Clinical aspects of juvenile rheumatoid arthritis

This paper reviews studies in epidemiology, differential diagnosis, clinical manifestations, and treatment of juvenile rheumatoid arthritis (JRA) that have appeared during the past year. One epidemiologic study suggested a decreased incidence recently; however, changes over time in the ethnic and racial characteristics of the patients studied may also have played a role. Findings from an Australian study suggested that some studies may underestimate the true incidence of JRA if visits of physicians are the only basis for the studies. Finally, a Canadian study of incidence showed no seasonal correlations--except for the Prairie region--raising the possibility that the disease varies by region because of environmental factors or variations in ethnic background. Differential diagnostic issues were covered in several reports. One study suggested that elevations in lactate dehydrogenase levels identified children with malignancies who presented with musculoskeletal symptoms. Another study of children with Lyme disease failed to find any patients with asymmetric joint involvement, in contrast to JRA patients. Two studies from Europe reached opposite conclusions regarding whether the incidence of celiac disease was increased in JRA patients. Clinical studies included a French study showing increased production of interleukin-6 and interleukin-1-Ra during fever spikes in children with systemic JRA. An Italian study explored the potential role of interleukin-6 in the anemia of JRA patients. An American study confirmed decreases in markers of bone formation in JRA patients. Two treatment studies addressed the use of intravenous gamma globulin in JRA. Another report described two JRA patients who developed nodules while receiving methotrexate. Finally, a report added confirmation to the successful use of cyclosporine for macrophage activation syndrome in JRA.

A case of chrysiasis

Chrysiasis and chrysoderma are terms used to describe permanent pigmentation of the skin due to the parenteral administration of gold salts. A case of chrysiasis, including a photomicrograph of the characteristic orange-red birefringence of gold in tissue when viewed under cross-polarized light, is presented. A review of the literature on the pathogenesis of the pigmentation seen in this disorder is also presented.

Transglutaminase activity is increased in Alzheimer's disease brain

Transglutaminase is a calcium-activated enzyme that crosslinks substrate proteins into insoluble, often filamentous aggregates resistant to proteases. Because the neurofibrillary tangles in Alzheimer's disease have similar characteristics, and because tau protein, the major component of these tangles is an excellent substrate of transglutaminase in vitro, transglutaminase activity and levels were measured in control and Alzheimer's disease brain. Frozen prefrontal cortex and cerebellum samples from Alzheimer's disease and control cases matched for age and postmortem interval were used in the analyses. Total transglutaminase activity was significantly higher in the Alzheimer's disease prefrontal cortex compared to control. In addition the levels of tissue transglutaminase, as determined by quantitative immunoblotting, were elevated approximately 3-fold in Alzheimer's disease prefrontal cortex compared to control. To our knowledge, this is the first demonstration that transglutaminase is increased in Alzheimer's disease brain. There were no significant differences in transglutaminase activity or levels in the cerebellum between control and Alzheimer's disease cases. Because the elevation of transglutaminase in the Alzheimer's disease samples occurred in the prefrontal cortex, where neurofibrillary pathology is usually abundant, and not in the cerebellum, which is usually spared in Alzheimer's disease, it can be suggested that transglutaminase could be a contributing factor in neurofibrillary tangle formation.

The use of amplified variable number of tandem repeats (VNTR) in the detection of chimerism following bone marrow transplantation. A comparison with restriction fragment length polymorphism (RFLP) by Southern blotting

