Hallazgos de imagen de las masas cardíacas (parte II): tumores malignos y lesiones pseudotumorales / Imaging findings in cardiac masses (part II): malignant tumors and pseudotumors

Los tumores cardíacos malignos son menos frecuentes que los tumores benignos; pueden ser primarios y secundarios. Los secundarios o metastásicos son entre 20 y 40 veces más frecuentes que los primarios, con una incidencia estimada del 0,05%. Las lesiones pseudotumorales no neoplásicas pueden presentarse como masas cardíacas con características de imagen que pueden plantear el diagnóstico con neoplasias. El objetivo de este trabajo es presentar los tumores cardíacos malignos y las lesiones pseudotumorales haciendo hincapié en los hallazgos en TC y RM y en las características que permiten diferenciarlos de los tumores cardíacos benignos (AU)

Malignant heart tumors are less common than benign ones. They can be primary or secondary. Secondary or metastatic heart tumors are 20 to 40 times more common than primary malignant heart tumors, which have an estimated incidence of 0.05%. Non-neoplastic pseudotumors can present as cardiac masses, with imaging characteristics than can suggest the diagnosis of a tumor. The aim of this article is to describe and illustrate malignant heart tumors and pseudotumors, stressing the CT and MRI findings that make it possible to differentiate them from benign cardiac tumors (AU)

[Imaging findings in cardiac masses. Part II: malignant tumors and pseudotumors]. / Hallazgos de imagen de las masas cardíacas. parte II: tumores malignos y lesiones pseudotumorales.

Malignant heart tumors are less common than benign ones. They can be primary or secondary. Secondary or metastatic heart tumors are 20 to 40 times more common than primary malignant heart tumors, which have an estimated incidence of 0.05%. Non-neoplastic pseudotumors can present as cardiac masses, with imaging characteristics than can suggest the diagnosis of a tumor. The aim of this article is to describe and illustrate malignant heart tumors and pseudotumors, stressing the CT and MRI findings that make it possible to differentiate them from benign cardiac tumors.

Hallazgos de imagen de las masas cardíacas (parte I): protocolo de estudio y tumores benignos / Imaging findings in cardiac masses (Part I ): study protocol and benign tumors

Las masas cardíacas son un reto diagnóstico porque las decisiones terapéuticas se basan en los hallazgos de las técnicas de imagen. La ecocardiografía, la resonancia magnética (RM) y la tomografía computarizada (TC) son fundamentales para la detección, caracterización, estadificación y planificación del tratamiento. La mayoría de los tumores primarios son benignos; los más frecuentes son el mixoma, el fibroelastoma papilar y el lipoma. La localización del tumor y sus características en la TC y la RM orientan el diagnóstico etiológico en la mayor parte de los casos. Se describen los protocolos de estudio de TC y RM de las masas cardíacas, así como los hallazgos morfológicos, las localizaciones preferentes y las características más útiles para caracterizar las masas cardíacas benignas y establecer el diagnóstico diferencial con los tumores cardíacos malignos y las lesiones pseudotumorales no neoplásicas (AU)

Cardiac masses represent a diagnostic challenge because decisions about treatment are based on imaging techniques. Echocardiography, magnetic resonance (MR) and computed tomography (CT) are fundamental for the detection, characterization, and staging of cardiac masses as well as for planning their treatment. Most primary cardiac tumors are benign; myxomas, papillary fibroelastomas, and lipomas are the most common. The location of the tumors and its characteristics on CT and MR orient the etiologic diagnosis in most cases. This article describes the protocols for CT and MR studies of cardiac masses as well as the morphologic findings, predominant locations, and most useful characteristics for characterizing benign cardiac masses and establishing the differential diagnosis with malignant cardiac tumors and non-neoplastic pseudotumors (AU)

Imaging findings in cardiac masses (Part I): study protocol and benign tumors.

Cardiac masses represent a diagnostic challenge because decisions about treatment are based on imaging techniques. Echocardiography, magnetic resonance (MR) and computed tomography (CT) are fundamental for the detection, characterization, and staging of cardiac masses as well as for planning their treatment. Most primary cardiac tumors are benign; myxomas, papillary fibroelastomas, and lipomas are the most common. The location of the tumors and its characteristics on CT and MR orient the etiologic diagnosis in most cases. This article describes the protocols for CT and MR studies of cardiac masses as well as the morphologic findings, predominant locations, and most useful characteristics for characterizing benign cardiac masses and establishing the differential diagnosis with malignant cardiac tumors and non-neoplastic pseudotumors.

Accuracy of Contrast-Enhanced Ultrasound in the Diagnosis of Bile Duct Obstruction.

