Background: Disease modifying antirheumatic drug (DMARD) therapy is believed to retard the radiological pro- gression of disease in rheumatoid arthritis (RA) patients. Sooner the treatment is introduced, better is the expected outcome. This concept was formally tested in this retrospective study by analyzing the relationship between time to institution of DMARDs in the first 5 years of RA and its radiological outcome. Methods: Two hundred adults with RA of more than 5 years duration taking DMARDs for at least 1 year were recruited in the study. Work up included detailed clinical evaluation, X-rays of both hands and feet AP view, assess- ment of rheumatoid factor (RF) titres, and calculation of van der Heijde-modified Sharp score, HAQ-DI and deformity score. Radiological score was correlated with the time to institution of DMARDs. Results: The mean age of study patients was 43.7 years and 92% were women. Median duration of disease was 7 years (IQR 5, 10) and 83% were RF positive. Time lag before starting DMARDs was divided into < 3 months, 3-12 months, 1-3 years and 3-5 years and the number of patients in these subgroups was 16, 86, 63 and 35 respectively. The corresponding median radiological scores were 5 (IQR 0, 30), 9.5 (IQR 0, 27), 22 (IQR 16, 36) and 36 (IQR 26, 56) respectively. There was a significant rise in radiological score with increasing time lag but the difference between < 3 months and 3-12 months categories was not statistically significant. Radiological score correlated significantly with RA articular damage index, HAQ score and total duration of RA but it did correlate with RF positivity. Conclusion: Crucial therapeutic window in RA appears to be the first year, after which the radiological score tends to rise sharply.

Objective: To evolve a treatment protocol for patients presenting in acute stage of chikungunya by identifying the best regimen from four treatment regimes. Materials and methods: One hundred and twenty patients diagnosed to have chikungunya arthritis clinically were randomized to one of four groups receiving combinations of aceclofenac (200 mg/day), hydroxychloroquine (400 mg/day) and prednisolone (10 mg/day). Group A received aceclofenac alone; Group B received aceclofenac plus hydroxychloroquine; Group C received aceclofenac and prednisolone and Group D, all three agents. Study medications were given for 6 weeks with weekly follow-ups followed by a 6 weeks drug-free follow-up with visits at week 8 and week 12. Efficacy variables including visual analog scale (VAS) for pain, 20-point modified Barthel index for activities of daily living (ADL) and instrumental activities of daily living (IADL) were assessed and recorded during start of therapy and at all follow-up visits. Results: Significant (P < 0.001) reduction in VAS scores and improvement in ADL and IADL scores were observed in groups C and D compared to groups A and B. Between groups A and B there was no significant difference; similarly, between groups C and D also there was no significant difference. Conclusion: Addition of prednisolone, and not hydroxychloroquine, to aceclofenac reduced pain and improved the quality of life in patients with acute chikungunya arthritis, compared to aceclofenac given alone in the management of early chikungunya fever. We propose a combination of non-steroidal anti-inflammatory drugs with corticosteroid as the best regimen in treating acute chikungunya cases with arthralgia.

The hand is one of the anatomical regions most frequently explored by ultrasonography (USG) in rheumatology. The high frequency USG allows for a quick and accurate assessment of even minimal pathological changes in patients with rheumatoid arthritis (RA) affecting the small joints and the soft tissues of the hand and wrist. Several studies have demonstrated the value of USG imaging of the hand and wrist in early diagnosis of RA by picking subclinical synovitis, effusion, erosions and increased vascularity. This article provides the basic knowledge, reviews the avail- able evidence and discusses the potential of USG in the evaluation of the hand and wrist in RA.

Macrophage activation syndrome (MAS) is a potentially fatal systemic disorder which results from uncontrolled activation and proliferation of T cells and excessive activation of macrophages. It is a distinct clinicopathologic entity that occurs in different haemophagocytic syndromes (HSs). Primary haemophagocytic lymphohistiocytosis (HLH) is recognized to have an immunogenetic basis, but the secondary HS (also referred to as MAS) occurs in a number of autoimmune disorders including systemic onset juvenile idiopathic arthritis, SLE, adult onset Still's disease and other disorders. In first of the two part series, the aetiology, molecular pathogenesis and diagnostic features will be enunciated. The second part will deal with clinical features and management issues.

The current perspective is based on the author's experience with COPCORD (community oriented program for con- trol of rheumatic diseases) in India and clinical practice in Center for Rheumatic Diseases (CRD), Pune. Almost half of the patients at the CRD consist of people from rural areas and small towns scattered all over Maharashtra. CRD also coordinates 13 COPCORD survey sites all over India. During the last three decades or so, COPCORD has accumulated an unprecedented quantum of community data on musculoskeletal pain and life styles and is thus an appropriate platform for describing the status and challenges of community rheumatology in India.