Nabumetone compared with naproxen in the treatment of rheumatoid arthritis: a multicenter, double blind, randomized, parallel group trial in hospital outpatients.

In this double blind, randomized, parallel group study, 298 patients with rheumatoid arthritis received nabumetone (2000 mg/day) or naproxen (1000 mg/day) for 3 months. At the end point, nabumetone treated patients exhibited significant improvement in pain, Ritchie articular index, and duration of morning stiffness when compared to baseline. In contrast, naproxen treated patients showed significant improvement only in Ritchie articular index. Nabumetone was significantly more effective than naproxen for pain relief. More nabumetone treated patients withdrew due to lack of efficacy than naproxen treated patients. However, nabumetone was better tolerated than naproxen because fewer patients withdrew for adverse events or experienced severe adverse events, and significantly fewer patients required treatment for adverse events.

The efficacy of calcium mupirocin in the eradication of nasal Staphylococcus aureus carriage.

In an open, non-comparative clinical study conducted at 102 hospitals in the UK and Ireland, 1,510 subjects were treated with 2% calcium mupirocin in a white soft paraffin/Softisan 649 base (Bactroban 'Nasal') during hospital outbreaks of methicillin-resistant Staphylococcus aureus (MRSA). In most subjects treatment was applied two or three times daily to both anterior nares for three to eight days. Of the 766 assessable subjects, nasal carriage of S aureus was cleared in 744 (97.1%). Initially, MRSA was present in 628 cases (79.4%), and the organism was eliminated in 609 of these (97.0%). Isolates of S aureus were tested for susceptibility to a variety of antibiotics by disc test: of 523 nasal isolates tested against mupirocin, 516 (98.7%) were sensitive. Treatment was very well tolerated. Adverse events were reported by 22 subjects (1.5%); these were mostly mild local effects and necessitated withdrawal of treatment only in three subjects. The results indicate that topical calcium mupirocin is a highly effective and well tolerated treatment for the eradications of nasal carriage of S aureus, including MRSA.

Study of IgG sub-class antibodies in patients with milk intolerance.

An ELISA was applied to measure IgG sub-class antibodies to cow's milk beta-lactoglobulin (BLG), alpha-lactalbumin (ALA) and alpha-casein (AC) and to hen's egg ovalbumin (OA) in the sera of nineteen adult patients with milk intolerance causing either asthma, eczema or both. Results were compared with those of forty blood donors and twenty adult patients with either asthma or eczema due to inhalant allergy. Apart from one blood donor, high titres of IgG sub-class antibodies to all three milk proteins were found only in the milk intolerance group. The most frequently detected antibody was AC-specific IgG4; being high (i.e. greater than 9.98 micrograms/ml) in eight milk intolerance cases: six with eczema, one with asthma and one with both. A variable proportion of these eight patients also had high levels of IgG1, IgG2 and IgG3 antibodies to AC and IgG1, IgG2, IgG3 and IgG4 antibodies to BLG and ALA. In contrast, IgG antibody to the egg protein, OA, was remarkably restricted to IgG4 and was present in high titres in 68.4% of milk intolerant patients, 60% of inhalant allergy patients and 30% of blood donors. However, the greater incidence of high titres of IgG4 antibody to OA, compared to AC, was due to the superior coating efficiency of OA resulting in a more sensitive assay. We conclude that some adult cases of milk intolerance, particularly those with eczema, can be diagnosed by detecting raised serum levels of IgG sub-class antibodies to milk proteins.

Detection of an IgM antiglobulin in the sera of atopic patients using insolubilized IgG4, and its capacity to release histamine from leucocytes.

ELISA plates coated with highly pure IgG4 were employed to detect IgM antiglobulin in atopic sera. The use of IgG4, rather than whole IgG, on the solid-phase was to provide direct evidence for the IgG4 reactivity of the antiglobulin. Bound IgM was shown to be antiglobulin in that binding can be inhibited by pre-absorption of serum with IgG. Some 75% of asthmatic patients and 29% of eczema patients were found to have significantly raised level of IgM antiglobulin. This antiglobulin resembles rheumatoid factor in that it appears to be directed against antigenic determinants common to human and rabbit IgG. Isolated antiglobulin-enriched IgM fractions released histamine from leucocytes of 7 out of 12 atopic patients. The histamine-releasing capacity of the IgM antiglobulin was shown to be operating via basophil-bound IgG in that the process can be blocked by pre-absorption of the antiglobulin with IgG. Furthermore, heating the antiglobulin-enriched IgM fraction did not affect its histamine-releasing capacity. We conclude that the IgM antiglobulin detectable in our atopic patients may contribute to the pathological changes in them.

IgE and IgG4 antibodies to bovine milk fat globule membrane in atopic eczema patients: a study of their occurrence, relevance and antigenic specificity.

