The effect of acupuncture on patients with rheumatoid arthritis: a randomized, placebo-controlled cross-over study

OBJECTIVE

Acupuncture is commonly used by patients with chronic painful musculoskeletal disorders. There are, however, few well-designed studies of its efficacy. This paper describes a randomized placebo-controlled cross-over design to evaluate acupuncture as a useful treatment adjunct in the management of patients with rheumatoid arthritis (RA).

METHODS

Sixty-four patients were centrally randomized from a hospital-based rheumatology out-patient clinic. Fifty-six patients were suitable for study, all were on second-line therapy and aged 18-75 yr. There had been no change in therapy for the preceding 3 months. Patients who had previous acupuncture, anticoagulation, fear of needles or infection were excluded. Single-point (Liver 3) acupuncture or placebo was given with an intervening 6 week wash-out period. The acupuncturist, patient and statistician were blinded as far as possible. The outcome measures included the inflammatory markers (erythrocyte sedimentation rate and C-reactive protein), visual analogue scale of pain, global patient assessment, 28 swollen and tender joint count, and a general health questionnaire.

RESULTS

The results demonstrated no significant effect of treatment or period and no significant interaction between treatment and period for any outcome variable. No adverse effects were reported.

CONCLUSION

Acupuncture of this type cannot be considered as a useful adjunct to therapy in patients with RA. Possible reasons why this is the case are discussed.

Cleavage of recombinant human corticotropin-releasing factor (CRF)-binding protein produces a 27-kilodalton fragment capable of binding CRF

CRF is both a peripheral and a central mediator of inflammation, the activity of which is modified by the presence of a 37-kDa binding protein (CRF-BP). The objective of this study was to measure and characterize this protein in the synovial fluid of rheumatoid arthritis patients and to observe the effects of this inflammatory condition on its structure and properties. Measured by immunoradiometric assays, the mean CRF-BP concentration in synovial fluid from 27 arthritic patients was 0.51 nmol/L (SD = 0.24 nmol/L); that for CRF was 6.31 pmol/L. The mean plasma concentration of CRF-BP in 24 control subjects was 1.38 nmol/L (SD = 0.35 nmol/L) and that for 10 arthritic patients was 2.89 nmol/L (SD = 0.84 nmol/L). Synovial fluids were found by immunoblotting to contain intact CRF-BP and a 10-kDa C-terminal CRF-BP fragment; synovial fluid from healthy controls was not examined. We previously reported that after purification of recombinant CRF-BP, spontaneous cleavage frequently occurs, resulting in a 27-kDa N-terminal and a 10-kDa C-terminal fragment. Because concentrations of native CRF-BP in synovial fluid were insufficient to study the effects of cleavage on ligand binding, they were determined using recombinant human CRF-BP. Tryptophan excitation fluorescence spectra of intact and cleaved recombinant CRF-BP revealed that cleavage was accompanied by conformational change in the N-terminal fragment, leading to exposure of the sole tryptophan residue to polar molecules (emission peak shift from 310 to 250 nm). Using gel filtration chromatography to separate the N- and C-terminal fragments, it was found that the N-terminal fragment of the recombinant protein bound human CRF, although dimerization was somewhat impaired. The C-terminal fragment did not bind CRF. Scatchard analysis confirmed that the affinity of both intact and cleaved CRF-BP for CRF was 1 x 10(10) L/mol. We conclude that synovial fluid contains intact CRF-BP in molar excess to CRF and fragmented CRF-BP. The significance of cleavage and the role of cleavage products have yet to be determined, although they may represent the generation of a novel bioactivity.

Valproate- and aminophylline-induced 'wet dog shakes'--a function of dose and time

The time course of appearance of 'wet dot shakes' (WDS) was examined following valproic acid (VPA, 100, 200, 300, 400 mg/kg i.p.) and aminophylline (AMP, 50, 100, 150 mg/kg i.p.) injections. VPA and AMP at various doses showed a qualitative difference in their ability to induce WDS with no difference in intensity, confirming 'all or none' nature of the phenomenon. There was a significant (p<0.001), dose-dependent increase in the number of whole body shakes following first three doses of VPA but not after the administration of its highest dose (400 mg/kg). In contrast, the numbers of WDS produced by AMP were inversely proportional to its increasing doses. The maximum numbers of WDS were observed at 300 mg/kg of VPA and 50 mg/kg of AMP, within 10 min and 20-30 min during 1 h and 1 h 30 min observation period, respectively. The present stereotyped behavior induced by acute, single dose administration of VPA and AMP in non-toxic doses, being a reproducible phenomenon, lasting for a brief period may be anticipated to serve as a tool to explore mechanisms underlying WDS.

