Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Selective IgA deficiency in children and adults with systemic lupus erythematosus

The objective of this study was to determine the frequency and clinical characteristics of selective IgA deficiency (SIgAD) in children and adults with systemic lupus erythematosus (SLE), and evaluate potential differences in presentation and course of the SLE. IgA deficiency was defined as a serum IgA concentration < or =0.01 mg/mL determined on two sera by radial diffusion. SLE was classified by the 1982 criteria of the American College of Rheumatology. Seventy-seven children with SLE followed prospectively for > or =20 years and 152 adults surveyed during a one-year period were assayed for serum IgA levels. Disease characteristics were compared among the deficient patients and the IgA-normal patients. Twelve patients with SIgAD were identified: 1) Juvenile(J)-SLE: four children with juvenile onset (< or =18 years) and four others encountered as adults; and 2) Adult(A)-SLE: four patients with adult onset. No significant differences were found in clinical presentation or course except for a possible increase in recurrent infections and the observation that there were only two African-Americans. Five patients had received blood transfusions with no reactions; three of these patients had serum anti-IgA antibodies. One pediatric patient developed low levels of IgA (<or =1 mg/mL) during a follow-up of three years. Two adult patients died (septicemia, carcinoma); one was on dialysis. SIgAD was identified in 5.2% of children and 2.6% of adults with SLE for an estimated 35-fold increase in frequency. This small number of patients did not appear to have an altered clinical presentation or course from that expected in patients with SLE who did not have SIgAD.

Medical management of children with juvenile rheumatoid arthritis

One of the most important and changing areas of research in paediatric rheumatology is the optimum approach to the treatment of children with chronic arthritis. Until recently all medications for children with arthritis were nonspecific in terms of our understanding, albeit poor, of the pathogenesis of these diseases. Of current therapies, low dose, once-a-week methotrexate has emerged as the therapeutic agent of choice for children who fail to respond adequately to administration of a nonsteroidal anti-inflammatory drug. Thereby, it has displaced the more traditional slower acting anti-rheumatic drugs, although one or more of them are often combined with methotrexate in the polypharmaceutical approach to childhood arthritis. Better and more specific agents are needed, especially for systemic onset disease, unremitting polyarticular involvement, and certain complications such as resistant chronic uveitis. At this time the introduction of the cyclo-oxygenase 2 inhibitors and etanercept (soluble tumour necrosis factoralpha.p75 fusion protein) may herald an era of more specific and effective therapy.

Osteopenia and osteoporosis in children

The purpose of this paper is to review the normal physiologic processes of skeletal accretion, abnormalities that may occur in children with chronic illnesses, and therapeutic maneuvers that the clinician may be able to employ to prevent or partially correct abnormalities of skeletal growth. Skeletal maturation in children is dependent upon bone formation exceeding resorption, whereas in adults these two fundamental processes of homeostasis are closely balanced. Skeletal growth is effectively completed at the end of the period of adolescent growth acceleration with closure of the epiphyses. An important determinant of future fracture risk and osteoporosis is the peak bone mass achieved during this second decade of life. If the hereditarily determined peak bone mass is not established during that time, the patient will enter young adulthood with osteopenia, an increased fracture risk, and accelerated postmenopausal osteoporosis or involutional osteoporosis. Thus osteopenia and osteoporosis have their origins in childhood and adolescence.

Trajectories of adaptation in pediatric chronic illness: the importance of the individual

This study used individual growth modeling to examine individual difference and group difference models of adaptation. The adaptation of 27 children with juvenile rheumatoid arthritis (JRA) and 40 children with insulin-dependent diabetes mellitus (IDDM) was tracked for 18 months from diagnosis. A control group of 62 healthy children was followed over the same time period. Clustering procedures indicated that child and family adaptation could be described by a number of distinct adaptation trajectories, independent of diagnostic group membership. In contrast, parental adaptation trajectory was associated with diagnostic group membership and control over disease activity for the JRA group and with diagnostic group membership for healthy controls. The observation of common patterns across trajectory sets, as well as the finding that trajectories were differentially related to a number of variables of interest, support the use of trajectories to represent adaptation to chronic disease.

