Labile assembly of a tardigrade protein induces biostasis

Tardigrades are microscopic animals that survive desiccation by inducing biostasis. To survive drying tardigrades rely on intrinsically disordered CAHS proteins, which also function to prevent perturbations induced by drying in vitro and in heterologous systems. CAHS proteins have been shown to form gels both in vitro and in vivo, which has been speculated to be linked to their protective capacity. However, the sequence features and mechanisms underlying gel formation and the necessity of gelation for protection have not been demonstrated. Here we report a mechanism of fibrillization and gelation for CAHS D similar to that of intermediate filament assembly. We show that in vitro, gelation restricts molecular motion, immobilizing and protecting labile material from the harmful effects of drying. In vivo, we observe that CAHS D forms fibrillar networks during osmotic stress. Fibrillar networking of CAHS D improves survival of osmotically shocked cells. We observe two emergent properties associated with fibrillization; (i) prevention of cell volume change and (ii) reduction of metabolic activity during osmotic shock. We find that there is no significant correlation between maintenance of cell volume and survival, while there is a significant correlation between reduced metabolism and survival. Importantly, CAHS D's fibrillar network formation is reversible and metabolic rates return to control levels after CAHS fibers are resolved. This work provides insights into how tardigrades induce reversible biostasis through the self-assembly of labile CAHS gels.

Sense of coherence and its impact on quality of life of patients with systemic lupus erythematosus

The sense of coherence (SOC) construct refers to a global orientation, which significantly determines the link between stressors, coping with disease and health. The aim of this work was to assess possible associations between SOC and quality of life (QOL) scores among women with SLE. Sixty consecutive SLE women and 88 healthy women were included in the study. QOL was assessed using the SF-36 and the WHO QOL-Bref scales. The SOC has three main sub-scales: comprehensibility, manageability and meaningfulness. Regression analyses were used to study associations between various parameters of SF-36, WHO QOL-Bref, SOC, SLEDAI, indices of end organ damage (SDI), and demographic variables. Mean SLEDAI and SDI scores were 4.5 (SD = 5.6) and 1.29 (SD = 2). SLE patients had significantly lower scores for all individual and summary sub-scales in the two QOL questionnaires compared with controls. SLE patients had significantly lower scores for the general, comprehensibility and meaningfulness sub-scales of SOC. No significant correlation was seen between SOC scores and measures of disease activity or end-organ damage. A strong linear correlation was seen between the scores of SOC, general WHO QOL-Bref, and the mental and physical component summary (MCS & PCS) scores of SF36. Age, SOC and SDI significantly affected the PCS score. SOC was the only variable independently associated with MCS. Education and SOC were significantly associated with the general WHO QOL-Bref. Age, education, SDI and SOC were independently associated with QOL of women with SLE.

Vulvar invasive squamous cell carcinoma occurring in a young woman with systemic lupus erythematosus

BACKGROUND

Although several studies have demonstrated a possible relationship between systemic lupus erythematosus (SLE) and non-Hodgkin's lymphoma, Hodgkin's lymphoma, leukemia and several solid tumors, it is still debatable whether SLE patients have an increased incidence of cancer overall.

CASE

We describe a 25-year-old patient with SLE who developed invasive squamous cell carcinoma of the vulva. The patient underwent radical vulvectomy and bilateral groin sentinel lymph node dissection and until to date, one year after surgery, she is alive without evidence of recurrent disease.

CONCLUSIONS

Only three cases of vaginal/vulvar cancer associated with SLE have previously been mentioned in the literature, but not described in detail. This is the first detailed case report in the literature of vulvar invasive squamous cell carcinoma occurring in a SLE patient. It can only be speculated that the SLE itself and/or the treatment with immunosuppressive drugs provoked malignant transformation and the development of vulvar squamous cell carcinoma in such a young patient.

Dobutamine stress echocardiography in women with systemic lupus erythematosus: increased occurrence of left ventricular outflow gradient

Dobutamine stress echocardiography (DSE) is an accurate noninvasive test used for the diagnosis and evaluation of patients with known or suspected coronary artery disease (CAD). The aim of this study was to determine the rate of positive findings in DSE, to define the echocardiographic and clinical characteristics of women with systemic lupus erythematosus (SLE) and to evaluate the safety of DSE in SLE patients. Thirty consecutive SLE patients were enrolled in the study and underwent DSE study. The mean age of patients was 44 years (range 20-76). Mean duration of SLE was 8.1 years and mean SLEDAI was 5.5. None of the DSE tests performed were positive for myocardial ischaemia. A left ventricular outflow gradient (LVOG) was found in 15/28 (54%) patients who completed the test, a result higher than the reported 20% prevalence of this finding in the literature. There were no significant differences in baseline characteristics between patients who developed a gradient and patients in whom a gradient was not found. There were no significant adverse effects during the study. In the general population, LVOG has been reported to be associated with an increased rate of chest discomfort and with a significantly lower prevalence of CAD. Whether this is true for SLE patients requires further study.

