Asthma mortality. How high is up? And is it up?
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Adult↗
Biomedical subjects
J M Esdaile
Publications and source records attributed to J M Esdaile.
A reappraisal of the United Kingdom epidemic of fatal asthma. Can general mortality data implicate a therapeutic agent?
The 1960s epidemic of asthma deaths that affected young persons in England and Wales, as well as in other countries, was attributed to the effect of newly available pressurized aerosols containing sympathomimetic bronchodilators. The subsequent decision to ban the nonprescription sale of these agents in the United Kingdom represented a unique use of national and international mortality data. The application of such data for decisions about therapeutic agents has implications for the current rise of asthma deaths in New Zealand, for the recent United States regulatory action regarding the nonprescription sale of aerosolized bronchodilators, and for the appraisal of adverse reactions to other pharmaceutical substances. This article is concerned with the quality of the scientific evidence used to implicate bronchodilators in the 1960s epidemic, and also with the strengths and weaknesses of the ecologic studies on which the implication depended. After concluding that the causal link between asthma deaths and bronchodilators was not supported by satisfactory scientific evidence, we present new data and an alternative diagnostic-exchange hypothesis that may, in part, help explain the original association.
Adolescent↗
Observational studies of cause-effect relationships: an analysis of methodologic problems as illustrated by the conflicting data for the role of oral contraceptives in the etiology of rheumatoid arthritis.
We review the structure of the two most common observational study designs, cohort and case-control studies, and outline guidelines to help clinicians evaluate the validity of studies that employ these designs. To demonstrate the use of these guidelines we apply them to the important issue of whether oral contraceptive usage may reduce the risk of developing rheumatoid arthritis. A recent case-control study has contradicted provocative evidence from two previous studies suggesting the existence of such a protective effect. Our analysis leads to the conclusion that the case-control study suggesting no association of oral contraceptives with the subsequent development of rheumatoid arthritis provides the best estimate of the effect of oral contraceptives currently available, and furthermore, the analysis permits recommendations to be made for the design of future investigations on this topic.
Arthritis, Rheumatoid↗
Lymphocyte transformation to connective tissue antigens in adult and juvenile rheumatoid arthritis, osteoarthritis, ankylosing spondylitis, systemic lupus erythematosus, and a nonarthritic control population.
Transformation of peripheral blood lymphocytes after exposure to connective tissue antigens was measured in patients with adult (n = 35) and juvenile rheumatoid arthritis (n = 34), osteoarthritis (n = 21), ankylosing spondylitis (n = 15), and systemic lupus erythematosus (n = 26) and in control subjects (n = 36). The connective tissue antigens included homologous cartilage-type proteoglycan, cyanogen bromide-derived peptides of type I, II, and III collagens, and type I and II helical collagens. Lymphocyte transformation was not detected in the osteoarthritic and control groups, with one exception. Sensitization to at least one connective tissue antigen was detected in approximately one-third of the rheumatoid arthritic and lupus patients and in one-quarter of the juvenile rheumatoid patients. In ankylosing spondylitis, positive responses occurred to proteoglycan in 20% of patients tested but never to collagens or peptides. Sensitivity to proteoglycan was detected only in ankylosing spondylitis except for one patient with juvenile rheumatoid arthritis. In patients with systemic lupus erythematosus and both forms of rheumatoid arthritis, lymphocyte transformation was usually more frequently detected to peptides than to the helical collagens. In adult rheumatoid arthritis, type II peptides elicited an elevated number of responses (14%) as did type I (9%) and III (8%) peptides to lesser degrees. Responses to type I (4%) and II (4%) helical collagens were infrequent. Rheumatoid arthritic patients usually exhibited sensitivity to only one antigen and lymphocyte transformation was often detected when the arthritis was improving. In juvenile rheumatoid arthritis, lymphocyte transformation was detected to peptides of type I (16%), II (9%), and III (29%) collagens and to helical type I (12%) and II (8%) collagens. In systemic lupus erythematosus, sensitization was detected to peptides of type I (13%), II (20%), and III (14%) collagens and to helical type I collagen (18%) but not type II collagen. Simultaneous sensitivity to several antigens often occurred in both systemic lupus erythematosus and juvenile rheumatoid arthritis. Examination of individual patients in all three rheumatic disease groups revealed that immune sensitivity developed to collagen peptides rather than to the helical molecules, particularly in the case of type II collagen. Thus, some patients with inflammatory arthritis exhibit immune responses to connective tissue components which are, as a group, characteristic for each type of arthritis. These responses, which were not obviously associated with disease activity, may develop as a result of inflammation or trauma which destroys connective tissue and exposes molecules, in either a native or degraded state, to cells of the immune system. Expression of sensitivity to these tissue antigens may contribute to the chronicity of the inflammatory arthritides.
