The hand in the child with juvenile rheumatoid arthritis

Clinical examination of 100 children showed frequent loss of wrist extension and ulnar deviation. Loss of flexion and radial deviation in the metacarpophalangeal joint is more frequent than in the adult. Statistical review of charts and roentgenograms of 200 patients showed all had ulnar shortening up to 9 mm but there was no correlation with ulnar deviation or netacarpophalangeal radial deviation. Conservative treatment is reviewed; surgery is rarely indicated.     

The effect of drugs on hand function in rheumatoid arthritis

In 30 inpatients with diagnosis of rheumatoid arthritis according ACR criteria we evaluated efficacy of non steroid-antiinflammatory drugs (NSAIDs) and corticosteroids (CS) on pain, morning stiffness and grip strength. NSAIDs and combination of NSAIDs and CS showed statistically significant analgesic effect (P < 0.005). Combination of NSAIDs and CS statistically significant shortened morning stiffness comparing NSAIDs or CS as single drug. Grip strength didn't rise in any investigated group. This could be explained with long disease duration (11.69 years). Morning stiffness is symptom not related only to extracellular fluid cumulation in affected areas but also to other progressive and longlasting disease signs.     

The second dorsal metacarpal flap with vascular pedicle composed of the second dorsal metacarpal artery and the dorsal carpal branch of radial artery

A pedicle second dorsal metacarpal flap, comprising the second dorsal metacarpal artery, the partial carpal arterial arch of the dorsal hand, and the dorsal carpal branch of radial artery, was designed. The flap may be rotated through two axes of rotation, one at the entry of carpal branch of radial artery into the first dorsal interosseous muscle and one at the entry of the recurrent cutaneous branch arising from the second dorsal metacarpal artery into the skin. The method introduced can increase as much as possible the length of the vascular pedicle of the second dorsal metacarpal flap. Thus, it can cover a small defect at a more distant area. If the width of this flap is not more than 3 cm, the donor site can be closed directly. The flap had been used in five cases with no necrosis of the flap or complication of the donor site. In further investigation of the postoperative patients, no stiffness and tightness have been observed through a short period of rehabilitation of the hand. The results are satisfactory. The anatomy, the operative technique, and three selective cases are described here.     

Plain X-rays in rheumatoid arthritis: overview of scoring methods, their reliability and applicability

Radiographs are a suitable outcome measure in patients with rheumatoid arthritis. They reflect the history of the joint pathology and provide a permanent record necessary for serial evaluation of the disease. Great care should be taken to overcome technical problems with radiographs to ensure that good quality films are available to score. Many scoring methods have been described ranging from a global score for the whole patient to the more sophisticated methods of scoring erosions and joint space narrowing in a selected number of joints. These latter abnormalities give additive information and are the most important features in scoring radiographs in rheumatoid arthritis. An overview of the most important methods is given with an emphasis on four selected methods: the Larsen method, a modification of this by Rau and Herborn, the Sharp method and a modification of this by van der Heijde. All four methods produce sufficient intra- and inter-observer reliability. Although data are scarce, the Sharp method and its modifications seem the most sensitive methods for detecting changes over time. However, these are more time-consuming than the Larsen method or its modifications. Depending on the type of study a choice can be made between the two types of methods. For clinical trials where small differences are important, the (modified) Sharp method seems the most appropriate. In working with large data sets, time might be a more crucial factor and, therefore, the (modified) Larsen method could be chosen.     

Clinical associations of dual-energy X-ray absorptiometry measurement of hand bone mass in rheumatoid arthritis

Hand bone mineral density (BMD) measurement by dual-energy X-ray absorptiometry (DXA) has potential as a marker of progression in early rheumatoid arthritis (RA). We examined a DXA methodology and studied in a cross-sectional manner 202 patients with RA. Hand BMD correlated inversely with age and was higher in males. Hand BMD correlated with lumbar and femoral sites. In females, BMD of the hand correlated positively with grip strength and negatively with disability. Those with higher C-reactive protein (CRP) had significantly lower hand BMD than those with normal CRP. In patients with a normal CRP, the hand BMD:lumbar BMD ratios were significantly higher in patients with longer disease duration. Hand BMD correlates with measures of disease activity, functional capacity and also with lumbar and femoral BMD. Hand bone loss occurs in early disease, in the absence of detectable systemic disease, and before lumbar BMD loss. It has the potential to be an outcome measure in early disease.     

3',5'-cAMP phosphodiesterase inhibitors in the combined treatment of patients with rheumatoid arthritis

A study was made of clinical effectiveness and mechanism of action of the inhibitor of the specific 3',5'-cAMP phosphodiesterase papaverine in a therapeutic complex of measures designed to treat RA patients involving an immunodepressive preparation free from any cytopenic effect prospidin as a basic mediator. It has been shown that the papaverine antiarthritic action is associated with its positive effects on the unspecific component of the immune-complex inflammation, viz. processes of lipid peroxidation, activity of the antioxidant system of defence as well as on the vascular tone and microcirculation. All this improves tissue metabolism, and in this way enhances efficiency of RA basic therapy.     

