Recipients of hip replacement for arthritis are less likely to be Hispanic, independent of access to health care and socioeconomic status.

OBJECTIVE: To compare the proportion of Hispanics among recipients of hip replacements for primary articular disorders, recipients of knee replacements for the same reason, and persons hospitalized for other reasons. METHODS: Twelve of the 17 accredited hospitals in Bexar County, Texas, in which hip or knee replacement surgery is performed permitted us to review their medical records. From 1993 through 1995, 3,100 elective, non-fracture-related, hip or knee replacements were performed. These individuals were matched by age, sex, hospital, and month of admission with 4,604 persons hospitalized for other reasons. Age, sex, ethnic background, type of medical insurance, median household income by zip code of residence, joint replaced, and surgical diagnosis were abstracted from the medical records. The validity of variables abstracted from the medical records was tested by comparison with self-report data in 115 patients interviewed prior to elective hip or knee replacement surgery. RESULTS: During the study period, 2,275 subjects had a total knee replacement and 825 had a total hip replacement. Recipients of hip replacements were significantly less likely to be Hispanic than were recipients of knee replacements (19.5% versus 29.9%; odds ratio [OR] 0.57, 95% confidence interval [95% CI] 0.46-0.71; P < or = 0.001) or persons hospitalized for other reasons (29.4% Hispanic; OR 0.67, 95% CI 0.55-0.81). The under-representation of Hispanics was more pronounced among persons undergoing hip replacement for osteoarthritis compared with recipients of knee replacements for the same disease (OR 0.48, 95% CI 0.37-0.62). This pattern persisted after adjusting for age, sex, type of medical insurance, and median household income by the zip code of residence. Concordance between medical records and self-report data on ethnic background was high (kappa = 0.93). CONCLUSION: Recipients of hip replacement are less likely to be Hispanic than are other hospitalized persons with a similar level of access to care. The reasons for this under-representation probably involve factors in addition to lack of access to health care and low socioeconomic status. Further research is needed to understand the nature of such factors.

Can immunization precipitate connective tissue disease? Report of five cases of systemic lupus erythematosus and review of the literature.

OBJECTIVES: To report a series of five patients who developed systemic lupus erythematosus (SLE) after immunization and review the literature on vaccine-associated connective tissue diseases and the theoretical mechanisms that could explain such an association. METHODS: Uncontrolled retrospective analysis of cases identified sporadically over 7 years at three centers. RESULTS: In our series of 5 patients, symptoms of SLE developed within 2 to 3 weeks after secondary immunization. All patients met American College of Rheumatology (ACR) criteria for the diagnosis of SLE. In most patients, symptoms have been persistent. CONCLUSION: Although a coincidental association between vaccination and the onset of SLE cannot be excluded, the temporal relationship with the development of symptoms makes it immunologically plausible that vaccination triggered systemic autoimmunity in these rare cases. We propose that epidemiological studies be performed to examine this potential association in more detail to quantitate the risk and identify possible genetic risk factors.

The role of endomyocardial biopsy in the diagnosis and treatment of Churg-Strauss syndrome.

Churg-Strauss syndrome (CSS) is a rare vasculitis characterized by the clinical triad of asthma, peripheral eosinophilia, and systemic vasculitis. Pulmonary symptoms occur commonly, but gastrointestinal, renal, cardiac, and musculoskeletal manifestations may also occur. Disease activity and expression can be variable, and progressive organ failure may occur in the absence of other clinical or biochemical evidence of disease activity. We report the case of a 73-year-old man who presented with signs and symptoms of an acute myocardial infarction, eosinophilia, a pulmonary infiltrate, and recent onset asthma. The cardiac catheterization was normal, but an endomyocardial biopsy specimen revealed eosinophilic myositis, granuloma formation, and small vessel vasculitis. A repeat endomyocardial biopsy 1 month after the initiation of high dose prednisone therapy showed no evidence of inflammation and no significant fibrosis. We suggest that a endomyocardial biopsy is a safe and useful tool in the diagnosis and monitoring of therapy in patients with CSS cardiac disease.

Antigen-specific antibody responses in lupus patients following immunization.

OBJECTIVE: To determine the safety and efficacy of 3 clinically relevant vaccines in patients with systemic lupus erythematosus (SLE). METHODS: We studied 73 consecutive SLE patients immunized with pneumococcal, tetanus toxoid (TT), and Haemophilus influenzae type B (HIB) vaccines. Patients were evaluated preimmunization and 12 weeks postimmunization for disease activity and immunization side effects. RESULTS: Eighty-four percent of the SLE patients developed a 4-fold titer increase in response to at least 1 vaccine, with 51% developing a 2-fold titer increase with all 3 vaccines. The majority of SLE patients developed protective levels of antibody to TT (90%) and HIB (88%). Although protective antibody levels could not be determined for pneumococcus, almost half of the patients (47%) developed a 4-fold antibody response. There was a trend toward a lower antibody response in patients with active disease treated with immunosuppressive therapy. Overall lupus disease activity was unaffected by immunization. CONCLUSION: Immunization is safe in SLE patients, with the overwhelming majority developing protective antibody levels. Therefore, SLE patients should receive immunizations according to the recommendations of the Centers for Disease Control and Prevention and the Immunization Practices Advisory Committee.

