Bronchospasm associated with anti-TNF treatment

The aetiology of breathing difficulties in patients with inflammatory arthritis being treated with anti-TNF agents can be multi-factorial. Exacerbation of fibrosing alveolitis in patients recently commencing Infliximab has been previously described. Bronchospasm, although reported in some study patients, has not been formally investigated so far. The objective of this study is to define the incidence of bronchospasm in patients treated with anti-TNF agents and investigate details of their respiratory problems. We retrospectively reviewed the notes for 421 patients with inflammatory arthritis being treated with anti-TNF agents at our centre to identify patients who had developed respiratory symptoms during the course of this treatment (cardiac or pleural disease, thromboembolic phenomena or infection were excluded). We identified 7 patients where bronchospasm was thought to be due to treatment with anti-TNF drugs (1.7%). Four of these had to discontinue anti-TNF treatment; two of these needed oral corticosteroid therapy. Two patients were stabilised with increased inhaled beta-2 agonist and steroid, while one patient did not need treatment. All patients had significant exposure to smoking. Bronchospasm is not an uncommon side-effect of anti-TNF treatment. The aetiology of this is probably multi-factorial, but current or previous smoking appears to be a predisposing factor. The frequency and severity of bronchospasm appears to be greater than previously anticipated, all three anti-TNF agents appear to be implicated.

Benchmarking: the five year outcome of rheumatoid arthritis assessed using a pain score, the Health Assessment Questionnaire, and the Short Form-36 (SF-36) in a community and a clinic based sample

BACKGROUND

Treatment, and therefore outcome, of rheumatoid arthritis (RA) will improve in the next few years. However, improvement in outcome can only be judged against the probability of certain outcomes with current conventional treatment.

AIM

To document the five year outcome of RA in the late 1990s.

SETTING

Norfolk Arthritis Register (NOAR).

DESIGN

Longitudinal observational cohort study.

METHODS

318 patients with recent onset inflammatory polyarthritis recruited by NOAR in 1990-91 completed five years of follow up. Four groups were assessed: the whole cohort, all those referred to hospital, those who satisfied criteria for RA at baseline, and those referred to hospital who satisfied criteria for RA at baseline. Outcome was assessed with a visual analogue scale for pain, the Health Assessment Questionnaire (HAQ), and the Short Form-36 (SF-36).

RESULTS

Of the RA hospital attenders, 50% had a visual analogue scale pain score of 5 cm or less and an HAQ score of 1.125 or less. SF-36 scores were reduced in all domains. Results are presented as cumulative percentages.

CONCLUSIONS

These results can be used for comparison and to set targets for improvement.

Time to first occurrence of erosions in inflammatory polyarthritis: results from a prospective community-based study

OBJECTIVE

To examine the time of occurrence of first radiographic erosions in a cohort of patients with inflammatory polyarthritis.

METHODS

Patients were recruited through the Norfolk Arthritis Register, which follows up patients annually. Patients with features of rheumatoid arthritis (other than erosions) sufficient, together with erosions, to meet the American College of Rheumatology (formerly, the American Rheumatism Association) 1987 revised criteria were requested to undergo radiographic examinations of the hands and feet at the first and/or second annual followup visits. All patients were requested to undergo radiographic examinations at the fifth annual followup visit. The most recent erosion-free radiograph was identified for 416 eligible patients, and these data were used to derive the duration of disease since the recalled date of onset of first symptoms. The rate of occurrence of first erosions was then determined (as a cumulative prevalence and as an incidence rate using Poisson regression) from analysis of followup films. Patients were assumed to be free of erosions at symptom onset.

RESULTS

The cumulative prevalence of erosions in patients whose first film was obtained 12-24 months after disease onset was 36%, equivalent to an incidence rate of 24.5/1,000 patient-months. We identified 3 analysis groups of patients who were free of erosions based on films obtained 12-24 months, 24-36 months, and 36-60 months since the recalled date of onset of first symptoms. New erosions were observed in all 3 groups, with cumulative prevalences of 23%, 28%, and 47%, respectively. These were equivalent to first-erosion incidence rates/1,000 patient-months of 5.4 (95% confidence interval [95% CI] 3.8-83), 6.8 (95% CI 4.7-10.0), and 13.0 (95% CI 8.9-19.2), respectively.

CONCLUSION

Many patients with erosive disease first develop their erosions >2 years from disease onset.

The association of cigarette smoking with disease outcome in patients with early inflammatory polyarthritis

OBJECTIVE

Cigarette smoking is known to increase rheumatoid factor (RF) and nodule formation in patients with rheumatoid arthritis (RA). In this study, we examined the influence of smoking on disease outcome at 3 years among patients newly presenting with inflammatory polyarthritis (IP).

METHODS

We studied 486 patients with IP who were referred to the Norfolk Arthritis Register, of whom 323 (67%) satisfied the American College of Rheumatology 1987 criteria for RA. Smoking status was assessed at baseline. Disease outcome was assessed at 3 years, using measures of joint inflammation, functional disability, and radiologic damage. The influence of smoking on disease outcome was explored using logistic regression techniques, with patients who had never smoked as the referent group. Results are expressed as odds ratios (ORs), with their 95% confidence intervals (95% CIs).

