1579 Effect of COVID-19 pandemic on the Suspected Colorectal Cancer Pathway at a District General Hospital

Aim

During the initial phase of the COVID-19 pandemic the British Society of Gastroenterology and Joint Advisory Group on GI Endoscopy published guidance to halt all non-emergency endoscopy. As a result, CT was used as the first-line investigation with delayed completion endoscopy. We reviewed the efficacy of this change to determine its influence on future practice.

Method

All patients referred via the suspected colorectal cancer pathway (SCCP) to our district general hospital from 15/04/20-15/05/20 (during the initial COVID-19 lockdown) were included. Retrospective analysis of patient electronic records, radiology and endoscopy was performed. Results were analysed using χ² statistic. Significant incidental pathology was defined as non-colorectal pathology requiring referral to different speciality or further imaging.

Results

115 patients were included for analysis, mean age 68 years. 2/115 (1.7%) were found to have a colorectal malignancy on CT, with no further diagnoses following completion colonoscopy. CT imaging detected significant incidental pathology in 31/115 (27%). Subgroup analysis by presenting complaint showed significant pathology was most likely to be detected in those presenting with weight loss (13/36, 36.1%, p = 0.049) or anaemia (12/31, 38.7% p = 0.084).

Conclusions

CT is a valuable first-line investigation in SCCP patients. In this cohort, no colorectal malignancies were missed on CT that were later detected on endoscopy and 27% of scans detected significant non-colorectal incidental pathology. Weight loss was found to have a statistically significant correlation with incidental pathology. These findings suggest CT as a possible first-line investigation in patients presenting with weight loss, anaemia or in the event of delayed access to endoscopy.

Subetta increases phosphorylation of insulin receptor β-subunit alone and in the presence of insulin

It has been previously shown that Subetta (a drug containing released-active forms of antibodies to the insulin receptor β-subunit and antibodies to endothelial nitric oxide synthase) stimulated insulin-induced adiponectin production by mature human adipocytes in the absence of insulin. Therefore, it was assumed that Subetta could activate the insulin receptor. To confirm this hypothesis, the capacity of Subetta to activate the insulin receptor in mature human adipocytes in the absence or presence of the insulin was investigated. Cells were incubated either with Subetta or with vehicle, or with basal medium for 3 days. Then, adipocytes were treated with water or insulin (100 nm) for 15 min. Following treatment, lysates were prepared and phosphorylation of insulin receptor β-subunits was analyzed by western blot analysis. It was shown that Subetta significantly increased (P<0.001) the ‘phosphorylated-insulin receptor β-subunit/total insulin receptor β-subunit' ratios in both the presence and the absence of insulin. These results support previously published data and indicate that Subetta could activate the insulin receptor through the effect on its β-subunits, whose conformational state is essential for insulin receptor activation. This action might serve as one of the primary mechanisms of the drug's antidiabetic effect.

W/O microemulsions for ocular delivery: Evaluation of ocular irritation and precorneal retention

Water-in-oil microemulsions (w/o ME) capable of undergoing a phase-transition to lamellar liquid crystals (LC) or bicontinuous ME upon aqueous dilution were formulated using Crodamol EO, Crill 1 and Crillet 4, an alkanol or alkanediol as cosurfactant and water. The hypothesis that phase-transition of ME to LC may be induced by tears and serve to prolong precorneal retention was tested. The ocular irritation potential of components and formulations was assessed using a modified hen's egg chorioallantoic membrane test (HET-CAM) and the preocular retention of selected formulations was investigated in rabbit eye using gamma scintigraphy. Results showed that Crill 1, Crillet 4 and Crodamol EO were non-irritant. However, all other cosurfactants investigated were irritant and their irritation was dependent on their carbon chain length. A w/o ME formulated without cosurfactant showed a protective effect when a strong irritant (0.1 M NaOH) was used as the aqueous phase. Precorneal clearance studies revealed that the retention of colloidal and coarse dispersed systems was significantly greater than an aqueous solution with no significant difference between ME systems (containing 5% and 10% water) as well as o/w emulsion containing 85% water. Conversely, a LC system formulated without cosurfactant displayed a significantly greater retention compared to other formulations.

