Magnetic resonance imaging of soft tissue and cystic masses about the knee

Magnetic resonance imaging (MRI) of the knee is the most frequently performed joint MRI examination. The use of MRI has revolutionized assessment of both intra-articular and periarticular musculoskeletal masses about the knee and has largely supplanted other radiologic methods of evaluation. The purpose of this article is to review the MRI appearance of the numerous types of soft-tissue and cystic masses that arise about the knee.     

Clinical and radiographic evaluation of juvenile rheumatoid arthritis: report of a case

Rheumatoid arthritis (RA) is an inflammatory disease of the synovium which may lead to proliferative and degenerative changes in the body's joints, including the temporomandibular joint (TM Joint). Although the exact etiology of rheumatoid arthritis remains unknown, it is suspected that the disease is often initiated by an infectious organism, or by genetic and/or environmental factors. Juvenile rheumatoid arthritis (JRA) is a chronic disease of childhood with a spectrum of joint involvement and associated systemic and other organ involvement. Five percent of all rheumatoid arthritis patients are children. In the United States, approximately 150,000 children are affected by JRA. With upper limb involvement, routine oral hygiene procedures become difficult. Dental evaluations/screenings may not be included in the initial team assessment of these patients until the TM Joint is affected; however, prior to this time, the patient may have had years of poor oral hygiene which could contribute to severe decay and early tooth loss. This case report describes the oral health status of a child with polyarticular juvenile rheumatoid arthritis and the specific recommendations for dental management.     

Morphological changes in chest radiographs of patients with acute respiratory distress syndrome (ARDS)

The value of ultrasonography (US), magnetic resonance imaging (MRI), computed tomography (CT) and plain radiography (PR) in detecting bone erosions on the humeral head was evaluated in a study of 26 in-patients (26 shoulders) with rheumatoid arthritis (RA). MRI depicted humeral erosions in 25 (96%), US in 24 (92%), CT in 20 (77%) and PR in 19 (73%) of the 26 shoulders. MRI and US were superior to CT in detecting small erosions. US was the most sensitive method to show surface erosions on the greater tuberosity. US, CT and MRI detected large erosions quite similarly. PR frequently missed small erosions. In the evaluation of early erosions in the rheumatoid shoulder, US and MRI are more sensitive methods than the traditionally used PR. US and MRI are suitable for the evaluation of soft-tissue involvement in the rheumatoid shoulder, but also for the detection of bone erosions of the humeral head.     

Detection of Aeromonas hydrophila serogroup 0:34 in faeces using an enzyme-linked immunosorbent assay

The efficacy of gadopentetate dimeglumine (Gd-DTPA) enhanced magnetic resonance (MR) imaging in the diagnosis and differentiation of soft-tissue, neoplastic and non-neoplastic lesion has not been well established. Thirty patients with soft tissue masses (18 neoplastic and 12 non-neoplastic) were studied, using MR imaging with and without administration of Gd-DTPA. Gd-DTPA proved helpful in characterisation of several entities, including differentiation of solid mass from proteinaceous cyst, demonstration of tumour nodules within haemorrhagic or necrotic masses, and delineation of tumour adjacent to oedema. The use of Gd-DTPA may provide additional information for tissue specificity and, in complicated cases, Gd-DTPA may also provide essential information that cannot be obtained using other methods. We recommend the use of contrast enhanced MR as an adjunct to conventional MR imaging in the initial assessment of musculoskeletal soft tissue masses. However, T2-weighted images show better tissue contrast of the lesions, and are equal to contrast enhanced images in delineation of tumour margins. Non-contrast enhanced images are, therefore, probably adequate for the delineation of lesions for surgical planning when a diagnosis has already been made.     

Fullerene lipids: synthesis of dialkyl 1,2-[6,6]-methano-[60]-fullerene dicarboxylate derivatives

OBJECTIVE: To determine the prevalence of chronic arthritis with special reference to rheumatoid arthritis. METHOD: A cross-sectional study was performed during the years 1990 and 1991 in a randomly selected sample of the urban population of Belgrade. RESULTS: Out of 2184 participants, > or = 20 yr old, surveyed by questionnaire, 756 (34.6%) reported peripheral joint complaints. Of those with complaints, 621 (82.1%) agreed to undergo detailed examination. Arthritis was diagnosed in four men (one had rheumatoid arthritis and three had spondylarthropathy with peripheral arthritis) and 11 women (three had rheumatoid arthritis, one had B27-positive polyarthritis and seven had undifferentiated chronic arthritis). The prevalence of chronic arthritis in the adult population was 0.69% (0.35% for men and 1.05% for women). The prevalence for rheumatoid arthritis was 0.18% (0.09% for men and 0.29% for women). Re-examination of 15 individuals with chronic arthritis 3 yr later showed changes in diagnosis only in those patients who at baseline examination had undifferentiated chronic arthritis. CONCLUSION: According to the results obtained, the urban population of Belgrade is among populations with a low prevalence of rheumatoid arthritis.     

