Rheumatoid arthritis: new approaches for its evaluation and management.

Rheumatoid arthritis is a chronic, progressive disease with a long-term outcome characterized by significant morbidity, loss of functional capacity, and increased mortality. The cornerstone of therapy includes the appropriate melding of pharmacological, rehabilitative, and surgical treatments. New developments in the care of patients with rheumatoid arthritis have focused on aggressive pharmacological therapy early in the course of the illness, ongoing assessment of disease activity and patient function, and a better understanding of the role of rehabilitative techniques such as therapeutic exercise and behavioral approaches to education.

Oral lesions in systemic lupus erythematosus. Do ulcerative lesions represent a necrotizing vasculitis?

Background: It has been suggested that oral lesions in patients with systemic lupus erythematosus (SLE) may be grouped clinically as erythema, discoid lesions, or oral ulcerations. Oral ulcerations have been said to foretell a severe systemic disease flare and the proposal that oral ulcers represent a mucosal vasculitis has been suggested to explain this hypothesis.

Objective: Our objective was to test the hypothesis that oral ulcers in patients with SLE result from vasculitis.

Musculoskeletal chest wall syndromes in patients with noncardiac chest pain: a study of 100 patients.

One hundred patients with chest pain and negative coronary arteriography were evaluated for musculoskeletal chest wall findings. Sixty-nine patients had chest wall tenderness. Typical chest pain was evoked by palpation in 16 patients.

Osteoarthritis of the knee: effects on gait, strength, and flexibility.

This study examined the differences in gait mechanics, isokinetic knee strength, and flexibility between a group of adults with symptomatic osteoarthritis (OA) of the knee (n = 15) and an age-, mass-, and gender-matched group of control subjects (n = 15). Both groups performed under similar environmental conditions. Our results suggest that patients with symptomatic OA of the knee have poorer flexibility in both the affected and unaffected legs and demonstrate significantly less (p less than .

Detection of anti-neutrophil cytoplasmic autoantibodies using the promyelocytic HL-60 cell-line.

IgG autoantibodies against antigen in the cytoplasm of cells of the neutrophil-monocyte cell lineage have been found in the sera of patients with Wegener's granulomatosis (WG). The indirect immunofluorescence test (IFT) is proving to be a valuable screening test for these antibodies, but obtaining neutrophils for substrate is time-consuming, and interpretation of the fluorescence patterns in ethanol-fixed cells requires considerable experience. We report an improved IFT using HL-60 cells as substrate.

Vasculitis. A practical approach to management.

Vasculitis encompasses a wide variety of diseases. Because diagnosis may be difficult, a careful evaluation is essential, including a detailed patient history, thorough physical examination, and appropriate laboratory studies. Diagnosis is based on clinicopathologic features that permit identification of the condition.

Clinical evaluation of radiographic progression in rheumatoid arthritis.

Four rheumatologists and 2 radiologists utilized 3 reading techniques to evaluate clinical radiographic progression in selected serial hand and wrist films from 5 rheumatoid arthritis patients. The carpometacarpal radio determinations were the most internally consistent; global assessment and total erosion + joint space narrowing scores showed the best between-method correlations; and the erosion + joint space narrowing scores depicted most sensitively the progression over time which was not affected by immunomodulating agent or non-steroidal anti-inflammatory agent therapy. In this study, instructed, non-experienced readers detected rheumatoid radiographic progression utilizing readily available scoring techniques.

Therapeutic exercise for rheumatoid arthritis and osteoarthritis.

Therapeutic exercise in rheumatoid arthritis and osteoarthritis may be useful in improving aerobic capacity, strengthening muscles, improving endurance and increasing flexibility. This article reviews the major studies of exercise in these conditions and summarizes the authors recommendations regarding the use of therapeutic exercise in the treatment of rheumatoid arthritis osteoarthritis.

An unusual manifestation of Paget's disease of bone: spinal epidural hematoma presenting as acute cauda equina syndrome.

Neurologic sequelae of Paget's disease of bone include involvement of the spinal cord or cauda equina due to mechanical compression by enlarged vertebrae, ischemia caused by a spinal artery, steal syndrome or neoplasm. We describe a patient with Paget's disease of bone who presented with acute cauda equina syndrome due to a spinal epidural hematoma. Clinicians need to recognize this entity since surgical intervention may result in a favorable outcome.

Prostaglandins in the gut and their relationship to non-steroidal anti-inflammatory drugs.

Prostaglandins are long-chain, saturated, oxygenated fatty acids. Relatively large quantities of prostaglandins have been found in gut mucosa, suggesting that these substances play an important role in gastrointestinal physiology. Non-steroidal anti-inflammatory drugs (NSAIDs) cause damage to the gastric, intestinal, and colonic mucosa in experimental animals and in humans.

Rheumatoid papules: lesions showing features of vasculitis and palisading granuloma.

Whether palisading granuloma formation occurs with leukocytoclastic vasculitis in rheumatoid nodules and in histopathologically similar conditions is debatable. Patients with high titers for rheumatoid factor and severe erosive rheumatoid arthritis are at risk for both rheumatoid vasculitis and rheumatoid nodules. A patient with all of these features developed a papular eruption.

Magnetic resonance imaging of the craniovertebral junction in rheumatoid arthritis.

Conventional radiography and magnetic resonance imaging (MRI) of the craniovertebral junction were evaluated in 12 patients with longstanding rheumatoid arthritis (RA) and neck pain with or without other neurologic signs or symptoms of cervical myelopathy. MRI demonstrated abnormal soft tissue masses thought to represent pannus in 9 patients. Three patients showed cord or brainstem compression due to pannus or atlantoaxial subluxation.

