Hepatic manifestations of autoimmune rheumatic diseases

Hepatic manifestations in autoimmune disease include chronic active hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis, and nodular regenerative hyperplasia. These diseases are rare and may occur concomitantly or serially. Clinicians must be aware of the possibility of liver disease so that it can be treated as soon as possible.

Symptoms related to the reproductive tract and mental health among women in rural southern India

BACKGROUND

Symptoms related to the reproductive tract and symptoms of psychological distress are commonly seen in women living in South Asia. This study aimed to determine the association, if any, between symptoms related to the reproductive tract and mental health among women in rural southern India.

METHODS

The study was conducted in a community setting of a comprehensive community health programme in a development block in rural southern India. It was a cross-sectional survey with a nested case-control study. The main outcome measure was the probability of mental distress as assessed by the Tamil version of the General Health Questionnaire-12 (GHQ).

RESULTS

Of the 622 subjects recruited, 150 (24.4%) complained of at least one symptom related to the reproductive tract. The commonest symptom was vaginal discharge (17.5%). Significantly higher scores on the GHQ were associated with the presence of many current and past symptoms related to the reproductive tract, and receiving treatment for the same, even after adjusting for age, education, current marital status and type of house, using multiple regression analysis. GHQ scores were positively correlated with a higher number of current and past symptoms. Significantly higher scores were also associated with greater knowledge about prevention of sexually transmitted diseases and reproductive tract infections. Being currently married and educated were significant protective factors. A nested case-control study was done with the presence of a current common mental disorder as the outcome. Symptoms and other factors dated prior to this outcome were considered potential risk factors. Logistic regression models were developed. The presence of a symptom related to the reproductive tract for more than one month (OR 3.6; 95% CI 1.8, 7.2) and a history of similar symptoms over the past year (OR 2.2; 95% CI 1.3, 3.7) were risk factors for the development of common mental disorders. Higher education (OR 0.5; 95% CI 0.3, 0.7) and being currently married (OR 0.2; 95% CI 0.1, 0.6) were protective factors.

CONCLUSION

The cross-sectional data suggest an association between symptoms pertaining to the reproductive tract and psychological distress. The results of the nested case-control study suggest that symptoms related to the reproductive tract are risk factors for common mental disorders, while education and being currently married are protective factors.

Oral contraception and cyclic changes in premenstrual and menstrual experiences

Despite the widespread use of oral contraceptives (OC) there is no consensus regarding their effect on menstrual cycle experiences. This study examines the cyclic changes of prospectively collected, daily menstrual cycle experiences of two groups of 'healthy women' using monophasic and triphasic OC compared with a group using non-hormonal contraception. A total of 119 'healthy women' using monophasic, triphasic or non-hormonal contraception for three months, made daily ratings over at least two complete menstrual cycles. Cyclic changes of ratings within and between the groups were analyzed. The three groups showed significant cyclic changes in abdominal fullness, abdominal discomfort, breast fullness, general 'premenstrual syndrome-like symptoms' and in at least two mood ratings. Maximal changes in ratings occurred during the late premenstrual and menstrual phases. There were no significant differences between the three groups in cyclic changes for any physical rating, but there were for tiredness or fatigue (non-OC users reported experiencing tiredness or fatigue more frequently than the OC users) and sadness or depression (non-OC users experienced sadness or depression less frequently than OC users during the early part of the cycle, followed by a sharp rise from early premenstrual to the menstrual phase). There were no significant cyclic differences in ratings between the monophasic and triphasic groups. In conclusion, 'healthy women' using OC experience premenstrual and menstrual changes. Any differences between OC formulations are subtle and not of clinical significance in 'healthy women' already established on monophasic or triphasic hormonal contraception.

Anxiety and feelings of medical students conducting their first gynecological examination

We examined the anxiety of medical students when they conduct their first gynecological examination. The students (226) from two universities completed anonymous questionnaires providing measures of state and trait anxiety and anxiety and confidence feelings, before and after conducting their first bimanual and speculum examination. This took place during a structured, self-directed learning session and involved examination of a professional patient. Students state anxiety was significantly elevated immediately before and fell to below baseline levels after the examination (p < 0.001). Students' reported feelings of increased confidence during the examination (p < 0.001). Students who had personally had a Pap smear test were most anxious before (p < 0.003) but during the examination, students who had experienced a gynecological exam felt less anxious (p < 0.002). The students experiencing the greatest decreases (before to after) in state anxiety were those who had never experienced sexual intercourse (p < 0.005). Most students (96%), particularly those who were more anxious during the examination (p < 0.001) and who experienced a greater decrease in anxiety from before to after the examination (p < 0.008) would recommend this method of learning to other students. In summary, medical students are anxious when they conduct their first gynecological examination, appear to be influenced by their personal experiences and appreciate methods of learning that reduce their anxiety.

