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Objectives. Treatment for rheumatoid arthritis (RA) should aim to achieve full remission. The aim of this study was to investigate predictors of persistent subclinical synovitis and whether longer clinical remission is effective in reducing subclinical synovitis. Methods. Forty-four RA patients who achieved DAS28ESR clinical remission for at least 3 months were enrolled in this study and underwent ultrasound examination of 22 joints (bilateral proximal interphalangeal joints, metacarpophalangeal joints, and wrists); bilateral hand X-ray; and blood examination. The severity of synovial effusion, synovial hypertrophy, and blood flow were semi-quantitatively graded from 0 to 3 using gray-scale (GS) and power Doppler (PD) modes. Results. Among patients with DAS28ESR-defined clinical remission, 59.1% (26/44) demonstrated residual synovitis (≥ PD1) in at least one joint. Genant-modified total Sharp score (TSS) demonstrated the highest statistical difference between patients with and without residual subclinical synovitis ( p = 0.0057), and full remission was only observed in patients with low TSS. A nonsignificant trend for decreased residual synovitis with longer sustained clinical remission was also observed ( p = 0.724). Conclusion. Residual synovitis can persist during clinical remission, particularly in patients with progressive bone destruction. Early treatment and longer sustained clinical remission prior to bone destruction are critical for full remission. [ABSTRACT FROM AUTHOR]

B cell activating factor (BAFF) and a proliferation-inducing ligand (APRIL) are known to be crucial for B cell maturation and survival, and increased expression of these factors in various autoimmune diseases has been reported. Human B cells produce two IgA subclasses: IgA1 and IgA2, the latter being abundant in the distal intestine, saliva, colostrum and bronchial fluid. We investigated these parameters in patients with mixed connective tissue disease (MCTD) complicated by interstitial lung disease (ILD+), and compared them with those in MCTD patients without ILD (ILD−). Sixty-three MCTD patients were divided into two groups: 21 ILD+ patients and 42 ILD− patients. In each patient group we analyzed soluble BAFF/APRIL using ELISA, and IgA1 and IgA2 using double immunodiffusion. Furthermore, we analyzed BAFF-APRIL receptors, BCMA, BAFF-R and TACI, using flow cytometry. The ILD+ patients had significantly higher levels of BAFF/APRIL than the ILD− patients. There were significant correlations between BAFF/APRIL, BAFF/KL-6 and APRIL/KL-6. Although there was no significant inter-group difference in the serum IgA1 level, ILD+ patients had a significantly elevated IgA2 level in comparison with ILD− patients. Moreover, although there were no significant inter-group differences in the expression of BCMA, BAFF-R and TACI on B cells, the expression of BAFF-R was significantly decreased in the ILD+ patients. In recent years, relationships between BAFF/APRIL and IgA subclass have been reported. Our results suggest that an elevated level of BAFF/APRIL drives the maturation of B cells, subsequently leading to IgA2 class switching, and possibly to the development of ILD in patients with MCTD. [ABSTRACT FROM AUTHOR]

Objective: To clarify the clinical features of systemic lupus erythematosus (SLE) patients, factors associated with flares, and changes over time., Methods: Patients having SLE with a visiting history were entered into the Juntendo University Database of Erythematosus. We included 423 cases in the long-term follow-up analysis, and 383 cases were followed for 10 years after the initiation of any therapeutic intervention (comparative analysis: 1973-1982, 82 cases; 1983-1992, 141, and 1993-2002, 160). We assessed changes in the patients' background characteristics, disease symptoms, flare rates, etc., Results: Among the 423 cases, the mean follow-up period was 25.9 years, and mean number of flares was 0.51. Of those, 31.9% had ≥1 flares. Thrombocytopenia at onset contributed to the flares. For disease symptoms at onset, a recent trend in increasing thrombocytopenia was observed. The combination rate of immunosuppressive agents for diseases other than lupus nephritis was slightly increased, and there was no improvement until the first flare or in the flare rate., Conclusions: Thrombocytopenia at onset is predictive factor for flares. Since SLE is a diverse disease with varying symptoms at recurrence, the treatment guidelines should be improved for thrombocytopenia from a long-term perspective.

Objective: To determine the degree of contribution and the contributing factors of ultrasound in the diagnosis of rheumatoid arthritis (RA) in daily clinical practice and the predictive differences depending on seropositivity., Methods: We included 122 patients who presented with the main complaint of finger and/or wrist joint pain but for whom no definite diagnosis was reached or treatment strategy was provided. Ultrasound was performed on at least 22 joints (both wrist joints, proximal interphalangeal joint, and metacarpophalangeal joints), and patients were followed for ≥6 months. Factors contributing to RA diagnosis were determined and compared between seropositive and seronegative RA patients., Results: RA was diagnosed in 52 of 122 patients, in whom the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) classification criteria (odds ratio [OR] = 4.74, P = 0.01) and gray scale (GS) grade of 3 (OR = 3.64, P = 0.04) for ≥ 1 joint were the contributing factors. In seropositive RA, the ACR/EULAR criteria (OR = 15.53, P < 0.001) and power Doppler (PD) ≥ 2 for ≥ 1 joint (OR = 10.48, P = 0.0048) were the contributing factors. In seronegative RA, PD ≥ 1 for ≥ 1 joint contributed the most (OR = 20.00, P = 0.0044), but the ACR/EULAR criteria did not contribute to RA diagnosis (P = 0.57)., Conclusion: Ultrasound findings contributed to RA diagnosis in clinical practice. The contributing factors are different in the presence or absence of seropositivity, and ultrasound complementation was particularly useful in seronegative RA patients.