Influenza virus vaccination of patients with SLE: effects on generation of autoantibodies

The sera of 24 women with SLE who received influenza vaccine were tested by ELISA for anti-DNA, anticardiolipin, anti-Sm, anti-Sm/RNP, anti-Ro and anti-La. Blood samples were withdrawn at the time of vaccination and 6 and 12 weeks after vaccination. The mean age at enrolment into the study was 46.1 years. The mean disease duration was 9.1 years. SLEDAI scores were 6.6 at vaccination, 4.9 at 6 weeks and 5.1 at week 12. The vaccine was not associated with the generation of anti-DNA. At time of vaccination a single patient had anti-Sm, four patients had anti-Sm/RNP antibodies, none of the patients had anti-La antibody and six had anti-Ro antibodies. Six weeks after vaccination four, eight, nine and three patients had autoantibodies reacting with Sm, Sm/RNP, Ro and La, respectively. Twelve weeks after vaccination none of the patients had anti-Sm, three had anti-Sm/RNP, five had anti-Ro and two had anti-La antibodies. Following vaccination six and three patients developed IgG and IgM anticardiolipin antibodies, respectively. In summary, although the influenza virus vaccine is clinically safe for patients with SLE it may trigger the generation of autoantibodies. This effect is usually short term and has no clinical significance.

The role of trace elements in psoriatic patients undergoing balneotherapy with Dead Sea bath salt

BACKGROUND

A beneficial effect was observed in patients with psoriasis vulgaris following balneotherapy with Dead Sea bath salt.

OBJECTIVES

To evaluate the possible role of trace elements in the effectiveness of balneotherapy.

METHODS

Serum levels of 11 trace elements were analyzed in 23 patients with psoriasis vulgaris who participated in a double-blind controlled study of balneotherapy with either Dead Sea bath salt (12 patients) or common salt (11 patients). Thirteen healthy volunteers served as controls.

RESULTS

The mean pre-treatment serum levels of boron, cadmium, lithium and rubidium were significantly lower in patients compared to controls, whereas the mean pre-treatment serum level of manganese was significantly higher in patients compared to controls. Balneotherapy with Dead Sea bath salt resulted in a significant decrease (P = 0.0051) in the mean serum level of manganese from 0.10 +/- 0.05 mol/L to 0.05 +/- 0.02 mumol/L. The mean reduction in the serum level of manganese differed significantly (P = 0.002) between responders (% Psoriasis Area and Severity Index score reduction > or = 25) and non-responders (% PASI score reduction < 25). Following balneotherapy with Dead Sea bath salt the mean serum level of lithium decreased in responders by 0.01 +/- 0.02 mumol/L, whereas its level in non-responders increased by 0.03 +/- 0.03 mumol/L. (P = 0.015).

CONCLUSIONS

Manganese and lithium may play a role in the effectiveness of balneotherapy with Dead Sea bath salt for psoriasis.

[Prevalence of fibromyalgia in type 2 diabetes mellitus]

This study aimed to assess the prevalence of fibromyalgia and other pain characteristics among patients with type 2 diabetes mellitus. We assessed 137 patients with type 2 diabetes mellitus and a control group of 139 patients matched for age and sex that do not suffer from diabetes mellitus. We examined 9 of 18 typical tender points and 4 control points with a dolorimeter. There was no difference in the prevalence of fibromyalgia among men in both groups. However, diabetic men had more tender points than men in the control group and their threshold for pain at the corresponding tender points was significantly lower compared to that of the men in the control group. The diabetic men also reported more pain than patients in the control group. Diabetic women, on the other hand, had a significantly higher prevalence of fibromyalgia than women in the control group: 23.3% versus 10.6% respectively (p = 0.043). There was no significant difference in the number of tender points and the pain threshold in the two groups of women. Diabetic women reported more pain than the women in the control group. In both diabetic men and women the number of tender points and dolorimeter count directly correlated with the duration of diabetes.

The effect of balneotherapy at the Dead Sea on the quality of life of patients with fibromyalgia syndrome

Fibromyalgia (FS) is an idiopathic chronic pain syndrome defined by widespread non-articular musculoskeletal pain and generalised tender points. As there is no effective treatment, patients with this condition have impaired quality of life (QoL). The aim of this study was to assess the possible effect of balneotherapy at the Dead Sea area on the QoL of patients with FS. Forty-eight subjects participated in the study; half of them received balneotherapy, and half did not. Their QoL (using SF-36), psychological well-being and FS-related symptoms were assessed prior to arrival at the spa hotel in the Dead Sea area, at the end of the 10-day stay, and 1 and 3 months later. A significant improvement was reported on most subscales of the SF-36 and on most symptoms. The improvement in physical aspects of QoL lasted usually 3 months, but on psychological measures the improvement was shorter. Subjects in the balneotherapy group reported higher and longer-lasting improvement than subjects in the control group. In conclusion, staying at the Dead Sea spa, in addition to balneotherapy, can transiently improve the QoL of patients with FS. Other studies with longer follow-up are needed to support our findings.

