This case report suggests the potential advantages of immunoadsorption in severe Sjögren's syndrome which is refractory to conservative treatment. After 16 months the patient remains free of tender and swollen joints, and the sicca symptoms remain stable. A current open trial will provide further data, allowing better assessment of the value of immunoadsorption in patients with Sjögren's disease.

Narrowband ultraviolet B phototherapy (NB-UVB) is a widely used modality in the treatment of psoriasis and is generally accepted as safe in pregnancy. Previous studies have described photodegradation of serum folate after exposure to UVA radiation but the effect of UVB is not known. We studied the effect of NB-UVB phototherapy on serum folic acid levels in patients with psoriasis and the relationship between changes in serum folate levels and the total cumulative dose of NB-UVB. Included in the study were 30 psoriatic patients between 13 and 55 years of age. Serum folate levels were measured at baseline, and after exposure to 18 and 36 sessions of NB-UVB irradiation. There were significant decreases in mean serum folate levels after NB-UVB exposure. After exposure to 18 and 36 sessions the decreases were 19% and 27%, respectively. After 18 sessions, the mean serum folate level had decreased in 18 patients (60%) from 8.64 ng/ml at baseline to 7.02 ng/ml (mean NB-UVB cumulative dose 40.02 J/cm(2); P = 0.019). After 36 sessions, the mean serum folate levels had decreased in 22 patients (73%) to 6.32 ng/ml (mean NB-UVB cumulative dose 118.16 J/cm(2); P = 0.002). The present study showed that high cumulative NB-UVB doses can induce folate photodegradation and decrease serum folate levels in patients with psoriasis and that this effect is directly related to the total cumulative dose of NB-UVB.

Seven renal abnormalities were diagnosed that had not been detected antenatally. Only one of the seven mothers had not attended for any scans; in the others the abnormality had not been found in appropriate scans. Four of these patients had vesicoureteric reflux, which is known to be difficult to diagnose antenatally. 4 The impact that early diagnosis of abnormalities of the fetal renal tract and subsequent intervention may have on the incidence of symptomatic renal disease later in life-for example, acute pyelonephritis and recurrent urinary tract infection-remains unknown. We also do not know what proportion of those in whom a renal abnormality was diagnosed antenatally would have suffered renal scarring or deterioration of renal function had the diagnosis been delayed until after a urinary tract infection. To obtain this information would require an untreated control group, which would not be ethical. We intend, however, to reassess this cohort of children at age 5 years to determine the incidence of renal disease.We found a high incidence of renal abnormalities in this study and conclude that antenatal ultrasonography at 28 weeks' gestation is an effective method of screening for structural renal abnormality.We thank Dr S A Price and the staff of the ultrasonography department for their help in collecting data. AbstractArthritis associated with leprosy is underreported. In Egypt 66 patients from a leprosy colony were studied, 20 of whom had arthropathy. This was characterised by an inflammatory symmetrical peripheral polyarthritis. The wrist, metacarpal and proximal interphalangeal joints of the hands, the knees, and the metatarsophalangeal joints of the feet were affected with associated morning stiffness. The arthritis was erosive in 11 out of 20 patients, had no features of the arthritis associated with erythema nodosum leprosum reactions, but symptomatically responded to antileprosy treatment.This arthritis would seem to be a previously unrecognised feature of leprosy.

The purpose of this study was to investigate the value of ultrasonographic examination in the diagnosis of Tietze's syndrome and assessment of the changes in costal cartilage following local steroid injection. Nine patients with Tietze's syndrome and 20 normal subjects were studied consecutively. Ultrasound examination was performed using a Sonoline SL Siemens Machine with a linear 5 MHz small parts transducer and ATL Apogee 800 with a 10 MHz linear array transducer. The affected costochondral joint was injected with a combination of 15 mg of triamcinolone hexacetonide and 1 ml of 2% lidocaine. Ultrasound examination was performed following the clinical evaluation and repeated immediately after the injection, then 1 and 4 weeks later. Abnormal echo appearance was detected as an inhomogeneous increase in the echogenicity with intense broad posterior acoustic shadow. Hypoechogenicity and a decrease in the size of costal cartilage were observed 1 week after local steroid injection with absence of the posterior acoustic shadowing. Ultrasonographic examination of costal cartilage is easy and quick to perform. We believe that ultrasound should be the screening procedure of choice for Tietze's syndrome. Local steroid injection proved to be clinically safe and effective in the treatment of patients with Tietze's syndrome.

Beta-endorphin is a neuroendocrine peptide, with morphine-like effects, produced by anterior pituitary, cells of the immune system, and synovial cells. The clinical significance of Plasma Beta-endorphin was investigated in a well characterized cohort of 20 RA patients and 10 healthy controls. Beta-endorphin extraction and concentration were carried out according to Wardlaw. Plasma Beta-endorphin assay was measured as described by Naber. Plasma Beta-endorphin levels in severe RA patients were significantly lower (16.1 +/- 6.2 pg/ml) than in mild RA patients (45.4 +/- 2.8 pg/ml), P < 0.0001. The mean serum levels of Beta-endorphin were also significantly lower in both RA groups than those in normal controls (62.1 +/- 5.7 pg/ml), P < 0.001. The results indicate that there is an inverse correlation with the plasma Beta-endorphin levels, the rheumatoid disease activity score, and the duration of RA. The depressed plasma Beta-endorphin in patients with RA may be used as an indicator of the disease activity.