Adult Onset of Multifocal Eosinophilic Granuloma of Bone: A Long-term Follow-up with Evaluation of Various Treatment Options and Spontaneous Healing

We report a case of multifocal–monosystemic Langherhans cell histiocytosis (LCH), formerly usually referred to as eosinophilic granuloma (EG) of bone. The condition developed in a 36-year-old man. A notable infrequent thoracic spine location and two successive distinct costal lesions were observed. Both the first costal site and the vertebral location healed spontaneously; the second costal lesion underwent biopsy resection. The patient’s disease course with an 8-year follow-up is discussed with reference to various treatment options, emphasising in selected cases a watchful conservative approach, in view of the widely documented potential for spontaneous healing. Received: 7 November 1997 / Accepted: 13 July 1998     

Localised Hyaline Vascular Type of Castleman’s Disease Mimicking Adult-Onset Still’s Disease

A previously healthy 18-year-old boy presented with daily spiking fever, polyarthritis, and evanescent skin rashes, as well as hepatomegaly and Raynaud’s phenomena for 2 months. He was initially diagnosed with adult-onset Still’s disease (AOSD). During the period of follow-up, intermittent fever and migratory polyarthritis persisted and an insidiously growing mass over the right axillary region was noted 1 year after the diagnosis of AOSD. Excisional biopsy of the mass revealed a group of lymph nodes with histological features of the hyaline vascular type of Castleman’s disease. The patient’s symptoms disappeared soon after excision of the lymph nodes. Received: 4 January 1999 / Accepted: 4 June 1999     

A comparative study of the effects of bucillamine and salazosulfapyridine in the treatment of rheumatoid arthritis

Bucillamine (Buc), developed in Japan, is a disease-modifying antirheumatic drug (DMARD) which has been used to treat numerous patients with rheumatoid arthritis (RA) in Japan and Korea with favorable results. However, it has not been used globally. In the present study, we compared the timing of onset of efficacy and the usefulness of this drug with that of the globally accepted agent salazosulfapyridine (SASP). There were 26 patients in the Buc group and 23 in the SASP group. We compared changes in the number of swollen joints, number of painful joints, duration of morning stiffness, grip strength, levels of inflammatory marker [erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)], rheumatoid factor (RF), physician’s rating by visual analogue scale (VAS), patient’s rating of pain, patient’s overall rating (VAS), and improvement according to European League against Rheumatism (EULAR) criteria (DAS28-CRP, DAS28-ESR) in these two groups of patients. Both Buc and SASP were shown to be efficacious within 3 months after the start of treatment. Both drugs were found to be suitable as first-line treatment of early RA. Signs of efficacy tended to occur earlier with Buc than with SASP, and Buc also tended to have higher efficacy than SASP.     

Expanding Clinical Empathy: An Activist Perspective

ABTRACT BACKGROUND  Discussions of empathy in health care offer important ways of enabling communication and interpersonal connection that are therapeutic for the patient and satisfying for the physician. While the best of these discussions offer valuable insights into the patient-physician relationship, many of them lack an action component for alleviating the patient’s suffering and emphasize the physician’s experience of empathy rather than the patient’s experience of illness. METHODS  By examining educational methods, such as reflective writing exercises and the study of literary texts, and by analyzing theoretical approaches to empathy and suggestions for clinical practice, this article considers how to mindfully keep the focus on what the patient is going through. CONCLUSION  Clinical empathy can be improved by strategies that address (1) the patient’s authority in providing first-person accounts of illness and disability, (2) expanding the concept of empathy to include an action component geared toward relieving patients’ suffering, and (3) the potential value of extending empathy to include the social context of illness. Clinical Empathy: Uncovering Assumptions and Acting for the Patient in Social Context     

Evaluation of the Finnish Versions of the Functional Indices BASFI and DFI in Spondylarthropathy

