Dual islet transplantation modeling of the instant blood-mediated inflammatory reaction

Islet xenotransplantation is a potential treatment for diabetes without the limitations of tissue availability. Although successful experimentally, early islet loss remains substantial and attributed to an instant blood-mediated inflammatory reaction (IBMIR). This syndrome of islet destruction has been incompletely defined and characterization in pig-to-primate models has been hampered by logistical and statistical limitations of large animal studies. To further investigate IBMIR, we developed a novel in vivo dual islet transplant model to precisely characterize IBMIR as proof-of-concept that this model can serve to properly control experiments comparing modified xenoislet preparations. WT and α1,3-galactosyltransferase knockout (GTKO) neonatal porcine islets were studied in nonimmunosuppressed rhesus macaques. Inert polyethylene microspheres served as a control for the effects of portal embolization. Digital analysis of immunohistochemistry targeting IBMIR mediators was performed at 1 and 24 h after intraportal islet infusion. Early findings observed in transplanted islets include complement and antibody deposition, and infiltration by neutrophils, macrophages and platelets. Insulin, complement, antibody, neutrophils, macrophages and platelets were similar between GTKO and WT islets, with increasing macrophage infiltration at 24 h in both phenotypes. This model provides an objective and internally controlled study of distinct islet preparations and documents the temporal histology of IBMIR.

Belatacept and sirolimus prolong nonhuman primate islet allograft survival: adverse consequences of concomitant alefacept therapy

Calcineurin inhibitors (CNI) and steroids are known to promote insulin resistance, and their avoidance after islet transplantation is preferred from a metabolic standpoint. Belatacept, a B7-specific mediator of costimulation blockade (CoB), is clinically indicated as a CNI alternative in renal transplantation, and we have endeavored to develop a clinically translatable, belatacept-based regimen that could obviate the need for both CNIs and steroids. Based on the known synergy between CoB and mTOR inhibition, we studied rhesus monkeys undergoing MHC-mismatched islet allotransplants treated with belatacept and the mTOR inhibitor, sirolimus. To extend prior work on CoB-resistant rejection, some animals also received CD2 blockade with alefacept (LFA3-Ig). Nine rhesus macaques were rendered diabetic with streptozotocin and underwent islet allotransplantation. All received belatacept and sirolimus; six also received alefacept. Belatacept and sirolimus significantly prolonged rejection-free graft survival (median 225 days compared to 8 days in controls receiving basiliximab and sirolimus; p = 0.022). The addition of alefacept provided no additional survival benefit, but was associated with Cytomegalovirus reactivation in four of six animals. No recipients produced donor-specific alloantibodies. The combination of belatacept and sirolimus successfully prevents islet allograft survival in rhesus monkeys, but induction with alefacept provides no survival benefit and increases the risk of viral reactivation.

Nondepleting anti-CD40-based therapy prolongs allograft survival in nonhuman primates

Costimulation blockade of the CD40/CD154 pathway has been effective at preventing allograft rejection in numerous transplantation models. This strategy has largely depended on mAbs directed against CD154, limiting the potential for translation due to its association with thromboembolic events. Though targeting CD40 as an alternative to CD154 has been successful at preventing allograft rejection in preclinical models, there have been no reports on the effects of CD40-specific agents in human transplant recipients. This delay in clinical translation may in part be explained by the presence of cellular depletion with many CD40-specific mAbs. As such, the optimal biologic properties of CD40-directed immunotherapy remain to be determined. In this report, we have characterized 3A8, a human CD40-specific mAb and evaluated its efficacy in a rhesus macaque model of islet cell transplantation. Despite partially agonistic properties and the inability to block CD40 binding of soluble CD154 (sCD154) in vitro, 3A8-based therapy markedly prolonged islet allograft survival without depleting B cells. Our results indicate that the allograft-protective effects of CD40-directed costimulation blockade do not require sCD154 blockade, complete antagonism or cellular depletion, and serve to support and guide the continued development of CD40-specific agents for clinical translation.

Use of clinical risk factors to identify postmenopausal women with vertebral fractures

INTRODUCTION AND HYPOTHESIS

Previous studies have been unable to identify risk factors for prevalent vertebral fractures (VF), which are suitable for use in selection strategies intended to target high-risk sub-groups for diagnostic assessment. However, these studies generally consisted of large epidemiology surveys based on questionnaires and were only able to evaluate a limited number of risk factors. Here, we investigated whether a stronger relationship exists with prevalent VF when conventional risk factors are combined with additional information obtained from detailed one-to-one assessment.

METHODS

Women aged 65-75 registered at four geographically distinct GP practices were invited to participate (n=1,518), of whom 540 attended for assessment as follows: a questionnaire asking about risk factors for osteoporosis such as height loss compared to age 25 and history of non-vertebral fracture (NVF), the get-up-and-go test, Margolis back pain score, measurement of wall-tragus and rib-pelvis distances, and BMD as measured by the distal forearm BMD. A lateral thoraco-lumbar spine X-ray was obtained, which was subsequently scored for the presence of significant vertebral deformities.