Fibrositis.

Fibrositis is a common clinical syndrome characterized by diffuse musculoskeletal pain and multiple tender points on physical examination. The symptoms wax and wane but do not produce severe disability. Although no single treatment is curative, a comprehensive program of patient education, drug therapy and appropriate physical activity is beneficial in many patients.

Comparison of parotid and minor salivary gland biopsy specimens in the diagnosis of Sjögren's syndrome.

We conducted a prospective study comparing minor salivary gland and parotid gland biopsy specimens obtained simultaneously from 24 patients who were undergoing evaluation for primary Sjögren's syndrome (SS). Adequate tissue for study was obtained with all minor salivary gland biopsies and 19 of 24 parotid gland biopsies. Parotid inflammation was seen in 6 of 11 patients whose minor salivary gland biopsy results indicated SS, but in none of 8 patients who had normal findings on minor salivary gland biopsy.

Prediction of pain behavior and functional status of rheumatoid arthritis patients using medical status and psychological variables.

This study examined the extent to which the psychological variables of depression, anxiety, and helplessness predicted the pain behavior and functional status of 64 rheumatoid arthritis (RA) patients beyond what could be predicted on the basis of demographic and medical status variables. Pain behavior was evaluated using a standardized observation method, and functional status was assessed using a modified Health Assessment Questionnaire (MHAQ) and rheumatologists' ratings. Regression analyses revealed that a modified rheumatoid activity index and/or disease duration were significant predictors of levels of guarding, rigidity, and total pain behavior.

Chest pain: a rheumatologist's perspective.

Chest pain is a frequent patient complaint that requires a careful history and physical examination to determine its cause. Cardiac and esophageal causes of chest pain are common, but musculoskeletal disorders such as Tietze's syndrome, chest wall pain syndromes, fibrositis, inflammatory arthritic conditions, cervical osteoarthritis, and disease of the thoracic spine may also result in chest pain. Musculoskeletal diseases must be differentiated from other causes of chest pain, since specific treatment of these rheumatic conditions often produces good results.

Effects of psychological therapy on pain behavior of rheumatoid arthritis patients. Treatment outcome and six-month followup.

A randomized clinical trial was performed to evaluate a psychological treatment intervention and a social support program, compared with a control program in which no adjunct treatment was rendered, and their effects upon pain behavior, affect, and disease activity of 53 patients with rheumatoid arthritis. The psychological intervention produced significant reductions in patients' pain behavior and disease activity at posttreatment. Significant reductions were also observed in trait anxiety at posttreatment and 6-month followup.

Sucralfate treatment of nonsteroidal anti-inflammatory drug-induced gastrointestinal symptoms and mucosal damage.

In a randomized, double-blind trial, sucralfate therapy, 1 g four times daily, was compared with placebo in 143 symptomatic patients to assess the treatment of gastrointestinal symptoms and gastric mucosal damage associated with nonsteroidal anti-inflammatory drugs (NSAIDs). All patients followed a fixed regimen of NSAIDs, were assigned to one of two groups based on the presence or absence of gastric erosions at baseline endoscopy, and were then assigned randomly to receive sucralfate or placebo for four weeks. Patients were then followed for up to six months while receiving open-label sucralfate 1 g twice daily to up to 1 g four times daily.

Human parvovirus B19 arthropathy in two adults after contact with childhood erythema infectiosum.

An arthropathy has been recently described in association with human parvovirus infection (HPV-B19). Human parvovirus B19 has also been implicated as the etiologic agent in erythema infectiosum, a childhood exanthem that may occur in adults in association with joint manifestations. In this study, two adults are described, in whom an acute arthropathy and rash developed after contact with children with erythema infectiosum.

Clinical and genetic characteristics of upper gastrointestinal disease in rheumatoid arthritis.

Clinical and genetic studies were analyzed in 47 patients with rheumatoid arthritis (RA) who had upper gastrointestinal (GI) endoscopies. Fifty-three percent of patients with RA had peptic ulcers and/or erosions. Sixty percent of patients with ulcers and/or erosions had a history of peptic ulcer disease.

NSAID-induced gastric mucosal damage.

Gastric mucosal damage is a common side effect of nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs may cause gastrointestinal symptoms, gastric erosions, peptic ulcers or upper gastrointestinal bleeding. Therefore, NSAIDs should be used cautiously in patients with a history of gastrointestinal lesions.

Analysis of combined rheumatoid factor determinations by the rheumatoid arthritis latex and sheep cell agglutination tests and the American Rheumatism Association criteria for rheumatoid arthritis.

The clinical records of randomly selected patients receiving both the sheep cell agglutination test (SCAT) and the latex agglutination test (RA latex) for rheumatoid factor (RF) were analyzed for the presence of American Rheumatism Association (ARA) criteria for rheumatoid arthritis (RA). When both tests were positive there was a 3-fold increase compared to only one test positive in the relative risk that a patient met ARA criteria for RA, and there was a 2-fold increase in the probability that a patient with 2 positive tests had classical RA compared to only a positive RA latex. The occurrence of RF reactive with both human and rabbit IgG identifies a population of patients likely to have more ARA criteria for RA and classical disease.

The assessment of pain in rheumatoid arthritis. Validity of a behavioral observation method.

It is difficult to objectively measure pain in rheumatoid arthritis (RA). A behavioral observation method for the assessment of RA pain has been developed. In this study, videotapes were made of 53 RA patients while they performed standardized maneuvers.