Pulsed methylprednisolone in active early rheumatoid disease: a dose-ranging study

A dose-ranging, double-blind study of pulsed methylprednisolone in 71 patients with active classical or definite RA is reported. Single pulses of 40 mg, 500 mg or 1 g were administered during a 24-h admission. All patients benefited transiently, but only in those who received 1 g was this prolonged beyond 3 weeks. Laboratory measurements showed no significant change in any group. Significantly more patients in the 1 g group felt the treatment worthwhile than in the other groups. The drop-out rates in the 40 mg and 500 mg groups differed significantly from that seen in the 1 g group and were such that statistical analysis beyond 3 weeks was difficult to interpret. Side-effects were mild. Three patients subsequently developed avascular necrosis, one in the 1 g and two in the 40 mg groups. The study suggests that single doses of MP below 1 g are not helpful in the management of acute RA.

Single-blind comparative study of nabumetone (Relafen) versus naproxen in the treatment of rheumatoid arthritis

Forty-seven patients with active rheumatoid arthritis were entered into a single-blind study to compare the safety and efficacy of nabumetone with naproxen. Patients were randomly assigned to receive a daily dose of 2 g of nabumetone or 1 g of naproxen after a placebo-washout period of at least three days. In addition to the usual clinical and laboratory measurements of disease activity, thermographic assessment was carried out at each visit and the heat distribution index was calculated. In addition, the safety and tolerance were assessed. Patients had improvement in severity of pain, severity and duration of morning stiffness, and articular index, and there was no statistical difference between the two treatment groups. By the end of six months, 13 patients had withdrawn from treatment; five patients in the naproxen treatment group and five in the nabumetone group were withdrawn from the study due to lack of efficacy. In no patient from the nabumetone group did an adverse reaction develop. In one patient in the naproxen group, a severe decrease in white blood cell count developed, and a skin rash and swollen gums developed in another patient. We conclude that nabumetone is well tolerated and of equal efficacy to naproxen in the treatment of active rheumatoid arthritis.

Paired serum and synovial fluid values of alpha 2-macroglobulin and TIMP in rheumatoid arthritis

The levels of alpha 2-macroglobulin and tissue inhibitor of metalloproteinases (TIMP) were determined in paired serum and synovial fluid samples from rheumatoid arthritis patients. Serum levels of alpha 2-macroglobulin (mean 1580 +/- 340 mg/l) were always higher than the corresponding synovial fluid although the spread of synovial fluid levels was broad (mean 520 +/- 340 mg/l). Tissue inhibitor of metalloproteinases was always higher in synovial fluid (mean 4.59 +/- 1.8 mg/l) than serum (mean 1.3 +/- 0.39 mg/l) indicating that local synthesis occurred within the joint.

Antibodies to intermediate filaments in polymyalgia rheumatica and giant cell arteritis: a sequential study

Serum specimens from 35 patients with polymyalgia rheumatica and giant cell arteritis (PMR/GCA) were obtained sequentially at variable time intervals up to a year from onset of disease. These were tested for antibodies to intermediate filaments by indirect immunofluorescence using HEp2 cells as substrate. Twenty four of 35 (68%) patients' sera at onset of disease were positive at an anti-intermediate filament antibody (AIFA) titre of greater than 1/40 compared with three outs of 19 (15%) control sera. AIFA were predominantly of IgM class, and there was no significant change in AIFA titres on follow up despite clinical remission of disease.

Immunological and histological study of guinea-pigs injected with insoluble human elastin

Guinea-pigs injected with insoluble human elastin in Freund's complete adjuvant developed delayed hypersensitivity to elastin as measured by skin testing. Circulating antibodies to both insoluble and soluble elastins were also found as well as an increase in lymphocyte stimulation by elastin. However, no histologically defined abnormalities were evident in the arterial vessels selected after 5 months.

Shoulder disorders in the elderly (a hospital study)

One hundred acute geriatric inpatients were assessed to investigate the prevalence of shoulder disorders; 21 had symptoms due to shoulder disease. Conditions included supraspinatus tendinitis (five), chronic rotator cuff rupture (seven), frozen shoulder (two), glenohumeral osteoarthritis (two), apatite related shoulder arthritis (one), stroke related shoulder disease (six). (Some patients had more than one shoulder condition.) The last group included painful stiff shoulders (three), glenohumeral subluxation (two), and acute shoulder-hand syndrome (one). Patients with rotator cuff rupture had bilateral disease. Only three patients had sought medical attention for their symptoms. The common occurrence of these conditions has possible implications for rehabilitation, and medical awareness is required as few may volunteer symptoms. A community based study is needed to assess the prevalence in the elderly population.

