Biomedical subjects
M B Stevens
Publications and source records attributed to M B Stevens.
The clinical spectrum of SLE.
Systemic lupus erythematosus is a complex immunologic disorder with an equally complex clinical presentation and course. In recent years, the earlier recognition of milder disease supported by immunologic markers coupled with means of intervention and suppression, as well as medical/surgical advances has resulted in increases in quality of life and survival.
The American College of Rheumatology 1990 criteria for the classification of giant cell arteritis.
Criteria for the classification of giant cell (temporal) arteritis were developed by comparing 214 patients who had this disease with 593 patients with other forms of vasculitis. For the traditional format classification, 5 criteria were selected: age greater than or equal to 50 years at disease onset, new onset of localized headache, temporal artery tenderness or decreased temporal artery pulse, elevated erythrocyte sedimentation rate (Westergren) greater than or equal to 50 mm/hour, and biopsy sample including an artery, showing necrotizing arteritis, characterized by a predominance of mononuclear cell infiltrates or a granulomatous process with multinucleated giant cells. The presence of 3 or more of these 5 criteria was associated with a sensitivity of 93.5% and a specificity of 91.2%. A classification tree was also constructed using 6 criteria. These criteria were the same as for the traditional format, except that elevated erythrocyte sedimentation rate was excluded, and 2 other variables were included: scalp tenderness and claudication of the jaw or tongue or on deglutition. The classification tree was associated with a sensitivity of 95.3% and specificity of 90.7%.
Catabolic effects of high-dose corticosteroids persist despite therapeutic benefit in rheumatoid arthritis.
Although corticosteroids (CS) cause nitrogen wasting in healthy humans, it is not known whether the salutary antiinflammatory and appetite-stimulating effects of CS in inflammatory diseases mitigate this effect. We measured nitrogen balance before, during, and after 3 d of high-dose methylprednisolone therapy in nine patients with flare-ups of rheumatoid arthritis. There was evidence of preexisting somatic protein and fat depletion in seven of nine subjects. Patients were allowed to eat freely on a metabolic ward. Nitrogen balances were -0.89 +/- 1.38 g/d (means +/- SEM) before CS therapy, -5.77 +/- 1.30 g/d during therapy (P less than 0.001), and -3.54 +/- 1.38 g/d after therapy (P less than 0.01) despite increased energy and nitrogen intake and clinical resolution of inflammation during and after the pulse therapy. We conclude that patients with rheumatoid arthritis are often cachectic and high-dose CS cause nitrogen wasting in these patients despite an antiinflammatory and appetite-stimulatory benefit.
Intravenous pulsed steroids in rheumatoid arthritis: a comparative dose study.
This prospective, double blind study was undertaken to test the efficacy of intravenous "minipulse" (100 mg) methylprednisolone (MP) therapy versus standard pulse (1000 mg) MP therapy in rheumatoid arthritis (RA). Thirty-six patients with RA synovitis flares were randomized to receive either 100 or 1000 mg MP IV QD x 3 doses. These 2 universally comparable groups exhibited no statistically significant differences in their striking prompt and sustained clinical improvement. These data suggest that minipulse MP is as efficacious as conventional pulse MP in the treatment of RA flares.
Usefulness and limitations of regional cardiac sympathectomy by phenol.
We evaluated the completeness and extent of regional sympathetic denervation of the left ventricle after epicardial painting with phenol in anesthetized dogs. In a region encircled by phenol, the effect of electrical stimulation of efferent sympathetic fibers on myocardial contractility and coronary vascular resistance was completely abolished within 30 min. Denervation extended to untreated regions innervated by sympathetic fibers crossing the phenol line. For at least 4 h after phenol application, intravenous infusion of isoproterenol or coronary arterial infusion of tyramine increased myocardial contractility in the denervated region; norepinephrine content and neurotransmitter uptake were normal, indicating that nerve terminals, postjunctional receptors, and myocardium remained functional. However, after 3-14 days, tissue catecholamine content and transmitter uptake in the encircled area were markedly reduced. The results suggest that careful evaluation is necessary in selecting a fully innervated control region in studies employing regional sympathetic denervation with phenol.
