The sulphated glycosaminoglycan levels in synovial fluid aspirates in patients with acute and chronic joint disease

Proteoglycan levels were measured in a series of synovial fluid samples from patients with acute and chronic joint diseases using a modified chemical dye binding method. Levels found in 50 miscellaneous inflammatory arthritis fluids (mean = 173.2 +/- 90.9 micrograms/ml) were higher than found in either 50 with rheumatoid arthritis (96.3 +/- 31.3 micrograms/ml) or 50 with osteoarthritis (83.8 +/- 27.3 micrograms/ml). For comparison, proteoglycan levels were measured in 15 cadaver synovial fluids (98.9 +/- 44.2 micrograms/ml) and 12 synovial fluids from patients with sports injury (163.7 +/- 79.4 micrograms/ml). Patients were recruited into a trial where synovial fluid was aspirated as often as possible over a 6-month period during which the patients were followed using a number of well proven clinical parameters. No correlation was found between the degree of joint destruction as measured by X-ray damage and the concentration or total amount of proteoglycan in the synovial fluid. In addition, there was no correlation between the level or total amount of proteoglycan and any clinical parameter of disease activity.

Salmonella enteritidis causing joint sepsis

A 22-year-old male taking dexamethasone following resection of a medulloblastoma developed an acutely painful swollen knee from which salmonella enteritidis was cultured. He had no gastrointestinal symptoms; one stool culture was positive. Active metalloproteinases without inhibitors were detected in the synovial fluid, a characteristic finding in septic joints. S. enteritidis infecting joints is extremely rare despite being the second most frequent salmonella species after S. typhimurium causing infections in man. The recent findings of S. enteritidis in eggs, and poultry points to one more source of infection. Immunosuppression is likely to facilitate infection.

A prospective double blind dummy placebo controlled study comparing triamcinolone hexacetonide injection with oral diclofenac 50 mg TDS in patients with rotator cuff tendinitis

A prospective double blind placebo controlled study was carried out to compare the effects of subacromial injection of triamcinolone and oral diclofenac in patients with rotator cuff tendinitis over a 4-week period. Both forms of treatment were superior to placebo in reducing pain, improving active abduction and reducing functional limitation. Triamcinolone showed the greatest effect in these respects, and was significantly superior to diclofenac when patients showing improvements in all 3 variables together (responders) were considered.

Identification of a new metalloproteinase inhibitor that forms tight-binding complexes with collagenase

Connective-tissue cells produce a family of metalloproteinases which, once activated, can degrade all the components of the extracellular matrix. These potent enzymes are all inhibited by the tissue inhibitor of metalloproteinases (TIMP), and it was thought that the levels of this inhibitor controlled the extracellular activity of these enzymes. We recently detected a new metalloproteinase inhibitor present in culture media of WI-38 fibroblasts. The inhibitor, named 'large inhibitor of metalloproteinases' (LIMP), can be separated from TIMP by gel filtration on Ultrogel AcA 44, where it is eluted with an apparent Mr of 76,000. A portion of this inhibitor-containing peak binds to concanavalin A-Sepharose, indicating that at least some of the inhibitor contains carbohydrate. LIMP inhibits collagenase (MMP-1), stromelysin (MMP-3) and gelatinase (MMP-2) in a dose-dependent fashion. Collagenase forms tight-binding complexes with LIMP, which can be separated from free collagenase on gel-filtration columns. The complex is eluted with Mr 81,600 (AcA 44) or Mr 60,000 (Superose 12). This complex is larger than that formed between collagenase and TIMP, which has Mr 52,800 (Aca 44) or 41,000 (Superose 12). Polyclonal antibody to TIMP does not recognize LIMP by immunoblotting, and will not block the inhibition of collagenase by LIMP, showing that LIMP is not a multimeric form of TIMP. The role of this new inhibitor in connective-tissue breakdown studies and its relationship to previously described inhibitors of metalloproteinases is discussed.

