Biomedical subjects
E Pascual
Publications and source records attributed to E Pascual.
Management of crystal arthritis.
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Most calcium pyrophosphate crystals appear as non-birefringent.
OBJECTIVE: To determine the proportion of calcium pyrophosphate dihydrate (CPPD) crystals that appear as non-birefringent when observed under the polarised light microscope. METHODS: Two observers examined independently 10 synovial fluid samples obtained during an episode of arthritis attributable to CPPD crystals. Ten synovial fluid samples from patients with acute gout were used as a reference. The examination was performed after placing a fluid sample in a Niebauer haemocytometric chamber; a crystal count was done first under ordinary light, then in the area corresponding to a 0.1 ml, under polarised light RESULTS: The percentages of birefringence appreciated for CPPD were 18% (confidence intervals (CI) 12, 24) for observer 1, and 17% (CI 10, 24) for observer 2 (difference NS). The percentages of birefringence for monosodium urate were 127% (CI 103, 151) for observer 1 and 107% (CI 100, 114) for observer 2 (difference NS). Percentages above 100% indicate that crystals missed under ordinary light became apparent under polarised light. CONCLUSION: Only about one fifth of all CPPD crystals identified by bright field microscopy show birefringence when the same synovial fluid sample is observed under polarised light. If a search for CPPD crystals is conducted under polarised light, the majority of the crystals will be missed. Ordinary light allows a better rate of CPPD crystal detection but observation under polarised light of crystals showing birefringence is required for definitive CPPD crystal identification.
[Capillary puncture in children: a protocol].
This article presents a synthesis of the "Nursing Protocol in Microextraction Procedures" which was developed in collaboration with nursing professionals in the Biochemical Laboratory and the Educational Department of the Maternity-Childcare Ward in the Vall d'Hebron Hospital in Barcelona. This synthesis states the different procedural steps to follow for capilary puncture microextraction in pediatrics, specifying the necessary materials and the role of the team in charge of these extractions. Furthermore, the problems caused by an incorrect microextraction are mentioned.
Treatment of acute attacks of gout with a small dose of intraarticular triamcinolone acetonide.
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Orderly arrayed deposit of urate crystals in gout suggest epitaxial formation.
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Survival analysis of 306 European Spanish patients with systemic lupus erythematosus.
OBJECTIVE: To describe survival of lupus in South European Spanish patients. PATIENTS AND METHODS: Observational study of all SLE Spanish patients seen at three University Hospitals between 1975 and 1993. The charts of all patients were retrospectively reviewed. Sixty-four clinic and laboratory variables were extracted from charts. Univariate analysis, multivariate Cox proportional hazard regression analysis, actuarial life tables and multiple logistic regression analysis were used to calculate survival probability and identify variables associated with survival. RESULTS: Three hundred and six (275 female and 31 male) patients were identified. Their mean age at diagnosis was 31.9 years (range 4 to 85). The mean duration of followup was 79 (1-126) months. Thirty-one patients died. The most common cause of death was infection (29%). Five, 10 and 15 years' survival rate was 90%+/-0.0158, 85%+/-0.0262 and 80%+/-0.0413, respectively. Log-rank analysis showed that male sex, proteinuria and nephropathy at diagnosis were associated with poor survival. By univariate and multivariate analysis male gender, nephropathy and CNS involvement were associated with worse survival. CONCLUSION: In SLE patients from Spain, rate of survival is similar to other Caucasian patients, and better than other ethnic groups of Spanish ancestry. Other factors rather than genetic factors could explain our findings.
Arthritis of shoulder and spinal cord compression due to Brucella disc infection.
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Comparison of manual and automated cell counts in EDTA preserved synovial fluids. Storage has little influence on the results.