PURPOSE: To investigate the ability of contrast-enhanced ultrasound (CEUS) to differentiate benign from malignant lesions causing biliary duct obstruction. MATERIALS AND METHODS: Between November 2006 and December 2013, 59 patients with bile duct obstruction of undetermined cause in baseline ultrasound underwent CEUS study. The enhancement and posterior washout were analyzed in real time all along the study duration (5'). The final diagnosis suggested by CEUS was compared with histologic diagnosis (47.5%) or with radiologic follow-up with TC, RM or ERCP. RESULTS: Final diagnoses included 42 malignant lesions (cholangiocarcinoma n=22, metastases n=6, pancreatic carcinoma n=6, hepatocarcinoma n=4, gallbladder carcinoma n=2, ampullary carcinoma n=1 and lymphoma n=1) and 17 benign lesions (lithiasis or biliary sludge n=15, xanthogranulomatous cholecystitis n=1 and indeterminate n=1). CEUS accuracy compared with final diagnoses based on combined reference standard was 86.4%. CEUS correctly identified 36 of 42 malignant lesions (sensibility 85.7%) and 15 of 17 benign lesions (specificity 88.2%). The positive predictive value of CEUS for malignancy was 94.7%, while the negative predictive value was 71.4%. CONCLUSION: CEUS is useful to differentiate between benign and malignant causes of obstructive jaundice. This technique improves the detection of bile duct invasion in hepatic neoplasms and permits better evaluation of intra- and extraductal extension of hilar hepatobiliary tumors.

Effects of alcohol and polyphenols from beer on atherosclerotic biomarkers in high cardiovascular risk men: a randomized feeding trial.

BACKGROUND AND AIMS: Moderate alcohol consumption exerts a cardioprotective effect, but no studies have evaluated the alcohol-independent cardiovascular effects of the non-alcoholic components of beer. We aimed to evaluate the effects of ethanol and the phenolic compounds of beer on classical and novel cardiovascular risk factors. METHODS AND RESULTS: Thirty-three high risk male volunteers were included in a randomized, crossover feeding trial. After a washout period, all subjects received beer (30 g alcohol/d, 660 mL), the equivalent amount of polyphenols as non-alcoholic beer (990 mL), and gin (30 g alcohol/d, 100 mL) for 4 weeks. All outcomes were evaluated before and after each intervention period. Moderate alcohol consumption increased serum HDL-cholesterol (∼5%), ApoA-I (∼6%), ApoA-II (∼7%) and adiponectin (∼7%), and decreased serum fibrinogen (∼8%), and interleukin (IL)-5 (∼14%) concentrations, whereas the non-alcoholic fraction of beer (mainly polyphenols) increased the receptor antagonist of IL-1 (∼24%), and decreased lymphocyte expression of lymphocyte function-associated antigen-1 (∼11%), lymphocyte and monocyte expression of Sialil-Lewis X (∼16%) and monocyte expression of CCR2 (∼31%), and tumor necrosis factor (TNF)-ß (∼14%) and IL-15 (∼22%) plasma concentrations. No changes were observed in glucose metabolism parameters or in body weight and adiposity parameters. CONCLUSION: The phenolic content of beer reduces leukocyte adhesion molecules and inflammatory biomarkers, whereas alcohol mainly improves the lipid profile and reduces some plasma inflammatory biomarkers related to atherosclerosis.

Annular erythema in primary Sjogren's syndrome: description of 43 non-Asian cases.

OBJECTIVE: The objective of this paper is to evaluate the prevalence and characterize the main epidemiological, clinical and immunological features of annular erythema (AE) in non-Asian patients with primary Sjögren's syndrome (SS). METHODS: We carried out a retrospective study searching for AE in 377 Spanish patients with primary SS fulfilling the 2002 American-European criteria. In addition, we searched PubMed (1994-2012) using the MeSH terms "annular erythema" and "primary Sjögren's syndrome" for additional cases. All cases with AE reported in patients with SS associated with systemic lupus erythematosus were excluded. RESULTS: In our Spanish cohort, we found 35 (9%) patients diagnosed with AE. All were white females, with a mean age of 47 years at diagnosis of AE. AE preceded diagnosis of SS in 27 (77%) patients. Cutaneous AE lesions involved principally the face and upper extremities. All patients reported photosensitivity, with cutaneous flares being reported during the warmest months in 93% of patients. Immunological markers consisted of anti-Ro/La antibodies in 31 (89%) patients. In the literature search, we identified eight additional non-Asian patients with primary SS diagnosed with AE. In comparison with 52 Asian patients, the 43 non-Asian patients with AE related to primary SS were more frequently women (100% vs 78%, p=0.008), and cutaneous lesions were less frequently reported in the face (55% vs 81%, p=0.045) and more frequently in the neck (40% vs 14%, p=0.041). Immunologically, non-Asian patients had a lower frequency of anti-Ro antibodies and a higher frequency of negative Ro/La antibodies, although the differences were not statistically significant. CONCLUSION: AE is not an exclusive cutaneous feature of Asian patients with primary SS. In addition to the characteristic cutaneous expression, AE has a very specific clinical and immunological profile: often presenting before the fulfillment of SS criteria, overwhelmingly associated with anti-Ro antibodies but weakly associated with other immunological markers and the main systemic SS-related features.