RESULTS

Current smokers were significantly more likely to be RF positive at baseline (47%) than were ex-smokers (34%) and never smokers (31%). After 3 years, rheumatoid nodules were significantly more common in smokers (13%) compared with ex-smokers/never smokers (4%), a relationship which persisted after adjusting for age and sex (OR 4.07, 95% CI 1.38-12). In contrast, after adjusting for age and sex, current smokers had significantly fewer swollen joints (OR 0.61, 95% CI 0.37-0.98). However, smoking status had no influence on the development of erosions or functional disability.

CONCLUSION

Despite smokers being more likely to develop nodules and to be RF positive, current smokers did not have higher levels of radiologic damage, and had fewer swollen joints. We hypothesize that this could be due to either the effect of cigarette smoking on the inflammatory response or other factors (e.g., reduced physical activity in smokers) which may limit joint inflammation and damage.

Geoepidemiology of systemic vasculitis: comparison of the incidence in two regions of Europe

OBJECTIVE

The aetiopathogenesis of the primary systemic vasculitides (PSV) is unknown but includes both environmental and genetic factors. The development of classification criteria/definitions for PSV allows comparison of the epidemiology between different regions.

METHODS

The same methods and the American College of Rheumatology (1990) criteria or Chapel Hill definitions were used to compare the epidemiology of Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and polyarteritis nodosa in Norwich (east England population 413 500) and Lugo (northwest Spain population 204 100). Patients with PSV were identified between 1 January 1988 and 31 December 1998.

RESULTS

Overall, the incidence of PSV in adults was almost equal in Norwich (18.9/million) and Spain (18.3/million). The incidence of Wegener's granulomatosis in Norwich (10.6/million) was greater than in Spain (4.9/million). There was a marked age-specific increase in incidence in Norwich with a peak age 65-74 years (52.9/million), but a virtually equal age distribution between ages 45 and 74 in Lugo (34.1/million). There was no significant increase with time in either population, or evidence of cyclical changes in incidence.

CONCLUSION

These data support the suggestion that environmental factors may be important in the pathogenesis of PSV.

The impact of rheumatoid arthritis on employment status in the early years of disease: a UK community-based study

OBJECTIVE

To establish the prevalence of work disability and predictors of change in employment status in patients with early rheumatoid arthritis (RA).

SETTING

The Norfolk Arthritis Register (NOAR), a primary-care based inception cohort of patients with recent-onset inflammatory arthritis.

METHODS

Two cohorts of patients notified to NOAR, who satisfied the 1987 ACR criteria for RA at the time of notification (baseline) and who were economically active at the time of RA symptom onset, were identified. Cohort 1 consisted of 160 patients with an onset of RA between 1989 and 1992, and was followed for a mean of 8.6 yr from symptom onset. For 110 of these cases, a control group, matched for age, gender and employment status at baseline, was identified from the local population. Their employment histories were compared in 1995. Cohort 2 consisted of 134 patients with an onset of RA between 1994 and 1997, and was followed for a mean of 4.1 yr from symptom onset.

RESULTS

One-third of RA cohort 1 had stopped working on the grounds of ill health by 1995. The baseline health assessment questionnaire (HAQ) score was the most important predictor of work disability. These patients were 32 times more likely to stop work on health grounds than the matched controls. The rates for work disability for the RA cases 1, 2, 5 and 10 yr after symptom onset were 14, 26, 33 and 39% respectively. For cohort 2, the rates for work disability 1 and 2 yr from onset were 23 and 33% respectively.

CONCLUSION

Work disability is an important outcome in RA patients of working age. Many people stop working very early in the disease process, often before they are referred to hospital or started on disease-modifying anti-rheumatic drugs. Although the peak rates for work disability are in the early years, people with RA continue to leave the work force several years after onset. Thus, the recent move to earlier, more aggressive treatment has had no effect on the rates of work disability.

Do B cells influence disease progression in chronic synovitis? Lessons from primary hypogammaglobulinaemia

We describe a 62-yr-old male patient with primary hypogammaglobulinaemia (PH) who fulfilled the 1987 American Rheumatism Association/American College of Rheumatology revised diagnostic criteria for rheumatoid arthritis (RA) but, despite persistent symmetrical synovitis, did not develop erosions. Virology studies and blood and synovial fluid (SF) cultures were consistently negative; a search for crystals in the SF was unrevealing. Peripheral blood (PB) B cells were absent, whilst the PB CD3(+) cell count was normal. The ratio of naive (CD45RA(+)) to memory (CD45R0(+)) cells was also normal (1:1) but the CD4:CD8 ratio was reversed. To our knowledge, this is the first report which combines the immunophenotypic analysis of the PB with that of the SF and synovial membrane (SM). This confirmed the absence of B cells and the reversed CD4:CD8 ratio. However, as in other chronic arthropathies, the SF and SM cellular infiltrate consisted almost exclusively of memory T cells, consistent with the preferential localization of this subset to inflamed tissues. This case indicates that synovitis can proceed persistently in the absence of B cells and that the migratory mechanisms of T cells are not altered. However, the case suggests that the absence of B cells and negativity for rheumatoid factor, combined with an increased presence of CD8(+) (suppresser/cytotoxic) T cells in the joint, might contribute to the non-erosive nature of the synovitis.

Secondary health service care and second line drug costs of early inflammatory polyarthritis in Norfolk, UK

OBJECTIVE

To estimate the secondary health service care and second line drug costs (including drug monitoring costs) for a cohort of people with early inflammatory polyarthritis (IP) and the subgroup classified as having rheumatoid arthritis (RA) recruited to a population based register.

