Proceedings of the Irish Soc for Rheumatology and Irish - IJMS | Irish ...

VOLUME 175 NUMBER 3 JULY, AUGUST, SEPTEMBER 2006 

2006;175(3) es2:1-102 

Proceedings of the Irish Soc for Rheumatology and Irish Rheumatology Health Professionals Society AGM 

September 2006

Proceedings of the Irish Soc for Rheumatology and Irish Rheumatology Health 

Professionals Society AGM September 2006 

ORAL PRESENTATIONS 

1. ORAL PRESENTATION: Plenary Session 

SHORT TERM CHANGES IN BIOMARKERS OF TYPE II COLLAGEN 

SYNTHESIS AND DEGRADATION PREDICT RADIOGRAPHIC 

PROGRESSION AFTER ONCE YEAR FOLLOWING INITIATION OF 

BIOLOGICAL THERAPY IN PATIENTS WITH INFLAMMATORY 

EROSIVE ARTHRITIS 

R.H. Mullan 1 , C. Matthews 1 , B. Bresnihan 1 , O. FitzGerald 1 , A.R. Poole 2 , U. 

Fearon 1 , D.J. Veale 1 

1 St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland, 2 Shriners 

Hospital, Cedar Avenue, Montreal, Quebec, Canada 

Aim: To investigate the predictability of short term changes in the serum of 

type II collagen (CII) degradation biomarkers C2C, C1,2C and the biomarker 

for the synthesis of type II procollagen (CPII) with one-year radiographic 

progression, in patients following initiation of biological therapy for 

inflammatory arthritis. 

Methods: Serum levels of biomarkers were measured at baseline, 1, 3, 6, 9 and 

12 months after initiation of biological therapy. A composite score reflecting 

changes in all three biomarkers from baseline (∆COL) was calculated. 

Associations with DAS28 clinical responses and radiographic progression using 

the modified Sharp/van der Heijde system (SHS) were assessed. 

Results: The 1-year SHS increase correlated with the one-month change in 

C2C (r =0.311, P=0.028) and ∆COL (r =0.342, P=0.015). Radiographic 

progression was predicted by increased C2C at one month (P=0.031) and C1,2C 

at three months (P=0.042). ∆COL significantly associated with one-year 

radiographic progression after 1 (P=0.022), 3 (P=0.015), 6 (P=0.048), and 9 

months (P=0.019) of therapy. Clinical remission was predicted by the onemonth 

fall in C2C to 92ηg/ml versus 141ηg/ml non-remission (P=0.008) and 

C1,2C (336 versus 389ηg/ml; P=0.036). By regression analysis, one month 

changes in C2C, C1,2C and CPII were independently associated with, and 

correctly predicted radiographic outcome in 88% of patients. 

Conclusion: Short term serum collagen biomarker changes following initiation 

of biologic therapy predict long term clinical and radiographic outcomes. 

Collagen biomarkers may therefore be valuable new early indicators of short 

term biologic treatment efficacy in clinical trials and in the treatment of patients 

with inflammatory erosive arthritis.




LACK OF INFLUENCE OF METHOTREXATE OR 

CORTICOSTERIOD THERAPY ON THE OUTCOME OF MANTOUX 

TESTING FOR LATENT TUBERCULOSIS IN PATIENTS WITH 

INFAMMATORY ARTHRITIS 

T. Rooney, P.J. Kavanagh, F.D. O'Shea, A. Cassidy, N. Ferris, S. Donnelly, 

G.M. McCarthy, C.J. McCarthy 

Department of Rheumatology, Mater Misericordiae University Hospital, Dublin 

7, Ireland 

Aim: To examine the effects of current methotrexate (MTX) and corticosteroid 

therapy on the outcome of mantoux testing in patients being screened for latent 

tuberculosis (LTB) prior to biologic therapy for inflammatory arthritis. 

Methods: All patients undergoing screening for LTB prior to commencing anti 

– cytokine therapy at the Mater Misericordiae Hospital department of 

Rheumatology from November 2000–April 2006 were included in the study. 

Patients were stratified into 4 groups according to whether they were receiving 

concomitant MTX, corticosteroid, neither, or both. For each group, the 

proportion of patients testing mantoux positive was calculated. Chi-square 

testing was used to examine differences between groups. 

Results: A total of 220 patients (158 female and 62 male) were screened for 

LTB. Mean (range) age was 50 (18–80) years. The underlying diagnoses were: 

rheumatoid arthritis (n = 161), psoriatic arthritis (n = 31), ankylosing spondylitis 

(n = 19), others (n = 9). 

Of the total patient group, 14.2% were receiving corticosteroid alone, 39% MTX 

alone, 26% both and 22% neither corticosteroid nor MTX. The proportions of 

patients who exhibited a positive mantoux test in each of these groups were, 

respectively, 26.7% and 26.8% in patients receiving corticosteroid or MTX as 

monotherapy, 40.7% in patients receiving both therapies and 41.3% in patients 

receiving neither. The differences between these proportions were not 

statistically significant. 

Conclusion: In patients being screened for LTB prior to biologic therapy for 

inflammatory arthritis, concomitant MTX or corticosteroid therapy does not 

significantly influence the outcome of mantoux testing.



3. ORAL PRESENTATION: 

Session A: Inflammatory Arthritis: Synovium and Angiogenesis 

INVESTIGATION OF HLA-Cw6 AND THE SHARED EPITOPE WITH 

PSORIATIC ARTHRITIS 

P. Ho, A. Barton, J. Worthington, W. Thomson, A. Silman, I.N. Bruce 

ARC-Epidemiology Unit, University of Manchester, Manchester, UK 

Background: Previous studies in psoriatic arthritis (PsA) have suggested that 

the association with HLA-Cw6 has been primarily with psoriasis. HLA- 

DRB1*07 and HLA-DRB1*04 have been associated with PsA, whilst HLA- 

DRB1*03, HLA-DRB1*04 and the shared epitope (SE) have been associated 

with erosive disease. The aim of this study was to test the association of HLA- 

Cw6 and the HLA-DRB1 gene with PsA susceptibility and disease severity. 

Methods: DNA was available for 480 UK Caucasian PsA patients and 467 

controls. HLA genotypes were determined using commercially available kits 

(http://www.dynalbiotech.com/). Allele frequencies were compared between 

PsA cases and controls using the χ 2 test. Within the PsA cohort, logistic 

regression was used to determine whether HLA-Cw6 and the SE predicted 

disease severity. 

Results: The characteristics of PsA cohort are shown (Table 1). HLA-Cw6 was 

associated with PsA patients with Type I psoriasis (OR 5.0, 95% CI 3.1 – 8.2, 

p= 4.4x10 -13 ), but not type II psoriasis (p=0.70). No association of the SE with 

PsA susceptibility was detected. Within the PsA cohort, patients carrying the 

HLA-Cw6 phenotype had fewer damaged (30%, 95% CI 13 – 44%, p = 0.001) 

and involved joints (20%, 95% CI 5 – 32%, p = 0.01). HLA-DRB1*07 was 

found to be in LD with HLA-Cw6 (r 2 = 0.46) and showed similar associations 

with PsA. The SE was not associated with disease severity. 

Conclusion: HLA-Cw6 is in LD with HLA-DRB1*07 and both are associated 

with PsA in patients with Type I psoriasis suggesting that the association is 

primarily with psoriasis. However, when present in PsA patients, they predict 

milder arthritis. 

Table 1: Characteristics of the PsA cohort (n=480) 

Gender Female = 275 (57%) 

Family history of psoriasis/arthritis 236 (49%) / 34 (7%) 

No. of involved /damaged joints Median 9 IQR (4-17) / Median 6 IQR (2 –15) 

Type I psoriasis (age onset ≤40) 354/477 (74%) 

Duration of psoriasis/arthritis Median 20 (IQR 9 – 33) / Median 10 (IQR 5– 

19) 

RF + (titre ≥ 1/40) 81 (17%) 

HAQ Median 1.25 (IQR 0.25 – 1.875)




Session A: Inflammatory Arthritis: Synovium and Angiogenesis 

ONCOSTATIN M AND IL-17 REGULATE MATRIX TURNOVER AND 

CARTILAGE DEGRADATION IN RA SYNOVIOCYTES AND HUMAN 

CARTILAGE EXPLANTS 

E.M. Moran, B. Bresnihan, O. FitzGerald, D.J. Veale, U. Fearon 

Department of Rheumatology, St. Vincent’s University Hospital and Conway 

Institute of Biomedical & Biomolecular Research, Dublin, Ireland 

Introduction: OSM and IL-17 are raised in the RA joint and correlate with 

markers of inflammation and cartilage destruction. 

Aim: To explore the mechanistic role of TNFα, OSM and IL-17 alone and in 

combination on matrix turnover and cartilage degradation. 

Methods: Primary RA synovial fibroblasts (SFC) and human cartilage explants 

were stimulated with TNFα (10ng/ml), OSM (10ng/ml) and IL-17 (50ng/ml) 

alone and in combination over a time course of 0-21 days. MMP-1 and TIMP-1 

expression in culture supernatants was measured by ELISA. Cartilage explants 

were histologically assessed and proteoglycan depletion was measured by 

Safranin-O/Fast Green staining. 

Results: OSM and IL-17 significantly stimulated MMP-1 production in human 

cartilage explants (p< 0.05) and in RASFC (p< 0.05) at day 4, an effect that was 

increased to day 17. In cartilage, OSM potentiated the effects of TNFα and IL- 

17 on MMP-1 production two fold (p< 0.05). The combination of IL-17 and 

TNFα had no further effect on MMP-1 production compared to either cytokine 

alone. OSM potentiated the effect of TNFα on MMP-1 production in RASFC 

(two fold), but did not potentiate the effect of IL-17. A shift in the relative ratio 

of MMP-1 to TIMP- in favour of matrix degradation in both RASFC and 

cartilage explants was demonstrated. Safranin-O stained cartilage sections 

demonstrated minimal proteoglycan depletion in response to TNFα, OSM and 

IL-17 alone but in combination resulted in almost complete proteoglycan 

depletion following 4 weeks culture. 

Conclusion: OSM, IL-17 and TNFα play a critical role in matrix turnover and 

cartilage invasion.




Session D - Hypothesis-Generating and Hypothesis-Driven Research: 

Application in Rheumatic Diseases 

THE PROTEOME OF DISEASE PROGRESSION IN JUVENILE 

IDIOPATHIC ARTHRITIS 

D. Gibson 1 , S. Blelock 1 , J. Curry 1 , A. Healy 1 , S. Pennington 2 , M. Dunn 2 , M. 

Rooney 1 

1 Arthritis Research Group, Musculoskeletal Education and Research Unit, 

Queen's University Belfast Musgrave Park Hospital, Belfast, BT9 7JB, 

2 Proteome Research Centre, Conway Institute, University College Dublin, 

Belfield, Dublin 4 

Aim: The synovial proteome was investigated to isolate a subset of biomarkers 

that are significantly over or under expressed in Juvenile idiopathic arthritis 

(JIA) patients displaying disease progression. These proteins could act as novel 

prognostic tools. 

Method: Serial synovial fluid (SF) and matched plasma samples were obtained 

from 49 JIA patients: 25 with oligoarticular arthritis, 7 extended oligoarticular 

and 18 polyarticular disease. Samples were pooled for each clinical subgroup, 

labelled with Cye dyes to differentiate plasma and SF, and subjected to protein 

separation by 2-dimension electrophoreisis (2DE). Focused gels were fixed, 

scanned and protein intensities quantified by software analysis. 20 protein spots 

were picked, digested by trypsin and extracted. Protein digests were identified 

by nanoelectrospray-ionisation with a ThermoFinnegan LCQ Deca ion trapmass 

spectrometer. 

Results: 2DE-DIGE reveals ~680 spots per gel within the pH 4-7 range for 

synovial fluid and plasma. On comparison of plasma and synovial gel scans, a 

subpopulation of spots uniquely expressed in synovial fluid, were identified. 

The expression levels of 12 synovial protein spots correlated positively with 

clinical and laboratory indices of disease progression. Furthermore they were 

over represented in those patients with inflammation spread to multiple joints 

(p



Saturday, 16 th September 2006 


OMEGA-3 FATTY ACIDS REDUCE PRODUCTION OF PRO- 

INFLAMMATORY PROSTANOIDS PGE 2 AND PROSTACYCLIN, AND 

INCREASE PRODUCTION OF ANTI-INFLAMMATORY 15D-PGJ 2 BY 

OSTEOARTHRITIC SYNOVIAL FIBROBLASTS TREATED WITH 

BASIC CALCIUM PHOSPHATE CRYSTALS 

B. McDonnell 1 , E.S. Molloy 1,2 , J. O’Byrne 3 , M.P. Morgan 1 , G.M. McCarthy 1,4 

1 Department of Molecular and Cellular Therapeutics, Royal College of 

Surgeons in Ireland, 123 St. Stephen’s Green, Dublin 2, Ireland, 2 Department of 

Rheumatic and Immunologic Diseases, Cleveland Clinic Foundation, Cleveland, 

Ohio, USA, 3 National Orthopaedic Hospital, Cappagh, Dublin 15, Ireland, 

4 Department of Rheumatology, Mater Misericordiae University Hospital, Eccles 

St., Dublin 7, Ireland 

Aim: Intra-articular basic calcium phosphate (BCP) crystals are implicated in 

osteoarthritis (OA) and amplify prostaglandin E 2 (PGE 2 ) and prostacyclin 

production in osteoarthritic synovial fibroblasts (OASF). 1 Eicosapentanoic acid 

(EPA) and docosahexanoic acid (DHA) are metabolised by cyclooxygenase 

enzymes and appear to have anti-inflammatory effects in arthritis. 2 We 

investigated the effect of omega-3 fatty acids on PG production in OASF cells 

treated with BCP crystals. 

Method: OASF obtained at the time of joint replacement surgery were cultured 

in monolayer. Quiescent cells were enriched with EPA or DHA (50µM) for 

24hours prior to stimulation with BCP crystals (18µg/cm 2 ). PG production was 

measured by enzyme immuno-assay and statistically analysed using the 

unpaired T-test. 

Results: Treatment with BCP crystals resulted in increased PGE 2 and 

prostacyclin production in OASF by approximately 10-fold and 5-fold 

respectively over untreated cells, with maximal induction after 4hours. 

Treatment of BCP-stimulated OASF with EPA and DHA (50µM) resulted in a 

statistically significant (p≤0.05) reduction in PGE 2 and prostacyclin levels at 

4hours. DHA treatment also resulted in a three-fold increase in production of 

15d-PGJ 2 , in contrast to a small increase (0.5 fold) in EPA treated cells. 

Conclusions: EPA and DHA reduce the pro-inflammatory effects of BCP 

crystals on OASF cells via a reduction in PGE 2 . Production of prostacylin 

which is implicated in inflammation, nociception and angiogenesis is also 

reduced. The increased production of 15d-PGJ2 may enhance an antiinflammatory 

effect through its role as an endogenous ligand for the intranuclear 

receptor PPARgamma and we propose to investigate this further. These data 

highlight the potential beneficial effects of omega-3 fatty acids in BCP-crystal 

associated OA.



1 Morgan MP, Whelan LC, Sallis JD, McCarthy CJ, Fitzgerald DJ, McCarthy 

GM. Basic calcium phosphate crystal-induced prostaglandin E2 production in 

human fibroblasts: role of cyclooxygenase 1, cyclooxygenase 2, and interleukin- 

1beta. Arthritis & Rheumatism. 2004 50 (5) 1642-9 

2 Curtis CL, Rees SG, Little CB, Flannery CR, Hughes CE, Wilson C, Dent CM, 

Otterness IG, Harwood JL, Caterson B. Pathologic indicators of degradation and 

inflammation in human osteoarthritic cartilage are abrogated by exposure to n-3 

fatty acids. Arthritis & Rheumatism 2002 46 (6) 1544-53




SINGLE NUCLEOTIDE POLYMORPHISMS WITHIN ADEDOSINE 

RECEPTOR A2a ARE ASSOCIATED WITH GASTROINTESTINAL 

(GI) ADVERSE EVENTS ON MTX THERAPY 

S.L. Hider 1 , L.F. Mack 1 , D.J. Armstrong 2 , M.F. Shadforth 3 , I.N. Bruce 1 , 

W.Thomson 1 

1 Arc Epidemiology Unit, University of Manchester, Manchester UK, 

2 Department of Rheumatology, Musgrave Park Hospital, Belfast, 

3 Rheumatology Department, University Hospitals of North Staffordshire, Stoke 

on Trent, UK 

The effect of methotrexate (MTX) in RA is in part mediated via adenosine 

release acting at the adenosine A2a receptor (ADORA2a). 

Aim: To determine whether single nucleotide polymorphisms (SNPs) in the 

ADORA2a gene are associated with increased toxicity or efficacy in RA 

patients with well defined outcomes after taking MTX. 

Methods: 309 Caucasian RA patients (74% female) who had received MTX 

and had one of 3 outcomes were recruited into the study. Patients were 

classified as very good responders (n=147) (ESR 6/12), inefficacy 

failures (n=101) (physician statement+ failure to reduce ESR by 20%) or side 

effect failures (61) (verified by medical record review). Adverse events were 

further sub-divided into GI (nausea and diarrhoea n=24), abnormal LFTs (n=20) 

or other (n=17). 8 SNPs within ADORA 2a were genotyped using Sequenom 

MALDI-TOF platform. 

Results: Of 8 SNPs, 2 were non-polymorphic and one was at low frequency. 

Five SNPs within ADORA2a were associated with an increased odds ratio for 

stopping MTX for adverse events (Table 1). Analysis by adverse event type 

showed that the association was specifically confined to GI toxicity with odds 

ratios of 1.92-2.32 (P



rs 5760410 5’ 47 42 1.5 (0.93-2.44) 0.07 2.36 (1.2-4.9) 0.009 

rs 2298383 5’UTR 35 50 1.72 (1.07-2.76) 0.02 2.16 (1.06-4.42) 0.02 

rs 3761422 1 st intron 47 32 1.86 (1.17-2.96) 0.005 2.32 (1.19-4.52) 0.007 

rs 2267076 1 st intron 44 30 1.8 (1.12-2.88) 0.009 1.93 (0.97-3.08) 0.04 

rs 2236624 2 nd intron 34 22 1.86 (1.12-3.05) 0.009 2.28 (1.13-4.53) 0.01




SPECIALIST INTERVENTIONS IN THE RHEUMATOLOGY 

OUTPATIENT CLINIC 

M.C. Wray, F.M. Pollock, G.D. Wright 

Rheumatology Department, Royal Victoria Hospital, Belfast, Northern Ireland 

We believe there is a perception that patients with chronic rheumatological 

conditions who attend hospital clinics on a regular basis require little change in 

their management and that many of these patients could be discharged to 

primary care. 

Methods: Over a 6 week period we reviewed the charts of 253 consecutive 

patients who had been attending the rheumatology outpatient clinic for more 

than 12 months. Their diagnosis and number of current disease modifying antirheumatic 

drugs (DMARDs) was recorded as well as all specialist interventions 

undertaken by the rheumatology team over the preceding 12 months. 

Results: The majority of patients under long term review had chronic 

inflammatory arthritis. Rheumatoid arthritis (47%) was the largest patient group 

followed by psoriatic arthritis (14%), osteoarthritis (13%), SLE (6%), 

ankylosing spondylitis (4%), other (16%). 61% of patients were taking at least 1 

DMARD. 90% of patients had at least 1 intervention, the median (31%) had 2 

interventions, mean number of interventions per patient was 2.07. 30% of 

patients had received an intra-articular or soft tissue injection. 32% had had a 

radiological examination. 30% had an adjustment to DMARD therapy. 26% 

had an adjustment to analgesia/anti-inflammatory medication. 20% referred to 

other members of the rheumatology multidisciplinary team. 

Conclusions: Only 10% of long term review patients required no intervention 

in a 12 month period. This study illustrates that patients with chronic 

rheumatological diseases require long term specialist care with appropriate 

adjustments to treatment, management of flares and access to the 

multidisciplinary team.




PROVISION OF RHEUMATOLOGY SERVICES FOR PATIENTS 

WITH RHEUMATOID ARTHRITIS (RA) IN IRELAND 

O. FitzGerald 1 , M. Doran 2 , J. Church 3 , A. Gilbert 3 

1 Department of Rheumatology, St. Vincent’s Hospital, Dublin, Ireland, 

2 Department of Rheumatology, St. James’s Hospital, Dublin, Ireland, 

3 Arthritis Ireland, Dublin, Ireland 

Aims: Rheumatoid Arthritis (RA) affects approximately 40,000 people in 

Ireland. Arthritis Ireland (AI) conducted a survey in 2005 to explore a number 

of issues affecting RA patients in Ireland. These included quality of life 

(QoL), access to services, waiting times and treatment choice, and the effect 

RA has on the workplace. 

Method: RA patients attending outpatient clinics were asked to complete a 

QoL questionnaire (SF-36) and telephone survey. 91 consented to take part. 

Results: Of the respondents, 79% were aged 1 week off work in the last 12 months due to their arthritis. 20% had 

had to wait >1 year for an initial rheumatology appointment, and over 25% 

had not seen their consultant rheumatologist in the last year. When patients 

were asked about their preferred route of administration on biologic therapies, 

61% of respondents claimed to prefer intravenous infusion over subcutaneous 

injection. Quality of life for RA patients was shown to be far below the adult 

norm. 

Conclusions: Many patients with RA are limited in their ability to work. 

There is a lack of consultant rheumatologists in Ireland meaning that many RA 

patients do not even get to see their rheumatologist once in a year. Access to 

biologic treatment by infusion remains a problem, with inadequate funding 

and facilities for administering these treatments in many hospitals.



SCIENTIFIC POSTERS 

POSTERS 

1. JUNB EXPRESSION IN PSORIATIC ARTHRITIS SYNOVIUM AND 

SKIN PRE- AND POST-TREATMENT WITH ETANERCEPT 

E. Pontifex 1 , M. Gogarty 1 , E. Murphy 2 , B. Bresnihan 1 , D. Veale 1 , O. 

FitzGerald 1 

1 St.Vincent’s University Hospital, Dublin, Ireland; 2 Conway Institute of 

Biomolecular and Biomedical Research, University College Dublin, Dublin, 

Ireland 

A recent study(1) showed that epidermal deletion of JunB and c-Jun in a 

mouse model resulted in the phenotype of psoriasis(Ps) and psoriatic 

arthritis(PsA) with 100% penetrance. 

Aim: To demonstrate JunB expression in synovium and skin of PsA patients 

and determine the effect of etanercept treatment on this expression. 

Method: 7 PsA patients underwent biopsies of inflamed knee synovium and 

lesional and non-lesional skin at baseline and 12 weeks after treatment with 

subcutaneous etanercept 25mg twice weekly. Clinical information was 

collected at weeks 0 and 12. Standard immunohistochemistry techniques were 

employed to evaluate JunB expression. Staining was scored semiquantitatively 

(0-4 scale) by two blinded assessors. The Wilcoxon signed rank 

test was used for statistical analysis. 

