Monosodium urate crystals stimulate monocytes and macrophages to release IL-1β through the NALP3 component of the inflammasome.

Objective. Patients with rheumatoid arthritis (RA) in whom the response to anti-tumor necrosis factor (anti-TNF) therapy is inadequate have several therapeutic options, such as switching to an alternative anti-TNF agent or initiating B cell-depleting therapy with rituximab (RTX). Although both therapeutic options have been proven effective in trials, no head-tohead comparisons are available. The aim of this study was to compare the effectiveness of RTX with that of an alternative anti-TNF agent in the management of patients with RA who had an inadequate response to anti-TNF therapy.Methods. This prospective cohort study was nested within the Swiss Clinical Quality Management RA cohort and included all patients who had an inadequate response to at least 1 anti-TNF agent and subsequently received either 1 cycle of RTX or an alternative anti-TNF agent. The primary outcome was the evolution of RA disease activity (as measured on the Disease Activity Score in 28 joints [DAS28]), which was analyzed using multivariate regression models for longitudinal data.Results. One hundred sixteen patients with RA were included; 50 patients received 1 cycle of RTX, and 66 patients were treated with a second or a third alternative anti-TNF agent. At baseline, there were no significant differences between the 2 groups in age, sex, disease duration, and disease activity. Evolution of the DAS28 was more favorable in the group that received RTX compared with the group that received an alternative anti-TNF agent (P ‫؍‬ 0.01). At 6 months, the mean decrease in the DAS28 was ؊1.61 (95% confidence interval [95% CI] ؊1.97, ؊1.25) among patients receiving RTX and ؊0.98 (95% CI ؊1.33, ؊0.62) among those receiving subsequent anti-TNF therapy.Conclusion. The results of this observational study suggest that treatment with RTX may be more effective than switching to an alternative anti-TNF agent in patients with RA in whom active disease persists despite anti-TNF therapy.

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Background: How to use clinical score, the rapid streptococcal antigen test (RSAT), and culture results is uncertain for efficient management of acute pharyngitis in adults. Methods: This prospective cohort study included 372 adult patients with pharyngitis treated at a Swiss university-based primary care clinic. In eligible patients with 2 to 4 clinical symptoms and signs (temperature Ն38°C, tonsillar exudate, tender cervical adenopathy, and no cough or rhinitis), we performed an RSAT and obtained a throat culture. We measured sensitivity and specificity of RSAT with culture as a gold standard and compared appropriate antibiotic use with cost per patient appropriately treated for the following 5 strategies: symptomatic treatment, systematic RSAT, selective RSAT, empirical antibiotic treatment, and systematic culture. Results: RSAT had high sensitivity (91%) and specificity (95%) for the diagnosis of streptococcal pharyngitis. Systematic throat culture resulted in the highest antibiotic use, in 38% of patients with streptococcal pharyngitis. Systematic RSAT led to nearly optimal treatment (94%) and antibiotic prescription (37%), with minimal antibiotic overuse (3%) and underuse (3%). Empirical antibiotic treatment in patients with 3 or 4 clinical symptoms or signs resulted in a lower rate of appropriate therapy (59%) but higher rates of antibiotic use (60%), overuse (32%), and underuse (9%). Systematic RSAT was more cost-effective than strategies based on empirical