Endotheliopathy in COVID-19-associated coagulopathy: evidence from a single-centre, cross-sectional study

BACKGROUND

An important feature of severe acute respiratory syndrome coronavirus 2 pathogenesis is COVID-19-associated coagulopathy, characterised by increased thrombotic and microvascular complications. Previous studies have suggested a role for endothelial cell injury in COVID-19-associated coagulopathy. To determine whether endotheliopathy is involved in COVID-19-associated coagulopathy pathogenesis, we assessed markers of endothelial cell and platelet activation in critically and non-critically ill patients admitted to the hospital with COVID-19.

METHODS

In this single-centre cross-sectional study, hospitalised adult (≥18 years) patients with laboratory-confirmed COVID-19 were identified in the medical intensive care unit (ICU) or a specialised non-ICU COVID-19 floor in our hospital. Asymptomatic, non-hospitalised controls were recruited as a comparator group for biomarkers that did not have a reference range. We assessed markers of endothelial cell and platelet activation, including von Willebrand Factor (VWF) antigen, soluble thrombomodulin, soluble P-selectin, and soluble CD40 ligand, as well as coagulation factors, endogenous anticoagulants, and fibrinolytic enzymes. We compared the level of each marker in ICU patients, non-ICU patients, and controls, where applicable. We assessed correlations between these laboratory results with clinical outcomes, including hospital discharge and mortality. Kaplan-Meier analysis was used to further explore the association between biochemical markers and survival.

FINDINGS

68 patients with COVID-19 were included in the study from April 13 to April 24, 2020, including 48 ICU and 20 non-ICU patients, as well as 13 non-hospitalised, asymptomatic controls. Markers of endothelial cell and platelet activation were significantly elevated in ICU patients compared with non-ICU patients, including VWF antigen (mean 565% [SD 199] in ICU patients vs 278% [133] in non-ICU patients; p<0·0001) and soluble P-selectin (15·9 ng/mL [4·8] vs 11·2 ng/mL [3·1]; p=0·0014). VWF antigen concentrations were also elevated above the normal range in 16 (80%) of 20 non-ICU patients. We found mortality to be significantly correlated with VWF antigen (r = 0·38; p=0·0022) and soluble thrombomodulin (r = 0·38; p=0·0078) among all patients. In all patients, soluble thrombomodulin concentrations greater than 3·26 ng/mL were associated with lower rates of hospital discharge (22 [88%] of 25 patients with low concentrations vs 13 [52%] of 25 patients with high concentrations; p=0·0050) and lower likelihood of survival on Kaplan-Meier analysis (hazard ratio 5·9, 95% CI 1·9-18·4; p=0·0087).

INTERPRETATION

Our findings show that endotheliopathy is present in COVID-19 and is likely to be associated with critical illness and death. Early identification of endotheliopathy and strategies to mitigate its progression might improve outcomes in COVID-19.

FUNDING

This work was supported by a gift donation from Jack Levin to the Benign Hematology programme at Yale, and the National Institutes of Health.

Radiographic outcome after three years of patients with early erosive rheumatoid arthritis treated with intramuscular methotrexate or parenteral gold. Extension of a one-year double-blind study in 174 patients

OBJECTIVE

To compare the radiographic outcomes after 36 months in patients with early erosive rheumatoid arthritis (RA) who were treated with methotrexate (MTX) or gold sodium thiomalate (GSTM).

METHODS

In a randomized, double-blind fashion, 174 patients from two centres were assigned to receive weekly intramuscular injections of either 15 mg MTX or 50 mg GSTM. After 12 months, the study was continued as an open prospective study for an additional 2 yr, administering the same amount of MTX and half of the GSTM dose. Radiographic outcomes were assessed by standardized methods in all patients at baseline and after 6, 12, 24 and 36 months.

RESULTS

Intention-to-treat analysis showed that patients treated with MTX had higher radiographic scores and more erosive joints at all follow-up points. However, there was no statistically significant difference between the two treatment groups. The progression rate was significantly slower during the second and third years of follow-up in both groups. Baseline and time-integrated (area under the curve over 6 months) disease activity parameters were good predictors of radiographic outcome after 3 yr. Seropositivity was not an independent predictor of progression. However, patients who were positive for rheumatoid factor had higher time-integrated disease activity (with less response to treatment) and thus their disease was significantly more progressive.

CONCLUSION

Both of the disease-modifying compounds used in this study, MTX and GSTM, were able to reduce the slope of radiographic progression during 3 yr of follow-up. There was some advantage for parenteral gold but no significant intergroup difference.