Results: Arthritis activity measures improved significantly after 12 weeks. 

PASI scores improved in 4 of 7 patients. Pre-treatment, there was prominent 

nuclear expression of JunB in the synovial lining layer and in inflammatory 

cell aggregates in the sub-lining. Dual-immunofluoresence staining colocalized 

JunB expression to synovial CD68 positive cells. There was a trend 

to reduced expression of JunB in both synovial layers post-treatment. 

In the 2 sets of skin examined to date, JunB was expressed in non-lesional 

skin, particularly the epidermal basal layer. In lesional skin this expression 

was reduced, but then restored following etanercept treatment. 

Conclusion: Epidermal JunB expression is down regulated in lesional 

compared to non-lesional Ps skin, a finding reversed by clinical improvement 

with etanercept. Macrophage expression of JunB in synovium is shown but in 

contrast to skin, expression is reduced by etanercept. 

Reference: 

(1) Zenz R et al. Psoriasis-like skin disease and arthritis caused by inducible 

epidermal deletion of Jun proteins. Nature 2005; 437(15):369-375.



2. NOVEL CLINICAL AND HISTOLOGICAL FINDINGS IN EARLY 

UNTREATED JUVENILE IDIOPATHIC ARTHRITIS 

S. Blelock 1 , D. Gibson 1 , S. Clarke 2 , C. McAllister 3 , M. Rooney 1 

1 Arthritis Research Group, Medicine, Queens University of Belfast, Belfast, 

UK, 2 Trauma Research Group, Medicine, Queens University of Belfast, 

Belfast, UK, 3 Rheumatology, Musgrave Park Hospital, Belfast, UK 

We are currently undertaking a five-year prospective study of early untreated 

juvenile idiopathic arthritis (JIA). Reported are our preliminary findings. 

Aim: To characterise the synovial membrane of early inflammatory disease in 

untreated JIA. 

Method: Synovial biopsies (n=5) were obtained from 20 JIA patients defined 

according to ILAR criteria. Biopsies were snap frozen, sectioned and assessed 

by immunohistochemistry. Three biopsies were analysed per patient, with 10 

high power fields (HPF) studied per biopsy (X40 mag.). 

Results: All Patients portrayed histological homogeneity within an individual 

joint. Synovial hyperplasia was variable; mean 7.5, range (2.4-10). Cellular 

infiltration was modest; universally low-moderate diffuse infiltrates within 

sublining layer were detected. Perivascular infiltrates were present in 47.1% 

of cases, with the diameter of the cellular infiltrate being mild in 25% and 

moderate in 75% of patients. Focal aggregates were detected in 30% of 

patients. 

Fibrosis was minimal in the majority of cases; mean 2.5 (0.9-7.3). Marked 

macrophage populations were present in both the lining layer and the 

sublining layer. The mean number of vessels per HPF was low at 2.8 (0-7). 

The T cell population were predominately CD4+. B cell density was lower 

than that reported for rheumatoid arthritis (RA). Diffuse, occasional B cells 

were observed in >70% of cases; mean 1.0 (0.5-1.9). 

Conclusions: Common synovial pathological traits that have been reported in 

RA are expressed within the synovium of early untreated JIA. We observed 

that JIA and RA share a common immuno-pattern, similar degrees of synovial 

hyperplasia but a reduction in B cells and vascularity.



3. REGULATION OF VEGF AND ANGIOPOIETINS IN 

INFLAMMATORY ARTHRITIS 

C. Sweeney* 1 , A. Kennedy* 1 , T. Walshe 2 , P.A. Cahill 2 , , O. Fitzgerald 1 , B. 

Bresnihan 1 , D.J. Veale 1 , U. Fearon 1 

1 Department of Rheumatology, St. Vincent’s University Hospital and Conway 

Institute, Dublin, Ireland, 2 The Vascular Health Research Centre, Dublin City 

University, Dublin, Ireland, *The first two authors contributed equally to this 

work 

Angiogenesis involves VEGF/Angiopoietin (Ang) interactions. 

Aim: This study investigates the effect of mechanical stress, hypoxia, and exposure 

to Substance P (SubP), corticotrophin releasing hormone (CRH), and Sonic hedgehog 

(Shh) on VEGF/Ang2 expression in the inflamed synovial membrane (SM). 

Methods: VEGF/Ang2 expression was measured in SM explants, synovial fibroblast 

(SFC) and endothelial cells (EC) by ELISA, following exposure to SubP (100ng/ml), 

CRH (100ng/ml) or Shh (3.5ug/ml). EC were exposed to shear stress (0.3- 

25dyn/cm 2 ), VEGF/Ang2 expression was analysed. 

Results: VEGF (300–1210pg/ml) and Ang2 (293–1262pg/ml) were spontaneously 

released from SM explants. Similar levels of VEGF (500–1000pg/ml) was also 

demonstrated in SFC, Ang2 levels were significantly lower (200pg/ml). EC released 

Ang2 (1400–1800pg/ml) but low levels of VEGF. Exposure of SM explants to SubP 

increased VEGF expression (3.3±1.1-fold), but did not change Ang2 expression. 

Exposure of EC to SubP/CRH caused no change in either VEGF/Ang2 expression. 

Shh increased VEGF expression in explants (1.93±0.52-fold) and EC (2.5±0.4-fold). 

Mechanical shear increased Ang2 (3.69±0.68-fold) and VEGF (1.85±0.15) expression 

in EC. Exposure of explants and SFC hypoxia resulted in maximal increases in 

VEGF expression at 1% (1.9±0.1-fold) and 3% O 2 (2.23±0.3-fold) respectively; no 

change was seen in Ang2 expression. Similarly, no alteration in VEGF/Ang2 

expression was observed in EC following exposure to graded hypoxia. 

Conclusion: Varying levels of VEGF/Ang2 are spontaneously released from SM 

expants, SFC and EC. Mechanical stress, hypoxia, SubP and Shh differentially 

regulate VEGF/Ang2 expression, and may prove to be important in future therapeutic 

targeting of angiogenesis in the inflamed joint.



4. LOSS OF EXPANSION OF CD94/ NKG2A EXPRESSING T CELLS MAY 

PREDICT DISEASE RELAPSE IN PATIENTS WITH RHEUMATOID ARTHRITIS 

(RA) FOLLOWING WITHDRAWAL OF ANTI-TUMOUR NECROSIS FACTOR- 

ALPHA (ANTI- TNFα) THERAPY 

C.A. Walsh 1 , C. O'Farrelly 2 , L. Golden-Mason 2 , D.J. Veale 1 , O. FitzGerald 1 , 

B. Bresnihan 1 , U. Fearon 1 

1 Department of Rheumatology, St. Vincent’s University Hospital, Dublin, 

Ireland, 2 Department of Immunology, St. Vincent’s University Hospital, 

Dublin, Ireland 

Disease modulating effects of anti-TNFα therapies in RA have been well 

described. However the effect of anti-TNFα therapies on the immune system 

has not been systematically studied. Natural killer receptor expressing 

(NKR+) T-cells are increasingly recognised as playing an important role in the 

pathogenesis of autoimmunity and were the focus of this study. 

Aim: To phenotypically characterise NKR+T-cell populations in patients 

with RA. 

Methods: NKR+ T-cell populations were studied in the peripheral blood of 

age and sex-matched subjects with (a) RA in clinical remission (DAS28



5. APOPTOTIC NEUTROPHILS FROM LUPUS PATIENTS, BUT NOT 

NORMALS, CAN INDUCE MATURATION OF IMMATURE MONOCYTE- 

DERIVED DENDRITIC CELLS AND ASSOCIATED T CELL 

PROLIFERATION 

A. McClurg 1 , A.L. Bell 2 , M. McHenry 2 , M.A. Armstrong 1 

1 Division of Pathology (Immunology), 2 Medical Education and Research Unit, 

(Lupus research Group), Queen’s University, Belfast, Northern Ireland 

We have reported an increase in apoptosis in neutrophils in SLE, and shown 

that they are resistant to the anti-apoptotic effects of cytokines (1). Dendritic 

cells (DC) are uniquely able to stimulate naïve T cells and their maturation can 

be induced by apoptotic cells (2). We wished to test the hypothesis that lupus 

apoptotic neutrophils can induce DC-dependent T cell proliferation, 

suggesting a novel mechanism of perpetuating the autoimmune response. 

Aim: To examine the effects of apoptotic neutrophils on DC maturation and 

ability to act as antigen in a mixed lymphocyte reaction (MLR). 

Method: Neutrophils were separated from whole blood of patients (N=5) and 

matched normals (n=5). Storage at -80 induced apoptosis, assayed by 

Annexin V and propidium iodide staining. Monocytes from the same sample 

were cultured with GM-CSF and IL-4. On day 6, immature DC were 

stimulated with apoptotic neutrophils (1:100) for 24 hours. Half the DC 

samples were harvested for flow cytometry phenotyping (CD1a, CD80, CD83, 

CD86), half to stimulate autologous CFSE-labelled T cells in MLR. Cells 

were cultured for five days, and examined by flow cytometry. 

Results: Apoptotic neutrophils from SLE donors alone were able to induce 

DC maturation and T cell proliferation. This result occurred only in the 

presence of control DC and T cells, arguing against MHC incompatibility, but 

supporting a unique effect of the apoptotic Lupus neutrophil. 

Conclusions: Our results suggest that the neutrophil cell death pathway in 

SLE generates antigenic apoptotic bodies of potential importance in Lupus 

autoimmunity. 

References: 

1. Armstrong et al, 2005, Clin. Exp. Rheumatol. 23(2):152 

2. Albert et al, 2001, Nat. Immunol. 2(11):1010



6. BONE REMODELING IN PATIENTS WITH RHEUMATOID 

ARTHRITIS AND PSORIATIC ARTHRITIS TREATED WITH ANTI-TNFα 

THERAPY 

A. Gibbs, B. Murray, B. Radovits, B. Bresnihan, D. Veale, M. McKenna, O. 

FitzGerald 

St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland 

Objective: 1. Compare markers of bone resorption and formation in patients 

with RA and PsA to each other and to a control group. 

2. Assess changes in bone metabolism in the same cohort after one month of 

treatment with anti-TNFα therapy. 

Methods: 33 patients (18 RA, 15 PsA) and 28 controls were assessed. Bone 

formation was assessed by measuring bone alkaline phosphatase (BAP), intact 

osteocalcin (OCI) and procollagen type 1N-propeptide (PINP). Bone 

resorption was determined by measuring N-terminal crosslinking telopeptide 

of type I collagen (NTX-1) and deoxypyridinoline (DPD). Data are expressed 

as mean (SD) and are compared using students t test. 

Results: At baseline, one bone formation marker (OCI) was significantly 

lower in both RA and PsA compared to controls (Table). As regards bone 

resorption markers, DPD and NTX-1 in RA and DPD in PsA were 

significantly higher compared to controls. After one month of anti-TNFα 

therapy, two formation markers (BAP, OCI) rose significantly in RA. 

Regarding resorption markers, both DPD and NTX-1 declined significantly in 

PsA, and NTX-1 declined significantly in RA. Comparing PsA and RA at 

baseline and post-therapy, no significant differences were noted. 

Conclusions: Anti-TNFα therapy appears to have a rapid and favorable 

impact on bone remodeling in RA and PsA. 

Control(n=28) Rheumatoid Arthritis(n=18) 

Psoriatic Arthritis(n=15) 

Baseline 1 month Baseline 1 month 

BAP 11.2(3.6) 10.9(3.6) 12.4(4.4)[p



7. SUPPRESSOR OF CYTOKINE SIGNALING-3 (SOCS-3) GENE 

POLYMORPHISMS ARE ASSOCIATED WITH CHRONIC 

INFLAMMATORY ARTHROPATHIES IN NORTHERN IRELAND 

V. Suppiah 1 , C. O’Doherty 1 , M. Rooney 2 , K. Vandenbroeck 1 

1 Applied Genomics Research Group, McClay Research Centre, Queen’s 

University of Belfast, Northern Ireland, UK, 2 Department of Neurology, 

Musgrave Park Hospital, Belfast, Northern Ireland, UK 

Rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) are 

autoimmune disorders characterized by localized infiltration of immune cells 

such as macrophages and lymphocytes, leading to inflammation of the joints. 

Cytokines that are produced locally as part of this autoimmune infiltrate have 

been implicated to play a vital role in the pathophysiology of these diseases. 

A vast array of counter-regulatory mechanisms, both at the extracellular as 

well as intracellular level exist to control the activity of cytokines. 

Recently, a new family of proteins called the suppressor of cytokine signaling 

(SOCS) was discovered whose expression is induced by cytokines and that in 

turn downregulate the same cytokine-activated JAK/STAT signalling 

pathway. The SOCS-3 gene maps onto chromosome 17q25.3 and consists of 

one exon spanning 850 nucleotides. 

It was recently shown that SOCS-3 inhibits STAT-3 activation during 

intestinal inflammation in animal models of chemically induced colitis and 

autoimmune arthritis. It has also been observed that the expression of SOCS-3 

effectively reduced bone destruction in murine autoimmune arthritis model. It 

was postulated that the expression of SOCS-3 could be associated with a 

general downregulation in the responses of the infiltrating mononuclear cells 

to IFN-γ and other cytokines, thus providing a rationale for a functional role in 

susceptibility to these autoimmune disorders. 

This study involved sporadic RA and JIA cases and healthy controls from 

Northern Ireland. As a preliminary study, two single nucleotide 

polymorphisms (SNP) have been studied and future work involves plan to 

scan the rest of the gene as well as its immediate vicinity to identify other 

SNPs that are also associated with these diseases to fully define the association 

of the haplotypes.



8. DETECTION OF SYNOVIAL FLUID CALCIUM PHOSPHATE 

CRYSTALS: A ROUTE TO IMPROVED DIAGNOSIS AND 

CHARACTERISATION OF OSTEOARTHRITIS 

G.P. McMahon 1 , R. Kilkenny 1 , K. Behan 1 , D.A. Smith 2 , G.M. McCarthy 3 

1 Chemical Sciences, Dublin City University, Glasnevin, Dublin 9, Ireland, 

2 Physics and Astronomy, University of Leeds, Leeds, LS2 9JT, England, 

3 Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, 

123 St. Stephen’s Green, Dublin 2, Ireland 

Basic calcium phosphate (BCP) crystals are found in up to 70% of OA joints. 

Current data suggest that intra-articular (IA) BCP crystals represent a potential 

therapeutic target in OA. However, no simple test for IA BCP crystals is 

currently available. 

Aim: To devise a sensitive and specific method to detect and quantify BCP 

crystals in OA synovial fluid (SF) samples. 

Methods: 

• Colorimetric analysis of SF based on dyes i.e. alizarin test for calcium 

(red), molybdate test for phosphate (blue), Gomorri’s silver test for urate 

(black) and Yasue’s test for oxalate (grey). 

• Atomic force microscopy (AFM) in tapping mode for imaging of the submicrometer 

size BCP in SF. 

• Raman spectroscopy using a source laser at 785nm which uses a unique 

peak 960cm -1 as a marker for SF BCP. 

• SF was obtained from knee joints from patients with moderate or severe 

OA. 

Results: Colorimetric testing has detected the presence of BCP in SF, and can 

distinguish between BCP, calcium pyrophosphate dihydrate (CPPD) and other 

crystals. 

Preliminary AFM results have shown the presence of small spheroids of 

inorganic-like material of the nanometer size expected of BCP crystals in 

samples from patients with severe OA which are not seen in control SF. 

Raman spectral data obtained from SF samples indicates that 960cm -1 is 

unique to BCP, 1043cm -1 is unique to CPPD and 1068cm -1 is unique to urate 

crystals. 

Conclusions: All three approaches offer potential as a simple objective 

diagnostic test for BCP crystals in OA. Colorimetric test-strips and portable 

Raman would be particularly suited to point-of-care and in-clinic applications.

Number (%) 

patients 



CLINICAL POSTERS 

9. DOES CARDIOVASCULAR RISK PROFILE INFLUENCE 

PRESCRIBING OF NSAIDS AND COX-2 INHIBITORS IN RHEUMATOID 

ARTHRITIS PATIENTS? 

D.J. Armstrong, A.D. Quinn, G.D. Wright, M.B. Finch 

Royal Victoria Hospital, Belfast, UK 

Background: Although it has been established that the long-term use of both 

conventional non-steroidal anti-inflammatory drugs (NSAIDS) and 

cyclooxygenase-2 inhibitors (COX-2) may increase the risk of cardiovascular 

and cerebrovascular events, there is little data examining how this influences 

prescribing habits among GPs and rheumatologists, either in the immediate 

past, or at present. 

Methods: The charts of 162 patients attending a rheumatoid arthritis (RA) 

cardiovascular (CVS) risk clinic were examined. 118 contained a full history 

of current and past NSAID and COX-2 use, and were analysed for 

conventional CVS risk factors. 

Results: 76 out of 118 RA patients (64%) were currently prescribed an antiinflammatory, 

of which 46 (60.5%) were NSAID, and 30 (39.5%) COX-2. 57 

patients out of 118 had been taking COX-2 at some point, suggesting that 

almost 50% of COX-2 users had discontinued the drug. 13 patients who had 

stopped COX-2 were now taking no anti-inflammatory, while 14 had been 

switched to a conventional NSAID. 37 patients had taken celecoxib at some 

point, 17 etoricoxib and 11 rofecoxib (some patients had taken more than one 

COX-2). The age of patients remaining on any anti-inflammatory was lower 

than those on none (mean (SEM) 58.9 (1.30) v 63.5 (1.91) p=0.05). 

The median number of CVS risk factors in the group was 2 (range 0 to 6), and 

19 patients (16%) had suffered MI, CVA or angina. There was a trend 

towards a higher number of CVS risk factors in patients not receiving any 

anti-inflammatory compared with those receiving either NSAID or COX-2 

(mean, (SEM) 2.81 (0.21) v 2.42 (0.13), p=0.08), and in those prescribed 

NSAID as compared with COX-2 (mean (SEM) 2.52 (0.14) v 2.27 (0.23) 

p=0.1). 

Numbers of patients receiving no anti-inflammatory, NSAID or COX-2 is 

shown below according to the number of CVS risk factors. 

0 CVS risk 

factors 

1 CVS risk 

factor 

2 CVS risk 

factors 

3 CVS risk 

factors 

4 CVS risk 

factors 

5 CVS risk 

factors 

6 CVS risk 

factors 

Total 4 (100%) 18 (100%) 38 (100%) 29 (100%) 23 (100%) 3 (100%) 1 (100%) 

No Treatment 1 (25%) 8 (44%) 7 (18%) 12 (41%) 9 (40%) 2 (67%) 1 (100%) 

NSAID 0 (0%) 5 (28%) 21 (55%) 12 (41%) 7 (30%) 1 (33%) 0 (0%) 

COX-2 3 (75%) 5 (28%) 10 (26%) 5 (17%) 7 (30%) 0 (0%) 0 (0%)



Conclusion: In all RA patients with one or more CVS risk factors, numbers 

prescribed NSAID equals or exceeds the number prescribed COX-2. Almost 

half of patients once on a COX-2 are no longer taking the drug. 15 (56%) of 

the 27 patients with 4 or more CVS risk factors continue to take either NSAID 

or COX-2, which may give cause for concern. 

The authors acknowledge the assistance of nursing staff on 6B outpatients, 

Royal Victoria Hospital, Belfast, in collection of this data.



10. MANAGING AN EFFECTIVE FRACTURE LIAISON SERVICE 

(FLS) WITHOUT BONE MINERAL DENSITY (BMD)? 

M. Fox, D. O’Gradaigh 

Rheumatology Day Ward, Waterford Regional Hospital, Waterford, 


Managing an effective Fracture Liaison service (FLS) without bone mineral 

density (BMD) measurement is desirable in the instance of resource 

limitations. The efficacy of using risk assessment alone is speculative. To 

date, studies have concentrated on an osteoporotic population, not a fragility 

fracture population. 

Aim: This study investigates the contribution of relative risks (RR) in 

predicting future fracture risk without BMD. 

Method: BMD and risk factors for fracture were assessed in a cohort of 

patients who had sustained a low trauma fracture i.e. fractures sustained 

following a fall from standing. Risk factors including prior fracture, age, body 

mass index, parental history of hip fracture, smoking and alcohol intake were 

assigned RR’s for future fracture based on previous research. The RR’s were 

integrated and a total sum reached. Distribution of the total RR scores with T- 

scores above and below the treatment threshold of -1.5 were plotted. 

Results: The RR score for the population below the –1.5 threshold was 7.695 

(2.232 SD) versus 5.409 (1.602 SD) for the population above the –1.5 

threshold. This suggests that the population between 2 and 9 RR score need 

BMD measurements to clarify future fracture risk. 

Conclusions: The study highlights that one cannot distinguish which patients 

do not need treatment based on RR scores alone. FLS’s cannot be maintained 

or anti-osteoporotic treatment decided based on RR scores without BMD 

measurements. 

4 

3 

H isto g ram o f risk sco re 

N o rm al 

Tx TH or LS ( T score -1. 5) 

Tx thre shhold not me t 

Tx Tre shhold me t T SC O R E < -1. 5 

M ean S tDev N 

5.409 1.602 11 

7.695 2.232 21 

Frequency 

2 

1 

0 

2 4 6 8 1 0 1 2 

risk sco re 

D istributio n o f the to tal R R sco re w ith T -sco res above & belo w the treatm ent thresho ld o f -1 .5



11. CARDIOVASCULAR RISK ASSESSMENT IN RHEUMATOID 

ARTHRITIS 

J.D. Pauling, A.K. Bhalla 

Royal National Hospital for Rheumatic Diseases, Bath, UK 

Increased mortality rate in Rheumatoid Arthritis (RA) is largely attributable to 

cardiovascular disease. The increased prevalence of cardiovascular mortality 

is not explained by traditional risk factors, and RA has increasingly become 

recognised as an independent risk factor for cardiovascular disease. Arthritis 

and Musculoskeletal Alliance (ARMA) guidance states that people with 

inflammatory arthritis should be offered a comprehensive, annual specialist 

review that includes cardiovascular risk assessment 1 . 

Aim: To assess our adherence to ARMA guidance regarding cardiovascular 

risk assessment in patients with RA. 

Method: 75 consecutive patients reviewed in rheumatology clinic were 

identified. A documented diagnosis of RA was required for inclusion. 

Medical records were scrutinised for evidence of cardiovascular risk 

assessment such as blood pressure (BP), cholesterol, and a recorded discussion 

regarding cardiovascular risk, in previous year. 

Results: A total of 64 medical files retrieved. 54 patients fulfilled inclusion 

criteria. 13 males. Mean age of 64.9 (33-83). Mean number of follow up 

appointments in last calendar year was 2.6 (1-7). 4 patients (7.4%) had a 

documented BP measurement. 1 patient (1.85%) had a documented 

cholesterol measurement. 2 patients (3.7%) had documented reference to 

cardiovascular risk. 

