Elevated anticardiolipin antibodies in a patient with vibration-white-finger, valvular heart disease and psoriatic arthritis.

We describe a case of irreversible severe vibration-white-finger (VWF) occurring in a male who used a compression-hammer daily at work for a 20-year period. Infra-red thermography following either a cold provocation or a vibratory stress was a sensitive objective method of documenting the condition. Persistent elevation of IgG anticardiolipin antibodies (aCL) was found in his serum and may be a marker of endothelial damage associated with either VWF or the patient's coincidental valvular heart disease.

A comparison of bone loss in early and late rheumatoid arthritis using quantitative phalangeal ultrasound.

This study compares amplitude-dependent speed of sound (AD-SoS) measured by phalangeal ultrasonography in a group of 60 patients with early rheumatoid arthritis (RA) with those who had had the disease for more than 4 years. The mean duration of the early disease group was 1.4 years, and the mean of the established RA group was 14.6 years. Plasma viscosity (PV), C-reactive protein (CRP) and HAQ scores were obtained. Forty-nine patients with early RA had hand radiographs assessed by the Larsen score method. The DBM Sonic system was assessed on normal volunteers and a coefficient of variation of 0.88% obtained. A significant correlation was found between the left and right hands of the patients groups studied ( r=0.84). The mean Z score of both hands was therefore used in comparing the two clinical groups. Results showed no correlation between CRP, PV and Z scores of AD-SoS. The HAQ scores showed a weak negative correlation, and there was no correlation between the Larsen score and Z score, or the number of swollen joints and Z score. However, the early and established groups with RA were significantly different (#E5/E5#=0.004). Within the early RA group the Z score for AD-SoS was lower in those with disease duration of less than 2 years (-1.71) than in those with disease duration of 2-4 years (-1.01). This suggests that bone loss in the fingers is greater in the first 2 years of disease than in the following 2 years, which might reflect an effect of treatment.

Heart rate evaluation of axillary and elbow crutches.

The aim of this study was to compare the possible effect on heart rate in patients with a walking disability using 11 different crutch designs. Eighteen patients, over the age of 18 years, who had used crutches for a minimum of 2 weeks before the study were divided into two groups: elbow and axillary crutch users respectively. The former tested six different designs of elbow crutches and the latter five different pairs of axillary crutches. Heart rate was recorded, using a portable digital pulse monitor during a 5-min walk on the level at self-selected velocities. Walking heart rates increased between 28.6 and 58.8% compared with the resting phase. No differences were found in either heart rate or walking speed between elbow crutches. However, a significant difference (p less than 0.001) in heart rate was noted between elbow crutch users who were non-weight bearing on their injured leg compared with those who were partial-weight bearing. The Canadian axillary crutch showed the lowest increase in heart rate at comparable walking speeds compared with other axillary crutches. Prescribers should be aware that the reduced energy requirements of the Canadian crutch would benefit patients with reduced cardiorespiratory function.

Testosterone and testosterone free index in mild ankylosing spondylitis: relationship with bone mineral density and vertebral fractures.

OBJECTIVE: To determine the androgen status of men with mild ankylosing spondylitis (AS) and to evaluate the relationship of sex hormones with bone mineral density (BMD) and vertebral fractures. METHODS: Fifty-six male patients with mild AS were studied. All patients had BMD measured by dual x-ray absorptiometry (DXA) of the lumbar spine and hip, and had radiographs of the thoracic and lumbar spines. Radiographs were evaluated morphometrically, and vertebral fractures were defined using established criteria. Serum total testosterone, sex hormone binding globulin (SHBG), follicle stimulating hormone (FSH), and luteininzing hormone (LH) were measured in the patients with AS and 52 age matched controls. Testosterone free index (TFI) was calculated. RESULTS: There was a small, not significant reduction in serum total testosterone in patients with AS compared to controls [16.02 (5.0) vs 21.0 (6.2) nmol/l]. Serum SHBG was significantly lower in patients with AS [27.29 (10.6) vs 35.0 (13.0) nmol/l; p < 0.001] compared to controls. There was no significant difference in the mean TFI between patients and controls [58.7 (21.2) vs 60 (22.2) nmol/l; p > 0.05] or in the levels of LH and FSH. No significant correlation was found between sex hormones, BMD, and vertebral fractures in patients with AS. CONCLUSION: Sex hormones are not altered significantly in patients with mild AS and do not appear to be related to BMD or vertebral fractures. Osteopenia in men with mild AS is therefore unlikely to be secondary to hypogonadism.

