More emphasis on the enthesis.
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Bone Regeneration↗
Biomedical subjects
G O Littlejohn
Publications and source records attributed to G O Littlejohn.
Current treatment concepts in arthritis.
Some forms of arthritis cause few symptoms and little or no disability, while others cause severe pain, deformity and loss of function, and may even be fatal. Management must vary accordingly between the simple and the complex, the latter necessitating the use of potentially toxic agents. This article highlights some therapeutic approaches and emphasises the factors that influence the decision making process. Some areas of difficulty are discussed, particularly the treatment of dyspepsia in chronic arthritis.
Anti-Inflammatory Agents, Non-Steroidal↗
Antiphospholipid antibodies in the connective tissue diseases: their relation to the antiphospholipid syndrome and forme fruste disease.
Anticardiolipin antibodies (aCL) were measured in the sera of patients with different connective tissue diseases and spondyloarthropathies. Elevated antibody binding was found in systemic lupus erythematosus (SLE), rheumatoid arthritis, scleroderma, primary sicca syndrome, dermatopolymyositis and psoriatic arthritis but not in ankylosing spondylitis. The 15 highest binding SLE patients included 10 with Raynaud's phenomenon, 5 with livedo reticularis, 7 with vasculitis, 3 with major thrombotic episodes and 3 with spontaneous abortions. aCL were also measured in patients with these clinical features in isolation. Seven of 18 patients with multiple thromboses and 3/22 with multiple spontaneous abortions had raised aCL binding. Normal or near normal levels were found in patients with idiopathic thrombocytopenia, livedo reticularis, a single cerebral thrombosis and uncomplicated myocardial infarction.
Abortion, Habitual↗
Detection of anti-DNA antibodies: a comparison between two Farr assays, Crithidia luciliae and a human chromosomal substrate assay.
Four commercially available assays were compared with a 14C DNA Farr assay for their ability to detect anti-DNA antibodies in 119 sera from 109 patients with systemic lupus erythematosus (SLE) and 25 control sera. The 14C DNA Farr assay was the most sensitive and specific assay (SLE, 57% positive, controls, 0%). A commercial 125I DNA Farr assay was significantly less sensitive (SLE, 39% positive). The fluorescence human chromosomal preparation assay was as sensitive as the 14C DNA Farr assay (SLE, 58% positive) but less specific (controls, 8% positive). The immunofluorescence Crithidia luciliae assay was specific, but less sensitive (SLE, 37% positive) than the 14C DNA Farr assay. Adaptation of Crithidia to immunoperoxidase did not alter its sensitivity or performance. These results confirm that the 14C DNA Farr assay, locally refined and performed by experienced hands, is the most sensitive and specific assay for anti-DNA antibodies. The 125I DNA Farr was no more sensitive than the Crithidia assay but considerably more laborious. The human chromosomal preparation may be suitable as a rapid screening test for anti-DNA antibodies.
Animals↗
Neuropsychiatric manifestations of systemic lupus erythematosus.
Forty-six episodes of major neuropsychiatric manifestations of systemic lupus erythematosus occurring in 35 patients over a ten-year period were reviewed. The frequency of central nervous system SLF was lower than that reported from overseas referral centres. Glucocorticosteroid treatment did not precipitate psychiatric problems in this group. Whilst neuropsychiatric recovery was the rule, such features indicated a subgroup of SLE with high short-term mortality.
Adolescent↗
The diagnosis and classification of scleroderma (systemic sclerosis).
Difficulty in the diagnosis of the disease scleroderma may occur at the early stage prior to the development of obvious skin sclerosis. A presumptive diagnosis may be made if Raynaud's phenomenon is accompanied by a positive 'neck test', 'scleroderma' capillary changes in the nailfolds or antinuclear antibodies. Definitive diagnosis may have to be delayed for several years from the onset of Raynaud's phenomenon until definite characteristic skin changes are seen. Ten cases in which an earlier diagnosis of scleroderma was not substantiated are listed. The earlier incorrect diagnosis would have been avoided by use of the methods described in this paper. Various terms have been used to denote subdivisions of scleroderma. These include acrosclerosis, diffuse scleroderma and CREST. We have used the terms Type 1, Type 2 and Type 3 based on the early extent of the skin sclerosis where Type 1 (limited extent) indicates sclerodactyly only, Type 2 (moderate extent) indicates sclerosis proximal to the metacarpophalangeal joints but excluding the trunk and Type 3 (extensive) indicates diffuse skin sclerosis including the trunk. The clinical value of this simple classification is reviewed and contrasted to other classifications which appear to be poorly defined and of limited use.
