History Of Osteoarthritis Research Articles

Unexplained Hemolytic Anemia with Multiorgan Failure

A 51-year-old white male with history of osteoarthritis, hypertension, and insomnia presented to the hospital with a 1-month history of fatigue, as well as a 1-week history of back pain, nausea, and dark urine. The patient worked as a construction contractor and lived with his wife. His family history was limited to his mother having diabetes. He was taking scheduled hydrochlorothiazide and celecoxib and taking zolpidem as needed. In addition, he was also taking a wide variety of nonprescribed nutritional supplements. At presentation, the patient had a decreased hemoglobin concentration of 3.5 g/dL [reference interval (RI),4 13.5–17.5 g/dL, with a baseline hemoglobin value of 12 g/dL obtained 6 months previously], a reticulocyte count of 1.2% (RI, 0.7%–3.2%), a total bilirubin value of 17.6 mg/dL (RI, 0.2–1.2 mg/dL), a direct bilirubin value of 4.6 mg/dL (RI, 0–0.5 mg/dL), a lactate dehydrogenase activity of 693 U/L (RI, 0–248 U/L), and a positive result in a direct antiglobulin test for IgG. His haptoglobin concentration was <30 mg/dL (RI, 48–224 mg/dL). A peripheral blood smear from the patient had 1 or 2 schistocytes and 1 or 2 spherocytes per high-power field, a typical platelet morphology, and hyperlobated neutrophils. He was transferred to an intensive care unit 2 days after presentation. Treatment with intravenous immunoglobulin and methylprednisone was initiated for immune hemolytic anemia. A bone marrow biopsy showed erythroid hyperplasia. His values for red blood cell folate, serum vitamin B12, C3, C4, rheumatoid factor, and red blood cell glucose-6-phosphate dehydrogenase activity were within their respective RIs, and the results of serum tests for antinuclear antibodies, cold agglutinin, and Mycoplasma antibodies were negative. He sequentially received rituximab, cyclophosphamide, and then plasmapheresis, in addition to methylprednisolone and intravenous immunoglobulin to treat his ongoing anemia. The patient was given transfusions of packed red blood cells …

A middle-aged woman with nausea, weight loss, and orthostatic hypotension

A 54-year-old, right-handed, Caucasian woman presented with intermittent nausea, vomiting, and orthostatic hypotension of 1 year duration. Following every meal, she would belch and vomit nonbloody undigested food. She reported constipation and fatigue and felt lightheaded and occasionally lost consciousness on standing. She denied visual changes, dysphagia, dysarthria, weakness, involuntary movement, or loss of urinary or fecal continence. She denied fever, chill, dysuria, diarrhea, or coughing. At one point, she was hospitalized for rehydration every 2 weeks. She had lost nearly 80 pounds over the prior year. She had a history of osteoarthritis with bilateral knee replacements. Her current medications were lansoprazole, midodrine hydrochloride, fludrocortisone acetate, and metoclopramide without significant relief. Her family history was remarkable for cancer and a brother had Down syndrome. She previously worked as a draftsman. She did not use tobacco or recreational drugs and rarely drank alcohol. General examination was significant for orthostasis. Supine blood pressure was 143/89 mm Hg with heart rate of 88 beats per minute. Upon standing, her blood pressure dropped to 63/44 mm Hg with heart rate increasing to 102 beats per minute. Mental status, language, and cranial nerve examination were normal. Sensation to vibration and pinprick was decreased distally in the lower extremities bilaterally. Light touch and temperature sensation were normal. Romberg sign was negative. Muscle strength and tone was normal in all extremities. Deep tendon reflexes were intact in biceps, triceps, brachioradialis, and patellar but absent at the Achilles. Plantar responses were flexor. Limb coordination was normal. She could stand without assistance for only under 1 minute before becoming lightheaded, requiring sitting. Extensive gastrointestinal workup at different hospitals including mesenteric lymph node biopsy led to the diagnosis of sclerosing mesenteritis. Treatment with prednisone provided only transient relief. Her endocrine evaluation did not reveal a cause for the orthostasis. Transthoracic …

Strontium ranelate effect in postmenopausal women with different clinical levels of osteoarthritis

