RA has a substantial impact on HRQoL. This supports recent NICE guidelines stipulating that RA patients should be regularly assessed for the impact their disease has on HRQoL and appropriate management provided.

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Objective. MTX is widely used to treat synovitis in PsA without supporting trial evidence. The aim of our study was to test the value of MTX in the first large randomized placebo-controlled trial (RCT) in PsA.Methods. A 6-month double-blind RCT compared MTX (15 mg/week) with placebo in active PsA. The primary outcome was PsA response criteria (PsARC). Other outcomes included ACR20, DAS-28 and their individual components. Missing data were imputed using multiple imputation methods. Treatments were compared using logistic regression analysis (adjusted for age, sex, disease duration and, where appropriate, individual baseline scores).Results. Four hundred and sixty-two patients were screened and 221 recruited. One hundred and nine patients received MTX and 112 received placebo. Forty-four patients were lost to follow-up (21 MTX, 23 placebo). Twenty-six patients discontinued treatment (14 MTX, 12 placebo). Comparing MTX with placebo in all randomized patients at 6 months showed no significant effect on PsARC [odds ratio (OR) 1.77, 95% CI 0.97, 3.23], ACR20 (OR 2.00, 95% CI 0.65, 6.22) or DAS-28 (OR 1.70, 95% CI 0.90, 3.17). There were also no significant treatment effects on tender and swollen joint counts, ESR, CRP, HAQ and pain. The only benefits of MTX were reductions in patient and assessor global scores and skin scores at 6 months (P = 0.03, P < 0.001 and P = 0.02, respectively). There were no unexpected adverse events.Conclusions. This trial of active PsA found no evidence for MTX improving synovitis and consequently raises questions about its classification as a disease-modifying drug in PsA.Trial registration. Current Controlled Trials, www.controlled-trials.com, ISRCTN:54376151.

Objective: To evaluate the existing evidence on the diagnosis and management of septic arthritis in native joints. Design: Systematic review.

Objective. To determine the integrity of the hypothalamic-pituitary-adrenal (HPA) axis responses to immune/inflammatory stimuli in patients with rheumatoid arthritis (RA).Methods. Diurnal secretion of cortisol and the cytokine and cortisol responses to surgery were studied in subjects with active RA, in subjects with chronic osteomyelitis (OM), and in subjects with noninflammatory arthritis, who served as controls.Results. Patients with RA had a defective HPA response, as evidenced by a diurnal cortisol rhythm of secretion which was at the lower limit of normal in contrast to those with OM, and a failure to increase cortisol secretion following surgery, despite high levels of interleukin-Ijl (IL-lm and IL-6. The corticotropinreleasing hormone stimulation test in the RA patients showed normal results, thus suggesting a hypothalamic defect, but normal pituitary and adrenal function.Conclusion. These findings suggest that RA patients have an abnormality of the HPA axis response to

on behalf of the British Society for Rheumatology Standards, Guidelines and Audit Working Group Scope and purpose Background to the disease The clinical presentation of a hot swollen joint is common and has a wide differential diagnosis. The most serious is septic arthritis, which accounts for significant morbidity, and has a case fatality of 11% [1]. Delayed or inadequate treatment leads to irreversible joint damage [2]. Rapid diagnosis and treatment is vital to prevent permanent joint dysfunction. This guideline will focus on the diagnosis and management of septic arthritis. Hot swollen joints commonly have other underlying diagnoses, including crystal arthritis, reactive arthritis and a monoarticular presentation of polyarthritis. The need for a guideline The hot swollen joint presents to many different clinicians in primary or secondary care. Poor outcomes including permanent joint destruction and death can occur if the diagnosis of sepsis is not made rapidly and treatment instigated appropriately. Septic arthritis can be difficult to recognize even for experienced clinicians, yet such patients frequently present to doctors unfamiliar with the assessment and management of joint disease. We hope that this guideline will aid accurate diagnosis and appropriate treatment when a joint is hot because of sepsis, whilst also ensuring that other causes such as crystal arthritis are recognized and not over-treated. Objectives of the guideline This guideline sets out recommendations for the diagnosis and initial management of septic arthritis presenting clinically as a hot swollen joint. These recommendations are based on a systematic review of the literature and evaluation of the evidence using standardized criteria.

Fibromyalgic RA affects 12-17% of RA outpatients and results in worse functional outcomes. DAS-28 scores over-interpret active disease in fibromyalgic RA.

The value of epidural injections of corticosteroid as an outpatient treatment of sciatica has been hitherto uncertain. An epidural injection of 80 mg methylprednisolone in 10 ml physiological saline was compared with an interspinous injection of 2 ml physiological saline in a double blind fashion amongst 39 outpatients. Significant differences of pain relief were seen between the two groups within 2 weeks. This benefit disappeared for six (35%) patients within 6 months of treatment although 11 (65%) successfully treated subjects had sustained improvement up to this time. Outpatient epidural injections of corticosteroid are thus a useful short-term means of relieving pain in sciatica but probably have little effect on the long-term natural history of symptoms. Factors associated with a failure to respond to epidural steroid injections are discussed.