Pneumococcal antibody levels after pneumovax in patients with rheumatoid arthritis on methotrexate.

INTRODUCTION: Immunisation against pneumococcus has been shown to reduce pneumonia in rheumatoid arthritis (RA). There is concern that methotrexate may reduce its efficacy. There are very few objective data on the effect of methotrexate on the efficacy of pneumococcal vaccination with pneumovax, and no objective evidence on whether revaccination is necessary in RA patients on methotrexate. METHODS: The authors collected information from 180 RA patients on methotrexate relating to their vaccination status and assayed their pneumococcal antibody levels. Data on pulmonary infection were retrieved in the same patients over the preceding decade. RESULTS: Full data were available for 152 patients, of whom 28 had never been vaccinated against pneumococcus. Median levels were significantly higher in those who had been vaccinated. Unvaccinated patients and those taking oral prednisone were more likely to have had pneumonia in the previous 10 years. The RR for developing pneumonia among non-vaccinated patients was 9.7 (p=0.005) and among steroid-treated patients was 6.5 (p=0.001), after adjusting for age, gender, disease duration and comorbidity. No significant correlation was found between pneumococcal antibody levels and time since vaccination. CONCLUSIONS: This study suggests that a single administration of pneumovax early in RA offers up to 10 years protection against the development of pneumococcal pneumonia in RA patients on methotrexate.

The causes of musculoskeletal chest pain in patients admitted to hospital with suspected myocardial infarction.

BACKGROUND: We wished to investigate the causes and characteristics of musculoskeletal chest pain leading to acute medical admission. METHODS: We studied patients admitted to Queen Elizabeth Hospital, Gateshead, over a 10-week period. Patients with chest pain for which no acute cardiorespiratory cause was evident were identified and only included if they were tender on anteroposterior chest compression, thoracic spine rotation or firm sternal pressure. A detailed clinical history, anxiety and depression scale and a focussed physical examination were done to define the nature of musculoskeletal disease and their therapeutic requirements. RESULTS: Fifty patients satisfying the inclusion criteria were admitted in the 10-week period and comprised 54% females with a mean age of 57 years (S.D.=13.48). Chest pain lasted for 1 h or less in 24 patients and was mostly anterior. Three distinct groups of patients were identified. Twelve patients had evidence of inflammatory joint disease, thirteen had fibromyalgia and half had regional syndromes with pain arising from the shoulder, neck, thoracic spine or sternocostal areas. Visual analogue scores were highest in fibromyalgia for pain, and highest in inflammatory arthritis for impaired mobility. Anxiety and depression scores were highest in fibromyalgia and lowest among patients with regional syndromes. CONCLUSIONS: Musculoskeletal causes for acute chest pain are common and varied. Most patients have an identifiable cause of pain, but accurate diagnosis is needed to select the most appropriate intervention. Anxiety and depression are frequent, with much self-reported pain and dysfunction. However, all patients in this study had a disorder that was amenable to treatment and diagnosis. Management needs to be actively pursued in all patients.

When should we use parenteral methotrexate?

Oral methotrexate is the benchmark against which other disease-modifying anti rheumatic drugs are measured. The use of parenteral methotrexate for those failing to tolerate or respond to oral therapy is accepted, but indications for its use and its place in the therapeutic ladder have not been fully investigated. We assessed the use of parenteral methotrexate (MTX) in our rheumatoid arthritis (RA) population and compared the characteristics of these patients to a matched group of those on oral therapy. We compared response rates to each approach using DAS 28 scores, ESR and visual analogue scales. Inferences on costs of parenteral therapy were made and predictors of response defined. We found that 10% of our total RA patient population were on parenteral methotrexate, having failed to tolerate or respond to oral therapy. Seventy-five percent of these met the criteria for the use of anti-tumour necrosis factor (TNF) agents. Overall response rates were equivalent to those obtained by responders to oral MTX. Patients on parenteral therapy were younger and were more likely to have extreme values of body mass index (BMI) than those on oral therapy. The approach was economically viable, although many patients unnecessarily attended hospital to receive their injections. We advocate consideration of parenteral MTX in all RA patients unresponsive to oral therapy prior to treatment with anti-TNF therapy. Response to parenteral therapy can be predicted by low BMI (below 22 kg/m(2)), possibly as a result of malabsorption, or by high BMI (over 30) as a result of gastrointestinal intolerance. A mechanism to deliver this option through self-administration in the community should be encouraged.

Upper limb musculoskeletal abnormalities and poor metabolic control in diabetes.

