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MEDICAL SCREENING OF OLD PEOPLE
323 ASSESSMENT OF INFLAMMATORY ACTIVITY IN KNEE JOINT
SIR,-A frequent obstacle to the study of arthritis is the lack of objective measures of severity. We have been testing a method for rapid assessment of the inflammatory activity in the knee joint,’ based on the technetium 99m pertechnetate (99"’TCO4 ) uptake technique2 which we modified. Two collimated thallium-activited sodium-iodide crystals were used to detect the y-radiation of the 99ffiTc in the knee joint as a function of time after intravenous injection of 200 tiCi 99C04 -. The patient rested for an hour beforehand to improve the reproducibility of the test. Radioactivity in the knee joint was measured shortly after injection (2tmin) or at 30 min at most. We investigated twenty-three healthy volunteers, twentytwo patients with clinical evidence of monoarticular arthritis, and twenty-four patients with bilateral arthritis. Radioactivity, shortly after injection of 99ffiTc04- was significantly lower in the knee joints of controls (mean 54.2±; S.D. 10.9 c.p.m./[,Ci) than in clinically inflamed knee joints in patients with monoarticular arthritis (93-3±17-7) or bilateral arthritis (96.1±28.7) (P<0.0001 in both instances). The reproducibility of the method was studied in fourteen controls. The standard deviation of the differences between the two tests (done 4 days to 3 months apart) was 6.88%. There was an excellent correlation between the results of the 99mTc04- uptake and the degree of warmth over the knee joint. In eleven patients complaining of painful knee joints but without obvious warmth and swelling, the diagnostic significance of 99mTcO4- uptake in the joint was investigated by comparison with the histologic findings at synovial biopsy. The vascular alterations (microscopically demonstrable vascular proliferation, vasodilatation, and cellular infiltration) were classified in four categories of severity. When an increased severity of hyperaemia was found the 99 cO 4 - uptake was also increased. Because we found identical results for different times after injection we opted for measurement very shortly after injection because it is important to the patient and the investigator that the examination takes as little time as possible. Rapid assessment of 99ffiTc04 - uptake can be useful in the diagnosis of doubtful arthritis and in clinical research (e.g., determination of the effect of local and systemic therapy on inflammatory activity in the knee joint). Department of Internal Medicine, Division of Rheumatology, and Division of Radioisotopes Laboratory, University Hospital, Nijmegen. Netherlands
AGNES M. TH. BOERBOOMS WIL C. A. M. BUIJS
MEDICAL SCREENING OF OLD PEOPLE
SiR,—Professor Brocklehurst and his colleagues (July 15, p. 141) seem to conclude from their outpatient survey of a hundred elderly people awaiting admission to local-authority home that, in general, old people in this situation should have outpatient investigation. I think that the establishment of such a routine would be inefficient, inhumane, and misleading. Everywhere there is considerable delay in arranging outpatient appointments. One can only guess at the effect of adding this to the social-work negotiations leading to the admission of a frail old person to shelter. The battery of outpatient investigations proposed by Brocklehurst et al. would mean long waiting-room sojourns for old people at a time of
bewilderment and distress. The medical history obtained in these circumstances could be very misleading, and it is perhaps relevant that Brocklehurst et al. make no mention of the sideeffects of medicines now known to form a significant proportion of elderly illness. Outpatient examination of the elderly is by no means infallible. Cerebrovascular disease was diagnosed in only 1 of this vulnerable group of patients, and parkinsonism was found in only 3 cases. Virus and other infections, particularly of the upper respiratory tract, are not mentioned-indeed it is difficult to imagine how the outpatient system would ever diagnose them, yet these must often be the straw that breaks the camel’s back, as evidenced by the considerable improvement of many patients after they have been admitted to local-authority homes. If action is needed for the benefit of some frail, elderly isolated person, it should not be impeded by a routine outpatient screening system. Screening could, if necessary, be done after the patient has been taken into shelter. Where the old person seems ill, there are more humane and effective ways of taking action than asking for an outpatient appointment. The patient could, for example, be seen by the consultant geriatric physician at home, and immediate admission for investigation in hospital arranged if necessary. If hospital admission is not possible or desirable, a useful alternative is assessment during a whole day at the local day hospital. Here in Exeter we have found this a much more humane and effective way of finding out a great deal about the patient (and her reaction to others in the day room), than in the outpatient department. Devon & Exeter Exeter EX1 2ED
Royal
Boerbooms, A. M. Th., Buijs, W. C. A. M. Arthr. Rheum. 1978, 21, 248. Dick, W. C., Neufeld, R. R., Prentice, A. G., Woodburn, A., Whaley, K., Nuki, G., Buchanan, W. W. Ann. rheum. Dis. 1970, 29, 135.