Rarity of synovitis in polymyalgia rheumatica

The joints of 56 patients with polymyalgia rheumatica were examined for evidence of inflammatory synovitis. x Rays, isotope scans, and thermography supplemented clinical examination. Control sternoclavicular joints were examined at necropsy. Peripheral and axial synovitis were uncommon and the results contrast with the findings of several recent studies.

Modulation of plasminogen activator production by interleukin 1: differential responses of fibroblasts derived from human skin and rheumatoid and non-rheumatoid synovium

Rheumatoid synovial fibroblasts were treated with purified porcine interleukin 1 alpha and recombinant human interleukin 1B, and the production of secreted and cell-associated plasminogen activator activity was measured. No stimulation of plasminogen activator activity was seen in response to either preparation of interleukin 1, and in more than half of the cell cultures interleukin 1 caused a significant decrease in the secreted levels of PA activity. Increased levels of prostaglandin E were produced in the same experiments, indicating that the cells were responsive to the interleukin 1 preparations. Both retinoic acid and unfractionated monocyte conditioned medium were able to stimulate the production of PA activity by the rheumatoid synovial fibroblast cultures. The rheumatoid synovial fibroblasts produced two species of plasminogen activator as indicated by SDS polyacrylamide gel electrophoresis, with apparent Mr of approx. 50,000 and 100,000. The Mr = 50,000 species co-migrates with urokinase-type plasminogen activator. No species is produced which co-migrates with tissue type plasminogen activator. Studies with antibodies also indicate that the activity produced is urokinase-type plasminogen activator. The Mr = 100,000 species may be an enzyme-inhibitor complex. Two non-rheumatoid synovial fibroblast cultures and two out of six human skin fibroblast cultures did produce elevated levels of plasminogen activator activity in response to recombinant human interleukin 1B. The results suggest that fibroblast populations may differ in their response to interleukin 1, in terms of production of plasminogen activator activity.

A comparison of two formulations of indomethacin ('Flexin Continus' tablets and 'Indocid' capsules) in the treatment of osteoarthritis

The efficacy and side-effect profiles of two formulations of indomethacin were compared in a multi-centre, double-blind, crossover study in 77 patients with osteoarthritis. Patients were allocated at random to receive 75 mg indomethacin per day either as 1 controlled-release tablet at night or as 1 immediate-release capsule given 3-times daily for a period of 4 weeks, after which patients were crossed over to receive the alternative treatment for a further 4 weeks. Pain scores, daily symptomatology and the requirement for escape analgesia recorded by the investigator and patient indicate that controlled-release indomethacin tablets, 75 mg given at night, were as efficacious as immediate-release indomethacin capsules, 25 mg given 3-times daily, in the treatment of osteoarthritis. The side-effect profiles of the two formulations were similar.

A comparison of two formulations of indomethacin ('Flexin Continus' tablets and 'Indocid' capsules) in the treatment of rheumatoid arthritis

A multi-centre, double-blind, crossover study was carried out in 80 patients with rheumatoid arthritis to compare the efficacy and side-effect profiles of two formulations of indomethacin. Patients were allocated at random to receive 75 mg indomethacin per day either as 1 controlled-release tablet at night or as 1 immediate-release capsule given 3-times a day for a period of 4 weeks before being crossed over to receive the alternative treatment for a further 4 weeks. Pain scores, daily symptomatology and the requirement for escape analgesia recorded by both investigator and patient indicated that controlled-release indomethacin tablets, 75 mg given at night, was as efficacous as immediate-release indomethacin capsules given 3-times daily. However, the controlled-release formulation had a superior side-effect profile with a reduced incidence of abdominal/epigastric pain compared to the immediate-release preparation.

