Anti-C1q antibodies in juvenile-onset systemic lupus erythematosus.

The objective of this study was to evaluate the presence of anti-C1q antibodies Hospital Israelita Albert Einstein Research Institute, São Paulo, Brazil in 67 juvenile systemic lupus erythematosus (JSLE) patients and 26 healthy controls and to assess the association of these antibodies with disease activity, nephritis, and presence of anti-double-stranded (ds)DNA. Anti-C1q antibodies were detected by ELISA. A higher frequency of anti-C1q antibodies was observed in JSLE patients compared to controls (20% vs. 0%, P = 0.016). Specificity of these antibodies was 100%[95% confidence interval (CI) 86.7-100%] and sensitivity was 19.4% (95% CI 10.7-30.8%) for a lupus diagnosis. The median anti-C1q antibodies was higher in JSLE patients compared to controls [median (range) 9.4 (5.5-127) vs. 7.3 (5-20) units, P = 0.004]. Remarkably, a positive Spearman's coefficient was found between anti-dsDNA and anti-C1q units (r = 0.42, P = 0.0004, 95% CI 0.19-0.60). Our results confirm a low frequency of anti-C1q antibody in our lupus populations, but the presence of anti-Clq antibodies appears to be a good marker for JSLE diagnosis.

Acute ethanol intoxication in a model of traumatic brain injury with hemorrhagic shock: effects on early physiological response.

OBJECT: Traumatic brain injury (TBI) is exacerbated by hypotension and hypoventilation. Because previous studies have shown a potentiating effect of ethanol (EtOH) on TBI and hemorrhagic shock (HS), the authors investigated the effects of EtOH on the early physiological response to TBI with and without HS. METHODS: Anesthetized swine, weighing approximately 20 kg each, underwent fluid-percussion TBI of 3 atm with or without 30 ml/kg hemorrhage for a period of 30 minutes. The mean arterial blood pressure, intracranial pressure, cerebral perfusion pressure (CPP), cardiac output, cerebral venous oxygen saturation, and metabolic parameters were monitored for 3 hours postinjury. Ventilation and the response to hypercapnia were also measured. Regional cerebral blood flow and renal blood flow were measured using dye-labeled microspheres. Five groups were studied: control, TBI, TBI/EtOH, TBI/HS, and TBI/HS/EtOH. The EtOH (3.5 g) was given intragastrically 100 minutes preinjury. The TBI/HS/EtOH group demonstrated a 3-hour mortality rate of 56% and postinjury apnea requiring ventilation in 44% of animals compared with 0% in all other groups. Minute ventilation and the hypercapnic ventilatory response were significantly reduced in the postinjury period in the TBI/HS/EtOH group. The animals in this group had significantly lower CPP and cardiac output in the first 60 minutes postinjury, as well as lower renal and cerebral blood flow. Postinjury cerebral venous lactate levels were higher, and cerebral venous pH was lower in the TBI/HS/EtOH group. CONCLUSIONS: In this model of TBI, acute EtOH intoxication in the presence of HS potentiates the physiological and metabolic alterations that may contribute to secondary brain injury.

Application of telethermography in the evaluation of preterm premature rupture of the fetal membranes.

The development of chorioamnionitis is a serious complication associated with preterm premature rupture of the fetal membranes (PPROM). There is no reliable early indicator of this infection. The objective of this study was to determine the sensitivity of telethermography (TTG) in the detection of subclinical chorioamnionitis in women with PPROM. Fourteen pregnant women with PPROM between 23 and 34 weeks' gestation were the subjects of the study. Serial frontal-abdominal TTG scans were obtained up to the time of delivery using the MARK-1026 telethermography imager. Following delivery, placental cultures and pathology results were obtained and infant sepsis evaluation was performed. Images were analyzed for temperature differences between umbilical, inguinal, four-quadrant average, and abdominal-wall hot spots. Data were compared with norms obtained from 12 pregnant women with intact membranes who served as gestational age-matched controls. Of five patients with pathology-proven chorioamnionitis and TTG scans within three days of delivery, four demonstrated significant increases in temperature differences between umbilical and abdominal-wall hot spots versus inguinal and four-quadrant averages (z-scores > or = 2.0). All three patients with negative pathology and cultures as well as scans within three days of delivery showed no increase in temperature differences of the above variables. No patient had any overt clinical sign of chorioamnionitis. This limited but consistent evidence demonstrates that telethermography is a sensitive, noninvasive diagnostic method for detecting subclinical chorioamnionitis in pregnant women with preterm rupture of the fetal membranes.

Forming a consortium: a design for interagency collaboration in the delivery of service following the disclosure of incest.

A central issue in the treatment of intrafamilial sexual abuse is the "secondary trauma" experienced by both the victimized child and her family when the wider system of regulatory and treatment agencies present redundant, incongruent, or conflicting perspectives and demands. This article describes an attempt to effect second-order change through formation of a consortium of regulatory and treatment agencies to develop a consistent and coordinated response to the disclosure of sexual abuse. Feminist, social constructionist, and organizational development ideas are used to develop principles of intersubjectivity, collaboration and a "both-and" stance, which have guided both the clinical and wider systems work.

Treating the sexually abused child: a recursive, multimodal program.