The aim of the study was to compare and evaluate the usefulness of Finnish versions of two functional indices used in spondylarthropathies. Seventy consecutive inpatients with different kinds of spondylarthropathies filled in self-administered questionnaires: the Bath Ankylosing Spondylitis Functional Index (BASFI) and the Dougados Functional Index for spondylarthropathies (DFI). Cronbach’s α as a coefficient of internal consistency was analysed for BASFI and DFI. Test-retest reliability was evaluated in 30 patients. For validity the functional indices were compared with the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), erythrocyte sedimentation rate (ESR), spinal movement measures of chest expansion (CE), Schober S1 test and occiput-to-wall distance (OWD), and radiological changes in the lumbar spine (RTGLS) and sacroiliac joints (RTGSI). The reproducibility of the indices BASFI and DFI was good; the intraclass correlation coefficient (ICC) for reliability was 0.99 and 0.98, and the coefficient of internal consistency (Cronbach’s α) was 0.94 for both BASFI and DFI. The functional indices correlated well with each other, r= 0.85 (95% CI 0.78–0.90). Validity in terms of correlation coefficients between disease activity index BASDAI and functional indices BASFI and DFI was 0.74 (95% CI 0.60–0.84) and 0.69 (95% CI 0.53–0.80), respectively. BASFI and DFI correlated with spinal mobility measurements and RTGLS, but DFI did not correlate with RTGSI. Neither BASFI nor DFI correlated with ESR and disease duration, and only DFI correlated with age. In conclusion, BASFI and DFI are reliable and valid for Finnish inpatients with spondylarthropathies. It is important to know that cultural differences do not reduce the usefulness of these indices. Received: 3 November 1999 / Accepted: 5 April 2000     

Leukocyte count in the synovial fluid of children with culture-proven brucellar arthritis

Brucellosis is an important cause of paediatric septic arthritis in endemic areas. Because the Gram stain is frequently negative and culture results are unavailable at the time of the patient’s admission, the diagnosis of brucellar arthritis is usually entertained on the bases of epidemiological considerations and cytological examination of the synovial fluid aspirate. The aim of this study was to assess the sensitivity of a synovial fluid leukocyte count >50 000 WBC/mm³ for detecting culture-proven brucellar arthritis in children. The medical records of all children with brucellar arthritis diagnosed since 1994 in a hospital serving an endemic area for brucellosis in southern Israel were reviewed. Nine patients (six males and three females), aged 3–14 years, were identified. A single joint was affected in all patients. The median leukocyte count in the synovial fluid was 9500 WBC/mm³ (range 300–61 500 WBC/mm³), and in eight of the nine patients it was less than 50 000 WBC/mm³. Brucella melitensis was recovered from the synovial fluid culture in all patients. The diagnosis of brucellar septic arthritis cannot be excluded on the basis of a low leukocyte count in the joint aspirate. A high index of suspicion and use of modern culture techniques are recommended to improve the diagnosis of brucellar arthritis. Received: 24 March 2001 / Accepted: 29 October 2001     

Transverse Myelitis in Patients with Antiphospholipid Antibodies – The Importance of Early Diagnosis and Treatment

Transverse myelitis (TM) is a rare manifestation of systemic lupus erythematosus (SLE) and the antiphospholipid syndrome (APS). No uniform therapeutic protocol exists for its treatment, and the prognosis is usually poor. Here we describe four patients having TM associated with antiphospholipid antibodies. Treatment measures and delay in diagnosis between symptom onset and the initiation of treatment varied between patients, but the earlier the diagnosis and the more aggressive the treatment the better was the patient’s outcome. Based on these cases and on a literature review we suggest that early aggressive treatment (usually with pulses of methylprednisolone and cyclophosphamide) might improve the prognosis of patients with TM associated with antiphospholipid antibodies. Received: 13 March 2001 / Accepted: 3 October 2001     

Translation and validation of the Persian version of the Arthritis Impact Measurement Scales 2-Short Form (AIMS2-SF) in patients with rheumatoid arthritis

Cultural adaptation and validation of the Persian version of the Arthritis Measurement Scales 2-Short Form (AIMS2-SF). The translation and cultural adaptation of the original questionnaire was carried out in accordance with published guidelines. Three hundred and fifty consecutive Persian-speaking patients with rheumatoid arthritis (RA) were asked to complete the AIMS2-SF, the Short Form Health Survey (SF-36), and four visual analog scales (VAS) for pain, joint stiffness, and patient’s and physician’s global assessment to test convergent validity. In addition, 90 randomly selected patients were asked to complete the questionnaire 48 h later for the second time. Moderate to high correlation were found between the AIMS2-SF and subscales of the SF-36 and VAS for pain, morning stiffness, and patient’s and physician’s global assessment. Cronbach’s alpha coefficient for the Persian AIMS2-SF scales ranged from 0.74 to 0.89. The Persian AIMS2-SF scales showed excellent test–retest reliability with Intraclass Correlation Coefficient ranging from 0.83–0.93 (p < 0.01). The results of the present study showed that the Persian AIMS2-SF has reasonably good convergent validity, internal consistency, and test–retest reliability in patients with RA. It can now be applied in clinical settings and future outcome studies in Iran.     

