High-resolution imaging of the human incudostapedial joint using synchrotron-radiation phase-contrast imaging.

The incudostapedial joint (ISJ) of the middle ear is important for proper transmission of sound energy to the cochlea. Recently, the biomechanics of the ISJ have been investigated using finite-element (FE) modelling, using simplified geometry. The objective of the present study was to investigate the feasibility of synchrotron-radiation phase-contrast imaging (SR-PCI) in visualising the ISJ ultrastructure. Three human cadaveric ISJs were dissected and scanned using SR-PCI at 0.9 µm isotropic voxel size. One of the samples was previously scanned at 9 µm voxel size. The images were visually compared and contrast-to-noise ratios (CNRs) were calculated (of both bone and soft tissues) for quantitative comparisons. The ISJ ultrastructure as well as adjacent bone and soft tissues were clearly visible in images with a 0.9 µm voxel size. The CNRs of the 0.9 µm images were relatively lower than those of the 9 µm scans, while the ratio of bone to soft tissue CNRs were higher, indicating better discernibility of bone from soft tissue in the 0.9 µm scans. This study was the first known attempt to image the ISJ ultrastructure using an SR-PCI scanner at submicron voxel size and results suggest that this method was successful. Future studies are needed to optimise the contrast and test the feasibility of imaging the ISJ in situ. LAY DESCRIPTION: The human middle ear consists of the eardrum, three small bones (the malleus, incus and stapes) and two joints connecting the bones (the incudostapedial joint and the incudomallear joint). The role of the middle ear is to amplify and transfer sound energy to the cochlea, the end organ of hearing. The incudostapedial joint (ISJ) of the middle ear is a synovial joint which is important for proper transmission of sound energy to the cochlea. Similar to other synovial joints it consists of meniscus, fluid and articulating surfaces. Recently, the biomechanics of the ISJ have been investigated using computational models, using grossly simplified geometry. Synchrotron radiation phase contrast imaging (SR-PCI) is a high-resolution imaging technique used to visualise small structures in three dimensions. The objective of the present study was to investigate the feasibility of using SR-PCI in visualising the ISJ ultrastructure. Three human cadaveric ISJs were dissected and scanned using SR-PCI at 0.9 µm isotropic voxel size. One of the samples was previously scanned at 9 µm voxel size. The images were both qualitatively and quantitatively compared. This study was the first known attempt to image the ISJ ultrastructure using an SR-PCI scanner at submicron voxel size and results suggest that this method was successful. Future studies are needed to optimise the contrast and feasibility of imaging the ISJ in situ.

Collaborative and partnership research for improvement of health and social services: researcher's experiences from 20 projects.

BACKGROUND: Getting research into policy and practice in healthcare is a recognised, world-wide concern. As an attempt to bridge the gap between research and practice, research funders are requesting more interdisciplinary and collaborative research, while actual experiences of such processes have been less studied. Accordingly, the purpose of this study was to gain more knowledge on the interdisciplinary, collaborative and partnership research process by investigating researchers' experiences of and approaches to the process, based on their participation in an inventive national research programme. The programme aimed to boost collaborative and partnership research and build learning structures, while improving ways to lead, manage and develop practices in Swedish health and social services. METHODS: Interviews conducted with project leaders and/or lead researchers and documentation from 20 projects were analysed using directed and conventional content analysis. RESULTS: Collaborative approaches were achieved by design, e.g. action research, or by involving practitioners from several levels of the healthcare system in various parts of the research process. The use of dual roles as researcher/clinician or practitioner/PhD student or the use of education designed especially for practitioners or 'student researchers' were other approaches. The collaborative process constituted the area for the main lessons learned as well as the main problems. Difficulties concerned handling complexity and conflicts between different expectations and demands in the practitioner's and researcher's contexts, and dealing with human resource issues and group interactions when forming collaborative and interdisciplinary research teams. The handling of such challenges required time, resources, knowledge, interactive learning and skilled project management. CONCLUSIONS: Collaborative approaches are important in the study of complex phenomena. Results from this study show that allocated time, arenas for interactions and skills in project management and communication are needed during research collaboration to ensure support and build trust and understanding with involved practitioners at several levels in the healthcare system. For researchers, dealing with this complexity takes time and energy from the scientific process. For practitioners, this puts demands on understanding a research process and how it fits with on-going organisational agendas and activities and allocating time. Some of the identified factors may be overlooked by funders and involved stakeholders when designing, performing and evaluating interdisciplinary, collaborative and partnership research.

