresponding concentrations of a similar cohort analyzed in the same two hospitals 12 years ago.

RESULTS

Of the 245 patients, 70% were women with a mean age of 81 (SD 10) years, while the men had a mean age of 78 (SD 12) years (p < 0.01). The total mean S-25(OH)D concentration was 73 (SD 31.3) nmol/L. Regional differences were found: 15% in hospital A and 36% in hospital B had a S-25(OH(D level < 50 nmol/L, and the mean S-25(OH)D level was 79.2 (SD 31.7) nmol/L in hospital A and 62.4 (SD 27.5) nmol/L in hospital B (p < 0.001). No differences were found in S-25(OH)D concentrations by either the place of residence or the time of year. Overall, the percentage of patients with a sufficient vitamin D level (> 50 nmol/L) was remarkably higher in 2015-2016 (77%) than in 2003-2004 (22%).

CONCLUSION

Our results indicate that vitamin D supplementation has been widely integrated into our current practice. However, regional differences were found in the S-25(OH)D concentrations for which the reasons are unknown.

Ankylosing spondylitis: current approaches to treatment

To date there is no definite cure for ankylosing spondylitis. However, modern treatment improves the quality of life and the final outcome for most patients. Patient education and physiotherapy form the basis of treatment. In pharmacotherapy, nonsteroidal anti-inflammatory drugs have a central role. Second-line drugs such as sulfasalazine, immunomodulating agents and other antirheumatic disease-modifying drugs should be applied if the disease is active. Corticosteroids are used mainly intra-articularly. The problem of osteoporosis in ankylosing spondylitis is gaining more interest, and efforts to prevent or treat it will increase. It is critical to make an early diagnosis of ankylosing spondylitis and in active cases start intensive therapy before irreversible damage takes place.

Fatal influenza A myocarditis with isolation of virus from the myocardium

A previously healthy 27-year-old woman developed an acute cardiac failure one week after onset of influenza-like respiratory infection, and died on her fourth day in hospital. Intravital differential diagnosis included myocardial infarction because of ECG changes and massive elevation of myocardial enzymes. Autopsy revealed severe myocarditis and intact coronary arteries. At microscopic examination the myocardium was heavily infiltrated with lymphocytes, and there was a marked myocytolysis. Influenza A virus was isolated from the myocardial tissue. An immunological mechanism of myocardial damage is suggested.

Association of tumour necrosis factor a, b and c microsatellite polymorphisms with clinical disease activity and induction of remission in early rheumatoid arthritis

OBJECTIVE

To study the associations of tumor necrosis factor (TNF) a, b and c microsatellite markers with 1) the clinical disease activity and 2) the induction of remissions in patients with early rheumatoid arthritis (RA) treated with two treatment strategies.

METHODS

In the FIN-RACo (FINnish Rheumatoid Arthritis Combination therapy) trial of two years, 195 patients with recent-onset RA were randomly assigned to receive either a combination (COMBI) (sulphasalazine, methotrexate, hydroxychloroquine, and prednisolone) or a single (SINGLE) (initially sulphasalazine with or without prednisolone) disease modifying antirheumatic drug (DMARD) therapy. TNF a, b and c microsatellite and HLA-DRB1 typings were carried out in 165 (79 COMBI; 86 SINGLE) study completers.

RESULTS

At baseline the 28 joint disease activity scores (DAS28) of the patients positive for TNFa2, a13 or b1 microsatellite markers were significantly higher than in the other patients. In the SINGLE patients the DAS28 improved comparably in patients with (n = 31) or without (n = 53) the TNFb1 marker (NS), while the DAS28 of the TNFb1-positive COMBI patients (n = 22) improved significantly more than that of the TNFb1-negative cases (n = 57) (p = 0.014). Respective 31.8% (7/22) and 28.1% (16/57) of the COMBI patients with or without TNFb1 allele achieved remission at one year. The corresponding figure in SINGLE patients were 0% (0/31) and 20.8% (11/53) (p = 0.006). At two years the remission frequencies in the TNFb1+/TNFb1- patients in the COMBI and SINGLE were 50.0%/38.6% and 9.7%/22.6%, respectively.

CONCLUSION

Early TNFb1+ RA patients have more active disease but respond more favourably to COMBI treatment than the patients without this microsatellite allele. The finding may be of clinical relevance for the choice of DMARDs in early RA.

Fatal myocardial necrosis caused by Staphylococcus lugdunensis and cytomegalovirus in a patient with scleroderma

A 42-year-old woman developed a rapidly progressing fatal heart failure. At the autopsy extensive necrosis of the myocardium was seen, with an almost complete absence of inflammatory cells and the presence of bacterial structures identified as Staphylococcus lugdunensis by PCR. In addition, the cytomegalovirus genome was found to be located inside the cardiomyocytes.

Which viruses should we look for in a recent onset polyarthritis

This review is concentrated on specifically diagnosable viral diseases causing recent onset polyarthritis. A suspicion of viral etiology of arthritis should arise when there are symptoms of infection such as fever, skin manifestations, neurologic signs, or when several cases are occurring at the same time, suggesting an outbreak. In addition to the history and clinical examination, serology is a key element in the diagnosis. Some of these infections are known to occur at certain geographic areas, and the local clinicians are aware of this possibility. HIV and HCV infections occur worldwide, and they should be kept in mind when treating patients with recent-onset arthritis.