Effect of sodium valproate and flunarizine administered alone and in combination on pentylenetetrazole model of absence seizures in rat

Sodium valproate (VPA) and flunarizine (FLU) administered individually and together were examined for their effects on behavioural, and EEG changes in the pentylenetetrazole (PTZ) induced rat model of absence seizures. PTZ, 20 mg/kg, i.p., produced behavioural staring and immobility with concomitant, repetitive 7 to 9 Hz spike/wave discharges (SWDs) in EEG, monitored continuously for 1 hr and thereafter, intermittently for 4 hr, post-vehicle/drug. The number and duration (sec) of SWDs/hr were the parameters used for evaluation of vehicle vs. drug effects in normal as well as rats made epileptogenic by repeated cortical stimulation. VPA, 200 mg/kg, i.p., produced a significant reduction in the number and duration of SWDs at 20 min only in epileptogenic rats, declining to non-significant levels at 60 min, whereas FLU, 10 mg/kg i.p. had no effect on either parameter. The combination of VPA and FLU produced a highly significant reduction of the number and duration of SWDs/h for 60 min in normal and epileptogenic rats. The results provide evidence for a synergistic effect of VPA and FLU in experimental absence seizures and possible potential benefit in pharmaco resistant seizures.

Chronic neck pain: a comparison of acupuncture treatment and physiotherapy

OBJECTIVE

To evaluate the effectiveness of acupuncture, as compared with physiotherapy, in the management of chronic neck pain.

DESIGN

Seventy adult patients with non-inflammatory neck pain of >6 weeks duration and with no abnormal neurology were randomly assigned to receive either of the treatments. Thirty-five patients were included in each group.

OUTCOME MEASURES

Pain by visual analogue scale and neck pain questionnaire, improvement in range of movement of neck relative to baseline, and well-being (general health questionnaire). Measurements were recorded at the start of treatment, at 6 weeks and at 6 months.

RESULTS

Both treatment groups improved in all criteria. Acupuncture was slightly more effective in patients who had higher baseline pain scores.

CONCLUSIONS

Both acupuncture and physiotherapy are effective forms of treatment. Since an untreated control group was not part of the study design, the magnitude of this improvement cannot be quantified.

Unemployment and underemployment in 1996 graduates of New York City gastroenterology training programs

OBJECTIVE

Based on anecdotal reports of young gastroenterologists facing extreme difficulty in finding a job, we sought to gain information about the success of newly trained gastroenterologists in finding employment in their subspecialty, and to find any possible predictors of unemployment.

METHODS

We surveyed all fellows finishing basic or advanced gastroenterology fellowship training in New York City in June 1996. Data were collected on unemployment, underemployment (practicing less than half-time gastroenterology), and also type of job, employment terms, training program, medical school, gender, and satisfaction with job plans.

RESULTS

Of the 59 study subjects who sought gastroenterology employment in the United States, data were collected on all of them (100%). Fifteen subjects (25%) were unemployed. An additional 10 subjects (17%) were underemployed. Of the 24 subjects expecting to be associates in a group practice, eight (33%) had either no signed contract, were underemployed, or both. Programs that did not participate in the National Residency Matching Program were more likely to have both unemployed and underemployed graduates.

CONCLUSION

Unemployment among newly trained gastroenterologists in New York City is very high. Also, there is substantial underemployment, and this phenomenon needs to be taken into account when studying the workforce.

A primate model of respiratory syncytial virus infection

To determine whether bonnet monkeys are susceptible to infection and disease due to respiratory syncytial virus (RSV), 4 juvenile bonnet monkeys (Macaca radiata) were inoculated with RSV intratracheally and sacrificed at 3, 5, 7 and 9 days post infection. RSV was cultured from pre-autopsy broncheoalveolar lavage fluid from all 4 animals with a peak titre of virus on day 9. Serum RSV neutralizing antibody was present by day 7. Animals developed tachypnoea and chest retractions by 5th day post infection and 2 animals had lobular pneumonia on chest radiography. The pathological changes were of a bronchovascular inflammation, interstitial pneumonia and alveolitis, akin to that seen in humans. These findings show that bonnet monkeys can be infected with RSV, and can develop immune response and clinical and pathological changes similar to those seen in human infants with RSV disease. Thus intractracheal RSV inoculation of juvenile bonnet monkeys appears to be a good model to study pathogenesis of RSV disease.

