Juvenile generalized pustular psoriasis is a chronic recalcitrant disease: an analysis of 27 patients seen in a tertiary hospital in Johor, Malaysia

BACKGROUND

Limited information exists regarding juvenile generalized pustular psoriasis (GPP). We aim to determine the clinical profile and outcome of Malaysians with juvenile GPP.

METHODS

Review of hospital case notes on patients with juvenile GPP.

RESULTS

Twenty-seven patients with juvenile GPP were identified. Female to male ratio was 1.4:1. The median age at onset of GPP was 6.5 years. Ten patients had prior psoriasis with a median pre-pustular duration of 2.7 years. Onset of GPP was earlier in patients without prior psoriasis (5.1 years vs. 12.0 years, P = 0.002). Precipitating factors identified included stress, upper respiratory tract infection, systemic steroid use, vaccination, and pregnancy. A positive family history of psoriasis and GPP was present in six and one patient(s), respectively. Twenty-one patients had acute, five annular, and one localized variant of GPP. Arthritis was present in 22.2%. Fever, leukocytosis, and transaminitis were mainly seen in patients with acute GPP at 80.9, 72.2, and 11.1%, respectively. Among 20 patients screened, eight carry IL36RN variants and one has CARD14 mutation. IL36RN-positive patients have more severe disease characterized by early onset, low prevalence of prior plaque psoriasis, high prevalence of systemic inflammation, and need for continuous long-term systemic therapy. Acitretin and cyclosporine were effective in aborting acute GPP in 100% of 16 and 66.7% of six patients treated, respectively. However, relapses were common. Only three of the 17 patients whose initial acute GPP was controlled with systemic agents were successfully weaned off treatment.

CONCLUSIONS

Juvenile GPP is a chronic recalcitrant disease. IL36RN-positive patients have more severe disease.

Evaluation of two automatic sphygmomanometers in Hong Kong: implications for the future development of automated blood pressure monitors in clinical practice

The application of automated devices in measuring patients' blood pressure has been widely adopted in nursing practice. This study compared blood pressure recordings of two automated blood pressure monitors which were commonly used in clinical settings in Hong Kong. Single-arm recordings were obtained from 31 subjects with both devices. Ten blood pressure recordings were obtained for each subject, with half of the subjects taking five measurements from one device first and five measurements from the other device second, and vice versa. A total of 155 sets of measurements were available for analysis. The results indicated that there was no significant difference in the variation of systolic, diastolic, mean arterial pressure and heart rate between these two devices. Implications for future research and development of an improved automated blood pressure device are made.

Psychological ill-health in Chinese communities in Hong Kong

Psychiatric symptoms are widely distributed in the general population while psychiatric impairment or psychological ill-health is prevalent in many communities, especially those with stressful environments. Data concerning Chinese communities are scanty. The present study employed the use of a General Health Questionnaire to screen the general population for psychological ill-health in Hong Kong and the results showed that between 18.3% and 26.3% of Chinese could be considered as probable or potential candidates for mental illness. The authors discuss the significance of these findings.

