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N J Gerber

Publications and source records attributed to N J Gerber.

At least 19 recordsLinked to original sources
PubMed2000

[Fever of unknown origin as a sign of calcium pyrophosphate deposition disease].

Calcium pyrophosphate dihydrate (CPPD) crystal deposition disease may manifest clinically as septic fever (40 degrees C), acute pseudogout attack of knee, wrist and shoulders, or as a variety of patterns of chronic inflammatory or degenerative joint disease. The association of pseudogout with fever is less widely recognised and may lead to over-investigation, delay in appropriate treatment and disproportionate costs. We report on a 67-year-old woman with a history of recurrent episodes of fever and polyarthritis every 2 months for the last 3 years. Because of this she was hospitalised several times, finally with suspected culture-negative endocarditis, and was treated for 6 weeks with gentamicin, rifampicin and vancomycin. During this therapy the patient again developed septic fever and acute arthritis of the right wrist. Radiographs of the wrist, knee and symphysis pubis revealed prominent chondrocalcinosis and destructive arthropathy.

Aged↗
PubMed1999

[Detection of Borrelia DNA in synovial fluid for diagnosis of Lyme arthritis].

AIM: To test sensitivity and specificity of a polymerase chain reaction (PCR) targeting the Borrelia specific outer surface protein (Osp) A gene in synovial fluid for the diagnosis of Lyme arthritis, and thus permit an earlier start to treatment. PATIENTS AND METHODS: Prospectively we examined the synovial fluid of 37 patients with the clinical diagnosis of Lyme arthritis or with other arthropathies of known or unknown origin, searching for the presence of detectable borrelial DNA in both arms of the study. Retrospectively we examined the stored synovial fluid from 50 patients of the Department of Rheumatology of the University Hospital, Berne, with the clinical diagnosis of monarthritis or oligoarthritis of unknown etiology, juvenile chronic arthritis or rheumatoid arthritis. The laboratory biologist was unaware of the clinical diagnosis. RESULTS: In the prospective study no true false positive results were found: of the 28 patients without strong clinical suspicion of Lyme arthritis 27 were PCR negative. In one case with positive PCR for borrelial DNA the diagnosis could not be clarified, Lyme arthritis remaining a possibility. Therefore the specificity in the prospective study was at least 96%. Borrelial DNA in the synovial fluid was found in 5 out of 9 patients with strong clinical suspicion of Lyme arthritis. All 7 patients in this group were new, untreated cases. All the 5 PCR positive results belonged to this group, thus the "sensitivity" of the tested method was 71% in untreated cases of Lyme arthritis. In the retrospective study we found borrelial DNA in the synovial fluid of 2 patients. These 2 patients had gonarthritis of unknown origin. Retrospectively these 2 cases could be diagnosed as Lyme arthritis. CONCLUSION: In cases with clinical suspicion of Lyme arthritis the PCR method targeting a borrelial Osp A gene fragment common to all 3 European genospecies shows very good specificity and in untreated cases acceptable sensitivity. Introduction of the method studied into clinical practice is justified.

Adolescent↗
PubMed1998

[Hypermobility syndrome. When too much activity causes pain].

Hypermobility of joints and spine is a consequence of abnormal laxity of ligaments, joint capsules and intervertebral discs. Hypermobility per se is a state, not a disease. However, it may lead to generalized arthralgia or localized symptoms (frequent ankle sprains, knee effusions, dislocations of the shoulders of recurrent episodes of back pain). These events may occur even after minor strains. Young women are preferentially affected. The term "hypermobility syndrome" is defined as a combination of hypermobility with arthralgia, low back pain, frequent dislocation or sprains. It is often the result of a hereditary disorder of connective tissue. Individuals with hypermobility are at increased risk for premature osteoarthrosis or polytopic disc degeneration of the spine. However, the vast majority of hyperlax individuals are free of symptoms. Those with symptoms who do not develop osteoarthrosis or disc degeneration usually experience spontaneous improvement with increasing age, thus losing their juvenile hyperlaxity. This usually occurs between the ages of thirty and forty. The present review article also provides guidelines for management and patient information.

