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Official Journal of the American College of Rheumatology

Special Articles

Guidelines for the Initial Evaluation of the Adult Patient with Acute Musculoskeletal Symptoms

• American College of Rheumatology Ad Hoc Committee on Clinical Guidelines 1

Review: Pathology and Pathogenesis of Vascular Injury in Systemic Lupus Erythematosus: Interactions of Inflammatory Cells and Activated Endothelium

• H. Michael Belmont, Steven B. Abramson, and J. T. Lie 9

Review: The T Cell Enigma in Lupus

• A. K. Dayal and Gary M. Kammer 23

Clinical Science

Development and Validation of the European League Against Rheumatism Response Criteria for Rheumatoid Arthritis: Comparison with the Preliminary American College of Rheumatology and the World Health Organization/International League Against Rheumatism Criteria

• A. M. van Gestel, M. L. L. Prevoo, M. A. van 't Hof, M. H. van Rijswijk, L. B. A. van de Putte, and P. L. C. M. van Riel 34
• EULAR criteria for the assessment of individual treatment response in RA are presented. The validity of the EULAR, ACR, and WHO/ILAR response criteria is examined.

Oral Type II Collagen Treatment in Early Rheumatoid Arthritis: A Double-Blind, Placebo-Controlled, Randomized Trial

• Joachim Sieper, Sonja Kary, Helmut Sorensen, Rieke Alten, Ulrich Eggens, Werner Huge, Falk Hiepe, Andrea Kuhne, Joachim Listing, Norbert Ulbrich, Jurgen Braun, Angela Zink, and Nicholas Avrion Mitchison 41
• This report describes the results of a trial of treatment of RA with oral type II collagen, which is potentially a highly selective and nontoxic therapy. Problems associated with such therapy and further perspectives for the application of oral tolerance therapy are discussed.

Percentage of Anti-CD4 Monoclonal Antibody-Coated Lymphocytes in the Rheumatoid Joint is Associated with Clinical Improvement: Implications for the Development of Immunotherapeutic Dosing Regimens

• Ernest H. S. Choy, Costantino Pitzalis, Alberto Cauli, J. A. Bijl, Allen Schantz, J. Woody, Gabrielle H. Kingsley, and Gabriel S. Panayi 52
• After treatment with the chimeric anti-CD4 monoclonal antibody, cM-T412, the degree of CD4 lymphopenia and the percentage of cM-T412-coated CD4+ cells in the peripheral blood and synovial fluid differed greatly. While peripheral blood CD4 lymphopenia was not associated with therapeutic efficacy, the percentage of cM-T412-coated CD4+ lymphocytes in the synovial fluid correlated with the degree of clinical improvement seen in patients.

Treatment of Xerostomia with Polymer-Based Saliva Substitutes in Patients with Sjogren's Syndrome

• Willy A. van der Reijden, Hanneke van der Kwaak, Arjan Vissink, Enno C. I. Veerman, and Arie V. Nieuw Amerongen 57
• Salivary flow rates were found to influence patients' preferences for the different saliva substitutes, although no treatment was truly effective. It is recommended that individual salivary flow rates be considered in choosing saliva substitutes for Sjogren's syndrome patients. The development of a variety of new polymer-based saliva substitutes with different viscoelastic properties should increase the success of managing oral dryness in such complicated diseases as Sjogren's syndrome.

Relationship of Running to Musculoskeletal Pain with Age: A Six-Year Longitudinal Study

• James F. Fries, Gurkirpal Singh, Dianne Morfeld, Peter O'Driscoll, and Helen Hubert 64
• The rheumatologist needs to understand risk factors for musculoskeletal pain and disability with age, and their relationship to clinical osteoarthritis. This report presents a model for musculoskeletal aging, and longitudinal data relating vigorous physical exercise to these end points. The model strengthens the knowledge base for ``preventive rheumatology.''

Distal Extremity Swelling with Pitting Edema in Polymyalgia Rheumatica: Report of Nineteen Cases

• Carlo Salvarani, Sherine Gabriel, and Gene G. Hunder 73
• Distal extremity swelling with pitting edema is a manifestation of polymyalgia rheumatica. Recognition of this manifestation will help facilitate appropriate diagnosis and therapy.