WILLIAM B. WRIGHT
AUER RODS: ANOTHER SACRED COW?
SIR,-The letter by Dr Getaz and Dr Henderson (July 1,
p.
the diagnostic specificity of Auer rods in leukxmia would suggest that this is an unassailable diagnostic structure. Terminal deoxynucleotidyl transferase (TdT) is considered to be a biochemical marker of lymphoid cells and may be present in primitive haematopoietic stem cells. 1Therefore, the presence of cells with lymphoblastic and myeloblastic morphology in TdT positive blast crisis of chronic myelogenous leukaemia (C.M.L.) is not surprising in view of a common progenitor cell. This would support the hypothesis of Janossy et al. and our personal experience that the blast cells in some cases of c.M.L. blast crisis and acute lymphoblastic leukxmia (A.L.L.) arise from the same pluripotential stem cell, whereas myeloblast crisis of C.M.L. arises in a more mature myeloid cell. In addition, Janossy suggests that the blast cell of common A.L.L. is a stem cell. The differentiation pathway of the progenitor cell may relate to setiology or may be random, but could account for the variety and varying proportions of blastic cell populations in leukaemia. Indeed, simultaneous lymphoid and myeloid populations have been reported in blast crisis of C.M.L.4 and acute leukaemia.5 In our case (May 13, p. 1042), we acknowledged the presence of lymphoblastic and myeloblastic cell lines. In view of Wright-Giemsa stain morphology, strong positivity of TdT by indirect immunofluorescence, only rare cells with Auer rods, less than 5% of the cells having sudanblack or myeloperoxidase activity (cytochemical markers of granulocytic), and less than 5% myeloperoxidase blasts by electron microscopy, we stated that the predominant cell was lym-
47)
1. 2.
1. 2.
Hospital (Heavitree),
on
Meyskens, F. L., Jones, S. E. New Engl. J. Med. 1978, 298, 846.
Coleman, M. S., Hutton, J. J., De Simone, P., Bollum, F. J. Proc. natn. Acad. Sci. U.S.A. 1976, 71, 4404. 3. Janossy, G., Roberts, M., Greaves, M. F. Lancet, 1976, i, 1958. 4. Forman, G. N., Padre-Mendoza, T., Smith, P. S. Blood, 1977, 49, 549 5. Mentlesmann, R., Koziner, B., Ralph, P., Pillipa, D., McKenzie, S., Arlin, A. A., Gec, T. S., Moore, M. A. S., Clarkson, B. D. ibid. 1978, 51, 1051.
SIR,-A frequent obstacle to the study of arthritis is the lack of objective measures of severity. We have been testing a method for rapid assessment of the inflammatory activity in the knee joint,’ based on the technetium 99m pertechnetate (99"’TCO4 ) uptake technique2 which we modified. Two collimated thallium-activited sodium-iodide crystals were used to detect the y-radiation of the 99ffiTc in the knee joint as a function of time after intravenous injection of 200 tiCi 99C04 -. The patient rested for an hour beforehand to improve the reproducibility of the test. Radioactivity in the knee joint was measured shortly after injection (2tmin) or at 30 min at most. We investigated twenty-three healthy volunteers, twentytwo patients with clinical evidence of monoarticular arthritis, and twenty-four patients with bilateral arthritis. Radioactivity, shortly after injection of 99ffiTc04- was significantly lower in the knee joints of controls (mean 54.2±; S.D. 10.9 c.p.m./[,Ci) than in clinically inflamed knee joints in patients with monoarticular arthritis (93-3±17-7) or bilateral arthritis (96.1±28.7) (P<0.0001 in both instances). The reproducibility of the method was studied in fourteen controls. The standard deviation of the differences between the two tests (done 4 days to 3 months apart) was 6.88%. There was an excellent correlation between the results of the 99mTc04- uptake and the degree of warmth over the knee joint. In eleven patients complaining of painful knee joints but without obvious warmth and swelling, the diagnostic significance of 99mTcO4- uptake in the joint was investigated by comparison with the histologic findings at synovial biopsy. The vascular alterations (microscopically demonstrable vascular proliferation, vasodilatation, and cellular infiltration) were classified in four categories of severity. When an increased severity of hyperaemia was found the 99 cO 4 - uptake was also increased. Because we found identical results for different times after injection we opted for measurement very shortly after injection because it is important to the patient and the investigator that the examination takes as little time as possible. Rapid assessment of 99ffiTc04 - uptake can be useful in the diagnosis of doubtful arthritis and in clinical research (e.g., determination of the effect of local and systemic therapy on inflammatory activity in the knee joint). Department of Internal Medicine, Division of Rheumatology, and Division of Radioisotopes Laboratory, University Hospital, Nijmegen. Netherlands
AGNES M. TH. BOERBOOMS WIL C. A. M. BUIJS
MEDICAL SCREENING OF OLD PEOPLE
