Background: Sacroiliac joints (SJ) involvement is a distinctive and charasteristic feature of Spondyloarthritis (SpA) and x-ray is the test routinely used to make a diagnosis. However, x-ray reveals late structural damage but cannot detect active inflammation. The objective of this study was to assess the validity of Doppler ultrasound in SJ. Methods: Prospective blinded and controlled study of SJ, in which three populations were compared. We studied 106 consecutive cases, who were divided into three groups: a) 53 patients diagnosed with SpA who had inflammatory lumbar and gluteal pain assessed by a rheumatologist; b) 26 patients diagnosed with SpA who didn’t have SJ tenderness and had normal physical examination; c) control group of 27 subjects (healthy subjetcs or with mechanical lumbar pain). All patients included that were diagnosed with SpA met almost the European Spondyloarthropathy Study Group (ESSG) classification criteria. Physical examination of the SJ included: sacral sulcus tenderness, iliac gapping, iliac compression, midline sacral thrust test, Gaenslen’s test, and Patrick s test were used as gold standard. Both SJ were examined with Doppler ultrasound (General Electric Logiq 9, Wauwatosa WI, USA) fitted with a 9-14 Mhz lineal probe. The ultrasonographer was blinded to clinical data. Doppler in SJ was assessed as positive when both Doppler colour and resistance index (RI) < 0.75 within the SJ area were present. Statistical analysis was performed estimating sensitivity and specificity against gold standard. The Kappa correlation coefficient was used for reliability study. Results: 106 cases (53 female, 55 male; mean age 36 10 years) were studied. There were no statistical differences between groups related to age or sex. Physical examination of SJ was positive in 38 patients (59 sacroiliac joints). US detected Doppler signal within SJ in 37 patients (58 SJ): 33 of them were symptomatic SpA (52 SJ), one of them were asymptomatic SpA (1 SJ) and one was a healthy control (1 SJ). The accuracy of US when compared to clinical data as gold standard at subject level in the overall group was: sensitivity of 68.6% and specificity of 85.7%, positive predictive value of 70.5% and negative predictive value of 84.5%. A positive likelihood ratio of 4.8, a negative likelihood ratio of 0.36 and a kappa coefficient of 0.55 were achieved. Conclusions: Doppler US of SJ seems to be a valid method to detect active SJ inflammation. Disclosure statement: The authors have declared no conflicts of interest.

Objective. The diagnosis of AS is often delayed in primary care. This may partly be due to inability to differentiate inflammatory back pain (IBP) from mechanical. The aim of this study was to assess current practice of general practitioners (GPs) in using clinical, radiological and laboratory investigations to assess patients with IBP.Methods. A postal questionnaire was sent to all GPs in Norfolk. It was designed to test GPs ability to identify symptoms suggestive of IBP in patients with back pain. It also enquired whether GPs considered other features of SpA. Their perceptions of usefulness of various investigations when considering a diagnosis of AS, management and their unmet needs were recorded.Results. A total of 62% of completed questionnaires were returned. Only 5% of GPs could identify all eight features known to be indicative of IBP, 78% between four and eight and 17% identified less than four features. GPs had a range of views regarding the utility of a positive family history, HLA-B27, use of X-ray and physiotherapy in patients with suspected IBP. GPs awareness of the associated features of SpA was low. There were inconsistencies in the use of diagnostic tests and management of AS. Improving musculoskeletal education in primary care was identified as one of the unmet needs by the majority of GPs.Conclusions. In a survey of GPs, we identified inconsistencies in their perceptions and approach to the diagnosis and management of AS. Education in primary care and the wider use of diagnostic algorithms may improve early detection and hence outcome of AS.