Objective The objective of this post hoc analysis was to investigate the effect of strontium ranelate on a cartilage degradation marker in postmenopausal women who participated in a randomized, placebo-controlled osteoporosis study. Women were stratified according to reported symptoms of osteoarthritis and to the baseline levels of a cartilage degradation marker.Methods The analysis included the 2617 postmenopausal women (75 years old) with osteoporosis randomized to strontium ranelate or placebo for a 36-month period. Cartilage degradation was evaluated using a validated urinary marker adjusted for creatinine (CTX-II/cr), whereas bone resorption was assessed by serum CTX-I. The presence of osteoarthritis was determined by individual interviews.Results CTX-II was significantly elevated at baseline in subjects with a history of osteoarthritis (OA+) compared to subjects who did not (OA−) (p < 0.0001), whereas CTX-I was unaffected by osteoarthritis status. Strontium ranelate caused a significant decrease from baseline in CTX-II over a 12-month period whatever the osteoarthritis status. Strontium ranelate-treated patients had a significant decrease in CTX-II compared to placebo in both OA+ and OA− groups up to 12 months, the difference remaining still significant at 36 months in patients from the OA− group (p < 0.001).Conclusions The CTX-II profile of changes over 3 years may reflect efficacy of strontium ranelate against cartilage degradation, with an enhanced beneficial effect in subjects with early or mild clinical osteoarthritis, probably exerting its putative chondroprotective influence in early stages of the disease. Carefully controlled studies in targeted populations with early osteoarthritis are warranted to assess the role of strontium ranelate halting osteoarthritis progression.

Periorbital edema associated with separate courses of ibuprofen and naproxen

A case of periorbital edema associated with separate courses of ibuprofen and naproxen is reported. An 80-year-old African- American woman with a history of osteoarthritis and hypertension came to the clinic. Her medication regimen included fosinopril sodium 40 mg daily, which she began two years prior. She had no known drug allergies and denied consuming any over-the-counter medications or herbal substances and reported a negative atopic status. She had seen her primary care provider several days prior and reported pain in the hands, fingers, and ankles, which would escalate in the morning and progressively lessen during the course of the day. Her physician prescribed naproxen 375 mg every eight hours as needed. After ingesting two doses of naproxen, she developed itching, swelling, and erythema around the left eye that became progressively worse and spread to the right eye. She contacted her primary care physician, who instructed her to discontinue the naproxen, and the reaction resolved within three days. The patient was maintained on acetaminophen for the arthritic pain with no issues. Approximately three months prior, ibuprofen 600 mg every eight hours as needed was prescribed for the same pain. She stated that after ingesting two doses of ibuprofen, she experienced a reaction similar to that recently experienced with naproxen. At that time, she was instructed to discontinue the ibuprofen, and her symptoms resolved. An elderly woman developed periorbital edema after taking ibuprofen on one occasion and naproxen on another.

High-resolution 18F-FDG PET with MRI for monitoring response to treatment in rheumatoid arthritis

Eur J Nucl Med Mol Imaging (2010) 37:1047 DOI 10.1007/s00259-009-1364-x IMAGE OF THE MONTH High-resolution 18 F-FDG PET with MRI for monitoring response to treatment in rheumatoid arthritis Abhijit J. Chaudhari & Spencer L. Bowen & George W. Burkett & Nathan J. Packard & Felipe Godinez & Anand A. Joshi & Stanley M. Naguwa & David K. Shelton & John C. Hunter & John M. Boone & Michael H. Buonocore & Ramsey D. Badawi Received: 20 November 2009 / Accepted: 10 December 2009 / Published online: 30 January 2010 # The Author(s) 2010. This article is published with open access at Springerlink.com Molecular imaging can potentially provide means for mon- itoring response to therapy in rheumatoid arthritis (RA) early in the course of disease [1].Quantitative measurements of RA disease activity made in the wrist by whole-body PET scanners, however, have inadequate accuracy because of limited spatial resolution [2]. A high-resolution PET/CT scanner for imaging extremities has been built at our insti- tution [3]. In conjunction with a clinical MRI scanner, high- resolution PET/MR images can be obtained for the wrist. The CT image is used for PET/MR image coregistration. A 57-year-old female with established RA was stable until a recent clinical flare-up in the right wrist. Clinical exami- nation revealed synovitis, swelling, and diminished range of motion. The patient also had a history of osteoarthritis (OA). An extremity 18 F-FDG PET/CT scan immediately following MRI at baseline was performed on this patient. Tumor necrosis factor alpha (TNF-α) inhibitor (etanercept) therapy was then initiated as a part of the patient’s standard of care. The patient was re-scanned 5 weeks after starting treatment. The figure shows high-resolution 18 F-FDG PET images (pseudocolor) overlaid on pre-contrast MRI images (gray This work was funded by the NIH grants UL1-RR024146, R01CA129561, R01EB002138 and the UC Davis Imaging Research Center. A. J. Chaudhari (*) : S. L. Bowen : G. W. Burkett : N. J. Packard : F. Godinez : D. K. Shelton : J. C. Hunter : J. M. Boone : M. H. Buonocore : R. D. Badawi Department of Radiology, UC Davis Medical Center, Sacramento, CA, USA e-mail: ajchaudhari@ucdavis.edu A. A. Joshi Department of Neurology, UCLA School of Medicine, Los Angeles, CA, USA S. M. Naguwa Department of Internal Medicine, UC Davis Medical Center, Sacramento, CA, USA scale) at baseline (left column) and 5 weeks (right column). Significant reduction in PET signal (suggesting reduced inflammation) in the synovium and at sites of erosions (white arrows) is visible. The green arrow shows inflammation due to OA. Physician examination at 3 months confirmed that this patient responded positively to etanercept. This case illustrates the potential of high-resolution PET with MRI for quantitative visualization of early response to therapy in RA. Open Access This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which per- mits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Clinical risk factors for osteoporotic fracture: A population-based prospective cohort study in Korea

