Fatigue in systemic lupus: the role of disease activity and its correlates

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune disease that leads to a variety of negative health outcomes resulting from inflammation in various organ systems. Although treatment continues to advance, fatigue remains one of the most salient, poorly understood and addressed patient complaints. Understanding the mechanisms of fatigue can help guide the development of interventions to improve health outcomes. The aim of this research was to evaluate the contribution of six variables (disease activity, insomnia, depression, stress, pain and physical health) to fatigue in SLE without concomitant fibromyalgia (FM).

METHODS

A total of 116 ethnically diverse, primarily female participants (91%) with SLE, receiving care at university medical centers, completed assessments of disease activity and quality of life outcomes (FACIT-FT, Insomnia Severity Index, Perceived Stress Scale (PSS-4), Pain Inventory, Depression-PHQ-9, and LupusPRO-physical function). All patients met the American College of Rheumatology classification criteria for SLE and did not have a known diagnosis of FM. Multivariate linear and stepwise regression analyses were conducted with fatigue (FACIT-FT) as the dependent variable, and the above six variables as independent variables.

RESULTS

Mean (SD) age was 39.80 (13.87) years; 50% were African American, 21% Caucasian, 13% Hispanic, 9% Asian and 8% other. Mean (SD) FACIT-FT was 20.09 (12.76). Collectively, these six variables explained 57% of the variance in fatigue. In the multivariate model, depression, stress and pain were significantly and independently associated with fatigue, but not disease activity, sleep or physical health. Stress had the largest effect on fatigue (β 0.77, 95% CI 0.17-1.38, p = 0.01), followed by depression (β 0.66, 95% CI 0.21-1.10, p = 0.005). On stepwise regression analysis, only stress, depression and pain were retained in the model, and collectively explained 56% of the variance in fatigue. All three remained independent correlates of fatigue, with the largest contribution being stress (β 0.84, 95% CI 0.27-1.42, p = 0.005), followed by depression (β 0.79, 95% CI 0.44-1.14, p < 0.001) with fatigue.

CONCLUSION

Stress, depression and pain are the largest independent contributors to fatigue among patients with SLE, without concurrent FM. Disease activity, sleep and physical health were not associated with fatigue. The evaluation of stress, depression and pain needs to be incorporated during assessments and clinical trials of individuals with SLE, especially within fatigue. This stress-depression-fatigue model requires further validation in longitudinal studies and clinical trials. Significance and innovation: • Disease activity, sleep, pain, stress, depression, and physical health have been reported individually to be associated with fatigue in lupus. This analysis evaluated the role of each and all of these six variables collectively in fatigue among patients with SLE without a known diagnosis of FM. • Disease activity, sleep and physical health were not significantly related to fatigue, but depression, stress and pain were. • The results emphasize the need to evaluate and treat fatigue in individuals with SLE utilizing a biopsychosocial approach, particularly in the realm of clinical trials. Behavioral medicine interventions are shown to be most effective for the treatment of depression, stress and pain.

Low-Dose Anti-Thymocyte Globulin (ATG) Preserves β-Cell Function and Improves HbA1c in New-Onset Type 1 Diabetes

OBJECTIVE

A pilot study suggested that combination therapy with low-dose anti-thymocyte globulin (ATG) and pegylated granulocyte colony-stimulating factor (GCSF) preserves C-peptide in established type 1 diabetes (T1D) (duration 4 months to 2 years). We hypothesized that 1) low-dose ATG/GCSF or 2) low-dose ATG alone would slow the decline of β-cell function in patients with new-onset T1D (duration <100 days).

RESEARCH DESIGN AND METHODS

A three-arm, randomized, double-masked, placebo-controlled trial was performed by the Type 1 Diabetes TrialNet Study Group in 89 subjects: 29 subjects randomized to ATG (2.5 mg/kg intravenously) followed by pegylated GCSF (6 mg subcutaneously every 2 weeks for 6 doses), 29 to ATG alone (2.5 mg/kg), and 31 to placebo. The primary end point was mean area under the curve (AUC) C-peptide during a 2-h mixed-meal tolerance test 1 year after initiation of therapy. Significance was defined as one-sided P value < 0.025.

