Dark skin discoloration of finger joints in juvenile arthritis

We examined the frequency of a known but poorly described finding, darkened skin over the proximal interphalangeal joints in patients with polyarticular juvenile arthritis. Examining a consecutive group of patients we found that 77% showed this sign. It reflects the presence of or previous episodes of inflammation of these joints. The reason for this finding is unknown.

Discoid lupus keratitis

Two patients with long-standing discoid lupus erythematosus developed acute, unilateral, corneal stromal infiltration and edema. No evidence of infection was found, and both responded rapidly to topical corticosteroid therapy. To our knowledge, only one case of stromal keratitis associated with discoid lupus erythematosus has been published previously. We describe the first cases, to our knowledge, in which a satisfactory response to corticosteroid therapy is demonstrated.

Erythrocyte sedimentation rate and C-reactive protein compared in the elderly

The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentrations were studied in 101 elderly individuals (mean age 72 y) to determine their utility as diagnostic aids in subjects with underlying infection/inflammation. Whereas ESR and CRP were both significantly increased in patients with infection or inflammation, or both, analysis of variance indicated that those subjects still alive six months later had significantly lower ESR values. Analysis of sensitivity, specificity, and positive predictive values indicated that neither test satisfactorily discriminated between patients with and those without ongoing active or chronic disease. Receiver-operating characteristic curve analysis confirmed the low true-positive/false-positive ratios of both ESR and CRP. In the elderly, neither CRP nor ESR has distinct advantages over the other, and both tests evidently have limited utility.

Erythrocyte sedimentation rate and C-reactive protein compared in the elderly

The erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) concentrations were studied in 101 elderly individuals (mean age 72 y) to determine their utility as diagnostic aids in subjects with underlying infection/inflammation. Whereas ESR and CRP were both significantly increased in patients with infection or inflammation, or both, analysis of variance indicated that those subjects still alive six months later had significantly lower ESR values. Analysis of sensitivity, specificity, and positive predictive values indicated that neither test satisfactorily discriminated between patients with and those without ongoing active or chronic disease. Receiver-operating characteristic curve analysis confirmed the low true-positive/false-positive ratios of both ESR and CRP. In the elderly, neither CRP nor ESR has distinct advantages over the other, and both tests evidently have limited utility.

Characterization of a partly folded protein by NMR methods: studies on the molten globule state of guinea pig alpha-lactalbumin

NMR spectroscopy has been used to investigate the structure of a partially folded state of a protein, the molten globule or A-state of alpha-lactalbumin. The 1H NMR spectrum of this species differs substantially from those of both the native and fully unfolded states, reflecting the intermediate level of order. The resolution in the spectrum is limited by the widespread overlap and substantial line widths of many of the resonances. Methods have therefore been developed that exploit the well-resolved spectrum of the native protein to probe indirectly the A-state. A number of resonances of the A-state have been found to be substantially shifted from their positions in the spectrum of the unfolded state and have been identified through magnetization transfer with the native state, under conditions where the two states are interconverting. The most strongly perturbed residues in the A-state were found to be among those that form a hydrophobic core to the native structure. A number of amides were found to be highly protected from solvent exchange in the A-state. These have been identified through pH-jump experiments, which label them in the spectrum of the native protein. They were found to occur mainly in segments that are helical in the native structure. These results enable a model of the A-state to be proposed in which significant conformational freedom exists but where specific elements of native-like structure are preserved.

Joint pain. It isn't always arthritis

When a history of trauma or overuse is absent in a patient presenting with pain and stiffness in a joint, bursitis and tendinitis should be considered, especially if the patient is elderly. Appropriate questioning can narrow the differential diagnosis, and physical examination confirms the impression gathered by history taking. Treatment may include one or more injections of a local anesthetic (with or without a long-acting corticosteroid), use of an oral corticosteroid or nonsteroidal antiinflammatory agent, and in some cases, surgery.