Additive anticonvulsant effect of flunarizine and sodium valproate on electroshock and chemoshock induced seizures in mice

The efficacy of Flunarizine (FLU), a calcium channel blocker, in combination with conventional antiepileptic drugs, phenytoin (PHT), carbamazepine (CBZ), sodium valproate (VPA), and ethosuximide (ESM), at ED50 doses, were examined for protective effects against maximal electroshock seizures (MES) and pentylenetetrazol (PTZ) induced seizures in mice. In both models, only VPA and FLU showed significantly enhanced protection, which was additive ie. 100% protection. In the MES test, though FLU combined with PHT did show a slightly enhanced protection (66.6%), with CBZ there was no enhancement as compared to either drug alone. In the PTZ test, FLU with ESM showed 83% protection this however was not statistically significant. The findings of this study in mice suggest that FLU would be a suitable candidate for add-on therapy with VPA for clinical epilepsy.

Synergistic effect of flunarizine and sodium valproate on seizure thresholds elicited by cortical stimulation in conscious rats

The effect of flunarizine (FLU) and sodium valproate (SV) alone and in combination were examined for their effects on seizure thresholds elicited by cortical stimulation in conscious rats. Two different pharmacodynamic parameters could be distinguished viz, the threshold for localised seizures (TLS) defined as the current (mu A) required to elicit forelimb clonus and the threshold for generalised seizure (TGS), defined as the current (mu A) required to elicit vigorous clonic activity without a tonic component. In preliminary neuro-behavioral studies on rats, the most favourable combination was FLU 10 mg/kg i.p. and SV 200 mg/kg i.p., which produced anticonvulsant efficacy with minimal neurotoxicity. With FLU alone, SV alone and the combination of FLU and SV, the mean % change +/- SEM from baseline values over a period of 6 h were for TLS: 3.8 +/- 0.8, 23.9 +/- 3.7, and 29.8 +/- 2.1; and for TGS 5.5 +/- 0.7, 15.6 +/- 2.7 and 190.9 +/- 22.7 respectively, indicating that FLU alone had no effect on TLS or TGS, SV significantly elevated TLS but had no effect on TGS and the combination of FLU plus SV produced a synergistic elevation of both TLS and TGS-the intensity of effect being more on TGS than on TLS. This model provides a new dimension to the profiling of two anticonvulsant agents with different mechanisms of anticonvulsant activity and offers predictive criteria for protective effects on clinical manifestations of partial or generalised tonic clonic seizure.

Influence of caffeine on pharmacokinetic profile of sodium valproate and carbamazepine in normal human volunteers

The present study evaluates effect of pharmacokinetic interaction between caffeine (300 mg) in three divided doses with sodium valproate (400 mg) and carbamazepine (200 mg) given as single doses, in normal human volunteers, using a open cross over design. Both the serum concentration of sodium valproate and pharmacokinetic parameters remained unaltered, as against significant reduction in plasma concentration and area under the concentration curve of carbamazepine following the coadministration of caffeine. Also, the plasma t 1/2 (of carbamazepine was prolonged by two folds and bioavailability reduced by about 32% in presence of caffeine. The results are of clinical significance as xanthine consumption may have to be restricted in patients on carbamazepine therapy and this aspect may need further investigation.

Enhancement of synaptic efficacy by presynaptic GABA(B) receptors

Activation of presynaptic inhibitory receptors or high-frequency synaptic stimulation normally inhibits excitatory synaptic transmission by reducing transmitter release. We have explored the interactions between these two pathways for reducing synaptic strength and found that for synapses stimulated at high rates, agonists of the GABA(B) receptor become excitatory and strengthen transmission. At an auditory glutamatergic synapse featuring strong synaptic depression, the GABA(B) agonist baclofen reduced by 90% postsynaptic currents elicited at low frequency. By contrast, synaptic currents elicited at high frequencies were 5-fold larger in baclofen and had a markedly increased likelihood of firing well-timed postsynaptic action potentials. Presynaptic GABA(B) receptors may thus regulate transmitter release to enable sustained transmission at higher stimulus frequencies, thereby extending the dynamic range of neural circuits.

The adolescent with rheumatic disease

Adolescence is a period of emotional and physical upheaval and a time when personal identity, need for independence, and peer relationships all evolve. This transition from dependence to independence can be a difficult process for healthy teenagers. Those with chronic illness and disability have additional concerns, rendering them especially vulnerable as they progress into adulthood.

