Cardiovascular disease: extraintestinal manifestation of inflammatory bowel disease

Inflammatory bowel disease (IBD) is a spectrum of diseases characterized by the interplay of the aberrant immune system, genetic factors, environmental factors, and intestinal microbiota, resulting in relapsing inflammation of the gastrointestinal tract. Underlying pro-inflammatory state and immune dysregulation act as a catalyst for increasing the likelihood of developing extraintestinal manifestations, including cardiovascular diseases (CVD) like atherosclerosis, pericarditis, myocarditis, venous and arterial thromboembolism, arrhythmias, despite a lower prevalence of classic CVD risk factors, like high body mass index or dyslipidemia compared to the general population. Chronic inflammation damages endothelium resulting in the recruitment of inflammatory cells, which induce cytotoxicity, lipoprotein oxidation, and matrix degradation, which increases the risk of atherosclerosis. Additionally, intestinal dysbiosis disrupts the intestinal mucosal barrier, releasing endotoxins and lipopolysaccharides into circulation, further exaggerating the atherosclerotic process. Abnormal collagen metabolism and alteration of nitric oxide-mediated vasodilation lead to blood pressure dysregulation in patients with IBD. Therefore, it is essential to make lifestyle modifications like smoking cessation, dietary changes, and increasing physical activity with adherence to medication to mitigate the risk of developing CVD in patients with IBD. This article reviews the potential links between IBD and the increased risk of CVD in such individuals.

Shedding light on weight loss: A narrative review of medications for treating obesity

Obesity and overweight are the major risk factors for numerous chronic diseases, including cardiovascular diseases such as heart disease and stroke, which are the leading causes of death worldwide. The prevalence of obesity has dramatically risen in both developed and developing countries, making it a significant public health concern and a global crisis. Despite lifestyle modifications being the first-line treatment, the high risk of relapse has led to a growing interest in non-invasive pharmacotherapeutic interventions to achieve and maintain weight loss and reverse the growth of the obesity epidemic. Cardiovascular diseases and cancer account for the highest mortality rates among other comorbidities associated with obesity and overweight. Excess and abnormally deposited adipose tissue secretes various inflammatory mediators, leading to cardiovascular diseases and cancers. Weight loss of 5-10% significantly reduces cardiometabolic risk. Medications currently approved in the USA for long-term management of obesity are orlistat, naltrexone, bupropion, phentermine/topiramate, and Glucagon Like Peptide-1 (GLP-1) agonists such as liraglutide and semaglutide. The benefit-to-risk of medications, comorbidities, and individual responses should guide the treatment decisions. The article provides a comprehensive overview and discussion of several weight loss medications used previously and currently, including their efficacy, mechanisms of action, and side effects.

Epidemiological shifts: the emergence of malaria in America

Plasmodium is a genus of parasites that comprises different species. The species falciparum, vivax, malariae, ovale, and knowlesi are known to cause a vector-borne illness called malaria, and among these, falciparum is known to cause major complications. The vector, the Anopheles mosquito, is commonly found in warmer regions close to the equator, and hence transmission and numbers of cases tend to be higher in Sub-Saharan Africa, South Asia, and Central America. The number of cases of malaria in the United States has remained stable over the years with low transmission rates, and the disease is mostly seen in the population with a recent travel history to endemic regions. The main reason behind this besides the weather conditions is that economically developed countries have eliminated mosquitos. However, there have been reports of locally reported cases with Plasmodium vivax in areas such as Florida and Texas in patients with no known travel history. This paper aims to familiarize US physicians with the pathophysiology, clinical features, and diagnostic modalities of malaria, as well as available treatment options.

A cross-sectional study of awareness and practices regarding thalassemia among parents of thalassemic children

Background:

This cross-sectional study was carried out in thalassemia ward of Rajindra Hospital, Patiala, among the parents of thalassemic children to determine awareness about side effects and complications of blood transfusion therapy, other treatment options, nature of disease, and food practices of transfusion-dependent patients. The study was carried out using a predesigned questionnaire and 118 parents participated in the study. About 50.84% patients belonged to the Sikh community, 45.76% patients practiced Hindu religion, and only 3.38% of the patients were Muslim. This study shows that 87.29% parents do not know how the disease is spread. About 55.93% have no knowledge about iron-containing food should not be included in the diet of transfusion-dependent patients. About 86.44% parents believed they had no role in transmission of the disease to their child, 79.66% parents do not understand the importance of screening before marriage, and 95.76% parents do not know about alternative treatment options. This study wants to shine light about the inadequate and superficial knowledge of thalassemia among general public and how awareness of the disease will bring down the incidence rates.