Toward a Biopsychosocial Understanding of the Patient–Physician Relationship: An Emerging Dialogue

Complexity theory has been used to view the patient–physician relationship as constituted by complex responsive processes of relating. It describes an emergent, psychosocial relational process through which patients and physicians continually and reciprocally influence each other’s behavior and experience. As psychosocial responses are necessarily biopsychosocial responses, patients and physicians must likewise be influencing each other’s psychobiology. This mutual influence may be subjectively experienced as empathy, and may be skillfully employed by the clinician to directly improve the patient’s psychobiology.     

Improvement of functional ability in children with juvenile idiopathic arthritis by treatment with etanercept

The objective of the study is to investigate the functional ability, i.e., the physical aspect of the health-related quality of life and its determining factors during therapy with etanercept in children with juvenile idiopathic arthritis (JIA). Assessment of the Child Health Assessment Questionnaire (CHAQ), the number of active joints, duration of morning stiffness, ESR, C-reactive protein, parent’s global assessment of the overall patient’s well-being, physician’s global assessment of the overall disease activity, concomitant treatment with methotrexat, number of aids/devices needed, and calculation of the PedACR-score. Data of 437 children were analyzed for disease severity and impact of the disease on functional abilities. Data of 114 children with a complete data set and a continuous treatment for at least 24 months were used for analysis of the impact of treatment on functional abilities. Before treatment with etanercept, patients with systemic arthritis and seropositive or seronegative polyarthritis were disabled more heavily than those with other subtypes of JIA. There was a correlation between high CHAQ scores and the number of active joints, aids/devices needed, parent’s global assessment of the overall patient’s well-being, morning stiffness, physician’s global assessment of the overall disease activity, and C-reactive protein (P < 0.005). Of the eight areas, “dressing and grooming”, “arising”, “eating”, “walking”, “hygiene”, “reach”, “grip” and “activities”, the latter was most severely affected. 96.5, 93.8, and 90.3% of the patients reached a PedACR-30, -50 and -70 score upon treatment with etanercept for 24 months. The areas of eating and walking were best before therapy and showed highest improvement with therapy. Under therapy with etanercept patients of all JIA subgroups significantly improved their functional ability (P < 0.0001), but patients with polyarthritis less frequently improved their physical functioning. Disease activity and the physical aspect of health-related quality of life including functional ability improved significantly during therapy with etanercept in children with JIA. Duties of everyday life were easier to accomplish.     

Validation of the Spanish Version of the WOMAC Questionnaire for Patients with Hip or Knee Osteoarthritis

The aim of this study was to validate a translated version of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) questionnaire in Spanish patients with hip or knee osteoarthritis (OA). The WOMAC questionnaire and the SF-36 were administered to a sample of 269 patients on the waiting list for hip or knee replacement. We studied the convergent validity and the item-scale correlation using Pearson’s correlation coefficient and Spearman’s π. For the reliability study we used another sample of 58 patients who received the WOMAC twice within 15 days. The Pearson’s, Spearman’s π, and intraclass correlation coefficients were calculated. Internal consistency was measured by Cronbach’s α. The responsiveness study was carried out by resending the two questionnaires to all patients 6 months after surgical intervention; responsiveness was measured by means of the paired t-test, the effect size I and the standardised response mean. The Pearson’s coefficients for the convergent validity ranged from −0.52 to −0.63. The coefficients obtained for the item–scale correlation of the pain area were 0.74 or higher, 0.91 or higher for stiffness, and 0.61 or higher for function. When measuring the test–retest reliability, the coefficients ranged from 0.66 to 0.81. Internal consistency yielded a Cronbach’s α ranging from 0.81 to 0.93. The responsiveness showed an effect size I ranging from 1.5 to 2.2 in patients who underwent hip replacement; for those who underwent knee replacement the range was 1 to 1.8. The standardised response mean ranged from 1.3 to 1.9 for patients with hip OA; those with knee OA ranged from 0.8 to 1.5. The Spanish version of WOMAC is a valid, reliable and responsive instrument in patients with hip or knee OA. Received: 12 November 2001 / Accepted: 21 May 2002 Correspondence and offprint requests to: Dr Antonio Escobar Martínez, Unidad de Investigación, Hospital de Basurto, Avenida de Montevideo, 18, 48013 Bilbao, Spain. Tel: +34 944006000 ext. 5307; Fax: +34 944006180; E-mail: aescobar@hbas.osakidetza.net     

