Hydroxychloroquine compared with placebo in rheumatoid arthritis. A randomized controlled trial

OBJECTIVE

To assess the efficacy of hydroxychloroquine, 400 mg daily, for rheumatoid arthritis.

DESIGN

Six-month, double-blind, randomized trial.

SETTING

Ambulatory referral clinic in a Mexico City, Mexico, teaching hospital.

PATIENTS

A total of 126 patients with early rheumatoid arthritis were randomly assigned to receive hydroxychloroquine, 400 mg/d, or placebo; 121 patients completed the study.

RESULTS

Hydroxychloroquine showed a clinically and statistically significant improvement over placebo in joint score (20% greater mean improvement; 10% more patients improved by > 50%); pain (40% greater mean improvement; 19% more patients improved by > 50%); grip strength (22% greater mean improvement; 21% more patients improved by > 50%); patient global assessment (16% more patients stated they had improved); and physician global assessment (12% more patients were judged to have improved). Side effects were mild, and no patients in the hydroxychloroquine group required discontinuation of therapy. Patient compliance with the study medication was high.

CONCLUSION

Hydroxychloroquine is moderately effective in early rheumatoid arthritis.

A non-hemorrhagic manifestation of vasa previa: a clinicopathologic case report

BACKGROUND

The rare entity of vasa previa occurs when fetal vessels lying between the amniotic and chorionic membranes cross the cervical os. This report presents a case that was associated with vessel compression and concomitant adverse effects on fetal hemodynamics.

CASE

A 23-year-old nulliparous woman at 36 weeks' gestation developed persistent, progressive severe variable decelerations several hours after spontaneous rupture of the membranes, resulting in a decision to perform a cesarean. At delivery, fetal vessels were noted in the membranes near the cervical os, leading into a marginally inserted cord. The decelerations were attributed to compression of the unprotected umbilical arteries by the fetal head.

CONCLUSION

Vasa previa often results in fetal death and may be associated with fetal hemorrhage, but lack of bleeding does not exclude the existence of vasa previa. Altered fetal hemodynamics from varying degrees of vessel compression by the presenting part during labor may result in hypoxia and acidosis. A high index of suspicion is necessary to make the diagnosis and institute proper, timely management.

Membrane-bound sorbitol dehydrogenase in human red blood cells. Studies in normal subjects and in enzyme-deficient subjects with congenital cataracts

Membrane-bound and soluble forms of erythrocyte sorbitol dehydrogenase (SORD) activity are compared in normal individuals. Both isoenzymes showed similar properties. In a family with red cell SORD deficiency and congenital cataracts, Km values for sorbitol and NAD+ as well as the effect of the enzymatic deficiency on sorbitol accumulation in red cells incubated in high-glucose or high-fructose media were determined. In SORD-deficient patients, the enzymatic deficiency was observed in both crude haemolysate and SORD-M preparations with sorbitol, galactitol, xylitol or ribitol as substrates. The mutation responsible for SORD deficiency did not modify the Km for sorbitol and NAD+. Finally, SORD deficiency produced a significant increase of sorbitol accumulation in red cells incubated in high-concentration glucose media and a significant decrease when the cells were incubated in high-concentration fructose media.

Extremely divergent histone H4 sequence from Trypanosoma cruzi: evolutionary implications

Trypanosoma cruzi presents six histones electrophoretically resolved in three gel systems. Indirect evidence shows that one of these histones, named e, corresponds to H4 in other species. We present evidence that histone e is H4 by sequencing its amino terminal end. The amino terminal of T. cruzi histone H4, unlike that of other H4s examined thus far is not blocked. Moreover, this protein presents two variants. This partial amino acid sequence of T. cruzi histone H4 differs greatly from homologous sequences of human, yeast, or Tetrahymena. Since the conservatism of the core histones (H2A, H2B, H3, and H4) is clearly illustrated by comparative sequence analyses, the data shown here demonstrates that T. cruzi histone H4 is the most divergent reported. Quantitative analysis of the data suggests that the rate of substitutions in the histone H4 amino terminal sequence varies among different lineages. We postulate a slow-down in the evolutionary rate of histone H4 amino terminal domain in the metazoa branch related perhaps to the appearance of a novel function for this domain.

