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To assess the impact of their illness on their whole life experience 345 patients with chronic arthritis were interviewed and completed a questionnaire. Four major sub-groups were identified--rheumatoid arthritis, gout, ankylosing spondylitis and osteo-arthritis. Taking into account definite inter-group differences, the commonest problems were pain (65%), stiffness (61%), inability to do everyday tasks (43%) and sexual difficulties (31%). The implications these problems raise in clinical practice are discussed and some suggestions for a rehabilitation programme made.

The nutritional status was assessed in a group of 220 patients with rheumatoid arthritis from three communities (coloured 89 patients, white 88 and black 43). The triceps skinfold (TSF) thickness, upper arm muscle circumference (UAMC), body mass index (BMI) and percentage of ideal body weight (% IBW) were measured and the serum albumin value determined. The mean age of the coloured patients was 49.8 years, white 57.7 years and black 44.8 years. Forty-five patients (20.5%) had a reduction of one or more anthropometric measurements (TSF, UAMC and/or %IBW) and a further 6 patients (2.7%) had a reduction of the serum albumin value alone. These 51 patients were considered to be malnourished and had a higher mean erythrocyte sedimentation rate and more severe functional disability than the remainder of the patients. The prevalence of malnutrition was lower if diagnosed only on abnormality of the TSF, UAMC and %IBW, since 25 patients (11.4%) had a reduction of only one measurement, 12 (5.5%) had a reduction of 2 and 8 (3.6%) had a reduction of all three measurements. Obesity (BMI greater than 30) was noted in 10.5% and there were no differences in the functional disability, disease activity and use of steroid therapy in the obese patients compared with the rest of the patients.

The records of 52 patients with amyloidosis admitted to Groote Schuur Hospital, Cape Town, between January 1969 and August 1982 were analysed. The male: female ratio was 1,3:1 and the mean age was 49,3 years. Forty-eight per cent of the patients had secondary amyloidosis, 21% had primary amyloidosis, 11,5% had localized amyloidosis and 11,5% had amyloidosis associated with multiple myeloma. Tuberculosis, chronic pulmonary sepsis and other chronic infections were present in 88% and rheumatoid arthritis in 16% of the patients with secondary amyloidosis. The commonest features at diagnosis were proteinuria (70%), oedema (52%) and hepatomegaly (39%). The diagnosis of amyloidosis was established by renal, liver and rectal biopsy (either singly or in combination) in 82% of cases. The prevalence of amyloidosis at autopsy was 0,28%.

Of 36 patients with systemic lupus erythematosus, 3 were demonstrated to have an abnormality in their haemostatic mechanism. In 2 this was believed to be on the basis of an auto-antibody to the phospholipid of platelets in the prothrombin activator complex. In the third an inhibitor was directed against factor VIII.

Ninety-two females with gout are reported. The preliminary ARA criteria for acute gout classified 60% of the patients. Forty patients were diagnosed by finding tophi or urate crystals in the synovial fluid, 16 patients had the ARA clinical criteria for gout, and a further 36 patients were considered to have good clinical grounds for gouty arthritis. Classification of the patients was difficult. A subacute pauci-/polyarthritis was the presenting feature in 64 (70%) patients and in 49 (77%) there was no history of a preceding recurrent monoarthritis. Seventy-two patients (78%) were on diuretics. Tophi were usually indolent and showed little surrounding inflammation. 87% of the patients had an associated disease.

This is a clinical description of an unusual arthropathy in 2 members of a family with familial cold urticaria. Relevant investigations, X-ray illustrations and the family pedigree are presented. The nature of the arthropathy and its possible relationship to other arthropathies is discussed.

The occurrence of cholesterol-rich synovial fluids in 2 patients with rheumatoid arthritis is described. These fluids are rare, and are readily mistaken for pus. Their origins are discussed in relation to chronic inflammation.

We report seven cases of patients with seropositive rheumatoid arthritis in whom involvement of the thoracic and lumbar vertebrae occurred. Histological corroboration is presented in four. Pathological lesions comprised various combinations of paravertebral joint erosions, erosive discitis, anteroposterior and rotatory instability, major lumbar nerve root compression, and vertebral collapse. Specific radiological features are presented, enabling a distinction to be made between pure degenerative spondylosis and rheumatoid spondylitis. We submit that subcervical rheumatoid spondylitis is commoner than is generally believed, though less common than rheumatoid involvement of the cervical spine.