Conclusions: We have highlighted our current poor adherence to ARMA 

guidance and recognise the importance of cardiovascular risk assessment in 

patients with inflammatory arthritis. We have introduced annual BP, 

cholesterol, smoking history and glucose onto our shared-care monitoring 

cards. We will raise awareness of this issue amongst local rheumatologists, 

general practitioners and patients. Re-auditing our adherence to ARMA 

guidance will take place in 1 year. 

(1) Arthritis and Musculoskeletal Alliance, Standards of Care for people with 

Inflammatory Arthritis (Standard 12), Nov 2004, ARMA, London 

www.arma.uk.net



12. AN AUDIT OF SYSTEMIC LUPUS ERYTHEMATOSUS (SLE) 

PATIENTS AND DUAL ENERGY X-RAY ABSORPTIOMETRY SCANNING 

M.T. McHenry, A.L. Bell 

Lupus Research Group, Queen’s University Belfast, Northern Ireland 

SLE is a chronic autoimmune condition. Osteoporosis is a potentially 

preventable condition with dual energy X-ray absorptiometry (DEXA) 

scanning as the gold standard test for detection. SLE patients are at increased 

risk of osteoporosis. Referral for DEXA scanning in a cohort of female lupus 

patients in Northern Ireland was carried out. 

Aim: Audit DEXA scanning in SLE patients. 

Methods: 141 SLE patients fulfilling the ACR criteria were enrolled. Any 

previous DEXA scan was checked using medical records and X-ray database. 

Results: 49.6% (70/141) SLE patients had a previous DEXA scan. 15.7% 

(11/70) had osteoporosis and 35.7% (25/70) had osteopenia. 84/141 patients 

had prior corticosteroid exposure, 28.6%(24/84) of these patients had no 

previous DEXA scan. 57/141 patients were postmenopausal, 36.8% (21/57) 

of these postmenopausal lupus patients had no prior DEXA scan. 46.5% 

(47/101) of those lupus patients with >4yrs duration had no DEXA scan and 

38.6% (17/44) of those with disease duration > 10 yrs had no DEXA scan. 

The average SLICC score of those SLE patients with a prior history of a 

DEXA scan was 1.27 compared to a SLICC score of 0.62 in those SLE 

patients those with no DEXA scan. 

Conclusion: 49.6% of patients had a previous DEXA scan. These patients appeared 

to have more damage with a greater average SLICC score. However, there were a 

significant number of patients with prior steroid exposure and prolonged disease 

duration that had no DEXA scan. Referral for DEXA scanning needs highlighted 

within the department, especially those patients at greatest risk. 

References: 

Pineau CA, Urowitz MB, Fortin PJ, Ibanez D, Gladman DD. 

Osteoporosis in systemic lupus erythematosus: factors associated with referral 

for bone mineral density studies, prevalence of osteoporosis and factors 

associated with reduced bone density. Lupus. 2004;13(6):436-41.



13. IMPROVEMENTS IN MANAGEMENT OF GLUCOCORTICOID- 

INDUCED OSTEOPOROSIS 2002-06 

A. Mohammad, J.G. Ryan, N. Ralph, C. Ryan, P.G. O’Connell 

Department of Rheumatology & Medicine at Beaumont Hospital, Dublin, 


Introduction: In 2002 we undertook an audit of management of 

glucocorticoid (GC) induced osteoporosis (GIO) in our hospital that showed 

wide variation in practice and considerable under-treatment. In 2006 we 

undertook a similar audit to establish if adherence to published guidelines for 

prevention of GIO had changed in the intervening 4 years. 

Methods: A retrospective chart audit of 3475 patients attending out patient 

clinics of 3 medical specialities originally audited in 2002. All patients 

prescribed GC over the past 6 months were identified. Demographic data and 

details of treatment were extracted. Findings were compared with results of 

the previous audit. 

Results: 253(7%) patients were identified as prescribed GC vs. 151(3%) in 

2002. GIO risk was mentioned in 71% (179) of the charts, vs. 13% (19) in 

2002. Compared to the previous audit where 46% (69) subjects were on some 

form of bone protection, 36% (55) on calcium/vitamin D, and 25% (37) on a 

bisphosphonate, the 2006 figures were 86% (218), 82% (207) and 54% (135) 

respectively. DXA scan was performed in 32% (82) of our patients. DXA 

scanning was not available in 2002. 15% (37) of the patients were diagnosed 

with osteoporosis. Between services, considerable variation in practice was 

still seen, with antiresorptive therapy prescription rates varying from 24% to 

70% and those of calcium/vitamin D supplements ranging from 15% to 95%. 

For the highest risk patients, those taking >7.5 or >10 mg of prednisolone, and 

for post-menopausal women, the prescription rates were 70% to 80% for 

antiresorptive therapy and almost 100% for calcium/vitamin D supplements. 

Conclusions: Over 4 years major improvements in GIO documentation / 

treatment have occurred in our institution. There still remains considerable 

variation in individual practices and under-utilisation of DXA scanning. We 

suspect these overall encouraging findings are generalisable to similar 

institutions.



14. EVALUATION OF THE APPLICATION OF STANDARD CRITERIA 

FOR TEMPORAL ARTERY BIOPSY IN THE DIAGNOSIS OF GIANT CELL 

ARTERITIS 

C.B. Malone, P.J. Sullivan, R. Coughlan 

Department of Rheumatology, University College Hospital Galway 

Giant cell arteritis (GCA) is the most common primary vasculitis. Temporal 

artery biopsy, (TAB), is the gold standard for diagnosis of GCA. The 

American College of Rheumatology has defined diagnostic criteria. 

Aim: To audit pre operative criteria used by physicians prior to temporal 

artery biopsy. 

Methods: A retrospective review of charts of all HIPE charted TABs. 

Results: Of seventy-two biopsies five were positive. Three patients were 

diagnosed with GCA clinically with negative biopsies, only one of these was 

referred to the rheumatology service for further evaluation. 

Of the five positive biopsies 4 had a documented new headache, 3 had 

abnormalities on examination of the artery and 3 had visual disturbance; the 

average age being 75 years with an average ESR of 106mm/hr. 

Of the 64 negative biopsies only 36 (56.2%) had an ESR greater that 50mm/hr 

and 8 had no ESR documented. The average age was 69.73 years with 3 

patients under 50 years of age. Twenty (31.25%) had new headache, 5 (7.8%) 

had positive clinical examination and only 18 (28.1%) had visual disturbances. 

In the positive group the average duration of steroids pre operatively was 1 

day with a maximum of 2 days. Of those patients with a negative biopsy 26 

(40.6%) were on steroids, the length of treatment varied between 0 day and 

150 days with an average of 19.48 days. 

Conclusion: The majority of TAB requested by physicians failed to 

adequately document recognized symptoms, signs and laboratory 

investigations. The diagnostic yield in this series was only 6.9%.



15. UNRESTRICTED PRESCRIBING OF BIOLOGICAL THERAPIES 

FOR RHEUMATOID ARTHRITIS IN IRELAND – HAVE OUR PRACTICES 

CHANGED? 

A. Gibbs, C. Walsh, O. FitzGerald, D. Veale, B. Bresnihan 


Objective: To investigate whether prescribing practices changed in our unit 

over two time-points, and look at the proportion of patients who would not 

have received biologic agents if the prescribing guidelines of the UK and the 

Netherlands had been applied. 

Methods: Data were collected prospectively on patients with rheumatoid 

arthritis started on biological therapies since 2000. A database was set up in 

2004 for ongoing data collection. Student’s T test was used to compare data 

from the two groups. 

Results: A high degree of similarity was seen in the demographic 

characteristics of the two patient populations. There was a significant decline 

in the number of DMARD failures and in baseline DAS28. However, the 

latter cohort still failed an average of over 2 DMARDS and there was no 

significant change in the number of patients who did not meet either of the 

above sets of criteria. 93.3% and 60% of patients in the initial group met the 

Dutch and British criteria respectively. This dropped to 92.7% and 48% in the 

latter cohort. 

Conclusions: Despite the fact that there are no restrictions to the prescription 

of biological therapies in Ireland, our prescribing practices have remained 

much the same over the last 6 years and correlate well with the Dutch criteria. 

In contrast, a high proportion of patients did not meet the British guidelines. 

2000-3 2004-2006 p value 

Patients 225 138 

Women(%) 65 70 n/s 

Age 50.8(12.5) 53.7(13.1) n/s 

Disease duration(years) 10.8(8.5) 12(9.1) n/s 

Previous DMARDS 3(1.6) 2.1(1.1) p



16. EVALUATION OF THE PREVENTION AND TREATMENT OF 

GLUCOCORTOID INDUCED OSTEOPOROSIS IN THE RHEUMATOLOGY 

OUTPATIENTS DEPARTMENT 

C.B. Malone, G. Mannion, R. Coughlan 

Department of Rheumatology, University College Hospital Galway 

The association between glucocorticoid treatment and osteoporosis is well 

established. There is a dose dependent risk which is above and beyond 

changes in bone mineral density. 

Aim: To audit screening for and treatment of osteoporosis in patients on long 

term steroids in the rheumatology clinic. To audit lifestyle factors that 

increase the risk of osteoporosis. 

Methods: A retrospective review of charts of patients on steroids attending 

the clinic over a two month period. Lifestyle factors and body mass index 

(BMI) were recorded at the clinic visit. 

Results: 45 charts were reviewed. Sixteen patients (35.6%) were over the 

age of 65. Of these the mean dose of prednisolone was 6.5mg with a mean 

duration of treatment of 7 years. The mean dose in the 29 patients under 65 

years was similar, the average duration of treatment was lower at 3.5 years. 

Two patients over 65 years had dual energy x-ray absortiometry (DEXA) 

scans and 3 had fractures. Only 7 patients were on calcium/vitamin D 

supplementation with 6 on bisphosphonates. 

In the under 65’s; 6 had DEXA scans and were on appropriate treatment. 

Interestingly there were 6 fractures in this population. There were 12 patients 

on vitamin supplementation, 7 on bisphosphonates and 3 on hormone 

replacement therapy. 

There was an increased prevalence of overweight patients and smokers in the 

under 65’s, with a higher number of obese patients over 65yrs. 

Conclusion: Management of steroid induced osteoporosis was unsatisfactory. 

New guidelines are being implemented and an osteoporosis nurse specialist 

has been appointed.



17. R.A.I.S.E (RHEUMATOID ARTHRITIS INFORMATION, SUPPORT & 

EDUCATION): THE IMPACT OF A FOUR WEEK MULTI-DISCIPLINARY 

EDUCATIONAL PROGRAMME IN AN OUT-PATIENT RHEUMATOLOGY 

SERVICE 

A. O’Gorman 1 , M. Nolan 2 , C. Doyle 3 , G. Cunnane 4 , M. Doran 4 

Senior Occupational Therapist 1 , Senior Physiotherapist 2 , Clinical Nurse 

Specialist 3 , Consultant Rheumatologist 4 , Rheumatology Department, St. 

James’s Hospital, James’s Street, Dublin 8 

Aim: Considerable evidence suggests that patient education, especially that 

based on self-efficacy theory, leads to significant and sustained improvements 

in the health status of patients with rheumatoid arthritis (RA). The multidisciplinary 

team at St. James’s Hospital piloted this educational programme 

with the following aims; improving health status, increasing self-efficacy 

beliefs, influencing joint protection behaviours, providing a group support 

network and promoting compliance with therapy recommendations. 

Methods: A cohort of 13 patients with a recent diagnosis of RA took part in 

this education programme and were evaluated using pertinent pre- and post 

outcome measures. A patient satisfaction survey was also utilized to gather 

relevant qualitative data. 

Results: Improvements in self-efficacy and joint protection knowledge were 

noted, with 9/13 participants showing improvement on the Joint Protection 

Knowledge Questionnaire (mean score increased from 70.2 - 79.6), and 11/13 

participants showing improvement on the Arthritis Self-Efficacy Scale (mean 

score increased from 5.6 - 6.9). A reduction on a pain verbal report scale was 

noted among participants (mean score dropped from 5.2 - 4.7), and 8/12 

participants reported an improved health state on the Euro-QOL EQ 5D scale. 

The Aims II Short form and Health Assessment Questionnaire yielded no 

significant improvements over the four week period as would be expected, 

given the short time-frame of the study. All 13 patients reported that they 

found the group to be beneficial. 

Conclusion: These initial results suggest that this education programme is of 

benefit to patients with RA, in terms of increasing self-efficacy, joint 

protection knowledge and health status.



18. ARE OUR RHEUMATOLOGY SERVICES PROPERLY UTILISED? 

AN AUDIT OF GP REFERRALS TO OUR OUTPATIENT CLINIC IN CORK 

CITY, IRELAND 

M. Haroon, M. Phelan, M.J. Regan 

Arthritis and Osteoporosis Centre, Department of Rheumatology, South 

Infirmary – Victoria University Hospital, Cork, Ireland 

Objective: Rheumatology departments in Ireland have long waiting lists. 

Our objective was to review the referral letters sent to our outpatient centre by 

general practitioners (GPs) and then to document our diagnoses. Our aim was 

to analyse how our rheumatology services are being utilised by referring GPs. 

Methods: We carried out a retrospective review of the charts of all new 

patients reviewed from July to September 2005. Eighty-three patients were 

identified. By chart review, the following information was documented: date 

of GPs referral letter, reason for referral, date of first visit, all medications the 

patients were taking and the final diagnosis after review by us. 

Results: Overall, out of 83 new patients, 17% had osteoarthritis and 45% had 

soft tissue rheumatism. Backache was the reason for referral in 25% of cases. 

We diagnosed uncomplicated musculoskeletal back pain in 14% of patients. 

The GPs had queried inflammatory joint disease in 29% of referrals; we 

determined that only 9% of patients had inflammatory joint disease. 

Conclusions: We found a notable disparity between the GPs reason for 

referring to us (their diagnoses) and our diagnoses. We could improve the 

delivery of outpatient services by further educating GPs regarding 

rheumatological diagnoses. Designing a screening questionnaire for GPs to 

fill in and attach to their referral letters would help us stratify patient referrals 

more effectively. This would help in the allocation of first appointment slots 

so that the patients most likely to benefit from early intervention would be 

seen earlier than others.



19. HOW WELL DO OUR PATIENTS UNDERSTAND A DIAGNOSIS OF 

OSTEOPOROSIS? 

N. Ambrose, G. Kearns, P. O’Connell 

Beaumont Hospital, Artane, Dublin 9, Ireland 

An audit of 300 consecutive patients in Beaumont Hospital rheumatology 

outpatients during February 2006 was carried out to assess patients 

understanding of osteoporosis and their medications. A questionnaire was 

given assessing what osteoporosis medications they were taking. We also 

assessed their compliance levels. 

90 of the 300 patients were on treatment for osteoporosis, but only 40% knew 

why they were taking these tablets. 36% of patients admitted to poor 

compliance in the previous 2 weeks either inadvertently or consciously not 

taking their tablets. 

40% of patients reported that they had been reminded to take their tablets by 

their doctors during the last 6 months. 

This audit highlights that only 60% of patients attending a tertiary referral 

centre had an understanding of the disease they were being treated for and of 

the benefits of treatment. This may have been compounded by the high 

prevalence of poly pharmacy, with patients in this audit receiving an average 

of 7 different tablets. It highlights the importance of reviewing patient’s 

medications and reasons for taking them. We have now introduced an 

information leaflet, which will be handed to all patients with osteoporosis in 

our clinics.



20. AUDIT OF CARDIOVASCULAR CARE IN 40 RHEUMATOID 

ARTHRITIS OUTPATIENTS 

N. Ambrose, G. Kearns, P. O’Connell 

Beaumont Hospital, Artane, Dublin 9, Ireland 

Cardiovascular risk is increased in Rheumatoid Arthritis (RA) patients. 

This audit was designed to assess the assessment of cardiovascular risk in our 

RA population. A chart review of 40 patients attending our DMARD 

monitoring service with RA was carried out. These patients have moderate to 

severe RA and are therefore at high risk of cardiovascular disease (CVD). 

We found that 80% of patients had not been adequately assessed for basic risk 

factors for CVD ( Hypertension, smoking history, weight, cholesterol, 

exercise, family history, diabetes, personal history). 40% of patients did not 

have their blood pressure documented in their entire chart and of the 35% of 

patients with documented hypertension, only 60% of them were receiving an 

anti-hypertensive. 

Findings were similar throughout all other categories – 42% of patients had 

not had their cholesterol checked, 35% had never had a glucose checked, 30% 

of patients had never been asked about a family history of CVD, 17.5% of 

patients had never been asked about smoking history, and of the 31% of 

patients who admitted to being current smokers, only half of these had been 

given advise to stop smoking. 

This audit highlighted the importance of documenting baseline assessment of 

CVD risk in patients attending our clinics with RA. On the basis of these 

findings, we have designed a formal cardiovascular evaluation sheet to be 

placed in every patient’s chart who attends our clinic with RA with a view to 

modifying RA patients cardiovascular risk profiles.



21. AUDIT OF NSAID PRESCRIBING IN A RHEUMATOLOGY 

OUTPATIENT POPULATION 

C. Sheehy, E. Murphy, M. Barry 

Department of Rheumatology, Connolly Hospital, Blanchardstown, Dublin 15, 


Concerns have recently arisen about increased cardiovascular risk related to 

use of the traditional non-steroidal anti-inflammatory drugs, (NSAIDs) 

following the withdrawal of some COX2 inhibitors. It is also known that 

some inflammatory rheumatological conditions confer an increased 

cardiovascular risk. 

Aim: This audit of our rheumatology outpatients was undertaken to assess the 

current use of these drugs and also to assess the prevalence of cardiovascular 

risks and co morbidities. 

Methods: A questionnaire was circulated to 200 patients at the rheumatology 

review clinic over a 3 month period. Patients were asked about frequency, 

length of use, and primary indication for NSAIDs. Co morbid diseases and 

concomitant medications were recorded. 

Results: 49% of the patients are on NSAIDS; 59% of them take them daily. 

GPs started the medication in 54% of cases while the rheumatology team 

started it in 43%. Rheumatoid arthritis was the most common indication at 

41%. 26% and 22% had hyperlipidaemia and hypertension respectively. 47% 

of patients on NSAIDS had had their cholesterol measured over the preceding 

year and 65% had had their blood pressure checked. 

Conclusion: The most striking feature from this audit is that nearly half of 

our outpatients are taking NSAIDs and 59% of those are taking them daily. 

This finding demands urgent attention with regards to education of both 

patients and health professionals. Secondly it highlights the fact that we 

should institute an annual cholesterol and blood pressure check to include 

those patients who are not being screened.



22. NATIONAL ADALIMUMAB AND ETANERCEPT PRESCRIBING 

PREVALENCE IN IRELAND FOR GMS PATIENTS WITH 

RHEUMATOLOGICAL CONDITIONS IN 2005 

C. Sheehy¹, T.I. Barron², J. Feely², M. Barry¹, E. Murphy¹, T. Duffy¹ 

¹Department of Rheumatology, Connolly Hospital, Blanchardstown, Dublin 

15, Ireland, ²Department of Pharmacology & Therapeutics, Trinity College, 

Dublin, Ireland 

Adalimumab and etanercept are self-injectable anti-TNF agents currently 

available in Ireland through the high technology medicine prescribing system. 

They are mostly used for treatment of inflammatory arthritis and psoriasis, 

although have been introduced for the treatment of inflammatory bowel 

disease (IBD) 

Aim: The aim of this audit was to assess the prevalence of prescribing of both 

adalimumab and etanercept for rheumatological conditions in a cohort of Irish 

patients. 

Methods: All general medical services (GMS) patients over 16 who received 

either adalimumab or etanercept or both in 2005 were identified from the high 

technology prescribing database. A rheumatological diagnosis was inferred 

from their prescribing history using the GMS pharmacy claims prescribing 

database from 2000-2004. Information regarding demographics, coprescribing 

and geographical distribution was also sought. 

Results: 1258 GMS patients received either one or both drugs in 2005. 1006 

patients were identified as having rheumatological conditions, having been 

prescribed DMARDs though the GMS system between 2000-2004, with or 

without topical anti-psoriatic medications. 30% were male. 85.6% had 

received methotrexate at one point since 2000. 31.8% of patients had received 

2 different DMARDs and 13.6% had been on 3 since 2000. 

Conclusions: Approximately one third of the population qualify for GMS 

prescribing and thus our cohort is a representative sample of the population. 

With this audit we have shown that adalimumab and etanercept are widely 

used and accepted therapeutic agents. We plan to obtain more information 

from the databases looking back at data from previous years.



23. ANTINUCLEAR ACTIVITY AND HAEMATOLOGICAL 

ABNORMALITIES SECONDARY TO ANTI-TNF THERAPY LOCAL AUDIT 

STUDYING KETTERING COHORT OF PATIENTS ON BIOLOGIC 

THERAPY 

A. Al-Ansari 1 , M. Devine 2 , G. Kallarackal 2 

1 Rheumatology Department, Leicester Royal Infirmary, Leicester, LE1 5AA, 

UK, 2 Rheumatology Department, Kettering General Hospital, Northants, 

NN16 8UZ, UK 

Aim: Anti-TNF is an established therapy for Inflammatory arthropathies. 

Manufacturers did not recommend any monitoring requirements. There are no 

specific guidelines established for monitoring Anti-TNF therapy. Monitoring 

is currently done for the coexisting disease modifying drugs. There are recent 

anecdotal reports of haematological complications, so, we reviewed the 

sequential blood tests pre and post Anti-TNF therapy for Anti-TNF cohort 

patients. 

Method: We reviewed a cohort of 47 Anti-TNF treated at least for six months 

with Anti-TNF therapy. We reviewed their sequential blood tests along with 

their clinical response and serological changes looking for any correlation 

between them. 

Results: Of the total of 47 patients 26 six patients were on Etanercept, 19 on 

Adalimumab and two on Infliximab. 38 patients are Rheumatoid arthritis, 28 

patients were on combined DMARDs. 

Six patients developed weak antinuclear activity seen with all three agents 

almost equally with overall percentage 12.7%. All the six patients were 

rheumatoid arthritis. Titres were (1/40 – 1/320). Half of them were on 

Methotrexate. No one developed clinical Lupus or other connective tissue 

disease. 

Four patients (9%) developed Neutropenia at some point during the course of 

their treatment. Neutropenia of 1.0-2.0 was compatible with continuing 

monitoring. Only one of them ended up with a diagnosis of military TB the 

other three continued on therapy with a close monitoring. Two milder 

neutropenia were on Methotrexate. 

Conclusion: In our audit we found a 12.7% developed a positive antinuclear 

factor and 9% of patients developed neutropenia. Neutropenia secondary to 

Anti-TNF therapy or other co-morbidity can be serious enough to call for a 

protocol establishment outline Anti-TNF therapy monitoring.