[Suitability of the practice of recording only the main health problem in primary care]

OBJECTIVE

To analyse if recording only the main health problem (P) can reflect in a valid way the totality of health problems (P+S) cared for and all the actions generated by a consultation.

DESIGN

Using a representative sample of the patients seen at the centre over a three-month period, information on P+S was gathered, P was identified and the actions generated by each one of the problems were recorded. Health problems were codified through CIPSAP-2-D and grouping diagnoses. SITE. General Medicine service in a Primary Care Centre.

PATIENTS AND OTHERS PARTICIPANTS

All the General Medical physicians at the Centre took part in the study by collecting data on the consultations established by the sampling.

MAIN MEASUREMENTS AND RESULTS

Frequency and order among the first 25 P+S and P problems were compared, as was the percentage of secondary problems encountered. Out of 559 consultations examined, Diabetes, Dislepemia and an irritated? Colon stood out as under-represented. Acute infections of the Upper Respiratory Tract, Conjunctivitis and ??Queratitis were over-represented. As for the activity generated, 83.1% corresponded to P, although there was great variability among the problems according to the percentage of secondary problems according to the percentage of secondary problems.

CONCLUSIONS

Recording only the main health problem can be a valid instrument for providing an initial view of problems seen.

[The effectiveness of breast cancer screening in our country]

The aim of this paper is to review the current state of breast cancer screening in our country, as well as to discuss the most appropriate approaches for its development. Firstly, the impact of breast cancer in Spain is presented, as well as the current evidence about the efficacy of the screening. The major programs and initiatives addressed to promote screening are described. Finally, a few recommendations are given in order to achieve that breast cancer screening be, not only efficacious, but also effective. It is concluded that it is necessary that health and professional authorities coordinate and monitor breast cancer screening programs.

Severe Silver-Russell syndrome and translocation (17;20) (q25;q13)

An 8-year-8-month-old girl with Silver-Russell syndrome (SRS) and a paternally inherited balanced t(17;20)(q25;q13) is described. This observation suggests that an SRS gene(s) maps on chromosome 17 or 20 and that the patient phenotype resulted from either unmasking of heterozygosity or genomic imprinting via paternal disomy.

Erythrocyte superoxide dismutase activity in patients with malignant neoplasms

Erythrocyte superoxide dismutase activity was determined in four groups of patients, two with hematologic neoplasms with and without therapy and two others with solid tumors also selected on the basis of therapy. Increased activities were found in the two groups where there was no treatment, whereas those under treatment showed normal levels. In addition, an inverse relationship (r = -0.25 p < 0.02) between superoxide dismutase activities and the time under therapy was observed.

[Effect of gene dosage on the glyceraldehyde-3-phosphate dehydrogenase enzyme (GAPD) in partial 12p13.3 pter trisomy]

A family with three brothers presenting 12p trisomy due to an adjacent-1 segregation of a paternal translocation (1;12) (q44;p12.2) is described. The patient's phenotype was compatible with the chromosomal imbalance including the gene dosage effect of the glyceraldehyde-3-phosphate dehydrogenase. The importance of the genetic counseling in these families is stressed.