Clinical risk factors (CRFs), either alone or in combination with bone mineral density, are used to determine the fracture risk for clinical assessment and to determine intervention thresholds. Because fracture risk is strongly affected by ethnicity and population-specific differences, we sought to identify Korean-specific CRFs for fracture, in combination with quantitative ultrasound (qUS) measurements of the radius and tibia. A total of 9351 subjects (4732 men and 4619 women) aged 40 to 69 years were followed for a mean of 46.3 +/- 2.2 months. We obtained CRF information using a standardized questionnaire and measured anthropometric variables. Speed of sound at the radius (SoSR) and tibia (SoST) were measured by qUS. Fracture events were recorded using a questionnaire, and a height-loss threshold was used as an indicator of vertebral fracture. Relative risks were calculated by Cox regression analysis. A total of 195 subjects (61 men and 134 women) suffered low-trauma fractures. Older age, lower body mass index (BMI), and previous fracture history were positively associated with fracture risk in both sexes. Decreased hip circumference, lack of regular exercise, higher alcohol intake, menopause, and osteoarthritis history were further independent CRFs for fracture in women. However, neither SoSR nor SoST was independently associated with fracture risk. In this study, we identified the major Korean-specific CRFs for fracture and found that smaller hip circumference was a novel risk factor. This information will allow optimal risk-assessment targeting Koreans for whom treatment would provide the greatest benefit.

Obesity Indices and Obesity-Related Quality of Life in Adults 65 Years and Older

Background: Obesity is known to influence on physical, mental, functional health problems but there have been no study of relationship between body mass index (BMI) and quality of life (QOL) in Korean elderly. Methods: A total of 216 elderly who had been attending two geriatric welfare facilities in Seoul answered the Korean version of obesity-related quality of life (KOQOL) questionnaire. Height, weight, waist circumference were measured. Body fat (%) was measured with HTM20 by impedance technique. Sociodemographic and medical factors were interviewed. QOL was assessed using KOQOL (ver.1) after excluding two sexual life related questions and one work related question. The total score is 48 points. The higher is the score, the poorer is the QOL. Results: In multivariable analysis, BMI, age, history of diabetes mellitus, history of osteoarthritis were associated with KOQOL score. Especially, BMI was significantly associated with KOQOL score after adjusting for waist circumference, body fat (%) (P = 0.002). Conclusion: The more BMI increases, the worse the obesity related QOL is in Korean ambulatory elderly.

