Biomedical subjects
Publications and source records attributed to M Doherty.
Shedding of crystals from cartilage into a joint space can cause pseudogout, the most common acute monarthritis in the elderly. The calcification may also be associated with structural change identical to osteoarthritis. Treatment seeks to reduce symptoms and improve function.
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OBJECTIVES: To assess race-specific incidence and prevalence rates for systemic lupus erythematosus (SLE) using 1991 National Census data and to ascertain the frequency of clinical/laboratory features of a geographically complete cohort of patients with SLE. METHODS: Multiple methods of retrieval were used to ascertain SLE patients including screening request cards for immunology investigations. Patients were classified according to the revised ARA criteria. Multiple logistic regression analysis was used to study the effects of age at diagnosis on the frequency of clinical/laboratory SLE features. RESULTS: The overall one year period prevalence rate for SLE was 24.7 (age adjusted, 95% CI: 20.7-28.8)/100,000. Highest rates were seen in Afro-Caribbeans (207 (111-302)/100,000), followed by Asians (48.8 (10.5-87.1)/100,000), and then Whites (20.3 (16.6-24.0)/100,000). The mean age at diagnosis of SLE was 40.9 years (range: 11-83) with a mean interval between first definite SLE symptom and diagnosis of 61 months (0-518). In 85% of patients the first definite lupus feature was musculoskeletal and/or cutaneous. In this SLE cohort renal disease (22%) was observed less commonly than in previous studies and the 'classic' butterfly rash was present in only 30% of patients. Malar rash, thrombocytopaenia, positive anti-dsDNA antibodies, hypocomplementaemia (C4), and positive IgG anticardiolipin antibodies were all seen less commonly with increasing age at diagnosis. CONCLUSIONS: A closer estimate of the true frequency of clinical/laboratory SLE manifestations is likely from this geographically complete cohort of patients compared with studies that may be skewed by referral patterns.
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For 74 years the Norwell Visiting Nurse Association has provided home health care, public health, and community services to the 27,000 residents of Norwell and Scituate, in Massachusetts. This article explores the history of this nurse-managed, nonprofit, free-standing visiting nurse association.
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Eighty-seven consecutive children with newly diagnosed optic glioma were managed at University of Toronto hospitals 1958-1990. Overall the 10-year survival, relapse-free survival and freedom from second relapse rates were 84%, 68% and 85%. Twenty-seven patients relapsed or progressed, of whom 40% were free of a second relapse 10 years after the first relapse. Fourteen patients had a second relapse. Thirteen are dead. None survived 5 years after second relapse. Patients with anteriorly located tumors (N = 35), which involved the optic nerve, or chiasm and optic nerves, fared better than those with posteriorly located tumors (N = 52) with spread beyond the chiasm, 10-year survival 95% versus 76%, (p = .02), 10-year relapse-free survival 80% versus 59% (p = .02), respectively. For posterior tumors primary irradiation was more effective than primary subtotal resection for prevention of subsequent relapse, 10-year relapse-free survival 75% versus 41% (p = .02), but salvage therapy was, in part, successful and multivariate analysis of prognostic factors influencing survival for posterior tumors indicated that neither primary resection nor primary irradiation were significant factors. For first relapse, primary irradiation and the presence of neurofibromatosis were the significant favorable factors. Since 1977 and for posterior optic glioma subtotal resection or surveillance were used in 21/29 (72%) patients compared with 4/23 (17%) previously. Ten-year survival rates before and after 1977 were 78% and 67% and 10-year relapse-free survival 64% and 56%, respectively.
A case of acute lower-body ischemia 2 days following intraaortic balloon pump insertion is reported. Fluoroscopy revealed persistent balloon inflation throughout the cardiac cycle with distal aortic occlusion. Attempts to manually deflate the balloon were unsuccessful until a guidewire was advanced through the gas-exchange lumen into the body of the balloon. The balloon catheter was removed without clinical sequelae other than transient oliguria and an asymptomatic increase in creatinine phosphokinase (CPK). This is a previously unreported complication of intraaortic balloon counterpulsation.
Primary fibromyalgia syndrome (PFS) is a common condition that often proves resistant to health interventions. Chlormezanone combines corrective effects on disturbed sleep with muscle-relaxant properties, and therefore could be of potential benefit in PFS. Forty-two female patients with PFS (mean age 49, range 24-72 years) were randomly and blindly allocated either chlormezanone 400 mg nocte or placebo. Patients were assessed by single observer at 0, 3 and 6 weeks of treatment; assessments included sleep quality, inactivity and morning stiffness, morning alertness, tender point score, mood change and global opinion (patient and observer). No beneficial therapeutic effect could be attributed to chlormezanone. Although there are problems in assessing severity of a predominantly subjective condition, this essentially negative finding is of interest in respect to the pathogenesis of PFS.