Aims:

The main objective of the study is to determine the degree of awareness of the disease, their knowledge of complications of blood transfusion therapy, and other treatment options among the parents of the children with thalassemia who are currently on blood transfusion therapy.

Subjects and Methods:

This cross-sectional study was conducted in thalassemia ward of Rajindra Hospital, Patiala from June 2018 to November 2018. After informed verbal consent was ensured, parents of the patients were interviewed using a questionnaire as the patients received blood transfusion. Questions include prevention, progression, cause, and spread, of the disease. The questions also include side effects and complications of blood transfusion therapy and other treatment options available.

Statistics Used:

Continuous variables were summarized as mean and standard deviation and categorical variables as proportion (%). Percentage and frequency was used wherever applicable.

Results:

Parents of about 118 patients were interviewed out of which 74.57% parents were illiterate and only 25.42% were literate. About 50.84% of the patients were Sikh, 45.76% were Hindu, and only 3.38% patients were Muslims. About 71.19% of the parents had no knowledge about the prevention of the disease, and 87.29% of the parents did not know mechanism of spread. Despite having transfusion-dependent children, only 44.07% of the parents restricted iron-containing food from the diet of their children. About 72.05% of the patients have inadequate information about risk of hepatitis B, hepatitis C, and HIV due to blood transfusions and only 21.29% of the patients understand the importance of hepatitis B vaccine.

Conclusion:

Awareness among both literate and illiterate parents was inadequate and sensitization among general public and parents of thalasemmic children should be initiated.

Abstract OT3-05-03: POLARIS: Palbociclib (P) in hormone receptor-positive (HR+) advanced breast cancer: A prospective multicenter noninterventional study

Background: P is a novel cyclin-dependent kinase 4/6 inhibitor approved in the United States and Canada in combination with endocrine therapy for HR+/human epidermal growth factor receptor 2–negative (HER2-) advanced breast cancer (ABC). Despite promising trial results, not all patients respond to P. Moreover, despite a median age at diagnosis of 62 years, elderly patients are underrepresented in targeted therapy trials, including the PALOMA studies assessing P. It is important to understand P use in real-world practice settings, including tolerability and outcomes in the vulnerable older population. In addition, understanding the mechanisms of P response or resistance is critical to identify clinical factors and biomarkers that can predict which patients will benefit from P. This multicenter observational and biomarker study will seek to address these and other data gaps.

Trial Design: This is a prospective, noninterventional study of 1500 patients treated with P from 100 US and 10 Canadian sites. Study duration will span 2 years of recruitment and 3 years of follow-up after P treatment, until patient withdrawal from the study or death. Study participation is not intended to alter routine treatment; all treatment decisions, including type and timing of disease monitoring, are at the discretion of the treating physician and patient.

Eligibility: Eligible patients are aged ≥18 years with a diagnosis of adenocarcinoma of the breast with (1) evidence of advanced or metastatic disease not amenable to treatment with curative intent, (2) documented HR+/HER2- status, and (3) planned treatment with P. Patients with a life expectancy <3 months at initial diagnosis, those participating in interventional trials, and those receiving active treatment for malignancies other than ABC at enrollment are ineligible.

Aims: In a large real-world cohort of HR+/HER2- ABC patients treated with P in routine clinical practice, this study aims to assess the following: prescribing and treatment patterns for ABC before, during, and after P therapy; overall clinical response to P; biomarker assessment investigating potential mechanisms of response and resistance to P based on genomic analyses of blood samples; patient quality of life, as measured by the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Core 30; geriatric assessments in patients aged ≥70 years at enrollment based on the G8 Geriatric Screening Tool and the Activities of Daily Living questionnaire; and sequencing of treatment for metastatic disease. Other outcomes to be assessed include survival and toxicity.

Methods: Data will be collected from routine clinical assessments. Patients will have the option to provide blood samples drawn at standard-of-care intervals at baseline, during P treatment, and at the end of treatment for potential biomarker identification. Analyses will be primarily descriptive, with point estimates and confidence intervals as well as Kaplan-Meier methods used to assess time-to-event outcomes.