Cutaneous ulcers of refractory adult dermatomyositis responsive to intravenous immunoglobulin.

We report the case of a woman from the Bahamas who presented with many of the classic manifestations of dermatomyositis. She responded well to initial therapy, which included oral corticosteroids, low-dosage methotrexate, and hydroxychloroquine. The cutaneous component of her disease flared dramatically months later, and progressed despite aggressive therapy with the higher dosages of the same medications. Therapy with intravenous immunoglobulin (IVIG) was initiated and the patient stopped forming new cutaneous ulcers within 1 to 2 weeks. Theories about the mechanism of action of IVIG, and practical guidelines for its use in treating patients with dermatomyositis, are briefly reviewed.

The effects of delta wave sleep interruption on pain thresholds and fibromyalgia-like symptoms in healthy subjects; correlations with insulin-like growth factor I.

OBJECTIVE: To assess the effects of delta wave sleep interruption (DWSI) on pain thresholds and fibromyalgia-like symptoms. To examine the potential correlations between DWSI and serum insulin-like growth factor 1 (IGF-1). METHODS: Thirteen healthy volunteers were subjected to 3 consecutive nights of DWSI (Group 1). Pain thresholds were measured by dolorimetry and symptoms by visual analog scale. Six subjects not undergoing DWSI served as dolorimetry and symptom controls (Group 2). Serum IGF-1 was measured by competitive binding radioimmunoassay before and after DWSI. RESULTS: No significant differences in pain thresholds as a function of condition (baseline, DWSI, recovery) or overnight change were detected between or within groups (p>0.05). Morning mean dolorimeter scores were lower than evening scores in both groups during all 3 conditions, and were lower in Group 1 than in Group 2 during DWSI. Group 1 subjects had higher composite symptom scores during DWSI (p< or =0.005), attributed largely to increases in fatigue. Serum levels of IGF-1 from Group 1 subjects showed no significant change after DWSI (p>0.05). CONCLUSION: In our study subjects, 3 nights of DWSI caused no significant lowering of pain thresholds compared with a control group. Subjects appeared to have lower pain thresholds in the mornings, and DWSI appeared to augment this effect. Symptoms were more apparent during DWSI, but were primarily related to fatigue. IGF-1 was not altered by 3 nights of DWSI. The low levels of IGF-1 seen in patients with fibromyalgia syndrome may result from chronic rather than acute DWSI, or may be dependent on factors other than disturbances of delta wave sleep.

Rheumatic findings in Gulf War veterans.

BACKGROUND: Rheumatic symptoms were commonly described among soldiers who served in previous wars. OBJECTIVE: To describe the frequency of rheumatology consultations, along with the diagnoses, and abnormal results on serologic testing in Gulf War veterans evaluated for Gulf War syndrome. METHODS: The medical records of the first 250 consecutive Gulf War veterans referred to the comprehensive clinical evaluation program at Wilford Hall Air Force Medical Center and Brooke Army Medical Center, San Antonio, Tex, were reviewed for demographic characteristics and frequency of subspecialty consultations. A retrospective review of rheumatic diagnoses and the frequency of abnormal serologic test results was recorded. RESULTS: Of the 250 Gulf War veterans evaluated in the comprehensive clinical evaluation program, 139 (56%) were referred for rheumatology consultation, which was the most common elective subspecialty referral. Of the patients evaluated, 82 (59%) had soft tissue syndromes, 19 (14%) had rheumatic disease, and 38 (27%) had no rheumatic disease. The most common soft tissue syndromes were patellofemoral syndrome (33 patients [25%]), mechanical low back pain (23 patients [18%]), and fibromyalgia (22 patients [17%]). Of the 19 patients with rheumatic disease, 10 had osteoarthritis, 2 had rheumatoid arthritis, 2 had gout, and 1 each had systemic lupus erythematosus, Behcet disease, parvovirus arthritis, psoriatic arthritis, and hypothyroid arthropathy. Abnormal serologic test results were common among the Gulf War patients regardless of the presence or absence of rheumatic disease. CONCLUSIONS: The rheumatic manifestations in Gulf War veterans are similar to symptoms and diagnoses described in previous wars and are not unique to active duty soldiers. Overall, the results of serologic screening were poor predictors of the presence of rheumatic disease.

Interferon-alpha associated arthritis.

We describe a patient who developed progressive inflammatory polyarthritis after treatment with interferon-alpha (IFN-alpha) for chronic hepatitis C infection. Rechallenge with the drug caused worsening of the arthritis, but withdrawal did not result in remission. Preexisting autoantibodies and HLA-DR4 were detected in this serum and are thought to be relevant in the etiology of IFN-alpha associated autoimmune disease.

Docetaxel (Taxotere) associated scleroderma-like changes of the lower extremities. A report of three cases.