Trajectories of adaptation in pediatric chronic illness: the importance of the individual

This study used individual growth modeling to examine individual difference and group difference models of adaptation. The adaptation of 27 children with juvenile rheumatoid arthritis (JRA) and 40 children with insulin-dependent diabetes mellitus (IDDM) was tracked for 18 months from diagnosis. A control group of 62 healthy children was followed over the same time period. Clustering procedures indicated that child and family adaptation could be described by a number of distinct adaptation trajectories, independent of diagnostic group membership. In contrast, parental adaptation trajectory was associated with diagnostic group membership and control over disease activity for the JRA group and with diagnostic group membership for healthy controls. The observation of common patterns across trajectory sets, as well as the finding that trajectories were differentially related to a number of variables of interest, support the use of trajectories to represent adaptation to chronic disease.

Disease and family contributors to adaptation in juvenile rheumatoid arthritis and juvenile diabetes

OBJECTIVE

Research in the areas of pediatric rheumatology and pediatric chronic illness has emphasized comprehensive models of adaptation involving risk and resistance factors. This study examined adaptation, within this framework, among a large sample of children with chronic illness and children without chronic illness.

METHODS

A comprehensive battery of adaptation measures was administered to a sample of 107 children with juvenile rheumatoid arthritis, 114 children with insulin-dependent diabetes mellitus, and 88 healthy controls.

RESULTS

Medical diagnosis was associated with mothers' depression and a composite measure of parental (mother and father) distress and passive coping. Children's emotional and behavioral functioning was not related to medical diagnosis, but mothers' depression and parental distress were associated with child behavior problems.

CONCLUSION

Because parental distress was associated with child functioning, interventions to ameliorate parental distress may have beneficial effects on the children's behavior and on parents' reactions to their children.

Progress in diagnosis and understanding chronic pain syndromes in children and adolescents

The frequency of chronic pain syndromes in pediatric rheumatology has increased over the past 25 years. Diagnosis is complex: underlying organic illness, somatization, and growing pains are all possibilities. The author reviews pain studies involving children and adolescents, offers guidelines to classify chronic pain syndromes, and describes different pain modalities.

Abnormalities in skeletal growth in children with juvenile rheumatoid arthritis

A review of the acquisition of peak skeletal mass in normal children and studies that have been reported for children with JRA lead to the following tentative conclusions: (1) The appendicular skeleton is predominantly the overall status of skeletal mineralization; (2) a failure to develop adequate bone mineralization is virtually universal in children with JRA and is characterized by a failure of bone formation. A failure to undergo the normal increase in bone mass during puberty is common in children with JRA and markedly decreases their potential to achieve an adequate peak skeletal mass; (3) the onset of accelerated skeletal maturation with puberty is a critical period of potential intervention in JRA. Conversely, therapeutic interventions later during adolescence offer less promise of reversal of inadequate bone mineralization; and (4) the most important therapeutic maneuver is likely to be control of the inflammation process, although there is hope, at present unsubstantiated, that supplemental dietary calcium and vitamin D, and normalization of physical activity, many lead to some "catch-up" mineralization.

Legal rights of children with musculoskeletal disabilities

As market forces increasingly control medicine, we must not forget the disabled, especially children. Although the costs of appropriate comprehensive services are substantial, it is well worth the cost to facilitate an adulthood in which these patients are on their own, possibly earning their livelihood, and experiencing the best quality of life our society can provide.

Bone mineralization and bone mineral metabolism in children with juvenile rheumatoid arthritis

OBJECTIVE

To identify mechanisms of the osteopenia associated with juvenile rheumatoid arthritis (JRA) by determining parameters of bone mineralization, and bone mineral content and density (BMC and BMD), in children with JRA.

METHODS

BMC and BMD were measured by dual x-ray absorptiometry in 41 children with JRA and 62 healthy children. Serum samples were analyzed for concentrations of minerals, vitamin D, parathyroid hormone, osteocalcin, bone-specific alkaline phosphatase (BAP), procollagen I carboxy-terminal propeptide, and tartrate-resistant acid phosphatase (TRAP), and urinary excretion of deoxypyridinoline crosslinks and calcium.

