Rheumatology patient preferences for timing and location of out-patient clinics.

OBJECTIVES: To determine the preferences of rheumatology patients for the time and location of their out-patient appointments. METHODS: All patients attending the rheumatology out-patient services at Dudley Group of Hospitals NHS Trust over a 2-week period were asked to complete a purpose-designed, scannable, previously piloted, self-administered questionnaire. RESULTS: Four hundred and nineteen patients completed questionnaires (response rate 87%). Age ranged from 16 to 92 yr; 38% of responders were over 65 yr, 72% were female, 57% had an inflammatory arthritis, 20% had a connective tissue disease, 8% had degenerative joint disease and 15% had another diagnosis; 29% were employed, 51% retired and 20% unemployed. Fewer than 1% of patients would like to be seen at community general practice centres (99.3% would prefer a hospital site). Proximity to their home was the main determinant of hospital choice. Monday was the most popular day for appointments, and days from Tuesday to Friday received equal rankings. Only 0.5% of patients would choose a weekend clinic. Fifty-eight per cent of patients would prefer morning appointments, 24% afternoon appointments and 2% evening appointments; 16% did not mind. Only being employed predicted out-of-hours preference. CONCLUSIONS: In this predominantly suburban, industrialized area, rheumatology out-patients prefer to be seen in the hospital rather than primary care environment, ideally close to their home, with appointments in the morning and on a weekday. These results may be generalizable to other districts and other chronic disease states, but we suggest that similar surveys become part of routine service provision and inform current and future planning.

Lymphoreticular malignancy and monoclonal gammopathy presenting as polymyalgia rheumatica.

Five patients presenting with polymyalgia rheumatica-like symptoms were found to have a monoclonal gammopathy. In addition one of these patients had acute myeloblastic leukaemia, two had early myeloma and one patient had probable Waldenström's macroglobulinaemia. The association of polymyalgia rheumatica-like symptoms, monoclonal gammopathy and lymphoreticular malignancies is discussed.

A 12-month comparative trial of auranofin and D-penicillamine in rheumatoid arthritis.

The oral gold salt auranofin, 6 mg per day, was compared with oral d-penicillamine, 500 mg per day, in a single-blind trial in 40 patients suffering with definite or classic rheumatoid arthritis. The patients were randomly allocated into the two therapeutic regimens (19 patients auranofin; 21 patients d-penicillamine) and monitored at a minimum of four-week intervals during the first year of treatment. Significant diminution in rheumatoid disease activity, as assessed by numerous clinical and laboratory parameters, was observed in both the auranofin- and penicillamine-treated groups. No significant differences existed for these parameters between the two groups, either initially or at the end of the trial period. Ten patients were lost from the trial over the 52-week period. Three subjects were withdrawn from the auranofin-treated group (increasing severity of rheumatoid arthritis at four weeks; severe diarrhea at four weeks; probable drug-related erosive gastritis at 40 weeks). Seven subjects were permanently withdrawn from the penicillamine-treated group (four, skin rashes four to eight weeks; one, heavy proteinuria at 24 weeks; one, therapeutic failure at 32 weeks; one, compliance failure at eight weeks), and treatment was temporarily withheld in three further patients because of thrombocytopenia (two) and proteinuria (one). We conclude that both drugs are effective in rheumatoid arthritis and that the lesser toxicity with auranofin will make it a valuable addition to our therapeutic armamentarium.

Penicillamine-induced myasthenia in rheumatoid arthritis: its clinical and genetic features.

The clinical features and genetic background of 18 patients with rheumatoid arthritis were investigated following the development of penicillamine-induced myasthenia (PIM). The initial myasthenia symptoms in all patients consisted of variable diplopia and/or ptosis with progression to a more generalized involvement in 7 of them. No clinical, humoral, or genetic factor was determined which would allow identification of individuals developing generalized as opposed to ocular myasthenia. Withdrawal of penicillamine was associated over 4-60 weeks with a slow resolution of symptoms, facilitated in 12 patients by the use of anticholinesterase agents. In 2 patients a persistent partial unilateral ptosis remains after 15 and 25 months, while in a further patient diplopia is present 42 months after resolution of the other myasthenic symptoms. The patients with PIM when compared with a healthy 'control' population had a significant increase in HLA Dr1 (p corr less than 0.005) and an absence of HLA Dr 3. A genetic susceptibility to the development of PIM, distinct from that observed in myasthenia gravis of spontaneous onset, is suggested by this abnormal distribution of HLA Dr antigens.

Jejuno-ileal bypass arthropathy: its clinical features and associations.