Determination of anticonvulsant effects on seizure thresholds using ramp generated cortical stimulation in conscious rats

The purpose of this investigation was to evaluate the new technique of direct cortical stimulation in conscious rats, using ramp generated pulse trains. In rats with electrodes permanently implanted in the frontoparietal cortex, twice daily stimulation for a fortnight, with ramp shaped trains of 2 msec duration, frequency 50 Hz, ramp time 200 sec and incrementing 5 microA per 0.1 sec yielded reproducible convulsive thresholds which could be repeated at short intervals over a period of time. Two different pharmacodynamic parameters viz Threshold for Localized Seizures (TLS) and Threshold for Generalised Seizure (TGS) could be distinguished. TLS is defined as the current (microA) required to elicit forelimb clonus or minimal restricted seizure activity and at the 14th session was found to be 650 +/- 91 microA (n = 14). TGS is defined as the current (microA), at which forceful clonic jerks and vigorous clonic activity without the tonic component occurred, and at the 14th session was found to be 1059 +/- 171 microA (n = 23). The effect of (doses, mg/kg, ip),phenytoin (PHY)10, carbamazepine (CBZ) 10 and 20; sodium valproate (SV) 300 and ethosuximide (ESM) 200 were studied on the TLS and TGS (n = 6). PHY, CBZ and SV significantly elevated both TLS and TGS, whereas ESM was ineffective. PHY and CBZ elevated thresholds within 0.5 hr and continued for 5 to 6 hr. For SV, significant elevation of TLS and TGS commenced at 5 to 10 min and lasted about 4 hr. Comparison of these results with conventional methods, suggests that this model provides a new dimension to profiling anticonvulsant compounds, with better extrapolation to clinical situations.

Safety pharmacology of a combination of tinidazole and oxyphenonium bromide

The effect of a combination of 150 mg tinidazole (CAS 19387-91-8) and 1 mg oxyphenonium bromide (CAS 50-10-2), referred to as the combination, was examined in various animal species to assess its safety. In mice and rats, the combination in the dose range 30-1000 mg/kg p.o. or 250 mg/kg i.p. did not produce behavioural or neurological changes, nor did it influence pentobarbital sleeping time, though, alcohol sleeping time was altered. In anaesthetised dogs, neither blood pressure, ECG, heart rate, respiration or gastrointestinal motility was affected after single intraduodenal administration of the combination 20 and 50 mg/kg or after chronic oral administration of 25 mg/kg daily for 15 days. In isolated organs, viz. perfused rabbit heart, guinea-pig ileum and rat ileum no significant changes were observed following various doses of the combination, compared to tinidazole and oxyphenonium bromide given alone in corresponding concentrations. In conclusion, the pharmacological profile of the aforementioned combination in the dosages employed in mice, rats, guinea-pigs, rabbits and dogs shows that it is safe and well tolerated.

Heterogeneity of the human corticotropin-releasing factor-binding protein

Human corticotropin-releasing factor (hCRF), secreted by the placenta, principally in the third trimester, is specifically bound in the peripheral circulation to a 37-kDa binding protein (CRF-BP). This complex is cleared from the circulation. We postulate that the protein may be returned to the blood in a form that is immunologically altered and not well recognized by the reported RIAs. We report that a stable isoform can result from temporary denaturation of recombinant CRF-BP by 8 mol/L urea. This isoform, urea-treated binding protein, which can bind CRF, has been found to bind to an antibody raised against a synthetic peptide comprising the first 24 amino acid residues of CRF-BP, but not to a second similar N-terminal antibody, although it was closely matched in titer. Urea-treated binding protein also cross-reacts poorly in the RIA with CRF-BP. It is proposed that as a result of in vivo post-ligand binding events, isoforms may be susceptible to cleavage. After affinity purification, which involves denaturation, recombinant CRF-BP was often found to be cleaved after storage in the presence of protease inhibitors. Here we present evidence for a C-terminally truncated form of the native binding protein in the plasma of subjects suffering from rheumatoid arthritis, which may parallel the in vitro truncation.

Influence of adenosine, dipyridamole, adenosine antagonists and antiepileptic drugs on EEG after discharge following cortical stimulation

The effects of adenosine (100 nM, icv), dipyridamole (DPM, 5 mg/kg, i.p.), adenosine A1 receptor antagonist 8-cyclopentyl-theophylline (8-CPT, 10 mg/kg, i.p.), and aminophylline (AMP) and caffeine (CAF) (at equivalent doses of 35 mg/kg, i.p.), were examined in rats. Anti-epileptic drugs (AEDs) were also administered i.p., viz, carbamazepine (CBZ, 10 mg/kg); phenobarbitone (PB, 10 mg/kg); phenytoin (PHT, 20 mg/kg); valproic acid (VPA, 300 mg/kg); and diazepam (DZP, 10 mg/kg), to study their effects on EEG after discharge (AD) and postictal depression (PID) induced by cortical stimulation. The AD parameters: (1) duration of EEG-AD (sec) and (2) number of spikes was noted both during pre and post drug treatment sessions. Adenosine and DPM had no special effects on AD parameters but showed significant prolongation of PID. All the adenosine antagonists, 8-CPT, AMP and CAF produced significant prolongation of AD duration, increase in number of spikes and reduced the duration of PID to a significant extent. Interestingly, some of the AEDs, viz. CBZ, VPA and DZP showed abolition of all the EEG-AD parameters whereas PB and PHT failed to show any significant effect. The results confirm previous findings on involvement of adenosine in postictal events.

