Mitochondrial NADH-->NAD transhydrogenation in adult Hymenolepis diminuta

Adult Hymenolepis diminuta mitochondria catalyze a transhydrogenation reaction between NADPH and NAD and between NADH and NAD. The NADPH-->NAD reaction is catalyzed by an inner membrane-associated pyridine nucleotide transhydrogenase, whereas the NADH-->NAD reaction is ostensibly catalyzed by another system(s). The source(s) of NADH-->NAD activity was evaluated by assessments of its intramitochondrial distribution and thermal lability and by comparisons with the distribution/thermal lability of NADH dehydrogenase, lipoamide dehydrogenase, and NADPH-->NAD transhydrogenase. The occurrence of NADH and lipoamide dehydrogenase components was readily demonstrable. Like NADPH-->NAD transhydrogenase, NADH dehydrogenase was essentially membrane bound. Lipoamide dehydrogenase and NADH-->NAD activities were, at different levels, in the membrane and soluble fractions. Based on thermal profiles, NADH and lipoamide dehydrogenase differed from each other and from NADPH-->NAD transhydrogenase. Although the NADH-->NAD profile closely paralleled that for lipoamide dehydrogenase, it also was similar to the NADH dehydrogenase profile. Collectively, these data are consistent with the supposition that the H. diminuta mitochondrial NADH-->NAD transhydrogenation reaction is catalyzed by lipoamide dehydrogenase and possibly by NADH dehydrogenase rather than by an independent transhydrogenase system.

The acute hot joint in medical practice

We have studied patients with acute hot joints presenting to general practice, casualty and inpatient rheumatology services. Their investigation, management and outcome were measured against guidelines. Different spectra of disease were seen in the different health care settings. The guidelines were not adhered to for crystal arthritis, particularly when it affected the first metatarso-phalangeal joints. The guidelines were broadly adhered to and useful for other joints, especially where septic arthritis was considered to be the likely diagnosis. We found no benefit on outcome from adhering to the guidelines. There was a tendency for the outcome to be worse where the guidelines were followed in full, suggesting that more investigations are performed in the more difficult cases. We conclude that drawing up guidelines for patient management is difficult even in an area where there is broad medical agreement.

Incidence of rheumatoid arthritis in a 10-year follow-up study of extended pedigree multicase families

A 10-year follow-up study was undertaken of 17 multicase RA families with extended pedigrees to (i) determine the incidence of RA in the previously unaffected members and (ii) to assess the stability of diagnosis as defined by the 1958 and 1987 ARA criteria. In all, eight individuals developed RA. Of these, six were surviving at 10 years--four first degree (FDR), one second degree (SDR) and one non-blood relative (NBR) of the proband equivalent to incidence densities of 9, 3, and 3 per 1000 person years of observation respectively. These are substantially greater than estimates for both the general population and a DR1/4 positive population. The risk of RA is greatest in FDR and this is likely to be due to both shared inherited and environmental factors. The risk in NBR, who share no genetic material is of similar magnitude to more distant blood relatives. Definite/classical RA is a stable diagnosis over time in the majority of cases unlike probable RA which may herald definite RA but usually does not.

Six-year follow-up of multiple joint replacement surgery to the lower limbs

We report a 6-yr follow-up study of an original population of 50 patients who had three or more major joints (hips and knees) replaced. Thirty-one of 32 surviving patients were still ambulant in the community, and all patients described significant pain relief. No RA patient was requiring permanent inpatient or residential care and the family remained the main social support. They remained a very disabled group with a median Health Assessment Questionnaire score of 2.75. Ten required revision surgery: three hips and seven knees; four patients required their fourth lower limb joint (hip/knee) replaced and seven patients required surgery to the upper limbs and nine feet during the follow-up period. The median 10-yr survival of hip and knee arthroplasties in multiple joint replacement (MJR) patients with RA was 90.5 and 78.6% respectively. There was an increased incidence of cervical myelopathy in MJR patients 16.9%. The mortality rate was higher than expected (standardized mortality ratio = 590) but the actual surgery was not implicated. MJR therefore appears to be a worthwhile policy, even at long-term follow-up.

Anti-Proteus antibodies and Proteus organisms in rheumatoid arthritis: a clinical study

We have studied anti-Proteus antibodies (APA), isolation of Proteus, and their relation to various measures of RA disease activity. Seventy RA patients with a CRP > 10 mg/l had higher APA titres than 17 RA patients with CRP < or = 10 mg/l (P = 0.006), and 36 non-RA controls (P = 0.003). However, in a cross-sectional study of the RA group, there was no correlation between APA and a number of clinical and laboratory measures of disease activity, including the CRP and Stoke RA activity index. A longitudinal study showed no correlation between changes in these measures of disease activity and change in APA titre. We were unable to isolate Proteus in the urine or faeces of RA patients more frequently than controls, and the isolation of Proteus did not correlate with serum APA titres. Urinary APA was present in equal frequencies in RA and non-RA patients. NSAIDs, DMARDs and steroids did not appear to influence APA titres in the RA group. These results suggest that APA may act as an acute phase protein, distinct from CRP, but not correlating with RA disease activity in its broadest context. The fact that the antibody we are measuring binds to Proteus may be irrelevant, and the study does not support a role for Proteus in RA.

