Are tender point scores assessed by manual palpation in fibromyalgia reliable? An investigation into the variance of tender point scores

To determine the reliability of tender point assessment by manual palpation in patients with fibromyalgia, and to investigate the sources of variance, tender point scores by manual palpation were obtained in 30 fibromyalgia patients by 2 investigators; the assessments were repeated after 1 week. Test-retest stability and inter-observer agreement of tender point scores was moderate to high. The most important sources of variance were inter-individual patient differences in (1) mean tenderness (pain thresholds) and (2) tender point profiles (consistent intra-individual differences between the 14 tender point scores), and (3) residual variance, not attributable to any systematic effect (error). It is concluded that the reliability of tender point assessment by manual palpation is acceptable. It seems to be not less than reliability of assessment by pressure algometer. Tender point scores in fibromyalgia reflect individual differences in mean pain thresholds as well as individual tender point profiles.

Endpoint measures in rheumatoid arthritis clinical trials: group summary and individual patient analysis

OBJECTIVE

To evaluate the responsiveness of measures of disability, discomfort, and disease process in rheumatoid arthritis (RA) clinical trials, when used as group summary variables and as variables of individual patient improvement.

METHODS

Disease outcome and process measures were assessed in 97 patients with RA of recent onset, who were participating in a prospective trial comparing the effectiveness of several drug treatment strategies. Measurements were done after 3 and 6 months of treatment. Group summary analysis was performed with tests of statistical significance of changes, and by calculating effect sizes (i.e., mean change in an endpoint divided by its standard deviation). Individual patient improvement was defined as improvement of > or = 33% compared to baseline, according to recommendations of the recently held Conference on Outcome Measures in Rheumatoid Arthritis Clinical Trials.

RESULTS

Almost all mean group changes in endpoints were statistically significant (p < 0.001). Effect sizes and figures on individual patient improvement provided additional information: physical discomfort measures were rapidly responding measures that did not further improve after 3 months; disease process measures, joint count, erythrocyte sedimentation rate and C-reactive protein also responded quickly and kept improving up to 6 months; the disability measures were relatively unchanged at 3 months, and only the self-report questionnaire score showed considerable improvement at 6 months.

CONCLUSION

Effect sizes and data on patients who showed clinical improvement in disease process or outcome measures offset the strongly significant p values of statistical tests for almost all endpoint measures. Although discomfort measures rapidly responded to therapy, disability and disease process measures may not reach optimal improvement within 6 months.

Interaction of antistasin-related peptides with factor Xa: identification of a core inhibitory sequence

Antistasin, isolated from the Mexican leech, is a 119 amino acid protein which is a selective and potent inhibitor of coagulation Factor Xa. Previous studies indicated that an arginine residue located at position 34 of the inhibitor was cleaved by Factor Xa during the inhibition reaction. To evaluate this residue as the reactive site of antistasin, and to define shorter fragments of antistasin displaying Factor Xa-inhibitory activity, a series of peptides were synthesized corresponding to amino acids 27-49 of the inhibitor. The most potent peptide synthesized was a disulfide-bridged, 19 amino acid peptide, ATS29-47, which inhibited Factor Xa with a Ki = 35 nM, and increased plasma clotting times by over 4-fold at a concentration of 33 uM. Reduction or sulfation of the cysteine residues in ATS29-47 reduced Factor Xa inhibitory activity by over 95%. Peptides as short as seven residues corresponding to position 33-39 of antistasin displayed Factor Xa inhibitory activity. The peptides did not inhibit thrombin or trypsin at concentrations 1000-fold higher than used in Factor Xa assays. The shortest peptide displaying anticoagulant activity in human plasma was the disulfide-bridged peptide, D-Arg-Cys-Arg-Val-His-Cys-Pro, which increased clotting times by 50% at micromolar concentrations. These results demonstrate that antistasin-related peptide sequences can serve as model structures for the development of novel, low molecular weight anticoagulants.

