Assessment of two screening tools to identify psoriatic arthritis in patients with psoriasis.

BACKGROUND: Many patients with psoriasis have undiagnosed psoriatic arthritis. Low specificity is found with many PsA screening tools. A new instrument, the CONTEST questionnaire, was developed utilizing the most discriminative items from existing instruments. OBJECTIVE: The aim of this study was to compare the CONTEST and PEST screening tools. METHODS: People attending secondary care clinics with psoriasis, but not PsA, completed the questionnaires, were assessed for function and quality of life, and had a physical examination. Patients thought to have PsA were compared to those without. The performance of CONTEST and PEST was compared using area under the receiver operating curve (AUC), and sensitivity and specificity at the previously published cut-offs. RESULTS: A total of 451 dermatology patients were approached, 35% were reviewed and 27 (17%, 95% CI 12.3-21.7) had unidentified psoriatic arthritis. The sensitivity and specificity (95% CI) of PEST were 0.60 (0.42-0.78)/0.76 (0.69-0.83) and for CONTEST 0.53 (0.34-0.72)/0.71 (0.63-0.79). The confidence limits for the AUC overlapped (AUC for PEST 0.72 (0.61-0.84), for CONTEST 0.66 (0.54-0.77). CONCLUSIONS: PEST and CONTEST questionnaires performed equally well, with no superiority of the new CONTEST tool.

Comparison of three screening tools to detect psoriatic arthritis in patients with psoriasis (CONTEST study).

BACKGROUND: Multiple questionnaires to screen for psoriatic arthritis (PsA) have been developed but the optimal screening questionnaire is unknown. OBJECTIVES: To compare three PsA screening questionnaires in a head-to-head study using CASPAR (the Classification Criteria for Psoriatic Arthritis) as the gold standard. METHODS: This study recruited from 10 U.K. secondary care dermatology clinics. Patients with a diagnosis of psoriasis, not previously diagnosed with PsA, were given all three questionnaires. All patients who were positive on any questionnaire were invited for a rheumatological assessment. Receiver operating characteristic (ROC) curves were used to compare the sensitivity, specificity and area under the curve of the three questionnaires according to CASPAR criteria. RESULTS: In total, 938 patients with psoriasis were invited to participate and 657 (70%) patients returned the questionnaires. One or more questionnaires were positive in 314 patients (48%) and 195 (62%) of these patients attended for assessment. Of these, 47 patients (24%) were diagnosed with PsA according to the CASPAR criteria. The proportion of patients with PsA increased with the number of positive questionnaires (one questionnaire, 19·1%; two, 34·0%; three, 46·8%). Sensitivities and specificities for the three questionnaires, and areas under the ROC curve were, respectively: Psoriatic Arthritis Screening Evaluation (PASE), 74·5%, 38·5%, 0·594; Psoriasis Epidemiology Screening Tool (PEST), 76·6%, 37·2%, 0·610; Toronto Psoriatic Arthritis Screen (ToPAS), 76·6%, 29·7%, 0·554. The majority of patients with a false positive response had degenerative or osteoarthritis. CONCLUSION: Although the PEST and ToPAS questionnaires performed slightly better than the PASE questionnaire at identifying PsA, there is little difference between these instruments. These screening tools identify many cases of musculoskeletal disease other than PsA.

Late-onset erythropoietic porphyria caused by a chromosome 18q deletion in erythroid cells.

The erythropoietic porphyrias, erythropoietic protoporphyria and congenital erythropoietic porphyria, result from germline mutations in the ferrochelatase gene and uroporphyrinogen III synthase gene, respectively. Both conditions normally present in childhood but rare cases with onset past the age of 40 y have been reported. Here we show that late-onset erythropoietic protoporphyria can be caused by deletion of the ferrochelatase gene in hematopoietic cells with clonal expansion as part of the myelodysplastic process. This is the first direct demonstration of porphyria produced by an acquired molecular defect restricted to one tissue. Some other cases of late-onset erythropoietic porphyria may be explained by a similar mechanism.