Effects of acute ischemia in the dog on myocardial blood flow, beta receptors, and adenylate cyclase activity with and without chronic beta blockade.
We ligated the left anterior descending coronary artery for 1 or 2 h in 31 purebred beagles. We did not detect any changes in beta-adrenergic receptor density or affinity when normal and ischemic zones were compared, either in the subendocardium or in the subepicardium. In the ischemic zones, there was a significant decline in all measures of adenylate cyclase activity, including activity mediated by the beta-adrenergic receptor. By contrast, after chronic beta-adrenergic blockade (1.5 mg/kg propranolol i.v. twice daily for 7 d), there was an increase in adenylate cyclase activity stimulated by (-)-isoproterenol relative to adenylate cyclase activity stimulated by guanyl-5'imidodiphosphate (GppNHp) in both normal and ischemic tissue, suggesting that one effect of chronic beta blockade may be to enhance coupling between the stimulatory guanine nucleotide regulatory protein (Gs) and the beta-adrenergic receptor, despite a reduction in the number or function of Gs units. Chronic beta blockade also led to up regulation of beta-adrenergic receptor density in subepicardial regions. After 20 min of reperfusion following 2 h of ischemia, adenylate cyclase activity tended to return to control levels, particularly in the subepicardium, where (-)-isoproterenol-stimulated adenylate cyclase activity was not different from normal myocardium. We conclude that chronic beta-adrenergic blockade may have beneficial effects during prolonged episodes of myocardial ischemia by preserving signal transduction mediated by the beta-adrenergic receptor.
The effect of verapamil on cerebral cortical and spinal cord blood flow during proximal descending thoracic aortic occlusion.
UNLABELLED: The mechanism of central nervous system (CNS) protection during proximal descending thoracic aortic cross-clamping (PDTAC) for aortic surgery using calcium channel blocking agents is not known. In order to determine the effect of verapamil on CNS blood flow during PDTAC, we calculated cerebral cortical (CC), proximal spinal cord (PSC), and distal spinal cord (DSC) blood flow using the microsphere method in Grade I beagles. Flow calculations were obtained at baseline (pre-PDTAC), following mobilization of the proximal descending aorta for 5-8 cm by ligating 3-5 pairs of intercostal arteries (ICA), during PDTAC (45 min), and during maximal reperfusion. Two groups were studied: 1) control (Cont) untreated (n = 5); 2) verapamil (Ver) treated (0.4 mg/kg IV just before PDTAC and just before reperfusion) (n = 5). CONCLUSIONS: I) Proximal ICA ligation produces no compromise to SC blood flow. II) Verapamil may protect the CNS by: 1) maintaining cerebral autoregulation during reperfusion; and 2) dampening hyperperfusion of the distal SC during reperfusion.
State screening for metabolic disorders in newborns.
Most states have mandatory screening programs for congenital and inherited disorders of metabolism. Physicians may be unaware of their state's requirements, and compiled lists of testing requirements are generally unavailable or incomplete. All states test for congenital hypothyroidism and phenylketonuria. Some states require that newborns be tested for up to six other specific congenital and inherited disorders of metabolism. Some states base their decision to test on demographic data, but there is no uniformity in the tests.
The reactive arthritis of giardiasis. A case report.
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Remission of rheumatoid arthritis with the successful treatment of acute myelogenous leukemia with cytosine arabinoside, daunorubicin, and m-AMSA.
We describe 2 patients in whom a sustained remission of longstanding rheumatoid arthritis occurred with treatment for acute myelogenous leukemia (cytosine arabinoside, daunorubicin, and m-AMSA), even though both illnesses had been refractory to therapy with standard disease-modifying agents. These 2 patients represent the first successful treatment of rheumatoid disease using such an approach.
