Some thoughts on the prevention of complaints in musicians and dancers.

This article summarizes the physical and psychological problems that can befall performing artists and aims to provide an insight into their prevention.

Malignancies presenting at a performing arts medicine clinic.

Four performing artists with musculoskeletal complaints were found to have an underlying malignancy.

Therapeutic efficacy of multiple intravenous infusions of anti-tumor necrosis factor alpha monoclonal antibody combined with low-dose weekly methotrexate in rheumatoid arthritis.

OBJECTIVE: To evaluate the efficacy, pharmacokinetics, immunogenicity, and safety of multiple infusions of a chimeric monoclonal anti-tumor necrosis factor alpha antibody (cA2) (infliximab; Remicade, Centocor, Malvern, PA) given alone or in combination with low-dose methotrexate (MTX) in rheumatoid arthritis (RA) patients. METHODS: In a 26-week, double-blind, placebo-controlled, multicenter trial, 101 patients with active RA exhibiting an incomplete response or flare of disease activity while receiving low-dose MTX were randomized to 1 of 7 groups of 14-15 patients each. The patients received either intravenous cA2 at 1, 3, or 10 mg/kg, with or without MTX 7.5 mg/week, or intravenous placebo plus MTX 7.5 mg/week at weeks 0, 2, 6, 10, and 14 and were followed up through week 26. RESULTS: Approximately 60% of patients receiving cA2 at 3 or 10 mg/kg with or without MTX achieved the 20% Paulus criteria for response to treatment, for a median duration of 10.4 to >18.1 weeks (P < 0.001 versus placebo). Patients receiving cA2 at 1 mg/kg without MTX became unresponsive to repeated infusions of cA2 (median duration 2.6 weeks; P=0.126 versus placebo). However, coadministration of cA2 at 1 mg/kg with MTX appeared to be synergistic, prolonging the duration of the 20% response in >60% of patients to a median of 16.5 weeks (P < 0.001 versus placebo; P=0.006 versus no MTX) and the 50% response to 12.2 weeks (P < 0.001 versus placebo; P=0.002 versus no MTX). Patients receiving placebo infusions plus suboptimal low-dose MTX continued to have active disease, with a Paulus response lasting a median of 0 weeks. A 70-90% reduction in the swollen joint count, tender joint count, and C-reactive protein level was maintained for the entire 26 weeks in patients receiving 10 mg/kg of cA2 with MTX. In general, treatment was well tolerated and stable blood levels of cA2 were achieved in all groups, except for the group receiving 1 mg/kg of cA2 alone, at which dosage antibodies to cA2 were observed in approximately 50% of the patients. CONCLUSION: Multiple infusions of cA2 were effective and well tolerated, with the best results occurring at 3 and 10 mg/kg either alone or in combination with MTX in approximately 60% of patients with active RA despite therapy with low-dose MTX. When cA2 at 1 mg/kg was given with low-dose MTX, synergy was observed. The results of the trial provide a strategy for further evaluation of the efficacy and safety of longer-term treatment with cA2.

Technical note: New applications for on-line automated solid phase extraction.

This technical note explains the disadvantages of manual solid phase extraction (SPE) techniques and the benefits to be gained with automatic systems. The note reports on a number of general and highly specific applications using the Sample Preparation Unit OSP-2A.

Extracapillary glomerulonephritis in a patient with juvenile chronic arthritis.

A patient with juvenile chronic arthritis (JCA) in remission developed the nephrotic syndrome 17 years after the onset of the disease. A renal biopsy showed diffuse extracapillary proliferative glomerulonephritis without immune complex deposits. The patient was treated with glucocortico-steroids and cyclophosphamide. Extracapillary glomerulonephritis without immune complex deposits appears to be a rare complication of JCA.

Idiopathic haemochromatosis: magnetic resonance signal intensity ratios permit non-invasive diagnosis of low levels of iron overload.

OBJECTIVE: The detection of low levels of iron overload by magnetic resonance imaging. METHODS: Eight consecutive patients suspected of having idiopathic haemochromatosis. Comparison of signal intensity ratios and absolute iron content of liver. RESULTS: There was a good correlation between the signal intensity ratios and iron content in the range 2-30 micrograms Fe/mg dry weight. CONCLUSIONS: The ability of a non-invasive technique to detect low levels of iron overload could be useful in the assessment of therapy and in the screening of relatives of probands with idiopathic haemochromatosis.

Spinal cord compression in renal osteodystrophy.

A patient undergoing regular haemodialysis for chronic renal insufficiency developed neck pain followed by progressive spinal cord compression due to subluxation at the level C3-4. Decompression, laminectomy and osteosynthesis led to an almost complete recovery. A review of all the histological specimens suggested that hyperparathyroidism and not amyloidosis caused the vertebral destruction.

