Computer based quantitative analysis of capillary abnormalities in systemic sclerosis and its relation to plasma concentration of von Willebrand factor

OBJECTIVES

To evaluate an objective and quantitative method for assessment of capillary abnormalities in systemic sclerosis (SSc).

METHODS

Nailfold capillaries were investigated by capillary microscopy and photographed in 17 consecutive SSc patients (five with diffuse cutaneous systemic sclerosis (dSSc) and 12 with limited cutaneous systemic sclerosis (lSSc)) and in 17 healthy controls. Investigators having no access to clinical data made drawings from magnified projections of coded photographs and analysed them using a computer program. Capillary density (capillary loops/mm in the distal row) and median capillary loop area were calculated. Presence of functional or organic arterial changes was evaluated by measurement of finger pressure with finger cooling. Plasma concentration of von Willebrand factor (VWF) was analysed using an enzyme linked immunosorbent assay (ELISA).

RESULTS

In 16 of 17 SSc patients and 13 of 17 controls the technical quality of the photographs was sufficient for computer analysis. Capillary density was decreased in dSSc (median 6.9 loops/mm) and in lSSc (median 3.8 loops/mm) compared with healthy controls (8.9 loops/mm) and median capillary loop area was increased in dSSc (7.3 x 10(-3) mm2) and in lSSc (8.5 x 10(-3) mm2) compared with healthy controls (5.0 x 10(-3) mm2). An inverse relation was found between capillary density and median capillary loop area in SSc patients. Plasma VWF was increased in patients (median 401 IE/l in dSSc and 409 IE/l in lSSc) compared with controls matched for age and sex (median 276 IE/l). Computer based analysis showed capillary density below the control range and median capillary loop area above the control range in 14 of 16 SSc patients. Measurement of finger pressure with finger cooling showed organic vascular changes in nine of 13 SSc patients.

CONCLUSION

Computer based quantitative analysis has low interobserver variability and is a quantitative and sensitive method of assessing capillary abnormalities in SSc.

Current pharmacological treatment of osteoarthritis

In this overview, the currently available symptomatic treatments of osteoarthritis from the published literature are evaluated. Paracetamol attracts growing interest as a less toxic yet potent alternative to NSAIDs. These latter agents are, however, used more widely than paracetamol, although adverse reactions associated with their use are of increasing concern among both patients and physicians. New NSAIDs are still under development. While there is not much evidence of important differences between NSAIDs in overall efficacy, they do vary with regard to toxicity. The cytoprotective effect of misoprostol in at-risk patients on NSAIDs is established but the cost-effectiveness is unclear. Furthermore, percutaneous administration of NSAIDs, capsaicin, and other substances may have some merit. Opioids, such as dextropropoxyphene, are used in combination with paracetamol in patients intolerant to NSAIDs or when pain is not controlled with NSAIDs. Locally administered glucocorticoids may have a disease-modifying effect and are of symptomatic use in certain situations. The role, if any, of hyaluronan therapy remains to be established. Although this agent appears to have a good safety profile, it is expensive. Chondroprotection is an interesting field for future research, although there is no good evidence supporting its existence in clinical medicine as practised now.

Associations of HLA-DRB and -DQB genes with two and five year outcome in rheumatoid arthritis

OBJECTIVE

To evaluate the clinical usefulness of genomic HLA typing during the first five years of established rheumatoid arthritis (RA).

METHODS

The HLA-DRB and -DQB alleles were determined by restriction length polymorphisms and polymerase chain reaction amplification with sequence specific primers in 99 Swedish patients with RA. Clinical features after two and five years disease duration were related to the genetic pattern. Seventy four patients were seropositive, 25 had nodules, 90 developed erosions, and 15 required joint replacements. Twelve patients were in remission after five years. Disability was assessed by health assessment questionnaire, and radiographic damage in hands and feet by the Larsen method.

RESULTS

Eighty seven per cent of the patients carried the conserved third hypervariable region sequence (HVR3), 32% had DRB1*04 on one allele, and 26% had DRB1*04 on both alleles (all frequencies significantly greater than in controls). Frequencies of DRB1*04 associated DQB*0301 and *0302 were normal. Patients carrying DRB1*04 on both alleles tended to have more radiographic changes after two years, but this difference had diminished after five years. Disability did not vary with regard to the genotype. Homozygous HVR3 patients had about three times greater risk of undergoing joint replacement. Homozygosity for HVR3 and presence of DQB*0302 both tended to be associated with erosive disease.