Chimerism analysis after allogeneic bone marrow transplantation (alloBMT) allows detection of early marrow engraftment, disease relapse, and graft rejection. Our objective was to do retrospective and prospective studies of chimerism analysis by restriction fragment length polymorphism (RFLP) by Southern blotting and variable number of tandem repeats (VNTR) by polymerase chain reaction (PCR) to compare and contrast the methods. The retrospective group comprised 46 samples from 26 patients previously analyzed by RFLP, while the prospective group contained 34 samples from 25 patients. Using four different VNTR primers (D1S80, D17S30, D1S111, and APO-B), the recipient and donor samples amplified by the PCR were screened for unique banding patterns. The VNTR primer with the unique banding pattern was used to detect chimerism in each sample. A total of 635 VNTR analyses were performed. Interpretation was blinded for previous RFLP results. A comparison between the VNTR and RFLP results and a cost analysis of the two procedures were done. A unique VNTR banding pattern was present in 49 of 51 patients (identical twins in one case). The VNTR analysis showed complete chimerism in 68 samples, mixed chimerism in 9, and recurrences in 2. This agreed with the RFLP results in 64 (80%) of 80 samples. Failure to detect 1% to 10% of recipient DNA accounted for 15 (VNTR, 8; RFLP, 7) discordances. Follow-up revealed all donor DNA in five cases, decreasing quantities of recipient DNA in two cases (six samples), and no additional studies available in four cases. In one case, VNTR detected a complete chimerism when the DNA was insufficient for RFLP analysis. The cost analysis revealed an approximately 50% savings with the use of VNTR; VNTR is a viable alternative to RFLP in the detection of chimerism after bone marrow transplantation and offers substantial cost savings, faster turnaround time, easier preparation of the DNA, smaller DNA requirements, and the elimination of radioisotopes and cumbersome restriction enzymes.

Expression of neuregulins and their putative receptors, ErbB2 and ErbB3, is induced during Wallerian degeneration

Schwann cell dedifferentiation and proliferation is a prerequisite to axonal regeneration in the injured peripheral nervous system. The neuregulin (NRG) family of growth and differentiation factors may play a particularly important role in this process, because these axon-associated molecules are potent Schwann cell mitogens and differentiation factors in vitro. We have examined Schwann cell DNA synthesis and the expression of NRGs and their receptors, the erbB membrane tyrosine kinases, in rat sciatic nerve, sensory ganglia, and spinal cord 0-30 d postaxotomy. Analysis of NRG cDNAs from these tissues revealed several novel splice variants and showed that cells endogenous to injured nerve express NRG mRNAs. A selective induction of mRNAs encoding the glial growth factor (GGF) subfamily of NRGs occurs in nerve beginning 3 d postaxotomy and thus coincides with the onset of Schwann cell DNA synthesis. In later stages of Wallerian degeneration, however, Schwann cell mitogenesis markedly decreases, whereas elevated GGF expression persists. Of the four known erbB kinases, Schwann cells express both erbB2 and erbB3 receptors over the entire interval studied. Expression of erbB2 and erbB3 is coordinately induced in response to axotomy, indicating that Schwann cell responses to NRGs may be modulated by changes in receptor density. Neuregulin (including transmembrane precursors) and erbB protein are associated with Schwann cells postaxotomy. Thus, in contrast to the concept of NRGs as axon-associated mitogens, our findings suggest that NRGs produced by Schwann cells themselves may be partially responsible for Schwann cell proliferation during Wallerian degeneration, probably acting via autocrine or paracrine mechanisms.

Effects of 3,4-methylenedioxymethamphetamine in decomposing tissues on the development of Parasarcophaga ruficornis (Diptera:Sarcophagidae) and detection of the drug in postmortem blood, liver tissue, larvae, and puparia

Larvae of Parasarcophaga ruficornis (Fabricius) (Diptera: Sarcophagidae) were reared on tissues from rabbits administered different dosages of 3,4-methylenedioxymethamphetamine to study the effects of this drug on the development of this insect species. The rabbits were given 11, 22.5, and 67 mg of the drug via ear vein infusion. These dosages correspond to a 0.5, 1.0, and 2.0 median lethal dose. Larvae from colonies fed on tissues from the rabbit receiving 67 mg and the control developed more rapidly from hours 24 through 114. The period required for completion of larval development was significantly shorter for the larvae from the colony fed on liver tissues from the rabbit receiving the 67 mg dosage. This colony also had the lowest total mortality rate during development. No significant differences were observed among the colonies in the duration of the puparial period. Analyses by liquid chromatography/mass spectrometry of the larvae and empty puparial cases following base extraction detected the drug in quantities directly related to the dosage of the drug administered to the rabbits serving as a food source. These results have implications for the determination of time since death when gauged by the development of this insect species.