HLA-DR-DQ haplotypes and genotypes in Finnish patients with rheumatoid arthritis

OBJECTIVES

To elucidate the contribution of HLA-DR-DQ haplotypes and their genotypic combinations to susceptibility to rheumatoid arthritis, and to evaluate the various models for HLA associated risk for the disease in a series of Finnish patients.

METHODS

322 Finnish patients with rheumatoid arthritis were typed for common north European HLA-DR-DQ haplotypes and compared with a series of 1244 artificial family based control haplotypes.

RESULTS

The association of the so called shared epitope (SE) haplotypes (DRB1*0401, *0404, *0408, and *01) with rheumatoid arthritis was confirmed. The DRB1*0401 haplotypes carried a far stronger risk for the disease than the (DRB1*01/10)-(DQA1*01)-DQB1*0501 haplotypes. Seven protective HLA haplotypes--(DRB1*15)-(DQA1*01)-DQB1*0602; (DRB1*08)-(DQA1*04)-DQB1*04; (DRB1*11/12)-DQA1*05-DQB1*0301; (DRB1*1301)-(DQA1*01)-DQB1*0603; (DRB1*1302)-(DQA1*01)-DQB1*0604; (DRB1*07)-DQA1*0201-DQB1*0303; and (DRB1*16)- (DQA1*01)-DQB1*0502--were identified. In accordance with the reshaped shared epitope hypothesis, all the protective DRB1 alleles in these haplotypes share either isoleucine at position 67 or aspartic acid at position 70 in their third hypervariable region motif. However, differences in the disease risk of haplotypes carrying the same DR but different DQ alleles were also found: (DRB1*07)-DQA1*0201-DQB1*0303 was protective, while (DRB1*07)-DQA1*0201-DQB1*02 was neutral. The same haplotypes carried different risks for rheumatoid arthritis depending on their combination in genotypes.

CONCLUSIONS

When assessing the influence of HLA genes on the susceptibility to rheumatoid arthritis, not only should the HLA-DR or -DQ alleles or haplotypes be unravelled but also the genotype. The effect of HLA class II region genes is more complicated than any of the existing hypotheses can explain.

Sindbis viruses and other alphaviruses as cause of human arthritic disease

Amongst the arthritis-causing arboviruses, i.e. those spread by insects, the alphavirus group is of special interest. These viruses occasionally cause vast outbreaks, such as O'nyong-nyong in Africa in 1959. In Fennoscandia, Sindbis-related Ockelbo, Pogosta, or Karelian fever viruses have been found to cause significant morbidity. The major symptoms in addition to joint inflammation are fever, fatigue, headache and rash. The joint symptoms may persist for weeks, even months. The diagnosis is based on the clinical picture and serology. The causative viruses are closely related but not identical. It appears that at least in Finland the Pogosta disease is more common than thought, and the symptoms may often be overlooked. Several factors related to the viruses, their hosts, and global environmental changes may affect the spread of these viruses. All over the world arbovirus-caused diseases have increased, because of global changes.

Reactive arthritis

Reactive arthritis is an infectious disease which may be initiated by several microbes in genetically susceptible hosts. The best known predisposing genetic factor is HLA-B27, but the mechanisms behind its action are still elusive. Worldwide agreement exists regarding the general guidelines in the diagnosis, differential diagnosis and management, even though official diagnostic criteria are not yet available. Several studies indicate that antibiotics are effective only if started before the immunological mechanisms of pathogenesis have been turned on. However, recent observations suggest that a 3-month course of antibiotics may diminish the late risk of chronic sequelae, especially in HLA-B27-positive patients with reactive arthritis.

Effect of a three month course of ciprofloxacin on the late prognosis of reactive arthritis

BACKGROUND

The value of antibiotics in the treatment of reactive arthritis (ReA) is still controversial.

OBJECTIVES

To analyse the long term outcome of patients with ReA, treated with a three month course of ciprofloxacin or placebo.

METHODS

Patients who had had ReA and had participated in a double blind, placebo controlled trial on the effectiveness of ciprofloxacin 4-7 years earlier were invited to a clinical examination. Of the 71 patients who were included in the original study, 53 agreed to visit the clinic for an examination. Twenty six of 53 patients had originally received ciprofloxacin and 27 had belonged to the placebo group. Of these, 20 in the ciprofloxacin and 25 in the placebo group were HLA-B27 positive.

RESULTS

11/27 (41%) patients in the original placebo group had now developed chronic rheumatic disease, as compared with only 2/26 (8%) patients originally treated with ciprofloxacin (p=0.006). Two patients who originally had received placebo, none in the ciprofloxacin group had developed ankylosing spondylitis, and three patients in the original placebo group, none in the ciprofloxacin group had recurrent anterior uveitis. The same tendency was seen when several different measures were analysed. Of the patients with chronic spondyloarthropathy, 10 in the placebo and none in the ciprofloxacin group were HLA-B27 positive.

CONCLUSION

Analysis 4-7 years after the initial ReA suggests that a three month course of antibiotics in the acute phase may have a beneficial effect on the long term prognosis.

The prevalence of antibodies against Sindbis-related (Pogosta) virus in different parts of Finland

OBJECTIVE

To study the occurrence of Sindbis-related (Pogosta) disease in Finland by serological means.

METHODS

A total of 2250 serum samples from five different areas were included in the study. Four hundred samples were collected from healthy blood donors and 1850 samples from patients who were suspected to have some viral infection. Antibodies of IgG and IgM classes against Pogosta virus were measured.

