Body size and substrate use affect ventral, but not dorsal, brightness evolution in lizards

Substrate properties can affect the thermal balance of organisms, and the colored integument, alongside other factors, may influence heat transfer via differential absorption and reflection. Dark coloration may lead to higher heat absorption and could be advantageous when substrates are cool (and vice versa for bright coloration), but these effects are rarely investigated. Here, we examined the effect of substrate reflectance, specific heat capacity (cp), and body size on the dorso-ventral brightness using 276 samples from 12 species of cordylid lizards distributed across 26 sites in South Africa. We predicted, and found, that bright ventral colors occur more frequently in low cp (i.e. drier, with little energy needed for temperature change) substrates, especially in larger body-sized individuals, possibly to better modulate heat transfer with the surrounding environment. By contrast, dorsal brightness was not associated with body size nor any substrate thermal property, suggesting selection pressures other than thermoregulation. Ancestral estimation and evolutionary rate analyses suggest that ventral brightness rapidly differentiated within the Cordylinae starting 25 Mya, coinciding with an aridification period, further hinting at a thermoregulatory role for ventral colors. Our study indicates that substrate properties can have a direct role in shaping the evolution of ventral brightness in ectotherms.

Evolution of eggshell structure in relation to nesting ecology in non-avian reptiles

Amniotic eggs are multifunctional structures that enabled early tetrapods to colonize the land millions of years ago, and are now the reproductive mode of over 70% of all terrestrial amniotes. Eggshell morphology is at the core of animal survival, mediating the interactions between embryos and their environment, and has evolved into a massive diversity of forms and functions in modern reptiles. These functions are critical to embryonic survival and may serve as models for new antimicrobial and/or breathable membranes. However, we still lack critical data on the basic structural and functional properties of eggs, particularly of reptiles. Here, we first characterized egg shape, shell thickness, porosity, and mineralization of eggs from 91 reptile species using optical images, scanning electron microscopy, and micro computed tomography, and collected data on nesting ecology from the literature. We then used comparative analyses to test hypotheses on the selective pressures driving their evolution. We hypothesized that eggshell morphology has evolved to protect shells from physical damage and desiccation, and, in support, found a positive relationship between thickness and precipitation, and a negative relationship between porosity and temperature. Although mineralization varied extensively, it was not correlated with nesting ecology variables. Ancestral state reconstructions show thinning and increased porosity over evolutionary time in squamates, but the opposite in turtles and crocodilians. Egg shape, size, porosity and calcification were correlated, suggesting potential structural or developmental tradeoffs. This study provides new data and insights into the morphology and evolution of reptile eggs, and raises numerous questions for additional research.

Untangling the structural and molecular mechanisms underlying colour and rapid colour change in a lizard, Agama atra

With functions as diverse as communication, protection and thermoregulation, coloration is one of the most important traits in lizards. The ability to change colour as a function of varying social and environmental conditions is thus an important innovation. While colour change is present in animals ranging from squids, to fish and reptiles, not much is known about the mechanisms behind it. Traditionally, colour change was attributed to migration of pigments, in particular melanin. More recent work has shown that the changes in nanostructural configuration inside iridophores are able to produce a wide palette of colours. However, the genetic mechanisms underlying colour, and colour change in particular, remain unstudied. Here we use a combination of transcriptomic and microscopic data to show that melanin, iridophores and pteridines are the main colour-producing mechanisms in Agama atra, and provide molecular and structural data suggesting that rapid colour change is achieved via melanin dispersal in combination with iridophore organization. This work demonstrates the power of combining genotypic (gene expression) and phenotypic (microscopy) information for addressing physiological questions, providing a basis for future studies of colour change.

Substrate thermal properties influence ventral brightness evolution in ectotherms

The thermal environment can affect the evolution of morpho-behavioral adaptations of ectotherms. Heat is transferred from substrates to organisms by conduction and reflected radiation. Because brightness influences the degree of heat absorption, substrates could affect the evolution of integumentary optical properties. Here, we show that vipers (Squamata:Viperidae) inhabiting hot, highly radiative and superficially conductive substrates have evolved bright ventra for efficient heat transfer. We analyzed the brightness of 4161 publicly available images from 126 species, and we found that substrate type, alongside latitude and body mass, strongly influences ventral brightness. Substrate type also significantly affects dorsal brightness, but this is associated with different selective forces: activity-pattern and altitude. Ancestral estimation analysis suggests that the ancestral ventral condition was likely moderately bright and, following divergence events, some species convergently increased their brightness. Vipers diversified during the Miocene and the enhancement of ventral brightness may have facilitated the exploitation of arid grounds. We provide evidence that integument brightness can impact the behavioral ecology of ectotherms.