Fatal cholestatic hepatitis caused by D-penicillamine

A 37-yr-old woman with RF-positive RA developed cholestatic hepatitis after 10 days of D-penicillamine therapy. This was discontinued immediately. The cholestasis persisted for the remaining 14 months of her life. Severe hypercholesterolemia developed with xanthelasmata and eventually pancytopenia, which was caused by a massive infiltration of the bone marrow by lipid-containing foam cells. The patient died of sepsis. Review of the literature shows intrahepatic cholestasis to be a rare and idiosyncratic complication of D-penicillamine therapy. To our knowledge, ours is the first documented case of persistent cholestatic icterus.

Local muscle hypertrophy due to an arterio-venous malformation

A 20-yr-old man with progressive, painful diffuse swelling of his right shoulder muscles is reported. The diagnosis was muscle hypertrophy secondary to a congenital arterio-venous malformation (CAVM). Since a CAVM is not infrequently asymptomatic until the age of 20 to 30 yr and develops insidiously, the diagnosis may be delayed. In our patient, MRI rather than ultrasound and CT, led to the final diagnosis.

Physical disability and psychological well being in recent onset rheumatoid arthritis

OBJECTIVE

The association between self-report physical disability scores and psychological well being in patients with rheumatoid arthritis (RA) has been described in several recent publications on patients with widely varying disease durations. We describe the results of a study into these relationships in patients with RA with a disease duration of less than 1 year.

METHODS

In this cross sectional study on 113 patients with recent onset RA disability was assessed with 3 self-report indices and with measurement of grip strength. Correlation coefficients between disability measures and disease activity measures (joint tenderness/swelling score, erythrocyte sedimentation rate [ESR)]), psychological well being (cheerful mood, depressive mood, and anxiety), and demographical variables were calculated; hierarchical regression analysis was done with disability measures as the dependent variables.

RESULTS

All disability scales were correlated moderately strongly with the joint score and ESR, and with psychological well being. No relation was found with age, sex, marital status, or rheumatoid factor status. Regression analysis showed the variance of 9-15% in disability could be explained by psychological well being after disease activity had been controlled for.

CONCLUSION

Patients with recent onset RA appear not to be obviously different with respect to the moderately strong association between physical disability and psychological well being from patients with RA of longer duration in other published reports.

Combinatorial chemistry--applications of light-directed chemical synthesis

Combinatorial methods in biology and chemistry are proving to be powerful methods for generating molecular diversity. One approach, light-directed chemical synthesis, combines semiconductor-based photolithography technologies with solid-phase organic chemistry to synthesize large arrays of molecules with potential biological activity. This novel technology has the potential to provide libraries of both natural and synthetic molecules that might be screened rapidly for biological activity.

Adjuvant oestrogen therapy does not improve disease activity in postmenopausal patients with rheumatoid arthritis

OBJECTIVE

To investigate whether oestrogens can be used as treatment to diminish disease activity in women with rheumatoid arthritis.

METHODS

Forty postmenopausal female patients with active rheumatoid arthritis participated in a placebo-controlled, double-blind study on the possible beneficial effect of adjuvant treatment of oestradiol on disease activity.

RESULTS

Thirty three patients completed 52 weeks of treatment with 2 mg oestradiol-valerate or placebo. No statistically significant difference was found in and between both treatment groups with regard to articular indices, pain score by visual analogue scale, erythrocyte sedimentation rate and health questionnaire on daily activities before, during and at the end of the study.

CONCLUSION

This first randomised prospective placebo-controlled study shows no beneficial effect of oestrogens on disease activity in postmenopausal female patients with rheumatoid arthritis.