RESULTS

Of the 509 subjects who underwent spinal radiographs, 37 (7.3%) were found to have one or more VF. Following logistic regression analysis, the four most predictive clinical risk factors for prevalent VF were: height loss (P=0.006), past NVF (P=0.004), history of back pain (P=0.075) and age (P=0.05). BMD was also significantly associated with prevalent VF (P=0.002), but its inclusion did not affect associations with other variables. Factors elicited from detailed one-to-one assessment were not related to the risk of one or more prevalent VFs. The area under ROC curves derived from these regressions, which suggested that models for prevalent VF had modest predictive accuracy, were as follows: 0.68 (BMD), 0.74 (four clinical risk factors above) and 0.78 (clinical risk factors + BMD). Analyses were repeated in relation to the subgroup of 13 patients with two or more VFs, which revealed that in this instance, the Margolis back pain score and rib-pelvis distance were associated with the presence of multiple VFs (P=0.022 and 0.026, respectively). Moreover, the predictive value as reflected by the ROC curve area was improved: 0.80 (BMD), 0.88 (the four most predictive clinical risk factors consisting of the height loss, past NVF, Margolis back pain score and rib-pelvis distance) and 0.91 (clinical risk factors + BMD).

CONCLUSIONS

Evaluation of additional risk factors from detailed one-to-one assessment does not improve the predictive value of risk factors for one or more prevalent vertebral deformities in postmenopausal women. However, the use of factors such as the Margolis back pain score and rib-pelvis distance may be helpful in identifying postmenopausal women at high risk of multiple prevalent VFs.

Factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis: a cross-sectional survey

OBJECTIVE

To determine the factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis.

DESIGN

Cross-sectional survey.

SETTING

National survey in the UK.

PARTICIPANTS

Participants were recruited through the National Osteoporosis Society and advertisements in the press and on the radio and included 533 women over age 50 with osteoporosis who were currently taking or had taken bisphosphonate therapy within the previous 12 months.

MAIN OUTCOME MEASURES

Self-reported factors influencing adherence and persistence to bisphosphonate therapy in osteoporosis: fracture history, pain, practical difficulties taking medication (frequency of dosing, dealing with comedications, impact on daily routine), perceptions of therapy, and concerns about bisphosphonate therapy.

RESULTS

Adherence to bisphosphonate therapy was 48% and was associated with previous fracture [odds ratio (OR) 1.62, 95% confidence interval (CI) 1.14-3.02], concerns about medication (OR 1.49, 95% CI 1.01-2.20), and less dissatisfaction with medication (OR 0.65, 95% CI 0.44-0.97). Nonpersistence was associated with dissatisfaction with medication (hazard ratio (HR) 1.83, 95% CI 1.38-2.43), side effects (HR 3.69, 95% CI 2.74-4.97), and concerns about bisphosphonate therapy (HR 2.21, 95% CI 1.48-3.30). For both daily (HR 1.53, 95% CI 1.1-2.33) and weekly bisphosphonates (HR 1.90, 95% CI 1.17-3.07), practical difficulties taking bisphosphonate medication-in particular, too frequent dosing-were associated with nonpersistence.

CONCLUSIONS

Self-reported nonadherence to daily and weekly bisphosphonates is independent of the decision to stop taking treatment (nonpersistence). Nonpersistence is associated with side effects and other factors that could be modified in clinical practice through education, information, and concordant partnerships.

Long-term NSAID use in primary care: changes over a decade and NICE risk factors for gastrointestinal adverse events

OBJECTIVES

To examine prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) in general practice and to compare the results with a 1993 study. To assess numbers at risk of gastrointestinal adverse events using the National Institute for Clinical Excellence (NICE) guidance on the use of cyclo-oxygenase (Cox) II selective drugs.

METHODS

Patients currently prescribed a NSAID for 2 months or more were identified from practice records. Demographic information, indications, previous gastrointestinal disease, serious co-morbidity and concomitant prescriptions were recorded. Data were compared with the 1993 survey and the NICE guidance.

RESULTS

Seven thousand nine hundred and fifty-eight patients were registered with the practice in 2003. Two hundred and four patients were receiving repeat prescriptions for conventional NSAIDs and 63 for Cox II selective drugs. As in 1993 diclofenac (38%) and ibuprofen (24%) were the commonest individual agents and the main indication was regional pain. Seventy-three per cent of patients prescribed Cox II selective drugs and 64% of patients prescribed conventional NSAIDs had at least one NICE risk factor for gastrointestinal adverse events. Frequency of co-prescription of aspirin or antacids was similar for conventional NSAIDs and Cox II selective drugs, but prescription of antacids was higher with NICE risk factors.

CONCLUSION

The indications for NSAIDs have not changed since 1993. Cox II selective drug prescribing was within the NICE guidance but a substantial proportion of patients taking other NSAIDs had risk factors for gastrointestinal adverse events. Discussion with the GPs highlighted the difficulties of balancing perceived risk of gastrointestinal adverse events with cardioprotection and further guidance is urgently needed.

