Rheumatoid arthritis: relation of serum C-reactive protein and erythrocyte sedimentation rates to radiographic changes

Prognostic significance of synovial fluid analysis in rheumatoid arthritis

Thirty patients with definite rheumatoid arthritis and hydropsy in a knee joint were followed for 42 months in a prospective study. The knee joints were initially aspirated and 15 synovial fluid variables investigated. The patients were split into two groups, those with and those without progress of radiologically detected destruction in the knee joints during the follow-up. Of the synovial fluid variables at the start synovial fluid proteins (P = 0.002) and acid phosphatase (P = 0.03) differed statistically significantly between the groups, both being higher in patients with worsening of knee joint. The results suggest that high synovial fluid proteins and acid phosphatase are predictors of poor prognosis in a joint affected by rheumatoid arthritis.

[C-reactive protein in inflammatory articular diseases: comparison of concentrations in blood and synovial fluid]

We evaluated the diagnostic value of measuring C-Reactive Protein (CRP) in blood and in synovial fluid for the detection of inflammatory articular diseases in 154 patients. High concentrations of CRP in blood were found in microcrystalin arthritis, polymyalgia rheumatica and Horton's disease. Our results show a good correlation between CRP and erythrocyte sedimentation rate for ankylosing spondylitis (p less than 0.01), systemic lupus erythematosus (p less than 0.01), rheumatoid arthritis (p less than 0.05), polymyalgia rheumatica and Horton's disease (p less than 0.05). The CRP measurement in blood did not separate seropositive versus seronegative rheumatoid arthritis, systemic lupus erythematosus versus rheumatoid arthritis and treated versus non-treated rheumatoid arthritis. There was a good correlation between CRP concentration in blood and in synovial fluid but the concentration was lower in synovial fluid than in blood (p less than 0.01). Then, the CRP measurement in synovial fluid does not have a higher diagnostic value than in blood.

Hydroxychloroquine sulphate in the treatment of rheumatoid arthritis: a double blind comparison of two dose regimens

A controlled, double blind, parallel group, long term study of hydroxychloroquine sulphate in the treatment of rheumatoid arthritis, comparing daily doses of 200 mg and 400 mg, is described. The trial involved 54 patients with moderate disease activity who had not previously received antimalarial drugs. Forty three patients completed the one year treatment. The groups receiving different doses were homogeneous and did not differ in any of the 25 monitored indicators. Both dose regimens were effective, and a significant reduction of disease activity was observed after one year's treatment. Of the nine laboratory and 11 clinical indices of efficacy monitored, no statistically significant differences were reported, but in the group of patients treated with the 400 mg daily dose the number of side effects was three times greater. As there have been no reports of retinopathy with hydroxychloroquine at daily doses of 200 mg the effectiveness of this dose is of practical importance.

Acute phase reaction during chemotherapy in small cell lung cancer

We have measured the serum concentration of the acute phase reactant, C-reactive protein (CRP), in 20 patients with histologically proven small cell lung cancer undergoing their first pulse of induction cytotoxic chemotherapy. Baseline CRP concentrations were raised in 16 of 20 patients (median baseline CRP 18.5 mg l-1; normal range less than 10 mg l-1). CRP levels more than doubled in 11 of 20 patients during induction chemotherapy. This acute phase reaction was seen in seven of the 10 chemosensitive patients, but was not observed in any of the five non-responding patients. Five patients were non-evaluable for chemoresponse. These data indicate that there is a previously undescribed quantifiable acute phase response during chemotherapy for small cell lung cancer which has potential for predicting chemoresponse.

Prediction of erosiveness and rate of development of new erosions in early rheumatoid arthritis

Fifty eight patients suffering from a recent onset of rheumatoid arthritis (RA) were studied. Fifty six patients were followed up for 24 months and two for 18 months. Erosions were detected in 17 patients at the onset and at the end of the follow up period the number of patients with erosions was 44. The erosiveness in the joint groups studied was as follows: metatarsophalangeal (MTP) (36 patients), metacarpophalangeal (MCP) (22), proximal interphalangeal (PIP) (21), interphalangeal (IP) joints of first toes and wrists (13), elbows and knees (two), and shoulders, ankles, and hips (one). Erosiveness in the feet was twice that in the fingers, and the erosions in the feet appeared at an earlier phase of disease. Destructions favoured the dominant hand. Swelling in the PIP joints appeared to be a better predictor of erosiveness than joint tenderness. The number of joints to become eroded was significantly increased in the patients with flexor tenosynovitis in the hands. Erythrocyte sedimentation rate (ESR) was more closely related to progression of joint damage than C reactive protein (CRP) or haemoglobin. The rate of development of new erosions was the same in seronegative and seropositive patients. In addition, HLA-DR4 allele did not correlate either with seropositivity or with erosiveness. Adequate antirheumatic drug treatment (gold in most instances) was not able to restrain the erosive process despite decreased rheumatoid disease activity.

