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OBJECTIVES: Hand and wrist problems are common, but little is known about characteristics of patients consulting the general practitioner (GP) for these problems. The objectives are: (i) to describe wrist and hand problems presented to the GP in terms of severity of symptoms, and their impact on physical, emotional and social functioning; (ii) to describe patient and disease characteristics across different diagnostic categories; and (iii) to study factors related to the severity of hand or wrist problems. METHODS: Patients consulting their GP with hand or wrist problems were sent a questionnaire containing questions on socio-demographic variables, characteristics of the complaint, physical activity and psychosocial factors. The GP recorded information on symptoms, signs and medical diagnosis. We studied the cross-sectional association between a variety of factors and severity of hand or wrist problems, using the Symptom Severity Scale as the outcome measure. RESULTS: Mean age of the 267 participants was 49.3 yrs and 74% were female. The three most frequently recorded diagnoses were osteoarthritits (17%), tenosynovitis (16%) and nerve entrapment (12%). The characteristics of patients varied slightly across diagnostic categories. Patients who did not have paid work, had longer duration of symptoms, diagnosis of entrapment, higher pain intensity, higher body mass index and higher scores on worrying reported significantly higher scores on severity of hand or wrist problems (P-value <0.10). CONCLUSION: Primary care patients with hand or wrist problems report pain and reduced function. Impact on other aspects of perceived health is limited. Severity seems to be associated with socio-demographic, physical and psychosocial factors, more than with medical diagnosis.

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OBJECTIVE: To assess the relationship between disease duration and foot function (expressed as pressure and gait parameters), foot pain and disability, in patients with foot complaints secondary to rheumatoid arthritis (RA). METHODS: Sixty-two patients with RA-related foot complaints were included. Disease duration was defined as the time since RA was diagnosed. A pressure platform was used to measure both pressure parameters (i.e. pressure-time integrals and peak pressures in the forefoot) and gait parameters (i.e. total loading time and loading time in different foot regions). In addition, measurements of foot pain, disability (i.e. walking time and self reported disability), forefoot joint damage and disease activity were obtained. Data were analysed using partial correlations (Spearman), correcting for age. RESULTS: Disease duration was significantly correlated with the maximum pressure-time integral (PTI) measured under the forefoot (r = 0.330, p = 0.01). Disease duration was also significantly correlated with gait parameters, i.e. total loading time (r = 0.265, p = 0.04), duration of heel loading and duration of toe loading (r = 0.326, p = 0.01 and r = -0.288, p = 0.03 respectively), and walking time (r = 0.297, p = 0.02). Disease duration did not correlate with self-reported foot pain or disability. CONCLUSION: In patients with RA-related foot complaints, longer disease duration is associated with impaired foot function and reduced walking speed. These findings are interpreted as an alteration in pressure distribution and gait pattern during the course of disease, with a shift from a heel-to-toe roll-over process to a more shuffling gait.

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OBJECTIVE: To assess (i) the relationship between forefoot joint damage and foot function (expressed as gait and pressure parameters), (ii) the relationship between foot function and pain, and (iii) the relationship between foot function and disability in patients with foot complaints secondary to rheumatoid arthritis (RA). METHODS: Sixty-two patients with RA-related foot complaints were included. Measurements of joint damage, gait characteristics, plantar pressure, pain and disability were obtained. Data were analysed using descriptive and correlational techniques. RESULT: s. Joint damage on radiographs of the forefoot correlated significantly with forefoot pressure (r = 0.296, P = 0.020). Further investigation of the metatarsophalangeal joints (MTPs) showed joint damage to correlate significantly with peak pressure and pressure-time integral (PTI) of MTP1 and MTP4. A significant correlation between PTI under the forefoot and barefoot pain was found (r = 0.290, P = 0.022). Gait parameters (total contact time and the duration of heel loading) and disability, measured with the Foot Function Index, were significantly correlated (r = 0.315, P = 0.013 and r = 0.266, P = 0.037, respectively). CONCLUSION: Forefoot joint damage in the rheumatoid foot is related to increased pressure under the forefoot, especially pressure under the first and fourth MTP joints. High forefoot pressure is associated with pain during barefoot walking. A prolonged stance phase and delayed heel lift are related to disability in daily activities.

