1984 American Olympic team about 11% of athletes had asthma or exercise induced bronchoconstriction.' The figures agreed with those of Weiler et al, who found self reported asthma in 12% of football players; basketball players had a low asthma prevalence.29 In a study from Portugal Gomes et al found normal bronchial responsiveness in elite runners.?0 In another study swimmers had a higher prevalence of asthma and bronchial hyperresponsiveness than other athletes and the authors postulated a relation with ambient swimming pool conditions.3' To our knowledge there are no other studies of skiers or other athletes performing exercise at low temperatures. From the few reports available there is no evidence that strenuous training by itself increases the risk of asthma. Strenuous training at low temperatures, however, seems to be pathogenetic for asthma, possibly due to the repeated breathing of large amounts of cold air. The expert technical help of Britt-Marie Sundblad and Wang Zhi-Ping is acknowledged. We thank the department of clinical physiology, Hospital of Ostersund, for spirometry. The study was partly financed by grants from the Swedish National Centre for Research in Sports.

Objectives-To investigate differing patterns and associations of osteoarthritis of the knee in patients referred to hospital. Methods-Two hundred and fifty two consecutive patients (161 women, 91 men; mean age 70 years, range 34-91 years) referred to hospital with osteoarthritis of the knee underwent clinical, radiographic, and synovial fluid screening. Results-Radiographic changes of osteoarthritis of the knee (definite narrowing with or without osteoarthritic features) were bilateral in 85% of patients. Of 470 knees affected, 277 (59%) were affected in two compartments and 28 (6%) in three compartments. Unilateral and isolated medial tibiofemoral osteoarthritis were more common in men. Calcium pyrophosphate crystal deposition was common (synovial fluid identification in 132 (28%) knees; knee chondrocalcinosis in 76 (30%) patients) and associated with disability, bilateral, multicompartmental and severe radiographic osteoarthritis, marked osteophytosis, attrition, and cysts. Multiple clinical nodes (58 (23%) patients) and radiographic polyarticular interphalangeal osteoarthritis (66 (26%)

3-17, respectively); warmth at the knee associated with change in any radiographic feature (odds ratio 2-22; 95% CI

This is the first report on the EQ-5D utility values of patients with PSS. These patients have significantly impaired utility values compared with the UK general population. EQ-5D utility values are significantly related to pain and depression scores in PSS.

Background Heterogeneity is a major obstacle to developing effective treatments for patients with primary Sjögren's syndrome. We aimed to develop a robust method for stratification, exploiting heterogeneity in patient-reported symptoms, and to relate these differences to pathobiology and therapeutic response. MethodsWe did hierarchical cluster analysis using five common symptoms associated with primary Sjögren's syndrome (pain, fatigue, dryness, anxiety, and depression), followed by multinomial logistic regression to identify subgroups in the UK Primary Sjögren's Syndrome Registry (UKPSSR). We assessed clinical and biological differences between these subgroups, including transcriptional differences in peripheral blood. Patients from two independent validation cohorts in Norway and France were used to confirm patient stratification. Data from two phase 3 clinical trials were similarly stratified to assess the differences between subgroups in treatment response to hydroxychloroquine and rituximab. FindingsIn the UKPSSR cohort (n=608), we identified four subgroups: Low symptom burden (LSB), high symptom burden (HSB), dryness dominant with fatigue (DDF), and pain dominant with fatigue (PDF). Significant differences in peripheral blood lymphocyte counts, anti-SSA and anti-SSB antibody positivity, as well as serum IgG, κ-free light chain, β2-microglobulin, and CXCL13 concentrations were observed between these subgroups, along with differentially expressed transcriptomic modules in peripheral blood. Similar findings were observed in the independent validation cohorts (n=396). Reanalysis of trial data stratifying patients into these subgroups suggested a treatment effect with hydroxychloroquine in the HSB subgroup and with rituximab in the DDF subgroup compared with placebo.Interpretation Stratification on the basis of patient-reported symptoms of patients with primary Sjögren's syndrome revealed distinct pathobiological endotypes with distinct responses to immunomodulatory treatments. Our data have important implications for clinical management, trial design, and therapeutic development. Similar stratification approaches might be useful for patients with other chronic immune-mediated diseases.

Objective-To test the hypothesis that high concentrations of extracellular inorganic pyrophosphate (PPi), which associate with increased cell synthesis and turnover in cartilage, may act as a marker for structural outcome in knee osteoarthritis (OA). Method-One hundred and thirty five consecutive patients referred to hospital with knee OA (59 men, 76 women; mean age 71 years, range 41-88) were followed prospectively for a median of 2 5 years (interquartile range 1-75-3-0). Synovial fluid (SF) aspirated at presentation (202 OA knees: 68 bilateral, 66 unilateral) was assessed for PPi content by radiometric assay. Knee radiographs at presentation and at final review were assessed for change in global (Kellgren)

Purpose Metacarpophalangeal (MCP) joint deformities caused by rheumatoid arthritis can be treated using silicone metacarpophalangeal joint arthroplasty (SMPA). There is no consensus whether this surgical procedure is beneficial. The purpose of the study was to prospectively compare outcomes for a surgical and a non-surgical cohort of rheumatoid arthritis patients. Methods The prospective cohort trial was conducted from January 2004 to May 2008 at 3 referral centers in the US and England. Over a 3 year period, 70 surgical and 93 nonsurgical patients were recruited. One year data are available for 45 cases and 72 controls. All patients had severe ulnar drift and/or extensor lag of the fingers at the MCP joints. The patients all had one year follow-up evaluations. Patients could elect to undergo SMPA and medical therapy or medical therapy alone. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales (AIMS2), grip/pinch strength, Jebson-Taylor test and ulnar deviation and extensor lag measurements at the MCP joints. Results There was no difference in the mean age for the surgical group (60) when compared to the non-surgical group (62). There was also no significant difference in race, education, and income between the two groups. At one year follow-up time, the mean overall MHQ score showed significant improvement in the surgical group, but no change in the non-surgical group, despite worse MHQ function at baseline in the surgical group. Ulnar deviation and extensor lag improved significantly in the surgical group, but the mean AIMS2 scores and grip/pinch strength showed no significant improvement. Conclusion This clinical trial demonstrated significant improvement for RA patients with poor baseline functioning treated with SMPA. The non-surgical group had better MHQ scores at baseline and their function did not deteriorate during the one year follow-up interval.

The influence of sex hormone related events and smoking on the development of OA in women was investigated in a case-controlled postal survey. One hundred and twenty-nine patients with nodal generalized osteoarthritis (NGOA) and 145 with non-nodal pauciarticular large joint osteoarthritis (LJOA) were identified from the database of a Nottingham OA clinic. For each patient, three age-matched controls were randomly selected from the same general practice. Sixty-three per cent of questionnaires (690/1096) were returned: NGOA, 95; NGOA controls, 226; LJOA, 113; LJOA controls, 256. There were no differences in age at menarche or menopause, rates of hysterectomy, oral contraceptive use, or hormone replacement use between cases and controls. Fewer OA patients had ever smoked [(Odds Ratio (OR) 0.65, 95% Confidence Interval (CI) 0.45-0.95)] and subset analysis demonstrated that this negative association occurred only in the LJOA group (OR 0.43, CI 0.25-0.72), particularly in those with knee OA (OR 0.29, CI 0.14-0.62). A previous successful pregnancy was negatively associated with NGOA (OR 0.47, CI 0.24-0.95). This study demonstrates no association between oestrogen-related hormonal events and OA, but a negative association between smoking and LJOA. Such data supports the concept that OA is a heterogeneous disease and underlines the need to differentiate OA subsets.