Postoperative arthropathy has been reported in patients undergoing jejunoileal bypass for morbid obesity. The true frequency of this complication, and its independence from preexisting joint disease and from osteomalacia have not been clearly established. Of 107 patients who had undergone jejunoileal bypass, and in whom osteomalacia had been excluded, 38 developed a distinctive arthropathy. This consisted of episodic polyarthralgia, and occasionally arthritis, affecting both large and small joints. The articular symptom complex was independent of other major postoperative complications and unrelated to metabolic disturbances consequent upon rapid weight reduction. Preoperative joint symptoms had a similar incidence in those who did and in those who did not subsequently develop the postoperative arthropathy. Reversal of the intestinal bypass was always associated with an immediate, complete, and permanent remission of arthropathic symptoms.

Thyroid dysfunction and rheumatic diseases.

Musculoskeletal symptoms developing during the treatment of thyroid disease were studied in 150 patients; 17 developed a symptom complex of early morning stiffness together with shoulder girdle pain and weakness; similar symptoms were seen in only 3 of 100 controls. A prospective study of 16 patients with recent onset rheumatoid arthritis followed during the first 6 months of penicillamine therapy showed no changes in thyroid function tests. It is suggested that changing or abnormal thyroid status may precipitate or exacerbate musculoskeletal disease. Finally, in a retrospective study of 26 patients with both thyroid disease and rheumatoid arthritis, 4 patients had a simultaneous onset of both myxoedema and rheumatoid arthritis, the activity of which was greatly improved by correction of the hypothyroid state.

Familial cheiroarthropathy without juvenile onset diabetes mellitus.

Cheiroarthropathy is a recently recognised complication of juvenile onset diabetes mellitus. It comprises inability to extend fully the fingers, contracted tendons, and waxy thickening of the skin overlying the fingers and to a lesser extent the hands. We report two families in which one parent and a number of siblings had the typical features of cheiroarthropathy without juvenile onset diabetes mellitus. The changes developed gradually during childhood and did not progress after adolescence. There were no other abnormal clinical findings, no persistently abnormal laboratory tests, and no association with a specific HLA phenotype. There are some similarities with scleroderma and its recognition is important to prevent unnecessary treatment and to reassure patients.

The effect of acetazolamide on the proteinuria of altitude.

Albumin was measured by dipstick tests and immunologically in 24-h and early morning urine (EMU) samples collected from 20 subjects during a high-altitude trek. Each was given acetazolamide (Diamox sustets) or placebo as part of a double-blind trial on the prophylactic use of acetazolamide in acute mountain sickness (AMS). At the highest altitudes, albuminuria was six times greater in those on placebo (p less than 0.001) and was related to the clinical features of AMS (p less than 0.01) and arterial oxygen tension (p less than 0.001). Urine dipsticks tests for proteinuria were also an index of AMS, but were inaccurate. The proteinuria is probably due to renal hypoxia, which causes increased glomerular permeability, reduced tubular readsorption, or both. The reduction in the clinical features of AMS achieved with acetazolamide therapy is also associate with improved renal function.

The distribution of fibronectin in the pannus in rheumatoid arthritis.

Fibronectin is an adhesive glycoprotein synthesized by mesenchymal cells. Its distribution in the rheumatoid pannus has been studied by immunofluorescence using a monospecific antiserum. All areas of the pannus contained immunoreactive fibronectin, including its junctions with synovium, ligaments, bone and cartilage. It formed a coarse extracellular meshwork which surrounded the inflammatory cells infiltrating the pannus and which codistributed with reticulin and "immature" collagen. The proliferative cellular areas of the pannus showed marked reactivity for fibronectin. Although fibronectin was present at the pannus-cartilage junction, it was not otherwise found in articular cartilage. Fibronectin in the pannus did not have any relationship to the distribution of immunoglobulins or complement. Fibronectin is a structural component of the rheumatoid pannus and may play a role in the pathogenesis of rheumatoid synovitis.

Significance of laminar antikeratin antibodies to rat oesophagus in rheumatoid arthritis.

Antikeratin antibodies reacting in a laminar distribution with keratinised rat oesophagus were found in the sera of a proportion of patients with rheumatoid arthritis but not in healthy controls. In rheumatoid arthritis (RA) the proportion of sera exhibiting this reactivity varied with the site tested in the rat's upper alimentary tract. There were 36.4% of 99 patients with RA who gave positive reactivity to the middle third of the rat oesophagus. This antikeratin reactivity was related to the occurrence of other antitissue antibodies (to reticulin, gastric parietal cells, smooth muscle, mitochondria, or nuclear components) in the same patients with rheumatoid arthritis. It was not related to the duration of early morning stiffness, the Ritchie index, the erythrocyte sedimentation rate, certain acute phase proteins (haptoglobin and C-reactive protein) nor to the levels of haemoglobin or immunoglobulins. Antikeratin antibodies were not specific for rheumatoid arthritis and also occurred in 50% of 16 patients with progressive systemic sclerosis.