Controlled trial of medical treatment of active chronic otitis media Active chronic otitis media is a common condition affecting 0 6%,' of adults in the United Kingdom. Initial management is usually by general practitioners, who annually prescribe systemic and topical antibiotics on at least 178 000 and 73 000 occasions respectively (unpublished observations). Despite this there have been few studies of the efficacy of antibiotics,'-4 and no study has included a control group of untreated patients or of patients treated solely by aural toilet. We undertook a controlled study comparing appropriate systemic or topical antibiotic treatment with weekly aural toilet and insufflation of boric acid and iodine powder.

ObjectiveTo investigate whether antidrug antibodies and/or drug non‐trough levels predict the long‐term treatment response in a large cohort of patients with rheumatoid arthritis (RA) treated with adalimumab or etanercept and to identify factors influencing antidrug antibody and drug levels to optimize future treatment decisions.MethodsA total of 331 patients from an observational prospective cohort were selected (160 patients treated with adalimumab and 171 treated with etanercept). Antidrug antibody levels were measured by radioimmunoassay, and drug levels were measured by enzyme‐linked immunosorbent assay in 835 serial serum samples obtained 3, 6, and 12 months after initiation of therapy. The association between antidrug antibodies and drug non‐trough levels and the treatment response (change in the Disease Activity Score in 28 joints) was evaluated.ResultsAmong patients who completed 12 months of followup, antidrug antibodies were detected in 24.8% of those receiving adalimumab (31 of 125) and in none of those receiving etanercept. At 3 months, antidrug antibody formation and low adalimumab levels were significant predictors of no response according to the European League Against Rheumatism (EULAR) criteria at 12 months (area under the receiver operating characteristic curve 0.71 [95% confidence interval (95% CI) 0.57, 0.85]). Antidrug antibody–positive patients received lower median dosages of methotrexate compared with antidrug antibody–negative patients (15 mg/week versus 20 mg/week; P = 0.01) and had a longer disease duration (14.0 versus 7.7 years; P = 0.03). The adalimumab level was the best predictor of change in the DAS28 at 12 months, after adjustment for confounders (regression coefficient 0.060 [95% CI 0.015, 0.10], P = 0.009). Etanercept levels were associated with the EULAR response at 12 months (regression coefficient 0.088 [95% CI 0.019, 0.16], P = 0.012); however, this difference was not significant after adjustment. A body mass index of ≥30 kg/m2 and poor adherence were associated with lower drug levels.ConclusionPharmacologic testing in anti–tumor necrosis factor–treated patients is clinically useful even in the absence of trough levels. At 3 months, antidrug antibodies and low adalimumab levels are significant predictors of no response according to the EULAR criteria at 12 months.

Osteoarthritis (OA) is the fastest growing cause of disability worldwide. The aim of this study was to understand the impact of OA on individuals and to explore current treatment strategies. An online UK-wide survey of people with self-reported OA was conducted composed of 52 questions exploring the impact of OA, diagnosis and treatment, the role of health professionals and self-management. 4,043 people were invited with 2,001 respondents (49% response, 56% women, mean age 65 years). 52% reported that OA had a large impact on their lives. 15% of respondents had taken early retirement, on average 7.8 years earlier than planned. In consultations with general practitioners, only half reported a discussion on pain; fewer reported discussing their fears (21%) or management goals (15%).Nearly half (48%) reported not seeking medical help until pain was frequently unbearable.Oral analgesics (62%), topical therapies (47%), physiotherapy (38%) and steroid injections (28%) were commonly used. The majority (71%) reported varying degrees of persistent pain despite taking all prescribed medication. Although 64% knew that increasing exercise was important, only 36% acted on this knowledge; 87% who increased exercise found it beneficial. Over half had future concerns related to mobility (60%), maintaining independence (52%) and coping with everyday activities (51%). OA had significant individual economic impact especially on employment. Current treatment strategies still leave most people in pain with significant fears for the future. There is considerable opportunity to improve the holistic nature of OA consultations especially in provision of information and promotion of self-management strategies.

SUMMARY Anticardiolipin antibodies have recently been described in association with arterial and venous thrombosis, and with neurological symptoms, in connective tissue diseases. In a study of 70 patients with Behcet's syndrome 13 patients had these antibodies. Of these 13 patients eight had a history of either retinal vascular pathology, cerebral infarction, or thrombophlebitis. The association of retinal vascular disease and the presence of anticardiolipin antibodies was statistically significant.

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