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A feasibility study for the installation of a CRDID (Common Rail Diesel Engine) on a medium helicopter is introduced. The total mass available for the CRDID is evaluated starting from fuel consumption and helicopter data. A derivative of an automotive engine was considered. The installation of the new CRDID was then studied. The result was the evaluation of the power plant installation mass that proved to be lower than the maximum admissible. The installation is then possible. Care should be taken in the cooling system to avoid large penalties in power and efficiency. For CRDID powered helicopters, the ejector exhaust system can be successfully used. With CRDIDs, huge advantages can be obtained on operating costs due to reduced fuel consumption, safety and helicopter availability. In fact, diesel fuel is available everywhere and flights to airports just for refueling can be avoided. © 2015, Pushpa Publishing House, Allahabad, India.

Objective. To evaluate in vivo expression of chemokine receptors in cartilage tissue samples from healthy and diseased joints. Methods. Presence and distribution of several chemokine receptors in cartilage samples from patients with osteoarthritis (OA) or inflammatory arthritis (IA) and from multi-organ donors were assessed by immunohistochemistry. The expression of messenger RNA (mRNA) for chemokine receptors was also analysed by reverse transcriptase-polymerase chain reaction (RT-PCR). Results. Normal and OA-affected cartilage showed a moderate to high expression of chemokine receptors, while staining of IA samples ranged from low to absent. Differences between OA and IA samples were present for all receptors but CCR2 and CXCR4. Moreover, mRNAs for CCR1, CCR5 and CXCR1 were found both in normal and pathological chondrocytes, suggesting that chemokine receptor down-modulation seen in IA samples could be a post-transcriptional event. Conclusion. Data on normal and pathological chondrocytes underline the role of chemokines in cartilage homeostasis and suggest an imbalance towards catabolic processes in inflammatory conditions.

Corticosteroids have long represented the drugs of choice for intra-articular treatment of osteoarthritis (OA), but their use has drawbacks, indicating the need for alternatives devoid of these effects. This comparative study examined the clinical efficacy and the structural effects of intra-articular injections of sodium hyaluronate (HA) of molecular weight (MW) 500–730 kDa (one injection weekly for 5 weeks) versus methylprednisolone acetate (MP) (one injection weekly for 3 weeks) in the treatment knee OA. We studied 99 patients with knee OA, primary or secondary to a traumatic event, classified according to criteria of the American College of Rheumatology. Pain assessments by VAS and arthroscopic examinations of synovial membrane and cartilage were performed at baseline and 180 days after the start of the treatment. Arthroscopic features were evaluated under blind conditions. Initially, MP showed a more immediate beneficial clinical effect in reducing pain than HA, but after 180 days the symptomatic effect of HA was more long lasting than that of MP. Arthroscopic findings at day 180, in comparison with baseline conditions, showed that both drugs were decreased synovial membrane inflammation but HA was superior to MP in reducing the grade and extent of cartilage damage. HA of 500–730 kDa represents a valid alternative to corticosteroids in the intra-articular treatment of OA with a beneficial effect on the structural alterations. This study supports previous data on a potential structure-modifying activity of HA in OA of the knee.

Background: this retrospective open label study evaluates the efficacy and tolerability of intra-articular injections of Hyaluronic Acid (HA) (MW 500-730 KDa - Hyalgan®) for the treatment of pain and disability of trapeziometacarpal joint osteoarthritis (TMCJ OA). Methods: fifty eight patients, 50 females (86%) and 8 male (14%), aged between 40-75 years, suffering from TMCJ OA according to Kellgren-Laurence grades 2-3 on standard plain radiography, were included. Patients with known inflammatory arthritis, previous thumb trauma and intra-articular (i.a.) injections with corticosteroids were excluded. Primary endpoints were: pain (VAS), NSAID intake, radial and palmar ab-/adduction, pinch strength. All patients received an i.a. injection of 0.8 mL of HA (MW 500-730 KDa) once weekly for three weeks. Control examinations were carried out at 1, 3, and 6 months. Results: intra-articular HA injections have significantly reduced spontaneous and provoked pain and improved hand mobility. At 1,3, and 6 months from baseline, the spontaneous and provoked pain revealed a statistically significant improvement (p

