Inflamed shoulder structures in polymyalgia rheumatica with normal erythrocyte sedimentation rate.
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OBJECTIVE: To investigate the inflammatory involvement of shoulder articular and extraarticular structures in polymyalgia rheumatica (PMR) patients with a normal erythrocyte sedimentation rate (ESR) at diagnosis. METHODS: This was a case-control study. All consecutive, untreated new outpatients diagnosed as having PMR with a normal ESR (<40 mm/hour) during a 6-month period were included in the study (case patients). Controls were 12 consecutive, untreated PMR outpatients with an ESR of >40 mm/hour who were observed after the case patients. Before starting corticosteroid therapy, all case patients and controls underwent bilateral shoulder ultrasonography (US) and magnetic resonance imaging (MRI). US and MRI scans were evaluated independently by two radiologists who were blinded to the reciprocal results. RESULTS: Six case patients (4 men and 2 women) and 12 controls (4 men and 8 women) were studied. Both US and MRI demonstrated bilateral subacromial/subdeltoid bursitis in all 6 case patients and in 11 of the 12 (92%) controls (P not significant [NS]). One control had unilateral bursitis. Glenohumeral joint synovitis was found in 4 of 6 case patients (67%) by MRI and in 3 of 6 case patients (50%) by US (P NS), as well as in 8 of 12 controls (67%) by MRI and in 7 of 12 controls (58%) by US (P NS). Both MRI and US detected biceps tenosynovitis in 5 of 6 case patients (83%) and in 8 of 12 controls (67%) (P NS). The severity of bursitis did not differ significantly between the groups. US was as effective as MRI in detecting inflammatory changes of the shoulder. CONCLUSION: MRI and US studies showed that PMR patients with normal or high ESRs have similar inflammatory shoulder lesions. Moreover, bilateral subacromial/subdeltoid bursitis represents the imaging hallmark in PMR patients with a high or normal ESR. MRI or US of the shoulder may facilitate the proper diagnosis in patients with the typical proximal symptoms of PMR who also have normal ESRs. (+info)
Chronic monarticular synovitis. Diagnostic and prognostic features.
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Data have been analysed from a retrospective review of 151 patients with monarthritis of more than 3 months' duration, usually involving the knee joint. The largest group, 49 patients (32%), had synovitis of unknown cause, 44 (29%) had synovitis probably associated with osteoarthrosis and 13 (9%) were diagnosable at presentation as having rheumatoid arthritis according to American Rheumatism Association (1959) criteria, which include serological and histological findings. There was only one case of tuberculous synovitis. Twelve of the thirteen patients diagnosed as rheumatoid arthritis developed involvement in other joints. In most other conditions, however, including synovitis of uknown cause, the prognosis was favourable, with either improvement or complete remission. (+info)
Effects of treatment with a fully human anti-tumour necrosis factor alpha monoclonal antibody on the local and systemic homeostasis of interleukin 1 and TNFalpha in patients with rheumatoid arthritis.
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OBJECTIVES: To study the short term effects of a single dose of D2E7, a fully human anti-tumour necrosis factor (TNFalpha) monoclonal antibody (mAb), on the local and systemic homeostasis of interleukin 1beta (IL1beta) and TNFalpha in patients with rheumatoid arthritis (RA). METHODS: All patients with RA enrolled in a phase I, single dose, placebo controlled study with D2E7 in our centre were studied. Systemic cytokine levels, acute phase reactants, and leucocyte counts were studied at days 0, 1, and 14 after the first administration of anti-TNF mAb (n=39) or placebo (n=11). The cellularity and the expression of IL1 and TNFalpha in synovial tissue were studied in knee biopsy specimens obtained at baseline and at day 14 in 25 consenting patients. RESULTS: A single dose of anti-TNF mAb induced a rapid clinical improvement, a decrease in acute phase reaction, and increased lymphocyte counts in patients with active RA. The protein levels of IL1beta in the circulation were low and remained unchanged, but the systemic levels of IL1beta mRNA (p=0.002) and the concentrations of IL1 receptor antagonist (IL1ra) and IL6 (p=0.0001) had already dropped within 24 hours and this persisted up to day 14. Systemic levels of TNFalpha mRNA were low and remained unchanged, though total TNFalpha (free and bound) in the circulation increased after D2E7, probably reflecting the presence of TNF-antiTNF mAb complexes (p<0.005, at days 1 and 14). Both TNF receptors dropped below baseline levels at day 14 (p<0.005). Despite clinical improvement of arthritis, no consistent immunohistological changes were seen two weeks after anti-TNF administration. Endothelial staining for IL1beta tended to decrease in treated patients (p=0.06) but not in responders. The staining for IL1beta and TNFalpha in sublining layers and vessels was mutually correlated (r(s)=0.47 and 0.58 respectively, p<0.0005) and the microscopic scores for inflammation correlated with sublining TNFalpha and IL1beta scores (r(s)=0.65 and 0.54 respectively, p<0.0001), though none of these showed significant changes during the study. CONCLUSIONS: Blocking TNFalpha in RA results in down regulation of IL1beta mRNA at the systemic level and in reduction of the endogenous antagonists for IL1 and TNF and of other cytokines related to the acute phase response, such as IL6, within days. At the synovial level, anti-TNF treatment does not modulate IL1beta and TNFalpha in the short term. The synovial expression of these cytokines does not reflect clinical response to TNF neutralisation. (+info)
Acute phase response in toxicity studies. II. Findings in beagle dogs injected with endotoxin or subjected to surgical operation.