Proteomic and functional variation within black snake venoms (Elapidae: Pseudechis)

Pseudechis (black snakes) is an Australasian elapid snake genus that inhabits much of mainland Australia, with two representatives confined to Papua New Guinea. The present study is the first to analyse the venom of all 9 described Pseudechis species (plus one undescribed species) to investigate the evolution of venom composition and functional activity. Proteomic results demonstrated that the typical Pseudechis venom profile is dominated by phospholipase A₂ toxins. Strong cytotoxicity was the dominant function for most species. P. porphyriacus, the most basal member of the genus, also exhibited the most divergent venom composition, being the only species with appreciable amounts of procoagulant toxins. The relatively high presence of factor Xa recovered in P. porphyriacus venom may be related to a predominantly amphibian diet. Results of this study provide important insights to guide future ecological and toxinological investigations.

Beyond colour: consistent variation in near infrared and solar reflectivity in sunbirds (Nectariniidae)

The visible spectrum represents a fraction of the sun's radiation, a large portion of which is within the near infrared (NIR). However, wavelengths outside of the visible spectrum that are reflected by coloured tissues have rarely been considered, despite their potential significance to thermal effects. Here, we report the reflectivity from 300 to 2100 nm of differently coloured feathers. We measured reflectivity across the UV-Vis-NIR spectra of different (a) body parts, (b) colour-producing mechanisms and (c) sexes for 252 individuals of 68 sunbird (family: Nectariniidae) species. Breast plumage was the most reflective and cap plumage the least. Female plumage had greater reflectivity than males. Carotenoid-based colours had the greatest reflectivity, followed by non-iridescent and iridescent melanin-based colours. As ordered arrays of melanin-filled organelles (melanosomes) produce iridescent colours, this suggests that nanostructuring may affect reflectance across the spectrum. Our results indicate that differently coloured feathers consistently vary in their thermal, as well as obvious visual, properties.

Correlation between ontogenetic dietary shifts and venom variation in Australian brown snakes (Pseudonaja)

Venom is a key evolutionary trait, as evidenced by its widespread convergent evolution across the animal kingdom. In an escalating prey-predator arms race, venoms evolve rapidly to guarantee predatory or defensive success. Variation in venom composition is ubiquitous among snakes. Here, we tested variation in venom activity on substrates relevant to blood coagulation among Pseudonaja (brown snake) species, Australian elapids responsible for the majority of medically important human envenomations in Australia. A functional approach was employed to elucidate interspecific variation in venom activity in all nine currently recognised species of Pseudonaja. Fluorometric enzymatic activity assays were performed to test variation in whole venom procoagulant activity among species. Analyses confirmed the previously documented ontogenetic shift from non-coagulopathic venom in juveniles to coagulopathic venom as adults, except for the case of P. modesta, which retains non-coagulopathic venom as an adult. These shifts in venom activity correlate with documented ontogenetic shifts in diet among brown snakes from specialisation on reptilian prey as juveniles (and throughout the life cycle of P. modesta), to a more generalised diet in adults that includes mammals. The results of this study bring to light findings relevant to both clinical and evolutionary toxinology.

Rituximab in refractory autoimmune diseases: Brazilian experience with 29 patients (2002-2004)

OBJECTIVE

Rituximab, a monoclonal antibody against B-lymphocytes that express CD 20, is already available for the treatment of non-Hodgkin's lymphoma. Due to the increased relevance of B-cell regulation in the pathogenesis of autoimmune diseases, rituximab is being used in the treatment of patients whose condition is refractory to conventional therapy.

METHODS

We retrospectively evaluated the short-term efficacy and tolerance of rituximab in patients with various autoimmune diseases who were treated at the Hospital Israelita Albert Einstein in the city of Sao Paulo.

RESULTS

During the period 2002-2004, 29 patients with various autoimmune diseases were treated with rituximab 375 mg/m2 for 4 consecutive weeks, or two doses of 1 g 2 weeks apart. We observed remarkable short-term results in all cases, except for one patient with thrombocytopenic purpura. Of note, we describe the results in two patients with diseases not previously treated with rituximab (hypergammaglobulinemic purpura of Waldenstrom and eosinophilic fasciitis with hypergammaglobulinemia). Treatment was well tolerated, with no unexpected adverse events. We also observed a marked reduction in steroid dosage.

CONCLUSION

Rituximab seems to be safe and effective in the treatment of patients with a variety of autoimmune diseases that are refractory to other modalities of treatment.

Resource utilization and cost of rheumatic fever

OBJECTIVE

The socioeconomic effects of rheumatic fever (RF) in Brazil, including direct and indirect costs to patients and their families and to society, are largely unknown. We evaluated the utilization of resources and costs related to RF in a tertiary center caring for low income patients in the city of São Paulo, Brazil.