SUMMARY Polymyalgia rheumatica (PMR) is a common disorder of the elderly: the pathogenesis of the syndrome is still debated, though active synovitis of the shoulder has recently been confirmed. To investigate the pathogenesis of this synovitis we evaluated cell adhesion molecule (CAM) expression in shoulder synovial tissue from patients with PMR, correlated synovial expression with the serum levels of soluble forms, and assessed the changes associated with corticosteroid treatment. Arthroscopic synovial biopsies were obtained from 12 untreated and seven corticosteroid (CS)-treated cases. CAM expression was evaluated by MoAb staining on frozen sections and computerized image analysis. Soluble CAM were quantified by ELISA. Endothelial cells expressed intercellular adhesion molecule-1 (ICAM-l), E- and P-selectins. Infiltrating cells were ICAM-1 and β1-integrin-positive, while L-selectin expression was limited to intravascular leucocytes. Synovial lining cells strongly expressed vascular cell adhesion molecule-1 (VCAM-1), and less intensely ICAM-1. Only the soluble form of ICAM-1 (sICAM-1) was elevated in untreated patients. CS treatment was associated with a decrease in ICAM-1, VCAM-1 and E- and P-selectin expression. sICAM-1 levels were in the normal range in treated patients. VLA-5 and 6 expression was widely distributed among cell types, and was not CS-sensitive. Active shoulder synovitis is associated with different CAM expression in PMR. ICAM-l expression is widely distributed and correlates with elevated levels of the soluble form; it is significantly lower in CS-treated asymptomatic cases.

Objective: To investigate the immunologic features of synovitis in patients with polymyalgia rheumatica (PMR) and to assess the modifications induced by corticosteroid. Methods. Arthroscopic biopsies of shoulder synovium were obtained from 12 patients with untreated PMR and from 7 patients with PMR that had been treated. Immunohistochemistry was performed on frozen sections utilizing a panel of monoclonal antibodies and computerized image analysis. Results. Synovitis was present in 10 of 12 (83%) untreated patients and in only 2 of 7 (29%) treated patients. The synovitis was characterized by vascular proliferation and leukocyte infiltration. Infiltrating cells consisted predominantly of macrophages and T Lymphocytes. Almost all T lymphocytes were CD45RO positive. A few neutrophils, but no B cells, natural killer cells, or γ/δ T cells were found. Intense expression of HLA class II antigens (DR moreso than DP moreso than DQ) was found in the lining layer cells as well as in macrophages and lymphocytes. DR, but not DP or DQ, was expressed by the endothelium of a few vessels. Class II antigen expression correlated with the number of macrophages and lymphocytes. Macrophage infiltration of arteriole walls was observed in 1 untreated patient without giant cell arteritis (GCA). In untreated patients, there was a positive correlation between the percentage of infiltrating T cells and the duration of disease. Steroid therapy was associated with a significant reduction in the number of blood vessels and of HLA class II expression. One treated patient who no longer had symptoms of PMR still had active synovitis: a relapse occurred 4 months after the biopsy. Conclusion. Our findings support the hypothesis that synovitis is a major cause of the musculoskeletal symptoms of PMR. There are immunologic similarities with the vascular inflammation observed in GCA. Corticosteroids act on both the vascular and cellular components of synovitis.

The recommendations for the management of osteoarthritis (OA) of the knee firstly proposed by the EULAR in 2000, have been updated in 2003. One of the most important objectives of the expert charged to provide these recommendations was their dissemination. Thus, the information generated may be used by each individual country to produce their own set of management guidelines and algorithms for treatment in primary care. The Italian Society of Rheumatology (SIR) and the Italian League against Rheumatism (LIMAR) have organised a Consensus on the EULAR recommendations 2003 with the aim to analyse their acceptability and the applicability according to our own experience and local situations in the Italy. The results of this Consensus have demonstrated that a large majority of the EULAR recommendations are endorsed by the Italian experts. Furthermore, the final document of the Italian Consensus clearly indicated the need that the specialists involved in the management of knee OA strongly encourage the dissemination of the EULAR 2003 recommendations also in Italy.

