Methotrexate therapy in rheumatoid arthritis. A two year prospective follow-up.

One hundred and thirty seven rheumatoid arthritis (RA) patients refractory to D-penicillamine and some of them (15%) refractory to other slow active drugs were treated with oral methotrexate (MTX) (10-15 mg weekly). After 12-24 months of treatment, 94 and 74 patients respectively showed a significant improvement as judged by duration of morning stiffness (p less than 0.0001), grip strength (p less than 0.0001), degree of joint swelling (p less than 0.01) and tenderness (p less than 0.0001) compared to pre-treatment values. This clinical improvement was also associated with a decrease of erythrocyte sedimentation rate (p less than 0.001), decrease of C-reactive protein (p less than 0.0001) and with improvement of anaemia (p less than 0.05). No changes were seen in rheumatoid factor titres. Seventy-four of the patients were followed for up to 24 months. Thirty-one of them (23%) had complete remission and 43 (31%) had an excellent response. Adverse drug reaction during MTX therapy included: elevated liver enzymes in 34 patients, mucosal ulcers in 21, nausea and vomiting in 8, diarrhoea in 4, leukopenia in 2, interstitial pneumonitis in one, intestinal bleeding in one and finally septic arthritis in another patient. The majority of these side effects were resolved without sequelae. However, 15 patients (11%) with adverse drug reactions had to discontinue the treatment. Forty-one of our patients who received a cumulative mean dose of MTX of 1550.5 +/- 235.5 mg underwent a percutaneous liver biopsy. Ten patients had normal tissue, 12 had minimal changes, 13 nonspecific changes and 6 patients had mild fibrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Aprindine-induced hepatic granulomata.

Aprindine is a very effective antiarrhythmic agent with a narrow therapeutic ratio. We report a patient who suffered from granulomatous hepatitis probably due to the administration of aprindine. Evidence of hepatitis appeared within 6 weeks of initiating aprindine therapy and resolved rapidly when the drug was withdrawn. Six months later, fibrosis but no granulomata were found in the expanded portal tracts. Our observations suggest that granulomatous hepatitis can occur during aprindine therapy.

Laparoscopic cholecystectomy using ultrasonically activated coagulating shears.

Ultrasonic energy has recently been used for surgical cutting and coagulating. A prospective randomized study was undertaken to determine the effectiveness of ultrasonic energy versus monopolar electrosurgery in human laparoscopic cholecystectomy. Two hundred patients were enrolled and randomized into two groups of 100 patients each. Group A patients underwent laparoscopic cholecystectomy with monopolar electrocautery. Group B patients underwent laparoscopic cholecystectomy with ultrasonically activated shears. In 18 cases of this group, the cystic artery was coagulated and cut without clips. Subhepatic closed drainage was left for 24 h in patients who were candidates for oozing of blood or leakage of bile. The median operating time was 45 min in group A and 37 min in group B. Subhepatic drainage was left in 37 patients of group A and 26 of group B. The median blood loss was 14 ml in group A and 2 ml in group B, while 3 patients of group A and none of group B had bile leakage from the bed of the gallbladder for 1, 1, and 6 days, respectively. Postoperative ultrasound examination showed a minor subhepatic fluid collection in 5 patients of group A and in 1 patient of group B. All these collections were treated without drainage. The length of hospital stay was 1.9 +/- 0.5 days in group A and 1.4 +/- 0.2 days in group B. Postoperative pain scores, nausea, and vomiting were equivalent in both groups. It is concluded that ultrasonically activated coagulating shears are safer, easier to use, faster, and less prone to intraoperative complications and postoperative morbidity than monopolar electrocautery in laparoscopic cholecystectomy.