Prevalence of Raynaud’s Phenomenon in General Practice in the East of Spain

Our aim was to establish the prevalence of Raynaud’s phenomenon in a general practice in the east of Spain and compare our results with those of other studies performed in geographical areas with similar climatic characteristics. Two hundred and seventy-six subjects visiting their general practitioner for whatever reason were randomly selected from a particular area of the city of Valencia. Each was interviewed by their GP following the guidelines of a structured questionnaire to establish whether they had Raynaud’s phenomenon or not. There were 205 women and 71 men. The mean age was 54.43, with a standard deviation of 18.22. Raynaud’s phenomenon was present in nine subjects, two men and seven women, with a prevalence of 2.8% and 3.4%, respectively. Of the nine positives (mean age 60.56 years, standard deviation 16.38), two were diagnosed with hypertension and two with migraine. None of them usually took Raynaud’s phenomenon-related drugs or performed physical exercise. No patient had a family history of Raynaud’s phenomenon or had already been diagnosed with it. All the positive males were affected only by the pallor stage. This study shows lower prevalences than those of other studies performed in different geographical areas with similar climatic conditions. Received: 22 November 1999 / Accepted: 6 September 2000     

Systemic sclerosis therapy with iloprost: a prospective observational study of 30 patients treated for a median of 3 years

Iloprost is useful in the short-term treatment of severe Raynaud’s phenomenon and ischaemic ulcers in patients with systemic sclerosis (SSc), but its long-term effects are largely unknown. The aim of this study was to report long-term outcome (median follow-up 36 months) in a prospective observational study of a cohort of 30 consecutive patients with SSc who received iloprost therapy with maintenance infusions every 3 weeks after an initial cycle of 5 consecutive days. At the end of the observation, compared to the pretreatment point, we observed complete healing of digital ulcers in 19/21 patients (90%), a decrease of the Raynaud’s phenomenon visual analogue score from 10/10 (25th–75th percentile 7–10) to 5/10 (4–6.75) (P <0.001) and, in patients with diffuse cutaneous involvement, of the modified Rodnan skin thickness score from 25.5 (16.5–31.5) to 16 (13.5–20) (P= 0.02), minimal improvement of the Health Assessment Questionnaire from 0.87 (0.68–1.37) to 0.75 (0.62–1.25), which was neither statistically nor clinically significant. The forced vital capacity was not significantly changed, but the diffusion capacity corrected for the alveolar volume decreased from 71% (54–76.7) of the expected value to 62% (51.5–71) (P= 0.02). In one patient with limited SSc a positive effect on pulmonary hypertension was observed. Six patients, after a median of 25 months of treatment and healing of digital ulcers, discontinued the therapy; after a median of 10 months ulcers did not recur in five of these six. Other reasons for discontinuation were: tolerability (1), disease progression (normotensive renal crisis: 1), and death due to intracranial haemorrhage (1). This same patient had previously suffered a central retinal vein thrombosis. In conclusion, long-term therapy with iloprost in patients with SSc has a durable effectiveness on ischaemic ulcers and Raynaud’s phenomenon, but it is not possible to conclude that the natural history of the disease was modified. Received: 23 August 2001 / Accepted: 22 November 2001     

Evaluation of Cerebrospinal Fluid for the Presence of Anticardiolipin Antibodies (aCL) in NP-SLE Patients

