Hyaluronate effects on synovium and synovial fluid. A prospective blinded study in patients with osteoarthritis of the knee.
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Anti-Inflammatory Agents, Non-Steroidal↗
Biomedical subjects
H R Schumacher
Publications and source records attributed to H R Schumacher.
Magnetic resonance imaging in the quantitative assessment of gouty tophi.
Measurements of tophus size can be important in monitoring the course of gout therapy, as tophus resolution is proposed as one measure of success of treatment. This multicentre study assessed the intra- and interreader reproducibility of quantitative tophus volume measurements from magnetic resonance images (MRI) in subjects with palpable gouty tophi. Subjects first underwent radiographic imaging of a selected tophus followed by MRI before and at <or=5, 10 and 20-min after gadolinium administration. After choosing optimal parameters, subjects underwent pre- and postgadolinium-enhanced MRIs of a selected tophus on two occasions separated by 5-10 days. Unenhanced spin-echo images provided satisfactory tophi images and were less subject to interfering artefacts than gadolinium-enhanced gradient-echo images. Intrareader reproducibility was excellent, with no statistically significant difference in mean tophus volume between visits (mean difference - 0.05 +/- 0.97 cm3). A small but statistically significant difference in interreader mean tophus volume was detected (mean difference 0.89 +/- 2.05 cm3; p < 0.05). MRI can quantify tophus size in gout and deserves further comparison with other techniques for tophus size monitoring in assessing effects of gout therapy.
Adolescent↗
Detection and initial characterization of synovial lining fragments in synovial fluid.
OBJECTIVE: Free fragments of synovium have occasionally been seen in synovial fluid but have not been studied systematically. We wished to establish a method for the reliable detection of these fragments in joint and bursa effusions and begin to characterize them by histochemical and immunohistochemical methods. METHODS: Cell smears, wet drop preparations and cytospins were prepared from 39 consecutive joint and bursa effusions. Paraffin cell blocks were prepared from a subset. Analysis encompassed standard and polarized light microscopy, histochemistry, immunohistochemistry and transmission electron microscopy (EM). Synovial biopsy tissue from one different patient was examined for comparison. RESULTS: Tissue fragments were not seen in Wright-stained cell smears and only rarely in wet drop preparations. In contrast, variously sized fragments with the histological appearance of hyperplastic synovial lining were detected in ethanol-fixed, haematoxylin/eosin-stained cytospins from bursitis and all arthropathies studied [17/24 (71%) of non-inflammatory and 12/15 (80%) of inflammatory specimens]. Immunostaining revealed CD68 expression in a subset of cells in a pattern characteristic of hyperplastic synovial lining. Juxtaposed cells with morphological features of macrophage-like and fibroblast-like synoviocytes were seen by EM. CONCLUSIONS: Synovial lining fragments can be detected in effusions from diverse arthropathies and bursitis. They maintain important properties of the synovial lining and can be analysed by immunohistochemistry. They may afford the opportunity to study a relatively pure preparation of synovial lining cells without the need for cell culture, and to evaluate their possible role in augmenting or perpetuating synovitis or joint damage.
Aged↗
Synovial Chlamydia trachomatis up regulates expression of a panel of genes similar to that transcribed by Mycobacterium tuberculosis during persistent infection.
BACKGROUND: Synovial tissues in patients with Chlamydia associated arthritis are persistently infected by C trachomatis, an organism for which genetic manipulation is not possible. M tuberculosis also engages in persistent infection, and because this bacterium is genetically tractable many groups have been able to define transcriptional characteristics of mycobacterial growth and persistence. OBJECTIVE: To investigate whether the pattern of gene expression underlying chlamydial persistence is similar to that underlying mycobacterial persistence. METHODS: 194 genes in M tuberculosis that are transcriptionally up regulated to support in vivo growth and persistence of that organism have previously been identified. Each of those genes was compared with the C trachomatis genome to identify orthologues. Expression of selected chlamydial orthologues so identified was assessed by real time RT-PCR in an in vitro model of chlamydial persistence and synovial tissues from patients who were PCR positive for C trachomatis at that site. RESULTS: 67 C trachomatis genes were identified as being orthologous to mycobacterial persistence related genes, representing 35% of the genes tested. The chlamydial orthologues fell into similar metabolic and other categories as those in M tuberculosis. Expression of a majority of selected chlamydial orthologues was strongly up regulated in an in vitro model of chlamydial persistence and in synovial tissues of relevant patients, compared with their expression during active infection. CONCLUSIONS: These observations provide new insight into the molecular genetic basis underlying chlamydial persistence, and indicate that this information can be obtained, in some instances, by extrapolating observations made in other biological systems and/or organisms.