The potential for efficacy of the modified (ICP 34.5(-)) herpes simplex virus HSV1716 following intratumoural injection into human malignant glioma: a proof of principle study

We have previously demonstrated the safety of intratumoural administration of the selectively replication-competent herpes simplex virus mutant HSV1716 in patients with high-grade glioma (HGG). Here we show its potential for efficacy by demonstrating that the virus survives and replicates when injected into the tumours of patients. Since HSV replication is a cytolytic process it must result in tumour cell killing. Twelve patients with biopsy-verified HGG received an intratumoural injection of 10(5) plaque-forming units (p.f.u.) of HSV1716. Four to 9 days after inoculation, tumours were removed and assayed for evidence of viral replication. In two patients, HSV1716, in excess of the input dose was recovered from the injection site. HSV DNA was detected by PCR at the sites of inoculation in 10 patients and at distal tumour sites in four. HSV-specific antigen was detected in tumour tissue from two patients. In five patients an immunological response to HSV1716, as detected by changes in levels of IgG and IgM, was demonstrated. This study demonstrates that HSV1716 replicates in HGG without causing toxicity in both HSV-seropositive and -seronegative patients.

Long-term survival following extra-neural metastasis from a pineoblastoma

A young woman presented with a pineoblastoma treated initially with whole neuraxis radiotherapy. She had biopsy confirmed metastatic disease to the left lateral pelvis which was treated on 2 separate occasions, and biopsy confirmed metastatic disease to the subcutaneous tissues of the left thigh. She currently remains well 8 years after the primary diagnosis and 6 years after the first systemic relapse.

Toxicity evaluation of replication-competent herpes simplex virus (ICP 34.5 null mutant 1716) in patients with recurrent malignant glioma

The herpes simplex virus (HSV) ICP34.5 null mutant 1716 replicates selectively in actively dividing cells and has been proposed as a potential treatment for cancer, particularly brain tumours. We present a clinical study to evaluate the safety of 1716 in patients with relapsed malignant glioma. Following intratumoural inoculation of doses up to 10(5) p.f.u., there was no induction of encephalitis, no adverse clinical symptoms, and no reactivation of latent HSV. Of nine patients treated, four are currently alive and well 14-24 months after 1716 administration. This study demonstrates the feasibility of using replication-competent HSV in human therapy.

Involvement of apolipoprotein E in multiple sclerosis: absence of remyelination associated with possession of the APOE epsilon2 allele

Lipids are a major constituent of myelin and apolipoprotein E (apoE) plays a key role in lipid transport. We therefore hypothesized that apoE is involved in the processes of demyelination and remyelination. Furthermore as there is a biologically significant polymorphism in the APOE gene, the APOE genotype may influence the course of multiple sclerosis (MS). Specifically, as there is reduced affinity of the apoE E2 isoform for receptors on glial cells, we hypothesized that remyelination is impaired in individuals with the apoE epsilon2 allele. We determined the apoE genotypes of 71 archival cases of multiple sclerosis and 41 controls, reviewed the neurohistology, and performed apoE immunohistochemistry. ApoE immunoreactivity was increased in demyelinated areas compared with control white matter. ApoE immunostaining was markedly increased in areas of active demyelination, specifically in macrophages and astrocytes. The APOE allele frequencies of the cases of MS (epsilon2 = 0.06, epsilon3 = 0.8, epsilon4 = 0.13) resembled those of controls. Evidence of remyelination was identified in 25/ 71 MS cases (35%): in 25/64 patients (39%) without an epsilon2 allele and 0/7 (0%) patients with an epsilon2 allele (p < 0.05). In conclusion, we provide evidence that apoE is involved in the trafficking of lipid in MS and, although the number of cases with this allele was small, remyelination may be defective in patients with the APOE epsilon2 allele.

Hereditary vascular dementia linked to notch 3 mutations. CADASIL in British families

The most common form of familial vascular dementia is considered to be CADASIL or cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy, which is now also increasingly manifest in the United Kingdom. CADASIL has been previously dubbed as a familial form of Binswanger disease. However, unlike in Binswanger disease CADASIL does not involve hypertension or other risk factors associated with cardiovascular disease. CADASIL appears to be essentially a disorder of the arteries that is linked to single missense mutations in the NOTCH 3 gene locus on chromosome 19. The pathogenesis of the disorder or the genetic mechanism leading to brain infarcts and dementia is not known. The elucidation of the microvascular pathology evident in CADASIL may be an interesting way to delineate effects of defective genes on brain cells from systemic vascular influences.

