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PubMed2001

What a difference a year makes: reflections on the ACR recommendations for the medical management of osteoarthritis.

Since the publication in 2000 of the updated American College of Rheumatology (ACR) recommendations for the medical management of patients with lower limb osteoarthritis (OA), additional recommendations, newer epidemiologic studies, systematic reviews, and clinical trials have been published. The results of these reviews, studies, and trials, which highlight the greater efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) for controlling pain and the potential serious upper gastrointestinal toxicity of acetaminophen, require us to reassess the use of acetaminophen as the first-line pharmacologic agent for all patients with knee OA. Furthermore, the documented efficacy of glucosamine for pain relief and function improvement in patients with knee OA, with an effect size that is comparable with that of NSAIDs, requires us to reassess the use of glucosamine as a potential first-line agent at least for patients with knee OA who have mild-to-moderate pain. The availability of the cyclo-oxygenase 2 (COX-2)-specific inhibitors and their documented greater safety relative to traditional dual-inhibitor NSAIDs with regard to serious upper gastrointestinal toxicity lead us to reassess the use of traditional NSAIDs in patients with OA, especially in those at increased risk for such adverse events. The COX-2-specific inhibitors cost less than the combination of a generic NSAID plus a proton-pump inhibitor. The results of ongoing and future studies, especially of structure-modifying anti- osteoarthritis drugs, will lead to further reassessment and updating of recommendations for the medical management of patients with knee OA. Hopefully, the use of such recommendations will improve the outcomes for patients with this debilitating chronic condition.

Acetaminophen↗
PubMedDate not supplied

Prevalence and level of antibodies to the circumsporozoite proteins of human malaria parasites, including a variant of Plasmodium vivax, in the population of two epidemiologically distinct areas in the state of Acre, Brazil.

A seroepidemiological study of the prevalence of antibodies against the repeating epitopes of circumsporozoite (CS) proteins of human malaria parasites was conducted in 2 different areas in the state of Acre, Brazil in 1987 and 1990. In 1987 antibodies against the CS protein of the VK 247 variant Plasmodium vivax as well as antibodies against the CS proteins of P. falciparum and the classic P. vivax were found at relatively high rates in the 2 areas, but significant microepidemiological differences were observed. In 1990, when large scale migration in Amazonia had ceased and control measures were applied in the study areas, the malaria endemicity decreased, as determined by the declining prevalence of anti-sporozoite antibodies against all Plasmodium species, and the small number of individuals with positive blood smears. Antibodies against sporozoites of the variant P. vivax did not cross-react with the CS proteins of the classic P. vivax, nor with antibodies against sporozoites of P. falciparum and P. malariae. Sera containing antibodies against the CS protein of P. malariae were found at a very low frequency, and only in 1987. The anti-CS protein antibody response to all Plasmodium species was age-related.

Adolescent↗
PubMedDate not supplied

Anophelines in the state of Acre, Brazil, infected with Plasmodium falciparum, P. vivax, the variant P. vivax VK247 and P. malariae.

Anophelines collected indoors and in the peri-domiciliary area in 3 localities in the Amazon region, state of Acre, Brazil, from August 1990 to January 1991 were examined by enzyme-linked immunosorbent assay (ELISA) using specific monoclonal antibodies directed against the repeats of the circumsporozoite proteins of Plasmodium falciparum, P. vivax, P. vivax V247, and P. malariae. Of the 3056 specimens collected, 2610 were Anopheles oswaldoi, 362 A. deaneorum, 60 A. triannulatus and 24 were A. darlingi. The infection rates of A. oswaldoi were 3.41% for P. falciparum, 2.26% for P. vivax, 1.22 for P. vivax VK247, and 0.42% for P. malariae. For A. deaneorum, the infection rates were 2.76% for P. falciparum, 0.55% for P. vivax, and 0.82% for P. vivax VK247. All samples of the other 2 species collected (A. triannulatus and A. darlingi) were negative in the ELISA. There were certain differences in the anopheline distribution and infection rates between these localities, and in one only A. oswaldoi was found to be infected. These results strongly point to A. oswaldoi as the main malaria vector in the region. No difference was found between the potential vectors of P. vivax and P. vivax VK247. The significance of these findings for malaria control is discussed.

