Objective. To test an intervention for improving self-management in rheumatoid arthritis (RA) using an online, cognitive-behavioral, self-management group program (RAHelp), with weekly telephone support. Methods. A 2-group, randomized study design was used to compare an intervention for RA versus a waiting-list control condition. The intervention used a secure web site (RAHelp.org) to provide a 10-week program with weekly educational modules for improving self-efficacy in self-management of RA, plus tools for group interaction. Weekly telephone contacts were made to encourage use of program tools and apply newly learned skills. A nationwide convenience sample of 106 adult participants (mean age 50 years, 93% women) was recruited primarily through online advertisements. Main outcome measures included the Arthritis Impact Measurement Scales 2 (affective, physical, role, social, and pain/ symptom components), Arthritis Self-Efficacy Scale (ASES), Center for Epidemiologic Studies Depression Scale, Quality of Life Scale (QLS), Rapid Assessment of Disease Activity in Rheumatology, Social Provisions Scale, and University of California, Los Angeles Loneliness Scale 3. Results. Group differences with large and moderate effect sizes (ES

Thiopurine methyltransferase catalyzes the S-methylation of azathioprine (AZA), 6-mercapto-purine (6-MP) and thioguanine, medications widely used to treat malignancies, rheumatic diseases, dermatologic conditions, inflammatory bowel disease and solid organ transplant rejection. TPMT activity exhibits a genetic polymorphism in 10% of Caucasians, with 1/300 individuals having complete deficiency. Patients with intermediate or deficient TPMT activity are at risk for excessive toxicity, including fatal myelosuppression, after receiving standard doses of thiopurine medications. The molecular basis for low TPMT activity has been elucidated, leading to the development of assays for the three signature mutations, which account for the majority of mutant alleles. TPMT genotype is correlated with erythrocyte and leukemia blast cell TPMT activity and associated with a risk of toxicity after thiopurine therapy. Recent studies defined target starting doses for mercaptopurine based on TPMT genotypes. This polymorphism is one of the best models for the translation of genomic information to guide patient therapeutics.

An OSM site provides a convenient, effective, and securely maintained health service, once restricted to clinic settings. The OSM application can be used to extend the benefits of SM programs to broad target audiences and serves as a model for the emerging generation of Internet-based clinical management/delivery systems.

Objective. To describe leflunomide (LEF) use in a national cohort of 3,325 veterans. Methods. Prescriptions for LEF and 9 disease-modifying antirheumatic drugs written between October 1998 and June 2001 at all Veterans Affairs (VA) medical centers were obtained from VA national databases. Results. LEF was initiated with a loading dose of 100 mg daily for 3 days in 61% of patients, and 42% of patients discontinued LEF. LEF was more likely to be discontinued if a 3-day 100-mg loading dose was prescribed, patients were younger than 44 years or older than 75 years, or reported an annual family income <$60,000. Review of medical records of 291 discontinuers revealed that the most common reasons for discontinuation were inefficacy (30%), gastrointestinal symptoms (29%), medication noncompliance or lost to followup (14%), and elevated liver enzymes (5%). Conclusion. LEF is relatively safe in clinical practice. The VA's national databases provide an excellent, inexpensive resource for postmarketing evaluation of rheumatologic medications.

Our work complements the emerging literature supporting acceptance and utility of Internet-based programming as a venue for SM education and social interaction among individuals with chronic illness.

A 45-year-old female presented to the rheumatology clinic with complaint of pain and swelling of multiple small joints of the hands and feet. She also complained of cough and shortness of breath onset around the same time. Since her cyclic citrullinated peptide antibody (anti-CCP) and rheumatoid factor tests were positive, rheumatoid arthritis (RA) was diagnosed and she was started on prednisone with plans for additional disease modifying therapy. Chest X-ray showed a small right pleural effusion. While additional pulmonary evaluation was being planned, a few weeks later she presented with dyspnea, fever and tachycardia. Spiral CT showed pulmonary emboli and increased pleural effusion and patient was started on anticoagulation. A chest tube was placed and exudative pleural effusion was drained. Cytology sample from bronchoscopy raised concerns for adenocarcinoma. Open lung biopsy confirmed moderately differentiated adenocarcinoma. The patient died of lung cancer in the hospital 8 weeks from her diagnosis of RA. We describe a case of paraneoplastic polyarthritis with positive anti-CCP antibody test which has not been reported before. We also review the literature on paraneoplastic arthritis which has been described in association with various other malignancies besides lung cancer.

Because traditional pharmacotherapy in rheumatology has been empirical and because of the slow acting nature of many anti-rheumatic medications, the risk of significant side-effects and the increasing armamentarium of drugs available, pharmacogenetics is particularly relevant to rheumatology. There are many scientific and non-scientific concerns that should be addressed in future studies.

Rheumatologic diseases have varied clinical presentations, and posterior reversible encephalopathy syndrome (PRES) can be one of their presentations. The exact etiology of PRES is unknown, but endothelial dysfunction and immunosuppressive medications seem to be the likely cause in rheumatologic diseases. Clinical features include headaches, seizures, altered mental status, cortical blindness, vomiting, and focal neurologic deficits. The diagnosis of PRES can be difficult because several neuropsychiatric illnesses are generally prevalent in rheumatologic diseases; however, a high index of suspicion among physicians along with neuroimaging can help in the accurate diagnosis. Treatment guidelines are lacking, but in a few case series, lowering the blood pressure, controlling the seizures, and removing the immunosuppressive drugs have shown good results. There is need for randomized controlled trials addressing the treatment of PRES in rheumatologic diseases. Medline search was done from year 1950 to March 2011 using "posterior reversible encephalopathy" as keyword, and articles relevant to rheumatology were reviewed. We found 48 case reports showing PRES in patients with rheumatologic disease. Most of the patients were female. Age range was from 6 to 59 years. Out of the 48 case reports, 38 patients had systemic lupus erythematosus and most of them had renal disease. Five patients with autoimmune diseases presented with PRES after being started on immunomodulatory drugs. The most frequent symptoms were headache, seizures, and visual changes.