Adolescent↗
PubMed1997

Quantitative liver function in patients with rheumatoid arthritis treated with low-dose methotrexate: a longitudinal study.

The objectives were to determine quantitative liver function prospectively in patients with rheumatoid arthritis (RA) treated with low-dose methotrexate (MTX), to search for risk factors for a loss of quantitative liver function and to assess the relationship between quantitative liver function and histological staging. A total of 117 patients with RA (ACR criteria, 85 women, mean age 59 yr) had measurements of galactose elimination capacity (GEC), aminopyrine breath test (ABT) and liver enzymes [aspartate amino transferase (AST), alanine amino transferase (ALT), alkaline phosphatase (AP), 7-glutamyl transferase (GGT), bile acids, bilirubin, albumin] before treatment with weekly i.m. MTX injections and every year thereafter. In 16 patients, liver biopsies were performed. Before the introduction of MTX, mean GEC was 6.6 mg/min/kg [5th to 95th percentile (5-95 PC) 5.1-8.5; reference range 6.0-9.1] and mean ABT was 0.80% kg/mmol (5-95 PC 0.42-1.30: reference range 0.6-1.0). During treatment with MTX [mean weekly dose 11.8 mg (5-95 PC 5.4-20.2), mean observation period 3.8 yr (5-95 PC 0.4-6.9)], significant declines of GEC (-0.12 mg/min/kg per year. t = 3.30, P < 0.002) and ABT (-0.06% kg/mmol per year, t = 4.81, P < 0.001) were observed. Negative correlations were found between the annual change in GEC and GEC at baseline (Rs = -0.40, P < 0.0001), and the annual change in ABT and ABT at baseline (Rs = -0.43, P < 0.0001). No correlations were found between the annual change in GEC or ABT and weekly MTX dose, age or percentage of increased liver enzymes, and no effect of a history of alcohol consumption > 30 g/week became evident. Two patients with Roenigk grade III had impaired quantitative liver function, while 14 patients with Roenigk grades I and II exhibited a high variability of GEC and ABT from normal to abnormal values. The continuous declines in GEC and ABT observed deserve attention in patients with prolonged treatment. Patients with a low GEC or ABT at baseline seem not to be at increased risk for a further loss of quantitative liver function. An impaired GEC or ABT does not necessarily concur with hepatic fibrosis on histological examination.

Alanine Transaminase↗
PubMed1996

Pulmonary function in rheumatoid arthritis treated with low-dose methotrexate: a longitudinal study.

Lung volumes and gas exchange were investigated prospectively in 96 patients with rheumatoid arthritis selected without regard to pulmonary disorders and treated with i.m. methotrexate (MTX) injections [mean weekly dose 13.0 mg (5th-95th percentile (5-95 PC) 7.6-20.8)]. Individual changes over time during MTX treatment [mean duration 2.9 yr (5-95 PC 0.4-5.3)] were assessed by regression analyses in each individual. Forced vital capacity (FVC) remained stable in the majority of patients [mean annual change +0.8% (5-95 PC -8.1 to +14.0) of calculated normal value]. In addition, transfer factor using the indicator gas CO (TL,CO) was unaltered in most patients [mean annual change -2.1% (5-95 PC -16.2 to +11.8) of predicted value]. However, there were significant decreases in the forced expiratory volume in 1 s (FEV1) before and after inhalation of 0.2 mg salbutamol [mean annual change -0.8% (5-95 PC -8.4 to +3.2) and -1.3% (5-95 PC -7.8 to +3.9) of the FVC measured, respectively]. In addition, there were significant increases in alveolar-arterial Po2 gradients (P(A-a),O2) at rest and after exercise [mean annual change +1.7 mmHg (5-95 PC -5.2 to +12.2) and +1.8 mmHg (5-95 PC -3.5 to 9.0), respectively]. Nevertheless, the amounts were small in view of the reliability of the methods applied and reflect, at least in part, the normal process of ageing. The annual change in FEV1/FVC was negatively correlated with FEV1/FVC at baseline (Rs = -0.46, P < 0.001). The annual change in TL,CO was also negatively correlated with TL,CO at baseline (Rs = -0.31, P = 0.028). No other risk factors for deterioration of lung volumes or gas exchange were found, including mean weekly MTX dose, age, gender, smoking, presence of rheumatoid factor and pulmonary function at baseline. We conclude that MTX has no major effect on pulmonary function in the majority of patients and that there is no evidence that patients with pre-existing pulmonary disease are at increased risk for further deterioration of lung function.