Comparison of two HIV testing strategies in primary care centres: indicator-condition-guided testing vs. testing of those with non-indicator conditions.

OBJECTIVES: The aim of the study was to compare prospectively indicator-condition (IC)-guided testing versus testing of those with non-indicator conditions (NICs) in four primary care centres (PCCs) in Barcelona, Spain. METHODS: From October 2009 to February 2011, patients aged from 18 to 65 years old who attended a PCC for a new herpes zoster infection, seborrhoeic eczema, mononucleosis syndrome or leucopenia/thrombopenia were included in the IC group, and one in every 10 randomly selected patients consulting for other reasons were included in the NIC group. A proportion of patients in each group were offered an HIV test; those who agreed to be tested were given a rapid finger-stick HIV test (€6 per test). Epidemiological and clinical data were collected and analysed. RESULTS: During the study period, 775 patients attended with one of the four selected ICs, while 66,043 patients presented with an NIC. HIV screening was offered to 89 patients with ICs (offer rate 11.5%), of whom 85 agreed to and completed testing (94.4 and 100% acceptance and completion rates, respectively). In the NIC group, an HIV test was offered to 344 persons (offer rate 5.2%), of whom 313 accepted (90.9%) and 304 completed (97.1%) testing. HIV tests were positive in four persons [prevalence 4.7%; 95% confidence interval (CI) 1.3-11.6%] in the IC group and in one person in the NIC group (prevalence 0.3%; 95% CI 0.01-1.82%; P < 0.009). If every eligible person had taken an HIV test, we would have spent €4650 in the IC group and €396,258 in the NIC group, and an estimated 36 (95% CI 25-49) and 198 persons (95% CI 171-227), respectively, would have been diagnosed with HIV infection. The estimated cost per new HIV diagnosis would have been €129 (95% CI €107-153) in the IC group and €2001 (95% CI €1913-2088) in the NIC group. CONCLUSIONS: Although the number of patients included in the study was small and the results should be treated with caution, IC-guided HIV testing, based on four selected ICs, in PCCs seems to be a more feasible and less expensive strategy to improve diagnosis of HIV infection in Spain than a nontargeted HIV testing strategy.

White matter abnormalities in primary Sjögren syndrome.

OBJECTIVE: To describe the main characteristics of patients with primary Sjögren syndrome (SS) and white matter abnormalities (WMA) seen by a specialist SS unit. METHODS: The study cohort included 321 consecutive patients fulfilling the 2002 classification criteria for primary SS. We retrospectively analyzed the results of neuroimaging studies performed in patients who presented with neurological symptoms. Patients were further evaluated by three neurologists to determine fulfillment of the McDonald criteria for the diagnosis of multiple sclerosis (MS). RESULTS: Fifty-one (16%) patients had at least one neuroimaging study, and 25 of these had WMA. WMA were classified as vascular pathological changes in 21 patients: 10 had multiple small focal lesions, 7 had beginning confluence of lesions and 4 had diffuse involvement of the entire region. WMA were classified as inflammatory/demyelinating lesions (MS-like) in 4 patients who fulfilled the MRI Barkhof criteria. Patients with inflammatory/demyelinating lesions were younger (53.7 vs. 73.5 years, P = 0.001) and had a lower frequency of hypertension (25% vs. 86%, P = 0.031) and altered glomerular filtration rate (0% vs. 70%, P = 0.047) in comparison with patients with vascular lesions. The multivariate age-sex adjusted model including the seven variables which were statistically significant in the univariate analysis (antimalarial therapy, leukopenia, anti-La/SSB antibodies, diabetes, hypertension, metabolic syndrome and HDL-c levels) identified hypertension (P = 0.019) and HDL-c levels (P = 0.032) as independent predictors of WMA in primary SS patients. CONCLUSION: Neuroimaging studies disclosed WMA in 49% of patients with primary SS and suspected neurological involvement. WMA were identified as vascular pathological changes in 80% of the patients, and hypertension and HDL-c levels as predictive factors for this association.