Table shows neutrophil count for four patients on Anti-TNF therapy 

month 

Before 

2 

4 6 8 10 12 14 16 18 20 22 

Anti- 

After 

Patient 

TNF 

therapy 

1 7.3 4.9 3.0 3.6 2.8 1.9 2.1* 2.0 2.2 2.1 1.9 10.0§ 

2 4.4 3.8 3.3 4.0 3.5 2.0 2.1 3.0 2.8 2.9 3.9 2.6* 

3 3.6 3.4 2.0 1.4 1.9 2.2 2.2 2.8 1.9 2.0 1.6 1.3 

4 3.4 2.6 2.0 1.6 2.3 2.5 2.0 2.6 2.1 2.5 2.2 2.6 

*Anti-TNF stopped 

§ Developed military TB and died 

Maintained Anti TNF 

References: 

1. Atzeni F, Turiel M, Capsoni F, Doria A, Meroni P, Sarzi-Puttini P. 

Autoimmunity and Anti-TNF-{alpha} Agents. Ann N Y Acad Sci. 2005 

Jun;1051:559-69. 

2. Atzeni F, Sarzi-Puttini P, Dell' Acqua D, de Portu S, Cecchini G, 

Cruini C, Carrabba M, Meroni PL. Adalimumab clinical efficacy is 

associated with rheumatoid factor and anti-cyclic citrullinated peptide 

antibody titer reduction: a one-year prospective study. Arthritis Res 

Ther. 2005 Nov 9;8(1):R3.



24. SCLERODERMA-HOW WELL ARE WE MONITORING FOR 

INTERSTITIAL LUNG DISEASE AND PULMONARY HYPERTENSION? 

J. Kitchen, D. Smith, G. Cunnane, M. Doran 

Department of Rheumatology, St. James’s Hospital, Dublin, Ireland 

Patients with scleroderma are at risk of pulmonary hypertension and interstitial 

lung disease. Monitoring is essential to detect abnormalities early and reduce 

morbidity and mortality. 

Aim: To audit the practice of monitoring patients with scleroderma for 

pulmonary hypertension and interstitial lung disease in St. James’s Hospital. 

Methods: A chart review was carried out on consecutive out-patients with 

scleroderma. Information collected included demographic details, 

documented respiratory symptoms, and investigations to identify evidence of 

lung involvement. 

Results: Fifteen patients were identified, all Caucasian females, of whom 12 

(80%) had limited scleroderma and 3 (20%) diffuse scleroderma. Average 

disease duration was 6.2 years (range 0.25- 18). Four had a smoking history. 

Respiratory symptoms were noted in 10 (66%). The entire cohort had 

previous chest radiographs but only 7 (47%) had one in the past year, of which 

5 were abnormal. Of these, only one had further investigation of this (with 

high resolution CT). Less than half (40%) of patients had pulmonary function 

tests in the preceding year, of which 2 had reduced DLCO, but neither had 

been further investigated with echocardiography or HRCT. 66% of patients 

(10) previously had echocardiography performed, but only 27% (4) of these 

had echocardiographs within the last year. Of the 7 patients who had HRCT 

performed at any time, 5 had evidence of interstitial fibrosis. 

Conclusion: Screening of scleroderma patients for pulmonary complications 

in this centre has been sub-optimal. We have introduced new measures to 

ensure that all scleroderma patients are screened for pulmonary complications 

at regular intervals.



25. AUDIT OF RENAL FUNCTION MONITORING IN A RHEUMATOID 

ARTHRITIS OUTPATIENT COHORT 

D. Smith, J. Kitchen, C. Doyle, G. Cunnane, M. Doran 

Department of Rheumatology, St. James’s Hospital, Dublin 8, Ireland 

Renal dysfunction in rheumatoid arthritis (RA) is associated with increased 

mortality, and may occur as a consequence of the disease itself, or the use of 

pharmacological agents in managing RA. 

Aim: This audit was undertaken to assess risk factors for renal dysfunction, 

and the frequency of screening for same in a cohort of RA patients. 

Method: Detailed chart reviews were performed over a 2-month period on 

consecutive RA patients attending outpatient clinics. Information was 

collected regarding demographics, frequency and type of renal function 

monitoring, disease duration, co-morbidities, disease modifying antirheumatic 

agents (DMARDs) and non-steroidal anti-inflammatory drugs 

(NSAIDs) use. 

Results: Of the 43 patients included, 70% were female. Mean age was 60.8 

years (range 44 to 83 years), and mean disease duration 12.5 years (range 1-62 

years). 93% of the cohort had been exposed to NSAIDs for at least 6 months 

since disease onset. Hypertension and diabetes mellitus were noted in 30% 

and 16% of patients respectively. Frequency of renal profile monitoring was 

variable, with most patients being monitored less often than six monthly 

intervals. 23% of study subjects had at least one abnormal renal profile or 

urinalysis recorded. 

Conclusion: Although this cohort had multiple risk factors for renal 

dysfunction, frequency of monitoring of renal function was low. We 

identified 23% of patients with evidence of renal dysfunction, however only 

30% of them went on to have any further appropriate investigations 

performed. This study highlights the need to perform regular monitoring of 

renal function in patients with RA.



26. AUDIT ON SAFE PRESCRIBING CONVENTIONAL NSAIDS VS 

SELECTIVE COX II INHIBITORS AGAINST CVS AND GI RISK FACTORS IN 

RHEUMATOLOGY OUTPATIENT CLINIC 

R. Stevens, J. Jamil, H. Timlin 

Rheumatology Department, Wycombe / Amersham Hospital, Amersham, 

Buckinghamshire, HP7 0JD, UK 

Rationale/indication: NSAIDs - Most widely prescribed drugs in clinical 

practice. The aim of this study was to report how many patients Safely 

prescribed Conventional NSAIDs(excluding low dose aspirin) VS Selective 

Cox II and assessment the potential risk factors. 

Standards to be met: Use of COX2 in patients with Age > 70 and no risk 

factors for CVA/IHD or age



27. TNF INHIBITORS FOR ANKYLOSING SPONDYLITIS IN THE REAL 

WORLD 

C.M. McVeigh, A.L. Bell, M.B. Finch, M.M.E. Rooney, A.J. Taggart, G.D. 

Wright, A.P. Cairns 

Department of Rheumatology, Musgrave Park Hospital, Stockman’s Lane, 

Belfast, BT9 7AB, Northern Ireland 

TNF inhibitors have revolutionized the treatment of ankylosing spondylitis 

(AS). 

Aim: To review our use of TNF inhibitors in AS. 

Method: Audit of patients who have received anti-TNF treatment for AS. 

Results: 44 AS patients (38 male) have received treatment with TNF 

inhibitors. 41 patients continue on treatment. 2 stopped because of chest 

infection, one of whom died. 1 stopped because of safety concerns (poor 

compliance). First line drugs used were: infliximab 26/44(59.1%), 

adalimumab 10/44(22.7%), etanercept 8/44(18.2%). 

28/44 (63.6%) patients had a good clinical response to their 1 st TNF inhibitor: 

infliximab 17/26 (65.4%), adalimumab 6/10(60.0%), etanercept 5/8(62.5%). 

13 (29.5%) patients had an inadequate clinical response to the initial drug and 

were switched to an alternative treatment. 4 (9.1%) patients failed two 

consecutive drugs and were switched to a third treatment. 

Of the 28 patients with a good initial clinical response, BASDAI, BASMI, 

ESR and CRP results were available for 82.1%, 75%, 92.9% and 92.9% 

respectively as shown in Table 1. 

Conclusions: Anti-TNF therapies have been initially effective for a large 

proportion of our AS patients. However a significant minority do not respond 

to 1 or more anti-TNF drug. Initial response rates were broadly comparable 

between the three drugs. 

Table 1: Median data for AS patients responding to 1 st TNF inhibitor 

Months since commencing TNF inhibitor 

0 3 6 9 12 18 24 

NUMBER OF PATIENTS(N) 26 25 22 20 15 12 5 

CRP 22.1 5 7.65 8.15 6.1 3.85 4.1 

ESR 25.5 7 7.5 8 10 11.5 21 

BASDAI 6.6 5 5 4 3.3 3.5 4.7 

BASMI 6 5.5 5 6.5 4 3.5 0



28. DESCRIPTION OF A PILOT PHYSIOTHERAPY SERVICE IN BONE 

HEALTH 

A. Craig¹, S. Van der Kamp², M. McKenna³, O. Fitzgerald 4 

¹Physiotherapy Department, St. Vincent’s University Hospital, Elm Park, 

Dublin 4, Ireland, ²DXA Scan Department, St. Vincent’s University Hospital, 

Elm Park, Dublin 4, Ireland, ³Endocrinology Department, St. Vincent’s 

University Hospital, Elm Park, Dublin 4, Ireland, 4 Rheumatology Department, 


Specific types of exercise have been shown in the literature to have a positive 

effect on bone strength and density, especially when used in conjunction with 

medication and dietary/ lifestyle changes. 

Aim: To develop the physiotherapy element of a multi-disciplinary Bone 

Health service. 

Method: Audits of the number of patients referred into the DXA unit and 

physiotherapy department with Osteoporosis and Osteopenia highlighted a gap 

in the provision of a multidisciplinary service. 

Collaboration between the physiotherapy department and DXA unit resulted in 

a single referral card into both services. 

The framework for the physiotherapy service was developed using the CSP 

‘Physiotherapy guidelines for the management of Osteoporosis’. 

Results: This post has been granted funding for an initial period of 12 

months. Data on the numbers referred to the service, their diagnosis, 

medication, fracture and falls history and the previous management of their 

condition will be analysed. Outcome measures of those attending the group 

exercise classes and results of a patient satisfaction survey will also be 

analysed. The collection of further data may become relevant as the service 

develops. 

Conclusions: As experts in exercise prescription, physiotherapists have an 

important role to play as a member of the multidisciplinary team in the overall 

management of patients with Osteoporosis and Osteopenia. 

This new post is the first senior physiotherapy post in the country to be solely 

dedicated to bone health. 

This pilot physiotherapy service has the potential to become a template for 

identical programmes throughout the country. 

DXA – Dual-energy X-ray Absorptiometry 

CSP – Chartered Society of Physiotherapists (UK)



29. SHOULD ANTI CCP ANTIBODIES BE TESTED IN A DISTRICT 

GENERAL HOSPITAL? 

K. Yein, L. Williamson, E.J. Price, D.A. Collins 

Department of Rheumatology, Great Western Hospital, Swindon Wiltshire, 

UK 

Difficulty in making a definite diagnosis of early rheumatoid arthritis (RA) 

can delay treatment when there is an opportunity to control disease 

progression. Antibodies to circulating citrullinated peptide (CCP) may be 

present in RA sera with a reported higher sensitivity and specificity than 

rheumatoid factor. 

Aim: To assess whether anti-CCP antibodies can be a useful diagnostic aid in 

undifferentiated early arthritis in a district general hospital. 

Method: 176 patients with an established diagnosis and 47 patients with early 

undifferentiated inflammatory joint pain were tested for anti-CCP antibodies. 

Results were analysed using positive predictive value, negative predictive 

value, specificity and sensitivity. 

Results: Of 47 patients with undifferentiated arthritis, 17 had a final 

diagnosis of RA. 

Of these 11 were anti-CCP +ve , 12 were Rheumatoid factor +ve. Two 

patients without RA were anti-CCP +ve and remain undiagnosed. 

Of 176 patients with established diagnoses, 67 patients had RA, of these 38 

were anti-CCP +ve and 34 were RF +ve. Three patients without RA were 

anti-CCP +ve. 

Conclusion: In cases of established diagnoses our findings confirm 

previously published observations. In early inflammatory arthritis anti-CCP 

antibodies have a better positive predictive value of 85% and 93% specificity 

compared to RF (75% and 86%). 

Combination of anti-CCP antibodies and RF gives a high positive predictive 

value for RA, allowing more confident initiation of early aggressive therapy. 

Undifferentiated Arthritis 

Anti CCP 

antibodies 

Rheumatoid 

Factor 

Established Diagnosis 

Anti CCP 

antibodies 

Rheumatoid Factor 

PPV 85% 75% 92% 64% 

NPV 82% 80% 78% 79% 

SPECIFICITY 93% 86% 97% 77% 

SENSITIVITY 85% 75% 92% 64%



30. A HOLISTIC PERSPECTIVE OF PATIENT MEDICATION 

MANAGEMENT 

M. Molloy¹, A. Grier¹, P. Minnock², B. Bresnihan¹, D. Veale¹, O. FitzGerald¹ 

¹Rheumatology Departments St. Vincent’s University Hospital, Elm Park, 

Dublin 4 and ²Our Lady’s Hospice Harold’s Cross, Dublin6W, Ireland 

Treatment of Arthritis relies heavily upon medication(s) to improve or 

maintain functional ability. Yet medication errors not only cause personal 

suffering for the patient, but ultimately result in a monetary and time cost to 

the whole health service (Roycroft-Malone et al. 2002). Patients must be 

educated about their medication and know its purpose, mode of action, 

possible adverse effects and monitoring guidelines (An Bord Altranais 2003). 

Aim: It was decided to examine patient information requirements, patient 

expectations and medication information experiences to date. 

Method: Over eight weeks a convenience sample of patients from our 

Rheumatology service was invited to complete a specially designed 

questionnaire. Local ethical approval was obtained and patient confidentiality 

was assured. 

Results: The 116 patients who responded were spread across a wide range of 

diagnoses, ages and educational backgrounds. Patients stated that their 

preferred first choice for medication information was the clinic doctor at 91% 

and the clinic nurse at 9%, while 70% would use a telephone helpline to 

answer medication queries. The Internet was used to access medication 

information by 75%. Drug company information leaflets were read by 92% 

however 34% found the language too technical and 87% stated they wish 

information to include possible serious events. 

Conclusions: 

1. For patients using the Internet there is a need to source reputable websites 

that give accurate information. 

2. Medical staff must emphasise to patients that medication management is 

part of the Nurse Specialist’s role. 

3. Telephone help lines can be used as a source of medication information. 

Using the Internet for information. 

This graph illustrates the number of patients across the stated age 

range who used the internet for medication information. 

35 

30 

25 

20 

15 

Don't Check 

Web check 

10 

5 

0 

21-30 31-40 41-50 51-60 61-70 71-80 81-90 yrs 

A majority in all age groups up to 80 use the internet for information



References: 

An Bord Altranais. (2003). Guidance to Nurses and Midwives on Medication 

Management. An Bord Altranais. Dublin. 

Roycroft-Malone J., Latter S., Yerrell P. and Shaw D. (2000). Nursing and 

Medication education. Nursing Standard. 14. (50) 35-39.



31. A STUDY EXAMINING THE IMPACT OF INFLAMMATORY 

ARTHRITIS ON HUMAN RELATIONSHIPS 

A. Grier, M. Molloy, P. Minnock, B. Bresnihan, D. Veale, O. FitzGerald 

Department of Rheumatology, St. Vincent’s University Hospital, Dublin 

Inflammatory Arthritis describes a group of chronic conditions characterised 

by pain and stiffness. Chronic illness can lead to loss of interest and social 

isolation, which has an impact on forming and maintaining relationships. 

Aim: To assess the extent of the impact of inflammatory arthritis on human 

relationships in order to improve holistic nursing care. 

Method: A quantitative and qualitative patient survey was developed by the 

author based around the topic of forming and maintaining relationships. This 

survey was conducted over a 6-week period by patients attending the 

rheumatology outpatient clinic of a Dublin hospital. This constituted a 

convenience sample. 

Results: 114 surveys were completed, 79 by females, 19 by males. 16 

respondents did not indicate their gender. 68 respondents were in a 

relationship, 5 separated and 10 widowed; the remainder described themselves 

as single. 

83.9% of respondents aged between 41 and 60 indicated that their arthritis has 

made them feel isolated from family and friends. 36.8% of all respondents 

indicated that arthritis put a strain on relationships with family and friends, 

with 51.78% describing their arthritis as having a negative impact on 

communication and intimacy. 42.1% of respondents indicated that family and 

friends did not have a good understanding of their condition. 

Conclusion: Effective communication with patients, their family and friends 

and involvement of family members in education sessions is important in the 

promotion of healthy relationships. Using the findings of this survey in a 

positive and practical way may enhance patient care.



32. REFERRAL PATTERNS FOR DIAGNOSIS OF OSTEOPOROSIS IN AN 

IRISH PRIMARY AND SECONDARY HEALTHCARE SETTING 

K. O’Connell, S. Van der Kamp, M. McKenna*, O. FitzGerald 

Departments of Rheumatology and Endocrinology*, St Vincent’s University 

Hospital, Elm Park, Dublin 4, Ireland 

The population prevalence of osteoporosis is estimated at ~5%. With the 

advent DXA scanning and the availability of effective treatments, the 

consequences of osteoporosis can be prevented. Prevalence of risk factors may 

differ in primary and secondary healthcare settings. 

Aim: The aim of this study was to examine referral patterns for patients being 

assessed for osteoporosis and evaluate whether differences exist between patients 

referred from primary and secondary care setttings. 

Method: In this cross-sectional study a group of 398 patient surveys and DXA 

scan results were assessed. These patients were selected at random over a fourmonth 

period from January to April 2005 and were found to be representative of all 

patients scanned in the department over the last ten years. 

Results: Of the 398 patients (349 female; 49 male) reviewed, 72 (18%) were 

diagnosed with osteoporosis. 61% were referred from secondary care and 39% 

from primary care settings. Only 2.7% of primary care referrals were men 

compared to 20% referred from secondary care. The incident rate of 

osteoporosis among men was 28% and among women was 26%. 47% of 

patients referred from secondary care setting had been exposed to 

corticosteroids compared with only 14% of primary care referrals. 

Conclusions: In this study population, the overall incidence of osteoporosis is 

comparable in men and women. As the number of male referrals is low 

particularly from the community, this suggests that there is a low index of 

suspicion of osteoporosis in males and that it is under-diagnosed. The high 

level of steroid use among hospital based referrals demonstrates an increased 

awareness for steroid-induced osteoporosis and reflects differences in the type 

of patients seen in primary and secondary healthcare settings.



33. DO ONCE AND SHARE – PUTTING RHEUMATOID ARTHRITIS ON THE 

COMPUTERS OF EVERY CLINICIAN IN ENGLAND (AND ANYONE ELSE WHO 

IS INTERESTED!) 

A.K. Clarke 1 , E. Mooney 1 , C. Fokke 1 , C. Washbrook 1 , H. Kingston 2 , L. Howard 3 , D. 

Squire 4 

1 Royal National Hospital for Rheumatic Diseases, Bath, U.K, 2 General Practitioner, 

Frome, Somerset, U.K, 3 Department of Health, Leeds, U.K, 4 Avon, Gloucester & 

Wiltshire Strategic Health Authority, Chippenham, Wilts, U.K 

The Department of Health has launched one of the most ambitious information 

technology projects in Europe, which aims to provide a unified nation-wide 

computerised information system for the whole of the National Health Service in 

England – Connecting for Health (CfH). It is expected that a healthcare professional 

attending a patient anywhere in England would have access to all the medical 

information required to ensure the best outcome for that patient. For this to be a 

success a number of elements are required. Firstly, the patient needs to be accurately 

identified. Security of access is essential and only available with the patient’s express 

permission. All data collected about the patient needs to be available. This requires 

as the first prerequisite the establishment of an electronic medical record which can 

be accessed remotely and which can be updated in real time. 

Another facility that could be offered is compendium of guidelines that would assist 

with the diagnosis and management of a wide range of clinical conditions. As part of 

CfH, the Do Once & Share (DOAS) programme has been established. So far 45 

conditions have been identified. One of these is Rheumatoid Arthritis (RA). The RA 

DOAS team has completed its work. The purpose of this presentation is to explain 

how the team set about its task, producing guidelines that were translated into 

integrated patient pathways, which were then developed into an interactive web-based 

programme and then agreed with the various stakeholders in the UK. 

The website can be accessed on 

www.doasra.pwp.blueyonder.co.uk/index.html



34. PATIENTS ON ANTI-TNF THERAPY: LEVELS OF 

SATISFACTION WITH THE RHEUMATOLOGY CLINICAL NURSE 

SPECIALIST SERVICE AT ST. JAMES’S HOSPITAL 

C. Doyle, G. Cunnane, M. Doran 


Anti-TNF therapy has emerged in recent years as a new treatment option for 

patients with rheumatoid arthritis. As it is important that patients receiving 

anti-TNF therapy have education and support available to them, the Clinical 

Nurse Specialist (CNS) reviews all patients prior to and at regular intervals 

during treatment with these therapies. 

Aim: The aim of this study was to evaluate patient satisfaction with this 

service. 

Method: A database is maintained for all patients receiving anti-TNF therapy 

(etanercept and adalimumab) at St. James’s Hospital. A patient satisfaction 

questionnaire was developed by the CNS and sent to all 60 patients on the 

database in January 2006. It consisted of 10 questions evaluating the service 

provided by the CNS. 

Results: Forty questionnaires were returned (67%). Of the respondents, 75% 

had been on anti-TNF therapy for at least 6 months. 85% of patients felt 

adequately supported and 82% rated the service as very good or excellent. 

The vast majority of patients (80%) found it easy to contact the CNS, either by 

phone, email or attendance at the Rheumatology Day Centre. Only one patient 

was unaware of the correct course of action to take in the event of developing 

an infection. 

Conclusion: These results confirm both the important role and the perceived 

benefit of the rheumatology CNS for patients receiving anti-TNF therapy. A 

small number of patients may require further education to increase awareness 

of the service that is provided by the CNS, and to highlight safety issues 

relating to anti-TNF therapy.



35. FIBROMYALGIA; THE ROLE OF THE RHEUMATOLOGY NURSE 

U. Bond, M.J. Regan, M. Phelan 

South Infirmary-Victoria University Hospital, Cork, Ireland 

Fibromyalgia is a syndrome of chronic widespread pain which results in 

abnormal sensory processing in the central nervous system. Onset is gradual, 

fatigue and sleep disturbances are characteristic features, leading to stress and 

coping difficulties. 

Successful management involves an individualised, comprehensive and goal 

orientated approach and should focus on increasing the patients knowledge of 

the syndrome, pain and pharmacological management, disordered sleep and 

coping strategies and co-ordinating the activities of the multidisciplinary team. 

Coping skills can be measured using health assessment questionnaire (HAQ) 

and fibromyalgia impact questionnaire. (FIQ) Visual analogue scale (VAS) 

can measure pain and fatigue, the impact of exercise can be measured using 

the (6) minute walk test. 

The role of the rheumatology nurse, in terms of education, support, coordinating 

activities of the multidisciplinary team and evaluating the success 

of the treatment strategies is pivotal to the successful management of the 

syndrome.



36. FATIGUE IS SENSITIVE TO CHANGE IN PATIENTS WITH 

INFLAMMATORY ARTHRITIS FOLLOWING ANTI-TNFα THERAPY 

P. Minnock, A. Gibbs, J. Martin, D. Veale, O. FitzGerald, B. Bresnihan 

Our Lady’s Hospice and St Vincent’s University Hospital, Dublin, Ireland 

Aim: To examine the sensitivity to change of fatigue, and its relative 

independence as an outcome measure, in patients with inflammatory arthritis 

commencing anti-TNFα therapy. 