Identification of domains in IL-16 critical for biological activity

IL-16 is a proinflammatory cytokine implicated in the pathogenesis of asthma and other conditions characterized by recruitment of CD4+ T cells to sites of disease. It is postulated that CD4 is an IL-16 receptor, although other receptors or coreceptors may exist. Among several known functions, IL-16 is a chemoattractant factor for CD4+ T cells and it inhibits MLR. We previously reported that an oligopeptide corresponding to the 16 C-terminal residues of human IL-16 inhibits chemoattractant activity. To identify functional domains with greater precision, shorter oligonucleotides containing native or mutated C-terminal IL-16 sequences were tested for IL-16 inhibition. Within the 16 C-terminal residues, the minimal peptide RRKS (corresponding to Arg106 to Ser109) was shown to mediate inhibition of IL-16 chemoattractant activity. Inhibition was lost when either arginine was substituted with alanine. Point mutations in IL-16 revealed that Arg107 is critical for chemoattractant activity, but MLR inhibition was unaffected by mutation of Arg107 or even deletion of the C-terminal tail through Arg106. Deletion of 12 or 22 N-terminal residues of IL-16 had no impact on chemoattractant activity, but MLR inhibition was reduced. Deletion of 16 C-terminal plus 12 N-terminal residues abolished both chemoattractant and MLR-inhibitory activity of IL-16. These data indicate that receptor interactions with IL-16 that activate T cell migration are not identical with those required for MLR inhibition, and suggest that both N-terminal and C-terminal domains in IL-16 participate in receptor binding or activation.

Processing and release of IL-16 from CD4+ but not CD8+ T cells is activation dependent

IL-16 is synthesized as a precursor molecule of 68 kDa (pro-IL-16) that is processed by caspase-3, a member of the IL-1 converting enzyme (ICE) family. This cleavage results in a 13-kDa carboxy terminal peptide, which constitutes the bioactive secreted form of IL-16. We have previously reported constitutive IL-16 mRNA expression and pro-IL-16 protein in CD4+ and CD8+ T cells. Although bioactive IL-16 protein is present in unstimulated CD8+ T cells, there is no bioactive IL-16 present in CD4+ T cells. Along these lines, unstimulated CD8+ T cells contain active caspase-3. In the current studies we investigated the regulation of IL-16 protein and mRNA expression in CD4+ T cells and determined the kinetics of secretion following stimulation of the TCR. CD4+ T cells release IL-16 protein following antigenic stimulation, and this release is accelerated in time by costimulation via CD28. However, CD3/CD28 costimulation did not alter IL-16 mRNA appearance or stability in either CD4+ or CD8+ T cells. The secretion of bioactive IL-16 from CD4+ T cells correlated with the appearance of cleavage of pro-caspase-3 into its 20-kDa active form. Thus, resting CD8+ T cells contain active caspase-3 that is capable of cleaving pro-IL-16, whereas CD4+ T cells require activation for the appearance of active caspase-3. The mechanism of release or secretion of bioactive IL-16 is currently unknown, but does not correlate with cellular apoptosis.

Conservation of structure and function between human and murine IL-16

IL-16 is a proinflammatory cytokine that signals via CD4, inducing chemotactic and immunomodulatory responses of CD4+ lymphocytes, monocytes, and eosinophils. Comparative analysis of murine and human IL-16 homologs could reveal conserved structures that would help to identify key functional regions of these cytokines. To that end, we cloned the murine IL-16 cDNA and found a high degree of amino acid similarity comparing the predicted murine and human IL-16 precursor proteins (pro-IL-16). The highest similarity (82.1%) was found in the C-terminal region, which is cleaved from pro-IL-16 to yield biologically active IL-16. Chemotaxis experiments with IL-16 of murine and human origin, using murine splenocytes or human T lymphocytes as targets, showed cross-species stimulation of motility. Synthetic oligopeptides and anti-peptide Ab were produced, based on the sequences of three predicted hydrophilic domains of IL-16 potentially presented in exposed positions. None of these peptides had intrinsic IL-16 bioactivity, but one (corresponding to a hydrophilic C-terminal domain of IL-16) partially displaced binding of OKT4 mAb to human lymphocytes. This peptide, and its cognate Ab, also inhibited IL-16 chemoattractant activity for human and murine cells. These studies demonstrate a high degree of structural and functional similarity between human and murine IL-16 and suggest that amino acids in the C terminus are critical for its chemoattractant function. The data suggest cross-species conservation of IL-16 receptor structures as well. Inhibitory peptides may be useful in disease states where the proinflammatory functions of IL-16 are detrimental to the host.