Familial neurofibromatosis microdeletion syndrome complicated by rhabdomyosarcoma

Neurofibromatosis type 1 with dysmorphism and developmental delay is reported in a mother and two children. The son required treatment for a prostatic rhabdomyosarcoma. His sister has an optic pathway glioma. Fluorescence in situ hybridisation confirmed a submicroscopic deletion at 17q11.2. New evidence suggests an increased malignancy frequency in microdeletion cases.

A fracture risk profile using single-site bone density assessment and clinical risk factors

The Risk Factor Profile combines single-site bone density assessment and selected clinical risk factors to help estimate the risk of osteoporotic fracture for Caucasian postmenopausal women over the next 5 years. The bone density assessment uses T score cut-off values equivalent to the WHO definitions of osteoporosis and osteopenia at the hip that would identify 16-17% of women over 50 years of age as "high" risk. The clinical risk factors are defined as "major" producing about a doubling of fracture risk independent of bone density, and "minor" where the predictive power is less certain. The indications for a risk factor assessment using the Profile are the same as for any bone density assessment with the exception of monitoring response to treatment. In practice the clinical risk factors can be measured at the time of the bone density estimation taking only a few minutes. The decision to treat, or not to treat, a postmenopausal woman at high or medium risk will ultimately depend on the overall assessment of risks and benefits, costs of treatment and the desires of the patient. The Risk Factor Profile aims to supply the clinician with a simple tool to aid treatment decision-making.

A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain

OBJECTIVE

To determine the clinical efficacy of sclerosing injections in patients with chronic low back pain.

METHODS

Randomized, double-blind, placebo-controlled trial of three, once weekly injections of dextrose-glycerine-phenol with lignocaine vs saline plus lignocaine in patients with mechanical back pain of more than 6 months' duration. All patient assessments were performed blind by an experienced physiotherapist. The injections to the ligaments of the L4-5 and L5-S1 lumbar motion segments were given by an orthopaedic physician experienced in the technique, blinded to the nature of the injection solution according to a standard protocol. Demographic and clinical data, the short-form McGill Pain Questionnaire, the modified Somatic Pain Questionnaire, the Zung Depression Inventory, Oswestry Disability Scale and the modified Schober method of measuring spinal flexion were undertaken at 0, 1, 3 and 6 months.

RESULTS

Seventy-four patients [mean (S.D.) age 45(11) yr, female:male ratio 1:1, median pain duration >10 yr] were recruited and there were no drop-outs over the study period. There were no statistically significant differences in patient characteristics between the placebo and treatment groups at baseline or for any measure at follow-up.

CONCLUSIONS

Three, weekly sclerosant injections alone may not be effective treatment in many patients with undifferentiated chronic back pain. Patient selection and combination with other treatment modalities may be factors in determining treatment success.

Chromosome 22qII deletions. An under-recognised cause of idiopathic learning disability

BACKGROUND

Velo-cardio-facial syndrome (VCFS), a syndrome of multiple congenital abnormalities including characteristic dysmorphology, congenital heart defects and learning disability, is associated with small interstitial deletions of chromosome 22qII. We tested the hypothesis that VCFS may be significantly under-diagnosed by screening a learning disabled population for chromosome 22qII deletions.

METHOD

Two hundred and sixty-five people with learning disability residing in two learning disability hospitals in South Wales were reviewed. They were selected for inclusion in the study if they fulfilled any of the following criteria: psychotic disorder (schizophrenia or affective disorder), family history of psychotic disorder, cleft palate and/or lip, congenital heart disease, broadly defined facial dysmorphism or a history of hypocalcaemia. Fluorescence in situ hybridisation studies were performed on 74 selected individuals.

RESULTS

Cytogenetic analysis revealed that two people demonstrated a previously undetected chromosome 22qII deletion. A third person demonstrated a previously undetected cytogenetically visible deletion on chromosome 15.

CONCLUSIONS

VCFS appears to be aetiologically significant in a proportion of individuals with idiopathic learning disability, especially in those where psychosis is associated with mild learning disability. We suggest that clinicians should consider a chromosome 22qII deletion in people who meet selection criteria.

Quantitative ultrasound (QUS) of the heel predicts wrist and osteoporosis-related fractures in women age 45-75 years

This study was designed to determine the ability of quantitative ultrasound (QUS) of the heel to predict fracture risk at different sites in postmenopausal women between the ages of 45 and 75 years. Heel QUS was measured at baseline using a Lunar Achilles scanner, and subsequent fractures were identified over 3 yr. The results were analyzed graphically after age adjustment and using Cox's proportional regression to estimate odds ratios for fracture risk; 3180 women were scanned (79% of sample). Sixty-three wrist, 12 hip, 4 vertebral, 7 proximal humerus, 3 pelvic, and 61 other fractures were identified over a mean followup of 31 mo. There was a fivefold difference in numbers of wrist and osteoporosis-related fractures (hip, vertebra, pelvis, and humerus combined) between the lowest and highest quartiles of QUS results adjusted for age. The odds ratios per 1 SD decline in QUS parameters adjusted for age were: wrist fractures BUA = 1.6, SOS = 1.5, stiffness = 1.8, osteoporosis-related fractures BUA = 1.9, speed of sound (SOS) = 1.6, stiffness = 2.2, and other fractures, BUA = 1.0, SOS = 1.1, stiffness = 1.1. When analyzed for each 10-yr age group, the odds ratios were generally higher in the 56-65 yr group than the other decades. In women between 45 and 75 yr, heel QUS can predict wrist and osteoporosis- related fractures at about the same level that dual-energy X-ray absorptiometry (DXA) of various sites can predict wrist fractures. This extends the current evidence that heel QUS can predict hip fracture risk in women over 75 yr to include other fracture sites in younger women. Heel QUS may be useful in the primary care assessment of osteoporotic fracture risk in women after the menopause.

Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis

OBJECTIVE

to evaluate the effects of brisk walking on bone mineral density in women who had suffered an upper limb fracture.

DESIGN

randomized placebo-controlled trial. Assessments of bone mineral density were made before and at 1 and 2 years after intervention. Standardized and validated measures of physical capacity, self-rated health status and falls were used.

SETTING

district general hospital outpatient department.

SUBJECTS

165 women drawn from local accident and emergency departments with a history of fracture of an upper limb in the previous 2 years. Women were randomly allocated to intervention (self-paced brisk walking) or placebo (upper limb exercises) groups.

INTERVENTION

both groups were seen at 3-monthly intervals to assess progress, measure physical capacity and maintain enthusiasm. The brisk-walking group were instructed to progressively increase the amount and speed of walking in a manner that suited them. The upper limb exercise placebo group were asked to carry out a series of exercises designed to improve flexibility and fine hand movements, appropriate for a past history of upper limb fracture.

RESULTS

drop-outs from both intervention and placebo groups were substantial (41%), although there were no significant differences in bone mineral density, physical capacity or health status between drop-outs and participants. At 2 years, among those completing the trial, bone mineral density at the femoral neck had fallen in the placebo group to a greater extent than in the brisk-walking group [mean net difference between intervention and placebo groups 0.019 g/cm2, 95% confidence interval (CI) -0.0026 to +0.041 g/cm2, P = 0.056]. Lumbar spine bone mineral density had increased to a similar extent (+0.017 g/cm2) in both groups. The cumulative risk of falls was higher in the brisk-walking group (excess risk of 15 per 100 person-years, 95% CI 1.4-29 per 100 person-years, P < 0.05). There were no significant differences in clinical or spinal x-ray fracture risk or self-rated health status between intervention and placebo groups.

CONCLUSION

the promotion of exercise through brisk-walking advice given by nursing staff may have a small, but clinically important, impact on bone mineral density but is associated with an increased risk of falls. Self-paced brisk walking is difficult to evaluate in randomized controlled trials because of drop-outs, placebo group exercise, limited compliance and lack of standardization of the duration and intensity of walking. Further work is needed to evaluate the best means of safely achieving increased activity levels in different groups, such as older women and those at high risk of fractures.

Isochromosomes of both short and long arms of chromosome 12 resulting in an additional copy of chromosome 12 in a case of splenic lymphoma with villous lymphocytes

We report a case of splenic lymphoma with villous lymphocytes showing a karyotype with an isochromosome for both the long arm and the short arm of chromosome 12, i(12)(p10) and i(12)(q10), effectively resulting in trisomy 12. This is, apparently, the first documented case of an additional copy of chromosome 12 resulting from isochromosome formation in a neoplastic disorder.

Handicap in inflammatory arthritis

Two instruments measuring handicap were evaluated and compared with clinical, laboratory and disability measures. Participants were 133 patients attending a rheumatology follow-up clinic in a district general hospital, of whom 102 were followed up after 3 months. Measurements included acute-phase response, early morning stiffness, pain, wellbeing, joint involvement (impairments), the Stanford Health Assessment Questionnaire (disability), the Disease Repercussion Profile and the London Handicap Scale (handicap). A substantial burden of disability and handicap was recorded. There were moderate correlations between impairments (0.4 < rho < 0.6), and moderate to strong correlations between disability and handicap measures (0.4 < rho < 0.8). Correlations between impairment and disability/handicap were weak (rho < 0.4). Mean changes in all variables over 3 months were small, and none was statistically significant. A comprehensive description of the impact of disease and treatment requires measurements to be made of impairments, disabilities and handicaps. The use of clinical and laboratory variables alone may be misleading.

Carpal tunnel syndrome: evaluation of a new method of assessing median nerve conduction at the wrist

OBJECTIVE

To compare median nerve conduction velocity measured using a new, portable electroneurometer with measurements made using conventional hospital nerve conduction apparatus.

METHODS

Twenty five patients were studied who were consecutively referred to a hospital neurophysiology department with a clinical diagnosis of carpal tunnel syndrome. Sensory and motor latencies for the median nerve at the wrist were measured bilaterally using the portable electroneurometer and a Medilec MS 92 hospital apparatus operated by a trained technician.

