Drug-induced pancytopenia in a patient with juvenile HLA-B27-associated spondylarthritis: comment on the article by Leipold et al.
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Adolescent↗
Biomedical subjects
K L Schmidt
Publications and source records attributed to K L Schmidt.
Ankylosing spondylitis and infections of the female urogenital tract.
Thirty-two female patients with confirmed ankylosing spondylitis (AS) and 33 women of similar age with pure ileitis terminalis Crohn were examined for genitourinary infection. Urethral syndrome was found in 15 out of 32 patients with AS: 11 of them had urethritis and 4 urethritis associated with vaginitis. Five women of the control group suffered from urethritis. In all cases with genitourinary infection, Chlamydia trachomatis was isolated. By comparing the AS-patients (urogenital infection group and the non-infected group) with regard to other present clinical parameters, it was found, as expected, that the erythrocyte sedimentation rate in the 1st hour was significantly higher in the infected group. In addition, the infected patients had a significantly higher incidence of enthesopathy, involvement of the spinal column, and higher C-reactive protein values (CRP > or = 5 mg/l). A family history of AS was equally present. Other clinical parameters, such as inflammatory involvement of the joints and HLA-B27 correlation, did not differ significantly between infected and non-infected patients.
Adult↗
[Aspects of quality assurance in a rheumatology clinic. A contribution to the problem of length of stay and unnecessary admission].
In a rheumatological hospital, quality assurance has many aspects. Diagnostic as well as classification criteria are essential; however, they should not be regarded as a strait-jacket. The very important radiological diagnostics require optimal technology. All x-ray-pictures should only be interpreted by experienced rheumatologists. Also of importance is the documentation of all relevant data, sometimes for decades, especially the kind of drugs, their effectiveness and side effects and the assessment of activity, stage, progression and functional ability. Very important is also a close communication with other medical disciplines. Nursing in rheumatology is mostly underestimated quantitatively and qualitatively as well; it cannot be compared with nursing in other patients. Physical and occupational therapy are indispensable parts of treatment of in-patients; under certain conditions, they may have priority in comparison to other treatments. For chronobiological reasons, physical therapy has a definite time requirement. A duration of 3 weeks is necessary to get therapeutically desired adaptation processes. Thus, the duration of stay in rheumatological departments must be longer than in other disciplines. An actual questionnaire, which has been sent to 50 rheumatological departments, asked the question, which reasons and indications will make future in-patient treatment necessary. As main reason, the comprehensive treatment options and induction of a special pharmacotherapy have been mentioned. Also an element of quality assurance in a rheumatological hospital is warmheartedness and humanity.
Arthritis, Rheumatoid↗
[Orthopedic therapy in rheumatic diseases].
The treatment of rheumatic disease requires an interdisciplinary approach in which the orthopedic surgeon is also involved. His contribution includes both conservative and operative procedures. Early synovectomy applied to joints and tendons is considered a preventive measure. Arthroscopic synovectomy belongs in the hands of an experienced operator. Joints that are not directly involved in weight-bearing can be treated by means of arthroplastic procedures, provided the cooperation of the patient is ensured. Arthrodesis is used preferentially to treat articular destruction of the ankle joint, the metacarpophalangeal joint of the thumb and the middle joints of the finger. Osteoporosis represents a relative contraindication. The treatment of rheumatic diseases of the joints using endoprostheses produces good primary results. The rate of loosening is not significantly increased, but late infection is somewhat higher than in other forms of articular disease.
Arthritis, Rheumatoid↗
Comprehensive strategy for the evaluation and triage of the chest pain patient.