Both inherited HLA-haplotypes are important in the predisposition to rheumatoid arthritis

The distribution of the HLA-DR allele frequencies of 105 RA patients has been compared with the expected distribution under recessive and dominant modes of inheritance using control data from 2041 controls and the antigen genotype frequency among patients methodology. The observed distribution was compatible with a recessive mode of HLA-linked inheritance in RA, with a dominant mode rejected, whether HLA-DR4 was considered alone, or HLA-DR4 and HLA-DR1 were combined as if they were behaving as a single predisposing gene. Mean sibship concordance rates (MSCRs) were calculated for categories of proband HLA-DR genotypes. The highest MSCR was for HLA-DR4 homozygous probands, and the lowest for HLA-DR2 or 7/non-4 genotypes. These combined observations suggest that interactions between both inherited HLA-haplotypes are important in the predisposition to RA.

Linkage of rheumatoid arthritis with HLA

OBJECTIVE

To determine whether HLA exerts a variable influence on the predisposition of siblings of probands with clinically mild and severe rheumatoid arthritis (RA).

METHOD

Calculation of crude and adjusted odds ratios for concordance rates in sibships sharing two, one and no HLA haplotypes with a proband with clinically mild and severe RA, and HLA haplotype sharing in multiply affected sibships in the same clinical groups.

RESULTS

Compared with a reference value of 1.0 in siblings sharing no HLA haplotypes with a proband with mild RA, siblings sharing two HLA haplotypes with a severely affected proband had a sibship concordance rate odds ratio of 9.7 (95% confidence interval 2.5 to 38.2). When adjusted for age, sex, and disease duration, the odds ratio was 7.6 (1.8 to 32.4). No other sibships showed concordance rates which were significantly higher than the reference group. HLA haplotype sharing in multiply affected sibships in which the proband had severe RA deviated significantly from random (two, one, and no HLA haplotypes shared: 53.3, 40, and 6.7%, respectively; expected 25, 50, and 25%), whereas in sibships of probands with mild RA they did not (14.6, 70.8, and 14.6%).

CONCLUSIONS

In the predisposition of siblings to RA, sharing HLA haplotypes with a proband is only important if the proband has severe RA. Mild RA is not genetically linked to the HLA region.

An evaluation of the Health Assessment Questionnaire in long-term longitudinal follow-up of disability in rheumatoid arthritis

We have used the Health Assessment Questionnaire (HAQ) to follow changes in disability in an unselected group of 245 patients with RA. The HAQ has been widely used in cross-sectional studies of disability in RA, but little is known about the dynamics of the change in HAQ score with long term follow-up. If it is to prove useful as a measure of health outcome it must not only be able to accommodate a wide range of disability but also show adequate sensitivity to change in disability. We administered the HAQ to 245 RA inpatients and outpatients at the beginning and end of a 5-yr period to address this important question. The mean change in individual HAQ score in the 175 patients for whom complete data was available was +0.18 (SD 0.66) over 5 yr, i.e. 0.03 units per year. It is likely that the observed rate of change in HAQ score is an under-estimate of the true rate of progression of disability, as the scale failed to accommodate change in disability toward its upper limit. The inherent design of the HAQ creates several 'ceilings' in functional subcategories (such as lower limb function) which may be masked by the overall HAQ score. Longitudinal studies of disability using the HAQ as outcome measure should therefore be interpreted with caution, and close attention paid to the baseline HAQ score.

Rheumatoid arthritis, HLA identity, and age at menarche

OBJECTIVE

To determine whether women with rheumatoid arthritis (RA) had differences in obstetric and gynaecological histories when compared with sisters without RA (controls)

METHODS

Ninety eight RA discordant sister pairs, 36 of whom were identical for histocompatibility locus antigen (HLA-A, HLA-B, and HLA-Cw) types, were asked to recall their age of menarche, duration of use of contraceptive pill, pregnancy history, and age of menopause.

RESULTS

The 98 siblings with RA had an older mean age of menarche (13.90 (95% confidence interval (95% CI) 13.56 to 14.24) years) than their sisters (13.49 (95% CI 13.22 to 13.76) years; mean difference within pairs 0.41, 95% CI 0.09 to 0.73 years, paired t test t = 2.54, p = 0.013). When the pairs were divided into identical HLA and non-identical HLA groups, the first showed no significant difference (mean difference 0.17 (95% CI -0.40 to 0.73) years), whereas the second did (mean difference 0.55 (95% CI 0.16 to 0.94) years, t = 2.80, p = 0.007). A multiple regression analysis to predict differences in menarche in the non-identical HLA sibling pairs failed to show any demographic or reproductive confounding variables. In 19 RA concordant sibling pairs, the seven HLA identical pairs had similar ages of menarche, whereas the 12 non-identical HLA pairs had interpair differences that narrowly missed significance (p = 0.054). All other obstetric and gynaecological variables were not significantly different within the pairs.