Bronchiectasis in primary Sjögren's syndrome: prevalence and clinical significance.

OBJECTIVES: To analyse the prevalence and clinical significance of bronchiectasis in a large series of patients with primary Sjögren's syndrome (SS) and evaluate its impact on disease expression and outcomes. METHODS: The study cohort included 507 patients with primary SS. Bronchiectasis were diagnosed according to pulmonary computed tomography (CT). As a control group, we included 37 consecutive SS patients evaluated by pulmonary CT during the same study period without pulmonary involvement. RESULTS: Fifty primary SS patients had bronchiectasis according to the pulmonary CT. Nine patients were excluded due to non-autoimmune processes and 41 were classified as bronchiectasis associated with primary SS (40 women, mean age of 64 years). All cases of bronchiectasis were of the cylindrical type and were located in the inferior lobes in 29 cases (71%). Patients with bronchiectasis were older at diagnosis of SS (60.39 vs. 52.54 years, p=0.022) and had a higher frequency of hiatus hernia (41% vs. 16%, p=0.024) in comparison with controls. Immunologically, patients with bronchiectasis had a lower frequency of anti-Ro/SS-A antibodies (27% vs. 54%, p=0.022) but a higher frequency of anti-smooth muscle--SMAantibodies (82% vs. 60%, p=0.043). During follow-up, patients with bronchiectasis had a higher frequency of respiratory infections (56% vs. 3%, p<0.001) and pneumonia (29% vs. 3%, p=0.002) in comparison with those without. CONCLUSIONS: Patients with primary SS and bronchiectasis are characterised by an older age, a high frequency of hiatus hernia, a specific immunologic pattern (low frequency of anti-Ro/SS-A and high frequency of anti-SMA) and during follow-up a much higher frequency of respiratory infections and pneumonia.

Cardiovascular risk factors in primary Sjögren's syndrome: a case-control study in 624 patients.

We evaluated the prevalence and clinical significance of cardiovascular risk factors in a large series of patients with primary Sjögren's syndrome (SS), focusing on the possible association with clinical and immunological SS features, the therapies administered, and the impact on cardiovascular disease. The study cohort included 312 patients fulfilling the 2002 classification criteria for primary SS, consecutively evaluated and followed in our department between 1984 and 2009. The control group consisted of 312 age- and sex-matched patients without systemic autoimmune diseases followed during the study period in a primary care centre. In comparison with the age- and sex-matched control group, patients with primary SS showed a higher frequency of diabetes mellitus (27% versus 13%, p < 0.001) and hypertriglyceridaemia (22% versus 15%, p = 0.023), and a lower frequency of hypertension (30% versus 46%, p < 0.001) and smoking (19% versus 31%, p < 0.001). The adjusted, multivariate analysis showed that SS patients with at least three cardiovascular risk factors had a higher mean age at SS diagnosis (p < 0.001), a higher frequency of liver involvement (p = 0.01) and central nervous system involvement (p = 0.001), higher mean levels of C-reactive protein (CRP, p = 0.001), a lower percentage of circulating gamma globulins (p = 0.001), and had received corticosteroids more frequently (p = 0.003) in comparison with patients without cardiovascular risk factors. Patients who had received corticosteroids showed a higher frequency of hypertension (37% versus 25%, p = 0.032), diabetes mellitus (37% versus 21%, p = 0.002), and hypertriglyceridaemia (33% versus 15%, p < 0.001). Patients with primary SS showed a twofold higher prevalence of diabetes mellitus and a 1.5-fold higher prevalence of hypertriglyceridaemia in comparison with primary care patients. Corticosteroid use was closely associated with cardiovascular risk factors. These results suggest that cardiovascular risk factors should be taken into account in the management of patients with primary SS and show the importance of recognizing and controlling both traditional and SS-related modifiable risk factors.

Lack of correlation between the central anti-nociceptive and peripheral anti-inflammatory effects of selective COX-2 inhibitor parecoxib.

