Benign Thoracic Pain

Seventy-three patients with mid-dorsal and/or unilateral chest pain seen consecutively in the rheumatology clinic by a single clinician over a three-year period were studied, after exclusion of visceral disease. The majority were young women. The pain was dull and continuous, was aggravated by coughing and sneezing and relieved by rest. There was frequently tenderness over the thoracic spine (T4–5) and an adjacent rib, and pain at extremes of thoracic spinal movement in one or two directions was invariable. Cutaneous hyperaesthesia in a radicular distribution was found in 16.4%, but there were no other neurological abnormalities. This clinical picture is probably the result of a thoracic disc prolapse, though confirmation by myelography was not thought to be ethically justified. The condition settled in most of the patients following manipulative treatment and advice on back care. No patient developed spinal cord compression. It is concluded that this is a common benign condition which deserves wider recognition.

Evaluation of an alternative model of anticoagulant care

BACKGROUND

Alternative models for the delivery of anticoagulant care are required in view of an estimated increase of 20% per annum in patients requiring treatment, and an inability for the present service to deal with this increase. This led to a restructuring of the anticoagulant service, which included the appointment of a nurse specialist and the implementation of a computer-assisted warfarin dosing system.

AIM

To assess the impact of changes in the delivery of anticoagulant care in one unit.

METHODS

A previous consultant-led delivery service of anticoagulant care was compared with the current nurse-led service. Two six month periods was compared. The end points of the study were INR control, appointment intervals and clinic size. A patient questionnaire was completed to assess patient satisfaction and education.

RESULTS

In two years, attendance at walk-in clinics increased by 43% but the number attending anticoagulant clinics decreased by 50%. There was a parallel increase in the number of patients presenting on a flexible 'walk-in' basis for phlebotomy with postal dosing with 76% of patients now being managed on a flexible postal system. Anticoagulant control and reattendance intervals compare favourably, the percentage of patients attending at the maximal reattendance interval of eight weeks has increased from 3% to 15%. Patient knowledge and satisfaction scores were high on the questionnaire. Financially, this model of care is more cost effective than employing further doctors.

CONCLUSION

The introduction of a nurse specialist managed service has allowed us to accommodate a 21% annual increase in patient numbers while improving the overall quality, efficiency and cost-effectiveness of the service and patient care.

Familial polyarteritis nodosa

Familial polyarteritis nodosa (PAN) is rare. We describe here two siblings who developed PAN 8 years apart. HLA typing showed that the affected family members shared a common haplotype with their unaffected mothers. Further study of the family history suggested the possibility of an inherited disorder of connective tissue predisposing to autoimmunity and aneurysm formation.

Haemarthrosis due to fracture through amyloid deposits in bone in Portuguese familial amyloidosis

A patient with Portuguese familial amyloid polyneuropathy who developed haemarthroses secondary to pathological fractures is described. Amyloid material was demonstrated on bone biopsy and confirmed immunohistochemically to be transthyretin (prealbumin). Although amyloid deposits in bone have been described in other types of amyloid, this is believed to be the first proved case of amyloid deposition resulting in pathological fracture in familial amyloidosis.

Correlation of histopathological features of pannus with patterns of damage in different joints in rheumatoid arthritis

The cartilage-pannus junction has been studied in multiple sections from 23 rheumatoid joints. Changes suggesting a metaplastic reaction of the articular cartilage, termed transitional fibroblastic zone, were commonly found in hips and knees, but were rarely present in metatarsophalangeal joints, in which an invasive pannus with cartilage degradation in close association with inflammatory cells was seen. Thus when multiple sections from rheumatoid joints were examined a transitional fibroblastic zone was found in 1/15 (7%) sections from metatarsophalangeal joints compared with 29/57 (51%) and 15/48 (31%) sections from knee and hip joints respectively. In contrast, an invasive pannus occurred in 11/15 (73%) sections from metatarsophalangeal joints compared with 22/57 (39%) sections from knees and 19/48 (40%) sections from hips. These findings led to the suggestion that this pathological variation between different joints may explain the predominance of erosive change in small joints as compared with joint space narrowing with secondary osteoarthritis found in large joints in rheumatoid arthritis. Inappropriate comparisons between different joints may in part explain the variation in findings of previous histopathological studies.

The synovium-cartilage junction of the normal human knee. Implications for joint destruction and repair

The immunohistology of the synovium-cartilage junction was studied in 8 normal human knees, using monoclonal antibodies. In all joints at the junction with synovium, a vascular, wedge-shaped tongue of tissue was found to cover the cartilage surface. This marginal tissue overlying cartilage was in continuity with and was immunohistochemically similar to the adjacent synovial tissue, and contained cells possessing class II HLA antigens and antigens present on macrophages and type B synoviocytes. Periosteal tissue adjacent to the synovium-cartilage junction contained not only macrophages and other class II-positive cells, but also cells and matrix that stained with monoclonal antibodies specific for articular cartilage (keratan sulfate and type II collagen). This study demonstrates the presence of immunocompetent cells in tissue overlying the cartilage surface and adjacent to bone in normal human joints. It is likely that pannus in chronic inflammatory rheumatic disease develops by the recruitment of inflammatory cells augmenting this normal marginal tissue. Furthermore, overgrowth of tissue onto the cartilage surface may not be necessary in the pathogenesis of joint destruction in rheumatoid arthritis. In addition, our findings suggest that cells in the periosteum, rather than those in the marginal synovium, may be involved in attempted "repair" mechanisms, such as osteophyte formation.