A 5-year prospective population-based study of juvenile chronic arthritis: onset, disease process, and outcome.

OBJECTIVES: To investigate, in a population-based cohort of patients with juvenile chronic arthritis (JCA), onset characteristics, progression, outcome, and prognostic factors longitudinally for 5 years. METHODS: This cohort consisted of 132 incidence cases identified between 1984 and 1986 in southwestern Sweden followed for 5 years with annual reports of subgroup, joint assessment, disease activity, eye examinations, laboratory measurements, and medication. At the 5-year follow-up, the Childhood Health Assessment Questionnaire (Child-HAQ) was evaluated. European League Against Rheumatism (EULAR) criteria for diagnosis and disease activity were used. RESULTS: During the 5 years only four patients were lost to follow-up, 34% changed subgroup and 8% developed uveitis. At the 5-year follow-up the disease was active in 12% of the patients, stable in 28%, inactive in 25%, and in remission in 34%. Among those examined, 24% had radiological changes, of whom half had advanced changes. The Child-HAQ median score at the 5-year follow-up was 0.13 (range 0.0-1.9). The number of involved joints at inclusion correlated positively with active disease at the 5-year follow-up. Age at disease onset, the number of involved joints, and the number of joints with arthritis correlated positively with continuous disease and Child-HAQ score. CONCLUSION. Our study shows a diverse disease course during the first 5 years of JCA where one-third changed subgroup and two-thirds did not reach remission. Age of disease onset, the number of involved joints, and the number of joints with arthritis at inclusion were associated with poor outcome at the 5-year follow-up.

Six Major Steps to Make Investigations of Suicide Valuable for Learning and Prevention.

OBJECTIVE: The decline in suicide rates has leveled off in many countries during the last decade, suggesting that new interventions are needed in the work with suicide prevention. Learnings from investigations of suicide should contribute to the development of these new interventions. However, reviews of investigations have indicated that few new lessons have been learned. To be an effective tool, revisions of the current investigation methods are required. This review aimed to describe the problems with the current approaches to investigations of suicide as patient harm and to propose ways to move forward. METHODS: Narrative literature review. RESULTS: Several weaknesses in the current approaches to investigations were identified. These include failures in embracing patient and system perspectives, not addressing relevant factors, and insufficient competence of the investigation teams. Investigation methods need to encompass the progress of knowledge about suicidal behavior, suicide prevention, and patient safety. CONCLUSIONS: There is a need for a paradigm shift in the approaches to investigations of suicide as potential patient harm to enable learning and insights valuable for healthcare improvement. Actions to support this paradigm shift include involvement of patients and families, education for investigators, multidisciplinary analysis teams with competence in and access to relevant parts across organizations, and triage of cases for extensive analyses. A new model for the investigation of suicide that support these actions should facilitate this paradigm shift.HIGHLIGHTSThere are weaknesses in the current approaches to investigations of suicide.A paradigm shift in investigations is needed to contribute to a better understanding of suicide.New knowledge of suicidal behavior, prevention, and patient safety must be applied.

Does removal of aids/devices and help make a difference in the Childhood Health Assessment Questionnaire disability index?

OBJECTIVE: To assess whether the removal of aids/devices and/or help from another person in the Childhood Health Assessment Questionnaire (C-HAQ) leads to a significant change in the disability index (DI) score and responsiveness in juvenile idiopathic arthritis (JIA). METHODS: Changes in the C-HAQ DI score in a cross-sectional sample of 2663 children with JIA and in 530 active patients with JIA in a trial of methotrexate (MTX) were compared. RESULTS: Patients in the MTX trial had higher disease activity and disability than the cross-sectional sample. The frequency of aids/devices (range 1.2-10.2%) was similar between the two samples, while help (range 5.3-38.1%) was more frequently used in the MTX group. Correlation between disease severity variables and the two different C-HAQ DI scoring methods did not change substantially. There was a decrease in the C-HAQ DI score for both the cross-sectional (mean score from 0.64 with the original method to 0.54 without aids/devices and help, p<0.0001) and the MTX sample (mean score from 1.23 to 1.07, p<0.0001). A linear regression analysis of the original C-HAQ DI score versus the score without aids/devices and help demonstrated the substantial overlap of the different scoring methods. Responsiveness in the responders to MTX treatment did not change with the different C-HAQ DI scoring methods (range 0.86-0.82). CONCLUSION: The removal of aids/devices and help from the C-HAQ does not alter the interpretation of disability at a group level. The simplified C-HAQ is a more feasible and valid alternative for the evaluation of disability in patients with JIA.