RESULTS

There was strong agreement between motor latency values obtained by the two techniques (r = 0.89, p < 0.001; mean difference -0.03 ms, limits of agreement -0.33 to 0.27 ms). Sensory latencies were less easy to detect with the electroneurometer, and correlated less well with the hospital apparatus (r = 0.78, p < 0.001; mean difference -0.16 ms, limits of agreement -0.50 to 0.18 ms).

CONCLUSION

The portable electroneurometer provides a convenient, rapid, and inexpensive means of assessing median nerve conduction velocity at the wrist. Measurements of motor latency obtained with this new instrument agree more strongly with those made by conventional apparatus than do measurements of sensory latency. Although the utility of the instrument in clinical practice will be limited, it provides a helpful tool in epidemiological studies of carpal tunnel syndrome.

Quality of life measures

Quality of life measures have become increasingly popular as outcome measures despite the lack of consensus on a definition of quality of life. This review describes the most frequently used measures, and discusses the conceptual and measurement issues surrounding quality of life measurement. Finally, it tries to place quality of life in the World Health Organization's model of disease impact.

A cytogenetic deletion, del(17)(q11.22q21.1), in a patient with sporadic neurofibromatosis type 1 (NF1) associated with dysmorphism and developmental delay

We report the first visible cytogenetic deletion involving the NF1 gene in a patient with sporadic neurofibromatosis, dysmorphic features, and marked developmental delay. The combined evidence of molecular and cytogenetic techniques based on dosage reduction, hemizygosity for microsatellite markers, high resolution G banding, and FISH analysis, predicts this deletion to be approximately 7 Mb in size. Our findings highlight the importance of conducting a detailed cytogenetic and FISH analysis in patients with NF1 who have additional dysmorphic features or particularly severe learning difficulties.

Can biochemical markers predict bone loss at the hip and spine?: a 4-year prospective study of 141 early postmenopausal women

A number of recent studies have suggested that non-invasive measures of bone turnover are associated with bone loss at the forearm in postmenopausal women. Whether bone turnover markers are predictive of bone loss from the clinically important sites of lumbar spine and femoral neck remain unclear, and was the aim of this 4-year prospective study. One hundred and forty-one normal, postmenopausal women (mean age 52.0 +/- 3.3 years, mean menopause duration 20.4 +/- 5.7 months) were recruited for the study in 1988. Fasting early morning samples of blood and urine were collected at the baseline visit and stored at -20 degrees C prior to analysis. Serum was assayed for osteocalcin, oestradiol, oestrone, oestrone sulphate, testosterone, sex hormone binding globulin, dehydroepiandrosterone sulphate and total alkaline phosphatase. Urine was assayed for calcium, hydroxyproline, oestrone glucuronide and the collagen cross-links pyridinoline and deoxypyridinoline using high-performance liquid chromatography. Bone density was measured at the lumbar spine and femoral neck using dual photon absorptiometry at time 0, 12, 24 and 48 months. The mean annual percentage change in bone density (SE) was -1.41% (0.18) at the lumbar spine and -0.86% (0.22) at the femoral neck. There was no evidence of bimodality or a fast loser subgroup as the rates of change were normally distributed. Both simple and multiple stepwise regression analyses revealed no significant correlation between the rates of change in bone density with any biochemical marker, either individually or in combination, despite the study having sufficient power (80%) to detect a correlation of 0.5 between any biochemical marker levels and bone loss. We conclude that single measurements of these markers of bone turnover and endogenous sex hormones appear unlikely to be clinically useful in predicting early postmenopausal bone loss from either the spine or the hip.

RAS and FMS mutations following cytotoxic therapy for childhood acute lymphoblastic leukaemia

Patients who have received cytotoxic therapy for primary neoplastic disease are at an increased risk of developing secondary (therapy-related) acute myeloid leukaemia (AML) or myelodysplasia (MDS). RAS and FMS mutations have been observed in patients with AML and MDS. It has been suggested that the mutational status within these genes may be predictive of early secondary leukaemic disease. In this study we have screened 50 haematologically normal patients in complete remission from childhood acute lymphoblastic leukaemia (ALL) for activating point mutations in the RAS and FMS proto-oncogenes. Such patients may be considered at risk of therapy-related disease. Codons 12, 13 and 61 were screened in RAS and codon 969 in FMS using the polymerase chain reaction (PCR) followed by oligonucleotide hybridization (ONH). Three of the 50 patients (6%) were found to harbour N12 RAS mutations. One of these three patients (2%) had both a N12 RAS and FMS 969 mutation. Upon sequencing the RAS mutations, substitutions of serine, cysteine and aspartic acid for glycine were identified. The FMS 969 mutation was also confirmed, by sequencing, as a histidine substitution. RAS mutations were not detected in presentation samples indicating that these lesions have been somatically acquired presumably subsequent to cytotoxic therapy for the primary disease. Continued follow-up of these patients may indicate a role for these mutations in the development of secondary malignancies.

