Prevalence of Neuropsychiatric Lupus in Psychosis Patients Who Have Tested Positive for Antinuclear Antibodies.

OBJECTIVE: Psychosis is a rare manifestation of neuropsychiatric systemic lupus erythematosus (NPSLE). Current guidelines do not make a recommendation regarding the use of antinuclear antibody (ANA) testing in the assessment of patients with psychosis. The present study was undertaken to determine the prevalence of NPSLE in patients with psychosis who were positive for ANAs. METHODS: A retrospective review of patients who were admitted to the mental health service of 2 metropolitan tertiary referral centers with a diagnosis of psychosis and had been tested for ANAs was conducted. A diagnosis of SLE was made when the 2019 American College of Rheumatology (ACR)/European Alliance of Associations for Rheumatology (EULAR) classification criteria were fulfilled. Attribution of psychosis-related events to NPSLE were made according to validated criteria. RESULTS: There were 10,205 mental health admissions with diagnoses of psychosis representing 4,766 individual patients, 911 patients (19%) were tested for ANAs, 135 (15%) of those tests returned a positive result with a titer of ≥1:160. The mean ± SD follow-up time was 47 ± 26 months. At discharge, there were 4 patients who met 2019 ACR/EULAR criteria for SLE, 2 of whom met criteria for NPSLE (2 patients had other manifestations of SLE), yielding an NPSLE prevalence of 1.5% (2 of 135) among patients who were positive for ANAs, and 0.2% (2 of 911) among all patients who underwent testing for ANAs. CONCLUSION: The prevalence of NPSLE in patients with psychosis who were positive for ANAs was low, at 1.5%. The low rate of clinically significant positive results would argue against routine testing for ANAs in patients with psychosis.

Gynecological involvement in eosinophilic granulomatosis with polyangiitis.

Gynceological involvement in antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides is rare. We describe a case of ANCA-associated vasculitis in an elderly woman presenting with fevers, cough and a rash. Further investigations revealed vasculitic involvement of the ovaries, fallopian tubes, uterus and omentum with an eosinophil-rich infiltrate.

Anncaliia algerae microsporidial myositis.

The insect microsporidian Anncaliia algerae was first described in 2004 as a cause of fatal myositis in an immunosuppressed person from Pennsylvania, USA. Two cases were subsequently reported, and we detail 2 additional cases, including the only nonfatal case. We reviewed all 5 case histories with respect to clinical characteristics, diagnosis, and management and summarized organism life cycle and epidemiology. Before infection, all case-patients were using immunosuppressive medications for rheumatoid arthritis or solid-organ transplantation. Four of the 5 case-patients were from Australia. All diagnoses were confirmed by skeletal muscle biopsy; however, peripheral nerves and other tissues may be infected. The surviving patient received albendazole and had a reduction of immunosuppressive medications and measures to prevent complications. Although insects are the natural hosts for A. algerae, human contact with water contaminated by spores may be a mode of transmission. A. algerae has emerged as a cause of myositis, particularly in coastal Australia.

Psychosocial interventions as adjunct therapy for patients with rheumatoid arthritis: a systematic review.

AIM: To identify the psychological interventions for which there is consistent, high quality evidence of efficacy in the treatment of patients with rheumatoid arthritis (RA). METHOD: A computer-aided search and manual screening of identified papers was conducted. Randomised controlled trials published in English in peer-reviewed journals, assessing the use of psychological interventions in adult patients with RA were included. RESULTS: Thirty-four papers published between 1981 and 2009 encompassing 31 studies with 2021 patients were included. There is consistent supportive evidence for the efficacy of disclosure therapy (four studies) and cognitive behavioural therapy (CBT) with maintenance therapy (five studies). There is supportive evidence for improvement with CBT of greater than 6 weeks duration (six studies) in the short-term but conflicting evidence for its long-term efficacy. There is some evidence for improvement with biofeedback-based interventions (two studies). There is conflicting evidence for the benefits of counselling (three studies), psychotherapy (two studies) mindfulness and meditation (two studies), and CBT of less than 6 weeks duration (six studies). There is limited evidence regarding relaxation therapy (two studies). Methodological limitations of the reviewed literature included failure of allocation concealment, blinding and conduction of intention-to-treat analysis, as well as the heterogeneity and choice of outcome measures. CONCLUSIONS: This review shows consistent supportive evidence for the use of disclosure therapy, and CBT with maintenance therapy as adjunct therapies in patients with RA. It also highlights methodological limitations in the current literature and the need for future research in this area.