METHODS

The study population consisted of 344 people with IP who had enrolled on the Norfolk Arthritis Register (NOAR) in 1990-91, an average of 24 weeks after onset of their symptoms. Utilizing resource use data from NOAR, augmented by unit cost data from other sources, the average (per person) and cumulative secondary care and second line drug costs were estimated for Years 1, 2, 3, 4, and 5 following registration with NOAR.

RESULTS

The total secondary health service care and second line drug costs were 472,125 (338,704 for RA subgroup) (1990-91 prices) over the 5 year study period, with inpatient stays, outpatient visits, and second line drugs accounting for 58, 9, and 33%, respectively. Nineteen percent of the study population neither visited hospital nor were prescribed second line drugs.

CONCLUSION

Overall, inpatient stay costs represented the largest proportion of secondary health service care and second line drug costs, making 21% of the total study cohort responsible for 80% of the total 5 year costs incurred.

Epidemiology of systemic vasculitis: a ten-year study in the United Kingdom

OBJECTIVE

To describe the epidemiology of the primary systemic vasculitides (PSV; Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, polyarteritis nodosa) in a well-defined population over a 10-year period.

METHODS

An inception cohort of patients from the Norwich Health Authority (NHA) who were >15 years of age and had PSV first diagnosed between January 1, 1988 and December 31, 1997 was collected. Incidence rates were adjusted for age and sex to the 1992 population. The prevalence of PSV in this cohort was estimated on December 31, 1997. Patients were classified according to the American College of Rheumatology 1990 vasculitis criteria and the Chapel Hill Consensus definitions.

RESULTS

Eighty-two NHA residents fulfilled the inclusion criteria. There were 47 men and 35 women, with a mean age of 62.9 years (median 65.0 years). The overall annual incidence of PSV among NHA residents was 19.8/million (95% confidence interval [95% CI] 15.8-24.6). The point prevalence on December 31, 1997 was 144.5/million (95% CI 110.4-185.3). PSV was more common in males (23.5/million; 95% CI 17.3-31.3) than females (16.4/million; 95% CI 11.4-22.8). The age- and sex-specific incidence showed a clear increase with age, with an overall peak in the 65-74 year age group (60.1/million).

CONCLUSION

In our study population, the annual incidence of PSV is slowly increasing with time and the incidence is greatest in the elderly.

Epidemiology of systemic vasculitis: a ten-year study in the United Kingdom

OBJECTIVE

To describe the epidemiology of the primary systemic vasculitides (PSV; Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, polyarteritis nodosa) in a well-defined population over a 10-year period.

METHODS

An inception cohort of patients from the Norwich Health Authority (NHA) who were >15 years of age and had PSV first diagnosed between January 1, 1988 and December 31, 1997 was collected. Incidence rates were adjusted for age and sex to the 1992 population. The prevalence of PSV in this cohort was estimated on December 31, 1997. Patients were classified according to the American College of Rheumatology 1990 vasculitis criteria and the Chapel Hill Consensus definitions.

RESULTS

Eighty-two NHA residents fulfilled the inclusion criteria. There were 47 men and 35 women, with a mean age of 62.9 years (median 65.0 years). The overall annual incidence of PSV among NHA residents was 19.8/million (95% confidence interval [95% CI] 15.8-24.6). The point prevalence on December 31, 1997 was 144.5/million (95% CI 110.4-185.3). PSV was more common in males (23.5/million; 95% CI 17.3-31.3) than females (16.4/million; 95% CI 11.4-22.8). The age- and sex-specific incidence showed a clear increase with age, with an overall peak in the 65-74 year age group (60.1/million).

CONCLUSION

In our study population, the annual incidence of PSV is slowly increasing with time and the incidence is greatest in the elderly.

Epidemiology of systemic vasculitis: a ten-year study in the United Kingdom

OBJECTIVE

To describe the epidemiology of the primary systemic vasculitides (PSV; Wegener's granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, polyarteritis nodosa) in a well-defined population over a 10-year period.

METHODS

An inception cohort of patients from the Norwich Health Authority (NHA) who were >15 years of age and had PSV first diagnosed between January 1, 1988 and December 31, 1997 was collected. Incidence rates were adjusted for age and sex to the 1992 population. The prevalence of PSV in this cohort was estimated on December 31, 1997. Patients were classified according to the American College of Rheumatology 1990 vasculitis criteria and the Chapel Hill Consensus definitions.

RESULTS

Eighty-two NHA residents fulfilled the inclusion criteria. There were 47 men and 35 women, with a mean age of 62.9 years (median 65.0 years). The overall annual incidence of PSV among NHA residents was 19.8/million (95% confidence interval [95% CI] 15.8-24.6). The point prevalence on December 31, 1997 was 144.5/million (95% CI 110.4-185.3). PSV was more common in males (23.5/million; 95% CI 17.3-31.3) than females (16.4/million; 95% CI 11.4-22.8). The age- and sex-specific incidence showed a clear increase with age, with an overall peak in the 65-74 year age group (60.1/million).

CONCLUSION

In our study population, the annual incidence of PSV is slowly increasing with time and the incidence is greatest in the elderly.

Primary renal vasculitis in Norfolk--increasing incidence or increasing recognition?