QTc prolongation and cardiac lesions following acute organophosphate poisoning in rats

Sarin and soman induced the following similar effects: prolongation of QT interval duration, cardiac lesions and immediate and statistically significant decrease in body weight. However, animals exposed to soman remained underweight and suffered delayed death. Thus, as sarin produced both cardiac lesions and QT prolongation, without exhibiting late death, it is unlikely that the late death observed in soman-poisoned rats are attributable to QT prolongation and the occurrence of life-threatening arrhythmias. It is postulated that low body weight may precipitate late mortality in soman-exposed rats. It is well documented that QT prolongation in the rat is explained in terms of blockade of the Ito potassium channels and the Na+/Ca+2 exchanger. Soman and sarin may exert their effect on QT interval duration through non-specific action on these sites. As drug-induced QT prolongation in man is mediated by blockade of Ikr potassium channels, the data presented in this study may not predict late death in humans in cases of organophosphate intoxication.

Medical students' opinions of chaperone use during gynecological and anorectal examinations

The opinions of medical students on chaperone use during physical examinations of the male and female was studied. The students (157) had conducted their first gynecological or first anorectal and prostate examination. Fifty-one percent of students were female, 56% younger than 25 years of age, and 77% males and 73% females had experienced sexual intercourse. Data on the use of a chaperone during vaginal, anorectal, breast and musculoskeletal examinations when conducted by doctors and by students was collected by anonymous questionnaires. Most students feel a chaperone is necessary when students-in-training conduct vaginal (94%), anorectal (94%) or breast (89%) examinations. Fewer students feel a chaperone is necessary when doctors rather than students conduct vaginal (41%), anorectal (22%) and breast (25%) examinations. Students were significantly more likely to feel a chaperone was necessary when a doctor of the opposite sex conducts vaginal (58%) and anorectal (34%) examinations, compared to a doctor of the same sex. Students who were male, 25 years or older or had not experienced sexual intercourse were significantly more likely to favour doctors using chaperones. The differences in responses of students of differing age, gender and sexual experience should be considered and discussed when students are learning invasive physical examinations.

Knowledge, beliefs, attitudes, and behaviors related to weight control, eating disorders, and body image in Australian trainee home economics and physical education teachers

OBJECTIVE

To examine the knowledge, beliefs, and attitudes about weight control and eating disorders among trainee home economics and physical education teachers and to assess their body image and weight control practices. The association between actual body weight and body image was also examined.

DESIGN

Survey research was undertaken using a self-report questionnaire. Height and weight were measured.

SUBJECTS/SETTINGS

Trainee home economics and physical education teachers (N = 216, 96% participation rate) in their last month of training at three major state teacher training universities completed a questionnaire during their regular class times.

MAIN OUTCOME MEASURES

Advice teachers give to overweight adolescents knowledge and beliefs about eating disorders, body image, desired weight, food habits, dieting, body appearance ratings, weight control practices, and diagnosed and self-reported eating disorders.

STATISTICAL ANALYSIS PERFORMED

Descriptive statistics, chi square, and analyses of variance compare gender and Body Mass Index differences.

RESULTS

Males (85%) and females (87%) advised young overweight adolescents to diet to lose weight. Twenty percent of females and 13% of males regularly skipped breakfast. The advise given showed a lack of specific nutrition education about weight control, adolescent nutritional needs, and fad diets. Participants held misconceptions about eating disorders, and a range of 14% to 72% answered these questions incorrectly. Fourteen percent of females self-reported that they currently had an eating disorder, but only 6% had received treatment. Some females used potentially dangerous methods of weight loss, including 19% who abused laxatives and 10% who induced vomiting.

IMPLICATIONS

Trainee home economics and physical education teachers need specific nutrition information and training about eating disorders, weight control, and suitable advice for overweight students. The female trainee teachers in our study had a poor body image and disordered eating similar to other young women in Western countries, and this should be taken into account by teacher training institutions.

Clearance of mobilized porcine peripheral blood progenitor cells is delayed by depletion of the phagocytic reticuloendothelial system in baboons

INTRODUCTION

Attempts to achieve immunological tolerance to porcine tissues in nonhuman primates through establishment of mixed hematopoietic chimerism are hindered by the rapid clearance of mobilized porcine leukocytes, containing progenitor cells (pPBPCs), from the circulation. Eighteen hours after infusing 1-2 x 10(10) pPBPC/kg into baboons that had been depleted of circulating anti-alphaGal and complement, these cells are almost undetectable by flow cytometry. The aim of the present study was to identify mechanisms that contribute to rapid clearance of pPBPCs in the baboon. This was achieved by depleting, or blocking the Fc-receptors of, cells of the phagocytic reticuloendothelial system (RES) using medronate liposomes (MLs) or intravenous immunoglobulin (IVIg), respectively.