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Occurrence of characteristic transient changes in WBC counts and fibrinogen values in beagle dogs subjected to single-dose toxicity studies was pointed out in the previous survey (Hoshiya et al., 2001). These changes were thought to belong to the category of "Acute Phase Response (APR)". The purpose of the present study is to compare the APR found in the single-dose toxicity studies surveyed in our previous report with those experimentally produced by intravenous injection of 1 microgram/kg endotoxin (Experiment 1), and surgical treatment (Experiment 2) (intravenous indwelling catheterization). The animals used in Experiment 2 were intravenously injected with 1 microgram/kg endotoxin 2 weeks after the operation (Experiment 3), and the results were compared with those of Experiments 1 and 2. Each experimental group consisted of 5 dogs, and clinical, hematological and blood chemical examinations were performed. Essentially the same changes were observed in response to the intravenous injection with endotoxin and the surgical operation for intravenous indwelling catheterization in beagle dogs. The most remarkable changes common to both treatments were transient increases in the fibrinogen values and WBC counts during the 2 days from Day 1 to Day 2 of the treatment. These changes were preceded by decreases in WBC counts and fibrinogen in Experiments 1 and 3. Increased erythrocyte sedimentation rates were recorded in parallel with the increase in fibrinogen. The results obtained in the present study were similar to those found in dogs treated with various xenobiotic substances in our laboratory. These changes due to different causes were thought to belong to the category of "APR" with the same biological significance as a non-specific defense mechanism. (+info)
Value of clinical factors in selecting postmenopausal women with rheumatoid arthritis for bone densitometry.
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OBJECTIVE: Criteria to decide which patients with rheumatoid arthritis (RA) should be examined by dual energy x ray absorptiometry (DXA) are currently not available. The rheumatologists from Amsterdam have proposed preliminary criteria based on clinical risk factors (age, disease activity, and functional status). These criteria are preliminary and not widely accepted but might be helpful in practice. The value of the proposal in a group of Spanish postmenopausal women with RA is analysed. METHODS: DXA (lumbar spine and femoral neck) was performed in 128 patients recruited from a clinical setting, and the proposed criteria were applied. T and Z scores were established for a Spanish reference population. RESULTS: The mean (SD) age of the patients was 61.3 (10.7) and mean duration of the postmenopausal period 14.5 (10.1) years. Mean duration of RA was 13.7 (7.7) years. Mean C reactive protein was 22 (21) mg/l; mean erythrocyte sedimentation rate 26 (18) mm/1st h; and mean Health Assessment Questionnaire score 1.25 (0.79). Ninety (70%) patients fulfilled the proposed criteria. Their sensitivity for the diagnosis of osteoporosis (T score < or =-2.5 SD) was 86% and their specificity, 43%. Positive predictive value was 54% and negative predictive value, 79%. CONCLUSIONS: The proposed criteria seem a good screening method for the selection of those patients with RA whose bone mineral density should be assessed as the sensitivity and negative predictive value are acceptable. (+info)
Why shouldn't we determine the erythrocyte sedimentation rate?
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A test that is meant to measure a given parameter is more likely to detect changes in that parameter if it is not affected by factors other than those which it is intended to quantitate. The clinical use of the laboratory test for determining the erythrocyte sedimentation rate is backed by nearly a century of experience. Although its nonspecificity is acknowledged, it has been used to quantitate the inflammatory process that underlies infectious, inflammatory, and neoplastic disorders. I believe that this venerable test is affected by too many factors in addition to that which we think we are measuring, to the point that its clinical usefulness is severely compromised. (+info)
The suitability of the ultrasound biomicroscope for establishing texture in giant cell arteritis.
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AIM: To establish whether ultrasound biomicroscope (UBM) is a helpful tool in locating the arterial segment responsible in patients with segmental attacks in giant cell arteritis METHODS: The superficial temporal arteries of 19 patients with suspected giant cell arteritis were examined with the UBM before biopsy. RESULTS: 20 specimens provided the histological proof of giant cell arteritis in five patients. Side differences, a dark perivascular halo, and high reflexivity of the intra-arterial space were found. CONCLUSION: it is assumed that there are two types of arteritic inflammation: (1) the occlusion of intra-arterial space due to intimal fibrosis (UBM: high reflexive "filling"), and (2) inflammation of the perivascular zone with oedematous thickening and infiltration of the media (UBM: dark halo) and its combination. UBM is helpful in obtaining an indication of the side and segment for biopsy. (+info)
Biopsychosocial mediators and moderators of stress-health relationships in patients with recently diagnosed rheumatoid arthritis.
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OBJECTIVE: To investigate the mediating and moderating roles of social support, coping, and physiological variables in the relationship between life events and health status. METHODS: Psychological and biological measurements were taken in 54 patients (38 women, 16 men, mean age +/- SD 56 +/-14.4 years) with recently diagnosed rheumatoid arthritis (RA). RESULTS: Life events were correlated with psychological distress, but not with disease activity. No mediators for the relationship of life events with psychological well-being and disease activity were observed. In 40 tests, 4 moderators were found: Problem-focused coping, perceived support, diastolic blood pressure, and total number of lymphocytes were moderators of the relationship between daily hassles and health status (P < or = 0.05). CONCLUSION: Our study provides limited support for the notion that the interactions of life stress with biopsychosocial variables have an impact on health. None of these variables were found to be crucial mediators of stress-health associations in recently diagnosed patients with RA, but some provocative evidence was given that biopsychosocial variables may have a minor impact on stress-health relationships. (+info)