Epidemiology of juvenile chronic arthritis in southwestern Sweden: a 5-year prospective population study.

Previous epidemiological studies of juvenile chronic arthritis (JCA) report divergent results owing to differences in diagnostic criteria, patient retrieval, and study designs. To investigate incidence and prevalence of JCA in a total population, this prospective survey was performed in southwestern Sweden between 1984 and 1988. Cases were identified using the European League Against Rheumatism criteria for JCA and were reported annually from eight pediatric departments and local pediatricians in the studied area. During the 5 years, 213 new cases of JCA were found, corresponding to an incidence of 54.6 per 100,000 children younger than 16 years of age. The average annual incidence was 10.9 per 100,000. The peak incidence rate, 18.3 per 100,000 was found in girls 0 through 3 years old. The lowest incidence rate, 6.4 per 100,000, was found among boys 12 through 15 years old. In December 1988, 334 cases of JCA were recorded, giving a prevalence of 86.3 per 100,000. When patients in remission were omitted the prevalence was 64.1 per 100,000. The monoarticular+pauciarticular onset type constituted 68.3% of the prevalence cases, while 21.9 were polyarticular and 6.6% had systemic onset. To avoid underestimation of incidence and prevalence, and to get a correct picture of disease patterns, epidemiological surveys of JCA should be population-based rather than referral center-based. Further descriptive studies of JCA in different well-defined geographic areas are important to make valid comparisons. Such comparisons could give clues to etiological factors, both genetic and environmental.

Juvenile arthritis--who gets it, where and when? A review of current data on incidence and prevalence.

Epidemiological studies of chronic arthritis in childhood can provide clues to genetic determinants of disease manifestations and environmental triggers. Available data are difficult to compare, however, because of the heterogeneity of the disease, differences in the classification criteria used for definition and inclusion, and differences in source populations and case ascertainment. Nevertheless, when the data are interpreted according to the methodologies used, geographical and ethnic differences can be found with regard to occurrence rates, age at onset, subgroup distribution and immunological markers. Seasonal variations have been detected in systemic disease. Variations in the incidence of childhood arthritis over time have also been observed, indicating environmental influences on disease frequency, while familial aggregations suggest the presence of genetic factors. These epidemiological data from a challenging puzzle which we hope will provide clues to future understanding of etiologies and cures, with the help of basic scientific research.

Measurement of functional status in juvenile chronic arthritis: evaluation of a Swedish version of the Childhood Health Assessment Questionnaire.

Few well-validated self-and/or parent-administered instruments are available for measuring functional status in children with rheumatic diseases. Parts of the Stanford Health Assessment Questionnaire (HAQ) have been adapted for use in children in the so-called Child HAQ. The aim of this study was to investigate the validity of this instrument in a Swedish setting. The Child HAQ was administered to 186 patients and 211 patients participating in a population-based follow-up study of juvenile chronic arthritis (JCA) in southwestern Sweden. The EULAR criteria were used for inclusion. Children who were 9 years of age or older self-reported. Reliability, evaluated by test-retest, inter-observer correlations and internal reliability, was excellent. Convergent validity was demonstrated by strong correlations of the disability index, pain, and morning stiffness with disease activity and the Steinbrocker functional classes. Discriminant validity was evidenced by the capacity of the instrument to evaluate patients as being active or in remission. Thus, the Child HAQ showed excellent measurement performance in a Swedish setting when using parents or children more than 9 years old as responders.

The Swedish version of the Childhood Health Assessment Questionnaire (CHAQ) and the Child Health Questionnaire (CHQ).

