[Quinines--past and present].

Quinines are known to mankind and have been in medical use against malaria for over 350 years. The revelation of quinines' activity against malaria in the 17th century brought a revolution to the medical world and had dramatic implications on the political arena of Europe at that time. The source of these materials is the bark of the Cinchona trees indigenous to remote mountain areas of Latin America. Great efforts were made in the search for the trees, and in growing them in other areas of the world. Today quinines are produced both synthetically and from the tree bark. Beside malaria, they are pivotal in the treatment of autoimmune disorders such as Lupus and rheumatoid arthritis.

Use of complementary and alternative medicine among patients attending rheumatology clinics in Israel.

BACKGROUND: Complementary and alternative medicine has recently attracted attention due to its widespread use. In a recent study in Israel, almost a half of CAM users in the general population used it for joint diseases or back pain. OBJECTIVE: To evaluate the prevalence of CAM use among patients with defined rheumatic diseases, and analyze the demographic features of CAM users, their reasons for using CAM and the use of specific CAM methods. METHODS: We conducted face-to-face structured interviews of 350 patients attending rheumatology clinics, regarding past or present use of CAM, specifying the various CAM types they used, and reasons for using CAM. Demographic data including age, gender, country of birth and origin, and level of education were also collected. RESULTS: Altogether, 148 patients reported using CAM (42%). In general, homeopathy and acupuncture were the most commonly used types (44% and 41% of the patients, respectively). The mean number of CAM methods per patient was 1.9 +/- 1.1. CAM was more commonly used by patients with advanced education (52% vs. 37% of patients with lower education, P= 0.007). Patients with rheumatoid arthritis used CAM significantly less than patients with other rheumatologic conditions (32% vs. 48%, P= 0.008). CONCLUSION: CAM use is influenced by level of education. The choice of the preferred CAM method among patients with rheumatic diseases seemed to follow the popular CAM methods in the general population, and was not specific to rheumatic diseases.

Desensitization to hydroxychloroquine--experience of 4 patients.

Hydroxychloroquine (HCQ) is an antimalarial agent with immunomodulatory effects. It is widely used in rheumatologic diseases, and has a very high efficacy/toxicity ratio. It is particularly important in the treatment of systemic lupus erythematosus (SLE) since it reduces new organ involvement and disease flares, and relieves skin and joint symptoms. Some patients develop hypersensitivity rash in response to HCQ. In such patients the drug is withdrawn and replaced by another medication. All the alternative medications for rheumatological patients are significantly more toxic than HCQ. We describe our initial experience of HCQ slow oral desensitization. All 4 patients who were recruited completed the procedure successfully without significant difficulty. Our results suggest that HCQ slow oral desensitization is safe, effective, and easy to perform.

Transient severe eosinophilia precipitating massive venous thrombosis in a patient with hereditary thrombophilia.

We describe a patient homozygous for both the prothrombin G20210A and methylenetetrahydrofolate reductase C667T mutations who was symptom-free for 40 years and developed near-catastrophic thrombotic complications following transient, severe eosinophilia. This course of events raises the possibility of an increased risk of thrombosis associated with transient eosinophilia in the presence of hereditary thrombophilia and supports the concept of multifactorial etiology of venous thrombosis. Our experience suggests that in patients with severe eosinophilia, evaluation for known causes of hereditary or acquired thrombophilia may be useful for identifying subjects at increased risk of thrombosis.

Rofecoxib, a COX-2 inhibitor, lowers C-reactive protein and interleukin-6 levels in patients with acute coronary syndromes.

BACKGROUND: Patients with acute coronary syndromes (ACS) have high levels of inflammatory mediators such as C-reactive protein (CRP) and interleukin (IL)-6. AIM: To evaluate whether patients with ACS treated with rofecoxib, a COX-2 inhibitor, will have reduced CRP, IL-6, and soluble tumor necrotic factor receptor-1 (sTNF-R1) levels and improved endothelial function. METHODS AND RESULTS: Thirty-four patients hospitalized with ACS were randomized to receive rofecoxib, 25 mg/d plus aspirin 100 mg/d, or placebo plus aspirin, 100 mg/d, for a period of 3 months. Blood samples for CRP, IL-6, and sTNF-R1 levels were drawn prior to randomization, and after 1 month and 3 months. CRP levels in the rofecoxib group (n = 18) were significantly lower both at 1 month and 3 months compared to the baseline levels (p < 0.02). IL-6 levels were significantly lower at 1 month (p < 0.02) in the rofecoxib group, but not at 3 months. There was no change in endothelial function or sTNF-R1 levels. CONCLUSION: Patients recovering from ACS had lower levels of CRP and IL-6 at 1 month and lower CRP levels at 3 months when treated with rofecoxib plus aspirin. Suppression of inflammatory processes may lead to retardation of coronary atherosclerosis and coronary events.

