Synovial fluid leukocytosis. A study of extremes.

Three hundred and eighty-eight synovial fluids from 310 patients with definite diagnoses were reviewed. Seventy per cent of the patients with culture-proved infections in the joint space had leukocyte counts above 50,000/mm³ whereas 12.5 per cent of the patients with gout, 10 per cent of those with pseudogout and 4 per cent of those with rheumatoid arthritis had leukocyte counts in this high range.White cell counts ranged from 6,000 to 46,000/mm³ in 30 per cent of the patients with infectious arthritis. However, their fluids contained 90 per cent neutrophils and poor mucin clots, and within 12 to 48 hours repeat aspirations of the same joint showed large increases in the leukocyte count. These patients were divided into two groups, one with mild infections due to Neisseria gonorrhea and Diplococcus pneumoniae, and another consisting of patients with complicated underlying diseases whose infections, usually due to more virulent organisms, were poorly controlled and whose mortality rate was 25 per cent within days of synovial fluid analysis.In one fourth of the fluids with sodium urate crystals and one third of the fluids with calcium pyrophosphate crystals, leukocyte counts were below 2,500/mm³. Compared to patients with gouty arthritis, a larger number of patients with pseudogout had normal mucin precipitates despite higher numbers of leukocytes. These data document the magnitude of overlap at extremes of synovial fluid leukocytosis in common forms of arthritis and suggest a need for a careful search for crystals in fluids with high as well as low leukocyte counts.     

Association between fluorescent antinuclear antibodies, capillary patterns, and clinical features in scleroderma spectrum disorders

Antinuclear antibody and in vivo capillary patterns were studied in 33 patients with Raynaud's phenomenon only and in 68 patients with scleroderma spectrum disorders; the results were correlated with clinical and laboratory findings. In addition, antinuclear antibody results in the groups with Raynaud's phenomenon only and scleroderma spectrum disorders were compared with those found in 70 patients with systemic lupus erythematosus (SLE). Distinct antinuclear antibody profiles were observed in the three diagnostic groups. Comparison of patients with anticentromere antibodies with others in the group with scleroderma spectrum disorders demonstrated that anticentromere antibody-positive patients tended to have a milder disease: less skin and visceral involvement, less frequent presence of hypertension, anemia, and elevated sedimentation rate. These differences did not, however, reach statistical significance. Comparison of patients with scleroderma spectrum disorders according to in vivo capillary patterns revealed that those with an "active" pattern had significantly more extensive skin involvement than those with a "slow" pattern. Visceral involvement tended to be greater in all organ systems in the group with an "active" pattern and reached statistical significance for muscle and kidney. Hypertension was also significantly more frequent in the group with an "active" pattern than in the group with a "slow" one. The latter was positively correlated with the presence of anticentromere antibody.     

Effect of tocilizumab combined with methotrexate on circulating biomarkers of synovium,cartilage, and bone in the LITHE study

Objective

We investigated the effects of tocilizumab (TCZ) on joint tissue remodeling in patients with moderate to severely active RA by measuring tissue-specific biomarker.

Methods

The LITHE biomarker study (n = 740) was a phase III study of 4- and 8-mg/kg TCZ in combination with MTX. Early response was evaluated at week 16 as ±20% improvement in swollen/tender joint counts; and ACR50 was evaluated at week 52. Biomarkers (tissue inflammation: C3M, CRPM, and VICM; cartilage degradation: C2M; and bone turnover: CTx and osteocalcin) were tested in serum from baseline, week 4, 16, 24, and 52, and dose-dependent effect was investigated. Patients were divided into the following three groups: early non-responders (ENR), ACR50 responders, and non-responders; their biomarker profiles were compared.

Results

At week 52, CRP was inhibited to 4% and 40% of baseline by TCZ8 and TCZ4, respectively. CRPM (63%), C2M (84%), C3M (69%), and VICM (42%) were significantly (p < 0.05) reduced by TCZ8, but not by TCZ4. MMP3 and osteocalcin changed to <58% and >111%, respectively, in response to TCZ. CTx was not changed significantly. ENRs had significantly less inhibition of CRPM (p < 0.05), C2M (p < 0.01), and C3M (p < 0.01) compared to early responders. There was a significant difference in the C2M, C3M, and CRPM profiles of the ENRs, non-responders, and responders. ACR50 responders had significantly inhibited levels (p < 0.001), irrespective of dose.