RESULTS

Eleven per cent of 2250 samples were positive for IgG and 0.6% were positive for IgM class antibodies against Pogosta virus. The antibody prevalence in Finland was almost equally distributed, being highest in western Finland (17%) and lowest in southern and northern Finland (9%). Of all samples with IgG class antibodies, 25% were taken from children under 10 yr of age.

CONCLUSIONS

The prevalence of antibodies against Pogosta virus was much higher than we expected. Additionally, they were detected from all locations studied and not only in eastern Finland, which has been thought to be the main endemic area for this disease. Pogosta disease has been considered to affect mainly middle-aged persons, but our results indicate a high prevalence also among children.

Prevalence of Sindbis-related (Pogosta) virus infections in patients with arthritis

OBJECTIVE

To determine the role of Pogosta virus as a triggering infection in non-specific arthritis.

METHODS

Serum samples of 142 patients with acute arthritis were screened for the evidence of Pogosta virus infection. Serological tests for Chlamydia trachomatis, salmonella, parvovirus B19, and Borrelia burgdorferi were also carried out. As verified later, 78 of the patients had rheumatoid arthritis and 63 seronegative poly- or oligoarthritis, while one had systemic lupus erythematosus.

RESULTS

In the early stage of the joint symptoms 4 patients with rheumatoid arthritis, 1 with seronegative polyarthritis and 1 with systemic lupus erythematosus had recent Pogosta virus infection. Four of them had probably had Pogosta disease at the time of the onset of arthritis. In 11 patients with a diagnosis of seronegative arthritis, serological evidence of preceding infection due to salmonella or Chlamydia trachomatis was found, strongly suggesting classical reactive arthritis in these cases.

CONCLUSIONS

Our study suggests that also a Sindbis virus infection may be associated both to an acute joint inflammation as a part of Pogosta disease or chronic arthritis. At present, this possibility still needs further research.

Reactive arthritis

Reactive arthritis is a disease affecting mostly young adults. Owing to a greater general awareness the diagnosis has become more common during recent years. It is well established that ReA is caused by an infection, mostly in genetically susceptible individuals. The pathogenetic mechanisms are still poorly understood, and the treatment rests mainly on anti-inflammatory drugs or steroids. Vigorous and early treatment of the triggering infection may prevent the development of ReA but this is rarely possible in everyday clinical practice. Despite its name, the disease should be considered as a general disorder that affects not only the joints. The prognosis is not as good as earlier believed, and relapses or chronic development are not unusual.

Bacteria-Triggered reactive arthritis: implications for antibacterial treatment

Reactive arthritis (ReA) is definitely caused by an infection. Several observations suggest that the triggering microbe may persist in the tissues of the patient for a prolonged time. The obvious conclusion is to consider antibacterial treatment. In two instances antibacterial agents are of definite value: in the primary and secondary prevention of rheumatic fever and for early eradication of Borrelia burgdorferi in order to prevent development of the arthritis associated with Lyme disease. Altogether, clinical and experimental data exist to indicate that if antibacterial treatment of ReA can be started very early during the pathogenetic process, the disease can be prevented or the prognosis improved. In fully developed ReA, the value of antibacterial agents is less certain. All available evidence indicates that short term antibacterial treatment has no effect on the prognosis and final outcome of ReA, and the results with long term administration of antibacterials are also overall poor. In some instances sulfasalazine appears useful, rather as a result of its antirheumatic effect or influence on an underlying inflammatory bowel disease than its action as an antibacterial agent. Tetracyclines have also been found to have an effect on ReA, but again, this is probably due to their anti-inflammatory action rather than any antibacterial effect.

Differences between female and male patients with familial rheumatoid arthritis

OBJECTIVE

To determine whether there are genetic differences between female and male patients with familial rheumatoid arthritis (RA).

METHODS

45 men and 119 women from 78 families with RA who all had at least one first degree relative with RA were compared. HLA-DRB1 alleles were analysed, including DRB1*04 subtypes and associations of DRB1*04 haplotypes with DQB1*0301 or DQB1*0302 alleles, the age of the patients at disease onset, the presence of rheumatoid factor (RF), joint erosions, and rheumatoid nodules.

RESULTS

HLA-DRB1*13 allele (the subtype allele of DR6, reported to be protective against the development of RA) was found in 14/119 (12%) of female but in none of the male patients (p=0.036). The HLA-DR4 allele was found slightly more often in men than women patients with familial RA (31/45 (69%) v 75/119 (63%), NS). Men were also more often RF positive than women (44/45 (98%) v 98/117 (84%); p=0.031). On the other hand, the mean age at onset of RA was significantly lower in the female group (40.4 years) than in men (46.6 years, p=0.0044).

CONCLUSION

The results indicate that there is stronger genetic background in familial male than female patients with RA in the genetic susceptibility defined by the studied HLA antigens. However, the earlier age of onset of the disease in female group and the increased proportion of women with RA indicate that there are additional sex related predisposing factors enhanced in familial cases.

Bacterial PCR in the diagnosis of joint infection

OBJECTIVES

To evaluate the value of broad range bacterial PCR in the diagnosis of joint infection and to find out if there are bacteria causing arthritis which are not cultivable by the present methods.

METHODS

Polymerase chain reaction (PCR) with broad range bacterial primers and DNA sequencing (bacterial PCR) was used to analyse 154 synovial fluid (SF) samples from patients with different arthritic diseases.