INTRODUCTION: An increased prevalence of musculoskeletal disease is recognised in diabetes and is a common source of disability. It is known to predominantly affect the upper limbs especially the hand and shoulder. The relationship with other complications of diabetes and glycaemic control is uncertain. We designed this study to clarify these relationships, and to assess differences between types 1 and 2 diabetes. METHODS: We identified a group of 96 people with established diabetes and examined them for the presence of locomotor disease focussing on the upper limbs. We recorded the mean HbA1c and the presence of diabetic complications, together with the health assessment questionnaire (HAQ) score. We explored correlations between locomotor disease and these variables using logistic regression. We compared data between type 1 and type 2 diabetics and contrasted the amalgamated data with that of a matched control population of medical out patients using Students t tests. RESULTS: Locomotor disease was present in 75% of diabetics with the upper limb the commonest site for abnormalities. This prevalence was significantly higher than that seen in the controls (53%) [p=0.02]. Shoulder capsulitis (25%), carpal tunnel syndrome (20%), tenosynovitis (29%), limited joint mobility (28%) and Dupuytrens contracture (13%) were the most frequent findings and were much commoner than in controls. Capsulitis usually coexisted with other upper limb abnormalities and best predicted the presence of retinopathy and/or neuropathy. The mean HbA1c was significantly higher in patients with combined shoulder and hand problems (9.1%) than in those with no upper limb problems (8.0%) [p=0.018]. The pattern of results was similar in type 1 and type 2 diabetes, although the prevalence of abnormalities and mean HAQ were significantly greater in type 2 patients, which may be in part a function of their greater mean age. CONCLUSION: Upper limb locomotor abnormalities are very common in diabetes and are associated with worse glycaemic control and more diabetic complications. Assessment of upper limb locomotor disease in diabetes should include an estimate of glycaemic control and a search for other complications.

Acute lower respiratory tract infections in patients with rheumatoid arthritis.

OBJECTIVE: To determine whether drugs used in the treatment of rheumatoid arthritis (RA) contribute to the increased risk of respiratory infection or influence its outcome. METHODS: We identified all episodes of lower respiratory tract infection (LRTI) in our RA population over a 12 month period. A detailed drug history was recorded in each case, together with the clinical outcome. Premorbid illnesses and admission data were collected and analyzed to assess the influence of oral steroids and disease modifying antirheumatic drugs (DMARD) on outcome. RESULTS: The overall annual incidence of LRTI in patients with RA was 2.3% with a mortality rate of 22.5%. Demographic factors predicting LRTI included older age and male sex. Oral steroids and not taking DMARD were also associated with an increased risk of hospital admission with LRTI. Being male and having RA for over 10 years trended to the prediction of death as a result of infection. Taking DMARD was not associated with any adverse outcome. CONCLUSION: Respiratory infection is common in patients with RA and carries a high mortality. Oral steroids predispose to infection, while DMARD do not. Increasing age and male sex also predispose to respiratory tract infection.

What effect does Helicobacter pylori infection have on the risk of peptic ulceration in patients receiving NSAIDs for rheumatoid arthritis?

BACKGROUND: Patients with rheumatoid arthritis (RA) frequently develop dyspepsia which may be due to peptic ulceration. There have been conflicting published data on the possible interactive roles of nonsteroidal anti-inflammatory drugs (NSAIDs) and colonisation of the gastric antrum with Helicobacter pylori in the development of peptic ulceration. METHODS: We have prospectively assessed the prevalence of peptic ulcers in dyspeptic RA patients and investigated the factors responsible. We endoscoped 100 RA patients comparing the endoscopic findings to those in 100 age- and sex-matched dyspeptic control subjects. Data on NSAID consumption and Helicobacter colonisation were collected for each patient. RESULTS: Endoscopic evidence of peptic ulceration was found in 29 RA patients and in 16 of the control subjects (P=0.03). Multiple ulcers (>2) were found in significantly more RA patients than in controls (10 vs. 2). NSAIDs were being used by 60 RA patients and 22 controls (P<0.001). Helicobacter was found in 41 RA patients and in 33 controls (P=NS). The consumption of NSAIDs conferred a relative risk (RR) of ulceration of 8.67 (1.19-62.87), while the presence of Helicobacter gave a RR for ulcers of 3.71 (0.37-37.35) in RA patients. The RR for the combination of NSAID consumption and Helicobacter colonisation was 14.44 (2.05-101). The corresponding RRs for the dyspeptic controls were 2.13, 1.57 and 1.42 (all P=NS). CONCLUSIONS: Rheumatoid patients have more major and more multiple pathology than age-, sex- and symptom-matched controls. This is due mainly to their increased consumption of NSAIDs. The prevalence of Helicobacter was no greater in RA patients than in controls, but Helicobacter infection increased the risk of NSAID-induced ulceration.