Arthritis, Reactive↗
NFAT transcription factors--new players in the pathogenesis of inflammatory arthropathies?
Inflammatory arthropathies are characterized by major changes in gene expression, which-ultimately-result from differential activities of intracellular signaling pathways and their associated inducible transcription factors. The nuclear factor of activated T cells' (NFAT) family of transcription factors plays diverse roles in a variety of processes in the immune system and other tissues. Preliminary evidence has recently emerged implicating NFAT family members directly in the pathogenesis of inflammatory arthropathies. Specific anti-NFAT drug therapy may add to the pharmacologic armamentarium against rheumatoid arthritis, other inflammatory arthropathies, and related autoimmune disorders.
Antirheumatic Agents↗
Elevated levels of IgM and IgA antibodies to Proteus mirabilis and IgM antibodies to Escherichia coli are associated with early rheumatoid factor (RF)-positive rheumatoid arthritis.
OBJECTIVE: Antibodies to Proteus mirabilis were previously detected in patients with established rheumatoid arthritis (RA). We examined the prevalence of antibodies to P. mirabilis and their associations with RA in early synovitis patients. METHODS: Two hundred and forty-six patients with inflammatory arthritis for less than 1 yr were prospectively evaluated for 1 yr. Of these patients, 30% had rheumatoid factor (RF)-positive RA, 16% RF-negative RA, 17% a spondyloarthropathy and 37% undifferentiated arthritis. Serum antibodies to P. mirabilis, Escherichia coli and other potentially arthritogenic organisms (Chlamydia, Salmonella, Shigella, Campylobacter, Yersinia and parvovirus B19) and for antibodies specific for immunoglobulin (Ig) G damaged with advanced glycation end-products (anti-IgG-AGE) were measured. RESULTS: IgM and IgA anti-Proteus antibodies were significantly higher in patients with RF-positive RA compared with all other patient groups (P < 0.0005 and P < 0.005). Anti-P. mirabilis IgG, and IgG, IgA, and IgM antibodies to other potentially arthritogenic pathogens did not differ in the patient groups. IgM antibodies to E. coli were elevated in RF-positive RA patients. Anti-P. mirabilis IgM and IgA results were not explained by false-positive reactions, because after absorption of RF there was no decrease in antibodies to Proteus in 10 of 12 patients. Proteus and E. coli antibodies were highest in patients positive for both RF and anti-IgG-AGE antibodies (P<0.001). Patients with erosions tended to have higher IgA anti-Proteus titres, but no association with the shared HLA epitope or treatment was detected. CONCLUSION: Anti-P. mirabilis IgM and IgA and anti-E. coli IgM antibody elevations are associated with early seropositive RA and the presence of anti-IgG-AGE antibodies. The role that P. mirabilis or E. coli plays in early RF-positive RA requires further investigation.
Adult↗
Gout epidemiology: results from the UK General Practice Research Database, 1990-1999.
OBJECTIVE: To examine the epidemiology of gout and gout treatment in the United Kingdom using a large national practice based population. METHODS: Data from the UK General Practice Research Database from 1990 to 1999 were examined. Physician diagnoses and drug codes were used, and trends in gout incidence and treatment examined. Additionally, disease prevalence for the year 1999 was assessed. To examine the association of gout with comorbid disease, the prevalence of select health conditions and drug use was compared with the corresponding prevalences seen in osteoarthritis, adjusting for both age and sex. RESULTS: From 1 January 1990 to 31 December 1999 overall gout incidence remained relatively stable, ranging from a low of 11.9 cases (95% confidence interval (CI) 11.5 to 12.3) in 1991 to a high of 18.0 cases (95% CI 17.6 to 18.4) per 10 000 patient-years in 1994. Gout prevalence in 1999 was 1.4% with rates approaching 7% in men over the age of 65. Drugs used for the treatment of gout remained constant in prevalent cases with the exception of a significant decline in non-steroidal anti-inflammatory drug use over the 10 year follow up. Compared with patients with osteoarthritis, patients with gout were significantly more likely to have cardiovascular disease, hypertension, diabetes, and chronic renal failure, and were more likely to have used diuretics or ciclosporin, or both. CONCLUSION: Although gout is common in the UK, particularly among older men, the incidence of the disease seems to have remained stable during the 1990s.
