Background: Rheumatoid arthritis (RA) is a highly prevalent condition worldwide with significant associated morbidity and disability. In recent decades, disease modifying anti-rheumatic drugs (DMARDs) have been employed as mono or combination therapy to halt disease progression and the sequelaefrom occurring. Due to immunomodulatory effects, the frequency of monitoring adverse effects and termination of medication has long been under scrutiny. Aim: This multicentre audit considered Leflunomide use in clinical practice. Factors considered include the underlying condition treated, starting and maintenance doses, whether it was a mono or combination therapy, side effects reported and monitoring conducted. Methods: A retrospective review of case-notes from Leflunomide-treated patients was conducted at three centres in the UK. A pre-agreed proforma was completed to collect data appropriate to each aim. Results: Four hundred and twenty-seven case-notes were reviewed. Over 95% of patients received it for RA, 20 mg was the commonest loading/maintenance dose and 80% were treated with Leflunomide as mono-therapy. Gastrointestinal symptoms (18%) were the most prevalent side effects with most occurring within the first 6 weeks. A reduction in clinical efficacy was noted in 21% of patients. Monitoring varied significantly at each of the centre but little difference in the outcome was noted. Conclusion: While DMARDs have become first-line treatmentsin RA, increasing evidence suggests that monitoring does not need to be as rigorous as previously believed. This audit highlights a relative advantagein using Leflunomide in terms of dosing, its use as a mono-or combination therapy, side effects, long-term tolerability and monitoring.

Background: Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) affects mainly elderly males, characterized by acute onset pitting edema of hands, negative rheumatoid factor and excellent result with short course of low dose corticosteroid therapy. Objective: To re-evaluate the clinical, laboratory features, management, and ultimate disease progression of RS3PE cases in rheumatology clinic in tertiary care hospital and compare results with previous literature. Methods: We selected the patients of RS3PE in the Rheumatology clinic, Medical College, Kolkata, between 1 January 2002 and 1 January 2010 and followed them up. Results: Among the cases reviewed 23 were female patients and 12 were male patients with mean (SD) age of 54.74 (3.03) and 58.33 (5.33) years, respectively. Oral Hydroxychloroquine was started in all, giving a satisfactory result in 21 patients; rest of the 14 patients needed additional corticosteroid, to alleviate musculoskeletal symptoms. Baseline mean (SD) C-reactive protein and erythrocyte sedimentation rate were 21.63 (2.08) mg/L and 81.34 (9.29) mm/hr, respectively, and reduced to 3.23 (0.95) mg/L and 17.43 (5.55) mm/hr, respectively, following therapy. During follow-up, musculoskeletal symptoms relapsed in 17 patients, seven (20%) of them were found to be associated with malig- nancy. At the time of last visit during the follow-up period, only four patients developed definite arthropathy (one seronegative rheumatoid arthritis, three undifferentiated spondyloarthropathy), rest of the 31 cases were remitted. Conclusion: Regarding RS3PE, results of our study showed similarity with previous reports excepting the gender. Hydroxychloroquine has been proved as a good steroid-sparing agent in RS3PE. This study supported the association of RS3PE with malignancy in the previous literatures.

Sjögren's syndrome (SS) is a systemic autoimmune disorder characterized by lymphocytic infiltration of the lacrimal and salivary glands, leading to dryness of the eyes and mouth. Epidemiologic studies have indicated a role of both genetic and environmental factors in pathogenesis. It is likely that viral infection can create an inflammatory micro- environment that alters the disposition of apoptic fragments that serve as autoantigens. Thus, the search for a single viral agent that is causative is likely to prove difficult. Attention has focused on viruses that have tropism for the sali- vary and lacrimal glands, particularly members of the herpesvirus family. Other infectious agents too may mimic the clinical appearance of SS or complicate the disease. This article reviews the role of infections in patients with Sjogren's syndrome.