Measurement of spleen size and its relation to hypersplenism and portal hemodynamics in portal hypertension due to hepatic cirrhosis

AIMS

Splenomegaly is common in portal hypertension due to hepatic cirrhosis, but there are little data comparing different methods of spleen measurement. We have compared ultrasound with radionuclide imaging in measuring splenomegaly. The relation of splenomegaly to hypersplenism and portal hemodynamic factors was also studied.

RESULTS

Ultrasound and radionuclide measures of spleen volume gave comparable results (r = 0.95, p < 0.0001). Phagocytic activity of the spleen measured by radionuclide uptake increased as the volume of the spleen increased (r = 0.46, p < 0.03) but was not related to diminishing liver phagocytic activity. Spleen volume was correlated negatively with leukocyte counts (r = 0.43, p < 0.05) but not with hemoglobin or platelet counts. Spleen radionuclide uptake was negatively correlated with hemoglobin (r = 0.48, p < 0.04) and leukocyte counts (r = 0.46, p < 0.04) but not with platelet counts. Spleen volume was related to portal vein cross-sectional area (r = 0.91, p < 0.0001) and portal vein blood flow volume (r = 0.57, p < 0.008) but not to portal vein blood flow velocity, portal pressure gradient, or azygos blood flow.

CONCLUSIONS

Spleen size measured by ultrasonography and radionuclide studies gives comparable results. Spleen phagocytic activity in cirrhosis increases as the spleen enlarges but not in relation to decreased hepatic phagocytic activity. Spleen phagocytic activity probably contributes to anemia and leukopenia in the splenomegaly of cirrhosis, but other factors must contribute to thrombocytopenia. Portal hemodynamics are probably important in the splenomegaly, but the interrelation is complex.

CD4 ligand IL-16 inhibits the mixed lymphocyte reaction

CD4 participation in TCR/CD3-associated activation through interaction with the MHC class II Ags results in formation of a CD4-TCR/CD3 complex capable of maximal signal transduction. When CD4 binds to alternative ligands such as HIV-1 gp120 or anti-CD4 Abs, Ag stimulation of TCR/CD3 is markedly inhibited, and an unresponsive state develops. To determine if the natural CD4 ligand interleukin-16 also induces unresponsiveness, we tested the effects of rIL-16 on T cell proliferation in mixed lymphocyte reactions. rIL-16 suppressed T cell proliferation in a dose-dependent manner at concentrations of 10(-11) to 10(-7) M. Inhibition of proliferation was present on days 5 to 9 of the mixed lymphocyte reaction. rIL-16 did not modulate membrane CD4, significantly change basal [3H]thymidine incorporation in resting T lymphocytes, or alter viability. The suppressive effect was specifically blocked by preincubation with neutralizing anti-rIL-16 mAb or with recombinant soluble CD4. While the expression of IL-2R on responder cells was unaffected by rIL-16, the addition of exogenous rIL-2 did not restore T cell responsiveness. The unresponsiveness induced by rIL-16 is distinct from that of other CD4 ligands in that CD4 and IL-2R expression are unaffected. The failure of rIL-2 to restore proliferation suggests that the decrease in T cell responsiveness induced by rIL-16 may result from an interruption in the IL-2R-signaling mechanism. These results may help explain how CD4 delivers both activating and inhibitory signals and provides a rationale for the role of IL-16 in the regulation of immune responses.

CD4 ligand IL-16 inhibits the mixed lymphocyte reaction

CD4 participation in TCR/CD3-associated activation through interaction with the MHC class II Ags results in formation of a CD4-TCR/CD3 complex capable of maximal signal transduction. When CD4 binds to alternative ligands such as HIV-1 gp120 or anti-CD4 Abs, Ag stimulation of TCR/CD3 is markedly inhibited, and an unresponsive state develops. To determine if the natural CD4 ligand interleukin-16 also induces unresponsiveness, we tested the effects of rIL-16 on T cell proliferation in mixed lymphocyte reactions. rIL-16 suppressed T cell proliferation in a dose-dependent manner at concentrations of 10(-11) to 10(-7) M. Inhibition of proliferation was present on days 5 to 9 of the mixed lymphocyte reaction. rIL-16 did not modulate membrane CD4, significantly change basal [3H]thymidine incorporation in resting T lymphocytes, or alter viability. The suppressive effect was specifically blocked by preincubation with neutralizing anti-rIL-16 mAb or with recombinant soluble CD4. While the expression of IL-2R on responder cells was unaffected by rIL-16, the addition of exogenous rIL-2 did not restore T cell responsiveness. The unresponsiveness induced by rIL-16 is distinct from that of other CD4 ligands in that CD4 and IL-2R expression are unaffected. The failure of rIL-2 to restore proliferation suggests that the decrease in T cell responsiveness induced by rIL-16 may result from an interruption in the IL-2R-signaling mechanism. These results may help explain how CD4 delivers both activating and inhibitory signals and provides a rationale for the role of IL-16 in the regulation of immune responses.

