Corticosteroids do not alter the threshold for vertebral fracture

Corticosteroid use is one of the most important secondary causes of osteoporosis. Generally, it has been believed that in addition to its effect on bone mineral density (BMD), it also causes an alteration in bone quality that means that fractures occur at a lower BMD than might be expected. To establish if this is the case, we have compared the relationship between BMD and vertebral fracture in patients receiving corticosteroids with that in patients who had never received such therapy. Information was gathered on those patients who had been referred to the participating centers and had both BMD measurements and lateral thoracolumbar radiographs. In all, 452 patients (391 female) were identified; of these 82 (63 female) were receiving corticosteroids. There was no significant difference in BMD between the patients on corticosteroids and those with other suspected causes of osteoporosis. Vertebral fractures were present in 53% of patients on steroids compared with 35% of those who had no such treatment (p = 0.0035). The fractures were more likely to be multiple in patients on corticosteroids (p = 0.0042). However, if the relationship between bone density and fracture is investigated by plotting the cumulative prevalence of fracture against the bone density, measured by T score, the median BMD for fractures actually was marginally lower in patients on steroids, -2.74 (95% confidence interval [CI], -2.77 to -2.70) compared with -2.65 (95% CI, -2.66 to -2.65) in those who had not received steroids. Our results fail to support the notion that the fracture threshold is altered in patients on long-term steroids and suggest that the same diagnostic criteria should be used for osteoporosis in patients whether or not they are taking corticosteroid therapy.

Is routine synovial fluid analysis necessary? Lessons and recommendations from an audit

This audit of 408 synovial fluid samples, analysed for cell counts and crystals, revealed that crystals were present in only 25 samples (6.1%). Of these, in only three patients was the diagnosis uncertain and therefore the analysis helpful. Cell counts and types generally reflected known underlying diagnoses of inflammatory arthritis or osteoarthritis. Routine synovial fluid analysis does not contribute to diagnosis or management in established rheumatic disorders and should be performed only when the underlying cause is uncertain or in newly presenting patients. Major savings can be made by abandoning routine synovial fluid analysis.

Increased prevalence of sicca complex and fibromyalgia in patients with irritable bowel syndrome

OBJECTIVE

As many as 70% of patients with fibromyalgia complain of the symptoms of irritable bowel syndrome (IBS), but there is a clinical impression that IBS patients do not suffer from fibromyalgia as frequently. The sicca complex (dry eyes and mouth) is also commonly observed in fibromyalgia, but its prevalence in IBS has not been evaluated. Our objective was to assess the frequency of fibromyalgia and sicca complex in secondary care patients with IBS.

METHODS

Forty-six secondary care patients with IBS and 46 healthy controls were assessed by a rheumatologist for the presence of fibromyalgia and objective evidence of sicca complex (Schirmer and Rose-Bengal tests). Psychological status was also assessed (HAD questionnaire).

RESULTS

Thirteen (28%) IBS patients suffered from fibromyalgia, compared with five (11%) controls, a difference of 17% (95% confidence intervals [CI], 2-33%). Fifteen (33%) IBS patients versus three (6%) controls had sicca complex, a difference of 27% (95% CI, 11-45%).

CONCLUSIONS

These results suggest that the prevalence of fibromyalgia in IBS is approximately half that of IBS in fibromyalgia. Furthermore, sicca complex seems to be another complaint that should be added to the list of extracolonic manifestations of IBS. Study of the overlap between functional disorders presenting to different specialties may give new insights into the pathophysiology of these puzzling conditions.

Mapping of a palmitoylatable band 3-binding domain of human erythrocyte membrane protein 4.2

Evidence accumulated over the years suggests that human erythrocyte membrane protein 4.2 is one of the proteins involved in strengthening the cytoskeleton-membrane interactions in the red blood cell. Deficiency of protein 4.2 is linked with a variety of hereditary haemolytic anaemia. However, the interactions of protein 4.2 with other proteins of the erythrocyte membrane remain poorly understood. The major membrane-binding site for protein 4.2 resides on the cytoplasmic domain of band 3 (CDB3). In order to carry out an initial characterization of its interaction with the CDB3, protein 4. 2 was subjected to proteolytic cleavage and gel renaturation assay, and the 23-kDa N-terminal domain was found to interact with band 3. This domain contained two putative palmitoylatable cysteine residues, of which cysteine 203 was identified as the palmitoylatable cysteine. Recombinant glutathione S-transferase-fusion peptides derived from this domain were characterized with respect to their ability to interact with the CDB3. Whereas these studies do not rule out the involvement of other subsites on protein 4.2 in interaction with the CDB3, the evidence suggests that the region encompassing amino acid residues 187-211 is one of the domains critical for the protein 4.2-CDB3 interaction. This is also the first demonstration that palmitoylation serves as a positive modulator of this interaction.

