A corneal pigmented line associated with Salzmann's nodular degeneration

A 62-year-old woman with Salzmann's nodular degeneration had a pigmented line at the base of the corneal nodules in each eye. The lines ran horizontally along the superior one third of the cornea and faded at the corneoscleral limbus on both sides. The lines curved around the bases of the raised corneal lesions.

The difficulty of determining the route of intraocular penetration of gentamicin after subconjunctival injection in the rabbit

In small animals such as the rabbit the ratio of eye size to body size is much larger than it is in humans. Accordingly, periocular injection of antibodies in this animal model results in significantly higher serum concentrations than does a comparable does in a human. To assess the effect of the systemic drug component on ocular penetration, we compared the levels of gentamicin in ocular tissues and fluids of the rabbit following injection of 20 mg by subconjunctival or intramuscular routes. Blood levels of gentamicin were similar with the two routes of administration. In normal rabbit eyes, no antibiotic was detectable in the vitreous humor for the first 3 hr after either subconjunctival or intramuscular injection. By 6 hr, low vitreous levels of drug were detectable after subconjunctival, but not after intramuscular, injection. Because these concentrations were so close to the threshold of sensitivity of the assay, it was not clear that the difference between the routes was significant in normal eyes. In infected eyes, the concentrations of gentamicin in the vitreous were similar after subconjunctival and intramuscular injection. These data indicate that the penetration of gentamicin in to the infected vitreous humor of rabbits after subconjunctival injection could be attributed as well to hematogenous carriage as to direct penetration. The problem in distinguishing systemic from direct transport with periocular injections may be inherent in any small animal model in which the ratio of eye size to body size is high.

Septic and aseptic olecranon bursitis in patients on maintenance hemodialysis

Over a period of four years, seven of 110 maintenance hemodialysis patients developed olecranon bursitis. In all patients it appeared in the arm on which AV access was constructed but one patient also had bilateral bursitis. None of the patients gave a history of trauma or gout. Despite similar clinical presentation, culture of bursal aspirate demonstrated septic bursitis in two patients. (One diabetic, the other on steroids). Sustained pressure on the olecranon bursa during maintenance hemodialysis and/or milk trauma in the anticoagulated state may be responsible for the lesion. Infection can occur in susceptible individuals despite no visible skin infection. Local steroid instillation and patient education to avoid putting pressure on bursa during dialysis was effective therapy in the aseptic group. Multiple aspirations and antibiotics were necessary in the septic group.

Oxacillin for bacterial endophthalmitis: subconjunctival, intravenous, both, or neither?

We compared the intraocular concentrations of oxacillin given by continuous intravenous infusion, subconjunctival injection, or combined therapy in a rabbit model of Staphylococcus aureus endophthalmitis. At equilibrium during intravenous infusion, concentrations in the aqueous humor, cornea, and choroid-retina were 25% to 30% of the serum level; in contrast, vitreous levels were only 2% of the serum concentration. Subconjunctival injection produced extremely high levels in the cornea and aqueous and moderate concentrations in the choroid-retina; vitreous penetration remained poor (<1 microgram/ml). Combined therapy offered little advantage in terms of concentrations in the aqueous or cornea and had a modest effect on levels in the choroid-retina. Vitreous concentrations showed a striking relation to serum levels with all regimens, including subconjunctival ones; although this could have been fortuitous, it suggests an important role for the hematogenous route in this model. Only those modes of delivery producing serum concentrations greater than 50 micrograms/ml consistently resulted in vitreous levels greater than 0.4 microgram/ml. The optimal therapy of bacterial endophthalmitis may require direct intravitreal injection of antibiotic.

A survey of Moraxella corneal ulcers in a derelict population

Infection with diplobacilli of the Moraxella group was the most common cause of bacterial corneal ulcer in a population of derelict alcoholics living in the Bowery district in New York City from 1965 through 1968. No distinction could be made between Moraxella subspecies on the basis of severity of ulcer or antibiotic sensitivities. Of 100 Bowery inhabitants examined, 35 harbored Moraxella in their noses. After 1968 and coinciding with an improvement in nutrition and sanitation, but with no apparent change in the incidence of alcoholism in this population, we noted a marked decline in the incidence of corneal ulcers caused by Moraxella species.

Basic tear flow. Does it exist?