Association of Radiographically Evident Osteoarthritis with Higher Bone Mineral Density and Increased Bone Loss with Age: The Rotterdam Study

• Huibert Burger, Paulus L. A. van Daele, Else Odding, Hans A. Valkenburg, Albert Hofman, Diederick E. Grobbee, Henry E. Schutte, Jan C. Birkenhager, and Huibert A. P. Pols 81
• This study demonstrated that subjects with osteoarthritis have increased bone mineral density and, therefore, possibly lower fracture risk. However, the accompanying increase in bone loss with age may cancel out this benefit in the long run.

The Epidemiology of Wegener's Granulomatosis: Estimates of the Five-Year Period Prevalence, Annual Mortality, and Geographic Disease Distribution from Population-Based Data Sources

• Mary Frances Cotch, Gary S. Hoffman, Diane E. Yerg, Gerald I. Kaufman, Paul Targonski, and Richard A. Kaslow 87
• A population-based estimate of the prevalence of Wegener's granulomatosis may be useful to clinicians and researchers in identifying communities where prevalence of the disease is high. Conducting in-depth epidemiologic investigations of individuals in such communities may facilitate further studies that attempt to address the issues of etiology and pathogenesis.

Cross-Cultural Adaptation of a Brief Outcome Questionnaire for Spanish-Speaking Arthritis Patients

• Agustin Escalante, Dionisio Galarza-Delgado, Thomas D. Beardmore, Bruce A. Baethge, Jorge Esquivel-Valerio, Ana Laura Marines, and Michelle Mingrone 93
• This report demonstrates the adaptation of the Activities of Daily Living Index of the Modified Health Assessment Questionnaire to the Spanish language. The original English version of this brief quesionnaire has been shown to be valid and reliable, and yet very easy to implement in clinical practice. Questionnaires such as the one presented will prevent the systematic exclusion of a large proportion of Hispanic patients from studies examining the outcome of arthritis and allied conditions.

Barriers to Return to Work Among Persons Unemployed Due to Arthritis and Musculoskeletal Disorders

• Karin V. Straaton, Richard Maisiak, J. Michael Wrigley, Mary B. White, Philip Johnson, and Philip R. Fine 101
• This prospective study determined barriers to work return among a group of persons with established unemployment due to arthritis and musculoskeletal disorders. The results provide insight into potentially modifiable factors influencing return to work among this group.

Basic Science

The Presence of Costimulatory Molecules CD86 and CD28 in Rheumatoid Arthritis Synovium

• Ming Fei Liu, Hitoshi Kohsaka, Hiroshi Sakurai, Miyuki Azuma, Ko Okumura, Ichiro Saito, and Nobuyuki Miyasaka 110
• In rheumatoid synovium, a subset of synoviocytes express CD86 costimulatory molecules, and surround CD28+ lymphoid aggregates. Their interaction might contribute to the aberrant immune activation seen in rheumatoid synovitis.

Synovial Tissue Macrophage Populations and Articular Damage in Rheumatoid Arthritis

• Diarmuid Mulherin, Oliver FitzGerald, and Barry Bresnihan 115
• The relative contribution of individual cell populations in the synovium to polyarticular destruction in RA remains controversial. This study related synovial immunohistologic features in 28 patients with RA to their radiologic course over a mean of 6 years and implicated synovial macrophages as critical mediators of articular destruction in these patients. These results have important implications for the development of new therapies which target synovial macrophages and their products.

Responsiveness of Human T Lymphocytes to Bacterial Superantigens Presented by Cultured Rheumatoid Arthritis Synoviocytes

• Carlene Tsai, Luis A. Diaz, Jr., Nora G. Singer, Lan Lan Li, Antia H. Kirsch, Raj Mitra, Brian J. Nickoloff, Leslie J. Crofford, and David A. Fox 125
• This study demonstrated that synovial fibroblasts from patients with RA can serve as accessory cells for activation of T lymphocytes by superantigens, and also by the lectin phytohemagglutinin. If synovial fibroblasts can mediate initiation of immune responses in vivo as well as in vitro, this mechanism could be important in the pathogenesis of early RA.