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OBJECTIVE: To compare the efficacy and toxicity of cyclosporin A (CsA) monotherapy with CsA plus methotrexate (MTX) combination therapy in patients with early rheumatoid arthritis (RA). PATIENTS AND METHODS: 120 patients with active RA, rheumatoid factor positive and/or erosive, were randomly allocated to receive CsA with MTX (n=60) or CsA with placebo (n=60). Treatment with CsA was started in all patients at 2.5 mg/kg/day and increased to a maximum of 5 mg/kg/day in 16 weeks. MTX was started at 7.5 mg/week and increased to a maximal dose of 15 mg/week at week 16. Primary outcomes were clinical remission (Pinals criteria) and radiological damage (Larsen score), at week 48. RESULTS: Treatment was discontinued prematurely in 27 patients in the monotherapy group (21 because of inefficacy, and six because of toxicity) and in 26 patients in the combination therapy group (14 and 12, respectively). At week 48, clinical remission was achieved in four patients in the monotherapy group and in six patients in the combination therapy group (p=0.5). The median Larsen score increased to 10 (25th, 75th centiles: 3.5; 13.3) points in the monotherapy group and to 4 (1.0; 10.5) points in the combination therapy group (p=0.004). 28/60 (47%) of patients in the monotherapy group v 34/60 (57%) of patients in the combination therapy group had reached an American college of Rheumatology 20% (ACR20) response (p=0.36) at week 48; 15/60 (25%) v 29/60 (48%) of patients had reached an ACR50 response (p=0.013); and 7 (12%) v 12 (20%) of patients had reached an ACR70 response (p=0.11). Their was a tendency towards more toxicity in the combination therapy group. CONCLUSIONS: In patients with early RA, neither CsA plus MTX combination therapy nor CsA monotherapy is very effective in inducing clinical remission. Combination therapy is probably better at improving clinical disease activity, and definitely better at slowing radiological progression. Combination therapy should still be compared with methotrexate monotherapy.

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OBJECTIVE: The balance between T cells able to produce interferon gamma (IFN-gamma) (type 1) and interleukin-4 (IL-4) (type 2) is considered to be important in the development of autoimmunity. In this study, we quantitated the percentage of both cell types in synovial fluid (SF) and peripheral blood (PB) of rheumatoid arthritis (RA) patients, non-rheumatoid arthritis patients and healthy controls. METHODS: After short-term stimulation of synovial mononuclear cells with phorbol ester and ionomycin, cytokine-producing cells were quantitated using an intracellular staining technique and flow cytometric analysis. RESULTS: Although no significant differences in CD8 + cells were found, significantly higher percentages of IFN-gamma-producing CD4 + (Th 1) and IL-4-producing CD4 + (Th2) cells were found in the peripheral blood of RA patients in comparison with healthy controls. However, the Th1/Th2 ratio was not different between the two groups. Comparative studies between PB and SF showed that in both RA and non-RA patients, percentages of Th1 cells were higher in SF than in PB, while Th2 cells were preferentially found in the PB, resulting in a higher Th1/Th2 ratio in the SF. The Th1/Th2 ratio in the SF correlated with disease activity as estimated by the erythrocyte sedimentation rate. CONCLUSION: These results are in agreement with the hypothesis that Th1 cells preferentially home to inflamed joints in both RA and non-RA patients, but show that this does not result in an altered Th1/Th2 ratio in the PB of RA patients.

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OBJECTIVE: We suggested fibromyalgia (FM) is a disorder associated with an altered functioning of the stress-response system. This was concluded from hyperreactive pituitary adrenocorticotropic hormone (ACTH) release in response to corticotropin-releasing hormone (CRH) and to insulin induced hypoglycemia in patients with FM. In this study, we tested the validity and specificity of this observation compared to another painful condition, low back pain. METHODS: We recruited 40 patients with primary FM (F:M 36:4), 28 patients (25:3) with chronic noninflammatory low back pain (LBP), and 14 (12:2) healthy, sedentary controls. A standard 100 microg CRH challenge test was performed with measurement of ACTH and cortisol levels at 9 time points. They were also subjected to an overnight dexamethasone suppression test, followed by injection of synthetic ACTH1-24. At 9 AM, the patients divided in 2 groups, received either 0.025 or 0.100 microg ACTH/kg body weight to test for adrenocortical sensitivity. Basal adrenocortical function was assessed mainly by measurement of 24 h urinary excretion of free cortisol. RESULTS: Compared to the controls, the patients with FM displayed a hyperreactive ACTH release in response to CRH challenge (ANOVA interaction effect p = 0.001). The mean ACTH response of the patients with low back pain appeared enhanced also, but to a significantly lesser extent (p = 0.02 at maximum level) than observed in the patients with FM. The cortisol response was the same in the 3 groups. Following dexamethasone intake there were 2 and 4 nonsuppressors in the FM and LBP groups, respectively. The very low and low dose of exogenous ACTH1-24 evoked a dose and time dependent cortisol response, which, however, was not significantly different between the 3 groups. The 24 h urinary free cortisol levels were significantly lower (p = 0.02) than controls in both patient groups; patients with FM also displayed significantly lower (p < 0.05) basal total plasma cortisol than controls. CONCLUSION: The present data validate and substantiate our preliminary evidence for a dysregulation of the HPA axis in patients with FM, marked by mild hypocortisolemia, hyperreactivity of pituitary ACTH release to CRH, and glucocorticoid feedback resistance. Patients with LBP also display hypocortisolemia, but only a tendency toward the disrupted HPA features observed in the patients with FM. We propose that a reduced containment of the stress-response system by corticosteroid hormones is associated with the symptoms of FM.