Low-dose aspirin and prevention of cranial ischemic complications in giant cell arteritis.

OBJECTIVE: Cranial ischemic complications such as cerebrovascular accidents (CVAs) and acute visual loss are among the leading causes of giant cell arteritis (GCA)-related morbidity. In this retrospective study, we evaluated the effect of treatment with low-dose aspirin on the incidence of cranial ischemic complications in GCA. METHODS: Charts of 175 consecutive patients in whom GCA was diagnosed between 1980 and 2000 were reviewed for medical data. Data for 166 patients who were followed up for at least 3 months were also available. RESULTS: At the time of the diagnosis of GCA, 36 patients (21%) had already been receiving low-dose aspirin (100 mg/day). In all cases, the indication for this treatment was ischemic heart disease. There were no significant differences between the aspirin-treated and non-aspirin-treated groups regarding the mean age of patients, the male-to-female ratio, duration of GCA-related symptoms, rates of headaches, systemic symptoms, and jaw claudication, and the mean erythrocyte sedimentation rate, hemoglobin count, and platelet count. Cerebrovascular risk factors (hypertension, hyperlipidemia, or diabetes mellitus) were more common in the aspirin-treated group (38.9% versus 20%; P= 0.03). Cranial ischemic complications were diagnosed in 43 patients at presentation: 30 patients had acute visual loss, 11 had CVAs, and 2 had both conditions simultaneously. Only 3 of the aspirin-treated patients (8%) presented with cranial ischemic complications, compared with 40 (29%) of the non-aspirin-treated patients (P = 0.01). Despite the use of steroid therapy, cranial ischemic complications developed in 14 of the 166 patients followed up for 3 months or longer. However, cranial ischemic complications developed in only 3% of the aspirin-treated patients, compared with 13% of the patients treated with prednisone only (P = 0.02). CONCLUSION: These data suggest that low-dose aspirin decreases the rate of visual loss and CVAs in patients with GCA.

Risk factors for cranial ischemic complications in giant cell arteritis.

Cranial ischemic complications (CICs) are among the presenting manifestations of giant cell arteritis (GCA). Yet patients with GCA may develop CICs at a later stage, despite steroid therapy. In the current report we delineate risk factors for CICs, both at presentation and during follow-up, and review the relevant literature. We reviewed charts of 175 patients with GCA. Follow-up data were available for 166 patients. CICs at presentation or developing within 2 weeks of GCA diagnosis were considered GCA related. CICs developing later were considered GCA related only when associated with other GCA-related manifestations or acute-phase reactions. Associations between CICs and other variables were tested by multivariate analysis. At presentation, 43 patients (24.6%) had CICs. Risk factors were transient cerebro-ophthalmic ischemic episodes (COIEs) (odds ratio [OR] 4.3) and male sex (OR 2.5), while the presence of systemic symptoms was "protective" (OR 0.3). During follow-up 8.4% of patients with GCA developed new CICs. Risk factors in these cases were previous CICs at presentation (OR 5.6) and transient COIEs developing during follow-up (OR 14.8). The use of low-dose aspirin was protective (OR 0.2). These data, together with data from the literature review, suggest that GCA patients with transient COIEs and without fever or other systemic symptoms are at increased risk of presenting with CICs. Risk factors for late-developing CICs were CICs at presentation and late-developing transient COIEs.

The predictive value of the halo sign in color Doppler ultrasonography of the temporal arteries for diagnosing giant cell arteritis.

OBJECTIVE: The diagnosis of giant cell arteritis (GCA) usually requires a temporal artery biopsy. Recently it has been reported that a periluminal dark halo, detected by color Doppler ultrasonography (US) of the temporal arteries, is a characteristic sign of GCA. We evaluated the predictive value of this dark halo sign in diagnosing GCA. METHODS: During a period of 2 years 69 patients suspected of having GCA were examined by US of both temporal arteries. Temporal artery biopsy was performed in 32 of these patients. The diagnosis of GCA was made if a patient had a biopsy showing arteritis, or met all the following criteria: (1) American College of Rheumatology GCA classification criteria were fulfilled; (2) there was a prompt clinical response to treatment with 40-60 mg/day of prednisone; and (3) no other diagnosis related to the patient's symptoms was made during 6 month followup. RESULTS: Periluminal dark halo was observed in 24 of 69 patients. GCA was diagnosed in 12 of them, giving a positive predictive value (PPV) of only 50%. No halo was detected in 45 cases of which only 2 had GCA, resulting in a high negative predictive value (NPV) of 96%. The sensitivity and specificity of the halo sign for diagnosing GCA were 86% and 78%, respectively. CONCLUSION: The PPV of the halo sign in US of the temporal arteries is unsatisfactory for diagnosing GCA. However, the NPV is very high. Thus the lack of a halo can practically serve to rule out a diagnosis of GCA, and precludes the need for a biopsy in most instances.