Results. Sixty-four patients were eligible for entry and were switched from oral MTX to 15 mg/week IM MTX. At baseline, the mean ؎ SD DAS28 was 5.6 ؎ 0.88; after 6 weeks of IM MTX, the DAS28 had improved by a mean of 0.42 (95% confidence interval [95% CI] 0.15-0.69). At 6 weeks, 54 patients still had a DAS28 of >3.2 and were therefore eligible for randomization. By 22 weeks, 1 patient (3.7%) in each group achieved the primary outcome of a DAS28 <3.2 (95% CI for the difference between the groups ؊15% to ؉15%). Five patients (18.5%) in each group showed an improvement of >1.2 in the DAS28 (95% CI for the difference between the groups ؊18% to ؉18%). One patient (3.7%) in each group achieved an ACR20 response, but none achieved a good response as defined by the EULAR response criteria. One patient in each group had a serious adverse reaction; minor adverse reactions were more frequently reported in the dose escalation group.Conclusion. Switching from oral to parenteral MTX 15 mg/week results in a minor improvement in disease control. For patients with active RA receiving 15

Objective: To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis.

BACKGROUND Guidelines recommend nonstatin lipid-lowering agents in patients at very high risk for major adverse cardiovascular events (MACE) if low-density lipoprotein cholesterol (LDL-C) remains ≥70 mg/dL on maximum tolerated statin treatment. It is uncertain if this approach benefits patients with LDL-C near 70 mg/dL. Lipoprotein(a) levels may influence residual risk. OBJECTIVES In a post hoc analysis of the ODYSSEY Outcomes (Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab) trial, the authors evaluated the benefit of adding the proprotein subtilisin/kexin type 9 inhibitor alirocumab to optimized statin treatment in patients with LDL-C levels near 70 mg/dL. Effects were evaluated according to concurrent lipoprotein(a) levels. METHODS ODYSSEY Outcomes compared alirocumab with placebo in 18,924 patients with recent acute coronary syndromes receiving optimized statin treatment. In 4,351 patients (23.0%), screening or randomization LDL-C was <70 mg/dL (median 69.4 mg/dL; interquartile range: 64.3–74.0 mg/dL); in 14,573 patients (77.0%), both determinations were ≥70 mg/dL (median 94.0 mg/dL; interquartile range: 83.2–111.0 mg/dL). RESULTS In the lower LDL-C subgroup, MACE rates were 4.2 and 3.1 per 100 patient-years among placebo-treated patients with baseline lipoprotein(a) greater than or less than or equal to the median (13.7 mg/dL). Corresponding adjusted treatment hazard ratios were 0.68 (95% confidence interval [Cl]: 0.52–0.90) and 1.11 (95% Cl: 0.83–1.49), with treatment-lipoprotein(a) interaction on MACE ( P interaction = 0.017). In the higher LDL-C subgroup, MACE rates were 4.7 and 3.8 per 100 patient-years among placebo-treated patients with lipoprotein(a) >13.7 mg/dL or ≤13.7 mg/dL; corresponding adjusted treatment hazard ratios were 0.82 (95% Cl: 0.72–0.92) and 0.89 (95% Cl: 0.75–1.06), with P interaction = 0.43. CONCLUSIONS In patients with recent acute coronary syndromes and LDL-C near 70 mg/dL on optimized statin therapy, proprotein subtilisin/kexin type 9 inhibition provides incremental clinical benefit only when lipoprotein(a) concentration is at least mildly elevated. (ODYSSEY Outcomes: Evaluation of Cardiovascular Outcomes After an Acute Coronary Syndrome During Treatment With Alirocumab; NCT01663402 )