Twenty-two patients with active rheumatoid arthritis were entered into a trial during which an oral gold formulation was administered at two dosages (4 mg/d and 6 mg/d) for 12 weeks. Seventeen patients completed the trial. Both dosages produced a similar improvement in the indices of inflammation. Five patients were not benefited by the treatment, adverse side-effects were reported in 10 and 5 were withdrawn from the trial.

During the period 1976-1983, 67 patients with rheumatoid arthritis attending the arthritis clinics at Groote Schuur Hospital and Princess Alice Orthopaedic Hospital, Cape Town, were treated with penicillamine. The information obtained from a retrospective study showed that 47 patients (70,15%) gained some benefit from the therapy, and that 28 (41,79%) went into complete remission; 36 (53,73%) developed side-effects which resulted in termination of therapy in 24 (35,82%). Urinary abnormalities were the commonest side-effect (28,36%), the relatively infrequently described haematuria being the most frequent. Seven patients failed to respond to therapy.

A patient with primary Sjögren's syndrome and a previous history of systemic vasculitis is presented to document neurological disease which suggests involvement of the brainstem and cerebellar connections with neuropsychiatric manifestations. The investigations and management are briefly outlined.

Our survey was undertaken to determine the prevalence of resorptive arthropathy in rheumatoid arthritis (RA). A group of 256 patients with classical or definite RA were studied and resorptive arthropathy was noted in 13 (5.1%). The age and sex ratio of the patients with resorptive arthropathy was similar to the remainder of the patients, but the duration of RA was significantly greater (p = 0.003). Patients with resorptive arthropathy had severe radiographic changes. There was no significant difference in the prevalence of nodules, a positive rheumatoid factor or antinuclear factor and functional classification (American Rheumatism Association) in patients with resorptive arthropathy when compared to the remainder of the patients. Our study shows that, in a hospital based study of patients with RA, resorptive arthropathy may be commoner than generally recognized, and its prevalence may be similar to the findings in psoriatic arthritis.

Radiogrammetry remains a convenient method of bone mass measurement. It is the only objective means of quantifying metacarpal osteoporosis (OP) in rheumatoid arthritis (RA). An automated technique using a digitizer (interfaced with an IBM PC) for measurement of combined cortical width (CCW) at the mid-shaft of six metacarpals was evaluated in three groups of individuals under 50 years of age (98 normal controls, 96 RA, 63 SLE). Intra-observer, inter-observer, and inter-institution reproducibility was assessed with a 'phantom' embedded in a rectangular mould of wax. Intra-patient variation was also assessed in RA patients seen on two occasions less than a month apart. Two hundred and fifty-seven subjects were studied. The method was found to be reproducible for a single observer, among five different observers and in two separate institutions. The RA subjects seen on two occasions showed no significant differences in CCW. The technique showed significant differences of CCW in the three groups of premenopausal subjects (controls; RA; SLE) studied (p less than 0.001). The six metacarpal bone mass was calculated in less than 5 min. The technique of digitized radiogrammetry is an improvement on the Vernier caliper technique. The method is useful for epidemiological cross-sectional studies and for evaluation of long-term radiological changes in RA.

The clinical features of gout in men and women are compared in a retrospective study of hospital patients and outpatients attending an arthritis clinic. Men had a readily recognized pattern of disease in terms of age of onset, duration of disease, and tophaceous gout. Recurrent mono-arthritis of the big toe metatarsophalangeal joint culminating in tophaceous polyarticular gout after many years was a stereotyped pattern. In women, polyarticular/tophaceous disease was often the first manifestation of gout, and a preceding recurrent mono-arthritis was found in joints other than the big toe. The duration of disease before tophi appeared was shorter. The use of diuretics was commonplace, and associated disease such as hypertension or chronic renal failure is frequent in women.