[Identification of inborn errors of galactose metabolism in patients with cataracts]

133 patients with congenital or idiopathic cataracts were studied (94 patients had ages between 1 month and 14 years; 10 patients had ages between 16 and 50 years and 29 patients did not have an age registry) along with 18 patients with a clinical diagnosis of classic galactosemia. The activity of galactokinase (GALAK) and that of erythrocyte galactose-1-phosphate uridyl transferase (GALT) was measured. There were no individuals with a total deficiency of GALK or GALT. The cataract patients of ages between 1 monthly and 14 years, 3 (3.19%) and 4 (4.25%) showed GALK and GALT levels in the range corresponding to the respective heterozygotes. As compared with the expected incidence of heterozygotes in the general population (0.2% for GALK and 0.8% for GALT) we found a significant rise of individuals with low levels of enzymes for the metabolism of galactose. The possibility that heterozygote galactosemic states contribute a risk factor in the development of cataracts and its therapeutic implications are discussed.

Reduced levels of uridine diphosphate glucose pyrophosphorylase activity in fetal and neonatal human and guinea pig liver

Uridine diphosphate glucose pyrophosphorylase (UDPGPP) is the first enzyme in the bilirubin conjugation pathway. A study aiming to screen for red blood cell UDPGPP deficiency in newborns with hyperbilirubinemia was carried out. No individuals with severe UDPGPP deficiency were found, however, levels of UDPGPP in premature and at term newborns were lower than in adults. These findings led to the study of UDPGPP in human fetal, neonatal and adult liver, using guinea pig tissues as a parallel control. UDPGPP activities in fetal and neonatal samples were also significantly lower than in adult ones in both species. Therefore, it is postulated that the reduced levels of UDPGPP in fetal and neonatal liver could be a factor which contributes to the pathogenesis of the physiologic jaundice in human newborns.

Screening for red blood cell sorbitol dehydrogenase deficiency in patients with diabetes or cataracts

Quantitative screening for red blood cell sorbitol dehydrogenase (RBC-SORD) deficiency in 111 patients with juvenile onset diabetes, 92 patients with adult onset diabetes, 42 patients with idiopathic cataracts and 192 professional blood donors was performed. A wide variability in RBC-SORD activity in controls and patients was observed. No significant differences in SORD activity either between patients with diabetes and patients with idiopathic cataracts or between diabetics with and without cataracts were observed. Whether or not there were carriers for either amorphous or hypomorphous alleles of the SORD locus in the population studied could not be defined in terms of enzymatic activity levels.

G-6-PD Jalisco and G-6-PD Morelia: two new Mexican variants

Two new G-6-PD variants designated G-6-PD Jalisco and G-6-PD Morelia were identified in two unrelated Mexican families. An additional G-6-PD variant was found in each family: G-6-PD Trinacria and G-6-PD A-. In both families compound heterozygotes were identified. G-6-PD Jalisco and G-6-PD Morelia belong to Classes 3 and 4, respectively. G-6-PD Morelia is the first variant from its class with a high Km for NADP and a low Ki for NADPH.

Sorbitol dehydrogenase deficiency in several pig tissues: potential implications for studies of experimental diabetes

Screening for red blood cell sorbitol dehydrogenase deficiency in 12 different mammalian species was performed. A wide inter-species variability in red cell sorbitol dehydrogenase with a virtually complete deficiency in pigs was observed. Aldose reductase and sorbitol dehydrogenase activities in 12 different pig tissues also were measured. Aldose reductase activity was present in all the tissues studied, whereas organ specificity for sorbitol dehydrogenase was observed. Sorbitol dehydrogenase activity was not detectable in lenses, among other tissues, making the pig a potential model for studies in experimental diabetes, particularly for the investigation of sorbitol dehydrogenase deficiency as a risk factor in the development of cataracts.