RESULTS

The 1-year mean AUC C-peptide was significantly higher in subjects treated with ATG (0.646 nmol/L) versus placebo (0.406 nmol/L) (P = 0.0003) but not in those treated with ATG/GCSF (0.528 nmol/L) versus placebo (P = 0.031). HbA_1c was significantly reduced at 1 year in subjects treated with ATG and ATG/GCSF, P = 0.002 and 0.011, respectively.

CONCLUSIONS

Low-dose ATG slowed decline of C-peptide and reduced HbA_1c in new-onset T1D. Addition of GCSF did not enhance C-peptide preservation afforded by low-dose ATG. Future studies should be considered to determine whether low-dose ATG alone or in combination with other agents may prevent or delay the onset of the disease.

Validation of the LupusPRO version 1.8: an update to a disease-specific patient-reported outcome tool for systemic lupus erythematosus

Objectives LupusPRO has shown good measurement properties as a disease-specific patient-reported outcome tool in systemic lupus erythematosus (SLE). For the purpose of clinical trials, the version 1.7 (v1.7) domain of Pain-Vitality was separated into distinct Pain, Vitality and Sleep domains in v1.8, and the psychometric properties examined. Methods A total of 131 consecutive SLE patients were self-administered surveys assessing fatigue (FACIT, SF-36), pain (Pain Inventory, SF-36), insomnia (Insomnia Severity Index), emotional health (PHQ-9, SF-36) and quality of life (SF-36, LupusPRO) at routine care visits. Internal consistency reliability (ICR) for each domain was obtained using Cronbach's alpha. The convergent construct validity of LupusPRO domains with corresponding SF-36 domains or tools were tested using Spearman correlation. Varimax rotations were conducted to assess factor structures of the LupusPRO v1.8. Results Mean (SD) age was 40.04 (14.10) years. Scores from the LupusPRO-Sleep domain strongly correlated with insomnia scores, while LupusPRO-Vitality correlated strongly with fatigue (FACIT) and SF-36 vitality. The LupusPRO-Pain domain correlated strongly with pain (SF36 Bodily-Pain, Pain Inventory) scores. Similarly, the LupusPRO domains of Physical and Emotional Health had significant correlations with corresponding SF-36 domains. The ICR for HRQoL and non-HRQoL were 0.96 and 0.81. LupusPRO (domains HRQoL and QoL) scores correlated with disease activity. Principal component analysis included seven factor loadings presenting for the HRQOL subscales (combined Sleep, Vitality, and Pain), and three factors for the NHRQoL (Combined Coping and Social Support). Conclusions LupusPRO v1.8 (including its Sleep, Vitality, and Pain domains) has acceptable reliability and validity. Use of LupusPRO as an outcome measure in clinical trials would facilitate responsiveness assessment.

Low response rate schools in surveys of adolescent risk taking behaviours: possible biases, possible solutions

STUDY OBJECTIVE

To examine the potential biases introduced when students in low response rate schools are dropped from classroom based surveys of adolescent risk taking behaviour.

DESIGN

Self administered confidential surveys were conducted in classrooms, with follow up visits to each school to survey students absent during the initial survey administration. Data on students in schools that achieved a 70% response rate are compared with data on students in schools that did not achieve this level of response.

SETTING

New York City, United States.

PARTICIPANTS

1854 10th graders in 13 public (state supported) high schools.

MAIN RESULTS

Students in schools with low response rates resulting from high rates of absenteeism have different demographic characteristics and engage in more risk behaviours than students in schools with low absenteeism and high response rates. Excluding schools with low rates of response can have an effect on estimates of risk behaviour, even after data are weighted for individual absences. The potential for bias is greatest when, in sampling schools, the proportion of schools with low response rates is large, and when such schools represent a large share of the students in the area under study.

CONCLUSIONS

Excluding schools with poor response rates from survey samples using a classroom based approach does not improve, and may, under some circumstances, underestimate risky behaviour among adolescent populations.