Corticosteroid pulse therapy in active rheumatoid arthritis

The infusion of high doses of corticosteroids (corticosteroid pulse therapy, CPT) is used to treat refractory rheumatoid arthritis (RA). In the first part of this article, literature on the efficacy of CPT is reviewed, and different CPT regimens (high-dose, low-dose, oral CPT) are compared. Several CPT regimens are beneficial in RA, the clinical effect lasting 4 to 10 weeks. Only high-dose CPT (1,000 mg methylprednisolone intravenously) has been shown to bridge the gap between the start and the effect (lag time) of a disease-modifying antirheumatic drug initiated at the same time. A retrospective study on the incidence of short-term and long-term side effects of CPT in 50 patients with RA who received a total of 78 pulse regimens is described in the second part. Side effects occurred frequently, but in most cases they were mild. The possible relationship between CPT and osteonecrosis of the femoral head is discussed. It is concluded that CPT is beneficial in RA. A substantial number of patients suffer side effects of varying severity.

Random and site-specific immobilization of catalytic antibodies

The effects of immobilization on the immunologic and catalytic activity of a catalytic antibody were compared for randomly immobilized (via glutaraldehyde) whole antibody and site-specifically immobilized (via the reactive sulfhydryl group at the base of the fragment) Fab' fragments. Upon immobilization, the specific binding capacity (n) and the catalytic activity decreased significantly for both systems. Increases in the Michaelis constant (KM) were accompanied by corresponding decreases in the equilibrium binding constant determined through immunoassays. For the immobilized Fab', n decreased dramatically with increased protein loading, suggesting that, despite the site-specific attachment and favorable orientation, molecular crowding denatured the Fab' fragments. These results also show that there is an optimal surface coverage, not necessarily at the maximum loading, for both immunologic and catalytic activity. Finally, the combining/active site conformation was probed using electron paramagnetic resonance (EPR) spectroscopy. In all antibody samples, there was no spectral evidence of conformational changes in the antibody active site.

An unnatural biopolymer

A highly efficient method has been developed for the solid-phase synthesis of an "unnatural biopolymer" consisting of chiral aminocarbonate monomers linked via a carbamate backbone. Oligocarbamates were synthesized from N-protected p-nitrophenyl carbonate monomers, substituted with a variety of side chains, with greater than 99 percent overall coupling efficiencies per step. A spatially defined library of oligocarbamates was generated by using photochemical methods and screened for binding affinity to a monoclonal antibody. A number of high-affinity ligands were then synthesized and analyzed in solution with respect to their inhibition concentration values, water/octanol partitioning coefficients, and proteolytic stability. These and other unnatural polymers may provide new frameworks for drug development and for testing theories of protein and peptide folding and structure.

Transient decrease in osteocalcin and markers of type 1 collagen turnover during high-dose corticosteroid pulse therapy in rheumatoid arthritis

The effect of corticosteroid pulse therapy on bone metabolism was studied in 10 patients with active RA. We measured alkaline phosphatase, osteocalcin and two recently introduced markers of collagen type 1 metabolism, reflecting synthesis (PICP) and degradation (ICTP). The day after the pulse therapy, there was a statistically significant (P < 0.05) decrease in osteocalcin, PICP and ICTP from the value at start. Three weeks after pulse therapy, these values had returned to baseline. During pulse treatment there is a transient decrease in bone formation, as shown by the changes in osteocalcin and PICP. Because of the changes in ICTP, we conclude that bone resorption is transiently reduced as well, but whether these changes result from a direct or an indirect effect on bone is not clear. ICTP has to be investigated further as a (serum) marker of bone resorption.

Self report functional disability scores and the use of devices: two distinct aspects of physical function in rheumatoid arthritis

OBJECTIVES

Self report scores of physical disability and the use of devices or assistance in performing activities are sometimes integrated in one index of physical function, although they are aimed at measuring different dimensions of physical disability. The properties of both parameters were evaluated in two groups of patients with rheumatoid arthritis (RA).

METHODS

A group of patients with RA of recent onset was compared with a group with established disease on four parameters of disability: use of devices, use of personal assistance, and scores on a validated Dutch version of the Health Assessment Questionnaire Disability Index, with and without integrating the use of devices or assistance. Correlation coefficients among disability parameters were calculated. In multiple regression analysis the influence of disease duration on the disability parameters was determined after disease activity, psychological wellbeing, and demographical characteristics had been controlled.

