Serum biochemistry in relation to the action of azathioprine in rheumatoid arthritis

In a long-term study we have been comparing biochemical changes in the blood of patients with classical or definite rheumatoid arthritis (RA) when groups of patients are treated for the first time with specific anti-rheumatoid drugs for a six-month period. One such group was treated for 26 weeks with azathioprine. Biochemical and clinical assessments were made at each of 10 clinic visits during the treatment period. Side-effects prevented six patients completing the study. Clinical improvement in the remaining patients was accompanied by a reduction in acute phase proteins, increases in total serum sulphydryl and serum histidine, but little or no change in immunological variables. Comparison of correlation matrices constructed between clinical and laboratory variables for azathioprine and drugs previously tested suggests that azathioprine is more effective than a control group on aspirin alone and in some ways comparable with D-penicillamine.

A clinical and biochemical evaluation of Clozic, a novel disease modifying drug in rheumatoid arthritis

We have compared two dose levels of Clozic, a novel agent with potential anti-rheumatoid activity, to D-penicillamine and aspirin in an observer blind randomised parallel group study of 56 patients with active rheumatoid arthritis. Eight clinical assessments and 26 laboratory assessments were performed on each patient at each visit over a six month period. Results were analysed by conventional methods and also by correlation matrices constructed between clinical and laboratory variables. Patients treated with D-penicillamine (500 mg/day) responded adequately and the control group on aspirin (up to 3.6 g of enteric coated formulation/day) performed well, though the withdrawal rate from this latter group was high, predominantly because of continued disease activity. Patients receiving Clozic (100 mg/day or 300 mg/day) improved more than patients receiving penicillamine, particularly at the higher dose. Comparison of methods of analysis validates the use of correlation matrices both for detecting anti-rheumatoid activity and for determining the optimum dose of a novel compound. This trial illustrates the problems of a study of this nature, with the powerful effect on patients of being enrolled in such a closely monitored investigation. It emphasises the greater value of biochemical changes in following disease changes.

Crohn's spondylitis: a family study

We report a case of HLA B27 negative Crohn's spondylitis with a detailed study of the proband's family, including tissue types of all living relatives. The family included cases of psoriasis, psoriatic spondylitis, and idiopathic ankylosing spondylitis. We believe this to be the first report of these associated diseases occurring in one family. All relatives were B27 negative, including one with psoriatic spondylitis. The aetiological implications of these findings are considered.

Biomechanics of the patello-femoral joint. Part I: A study of the contact and the congruity of the patello-femoral compartment and movement of the patella

Techniques are described for studying the pattern of contact and congruence of the patello-femoral joint, and the movement of the patella at different angles of knee flexion. The study is carried out on cadaveric knee specimens.

Gastro-intestinal blood loss with high dose tilcotil (Ro 12-0068) and aspirin: an open crossover clinical trial and pharmacokinetic assessment in normal volunteers

An open crossover study was carried out in 8 normal volunteer subjects to compare faecal blood loss resulting from tilcotil (Ro12-0068), a new anti-inflammatory agent, and from enteric-coated aspirin. After a 1-week run-in period, subjects were allocated at random to receive treatment for 2 weeks with either 40 mg tilcotil as a single dose per day or aspirin, 900 mg 4-times daily, reduced if necessary to a maximum tolerated dose. Subjects were then crossed over to the alternative treatment for a further 2 weeks. The results showed that tilcotil produced less blood loss, assessed by a radioactive labelling method, and was better tolerated than aspirin. Plasma concentrations of tilcotil showed that the drug's half-life was approximately 50 hours, compatible with once daily dosage, and steady state concentrations on multiple dosing were reached after 10 to 12 days.

Biomechanics of the patello-femoral joint. Part II: A study of the effect of simulated femoro-tibial varus deformity on the congruity of the patello-femoral compartment and movement of the patella

This paper investigates the effect of different degrees of varus deformity on the pattern of contact, congruence of the patello-femoral joint, and movement of the patella. Varus deformity of 5, 10, and 15 degrees was imposed on the same cadaveric knee specimen used in the study reported in Part I (Fujikawa, Seedhom, Wright, 1983). This was done by high tibial osteotomy and the introduction of a wooden wedge of the appropriate thickness to effect the deformity. It was found that the contact gradually shifted to the medial side of the knee, and the congruence of the patello-femoral compartment was gradually destroyed as the degree of varus deformity increased to 15 degrees, although the effect of 5 degrees of varus deformity was minimal.

