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Copyright of Annals of the Rheumatic Diseases is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of Annals of the Rheumatic Diseases is the property of BMJ Publishing Group and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

We determined serum alpha 1-antitrypsin phenotypes and levels in 281 patients with classical or definite rheumatoid arthritis (RA). The prevalence of the MZ phenotype in our patients with RA was not increased, as there were only 3 MZ cases (1.1% of all cases and 1.4% of seropositive cases) compared to the 3% prevalence in controls. The FM phenotype was detected in 6 cases, a prevalence rate of 2.1%, significantly higher than in controls (prevalence less than 0.4%). Increased serum levels of alpha 1-antitrypsin were independently associated (p less than 0.01) with the presence of wrist joint erosions and the use of gold and/or penicillamine for treatment; this association may represent a serum antitrypsin response to more severe disease.

Roentgenograms of hands and wrists from rheumatoid arthritis patients treated with auranofin for 12 and 24 months were scored for severity of erosive disease. Scores were analyzed by a method in which a calculated mean annual rate of erosion prior to treatment was compared with the annualized rate during therapy. The original films from a previous Myochrysine versus placebo study were reanalyzed in order to compare the results of different scoring methods and to provide an auranofin versus placebo comparison. Two readers found the rate of erosion during oral gold therapy to be less than that predicted by the analytical model. Interobserver differences in scoring were demonstrated. A breakdown of patient scores by duration of disease showed the greatest difference between scores observed during treatment with those predicted by the model in patients with early disease.

HL-A antigens were determined in Haida and Bella Coola native Indians, two communities known to have a high prevalence of ankylosing spondylitis. Tests were conducted on those with x-ray evidence of sacroiliitis and on a sample of the community at large. Sacroiliitis was found to prevail in approximately 10% of adult Haida males and in over 2% of Bella Coola adult males. Of 20 Haidas with sacroiliitis. 17 were HL-A 27 positive. Fifty percent of the Haida community at large were HL-A 27 positive. Three Bella Coolas known to have sacroiliitis were all HL-A 27 positive, while 25% of the community sampled at large were HL-A 27 positive. About one in five adult Haida males who were HL-A 27 positive showed evidence of sacroiliitis, a proportion close to that ascertained in Caucasian communities. It would appear, therefore that the risk of disease in HL-A 27 positive Bella Coola males is considerably lower.

Patients with low back pain who were found to have a leg length discrepancy were treated with a lift to the shoe on the short side. A small group of such patients with longstanding pain had major or total relief over a long period of followup. Clinical characteristics of the low back pain symptoms were distinctive. A useful method to establish leg length discrepancy clinically is described.

PA radiographs of hands and wrists from a randomized 6 month study of auranofin (AF) vs placebo followed by 6 months of open AF were scored for progression of erosive disease by 2 independent readers. The readers were blinded both to treatment and sequence (month 0 vs month 12) of the films. The results of our study demonstrate a reduction in the advancement of erosive disease during AF therapy compared to placebo.

Forty-one coded radiographic films from 16 patients with rheumatoid arthritis were read by 13 observers, using 4 different methods for scoring abnormalities. Although absolute scores differed widely among individual observers, correlation coefficients were greater than 0.850 for approximately 2 of 3 comparisons. When films were ranked, using the median rank of all readers, 72% of individual ranks were within 10% of the median ranks. Among serial films on individual patients, 92% of comparisons between early and late films were interpreted as demonstrating progression of abnormalities when mean standardized scores showed an increase in scores of 15 units or greater. Films with lesser changes were interpreted inconsistently. This study shows good general agreement among readers in scoring radiologic abnormalities of hands and wrists, when applied to a film set showing a broad spectrum of severity, and defines the sensitivity of radiologic detection of disease progression.

