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RHEUMATOID ARTHRITIS AND COELIAC DISEASE
330 DESTITUTION AT THE FESTIVE SEASON
RHEUMATOID ARTHRITIS AND COELIAC DISEASE
SIR,-Dr Weller and colleagues (Jan 28, p 220) report preliminary findings from their Christmas and New Year survey. We add our experience. Over five days around Christmas, 1988, about 1000 of London’s homeless people spent some time at a shelter provided by the charity Crisis at Christmas and 375 visited the on-site medical centre, which was open all day. Most of the patients attending the medical centre answered a
SIR,-Dr O’Farrelly and colleagues (Oct 8, p 819) highlight the complex relation between bowel and joint disease. Professor Corbeel and colleagues’ case-report (Dec 17 p 1420) complicates the issue. They describe a girl who failed to thrive and had daily
questionnaire about their health and
access to
medical
care.
Not all
patients answered all questions. 179 (61 %) of 294 patients admitted to having an alcohol problem and 73 (37%) of 200 had had psychiatric care. Review of medical notes showed 106 (28%) of the 375 patients to have significant illness requiring investigation and/or treatment. (For this analysis alcoholism or psychiatric illness were not regarded as significant, unless there was an acute problem.) 61 (58%) of the 106 patients with significant illness had an acute problem including 11 (10%) with alcohol withdrawal, 11 with trauma, and 11 with respiratory infections or asthma; 6 (6%) had dental problems, and a 51-year-old man had a two week history of dysphagia to solids. 45 cases (42%) had chronic problems, including lice/scabies in 25 (24%), probable duodenal ulceration in 5 (5%), angina in 3 (3%), and a young man with a six month history of fits and headache. Only 144 (43%) of 333 had a general practitioner in London. Patients with or without a general practitioner in London were equally likely to have significant acute (15% vs 19%, respectively) or chronic (14% vs 12%, respectively) illness. The lack of benefit of having a local general practitioner might be because patients ignore their doctor’s advice or because their doctors do not meet the needs of the homeless. We attribute the popularity of the Crisis at Christmas medical centre to the fact that it is open on a walk-in basis. Long opening hours are not essential as 70% of patients came between 0900 and 1800. In addition to the high prevalence of alcoholism and psychiatric illness in this population which Weller and colleagues report (and have reported previously), at least 10% of those attending Crisis at Christmas had significant illness. Similar clinics are needed throughout the year to alleviate the medical problems of the homeless. Central Birmingham Health Authority, Birmingham B15 2TZ
MICHAEL R. BRADDICK
Crisis at Christmas, London E1 1BJ
MIKE TOMSON
BGA, Weller MPI, Coker E, Mahomed S. Crisis at Christmas 1986. Lancet 1987, i: 553-54.
1 Weller
recurrent
fever,
a
rash, and diarrhoea at the age of 1
further flare with arthritis at 8 years. This child clearly has systemic-onset juvenile chronic arthritis (JCA),1 a disease very different from and with a different prognosis from the adult rheumatoid arthritis that O’Farrelly and colleagues describe. The nearest equivalent childhood arthritis is seropositive juvenile rheumatoid arthritis, which is always seropositive within the first year, causes erosive change early, and is unusual at this age of onset.2 Systemic JCA often relapses and remits2 and systemic features usually appear before the arthritis. Follow-up series, at 10-15 years after onset, show no or slight physical limitation in about half the patients; active disease that remits within 5 years has a better prognosis.3 The association of coeliac disease and JCA is not common in childhood although transient episodic polyarthritis has been seen.’ Pinals’ described a girl who had a pauciarticular-type JCA with arthritis of the knees and ankles at the age of 12 years and who was later found to have the small bowel changes of coeliac disease; both conditions responded to a gluten-free diet. This type of arthritis resembles the seronegative spondylarthritis described by Bourne et al,5 who reported 6 patients (youngest 17 years at onset of arthritis) who remitted totally or in part on such a diet. Lumbar spine, hips, knees, and shoulders were commonly affected. 3 similar cases were seen in a series of 314 adult patients with coeliac disease.6 A further 2 had true rheumatoid arthritis. Diet did not appear to affect the arthritis. Seropositive rheumatoid arthritis has been reported by others.7 In only 1 of the 3 cases did the arthritis respond to diet. Thus Corbeel and colleagues’ case is different from the patients in the original study who had no bowel or malabsorption signs, arthritis previously described in coeliac disease, or true rheumatoid arthritis. It is possible that Corbeel and colleagues’ case is a chance association of an often naturally remitting disease and coeliac disease. Whilst the association is of interest, it is difficult to draw conclusions that would be applicable to adults. Department of Rheumatology and Rehabilitation, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ 1. Munthe senes
ed. The 3: 43.
E,
care
3. 4.