Glycoconjugate abnormalities in cultured keratoconus stromal cells

We examined the plasma membrane glycoconjugates of cultured corneal stromal cells derived from patients with keratoconus and healthy subjects. Using radiolabeled lectins as probes, we found that a majority of our keratoconus strains contained more binding sites for concanavalin A, Ricinus communis agglutinin I, and soybean agglutinin than did the controls. The number of binding sites in cultured keratoconus cells for radioactive peanut agglutinin, wheat germ agglutinin, and Griffonia simplicifolia agglutinin I, however, was similar to that found in normal controls. Using a second method with biotin-labeled lectins as probes, we confirmed that increased amounts of glycoconjugates would bind to concanavalin A and R communis agglutinin I in stromal cells of patients with keratoconus compared with those of the control subjects. This study suggests that plasma membranes of cells derived from some patients with keratoconus may contain elevated amounts of glycoconjugates with glucose and/or mannose, terminal galactose, and N-acetylgalactosamine residues.

Involvement of the hip in juvenile rheumatoid arthritis. A longitudinal study

Thirty-five children who had rheumatoid arthritis were followed for three to twenty-two years. Four categories of involvement of the hip were seen. In the first group, thirteen patients had mild disability and slight radiographic changes. In six of those patients the disease was in remission at the time of writing, and the patients were asymptomatic. In the second group, two patients had episodic disability that correlated with the activity of the disease. In the third group, fourteen patients had progressive disability and radiographic changes. Fifty-five of the fifty-nine procedures that were performed on the hip and knee in this series were done on those fourteen patients. In the fourth group, six patients had dramatic clinical and radiographic findings but, at the time of the latest follow-up, had little functional disability. In all six of these patients, the disease was in remission. In the children in this study, protrusio acetabuli was more cephalad than has been found in adults who have rheumatoid arthritis. All of the children had psychosocial problems, but they responded well to counseling. These problems influenced the timing of the surgical treatment.

HLA-B27 associated dactylitis in children

A number of conditions have been found to be associated with the HLA-B27 locus including ankylosing spondylitis, psoriatic spondylitis, Reiter's syndrome, juvenile arthritis, and others. An unusual clinical syndrome of "sausage-like" toe, or dactylitis, associated with an oligoarthritis involving the lower extremities has been reported in adults, as has HLA-B27 associated spondyloarthritis and enthesopathy in children. We describe 3 children with dactylitis of the toe who carry HLA-B27. Their course and treatment are presented, and the importance of establishing this diagnostic entity is discussed.

Plasmapheresis treatment in patients with severe atopic keratoconjunctivitis

A 19-year-old woman with hyperimmunoglobulinemia E (the hyper-IgE syndrome [HIE]) and a 62-year-old man with atopic dermatitis experienced dramatic improvement in their chronic ocular symptoms and signs of atopic keratoconjunctivitis after plasmapheresis was instituted. Both patients had previously received topical and oral corticosteroids as well as topical cromolyn sodium without significant beneficial effect. The authors recommend a trial of plasmapheresis in selected patients with recalcitrant and debilitating atopic keratoconjunctivitis when standard therapy proves unsuccessful.

Bilateral keratitis as a manifestation of Lyme disease

An 11-year-old girl developed bilateral keratitis, which we believe was a manifestation of Lyme disease. She had had several attacks of Lyme arthritis and was twice treated with parenteral penicillin. The keratitis developed five years after the initial episode of Lyme arthritis at a time when there were no other manifestations of Lyme disease. It cleared completely in both eyes after topical corticosteroid therapy.

Clinically atypical granular corneal dystrophy with pathologic features of lattice-like amyloid deposits. A study of these families

Four patients from families in Pennsylvania, Massachusetts, and Argentina were diagnosed clinically as having granular dystrophy. Results of pathologic examination of the corneal buttons from each patient after penetrating keratoplasty confirmed granular deposits in the anterior third of the stroma. Amyloid was demonstrated within some of these granular deposits by Congo red staining with birefringence and dichroism and by electron microscopy. In addition to the morphologically granular deposits, numerous fusiform deposits identified as amyloid by histochemistry and electron microscopy and morphologically identical to those seen in lattice corneal dystrophy were detected deep to the granular deposits. It was further shown that the histochemical pattern of staining of the granular material by a series of lectins was similar to that present in corneas with lattice dystrophy. Although a relationship between these patients cannot be definitively proven, each family traces its origins to the Italian province of Avellino.