Adult↗
Jaccoud's arthritis and panvasculitis in the hypocomplementemic urticarial vasculitis syndrome.
We describe a woman who developed hypocomplementemic urticarial vasculitis syndrome, and who demonstrated 2 rare features. As well as vasculitis of the small cutaneous vessels, vasculitis affected the femoral, cystic and renal arteries. Her arthritis led to subluxation of the metacarpophalangeal joints, without radiological evidence of rheumatoid-like erosions. This deformity could be passively corrected, and therefore conformed to the pattern described by Jaccoud.
Adult↗
Severe bone marrow failure due to low dose oral methotrexate.
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Acute Disease↗
A survival study of patients with scleroderma diagnosed over 30 years (1953-1983): the value of a simple cutaneous classification in the early stages of the disease.
A longitudinal study was carried out on 177 patients with scleroderma between 1953 and 1983. Patients were classified into 3 types according to the extent of skin sclerosis within one year of presentation: Type 1 with sclerodactyly only; Type 2, skin stiffness proximal to the metacarpophalangeal joints but sparing the trunk; and Type 3, diffuse skin stiffness including the trunk. Ten year survival was 71% in Type 1, 58% in Type 2 and 21% in Type 3. Quality of life was best in Type 1, intermediate in Type 2 and worst in Type 3. Nailfold capillary abnormalities did not discriminate between the types, but anticentromere antibody correlated strongly with Type 1. The simple subdivision of scleroderma based on the early extent of clinical skin involvement has been found to be useful in predicting longterm outcome in this highly variable disease.
Adult↗
Mycobacterial disease in the musculoskeletal system.
Over a six-year period, 12 patients were admitted to a Melbourne teaching hospital with mycobacterial infections of the musculoskeletal system. Four of the infections involved soft tissue and these included three atypical mycobacterial infections. The average age at diagnosis was 60 years. Five patients were born outside Australia. The predisposing factors included a past or family history of tuberculosis, pre-existing arthritis, alcoholism, earlier trauma, and membership of certain occupations. The average delay in diagnosis was four months. Treatment involved a combination of appropriate medication and surgical procedures that ranged from diagnostic aspiration to amputation. Mycobacterial infection of the musculoskeletal system, although uncommon in Australia, remains an important problem that requires continued awareness for early diagnosis.
Adult↗
The clinical significance of the anticentromere antibody.
To elucidate further the clinical significance of the anticentromere antibody (ACA), 32 Australian-born Caucasian patients with scleroderma (SD) or CREST (calcinosis, Raynaud's phenomenon, oesophageal dysmotility, sclerodactyly and telangiectasia) were reclassified as ACA-positive (19 patients) or ACA-negative (13 patients). The clinical features of the two groups were compared. Mean disease duration was 11.7 years for the ACA-positive group and 1.1 years for the ACA-negative group. No ACA-positive patient had generalized skin SD, whereas all ACA-negative patients with disease duration greater than 6 months had moderate or severe proximal scleroderma. Only one ACA-positive patient had serious extra-oesophageal internal organ involvement, excluding primary biliary cirrhosis (three patients) which is itself associated with ACA. Three ACA-negative patients had serious extra-oesophageal internal organ involvement. No ACA-positive patient had been treated with penicillamine or captopril compared with 11 ACA-negative patients. Thus ACA appears to be a favourable prognostic indicator. Analysis of individual CREST manifestations in ACA-positive patients revealed that most had 'incomplete CREST', lacking one or two of the five features. The classification of SD patients as ACA-positive or ACA-negative is suggested.
Adult↗
Comparison of immunofluorescence and immunoperoxidase for demonstration of antinuclear antibodies on HEp-2 substrate.
A comparison of antinuclear antibody (ANA) detection on HEp-2 cell substrate, using immunofluorescence (IF) and immunoperoxidase (IP) techniques, was performed on 183 sera from 178 individuals, with and without connective tissue diseases. All sera were number coded and scored blindly by two independent observers. ANA was detected in 61% of sera by IF and 62% of sera by IP. Positive and negative results corresponded between the two techniques in 97% of sera. Patterns and titres corresponded in 85% of positive sera. The two independent observers scored ANA more consistently with IP than with IF. Both methods were technically simple to perform and produced consistent results with control sera. These data show that IP provides results equivalent to the traditional IF technique for demonstrating ANA on HEp-2 substrate. Fewer discordant results between two independent observers using IP suggests that this technique has technical advantages for interpretation of ANA on HEp-2 substrate.
Antibodies, Antinuclear↗
Costotransverse joint injection description of technique.
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Back Pain↗
Lupus and non-lupus cutaneous manifestations in systemic lupus erythematosus.