RESULTS

Functional disability scores were mainly related to inflammatory activity and psychological wellbeing, whereas the uses of devices had a strong relation with disease duration, independent of current disease activity. Integrating these parameters of disability yielded a parameter that was still mainly associated with disease activity.

CONCLUSION

Self report scores of functional disability and the use of devices represent distinct dimensions of physical function in RA. Integrating both parameters into one measure of physical disability does not provide an index adequately reflecting both dimensions. The use of both parameters to measure outcome in long term clinical studies is recommended.

Measurement of functional ability and health status in the arthritic patient

Chronic arthritis may have great impact on the patient but also on his or her family, relatives and friends. The assessment of the consequences of chronic arthritis and the effect of therapy not only in terms of physical, but also psychological and social dimensions deserves more attention. Functional ability and health status can be measured using a questionnaire or 'instrument', high-lighting important aspects not quantified with more traditional measurements. In this paper, arguments to apply such instruments more frequently are given. Health status instruments can be used not only to assess beneficial but also deleterious (side-) effects of therapeutic interventions. The properties are summarized of the most frequently used instruments assessing functional ability and health status. Many of these instruments have been evaluated sufficiently for validity and reliability; their sensitivity to detect change seems to be satisfactory. Therefore it is advisable to choose an internationally accepted, frequently used instrument, reflecting the area of interest.

Evaluation of the Thompson articular index

Three articular indices for measuring disease activity are compared. In a cross sectional study the Thompson articular index (a modified Lansbury index) correlated better with laboratory variables than the Ritchie articular index or a swollen joint score (Thompson 0.74-0.77; Ritchie 0.57-0.58; swollen joint count 0.51-0.59). In a longitudinal study it was shown that the Thompson articular index is sensitive to detect changes of disease activity. We suggest that this index is appropriate for clinical trials.

Kates forefoot arthroplasty in rheumatoid arthritis. A 5-year followup study

The longterm results of Kates forefoot arthroplasty in 74 feet of 41 patients with rheumatoid arthritis (RA) after a mean followup of 5.2 years was considered to be good by 38 patients and poor by 3 patients. The average walking distance had doubled. The mean hallux valgus angle was reduced from 46 to 27 degrees. Surgical results proved to depend on the quality of the arc of the remaining stumps, and not on the severity or activity of RA. Reoperations were necessary in 16 feet of 10 patients because of too prominent distal metatarsal stumps. Despite the absence of pain, 28 patients were not satisfied with the function of the hallux. This might be improved by performing arthrodesis of the first metatarsophalangeal joint.

Bacterial arthritis in a district hospital

Between 1977 and 1988 in the Enschede hospital 72 patients were seen with bacterial arthritis of one or more joints. Staphylococcus aureus was most frequently the causative agent (52%) and the knee was the most frequently infected joint (42%); the mortality rate was 11%. Complete restoration of pre-existent function was seen in 52% of the affected joints. In patients with severe deterioration of joint function after the bacterial infection, the period between the first symptoms and start of treatment (mean 30 days) was significantly longer than in patients with no or moderately deteriorated joint function (mean 10 days). The primary focus was mostly a skin infection, predominantly localized on the lower extremities. Half of all cases of bacterial arthritis occurred in patients with rheumatoid arthritis (RA). We therefore conclude that patients with RA and skin infections, especially if localized on legs or feet, should be treated without delay and that one should not hesitate to prescribe antibiotics. Erythrocyte sedimentation rate (ESR) was less than 20 mm after one hour in 13% and blood leucocyte count less than 10 x 10(9)/liter in 55% of all patients, showing that a normal ESR and/or blood leucocyte count do not exclude bacterial arthritis. In 4 out of 9 patients with infected prosthetic joints the infection resulted in loosening of the joint, before antibiotic treatment was started. In the other 5 patients bacterial arthritis recurred, in one patient resulting in loosening of the joint, only shortly after stopping long-term successful antibiotic treatment (6-24 months). Thus, we feel that lifelong treatment with antibiotics is a reasonable alternative in cases, where the risk of surgery is very high.