Latex allergy in an orthognathic patient and implications for clinical management.

A 19-year-old girl with mild asthma had had 16 months of orthodontic treatment as part of the joint orthodontic/orthognathic approach to her 9.5 mm overjet. At the time of banding her second molars she developed latex protein allergy as a reaction to the operator's non-sterile powdered latex gloves. She also gave a history of allergy to other substances as well as of eczema. The patient was confirmed as allergic to latex protein by radioallergosorbent test (RAST) for IgE, requiring precautions be taken during further orthodontic procedures as well as during the subsequent orthognathic surgery for the underlying Class II skeletal pattern.

Notomastus lobatus chloroperoxidase and Amphitrite ornata dehaloperoxidase both contain histidine as their proximal heme iron ligand.

Two novel heme-containing peroxidases, one able to incorporate halogens into aromatic substrates and the other able to remove them, have recently been isolated from marine sources and initially characterized by Chen et al. [(1991) J. Biol. Chem. 266, 23909-23915; (1996) J. Biol. Chem. 271, 4609-4612]. The haloperoxidase Notomastus lobatus chloroperoxidase (NCPO) is unusual in requiring a flavoprotein component for peroxidase activity. The dehaloperoxidase (DHP), isolated from Amphitrite ornata, is the only heme-containing peroxide-dependent dehalogenase known to be capable of removing halogens including fluorine. Both enzymes are also quite atypical in that the molecular weights of their heme-containing subunits are less than 16,000, approximately one-half to one-fifth the size of typical heme-containing peroxidases. Interestingly, we have also found that both enzymes are isolated in their oxyferrous states even though all protein purification was done in the absence of any reductant. In the present study, we have examined these two enzymes with magnetic circular dichroism and UV-visible absorption spectroscopy in order to determine the identity of their proximal heme iron ligand. Four derivatives of each enzyme, cyanoferric, deoxyferrous, oxyferrous, and (carbonmonoxy)ferrous, have been examined and spectroscopically compared to parallel derivatives of myoglobin, a well-studied histidine-ligated heme protein. The spectra observed for each derivative of the two new enzymes are very similar to each other and, in turn, to the spectra of the same derivatives of myoglobin. We conclude that both new heme enzymes contain histidine as their proximal heme iron ligand. This makes NCPO the first histidine-ligated heme-containing peroxidase capable of chlorinating halogen acceptor substrates using chloride as the halogen donor. Further, the novel reactivity of DHP is not the result of an unusual proximal ligand. The present results with NCPO and DHP challenge the current dogma of how heme-containing peroxidases function: one chlorinates substrates without having a thiolate proximal ligand, and the other both oxygenates and dehalogenates haloaromatics and yet has a histidine proximal ligand like numerous other peroxidases that are not capable of such a combined reactivity.

Psoriatic arthritis: outcome of disease subsets and relationship of joint disease to nail and skin disease.

Subgroups of PsA have been described but their relationship to the mode of onset of arthritis, to DIP joint disease and to nail and skin disease remains controversial. Therefore, the pattern of disease was documented in 100 patients with PsA in whom the mode of onset was known. The patients were divided into six subgroups: monoarthritis; DIP joint disease only; oligoarthritis; polyarthritis; spondyloarthropathy and arthritis mutilans. Sixty-four patients changed pattern. Nail disease (67% of total) was more common in patients with DIP joint disease (27% of total) and was significantly associated with adjacent DIP joint disease. Skin and nail disease severity did not correlate with joint severity, joint activity or functional status, nor differ between subgroups. Therefore, the mode of onset does not predict outcome in the majority. The topographic association of nail disease and involvement of the adjacent DIP joints suggests a common local inflammatory mechanism.

Subungual keratoacanthoma--a report of four cases and review of the literature.