Other pain syndromes to be differentiated from fibromyalgia

Several common chronic pain syndromes come to the attention of the rheumatologist demanding for differentiation from fibromyalgia (FM), although they are often associated with it. They may mimic FM by (1) the occurrence of wide spread pain, (2) the chronicity of complaints, (3) the preponderance of females in some of these, and (4) the lack of objective data to be derived from imaging techniques and laboratory tests. Pain is produced by the disturbance of normal function ("dysfunctional syndromes", MASI, ref. 6). Recognition requires examination of the locomotor system under biomechanical auspices both at rest and during movement in order to diagnose hyper- and hypomobility syndromes; treatment of these conditions is guided by principles to improve biomechanical function. In addition, the skin needs to be examined to detect panniculosis (also called "cellulitis"), which may be mixed up with FM due to its preferential occurrence in peri- or postmenopausal women. It is concluded that the aforementioned differential diagnosis needs to be considered appropriately in coinciding FM and all studies dealing with FM.

Progression in early erosive rheumatoid arthritis: 12 month results from a randomized controlled trial comparing methotrexate and gold sodium thiomalate

OBJECTIVE

To compare radiographic outcomes in patients with active early erosive rheumatoid arthritis (RA) who were treated with methotrexate (MTX) and gold sodium thiomalate (GSTM).

METHODS

A total of 174 patients from two centres were randomly assigned to receive weekly i.m. injections for 12 months of either 15 mg MTX or 50 mg GSTM in a double-blind fashion. Radiographic evaluations including standardized scoring of 38 joints of the hands, wrists and forefeet, and count of eroded joints, were carried out at baseline and after 6 and 12 months in all patients, including withdrawals.

RESULTS

An intention-to-treat analysis revealed no statistically significant difference in the progression of radiographic scores between treatment groups after 6 months (3.4 with MTX vs 2.6 with GSTM, P = 0.66) and after 12 months (6.0 vs 4.8, P = 0.44). A similar pattern was observed for the number of joints with erosions. The slope of radiographic progression was significantly reduced in the second half-year compared to the first 6 months in both groups. Erythrocyte sedimentation rate and C-reactive protein at baseline, and the presence of rheumatoid factor (RF), were the main predictors of progression in bivariate analysis. RF remained as the only predictor for radiographic outcome in multivariable analysis.

CONCLUSION

In parallel to clinical improvement, both GSTM and MTX reduce the slope of radiographic progression in patients with active erosive RA.

A 36 month comparative trial of methotrexate and gold sodium thiomalate in the treatment of early active and erosive rheumatoid arthritis

OBJECTIVE

To compare the safety and efficacy of methotrexate (MTX) and gold sodium thiomalate (GSTM) in patients with active early erosive rheumatoid arthritis (RA) during 3 yr.

METHODS

A total of 174 patients from two centres were randomly assigned to receive weekly i.m. injections of either 15 mg MTX or 50 mg GSTM for 1 yr in a double-blind fashion. Thereafter, the study was continued as an open prospective trial for an additional 2 yr with the same dose of MTX and half of the GSTM dose. Clinical and laboratory evaluations were carried out at baseline and at months 6, 12, 18, 24 and 36 in all patients, including withdrawals.

RESULTS

An intention-to-treat analysis revealed inactivation ['clinical remission': no swollen/tender joints, erythrocyte sedimentation rate (ESR) of < 20 mm/h in males and < 30 mm in females, no corticosteroids within the last 4 weeks] in 33.3% of MTX patients and 37.9% of GSTM patients. The mean time to inactivation was insignificantly shorter with GSTM (MTX: 12.1 months; GSTM: 9.1 months; P = 0.06). At least marked improvement (> 50% reduction of the number of swollen/tender joints and of the ESR) was found in 78.2% (MTX) and 87.4% (GSTM). Withdrawal from the study due to toxicity was recorded in 16.1% of MTX and 52.9% of GSTM patients after a mean time of 30.6 and 6.1 months, respectively (P = 0.0001). In MTX and GSTM non-completers, inactivation was recorded in 24.2 and 54.7% of all patients. Among completers (54 and 34 patients, respectively), significant improvement compared to baseline was noted in all seven clinical variables (morning stiffness, overall joint pain, count of tender/swollen joints, Lansbury articular score, functional score and grip strength), ESR and C-reactive protein without significant intergroup differences. The steroid-sparing effect appeared more pronounced with GSTM.

CONCLUSION

Over 36 months, treatment with MTX or GSTM induces inactivation ('clinical remission') of early and erosive RA in about one-third and at least marked improvement in four-fifths of patients (intention-to-treat analysis). Patients withdrawn from MTX or GSTM due to toxicity develop a clinical remission from the disease; this occurred more often with GSTM. Tolerability is significantly better with MTX.

[Differential diagnosis of polyarthritis pain syndrome of the locomotor apparatus]

Widespread pain syndromes of the musculoskeletal system present to general practitioners, internists, neurologists and orthopedic surgeons every day. The syndromes may result both from organic diseases (inflammatory joint diseases, rheumatic manifestations of organ diseases) as well as dysfunctional syndromes, the latter including mainly biomechanically induced syndromes and fibromyalgia. The approach is predominantly clinically oriented and requires laboratory means or technical procedures only in a limited extend. The duration of history, the recognition of synovitis and of myofascial trigger points or of integumental tender points allow in most patients to achieve appropriate diagnostic criteria.