The complex symptoms occurring in several internal knee diseases are usually related to changes in the synovial membrane, causing diagnostic and therapeutic problems. The conventional arthroscope, useful in establishing the diagnosis of internal derangement, is of questionable value in the differential diagnosis and evaluation of the stages of arthritis. With magnifying arthroscopy, it is possible to better show various forms of synovitis. Between 1983 and 1989, 3,000 knee joints were studied with conventional arthroscopy. In 400 of these joints, magnifying arthroscopic examination (microarthroscopy) was performed: 34 were normal, 57 had meniscal and ligamentous lesions, 220 had osteoarthritis, and 89 had inflammatory synovitis. We used two types of arthroscopes, Hamou-Storz and Microview-Wolf, adapted from a microhysteroscope, which provided a x 150 magnification of the conventional field. Referring to established microarthroscopic aspects of the synovial membrane in normal and pathological conditions, we have suggested microarthroscopic criteria for the differential diagnosis of synovitis in various pathological disorders. We believe that there are new applications for microarthroscopy because the instruments appear to have great potential value for both research and diagnosis.

Joint fluid aspiration, or arthrocentesis, is one of the most useful and commonly performed procedures for the diagnosis and treatment of rheumatic diseases, but to date no definite guidelines have been published. For this reason, a group of experts of the Italian Society of Rheumatology (SIR) produced evidence based recommendations for performing arthrocentesis. Among them, the most relevant are: a) arthrocentesis is necessary when synovial effusion of unknown origin is present, especially if septic or crystal arthritis is suspected; b) the patient should be clearly informed of the benefits and risks of the procedure in order to give an informed consent; c) ultrasonography should be used to facilitate arthrocentesis in difficult joints; d) fluid evacuation often has a therapeutic effect and facilitates the success of the following intraarticular injection; e) careful skin disinfection and the use of sterile, disposable material is mandatory for avoiding septic complications. Disposable, non sterile gloves should always be used by the operator, mainly for his own protection; f) contraindications are the presence of skin lesions or infections in the area of the puncture; g) the patient's anticoagulant treatment is not a contraindication, providing the therapeutic range is not exceeded; h) joint rest after arthrocentesis is not indicated. Several of these recommendations were based on experts' opinion rather than on published evidence which is scanty.

The recommendations for the management of osteoarthritis (OA) of the hip were proposed by EULAR in 2005. Among the most important objectives of the expert charged to provide these recommendations were their wide dissemination and implementation. Thus, the information generated can be used by each individual country to produce their own set of management guidelines and algorithms for treatment in primary care. According with that previously executed for the EU-LAR recommendation 2003 for the knee, the Italian Society of Rheumatology (SIR) has organised a Consensus on the EULAR recommendations 2005 for the management of hip OA. To obtain an acceptability as large as possible, the group of experts was composed by many physicians interested in the management of hip OA, including Orthopaedics, Rheumatologists, Physiatrists, and General Practitioners. Main aim of the Consensus was to analyse the acceptability and applicability of the recommendations according to own experience and local situations in the Italy. The results of this Consensus have demonstrated that a large majority of the EULAR recommendations are endorsed by the Italian experts. Furthermore, the final document of the Italian Consensus clearly indicated the need that the specialists involved in the management of hip OA strongly encourage the dissemination of the EULAR 2005 recommendations also in Italy.

uman osteoarthritis (OA) is a heterogeneous andmultifactorialdiseasewithmultiplepathogeneticmech-anism implicated in its development and progression. Carti-lage degradation and loss are the major features of OA; de-generative changes include fibrillation, chondrocyteproliferation into cell clusters, and matrix disruption. Al-though biomechanical factors are strongly implicated, it isunclear which stimuli regulate the hyperactive phenotype ofOAchondrocytes,includingtheirabilitytoexpresscartilage-degradingproteinases(1).Recentstudieshaveimplicatedtheupregulation of several matrix-degrading metalloproteinases(MMPs)inOAcartilageandhavesuggestedthatchondrocyteproduction of MMPs in OA cartilage reflects local synthesisthat varies with the extent of cartilage degeneration. Thedemonstration of chondrocytes producing interleukin-1and tumor necrosis factor Theseverityofcartilagelesionshasbeenassessedusinganwithin the superficial zones ofOA cartilage supports the concept that cytokine-MMP asso-ciations contribute to a highly catabolic state, chondrocyteapoptosis, and the resultant progressive degeneration of ar-ticular cartilage (2-6).