Incidence of rheumatoid arthritis in Finland during 1980-1990

OBJECTIVE: To obtain information on the incidence of rheumatoid arthritis and on its recent trends in Finland. METHODS: The study covered those subjects entitled to receive specially reimbursed medication for rheumatoid arthritis under the nationwide sickness insurance scheme in five out of 21 central hospital districts in Finland (population basis about one million adults) during three years: 1980, 1985, and 1990. RESULTS: The annual incidence of rheumatoid arthritis in 1980 and 1985, satisfying the American Rheumatism Association 1987 classification criteria, was 39/100,000 of the population > or = 16 years of age. The combined incidence of rheumatoid factor (RF) positive arthritis and RF negative polyarthritis was 46/100,000. A decline of approximately 40% occurred in the number of RF negative rheumatoid arthritis cases in 1990 compared with the earlier years. The declining trend was statistically significant (P = 0.008). CONCLUSION: The decline in incidence of RF negative rheumatoid arthritis in Finland may reflect changes in the environment specifically affecting the risk of RF negative disease.     

Is day care equivalent to inpatient care for active rheumatoid arthritis? Randomised controlled clinical and economic evaluation

OBJECTIVE: To test the clinical equivalence and resource consequences of day care with inpatient care for active rheumatoid arthritis. DESIGN: Randomised controlled clinical trial with integrated cost minimisation economic evaluation. SETTING: Rheumatic diseases unit at a teaching hospital between 1994 and 1996. SUBJECTS: 118 consecutive patients with active rheumatoid arthritis randomised to receive either day care or inpatient care. MAIN OUTCOME MEASURES: Clinical assessments recorded on admission, discharge, and follow up at 12 months comprised: the health assessment questionnaire, Ritchie articular index, erythrocyte sedimentation rate, hospital anxiety and depression scale, and Steinbrocker functional class. Resource estimates were of the direct and indirect costs relating to treatment for rheumatoid arthritis. Secondary outcome measures (health utility) were ascertained by time trade off and with the quality of well being scale. RESULTS: Both groups had improvement in scores on the health assessment questionnaire and Ritchie index and erythrocyte sedimentation rate after hospital treatment (P < 0.0001) but clinical outcome did not differ significantly between the groups either at discharge or follow up. The mean hospital cost per patient for day care, 798 Pounds (95% confidence interval 705 Pounds to 888 Pounds), was lower than for inpatient care, 1253 Pounds (1155 Pounds to 1370 Pounds), but this difference was offset by higher community, travel, and readmission costs. The difference in total cost per patient between day care and inpatient care was small (1789 Pounds (1539 Pounds to 2027 Pounds) v 2021 Pounds (1834 Pounds to 2230 Pounds)). Quantile regression analysis showed a cost difference in favour of day care up to the 50th centile (374 Pounds; 639 Pounds to 109 Pounds). CONCLUSIONS: Day care and inpatient care for patients with uncomplicated active rheumatoid arthritis have equivalent clinical outcome with a small difference in overall resource cost in favour of day care. The choice of management strategy may depend increasingly on convenience, satisfaction, or more comprehensive health measures reflecting the preferences of patients, providers, and service commissioners.     

Fine needle aspiration of soft-tissue lesions

The heterogeneity of soft-tissue neoplasms constantly challenges the diagnostic skills of pathologists. Fine needle aspiration biopsy (FNAB) cytology can provide a quick and relatively safe assessment of soft-tissue masses and can significantly contribute to patient management. This article illustrates the FNAB cytologic features of the most commonly encountered soft tissue lesions and discusses their differential diagnoses.     