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OBJECTIVES: To determine the incidence and sources of bacterial arthritis in the Amsterdam health district and the maximum percentage of cases that theoretically would be preventable. METHODS: Patients with bacterial arthritis diagnosed between 1 October 1990 and 1 October 1993 were prospectively reported to the study centre by all 12 hospitals serving the district. Data were gathered on previous health status, source of infection, and microorganisms involved. RESULTS: 188 episodes of bacterial arthritis were found in 186 patients. Most of the 38 children were previously healthy. Fifty per cent of the adults were 65 years or older. Of the adults 84% had an underlying disease, in 59% a joint disorder. Joint surgery constituted the largest part of direct infections (33%) and skin defects were the most important source of haematogenous infections (67%). Infection of joints containing prosthetic or osteosynthetic material by a known haematogenous source occurred 15 times (8%). Staphylococcus aureus was the causative organism in 44% of all positive cultures. CONCLUSION: The incidence of bacterial arthritis was 5.7 per 100,000 inhabitants per year. Preventive measures directed to patients with prosthetic joints or osteosynthetic material, and a known haematogenous source would have prevented at most 8% of all cases.

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In a comparative study, the influence of several polypeptide growth factors on proliferation and matrix synthesis in secondary mandibular condylar and primary costal cartilage of the rat were determined using a serum-free culture system. Somatomedin-C, multiplication-stimulating activity (MSA), epidermal growth factor (EGF) and insulin had a significant dose-dependent stimulating effect on proliferation in mandibular condylar cartilage. In costal cartilage, the same factors as well as parathyroid hormone (fragment 1-34), platelet-derived growth factor (PDGF) and high doses of human growth hormone (1 microgram/ml) significantly stimulated proliferation. Matrix synthesis in both cartilages could only be stimulated by high doses of insulin (100 micrograms/ml) and in costal cartilage also by parathyroid hormone. In this culture system fibroblast growth factor reduced proliferation and matrix production, while cartilage-derived factor had no marked effect on the growth processes in both cartilage types. Prominent differences between condylar and costal cartilage were demonstrated by the effects of parathyroid hormone and fetal calf serum. Although the effects on matrix synthesis were very moderate in the tissue culture system used, this study demonstrates that most factors conducive to growth in primary cartilage also stimulate growth in condylar cartilage only exposure to growth substances that interfere with the differentiation of prechondroblasts into chondroblasts, a process that is specific for appositionally growing secondary cartilage, may result in different responses between primary and secondary cartilage.

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Release of inorganic pyrophosphate (PPi) by rabbit articular chondrocytes in vitro was measured by a newly developed assay which utilizes radioactive orthophosphate (32Pi) labeling and anion exchange high performance liquid chromatography. Chondrocytes in monolayer and high density culture failed to release PPi. Explants (cartilage fragments), however, released newly formed PPi into the culture medium. Trypsin treatment of cartilage fragments almost completely blocked the PPi extrusion. Collagenase treatment had no effect on PPi extrusion. There was no clear correlation between proteoglycan synthesis, measured by 35SO4 incorporation, and PPi release. Suppression of proteoglycan synthesis with tunicamycin did not influence the PPi release of the explants.