Isolation of digoxin-like immunoreactive factors from mammalian adrenal cortex

Endogenous digoxin-like immunoreactive factors (DLIF) are present in serum and tissues of humans and animals. To date, a tissue source for these factors has not been rigorously defined nor have these factors been isolated to identifiable homogeneity. In this study, we define the distribution of DLIF in mammalian tissues, demonstrate the adrenal cortex to be the principal source of this factor in bovine, and isolate DLIF to chromatographic homogeneity using high performance liquid chromatography (HPLC). DLIF concentrations in tissue extracts from rats measured as follows: adrenal glands, 44.3; serum, 6.3; liver, 5.2; kidney, 1.2; heart, brain, or lungs, less than 1.4 ng of digoxin-equivalent per g of protein. Human tissues showed similar results. In dogs, the ratio of the DLIF concentration in lumbar vein serum to that in infrarenal inferior vena cava serum was 3.3 +/- 0.4 (mean +/- S.E., n = 4). Bovine adrenal cortex contained 7 times more DLIF per g of tissue than the adrenal medulla. 70 +/- 4% (n = 7) of the total bovine cortical DLIF activity (6,159 pg of digoxin-equivalent) applied to a reverse phase HPLC column eluted as one definitive fraction. 60% of the digoxin-like immunoreactivity extracted from bovine serum also co-eluted with DLIF from adrenal. None of the 14 steroid molecules or 7 cardiac glycoside congeners co-eluted with the major DLIF activity. Our data indicate that 947 pmol of DLIF is equivalent to 1 pmol of digoxin-equivalent immunoreactivity. Preliminary mass spectral analysis suggests that purified DLIF has a molecular mass of 780 daltons comprised of one 390-dalton aglycone component plus several sugar moieties. This study establishes a definitive link between DLIF in serum and the adrenal cortex as a source tissue. We also demonstrate a method for purifying DLIF to chromatographic homogeneity with an extraction capacity of 1.2 nmol of DLIF per g of adrenal cortex.

Reassurance does not always help

Reassurance is the most commonly misused form of supportive intervention in medical practice. It is superficial in activity and transient in its effects. It does not appear to be a very powerful therapeutic technique. To be effective, it should be realistic, sincere, given at the right time, directed at the appropriate target, based on sound grounds, and provided by a proper authority. It must always be given judiciously.

Pyroglutamic acidemia in an adult patient

Pyroglutamic acidemia, a rare metabolic disorder, usually appears in infancy. It is characterized by retardation, ataxia, hemolytic anemia, and chronic acidosis and is caused by a marked deficiency of glutathione synthetase (EC 6.3.2.3) activity. This disease is inherited as an autosomal recessive trait, but the clinical condition is also detected in heterozygotes. We report an unusual case of high-anion-gap metabolic acidosis in a 52-year-old woman who was admitted with neurological complaints and breathing problems but without the characteristic clinical features of congenital glutathione synthetase deficiency. The etiology of the acidosis could not be attributed to ketoacidosis, lactic acidosis, or ingestion of methanol, salicylate, or ethylene glycol. Analysis of the patient's plasma and urine for organic acids revealed the presence of high concentrations of pyroglutamate (5-oxoproline), which remained high throughout her hospitalization.

Pyroglutamic acidemia in an adult patient

Pyroglutamic acidemia, a rare metabolic disorder, usually appears in infancy. It is characterized by retardation, ataxia, hemolytic anemia, and chronic acidosis and is caused by a marked deficiency of glutathione synthetase (EC 6.3.2.3) activity. This disease is inherited as an autosomal recessive trait, but the clinical condition is also detected in heterozygotes. We report an unusual case of high-anion-gap metabolic acidosis in a 52-year-old woman who was admitted with neurological complaints and breathing problems but without the characteristic clinical features of congenital glutathione synthetase deficiency. The etiology of the acidosis could not be attributed to ketoacidosis, lactic acidosis, or ingestion of methanol, salicylate, or ethylene glycol. Analysis of the patient's plasma and urine for organic acids revealed the presence of high concentrations of pyroglutamate (5-oxoproline), which remained high throughout her hospitalization.

Criteria for identifying endogenous compounds as digoxin-like immunoreactive factors in humans

Endogenous digoxin-like immunoreactive factors (DLIF) are factors in plasma that interact with anti-digoxin antibodies. In this report we propose specific empirical criteria that must be satisfied by any group of endogenous compounds purported to account for DLIF activity in human plasma. These criteria include immunoreactive potency relative to existing physiologic concentrations as well as the biochemical and protein binding properties of these compounds. Recent studies have identified several congeners of fatty acids and phospholipids, hydrocortisone, and dehydroepiandrosterone-sulfate as compounds likely to account for DLIF activity in plasma. Using the above criteria we demonstrate that the highest reported plasma concentrations of these compounds combined account for less than 25% of DLIF reported in healthy adult subjects, less than 11% in newborns, less than 27% in pregnant women, and less than 39% in patients with renal failure. Human serum albumin at a concentration of 40 g/l completely abolished any detectable interaction of these compounds with both anti-digoxin antibodies or canine kidney Na/K-ATPase. The immunoreactive and physical properties of these compounds are also not consistent with those reported for DLIF. We conclude that these compounds do not account for the plasma DLIF concentrations measured in human subjects nor are they likely to play a role as specific endogenous regulators of Na/K-ATPase.