Many neurological or psychiatric manifestations of SLE (NP-SLE) are related to the presence of anticardiolipin antibodies (aCL) in the patient’s sera. The aim of this study was to evaluate the presence of aCL in cerebrospinal fluid (CSF) in SLE patients with NP features. Fifteen SLE patients were studied, all with NP features. CSF was evaluated for intrathecal IgG synthesis, oligoclonal IgG, and blood–brain barrier impairment. Sera and CSF were tested by ELISA for the presence of aCL-IgG and aCL-IgM with and without β₂ glycoprotein (β₂ GPI) cofactor. CSF and sera of 50 low back pain patients served as controls. Six patients were aCL(+) and nine aCL(–). In all patients the general CSF examination was normal. In all patients the value of indices of intrathecal IgG synthesis were normal but oligoclonal protein was present in the CSF of three patients. In none of the patients was the blood–brain barrier impaired. Neither aCL-IgG nor aCL-IgM was detected in the CSF of any NP-SLE patient. Mean levels of aCL in patients without cofactor β₂ GPI and with cofactor were as follows: for IgG class 0.005 and 0.057 OD (negative); for IgM class 0.004 and 0.024 OD (negative). We could not detect aCL in the CSF of patients with NP-SLE, even if sera were positive for aCL. Received: 6 July 1999 / Accepted: 18 January 2000     

Hyperviscosity Syndrome in Rheumatoid Arthritis with Felty’s Syndrome: Case Report and Review of the Literature

Hyperviscosity syndrome (HVS) is characterised by high serum viscosity and the involvement of multiple organs, commonly causing retinal haemorrhage, bleeding diathesis, pulmonary hypertension, congestive heart failure (CHF), neurologic deficits and death. It has been reported that HVS is mostly encountered in Waldenstro¨m’s macroglobulinaemia (80%–90% of all HVS cases) and occasionally in multiple myeloma. HVS in patients with connective tissue diseases (CTD) has rarely been reported. Of 28 cases of HVS reported in patients with CTD, 19 were with seropositive rheumatoid arthritis (RA). However, only six of these 19 cases had Felty’s syndrome. Here we report another case of HVS in a patient with RA as well as Felty’s syndrome. Received: 15 March 2001 / Accepted: 8 August 2001     

Ethics at the end of life

Some of the physician’s most difficult decisions involve whether to give cardiopulmonary resuscitation (CPR). Current research, hospital policies, and case law provide little guidance for these decisions, but medical ethics offers three useful principles. All three are based on patients’ wishes. First, a victim of cardiopulmonary arrest should receive CPR unless compelling reasons indicate he would not want it. Second, a patient has the right to refuse CPR. Finally, if CPR will serve no therapeutic goals defined from the patient’s wishes, it should not be given. Applying these principles requires a sympathetic, directed history which elicits the patient’s wishes relevant to resuscitation. This article uses an actual case and a simple algorithm to show how these principles promote ethically sound resuscitation decisions. Received from the Division of General Medicine, Department of Medicine, The University of Texas Health Science Center, San Antonio, Texas.     

Factors Associated with Anxiety, Depression and Suicide Ideation in Female Outpatients with SLE in Japan

The subjects consisted of 84 female SLE outpatients who were all over 20 years of age. These patients were able to maintain relatively stable physical conditions and lead normal daily lives, and they were regularly treated at the outpatient clinic. All subjects were Japanese. Psychological features (trait anxiety, state anxiety, depression and suicide ideation) were evaluated using psychological tests, and the relationships between the respective psychological features and background factors were statistically evaluated using stepwise multiple logistic regression analyses. In this study, we found that ‘the self-evaluation of not having understood SLE at the time of starting SLE treatment’ was the background factor significantly affecting depression or trait anxiety. ‘No spouse’ had a statistically significant effect on depression, and ‘self-awareness as problems of side-effects due to steroids’ had a statistically significant effect on state anxiety. We also found ‘human relations among family members’ and ‘high daily steroid dosage’ to be significantly correlated with suicide ideation. However, there were no correlations between the psychological features and ‘disease activity at the time of investigation’ or ‘history of neuropsychiatric diseases’. In female SLE outpatients, performing psychological approaches focusing on ‘understanding SLE at the beginning of treatment’, ‘the human relationships among family members’, or ‘issues related to steroid therapy’ may be useful for the early treatment or prevention of various major mental problems. Received: 14 March 2001 / Accepted: 16 May 2001     