[Basic therapeutic combination therapy in chronic polyarthritis: an overview]

Therapy of rheumatoid arthritis with a combination of several disease-modifying drugs aims towards better control of the disease than achievable by monotherapy. Based on a broad variety of clinical studies, revealing more or less positive results, several combinations have been suggested: the inclusion of cyclosporin into combinations with methotrexate, the inclusion of sulfasalazine into combinations with methotrexate, the combined use of two chemotherapeutic substances, including methotrexate, azathioprine and cyclophosphamide, the inclusion of chloroquine derivatives into such or other combinations, and the combination of methotrexate with injectable gold. The validity of some of the studies is affected by high drop out rates and by the unknown influence of concomitant therapy with corticosteroids. Our own beneficial experience with the triple combination of methotrexate with azathioprine and chloroquine in 21 patients with refractory rheumatoid arthritis is summarized.

Decrease of interleukin 6 during the first 12 months is a prognostic marker for clinical outcome during 36 months treatment with disease-modifying anti-rheumatic drugs

The aim of this study was to determine prognostic markers for the outcome after 36 months of therapy with disease-modifying anti-rheumatic drugs (DMARDs) in patients with rheumatoid arthritis (RA) and to study serial cytokine serum levels. During 36 months, 20 patients receiving DMARDs (nine patients gold sodium thiomalate and 11 patients methotrexate, no comparison undertaken) were followed for clinical and laboratory data. Investigation at baseline, 12, 24 and 36 months, included clinical, radiological and laboratory parameters such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), and interleukin (IL)-1 beta, IL-6, tumor necrosis factor alpha (TNF-alpha), IL-1 receptor antagonist (IL-1RA) and IL-2. During the 3 yr of therapy, the patients showed significant clinical improvement and decline of ESR, CRP, and serum levels of IL-6 and IL-2. The decrease in IL-6 serum levels during the first year of therapy correlated significantly with the decrease, after 36 months, in the number of inflamed joints (r = 0.7608, P < 0.005), Lansbury index (r = 0.6642, P < 0.005) and morning stiffness (r = -0.6561, P < 0.005). In contrast to IL-6 or IL-2, TNF-alpha and IL-1RA did not vary significantly during the 3 yr of therapy. During 36 months of therapy, patients treated with DMARD showed significant improvement of clinical parameters and a trend for delayed progression of radiographic damage. The decrease in IL-6 concentration in serum during the first 12 months was the best prognostic marker for the clinical outcome after 36 months of DMARD therapy.

[Combination therapy with remission-inducing drugs in chronic polyarthritis: 1996 update]

Therapy of rheumatoid arthritis with a combination of several disease-modifying drugs aims to better control of the disease than achievable by monotherapy. Subsequent to a paper written two years ago, this publication reviews studies dealing with combination therapy issued mainly in 1995 and 1996. Most studies deal with MTX as one of the partners. Beneficial results were reported for the combination of methotrexate with antimalarials, cyclosporine or sulfasalazine. The triple combination of methotrexate with hydroxychloroquine and azathioprine is especially promising although the studies presented up to now are still insufficient for its final assessment, due to methodologic problems. Similarly, the value of the combination of sulfasalazine with injectable gold, of sulfasalazine with methotrexate and hydroxychloroquine, or of methotrexate with injectable gold is still uncertain.

Comparison of intramuscular methotrexate and gold sodium thiomalate in the treatment of early erosive rheumatoid arthritis: 12 month data of a double-blind parallel study of 174 patients

The objective was to compare the safety and efficacy of methotrexate (MTX) and gold sodium thiomalate (GSTM) in patients with early erosive rheumatoid arthritis (RA). A total of 174 patients with active early erosive RA without deformities were enrolled in a 12 month, two-centre double-blind randomized trial. They received a weekly i.m. dose of 15 mg MTX (n = 87) or 50 mg GSTM (n = 87), respectively. Clinical and laboratory evaluations were carried out every 3 months in all patients, including the withdrawals. Ten patients (11.5%) in the MTX group and 21 patients (24.1%) in the GSTM group achieved a clinical remission of the disease [no swollen joints, erythrocyte sedimentation rate (ESR) < 20 mm, no steroids] within the study period (P < 0.05). An at least marked improvement (> 50% reduction of the number of swollen and tender joints and the ESR) was assessed in 59/87 (68%) and 66/87 (76%) patients treated with MTX or GSTM, respectively (P > 0.05). Significantly more patients in the GSTM group were withdrawn due to toxicity (six MTX/32 GSTM). A total of 126 patients (73 on MTX and 53 on GSTM) completed 12 months on their original medication. In the completers, a significant improvement of > 50% compared to baseline was noted in all six clinical variables [morning stiffness, joint count of swollen and tender joints, Lansbury index, grip strength and activities of daily living (ADL) score], the ESR and the C-reactive protein, without intergroup differences. The number of patients taking prednisone was reduced from 21 to 7% in the MTX group and from 15 to 4% in the GSTM group. While significantly more patients achieved a clinical remission with GSTM treatment, tolerability was significantly better with MTX.