Reviewer’s comment concerning “Technical factors related to the incidence of adjacent superior segment facet joint violation after transpedicular instrumentation in the lumbar spine” (Zhao Jie et al., MS-No. ESJO-D-08-00308)

This is a prospective study to analyze the incidence of superior segment facet joint violation after pedicel screw instrumentation in the lumbar spine and to evaluate technical factors related to the incidence. The study is well designed with clinical evidence. Unfortunately it only repeats widespread clinical knowledge using sophisticated investigation tools as special CT scanning. It is a known fact that pedicle screw insertion should not interfere with the integrity of adjacent (upper level) facets. Unfortunately this is not always possible especially in the advent of severe arthritic changes. It is also a well known fact that the Weinstein or Magerl technique of pedicle screw application results in a less amount of facet joint violation compared to Roy Camille’s. The authors repeat this using an indirect tool (CT scan) to once again prove what is known. The information, which was gained by sophisticated tools could have been reported by the surgeon easily. I would have appreciated if the authors had taken their patient group and looked for degeneration in an adjacent segment violated by a pedicle screw. This could be compared to a nonviolated group to find out about the influence of facet joint irritation on the history of osteoarthritis. Using the exact CT scanning method the authors have set up an even more valuable scientific result could have been achieved. Maybe this can be done in further analysis of the material.

Elderly patient refractory to multiple pain medications successfully treated with integrative East&ndash;West medicine

Polypharmacy is a common and serious problem in the elderly today. Few solutions have been effective in reducing its incidence. An 87-year-old female with a history of osteoarthritis and spinal stenosis presented with a five month history of severe right hip pain. She had been seen by multiple specialists and hospitalized many times. During these encounters, she was prescribed a long list of pain medications. However, these medications did not improve her pain and added to her risk of adverse drug events. After exhausting traditional Western medical therapies, she received a referral to the UCLA Center for East-West Medicine. There, clinicians treated her with a nonpharmacological integrative East-West medicine approach that included acupuncture, dry needling of trigger points, and education on self-acupressure. Her pain began improving and she was able to cut back on analgesic use under physician supervision. Ultimately, she improved to the point where she was able to discontinue all of her pain medications. Symptomatic relief was evidenced by improvement in health-related quality of life (HRQOL). This case study suggests that integrative East-West medicine may have the potential to reduce the incidence of polypharmacy in elderly patients presenting with pain conditions and improve their quality of life.

Prevalence and associations of hallux valgus in a primary care population

To determine the population prevalence and examine factors associated with hallux valgus in a primary care population. A questionnaire was mailed to all adults age >30 years registered with 2 general practices. Validated instruments assessed self-reported hallux valgus, nodal osteoarthritis, and knee pain. The questionnaire also asked about big toe pain, joint replacement, and history of osteoarthritis and rheumatoid arthritis. Hallux valgus prevalence was calculated and standardized by the source population in terms of age, sex, knee pain, osteoarthritis, and rheumatoid arthritis. A nested case-control study was undertaken and age-sex adjusted odds ratios (ORs) were calculated between hallux valgus and age, sex, body mass index, nodal osteoarthritis, knee pain, big toe pain, joint replacement, self-reported osteoarthritis, and self-reported rheumatoid arthritis, using a binary logistic regression model. A total of 13,684 questionnaires were mailed and 4,249 (32%) responses were received. The standardized prevalence of hallux valgus was 28.4%. Hallux valgus was associated with age (adjusted OR 1.61 per decade; 95% confidence interval [95% CI] 1.52-1.69), female sex (adjusted OR 2.64; 95% CI 2.26-3.08), nodal osteoarthritis (adjusted OR 1.66; 95% CI 1.26-2.17), knee pain (adjusted OR 1.96; 95% CI 1.65-2.32), big toe pain (adjusted OR 3.28; 95% CI 2.48-4.33), self-reported osteoarthritis (adjusted OR 1.41; 95% CI 1.15-1.72), and self-reported rheumatoid arthritis (adjusted OR 2.04; 95% CI 1.43-2.91). Hallux valgus is prevalent in the community and is associated with age, female sex, and components of generalized osteoarthritis such as nodal osteoarthritis, knee pain, big toe pain, and self-reported osteoarthritis.

An unusual case of knee pain

A 75-year-old man was referred to the orthopaedic department to discuss left total knee replacement surgery. He had attended his G.P.’s surgery with a stiff joint, which had become increasingly painful over a 3-month period. A clinical diagnosis of osteoarthritis was made and he had an intra-articular steroid injection, which failed to improve his symptoms. He was therefore referred on to the orthopaedic clinic. No radiological examinations had been requested at this stage. He had a history of osteoarthritis of the left hip for which he had undergone a total hip replacement in 1987. In 1996 he had sustained a peri-prosthetic fracture following a fall. After 6 weeks in skeletal traction there had been no evidence of bone healing and revision surgery was performed. In February 1997 he had undergone a cemented revision arthroplasty using a long-stem Charnley prosthesis with allogenic bone grafting. Postoperative X-rays showed good position and although at the 2-month stage a degree of peri-prosthetic loosening was noted, this did not progress in the two and a half years of post-operative follow-up. In November 1999 he had been discharged from clinic.

