Panoramic nailfold capillaroscopy: a new reading method and normal range.

Current interpretation of nailfold capillaroscopy is largely based on qualitative and subjective parameters. These parameters make the accurate assessment of the extent of the nailfold microangiopathy difficult. The authors present a comprehensive method in which several quantitative or semiquantitative parameters are used to assess the main microangiopathic features, such as microhemorrhage, plexus visibility, devascularization, and morphologic anomalies of the end row loops. The method is checked for reproducibility and applied to a sample of 800 healthy people to establish the normal range. The influences of extrinsic variables, such as gender, ethnicity, age, and local nailfold conditions are also included.

Open multicentre clinical trial of diftalone in osteoarthrosis.

An open, multicentre trial was carried out in 140 patients with coxarthroxis and/or gonarthrosis to assess the effectiveness of treatment with diftalone. The trial lasted 4 weeks with a drug dosage decreasing from 1000 mg (Week 1) to 750 mg (Week 2), and to 500 mg (Weeks 3 and 4). In almost all of the objective and subjective assessments used for the measurement of effectiveness there was a statistically significant improvement with treatment, which was dose related, the greatest improvement being seen during the first week. Tolerance of treatment was assessed as good in the majority of patients and again, side-effects appeared to be dose related.

Treatment of the cutaneous lesions of systemic lupus erythematosus with thalidomide.

Twenty three patients with SLE and cutaneous lesions not responsive to chloroquine, photoprotectors and corticosteroid in doses < 0.5 mg/kg/day were treated with thalidomide 300 mg/day. Three patients presented side effects and had to discontinue treatment. Eighteen of the remaining 20 patients (90%) had complete remission of the cutaneous lesions and 2 had partial improvement. Another important parameter of improvement was a reduction in the average prednisone dose required from 40.5 mg/day to 17.4 mg/day. The most frequent side effects were drowsiness in 52% of cases and abdominal distention in 22%. These symptoms were reversed by dose reductions in all but one patient. Thalidomide was shown to be efficient in the treatment of cutaneous lesions unresponsive to more usual treatments.

A study of synovial membrane of patients with systemic lupus erythematosus (SLE).

In this study, 30 percutaneous synovial knee biopsies were taken from patients with systemic lupus erythematosus (SLE) that had been diagnosed in accordance with ARA criteria. Acute articular involvement was present in 16 cases. The synovial membrane was then examined using routine histological techniques and by direct immunofluorescent methods. The most frequently observed histological picture was comprised of: a) synoviocyte hyperplasia, b) scarce inflammatory infiltrate, c) vascular proliferation, d) oedema and congestion, e) fibrinoid necrosis and intimal fibrous hyperplasia of blood vessels, g) presence of fibrin on the synovial surface and fibrin-like deposits in the chorion. It is concluded that immunofluorescence can be used in the characterization of typical cases but is not specific.

Systemic lupus erythematosus: a family study of 25 probands.

We studied 120 first-degree relatives (FDRs) of 25 systemic lupus erythematosus (SLE) probands and 59 non-genetically associated individuals who were in close contact with the SLE patients. A significantly greater frequency of antinuclear antibody (ANA) positivity was found among the FDRs than in the control group (p less than 0.01). No significant difference was found in ANA positive between the female and male FDRs. Articular complaints or Raynaud's phenomenon were observed in 15% of the FDRs and in only 2% of the controls (p less than 0.05). Female FDRs had a greater number of rheumatic complaints than male FDRs (p less than 0.05) and a significant association was found between rheumatic complaints and ANA positivity (p less than 0.001) among the total FDRs.

EPM-ROM Scale: an evaluative instrument to be used in rheumatoid arthritis trials.

Different tools are available for the measurement of functional status; however, only a few of them are based on the evaluation of the joint range of motion (ROM). This study is aimed at the design and evaluation of the measurement properties of a ROM scale to be used as an evaluative instrument in rheumatoid arthritis (RA) trials. The EPM-ROM Scale evaluates 10 distinct movements of the small and large joints. The score of each joint varies from 0 (full movement) to 3 (severe limitation) and the cut-off degrees of motion are, in general, based on the lack of ability to perform some determined activities of daily living. The test-retest characteristic of the scale was assessed by administering the scale twice, 5 days apart, to 35 RA patients. The product moment correlation was 0.775 (P less than 0.001). The cross-sectional construct validity of the scale was assessed by the concomitant scoring of the EPM-ROM Scale and the functional ability dimension of the Health Assessment Questionnaire (a reliable, valid and responsive instrument) in these patients. The product moment correlation was 0.518 (P less than 0.001). The evaluation of its longitudinal construct validity and responsiveness are now in progress.