STUDY OBJECTIVE: To evaluate the safety and efficacy of a systematic evaluation and triage strategy including immediate resting myocardial perfusion imaging in patients presenting to the emergency department with chest pain of possible ischemic origin. METHODS: We conducted an observational study of 1,187 consecutive patients seen in the ED of an urban tertiary care hospital with the chief complaint of chest pain. Within 60 minutes of presentation, each patient was assigned to one of five levels on the basis of his or her risk of myocardial infarction (MI) or unstable angina (UA): level 1, MI; level 2, MI/UA; level 3, probable UA; level 4, possible UA; and level 5, noncardiac chest pain. In the lower risk levels (3 and 4), immediate resting myocardial perfusion imaging was used as a risk-stratification tool alone (level 4) or in combination with serial markers (level 3). RESULTS: Acute MI, early revascularization indicative of acute coronary syndrome, or both were consistent with risk designations: level 1: 96% MI, 56% revascularization; level 2: 13% MI, 29% revascularization; level 3: 3% MI, 17% revascularization; level 4: .7% MI; 2.5% revascularization. Sensitivity of immediate resting myocardial perfusion imaging for MI was 100% (95% confidence interval [CI], 64% to 100%) and specificity 78% (74% to 82%). In patients with abnormal imaging findings, risk for MI (7% versus 0%, P < .001; relative risk [RR], 50; 95% CI, 2.8 to 889) and for MI or revascularization (32% vs 2%, P < .001; RR, 15.5; 95% CI, 6.4 to 36) were significantly higher than in patients with normal imaging findings. During 1-year follow-up, patients with normal imaging findings (n = 338) had an event rate of 3% (revascularization) with no MI or death (combined events: negative predictive value, 97%; 95% CI, 95% to 98%). Patients with abnormal imaging findings (n = 100) had a 42% event rate (combined events: RR, 14.2; 95% CI, 6.5 to 30; P < .001), with 11% experiencing MI and 8% cardiac death. CONCLUSION: This strategy is a safe, effective method for rapid triage of chest pain patients. Rapid perfusion imaging plays a key role in the risk stratification of low-risk patients, allowing discrimination of unsuspected high risk patients who require prompt admission and possible intervention from those who are truly at low risk.
Adult↗
Value of acute rest sestamibi perfusion imaging for evaluation of patients admitted to the emergency department with chest pain.
OBJECTIVES: This study sought to determine the ability of early perfusion imaging using technetium-99m sestamibi to predict adverse cardiac outcomes in patients who present to the emergency department with possible cardiac ischemia and nondiagnostic electrocardiograms (ECGs). BACKGROUND: Evaluation of patients presenting to the emergency department with possible acute coronary syndromes and nondiagnostic ECGs is problematic. Accurate risk stratification is necessary to prevent serious adverse outcomes. Initial results suggest that early perfusion imaging using technetium-99m sestamibi enables reliable risk stratification. METHODS: Patients presenting to the emergency department with a low to moderate probability of acute coronary syndromes underwent rapid sestamibi injection with gated single-photon emission computed tomographic imaging. Studies showing perfusion defects with associated wall motion abnormalities were considered positive. RESULTS: A total of 532 consecutive patients underwent serial myocardial marker analysis and rest perfusion imaging. Of these patients, perfusion imaging was positive in 171 (32%). Positive perfusion imaging was the only multivariate predictor of myocardial infarction (MI) (p < 0.0001, odds ratio [OR] 33, 95% confidence interval [CI] 7.7 to 141) and was the most important independent predictor of MI or revascularization (p < 0.0001, OR 14, 95% CI 7.3 to 25), followed by diabetes (p < 0.01, OR 2.8, 95% CI 1.5 to 5.1), typical angina (p = 0.01, OR 2.1, 95% CI 1.2 to 3.7) and male gender (p = 0.03, OR 1.9, 95% CI 1.1 to 3.5). The sensitivity of positive perfusion imaging for MI was 93% (95% CI 77% to 98%), and for MI or revascularization it was 81% (95% CI 71% to 88%), with negative predictive values of 99% (95% CI 98% to 100%) and 95% (95% CI 92% to 97%), respectively. CONCLUSIONS: Positive rest perfusion imaging accurately identified patients at high risk for adverse cardiac outcomes, whereas negative perfusion imaging identified a low risk patient group. Early perfusion imaging allows for rapid and accurate risk stratification of emergency department patients with possible cardiac ischemia and nondiagnostic ECGs.
Aged↗
Cognitive triad: relationship to depressive symptoms, parents' cognitive triad, and perceived parental messages.