OBJECTIVE: To determine the precision and agreement of synovial fluid (SF) cell counts done manually and with automated counters, and to determine the degree of variability of the counts in SF samples, kept in the tubes used for routine white blood cell (WBC) counts--which use liquid EDTA as anticoagulant--at 24 and 48 hours at 4 degrees C, and at room temperature. METHODS: To determine precision, cell counts were repeated 10 times--both manually and by an automated counter--in a SF sample of low, medium, and high cellularity. The variances were calculated to determine the interobserver variation in two manual (M1,M2) and two automated cell counts (C1,C2). The agreement between a manual (M1) and automated counter (C1) results, was analysed by the Bland and Altman method and the difference against the mean of the two methods was plotted. Then, the mean difference between the two methods was estimated and the standard deviation of the difference. To determine the effects of storage, SF samples were kept in a refrigerator at 4 degrees C, and at room temperature; cell counts were done manually (M1) and automatically (C1) at 24 and 48 hours and the changes analysed by the Bland and Altman method. The variances were compared using an F test. RESULTS: (1) Precision. With the manual technique, the coefficients of variation were 27.9%, 14%, and 10.7% when used for counting the SF with low (270), medium (6200), and high cellularities (25,000). With the automated technique the coefficients of variation were 20%, 3.4%, and 2.9% in the same SF samples. In the fluids of medium and high cellularity, the variances of the automated cell counts were significatively lower (F test, p < 0.002) than those of the manual counts. (2) Interobserver variation. The variance between C1 and C2 (25 SF) was significatively lower (F test, p < 0.002) than that of the manual counts (41 SF). (3) Agreement between the two techniques (100 SF). For cellularities above 2000 cells/mm3, the manual method gave results between +10% to -34% of the results obtained by the coulter. For cellularities below 2000 cells/mm3, manual cell counts were between +60 to -1280 cells/mm3 of those obtained by the automated counter. (4) Influence of storage. The coulter counts of SF samples preserved at 4 degrees C showed less variance (F test, p < 0.05) than the manual counts. The worst results were obtained in manual counts of SF samples kept at room temperature; these samples at 48 hours showed a variation between -47% to 42% of the initial results. CONCLUSIONS: Automated cell count of the SF offers advantages: it gives higher precision and consumes less time. The stability of the samples preserved in the EDTA tubes used for routine WBC counts is of additional interest, because if delay cannot be avoided, the results of the WBC counts are still accurate at 24 and even at 48 hours, at least for clinical purposes.
Urinary albumin excretion in patients with systemic lupus erythematosus without renal disease.
OBJECTIVES: To investigate the prevalence of microalbuminuria, urinary albumin excretion (UAE) between 20-200 micrograms/min, in systemic lupus erythematosus (SLE) patients without clinical renal disease, and to discover if this could predict the development of renal disease. METHODS: This study made six monthly measurements of UAE, creatinine clearance, serological and clinical data in 22 ambulatory women patients with SLE, without clinical renal disease, hypertension, diabetes or heart failure. The patients were followed up for a period of 18 months (four measurements). Age and sex matched healthy controls were used as a comparative group. UAE was measured by nephelometry in three timed overnight urine samples at each visit. RESULTS: There were no significant differences in the creatinine clearance between the control group and the SLE patients. Creatinine clearance did not show significant changes throughout the study period. SLE patients had wide variations in the UAE rate compared with healthy controls. In five patients (5 of 22; 23%), on occasions, there was mild, transient increase in UAE reaching the level of microalbuminuria. During follow up, one patient with basal (4.67 micrograms/min) and six month (4.73 micrograms/min) normal UAE rate, was admitted with a nephrotic syndrome confirmed on biopsy examination to be proliferative lupus nephritis. Six months after beginning treatment with prednisone and cyclophosphamide her UAE rate returned to normal values (4.65 micrograms/min). CONCLUSION: SLE patients without clinical renal disease may have microalbuminuria, although this does not seem to warrant any specific action.
The diagnosis of gout and CPPD crystal arthropathy.
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Systemic capillary leak syndrome.
Systemic capillary leak syndrome is a rare, severe disorder with a high mortality rate. It consists of the shift of fluid and proteins from the intravascular to the extravascular compartment with subsequent hypovolemic shock. We describe a 34-year-old-woman who had several episodes of generalized edema that evolved to hypovolemic shock. During the acute phase, laboratory investigations revealed marked hypoproteinemia, leukocytosis, and high levels of hematocrit and hemoglobin. A paraprotein IgG kappa chain was detected. Although different therapeutic trials were used, the patient continued to have similar episodes and she died during an acute episode 2 1/2 years after the first symptom of this disorder. The cause of systemic capillary leak syndrome is unknown. The presence of a paraprotein IgG is frequent in this group of patients.
Management of gout in patients with renal insufficiency and a gastrointestinal bleed--an answer to Dr Dunne's letter.
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A quantitative study of the phagocytosis of urate crystals in the synovial fluid of asymptomatic joints of patients with gout.
