Determinants of cognitive performance in systemic lupus erythematosus.

Patients with systemic lupus erythematosus (SLE) may have a variety of neuropsychiatric syndromes. Assessment of cognitive functioning for these patients is complicated by increased prevalence and disease severity among groups obtained lower scores on measures of cognitive functioning in normative national samples. Cognitive ability was quantified in a diverse cohort of patients with SLE and a demographically matched group of control participants. Hierarchical regression demonstrated a small increase (6%) in explained variation in cognitive functioning when presence of SLE was added to the equation derived from demographic variables. No significant interaction was found between race and disease. These results suggest that increased frequency of cognitive impairment in African Americans with SLE is due to the additive effects of psychosocial variables.

Corticosteroid injection in rheumatoid arthritis does not increase rate of total joint arthroplasty.

OBJECTIVE: To determine the relationship between frequent intraarticular corticosteroid injection and subsequent joint replacement surgery. METHODS: A 1987 database of patients with rheumatic diseases was reviewed to find patients with rheumatoid arthritis (RA) who had received 4 or more intraarticular injections in an asymmetric pattern in a single year. RESULTS: A subset of 13 patients with an average of 7.4 years of followup was established as the cohort of a 5 year prospective study. In this highly selected cohort of patients with RA in a university practice who received 1622 injections, joint replacement surgery was not significantly more common in the heavily injected joints. CONCLUSIONS: A strategy of frequent intraarticular steroid injection does not greatly increase, through added risk of joint replacement, the risk inherent in continued disease activity for patients with established RA. Frequent corticosteroid injection may offer some chondroprotection when the alternative is continuous disease activity.

Dry taps and what to do about them: a pictorial essay on failed arthrocentesis of the knee.

PURPOSE: To determine and illustrate the causes of unproductive arthrocentesis of the knee. PATIENTS AND METHODS: Consecutive patients were studied who had inflammatory (rheumatoid or psoriatic) arthritis affecting the knees and experienced unproductive arthrocentesis during a randomized, controlled trial. Magnetic resonance imaging (MRI) was used, supplemented first by intravenous gadolinium contrast and subsequently by manual mixing of the diffused contrast to outline the furthest possible penetration of contrast within the joint cavity. RESULTS: In 4 out of 5 patients studied, failed arthrocentesis was due to combinations of inspirated joint fluid too viscous to be withdrawn or to mix with contrast, adipose tissue, and lipoma arborescens (thickened synovium with fat replacement). One MRI exam was normal. More free synovial fluid was imaged on the lateral side. CONCLUSIONS: Failure to aspirate synovial fluid from the knee is explicable to anatomic terms; in particular, fluid viscosity and lipoma arborescens play a role in chronic effusions. Although surface anatomic landmarks for knee arthrocentesis may be more visible medially, the lateral approach is more likely to yield fluid for synovial analysis in difficult cases. Internal medicine trainees should be taught the lateral approach.

A comprehensive investigation of inpatient intravenous colchicine use shows more education is needed.

OBJECTIVE: To test the hypothesis that colchicine therapy for patients in whom treatment was guided by rheumatology consultation was more appropriately prescribed than therapy for patients not receiving consultation. METHODS: A retrospective chart review of all inpatients with acute crystal induced arthritis who received intravenous (iv) colchicine was performed to assess iv colchicine prescribing errors and any adverse outcomes of iv colchicine therapy. RESULTS: Errors in the prescribing of iv colchicine occurred in 5 of 19 patients (26%). A rheumatology consultation was not obtained in any of these cases. Overall, there was a significant increase in the prescribing error rate in the no-consultation versus the consultation groups (p = 0.045). These 5 errors did not lead to serious adverse outcomes, but leukopenia occurred in one patient and the white blood cell count decreased from 7.3 to 4.3 cells/mm3 in another patient. Leukopenia also occurred in 3 patients in whom iv colchicine was used appropriately. CONCLUSION: (1) Previously published guidelines for iv colchicine use appeared successful at preventing serious colchicine toxicity. (2) These guidelines do not protect against leukopenia occurring from colchicine use. (3) Rheumatology consultation may help prevent errors in the use of iv colchicine. (4) Further education is needed in the correct use of iv colchicine.

Well-imaged large vessel vasculitis attributed to anticardiolipin antibody.

OBJECTIVE: We report a case of large vessel vasculitis, compare imaging techniques, and briefly review the literature. METHODS: Anticardiolipin antibody titers, acute-phase response, and ischemic symptoms in a 50-year-old man admitted for treatment of vasculitis-related ischemia of the fingers were monitored over a 14-month period. Images from serial magnetic resonance angiography (MRA) were compared with images from conventional arteriography in the evaluation of peripheral arterial circulation. RESULTS: The acute-phase response and anticardiolipin antibody levels were found to vary in parallel with slow resolution of ischemic symptoms following monthly treatment with pulse methylprednisolone and cyclophosphamide. CONCLUSION: Attribution of ischemic symptoms to anticardiolipin antibody is supported by the correlation of anticardiolipin antibody titers, acute-phase response parameters, and ischemic symptoms. The serial images from MRA demonstrate its usefulness as a noninvasive tool for followup studies of both large and medium-sized vessels affected by vasculitis.

Gout attacks in chronic alcoholics occur at lower serum urate levels than in nonalcoholics.

OBJECTIVE: To determine if patients with gout with chronic alcoholism have lower serum urate levels than nonalcoholic patients. METHODS: Of 95 consecutive consults for acute gout at a VA medical center, 42 were excluded from study due to lack of crystal documentation, lack of urate value within 2 years, or treatment with allopurinol or probenecid. The remaining 53 patients were grouped by alcohol use and a retrospective chart review was done for these patients. RESULTS: Mean intercritical serum urate values for chronic alcoholics and nonalcoholics were similar at 9.7 +/- 2.1 for alcoholics and 9.5 +/- 2.1 for nonalcoholics. Yet, despite these similar intercritical serum urate values, and despite no difference between chronic alcoholics and nonalcoholics in frequency or severity of acute gout flares, patients with chronic alcoholism had index serum urate levels which were significantly lower than those of nonalcoholics. These mean index values, with standard deviations, were 7.7 +/- 1.3 for 15 chronic alcoholics and 10.1 +/- 1.3 for 34 nonalcoholics; p < 0.01). CONCLUSION: Alcoholics and nonalcoholics had comparable intercritical values. However, on presentation with acute arthritis, the index serum urate values for alcoholics were lower than in nonalcoholics. Values for serum urate below 8.5 mg/dl are of less value in excluding gout in chronic alcoholics than in nonalcoholics presenting with acute gout flares.