Tear flow and volume were measured in 15 normal volunteers, divided into young and old age groups, using subjective fluorophotometric analysis and Schirmer testing with and without topical anesthesia. Proparacaine 0.5% was found to anesthetize cornea and conjunctiva better than cocaine 4% and produced fewer complications. Older subjects responded to stimulation with less reflex tearing than younger subjects, but had an identical rate of physiologic tear flow, and equivalent corneal and conjunctival sensitivity. Tear flow and volume decreased significantly below physiologic values in both age groups following topical anesthetic instillation. Lid margin and cilia stimulation increased the tear turnover rate more than 300% despite adequate topical anesthesia. Flow rates determined by Schirmer testing with topical anesthesia were higher than both physiologic tear flow and tear flow following topical anesthesia when these values were determined by fluorophotometry. As sensory input was decreased, tear secretion fell correspondingly, implying that all significant tear flow results frp, reflex secretion.

Juvenile rheumatoid arthritis. A comparison of patients from the USSR and USA

Juvenile rheumatoid arthritis (JRA) in the Union of Soviet Socialist Republics (USSR) and the United States (USA) shows a remarkable similarity in age of disease onset, subtype onset, frequency, and most laboratory measurements. There is variation in the therapeutic approach with heavier reliance on aspirin in the USA. The evolution of JRA from onset subtype to final subtype over 5 years was the same in both groups and was independent of the type of therapy.

[Postoperative hypalgesia following electrostimulation -- anaesthesia by stimulation of typical acupuncture points (author's transl)]

"Postoperative hypalgesia" following electroacupuncture or electrostimulation anesthesia is considered to be a notable advantage of these techniques, which supports the thesis, that endorphines may be involved in the mechanism of pain relief by these methods. After establishing definitive criteria postoperative hypalgesia was observed in 50% of patients undergoing operations on the lumbar vertebral column with electroacupuncture. A comparative investigation using psychological tests showed, that these patients are more pain tolerant than those, in whom postoperative hypalgesia was not observed. Observation alone of the patients during the postoperative period is unreliable to assess real postoperative pain relief objectively. Exact documentation and critical proof of the phenomenon of "postoperative hypalgesia" must be emphasized. These may be possible essentials to establish optimal methods of electrostimulation -- anesthesia.

Carpal tunnel syndrome in patients undergoing maintenance hemodialysis

Five of 62 maintenance hemodialysis patients were found to have carpal tunnel syndrome, and another five had prolonged distal motor latencies. Contrary to previous reports, there was no relation between carpal tunnel syndrome and the site of vascular access. Synovial biopsy specimens from flexor tendons demonstrated edema without inflammation, suggesting that extracellular fluid volume excess in the presence of flexion and immobility during dialysis may be pathogenetically important.

The effect of immunization on polymorphonuclear leukocyte chemotaxis in influenza

Challenge of human subjects with influenza virus produced a significant fall in the chemotaxis of polymorphonuclear leukoyctes (PMN's) obtained from their peripheral blood. This was seen by 3 days with some return toward normal function at 7 days but with a persistent defect still found at 20 days after challenge.

The amyloidosis of juvenile rheumatoid arthritis - comparative studies in Polish and American children II. Serum immunoglobulins, kappa and lambda light chain and C3 levels

The concentration of serum IgG, IgM, IgA, IgD, IgE and complement C3 as well as Kappa and Lambda free and bound light chains were determined in sera from 21 amyloidotic Polish children with juvenile rheumatoid arthritis (JRA), Polish and American children with JRA, and control children from a Polish population. Comparable concentrations of IgG, IgM, IgA, IgE and C3 were found in amyloidotic children when compared to Polish JRA children with active polyarticular disease. However, the amyloidotic Polish children with JRA had significantly higher levels of IgG, IgM, IgA, IgE and complement C3 fraction when compared to American JRA children. The levels of IgA and IgE were significantly elevated in amyloidotic and Polish JRA populations when compared to American JRA patients. Free immunoglobulin light chains were not found in the sera of any of the children tested in this study. However, in the patients with amyloidosis, significantly diminished levels of bound Kappa and Lambda light chains were found.