Accrual: Presently, 46 patients from 20 sites are enrolled.

Funding: Pfizer Inc.

Citation Format: Tripathy D, Bardia A, Blum JL, Rocque G, Wilks S, Lakhanpal S, Migas J, Cappelleri J, Perkins J, Comstock G, Wang Y. POLARIS: Palbociclib (P) in hormone receptor-positive (HR+) advanced breast cancer: A prospective multicenter noninterventional study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT3-05-03.

Radiofrequency ablation of the great saphenous vein, comparing one versus two treatment cycles for the proximal vein segment

Objective

To evaluate the results of radiofrequency ablation (RFA) of the great saphenous vein (GSV) using one versus two 20 s energy cycle treatment in the proximal 7 cm segment of the GSV.

Methods

All patients who underwent RFA of the GSV from 1 May 2013 to 30 September 2013 in eight of our vein centers were included. Duplex ultrasound scans (DUSs) were performed prior to treatment on all patients and 2–3 days, and 1 month after procedure. Demographic data, GSV diameters, and other relevant data were recorded. Clinical, Etiologic, Anatomic, Pathologic (CEAP) classification and Venous Clinical Severity Scores (VCSSs) were determined prior to ablation and one month later. Patients who developed endovenous heat induced thrombosis (EHIT) were followed till resolution.

Results

A total of 205 patients had one cycle treatment (group A) and 204 had two cycle treatment (group B). The two groups were comparable in their demography, CEAP classification, and VCSS scores. The rate of failure of ablation and incidence of EHIT were also not significantly different. The incidence of complications was low, <5% in both groups and all were minor.

Conclusion

Two cycle treatment of the proximal GSV for vein ablation does not improve the success rate of vein closure in the short term, compared to one cycle treatment. It also does not increase the risks of DVT, EHIT, major bleeding, and other complications. However, we do not know at what diameter two cycles may be superior to one cycle.

Endovenous heat-induced thrombosis after ablation with 1470 nm laser: Incidence, progression, and risk factors

Objectives

To evaluate the incidence of heat-induced thrombosis, its progression and risk factors that may contribute to its formation after endovenous laser ablation.

Methods

This was a prospective evaluation of all patients who had endovenous laser ablation of the great saphenous vein, accessory saphenous vein, and small saphenous vein using 1470 nm wavelength laser, from March 2010 to September 2011. All patients who developed endovenous heat-induced thrombosis at the saphenofemoral junction or at the saphenopopliteal junction were included. Demographic data, history of venous thrombosis, body mass index, vein diameter, reflux time, catheter tip position, endovenous heat-induced thrombosis progression, number of phlebectomies, and venous clinical severity scores were analyzed. Duplex ultrasound was done in all patients preoperatively, and 2–3 days postoperatively.

Results

Endovenous laser ablation was performed in 2168 limbs. Fifty-seven percent had great saphenous vein, 13% accessory saphenous vein, and 30% small saphenous vein ablation. Endovenous heat-induced thrombosis was developed in 18 limbs (12 at saphenofemoral junction and six at saphenopopliteal junction) for an incidence of 0.9%. Eight were class 1 and 10 were > class 2. No pulmonary embolism was reported. The percentage of men with endovenous heat-induced thrombosis was higher compared to those without (39% vs. 24%, p = .14). The median age for endovenous heat-induced thrombosis patients was 59.6 compared to non-endovenous heat-induced thrombosis ( p = .021). Great saphenous vein/accessory saphenous vein diameter for endovenous heat-induced thrombosis patients was 8.0 mm versus 6.3 mm for non-endovenous heat-induced thrombosis patients ( p = .014), and for small saphenous vein it was 5.7 mm versus 4.5 mm ( p = .16). Multiple concomitant phlebectomies were performed in 55.6% of the endovenous heat-induced thrombosis patients compared to 37% in non-endovenous heat-induced thrombosis ( p = .001). All other parameters were similar between endovenous heat-induced thrombosis and non-endovenous heat-induced thrombosis group. Endovenous heat-induced thrombosis resolution occurred in 16 cases at 2–4 but two cases progressing from class 1 to 2, before resolution. The mean VCSS score for endovenous heat-induced thrombosis patients preoperatively was 5.6 and improved to 2.8 ( p = .003) at one month.