Algodystrophy: a common unrecognized cause of chronic knee pain

Thirty-three patients with undiagnosed chronic knee pain had features of autonomic disturbance. Thermography is a useful imaging technique for demonstrating this abnormality. The patients lacked the thermographic symmetry observed in 16 normal controls but this returned with resolution of the pain. Recognized radiological and scintigraphic features of algodystrophy were found. The long duration of symptoms, high proportion of young females and the severity of the associated disability were notable. It is suggested that algodystrophy is a more frequent cause of chronic knee pain than previously recognized. Autonomic abnormalities may be less intense in disease at this site, particularly in young females and may be overlooked. This characteristic of algodystrophy of the knee may contribute to chronicity and subsequent disability.

Isolation and analysis of immune complexes from sera of patients with polymyalgia rheumatica and giant cell arteritis

Serum samples were obtained from patients with polymyalgia rheumatica (PMR: n = 10) or giant cell arteritis (GCA; n = 7), or both. Samples were taken either before treatment or within one week of starting prednisolone. Immune complexes (IC) were concentrated by polyethylene glycol (PEG) precipitation then purified with either IgG anti-C1q-Sepharose or IgG anti-C3c-Sepharose. Complex components were separated by sodium dodecyl sulphate (SDS) gradient polyacrylamide gel electrophoresis then transferred to nitrocellulose by Western blotting. Identification of proteins was carried out using specific antisera. All the IC contained IgM (mu chain), some contained IgA (alpha chain), and IgG (gamma chain). C1r, C1s, C1q, C3, C4, and C reactive protein (CRP), where tested, were found in most but not all IC. The occurrence of properdin, factor B, alpha 2 macroglobulin (alpha 2M), factor H (beta 1H), C1 esterase inhibitor, and C4 binding protein was also investigated. Immune complexes in PMR and GCA differed from those previously characterized in rheumatoid arthritis (RA)1 purified by anti-C1q-Sepharose which contained immunoglobulins and C1q only. No properdin or factor B were detected in RA IC purified with either anti-C1q-Sepharose or anti-C3c-Sepharose.

Isolation and growth characteristics of adult human tendon fibroblasts

An explant method for the isolation of fibroblasts from adult human tendon is described. Cells were successfully isolated from 22 out of 27 common biceps tendons obtained from cadaveric donors (age range 11-83 years). The fibroblasts could be maintained in culture using standard methods and morphologically resembled those of synovial rather than dermal origin. Growth characteristics of 12 cell lines were assessed by deoxyribose nucleic acid (DNA) synthesis using [3H]thymidine incorporation in response to stimulation by fetal calf serum. Cells obtained separately from superficial and deep parts of the tendons produced almost identical responses. No significant reduction in growth response with increasing age was found when related to the age of the donor. Therefore this study did not show any age related defect in the short term tendon fibroblast replicative responses to serum.

Production of cartilage degrading activity by human synovial tissues

Human synovial tissues have been assayed for the production of cartilage degrading activity (CDA). This activity is thought to be homologous with catabolin/interleukin 1 (IL1) produced by porcine synovium and leucocytes and by human leucocytes. The CDA of 26 rheumatoid (RA) and 41 non-rheumatoid synovia was measured on a dry weight basis. The rheumatoid synovia showed a threefold increase in activity over the non-rheumatoid, but there was no significant overall difference on a deoxyribonucleic acid (DNA) basis. The rheumatoid synovia appeared to consist of two populations; in over half the samples CDA was not related to cellularity, but eight patients had a high CDA and a high cellularity.

A controlled study of oral prednisolone in frozen shoulder

Forty patients with frozen shoulder were randomly allocated to a treated group who received oral prednisolone or a nontreatment group who received no specific therapy. All the patients were encouraged to perform home pendular exercise. The improvement in pain at night showed a significantly different pattern in the two groups (p less than 0.05), with the treated group improving more rapidly. Pain on movement and at rest and the recovery in the range of movement was not significantly different in the two groups. There was no difference between the patient groups at the end of the study (8 months follow-up) and patients still had a marked restriction in range (p less than 0.0001) when compared to normal controls of similar age and sex.