RESULTS

BMD was decreased in all sites in JRA patients. BMD, corrected for age, height, weight, and bone area, was decreased at cortical bone sites (1/3 radius, upper and lower extremities, and whole body). Low concentrations of osteocalcin and BAP suggested reduced bone formation, and low TRAP levels suggested decreased resorption. Clinical scales of disease severity were negatively correlated with measures of bone mass. Laboratory markers of disease severity were highly correlated with decreases in markers of bone formation, but not with those of resorption. Although laboratory findings were similar for children with oligoarticular and polyarticular disease, differences in bone mass were greater in children with polyarticular disease.

CONCLUSION

These data suggest an association between decreased bone mineralization in JRA and low bone formation that is related to disease severity. Efforts to stimulate bone formation, therefore, need to be considered clinically in prepubertal children with active JRA.

Bone mineral metabolism in children with juvenile rheumatoid arthritis

Osteopenia has emerged as a major determinant of the outcome of children with juvenile rheumatoid arthritis. Although vertebral compression fractures and fractures of long bones were recognized historically as important clinical developments in the course of disease, a decrease in skeletal mass could only be quantitated and documented early in disease by the recent introduction of bone absorptiometry. This article is limited to recent data from studies on osteopenia in juvenile rheumatoid arthritis and suggests directions of future research that have relevance to current unanswered questions in prevention or management.

Elevated serum prolactin levels in children with juvenile rheumatoid arthritis and antinuclear antibody seropositivity

OBJECTIVE

To determine if antinuclear antibody seropositivity in girls with juvenile rheumatoid arthritis (JRA) is associated with elevated serum levels of the anterior pituitary hormone prolactin.

METHODS

Nineteen premenarchal girls meeting ACR classification criteria for JRA were evaluated for disease activity, antinuclear antibodies (ANA) seropositivity, and serum concentrations of prolactin, estrogen, and thyroid stimulating hormone.

RESULTS

The mean serum prolactin concentration of ANA seropositive patients with JRA (10.9 +/- 1.9 micrograms/l) was significantly higher than that for ANA negative patients (5.7 +/- 1.0 micrograms/l; p = 0.043) and an age matched control group (5.8 +/- 1.3 micrograms/l; p = 0.048).

CONCLUSION

Children with ANA seropositive JRA have elevated serum levels of the immunostimulatory hormone prolactin.

Evaluation of growth hormone secretion in children with juvenile rheumatoid arthritis and short stature

Children with juvenile rheumatoid arthritis (JRA) often exhibit delayed skeletal development. Previous evaluations of growth hormone (hGH) levels in these children have used single-value blood determinations. We sought to extend information on possible hGH deficiency in children with short stature and JRA by measuring 24-hour hGH pulsatile secretion. Five children with JRA were identified as having a height less than the 3rd percentile, and one child with a height at the 25th percentile. Three of these had abnormally low 24-hour serum hGH secretion. Two underwent a 24-month trial of human recombinant hGH; both exhibited only marginally accelerated growth. These results suggest that children with JRA and persistent short stature may have low hGH secretion without an adequate physiologic response to exogenous hGH administration.

Predicting pain among children with juvenile rheumatoid arthritis

OBJECTIVE

Children and adolescents with juvenile rheumatoid arthritis (JRA) often report pain as a major symptom that affects their daily activities. Little is known about the factors that contribute to pain, however. Demographic, disease status, and social-psychologic variables were used to predict pain of JRA.

METHODS

Participants were 37 girls and 23 boys who were 7 to 17 years old. Measures included the Hopelessness Scale for Children, the Sadness Scale from the Differential Emotions Scale--IV, and the Social Support Questionnaire--Revised. A pain visual analogue scale served as the criterion measure.

RESULTS

Reported pain was modestly correlated with disease duration and age. A hierarchical regression indicated that the predictor variables accounted for a modest amount of variance in pain scores.

CONCLUSIONS

The results suggest that the factors contributing to pain in children with JRA are different from those in adults with rheumatoid arthritis (RA). Research is needed to identify the psychologic and socioenvironmental variables that influence pain among children with JRA.

Progress in diagnosing and understanding chronic pain syndromes in children

Chronic pain syndromes such as fibromyalgia and reflex sympathetic dystrophy constitute an increasing percentage of new patient referrals to pediatric rheumatology clinics. It is surprising then that so few studies have been published on these syndromes. This review focuses on the investigations that are central to our understanding of this difficult diagnostic area.

