Clinical and immunological characteristics of 150 systemic lupus erythematosus patients in Jamaica: a comparative analysis.

Background Epidemiological studies in systemic lupus erythematosus have been reported in the literature in many countries and ethnic groups. Although systemic lupus erythematosus in Jamaica has been described in the past, there has not been a detailed evaluation of systemic lupus erythematosus patients in urban Jamaica, a largely Afro-Caribbean population. The goal of this study was to describe the clinical features, particularly disease activity, damage index and immunological features, of 150 systemic lupus erythematosus subjects. Methods 150 adult patients (≥18 years) followed in rheumatology clinic at a tertiary rheumatology hospital centre (one of two of the major public referral centres in Jamaica) and the private rheumatology offices in urban Jamaica who fulfilled Systemic Lupus International Collaborating Clinics (SLICC) criteria were included. Data were collected by detailed clinical interview and examination and laboratory investigations. Hence demographics, SLICC criteria, immunological profile, systemic lupus erythematosus disease activity index 2000 (SLEDAI-2K) and SLICC/American College of Rheumatology (ACR) damage index (SDI) were documented. Results Of the 150 patients, 145 (96.7%) were female and five (3.3%) were male. The mean age at systemic lupus erythematosus onset was 33.2 ± 10.9. Mean disease duration was 11.3 ± 8.6 years. The most prevalent clinical SLICC criteria were musculoskeletal, with 141 (94%) of subjects experiencing arthralgia/arthritis, followed by mucocutaneous manifestations of alopecia 103 (68.7%) and malar rash 46 (30.7%), discoid rash 45 (30%) and photosensitivity 40 (26.7%). Lupus nephritis (biopsy proven) occurred in 42 (28%) subjects and 25 (16.7%) met SLICC diagnostic criteria with only positive antinuclear antibodies/dsDNA antibodies and lupus nephritis on renal biopsy. The most common laboratory SLICC criteria were positive antinuclear antibodies 136 (90.7%) followed by anti-dsDNA antibodies 95 (63.3%) and low complement (C3) levels 38 (25.3%). Twenty-seven (18%) met SLICC diagnostic criteria with only positive antinuclear antibodies/anti-dsDNA antibodies and lupus nephritis on renal biopsy. Mean SLEDAI score was 6.9 ± 5.1 with a range of 0-32. Organ damage occurred in 129 (86%) patients; mean SDI was 2.4 ± 1.8, with a range of 0-9. Conclusion These results are similar to the clinical manifestations reported in other Afro-Caribbean populations; however, distinct differences exist with respect to organ involvement and damage, particularly with respect to renal involvement, which appears to be reduced in our participants.

Long-term results of the Manchester knee. Surface arthroplasty of the tibiofemoral joint.

Unicompartmental knee replacement is increasing in popularity. Long-term analysis of an early bi-compartment variety, the Manchester knee, therefore has relevance. One hundred fifty-six consecutive Manchester knee replacements were observed, 47 for longer than ten years. Using survivorship tables, the authors found that the annual failure rate did not increase during the ten-year period. The cumulative success rate was 73% for all knees and 69% for the osteoarthritic ones. The main cause of failure was subsidence. Correction of mechanical axis had no effect on the outcome. Polyethylene wear was not significant clinically or on measurement of retrieved specimens.

Curved Kuntscher nail arthrodesis after failure of knee replacement.

We report the use of long curved Kuntscher nails to maintain stability during arthrodesis of nine infected and five uninfected failures of total knee replacement. The curvature of the nail helps positioning and avoids the need for cortical perforation. A single-stage operation was possible in most cases. Union rates are comparable with those of other series and even patients with delayed union have satisfactory function.

Treatment of subtrochanteric fractures of the femur: a study of intramedullary compression nailing.

The results of prospective treatment of 31 patients with subtrochanteric fractures using the Derby intramedullary nail are presented. The nail design, plus cerclage wires in unstable cases, allows axial compression of the fracture, to give rigid fixation and load-sharing between bone and nail. Twenty-seven patients were followed up for an average of 21.7 months. There were no mechanical failures of the nails, and all 27 fractures united, two in minimal varus. Relatively early mobilization of the patients with isolated fractures occurred.

External fixation or plaster for severely displaced comminuted Colles' fractures? A prospective study of anatomical and functional results.

We report a prospective, randomised, controlled trial of 50 severely displaced comminuted Colles' fractures treated by either external fixation or manipulation and plaster. Each patient was assessed radiographically throughout treatment, and functionally by an independent observer at three and six months. The functional result correlated with the anatomical result, which was significantly better in patients treated by external fixation. This resulted in significantly improved function especially in young patients, and also a lower complication rate. We recommend the use of external fixation for young patients with comminuted displaced Colles' fractures unless manipulation and plaster show excellent reduction.

Epidurography in the management of sciatica.

Fifty consecutive patients starting treatment for sciatica with epidural injections of steroid and local anaesthetic underwent concomitant epidurography. The prognostic potential of this combination was investigated. Epidurography was confirmed as a safe out-patient procedure. Incorrect needle siting accounted for five total and two partial failures. The procedure was found to be a sensitive investigation, 36 showing definite abnormalities. It was of particular value in the diagnosis of lateral canal stenosis. However, it was found to have no prognostic value. For 12 of 16 patients requiring invasive therapy, it was considered that epidurography would have obviated later radiculography had the results been known. It is suggested that the combination of this out-patient investigation with the last of three epidural anaesthetic injections in patients whose symptoms persist, represents an improvement in management both financially and in terms of patient convenience.

