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On the heterogeneity of HLA association in juvenile rheumatoid arthritis.

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LETTERS
1216
dextrose injection or any other fluid which would even
slightly change the pH of the colchicine solution since
this may cause precipitation.”
Because this is a revision of previous package labeling, we directed inquiries to the Eli Lilly Company,
the only pharmaceutical concern currently supplying
colchicine for intravenous use. We were informed that
this change resulted from communications to them from
physicians who had noted precipitates in solutions following dilution of colchicine with dextrose or saline. As
a consequence, the company restudied batches of injectable colchicine produced over the last several years but
to date has been unable to identify a specific contaminant. Using normal saline as diluent, they have not
found significant precipitation. It has been decided to
shorten the “out-date’’ time to 4 years, and we have
been informed that future product inserts will state that
if the solution of colchicine is to be diluted, 0.9% Sodium Chloride Solution USP XX be used, while recommending against the use of 5% dextrose solution or any
solution containing a bacteriostatic agent (7).
Physicians should, of course, discard any solution in which a precipitate is noted. Precipitate is best
seen by holding a solution against a dark background
with light directed at the solution from the side. In any
event, it would be judicious to use an intravenous system equipped with a final filter when giving diluted colchicine.
DAVID
J. NASHEL,
MD
Chief, Rheumatology Section
Veterans Administration Medical Center
50 Irving Street, N W
Washington, DC 20422
1. McCarty DJ: Pathogenesis and treatment of crystal-induced inflammation, Arthritis and Allied Conditions. Edited by DJ McCarty. Philadelphia, Lea & Febiger, 1979, p
1257
2. Kelley WN: Gout and related disorders of purine metabolism, Textbook of Rheumatology. Vol. 2. Edited by WN
Kelley, ED Harris, S Ruddy, CB Sledge. Philadelphia, WB
Saunders, 1981, p 1421
3. Tabatabia MR,Cummings NA: Intravenous colchicine in
the treatment of acute pseudogout. Arthritis Rheum
23:370-374, 1980
4. Spilberg I, McLain D, Simchowitz L, Berney S: Colchicine
and pseudogout. Arthritis Rheum 23: 1062-1063, 1980
5 . Wallace SL: The treatment of gout. Arthritis Rheum
15:317-323, 1972
6. Wyngaarden JB, Kelley WN: Gout and Hyperuricemia.
New York, Grune and Stratton, 1976, pp 466471
7. Dyke R: Eli Lilly Company, personal communication
Table 1. Incidence of HLA-B27 in J R A patients
Onset.
No. patients
B27+
96
6
11
14
-
-
1
8
50
Males and females
A
P
0
I
Males only
A
P
0
*A
-
acute onset; P = polyarticular, 0 = oligoarticular.
On the heterogeneity of HLA association in
juvenile rheumatoid arthritis
To the Editor:
In response to a recent article entitled “Heterogeneity of HLA Associations in Systemic Onset Juvenile
Rheumatoid Arthritis” by Glass and Litvin (I), we
would like to contribute some information about the
presence of different HLA antigens in the various subgroups of juvenile rheumatoid arthritis (JRA).
The results described in this letter were already
discussed at our Rheumatology Congress in 1978 (2).
Our experience was based on the typing of 31
JRA patients, 6 with the acute onset form, 11 with the
polyarticular form, and 14 with oligoarticular form. Diagnosis conformed to American Rheumatism Association criteria (3); most antisera used for HLA typing
have been accepted by the international workshop.
B27 antigen was present in 27% of patients of the
entire group. Its incidence rose to 85% in males with oligoarticular form and tended to be higher in patients
older than 10 (Table 1). Bw35 incidence was higher in
patients with the acute form ( 5 of 6) as shown in Table
2. We did not take into account this result, however, because of the small number of subjects and the high incidence of this antigen in our control group (32.09%).At
the present time, our cases have almost doubled, and
Bw35 is present in 6W0 of the patients with acute onset
JRA (4); therefore, our previous report about the incidence of B27 in the oligoarticular form is substantially
confirmed (5).
Table 2. Acute onset J R A
LETTERS
1217
We wish to acknowledge Prof. V. Gandini and
colleagues (Institute of “Genetica Medica,” Rome University) for HLA typing assistance.
L. SCHIAVETTI
M. GALEAZZI
T. Tuzi
Rheumatology Center
S. Camillo Hospital
Rome, Italy
I . Glass DN, Litvin DA: Heterogeneity of HLA association
in systemic onset juvenile rheumatoid arthritis.