METHODS

One hundred patients with RF, younger than 18 yrs, with followup of at least one year, were sequentially selected to provide complete information on a questionnaire. Additional data were collected from patients' charts. The utilization of resources was evaluated for each patient throughout the entire disease course. Costs were determined for patients and their families as well as for the society, using variables from 3 different systems: the national public health system, used by most lower income groups; the Brazilian Medical Association, which regulates charges and fees utilized by health plans and insurance companies; and costs charged by private practitioners, paid directly by patients.

RESULTS

The RF population studied belonged to a low socioeconomic level. The mean monthly family income was $625.20 US. The mean disease duration was 3.9 yrs (range 1-10). Patients had a total of 1657 medical consultations, 22 hospital admissions, and 4 admissions to intensive care unit. Work absenteeism among parents was calculated as 22.9%, equivalent to 901 days of missed work; about 5% of the parents lost their jobs. Patients showed a high rate of school failure (22%). Considering the public system as a reference, direct, indirect, and total costs to society per 100 patients throughout the entire disease duration were $105,860 US ($271/patient/yr), $18,803 US ($48/patient/yr), and $124,663 US (US $319/patient/yr), respectively. When health care plan and private systems were taken as reference, the total costs were $423,550 US and $684,351 US, respectively.

CONCLUSION

RF and rheumatic heart disease have an important socioeconomic impact in Brazil; costs of RF made up roughly 1.3% of annual family income. The estimated annual cost of RF for society in Brazil is $51,144,347.00 US.

Bone mineral density of the lumbar spine of Brazilian children and adolescents aged 6 to 14 years

The authors performed a study of bone mass in eutrophic Brazilian children and adolescents using dual-energy X-ray absorptiometry (DXA) in order to obtain curves for bone mineral content (BMC) and bone mineral density (BMD) by chronological age and correlate these values with weight and height. Healthy Caucasian children and adolescents, 120 boys and 135 girls, 6 to 14 years of age, residents of São Paulo, Brazil, were selected from the Pediatric Department outpatient clinic of Hospital São Paulo (Universidade Federal de São Paulo). BMC, BMD and the area of the vertebral body of the L2-L4 segment were obtained by DXA. BMC and BMD for the lumbar spine (L2-L4) presented a progressive increase between 6 and 14 years of age in both sexes, with a distribution that fitted an exponential curve. We identified an increase of mineral content in female patients older than 11 years which was maintained until 13 years of age, when a new decrease in the velocity of bone mineralization occurred. Male patients presented a period of accelerated bone mass gain after 11 years of age that was maintained until 14 years of age. At 14 years of age the mean BMD values for boys and girls were 0.984 and 1.017 g/cm2, respectively. A stepwise multiple regression analysis of paired variables showed that the "vertebral area-age" pair was the most significant in the determination of BMD values and the introduction of a third variable (weight or height) did not significantly increase the correlation coefficient.

Translation, adaptation and validation of the Roland-Morris questionnaire--Brazil Roland-Morris

The purpose of the present study was to translate the Roland-Morris (RM) questionnaire into Brazilian-Portuguese and adapt and validate it. First 3 English teachers independently translated the original questionnaire into Brazilian-Portuguese and a consensus version was generated. Later, 3 other translators, blind to the original questionnaire, performed a back translation. This version was then compared with the original English questionnaire. Discrepancies were discussed and solved by a panel of 3 rheumatologists and the final Brazilian version was established (Brazil-RM). This version was then pretested on 30 chronic low back pain patients consecutively selected from the spine disorders outpatient clinic. In addition to the traditional clinical outcome measures, the Brazil-RM, a 6-point pain scale (from no pain to unbearable pain), and its numerical pain rating scale (PS) (0 to 5) and a visual analog scale (VAS) (0 to 10) were administered twice by one interviewer (1 week apart) and once by one independent interviewer. Spearman's correlation coefficient (SCC) and intraclass correlation coefficient (ICC) were computed to assess test-retest and interobserver reliability. Cross-sectional construct validity was evaluated using the SCC. In the pretesting session, all questions were well understood by the patients. The mean time of questionnaire administration was 4 min and 53 s. The SCC and ICC were 0.88 (P<0.01) and 0.94, respectively, for the test-retest reliability and 0.86 (P<0.01) and 0.95, respectively, for interobserver reliability. The correlation coefficient was 0.80 (P<0.01) between the PS and Brazil-RM score and 0.79 (P<0.01) between the VAS and Brazil-RM score. We conclude that the Brazil-RM was successfully translated and adapted for application to Brazilian patients, with satisfactory reliability and cross-sectional construct validity.