[Combined-electrostimulation-hypalgesia in surgery of the lumbar vertebral column. A tentative evaluation of this method (author's transl)]

A new concept of anaesthesia in patients undergoing operations of the lumbar vertebral column is presented. Electrostimulation of four auricular acupuncture points is combined with controlled ventilation of nitrous-oxide oxygen mixture. This combination is comparable to similar anaesthesia procedures of other operative fields. In 30 patients the anaesthesia was performed as a "combined electrostimulationhypalgesia". In a control study of 30 similar patients a mixture of nitrous-oxide and oxygen only was used. For 120 min systolic and diastolic blood pressure as well as heart rate of both groups are measured and compared. The postoperative state as well as individual data from the patients are included in the investigation. The analgesia established by "combined electrostimulationhypalgesia" seems to be based essentially on the effect of nitrous-oxide as well as premedication, induction of anaesthesia, relaxation and kind of ventilation. Electrostimulation of auricular acupuncture points seems to induce stabilisation of the circulatory system. On account of our findings the relevance of electrostimulation in this method of anaesthesia must be judged very critically.

Emergency hospital care: issues of treatment and liability

Increased utilization of hospital emergency rooms, and a departure from traditional physician-patient relationships, have resulted in increased litigation. Risks to hospitals can be minimized if certain policies are pursued.

Radioactive and bioassay of intraocular antibiotics: double-assay technique to compare penicillin G, cefamandole, and gentamicin in ocular tissues in vivo

We examined the correlation between radioactive assay and trephine-discbioassay of penicillin G sodium, cefamandole nafate, and gentamicin sulfate in ocular tissues of pigmented rabbits after subconjuctival administration of antibiotic. We devised a technique whereby a single sample of tissue could be assayed by both methods. This was achieved by performing the bioassay first, then measuring the resudual radioactivity in the agar and specimens. The results of both methods were generally within 13%. An exception was gentamicin in iris and choroidretina, for which the bioassay result was strikingly less than the radioassay value. No such discrepancy was evident when similar studies were carried out with gentamicin in albino rabbits. This suggests that the phenomenon is due to tight binding of gentamicin by melanin-containing tissues. The trephine-disc bioassay provides an accurate measure of diffusible bioactive antibiotic in ocular tissues.

Marked differences between pigmented and albino rabbits in the concentration of clindamycin in iris and choroid-retina

The concentrations of clindamycin were significantly higher in iris and choroid-retina or pigmented rabbits than in those of albino rabbits after subconjunctival injection. Equilibrium dialysis experiments showed no affinity of clindamycin for synthetic melanin or for collagenase digests of pigmented tissues. In contrast, strips of iris and choroid-retina took up clindamycin rapidly from solution, achieving concentrations substantially higher than those in the medium. Uptake by tissue strips was not influenced by temperature (4 C vs. 37 C), cyanide, or ouabain. However, N-ethylmaleimide, which reacts with sulfhydryl groups, decreased the tissue-to-medium ratios by about 50% for both albino and pigmented choroid-retina. Even in the presence of this inhibitor, the ratio for pigmented tissues remained higher than that for albino specimens. These findings suggest the existence of one, or possibly two, mechanisms of energy-independent accumulation of clindamycin by pigmented ocular tissues: one may relate to protein sulfhydryl bonds that are present in both breeds; the other may involve the pigmentation apparatus.

[Characteristics of electrostimulation with the multi-purpose therapy apparatus 71-3 for electroacupuncture analgesia]

The stimulating impulses employed in electroacupuncture analgesia are of widely differing character and strength. Experiences with the Chinese impulse generator MPTA 71-3 clearly show the necessity to determine the performance of the generator and to measure and record the strength, configuration and frequency of the electrical impulses employed. A simple equipment for measuring these factors is described. The apparatus makes it possible to record the character and type of the stimuli and to compare different techniques of stimulation.

The use of penicillamine in the treatment of rheumatoid arthritis and scleroderma

The use of penicillamine in the treatment of rheumatoid arthritis and scheroderma is reviewed. Much of the worlds literature was collected including both open studies and control studies. Both types with over 1,300 patients in the open trials and as one would expect, a smaller group in the control trials, showed about 64 percent of the patients having good results. Side effects range from one quarter to one third of the treated patients. This seems to show penicillamine as an effective drug for the treatment of rheumatoid arthritis though with a multiplicity of side effects. Its use in the treatment of scleroderma is still uncertain. Because of the rarity of the disease the number of patients treated has been small and the data is conflicting.

