Our findings suggest that the benefits of AM treatment for SLE may extend to preventing serious infections. Although the study included > 3000 patients, the statistical power to examine GC dosages < 15 mg/day was poor.

Malignant B lymphocytes from several patients with chronic lymphocytic leukemia (CLL) were examined for reactivity with murine monoclonal antibody 17.109. This antibody, prepared against the rheumatoid factor (RF) (4,5). Subsequent mutation of the expressed variable-region genes (V genes) generates antibodies with primary structures differing markedly from those possible through simple rearrangement of the genetic elements present in the germ-line . Combined, these processes of somatic rearrangement and mutation generate an antibody repertoire of enormous diversity.Testament to the success of these mechanisms is the strikingly small number ofinherited human antibody V genes. For example, the human genome may contain only 25-50 K light-chain V genes (13, 14), which have been divided into four variable-region subgroups (15,16

A structured pharmacist-staffed program was more effective than usual care for achieving target sUA levels. These results suggest a structured program could greatly improve gout management.

Rheumatoid factors (RFs)

ObjectivesThe study objective was to determine the feasibility of using a pharmacist-staffed, protocol-based structured approach to improving the management of chronic, recurrent gout.SettingThe study was carried out in the outpatient clinic of a single Kaiser Permanente medical centre. This is a community-based clinic.ParticipantsWe report on 100 consecutive patients between the ages of 21 and 94 (75% men) with chronic or recurrent gout, referred by their primary physicians for the purpose of management of urate-lowering therapy. Patients with stage 5 chronic kidney disease or end-stage kidney disease were excluded.InterventionsThe programme consisted of a trained clinical pharmacist and a rheumatologist. The pharmacist contacted each patient by phone, provided educational and dietary materials, and used a protocol that employs standard gout medications to achieve and maintain a serum uric acid (sUA) level of 6 mg/dL or less. Incident gout flares or adverse reactions to medications were managed in consultation with the rheumatologist.Primary outcome measureThe primary outcome measure was the achievement and maintenance of an sUA of 6 or less for a period of at least 3 months.ResultsIn 95 evaluable patients enrolled in our pilot programme, an sUA of 6 mg/dL or less was achieved and maintained in 78 patients with 4 still in the programme to date. Five patients declined to participate after referral, and another 13 patients did not complete the programme. (The majority of these were due to non-adherence.)ConclusionsA structured pharmacist-staffed programme can effectively and safely lower and maintain uric acid levels in a high percentage of patients with recurrent gout in a primary care setting. This care model is simple to implement, efficient and warrants further validation in a clinical trial.