Conclusion

Risk factors associated with endovenous heat-induced thrombosis formation after endovenous laser ablation include: vein size, age, and multiple phlebectomies. Endovenous heat-induced thrombosis resolves in 2–4 weeks in most patients but it may worsen in few.

Superficial vein ablation for the treatment of primary chronic venous ulcers

Objective

This retrospective study was undertaken to review our experience with ablation of superficial veins with significant reflux, using VNUS ClosureFAST RF (radiofrequency) or laser 980 nm, in patients with primary chronic venous ulcers, and also determine its effects in ulcer healing and ulcer recurrence.

Method

Included were 25 limbs (18 patients with chronic primary venous ulcers (clinical, aetiological, anatomical and pathological elements [CEAP] classification C6), who underwent endovenous ablation with RF for the axial veins or laser for the perforating veins during a two-year period.

Results

Of the 18 patients, there were eight men and 10 women. The median age of the group was 68 (range 37–89) years. The number of ablations done in each leg with an ulcer varied from one to eight, with a median of three. During a follow-up period of 6–12 months, one patient failed ulcer healing despite sequential ablations of refluxing veins. There was one case that developed recurrence of a small ulcer after six months and was successfully treated with a perforator ablation.

Conclusion

Endovenous ablation of incompetent superficial veins improves the healing of chronic primary venous ulcers and decreases the recurrence rates.

Phase II study of 4-ipomeanol, a naturally occurring alkylating furan, in patients with advanced hepatocellular carcinoma

BACKGROUND/PURPOSE

4-Ipomeanol (IPO; NSC 394438), a naturally occurring furan isolated from common sweet potatoes (Ipomoea batatas) infected with the fungus Fusarium solani was the first agent to be developed by the National Cancer Institute based on a biochemical-biological rationale as an anticancer agent targeted specifically against lung cancer. Prior to clinical development, IPO was shown to induce pulmonary toxicity in the lungs of several mammalian species because the agent is metabolized to a highly reactive furan epoxide by specific cytochrome P450 monooxygenases found in pulmonary Clara cells and type II pneumocytes, which share biochemical features with bronchogenic carcinoma. However, instead of inducing the anticipated lung toxicity in patients with lung cancer in disease-directed phase I studies, hepatotoxicity was the principal toxic effect of IPO in humans. Based on the presumption that IPO may be preferentially activated by cytochrome P450 monooxygenases in liver cells and biochemically-related hepatic malignancies, a phase II study was conducted to determine the activity and evaluate the toxicity of IPO in patients with advanced hepatocellular carcinoma.

PATIENTS AND METHODS

Nineteen patients with advanced measurable hepatocellular carcinoma were enrolled on the phase II trial. All patients had an Eastern Cooperative Oncology Group performance status of at least two, no evidence of pulmonary dysfunction, and had either no prior treatment or minimal prior therapy. Patients were treated with IPO at a dose of either 1032 mg/m2, which was the maximum tolerated and recommended phase II dose previously derived for patients with normal hepatic function (15 patients) or 826 mg/m2 if they had serum bilirubin concentrations in the range of 2.0 to 3.0 mg/dL (four patients). Treatment was repeated every three weeks. Objective tumor response, the primary endpoint of the study, was assessed after every two courses of treatment, and both pulmonary function and lung density were rigorously monitored using successive pulmonary function testing and computerized tomography.

RESULTS

All nineteen patients were evaluable for both response and toxicity. No major objective responses were observed. One patient had a minor, brief reduction in lung metastases. Although marker lesions and overall disease remained stable for at least 12 and 24 months in three and two patients, respectively, the median time to progression was three months and the median survival was five months for all patients. The principal toxicity was reversible elevations in hepatic transaminases, which occasionally resulted in dose reduction. No clinically-significant pulmonary toxicity was noted.

CONCLUSION

IPO at a dose of either 826 or 1032 mg/m2 administered every three weeks did not demonstrate a relevant degree of clinical activity against advanced hepatocellular carcinoma. Further evaluations of TO is not recommended for this disease.

Sporotrichosis in an unusual location--dermatologically and geographically

We report the unusual fixed cutaneous variety of sporotrichosis in a patient hailing from Uttarkashi (Uttar Pradesh) in the north-western part of India.