Evaluating the relationship between children's depressogenic thinking, children's depressive symptoms, parents' depressogenic thinking, and perceived parental messages about the self, world, and future was the primary objective of this investigation. Children (n = 133) from grades 4 to 7 completed measures of depression and anxiety, including a semistructured clinical interview, a measure of their cognitive triad, and a measure of perceived parental messages about the self, world, and future. Mothers (n = 112) and fathers (n = 95) completed a measure of their own cognitive triad. Results of a series of regression analyses revealed that (1) children's views of self, world, and future (cognitive triad) are related to severity of depression; (2) mothers' but not fathers' cognitive triads are related to their children's cognitive triads; (3) perceived parental messages to the children about the self, world, and future are predictive of the children's cognitive triads and ratings of depression; and (4) the relationship between perceived parental messages and depression is completely mediated by children's cognitive triads. Analyses of covariance indicated that the obtained mediational relationship between children's views of self, world, and future, perceived parental messages, and children's depressive symptoms was specific to depressive versus anxious symptomatology. Implications for existing theory and research are discussed.
Adolescent↗
Implementation of the Agency for Health Care Policy and Research Pain Guidelines.
Implementation of clinical practice guidelines in a large setting is a complex process. This article describes the many issues encountered in trying to implement Agency for Health Care Policy and Research acute pain and cancer pain guidelines in an academic medical center. Issues addressed include the membership of the task forces involved, incorporation of the guidelines into the institution-specific standards of care, selection and implementation of self-reporting tools for assessment of pain throughout the institution, issues involved in standardizing documentation of pain throughout the institution, measurement of the current status of pain control and integration into the existing quality assessment and improvement program, various analgesic interventions addressed throughout the hospital, educational strategies used and planned, and how multidisciplinary involvement was obtained.
Humans↗
Size, detail, and line heaviness in children's drawings as correlates of emotional distress: (more) negative evidence.
This study examined the reliability and validity of three commonly used indicators of emotional distress in children's projective drawings--size, detail, and line heaviness--and assessed their relation to established objective and projective measures of childhood depression and anxiety. Participants were 80 child and adolescent psychiatric inpatients (53 boys, 27 girls; ages 6 to 16; M = 10.69, SD = 2.94). Although the present results indicated that these drawing indices can be assessed with very high reliability, they were not significantly associated with self-report or thematic projective measures of depression and anxiety. Age and defensiveness did not moderate the relation between the drawing indices and the non-drawing measures of emotional distress. The patterning of the intercorrelations among and within the drawing indices, projective stories, and self-report measures indicated greater support for the self-report measures, in terms of convergent and discriminant validity. This study did not support the continued use of these three projective drawing indices of emotional distress.
Adolescent↗
Low-end specificity of childhood measures of emotional distress: differential effects for depression and anxiety.
This study examined the low-end specificity of self-report measures of anxious and depressed symptoms among a clinical sample of 96 child and adolescent psychiatric inpatients (54 boys, 42 girls; ages 8 to 16; M = 12.34, SD = 2.43). To our knowledge, the study is one of the first to examine the issue in a clinical sample, and the first to address this issue in children and adolescents. Participants completed the Children's Depression Inventory (CDI) and the Revised Children's Manifest Anxiety Scale (RCMAS). As predicted, CDI low-end participants obtained higher RCMAS Lie scale scores than depressed participants, suggesting a tendency to deny symptoms and to attempt to appear in a favorable light. In contrast, but also consistent with prediction, low-end RCMAS participants did not obtain higher Lie scale scores than anxious participants. Gender and age did not moderate the findings in any way. Thus, our results support hypotheses that defensiveness would affect a self-report measure of depression but not a self-report measure of anxiety. Recommendations for addressing low-end specificity problems in both research and clinical work are discussed.
Adolescent↗
[Arthropathy as a diagnostic early symptom of hereditary systemic disease].
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Diagnosis, Differential↗
[Therapy of rheumatoid arthritis at the turn of the century. Current status and trends of the '90's].
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Anti-Inflammatory Agents↗
Protective effect of dimethylthiourea against mucosal injury in rat stomach. Implications for hydroxyl radical mechanism.