Progressive joint damage during penicillamine therapy for rheumatoid arthritis

Progressive joint damage characterises rheumatoid arthritis despite treatment with slow-acting drugs such as penicillamine. We examined a cohort of 145 RA patients, treated with 250 or 500 mg penicillamine daily for 18 months to study progressive joint damage measured using Larsen's standard radiographs. Overall damage increased significantly over 18 months at both doses of penicillamine. Radiological changes between 6-18 months were studied in detail in 55 cases. They were divided into rapidly progressive (increases in Larsen score of more than 5) or slowly progressive (increases in Larsen score of 5 or less). Overall clinical response, visual analogue pain score, ESR, haemoglobin and platelet count were significantly lower in the slowly progressive patients; articular index and duration of morning stiffness were slightly lower; latex titre, RAHA titre, joint size and white cell count showed no differences between groups. There is an indirect relationship between progressive joint damage and some clinical and laboratory measures. The reasons underlying our failure to control progression in some cases need further definition.

Influence of prognostic features on the final outcome in rheumatoid arthritis: a review of the literature

The literature on prognostic features on the final outcome in RA is reviewed. It is generally agreed that female sex and a positive RF are variables indicating a poor prognosis. Longstanding increased ESR and CRP values, decreased Hb, or the appearance of subcutaneous nodules are indicators of a less favorable clinical course. No conclusions can be drawn regarding other factors due to the incomplete and heterogeneous study designs.

Value of joint scintigraphy in the prediction of erosiveness in early rheumatoid arthritis

The value of scintigraphy in predicting development of new erosions in small peripheral joints was studied by visual evaluation of scintigrams and by three computerised methods. In 13 patients with newly diagnosed rheumatoid arthritis a total of 387 joints were examined clinically, scintigraphically, and radiographically. The follow up period was 24 months. Four eroded joints in three patients were found at the onset. Of the joints which were to become eroded, 46/47 were scintigraphically active at all the check ups. Erosions were detected earlier in foot joints than in finger joints. New erosions were especially prone to appear in joints with persisting and high scintigraphic activity. On the contrary, inactive joints by repeated scanning never eroded. Scintigraphic and clinical activity and radiographic erosiveness correlated significantly with each other. The sensitivity and specificity of visual scintigraphic assessment and the relative pixel activity method proved to be superior to the region of interest methods and clinical evaluation for prediction of erosiveness.

Radiographic assessment in relation to clinical and biochemical variables in rheumatoid arthritis

Radiographs of hands and feet were obtained from 125 consecutive patients with rheumatoid arthritis (RA) and the degree of destruction was assessed numerically on a 200-point scale using Larsen's standard radiographs as reference. The method is shown to possess a satisfactory degree of reproducibility. In 96 of these 125 patients, values of another 15 simultaneously determined clinical and biochemical variables were obtained. On applying linear and quadratic multiple regression analysis to this set as well as to the male and female subsets, an 'automatic' selection procedure (stepwise regression) proved duration of disease to be the most important factor relating to the 'Larsen index'. The 96 patients were therefore ranked with respect to duration of disease and divided into 4 subsets of equal magnitude. In the 3 subsets with duration of disease less than 21 years, stepwise regression produced in the final step linear or quadratic combinations not containing duration of disease but correlating quite well with the 'Larsen index' (R = 0.64-0.96). A similar result was obtained upon performing an analogous procedure in the female subset. In all instances, positive contributions of varying degree were obtained from Ritchie's index, ESR, a-antitrypsin (A1-AT), orosomucoid, fibrinogen, and IgM, while negative correlations were associated with ceruloplasmin, IgG, and IgA.

The relation of radiographic changes to serum acute-phase proteins and rheumatoid factor in 200 patients with rheumatoid arthritis

Radiographic parameters in 200 patients with rheumatoid arthritis (RA) were correlated with laboratory parameters, including hemoglobin (Hb), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), orosomucoid (OROS), immunoglobulin G (IgG), IgM, IgA, and rheumatoid factor (RF). CRP, OROS, and Hb showed a significant association with the severity and progress of radiographic parameters. ESR and WARO showed a significant association with the severity of radiographic parameters in late RA only. IgG, IgM, and IgA did not show any significant correlation with radiographic parameters.

Relationship between disorder in the stomatognathic system and general joint involvement in individuals with rheumatoid arthritis

Seventy-one individuals with rheumatoid arthritis (RA) were examined and compared with 52 individuals without history or symptoms of joint disease (C group) with regard to disorders of the stomatognathic system. Laboratory findings and articular and functional rheumatologic indices were compared. The clinical dysfunction index of Helkimo for the stomatognathic system was positively correlated to both the articular Ritchie index and the functional Lee index. The concentration of C-reactive protein (CRP) and the Ritchie index were positively correlated to temporomandibular joint (TMJ) pain. Vertical overbite was negatively correlated to the Ritchie index. In addition, there were positive correlations among TMJ crepitus, anterior open bite, sagittal distance between retruded position and intercuspal position, and erythrocyte sedimentation rate (ESR). The concentration of CRP, the ESR, and the Ritchie and Lee indices were highest in the individuals with bilateral current TMJ symptoms and lowest in those with previous but not current TMJ symptoms. It was concluded that the severity of TMJ involvement in RA is correlated to concentration of serum acute-phase reactants and to rheumatologic indices.

