Following the demise of probenecid Robin has been watching for alternative urate-lowering drugs for his allopurinol patients, so he was interested to see an update on leflunomide, which does this (not that anyone will treat gout with it or will someone get a paper out of trying?). Perez-Ruiz and Nolla (Journal Clin Rheumatol 2003; 9:215218) show that it enhances both urate and phosphate loss they suggest that what the latter might mean clinically should be studied further and measurements might be useful in monitoring treatment compliance.
MRI imaging detects erosions at least a year before X-ray (
Østergaard et al., Arthritis Rheum 2003; 48: 21282131).[CrossRef][ISI][Medline] Robin admits that he thinks he has heard it before (in the Journal of Obvious Conclusions, perhaps) but this study showed that the finding of baseline MRI erosions was predictive of an increased risk of progression. So is it time to abandon baseline X-rays of hands and feet, and replace them with the all-seeing magnet? The same applies to OA, it seems, as the development of oedema in bone marrow seems to predict progression (
Felson et al., Ann Int Med 2003; 139: 330336).
Now everyone is aware of calf pain mimicking venous thrombosis when a popliteal cyst ruptures, but did you all know that you can get an anterior compartment syndrome? Ushiyama and colleagues report such a case (Modern Rheumatology 2003; 13: 189190). One needs to think outside the box. Funny swellings should be treated with great suspicion. So, it appears, should jaw claudication the hallmark sign of giant cell arteritis until Churchill and colleagues report two cases caused by primary amyloidosis (J Rheumatol 2003; 30: 22836).[ISI][Medline] So perhaps we do have to do biopsies after all, just to make sure we are not missing the proverbial hen's teeth.
Robin was interested to read, given the UK bureaucratic tangle of drug funding, NICE and the hysterical and total dependence on evidence-based medicine, a review of therapy in psoriatic arthritis (Gladman, Semin Arthritis Rheum 2003; 33:2937).[ISI][Medline] Now the cost-cutters have a problem! Only one drug shows unequivocal proof of efficacy sufficient for the US Food and Drug Administration to recommend it etanercept. Wowie. How can anyone justify its withholding when any current alternatives (we all use methotrexate and sulfasalazine) don't cut the mustard? Robin is looking forward to a confrontation over his continuing funding difficulties.
Robin tortures himself by reading immunology now and then, and has previously indicated how out of his depth he is in this intensely cerebral discipline, but somehow he cannot resist continuing his self-flagellation, and brings, accordingly, to your attention an important paper on osteoclasts. The title is enough to cause a general protection fault in Robin's brain: Receptor Activator of NF-B Ligand Stimulates Recruitment of SHP-1 to the Complex Containing TNFR-Associated Factor 6 That Regulates osteoclastogenesis and the abstract contains impenetrable statements like GST pull down experiments indicated that the association of SHP-1 with TRAF6 is mediated by SHP-1 lacking the two Src homology 2 domains. RANKL-stimulated I
B-
phosphorylation, I
B-
degradation and DNA binding ability of NF-
B were increased after over-expression of SHP-1(C453S)
(Zhang, Jimi and Bothwell, J Immunol 2003; 171: 36203626).
Are isolated antinucleolar antibodies a marker of scleroderma, ask
Jolly et al. (J Clin Rheumatol 2003; 9: 291295).[ISI] Answer no. Does the appearance of autoantibodies herald the future development of SLE? Answer yes
(Arbuckle et al, New Engl J Med 2003; 349:15261533)
It's very tempting to discuss Giesecke and colleagues' paper on the subgrouping of fibromyalgia (Arthritis Rheum. 2003; 48:291622)[ISI][Medline] but Robin will resist the temptation to ask how you can subdivide zero, and instead remind you that search engines can be fallible. Two of Robin's collecting bins for interesting items contain the same article about lupus, but the collator of each is clearly not medical, else they would know that lupus vulgaris is all about tuberculosis (and yes, Robin has actually seen a case, and has the photographs to prove it).
Always interested in possible causes for diseases of the rheumatic type, Robin came across a paper reminding him to look for other snowballs in hell. This one looks newish, and has the potential to tap a huge case cohort so far under-researched (Remoroza and Wu, Chinese Journal of Digestive Disease 2003; 4: 9399). It lists some of the associations of hepatitis C infection cryoglobulinemia, membranoproliferative glomerulonephritis, leukocytoclastic vasculitis and Sjogren's syndrome. Yet another test to do; Robin wonders how often it might be positive in his part of the world and if it is worth the aggravation to the lab, but supposes he will have to consider it.
Ah, well. Robin ponders a new year sans kids (the baby Robins have left the nest, and appear to be at least temporarily self-financing), a new contract of considerable financial attraction, and a healthier bank balance as a result of both of the above. A very happy Christmas and New Year to all.