Comparison of the results of PCA knee joint endoprosthesis in patients with rheumatoid arthritis and gonarthrosis

Hundred and forty two porous-coated anatomic (PCA) total condylar arthroplasties were performed from 1985 to 1991 in hundred and twenty-four patients, ninety-seven women and twenty-seven men. The diagnosis was osteoarthritis in 96 cases and rheumatoid arthritis in 46 cases. The mean follow-up was 88 months, range from 51 to 137 months. All operated patients were evaluated based on survivorship of the endoprosthesis with the cumulative survivorship method according to Kaplan-Meier method. The end point was defined as endoprosthesis in situ. The overall cumulative survival rate for mean follow up time was 77%. The survival rate of the rheumatoid arthritis group was significantly higher (82.5%) than that of the osteoarthritis group (73.8%). 108 PCA arthroplastes were evaluated regarding Baltimore's score. The mean postoperative Baltimore's score was 68.7. In the rheumatoid arthritis group score was 74.8 and in the osteoarthritis group it was 65.9 but this difference is not statistically significant (p = 0.06).     

Comparison of 3 quantitative measures of hand radiographs in patients with rheumatoid arthritis: Steinbrocker stage, Kaye modified Sharp score, and Larsen score

OBJECTIVE: To compare 3 quantitative hand radiograph scores, Steinbrocker stage, Larsen score, and Sharp score modified by Kaye, to one another and to other measures of clinical status in a cross sectional analysis of hand radiographs of 173 patients with rheumatoid arthritis (RA). METHODS: Radiographs were scored and compared to other measures of clinical status according to correlation and cross tabulation analyses. RESULTS: In these cross sectional studies, radiographic scores according to all 3 methods were correlated at high levels (r(s) > 0.5) with one another and duration of disease, as well as with scores for physical joint deformity and limited motion; at lower levels (0.3 < r(s) < 0.5) with physical joint swelling scores, functional status, and age; and at low levels of marginal or no clinical importance (r(s) < 0.3) with physical joint tenderness scores, laboratory data, and pain scores. CONCLUSION: The 3 scoring methods give similar quantitative information concerning hand radiographs of patients with RA. The Larsen and modified Sharp scores are preferred measures, as the detailed information facilitates comparison of different patients and monitoring of individual patients over time.     

Minocycline for the treatment of rheumatoid arthritis

This study examines the expression of the multi-functional cytokine, vascular permeability factor/vascular endothelial growth factor (VPF/VEGF) in the rat uterus during early proestrus, proestrus, estrus and diestrus. Groups of ovariectomized or hypophysectomized rats served as endocrine controls. Expression of VPF/VEGF mRNA was 2-fold greater in uteri during proestrus and estrus than in other phases of the estrous cycle. In situ hybridization techniques indicated that VPF/VEGF mRNA expression was confined to the luminal epithelium during proestrus, but shifted to the stromal compartment during estrus. Ovariectomized, hypophysectomized or diestrus rats exhibited scattered localization of VPF/VEGF mRNA among glandular epithelium and endometrial stromal compartments. Although VPF/VEGF mRNA was expressed throughout the estrous cycle, but in different compartments of the endometrium depending on the stage of the estrous cycle, VPF/VEGF protein expression appears to be restricted to the epithelial compartment during proestrus and estrus. Results indicate that circulating levels of gonadal steroids and LH may be associated with the differential expression of VPF/VEGF mRNA and its translation activity in the endometrium during different stages of the estrous cycle.     

Positivity for antinuclear antibody in patients with advanced rheumatoid arthritis

Some patients with rheumatoid arthritis (RA) as well as those with other collagen diseases are positive for antinuclear antibody (ANA). We investigated the frequency of positivity for ANA in 104 patients with RA and evaluated the clinical features and laboratory data in the ANA-positive and -negative groups. The presence of ANA in sera was studied by indirect immunofluorescence using HEp-2 cells as the antigen substrate. Sera with a positive fluorescence at a dilution of 1:20 were considered to be positive for ANA. Of the 104 patients, 39 (37.5%) were positive for ANA. The staining pattern in the positive cases varied, but most were speckled (64.1%) and homogeneous (48.7%). A small number showed a nucleolar (20.5%) or a centromere (10.3%) pattern. None showed a shaggy pattern. The ANA titer was lower in RA patients compared with those with other collagen-related diseases such as systemic lupus erythematosus or progressive systematic sclerosis. None of the patients positive for ANA with either a nucleolar or centromere staining pattern had progressive systemic sclerosis or the CREST syndrome. One patient each had Raynaud's phenomenon and pulmonary fibrosis. There was no correlation between ANA positivity and indicators of joint inflammation. The prevalence of ANA positivity in patients with advanced or prolonged disease was higher than those with early stages or short durations. There was no correlation with drug therapy.     