Adult↗
HLA-Bw35 and prognosis in adult Still's disease.
Twenty-five patients with adult Still's disease were studied to determine clinical course and possible HLA associations. Two types of disease evolution were distinguishable clinically: a self-limited remitting disease with or without recurrent cyclic exacerbations was found in 11 patients, and a persistent disease with continuous activity for more than 1 year, generally accompanied by progressive joint disease, was determined in 8. Disease course could not be classified in 6 patients. The antigen frequencies of HLA-Bw35 (40%, P less than 0.05) and Cw4 (44%, P less than 0.05) were increased in adult Still's disease as compared to controls (18% and 20%, respectively). Because HLA-Bw35 was associated with self-limited remitting type disease (P less than 0.02), this antigen may be a favorable prognostic marker in adult Still's disease.
Adolescent↗
Deforming arthritis in systemic lupus erythematosus.
Of 45 patients in the McGill Lupus Registry 6 were found to have Jaccoud's deformities. One of these 6 and 4 others had fixed flexion contractures of the elbows. Those with Jaccoud's deformities were similar to the other patients with systemic lupus erythematosus in all respects except that those with Jaccoud's syndrome had had their disease and their arthritis significantly longer. It is concluded that Jaccoud's deformities are the result of longstanding arthritis and that elbow contractures occur via a different mechanism.
Adult↗
Prospective evaluation of sacroiliac scintigraphy in chronic inflammatory back pain.
To assess the usefulness in screening for sacroiliitis of a wide band profile cut which included the entire sacroiliac (SI) joint, 34 patients with chronic inflammatory back pain (IBP) underwent sacroiliac joint scintigraphy with 99mTc-methylene diphosphonate while receiving no antiinflammatory therapy. The sacroiliac joint to sacrum (SIJ/S) ratios in those with back pain differed significantly from the ratios of an age-matched control group. However, 12 of the 34 patients with inflammatory back pain had normal or equivocal sacroiliac radiographs and 4 of 12 had normal SIJ/S ratios. All 4 were HLA-B27 positive, had diminished lumbar movement, and required antiinflammatory medication; 2 had diminished chest expansion; 1 has developed iritis. We conclude that this technique is not a reliable screening procedure. Therapy with antiinflammatory drugs was associated with a significant decrease in the SIJ/S ratios in 19 of the 34 who were reimaged.
Adolescent↗
Adult Still's disease.
The clinical and laboratory features in six patients with adult Still's disease are presented and compared with those in 52 other cases gathered from the literature. Although there is no pathognomonic abnormality, the condition can be readily recognized by the striking constellation of clinical and laboratory abnormalities. The typical rash occurs in 90 per cent of the cases, arthritis in 88 per cent, a fever with temperatures of 40 degrees C or more in 83 per cent and leukocytosis of 18,000 cells/mm3 or more in 67 per cent. One or more ot the following are frequently found: lymphadenopathy (48 per cent), splenomegaly (45 per cent), pleuritis or pneumonitis (31 per cent) and pericarditis (26 per cent). The initial therapy of choice is high doses of nonsteroidal anti-inflammatory drugs. This is not an uncommon disease, as was once thought, and awareness of it will avoid unnecessary diagnostic procedures and delay in initiating therapy.
Adolescent↗
HLA B27 in rheumatoid factor-negative polyarthritis.
Eighty-three consecutive patients with rheumatoid factor-negative polyarthritis seen during a 1-year period were evaluated clinically, radiologically, and with the B27 test. Patients with definite spondylitis, juvenile chronic polyarthritis, a collagen disease, a known metabolic arthropathy, or primary generalized osteoarthritis were excluded. The patients could be classified into two groups independent of any knowledge of B27 testing. Twenty-five had a spondylitic "variant" syndrome. These could be diagnosed on clinical grounds, and included a male preponderance and a high frequency of B27 positivity. Fifty-eight patients, who could generally be classified by American Rheumatism Association criteria as having definite or classic rheumatoid arthritis, included a female preponderance and a normal prevalence of B27. Thus the B27 test was not more helpful than clinical diagnosis in the classic spondylitic variant syndromes, nor did it separate out a population of patients from among the seronegative rheumatoid arthritis group.