The population of Southern Africa is currently estimated at least 40 million and comprises people of 3 major--groups Negroid, Khoisan and Caucasoid. In addition to these, there are also smaller groups whose origin is Asiatic or Oriental, and a mixed group (coloured) which has resulted from the miscegenation between the Negroid-Caucasoid and other groups [1]. This great diversity of peoples and cultures permits unique opportunities for studies in comparative medicine which may provide valuable information about the pathogenesis and natural history of disease. The rheumatic diseases have not been looked at in this comparative way until recently. This is, in part, because the demands of infective and nutritional diseases on medical services have tended to overshadow the rheumatic diseases. This paper reviews the investigation of inflammatory rheumatic disease in Southern Africa.

During the period 1971-1979, 114 patients with rheumatoid arthritis attending the arthritis clinics at Groote Schuur Hospital and Princess Alice Orthopaedic Hospital were treated with gold sodium aurothiomalate (Myocrisin). Data obtained from 104 completed protocols showed that 70 patients (67,3%) benefited from chrysotherapy. Forty of these patients went into complete remission. Therapy was discontinued in 58 patients, side-effects accounting for this in 33 cases (31,8%). Adverse reactions included skin rashes in 41 (39%) and renal complications in 16 (14%); 7 (6%) developed haematological complications, which resulted in death in 2 cases. HLA tissue typing in 37 patients with side-effects showed no increase in the HLA Dw2 or HLA Dw3 antigen. There was, however, a significant increase in the HLA DRw4 antigen in both Whites and Coloureds (P less than or equal to 0,008 and P less than or equal to 0,001 respectively).

This study was designed to investigate further the hyperglobulinaemia which followed portal or splenic venous diversion but not mesenteric venous diversion. It was observed that levels of IgG and IgM were elevated from 3-6 weeks after portacaval shunt, portacaval transposition or splenacaval shunt. IgA levels were increased after all forms of portal venous diversions including after mesentericocaval shunt. The failure of levels of IgG and IgM to rise after mesocaval shunting suggests that some component of splenic venous blood may regulate the ability of the reticulo-endothelial system of the liver to respond to antigenic influences.

Seven patients with severe rheumatic heart disease and joint deformities, in whom there were no signs of active arthritis, are described. The fulfill the criteria for the diagnosis of Jaccoud's arthropathy (or 'chronic post-rheumatic arthritis'). We postulate that hypermobility may be a predisposing factor in the development of the deformity. This rare condition should be distinguished from rheumatoid arthritis because of its relatively favourable prognosis.

A double-blind crossover, within-patient trial was conducted, to compare the efficacy of tolmetin (Tolectin; Ethnor) with that of aspirin in the treatment of rheumatoid arthritis. Tolmetin significantly improved morning stiffness (P less than 0.01), while aspirin was superior in reducing the number of painful joints (P less than 0.001) and the articular index (P less than 0.01). Tolmetin, in marked contrast to aspirin, was well tolerated, producing virtually no side-effects. An elevation of the alkaline phosphatase was noted in 4 patients on tolmetin therapy. When used after aspirin, tolmetin had a significantly adverse effect on the erythrocyte sedimentation rate (P less than 0.05). The results of this study indicate that tolmetin is a useful addition to the therapeutic agents for the treatment of rheumatoid arthritis, because of its ability to reduce morning stiffness and its lack of side-effects.

An open comparative study of 26 patients on auranofin (AF) and 26 patients on gold sodium thiomalate (GSTM) was undertaken. The GSTM patients responded more rapidly and there were more clinical remissions. The changes produced by AF were slower in onset. AF produced no significant changes in the erythrocyte sedimentation rate or C-reactive protein but it did reduce rheumatoid factor titers. Both AF and GSTM produced a temporary retardation of the radiological progression. Side effects occurred more frequently on GSTM and more patients had to be withdrawn from the trial.

The effect of sodium salicylate on peripheral blood leucocyte migration is described. At a concentration of 3,5 mmol/ml, no effect on leucocyte migration was seen, but this concentration appears to influence the leucocyte migration in the presence of specific antigen, either by increasing or by decreasing leucocyte migration inhibition.