Adult↗
Lack of association of matrix metalloproteinase 3 (MMP3) genotypes with ankylosing spondylitis susceptibility and severity.
OBJECTIVE: To study the linkage and association of ankylosing spondylitis (AS) with genotypes for matrix metalloproteinase 3 (MMP3), a gene located at chromosome 11q22.3 and lying within the 101-124 cM region observed in a recent genome-wide scan as a region associated with AS susceptibility. METHODS: MMP3 genotypes were examined in 229 pedigrees with AS, 131 sporadic AS cases and 87 Caucasian controls. Eight single-nucleotide polymorphisms (SNPs) were selected and genotyped using Taqman. Non-parametric linkage (NPL) analysis was conducted between the eight MMP3 SNPs and AS using the NPL-all statistic and two-point parametric linkage analysis using GeneHunter Plus. Unrelated AS cases and controls were compared using chi2 statistics, and family-based controls using the transmission disequilibrium test and pedigree disequilibrium test. RESULTS: None of the eight MMP3 SNPs were significantly associated with AS, either using the 131 sporadic cases alone or in analyses which combined these cases with the 226 unrelated affected AS patients derived from the pedigrees. Analysis of linkage disequilibrium (LD) demonstrated that seven of the eight SNPs studied were in strong LD except for rs626750, which is about 6 kb upstream of the 5' end of the gene. No significant linkage was observed using NPL and LODs in the families. No association was seen of any of the MMP3 SNPs with disease severity (defined by patient functioning), as measured either by the Bath Ankylosing Spondylitis Functional Index or the modified Health Assessment Questionnaire. CONCLUSION: These data suggest that MMP3 genotypes are not involved in AS susceptibility or severity.
Adult↗
Utility of digital photographs of the hand for assessing the presence of hand osteoarthritis.
OBJECTIVES: Nodal osteoarthritis of the hand (hand OA) is a subset of OA with a strong heritable component. Multiple genetic analyses of this condition have been performed and are underway. Highest yield from any genetic study depends upon a clear clinical phenotype for case definition. Radiographs may provide the most detail about the nature of the lesion. Physical examination is an imperfect means of evaluating each patient, particularly when hundreds or thousands of patients are required for study. Our study evaluated the accuracy, relative to a radiograph, of a digital photograph of the hands for the presence of OA in a particular joint, as well as for the diagnosis of nodal hand OA. METHODS: Consecutive patients were evaluated as part of the I-NODAL study (Investigation of Nodal Osteoarthritis to Detect an Association with Loci encoding Interleukin-1 [IL-1]). Evaluation included a physical examination by a trained rheumatologist, a postero-anterior radiograph of the hands, and a digital photograph of each hand. Radiographs were read by one trained observer using the Kellgren-Lawrence scale. Photographs were taken by one individual and were analyzed by an experienced rheumatologist. Kappa statistics were determined for each modality and accuracy was assessed using radiographic readings as a gold standard. RESULTS: Intra-reader reliability for radiograph interpretation was good for the overall diagnosis of hand OA (kappa0.76 [0.45,1.07]), but varied widely for the presence or absence of K-L grades 2-4 in individual joints (median kappa0.70, range 0.49-0.87 for ACR index joints). Distal interphalangeal joint (DIP) nodes on physical examination were sensitive (median 96.27, 93.94-100), but not specific for radiographic hand OA in the corresponding joint (median 33.0, 17.24-42.86). Physical examination evidence of OA in the 1st carpo-metacarpal (CMC) and proximal interphalangeal (PIP) joints provided only moderate sensitivity and specificity. However, the negative predictive value of the examination of individual joints was good (median negative predictive value was 82.58 for IP joints with a range 68.29-100.00), particularly in the DIP joints. Specificity of a node visualized on hand photograph was variable (median for all IP joints and 1st CMC 83.77, range 53.37-96.97), with greatest specificity for radiographic OA in the corresponding joint found in the 1st CMC and the PIP joints. Clinical hand OA was sensitive, but not specific for the radiographic diagnosis of hand OA; while, photographic OA was moderately specific, but insensitive. CONCLUSION: The visualization of a node on a digital photograph of the hand provides fair to moderate specificity for radiographic hand OA in the corresponding joint, with generally poor sensitivity. A photograph has limited value as a screening tool for the diagnosis of radiographic hand OA.
Aged↗
Immunohistochemistry of normal human knee synovium: a quantitative study.
