Jack Zuckner

Heart disease in systemic sclerosis

Primary cardiovascular manifestations of SSc include pericardial disease, myocardial disease, conduction abnormalities, and cardiac arrhythmias. Significant cardiac abnormalities are present in more than half of SSc patients at autopsy. As the frequency of subclinical cardiac involvement is now appreciated and noninvasive cardiac diagnostic modalities continue to improve, the ability to detect early asymptomatic involvement in SSc has improved. Two-dimensional echocardiography, radionucleotide imaging, and ambulatory ECG allow recurrent serial testing with virtually no morbidity. The current treatment of cardiac involvement in SSc is emperic and primarily directed at symptomatology. Large prospective randomized trials are needed to determine if preventive therapy is effective. With the advent of new immunological and cardiotropic agents and a better understanding of the primary disease process, our ability to alter the pathogenesis and final outcome of cardiac involvement in SSc should improve.

Rheumatologic complications of vitamin A and retinoids.

Retinoids are synthetic derivatives of vitamin A. They are administered primarily for dermatological conditions, such as psoriasis, acne, and disorders of keratinization. Toxicity has proven a significant problem with long-term administration of the retinoids. Bone abnormalities mimicking seronegative spondyloarthropathy or diffuse idiopathic skeletal hyperostosis have been described in many cases, as well as other rheumatologic manifestations such as arthritis, myopathy, and vasculitis. These retinoid-related adverse effects are reviewed.

Cholesterol Crystals in Synovial Fluid

Excerpt The finding of crystals in synovial fluid has been the subject of much current interest following the recent description by McCarty and Hollander (1) and others (2) of uric acid crystals in...

Skin lesions in viral hepatitis: Histologic and immunofluorescent findings

A variety of skin rashes are knowned to occur as a part of the serum sickness-like prodrome of acute viral hepatitis which is thought to be due to immune complex deposition. We report the histologic and immunofluorescent findings in the skin and the seroloigc abnormalities in a patient with both erythematous maculopapular and purpuric rashes. We found circulating hepatitis B surface antigen (HBsAg), hypocomplementemia and cultaneous vasculitis associated with deposition of immunoglobulin and complement in the skin. We could not demonstrate intradermal deposition of HBsAg, but the findings are consistent with the immune complex hypothesis.

International Experience with Diclofenac in Rheumatoid Arthritis

Rheumatoid arthritis, although not the most common of the rheumatic diseases, is potentially the most disabling. For this reason, it is considered the principal disorder for determining the therapeutic effectiveness of any new antirheumatic agent. Diclofenac sodium, a nonsteroidal anti-inflammatory drug, has been studied extensively in international clinical trials since the early 1970s. It has proved to be at least equal in efficacy to other nonsteroidal anti-inflammatory drugs. In addition, its superior safety profile suggests that diclofenac will be a valuable agent in the treatment of rheumatoid arthritis, for which long-term drug therapy is usually required.

Hidden 19S IgM rheumatoid factor in juvenile rheumatoid arthritis.

Summary: One-hundred twenty-five serum samples from 82 patients with juvenile rheumatoid arthritis (JRA) were studied for the presence of hidden rheumatoid factor (RF) in an effort to find a better serologic marker to define JRA. Hidden 19S IgM RF was detected by means of a hemolytic assay utilizing the IgM-containing fraction of serum. The IgM fraction was obtained after acid separation of serum on a Sephadex G-200 column. Hidden 19S IgM RF was present in 68% of patients with seronegative JRA with a mean titer of 1:63. The mean titer for the polyarticular JRA group was 1:83, for the pauciarticular JRA group, it was 1:32, and for the systemic type-onset JRA patients, it was 1:32. When disease was active, the mean titer for all JRA patients was 1:108, for the active polyarticular JRA group it was 1:119, for the active pauciarticular JRA, it was 1:97, and for the active systemic JRA patients, it was 1:64. All values were significant at the P ≤ 0.001 when compared to disease and normal controls.The hemolytic assay for RF on the IgM-containing fraction of serum thus enhances the serologic capabilities of defining JRA.Speculation: These studies showing the correlation of disease activity and the presence of hidden rheumatoid factor will aid in evaluating and following disease activity in juvenile rheumatoid arthritis.

Autoantibodies in juvenile arthritis

Sera from 104 children with JA with different onset-types of disease were evaluated for 19S IgM RF by the LFT , hidden 19S IgM RF by the hemolytic assay, ANA by HEp-2 cell substrate, and levels of IC by the C1qSPA . Their relationship to active disease was determined. Classical 19S IgM RF were detected by the LFT in only seven patients. All were late-onset polyarticular females. Hidden 19S IgM RF were detected by the hemolytic assay in the separated IgM-containing fraction in 55 patients of all onset-types. Clinical activity correlated with the presence of hidden 19S IgM RF in 82% of cases. ANA, using the HEp-2 cell substrate, were found in 61 patients, the majority showing a speckled, immunofluorescent pattern. ANA were noted in all RF positive patients and in nine of 10 patients with iridocyclitis. IC were found in 39 patients, and correlation with clinical activity occurred in 54% of cases. A search for positive associations among the four parameters showed no statistically significant correlations except for the concordance of ANA positivity in all seven RF positive patients. The presence of hidden RF correlated more closely with disease activity (P less than 0.001) than did that of ANA or IC. The significance of these data and previous studies remains to be determined. We have demonstrated that in the average JA population 7% have 19S IgM RF and about 60% have hidden RF, ANA, or elevated levels of IC. The present findings of 98 of 104 patients with at least one of the abnormal immunoproteins , the association of ANA in patients with iridocyclitis or with RF positivity, of hidden RF with disease activity, and the presence of 19S IgM RF in isolated IC suggest a possible immunologic etiology for JA.

