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Objective: To compare the efficacy of arthroscopic lavage plus corticosteroids (ALC), arthroscopic lavage plus placebo (ALP), and joint aspiration plus corticosteroids (JAC) in patients with arthritis of the knee, and to identify clinical or histological factors that predict outcome., Design: Prospective, randomised., Method: Patients with arthritis of the knee (not due to gout, osteoarthritis or septic arthritis) were randomised to 1 of 3 treatment arms: ALC, ALP or JAC. The primary endpoint was time to recurrence; recurrence was defined as recurrent or persistent symptomatic knee swelling requiring local treatment, and/or non-improvement in knee joint score. Synovial tissue specimens were collected for histological analysis., Results: Of the 78 patients enrolled, 3 did not receive the intended therapy and 3 were lost to follow-up. The median time to recurrence was 9.6 months in the ALC group, 3.0 months in the JAC group and 1.0 month in the ALP group. Compared with ALC, the relative risk of recurrence of arthritis (RR) was 2.2 for JAC (95% CI: 1.2-4.2; p = 0.02) and 4.7 for ALP (95% CI: 2.3-9.4; p < 0.0001). In the ALC group, extensive synovial fibrosis was associated with a higher risk of recurrence (RR 5-7; 95% CI: 1.6-20.5; p < 0.01)., Conclusion: Arthroscopic lavage plus corticosteroids was more effective than arthroscopic lavage plus placebo or joint aspiration plus corticosteroids. The absence of synovial fibrosis predicted a beneficial response.

Tumour necrosis factor (TNF) a has been identified through basic research as a molecule that has a central role in the regulation of many autoimmune chronic inflammatory diseases. Experimental and clinical research with TNF antagonists has validated this observation. At this time, TNF blockade is indicated for rheumatoid arthritis, Crohn's disease, ankylosing spondylitis and psoriasis. Recent clinical study with this type of molecularly targeted intervention has determined that chronic inflammatory diseases can share some pathophysiological mechanisms, while others are more specific for certain diseases. Therefore, TNF appears to play a central role in multiple forms of inflammation, but the underlying pathogenic mechanism remains intact during TNF blockade. For this reason, there is much interest in studies of combination therapy in which TNF antagonists are added to other treatments, such as methotrexate. Anti-TNF therapy is expensive; therefore, treatment strategies are needed that are affordable and provide optimal care for groups of patients that do not adequately respond to conventional therapy.

The current pharmacotherapy of rheumatoid arthritis (RA) consists of non-steroidal anti inflammatory drugs (NSAIDs) and disease-modifying antirheumatic drugs (DMARDs) such as sulphasalazine, leflunomide and methotrexate. DMARDs can be given as monotherapy or in combination. However, not all patients show an adequate response due to toxicity or lack of efficacy. From animal studies and clinical studies in patients with RA, we know that tumour necrosis factor (TNF) is directly involved in the pathogenesis of RA. Two forms of TNF inhibition therapy have been extensively investigated in RA: anti-TNF monoclonal antibodies (infliximab) and TNF receptor-Fc fusion protein (etanercept). Both types of TNF inhibition induce a rapid improvement in multiple clinical measures of disease activity and patient functional status. Furthermore, a beneficial effect was demonstrated on radiographic progression of joint damage. Etanercept and the combination infliximab-methotrexate are generally well tolerated.

Remissions of autoimmune diseases can be accomplished in animals by myeloablative chemotherapy followed by allogeneic or autologous bone marrow transplantation. Remissions of autoimmune diseases have been reported in patients with concomitant malignancies for which they were treated with myeloablative chemotherapy followed by stem cell transplantation. Survival of patients with systemic rheumatic autoimmune disease is reduced. Since transplantation related mortality after autologous stem cell transplantation is less than 5%, this treatment becomes a possibility for patients with severe systemic rheumatic autoimmune disease, such as systemic sclerosis.

Slow-acting antirheumatic drugs (SAARDs) are usually prescribed in rheumatoid arthritis only when non-steroid anti-inflammatory drugs can no longer suppress the inflammation or when articular damage is radiologically apparent. It was established recently that articular damage occurs in an early phase of RA. This damage is linked to subsequent disability; to prevent it is the purpose of SAARDs. In view of the short-term reduction of arthritis activity and improvement of function as well as the meanwhile established fact that the side effects of SAARDs are not different from those of other antirheumatic agents, SAARDs should be prescribed in an early phase of RA.

Two previously healthy adults, a man aged 69 and a woman aged 51 years, presented with spondylitis caused by Streptococcus agalactiae. One patient had fever and acute pain in the neck, the other progressive pain in the lower back. From cultures of blood and bone respectively. S. agalactiae was isolated. Both patients recovered after treatment with benzylpenicillin. S. agalactiae (group B streptococcus) is a wellknown cause of invasive infections in neonates and pregnant adults. Infections in nonpregnant adults are increasingly reported. Chronic conditions such as diabetes mellitus are strongly associated with disease caused by S. agalactiae.

Objective: To investigate the occurrence, diagnosis and course of all new inflammatory arthropathies seen in a special Early Arthritis Clinic (EAC)., Design: Prospective cohort study., Setting: Academic Medical Hospital, Leiden, The Netherlands., Methods: An Early Arthritis Clinic (EAC) was started in the outpatient clinic of rheumatology of Leiden University Hospital for diagnostic work-up according to protocol of patients with recent-onset arthritis. Inclusion criteria were: active arthritis with onset < 2 years without traumatic aetiology and no referral for a second opinion., Results: In the first 18 months 276 patients were sent to the EAC, 212 met the inclusion criteria. After 2 weeks the following diagnoses were made: rheumatoid arthritis (RA) (58; 28%), psoriatic arthritis (8; 4%), reactive arthritis (11; 5%) sarcoidosis (9; 4%), crystal arthritis (30; 14%), osteoarthritis (8; 4%), other diagnosis (18; 8%). The remaining 70 patients (33%) were classified as arthritis e causa ignota (e.c.i.). After follow-up, the first diagnoses changed in 27 (12%) patients, of whom 20 patients originally had had the diagnosis of arthritis e.c.i. Persistent arthritis was found in 90% of RA and in 35% of arthritis e.c.i. Other forms of arthritis seldom showed persistent activity., Conclusion: In the EAC, RA, arthritis e.c.i. and crystal arthritis were seen most often. Almost all RA patients showed persistent arthritis, as against only a third of those with arthritis e.c.i. Because of the early diagnosis treatment could start early in patients with joint disease entailing irreversible joint destruction.