Non-steroidal anti-inflammatory drugs (NSAIDs) are thought to exert their pharmacological actions by a common mechanism: inhibition of cyclooxygenase (COX)-mediated prostanoid synthesis. Yet, differences and dissociation between their analgesic and anti-inflammatory effects have not been related to this enzymatic mechanism but mainly to pharmacokinetic factors. Thus, we have compared the effects of an equieffective anti-inflammatory dose (6 mg/kg i.p.) of two NSAIDs with comparable spinal pharmacokinetics, ketoprofen (moderately preferential for COX-1) and parecoxib (selective COX-2), on the activation of spinal nociceptive neurons (measured as c-Fos expression) induced by carrageenan-induced acute inflammation in the rat paw. Both NSAIDs showed a similar anti-inflammatory effect when administered after carrageenan injection (post-treatment). Post-treatment with ketoprofen produced inhibition of c-Fos but parecoxib did not have any significant effect. In addition, parecoxib anti-inflammatory effect was greater than that of ketoprofen, when administered before carrageenan injection (pre-treatment). Paradoxically, pre-treatment with ketoprofen produced a greater inhibition of c-Fos expression than with parecoxib, in all lamina of ipsilateral dorsal horn of the lumbar spinal cord. This suggests that NSAIDs therapeutic profile is related to their selectivity for COX isoforms and COX-2 is involved in the initiation but not in the maintenance of nociceptive spinal activation, which depends on COX-1.

Previous antimalarial therapy in patients diagnosed with lupus nephritis: influence on outcomes and survival.

The aim of this study was to analyze the effect of exposure to antimalarial drugs at diagnosis of lupus nephritis on the outcome of the disease, especially renal failure, comorbid processes, and survival. We analyzed a cohort of 206 consecutive patients with biopsy-proven lupus nephritis. Renal biopsies were categorized according to the classification proposed by the ISN/RPS in 2003. Exposure to antimalarial drugs (chloroquine and hydroxychloroquine) was defined as the use of these drugs before the diagnosis of lupus nephritis independent of dose and duration. Fifty-six (27%) patients had received antimalarials before the diagnosis of lupus nephritis. During the follow-up, these patients had a lower frequency of creatinine values >4 mg/dL (2% vs 11%, P = 0.029) and end-stage renal failure (2% vs 11%, P = 0.044) in comparison with those never treated with antimalarials. Patients exposed to antimalarials also had a lower frequency of hypertension (32% vs 50%, P = 0.027), infections (11% vs 29%, P = 0.006), and thrombotic events (5% vs 17%, P = 0.039). Twenty patients (10%) died during the study period. Patients exposed to antimalarials had a lower mortality rate at the end of the follow-up (2% vs 13% for those not exposed to antimalarials, P = 0.029). Multivariate analysis identified thrombosis and infections as statistically significant independent variables. Kaplan-Meier plots showed a lower rate of end-stage renal failure (log rank = 0.04) in patients exposed to antimalarials. In conclusion, exposure to antimalarials before the diagnosis of lupus nephritis was negatively associated with the development of renal failure, hypertension, thrombosis and infection, and with a better survival rate at the end of the follow-up. This, together with other published data, suggests that antimalarials should be considered a mandatory therapeutic option in all patients diagnosed with systemic lupus erythematosus.

[How to increase the involvement of casualty patients in their treatments: efficacy of some informative posters]. / Cómo aumentar la implicación del paciente de urgencias en su tratamiento? Eficacia de unos pósters informativos.

OBJECTIVE: To determine whether posters/leaflets increase doctors' information on the allergies and on the medication their patients are taking and patients' understanding of their treatment. DESIGN: First stage: multi-centre transversal descriptive study. Second stage: intervention with control and without randomisation. SETTING: Primary care medical emergency services (MES). PARTICIPANTS: MES patients under prescribed drug treatment. INTERVENTIONS: Use of posters/leaflets. MAIN MEASUREMENTS: 1) Proportion of patients for whom the doctor was ignorant of allergies to drugs or of accompanying medication. 2) Proportion of prescriptions in which patients understood the dosage of the medication prescribed. SOURCE: ad hoc questionnaire to patients. ANALYSIS: chi2 test (category variables). In some cases, the Breslow-Day and Tarone tests were conducted. RESULTS: Total patients included, 1233; 1766 prescriptions analysed; 53.4% women. Mean age: 29+/-18 years old. 1) Doctor's understanding of accompanying medication: at the second stage, drop of 25.5% (95% CI, 33.5-17.5) for intervention group versus drop of 12.5% (95% CI, 19.8-5.2) for control group, in the number of patients for whom the doctor did not know the medication (P=.024). 2) Patient's understanding of dosage: at the second stage, increase of 16.8% (95% CI, 9.8-23.8) for intervention group, versus a decrease of 1% in control group, in the medicines whose dosage the patient was aware of (P<.001). CONCLUSIONS: The dissemination of posters/leaflets was effective in increasing patients' knowledge of their medication's dosage and doctors' understanding of questions affecting prescription.