The absence of differences in cellular immunity in elderly individuals with and without delayed local cutaneous reactions to influenza vaccine

Two groups of elderly subjects who received bivalent influenza virus vaccine were identified. Those in Group I manifested marked local reactions, suggestive of delayed hypersensitivity reactions, whereas those in Group II, matched with Group I for vaccine preparation, had no cutaneous reactions. In vitro assays of immune function were performed on pairs of subjects from the two groups and included serum immunoglobulin and complement levels, antibody response to vaccine, lymphocyte transformation to mitogens (phytohemagglutinin, pokeweed mitogen and concanavalin A) and antigens (streptokinase-streptodornase, influenza virus vaccine antigens and multiple mixed lymphocytes), and polymorphonuclear leukocyte chemotactic responsiveness. There was no demonstrable correlation between delayed local cutaneous reaction and preservation of in vitro cell-mediated immune function in these elderly individuals.

Efficacy of penicillin G, cefazolin, and gentamicin in M-K medium at 4 degrees C

Corneal-scleral shells are routinely stored in McCarey-Kaufman (M-K) medium at 4 degrees C. Antibiotics are added to the medium to suppress bacterial growth. We examined the antibacterial activity of penicillin G potassium, 100 microgram/ml, cefazolin sodium, 100 microgram/ml, and gentamicin sulfate, 20 microgram/ml against test organisms in M-K medium at 4 degrees, 23 degrees, and 37 degrees C for periods up to 18 hours. Within the limits of the experimental conditions, none of the antibiotics used could be relied on to sterilize an inoculum of sensitive bacteria in M-K medium at 4 degrees C, the recommended storage temperature.

The amyloidosis of juvenile rheumatoid arthritis--comparative studies in Polish and American children. I. Levels of serum SAA protein

Serum SAA concentration was determined by radioimmunoassay in 21 Polish children with amyloidosis secondary to juvenile rheumatoid arthritis (JRA). The results were compared to controls and children with JRA in Polish populations (where amyloidosis is a frequent complication of JRA) as well as to American children with JRA (where amyloidosis in JRA has been observed only sporadically) and American control children. No significant differences of SAA protein levels were found in the amyloidotic Polish children when compared to JRA Polish and American children. However, significantly higher levels of SAA protein were present in amyloidotic Polish children when compared to the control Polish and American group. High serum SAA protein concentration in JRA children did not necessarily correlate with the presence of secondary amyloidosis. Other mechanisms are probably involved in the development of amyloidosis.

Intraocular penetration of gentamicin after subconjunctibal and retrobulbar injection

We compared the ocular penetration of labeled with radioactive carbon gentamicin in squirrel monkeys after subconjunctival and retrobulbar administration. In both normal and infected (Staphylococcus aureus endophthalmitis) eyes, high concentrations of drug were achieved in the sclera and choroid-retina by both routes, while corneal levels were markedly higher after subconjunctival injection than after retrobulbar injection. Regional variations in concentration were evident in these tissues; the highest levels were clustered about the site of injection. Aqueous humor concentrations were lowest in the group with normal eyes treated by the retrobulbar route; vitreous humor levels were extremely low in normal eyes injected subconjunctivally. These data differ from those in rabbits, especially with regard to penetration of the vitreous humor of normal eyes. Interspecies differences were less marked in inflamed eyes. The two species were similar in demonstrating maximum access to the cornea and aqueous humor with subconjunctival injection, and equivalence of the two routes in penetrating the vitreous humor of the inflamed eyes.

Psychosocial factors in juvenile rheumatoid arthritis

A detailed survey of 88 children with juvenile rheumatoid arthritis (JRA) was made in an attempt to elucidate characteristics that may participate in the etiologic mechanism. Data from a random pediatric population from the same geographic area were also included for comparisons. The most striking findings were psychosocial factors. Children whose parents were unmarried as a result of divorce, separation, or death comprised 28.4% of the JRA population, compared to 10.6% of the comparison group. In addition, adoption occurred three times more often in the JRA population. Fifty-one percent of these events (divorce, separation, death, or adoption) occurred near the date of onset of the disease.