Antinuclear antibodies and the diagnosis of systemic lupus erythematosus in patients with acute intermittent porphyria

To investigate the previously postulated association of systemic lupus erythematosus (SLE) and porphyria 38 patients with various types of porphyria were investigated for clinical and laboratory evidence of a connective tissue disease. Antinuclear antibodies (ANAs) were found in 8/15 (53%) patients with acute intermittent porphyria. These patients were more likely to have had a recent acute attack of porphyria, but only one patient had clinical evidence of SLE. Antinuclear antibodies were not found in any patients with latent acute intermittent porphyria or appreciably in any of the other types of porphyria studied. This finding of ANAs in patients with acute intermittent porphyria may explain the previously described association with SLE. Strict diagnostic criteria need to be used in any one patient as these two disorders have many similar clinical manifestations.

Systemic lupus erythematosus and acute intermittent porphyria

A patient with systemic lupus erythematosus who subsequently developed attacks of acute intermittent porphyria is described. This case illustrates both the problems involved in the diagnosis and management of two disorders which share several clinical manifestations, and the influence of a connective tissue disease and its treatment on the expression of acute porphyria. The inter-relationship between these disorders and their possible association is discussed.

Arthritis associated with adjuvant mycobacterial treatment for carcinoma of the bladder

A patient who developed an inflammatory polyarthritis following intravesical administration of bacillus Calmette-Guérin (BCG) used in the treatment of bladder cancer is described. An inflammatory synovitis comprising predominantly T lymphocytes was demonstrated on synovial biopsy. The synovitis resolved spontaneously within 14 days in this 'human model' of adjuvant arthritis.

Immuno-electron microscopy of chondrocyte-derived cells in the rheumatoid cartilage-pannus junction

Immuno-electron microscopy has been utilised to examine the cartilage-pannus junction in seven patients with rheumatoid arthritis. Using a monoclonal antibody, keratan sulphate was localised to cells with the ultra-structural appearance of fibroblasts within a transitional fibroblastic zone in the pannus in two cases. This confirms previous light microscopy evidence that this area (which is clearly separate from articular cartilage) contains cells which produce keratan sulphate, and strengthens the hypothesis that these cells are derived from cartilage rather than from the adjacent synovial membrane.

Cells and matrix expressing cartilage components in fibroblastic tissue in rheumatoid pannus

Our studies of the cartilage-pannus junction in rheumatoid joints have demonstrated the frequent presence of a transitional fibroblastic zone (TFZ) overlying articular cartilage. Using immunohistochemical techniques this zone has been shown to contain cells and matrix expressing specific cartilage components but not antigens present on cells in invasive vascular pannus. These findings support the concept that fibroblastic pannus is derived from the underlying articular cartilage rather than adjacent tissues. This type of reaction involving a metaplastic change in the chondrocyte is particularly common in large weight-bearing joints and may represent a different mechanism of cartilage degeneration to the classically described direct invasion of cartilage by hypertrophic synovial tissue.

Limitations of safranin 'O' staining in proteoglycan-depleted cartilage demonstrated with monoclonal antibodies

The intensity of safranin 'O' staining is directly proportional to the proteoglycan content in normal cartilage. Safranin 'O' has thus been used to demonstrate any changes that occur in articular disease. In this study, staining patterns obtained using monoclonal antibodies against the major components of cartilage proteoglycan chondroitin sulphate (anti CS) and keratan sulphate (anti KS), have been compared with those obtained with safranin 'O' staining, in both normal and arthritic tissues. In cartilage where safranin 'O' staining was not detectable, the monoclonal antibodies revealed the presence of both keratan and chondroitin sulphate. Thus, safranin 'O' is not a sensitive indicator of proteoglycan content in diseases where glycosaminoglaycan loss from cartilage has been severe.

Co-existent anti-La antibodies and rheumatoid factors bear distinct idiotypic markers

This study describes the distribution of isotypes and idiotypes of two autoantibody populations, anti-La and rheumatoid factor, which co-exist in both the sera and saliva of patients with primary Sjögren's syndrome. The two autoantibodies are distinguished not only by their antigenic specificity but also by the nature of their idiotypic markers. IgA anti-La antibodies bearing restricted idiotypes are specifically enriched in saliva compared to serum suggesting their local synthesis. In contrast, rheumatoid factors bear cross-reactive idiotypes and may arise as a direct consequence of the secondary immune response.

Chondrocyte-derived cells and matrix at the rheumatoid cartilage-pannus junction identified with monoclonal antibodies

In the cartilage-pannus junction of 14 patients with rheumatoid arthritis (RA) and seven patients with osteoarthritis (OA), monoclonal antibodies to keratan sulphate (KS) and chondroitin sulphate (CS) stained a transitional fibroblastic zone (TFZ) within the pannus in nine RA patients and one OA patient. In three patients this was clearly localised to the cytoplasm of cells in this zone, but in all remaining cases KS and CS could be demonstrated in the surrounding matrix. This area was distinguished from adjacent pannus which contained many blood vessels and cells positive for MHC Class II antigen. Specific markers for glycosaminoglycans have been employed to demonstrate that chondrocyte-derived cells and matrix contribute to the changes seen at the cartilage-pannus junction in RA-affected joints.