A randomized controlled trial to evaluate the effectiveness of an exercise program in women with rheumatoid arthritis taking low dose prednisone.

OBJECTIVE: To evaluate the effects of a 12 month, weight bearing, aerobic exercise program on disease activity, physical function, and bone mineral density (BMD) in women with rheumatoid arthritis (RA) taking low dose prednisone. METHODS: A group of women with RA (n = 23) not receiving steroid therapy and in American College of Rheumatology functional class I or II was compared to 30 steroid treated patients with similar demographics. The latter group was randomized to usual care (n = 16) or an aerobic, weight bearing exercise program (n = 14) 3 times a week for 12 months. All subjects were recruited from an outpatient rheumatology clinic or physical therapy department and met the study inclusion criteria. Outcome measures included disease activity (erythrocyte sedimentation rate, active joint count), physical function (Health Assessment Questionnaire disability index, activity level) and BMD of the spine and femoral neck (by dual energy projection radiology). RESULTS: Subjects in the exercise group had a small but nonsignificant decrease in disease activity and statistically significant improvements in function (p = 0.05) and activity levels (p = 0.05). BMD remained unchanged in the exercise group, decreased significantly (p = 0.004) in the nonsteroid comparison group (hip), and changed nonsignificantly in the control group. However, between-group changes in spinal BMD of the steroid treated groups was not significant (p = 0.09). CONCLUSION: Women with RA taking low dose steroid therapy can safely participate in a dynamic, weight bearing exercise program with positive effects on their physical function, activity and fitness levels, and BMD with no exacerbation of disease activity.

Natural history of the spontaneous reperfusion of human cerebral infarcts as assessed by 99mTc HMPAO SPECT.

OBJECTIVE: Little is known about the effect of spontaneous reperfusion of human cerebral infarcts. Single photon emission computerised tomography (SPECT) data were analysed from a study using 99Tc(m) HMPAO (99Tc(m) hexamethylpropyleneamine oxime) in human cerebral infarction for the frequency of reperfusion and to see if it affected infarct size, oedema, haemorrhagic transformation, or functional outcome. METHODS: Fifty sequential cases of ischaemic stroke were studied with 124 99Tc(m) HMPAO SPECT at around one day, one week, and three months after stroke along with detailed clinical and functional assessments. RESULTS: Visually apparent reperfusion occurred in 14 of 50 patients (28%) with a mean delay of 5.8 days and reperfusion was seen in seven others in whom it was identified on the basis of changes in perfusion deficit volume. It occurred in 13 of 23 embolic events but only in three of 23 other events. In only two cases did spontaneous reperfusion occur early enough to preserve tissue or function. Reperfusion did not otherwise reduce infarct size, or improve clinical or functional outcome, and was not associated with oedema but an association with haemorrhagic transformation was suggested. Reperfusion significantly decreased the apparent perfusion defect as measured by SPECT one week from the ictus, but was mostly non-nutritional and transient. The mean volume of tissue preserved by nutritional reperfusion was 10 cm3, but this was unequally distributed between cases. Late washout of 99Tc(m) HMPAO from areas of hyperaemic reperfusion may be a good prognostic marker but is a rare phenomenon and too insensitive to be of general applicability. CONCLUSIONS: Spontaneous reperfusion after cerebral infarction occurs in 42% of cases within the first week but is associated with clinical improvement in only 2%. It has few adverse consequences although it may be associated with haemorrhagic transformation.

CT standard protocols are of limited value in assessing actual patient dose.

In the last 10 years the use of computed tomography in radiodiagnosis has increased markedly and CT scanners are now present in most district general hospitals. Modern CT scanners are versatile in their operation and offer the operator a wide choice in exposure parameters which affect the doses received by the patients. As CT is a major contributor to medical radiation doses, the National Radiological Protection Board (NRPB) recommends that an estimate of typical patient dose should be made for commonly used local scanning protocols. A survey has been undertaken in the Anglia and Oxford region covering 12 CT scanners. Common procedures were chosen, concentrating on those most frequently carried out and giving higher effective doses. These included routine heads, routine chests, high resolution chests and abdomen/pelvis examinations. Questionnaires were sent out to each CT centre to collect data on standard protocols and to record the procedure used for five actual patients for each examination type thus enabling a comparison of the two methodologies. This study has shown that many examinations are tailored to the individual patient size and clinical indications, particularly in the chest/abdomen/pelvis. Thus, assessing doses based on collecting standard protocols may not give a true indication of the effective doses being received by particular patients.

Case Report: a patient with primary biliary cirrhosis and autoimmune hemolytic anemia.