To test a hypothesis of compartmentalized pathogenesis of different types of arthritis, namely inflammatory arthritis (IA) and osteoarthritis (OA), synovial and cartilage biopsies were examined for the expression of TNF and IL-1 receptors. In cartilage, we found constitutive expression of all receptors in normal tissues, and decreased expression of signal-transducing receptors in pathological chondrocytes. In synovium, there was a lower expression of signal-transducing receptors in cases of OA compared to those of IA. In OA, the three signal-transducing receptors were more abundantly expressed in cartilage, while in IA they were mainly present in synovial tissue (TNFRp75 being expressed more than p55). IL-1 decoy receptor type II was low or absent in synovial tissues, but present in cartilage. The increased expression of TNFRp75 and IL-1RI in OA cartilage, compared to IA, in addition to the abundant local cytokine production, strengthens the hypothesis of autocrine/paracrine action by inflammatory cytokines in the pathogenesis of cartilage damage.

A clinical case of Relapsing Polychondritis (RP) with Microscopic Polyangiitis (MPA) is described in a 66 years old woman. This case represents a rare association of the two pathologies. Polychondritis is a rare inflammatory disease of unknown origin, but immunological mechanisms are essential in the pathogenesis. Histological features are inflammation and destruction of cartilage. The disease is systemic, may have a remitting course. The osteoarticular lesions are sometimes unusual, involving the temporomandibular or cervical articulations, and the renal lesions may be severe. This can be primary or associated with several other diseases. Microscopic Polyangiitis is a systemic disorder characterized by necrotizing vasculitis, affecting the small vessels. Most patient with MPA have Antineutrophil Cytoplasmic Antibodies for Myeloperoxidase (MPO-ANCA). ANCA have become an established tool for the diagnosis of systemic vasculitis. The primary target antigens for ANCA are myeloperoxidase (enzyme present in the secretory granules of neutrophils and monocytes) and antibodies to these antigens are tested by ELISA and IIF (indirect immunofluorescence). We describe a case of histologically confirmed MPA with Relapsing Polychondritis. Clinically she presented livedo reticularis in the lower limbs and pain in the joints. During the follow-up the patient developed asymmetric oligoarticular arthritis. Immunosuppressive drugs like glucocorticoids and cyclofosfamide are the drugs of choice, depending on the stage and severity of the disease.

Objective Histomorphometric study on cartilage samples taken from osteoarthritic human knees before and 6 months after intraarticular injections of a specific fraction (500–730kDa) of hyaluronan. The results obtained with hyaluronan were compared with the results of methylprednisolone acetate treatment. Methods Twenty-four subjects with primary osteoarthritis (OA) of the knee were considered. Eleven patients were treated with Hyaluronan (Hyalgan ® , 20mg/2ml once a week for 5 weeks) and 13 with methylprednisolone (Depo-Medrol ® , 40mg/1ml once a week for 3 weeks). At the time of baseline and after 6 months from the start of treatment, biopsies of cartilage were taken and processed for electron microscopy. Articular surface morphology, territorial matrix, chondrocyte number and ultrastructure were characterized by a set of morphometric parameters. Samples from 19 informed patients showing no arthroscopic sign of OA were also used for comparison. Results Six months after hyaluronan treatment a significant reconstitution of the superficial layer were observed together with an improvement in chondrocyte density and territorial matrix appearance. Furthermore, chondrocytes appeared significantly improved in their metabolism, as indicated by the increased extension of the synthetic structures and mitochondria with respect to the organelles having catabolic or storage functions. Hyaluronan treatment produced results that were significantly superior to those delivered with Methylprednisolone in almost all the morphometric estimators. Conclusions These results cannot be explained simply by temporary restoration of the synovial fluid viscoelasticity, and provide further evidence that the specific fraction of hyaluronan used in this study is a useful tool in OA treatment, with a potential structure-modifying activity.