Balneotherapy for fibromyalgia at the Dead Sea

The aim of this study was to evaluate the effectiveness of balneotherapy on patients with fibromyalgia (FM) at the Dead Sea. Forty-eight patients with FM were randomly assigned to a treatment group receiving sulfur baths and a control group. All participants stayed for 10 days at a Dead Sea spa. Physical functioning, FM-related symptoms, and tenderness measurements (point count and dolorimetry) were assessed at four time points: prior to arrival at the Dead Sea, after 10 days of treatment, and 1 and 3 months after leaving the spa. Physical functioning and tenderness moderately improved in both groups. With the exception of tenderness threshold, the improvement was especially notable in the treatment group and it persisted even after 3 months. Relief in the severity of FM-related symptoms (pain, fatigue, stiffness, and anxiety) and reduced frequency of symptoms (headache, sleep problems, and subjective joint swelling) were reported in both groups but lasted longer in the treatment group. In conclusion, treatment of FM at the Dead Sea is effective and safe and may become an additional therapeutic modality in FM. Future studies should address the outcome and possible mechanisms of this treatment in FM patients.

Systemic sclerosis: another rheumatic disease associated with hepatitis C virus infection

The first case of a patient with chronic infection with hepatitis C virus who developed systemic sclerosis, manifested by severe Raynaud's phenomenon, progressive skin thickening, painful fingertip ulcers, dysphagia and Sjogren's syndrome, is described. The role of interferon therapy is discussed.

Balneotherapy at the Dead Sea area for patients with psoriatic arthritis and concomitant fibromyalgia

BACKGROUND

Balneotherapy has been successfully used to treat various rheumatic diseases, but has only recently been evaluated for the treatment of fibromyalgia. Since no effective treatment exists for this common rheumatic disease, complementary methods of treatment have been attempted.

OBJECTIVES

To assess the effectiveness of balneotherapy at the Dead Sea area in the treatment of patients suffering from both fibromyalgia and psoriatic arthritis.

METHODS

Twenty-eight patients with psoriatic arthritis and fibromyalgia were treated with various modalities of balneotherapy at the Dead Sea area. Clinical indices assessed were duration of morning stiffness, number of active joints, a point count of 18 fibrositic tender points, and determination of the threshold of tenderness in nine fibrositic and in four control points using a dolorimeter.

RESULTS

The number of active joints was reduced from 18.4 +/- 10.9 to 9 +/- 8.2 (P < 0.001). The number of tender points was reduced from 12.6 +/- 2 to 7.1 +/- 5 in men (P < 0.003) and from 13.1 +/- 2 to 7.5 +/- 3.7 in women (P < 0.001). A significant improvement was found in dolorimetric threshold readings after the treatment period in women (P < 0.001). No correlation was observed between the reduction in the number of active joints and the reduction in the number of tender points in the same patients (r = 0.2).

CONCLUSIONS

Balneotherapy at the Dead Sea area appears to produce a statistically significant substantial improvement in the number of active joints and tender points in both male and female patients with fibromyalgia and psoriatic arthritis. Further research is needed to elucidate the distinction between the benefits of staying at the Dead Sea area without balneotherapy and the effects of balneotherapy in the study population.

Comparative study of osteoarthritis of the contralateral knee joint of male amputees who do and do not play volleyball

OBJECTIVE

To assess the prevalence of osteoarthritis (OA) of the contralateral knee of men with traumatic amputation who do and do not participate in regular, vigorous physical activity.

METHODS

Three groups of patients were assessed. Group 1 consisted of 8 male amputee volleyball players. Group 2 consisted of 24 male amputees who do not play volleyball, and Group 3 was made up of 24 healthy controls matched by age and weight to Group 2. The prevalence of contralateral knee OA in Groups 1 and 2 was assessed by questionnaire, physical examination, and radiographs, and was compared with findings for Group 3.

RESULTS

The rate of OA in all amputees (Groups 1 and 2 together) was 65.6%, which was significantly higher than among the controls (p < 0.05). The most common findings among the amputees were patellar and medial osteophytosis of the tibiofemoral joint, with a tendency to medial narrowing of the tibiofemoral joint space.

CONCLUSION

Traumatic amputees have a higher prevalence of OA in the knee of the nonamputated leg than matched healthy controls.