[Radiologic healing phenomena in chronic polyarthritis treated with methotrexate or sodium aurothiomalate]

PROBLEM

Do radiographs of hands and forefeet obtained from patients with rheumatoid arthritis present with healing phenomena? What is their importance relative to progressive changes?

METHODS

Dorsopalmar/-plantar radiographs of hands and forefeet of 43 patients with early rheumatoid arthritis (median disease duration 1.7 years, anatomical Steinbrocker's age < or = 2, patients selected from a prospective study, treatment with methotrexate vs gold-sodiumthiomalate) were obtained at months 0, 6, 12, 24 and 36. Radiographs were evaluated without knowing the mode of treatment at 34 sites according to their time sequence for the following variables: a modified Larsen index, numbers of erosive and of radiologically active joints, and the numbers of joints being improved vs. deteriorated in relation to the preceding x-ray.

RESULTS

The radiologic progression could be measured by both a score derived from the modified Larsen index as well as by the numbers of erosive joints with the result of an increasingly crescent, but flattening curve. The number of erosive joints was more sensitive to progression than the score derived from Larsen index. The number of joints deteriorating, compared with the preceding x-ray, decreased from month 6 to month 36 from 16.1% to 7.1% resp. At the same time, 90% of patients increasingly developed radiologic improvement in 2.9% zu 9.3% of joints, including diminution in size and recortication of erosions and particular cysts with a "filling in" by trabecular bone and recovery of a bony outline. There were no relevant differences between therapy groups.

CONCLUSIONS

Progression in early rheumatoid arthritis is best measured by the number of joints with erosions. Reparative signs show up with increasing frequency during the course of the disease. After 3 years of treatment the numbers of joints exhibiting improvement predominate those with deterioration. The data support the concept of early aggressive therapy of rheumatoid arthritis and suggest the inclusion of reparative phenomena into the criteria for improvement of this disease.

Progression and repair in radiographs of hands and forefeet in early rheumatoid arthritis

OBJECTIVE

To evaluate radiographs of patients with early rheumatoid arthritis (RA) for progression and repair.

METHODS

Radiographs of hands and forefeet over 3 years were evaluated at 34 joints based on the modified Larsen-index, the number of joints with erosions, the area of osseous defects including erosions and cysts, the radiologic activity of lesions and--in relation to preceding status--the number of joints with qualitative radiologic improvement or deterioration, respectively, not necessarily seen by the other methods.

RESULTS

Counting of joints with erosions and assessment of the area of osseous defects yielded the most impressive results for disease progression with the number of eroded joints being the simplest method. Reparative phenomena included recortication, "filling in" and diminution in size of erosions and paraarticular cysts, newly developing demarcation of a previously indistinct articular outline, and the increase in trabecular structure in the vicinity of erosions. The evaluation of qualitative changes showed reparative phenomena with increasing frequency involving up to 9.3% of the joints during the 3rd year, compared with 7.1% of the deteriorating joints.

CONCLUSION

Progression in early RA can be quantitated easily by counting joint erosions. This method appears to be more sensitive than Larsen's approach. Repair can be shown early in the course of the disease (as early as the second 6-month observation period) by assessing both radiologic activity and qualitative changes, which are not necessarily apparent in the foregoing quantitative methods. Reparative phenomena associated with healing of erosions and cysts can be noted increasingly during continuous longterm observation. Evaluation for healing phenomena should be standardized and considered for inclusion in therapeutic trials of RA.

Immunoprinting: various genes are associated with increased risk to develop rheumatoid arthritis in different groups of adult patients