Evaluation of the European Spondylarthropathy Study Group (ESSG) preliminary classification criteria in Brazilian patients.

OBJECTIVE: To evaluate the sensitivity and specificity of the ESSG criteria when applied to Brazilian patients with SpA and control patients with other rheumatic diseases. METHODS: Seventy patients with spondylarthropathies and 62 patients with other rheumatic diseases were interviewed, examined and had their charts reviewed. The diagnoses of the diseases were based on published diagnostic guidelines or classification criteria. Data were also collected according to the ESSG criteria. RESULTS: The sensitivity and specificity of the ESSG classification criteria were 98.5% and 88.7%, respectively. The sensitivities of the criteria in the different subgroups of SpA ranged from a low of 97.7% in AS to a high of 100% in other SpA studied. CONCLUSION: Despite differences in the socio-cultural and geographic characteristics and in individual disease frequencies, the ESSG preliminary classification criteria performed well when applied to Brazilian patients.

Availability of over-the-counter drugs for arthritis in Sao Paulo, Brazil.

Seventy pharmacies located in Sao Paulo were randomly selected and visited. Seven researchers posed as ordinary clients presenting with a standardized complaint of symptoms according to a scenario previously defined. The client asked for medicines to relieve his/her pain or discomfort. After the seller's suggestion the client asked for 2 drugs randomly selected from a drug list containing 30 trademarked drugs commonly prescribed to arthritis patients. These drugs should be available only on prescription. In only 12.8% of the pharmacies did the seller initially suggest the client see a physician. The sellers "prescribed' non-steroid anti-inflammatory drugs (NSAID), vitamins, analgesics (AN) and corticosteroids (CO) in respectively 42.8, 20.0, 14.3 and 5.7% of the visits. From the drug list, the client secured 67.7% of the NSAID, 65.0% of the CO and 20.0% of the sedatives without presenting a prescription. Pharmacy sellers usually comply with the clients demands. Future studies should aim at the evaluation of interventions to reduce the availability of the over-the-counter drugs for arthritis.

Symptomatic cardiac involvement in juvenile rheumatoid arthritis.

In a retrospective study of 172 patients with juvenile rheumatoid arthritis, symptomatic cardiac involvement occurred in 13 (7.6%) patients (11 systemic and 2 polyarticular). There was predominance of the male sex and in most patients the involvement occurred in the initial years of the disease. Pericarditis occurred in seven patients; perimyocarditis in four and myocarditis in two patients. In the follow-up, one of the patients with pericarditis died of an arrhythmia during pericardiocentesis for cardiac tamponade. Among the patients with myocarditis, three died of septicemia during active disease. One of these three patients had myocarditis associated with cardiac tamponade. Among the 172 patients with juvenile rheumatoid arthritis, five children died; four belonged to the symptomatic cardiac involvement group (P less than 0.001). Cardiac involvement, in particular myocarditis and cardiac tamponade, can be regarded as a factor of worse prognosis.

Psychological aspects of Brazilian women with fibromyalgia.

In order to determine the occurrence of psychological disturbances the authors studied 47 women who fulfilled the American College of Rheumatology Criteria for the classification of fibromyalgia and 25 random selected control patients without chronic muscle pain, all of whom live in Sorocaba, SP, Brazil. Personality disturbances were observable in 63.8% of the patients and 8.0% of the control group (p < 0.05); depression in 80.0% of the fibromyalgia group and 12.0% of the controls (p < 0.05) and anxiety in 63.8% of the patients and 16.0% of the controls (p < 0.05). The Hamilton test mean scores showed higher values for depression and anxiety among the fibromyalgia patients when compared to the control group. A significant association between fibromyalgia and depression, anxiety and personality disturbances was studied and recorded.