Manifestations of three HHV-8-related diseases in an HIV-negative patient: immunoblastic variant multicentric Castleman's disease, primary effusion lymphoma, and Kaposi's sarcoma

We describe a 73-year-old HIV negative patient who presented with symptomatic hypoglycemia. Over the course of several months she was diagnosed with three human herpesvirus-8 related diseases: multicentric Castleman's disease, primary effusion lymphoma and Kaposi's sarcoma. No improvement was observed following cytotoxic therapy and she died 16 months after her initial presentation. The etiology of the hypoglycemia remained obscure over the course of this patient's disease. This case is the first report of a patient with three human herpesvirus-8 related diseases, and the first report of severe hypoglycemia as the presenting symptom of any of these diseases.

Kingella endocarditis and meningitis in a patient with SLE and associated antiphospholipid syndrome

We describe a patient with SLE and antiphospholipid syndrome who presented with severe headache and fever. Lumbar puncture analyses indicated meningitis. Kingella kingae was isolated from her blood cultures. A large mobile vegetation was seen on her mitral valve. The association between SLE, Libman-Sacks endocarditis and bacterial endocarditis is discussed.

Influenza virus vaccination of patients with systemic lupus erythematosus: effects on disease activity

OBJECTIVE

To determine whether vaccination of patients with systemic lupus erythematosus (SLE) with influenza virus vaccine is associated with exacerbation of SLE.

METHODS

The study population comprised 24 patients with SLE who received influenza vaccine (cases group) and 24 other SLE patients who did not receive the vaccine (controls group). The primary outcome measure was the SLE Disease Activity Index (SLEDAI) scores 6 weeks and 12 weeks after vaccination. Secondary outcome measures included: number of SLE flares, defined as any increase in the SLEDAI > or = 3 points, and activity of renal disease. Repeated measurements MANOVA was used to compare the SLEDAI scores of the cases and controls.

RESULTS

All patients were women. The mean age at enrollment into the study was 46.1 and 40.6 years for the cases and controls, respectively. The mean disease duration was 9.1 for the cases and 9.3 years for the controls. SLEDAI scores for the cases and controls were 6.6 and 8.9 at vaccination, 4.9 and 6.8 at Week 6, and 5.1 and 6.7 at Week 12, respectively. The SLEDAI scores of the cases and controls at the 3 different assessments were not statistically different (p = 0.28). However, within each group the decrease in the SLEDAI over time was statistically significant (p = 0.02). Three and 6 flares were observed in the cases and controls, respectively, (p = 0.27) during the 12 weeks of followup. Improvement in the renal disease was observed in the cases and controls.

CONCLUSION

Influenza virus vaccine is safe for patients with SLE. Patients with SLE should be encouraged to receive the vaccine according to the recommendation given by the Immunization Practices Advisory Committee.

The role of spa therapy in various rheumatic diseases

Spa therapy seems to have a role in the treatment of a broad range of joint diseases. It cannot substitute for conventional therapy but can complement it. The improvement reported in some of the studies is of short duration, lasting for months. It should be considered for patients suffering from various types of inflammatory arthritides or noninflammatory arthritides who are symptomatic, despite accepted medical therapy and conservative physiotherapy, if they can afford the expense. The patients should be told that the effectiveness and success of this therapy cannot be predicted in advance. Because we have no way to date, of curing most rheumatic diseases, clinical trials of alternative therapeutic methods are justified. These methods may alleviate patient suffering and are almost totally devoid of serious adverse effects. No studies have been reported that evaluate their cost-effectiveness.

Balneotherapy at the Dead Sea area for knee osteoarthritis

BACKGROUND

Balneotherapy at the Dead Sea area has been applied in various inflammatory rheumatic diseases such as rheumatoid arthritis and psoriatic arthritis. The efficacy of balneotherapy at the Dead Sea area for the treatment of degenerative rheumatic diseases has not yet been formally evaluated.

OBJECTIVE

To evaluate the efficacy of balneotherapy at the Dead Sea area in patients suffering from osteoarthritis of the knees.

METHODS

Forty patients were randomly allocated into four groups of 10 patients. Group I was treated by bathing in a sulphur pool, group 2 by bathing in the Dead Sea, group 3 by a combination of sulphur pool and bathing in the Dead Sea, and group 4 served as the control group receiving no balneotherapy. The duration of balneotherapy was 2 weeks.

RESULTS

Significant improvement as measured by the Lequesne index of severity of osteoarthritis was observed in all three treatment groups, but not in the control group. This improvement lasted up to 3 months of follow-up in patients in all three treatment groups.

CONCLUSION

Balneotherapy at the Dead Sea area has a beneficial effect on patients with osteoarthritis of the knees, an effect that lastas at least 3 months.