Correlation of immunoglobulin and C reactive protein levels in ankylosing spondylitis and rheumatoid arthritis

Serum C reactive protein (CRP), IgG, and IgA levels were measured in 22 patients with ankylosing spondylitis (AS) and in 20 patients with rheumatoid arthritis (RA) to study the regulation of these proteins in inflammatory disease states. In both RA and AS the mean CRP, IgG, and IgA levels were raised above normal values. Although IgA and CRP levels showed a significant positive correlation in RA (r = 0.53, p = 0.02), there was no correlation between these values in AS (r = 0.24, p = 0.29). The difference in correlation coefficients between the AS and RA groups was significant at a p = 0.05 level. In RA the raised IgA levels may be another manifestation of the acute phase response, as shown by the good correlation between IgA and CRP in that disease. In AS, however, the IgA levels, although raised, do not correlate with CRP levels, suggesting that the mechanism of increase of IgA in the two diseases is different. Gut mediated immune stimulation has been proposed as a cause of raised IgA levels in AS.

Predictors of acute relapse of Crohn's disease. A laboratory and clinical study

Relapses of Crohn's disease appear to be almost random. If these attacks could be reliably predicted, it might be possible to abort them with early treatment. In order to identify laboratory and clinical parameters that would predict an acute relapse, patients who had been assessed clinically in the three months prior to an attack were studied. Published clinical indices as well as variety of laboratory parameters were measured. The clinical indices and the serum C-reactive protein, orosomucoid, alpha 1-antitrypsin, and iron were increased at the time of the attack as compared to three months earlier, while only the clinical indices, orosomucoid and alpha 1-antitrypsin increased between three months and one month prior to the attack. There was a poor correlation of the parameters to each other. Further prospective studies are needed to determine the specificity of the suggested indices in predicting acute relapses of Crohn's disease.

C-reactive protein in the assessment of disease activity in juvenile rheumatoid arthritis and juvenile spondyloarthritis

Disease activity in 31 children with JRA and 12 with JSA was investigated clinically and by serial measurements of serum CRP and ESR over a one-year period. Prior mean duration of disease was 4.3 years. There was a significant correlation of CRP with ESR and both parameters correlated significantly with clinical disease activity. CRP concentrations and ESR in active disease were significantly higher than in moderately active and inactive disease, though neither parameter showed any significant difference between moderately active and inactive disease. Clinical scoring was more sensitive in detection of moderate disease activity than were CRP and ESR. However, in systemic JRA without articular involvement, laboratory parameters were more useful for assessing disease activity.

Long term experience of salazopyrin EN in rheumatoid arthritis (RA)

Our studies have shown that Salazopyrin EN is an effective slow-acting anti-rheumatic drug, improving clinical synovitis, depressing the acute phase response, capable of inducing remissions and possibly influencing the progression of joint damage. It is well-tolerated in the long-term with comparatively few serious side effects. Its mechanism of action, however, is still not entirely clear. We have found that the sulphapyridine moiety penetrates the synovial membrane and also that it can modify immune function. While Salazopyrin undoubtedly has an important role in the therapy of rheumatoid arthritis, it probably also has a place in the treatment of seronegative arthropathies and the spondyloarthritides. Furthermore we suggest that it should be used as an anchor drug in combination therapy to attempt to suppress disease activity further and limit joint damage.

Prediction of progressive joint damage in patients with rheumatoid arthritis receiving gold or D-penicillamine therapy

Seventy two patients with classical or definite rheumatoid arthritis (RA) were randomly allocated to receive gold or D-penicillamine therapy (DPA) in a prospective study designed to evaluate whether it is possible to predict which patients will show radiological progression despite therapy. Forty five patients completed 12 months' treatment. There were no significant demographic or clinical differences between them and the 27 drop outs. Twenty of the 45 patients showed no radiological progression between six and 12 months. These patients had less severe initial radiological damage, lower levels of serum aspartate transaminase (serum AST) and lactic dehydrogenase (LDH), but higher levels of serum cholesterol. Twenty five patients did show progression during the six to 12 month period. This group included all the men with nodules. Of the 43 pretreatment clinical and laboratory variables examined, however, the majority failed to predict whether or not progression would subsequently occur. This included the acute phase response and seropositivity.

Effects of aurothioglucose and auranofin on radiographic progression in rheumatoid arthritis

Radiographic films of 40 patients participating in a single centre patient blind study of auranofin versus aurothioglucose were evaluated in a random order by one reader. The two treatment groups were comparable with respect to number of erosions and total radiographic score at the start of the study. Only in the auranofin-treated patients was a statistically significant increase in the mean number of new erosions (p less than 0.001 at 6 months and p less than 0.01 at 12 months treatment, paired t-test) as well as in the total radiographic score (p less than 0.01 at 6 and 12 months treatment, paired t-test) observed. Results of this study confirm that parenteral gold compounds do retard radiographic progression of joint destruction in the treatment of rheumatoid arthritis. The effects on radiographic progression shown in this study are in agreement with other reports which, based on clinical and biochemical parameters, have shown that auranofin is somewhat less effective than the injectible gold salts.