Aged↗
PubMed1996

Severe osteoporosis due to systemic mast cell disease: successful treatment with interferon alpha-2B.

We describe a 33-year old man suffering from severe vertebral osteoporosis and urticaria pigmentosa due to systemic mast cell disease (SMCD). Because i.v. clodronate therapy could not prevent further vertebral fractures, an additional treatment with interferon alpha-2b was initiated. During 24 months of treatment, our patient had no further pain episodes, no new vertebral fractures were discovered, trabecular bone mineral density (BMD) increased significantly and urticarial symptoms improved. Nevertheless, the extent of skin lesions remained unchanged. On histological examination, a remarkable decrease of mast cells was observed in the bone marrow, but not in the skin. Five months after discontinuation of interferon alpha-2b, trabecular BMD decreased and urticarial symptoms deteriorated. These findings illustrate a beneficial effect of interferon alpha-2b on SMCD-induced osteoporosis as well as urticarial symptoms, and raise the question whether this treatment may have a diverse impact on mast cell population in different tissues.

Adult↗
PubMed1996

Interleukin 1 (IL-1) receptor antagonist, soluble tumor necrosis factor receptors, IL-1 beta, and IL-8--markers of remission in rheumatoid arthritis during treatment with methotrexate.

OBJECTIVE: To examine circulating levels of cytokines and cytokine inhibitors and their production by blood mononuclear cells (MNC) in patients with active rheumatoid arthritis (RA) before treatment with methotrexate (MTX) and inactive disease upon treatment as well as healthy control individuals. METHODS: Interleukin-1 receptor antagonist (IL-1ra), soluble tumor necrosis factor receptors p55 and p75 (sTNFr; p55 and p75), interleukin-1 beta (IL-1 beta), tumor necrosis factor alpha (TNF-alpha), interleukin-8 (IL-8), and monocyte chemoattractant protein 1 (MCP-1) were assessed by immunoassays in sera and MNC culture supernatants of 27 patients with RA with active disease before and 14 patients with inactive disease during MTX treatment, and 10 healthy controls. RESULTS: Levels of circulating IL-1ra, sTNFr p55 and p75 were higher in patients with active RA compared to those with inactive disease or controls. At the cellular level, resting MNC of patients with active RA released more IL-1 beta and IL-8, but less IL-1ra, and showed a lower ratio of IL-1ra:IL-1 beta than MNC of patients without inflammatory symptoms or healthy controls. In addition, unstimulated and in vitro lipopolysaccharide stimulated MNC cultures of patients with inactive RA released higher amounts of sTNFr p75 than MNC of patients with active RA. CONCLUSION: Circulating levels of IL-1ra and sTNFr as well as IL-1 beta, IL-8, and sTNFr p75 release from MNC and the ratio of IL-1ra:IL-1 beta production by these cells serve as markers to assess complete disease remission in patients with RA during MTX treatment.

Adult↗
PubMed1995

[Gluten-sensitive enteropathy with intestinal T-cell lymphoma: an unusual cause of in disabling osteomalacia].