IgE and IgG4 antibodies to bovine milk fat globule membrane (FGM) were measured in atopic eczema patients to determine whether their presence would account for allergy to milk in cases where whole or individual milk protein-specific antibodies are not detectable. The study demonstrates that the measurements of IgE and IgG4 antibodies to FGM do not offer any additional diagnostic value in milk exacerbated cases of atopic eczema. Furthermore, cross-inhibition studies with four milk proteins showed that these FGM-reactive IgE and IgG4 antibodies are directed against alpha-casein.

The effect of oxygen inhalation and intravenous naftidrofuryl on the transcutaneous partial oxygen pressure in ischaemic lower limbs.

The effect of oxygen inhalation at atmospheric pressure and Naftidrofuryl infusion (N) on the TCpO2 is shown. At the central control site--5 cm below the midclavicular line--oxygen inhalation produced a significant increase in TCpO2, whereas there was no change after Naftidrofuryl infusion. At the 10 cm below-knee site, there were significant rises after oxygen inhalation alone, Naftidrofuryl alone and both combined. The study was conducted on 20 patients (23 legs). It is suggested that this study can form the basis for a regimen to improve the viability of ischaemic limbs showing borderline TCpO2 readings, and increase the chances of a successful below-knee amputation.

Relationship between serum levels of total and milk- and egg-specific IgG4 and the expression of G2m(n) in atopic eczema patients.

The percentage incidence of G2m(n) in a group of atopic eczema patients was found to be within the range quoted for normal Caucasian populations. Interestingly, however, grossly elevated serum levels of total and milk- and egg-specific IgG4 occurred much more frequently in the G2m(n)-positive group than in the G2m(n)-negative group.

The place of amputation in the management of the ischaemic lower limb in the dysvascular geriatric patient.

Statistics show that today the majority of amputations of the leg are peripheral vascular disease in patients over the age of 60. The stages of management are discussed and in particular a plea made for taking a balanced view of vascular salvage procedure and amputation as alternative treatments. The advantages are stressed for these patients to be treated in a unit where the resources for appropriate investigation are available and the surgeon has the support of a multi-disciplinary team. The importance of the pre- and post-amputation rehabilitation programme is discussed.

The early rehabilitation of lower limb amputees using a pneumatic walking aid.

A pneumatic walking training aid for amputees is described. It was developed by the late Biomechanical Research and Development Unit, Roehampton, from an original design by Professor Little in Australia. The walking aid has been used successfully on the majority of below-knee and through-knee patients rehabilitated in the Roehampton Walking Training School since 1976. There have been no complications that could be attributed to the use of the pneumatic walking aid.

Transcutaneous partial oxygen pressure assessment of the ischemic lower limb.

As a result of these studies, it can be concluded that the TCpO2 is a reliable indicator of the state of perfusion of the skin in both the healthy and ischemic legs and can be used to predict the healing potential if amputation is performed. The most meaningful reading is obtained at 10 centimeters below knee anteriorly. The critical value is approximately 35 millimeters of mercury, since the pO2 value for below-knee amputations performed upon most patients with a 10 centimeter below knee amputation was less than this, further surgical treatment was required, while all patients with values above this underwent successful amputation. Determination of the 10 centimeter below knee-control site ratio does not appear to provide any further advantage over the absolute 10 centimeter below knee site value. However, the control site measurement should be taken to eliminate central circulatory failure. The technique can be easily undertaken by hospital technicians or regular nursing or junior medical staff. A site reading requires an average of 35 minutes. The capital outlay is well within the capability of an average general hospital, and the running costs are negligible.

Total surface bearing self suspending above-knee sockets.

A new type of above-knee socket has been designed to provide total surface support and to dispense with ischial bearing as the primary weight bearing area. The socket is based upon the hypothesis that if the soft tissues of an above-knee stump are adequately supported in a suitably shaped container they will behave under load as an elastic solid with low stiffness. A method has been devised for taking the cast for the new type socket using an elastic sleeve as a "compliant socket". The grip of the elastic sleeve and the use of traction weights deform the stump tissues to the required shape while the cast is setting. The results of laboratory measurements of the transinterface pressures in these sockets under axial loading conditions have correlated well with the figures forecast by calculation. The new socket is now available to patients at a number of Centres in England.

A new approach to the management of wounds of the extremities. Controlled environment treatment and its derivatives.

Controlled Environment Treatment is a new approach to wound management--for the first time it provides the surgeon with the means of controlling and optimizing the wound environment for the duration of the healing period. Equipment is commercially available and the technique is now being applied internationally; the technique has been established for the treatment of limbs--application to the trunk requires further investigation and development. Spin-offs have already occurred, one being the control of certain types of lymphoedema by the patient in their own home; the other concerns the application of plaster of Paris to produce casts having significantly superior physiological characteristics using minimal manipulative skills. The former is known as Pressure Environment Treatment, the latter is known as Controlled Pressure Casting; equipment is commercially available internationally.

Post-amputation pneumatic walking aid.

A pneumatic walking training aid is described that has been developed by the Biomechanical Research and Development Unit, Roehampton, from the original design by Little. The new design has been used in the management of 87 amputations, including 44 patients over the age of 70. Ninety-four per cent of these patients were rehabilitated to walking independently on a pylon or prosthesis.