A longitudinal study of anticardiolipin antibody in polymyalgia rheumatica and giant cell arteritis.

OBJECTIVE: To determine the incidence of elevated levels of anticardiolipin antibody (aCL) in patients with newly diagnosed polymyalgia rheumatica (PMR) and/or giant cell arteritis (GCA); and to determine the relationship between these antibodies at diagnosis and subsequent course of the disease over a period of 2 yrs. METHODS: Ninety-eight consecutive patients with PMR and/or GCA were examined for the presence of aCL, at presentation and every 6 mo for 2 yrs. Sixty-four patients had PMR alone, 22 had coexistent PMR and GCA, and 12 presented with pure GCA. Patients presenting with suspected clinical diagnosis, overt or covert, of GCA were subjected to temporal artery biopsy from the symptomatic side within 3 days of presentation. Appropriate serological, biochemical, and hematological investigations were undertaken at presentation and subsequently at times of periodic assessments. One hundred healthy age and sex matched elderly subjects were also screened for the presence of aCL as a control group. RESULTS: Elevated levels of aCL were detected in 20 patients at presentation. These included 9 patients with PMR/GCA and 11 patients with pure PMR. During followup, 10 patients with pure PMR at presentation developed GCA. These comprised 5 of the 11 patients with high aCL at presentation and 5 of the 53 patients with normal levels of aCL at presentation. This was statistically significant with relative risk (4.82, 95% CI, 1.72-13.51) of developing GCA in the presence of PMR and a high aCL at presentation. Furthermore, 3 of the 5 patients with pure GCA and high aCL at presentation progressed to severe vascular complications (stroke, 2; anterior ischemic optic neuritis, 1) compared to none of the other patients in the study. Elevated levels of antineutrophilic cytoplasmic antibody were also analyzed and detected in only 4 patients, 3 with pure PMR and one with biopsy proven GCA. CONCLUSION: This prospective study suggests that a significant number of patients with PMR and/or GCA with elevated levels of aCL at presentation have increased risk of developing GCA or other major vascular complications. It is possible that aCL may be an independent prognostic marker for future vascular complications in patients with PMR and/or GCA.

Alpha 1-antichymotrypsin, C-reactive protein and erythrocyte sedimentation rate in polymyalgia rheumatica and giant cell arteritis.

Forty-four patients with polymyalgia rheumatica and/or giant cell arteritis (PMR/GCA) were followed from presentation, through remissions and relapses for a median duration of 36 months. Clinical disease activity, ESR, CRP and alpha 1-antichymotrypsin (alpha 1-ACT) were measured. Before treatment ESR, CRP and alpha 1-ACT were all significantly raised, compared with age- and sex-matched controls. On clinical remission with prednisolone treatment, ESR and CRP fell to control levels but alpha 1-ACT behaved quite differently, remaining raised for 18 months or until prednisolone treatment could be withdrawn. At 18 month follow-up of PMR/GCA, and alpha 1-ACT level of < or = 0.7 g/l was associated with a reduced risk of subsequent relapse (P = 0.006). At clinical relapse during treatment, ESR was not raised compared with controls, and CRP, although significantly higher than controls (P = 0.015), remained less than 6 mg/l in the majority of patients. The three laboratory investigations were, therefore, of limited value in confirming relapses of PMR/GCA during prednisolone treatment, but alpha 1-ACT may be useful as an indicator of underlying disease activity and hence as a guide to the speed that the prednisolone dosage should be reduced.

Effects of single dose compared with three days' prednisolone treatment of healthy volunteers: contrasting effects on circulating lymphocyte subsets.

AIMS: To investigate the effects of longer term corticosteroid treatment on circulating lymphocyte subsets. METHODS: Prednisolone (20 mg daily) was given to 12 healthy volunteers in a single morning dose for three days. Circulating lymphocyte subsets were measured by flow cytometry after whole blood lysis. RESULTS: Seven hours after the first dose of prednisolone there was a significant fall in absolute numbers of lymphocytes, T cells, CD4+ and CD8+ cells, and B cells. The percentage of T cells fell significantly, due to a fall in percentage of CD4+ cells. In contrast to the seven hour findings, at 72 hours there was a significant rise in absolute numbers of lymphocytes, T cells, CD4+, CD8+, and B cells. This trend was already apparent by 24 hours. The percentage of CD4+ cells was significantly raised at 72 hours, while that of CD8+ cells had fallen significantly. The percentage of natural killer cells had fallen at 72 hours; that of B cells remained increased at 72 hours. CONCLUSIONS: These findings show that corticosteroid treatment causes significant changes in lymphocyte subsets, and that such changes must be considered when designing studies of lymphocyte subsets during illness.

Circulating T cell subtypes in polymyalgia rheumatica and giant cell arteritis: variation in the percentage of CD8+ cells with prednisolone treatment.

OBJECTIVES: Some reports have described a decreased percentage of circulating CD8+ cells in patients with polymyalgia rheumatica and giant cell arteritis (PMR/GCA) before treatment and persisting for some months during treatment with corticosteroids. Other studies have found no such changes. There are overt methodological variations between these studies and there may also hidden differences, such as the timing of blood samples. The purpose of this study was to investigate T cell subtypes in patients with PMR/GCA while controlling for variables known to affect T cells. METHODS: Circulating T cell subsets were measured in 36 patients with PMR/GCA before and during treatment with prednisolone. Blood samples during treatment were taken before the daily dose of prednisolone. The whole blood lysis method was used followed by flow cytometry. RESULTS: Compared with controls, CD8+ cells were not reduced before treatment in patients with PMR/GCA (0.44 x 10(9)/l; 28% of lymphocytes). CD4+ cells were also normal (0.78 x 10(9)/l; 48% of lymphocytes). During treatment with prednisolone total T cells increased from 1.18 to 1.59 x 10(9)/l and CD4+ cells increased from 0.78 to 1.05 x 10(9)/l. The percentage of CD8+ cells decreased on treatment from 28 to 25%. CONCLUSIONS: This study does not confirm the finding of some groups that the percentage of circulating CD8+ cells is reduced in patients with PMR/GCA before treatment. It does show that the percentage of CD8+ cells decreases during treatment with corticosteroids. This needs to be considered when designing studies of lymphocyte subsets in diseases treated with corticosteroids.