To identify genes that contribute to the manifestation of rheumatoid arthritis we performed association studies via microsatellite analyses of immunorelevant loci (HLA-DRB, 5 T cell receptor loci, TNFa IL1, IL2, IL5R and CD40L). A total of 183 patients and 275 healthy controls were typed in terms of HLA and grouped according to the known predisposing HLA-DRB1 genes (DRB1*04; relative risk approx. 5; DRB1*01, relative risk approx. 2; a third group carried neither allele). Microsatellite polymorphisms characterizing the TCRBV6S3, CD3D, IL1A, IL2, and IL5R genes did not show significant associations with rheumatoid arthritis, whereas TCRBV6S1, TCRBV6S7, TNFa, and CD40L genes may influence relative protection or risk in certain groups of patients. Analysis of a microsatellite marker adjacent to the transcription element alpha (TEA) in the T cell receptor alpha delta complex indicates that in the cohort carrying neither the DRB1*04 nor the DRB1*01 allele the relative risk to acquire rheumatoid arthritis is increased (> 13) or decreased (< 0.07), depending on the inherited microsatellite allele adjacent to the TEA locus. Sequence analysis of the closely linked TEA region from patients and controls revealed a novel dimorphism. Only the newly identified TEA allele leads to binding of a nuclear protein that may be involved in the regulated expression of the TCRDA genes. Subsequent typing of rheumatoid arthritis patients and controls revealed, however, that the association of the microsatellite marker is largely independent of the TEA allele, confirming incomplete linkage in the 2 kb region of the TCRDA locus. These results are discussed in the context of hot spots of recombination in this genomic region and other linked candidate sequences that predispose to develop rheumatoid arthritis.

The efficacy and relative bioavailability of diclofenac resinate in rheumatoid arthritis patients

The pharmacodynamics and pharmacokinetics of 75 mg resin-bound diclofenac (resinate) were compared with enteric-coated tablets containing 75 mg of diclofenac in a double-blind randomized crossover trial in 16 patients suffering from rheumatoid arthritis. Diclofenac was significantly faster absorbed from the resinate than from the enteric coated formulation (tlag = 0.454 h vs. 0.998 h, tmax = 1.41 h vs. 2.56 h) and reached lower peak concentrations (Cmax = 1.64 micrograms/ml vs. 2.59 micrograms/ml). No significant differences were found concerning the area under the plasma level-time curves and the mean residence times. Smaller variances were found for the tmax and the mean residence times in the group treated with diclofenac resinate. Onset and duration of analgesia, as assessed by visual analogue scales were similar in both treatment groups, but did not correlate with the plasma concentrations. Four patients experienced adverse effects including gastric pain, transaminase increases, proteinuria and plasma creatinin increase. No uncommon adverse effects were observed with the new preparation.

Intra-articular treatment of rheumatoid knee-joint effusion with triamcinolone hexacetonide versus sodium morrhuate. A prospective study

Thirty-one patients with knee effusions associated with rheumatoid arthritis (RA) have been treated with two intraarticular (i.a.) injections of each 330 mg sodium morrhuate (SM) used for synoviorthesis versus a single injection of 20 mg triamcinolone hexacetonide (TA). During an observation period of one year, five articular parameters as well as patient's and doctor's global assessments were evaluated. TA showed an earlier onset and a longer duration of therapeutic effects with high statistical significance. The maximum improvement was significantly more pronounced with TA than with SM. Finally after one year improvement measured by a remission index was observed in 81% versus 33% resp. of all joints injected. Due to ineffectiveness of the primary treatment nine patients (60%) out of the SM group, but not patient out of the TA group had to be crossed over to the other treatment. SM usually caused a reactive effusion within hours after injection requiring arthrocentesis. In conclusion efficacy and tolerability are clearly better for TA than for SM.

Oligoclonal T cells in rheumatoid arthritis: identification strategy and molecular characterization of a clonal T-cell receptor

Immunodominant antigens in rheumatoid arthritis (RA) should induce an expansion of T cells bearing a corresponding T-cell receptor (TCR). We therefore analysed the TCR repertoire at the site of inflammation using two fundamentally different strategies. The total TCR repertoire was examined by generating 'representative' T-cell clone panels, which were subsequently tested for clonality by restriction mapping of the TCR beta gene locus. No clonality was detected in large T-cell clone panels generated with cells from three patients. However, when we selectively analysed the TCR repertoire of in vivo pre-activated, interleukin-2 (IL-2)-responsive T cells, significant T-cell/TCR clonality was found in 2 out of 4 patients. The clonal T cells represented a minority of the total T-cell population with an estimated frequency of 1 in 300 to 1 in 1000 cells. Molecular characterization of a clonal TCR and the use of a specific TCR V beta MoAb ruled out an over-representation of T cells bearing the same V beta element in the total T-cell population, rendering the involvement of super-antigens in the induction of T-cell clonality in this case unlikely.

[Not Available]

Different therapeutic modalities are available for the treatment of rheumatic pain. The most important one, besides physiotherapy, is medication with analgesics and adjuvant drugs. Analgesics are given orally and by a stepwise approach in keeping with the principles of cancer pain therapy. In the first step nonopioid analgesics are prescribed, especially non-steroid anti-inflammatory drugs (NSAID) if pain is caused by inflammation. Other nonopioid analgesics, which can be used as alternatives for patients with non-inflammatory pain, are metamizol and paracetamol. Weak or even strong opioids must be administered to patients with rheumatic diseases when pain relief is insufficient or side-effects occur during medication with non-opioids. Long-term treatment of rheumatic pain even with strong opioids such as oral morphine involves only a small risk of severe side-effects such as respiratory depression or the development of tolerance and drug abuse. Patients often suffer from constipation, nausea and vomiting, but these side-effects can be treated with laxatives and antiemetic drugs. There is no reason to differentiate between opioid medication in a cancer patient with pain and in a patient with "non-malignant" rheumatic pain. Centrally acting muscle relaxants may be helpful as adjuvant medication in patients with myalgia for example, and tricyclic antidepressants can also be beneficial, especially in neuropathic pain and for patients with psychiatric distress associated with pain.

