Low Prevalence of Nodules in Rheumatoid Arthritis Patients in Kuwait: A Description and a Comparison of Patients from the Kuwait Registry for Rheumatic Diseases.

OBJECTIVES: To describe the prevalence of rheumatoid nodules (RN) in patients with rheumatoid arthritis (RA) and to compare their features with those of patients without RN. SUBJECTS AND METHODS: Adult RA patients (n = 952) in the Kuwait Registry for Rheumatic Diseases from February 2013 to December 2015 were evaluated for RN. Demographic and serological features and disease activity and severity were obtained from the registry. RESULTS: Of the 952 RA patients, 22 (2.3%) had RN and 930 (97.7%) did not. Age, sex, disease duration, smoking, and family history of an autoimmune rheumatic disease were similar. Obesity was more prevalent in the RN group, i.e. 11 (50%) vs. 326 (35.1%), p = 0.016. There was no difference in rheumatoid factor (RF) or anti-cyclic citrullinated peptide antibody positivity. Patients with RN had more sicca symptoms, i.e. 8 (36.4%) vs. 152 (16.3%), p = 0.025, a higher mean score on the visual analogue scale pain (3 ± 2.9 vs. 2 ± 2.7, p < 0.001), more tender joints (6.4 ± 8.8 vs. 4.2 ± 7.2, p = 0.001), a higher patient global assessment of disease activity (3.3 ± 2.7 vs. 2.3 ± 2.7, p < 0.001), and more deformities, i.e. 3 (13.6%) vs. 74 (8%), p = 0.034. The mean health assessment questionnaire score in RN patients was 1.1 versus 0.9 in patients without RN (p = 0.08). Patients with RN had a low disease activity (means: disease activity score [DAS-28], 3.02; clinical disease activity index, 7.7; and simple disease activity index, 10.4), similar to the other group. While the rates of methotrexate treatment were comparable, biologic therapy was administered more in patients with RN (i.e. 15 [68.2%] vs. 478 [51.4%], p < 0.001). CONCLUSION: In Kuwait, the prevalence of RN is low among RA patients. Patients with and without RN are similar in terms of demographics and serologic features, except for more obesity. However, patients with RN have more sicca symptoms, joint deformities, and painful and tender joints. Disease activity scores are low with more frequent biologic therapy.

CHANGING CLINICAL PROFILE OF ACUTE RHEUMATIC FEVER AND RHEUMATIC RECURRENCE.

BACKGROUND: Clinical profile of acute rheumatic fever and rheumatic recurrence seems to have changed in countries where rheumatic fever is still endemic. The objectives of this study were to compare clinical profile and outcome of patients suffering initial and recurrent episodes of acute rheumatic fever in children. METHODS: This prospective study was conducted in two tertiary care hospitals from January to June 2011. The diagnosis was based on the modified Jones criteria. Sixty children were included in the study, 15 having first episode of rheumatic fever and 45 with rheumatic recurrence. The severity of carditis was assessed by Clinical and echocardiography means: RESULTS: Carditis was the commonest presentation in both first (80%) and recurrent attacks (100%). Arthritis was seen in 60% of children with first episode and in 26.7% with recurrence. The frequency of subcutaneous nodules, invariably associated with carditis, was very high (33.3% in the first and 48.3% in recurrent episodes). Carditis was generally mild during first episode (53.3%) and severe with rheumatic recurrence (55.6%). There was no death in either group. One patient with severe mitral regurgitation and rheumatic recurrence underwent mitral valve repair for intractable heart failure. CONCLUSION: Clinical profile of rheumatic recurrence and acute rheumatic fever has changed. Rheumatic recurrence is associated with severe carditis. Carditis is more common than arthritis even in the first attack. Sub-cutaneous nodules are a frequent finding invariably associated with carditis.

Associations of Circulating Cytokines and Chemokines With Cancer Mortality in Men With Rheumatoid Arthritis.