To evaluate the presence of interleukin-17 (IL-17) and the expression of IL-17 receptor (IL-17R) in joint tissues from subjects with different arthritides.Immunohistochemistry was used on frozen synovial and cartilage biopsies to identify cells expressing IL-17 and IL-17R.IL-17 staining was present only in synovial biopsies of rheumatoid arthritis (RA) (seven out of nine cases). IL-17R was expressed by all synovial biopsies evaluated except for three cases of post-traumatic arthritis (PTA). Vascular endothelial cells mainly expressed IL-17R. The percentage of IL-17R(+) vessels was the highest in RA synovium and the lowest in PTA. Chondrocytes from all types of arthritides were negative for IL-17 staining, but expressed IL-17R; the highest percentage of positive chondrocytes was found in seronegative spondylarthritis and the lowest in RA.IL-17-positive cells are found exclusively in RA. On the other hand, synovial endothelial cells and chondrocytes expressing IL-17R are found in the majority of patients with different types of arthritis. This finding suggests a role for a second ligand for IL-17R, which could be either a different cytokine or a different isoform of IL-17.

Objective. The study was part of a randomized open-label clinical trial designed to evaluate the effects of intra-articular injections of hyaluronan (Hyalgan®) (HY) in osteoarthritis (OA) of the human knee. Data were compared with those obtained after treatment with methylprednisolone acetate (Depomedrol®) (MP). Methods, Synovial membranes from patients with OA of the knee, primary or secondary to a traumatic event and classified according to the American College of Rheumatology criteria, were examined by arthroscopy and by light and electron microscopy before and 6 months after local injection of HY (2 ml of 500-730 000 MW hyaluronan, 10 mg/ml in saline, one injection per week for 5 weeks) or MP ( ml of methylprednisolone acetate, 40 mg/ml, one injection per week for 3 weeks). Results. Arthroscopy revealed a significant decrease in inflammatory score after both treatments. Histology showed that HY treatment was effective (P ≤ 0.05) in reducing the number and aggregation of lining synoviocytes, as well as the number and calibre of the vessels. MP treatment significantly reduced the number of mast cells in primary OA. Both treatments tended to decrease the number of hypertrophic and to increase the number of fibroblast-like lining cells, to decrease the numbers of macrophages, lymphocytes, mast cells and adipocytes, and to decrease oedema, especially in primary OA, and to increase the number of fibroblasts and the amount of collagen. These phenomena were evident throughout the thickness of the synovial tissue. Conclusion, At least in the medium term, both HY and MP modified a number of structural variables of the synovial membrane of the osteoarthritic human knee towards the appearance of that of normal synovium. The effect was more evident in primary OA than in OA secondary to a traumatic event. This is the first evidence that local hyaluronan injections modify the structural organization of the human knee synovium in OA.

The distribution of T-lymphocytes expressing CD3 and T-cell receptor gamma-delta (T gamma/delta) has been examined by immunocytochemistry in the synovial membrane of eight patients with inflammatory arthritis (six rheumatoid arthritis, two spondyloarthritis) and eight with non-inflammatory arthritis (four osteoarthritis, four post-traumatic arthritis). T gamma/delta cells were present in eight out of eight inflammatory arthritis synovial membranes, but in only one out of eight non-inflammatory membranes (P less than 0.005). The mean T gamma/delta percentage (of total T-cells) in inflammatory arthritis was 14% (range 7-25%). T gamma/delta cells were found mainly in the transitional area of the synovial membrane with a scattered distribution as single cells or couplets. No relation was found between the presence and percentage of T gamma/delta cells and disease duration or steroid treatment.

