Diagnosis and assessment of systemic vasculitis.

The diagnosis of systemic vasculitis requires clinical evidence with appropriate symptoms and physical signs, supported by histological or radiological confirmation. Earlier recognition of these diseases has been facilitated by a greater awareness of their incidence, and also by the more widespread introduction of the anti-neutrophil cytoplasmic antibody (ANCA) test. Early diagnosis provides a greater potential for effective intervention in the course of disease and this may limit subsequent damage. However, an early diagnosis poses the more difficult challenge in the classification of the vasculitides, since traditional classification systems have depended on the presence of well-established manifestations of the disease. The accurate assessment of disease activity and damage in vasculitis has become necessary as a result of significant improvements in survival with the use of chemotherapy. The disease course however is frequently characterised by relapse as well as the scars of irreversible organ damage from disease and drug toxicity. Clinical methods of assessment are simple to apply, reliable and often more effective than any current laboratory test in evaluating the effects of therapy and determining changes in therapy. The increasing use of surrogate clinical measures of disease should provide a greater opportunity to establish the effectiveness of existing and novel therapies in the management of these complex diseases.

The assessment and management of leg ulcers in rheumatoid arthritis.

Patients with rheumatoid arthritis appear to be at increased risk of developing chronic leg ulcers. This review identifies the factors that predispose these patients to leg ulceration and highlights how this problem can be managed and the risk of recurrence reduced.

The short-term health outcome of out-patient rheumatology consultations in relation to rationing: a pilot study.

The objectives were to test whether the short-term health outcome of rheumatology out-patients differs according to clinical priority. The setting was an NHS regional rheumatology out-patient department serving a catchment population of over 1 million. The subjects were 249 consecutive rheumatology out-patients categorized on the basis of the referral letter as 'urgent' (n = 50), 'soon' (n = 100) or 'routine' (n = 99). Primary outcome measures were the proportion of patients reporting improvement in health categorized by clinical priority (urgent, soon or routine) or main diagnostic group (inflammatory or non-inflammatory disease). Secondary outcome was change in health status measured using the EuroQol generic health instrument (EQ-5D). Small but insignificant differences in the proportion of patients reporting health improvement were found between the urgent (28%), soon (23%) and routine (17%) categories (Kruskal-Wallis, P = 0.186). Thirty per cent of patients with inflammatory joint disease reported improvement compared with 17% of those with non-inflammatory conditions (Mann-Whitney U, P = 0.019). In patients reporting improvement, the median (interquartile range) improvement in EQ-5D health utility score was +0.2 (0.58) (P = 0.0001) and that of visual analogue health score was +5 (16) (P = 0.001). Clinical priority setting, by giving priority to some patients over others, results in rationing by delay. These data do not support the hypothesis that fewer patients given a low clinical priority gain health benefit compared with those given a high priority. However, those with inflammatory joint disease do appear to have better short-term health outcomes.