OBJECTIVE: To examine the potential of circulating cytokines and chemokines as biomarkers of cancer mortality risk in patients with rheumatoid arthritis (RA). METHODS: Male participants in the Veterans Affairs RA registry were followed up from the time of enrollment until death or December 2013. Cytokines and chemokines were measured in banked serum obtained at the time of enrollment, using a bead-based multiplex assay, and a previously developed cytokine score was calculated. Vital status and cause of death were determined through the National Death Index. Associations of cytokines with cancer mortality were examined using multivariable competing-risks regression. RESULTS: Among 1,190 men with RA, 60 cancer deaths (30 of which were attributable to lung cancer) occurred over 5,307 patient-years of follow-up. The patients had a mean age of 64.5 years, had established disease (median duration 8.7 years), were seropositive for rheumatoid factor (81%) or anti-cyclic citrullinated peptide antibody (77%), and frequently had a history of smoking (82% current or former). Seven of 17 analytes examined were individually associated with cancer mortality. The cytokine score was associated with overall cancer (subhazard ratio [SHR] 1.42, 95% confidence interval [95% CI] 1.08-1.85) and lung cancer (SHR 1.86, 95% CI 1.57-2.19) mortality in multivariable analyses. Those in the highest quartile of cytokine scores had a >2-fold increased risk of overall cancer mortality (P = 0.039) and a 6-fold increased risk of lung cancer mortality (P = 0.028) relative to the lowest quartile. A synergistic interaction between current smoking and high cytokine score was observed. CONCLUSION: Serum cytokines and chemokines are associated with cancer and lung cancer mortality in men with RA, independent of multiple factors including age, smoking status, and prevalent cancer.

Radiographic thumb osteoarthritis: frequency, patterns and associations with pain and clinical assessment findings in a community-dwelling population.

OBJECTIVES: The aim of this study was to investigate: (i) the frequency and patterns of radiographic OA (ROA) in the thumb joints; and (ii) associations between thumb ROA and the clinical characteristics of thumb OA in older adults with hand pain or problems. METHODS: Participants were 592 community-dwelling older adults with hand pain or hand problems who attended a research clinic. Hand X-rays were taken and 32 joints were scored for the presence of ROA. The occurrence and pattern of ROA in the hand were examined. Univariable and multivariable associations of thumb pain and clinical assessments (nodes, deformity, enlargement, thenar muscle wasting, grind test, Kapandji index, Finkelstein's test and thumb extension) with ROA were investigated. RESULTS: The first CMC and thumb IP joints were the hand joints most frequently affected with ROA. The thumb (thumb IP, first MCP, first CMC, trapezioscaphoid) was the most commonly affected joint group (n = 412). Isolated thumb ROA occurred more frequently than in any other isolated joint group. Multivariable analyses showed that older age, thumb pain, thenar muscle wasting and presence of nodes, deformity or enlargement best determined the presence of thumb ROA. CONCLUSION: The first CMC and thumb IP joints were frequently affected with ROA. Prevalence estimates of ROA would be underestimated if these were not scored. One-third of the individuals with thumb ROA did not have involvement of the first CMC joint. The presence of thumb ROA was strongly associated with a combination of older age, thumb pain and clinical features of OA.

A review of methotrexate-induced accelerated nodulosis.

OBJECTIVE: To review the English-language literature on methotrexate-induced accelerated nodulosis, compile case reports of its occurrences, and make recommendations on the clinical management of patients. METHODS: A comprehensive search of MEDLINE, TOXLINE, and EMBASE databases was performed, along with a bibliographic search of key articles. Case reports were compiled separately. The Naranjo adverse drug reaction probability scale was used to assess causality. RESULTS: Twenty-seven case reports of patients with methotrexate-induced accelerated nodulosis were identified along with one series of 10 patients and one series of 21 patients. Probability assessment for most of the case reports was weak and left room for doubt regarding causality. Most patients were older than 50 years, were positive for rheumatoid factor, and had nodules on their fingers but did not have concurrent vasculitis. Some unusual sites of nodulosis were the larynx, lungs, Achilles tendon, and heart. Of 19 patients given hydroxychloroquine, colchicine, sulfasalazine, azathioprine, or D-penicillamine, all except two showed regression of the nodules; the response was unknown for one patient. CONCLUSION: Controversy surrounds the management of patients who develop accelerated nodulosis while receiving methotrexate therapy for rheumatoid arthritis. Our review of these data does not allow definitive conclusions because the available case reports and clinical trials are fragmented and incomplete.

Extra-articular manifestations are uncommon in southern Chinese with rheumatoid arthritis.