Relief of pain in acute herpes zoster by nerve blocks and possible prevention of post-herpetic neuralgia

This report describes two cases of acute herpes zoster (AHZ) treated by nerve block resulting in immediate pain relief and possible prevention of post-herpetic neuralgia (PHN). Two elderly females with AHZ of cervical dermatomes and severe pain received deep cervical and greater occipital nerve blocks with a local anesthetic, epinephrine and steroid. In both patients, pain resolved immediately and permanently (one year follow-up) after a single treatment. Case #1: A 79-yr-old female with a mechanical mitral valve and anticoagulated with warfarin presented with AHZ of 17 days duration of the right C2, 3, 4 dermatomes and severe pain. A stellate ganglion block was not performed because of anticoagulation. Rather, a deep cervical root block at C3 and a greater occipital nerve block were performed with bupivacaine, epinephrine and methylprednisolone. No adverse events were evident. Case #2: A 73-yr-old female with a history of osteoarthritis and Meniere's disease presented with AHZ of seven days duration of the left C2, 3, 4 dermatomes and severe pain. Deep cervical root blocks at C3 and C4 and a greater occipital nerve block were performed with bupivacaine, epinephrine and methylprednisolone. Side effects of dizziness, hoarseness, hypertension and Horner's syndrome resolved in a few hours. A mild sensation of itching persisted for two weeks. This report illustrates the potential of nerve blocks in severe AHZ to treat acute pain and possibly prevent PHN.

The histologic changes of the olecranon fossa membrane in primary osteoarthritis of the elbow

Eight randomly selected patients undergoing the Outerbridge-Kashiwagi (ulnohumeral arthroplasty) debridement procedure for primary osteoarthritis of the elbow had fenestration of the olecranon fossa by use of a bone trephine. The cores of bone removed were compared histologically with age- and sex-matched controls derived from necropsy samples with no history of osteoarthritis. All components of the olecranon fossa membrane (anterior cortical bone, medullary cavity, posterior cortical bone, and anterior and posterior fibrous tissue) were noted to be of increased thickness in those patients with osteoarthritis of the elbow when compared with the control group. With the exception of the anterior surface fibrous tissue, these differences were of statistical significance by use of the Wilcoxon signed rank test (anterior cortical bone, P = .01; medullary cavity, P = .01; posterior cortical bone, P = .02; and posterior surface fibrous tissue, P = .01). Bone volume was also measured in the two groups and was statistically greater in the patients with osteoarthritis compared with the control group ( P = .01).

The effects of physician specialty and patient comorbidities on the use and discontinuation of coxibs.

To examine the effects of physician specialty and comorbidities on cyclooxygenase 2-selective nonsteroidal antiinflammatory drugs (NSAIDs; coxibs) utilization. Medical records of 452 patients from a regional managed care organization with >/=3 consecutive NSAID prescriptions from June 1998 to April 2001 were abstracted. Multivariable adjusted associations between coxib initiation and discontinuation and patient and provider characteristics were examined. A total of 1,142 NSAID prescriptions were written over 9,398 total patient-months of followup. Compared with patients seeing family or general practitioners, patients seeing rheumatologists (odds ratio [OR] 3.4, 95% confidence interval [95% CI] 2.1-5.7) and internists (OR 2.3, 95% CI 1.5-3.6) were significantly more likely to receive a coxib, as well as patients with a history of osteoarthritis (OR 2.6, 95% CI 1.7-3.8), gastrointestinal disease (OR 2.3, 95% CI 1.2-4.5), and congestive heart failure (OR 4.1, 95% CI 1.0-16.4). Although specialists were more likely than generalists to prescribe coxibs, only family or general practitioners were significantly more likely to selectively use coxibs among their patients with a history of gastrointestinal disease. Fifty-four percent of NSAID prescriptions were discontinued, and coxibs were significantly less likely to be discontinued than were traditional NSAIDs (OR 0.6, 95% CI 0.5-0.8). Our findings suggest significantly greater, but perhaps less selective use of coxibs among specialists, even after accounting for important covariates. The initiation and discontinuation of coxibs was influenced by physician specialty and by patient risk factors.