¿Cómo aumentar la implicación del paciente de urgencias en su tratamiento?: eficacia de unos pósters informativos / How to increase the involvement of casualty patients in their treatments: efficacy of some informative posters

Objetivo. Determinar si unos pósters/folletos aumentan la información del médico sobre las alergias a la medicación que están tomando los pacientes y la comprensión del tratamiento por parte de éstos. Diseño. Primera fase: descriptivo, transversal, multicéntrico. Segunda fase: de intervención, controlado, sin aleatorización. Emplazamiento. Servicios de urgencias médicas no hospitalarios (SUM). Participantes. Pacientes del SUM con tratamiento farmacológico prescrito. Intervenciones. Difusión de los pósters/folletos. Mediciones principales. La proporción de pacientes de los que el médico no conocía la alergias a medicamentos o la medicación concomitante, y la proporción de prescripciones en las que el paciente conocía la posología del fármaco recetado. Fuente: cuestionario ad hoc realizado a los pacientes. Análisis: test de la *2 (variables categóricas). En algunos casos se efectuó la prueba de Breslow-Day y Tarone. Resultados. Se incluyó a un total de 1.233 pacientes; se analizaron 1.766 prescripciones; el 53,4% eran mujeres y la edad media era de 29 ± 18 años. 1. Desconocimiento de la medicación concomitante por parte del médico: en la segunda fase, disminución del 25,5% (intervalo de confianza [IC] del 95%, 33,5-17,5) en el grupo de intervención frente al 12,5% (IC del 95%, 19,8-5,2) en el grupo control del número de pacientes en que el médico desconocía esta medicación (p = 0,024) 2. Conocimiento de la posología por parte del paciente: en la segunda fase, incremento del 16,8% (IC del 95%, 9,8-23,8) en el grupo de intervención frente a un decremento del 1% en el grupo control del número de prescripciones en que el paciente conocía la posología (p < 0,001). Conclusiones. La difusión de pósters/folletos dirigidos a los pacientes fue eficaz para incrementar el conocimiento sobre la posología de su medicación y para que el médico conociera más la medicación concomitante a su prescripción

Objective. To determine whether posters/leaflets increase doctors' information on the allergies and on the medication their patients are taking and patients' understanding of their treatment. Design. First stage: multi-centre transversal descriptive study. Second stage: intervention with control and without randomisation. Setting. Primary care medical emergency services (MES). Participants. MES patients under prescribed drug treatment. Interventions. Use of posters/leaflets. Main measurements. 1) Proportion of patients for whom the doctor was ignorant of allergies to drugs or of accompanying medication. 2) Proportion of prescriptions in which patients understood the dosage of the medication prescribed. Source: ad hoc questionnaire to patients. Analysis: *2 test (category variables). In some cases, the Breslow-Day and Tarone tests were conducted. Results. Total patients included, 1233; 1766 prescriptions analysed; 53.4% women. Mean age: 29±18 years old. 1) Doctor's understanding of accompanying medication: at the second stage, drop of 25.5% (95% CI, 33.5-17.5) for intervention group versus drop of 12.5% (95% CI, 19.8-5.2) for control group, in the number of patients for whom the doctor did not know the medication (P=.024). 2) Patient's understanding of dosage: at the second stage, increase of 16.8% (95% CI, 9.8-23.8) for intervention group, versus a decrease of 1% in control group, in the medicines whose dosage the patient was aware of (P<.001). Conclusions. The dissemination of posters/leaflets was effective in increasing patients' knowledge of their medication's dosage and doctors' understanding of questions affecting prescription

Anti-chromatin antibodies in systemic lupus erythematosus: a useful marker for lupus nephropathy.

BACKGROUND: Anti-chromatin antibodies have recently been described in patients with systemic lupus erythematosus (SLE) and it has been suggested that their presence is associated with lupus nephritis. OBJECTIVE: To assess the prevalence and clinical associations of these antibodies in SLE. METHODS: The presence of anti-chromatin antibodies in 100 patients with SLE was investigated by an enzyme linked immunosorbent assay (ELISA). To determine the specificity of these antibodies, 100 patients with primary Sjögren's syndrome, 30 with primary antiphospholipid syndrome (APS), 10 with systemic sclerosis, and 100 normal controls were also tested. RESULTS: Positive levels were detected in 69/100 (69%) patients with SLE. In contrast, they were found in only 8/100 (8%) of those with primary Sjögren's syndrome, in 1/10 (10%) with systemic sclerosis, in 2/30 (7%) with primary APS, and in none of the 100 healthy controls. Patients with anti-chromatin antibodies had a twofold higher prevalence of lupus nephropathy than those without these antibodies (58% v 29%, p<0.01). A significant correlation was found between the levels of anti-chromatin antibodies and disease activity score as measured by the European Consensus Lupus Activity Measurement (ECLAM; p=0.011). CONCLUSIONS: The measurement of anti-chromatin antibodies appears to be a useful addition to the laboratory tests that can help in the diagnosis and treatment of SLE. These antibodies are both sensitive and specific for SLE, and are a useful marker for an increased risk of lupus nephritis.