Nabumetone induces less gastrointestinal mucosal changes than diclofenac retard

The aim of the study was to compare the efficacy and the effects on the mucosa of the gastrointestinal tract (GIT) of nabumetone and diclofenac retard in patients with osteoarthritis (OA). An open, multicentre, randomised, comparative, endoscopy-blind parallel group study included 201 patients with nabumetone and 193 patients with diclofenac retard suffering from moderate to severe OA of the knee or hip joint. Twelve clinical efficacy variables were assessed and a portion of the population underwent gastroduodenoscopy. All patients exhibited significant improvement in pain severity and pain relief (p < 0.001 and p < 0.0001, respectively) but there were no differences between the groups for all the efficacy variables. Eleven per cent of patients on nabumetone and 19% on diclofenac experienced GIT side-effects. Sixty-nine patients with nabumetone and 61 with diclofenac underwent gastroduodenoscopy. The differences in the mucosal grade for the oesophagus, stomach and duodenum at baseline were not significant. In the oesophagus there were significantly less changes after treatment with nabumetone (p = 0.007) than with diclofenac; there were similar findings in the stomach (p < 0.001) but the difference in the duodenum was not significant. This study indicates that nabumetone and diclofenac retard have similar efficacy in the treatment of OA, but nabumetone has significantly fewer GIT side-effects.

Different modalities of spa therapy for skin diseases at the Dead Sea area

BACKGROUND

Balneology and spa therapy, although not accepted as well-established treatment modalities in dermatology, are used throughout the world. The therapeutic properties for skin and rheumatic diseases of the Dead Sea area may be attributed to unique climatic characteristics and unique natural resources. The mechanisms by which a broad spectrum of diseases are alleviated by spa therapy may involve mechanical, thermal, and chemical effects.

OBJECTIVE

To review and discuss various spa therapy modalities, used at the Dead Sea area for a wide spectrum of skin diseases.

CONCLUSIONS

Existing evidence indicates the therapeutic potential of Dead Sea spa therapy modalities for psoriasis and psoriatic arthritis. A beneficial effect is hinted at for other skin diseases, but the absence of relevant methodological and clinical information precludes the drawing of any scientific conclusions. It is essential to establish therapeutic guidelines to determine the optimal treatment modality for each disease, and the optimal protocol of each treatment component, adjusted individually for each patient, with respect to remission and long-term adverse effects.

Blood pressure changes at the Dead Sea (a low altitude area)

The Dead Sea (barometric pressure: 800 mm Hg) is an important balneotherapeutic centre for chronic dermatologic and arthritic diseases. In the past, hypertensive patients have complained sporadically of weakness and dizziness during a stay in the Dead Sea. It was therefore recommended that hypertensives do not stay at these health centres. The aim of our study was to investigate the changes in blood pressure (BP) parameters of 72 hypertensive and normotensive osteoarthritic and rheumatoid arthritic elderly patients during a 2-week stay in the Dead Sea, and to further evaluate the effect of different balneotherapeutic means on these BP changes. Following a primary BP assessment at the out-patient clinic (Beer Sheva barometric pressure: 745 mm Hg), the patients were divided into four groups: (1)thermomineral pool; (2)Dead Sea water baths; (3) combination of the aforementioned treatments; and (4) controls (no balneotherapy). We demonstrated that the systolic BP (SBP) of hypertensives and normotensives decreased by an average of 17 mm Hg and that diastolic BP (DBP) decreased by an average of 8 mm Hg from their basic clinic-measured values. These favourable results were sustained during the first 10 days duration, and by the end of their stay they had diminished slightly. Thermomineral water had an additional lowering effect on the BP of the normotensives, but the SBP of hypertensives increased. Immediately following Dead Sea bath immersion, we noted a temporary increase of SBP in normotensives only. No patient, hypertensive or normotensive, complained of dizziness, malaise, or any other complaint. In our experience, patients feel well at low altitudes, and there is no justification in upholding hypertension as a contraindication to balneotherapy in the Dead Sea.

Clinical and radiographic outcomes of rheumatoid arthritis patients not treated with disease-modifying drugs

OBJECTIVE

To compare the radiographic and clinical features of rheumatoid arthritis (RA) patients who were not given disease-modifying antirheumatic drugs (DMARDs) with those of RA patients who were followed up and treated with DMARDs at a rheumatology clinic.

METHODS

The population of this case-control study includes a series of RA patients who immigrated to Israel from the previous Union of Soviet Socialist Republics and who were treated only with nonsteroidal antiinflammatory drugs. Control patients who were followed up and treated with DMARDs at our rheumatology clinic were matched by sex, disease duration, number of actively inflamed joints, and the presence of serum rheumatoid factor. The outcome measures were the number of deformed and radiographically damaged joints. Radiographic damage was evaluated by the methods of Steinbrocker and Sharp.