METHODS

Baboons (preliminary studies, n=4) were used in a dose-finding and toxicity study to assess the effect of MLs on macrophage depletion in vivo. In another study, baboons (n=9) received a nonmyeloablative conditioning regimen (NMCR) aimed at inducing immunological tolerance, including splenectomy, whole body irradiation (300 cGy) or cyclophosphamide (80 mg/kg), thymic irradiation (700 cGy), T-cell depletion, complement depletion with cobra venom factor, mycophenolate mofetil, anti-CD154 monoclonal antibody, and multiple extracorporeal immunoadsorptions of anti-alphaGal antibodies. The baboons were divided into three groups: Group 1 (n=5) NMCR+pPBPC transplantation; Group 2 (n=2) NMCR+ML+pPBPC transplantation; and Group 3 (n=2) NMCR+IVIg+pPBPC transplantation. Detection of pig cells in the blood was assessed by fluorescence-activated cell sorter and polymerase chain reaction (PCR).

RESULTS

PRELIMINARY STUDIES

ML effectively depleted macrophages from the circulation in a dose-dependent manner. Group 1: On average, 14% pig cells were detected 2 hr postinfusion of 1 x 10(10) pPBPC/kg. After 18 hr, there were generally less than 1.5% pig cells detectable. Group 2: Substantially higher levels of pig cell chimerism (55-78%) were detected 2 hr postinfusion, even when a smaller number (0.5-1 x 10(10)/kg) of pPBPCs had been infused, and these levels were better sustained 18 hr later (10-52%). Group 3: In one baboon, 4.4% pig cells were detected 2 hr after infusion of 1 x 10(10) pPBPC/kg. After 18 hr, however, 7.4% pig cells were detected. A second baboon died 2 hr after infusion of 4 x 10(10) pPBPC/kg, with a total white blood cell count of 90,000, of which 70% were pig cells. No differences in microchimerism could be detected between the groups as determined by PCR.

CONCLUSIONS

This is the first study to report an efficient decrease of phagocytic function by depletion of macrophages with MLs in a large-animal model. Depletion of macrophages with MLs led to initial higher chimerism and prolonged the survival of circulating pig cells in baboons. Blockade of macrophage function with IVIg had a more modest effect. Cells of the RES, therefore, play a major role in clearing pPBPCs from the circulation in baboons. Depletion or blockade of the RES may contribute to achieving mixed hematopoietic chimerism and induction of tolerance to a discordant xenograft.

Safety and efficacy of repeat transradial access for cardiac catheterization procedures

To determine the safety and efficacy of repeat transradial cardiac catheterization, 1,362 consecutive transradial procedures were examined. Repeat transradial procedures were identified (group I, n = 73) and compared with index procedures (group II, n = 1,289). Baseline patient characteristics, procedure success rates (100% vs. 97.9%; P = NS), complication rates (0% vs. 0.08%; P = NS), and procedure times (23.9 +/- 27.3 min vs. 18.2 +/- 14.7 min; P = NS) were similar between groups. This study suggests that repeat transradial catheterization procedures can be performed safely and successfully in appropriately selected patients.

Blocking tumor growth, invasion, and metastasis by maspin in a syngeneic breast cancer model

Maspin is a unique serine protease inhibitor of which the down-regulation is associated with the development of breast cancers. In vitro, recombinant maspin inhibits tumor cell migration and invasion. Overexpression of maspin in transgenic mice is protective against tumor progression. Additionally, maspin acts as an angiogenesis inhibitor in rat cornea model and in a xenograft tumor model. To additionally prove that maspin is directly involved in the suppression of tumor growth and metastasis, we tested maspin in a new syngeneic mammary tumor model, TM40D. This model involves the implantation of TM40D mammary tumor cells orthotopically to the mammary gland; tumors grew within the gland and then become invasive and metastatic to other organs. Here we demonstrate that TM40D cells in implanted mammary glands are highly invasive. Overall, a 75% rate of invasion and metastasis was observed in this model. However, both primary tumor growth and metastasis were significantly blocked in TM40D cells that overexpress maspin as a consequence of plasmid or retrovirus infection. Maspin-transfected tumors tended to have tumor encapsulation and less necrosis, which were associated with better prognosis and lower invasiveness. Thus, maspin can block primary tumor growth as well as invasion and metastasis. These data support the concept that maspin has a strong protective role against tumor progression.