The incidence and prevalence of systemic lupus erythematosus (SLE) in a well defined area in the Midlands was determined, by case ascertainment using multiple sources, during the period 1.5.89 to 30.4.90. This first such study of SLE in the UK showed incidence rates of 1.5/100,000/year for males and 6.5/100,000/year for females. The highest incidence was seen in age groups 40-49 and 50-59 years, with rates for females of 10.5 and 18.4/100,000/year respectively. Prevalence rates were 3.7/100,000/year for males and 45.4/100,000/year for females: SLE was found to be more prevalent amongst Afro-Caribbean groups. The socioeconomic status of the SLE patients was similar to the local study population, using social class by occupation and disadvantage by geographical area as indicators. Marked overlap between different sources of retrieval suggests that ascertainment of cases was high.
Seventy-two patients (65 F, 7 M; mean age 52, range 18-81 years) fulfilling criteria for primary fibromyalgia syndrome (PFS) were reviewed at a mean of 4 years (range 1.5-6) following diagnosis. Ninety-seven per cent still had symptoms typical of PFS (60% worse, 26% better than at presentation); 85% had multiple hyperalgesic tender sites and still fulfilled criteria for PFS; 8% had more limited, and 7% had no tender sites at review. Many had significant disability (median score 1.0, range 0-2.75, on the Health Assessment Questionnaire; median 2, range 1-3 on the Steinbrocker index) and 92% scored highly (> 12) on the Hospital Anxiety and Depression index. In no patient did screening investigations reveal development of inflammatory, metabolic, endocrine or muscle disease. This study confirms a poor outcome for PFS patients and association with often marked functional disability and high levels of anxiety and depression. Contrary to one previous study there was no evidence that PFS predates the onset of other disease.
One hundred and four consecutive patients with pyrophosphate arthropathy were followed prospectively and re-studied at a mean of 4.6 years. Sixty-four patients (43F, 21M; mean age at review 71.2 years) completed the study (24 died of unrelated disease, 16 were unavailable for review). The knee had been the major presenting joint in 91%. Symptoms were improved in 41%, unchanged in 33% and had worsened in only 27%: 27% developed symptoms in new joints. Radiographic changes of arthropathy were unaltered in 50%: although 'worsening' of previously involved joints was seen in 16%, the most common change was increase in osteophyte with bone remodelling (31%). Despite dynamic changes in chondrocalcinosis in most patients (77%) there was no correlation between extent of calcification and progression of arthropathy. It is concluded that the outcome of pyrophosphate arthropathy is not necessarily progressive, patients presenting with acute attacks alone do particularly well.
Four women with chondrocalcinosis are described. Each developed acute attacks of synovitis during pregnancy (confirmed pseudogout, two; presumptive pseudogout, two). All patients had recognized predisposing factors (metabolic, familial, traumatic) for premature calcium pyrophosphate deposition, and in three this was their first episode of synovitis. This first report of provocation of pseudogout by pregnancy is of interest in respect of putative mechanisms of crystal shedding.
The influence of sex hormone related events and smoking on the development of OA in women was investigated in a case-controlled postal survey. One hundred and twenty-nine patients with nodal generalized osteoarthritis (NGOA) and 145 with non-nodal pauciarticular large joint osteoarthritis (LJOA) were identified from the database of a Nottingham OA clinic. For each patient, three age-matched controls were randomly selected from the same general practice. Sixty-three per cent of questionnaires (690/1096) were returned: NGOA, 95; NGOA controls, 226; LJOA, 113; LJOA controls, 256. There were no differences in age at menarche or menopause, rates of hysterectomy, oral contraceptive use, or hormone replacement use between cases and controls. Fewer OA patients had ever smoked [(Odds Ratio (OR) 0.65, 95% Confidence Interval (CI) 0.45-0.95)] and subset analysis demonstrated that this negative association occurred only in the LJOA group (OR 0.43, CI 0.25-0.72), particularly in those with knee OA (OR 0.29, CI 0.14-0.62). A previous successful pregnancy was negatively associated with NGOA (OR 0.47, CI 0.24-0.95). This study demonstrates no association between oestrogen-related hormonal events and OA, but a negative association between smoking and LJOA. Such data supports the concept that OA is a heterogeneous disease and underlines the need to differentiate OA subsets.