A clinical and echocardiographic study was carried out in a randomly selected group of 101 patients with rheumatoid arthritis to determine the prevalence of cardiac abnormalities. Adequate two-dimensional assessments were obtained in 84 patients and 77 patients had adequate M mode recordings. Thirty-one patients (37 per cent) had 45 echocardiographic abnormalities. Five patients (6 per cent) had a pericardial effusion. Eleven abnormalities of the mitral valve were noted in 10 patients (13 per cent). Three patients had mitral valve prolapse, one patient with aortic incompetence had flutter on the mitral valve, five patients had mitral annular calcium and one patient had hypertrophic obstructive cardiomyopathy and mitral annular calcification. A reduction in the E-F slope was noted in 12 patients, seven of whom had associated cardiac disease, one patient had a sinus tachycardia and four patients (5 per cent) had a mild reduction without any other cardiac abnormality. Apart from the presence of pericardial effusion in 6 per cent and minor abnormalities of the E-F slope in 5 per cent of patients, all the other significant echocardiographic abnormalities could be related to the presence of associated cardiac disease.

The prevalence of rheumatic disease in subjects over 65 years of age was measured in a rural and an urban population in the Western Cape by means of a questionnaire and a clinical/radiological investigation. The completion rates were 88% and 85% for the rural and the urban groups respectively. Recall of previous arthritis/backache and shoulder pain/shoulder disease and osteo-arthrosis was more frequent in the urban population, and osteoporosis occurred with equal frequency in both populations. The relevance of these findings is discussed in terms of their actual and potential impact on the treatment of elderly persons.

Overt pulmonary hypertension in systemic lupus erythematosus (SLE) is rarely reported. We have documented 4 such patients, all of whom had severe extrapulmonary manifestations of the disease and also Raynaud's phenomenon. The relationship between Raynaud's phenomenon and pulmonary hypertension in SLE is borne out by a review of the literature. A common vasospastic aetiology is suggested.

The association between rheumatoid arthritis and HLA was studied in three South African populations: whites (N = 66), blacks (N = 33) and patients of mixed ancestry (Cape Coloureds) (N = 183). The antigens of the HLA-A, B, C, DR and DQ loci were detected by microlymphocytotoxicity assay and their frequencies in the three patient groups were compared with the corresponding frequencies in normal individuals of the same population group. HLA-DR4 was significantly associated with rheumatoid arthritis in whites (P less than 0.0001), blacks (P less than 0.001) and patients of mixed ancestry (P less than 10(-6]. The relative risk for HLA-DR4 was 3,2 in whites, 3,9 in blacks and 3,7 in patients of mixed ancestry. Other significant associations detected were with HLA-A2 in whites and HLA-B8 and DQw3 in patients of mixed ancestry. The constant association with HLA-DR4 seen in the different populations provides support for the suggestion that the HLA genes themselves are responsible for the genetic susceptibility to rheumatoid arthritis.

In previous studies of rats with portacaval shunts, elevated gamma-globulin levels 2 weeks after shunt were attributed to antibodies to bacterial lipopolysaccharide, which were normally filtered by the liver. This study was designed to determine the tempo of this rise and the magnitude of hepatocellular damage within the first 4 days of the operation. Acute reversible hepatocellular damage was shown by elevated levels of aspartate aminotransferase which returned to normal within 48 hours. This was confirmed on histology. There was no rise in gamma-globulin during this study but levels of albumin were better maintained in shunted rats than in sham-operated rats. Levels of alpha2 and beta-globulin in the former fell in comparison with the latter animals.

A Xhosa father and daughter with ankylosing spondylitis are reported. Review of the literature revealed a low incidence of ankylosing spondylitis in Blacks in general, with only isolated reports from the continent of Africa itself. To our knowledge, there has been no documentation of ankylosing spondylitis in a black female, or of ankylosing spondylitis in first-degree Black relatives. The clinical features of ankylosing spondylitis in the female, and the role of human leucocyte antigen (HLA) B27 in the disease are also discussed.

One hundred and two patients with either rheumatoid arthritis or osteo-arthrosis were treated for prolonged periods with diclophenac sodium (Voltaren; Geigy) to evaluate the efficacy and tolerability of the drug. Fifty-seven patients completed a trial of 12 months. A total of 70% showed an improvement in functional class, and 40% of the total had complete functional capacity by the end of the trial. The drug was well tolerated. The side-effects (heartburn, abdominal cramps, headache and dizziness) were mild and in most cases did not require cessation of treatment. In 9 patients the Coombs test became positive during the trial, but this did not require cessation of therapy.