BACKGROUND

The incidence of renal vasculitis has previously been estimated using histological definitions or only a single clinical diagnosis, e.g. Wegener's Granulomatosis (WG). Our hospital is the single referral centre for the former Norwich Health Authority (NHA) which encompasses a stable, homogeneous, well-defined and studied population. We estimated the overall incidence of primary renal vasculitis and the incidence within individual clinical disease classifications.

METHODS

All cases of primary renal vasculitis diagnosed within the NHA over 66 months (1992-1997) were identified by review of renal biopsies, the Norfolk Vasculitis Register, hospital discharge summaries and plasmapheresis records. Patients were classified using the 1990 American College of Rheumatology criteria for Polyarteritis Nodosa (PAN), Churg Strauss Syndrome (CSS) and Henoch-Schonlein Purpura; the Chapel Hill Consensus Conference Definitions for Microscopic Polyangiitis (mPA) and the Lanham criteria for CSS. Incidence figures were calculated using the NHA adult population of 413747 (1994). Ninety-five per cent confidence intervals (C.I.) were calculated using the poisson distribution.

RESULTS

The overall annual incidence for primary renal vasculitis was 18/million (C.I. 12.9-24.4). The annual incidence of renal involvement of individual diseases was as follows: WG 7.9/million (95% C.I. 4.7-12.5); mPA 7.5/million (95% C. I. 4.4-12.0); PAN 7.0/million (95% C.I. 4.0-11.4); HSP 3.1/million (95% C.I. 1.2-6.3); CSS 1.3/million (95% C.I. 0.3-3.9).

CONCLUSIONS

The annual incidence for primary renal vasculitis overall and the individual subtypes in Norfolk is much higher than previous European estimates. This may reflect an increasing incidence in primary renal vasculitis with time or underestimation in previous studies. However the incidence of renal vasculitis in our population is markedly lower than reported in Kuwait. There may therefore be true variation in incidence between populations which could have implications for the aetiology of primary vasculitis.

Pyramids to myriads: the combination conundrum in rheumatoid arthritis

Rheumatoid arthritis continues to be a cause of significant morbidity and disability. Increased understanding of the immunopathogenesis of the disease, of its progression over time, and of patient characteristics which correlate with outcome, have allowed more appropriate therapy. However, currently available disease-modifying therapy fails to adequately control disease in many patients, and many combinations of these drugs have therefore been described. In this review, we critically evaluate the existing literature, identifying combinations for which reasonable evidence of efficacy exists, and highlighting important issues in interpreting such evidence as well as issues of drug monitoring in such patients.

Estimating the incidence of rheumatoid arthritis: trying to hit a moving target?

OBJECTIVE

To examine the effect of delay between symptom onset and notification to an arthritis register and the effect of application of the American College of Rheumatology (ACR; formerly, the American Rheumatism Association) 1987 criteria in a cumulative manner on estimates of the incidence of rheumatoid arthritis (RA).

METHODS

General practitioners and/or hospital consultants in the Norwich Health Authority, Norfolk, UK, notified the Norfolk Arthritis Register (NOAR) of all patients who had onset of inflammatory polyarthritis (swelling of > or =2 joints) during 1990. The patients were assessed within 2 weeks of notification and annually thereafter. The ACR 1987 criteria for RA were applied at each assessment. Age- and sex-specific incidence rates were calculated.

RESULTS

If up to 12 months elapsed from symptom onset to notification to NOAR and the ACR criteria were applied at the baseline assessment, RA incidence estimates, age-adjusted to the population of England and Wales, were 30.8/100,000 for women and 12.7/100,000 for men. If up to 5 years elapsed from symptom onset to notification, these estimates rose by 45% for women and 36% for men. If up to 5 years elapsed between symptom onset and notification and the criteria were applied cumulatively, the estimates rose by 75% and 93% for women and men, respectively, compared with the 1-year data, reaching 54.0/100,000 for women and 24.5 per 100,000 for men.

CONCLUSION

Accurate estimation of the incidence of RA requires long-term followup of patients who present with undifferentiated inflammatory polyarthritis. The highest age-adjusted estimates from this study are probably the best that are available.

Safety and tolerability of conversion from stable Sandimmun maintenance treatment to Sandimmun Neoral in patients with rheumatoid arthritis

OBJECTIVE

To assess the safety and tolerability of converting patients with rheumatoid arthritis (RA) taking a stable dose of cyclosporin A (CyA) maintenance treatment (Sandimmun, SIM) to a new microemulsion capsule formulation, Sandimmun Neoral (Neoral), at an initial dose of 2.5 mg/kg/day.

METHODS

In this single arm, open multicenter study, 28 patients were recruited to enter a 6 week pre-conversion period; of these, 22 patients completed 12 weeks' treatment with Neoral.

RESULTS

During the 12 week post-conversion period, 11 patients experienced adverse events considered to be drug related; most were mild to moderate in severity and reflected the known safety profile for CyA. Only slight differences in efficacy variables were observed after conversion. The mean Neoral dose at Week 12 (2.84 mg/kg/day) was lower than the mean SIM pre-conversion dose (3.38 mg/kg/day). The study showed that, in patients with RA undergoing stable SIM maintenance treatment, conversion to an initial Neoral dose of 2.5 mg/kg/day did not give rise to any clinically relevant safety and tolerability concerns, and efficacy of the treatment was maintained compared with SIM.