OBJECTIVE: To describe the immunohistochemical characteristics of knee synovium from normal healthy subjects. METHODS: 12 healthy subjects underwent needle biopsy of knee synovium. Using antibodies directed against CD3, CD4, CD8, L26, Kp-1,and HLA-DR, detailed quantitative immunohistochemical analysis of various cell subpopulations was undertaken. RESULTS: The mean (SD) age of the subjects was 37 (9) years (five male, seven female). All had a negative history for arthritis, no knee pain, and a totally normal joint examination except for the presence of retropatellar crepitus in five. For technical reasons staining for all immunohistochemical markers could not be achieved in all subjects. CD3+ T lymphocytes were seen in nine of 10 subjects, either diffusely or, more commonly, in perivascular areas. CD4+ cells were seen in synovium in three of seven subjects and CD8+ cells in six of eight subjects, in almost equal numbers (CD4:CD8, 1.1:1). L26+ B lymphocytes were not seen in any biopsy. Kp1+ macrophages were found in 10 of 10 subjects, predominantly in surface lining cells, and in small numbers in diffuse and perivascular locations. HLA-DR+ cells were seen in 10 of 10 subjects, predominantly in surface lining cells and diffusely, but a few were seen perivascularly. CONCLUSIONS: Synovium from apparently normal subjects contained a wide range of different cell subpopulations but no B cells. The significance of these immune cells in normal synovium is unclear. A better understanding of their role in normal synovium may be important in analysing the transition to synovitis.
Adult↗
Intra-articular corticosteroid preparations: different characteristics and their effect during inflammation induced by monosodium urate crystals in the rat subcutaneous air pouch.
OBJECTIVE: To examine the effects of three commonly used intra-articular depot corticosteroid preparations tested in a rat air pouch model and their effect against monosodium urate (MSU) crystal-induced inflammation. Rheumatologists use intra-articular corticosteroid preparations to relieve pain and inflammation of acute monoarthritis without really knowing their effects on the synovial fluid and membrane or the differences between distinct preparations. This work compares the effect of three commonly used corticosteroid preparations in vivo, showing that they behave differently. METHODS: A subcutaneous air pouch was formed in male Sprague-Dawley rats. A first group of 6-day-old air pouches were injected with 10 ml of 6 mg/ml normal saline solution, 6 mg/ml betamethasone containing both depot betamethasone acetate and soluble betamethasone phosphate (Celestone) in 9 ml of normal saline solution, 20 mg/ml of prednisolone tebutate (Hydeltra) in 9 ml of normal saline solution or 20 mg/ml of triamcinolone hexacetonide (Aristospan) in 9 ml of normal saline solution. A second group (group 2) of air pouches were injected with 15 mg of synthetic MSU crystals and 24 h later they were reinjected with 1 ml of the same three corticosteroid suspensions. For each condition four rats were killed at 6, 24, 48 h and 7 days. Pouch fluid and tissue were analysed. RESULTS: In the first 6 h after normal saline solution or corticosteroid injection into the air pouch there were mildly increased leucocyte counts in the air pouch fluid. Betamethasone-injected pouches showed no cells in the fluid after 6 h and no crystals after 24 h, triamcinolone-injected pouches still showed rare cells at 7 days. Both triamcinolone and prednisolone crystals persisted in higher numbers and lasted longer in the fluid than did betamethasone (P<0.05). In group 2 MSU crystal phagocytosis in the fluid was decreased in the betamethasone- (P<0.01), prednisolone- (P<0.003) and triamcinolone- (P<0.006) injected pouches when compared with the MSU crystal-injected pouches alone. Pouches injected with MSU crystals alone showed the most intense tissue inflammation at all times. After MSU, betamethasone-injected pouches had a rapid but mild decrease in the number of lining cells and inflammation. In contrast, triamcinolone- and prednisolone-injected pouches showed a very thin tissue with few or no vessels and almost no inflammation at 7 days. The pouches injected with MSU crystals and any of the corticoid preparations had three times more tophus-like structures and persistent crystals identified than the ones injected with MSU crystals alone. CONCLUSION: Each of the corticosteroid preparations by themselves produced very mild transient inflammation. The betamethasone preparation with a soluble steroid component had a quicker but milder anti-inflammatory effect on MSU crystal-induced inflammation. In contrast to the doses used, prednisolone tebutate and triamcinolone hexacetonide preparations dramatically suppressed urate crystal-induced inflammation at 7 days, but both produced atrophy and necrosis of the membrane, yielding a very thin membrane with almost no vessels. When used for MSU crystal-induced inflammation these corticosteroid preparations suppressed some aspects of inflammation but may actually promote the persistence of MSU crystals and the formation of tophi.