RESULTS

Bacterial DNA was detected in 18 SF samples, including samples from six patients with culture proven purulent arthritis, and from three patients with possible purulent arthritis. Three samples from patients with culture confirmed purulent arthritis remained negative in bacterial PCR.

CONCLUSIONS

The results indicate that in the usual diagnostic laboratory setting bacterial PCR does not offer any obvious advantage over bacterial culture in the microbiological diagnosis of joint infection.

BPI-ANCA is found in reactive arthritis caused by Yersinia and Salmonella infection and recognise exclusively the C-terminal part of the BPI molecule

OBJECTIVE

To examine the prevalence, binding sites and functional interactions of antineutrophil cytoplasmic autoantibodies (ANCA) against the bactericidal/permeability increasing protein (BPI) in reactive arthritis (ReA).

METHODS

Sera were analysed for the occurrence of ANCA by indirect immunofluorescence microscopy (IIF) and ELISA. Binding sites were determined using BPI, lipopolysaccharid binding protein (LBP), and fusion proteins of both proteins in ELISA. In addition, the effect of antibodies on the antibiotic activity of BPI was examined.

RESULTS

BPI-ANCA was found in patients with Yersinia- and Salmonella-triggered ReA and directed against the C-terminal portion of BPI. Goat anti BPI antibodies recognising this part inhibited the antibiotic activity of BPI in vitro.

CONCLUSION

BPI-ANCA was associated with ReA triggered by Salmonella and Yersinia infection. Directed against the C-terminal part of BPI, it can potentially inhibit its antibiotic activity and might be useful to identify patients with infectious bowel disease prone to extraintestinal sequelae.

HLA haplotype analysis in Finnish patients with rheumatoid arthritis

OBJECTIVE

To further characterize the HLA gene products that play an important role in the pathogenesis of rheumatoid arthritis (RA).

METHODS

One hundred thirty-four haplotypes from 67 Finnish RA patients and 77 control haplotypes were analyzed for HLA-DRB1 loci, associated alleles of the HLA-DQB1 locus, alleles of the type 2 transporter-associated antigen processing (TAP2) genes, and HLA-B27. In addition, a panel of microsatellite markers within the HLA class I and class III regions was studied.

RESULTS

The frequency of HLA-DRB1*04 in the haplotypes of RA patients was found to be 34% (45 of 134) compared with 14% (10 of 72) in control haplotypes (P = 0.004). The frequency of HLA-DRB1*13 was decreased in RA haplotypes (4%, or 5 of 134) in contrast to control haplotypes (24%, or 17 of 72) (P = 0.000031). The decrease in DRB1*13 was not secondary to the increase in DRB1*04, since it was also found among DRB1*04-negative haplotypes (P < 0.001). The DRB1*13-associated DQB1*0604 allele was similarly decreased in RA haplotypes (P = 0.025). The TAP2I allele of I/J dimorphism was increased in RA patients (85%, or 114 of 134) as compared with controls (69%, or 49 of 71) (P = 0.011). Of the tumor necrosis factor (TNF) microsatellite alleles, TNFa6 and TNFb5 were found to be increased in RA haplotypes (for a6 27% versus 5% in controls [P = 0.00043], and for b5 43% versus 26% in controls [P = 0.037]).

CONCLUSION

Both protection-associated and susceptibility-associated alleles can be found among HLA class II genes, and the results suggest that loci outside DR/DQ may contribute to the pathogenesis of RA.

Increase in T-cell subsets of oral mucosa: a late immune response in patients with treated coeliac disease?

BACKGROUND AND AIMS

In coeliac disease, the gut involvement is gluten-dependent. Following the introduction of a gluten-free diet, inflammatory cell infiltration decreases in the small intestinal mucosa. Our hypothesis was that the oral mucosa might mirror the changes found in coeliac disease similarly to the mucosa of the small intestine. Thus, the number of inflammatory cells in the oral mucosa would decrease in patients with coeliac disease on a gluten-free diet.

METHODS

The distribution CD45RO+ and CD3(+) T cells, T-cell subpopulations (CD4(+), CD8(+), T-cell receptor (TCR)alpha beta+ and TCR gamma delta+ cells) and HLA DR expression were studied in the buccal mucosa of 15 untreated and 44 gluten-free diet treated coeliac disease patients, and of 19 controls. All 15 patients with untreated coeliac disease were immunglobulin (Ig)A endomysial antibody positive and all 44 patients on gluten-free diet except one were endomysial antibody negative, as were all control subjects.

RESULTS

Untreated coeliac disease patients did not differ from controls in the densities of CD45RO+ cells, CD3(+) cells or of T-cell subsets. In contrast, in treated coeliac disease patients, a significant increase in the numbers of mast cells, CD3(+) and CD4(+) lymphocytes was found in the lamina propria of oral mucosa as compared with patients with untreated coeliac disease and controls. The increase in CD3(+) T cells was in part owing to an increase in lymphocytes expressing no TCR. No differences were found in the expression of human leucocyte antigen (HLA) DR in the epithelium or in the lamina propria in the patient groups studied or in the controls. In treated coeliac disease patients only a few TCR gamma delta+ T cells were found intraepithelially and in the lamina propria, but these cells were not detected in the lamina propria of oral mucosa of patients with untreated coeliac disease or in the controls.

