Management of uraemic pericarditis.

Of 250 patients undergoing haemodialysis from 1967 to 1974 17 presented with uraemic pericarditis. Seven of these patients who had been transferred early enough to peritoneal dialysis treatment were cured without pericardiectomy (mean survival 18 months (range 6-36); no deaths). Only one patient was cured from his pericarditis by "aggressive haemodialysis." In seven out of 10 patients treated with haemodialysis, pericardiectomy finally had to be performed because of pericardial tamponade (postoperative survival 20 months (range 8-36); one death). Two patients died from pericardial tamponade before surgery. In patients with evidence of uraemic pericarditis frequent peritoneal dialysis with high fluid withdrawal is the treatment of choice, but in cardiac tamponade pericardiectomy should follow a preoperative pericardiocentesis with limited fluid aspiration. Of possible significance in the aetiology of pericarditis were the findings that 10 of the 17 patients had hypertension with cardiac enlargement and that 14 presented with evidence of underdialysis, possibly due to the reuse of dialysis components.     

"Floating arm" injury in a child with fractures of the proximal and distal parts of the humerus: a case report

Introduction

Primary malignant pericardial mesothelioma is a very rare pericardial tumor of unknown etiology.

Case presentation

A 61-year-old Caucasian woman was admitted to our hospital complaining of exertional dyspnea due to a large pericardial effusion. Intrapericardial fluid volume declined after repeated pericardiocentesis, but the patient progressively developed a hemodynamically relevant pericardial constriction. Pericardiectomy revealed a pericardial mesothelioma. Subsequently, four cycles of chemotherapy (dosage according to recently published trials) were administered. The patient remained asymptomatic, and there was no recurrence of the tumor after three years.

Conclusion

Pericardial mesothelioma should be considered and managed appropriately in non-responders to pericardiocentesis, and in patients who develop constrictive pericarditis late in their clinical course.     

Occurrence of lymphomas and lupus erythematosus-like syndrome in the course of experimental Candida albicans infection in mice

Occurrence of four lymphomas was seen following injection of 1.4×10³ Candida albicans cells to the spleen of eighty non - inbred albine mice. These neoplastic changes occurred in three to seven months of the duration of the experiment. Extensive invasion of the subcutaneous tissue by the tumor was found in one animal. Two of the animals with lymphoma also had changes in the kidneys compatible with lupus erythematosus and presence of LE cells in the blood. In other animals most frequent and extensive pathological changes were found in the kidneys and in order of frequency were as follows: thickening of the basement membrane, fibrinoid degeneration, presence of hematoxylin bodies, wireloop formation. In total, the presence of positive LE cells in blood was found in seven instances and suggestive LE cells was observed in eight animals. Finding of perisplenitis, exudative pleuritis and pericarditis gave additional support to the resemblance of observed pathological changes with human lupus erythematosus. The fact that occurrence of lymphomas and lupus erythematosus together has been reported in humans provides additional interest to the results reported.Results presented here and previously suggest that there may be more extensive interrelationship among variety of pathological changes observed than is accepted until now. Better understanding of host — parasite relationship ofCandida albicans, and possible other fungi, could advance out knowledge of pathogenesis of these diseases.This work was supported partially byDora Kaplan, Joan Sloan, Memorial Funds and the Roon Foundation.     

Cytological Aspects of Pleural, Peritoneal and Pericardial Fluids From Patients With Systemic Lupus Erythematosus

Serous effusions of nine of 33 patients with systemic lupus erythematosus contained lupus erythematosus (LE) cells, identifiable in Papanicolaou-stained smears, wet films stained with toluidine blue, and cell blocks stained with haematoxylin and eosin. Specimens in which LE cells were found contained at least a moderate number of polymorphonuclear neutrophilic leucocytes. Most specimens containing LE cells also contained cells that resembled LE cells (tart cells), which appeared to be small macrophages that had phagocytosed a non-homogenized nucleus of a cell that had undergone degeneration. In 34 years of cytologic practice we have recognized LE cells in serous effusions only from patients who were already diagnosed as having systemic lupus erythematosus.     