A controlled study of acupuncture in neck pain

Twenty-five out-patients with chronic neck pain participated in a prospective, randomized trial of acupuncture versus placebo transcutaneous nerve stimulation. A single-blind, non-cross-over design incorporated several outcome measures in an attempt to determine any particular facet of pain that responded to acupuncture. No significant difference between the two treatments was found either post-treatment or at follow-up. Whilst the small population studied limits the conclusions that may be drawn, these findings suggest that acupuncture may have no greater effect than that of a powerful placebo.

Effects of heparin, histamine, and salmon calcitonin on mouse calvarial bone resorption

A quantitative mouse calvarial bone resorption assay was employed to investigate the effects of the mast cell products, heparin and histamine, and of salmon calcitonin. 'Amorphous' heparin, containing a range of molecular weight fractions, inhibited resorption by 15-20% at concentrations of 0.75-5.0 mg/ml. A 'defined' heparin species of mol.wt 13 500 inhibited resorption by 14-28% at 10(-5)-10(-4) mol/l. Histamine inhibited resorption by 19-55% at 10(-3)-10(-2) mol/l. It is proposed that heparin and histamine depress coupled bone resorption and formation and may lead to net loss of bone. Salmon calcitonin inhibited resorption at concentrations as low as 10 pg/ml. 'Amorphous' (but not 'defined') heparin blunted calcitonin induced inhibition of bone resorption and may derepress osteoclasts.

Azathioprine in giant cell arteritis/polymyalgia rheumatica: a double-blind study

The ability of azathioprine to reduce the maintenance prednisolone requirement of 31 patients with polymyalgia rheumatica (PMR) or giant cell arteritis (GCA), or both, was tested in a double-blind placebo controlled study over one year. Clinical and laboratory assessments were made at four-weekly intervals over a period of 52 weeks. A statistically significant difference (p less than 0.05) in mean prednisolone dose was noted between the two groups at the end of 52 weeks, there being a fall in steroid requirement in the azathioprine treated group.

Thermographic diagnosis in athletes with patellofemoral arthralgia

Pain in front of the knee is common in athletes and is often called patellofemoral arthralgia, but it is difficult to prove that the pain arises in that joint. Thermograms of 30 athletes clinically considered to have patellofemoral arthralgia were compared with those of a similar number of unaffected athletes matched for age and sex. A comparison was also made with thermograms of two older groups of 30 patients with knee involvement from either rheumatoid arthritis or osteoarthritis. Twenty-eight of the athletes with patellofemoral arthralgia had a diagnostic pattern on thermography. The anterior knee view showed a rise in temperature on the medial side of the patella and the medialis knee view showed that this temperature rise radiated from the patellar insertion of the vastus medialis into the muscle itself. The possible aetiological role of quadriceps muscle imbalance in athletes with patellofemoral arthralgia is discussed in relation to these findings.

A rapid and reproducible method for the analysis of immune complexes using affinity chromatography and Western blotting

A new procedure which couples different analytical techniques in a format permitting the rapid analysis of immune complex components is described. Complexes obtained from sera by polyethylene glycol (PEG) precipitation were resuspended and then added, using a batch method, to antibody coupled to Sepharose beads. Antibody directed against either human C1q or human C3c were used in the present study. Bound immune complexes were washed and then eluted from the Sepharose by sodium dodecyl sulphate (SDS) treatment and simultaneously reduced with dithiothreitol. Individual components were separated by SDS gradient polyacrylamide gel electrophoresis and then transferred to nitrocellulose by Western blotting. Individual strips of nitrocellulose were investigated using specific antisera and a radiolabelled probe. Immune complexes (IC) isolated from the sera of 7 rheumatoid arthritis (RA) patients were analysed using this method and the results obtained for both affinity adsorbents compared.