Subungual keratoacanthoma is a rare benign neoplasm which most commonly occurs in middle-aged Caucasians. It usually presents as a painful, rapidly growing lesion of the terminal phalanx. Radiography consistently demonstrates a well-defined cup-shaped erosion of the underlying bone. Clinically, subungual keratoacanthoma must be distinguished from subungual squamous carcinoma. We report four further cases and discuss the literature.

Localization of the Chloroperoxidase of the Capitellid Polychaete Notomastus lobatus.

Antisera against the two constituent proteins of the chloroperoxidase enzyme of the capitellid polychaete Notomastus lobatus were used to identify and localize these polypeptides by immunoblotting and indirect immunofluorescence. Immunofluorescence staining showed the enzyme to be localized primarily in tissues of the tail region of the worm. Some reactivity was also observed in the epidermis of the mid-body, but none was seen in the head region. These immunofluorescence results were supported by immunoblotting experiments, which also showed that chloroperoxidase holoenzyme is localized in the tail. Immunological results were substantiated by the distribution of enzyme activity and the in vivo products of the chloroperoxidase, 4-bromophenol, 2,4-dibromophenol, and 2,4,6-tribromophenol. Chloroperoxidase is the principal enzyme involved in the production of bromoaromatics in N. lobatus. Localization of most of this enzyme in the tail region explains the detection of high levels of bromophenols in the tail, the most exposed portion of this head-down, deposit-feeding worm. This pattern of bromoaromatic distribution is consistent with the hypothesis that the worms produce these compounds as defensive chemicals against epifaunal predators.

Prophylactic PUVA and UVB therapy in polymorphic light eruption--a controlled trial.

A double-blind controlled trial of low-dose prophylactic oral psoralen photochemotherapy (PUVA) and ultraviolet-B (UVB) irradiation therapy was undertaken from April to September 1983 in 42 patients with polymorphic light eruption (PLE). Patients were randomly allocated to three groups, PUVA with oral 8-methoxypsoralen (8-MOP), UVB with oral placebo, and control low-dose UVA with oral placebo. The initial dose given to each active treatment group was a third of the predetermined minimal phototoxic or erythema dose, followed three times weekly for 6 weeks by doses incremented by an eighth on each occasion in the PUVA group and by a seventh in the UVB group. Ultraviolet radiation exposure was monitored throughout with polysulphone film lapel badges. Patients recorded their symptoms on a visual analogue scale. Symptoms of rash and itch in patients treated with PUVA and UVB were significantly less affected by increasing exposure to ultraviolet radiation than were these symptoms in control patients.

UVB-induced collagen changes in the skin of the hairless albino mouse.

Biochemical techniques have been used to measure ultraviolet-B (UVB)-induced changes in dermal collagen composition. Hairless albino mice were irradiated dorsally with a daily dose of 62 mJ/cm2 UVB for 12, 24, 30, and 36 weeks. Nonirradiated controls were housed under identical conditions. Additional groups were irradiated for similar periods and kept for a further 6-24 weeks without irradiation. Skin samples were taken from dorsal and ventral (nonirradiated) surfaces and types I and III collagen were quantified densitometrically after cyanogen bromide digestion and polyacrylamide gel electrophoresis. Type III collagen was expressed as a percentage of the total types I and III collagen and the ratio of dorsal/ventral type III (D/V III) was determined for each mouse. The ratio increased significantly in irradiated animals whereas it decreased in the corresponding period in control animals. In irradiated mice withdrawn from UV exposure the ratio D/V III tended to revert to control levels. These data are in agreement with those of our previous human studies, which showed an increase in type III collagen in sun-exposed skin when compared with covered sites.

Chronic sarcoid synovitis in the Caucasian: an arthroscopic and histological study.

Chronic synovitis is a rare complication of sarcoidosis, virtually confined to the black population. Synovial histology may be nonspecific or show typical sarcoid granulomata. We report 2 cases of chronic sarcoid synovitis in Caucasians. Histology showed typical granulomata in one patient, whose distinctive arthroscopic appearance is discussed.