CONCLUSION

This conversion strategy constitutes a clinically acceptable alternative to a 1:1 dose conversion.

Cutaneous vasculitis in a defined population--clinical and epidemiological associations

OBJECTIVE

To examine the value of the American College of Rheumatology (ACR) 1990 criteria for Henoch-Schönlein purpura (HSP) and hypersensitivity vasculitis (HSV) and the Chapel Hill Consensus Conference (CHCC) definition of cutaneous leukocytoclastic angiitis (CLA) in the classification of cutaneous vasculitis and to estimate the annual incidence of biopsy proven cutaneous vasculitis in a well defined population.

METHODS

ACR criteria for HSP and HSV and the CHCC definition for CLA and HSP were applied to an unselected cohort of 84 patients with biopsy proven cutaneous vasculitis attending a single district hospital in the United Kingdom between January 1990 and December 1994.

RESULTS

Thirty-seven patients fulfilled ACR criteria for HSV, of whom 27 also fulfilled the ACR criteria for HSP. Thirty-two patients met the CHCC definition for CLA and 7 the CHCC definition for HSP. The overall annual incidence of cutaneous vasculitis was 38.6/million (95% CI 30.6-48.1), and for CLA 15.4/million (95% CI 10.6-21.8).

CONCLUSION

The ACR 1990 criteria for HSP and HSV overlap; the CHCC definitions for CLA and HSP provide clearer distinction. Cutaneous vasculitis is as common as systemic vasculitis.

Churg-Strauss syndrome in a district hospital

Published series on Churg-Strauss syndrome (CSS) come from tertiary referral centres. We retrospectively studied 23 patients with CSS (18 male) seen over 14 years (1982-1995) in a District General Hospital serving a population of 500,000. Mean age of onset of vasculitis was 57, 10-19 years older than in previous series. The commonest clinical features were asthma (22) and eosinophilia > 1.5 x 10(9)/l (21). Systemic vasculitis involving two or more extrapulmonary organs occurred in 22 patients, with specific organ involvement of nervous system (18), joints (13), muscles (13), lungs (11), skin (11), kidneys (11), heart (10), and bowel (7). Various classification systems were applied including the Lanham criteria, which were met in 19 patients; the American College of Rheumatology criteria, met in 14; Churg and Strauss criteria, met in four; and the Chapel Hill Consensus definition, met only in two. ANCA was detected in 10/17 patients where measured. Treatment included corticosteroids (21), cyclophosphamide (8), azathioprine (9), immunoglobulin (2), and methotrexate (1). During follow-up six patients died, two due to myocardial vasculitis (mean age 52 years), three due to infection (mean age 80 years), and one cause unknown. Significant long-term disability was due to asthma in five and neuropathy in six.

Blood transfusion, smoking, and obesity as risk factors for the development of rheumatoid arthritis: results from a primary care-based incident case-control study in Norfolk, England

OBJECTIVE

To examine a range of demographic, social, and clinical risk factors for the development of rheumatoid arthritis (RA).

METHODS

Population-based case-control study in Norfolk, England, involving adult patients, ages 18-70, with an inflammatory polyarthritis of <12 months' duration who were recruited from the Norfolk Arthritis Register. Controls, matched for sex and date of birth, were selected from the primary care register of the Norwich Health Authority. Both cases and controls completed identical self-administered questionnaires. Matched analysis of the 165 case-control sets was conducted for the whole group and for the subset in which the cases satisfied the 1987 American College of Rheumatology criteria for RA.

RESULTS

The controls were of higher socioeconomic status than the cases. This was probably due to response bias. Having a body mass index > or =30 was associated with an adjusted odds ratio (OR) of 3.74 for developing RA (95% confidence interval [95% CI] 1.14-12.27). RA was also associated with a history of blood transfusion (OR 4.83, 95% CI 1.29-18.07). Even after correcting for social class, a history of having ever smoked was associated with a higher risk of developing RA (OR 1.66, 95% CI 0.95-3.06). There was no difference between cases and controls in previous exposure to childhood infections, certain surgical procedures, or reproductive history variables.

CONCLUSION

RA has a number of potential environmental triggers, including smoking, obesity, and blood transfusion.

Neoral--new cyclosporin for old?

Cyclosporin A is now well established as an effective second-line drug to treat rheumatoid arthritis. In April 1995, the microemulsion-based formulation of cyclosporin (Neoral) was introduced based on its increased bioavailability at 'no extra cost'. There may have been concerns that with increased bioavailability of Neoral, some patients might experience increased toxicity, particularly if transferring from Sandimmun to Neoral at the same dose. We describe our experience of 51 patients treated with Neoral--39 with rheumatoid arthritis, six with psoriatic arthritis and the remainder with a variety of diseases, including Behçet's, systemic lupus erythematosus and juvenile chronic arthritis. All patients continued their other medication including non-steroidal anti-inflammatory drugs and analgesics. Five continued low dose prednisolone (average 7.5 mg per day) all patients were monitored for safety and efficacy throughout their treatment according to standard protocol. Five patients were enrolled in a study of efficacy and safety where the dose of cyclosporin was reduced to 2.5 mg/kg/day at the time of conversion, i.e. to Neoral 2.5 mg/kg/day; 19 patients were converted dose for dose, cyclosporin A dose range 2.5-4 mg/kg/day converted to Neoral dose range 2.5-4 mg/kg/day and 27 patients started Neoral de novo. We conclude that cyclosporin is a useful disease modifying anti-rheumatic agent, and our experience suggests that the new formulation, Neoral, has a similar safety and efficacy profile to the original preparation (Sandimmun). Neoral was relatively easy to manage and we noted a slight reduction in dose when compared to Sandimmun. With dose adjustments over 18 months the mean dose for patients with RA fell from 3.2 to 2.7 mg/kg/day and of the 27 patients starting Neoral de novo only seven required an increased dose above 2.5 mg/kg/day in order to establish efficacy.