The present study was undertaken to determine whether dimethylthiourea (DMTU), a hydroxyl radical scavenger, could prevent gastric injury in the rat stomach induced by various noxious agents. Fasted rats (N = 6-8/group) were given a 1-ml oral bolus of saline or DMTU over the dose range 10-500 mg/kg. After 30 min, animals received 1 ml of 100% ethanol orally and were sacrificed 5 min later. At sacrifice, stomachs were harvested and the degree of macroscopic damage was assessed by planimetry. In selected animals, specimens of gastric mucosa were also processed for histology. Saline pretreatment prior to ethanol exposure resulted in 22.5% injury to the glandular epithelium when assessed macroscopically. DMTU pretreatment prevented such injury in a dose-related fashion with only 2% of the mucosa showing injury with a 500 mg/kg dose (P less than 0.01 vs control). Although the superficial injury involving surface mucous cells induced by ethanol was not altered by DMTU, the deep damage to gastric glands was almost completely prevented. Other experiments in which DMTU was given intraperitoneally demonstrated similar protective effects against ethanol injury. Additional studies showed that indomethacin did not prevent the protective effects of oral or intraperitoneal DMTU, excluding a role for endogenous prostaglandins, and that DMTU was equally protective when administered within minutes or as long as 2 hr prior to ethanol exposure. Furthermore, DMTU was also shown to be protective against gastric injury induced by concentrated acid or base. In in vitro studies in which hydroxyl radicals were actually generated, DMTU was noted to scavenge the hydroxyl radical in a dose-related fashion. The ability of DMTU to prevent gastric injury by three different damaging agents suggests that the hydroxyl radical may play a major role in the pathogenesis of such injury and that DMTU mediated its protective action by scavenging this radical species.
Animals↗
Colloidal gold localization of type IV collagen in the extracellular matrix of rat gastric mucosa: influence of alcohol and prostaglandin.
The effect of acute alcohol exposure on the gastric mucosal basal lamina, and its major structural protein type IV collagen, was assessed by transmission electron microscopy (TEM) and immunogold (IG) labeling of this collagenous material. Fasted rats orally received either 50% or 100% ethanol. Five or 60 minutes later animals were sacrificed and mucosal samples were obtained from the glandular epithelium for TEM or IG localization of type IV collagen. For IG studies, the number of gold particles/area lamina densa was quantified in interfoveolar, pit, and gland regions as an index of the molecular integrity of type IV collagen. Both ethanol concentrations induced epithelial exfoliation with pleating of the denuded lamina densa. Absolute ethanol, and to a lesser extent 50% ethanol, caused frequent rupture of a thickened, precipitated lamina densa. Immunolabeling of type IV collagen varied with the experimental protocol. In control tissues exposed to oral saline, binding was greatest in the interfoveolar zone. Low binding occurred with 100% ethanol in all regions when compared with controls, but 50% ethanol evoked significantly higher binding in interfoveolar regions, in a similar fashion to controls. In additional studies in which 16,16 dimethyl prostaglandin E2 (PGE2) (10 micrograms/kg) was injected subcutaneously prior to oral ethanol exposure, PGE2 pretreatment prevented the large decrease in IG binding induced by absolute ethanol, but the level still remained significantly less than with corresponding controls. In contrast, pretreatment with PGE2 prior to 50% ethanol exposure restored type IV collagen immunolabeling to control levels. These results indicate that ethanol induces a concentration-dependent lowering of IG binding to type IV collagen which also effects its reversibility by PGE2.
Animals↗
Protection against ethanol injury in the canine stomach: role of mucosal glutathione.
The present study determined the role that mucosal glutathione (GSH) levels play in mediating the protective effects of a prostaglandin and a mild irritant against alcohol-induced gastric injury. An in vivo canine chambered stomach preparation was used in which the exteriorized mucosa was partitioned into two equal halves, one serving as control. Animals (5-8/group) received a subcutaneous injection of either normal saline (NS) or the GSH depletor N-ethylmaleimide (NEM; 50 mg/kg) and then were assigned to one of a variety of groups based on the perfusate used to bathe the experimental side of the chamber; NS bathed the control mucosa. At completion of the studies, mucosa from each side of the chamber was assayed for total GSH (mumol/g wet wt) and evaluated for microscopic damage. Both 16,16-dimethyl prostaglandin E2 (PGE2) (1 microgram/ml) and the mild irritant 8% ethanol, when topically applied to the gastric epithelium, increased mucosal GSH levels by approximately 20% compared with control values, and elicited no deleterious effects to the mucosa. Treatment of animals with NEM prevented these GSH effects by PGE2 and 8% ethanol without damaging the mucosa. Application of 40% ethanol to the mucosa markedly reduced levels of GSH and caused significant injury to the mucosal surface, much of it extending to the level of the gastric glands. When mucosa was pretreated with PGE2 or 8% ethanol before 40% ethanol exposure, deep gastric gland injury was virtually abolished. In animals receiving NEM, the protective effects of these agents against injury by 40% ethanol were prevented. Perturbations in tissue levels of GSH under these various experimental conditions failed to correlate histologically with the status of gastric mucosal integrity.
