LETTERS 1269 derma. Treatment with penicillamine and colchicine was instituted, but the patient did not improve. By June 1980, painful ulcerations appeared over the proximal interphalangeal joints of both hands, and the degree of flexion contracture increased. Despite warm weather, the episodes of Raynaud’s phenomenon became almost continuous, numbering more than 20 per day. Initially, she responded to intraarterial reserpine, which resulted in partial healing of the ulcers and a lessening of the frequency and severity of the vasospasm. After 6 treatments in a 4-month period, the reserpine had lost most of its effectiveness, and arterial access became increasingly difficult due to the thickening of the skin in the forearms and axillae. She was admitted to the hospital on 3 occasions for intravenous PGEl administered via a central catheter. This resulted in improvement in the Raynaud’s phenomenon, confirmed by doppler, but the benefit was transient, and there was no healing of the lesions. New ulcerations formed over both elbows as the skin became more hidebound. Successive courses of treatment with hydralazine (100 mgi day), prazosin (4 mg/day), and captopril (200 mg/day) were attempted, but there was no response to any of these drugs, perhaps because postural hypotension was a dose-limiting side effect to all of them. A series of stellate ganglion blocks was performed without benefit. In September 1981, nifedipine was begun at a dose of 20 mg 3 times daily. There was a prompt and progressive decrease in the frequency of the Raynaud’s phenomena to an average of 2 episodes daily. The secondary infection in some of the ulcers, which had responded poorly to various antimicrobial agents, cleared completely by the end of the second week. After 1 month of treatment, all of the ulcers including those on the elbows showed definite healing. At the end of 2 months, there were signs of partial relapse, as evidenced by an increase in the Raynaud’s phenomenon and some breakdown of newly formed skin. The dose of nifedipine was raised to 20 mg 4 times daily, and the relapse abated. The only adverse effect to the drug was moderate nausea that developed with the higher dose. By 3 months, all of the ulcers had completely healed (Figure I), but there was no improvement in the scleroderma itself. A controlled trial of calcium channel blocking agents in the treatment of cutaneous ischemic ulceration in progressive systemic sclerosis is warranted. Treatment of hip damage in children with juvenile rheumatoid arthritis To the Editor: Garcia-Morteo and colleagues (1) have again demonstrated that remodeling of the hip joint is possible in children with juvenile rheumatoid arthritis (JRA), but have failed to associate the unusually severe changes initially seen in their patients with the bed rest and skin traction they prescribed, and to recognize that the radiographic improvement follows ambulation. This was most clearly defined by Bernstein ( 2 ) and reiterated in a recent communication of ours (3). Experimental and clinical evidence indicates that joint motion alone, in the absence of normal loading (weight bearing), does not maintain normal articular cartilage. Weight bearing actually seems to prevent some of the damage that occurs in the hips of children with severe JRA. A therapeutic program for such children must have the maintenance of weight bearing as one goal, no matter how severe the disease, since accelerated hip destruction seems inevitable if the child is confined to bed (3). The authors state, “Remodeling of the hip joint in JRA is an interesting phenomenon.” It is more than that. The advantages of patients with rheumatoid arthritis leading an active life and maintaining good muscle tone and life style are well known to all rheumatologists. However, this knowledge is not always applied to children. Bed rest is not an acceptable treatment for children with arthritis and should not be prescribed for them. Jerry C. Jacobs, MD Professor of Clinical Pediatrics Director, Section of Pediatric Rheurnatology College of Physicians & Surgeons of Columbia University New York, N Y 10032 1. Garcia-Morteo 0, Babini JC, Maldonado-Cocco JA, Gagliardi S , Yabkowski J: Remodeling of the hip joint in juvenile rheumatoid arthritis. Arthritis Rheum 24: 1570-1574, 1981 