Animals↗
PubMed1996

High incidence of bites and stings by snakes and other animals among rubber tappers and Amazonian Indians of the Juruá Valley, Acre State, Brazil.

Among forest-dwelling Amazonian Indians and rubber tappers (seringueiros) of the Juruá valley in Acre State, north-western Brazil, snakebite is an important cause of morbidity and death. Overall, 13% of a surveyed population had been bitten during their lifetime. Seventeen per cent of Katukina Indians, but only 8% of Ashaninkas, had been bitten by snakes reflecting, perhaps, different levels of traditional knowledge of the forest and its dangers. Most bites occurred in the jungle or on jungle trails (56%), while people were working (41%) or walking (26%), and were inflicted on the feet (54%). Ninety per cent of bite victims received treatment, usually traditional (93%); the majority (80%) recovered fully. Mortality was estimated at about 400 deaths per 100,000 population per lifetime. Bites and stings from other venomous forest and river animals, especially the freshwater sting ray (Potamotrygon sp.), were also extremely common. One death from an ant bite was recorded.

Animals↗
PubMed1994

The Environmental Health Profile (EHP) for the Acre Valley (Israel): xenobiotics in animals and physiological evidence of stress.

The scope of this study was to analyse the levels of various xenobiotics in animals, wild and domestic, of the Acre Valley in the north of Israel, the most polluted and dense urbanised part of the country. The focus was placed upon the bioaccumulation of heavy metals, such as Pb, Hg, Cu, Zn, Al, Fe, as well as other elements and PCBs. Analysis was also performed on levels of cholinesterase and acetylcholinesterase in birds and man influenced by insecticides in the same region. For this study we used X-ray scanning electron microscopic (S.E.M.) electron probe, atomic absorption spectrophotometry, gas chromatography for PCBs and biochemical methods specific for enzymes. We studied four species of littoral molluscs, four species of birds and five species of mammals including dogs and cats. The results showed very high levels of metals and PCBs and enzyme deviations in birds and man around the sprayed cotton fields, as compared to man from the close to towns. All the collected data will serve as an Environmental Health Profile for immediate and future consideration.

Animals↗
PubMed1990

New cisplatin schedule in combination with aclarubicin (ACR) with high response rate in recurrent gynecological adenocarcinomas.

Fourteen patients with recurrent gynecological adenocarcinomas (nine with endometrial cancer and six with ovarian cancer) were treated with cisplatin given by 14-day continuous infusion at a daily dose of 10 mg/m2 in combination with aclarubicin (ACR) at a dose of 20 mg/body on alternate days during each 14-day course. The daily dose of cisplatin was given with 1 liter of fluids; no diuretics were administered. The overall response rate was 71.4% (50% in endometrial cancer and 100% in ovarian cancer). It was especially interesting that a 100% response rate was obtained in five patients previously treated with cisplatin; i.e., the present cisplatin dosing schedule was highly effective as second-line therapy in these patients. No renal or gastrointestinal toxicity was observed. These results were pharmacokinetically explained by the plasma concentration of filterable platinum. A low-level, plateau-like curve with a great area under filterable [Pt]-time curve (AUC) seemed to ensure exposure of cancer cells to filterable platinum for sufficiently long periods and freedom from gastrointestinal and renal side effects.

Aclarubicin↗
PubMed2006

Breast imaging reporting and data system (BI-RADS) or French "classification ACR" What tool for what use? A point of view.