Goldenhar's syndrome

We present a report on 16 patients with Goldenhar's syndrome. The criteria we required for the diagnosis of Goldenhar's syndrome consisted of an eye abnormality (lipoma, lipodermoid, epibulbar dermoid, or upper eyelid coloboma) associated with ear, mandibular, or vertebral anomalies (two of the three). Although Treacher Collins' syndrome can be easily differentiated from Goldenhar's syndrome, the differences between Goldenhar's syndrome and hemifacial microsomia are more difficult to delineate.

Excretion of gentamicin in rabbit tears after subconjunctival injection

We subconjunctivally, injected gentamicin, in a dose of 10 mg, into normal and inflamed (Staphylococcus aureus endophthalmitis) rabbit eyes in which the nasolarcrimal ducts had been blocked. We retrieved approximately 10% of the dose of drug in the tears, the majority in the first 30 minutes. The difference in lacrimal excretion of the drug between normal and inflamed eyes was not significant. Higher concentrations of gentamicin found in the ocular tissues of normal eyes than inflamed eyes cannot be attributed to loss in the tears.

Comparison of tolmetin sodium and aspirin in the treatment of juvenile rheumatoid arthritis

The Pediatric Rheumatology Collaborative Study Group was established in 1973 to undertake systematic trials of new drugs in the treatment of juvenile rheumatoid arthritis. The first drug evaluated was tolmetin (1-methyl-5-p-toluoylpyrrole-2 acetic acid), a new nonsteroid anti-inflammatory agent. A four-week open trial with 30 patients and a subsequent 12-week double-blind trial against aspirin with 107 patients were conducted. Tolmetin and aspirin had equal anti-inflammatory and analgesic effects in the treatment of JRA. Elevations of transaminase values attributed to aspirin were not found with tolmetin. Adverse effects accompanying administration of tolmetin did not appear to be of major clinical significance.

Antibody levels to enteric bacteria in juvenile rheumatoid arthritis

In order to determine the immunologic status and possible susceptibility to bacterial infection in children with juvenile rheumatoid arthritis (JRA), titer of hemagglutingating antibodies to E coli 055, E coli 086, common antigen, and Shigella polyvalent antigen were measured. Immunoglobulin G was the predominant antibody. IgA antibodies were found in higher titer in children with JRA. No significant differences were found between children with JRA do not have any deficit in antibody production to specific bacterial antigens, and any increased appearance of infection in these children is more probably due to deficiencies in cellular factors.

The effect of D-penicillamine on polymorphonuclear leukocyte function

D-Penicillamine, a reducing and chelating agent used in the treating of rheumatoid arthritis, was tested for its effects of polymorphonuclear leukocyte chemotaxis, phagocytosis, and lysosomal enzymes. beta-Glucuronidase release from polymorphonuclear leukocytes after phagocytosis of latex particles was not affected by D-penicillamine at concentrations ranging from 25 to 400 mg/liter. No direct effect was seen on enzyme activity at the maximum concentration of the drug. There was no inhibition of latex particle ingestion. No cell damage was found at 400 mg/liter penicillamine as measured by lactic dehydrogenase release. At this drug concentration there was only a 15% reduction in hemolytic complement levels. Chemotaxis was significantly decreased at concentrations of 50 mg/liter with a dose-dependent effect at higher concentrations which showed a plateau from 200 to 400 mg/liter. The parent compound D-cysteine was also tested in these systems. The same lack of effect of phagocytosis and enzyme release was found. D-Cysteine did inhibit chemotaxis but to a lesser degree than D-penicillamine. This dicotomy of drug effect may indicate that the beneficial action of D-penicillamine in the treatment of rheumatoid arthritis is due to the decreased chemotaxis of polymorphonuclear leukocytes into the joint, while the absence of an effect of phagocytosis and lysosomal enzymes shows the cells can still function to ingest and destroy bacteria. This latter effect correlates with the absence of infection in patients treated with this compound.

Inhibition of antibiotic activity in vitro by synthetic melanin

Synthetic melanin (100 to 1,000 mug/ml) markedly inhibited the in vitro activity of aminoglycosides and tetracyclines but did not affect the activity of betalactam antibiotics, erythromycin, or clindamycin.