Method: Successive patients with rheumatoid arthritis (RA) and 

spondyloarthritis (SpA) commencing anti-TNFα therapy were evaluated at 

baseline and 3 months. Fatigue was measured using a 10-point numeric rating 

scale (NRS). Sensitivity to change of fatigue in RA was compared with the 

core set outcome measures and determined by calculating the standardized 

response means (SRM). Multiple regression analysis was employed to 

determine the independent variance. 

Results: A total 106 patients were evaluated (RA, 49; SpA, 57). At baseline, 

mean (SD) fatigue levels were 6.8 (2.1) and 5.6 (2.3) in RA and SpA, 

respectively. At 3 months, fatigue levels had fallen to 4.4 (2.6) (p=0.001) and 

3.6 (2.2) (p=0.001). Test-retest correlation of fatigue in RA was 0.72, 

p=0.009. Fatigue was ranked third in its relative sensitivity to change: pain 

1.37, TJC 1.09, fatigue 0.92, SJC 0.86, HAQ 0.82, CRP 0.69, ESR 0.68, GH- 

0.25. The relative independent variance of fatigue was 26%, greater than the 

core set measures: TJC 24%, pain 23%, SJC, 19%, HAQ 8%, ESR 0%, and 

CRP 0%. The changes in fatigue levels at 3 months did not correlate with the 

changes in DAS28 values in either group, suggesting that improvements in 

fatigue levels were independent of the treatment effects on disease activity. 

Conclusion: Measures of fatigue are reliable and sensitive to change in 

patients with inflammatory arthritis following TNFα blockade. These 

observations support the suggestion that inflammation is not the sole 

determinant of fatigue in either RA or SpA.



37. REDUCED INFUSION TIMES IN PATIENTS RECEIVING 

INTRAVENOUS INFLIXIMAB: A PROTOCOL FOR PRACTICE 

E. Shinners, M. O Neill, L. Moore, R. Adams, B. O’Grady, B. Sanchez, C. 

Slattery, I. Cormican, D. Veale, O. FitzGerald, B. Bresnihan, P. Minnock 

St. Vincent’s University Hospital and Our Lady’s Hospice, Dublin, Ireland 

Intravenous (IV) infliximab is an established second line treatment of 

moderate to severe rheumatoid arthritis, psoriatic arthritis, and ankylosing 

spondylitis. According to product information infliximab infusions should be 

administered over 2 hours, with half hourly monitoring of vital signs for the 

duration of the infusion and 1 hour post. 

Aim: To implement evidence based policy and procedure protocol for safely 

reducing infusion times in patients prescribed infliximab. 

Methods: Guided by available reported studies the established policy and 

protocol for practice was updated. All infusions were administered in our day 

care unit using the following infusion and monitoring regimen: 

Results: Since its introduction 98 patients established on the old infusion 

regimen have changed to the reduced infusion rate. One patient with a history 

of mild infusion related reactions is maintained on the 1-hour infusion 

duration without incident to date. All patients newly prescribed infliximab 

since the policy was updated receive their infusion according to the new 

schedule. Over 479 infusions have been administered. The incident of 

infusion related reactions was minimal with only one case of severe 

bronchospasm reported. 

Conclusion: Our positive experience adds to the limited evidence base for 

safely reducing infusion times in patients prescribed IV infliximab with 

associated cost-effectiveness and patient satisfaction. 

Infusion number Infusion duration Monitoring schedule Post infusion monitoring 

1-5 2 hours ½ hourly TPR, B/P ½ hourly TPR, B/P for 2 hours 

6-10 1 hour ½ hourly TPR, B/P ½ hourly TPR, B/P for 1 hour 

10+ 30 minutes TPR B/P prior and post TPR, B/P 30 mins post 

Greatest care is taken during the first 5 infusions. Infusion 6+ can be administered at the faster rate 

provided no adverse events are observed during the first 5 infusions.



38. ADMINISTRATION OF INTRAVENOUS CYCLOPHOSPHAMIDE IN 

RHEUMATOLOGY CLINICAL PRACTICE: LOCAL POLICY AND 

PROCEDURE DEVELOPMENT TO SUPPORT SAFE PRACTICE 

M. O Neill, R. Adams, M. Lynch, L. Moore, E. Noone, E. Shinners, B. 

Sanchez, C. Slattery, D. Veale, O. FitzGerald, B. Bresnihan, P. Minnock 

St. Vincent’s University Hospital and Our Lady’s Hospice, Dublin, Ireland 

Cyclophosphamide is used to treat systemic rheumatic diseases. Its ‘neutral 

group 5’cytotoxic drug classification indicates the relative low risk of 

associated tissue necrosis in the event of tissue extravasations. 

Aim: To implement evidence protocol to govern the appropriate use and safe 

administration of intravenous (IV) cyclophosphamide outside of traditional 

oncology departments. 

Methods: Using the local policy template a protocol to govern the safe 

handling and administration of iv cyclophosphamide was collaboratively 

developed. An experienced oncology nurse delivered appropriate training for 

staff on the safe handing, administration, patient monitoring and disposal of 

necessary equipment. 

Results: Since 2002 144 IV cyclophosphamide infusions have been 

administered to 37 patients. Diagnoses include systemic vasculitis (n), 

systemic sclerosis (n), wegener’s granulomatous (n). Usual treatment regimen 

are 10-15mgs per KG or 500-1357mg/m 2 in 100mls of normal saline 0.9%, 

infused over 30 minutes, monthly for 6 months. Cytotoxic induced side 

effects are managed with either first line anti-emetic premedication, cyclizine 

50mgs po, or second line, ondansetron 8mgs po, each 30minutes prior to 

treatment, potential urothelial toxicity is prevented by co-prescription of 

urometixan 2 hours prior and 2 and 6 hours post infusion. Infusions are 

administered to patients in our day care unit ordinarily. Over night 

accommodation was arranged as required for patients who experienced 

distressing nausea and vomiting post 1 st treatment. The 2 nd line anti-emetic 

agent successfully prevented the reoccurrence of these events. 

Conclusion: This collaboratively developed policy supports the safe and 

effective introduction of this ‘neutral group 5’cytotoxic drug in rheumatology 

departments.



39. FEASIBILITY AND SAFETY OF ADMINISTRATION OF 

RITUXIMAB IN RHEUMATOLOGY CLINICAL PRACTICE: LOCAL 

POLICY AND PROCEDURE DEVELOPMENT TO SUPPORT SAFE 

PRACTICE 

L. Moore, M. Lynch, R. Adams, E. Noone, S. Gonzalez, B. Sanchez, D. 

Veale, O. FitzGerald, B. Bresnihan, P. Minnock 

St. Vincent’s University Hospital, and Our Lady’s Hospice Dublin, Ireland 

Rituximab is a chimeric, anti-CD20 monoclonal antibody, developed to treat 

patients with B cell lymphoma. Evidence exists that selective B cell depletion 

using rituximab is beneficial in patients with rheumatoid arthritis (RA), 

systemic lupus erythematous (SLE), and other autoimmune diseases. 

Aim: To implement evidence based policy and protocol to govern the 

appropriate use and safe administration of intravenous (IV) rituximab. 

Method: A comprehensive literature review of available reported studies was 

undertaken by the relevant members of the multidisciplinary team; nurses, 

pharmacist, doctors and administrative staff. The local policy template was 

employed and a protocol to govern the safe administration of rituximab was 

collaboratively written. The protocol provides a succinct report on general 

drug information, indications for use, guidelines on pre-treatment screening, 

optimal dose, treatment schedules and recommended adjuvant therapy, 

potential adverse events, special precautions, and management of infusion 

related reactions. 

Results: To date 84 rituximab infusions have been administered to 36 

patients. Four different combination treatment regimens have been used. 

Recommended infusion rate of rituximab is 4 hours 15 minutes. Nursing time 

allocation is approximately 7 hours when preparation, pre-treatment screening, 

premedication with methylprednisolone and patient support are considered. 

The experience of adverse events was minimal and infusion related reactions 

were effectively managed according to protocol. 

Conclusion: This collaboratively developed policy facilitated the safe and 

effective introduction of IV rituximab into clinical practice locally. Sharing of 

new treatment protocols across rheumatology centres nationally would 

enhance standardisation, feasibility, safety, learning and cost effectiveness. 

Protocols could be adapted to suit local needs.



40. RHEUMAOTOLOGICAL CONDITIONS AND THEIR 

MANAGEMENT IN THE COMMUNITY 

L. Spooner, S. Donnelly, C.J. McCarthy, G.M. McCarthy 

Rheumatology Department, Mater Misericordiae University Hospital, Eccles 

Street, Dublin 7, Ireland 

Aims: To identify a system of effective care for common musculoskeletal 

disorders in conjunction with GPs. 

Methods: A twenty-four item questionnaire on: osteoarthritis (OA), 

osteoporosis (OP), acute inflammatory arthritis and fibromyalgia (FM)) was 

circulated among GPs in the hospital catchment area. 

100 questionnaires were distributed by post or hand at a GP postgraduate 

seminar in MMH. 

Results: 40 fully completed questionnaires, were analysed. 68% of GPs 

report access to physiotherapy as non-existent. 

65% perform joint aspirations/injections. Of those who do not 52% lack skill, 

42% lack time. In OP, 90% of high risk patients are referred for DEXA 

scanning. 

65% of GPs arrange follow-up DEXA scanning, 65% of whom also find it 

easy to schedule DEXA. Difficulties in obtaining DEXA are attributed to cost 

not covered by medical card (65%). 50% of GPs treat OP without DEXA. 

50% of GPs diagnose FM on a monthly basis, 36% never diagnose the 

condition and 4% diagnose it daily. 

80% of GPs investigate FM, 71% refer to physiotherapy. 

68% of GPs see 20-30 cases of acute inflammatory arthritis yearly and 95% 

agree that time to OPD too long. 85% of GPs believe a template referral letter 

or e-mail referral to rheumatology departments would improve service. 

Conclusions: Limitations to the management of acute and chronic 

musculoskeletal disorders in the community are highlighted by our study, 

particularly in acute inflammatory arthritis. An increase in numbers of 

rheumatologists and musculoskeletal physiotherapists are needed.



41. QUALITY OF LIFE AND EXERCISE ACTIVITY IN PATIENTS 

WITH ANKYLOSING SPONDYLITIS: A CROSS-SECTIONAL SURVEY 

M. Fitzpatrick 1 , O. FitzGerald 2 , A. Staines 3 , D.A. Hurley 4 

1 Physiotherapy Department, St. Vincent’s University Hospital, Dublin, 

Ireland, 2 Rheumatology Department, St. Vincent’s University Hospital, 

Dublin, Ireland, 3 UCD School of Public Health and Population Science, 

Earlsfort Terrace, Dublin, Ireland, 4 School of Physiotherapy and Performance 

Science, UCD Health Sciences Centre, Belfield, Dublin, Ireland 

Aim: The aim of this study was to determine the health-related quality of life 

(HRQoL) and exercise activity of patients with Ankylosing Spondylitis (AS). 

Methods: A cross-sectional postal questionnaire survey was conducted. 

Patients with AS in two centres were eligible for inclusion. The survey 

included a demographic profile sheet, bath AS disease activity index 

(BASDAI), AS quality of life questionnaire (ASQoL), short form 36 version 2 

(SF-36v2) and a researcher-designed exercise questionnaire. Data were 

entered into spreadsheets for descriptive statistical analysis using the 

Statistical Package for the Social Sciences Version 11. 

Results: There was a 54.4% response rate (198/364): 140 males (70.7%), age 

(mean ± SD) 44.3 ± 12.3 years, and disease duration13.8±10.6 years. The 

scores (mean ± SD) were BASDAI (from 0 the best to 10 the worst) 4.3±2.2, 

ASQoL (from 0 good QoL to 18 poor QoL) 6.9±5.2, SF36v2 (from 0 the 

worst possible health state to 100 best possible health state) physical 

component summary 41.7±9.6 and SF36v2 mental health component summary 

45.7±12.7. Only 20.5% were performing an exercise programme to a 

therapeutically beneficial level. Similarly, only 30.3% were physically active 

for >200 minutes per week. The most common obstacles to exercise were 

lack of time and motivation. There was no statistically significant difference 

in quality of life scores between either exercise compliers or non-compliers. 

Conclusions: AS patients experienced adverse effects on their HRQoL. Only 

a minority practice a therapeutically beneficial regular exercise regime. The 

results showed that there were no significant associations between HRQoL 

and performance of exercise.



42. 5 YEAR CHANGES IN HAQ IN THE RA CLINIC PATIENT 

POPULATION IN THE PRE-BIOLOGIC AND BIOLOGIC ERAS 

J. Rathi, M.C. Greenwood, D.V. Doyle 

Academic Rheumatology and Osteoporosis Unit, Whipps Cross University 

Hospital, London, UK 

Aims: To determine whether the overall rate of progression in disability as 

measured by HAQ across all RA patients attending clinic has been reduced 

now that biologic therapies are an option for patients with more severe disease 

(NICE/BSR guidelines). 

Method: Changes in HAQ were calculated for two cohorts of patients 

attending the same clinic. Cohort 1 was assessed over 5 years in the prebiologic 

era and cohort 2 over the next five years during which biologic 

therapy was introduced into practice. 

Results: 

Cohort 1 

(93/94 to 98/99) 

Cohort 2 

(98/99 to 03/04) 

23 men, 52 women 41 men, 103 women 

Mean initial age 60 yrs 61 yrs 

Median initial disease 14 yrs 10 yrs 

duration 

Significant comorbidity 28% 22% 

Median initial HAQ 1.50 1.50 

Median initial ESR 20 24 

Mean 5 year HAQ score 

change * 

+ 0.18 

95% CI (0.06, 0.29) 

+ 0.12 

95% CI (0.04, 0.21) 

25 (17%) of cohort 2 had commenced biologic therapy 

*No significant difference (t-test 2-tail p = 0.484) 

Conclusions: Improvement in physical function is a significant patientperceived 

benefit of Anti-TNF therapy [1] but 5 year follow up by HAQ was 

unable to demonstrate that their introduction into clinical practice had reduced 

the burden of disability among our RA clinic patient population as a whole. 

This may be due to poor responsiveness of HAQ in patients with more 

advanced disease and indicates a need for an alternative measure capable of 

reflecting the response to biologic therapy of patients with longstanding RA. 

Reference: 

1. Marshall NJ, Wilson K, Lapworth K and Kay LJ. Patient perceptions of 

treatment with anti-TNF therapy for rheumatoid arthritis: a qualitative study, 

Rheumatology 2004;43:1034-1038



43. COMPLEMENTARY AND ALTERNATIVE MEDICINE USE IN 

RHEUMATOID ARTHRITIS AND ITS EFFECTIVENESS AS PERCEIVED 

BY PATIENTS 

A.J. Kinder, J. Edwards, S. Smith, W. Hassan 

Rheumatology, Leicester Royal Infirmary, Leicester, UK 

Complementary and alternative medicine (CAM) use is increasing particularly 

in those with chronic diseases. 

Aim: To establish the number of patients with rheumatoid arthritis who use 

CAM and what they are using. 

Method: 141 patients filled in a questionnaire on disease demographics and 

CAM. 

Results: The 141 patients consisted of 109 females and 32 males with 

average age 59 (min 18; max 85). All had rheumatoid arthritis with average 

disease duration of 7.9 years (min 1; max 37). 

121/141(86%) of patients had tried CAM with 74/141(52%) trying cod liver 

oil, 37/141(26.2%) using glucosamine and 25/141(17.7%) trying a copper 

bracelet. Patients had also used acupuncture (17%), reflexology (5.7%), fish 

oil (10.6%), ice (14.2%), heat (12.7%), vitamins (14.2%), yoga (4.9%), 

evening primrose oil (11.3%), magnet therapy (5.6%) and aromatherapy 

(6.4%). 

46/121(38%) of patients felt CAM had worked and 19/121 (15.7%) thought it 

had partially helped their symptoms. 36/121(29.7%) felt CAM gave them no 

benefit. 

83/141(58.9%) of patients felt CAM should be available on the health service. 

Conclusion: CAM use is widespread among patients with rheumatoid 

arthritis. From our study 54% of patients found some benefit from CAM. 

59% of patients felt CAM should be provided by the health service. Patient 

empowerment is strong on the agenda of the modern health service so this 

raises the question on whether we should be providing CAM.



44. QUALITY OF LIFE ISSUES: JUVENILE IDIOPATHIC ARTHRITIS 

AND YOUNG PEOPLE IN IRELAND 

M. O’Hara 

Department of Nursing & Midwifery Studies, National University of Ireland, 

Galway, Co Galway, Ireland 

Juvenile idiopathic arthritis (JIA) is a complex chronic inflammatory group of 

conditions that can cause serious complications in physical function and may 

significantly affect the well-being of the young person. Classification of JIA 

continues to evolve, resulting in better knowledge and understanding of the 

patient subgroups. Manners (2002) reported the prevalence of JIA as varying 

between 0.07 and 4.01 per 1000 children with an annual incidence of 0.008- 

0.226 per 1000 children. Physical function limitations, and psychosocial 

issues may impact on the health related quality of life. Disease management is 

often complex. The aim is to achieve disease remission. Treatment goals 

include the prevention of damage to joints and other organs and the promotion 

of normal physical and psychosocial development (Wallace 2006). The 

condition frequently necessitates visits to specialised medical services and inhospital 

stays. These can impact on the young person’s social time and 

education (Sallfors 2002 et al.). Concerns including altered body image, 

social acceptance, independence and future prospects may have an impact on 

the health related quality of life of young people with JIA (Barlow et al. 1999). 

Aim: This PhD study is exploring quality of life issues as perceived by young 

people aged between 12-18 years with juvenile idiopathic arthritis. 

Method: During phase two of three phases of the data collection 10 young 

people with JIA were interviewed. 

Results: This poster presentation highlights some of the key themes identified 

by those interviewed in relation to JIA and the approach they would like to the 

provision of their health care. 

Conclusions: Quality of life may be impacted by JIA. 

Reference: 

Manners PJ & Bower C worldwide prevalence of juvenile arthritis – why does 

it vary so much? The Journal of Rheumatology (2002) 29 pp.1520-1530.



45. REDUCTION OF DMARD’S IN RHEUMATOID ARTHRITIS 

PATIENTS AFTER INITIATION OF ANTI – TNF THERAPY 

P.J. Kavanagh, N. Ferris, A. Cassidy, G.M. McCarthy, C.J. McCarthy 

Department of Rheumatology, Mater Misericordiae University Hospital, 

Dublin 7, Ireland 

The aim of this study is to examine the reduction of conventional disease 

modifying anti – rheumatic drugs (DMARD’s) after the introduction of anti – 

TNF therapy in a rheumatoid arthritis (RA) patient cohort. 

Method: Data was collected on patients who had commenced anti – TNF 

therapy between November 2000 and October 2005 for RA. This consisted of 

128 patients; 103 female and 25 male. Age range 19 - 80 years with a mean 

age of 53 years. On initiation of anti – TNF therapy, 12 patients were not 

receiving any DMARD. 

Results: The results showed that of the 116 patients receiving DMARD’s, 37 

were receiving a single DMARD and 79 were receiving a combination of 

DMARD’s. Within six months of commencing anti – TNF therapy 21 patients 

(18%) had ceased taking one or more DMARD’s. During the timeframe of the 

study we identified that 36 patients (31%) reduced the dose of their DMARD 

while 17 (15%) increased the dose. A total of 29 patients (25%) stopped one 

or more DMARD’s while 108 patients (93%) remain on one or more 

DMARD. Ninety five patients were receiving methotrexate on 

commencement of anti – TNF therapy; of which 9 (9%) discontinued during 

the course of the study. 

Conclusion: This study has shown that the introduction of anti – TNF therapy 

has allowed for reduction of traditional DMARD medication within a short 

period of time, therefore reducing the risk of toxicity. We plan to develop a 

protocol derived from this information to have a schedule of DMARD 

reduction after the introduction of anti – TNF treatment. 

Number of DMARD’s 1 2 3 4 

Patient Number at anti –TNF initiation 37 57 20 2 

Patient Number 6 months post initiation of anti – TNF 

therapy 

34 43 17 1



46. THE RELATIONSHIP BETWEEN ANAEMIA OF CHRONIC 

DISEASE, DISEASE ACTIVITY AND HEALTH-RELATED QUALITY OF 

LIFE IN PATIENTS WITH RHEUMATOID ARTHRITIS TREATED WITH 

ANTI-TNFα THERAPY 

A. Gibbs, C. Walsh, O. FitzGerald, D. Veale, B. Bresnihan 


Objective: To looked at the effects of anti-TNFα therapy on ACD and 

investigate if there is a correlation between change in haemoglobin (Hb) and 

change in disease activity and general health. 

Methods: ACD was defined as Hb < 11.5 for females and



47. CLINICAL AND IMMUNOHISTOLOGICAL OUTCOMES IN 

PATIENTS WITH PSORIATIC ARTHRITIS TREATED WITH ANAKINRA 

A. Gibbs, M. Gogarty, B. Bresnihan, D. Veale, O. FitzGerald 


Aim: To assess the effects of IL-1 inhibition on clinical and 

immunohistological features of PsA disease activity. 

Methods: 12 patients (7 male; 5 female, average age 46 years (22-61)) were 

enrolled in a 12 week open-label study of anakinra 100mg daily. Physical 

examination, ESR, CRP and PASI were performed at all visits. MRI and 

arthroscopy of an inflamed knee joint, HAQ, patient assessment of disease 

activity and pain were done at baseline and week 12. Synovial biopsies were 

stained for CD3, CD68 and factor VIII. Digital image analysis was used to 

quantify these markers. The primary clinical endpoint was the proportion of 

patients who met PsARC at 12 weeks. 

Results: 6/10 patients met the PsARC at week 12. Mean DAS28 score 

changed from 5.3 (3.8-7.2) to 4.2 (2.3-6) [p=0.027]. Other relevant clinical 

data are listed. Mean FVIII, CD3 and CD68 scores changed from 6.1(1.6- 

10.3), 2.77(0.3-13.0) and 20.9(8.2-53.1) respectively to 8.2(4.5-15.4) 

[p=0.66], 4.7(4.9)[p=0.11] and 25.9(11.6-49.3)[p=0.21] respectively. 

Conclusions: This open-label, proof-of-concept study shows anakinra to be 

of modest benefit for articular but not skin disease in PsA. These clinical 

improvements however, did not correlate with immunohistological findings, 

which showed a trend to overall worsening of disease activity. 

