Clinical navigation for beginners: the clinical utility and safety of the Paramedic Pathfinder.

Background: English Ambulance Services are faced with annual increases in emergency demand. Addressing the demand for low acuity emergency calls relies upon the ability of ambulance clinicians to accurately identify the most appropriate destination or referral pathway. Given the risk of undertriage, the challenge is to develop processes that can safely determine patient dispositions, thereby increasing the number of patients receiving care closer to home.

Inflammatory osteoarthritis which was precipitated by Arimidex and resolved with tamoxifen.

We report the case of a 51-year-old woman who presented with an inflammatory flare of osteoarthritis of the small joints of her hands occurring in a temporal relationship with the commencement of Arimidex, prescribed to reduce systemic oestrogen levels to treat breast cancer. Following the cessation of Arimidex and the initiation of tamoxifen, a specific oestrogen receptor antagonist, this flare resolved. It has long been observed that during the menopause, as oestrogen levels decline, many women develop osteoarthritis or experience progression of the disease.

Panniculitis, arthritis and pancreatitis.

Subcutaneous fat necrosis is seen in 2% of patients with pancreatic disorders and may predate clinical symptoms by up to 3 weeks. Furthermore, 2% of cases of acute pancreatitis are clinically silent. Therefore, the differential diagnosis is extensive and the definitive diagnosis is evasive.

The association of HLA DR beta alleles with self-limiting and persistent forms of early symmetrical polyarthritis.

RA is associated with a group of class II DR beta alleles, which share a conserved sequence in the third allelic hypervariable region (3AHVR). These include the DR4 subtypes Dw4, Dw14 and Dw15, and also DR1. In contrast Dw10 and Dw13 which are also DR4 subtypes show no association with RA and have a quite distinct 3AHVR.

Differentiating persistent from self-limiting symmetrical synovitis in an early arthritis clinic.

Early rheumatoid arthritis (RA) must be differentiated from benign self-limiting polyarthritis because of the risks associated with treatment of RA. Conventional, widely available clinical and laboratory variables, measured at first clinic visit, were studied for their ability to predict persistence in 112 patients with up to 6 months of joint symptoms. Those 65 patients with symmetrical peripheral polyarthritis were followed for 1 year: 36 who underwent spontaneous remission were classified self-limiting synovitis (SLS); the remaining 29 were termed persistent synovitis (PS).

Genetically determined factors as predictors of radiological change in patients with early symmetrical arthritis.

Objective: To determine whether genetic factors associated with established rheumatoid arthritis could, in combination with rheumatoid factor, predict the development of radiological erosions in patients with early symmetrical (rheumatoid-like) arthritis.

Design: Prospective study.

Setting: Teaching hospital, early arthritis clinic.

Genetic factors influencing the outcome of early arthritis--the role of sulphoxidation status.

A minority of individuals have an impaired ability to oxidize sulphur. An increased prevalence of this poor S-oxidation capacity has been observed in patients with established rheumatoid arthritis (RA). The role of this enzyme system in the development of disease was studied by testing the S-oxidation capacity of 54 patients with recent onset symmetrical poly-arthritis, who were followed up at 1 and 4 years.

Immunodeficiencies associated with sulphasalazine therapy in inflammatory arthritis.

Abnormalities in serum immunoglobulin levels (Igs) are documented in a series of 350 patients with rheumatoid arthritis (RA) and other inflammatory joint diseases treated with sulphasalazine (SASP) for up to 10 years. Low Ig levels occurred in just over 10% of patients after therapy. Three per cent developed selective IgA deficiency between 8 and 20 weeks after starting SASP.

Qualitative and quantitative expression of VHI associated cross reactive idiotopes within IgM rheumatoid factor from patients with early synovitis.

Monoclonal rheumatoid factors (RFs) of the major Wa cross reactive idiotype group have been shown to express exclusively VKIII subgroup light chains and VHI subgroup heavy chains. A VKIII associated cross reactive idiotope (CRI) (17-109), however, was shown not to be exclusively expressed on IgM paraproteins having rheumatoid factor activity or to be present at increased levels in the sera of patients with rheumatoid arthritis (RA). Three VHI associated CRIs have been defined with monoclonal antibodies and quantitative studies of their representation are reported, together with VKIII, in IgM and IgM RF isolated from the sera of patients with early synovitis, some of whom progressed to classical RA.

Combination therapy with gold and hydroxychloroquine in rheumatoid arthritis: a prospective, randomized, placebo-controlled study.

We studied combination therapy with two slow-acting antirheumatic drugs given concurrently in active rheumatoid arthritis (RA). A 12-month prospective randomized controlled trial compared gold and hydroxychloroquine in 52 patients to gold and placebo in 49. The patients continued to receive non-steroidal anti-inflammatory drugs and analgesics.

Sulphasalazine in rheumatoid arthritis: haematological problems and changes in haematological indices associated with therapy.

This prospective study documents the haematological responses in 300 rheumatoid patients (RA) treated with sulphasalazine (SASP) for between 1 and 9 years. It also examines the effect of SASP on the total white cell and platelet counts over 2 years in relation to disease activity in 80 RA patients. Neutropenia occurred in six (2%) (three severe--neutrophil count less than 0.

Thyroid stimulation by (Fab)2 and Fab fragments of TSH receptor antibody.

The TSH receptor binding and thyroid stimulating properties of (Fab)2 and Fab fragments of Graves' IgG have been investigated. (Fab)2 fragments were prepared by pepsin digestion of IgG and Fab fragments by reduction of (Fab)2 or papain digestion of IgG. (Fab)2 and Fab were effective in inhibiting TSH binding to its receptor with all five patients' sera studied and both preparations stimulated cyclic AMP release from isolated thyroid cells.

The long term effects of sulphasalazine in the treatment of rheumatoid arthritis and a comparative study with penicillamine.

The long term efficacy and tolerability of sulphasalazine (SASP) in the treatment of 21 patients with active classical or definite rheumatoid arthritis (RA) were examined and compared with the effects of penicillamine in a similarly active group of RA patients. Nineteen of the 21 patients treated with SASP improved during the first 6 months as shown by significant changes in the clinical and laboratory variables. Clinical improvement was maintained for the remainder of the year.