We report herein the results of the cross-cultural adaptation and validation into the Swedish language of the parent's version of two health related quality of life instruments. The Childhood Health Assessment Questionnaire (CHAQ) is a disease specific health instrument that measures functional ability in daily living activities in children with juvenile idiopathic arthritis (JIA). The Child Health Questionnaire (CHQ) is a generic health instrument designed to capture the physical and psychosocial well-being of children independently from the underlying disease. The Swedish CHAQ CHQ were already published and therefore were revalidated in this study. A total of 129 subjects were enrolled: 69 patients with JIA (13% systemic onset, 39% polyarticular onset, 25% extended oligoarticular subtype, and 23% persistent oligoarticular subtype) and 60 healthy children. The CHAQ clinically discriminated between healthy subjects and JIA patients, with the systemic, polyarticular and extended oligoarticular subtypes having a higher degree of disability, pain, and a lower overall well-being when compared to their healthy peers. Also the CHQ clinically discriminated between healthy subjects and JIA patients, with the systemic onset, polyarticular onset and extended oligoarticular subtypes having a lower physical and psychosocial well-being when compared to their healthy peers. In conclusion the Swedish version of the CHAQ-CHQ are reliable, and valid tools for the functional, physical and psychosocial assessment of children with JIA.

Craniomandibular function in juvenile chronic arthritis. A clinical and radiographic study.

Craniomandibular function was studied in 70 subjects with juvenile chronic arthritis (JCA). The subjects represented the total group of children and adolescents with the diagnosis JCA in a Swedish county. At examination, the median age of the subjects was 11.9 years and the median duration of the disease was 2.6 years. The most important finding of the study was the high prevalence (41%) of radiographic signs of temporomandibular joint (TMJ) pathology. Few subjects showed the typical craniofacial abnormalities associated with JCA, like mandibular micrognathia, facial asymmetries and open bite. Subjective symptoms of dysfunction were almost absent in subjects younger than seven years but were reported by 56% of the older subjects. TMJ sounds and pain on jaw movements were the most frequent symptoms reported. At the clinical examination, TMJ crepitations and restricted horizontal jaw movements were noted in 26% and 32% respectively. The high prevalence of TMJ involvement found in this study underlines the importance that dentists become part of the medical team responsible for the treatment of children and adolescents with JCA.

[Rheumatic diseases in children as an important specialty. Bone marrow transplantation is the hope for the most severely ill patients]. / Reumatiska sjukdomar hos barn viktigt specialområde. Benmärgstransplantation ger ökat hopp för de svårast sjuka.

Chronic inflammatory joint disorders can be viewed as a spectrum of disease presenting one set of characteristics during childhood and another in adulthood. Few of the disorders are specific for children of a specific age, even if some conditions might be very rare in certain age groups. Juvenile idiopathic arthritis is a new name suggested for pediatric chronic inflammatory joint disorders. Drug therapy is based on the same principles as for adults: an aggressive approach with NSAID-drugs and low dose methotrexate in combination with local steroid injections. New drugs like TNF-blockade and COX-2 inhibitors are almost untested in children, with the exception of etanercept which has been studied in children with polyarticular disease and proven to be very effective. For rare cases with very severe joint disease hematopoietic stem cell transplantation is under evaluation.

Health-related quality of life of patients with juvenile idiopathic arthritis coming from 3 different geographic areas. The PRINTO multinational quality of life cohort study.

OBJECTIVES: To compare health-related quality of life (HRQL) and to identify clinical determinants for poor HRQL of patients with juvenile idiopathic arthritis (JIA) coming from three geographic areas. METHODS: The HRQL was assessed through the Child Health Questionnaire (CHQ). A total of 30 countries were included grouped in three geographic areas: 16 countries in Western Europe; 10 in Eastern Europe; and four in Latin America. Potential determinants of poor HRQL included demographic data, physician's and parent's global assessments, measures of joint inflammation, disability as measured by Childhood Health Assessment Questionnaire (CHAQ) and erythrocyte sedimentation rate. Poor HRQL was defined as a CHQ physical summary score (PhS) or psychosocial summary score (PsS) <2 S.D. from that of healthy children. RESULTS: A total of 3167 patients with JIA, younger than 18 yrs, were included in this study. The most affected health concepts (<2 S.D. from healthy children) that differentiate the three geographic areas include physical functioning, bodily pain/discomfort, global health, general health perception, change in health with respect to the previous year, self-esteem and family cohesion. Determinants for poor HRQL were similar across geographic areas with physical well-being mostly affected by the level of disability while the psychosocial well-being by the intensity of pain. CONCLUSION: We found that patients with JIA have a significant impairment of their HRQL compared with healthy peers, particularly in the physical domain. Disability and pain are the most important determinants of physical and psychosocial well-being irrespective of the geographic area of origin.