SiR,—In the UK there are now many one-person-operated buses with driver-controlled exit doors. Most of these doors close with considerable force and do not spring back or give a warning to the driver if they encounter an obstruction. Arms, legs, coats, and shoulder-bags have been trapped in this way. If the driver is unaware of what has happened, he may move off dragging his ex-passenger along, to be injured or even killed. This horrific form of accident is not rare. Inquiries that I have made since my mother was disabled in this way a few months ago suggest that the figure is likely to be many hundreds a year. The tragedy is that these accidents need never occur. It would be easy for the Government to insist that bus-doors were fitted with safety devices in the same way as underground trains or lifts. Although the problem has been recognised for some time, nothing has been done. I appeal to colleagues to join me in urging action through their Members of Parliament and to send me, in confidence, information about any such accidents they have encountered. Department of Child Health, Southmead Hospital, Bristol BS10 5NB
PETER M. DUNN
5. 6. 7.
RICHARD HULL
of the rheumatic child. Basle: EULAR, 1978:
2. Ansell BM Rheumatic disorders in childhood. In Apley J, ed.
BUS-DOOR ACCIDENTS
year and who
diagnosed as having coeliac disease. There was a further with raised immunoglobulins at 2 years before the flare systemic onset of arthritis 6 months later. She was well by 5 years but had a had been
monograph
Postgraduate paediatric
series. London: Butterworths, 1980: 41-151. Hull RG. Outcome in juvenile arthritis. Br J Rheumatol 1988; 27 (suppl 1): 66-71 Pinals RS Arthritis associated with gluten sensitive enteropathy. J Rheumatol 1986, 13: 201-04. Bourne JT, Kumar P, Huskisson EC, Mageed R, Unsworth DJ, Wojtuleski JA Arthritis and coeliac disease. Ann Rheum Dis 1985; 44: 592-98. Cooper BT, Holmes GKT, Cooke WT. Coeliac disease and immunological disorders. Br Med J 1978; i: 537-39. Parke AL, Fagan EA, Chadwick VF, Hughes GRB. Coeliac disease and rheumatoid arthritis. Ann Rheum Dis 1984; 43: 378-80.
SYSTEMIC CAPILLARY LEAK SYNDROME
SIR,-Dr Fellows (Nov 12, p 1143) and Dr Ewan and colleagues and Dr Doorenbos (Dec 24/31, p 1496) report their experience with the systemic capillary leak syndrome. We too have managed a patient with this condition. Our patient, a man aged 46, had symptoms, signs, and investigative findings typical of the systemic capillary leak syndrome, which ran a rapid and fatal course. On eight occasions over 18 months the patient required resuscitation for severe hypovolaemic shock. He died during a particularly severe attack. The characteristic reciprocal relation of elevated haematocrit and reduced serum albumin was observed during attacks. Cl esterase inhibitor activity during and between attacks was normal. An IgG-kappa paraprotein was demonstrated but skeletal survey and
RHEUMATOID ARTHRITIS AND COELIAC DISEASE
SIR,-Dr Weller and colleagues (Jan 28, p 220) report preliminary findings from their Christmas and New Year survey. We add our experience. Over five days around Christmas, 1988, about 1000 of London’s homeless people spent some time at a shelter provided by the charity Crisis at Christmas and 375 visited the on-site medical centre, which was open all day. Most of the patients attending the medical centre answered a
SIR,-Dr O’Farrelly and colleagues (Oct 8, p 819) highlight the complex relation between bowel and joint disease. Professor Corbeel and colleagues’ case-report (Dec 17 p 1420) complicates the issue. They describe a girl who failed to thrive and had daily
questionnaire about their health and
access to
medical
care.
Not all
patients answered all questions. 179 (61 %) of 294 patients admitted to having an alcohol problem and 73 (37%) of 200 had had psychiatric care. Review of medical notes showed 106 (28%) of the 375 patients to have significant illness requiring investigation and/or treatment. (For this analysis alcoholism or psychiatric illness were not regarded as significant, unless there was an acute problem.) 61 (58%) of the 106 patients with significant illness had an acute problem including 11 (10%) with alcohol withdrawal, 11 with trauma, and 11 with respiratory infections or asthma; 6 (6%) had dental problems, and a 51-year-old man had a two week history of dysphagia to solids. 45 cases (42%) had chronic problems, including lice/scabies in 25 (24%), probable duodenal ulceration in 5 (5%), angina in 3 (3%), and a young man with a six month history of fits and headache. Only 144 (43%) of 333 had a general practitioner in London. Patients with or without a general practitioner in London were equally likely to have significant acute (15% vs 19%, respectively) or chronic (14% vs 12%, respectively) illness. The lack of benefit of having a local general practitioner might be because patients ignore their doctor’s advice or because their doctors do not meet the needs of the homeless. We attribute the popularity of the Crisis at Christmas medical centre to the fact that it is open on a walk-in basis. Long opening hours are not essential as 70% of patients came between 0900 and 1800. In addition to the high prevalence of alcoholism and psychiatric illness in this population which Weller and colleagues report (and have reported previously), at least 10% of those attending Crisis at Christmas had significant illness. Similar clinics are needed throughout the year to alleviate the medical problems of the homeless. Central Birmingham Health Authority, Birmingham B15 2TZ
MICHAEL R. BRADDICK
Crisis at Christmas, London E1 1BJ
MIKE TOMSON
BGA, Weller MPI, Coker E, Mahomed S. Crisis at Christmas 1986. Lancet 1987, i: 553-54.