Nail fold capillaroscopy: normal findings in children and adolescents

OBJECTIVES

Capillaroscopy is a simple diagnostic method that permits noninvasive in vivo study of the capillary network. Studies designed to standardize capillary normality in children are limited. This article presents the capillaroscopic findings in healthy children and adolescents, thus making the application of this methodology viable for patients in this age range.

MATERIAL AND METHODS

Healthy children were recruited from a private elementary school and junior high school. Nail fold capillaroscopy was performed using a stereomicroscope at 16 times magnification, addressing the following parameters: capillary morphology, capillary enlargement, devascularization, microhemorrhage, and subpapillary venous plexus visibility (PVS). These parameters were related to age, sex, ethnicity, and local periungal conditions.

RESULTS

The sample comprised 329 individuals with mean age of 8.2 years. We observed atypical capillary morphology in 118 of the studied cases (36%), mainly bizarre capillaries in 90 (27%), meandering capillaries in 32 (10%), and bushy capillaries in 20 (6%). The enlarged capillary phenomenon was uncommon, being observed in 30 cases (9%). The number of capillaries per millimeter varied from five to nine. Deletion areas were detected in only seven individuals (2%). The subpapillary venous plexus was not visualized in 13 (4%) cases. Younger children presented higher PVS scores and fewer capillaries/mm as compared with older children. PVS scores were lower in males and in nonwhite children. Other variables were not associated with sex or ethnicity.

CONCLUSIONS

The normal nail fold capillary network in children resembles that observed in adults with some differences, such as a lower number of loops per millimeter, a higher PVS score, and a higher frequency of atypical loops. This information is important for the diagnostic evaluation of children in the context of autoimmune rheumatic diseases.

Pediatric Escola Paulista de Medicina Range of Motion Scale: a reduced joint count scale for general use in juvenile rheumatoid arthritis

OBJECTIVE

Different instruments are available to measure functional status in juvenile rheumatoid arthritis (JRA); however, none is based on the evaluation of joint range of motion (ROM). We designed and evaluated a ROM scale to be used as a complementary instrument in daily practice with JRA as well as in trials.

METHODS

The 10 joint movements of the Pediatric Escola Paulista de Medicina Range of Motion scale (Pediatric EPM-ROM) were derived from 25 initial movements. The selection was based on 2 criteria: (1) consensus among 3 pediatric rheumatologists, one physical therapist, and one occupational therapist; and (2) choice of movements that presented the highest scores in a pilot study involving patients with JRA. The score for each joint ranges from 0 (full movement) to 3 (severe limitation) and the cutoff degrees of motion are, in general, based on the lack of ability to perform some activities of daily living. The test-retest reliability was assessed by administering the scale twice by the same observer, 4 to 10 days apart, always in the morning. The interobserver reliability was evaluated on the same day by 2 independent observers. Cross sectional construct validity was also assessed by correlating the values of some clinical variables with the scores of the Pediatric EPM-ROM scale.

RESULTS

The instrument was applied to 34 patients with JRA, 11 systemic, 11 polyarticular, and 12 pauciarticular. The mean EPM-ROM score was 0.57 (SD 0.54, min 0, max 2.05). The test-retest and interobserver correlation coefficients were 0.96 and 0.98, respectively. The Pearson correlation coefficients comparing scores of the Pediatric EPM-ROM scale and other variables were satisfactory: Childhood Health Assessment Questionnaire, r=0.55 (p<0.001); American College of Rheumatology global functional class, r=0.56 (p<0.001); and number of limited joints, r=0.65 (p<0.001).

CONCLUSION

Our results provide evidence that the Pediatric EPM-ROM scale is a valid instrument to measure joint ROM in JRA.

Gastroduodenal lesions in children with juvenile rheumatoid arthritis

BACKGROUND/AIMS

There are few studies about gastrointestinal abnormalities in patients with juvenile rheumatoid arthritis-probably due to the fact that this association is not frequently recognized. The aim of our study was to observe the prevalence of endoscopic gastroduodenal lesions in these patients.

METHODOLOGY

Fourteen patients with juvenile rheumatoid arthritis, all of them using non-steroidal anti-inflammatory drugs associated or not with methotrexate, were assessed clinically and by endoscopy. Gastric antrum biopsy and Helicobacter pylori search were also performed.

RESULTS

The mean age of the patients was 10.6 years (7 boys). Abdominal pain was observed in 27% of them. Macroscopic endoscopic lesions were found in 43% and infection by Helicobacter pylori in 57%. The correlation between anemia and endoscopic abnormalities was statistically significant (p < 0.05).

CONCLUSIONS

Our data show that patients with juvenile rheumatoid arthritis have considerable susceptibility to gastroduodenal lesions, especially if they are using any drug association and present anemia.