Murine type II collagen arthritis. Association of an acute-phase response with clinical course

The acute-phase reactant, C-reactive protein, is a good index of disease activity in patients with rheumatoid arthritis. We examined the murine acute-phase reactant, serum amyloid P, as an index of disease in type II collagen-induced arthritis in 3 mouse strains. The onset of type II collagen-induced arthritis, which is characterized by paw swelling, is associated with a significant, but transient, elevation of serum amyloid P. Anticollagen antibody titers are not temporally associated with the onset of disease. Although murine type II collagen arthritis fails to show the chronic acute-phase reactant elevation that is characteristic of arthritis in humans, the transient elevation of the acute-phase reactant is a reliable indicator of the onset of disease.

Ranking of laboratory tests by consensus analysis

A new analytical technique (consensus analysis) was devised to assess the performance of laboratory tests that are commonly used to monitor the acute and chronic phases of inflammatory disease. On thirty-one tests carried out monthly for 7 months in seventeen patients with rheumatoid arthritis, the consensus analysis procedure ranked plasma viscosity and erythrocyte sedimentation rate in a tie for first place. Measurement of the acute-phase serum protein orosomucoid ranked third. Consensus analysis has the potential to reduce laboratory costs by identifying the most useful tests; it also promises to be helpful in the design of new laboratory tests that are more sensitive and specific.

Acute phase protein changes in antigen-induced mono-articular arthritis in rabbits and mice

Acute phase protein levels have been measured during the induction and progression of antigen-induced mono-articular arthritis in rabbits and mice. In rabbits there was a short lived elevation in serum C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) immediately following intra-articular injection which returned to baseline levels 10-12 days after the injection. In BALB/c mice, serum amyloid P-component (SAP) and the third component of complement (C3) were elevated after intra-articular injection, returning towards baseline levels 6 weeks after the injection. The levels of CRP and SAP correlated with the inflammatory changes in the joints during the acute phase of the arthritic response (7 days after intra-articular injection). During the chronic phase the levels of these acute phase proteins bore no relationship to the degree of connective tissue destruction.

Long term progression of joint damage in rheumatoid arthritis

Joint damage in rheumatoid arthritis is assessed radiologically. Previous studies have not examined in detail its long term progression. We evaluated the overall changes of peripheral joint damage radiologically in 50 rheumatoid patients followed up at one rheumatology centre for 10 years. All peripheral joints were scored in 12 groups with Larsen's standard films at 0 and 10 years. In 48 cases the total scored deteriorated (mean increase 13% maximum damage). There was no different pattern of progression in any of the patients, though seropositive patients had more initial damage and a greater rate of progress. The wrist and small joints of the feet were most affected initially. During the 10 years most progression occurred in the wrist, knee, and metacarpophalangeal joints. Progression occurred in both initially normal and abnormal joints. By 10 years only 16.5% joint groups showed no damage. Complete destruction was most common in the wrist, knee, and small joints of the feet. Damage to the hands and wrists have a god indication of overall changes at 0 and 10 years and also the increase in damage (correlation coefficients were from r = 0.74 to r = 0.85). These results show that specific joints are involved in different stages of the disease. Some joints are frequently involved and some less often. The hands and the wrists give a reasonable picture of the overall progression of damage.

Behçet's disease. Relation of serum C-reactive protein and erythrocyte sedimentation rates to disease activity

In a prospective study of 150 patients with Behçet's disease, significant associations were shown between CRP positivity and the presence of erythema nodosum (p less than 0.02) and acute thrombophlebitis (p less than 0.05) and between ESR and erythema nodosum (p less than 0.01), acute thrombophlebitis (p less than 0.001), and acute arthritis (p less than 0.01). Mucocutaneous, ocular, or central nervous system activities did not show significant associations with these indices of inflammation. In 50 patients in whom quantitative CRP determinations were performed, clinical disease activity was accompanied by slight to moderate increases in CRP and ESR.

Variables affecting efficacy and toxicity of sulphasalazine in rheumatoid arthritis. A review

Studies of sulphasalazine in rheumatoid arthritis have used largely empirical doses. The available literature suggests that the optimum dose appears to be greater than 40 mg/kg/day. Despite the relationship between dose and efficacy and a good correlation between dose and serum concentrations of sulphasalazine and its metabolites, no relationship has been demonstrated between efficacy and serum concentrations of sulphasalazine or its metabolites, although there is some suggestion that higher concentrations on single dosing are achieved in patients who develop upper gastrointestinal symptoms. Furthermore, acetylator phenotype does not affect efficacy, although upper gastrointestinal symptoms are more common in slow acetylators.

Assessing the progression of joint damage in rheumatoid arthritis

Joint damage in rheumatoid arthritis can be assessed by plain radiographs of the hands and wrists. There are a number of established methods that give reproducible scores which relate to increasing joint damage by measuring erosions and loss of joint space. Only 3 placebo-controlled trials have shown convincing evidence that gold or cyclophosphamide reduce the rate of progression of joint damage. Most placebo-controlled studies have failed to show a beneficial effect of slow acting antirheumatic drugs on radiological joint damage progression. However, comparative studies or analyses of cohorts of patients taking slow acting antirheumatic drugs show comparable amounts of progression for patients receiving gold and other drugs in this category. In addition, patients who show a clinical response also have less radiological progression after 6 months' therapy. In these circumstances, sulphasalazine produces comparable rates of radiological progression to those produced by gold and penicillamine. There are many problems associated with the use of radiological assessments to determine the progression of rheumatoid arthritis; thus, this method should not be deemed the most important technique by which to measure the success of therapy.