Patient 

assessment of 

disease activity 

Physician 

assessment of 

disease activity 

TJC SJC Patient 

assessment 

of pain 

PASI ESR CRP 

Baseline 2.2 

(1-3) 

2.4 

(1-3) 

28 

(11-51) 

21 

(7-29) 

63 

(21-91) 

6.3% 

(1-16) 

22 

(3-79) 

26 

(4-70) 

Week 12 1.7 

(1-3) 

p=0.25 

1.6 

(1-3) 

p=0.016 

16 

(2-36) 

p=0.01 

10 

(0-25) 

p=0.018 

47 

(20-75) 

p=0.18 

6.8% 

(0-26) 

p=0.81 

14 

(2-46) 

p=0.04 

10 

(4-29) 

p=0.08



48. HEALTH-RELATED QUALITY OF LIFE (QOL) IN 

MUSCULOSKELETAL DISEASES – A COMPARISON BETWEEN 

RHEUMATOID ARTHRITIS, PSORIATIC ARTHRITIS AND ANKYLOSING 

SPONDYLITIS 

A. Gibbs, D. Veale, O. FitzGerald, B. Bresnihan 


Objective: 1. Compare QoL measures in patients with inflammatory arthritis 

with a healthy control population [1]. 

2. Compare QoL measures in patients with PsA and AS to patients with RA. 

Methods: Health-related QoL was measured using the SF-36 and the HAQ. 

Logistic regression analysis was used to compare results in the different 

disease categories. 

Results: 247 patients were evaluated. In each of the 3 patient populations, all 

QoL measures were significantly lower than in the control population 

(p



49. ECONOMIC IMPLICATIONS OF SWITCHING ANTI-TUMOUR 

NECROSIS FACTOR-ALPHA (ANTI-TNFΑ) THERAPY IN PATIENTS 

WITH RHEUMATOID ARTHRITIS (RA) 

C.A.E. Walsh, P. Minnock, C. Slattery, N. Kennedy, F. Pang, D.J. Veale, B. 

Bresnihan, O. FitzGerald 

Department of Rheumatology, St. Vincent’s University Hospital, Dublin, 


Aim: To evaluate quality of life (QoL), economic and clinical impact of 

switching patients with RA from infliximab therapy to adalimumab. 

Methods: Patients established on infliximab received 2 further infusions and 

were switched to adalimumab once fortnightly and followed for 16 weeks. 

Clinical, functional, laboratory and economic data were collected. Economic 

data included health professional’s salaries, patient-related loss of earnings 

and travel costs, laboratory, concomitant medication and anti-TNFα therapy 

costs. 

Results: Nineteen patients were recruited and completed the study. No 

significant difference was seen in HAQ, RAQoL or SF-36 scores after switch. 

Total costs prior to switch were €114,980 and after switch were €131,549. 

One-year extrapolation data showed potential reductions in costs following 

switching to adalimumab primarily attributable to reductions in patient and 

staff-related costs (Table 1). A significant reduction was seen in the DAS28 

and CRP (p



50. CLINICAL OUTCOME IN PATIENTS SWITCHING BIOLOGIC 

THERAPIES FOR INFLAMMATORY ARTHRITIS 

T. Rooney, P.J. Kavanagh, A. Cassidy, N. Ferris, S. Donnelly, G.M. 

McCarthy, C.J. McCarthy 

Department of Rheumatology, Mater Misericordiae University Hospital, 

Dublin 7, Ireland 

Aim: To examine the efficacy of biologic therapy for inflammatory arthritis 

in patients changing biologic agents due to lack of efficacy or intolerance. 

Methods: All patients receiving a second or subsequent biologic therapy for 

inflammatory arthritis between November 2002 and May 2006 at the Mater 

Misericordiae Hospital department of Rheumatology were identified. Chart 

review was performed and current therapy defined as successful based on 

physician’s opinion and lack of requirement for additional maintenance or 

rescue therapy. 

Results: From a total of 191 patients receiving biologic therapy, 44 (23%) 

were included in the study. Mean (range) age was 51 (19 – 69) years and 37 

(84.1%) were female. The underlying diagnoses were: rheumatoid arthritis (n 

= 35), psoriatic arthritis (n = 4), ankylosing spondylitis (n = 3), adult-onset 

Still’s disease (n = 1) and undifferentiated spondylarthropathy (n = 1). 

Of these patients, 79.5% had received 1 previous biologic agent, while 15.9% 

had received 2 and 2.3% had received more. Therapy was changed due to lack 

of efficacy in 70.5% of patients and drug intolerance in 29.5%. 

Of 35 patients who had required one change of biologic agent, current therapy 

was successful in 77.3%, whereas of the remaining 9 patients requiring more 

than 1 change, 55.6% had satisfactory disease control. Similar outcomes were 

observed in patients changing therapy whether due to inefficacy or 

intolerance. 

Conclusion: Successful control of inflammatory arthritis is achieved in the 

majority of patients changing biologic therapy due to lack of efficacy or 

intolerance.



51. CANCER OCCURRENCE IN NORTHERN IRELAND SYSTEMIC 

LUPUS ERYTHEMATOSUS PATIENTS 

M.T. McHenry 1 , N. Anderson 2 , R. Clarke 3 , A.L. Bell 1 

1 Lupus Research Group, Queen’s University Belfast, Northern Ireland, 

2 Pathology Department, Belfast Link Laboratories, Belfast, Northern Ireland, 

3 Pathology Department, Craigavon Area Hospitals Trust, Craigavon, Northern 


An association between lupus and malignancy has been previously 

investigated and conflicting results found. Northern Ireland’s lupus 

population has not previously been studied. 

Aim: Review of malignancy in Northern Ireland’s lupus population. 

Methods: 233 female lupus patients were recruited. Details were obtained 

from medical records, the Northern Ireland Pathology Database and the 

Northern Ireland Cancer Registry. 

Results: 20 malignancies were identified in 11/233 lupus patients, (Table 1). 

The lupus population was compared to a matched population with diagnosis of 

cancer between 1993-2003 therefore 3 SLE patients were excluded. 8 

observed rather than 12 expected lupus patients developed a malignancy SIR 

0.67(95% CI 0.21-1.14). 

There was no significant difference in the distribution of lupus patients 

diagnosed with more than one primary tumour or more than one malignant 

tumour, (P value not significant). 

Conclusions: The lupus patients had a lower SIR than the Northern Ireland 

population however the standard error was high and therefore results not 

significant. 

There was no indication of a significance difference between cancer in lupus 

patients and in the population as a whole. However, the sample size was 

small. 

Table 1 

Patient ID Malignancy Year of malignancy 

1 Stomach adenocarcinoma 2003 

2 3 Breast carcinoma 1993 

3 Breast ductal carcinoma 1996 

4 Breast ductal carcinoma 1992 

5 Cervix malignant 1992 

6 Endometrium adenocarcinoma 2001 

7 Ovary endometroid carcinoma 1993 

8 3 Ovary serous carcinoma 2004 

9 Kidney renal cell carcinoma 1995 

10 2 Brain neuroepithelioma 1998 

11 2 NHL & 3 salivary gland melanoma 2002



52. CERVICAL SMEAR REPORTING IN NORTHERN IRELAND 

SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS 

M.T. McHenry 1 , N. Anderson 2 , R. Clarke 3 , A.L. Bell 1 





SLE is an autoimmune disease with the potential for multi-organ involvement. 

It has been suggested that SLE patients may be at increased risk of cervical 

dysplasia. 

Aim: We studied a cohort of Northern Ireland Lupus patients and compared 

them to controls within the same geographical location assessing their cervical 

smear histories and performed an up-to-date cervical smear. 

Methods: 141 SLE patients fulfilling the ACR criteria for lupus were 

enrolled into the study. They were compared to 138 control patients who were 

due to attend for a routine cervical smear within the same geographical 

location. Each patient gave written consent to be involved in the study 

including access to medical records and pathology data. 

Results: 

Cervical SLE 

Smear report N=141 

Unsuitable 5.7% 

(8/141) 

Low grade 15.6% 

(22/141) 

High grade 4.3% 

(6/141) 

Life time 41.8% 

occurrence of (59/141) 

any abnormal 

cervical smear 

Controls 

N=138 

9.4% 

(13/138) 

10.9% 

(15/138) 

2.2% 

(3/138) 

29% 

(40/138) 

Conclusion: 

Latest cervical smear reports between the 2 groups showed an increase in low 

grade and high grade cervical smear abnormalities in the SLE group. 

SLE patients appear to have an increased rate of lifetime occurrence of 

abnormal smear. The control group of patients were younger than SLE 

patients and when this was taken into consideration using logistic binary 

regression to correct for co-variates the risk of lupus patients having an 

abnormal smear history compared to controls became highly significant RR 

2.53 (1.44-4.43) P=0.001.



53. CERVICAL DYSPLASIA AND RISK FACTORS IN NORTHERN 

IRELAND SYSTEMIC LUPUS ERYTHEMATOSUS PATIENTS 

M.T. McHenry 1 , K.S. Cuschieri 2 , C. Moore 2 , H.A. Cubie 2 , N. Anderson 3 , R. 

Clarke 4 , A.L. Bell 1 


2 Specialist Virology Centre, New Royal Infirmary, Edinburgh, Scotland, 




An increased risk of cervical dysplasia has previously been reported in lupus. 

The role of traditional related risk factors are unclear. 

Aim: We assessed the role of traditional cervical cancer risk factors including 

human papilloma virus (HPV) detection in a cohort of Northern Irish lupus 

patients. 

Methods: 141 SLE patients fulfilling the ACR criteria for lupus were 138 

control patients who were due to attend for a routine cervical smear. Each 

patient completed a cervical cancer risk factor questionnaire. A cervical smear 

was taken and residual material used to test for the presence of high risk- 

HPV. Positive samples were then genotyped. 

Results: SLE patients in this study had an increased lifetime occurrence of an 

abnormal cervical smear. 

Although a similar detection rate of HR-HPV positivity was found in SLE 

(15.6%) and control women (17.4%), the mean age of the SLE HPV+ women 

was 43years compared with 30 years for the HPV+ controls. 

See Table 1. 

Discussion: Parity and number of sexual partners may be important 

traditional risk factors. 

HPV positive SLE patients tend to be older. 

HR-HPV may represent an opportunistic infection in these women as in other 

immunosuppressed disease states. 

Genotyping results suggest the same HPV types as non-SLE women and no 

single type predominated. 

Table 1: Co- Variate Analysis of risk factors 

VARIABLE RR (95% CI) P value 

Ever conceived 2.52 (1.37-4.64) P= 0.003 

>1 sexual partner 3.46 (2.03-5.91) P



54. VITAMIN D STATUS IN INDIVIDUALS WITH SYSTEMIC LUPUS 

ERYTHEMATOSUS (SLE) AND ITS RELATIONSHIP WITH DISEASE 

ACTIVITY 

E.M. Duffy¹*, H.G. Mulholland¹, S. Wright², M. Barnes¹, J. Wallace¹, A.L. 

Bell² 

¹Northern Ireland Centre for Food and Health, School of Biomedical Sciences, 

University of Ulster, Cromore Road, Coleraine, BT52 1SA, Northern Ireland, 

²Queens University Belfast, Musculoskeletal Education and Research Unit, 

Musgrave Park Hospital, Stockman's Lane, Belfast, BT9 7JB, Northern 


Photosensitivity is common in SLE, particularly when exposed to sunlight, 

and individuals are advised to use sunscreen with a minimum sun protection 

factor (SPF) of 15 (Callen et al, 1991). The predominate source of vitamin D 

is endogenous synthesis, where 7-dehydrocholesterol is converted to 

previtamin D 3 via UVB radiation on the skin. SPF15 blocks over 98% of 

previtamin D 3 synthesis, rendering SLE patients at risk of sub-optimal vitamin 

D status (Matsouka et al, 1987). 

Aim: This study aimed to compare vitamin D status in individuals with SLE 

(n=21) with healthy age and gender-matched controls (n=19) residing in 

Northern Ireland. The relationship between Vitamin D status in SLE and 

disease activity was investigated. 

Method: A 4-day diary of habitual diet estimated intake of vitamin D and 

calcium. 25-hydroxyvitamin D was measured using enzyme linked 

immunoassay. Disease activity in SLE was assessed using the revised 

Systemic Lupus Activity Measure (SLAM-R). 

Results: SLE and controls had insufficient intakes of vitamin D to meet 

requirements (mean ± SD = 2.99±2.41 and 2.22±1.25 respectively). Disease 

activity correlated negatively with dietary vitamin D intake (r = -0.632; p = 

0.006). 

Conclusions: Northern Ireland, at latitude of 53°, has insufficient UVB 

radiation to produce adequate vitamin D for six months of the year. Status is 

further compounded by a low dietary intake of vitamin D together with the 

application of SPF in SLE. Negative correlation of status with disease activity 

warrants further research with the potential of identifying vitamin D as having 

a beneficial role in the management of SLE. 

References: 

Callen JP, Roth DE, McGrath C & Dromgoole SH, Safety and efficacy of a 

broad-spectrum sunscreen in patients with discoid or subacute cutaneous lupus 

erythematosus, Cutis, 1991, 47, 130-6. 

Matsuoka LY, Ide L, Wortsman J, MacLaughlin JA & Holick MF, Sunscreens 

suppress cutaneous vitamin D 3 synthesis, J Clin Endocrinol Metab, 1987, 64, 

1165-8.



55. ASSESSING REPEAT DXA MEASUREMENTS: IMPORTANCE OF 

PRECISION ANALYSIS 

S. Van der Kamp, M. J McKenna, O. Fitzgerald 

DXA Unit, St. Vincent’s University Hospital, Dublin, Ireland 

Dual-energy X-ray absorptiometry (DXA) is the pre-eminent technique for 

both diagnosing osteoporosis and for assessing the response to medical 

intervention. Defining the reproducibility of DXA is required in order to 

ascertain whether a repeat DXA result is significantly different from the prior 

scan. It is not sufficient to accept the precision error supplied by the 

manufacturer. In-vivo precision is assessed by repeated measurements of 

individuals and is considered to be the best estimate of the skill level of a 

DXA technologist. 

One of us performed repeated measurements in 30 patients as per guidelines of 

the International Society of Clinical Densitometry (ISCD). Each subject was 

studied at the same session by repositioning after each scan. Subjects were 

patients who had been referred for routine scans. All gave informed signed 

consent. Our Ethics Committee approved the study. 

The standard deviation of the difference between each scan was calculated; 

this result was expressed in absolute units and as a percent of the mean of the 

means of the two scans. The least significant difference was calculated in 

absolute units and as a percent by multiplying the precision results by 2.7. 

The results are given in the following table. 

BMD 

g/cm 2 

Precision 

g/cm 2 

Precision 

% 

LSC 

g/cm 2 

LSC 

% 

ISCD: LSC 

Limits % 

Spine 0.885 0.010 1.1 0.027 3.0 5.3 

Femur: Total 0.874 0.007 0.8 0.020 2.3 5.0 

Femur: Neck 0.749 0.014 1.9 0.039 5.2 6.9 

Femur: Trochanter 1.021 0.011 1.1 0.029 2.8 - 

Femur: Intertrochanter 0.682 0.013 1.9 0.035 5.1 - 

Our precision is well within the guidelines of the ISCD. Precision is best at 

the total femur site: a percentage difference of 2.3 % is significant. Whereas a 

difference of 5.2% is required to identify significant change at the femoral 

neck. In our practice, we favour use of absolute change rather than percentage 

change. 

In summary, we performed an in-vivo precision analysis of DXA and 

demonstrated a high level of reproducibility. Caution should be taken in 

determining significance of repeat tests, especially for the femoral neck site. 

All DXA operators should perform a precision assessment.



56. BMD RESPONSE TO TERIPARATIDE IS GREATEST AT THE 

LUMBAR SPINE AND IN OLDER PATIENTS WITH LOWER INITIAL 

BONE DENSITY 

N. O’Mahony 1 , B. Whelan 2 , E. Falvey 2 , M. Daly 2 , S. Harney 2 , F. Shanahan 1 , 

M.G. Molloy 2 

1 Department of Medicine, University College Cork, Ireland, 2 Department of 

Rheumatology and Sports Medicine, Cork University Hospital, Wilton, Cork, 


The field of osteoporosis treatment has seen a revolution in recent times with 

the introduction of anabolic agents. The primary anabolic agent is a 

recombinant human parathyroid hormone (teriparatide). 

Aims: Our aims were to compare the efficacy of teriparatide in increasing 

bone mineral density (BMD) at various skeletal sites to that of the potent oral 

bisphosphonates (risedronate and alendronate) and to determine clinical 

predictors of response to teriparatide. 

Methods: Postmenopausal women starting treatment with teriparatide were 

enrolled as cases. Clinical data and BMD were assessed prior to enrolment. 

All had follow up scans performed after completing 18 months of therapy with 

teriparatide. Controls were selected from an existing database and were 

matched for age, sex, postmenopausal status, and initial BMD. Data was 

analysed using SPSS (v.11.0). 

Results: 13 cases treated with teriparatide were enrolled and 29 controls 

treated with either risedronate or Alendronate were enrolled. There was no 

significant difference between the groups in terms of age (p=0.117), initial 

BMD at any site (p=0.241-0.494) or interval between initial and follow up 

scans (p=0.187). The teriparatide group gained significantly more bone mass 

at the lumbar spine during the treatment period than the bisphosphonate group 

(p



57. OSTEOPOROSIS ASSESSMENT IS IMPROVED BY PERFORMING 

LATERAL VERTEBRAL ANALYSIS (LVA) AT TIME OF DEXA SCANNING 

Vertebral fracture prevalence and severity are significantly age and BMD 

dependant. 

B. Whelan 2 , S. Chavrimootoo 2 , P. Hodnett 3 , M. O’Sullivan 2 , E. Falvey 2 , M. 

Daly 2 , S. Harney 2 , F. Shanahan 1 , M. Maher 3 , M.G. Molloy 2 

1 Department of Medicine, University College Cork, Ireland, 2 Department of 

Rheumatology and Sports Medicine, Cork University Hospital, Wilton Cork, 

Ireland, 3 Department of Radiology, Cork University Hospital, Cork, Ireland 

Vertebral fractures are the second most common type of osteoporotic fracture. 

They are difficult to diagnose and up to 40% are asymptomatic. The presence 

of one osteoporotic fracture is a major risk for further osteoporotic fracture 

(both vertebral and non-vertebral). 

Aims: To determine the number of patients with osteoporotic fractures who 

would not otherwise have met criteria for treatment based solely on BMD 

measurement. 

Methods: 300 randomly selected postmenopausal women who had LVA 

scans performed at the time of DEXA scanning using an iDXA ® scanner 

were included in the study. LVA images were assessed by a blinded 

investigator (SC) and fractures were graded based on the semi-quantitative 

system of Genant and Wu 1 . 

Results: Of the 300 cases included 207 (69%) had at least one vertebral 

fracture identified. Of these only 11 (5.3%) had a previously documented 

fracture. 13 of those with normal BMD (based on a lowest any site t-score) 

had multiple fractures and 29 had single fractures (Table 1). Of those with 

osteopenia 44 had at least one osteoporotic fracture. 11 of those with 

osteopenia had moderate or severe fractures. 

Conclusions: Lateral Vertebral Analysis is an efficient and safe method of 

screening for osteoporotic vertebral fractures. It can be used to identify those 

at risk of fracture even with normal t–scores. 

Table 1: Frequency of fractures by diagnostic category (based on t-score) 

None Single Multiple 

Normal 30 19 29 

Osteopenia 51 68 20 

Osteoporosis 12 48 23 

References: 

1. Wu CY, Li J, Jergas M, Genant HK. Comparison of semiquantitative and 

quantitative techniques for the assessment of prevalent and incident vertebral 

fractures. Osteoporos Int. 1995; 5(5):354-70.



58. VERTEBRAL FRACTURE PREVELANCE AND SEVERITY ARE 

SIGNIFICANTLY AGE AND BMD DEPENDANT 

S. Chavrimootoo 2 , B. Whelan 2 , P. Hodnett 3 , M. O’Sullivan 2 , E. Falvey 2 , M. 

Daly 2 , S. Harney 2 , F. Shanahan 1 , M. Maher 3 , M.G. Molloy 2 , 

1 Department of Medicine, University College Cork, Cork, Ireland, 

2 Department of Rheumatology and Sports Medicine, Cork University 

Hospital, Wilton, Cork, Ireland, 3 Department of Radiology, Cork University 

Hospital, Cork, Ireland 

Vertebral fractures are the second most common type of osteoporotic fracture. 

They are difficult to diagnose and up to 40% are asymptomatic. The presence 

of one osteoporotic fracture is a major risk for further osteoporotic fracture 

(both vertebral and non-vertebral). 

Aims: To determine the influence of age and BMD on the prevalence, 

severity, site and type of vertebral fractures in postmenopausal women 

presenting for screening DEXA scans. 

Methods: 300 randomly selected postmenopausal women who had LVA 

scans performed at the time of DEXA scanning using an iDXA ® scanner 

were included in the study. LVA images were assessed by a blinded 

investigator (SC) and fractures were graded based on the semi-quantitative 

system of Genant and Wu 1 . 

Results: 361 fractures were identified in 207 subjects. The prevalence of 

osteoporotic fracture was 36%. Those who had fractures were significantly 

older and had significantly lower BMD (p



59. FRONT LINE BACK PAIN: THE PREVALENCE OF SACROILIAC 

JOINT DISEASE IN A PRIMARY BACK PAIN COHORT 

F.D. O’Shea¹, D. Salonen¹, C. Ammendolia², W. Hsu², C. Peterson², R.D. 

Inman¹ 

¹Toronto Western Hospital & ²Canadian Memorial Chiropractic College, 

Toronto, Canada 

The sacroiliac joint (SIJ) is pivotal to the diagnosis of ankylosing spondylitis 

(AS). Yet the prevalence of SIJ abnormalities in the low back pain population 

at large remains unresolved. 

Aims: To define (i) the prevalence of SIJ disease in a primary back pain 

cohort, and (ii) the prevalence of sacroiliitis in this cohort. 

Methods: All AP pelvis and lumbar spine X-rays taken at a chiropractic 

college from 2003 - 2005 were reviewed. The films were scored by 3 readers 

(1 MSK radiologist, 2 rheumatologists). Abnormal X-rays were classified as 

(1) definite degenerative changes with osteophytes; (2) dense sclerosis 

interpreted as degenerative; (3) inflammatory changes but < Grade II in 

degree; (4) diagnostic sacroiliitis (≥ bilateral Grade II or unilateral Grade III). 

Results: 315 patients (173M, 142F), ages 18-60 yr, had adequate views of the 

SIJs. 

100 patients (31%) demonstrating SIJ abnormalities: 73 degenerative, 25 

inflammatory, 2 with osteiitis condensans ilii – see Table. 

Degenerative disease was predominantly female. Inflammatory disease was 

predominantly male. 

Conclusion: In this large primary back pain cohort, radiographic sacroiliitis 

consistent with AS was found in 3.8%. Significantly, degenerative changes in 

the SIJ were found in 23.2%. The higher prevalence of degenerative joint 

disease in the SIJ is an important factor for interpreting prevalence studies, 

and also for case definition in genetic studies or therapeutic trials. 