Epidemiological and genetic study of 121 cases of oral clefts in Kuwait

AIM

The aim of the study was to ascertain some epidemiological factors such as sex and consanguinity that may be associated with cleft lip with or without cleft palate (CL +/- CP) in Kuwait as well as to conduct genetic segregation analysis of these families.

SETTING AND SAMPLE POPULATION

A total of 113 families ascertained through 121 CL +/- CP and CP surgical probands in Kuwait. The frequencies of cleft types and the epidemiological variables were calculated using SPSS version 5.0 software. Chi-square for goodness-of-fit test was used to test the significance of the associated epidemiological variables to facial clefts. Genetic segregation analysis was performed on 76 families with extended pedigrees and included only those with non-syndromic CL +/- CP (NS CL +/- CP). Major locus segregation analysis was used to fit models to the observed family patterns under Class A regressive models as implemented by REGD routine in S.A.G.E. release 4.0. A test for heterogeneity was also conducted to complete data set in addition to two subsets: Arabs and nomads.

RESULTS

Of the 121 patients, 34(28.1%) had CP, 30(24.8%) had CL and 57 (47.1%) had CL + CP. The male to female ratio was 0.89 for CP, 1.14 for CL, 1.35 for CL + CP and 1.2 for all the clefts. The percentage of consanguineous families among those with a positive family history (60%) was not significantly different from that of the general population (54.3%), whereas for all the families with clefts the percent consanguineous was significantly lower (38%). No evidence of heterogeneity in the results between the Arab and nomad subsets was observed. The results for the major locus segregation analysis were inconclusive.

CONCLUSION

No definite association was observed between consanguinity and the occurrence of facial clefts in Kuwait. General transmission models in the full data set showed no evidence of heterogeneity in the results between the Arab and nomad subsets.

A universe with no designer

Does the universe shows signs of having been designed by a deity like those of traditional monotheistic religions? Physics is in a better position than religion to give a partly satisfying explanation of the world. Recent developments in cosmology help explain why the measured values of the cosmological constant and other physical constants are favorable for the appearance of intelligent life. The presence of evil and misery disturbs those who believe in a benevolent and omnipotent God. It is not necessary to argue that evil in the world proves that the universe is not designed, but only that there are no signs of benevolence that might have shown the hand of a designer.

Developmental screening of children diagnosed with congenital heart defects

Children with congenital heart disease (CHD) are more likely than normal children to have developmental delays. The development of 64 children with CHD less than 6 years old was screened with the Denver II. Thirty-five of the 64 children had CHD that required surgical or catheter intervention. These 35 children were significantly less likely than other children with CHD to be normal on developmental screening (46% vs 86%, respectively). Thirty-four percent of children with more severe CHD were referred for early intervention. As research shows the efficacy of early intervention, results indicate the need for early developmental evaluation of children with CHD of hemodynamic significance.

The use of intra-articular opioids and bupivacaine for analgesia following temporomandibular joint arthroscopy: a prospective, randomized trial

PURPOSE

This investigation evaluated the efficacy of using intra-articular morphine, bupivacaine, or a combination of both in the management of postarthroscopy temporomandibular joint (TMJ) pain.

MATERIALS AND METHODS

Thirty-two consecutive patients with internal derangements of the TMJ and persistent pain underwent TMJ arthroscopy. The patients were randomized equally into 4 groups. Group 1 received a sterile saline solution (control), group 2 received bupivacaine alone, group 3 received only a morphine solution, and group 4 received morphine mixed with bupivacaine. The patients recorded postarthroscopy pain using a visual analog scale (VAS), as well as analgesic consumption for 24 hours. The VAS and analgesic consumption were compared in the 4 groups.

RESULTS

Group 3 (bupivacaine alone) consumed, on average, 5.1 fewer analgesic equivalents than did group 1 (control) over the 24-hour period of study (P <.05). Otherwise, there was no significant difference in the number of analgesic equivalents consumed by the 4 groups. Patients treated with bupivacaine alone and those with morphine alone had significantly lower pain scores than the controls. However, there was no significant difference between the pain scores of the morphine and bupivacaine groups at any time. Patients treated with the mixture of morphine and bupivacaine showed no significant difference from controls at any time.