Wa idiotype in seropositive rheumatoid arthritis.

Antibodies against cross-reactive idiotypes (CRIs) may prove useful as phenotypic tracers of immunoglobulin variable region genes (VH or VL). CRIs of human rheumatoid factors (RFs) seem to be useful in the elucidation of the incidence and structural characteristics of the latter. Anti-Wa CRI antibodies were produced and an enzyme immunoassay was developed to test polyclonal RFs isolated from sera of 20 rheumatoid arthritis (RA) patients, 7 males and 13 females, aged 17 to 74 years. Seventeen patients had clinically active disease and three were in remission. Disease duration ranged from 1 to 25 years and RF titers ranged from 1:160 to 1:640. The immunoassay could detect as little as 8 ng of a monoclonal purified WaRF and positive results were found in 30% of patient sera. Therefore, we may conclude that at least part of the RFs seen in RA patients derives from germ line genes.

A study of the gram-negative bacterial flora in patients with ankylosing spondylitis.

1. Twenty-eight patients with active definite primary ankylosing spondylitis and fifty-four healthy control subjects were studied. 2. The HLA-B27 antigen was found in 75% of patients and 3.7% of controls. 3. Fecal samples from these subjects were cultured for gram-negative enteric bacteria on two occasions within one month. Positive cultures for Klebsiella sp were found in 32.1% of patients and in 22.2% of healthy controls, but this difference was not statistically significant. All other microorganisms detected were qualitatively and quantitatively similar in both groups. 4. Significantly increased mean values of serum IgA levels were found in the patient group when compared with the control group (P less than 0.01). The mean serum IgG and IgM levels did not differ statistically between the two groups. There was no correlation between any laboratory or clinical parameter and presence of Klebsiella sp carriage in ankylosing spondylitis patients. 5. These data are consistent with the view that a long time elapses between exposure to a trigger factor and clinical manifestations of the disease.

A simple radial immunohemolysis assay for the measurement of functional complement C2 activity.

1. This study describes a simple radial immunohemolysis method for determining the hemolytic activity of the second component of complement (C2) in human serum. The assay is based on the recovery of hemolytic activity of normal serum which has been pretreated to inactivate endogenous C2 and then mixed with test serum containing an unknown amount of C2. 2. The pretreated serum, designated R2 reagent, is obtained by heating normal human sera under carefully standardized conditions of temperature, time, volume and type of test tube. 3. R2 reagent is incorporated into agarose together with hemolysin-sensitized erythrocytes, and spread on a plate. The test serum is placed in wells cut in the agarose and, after appropriate incubation, the diameters of the hemolytic areas are measured. The area of hemolysis is directly proportional to the logarithm of the serum concentration. As a standard for C2 functional activity, dilutions of a pool of normal sera are tested on the same plate. 4. The method is specific for C2 and can detect as little as 20% of the C2 in normal serum (about 6 micrograms C2 protein/ml). The error in reproducibility is about 3% of the mean. In normal serum, the lower confidence limit of the distribution of the C2 values (based on a sample of 80 individuals) corresponded to 70% of undiluted serum. 5. This method is suitable for use in clinical laboratories since it is simple, rapid, quantitative and inexpensive, and does not require special equipment.

[Carpal tunnel syndrome: electroneuromyographic study of 135 cases]. / Síndrome do canal carpeano: estudo eletroneuromiográfico de 135 casos.

One hundred thirty five patients with carpal tunnel syndrome were studied trough electrophysiological techniques. Nerve sensory conductions, motor conductions and electromyography were performed in all patients and the results discussed. The authors call the attention for the technic of sensory conduction stimulating palma and picking up the potentials on the wrist as the most sensitive technic for the early detection of carpal tunnel syndrome.

Do estrogens improve bone mass in osteoporotic women over ten years of menopause.