CONCLUSIONS

The infiltration of T cells into oral mucosa was increased in treated coeliac disease patients in spite of adherence to a gluten-free diet. Because the CD3(+) T cell count was higher than those of the TCR alpha beta+ and TCR gamma delta+ T cells, there must be other cells involved, probably natural killer (NK) cells. The increase in T-cell subsets in the treated coeliac disease patients seems not to result from poor dietary compliance, but might occur as a late immune response in coeliac disease and reflect chronic immunologic stimulation followed by regeneration of memory T cells.

Prolonged arthritis associated with sindbis-related (Pogosta) virus infection

OBJECTIVE

A follow-up study of musculoskeletal symptoms after Pogosta virus infection.

METHODS

Twenty-six patients with earlier serologically confirmed Pogosta disease were examined. Ultrasonography of affected joints was performed in patients who had chronic musculoskeletal symptoms. Serum antibodies against Sindbis virus were determined. The patients were typed for HLA-DR and B27. Efforts were made using the polymerase chain reaction to demonstrate the virus.

RESULTS

Only 50% of the patients were symptomless 2.5 yr after onset of Pogosta disease. Three patients had fibromyalgia, six had occasional arthralgia and two had chronic arthritis.

CONCLUSIONS

The epidemiology of Pogosta disease is changing and practitioners should be better aware of it. Pogosta virus infection may lead to chronic musculoskeletal discomfort and arthritis.

Local challenge on oral mucosa with an alpha-gliadin related synthetic peptide in patients with celiac disease

OBJECTIVE

Gluten-derived peptides (e.g., amino-acids 31-49 of alpha-gliadin) have been shown to cause changes typical of celiac disease in the gut. Gluten-derived peptides have mostly been used in in vitro studies. The easiest access to the gastrointestinal system may be the mouth. In the present study we were interested to see whether a synthetic peptide corresponding to amino-acids 31-49 of alpha-gliadin could induce inflammatory changes in the oral mucosa after a local challenge in celiac disease patients.

METHODS

The challenge was made by injecting the peptide solution at a concentration of 10 microg/ml submucosally into the oral mucosa of 10 celiac disease patients after a gluten-free diet (GFD) and 12 healthy control subjects. B and CD45RO+ T cells, mast cells, CD3+, CD4+, CD8+ lymphocytes, and alphabeta and gammadelta T-cell receptor-bearing (TcR alphabeta, TcR gammadelta) lymphocytes were counted and HLA DR expression was determined. The expression of CD25 and Ki-67 antigen was also examined.

RESULTS

The peptide significantly increased the total number of T cells in the lamina propria of the celiac disease patients. The expression of T-cell activation marker CD25 (IL-2 receptor), but not that of cell proliferation marker Ki-67, was also significantly increased in the lamina propria after peptide challenge. Such a reaction was not observed in the controls. The numbers of CD3+ and CD4+ T cells in the lamina propria were also increased in celiac disease patients after the challenge. The count of TcR gammadelta+ cells was very small in the oral mucosa in celiac disease and showed no increase when the oral mucosa was challenged with the peptide. The expression of HLA DR staining was enhanced after the submucosal peptide challenge in celiac disease; however, the difference was not statistically significant.

CONCLUSIONS

The results show that in the celiac disease patients after the peptide challenge the oral mucosal lamina propria responds with a nonproliferative increase of lymphocytes. Thus, submucosal challenge with the peptide 31-49 can be used as an aid in the diagnosis of celiac disease. However, further studies with optimized methodology, including various concentrations of the peptide, adjuvants, other peptides, etc., are warranted, especially because the oral mucosa provides the easiest access to an in vivo peptide challenge in celiac disease.

Reactive arthritis

During the past year, no big advances were reported in understanding the pathogenesis or treatment of reactive arthritis (ReA). The need for generally accepted diagnostic criteria has become a central issue. Regarding pathogenesis, attention has been drawn to a similarity between ReA and the experimental antigen-induced arthritis. Molecular mechanisms of the HLA-B27-associated pathogenesis have remained, in spite of intensive research, so far a mystery. It is apparent that antibiotics have no effect on the fully developed reactive arthritis, with the exception of patients with Chlamydia-triggered ReA, who might benefit from a course of antibiotics.

Effect of a three month course of ciprofloxacin on the outcome of reactive arthritis

BACKGROUND

Treatment of reactive arthritis (ReA) with antibiotics has so far remained controversial. Eradication of the causative microbe appears logical, but short term antibiotic treatment has no beneficial effect on the outcome of ReA.

OBJECTIVE

To evaluate the effect of a three month course of ciprofloxacin on ReA.

METHODS

In a randomised, double blind, placebo controlled trial, between December 1992 and February 1996, 71 patients with acute ReA triggered by a gastrointestinal or a urogenital infection were randomly assigned to receive ciprofloxacin 500 mg or placebo twice daily for three months. Patients were assessed at study entry, at 6 weeks, 3 months, 6 months, and 12 months. Sixty two patients were valid for the efficacy analysis. The primary outcome measures were erythrocyte sedimentation rate, number of swollen joints, patients self assessment, and complete recovery.

RESULTS

Adverse events were mostly mild and occurred in both treatment groups. There were no statistically significant differences in any of the primary or secondary efficacy variables between the study groups at baseline or during the 12 month follow up. All primary outcome measures indicated that the condition of the patients improved during the study.

CONCLUSION

Both groups tended to recover. Ciprofloxacin, given as a three month course, had no advantage over placebo treatment.