CONCLUSIONS

We confirmed a strong association of disease with the presence of the shared epitope on one or two alleles. However, genotype was not strongly associated with disease severity after two and five years disease duration, and thus the value of genomic typing to select patients for early aggressive therapy is questionable.

Improved pulmonary function in systemic sclerosis after treatment with cyclophosphamide

OBJECTIVE

Pulmonary fibrosis is a common feature of systemic sclerosis (SSc) and a major cause of morbidity and mortality. Since alveolitis may be an essential step in the development of pulmonary fibrosis, we investigated the use of immunosuppressive drug therapy to improve pulmonary function in patients with SSc.

METHODS

Eighteen patients with progressive pulmonary dysfunction, diminished vital capacity (VC), and/or decreased static lung compliance (Cst) were treated with cyclophosphamide and corticosteroids for 1 year. Eight patients had diffuse cutaneous SSc and 10 had limited cutaneous SSc. The median disease duration was 2.5 years (range 0.5-17 years).

RESULTS

VC increased in 14 of 18 patients and the median VC rose from 74% to 80% of predicted. Cst improved in 8 of 12 patients and the median Cst increased from 59% to 66% of predicted. Pulmonary nonfibrotic opacities disappeared in 9 of 12 patients. The erythrocyte sedimentation rate (ESR) and serum concentrations of orosomucoid, C-reactive protein, and aminopropeptide type III collagen all improved. The patients were divided into 2 groups based on the presence or absence of elevations in acute-phase protein levels and ESR before therapy. Among the 12 patients with biochemical signs of inflammation, VC increased in 11, and Cst improved or was unchanged in 7 of the 8 who were tested. The median VC in this subgroup increased from 73% to 80% of predicted and the median Cst increased from 57% to 60% of predicted. In the group of 18 patients overall, the skin score decreased, while esophageal and renal function remained stable.

CONCLUSION

Cyclophosphamide may have a beneficial effect on pulmonary fibrosis in patients with SSc and elevated levels of acute-phase proteins. Controlled trials of cyclophosphamide in pulmonary SSc should be performed and should focus on such patients.

Inverse relation between plasma concentration of von Willebrand factor and CrEDTA clearance in systemic sclerosis

OBJECTIVE

Microvascular abnormalities involving endothelial cell dysfunction occur as an early event in systemic sclerosis. We studied plasma concentrations of von Willebrand factor (vWf), a substance released from injured endothelial cells, and its relation to pulmonary and renal dysfunction.

METHODS

vWf was determined by immunoelectrophoresis. Renal function was assessed by CrEDTA clearance, an accurate measure of glomerular filtration rate and pulmonary function by spirometry and carbon monoxide diffusing capacity. Pulmonary pressure was measured by Doppler cardiography.

RESULTS

In 22 patients with scleroderma, vWf concentrations related inversely to CrEDTA clearance. In contrast, no relationship between plasma vWf and pulmonary function was found; 9/10 patients with pulmonary hypertension and 9/12 patients with normal pulmonary pressure showed elevated levels of vWf. However in 5 patients with pulmonary hypertension without radiographic evidence of pulmonary fibrosis there was a strong correlation between plasma vWf and pulmonary pressure (rho = 0.90) which fell short of statistical significance due most likely to small population size.

CONCLUSION

Renal but not pulmonary dysfunction was associated with elevated plasma levels of vWf.

Learned helplessness and its correlation to impairment, pain, anxiety and depression in rheumatoid arthritis

A Swedish version of the self-report instrument Arthritis Helplessness Index (AHI) is presented. Validity and reliability of the translation has been analyzed. 100 consecutive patients with rheumatoid arthritis (RA) were studied, 78 of which completed 2 self-administered questionnaires with AHI, impairment, pain, anxiety and depression. Furthermore 20 of the patients were interviewed with regard to AHI. Forty-two other patients with RA were analyzed for correlation between AHI and biochemical activity and Signals of Functional Impairment (SOFI). We conclude that the Swedish version of AHI has satisfactory validity and reliability. It correlates with age, physical impairment, pain, anxiety and depression but not with sex or disease activity. Five of the original 15 items could for various reasons be omitted, leaving a 10 statement instrument. AHI is promising as a variable in future outcome studies of RA.

