Persistent functional and social benefit 5 years after a multidisciplinary arthritis training program.

OBJECTIVE: To assess the sustainable benefits of a professional, multidisciplinary training program for patients with rheumatoid arthritis. DESIGN: Two studies with different observation periods. Study I was a prospective, randomized trial for 1 year. Study II was a noncontrolled observation over 5 years. SETTING: The 9-day program for eight patient groups encompassed a multidisciplinary cooperation between rheumatologists, orthopedists, physicotherapists, psychologists and social workers. PATIENTS: Sixty-eight consecutive patients with rheumatoid arthritis participated in an arthritis training program either immediately after enrollment in the program or after 1 year. INTERVENTIONS: The program covered the following fields: pathogenesis of rheumatoid arthritis, drug therapy, physicotherapy, practical exercise in remedial gymnastics, use of joint protection devices, orthopedic perspectives, psychological counseling, dietetics, information about unproven cures and social assistance. MAIN OUTCOME MEASURES: Clinical outcome was assessed by self-report questionnaires: (1) Stanford Health Assessment Questionnaire, (2) Freiburg Questionnaire of Coping with Illness, (3) Beck Depression Inventory, and (4) a 21-point scale to evaluate cognitive-behavioral and environmental impact. RESULTS: A significant and persistent improvement of all investigated parameters was demonstrated in the 1-year controlled trial. Between the end-point of the 1-year study and the 5-year evaluation, this improvement increased even more for functional status and coping with illness, whereas depression returned to baseline values. These effects were seen even without reinforcement of the training. CONCLUSION: A professional, multidisciplinary approach to educate patients with rheumatoid arthritis leads to a significant and sustained improvement of the clinical outcome and is an approach that should be established as a part of conventional therapy.

Isradipine increases platelet--low-density lipoprotein binding: evidence from ex-vivo studies in humans.

The effects of isradipine (2.5 mg twice daily) on platelet--radioiodine-labeled [123I] low-density lipoprotein (LDL) binding were measured in 16 hypertensive patients (mean age 46.2 +/- 10.7 years) with (cholesterol > 250 mg/dl; n = 8) and without (cholesterol < 200 mg/dl; n = 8) hypercholesterolaemia during 4 weeks of isradipine treatment after 4 weeks of pretreatment placebo followed by 2 weeks of post-treatment placebo periods. Radioligand LDL-binding studies revealed that isradipine induced a significant (p < 0.001) rise in maximum binding capacity (Bmax) from a mean of 1148.6 +/- 244.3 ng protein/10(9) platelets to a mean of 1262.3 +/- 204.1 ng protein/10(9) platelets [dissociation constant (Kd): 9.7 +/- 4.9 micrograms protein/ml before treatment vs 7.8 +/- 3.7 g protein/ml after treatment]. After the post-treatment placebo phase, both Bmax and Kd returned to baseline levels. When the hypercholesterolaemic patients were compared with the normocholesterolaemics, the former revealed a more pronounced increase in platelet [125I]-LDL-binding capacity. Correspondingly, the dissociation constant showed a significantly (p < 0.05) greater decrease. In accordance with these results, both total and LDL cholesterol were reduced after 4 weeks of therapy with significant (p < 0.03) rises through to the end of the post-treatment placebo period. It is suggested that the observed increase in high-affinity platelet--LDL binding with isradipine treatment reflects a state of decreased in-vivo platelet activation, an effect which may be of particular clinical value in hyperlipidaemic patients.

[Radiosynovectomy with dysprosium-165 iron hydroxide]. / Radiosynovektomie mit Dysprosium-165-Eisen-Hydroxid.