CONCLUSIONS

Bupivacaine alone provides a better analgesic effect than morphine alone or the combination of morphine and bupivacaine. Morphine alone has a longer time of onset, with less effect on the pain scores during the 24-hour observation period.

Internal derangements of the temporomandibular joint: the role of arthroscopic surgery and arthrocentesis

Arthroscopic surgery appears to be a safe, minimally invasive and effective method for treating internal derangements of the temporomandibular joint (TMJ), reducing pain and increasing mandibular range of motion for approximately 80% of patients. Although these results are encouraging, they are largely based on retrospective, uncontrolled and short-term studies. The landmark observation that lysis and lavage in only the upper compartment of the TMJ produce successful clinical results without repositioning the disc has prompted clinicians to question the importance of disc position as a significant factor in the etiology of TMJ pain dysfunction. Although there are prospective, controlled, randomized short-term studies indicating that arthrocentesis and arthroscopic surgery have comparable success rates in the management of acute TMJ closed lock, similar long-term studies are lacking. Until they have been done, the roles of arthroscopic surgery and arthrocentesis in the management of TMJ internal derangements remain unclear.

Lipid parameters predicting liver function in patients with cirrhosis and after liver transplantation

BACKGROUND/AIMS

The liver plays a central role in the production and metabolism of lipoproteins, regulating their synthesis and degradation. The protein content of the lipoproteins are the so-called apolipoproteins. Some of the apolipoproteins serve as cofactors for enzymatic reactions, as ligands for interaction with specific receptors, and as structural proteins. Apolipoprotein B (apoB) is the primary structural component of the atherogenic low density lipoprotein (LDL) particles and has a specific binding region for interacting with the LDL-receptor. In contrast, apolipoprotein A-I (apoA-I) represents the primary protein content of the high density lipoprotein (HDL) particles, which interacts with the putative HDL-receptor, and stimulates the enzymatic reaction of lecithin-cholesterol acyltransferase (LCAT) resulting in esterified cholesterol, which is the essential step in the process of reverse cholesterol transport.

METHODOLOGY

We studied lipid parameters in arterial and hepatic venous serum samples from 52 patients with cirrhosis and from 16 patients in the clinically stable long-term course after liver transplantation. Splanchnic blood flow was measured (indocyanine-green steady-state infusion) and hepatic extraction/production rates were calculated. To assess the influence of the clinical stage of established cirrhosis, the quantitated parameters were statistically analyzed.

RESULTS

In cirrhosis, apolipoprotein A-I levels are decreased depending on the clinical stage (p<0.01). This parameter showed excellent correlations to liver function tests. Triglycerides (TG) (p<0.05) and cholesterol (Chol) (p<0.05) were reduced as well, whereas apolipoprotein B levels did not change. In cirrhosis, hepatic production of both cholesterol and triglycerides were decreased (p<0.05 each), as well as hepatic extraction of free fatty acids (FFA) (p<0.01). Except for cholestatic liver disease with raised serum cholesterol (p<0.05) and apolipoprotein B levels (p<0.001), the etiology of cirrhosis had no impact on the observed serum lipid alterations.

CONCLUSIONS

The serum concentrations of the determined lipid parameters depend primarily on liver function. Decreased liver function was associated with reduced extraction of free fatty acids and reduced cholesterol and triglyceride synthesis. Liver transplantation restored the lipid abnormalities to normal. Finally, apolipoprotein A-I served as an excellent parameter for predicting liver function in the studied patients.

Chronic mandibular dislocation: the role of non-surgical and surgical treatment

Although the management of acute dislocations of the temporomandibular joint (TMJ) has not changed significantly in recent years, chronic dislocations continue to be treated by a variety of methods. Long-standing cases are the most difficult and frustrating to manage. This paper reports on four cases demonstrating the signs and symptoms associated with some forms of chronic. TMJ dislocations, and the difficulties encountered in the management of some of these conditions. An algorithm based on a critical review of the literature is proposed for the management of both acute and chronic TMJ conditions, and recommendations are made on how to eliminate or reduce their recurrence.