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A method is described for determination of inorganic pyrophosphate (PPi) in cell culture medium and in rabbit articular chondrocytes grown in the presence of radioactive orthophosphate (32Pi). Intra- and extracellular 32PPi formed was measured using high-performance liquid chromatographic (HPLC) separation of the PPi from orthophosphate (Pi) and other phosphate-containing compounds. The chromatographic separation on a weak anion-exchange column is based on the extent to which various phosphate compounds form complexes with Mg2+ at low pH and the rate at which such formation occurs. These complexes are eluted more readily than the uncomplexed compounds. Best results were obtained using a simultaneous gradient of Mg2+ ions and ionic strength. In this case separation of small amounts of PPi from a large excess of Pi was possible without prior removal of Pi or extraction of the PPi fraction. The assay is also useful for measurement of inorganic pyrophosphatase activity. The sensitivity of the assay depends on the specific activity of the added 32Pi and on the culture conditions, but is comparable with the most sensitive of the enzymatic assays. Sample preparation, particularly deproteinization, proved to be of importance. The losses of PPi which occur during procedures of this sort due to hydrolysis and coprecipitation were quantitated.

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In this study, scores on the sexual motivation scale (which measures the tendency to engage in sexual interaction versus the tendency to be averse to sexual interaction) were determined, by interview, in ankylosing spondylitis (AS) and rheumatoid arthritis (RA) patients and compared with the scores of healthy matched controls. AS patients did not score differently from the healthy population, but scores of men and women with RA were more in the direction of sexual aversion than those of healthy men and women. In female RA patients, some relationship was found between disease variables such as joint index and erythrocyte sedimentation rate and the score on the sexual motivation scale. In the second part of the interview, preference for certain coital positions was investigated, and the demand for help with sexual problems was explored. The percentage of RA patients expressing a need for advice was considerably greater than the percentage of AS patients.

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The effect of 3 purified peptide growth factors--platelet-derived growth factor (PDGF), epidermal growth factor (EGF), pituitary fibroblast growth factor (FGF)--heat-inactivated fetal bovine serum (FBS), insulin, and 0.2 mM ascorbate on synthesis of sulfated proteoglycan by rabbit articular chondrocytes was studied in monolayer culture. Growth of the cells increased linearly as the concentration of heat-inactivated FBS rose from 0 to 30%. Glycosaminoglycan (GAG) synthesis (35SO4/micrograms DNA) was enhanced as the concentration of heat-inactivated FBS went from 0 to 5%. At higher levels of serum, radiosulfate incorporation declined progressively. Two modes of study of the test factors were used: 1) the dose of the factor was increased while the serum concentration was fixed at a low basal level (1% heat-inactivated FBS); 2) the dose of the test factor was kept constant but the level of heat-inactivated FBS varied from 0 to 10%. There was an inverse relationship between GAG and DNA synthesis when proliferation of cells was increased by EGF and platelet lysate. PDGF (1 U/ml) stimulated radiosulfate incorporation as well as DNA formation in the serum-free medium; the values for GAG synthesis did not increase as the serum concentration increased, but the cell mass did. The action of FGF was intermediate between that of EGF and PDGF: with 50 ng FGF/ml, increasing concentrations of serum caused a large progressive reduction of radiosulfate incorporation as growth was stimulated. In basal medium, however, FGF caused mild enhancement of GAG synthesis. Insulin increased aggregatable proteoglycan production far out of proportion to its growth-promoting activity in the presence of 1% heat-inactivated FBS. The response was effaced when higher concentrations of serum were employed. Ascorbate had a unique anabolic effect, increasing both cell growth and proteoglycan synthesis that is not suppressed by higher concentrations of serum. The content of serum and its several peptide and hormonal components thus have divergent effects on growth and proteoglycan synthesis in cell culture. This phenomenon must be taken into account in studying biochemical processes and pharmacologic reactions of articular chondrocytes in vitro.

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The ability of purified growth factors, insulin, ascorbate, and several other compounds to stimulate DNA synthesis by rabbit articular chondrocytes was studied in monolayer culture. Platelet-derived growth factor (1 U/ml), pituitary fibroblast growth factor (1-100 ng/ml), and epidermal growth factor (1-50 ng/ml) were stimulatory in a basal medium supplemented with 1% heat-inactivated fetal bovine serum. Insulin, 1-50 micrograms/ml, has small growth-promoting effects but acted synergistically with platelet-derived, pituitary fibroblast, and epidermal growth factors. Increasing concentrations of serum up to 10% enhanced the growth-promoting action of the purified factors, but not of insulin. There were indications of cooperation between insulin and bovine serum albumin and dexamethasone. Ascorbate (0.2 mM) reduced or had little growth-promoting action in the basal medium. At 5 and 10% serum concentrations, however, ascorbate promoted DNA synthesis as effectively as the purified growth factors. No significant stimulatory effect was shown by transferrin, thrombin, L-glutamine, putrescine, selenous acid, dexamethasone, 7S nerve growth factor, or multiplication-stimulating activity.

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