The effect of regular intramuscular corticosteroid therapy on bone mineral density in rheumatoid patients

To evaluate the effect of long term regular bolus doses of intramuscular corticosteroid on bone mineral density in rheumatoid patients we undertook a retrospective cross-sectional study of 68 rheumatoid patients. Patients were divided into three groups; those who had received maintenance doses of intramuscular corticosteroid (steroid), those who had been taking regular doses of oral steroid and those who had never received steroid by either route. Bone mineral density (BMD) was measured at the hip and lumbar spine by dual photon X-ray absorptiometry (DEXA). Z scores were calculated for each patient at both sites. There is a statistical difference in Z scores at the hip in both steroid treated groups compared with the no steroid group (p < 0.001). Total steroid was less in the IM treated group compared to the oral steroid group. These results suggest that maintenance therapy with IM steroids produces significant losses of bone mineral density at the hip in rheumatoid patients and that this effect appears to be independent of the total dose.

Red cell dimorphism in a young man with a constitutional chromosomal translocation t(11;22)(p15.5;q11.21)

A constitutional, balanced chromosomal translocation t(11;22)(p15.5;q11.21) was discovered in a tall young man during investigation of a red cell dimorphism. The red cells are predominantly normochromic and normocytic with a small population of hypochromic, microcytic cells. Contained within the regions involved in the translocation are determinants of height (IGF2:11p15.5), red cell haemoglobinization (non-alpha globin gene complex: 11p15.5) and oncogenesis (cHa-Ras-1, Beckwith-Wiedemann syndrome: 11p15.5; BCR, Burkitts lymphoma, Ewings sarcoma: 22q11.21). To map these regions in the patient, somatic cell hybrids were generated and cell lines that segregated the chromosomes 11, 22 and 22q- were obtained. All 11p15.5 sequences investigated, in particular the whole of the non-alpha globin gene complex including its 5' and 3' regulatory sequences, were found to be translocated to 22q-. All chromosome 22 sequences studied were missing from the 22q- cell lines, including the proximal anonymous marker D22S24, and therefore assumed to be translocated to 11p+. These results suggest that the non-alpha globin gene complex has been moved close to the centromeric region of chromosome 22q-. It is postulated that such a positioning subjects the complex to a variegated position-effect bringing about a clonal exclusion of the complex and thus producing a beta-thalassaemia trait mosaic.

Towards a measure of patient-perceived handicap in rheumatoid arthritis

The impact of chronic disease on an individual depends not only on the severity of the disease, but on his/her life role i.e. his/her needs, expectations etc. The World Health Organization expresses the impact of chronic disease in terms of impairment, disability and handicap, where handicap is the social disadvantage resulting from disease. This article argues that the assessment of patient-perceived handicap is essential to the clinical management of chronic disease because it provides the physician with clinically relevant information about the meaning of disease for each patient, enabling treatment and intervention to be tailored to meet individuals' needs. The development of a method for assessing patient-perceived handicap using patient profiles with the object of supplying the physician with a simple clinical tool is described.

Non-dysplastic myelodysplasia?

Patients successfully treated for a malignancy with cytotoxic therapy have an increased risk of developing secondary myelodysplasia (MDS) and acute myeloid leukemia (AML). We report a patient in remission from Hodgkin's disease (HD) who remains hematologically normal 4 years after combination chemotherapy, but who has biological and genetic abnormalities characteristic of myelodysplasia. X-inactivation analysis using a 5' phosphoglycerate kinase (PGK) probe demonstrates polyclonal hematopoiesis, but cytogenetic analysis reveals a clonal population with a minority of metaphases having a 7q-deletion. NRAS mutations are not detectable 1 year after treatment, but are present in two separate clones (at codons 12 and 15) analyzed by single-stranded conformational polymorphism (SSCP), followed by cloning and sequencing 4 years after treatment. The presence of an activated NRAS with the same codon 12 mutation was independently confirmed by the nude mouse tumorigenicity assay. In vitro peripheral blood granulocyte-macrophage colony-forming units (CFU-GM) have changed from normal to undetectable levels while erythroid burst forming units (BFU-E) were significantly reduced on two occasions during the period of observation. These abnormalities are characteristic of MDS. Continued clinical follow-up will determine whether these evolving genetic and biological abnormalities pre-date the onset of clinical and morphological features of MDS.

C-anaphase in a case of acute nonlymphocytic leukemia

C-anaphase was seen in approximately 50% of bone marrow cells from a patient with acute nonlymphocytic leukemia (ANLL). The abnormality acting as a marker for the disease, being present at diagnosis, disappearing during remission and returning at relapse.

Trisomy 4 with double minute chromosomes in acute nonlymphocytic leukemia

We report on three further cases of trisomy 4 in acute nonlymphocytic leukemia. In one case the trisomy 4 was accompanied by double minute (dmin) chromosomes. Of the 34 reports of trisomy 4, dmin were also found in five cases, showing a clear nonrandom association between the two cytogenetic abnormalities.

A double-blind study to determine the duration of action of flurbiprofen in a sustained release preparation

This double-blind, placebo-controlled, parallel-group study proves that the duration of activity of a sustained-release preparation of flurbiprofen 200 mg covers a full 24 hour period. In a group of 24 patients with clinically active rheumatoid arthritis a statistically significant increase of pain was noted 37 hours after the last active dose. The increase in disease symptoms was inversely related to the plasma flurbiprofen levels and was rapidly reversed with one active dose of sustained release flurbiprofen.