Endogenous digoxin-like immunoreactivity in elderly patients with normal serum creatinine concentrations

The effect of digoxin-like immunoreactive substance (DLIS) on serum digoxin determinations in elderly patients with normal serum creatinine concentrations was studied. Patients in the study group were over 70 years of age; the control population was under 55 years of age. All patients had serum creatinine concentrations of less than or equal to 1.5 mg/dL. Apparent digoxin content of serum samples from patients receiving digoxin and from patients in each age group who were not receiving digoxin was determined in duplicate by each of two radioimmunoassays: RIANEN (New England Nuclear), which detects DLIS, and Immophase (Corning Medical and Scientific), which is far less cross-reactive with DLIS. Results from the patients under 55 years of age were analyzed for inherent bias between the assay methods. In patients over 70 years of age, concentrations of DLIS (differences between serum digoxin concentrations measured by RIANEN and Immophase) were compared with creatinine clearance values. No DLIS was detected in sera of patients who had not received digoxin. For patients who received digoxin, nearly all apparent digoxin concentrations were within the usual therapeutic range. For patients without liver or renal failure who received digoxin, no significant difference in digoxin concentrations was observed between the RIANEN and Immophase assays in either the young (n = 17) or elderly (n = 26) patients. There was no significant increase in the difference between the RIANEN and Immophase results with decreasing creatinine clearance. In the elderly patients with normal serum creatinine concentrations, there was no evidence that measurement of serum digoxin concentration using the RIANEN and Immophase assays was compromised by DLIS.

Endogenous digoxin-like immunoreactivity in blood is increased during prolonged strenuous exercise

Digoxin-like immunoreactive factors (DLIFs) in serum may represent endogenous cardiotropic agents. We determined if blood levels of these endogenous factors changed during prolonged strenuous exercise. Total and loosely protein-bound (LPB) DLIF were measured by radioimmunoassay in the serum of nine healthy subjects during prolonged exercise to exhaustion. Mean total and LPB serum levels of DLIF increased by 72% (580 to 945 pg/mL) and 63% (53 to 91 pg/mL) over baseline values in digoxin equivalents (p less than 0.01), respectively, after three hours of exercise at 70% of VO2max. The prevalent serum nonesterified fatty acids (arachidonic, linoleic, oleic, palmitic, and stearic acids) as well as hydrocortisone did not account for the observed elevations in DLIF. Percent left ventricular fractional shortening (%FS) and mean velocity of left ventricular circumferential fiber shortening (mVCF) measured echocardiographically were lower (-18.0% and -16.4%, respectively, p less than 0.05) after exercise as compared to prior to exercise. Cardiac left ventricular dysfunction as measured by %FS did correlate with blood levels of DLIF (r = -0.680, p less than 0.02). These observations may suggest a relationship between serum levels of DLIF and cardiac fatigue.

The theophylline method of the Abbott "Vision" analyzer evaluated

We evaluated the analytical performance of the Abbott "Vision" analyzer for theophylline measurement. The within-day precision (CV) was 1.8% and 3.1% at theophylline concentrations of 15.2 and 25.2 mg/L, respectively; between-day precision was 3.5% and 4.8% at 14.9 and 24.4 mg/L, respectively. Bilirubin (143 mg/L) and triglyceride (7.4 g/L) did not interfere, but hemoglobin caused lower values for apparent theophylline, the magnitude of the decrease being proportional to the hemoglobin concentration. At the cutoff concentration of 1 g/L programmed into the instrument by the manufacturer, hemoglobin reduced the theophylline value by less than 10%. Results by the Vision method (y) compared well with those by the "TDX" procedure (x): r = 0.98, y = 0.978x - 0.270 mg/L. The Vision method gave comparable theophylline values for serum, plasma, and whole-blood samples. We also validated analytically and clinically that capillary blood samples collected by finger stick can be used interchangeably with blood samples collected by venipuncture for monitoring theophylline therapy.