Lupus or lupoid hepatitis with mesenteric vasculitis

A 15-yr-old girl with lupus presented with hepatitis and later a mesenteric vasculitis requiring bowel resection. The gastroenterological manifestations of lupus are reviewed with particular reference to hepatic involvement.

Modulation of Ca2+ and K+ conductances in an identified insect neurone by the activation of an alpha-bungarotoxin-resistant cholinergic receptor

The effects of activation of a population of [alpha]-bungarotoxin ([alpha]-bgt)-insensitive cholinergic receptors on the soma of the cockroach fast coxal depressor motor neurone (Df) have been examined under two-electrode voltage-clamp conditions. Activation of these receptors was achieved by bath-application either of acetylcholine (ACh) in the presence of [alpha]-bgt or of the muscarinic agonist McN-A-343 (McN). Since these receptors have been shown previously to respond to some nicotinic agonists, we refer to them as 'McN-sensitive or mixed pharmacological profile muscarinic receptors' (mMAChRs). Activation of these receptors normally results in a biphasic response consisting of an initial outward current component, which reverses near -70 mV, and a later (delayed) inwardly directed current, which is only observed at membrane potentials more positive than -40 to -20 mV. The initial outwardly directed component of the McN-induced current appears to result from an increase in K+ conductance since it reverses at potentials close to the K+ equilibrium potential (EK) (approximately -70 mV under the experimental conditions used) and is blocked by internal Cs+. This increase in K+ conductance is probably due to an increase in Ca2+-activated K+ current (IK,Ca) which is known to form a large proportion of the outward current observed when this neurone is depolarized. The delayed inwardly directed current induced by McN results from suppression of a Ca2+ current (ICa) which, in turn, causes a decrease in IK,Ca. The net effect is a reduction in outward current, because IK,Ca is considerably larger than ICa. Evidence for an action of McN upon Ca2+ channels is provided by experiments in which K+ currents have been suppressed by internal Cs+ to reveal inward currents produced by the movement of Ba2+ through voltage-dependent Ca2+ channels. Ba2+ currents observed under these conditions are suppressed by bath application of McN. The inwardly directed current component of the McN response is unlikely to involve direct regulation of IK,Ca, since McN has no effect upon this current when it is induced by brief intracellular Ca2+ injections. Both the initial outwardly directed component and the delayed inwardly directed component of the McN-induced current were suppressed by intracellular injection of the Ca2+ chelator BAPTA. These observations suggest that a rise in [Ca2+]i mediates the electrophysiological effects of McN in Df somata.

Childhood-onset scleroderma: is it different from adult-onset disease

OBJECTIVE

To distinguish childhood-onset scleroderma from adult-onset disease.

METHODS

The clinical and serologic features of 58 patients with childhood-onset scleroderma (11 patients with diffuse cutaneous systemic sclerosis [SSc], 16 with linear SSc, 14 with linear morphea, and 17 with morphea) were examined in the largest cohort of such patients studied to date. These parameters were compared with data obtained from patients with adult-onset disease.

RESULTS

Childhood-onset scleroderma resembled adult-onset disease with regard to the heterogeneity of clinical expression and subsets of disease, but it also differed from adult-onset disease in a number of clinical and laboratory parameters. The predominant childhood-onset disease presentation was the localized form of the disease, with limited and diffuse SSc being less notable. There was a significant association of trauma with childhood-onset scleroderma (P < 0.0001), which was not noted in adult-onset disease. Furthermore, in contrast to adult disease, patients with childhood-onset disease had normal levels of parameters of vascular activation (von Willebrand factor, angiotensin-converting enzyme, E-selectin, and endothelin-1), T cell activation (soluble interleukin-2 receptors), and collagen synthesis (carboxy-terminal type I and amino-terminal type III), a notable lack of anticentromere antibodies, and abnormal coagulation indices.

CONCLUSION

A number of features distinguish childhood-onset scleroderma from adult-onset disease.