Purification of a metalloproteinase inhibitor from human rheumatoid synovial fluid

A metalloproteinase inhibitor present in human rheumatoid synovial fluid was purified by a combination of heparin-Sepharose chromatography, concanavalin A-Sepharose chromatography, ion-exchange chromatography and gel filtration. The Mr of the purified inhibitor was 28000 by SDS/polyacrylamide-gel electrophoresis and 30000 by gel filtration. The inhibitor blocked the activity of the metalloproteinases collagenase, gelatinase and proteoglycanase, but not thermolysin or bacterial collagenase. The serine proteinase trypsin was not inhibited. The inhibitory activity was lost after treatment with trypsin (0.5 micrograms/ml) at 37 degrees C for 30 min, 4-aminophenylmercuric acetate (1 mM) at 37 degrees C for 3 h, after incubation for 30 min at 90 degrees C and by reduction and alkylation. These properties suggest that the inhibitor closely resembles the tissue inhibitor of metalloproteinases ('TIMP') recently purified from connective-tissue culture medium.

Chronic lateral humeral epicondylitis--a double-blind controlled assessment of pulsed electromagnetic field therapy

Pulsed electromagnetic fields (PEMF) have been shown to be beneficial in the treatment of rotator cuff tendinitis. As lateral humeral epicondylitis (tennis elbow) is a similar chronic tendon lesion, 30 patients with both clinical and thermographic evidence of tennis elbow were randomly allocated to receive either active or inactive PEMF therapy. Treatment was continued for a minimum period of eight weeks. At this time there was no statistical difference between the two groups.

Disease activity indexes in rheumatoid arthritis; a prospective, comparative study with thermography

There are many difficulties associated with the assessment of disease activity in rheumatoid arthritis. Infrared thermography has been used to quantify joint inflammation. The heat distribution index (HDI) is reproducible, sensitive, quantifiable, and not subject to circadian variation or interobserver error. In this study the HDIs for both elbows, wrists, knees, and ankles were summated and compared with other parameters of disease activity. There were 167 sets of observations in 20 patients with classical, seropositive, rheumatoid arthritis followed up over 12 months. There was a significant correlation (p less than 0.001) for thermography with the Ritchie articular index, Mallya score, grip strength, morning stiffness, erythrocyte sedimentation rate, and pain score. Significant correlations (p less than 0.05) for thermography with these parameters were found in individual patients. The summated HDI is a suitable, objective method for the assessment of response to therapy in patients with rheumatoid arthritis.

Is therapeutic ultrasound effective in treating soft tissue lesions?

Of 76 patients with lateral epicondylitis, 38 were randomly allocated to receive ultrasound treatment and 38 placebo. All 76 were given 12 treatments each over four to six weeks. The conditions of 24 patients (63%) treated with ultrasound and 11 (29%) given placebo improved, the difference being significant at the 1% level. Improvement in particular clinical variables (pain score, weight lifting, grip strength) also showed an advantage for the patients given ultrasound treatment. A simple underwater radiation balance showed considerable fluctuation in ultrasonic output, and frequent checks of output were shown to be necessary. Ultrasound enhances recovery in most patients with lateral epicondylitis.

Measurement of rheumatoid factors by an enzyme-linked immunosorbent assay (ELISA) and comparison with other methods

IgM rheumatoid factor (RF) was measured in the sera of 48 rheumatoid patients and of 48 age and sex-matched normal controls by the Rose-Waaler and latex agglutination tests, a rate nephelometer, and an enzyme-linked immunosorbent assay (ELISA). Good correlation was obtained between all assays. The rate nephelometer assay was the easiest and quickest to perform and gave results in international units/ml. The Rose-Waaler was the least sensitive assay and the most difficult to perform and interpret. Both the latex agglutination and the ELISA were sensitive, though some overlap of patient and control sera was seen with all the assays. In addition to IgM RF the ELISA was used to measure IgG RF and IgA RF in both rheumatoid and control sera. Although some normal sera had detectable amounts of IgG and IgA RF, the levels of both were significantly raised in the rheumatoid sera. IgG RF levels were lower after pepsin digestion of the sera, suggesting that IgM RF interfered with the assay for IgG RF unless this treatment was included.

The timing of prednisolone dosage and its effect on morning stiffness in rheumatoid arthritis

Forty-one patients with rheumatoid arthritis (RA) maintained on low dose prednisolone (mean 5.8 mg) participated in a double-blind cross-over study to determine the effect of timing (morning or night) of prednisolone dosage on morning stiffness. Prednisolone given at night resulted in a significantly shorter duration of morning stiffness (p = 0.0001) than did an equivalent dose given in the morning.