We describe a 64-year-old woman with a malignant intestinal T-cell lymphoma who presented four years later with disabling osteomalacia and secondary hyperparathyroidism due to malabsorption. Only two years later, when the patient had developed fatty stools, flatulence and weight loss, diagnosis of gluten-sensitive enteropathy (GSE) was confirmed by small-intestine biopsy. This case report illustrates that in adults GSE can be oligosymptomatic for long periods. In cases of osteomalacia or rare intestinal T-cell lymphoma a detailed history of bowel movements, inspection of stools, quantification of fat excretion in stools and laboratory tests for malabsorption are recommended. Positive antibodies against gliadin, endomysium and reticulin may support the diagnosis of GSE. However, intestinal biopsy is necessary to verify the presence of GSE. In view of the unspecific histological changes, a follow-up biopsy is recommended in oligosymptomatic cases. Serial measurements of antibodies allow supervision of compliance for a diet strictly free of gluten. In addition, lactose containing milk products need to be restricted initially because of secondary lactase deficiency.

Celiac Disease↗
PubMed1995

Diffuse idiopathic skeletal hyperostosis (DISH) of the shoulder. A controlled radiological study.

The prevalence of hyperostotic spurs (HS) in different areas of the shoulder was studied in 36 probands with and 58 probands without thoracospinal hyperostosis on lateral chest radiographs. Bilateral shoulder radiographs in three projections were analysed blindly, recording the presence of HS at six separate sites (glenoid, greater tuberculum, acromion, acromioclavicular joint, coracoid and humeral shaft) and applying defined grading criteria. The prevalence of HS ranged from 11.7% of the shoulders at the coracoid to 50.0% at the glenoid. The prevalence of HS was similar on both sides [right, 30.1% of the sites versus left, 27.0%, relative risk (RR) 1.12 (95% confidence interval [Cl] 0.93-1.35)] and was not related to sex and history of work. Classification for the presence of shoulder hyperostosis was identical on both sides with the exception of one individual. In probands with thoracospinal and shoulder hyperostosis all areas analysed contributed to the classification. However, this was particularly prominent at the humeral shaft [RR 5.3 (95% Cl 2.1-13.0)] and the coracoid [RR 8.4 (95% Cl 1.9-36.4)]. These results indicated that the prevalence of HS and the specificity for the presence of diffuse idiopathic skeletal hyperostosis (DISH) vary between different sites. We suggest that future grading criteria for shoulder hyperostosis take into account the localization of HS, in addition to their number and size.

Aged↗
PubMed1995

Methotrexate action in rheumatoid arthritis: stimulation of cytokine inhibitor and inhibition of chemokine production by peripheral blood mononuclear cells.

This open label study examines whether methotrexate (MTX) treatment modulates ex vivo synthesis of interleukin-1 receptor antagonist (IL-1ra), soluble tumour necrosis factor receptors (sTNFR p55 and p75), interleukin-1 beta (IL-1 beta), tumour necrosis factor alpha (TNF-alpha), interleukin-8 (IL-8) and monocyte chemoattractant protein-1 (MCP-1) by peripheral blood mononuclear cells (PBMC) and whether changes reflect clinical response. Significant stimulation of IL-1ra and sTNFR p75 as well as inhibition of IL-8 production of PBMC were associated with clinical improvement observed in patients treated with MTX. When defining the characteristics of patients at study entry retrospectively in responders and non-responders, a significantly lower ratio of IL-1ra:IL-1 beta production before and its increase upon treatment was associated with clinical response in 13 patients compared to five patients not responding to MTX. In addition, clinical improvement was associated with decreased synthesis of IL-1 beta, TNF-alpha and IL-8 induced by bacterial lipopolysaccharide, IL-1 alpha and IL-1 beta in PBMC in vitro. These findings suggest that MTX therapy reverses the inflammatory type of rheumatoid arthritis (RA) blood mononuclear cells by stimulating cytokine inhibitor production while inhibiting inflammatory cytokine release at the same time. This may explain the powerful anti-inflammatory properties of low-dose MTX as observed in most RA patients. Pretreatment determination of the IL-1ra:IL-1 beta ratio in PBMC may be predictive with regard to a favourable therapeutic response and therefore may be useful for the selection of RA patients to be treated with MTX.

