Enthesitis, arthritis, and heel pain

Often, individuals who present with "isolated" heel pain but with normal laboratory findings are dismissed without diagnosis. However, if these patients are carefully questioned and examined, a significant proportion are found to have a spondyloarthropathy. The keys to making this diagnosis are obtaining a thorough medical history and performing a complete physical examination. The classic complaints of back pain and enthesitis in other areas are frequently not reported by patients unless specifically sought, because they are thought to be unrelated to the heel pain.     

Management of psoriatic arthritis

As current techniques for the quantification of bacteria are laborious and often imprecise, instrumental approaches such as sedimentation field-flow fractionation (SdFFF) are attractive. In this technique, fluorogenic dyes specific for nucleic acids are used to identify bacterial cells. Bacterial biomass can be quantified directly with SdFFF if the specific fluorescence of bacterial cells is constant. The effect of different growth conditions on the specific fluorescence of one strain each of Escherichia coli, Pseudomonas aeruginosa, Proteus mirabilis and Staphylococcus epidermidis stained with 4',6-diamidino-2-phenylindole was examined. Specific fluorescence varied over a 500-fold range, from 0.22 to 103 arbitrary fluorescence units per cell. Specific fluorescence was highest when cells were in log phase, and lowest when cells were in stationary phase. Specific fluorescence decreased when cells harvested in log phase were starved for 7 d in a carbon-free minimal medium, and increased rapidly (within 2 h) after cells were relieved from carbon limitation. Such variations in specific fluorescence must be considered when using gross fluorescence as a direct indicator of bacterial numbers in the SdFFF technique for quantifying bacterial biomass. Moreover, they have serious implications for the application of fluorescence techniques in other instrumental approaches for bacterial enumeration in environmental samples.     

Patterns of psoriatic arthritis in Orientals

OBJECTIVE: To determine the clinical features of psoriatic arthritis (PsA) in a multiethnic Oriental population and to study the effect of ethnicity on disease patterns. METHODS: A retrospective study of 80 patients with PsA seen at either a rheumatology or dermatology referral center. Patients and case records were reviewed and data abstracted according to a standard protocol. Eighty consecutive patients with psoriasis without PsA seen at the dermatology center were recruited as controls. RESULTS: Asymmetric polyarthritis developing in the 4th decade with an equal male to female ratio was the commonest pattern of arthritis among Chinese, Indians, and Malays. Clinically apparent lumbar spondylitis was significantly more common in Indians than Chinese (10/11 vs 11/20, respectively; p = 0.046), although the prevalence of lumbar spondylitis was similar in all ethnic groups. Eighty-nine percent of subjects required nonsteroidal antiinflammatory drugs and 51% required disease modifying antirheumatic drugs at some time for control of joint disease. PsA was significantly more common among Indians compared to the ethnic distribution of the Singapore population (p < 0.000001). Multiple logistic regression identified Indian ethnicity as a risk factor for the development of PsA (OR 2.39, 95% confidence interval 1.02 to 5.60). CONCLUSION: The commonest pattern of PsA in all ethnic groups was asymmetric polyarthritis. Ethnicity affected the development and presentation of PsA in our series: Indians with psoriasis had double the risk of developing PsA compared to Chinese with psoriasis, and lumbar spondylitis when present in Chinese subjects was asymptomatic in 45%, being detectable only on radiological examination.     

Corticosteroid prescribing in rheumatoid arthritis and psoriatic arthritis

Embryos from certain mouse strains are arrested at the 2-cell stage in cell culture ('2-cell block'), whereas those from other strains develop to the blastocyst stage under the same conditions. It was previously shown that blocking embryos can be rescued in culture by aggregation with an excess of 2-cell stages of a non-blocking strain such as CBA x C57BL/6 F2. Here we have employed a LacZ transgene in a blocking strain (NMRI) to follow the fate of rescued blastomeres up to the blastocyst stage. We found that rescued blastomeres can participate in both inner cell mass and trophoblast formation, thus completely overcoming the 2-cell block.     

