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Rheumatoid arthritis (RA) is an autoimmune disease whose diagnosis was long based solely upon the demonstration of rheumatoid factors (RF) which are IgM antibodies with anti-IgG specificity. The development of modern techniques which are more sensitive and/or detect non-IgM rheumatoid factors has reduced the percentage of presumptive seronegative RA. Immunological studies of the disease also reveal other evidences of polyclonal B-lymphocyte activation: hypergammaglobulinemia, high levels of beta-2-microglobulin and circulating immune complexes, presence of various autoantibodies (anti-collagen, antilymphocyte and, in some instances, anti-nuclear antibodies). These anomalies are found, not only in the blood, but above all in the synovial fluid, which explains the low synovial complement level. The disturbances of cellular immunity cannot yet be used for diagnostic purposes, but suggest that the physiopathologic mechanism of RA involves a decreased T-suppressor lymphocyte activity and/or B-cell unresponsiveness to suppressor influences.

222 consecutive and unselected patients suffering form classical or definite rheumatoid arthritis wee studied. 397 of their feet were examined. Talonavicular arthritis was the commonest finding (31.5% of all patients), followed by sub-talar (23.3%), cuneo-navicular (20.4%) cuneo-metatarsal (14.9%) and tibio-tarsal arthritis (12.6%). Rheumatoid disease of the tarsus becomes commoner as the disease progresses. The incidences of involvement of the talo-navicular and sub-talar joints show a similar pattern, with a leap of 25% between 5 years of duration of the disease and 10 years. The same is seen with involvement of the cuneo-navicular and cuneo-metatarsal joints, between a duration of 10 years of the disease and 15 years. The percentage of flat foot is greater in feet with tarsal arthritis (p less than 0.001). The authors observed a relationship between tarsal arthritis, the length of history of rheumatoid arthritis, and flat foot. The method of investigation is discussed, and theories about evolution of the rheumatoid foot are considered.

In a study on the frequency of the HLA A, B, C and DR antigens seen in 100 controls and 31 patients with rheumatoid arthritis, the authors found a significant increase in the DR4 antigen in rheumatoid arthritis. (50% as against 25%; X2 = 8,5; 0,04 greater than Pc greater than 0,008; RR = 3,43). The other antigens on loci A, B. C and DR are not altered significantly. However the increase in DR4 which does not seem to be related to the severity of the rheumatoid arthritis, seems to be proportional to the level of rheumatoid factor. The authors review literature on HLA in rheumatoid arthritis and the figures for the antigenic frequency of HLA-DR4 are compared with their own results. The findings are of interest especially from a pathogenic point of view.

Twenty patients with classical or proved rheumatoid arthritis were treated with Isoprinosine. 13 patients received a dose of 25 mg/kg/day and 7 received a dose of 50 mg/kg/day, continuously for 2 months and then discontinuously, 5 days every fortnight. The series being treated with 25 mg/kg/day (7 patients) have received treatment for 12 months. No side effects have been observed; the only reason for ceasing treatment was its ineffectiveness (after at least 3 months of administration). The dosage of the associated anti-inflammatory drugs did not need to be increased, but neither was it decreased. The authors conclude that Isoprinosine is largely ineffective clinically, on laboratory tests and in terms of immunology, at least with the therapeutic protocols tested here.

The authors report their experience in the treatment of metatarsophalangeal arthritis of chronic inflammatory rheumatism by Erbium 169 synoviortheses (112 joints treated) and by infiltrations of triamcinolone hexacetonide (53 joints treated). The steroid appears to have a marked early superiority as it gives 85% good results compared to 61.6% for Erbium 169 after a period of one to three months. However, its results then deteriorate more rapidly and after 6 months, the proportion of good results is greater with the radioactive treatment (64% compared to 46.7%). The authors consider it reasonable to use triamcinolone hexacetonide as the first line treatment as it is easier to manage and less expensive, reserving the radioactive synoviortheses for later with the prospect of more lasting results.

Flow-cytometry studies of DNA and RNA content were carried out in acridine orange-stained synovial fluid lymphocytes from 11 patients presenting with classical or definite rheumatoid arthritis. Monoclonal antibodies were used to detect specific T cell surface antigens (OKT3, OKT4, OKT8) and antigens associated with lymphocyte activation (OKIa 1, OKT10). T3 positive cell percentages were comparable to those of normal blood, although T4/T8 ratios were decreased in 4 out of 5 cases, and HLA-DR positive cells increased. Six out of 11 patients showed percentages of dividing cells varying from 2.2 to 7.2% as compared with less than 1% in the other patients and in normal blood. Nondividing cells were characterised by an increase in their RNA content compared with normal blood. A greater increase of RNA content was observed in patients with lower percentages of dividing cells, suggesting a G1/S block. Changes in cellular DNA and/or RNA contents provide a valuable parameter of lymphocyte activation, not necessarily linked to the expression of differentiation antigens by activated cells.

Synovial fluid lymphocytes were studied by cytofluorometry in 11 patients with classical or definite rheumatoid arthritis. This method allowed the study of the cellular cycle after acridine orange staining and of membrane antigens, expressed by normal and/or activated lymphocytes, which were demonstrated by using various monoclonal antibodies (OKT3, OKT4, OKT8, OKIa1, OKT10). The OKT4/OKT8 ratio was decreased in 4 out of 5 cases and the percentage of HLA DR + cells was clearly increased. In 6 out of the 11 patients, the percentage of dividing cells varied from 2.2 to 7.2 and was less than 1 in the others as in normal blood lymphocytes. Increase in cellular RNA content characterized the non dividing cells. The most elevated values of the cellular RNA content were observed in patients who had the smallest percentage of dividing cells, suggesting that the cellular cycle was stopped between the G1 and S phases. Study of the cellular cycle may reveal a lymphocyte activation parameter which could be unrelated to the expression of differentiation membrane antigens.