Association of ankylosing spondylitis, Crohn's disease and Takayasu's arteritis in a child

The authors report the case of a 15-year-old, HLA-B27-positive male patient who presented a rare association of ankylosing spondylitis, Crohn's disease and Takayasu's arteritis, which resulted in death. A brief review of the literature is provided.

Ultrasonography in the early diagnosis of hip joint involvement in juvenile rheumatoid arthritis

OBJECTIVE

To determine the value of ultrasonography in detection of early alterations and subsequent evolution of hip joint disease in patients with juvenile rheumatoid arthritis (JRA).

METHODS

Hip joints of 53 patients were evaluated clinically, by conventional radiography and ultrasound. Ten children free of signs/symptoms related to rheumatic diseases were chosen as a control group. Nine patients were followed up 28 months after baseline examinations. The clinical, radiological, and ultrasound evaluations were repeated.

RESULTS

Conventional radiography showed alterations in 10 patients (18.9%) who had shown clinical manifestations of advanced disease of the hip joint while ultrasound detected abnormalities in asymptomatic patients who had had normal radiographs. Ultrasound revealed the occurrence of 47.2% involvement in the hips of patients with JRA. Thus, ultrasound was apparently more sensitive than conventional radiographs in diagnosing changes in the hip joints of patients with JRA. Further, such involvement was found with greater frequency in the systemic and polyarticular types of JRA, in children less than 5 years of age, in those with longer duration of disease, and in those who belonged to a poorer functional class. In 3 of 9 patients who initially had normal radiographs and altered ultrasound, we found severe hip alterations upon reevaluation by radiography, after a period ranging from 21 to 39 months.

CONCLUSION

Ultrasonography is a method of diagnosis that must be considered in hip joint evaluation of patients with JRA.

Juvenile fibromyalgia: clinical and polysomnographic aspects

OBJECTIVE

To identify the child-mother diagnostic correlation in fibromyalgia (FM), to study sleep disturbance in juvenile FM, and to compare clinical aspects and sleep disorders between these groups.

METHODS

We studied 34 children with confirmed FM aged 11 +/- 1 years, 10 children with diffuse pain, and 17 age and sex matched asymptomatic controls. The respective 61 mothers were included: 34 asymptomatic and 27 with FM. All participants were subjected to clinical evaluation, a sleep questionnaire, and nocturnal polysomnography, preceded by a night of adaptation. Sleep scoring was done visually and a computerized analysis was performed for alpha, theta, and delta waves in slow wave sleep (SWS).

RESULTS

A significant predominance of mothers with FM was observed in the group of children with FM (71%) compared to children with diffuse pain (30%) and asymptomatic children (0%). According to the sleep questionnaire, the complaints of superficial sleep and nonrestorative sleep were more prominent in mothers with FM than in children with FM, whereas motor agitation during sleep was more frequent in the children with FM. Polysomnographic anomalies were also more prominent in mothers with FM than in children with FM in terms of decrease in sleep efficiency, increase of number of arousals during sleep, and alpha intrusion in SWS. Both FM groups presented an increased alpha + theta time/delta time index during SWS compared to respective controls, and mothers with FM also showed an increase in alpha time/delta time index during SWS, compared to asymptomatic mothers. A correlation was found between alpha + theta time/delta time index during SWS and intensity of clinical manifestations of pain and sleep anomalies in children and their mothers.

CONCLUSION

Significant concordance was observed regarding FM diagnosis in children and their mothers. Sleep complaints and polysomnography findings were less prominent in affected children compared to mothers with FM. In addition, we observed a significant correlation between polysomnographic indexes, sleep anomalies, and pain manifestations in children and their mothers.

[Severe pulmonary thromboembolism caused by contraceptives in adolescents]

A 16 year-old female patient on oral contraceptive (gynera-ethynilestradiol+gestadone) for 4 months, presented with acute and severe pulmonary thromboembolism (PT), and was successfully treated with IV streptokinase. The contraceptive use was an importante risk factor for PT and the thrombolytic therapy provided early clinical improvement. Blood pressure, heart rate, and hypoxemia, along with echocardiography and pulmonary arteriography abnormalities, improved after this treatment.

Temporomandibular joint and mandibular growth alterations in patients with juvenile rheumatoid arthritis

OBJECTIVE

To determine the frequency and type of lesions of the temporomandibular joints (TMJ) as well as orthodontic alterations present in patients with juvenile rheumatoid arthritis (JRA).

METHODS

Twenty-six patients had their TMJ evaluated clinically and by high resolution computer tomography. The patients were also submitted to orthodontic evaluation. Children with isolated malocclusion were used as a control group.