Adult↗
PubMed1994

Intraindividual variability of the bioavailability of low dose methotrexate after oral administration in rheumatoid arthritis.

OBJECTIVES: To analyse whether the intraindividual variability of the bioavailability of oral methotrexate in rheumatoid arthritis (RA) is as high as the interindividual variability and whether the bioavailability testing can be simplified. METHODS: Fifteen mg methotrexate was given orally after an overnight fast to 10 patients with RA on two occasions, one week (n = 4) or two years (n = 6) apart, respectively. Plasma samples were taken at specific time intervals and analysed by fluorescence polarisation immunoassay. The areas under the plasma concentration versus time curves from 0 to infinity (AUC) were calculated after fitting to a two-compartment extravascular model with lag time. RESULTS: The interindividual variability of the AUCs showed a more than five fold range from 77 to 471 min x mumol/l. In contrast, the intraindividual differences of AUCs between the two visits ranged from 3 to 100 min x mumol/l, reflecting a 3-30% change in nine of 10 patients. Close correlations were found between the AUCs and the plasma concentrations with a most pronounced correlation eight hours after methotrexate intake (r = 0.975; p < 0.001). CONCLUSIONS: The high interindividual variability of the AUCs was confirmed. Conversely, only a modest intraindividual variability was disclosed. Plasma sample analysis at a single time point four to eight hours after methotrexate application could simplify estimation of the bioavailability.

Administration, Oral↗
PubMed1994

[Backache--what to remember?].

This review tries to help the general physician to discriminate between extravertebral and vertebral causes of back pain by medical history and clinical investigation. The extravertebral causes are most often related to psychobiosocial disturbances, less often to muscular overload, viscerogenous or neurogenous causes. The vertebral causes, on the other side, are often related to functional disturbances of intervertebral joints or degenerative disorders or, in rarer instances, to metabolic, inflammatory, tumourous, or developmental disorders of the spine.

Back Pain↗
PubMed1993

Prophylaxis of falls and treatment of fractures.

This review has highlighted important preventive measures for falls and fractures in elderly osteopenic patients, and has discussed the therapeutic possibilities after an osteoporotic fracture has occurred. Assuming that a large proportion of osteoporotic fractures are a consequence of traumatic falls, and are not spontaneous, due to osseous weakness, preventive measures in elderly people are best directed to counteract muscular weakness, improve agility and correct visual impairment. It is also important to guard against unnecessary obstacles in the home and the reflex habits of doctors to prescribe hypnotics and tranquillizers, as well as their occasional tendency to overtreat hypertension. Practical examples of rational measures to protect against these causes of fractures have been given. In the second part of the review, the treatment of fractures has been delineated. The goals are adequate pain relief, early immobilization of the patient, avoidance of overtreatment and fast restoration of the quality of life. Three stages of pain relief by drugs are outlined. The first consists of a simple non-narcotic analgesic, such as paracetamol. In a second stage, either the combination of paracetamol with a muscle relaxant or the administration of a narcotic analgesic of medium potency is proposed. As a third stage, several therapeutic approaches to the administration of potent narcotic analgesics have been discussed. Non-drug measures, such as the use of heat, ultra-soft mattresses, walking frames, crutches and sticks, as well as active forms of physiotherapy, have been discussed both in terms of pain relief and early mobilization.

Accidental Falls↗
PubMed1992

[Identification of crystals in synovial fluid: joint-specific identification rate and correlation with clinical preliminary diagnosis].