Biochemical markers of bone metabolism in mild ankylosing spondylitis and their relationship with bone mineral density and vertebral fractures.

OBJECTIVE: To determine the relationship of biochemical markers of bone metabolism in patients with mild ankylosing spondylitis (AS) with disease activity, bone mineral density (BMD), and vertebral fractures. METHODS: A total of 56 male patients with mild AS were studied. All patients had BMD measured by dual x-ray absorptiometry of the lumbar spine and hip and radiographs of the thoracic and lumbar spines. Radiographs of patients with AS were evaluated morphometrically and vertebral fractures were defined using established criteria. Serum osteocalcin, total and bone alkaline phosphatase (ALP, BALP, respectively), 25-hydroxyvitamin D (25-OHD), parathyroid hormone (PTH), urinary deoxypyridinoline (Dpyr), and pyridinoline (Pyr) were measured in the patients with AS and compared with 52 age and sex matched controls. Thirty-nine healthy male subjects aged 50-60 years, recruited from primary care registers, had spinal radiographs and served as controls for vertebral fractures. RESULTS: Patients with AS had reduced BMD of the lumbar spine, 0.98 (0.1) g/cm2 [T score = -1.14 (1.2) and Z score = -1.01 (1.2)], and femoral neck, 0.83 (0.1) g/cm2 [T score = -1.44 (1.2) and Z score = -0.73 (1.1)]. Of the 56 patients with AS, 11 (19.6%) had a vertebral fracture, whereas only one of 39 control subjects did (2.6%). Patients with AS had significantly lower mean serum osteocalcin compared with controls [9.03 (2.7) microg/l vs 11.05 (2.33) microg/l; p < 0.001], and significantly higher mean serum ALP [73.09 (19.5) U/l vs 53.02 (16.7) U/l; p < 0.001] and BALP [38.54 (9.9) U/l vs 30.35 (8.28) U/l; p < 0.001]. There was no significant difference in the excretion of Dpyr and Pyr between patients with AS and controls [4.90 (3.9) nmol/mmol vs 4.00 (3.6) nmol/mmol, and 15.66 (10.8) nmol/mmol vs 12.24 (10.3) nmol/mmol, respectively]. There were no significant differences in the mean 25-OHD and PTH levels in patients with AS compared to controls [20.03 (1.6) micromol/l vs 18.9 (2.9) micromol/l and 3.31 (1.5) pmol/l vs 2.63 (0.4) pmol/l, respectively]. The biochemical markers of bone formation and resorption correlated well with inflammatory indices of disease activity (acute phase reactants), but not with BMD of the lumbar spine or femoral neck. No significant difference was seen in any marker of bone turnover when AS patients with vertebral fractures were compared with those without. CONCLUSION: Bone turnover in patients with mild AS is characterized by low serum osteocalcin and ALP in the presence of normal calciotropic hormones. Biochemical markers of bone metabolism do not correlate with BMD or vertebral fractures. The disparity between osteocalcin and alkaline phosphatase in patients with AS needs further evaluation.

Low level laser therapy is ineffective in the management of rheumatoid arthritic finger joints.

Low level laser therapy (LLLT) is a relatively new and increasingly popular form of electrotherapy. It is used by physiotherapists in the treatment of a wide variety of conditions including RA despite the lack of scientific evidence to support its efficacy. A randomized, double-blind and placebo-controlled study was conducted to evaluate the efficacy of LLLT. The patient sample consisted of chronic RA patients with active finger joint synovitis. Forty RA patients with involvement of some or all of MCP or PIP joints were recruited. Following random allocation they received either active or placebo laser three times a week for 4 weeks. Measurements were taken prior to entry, after the treatment, 1 month and 3 months at follow-up. The groups were well matched in terms of age, sex, disease duration and severity. Few significant differences were noted in grip strength, duration of morning stiffness, joint tenderness, temperature of inflamed joints, range of movement or pain either within or between groups. Using these irradiation parameters the efficacy of LLLT is ineffective.