The management of ankylosing spondylitis (AS) has been revolutionized by the introduction of anti-tumour necrosis factor (TNF) drugs. The long-standing need for an effective treatment for AS seems to have been met at least partially and at a price. There is ample evidence that treatment with infliximab, etanercept and adalimumab reduces pain and stiffness, greatly enhances the sense of well-being and improves functional outcome in patients with long-standing AS [1–3]. Moreover, this symptomatic improvement is accompanied by a significant degree of reduction in spinal inflammation as detected by magnetic resonance imaging [4–6]. There is no doubt then that, for the first time ever, the outlook for people with AS is radically better. But, in spite of such good news it is clear that much important ground work has not been done—for good reasons—so that critical, unresolved questions remain. The answers to these are all the more critical for a treatment which carries substantial real and potential risk and huge cost. Some of these questions concern the best ways to use biologic treatments, others the balance between cost and benefit. It is no surprise that in a disease that has been all but untreatable research has not focused on these issues in the past but there is no time to lose now in resolving them. The balance of cost and benefit hangs on the kind of long-term benefit biologic treatment confers and the likely necessary duration of treatment. Chief amongst these unanswered questions is: does TNF blockade modify the disease? In recent years the term ‘disease modification’, used in rheumatoid arthritis, has come to refer principally to radiographic progression as a marker of biological change in the affected sites [7]. However, no such clear understanding exists in AS. Disease modification in AS encompasses a combination of spinal movement and function, well-being, comorbidities and radiographic progression including prevention of ankylosis, all reflected in changes from that which would be expected in work capacity, independence and recreational ability. A positive trend towards improvement in spinal measurements (Bath Ankylosing Spondylitis Metrology Index) with anti-TNF therapy has been demonstrated [1, 3] but the changes are not dramatic. Inevitably, as these are relatively insensitive measures, this question will take time to answer. Small but important changes in functional state, reflected by the Bath Ankylosing Spondylitis Functional Index (BASFI) have been consistently demonstrated in AS patients treated with anti-TNF therapy as having significant improvements in patient healthrelated quality of life [8]. Any impact on work and recreation is not yet clear in spite of this being a crucial indicator of true disease modification. Listing et al. [9] showed that infliximab treatment for 2 yrs in a small cohort of patients (n1⁄4 49) led to a reduction in the number of hospital in-patient days and days of sick leave. More recently, van der Heijde et al. [10] showed that infliximab treatment significantly improved the daily productivity of patients with active AS and also reduced workday loss among employed patients with AS. However, no significant improvement in employment status was observed and not many unemployed patients returned to work. This area needs further prospective evaluation. A trend towards deceleration of X-ray progression after treatment with anti-TNF therapy has been reported [11, 12]. However, these were small study samples of short duration. MRI studies have shown a reduction in inflammatory spinal changes [4–6] within a short time of starting anti-TNF treatment. Persistence of inflammation, however, has been seen in a proportion of patients continuing treatment [4, 5]. MRI may not be the perfect tool but its potential use as a predictor of outcome needs urgent clarification. It is clear that the correlation between symptomatic response to treatment and changes in MRI scanning are at best suboptimal. More importantly, it remains unclear whether lesions demonstrable on MRI scanning correlate with subsequent ankylosis and/or socioeconomic outcomes. It is clear that modifying both the biology and outcome of AS is the prime objective of treatment but that both a consensus of what constitutes ‘disease modification’ and essential research to demonstrate it are still lacking.

OBJECTIVES:Rituximab has recently been shown to be effective in suppressing disease activity in patients with rheumatoid arthritis (RA) who fail anti-TNF therapy. We present our experience of treating patients with long-standing, multi-DMARD and anti-TNF resistant RA with rituximab in 'real-life' setting.METHODS:Patients with RA resistant to more than two anti-TNF drugs and with persistent disease activity (DAS28 > 5.1) were considered for treatment with rituximab (two infusions 1000 mg each, a fortnight apart). DAS28 and HAQ scores were performed at baseline, 3 and 6 months post-treatment. Response to rituximab was defined as per the EULAR response criteria. Re-treatment with a second cycle of rituximab was offered if they had responded to the earlier one but flared.RESULTS:Twenty patients received rituximab. Median disease duration was 16 yrs (range 5-39) and 90% were rheumatoid factor positive. Median number of biologics received pre-treatment was two (range 2-4). Rituximab treatment led to a significant reduction in DAS28 score (P < 0.0001) at 3 months and various other disease parameters. The benefit was sustained at 6 months. Moderate-to-good EULAR response was seen in 85% of patients at 3 months and 60% at 6 months. No significant side effects were observed. 50% of the patients flared and received re-treatment. Interval to re-treatment varied from 6 to 18 months. The majority of the RA patients responded to re-treatment with rituximab and no major side effects were observed.CONCLUSION:Rituximab was effective in controlling disease activity in anti-TNF therapy resistant RA patients in 'real-life' setting. Rituximab was safe with no major side effects. Re-treatment with rituximab was safe and efficacy was maintained.