A 57-Year-Old Man With Osteoarthritis of the Knee

DR SHIP: Mr V is a 57-year-old man who has had knee pain for at least 30 years. He lives in Boston with his wife, with whom he owns and runs a business. He has managed care insurance and sees his primary care physician, Dr P, at Beth Israel Deaconess Medical Center. Mr V dates the onset of his left knee problems to a soccer injury at age 26. He was diagnosed with rupture of 2 ligaments and underwent a course of physical therapy. His pain diminished over time, but he was aware that his left knee was never again at “100%.” He continued his active athletic life, which included soccer, bicycle racing, and running at least 3 times per week. About 15 years ago, however, pain in his left knee recurred and became severe enough that he stopped running and moved largely to long-distance cycling. Thirteen years ago he underwent an arthroscopic debridement. This improved his level of function and decreased his pain for approximately 2 years, but symptoms subsequently recurred. He has since had several courses of physical therapy but has found the recommended exercises to be so painful that he could not complete them. Despite persistent, often severe, knee pain, Mr V remains a very active long-distance (“ultra marathon”) bicyclist, cycling in qualifier events and races of more than 700 miles (1120 km). He estimates his annual cycling distance to be about 7000 miles (11200 km), a number that he views as a marked reduction from his previous distance of between 10000 and 12000 miles (16000-19200 km) annually. In addition, he continues to lift weights and work out regularly. His knee pain has progressed, however, so that he often has severe pain after standing for long periods as he needs to during work, and he is unable to garden because of pain brought on by bending his left knee. He was prescribed naproxen, 1000 mg/d, but finds that 500 mg/d is effective at “helping” with the pain, and he is hesitant to take the higher dose. Other than knee pain, Mr V is very healthy. He has no other medical problems and has had no other surgical procedures. He follows a vegetarian diet and neither smokes nor drinks. In addition to the naproxen, he takes garlic pills. He is not allergic to any medications. There is no family history of osteoarthritis. On physical examination, Mr V was 5’10” tall and weighed 155 lb. His left knee appeared slightly larger than his right but had no erythema or warmth. When standing, he had varus deformities of both knees and a slightly antalgic gait. Range of motion on the left knee was 5° to 120° compared with 5° to 140° on the right. Collateral and cruciate ligaments were stable. Crepitus was noted. There was a moderate effusion in the left knee and a palpable semi-membranous bursa. There was no distal neurovascular compromise in either knee. Hip range of motion was full and pain-free bilaterally. Radiographs of the left knee in 1999 revealed marked tricompartmental osteoarthrosis with prominent osteophyte formation and severe joint space narrowing. The medial joint space was the most narrowed compartment. There was subchondral sclerosis, most prominently also in the medial hemijoint space, and lateral subluxation and varus angulation were noted. Significant subchondral cystic changes were identified involving the tibial plateau centrally as well as the medial femoral condyle, thought to represent geode formation from osteoarthrosis. Total knee replacement has been offered to Mr V, but different orthopedists have varied in their recommendations regarding the timing of the surgery. Mr V wonders whether and when he should plan to undergo knee replacement and how long he can expect the prosthesis to last.

Facial swelling and eosinophilia in a 44-year-old woman

CHIEF COMPLAINT A 44-year-old woman was referred to our institution for evaluation of facial swelling and progressively increasing eosinophilia, which began 2 months before she was seen. The patient first noticed right-sided temple and periorbital angioedema 2 days after completing a 10-day course of cefuroxime (Ceftin, GlaxoSmithKline, Research Triangle Park, NC) for a presumed upper respiratory infection/flulike illness. A complete blood count done 4 days after cefuroxime treatment was completed revealed an eosinophil count of 1,384 cells/mm3. The patient was then evaluated by an otolaryngologist and treated with a methylprednisolone acetate (Medrol Dose Pak Pharmacia, Peapack, NJ) and cetirizine hydrochloride (Zyrtec, Pfizer, New York, NY), which resulted in complete resolution of swelling. Angioedema recurred 2 days after she completed the methylprednisolone course (GlaxoSmithKline, Research Triangle Park, NC). Because of recurrent symptoms, she was started on zafirlukast (Accolate, AstraZeneca, Wilmington, DE) 20 mg twice a day and ranitidine (Zantac, GlaxoSmithKline) 75 mg twice a day. Angioedema persisted. Two weeks before the patient was seen in our institution, her eosinophil count increased to 5,742 cells/mm3. At that time, she was given a second methylprednisolone course. The angioedema again resolved completely and then recurred several days after methylprednisolone was completed. Two days before we saw her, her eosinophil count increased further to 13,050 cells/mm3. The patient was seen at our institution complaining of facial and upper extremity swelling, a 16-pound weight gain over the past 2 months, fatigue, and a nonpruritic rash on bilateral antecubital fossae for the past 2 to 3 days. She denied any headaches, shortness of breath, chest tightness, abdominal pain, bloody stools, lower extremity edema, or numbness/tingling in any extremities. MEDICAL HISTORY The patient had a history of osteoarthritis and mild mitral regurgitation. Surgical history was significant for breast biopsy of a benign tumor 6 years before and a total abdominal hysterectomy and bilateral oopherectomy 3 months before she was seen. She experienced allergy to penicillin 1.5 years earlier, which manifested as self-limited hives. There was no history of asthma, urticaria, food allergy, or recurrent respiratory infection.