Hip replacement with the McKee-Farrar prosthesis in rheumatoid arthritis

A follow-up investigation was made of 74 patients suffering from rheumatoid arthritis (RA) who underwent total hip replacement (THR) according to McKee-Farrar during the years 1969-1975. There were 27 bilateral cases. The mean observation time was 47 months (range 9-85 months). The results were graded according to the method of d'Aubigné & Postel. As regards pain relief and increase in hip mobility after THR the results were good, but walking ability was not greatly improved, partly because many other factors besides the state of the hips influence walking ability. In addition to the THRs, 332 other orthopaedic operations were performed on the 78 patients. No correlation was shown between the results and RA serology, age at THR, preoperative classification of hip radiographs, or observation times. A high frequency of migration of the prosthetic components was found.     

Specificity of antiperinuclear factor for rheumatoid arthritis in rheumatoid factor-positive sera

Although antiperinuclear factor (APF) has the same specificity for rheumatoid arthritis (RA) as rheumatoid factor (RF), there is no evidence that this specificity is maintained in patients with positive RF-agglutination tests. Thus, we evaluated the specificity and usefulness of APF for RA diagnosis, regardless of RF titre. APF was tested (1:100 threshold) on 214 sera sent for RF evaluation over a 9-month period. These sera were previously determined to have latex or Rose-Waaler (RW) titres > or = 12 or 4 IU, respectively, but not necessarily above the threshold values of 100 and 32 IU. The APF test was performed blindly, and physicians were not advised of the results. In the patient population (119 RA and 95 non-RA) APF still demonstrated good specificity (0.82) for RA. As expected, APF proved useful for RA diagnosis in 28/33 (85%) RA cases with an RF level below 1:100 for latex and 1:32 for RW, thus reducing the number of 'seronegative' RA from 33/119 to 5/119. However, it also improved the serological positive predictive value for RA, even in cases when RW results were > or = 32 IU. Indeed, the positive predictive value for RA when both tests were positive was 0.94 (68/72), whereas concordant results (either positive or negative) for both APF and RW tests allowed correct classification (RA or non-RA) in 94% of cases.     

Talonavicular arthrodesis for rheumatoid arthritis of the hindfoot

In recent years there has been an increased interest in the development of neuropsychological tests that can diagnose accurately brain damage. The most successful of these test are represented in the Halstead-Reitan Neuropsychological Battery, which has been shown to be 90% or more effective in the diagnosis of brain damage. However, this battery is not available to many psychologists or clients because of its length, cost, and the considerable background required to use it properly. The present study tested 121 Ss (30 normal, 91 brain-damaged) to develop an abbreviated version of the battery that is relatively brief (1 hour) and inexpensive, but accurate. It was found by discriminant analysis that the abbreviated battery is capable of diagnosing brain damage equally as well as the full battery 93% of the time. The limitations and advantages of the abbreviated battery are discussed.     

Randomised comparison of combined step-down prednisolone, methotrexate and sulphasalazine with sulphasalazine alone in early rheumatoid arthritis

BACKGROUND: The value of intensive combination therapy in early rheumatoid arthritis is unproven. In a multicentre, double-blind, randomised trial (COBRA), we compared the combination of sulphasalazine (2 g/day), methotrexate (7.5 mg/week), and prednisolone (initially 60 mg/day, tapered in 6 weekly steps to 7.5 mg/day) with sulphasalazine alone. METHODS: 155 patients with early rheumatoid arthritis (median duration 4 months) were randomly assigned combined treatment (76) or sulphasalazine alone (79). Prednisolone and methotrexate were tapered and stopped after 28 and 40 weeks, respectively. The main outcomes were the pooled index (a weighted change score of five disease activity measures) and the Sharp/Van der Heijde radiographic damage score in hands and feet. Independent health-care professionals assessed the main outcomes without knowledge of treatment allocation. FINDINGS: At week 28, the mean pooled index was 1.4 (95% CI 1.2-1.6) in the combined treatment group and 0.8 (0.6-1.0) in the sulphasalazine group (p < 0.0001). At this time, 55 (72%) and 39 (49%) patients, respectively, were improved according to American College of Rheumatology criteria. The clinical difference between the groups decreased and was no longer significant after prednisolone was stopped, and there were no further changes after methotrexate was stopped. At 28 weeks, the radiographic damage score had increased by a median of 1 (range 0-28) in the combined-therapy group and 4 (0-44) in the sulphasalazine group (p < 0.0001). The increases at week 56 (2 [0-43] vs 6 [0-54], p = 0.004), and at week 80 (4 [0-80] vs 12 [0-72], p = 0.01) were also significant. Further analysis suggests that combined therapy immediately suppressed damage progression, whereas sulphasalazine did so less effectively and with a lag of 6 to 12 months. There were fewer withdrawals in the combined therapy than the sulphasalazine group (6 [8%] vs 23 [29%]), and they occurred later. INTERPRETATION: This combined-therapy regimen offers additional disease control over and above that of sulphasalazine alone that persists for up to a year after corticosteroids are stopped. Although confirmatory studies and long-term follow-up are needed, this approach may prove useful in the treatment of early rheumatoid arthritis.