Vitamin D metabolism and bone mineralization in children with juvenile rheumatoid arthritis

OBJECTIVE

To examine bone mineralization and bone mineral content in a cross-sectional population of children with juvenile rheumatoid arthritis (JRA).

METHODS

Bone mineral content was measured by single-photon absorptiometry in 44 children with JRA and 37 control children. Serum concentrations of minerals, vitamin D, parathyroid hormone, osteocalcin, bone alkaline phosphatase, and tartrate-resistant acid phosphatase, and urinary concentrations of minerals, were determined.

RESULTS

Bone mineral content was decreased in children with JRA. Significantly lower concentrations of osteocalcin (7.4 +/- 3.4 vs 12.5 +/- 2.5 micrograms/L) and bone alkaline phosphatase (78.8 +/- 36.4 vs 123.0 +/- 46.0 IU/L) suggested reduced bone formation; lower levels of tartrate-resistant acid phosphatase (10.3 +/- 4.1 vs 14.4 +/- 5.8 IU/L) and a lower urinary calcium/creatinine ratio (0.07 +/- 0.06 vs 0.12 +/- 0.09) suggested decreased bone resorption. The serum calcium concentration was significantly lower (9.3 +/- 1.0 vs 10.0 +/- 0.4 mg/dl), as was the parathyroid hormone concentration (19.8 +/- 8.6 vs 26.7 +/- 9.3 ng/L); 1,25-dihydroxyvitamin D values (30.1 +/- 10.5 vs 30.4 +/- 9.3 pg/ml) were normal.

CONCLUSION

These data suggest that decreased mineralization in JRA is related to low bone turnover; parathyroid hormone and 1,25-dihydroxyvitamin D levels may be inappropriately normal for the decreased serum calcium concentration in children with JRA.

Assessing anger expression in children and adolescents

Anger expression styles are associated with psychological and physical well-being among adults. Little is known about the role of anger expression in children's functioning. This lack of knowledge has resulted, in part, from a lack of validated tools for anger expression measurement. The Pediatric Anger Expression Scale-3rd edition (PAES-III; Jacobs, Phelps, & Rohrs, 1989; Jacobs & Kronaizl, 1991) has been proposed as a reliable and valid assessment instrument of anger expression styles. The PAES-III includes three scales that measure anger turned inward, anger expressed outwardly, and anger controlled cognitively or behaviorally. We evaluated the psychometric properties of this instrument when it is administered verbally to children with juvenile rheumatoid arthritis, children with juvenile diabetes mellitus, and healthy children. Internal consistency was adequate for anger-in and anger-out, but marginal for anger-control. Concurrent validity was supported for the total sample. A principal components analysis suggested a four-factor model of anger expression. Overall, the PAES-III was found to have psychometric limitations. Use of a modified PAES-III may facilitate pediatric behavioral medicine research addressing risk factors for maladjustment among children with chronic illnesses.

U1-70-kd autoantibody-positive mixed connective tissue disease in children. A longitudinal clinical and serologic analysis

OBJECTIVE

To obtain longitudinal data on the clinical, serologic, and immunogenetic features of children with mixed connective tissue disease (MCTD).

METHODS

Eleven children with MCTD were followed up for a mean of 9.8 years. Enzyme-linked immunosorbent assay and immunoblotting were used to analyze sera for autoantibodies to small nuclear ribonucleoprotein polypeptides. HLA types were determined in 9 patients, by microcytotoxicity and DNA typing.

RESULTS

All 11 children had anti-U1-70-kd auto-antibodies. Six of 9 were positive for HLA-DR2, 4 of 9 for HLA-DR4, and 9 of 9 for either HLA-DR2 or DR4. Outcomes were favorable with no functional impairment in 8 of the 11 children and were poor in 3.

CONCLUSION

The frequency of HLA-DR2/DR4 is increased among children with anti-U1-70-kd autoantibody positive MCTD.

Methotrexate in juvenile rheumatoid arthritis. Do the benefits outweigh the risks?