Conclusions

TCZ8 strongly inhibited the biomarkers of joint tissue remodeling suggesting that TCZ actively suppresses key pathobiological processes at the site of inflammation in RA patients. The differences in biomarkers' profiles of responders and non-responders indicate that specific responder profiles exist.     

Realidad de la Reumatología en España y sus comunidades autónomas antes de la pandemia

ObjectivesTo determine the number of rheumatologists per 100,000 inhabitants working in public or private centres in Spain as a whole, and by Autonomous Community and their distribution by age and sex.Material and methodCross-sectional study based on the information contained in the database of the Spanish Society of Rheumatology. Quality control was performed by contact (e-mail and telephone call) with the heads of the clinical services of each of the hospitals (public and private). The information analysed was the age, sex and place of work of active rheumatologists in February 2020. The rates of rheumatologists per 100,000 inhabitants were calculated from population data from the National Institute of Statistics.ResultsThe rate of rheumatology specialists per 100,000 inhabitants in Spain was estimated at 2.17. The percentage of women was 59.7%, with a higher female/male ratio at younger ages. The lowest proportion of specialists per 100,000 inhabitants was in the community of Valencia (1.6), and the highest in Cantabria (3.2).ConclusionsVariations were found in the rate of rheumatologists per 100,000 inhabitants among the Autonomous Communities. The distribution by age and sex showed a tendency towards female rheumatologists, especially in the younger age strata.     

Diffuse lymphoma of the intestines with a monoclonal gammopathy of IgG3 kappa type

Monoclonal gammopathy of IgG₃ kappa type is described in a young man with diffuse lymphoid infiltration of the stomach duodenum and intestines.     

Japan College of Rheumatology guideline for the use of methotrexate in patients with rheumatoid arthritis

Methotrexate (MTX), the anchor drug in the current treatment strategy for rheumatoid arthritis (RA), was first approved for treatment of RA in Japan in 1999 at the recommended dose of 6–8?mg/week; it was approved as first-line drug with the maximum dose of 16?mg/week in February 2011. However, more than half of Japanese patients with RA are unable to tolerate a dose of 16?mg/week of MTX. Moreover, some serious adverse events during the treatment with MTX, such as pneumocystis pneumonia (PCP) and lymphoproliferative disorders (LPD) have been observed much more frequently in Japan than in other countries. Therefore, this article, an abridged English translation summarizing the 2016 update of the Japan College of Rheumatology (JCR) guideline for the use of MTX in Japanese patients with RA, is not intended to be valid for global use; however, it is helpful for the Japanese community of rheumatology and its understanding might be useful to the global community of rheumatology.     

Characterizing the clinical practice and professional behaviour of rheumatology nurse specialists: a pilot study

Background: There is a need to characterize the practice of nurse specialists, for several reasons: to identify the skills and knowledge required for the role, to safeguard the role and to facilitate appropriate remuneration of activities. Objective: To develop an instrument, which characterizes the clinical and professional activities of rheumatology nurse specialists (RNSs). Methods: A questionnaire was produced, informed by the Nursing and Midwifery Council (NMC), to assess competencies in advanced nursing practice and completed by senior clinical rheumatology nurses in the UK undertaking an MSc in rheumatology nursing. Consenting respondents were also interviewed, to enable triangulation of the data. Results: A 38‐item questionnaire was produced. It comprised four sections: clinical activities, non‐patient‐based activities, professional behaviour and perceived confidence in a number of areas of practice. Thirteen nurses completed the questionnaire and seven of these took part in a telephone interview. All RNSs were engaged in the follow‐up care of patients with rheumatoid arthritis, providing education, psychological support, monitoring and changing of drug treatments, and referrals to other health professionals. The RNSs produced guidelines, conducted audits and provided mentorship. They had low levels of confidence in seeing new patients, presenting the results of an audit at a conference, and writing a business case. Conclusions: We have begun the process of developing a questionnaire that can identify the clinical activities, perceived self‐competence and professional behaviour of RNSs. This method of characterizing advanced nursing practice offers potential as a model for nurse specialists in other disciplines. Further work is required to validate the questionnaire on a large cohort of RNSs. Copyright © 2010 John Wiley & Sons, Ltd.