Pericarditis with Cardiac Tamponade and Addisonian Crisis as the Presenting Features of Autoimmune Polyglandular Syndrome type II: a Case Series

ObjectiveTo present 3 cases of cardiac tamponade and addisonian crisis as the presenting features of autoimmune polyglandular syndrome (APS) type II.MethodsWe present the clinical features, physical examination findings, radiographic findings, and laboratory investigations in 3 patients and provide an overview of the published cases of pericarditis and APS type II found in a MEDLINE search.ResultsPatient 1, a 34-year-old woman, and Patient 3, a 35-year-old woman, had known autoimmune thyroid disease. Patient 2 was a 58-year-old man with no known history of autoimmune disease. All presented with a history of long-standing lethargy, nausea, weight loss, dyspnea, chest pain, and striking hyperpigmentation. Physical examination, laboratory, and radiographic findings were consistent with cardiac tamponade and addisonian crisis. In all 3 patients, serum cortisol was either very low or undetectable with a subnormal response to cosyntropin (250 mcg) stimulation. Cells in the pericardial fluid were predominantly neutrophils, and findings from cytology, microbiology, and serology investigations were normal. Symptoms and pericardial fluid resolved during treatment with high-dose glucocorticoids and various anti-inflammatory agents. Over the follow-up period of at least 2 years, all 3 patients experienced recurrent pericarditis and/or pleuritis despite replacement doses of glucocorticoids, which resolved with high-dose anti-inflammatory therapy.ConclusionsPericarditis is a rare, but life-threatening manifestation of APS type II that is currently not considered to be a key manifestation of the syndrome. Our experience suggests that APS should be considered in the differential diagnosis for patients presenting with unexplained pericarditis. In patients with established APS, one should be vigilant for the development of recurrent pericarditis. (Endocr Pract. 2008;14:474-478)     

INITIAL CARE OF ACUTE BACK INJURIES

The mechanism of injury to the back should be obtained with the utmost accuracy and set down in the history as a separate paragraph under that heading. This is usually best obtained by questioning and requestioning the patient during the course of the examination. A history of any previous back affections should also be obtained at the first visit.The detailed examination of the back is not complete without a general physical examination.X-ray studies should be done immediately in all cases in which the injury has been caused by direct violence or forceful indirect violence (as in “jackknife” injury).Terms such as “disc disease,” “ruptured intervertebral disc” and various others that convey a similar meaning should not be used as the initial diagnosis and should be withheld until such a diagnosis is definitely established.The plan of treatment may include a period in hospital or of rest at home, or it may be carried out with the patient ambulatory. Corsets and braces should be prescribed only when they are to serve a definite function and the same can be said of physiotherapy.     

Influence of involvement of anterior leaflet versus posterior leaflet on residual regurgitation as assessed by transesophageal echocardiography in patients undergoing valve repair for mitral regurgitation due to mitral valve prolapse

Cardiac tamponade is the phenomenon of hemodynamic compromise caused by a pericardial effusion. Following a myocardial infarction, the most common causes of pericardial fluid include early pericarditis, Dressler's syndrome, and hemopericardium secondary to a free wall rupture. On transthoracic echocardiography, pericardial fluid appears as an echo-free space in between the visceral and parietal layers of the pericardium. Pericardial fat has a similar appearance on echocardiography and it may be difficult to discern the two entities. We present a case of a post-MI patient demonstrating pseudo tamponade physiology in the setting of excessive pericardial fat.     

Physical Properties of Lipid Monolayers on Alkylated Planar Glass Surfaces

A method for transferring a lipid monolayer from an air-water interface to an alkylated glass slide is described. Specific antibodies bind tightly to lipid haptens contained in these monolayers on the glass slides. We conclude that the polar head groups of the lipids face the aqueous phase. A monolayer containing a fluorescent lipid was used to show that the monolayer is homogeneous as observed with an epifluorescence microscope. A periodic pattern photobleaching technique was used to measure the lateral diffusion of this fluorescent lipid probe in monolayers composed of dipalmitoyl phosphatidylcholine and dimyristoyl phosphatidylcholine. Different regions of the pressure-area isotherms of the monolayers at the air-water interface can be correlated with the diffusion of the fluorescent probe molecules on the monolayer-coated glass slide. Monolayers derived from the so-called “solid-condensed” state of a monolayer at the air-water interface showed a very low probe diffusion coefficient in this monolayer when placed on a glass slide, D ≤ 10^-10 cm²/s. Monolayers derived from the “liquid condensed/liquid expanded” (LC/LE) region of the monolayer isotherms at the air-water interface showed rapid diffusion (D > 10^-8 cm²/s) when these same monolayers were observed on an alkylated glass slide. The monolayers attached to the glass slide appear to be homogeneous when derived from monolayers in the LC/LE region of monolayers at the air-water interface. There is no major variation of the diffusion coefficient of a fluorescent lipid probe when this diffusion is measured on a lipid monolayer on a glass slide, for monolayers derived from various regions of the LC/LE monolayers at the air-water interface. This is consistent with the view that the LC/LE region is most likely a single fluid phase. Monolayers supported on a planar glass substrate are of much potential interest for biophysical and biochemical studies of the interactions between model membranes and cellular membranes, and for physical chemical studies relating the properties of lipid monolayers to the properties of lipid bilayers.     

