Hypocalcaemia after parathyroid surgery.
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Biomedical subjects
Publications and source records attributed to O Laitinen.
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No significant differences were found in plasma concentrations and urinary excretion of prostaglandin E2 (PGE2), 6-keto-prostaglandin-F1 alpha (6-keto-PGF1 alpha) and thromboxane B2 (TxB2), between rheumatoid arthritis patients and controls. However, urinary excretion of PGEe and 6-keto-PGF1 alpha tended to be greater and plasma levels of TxB2 lower in rheumatoid arthritis. Plasma concentrations and urinary excretion showed no marked circadian variation, although night or morning values were slightly lower. Plasma and urine prostaglandins do not correlate with clinical symptomatology in rheumatoid arthritis.
The pathogenesis of HLA-B27 linked diseases, including reactive enteroarthritides, is not known. Differences in immune response, cross-reaction between microbial antigens and host cell structures, attachment of microbial components on the host cell surfaces with subsequent autoimmune reaction, and inflammatory responsiveness of the host may be involved. In this contribution we present evidence to show that HLA-B27 positive subjects may be prone to an exaggerated inflammatory response, as compared with HLA-B27 negative subjects.
The effects of acetylsalicylic acid, indomethacin and paracetamol on the plasma and serum levels and the urinary excretion of arachidonic acid metabolites in man were demonstrated. The inhibition of prostaglandin synthesis was reflected better in the urinary excretions than in the plasma levels of arachidonic acid metabolites. A clear-cut reduction by acetylsalicylic acid and indomethacin in serum T X B2 can be reached within 24 h. Paracetamol had no uniform influence on the prostaglandins studied. The values returned to the initial level in seven days after indomethacin and in two weeks after acetylsalicylic acid treatment. In some cases a rebound overshoot in prostaglandin concentrations was observed after the discontinuation of the treatment.
An analysis of 160 patients with Reiter's disease, 144 with yersinia arthritis, and 9 with salmonella arthritis was performed, Complete or incomplete Reiter's syndrome was observed in one-third of the patients with yersinia arthritis and in most of those with salmonella arthritis. During the followup period, chronic back pain and joint symptoms were frequent in all the patient groups. Patients who were HLA-B27 positive had a more severe acute disease (more frequent back pain, urologic symptoms, mucocutaneous manifestations, and a longer duration of the disease) and more frequent chronic back pain and sacroiliitis.
Chemotactic and chemokinetic migration of polymorphonuclear leukocytes in sera from patients with previous yersinia arthritis and from healthy subjects with or without HLA--B27 were studied by the leading front method. Irrespective of yersinia arthritis, zymosan-activated sera from subjects who were HLA--B27 positive were significantly more chemokinetic than were HLA--B27 negative zymosan-activated sera from healthy control subjects. The chemotactic activities of zymosan-activated sera that were HLA--B27 positive or negative, as determined by chemotactic increments, were much the same. The results suggest that zymosan-activated serum that is HLA--B27 positive stimulates random migration of polymorphonuclear leukocytes, but not their directional migration, more than does HLA--B27 negative serum that has been zymosan activated. This may contribute to accumulation of polymorphonuclear leukocytes at the site of inflammation in vivo and thereby to inflammatory symptoms in yersinia arthritis patients with HLA--B27.
A 32-year-old woman is described with polyarteritic changes concentrated to the calves. The disease has manifested itself in several acute episodes with swelling and pain in the calves, following symptomless phases. The response of to corticosteroid therapy has been good. Biopsy of the gastrocnemius muscle revealed peculiar multiple layers of intense NADH-tetrazolium reductase activity resembling annual rings in muscle fibers, a finding which has not been described earlier.
The frequency of associated rheumatic diseases was studied in 271 patients with acute anterior uveitis (AAU). In a retrospective examination of 154 patients with AUU (mean follow-up period of 6 years) associated rheumatic symptoms were observed in 64 (41.6%). Forty-one patients (26.6%) had ankylosing spondylitis and 39 (25.3%) manifestations of Reiter's disease. Radiographic sacro-iliitis was seen in 35 (34%) of 103 consecutive x-ray examined patients with AAU. Furthermore, in another series of 38 patients, who all, in addition to having AAU, also complained of low back pain or had manifestations of Reiter's disease, 23 (60.5%) had radiographic sacro-iliitis. Classical ankylosing spondylitis was more frequent in men with AAU whereas milder forms of the disease occurred more equally in both sexes. HLA-B27 occurred in 35 (87.5%) of 40 HLA-typed patients with AAU. Associated rheumatic diseases occurred in 18 (51.4%) of the 35 HLA-B27 positive patients but in none of the HLA-B27 negative patients. The results support the hypothesis that a pleiotropic HLA-B27 associated gene may determine the susceptibility to AAU, sacro-iliitis, ankylosing spondylitis, and Reiter's disease.
A 53-year-old man with scleroderma, pulmonary fibrosis, cardiac decompensation and secondary polycythaemia, but no arterial hypertension, developed central retinal vein occlusion (CRVO) in the left eye. 1.5 years later, during the treatment with systemic steroids and anticoagulants, he developed CRVO in the right eye, and a further half year later, secondary glaucoma in the left eye and loss of the visual acuity to counting fingers at 2.5 m in the right eye and at 0.5 m in the left. Retinal vascular changes, pulmonary and cardiac insufficiency and secondary polycythemia, symptoms of scleroderma, most probably contributed to the development of bilateral CRVO.