RESULTS

The study population consisted of 22 RA patients (15 women, 7 men) who were not treated with DMARDs and 22 patients (15 women, 7 men) who were treated with DMARDs. The mean disease duration was 16.2 years for the study patients and 14.3 years for the controls. Compared with the matched controls, RA patients who were not treated with DMARDs were found to have a significantly higher mean number of deformed joints (13.8 versus 7.2), a higher mean number of damaged joints (24.4 versus 15.5), and a higher overall damage score by the Sharp criteria (146.1 versus 65.7).

CONCLUSION

RA patients who were not given DMARDs had a 1.57-fold increased number of radiographically damaged joints and a 2.22-fold increased overall Sharp damage score compared with patients who were treated with second-line agents.

Leukocytoclastic vasculitis induced by low-dose methotrexate: in vitro evidence for an immunologic mechanism

The rare occurrence of methotrexate (MTX)-induced vasculitis has been associated mainly with high or intermediate MTX doses. We report herein a case of cutaneous leukocytoclastic vasculitis (LCV) following treatment with low-dose oral MTX (7.5 mg/week) for rheumatoid arthritis. The histological findings of a cutaneous lesion were consistent with drug-induced vasculitis. The clinical and histological findings, including the temporal relationship between MTX intake and the onset of vasculitis, and the results of withdrawal and rechallenge tests, suggest a causal relationship, and indicate a drug-induced LCV due to MTX. The role of MTX in the induction of the vasculitis was further supported by a positive mast cell degranulation (MCD) test.

[Chronic tophaceous gout]

A 51-year-old immigrant from the Caucasus had had chronic tophaceous gout for over 20 years, but had never been treated with anti-hyperuricemic drugs. He had developed large, multiple tophi in many locations, including both ankles and feet. The enormous size and unique location of the tophi caused considerable pain, and difficulty in standing and on walking. Since surgical removal of the tophi was refused by the patient, a course of allopurinol, 300 mg/day, was begun.

Balneotherapy in autoimmune disease

The mechanisms of action of balneotherapy in the treatment of autoimmune disease are not sufficiently clear. Although this therapy does not replace but rather complements conventional drug therapy, it is certainly beneficial in suitable cases. Additional controlled studies are needed to delineate the mechanisms of actions and the effectiveness of balneotherapy in autoimmune disease.

Superior sagittal sinus thrombosis in a patient with systemic lupus erythematosus

Cerebral venous thrombosis is a rare cause of focal neurological damage in patients with SLE. We describe a patient with SLE who presented with a focal neurological deficit and subsequently developed increased intracranial pressure. A superior sagittal sinus thrombosis was diagnosed by MRI. The association between SLE and superior sagittal sinus thrombosis is discussed. Early diagnosis is essential because treatment leads to a positive clinical outcome.

Balneotherapy for rheumatic diseases at the Dead Sea area

The Dead Sea region is the major spa area in Israel for patients with various types of arthritis. The unique climatic conditions in this area, and the balneologic therapy-which is based primarily on mud packs and bathing in sulfur baths and in Dead Sea water-combine to alleviate the symptoms of arthritis. Controlled studies conducted over the last 10 years have demonstrated that treatments provided at the Dead Sea have a positive effect on patients with inflammatory arthritides such as rheumatoid and psoriatic arthritis, and on non-inflammatory arthritides such as osteoarthritis. In addition, the use of mud packs and Dead Sea salts dissolved in regular bath water outside the Dead Sea region are also effective, although to a lesser degree than when applied at the Dead Sea area itself.

Musculoskeletal manifestations of brucellosis: a study of 90 cases in Israel

Rheumatological manifestations are frequently reported in patients with brucellosis. In a retrospective study of 90 patients diagnosed with brucellosis over a period of 18 years, 83 (92%) patients were Bedouins, 55 of whom (61%) reported ingestion of unpasteurized goat milk and goat milk products. The male/female ratio was 1:1, and the adult to child ratio was 3:2. The mean age of the patients was 25 years (range, 1-72 years). Rheumatological manifestations (myalgia, arthralgia, and arthritis) were reported in more than half of the patients. These manifestations started on days 3 and 4 of the disease and were mild to moderate in severity. Myalagia was evident in 49 (54%) patients and was more common in adults than in children (67% versus 37%; P < .01) and in men (67%) than in women (42%; P < .01). Arthralgia was the most common musculoskeletal manifestation, found in 55 (61%) patients, and occurred more often in children than in adults (74% versus 52%; P < .05). Arthritis was detected in 37 (41%) patients. The hip and knee joints were the most common sites of arthritis (31% each) followed by sacroiliac involvement (17%) and shoulder or spine involvement (5% each). Arthritis was also more common in children (63% versus 29%; P < .01). The prevalence of arthritis was similar in men and women. Cure was achieved in all patients after antibiotic therapy.