Doxycycline prophylaxis of travelers' diarrhea in Honduras, an area where resistance to doxycycline is common among enterotoxigenic Escherichia coli

Daily doxycycline (DX), known to be effective prophylaxis against travelers' diarrhea (TD) in areas of the world where enterotoxigenic Escherichia coli (ETEC) are sensitive to the drug, has not been extensively studied in geographic areas where antibiotic resistance is common. Therefore we studied 44 U.S. Peace Corps Volunteers during their first 5 weeks in Honduras, which is such an area. During the first 3 weeks, volunteers took daily either 100 mg DX or placebo (PL) in a double-blind, randomized fashion. All 22 taking PL developed TD during the first 3 weeks, compared to 7 of 22 (32%) taking DX (P less than 0.001; 68% protection). ETEC were isolated from 39% of episodes of TD. From the PL group, ETEC from 7 of 13 stool samples (54%) were resistant to DX, whereas from the DX group, ETEC from 10 of 11 stool samples were resistant (P less than 0.05). TD that developed in persons taking DX was also found to be less severe, as judged by length of illness (P less than 0.01) and frequency of stools (P less than 0.05). This study demonstrates that DX 1) significantly prevents TD even in areas where antibiotic resistance is common, although it does not prevent TD caused by docycycline -resistant ETEC, and 2) significantly diminishes the severity of illness.

Paroxysmal spike and wave activity in drowsiness in young children: its relationship to febrile convulsions

Paroxysmal rhythmic theta waves appearing during early stages of sleep have long been recognized in the EEGs of normal children. A similar pattern with intermixed spikes appears to have a different correlation. We called this pattern 'hypnagogic paroxysmal spike wave activity' or 'hypnagogic PSW.' This investigation was designed to test whether there exists a relationship between hypnagogic PSW, febrile convulsions (FC) and age. We selected 3 cohorts of children: G-1 or normal control consisted of 94 children selected with the following criteria: complete normal neurodevelopmental examination and no personal or family history of FC, epilepsy, or other neurological disorder. They all had one EEG obtained without drug induction showing a clear sequence of awake-drowsy-sleep-arousal-awake states. G-2 or pathological control group consisted of 126 children selected at random, referred to the Division of Neurophysiology at the Children's Hospital Medical Center for any problem excluding FC. At least one EEG met the criteria mentioned above. G-3 or FC group consisted of 375 children in whom the very first seizure was associated with fever without evidence of other causes for the convulsion. All met the same EEG criteria of G-1 and G-2. The medical record of 169 children of this group (40 with hypnagogic PSW and 129 without hypnagogic PSW) were reviewed.(ABSTRACT TRUNCATED AT 250 WORDS)

A fluorimetric method for red blood cell sorbitol dehydrogenase activity

A new fluorimetric method for the quantification of red blood cell (RBC) sorbitol dehydrogenase is described. It is based on the oxidation of sorbitol to fructose, in presence of NAD+, catalysed by the RBC-sorbitol dehydrogenase. The quantity of NADH formed is then measured in a filter fluorimeter. Comparison with an indirect spectrophotometric assay yielded good correlation; however, the present method offers several advantages: it is more rapid, simple and inexpensive. It should be useful to screen for sorbitol dehydrogenase deficiency in large numbers of individuals, particularly patients with diabetes or cataracts.

Screening for inborn errors of the erythrocyte metabolism in Northwestern Mexico

Data from a program aiming to the detection of inborn errors of the erythrocyte metabolism (IEEM) in Northwestern Mexican populations are presented. 5,998 individuals were studied and divided in 5 groups: a) 1,022 full-term newborns without jaundice; b) 872 randomly selected full-term newborns; c) 3,243 full-term newborns with jaundice; d) 54 patients with hemolytic anemia, and e) 807 professional blood donors. In groups b, c and d screening for 9 out of 14 IEEM clearly associated with hemolysis was carried out by means of enzymatic fluorescent procedures. In groups a and e only G-6-PD deficiency was investigated. The results suggest that 0.34%, 0.77%, 24% and 0.37% of the individuals from groups b, c, d and e, respectively, have an IEEM. The frequency of G-6-PD deficiency was 0, 0.43%, 1.1%, 30.3% and 0.37% in the males from groups a, b, c, d and e, respectively. The IEEM as a cause of neonatal jaundice seem not to be a public health problem in the studied populations. Systematic screening for: 1) G-6-PD deficiency in newborns with jaundice and 2) IEEM in patients with hemolysis, is recommended.