Animals↗
Effects of alcohol on laminin in rat gastric mucosa.
Following ethanol exposure, the gastric surface epithelium often exfoliates, leaving a denuded basal lamina. Viable cells from the gland migrate along the basal lamina to repair the defect, a process known as restitution. Laminin, the major non-collagenous glycoprotein of basal laminae, functions in cellular adhesion and migration and, therefore, any alteration of this molecule by ethanol may influence subsequent restitution. After a 5 or 60 minutes treatment with saline, 50% or 100% ethanol, gastric tissues were removed from fasted female Sprague-Dawley rats, fixed in 1% paraformaldehyde and processed in Lowicryl. Once embedded and sectioned, specimens were incubated in anti-laminin followed by protein A-gold. The area of lamina densa from interfoveolar, pit and gland regions was measured and gold particles counted. Absolute ethanol caused diminished immunogold binding in all regions at all time periods, except the gland at 60 minutes. Exposure to 50% ethanol for 5 minutes did not alter laminin binding, although 60 minutes after 50% alcohol, laminin immunolabelling was increased. Alcohol concentration alters laminin immunogold binding, and therefore may influence restitution.
Animals↗
[Generalized tendomyopathy (fibromyalgia): differential diagnosis, therapy and prognosis].
The generalised tendomyopathy is one of the most variegated and fascinating disease of man. The unusual constellation and combination of symptoms constrain to the differential-diagnostic demarcation of a great number of rheumatic and non-rheumatic diseases. While the rheumatic polymyalgia and myositis are easily to be demarcated, the decision between a primary and secondary generalised tendomyopathy can be difficult. In individual cases a classical tendomyopathy can be accompanied by antinuclear factors and then it is at the earliest a "collagenosis the state of waiting". The therapy of tendomyopathy is altogether unsatisfactory. All forms of therapy (medicamentous, physical, psychotherapy) help at the utmost in 50%. Surprisingly, on the part of the medicaments the non-steroidal antiphlogistic drugs and the glucocorticoids in most cases completely fail, and also the physical therapy is frequently not tolerated and/or has only a short duration of effect. The more important are the influence on possible evoking factors, the optimization of the social background and the utilization of the possibilities of the "secondary prevention" (balneotherapy in a health resort, sauna bath, Kneipp's applications, change of the living and working conditions, easy sports activities). Since the disease is frequent, but not yet known in general, it should be made better acquainted among the physicians. The generalised tendomyopathy is and remains a cardinal problem not only of rheumatology, but of the physician's working-day in general.
Anti-Inflammatory Agents, Non-Steroidal↗
[Physical therapy and balneotherapy of arthritis].
The "points of attack" of physical therapy in osteoarthritis are the impaired metabolism of cartilage, the accompanying extra-articular pains in ligaments and muscles and the secondary inflammation. Heat treatment and exercises both have useful metabolic effects; furthermore they influence pain, muscle tone, mobility and blood flow. When secondary inflammation occurs, osteoarthritis should be treated like joint inflammations with short time immobilisation and cold treatment. Osteoarthritis of small finger joints can be treated in the same manner as osteoarthritis of large joints by movement-exercises in warm or cold mud. Spa-treatment as a combination of warm springs, mud etc, with exercises, dietary supplement and health education is a very traditional and useful kind of treatment of osteoarthritis with long term effects. Measurements of physical therapy are also of preventive value. Since physical therapy primarily is always strenuous for the organism, in higher age it must be used careful and well adapted to the tolerability of patients.
Aged↗