Duncan A. Gordon

The bimodal mortality pattern of systemic lupus erythematosus

The changing pattern of mortality in systemic lupus erythematosus (SLE) led to an examination of the deaths in a long-term systematic analysis of 81 patients followed for five years at the University of Toronto Rheumatic Disease Unit. During the follow-up 11 patients died; six patients died within the first year after diagnosis (group I) and five patients died an average of 8.6 years (from 2.5 to 19.5 years) after diagnosis (group II). In those who died early, the SLE was active clinically and serologically, and nephritis was present in four. Their mean prednisone dose was 53.3 mg/day. In four patients a major septic episode contributed to their death. In those who died late in the course of the disease, only one patient had active lupus and none had active lupus nephritis. Their mean prednisone dose was 10.1 mg/day taken for a mean of 7.2 years. In none was sepsis a contributing factor to their death. All five of these patients had had a recent myocardial infarction at the time of death; in four, ti was the primary cause of death. Mortality in SLE follows a bimodal pattern. Patients who die early in the course of their disease, die with active lupus, receive large doses of steroids and have a remarkable incidence of infection. In those who die late in the course of the disease, death is associated with inactive lupus, long duration of steroid therapy and a striking incidence of myocardial infarction due to atherosclerotic heart disease.

The extra-articular features of rheumatoid arthritis. A systematic analysis of 127 cases.

Abstract A systematic analysis was undertaken of 127 hospitalized patients with definite or classic rheumatoid arthritis. Of the group studied 76 per cent had one or more extra-articular feature including nodules, pulmonary fibrosis, digital vasculitis, skin ulceration, lymphadenopathy, noncompressive neuropathy, splenomegaly, episcleritis or pericarditis. The presence of one or more of these features correlated with signs of persistent articular inflammation, roentgenologic stages of more severe joint disease and the presence of soluble immune complexes and high titers of rheumatoid factor. They did not appear to be related to the use of corticosteroids or to the duration of rheumatoid disease. On follow-up of the total group of patients after five years a mortality of 20 per cent was found. This was twice as great in the group with extra-articular features and was particularly striking in patients 50 years of age or less. These results obtained in hospitalized patients indicate that the manifestations of rheumatoid arthritis form a spectrum in which extra-articular features should be considered as classic criteria of rheumatoid arthritis. Furthermore, these extra-articular features appear to have an important bearing on prognosis.

Amyloid arthritis simulating rheumatoid disease in five patients with multiple myeloma.

Abstract Five patients with multiple myeloma, three of whom had kappa light chain disease, presented with a symmetrical polyarthritis simulating rheumatoid arthritis. In all instances amyloid infiltration of synovial tissues appeared to account for the articular manifestations. Synovial fluids examined in four of these cases lacked the inflammatory characteristics of rheumatoid synovial fluid and three of them contained M components. In the course of synovial fluid analysis, small fragments of amyloid-containing material were detected in the aspirates from three of the patients, thereby establishing the diagnosis prior to confirmation by tissue biopsy. In the past patients with verified amyloidosis involving synovial tissues have been erroneously considered to have rheumatoid arthritis.

Gold induced thrombocytopenia: 12 cases and a review of the literature

Gold induced thrombocytopenia is immune mediated, with the production of platelet associated IgG leading to peripheral platelet destruction. An association with HLA-DR3 has been demonstrated. Corticosteroid therapy is effective in treatment, although other modes of therapy may be as efficacious.

The Cauda Equina Syndrome of Ankylosing Spondylitis

Abstract The occurrence of the cauda equina syndrome with long-standing ankylosing spondylitis is a little-known association that may be overlooked or misdiagnosed. Three patients are reported and ...

The Hemorrhagic Crescent Sign of Acute Synovial Rupture

Excerpt Popliteal synovial cysts are common in patients with rheumatoid arthritis. They may rupture and produce clinical features indistinguishable from acute thrombophlebitis (1). As well, Tibbutt...

Pericardial fluid analysis in scleroderma (systemic sclerosis)

A patient with scleroderma who presented with pericarditis and effusion is described. Aspirates from this pericardial effusion had the characteristics of an exudate with no evidence of autoantibodies, immune complexes or complement depletion. These findings suggest that the mechanisms operating in the production of pericardial effusion in scleroderma may be different from those found in rheumatoid arthritis and systemic lupus erythematosus.

The Journal — A More Rapid Publication Process

As Editors of The Journal of Rheumatology we are pleased to inform you that The Journal is offering our traditional excellence in clinical research to the international rheumatology community more rapidly! Advances in our peer review and editorial production processes have resulted in a shorter time from submission to first decision and from acceptance to publication, despite steadily increasing submissions since 2006. In 2009 The Journal received about 1500 submissions, of which 1000 were full length manuscripts. As authors, reviewers, board members (Table 1), and staff make better use of our integrated Web based review system, we can shorten …

Brachial Plexus Radiculopathy and Computed Tomography

Excerpt To the editor: Computed tomography of the body is used frequently to diagnose lumbosacral disorders (1, 2). Compared to myelography, computed tomography has few adverse effects (3). We repo...

In Memoriam – Hugh A. Smythe, 1927–2012

Murray B. Urowitz Dr. Hugh Arthur Smythe died peacefully at his home in Toronto, Canada, on Sunday, October 14, 2012, at age 85, with his family around him: his beloved wife of 62 years, Bernice, his children Richard (Barb), Anne (Bob), and Conn (Christine). I have known Hugh for over 4 decades but have always found it a challenge to adequately describe this very eclectic person. Hugh was a physician, a scientist, an educator, an administrator, a hockey doctor, a collector and patron of the arts, and a philanthropist. As a physician, Hugh cared for patients with rheumatologic diseases for almost a half century. When he began his career, there were only a handful of rheumatologists in all of Canada and he can truly be credited with attracting so many into the field, including me. He was instrumental in having rheumatic disease units achieve equal recognition with the other medical subspecialties for government healthcare resources and was an important influence in having rheumatology recognized as a speciality by the Royal College of Physicians and Surgeons of Canada. The many students that he taught over the years carry on his caring legacy. As a scientist, Hugh was engaged in basic, clinical, and epidemiologic research. His work with Fraser Mustard on the role of platelets in the development of atherosclerosis has stood the test of time. Similarly, he studied the mechanisms of inflammation in the heart/aorta of patients with ankylosing spondylitis. In clinical investigation he was a leader in the description of fibromyalgia as a valid clinical entity and he studied its associated mechanical and sleep-associated mechanisms. Hugh was an ardent advocate for valid clinical measurement of rheumatologic diseases, and his joint and point count studies remain relevant today. His “pooled index” predated the ACR20 by many years. Finally, Hugh was also …