The American College of Radiology Task Force on Breast Cancer published in 2003 the fourth edition of BI-RADS for Mammography. It is a lexicon of mammography terms including illustrations of each feature described, followed by a reporting format with assessment categories according to the degree of concern. The aim is to reduce inconsistencies in mammography reports and recommendations for assessment, to facilitate outcome monitoring and to allow each radiologist to audit his own mammography practice. In France, the Société Française de Radiologie acquired the rights to translate BI-RADS, word for word and without adaptation or influence. The last edition was published in 2004. Simultaneously, French Haute Autorité de Santé and National Committee for Breast Cancer Screening proposed to all community practice mammography facilities a classification of detected abnormalities stating more clearly than BI-RADS do which feature has to be included in such and such assessment category and how to manage it. This "classification ACR" is adapted from BI-RADS but strongly influenced by the context of the French nationwide screening programme, and by European recommendations to limitate undesirable risks of screening such as false positive and overdiagnosis. The differences between the two systems are discussed.

Breast Diseases↗
PubMed2006

Factors that affect the number of tender points in fibromyalgia and chronic widespread pain patients who did not meet the ACR 1990 criteria for fibromyalgia: are tender points a reflection of neuropathic pain?

OBJECTIVE: This study aims to compare fibromyalgia (FM) and chronic widespread pain (CWP) patients who do not fulfill the criteria for tender points (TP). METHODS: We included 150 patients diagnosed with FM according to ACR 1990 criteria and 42 patients with CWP who did not fulfill TP criteria for FM into the study. The clinical features of the patients were recorded, and the TP count was determined. By means of a visual analog scale (VAS), all patients were questioned about the severity of pain and FM-related symptoms. In addition, the patients were administered the Duke Anxiety Depression (Duke-AD) scale and somatization symptom questionnaire. Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) pain scale was used to determine the neuropathic pain score. RESULTS: According to VAS, the severity of pain, sleep disturbance, the number of somatization symptoms, LANSS, and Duke-AD scores were significantly higher in FM patients than in patients with CWP (all P values <0.05). The number of TP correlated with severity of pain (r = 0.32, P < 0.001), the number of somatization symptoms (r = 0.26, P = 0.01), sleep disturbance (r = 0.18, P = 0.01), and LANSS score (r = 0.4, P < 0.001). Multiple logistic regression analysis revealed that independent factors that affected the presence of > or =11 TP were the severity of pain on VAS (OR: 1.03, 95% CI: 1.01-1.06, P = 0.045) and LANSS score (OR: 1.36, 95% CI: 1.12-1.62, P = 0.001). CONCLUSIONS: CWP patients have symptoms similar to FM patients, though less severe. The most important factor that affects the criteria for fulfilling the number TP in CWP patients is the neuropathic pain score, which suggests that FM is primarily a neuropathic pain syndrome.

Adult↗
PubMed2000

Magnitude and consequences of error in coronary angiography interpretation (the ACRE study).

In the routine reporting of coronary angiograms, there are no contemporary estimates of the magnitude and consequences of interobserver variability. We therefore measured the agreement beyond chance between (1) the number of narrowed arteries on an angiographic report extracted from case notes and independent assessments by 2 cardiologists, and (2) actual patient management over an 18-month follow-up period and each cardiologist's hypothetical management proposal based on abstracted clinical details. Two hundred nine angiograms were randomly selected from 4,121 patients in a prospective study (Appropriateness of Coronary Revascularisation [ACRE study]). The number of narrowed arteries was defined using Coronary Artery Surgery Study (CASS) criteria. For the number of narrowed arteries, cardiologists A and B agreed with the angiographic report in 126 patients (60%, weighted kappa = 0.64) and 124 patients (59%, weighted kappa = 0.63), respectively. In a subset of 92 patients (44%) there was unanimous agreement on the number of narrowed arteries (both cardiologists agreed with the angiographic report). Comparing actual management (34 percutaneous transluminal coronary angioplasty and 39 coronary artery bypass grafting procedures on follow-up) with each of the cardiologist's management recommendations showed agreement in 150 patients (72%, kappa = 0.46) and 154 patients (74%, kappa = 0.48) for cardiologists A and B, respectively. These agreements on management improved (p = 0.05) for cardiologist B (but not A) when analysis was confined to the subset of 92 patients, showing agreement in 73 patients (79%, kappa = 0.60). Thus, in routine clinical practice, the agreement beyond chance in interpretation of the number of narrowed arteries was good. Disagreements on subsequent patient management arose as a result of, and independent of, errors in angiographic interpretation.