Animals↗
Synovial fluid features and their relations to osteoarthritis severity: new findings from sequential studies.
OBJECTIVE: Many factors are involved in the osteoarthritic process. It is not yet known which are initiators, promoters or simply results. Thus, we have evaluated some of those potentially important factors in osteoarthritis (OA) as observed sequentially for the first time in synovial fluids. DESIGN: Synovial fluids (SF) obtained between 1992-2002 were all routinely evaluated for gross appearance, leukocyte counts and microscopic examination of wet drop preparations. We used regular and polarized light and alizarin red s stains. We separated out all OA patients, then we looked for patients who had more than two synovial fluid analyses to get sequential information. Time between first and final aspiration ranged from 2 to 7 (3.6+/-1.6) years and number of analyses per patients from 3 to 6 (3.3+/-0.7). We related synovial fluid crystals, fibrils and white blood cell count (WBC) to age, sex, disease duration and radiographic assessment according to the Kellgren-Lawrence radiographic rating system. RESULTS: Of 4523 synovial fluid examinations, we found 855 in patients with knee OA; 330 patients with adequate clinical details for comparison were included in our study. Twenty-six patients (one woman and 25 men) had sequentially examined SF. We found that 52% of those OA patients with effusions studied had crystals identified in their synovial fluid. Twenty-one percent of all the patients had CPPD crystals, 47% had hydroxyapatite, also called basic calcium phosphate (BCP) crystals and 16% had both types of crystals. Microscopically identifiable fibrils were found in 60% of SF. In sequentially examined patients, CPPD crystals and apatite (BCP) were found in 19% and 23%, respectively, at the first aspiration and, in 34% and 58% at the final aspiration. Fibrils were seen in 54% at first examination and 85% later. Apatite and fibrils showed more significant correlation with time (r=0.51,r =0.92) than did CPPD (r=0.32). SF WBC correlated only with CPPD crystals and did not increase with OA duration or severity. CPPD, apatite and fibrils all correlated with higher radiographic grades of OA. CONCLUSIONS: As noted before CPPD and apatite crystals were more common in patients with more severe OA. New findings are that our sequential cases showed that there were some patients with no crystals at onset but that crystals appeared with progression of the disease. Fibril presence in SF also correlated with progression of the disease.
Aged↗
Calcium apatite crystals in synovial fluid rice bodies.
BACKGROUND: Rice bodies can occur in the joints in many rheumatic conditions, but they are most common in rheumatoid arthritis. They are generally believed to occur rarely in patients with osteoarthritis, but one study reported rice bodies with apatite crystals. OBJECTIVE: To report on a series of joint fluids with rice bodies containing apatite clumps and examine their clinical pictures. METHODS: All synovial fluid analysis reports for 10 years were reviewed for rice bodies and eight patients were reported on. A series of patients with a variety of diseases with synovial fluid rice bodies found to contain calcific material is described. All were examined by compensated polarised light and alizarin red stain, and four were examined by electron microscopy. RESULTS: The eight patients all had alizarin red S chunks embedded throughout the rice body. Transmission electron microscopy disclosed the presence of a matrix of collagen, fibrin, and amorphous materials containing typical apatite crystals. Clinical diagnoses, radiographic findings, and leucocyte counts varied, but six of the eight patients had had previous repeated corticosteroid injections into the joints. CONCLUSION: Aggregates of apatites may be more common than previously recognised in rice bodies as they are not routinely sought. Whether they are a result of joint damage or depot steroid injections and whether that might contribute to further joint injury now needs to be investigated.
Anthraquinones↗
Acute erythremic myelosis (true erythroleukaemia): a variant of AML FAB-M6.
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Humans↗
Chromosomal DNA from a variety of bacterial species is present in synovial tissue from patients with various forms of arthritis.