Chemotaxis, chemokinesis, and spontaneous locomotion of polymorphonuclear leukocytes (PMNs) of yersinia arthritis (YA) patients and healthy subjects with or without HLA-B27 were studied by agarose assay and membrane filter technique. HLA-B27 positive healthy control subjects and yersinia patients showed significantly higher response to chemotactic stimulus than HLA-B27 negative controls. Consequently, the high response was associated with HLA-B27 irrespective of YA. The high responder PMNs may contribute to the more severe inflammatory symptoms in YA patients with HLA-B27.
We studied characteristics of ocular inflammation associated with Yersinia infection in 23 patients. After an acute onset with fever, diarrhea, and abdominal pain, 22 patients developed arthritis, 11 patients developed myalgia, 11 patients developed Reiter's syndrome, 17 patients developed acute anterior uveitis, and nine patients developed conjunctivitis. Sacroiliitis was found in 12 patients. The patients had high erythrocyte sedimentation rates, leukocytosis, and lack of antinuclear antibodies and rheumatoid factor. All 17 patients tested had HLA-B27 antigen. The patients with acute anterior uveitis showed aqueous flare, cells, fine keratic precipitates, and often exudates, posterior synechiae, vitritis, and macular edema. Acute anterior uveitis was mostly unilateral and resolved during corticosteroids on the average during the first six weeks; recurrences were seen in about half of the cases. Conjunctivitis was generally mild with no chemosis, follicles, or keratitis; and it resolved in one week without treatment. Our results indicate that in HLA-B27 positive patients infective agents can trigger acute anterior uveitis or conjunctivitis, which often occur together with rheumatic diseases.
Serum immunoreactive prolyl hydroxylase protein (S-IRPH) was measured in 56 patients with inflammatory rheumatic diseases, and the values were compared with those in 32 control subjects. S-IRPH was above the 95% confidence limit of the controls in about 70% of the patients with active systemic lupus erythematosus, rheumatoid arthritis, scleroderma, Reiter's syndrome, Sjögren's syndrome, polyarteritis nodosa, or polymyositis. Raised values were observed in about half of the patients with an erythrocyte sedimentation rate (ESR) of 21-50 and in about 90% of those with ESR of over 50, whereas only about 10% of the patients with an inactive disease had an S-IRPH concentration exceeding this limit. Only 1 out of 8 patients with active ankylosing spondylitis had a raised S-IRPH value. The results support previous data indicating that significant changes in collagen metabolism occur in active connective tissue diseases. Assays of S-IRPH might be of some value in assessing the activity of these diseases and in monitoring the treatment provided.
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ECG changes in 49 patients with rheumatoid arthritis, 18 with ankylosing spondylitis, 47 with systemic lupus erythematosus, 17 with dermatomyositis, 21 with scleroderma and 7 with polyarteritis nodosa were compared with ECG changes in 106 control subjects. The classification of ECG findings was based mainly on the Minnesota Code. Compared with control subjects, pathological Q--QS, ST segment and T wave patterns were more common in all patient groups--including dermatomyositis, in which cardiac involvement has rarely been reported. P terminal force (PTF) was higher in the patient group. Conduction defects were probably more common in connective tissue diseases, whereas differences in ectopic beats, arrhythmias, QRS duration and QRS axis and R wave amplitude were not significant. The only significant difference between the steroid-treated patients and those without such treatment was the higher frequency of ST changes in the steroid-treated group. The results imply that heart affection is common in all connective tissue diseases. The several mechanisms underlying the cardiac involvement are reflected in many ways in the electrocardiograms of these patients, including an increased frequency of ECG changes mimicking those met in coronary heart disease.
A study of 74 yersinia arthritis patients implied that the clinical picture of the disease may be modified by genetic background associated with the histocompatibility antigen B27 (HLA-B27). Sixty-six percent of patients were B27 positive. Joint symptoms were somewhat more severe in B27+ patients. Iritis, conjunctivitis, carditis, signs of urologic inflammation, and complete Reiter's triad occurred only in the B27 + group, whereas erythema nodosum was more common in B27 - group. Several B27 + patients also had "B27 + rheumatic diseases," such as ankylosing spondylitis or Reiter's disease, in their history.
Several laboratory parameters have been followed before and after surgery in a 69-year-old woman with parathyroid adenoma and severe skeletal involvement. High preoperative levels of immunoreactive parathyroid hormone rapidly decreased postoperatively, accompanied by a similar fall in the peptide-bound hydroxyproline (HP) excretion in the urine. Renal clearance of free HP was high both pre- and postoperatively, probably because of renal damage associated with the disease. The high serum alkaline phosphatase levels increased slightly after the operation. The patient developed severe postoperative hypocalcaemia, and prolonged calcium supplement therapy was necessary. The results imply a clear correlation between the changes in Ca homeostasis and the breakdown rate of bone collagenous matrix. Postoperative hypocalcaemia was mainly due to the rapid change in the rates of bone formation and destruction.