Adult↗
PubMed2004

[Study on the management of patients following detection of a "probably benign" mammographic abnormality (ACR BI-RADS category 3): a review of 176 radiologists].

OBJECTIVES: To evaluate mid-term management of patients with category 3 findings (probably benign, ACR BI-RADS) at mammography three months after a CME course on breast cancer. METHODS: A questionnaire (33 items) was sent to 529 radiologists, three months after the CME course (May-December 2002). The answers were analysed using the chi-square test. RESULTS: A total of 176 radiologists completed the questionnaire; 63 were part of an organized screening mammography program; 162 used the BI-RADS classification. In the presence of a class 3 finding, 158 radiologists recommended short term follow-up, 28 recommended biopsy, 9 upgraded the level of abnormality, 116 consulted another radiologist, 42 consulted an expert mammographer, 36 submitted the case to a multidisciplinary committee and 12 asked for an overread. Management with short term interval follow-up was worrisome to 91 radiologists for fear of unfavorable outcome, and to 47 radiologists because of possible litigation. Twenty-six radiologists had difficulty explaining to patients the need for short term follow-up. The median score for perceived stress by the radiologists was 3 (0=low and 10=high). CONCLUSION: The practices of this sample of French radiologists are consistent with the recommendations presented during the CME course and by the ANAES. They may have some difficulty in communicating with patients the need for follow-up. The ethics of radiology are based on "primum non nocere".

Breast Neoplasms↗
PubMed2001

Gender differences in descriptions of angina symptoms and health problems immediately prior to angiography: the ACRE study. Appropriateness of Coronary Revascularisation study.

Although the prevalence of angina in women is increasing, women are less likely than men to undergo invasive management of coronary disease. Gender differences in language use may contribute to disparities in management, since the diagnosis of angina relies on a patient's description of their symptoms. This study set out to investigate whether gender differences exist in the language used when describing angina symptoms and perceived health problems at the time of angiography, which might influence the rate of subsequent revascularisation. Content analysis was used to analyse written accounts of 'symptoms and health problems' in 200 (96 female) patients randomly selected within age strata who were undergoing coronary angiography for chronic stable angina in the Appropriateness of Coronary Revascularisation (ACRE) study. Written free text was coded into seven categories: pain location (chest or arm and throat, neck or jaw); pain character; breathlessness; other symptoms; effects on lifestyle; symptom attributions; and patient discourses ('story' or 'factual'). Women described more throat, neck or jaw pain than men among those with low physical functioning ( p=0.06), in the presence of coronary artery disease (p = 0.04) and in those who were not subsequently revascularised (p =0.05). Women also gave more accounts than men of breathlessness and other symptoms, but there was little evidence for gender differences in the use of 'factual' discourses. We conclude that from the time of angiography, gender differences in language use do exist and description of angina pain may influence subsequent revascularisation. Further research is necessary to investigate the nature and consequences of gender differences in language use at this and earlier stages in the referral process.

Activities of Daily Living↗
PubMed2002

Update of ACR guidelines for osteoarthritis: role of the coxibs.