Tarsorrhaphy for corneal disease in patients with rheumatoid arthritis

We report two patients with keratoconjunctivitis sicca and rheumatoid arthritis whose corneal surfaces regained their integrity following tarsorrhaphy when conservative therapeutic measures were unsuccessful. We suggest that tarsorrhaphy be considered early in the course of the disease in such patients when other measures have failed to arrest progressive thinning of the cornea.

A histochemical comparison of human corneal stromal glycoconjugates with eight other species. Distinct species-dictated differences in binding sites of Griffonia simplicifolia I

Frozen sections of human, calf, rabbit, rat, cat, dog, goat, lamb, and hog corneas were stained with various lectins using an avidin-biotin-peroxidase complex to study glycoconjugates of stromal matrix. Staining of the stromal matrix and keratocytes with an alpha-galactose-specific lectin, Griffonia simplicifolia I (GSA-I) was species-dependent. The stromal matrices of cat, dog, and hog corneas invariably reacted intensely with this lectin, whereas those of the human, calf, rabbit, rat, and lamb did not react. A positive reaction with GSA-I could be abolished in each instance by preincubation of the sections with alpha-galactosidase. The stromal matrices and keratocytes of all nine species reacted positively with wheat germ agglutinin, concanavalin A, and Ricinus communis agglutinin but did not react with soybean agglutinin. Results of this study may help select an appropriate animal model for further investigate human corneal stromal glycoconjugates.

Hypermobility: features and differential incidence between the sexes

Six hundred sixty individuals from a music school were studied to determine the frequency of incidence and the nature of their hypermobility. They were interviewed and examined for the 5 recognized features of hypermobility (laxity of the thumbs, fingers, elbows, spine, and knees). The incidence of hypermobility, according to the number of joints involved, followed an empiric geometric law. Approximately 27% of the individuals had 1 lax joint, whereas only 3% possessed all 5 features. Specific features were present at different frequencies in the 2 sexes. The ratio of the occurrence of 2 features in women compared with the occurrence in men was 2:1. Ratios for the occurrence of 3, 4, and 5 features were 4:1, 8:1, and 3:1, respectively. Thus, hypermobility was a predominantly female characteristic. Joint laxity declined with age, although not to a statistically significant degree. In men, the decline started when they were in their mid-twenties; however, in women, joint laxity continued through the mid-forties.

Optimal time for postoperative irradiation of pterygia

A prospective study of the optimal time for postoperative beta irradiation of pterygia in 54 eyes of 54 patients suggested that immediate postoperative irradiation, given as a single dose of 2000 rad, was associated with a lower rate of recurrence than a similar dose given 4 days postoperatively. The authors suggest that patients with recurrent pterygia, selected to have postoperative beta radiation, receive the radiation as a single dose of 2000 rad at the end of the surgical procedure.

Transscleral iontophoresis as an adjunctive treatment for experimental endophthalmitis

We examined the efficacy of transcleral iontophoresis as an adjunct to intravitreal injection in the treatment of experimental Pseudomonas endophthalmitis in rabbits. Animals received no antibacterial treatment (untreated controls; group 1), a single intravitreal injection of 100 micrograms of gentamicin sulfate (group 2), or the same dose of gentamicin sulfate along with two treatments of transscleral iontophoresis given 24 and 48 hours after the intravitreal injection (group 3). Treatment was initiated 16, 24, or 48 hours after the induction of infection. For each interval from infection to treatment, there was a lower bacterial count and a higher rate of sterilization in the eyes in group 3 than in group 2; both treated groups had better outcomes than the untreated controls. These data suggest that transscleral iontophoresis could be clinically useful as a supplement to intravitreal injection for a refractory type of endophthalmitis such as that caused by Pseudomonas aeruginosa.