[Data of two years of the comparative study methotrexate/aurothiomalate in 102 patients]

102 patients (pat.) with active erosive rheumatoid arthritis (RA) with a median disease duration of only 14 months without malalignment or deformities entered a randomized study to compare the effects of 15 mg methotrexate (MTX) and 50 mg gold sodium thiomalate (GST) administered intramuscularly once a week. The study was double blind during the first year and open during the second year. Clinical and laboratory evaluations were made every three months. X-rays of hands, wrists and forefeet in standard a.p.-projection were taken at month 0, 6, 12 and 24. 32 joints were evaluated according to Larsen. 17/52 (MTX) and 21/50 (GST) patients were withdrawn for several reasons. Withdrawals for toxicity were significantly more frequent in the GST group. 35 patients in the MTX group and 26 patients in the GST group were evaluated for efficacy. All clinical parameters, ESR and CRP improved by more than 50% in both groups without significant intergroup difference. The greatest improvement was seen already after six months. An > 50% improvement occurred in 57% of pat. in both groups. The Larsen score (sum of the Larsen grades of 32 joints) deteriorated significantly in both groups during the first six months (MTX = 3.0, GST = +4.3), it remained stable thereafter in the MTX group and decreased in the gold group. The number of erosive joints increased significantly in both groups during the first six months. This increase was slowed down after six months in the MTX group, in the gold group a decrease was seen indicating a healing of erosions. All differences between the groups were not significant, however.

CONCLUSION

While tolerability was better with MTX, both drugs were similarly effective in the treatment of RA and slowed down radiologic progression.

A double-blind comparison of parenteral methotrexate and parenteral gold in the treatment of early erosive rheumatoid arthritis: an interim report on 102 patients after 12 months

One hundred two patients with active erosive rheumatoid arthritis (RA) without malalignment or deformities (median disease duration, 14 months) entered a double-blind, randomized study to compare the effects of 50 mg gold sodium thiomalate (GST) with 15 mg methotrexate (MTX) administered intramuscularly for 12 months. Roentgenograms of hands, wrists, and forefeet were taken at baseline and after 6 and 12 months, and 32 joints were evaluated according to Larsen. Sixteen of 50 patients in the MTX group were withdrawn; one patient in the MTX group died of cerebral bleeding that was not related to treatment. Thirty-four GST patients and 44 MTX patients were evaluated for efficacy. Thirty-eight joints were counted. The number oftender and swollen joints, the Lansbury articular index, morning stiffness, activities of daily living (ADL) score, and erythrocyte sedimentation rate improved significantly in both groups without statistical intergroup differences. After 12 months, there was a significant deterioration of the mean Larsen index and the number of joints with erosions without intergroup difference. However, the radiological progression was retarded significantly during the second 6-month period in the gold group, whereas this effect was less pronounced in the MTX group. At 12 months, the progression rate was the same in both groups.

Expression of the CD2 activation epitope T11-3 (CD2R) on T cells in rheumatoid arthritis, juvenile rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, and Lyme disease: phenotypic and functional analysis

CD2R is an activation-associated epitope unmasked by a conformational change of the CD2 cell-surface glycoprotein. In spite of elaborate studies on the role of CD2 and CD2R in adhesion and stimulation of T cells in vitro, no instances of CD2R expression in vivo were known to date. We report high levels of CD2R observed on blood and synovial fluid T cells in rheumatoid arthritis and on peripheral blood T cells in juvenile rheumatoid arthritis, systemic lupus erythematosus, ankylosing spondylitis, and Lyme disease. In vivo, expression of CD2R was restricted to T cells, not limited to a particular T-cell subset and not correlated with the expression of p55 interleukin 2R (IL-2R) (CD25) or major histocompatibility complex (MHC) class II molecules. When stimulated to proliferation via CD2 or CD3, ex vivo CD2R+ T cells showed the same basic activation requirements as CD2R-T cells.

