THE DIAGNOSTIC VALUE OF SYNOVIA BIOPSY IN PATIENTS WITH ARTHRITIS OF UNKNOWN CAUSE

Synovial biopsy of a knee joint was performed in 59 patientswith arthritis of unknown cause. Light microscopy revealed adiagnosis in three. A cause became apparent in only a further23 over a prolonged period of follow-up. Neither light microscopy,immunofluorescence nor electron microscopy discriminated betweenthe principal diagnostic groups. Synovial fluid analysis wasbetter than synovial biopsy at predicting osteoarthritis. Fivemen with giant effusions developed osteoarthritis and thesemight represent an entity. Synovial inflammatory changes wereless pronounced in those with longer histories. Disease durationand activity may have more influence on synovial characteristicsthan the nature of the disorder. KEY WORDS: Diagnosis, Synovium, Light microscopy, Immunofluorescence, Electron microscopy     

早期类风湿关节炎病人中类风湿因子的临床意义

报告９６例早期类风湿关节炎病人血清中ＩｇＭ类风湿因子和ＩｇＡ免疫球蛋白测定的３年随访结果。根据Ｘ线摄片评价骨侵蚀的情况。结果发现，ＩｇＭ类风湿因子和ＩｇＡ免疫球蛋白越高，越容易引起发病头３年内的骨侵蚀。这说明它们是早期诊治类风湿关节炎的２项有价值的实验室指标。这个结果还为早期使用ＩＩ线药物提供了科学依据。     

CLINICAL AND ENDOSCOPIC FEATURES OF AMYLOIDOSIS SECONDARY TO CROHN'S DISEASE: DIAGNOSTIC VALUE OF DUODENAL OBSERVATION AND BIOPSY

Aim: Recent reports have focused on the development of secondary amyloidosis (AMY) as a complication of Crohn's disease (CD). The present study was carried out to investigate the frequency of AMY secondary to CD, its clinical and endoscopic features, and the importance of duodenal biopsy in detecting this disease. Methods: This study involved 408 patients diagnosed with CD who were endoscopically and histologically examined at our hospital. At follow up, we analyzed the incidence of AMY complications, the clinical features of AMY and the methods to diagnose AMY. Results: The incidence of AMY was 2.5% (10/408). The disease type at the time of CD diagnosis was small and large bowel type (SL) in eight patients, small bowel type in one and large bowel type in one. The incidence of AMY was significantly higher in patients with SL than in patients with other disease types. The length of time from onset of CD to diagnosis of AMY was 14.1 ± 8.0 years. The cumulative incidence of AMY was 1.0% at 10 years and 5.7% at 20 years after onset. In terms of the method used to diagnose AMY, the positive rate of AMY diagnosis was 100% with endoscopic duodenal biopsy. Conclusion: The incidence of AMY as a complication of CD was low (2.5%). However, because this complication adversely affects patients' prognoses, it is important to check for the presence of AMY, particularly in the duodenum, in patients for whom more than 10 years have elapsed since the development of CD.     

SEVERE AUTONOMIC NEUROPATHY IN AMYLOIDOSIS SECONDARY TO RHEUMATOID ARTHRITIS

Abstract Autonomic neuropathy, although reported to occur in 15% of patients with AL (primary) amyloidosis, is extremely rare in AA (secondary) amyloidosis. We report a patient with amyloidosis secondary to rheumatoid arthritis in whom autonomic neuropathy resulted in severe and disabling orthostatic hypotension. Extensive amyloid deposits were found throughout the autonomic nervous system. (Aust NZ J Med 1986; 16: 705–707.)     

COMPARISON OF FAECAL FLORAE IN PATIENTS WITH RHEUMATOID ARTHRITIS AND CONTROLS

The faecal flora of 25 out-patients with active rheumatoid arthritis(RA) was compared with that of 25 age- and sex-matched controls.A comprehensive survey revealed a significantly higher carriagerate of Clostridium perfringens in the RA population (88%) thancontrols (48%) (p<0.01). Coliform counts also tended to behigher, but there were no other significant differences betweenpatients and controls. When the study was enlarged to include a further 113 RA patientswith variable disease activity and a further 38 controls, clostridiawere again more frequently carried by those with RA (70%) thancontrols (45%) (p<0.01) and clostridial counts were significantlyhigher in the patient group (p = 0.006). Moreover, counts inpatients with active or moderately active disease were significantlyhigher than in those with inactive disease (p < 0.001). These data are consistent with the hypothesis that Cl. perfringensplays a role in triggering or is otherwise associated with diseaseactivity in RA. The findings may be alternatively an effectof the disease or its treatment with, for example, anti-inflammatorydrugs. KEY WORDS: Rheumatoid arthritis, Faecal flora, Closiridium perfringens ^*Present address: Department of Bactenology, University MedicalSchool, Edinburgh, UK. Present address: Central P.H.L., Division of Hospital Infection,61 Colindale Avenue, London NW9 5HT, UK.     