A retrospective analysis of 24 patients with established osteoporosis and with ten or more years of menopause treated with conjugated estrogen, progesterone and calcium followed for one year has been performed. Treated women received 0.625 mg/day of conjugated estrogen from day 1 to 25, 5 mg/day of medroxiprogesterone from day 13 to 25, of each cycle, plus calcium (500-1000 mg/day), during one year (12 cycles). As control group was used 18 age-matched that received only calcium (500 a 1000 mg/day). All patients had at least two dual-photon spine and proximal femur (neck, Ward's triangle and trocanter) densities measurements performed 12 months apart. Estrogen treatment was associated with increased bone mineral density at spine and trocanter. Control group did not present any statistically change after one year in any site studied. We concluded that women with ten or more years of menopause and established osteoporosis treated with replacement hormonal therapy and calcium results in improvement of bone mineral density. These data support that women with ten or more years of menopause respond to estrogen replacement therapy with absolute increments in bone density similar to those seen in younger women, in the early menopause.

[Rheumatic manifestations of acquired immunodeficiency syndrome (AIDS)]. / Manifestações reumáticas na síndrome de imunodeficiência adquirida (AIDS).

120 AIDS patients (mean age 33 +/- 9 years, 108 males) were evaluated regarding rheumatic manifestations. According to CDC's classification, 18.3% belonged to group II, 28.3% to group III, and 53.4% to group IV. Arthralgia was present in 33 patients (27.5%), and in only 8 could be associated with infections other than HIV (5 cases of tuberculosis, 3 P. carinii, and 1 gonococcal infection). Incidence of arthralgia was equal in either sex. Arthritis was present in 8 patients, 2 of them with Reiter's syndrome. In 6 patients arthralgia was the first symptom (3 with arthritis) before AIDS diagnosis. There was a higher incidence of dry mouth, dry eyes, and muscular complaints in patients with arthralgia than in patients without arthralgia. Antinuclear antibodies and rheumatoid factor were absent in the serum of the patients studied. Arthritic manifestations possibly occur in AIDS, even in patients without other clinical manifestations, as a reactive state to HIV infection.

[A short-term randomized controlled study with methotrexate in rheumatoid arthritis]. / Estudo controlado e randomizado a curto prazo com metotrexato na artrite reumatóide.

Randomized, controlled and double-blind study of 36 patients aimed at the evaluation of the efficacy and toxicity of MTX in the treatment of rheumatoid arthritis. Twenty-eight patients completed the study period: 14 in the MTX group and 14 in the placebo group. The patients treated with MTX presented a statistically significant improvement (p < 0.05) in pain, grip strength and functional ability when compared to placebo treated patients. Mild adverse effects were observed in 4 patients treated with MTX and in 2 patients treated with placebo. These findings support other studies and give to methotrexate a relevant position in the treatment of rheumatoid arthritis, owing to its convenient posology, beneficial effectivity and favourable toxicity.

[Infantile scleroderma. Apropos of 11 cases]. / La sclérodermie infantile. A propos de onze cas.

Scleroderma is uncommon in children and adolescents. Eighty-four cases have been reported. With reference to a new series of 11 cases, the clinical features and course of the disease are described. Prognosis was good. There have been no deaths and none of the patients have significant visceral organ damage.

[Estimation of benefits and risks of the treatment of rheumatoid polyarthritis with glucocorticoids using the health-related quality of life measurements]. / Estimation des bénéfices et des risques du traitement de la polyarthrite rhumatoïde par les glucocorticoïdes à l'aide de mesures des préférences.

The purpose of this study was to use the utility approach to evaluate the risks and benefits of corticosteroid therapy in rheumatoid arthritis patients. The utility approach provides us with a quantitative measure of the value or preference a patient attaches to his overall health status defined on a scale from perfect health (1) to death (0). Benefits and toxicity are combined into a number reflecting the patients combined assessment of the benefits of treatment and the side-effects associated with it. Utility of 3 scenarios (rheumatoid arthritis patients treated respectively with no, 5 mg/day and 15 mg/day of prednisone) were determined through the time trade-off (TTO) and thermometer scale (TS) techniques. Twenty-five rheumatoid arthritis patients selected at random among subjects attending an outpatient clinic and 25 rheumatologists were interviewed using visual aids. Treatment with 15 mg/d prednisone was assigned the highest utilities by both patients and physicians. Coefficients of correlation between thermometer scale and time trade-off utilities were 0.675 (p < 0.01) for physician-assigned utilities and 0.518 (p < 0.05) for patient-assigned utilities. Medical decisions concerning rheumatoid arthritis patients should take into account the preferences of patients and physicians.