A review of common dental treatments during pregnancy: implications for patients and dental personnel

In general, pregnant females tend to over estimate the risk of teratogenicity in the foetus resulting from medical and dental procedures and/or drugs. This may cause them to avoid necessary treatment, leading to detrimental health effects for both the foetus and themselves. In this review, the concerns of pregnant dental patients and personnel will be discussed, including the perceived risks associated with amalgam restorations, radiation, local anesthetics, nitrous oxide gas, antibiotics and analgesics administered in a dental setting. Pregnant dental personnel have special concerns related to their daily occupational exposure to mercury and nitrous oxide. After assessing the potential risks of undergoing dental treatment during pregnancy, it can be stated that necessary treatment should not be with-held. In addition, dental treatments are best performed in the second trimester for the benefit of the foetus, and optimal comfort for the pregnant woman.

Extensive maxillary odontogenic keratocyst: review of the literature and report of a case

Odontogenic keratocysts arising in the maxilla are relatively uncommon, small unilocular lesions that rarely involve the maxillary sinus. This paper reviews the clinical, radiologic and histologic features of an extensive maxillary odontogenic keratocyst involving the maxillary sinus, and the complications associated with its management. The authors emphasize the importance of regular patient follow-up examinations and imaging studies in order to detect and treat recurrent lesions when they are small and well-localized.

Pre-auricular swelling and malocclusion

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Validation of a scale for network therapy: a technique for systematic use of peer and family support in addition treatment

Substance abuse treatments are increasingly employing standardized formats. This is especially the case for approaches that utilize an individual psychotherapy format but less so for family-based approaches. Network therapy, an approach that involves family members and peers in the patient's relapse prevention efforts, is theoretically and clinically differentiated in this paper from family systems therapy for addiction. Based on these conceptual differences, a Network Therapy Rating Scale (NTRS) was developed to measure the integrity and differentiability of network therapy from other family-based approaches to addiction treatment. Seven addictions faculty and 10 third- and fourth-year psychiatry residents recently trained in the network approach used the NTRS to rate excerpts of network and family systems therapy sessions. Data revealed the NTRS had high internal consistency reliability when utilized by both groups of raters. In addition, network and nonnetwork subscales within the NTRS rated congruent therapy excerpts significantly higher than noncongruent therapy excerpts, indicating that the NTRS subscales measure what they are designed to measure. Implications for research and training are discussed.

Surgical arthroscopy of the temporomandibular joint

Currently, surgical arthroscopy of the TMJ is primarily confined to the superior joint space, unless there is a perforation in the disc. This is due mainly to the technical limitations imposed in attempting to manipulate a 0.69 mm arthroscope with advanced fibreoptics in the lower joint space. At the present time, operative arthroscopy is "state of the art" treatment for many pathological entities involving the TMJ. Disc entrapment, synovitis, adhesions, chondromalacia, osteoarthritis and lateral capsular impingement can be effectively treated with this technique. While many patients will achieve successful results with this form of therapy, operative arthroscopy is not a panacea, and the need for open arthrotomy must still be reserved for those patients with advanced intracapsular disease. Specifically, anterior disc displacement with reduction, extensive intra-articular fibrosis, failed arthroscopy, avascular necrosis, osteochondritis dissecans, and joint reconstruction often require open arthrotomy for their successful management.

Analysis of facial and trigeminal nerve function after arthroscopic surgery of the temporomandibular joint

PURPOSE

This study analyzes facial and trigeminal nerver function after arthroscopic surgery.

PATIENTS AND METHODS

Eighty-one consecutive patients (81 joints) who underwent unilateral temporomandibular joint (TMJ) arthroscopic surgery were assessed postoperatively for facial and trigeminal nerve function.