Rheumatoid arthritis is characterized by both articular and extra-articular manifestations. Few studies have addressed the prevalence of extra-articular manifestations in non-Caucasoid races. We have studied 153 Southern Chinese patients with RA and found that such features are uncommon when compared with previous reports in Caucasoids. The only extra-articular manifestations were rheumatoid nodules which were present in 4.6%, and episcleritis and cutaneous vasculitis in 0.7% each. A further 12.4% had mild sicca symptoms. These findings were in direct contrast with the severity of articular disease as 73% of patients had erosive disease which was graded as severe in 37%. The reason for the low prevalence of extra-articular manifestations is not known but may be due, in part, to the rarity of the HLA-DR4 subtype, HLA-Dw4 in the Southern Chinese population.

Granuloma anular subcutâneo: relato de um caso / Subcutaneous granuloma annulare: case report

Um caso de uma paciente do sexo feminino de seis anos de idade com lesäo de granuloma anular subcutâneo na regiäo plantar é relatado. Após dois meses ela desenvolveu uma lesäo típica de granuloma anular na perna. Uma revisäo da literatura também é apresentada

The prevalence of palpable finger joint nodules in diffuse idiopathic skeletal hyperostosis (DISH). A controlled study.

The presence of clinically palpable finger joint nodules (Heberden's and Bouchard's nodes) was documented in 123 consecutive cases with diffuse idiopathic skeletal hyperostosis (DISH) of the thoracic spine and 191 matched DISH negative controls. The prevalence of palpable finger joint nodules was almost twice as frequent in cases with spinal DISH compared to controls (46% versus 31%, chi 2 = 7.67, P less than 0.01; multivariate adjusted odds ratio OR = 1.84; 95% CI: 1.14-2.98). This increase was most marked at the proximal interphalangeal joint, in males and in patients up to the age of 65 years. In addition and independent of other variables such as hyperostotic features, age and sex, the prevalence of palpable finger joint nodules was about twice as high in probands with a history of physically heavy work compared to those without (43% versus 26%, chi = 9.18, P less than 0.005; multivariate adjusted odds ratio OR = 2.10; 95% CI: 1.26-3.52). From these results we conclude that DISH should be considered as an independent risk factor in the development of finger joint nodules.

Extraarticular manifestations of rheumatoid arthritis and HLA antigens in northern Italy.

We performed retrospective analysis of 141 Northern Italian patients with rheumatoid arthritis (RA). This series represents all the patients seen as in and/or outpatients at the rheumatologic unit of Reggio Emilia Hospital during a 2 year period (1987-88). We observed a low frequency of nodules (16%) and vasculitis (2.1%). Thus, RA seems to be milder in our population compared to Caucasian patients with RA originating from North America or England. We observed a weak association with DR4 (RR = 2.4) in the total group of patients with RA. A low frequency of DR4 was observed in patients and controls (29 vs 14.5%, p = 0.001). When compared with controls the frequency of DR4 was significantly higher in seropositive (p = 0.001), but not in seronegative patients. We found that DR4 was significantly associated with nodules (RR = 6.4), with extraarticular features (EAF) (RR = 4) and with erosions (RR = 3) compared with controls. The subgroups with nodules and EAF had a DR4 frequency (respectively, of 52 and 40%) which was significantly higher than that observed in remaining patients (respectively, 25 and 24%). No significant difference was observed in the DR4 frequency between the patients with erosions and those without (34 vs 18%). Thus, DR4 in our population seems to be predominantly associated with a subgroup of patients characterized by seropositivity and EAF.

Aschoff bodies in operatively excised atrial appendages and in papillary muscles. Frequency and clinical significance.

Among 481 patients undergoing various mitral valve operations, Aschoff bodies were found in 40 (21%) of 191 operatively excised left atrial appendages, in four (2%) of 273 operatively excised left ventricular papillary muscles (1 per patient), and in one (6%) of 17 patients with both left atrial appendage and papillary muscle operatively excised. Of the total of 45 patients with Aschoff bodies, 44 preoperatively had mitral stenosis, and only one, a 10-year-old boy, had pure mitral regurgitation. Sinus rhythm was present in 38 (84%), and atrial fibrillation in seven (16%). Perioperatively, only one of the 45 patients with Aschoff bodies had clinical or laboratory stigmata compatible with acute rhematic fever, and 58% had an illness compatible with acute rheumatic fever at any time.