The forensic application of testing hair for drugs of abuse

Hair testing is only used by the Federal Bureau of Investigation (FBI) when other information exists that indicates drug use and can remove a person from suspicion or associate them with criminal activity. The detection of cocaine in hair has been the FBI's first priority in hair testing for drugs of abuse because of its prevalence. Several cases when hair testing was used are reported in this chapter. Further, analysis of over 100 samples was performed on hair obtained from a medical examiner's random autopsy collection. Sixty-five percent of the samples tested positive for cocaine or opiates. The results of hair testing for drugs of abuse were found to be consistent with autopsy toxicology reports. The analysis of hair washes and nails from the autopsy samples suggests external contamination of hair with drugs is not widespread.

Colcemid alters S phase and other parameters in skin during chronic exposure to benzo(a)pyrene

The administration of Colcemid for collecting mitotic figures in a carcinogenesis study, using benzo(a)pyrene (BaP), diminished the experimental differences between exposed and control mice. A dose-related increase in noncollected mitotic index (n-mitotic index) was seen in keratinocytes in the dorsal epidermis of mice which received four weekly treatments of BaP at 16, 32 and 64 micrograms in 50 microliters of acetone. In contrast, the number of mitotic figures collected for 4 hr by Colcemid block (c-mitotic index) was depressed at 16 micrograms, unchanged at 32 micrograms, and elevated at 64 micrograms of BaP. Weekly treatments with 4,8 or 16 micrograms BaP for 3-8 months induced an elevation in both n-mitotic and c-mitotic indices. The differences in results produced by the two methods of determining mitotic index depended upon dose and duration of treatment with BaP. The administration of Colcemid to acetone-treated mice increased the labeling index (number of labeled cells) and reduced the rate of DNA synthesis (low grain count per keratinocyte nucleus). After chronic application of BaP, Colcemid abrogated the increase in labeling index, but produced no additional effect on the number of grains per labeled keratinocyte. The modifying effect of Colcemid was greatest when administered during the peak of the tissue response to BaP. A number of significant changes in morphology of the skin associated with chronic exposure to BaP were attenuated by the use of Colcemid.

Trichostasis spinulosa: a clinical simulant of acne open comedones

Trichostasis spinulosa is a disorder of the pilosebaceous follicles that may simulate acne open comedones. It is a commonly reported cosmetic annoyance in adults but not children. A review of the literature and a case of trichostasis spinulosa in a 13-year-old black girl with a history of onset at 18 months of age are presented.

Cell proliferation and nuclear abnormalities are increased and apoptosis is decreased in the epidermis of the p53 null mouse after topical application of benzo[a]pyrene

Cell proliferation and cell death in mouse epidermis are altered by topical application of benzo[a]pyrene (BaP), a procarcinogen, which yields metabolites that can form DNA adducts. The mitotic rate, nuclear abnormalities, labelling index, grain density, necrosis and apoptosis were compared in the epidermis of TSG-p53 null (p53-/-) and C57BL wild-type (wt) mice after weekly treatments with BaP to determine whether the absence of the p53 gene altered cytokinetic responses to DNA damaging agents in vivo. Acetone alone or 64 micrograms BaP in 50 microliters acetone was applied to the clipped dorsum of mice once, or in four consecutive weekly treatments. Indices of cell proliferation and cell death were the same in both wt and p53-/- mice treated only with acetone. One application of BaP depressed mitosis and slowed the rate of DNA synthesis in both genotypes. After four applications of BaP the number of keratinocytes in S phase increased substantially, while there was no further slowing in the rate of S phase in the wt and p53-/- mice. Cell proliferation rates and numbers of cells with nuclear abnormalities were higher and there were fewer apoptotic cells and apoptotic bodies in the p53-/- mice than in the wt mice. Numbers of 'sunburn' cells were similar in both types.

Systemic lupus erythematosus

Systemic Lupus Erythematosus (SLE) of childhood is a complex and challenging disease which can occur at any age. Identification of disease early in it's course and aggressive, appropriate management leads to improved outcome for an individual child. The history of SLE indicates how much progress has been made in the last quarter century. A discussion of the etiopathogenesis of SLE demonstrates the complexity of the syndrome. This is followed by a description of clinical manifestations, including diagnostic criteria, differential diagnosis and suggested methods for eliciting important symptoms to make the diagnosis. Evaluation of specific organs is next reviewed highlighting critical organ manifestations that are significant for future prognosis. Treatment of SLE includes a variety of medications, including non-steroidal anti-inflammatory medications, steroids and immuno-suppressive drugs. Attention to physical activity, stress and nutrition is equally important. Signs and symptoms that indicate disease flare or infection are described. Lastly, related syndromes are reviewed.