Treatment of chronic rheumatoid synovitis (RS) is directed to control the inflammatory process causing pain and disability. Radiation synovectomy is suggested to be an alternative to surgical treatment, but its clinical use has been restricted because of significant leakage (> 10%) associated with the use of the standard radionuclide 90-Yttrium (used as 90-Yttrium silicate colloid) and because of its long physical half-life of 64 hours prolonging the patients' stay in the hospital. 165-Dysprosium possesses promising nuclear properties for the treatment of patients suffering from RS. The maximum soft tissue penetration of its beta-particles is 5.7 mm which is the range being necessary to penetrate the inflamed synovia. Using as carrier ferric hydroxide macroaggregates (DFH) 165-Dy is expected to minimize the cumulative radiation dose to non-target organs by its very low leakage. Animal studies were performed in 13 rats and 6 rabbits to obtain the rationale and safety data for its clinical evaluation. These studies revealed that 98.2 +/- 0.6% of the injected dose remained in the joint with a nontarget organ uptake of less than 0.1%. Clinical results were obtained from 8 patients with rheumatoid arthritis. 24 hours after injection scintigraphy was performed over the treated joint and the liver region revealing no detectable leakage of the injected activity from the joint. Blood pool activity was also assessed revealing a leakage of 0.02% of the dose injected in the knee 24 hours after injection.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of age on outcome of mechanically ventilated patients in an intensive care unit.

OBJECTIVE: To assess the influence of age on the outcome of patients receiving prolonged mechanical ventilation. DESIGN: Retrospective study. SETTING: Intensive care unit. PATIENTS: A total of 1,141 patients in our ICU during a 32-month period. A total of 536 patients required mechanical ventilation. After exclusion of 171 patients ventilated for less than 24 hrs after surgery, 365 patients were investigated. MEASUREMENTS AND MAIN RESULTS: Two hundred sixty-six (73%) patients were aged less than 70 yrs; 99 (27%) patients were greater than or equal to 70 yrs. There was no significant difference in mortality rate between the younger and the older age groups. There was no significant influence of other important factors, such as severity of illness, duration of mechanical ventilation, or length of ICU stay. The only factor showing a significant influence on patient outcome was the reason for mechanical ventilation. There were more survivors in the group being ventilated because of ventilatory insufficiency than in the group with oxygenation impairment (57.8% vs. 23.9%, p less than .001). CONCLUSION: An influence of age on the outcome of mechanically ventilated patients in the ICU could not be ascertained in this study.

[Color-coded Doppler sonography of the thyroid: an advance in carcinoma diagnosis?]. / Farbkodierte Doppler-Sonographie der Schilddrüse: ein Fortschritt in der Karzinomdiagnostik?

There are several papers suggesting that colour-coded Doppler sonography is a useful diagnostic tool for the differentiation of malignant and benign lesions of the thyroid gland. This hypothesis (hypervascularization of malignant nodules) is reconsidered by preoperative examination of 65 patients by using colour-coded Doppler sonography and scintigraphy. Among these patients 21 carcinomas and 2 malignant lymphomas of the thyroid gland were found histologically. Colour-coded Doppler sonography was true positive in 10 cases, true negative in 28 cases, false positive in 14 cases and false negative in 13 cases. Our conclusion is that colour-coded Doppler sonography cannot be used unconditionally for the detection of carcinoma of the thyroid gland.

Induction of systemic lupus erythematosus by interferon-gamma in a patient with rheumatoid arthritis.

The development of systemic lupus erythematosus (SLE) after 38 months of therapy with recombinant human interferon gamma (rIFN-gamma) was observed in a patient with rheumatoid arthritis. In addition to glomerulonephritis and a butterfly rash, previously negative tests for antinuclear, anti-dsDNA and anti-Sm antibodies became positive. We assume that rIFN-gamma induced the de novo development of SLE in our patient.

Emergency ventilation using the Combitube in cases of difficult intubation.