Prevention of joint destruction in antigen-induced arthritis

In rheumatoid arthritis (RA) erosive joint changes are the dominating cause of chronic disability. In a cohort of patients with RA followed from early stages of the disease, we have observed a much larger prevalence of destructions in hips than in knee joints. The latter were frequently injected with triamcinolone hexacetonide in contrast to the former. In order to elucidate a possible role of local glucocorticoids we studied the antigen-induced arthritis model of Dumonde and Glynn in rabbits which, untreated, caused advanced joint destruction in 3/5 animals, whereas 0/14 animals receiving 3 injections of triamcinolone hexacetonide developed no such changes. The treatment was effective when started up to 2 weeks after induction of the arthritis. It is suggested that locally administered glucocorticoids may prevent or delay large joint destruction in RA.

Early pulmonary disease in systemic sclerosis: a comparison between carbon monoxide transfer factor and static lung compliance

OBJECTIVES

Pulmonary disease is responsible for considerable morbidity and mortality in systemic sclerosis (SSc). Static lung compliance (Cst) has been observed to be decreased more often in SSc than the vital capacity, indicating that it is a sensitive measure of lung restriction. In this study Cst was compared with the carbon monoxide transfer factor (TLCO), a widely used measure of the function of the alveolar capillary unit, and with lung volumes in 59 patients with confirmed or suspected SSc.

METHODS

Cst was calculated from the oesophageal pressure at different lung volumes and the TLCO was measured with the single breath method.

RESULTS

The TLCO was found to be the earliest sign of pulmonary disease and was already decreased at a disease duration of one year or less. Surprisingly, no relation was found between the TLCO and smoking habits, nor the degree of peripheral vascular disease. The TLCO correlated with the Cst and vital capacity.

CONCLUSIONS

An early pulmonary lesion can be identified in patients with SSc with decreased TLCO at a time when no fibrotic changes are manifested.

Characterization and functional assessment of patients subjected to occipito-cervical fusion for rheumatoid atlanto-axial dislocation

20 patients with rheumatoid arthritis and atlanto-axial dislocation subjected to occipito-cervical fusion were studied. The patients were evaluated by a rheumatologist before surgery and 6-12 months after the fusion procedure. Joint tenderness was assessed by Ritchie's Index while the functional capacity was evaluated using a health assessment questionnaire and according to the classification by Steinbrocker. Localization and character of the symptoms from the head-neck region were registered. The neck pain was measured on a visual analogue scale. Radiographs of hands and wrists were obtained before surgery and joint destruction was classified according to the Larsen Dale Index. Reduction of pain and neurological symptoms was observed in the majority. There was, however, little evidence of improved functional capacity.

Carboxyterminal type I procollagen peptide concentrations in systemic sclerosis: higher levels in early diffuse disease

Systemic sclerosis (SSc) is characterized by increased collagen deposition in skin and internal organs, and increased serum concentrations of different connective tissue metabolites have been reported. In this study serum concentrations of carboxyterminal type I (PICP) and aminoterminal type III procollagen peptide (PIIINP) were higher in 24 patients with diffuse cutaneous systemic sclerosis (dSSc), than in 30 patients with limited cutaneous systemic sclerosis (lSSc). Thirty patients with advanced and progressing disease had higher serum concentrations of both peptides than 24 patients with milder disease. In patients with advanced disease, both peptides showed a negative correlation to disease duration. Despite being relatively higher both in early, widespread and advanced disease, serum PICP concentrations varied only within the normal range for healthy controls. Thus PICP is of limited value as a marker of disease activity in SSc.