Numerous methods for reading abnormalities of rheumatoid arthritis in hand and wrist radiographs have been proposed over the past several decades. There are many differences among these methods, one of the more striking of which is the variation in the number of joints that are scored. In this study, we tested the number of joints that need to be read in order to represent abnormalities accurately and reproducibly, using the scores of multiple observers. Thirteen rheumatologists and radiologists each read a set of 41 hand and wrist films from patients with rheumatoid arthritis. Ten of 13 readers scored 27 joints in each hand and wrist; the other 3 readers scored fewer areas. Fourteen combinations of joints were selected based on the frequency of involvement and the technical adequacy of routine films in assessing a given area. After testing these 14 different combinations, 1 scheme, which included 17 areas read for erosions and 18 areas read for joint space narrowing, was tested further. The correlation coefficients for 10 intraobserver scores derived from this modified scheme compared with the original scores were between 0.981 and 0.997. Seventy-one of 78 interobserver comparisons were better using the new scheme than using the original scheme. These data indicate that the simplified scheme, using a combination of 17 joints to score erosions and 18 to score joint space narrowing, more accurately reflects the extent of abnormalities perceived by a panel of experts than does the original scheme. This abbreviated number of joints shortens the amount of time required to read a set of films and simplifies the scoring of films, since a number of areas that are difficult to read are eliminated from radiographic assessment.

HL-A antigens were determined in Haida and Bella Coola native Indians, two communities known to have a high prevalence of ankylosing spondylitis. Tests were conducted on those with x-ray evidence of sacro-iliitis and on a sample of the community at large. Sacro-iliitis was found to prevail in approximately 10 per cent of adult Haida males and in over two per cent of Bella Coola adult males. Of 20 Haidas with sacro-iliitis, 17 were HL-A 27 positive. Fifty per cent of the Haida community at large were HL-A 27 positive. Three Bella Coolas known to have sacro-iliitis were all HL-A 27 positive, while 25 per cent of the community sampled at large were HL-A 27 positive. About one in five adult Haida males who were HL-A 27 positive showed evidence of sacro-iliitis, a proportion close to that ascertained in Caucasian communities. It would appear, therefore that the risk of disease in HL-A 27 positive Bella Coola males is considerably lower.

An x-ray method is described for the determination of leg-length inequality in the standing subject, Its precision is compared to that of other methods in current use. The geometrical considerations which are inherent in any radiographic method of leg-length determination are summarized. Sixty-seven patients with OA hip were studied; 62 were considered to be idiopathic and 36 of these idiopathic cases were superolateral in type. Measurements in these 36 patients showed significant leg-length disparity, most of the diseased hips being found on the side of the longer leg. If allowance is made for shortening due to disease, the frequency and bias of the disparity are highly significant. The strong association between OA hip of this type and a long leg suggests a causal relationship.

A definition and classification of primary OA hip is presented based on radiological criteria. Most cases of unilateral idiopathic OA hip remain unilateral over the years and the majority of these show a distinct radiological pattern with articular cartilage loss in the superolateral area of the joint. In contrast, OA hip with loss of cartilage in the medial area is usually bilateral. A supermedial form appears to be an intermediate type, but is less well defined.It is suggested that superolateral and medial forms of OA hip are fundamentally different in nature. Leg-length disparity, to be discussed in a subsequent section, is related to the superolateral type.

Present knowledge of hip biomechanics supports the contention that the stresses imposed on the hip on the side of the longer leg are greater than normal; those on the short side are comparably reduced. Indirect measurements by various authors have demonstrated greater stress on the hip if the pelvis is adducted, a persistent and chronic condition of the hip joint on the side of a long leg. Furthermore the pressure on the acetabulum will be displaced laterally in these circumstances. The consistent pattern of degeneration in unilateral superolateral O A hip is what would be expected if the consequences of leg-length disparity were as described. Leg-length inequality may be a major contributing factor in the development of unilateral degenerative disease of the hip of this type.A clinical method of estimating leg-length disparity is described. Clinical findings in patients support the hypothesis that hip stress is increased on the side of a longer leg.

Although congenital subluxation of the hip is an important primary abnormality, upon which OA hip may later supervene, other factors may also be important in individual patients. When osteoarthritis is seen with subluxation, it probably represents congenital subluxation and not displacement of the femoral head secondary to remodelling. Osteoarthritis in these cases is usually superolateral or supermedial in type, with the major impact of the disease in the superior articular cartilage. A similar form of osteoarthritis is seen in cases where leg-length disparity exists, with or without the presence of congenital subluxation, the wear occurring on the side of the long leg. It has been suggested that bio-mechanical considerations support the contention that stress is likely to be increased in the superior area of the joint on the side of a long leg, and wear can be expected to occur here. If either anomaly may provoke the later development of OA hip, it remains to be shown which is more important when both are present in the same patient.