Juvenile rheumatoid arthritis (JRA) is a heterogeneous group of autoimmune diseases resulting in chronic idiopathic peripheral arthritis. The aetiology of JRA is unclear, and current pharmacotherapy is ameliorative rather than curative. Nonsteroidal anti-inflammatory drugs are given initially, but only one-third to one-fourth of patients are managed adequately with these agents. Advanced therapeutic drugs, frequently referred to as disease-modifying antirheumatic drugs or second-line agents, are given to the child with aggressive or resistant disease. Among these, the antimetabolite methotrexate has proven to be the most effective in alleviating articular disease manifestations and reducing laboratory parameters of inflammation. When given orally in low dosages (10 to 15 mg/m2/week), methotrexate is well tolerated, without evidence of substantial bone marrow suppression or severe hepatotoxicity. Extensive long term tolerability data are not yet available for children, but longitudinal studies in adult patients with rheumatoid arthritis suggest that the drug may be given safely for extended periods in many patients. Paediatric rheumatologists are beginning to give higher dosages of methotrexate (up to 1 mg/kg/week) parenterally with some success. The long term consequences of higher dose methotrexate in children are unknown. Methotrexate has now become, and will probably remain for some time, the drug of first choice for children with recalcitrant JRA.

Comparative efficacy and safety of advanced drug therapy in children with juvenile rheumatoid arthritis

Results from three randomized placebo-controlled trials were combined in a meta-analysis to compare the clinical utility of four advanced drug therapy agents used to treat juvenile rheumatoid arthritis (JRA): D-penicillamine (10 mg/kg/d), hydroxychloroquine (6 mg/kg/d), auranofin (oral gold, 0.15 to 0.20 mg/kg/d), and two low dose levels of methotrexate [5MTX, 5 mg/M2/wk; 10MTX, 10 mg/M2/wk]. A total of 520 children with JRA were enrolled into these trials. Only 10MTX resulted in significantly greater improvement than placebo in variables that assess effectiveness: physician's global assessment, a composite index, and erythrocyte sedimentation rate. Treatment effect sizes were the largest in the 10MTX group for all articular disease indices. The short-term safety profiles were similar across all treatment groups. It is concluded that the current trend among pediatric rheumatologists to use oral methotrexate as the first advanced drug therapy in JRA is appropriate and that the minimum effective dose is 10 mg/M2/wk.

Methotrexate in resistant juvenile rheumatoid arthritis. Results of the U.S.A.-U.S.S.R. double-blind, placebo-controlled trial. The Pediatric Rheumatology Collaborative Study Group and The Cooperative Children's Study Group

BACKGROUND

The antimetabolite methotrexate has been shown in placebo-controlled trials to be effective in adults with rheumatoid arthritis. Methotrexate may also be effective in children with resistant juvenile rheumatoid arthritis, but the supporting data are from uncontrolled trials.

METHODS

Centers in the United States and the Soviet Union participated in this randomized, controlled, double-blind trial designed to evaluate the effectiveness and safety of orally administered methotrexate. Patients received one of the following treatments each week for six months: 10 mg of methotrexate per square meter of body-surface area (low dose), 5 mg of methotrexate per square meter (very low dose), or placebo. The use of prednisone (less than or equal to 10 mg per day) and two nonsteroidal antiinflammatory drugs was also allowed.

RESULTS

The 127 children (mean age, 10.1 years) had a mean duration of disease of 5.1 years; 114 qualified for the analysis of efficacy. According to a composite index of several response variables, 63 percent of the children who received low-dose methotrexate improved, as compared with 32 percent of those in the very-low-dose group and 36 percent of those in the placebo group (P = 0.013). As compared with the placebo group, the low-dose group also had significantly larger mean reductions from base line in the number of joints with pain on motion (-11.0 vs. -7.1), the pain-severity score (-19 vs. -11.5), the number of joints with limited motion (-5.4 vs. -0.7), and the erythrocyte sedimentation rate (-19.0 vs. -6 mm per hour). In the methotrexate groups only three children had the drug discontinued because of mild-to-moderate side effects; none had severe toxicity.

CONCLUSIONS

Methotrexate given weekly in low doses is an effective treatment for children with resistant juvenile rheumatoid arthritis, and at least in the short term this regimen is safe.