RESULTS

Computer tomography detected TMJ alterations in 13 (50%) patients with JRA. Bilateral mild lesions were the most frequent. TMJ alterations were especially observed in young patients with JRA with the systemic and polyarticular type of onset. Worse functional class and corticosteroid therapy were also related to TMJ involvement. We observed orthodontic alterations in 18 patients with JRA (69%): midline deviation, convex facial profile. Class II molar relation, crowded lower anterior teeth, anterior open bite, and reduction in the maximum opening of the mouth. Severe TMJ lesions were correlated to cephalometric alterations, suggesting decreased mandibular growth.

Lymphoma of unknown origin located in paravertebral muscles: an unusual cause of low back pain in children

The authors report a case of an adolescent with a poorly differentiated lymphoma of unknown origin located at paravertebral muscles, whose presently symptom was low back pain.

Crosscultural reliability of the Childhood Health Assessment Questionnaire

OBJECTIVE

To translate into Portuguese the Childhood Health Assessment Questionnaire and to evaluate the reliability of the Portuguese version.

METHODS

The original questionnaire was translated into Portuguese, without modifications, and it was administered to 53 children with juvenile rheumatoid arthritis and their parents. The reproducibility and construct validity were studied.

RESULTS

We observed satisfactory Spearman's correlation coefficients among the instrument's score, a pain score (visual analog scale) and conventional clinical variables commonly used by the pediatric rheumatologists: disease activity index, number of involved joints, American College of Rheumatology functional class, and erythrocyte sedimentation rate. The test-retest reliability was established.

CONCLUSION

Our results provide evidence of the reliability of the Portuguese version of the Childhood Health Assessment Questionnaire.

Evaluation of the 1982 ARA lupus criteria data set in pediatric patients. Committees of Pediatric Rheumatology of the Brazilian Society of Pediatrics and the Brazilian Society of Rheumatology

OBJECTIVE

Although commonly used, the 1982 revised criteria for the classification of Systemic Lupus Erythematosus (SLE) have not been completely evaluated in pediatric patients. This study was aimed at evaluating the sensitivity and specificity of the 1982 revised criteria when applied to pediatric patients.

METHODS

One hundred and three children with SLE and 101 children with other rheumatic diseases were selected from 5 rheumatology centers in Brazil. Diagnosis of SLE by the 1982 criteria were compared with our clinical diagnosis. The diagnosis of other diseases was made according to internationally accepted classification criteria or, when these were not available, according to the physician's own experienced judgement.

RESULTS

The median number of criteria fulfilled by the patients with SLE and the controls were 6 and 1, respectively. The most common criteria observed in children with SLE were: abnormal antinuclear antibody titers (94%), arthritis (83%), immunologic disorder (83%), hematologic disorder (70%), malar rash (67%), and photosensitivity (58%). When the immunologic disorder was broken down into its constituent elements, antibodies to dsDNA and Sm were observed in 73.0% (65/89) and 31.4% (15/48), respectively. The sensitivity and specificity observed were 96% and 100%, respectively.

CONCLUSION

The 1982 classification criteria can be successfully applied to children with SLE. These criteria may serve as a basis for multi-center collaborative studies on children with SLE.

7S IgG rheumatoid factor and hidden 19S IgM rheumatoid factor in juvenile chronic arthritis

Hidden 19S IgM rheumatoid factor (RF) and 7S IgG RF were assayed in 24 children with juvenile chronic arthritis (JCA) and 26 controls, in whole sera and in the IgM and IgG containing fractions of the serum after separation by acid gel filtration. When non-fractioned serum was used, IgM RF detection was positive in 4.2% by latex fixation test and 4.2% by ELISA. IgG RF was positive in 91.7% by ELISA. In the IgM containing fraction of the serum, the positivity for IgM RF was 41.7% by LFT and 54.2% by ELISA. In the IgG containing fraction the positivity for IgG RF was 100%. These results suggest toward the need of previous serum dissociation before hidden 19S IgM RF is assayed and demonstrate high prevalence of 7S IgG RF.

[Infantile scleroderma. Apropos of 11 cases]

Scleroderma is uncommon in children and adolescents. Eighty-four cases have been reported. With reference to a new series of 11 cases, the clinical features and course of the disease are described. Prognosis was good. There have been no deaths and none of the patients have significant visceral organ damage.

Juvenile dermatomyositis and pregnancy: report and literature review

Reports of dermatomyositis (DM) and polymyositis complicating pregnancy are rare. Only nineteen cases have been published. We describe the first case in which juvenile DM appeared during pregnancy. An emergency cesarean section had to be performed due to fetal distress at 37 weeks of gestation. Patient and infant are doing well after 8 months of followup.