[Cardiovascular morbidity and its relationship to left ventricular hypertrophy in a cohort of hypertensive patients: the Gòtic study]. / Morbilidad cardiovascular y su relación con la hipertrofia ventricular izquierda de una cohorte de pacientes hipertensos: estudio Gòtic.

BACKGROUND: To describe cardiovascular morbidity of a hypertensive patients cohort and relate it to the presence of left ventricular hypertrophy (LVH), LVH geometric patterns, other cardiovascular risk factors (CRF), previous pathology (PP) and a range of variables. DESIGN: Prospective study of the cohort visited in a from 1993 to 1998. Place. Downtown primary care center. PATIENTS: A random sample of 267 hypertensive patients under 80 years old was used. Method and procedures. The presence of universals of CRF, PP and a range of variables such as age, sex, systolic and diastolic blood pressure (SBP and DBP), heart rate, body mass index (BMI), left ventricular mass index (LVMI) and Cornell and Sokolov-Lyon electrocardiographic criteria were registered. Also cardiovascular events (CE) were recorded: heart failure (HF), coronary heart disease (CHD), stroke, arrythmia and peripheral vascular disease (PVD). Then the association between these variaables and CE appearance was studied. MEASURES AND RESULTS: The total amount of CE was 60, with an accumulated incidence of 22.5% (confidence interval 95% from 19.4 to 25.7%).HF was more frequent among patients with a higher BMI (p = 0.05). The patients with HF showed a stronger smoking habit as CRF and a higher PAS (p = 0.05). The PVD was more common among hypertensive patients with smoking habit as CRF (p = 0.05).EC was highly observed in those patients either with LVH or CRF, especially in those cases such as HF (90% had LVH), stroke (87.5%) and arrythmias (83.3%). However, it was less observed in those ones with PVD (66.7%) and HF (60%). No relation was found between the patterns of LVH and EC. CONCLUSIONS: The HF was more frequent among the hypertensive patients with a higher LVMI, the HF among the smokers and a higher PAS and PVD among the smokers. The LVH is strongly related to the HF, stroke and arrythmias. The differences among the populations with cardiovascular epidemiology as well as the short span of follow-up may have contributed to obtaining such results.

Morbilidad cardiovascular y su relación con la hipertrofia ventricular izquierda de una cohorte de pacientes hipertensos: estudio gòtic / Cardiovascular morbidity and its relationship to the left ventricular hypertrophy of a cohort of hypertense patients: gòtic study

Objetivo. Describir la morbilidad cardiovascular de una cohorte de pacientes hipertensos y relacionarla con la presencia de hipertrofia ventricular izquierda (HVI) y sus diferentes patrones geométricos, otros factores de riesgo cardiovascular (FRCV), patología de base (PB) y una serie de variables. Diseño. Estudio prospectivo de la cohorte seguida desde 1993 a 1998. Emplazamiento. Centro de atención primaria urbano. Pacientes. Muestra aleatoria de 267 hipertensos menores de 80 años. Intervenciones. Se recogió la presencia o no de los FRCV según criterios universales, la PB y las variables sexo, edad, cifras de TA, pulso, índice de masa corporal (IMC) y ventricular izquierdo (IMVI) y valores electrocardiográficos de Cornell y Sokolov-Lyon. Además se contabilizaron los episodios cardiovasculares mórbidos (ECM): insuficiencia cardíaca (IC), cardiopatía isquémica (CI), arritmia, vasculopatía periférica (VP) y accidente cerebrovascular (ACV). A partir de estos datos se estudió la asociación entre las citadas variables y la presentación de los ECM. Mediciones y resultados principales. La cifra total de ECM fue de 60, con una incidencia acumulada de 22,5 por ciento (IC del 95 por ciento, 19,4-25,7 por ciento). La IC fue más frecuente en los pacientes con un valor de IMVI más elevado (p = 0,05). Los enfermos con CI presentaron más tabaquismo como FRCV y un valor de PAS más alto (p = 0,05). La VP fue más común en los hipertensos con tabaquismo como FRCV (p = 0,05). Los ECM fueron más observados en los pacientes con HVI como FRCV, en especial en el caso de la IC (un 90 por ciento presentaba HVI), los AVC (87,5 por ciento) y las arritmias (83,3 por ciento), siéndolo menos en la VP (66,7 por ciento) y la CI (60 por ciento). No se halló relación entre los patrones de HVI y los ECM. Conclusiones. La IC es más frecuente en los hipertensos con mayor IMVI, la IC en los fumadores y con mayor PAS y la VP en los fumadores. La HVI se asocia sobre todo a la IC, los AVC y las arritmias. Tanto las diferencias poblacionales en epidemiología cardiovascular como el limitado tiempo de seguimiento pueden haber contribuido a estos resultados (AU)

Circulating levels of Th1/Th2 cytokines in patients with primary Sjögren's syndrome: correlation with clinical and immunological features.