Clinically, contact is shifted to the lateral side of the knee with varus deformity, but this is invariably associated with lateral tibial rotation. This rotation explains the difference between the results of the varus deformity imposed on cadaveric knees and those observed clinically. It is proposed that an adverse change in the congruence of the knee will occur after a sudden correction by high tibial osteotomy, just as that occurring in the normal cadaveric knee after imposing a sudden varus deformity, and therefore it may be useful to consider performing the correction at an early stage of the deformity.

The effect of the varus deformity on the movement of the patella is also described.

A phenylbutazone dose-finding study in rheumatoid arthritis

Different doses of phenylbutazone have been compared in a double blind study on 32 patients with rheumatoid arthritis in order to determine the minimum effective dose. Of 8 different dose levels studied (90 mg, 150 mg, 180 mg, 240 mg, 270 mg, 300 mg, 360 mg and 450 mg/day) the most efficacious was found to be 300 mg/day. Doses below this did not produce full benefit; no further improvement occurs with higher doses. Although 7/32 patients developed adverse reactions there was no relationship between these and the plasma levels of either phenylbutazone or oxyphenbutazone. An attempt was made to distinguish 'responders' from 'non-responders'. We found no relationship between response and plasma levels of phenylbutazone or oxyphenbutazone.

Surface geometry of the human ankle joint

Human ankle joint specimens were dissected and the dimensions required for lubrication analysis were measured. In planes parallel to the principal direction of motion, the radii of curvature of the tibial surfaces were slightly larger than those of the corresponding regions of the talar surfaces. A detailed error analysis was performed to ensure that this result was accurate. Also, length and width of the articulating regions and cartilage thicknesses were recorded. Based on the measurements of the present study an equivalent bearing geometry for the human ankle was proposed which had a reduced radius of 0.35 m for the curved surfaces.

A pharmacological and clinical comparison of prednisolone and betamethasone in rheumatoid arthritis

1. Two oral corticosteroids, prednisolone (8 mg/day) and betamethasone (1 mg/day) have been compared in terms of efficacy and adrenal suppressive activity when used in chronic oral dosage in rheumatoid arthritis. 2. 20 patients were entered to a single blind crossover study receiving each drug for a two-week period. Clinical and laboratory assessments were performed. 3. At this dosage there was no significant difference between any of the clinical parameters assessed for either drug though patient preference was 13 for prednisolone and 7 for betamethasone. 4. At this dosage adrenal suppression was not equivalent, being significantly more marked with betamethasone. 5. The results suggest that prednisolone is the drug of choice for chronic dosage.

A functional study of the rheumatoid elbow

A clinical and functional study of rheumatoid elbows has been done to discover the magnitude and frequency of disabilities caused by elbow problems. Pain and weakness were found to affect all activities which were tested, with adjacent joint involvement, flexion deformity, and lack of supination causing significant disability. Instability was not a frequent problem. The frequency of functional disabilities, linked to severe pain, suggests that the development of an elbow joint replacement would be worthwhile.

Comparison of serum 1,25-dihydroxycholecalciferol concentrations in rheumatoid arthritis and osteoarthrosis

We have previously compared 25-hydroxycholecalciferol levels in the serum of patients with osteoarthrosis and rheumatoid arthritis, finding no significant difference between the circulating levels of this hormone. We have now estimated 1,25-dihydroxycholecalciferol levels on stored sera from the same groups of patients and found no significant difference in the levels of this hormone between the 2 groups. The osteopenia that distinguishes rheumatoid arthritis from osteoarthrosis is not the result of altered levels of systemic 25OHD3 or of 1,25(OH)2D3. Local factors may be more important in its pathogenesis.