Objectives: The purpose of this study was to determine if routine clinical measures can predict the presence and severity of ultrasound synovitis in rheumatoid arthritis (RA) patients., Methods: Bilateral 1-5 MCP (metacarpopharangeal) and wrist joints were examined using power Doppler (PD) ultrasound (US). Correlations between PD scores and routine clinical measures of RA - swollen joint count (SJC), tender joint count, patient's global assessment (GA), physician's GA, CRP, ESR, MMP-3, RF and anti-CCP antibody - were determined and used to identify significant predictors of PD score. Clinical measures were then compared between two groups (patients with and without PD) and analysed using multiple logistic regression, to derive a model that predicted the absence of PD signals., Results: SJC was the most significant predictor of PD score (R2 = 0.4566, p value <0.0001), but was an inadequate predictor of PD signal remission. However, the combination of Steinbrocker's stage I or II (odds ratio [OR] 9.23, p=0.0049), SJC=0 in 1-5 MCP and wrist joints on both sides (OR 6.60, p=0.0039), and SDAI (or CDAI) remission (OR 5.06, p=0.0450) had a positive predictive value of 100%, predicting the absence of PD signals in all study patients meeting the 3 criteria., Conclusions: PD score and absence of PD signals can be predicted using routine clinical measures. When used in combination, Steinbrocker's stage, SJC and SDAI (or CDAI) can estimate disease activity and identify patients likely to have synovitis and requiring US.

Objectives: Ultrasound (US) examination can visualise and clarify involved joints anatomically in patients with rheumatoid arthritis (RA), and it enables physicians to verify the accuracy of clinical assessments of involved joints. Here, we studied the practical 'miscount'- calculated by subtracting US-determined involved joint count from clinically determined involved joint count - and analysed possible contributing factors for increased miscount., Methods: The study population consisted of 137 patients with RA. Physical joint examination was performed by 3 assessors with different levels of experience in rheumatology, followed by US joint examination. Clinical and US examinations were performed on 28 joints (proximal interphalangeal, metacarpophalangeal, wrist, elbow, shoulder, and knee on both sides). Miscount was calculated for all patients, and multivariate analysis was conducted on possible contributing factors for miscount, including age, sex, body mass index, disease duration, Steinbrocker stage, erythrocyte sedimentation rate (ESR), C-reactive protein level, patient global assessment (GA), evaluator GA, matrix metalloproteinase-3 level, and power Doppler (PD) score., Results: A high variability in concordance rate among the joint sites was observed among the 3 assessors. The average miscount was 1.07 (SD, 5.19; range, 18 to -11). ESR and patient GA were determined as significant contributing factors for false-positive miscount, whereas PD score and age were significant factors for false-negative miscount., Conclusions: In addition to the condition of the involved joint distribution and the assessor's clinical examination skills, the patients' background can also lead to increased miscount. Assessors should be blinded to patients' background information, and US complementation should be included in usual clinical joint examinations.

Twenty patients with collagen diseases complicated with Pneumocystis pneumonia (PCP) were retrospectively examined in reference to the criteria for its protective therapy provided by the Ministry of Health Labor and Welfare. The breakdown of 20 patients was rheumatoid arthritis (RA) in 5 cases, systemic lupus erythematosus (SLE) in 5, dermatomyositis (DM) in 2, systemic scleroderma (SSc) in 1, mixed connective tissue disease (MCTD) in 1, Sjögren syndrome (SjS) in 1, polyarteritis nodosa (PN) in 3, rapidly progressive glomerulonephritis (RPGN) in 1, Schönlein-Henoch purpura in 1. Patients having interstitial pneumonia (IP) or renal dysfunction before acquiring PCP showed poor prognosis. High level of beta-D glucan was observed in all patients, and elevated levels of LDH and KL-6 were also characteristic of PCP. For the treatment of their own collagen diseases, high dose steroids had been given in 11 patients (55%), and immunosuppressive agents in 12 (60%), resulting in severe suppression of immune function in these patients. They were treated with Sulfamethoxazole/trimethoprim (ST) after Pneumocystis infection, however, 10 patients died and 8 of them died of respiratory failure in spite of high dose steroids. Nine patients fulfilled the criteria for PCP protective therapy provided by Ministry of Health Labor and Welfare, and 7 of them died of respiratory failure. The frequency of PCP remarkably decreased in our hospital after we had started the protective therapy with ST using the criteria, suggesting that it is effective for the protection of PCP. However, some patients who do not fulfill the criteria may acquire severe PCP.