Current status of the medical treatment of children with juvenile rheumatoid arthritis

Based on clinical experience and the aforementioned studies, a number of opinions can be entertained concerning the historically traditional conservative management of children with JRA. 1. Because the inflammatory changes of JRA on the bones and joints once established are irreversible in most children, there are ample theoretical reasons to start more effective therapy (if available) early. 2. Most of the currently available drugs control inflammation only partially or temporarily. 3. Most children stop taking the various SAARDS after approximately 2 years of disease because of lack of efficacy or the development of toxicity. 4. Whereas corticosteroids are the most potent and effective anti-inflammatory agents, long-term use in children, even in low dosage, is severely limited, especially by their effect on growth. 5. Methotrexate appears to be the most effective of the alternative agents and much safer than expected when used in the currently recommended protocol. 6. More effective therapy must await a better understanding of the pathogenesis of JRA, although currently available medications might be used more rationally by taking into consideration available pharmacologic studies.

Estimation of bone mineral density in children with juvenile rheumatoid arthritis

Bone mineral content of different areas of the skeleton was measured by dual photon absorptiometry in 20 children with juvenile rheumatoid arthritis (JRA) and compared to 20 age and sex matched healthy children. Spinal density was similar in both groups in prepubertal children but decreased in the postpubertal girls with JRA. Total bone density was also decreased in the postpubertal girls. Six children with JRA had repeat scans 12 to 24 months later; in 3 children total bone mineral content increased significantly with an intensive management program. Our study suggests that bone mineral density does not show a pubertal increase in children with JRA, as it does in healthy children.

Pediatric rheumatology: fellowship training requirements and survey of specialty needs

This article documents the growth of pediatric rheumatology in the decade since Park City I as an emerging academic pediatric subspecialty. Current staffing patterns are surveyed for our medical schools and estimates of future requirements for fellowship training are provided. Impediments to the necessary growth of this subspecialty for the needs of clinical practice and research are outlined and criteria for certification are reviewed.

Miscellaneous conditions associated with arthritis in children

Miscellaneous conditions associated with arthritis in children are reviewed as distinct entities in the differential diagnosis of the many types of juvenile arthritis reviewed here and in other articles.

Respiratory dysfunction in patients with common variable hypogammaglobulinemia

Patients with common variable hypogammaglobulinemia (CVH) are susceptible to recurrent respiratory infections. We studied the prevalence and severity of respiratory dysfunction in 32 patients with CVH by measuring routine pulmonary function tests (PFT) and interpreting chest radiographs using a quantitative score system. Pulmonary symptoms were determined by patient interview and standard questionnaire. The mean age of 29 living patients was 28 +/- 2.2 yr; there were 22 males and 10 females. The mean age at diagnosis was 17.3 +/- 2.4 yr. Sinopulmonary symptoms were present in all 32 patients and included chronic sinusitis, otitis, bronchitis, recurrent pneumonia, and bronchiectasis. Complete PFT in 25 patients revealed restrictive, obstructive, and normal patterns in 10, 6, and 9 patients, respectively. Nine patients had dyspnea on exertion. Recent chest radiographs in 32 patients showed evidence of recurrent pulmonary infection, including air trapping, linear markings, and pleural abnormalities. Panlobular emphysema, documented in one case at autopsy, was suggested in 5 other patients by the presence of lower lobe bullous lesions and marked lower lobe hyperlucency on chest radiographs. The forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) had remained stable in 19 adults (18 receiving adequate immunoglobulin replacement therapy) for 6.9 +/- 0.7 yr. The expected increase of the FEV1 and FVC with growth was normal in 6 of 8 children (all 8 receiving adequate therapy). Chest radiograph scores deteriorated only slightly from 20.3 +/- 0.6 to 18.4 +/- 0.8 (25 = normal) during the 6.9 +/- 0.7 yr in 30 patients (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

A study of classification criteria for a diagnosis of juvenile rheumatoid arthritis

Criteria for the classification of juvenile rheumatoid arthritis were analyzed in a detailed database of 250 children in order to assess the accuracy of diagnosis and validity of onset types and course subtypes. A number of conclusions have been derived from this study: All definitions of the 1973 criteria for classification of juvenile rheumatoid arthritis should be retained. The addition of onset types to the 1976 revision of the criteria has been validated. The course of the disease after the onset period of 6 months is as important to the outcome of a group of children as is the onset type. The current classification should be broadened to include the course subtypes.

