Frequency of abnormal hand and wrist radiographs at time of diagnosis of polyarticular juvenile rheumatoid arthritis.

OBJECTIVE: To determine the frequency of radiographic abnormalities in hand/wrist radiographs of children with newly diagnosed polyarticular juvenile rheumatoid arthritis (polyJRA) because radiographs of small joints are an important tool in assessing outcomes in RA and there are clinical similarities between RA and polyJRA. METHODS: A medical record review was performed to identify cases of polyJRA seen at Mayo Clinic from January 1, 1994, to December 31, 2001. Hand/wrist radiographs, obtained at the time of diagnosis, were reviewed by 3 radiologists with attention to periarticular osteopenia, joint space narrowing (JSN), or erosion. At least 2 radiologists had to independently identify abnormal findings on the same radiograph. The relative carpal length (RCL), judged by Poznanski's method, was also determined. RESULTS: From the review of 159 medical records, 60 cases of newly diagnosed polyJRA were identified. Twenty-five of these had hand/wrist radiographs at diagnosis; 18 sets were available for this study. Of those, 2/3 were female, 6% (1/18) had subcutaneous nodules, 7% (1/14) had elevated levels of serum rheumatoid factor, and 44% (7/16) had elevated serum levels of antinuclear antibodies. Median age at diagnosis was 10.2 years, median duration of hand/wrist symptoms at diagnosis was 10 months, and median number of joints with either swelling, pain on range of motion (ROM), or limited ROM was 14.5. Sixty-one percent of radiographs taken at the time of diagnosis of polyJRA were abnormal. While 44% had periarticular osteopenia, 28% had either erosions or JSN. Six (33%) had RCL > 2 SD below the mean for age. Five (83%) of those with RCL, > 2 SD below the mean for age, had periarticular osteopenia, JSN, or erosion. CONCLUSION: We conclude the frequency of abnormal hand/wrist radiographs is very high very early in the course of polyJRA. More studies are needed to determine to what extent these radiographic abnormalities correlate with clinical outcomes.

Long-term fracture risk in patients with Crohn's disease: a population-based study in Olmsted County, Minnesota.

BACKGROUND & AIMS: Osteoporosis is common in patients with Crohn's disease, but less is known about their risk of actual fractures. METHODS: The medical records of all 238 Olmsted County, Minnesota, residents diagnosed with Crohn's disease between 1940 and 1993 were reviewed for evidence of subsequent fractures compared with a control group of county residents matched by age and sex. The risk ratio of fracture in patients relative to controls was estimated using the Cox proportional hazards regression model. The cumulative incidence of fracture following diagnosis was estimated using the Kaplan-Meier method. RESULTS: Sixty-three patients had 117 different fractures. The cumulative incidence of any fracture from the time of diagnosis onward was 36% at 20 years versus 32% in controls (P = 0.792). Compared with controls, the overall risk ratio for any fracture was 0.9 (95% confidence interval [CI], 0.6-1.4), whereas the relative risk for an osteoporotic fracture was 1.4 (95% CI, 0.7-2.7). The risk ratio for thoracolumbar vertebral fracture was 2.2 (95% CI, 0.9-5.5). Cox proportional hazards regression identified only age as a significant clinical predictor of fracture risk (hazard ratio per 10-year increase in age, 1.3; 95% CI, 1.1-1.5). Specifically, use of corticosteroids and surgical resection did not predict risk of fracture among these unselected patients with Crohn's disease from the community. CONCLUSIONS: In this population-based inception cohort of patients with Crohn's disease, the risk of fracture was not elevated relative to age- and sex-matched controls.

Formation of the killer Ig-like receptor repertoire on CD4+CD28null T cells.

Killer Ig-like receptors (KIRs) are expressed on CD4(+)CD28(null) T cells, a highly oligoclonal subset of T cells that is expanded in patients with rheumatoid arthritis. It is unclear at what stage of development these T cells acquire KIR expression. To determine whether KIR expression is a consequence of clonal expansion and replicative senescence, multiple CD4(+)CD28(null) T cell clones expressing the in vivo dominant TCR beta-chain sequences were identified in three patients and analyzed for their KIR gene expression pattern. Based on sharing of TCR sequences, the clones were grouped into five clone families. The repertoire of KIRs was diverse, even within each clone family; however, the gene expression was not random. Three particular receptors, KIR2DS2, KIR2DL2, and KIR3DL2, had significant differences in gene expression frequencies between the clone families. These data suggest that KIRs are successively acquired after TCR rearrangement, with each clone family developing a dominant expression pattern. The patterns did not segregate with the individual from whom the clones were derived, indicating that peripheral selection in the host environment was not a major shaping force. Several models were examined using a computer algorithm that was designed to simulate the expression of KIRs at various times during T cell proliferation. The computer simulations favored a model in which KIR gene expression is inducible for a limited time during the initial stages of clonal expansion.