The clinical usefulness of the preoperative bleeding time

OBJECTIVES

To determine the clinical utilization of the Simplate bleeding time test as a preoperative screen, to examine the clinical utilization of the bleeding time test by multiple surgical services, and to correlate the indicators of bleeding risk (bleeding history, thrombocytopenia, prolonged prothrombin time/activated partial thromboplastin time, increased creatinine, and medications known to interfere with platelet function) with the bleeding time and the occurrence of clinically significant perioperative bleeding.

DESIGN

Retrospective data analysis.

SETTING

A large tertiary-care hospital.

PATIENTS

One hundred sixty-seven consecutive surgical patients tested for preoperative bleeding time.

MAIN OUTCOME MEASURES

The occurrence of clinically significant perioperative bleeding and the positive and negative predictive value of the preoperative screening bleeding time test.

RESULTS

Patients with a positive bleeding history were more likely to have an abnormal bleeding time (P = .04), but there was no statistically significant association between patients with an abnormal bleeding time and the other indicators of bleeding risk examined or the occurrence of clinically significant perioperative bleeding. The positive predictive value of the preoperative bleeding time was 5%, and the negative predictive value was 95%.

CONCLUSIONS

Screening for preoperative bleeding time is not a reliable test for assessing the risk of clinically significant perioperative bleeding and should not be used for this purpose.

An atypical piloleiomyoma presenting as a nonhealing ulcerated nodule

Piloleiomyomas are benign smooth muscle tumors arising from the arrectores pilorum muscles in the skin. They vary in size and number, and are often spontaneously painful or sensitive to touch and cold. An unusual case of an ulcerated and painless piloleiomyoma is presented.

Differential effects of nonhydroxylated flavonoids as inducers of cytochrome P450 1A and 2B isozymes in rat liver

Flavanone, flavone, and tangeretin differentially affected the activities of cytochrome P540 1A and 2B isozymes in rat liver. Flavone and, to a lesser extent, tangeretin, increased activities of ethoxyresorufin O-deethylase, methoxyresorufin O-demethylase, and pentoxyresorufin O-dealkylase (PROD), whereas flavanone mainly enhanced PROD activity. Immunoblot analysis indicated that flavone and tangeretin increased cytochrome P450 1A1, 1A2, and 2B1,2 forms, whereas flavanone only enhanced the cytochrome P450 2B isozymes. Northern blot study showed that flavone and tangeretin increased the level of the cytochrome P450 1A2 mRNAs. The concentration of the other mRNAs were slightly or not affected by flavonoids. These results suggest that the induction of P450 1A2 by flavone and tangeretin might involve a transcriptional and/or post-transcriptional mechanism.

Effects of inhalation of cadmium on the rat olfactory system: behavior and morphology

To investigate the effects of cadmium on olfaction, two separate studies were conducted in which male adult rats were exposed to CdO, via inhalation, for 5 h per day, 5 days a week for 20 weeks. Target exposure values of 250 and 500 micrograms/m3 were measured at 200 and 325 micrograms/m3 for the low concentration in two experiments, and 550 and 660 micrograms/m3 for the high concentration. Prior to exposure, olfactory thresholds were obtained using a conditioned suppression technique. After 20 weeks of cadmium exposure, there was no evidence of anosmia in any of the rats nor were there any significant changes observed in olfactory thresholds. Although olfaction was not impaired, cadmium levels in the olfactory bulbs of exposed rats were significantly elevated compared to controls. Cardiac and respiratory histopathology were observed at all exposure levels, but there was no evidence of nasal pathology related to exposure to cadmium. Failure of cadmium to produce olfactory dysfunction may be due to the protective effects of metallothionein and/or to the highly resilient nature of the rodent olfactory system.