HLA markers and progression in psoriatic arthritis

OBJECTIVE: To investigate whether the addition of all serologically defined HLA antigens to a baseline model further influences the predisposition to disease progression in psoriatic arthritis (PsA). METHODS: Patients with PsA followed prospectively over 19 years were studied. Clinical and laboratory assessments of both active inflammation and clinical damage were performed at 6 month intervals according to a standard protocol. Progression of damage was defined as transition to higher damage states defined by the number of damaged joints. A model that provides estimates of the ratio of transition rates for an individual with the antigen versus one without, and examines the antigen effect on each of the 3 transition rates, was used. HLA antigens were examined in groups by loci under the assumption of common effects across transitions when added to the basic model. The significance levels were examined in comparison with Bonferroni type corrections. Likelihood ratio chi-squared statistics were used as a basis for the significance levels. In total, 292 patients with PsA were included in the study. RESULTS: Only HLA-B22 was added to the original model, which includes HLA-B39, providing risk for progression in early stages, HLA-B27 in the presence of HLA-DR7 providing risk for progression through all states, and DQw3 providing increased risk in the absence of DR7, while in the presence of DR7 it provides "protection." HLA-B22 provides protection from disease progression through all states. CONCLUSION: This study extends our report that HLA antigens serve as markers for disease progression in PsA.     

Posttraumatic elbow arthritis and arthroplasty

Elbow contractures without significant articular injury can be treated with soft-tissue procedures, such as joint capsular releases, resection of heterotropic ossification, and joint debridement. Elbows with significant intra-articular injuries or posttraumatic arthritis require some form of joint reconstruction, such as a distraction arthroplasty, interposition arthroplasty, or implant replacement arthroplasty. With a better understanding of the surgical indications for elbow arthroplasty, improvements in surgical technique, improvements in elbow implants, and increased surgical experience, the results of implant arthroplasty for the posttraumatic elbow continue to improve.     

Interleukin-2 is found in the synovium of psoriatic arthritis and spondyloarthritis, not in rheumatoid arthritis

Many factors have been reported to stimulate the release of brain natriuretic peptide (BNP) as well as atrial natriuretic peptide (ANP). In hypertensive patients, however, little is known about whether these factors differ from those in normotensive subjects or if they are influenced by antihypertensive treatment. We measured the plasma concentrations of BNP and ANP in 12 hypertensive patients and examined the chronic effects of beta-adrenoceptor blockade on BNP secretion during exercise with a bicycle ergometer. The exercise raised both plasma BNP and ANP with concomitant increases in systolic blood pressure, heart rate (HR) and plasma norepinephrine (NE) and epinephrine (Epi) before and after treatment. Before treatment, the changes in ANP and BNP correlated with that in HR (p < 0.05). After treatment 4 wk of treatment, the change in ANP correlated with those in NE and Epi as well as HR. Multivariate regression analysis indicated that only NE was a significant stimulus for ANP secretion during the treatment period. As for BNP, HR was the only significant stimulant for its secretion both before and after treatment. In essential hypertension, beta-adrenergic receptor blockade affected the factors stimulating exercise-induced ANP release but not those stimulating BNP release. BNP release, therefore, seems to be stimulated by similar but distinct factors from those that stimulate ANP release.     

T cell derived cytokines in psoriatic arthritis synovial fluids

OBJECTIVE: The aim of this study was to investigate the concentrations of T cell derived cytokines in the synovial fluids (SFs) of patients with psoriatic arthritis (PsA) in comparison with rheumatoid arthritis (RA) and osteoarthritis (OA). METHODS: Th1 type cytokines (interleukin 2 (IL2), tumour necrosis factor beta (TNF beta), and interferon gamma (INF gamma) and Th2 type cytokines (IL4, IL10) were measured by means of enzyme linked immunosorbent assays. RESULTS: IL2 was usually not detectable in any of the disease groups. TNF beta was found in 3 of 31 PsA SFs (mean (SEM) 11.1 (2.3) pg/ml) and in a significantly lower concentration than in 20 of the 40 RA SFs (42.2 (15.6) pg/ml; p < 0.002). INF gamma was measurable in 2 of 10 PsA and 6 of 16 RA SFs (p > 0.05). IL4 was present at low concentrations in 4 of 22 PsA SFs (0.41 (0.8) pg/ml), and in 15 of 20 RA SFs (0.63 (0.09) pg/ml; p < 0.01). IL10 was found in 4 of 27 PsA SFs (12.3 (0.9) pg/ml) and in 27 of 32 RA SFs (37.3 (4.9) pg/ml; p < 0.0001). In all OA SFs cytokine concentrations were below the limit of detection. CONCLUSION: The pattern of T cell derived cytokines in PsA SFs was similar to that of RA SFs. However, both the frequency and the concentrations of cytokines were lower in PsA SFs than in RA SFs, while OA SFs generally lacked any detectable T cell cytokines altogether. The presence of Th1 and Th2 cell derived cytokines in PsA SFs suggests the presence of activated T cells in the inflamed joint tissues and their participation in the immunoinflammatory events.     