The American College of Rheumatology (ACR) recently provided an update to the guidelines published in 1995 on the management of osteoarthritis (OA) of the knee and hip. Members of the Ad Hoc Committee on OA Guidelines followed an evidence-based medicine approach to revise the guidelines by reviewing an extensive literature search of the Cochrane and Medline databases and published abstracts, and discussing evidence with expert rheumatologists. The goal of the guidelines is to provide recommendations to control patients' OA pain, improve function and health-related quality of life, and avoid therapeutic toxicity. As in the original guidelines, nonpharmacologic interventions involving patient education and physical measures are recommended following initial diagnosis of OA. The pharmacologic algorithm was updated to include currently available therapeutic agents. Acetaminophen remains first-line therapy because of its cost, efficacy, and safety profiles. Cyclooxygenase-2-selective inhibitors (coxibs) have been included as an alternative to nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) in patients at risk for upper gastrointestinal adverse events. Tramadol is an available alternative for patients who have a contraindication to coxibs or nonselective NSAIDs or for those who have not responded to previous oral therapy. Intra-articular injections or topical therapy may be used as monotherapy, or as an adjunct to oral analgesia. Surgical treatment of OA remains a last resort for patients who have failed to respond to nonpharmacologic and pharmacologic treatment approaches, and have progressive limitation in their activities of daily living. Several therapies for the prevention or treatment of OA are currently under investigation, including nutritional supplements, such as glucosamine and chondroitin, disease-modifying OA drugs, and devices, such as acupuncture and electromagnetic therapy. It is anticipated that the guidelines for the management of OA will continue to evolve as new therapies become available.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2004

The vomiting neonate: a review of the ACR appropriateness criteria and ultrasound's role in the workup of such patients.

Ultrasound (US) plays a central role in the diagnostic imaging workup for infantile vomiting. This paper reviews the major causes of vomiting in the first months of life and the use of US and other modalities for their imaging assessment. The differential diagnostic possibilities are reviewed by examining 3 clinical scenarios of bilious vomiting during the first days of life, nonbilious vomiting since birth, and projectile vomiting first occurring after several weeks of life. These are the 3 scenarios that were used for the American College of Radiology (ACR) Appropriateness Criteria for Vomiting in Infants up to 3 Months of Age.

Education, Medical, Continuing↗
PubMed2003

Burden of congenital rubella syndrome after a community-wide rubella outbreak, Rio Branco, Acre, Brazil, 2000 to 2001.

BACKGROUND: During 1999 and 2000 rubella outbreaks were reported in 20 of 27 states in Brazil, many among young adults. We investigated a large rubella outbreak in Rio Branco, Acre, in northwestern Brazil, where rubella vaccination targeting children 1 to 11 years old had been introduced in April 2000. Surveillance for congenital rubella syndrome (CRS) was initiated after the outbreak. METHODS: Suspected rubella cases were detected through active and passive surveillance. Confirmed rubella cases were patients with fever, rash and rubella-specific IgM antibodies. Suspected CRS cases were infants born with CRS-compatible defects or born to mothers with a history of rubella during pregnancy. Confirmed cases were infants with CRS-compatible defects and rubella-specific IgM antibodies. RESULTS: From April 1 to December 31, 2000, 391 confirmed rubella cases were reported. The incidence among persons ages 12 to 19 years (3.3 per 1000 population) was increased 3.7-fold relative to children ages 1 to 4 years (95% confidence interval, 2.4 to 5.8). Of 21 infants with suspected CRS cases, 17 (91%) were tested for rubella-specific antibodies, of whom 7 were IgM-positive and 5 had confirmed CRS. The peak incidence of confirmed CRS (4.3 per 1000) was in March 2001, 7 months after the outbreak peak, with an annualized incidence of 0.6 per 1000. CONCLUSIONS: Vaccination among school age children was insufficient to prevent a rubella outbreak among young adults that resulted in the occurrence of at least 5 cases of CRS. To prevent further cases of CRS, outbreak vaccination of young adults was conducted in November 2000 and among women ages 12 to 39 years in 2001 as part of a national campaign, with a coverage of 98% statewide.

Adolescent↗
PubMed1992

Introduction to the ACR-NEMA DICOM standard.

