Neil McKay

Brief Report: Predicting Functional Disability: One‐Year Results From the Scottish Early Rheumatoid Arthritis Inception Cohort

To identify baseline prognostic indicators of disability at 1 year within a contemporary early inflammatory arthritis inception cohort and then develop a clinically useful tool to support early patient education and decision‐making.

Novel photoplethysmography cardiovascular assessments in patients with Raynaud’s phenomenon and systemic sclerosis: a pilot study

OBJECTIVE Multisite photoplethysmography (PPG) cardiovascular assessments can evaluate endothelial, peripheral autonomic and arterial dysfunction. The aim of this pilot study was to investigate the potential clinical utility of the technology in assessing patients with SSc and primary RP (PRP). METHODS Multisite PPG pulse measurements, a reference ankle brachial pressure index (ABPI) and a full clinical assessment were undertaken for three subject groups: SSc, PRP and controls. Endothelial and autonomic function and arterial disease measures were obtained using pulse wave analysis. RESULTS Nineteen SSc, 19 PRP and 23 control subjects were assessed and compared. Endothelial function was significantly impaired in SSc (P < 0.02), but with no difference between controls and PRP. Receiver operating characteristic-based classification accuracy was 81% (sensitivity 90%, specificity 74%) for separating SSc from controls and 82% (sensitivity 84%, specificity 79%) for separating SSc from PRP. SSc patients with digital ulcers had significantly lower endothelial function compared with those without ulcers (P < 0.05). Autonomic dysfunction was suggested in both SSc and PRP and was most exaggerated in patients with diffuse SSc. All groups had overall normal ABPI and arterial stiffness timing measures. Bilateral timing differences at the toes, which represents peripheral occlusive arterial disease, did show increased asymmetry in SSc (P < 0.02). CONCLUSION Multisite PPG pulse technology showed potential diagnostic ability. By using measures of endothelial function, it differentiated SSc from control and PRP subjects with an accuracy of at least 81%. Objective pulse-derived measures of autonomic function and arterial disease in SSc have also been reported in this pilot study.

Dermatomyositis as presenting feature of ovarian cancer, treated with neo-adjuvant chemotherapy and interval debulking surgery

Highlights • Dermatomyositis in ovarian cancer responds to treatment with neo-adjuvant carboplatin and paclitaxel in conjunction with corticosteroids.• Recurrence of dermatomyositis symptoms is often the first sign of relapsed disease.• Prognosis of ovarian cancer in context of dermatomyositis is poor.

A case of hypocomplementaemic urticarial vasculitis with cardiac valve involvement successfully treated with cyclophosphamide and high-dose glucocorticoids

Dear Editor, Hypocomplementaemic urticarial vasculitis (HUV) is a rare small vessel vasculitis, characterized by urticarial vasculitis and hypocomplementaemia and is associated with potentially life-threatening complications such as rapid progressive glomerulonephritis or necrotizing vasculitis affecting the cardiac valves. Here we present a case of a 24-year-old male primary school teacher who presented to his general practitioner with a 2-month history of urticarial rash affecting his torso (Fig. 1a) and upper limbs. The rash persisted despite oral antihistamines and topical glucocorticoid treatment. Over the following months the patient developed flitting arthralgia of his hands, knees and ankles and bilateral episcleritis (Fig. 1b). A dermatology review, now 7 months after his initial symptoms, noted widespread urticarial lesions. A skin biopsy was performed and showed a neutrophilic necrotizing vasculitis affecting the small vessels within superficial to deep dermis (Fig. 1c,d). Blood tests showed normal hemoglobin and white cell count, thrombocytosis (509 9 10; normal range: 150–400), high inflammatory markers in C-reactive protein (166 mg/L; normal: 0–10) and erythrocyte sedimentation rate (63[0–10] mm/h) and hypocomplementaemia (C3 = 0.35 g/L [normal: 0.73–1.4] and C4 = 0.07 g/L [normal: 0.12–0.3]). Antinuclear antibodies, double-stranded DNA, extractable nuclear antigen and anticyclic citrullinated peptide antibody, antineutrophil cytoplasmic antibodies and anticardiolipin antibodies (IgG and IgM) were negative. His symptoms of morning stiffness and swelling of hands and feet, became more prominent and a musculoskeletal ultrasound confirmed the presence of synovitis and effusion at the second metacarpophalangeal joints of the left hand and the right wrist. A cardiovascular examination at this stage was normal. The symptom complex consisting of chronic urticarial rash, hypocomplementaemia, leukocytoclastic vasculitis, arthritis and bilateral episcleritis led to the diagnosis of HUV. The patient was started on oral prednisolone 20 mg/day and methotrexate 25 mg/week, to which he responded partially with improvement of his arthritis and his complement levels (C3). However, methotrexate had to be discontinued 8 months later because of nausea. Subsequent worsening of symptoms and decreasing complement levels prompted further trials of immunomodulating agents. Hydroxychloroquine 400 mg/day and azathioprine 200 mg/day were stopped after 5 months because of persistent urticaria and episcleritis and the patient was switched to mycophenolate mofetil 2 g/day which was stopped after 8 weeks because of development of neutropaenia. Eighteen months after disease onset the patient was admitted to hospital presenting generally unwell with a troublesome itchy rash, joint pains and new onset palpitations. Clinical examination revealed an ongoing urticarial rash, episcleritis and Jaccoud’s arthropathy of both hands. A transthoracic echocardiogram now demonstrated moderate to severe aortic regurgitation with preserved left ventricular function. Infective endocarditis was excluded and a subsequent magnetic resonance imaging (MRI) confirmed severe aortic regurgitation most likely as a result of a necrotizing vasculitis as previously reported. At this stage the hypocomplementaemia was more pronounced, inflammatory markers were markedly raised (Table 1) and C1q levels 90 mg/L (50–250) and C1q antibody levels 2 U/mL (< 10), obtained after initiation of high-dose glucocorticoids, were within normal range. Prednisolone 1 mg/kg daily and intravenous cyclophosphamide 15 mg/kg were commenced. After six courses of cyclophosphamide his general condition, skin and eye symptoms improved remarkably, his joint symptoms resolved, inflammatory markers improved and complement levels normalized (Table 1). To date, successful clinical and serological remission has been maintained with mycophenolate