Diseases of an autoimmune nature are well recognized in association with primary biliary cirrhosis. Although autoimmune thyroiditis and many rheumatological conditions are well described in primary biliary cirrhosis, autoimmune haematological diseases have been less well reported. We report on a 66 year old North American Indian man with coincident primary biliary cirrhosis and warm antibody haemolytic anaemia. This case report supports the suggestion of an association between autoimmune haemolytic anaemia and primary biliary cirrhosis.

Single-photon emission computed tomography using hexamethylpropyleneamine oxime in the prognosis of acute cerebral infarction.

BACKGROUND AND PURPOSE: The role of single-photon emission CT (SPECT) in the prognosis of cerebral infarction is controversial, but most studies report that SPECT using a variety of radiopharmaceutical agents gives useful prognostic information. Only one study has questioned whether acute perfusion deficits independently add to a valid clinical prognostic score. This study was limited to middle cerebral artery territory infarcts and was negative. We present data on the prognostic utility of SPECT using 99mTc-hexamethylpropyleneamine oxime (HMPAO) in cerebral infarction, unselected by site. METHODS: Fifty consecutive unselected patients admitted to the hospital with acute cerebral infarction, of whom 10 died and 7 withdrew, had SPECT performed serially at onset and at 1 week and 3 months after stroke onset using 99mTc-HMPAO and the NOVO 810 dedicated high-resolution head tomograph. Clinical severity at presentation and outcome was measured with the Canadian Neurological Scale and the Barthel Index. Infarct volumes were measured from both the SPECT and CT scans. The data for the 43 subjects who completed the study or died were evaluated to determine the most powerful prognostic measures. Predictors were the Canadian Neurological Scale score at onset and 1 week, the Barthel Index at 1 week, the CT infarct volume typically done between 3 and 7 days after stroke onset, and the infarct volumes at the first and second SPECT. Outcome measures were the Canadian Neurological Scale score and Barthel Index score at 3 months, scored as zero for those patients who died. RESULTS: The clinical prognostic indicators correlated with the outcome measures, with coefficients between .617 and .821 (P < .0006 in all cases). The Canadian Neurological Scale score measured at 1 week was the best of these. Infarct volumes measured from SPECT correlated less well (coefficients between -.518 and -.683, P < .0019 in all cases). CT infarct volume was the poorest predictor. Although SPECT infarct volumes predicted outcome, they did so less well than clinical examination. Spontaneous infarct reperfusion did not affect outcome. CONCLUSIONS: Although the measurement of infarct volume on SPECT using 99mTc-HMPAO provides a predictor of stroke outcome, it is not a better predictor than the Canadian Neurological Scale score.

The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone.

To determine the safety and efficacy of viscosupplementation with hylan G-F 20, a cross-linked hyaluronan preparation, used either alone or in combination with continuous non-steroidal anti-inflammatory drug (NSAID) therapy, a randomized, controlled, multicenter clinical trial, assessed by a blinded assessor, was conducted in 102 patients with osteoarthritis (OA) of the knee. All patients were on continuous NSAID therapy for at least 30 days prior to entering the study. Patients were randomized into three parallel groups: (1) NSAID continuation plus three control arthrocenteses at weekly intervals; (2) NSAID discontinuation but with three weekly intra-articular injections of hylan G-F 20; and (3) NSAID continuation plus three injections, one every week, intra-articular injections of hylan G-F 20. Outcome measures of pain and joint function were evaluated by both the patients and an evaluator at baseline and weeks 1, 2, 3, 7 and 12, with a follow-up telephone evaluation at 26 weeks. At 12 weeks all groups showed statistically significant improvements from baseline, but did not differ from each other. A statistical test for the equivalence, the q-statistic, demonstrated that viscosupplementation with hylan G-F 20 was at least as good or better than continuous NSAID therapy for all outcome measurements except activity restriction. At 26 weeks both groups receiving hylan G-F 20 were significantly better than the group receiving NSAIDs alone. A transient local reaction was observed in three patients after hylan G-F 20 injection; only one patient withdrew from the study as a result and all recovered without any sequela. Hylan G-F 20 is a safe and effective treatment for OA of the knee and can be used either as a replacement for or an adjunct to NSAID therapy.

Acute local reactions after intraarticular hylan for osteoarthritis of the knee.

OBJECTIVE: To describe acute local reactions following intraarticular hylan injection and determine their frequency. METHODS: Retrospective review of all patients with osteoarthritis of the knee treated with hylan by 3 rheumatologists. RESULTS: Twenty-two patients had 88 injections to 28 knees. Six patients had reactions within 24 h of injection characterized by pain, warmth, and swelling, lasting up to 3 weeks. This occurrence was unpredictable. Corticosteroid injections were sometimes required. Synovial fluid cell counts were 5.0-75.0 x 10(9)/l, often with a prominent mononuclear component. Crystal studies and cultures were negative. Radiographic chondrocalcinosis was present in only 1 patient. One patient had serum antibodies to chicken serum proteins. CONCLUSION: Intraarticular hylan was associated with significant local inflammatory reactions in 27% of patients, or 11% of injections. The mechanism(s) and long term sequelae are unclear.