Acute inflammatory (non-purulent) arthritis concomitant with a developing breast abscess

A 34 year old female presented 7 weeks post-partum with acute diffuse arthritic manifestations and pyrexia. Extensive investigations (grossly raised erythrocyte sedimentation rate [ESR], C-reactive protein [CRP], normal serology and others) were performed to pursue a diagnosis. Subsequently a breast abscess was diagnosed. Surgical treatment of this led to almost immediate resolution of the joint complaints and return of ESR/CRP to normal levels. This was considered a hitherto unreported case of acute non-purulent inflammatory arthritis concomitant to an existing infection elsewhere in the body. The pathogenic mechanism is unclear but speculatively toxin-mediated.

A cyberclinic in rheumatology

OBJECTIVE

To evaluate the feasibility of a rheumatology consultation and advisory service using internet and e-mail.

METHODS

We placed a detailed rheumatology proforma on our website for general practitioners to complete and e-mail to our outpatients clinic. To study its feasibility, two junior doctors interviewed and completed the proforma for 207 new patients. Based on this information, the consultant provided provisional diagnoses, work up & management plans, which were then compared with those drawn up following face-to-face assessment of the same patients in the outpatients clinic.

RESULTS

In most instances the pre- and post-examination diagnoses, work up & management plans were similar. Diagnostic concurrence was noted in 178 (86%) patients; no changes were required in x-rays and other tests requested in 129 (62%) patients; and the suggested treatment (including corticosteroid injections) remained the same in 153 (74%) patients.

CONCLUSION

Our results suggest that it is feasible to offer an e-mail or internet based outpatients consultation and advisory service in rheumatology and possibly other disciplines.

What counselling do patients with ankylosing spondylitis receive? Results of a questionnaire survey

This questionnaire survey of 71 patients with ankylosing spondylitis (members of the National Ankylosing Spondylitis Society of the UK) revealed that a substantial proportion of patients were apparently not told of several aspects of their illness by their doctors such as likely cause(s), familial clustering, role of HLA tissue typing and diet (appropriately). Only a small percentage (4.2%) were counselled to actively seek screening for close family members. As HLA B27 presence is not diagnostic of ankylosing spondylitis, and it cannot be prevented or arrested even if diagnosed at onset or early stages, routine screening of close family members cannot be justified at present.

Why do outpatients fail to keep their clinic appointments? Results from a survey and recommended remedial actions

We undertook a survey of 2555 outpatients (both new and review) to look at the reasons for high non-attendance (DNA) rates. Completed questionnaires (n = 983, 38.5% response) indicated the main reasons: forgetting or not receiving the appointment because of illness, and less often because of feeling better; transport problems; and short notice. Our remedial actions included improving the clerical system, announcing DNA rates on a regular basis in GP surgeries and in the outpatient department, introducing a tear-off slip with the appointment letter for patients to return, installing a free answerphone, active GP/consultant involvement in DNA-related problems and local publicity campaigns. A new scheme in our trust--outpatient telephone follow-up--may also help in reducing DNA rates.

An audit of post fracture rehabilitation with special emphasis on osteoporosis assessment and treatment

OBJECTIVE

To study the outcome of osteoporosis assessment and rehabilitation in post-fracture patients.

METHODS

This was a retrospective survey of the records of patients who had been referred to us from orthopaedic departments for rehabilitation after a fracture.

RESULTS

A significant number of patients had had previous fractures (n = 17) or risk factors for osteoporosis (n = 16). The mortality rate was 4%. A significant proportion of patients (9/44) who had been living in their homes required placement in residential or nursing homes and additional care after rehabilitation.

CONCLUSION

Our audit showed that post-fracture patients received optimum care, as set out in the Royal College of Physicians guidelines, but could benefit additionally from assessment and treatment of osteoporosis as set out in the Department of Health (DOH) Guidelines.

Response to low-dose interferon in chronic liver disease due to hepatitis B virus infection

BACKGROUND

Interferon is at present the only effective therapy for chronic hepatitis B virus (HBV) infection. Data regarding its efficacy in India are scant. The present study was undertaken to assess the efficacy of low-dose interferon in chronic liver disease due to HBV infection.

METHODS

Twenty four patients with histologic evidence of chronic hepatitis with or without cirrhosis, and persistent elevation of serum aminotransferases and persistent positivity for HBsAg and HBeAg for more than six months, were included. Fourteen patients were treated with interferon alpha-2b, 3 million units thrice weekly for 16 weeks; ten patients who could not afford the drug were followed up as controls without specific therapy. Patients were examined weekly for the first 4 weeks, followed by two weekly for 12 weeks and then every two months. Blood tests for viral markers and liver biochemistry were done at 0, 4, 8, 12, 16 weeks and then at two-month intervals for at least one year after therapy. Patients who cleared HBeAg were followed up for 2.2 (1-4) years for HBsAg clearance.