Post-kala-azar dermal leishmaniasis--an unusual presentation

Post-kala-azar dermal leishmaniasis can present as hypopigmented macules, erythematous to skin-coloured papules, nodules and photosensitive butterfly erythema on the face. We present a patient with disseminated annular lesions of post-kala-azar dermal leishamaniasis. The patient was treated with daily intravenous injections of sodium antimony gluconate for 120 days at a dose of 20 mg/kg body weight with complete clearance of lesions.

Coronary sinus injury during retrograde cardioplegia: a report of three cases

Coronary sinus injuries related to the use of retrograde cardioplegia are uncommon. In most cases injuries are encountered with overinflation of the coronary sinus catheter balloon or traumatic catheter insertion. This article describes three cases of coronary sinus injury during retrograde cardioplegia administration in patients with ventricular hypertrophy, while the heart was manually retracted to expose the posterior myocardium. We propose that the risk of coronary sinus injury during retrograde cardioplegia, in patients with left ventricular hypertrophy, can be minimized by avoiding excessive retraction of the heart, deflation of the retrograde catheter during retraction, and the use of a left ventricular vent.

Angiocentric T cell lymphoma masquerading as cutaneous vasculitis

Angiocentric T cell lymphoma may present with cutaneous inflammatory lesions masquerading as cutaneous vasculitis both clinically and pathologically. We describe a case of angiocentric T cell lymphoma. Although initial biopsies in this patient resembled polyarteritis nodosa, subsequent biopsies exhibited more characteristic changes and immunohistochemical stains confirmed the diagnosis of large cell angiocentric cutaneous T cell lymphoma. It is important to differentiate these diseases as treatment and prognostic implications are very different.

Diagnostic value of C-reactive protein in acute appendicitis

Serum C-reactive protein was measured in 56 patients hospitalized with a suspected diagnosis of acute appendicitis. Based on these determinations, four groups of patients were defined: Group A = 26 patients with acute appendicitis who had a C-reactive protein level higher than 2.5 mg/dl. Group B = 4 patients with a C-reactive protein level lower than 2.5 mg/dl who, after surgery based on a presumed diagnosis of acute appendicitis, were found to have a normal appendix. Group C = 22 patients with nonspecific abdominal pain, 18 (72 percent) of whom had an elevated C-reactive protein level, although in only 4 (7.1 percent) were these levels higher than 2.5 percent mg/dl. Group D = 4 patients who had diseases other than acute appendicitis. It is concluded that an increase in C-reactive protein levels to more than 2.5 mg/dl is not a definite indicator of acute appendicitis. However, if the C-reactive protein level in blood drawn 12 hours after the onset of symptoms is less than 2.5 mg/dl, acute appendicitis can be excluded.

Priapism as a manifestation of isolated genital vasculitis

Vasculitis may affect virtually any organ system in the body. We describe a patient who presented with priapism due to isolated genital vasculitis. This responded promptly to oral corticosteroids. In patients presenting with priapism, a possible underlying vasculitis should be considered in the differential diagnosis; the treatment for this may be nonsurgical.

Lymphoreticular disorders masquerading as rheumatic disease syndromes

We describe four cases, each with a distinct rheumatologic presentation. Three had lymphoma, and the fourth, though initially suggestive of lymphoma, had a tuberculous infection. Clinicians should be alert for diseases masquerading as diverse clinical syndromes. It is important to establish rheumatic, lymphoproliferative, or infectious etiology because of major differences in therapeutic and prognostic implications.

Eosinophilic fasciitis: clinical spectrum and therapeutic response in 52 cases

The clinical course of 52 cases with eosinophilic fasciitis observed at the Mayo Clinic has been described. Cutaneous changes included pitting edema, peau d'orange, and induration, and may affect virtually any body surface area. In addition, localized morphea was present in 15 cases. Arthritis was observed in 21 patients; 29 patients had flexion contractures and 12 had carpal tunnel syndrome. Associated hematologic diseases were found in five patients; thrombocytopenia in two, myeloproliferative disorder in one, myelomonocytic leukemia in one, and chronic lymphocytic leukemia in one. Peripheral blood eosinophilia was noted in 33 of 52 patients, hypergammaglobulinemia was noted in 17 of 49, and elevated sedimentation rate was noted in 15 of 52. Nonspecific EMG changes were seen in 11 of 15 patients. None had clinical involvement of the kidneys, lungs, or heart. No significant association between any HLA-A, -B, or -DR and eosinophilic fasciitis was seen. Prednisone and hydroxychloroquine seemed equally beneficial in treatment; however, some cases showed spontaneous recovery, making evaluation of therapeutic efficacy difficult. Relapses occurred in some cases.