KNEE LAXITY IN PATIENTS WITH OSTEOARTHRTTIS AND RHEUMATOID ARTHRITIS

Thirty-four patients with osteoarthritis (OA) and 32 patientswith rheumatoid arthritis (RA) were studied to determine theeffects of OA and RA on the laxity of the knee joints. Laxitywas measured with the Genucom Knee Analysis System. The antero-posteriorlaxity of the OA and RA knees was greater than the control,normal knees in the early stage, and decreased with the severityof disease in OA, but not in RA. Severe OA and RA were associatedwith a restricted internal-external rotation at the knee jointcompared with the control. Internal-external rotation decreasedwith worsening of both diseases. Varus-valgus laxity tendedto increase slightly with the severity of disease. While themorphological changes of the cruciate ligaments in advancedOA and RA were not statistically different, the laxity of OA-afflictedknees was affected slightly by the severity of the damage tothe cruciate ligaments. KEY WORDS: Osteoarthritis, Rheumatoid arthritis, Knee joint, Laxity, Cruciate ligament     

BIOAVAILABILITY OF HYDROXYCHLOROQUINE TABLETS IN PATIENTS WITH RHEUMATOID ARTHRITIS

Nine patients with RA received two doses of 155 mg racemic hydroxychloroquineeach, as a tablet and by i.v. infusion, in a randomized cross-overdesign study. Blood concentrations over the first 32 h followingeach dose were determined. Bioavailability was estimated usinga sequential exponential least squares deconvolution method. The mean fraction absorbed from the tablet was 0.79 (range 0.39to 1.27). The mean absorption lag-time was 1.3 h (range 0.5to 3.7 h) and the mean time for 50% absorption was 4.3 h (range1.9 to 10.3 h). Mean rate and extent of hydroxychloroquine absorptionwere not significantly different from that previously reportedfor healthy volunteers, although the interindividual variabilityin absorption parameters was greater in the patient group. Variabilityin the extent of absorption would lead to differences in steady-statehydroxychloroquine concentrations between patients, potentiallycontributing to the variability in response observed in clinicalpractice. KEY WORDS: Pharmacokinetics, Hydroxychloroquine, Bioavailability Present address: Department of Pharmacy, University of Manchester,Manchester M13 9L     

PREVALENCE OF SELF-REPORTED DEPRESSION IN PATIENTS WITH RHEUMATOID ARTHRITIS

The prevalence of self-reported depressive symptoms was investigatedin a case-control study of patients with rheumatoid arthritis(RA) attending an out-patient clinic at the Middlesex Hospital.Patients selected their own controls, matched for age and sex.Previous attempts to measure depressive symptoms in RA havesuffered from measurement error due to criterion contamination,where psychological symptoms augment depressive scores. A totalof 163 patients (77% of the sample) and 115 matched pairs completedthe Hospital Anxiety and Depression Scale (HADS). The resultsIndicated that RA patients are more depressed and anxious thancontrols. The prevalence of depression above the cut-point was15%. This figure is comparable to other reports adjusted forcriterion contamination, but is lower than that of other studieswhich employ ‘contaminated’ tools. The depressionscale of the HADS appeared to be relatively free of criterioncontamination. Subject to further reliability testing, the HADSmay be a practical screening tool for practitioners to assesspatients in need of psychological interventions. KEY WORDS: Depression, Rheumatoid arthritis, Criterion contamination     

LACK OF INTERACTION BETWEEN SULPHASALAZINE AND CIMETIDINE IN PATIENTS WITH RHEUMATOID ARTHRITIS

The interaction between sulphasalazine and cimetidine has beenstudied, a drug combination which is quite likely in view ofthe higher incidence of peptic ulceration in patients with RA.Nine patients with RA on sulphasalazine (group I) were givencimetidine 400 mg three times daily and followed up for 18 weeks.In addition, five patients on sulphasalazine alone (group II),who served as a control group, were also followed up in thesame manner as group I. Monitoring included assessment of diseaseactivity and haematological variables, and measurement of plasmaand urinary levels of sulphapyridine and its metabolites. Therewas no significant change in either the haematological parametersor sulphapyridine pharmacokinetics upon administration of cimetidine.We therefore conclude that cimetidine may be safely used inpatients with RA who are being treated with sulphasalazine. KEY WORDS: Sulphasalazine, Cimetidine, Interaction ^*Present address: Pharmaceutical Sciences Institute. Universityof Aston. Aston Triangle. Birmingham B4 7EY.     