Local challenge of oral mucosa with gliadin in patients with coeliac disease

In coeliac disease, gluten-containing diet challenges over many years are sometimes required for diagnosis, especially if the initial diagnosis was equivocal. The rectal gluten challenge has been proposed to simplify coeliac disease diagnosis. We were interested in studying whether the oral mucosa could be used for local challenge with gliadin as an aid in finalizing the diagnosis of coeliac disease. The study groups consisted of 37 treated coeliac disease patients and 10 controls. The challenges on the oral mucosa were performed either supramucosally with gliadin powder (coeliac disease patients) or by submucosal injection of dissolved gliadin (10 microg/ml) (coeliac disease patients and controls). A control challenge with submucosal gliadin solvent was made in the coeliac disease patients. B and T cells, mast cells and T cell subsets were counted and HLA-DR expression was determined. Biopsies were taken from each provoked area 24 h post-challenge. A significant increase in the number of CD4+ lymphocytes in the lamina propria (observed in 27/37 patients), but a decrease in the number of mast cells was observed in treated coeliac disease patients after submucosal challenge with gliadin. Following supramucosal challenge with gliadin the counts of intraepithelial CD4+ (in 25/37 patients) and CD8+ T cells (in 27/37 patients) increased significantly and the number of CD4+ T cells in the lamina propria was also significantly increased. Control subjects were tested by submucosal gliadin challenge and no significant changes in the number of cells were observed. HLA-DR expression did not show increased positivity in coeliac disease patients on submucosal challenge. For the first time the oral mucosa has been used for immunological testing and shown to react to gliadin challenge in coeliac disease patients. Recruitment of T cells upon submucosal gliadin challenge occurred towards the lamina propria, whereas it occurred towards the epithelium in supramucosal gliadin challenge. The numbers of T cells increased in the lamina propria after submucosal challenge. The results suggest that local oral challenge with gliadin may be used as a diagnostic method in coeliac disease; however, further studies in untreated coeliac disease patients are needed to evaluate the usefulness of this method.

Immunogenetic differences between patients with familial and non-familial rheumatoid arthritis

OBJECTIVE

To search for possible immunogenetic differencies between the patients with familial and non-familial rheumatoid arthritis (RA).

METHODS

The study compared 129 familial RA patients with 217 non-familial patients for the frequencies of HLA-DR antigens including DR4 subtypes, DR4-DQB1*0301 and DR4-DQB1*0302 haplotypes and HLA-B27 antigen as well as the age of disease onset and existence of rheumatoid factor or joint erosions.

RESULTS

Two major differences between familial and non-familial groups were found: firstly, familial RA patients had increased frequency of HLA-DR4 as compared with the non-familial RA group (68.2 v. 54.8%; p = 0.019). Secondly, the mean age at onset of RA was significantly lower in the familial than in the sporadic RA patients (42.0 v. 46.5 years; p = 0.0020) and the difference still remained when the DR4 positive and negative subgroups were compared separately.

CONCLUSION

These results confirm the more prominent association with HLA-DR4 in familial than in the non-familial cases and suggest that accumulation of HLA risk genes may, at least partly, explain the familial occurrence of the disease. Other susceptibility genes may also be concentrated in multiplex case families as suggested by an earlier age at the onset of RA in both HLA-DR4 positive and negative familial patients.

Bone mineral density of the lumbar spine in patients with advanced rheumatoid arthritis. Influence of functional capacity and corticosteroid use

We investigated factors that are related to generalized osteoporosis in advanced rheumatoid arthritis (RA). In this cross-sectional study we measured trabecular bone mineral density (BMD), by quantitative computerized tomography (QCT), in the lumbar spine of 57 patients with RA, most of whom were premenopausal women. In our material, 27 out of 57 patients (47%) had BMD <-1 SD expressed as Z-score and five patients had suffered from fractures. Our study shows that a cumulative corticosteroid dose (r = -0.41, p<0.010) and functional impairment (r = -0.37, p<0.050) were negatively related to spinal BMD, while daily intake of calcium correlated positively on BMD (r = 0.37, p<0.010). Our results indicate that low BMD is common in patients with advanced RA and it is associated with long-term corticosteroid use. Thus, in clinical practice we have to consider the benefits and harms of corticosteroid treatment and preventive therapy to osteoporosis.

Two forms of reactive arthritis?

Inflammatory arthritides developing after a distant infection have so far been called reactive or postinfectious, quite often depending on the microbial trigger and/or HLA-B27 status of the patient. For clarity, it is proposed that they all should be called reactive arthritis, which, according to the trigger, occurs as an HLA-B27 associated or non-associated form. In addition to the causative agents and HLA-B27, these two categories are also distinguished by other characteristics. Most important, HLA-B27 associated arthritis may occur identical to the Reiter's syndrome with accompanying ureteritis and/or conjunctivitis, whereas in the B27 non-associated form this has not been clearly described. Likewise, only the B27 associated form belongs to the group of spondyloarthropathies.