The esophageal-tracheal Combitube (Sheridan, Argyle, NY) is a new device for emergency intubation, which can be inserted blindly without the use of a laryngoscope. Ventilation is independent of the position of the Combitube in either the esophagus or the trachea, since ventilation is always provided by the tube's double channel. The "tracheal" channel acts as a conventional endotracheal airway and has an open distal end. The "esophageal" channel has a blocked distal end, so that together with the inflated distal cuff it acts as an esophageal obturator in cases of esophageal intubation. Perforations at the pharyngeal section direct the airflow to the trachea. At the oropharyngeal section a large elastic balloon is positioned in order to obturate the oral cavity and the nasopharynx. Two patients are described to exemplify the Combitube's clinical use. Both had rapidly enlarging cervical hematomas causing upper airway obstruction and thus requiring immediate intubation. Endotracheal intubation failed because the glottis could not be visualized with a laryngoscope. In both cases the Combitube was applied successfully and adequate ventilation was provided via the Combitube placed esophageally. To better secure each patient's airway, tracheotomy was performed during ventilation without any complications.

Soluble interleukin-2 receptor and soluble CD8 antigen in active rheumatoid arthritis.

Concentrations of soluble interleukin-2 receptor (sIL-2R) and of soluble CD8 antigen (sCD8) in sera and in supernatants of phytohemagglutinin (PHA)-stimulated peripheral blood mononuclear cells (PBMC) derived from patients with active rheumatoid arthritis (RA) were studied. sIL-2R concentrations in sera derived from patients with RA (1484 +/- 382 U/ml) were significantly higher than in sera derived from healthy controls (380 +/- 110 U/ml; P less than 0.0005). In contrast, supernatants of PHA-stimulated PBMC derived from patients with RA contained similar amounts of sIL-2R (727 +/- 467 U/ml) as those derived from healthy control individuals (833 +/- 508 U/ml; P greater than 0.1). When investigated for the presence of sCD8 antigen, sera derived from patients with RA contained significantly lower amounts (30 +/- 28 U/ml) than sera derived from healthy controls (405 +/- 136 U/ml; P less than 0.0005). Similarly, PHA stimulation of PBMC derived from patients with RA resulted in a significantly lower production of sCD8 (35 +/- 46 U/ml) as compared to the one obtained by PHA stimulation of PBMC derived from healthy controls (177 +/- 59 U/ml; P less than 0.0005). This difference could not be explained by a lower proliferative response to PHA by PBMC derived from patients with RA (21,474 +/- 14,022 cpm) as compared to healthy controls (29,549 +/- 11,188 cpm; P greater than 0.05). Our data demonstrate that PBMC derived from patients with active RA differ from PBMC derived from healthy individuals concerning their ability to produce sIL-2R and sCD8.

Modulation of leucocyte locomotion by interleukin-1.

The influence of interleukin-1 (IL-1) upon leucocyte locomotion in vitro was studied, using either casein or zymosan-activated serum (ZAS) as chemotaxigens. A pre-incubation of polymorphonuclear cells (PMNC) with ultrapure (purity 99%) human IL-1 (1 U/ml) for 2 and 5 h followed by a washing step resulted in a significant decrease in leucocyte locomotion against casein (P less than 0.0005 and P less than 0.01, respectively), but not against ZAS (P greater than 0.1). Moreover, the direct addition of this IL-1 preparation to leucocyte locomotion assays without pre-incubation produced a similar and significant inhibition of leucocyte locomotion directed against casein (P less than 0.05). This inhibitory effect could not be augmented further by higher concentrations of ultrapure IL-1. In order to exclude the effect of possibly contaminating cytokines in the ultrapure IL-1 preparation used, additional assays with recombinant human IL-1 (rIL-1) alpha and rIL-1 beta (1 U/ml) were performed to investigate their influence upon leucocyte locomotion. It was found that both rIL-1 alpha and rIL-1 beta inhibited leucocyte locomotion directed against casein significantly (P less than 0.005). Similar to the previous experiments, leucocyte locomotion could not be further inhibited by higher concentrations (10 U/ml) or rIL-1. Thus, both ultrapure and rIL-1 were found to have the ability to inhibit leucocyte locomotion in vitro.