The theophylline method of the Abbott "Vision" analyzer evaluated

We evaluated the analytical performance of the Abbott "Vision" analyzer for theophylline measurement. The within-day precision (CV) was 1.8% and 3.1% at theophylline concentrations of 15.2 and 25.2 mg/L, respectively; between-day precision was 3.5% and 4.8% at 14.9 and 24.4 mg/L, respectively. Bilirubin (143 mg/L) and triglyceride (7.4 g/L) did not interfere, but hemoglobin caused lower values for apparent theophylline, the magnitude of the decrease being proportional to the hemoglobin concentration. At the cutoff concentration of 1 g/L programmed into the instrument by the manufacturer, hemoglobin reduced the theophylline value by less than 10%. Results by the Vision method (y) compared well with those by the "TDX" procedure (x): r = 0.98, y = 0.978x - 0.270 mg/L. The Vision method gave comparable theophylline values for serum, plasma, and whole-blood samples. We also validated analytically and clinically that capillary blood samples collected by finger stick can be used interchangeably with blood samples collected by venipuncture for monitoring theophylline therapy.

Efflux of adenine nucleotides in mitochondria from rat tumor cells of varying growth rates

The efflux of adenine nucleotides was studied in mitochondria isolated from normal rat liver, host livers, and the tumors from four Morris hepatoma lines of varying growth rates. [3H]Adenosine diphosphate (ADP) or [3H]adenosine triphosphate (ATP) was preloaded to the energized mitochondria, and the initial rates of exchange with unlabeled extramitochondrial nucleotides were measured with the carboxyatractyloside stop method. Results indicate that the Vmax values of ATP efflux in mitochondria from fast and intermediately growing tumors (hepatoma cell lines 7777, 7800, and 5123D) are significantly smaller than that of host or normal liver mitochondria, while in slow growing tumor (line 16) the Vmax is not different. On the other hand, for ADP efflux, the opposite (namely, higher in tumor than in host) is observed in the mitochondria of fast growing tumors. Preincubation with the divalent cation ionophore A23187 and calcium chelator ethyleneglycolbis(beta-aminoethyl ether)-N,N'-tetraacetic acid increases the efflux of both ATP and ADP (to a lesser extent) in these tumor mitochondria, indicating that the extraordinarily high concentrations of calcium form complexes with adenine nucleotides (particularly ATP) and thus lower the effective concentrations of free nucleotides for translocation. Together with previously published results (R. L. Barbour and S. H. P. Chan, Cancer Res., 43: 1511-1517, 1983) on lower nucleotide uptake rates in these tumor mitochondria, we propose that the lower ATP efflux and higher ADP efflux rates may cause a futile cycle of ADP transport across the mitochondrial membrane which may contribute to high rates of aerobic glycolysis (by stimulating key glycolytic enzymes such as hexokinase and phosphofructokinase) observed in these fast and intermediately growing tumors.

Paths to psychiatric care in Hong Kong

The pattern of psychiatric consultation in Hong Kong is examined among 226 patients at a public outpatient clinic and 56 patients at a private psychiatric clinic. The approach to psychiatric services is marked by lengthy delay during which patients get help from their family members or close friends. Arrival at the present psychiatric clinic was diverted through other medical resources, primarily Western-style medical services, and to some extent, traditional Chinese medicine. Individual routes were diverse, characterized by frequent switches among resources especially in the private sector. The nature of the patients' presenting complaints as well as the conceptualization of their initial complaints were multi-faceted, including both psychological and somatic factors. The overall consultation pattern of patients in Hong Kong is compared with other studies on Chinese and Western patients. Questions are raised for further analysis.