Mucocutaneous manifestations occur frequently in systemic lupus erythematosus (SLE). Common non-lupus dermatoses may be confused with lupus rashes, with important clinical consequences. A study of 84 consecutive patients with SLE was performed to determine the comparative frequency of lupus and non-lupus mucocutaneous abnormalities, the comparative sensitivity of routine histology and immunofluorescence in the diagnosis of lupus rashes, and the association of skin manifestations with other clinical and serological features. Thirty-five patients had dermatoses attributable to SLE (mean 3.7 per patient) and 58 had dermatoses which were not directly attributable to SLE (mean 2.1 per patient), highlighting the need for accurate diagnosis of skin rashes in SLE patients. Routine histology confirmed the clinical diagnosis of typical cutaneous lupus in 100% of malar lupus rashes and in approximately 90% of subacute cutaneous and discoid lupus rashes. Direct immunofluorescence of the affected skin provided supportive evidence of cutaneous lupus in 60% of malar lupus rashes and approximately 50% of subacute cutaneous and discoid lupus rashes. This reaffirmed the poor sensitivity of immunofluorescence, compared with routine histology, in the diagnosis of lupus rashes. The association of subacute cutaneous lupus with anti-Ro antibodies was confirmed.
Biopsy↗
Increased neurogenic inflammation in fibrositis syndrome.
Mechanically induced vasodilatation or flare on the skin, known as dermatographia, is a common clinical observation in fibrositis syndrome and is thought to be a neurogenically mediated axon reflex response. In our study, mechanically and chemically induced flares were quantitated in 13 patients with fibrositis syndrome and 14 control subjects. There was a reduced threshold for chemically induced flare response and the area of flare was greater in patients compared to controls, although there was a wide range of responses in both groups. There was also a significant positive correlation between mechanically and chemically induced flares, and the number of tender points in all subjects correlated with the size of the chemically induced flare. We suggest that exaggerated neurogenic inflammatory responses in patients with fibrositis syndrome reflect increased activity of polymodal nociceptors of unmyelinated primary afferent nerves. This increased receptor activity may also contribute to the pain and tenderness experienced by these patients.
Adolescent↗
Neurogenic flare responses in chronic rheumatic pain syndromes.
Chronic rheumatic pain syndromes such as the fibrositis syndrome, 'whiplash' syndrome, low back pain syndrome and regional pain syndrome are common clinical disorders of unknown cause. The presence of tender points in predictable anatomical locations is essential to their diagnosis. Exaggerated dermatographia or flare response to mechanical stimulation is also a commonly observed physical finding. Dermatographia is thought to be a local axon reflex mediated phenomenon, and, as such, is a component of the neurogenic inflammatory response. Because neurogenic inflammation may be mediated by polymodal nociceptors we examined the flare response to topical capsaicin, a chemical method of stimulating local axon reflexes, in 12 patients with chronic rheumatic pain syndromes and in 10 controls. There was a significant correlation (rs = 0.61; p less than 0.01) between the area of flare induced by mechanical stimulation and the area of flare induced by chemical stimulation for all subjects. Patients with chronic rheumatic pain syndromes had a lower threshold for capsaicin-induced flare responses compared with controls. They also had larger flares at capsaicin concentrations of 0.02 and 0.033 mg/mL (p less than 0.05) applied as 20 microL aliquots over 30 minutes. It is concluded that neurogenic flare responses are increased in patients with chronic rheumatic pain syndromes.
Afferent Pathways↗
Livedo reticularis associated with increased titers of anticardiolipin antibodies in systemic lupus erythematosus.
Seventy-eight consecutive patients with systemic lupus erythematosus were assessed for the presence of livedo reticularis. The possible association of livedo reticularis with other clinical and laboratory features including anticardiolipin antibodies was explored. Thirty-eight patients had livedo reticularis. Four cases were severe, 11 moderate, and 23 mild. There was a statistically significant association between the combined moderate and severe livedo reticularis group and elevated levels of anticardiolipin antibodies. The recognized association of anticardiolipin antibodies with thrombotic events suggests a possible pathogenetic role. The presence or history of central nervous system disease, renal disease, vasculitis, or lupus inhibitor was significantly associated with the moderate and severe livedo reticularis group. Livedo reticularis may be a cutaneous marker for the later development of important systemic events in systemic lupus erythematosus.
Adolescent↗
Severe visceral disease in subacute cutaneous lupus erythematosus.
Subacute cutaneous lupus erythematosus has been heralded as a marker of relatively benign subset of systemic lupus erythematosus. In this article, we describe two cases with severe visceral disease and suggest that it may be less reliable as a predictor of benign disease than was previously accepted.
Adult↗