Influence of previous gold treatment and other patient variables on outcome of treatment with disease modifying anti-rheumatic drugs (DMARD) in patients with rheumatoid arthritis

Based on a 2-year controlled double-blind trial of levamisole, penicillamine, and azathioprine (L, P, and A), a computer aided search for predictive factors of outcome was instituted. Already at month 4 several indicators of synovitis activity were able to discriminate between patients staying in the trial for 24 months and patients whose treatment was discontinued before that time. Patients who had previously received gold therapy responded less favourably to L, P, and A than those who had not received gold. This reduction of response was more pronounced in gold resistant patients than in patients whose gold treatment had been discontinued for other reasons. The only phase protein (of several) with a predictive value was haptoglobin. If, after 4 months of treatment, haptoglobin did not normalize, this finding indicated a lack of response to treatment or a deterioration of synovitis activity during the following 4 months. The response to treatment was not influenced by HLA-types, sex, age, or clinical synovitis, disease duration, functional or anatomical aberrations at the start of treatment. The shape of the response curve as reflected by means of monthly measurements of serum-albumin and ESR was not related to disease duration, HLA-types, or previous gold treatment.

Radiological evaluation of erosions: a quantitative method for assessing long-term remittive therapy in rheumatoid arthritis

1 The most reliable method for evaluating possible remission-inducing properties in a drug is to measure how well it prevents the appearance of new erosions in serial X-rays of the hands. 2 I have reviewed the literature on the development, over the last 25 years, of a standard method for quantitatively assessing the progress of erosions radiologically. 3 The only drugs thus far shown to be genuinely remission-inducing are cyclophosphamide, high-dose penicillamine, and (most consistently over several decades) gold-thiols, all drugs with life-threatening toxicity. 4 The search for a non-steroidal drug with remission-inducing properties is crucial in our efforts to find a safe drug to control the progression of rheumatoid arthritis.

Rapid enzyme immunoassay for quantification of C-reactive protein (CRP)

A simple, rapid enzyme immunoassay (EMIT CRP assay) for C-reactive protein (CRP) was assessed using human acute phase sera and purified human CRP. The calibration curve was established from 10 micrograms/mL to 150 micrograms/mL. The precision evaluations of the assay, carried out under optimal conditions of the test, (CRP levels: 20-100 micrograms/mL) showed coefficients of variation less than 7%, both for within-run and day-to-day precision. The limit of sensitivity was 10 micrograms/mL. The coefficients of correlation with radial immunodiffusion and immunonephelometry were respectively 0.988 and 0.956. The dilution assay showed a linear response. No significant changes in the CRP level were observed after sample storage either at 4 degrees C or -20 degrees C for 3 to 10 days, or after removing lipoproteins from sera. The EMIT CRP assay is characterized by its short assay time, its excellent precision, and its sensitivity is sufficient to detect an ongoing inflammatory process.

Low-dose methotrexate treatment of rheumatoid arthritis. Long-term observations

Of 21 patients with rheumatoid arthritis who began to receive low-dose weekly methotrexate up to five years ago, 15 (71 percent) have continued to take this drug for a mean of 42 months and have received a mean total dose of 2,021 mg (range: 915 to 3,075). The clinical improvement noted at the first follow-up (11 months) was sustained throughout this follow-up period (42 months). Three patients (14 percent) have had complete clinical remission and nine others (43 percent) have had an excellent response. Methotrexate was discontinued in four patients between the first and second follow-up because of planned pregnancy (one), gastrointestinal toxicity (two), and fear of toxicity (one). Liver toxicity assessed in these 21 patients and four others receiving long-term methotrexate therapy revealed acute hepatitis in one and elevated transaminase levels in 12 (48 percent). Liver biopsy specimens in 17 patients after a mean of 1,950 mg of methotrexate (range: 915 to 3,125) revealed mild fibrosis in six and no cirrhosis. Methotrexate can continue to suppress rheumatoid synovitis over a prolonged period of time with minimal toxicity in most patients. Hepatic fibrosis and cirrhosis due to methotrexate may be less common in rheumatoid arthritis than has been reported in psoriasis.

Serum C-reactive protein in polymyalgia rheumatica. A prospective serial study

A prospective serial study of 13 well-documented, previously untreated cases of polymyalgia rheumatica was undertaken in order to assess the behavior of the nonspecific indices of disease activity, erythrocyte sedimentation rate and serum C-reactive protein (CRP) concentration, during induction of disease remission by prednisolone therapy. The clinical manifestations of all patients responded rapidly and completely to steroids, and the serum CRP value, which was raised in all patients at presentation, fell to normal at a rate which precisely reflected the clinical improvement. The erythrocyte sedimentation rate also fell, but did so much more slowly than the CRP concentration and, in half the patients, was still not normal after 14 days. These results indicate that assay of serum CRP provides a precise means of objectively assessing the course of polymyalgia rheumatica during initial therapy with steroids, and suggest that routine measurements of CRP may make a useful contribution to the management of the disease.