Popliteal cysts

Popliteal cysts may be formed by the escape of a synovial effusion into one of the popliteal bursae. There is usually preexisting knee joint pathology. Presenting complaints include pain and swelling in the posterior aspect of the knee. The cyst may dissect into the calf between the muscle planes and produce pressure on draining lymphatics and veins, resulting in lower leg edema. These cysts are often mistakenly treated as deep vein thrombosis.

Immune induction of human monocyte plasminogen activator. Characteristics of an assay for cell-mediated immunity

We characterized immunologic induction of monocyte plasminogen activator (PA) to determine whether assay for PA induction reliably detected cell-mediated immunity (CMI). Mononuclear leukocytes (MNL) were incubated in teflon-lined culture tubes for 1-4 days in the presence or absence of phytohemagglutinin-P (PHA), concanavalin A (Con A) or Candida antigen. PA activity of the monocytes in those suspensions was then measured using a micro fibrin plate assay. Monocytes in stimulated MNL had more PA activity than monocytes in unstimulated MNL. Maximal differences between stimulated and unstimulated cells were seen after 2 days of culture. Dose-response studies demonstrated that PA induction occurred at submitogenic concentrations of stimuli. Peak induction was seen using suboptimally mitogenic concentrations of PHA, Con A and Candida antigen. PA induction in response to Candida stimulation corresponded with skin test results. More than 90% of healthy adults tested had positive assays to all stimuli. LPS, in picogram concentrations, induced PA activity in the absence of lymphocytes, but such induction was prevented by polymyxin B. Supernates from activated MNL also induced PA in purified monocytes. This indirect assay of PA induction was less sensitive than direct assay of the MNL. A standard indirect assay for leukocyte inhibitory factor (LIF) was also less sensitive than the direct PA induction assay. The direct PA induction assay is sensitive and convenient and requires small volumes of blood. It may prove valuable in in vitro analysis of cell-mediated immunity in health and disease.

Immunity in dilated cardiomyopathy

Although several immunologic parameters have been found to be abnormal, their precise relationship to the cause of the disease remains unclear. It is believed that a virus initiating a bout of myocarditis may play a role in the perpetuation of the chronic phase, probably via immunologic mediation. A selection acquired defect or damage to a subpopulation of suppressor T lymphocytes is possible, providing the basis for the development of an autoimmune disorder. Studies in mice have shown a clear link between active viral myocarditis and the subsequent development of cardiomyopathy. However, the trigger mechanism that initiates the cardiomyopathy is still elusive. Specific antigens, possibly altered virus or damaged cardiac tissue, may be playing the role of the "hidden or cloistered" antigen in eliciting the immunologic reactions through a cytotoxic T-cell mechanism. Identification and isolation of the specific "antigen" in question could resolve the dilemmas about the immunopathogenesis of cardiomyopathy in humans.

HLA-DR and MT associations with the clinical and serologic manifestations of pauciarticular onset juvenile rheumatoid arthritis

Significant HLA-DR and MT associations were observed with certain clinical and serologic manifestations of pauciarticular onset juvenile rheumatoid arthritis (PO-JRA). An increase in the MTI frequency was found in 56 children with PO-JRA in comparison to 95 normal controls. This association was limited to children with a younger age of onset (less than 6 years) and a persistent pauciarticular course. An increase in HLA-DRW8 and a decrease in DR4 were associated with a younger age of onset and antinuclear antibody (ANA) seropositivity. In addition, an increased frequency of DR5 was seen in ANA positive children. All of these HLA-DR and MT associations were independent of coassociating Ia specificities.

Modern ergotism

A patient taking excessive amounts of an ergot alkaloid for the treatment of migraine headaches developed cool, painful, swollen lower extremities with intermittent claudication and sensory changes. Symptoms subsided and pulses returned within a day of cessation of therapy. "St. Anthony's fire" may be due to stimulation of alpha-adrenergic receptors in the peripheral vasculature. Rebound headache after withdrawal of ergot alkaloids may lead to self-medication and overdosage, with subsequent risk of ergotism.