Efficacy and safety of leflunomide compared with placebo and sulphasalazine in active rheumatoid arthritis: a double-blind, randomised, multicentre trial. European Leflunomide Study Group

BACKGROUND: Phase II trials of leflunomide, an inhibitor of de-novo pyrimidine synthesis, have shown efficacy in rheumatoid arthritis. This double-blind randomised trial compared leflunomide with placebo and sulphasalazine in active rheumatoid arthritis. METHODS: 358 patients were randomly assigned leflunomide (100 mg daily on days 1-3, then 20 mg daily), placebo, or sulphasalazine (0.5 g daily, titrated progressively to 2.0 g daily at week 4). The primary endpoints were tender and swollen joint counts and investigator's and patient's overall assessments. Analyses were by intention to treat. FINDINGS: The mean changes in the leflunomide, placebo, and sulphasalazine groups were -9.7, -4.3, and -8.1 for tender joint count; -7.2, -3.4, and -6.2 for swollen joint count; -1.1, -0.3, and -1.0 for physician's overall assessment; and -1.1, -0.4, and -1.1 for patient's overall assessment. Leflunomide and sulphasalazine were significantly superior to placebo (p=0.0001 for joint counts; p<0.001 for assessments). Radiographic disease progression was significantly slower with leflunomide and sulphasalazine than with placebo (p<0.01). Most common adverse events with leflunomide were diarrhoea (17%), nausea (10%), alopecia (8%), and rash (10%). Transiently abnormal liver function was seen in three leflunomide-group patients and five sulphasalazine-group patients. There were two cases of reversible agranulocytosis in the sulphasalazine group. INTERPRETATION: Leflunomide was more effective than placebo in treatment of rheumatoid arthritis and showed similar efficacy to sulphasalazine. Leflunomide was well tolerated. This drug may be a useful option as a disease-modifying antirheumatic drug.     

Recent advances and future directions in the biopsychosocial assessment and treatment of arthritis.

This article provides an overview of the emerging literature on biopsychosocial assessment and treatment for two of the most common forms of arthritis: osteoarthritis and rheumatoid arthritis. The article is divided into 3 parts. In the 1st part, the basic elements of the biopsychosocial approach to assessing and treating persons having arthritis is described. In the 2nd part the authors evaluate studies of biopsychosocial approaches to the assessment of arthritis pain and disability. Six research areas are reviewed: learned helplessness, depression, stress, pain coping, self-efficacy, and the social context of arthritis. The 3rd part of the article reviews studies that testing the efficacy of biopsychosocial treatment approaches for persons having osteoarthritis and rheumatoid arthritis. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

2 clinico-genetic types of primary congenital glaucomas in Slovakia

We studied transketolase activity of red blood cell hemolysates, and Na+, K+, ATPase activity and sialic acid concentration in red blood cell membranes from 52 patients with rheumatoid arthritis and 24 control subjects. Decreased red blood cell membrane Na+, K+, ATPase activity and sialic acid concentration and decreased transketolase in red blood cell hemolysates were observed in rheumatoid arthritis patients compared with control subjects (p < 0.001). Erythrocyte sedimentation rate and C-reactive protein values were increased in rheumatoid arthritis patients compared with control subjects (p < 0.0001). Significant correlations between sialic acid and Na+, K+, ATPase (r = 0.65, p < 0.001) and between sialic acid and transketolase (r = 0.58, p < 0.001) were observed. Erythrocyte sedimentation rate and C-reactive protein levels did not correlate with Na+, K+, ATPase activity or with sialic acid or transketolase in rheumatoid arthritis patients. These data show that decreases in Na+, K+, ATPase, and transketolase activities and sialic acid concentration are present in rheumatoid arthritis patients, and that the decrease in Na+, K+, ATPase and transketolase activities in rheumatoid arthritis might be due to decreased sialic acid.     

Modulation of the immunologic response to acute stress in humans by beta-blockade or benzodiazepines

Autoantibodies against heat shock protein (hsp) 60 have been reported to be detected in sera of non-obese diabetic mice, in an experimental model of IDDM. However, there are only a few studies which have examined IDDM patients for antibodies against mammalian hsp60. We produced murine hsp60 derived from pancreatic beta cells which has high homology to human hsp60 and examined antibodies against the hsp60 in IDDM patients using an enzyme-linked immunosorbent assay. We extended the analysis to patients with other immune-mediated diseases and non-insulin-dependent diabetes mellitus (NIDDM). Positive sera for hsp60 antibody were more frequently detected in 13 out of 84 IDDM (15.5%) and 5 out of 25 rheumatoid arthritis patients (20%), when compared to healthy subjects (1/85; 1.2%, P < 0.001 and P < 0.01, respectively). The levels of hsp60 antibodies of IDDM (0.218 +/- 0.227) and rheumatoid arthritis patients (0.259 +/- 0.191) were significantly higher than those of healthy subjects (0.076 +/- 0.131, P < 0.001, P < 0.01, respectively). Patients with slowly progressive IDDM (n = 26), autoimmune thyroid disease (n = 42), or NIDDM (n = 40) had levels of hsp60 antibodies similar to those in healthy subjects. We found no relationship between the levels of hsp60 antibodies and islet cell antibodies (ICA) or antibodies to glutamic acid decarboxylase (GAD65) in IDDM patients. In conclusion, hsp60 antibodies were detected in Japanese IDDM as well as in rheumatoid arthritis patients. Although the positivity was low, the detection of hsp60 antibodies may be helpful for diagnosis of IDDM especially in GAD65 Ab- or JCA-negative Japanese patients.     