Cutaneous Lymphocyte Antigen-Positive T Lymphocytes Preferentially Migrate to the Skin but Not to the Joint in Psoriatic Arthritis

• Costantino Pitzalis, Alberto Cauli, Nicolo Pipitone, Catherine Smith, Jonathan Barker, Antonio Marchesoni, Ghada Yanni, and Gabriel S. Panayi 137
• This study found that CLA+ T cells preferentially accumulate in the skin, but not the joint, of patients with PsA, and also predominate in the delayed-type hypersensitivity skin lesions and epidermal skin blisters of patients with rheumatoid arthritis. This pattern of T cell infiltration is regulated by both organ-specific homing and general inflammation-related mechanisms. These findings have notable pathogenetic implications for the formation of skin and synovial lesions in PsA and, in general, for the generation of the inflammatory/immune cell infiltrate in different tissues.

Autoantibodies to Glycyl-Transfer RNA Synthetase in Myositis: Association with Dermatomyositis and Immunologic Heterogeneity

• Michito Hirakata, Akira Suwa, Yoshihiko Takeda, Yasuo Matsuoka, Shoichiro Irimajiri, Ira N. Targoff, John A. Hardin, and Joe Craft 146
• Antibodies to aminoacyl-tRNA synthetases are the most common autoantibodies found in individuals with polymyositis and dermatomyositis, and are valuable aids in the diagnosis of these diseases. This report describes the presence of novel autoantibodies to glycyl-tRNA synthetase in a patient with dermatomyositis and emphasizes that, based on this finding and a review of published work, this specificity is associated with the illness. Moreover, this work underscores the fact that autoantibodies to aminoacyl-tRNA synthetases may be more immunologically variable than originally recognized, suggesting that there are diverse mechanisms for their genesis.

Clinical Images

Mees' Lines

• David R. Finger and Martin B. Giandoni 151

Case Reports

The Coexistence of Systemic Sclerosis and Rheumatoid Arthritis in Five Patients: Clinical and Immunogenetic Features Suggest a Distinct Entity

• Terumi Horiki, Junko Moriuchi, Masatoshi Takaya, Mitsuaki Uchiyama, Yuichi Hoshina, Kenichi Inada, Hidetoshi Inoko, Kmiyoshi Tsuji, and Yukinobu Ichikawa 152

The Antiinflammatory and Antiviral Effects of Hydroxychloroquine in Two Patients with Acquired Immunodeficiency Syndrome and Active Inflammatory Arthritis

• Matthew H. Ornstein and Kirk Sperber 157

Healing Phenomena of Erosive Changes in Rheumatoid Arthritis Patients Undergoing Disease-Modifying Antirheumatic Drug Therapy

• Rolf Rau and Gertraud Herborn 162

Splinter Hemorrhages Following Arterial Puncture

• Peter B. Martens, James A. Levine, and Gene G. Hunder 169

Complete Remission of Multicentric Reticulohistiocytosis with Combination Therapy of Steroid, Cyclophosphamide, and Low-Dose Pulse Methotrexate: Case Report, Review of the Literature, and Proposal for Treatment

• George C. Liang and Arthur S. Granston 171

Rocky Mountain Spotted Fever Presenting with Acute Monarticular Arthritis

• John S. Sundy, Nancy B. Allen, and Daniel J. Sexton 175

Concise Communication

Evaluation of Two Interventions to Reduce the Ancillary Costs of Outpatient Care for Rheumatoid Arthritis

• Jeffrey N. Katz, Elizabeth A. Wright, Kari D. Lynch, and Michael E. Weinblatt 177

Letters

The Paradoxical Association Between Immunodeficiency and Autoimmunity: Comment on the Article by Atkinson

• Nikolai Petrovsky 179

Reply

• John P. Atkinson 180

Treatment of Scleroderma Lung Disease: Comment on the Article by Steen et al

• Michael J. Fairfax 180

Fibromyalgia or Multi-Organ Dysesthesia?

• Arthur F. Kavanaugh 180

Synovial Tissue Responses Following Treatment of Rheumatoid Arthritis with the Humanized Monoclonal Antibody CAMPATH-1H

• Enrique R. Soriano, Jonathan Dixey, Nicolas D. Hall, Joan Davies, and Peter J. Maddison 181

Fatal Postpartum Vasculitis in Systemic Lupus Erythematosus

• Osvaldo Hubscher, Alicia Eimon, and Roberto M. Arana 182

ACR Announcements 6A