Objective. To evaluate peripheral production and synovial expression of vascular endothelial growth factor (VEGF) in polymyalgia rheumatica (PMR). Methods. Circulating levels of VEGF in PMR (serum concentration and in vitro release by peripheral blood mononuclear cells [PBMC]) were investigated by enzyme-linked immunosorbent assay. Local expression of VEGF in shoulder synovial tissue was investigated by immunohistochemical analysis. Investigations were performed in patients with active, untreated disease and in patients treated with corticosteroids. Results. VEGF serum concentrations were significantly higher in untreated PMR patients than in normal control subjects. During steroid treatment, VEGF serum concentrations reached their lowest level after the sixth month of treatment. PBMC isolated from untreated PMR patients spontaneously secreted a higher amount of VEGF compared with PBMC from control subjects. Corticosteroid therapy did not affect the ability of PBMC to produce VEGF. Immunohistochemical staining performed on shoulder synovial tissue showed VEGF expression in both the lining layer and the sublining area. In 3 of 4 treated patients, no VEGF staining was found in synovial tissue during corticosteroid therapy. VEGF expression correlated with vessel density, but was not associated with avb3 and avb5 integrin expression. Conclusion. Peripheral and local VEGF releases have different responses to steroid treatment in PMR. The lack of response to corticosteroids by peripheral VEGF production supports the hypothesis that systemic involvement is dominant in PMR. At the synovial level, VEGF production is linked to vascular proliferation and is thus directly involved in the pathogenesis of synovitis.

OBJECTIVE To evaluate the sites of expression of interleukin-1beta (IL-1beta), tumor necrosis factor alpha (TNFalpha), and inducible nitric oxide synthase (iNOS) in patients with inflammatory and degenerative joint diseases. METHODS Cytokines and iNOS were detected by immunohistochemistry analysis of synovial and cartilage biopsy specimens obtained at knee arthroscopy in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), osteoarthritis (OA), and traumatic knee arthritis. Cytokine and iNOS expression was quantified using computerized image analysis. RESULTS IL-1beta, TNFalpha, and iNOS were highly expressed by synovial cells (lining layer cells, infiltrating leukocytes, endothelial cells) from patients with inflammatory arthritides and significantly less by synovial cells from patients with OA and traumatic arthritis. In contrast, the latter patients showed high chondrocyte expression of cytokines and iNOS while RA and PsA patients had only minor chondrocyte positivity. In both joint compartments, IL-1beta expression, TNFalpha expression, and iNOS expression were strongly correlated. CONCLUSION The enhanced and coordinated expression of IL-1beta, TNFalpha, and iNOS by chondrocytes strongly supports the hypothesis that chondrocytes are the major site of production of mediators of inflammation in human OA, thus playing a primary role in the pathogenesis of this disease.

To evaluate, in a pilot, open clinical trial on 40 patients with knee osteoarthritis, the structural changes in the synovial membrane and cartilage following treatment with intra-articular hyaluronic acid (HA-Hyalgan).The structural effects of HA given as 5 weekly injections (20 mg/2 ml once a week for 5 weeks), were evaluated by microarthroscopy and morphological analysis of biopsy samples taken at baseline and after 6 months, under blind conditions. Clinical efficacy was also evaluated using visual analogue scales for pain and functional parameters.At 6 months, the microarthroscopic evaluation indicated that the majority of the patients (60%) showed no changes compared to baseline, while 32.5% of the patients showed improvement in the grading and/or extension of cartilage lesions and 7.5% showed a worsened condition. These changes were accompanied by a statistically significant reduction in the synovial inflammation (p = 0.001). The results were confirmed by morphological examination of the cartilage and synovial membrane. At 6 months compared to baseline, a statistically significant reconstitution of the superficial amorphous layer of the cartilage (p = 0.0039), an improvement in the chondrocyte density (p = 0.0023) and vitality (p = 0.05), and a statistically significant reduction in synovial inflammation (p = 0.0001) accompanied by a significant increase in the synovial repair process (p = 0.0001) were observed. Significant and long lasting improvement in pain and joint mobility were also seen after HA treatment. Joint effusion, when present, was reduced. The treatment was well tolerated.Hyalgan represents a useful therapy for knee OA, with long-lasting symptomatic efficacy and potential positive effects on joint tissues. Other studies, in particular placebo-controlled studies, are warranted to confirm these promising results observed on joint tissues.