Quantitative nailfold capillaroscopy findings in a population with connective tissue disease and in normal healthy controls.

OBJECTIVE: To describe and quantify the morphological characteristics of nailfold capillaries that distinguish different forms of connective tissue disease from healthy controls. METHODS: A CCD video microscope with fibreoptic illumination and PC based image processing was used to visualise nailfold capillaries and to quantify findings in 23 patients with systemic sclerosis (SSc), 22 patients with systemic lupus erythematosus (SLE), 21 patients with undifferentiated connective tissue disease (UCTD), and 38 healthy controls. RESULTS: Capillary density was reduced in SSc (5.2 (SD 1.3) capillaries/mm) compared with other patient groups and controls. The average number of enlarged capillaries/finger was high in all disease groups (5.5-6.6) compared with controls (2). However, giant capillaries were most frequent in SSc (43%) and were not present in controls. Mild and moderate avascular areas were present in all groups (35%-68%), but severe avascularity was most frequent in SSc (44%) compared with other patients (18%-19%) and controls (0%). The greatest frequency of extensive haemorrhage was in SSc (35%). CONCLUSIONS: There is a range of abnormal capillary findings in patients with connective tissue disease and healthy controls. However, certain abnormalities such as a reduced number of capillaries, severe avascularity, giant capillaries, and haemorrhage are most commonly associated with SSc. Videomicroscopy with image processing offers many technical advantages that can be exploited in further studies of nailfold capillaries.

The prevalence of vertebral fractures in mild ankylosing spondylitis and their relationship to bone mineral density.

OBJECTIVE: To determine bone mineral density (BMD) in patients with mild ankylosing spondylitis (AS), to establish the prevalence of vertebral fractures and fracture risk in these patients, and to determine the relationship between BMD and vertebral fractures. METHODS: Sixty-six men with mild AS were studied. BMD of the lumbar spine and femoral neck was measured by dual X-ray absorptiometry (DXA) and radiographs of the thoracic and lumbar spine were obtained in all subjects. From the radiographs, vertebral fractures were characterized by a morphometric technique using established criteria. Thirty-nine healthy male subjects aged 50-60 yr, recruited from primary care registers, had spinal radiographs performed and served as controls for vertebral fractures. RESULTS: In patients with AS, BMD was reduced in both the lumbar spine 0.97 (0.1) g/cm(2) [T score -1.10 (1.3), 95% confidence interval (CI) -0.50, +0.14] and femoral neck 0.82 (0.1) g/cm(2) [T score -1.40 (1.2), 95% CI -0.51, +0.09]. There was no correlation between BMD of either the lumbar spine or femoral neck and duration of disease in patients with AS. Eleven of 66 (16.7%) patients with AS had a vertebral fracture, compared with one of 39 (2.6%) controls; odds ratio 5.92 (95% CI 1.4, 23.8). AS patients with fractures were not significantly older (mean age 41.4 vs 37.8 yr, P=0.17), but had significantly longer disease duration (12.4 vs 9.3 yr, P<0.05) than patients without fractures. No significant difference was found in the visual analogue scores for pain in AS patients with fractures compared with those without. No significant correlation was observed between BMD of the lumbar spine or femoral neck and vertebral fractures in patients with AS. In addition, there was no significant difference in the lumbar spine or femoral neck BMD in AS patients with fractures compared with those without. CONCLUSIONS: Spinal and hip osteopenia and vertebral fractures are a feature of mild AS. However, there was no correlation between BMD and vertebral fractures in these patients. AS patients with mild disease had a higher risk of fractures compared with the normal population and this increased with the duration of disease.