Intra-Articular Hydrocortisone (Compound F) Acetate : A Preliminary Report

The suppression of inflammation in the joint structures of patients with rheumatoid arthritis by cortisone acetate administered systemically is well known. Hydrocortisone acetate, formerly known as Compound F acetate (17-hydroxycorticosterone-21-acetate), administered orally or intramuscularly, has recently been shown to have a similar suppressive effect upon this inflammation (Ward and others, 1951; Freyberg, Stevenson, Traeger, and Zuckner, 1952). One of the most important objections to the systemic use of these steroids is that amounts adequate to produce a beneficial effect may cause undesired physiological changes of hyperadrenocorticalism. Thorn (1951) is reported to have been the first to inject hydrocortisone acetate into an inflamed joint of a patient with rheumatoid arthritis with improvement in the inflammation. Hollander and others (1951) reported sustained local benefit and no systemic effect, after intra-articular injections of hydrocortisone into patients with various illnesses including rheumatoid arthritis. They reported no objective improvement after intra-articular injections of cortisone -acetate. Other workers have demonstrated that cortisone acetate injected directly into an inflamed joint produces local improvement which is manifested clinically and by changes in the synovial fluid without producing a significant systemic effect (Freyberg and others, 1951). After repeated intra-articular injections of cortisone acetate, however, the response in most patients becomes less. In a few others this material seemed to be irritating as shown by worsening of the inflammation at the joint treated and an increase in the number of cells in the synovial fluid. The present study deals with clinical and synovial fluid changes observed after intra-articular injections of hydrocortisone acetate in patients with rheumatoid arthritis. Procedure Hydrocortisone acetate was supplied for this investigation§ in two forms: the usual aqueous suspension (25 mg. per 1 0 ml.) containing Tween-80 and butyl alcohol, and also the dry crystalline state. The crystalline material was studied to determine whether any of the effects observed with the usual suspension were produced by any of its components apart from the steroid. The physical instability and uneven suspension of the

Local application of dimethyl sulfoxide and DMSO combined with triamcinolone acetonide in rheumatoid arthritis.

Dimethyl sulfoxide (DMSO) is a solvent with an unusual capability for permeating the skin. I ts salutary effects have been reported widely for many rheumatic diseases, but there are also contradictory opinions as to its clinical effectiveness for this group of illnesses. Most of the beneficial reports have been in reference to acute muscular, or closely related, conditions. The effectiveness in patients with chronic rheumatoid arthritis has been questioned. The present investigation was, therefore, undertaken to evaluate the usefulness of DMSO in patients with rheumatoid arthritis. This study was perfoMed in two parts. Initially, DMS0,t 90% in water, was applied topically to various inflamed articulations of 21 patients with rheumatoid arthritis. Subsequently, 11 rheumatoid patients were part of a single blind study whereby DMSO, 90% in HzO was compared with DMSO, 90% in H20 combined with 0.1% triamcinolone acetonide (T Actn).t Eight of the patients in this latter comparison study were also subjects in the initial investigation when DMSO was used alone. A total of 24 different rheumatoid patients had DMSO alone or in combination with steroid, and these will be grouped together in reporting the results of the first part of the study. The steroid, T Actn, which was combined with DMSO is a potent corticosteroid that has marked antiinflammatory, antipruritic, and antiallergic actions. DMSO was administered topically to the skin over inflamed articulations with a cotton swab; all peripheral joints were used with no particular predeliction for any one. Administration of DMSO was nat uniform for all patients because of differences in tolerance and because of differences in the amount applied by the subjects studied. In most individuals, attempts were made to have the drug applied four times daily, but fewer daily applications were made in some. The treated surface area was to be covered five times with each application. Total dosages of 5 to 175 cc were administered, averaging about 40 cc per patient. Most patients used the preparation for ten days or more; 30 days was the maximum. The patients were classified according to criteria of the American Rheumatism Association, and there was, in general, representative distribution

Treatment of Rheumatoid Arthritis with Flurbiprofen or Ibuprofen

Flurbiprofen and ibuprofen were compared in a six-week double-blind randomized study in 208 patients with rheumatoid arthritis. Daily dosages were 120 mg flurbiprofen and 2400 mg ibuprofen for six weeks. Both drugs were effective in providing partial control of RA symptoms. Either or both drugs produced statistically significant improvement in mean values of time of onset of fatigue, grip strength and tender and swollen joint counts. All other standard endpoints of efficacy (except ESR) were improved but not at a statistically significant level. Slightly more than half of the patients improved during the trial. There was no statistically significant difference in the efficacy of the drugs. The incidence of side effects was low with both drugs. Most side effects were related to gastrointestinal tract irritation.