Monitoring of anti-inflammatory drugs

Advances in analytic technology have allowed clinical laboratories to accurately measure plasma levels of NSAIDs. With the exception of salicylate, however, there is no relationship, or only a weak one, between plasma NSAID levels and clinical responses. Therefore, therapeutic drug monitoring of NSAIDs other than salicylate is of little value to clinicians in their management of patients with rheumatoid arthritis. On occasion, however, it may be helpful to monitor specific patients suspected of noncompliance by measuring plasma drug levels. Routine therapeutic drug monitoring of these NSAIDs must await further work on the refinement of quantitating clinical response and the possible relationship between free drug level and drug effects.

[Anesthesia systems]

A clear understanding of technical details is essential for safe handling of anesthetic machines. Following the ideas of E.A. Ernst, it is suggested that anesthesia systems be differentiated according to the underlying principles of construction into rebreathing systems, flow- and valve-controlled non-rebreathing systems, and systems without reservoirs. This classification seems much clearer than the usual differentiation into closed, semiclosed, semiopen, and open systems, which is based upon functional criteria. Anesthesia systems must be understood as technical parts (hardware) of anesthetic machines with variable function according to the chosen fresh gas flow (software). An unequivocal characterization of an anesthetic system will only be possible if its technical properties are described together with the fresh gas flow used. Most anesthetic machines currently in use are equipped with a circle system and sophisticated monitoring, which is designed for the rebreathing technique. This technique can only be used advantageously, however, if the rebreathing system is used in conjunction with substantially reduced fresh gas flows.

Transscleral iontophoresis of gentamicin in monkeys

Experiments in rabbits have shown that the novel technique of transscleral iontophoresis is a safe, effective, noninvasive way to produce high concentrations of antibiotics in the vitreous humor. The authors have now studied the effects of repeated transscleral iontophoresis in the eyes of cynomolgus monkeys. Six treatments with gentamicin sulfate, 1.5 mA for 10 min, were applied to both eyes of three monkeys over a 2-week period. The concentrations of gentamicin in the vitreous humor 24 hr after treatment were determined for each eye on three occasions. The mean concentration was 28 micrograms/ml (range, 11-44 micrograms/ml) after the first treatment and 12 micrograms/ml (range, 2-21 micrograms/ml) after the fifth treatment. Indirect ophthalmoscopy completed after the last treatment showed only small retinal burns up to 2.5 mm in diameter in four eyes in the area of the pars plana over which the electrode had been applied. Electroretinograms were normal after treatment. These experiments confirm the efficacy and safety of transscleral iontophoresis in the primate's eye and suggest that investigations of this potentially useful technique are warranted in humans.

Lectin receptors of amyloid in corneas with lattice dystrophy

We analyzed lectin binding patterns of amyloid glycoconjugates in patients with lattice dystrophy of the cornea. Results of paraffin and frozen sections differed in some instances. With paraffin sections, three lectins--wheat germ agglutinin (WGA), Ricinus communis agglutinin I (RCA-I), and concanavalin A (Con A)--stained the abnormal deposits. In frozen sections, the abnormal deposits were stained by five lectins--WGA, RCA-I, Con A, peanut agglutinin (PNA), and soybean agglutinin (SBA). In paraffin sections, PNA and SBA did not stain amyloid deposits. In both paraffin and frozen sections, some lectin-positive deposits corresponded to the Congo red-positive material, whereas others were present surrounding and encroaching on the Congo red-reactive material. This study demonstrates that WGA-, RCA-I-, Con A-, PNA-, and SBA-positive abnormal deposits are present in corneas with lattice dystrophy. Since lectins bind to specific sugar residues, we conclude that the abnormal deposits consist, at least in part, of glycoconjugates and that these glycoconjugates contain oligosaccharides with N-acetylglucosamine/sialic acid, mannose/glucose and terminal beta-galactose residues and chains with terminal beta-galactose-N-acetylgalactosamine disaccharides.