Prospective study of the early course of rheumatoid arthritis in young adults: comparison of patients with and without rheumatoid factor positivity at entry and identification of variables correlating with outcome.

The early course of newly diagnosed RA among young adult patients (16-44 yr) is described from results of an ongoing study with a mean follow-up of 3.4 yr. Study diagnosis was based on the judgement of experienced rheumatologists, and data on several hundred variables were obtained on entry and annually for the purpose of defining patterns of onset and course of disease. Race and sex factors, as well as certain entry manifestations, e.g., RF, were found to correlate with onset and course patterns. Females, and especially white females, had significantly greater numbers of swollen upper extremity joints than males at entry and at last observation, with increased likelihood of developing bone erosions. At entry, RF positive patients differed only on few articular manifestations from RF negative patients, but had a higher frequency of positive ANA at entry and more subcutaneous nodules and bone erosions during follow-up. Seropositive white females at entry had significantly more swollen upper joints than their seronegative counterparts, but with no difference found at last follow-up. White females of each serogroup had more joint involvement at last examination than patients of other race-sex groups. Males had more acute onset, especially under age 30, with significantly greater improvement in arthritis and in ESR than did females. The majority (55%) of patients entered as seropositive, converted to seronegative during follow-up, and no correlation of either joint swelling or erosions was noted with this phenomenon. At last visit, RF positively did not correlate with bone erosions, but patients developing bone erosions had higher frequency of ANA and higher mean serum complement levels at last examination. The following entry factors were found to correlate significantly with a better outcome: maleness, acute onset under age 30, less swollen upper joints, and negative RF. Type of drug therapy tended to reflect severity of arthritis, rather than vice versa, and functional capacity improved significantly from entry to last evaluation in both males and females, even though the latter had stable or progressive arthritis. Further study is necessary over long intervals and in wider age range to more adequately interpret the biologic implications of findings of this ongoing study. A better understanding of the pathogenesis of RA may be derived from critical studies of the contribution of host factors, e.g., sex, and other variables predisposing to the development of RF positivity (and ANA), subcutaneous nodules, and bone erosions, particularly in systematic ongoing studies of patients with early diagnosed disease.

The prognostic value of DNA ploidy combined with histologic substaging for incidental carcinoma of the prostate gland.

Although current methods of histologic substaging for incidental prostatic carcinoma are useful, they offer only general indications of potential tumor behavior. To further define the biologic tendencies of stage A cancers, an examination was made of the role of DNA ploidy combined with histologic staging in archival material selected to achieve both a representative sample and long-term follow-up. With histology alone, 36% of stage A2 cancers and 9% of A1 neoplasms were progressive. Adding DNA flow cytometry to histology resulted in a significant improvement in the capacity of pathologic evaluation to predict outcome. Progression occurred in 67% of aneuploid stage A2 prostate cancers and in none of the nonaneuploid stage A1 tumors. Despite current limitations in the interpretation of DNA histograms from archival tissue, flow cytometry has significant potential in the pathologic evaluation of incidental prostatic carcinomas.

Female gonorrhea: its relation to abnormal uterine bleeding, urinary tract symptoms, and cervicitis.

Data are presented from an investigation of the assocation of presenting complaints with gonococcal infection in females seeking primary care in an urban emergency room. Over 27% of patients in the study had cultures positive for Neisseria gonorrhoeae (GC). The GC positivity rates which were significantly higher than expected were found in patients with abnormal uterine bleeding, urinary tract symptoms, and cervicitis, as well as acute PID. Clinical findings suggest an etiologic role for the gonococcus in the pathogenesis of these disorders. Where the incidence of gonorrhea is high, new approaches in the managment of patients with these presenting complaints are necessary in order to prevent the more serious complications of gonorrhea and further spread of the disease.

Repair of distal biceps tendon ruptures in athletes.

Ten athletes with distal biceps tendon ruptures that had been anatomically repaired with a double-incision techniques were reviewed to determine their functional recovery. All of the patients were men, with an average age of 40 years (range, 25 to 49). Eight of the 10 patients were weight lifters or body builders, and 7 had participated on a competitive level at some point in their athletic careers. Six injured their dominant extremity, and 4 their nondominant extremity. Isokinetic muscle testing of supination and flexion was performed in 8 patients and the results were compared to a control group. Followup averaged 50 months (range, 12 to 105). Patients uniformly graded their subjective results as excellent, with a group mean rating of 9.75 on a 10-point scale. All athletes returned to full, unlimited activity. The contour of the biceps muscle was restored in all cases. Isokinetic muscle testing demonstrated that in those patients with a repaired dominant extremity, supination strength and endurance was normal; in flexion, they had normal strength, but averaged 20% less endurance. Testing of the group that had the nondominant extremity repaired revealed a supination strength deficit of 25%, but normal endurance. Flexion strength and endurance were essentially normal in this group. Anatomic repair of a distal biceps tendon rupture gives consistently excellent subjective and good objective results in athletes, particularly for those sports with high strength demands such as weight lifting and body building. Rehabilitation of the operated arm, especially the repaired nondominant extremity, should be emphasized.