Reduced chemokine and matrix metalloproteinase expression in patients with rheumatoid arthritis achieving remission.

OBJECTIVE: To quantify the changes in synovial expression of mediators of macrophage chemotaxis, matrix degradation, and macrophage infiltration in the synovial membrane of patients with rheumatoid arthritis (RA) achieving American College of Rheumatology (ACR) defined remission and radiological arrest. METHODS: Knee synovial biopsies were taken from a selected group of 18 patients with RA before and after treatment and immunostained with antibodies specific for CD68; the chemokines macrophage inflammatory protein (MIP)-1a and monocyte chemoattractant protein (MCP)-1; matrix metalloproteinases (MMP-1 and 3) and their inhibitors, the tissue inhibitors of metalloproteinases (TIMP-1 and 2); as well as isotype-specific negative controls. Immunostaining was quantified using a computer assisted color video image analysis system. Radiographs were performed before and after treatment and the Larsen score determined. Patients were arbitrarily divided into 2 groups: the radiological arrest group (defined as change in Larsen score pound 5 from baseline) and radiological progressors (defined as change in Larsen score > 5). Patients were classified according to ACR response criteria. RESULTS: In the 8 patients who achieved ACR defined remission, there were tendencies toward reductions in the synovial lining layer (LL) expression of MIP-1a by 36% (p = 0.1) and MCP-1 by 48% (p = 0.1). Significant reductions occurred in the expression of MMP-1, by 53% in the LL (p = 0.008) and 59% in synovial sublining layer (SL) (p = 0.02) and MMP-3, by 76% in LL (p = 0.02), and 72% in SL (p = 0.008), but not in TIMP expression. In this group of patients there were reductions in MMP:TIMP ratios, in particular the MMP-1:TIMP-1 ratio in the LL (p = 0.05), MMP-3:TIMP-1 ratio in the LL (p = 0.05) and SL (p = 0.008), and MMP-3:TIMP-2 ratio in the LL (p = 0.04) and SL (p = 0.08). In this group of patients CD68+ macrophage infiltration was significantly reduced in the LL by 59% (p = 0.008) and in the SL by 52% (p = 0.008), which corresponded with the reductions in chemokine expression. In the remaining 10 patients who did not achieve full remission there were no significant changes in the variables studied. In the group achieving ACR 50% or 70% response there was a reduction in CD68 expression that approached significance (p = 0.06 in LL and SL), but there was no significant change in the other variables. There were no significant changes in the patients with an ACR 20% response. In the radiological arrest group (12 patients) there was a 41% reduction in LL expression of MIP-1a (p = 0.05) and MMP-1 (p = 0.06). Reductions in MMP:TIMP expression were also noted, in particular in MMP-1:TIMP-1 expression in the LL (p = 0.04) and MMP-3:TIMP-1 in the SL (p = 0.01). There were corresponding reductions in CD68 expression by 49% (p = 0.009) in LL and by 42% (p = 0.0005) in SL. In the radiological progressors (6 patients) there were no significant reductions in mediator expression. CONCLUSION: In RA, ACR defined remission is associated with reductions in MMP-1 and 3 expression, with a corresponding reduction in macrophage infiltration and a tendency to reduction in MIP-1a expression. Radiological arrest is associated with reductions in MMP-1 expression, and significant reductions in macrophage infiltration, MIP-1 expression, and MMP:TIMP ratio.

Remission of lymphoma after drug withdrawal in rheumatoid arthritis.

A 63-year-old man with rheumatoid arthritis presented with pain and swelling of his right buttock. Imaging and tissue biopsy revealed a diffuse large B-cell, non-Hodgkin's lymphoma. The disease-modifying drugs he was taking, cyclosporin and methotrexate, were stopped, and the lymphoma resolved spontaneously without the use of chemotherapy.

The road to consensus: considerations for the safe use and prescribing of COX-2-specific inhibitors.

We describe a process which aimed to achieve consensus on evidence-based considerations for the safe prescribing and use of the COX-2-specific inhibitors available in Australia among a group of 31 clinicians and other health professionals, drawn from practice, academia and industry. Difficulties were encountered at several points: the composition of the working group was contentious; the evidence, drawn from large clinical studies, was criticised by some for problems of study design, data analysis and reporting; interpretation of study results was influenced by the interpreter's knowledge, skills and biases; and the formulation of the "Considerations" became more controversial as summary statements were contracted and simplified. Agreement on the final draft was achieved among 23 of 31 participants. Evidence-based practice guidelines are a welcome development in modern medicine, but the consensus required to produce them can mask important diversity of opinion.