Coexisting psoriatic arthritis, gout, and chondrocalcinosis

BACKGROUND: Constructional impairment following left vs. right hemisphere damage has been extensively studied drawing tasks. A confounding factor in these studies is that right-handed patients with left hemisphere damage (LHD) are often forced by weakness to use their non-dominant (left) hand or hemiparetic dominant hand. Qualitative differences in the drawing characteristics of left and right hand drawings by normal subjects have not previously been characterized. The present study was undertaken to determine the qualitative differences between left and right hand drawings of normal subjects. METHODS: Thirty right-handed, elderly subjects without a history of neurological disease were asked to draw, from memory, seven objects using the right and left hand. Half of the subjects were randomly assigned to draw with the left hand first, and half the right hand first. Right and left hand drawings were compared using a standardized scoring system utilized in several previous studies of drawing in focal and diffuse neurological disease. Each drawing was scored on eighteen criteria. Right and left hand drawing scores were then compared using the t-test for paired samples or the Wilcoxon matched-pairs test. RESULTS: Drawings made using the left hand were found to be significantly simpler, more tremulous and of poorer overall quality than drawings made by the same subjects using the right hand. CONCLUSIONS: The deficits found in left versus right hand drawings of normals are similar to those found in patients with LHD, suggesting that much of the drawing impairment seen following LDH is due to an elementary motor disturbance related to use of the non-dominant hand.     

Serum chemokines in patients with psoriatic arthritis treated with cyclosporin A

OBJECTIVE: To investigate the possible effects of neuropeptide Y on steroid release by human granulosa cells in culture. DESIGN: Prospective study. SETTING: A university laboratory and the division of obstetrics and gynecology in a hospital. PATIENT(S): Sixteen normally ovulating women. INTERVENTION(S): Ovulation induction for IVF-ET with an LH-releasing hormone analogue and gonadotropins. MAIN OUTCOME MEASURE(S): E2 and progesterone were assayed in the media conditioned by granulosa cells with the use of a double-antibody RIA. RESULT(S): Neuropeptide Y stimulates E2 production in a dose-dependent fashion. Preincubation for 3 hours with hCG led to a statistically significant increase in neuropeptide Y-induced E2 secretion. In contrast, whereas 3 hours of preincubation with 10(-7) mol/L of neuropeptide Y did not elicit a statistically significant increase in hCG-induced E2 secretion, coincubation for 48 hours significantly increased hCG-stimulated secretion. Unlike E2, progesterone secretion did not undergo any statistically significant or dose-dependent variation after treatment with neuropeptide Y. CONCLUSION(S): Neuropeptide Y plays a role in human ovarian steroidogenesis directly at the level of the granulosa cells of the follicles in the early stage of luteinization. In this way, neuropeptide Y could play an important role in controlling the positive feedback effect exerted by the ovarian steroids on LH-releasing hormone and gonadotropins in humans.     