Recalcitrant femoral pseudarthrosis healed with a torsionally stiff intramedullary nail.

A case of long-standing femoral pseudarthrosis was successfully treated by replacement of a torsionally less rigid intramedullary nail by one approximately 20 times more rigid. Complete union occurred 6 months after nail exchange.

Complex volar distal radioulnar joint dislocation occurring in a Galeazzi fracture.

The Galeazzi fracture-dislocation of the forearm consists of a transverse or short oblique fracture of the radius at the junction of the middle and distal thirds with an associated subluxation or dislocation of the distal radioulnar joint. Anatomic reduction with rigid internal fixation of the radius typically produces anatomic reduction of the distal radioulnar joint and is the favored treatment. At least three cases of a mechanically blocked distal radioulnar joint requiring open reduction through a separate exposure have been reported. In all three cases there was dorsal displacement of the ulna. We report a case of an irreducible volar dislocation of the distal radioulnar joint following open anatomic reduction of the radius.

Management of complex ankle fractures in athletes.

Outcome from complex ankle fractures depends on the severity of the injury, the accuracy of the reduction, and the institution of soft-tissue rehabilitation. The timing of surgery must take into consideration the degree of soft-tissue swelling and the overall condition of the patient. Good operative technique is vital in preventing complications, restoring anatomic relationships, and obtaining rigid stability. In order to diminish time away from sports, the rehabilitation phase should overlap the healing phase.

Limitations of conventional nailing.

The ideal case for conventional closed nailing consists of: Isthmal fractures or fractures in which the isthmus can be extended by reaming or fractures with inherent stability by virtue of cortical interdigitations; closed and open type I and II; transverse, comminution grade I, II, and some grade III. Some segmental and short oblique fractures are amenable to conventional nailing. The canal length and geometry should be studied to avoid mishap in the operating room and the proper equipment. assembled along with a well trained team. Once these prerequisites have been met, conventional nailing will prove successful for the majority of patients and fractures of the femoral shaft.

Tibial fractures associated with civilian gunshot injuries.

Forty patients with 41 fractures of the tibia produced by civilian gunshot injuries were reviewed. The usual patient was male, 28 years of age, and had been shot by an unknown assailant. Thirty-two of the 41 fractures (78%) were the result of low-energy missiles (less than 500 foot pounds or 680 Nm) while six (15%) were from intermediate (500 to 1,200 foot pounds or 680-1,627 Nm) and three (7%) from high-energy missiles (greater than 1,200 foot pounds or 1,627 Nm). Characteristic fracture patterns for the low energy group consisted of the drill hole, unicortical, oblique, spiral, butterfly, and comminuted. All of the intermediate- and high-energy missiles produced highly comminuted fractures. Intermediate- and high-energy missile injuries resulted in significantly longer initial hospitalization, higher incidence of fibular fracture, neurologic deficit, type 2 or 3 wound, and a higher incidence of infection. The time to fracture union was also higher with these injuries, even though the two nonunions in the series occurred with low-energy missiles. Factors other than the energy of the missile, however, may have contributed to the healing failure in those two patients. These factors included an intact fibula in one and advanced age in the other.

Relative deoxyribonucleic acid content of interphase leukocytes by flow cytometry: a method for indirect diagnosis of chromosomal abnormalities with potential for prenatal diagnosis.

A major goal of prenatal cytogenetic analysis is the development of minimally invasive techniques by which all pregnancies may be screened. That nucleated fetal cells exist in the maternal circulation raises the possibility that their cytogenetic status could be determined. However, these cells may not respond to commonly used mitogens. Thus it will probably be necessary to develop methods to analyze nondividing (interphase) cells. We therefore evaluated the use of flow cytometry as a means of determining whether the relative deoxyribonucleic acid content of G0-G1 leukocytes (expressed as the deoxyribonucleic acid index) could be used to verify aneuploidy or other chromosomal abnormalities. Our findings indicate this is indeed possible. We determined that the mean deoxyribonucleic acid index of circulating leukocytes from normal adult men (n = 15) was significantly different from that of leukocytes from normal adult women (n = 15). Similar results were obtained in leukocytes from umbilical cord blood of normal male neonates (n = 15) and normal female neonates (n = 15). Most importantly, values for leukocytes from each of 13 aneuploid individuals fell outside the range of values for leukocytes from normal adults of the same sex.