(n=315) Male:173 Female:142 

Degenerative: 73 (23.2%) 

• Osteophytosis 

56 (17.8%) 

15 

41 

• Sclerosis 

17 (5.4%) 

8 

9 

Inflammatory: 25 (7.9%) 

• < bilateral Grade II 

13 (4.1%) 

10 

3 

• ≥ bilateral Grade II 

12 (3.8%) 

6 

6



60. MUSCULOSKELETAL ULTRASOUND CAN BE USED IN KNEE 

OSTEOARTHRITIS TO PREDICT RESPONSE TO INTRA-ARTICULAR 

STEROIDS 

A. Pendleton, A. Millar, D. O’Kane, G.D. Wright, A.J. Taggart 

Department of Rheumatology, Musgrave Park Hospital, Green Park Health 

Care Trust, Belfast, Northern Ireland 

Aim: Assess musculoskeletal ultrasound (MSUS) detection of response 

predictors to intra-articular (IA) corticosteroids (CS) in Knee Osteoarthritis 

(OA). 

Methods: Patients with symptomatic primary knee OA were recruited. 

Disease duration, patient height, weight and BMI were recorded. Two 

separate investigators performed assessments, one clinical on with MSUS 

(12MHz linear probe). All received a single IA CS. Pain, stiffness and 

function were evaluated at baseline, 1 and 6 weeks using WOMAC OA index. 

Data was assessed using multivariate regression analysis for response 

predictors. 

Results: 86 patients (24 male, 62 female; 47 - 87 years) had baseline 

assessment. Clinically 76% patients had knee tenderness, 37% had calor, 47% 

had effusion. Using MSUS 91% had effusion, 62% with synovial hypertrophy 

of which 5.6% showed increased PD signal, 36% had a popliteal cyst, 12% 

had anserine bursal swelling and 4.6% had patellar tendonopathy. 

Following IA CS 67% and 53% had at least a 20% reduction while 49% and 

35% had more than 50% reduction in WOMAC pain at week 1 and 6. Sixty 

four percent and 49% recorded at least a 20% functional improvement at week 

1 and 6. Multivariate regression analysis revealed higher baseline WOMAC 

scores for total pain, night pain, stiffness, and function were associated with 

statistically significant improvements in outcome at 1 week (p



61. A NOVEL MAGNETIC RESONANCE IMAGING SYNOVITIS 

SCORING METHOD USED TO EVALUATE COMPARTMENT-SPECIFIC 

SYNOVITIS IN PSORIATIC ARTHRITIS 

A. Gibbs, B. Bresnihan, D. Veale, R. Gibney, O. FitzGerald 


There is currently no validated MRI scoring system to assess synovitis in PsA. 

Objective: To incorporate a novel compartment-specific synovitis scoring 

system [1] in the assessment of MRI scans of the knee in a study evaluating 

the efficacy of anakinra in PsA. 

Methods: 10 patients with active PsA were enrolled in a 12 week singlecentre 

open-label study to assess the efficacy anakinra. All patients had an 

MRI scan of an index knee joint at baseline and 12 weeks. Sagittal and 

coronal T2-weighted images were obtained pre- and post-contrast. 4 

anatomical sites were evaluated: the medial and lateral parapatellar recesses, 

suprapatellar pouch and intercondylar notch. Synovitis was graded on a scale 

of 0-3. A single observer (R.G.) performed all the analyses in a blinded 

fashion. 

Results: 8/10 patients had baseline and week 12 MRI scans. There was no 

significant change seen in synovitis score in any of the knee compartments. 

These findings were reflected in the fact that only modest, unsustained clinical 

benefit was seen. 

Conclusions: The lack of MRI response in this study was mirrored by an 

unsustained clinical response. This novel scoring system, although developed 

for assessing synovitis in osteoarthritis, can also be applied to other 

inflammatory arthritides such as PsA. It is quick and easy to use, and would 

enable feasible evaluation of synovium in larger cohorts. 

Baseline week 12 

Global Synovitis Score (0-3)*: 

Compartment A 1.25(1.03) 1.37 (0.74)[p=0.7] 

Compartment B 1.25(1.03) 1.25 (0.46)[p=1] 

Compartment C 1.25(1.16) 1.37(0.74)[p=0.78] 

Compartment D 1.25(1.16) 1.5(0.93)[p=0.6] 

* values expressed as mean(SD) 

Reference: 

1. Rhodes LA, Keenan AM, Grainger AJ, Emery P, McGonagle D, 

Conaghan PG. The relationship between limited MRI section analyses and 

volumetric assessment of synovitis in knee osteoarthritis. Clin Radiol 

2005; 60(12): 1295-9.



62. QUADRICEPS SENSORIMOTOR DYSFUNCTION IN OSTEOARTHRITIS 

OF THE KNEE; WHICH TYPE OF EXERCISE IS BEST? A BLINDED 

RANDOMIZED CONTROLLED TRIAL 

F. Keogan 1 , C. Gilsenan 1 , J. Hussey 3 , P. O’Connell 2 

1 Physiotherapy Department and 2 Rheumatology Department, Beaumont 

Hospital, Dublin 9, Ireland, 3 School of Physiotherapy, Trinity College, Dublin 

8, Ireland 

Quadriceps weakness and deficits in joint position sense (JPS) are associated 

with pain and reduced functional performance in patients with osteoarthritis of 

the knee (OA) 1 . 

Aim: To investigate the efficacy of open kinetic chain (OKC) versus closed 

kinetic chain (CKC) quadriceps exercises for knee OA on quadriceps strength 

and joint position sense (JPS). 

Method: Ninety subjects (f=58, m=32) with knee OA were randomly 

assigned to one of three groups; control, CKC or OKC. Subjects in the CKC 

and OKC groups participated in a 6-week programme of OKC (free-weight) or 

CKC (weight-bearing) exercises. Measurements were recorded at baseline, at 

6 and 12 weeks. Isokinetic quadriceps force was assessed using the Kin-com ® 

isokinetic dynamometer. JPS was measured using an electrogoniometer 

(Penny and Giles © ). 

Results: Change scores were calculated using Datadesk ® software. As data 

was parametric, paired t-tests and ANOVA were used for within group 

analysis and unpaired t-tests and ANOVA for between group analysis. 

There was no statistically significant difference (p



Reference: 

Hurley MV, Scott DL Improvements in quadriceps sensorimotor function and 

disability of patients with knee osteoarthritis following a clinically practicable 

exercise regime. British J Rheum (1998) 37:1181-1187.



63. THE IMPACT OF PERCEIVED SELF-EFFICACY ON QUALITY OF LIFE 

IN PERSONS WITH RHEUMATOID 

ARTHRITIS 

S. Goff 

Rheumatology Department, Waterford Regional Hospital, Dunmore Road, Waterford, 


The term self-efficacy is derived from social learning theory. It describes an 

important human characteristic which if present in sufficient quantity can lead 

to improved coping and adaptation. More importantly, when individuals 

exhibit high levels of self-efficacy in the face of stressors they are more likely 

to exhibit constructive coping behaviours and to maintain a positive sense of 

well being (Bandura, 1977). 

Aim: The primary aim of this study was to examine the relationship between 

perceived self-efficacy and quality of life in persons with rheumatoid arthritis. 

Method: This cross-sectional study used a convenience sample. Data was 

collected from study participants (n=49) using two questionnaires, the 

Arthritis Self-Efficacy Scale and the Arthritis Impact Measurement Scale 2- 

Short Form. Both of these forms have been shown to be both valid and 

reliable for use in the rheumatology setting. A descriptive correlational 

approach was used for data analysis. All correlations were carried out using 

Pearson’s correlation co-efficient. 

Results: There was a significant positive correlation between overall arthritis 

self-efficacy and quality of life. Further analysis revealed a significant 

relationship between self-efficacy for pain and quality of life and self-efficacy 

for function and quality of life. 

Conclusion: Levels of self-efficacy were found to have a significant impact 

on quality of life in persons with rheumatoid arthritis. 

Correlations 

Self-Efficacy Pain and Other 

Sympyoms Self-Efficacy Other Symptoms 

Self-Efficacy Function 

Self-Efficacy Pain 

Arthritis Self-Efficacy 

Years since diagnosis 

Pearson Correlation 






**. Correlation is significant at the 0.01 level (2-tailed). 

Quality of Life 

.604** 

.638** 

.709** 

.472** 

.693** 

-.239 

References: 

Bandura, A. (1997) Self-Efficacy: The Exercise of Control. New York: 

Freeman.



Brekke, M., Hjortdahl, P. and Kvien, T.K. (2001) Self-efficacy and health 

status in rheumatoid arthritis: a two-year longitudinal study. Rheumatology 40 

387-392.



64. FACTORS INFLUENCING EXERCISE TAKEN BY 

RHEUMATOLOGY OUTPATIENTS 

K. Yein, E.J. Price, D.A. Collins, L Williamson 

Department of Rheumatology, Great Western Hospital, Swindon, Wiltshire, 

SN3 6BB, UK 

Exercise in rheumatology patients is crucial for weight control, joint 

protection, and cardiovascular fitness. 

Aim: We looked at factors that might influence patient exercise including 

weight, pain, and psychological health. 

Method: 108 routine rheumatology outpatients completed an anonymous 

questionnaire asking about: types of exercises undertaken; limiting and 

encouraging factors for exercise: 10cm pain visual analogue score (VAS); 

hospital anxiety and depression score (HAD); health assessment questionnaire 

(HAQ) and Body Mass Index (BMI). 

Results: Mean BMI 27.2 (SD 5.9); mean age 56.6 (SD 16) years; 74 % 

female; 52% exercised daily; 19% exercised weekly; 8% exercised monthly. 

Exercises were minimal or modest: walking (76%); stretching and 

strengthening (26%); swimming (6%). No patient undertook regular activity 

enough to improve aerobic fitness. Exercise helped reduce pain and stiffness 

(p=0.04). The main factors preventing regular exercise were pain (63%), 

shortness of breath (23.8%), lack of motivation (22.6%), time (7%) and 

confidence (5.9%). 10% patients preferred group exercises. There was no 

significant relationship between regular daily exercise and BMI (p = 0.36), 

pain VAS, HAD or HAQ. There were modest correlations between pain VAS 

and anxiety score (0.56), depression score (0.53) and HAQ (0.53). 

Conclusions: Most rheumatology outpatients are overweight and although 

many claim to exercise, they do not exercise enough to lose weight or improve 

cardiovascular fitness. Pain, psychological factors and BMI do not play major 

roles. We need to raise patient expectation of exercise with guidance towards 

more strenuous exercise regimes.



65. A SURVEY OF GOUTY ARTHROPATHY: CLINICAL FEATURES 

AND ASSOCIATED RISK FACTORS IN THE MODERN HOSPITAL 

SETTING 

K.A. Khan, G. Kearns, P. O'Connell 

Department of Rheumatology, Beaumont Hospital, Dublin 9, Ireland 

Gout remains a clinical problem today despite availability of effective 

treatment for most patients. In our hospital in a recent review, 12% of all 

rheumatology consults were for gouty arthropathy (12/104). 

Aim: We undertook this study to define the clinical features of gout and 

associated cardiovascular and other risk factors in a modern hospital setting. 

Methods: We reviewed the charts of 50 patients referred with gout to the 

rheumatology service. Diagnosis of gout was based on ACR criteria for the 

classification of acute gouty arthritis. 

Results: Twelve patients (24%) were female and 38 (76%) male. Nineteen 

patients (38%) had recent onset of gout and 31 patients (62%) had 

longstanding gout, of whom 9 (18%) had acute on chronic tophaceous gout. 

Thirty two patients (64%) had acute monoarticular gout, and 9 (18%) had 

polyarticular gout, of whom 2 had a first presentation with acute polyarticular 

gout. Urate levels were normal in 26% at presentation. Two or more risk 

factors for gout were found in most patients. Renal impairment (76%), use of 

aspirin (66%), diuretics (46%) and alcohol excess (30%) were most frequent, 

with cyclosporin use, neoplasms, and anti-TB therapy rarer. In 3 patients, 

alcohol intake greater than 40 units/week was the sole risk factor. A high 

prevalence of cardiovascular (CV) pathology was found with hypertension 

(72%), ischaemic heart disease (46%), hyperlipidaemia (44%), CVA (20%), 

and NIDDM (18%) all common finding. 

Conclusion: In the hospital setting, gout defines a population with multiple 

co-morbidities including CV, metabolic and renal disease. Hyperuricaemia is 

not universal at presentation.



66. SERUM RETINOL (VITAMIN A) LEVELS ARE DECREASED IN 

ANKYLOSING SPONDYLITIS AND ARE INDEPENDENT OF DISEASE 

ACTIVITY 

F.D. O'Shea¹, F.W.L. Tsui¹, H.W. Tsui¹, B. Chiu¹, M. Yazdanpanah², R.D. 

Inman¹ 

¹Toronto Western Hospital & ²Division of Biochemistry, Toronto General 

Hospital, Toronto, Canada 

Retinol plays an important role in bone structure and function. Treatment with 

retinoids is associated with bone abnormalities mimicking 

spondyloarthropathy and diffuse idiopathic skeletal hyperostosis (DISH). 

Aims: (i) To compare serum levels of retinol in ankylosing spondylitis (AS) 

and healthy controls, (ii) to correlate retinol levels with disease activity, (iii) to 

identify any genetic association with the CYP26A1 (responsible for retinol 

metabolism) gene. 

Methods: 40 AS patients and 47 healthy controls had retinol levels measured 

by mass spectrometry. Retinol levels were compared with CRP, ESR, alkaline 

phosphatase, and with the clinical indices BASDAI & BASFI. Subsequently, 

genetic analysis of CYP26A1 was performed on 123 AS patients and 131 

controls. 

Results: Mean retinol level for the AS cohort was 2.39umol/L ± 0.88 and for 

controls was 3.34umol/L ± 1.01 (p 4). Mean retinol level for the active AS was 2.22umol/L and 

inactive AS was 2.61umol/L (p=NS). Retinol levels showed no correlation 

with CRP, ESR, alkaline phosphatase, nor with BASDAI or BASFI. 

Genetic analysis of CYP26A1 demonstrated that the frequency of rs11187265 

[A] was 11.4% (28/246) for the AS patients and 9% (24/262) for the controls 

(p=NS). 

Conclusion: Contrary to expectations, serum retinol is lower in AS patients 

than in healthy controls. Retinol does not function as an acute phase reactant 

or as a marker of disease activity. Cytochrome p450 genes (such as CYP2D6) 

have been implicated in genome-wide scans in AS. Although our analysis of 

CYP26A1 has yielded no distinct genotype associated with AS, further 

analysis are warranted.



67. VITAMIN D DEFICIENCY: HOW PREVALENT IS THIS? 

M. Haroon, M. Phelan, C. Schilling, S. McArdle, M. J. Regan 

Arthritis and Osteoporosis Centre, Department of Rheumatology, 

South Infirmary – Victoria University Hospital, Cork, Ireland 

Introduction: Mild-moderate vitamin D deficiency is thought to have a role 

in causing non-specific musculoskeletal pain/weakness quite apart from it’s 

clear role in causing osteomalacia, where the vitamin D levels are very low. 

Objective: To assess the prevalence of vitamin D deficiency in new patients 

referred to our rheumatology clinic. 

Methods: We analysed vitamin D levels in new patients seen by us between 

July - September 2005. Regardless of the reason for referral, 25 new patients - 

picked at random - had these labs checked: vitamin D (25-OH Vit D), 

parathyroid hormone, creatinine, calcium, phosphate and alkaline phosphatase 

levels. In this study, vitamin D deficiency was defined as a level



68. THE DEVELOPMENT OF A BIOLOGIC INFORMATION WEBSITE 

FOR HEALTHCARE PROFESSIONALS 

F. Kelly 1 , D. Veale 2 , O. Fitzgerald 2 , B. Bresnihan 2 , P. Minnock 2 , R. Adams 3 

1 St. James’ Hospital, 2 St.Vincent’s University Hospital and 3 Our Lady’s 

Hospice, Dublin, Ireland 

The wide use of biologic agents over the last number of years in the treatment 

of rheumatological diseases has produced a steep learning curve for healthcare 

professionals. There are currently five agents used regularly and a need was 

identified to collate information on these agents that would be easily 

accessible to healthcare professionals. 

Aim: To develop a website containing information on biologic agents for 

healthcare professionals working in rheumatology. 

Methods: Literature review completed collating all available information on 

biologic agents. The website was developed using Microsoft Frontpage and 

was made available on hospital intranet. A questionnaire was circulated to 

staff to evaluate ease of access, relevance to practice and benefit to practice. 

Results: The site was accessed a total of sixty times in a three week period. 

Ninety per cent of staff found the site relevant to practice. Eighty four per 

cent would use the site as a first reference source. Ninety two per cent thought 

a website was an appropriate way to access such information. 

Conclusion: The website is very well accepted as a means of collating 

information such as protocols, licensing and frequently asked questions while 

also providing links sites such as adverse reaction reporting. It may now be 

appropriate to develop the site as a national information source for biologic 

agents.



CASE REPORT POSTERS 

69. ORAL TB COMPLICATING TREATMENT WITH ADALIMUMAB 

S. Moore, A. Moorthy, A. Kinder 

Rheumatology Department, Leicester Royal Infirmary, Infirmary Square, 

Leicester, LE1 5WW. United Kingdom 

A 66 year old first generation Asian lady was diagnosed with rheumatoid 

arthritis in 2002. After a number of DMARDs had to be withdrawn due to 

treatment failure or side effects she fulfilled the criteria for anti - TNF and so 

was duly assessed. In the interim she took a maintenance dose of prednisolone 

5 mg daily. 

Anti - TNF assessments were carried out in June 2004, she denied history of 

or contact with TB. Mantoux test was negative and chest x-ray was reported 

as normal. Anti - TNF was then delayed by twelve months due to surgery for 

a Colles fracture and elective cataract surgery. 

In July 2005 she started on adalimumab. After six injections she developed a 

painful mouth ulcer and the left side of her face swelled up. Adalimumab was 

stopped and a biopsy of the oral lesion revealed florid granulation with 

caseation. A diagnosis of oral TB was made and she started on quadruple 

therapy. Her anti - TNF remains suspended. 

Several important points are highlighted by our case. 

• Is a small dose of regular prednisolone, for example 5 mg daily, enough to 

make a false negative result in a Mantoux test more likely? 

• The new guidelines mean that if she was assessed for anti - TNF now, the 

treatment algorithm would recommend chemoprophylaxis based on 

calculations that her risk of TB outweighs the risk of prophylaxis 

considering her social background. This may be the case in a number of 

our patients. 

• Infections and anti - TNF therapy remains a challenging area.



70. PACHYMENINGITIS AN UNDER-RECOGNISED MANIFESTATION 

OF RHEUMATIC DISEASES 

E.S. Molloy, L.H. Calabrese, P. Embi, J.J.Carey 

Department of Rheumatic and Immunologic Diseases, A50, The Cleveland 

Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA 

Pachymeningitis is a rare complication of several rheumatic diseases, 

historically associated with a high mortality and often not diagnosed until 

post-mortem. 

Aim: To describe the clinical features, treatment and clinical course of five 

cases of pachymeningitis. 

Method: Retrospective case series. 

Results: 2 subjects had features of pachymeningitis at the time of diagnosis 

(1 rheumatoid arthritis, 1Wegener’s granulomatosis), and 3 developed this 

phenomenon as a late complication of their disease (1 each of rheumatoid 

arthritis, Wegener’s granulomatosis and sarcoidosis). All had pachymeningitis 

on imaging and negative CSF cultures. 4 had pathologic confirmation, 1 did 

not have a biopsy as the clinical presentation was confirmatory. All were 

treated with corticosteroids and additional DMARDs (3 cyclophosphamide). 

All patients improved with treatment and remain alive at follow-up: range 5 to 

31 months. 1 had recurrent disease, 1 is finishing a course of intravenous 

cyclophosphamide. 3 remain in remission. Details of each case will be 

presented including images of MRI scans and pathology. 

Conclusions: These cases highlight the clinical features and course of 

pachymeningitis, a rare manifestation of some rheumatic diseases. 

Presentation may occur at various stages in the disease course and is often 

insidious in nature. Diagnosis is based on typical MRI, CSF and/or pathologic 

findings, following the exclusion of other aetiologies such as infection and 

malignancy. Early and aggressive treatment is warranted, which may 

ameliorate the disease and improve prognosis. Pachymeningitis should be 

considered in the differential diagnosis of rheumatology patients presenting 

with headache or other neurologic symptoms. 

Kato T. Rheumatoid meningitis: an autopsy report and review of the literature. 

Clin Rheumatol. 2003; 22(6):475-80. 

Seror R. Central nervous system involvement in Wegener granulomatosis. 

Medicine (Baltimore). 2006; 85(1):54-65.



71. TROPONIN T (TNT) AS A MARKER OF SUB-CLINICAL 

MYOCARDITIS IN CONNECTIVE TISSUE DISORDERS? 

E.M.A. McCausland, N.L. Maiden 

Department of Rheumatology, Antrim Area Hospital, Antrim, N.Ireland 

Troponin T is a very specific marker for cardiac muscle damage and has 

become the gold standard marker of acute coronary syndromes. It may also be 

elevated in a variety of other clinical situations (eg. PE, pulmonary oedema, 

renal failure, septic shock).¹ We describe four cases of elevated TNT in the 

absence of overt cardiac injury/dysfunction or any other demonstrable cause. 

In the three patients with myositis, the TNT levels returned to normal (



72. NON ISCHEMIC DILATED CARDIOMYOPATHY FOLLOWING 

BIOLOGIC THERAPY 

Anorthic, S. Moore, A. Clarke, W. Hassan 

Department of Rheumatology, University Hospitals of Leicester NHS Trust, 

Leicester, UK 

Background: 1 The Anti TNF therapy is relatively new and effective 

treatment for ankylosing Spondylitis. We report a case of nonIscheamic 

dilated cardiomypopathy following Anti - TNF therapy. This side effect to 

our knowledge has not been reported in literature. 

Case summary: 

Our 36 year old patient was diagnosed to have ankylosing spondylitis at the 

age of 9 following Yesinia infection. The spinal disease was initially managed 

well with standard treatment. Over the last few years his disease became more 

aggressive and generalised involving spine and peripheral joints. The 

conventional therapy was not controlling his disease and he was refereed for 

Anti - TNF assessment. He was assessed as per BSR guidelines and screened 

for the biologic treatment, was commenced Infliximab at 5mg /Kg body 

weight. His musculoskeletal symptoms and his BASDAI Score improved 

dramatically following six Infusions. 

While he was on the anti - TNF therapy he developed severe chest infection 

associated with shortness of breathing. His biologic treatment was withdrawn. 

A complete infection screen failed to identify any causative organism. His 

chest X-Ray revealed cardiomegaly. Further investigations by the cardiologist 

shows evidence of significant dilated cardiomyopathy on echo, angiogram, 

cardiac MRI. He is currently on treatment for his cardiac failure from which 

he is making progress. 

