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Sulindac (400 mg/day) has been compared with ibuprofen (1200 mg/day) in 40 patients with osteoarthrosis of the hip, over an eight-week period, in a double-blind controlled clinical trial. The two drugs were comparable in terms of patient preference, effects on hip movements, and toxicity. Sulindac showed superior analgesic properties to ibuprofen, resulting in a significantly greater reduction in pain on weight-bearing and with passive movements (P less than 0.01).

The value of epidural injections of corticosteroid as an outpatient treatment of sciatica has been hitherto uncertain. An epidural injection of 80 mg methylprednisolone in 10 ml physiological saline was compared with an interspinous injection of 2 ml physiological saline in a double blind fashion amongst 39 outpatients. Significant differences of pain relief were seen between the two groups within 2 weeks. This benefit disappeared for six (35%) patients within 6 months of treatment although 11 (65%) successfully treated subjects had sustained improvement up to this time. Outpatient epidural injections of corticosteroid are thus a useful short-term means of relieving pain in sciatica but probably have little effect on the long-term natural history of symptoms. Factors associated with a failure to respond to epidural steroid injections are discussed.

Forty-seven patients with active rheumatoid arthritis took part in an 8-week controlled study in which clotrimazole was compared with a standard nonsteroidal anti-inflammatory agent, ketoprofen. Although clotrimazole was shown to be effective in the treatment of the disease and superior to ketoprofen in certain measurements, if was also responsible for a high incidence of adverse effects. Improvement with clotrimazole took place more slowly but was more sustained than with ketoprofen. A significant rise in plasma cortisol and a fall in white cell count was observed in the clotrimazole treated patients.

In this paper we report the use of the technetium-99m diphosphonate bone scan in the diagnosis and management of traumatic bone lesions in the ballet dancer's foot. Nine illustrative case histories are given. We conclude that this is a useful technique particularly in the recognition of stress lesions not identified by conventional radiography.

A survey of joint mobility was conducted in 295 healthy children between the ages of 5 and 10 years who attended a London primary school. Estimates of the commonly used measurements, that is passive dorsiflexion of the wirsts and ankles, passive hypertension of the elbows and knee, were too insensitive to detect any age effect. However, a method of estimating extensibility of the 5th metacarpophalangeal joint in response to a standard load detected a highly significant inverse correlation between joint mobility and age in the samples significant inverse correlation between joint mobility and age in the samples tested ( r = -0.586; P less than 0.0001). There was no apparement sex difference. Skinfold thickness using the Harpenden caliper over the 3rd metacarpal bone and the in vivo skin elasticity measured using a suction cup device performed on a sample of 78 of the children revealed no influence of either age or sex on these parameters. This is in sharp contradistinction to the effect of both age and sex in these two parameters in adults...

A double-blind cross-over study of cyclofenil and placebo treatments was conducted in 11 scleroderma patients. Each treatment period was for four months. A range of subjective and objective measurements failed to reveal any consistent or obvious response to cyclofenil. One patient died of his disease during active treatment. Four were withdrawn because of liver dysfunction which was attributed to cyclofenil. It remains to be seen whether treatment over longer periods will exert a clinically significant effect.

SummaryAlthough patient counselling has become a well-established practice in a number of areas of medicine, it has been neglected to a large extent by rheumatologists. The current concept of patient counselling is reviewed and ways are suggested in which the principles may be usefully applied by doctors and other health workers to improve the quality of care for patients with rheumatic diseases.

In this report we present 21 instances in which live rubella virus was isolated from synovial fluid obtained from 6 cases of inflammatory oligoarthritis or polyarthritis over a period of 2 years in the absence of firm clinical evidence of rubella. In 3 cases (cases 1, 2, 6,) a persistent oligoarthritis predominantly affecting the knee joints occurred in 2 adult women and one man, lasting to date 27, 29, and 18 months respectively, and in one of these cases virions were found in cells of the synovial membrane. In case 3 a boy of 9 presented with an illness indistinguishable from the systemic variety of juvenile chronic arthritis (Still's disease). In case 4 a young man with persistent monoarthritis was found to have ankylosing spondylitis, and in case 5 a progressive erosive polyarthritis developed 5 years after an attack of rubella complicated by rubella arthritis. The virus was identified by a variety of virological techniques and infection confirmed by immunofluorescence and (in one case) electron microscopy.