2. Bernstein B, Forrester D, Singsen B, King KK, Kornreich H, Hanson V: Hip joint restoration in juvenile rheumatoid arthritis. Arthritis Rheum 20:109Y-1104, 1977 3. Jacobs JC, Dick HM, Downey JA, Edgar A, Sternstein R, Berdon WE: Weight-bearing as treatment for damaged hips in juvenile rheumatoid arthritis. N Engl J Med 305:409, 1981 Israeli A. Jaffe, MD College of Physicians & Surgeons of Columbia University New York, N Y 1. Kahan A, Weber S, Amor B, Saporta L, Hodara M, Degeorges M: Nifedipine and Raynaud’s phenomenon. Ann Intern Med Y4:546, 1981 2. Vayssairat M, Capron L, Fiessinger J-N, Mathieu J-F, Housset E: Calcium channel blockers and Raynaud’s disease. Ann Intern Med 95:243, 1981 Use of azathioprine for rheumatoid arthritis To the Editor: We read with interest Dr. Franck’s letter (1). He was concerned about the statement in the February 1981 issue of Arthritis and Rheumatism (the 24th Rheumatism Review) 1270 that “azathioprine has now been approved for use in the treatment of RA” (2). According to J. R. MacDougal, MD, Medical Director of Burroughs Wellcome in Montreal (personal communication), azathioprine was approved by the FDA for use in the treatment of rheumatoid arthritis (RA) on April 13, 1981. Moreover, the last five issues of Arthritis arid Rheumatism, including the October 1981 issue that contained Dr. Franck’s letter, have carried full-page advertisements on the use of azathioprine “for adults with severe, active erosive rheumatoid arthritis.” Surely the authors of the RA section of the 24th Rheumatism Review anticipated this FDA approval because it was pending when the statement in question was written. Although the use of azathioprine for the treatment of adults with severe active RA may no longer be considred “experimental,” we agree with Dr. Franck that its use in RA should not be taken lightly (3). The use of azathioprine in RA requires careful medical supervision and long-term fol- LETTERS lowup. For this reason, one of u s (MBU) has set up a registry at the Wellesley Hospital in Toronto to document possible side effects of azathioprine. Duncan A. Gordon, MD Murray B. Urowitz, MD University of Toronto Rheitmatic Disease Unit The Toronto and Wellesley Hospitals Toronto, Ontario, Canado I . Franck WA: Use of azathioprine for rheumatoid arthritis. Arthritis Rheum 24:1327, 1981 2. Rheumatism Review Subcommittee, American Rheumatism Association: Rheumatoid arthritis. Arthritis Rheum 24:147, 1981 3. Azathioprine (Imuran) for rheumatoid arthritis. Med Let Drugs Ther 23237-88, 1981 BOOK REVIEW Joints and Synovial Fluid, Volume 11. Edited by Leon Soko[off,MD. New York, The Academic Press. 1980. 561 pages. Illustrated. $55.00. In the second volume of this series, contributions include chapters by Dr. Sokoloff on in vitro culture of joints in articular cartilage, Helen Muir on the chemistry of ground substances, F. Happey on the structure and aging of the intervertebral disc, John Paul on the kinetics of joints, Geoff Kempson on the mechanical properties of articular cartilage, Alice Maroudas on the physical chemistry of cartilage and disc, and Dan McCarty on the physiology of synovium. In the last third of the book, devoted to the pathology of synovial joints, Dougal Gardner discusses the pathology of peripheral joints and Eric Bywaters the pathology of the spine. All in all, the scholarly contributions are intended for the prepared mind. Most require a degree of sophistication for a complete understanding. Particularly appealing are the chapters on ground substance chemistry and the pathology of the spine, which are gems. Starting from the most elemental beginnings, they carry the reader to the heights of current sophisticated understanding. As in the preceding volume, the scope of techniques discussed is diverse and considerable. From this volume one gains understanding, for example, of x-ray diffraction, dissociative biochemistry, tensile and compressive mechanical testing. gait analysis, and cartilage culture. The book is extremely strong in its discussion of the changes with age of the target tissues, both structurally and chemically. Taken as a whole this volume is well worth having and will be referred to often by anyone in this field. Eric L. Radin, MD Morgantown, WV
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