Opinions of patients with rheumatoid arthritis about their own functional capacity: how valid is it?

Self assessment health status questionnaires are increasingly used to measure health status or the effect of treatment in patients with rheumatoid arthritis (RA). Most of these questionnaires measure functional (physical) disabilities. The question arises, however, as to how well self assessment questionnaires reflect the true functional status of patients or whether they only reflect their imaginary functional capacities. How valid is the opinion of patients with RA about their own functional capacity? To answer this question an investigation was performed in 80 patients with RA. Forty Dutch and 40 Belgian patients with RA completed the functional items of the DUTCH-AIMS, the Dutch version of the Arthritis Impact Measurement Scales (AIMS), a self assessment questionnaire specific to arthritis. Their scores on the functional scales were compared with the scores on the same scales completed by two experienced physiotherapists after evaluation of the functional ability of these patients. This was achieved by observing the patients perform the tasks given in the questionnaire. Correlation coefficients between the scores of the patients and the physiotherapists were highly significant for all the scales. No significant differences were found between the patients' and physiotherapists' mean scale scores except for the mobility scale in the Dutch patients. The strength of agreement (Cohen's kappa) of most scale scores of the patients and physiotherapists was substantial. The estimates of the overall functional capacity (the mean of the five scale scores) of the Belgian and Dutch patients show high correlations between the patients and the physiotherapists. It is concluded that patients' opinion about their functional ability is valid in that it is in agreement with their real functional abilities. This study provides further evidence for the validity of the DUTCH-AIMS as a measure of functional disability and health status in Dutch and Belgian patients with RA.

An inhibitor of collagen-stimulated platelet activation from the salivary glands of the Haementeria officinalis leech. I. Identification, isolation, and characterization

A protein that blocks collagen-stimulated platelet aggregation has been identified and isolated from the soluble fraction of salivary glands from Haementeria officinalis leeches. We have named this protein leech antiplatelet protein (LAPP). LAPP was isolated from soluble crude salivary gland extract by heparin-agarose, size exclusion, and C18 reverse phase high-performance chromatography. Its molecular weight is approximately 16,000 on sodium dodecyl sulfate-polyacrylamide gel electrophoresis under both reduced and nonreduced conditions. The sequences of peptides generated by V8 digestion of LAPP as well as its amino acid composition suggested no homology to other known proteins. The IC50 for LAPP to inhibit platelet aggregation was approximately 60 nM. This inhibitory activity is specific for collagen-induced aggregation. Platelet aggregation in response to ADP, arachidonic acid, U46619, thrombin, and ionophore A23187 was not inhibited by LAPP at a concentration that blocked platelet aggregation to collagen by 100%. In contrast, crude salivary gland-soluble extract contained activity(ies) which inhibited aggregation to all these agonists except thrombin at 1 unit/ml and 2 microM A23187. Thus, the H. officinalis leech has evolved multiple mechanisms to prevent hemostasis, including an inhibitor of collagen-stimulated platelet aggregation. The identification and isolation of LAPP demonstrates the existence of a new type of platelet inhibitor that should be useful to better understand the mechanism of collagen stimulation of platelets.

The impact of endpoint measures in rheumatoid arthritis clinical trials

In clinical trials on the effectiveness of disease-modifying antirheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA), it is common to apply a large number of endpoint measures. This practice has several disadvantages. To determine which endpoint measures are most valuable, reports of 32 clinical trials on six DMARDs were reviewed. The frequency with which each endpoint measure was used is described and discussed, as well as the frequency with which the values of each endpoint were significantly different in statistical comparisons within or between groups, thus showing ability to discriminate between drugs not equally effective. The results of this review are discussed and compared with other reports in the literature on the choice of endpoint measures in RA clinical trials. The authors conclude that it is still common practice to evaluate multiple outcome measures. The number of measures could be reduced by using only those that are generally considered important, are sensitive to change, and are able to differentiate between drugs in clinical trials. A joint count, assessment of pain, a questionnaire on functional status, and measurement of erythrocyte sedimentation rate are sufficient.