Increased levels of urinary collagen crosslinks in females with rheumatoid arthritis

Bone loss is a feature of RA, but the exact mechanisms involved are not clear. The collagen crosslinks deoxypyridinoline (DPYR) and pyridinoline (PYR) are specific indices of 'mature' collagen breakdown and reflect increased bone turnover. The aims of the study were to examine crosslink levels in RA and their association with disease activity and the effect of steroids. Urinary crosslinks corrected for creatinine were measured on morning fasting samples by HPLC in 70 postmenopausal women with rheumatoid arthritis (RA) aged 45-65 and compared with 169 postmenopausal healthy age-matched controls from the population. Mean levels of PYR were significantly higher in RA cases than in controls (52.4 versus 37.5 nmols/mmolCr) although mean levels of DPYR did not differ significantly. A weak correlation was found with ESR and PYR (r = 0.35) but not with other markers of disease activity. Thirteen of the RA cases were current steroid users and their levels of DPYR and PYR even with low doses, were significantly elevated above those of non-users, ex-users and controls. The finding of raised urinary PYR but not the bone specific DPYR in nonsteroid using RA cases suggests that the increased collagen breakdown does not primarily come from bone but from other sources such as cartilage and synovium. The large increases in collagen excretion in low dose steroid users, may reflect the higher risk of osteoporosis in this group.

Biochemical changes in the collagen of human osteoporotic bone matrix

Although it is known that collagen imparts mechanical strength to bone no detailed biochemical analysis has been made of osteoporotic bone collagen. We report for the first time significant changes in the properties of the collagen. Analysis of collagen types revealed little change in the proportion of Type III collagen, but in some cases there was a significant loss of the Type VI. However, the major differences were observed in the post-translational modifications, namely, in the stabilizing cross-links and the hydroxylation of the collagen. These changes indicated a higher turnover in the head region compared to the neck region of the femoral head and are consistent with the susceptibility of the neck region to fracture. Clearly, the collagen is altered in osteoporosis and these changes may play a role in the pathogenesis of the disease.

Urinary collagen crosslinks reflect the radiographic severity of knee osteoarthritis

The collagen crosslinks deoxypyridinoline and pyridinoline are indices of mature collagen breakdown and reflect increased bone turnover. Urinary levels were found to be significantly raised in a group of 59 women with knee OA compared to 110 female controls from the general population. Levels of the crosslinks correlated significantly with X-ray grade of all subjects including women from the general population with mild, often asymptomatic, disease. These correlations were not diminished after adjustment for age and weight.

Use of a risk factor and dietary calcium questionnaire in predicting bone density and subsequent bone loss at the menopause

One hundred and thirty six healthy white females within 30 months of their last menstrual period (mean age 52 years) were examined to determine the usefulness of a risk factor questionnaire in predicting bone density and subsequent loss. Bone density was assessed at baseline and at 12 monthly intervals. None of the proposed risk factor variables with the exception of nulliparity correlated with the baseline spinal or femoral bone density. As a predictor of bone loss only drinking alcohol (more than four units/day) was significant. A risk factor score derived from the questionnaire before its administration did not correlate with baseline bone density or subsequent bone loss. In most normal women questioned soon after a natural menopause, an estimate of bone density and subsequent bone loss and hence osteoporotic risk cannot be reliably made using a simple risk factor questionnaire.

Keratan sulphate in rheumatoid arthritis, osteoarthritis, and inflammatory diseases

Serum concentrations of antigenic keratan sulphate determined by an enzyme linked immunosorbent assay (ELISA) with a monoclonal antibody were studied in patients with rheumatoid arthritis (RA), osteoarthritis, ankylosing spondylitis, other inflammatory diseases, and a large control group of women without arthritis. Mean keratan sulphate concentrations were low in 117 women with RA compared with 227 female control subjects matched for age drawn from a community survey. There were significant correlations between serum keratan sulphate concentrations in patients with RA and serum C reactive protein and the erythrocyte sedimentation rate. Serum keratan sulphate concentrations were also low in 29 men and women with ankylosing spondylitis and 29 patients with arthritis and high concentrations of C reactive protein. In 98 women undergoing an operation for benign breast disease there were decreases in serum keratan sulphate concentrations after the operation which correlated with doses in serum C reactive protein. No differences were found in keratan sulphate concentrations in 137 women with osteoarthritis compared with controls. Within the group with osteoarthritis there were no differences for the various joint groups and there was no obvious correlation with radiographic severity or progression. These findings suggest serum keratan sulphate is unlikely to be useful as a diagnostic marker in osteoarthritis or RA but indicate a role for inflammation in the regulation of cartilage loss.