Patient education program to teach energy conservation behaviors to patients with rheumatoid arthritis: a pilot study.
We report a prospective, randomized pilot study comparing a new workbook-based program, designed to teach patients with rheumatoid arthritis (RA) energy conservation behaviors, with standard occupational therapy (OT). Sixteen patients took part in the new program and nine received the standard therapy. Data on the number of tender or swollen joints, grip strength, walk time, activities of daily living, psychologic adjustment to illness, and daily activity log, were measured before and three months after intervention. Eleven percent of those who received standard therapy and 50% of those who received the workbook increased their amount of physically active time (p = .10). Twenty-two percent of the control group and 50% of those in the workbook group achieved a better balance of rest and physical activity (p = .07). We conclude that the adoption of energy conservation behaviors is different in the two groups. This initial study suggests that interrupting physical activity with rest periods may result in increased physical activity in patients with RA.
A long-term evaluation of the treatment of osteoarthritis.
In a study of the long-term safety and efficacy of piroxicam (20 mg daily) in the treatment of osteoarthritis, 30 female patients with a mean duration of more than seven years of treatment were evaluated. Despite having had poor or no response with other drug therapies, in the majority of cases in which piroxicam was used half of the patients (15 of 30) reported feeling very good or good at their last visit, 13 said they felt fair, and only two reported feeling poor or very poor in terms of their sense of well-being. The incidence of adverse events was somewhat less than one event per patient year of exposure, and 94 percent of adverse events were mild or moderate. Laboratory measurements of drug safety did not reveal any evidence of renal, hepatic, or hematologic toxicity. It is significant that patients were willing to commit themselves to long-term piroxicam therapy for at least five years after an initial trial and that they preferred to continue taking the drug rather than switch to alternative forms of therapy.
Severe retinal vaso-occlusive disease in systemic lupus erythematous.
Retinopathy in systemic lupus erythematosus generally consists of cotton-wool spots with or without intraretinal hemorrhages. Although rare, a more severe retinal vaso-occlusive disease, termed retinal vasculitis, has been described. We report data from 11 patients with SLE and severe retinal vaso-occlusive disease. Visual outcome was often poor, with 55% of the involved eyes suffering visual loss, frequently to an acuity of worse than 20/200. The systemic feature significantly associated with severe retinal vascular disease was central nervous system involvement (CNS lupus), present in eight (73%) of the 11 patients vs an overall prevalence of 37%. The association of CNS lupus with severe retinal vaso-occlusive disease probably reflects a similar pathogenetic mechanism and microangiopathy.
Optic neuropathy in systemic lupus erythematosus.
We report data from seven cases of optic neuropathy in systemic lupus erythematosus. The visual outcome varied, but improvement occasionally occurred following treatment with corticosteroids. The clinical picture was variable and could present as acute retrobulbar optic neuritis, ischemic optic neuropathy, or slowly progressive visual loss. Visual evoked response testing revealed increased latency in two patients and loss of amplitude in two others; a fifth patient had both findings in the involved eye. Despite the variable presentation, the probable pathogenesis in all cases is vaso-occlusive disease in small vessels of the optic nerves.
The early diagnosis of ischemic necrosis of bone.
One hundred sixty-nine patients with radiographic or histologic evidence of ischemic necrosis of bone (INB) were evaluated. Ninety-nine (59%) of the 169 patients had multiple sites of INB, with 310 bones affected. Two hundred sixty-three (85%) of the 310 ischemic bones were symptomatic. Routine radiography produced negative findings in 58 (20%) of the bones with histologically confirmed INB. Results of hemodynamic studies, including baseline bone marrow pressure, saline stress test, and/or intraosseous venography, were abnormal in 243 (94%) of 259 ischemic bones so evaluated. Most importantly, hemodynamic studies detected 51 (93%) of the 55 bones that were radiographically normal but had histologically confirmed INB.