To evaluate the efficacy of a new formulation of sucralfate as gel (Gastrogel) in the short-term prevention of gastroduodenal lesions in arthritic patients receiving nonsteroidal anti-inflammatory drugs.One hundred seven patients with arthritis (M/F 18/89, mean age 55.2 +/- 9.7 yr) enrolled in two centers were considered eligible for the study if initial endoscopy showed the absence of any relevant mucosal damage. Patients were randomly allocated to receive diclofenac 200 mg/day or naproxen 1 g/day plus either sucralfate gel 1 g b.i.d. (N = 53) or identical placebo (N = 54) for 14 days in a randomized double-blind study. Repeated assessment of GI symptoms and endoscopy were performed at the end of the study period.At final endoscopy the incidence of erosion and the mean endoscopic score for both stomach and duodenum were significantly lower in the sucralfate gel group compared with placebo group (p0.05). Both heartburn and epigastric pain were significantly less frequent in patients receiving sucralfate gel than placebo (51 vs 30% and 49 vs 28% for heartburn and epigastric pain, respectively, p0.05). No differences were observed in the incidence or in the mean score for nausea. An unexplained difference in the incidence of ulcers was found between the two centers, but in both a similar reduction in the incidence of ulcers was observed between patients receiving sucralfate gel compared with those receiving placebo. The overall difference (8% in sucralfate-treated patients, 28% in patients receiving placebo) of gastroduodenal ulcers was statistically significant (p0.05).Sucralfate gel reduces both the incidence of acute gastroduodenal mucosal lesions and symptoms in patients with arthritis receiving short-term nonsteroidal anti-inflammatory drugs.

Cytochemical and immunocytochemical approaches have been applied to the study of the surface of articular cartilage in humans, bovine and rats. Specimens were fixed in situ or soon after bioptic sampling with chemicals able to preserve and visualize proteins (glutaraldehyde, tannic acid), lipids (osmium tetroxide, malachite green, uranyl acetate) and proteoglycans (toluidine blue O, cuprolinic blue, cetyl pyridinium chloride). Mixtures of reagents were also used. Oriented serial thin sections were observed as such or after treatment with chemicals (chloroform-methanol, Triton X 100) or enzymes (chondroitinases, hyaluronidases, trypsin). Hyaluronan was detected by the use of glial-hyaluronate-binding-protein and antibodies against it. High concentration of osmium tetroxide or fixatives containing markers for lipid or for proteoglycans revealed that the surface of the articular cartilage, in all animal species examined, was covered by mono-multilayered discontinuous three-laminar sheets, which could be partly removed by chloroform-methanol and Triton X 100, were sensitive to hyaluronidase, chondroitinase and trypsin, and were immunopositive for hyaluronan. Each three-laminar sheet was 12-14 nm thick, was always separated from the cartilage itself and could be easily displaced. It is proposed that the surface of normal articular cartilage is covered by a discontinuous mono/multilayered pseudo-membrane, that can be better preserved by fixatives injected into the joint cavity and seems to consist of phospholipids, glycosaminoglycans and proteins. This membrane-like structure might have a protecting role in preventing direct contacts between the articular cartilage and toxic agents present in the synovial fluid and/or exert a lubricating effect within the articular joint.

70 patients, mainly females with rheumatoid arthritis, underwent consecutively conventional radiography and storage phosphor digital radiography examination of different skeletal parts. The presence (or absence) of some radiological signs was analyzed on each examination, with both techniques, by three indipendent radiologists, using a 1–4 score as confidence level; ROC analysis of the results was performed. The values resulted always higher with digital modality than with conventional one, but the difference resulted statistically significant only in the detection of soft tissue lesions.