HistopathologyVolume 51, Issue 5 p. 709-712 Methotrexate-associated lymphoproliferative disorder masquerading as interstitial lung disease R N Jois, R N Jois Norfolk and Norwich University Hospital, Norwich, St Thomas Hospital, LondonSearch for more papers by this authorK Gaffney, K Gaffney Norfolk and Norwich University Hospital, Norwich, St Thomas Hospital, LondonSearch for more papers by this authorP Cane, P Cane Norfolk and Norwich University Hospital, Norwich, St Thomas Hospital, LondonSearch for more papers by this authorA G Nicholson, A G Nicholson Royal Brompton Hospital, London, UKSearch for more papers by this authorA C Wotherspoon, A C Wotherspoon Royal Brompton Hospital, London, UKSearch for more papers by this author R N Jois, R N Jois Norfolk and Norwich University Hospital, Norwich, St Thomas Hospital, LondonSearch for more papers by this authorK Gaffney, K Gaffney Norfolk and Norwich University Hospital, Norwich, St Thomas Hospital, LondonSearch for more papers by this authorP Cane, P Cane Norfolk and Norwich University Hospital, Norwich, St Thomas Hospital, LondonSearch for more papers by this authorA G Nicholson, A G Nicholson Royal Brompton Hospital, London, UKSearch for more papers by this authorA C Wotherspoon, A C Wotherspoon Royal Brompton Hospital, London, UKSearch for more papers by this author First published: 09 October 2007 https://doi.org/10.1111/j.1365-2559.2007.02830.xCitations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume51, Issue5November 2007Pages 709-712 RelatedInformation

OBJECTIVES:Infliximab has been shown to be effective in the treatment of ankylosing spondylitis (AS) when treated in a dose of 5 mg/kg at 6 weekly intervals. This dose of infliximab has not been determined by any structured randomized trials and has significant cost implications. We describe our experience of treating AS with low-dose infliximab (3mg/kg at 8 weekly intervals). The efficacy and cost implications are discussed.METHODS:Patients who had active AS [Bath AS Disease Activity Index (BASDAI) > or = 4] were treated with infliximab 3 mg/kg at 0, 2, 6 weeks and thereafter at 8 weekly intervals. Response to treatment was defined as 50% improvement in BASDAI. Other response criteria such as ASAS 20, 40 and five of the six criteria were also assessed. Direct drug costs for infliximab were determined.RESULTS:Twenty-two consecutive AS patients received infliximab. All 22 completed treatment for 3 months, 15 patients for 6 months and 14 for 12 months. Mean age was 45 years (range 21-62) and mean disease duration 14.5 years (range 2-43). Of the patients, 54% achieved a 50% BASDAI response at 3 months and the benefit was sustained at 12 months in 63%. Similar response rate was seen with the other assessment criteria. Direct drug costs were significantly lower when low-dose infliximab regimen was used.CONCLUSIONS:Low-dose infliximab (3 mg/kg at 8 weekly infusions) is effective in the treatment of AS. Higher doses are required in a small proportion of patients when treatment is only partially effective. Titrating the dose and frequency of infusions may be required in individual patients to achieve optimal response. Using low-dose infliximab has significant economic implications.

Chronic periaortitis commonly involves the infrarenal portion of the abdominal aorta. Idiopathic retroperitoneal fibrosis, inflammatory abdominal aortic aneurysm and perianeurysmal retroperitoneal fibrosis are its various clinical presentations. They present as a non-specific systemic inflammatory disorder and may lead to ureteric obstruction and consequent renal failure. An exaggerated inflammatory response to advanced atherosclerosis has been thought to be the main pathogenetic process. Autoimmunity has also been proposed as a contributing factor. Contrast-enhanced CT scanning is the diagnostic test of choice. Steroids and immunosuppressive agents are successfully used in the treatment of idiopathic retroperitoneal fibrosis and selected cases of inflammatory abdominal aortic aneurysm, and surgery is used in others. Early diagnosis is important in order to reduce morbidity from complications such as renal failure and mortality from aortic rupture.