Indications and methods for compression distraction osteosynthesis (author''s transl)

The roentgen appearance and pathogenesis of carpal instability are described in an evaluation of patients and cadavers with rheumatoid arthritis and calcium pyrophosphate deposition disease. Dorsiflexion (16%) and palmar flexion (8%) instability occurs in rheumatoid arthritis, particularly in patients with moderate to advanced disease. Navicular-lunate dissociation frequently accompanies dorsiflexion instability and results from involvement of the interosseous ligament between the two bones by rheumatoid pannus. Carpal instability and navicular-lunate dissociation also accompany pyrophosphate arthropathy, resulting from calcific deposition and cystic degeneration of ligamentous structures.     

Chronic arthritis and carpo:metacarpal ratio in Japanese patients with adult Still's disease

OBJECTIVE: To characterize Japanese patients having adult Still's disease (ASD) with chronic arthritis (> 6 months) and to examine the association of chronic arthritis with carpo:metacarpal ratio (CMC ratio), an index of radiographic progression in rheumatoid arthritis (RA). METHODS: Twenty-seven patients with ASD (16 women and 11 men, mean age at disease onset 27.7 years) were classified into 2 groups: patients with (chronic articular ASD, 16 patients, 59%) or without (systemic ASD, 11 patients, 41%) chronic arthritis. Clinical and laboratory findings were compared between both groups. CMC ratio was calculated on serial hand radiographs in patients with chronic articular ASD. RESULTS: In our series, serositis was rarely observed in chronic articular ASD. Peripheral arthritis (including transient arthritis), such as metacarpophalangeal, proximal interphalangeal, or ankle joint, was more frequently observed in chronic articular ASD than in systemic ASD (p < 0.05). Wrist arthritis was frequently observed also in systemic ASD; however, joint space narrowing of carpometacarpal or intercarpal joints was recognized only in chronic articular ASD (44%). CMC ratio at the last observation in 14 patients with chronic articular ASD was significantly decreased (0.526 +/- 0.039) compared to that at disease onset (0.553 +/- 0.034) (p < 0.05), while no decrease was observed in 4 with systemic ASD (0.565 +/- 0.062 at disease onset, 0.563 +/- 0.043 at the last observation). CONCLUSION: It is suggested that chronic articular ASD has certain characteristics. CMC ratio may be a quantitative index for assessment of radiographic changes of carpal joints, not only in RA but also in chronic articular ASD.     

Heart tumors

Tumors of the heart are very rare. Due to the nonspecific clinical presentation the diagnosis is usually made by radiological procedures. Cardiac myxomas and thrombi are the most common cardiac masses. Two-dimensional echocardiography is the method of choice for the initial evaluation of cardiac tumors, because it permits the accurate determination of the tumor's size, localization, point of attachment, mobility and haemodynamic significance. Inadequate or nondiagnostic ultrasound examination and the need for preoperative assessment are indications for further examinations, such as magnetic resonance imaging (MRI) and computed tomography. Both these methods are helpful in the assessment of paracardiac structures and of the tumor invasion into great vessels and the mediastinum. MRI allows a limited degree of assessment of whether or not the tumor is malignant by soft tissue characterization. In the case of resectable, symptomatic, cardiac tumors surgical excision should be performed.     