Increased tau immunoreactivity in oligodendrocytes following human stroke and head injury

Tau immunohistochemistry was performed on post-mortem brain tissue from patients who died following head injury or stroke and from neurologically normal controls. Tau-positive oligodendrocytes were detected with three different tau antibodies in head injured or stroke patients, but not in control cases. Tau-positive oligodendrocytes were detected 2 h following head injury indicating that accumulation of tau may be an acute response of these cells to brain injury. The mechanisms underlying accumulation of tau in oligodendrocytes after acute brain injury may be similar to those which occur in chronic neurodegenerative conditions such as progressive supranuclear palsy (PSP) and multi-system atrophy (MSA).

Interleukin 1 beta, hand and foot bone mineral content and the development of joint erosions in rheumatoid arthritis

OBJECTIVE

To assess the relationship between plasma levels of the cytokine interleukin-1 beta (IL-1 beta) and the progression of rheumatoid arthritis (RA).

METHODS

Two subgroups of patients, one with persistently raised ESR (>/= 50 mm/hour, n = 16, group A) and one with persistently low ESR (</= 28 mm/hour), n = 18, group I) were chosen to represent stable extremes of inflammatory activity from a prospective study of 106 patients with active RA studied over one year in a single centre. The change from baseline in hand, foot and calcaneal bone mineral content measured by single photon absorptiometry and radiographic score of joint damage was measured over 12 months, together with plasma IL-1 beta and erythrocyte sedimentation rate.

RESULTS

Significant progression of joint damage occurred in both subgroups over one year (p < 0.0001, paired t test) though progression was significantly less in the subgroup with low ESR (p < 0.05, ANOVA). Hand and foot bone mineral content decreased by almost 10% in the subgroup with raised ESR (p < 0.005, paired t test). Stepwise linear regression analysis revealed significant independent relationships between radiographic progression over one year and plasma IL-1 beta and ESR (multiple R 0.674, F = 11.64, p < 0.0002). No such relationships were observed for changes in bone mineral content parameters.

CONCLUSIONS

Plasma IL-1 beta levels correlate weakly with progression of joint damage though not with loss of peripheral bone density in RA. A significant reduction in peripheral bone mineral content occurs over one year in patients with active RA with persistently raised ESR.

A short latency cortical component of the foveal VEP is revealed by hemifield stimulation

Transient evoked potentials were recorded simultaneously over 5 electrodes placed in a horizontal row across the occiput. A range of spatial frequencies were presented as either full-field or hemifield stimuli. Subjects were 11 normal observers and 5 patients with lesions causing a homonymous hemianopic field defect. The shortest latency peak response was at approximately 70 msec, a negative potential (N70). For all spatial frequencies, full-field stimuli evoked a lower amplitude N70 at the midline than the sum of N70 amplitudes to two hemifield stimuli, suggesting partial cancellation. The latency and amplitude of N70 increased as spatial frequency increased. N70 and P100 differed in respect to their response to spatial frequency and field size, further suggesting that they may not be subsets of a unitary response. For hemifield stimulation, N70 had an ipsilateral maximum and attenuated or completely reversed in polarity across the midline. Consistent with the data of normals using hemifield stimuli, in 5 patients a full-field stimulus elicited an N70 lateralized contralaterally to the homonymous hemianopia, i.e., the ipsilateral N70 was absent. The absolute amplitude difference between the left and right electrodes was significant for hemifield stimulation in normals and full-field stimulation in the patients, but not for full-field stimulation in normals. Our results imply that the evaluation of N70 hemispheric distribution is useful for the evaluation of paramacular visual field defects.