Evidence for linkage of IgA deficiency with the major histocompatibility complex

A 57-year-old woman with IgA deficiency and Still's disease was the proband in a 20-member, three-generation kindred in which we studied the possible linkage of IgA deficiency with her HLA-A1-B8 haplotype. The presence of paternal A1-B8 haplotype complicated the analysis. Known maternal HLA-A1-B8 haplotype, present in three of the children of the proband, was associated with IgA deficiency, whereas all five family members with exclusively paternal A1-B8 had normal IgA. Of three third-generation family members whose A1-B8 haplotype was of indeterminate origin--that is, potentially either maternally or paternally derived--two had IgA deficiency and one did not.

Eosinophilia associated with perimyositis and pneumonitis

We describe a patient who had severe myalgias, bronchial asthma, pulmonary infiltrates, and eosinophilia. The findings on physical examination and the erythrocyte sedimentation rate were normal; there was no elevation of the serum creatine kinase. Muscle biopsy demonstrated an inflammatory exudate that contained eosinophils, localized primarily to the perimysium. Pulmonary and muscle manifestations responded to corticosteroids. Systemic eosinophilic disease associated with perimyositis or myositis has not been reported previously. In addition, we review the spectrum of eosinophilic muscle diseases--eosinophilic perimyositis, eosinophilic polymyositis, and focal eosinophilic myositis.

Tuberculous fasciitis with tenosynovitis

A case of tuberculous fasciitis with tenosynovitis is described. No other organs were affected and tissue histology was not diagnostic. The diagnosis was confirmed by tissue culture and our patient was treated by surgical debridement and antituberculous drug therapy. A high index of suspicion for tuberculosis will alert clinicians to the correct diagnosis in unusual clinical presentations.

Interleukin 2 induces proliferation of normal "resting" human T cells in the absence of other known external stimulation

Interleukin 2(IL-2) is known to stimulate the progression of activated T cells from G1 through the rest of the cell cycle. We have demonstrated that addition of purified recombinant human IL-2 (rIL-2) to fresh normal human peripheral blood mononuclear cells (PBM), which were IL-2 receptor (Tac) negative by FACS analysis, stimulated marked proliferation of the PBM. IL-2-induced proliferation was also observed with umbilical cord blood mononuclear cells. Monocyte depletion of PBM resulted in a marked reduction of rIL-2-induced proliferative response which could be restored by adding back autologous irradiated monocytes but not by interleukin 1. The T cells preincubated with rIL-2 showed a five to six times enhanced autologous mixed-lymphocyte reaction (AMLR) compared to controls. The rIL-2-induced proliferative response of PBM was inhibited in a concentration-dependent fashion by preincubation of PBM with an anti-HLA-DR framework monoclonal antibody. The proliferating cells were shown by two-color flow cytometric analysis to be primarily Leu-1+ and Leu-4+ T cells (both leu-3+ and Leu-2+ subsets); however, 6 to 19% of responding cells had surface markers for B cells or NK cells. The data demonstrate that rIL-2 can induce proliferation of "resting" human T cells. The phenomenon may be related to a monocyte-dependent AMLR which induces IL-2 receptors and IL-2 responsiveness in a subset of T cells.

Synovial fluid analysis for diagnosis of amyloid arthropathy

To detect the presence of amyloid, we studied synovial fluid samples from 7 patients who had biopsy-proven amyloidosis and clinical arthropathy and from 98 patients who had other forms of arthritis. Centrifuged sediments from synovial fluids of all 7 patients with amyloid and clinical arthropathy were positive on staining with Congo red, whereas the 98 others were negative. Under polarized microscopy, the amyloid appeared as an amorphous material with strong Congo red uptake and typical apple-green birefringence. These findings indicate that analysis of synovial fluid sediments with Congo red may represent a simple, yet sensitive, test for the diagnosis of amyloid arthropathy.