Functions of the LE sensory neurons inAplysia

Mechanosensory neurons which innervate the siphon and have their cell bodies in the LE cluster of the abdominal ganglion ofAplysia have revealed many cellular and molecular processes that may play general roles in learning and memory. It was initially suggested that these cells are largely responsible for triggering the gill-withdrawal reflex evoked by weak siphon stimulation, and that most of this effect is mediated by their monosynaptic connections to gill motor neurons. This implied a simple link between plasticity at these synapses and modifications of the reflex during learning. We review more recent studies from several laboratories showing that the LE cells are not activated by very weak tactile stimuli that elicit the gill-withdrawal reflex, and that an unidentified population of siphon sensory neurons has lower mechanosensory thresholds and produces shorter latency responses. Furthermore, the direct connections between LE cells and gill motor neurons make a minor contribution when the reflex is elicited in pinned siphon preparations by light stimuli that weakly activate the LE cells. Because weak mechanical stimulation of the unrestrained siphon causes little or no LE cell activation, it is unlikely that, under natural conditions, sensitization or conditioning of reflex responses elicited by light siphon touch depends upon plasticity of LE cell synapses onto either motor or interneurons. The LE cells appear to function as nociceptors because they are tuned to noxious stimuli and, like mammalian nociceptors, show peripheral sensitization following nociceptive activation. This sensitization and the profound activity-dependent potentiation of LE synapses indicate that LE cell contributions to defensive reflexes should be largest during and after intense activation of the LE cells by noxious stimulation (with the LE cell plasticity contributing to long-lasting memory of peripheral injury). The LE sensory neurons offer special opportunities for direct tests of this and other hypotheses about specific mnemonic functions of fundamental mechanisms of neural plasticity.     

Cholesterol-binding molecules MLN64 and ORP1L mark distinct late endosomes with transporters ABCA3 and NPC1

Cholesterol is an essential lipid in eukaryotic cells and is present in membranes of all intracellular compartments. A major source for cellular cholesterol is internalized lipoprotein particles that are transported toward acidic late endosomes (LE) and lysosomes. Here the lipoprotein particles are hydrolyzed, and free cholesterol is redistributed to other organelles. The LE can contain over half of the cellular cholesterol and, as a major sorting station, can contain many cholesterol-binding proteins from the ABCA, STARD, and ORP families. Here, we show that metastatic lymph node 64 (MLN64, STARD3) and oxysterol-binding protein-related protein 1L (ORP1L) define two subpopulations of LE. MLN64 is present on a LE containing the cholesterol transporter ABCA3, whereas ORP1L localizes to another population of LE containing Niemann Pick type C1 (NPC1), a cholesterol exporter. Endocytosed cargo passes through MLN64/ABCA3-positive compartments before it reaches ORP1L/NPC1-positive LE. The MLN64/ABCA3 compartments cycle between LE and plasma membrane and frequently contact “later” ORP1L/NPC1-containing LE. We propose two stages of cholesterol handling in late endosomal compartments: first, cholesterol enters MLN64/ABCA3-positive compartments from where it can be recycled to the plasma membrane, and later, cholesterol enters ORP1L/NPC1 endosomes that mediate cholesterol export to the endoplasmic reticulum.     

Ocular Complications of Chloroquine Therapy

Ocular complications of long-term chloroquine therapy were observed in 18 of 45 patients so treated. This therapy was used in patients with rheumatoid arthritis, lupus erythematosus, sarcoidosis, discoid lupus and other chronic “collagen disease”. Thirteen patients had reversible corneal opacifications, and seven had irreversible retinal changes, with visual loss and visual field defects. Pathological evidence of chloroquine retinopathy was obtained in one patient. Physicians are therefore warned to use this drug only after careful consideration. If it is used, repeated ocular examinations should include assessment of visual acuity, visual fields on a tangent screen and fundus examination through a dilated pupil.     