RESULTS

Twenty-four of 81 patients (29.6%) had some degree of sensory or motor nerve dysfunction. Two patients (2.5%) showed signs of facial nerve dysfunction, which completely resolved in one patient in 11 weeks, but persisted mildly in the other at the 1-year follow-up examination.

CONCLUSIONS

Auriculotemporal syndrome was not detected in any of the 40 patients tested. However, transient numbness over the distribution of the auriculotemporal nerve was present in 19 of 81 patients (23.4%). This numbness persisted for 3 days to 3 months with a mean duration of 14 days. Three of the 81 patients (3.6%) showed signs of inferior alveolar and lingual nerve involvement, which returned to normal in 4 to 12 weeks in all 3 patients.

Calcium pyrophosphate dihydrate deposition disease of the temporomandibular joint. A case report and review of the literature

An asymptomatic preauricular swelling in a 58-year-old man appeared as a parotid mass and was diagnosed as calcium pyrophosphate dihydrate crystal deposition disease of the temporomandibular joint. This article describes the diagnostic criteria and management of this rare condition and reviews the 13 cases that have been reported to date.

Hyperendemic penicillinase-producing Neisseria gonorrhoeae genital infections in an inner city population

PURPOSE

To determine: 1) the proportion of Neisseria gonorrhoeae caused by penicillinase-producing Neisseria gonorrhoeae (PPNG) in our inner-city population; 2) any difference in the isolation rates of PPNG between adolescents and adults; 3) co-infection rates with Chlamydia trachomatis in this adolescent population; and 4) the appropriateness of current CDC recommendations for initial treatment of patients with suspected gonococcal infection.

METHODS

Genital cultures for GC were obtained from 1990 patients seen in the emergency room or primary care clinics. Of these, 285 were adolescents between 12 and 19 years of age. All adolescent patients were tested for chlamydial infection. Comparisons of gonococcal infection rates were made between adults and adolescents and between males and females. The rates of symptomatic versus asymptomatic adolescents were compared.

RESULTS

Genital cultures were positive for GC in 13% of the patients tested. Of these, 51% were identified as being caused by PPNG. Among the adolescents, cultures were positive in 25%, and 63% of these were identified as PPNG. The rate of PPNG was significantly higher in adolescents than in adults. The rate of PPNG was highest in adolescent females and lowest in adult males. There was no difference in the rate of PPNG between adolescents and adult males. Of the 71 adolescents with GC, 58% were coinfected with C. trachomatis. Adolescents with PPNG had a higher rate of concomitant infection with C. trachomatis than those with a penicillin-sensitive strain. Adolescents with N. gonorrhoeae were more likely to be infected with PPNG if they had GU symptoms.

CONCLUSIONS

Our data supports the most recent CDC recommendations that the initial treatment for suspected N. gonorrhoeae be effective against PPNG. Furthermore, chlamydia screening and treatment is warranted in patients suspected of having an STD.

Erythroid progenitor (BFU-E, CFU-E) proliferation as inferred from 5'bromodeoxyuridine labeling

Survival patterns of burst-forming unit-erythroid (BFU-E) and cluster-forming unit-erythroid (CFU-E) were studied in B6D2F1 mice after 5'bromodeoxycytidine (BrdCyd) infusion and near-ultraviolet (near-UV) light treatment. Comparison of the kinetics of BrdCyd sensitization of these colony formers with the kinetics of granulocyte-monocyte colony-forming cells (GM-CFC) and colony-forming unit-spleen (CFU-S) demonstrated a similar, but distinguishable, pattern of labeling between BFU-E and CFU-S. BFU-E and CFU-S each contain a subpopulation of unlabeled cells that diminishes with a half-life of 35 to 40 hours. Subsequent comparisons of this close association of BFU-E and CFU-S in Sl/Sld mice, again, showed similar patterns of BrdCyd labeling without evidence of an unlabeled or G0 subpopulation. These results are discussed with respect to the likelihood of a precursor relationship between these two cell types.

Life in the universe

We comprehend the universe and our place in it. But there are limits to what we can explain at present. Will research at the boundaries of science reveal a special role for intelligent life?

