Current management of rheumatoid arthritis

Rheumatoid arthritis (RA) is usually a relentlessly progressive disease leading to joint damage and disability. While the long-term value of disease-modifying drugs is still questioned, the quality of life of RA patients has improved, possibly reflecting the earlier more aggressive and multifaceted approach to management and/or the innate attenuation in the disease over recent years.

Value of written health information in the general practice setting

The value of a library for patients as a way of providing written health information in the general practice setting has been investigated using a questionnaire. In 15 months, 243 books were borrowed from one library. Each book contained a questionnaire and 163 questionnaires were returned (67%). It was found that 106 respondents (65%) would not have sought the information elsewhere and 159 respondents (98%) found the books they had read to be very useful or of some use. The perceived level of anxiety after reading was raised in nine respondents (6%) but reduced in 71 (44%). Patients read books on 53 separate topics overall, although 73 respondents (45%) read on 10 recurring topics. A patients' library thus enables most patients to gain useful information from their general practice without increasing their anxiety.

Lesions of the mid-shaft of the humerus presenting as shoulder capsulitis

We describe three patients who presented with pain and restriction of movement at the shoulder suggestive of capsulitis, but proved to have lesions of the mid-shaft of the humerus. It is important to be aware of the possibility of this cause of a 'frozen shoulder', since radiographs of the shoulder are usually cropped at the mid-humerus and lesions at this level may easily be missed. A radiograph of the entire humerus, or an isotope bone scan, may be more useful than repeated shoulder radiographs in patients whose shoulder symptoms do not respond to standard treatment.

Extensor tendon rupture related to calcium pyrophosphate crystal deposition disease

We report a case of rupture of the extensor tendons at the wrist shown histologically to be related to calcium pyrophosphate crystal deposition disease. This cause for extensor tendon rupture has not previously been described.

Giant cell arteritis presenting as limb claudication

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Cyclosporin A in the treatment of severe Behçet's uveitis

Twelve patients with active Behçet's uveitis with marked deterioration of visual acuity in at least one eye were treated with cyclosporin A (CyA). An initial improvement in the severity of ocular inflammation and systemic features occurred in all cases and persisted until the dose was reduced or the drug withdrawn when a rapid recurrence of symptoms was noted. The visual acuity also initially improved in ten patients and this was maintained in seven cases until the dose of CyA was reduced. At this time, acuity was unchanged in two patients and was worse in three others-two of the latter as a result of vitreous haemorrhage in the absence of active inflammation. Seven of the 12 patients had therapy stopped because of complications; severe malaise and nausea (three cases), decreased renal function (three cases), and blindness (one case). Cyclosporin A is of value in the control of Behçet's uveitis but toxicity limits its use and the benefits only last while the patient is on this therapy.

Intensive immunosuppression in intractable rheumatoid arthritis

Twelve patients with intractable rheumatoid arthritis were treated with antilymphocyte globulin (ALG), prednisolone and a cytotoxic agent, usually azathioprine, and were followed for 1 year. There was a significant (p less than 0.05) improvement in the mean score for early-morning stiffness, grip strength and the severity of nodules and vasculitis at 6 weeks and 3 months when compared to the initial visit. However, in most patients, this benefit was not sustained despite continued cytotoxic and steroid therapy. A rise in the haemoglobin and fall in ESR was maintained throughout the study period.

Frozen shoulder: an arthrographic and radionuclear scan assessment

The diagnostic criteria and nomenclature used to describe the painful stiff shoulder remain confused. Arthrographic features of capsulitis have come to be accepted as characteristic of the frozen shoulder. Increased technetium uptake has also been noted. Both features have been considered to have possible prognostic and therapeutic importance. During a therapeutic study of strictly defined clinical frozen shoulder 35 of 38 patients showed increased technetium diphosphonate uptake in the affected shoulder in comparison with the opposite side. Of 36 patients who had arthrography 15 showed evidence of capsulitis, 11 rupture of the rotator cuff, and five no abnormality. Five tests failed owing to technical difficulty. There was no association between the technetium uptake and the arthrographic features, and neither was useful in predicting the rate or extent of recovery. Frozen shoulder of traumatic onset behaved no differently from that which arose spontaneously. We do not therefore consider that arthrography or technetium diphosphonate scanning performed at presentation contributes to the assessment of the painful stiff shoulder.

Frozen shoulder: prospective clinical study with an evaluation of three treatment regimens

Forty-two patients with frozen shoulder were followed up closely for eight months. They were all taught pendular exercises and randomly allocated to one of four treatment groups: (a) intraarticular steroids, (b) mobilisations , (c) ice therapy, (d) no treatment. This study has shown that there is little long-term advantage in any of the treatment regimens but that steroid injections may benefit pain and range of movement in the early stages of the condition.

Frozen shoulder: a long-term prospective study

As the natural history of frozen shoulder is poorly documented, a prospective study of 40 patients followed up for 40-48 months (mean 44 months) is described. The range of movement was significantly less than age- and sex-matched controls. Objective restriction was severe in five patients and mild in a further 11. Patients were often unaware that shoulder range was impaired. Dominant arm involvement, manual labour, and mobilisation physiotherapy were associated with a less satisfactory outcome. We conclude that, while objective restriction persists, there is little functional impairment in the late stage of frozen shoulder.

Lateral humeral epicondylitis--a study of natural history and the effect of conservative therapy

One hundred and twenty-five patients with lateral humeral epicondylitis treated in a rheumatology clinic were reviewed 1-5 years after presentation. Ten per cent of patients remained symptomatic at discharge, 26% had recurrence of symptoms and many were symptomatic at review. Over 40% of patients had prolonged minor discomfort which affected some activities. Thus tennis elbow is often associated with prolonged disability. This disability is not necessarily recognized by their medical practitioners as frequently patients do not return for further treatment. Ultrasound was not as effective (53% improved) as steroid injection (89% improved), but recurrence was less frequent.