The search for laboratory measures of outcome in rheumatoid arthritis

A large number of laboratory tests have been developed within the past decade to measure factors involved in the immune inflammation of RA. These can be divided into genetic markers, general measures of inflammation, autoantibodies and tissue-specific markers. In general, it is simpler to prove the power of a certain test to measure the disease process than to predict outcome. Apart from RF positivity and CRP/ESR, few, if any, tests have proven to be of importance in independent studies from different centres. Among the promising candidates for future work are detailed analysis of the HLA-D region genes, sulphoxidation status, the autoantibody against RA33 nuclear antigen, soluble IL-2 receptor measuring lymphocyte activity, hyaluronate/hyaluronan or PIIINP from synovial tissue, the combined use of COMP and proteoglycan epitope tests for cartilage matrix, and pyrodinoline cross-linking for collagen from bone and cartilage. The ideal setting for testing such markers are prospective cohort studies starting early in the disease, and since many such studies have been initiated recently, one can expect much new information in coming years. Attention needs to be devoted to the kinetics of marker metabolism, since many are degraded or removed at very fast rates from the circulation, making serum assays less informative.

Long-term evaluation of penicillamine or cyclofenil in systemic sclerosis. Results from a two-year randomized study

In a two-year prospective therapeutic trial 13 patients with systemic sclerosis (SSc) were treated with penicillamine, 9 with cyclofenil, and 7 with neither. At entry skin involvement and esophageal, lung, heart, and kidney function did not differ significantly between the groups. Reevaluation after one and two years did not show any significant changes in skin, esophageal, heart, and kidney manifestations, while lung function had slightly improved in both drug-treatment groups. This study thus shows little overall effect of penicillamine and cyclofenil, although both drugs may arrest worsening of pulmonary dysfunction.

Disease activity and joint damage progression in early rheumatoid arthritis: relation to IgG, IgA, and IgM rheumatoid factor

The clinical and biochemical correlations with joint damage progression over two years in a consecutive group of 68 patients with rheumatoid arthritis with disease duration of less than two years are reported. Joint damage was assessed with Larsen's severity scale and a measure of change in progression rate constructed. Initial haemoglobin concentration, Ritchie index, and Waaler-Rose titre in combination accounted for one third of the variance in joint damage progression. Rheumatoid factor (RF) concentrations were followed with enzyme linked immunosorbent assays (ELISAs) for IgG RF, IgA RF, and IgM RF. The RF concentrations, except IgG RF, decreased with time; significant correlations between RFs and disease activity were few and barely clinically useful. After two years IgG RF correlated significantly with a radiological score if early non-erosive changes were omitted. All RFs tended to correlate better with this radiological score at all three observation points. Analyses of the change in progression rate indicated a time delay between development of radiographic changes and increase of IgG RF. These results suggest an indirect relation between RFs and joint damage. Clinical and biochemical improvements in early RA occur despite joint damage progression, and conventional markers have insufficient predictive value.

Effects of sulindac and naproxen on prostaglandin excretion in patients with impaired renal function and rheumatoid arthritis

PURPOSE

The purpose of the current investigation was to study the influence of sulindac and naproxen on renal function and urinary excretion of the stable hydration product of prostacyclin, 6-keto-PGF1 alpha, in patients with arthritis and impaired renal function.

PATIENTS AND METHODS

In a placebo-controlled, double-blind, cross-over design, the effects of 7 days of oral sulindac 200 mg twice a day were compared with naproxen 500 mg in the morning and 250 mg in the evening in 10 patients with polyarthritis and stable impaired renal function. Inulin and para-amino-hippurate sodium were used to calculate glomerular filtration rate and renal plasma flow. The excretion rate of 6-keto-PGF1 alpha was measured in urine collected overnight. After patients ingested drugs in the morning, urine was collected in fractions by spontaneous voiding. Venous blood samples were drawn repeatedly for assay of electrolytes, creatinine, proteins, hormones, and drugs. Grip strength and Ritchie articular index were recorded as indicators of symptomatic antiarthritic effectiveness.