Age-associated changes of the human synovium have been investigated by microarthroscopy, optical and electron microscopy, immunohistochemistry, and cytochemistry. The knee joints of nineteen 15- to 56-year-old subjects, classified as normal by inspection, were carefully examined by microarthroscopy; small synovial tissue biopsy specimens from both the suprapatellar pouch and the medial tibiofemoral gutter were taken. Microarthroscopy showed that the villi were more numerous and the vascular network and cell distribution and profiles less regular in aged individuals. These data were confirmed by scanning electron microscopy, which also showed large areas of the synovial surface devoid of cells and collagen bundles in contact with the joint cavity in aged subjects. Light and transmission electron microscopy confirmed these data and allowed evaluation of the number, distribution, shape, and internal organization of cells as well as the distribution of vessels and the organization of the extracellular matrix in the full thickness of the synovium (down to 2 mm). Particular attention was paid to synovial lining cells, among which three main phenotypes could be recognized: synthetic type (present at all ages and hypertrophied in aged subjects), macrophagelike (increasing with age), and fibroblastlike. Collagen increased with age. Further studies are needed for comprehensive understanding of age-associated changes in the human synovium.

The microhysteroscope, which affords direct in vivo observation of otherwise inaccessible surfaces, can be used to great advantage in arthroscopy. Although conventional arthroscopy can distinguish between 'inflammatory' and 'reactive' (post-traumatic) synovial changes, the microendoscope offers the possibility of more precise differentiation. Synovial membranes, joint cartilage, and menisci were studied at four different magnifications, including microscopic observation of vitally stained cells. Frankly pathological synovia (e.g., rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis) were compared and distinguished from examples of less florid synovial changes. The fibrocartilaginous structure of the menisci and secondary undulations and tertiary depression of joint cartilage become visible in vivo with the microendoscope; these may well point to early damage to these structures. The authors believe that the three dimensional images at the magnifications provided by this microendoscope go some way towards bridging the gap between the conventional arthroscope, the light microscope, and the scanning electron microscope. This report presents preliminary findings with this new technique.

One case of spontaneous osteonecrosis (S.O.N.) of the femoral condyles is described. Lesions were seen in both lateral femoral condyles; this implies a local, microtraumatic or circulatory factor. It is interesting that the patient was so young (a 14 year old girl). She presented with persistent pain in the right knee and at examination only a mild tenderness was noted. Radiography showed a radiolucent "halo" in the lateral condyles with a surrounding sclerotic reaction. Femoral condyles at arthroscopic examination appeared with a slight flattening over the articular cartilage. The diagnosis of S.O.N. was made by a bone scan that demonstrated an increased uptake of the tracer in the lateral femoral condyle bilaterally. A conservative therapy was successful after 18 months.

The diagnosis of internal derangements of the knee sometimes presents a graft deal of difficulty. If today the expression "Internal derangement of the knee" is much more rare, it is due to the progress made in the field of diagnosis thanks, in particular, to arthrography and arthroscopy. The authors report the results of 300 arthroscopies of the knee. They present the most significant forms of the problem knee: hypertrophy of the adipose tissue, hypertrophy of the synovial folds, villo-nodular synovitis, synovial chondromatosis, radiolucent mobile foreign bodies, osteochondritis dessicans hidden meniscal lesions and specific and non-specific mono-arthritis. In the majority of cases, the clinical suspicion was confirmed, but in 29% of cases arthroscopy corrected the diagnosis. Arthroscopy, is judged to be of great value in the diagnosis of doubtful forms of the painful knee syndrome. Often it eliminates the need to open the joint and almost always directs the incision to the most appropriate region and, above all, it prevents the risk of unnecessary operation.

One-hundred and eighteen patients with rheumatoid arthritis were treated for 4 weeks with flurbiprofen 300 mg/day (sixty patients) or naproxen 750 mg/day (fifty-eight patients) in a six-centre randomized trial. Flurbiprofen proved to be more effective than naproxen in reducing morning stiffness (p < 0·01), Ritchie articular index (p < 0·01) and number of swollen joints (p < 0·05) and in relieving night pain (p < 0·01).The incidence and severity of side-effects, mainly gastric, were both low and similar with flurbiprofen (17%) and naproxen (19%).