Soft tissue swellings in the foot: Rheumatoid nodulosis

Background rheumatoid nodulosis is a rare disease characterised by multiple subcutaneous nodules, a high titre of rheumatoid factor, radiologically detectable cystic bone lesions, but with none or few of the systemic manifestations or joint activity of rheumatoid disease. Histopathologically, nodulosis is the same as the nodules found in rheumatoid arthritis. It is considered to be a benign variant of rheumatoid arthritis. A 69 year old male presents with multiple subcutaneous nodules on the feet. This case study highlights the benefits of ultrasound in establishing a correct diagnosis and management. Although rare, rheumatoid nodulosis is a consideration in the differential diagnoses of soft tissue swellings in the feet.

Level of agreement between three-dimensional volumetric ultrasound and real-time conventional ultrasound in the assessment of synovitis, tenosynovitis and erosions in rheumatoid arthritis patients

The aim of the study was to assess agreement between three-dimensional volumetric ultrasound (3D US) performed by inexperienced staff and real-time conventional ultrasound (2D US) performed by experienced rheumatologists in detecting and scoring rheumatoid arthritis (RA) lesions. Thirty-one RA patients underwent examination of seven joints by 2D and 3D US for synovitis and tenosynovitis in B and PD modes and erosions in B mode. A global score for synovitis and global counts for synovitis, tenosynovitis and erosions were also calculated for every patient. Agreement between 2D and 3D US was analysed for counts and scores at the patient level with the intraclass correlation coefficient (ICC) and for counts at the joint level with Cohen’s kappa coefficient. B-mode synovitis was detected at a median of five joints in each patient, frequently in wrists and hand joints but less frequently in foot joints. PD-mode synovitis, tenosynovitis and erosions were detected less frequently. All ICCs for agreement between 2D and 3D US findings were significant. All kappa coefficients were significant for B- and PD-mode synovitis and for erosions (except PIP3), while those for tenosynovitis were only significant for MCP2 (B and PD modes) and PIP2 (B mode). Although the 3D US volumes were acquired by inexperienced operators, agreement between 2D and 3D US was acceptable in detecting and scoring synovitis. A higher level of agreement was attained for patient-level global scores and counts than for individual joints.

Predicting functional disability: One year results from the Scottish Early Rheumatoid Arthritis Inception Cohort

To identify baseline prognostic indicators of disability at 1 year within a contemporary early inflammatory arthritis inception cohort and then develop a clinically useful tool to support early patient education and decision‐making.

Brief Report: Predicting Functional Disability: One-Year Results From the Scottish Early Rheumatoid Arthritis Inception Cohort: PREDICTORS OF FUNCTIONAL DISABILITY AT 1 YEAR IN RA

To identify baseline prognostic indicators of disability at 1 year within a contemporary early inflammatory arthritis inception cohort and then develop a clinically useful tool to support early patient education and decision‐making.