OBJECTIVE: To analyse the circulating levels of Th1 and Th2 cytokines in patients with primary Sjögren's syndrome (SS), as well as to investigate their association with clinical and immunological manifestations. METHODS: We included 62 consecutive patients (58 women and 4 men) seen in our Unit. All patients fulfilled 4 or more of the European diagnostic criteria for SS. Serum levels of IL-6 (pg/mL), IL-2 (pg/mL), srIL-2 (pM), TNFalpha (pg/mL) and IL-10 (pg/mL) were determined using a solid phase enzyme immunoassav performed on microtiter plate. RESULTS: When compared with the control group, high levels of Th1 (11-2, srIL-2) and Th2 (IL-6, IL-10) cytokines were detected in SS patients, although only IL-6 levels reached statistical significance. On the other hand, analysis of the mean serum concentrations of cytokines showed distinct patterns of elevated cytokines according to the organ involved, and elevated levels of IL-6 (126.5 v 20.6 pg/mL, p < 0.05) and IL-10 (10.6 v 2.2 pg/mL, p < 0.005) were observed in those patients with liver involvement. Analysis of the cytokine levels according to the presence of immunological features showed: higher levels of srIL-2 (95.6 v 54.0 pM, p < 0.05) in patients with anti-Ro/SS-A antibodies; increased levels of srIL-2 (111.4 v 59.4 pM, p < 0.05) in patients with antiLa/SS-B antibodies; higher levels of srIL-2 (90.4 vs 50.8 pM, p < 0.05) and TNFalpha (37.9 v 22.6 pg/mL, p = 0.001) in patients with RF and higher levels of IL-6 (88.0 v 23.1 pg/mL, p < 0.05) in patients with cryoglobulins and in those with hypocomplementemia (130.3 vs 21.0 pg/mL, p < 0.05). CONCLUSION: We found a significant elevation of several circulating cytokines in some clinical and immunological subsets of patients with primary SS. These cytokine patterns may be markers for specific extraglandular involvement in SS and could be of interest in assessing the response to treatment protocols or in monitoring the disease evolution.

Cryoglobulinemia in systemic lupus erythematosus: prevalence and clinical characteristics in a series of 122 patients.

OBJECTIVES: To determine the prevalence and nature of cryoglobulins in 122 patients with systemic lupus erythematosus (SLE) and identify the clinical and immunologic features related to their presence. METHODS: In a cross-sectional study, we investigated 122 consecutive patients (106 women and 16 men) with SLE who fulfilled the 1982 revised criteria of the American College of Rheumatology for the classification of SLE. All patients had documented medical histories and underwent a medical interview as well as a routine general physical examination by a qualified internist, and their clinical and serologic characteristics were collected on a protocol form. Serum samples were obtained at 37 degrees C, and cryoglobulinemia was estimated by centrifugation at 4 degrees C after incubation for 7 days in all patients. The type of cryoglobulinemia was identified by agarose gel electrophoresis and immunofixation. RESULTS: Cryoglobulins were detected in the sera of 31 SLE patients (25%): 20 patients (65%) had a cryocrit lower than 1%, 8 (26%) had percentages ranging between 1% and 5%, and only 3 patients (9%) had a cryocrit over 5%. Only cutaneous vasculitis (39% v 16%; P = .01) was more prevalent in patients with than in those without cryoglobulins. Rheumatoid factor (RF) (42% v 15%; P = .002) and low CH50 levels (84% v 49%; P <.001) were more prevalent in SLE patients with cryoglobulins. Hepatitis C virus (HCV) infection was investigated in 24 of the 31 cryoglobulinemic SLE patients and was detected in 5 (21%). In comparison, 4 (5%) of the 75 noncryoglobulinemic SLE patients studied were positive (P = 0.035; odds ratio, 4.67). Patients with a cryocrit greater than 1% showed a higher frequency of HCV infection than those with a cryocrit less than or equal to 1% (46% v 0%, P = .01). CONCLUSIONS: Cutaneous vasculitis, RF, hypocomplementemia, and HCV infection were associated with cryoglobulins in SLE patients. Testing for HCV infection is therefore recommended for patients with SLE and cryoglobulinemia to identify this subset of patients for prognostic and therapeutic reasons.