OBJECTIVE: We and others have reported the presence of Chlamydia and other bacterial species in joint specimens from patients with reactive arthritis (ReA). The present study was conducted to investigate whether bacteria other than those specified by diagnostic criteria for ReA could be identified in synovial fluid (SF) or tissue from patients with various arthritides, and whether the presence of such organisms corresponds to particular clinical characteristics in any patient set or subset. METHODS: DNA in synovial biopsy samples and SF obtained from 237 patients with various arthritides, including ReA, rheumatoid arthritis, and undifferentiated oligoarthritis, was assayed by polymerase chain reaction (PCR) using "panbacterial" primers; we chose only samples known to be PCR negative for Chlamydia, Borrelia, and Mycoplasma species. PCR products were cloned, and cloned amplicons from each sample were sequenced; DNA sequences were compared against all others in GenBank for identification of bacterial species involved. RESULTS: Ten percent of patient samples were PCR positive in panbacterial screening assays. Bacterial species identified belonged to the genera Neisseria, Acinetobacter, Moraxella, Salmonella, Pseudomonas, and others. Thirty-five percent of PCR-positive patients showed the presence of DNA from more than a single bacterial species in synovium; overall, however, we could identify no clear relationship between specific single or multiple bacterial species in the synovium and any general clinical characteristics of any individual or group of patients. CONCLUSION: This analysis provides the first systematic attempt to relate bacterial nucleic acids in the synovium to clinical characteristics, joint findings, and outcomes. Many patients with arthritis have bacterial DNA in the joint, and, in some cases, DNA from more than a single species is present. However, except for 1 case of a control patient with staphylococcal septic arthritis, it is not clear from the present study whether the synovial presence of such organisms is related to disease pathogenesis or evolution in any or all cases.
Acinetobacter↗
Expression of Chlamydia trachomatis genes encoding products required for DNA synthesis and cell division during active versus persistent infection.
During persistent infection, the intracellular bacterial pathogen Chlamydia trachomatis is viable but severely attenuates the production of new, infectious elementary bodies (EBs). To investigate the reasons for this lack of new EB output, we analysed the expression of chlamydial genes encoding products required for DNA replication and cell division, using in vitro models of active versus persistent infection and synovial tissue samples from patients with chronic Chlamydia-associated arthritis. Hep-2 cells were infected with K serovar C. trachomatis and harvested at t = 0-48 h post-infection (p.i; active). Human monocytes were infected similarly and harvested at t = 1-7 days p.i. (persistent). RNA preparations from infected/uninfected cells and patient samples were subjected to reverse transcription-polymerase chain reaction (RT-PCR) targeting polA, dnaA, mutS and parB mRNA, related to chlamydial DNA replication/segregation; these were expressed in infected Hep-2 cells from 11 to 48 h p.i; ftsK and ftsW, related to cell division, were expressed similarly. Real-time PCR analyses demonstrated that significant accumulation of chlamydial chromosome began at about 12 h p.i. in infected Hep-2 cells. In infected human monocytes, polA, dnaA, mutS and parB mRNA were produced from days 1-7 p.i. and were weakly expressed in patient samples. Real-time PCR indicated the continuing accumulation of chlamydial chromosome during the 7 day monocyte infection, although the rate of such accumulation was lower than that occurring during active growth. However, transcripts from ftsK and ftsW were detected only at 1 day p.i. in infected monocytes but not thereafter, and they were absent in all patient samples. Thus, genes whose products are required for chlamydial DNA replication are expressed during persistence, but transcription of genes whose products are required for cytokinesis is severely downregulated. These data explain, at least in part, the observed attenuation of new EB production during chlamydial persistence.
Bacterial Proteins↗
How does one assess early rheumatoid arthritis in daily clinical practice?
In past years, consensus has been reached on the assessment of rheumatoid arthritis in clinical trials. Next to a core set of disease activity variables, response criteria have been developed and validated. These criteria are, however, of limited value in daily clinical practice. In this situation, emphasis should be paid to accurate measurement of disease activity on a continuous scale using the lowest possible number of core set variables. Different studies have shown that the DAS28 is a valuable instrument for this purpose. Many factors have been identified to possess a prognostic value; however, the IgM rheumatoid factor is still the only one which is of any importance in daily clinical practice.
Arthritis, Rheumatoid↗
Gout: can management be improved?
Ongoing reviews of Cochrane collaboration show that there is still very little reliable information based on randomized controlled trials on which to base treatment decisions in acute and chronic gout. Recent studies have stressed that avoidance of factors contributing to development of gouty attacks such as diuretic therapy, weight gain, and alcohol consumption may lead to a decrease in gouty arthritis. Attention to minidose aspirin and its effect on serum uric acid levels was addressed. A low carbohydrate, high protein and unsaturated fat diet was recommended for gouty patients since they all enhance insulin sensitivity and therefore may promote a reduction in serum uric acid levels. Treatment of gout in transplant recipients brings into focus some of the issues regarding management of gout, because gout is a common problem among transplant patients.
Acute Disease↗