The effect of the anabolic steroid, stanozolol, on the production of procollagenase by human synovial and skin fibroblasts in vitro

The ability of the anabolic steroid, stanozolol, to stimulate procollagenase production by human synovial and skin fibroblasts was examined in an in vitro assay system. Stanozolol is used therapeutically to treat a variety of connective tissue and vascular disorders and its clinical effects suggest that it can modulate connective tissue breakdown. The results showed that stanozolol was capable, in a dose dependent manner, of significantly stimulating procollagenase production by skin fibroblasts. However, in three synovial fibroblast lines no evidence was found of increased collagenase production following treatment with stanozolol; although the synovial fibroblasts secreted significantly increased amounts of procollagenase in response to IL-1. These results may shed some light on the mechanism of action in vivo of stanozolol in the treatment of connective tissue disorders.

Synovial fluids from infected joints contain active metalloproteinases and no inhibitory activity

Serial samples of synovial fluid aspirated from two patients with septic arthritis were assayed for proteinases and proteinase inhibitors. Active metalloproteinases but no proteinase inhibitors were present in all samples taken prior to treatment. The levels of active metalloproteinases fell with time although proenzyme forms were still present in the fluids. Both alpha 2-macroglobulin and the tissue inhibitor of metalloproteinases were found in the septic synovial fluids after treatment commenced. It is proposed that the lack of inhibitors and the presence of active proteinases capable of digesting collagen, gelatin and proteoglycan accounts for the rapid loss of cartilage found in septic arthritis.

Treatment of polymyalgia rheumatica and giant cell arteritis. II. Relation between steroid dose and steroid associated side effects

In a prospective study of 74 patients and a retrospective study of 35 patients with polymyalgia rheumatica/giant cell arteritis steroid related side effects occurred in at least one third of patients, and in two thirds if weight gain was included. Side effects were significantly related to an initial prednisolone dose of more than 30 mg and to the cumulative prednisolone dose. Patients taking a mean daily dose of 5 mg prednisolone or less were significantly less likely to develop side effects.

Erythrocyte sedimentation rate and C reactive protein in the assessment of polymyalgia rheumatica/giant cell arteritis on presentation and during follow up

The erythrocyte sedimentation rate (ESR) and C reactive protein (CRP) were measured in 74 patients with polymyalgia rheumatica (PMR)/giant cell arteritis (GCA) on presentation, in the first month of treatment, and at long term follow up (up to 177 weeks). Before treatment the ESR was raised (greater than 30 mm/h) in all cases and the CRP was raised (greater than 6 mg/l) in 49/55 cases. The ESR was a better indicator of clinical disease activity except in patients who felt completely well at week 1. 'False positive' increases of ESR or CRP were rare. During relapses ESR was normal in 37/77 (48%) of cases and CRP in 41/73 (56%). It is suggested that ESR is the most useful laboratory parameter in assessing PMR/GCA.

Treatment of polymyalgia rheumatica and giant cell arteritis. I. Steroid regimens in the first two months

Thirty nine patients with polymyalgia rheumatica (PMR) and 35 with giant cell arteritis (GCA) were treated with high or low dose steroid regimens in a prospective study of the first two months of treatment. Patients with PMR needed 15-20 mg prednisolone initially; 13/20 (65%) relapsed on an initial dose of 10 mg/day. All but two patients with GCA were successfully treated with 40 mg/day prednisolone initially but relapsed on a reduction to 20 mg/day. One patient with GCA receiving 30 mg/day relapsed after four weeks. Six patients with PMR developed GCA during the first two months and required an increased prednisolone dose to control symptoms. The erythrocyte sedimentation rate or C reactive protein did not predict relapse.

Transforming growth factor-beta causes partial inhibition of interleukin 1-stimulated cartilage degradation in vitro

We show that purified human transforming growth factor-beta (1-10ng/ml) inhibits interleukin 1-stimulated loss of proteoglycan from cartilage in vitro. Inhibition is incomplete, as interleukin 1 retains the ability to cause a dose dependent stimulation of proteoglycan release in the presence of high levels of transforming growth factor-beta (100ng/ml) although both basal and interleukin 1-stimulated levels can be reduced by up to 50 per cent. This observation, together with its ability to stimulate proteoglycan synthesis and to stimulate proteinase inhibitor production, suggests a possible role for transforming growth factor-beta in limiting cartilage proteoglycan loss in inflammatory conditions such as rheumatoid arthritis.