Salivary antigliadin and antiendomysium antibodies in coeliac disease

The definitive diagnosis of coeliac disease is based on typical changes in the small intestine biopsy specimens. To screen individuals for coeliac disease serum IgA and IgG antigliadin (AGA), IgA antireticulin (ARA) and IgA antiendomysium (EmA) antibodies are used. The aim of this study was to investigate whether these antibodies can also be detected in saliva as diagnostic markers of coeliac disease. The study population comprised 30 patients with coeliac disease treated with a gluten-free diet, 14 patients with untreated coeliac disease and 13 healthy control subjects. Sera and saliva were tested simultaneously for the presence of IgA and IgG AGA and IgA EmA. None of patients studied had a selective IgA deficiency. There was no significant difference in salivary IgA AGA levels between the three groups tested and there was no correlation between the individual serum and salivary values of IgA AGA. Salivary IgG AGA levels were very low or undetectable. Serum IgA AGA showed a low sensitivity (36.4%) to detect an untreated patient with coeliac disease. All salivary samples, regardless of the study group were negative for IgA EmA. Serum IgA EmAs were universally detected in the sera of patients with newly diagnosed coeliac disease and also in the sera of five of 30 patients with treated coeliac disease. No IgA EmA was detected in the sera of controls. None of the patients studied had a selective IgA deficiency either. Serum IgA EmA is the most sensitive, and IgA and IgG AGA are good indicators for coeliac disease, but salivary IgA or IgG AGA and salivary IgA EmA are not helpful for the diagnosis or follow-up of coeliac disease patients.

Sustaining and improving working capacity--programme description and two years follow-up

In 1991 the Social Insurance Institution Rehabilitation Act introduced a working capacity sustaining and improving training programme (TYK). The goal of this programme is to sustain the physio-psycho-social competences of older workers and employees by creating a chain of in-house rehabilitation phases and training phases at the workplace. We describe the programme in its early state of implementation. Two years after entering the programme 17 patients were working, six were on sick leave, three were out of work, 16 were on pension, and six patients could not be retrieved.

Tumour necrosis factor microsatellites in reactive arthritis

The purpose was to study tumour necrosis factor (TNF)-a, -b and -c microsatellites as potential new susceptibility markers for reactive arthritis (ReA). Fifty-nine patients typed for HLA-B27 were studied for frequencies of TNF microsatellite alleles and compared with allele frequencies determined from 285 random haplotypes and 46 healthy HLA-B27-positive controls. TNFa, -b and -c microsatellite sequences were amplified by the polymerase chain reaction, and the size of the product was defined by an automated sequencer. The frequencies of TNFa6 and -c1 alleles were found to be increased in patients with ReA, whereas TNFa11 and -c2 frequencies were decreased as compared to control haplotypes. The increase in the c1 allele in patients with ReA independently from HLA-B27 suggests that it might be a new susceptibility marker for the disease. The association of ReA with other alleles was due to a linkage disequilibrium with HLA-B27.

Pogosta disease: clinical observations during an outbreak in the province of North Karelia, Finland

OBJECTIVE

To characterize the clinical picture of Pogosta disease.

METHOD

The data of 73 patients who had had Pogosta disease in 1981 and who then had been seen by a local physician in North Karelia were analysed.

RESULTS

The main manifestations were fever (23%), rash (88%) and joint symptoms (93%). The joint symptoms in some patients lasted for several months and were severe enough to cause immobilization. The clinical picture was identical in those patients who had a definite serological diagnosis and those who did not have a detectable antibody response.

CONCLUSION

The symptoms of Sindbis virus-induced Pogosta discase consist of fever, rash and joint symptoms, whic may be severe and prolonged.

Oral mucosal changes in coeliac patients on a gluten-free diet

Oral mucosal lesions or dental enamel defects may be the only presenting features of coeliac disease. A series of 128 patients with coeliac disease (CD) on a gluten-free diet (GFD), 8 patients with a newly diagnosed CD, and 30 healthy controls participated in a clinical and histopathological study of their oral mucosa. Oral mucosal lesions occurred in 71/128 GFD-treated CD patients. in 4/8 untreated and in 10/30 controls, and oral symptoms in 85/128, in 6/8 and in 10/30, respectively. Five CD patients had aphthous ulcers. Moderate to severe lymphocytic inflammation occurred in 36/117 and in 14/117 of the biopsy specimens of GFD-treated CD patients, in 1/8 and 2/8 of untreated CD patients, and in 3/30 and in 1/30 of controls, respectively. Intraepithelial T-cells were significantly more frequent in GFD-treated CD patients than in controls. There was no difference between untreated CD patients and controls. In the lamina propria of the GFD-treated CD patients, T-cells were more frequent than in the other groups. Mast cells were significantly more frequent in patients with GFD-treated CD. Nine GFD-treated CD patients had raised serum endomysium IgA antibody titres, although five of them reported to follow a strict GFD. A lack of strict compliance with a GFD may be related to the high prevalence of oral changes and symptoms. In addition, T-cell infiltration in the oral mucosa tends to increase with a longer duration of CD, independent of GFD-treatment. Clinically, it is important to study the oral cavity of patients suspected of having CD where the only clue to the disease may reside, since no less than 66% of the patients in this study had oral symptoms.

