Background: Rheumatoid arthritis (RA) is associated with increased cardiovascular morbidity and mortality which is mainly due to accelerated atherosclerosis. The inflam- mation in rheumatoid arthritis is likely to alter the lipid profile in these patients resulting in dyslipidaemia which is an important cardiovascular disease (CVD) risk factor. Material and methods: 46 patients diagnosed with RA as per 1987 revised American Rheu- matology Association criteria were included in the study. Of the 46 patients, 24 were newly diagnosed RA patients and 22 patients were undergoing treatment with a combination of DMARDs with (n ¼ 14) or without (n ¼ 8) corticosteroids. 46 age and sex matched healthy subjects were included as controls. Total cholesterol (TC), triglycerides, HDL cholesterol, lDL cholesterol, apolipoprotein A-1 (apo A-1), apolipoprotein B (apo B) and lipoprotein(a) (Lp(a)) were measured. Results: TC, HDL cholesterol and LDL cholesterol levels were similar in all the three study groups. Both groups of patients had significantly elevated triglyceride, apo B and Lp(a) levels compared to controls ( p < 0.05). RA patients undergoing treatment had significantly elevated apo A-1 levels when compared to controls ( p < 0.05). Conclusions: The dyslipidaemia pattern in RA patients in the present study is evident in the form of elevated triglycerides, apo B and Lp(a) levels. The beneficial effects of a higher atheroprotective apo A-1 in patients undergoing treatment may be counteracted by the presence of high triglycerides, apo B and Lp(a).

Introduction: Rheumatoid arthritis is a chronic disabling disease. Presently there is great emphasis on early diagnosis and treatment to prevent damage and disability. There is however, lack of awareness of urgency to treat amongst lay persons and doctors resulting in treatment delays. We have studied the delay in referral, disease activity and damage at first presentation to our clinic. Patients: This is a retrospective chart analysis of 357, consecutively seen patients between January 2002 and December 2005. At first visit demographic details, details of prior treat- ment, disease activity, disability index, clinical and radiological damage were noted in a predesigned form. Results: There were 313 females, 44 males. The median age was 50 years and the disease duration was 88 months. The median delay in seeing a rheumatologist was 24 months (1 e372). 278 (78%) had received DMARD with 163 (58%) patients taking regular DMARD treatment. Methotrexate monotherapy was the most common DMARD used: 160 (74%) were on <10 mg per week. 143 (40%) had received or were on steroids, 260 (73%) had taken alternate form of treatment. 257 (72%) had evidence of radiological damage. HAQ (325 patients) was <1 in 159 (49%), 1e2 in 134 (41%), and >2 in 32 (10%). DAS-28 (3) (350 patients) was, <2.4 in 14 (4%), 2.4e3.2 in 21 (6%), 3.2e5.1 in 112 (32%), >5.1 in 203 (58%). Conclusions: There is a long delay in referral to a rheumatologist. Even on treatment, disease is not well controlled. Majority of the patients have high disease activity with significant disability and evidence of joint damage. Special efforts are needed to ensure early insti- tution of therapy with the aim to achieve maximum disease control as early as possible.

Background: Patients with chronic pain suffer significant reduction in physical, psycho- logical, and social well-being. Anxiety and depressive disorders occur in 20%e25% of pa- tients with Rheumatoid Arthritis (RA). Antidepressants are useful in the treatment of major depression, however the analgesic properties of this class of drugs is not clear. Objective: To study the association between RA and depression along with independent effect of fluoxetine on depression and arthritis. Method: One hundred women attending a rheumatology clinic with RA were included in the study along with controls. Hospital Anxiety Depression Rating Scale (HADS), Montgomerye Asberg Depression Rating Scale (MADRS) and Clinical Global Impression - Change Scale (CGI) were applied. Both the groups were treated with DMARD. RA with depression group also received fluoxetine. Results: Depression is significantly associated with RA; however severity of RA has no relationship with severity of depression. Treatment outcome was better and earlier with add on fluoxetine in the RA with depression group as compared to RA without depression. Conclusion: Treatment of associated depression may expedite the recovery of physical symptoms thus improving the quality of life of an individual with chronic painful conditions.

Recent studies have continued to clarify the pathogenic mechanisms responsible for muscle damage and weakness in inflammatory myopathies. Traditionally, adaptive im- mune mechanisms such as cell mediated (cytotoxic) and humoral (autoantibodies and complement) components have been implicated in the pathogenesis of polymyositis/in- clusion body myositis and dermatomyositis, respectively. However, recent studies have shown a significant overlap of immune components in these disorders. Likewise, studies have provided evidence not only for adaptive immune pathogenic mechanisms but also for innate immune, such as the TLR-NF-kB signaling, and non-immune mechanisms, such as endoplasmic reticulum stress response, autophagy, metabolic deficits in ATP generating pathways and hypoxia. These recent studies indicate that the muscle fiber damage and weakness in myositis may not be solely mediated by an adaptive immune attack (e.g., autoreactive CTLs or autoantibodies) but also mediated through innate immune and metabolic mechanisms. In this review, we have briefly outlined the current developments in immune (adaptive, innate) and non-immune components of disease pathogenesis in inflammatory myopathies.

Rheumatoid arthritis (RA) affects approximately 0.5% of adult Indian population. The last few decades have seen significant advances in the treatment of RA. Pari-pasu, the goals of treatment have moved from symptomatic relief and disease modification to remission and even possible cure. One major hurdle in providing effective therapy is the high cost of medications. In a developing country like ours, cost-effective management of RA patients becomes an important issue. Paucity of trained rheumatologists, poverty, inaccessibility etc. are added hurdles in the delivery of cost-effective treatment. This communication is an overview of the various issues and the possible ways to address them.

Diabetic myonecrosis is a rare and under diagnosed complication of long standing dia- betes. Its diagnosis requires high index of suspicion because the clinical features mimic with those of pyomyositis, deep vein thrombosis and muscle hematoma. MR imaging is the cornerstone for diagnosis of the condition and treatment is mainly conservative by giving rest to the affected limb and NSAIDs. We report a case of diabetic patient who developed this condition twice and was managed successfully both the times with analgesics alone because of timely diagnosis based on characteristic MRI findings.