The diagnostic clarification of joint effusions of unknown origin is a challenge to every primary-care physician. Important diagnostic procedures are arthrocentesis and analysis of the aspirated synovial fluid. Synovial fluid analysis frequently allows differentiation between harmless effusions due to osteoarthritis and crystal induced inflammation, or the more devastating septic arthritis. 4475 synovial fluids were evaluated retrospectively to calculate the identification rate of crystals compatible with calcium pyrophosphate dihydrate (CPPD) and monosodium urate monohydrate (MSUM). 40.8% (1827) of synovial fluids were taken from females and 59.2% (2648) from males. The frequency of crystal identification varied considerably: 13.2% CPPD crystal identification in females, 10.9% in males; MSUM was identified in 1.5% of females, and in 10.9% of males. The spectrum of joint involvement was nearly identical in CPPD and MSUM positive synovial fluids. Exceptions were the higher frequency of CPPD identification in shoulder joints (CCPD:MSUM = 15.6:1), the higher frequency of MSUM identification in the ankle (MSUM:CPPD = 15.6:1) and the first metatarsophalangeal joints (MSUM:CPPD = 8:1). Clinical suspicion correlated well with crystal identification in MSUM positive samples (60%), but was poor in CPPD positive samples (36%). The poor correlation between clinical suspicion and crystal identification in CPPD positive synovial fluids is explicable by the less characteristic clinical presentation of pyrophosphate arthropathy in contrast to classical gout. A high percentage of crystal identification was found in joints or periarticular swellings in which aspiration is difficult and therefore rare (e.g. tendon sheaths, first metatarsophalangeal and first metacarpophalangeal joints), underlining the importance of synovial fluid aspiration despite the difficulty of arthrocentesis.

Adolescent↗
PubMed1992

[Vasculitic skin lesions caused by nonsteroidal anti-inflammatory agents].

Today, non-steroidal anti-inflammatory drugs are very frequently prescribed agents. These drugs are responsible for side effects which are rarely recognized and poorly understood. One of these side effects is leukocytoclastic vasculitis with or without skin ulcerations. Rheumatoid arthritis and other mixed connective tissue diseases may also lead to vasculitis ulcerations, which explains the difficulty of correct diagnosis in each case. In addition, disease-modifying drugs such as methotrexate, frequently used in the above-mentioned syndromes, further complicate the situation because these agents may also produce vasculitis. In the present case study we analyze and discuss the diagnosis and follow-up in three of our patients with vasculitis skin ulcerations. In two of them, the vasculitis was attributed to the use of naproxen. Despite thorough examination and documentation of all three cases, etiologic evaluation was difficult and complex.

Aged↗
PubMed1992

[Mono-arthritis of uncertain etiology--a follow-up study].

78 patients in whom the cause of a monoarticular arthritis remained unclear after an initial workup were contacted for a follow-up interview (and an additional clinical examination in 64 cases) after 6 to 11 years (mean 8 years). The mean age at the onset of symptoms was 39 years, with 51% of the patients presenting in the range between 20 and 40 years. There was a slight male preponderance (56%). Large joints, mainly the knee, and less often the wrist, ankle or hip, were affected in 79%. Finger, toe and other small joints were involved in only 21%. During the course of the disease 14% of the cases developed arthritis in other joints. At the time of follow-up an etiologic or nosologic diagnosis was possible only in 5%: 1 infectious Pneumococcus pneumoniae arthritis, 1 Lyme arthritis (Borrelia burgdorferi), 1 gouty arthritis and 1 erosive seronegative rheumatoid arthritis. 95% of all cases remained unclear. However, 91% of all patients became free of symptoms after 6 years. The remaining patients (9%) suffered from arthralgia of undetermined origin (n = 5), from nonclassified destructive coxitis with consecutive development of unclear gonarthritis (n = 1), or from erosive seronegative rheumatoid arthritis (n = 1). 10 patients (13%) underwent a total of 16 invasive procedures related to their arthritis, such as synoviorthesis, synovectomy or arthrodesis. The result of the erythrocyte sedimentation rate had no influence on the outcome. The following conclusions are offered: monoarticular arthritis initially should prompt a thorough investigation in order to exclude infectious or metabolic etiologies for their destructive potential.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