Transient regional osteoporosis. A study of 56 cases and review of the literature

We describe the clinical features and course of disease in 56 patients (33 men and 23 women) with transient regional osteoporosis. The median age at hospitalization was 48 years. All patients had monoarticular or oligoarticular joint pain that was aggravated by weight bearing. Eighteen also had pain at rest in the involved joints and 6 had nocturnal pain. The joints of the lower extremities were affected in 54 patients; the hip was the most commonly affected joint. There was little evidence of synovitis. Osteoporosis was diagnosed on the basis of characteristic clinical findings and the results of roentgenograms and bone scans. The osteoporosis resolved spontaneously over several months. Treatment consisted of joint protection, initiation of gradual ambulation, and administration of nonsteroidal anti-inflammatory agents. Although its cause is unknown, osteoporosis appears to be a regional rather than a systemic process.

A flow cytofluorometric double staining technique for simultaneous determination of human mononuclear cell surface phenotype and cell cycle phase

A double staining technique for the simultaneous determination by flow cytofluorometry of cell surface phenotype and cell cycle phase is described. Peripheral blood mononuclear cells were stained with fluorescein-conjugated monoclonal antibodies for cell surface phenotype, fixed serially with 2% paraformaldehyde and 71.25% ethanol, and stained with propidium iodide to label cellular DNA. The cells were then analyzed by flow cytofluorometry for both green and red fluorescence. A variety of cells, including T cells and their subsets, B cells, NK cells and monocyte/macrophages, can be identified by this technique with simultaneous determination of cell cycle phase.

Interleukin 2 receptors and responsiveness to recombinant human interleukin 2 in patients with systemic lupus erythematosus

Defects in interleukin 2 (IL2) responsiveness may contribute to immunologic abnormalities in systemic lupus erythematosus (SLE). We studied the acquisition of IL2 receptors and responsiveness to recombinant human IL2 (rIL2) in the peripheral blood mononuclear cells (PBM) of patients with SLE and matched control subjects. Peak rIL2-induced proliferation was significantly decreased (mean reduction of 58%) in 5 of the 10 patients with SLE. Five of six patients with SLE studied for phytohemagglutinin-induced IL2 receptors had acquisition of IL2 receptors comparable to that of the control subjects. Some patients with SLE have a defect in rIL2-induced proliferation of their "resting" PBM that seems unrelated to a concomitant defect in phytohemagglutinin-induced IL2 receptor acquisition. This finding suggests that the defect in rIL2-induced proliferation may be due to either an abnormality in postreceptor signaling or an impairment in induction of high-affinity IL2 receptors.

Pulmonary disease in polymyositis/dermatomyositis: a clinicopathological analysis of 65 autopsy cases

The clinical and autopsy records of 65 patients with either polymyositis (24) or dermatomyositis (41) and pulmonary disease were reviewed. Pulmonary symptoms were recorded in 43 of the cases and included dyspnoea in 31, cough in 23, and chest pain in six. Interstitial lung disease was noted at autopsy in 27 patients; almost half of these had arthritis. Bronchopneumonia was found in 35 patients, 31 of these had received prednisone. Dysphagia was present in a similar proportion of patients with and without pneumonia. Pulmonary vasculitis was seen in five patients; pulmonary symptoms, arthritis, and raised erythrocyte sedimentation rate were present in four of these cases and all five had associated interstitial lung disease. Other pulmonary manifestations included pulmonary oedema, primary pulmonary malignancy, diffuse alveolar damage, fibrinous pleuritis, pulmonary emboli, and diaphragmatic atrophy. The mean survival after disease onset was 29 months but was much less for those with interstitial lung disease and pulmonary vasculitis.

Stimulation of resting normal human peripheral blood mononuclear cells by fetal calf sera. Activation to an interleukin-2 responsive state

Normal adult human peripheral blood mononuclear cells which are negative for interleukin-2 (IL-2) receptors as assessed by flow cytofluorometry, acquire IL-2 receptors and IL-2 responsiveness after culture in media supplemented with fetal calf sera. Thus, in the absence of any known external stimuli, fetal calf sera used to supplement culture media can induce the transformation of resting (G0) peripheral blood mononuclear cells to an activated (G1) state. The activated (G1) cells are able to progress through the rest of the cell cycle (S, G2, M) in the presence of IL-2. As a result, studies of human peripheral blood mononuclear cells in fetal calf serum-supplemented culture media should be interpreted with appropriate caution.

Polymyositis-dermatomyositis and malignant lesions: does an association exist?