BACKGROUND: The Cp50 (minimal steady state plasma concentration of an intravenous analgesic/anesthetic required to prevent a somatic response in 50% of patients following skin incision) and the Cp50-BAR (minimal plasma concentration of an analgesic/anesthetic required to prevent either a somatic, hemodynamic, or autonomic response in 50% of patients following skin incision) have been recently proposed as a measure, like minimum alveolar concentration (MAC; and MAC-BAR), to establish the relative potency of intravenous analgesics. This study was conducted to establish the Cp50 for fentanyl. METHODS: Unpremedicated patients were administered fentanyl (in the presence of 70% N2O) via computer-assisted continuous infusion, a pharmacokinetic model-driven infusion device. After induction of anesthesia with fentanyl, the randomized target fentanyl concentration was entered into computer-assisted continuous infusion. This target fentanyl concentration was maintained until skin incision. Before induction, prior to skin incision, and immediately after skin incision, arterial blood samples were obtained for measurement of fentanyl and norepinephrine concentrations. At skin incision, patients were observed for a somatic, hemodynamic, or autonomic response. Only patients in whom the pre- and postincision fentanyl concentrations were within +/- 30% were included in the calculation of the Cp50. The Cp50 was calculated using logistic regression. RESULTS: The Cp50 for fentanyl was 3.26 ng/ml, and the Cp50-BAR was 4.17 ng/ml. CONCLUSIONS: Comparing these results with the previously published Cp50 of alfentanil, the potency of fentanyl relative to alfentanil is 1:58. Establishing the Cp50, once effect site equilibration has occurred, will allow pharmacodynamic comparisons between the opioids at equipotent concentrations.
Associations between compartmental distribution of radiographic changes of osteoarthritis (OA), individual features of OA (joint space loss, sclerosis, cyst, osteophyte; each scored 0-3), and presence of synovial fluid calcium particles (calcium pyrophosphate dihydrate (CPPD) crystals identified by polarised light microscopy and other calcium particles by alizarin red positivity (ARP) were sought in 300 osteoarthritic knees (178 patients; mean age 72, range 33-96 years). Patients whose knees were symptom free as well as those with symptoms were included. Osteoarthritis of two or three compartments but not unicompartmental OA was associated with the presence of CPPD or ARP. Involvement of any compartment (not just patellofemoral), and higher mean scores for both total and individual osteoarthritis changes (except cysts) was associated with CPPD and ARP; CPPD, but not ARP, was associated with symptoms: knees reported as having symptoms had higher mean total OA scores. Femoral cortical erosion, found more often in women, was associated with higher mean total OA score at the patellofemoral compartment but not with the presence of particles. Attrition, remodelling, and chondrocalcinosis (each scored as present or absent) occurred more often in knees with CPPD. Age did not correlate with any aspect of the OA score. This study confirms the association of calcium particles with the process of OA. Unlike previous studies confined to symptomatic knees, a radiographic pattern specific to CPPD ('pyrophosphate arthropathy') did not emerge.
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Various factors have been considered important in the rate of progression of osteoarthritis of the hip, though few data are available from large longitudinal studies. One hundred and thirty six patients referred to hospital (85 women, 51 men; mean age 65 years, range 29-86 years) with osteoarthritis of the hip (192 affected hips) were followed up for a median of 27 (range 3-72) months. One hundred and six patients (144 affected hips) were reviewed for a minimum of one year (median 28, range 12-72 months). Fifty three per cent of all osteoarthritic hips required an operation at a median of 14 (range 3-48) months from entry. All radiographs before and after entry were examined (median four films for each patient over a median of three years, range 0.5-19 years). Hips showing rapid radiographic progression on prospective films more often had superior migration, or an atrophic bone response; those with no progression more often had an indeterminate, medial, or axial migration pattern, protrusio or mild osteoarthritis at presentation. A higher occurrence of rapid progression was seen in women, in those of older age at symptom onset, and in hips with a higher Kellgren grade at entry; men more often showed no progression. Age at presentation, body mass index, symptom duration, or presence of chondrocalcinosis, hand osteoarthritis/nodes, or Forestier's disease did not influence progression. This study supports the contention that, at the time of hospital referral, certain patient characteristics and radiographic features at the hip may help to identify those at high risk of rapidly progressive hip osteoarthritis.