The Fluorescent Antibody Method in the Study of Immunopathologic Conditions

Histochemical studies of immunopathologic conditions were carried out, using Coons'' fluorescent antibody technique. Experimental conditions studied were: serum sickness, generalized anaphylaxis, the Arthus reaction and experimental glomerulonephritis. Human diseases studied were those referred to as “collagen diseases”. Specific immunologic reactants were localized in the lesions of all experimental conditions studied, thus offering objective evidence of a possible immunologic pathogenesis of the lesions. In human diseases, gamma globulin was localized in the lesions of rheumatic fever, rheumatoid arthritis, systemic lupus erythematosus and amyloidosis. Although the finding of gamma globulin in human lesions might suggest that it is an antibody, such an interpretation should be made with care since the gamma globulin could be deposited on a non-immunologic basis.The tissue-localizing properties of sera from different disease states showed appreciable variability within a given disease, as well as similar localizing properties among sera of different diseases. It is suggested that these serum factors (“autoantibodies”) might result as a host response and are not primarily involved in the pathogenesis of the disease.     

“Capillary Permeability” in Patients with Collagen Vascular Diseases

“Capillary permeability” to serum albumin has been measured in patients with collagen vascular diseases by a method which compares the dilution of intravenously injected ¹³¹I-human serum albumin and ⁵¹Cr-R.B.C.s. The results indicate an increased capillary permeability comparable to that which occurs in patients with extensive inflammatory skin disease. We suggest that this increased capillary permeability may be the cause of the episodes of oedema which occur in patients with collagen vascular diseases such as disseminated lupus erythematosus, systemic sclerosis, dermatomyositis, polyarteritis nodosa, and rheumatoid arthritis. “Spontaneous periodic oedema” may be the presenting feature of collagen vascular disease and is due to increased capillary permeability.     

MANDIBULAR HERPES ZOSTER—With Report on the Use of Cortisone in a Case with Geniculate Ganglion Symptoms

Herpes zoster, an acute specific viral infection, occurs more commonly than is generally supposed. It should be differentiated from other diseases involving the ear and skin; it must be considered as a possible etiologic agent in some palsies of the facial, glossopharyngeal or vagal nerves.The type of cephalic herpes zoster should be carefully differentiated; cases involving the “geniculate zone” may be other than “Ramsay Hunt''s syndrome.” This syndrome is now defined as a herpes zoster eruption of the external ear at the “geniculate zone” with involvement of the seventh or seventh and eighth nerves.The “topognostic” method is the best for determining the level at which the facial nerve has been affected.It is questioned whether there is a single outstanding therapeutic agent for this disease. Cortisone had no apparent therapeutic effect in a case reported herein.     

When Does Reward Maximization Lead to Matching Law?

What kind of strategies subjects follow in various behavioral circumstances has been a central issue in decision making. In particular, which behavioral strategy, maximizing or matching, is more fundamental to animal''s decision behavior has been a matter of debate. Here, we prove that any algorithm to achieve the stationary condition for maximizing the average reward should lead to matching when it ignores the dependence of the expected outcome on subject''s past choices. We may term this strategy of partial reward maximization “matching strategy”. Then, this strategy is applied to the case where the subject''s decision system updates the information for making a decision. Such information includes subject''s past actions or sensory stimuli, and the internal storage of this information is often called “state variables”. We demonstrate that the matching strategy provides an easy way to maximize reward when combined with the exploration of the state variables that correctly represent the crucial information for reward maximization. Our results reveal for the first time how a strategy to achieve matching behavior is beneficial to reward maximization, achieving a novel insight into the relationship between maximizing and matching.     

CYTOLOGIC DETECTION OF CERVICAL CANCER—Four Years' Experience with Routine Smear Examination in Private Practice

Simplified Papanicolaou smear techniques appear to be adaptable to private clinical practice when experienced cytodetection laboratory facilities are available. A private physician''s office seems potentially an efficient, economical and practical place for detection of cervical cancer by use of the smear technique as a routine part of examination of patients.In a series here reported upon, examination of 11,207 cervical smears taken at the first examination of patients of all ages led to diagnosis of unsuspected malignant disease in 80 cases—in all instances at a stage when it should be easily curable. Cancer was not detected in examination of 6,060 smears taken later from women who had had a “negative” smear at the time of first examination, which seems to indicate that the first screening was reasonably accurate.In a few cases, early cancer was detected when smears were reported as “atypical” or “suspicious.” Such reports demand as careful follow-up as do “positive” reports.There are dangers and limitations in wide-spread clinical application of screening by this method. Care must be observed in the development of programs for its use lest the potential benefits in early detection be outweighed by the dangers from misuse.     