RESULTS

Naproxen decreased urine levels of 6-keto PGF1 alpha by 59% (p less than 0.01). Sulindac had no effect on renal prostaglandin excretion. Naproxen reduced the glomerular filtration rate and renal plasma flow by 18% (p less than 0.05) and 13% (p less than 0.05), respectively, while no significant change was observed during the sulindac treatment periods. Serum levels of creatinine and complement factor D were unaffected by either drug. Plasma renin activity decreased during naproxen and sulindac treatments by 38% (p less than 0.05) and 22% (p less than 0.05). No significant change in plasma aldosterone was observed during the two drug treatments, but urinary aldosterone declined significantly (p less than 0.05) by 34% with naproxen. Albuminuria decreased (p less than 0.05) during both naproxen (41%) and sulindac treatment (72%), while the albumin/creatinine clearance ratio decreased by 59% (p less than 0.05) only during treatment with sulindac. N-acetyl-beta-D-glucosaminidase in urine was not changed by either drug. Sulindac and naproxen had no discernible effects on base excess, excretion of water, sodium, or potassium, or on osmolal clearance. However, serum potassium increased slightly but significantly (p less than 0.01) during treatment with naproxen. Sulindac sulfide, the active metabolite of sulindac, could not be traced in the urine from any of the patients. Mean arterial blood pressure declined significantly (p less than 0.05) during sulindac treatment but did not change during treatment with naproxen. Both drugs produced equal clinical improvement as measured by grip strength and the Ritchie articular index.

CONCLUSION

The results suggest that when sulindac and naproxen are given in clinical equipotent doses to patients with impaired renal function, sulindac does not affect renal prostaglandin synthesis or renal function, whereas naproxen induces suppression of renal prostaglandin synthesis and a further decrease in renal function.

Early rheumatoid arthritis--onset, course, and outcome over 2 years

Eighty-nine patients, 33 men and 56 women, with early definite rheumatoid arthritis were followed for 2 years. Two-thirds were seropositive. About 1/3 were eventually treated with second line drugs. The disease mostly had an insidious onset initially involving the finger joints. Early remission occurred in 16%. Patient relevant measures such as pain, patient's overall assessment of disease activity and anxiety decreased significantly. Disability evaluated by the HAQ disability index remained at a low level. The joint damage score (JDS) in hands and feet increased steadily and only 18% were nonerosive after 2 years. One-third developed hand deformities which was associated with higher JDS. A joint function index (SOFI) correlated significantly with JDS. Twenty-eight percent had a slower rate of joint damage progression the second year. There was no significant correlation between JDS and disease duration. Six patients developed rapidly progressive damage in larger joints, five in the hip joints and one in the shoulder joint, all requiring joint replacement. The ability to predict outcomes with clinical and laboratory variable obtained at entry was of limited clinical usefulness. By applying discriminant analyses 67%-80% of the cases who fared worst regarding clinical, functional, and radiological features could be correctly classified.

Intraarticular corticosteroid injection into rheumatoid arthritis knees improves extensor muscles strength

Eleven arthritic knee joints in seven patients with rheumatoid arthritis were studied before and after intraarticular injection of a corticosteroid preparation. Extensor muscle torque and quantitative electromyography increased on days 7 and 14 after treatment, indicating that muscle function had been inhibited by synovitis. Clinical signs of synovitis, such as pain, range of motion and knee circumference, also improved. Synovial fluid withdrawal alone improved extensor muscle torque. Joints with instability and/or radiological cartilage involvement also improved.

Joint capsular stiffness in knee arthritis. Relationship to intraarticular volume, hydrostatic pressures, and extensor muscle function

Increased intraarticular hydrostatic pressure (Pia) may inhibit juxtaarticular muscle function, obstruct blood supply to joint structures and promote anoxic joint destruction in chronic arthritis. Joint capsular stiffness together with synovial fluid volume determines Pia at rest. Seventeen knee joints with effusive arthritis and different degrees of radiological cartilage involvement in 13 patients with chronic arthritis were examined. Since capsular elastance was difficult to standardize, we introduce a measure of joint capsular stiffness where the intraarticular volume yielding a pressure of 50 mm Hg (V50) is used. After normalization of injected volumes according to the V50, pressure volume curves became similar. Intraarticular hydrostatic pressure and maximal voluntary isometric extensor torque were measured simultaneously, while altering the intraarticular fluid volume in 9 knee joints. In 5 of these, quantified electromyography (EMG) of the vastus medialis and lateralis portion of the quadriceps muscle was also monitored. Progressive inhibition of extensor torque and EMG was found as the intraarticular pressure volume was increased in both intact and destroyed joints. No difference in inhibition was found for the 2 portions of quadriceps muscle tested. Increased intraarticular hydrostatic pressure Pia levels between 200 and 1150 mm Hg were observed during maximal voluntary activation of extensor muscles. The reproducibility was good for all variables studied. In a few instances evidence of intraarticular compartmentalization was found at low volumes. We conclude that the V50 is a convenient expression of capsular stiffness. Furthermore, increasing Pia caused by joint effusion inhibits knee extensor muscle function and impairs synovial blood flow. Awareness of these relations will facilitate more rational therapeutic approaches in chronic arthritis.