Anti-DNA antibodies: the choice of assays for routine diagnostic work

Sixty-six sera from 23 patients with systemic lupus erythematosus (SLE), 26 sera from patients with rheumatoid arthritis (RA), and 22 sera from normal healthy subjects were tested for the presence of antibodies against native (ds) DNA by the Crithidia luciliae immunofluorescence test and by the Farr assay, and for the presence of antibodies against denaturated (ss) DNA by the enzyme-linked immunosorbent assay (ELISA). Anti-dsDNA antibodies were detected in 57% of the SLE patients by the Crithidia test and in 65% by the Farr assay. Two of the RA sera were positive in the Crithidia test, whereas all were Farr negative. Anti-ssDNA antibodies of IgG class could be detected in 74% of the SLE patients and in none of the RA sera, while anti-ssDNA antibodies of IgM class were found in 26% of the SLE patients and in one RA serum. There was a good correlation between the results of the Farr assay and the IgG-anti-ssDNA ELISA but no agreement was found between the results of the Farr assay and the Crithidia test. We also measured the amount of C-reactive protein (CRP) in the sera but no correlation was seen between the levels of CRP and anti-DNA antibodies. We conclude that the demonstration of anti-ssDNA antibodies of IgG class is a good screening method in the diagnosis of SLE, and that antibodies against native DNA should be determined, preferably both by the Crithidia test and the Farr assay to confirm the diagnosis and in the follow-up of the patients.

Joint damage in rheumatoid arthritis: radiological assessments and the effects of anti-rheumatic drugs

Joint damage is a major problem in the long-term course of rheumatoid arthritis. It is usually assessed radiologically. In this review the methods of measuring the radiological changes are outlined, and the effects of anti-rheumatic drugs on radiological progression summarised. Two methods of scoring radiographs have become standard techniques; these are the Sharp index and the Larsen index. They both concentrate on cartilage loss and erosive damage in the hands and wrists. Investigations of the effects of drugs upon the radiological progression of rheumatoid arthritis include: indirect studies evaluating the inter-relationships between clinical, laboratory and radiological variables; placebo-controlled studies of slow-acting drugs and similarly controlled studies without a placebo group; open studies evaluating the long-term effects of treatment of slow-acting drugs. Only slow-acting drugs such as gold have been persistently considered to have a possible effect on reducing radiological progression. Unfortunately the therapeutic studies use a wide range of different radiological assessment techniques, and the incomparability is therefore difficult. None of the studies give a good indication that there is a marked reduction in joint damage by slow-acting drugs. On balance studies do suggest minor effects on the process of progression. Instead of debating how strong the evidence of such minor effect really is, it is concluded that rheumatologists should look towards novel therapeutic approaches to induce a major reduction in the rate of damage.

Prognostic factors and diagnostic criteria in early rheumatoid arthritis

The purpose of the present undertaking was to investigate prognosis of patients with non-specific or rheumatoid arthritis and to study the value of different diagnostic criteria for rheumatoid arthritis (RA) at the beginning of the disease. During the years 1973-75, a total of 442 patients with recent (less than or equal to 6 months) arthritis were studied at the Rheumatism Foundation Hospital, Heinola, Finland. In 1982 the outcome of the 200 patients with the diagnosis of RA or non-specific arthritis was established. Their ages at the time of the first hospitalization were 16-77 years, mean 41. There were 63 men and 137 women. The follow-up period was 6-9 years, mean 7.6. The outcome was measured by joint score, function score, the sum of ESR and CRP, X-ray index, outcome index, which was composed of the preceding ones, ESR, and CRP. The outcome was poor in half of the patients. Ninety-eight signs and symptoms registered at the first hospitalization were compared with the seven facets of outcome using Pearson's correlation coefficient r. The significances of the correlation coefficients were tested by Student's t-test. From 10 to 39 variables correlated highly significantly (p less than 0.001) with the measures of outcome; however, most of the variables had only moderate correlations. At best 14 variables showed 0.40 less than r less than 0.58 when correlated with the outcome index. In conclusion, at the onset of an arthritic disease symmetrical polyarthritis in peripheral joints, serum rheumatoid factor, X-ray changes, morning stiffness, high ESR, and old age correlated best with a destructive joint disease. Plasma proteins as indices of non-specific inflammation mattered less. The relationships between 22 entry variables and the seven facets of prognosis were further evaluated by means of stepwise multiple regression analysis. The results were essentially the same as reached above. One or two variables, most often the number of diseased peripheral joints and serum Waaler-Rose test, always explained the variance better than the number of ARA criteria alone. To study the value of the diagnostic criteria, diagnosis of the patients was made in the following three ways: RA with five or more erosive joints (N = 78), RF-positive and erosive RA (N = 93), RF-positive and nonerosive or RF-negative and erosive RA (N = 125). The patients outside each of the diagnostic groups formed the corresponding control groups.(ABSTRACT TRUNCATED AT 400 WORDS)

"Normal" acute phase response in systemic sclerosis

An Italian woman with classic active progressive systemic sclerosis had a normal serum concentration of C reactive protein (less than 6 mg/1). During an infection with Staphylococcus aureus, however, the concentration rose to 250 mg/1. This was unexpected, since in scleroderma the acute phase response to infection (a brisk rise in serum concentrations of various proteins, including C reactive) has been thought to be defective. This patient is evidence that the acute phase response does occur in systemic sclerosis and that probably it is the nature of the primary disease that masks the response in some cases.