SiR,—Professor Brocklehurst and his colleagues (July 15, p. 141) seem to conclude from their outpatient survey of a hundred elderly people awaiting admission to local-authority home that, in general, old people in this situation should have outpatient investigation. I think that the establishment of such a routine would be inefficient, inhumane, and misleading. Everywhere there is considerable delay in arranging outpatient appointments. One can only guess at the effect of adding this to the social-work negotiations leading to the admission of a frail old person to shelter. The battery of outpatient investigations proposed by Brocklehurst et al. would mean long waiting-room sojourns for old people at a time of
bewilderment and distress. The medical history obtained in these circumstances could be very misleading, and it is perhaps relevant that Brocklehurst et al. make no mention of the sideeffects of medicines now known to form a significant proportion of elderly illness. Outpatient examination of the elderly is by no means infallible. Cerebrovascular disease was diagnosed in only 1 of this vulnerable group of patients, and parkinsonism was found in only 3 cases. Virus and other infections, particularly of the upper respiratory tract, are not mentioned-indeed it is difficult to imagine how the outpatient system would ever diagnose them, yet these must often be the straw that breaks the camel’s back, as evidenced by the considerable improvement of many patients after they have been admitted to local-authority homes. If action is needed for the benefit of some frail, elderly isolated person, it should not be impeded by a routine outpatient screening system. Screening could, if necessary, be done after the patient has been taken into shelter. Where the old person seems ill, there are more humane and effective ways of taking action than asking for an outpatient appointment. The patient could, for example, be seen by the consultant geriatric physician at home, and immediate admission for investigation in hospital arranged if necessary. If hospital admission is not possible or desirable, a useful alternative is assessment during a whole day at the local day hospital. Here in Exeter we have found this a much more humane and effective way of finding out a great deal about the patient (and her reaction to others in the day room), than in the outpatient department. Devon & Exeter Exeter EX1 2ED
Royal
Boerbooms, A. M. Th., Buijs, W. C. A. M. Arthr. Rheum. 1978, 21, 248. Dick, W. C., Neufeld, R. R., Prentice, A. G., Woodburn, A., Whaley, K., Nuki, G., Buchanan, W. W. Ann. rheum. Dis. 1970, 29, 135.
WILLIAM B. WRIGHT
AUER RODS: ANOTHER SACRED COW?
SIR,-The letter by Dr Getaz and Dr Henderson (July 1,
p.
the diagnostic specificity of Auer rods in leukxmia would suggest that this is an unassailable diagnostic structure. Terminal deoxynucleotidyl transferase (TdT) is considered to be a biochemical marker of lymphoid cells and may be present in primitive haematopoietic stem cells. 1Therefore, the presence of cells with lymphoblastic and myeloblastic morphology in TdT positive blast crisis of chronic myelogenous leukaemia (C.M.L.) is not surprising in view of a common progenitor cell. This would support the hypothesis of Janossy et al. and our personal experience that the blast cells in some cases of c.M.L. blast crisis and acute lymphoblastic leukxmia (A.L.L.) arise from the same pluripotential stem cell, whereas myeloblast crisis of C.M.L. arises in a more mature myeloid cell. In addition, Janossy suggests that the blast cell of common A.L.L. is a stem cell. The differentiation pathway of the progenitor cell may relate to setiology or may be random, but could account for the variety and varying proportions of blastic cell populations in leukaemia. Indeed, simultaneous lymphoid and myeloid populations have been reported in blast crisis of C.M.L.4 and acute leukaemia.5 In our case (May 13, p. 1042), we acknowledged the presence of lymphoblastic and myeloblastic cell lines. In view of Wright-Giemsa stain morphology, strong positivity of TdT by indirect immunofluorescence, only rare cells with Auer rods, less than 5% of the cells having sudanblack or myeloperoxidase activity (cytochemical markers of granulocytic), and less than 5% myeloperoxidase blasts by electron microscopy, we stated that the predominant cell was lym-
47)
1. 2.
1. 2.
Hospital (Heavitree),
on
Meyskens, F. L., Jones, S. E. New Engl. J. Med. 1978, 298, 846.
Coleman, M. S., Hutton, J. J., De Simone, P., Bollum, F. J. Proc. natn. Acad. Sci. U.S.A. 1976, 71, 4404. 3. Janossy, G., Roberts, M., Greaves, M. F. Lancet, 1976, i, 1958. 4. Forman, G. N., Padre-Mendoza, T., Smith, P. S. Blood, 1977, 49, 549 5. Mentlesmann, R., Koziner, B., Ralph, P., Pillipa, D., McKenzie, S., Arlin, A. A., Gec, T. S., Moore, M. A. S., Clarkson, B. D. ibid. 1978, 51, 1051.