Beneficial effect of monoclonal antibody to interleukin 2 receptor on activated T cells in rheumatoid arthritis

Campath 6, a rat IgG2b monoclonal antibody to the interleukin 2 receptor on activated T cells, was used to treat three patients with active rheumatoid arthritis unresponsive to conventional treatment. Two patients had an excellent response for about three months. There were no significant side effects. The results suggest that activated T cells are of importance in the pathogenesis of rheumatoid arthritis. Although infusions of rat monoclonal antibodies could not be repeated because of the risk of sensitisation, the development of humanised monoclonal antibodies targeted against specific T cell sets would allow repeated courses of treatment to be given.

Incidence of gastropathy in destructive arthropathies

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving the symptoms of arthritis, but may have serious side-effects such as gastrointestinal lesions. This paper reviews the current status of knowledge concerning NSAID-induced gastropathy. In general, patients who present with bleeding peptic ulcers are more likely to be using a NSAID than are matched controls. The incidence of gastric lesions is increased in patients receiving more than one NSAID, suggesting a cumulative risk for these drugs. Endoscopic studies, which have attempted to relate the presence of a lesion to dyspeptic symptoms have shown a poor correlation, indicating a high risk of perforation and bleeding without prior symptomatic warning. Peptic ulcer disease is equally prevalent in patients with rheumatoid arthritis or with osteoarthritis, so the underlying condition does not appear to influence the onset of NSAID-induced gastropathy. Care is required when prescribing NSAIDs; they should not be used in trivial or self-limiting conditions or in existing cases of active peptic ulceration. In addition, caution should be exercised in patients with a history of peptic ulceration, and in the elderly.

The long-term outcome of rotator cuff tendinitis--a review study

Rotator cuff tendinitis is believed to resolve in the majority but the long-term outcome has not been well documented. This review of 137 patients treated conservatively found active tendinitis in 35 individuals at a mean of 19 months after presentation. In addition, 40 patients had residual pain and eight developed pain due to another cause. Early presentation and a history of overuse unrelated to occupation distinguished the 54 who had resolved from those with active tendinitis (p less than 0.01). Dominant arm involvement was associated with a poorer prognosis (p less than 0.05). Functional impairment occurred in 29 patients, two having lost employment. The sizeable proportion of patients with chronic tendinitis resistant to conservative treatment suggests that rotator cuff tendinitis is not an early self-limiting condition and improvement in management is required.

Serum alpha 1 antichymotrypsin concentration as a marker of disease activity in rheumatoid arthritis

Serum alpha 1 antichymotrypsin (alpha 1ACT), C reactive protein (CRP), orosomucoid, and erythrocyte sedimentation rate (ESR) were measured sequentially in 20 patients with rheumatoid arthritis (RA) treated with gold or penicillamine. Pain score, morning stiffness, grip strength, and articular index were measured and a Mallya score calculated. Based on a total of 148 sets of observations, significant correlations were found between alpha 1ACT and other variables (p less than 0.001 except morning stiffness at p less than 0.05). The actual correlation coefficients indicated a closer association with the other laboratory tests, CRP (0.62), orosomucoid (0.69), and ESR (0.61), than with clinical measurements: pain score (0.38), articular index (0.41), grip strength (-0.3), morning stiffness (0.19), and Mallya score (0.5). Sequential data on individual patients showed differing patterns of change in the variables indicating the importance of measuring more than one acute phase protein (APP), especially when CRP is inappropriately low. Serum alpha 1ACT concentration does reflect disease activity in RA. Its potential advantages are discussed.