[Rheumatic fever: atypical joint manifestations]

The diagnosis of rheumatic fever (RF) continues to be a difficult one in Pediatrics, mainly because of the polymorphism of its clinical presentation and the lack of specific laboratory test. Among the Jones' major criteria, arthritis is the most frequent and the least specific. Ninety three children with RF who presented 117 flares of the disease were studied in the Department of Pediatrics, Escola Paulista de Medicina, between Dec. 1989 and Dec. 1991. The presence of arthritis was defined as an inclusion criterion. The diagnosis was based on history, physical and laboratory examinations (Modified Jones' Criteria). The mean age was 10 years and the sex ratio was 1 male: 1.4 female. In 45% of the flares, arthritis was the only major criterion. In 44% there were arthritis and carditis, in 7% arthritis and chorea and in 4% arthritis, carditis and chorea. In 64% of the flares the pattern of articular involvement was migratory and in 36% addictive. Polyarthritis and oligoarthritis were observed respectively in 64% and 36%. Monoarthritis was reported in 3%. The definitive diagnosis of RF with atypical articular involvement only was possible in the presence of carditis or chorea. The authors conclude that physicians should be aware of the atypical involvement observed in some cases of RF, specially when arthritis is the only major criterion.

Philtral fistula in median cleft lip: cause and effect or coincidence?

An unusual case of a central upper lip fistula, which was associated with a median cleft deformity, is presented. Its potential association with midline facial defects as well as an alternative embryological explanation is discussed.

Serum penicillin concentrations after intramuscular administration of benzathine penicillin G in children with rheumatic fever and controls

Serum and urine penicillin levels were determined in 11 children with rheumatic fever (RF) who were receiving benzathine penicillin G (BPG) prophylactically every 3 weeks and in 10 children without RF who received the drug for the treatment of other infections. The dose given was 600,000 units for children weighing less than 25 kg and 1,200,000 units for those with a weight above 25 kg. Blood and urine samples were collected from both groups before and on days 7, 14 and 21 after BPG administration. Our results showed that: minimum inhibitory concentrations (MICs) of BPG for group A beta-hemolytic streptococci were 0.02 IU/ml or 0.0125 microgram/ml; intramuscular BPG did not give adequate serum levels to block the growth of group A beta-hemolytic streptococci in approximately 24 and 62% of children included in the study on days 14 and 21 after its administration, respectively; BPG metabolism was similar in both groups and did not depend on the underlying disease; serum and urine levels did not vary according to sex and weight; and there was a small correlation between serum and urine levels.

Sydenham chorea: clinical and laboratory findings. Analysis of 187 cases

Sydenham's chorea (chorea minor, St. Vitus dance, rheumatic encephalitis), described by Thomas Sydenham in 1686, is considered one of the major manifestations of rheumatic fever (1, 2, 3, 4). Clinically it is characterized by involuntary movements, hypotonia, dysarthria, emotional disorders, and less frequently, by other neurological manifestations such as weakness, headache, seizures and sensory abnormalities (1,4). The motor disorders may be generalized or unilateral, in this case constituting a hemichorea (3). Chorea may present associated to other rheumatic fever manifestations during an acute episode, or in isolated form, characterizing the so-called "pure" chorea (5, 6, 7). Its etiology and pathophysiological mechanisms are still unclear, although its relation with a previous pathophysiological group A Beta-hemolytic streptococcus infection is well established (8). There is also evidence of the participation of immunological mechanisms in its pathogenesis, such as the finding of serum anti-nucleus caudatus and anti-subthalamic antibodies (9) and increase in IgG levels in cerebrospinal fluid of patients with chorea (10). In developed countries due to the reduction in rheumatic fever incidence and decrease in frequency of chorea as its manifestation (3, 11), the latter has become rare. However, in developing countries rheumatic fever remains a public health problem. In Brazil, in the last years an increase in the incidence of chorea has been observed as part of the clinical picture of rheumatic fever (12). The present study reports the clinical and laboratory findings of 187 cases of Sydenham's chorea followed-up during the period of January 1980 to December 1990 in two university centers in the city of Sao Paulo, Brazil.

Symptomatic cardiac involvement in juvenile rheumatoid arthritis

In a retrospective study of 172 patients with juvenile rheumatoid arthritis, symptomatic cardiac involvement occurred in 13 (7.6%) patients (11 systemic and 2 polyarticular). There was predominance of the male sex and in most patients the involvement occurred in the initial years of the disease. Pericarditis occurred in seven patients; perimyocarditis in four and myocarditis in two patients. In the follow-up, one of the patients with pericarditis died of an arrhythmia during pericardiocentesis for cardiac tamponade. Among the patients with myocarditis, three died of septicemia during active disease. One of these three patients had myocarditis associated with cardiac tamponade. Among the 172 patients with juvenile rheumatoid arthritis, five children died; four belonged to the symptomatic cardiac involvement group (P less than 0.001). Cardiac involvement, in particular myocarditis and cardiac tamponade, can be regarded as a factor of worse prognosis.