Hereditary deficiency of the fifth component of complement in man. II. Biological properties of C5-deficient human serum

The first known human kindred with hereditary deficiency of the fifth component of complement (C5) was documented in the accompanying report. This study examines several biological properties of C5-deficient (C5D) human serum, particularly sera obtained from two C5D homozygotes. The proband, who has inactive systemic lupus erythematosus is completely lacking C5, while her healthy half-sister has 1-2% of normal levels. Both sera were severely impaired in their ability to generate chemotactic activity for normal human neutrophils upon incubation with aggregated human gamma-globulin or Escherichia coli endotoxin. This function was fully restored in the sibling's serum, and substantially improved in the proband's serum, by addition of highly purified human C5 to normal serum concentrations. Sera from eight family members who were apparently heterozygous for C5 deficiency gave normal chemotactic scores. The ability of C5D serum to opsonize Saccharomyces cerevisiae (baker's yeast) or Candida albicans for ingestion by normal neutrophils was completely normal. In addition, C5D serum was capable of promoting normal phagocytosis and intracellular killing of Staphylococcus aureus. The proband's serum was incapable of mediating lysis of erythrocytes from a patient with paroxysmal nocturnal hemoglobinuria in both the sucrose hemolysia and acid hemolysis tests, and also lacked bactericidal activity against sensitized or unsensitized Salmonella typhi. The sibling's serum, containing only 1-2% of normal C5, effectively lysed S. typhi, but only at eightfold lower serum dilutions as compared to normals. These findings underscore the critical role of C5 in the generation of chemotactic activity and in cytolytic reactions, as opposed to a nonobligatory or minimal role in opsonization, at least for the organisms under study.

The effect of aging and acute illness on delayed hypersensitivity

A group of standard antigens (monilia, mosquito, mumps, purified protein derivative [PPD], staphylococcus toxoid, streptokinase-streptodornase [sk-sd] and trichophyton) were applied to 321 normal volunteers, 60 patients admitted to a medical ward, and 41 patients in an intensive care unit (ICU) to evaluate their delayed hypersensitivity skin test response. Eighty-eight per cent of the normal subjects reacted with at least 5 mm. induration to one or more skin tests without any decrease in reactivity occurring with increasing age. In the hospitalized group, only 62 per cent of the ward and 63 per cent of the ICU patients reacted to the same skin tests. All (8/8) anergic ICU patients tested after discharge regained normal reactivity. Acute illness but not increasing age will impair the delayed hypersensitivity skin test response.

Carpal tunnel syndrome in temporal arteritis

An 88 year old man presented with pain in the hands and wrists, associated with electrodiagnostic studies compatible with a carpal tunnel syndrome in the right wrist. Approximately seven months later he developed manifestations of bilateral temporal arteritis resulting in monocular blindness. Electrodiagnostic studies at this time confirmed the presence of a more severe carpal tunnel syndrome, now present bilaterally. We have been unable to find other case reports of carpal tunnel syndrome related to temporal arteritis. This association may be recognized more frequently if electrodiagnostic studies are performed in patients with temporal arteritis associated with pain in the hands and wrists.

The roles of IgG, IgM rheumatoid factor, and their complexes in the induction of polymorphonuclear leukocyte chemotactic factor from complement

The induction of chemotactic factor by rheumatoid factor (RF) and by rheumatoid complexes and their constituents was investigated. The presence of chemotactic factor was measured by the number of polymorphonuclear leukocytes (obtained from normal individuals) attracted through a 3 mum Millipore filter and is expressed as a "chemotactic index." The chemotactic index was used to measure the effect of immunoglobulins and their complexes in stimulating production of complement-derived chemotactic factors from the sera of normal individuals. Two sources of IgG (F-II and DEAE-purified IgG) were used. These were prepared for use in the native and heat-aggregated states. The same chemotactic index was obtained with both these preparations of IgG. The chemotactic index increases when (a) increasing concentrations of gamma globulin were added to a constant concentration of complement and (b) when the amount of complement alone was increased. The addition of a purified IgM RF to the mixture of IgG and complement caused a decrease in the chemotactic index. Incubation of IgG and complement before addition of IgM RF produced no change in the chemotactic index. The addition of a nonrheumatoid factor IgM to IgM and complement had no effect on the chemotactic index. IgM RF and IgG alone were not chemotactic. These studies confirm the concept of "complement deviation" by IgM RF which occurs with, and as a result of, the immune complex formation between IgG and IgM RF. The successful activation of complement chemotactic factors by IgG may explain the synovitis with high polymorphonuclear leukocyte counts found in RF-negative arthritis.