Contribution of diaschisis to the clinical deficit in human cerebral infarction.

BACKGROUND AND PURPOSE: Regions of decreased cerebral blood flow are often seen on single-photon emission computed tomography (SPECT) after stroke and have been widely reported to add to the clinical deficit. However, such reports have not distinguished between correlation and causation. We analyzed 124 serial SPECT scans performed in 50 patients to assess the role of diaschisis in the clinical deficit after stroke. METHODS: SPECT with the use of 99mTc-hexamethylpropyleneamine oxime (99mTc-HMPAO) was performed in a prospective, unselected series of 50 patients with cerebral infarcts studied at a median of 1.1, 6.8, and 95 days after ictus. Patients were also assessed with the use of the Canadian Neurological Scale, the Barthel Index, a neuropsychological evaluation, and infarct volume measurement. RESULTS: One hundred twenty-four serial SPECT scans were done in 50 patients. Diaschisis was identified at 168 sites. There was insufficient correlation between diaschisis and the clinical measurements to support the suggestion that diaschisis independently causes clinical deficits beyond those due to the infarct itself. Unlike the clinical status, diaschisis showed little tendency to resolve during the 3-month follow-up period of the study. Several of the instances of correlation were shown to be of a noncausal kind, with both the diaschisis and the clinical deficit being due to the lesion directly; there was no known mechanism for the diaschisis to cause the clinical deficit. CONCLUSIONS: Diaschisis does not independently add to the clinical deficit after stroke. It is more likely that it simply represents part of the damage done by the stroke.

Cognition in stroke.

INTRODUCTION: Despite the current interest in criteria for vascular dementia, global, as opposed to focal, cognitive change after cerebral infarction has rarely been studied. MATERIAL AND METHODS: We documented the neuropsychological changes one to three weeks and three months post infarct in 25 unselected patients with acute, first cerebral infarcts. RESULTS: Improvements were seen in processes through to have a large subcortical component and in those mediated in the right hemisphere. Memory was relatively lightly affected. CONCLUSION: The minimal deficits seen in memory and the predominance of subcortical changes are at variance with the currently suggested criteria for vascular dementia. Further data of this kind are needed before firm criteria can be proposed for the global pattern of cognitive changes expected in vascular dementia.

High resolution SPECT, small deep infarcts and diaschisis.

Eighteen cases of lacunar infarction are presented. Six of these cases had a purely motor clinical deficit. All the cases were studied by serial high resolution SPECT (single photon emission computerized tomography) using 99Tcm HMPAO. The degree and extent of the changes in cerebral perfusion consistent with diaschisis were noted and these compared with the severity of the clinical deficit at presentation and over time. No significant correlation between diaschisis and the clinical state was found at any stage. The nature, aetiology and importance of diaschisis are discussed and it is suggested that caution should be exercised in attributing clinical features to diaschisis simply because it may be present.

Crossed anomic aphasia: mild naming deficits following right brain damage in a dextral patient.

A detailed case study is reported of crossed aphasia (CA) in a dextral patient, bearing upon such controversial issues as intrahemispheric localisation of language function and hemispheric reversal of nonverbal function. DA, a man aged 37, developed a mild naming problem due to right temporal lobe haematoma. Apart from a mild acquired stutter, his continuous speech was fluent and had a normal proportion of open to closed class lexical items. His naming deficit appears to originate in the 'blocking' or 'disconnection' of the phonological lexicon: he could usually give a functional definition of un-named items and retrieve them with the help of a phonemic cue. Lexical retrieval appears his only language deficit, as he had no comprehension or phonological discrimination deficits. DA showed no visuo-spatial or auditory-nonverbal deficits, suggesting the complete reversal of hemispheric specialisation.

Clinical application of an electronic imaging device for assisting patient set-up in radiotherapy.

As radiotherapy treatment set-ups are becoming more complicated and a greater emphasis is placed on accuracy, there is an increasing need to verify and record the actual treatments being given. A direct electronic imaging device is currently marketed by Varian (the DYNARAY ID), which uses the latest technology in detection and image processing to obtain digital images of the patient's anatomy using the actual treatment beam. At Norwich we have been using a prototype machine in a busy district radiotherapy centre and have examined over 50 patients. We have found the images easy to obtain and the technique superior to the standard practice of using verification radiographs. The role of this device lies in aiding quality assurance of treatments whilst generating a permanent record of the actual treatment given.