The case is reported of a 63 year old man presenting with a rapidly destructive symmetrical polyarthritis and widespread papular nodular skin lesions, confirmed by a biopsy to be due to multicentric reticulohistiocytosis. Biventricular cardiac failure developed secondary to extensive myocardial infiltration with multicentric reticulohistiocytosis, a complication of this disease which has not previously been reported. The joint, skin, and cardiac manifestations of multicentric reticulohistiocytosis substantially regressed following resection of an associated squamous cell carcinoma. This report adds to the small amount of published work which suggests that multicentric reticulohistiocytosis can be a paraneoplastic disease that may respond to treatment directed at the underlying tumour.Multicentric reticulohistiocytosis is an uncommon disease of unknown aetiology sufficiently similar in its presentation to rheumatoid arthritis for it often to be initially mistaken as such. Although the joints and skin are the most commonly affected sites, multicentric reticulohistiocytosis may become a systemic disease with a poor prognosis. ' 2 contained periodic acid-Schiff positive material typical of this disease. The synovial fluid aspirate contained polymorphs, a few macrophages and lymphocytes, but there were no specific features of multicentric reticulohistiocytosis.The patient was initially treated symptomatically with rest, non-steroidal anti-inflammatory drugs (NSAIDs) and intra-articular steroids. The synovitis persisted, however, and cyclophosphamide (15 mg/kg/month) was given by intermittent intravenous infusion. There was some improvement in joint symptoms and synovitis after two infusions but the skin lesions remained static.Three months later the patient presented with dyspnoea at rest and signs of acute biventricular cardiac failure. Flexor tenosynovitis with deformities of the fingers had developed. The skin disease had progressed with the development of several larger nodules which were freely mobile within the subcutaneous tissue over the extensor aspect of his forearms and hands (fig 1) Case report A 63 year old previously healthy man presented with a three month history of polyarthralgia and morning stiffness affecting the hands, wrists, and knees together with an extensive painless, pruritic rash. Examination showed synovitis, bilateral knee effusions, and olecranon bursitis. Crops of red and brown papules 1-5 mm in diameter were present over the chest and abdomen. Xanthelasmata were noted but there were no other cutaneous features of hyperlipidaemia and the examination was otherwise normal.The erythrocyte sedimentation rate was increased at 43 mm in the first hour but the full blood count, plasma urea and electrolytes, liver function tests, fasting lipids, immunoglobulins, and rheumatoid factor were all normal. Hand radiographs showed soft tissue swelling, periarticular osteoporosis, and loss of articular cartilage of the proximal and distal interphalangeal joints. The diagnosis of multicentric ret...

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Instrumental musicians are prone to a variety of occupationally determined upper limb problems that produce significant disability and loss of earnings. As the majority of these affect the musculoskeletal system in one way or another they assume a particular relevance to the practice of rheumatology. Recent advances in our understanding of the aetiology of these conditions are described together their mode of presentation, differential diagnosis, investigation and the therapeutic options available for them.

Aggregated data from Manchester practices participating in the Diabetes 2000 project were used to develop peer group standards of mean performance and of excellence. The crude prevalence of known diabetes mellitus was 1.21% of which 20.2% had Type 1 diabetes. The aggregated mean of patients who had the following examinations performed in the preceding year were: glycated haemoglobin 56.8%; weight or body mass index 67.8%; foot pulses 37.3%; ankle reflexes 31.3%; proteinuria 60%; fundoscopy 48.2%; blood pressure 81.1%; serum cholesterol or lipids 34%. The percentage of patients referred to or seen by health care professionals in the preceding year were 14.4% to diabetes specialist nurses; 22.1% to opticians or ophthalmologists; 25% to chiropodists; and 21.5% to dietitians. The best performing practices examined 79% of patients fundi in the preceding year, 84% of their foot pulses, 74% of their ankle reflexes, and gave appropriate smoking advice in 65% of cases. These standards were fed back to the participating practices so that they could compare their own performance with that of the city-wide mean, and with the best performing practices. From these data practices have then been able to set themselves realistic targets for improved performance in the following year.

Health economic evaluation comprises the systematic appraisal of the costs, the benefits and the relative economic efficiency of different medical interventions. The first section of this paper outlines the techniques of economic analysis and how they relate to the efficient use of health resources. This is followed by a review of the health economics of rheumatoid arthritis as a model for the wider application of health economics in the field of rheumatology.