Treatment of Paget's disease of bone with single dose intravenous pamidronate.

OBJECTIVES: To assess the efficacy of a single intravenous infusion of pamidronate in Paget's disease of bone. METHODS: Fourteen patients with active Paget's disease (raised serum alkaline phosphatase, bone pain or neurological involvement) were treated with a single intravenous infusion of 105 mg pamidronate. Patients were assessed for biochemical and clinical improvement for up to two years following treatment. A further infusion was given following symptomatic relapse (pain at a known site of pagetic involvement). RESULTS: Serum alkaline phosphatase fell following treatment, with a nadir 5.9 months after treatment. Bone pain was improved in nine of 12 patients after six months. Retreatment of four patients resulted in a similar response. CONCLUSION: Single dose intravenous pamidronate (105 mg) is a convenient and effective treatment for Paget's disease.

Musculoskeletal pain in Omanis, and the relationship to joint mobility and body mass index.

In a house-to-house population survey of representative areas of Oman, 920 adults were examined and questioned about musculoskeletal pain. Back pain was reported in 42% of females and 25% of males, and knee pain in 15% of females and 18% of males. Hip pain occurred in only three females (0.6%) and one male (0.2%), which is consistent with a protective effect of squatting. In rural communities musculoskeletal pain was more common, and less anatomically localized. Joint mobility scores were higher in females than males and, at all nine sites included in the Beighton score, laxity was significantly more common in females than males. The scores declined with age, and were higher than those reported in Europeans and similar to those in Africans and Indians. Extreme joint laxity (score 7-9), seen only in females, was associated with increased symptoms in those aged 16-25 years. Body mass index was higher in females with back or knee pain than in those without such pain. In males, only knee pain was associated with higher body mass index.

The prevalence of rheumatoid arthritis in the Sultanate of Oman.

One thousand nine hundred and twenty-five Omani adults aged 16 and over were studied in a house-to-house survey in representative areas of Oman. Seven cases (five female) are described who satisfied the 1987 ARA criteria for rheumatoid arthritis (RA), indicating a prevalence of 3.6 per thousand adults. Adjusted for the population structure, the prevalence was 8.4 per thousand adults. Complementary data are also presented on cases of RA ascertained by special screening clinics in rural health centres and by hospital rheumatology clinics. In all parts of the study, cases of RA were less often seropositive than in European populations which may account for the lower prevalence of erosive disease.

Serial measurements of fibrinolytic activity in acute low back pain and sciatica.

A fibrinolytic defect is common in chronic back pain syndromes. Its role in the chronicity of these conditions is not fully understood. To elucidate the possible mechanisms, 11 patients with acute low back pain were studied over 12 months and compared with controls. The patients showed prolongation of the euglobulin lysis time throughout the study; the fibrin plate lysis area was initially normal but became abnormal within 2 weeks. In five patients, the symptoms resolved and the initial fibrinolytic defect improved. In contrast, the fibrinolytic defect remained in six patients with persistent pain. These results suggest that the fibrinolytic defect is secondary to mechanical damage but, if persistent, may become a secondary pathogenic factor associated with the chronicity of some back pain problems.

Impaired fibrinolytic activity in defined chronic back pain syndromes.

Fibrinolytic activity was studied in 34 patients who had chronic low-back pain of defined types (spondylosis, post-laminectomy and postmyelography-proven arachnoiditis, postlaminectomy and postmyelography-possible arachnoiditis, chronic prolapsed intervertebral disc (PID), spinal stenosis, and nonspecific low-back pain). Fibrinolysis was significantly impaired in the back pain patients as a whole compared with matched controls. Similar changes were observed in all the different back pain syndromes. In the smaller subgroups, these did not reach significance but were significant in spondylosis, proven arachnoiditis, and nonspecific back pain. It is suggested that the abnormal persistence of a defect in fibrinolytic activity, leading to fibrin deposition and chronic inflammation, may be an important factor in the chronicity of many back pain syndromes.

Developmental aspects of the hip in juvenile chronic arthritis. A radiological assessment.

The aim of this study in sero-negative juvenile chronic arthritis was to examine the radiological changes in the hip joints in relation to age and mode of onset of disease. Particular attention was paid to periods of complete immobilization or reduction in weightbearing, irrespective of clinical hip involvement. Twenty-two children with an early onset of disease (i.e. less than 5 years) with clinical hip involvement were compared with 12 similarly aged children without clinical hip involvement, and 22 children with a later onset but with clinical hip involvement. In all the children with an early onset of disease the initial radiographic findings were developmental rather than destructive. In those with clinical hip involvement, destructive changes supervened, while those with later onset had destruction as the first feature, often followed by the development of protrusio acetabula. The 12 children without clinical hip involvement who had prolonged periods of non-weightbearing in early life, usually because of knee involvement, showed developmental abnormalities. These findings suggest that weightbearing should be encouraged, to promote the normal development of the hips.