Serum C1q levels as a prognostic guide to articular erosions in patients with rheumatoid arthritis

C1q was measured serially by single radial immunodiffusion in 54 rheumatoid arthritis (RA) patients over a period of more than 5 years, and values were correlated with laboratory, radiographic, and clinical findings. The number of joints with erosion (NJE) was determined retrospectively from radiographs of patients who had RA of greater than 7 years duration. In patients with clinically "burned out" RA, C1q levels were not statistically different from those of healthy adults. During the period of active disease, each patient's C1q level remained very constant, irrespective of erythrocyte sedimentation rate, C-reactive protein (CRP) level, or whether the RA was active or in remission. No sustained correlation was found between the C1q level and the other 2 acute phase reactants, but patients with C1q levels of at least 250 micrograms/ml showed a positive CRP over a period of years, in contrast to those with C1q levels below 250 micrograms/ml. Patients with an initial C1q above 250 micrograms/ml had more erosive RA when compared with those having C1q levels below 250 micrograms/ml. These data suggest that active RA can be classified into two subsets by C1q levels, one with persistent inflammation and a high NJE and another without persistent inflammation and with a low NJE.

A solid-phase enzyme immunoassay for C-reactive protein: clinical value and the effect of rheumatoid factor

Measurement of serum C-reactive protein (CRP) concentration is useful in monitoring the progress of chronic inflammatory diseases. Rheumatoid factor, by its interaction with the Fc portion of IgG, has the potential to interfere with solid-phase immunoassays for CRP and other serum proteins. To determine the effect of RF on a solid-phase enzyme immunoassay for CRP we compared assays employing whole antisera or F(ab')2 fragments. In 92 sera with RF latex titres ranging from 1/80 to 1/81,920, no correlation was found between RF concentrations and CRP measurements. CRP concentrations measured by use of whole antisera (mean +/- standard error of the mean, 59.7 +/- 5.7 mg/l, n = 92) were lower than those measured with F(ab')2 fragments (62.5 +/- 5 mg/l), indicating that exaggeration of CRP measurements did not occur in RF containing sera under the conditions of the assay. Our results show that in the CRP-ELISA, interference from RF was precluded by the high serum dilutions employed. At lower serum dilutions RF binding was detected. Consequently, in solid-phase enzyme immunoassays at lower serum dilutions the presence of RF may lead to false positive results and exaggerated measurements.

Progression of radiological changes in rheumatoid arthritis

A prospective study over one year of patients who had active rheumatoid arthritis discovered 64 who had received treatment for an adequate time with second-line drugs. In these patients there was evidence of continuing joint destruction as shown by radiological progression. During the year there were highly significant correlations between improvements in clinical and laboratory measurements, but neither group of tests was related to the degree of radiological change. However, in the second 6 months of treatment there was evidence that radiological progression was reduced. In a second prospective study of 88 patients with rheumatoid arthritis given prolonged, intensive therapy with second-line drugs and followed up for 10 years two-thirds showed radiological progression. However, the number of joints damaged per year fell significantly during the study period. There was a divergence between deterioration in radiological features and improvements in the ESR and functional capacity, though patients with a persistently low ESR had less radiological progression. These studies provide evidence that treatment may be associated with a reduced rate of radiological progression but suggest that changes in radiological progression and clinical and laboratory measurements may result from different mechanisms.

The oxidation of serum sulph-hydryl groups by hydrogen peroxide secreted by stimulated phagocytic cells in rheumatoid arthritis

Levels of free sulph-hydryl (SH) groups are depressed in the sera of patients with rheumatoid arthritis, especially during active disease. However, the mechanism underlying this effect is not known. We have investigated several oxidative species generated during the inflammatory process for their ability to react with serum SH in vitro. Our results show that serum oxidase enzymes (e.g. caeruloplasmin) do not have this activity but that "active oxygen species" generated either by an enzymatic reaction (xanthine plus xanthine oxidase) or by neutrophils stimulated with heat-aggregated IgG cause rapid oxidation of serum SH groups. The use of selective inhibitors of active oxygen species has demonstrated that this reaction is mediated by hydrogen peroxide. This compound is secreted in considerable amounts by activated phagocytic cells, especially neutrophils. Thus, serum SH levels may reflect phagocytic activity in patients with rheumatoid arthritis. We suggest that serum SH groups act as important extracellular scavengers of peroxides and so help to protect cells from damage by these molecules.