Differences in the urinary metabolites of the tobacco-specific lung carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone in black and white smokers

Incidence and mortality rates for lung cancer in the United States are significantly greater in blacks than in whites. This disparity cannot be explained by differences in smoking behavior. We hypothesize that the observed racial differences in risk may be due to differences in the metabolic activation or detoxification of the tobacco-specific lung carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). To test this, different biomarkers of NNK exposure and metabolism, including the urinary metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and the presumed detoxification product [4-(methylnitrosamino)-1-(3-pyridyl)but-1-yl]-beta-O-D-glucosiduronic acid (NNAL-Gluc), were examined along with questionnaire data on lifestyle habits and diet in a metabolic epidemiological study of 34 black and 27 white healthy smokers. Results demonstrated that urinary NNAL-Gluc:NNAL ratios, a likely indicator of NNAL glucuronidation and detoxification, were significantly greater in whites than in blacks (P < 0.02). In addition, two phenotypes were apparent by probit analysis representing poor (ratio < 6) and extensive (ratio > or = 6) glucuronidation groups. The proportion of blacks falling into the former, potentially high-risk group was significantly greater than that of whites (P < 0.05). The absolute levels of urinary NNAL, NNAL-Gluc, and cotinine were also greater in blacks than in whites when adjusted for the number of cigarettes smoked. None of the observed racial differences could be explained by dissimilarities in exposure or other sociodemographic or dietary factors. Also, it is unlikely that the dissimilarities are due to racial differences in preference for mentholated cigarettes, because chronic administration of menthol to NNK-treated rats did not result in either increases in urinary total NNAL or decreases in NNAL-Gluc:NNAL ratios. Altogether, these results suggest that racial differences in NNAL glucuronidation, a putative detoxification pathway for NNK, may explain in part the observed differences in cancer risk.

Presence of psoriasis does not influence the presentation or short-term outcome of patients with early inflammatory polyarthritis

OBJECTIVE

To determine whether the presence of psoriasis influences the presentation and early outcome of disease in a primary case based inception cohort of patients with early inflammatory polyarthritis.

METHODS

In total, 966 patients with early inflammatory polyarthritis referred to the Norfolk Arthritis Register were studied. The clinical and demographic variables of patients with and without psoriasis were compared.

RESULTS

Fifty-one patients (5.3%) had psoriasis on examination. Compared to other patients with inflammatory polyarthritis, those with psoriasis were significantly more likely to be male (49 vs 34%) and less likely to be seropositive for rheumatoid factor (RF) (13 vs 31%). The pattern of joint involvement was similar, as was the outcome at one year. Fewer patients with psoriasis developed radiological erosions (22 vs 39%). Multivariate analysis suggested that this was due to RF acting as a confounder.

CONCLUSION

Among patients with early inflammatory polyarthritis there are few strong differences between patients with and without psoriasis, some of which may be accounted for by the absence of RF.

Classification and epidemiology of the vasculitides

The systemic vasculitides are rare inflammatory conditions of blood vessel walls. A number of different classification schemes have been published since the first in 1952. The important developments have been the recognition of dominant blood vessel size, the distinction between primary and secondary vasculitis and the incorporation of pathogenic markers such as anti-neutrophil cytoplasmic antibodies. In 1990 the American College of Rheumatology (ACR) published criteria for the diagnosis of polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, hypersensitivity vasculitis, Schönlein-Henoch purpura, giant cell arteritis and Takayasu arteritis. Sensitivity and specificity rates varied considerably: 71.0-95.3% for sensitivity and 78.7-99.7% for specificity. The criteria were not tested against the general population or against patients with other connective tissue diseases or rheumatic conditions. Four years later the Chapel Hill Consensus Conference (CHCC) produced definitions for the major types of vasculitis, however, these have proved controversial. Comparison in unselected patients with systemic vasculitis (in particular polyarteritis nodosa and microscopic polyangiitis) has shown that the ACR criteria and CHCC definitions identify different patients. The systemic vasculitides are somewhat more common than previously believed. The overall annual incidence approaches 40/million adults. The most common form of primary systemic vasculitis is giant cell arteritis; Wegener's granulomatosis, microscopic polyangiitis and Churg-Strauss syndrome have similar incidences. Classical polyarteritis nodosa and Takayasu arteritis are very rare in the UK.

Inflammatory polyarthritis in the community is not a benign disease: predicting functional disability one year after presentation

OBJECTIVE

To predict which patients with early inflammatory polyarthritis presenting to primary care will be functionally disabled one year after presentation, in order to inform treatment and referral decisions.