A case control study of 50 rheumatoid factor positive (RA+) and 50 rheumatoid factor negative (RA-) patients with rheumatoid arthritis has been carried out. As expected, the RA+ group has significantly more nodules and vasculitis. In terms of clinical joint involvement, the RA- had large-joint involvement. Radiologically, seropositive disease was characterized by more severe involvement of the metacarpophalangeal joints of the thumb and index fingers and in all the metatarsophalangeal joints of the feet. There was no difference either clinically or radiologically between the two groups in terms of symmetry of joint disease or wrist involvement. Of special interest was the finding that the prevalence of HLA-DR4 was elevated to the same degree in both groups but that genetic markers for ankylosing spondylitis and for psoriasis (HLA-B27 and Cw6 respectively) were similar in both groups and not increased above control population levels. It is concluded that the entity defined as RA includes patients with and without rheumatoid factor (RF) in their serum and that this determines differences in disease expression. Whether these differences are the consequences or the cause of RF cannot be concluded on the basis of this study.

A double-blind cross-over study is being undertaken in fifty patients with "definite" rheumatoid arthritis, comparing ketoprofen (2-(3-phenylbenzoyl proprionic acid) 75 mg daily orally and 100 mg suppository at night with indomethacin in the same dosage. A pilot study of twenty-four patients has been completed, fifteen having finished the trial. The objective assessment of grip strength and articular index were comparable with the two drugs, but subjective assessment showed that relief of early morning stiffness was better with indomethacin, although pain relief was no different. Evidence so far available shows that ketoprofen is a useful anti-inflammatory analgesic drug which is well tolerated and that the use of a suppository may be helpful in a few patients who find the oral route unacceptable. A larger study is necessary to evaluate finally the use of a combined administration.

Feprazone, a new anti-inflammatory drug, is a useful antirheumatic preparation which causes little gastrointestinal upset. This short cross-over study shows no significant gastrointestinal blood loss with either feprazone or phenylbutazone by the red-cell chromium-51 labelling method.

Discussion sur la reponse de ce systeme de soins vieux de plus de 40 ans. Necessite de le modifier en tenant compte de l'experience passee. Expression des inquietudes concernant les patients souffrant de rhumatismes inflammatoires chroniques sous la forme de 12 questions

Four cases of the triad of rheumatoid lung disease, spontaneous pneumothorax, and peripheral blood eosinophilia are reported. Cavitation of a rheumatoid lung nodule caused the pneumothorax in at least 1 case. The significance of eosinophilia and its value as a marker of extra-articular manifestations of rheumatoid disease are discussed.

Fifty-nine patients were entered into a double-blind, parallel comparison of the efficacy and side-effects of naproxen sodium (825 mg daily) and indomethacin (100 mg daily) in the treatment of periarthritis of the shoulder joint. Assessments were made on entry to the study, at two weeks, and at the end of four weeks when objective and subjective recordings of mobility, loss of function, pain and the presence of absence of side-effects were noted. The two treatment groups were found to be matched for age, sex and duration of disease, and an assessment at the start of the study differed only in respect of the degree of active medial rotation of the shoulder joint and pain. There was an overall improvement from the time of admission to the study in both the naproxen sodium and the indomethacin treatment groups but there was no significant difference between the efficacy of the two groups. One patient from the naproxen sodium group and three patients from the indomethacin group withdrew from the trial because of side-effects which in each case involved the gastro-intestinal tract.

The familial undifferentiated hypermobility syndromes are a heterogeneous group of disorders in which generalised joint laxity is the primary clinical manifestation. The Ehlers-Danlos syndrome (EDS) (Chap. 9) and other rare genetic conditions (Chap. 11) which have additional non-articular stigmata are excluded from this category.