Juvenile psoriatic arthritis: followup and evaluation of diagnostic criteria

Platelet counts in newborns are similar to those of adults and children. However, newborn infants admitted to intensive care nurseries have a high prevalence of thrombocytopenia. The mechanisms responsible for the increased susceptibility to thrombocytopenia are not known. In addition, some studies have documented functional abnormalities in newborn platelets. In an effort to understand differences between platelets in newborns and in adults, we examined megakaryocyte ploidy in bone marrow from fetuses and compared it with bone marrow from adults, using a modified Feulgen stain to measure DNA of individual megakaryocytes. Faced with small fixed tissue samples, we developed a technique for use on bone marrow biopsies to estimate megakaryocyte ploidy and compared the results obtained with this method to those obtained from bone marrow aspirates. This study demonstrated that the overall mean ploidy of fetal megakaryocytes is decreased compared with adults. Additionally, fetal megakaryocyte ploidy increases as megakaryocyte maturation increases, but not to the same extent that adult megakaryocyte ploidy increases with megakaryocyte maturation. Over the gestational period studied, there was no relationship between gestational age and mean ploidy. The small size, shift to a less mature population, and decreased ploidy of fetal megakaryocytes indicate that there are differences in the post mitotic phase of megakaryocyte development in the fetus. Such differences may be related to quantitative and qualitative platelet abnormalities in the newborn. Understanding the physiology and regulation of megakaryocytopoiesis in the fetus and newborn will be valuable in determining the pathophysiologic basis of platelet dysfunction in the newborn.     

Antibodies to streptococcal cell wall in psoriatic arthritis and cutaneous psoriasis

Increased intracranial pressure is a risk factor which may result in secondary brain damage, and affect neurological outcome in head injured patients. In case of diffuse brain lesions, elevated intracranial pressure is characterised by two important features. First, it results from vasogenic or cellular oedema, or from an increase in cerebral blood volume. Second, it is strongly associated to biochemical disorders. The latter may be considered as a direct consequence of the initial traumatic impact, mediating factors of the secondary neurological lesion and the biochemical result of cerebral ischaemia. They contribute to increased intracranial pressure and ischaemia by inducing physiological disorders and cell lesions. They also reflect the degree of cerebral ischaemia. Cerebral acidosis, free radicals and excitatory amicoacids are the main biochemical disorders implicated in this vicious circle leading to neuronal death.     

Acute psychoses in patients with psoriatic arthritis during treatment with sulfasalazine

A 10-year-old boy with acute promyelocytic leukemia (APL) was treated with all-trans-retinoic acid (ATRA) at a dose of 60 mg/m2/day. Recombinant erythropoietin was also used. The patient parents and other relatives, all Jehova's Witnesses, refused any type of hemotherapy. After 43 days of ATRA treatment complete remission was obtained without the use of hemotherapy. This case exemplifies the advantages provided by ATRA treatment in APL.     

Arthroscopic synovectomy of the elbow for rheumatoid arthritis. A prospective study

The short-term assessment of 14 arthroscopic synovectomies of the elbow in 11 patients with rheumatoid arthritis showed that 93% achieved a short-term rating of excellent or good on the Mayo Elbow Performance Score. At the most recent assessment at an average of 42 months, however, only 57% maintained excellent or good results; four had required total elbow replacement. Although rehabilitation is facilitated by an arthroscopic procedure the results deteriorate more rapidly than after open synovectomy. This may be due to the limitations of the arthroscopic technique and is consistent with experience of the similar procedure in the knee. Recognition of the short-term gain and the potential for serious nerve injury should be considered when offering arthroscopic synovectomy.     

Measuring health status in psoriatic arthritis: the Health Assessment Questionnaire and its modification

OBJECTIVE: The Health Assessment Questionnaire (HAQ) has proven to be a reliable and valid measure of outcome for a variety of arthritides. A recent modification of HAQ for spondyloarthropathy (HAQ-S) has also been reported. Our purpose was to evaluate the HAQ and HAQ-S as outcome measures in the assessment of patients with psoriatic arthritis (PsA). METHODS: The HAQ, including HAQ-S was administered to all patients attending our Psoriatic Arthritis Clinic between June and December, 1993. Clinical and radiological assessments were performed according to a standard protocol that measures disease activity, fibrositic tender points (TP), disease severity and damage. Analysis was performed using SAS for the PC. RESULTS: The patient population included 114 patients, 70 men and 44 women with a mean age of 49.3 years and a mean arthritis duration of 15.1 years. The mean HAQ score was 0.50, while the mean HAQ-S score was 0.53 (scores range 0 to 3 for this instrument). The overall HAQ and HAQ-S disability scores were highly correlated with several clinical measures of function, including grip strength (r = -0.63 and -0.59, respectively). American College of Rheumatology functional class (r = 0.59 and 0.60, respectively), as well as the number of fibrositic TP (r = 0.54 and 0.57, respectively). These disability scores also correlated highly with the overall number of actively inflamed joints (r = 0.49 and 0.50, respectively); however, they correlated only moderately or poorly with other measures of disease activity such as morning stiffness, total number of joint effusions, erythrocyte sedimentation rate (ESR) and the PASI score for psoriasis and with all measures of disease severity. A similar pattern of correlations was found between the individual subscales of the HAQ and HAQ-S and the clinical measures of function, activity, and severity, as well as between the pain scale and the various clinical measures. However, the correlations are generally lower. CONCLUSION: Our data suggest that HAQ and HAQ-S capture clinical measures of function and pain in PsA but do not correlate with disease severity. The HAQ and its modification for spondyloarthropathy may reflect fibromyaglia as a measure of pain and tenderness in these patients. Thus, the clinical assessment of disease activity and both clinical and radiological assessments of joint damage remain important outcome measures in PsA.     