BACKGROUND: Docetaxel (Taxotere) is a microtubule-stabilizing agent that is potentially important in chemotherapy for a variety of malignancies. METHODS: A clinical study of the cutaneous reactions experienced by a group of patients receiving docetaxel chemotherapy was undertaken. Patients were examined before initiation of therapy, before and after each cycle of therapy, and were followed subsequent to the completion of docetaxel chemotherapy. RESULTS: Three patients developed diffuse lower extremity edema (3-18 kg) and subsequent scleroderma-like changes after receiving multiple cycles of docetaxel therapy. These patients had different underlying malignancies and dissimilar prior therapy. Rheumatoid factor, antinuclear antibodies, anticentromere, and topoisomerase antibodies were not present in any patient. The diffuse lower extremity edema did not resolve with diuretic therapy. Cutaneous biopsies in two patients revealed diffuse sclerosis. One patient had a normal lymphangiogram during the edematous phase. Discontinuation of docetaxel correlated with resolution of edema and softening of the skin. CONCLUSION: The etiology of the scleroderma-like skin changes is unclear but appears to be either a toxic effect of docetaxel or an effect of polysorbate 80 (Tween 80), the vehicle for docetaxel.

Case report: cerebral venous thrombosis as a manifestation of acute ulcerative colitis.

Ulcerative colitis is associated with a number of extraintestinal complications, including the infrequent occurrence of thromboembolic disease. Cerebral venous thrombosis is extremely rare, with only 15 cases reported in the literature. The outcome in this group of patients is poor; the result in more than 80% of the cases is permanent neurologic sequelae or death. The precise mechanisms involved in thrombogenesis remain unclear. A hypercoagulable state may occur in ulcerative colitis because of well-documented associations of thrombocytosis, elevated factors V and VIII and fibrinogen, and decreased antithrombin III. Treatment regimens for cerebral venous thrombosis remain controversial and include anticoagulation with heparin, surgical thrombectomy, and systemic and local infusion of fibrinolytic regimens. A conservative approach with antiedemic agents, anticonvulsants, antiplatelet therapy, and acetazolamide also may be beneficial and offers a substantially reduced hemorrhagic potential. A case of primary superior sagittal sinus thrombosis associated with active ulcerative colitis treated by the latter method is reported. The patient's neurologic recovery was complete, with recanalization of the thrombosed venous sinus being demonstrated by magnetic resonance imaging studies.

Dexamethasone inhibits human interleukin 2 but not interleukin 2 receptor gene expression in vitro at the level of nuclear transcription.

Glucocorticosteroids have an inhibitory effect on the expression of interleukin 2 (IL-2) and interleukin 2 receptor (IL-2R) genes. To determine the mechanisms of this inhibition, human T lymphocytes were stimulated with mitogens in the presence of dexamethasone. Nuclear transcription run-off assays showed that high doses of dexamethasone inhibited the transcription of the IL-2 gene but not that of the IL-2R gene. Post-transcriptionally, high doses of dexamethasone (10(-4) M) were required to inhibit IL-2R mRNA levels by 50%, whereas lower doses (10(-6) M) inhibited by greater than 70% the accumulation of IL-2 mRNA. IL-2 mRNA half-life decreased in the presence of dexamethasone (10(-6) M) by approximately 50%. At the protein product level, dexamethasone inhibited both IL-2 production, as well as cell surface and soluble forms of IL-2R. IL-2R gene expression was inhibited for at least 72 h after exposure of cells to dexamethasone. In the presence of exogenous IL-2, dexamethasone failed to exert a significant effect on the production of IL-2R protein. These data indicate that dexamethasone has a greater effect on the expression of the IL-2 gene than on the IL-2R gene. Dexamethasone both inhibits transcription of the IL-2 gene and decreases the stability of IL-2 mRNA. The effect of dexamethasone on the IL-2R gene is post-transcriptional and may result indirectly from decreased IL-2 production.

c-myc proto-oncogene expression in peripheral blood mononuclear cells from patients with primary Sjögren's syndrome.

We examined peripheral blood mononuclear cells (PBMC) from 16 patients with Sjögren's syndrome (SS) and 7 normal control subjects for the expression of the c-myc proto-oncogene. Patients with SS were found to have a significantly increased expression of c-myc messenger RNA compared with normal individuals. No abnormal forms of c-myc RNA were detected in the SS patients. DNA analysis did not show deletion, rearrangement, or amplification in the c-myc proto-oncogene. The methylation status of the c-myc gene in patients with SS was found to be comparable with that of the control subjects. Nuclear run-off assays showed increased transcription of the c-myc gene in some patients but normal transcription in others, suggesting that posttranscriptional mechanisms are also involved in the increased c-myc messenger RNA observed in these patients. Two patients with primary SS and B cell lymphomas were found to have normal c-myc expression in their PBMC. These results demonstrate the presence of activated PBMC in patients with primary SS and delineate some of the mechanisms that are involved at the molecular level. We speculate that increased c-myc expression may represent an early permissive event in the progression toward neoplasia in these patients.