Epidermal cytokinetics, DNA adducts, and dermal inflammation in the mouse skin in response to repeated benzo[a]pyrene exposures

Few studies have investigated the chronic cytokinetic effects of carcinogen exposure in the mouse skin. We report two experiments involving the repeated application of benzo[a]pyrene (BaP) to the dorsal skin of female Ha/ICR mice. In the first experiment, the cytokinetic, inflammatory, and DNA adduct responses were studied daily over a 9-day period encompassing the fourth and fifth weekly applications of BaP at doses of 16, 32, and 64 micrograms. The second experiment involved the same cytokinetic measurements at 1, 3, 5, and 8 months, and the weekly BaP doses were 4, 8, and 16 micrograms. The first study showed that after each application of 32 or 64 micrograms BaP, there was a wave of slow DNA synthesis in the epidermis which peaked at 24 hr, in coincidence with a wave of BaP-DNA adducts, followed by the appearance of dead and damaged keratinocytes. For the first few days after BaP application there was a depression in the mitotic rate which recovered several days before the next BaP application. There was a predominantly monocytic dermal inflammation throughout the observation period. In the second experiment, at the lower BaP doses, there was proliferative depression at 1 month, without dermal inflammation. With continued exposure, the proliferative depression changed to a dose-dependent increase in the rate of proliferation and dermal inflammation. The level of BaP-DNA adducts was followed in the 4 micrograms/week dose group, which showed a threefold increase after 4 months with the appearance of inflammation and heightened cell proliferation. These results suggest that the delayed inflammatory reaction, possibly based on a cell-mediated immune reaction to BaP, might have been responsible for the late cytokinetic responses and the associated increase in the level of BaP-DNA adducts.

Relationships between the nuclear membrane, nuclear pore complexes, and organelles in the type II pneumocyte

Functional relationships among organelles of the type II cell are suggested based upon the proximity of organelles to specialized areas of the plasma- and nuclear membranes. In a two-dimensional morphometric analysis of the profiles of organelles in type II cells of the ferret and rat (and beagle dog), lamellar bodies were more likely to be located near the nuclear membrane than at the alveolar space (where exocytosis occurs). The size of lamellar body profiles was not correlated with distance from the nuclear membrane; however, large profiles were nearer the apical membrane, and smaller ones nearer the basement membrane. Profiles of highly branched mitochondria were 10 times more frequently associated with nuclear pore complexes than with the inter-pore nuclear membrane. Forty percent of all mitochondrial profiles were within 0.25 microns of the nucleus, 5% were within 0.02 microns and half of these appeared to touch the filaments of the nuclear pore complexes. The size of mitochondrial profiles was not correlated with distribution. In the ferret and rat, 8.6% and 2.5% respectively, of the nuclear pore complexes were associated with mitochondria. Sebaceous cells, from control mice, demonstrated a spatial distribution of granules which was size dependent but unrelated to the nuclear membrane.

The preoperative bleeding time test: assessing its clinical usefulness

The bleeding time test can aid in the diagnostic evaluation of patients with clinical hemorrhagic disorders or a history of bleeding. However, its low positive predictive value in predicting perioperative bleeding should force one to abandon it as a routine preoperative screening test.

Abnormal muscle MRI in a patient with systemic juvenile arthritis

Although myositis has been described in children with systemic-onset juvenile arthritis (JA), its documentation by MRI has not been reported. We describe a 13-year-old boy with systemic-onset JA, severe myalgia, and elevated muscle enzymes, but normal muscle strength, who had an MRI consistent with myositis. Magnetic resonance imaging can identify the specific location of myositis, allowing more precise definition of a potential complication of systemic JA.

Fever of unknown origin

The causes of fever in a child can vary from minor brief illnesses to life-threatening infectious, malignant, or autoimmune diseases. The physician often has to evaluate children with fevers of as yet undiagnosed cause lasting fewer than 2 weeks, in whom it is important to determine whether localizing findings are present. Fever without localizing signs and fevers complicating chronic disease and resulting from specific localized infection are considered in the sections concerning infectious causes, immunodeficiency diseases, and rheumatic diseases. The diagnostic and therapeutic approaches to the child with both prolonged fever and fever of unknown origin are then discussed, with emphasis on rheumatic diseases.