METHODS

The study population consisted of 381 patients notified to the Norfolk Arthritis Register, a primary care based inception cohort of patients with inflammatory polyarthritis. Patients were regarded as functionally disabled if they had a Health Assessment Questionnaire (HAQ) score of one or more. Clinical, laboratory, and demographic variables easily measured at baseline were analyzed for their ability to predict future disability. Recursive partitioning was used to create a simple decision tree to predict those patients who would be disabled at one year. A logistic regression model was generated on a sample of 277 patients and tested on an independent sample of 104 patients. This was compared with other models, one of which consisted of the 1987 ARA criteria.

RESULTS

112 (29%) patients had a HAQ score of at least 1 at one year. The strongest predictors of future disability were a high baseline HAQ, large joint involvement, female sex, and longer disease duration. The decision tree predicted disability accurately in 67% of patients.

CONCLUSION

It is possible to predict functional outcome at one year among patients with early inflammatory polyarthritis presenting to primary care using simple clinical variables measured at baseline. Satisfying the 1987 ARA criteria could not be used to predict future disability.

Effect of classification on the incidence of polyarteritis nodosa and microscopic polyangiitis

OBJECTIVE

Polyarteritis nodosa (PAN) has been used as a generic term for systemic vasculitis. The distinction between classic PAN and microscopic polyangiitis (MPA) has not always been made. The aims of this study were to compare the American College of Rheumatology (ACR) criteria for PAN with the Chapel Hill Consensus Conference (CHCC) definitions of classic PAN and MPA, and to estimate the annual incidence of PAN and MPA.

METHODS

The 1990 ACR criteria and CHCC definitions for systemic vasculitis were applied to an unselected cohort of 130 patients with systemic vasculitis attending a single district hospital in the UK between February 1, 1988 and January 31, 1994.

RESULTS

Eight patients who met the ACR criteria for PAN and who also met the CHCC definition of MPA but not classic PAN were identified. A further 5 patients met the CHCC definition of MPA but not the ACR criteria for any other type of systemic vasculitis. No patient who met the CHCC definition of classic PAN was identified. The annual incidence of MPA was calculated to be 3.6/million (95% confidence interval 1.7-6.9), and the annual incidence of PAN (ACR criteria) was 2.4/million (95% confidence interval 0.9-5.3).

CONCLUSION

Classic PAN as defined by the CHCC is rare, because small vessel involvement is excluded from this definition.

Wegener's granulomatosis--increased incidence or increased recognition?

We aimed to calculate the annual incidence of Wegener's granulomatosis (WG) in Norfolk (UK) and to compare the clinical spectrum of disease to that seen in tertiary centres in both the UK and USA. We also aimed to examine the seasonal onset of symptoms. This was a prospective study of all patients presenting with WG to a district hospital with a well-defined stable population (515,000) during the period 1988-1993. The annual incidence for WG in the adult population is 8.5/million (95% CI 5.2-12.9). These are the first incidence figures for a well-defined population and are higher than previously published. The clinical spectrum of disease in Norfolk was similar to that seen in tertiary centres and there is supportive evidence for a seasonal variation in the onset of symptoms (highest in winter).

Isolated nail fold vasculitis in rheumatoid arthritis

OBJECTIVES

To establish the clinical significance of isolated nail fold vasculitis in patients with rheumatoid arthritis (RA).

METHODS

Patients attending hospital with established RA were assessed by a single observer using unaided vision. Isolated nail fold vasculitis (NFV) was diagnosed as small nail edge or nail fold lesions without any evidence of other extra-articular or systemic vasculitis. Patients were followed prospectively.

RESULTS

Thirty patients with isolated NFV were identified and followed for a median interval of 22 months. Three patients died within three months of diagnosis and six developed complications possibly indicative of extra-articular disease: xerostomia (three), pericarditis (one), pleural effusion and empyaema (one), pulmonary fibrosis (one). No patient developed systemic vasculitis.

CONCLUSION

Isolated NFV has a favourable prognosis compared with systemic vasculitis. There is a low risk of developing systemic or extra-articular disease.

A longitudinal study of anticardiolipin antibody in polymyalgia rheumatica and giant cell arteritis

OBJECTIVE

To determine the incidence of elevated levels of anticardiolipin antibody (aCL) in patients with newly diagnosed polymyalgia rheumatica (PMR) and/or giant cell arteritis (GCA); and to determine the relationship between these antibodies at diagnosis and subsequent course of the disease over a period of 2 yrs.

METHODS

Ninety-eight consecutive patients with PMR and/or GCA were examined for the presence of aCL, at presentation and every 6 mo for 2 yrs. Sixty-four patients had PMR alone, 22 had coexistent PMR and GCA, and 12 presented with pure GCA. Patients presenting with suspected clinical diagnosis, overt or covert, of GCA were subjected to temporal artery biopsy from the symptomatic side within 3 days of presentation. Appropriate serological, biochemical, and hematological investigations were undertaken at presentation and subsequently at times of periodic assessments. One hundred healthy age and sex matched elderly subjects were also screened for the presence of aCL as a control group.