Facial nerve function following temporomandibular joint surgery using the preauricular approach

Sixty-eight patients (83 temporomandibular joints) consecutively operated on who had a variety of temporomandibular joint operations using a preauricular approach were assessed for facial nerve function following surgery. Nine patients (10.84%) showed signs of facial nerve injury in which the temporal and zygomatic branches were involved. The incidence of facial nerve injury was greater in patients who had undergone previous temporomandibular joint surgery (17.64%) than in patients with previously unoperated joints (9%). Normal facial nerve function returned in 9 to 14 weeks except in one patient who showed a mild deficit of the zygomatic branch at 20 weeks. The nature and duration of the surgical procedure did not correlate with facial nerve injury. Scarring of tissues as a result of previous temporomandibular joint surgery may significantly increase the risk of facial nerve injury during subsequent temporomandibular joint surgery.

The paradental cyst of the mandibular permanent first molar: report of a bilateral case

A case of bilateral paradental cysts affecting the first permanent molars is described. Radiographic characteristics and differential interpretations of the lesion are discussed.

Pathophysiologic considerations in carotid artery imaging: current status and physiologic background

Carotid endarterectomy now has an established place in the management of selected patients with carotid artery disease. This success rests in part on the invasive and non-invasive techniques available for imaging of both the pre- and postsurgical carotid artery. While contrast angiography has retained its place as a key presurgical imaging procedure, newer methods, including Doppler ultrasound, MRI angiography, SPECT, and PET scanning are providing additional anatomic, physiologic, functional, and biochemical information. An understanding of the complementary roles of these procedures is helpful to providers working to prevent strokes of carotid origin.

Disseminated histoplasmosis with embolic endovascular complications: a case report

A 57-year-old man had subacute embolic ischemia of his right foot and subsequent acute embolic ischemia of his left foot after angiography. Thrombus removed at the time of the left femoral thromboembolectomy grew Histoplasma capsulatum confirming the diagnosis of disseminated histoplasmosis. Surgical revascularization of the right leg and parenteral amphotericin B was followed by chronic ketoconazole therapy for 16 months. The patient has remained asymptomatic at 30 months after operation. Effective treatment of endovascular infection with ischemic complications of Histoplasmosis requires surgical revascularization and intensive chemotherapeutic intervention. Histoplasmosis is a ubiquitous infection in endemic areas that often has an asymptomatic subclinical course. Involvement of the cardiovascular system is rarely reported. Previous case reports have described infected cardiac valves and aortic aneurysms. This report describes the uncommon presentation of disseminated Histoplasma capsulatum infection as a peripheral embolic event and the successful management with revascularization combined with systemic amphotericin B followed by ketoconazole therapy.

Effects of microamperage, medium, and bacterial concentration on iontophoretic killing of bacteria in fluid

Prevention of nosocomial urinary tract infections by iontophoresis is addressed. An iontophoretic generator was used to provide microamperage (10 to 400 microA) to vials containing either synthetic urine or supplemented synthetic urine. Bacteria were added to vials, and parameters of growth, bacterial killing, and multiple electrode materials were examined. Escherichia coli and Proteus species were both inhibited and killed at various microamperages and with several electrode types, the most efficient being gold-gold as the anode-cathode combination. Klebsiella pneumoniae in supplemented synthetic urine was least inhibited in growth, and higher microamperage (200 to 400 microA) was most effective in killing the bacteria. Bacterial growth reduction and killing were directly related to increasing microamperage and were inversely related to bacterial concentration.

An assessment for auriculotemporal syndrome following temporomandibular joint surgery through the preauricular approach

Twenty temporomandibular joints (TMJs) were operated on for the correction of arthrographically confirmed internal derangements using a modified preauricular approach. Postoperatively, three of the 20 patients tested exhibited auriculotemporal syndrome as deduced from a starch-iodine test. The manifestation was subclinical and consisted of sweating only over the distribution of the auriculotemporal and great auricular nerves in response to a gustatory stimulus. The response was variable from patient to patient.