This is the largest study of RA-ILD in the UK. Anti-CCP antibodies were strongly associated with RA-ILD in both sexes. Smoking was strongly associated with ILD in males, which may explain the higher frequency of RA-ILD in men. The predominant HRCT pattern was UIP and most patients had limited disease at presentation. The presence of UIP and extensive disease are associated with increased mortality. Baseline gas transfer is a useful screening tool for ILD, while the preservation of VC at baseline might predict limited disease on HRCT.

-The modified early warning score (MEWS) was developed as a track and trigger tool for the prompt identification of seriously ill patients on an acute medical ward. This paper examines its value in the setting of an acute medical admissions unit (MAU) and compares it to biochemical markers of acute and chronic disease. Three hundred unselected acute admissions to the MAU of the Queen Elizabeth Hospital, Gateshead, were assessed. Correlations between MEWS score and C-reactive protein (CRP) and albumin separately were assessed, and then the relationship between MEWS and the CRP/albumin ratio across the age spectrum was examined. The findings demonstrated a strong correlation between the MEWS score and CRP/albumin ratio (r=0.88, p<0.001) across the whole age spectrum. Length of stay correlated poorly with MEWS (r=0.08) and CRP/albumin ratio (r=0.15). Overall mortality was 5% and was predicted by both tools, with a MEWS score of >4 (relative risk (RR)=7.8) outperforming a CRP/albumin of >2 (RR=2.6). MEWS remains the gold standard for assessing outcome in acute medical admissions, but does have limitations in the elderly (those aged over 70 years). A raised CRP/albumin ratio was less sensitive for overall mortality than MEWS. It did, however, appear to be of greater value in the elderly, especially in those with acute exacerbations of chronic disease. Neither test accurately predicted length of stay.KEY WORDS: albumin, C-reactive protein, death, early warning system, length of stay, outcome

No abstract

This long term follow up of lung disease in primary SS is reassuring, and suggests that most patients do not develop progressive lung disease. Pulmonary disease occurs predominantly in anti-Ro antibody positive patients and presents early in the course of the disease.

We performed high resolution computed tomography (HRCT) on the lungs of 20 patients with RA and clinical and radiological evidence of interstitial lung disease (ILD). A case control group of patients with RA but without evidence of ILD were similarly studied and all patients underwent detailed pulmonary function testing. Clinical findings, drug therapy, smoking status, the presence/absence of SS and disease activity were also assessed. HRCT showed a range of abnormalities among patients thought to have ILD. Interstitial fibrosis was confirmed in 16 but was frequently associated with emphysema. Ground glass opacification was present in seven, while basal honey-combing was also evident in seven patients. Both these features were present in two patients with ILD. Bronchiectasis was identified in six patients and was the predominant finding in two patients previously thought to have ILD. Among the control patients, HRCT was normal in only five. Clinically unsuspected ILD was present in four patients, while a further four had bronchiectasis. Pleural disease was identified in seven controls. Pulmonary function tests were generally poor predictors of HRCT findings, although a reduced residual volume (RV) [> 1 S.D.] was 83% specific for the presence of ILD and a raised RV [> 1 S.D.] was 64% specific for emphysema. Smoking did not correlate with the presence of either ILD or emphysema and there were no correlations between disease activity and HRCT findings. RA patients with evidence of ILD have abnormalities on HRCT which cannot be confidently predicted on any other non-invasive test.(ABSTRACT TRUNCATED AT 250 WORDS)

Rheumatoid arthritis (RA) is a systemic autoimmune disease affecting 0.5-1% of the worldwide population. Whilst predominantly causing chronic pain and inflammation in synovial joints, it is also associated with significant extra-articular manifestations in a large proportion of patients. Among the various pulmonary manifestations, interstitial lung disease (ILD), a progressive fibrotic disease of the lung parenchyma, is the commonest and most important, contributing significantly to increased morbidity and mortality. The most frequent patterns of RA-associated ILD (RA-ILD) are usual interstitial pneumonia and nonspecific interstitial pneumonia. New insights during the past several years have highlighted the epidemiological impact of RA-ILD and have begun to identify factors contributing to its pathogenesis. Risk factors include smoking, male sex, human leukocyte antigen haplotype, rheumatoid factor and anticyclic citrullinated protein antibodies (ACPAs). Combined with clinical information, chest examination and pulmonary function testing, high-resolution computed tomography of the chest forms the basis of investigation and allows assessment of subtype and disease extent. The management of RA-ILD is a challenge. Several therapeutic agents have been suggested in the literature but as yet no large randomized controlled trials have been undertaken to guide clinical management. Therapy is further complicated by commonly prescribed drugs of proven articular benefit such as methotrexate, leflunomide (LEF) and anti-tumour necrosis factor α agents having been implicated in both ex novo occurrence and acceleration of existing ILD. Agents that offer promise include immunomodulators such as mycophenolate and rituximab as well as newly studied antifibrotic agents. In this review, we discuss the current literature to evaluate recommendations for the management of RA-ILD and discuss key gaps in our knowledge of this important disease.

Recent findings have highlighted the potential initiation of ACPA in sites away from the joint. Periodontitis is an example of this concept. This process in the gums appears to be independent of smoking, the main environmental risk factor for ACPA-positive RA. There is extensive literature regarding the potential role of smoking in the pathogenesis of ACPA-positive RA. As a consequence of this strong association, the lung has become the focus of research to determine whether processes within the lung are linked to the generation of ACPA. Here we outline the current body of evidence and explore the hypothesis that the lung as an organ of immune defence has a role in the pathogenesis of the autoimmune disease ACPA-positive RA.

Clinical and radiological assessment of 100 patients (97 female) with primary