Epidemiology.

Epidemiological research in the field of paediatric rheumatology is important for reasons such as the identification of possible aetiological factors, description of the natural history, identification of biologically homogeneous disease groups and health care planning. This review will focus on the epidemiology of 'idiopathic' juvenile arthritis (JA) where data are available for comparison in terms of time, space and ethnic origin. Methodological issues that make comparisons of data difficult, such as case definition, source population and case ascertainment, will be discussed in relation to the data presented. The incidence and prevalence of JA cover a wide range, but, in studies that use similar methodology, an incidence of 5-18 and a prevalence of 30-150 per 100,000 children under the age of 16 is found in Europe and on the American continent. Studies from other parts of the world indicate differences in age of onset and subgroup distribution related to geographical location and/or race.

Epidemiology of rheumatic disease in children.

Major problems associated with interpreting and comparing epidemiologic studies on chronic arthropathies in children include the diversity of classification criteria and selection bias. A new set of classification criteria for peripheral arthritis in children, aiming toward defining biologically homogeneous subgroups, was recently proposed and should be further tested. Descriptive studies from all over the world are now emerging on childhood rheumatic diseases, increasing the potential for comparing the impact of genetic and environmental factors on disease frequency and manifestations. Awareness about pain syndromes in children, such as juvenile primary fibromyalgia and reflex sympathetic dystrophy, has increased, and this population now forms a substantial portion of clinic visits in pediatric rheumatology. The impact of the rheumatic diseases in children on disability and quality of life during childhood and in adult life is still to a large extent unknown and must be further studied in an epidemiologic context.

The natural history of juvenile chronic arthritis: a population based cohort study. I. Onset and disease process.

OBJECTIVE: To study the natural history and the disease process in a population based cohort of patients with juvenile chronic arthritis (JCA) who were in the process of being transferred from pediatric to adult rheumatology care. METHODS: From a prospective population based epidemiological study in southwestern Sweden the cohort of patients with JCA born from 1968 through 1972 were investigated after a median disease duration of 7.1 years. The study cohort constituted of 124 patients with median age 17.7 years. RESULTS: At followup 49.2% patients still required medication, 20.2% had inactive disease and 30.6% were in remission. The highest risk of continuing disease activity was observed in patients with short disease duration (RR = 9.0) or very long duration (RR = 2.5) compared with those having medium long duration. Girls were 5 times more likely than boys to have continuing disease activity. Based on incidence data from the total population of the epidemiological study it can be estimated that an additional 100 patients with JCA, who were in remission in the beginning of the study, should be included in the present cohort. Thus a total of 60% of the patients with JCA had disease in remission and 70% were rid of disease activity when reaching adulthood in a population based setting. CONCLUSION: The selection of patients in studies of the natural history of JCA markedly influences the results, which may be one explanation for the divergent views of JCA as both a mild and a progressive disease.

The natural history of juvenile chronic arthritis: a population based cohort study. II. Outcome.

OBJECTIVE: To investigate the outcome in a population based cohort of patients with juvenile chronic arthritis (JCA) who were in the process of being transferred from pediatric to adult rheumatology care. METHODS: The cohort of patients born in 1968 through 1972, recruited from a population based epidemiological study in southwestern Sweden, were called to a followup after a median disease duration of 7.1 years. The study group consisted of 124 patients with a median age of 17.7 years. The disability and discomfort dimensions were evaluated using the Childhood Health Assessment Questionnaire (C-HAQ). The impact of the disease on social life was evaluated by patients and parents. RESULTS: The median C-HAQ disability index was 0.19 with a range from 0 to 2.75 (maximum possible score = 3). Sixty percent of the patients indicated some difficulty in daily activities. Female sex and a polyarticular disease course were risk factors for disability. The strongest determinants for disability were continuing disease activity and a positive IgM rheumatoid factor. Social impact of the disease was strongly linked to a raised C-HAQ disability index. CONCLUSION: Even in a population based study of JCA, which includes many mild cases, the majority of patients experienced some difficulty in daily activities when judged by themselves. This underlines the necessity to use the patient's own values in outcome studies, rather than the physician's. Further development of internationally accepted, standardized instruments to evaluate the handicap dimension of childhood arthritis is called for.

Serum concentration of hyaluronan, IgM and IgA rheumatoid factors in a population based study of juvenile chronic arthritis.