[Dead Sea bath salts for osteoarthritis of the knee]

26 patients with osteoarthritis of the knees were randomly divided into 2 groups of 13 each with patients of similar ages, sex distribution and duration and severity of disease. All were treated with daily baths at 34-35 degrees C for 20 min. containing Dead Sea bath salts (Group I) or sodium chloride (Group II). The study was double-blind and of 2 weeks duration. Patients were evaluated by a rheumatologist before, at the end of treatment and 1 month later. Clinical parameters evaluated included index of severity of osteoarthritis, patient's assessment of disease severity, range of movement of knees, soft tissue swelling, effusion and crepitus. There was significant improvement in the index of severity of osteoarthritis at the end of the treatment in both groups (p < 0.01). 1 month later, in Group I the significance of the index was still p < 0.01, but p < 0.05 in Group II. Patient's assessment of improvement was significant only in Group I at the end of the treatment period (p < 0.01). There was no statistical improvement in either group in the other parameters assessed.

Balneotherapy for rheumatoid arthritis at the Dead Sea

Thirty-six patients with active rheumatoid arthritis were treated for 12 days at the Ein Gedi Spa. The patients were allocated randomly to four study groups. Group 1 (n = 9) was treated with daily baths in the Dead Sea, group 2 (n = 9) was treated with daily sulphur baths, group 3 (n = 10) was treated with a combination of daily Dead Sea bathing and sulphur baths, and group 4 (n = 8) served as a control group. All patients were assessed by a rheumatologist who was blinded to the treatment modalities and group allocation. Clinical parameters assessed included: duration of morning stiffness, 15 m walk time, grip strength, activities of daily living, patient's assessment of disease severity, number of active joints, and the Ritchie articular index. Statistically significant improvement lasting up to 3 months was observed only in the three treatment groups.

Fibromyalgia syndrome in children--an outcome study

OBJECTIVE

To assess the outcome of fibromyalgia syndrome (FM) in a 30-month followup study of children with FM.

METHODS

In the original study to assess the prevalence of FM in healthy schoolchildren, we found 21 children with FM and an additional 7 fulfilling the point count criterion only (11 of 18). Fifteen of the 21 and all 7 were recruited for a 2nd assessment in our present study. In all children, a count of 18 tender points (TP) was conducted by thumb palpation. Tenderness of 9 of the TP sites as well as 4 control point sites was further assessed using a Chatillon dolorimeter. All children were questioned concerning the presence of widespread pain or aching. Children were considered to have FM if they met the American College of Rheumatology criteria for diagnosis.

RESULTS

After 30 months, 11 of the 15 children with FM (73%) were no longer fibromyalgic. The mean point count of the 15 children significantly decreased from 12.5 to 4.6 (p < 0.001). The mean tenderness threshold of the 9 tender sites increased from 2.4 to 3.4 kg (p < 0.01), and the mean tenderness threshold of the 4 control sites increased from 4.1 to 5.6 kg (p < 0.05). Of the 7 children initially fulfilling the point count criterion only, none had developed FM. Their mean point count decreased from 11.4 to 3.4 (p = 0.001), and their mean tenderness thresholds increased from 2.7 kg to 3.9 kg (p = 0.001) at tender sites and from 4.3 kg to 6.8 kg (p < 0.001) at control sites.

CONCLUSION

We suggest that the outcome of FM in children is more favorable than in adults. More followup studies are needed to clarify the longterm outcomes of FM in children and adults.

Treatment of psoriatic arthritis at the Dead Sea

OBJECTIVE

To evaluate the effectiveness of balneotherapy (mud packs and sulfur baths) on patients with psoriasis and psoriatic arthritis (PsA).

METHODS

One hundred and sixty-six patients with psoriasis and PsA were treated at the Dead Sea for a period of 3 weeks. The patients were divided into 2 groups. Both groups had the regular regimen of bathing in Dead Sea water and exposure to the sun's ultraviolet rays. The study group, which consisted of 146 patients also was treated with mud packs and sulfur baths. The control group, which had no additional therapy, consisted of 20 patients. The main clinical variables assessed were duration of morning stiffness, grip strength, activities of daily living, subjective patient assessment of disease severity, number of active joints, number of effluent joints. Ritchie index, psoriasis area and severity index score, cervical, thoracic, and lumbar spine pain and limitations of movement.

RESULTS

Statistically significant improvement was found in most variables in both groups. However, better results were observed in the study group. In 2 variables, reduction of spinal pain and range of movement in the lumbar spine, significant improvement (p < 0.001 and p = 0.022, respectively) was observed in the study group only.

CONCLUSION

Treatment of psoriasis and PsA at the Dead Sea area is very efficacious and the addition of balneotherapy can have additional beneficial effects on patients with PsA. Other controlled studies with longer followup periods are needed to verify our results.