2. EULAR/WHO Workshop on the Care of Rheumatic Children. Oslo 21-24 March 1977. EULAR Bulletin, monograph No. 3, 1980
3. Schaller JG, Ochs HD, Donna1 TE: Histocompatibility antigens in childhood-onset arthritis. J Pediatr 88:926-930,
1976
4. Schiavetti L, Tuzi T, Galeazzi M, Lulli P, Cascino I, Trabace S: HLA e artrite reumatoid giovanile. In press
5 . Schiavetti L, Tuzi T. Minisola G: Sistema maggiore della
istocompatibilitii e malattie reurnatiche. Reumatismo
4858. 1979
Down-to-earth syndrome
To [he Editor:
Low back pain is frequently associated with industrial or vocational injury and has recently been attributed to participation in athletic activities such as
gymnastics and football (1,2). The available medical literature, however, does not provide evidence of an association between transcendental meditation and back
pain or back injury. Recently, I had the opportunity to
examine a patient with low back pain that had occurred
after a meditation session. She reported that this injury
was frequent among her meditating colleagues and that
her school retained a practitioner of chiropractic to care
for this frequent injury. It was my opinion that this injury may be more frequent than is commonly acknowledged and that the pathogenesis of this disorder is extremely interesting. I hope that this report may cause
other physicians to elicit historic data in an attempt to
discover other examples of this syndrome.
A 23-year-old female college student, who had
been attending a university of international transcendental meditation, complained of back pain. The patient stated she had experienced pain off and on as a
younger woman and had once fallen off a bicycle and
developed pain in her left groin. She was hospitalized
and treated with lumbar traction successfully for 4 days.
Recently, however, she developed back pain after practice in transcendental meditation. Specifically, she was
“performing levitation and fell back down to earth.”
The patient reported that her pain had been exacerbated by coughing, and that it was increased by sitting for prolonged periods in her car. Review of systems
and history was otherwise negative. The physical examination was entirely normal.
I pointed out that I was not familiar with the art
of levitation and would appreciate a safe demonstration
of the exact mechanism by which this was performed
and during which she injured herself. The patient then
sat cross-legged on the examining table and attempted
to rise in the air by pressing her feet firmly against the
table and extending her knees and hips, without using
her arms. In my childhood, I and my companions had
practiced the same maneuver, strictly to see who could
do it. Only those with expert balance and gymnastic
tendencies could do so.
The patient asserted that assuming this posture
while in a meditation frame of mind was levitation, and
she referred to her colleagues as “flying around the
room.”
It was easy to see that, if one lost his or her balance during this maneuver and fell backwards, sacrococcygeal or low back pain could easily ensue.
Review of the literature has revealed no examples of levitation falls causing back pain. Current
psychiatric texts refer to transcendental meditation as a
relatively harmless means of concentrating, relaxing the
body, and freeing the mind from the mundane responsibilities of everyday life (3-5). Apparently, when levitation is added to transcendental meditation, the subject
may fall from a state of meditation rather sharply and
sustain backache in this “down-to-earth syndrome.”
JOHNJ. NICHOLAS, MD
Presbyterian- University Hospital
DeSoto at O’Hara Streets
Pittsburgh, PA I521 3
1. Jackson DW, Wiltse LL, Circincione RJ: Spondylolysis in
the female gymnast. Clin Orthop 117:68-73. 1976
2. Ferguson RJ: Low-back pain in college football linemen
(abstract). J Bone Joint Surg (Am) 156:1300, 1974
3. Ostow M: Religion and psychiatry, Comprehensive Textbook of Psychiatry. Third edition. Edited by HI Kaplan,
AM Freedman, BJ Sadock. Baltimore, Williams and Wilkins, 1980, pp 3201-3202
4. West LJ, Singer MT: Cults, quacks, and nonprofessional
psychotherapies, Comprehensive Textbook of Psychiatry.
Third edition. Edited by HI Kaplan, AM Freedman. BJ
Sadock. Baltimore, Williams and Wilkins, 1980, p p 32543255
5 . Freedman AM. Kaplan HI. Sadock BJ, editors: Modern
Synopsis of Comprehensive Textbook of Psychiatry 11.
Second edition. Baltimore, Williams and Wilkins, 1976, pp
1275- 1276
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