The term hypermobility syndrome (HMS) was coined to denote the presence of rheumatic symptoms with generalised joint laxity, in the absence of any demonstrable systemic rheumatic disease (Kirk et al. 1967). Of 9275 consecutive patients attending the rheumatology clinic at Guy’s Hospital, 2% were diagnosed as suffering from HMS. Of these, 85% were female (see Chap. 6). A similar prevalence (1.7%) has been seen among 690 new referrals to a paediatric rheumatology centre (Ansell 1972).

A double-blind cross-over trial of Prenazone 600 mg and Aspirin 4 g daily was carried out on 20 patients suffering with rheumatoid arthritis. The analgesic and anti-inflammmatory activity was indistinguishable from that of aspirin under the conditions of the trail. Twelve patients expressed a general preference for Prenazone and six for aspirin. Prenazone appeared to be well tolerated and free from serious side-effects. These results suggest that it will be a useful drug in the management of rheumatoid arthritis.

In vivo skin elasticity was measured on unaffected forearm skin of twenty-five patients with pseudo-xanthoma elasticum and compared with age and sex-matched controls. The elastic modulus was raised in the recessive type I group and reduced in the dominant types I and II groups. No significant difference in skin thickness was found.

A cytopathic agent indistinguishable from rubella virus was isolated from the synovial fluid of five patients (two male and three female). In two patients isolations were made on two separate occasions, and in two others on five separate occasions. The patients ranged in age from 9-58 years, and they presented with a variety of clinical syndromes. In particular, none had clinical features suggestive of recent rubella infection; but most cases had very high serum rubella haemagglutination inhibition titres. The identity of the cytopathic agent was shown by a variety of virological techniques to be rubella virus.

The possible aetiology of joint hypermobility has become complicated in recent years. At one time a facile explanation sufficed; joint hyperlaxity, presumably related in some way to collagen structure, was regarded as an inherited abnormality explicable in terms of a simple, but at that stage undetermined, alteration in conventional collagen structure. However, in the last few years our understanding of hyperlaxity has increased considerably (Bird 1982), and any discussion on possible alteration of structure in hyperlax joints has to take into account the following observations: 1) The range of movement at a joint depends on several aetiological factors including the shape of the bone and cartilage (e.g. acetabular dysplasia), muscular power and tone and the laxity of the ligaments and joint capsule; 2) For any single joint, movements vary in Gaussian fashion throughout a population (Wood 1971); 3) There is probably ethnic variation; 4) Some individuals with hyperlax joints have connective tissue changes at other sites in the body which lead, for example, to floppy heart valves (Grahame et al. 1981); 5) An increasing number of discrete disorders of connective tissue such as the Ehlers-Danlos (EDS) and Marfan syndromes have been recognised. There is considerable overlap of variants of some of these conditions with familial undifferentiated joint hypermobility (Beighton et al. 1969; Walker et al. 1969)

A double-blind within-patient trial in rheumatoid arthritis comparing the new anti-inflammatory drug benoxaprofen with naproxen is reported. Patients received naproxen 250 mg b.d. for two weeks and benoxaprofen 200 mg b.d. for three weeks. Both drugs demonstrated efficacy. There was no statistically significant difference between them, except for grip strength which favoured naproxen. Side-effects were mild, infrequent and similar for both drugs. Evidence is presented which confirms the long duration of action of benoxaprofen, a fact which may be of clinical significance.

Rheumatoid arthritis and primary hyperparathyroidism have been diagnosed in three patients. This is likely to represent the coincidence of two common diseases but the clinical features are discussed with particular reference to the presence and withdrawal of raised levels of circulating parathyroid hormone (PTH). It is argued that raised levels of PTH potentiate the effects of the rheumatoid disease on bone and joints. Other musculoskeletal features of hyperparathyroidism and the actions of PTH on bone are reviewed.