DENTAL STUDY IN PATIENTS WITH RHEUMATOID ARTHRITIS

Twenty-one patients with rheumatoid arthritis took part in acomparison of three toothbrushes, each used for one month ina randomized trial. The three toothbrushes were a conventionaltoothbrush with modified handle to allow ease of gripping, anelectric toothbrush, and thirdly a fingerstall attached to anormal toothbrush. There was no change in the patients' rheumatoid status duringthe trial. The patients were scored for plaque and gingivalchanges but no difference was found between the three toothbrushes. We recommend a standard toothbrush with a modified grip forthe rheumatoid hand; the extra expense of an electric toothbrushcannot be justified. ^*Paper read at the Annual Meeting of the British Associationfor Rheumatology and Rehabilitation, London, 17 April, 1980.     

METABOLIC ABNORMALITIES OF TRYPTOPHAN AND NICOTINIC ACID IN PATIENTS WITH RHEUMATOID ARTHRITIS

The mean plasma total tryptophan concentration of 13 long-standingrheumatoid arthritis patients was found to be lower than thatof seven nonrheumatoid control subjects, but the plasma nicotinicacid concentration was unchanged. In the rheumatoid patientsthe urinary excretion of the tryptophan metabolites, kynurenine,xanthurenic acid and 3-hydroxyanthranilic acid, was increasedseveral fold, but the excretion of N-methylnicotinamide wasnormal. These findings are discussed in relationship to thedietary intakes of tryptophan, nicotinic acid and pyridoxine,the effect of antirheumatoid drugs on plasma tryptophan andliver tryptophan pyrrolase, and the requirement of rheumatoidpatients for pyridoxine. ^*Present address: The National Research Institute for NutritionalDiseases, P.O. Box 70, Tygerberg 7505, South Africa.     

FEMORAL BONE MASS IN PATIENTS WITH RHEUMATOID ARTHRITIS AND OSTEOARTHROSIS

Femoral bone mass has been measured in 42 patients with rheumatoidarthritis and in 27 with osteoarthrosis. Measurements were madeby scanning the leg with a photon beam from ²⁴¹Am. The resultshave been compared with normal subjects and correlated withclinical, biochemical and radiological parameters of the arthriticpatients. In general, femoral bone mass was lower than normalin patients with arthritic changes. Reduced physical activityrather than the arthritis itself seemed to be the cause of thelow bone mass. In rheumatoid arthritis the bone mass appearedto be an accurate representation of the clinical assessmentof the disease.     

DECREASED BIOACTIVITY OF CIRCULATING PROLACTIN IN PATIENTS WITH RHEUMATOID ARTHRITIS

Growth hormone and prolactin (PRL) were measured by radio-immunoassayin sera of 36 patients with rheumatoid arthritis (24 femalesand 12 males) and of 50 normal blood donors (25 males and 25females). The bioactivity of PRL was also determined for bothgroups, using the Nb2 rat lymphoma proliferation assay. Althoughno significant difference was found between serum PRL valuesof patients and controls when determined by radio-immunoassay,the bioactivity of PRL was significantly decreased in patientssera, when compared to values obtained in age and sex-matchedcontrols. This decreased PRL bioactivity could not be attributedto drug treatments administered to the patients examined. KEY WORDS: Rheumatoid arthritis, Prolactin bioactivity, Prolactin immunoreactivity ^* Present address: Shaughnessy Hospital, 4500 Oak St., Vancouver,B.C., Canada. Present address: MRC Reproductive Biology Unit, 37 ChalmersSt., Edinburgh EH3 9EW, UK.     

DOUBLE-BLIND CROSS-OVER STUDY OF ORUDIS AND PLACEBO IN FIFTY PATIENTS WITH RHEUMATOID ARTHRITIS

In a double-blind cross-over study of Orudis and placebo in50 patients with active rheumatoid arthritis, symptomatic reliefproduced by Orudis was found to be significantly greater (p<0.01) than by placebo. Toxic effects were few and trivial. Present address: University College Hospital, London, W.C.I.     