Adult↗
A case-control analysis of nonsteroidal anti-inflammatory drugs and Alzheimer's disease: are they protective?
In many studies of nonsteroidal anti-inflammatory drugs (NSAIDs) and Alzheimer's disease (AD), the exposure to NSAIDs was concurrent with AD or based on self (or surrogate) report. We conducted a case-control analysis of the Québec participants in the Canadian Study of Health and Aging who received a diagnosis of AD (cases) or were found to be cognitively unimpaired on screening (controls). Information on drug use was obtained from the Québec Provincial Pharmaceutical Services Database. There was no significant difference in the proportion of cases and controls who had received any NSAID prescriptions in the 3 years prior to the onset of symptoms of dementia; amongst NSAID users, there was no difference in mean dose or duration. Our findings, using a measure of drug use prior to symptom onset and not subject to recall bias, do not support a protective effect for NSAIDs.
Aged↗
Viscosupplementation: therapeutic mechanisms and clinical potential in osteoarthritis of the knee.
Viscosupplementation by means of intra-articular injections of hyaluronic acid has been used to treat osteoarthritis of the knee. The proposed mechanisms of action result from the physical properties of hyaluronic acid, as well as from its anti-inflammatory, anabolic, local analgesic, and chrondroprotective effects. Adverse reactions from hyaluronic acid injections into the knee occurred in 8.3% of the 336 patients treated in one study, but at a rate of less than 3% per injection. Reactions were almost always local and generally resolved over 1 to 2 days. Hyaluronic acid injections were approved by the US Food and Drug Administration as a medical device; thus, the level of efficacy demonstrated is less than might have been required for approval as a drug. Several studies have failed to show statistically significant benefit compared with placebo. Furthermore, the treatment is relatively expensive; the cost of the drug for a series of injections is more than $500 per knee. Therefore, widespread use of these agents should be limited until more convincing data on their efficacy are available from well-designed clinical trials.
Analgesics↗
Agreement among Ayurvedic practitioners in the identification and treatment of three cases of inflammatory arthritis.
OBJECTIVE: To conduct a preliminary investigation into the consistency of approach between three Ayurvedic medicine experts on treatments for inflammatory polyarthritis. METHODS: A convenience sample of three experienced Ayurvedic practitioners was recruited. These practitioners independently assessed three subjects with inflammatory polyarthritis for health status, treatment history, and lifestyle, conducted a physical examination, and then independently determined the treatment plan. The treatment plan was recorded on standardized collection forms. The subject examination order was randomized for each practitioner. Following completion of the assessments, a facilitated discussion among the practitioners permitted each to discuss all aspects of the recommended therapies. Proceedings were audio-taped and the content analyzed. RESULTS: All three practitioners agreed upon a unified concept of Ayurvedic disease origin, disease diagnosis, and treatment approach for each patient. Seven specific treatment groupings (i.e. modalities) emerged: diet, exercise, relaxation, analgesic, anti-inflammatory, immune-enhancing, and detoxification/cleansing. Based on the single visit, the practitioners agreed upon 17 of 21 treatment groups for the three patients. CONCLUSION: Despite Ayurvedic medicine's individualized approach, considerable agreement existed among the practitioners studied. The identified Ayurvedic treatment approaches require investigation in a controlled clinical setting.
Aged↗
[Lupus. The disease with a thousand faces].
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Antimalarials↗
Hepatic abnormalities in adult onset Still's disease.
Five patients with adult onset Still's disease are reported. Three had abnormal liver function tests (LFT) prior to receiving salicylates. Liver biopsy in 1 of these 3 and in another with normal LFT was abnormal. The elevated LFT returned to normal with high dose salicylate therapy coincident with remission of disease activity. It is proposed that hepatic abnormalities in Still's disease frequently reflect the underlying disease and not salicylate hepatotoxicity (SH).
Adolescent↗
Vasculitis as a presenting manifestation of primary biliary cirrhosis: a case report.
The association of vasculitis and asymptomatic primary biliary cirrhosis (PBC) was documented in a 39 year old female. Cyclophosphamide was used with good results. The Raji cell assay for circulating immune complexes (CIC) was positive initially with further values changing in parallel with disease activity. The C1q binding assay failed to reveal significant levels of CIC at any time. Lymphocytotoxic antibodies were not detected in the serum. Sucrose density ultra-centrifugation experiments revealed 9-17S material in sera that were positive for CIC by the Raji cell assay. We conclude that intermediate size CIC may be important in the pathogenesis of the vasculitis associated with PBC.
Adult↗