Childhood dermatomyositis: factors predicting functional outcome and development of dystrophic calcification

The medical records of 47 children with dermatomyositis who were seen in the pediatric rheumatology clinic at the University of Michigan between 1964 and 1982 were reviewed. Although most children with dermatomyositis have a good prognosis, the best predictor of both good functional recovery and minimal calcinosis is early treatment after the onset of symptoms, using high doses of prednisone for an adequate length of time. Of the children given such treatment, 78% had good functional outcomes, and disabling calcinosis was seen in 20% or less. Children given treatment late in the course of disease and with low doses of steroids are more likely to be functionally limited and have a greater amount of dystrophic calcium salt deposition. In our study, only 33% of patients given such treatment had a mild disease course with good functional outcome. We have identified a subgroup of children with dermatomyositis who appear to do poorly despite optimal therapeutic regimens. These patients are distinguished by a severe disease course responding minimally to corticosteroid therapy and manifested by persistent muscle weakness, elevations of muscle enzyme activity, and severe generalized cutaneous vasculitis. These children are at high risk for the development of exoskeleton-like calcification; consideration should be given to combined immunosuppressive therapy early in the course of disease.

Inhibition of leucocyte migration by stimulated mononuclear cell supernatants from patients with ischaemic heart disease

Leucocyte migration inhibition in patients with ischaemic heart disease was evaluated as an assay for progressive myocardial damage. Abnormal results were observed in 50% of patients with ischaemic cardiac disease. The prevalence of abnormal leucocyte migration inhibition was unrelated to clinical presentation, extent of coronary artery disease, or degree of impairment of left ventricular function. Six of the eight patients with unstable angina pectoris and abnormal leucocyte migration inhibition developed life threatening cardiac complications in the follow-up period compared with five patients with unstable angina and normal tests who developed no complications. A similar association between abnormal leucocyte migration inhibition and complications was not observed in patients with angina pectoris or previous myocardial infarction. Thus, leucocyte migration inhibition may be useful as a prognostic marker in unstable angina and may be an important additional variable to identify a high risk subset.

Mucha-Habermann disease in children -- the association with rheumatic diseases

Two children are described who developed Mucha-Habermann disease as infants. One boy had juvenile rheumatoid arthritis that ran a progressive course over 10 years, although his skin disease responded to a low dose of corticosteroids. One girl had polyarthritis associated with onset of her rash but both resolved over several years without treatment. She has since developed scleroderma followed by a reappearance of her skin lesions.

Sodium meclofenamate (Meclomen) in the treatment of juvenile rheumatoid arthritis. A segment I study

Thirty-nine patients with JRA were treated with sodium meclofenamate (Meclomen) during a 4-wk open-labeled, non-controlled trial. Increasing doses started at 3 mg/kg/d qid, up to 7.5 mg/kg/d, not to exceed 300 mg/d. Seven patients dropped out due to adverse side effects, and 1 from inefficacy. Efficacy analysis showed statistically significant decreases in several disease indices, in particular the duration of morning stiffness. Twenty-one patients who completed the 4-wk study entered an extended open-labeled study. Nine patients completed at least 9 months of sodium meclofenamate therapy. At 9 months, these 19 showed mean decreases in all rheumatologic disease indices measured. The drug has recently been approved by the Food and Drug Administration for use in adults.

Tubercle bacilli retain pathogenicity after seven weeks chemotherapy

Guinea pig inoculation of sputum from patients on anti-tuberculous therapy shows that, in some cases, the tubercle bacilli retain their pathogenicity for seven weeks or more. It is and has been accepted in general for many years now that patients with active pulmonary tuberculosis receiving anti-tuberculous drugs become noninfectious in a relatively rapid time. Several factors have been said to contribute to this. Among these are: (i) patients on chemotherapy have a reduced cough and consequently expel fewer tubercle bacilli into the atmosphere; (ii) it has been suggested that patients receiving antituberculous drugs excrete these in the sputum droplets along with the tubercle bacilli and evaporation of the droplets causes concentrations of the anti-tuberculous drugs to increase, thereby reducing or destroying the viability of the organism; and (iii) chemotherapy rapidly reduces the number of bacilli excreted in sputum and this in itself may reduce the possibility of infection.