This article describes a recursive, multimodal therapy approach for children who have been sexually abused by members of their family. The different therapeutic modalities (family, group, and individual) are conceived of as different "communities" that provide a variety of relationships, information, and perspectives on the incest experience. The child's involvement in these different communities allows her or him to develop a multiplicity of self-accounts. Meaning is further expanded through the recursive transfer of material across modalities. By determining the content that is discussed in any particular session, and by participating actively in decisions about transferring material across modalities, the child both develops an enhanced sense of personal agency and a connection to trustworthy family members. This approach is designed to allow each child's unique experience with incest to emerge. Clinical examples are provided, along with a description of the program that provides the setting for our multimodal approach to incest.

Navigating treatment impasses at the disclosure of incest: combining ideas from feminism and social constructionism.

This article describes an approach to the social and emotional schisms that characterize the disclosure of intrafamilial sexual abuse (incest). It argues that ideas from social constructionism and feminism can be combined in such a way that what appear as either/or choices become both--and possibilities. These include: social control versus therapy, shame versus pride, attachment to one's abusive partner versus attachment to one's injured child, and "justice" versus "care."

Continuous monitoring of jugular venous oxygen saturation in head-injured patients.

The continuous measurement of jugular venous oxygen saturation (SjvO2) with a fiberoptic catheter is evaluated as a method of detecting cerebral ischemia after head injury. Forty-five patients admitted to the hospital in coma after severe head injury had continuous and simultaneous monitoring of SjvO2, intracranial pressure, arterial oxygen saturation, and end-tidal CO2. Cerebral blood flow, cerebral metabolic rates of oxygen and lactate, arterial and jugular venous blood gas levels, and hemoglobin concentration were measured every 8 hours for 1 to 11 days. Whenever SjvO2 dropped to less than 50%, a standardized protocol was followed to confirm the validity of the desaturation and to establish its cause. Correlation of SjvO2 values obtained by catheter and with direct measurement of O2 saturation by a co-oximeter on venous blood withdrawn through the catheter was excellent after in vivo calibration when there was adequate light intensity at the catheter tip (176 measurements: r = 0.87, p less than 0.01). A total of 60 episodes of jugular venous oxygen desaturation occurred in 45 patients. In 20 patients the desaturation value was confirmed by the co-oximeter. There were 33 episodes of desaturation in these 20 patients, due to the following causes: intracranial hypertension in 12 episodes, hypocarbia in 10, arterial hypoxia in six, combinations of the above in three, systemic hypotension in one, and cerebral vasospasm in one. The incidence of jugular venous oxygen desaturations found in this study suggests that continuous monitoring of SjvO2 may be of clinical value in patients with head injury.

Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients.

The traditional practice of elevating the head in order to lower intracranial pressure (ICP) in head-injured patients has been challenged in recent years. Some investigators argue that patients with intracranial hypertension should be placed in a horizontal position, the rationale being that this will increase the cerebral perfusion pressure (CPP) and thereby improve cerebral blood flow (CBF). However, ICP is generally significantly higher when the patient is in the horizontal position. This study was undertaken to clarify the issue of optimal head position in the care of head-injured patients. The effect of 0 degree and 30 degrees head elevation on ICP, CPP, CBF, mean carotid pressure, and other cerebral and systemic physiological parameters was studied in 22 head-injured patients. The mean carotid pressure was significantly lower when the patient's head was elevated at 30 degrees than at 0 degrees (84.3 +/- 14.5 mm Hg vs. 89.5 +/- 14.6 mm Hg), as was the mean ICP (14.1 +/- 6.7 mm Hg vs. 19.7 +/- 8.3 mm Hg). There was no statistically significant change in CPP, CBF, cerebral metabolic rate of oxygen, arteriovenous difference of lactate, or cerebrovascular resistance associated with the change in head position. The data indicate that head elevation to 30 degrees significantly reduced ICP in the majority of the 22 patients without reducing CPP or CBF.

Love and violence: gender paradoxes in volatile attachments.

This article presents a multidimensional, theoretical model for the understanding of relationships in which men are violent toward women. It argues that abusive relationships exemplify, in extremis, the stereotypical gender arrangements that structure intimacy between men and women generally. Moreover, it proposes that paradoxical gender injunctions create insoluble relationship dilemmas that can explode in violence. A multifaceted approach to treatment, which incorporates feminist and systemic ideas and techniques, is described.

Obsessions/counter-obsessions: a construction/reconstruction of meaning.

In this article, obsessions and phobic responses are examined in relation to the maintenance and development of a cross-generational coalition organized by a premise about exclusivity, as well as the specific, idiosyncratic "signature premises" characteristic to each case. It is suggested that the obsession develops when a developmental or situational crisis conflicts with the exclusive relationship definition (that is, coalition). Two forms of intervention for disrupting obsessions--the "conversation" and the "counter-obsession"--are discussed and illustrated. Both interventions conceptualize the obsession as an oscillation between remaining in the coalition and not remaining in the coalition, and both interventions challenge the signature premise that defines the coalition.

The debate: a strategic technique.

This paper describes the work of a strategic team that came out from behind the one-way mirror. A debate among the team is enacted before the family as a strategy for change. The case of a family that refused to provide information illustrates an application of this method. The debate among the therapists represents a dilemma that is a strategically constructed isomorph of the family situation. From this position, therapists have the option of changing levels between themselves and the family, asking the family to help solve the therapists' dilemma so that they in turn can be free to help the family. The combination of the debate and the change of levels between the therapists and the family creates a therapeutic neutrality for the family. From their meta position, they observe the therapists' struggle to solve the family's problem, which is re-presented as a problem among the therapists. This perspective offers the family the choice of more adaptive solutions to their own dilemma.