Discussion: 

• This case draws the attention of clinician to be aware of unusual cardiac 

complications following the anti - TNF treatment 

• To our Knowledge there have been no case reports on cardiomyopathy in 

Ankylosing spondylitis parse or following infliximab therapy. 

Reference: 

1.Treatment of active ankylosing spondylitis with infliximab: a randomised 

controlled multicentre trial. 

Braun J, Brandt J, Listing J, Zink A, Alten R, Golder W, Gromnica-Ihle E, 

Kellner H, Krause A, Schneider M, Sorensen H, Zeidler H, Thriene W, Sieper 

J.



73. ANTI TNF TREATMENT AND SEPTIC ARTHRITIS…… BEWARE 

OF RARE BUGS GAMELLA……. 

A. Moorthy , M. Zaman, A. Clarke, A. Kinder 

Department of Rheumatology, University Hospitals of Leicester NHS Trust, 

Leicester 

Introduction: Anti TNF Treatment is the new kid on the block, in terms of 

immunosuppressive treatment for several Auto immune diseases, and the 

dramatic improvement seen after treatment, makes both Doctor and patients 

lean more towards it. We are still in early days to recognise the complications. 

Case Report: 

We report a case of 69 year old lady diagnosed with sero negative Rheumatoid 

arthritis for seven years. During which time she had more aggressive course 

of disease and consistently failing on any disease modifying treatment offered, 

leading to replacement of both Knee and Hip. She was screened for Biologics 

treatment as per BSR Guidelines and started on Infliximab and Methotrexate 

which was withdrawn when she had persistent thrombocytopenia. She was 

started on second biologic treatment in the form of Etanercept, to which she 

had an excellent response. After a period of six month on the second biologic 

therapy she developed sudden onset of pain and swelling on her replaced hip. 

The Hip was aspirated and the culture grew a rare gram positive organisms 

called gamella hemolysans. 

Discussion: 

• Infection is recognised complication following Anti TNF Treatment. 

• This is the first case of septic arthritis due to the rare Gamella hemolysan. 

• It is difficult to identify as it close resemblance to both Neiseria and 

streptococcus viridians. 

• We need to be extremely vigilant when we deal infection in patient 

receiving biologic therapy. 

References: 

Maini RN, Breedveld FC, Kalden J.R., et al. Therapeutic efficacy of multiple 

intravenous infusions of anti-tumor necrosis factor a monoclonal antibody 

combined with low-dose weekly methotrexate in rheumatoid arthritis. 

Arthritis Rheum 41:1552-1563, 1998. 

Rothe J, Lesslauer W, Lotscher H, Lang Y, Koebel P, Kontgen F, and Althage 

A. Mice lacking the tumor necrosis factor receptor 1 are resistant to TNFmediated 

toxicity but highly susceptible to infection by Listeria 

monocytogenes. Nature 364:798-802, 1993



74. PARRY-ROMBERG SYNDROME: MORE THAN SKIN DEEP? 

C.F. Matthews 1 , E. McKenna 2 , M.M.E. Rooney 3 , A.E. Smyth 1 

1 Department of Rheumatology, Ulster Hospital, Dundonald, Northern Ireland 

2 Department of Radiology, Ulster Hospital, Dundonald, Northern Ireland 

3 Department of Rheumatology, Musgrave Park Hospital, Belfast, Northern 


Parry-Romberg syndrome or progressive facial hemiatrophy is a rare clinical 

entity of unknown etiology, it manifests with thickening of the dermis that 

often extends to underlying muscles and bone. 

An 18 year old girl presented initially to the dermatology department due to an 

indentation of her forehead. A skin biopsy showed a normal appearance of the 

epidermis with pathological changes in the collagen fibres within the dermis. 

The findings were felt to be consistent with morphoea. Due to progression of 

the skin lesion that extended from the vertex to the mid brow on the right an 

MRI scan was performed to define the extent of local involvement. In 

addition to a shallow defect within the subcutaneous fat, there was an area of 

abnormal T2 and FLAIR high signal in the right frontal lobe extending to the 

genu of the corpus callosum and slight distortion of the frontal horn of the 

right lateral ventricle. 

In view of the progression of the cutaneous features, this patient was treated 

with immunosuppressant therapy that included methylprednisolone, oral 

methotrexate and topical tacrolimus. Serial MRI scans were required as an 

intracerebral neoplasm formed part of the differential diagnosis. 

While this case illustrates the known association of central nervous system 

involvement in Parry-Romberg’s syndrome, it is unusual in that the 

intracerebral lesions are usually subjacent to the area of involved skin. 

This case highlights both the need to consider involvement of the central 

nervous system and the importance of neuroimaging to monitor disease skin 

extent and progression.



75. SINUSITIS: A POSSIBLE LINK WITH ADALIMUMAB 

M. Haroon, U. Bond, M.J. Regan and M. Phelan 

Arthritis and Osteoporosis Centre, Department of Rheumatology, South 

Infirmary – Victoria University Hospital, Cork, Ireland 

The anti tumour necrosis factor agents (Anti-TNF) have redefined therapy for 

different inflammatory conditions, and the use of these agents has increased 

worldwide. The experience with anti-TNF agents is relatively short and with 

time we are learning more about the frequency of occurrence of different 

adverse events as the original trials were either too small or too brief. 

We report an observation that from June 2005 to May 2006, we commenced 

57 patients with inflammatory arthopathies on Adalimumab and four of these 

patients developed new onset of recurring sinusitis. These symptoms resolved 

when their anti-TNF therapy was switched to a different formulation. 

Sinusitis is a common condition affecting a large segment of population. It 

can be either due to an allergic reaction or secondary to an infectious agent, 

and only 30% to 40% of CT scans of sinuses show some abnormality. The 

IPHA (Irish Pharmaceutical Health Association) summery of product 

characteristics regarding Adalimumab describes that Adalimumab use 

increases the risk of non serious infections marginally, and most of the 

patients continued on Humira after the infection resolved. FDA describes the 

occurrence of sinusitis with Adalimumab as 11% versus 9% for placebo, and 

in the majority of the cases it was not clinically significant enough to warrant 

changing therapy. But our recent observation raises the concern of probable 

higher incidence. While these complications are rare, clinicians should be 

aware of their occurrence and able to identify them.



76. PALMAR FASCIITIS AND POLYARTHRITIS SYNDROME: A CASE 

REPORT 

C.Sheehy¹, J.Ryan¹, M.Kelly², E.Murphy¹, M.Barry¹ 

¹Department of Rheumatology, Connolly Hospital, Blanchardstown, Dublin 

15, Ireland, ²St. Francis Hospital, Mullingar, Co.Westmeath, Ireland 

Palmar fasciitis and polyarthritis syndrome is a rare paraneoplastic 

phenomenon, with just over 30 reports in the literature. The first series in 

1982 1 , described the syndrome associated with ovarian carcinoma. It has 

since been described occurring with various solid tumours as well as 

haematological malignancies. The underlying pathology of the paraneoplastic 

mechanism remains unclear, but it has been seen that early surgical 

intervention or chemotherapy can bring about improvement or even resolution 

of the changes. 2 

Background: A 56 year old male ex-smoker presented with pain and stiffness 

in both shoulders and over the following 3 months developed severe, rapidly 

progressive contractures of all fingers with the exception of the thumbs. He 

had lost 10kg in weight but denied any other symptoms. Examination 

revealed subcutaneous thickening in both palms with fixed flexion deformities 

of all digits except the thumbs. Initial laboratory investigations including an 

autoantibody screen were all normal/negative. As the primary differential 

diagnosis was palmar fasciitis and polyarthritis syndrome, a full malignancy 

screen was performed but was negative. 

Results: He received low dose intravenous cyclophosphamide for 6 months 

which had no effect on his hands. 18 months after initial presentation, 

paratracheal lymphadenopathy was seen on CT Thorax; biopsy confirmed 

metastatic non small cell lung carcinoma. Palliative chemotherapy brought 

relief of joint symptoms but no effect on the hands. 

Conclusion: Although rare, this is an important paraneoplastic syndrome for 

physicians to be aware of as the musculoskeletal symptoms may precede 

neoplastic manifestations by months, and may improve with appropriate 

treatment. 

References: 

1. Medsger TA, Dixon JA, Garwood VF. Palmar fasciitis and polyarthritis 

associated with ovarian carcinoma. Ann Intern Med 1982; 96(4):424-31. 

2. Enomoto M, Takemura H, Suzuki M, Yuhara T, Akama T, Yamane K, et 

al. Palmar fasciitis and polyarthritis associated with gastric carcinoma: 

complete resolution after total gastrectomy. Intern Med 2000; 39(9):754-7.



77. EFFECTIVE CO-ADMINISTRATION OF INFLIXIMAB AND 

ETANERCEPT IN A PATIENT WITH HLA-B27 ASSOCIATED 

ARTHROPATHY: A CASE REPORT 

C. Sheehy, E. Murphy, M .Barry 

Department of Rheumatology, Connolly Hospital, Blanchardstown, Dublin 15, 


The biologic agents have revolutionised the treatment of inflammatory 

arthritis. However there remain a small but significant proportion of patients 

who do not respond to any biologic agent (tumour necrosis factor (TNF) 

blockers, anakinra or rituximab). We report the effective co-administration of 

infliximab and etanercept in a patient with refractory HLA-B27-associated 

arthropathy. 

Background: A 28 year old man presented in 1999 with an 8 month history 

of left knee and wrist synovitis. HLA-B27-associated inflammatory arthritis 

was diagnosed following an extensive inflammatory arthritis and infectious 

screen. Over the following 6 years he was tried on salazopyrin, methotrexate 

(MTX), the 3 anti-TNF agents, with MTX, lefluonmide, anakinra with MTX, 

doxycycline with myocrisin and rituximab with steroid. He had intraarticular 

MTX and infliximab injections of the left knee as well as surgical 

synovectomy. None of these treatments provided improvement for any longer 

than 8 weeks. Acute phase reactants remained high throughout. He latterly 

developed right knee and ankle symptoms. In May 2005 he was commenced 

on etanercept with infliximab and cotrimoxazole. 

Results: Within weeks of commencing this combination, there was a 

dramatic improvement in the affected joints. ESR and platelet count fell 

rapidly to normal levels for the first time since 1999. His condition has been 

in remission for 6 months, with no complications to date. 

Conclusion: In this individual, the combination was highly effective 

following the failure of the agents used individually with MTX. For those 

patients with refractory inflammatory arthritis, the possibility of using a 

combination of therapies merits further investigation.



78. A CASE OF HCV INFECTION ASSOCIATED WITH 

CRYOGLOBULINAEMIC VASCULITIS TREATED WITH 

CYCLOPHOSPHAMIDE, STEROIDS AND MYCOPHENOLATE MOFETIL 

A. Al-Ansari 1 , C. White 3 , G. Kallarackal 2 

1 Department of Rheumatology, Leicester Royal Infirmary, UK, 2 Department 

of Rheumatology, Kettering General Hospital, UK, 3 Department of Medicine, 

Kettering General Hospital, UK 

Aim: We present a case where progressive cryoglobulinemic vasculitis 

secondary to HCV infection with mononeuritis multiplex treated with 

immuno-suppressive regime of Cyclophosphamide and steroid followed by 

Mycophenolate Mofetil, resulting in resolution of the vasculitis with no 

adverse effect on subsequent anti-viral therapy for HCV clearance. 

Method: A 43-year-old Caucasian drug abuser presented with Purpuric skin 

rash, generalised weakness and mononeuritis multiplex with distal sensory 

neuropathy. 

Investigations revealed ESR of 45mm/hr and CRP 151 mg/l, Normal 

haematology and renal profile, Rheumatoid factor was positive 160 iu/l. 

Antinuclear antibodies (ANA), and antinuclear cytoplasmic antibodies 

(ANCA), Complement levels and HIV titre were all negative. Positive 

cryoglobulin level at 16% of mixed pattern type 2 detected. Hepatitis screen 

confirmed a Hepatitis C positive titre > 500.000, genotype was of type 2A. 

EMG confirmed peripheral neuropathy. 

Result: A clinical diagnosis of cryoglobulinemic vasculitis has been made 

and treated with steroids and i.v Cyclophosphamide. CRP and skin rash 

improved totally and some improvement in neurological signs and 

cryoglobulin level dropped to 8%. 

Maintenance treatment with Mycophenolate Mofetil (MMF) and steroids 

tapering resulted in his cryoglobulin level decreased further to 2%, He 

regained 3/5 power in the right wrist and left foot with rehabilitation and 

thereafter treated with Ribavarin and Peginterferon. His viral load dropped to 

undetectable level



Cacoub P, Lidove O, Maisonobe T, Duhaut P, Thibault V, Ghillani P, Myers 

RP, Leger JM, Servan J, Piette JC. Interferon-alpha and ribavirin treatment in 

patients with hepatitis C virus-related systemic vasculitis. Arthritis Rheum. 

2002 Dec;46(12):3317-26.



79. UNUSUAL INFECTIONS IN PATIENTS ON BIOLOGIC AGENTS: 

TWO CASE REPORTS 

J. Kitchen, G. Cunnane, M. Doran 

Department of Rheumatology, St. James’s Hospital, Dublin, Ireland 

Case 1: A 69 year-old lady with a four-year history of rheumatoid arthritis 

presented with a two-week history of abdominal and lower back pain. 

Medications included azathioprine 75mg/d and adalimumab. 

On admission, she was febrile (38.2 o C) with a tender non-expansile mass 

above the umbilicus and left iliac fossa tenderness. Full blood count was 

normal and inflammatory markers were raised. MR imaging of the abdomen 

showed a 4.2cm abdominal aortic aneurysm containing thrombus and a periaortic 

collection. Radiologically-guided drainage of same, isolated Salmonella 

enteritidis. The patient underwent aortic resection and right axillary-bifemoral 

bypass for purulent septic aortitis. She made a slow post-operative recovery, 

and required prolonged ciprofloxacin therapy. 

Case 2: A 31 year-old man with resistant adult onset Still’s disease presented 

with recent onset of pleuritic chest pain, back pain and fever, and a nonpruritic 

maculopapular rash. Medications included methotrexate 15mg/wk, 

azathioprine 100mg/d, salazopyrine 3g/d, prednisolone 10mg/d, and 

adalimumab. 

On admission, he was drowsy, febrile (40.1°C), tachycardic (133), and had a 

maculopapular rash with vesicular lesions. Laboratory results showed 

leucopenia (WCC 3.2, Neutrophils 1.6, lymphocytes 1.1) and 

thrombocytopenia. He was coagulopathic with hepatic dysfunction and 

hypoxia. 

He was transferred to ICU with a presumptive diagnosis of primary varicella 

infection with pneumonitits and hepatitis, which was confirmed with positive 

varicella zoster IgM. He responded well to treatment with intravenous 

acyclovir. 

To our knowledge, Case 1 is the first case report of salmonella aortitis in a 

patient on biologic therapy. Both of these cases highlight the need for 

vigilance in patients on anti-TNF treatments.



80. KIKUCHI-FUJIMOTO DISEASE MIMICKING SYSTEMIC LUPUS 

ERYTHEMATOSUS: A CASE REPORT 

D. Smith, J. Kitchen, C. Doyle, G. Cunnane, M. Doran 


Kikuchi-Fujimoto is a rare benign condition characterised by necrotising 

histiocytic lymphadenitis. It can mimic many of the clinical, laboratory and 

histological features of systemic lupus erythematosus (SLE). 

Background: A 45-year-old lady presented with a 5 month history of 

malaise, weight loss, fevers, generalised arthralgias and cervical 

lymphadenopathy. She had a background of immune thrombocytopaenic 

purpura, splenectomy and depression. Examination revealed pyrexia of 

38.5°C, tender cervical and axillary lymphadenopathy and mild synovitis in 

bilateral metacarpophalangeal joints. 

Methods: Laboratory investigations revealed normochromic anaemia, 

lymphopaenia, normal renal function and raised LDH. ESR was 75mm/h and 

CRP 55. ANA was negative, ENA and ANCA were positive. C4 level was 

low. Monospot, HIV and hepatitis screens were negative, and urinalysis 

normal. Chest x-ray, mammogram and transoesophageal echocardiography 

were normal. 

Results: She remained unwell, spiking high fevers (> 38.5°C) daily. Serial 

blood, fungal and TB cultures were negative. Axillary lymph node biopsy 

showed reactive changes. Serology tests were negative for Coxiella, Lyme, T 

Whippellii, Brucella, Mycoplasma, Chlamydia, Histoplasma, Legionella, 

Bartonella and HAECK. Further imaging with CT thorax, abdomen and 

pelvis, isotope bone scan, MRI brain and mesenteric angiogram was 

unhelpful. Repeat axillary lymph node excision biopsies were then performed, 

revealing necrotising histiocytic lymphadenitis, consistent with Kikuchi- 

Fujimoto disease. 

Conclusion: This interesting condition often proves a diagnostic dilemma as 

the features can in many cases be indistinguishable from SLE. A greater 

awareness of this disease is important for the rheumatologist as appropriate 

treatment and long term prognosis for this disease are very different to that of 

SLE.



81. BURSTING THE BELLY: THE FIRST CASE OF 

FLUOROQUINOLONE-ASSOCIATED MUSCLE RUPTURE 

D. Smith, G. Cunnane 

Department of Rheumatology, St James's Hospital, Dublin 8, Ireland 

Tendon rupture is a well-known side-effect of treatment with fluoroquinolone 

antibiotics. However, rupture of a large muscle group has not been described 

with these drugs. This is the first reported case of spontaneous muscle rupture 

in a patient treated with ciprofloxacin. 

Case report: A 59 year old doctor undergoing treatment for lung cancer was 

admitted to hospital with neutropenic sepsis during his 2 nd cycle of 

chemotherapy (gencitabine, cisplatin). He was diagnosed with pneumonia and 

commenced on ciprofloxacin 400mg bd. After five days of antibiotic therapy, 

he developed sudden onset of severe left calf pain while resting in bed. 

Examination revealed an extremely tender and swollen calf. His left knee was 

completely normal, with no evidence of a Baker’s cyst. Movement of the left 

foot was excruciating and the patient was unable to weight-bear on that side. 

MRI demonstrated an extensive tear within the medial head of gastrocnemius 

but no evidence of metastatic disease to the area. He was treated with 

NSAIDs and several external therapeutic modalities but made a slow recovery. 

One month later, he continued to complain of severe pain and difficulty 

walking on that leg. 

Conclusion: Although the patient had previously received intermittent pulses 

of corticosteroids, the temporal association of muscle rupture during 

fluoroquinolone use and the absence of other risk factors suggest that 

ciprofloxacin was a dominant cause of the spontaneous gastrocnemius rupture 

in this case. This extremely painful problem should be highlighted as a 

potentially disabling side-effect of fluoroquinolone drugs.



82. ALLOPURINOL – AN AGENT FOR RESISTANT PSORIASIS? 

A.S. Malipeddi, J. Francis 

Department of Rheumatology, Kettering General Hospital UK 1 University 

Hospitals of Leicester NHS Trust, Leicester, UK 

Arthritis associated with psoriasis is commonly seen in rheumatology clinics 

and it can some times be difficult to achieve satisfactory disease control. 

Method: A 65-year-old gentleman was diagnosed with extensive cutaneous 

psoriasis involving 70% - 80% of his body surface. He had tried various 

treatments with minimal benefit. He also had psoriatic arthritis, which was 

treated with azathioprine 50mg/bd. 

He presented with acute painful right knee joint two years ago. On 

examination his right knee was inflamed with evidence of moderate effusion. 

He had gouty tophi in hands and feet. Synovial fluid analysis showed 

abundant urate crystals. A diagnosis of polyarticular gout was made and was 

started on oral colchicine followed by allopurinol after six weeks. After two 

weeks of starting allopurinol, a significant improvement in his cutaneous 

psoriasis lesions and arthritic symptoms were noted. 

Discussion: Goldman hypothesized that psoriasis like gout may be a result of 

disorder of purine metabolism and monosodium urate crystals may be 

responsible for cell proliferation that is characteristic of psoriatic plaques (1). 

Psoriasis is believed to be characterized by type I cytokine pattern with 

predominant expression of interferon - γ, interleukin – 2 and tumour necrosis 

factor - α. Allopurinol, a xanthine oxidase inhibitor, is believed to reduce the 

oxidative tissue damage through its free radical scavenging ability and 

decreases the production of TNF - α and down regulates the expression of 

ICAM – 1 and P2X (2,3) . It is debatable whether our patient was symptomatic 

from gout rather than psoriatic arthritis as he responded so well to allopurinol 

and managed to stop azathioprine with no recurrence of his symptoms. 

Conclusion: Allopurinol may be used as anti psoriatic agent in resistant 

psoriasis. It is well tolerated, low cost and has minimal side effects. The 

possibility of arthritis secondary to gout should always be considered in 

patients with psoriasis and inflammatory arthritis whose disease is not 

responding to disease modifying drugs. 

References: 

1. Goldman M. Uric acid in the etiology of psoriasis. Am J Dermatopathol 

1981 Winter; 3(4): 397-404.



83. AN UNUSUAL CASE OF BACK PAIN AND FEVER 

C.M. McVeigh, M. Elliott 2 , A.P. Cairns 

Departments of Rheumatology and 2 Radiology, Musgrave Park Hospital, 

Stockman’s Lane, Belfast, Northern Ireland, BT9 7JB, Northern Ireland 

History and clinical examination are key to making a correct diagnosis. 

Case history: 

A 53 year old lady presented with severe back pain and fever. Recent 

investigations in a surgical unit for “back pain” and fever had revealed lumbar 

degenerative changes on MRI and urinary infection. Her back pain persisted. 

Her pain was mostly felt in the right buttock region. She was pyrexic 

(38.5 0 C). She was exquisitely tender around her right sacroiliac joint. 

Examination also revealed a mild peripheral joint synovitis. 

CRP was 392mg/l; WCC 16.3x10 9 /l; Urate 0.44mmol/l. Pelvic X-Ray was 

unremarkable. 9mls fluid was aspirated from her right knee. Pelvic MRI 

revealed right sacroiliac joint effusion, with cortical irregularity and an area of 

sacral oedema. Fluoroscopically guided aspiration was attempted. No 

significant aspirate was obtained; saline was injected and aspirated and sent 

for analysis. 

Intravenous antibiotics were commenced but she made slow progress. Results 

of aspirates then became available. There was no growth from blood, urine or 

either joint. Gouty crystals were isolated from her knee and sacroiliac joint. 

Antibiotics were discontinued and colchicine and prednisolone added. She 

responded rapidly and within 7 days became asyptomatic with normal CRP. 

Conclusions: 

1. It was clear on questioning that this “back pain” related to the sacroiliac 

joint. Examination confirmed this and also the peripheral joint 

involvement (which she had not complained of). 

2. Sacroiliac X-Rays may appear normal, despite significant MRI 

abnormalities. 

3. Joint aspiration is key to confirming the diagnosis. 

4. Gout may present initially in a sacroiliac joint.

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