[Juvenile rheumatoid arthritis: review and update]

Major current clinical, laboratory, and etiopathogenic aspects of juvenile rheumatoid arthritis (JRA) are focused by this article. The authors make a comparison of data of their patients to those described in the literature. A retrospective clinicolaboratory study was performed of 130 patients with JRA followed in the Pediatric Rheumatology Department of the Division of Allergy, Rheumatology, and Clinical Immunology of the Service of Pediatrics of Escola Paulista de Medicina from 1982 to 1989. These patients (73 female and 57 male) were analyzed for the type and age of onset, clinical manifestations (articular and extraarticular), laboratory data, and prognosis. The findings of the authors are similar to those reported, with the exception of eye involvement (chronic iridocyclitis) and of the presence of the IgM rheumatoid factor (RF) and the antinuclear antibody (ANA), which were lower than those described by other authors. With respect to prognosis, the authors verified the greatest number of remissions (40%) with the pauciarticular type, whereas the polyarticular type presented the lowest number of remissions (27%). The two deaths occurred in the series were of children with the systemic type of the disease. Although etiology and the mechanism responsible for its release are not yet known, therefore, not allowing a definite type of treatment, experience gathered throughout the years has made it possible for physicians who attend to these patients not only to make an early diagnosis but also to resort to more efficient means of control.

Chemotaxis of leukocytes from peripheral blood of patients with juvenile rheumatoid arthritis (JRA)

Spontaneous and stimulated migration of leukocytes from peripheral blood was studied in 15 patients with JRA and 15 controls. Cells from both groups showed equal migratory ability. However, in the presence of the activated serum of the JRA patients, there was a significant decrease in migration of leukocytes from JRA patients and from controls, suggesting the existence of a serum factor responsible for this chemotactic impairment. The effect of washing on the migration of these cells was also studied. A significant decrease could be observed in the spontaneous and stimulated migration of washed cells from both JRA patients and controls.

Cardiac tamponade in juvenile chronic arthritis: report of two cases and review of publications

Two cases of systemic juvenile chronic arthritis, complicated by cardiac tamponade and eight previously reported cases are described. The clinical features and radiological, electrocardiographic, and echocardiographic findings were similar for all cases. One patient in this series was treated with corticosteroids and underwent pericardiectomy, dying of sepsis 30 days after surgery. The other patient was also treated with corticosteroids, underwent pericardiocentesis and developed fatal ventricular tachycardia. Of the 10 cases, only six were successfully treated. Early diagnosis and appropriate treatment are essential for a favourable outcome.

[Carpal tunnel syndrome: electroneuromyographic study of 135 cases]

One hundred thirty five patients with carpal tunnel syndrome were studied trough electrophysiological techniques. Nerve sensory conductions, motor conductions and electromyography were performed in all patients and the results discussed. The authors call the attention for the technic of sensory conduction stimulating palma and picking up the potentials on the wrist as the most sensitive technic for the early detection of carpal tunnel syndrome.

Flavokinase and FAD synthetase from Bacillus subtilis specific for reduced flavins

A flavokinase preparation from Bacillus subtilis is described which catalyzes the phosphorylation of reduced, but not oxidized, riboflavin. The enzyme is distinguished from other known flavokinases also in having an unusually low Km for the flavin substrate, 50 to 100 nM. ATP is the obligatory phosphate donor; one ATP is utilized for each FMNH2 formed. Mg2+ or Zn2+ is required for the reaction; Co2+ and Mn2+ will substitute, but less effectively. The same enzyme preparation catalyzes the synthesis of FADH2 from FMNH2 and ATP, but not the synthesis of FAD from FMN and ATP. FADH2 is also formed from reduced riboflavin, presumably by sequential flavokinase and FAD synthetase action. Zn2+ cannot replace Mg2+ in FADH2 formation. The reverse reaction, formation of FMN from FAD, occurs only with reduced FAD, giving rise to FMNH2, and is dependent on the presence of inorganic pyrophosphate. The enzyme thus appears to be an FADH2 pyrophosphorylase. The two enzymatic activities, flavokinase and FADH2 pyrophosphorylase, although not separated during the purification procedure, are distinguished by differences in metal ion specificity, in concentration dependence for ATP (apparent Km for ATP = 300 microM for FADH2 synthesis and 6.5 microM for flavokinase), and in the inhibitory effects of riboflavin analogues.