CONCLUSIONS

The interpretations of these results are that either delayed menarche may predispose to or act as a marker of RA, or HLA linked genes are important in determining the age of menarche irrespective of disease state. This study fails to support a significant role for other obstetric and gynaecological variables in RA.

A questionnaire for patients' evaluations of their physicians' humanistic behaviors

OBJECTIVES

To determine what behaviors patients perceive as reflecting a physician's humanistic qualities, to develop an instrument for patients to use to assess the humanistic behaviors of their own physicians, and to compare patient assessment of residents' humanistic behaviors with patient satisfaction and the assessment of attending physicians.

DESIGN

Cross-sectional descriptive study, using patient interviews and questionnaires, and evaluations of residents by attending physicians.

SETTING

Inpatient medical service in a tertiary care teaching hospital and in a primary care internal medicine clinic.

PARTICIPANTS

Six medical interns and six medical residents, 119 medical patients in the hospital, and 111 patients in the internal medicine clinic.

MEASUREMENTS AND MAIN RESULTS

The 25-item Physicians' Humanistic Behaviors Questionnaire (PHBQ) was developed from patients' statements about important humanistic behaviors. The mean PHBQ scores were 4.46 +/- 0.22 (mean +/- SD, on a scale of 1 to 5) in the clinic and 4.18 +/- 18 in the hospital (p = 0.003). The Spearman's rank correlations between the PHBQ and the Medical Interview Satisfaction Scale (MISS) were r = 0.8741 (p < 0.001) in the hospital and r = 0.8751 (p < 0.001) in the internal medicine clinic. The Spearman's rank correlation between the hospital PHBQ and the attending physician evaluations (for the six residents for whom the authors had complete data) was r = 0.5753 (p = 0.232).

CONCLUSIONS

Patients can evaluate the humanistic behaviors of their physicians using the PHBQ. There is good correlation between the PHBQ and patient satisfaction, which supports the validity of the PHBQ. The relative lack of agreement between patients and attending physicians suggests different observations, criteria, or standards. The higher ratings from patients in the clinic compared with those from patients in the hospital suggest that residents' behaviors are different or that patients have different observations, criteria, or standards in the two settings. Therefore, a complete assessment of residents' humanistic behaviors may require sampling in both settings.

P blood group phenotype, proteus antibody titres, and rheumatoid arthritis

The interrelationships between P blood group phenotype, proteus antibodies and rheumatoid arthritis (RA) were investigated in 140 patients with RA and 114 of their siblings who did not have RA. In the group with RA P2 subjects had significantly higher titres of proteus antibodies than P1 patients. This was not observed in the group without RA, or for antibodies to Escherichia coli. Although C reactive protein was the best predictor of proteus antibodies in the group with RA, the P blood group had an independent and significant influence. These observations suggest a testable model in which asymptomatic carriage of proteus in the urinary tract may lead to antibody production, which in turn may be important in the pathogenesis of RA.

Sex hormones in postmenopausal HLA-identical rheumatoid arthritis discordant sibling pairs

Dehydroepiandrosterone sulfate (DHEAS), testosterone, androstenedione, 17-beta estradiol and sex hormone binding globulin have been assayed in 50 HLA-identical postmenopausal rheumatoid arthritis (RA) discordant sibling pairs. The only difference was for DHEAS, siblings with RA having a significantly lower level than their sisters. However, in 68 patients with RA, the level of DHEAS inversely correlated with disease duration, a radiographic grading score, the Health Assessment Questionnaire score, duration of morning stiffness, and a clinical score of disease activity and severity (the Spread/Severity index). These observations, taken with that of previous work on DHEAS, suggest that low levels may be a consequence of RA rather than predisposing to the disease. The role of sex hormones in RA will have to be approached in alternative ways.

Specificity of the proteus antibody response in rheumatoid arthritis

Antibodies to proteus were determined by indirect immunofluorescence in 146 serum samples from patients with rheumatoid arthritis (RA). An autoantibody screen was performed in the same samples and in 52 of these antibody titres to the viruses influenza A, adenovirus, rubella, and parvovirus were determined. There was no significant correlation between proteus antibodies and any of the other antibodies tested. Dividing the samples into those from patients with active (C reactive protein > 10 mg/l) and inactive RA showed that the only antibodies to be significantly increased in active RA were the proteus antibodies. These observations suggest that the proteus antibody response in RA is specific.