Fibromyalgia in familial Mediterranean fever

OBJECTIVE

To determine whether chronic lower body pain in a subpopulation of patients with familial Mediterranean fever (FMF) is due directly to the musculoskeletal manifestations of FMF or whether they are connected to mechanical problems in the low back and leg/foot or to other factors operative in fibromyalgia (FM).

METHODS

In 93 consecutive patients with FMF a point count of 14 tender points (TP) was conducted by thumb palpation. Tenderness thresholds were assessed in some of the TP and of control point sites by Chatillon dolorimeter.

RESULTS

In female patients with FMF dolorimeter thresholds of fibrositic and control point sites were significantly lower than in male patients with FMF (p < 0.004). Also patients with FMF with back pain and foot/leg pain are more tender than patients with FMF without this characteristic (p < 0.001).

CONCLUSION

The detection of FM and definition of tenderness thresholds is relevant to this disease, since musculoskeletal complaints are common in this group of patients but not always explained by objective findings.

Ureaplasma urealyticum in Reiter's syndrome

OBJECTIVE

To evaluate the role of Ureaplasma urealyticum (Uu) in the pathogenesis of Reiter's syndrome (RS).

METHODS

Infection with Uu was determined in 31 patients with RS and 28 patients with other arthritides by urethral, cervical and synovial fluid (SF) culture and by measuring anti-Uu serum antibody. Infection with Chlamydia trachomatis was determined by examining SF by a direct immunofluorescence technique, by a polymerase chain reaction and by measuring anti-C. trachomatis serum antibody. The proliferative response of SF and peripheral blood mononuclear cells (PBMC) to Uu antigens in patients with RS was compared to that of a control group. The effect that treatment of 6 patients with RS with ciprofloxacin had on repeated cultures, on titer of anti-Uu antibody and on mononuclear cell reactivity was measured sequentially.

RESULTS

The colonization rate of Uu in patients with RS (74%) was significantly greater than in patients with other arthritides (14%). Genital C. trachomatis isolation and serum anti-C. trachomatis antibody were uncommon in both groups (11 and 13%, respectively). SF mononuclear cells of the patients with RS proliferated specifically in response to Uu antigens [up to 6.9 stimulation index (SI)], as did their PBMC (up to 14.5 SI). In some patients, high anti-Uu antibody titers were measured in the serum. Clinical remission was observed in 4 of 6 patients and correlated with eradication of Uu, decrease in antibody titers and disappearance of mononuclear cell reactivity to Uu antigens.

CONCLUSION

Our findings suggest that Uu might be a causative agent or a trigger in the development of sexually acquired RS.

Assessment of nonarticular tenderness and prevalence of fibromyalgia in hyperprolactinemic women

OBJECTIVE

To assess nonarticular tenderness and prevalence of fibromyalgia syndrome (FMS) in hyperprolactinemic subjects.

METHODS

Twenty-one consecutive women with hyperprolactinemia (HPRL) and 44 consecutive women with normal prolactin levels (PRL) were examined in the fertility unit by one observer during a 24-month period. Mean age was 31 years, range 22-46 years. Hyperprolactinemia was defined as PRL levels > 24.5 ng/ml (immunoradiometric assay). In all women, a count of 18 tender points (TP) was conducted by thumb palpation. Tenderness of some of the TP sites (9 points) as well as control point sites (4 points) was further assessed using a Chatillon dolorimeter. All women were questioned about the presence of widespread pain or aching. Women were considered to have FMS if they met the American College of Rheumatology (ACR) criteria for diagnosis.

RESULTS

Of the 21 women with HPRL, 15 (71%) had FMS vs only 2 of 44 (4.5%) normoprolactinemic women (p < 0.0001). Thresholds of tenderness of 9 fibrositic points were 2.7 (1.5) kg [mean (standard deviation)] for HPRL women vs 5.0 (1.4) (kg) for women with normal PRL (p < 0.0001). Thresholds of tenderness of 4 control points were 5.2 (1.5) (kg) for women with HPRL vs 6.8 (1.1) (kg) for normoprolactinemic women (p < 0.0001). The frequency of FMS was directly associated with the level of PRL.

CONCLUSIONS

We suggest that FMS is very common in a subset of women with HPRL and that its frequency is directly associated with the degree of hyperprolactinemia. Women with HPRL have lower thresholds of tenderness than women with normal PRL. More studies are needed to clarify the relationships between PRL, FMS and tenderness.

Benign synovitis of the hip in adults

Hip synovitis plays a part in many rheumatic diseases. In the young adult acute arthritis may be due to reaction to trauma, infection or gout. Although transient synovitis of the hip is a well-known phenomena in children the condition is not well-documented in adults. We present 10 young adults with idiopathic transient synovitis of hip who had attended the Soroka Medical Centre between 1986 and 1990.