HLA typing in families with multiple cases of rheumatoid arthritis

Thirty one white patients from 14 families with multiple cases of rheumatoid arthritis (RA) and 42 of their healthy relatives were completely HLA typed. In contrast with class I antigens, the class II antigens DR1 and DR4 were significantly more common in the patients than in a group of 200 healthy local white controls (DR1: 32% v 12%; DR4: 48% v 28%, in patients and controls respectively). Owing to the small number of cases the data from this study were combined with those of published reports. Examination of patients for DR1 and DR4 homozygosity and DR1/4 heterozygosity showed an increase of DR1 homozygous patients, which was not statistically significant. There was no striking deviation from random expectation in haplotype sharing of affected sib pairs. These results are compatible with a dominant influence of DR1 and DR4 in the mode of inheritance. The nearly random haplotype sharing and the molecular relation between DR1 and DR4 support the hypothesis of a direct influence of these antigens in the pathogenesis of RA. Only 68% of the patients in this study possessed either DR1 or DR4, possibly indicating a subtype of RA which is independent of HLA. Clinical and serological variables were measured and indicated no significant difference between DR1 (or DR4) positive and DR1 (or DR4) negative disease. In this small group of patients the clinical course of RA seemed to be determined mainly by other genetic or environmental factors.

A double blind randomized parallel trial of intramuscular methotrexate and gold sodium thiomalate in early erosive rheumatoid arthritis

In a double blind study 57 patients with active erosive rheumatoid arthritis without malalignment or deformities (median disease duration 13 months) were randomly treated with 50 mg gold sodium thiomalate (GSTM) or 15 mg methotrexate (MTX) intramuscularly for 6 months. In the GSTM group, 5/28 patients had to be withdrawn because of side effects; in 2/28 the dose was reduced. In the MTX group, 2/29 were withdrawn, one was lost to followup. The number of swollen joints improved by over 6 in 18/26 (MTX) and in 15/21 (GSTM). Five clinical variables and the sedimentation rate improved significantly in both groups without significant intergroup differences. The radiographs of hands, wrists and forefeet (32 joints evaluated according to Larsen) showed a radiological progression in 11/26 (MTX) and in 8/20 patients (GSTM); however, the deterioration of the mean Larsen index was not significant. While there was no significant difference in effectivity, tolerability was better in the MTX group.

Expression of activation antigens on T cells in rheumatoid arthritis patients

The aim of our study was to identify differences in cell surface marker expression between T cells taken from the peripheral blood (PB) of healthy individuals and T cells recovered from inflamed joints of rheumatoid arthritis (RA) patients. Out of 118 monoclonal antibodies (MoAbs) directed against activation antigens on haematopoietic cells, 12 MoAbs recognizing nine distinct surface molecules were selected after a screening procedure to study the expression of the corresponding antigens on T cells from the PB, synovial fluid and synovial tissue of RA patients, and also on T cells from PB and spleens of controls. Using two-colour flow cytometry and immunohistology we found the molecules B-C5, CD39, CD40, CD45 R0, CD54, CD76 and potentially 1D11 to be substantially up-regulated on T cells from various body compartments in RA patients. We thus could determine that the cell surface of T cells in RA patients not only differs in MHC class II expression, but also in a number of other activation-associated cell surface molecules from T cells in healthy individuals.

[Pathogenesis of tendon-/muscle pain with special reference to posture--a concept related contribution to the understanding of generalized tendomyopathy]

Tendomyopathies (TM) comprise two subgroups. Both are caused by the irritation of nociceptors (IN). Type I results from IN within muscles and tendons with the consequence of local pain, whereas type II refers to TM occurring at a site distant from IN anywhere in the body. Such TM-type II are understood to serve for the protection of the organism from further IN and depend on the regulatoric role of the central nervous system ("reflectoric TM"). Reflectoric shoulder pain emerging from arthritis in carpal joints (Hiemeyer et al.: Z. Rheumatol. 48, 1989, 139-143) is quoted as an example of such "regulatoric pain". Abnormal spinal posture (ASP) is believed to cause IN at various sites of the sceletomotoric system with the consequence of localized or generalized fibromyalgic syndromes (FS) of the type II subgroup. Now clinical signs of TM such as pain during motion, compression or stretching as well as muscular stiffness and fatigue are characteristic for so called primary FS; in addition, the majority of such patients exhibits ASP, especially increased thoracospinal kyphosis (Hiemeyer et al.: Akt. Rheumatol. 14, 1989, 193-201). For these reasons we arrive at the conclusion that ASP is a disposing factor for the development of FS. Therefore FS should not be called primary unless spinal posture has not been examined thoroughly. As a result of this concept we consider control of spinal posture by physiotherapy as an essential part in the causal treatment of FS.

[Assessment of the functional origin of shoulder pain in chronic polyarthritis by diagnostic local anesthesia of inflamed distal joints. A pilot study]

We examined 40 patients with rheumatoid arthritis suffering from painful shoulder. While the shoulder itself was not treated, Mepivacain was injected into an arthritic joint of wrist or elbow. In 36 out of 40 patients we achieved full or partial improvement of pain and movement of the shoulder. We conclude that pain in the shoulder of these patients was caused by a regulatory mechanism, triggered by nociceptors in an arthritic distal joint in order to protect this damaged structure. The therapeutic consequence implies treatment of the distal joint rather than treatment of the painful shoulder itself.

