Chemotaxis of polymorphonuclear leukocytes from patients with rheumatoid arthritis.

Using a new in vitro method of measuring the chemotaxis of polymorphonuclear leukocytes from peripheral blood, a chemotactic index has been calculated. The mean chemotactic index of 320 in 24 patients with definite rheumatoid arthritis, was significantly less (P < 0.0005) than the mean of 555 in 24 normal controls matched for age and sex. The mean chemotactic index of 435 in eight patients with juvenile rheumatoid arthritis was also significantly less (P < 0.01) than that of 553 in similarly matched controls. The chemotactic index could not be correlated with age, sex, disease activity, drugs used in treatment, latex titer, immunoglobulin levels, or protein coating on the cells. However, there was a correlation between the chemotactic index and the serum complement B(1e)/B(1a) value (P < 0.01) in 17 patients with adult onset rheumatoid arthritis. Although the serum complement B(1e)/B(1a) values were within the normal range, the lowest chemotactic indices were associated with the lowest complement values. The chemotactic indices in three patients with severe connective tissue disease (seropositive rheumatoid arthritis, systemic lupus erythematosus, and polymyositis) returned to normal after 5 days' treatment with 60 mg of prednisolone per day. Incubation of the cells from patients with rheumatoid arthritis with hydrocortisone in vitro failed to alter the chemotactic indices. Prior incubation of normal cells with purified rheumatoid factor complexes, rheumatoid serum, or macromolecules of iron dextran impaired their chemotaxis. It is suggested that phagocytosis of complexes in vivo is a possible mechanism by which the chemotaxis of the polymorphonuclear leukocytes of patients with rheumatoid arthritis is impaired. This impairment in chemotaxis may explain the increased incidence of bacterial infection, both during life and as a cause of death in these patients.

Cytodiagnosis of rheumatoid pleural effusions.

The stained smears of the deposits from one pericardial and 19 pleural effusions complicating rheumatoid arthritis were examined. On the basis of clinical and biochemical evidence it was considered that in six cases the effusions were due to the rheumatoid disease while in a further nine cases the association was considered likely. In the remaining five cases the association was considered to be due to chance as other causes for the effusions were diagnosed. On cytological examination, seven cases showed a characteristic picture of degenerating polymorphs with amorphous extracellular material and epithelioid cells many of which were multinucleate. Five others contained similar amorphous material without epithelioid cells; of these two had many plasma cells and a third numerous macrophages probably containing ;droplets' of rheumatoid factor complex. Thus in 12 of 15 cases a definite diagnosis of rheumatoid effusion could be made. In the remaining five cases cytological examination confirmed that the effusions were unrelated to the rheumatoid disease.The extracellular material gave a non-specific fluorescence with labelled anti-gamma globulin antisera, and since this reaction was not seen in control pleural fluid deposits, or with preparations of fibrin, it may have a confirmatory value. It is concluded that in many cases reliable cytological evidence can be found to confirm or refute a diagnosis of rheumatoid pleural or pericardial effusion. This may be helpful in the management of the rheumatoid disease.

Spinal movements in ankylosing spondylitis and the effect of treatment.

Fourteen male patients with ankylosing spondylitis, admitted for a 2-week period of inpatient treatment, had their spinal mobility assessed on admission and at the end of treatment by clinical measures and a three-dimensional radiographic technique. The patients were given injections of low-dose corticotrophin (ACTH) or placebo under a double-blind protocol. Initially all the patients had restricted movements compared with normal. After treatment all showed some improvement of mobility but no additional benefit accrued from ACTH. Clinical measures of mobility must be interpreted with care as the changes in these measurements were not closely reflected in the lumbar movements measured radiographically. Changes seen in plain radiographs were of little predictive value for improvements in mobility.

The effect of heel pads on the treatment of Achilles tendinitis: a double blind trial.

Thirty-three subjects entered a blind-observer, random, prospective study of three forms of conservative treatment of sports-induced Achilles tendinitis, results being assessed by clinical and biomechanical parameters. Two patient groups received heel pads, ultrasound, and exercises, while the third received only ultrasound and exercises. All three groups showed some improvement at both 10 day and 2 month assessment, but the claimed benefit of viscoelastic pads widely used by athletes was not substantiated. The more striking benefit from ultrasound and exercises alone occurred in patients with a shorter history; a comparison of duration of injury in all three groups suggested this was an important factor influencing outcome. The study has highlighted the need for biomechanical outcome measures as well as for more objective clinical outcome measures in the assessment of physical therapy.

Synovectomy of the elbow and radial head excision in rheumatoid arthritis. Predictive factors and long-term outcome.

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50 degrees in supination-pronation and 11 degrees in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

Levamisole and cellular immunity in rheumatoid arthritis--a review.

It has been suggested that many of the pathological changes in rheumatoid arthritis can be explained on the basis of T cell hypofunction and that the chronicity of the lesions can be maintained by abnormalities in macrophage and neutrophil function. Although there is some evidence to suggest that levamisole can correct many of these abnormalities and that its mechanism of action in this disease can therefore be explained the current, often conflicting, information does not offer proof of this suggestion and indeed some of the noted changes may merely represent secondary rather than primary events.

Dose-range studies of benoxaprofen compared with placebo in patients with active rheumatoid arthritis.

The new nonsteroidal antiinflammatory drug benoxaprofen was compared with placebo in separate double-blind crossover studies in patients with active rheumatoid arthritis given 400 mg, 600 mg, or 800 mg a day. Benoxaprofen was significantly better than placebo at all doses studied. The 800 mg dose was the most effective but there were slightly more gastrointestinal side effects with this dose. The 600 mg dose was more effective than the 400 mg dose with an acceptably low incidence of side effects at both these doses. For most patients, 600 mg once daily will probably be the usual dose of the drug, but some will need the higher dose to 800 mg, while the condition of others may be satisfactorily controlled with just 400 mg daily.