A Flexible Daily Dosage Regimen of Oxaprozin Potassium in Patients with Acute Knee Pain Associated with Osteoarthritis

To assess the 24-hour analgesic durability of oxaprozin potassium at dosages of 1200 to 1800 mg/day and safety at dosages up to 1800 mg/day for 14 days for the treatment of acute knee pain associated with osteoarthritis. A multicentre, double-blind, placebo-controlled, randomised, parallel-group study was conducted at 24 centres throughout the United States. Patients (n = 491) with at least a 6-month history of osteoarthritis of the knee and current evidence of acute pain flare were enrolled. Patients self-administered oral oxaprozin potassium 1200 to 1800mg (1200mg plus an optional, additional 600mg), oxaprozin potassium 1800mg (as a single daily dose), ibuprofen 400mg, or placebo daily for 14 days. The Pain Intensity Difference (PID) in the treatment group (n = 168) receiving oxaprozin potassium 1200 to 1800mg was significantly (p < 0.05) different compared with placebo at 15, 18 and 21 hours, and numerically superior (p = 0.062) at 24 hours. Analysis of summed measures [Sum of Pain Intensity Difference (SPID), combined Pain Relief and Pain Intensity Difference (PRID) and Summed PRID (SPRID)] found that oxaprozin potassium 1200 to 1800mg was significantly (p < 0.05) different compared with placebo at 15, 18, 21 and 24 hours for all three measures. Adverse events resulting in withdrawal were reported by 8% of patients in the placebo group, 10% of patients in the oxaprozin potassium 1200 to 1800mg treatment group, 14% of patients in the oxaprozin potassium 1800mg treatment group, and by 4% in the ibuprofen 400mg treatment group. There were no serious adverse events attributable to study medication. Oxaprozin potassium 1200 to 1800mg daily is a well-tolerated and efficacious analgesic with 24-hour duration in patients with acute knee pain associated with osteoarthritis. The flexible drug administration regimen empowers patients to manage their variability in pain with the lowest effective dose of prescribed medication for pain relief.

Accidental Intravenous Levobupivacaine

Accidental Intravenous Levobupivacaine

Multiple Plaques of Morphea Developing in a Patient With Eosinophilic Fasciitis

<h3>To the Editor.—</h3> Eosinophilic fasciitis (EF) is characterized by sclerodermalike changes associated with peripheral blood eosinophilia, hypergammaglobulinemia, and an elevated erythrocyte sedimentation rate.¹Since the first description by Shulman in 1974,²over 200 patients with EF have been described. Whether EF is a variant of scleroderma or a separate disease entity is still unclear. Multiple plaques of morphea developed in our patient 1 year after EF was diagnosed, which suggests a possible relationship between the two disorders. <h3>Report of a Case.—</h3> In January 1989, a 62-year-old white woman with a history of osteoarthritis was referred to the outpatient clinic of our department because of pain and stiffness in the skin of her lower extremities. She had not taken any drugs or L-tryptophan. On examination, the skin of her lower extremities was edematous and indurated. A full-thickness (down to underlying muscle) biopsy specimen from the upper leg revealed a

Septic arthritis caused by treatment resistant Pseudomonas cepacia.

A case of septic arthritis of the knee caused by Pseudomonas cepacia following an intraarticular corticosteroid injection in a patient with a history of osteoarthritis is presented. This is the second report of this agent causing infection in a diarthrodial joint, which proved difficult to eradicate despite in vitro antibiotic sensitivity.