Inhibitors of branched-chain amino acid biosynthesis as potential antituberculosis agents

Previous studies have shown that rheumatoid arthritis aggregates within families. However, no formal genetic analysis of rheumatoid arthritis in pedigrees together with other autoimmune diseases has been reported. We hypothesized that there are genetic factors in common in rheumatoid arthritis and other autoimmune diseases. Results of odds-ratio regression and complex segregation analysis in a sample of 43 Caucasian pedigrees ascertained through a rheumatoid arthritis proband or matched control proband, revealed a very strong genetic influence on the occurrence of both rheumatoid arthritis and other autoimmune diseases. In an analysis of rheumatoid arthritis alone, only one inter-class measure, parent-sibling, resulted in positive evidence of aggregation. However, three inter-class measures (parent-sibling, sibling-offspring, and parent-offspring pairs) showed significant evidence of familial aggregation with odds-ratio regression analysis of rheumatoid arthritis together with all other autoimmune diseases. Segregation analysis of rheumatoid arthritis alone revealed that the mixed model, including both polygenic and major gene components, was the most parsimonious. Similarly, segregation analysis of rheumatoid arthritis together with other autoimmune diseases revealed that a mixed model fitted the data significantly better than either major gene or polygenic models. These results were consistent with a previous study which concluded that several genes, including one with a major effect, is responsible for rheumatoid arthritis in families. Our data showed that this conclusion also held when the phenotype was defined as rheumatoid arthritis and/or other autoimmune diseases, suggesting that several major autoimmune diseases result from pleiotropic effects of a single major gene on a polygenic background.     

Superficial soft-tissue masses suggestive of recurrent malignancy: sonographic localization and biopsy

OBJECTIVE: We investigated the usefulness of high-resolution sonography to localize superficial soft-tissue masses and to guide needle sampling for recurrent malignancy. MATERIALS AND METHODS: High-resolution sonography (10-MHz) was used to locate and guide needle sampling of 16 palpable and eight impalpable superficial masses suggestive of recurrent malignancy in 23 patient (12 men, 11 women; 34-85 years old). After detection, 22 (92%) of the masses were immediately sampled by fine-needle aspiration with 18- to 25-gauge needles and two (8%) were sampled by a 20-gauge core gun. RESULTS: Diagnostic material was obtained without complication from all 24 masses and proved positive for recurrent disease in 13 (54%). Ten (63%) of 16 palpable and three (38%) of eight impalpable masses proved positive for recurrent malignancies. One third of superficial soft-tissue masses were detected by imaging only, and of the masses not revealed on imaging, three (23%) of 13 were the site of first recurrence. Most nonnodal superficial masses (8/13) were benign, unlike the lymph nodes, of which three (27%) of 11 were benign. CONCLUSION: Not all early recurrent malignancies within the skin and subcutaneous tissues are detected by clinical examination. High-resolution sonography provided us with a rapid, safe, and accurate means of localizing and then guiding needle biopsies of superficial soft-tissue masses suggestive of recurrent malignancy.     

CRP levels in autoimmune disease can be specified by measurement of procalcitonin

Autoimmune diseases (AID) are prone to infection particularly under immunosuppression. The differentiation of infection from active AID is often difficult. In order to specify the diagnostic value of measurement of procalcitonin (PCT) in AID 81 patients with anti-neutrophil cytoplasmic antibody (ANCA)-positive vasculitis were analyzed, 27 with rheumatoid arthritis and 25 patients with systemic lupus erythematosus at various stages of the disease. Although PCT levels (95th percentile) were below 0.5 ng/ml in patients with active systemic lupus erythematosus and rheumatoid arthritis, the cutoff for normal values (95th percentile) in patients with active ANCA-positive vasculitis was 0.89. Therefore PCT levels of < 1 ng/ml are recommended as cutoff for invasive infections in patients with ANCA-positive vasculitis. In view of the increased mortality under immunosuppression in patients with AID and additional bacterial infection the measurement of PCT is helpful when an infectious origin is suspected.     

How to evaluate measuring methods in the case of non-defined external validity

In the clinical routine of chronic diseases, a new measurement has to be compared to an established criterion to see whether there is agreement on assessing disease progress. Because of the nonexistence of established criteria for rheumatoid arthritis the evaluation of grading systems for radiological assessment needs an alternative approach. Using the measurement error as a measure for repeatability and rater agreement in comparison to the progress of the grading score might be a solution to this dilemma.     

The effects of anti-rheumatoid drugs on the in vitro activity of human serum hyaluronidase

Fourteen antirheumatoid drugs were tested for their effects on the in vitro hyaluronidase activity of normal human serum. Four drugs produced significant changes in enzyme activity. Different results were obtained with ovine testicular hyaluronidase when diluted with either saline or inactivated human serum. No increase in serum hyaluronidase activity was found in patients with rheumatoid arthritis. There was no evidence for the existence of tissue specific isoenzymes of hyaluronidase in the serum of either normal subjects or patients with rheumatoid arthritis.