Sulphasalazine in psoriatic arthritis: a randomized, multicentre, placebo-controlled study

A prospective double-blind, placebo-controlled, randomized study of 24 weeks duration was carried out comparing the efficacy and tolerability of sulphasalazine (SSZ) versus placebo in patients with psoriatic arthritis. A total of 120 patients were included in nine centres. All patients had active disease and fulfilled the criteria of definite psoriatic arthritis of at least 3 months duration. They received either SSZ (2.0 g/day) or placebo. Efficacy variables included pain, patient's overall assessment of joint and skin improvement, morning stiffness, Ritchie articular index, ESR and CRP. An intention-to-treat (ITT) analysis was performed for the 117 patients who qualified (three patients did not qualify due to missing data after baseline). A per-protocol analysis was performed for the 81 patients who completed the 6 months study period (SSZ = 38, placebo = 43). Major reasons for withdrawal were inadequate response (SSZ = 4, placebo = 7) and adverse events (SSZ = 8, placebo = 12). Pain was the only statistically significantly different primary outcome variable at end point in favour of SSZ in the ITT analysis. No significant differences were present in other clinical or biological variables, although there was a trend in favour of SSZ for some variables. SSZ, at a dose of 2.0 g/day, appeared to be a safe treatment in patients with psoriatic arthritis. At this dosage, its efficacy was only demonstrated for the pain variable.     

Comparison of the Health Assessment Questionnaire and Arthritis Impact Measurement Scale in patients with psoriatic arthritis

OBJECTIVE: To determine which of two instruments, the Health Assessment Questionnaire (HAQ) and the Arthritis Impact Measurement Scales (AIMS), was more closely correlated with the main parameters reflecting activity and severity of psoriatic arthritis. METHODS: Both instruments were administered to 72 consecutive patients with psoriatic arthritis. RESULTS: Global HAQ and AIMS scores were closely correlated with each other (rs = 0.747; P < 0.00001). AIMS physical function scales--namely physical activity, dexterity, social activity and activities of daily living--were moderately or closely correlated with the main clinical disease activity parameters, most notably morning stiffness of axial joints (rs = 0.271-0.551). Scales measuring psychological status yielded weaker correlations with disease activity parameters (rs = 0.241-0.277) and were also correlated with the visual analog scale score for skin lesion severity. Morning stiffness of peripheral joints was correlated only with two AIMS scales, namely pain (rs = 0.532) and activities of daily living (rs = 0.303). Severity of radiological damage of peripheral and axial joints was most closely correlated with the scales of physical function, most notably physical activity. The global and scale HAQ scores showed moderate to close correlations with the main clinical disease activity parameters, most notably morning stiffness of axial joints. The global HAQ score was also correlated with radiological carpal involvement and with the radiological severity of peripheral joint involvement, whereas only the arising and hygiene scales were (moderately) correlated with the radiological severity of spinal involvement. CONCLUSION: Although both the HAQ and the AIMS were useful in assessing health status in psoriatic arthritis patients, only the AIMS captured some of the effects of the skin lesions. Our data also suggest that the AIMS may be more effective than the HAQ for evaluating the effect of radiological lesions produced by psoriatic arthritis.