Increased serum levels of hyaluronan (HA) have been found in patients with liver diseases, psoriasis, malignancies as well as in rheumatoid arthritis and osteoarthritis. In the two latter groups serum HA levels may reflect the extent of synovial involvement and inflammation, rather than only unspecific information. This study was performed to elucidate the value of measuring HA in children with juvenile chronic arthritis (JCA) and to study its relation to class specific rheumatoid factors (IgM Rf and IgA Rf). HA was analysed in sera from 271 patients with JCA and 130 controls using a radiometric assay and IgM Rf and IgA Rf were analysed using an enzyme immunoassay. The results were analysed in relation to JCA subgroup, disease activity and functional outcome. In patients and controls higher levels of HA were found in young children than in older. Raised levels of HA and IgM Rf were mainly found in children with polyarticular disease. Impaired functional outcome was related to raised HA levels. No correlation was found between HA levels and IgM Rf or IgA Rf. Measurement of HA levels in JCA is of no diagnostic value because of low sensitivity. Quantification of HA may, however, have prognostic value in a subgroup of patients belonging to the polyarticular subgroup.

Physical training of children with juvenile chronic arthritis. Effects on force, endurance and EMG response to localized muscle fatigue.

We examined force, endurance and the electromyographic response to muscle fatigue in ten children with juvenile chronic arthritis (JCA) and ten age-matched healthy controls before and after physical training. Our main finding was a reduced electromyographic response to localized muscle fatigue in the patient group. After training there was a tendency towards a normalized response pattern. A possible explanation may be selective type-II muscle fiber atrophy, and recovery of these fibers after training.

Development of a Costa Rican version of the Childhood Health Assessment Questionnaire.

OBJECTIVE: To validate a Spanish language version of the Childhood Health Assessment Questionnaire (CHAQ) for use in Costa Rica and to evaluate the feasibility, reliability, and cross cultural equivalency of this version. METHODS: The original questionnaire, translated without modification into Spanish, was administered to 12 children, all above 10 years of age, with the diagnosis of juvenile chronic arthritis (JCA) and to their parents. There were several problems in comprehension, and self-administration with this version was not possible. For this reason a teacher and a psychologist were consulted to create a modified Costa Rican version. We administered this 2nd version to 46 children with JCA and 62 of their parents. RESULTS: The modified Costa Rican HAQ (CR-CHAQ) was self-administered by 93.5% of the patients and 84% of the parents. The median time to complete the questionnaire was 12 min for the children, 10 min for the parents. The main difficulty in comprehension was the pain score for both groups. Test-retest (Spearman R = 0.73) and interobserver (Spearman R = 0.70) reliability were good. Validity of the instrument was confirmed by the high correlation between the disability and discomfort scores and conventional clinical variables. There was satisfactory correlation between the disability score and conventional clinical variables. Discriminant validity was confirmed by the capacity of the CR-CHAQ to evaluate patients as being in different categories of disease activity. CONCLUSION: After modifications, the CR-CHAQ achieved cross cultural equivalency.

Use of anti-thymocyte globulin in the management of refractory systemic autoimmune diseases.

The purpose of our pilot study was to evaluate the short-and long-term efficacy of T-lymphocyte depletion in the management of patients with refractory, systemic autoimmune diseases. Nine patients with severe, therapy-resistant autoimmune diseases were subjected to T-cell depletion procedure using polyclonal anti-T-cell antibodies combined with peroral administration of azathioprine and/or cyclosporine. The proband group consisted of 4 patients with systemic lupus erythematosus, 3 with progressive systemic sclerosis, and 2 with rheumatoid arthritis. Administration of polyclonal anti-T-cell antibodies was performed at a single occasion via a central venous catheter during 9-10 days. Immunological analyses of T-cell phenotypes and function and assessment of organ function (kidneys, lungs, bone-marrow) has been performed prospectively in all the patients studied. This treatment resulted in prompt and long-lasting (mean follow-up time: 25.6 months) improvement of autoimmune hemolytic anemia, glomerulonephritis, lung fibrosis, skin and joint involvements in the majority of cases. Adverse effects of this treatment included two episodes of infection (E. coli and Cytomegalovirus) and three cases of serum sickness, and were all easily managed. We suggest that this treatment modality adopted from transplant rejection therapy could be employed in cases of severe autoimmune diseases unresponsive to regular immunosuppressive treatment.