Randomised double-blind comparison of chimeric monoclonal antibody to tumour necrosis factor alpha (cA2) versus placebo in rheumatoid arthritis.

Tumour necrosis factor alpha (TNF alpha) is a critical inflammatory mediator in rheumatoid arthritis, and may therefore be a useful target for specific immunotherapy. In support of this hypothesis, we previously observed beneficial responses in patients with active rheumatoid arthritis after open-label administration of a chimeric monoclonal antibody to TNF alpha (cA2). We now report the results of a four-centre, randomised double-blind trial of a single infusion of 1 or 10 mg/kg cA2 compared with placebo in 73 patients with active rheumatoid arthritis. The primary endpoint of the study was the achievement at week 4 of a Paulus 20% response, an amalgam of six clinical, observational, and laboratory variables. Intention-to-treat analysis of data from individual patients showed only 2 of 24 placebo recipients responding at this time, compared with 11 of 25 patients treated with low-dose cA2 (p = 0.0083) and 19 of 24 patients treated with high-dose cA2 (p < 0.0001). Over half of the high-dose cA2 patients responded by the more stringent 50% Paulus criteria at this time (p = 0.0005). The magnitude of these responses was impressive, with maximum mean improvements in individual disease-activity assessments, such as tender or swollen-joint counts and in serum C-reactive protein, exceeding 60% for patients on high-dose treatment. There were two severe adverse events. 1 patient on 1 mg/kg cA2 developed pneumonia ("possibly" treatment-related) and 1 on 10 mg/kg had a fracture ("probably not" treatment-related). The results provide the first good evidence that specific cytokine blockade can be effective in human inflammatory disease and define a new direction for the treatment of rheumatoid arthritis.

[Osteitis in psoriasis]. / Osteïtis bij psoriasis.

A 56-year-old man was diagnosed with psoriasis, after a year with pain over the manubrium sterni, a stiff neck and shoulders and an increased erythrocyte sedimentation rate. Imaging studies revealed widening and sclerosis of the manubrium sterni, ossification of the insertions of the first ribs and involvement of the sternoclavicular joints. Histological examination of the sternum showed signs of a chronic inflammatory process. Improvement of the skin lesions was accompanied by a reduction of the pain. Psoriasis may be complicated by osteitis/hyperostosis, which may precede the skin lesions. An effective therapy is lacking, although analgetics and antiphlogistics are often useful.

Gastric outlet obstruction as a presenting manifestation of systemic lupus erythematosus.

A patient with nausea and vomiting who subsequently proved to have systemic lupus erythematosus is described. Although gastrointestinal involvement is common in systemic lupus erythematosus it is rare as an initial manifestation. Gastric outlet obstruction was shown on the air contrast examination while the mucosa at endoscopy was normal. The gastric symptoms regressed after treatment with high dose corticosteroids and a repeat air contrast examination of the stomach was normal. This stricturing process may have been caused by a local peritonitis.

Polyarthritis as the presenting symptom of the occurrence and recurrence of a laryngeal carcinoma.

A 50 year old male smoker presented with an identical seronegative polyarthritis before both the occurrence and recurrence of a laryngeal tumour. The interval between the joint symptoms and discovery of the tumour was 11 and 13 months respectively. Treatment of the tumour resulted in complete disappearance of the arthritis on both occasions.

Clinical significance of a low serum alkaline phosphatase.

The reasons for a low serum alkaline phosphatase activity were reviewed in a 1-yr retrospective study of all the results emanating from a central, university hospital laboratory. Apart from occasional errors, hypophosphatasaemia was encountered in neonates undergoing exchange transfusions with plasma, in patients (particularly children) receiving chemotherapy and during cardio-pulmonary bypass. Low activity values were recorded in several individuals in the absence of any obvious cause. This would suggest that the definition of the lower limit of the reference range for alkaline phosphatase is arbitrary, thus limiting the use of low serum activity as a marker of disease.

Inclusion body myositis: its relative frequency in elderly people.

Inclusion body myositis (IBM) is a distinct, steroid resistant, form of inflammatory myopathy. Its recognition is the more important because of the preponderant occurrence in the elderly, in whom steroid treatment is hazardous. Since the relative frequency of IBM among inflammatory myopathies in the elderly is undetermined, we retrospectively studied its frequency among all our patients over 50 years, diagnosed between 1980 and 1991 with inflammatory myopathy. Nine of 15 patients with inflammatory myopathy appeared to suffer from IBM. In a further 2 patients this diagnosis was strongly suspected. We conclude that IBM is the most frequent inflammatory myopathy in the elderly. This observation warrants restraint with steroids in the management of inflammatory myopathy in the elderly.