C-reactive protein in the serial assessment of disease activity in rheumatoid arthritis

C-reactive protein (CRP) levels were measured in 105 patients with rheumatoid arthritis (RA) during treatment with slow-acting anti-rheumatoid drugs D-penicillamine, alclofenac, hydroxychloroquine, gold, sulphasalazine and azathioprine. A control group treated with aspirin alone was also included. Patients were assessed clinically (pain score, articular index and summated change score) and in terms of acute-phase reactants (CRP, haptoglobin, fibrinogen, ESR and plasma viscosity) at eight separate clinic visits during the 6-month treatment period. The estimation of CRP was found to be more useful than haptoglobin, fibrinogen or ESR as an index of disease activity.

Factors related to the progression of joint destruction in rheumatoid arthritis

In 103 (M = 25, F = 78) of 150 consecutive RA patients, values of the following variables were obtained at the start and end of a 2-year follow-up period: radiographic destruction score of hands and feet according to Larsen (Larsen index), Ritchie index, B-hemoglobin, ESR and plasma proteins (alpha 1-antitrypsin, ceruloplasmin, CRP, fibrinogen, haptoglobin, orosomucoid, IgA, IgG, IgM, C3 and C4). 60% of the values of delta LI (final minus initial value of Larsen index) were significantly larger than zero (11-44 units, p less than 0.05). delta LI was larger in females than in males (p = 0.11). Comparing women with duration of disease (DoD) 1-6 years versus 7-52 years. delta LI was larger in the former group (p = 0.005). Comparing women with the largest delta LI (19-44 units) with the remainder ones (delta LI = -9-18 units), CRP and haptoglobin was higher and IgM lower in the former group (p = 0.03, 0.02 and 0.03 respectively). In women with DoD 1-6 years (and only in this interval) significant linear relationships were found between delta LI and hemoglobin (r = 0.52, p less than 0.01) Ritchie index, haptoglobin, CRP (r = 0.41-0.46, p less than 0.05) and IgM (r = -0.43, p less than 0.05). The mean of repeated hemoglobin values correlated even more strongly with delta LI (r = 0.70, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

C-reactive protein and serological indices of disease activity in systemic lupus erythematosus

The concentration of C-reactive protein (CRP) in sera from 70 patients with systemic lupus erythematosus (SLE) showed no correlation with commonly accepted laboratory indices of disease activity. Most patients had detectable serum CRP, but in some patients CRP was not found despite repeated testing. This absence of a CRP response did not appear to be related to medication. In some patients high levels of CRP were seen in the absence of infection. Measurement of serum CRP in SLE is unlikely to be useful in the laboratory diagnosis of disease activity.

Remission-inducing therapy in rheumatoid arthritis

Rheumatoid arthritis is characterized by immunologically mediated chronic inflammation of synovial structures. Remission-inducing drugs, such as gold compounds, antimalarials, and D-penicillamine, have been shown to suppress disease activity in rheumatoid arthritis while having minimal nonspecific anti-inflammatory properties. The possibility that these agents are effective because they modulate the underlying immunologic reactivity prompted an examination of the immunosuppressive properties of these drugs. The evidence indicates that immunosuppression is an action that is shared by these agents and thus supports the view that remission induction may result from suppression of the immunologic activity that underlies rheumatoid inflammation. Despite the fact that these agents can function as immunosuppressives, each appears to have a unique site of action, specifically inhibiting the function of only one of the populations of cells likely to be involved in chronic immunologically mediated inflammation. Gold compounds and anti-malarials appear to be active by virtue of their capacity to depress various functions of mononuclear phagocytes, while D-penicillamine acts by inhibiting a number of the activities of T lymphocytes. These results imply that the means by which these drugs suppress rheumatoid inflammation are fundamentally different. This suggests the conclusion that the remission-inducing drugs may be classified as T cell-active and mononuclear phagocyte-active agents. A better understanding of the pathophysiology of rheumatoid arthritis should thus be helpful in deciding which of these classes of drugs is appropriate in individual cases.

Comparison between penicillamine and sulphasalazine in rheumatoid arthritis: Leeds-Birmingham trial

Sulphasalazine was first formulated by Svartz in the early 1940s, specifically for use as a remission inducing drug in rheumatoid arthritis. After the publication of an unfavourable trial, however, the drug was restricted to patients with ulcerative colitis. In the late 1970s sulphasalazine was re-examined in rheumatoid arthritis and favourable results reported in "open" trials. A double blind controlled trial was therefore conducted comparing enteric coated sulphasalazine and D-penicillamine in patients with active rheumatoid arthritis. A total of 63 patients were recruited in two centres; 31 were treated with sulphasalazine and 32 received penicillamine. After 16 weeks' treatment both drugs had produced significant improvements in clinical score, pain score measured on a visual analogue scale, grip strength, Ritchie articular index, erythrocyte sedimentation rate, and serum C reactive protein concentration. Nausea was the major side effect in the sulphasalazine treated group. No potentially dangerous effects of sulphasalazine were encountered in contrast with those seen in the penicillamine group. The results suggest that sulphasalazine is an effective and safe drug capable of producing remissions in active rheumatoid arthritis. They also lend confidence to the use of preliminary "open" trials as a means of screening for remission inducing drugs in rheumatoid arthritis.