The objective of this study was to determine whether monosodium urate (MSU) crystals are phagocytosed in the synovial fluid (SF) of the asymptomatic joints of patients with gout. SF samples were obtained from 20 asymptomatic knees of 19 different patients. Cell and differential counts were done. Intracellular MSU crystals were identified by ordinary and polarizing light microscopy. We found that in 19 out of the 20 SF samples intracellular MSU crystals have been found. A mean of 22.55% [confidence interval (CI) 13.92, 31.18; range 0-62] of all the cells contained intracellular MSU crystals. The majority of the cells which contained intracellular crystals were mononuclear cells (MC), and polymorphonuclear (PMN) leucocytes containing intracellular crystals accounted only for 0.5% (CI 0, 1.05; range 0-5) of the total. The total cell count was 527 cells/mm3 (CI 226, 828, range;: 30-2670). Poor correlation was found between the percentage of cells with intracellular crystals and both the total cell count (r = -0.22) and the percentage of PMN leucocytes (r = -0.26). We conclude that cells containing phagocytosed MSU crystals--generally mononuclear cells--are a regular finding in the SF of asymptomatic joints of patients with gout. This finding indicates that other factors besides intra-articular interaction between crystals and cells are necessary to produce arthritis in gouty patients.
[Clinical and serological manifestations of 307 Spanish patients with systemic lupus erythematosus. Comparison with other ethnic groups].
There is evidence suggesting that clinical manifestations and severity in systemic lupus erythematosus (SLE) are associated with age, sex and ethnicity. The influence of genetic factors, particularly HLA antigens, on disease expression is revealed by the diversity of clinical conditions in patients from different ethnic groups. The aim of this work was to analyze the impact of demographic factors on SLE expression in the Spanish population. Therefore, a retrospective analysis was undertaken of clinical records of 307 patients diagnosed in three Rheumatology Services, with a mean follow-up of 79 months. The distribution of clinical manifestations according to age and sex was studied and compared with those observed in other ethnic groups. The results show the influence of sex and age on our patient population. Thus, female had a higher frequency of malar rash, photosensitivity and lymphopenia. Males had a higher CNS and renal involvement. Patients under 15 years had a higher involvement of CNS and kidney. Patients under 15 years had a higher frequency of nephropathy, hematological, cutaneous and CNS changes. Patients older than 50 had a higher frequency of pleuropericarditis, but without renal involvement. Our ethnic group expressed a disease with a severity similar to that observed in north-european caucasians, higher than in north-american caucasians and lower than in south-american caucasians, asiatic and africans. In conclusion, patients with SLE from the south-european ethnic groups express a clinical picture with characteristics and severity similar to those observed in europeans from other latitudes and different from those reported in other ethnic groups.
Differences between Spanish and British patients in the severity of rheumatoid arthritis: comment on the article by Drosos et al.
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Hyperuricemia and gout.
Due to high uric acid clearance, which occurs prior to puberty, hyperuricosuria rather than hyperuricemia may be the only clue to diagnosis of purine overproduction in children who have enzymatic defects or who develop the condition in the course of treatment of malignancies. The probable inclusion of hyperuricemia as a part of syndrome X associated with insulin resistance may help in understanding its clinical associations, including coronary artery disease. Gout, hypertension, and lead often go together; thus, perhaps we should check for lead toxicity routinely in this setting. Asymptomatic joints of patients with gout contain monosodium urate crystals, and research on the factors that determine the occurrence of clinical inflammation in this setting continues as an area of current interest. Coating of the crystals by different proteins may modify their inflammatory potential and may be an important modulating mechanism.
Reliability of the diagnosis of rheumatic conditions at the primary health care level.
OBJECTIVE: To assess the reliability of the diagnosis given to rheumatic disease patients at the primary care level, the clinical records of 612 patients at the outpatient clinic of rheumatology of the main General Hospital in Alicante (Spain) were studied. METHODS: The accuracy indices (sensitivity, specificity), the predictive values of tentative diagnosis made by the referring physicians and the degree of agreement (Kappa statistics) with the final diagnoses made by rheumatologists at the outpatient clinic of rheumatology were calculated. RESULTS: There were differences in diagnosis agreement depending on the age of the referring doctor, with a greater degree of concordance among younger ones. More than 50% of the referral diagnoses were modified at the rheumatology outpatient clinic. In the most frequent diagnoses (inflammatory rheumatic diseases, osteoarthritis, soft tissue rheumatism) the level of concordance and the predictive values were low. CONCLUSION: Our results highlight the need for upgrading courses in rheumatology for primary care physicians who have not been exposed to systematic training in rheumatology during their undergraduate studies. The epidemiological studies on rheumatic diseases based on primary care data should be interpreted with caution.