Kidney disease in lupus is not always 'lupus nephritis'

In lupus erythematosus, elevated serum creatinine levels and urinary abnormalities implicate a kidney disorder, which may not always be lupus nephritis as defined by the current classification of the International Society of Nephrology/Renal Pathology Society. The signs of renal dysfunction may be caused by lupusunrelated renal injury such as drug toxicity or infection or by lupus-associated mechanisms that are not part of the classification, such as minimal change nephrotic syndrome or thrombotic microangiopathy. The latter seems to complicate lupus nephritis more frequently than previously thought. An unbiased assessment of kidney disease in lupus requires a kidney (re-)biopsy to define the appropriate management.In the previous issue of Arthritis Research & Therapy, Song and colleagues [1] discussed specific kidney abnormalities in patients with lupus erythematosus (LE). LE can manifest as cutaneous LE or as a systemic disorder (systemic lupus erythematosus, or SLE) [2]. In patients with LE, renal abnormalities, such as elevated serum creatinine levels or urinary abnormalities, require further diagnostic work-up because they may indicate renal involvement in SLE or an unrelated form of renal disease [3]. Furthermore, renal symptoms may indicate flares of disease activity in patients with established lupus nephritis but may also reflect renal injury due to concomitant toxicity or infectious disease. How should lupus nephritis be defined? The current classification of the International Society of Nephrology/Renal Pathology Society (ISN/RPS) is based on the phenotype of immune complex glomerulonephritis that depends on the predominant site of immune complex deposition within the glomerulus and on different stages of acute (and potentially reversible) injury and chronic (and potentially irreversible) scarring [4]. The article on ISN/RPS classification of lupus nephritis [4] emphasizes the importance of including all other forms of kidney injury, separate from immune complex-mediated glomerulonephritis, in the diagnostic evaluation of the renal biopsy in SLE, including thrombotic microangiopathy (TMA). The article advocates that ''the extent, severity, and type of tubulointerstitial injury (tubular atrophy, interstitial fibrosis, and chronic lesions) and vascular disease (vascular deposits, thrombi, vasculitis, sclerosis) should also be documented and graded (mild, moderate, severe) in the diagnostic line'' [4].Song and colleagues [1] presented a detailed histopathological analysis of a series of 148 patients with biopsy-proven lupus nephritis, focusing on the prevalence of TMA. The authors defined TMA by light microscopy as interlobular artery, arteriole, and glomerular capillary lesions, including endothelial swelling, lumen narrowing or obliteration, and thrombi formation. Electron microscopic TMA criteria are swelling of glomerular endothelial cells, detachment from glomerular basement membrane, and widening of the subendothelial space. Fibrin staining identifies acute microthrombi, whereas mucoid changes and onionskin lesions of arterioles were considered chronic. The authors found such TMA lesions in 36 out of the 148 patients with lupus nephritis [1]. In some of these cases, TMA was a manifestation of associated systemic autoimmune states such as the anti-phospholipid antibody syndrome, scleroderma, or thrombotic thrombocytopenic purpura, which have specific diagnostic criteria and are not included as a specific category in the current ISN/RPS classification of lupus nephritis [4].In the majority of cases, TMA was associated with immune complex-mediated forms of lupus nephritis. According to the authors, such cases can be missed easily unless fibrin immunostaining is performed. TMA results from severe injury to the vascular endothelium, which Song and colleagues [1] found to be associated with poorer renal outcomes as compared with patients with non-TMA lupus nephritis. As such, reporting TMA in the renal biopsy and defining the ISN/RPS class are important, even though the management implications remain unclear unless a causative disorder such as the anti-phospholipid antibody syndrome (anticoagulation), overlap syndrome with scleroderma (angiotensin inhibition), or thrombotic thrombocytopenic purpura (plasma exchange) can be identified.The report by Song and colleagues reminds us that, in LE, elevated serum creatinine levels or urinary abnormalities (or both) may not always represent immune complex glomerulonephritis (that is, ''lupus nephritis''). In addition, patients with SLE can develop other kidney disorders that may be related or unrelated to SLE and SLE management (Table ​(Table1)1) [3].

Table 1

Types of kidney disease in patients with systemic lupus erythematosus