[The cell cycle in normal human chorionic and placental villi. A study using flow cytometry]. / Bunecný cyklus v normálních lidských choriových a placentárních klcích. Studie pomocí prutokové cytometrie.

The amount of DNA in cells obtained from chorionic and placental villi by collagenase digestion was analyzed by flow cytometry. 15 cases ranging from 7th to 40th gestational weeks were analyzed. Approximately 1 X 10(4) cell nuclei were measured in each specimen. At 7th gestational week, 16-18.4% of cells were at S-phase, and 16.5-20.6% of cells at G2 + M phase. During midpregnancy, about 6.2-13.2% of cells were at S-phase and 5.3-9.1% of cells at G2 + M phase. At full term, in placentas from 40th gestational week 6.0-8.6% of cells were at S-phase and 3.0-5.0% of cells at G2 + M phase. The results suggest, that at term still 11% of placental cells are able to enter mitosis. Using flow cytometry, the DNA content in cell nuclei can be measured in specimens obtained by CVS A.

Treatment of fractures about hip prostheses with compression plating.

Between 1984 and 1986, 10 patients who sustained a femur fracture about a hip prosthesis were treated with open reduction and internal fixation using compression plating. Nine of the 10 fractures healed in an average time of 5 months. Other than one nonunion, no significant complications were noted. Follow-up study, ranging from 13 to 44 months (average, 26 months), was obtained on all 10 patients. One had a loose femoral component, which was attributed to inadequate stem size. None of the other patients had either clinical or radiographic evidence of loosening. Based on Harris hip scores, there was no indication that plating significantly interfered with hip function. The authors believe that these results demonstrate that plating can be an effective method of treating femoral fractures about hip prostheses.

The functional cost of dislocation following total hip arthroplasty.

The consequences of dislocation following total hip arthroplasty were assessed using quantitative gait analysis. As a preliminary study, a review of 18 patients having undergone hip arthroplasty without dislocation provided as understanding of the improvement in gait in the first two years after surgery. Seven patients with a single dislocation and six patients with multiple dislocations were compared with patients matched according to age and preoperative gait characteristics and who experienced an uncomplicated recovery following hip arthroplasty. One year after surgery patients with a single dislocation could not be differentiated from the matched patients with respect to gait velocity and single limb support time. However, patients, with multiple dislocations walked significantly slower and had a significantly decreased single limb support time in the involved extremity than their respective matched patients.

Renal cell carcinoma presenting as a skeletal muscle mass: a case report.

A 62-year-old man presented with a 17-month history of a slowly enlarging biceps muscle mass. A diagnosis of metastatic renal cell carcinoma was made in the outpatient department using a soft tissue biopsy needle. Despite the rarity of muscular metastases in renal cell carcinoma, early definitive diagnosis of soft tissue masses is recommended.

Flow cytometry of deparaffinized nuclei compared to histological grading for the pathological evaluation of transitional cell carcinomas.

Recent developments in flow cytometric analyses have resulted in a practical method to examine the deoxyribonucleic acid ploidy of various tissues, including bladder cancers. Although the technique provides information not readily available from usual pathological examinations, its value as a diagnostic test in clinical urology remains to be investigated. We confirm previous reports that flow cytometry can be performed on tissues stored in paraffin and demonstrate a positive correlation among deoxyribonucleic acid ploidy, histological grade and clinical outcome in patients with transitional cell carcinoma. Nevertheless, deoxyribonucleic acid ploidy offered no more prognostic information than histological grading alone when these tests were performed on the initial bladder tumors in 63 patients.

The results of quadricepsplasty on knee motion following femoral fractures.

Knee motion following femoral fractures is often less than satisfactory. Surgical procedures to increase knee motion are rarely done. This paper presents a series of nine patients who had severe femoral fractures, primarily in the distal third. Once union was obtained, all patients had knee flexion incompatible with normal gait (average 30.2 degrees). All patients underwent a quadricepsplasty at Rancho Los Amigos Medical Center. Eight of the nine achieved knee flexion allowing normal gait (average 78 degrees). This paper presents our indications, methods, results, and complications in performing quadricepsplasty to achieve knee flexion following femoral fractures.