Postheparin plasma lipoprotein lipase in copper-deficient rats

Postheparin plasma lipoprotein lipase has been investigated in male sprague-Dawley rats fed a diet deficient in copper. Deficiency was verified by the detection of anemia, hypercholesterolemia and decreased myocardial copper. Three experiments were done; they showed significant decrease in enzyme activity (40-47% reduction) in deficiency. Copper may be required for the formation of the activator complex of the enzyme. Decreased lipoprotein lipase activity may be responsible for the hypertriglyceridemia of copper deficiency, and that may also explain its hypercholesterolemia.

Effects of fluoride on sugar phosphate phosphohydrolase from Escherichia coli and Neisseria meningitidis

The purified sugar phosphate phosphohydrolase from E. coli and N. meningitidis were used for our study and biphasic responses were observed in the presence of fluoride. 2. From the kinetic studies of fluoride inhibition, the enzymes from both bacteria appear to catalyze the hydrolysis of alpha-D-aldohexose 1-phosphate and alpha-D-aldohexose 6-phosphate at two distinct catalytic sites.

Plasma lecithin: cholesterol acyltransferase in copper-deficient rats

Some groups of people with high risk of ischemic heart disease have low lecithin:cholesterol acyltransferase activity in plasma and vice versa. Because we hypothesized a relationship between inadequate copper nutriture and the risk of ischemic heart disease, we measured plasma lecithin: cholesterol acyltransferase in copper deficient male Sprague-Dawley rats. Deficiency was verified by the presence of anemia, hypercholesterolemia and low copper concentrations in kidney and skeletal muscle. Three experiments showed a significant decrease (22-32% reduction) in enzyme activity in deficiency. Copper may be required for the synthesis of the enzyme or as a constituent of the enzyme.

The medical recommendation for psychiatric remands into prison--the Hong Kong scene

A review is presented of all the remand cases who were referred from the courts to the psychiatric staff of the Psychiatric Observation Unit in the Lai Chi Kok Reception Centre, Prisons Department, Hong Kong Government. Altogether 607 defendants were assessed during the 24-month period and reports were furnished which indicated the psychiatric diagnosis, medical recommendation and fitness to plead of each case.

It is noted that over half of the remands were not mentally disordered and a psychiatric diagnosis was possible in less than half of the sample. Most of the cases belonged to the younger age group, namely 19–39, which is compatible with the finding of schizophrenia in the majority of the mentally ill remands. A considerable number of them had a history of previous psychiatric contact. The nature of the offences varied and they involved those against the person, the property and the public order. In comparison, the schizophrenics committing offences against the person of a non-sexual nature formed the largest sub-group. On the whole, the schizophrenics were most frequently remanded for psychiatric examination, most likely to be recommended for a medical disposal and almost certainly allowed to benefit from the treatment proposed. Factors associated with positive or negative as well as accepted or rejected recommendation were discussed. Special consideration was given to some of the problems concerning the treatment orders which are peculiar to Hong Kong.

Somatization among Chinese depressives in general practice

Depressive illness was a common clinical syndrome found in general practice in Hong Kong. The phenomenon of somatization among Chinese depressives in general practice was investigated. Patients clinically identified as depressed were compared with organic patients in terms of their presenting complaints and responses to a symptom checklist. Sleep disturbances, general malaise, pains and aches, dizziness, and menopausal symptoms were the most frequent distrubances that prompted Chinese depressives to seek help in general practice. When directly asked, these patients admitted having various psychological features including dysphoric mood, self-reproach, loss off interest in social activities and in sex. Subgroup comparisons showed little sex difference in initial complaints and admitted symptomatology among the depressives. Some age differences were observed in the presenting complaints. The discrepancy between the pattern of presenting complaints and admitted symptoms suggest that patients were aware of their emotional disturbance even though they tended to express these distrubances in somatic terms in their help-seeking processes. Distinction between the expression mode and the recognition mode of somatization was discussed.