RESULTS

Elevated levels of aCL were detected in 20 patients at presentation. These included 9 patients with PMR/GCA and 11 patients with pure PMR. During followup, 10 patients with pure PMR at presentation developed GCA. These comprised 5 of the 11 patients with high aCL at presentation and 5 of the 53 patients with normal levels of aCL at presentation. This was statistically significant with relative risk (4.82, 95% CI, 1.72-13.51) of developing GCA in the presence of PMR and a high aCL at presentation. Furthermore, 3 of the 5 patients with pure GCA and high aCL at presentation progressed to severe vascular complications (stroke, 2; anterior ischemic optic neuritis, 1) compared to none of the other patients in the study. Elevated levels of antineutrophilic cytoplasmic antibody were also analyzed and detected in only 4 patients, 3 with pure PMR and one with biopsy proven GCA.

CONCLUSION

This prospective study suggests that a significant number of patients with PMR and/or GCA with elevated levels of aCL at presentation have increased risk of developing GCA or other major vascular complications. It is possible that aCL may be an independent prognostic marker for future vascular complications in patients with PMR and/or GCA.

Vasculitis

The systemic vasculitides are a group of rare inflammatory conditions resulting in inflammation and necrosis of blood vessel walls. They are somewhat commoner than previously believed with an annual incidence approaching 40 per million. Furthermore the annual incidence of rheumatoid vasculitis is 12.5 per million and Wegener's granulomatosis is 8.5 per million. The first useful classification system for systemic vasculitis was published in 1952, since then a number of different schemes have been published. The major changes have been the recognition of the importance of dominant blood vessel size, the distinction between primary and secondary vasculitis and the incorporation of pathogenetic markers such as ANCA (see Table 6). Until relatively recently there were no widely agreed diagnostic or classification criteria. In 1990 the ACR published criteria for the diagnosis of polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, hypersensitivity vasculitis, Henoch-Schönlein purpura, giant cell arteritis and Takayasu's arteritis. The criteria were provided in both traditional and tree format. Sensitivity and specificity rates varied considerably: 71.0-95.3% for sensitivity and 78.7-99.7% for specificity. The criteria were not tested against the general population or against patients with other connective tissue diseases or rheumatic conditions. In 1993/94 the Chapel Hill Consensus Conference developed and published definitions for the nomenclature of systemic vasculitis based on clinical features. These have not met with universal acceptance. However, they are a useful addition, since their use should result in different centres studying more homogeneous populations of patients and facilitate comparison of data between different centres. Assessment of vasculitis comprises an activity score (BVAS), damage index and quality of life/health status (SF-36). These are recent developments which are still undergoing validation.

Epidemiology of systemic vasculitis: changing incidence or definition?

The epidemiology of the systemic vasculitides is poorly documented. Many studies have been conducted from tertiary referral centers, with resulting problems of referral bias and uncertainty of denominator population, or have involved small populations. We have estimated the incidence of the major forms of systemic vasculitis in a stable, ethnically homogeneous population of 414,000 adults from 1988 to 1994. The overall annual incidence of systemic vasculitis (excluding giant cell arteritis) is 39/million (95% confidence intervals; ranging from 31 to 47). The annual incidence of Wegener's granulomatosis is 8.5/million (range, 5.2 to 12.9), Churg-Strauss syndrome 2.4/million (0.9 to 5.3), microscopic polyangiitis 2.4/million (0.9 to 5.3), adult Henoch-Schonlein purpura 1.2/million (0.3 to 3.5), and systemic rheumatoid vasculitis 12.5/million (8.5 to 17.7). These data suggest that the overall incidence of systemic vasculitis is greater than previously thought (10/million) with Wegener's granulomatosis and systemic rheumatoid vasculitis being the most common. Whether this represents a genuine increase in incidence or increased physician awareness is uncertain.

ABC of rheumatology. Rashes and vasculitis

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The arthropathy of the Muckle-Wells syndrome

Muckle-Wells syndrome (MWS) is a rare condition characterized by urticaria, arthralgias, deafness and amyloid nephropathy. The arthropathy is poorly documented. We describe the arthropathy occurring in four cases of MWS and discuss the management. Each patient developed recurrent bouts of transient synovitis. One patient developed a persistent sterile pyoarthrosis.

A single infusion of bisphosphonate AHPrBP in the treatment of Paget's disease of bone

OBJECTIVE

To assess the efficacy of single infusion of bisphosphonate AHPrPB (APD) (60 mg) in active Paget's disease of bone.

METHODS

Twenty-six patients with symptomatic Paget's disease of bone were treated with a single infusion of APD (60 mg) over 12 h and were assessed for clinical as well as biochemical improvement for a mean period of 2 years. Treatments were repeated if relapse occurred during followup.

RESULTS

Bone pain improved in 92% of patients within one month and over 76% of patients had no pain at 6 months. Serum alkaline phosphatase fell to normal level in 78% of patients at 6 months and about 77% at one year. Further treatment with intravenous (iv) APD (60 mg) was given for relapse in 7 patients at one year, 13 at 18 months and 2 at 24 months.

CONCLUSION

Our prospective study demonstrates that 60 mg APD given iv is an effective, simple, safe and less expensive treatment for active Paget's disease of bone and this therapy may well be given in a daycare unit or an outpatient setting.

Digital vasculitis associated with joint sepsis in rheumatoid arthritis

Digital vasculitis complicating RA is not infrequent and is usually benign but may herald the onset of systemic vasculitis. A case is reported of a man with longstanding seropositive RA who developed digital vasculitis in association with septicaemia and multiple joint sepsis. Awareness that the onset of digital vasculitis in RA may be related to infection is important. This is especially so since aggressive immunosuppressive therapy is often used in patients with systemic vasculitis.