[Detritus synovitis in chronic polyarthritis: a clinical and operation histologic evaluation]

In rheumatoid arthritis (RA) joint inflammation is due to two processes: 1) the underlying inflammatory process (UIP) characterized by a lymphoplasmacellular infiltration of the synovial tissue, as well as pannus formation, and 2) the detritogenic synovitis (DS), a synovial response to articular wear products from cartilage and bone (detritus) that induces a preferentially fibrinous inflammation. In order to estimate the role of DS in the clinical presentation of such joints, 40 patients with RA undergoing knee-joint surgery on 48 occasions were evaluated for clinical parameters, radiological stage (Larsen), and histopathological characteristics of UIP and DS. The clinical parameters were comparable in knee joints with predominantly UIP or DS. However, DS was regularly seen in knees with advanced destruction according to Larsen's stages 4 to 5, while UIP occurres in joints even without radiological damage. In conclusion, it is assumed that the poor response of patients with advanced RA to so-called long-term drug therapy may be in part explained by the modifying influence of joint detritus on the underlying "rheumatoid" inflammatory process.

Oxygen radicals as effectors of cartilage destruction. Direct degradative effect on matrix components and indirect action via activation of latent collagenase from polymorphonuclear leukocytes

Degradation of intact cartilaginous tissue (bovine nasal cartilage) by oxygen-derived free radicals (ODFR) generated enzymatically by xanthine oxidase and hypoxanthine was studied. The degree of tissue destruction was determined by measuring the indentation under a defined compression force as well as by the loss of uronic acid- and hydroxyproline-containing matrix components. Cartilage slices altered by prior elastase treatment were more susceptible to oxygen radical attack than were intact tissue specimens. Degradation of cartilage matrix by ODFR was strongly inhibited by superoxide dismutase or catalase. Coincubation of latent collagenase from polymorphonuclear leukocytes with the ODFR-generating system led to activation of collagenolytic activity, resulting in marked degradation of the bovine cartilage slices. In further studies, activated polymorphonuclear leukocyte-collagenase was shown to degrade intact human articular cartilage to a degree of mechanical insufficiency. Thus, our assay system serves as an in vitro model of tissue damage, which may be relevant to pathophysiologic states such as rheumatoid arthritis.

[Long-term drug therapy in inflammatory rheumatic diseases using chronic polyarthritis as an example. 2. Basic principles of long-term drug therapy: choice of optimal therapeutic agents]

The article reviews the principles of the long-term drug therapy of rheumatoid arthritis. A nomogram is presented which allows selection of adequate antiphlogistic and long-term drugs according to activity and progression of the disease. Steroids, non-steroidal antiphlogistics, gold, D-penicillamine and azathioprine are described in the order of their application during treatment of a severe polyarticular flare-up. Some of the drug regimens are relevant also to diseases other than rheumatoid arthritis, but drug therapy reflects only a single aspect in the treatment of these diseases and has to be applied together with non-pharmacologic methods (surgery, physical therapy, functional therapy, psychology etc.).

[Immune complexes: mediators for the formation of inflammatory granulation tissue? Immunohistologic studies of the hyaline articular cartilage in chronic polyarthritis]

Previous reports describe the presence of immunoglobulins and complement components within rheumatoid articular cartilage, thereby suggesting an effect of immune complexes on the formation of pannus. This hypothesis is reinvestigated in this paper. As confirmed in our work, the superficial layer of rheumatoid hyaline cartilage may fulfill the immunohistological criteria for the presence of immune complexes. In osteoarthritis, however, a noninflammatory disease not mediated by immunologic mechanisms, similar results can be obtained. The presence of immune-proteins within hyaline cartilage therefore requires a cautious interpretation. Hyaline cartilage in rheumatoid arthritis is replaced by granulation tissue growing not only at its surface (pannus), but also in subchondral bone. We therefore also thoroughly investigated deep layers of hyaline cartilage in the vicinity of such subchondral tissue, but could not obtain any evidence for the presence of immune complexes therein. The growth of subchondral granulation tissue and the accumulation of PMN in the region of its junction with hyaline cartilage therefore appear to be independent of immune complexes within rheumatoid hyaline cartilage. It is suggested on the basis of these data that immune complexes possibly present in hyaline cartilage do not play an essential role in the formation of granulation tissue replacing cartilage in rheumatoid arthritis. It is, however, not entirely excluded that during advanced stages of rheumatic cartilage degradation immune complexes are formed within the matrix or carried into it from the extra-cartilaginous environment, and that they may then contribute to further cartilage destruction by enzyme release during phagocytic processes.