CLINHAQ Scale – Validation of a Hebrew Version in Patients with Fibromyalgia

Assessment of health status in patients with rheumatic disease, including fibromyalgia (FM), using structured questionnaires has become an important approach to evaluate treatment and outcome. The objectives of this study were to validate a translated version of the Clinical Health Assessment Questionnaire (CLINHAQ) to be used by Hebrew-speaking populations, and specifically to evaluate its usefulness in fibromyalgia syndrome (FM). The CLINHAQ was translated into Hebrew and administered to 90 women with FM along with the Hebrew versions of the Fibromyalgia Impact Questionnaire (FIQ) and the Quality of Life (QOL) Scale. The CLINHAQ includes scales of functional disability, helplessness, anxiety and depression, as well as assessment of current health status and satisfaction with this. All subjects were asked about the presence and severity (assessed by visual analogue scale) of current FM symptoms (pain, fatigue, anxiety etc.); a count of 18 tender points was conducted by thumb palpation, and tenderness thresholds were measured by dolorimetry. Test–retest reliability was assessed by Pearson correlation coefficients, and internal consistency was evaluated with Cronbach’s α coefficient of reliability. Construct validity was tested by correlating the CLINHAQ items with measures of symptom severity, count of tender point, tenderness thresholds, physical functioning measured by FIQ, and with a score of QOL. Test–retest reliability coefficients ranged from 0.82 to 0.99, and Cronbach’s α coefficients from 0.725 to 0.929. Significant moderate to high correlations were obtained between most subscales of CLINHAQ and measures of physical functioning, quality of life and severity of FM symptoms. In conclusion, the CLINHAQ is a reliable and valid instrument for measuring health status and physical functioning in Israeli women with FM. Received: 22 June 1999 / Accepted: 24 September 1999     

Biochemical Bone Turnover Markers in Patients with Ankylosing Spondylitis

In this study, bone formation markers [alkaline phosphatase (ALP), bone-specific alkaline phosphatase (BALP) and osteocalcin (BGP)] and bone resorption markers [pyridinium cross-links: pyridinoline (Pyd) and deoxypyridinoline (Dpyd)] were studied in 44 patients with ankylosing spondylitis (AS) and in a control group of 41 subjects. The AS group was classified according to duration of disease, erythrocyte sedimentation rate (ESR) values and gender. Urinary Pyd and Dpyd concentrations of the patients were higher than in the control group, concomitant with the lower T-score values of the patients in both the anteroposterior lumbar spine and femoral neck. Although a correlation between markers of disease activity [ESR and C-reactive protein (CRP)] and bone turnover markers was not observed, urinary excretion of Dpyd and Pyd was enhanced in the ESR >20 mm/h subgroup compared with the ESR ≤20 mm/h subgroup. A significant elevation of urinary Dpyd was also observed in the female subgroup and long disease duration subgroup. Serum ALP, BALP and BGP levels of the patients and control group were not statistically different (p> 0.05). No significant differences were observed between mineral and calcitropic hormone levels in either group, and total testosterone levels of the patients were within the reference range. According to this study, urinary Pyd levels are elevated in patients with AS. Gender, duration of disease and ESR also have an impact on urinary excretion of these collagen compounds. It can be concluded that bone turnover in patients with AS reflects normal osteoblastic activity and high osteoclastic activity. Received: 12 March 1999 / Accepted: 25 August 1999     

General or personal diet: the individualized model for diet challenges in patients with rheumatoid arthritis

This study was performed to evaluate the effect of individualized diet challenges consisting of allergen foods on disease activity in rheumatoid arthritis (RA) patients. Twenty patients with positive skin prick test (SPT) response for food extracts and 20 with negative SPT response were included. All patients were instructed to restrict the most common allergen foods during 12 days and then assigned into two groups according to SPT results. Food challenges were performed with all of the allergen foods in prick test positive group (PTPG) and with corn and rice in prick test negative group (PTNG) during 12 days. Allergen foods were then eliminated from PTPG patients’ diet, while corn and rice were removed in PTNG. Clinical evaluations were performed after fasting (baseline), at the end of the challenge phase and reelimination phase. Stiffness, pain, physician’s and patient’s global assessment of disease activity, health assessment questionnaire (HAQ), Ritchie’s index, serum amyloid A protein, erythrocyte sedimentation rate and C-reactive protein were determined. All of the disease variables, except HAQ, were increased with food challenges in PTPG. In PTNG, no significant change was observed in any of the variables except pain (P<0.05) and patient’s global assessment (P<0.05). Our results showed that the individualized dietary manipulations may effect the disease activity for selected RA patients.