RESULTS

HBeAg clearance occurred in 9 patients (64%) in the interferon group, and in one control patient (p < 0.01). HBsAg clearance occurred in only one patient in the treatment group during follow up of mean 2.4 years. No patient in the control group cleared HBsAg. Patients having high ALT level at the beginning of treatment had significantly higher HBeAg clearance rate (7 of 7) than patients with low ALT levels (2 of 7; p < 0.05).

CONCLUSION

Low-dose interferon therapy is effective in attaining HBeAg, but not HBsAg, clearance in chronic HBV infection.

Spectroscopic characterization of gelonin--assignments secondary structure and thermal denaturation

Gelonin, a type 1 ribosome inactivating protein (RIP), having only one polypeptide chain, and which could be used against deadly diseases like cancer and AIDS is investigated spectroscopically through infrared (IR), diffused reflectance infrared fourier transform (DRIFT) and Raman techniques and observed vibrational modes are assigned. It is found that gelonin is having mainly alpha-helix and beta-sheet structure with some turn and disordered structure, the estimated percentage structure using Raman data being approximately 32% alpha-helix, approximately 20% beta-sheet, approximately 26% turn and approximately 22% disorder type. The temperature dependent infrared study of gelonin reveals its thermal stability, the denaturation temperature being around 60 degrees C and disordered contribution increasing with heating.

Weak association between subjective symptoms or and objective testing for dry eyes and dry mouth: results from a population based study

OBJECTIVES

To determine associations between symptoms of dry eyes and dry mouth and objective evidence of lacrimal and salivary gland dysfunction in a population based sample. To determine associations between these elements and the presence of autoantibodies.

METHODS

A cross sectional population based survey. Subjects were interviewed and examined (Schirmer-1 test and unstimulated salivary flow) for the presence of dry eyes and mouth. Antibodies (anti-Ro [SS-A], anti-La [SS-B], rheumatoid factor, antinuclear antibody) were measured.

RESULTS

341 subjects were examined. Twenty four per cent had dry eye symptoms, 29% dry mouth symptoms, and 14% both. There was only a weak association between the presence of oral or ocular symptoms and their respective test results. Associations were strongest between dry mouth symptoms and positive test results, and in subjects under 55 years of age. There was no association between the presence of autoantibodies and either symptoms or signs of dry eyes or dry mouth.

CONCLUSION

Only weak associations were found between self reported symptoms of dry eyes and dry mouth and objective measures said to define Sjögrens syndrome in the general population. The clinical significance of these symptoms in the community needs reappraisal.

The management of osteoporosis-related fractures: a survey of orthopaedic surgeons' practice

A questionnaire survey of 70 orthopaedic surgeons regarding their policy for the management of osteoporosis-related fractures revealed that, in the main, UK Department of Health guidelines on osteoporosis are not followed uniformly, although Royal College of Physicians guidelines regarding rehabilitation are met more frequently. A written policy or agreed protocol with an osteoporosis service may potentially benefit a large number of patients and reduce future fracture risks.

Management of idiopathic carpal tunnel syndrome (ICTS): a survey of rheumatologists' practice and proposed guidelines

This questionnaire survey was undertaken to study the approaches to diagnosis and management of idiopathic carpal tunnel syndrome by rheumatologists. Analysis of the completed questionnaires (81% response) showed variations in availability and referral for electrophysiological tests (EMG), initial choice of treatment (depending on patient's age and occupation, duration of symptoms, severity of clinical and EMG findings) and decompression surgery. This led the authors to propose guidelines in the management of this common condition.

Serodiagnosis and immune profile in rheumatoid arthritis

One hundred and seventy-five cases of clinically diagnosed rheumatoid arthritis, 82 non-rheumatoid cases suffering from various other diseases and 40 healthy normal controls were investigated for detection of rheumatoid factor, quantitation of serum immunoglobulin, demonstration of antinuclear antibody (ANA) and LE cell phenomenon. Microlatex agglutination test of serum for rheumatoid factor (RF) showed 64% positivity in rheumatoid group and 1.2% positivity in non-rheumatoid group. All three immunoglobulins (IgG, IgM, IgA) were found to be raised in serum of patients with rheumatoid arthritis, whereas only IgA level was elevated in serum of patients with non-rheumatoid diseases. ANA and LE cell phenomenon were observed in 3.4% and 2.8% cases respectively in cases of clinically diagnosed rheumatoid arthritis who had been suffering from severe active rheumatoid arthritis. In non-rheumatoid group RF was positive in significant titre in only one case of leprosy. Synovial fluid and synovium were found to be heavily infiltrated by plasma cells and lymphocytes. RF appears first in synovial fluid and then in serum. Hence RF titre in blood may not attain significant level for the first several months.