1 Weller
recurrent
fever,
a
rash, and diarrhoea at the age of 1
further flare with arthritis at 8 years. This child clearly has systemic-onset juvenile chronic arthritis (JCA),1 a disease very different from and with a different prognosis from the adult rheumatoid arthritis that O’Farrelly and colleagues describe. The nearest equivalent childhood arthritis is seropositive juvenile rheumatoid arthritis, which is always seropositive within the first year, causes erosive change early, and is unusual at this age of onset.2 Systemic JCA often relapses and remits2 and systemic features usually appear before the arthritis. Follow-up series, at 10-15 years after onset, show no or slight physical limitation in about half the patients; active disease that remits within 5 years has a better prognosis.3 The association of coeliac disease and JCA is not common in childhood although transient episodic polyarthritis has been seen.’ Pinals’ described a girl who had a pauciarticular-type JCA with arthritis of the knees and ankles at the age of 12 years and who was later found to have the small bowel changes of coeliac disease; both conditions responded to a gluten-free diet. This type of arthritis resembles the seronegative spondylarthritis described by Bourne et al,5 who reported 6 patients (youngest 17 years at onset of arthritis) who remitted totally or in part on such a diet. Lumbar spine, hips, knees, and shoulders were commonly affected. 3 similar cases were seen in a series of 314 adult patients with coeliac disease.6 A further 2 had true rheumatoid arthritis. Diet did not appear to affect the arthritis. Seropositive rheumatoid arthritis has been reported by others.7 In only 1 of the 3 cases did the arthritis respond to diet. Thus Corbeel and colleagues’ case is different from the patients in the original study who had no bowel or malabsorption signs, arthritis previously described in coeliac disease, or true rheumatoid arthritis. It is possible that Corbeel and colleagues’ case is a chance association of an often naturally remitting disease and coeliac disease. Whilst the association is of interest, it is difficult to draw conclusions that would be applicable to adults. Department of Rheumatology and Rehabilitation, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ 1. Munthe senes
ed. The 3: 43.
E,
care
3. 4.
SiR,—In the UK there are now many one-person-operated buses with driver-controlled exit doors. Most of these doors close with considerable force and do not spring back or give a warning to the driver if they encounter an obstruction. Arms, legs, coats, and shoulder-bags have been trapped in this way. If the driver is unaware of what has happened, he may move off dragging his ex-passenger along, to be injured or even killed. This horrific form of accident is not rare. Inquiries that I have made since my mother was disabled in this way a few months ago suggest that the figure is likely to be many hundreds a year. The tragedy is that these accidents need never occur. It would be easy for the Government to insist that bus-doors were fitted with safety devices in the same way as underground trains or lifts. Although the problem has been recognised for some time, nothing has been done. I appeal to colleagues to join me in urging action through their Members of Parliament and to send me, in confidence, information about any such accidents they have encountered. Department of Child Health, Southmead Hospital, Bristol BS10 5NB
PETER M. DUNN
5. 6. 7.
RICHARD HULL
of the rheumatic child. Basle: EULAR, 1978:
2. Ansell BM Rheumatic disorders in childhood. In Apley J, ed.
BUS-DOOR ACCIDENTS
year and who
diagnosed as having coeliac disease. There was a further with raised immunoglobulins at 2 years before the flare systemic onset of arthritis 6 months later. She was well by 5 years but had a had been
monograph
Postgraduate paediatric
series. London: Butterworths, 1980: 41-151. Hull RG. Outcome in juvenile arthritis. Br J Rheumatol 1988; 27 (suppl 1): 66-71 Pinals RS Arthritis associated with gluten sensitive enteropathy. J Rheumatol 1986, 13: 201-04. Bourne JT, Kumar P, Huskisson EC, Mageed R, Unsworth DJ, Wojtuleski JA Arthritis and coeliac disease. Ann Rheum Dis 1985; 44: 592-98. Cooper BT, Holmes GKT, Cooke WT. Coeliac disease and immunological disorders. Br Med J 1978; i: 537-39. Parke AL, Fagan EA, Chadwick VF, Hughes GRB. Coeliac disease and rheumatoid arthritis. Ann Rheum Dis 1984; 43: 378-80.
SYSTEMIC CAPILLARY LEAK SYNDROME
SIR,-Dr Fellows (Nov 12, p 1143) and Dr Ewan and colleagues and Dr Doorenbos (Dec 24/31, p 1496) report their experience with the systemic capillary leak syndrome. We too have managed a patient with this condition. Our patient, a man aged 46, had symptoms, signs, and investigative findings typical of the systemic capillary leak syndrome, which ran a rapid and fatal course. On eight occasions over 18 months the patient required resuscitation for severe hypovolaemic shock. He died during a particularly severe attack. The characteristic reciprocal relation of elevated haematocrit and reduced serum albumin was observed during attacks. Cl esterase inhibitor activity during and between attacks was normal. An IgG-kappa paraprotein was demonstrated but skeletal survey and