Metacarpo-phalangeal joint replacement with a new prosthesis: description and preliminary results of treatment with the Helal flap joint.

A new prosthesis for the metcarpo-phalangeal joint is presented. Its advantageous design features and the early results following its use suggest that it is of value in treating the painful, stiff and ulnar deviated metacarpo-phalangeal joint in the rheumatoid hand.

Compilation of reported biological effects data and ultrasound exposure levels.

A compilation of reports of biological effects and related ultrasound exposure levels can be useful in the identification of trends in effects data that may be developing in the literature. The exposures in the experiments reviewed were at frequencies used in medicine. For short (10 minutes or less) continuous wave exposure, with the exception of behavioral effects where variable results have been observed, this tabulation did not identify any in vivo or in vitro effects at spatial peak, temporal average (SPTA) intensities less than 100 mW/cm2. However, a number of effects using pulsed sources with SPTA intensities under this level have been reported. There are several frequently recurring topics in recent reports which include developmental effects and microstructure changes at the cellular level. In addition to animal investigations, there are some limited human epidemiological studies reporting an association between medical ultrasound exposure in utero and developmental effects. Although sufficient research has not been completed to draw conclusions, the findings deserve further investigation. A systematic pattern of directed research on a large scale is not apparent. The available data consist of many scattered studies conducted by individual investigators and groups throughout the world.

Factors affecting the outcome of Colles' fracture: an anatomical and functional study.

A prospective radiological and functional assessment has been performed on 235 consecutively treated displaced Colles' fractures. The age and sex of the patients, as well as the initial displacement, involvement of articular surface and the adequacy of reduction of the fracture, were all analysed. Because of their greater potential for collapse, the better reduced fractures tended to lose more position during treatment. Despite this, in general, the better the reduction, the better was the final anatomical position of the fractures. The functional result at 3 months was related to the severity of initial displacement of the fracture and, to a lesser extent, to the anatomical result. Involvement of the radiocarpal and the distal radioulnar joints did not seem to affect adversely the patients' rehabilitation, but this was slower and less complete in the elderly. At 6 months, 60 per cent of patients had good or excellent function in the hand and wrist.

The hand complications of Colles' fractures.

Two hundred and thirty-five patients with displaced Colles' fractures were followed to union, and 209 patients to six months, specifically searching for hand pathology. The incidence of carpal tunnel syndrome was seventeen per cent at three months and twelve per cent at six months. The patients with the syndrome were significantly older and their fractures showed significantly greater residual dorsal angulation. Sixteen patients developed Dupuytren's disease between three and six months, when the incidence was eleven per cent. These patients were significantly older and had average fractures and anatomical results. All cases were mild, with only two contractures. Twenty-one patients were reviewed at a mean of 20.7 months post-fracture, when no case had significantly progressed.

Functional cast-bracing for Colles' fractures. A comparison between cast-bracing and conventional plaster casts.

The use of Orthoplast cast-bracing to allow early hand function in the treatment of displaced Colles' fractures was investigated in 243 patients. They were randomly allocated into three groups: in the first a conventional Colles' type plaster was used; in the second an above-elbow cast-brace with the forearm in supination; and in the third a below-elbow cast-brace. Radiographic measurements were made at each stage of treatment, and the final anatomical result was scored using Sarmiento's (1975) criteria. Function was assessed at three months and at six months. The anatomical result was not influenced by the method of immobilisation but was related to the efficacy of reduction. Loss of position in the braces was no greater than in plaster. The functional result at three months also was uninfluenced by the method of immobilisation; it was, however, related to the severity of the initial displacement, and (to a lesser degree) to the anatomical result, an effect which was lost at six months. Early hand function and the supinated position advocated by Sarmiento were found to confer no anatomical or functional advantage; we could see no reason to change from the use of conventional plaster casts in the treatment of uncomplicated Colles' fractures.

Pugh's nail fixation versus Thompson's prosthesis for displaced subcapital fractures of the femur.

A retrospective study of 100 fresh displaced subcapital fractures of the femoral neck is reported, comparing the results of treating 50 by primary Thompson's prostheses with 50 of those treated by internal fixation with Pugh's nail and plate. Up to 3 months, the mortality following Thompson's prosthesis was higher than that following internal fixation but was comparable at 1 year. In general the results were comparable at 1 year but the failure rate in that time was higher following internal fixation, leading to a much higher number of second operations.

The hip cast-brace for hip prosthesis instability.

The use of a hip cast-brace in the treatment of unstable hips following prosthetic replacement is described. A retrospective study of 21 patients with 22 hip prostheses treated with the cast-brace is reported. Seventeen Charnley low friction arthroplasties (LFA) were treated--four cast-braces were used for prophylaxis, five for single dislocations and eight for recurrent dislocations. To date, only four hips have required an operation to achieve stability. Five patients with Thompson hemi-arthroplasties were treated following dislocation with only one requiring surgery to achieve stability. A hip cast-brace is recommended as a useful alternative to surgical management of prosthetic instability.