In 1982, the American College of Radiology (ACR) and the National Electrical Manufacturers Association (NEMA) formed a committee to develop standards for the interconnection of digital imaging devices. Version 1.0 of the standard, published in 1985, specifies a hardware interface supporting point-to-point (not network) image transmission, a data dictionary (a set of rules for encoding information), and a set of commands to initiate transactions. Version 2.0, published in 1988, also addresses point-to-point image transmission and provides semantic rules by which messages (streams of bits representing information in transit from one device to another) are organized. Version 3.0, also referred to as DICOM (Digital Imaging and Communications in Medicine), will be finalized in 1992. The DICOM standard encourages open systems interconnection of imaging equipment over standard networks, while maintaining compatibility with earlier point-to-point connection standards. The DICOM standard conforms fully with the International Standards Organization reference model for network communications (ISORM), addresses the issue of conformance, and incorporates the concept of object-oriented design.

Computer Communication Networks↗
PubMed1991

Chromosomal assignment of four rat genes coding for the spermatid-specific proteins proacrosin (ACR), transition proteins 1 (TNP1) and 2 (TNP2), and protamine 1 (PRM1).

The genes for proacrosin, protamines, and transition proteins are exclusively expressed in haploid spermatogenic cells. From the analysis of mouse x rat cell hybrids which segregate rat chromosomes, the rat gene for proacrosin (ACR) was assigned to chromosome 7, that for transition protein 1 (TNP1) to chromosome 9, and the genes for transition protein 2 (TNP2) and protamine 1 (PRM1) to chromosome 10.

Acrosin↗
PubMed2004

Dermatology position paper on the revision of the 1982 ACR criteria for systemic lupus erythematosus.

The 1982 ACR classification criteria have become de facto diagnostic criteria for systemic lupus erythematosus (SLE), but a review of the criteria is necessary to include recent diagnostic tests. The criteria were not developed with the help of dermatologists, and assign too much weight to the skin as one expression of a multiorgan disease. Consequently, patients with skin diseases are classified as SLE based mostly on skin symptoms. We discuss specific problems with each dermatologic criterion, but changes must await a new study. We suggest the following guidelines for such a study, aimed at revision of the criteria. 1) The SLE patient group should be recruited in part by dermatologists. 2) The study should evaluate an appropriate international ethnic/racial mix, including late onset SLE as well as pediatric patients. 3) All patients should have current laboratory and clinical evaluations, as suggested in the paper, to assure the criteria can be up-to-date. This includes anti-SS-A and anti-SS-B antibodies and skin biopsies for suspected cutaneous lupus erythematosus except for nonscarring alopecia and oral ulcers. 4) The study should be based on a series of transparent power calculations. 5) The control groups should represent relevant differential diagnoses in numbers large enough to assess diagnostic problems that might be specific to these differential diagnoses. In order to demonstrate specificity of the criteria with a 95% confidence interval between 90 and 100%, each control group of the above should have at least 73 patients.

Classification↗
PubMed2004

Review of ACR hematologic criteria in systemic lupus erythematosus.

We have conducted a thorough literature review to evaluate the relative value of the hematologic criterion in making a diagnosis of systemic lupus erythematosus (SLE), its clinical relevance, and its prognostic significance. In the updated 1982 ACR criteria, the presence of one or more of the four elements: 1) hemolytic anemia (with reticulocytosis); 2) leukopenia (<4000/microL on two or more occasions); 3) lymphopenia (< 1500/microL on two or more occasions); or 4) thrombocytopenia (< 100,000/microL in the absence of offending drugs) is now considered as a single hematologic disorder. The sensitivity and specificity of the individual elements of the hematologic criterion range from 18 to 46% and 89 to 99%, respectively. The accuracy of the hematologic criterion requires proper interpretation. For example, many studies reported the presence of anemia that was not clearly defined and likely included anemia from etiologies other than hemolytic anemia, thereby causing an overestimation of the prevalence. In addition, medications such as corticosteroids and cytotoxic agents, and viral infections, can also contribute to a reduction in lymphocyte count. Despite these limitations, the SLICC committee recommends no change in the elements of the hematologic criterion when this criterion is properly interpreted and other causes of cytopenia are excluded.

Anemia, Hemolytic↗