Post-translational modifications in the collagen of human osteoporotic femoral head

No detailed biochemical analysis has been made of the possible compositional changes in the collagen relating to the fragility of osteoporotic bone. We report for the first time significant changes in the compositional properties of the collagen. The major differences were observed in the post-translational modifications, namely, in the hydroxylation of lysine residues and the nature of the stabilizing cross-links of the collagen fibre. The increase in hydroxylation was greater in the head region compared to the neck region of the femoral head, whilst the decrease in the intermediate cross-links was greater in the neck region. Clearly, the collagen is altered in osteoporosis and it is important that these changes are recognised in studies of bone metabolism in osteoporosis since they may play a role in the pathogenesis of the disease.

Juvenile chronic arthritis and Wegener's granulomatosis

We present a case of Wegener's granulomatosis in a teenage boy with systemic onset juvenile chronic arthritis. We discuss the implication of these two uncommon conditions coexisting in one patient. The recent characterization of the antineutrophil cytoplasmic antibody (ANCA) as a marker of small vessel vasculitis has helped in the differential diagnosis of pulmonary renal syndromes.

Morphological evidence that activated polymorphs circulate in the peripheral blood of patients with rheumatoid arthritis

Purified peripheral blood polymorphonuclear leucocytes (PMNs) from patients with rheumatoid arthritis (RA) have been found to differ from purified PMNs from normal subjects in ways that are consistent with their prior activation. However, it is currently contentious whether activated PMNs really circulate in patients with RA, or whether they are produced as an in vitro artefact of purification. Recently developed rapid leucocyte fixation and preparation technique showed that the proportion of polarised (activated) PMNs (36.9 (24.7)%, mean (SD); n = 31) was increased relative to that in control subjects (8.1 (5.6)%; n = 12). Serum cytidine deaminase levels, a biochemical marker of PMN lysis, were also increased in patients with RA (11.59 (7.26) U/ml) compared with those in controls (6.82 (3.78) U/ml), but the proportion of polarised PMNs and the levels of cytidine deaminase activity were unrelated to clinical assessments of inflammatory disease activity. Twelve patients who were not receiving drugs or who were receiving only non-steroidal anti-inflammatory drugs (NSAIDs) had more polarised PMNs than 19 patients receiving second line treatment in addition to NSAIDs (patients receiving NSAIDs, 49.6 (25.9)%; patients receiving second line treatment, 27.5 (21.1)%). Fluorescence activated cytometric analysis of CR1 and CR3 expression on PMNs from a randomly selected subgroup of patients with RA showed that the serum level of cytidine deaminase activity was correlated positively with the expression of CR1 (the C3b receptor) on the cell surface and that the proportion of polarised PMNs was positively correlated with the expression of CR3 (or CD11b/CD18), the iC3b receptor that is upregulated on activation. It is suggested that the polarised PMNs which circulate in blood samples from patients with RA represent cells which have been activated but not yet marginated, or activated cells which have marginated but subsequently returned to the circulating pool.

Immune complexes in ankylosing spondylitis

Immune complexes have been reported in ankylosing spondylitis (AS) and may implicate infectious agents. Serum samples from 49 patients with AS were assayed for immune complexes by polyethylene glycol precipitation, followed by radial immunodiffusion and pepsinogen binding immunoassay. Both methods showed increases in IgA containing immune complexes, which correlated with serum IgA and with IgA rheumatoid factor concentrations, but did not show increases in other immune complex components. Increased immune complexes were associated with peripheral joint synovitis, but showed no correlation with other clinical or laboratory indices of disease activity. Immune complexes from nine AS serum samples and one AS synovial fluid were electrophoretically separated then probed with anti-Klebsiella pneumoniae, but AS specific antigens were not identified. This study did not suggest a major role for immune complexes in AS without peripheral disease, nor provide serological evidence for the involvement of klebsiella antigens.

A comparison of disability measured by the Stanford Health Assessment Questionnaire disability scales (HAQ) in male and female rheumatoid outpatients

Eighty-five consecutive rheumatoid patients (M:F = 22:63) seen during a 10-week period were studied. There were significant differences between the sexes for haemoglobin (means (SD) M = 13.5 (1.2), F = 12.0 (1.6) g/dl, P less than 0.01), presence of nodules (M = 50%, F = 19%, P less than 0.05) and for the HAQ scores (mean (SD) score M = 1.1 (0.9), F = 1.7 (0.9), P = 0.03) but not for age, disease duration, presence of erosions, Larsen score, treatment, pain, early morning stiffness, articular index, ESR, and C-reactive protein. The results suggest that the patients were matched for age, disease activity, severity and duration. The difference in haemoglobin between the sexes is in keeping with a reference population. The data suggest that the impact of RA has a greater effect on the functional status of women.

Comparison of four articular indices for use in clinical trials in rheumatoid arthritis: patient, order and observer variation

Using a Latin square design, 4 patients were examined by 4 rheumatologists. Joints were scored for tenderness and inflammation. The Ritchie, the index of the American Rheumatism Association (ARA), the Hart modified Ritchie and a simplified Lansbury index were calculated from the raw data. The results suggest that an articular index consisting of a simple count of tender joints (Hart modified Ritchie) or a simple count of tender or swollen joints (ARA index) are the most reproducible with multiple observers. We suggest that these indices would be most appropriate for multicenter clinical trials.