TAP2 alleles in inflammatory arthritis

Sixty patients with reactive arthritis (ReA) and 40 with rheumatoid arthritis (RA), were typed for H LA-B27 and class II antigens DR and DQ, and studied for TAP2 gene polymorphism in comparison with 60 healthy controls. TAP2 polymorphisms at positions 379, 565, 665, and 687 were analyzed using amplification refractory system-based PCR and polymorphisms at positions 386 and 651 using oligonucleotide hybridization. The frequency of the TAP2A/A genotype was 30%(12/40) in RA, in contrast to 13% (8/60) in the controls. This genotype was further associated with DRB1*04 positive RA (10/24, 42%, P=0.01), as well as the TAP2A allele (31/48, 65%, P =0.012). Thr/Thr dimorphism at TAP2 position 665 (24/40, 60%, P=0.024) and Stop/Stop dimorphism at TAP2 position 687 (24/40, 60%, P=0.024) were found to be increased in RA patients as compared to controls. When TAP2I/J polymorphism was studied, TAP2J positivity was found associated with the HLA-B27DR4-DQB1*0301-haplotype in ReA patients. 9/12 of these were positive as compared to 20/60 in random controls (P=0.010). Polymorphisms of the TAP2 gene were found to be associated with subgroups of RA and ReA patients with disease associated markers (e.g. TAP2A in DRB1*04 positive RA, or TAP2J in HLA-B27-DRB1*04-DQB1*0301 positive ReA). These may thus serve as additional markers of specific haplotypes associated with susceptibility to inflammatory arthritis.

Out-of-hours utilization in primary and secondary care. A favourable experience in a Finnish health centre

OBJECTIVE

To clarify whether out-of-hours health centre visits and referrals to hospital are equally distributed in the three different duty models being used for health care in southwestern Finland.

DESIGN

A medical audit of 2926 health centre visits and 223 referrals to hospitals by general practitioners (GPs) on duty. The duty models were formed on the basis of a possibility to utilize a local health centre during nights and weekends. Two-month follow-up period.

SETTING

Primary health care. Population 46438.

MAIN OUTCOME MEASURES

Out-of-hours visits to health centres and referrals to hospital, and the effect of age and duty model on referrals and visits.

RESULTS

Patients over 64 years of age received most of the referrals although they visited the health care centre less frequently than the 0-14 year-olds (p < 0.001). The people who had an opportunity to utilize their local health centres visited more during out-of-hours than those who did not have this opportunity (p < 0.001).

CONCLUSIONS

The health centre visits were not equally distributed in the three examined duty models. The over 64 year-olds in particular had the least visits and the most referrals.

Salivary carbonic anhydrase VI concentration and its relation to basic characteristics of saliva in young men

Two successive saliva samples were collected under strictly standardized conditions from 209 healthy, selected male soldiers prior to and after breakfast in the morning and were assayed for carbonic anhydrase (CA) VI concentrations using a specific time-resolved immunofluorometric assay. Salivary secretion rates, pH and buffer capacity pH values, and amylase activity levels were also determined. CA VI concentrations correlated positively to salivary secretion rates and amylase activity levels. By contrast, no significant correlation was seen between CA VI concentrations and pH or buffer capacity pH values, nor between amylase activity levels and salivary secretion rates, pH or buffer capacity pH values. The smokers had unaltered salivary secretion rates, CA VI and amylase activity levels, but lower salivary pH and buffer capacity pH values than the non-smokers. Present results suggest that salivary CA VI is not directly involved in the regulation of pH in saliva.

Different course of reactive arthritis in two HLA-B27 positive brothers with fatal outcome in one

During an outbreak of Yersinia pseudotuberculosis III, one of two HLA-B27 positive brothers developed reactive arthritis (ReA), mild at first, but later severely destructive and ultimately fatal. The reactivation of ReA was possibly triggered by an oral polio vaccine. The cause of death was severe secondary amyloidosis. The other brother was exposed to the same Y. pseudotuberculosis strain but did not develop any disease during or after the outbreak. However, he later developed ReA due to a Salmonella infection, with a benign course.

Reactive arthritis

The complex interactions between the triggering microbe and the defense mechanisms of the host in reactive arthritis have been studied in several laboratories around the world, and interesting observations have been made. Research has also focused on the mediators in the inflammatory process in joints, and these results are helping to slowly build a comprehensive picture about the pathogenetic process in reactive arthritis. For the practicing clinician, some important new findings have emerged. It is known that asymptomatic urogenital infections are quite common as a trigger of reactive arthritis. More aggressive treatment, including disease-modifying drugs as used in the therapy of rheumatoid arthritis, is becoming accepted. The value of antibiotic treatment is being studied, but final conclusions will not be made for perhaps a few years.

Experimental Yersinia-triggered reactive arthritis: effect of a 3-week course of ciprofloxacin

Lewis rats were injected i.v. with live Yersinia enterocolitica, resulting in 1-2 weeks in an arthritis greatly resembling human reactive arthritis. Starting on day 3, 5, 10 or 13 after the bacterial inoculation, the rats were treated for 3 weeks with 20 mg/kg/day of ciprofloxacin. The development of arthritis was completely prevented if the antibiotic treatment was started on day 3. In a group of rats treated with ciprofloxacin from day 5 onwards, 2/14 rats already showed mild arthritis at the time when the treatment was started. Antibiotic treatment cured the arthritis of these rats as well as that of one additional individual in this group which developed arthritis. No later exacerbations occurred. If the antibiotic treatment was started on day 10 or 13, i.e. at the time of well-developed arthritis, no effect on arthritis was observed; rather, increased faecal excretion of Yersinia occurred following the antibiotic treatment. We conclude that experimental Yersinia reactive arthritis can be cured by antibiotics introduced at an early phase of arthritic development. Regarding acute human enterogenic arthritis, the decision on antibiotic treatment is not a straightforward matter. Our experimental results indicate that the earlier the treatment is started, the better the result, whereas late treatments seem to favour bacterial persistence.