How long should we talk to patients? A study in doctor-patient communication

The 13 questions to which 173 rheumatic outpatients most frequently wished to know the answer were made the basis of a structured interview. Two lengths of interview were conducted in a controlled trial (short being of 2 minutes' duration, long ranging from 4 to 11 minutes). Sixty patients referred directly from their general practitioners, and not being in any of the remedial professions, were randomly assigned to one of the 2 groups. They were tested by an independent observer immediately after interview, and one month later at their return appointment, by means of a questionnaire that covered the 13 items of information given to all the patients. The longer interview resulted in significantly more information being retained. Of individual questions only 3 scored significantly better with the longer interview--that about the reasons for x-rays immediately after interview, and the role of heredity and the place of rest at delayed recall.

Changes in joint laxity occurring during pregnancy

We have studied changes in peripheral joint laxity occurring during pregnancy in 68 females using both the finger hyperextensometer to quantify laxity at the metacarpophalangeal joint of the index finger and Beighton et al.'s modification of the Carter and Wilkinson scoring system. Although the latter system recorded no change, the more sensitive hyperextensometer demonstrated a significant increase in joint laxity during the last trimester of pregnancy (0.02 greater than p greater than 0.01) over the readings from the same individuals after parturition. When primigravidae and multigravidae were compared, a highly significant increase in laxity was found in women having their second baby over those having their first (0.01 greater than p greater than 0.001), though no further increase in laxity occurred in subsequent pregnancies.

The run-in period in trial design: a comparison of two non-steroidal anti-inflammatory agents in psoriatic arthropathy

Psoriatic arthropathy is a relatively uncommon arthritis that exists in a wide variety of clinical forms. These two features of the disease cause problems in the design of clinical trials. In a comparison of two non-steroidal anti-inflammatory agents in this condition we attempted to overcome the difficulties by using a run-in period during which the dosage of one of the trial drugs was adjusted to suit the individual patient. After two weeks on indomethacin (75 mg or 150 mg/day) patients were allocated to four-week periods of indomethacin in the chosen dosage or diclofenac (75 mg or 150 mg/day) in a double-blind randomized crossover trial that used double dummy packaging. Of the 35 patients that entered the study, 19 completed both study groups. No significant differences were observed between the clinical improvements due to both drugs during the course of the study. In general more side-effects were seen during indomethacin treatment, though the study design precluded exact comparison. In a study biased against diclofenac, patient preference was 9/19 for indomethacin, 4/19 for diclofenac and 7/19 expressing no choice. Advantages and disadvantages of the study design are discussed.

A sequential study of the relationship between faecal Klebsiella aerogenes and the common clinical manifestations of ankylosing spondylitis

An 8-month sequential study at 4-weekly intervals of faecal Klebsiella aerogenes and clinical activity of ankylosing spondylitis is described. Similar frequencies of faecal K. aerogenes were found in the 44 patients and 36 healthy controls studied. Eighteen patients on 19 occasions had K. aerogenes cultured from their faeces, when the preceding specimen had been negative. Six (31.6%) of these occasions were associated with a deterioration in clinical state compared with a similar deterioration associated with only 17 (9.8%) of the remaining 174 faecal culture sequences (p less than 0.02). These results suggest that clinical deterioration in ankylosing spondylitis may be associated with the acquisition of faecal K. aerogenes.

Naproxen and indomethacin in periarthritis of the shoulder

Forty-one patients with periarthritis of the shoulder were entered into a double-blind, parallel comparison of naproxen and indomethacin. Both drugs were given twice daily, naproxen 250 mg in the morning and 500 mg at night and indomethacin 50 mg b.d. Twenty patients received naproxen and 21 received indomethacin. Patients were treated for four weeks. Both drugs significantly reduced pain and patients subjective impression of shoulder restriction, but had little significant effect on objective measurements of mobility. Fourteen patients from the naproxen group and 16 patients from the indomethacin group reported side-effects, the most common being nausea and headache. Three patients stopped naproxen and five patients stopped indomethacin because of side-effects. In conclusion, both drugs were equally effective in treating the pain of periarthritis of the shoulder but did little to change the partial loss of movement associated with the disorder.