Obstetricians and maternal body weight and eating disorders during pregnancy

Intrauterine growth restriction (IUGR) is associated with maternal prepregnancy body mass index (BMI), body weight gain during pregnancy and smoking, eating and weight-losing behaviors. The aim of this pilot study was to examine the practices of obstetricians to determine whether more can be done to prevent IUGR and 'do no harm' to the body image of women during pregnancy. Obstetricians (n = 67) who reported delivering an average of 125 babies in the previous year completed a questionnaire that enquired about their antenatal practice of maternal weighing, history taking and referral of pregnant women. No doctor calculated the prepregnancy BMI. Women (90%) were weighed during some or all antenatal visits, usually by the nurse-receptionist, but one-third of the obstetricians did not refer to these body weight records. Most obstetricians asked women about their cigarette smoking and alcohol intake before pregnancy, and during pregnancy discussed supplements and nausea and vomiting. Fewer than 50% of doctors asked about depression, body weight control and disordered eating. One-third of doctors were not aware of having seen a woman with an eating disorder in the previous year. Obstetricians who asked about eating disorders were more likely to ask about depression, and obstetricians in private practice were significantly less likely to ask women about a history of depression and to refer women to a psychologist or psychiatrist Obstetricians could improve antenatal care by asking about body weight and calculating prepregnancy BMI, and investigating weight-losing behavior and psychological or psychiatric problems such as eating disorders.

Detection of Y chromosome-specific DNA in the plasma and urine of pregnant women using nested polymerase chain reaction

The present study was undertaken to evaluate a nested polymerase chain reaction (PCR) for detection of Y chromosome-specific fetal DNA in maternal plasma and urine of pregnant women during different gestational stages. DNA isolated from plasma and urine samples of 80 pregnant women (between 7 and 40 weeks' gestation) underwent amplification for Y chromosome-specific 198 bp DNA by nested PCR. The postpartum analysis of fetal gender showed that 55 women carried male and 25 female fetuses. Among the 55 women bearing male fetuses, Y chromosome-specific signals were detected in 53 (96%) plasma and 21 (38%) urine samples. Moreover, out of 25 women bearing female fetuses, 3 (12%) and 1 (4%) women had Y chromosome-specific signal in plasma and urine, respectively. Analysis of results with respect to gestational age revealed that there was no significant difference in the detection of Y chromosome-specific DNA between different trimesters in maternal plasma of women bearing male fetuses. These results showed that fetus-specific DNA was detected with high sensitivity (96%) and specificity (88%) in the maternal plasma by nested PCR, and therefore the method could be useful as a non-invasive procedure for fetal sex determination and prenatal diagnosis.

Effects of specific anti-B and/or anti-plasma cell immunotherapy on antibody production in baboons: depletion of CD20- and CD22-positive B cells does not result in significantly decreased production of anti-alphaGal antibody