Metastasis of a renal carcinoma to a cerebellar haemangioblastoma in a case of von Hippel-Lindau disease

A patient with Von Hippel-Lindau disease had a long-standing cerebellar cyst which recurred for the fifth time. At operation there was evidence of a renal carcinoma metastasis in the wall of the cyst which was probably a haemangioblastoma.

Altered lung vascular permeability during intermittent haemodialysis

Hypoxia is known to develop during intermittent haemodialysis. To investigate if increased pulmonary capillary permeability to protein contributes to this phenomenon, a dual-isotope technique using Indium-labelled transferrin and Technetium-labelled red blood cells was used. Lung vascular permeability was measured in eight patients with dialysis-dependent chronic renal failure immediately before and during intermittent haemodialysis with cuprophane membranes. As a group there was a significant increase in lung vascular permeability during the early stages of haemodialysis, compared to predialysis values (P less than 0.05) and this increase occurred during the period when the patients were leucopenic and maximally hypoxic. During the haemodialysis period, but not the predialysis period, the permeability index was also significantly increased compared to a group of eight controls (P less than 0.05). These results suggest that increased vascular permeability may contribute to dialysis-induced hypoxia and that this may relate to neutrophil activation within the pulmonary vascular bed.

The seasonal variation of total body calcium

Total body calcium was measured using in vivo neutron activation analysis in 156 patients with rheumatic diseases at six-month intervals. Evidence of seasonal variation was sought by relating deviation from a linear change to the month in which the measurement was made. A cyclic regression fitted to the data had an amplitude of 0.25% but a significance of only P = 0.08. The calcium balance studies of Malm were re-analysed to quantify the seasonal variation he had demonstrated in one group of men. The deduced variations of body calcium were highly significant, with a phase and amplitude very similar to the regression of our data. Both analyses differed from two previous reports of seasonal variations of part-body bone mineral of much greater amplitude and different phase.

Total and peripheral bone mass in patients with psoriatic arthritis and rheumatoid arthritis

Psoriatic arthritis is thought to be associated with periarticular osteoporosis while rheumatoid arthritis may be associated with generalised as well as periarticular bone loss. To assess the extent of total and peripheral bone loss in these two diseases, total body calcium was measured by in vivo neutron activation analysis and peripheral bone mass was assessed by metacarpal indices in age-matched patients with psoriatic arthritis and rheumatoid arthritis treated with nonsteroidal anti-inflammatory drugs alone. In comparison with age and sex-matched normal controls, total and peripheral bone mass was normal in psoriatic arthritis. There were significant reductions in total (6.2% in men; 7.9% in women) and peripheral (10.9% in men; 12.8% in women) bone mass in patients with rheumatoid arthritis compared with controls. Peripheral bone mass was significantly correlated with the degree of radiographic damage in male and female patients with rheumatoid arthritis. The mean annual loss of total body calcium was insignificant in psoriatic arthritis (0.6% in men; 1.9% in women) but markedly greater in rheumatoid arthritis (4.4% in men; 2.7% in women). The data suggested that total and peripheral bone loss is greater in rheumatoid arthritis than psoriatic arthritis. Substantial reductions in peripheral bone mass in patients with rheumatoid arthritis not receiving corticosteroids may account in part for the small reductions in total bone mass.

Bone loss in rheumatoid arthritis and primary generalized osteoarthrosis: effects of corticosteroids, suppressive antirheumatic drugs and calcium supplements

The annual rate of bone loss in rheumatoid arthritis (RA) and primary generalized osteoarthrosis (PGOA) was determined by measurement of total body calcium (TBCa). The mean annual rate of bone loss in 24 patients with RA treated with nonsteroidal anti-inflammatory drugs (NSAIDs) alone was 3.4%. This rate of bone loss was not reduced in ten RA patients responding to suppressive antirheumatic drugs (4.3%) or seven patients receiving oral calcium supplements (4.5%). The mean annual rate of loss of TBCa in 19 patients with PGOA was 1.6%, a figure which probably represents age-associated bone loss. The rate of bone loss in PGOA was significantly less than that in RA patients not receiving corticosteroids. The mean annual rate of change of TBCa in 30 RA patients receiving corticosteroids (+0.7%) was significantly less than that in any of the other RA groups despite an initial normalized bone mass which was significantly less than in those RA patients receiving NSAIDs alone. The data supported the hypothesis that bone loss occurred early in the course of corticosteroid therapy and thereafter the drugs might have a protective effect on the loss of bone in RA.