To examine the purported association between polymyositis-dermatomyositis and malignant lesions, we identified all patients with histopathologically proven polymyositis-dermatomyositis examined at our institution from 1965 to 1974. For each patient, a control subject was selected, matched for age, sex, race, year and department of clinical evaluation, and geographic area of residence. Although the proportion of patients who ever had a diagnosis of malignant disease (25%) was greater than that for controls (17%), the difference was not statistically significant (P = 0.14). The slight excess of cancer seen among patients was contributed by the most distant referrals and may best be explained on the basis of referral bias. No clinical differences were found between patients with polymyositis-dermatomyositis who had a malignant neoplasm and those who did not, and intensive clinical investigation to exclude "occult" underlying malignant growths did not seem to be cost-effective. Although the present study does not prove that there is no association between polymyositis-dermatomyositis and malignant lesions, the existence of a clinically significant relationship seems unlikely.

Interference with total hemolytic complement assay in rheumatoid arthritis: correlation with disease activity

A subgroup of patients with rheumatoid arthritis (RA) whose sera agglutinated sensitized sheep erythrocytes used for total hemolytic complement determination has been identified. These patients have higher titers of rheumatoid factor (RF) and more severe rheumatoid disease compared to controls. The agglutination of sensitized sheep erythrocytes by sera of some patients with RA may be related to qualitative or quantitative variations in their RF.

Insufficiency-type stress fractures in rheumatoid arthritis: report of an interesting case and review of the literature

A case of multiple insufficiency-type stress fractures (32 fractures), in the absence of any trauma, in a 51-year-old white woman with rheumatoid arthritis is described. The fractures healed satisfactorily with rest, treatment of osteoporosis, and discontinuation of her steroid therapy, following which a proximal humeral and total knee arthroplasties were successfully performed. The factors contributory to the development of stress fractures in rheumatoid arthritis are discussed, the literature is reviewed, and the salient features of our case are highlighted.

D-penicillamine in Felty's syndrome

We report our experience with 8 patients with Felty's syndrome who were treated with D-penicillamine for a mean of one year. Six of the 8 patients experienced improvement in their neutropenia. Cutaneous ulcers healed in 4 of 6, while recurrent infections cleared in 3 of 5 patients. The drug was withdrawn in 6 patients--lack of response in one, thrombocytopenia in one, urticaria in one, rash in one, and granulocytopenia in 2. One of the latter 2 patients developed pancytopenia and died. Although D-penicillamine is effective in treatment of Felty's syndrome, its side effects can be serious and potentially lethal. Its use should be limited to patients who have failed other treatments.

Pathologic features of Behçet's syndrome: a review of Japanese autopsy registry data

The data recorded from 170 autopsies of patients with Behçet's syndrome in Japan during the period from 1961 to 1976 were analyzed. The patients had been in the second to the eighth decade of life, and the ratio of males to females was 5 to 2. A wide spectrum of pathologic findings was observed, with involvement of neurologic, ophthalmic, cardiovascular, pulmonary, gastrointestinal, visceral, genitourinary, and mucocutaneous systems. Some of the common acknowledged clinical features of the syndrome, such as oral ulcers, synovitis, retinal and cutaneous vasculitis, and venous occlusions, were underreported. This apparent discrepancy in an autopsy series may be due to the effects of treatment or the healing process, as well as to the possible incompleteness of the postmortem examination. The accessibility of recorded data in a national autopsy registry offers a unique opportunity for review of the pathologic features of Behçet's syndrome.

Clinical and prognostic significance of vasculitis as an early manifestation of connective tissue disease syndromes

The courses of 18 patients with arthritis and vasculitis in the first 2 years after onset of disease (mean follow-up, 54 months) were studied. The patients were categorized as having rheumatoid vasculitis, systemic vasculitis, and undifferentiated connective tissue syndrome. These patients cannot be distinguished on basis of organ involvement by vasculitis or histopathologic findings on biopsy, but can be separated clinically by the extent of joint involvement and the presence or absence of rheumatoid factor and antinuclear antibody. Early onset of vasculitis is associated with a poor outcome, especially in patients with rheumatoid arthritis, with rapid progression to vasculitic involvement of the viscera, resulting in death. On the basis of the 54-month follow-up period involving this selected series, the prognosis of patients with systemic vasculitis and undifferentiated connective tissue syndrome appears more favorable than that of patients with rheumatoid vasculitis.