Anti-Galalpha1-3Gal antibodies (antialphaGal Ab) are a major barrier to clinical xenotransplantation as they are believed to initiate both hyperacute and acute humoral rejection. Extracorporeal immunoadsorption (EIA) with alphaGal oligosaccharide columns temporarily depletes antialphaGal Ab, but their return is ultimately associated with graft destruction. We therefore assessed the ability of two immunotoxins (IT) and two monoclonal antibodies (mAb) to deplete B and/or plasma cells both in vitro and in vivo in baboons, and to observe the rate of return of antialphaGal Ab following EIA. The effects of the mouse anti-human IT anti-CD22-ricin A (proportional to CD22-IT, directed against a B cell determinant) and anti-CD38-ricin A (proportional to CD38-IT, B and plasma cell determinant) and the mouse anti-human anti-CD38 mAb (proportional to CD38 mAb) and mouse/human chimeric anti-human anti-CD20 mAb (proportional to CD20 mAb, Rituximab, B cell determinant) on B and plasma cell depletion and antialphaGal Ab production were assessed both in vitro and in vivo in baboons (n = 9) that had previously undergone splenectomy. For comparison, two baboons received nonmyeloablative whole body irradiation (WBI) (300 cGy), and one received myeloablative WBI (900 cGy). Depletion of B cells was monitored by flow cytometry of blood, bone marrow (BM) and lymph nodes (LN), staining with anti-CD20 and/or anti-CD22 mAbs, and by histology of LN. EIA was carried out after the therapy and antialphaGal Ab levels were measured daily. In vitro proportional to CD22-IT inhibited protein synthesis in the human Daudi B cell line more effectively than proportional to CD38-IT. Upon differentiation of B cells into plasma cells, however, less inhibition of protein synthesis after proportional to CD22-IT treatment was observed. Depleting CD20-positive cells in vitro from a baboon spleen cell population already depleted of granulocytes, monocytes, and T cells led to a relative enrichment of CD20-negative cells, that is plasma cells, and consequently resulted in a significant increase in antialphaGal Ab production by the remaining cells, whereas depleting CD38-positive cells resulted in a significant decrease in antialphaGal Ab production. In vivo, WBI (300 or 900 cGy) resulted in 100% B cell depletion in blood and BM, > 80% depletion in LN, with substantial recovery of B cells after 21 days and only transient reduction in antialphaGal Ab after EIA. Proportional to CD22-IT depleted B cells by > 97% in blood and BM, and by 60% in LN, but a rebound of B cells was observed after 14 and 62 days in LN and blood, respectively. At 7 days, serum antialphaGal IgG and IgM Ab levels were reduced by a maximum of 40-45% followed by a rebound to levels up to 12-fold that of baseline antialphaGal Ab by day 83 in one baboon. The results obtained with proportional to CD38-IT were inconclusive. This may have been, in part, due to inadequate conjugation of the toxin. Cell coating was 100% with proportional to CD38 mAb, but no changes in antialphaGal Ab production were observed. Proportional to CD20 mAb resulted in 100% depletion of B cells in blood and BM, and 80% in LN, with recovery of B cells starting at day 42. Adding 150cGy WBI at this time led to 100% depletion of B cells in the BM and LN. Although B cell depletion in blood and BM persisted for > 3 months, the reduction of serum antialphaGal IgG or IgM Ab levels was not sustained beyond 2 days. Proportional to CD20 mAb + WBI totally and efficiently depleted CD20- and CD22-positive B cells in blood, BM, and LN for > 3 months in vivo, but there was no sustained clinically significant reduction in serum antialphaGal Ab. The majority of antibody secretors are CD38-positive cells, but targeting these cells in vitro or in vivo with proportional to CD38-IT was not very effective. These observations suggest that CD20-and CD22-positive B cells are not the major source of antialphaGal Ab production. Future efforts will be directed towards suppression of plasma cell function.

3,4-Methylenedioxymethamphetamine (ecstasy)-induced hepatotoxicity: multidetector CT and pathology findings

3,4-methylenedioxymethamphetamine ("Ecstasy") abuse may cause severe hepatotoxicity. The computed tomography and pathologic findings of such a case are described.

Risk factors for leg wound complications following endoscopic versus traditional saphenous vein harvesting

BACKGROUND

Risk factors for leg wound complications following traditional saphenectomy have included: obesity, diabetes, female gender, anemia, age, and peripheral vascular disease. Use of an endoscopic saphenectomy technique may modify the risk factor profile associated with a traditional longitudinal incision.

METHODS

From September 1996 to May 1999, 276 consecutive patients who underwent elective isolated coronary artery bypass grafting performed by a single surgeon (K.B.A.) had their greater saphenous vein harvested endoscopically. During the period from January 1999 to May 1999, the surgical records of 643 patients who underwent the same operation and had a traditional longitudinal saphenectomy were reviewed for postoperative leg wound complications. Group demographics were similar regarding preoperative risk stratification and traditionally identified wound complication risk factors (diabetes, gender, obesity, preoperative anemia, and peripheral vascular disease). Leg wound complications were defined as: hematoma, dehiscence, cellulitis, necrosis, or abscess requiring dressing changes, antibiotics and/or debridement prior to complete epithelialization. Follow-up was 100% at six weeks.

RESULTS

Leg wound complications following endoscopic harvest occurred in 3% (9/276) of patients versus 17% (110/643) of traditional harvest patients (p < 0.0001). No univariate risk factors for wound complications were associated with endoscopic saphenectomy. Univariate predictors of wound complications following traditional saphenectomy included: diabetes (p = 0.001), obesity (p = 0.0005), and female gender (p = 0.005). Multivariable risk factors for leg wound complications following saphenectomy were traditional harvest technique (OR 7.56, CI 3.8-17.2, p < 0.0001), diabetes (OR 2.10, CI 1.4-3.2, p = 0.0006) and obesity (OR 1.82, CI 1.2-2.8, p = 0.007).

CONCLUSIONS

Traditional longitudinal saphenectomy is a multivariable risk factor for development of leg wound complications. Endoscopic saphenectomy modifies the risk factor profile for wound complications and should be the standard of care, particularly for obese and/or diabetic patients who require venous conduit during coronary artery bypass grafting.