Organ manifestations in 100 patients with progressive systemic sclerosis: a comparison between the CREST syndrome and diffuse scleroderma

Internal organ function, biochemical, and immunological variables were assessed in 100 patients with progressive systemic sclerosis (PSS), 37 with diffuse scleroderma and 63 with the CREST syndrome. The frequency of oesophageal symptoms and dysmotility did not differ between the two subsets, but patients with diffuse scleroderma had more pronounced motility disturbances. Calcinosis, Raynaud's phenomenon, and telangiectasia were equally frequent in the two groups. Vital capacity, total lung capacity, and static lung compliance were lower among patients with diffuse scleroderma (p less than 0.001), who also had a higher frequency of lung fibrosis (p less than 0.001) and cardiomegaly (p less than 0.01). Sixty eight per cent of the patients with diffuse scleroderma and 62% of those with the CREST syndrome had a positive antinuclear antibody test, which was associated with oesophageal hypomotility (p less than 0.001), fat malabsorption (p less than 0.01) and pulmonary dysfunction (p less than 0.05). Thus, the severity of organ manifestations varied not only with the form of PSS, but also with the absence/presence of antinuclear antibody. This study shows that the term 'CREST syndrome' could be replaced by 'limited cutaneous systemic sclerosis'.

Synovial fluid acidosis correlates with radiological joint destruction in rheumatoid arthritis knee joints

Metabolic variables in samples of synovial fluid (SF) from 33 rheumatoid arthritis (RA) knees were analyzed. These variables were correlated with radiological destruction and SF proteoglycan concentrations. SF acidosis correlated with radiological involvement (rs = 0.62, p less than 0.002), but not with proteoglycan concentrations. A weak correlation was found between SF acidosis and granulocyte concentrations (rs = 0.37, 0.02 less than p less than 0.05). Metabolic variables covaried as expected. Samples from right and left knees from the same patients correlated regarding cellular and metabolic variables. Our results indicate insufficient nutritional supply in RA joints with increasing radiological involvement.

Direct assessment of synovial blood flow and its relation to induced hydrostatic pressure changes

A method for measuring synovial blood flow changes using the laser Doppler technique is described. Mean blood flow and mean pulse amplitude decreased by 50-70% in relation to the reference level when the intra-articular hydrostatic pressure in effusive knee joints of patients with rheumatoid arthritis was increased. As an increase of intra-articular pressure of as little as 20 mmHg decreased synovial blood flow significantly it is suggested that hypoxia may occur in vivo during joint use in the presence of an effusion. This may be of aetiopathogenetic importance for tissue destruction and the persistence of chronic synovitis.

Cineradiography identifies esophageal candidiasis in progressive systemic sclerosis

Cineradiography of the esophagus showed signs of esophageal candidiasis in 11 out of 71 patients with progressive systemic sclerosis (PSS) - both in diffuse scleroderma and the CREST syndrome. Culture of esophageal brushings confirmed the presence of Candida albicans in eight of these 11 patients. Antimycotic treatment decreased the cineradiographic signs of candidiasis and the degree of dysphagia. Since impaired esophageal motility and treatment with immunosuppressive drugs may predispose to candida esophagitis, and since dysphagia will decrease after antimycotic treatment esophageal mycosis should always be sought in patients with PSS.

Detection of tumor necrosis factor alpha but not tumor necrosis factor beta in rheumatoid arthritis synovial fluid and serum

Synovial fluids from 6 of 12 patients with rheumatoid arthritis (RA) and from 3 of 11 patients with reactive arthritis contained measurable levels of tumor necrosis factor alpha (TNF alpha). Seven of 12 sera from RA patients contained TNF alpha, while only 1 of those from reactive arthritis patients was positive. Gamma-interferon was detected in the synovial fluids and sera of only the RA patients. Tumor necrosis factor beta was not detected in any sera or synovial fluids. RA patients with detectable TNF alpha had higher erythrocyte sedimentation rates and synovial fluid leukocyte counts.