TRANSFERRIN C SUBTYPES IN PATIENTS WITH RHEUMATOID ARTHRITIS

Transferrin (TF) subtypes were investigated in 128 patientswith rheumatoid arthritis (RA) and the frequencies of TfC subtypeswere compared with the results in normal individuals. The frequenciesof the Tf genes: C1, C2, C3, D1, and D2 were 0.4765, 0.3867,0.0742, 0.0390 and 0.0234, respectively. The frequency of TfC2gene was significantly higher in these patients (0.3867) comparedto the value in the control group (C2 = 0.247). The relativerisk of RA in association with TfC1C2 type was 2.0, while itwas 0.18 in association with TfC1C1 type and the results werestatistically significant. This paper confirms the significant association between TfC2and RA. Furthermore, it appears from our results that TfC1 homozygousphenotype is protective for the development of RA. The resultsare discussed in the light of earlier suggestions that the TfC2subtype confers an increased risk of cellular damage by enhancinghydroxyl radical formation, although it is possible that thereexists a genetic linkage of Tf variant to some other locus whichis influencing susceptibility to RA. KEY WORDS: Iron transport, Spontaneous abortion, Hydroxyl-radical formation, Oxygen-derived free radicals, Isoelectric focusing, Holotransferrin     

COMPARISON OF RECONSTRUCTIVE ORTHOPAEDIC SURGERY IN PATIENTS WITH SEROPOSITIVE AND SERONEGATIVE RHEUMATOID ARTHRITIS

The longitudinal orthopaedic history of 107 unselected patientswith rheumatoid arthritis undergoing reconstructive surgerywas studied to define the relationship between serology andsurgery. Using strict criteria 85 patients were seropositiveand 22 seronegative. Age. disease duration, number of reconstructiveorthopaedic operations, and second-line or corticosteroid drugtreatment were similar in seropositive and seronegative patientsUsers of steroids and/or second-line drugs had a similar numberof operations to non-users However, patients undergoing onlyhip or knee surgery used steroids more often in the pre-operativedisease than those only having other operations (p > 0.05).This may reflect more-aggressive disease or the direct effectof steroids The expected proportions of seropositive and seronegativepatients together with their similar surgical and treatmentpatterns do not suggest that they have different diseases. KEY WORDS: Orthopaedic surgery, Seropositive, Seronegative, Rheumatoid arthritis     

ELBOW JOINT FORCES IN PATIENTS WITH RHEUMATOID ARTHRITIS

Whilst developing an elbow endoprosthesis, the joint forceswere estimated for patients with rheumatoid arthritis. Elbowflexion strength of rheumatoid patients was found to be 45 %of normal. Muscle strengths and limb geometry data were foundby a dissection technique, which allowed joint forces to becalculated during flexion, extension and abduction efforts.Forces up to 2.4 kN were predicted to act on the distal humerus,with similar forces acting in both radius and ulna. The skeletalstructure is well adapted to carry the predicted forces, andonlay-type prostheses are recommended for elbow replacement. _*Paper read at the Annual Meeting of the British Associationfor Rheumatology and Rehabilitation, London, April 1979.     

ENDOGENOUS OPIOID TONE IN PATIENTS WITH RHEUMATOID ARTHRITIS

We have previously shown that there is deficient hypothalamic-pituitary-adrenal(HPA) responsiveness in rheumatoid arthritis (RA) patients.The basis for this deficient response is not known. The purposeof the project was to investigate whether the defective HPAresponse in RA patients is the result of increased endogenousopioid tone secondary to chronic pain which can suppress corticotrophin-releasinghormone (CRH) production. We conducted a double-blind placebo-controlledcross-over trial to study the effect of the opiate antagonist,naloxonc, on psychometric function together with plasma adrenocorticotrophichormone (ACTH), cortisol and prolactin. Seven RA patients withactive and established disease and eight healthy controls werestudied. Each received either a bolus i.v. infusion of 20 mgnaloxone or normal saline. After at least 72 h, they receivednaloxone if they had previously received normal saline or viceversa. The pain score was statistically significantly higherat baseline in the RA group compared with controls (5.7 ±3.25 vs 0.35 ± 0.21, P < 0.001). No difference wasfound in the other psychometric assessments throughout the study.Patients receiving normal saline did not show any significantchange in cortisol or ACTH. Cortisol and ACTH showed a sharpand significant rise after naloxone treatment in both RA andnormal subjects (P < 0.001 and P < 0.01), but no differencewas observed between the two groups. The mean prolactin levelshowed no significant change in both groups after any treatment.We conclude that endogenous opioid tone does not appear to bea major contributor to the HPA defect in RA. However, the numberof patients studied was small and this result will require confirmationfrom larger trials. KEY WORDS: Rheumatoid arthritis, Endogenous opioid, Opiate, Hypothalamus-pituitary-adrenal axis, Cortisol, Naloxone, ACTH, Prolactin