The Ehlers—Danlos syndrome (EDS) is an inherited disorder of connective tissue which is characterised by the clinical triad of articular hypermobility, dermal extensibility and cutaneous scarring. The manifestations are very variable although usually fairly consistent within any kindred, and it has become increasingly evident that EDS is very heterogeneous.

In addition to the Ehlers—Danlos syndrome (EDS) (Chap. 9) and the familial undifferentiated hypermobility syndromes (Chap. 10), joint laxity is present in a number of inherited disorders. In some it is a major feature, while in others the hypermobility is overshadowed by other syndromic components.

Yttrium-90 synovectomy resulted in complete resolution of chronic knee synovitis in 40% of a group of 15 patients. These patients would have otherwise required surgical synovectomy. The number of chromosomal aberrations detected in 30 patients after yttrium-90 synovectomy showed a statistically significant increase over the pre-treatment analysis, and, following treatment, chromosomal damage was noted in nine patients who had no damage before treatment. The risk arising from this chromosomal damage is uncertain but, while the long-term implications of the chromosomal aberrations are investigated in those who have already been treated, this therapy should be reserved for the older patient.

Artificial insemination by donor (AID) has been complicated by the transmission of several genital infections. We describe the case of a man with Reiter's syndrome whose illness followed AID treatment of his wife.

Hypermobile patients can be spared much unnecessary suffering by the establishment of the correct diagnosis. As indicated in Chap. 6, hypermobility is one of the great mimics in rheumatology. Many hapless individuals are misdiagnosed as suffering from rheumatoid arthritis (both adult and juvenile). Needlessly they are forced to suffer the anguish of living with that diagnosis and are exposed to the dangers of the slow-acting anti-rheumatoid drugs and other potentially hazardous treatments. Others, in the absence of observed physical signs to explain their symptoms (joint hypermobility is often overlooked), are labelled as neurotic. They either accept this and become resigned to a life of misery and disability, or reject it and go from one specialist to another in their quest for relief. Not surprisingly many seek help from practitioners of alternative medicine. It is self-evident that reassuring the patient that he or she has neither a potentially crippling disease nor, for that matter, a psychological one can have a profoundly beneficial effect on morale!

In pathology there has always been an urge to find a “unifying concept” and a “basic defect” in a group of conditions with clinical similarities. So it has been with joint hypermobility. However this is not always a legitimate goal, and, except at a very superficial level, does not help us to understand the molecular basis of abnormal joint laxity. The reason for this lies in the diverse aetiologies of joint hypermobility, which span the inherited and the acquired, with both qualitative and quantitative differences in joint tissues. “But surely it’s a collagen defect?” is a common and understandable response — indeed one which has influenced the direction of research into the molecular basis of hypermobility. Why should this be so? Firstly, common sense tells us that the collagenous components of the joint connective tissues dictate the mechanical limitations of movements; after all, we are all aware of the physical attributes of tendons, ligaments and joint capsules — notably their tensile strength and high elastic modulus (resistance to deformation). Secondly, joint laxity can undoubtedly occur when these tissues are physically weakened — either surgically or by the erosion accompanying, for instance, rheumatoid arthritis. Thirdly, some genetic defects of collagen biosynthesis have been identified and associated with joint hypermobility — notably variants of the Ehlers—Danlos syndrome (EDS) and osteogenesis imperfecta (see Chap. 10). Fourthly, pharmacological interference with collagen biosynthesis, for instance with d-penicillamine, can increase joint laxity.

The effectiveness of spinal manipulation carried out by a non-medical qualified osteopath was compared with that of short-wave diathermy (SWD) and a placebo (detuned SWD) in 109 patients with low back pain. More than half the subjects in each of the 3 treatment groups benefited immediately from therapy. Significant improvements were observed in the 3 groups at the end of 2 weeks' treatment, and these were still apparent at 12 weeks. The outcome of treatment was unrelated to the initial severity or duration of pain or to the trend of pain towards deterioration or improvement. It is, therefore, unlikely that the results simply reflect the natural history of low back pain. Benefits obtained with osteopathy and SWD in this study may have been achieved through a placebo effect.