Clinical and subclinical cardiovascular disease in female SLE patients: Interplay between body mass index and bone mineral density.

BACKGROUND AND AIMS: Since accelerated atherosclerosis has been reported in systemic lupus erythematosus (SLE), predictive biomarkers of cardiovascular disease (CVD) are needed. Among non-traditional risk factors, bone mineral density (BMD) has been related to CVD. However, its role in SLE remains controversial. This study aims to analyze the associations of subclinical atherosclerosis with traditional and non-traditional CV risk factors. METHODS AND RESULTS: In a cross-sectional study, atherosclerosis burden was compared between 112 female SLE patients and 31 controls. Plaque number and carotid intima-media wall thickness (cIMT) were assessed by ultrasonography. In a retrospective study, BMD determinations obtained 5-years before the ultrasonography assessment were analyzed in a subgroup of 62 patients. Plaque frequency was increased in SLE, even in patients without CV events or carotid wall thickening. cIMT was increased in patients with CVD, positively correlated with body mass index (BMI). Interestingly, a paradoxical effect of BMI on carotid parameters was observed. Whereas underweight patients (BMI < 20) showed increased prevalence of carotid plaques with low cIMT, those with BMI > 30 showed higher cIMT and plaque burden. Overweight patients (25 < BMI<30) exhibited both elevated cIMT and plaque number. BMI was an independent predictor of BMD. In our retrospective study, patients with either clinical or subclinical CVD exhibited lower BMD levels than their CV-free counterparts. A low lumbar spine BMD independently predicted CVD development after adjusting for confounders. CONCLUSION: SLE was associated with a higher subclinical atherosclerosis burden, a bimodal effect being observed for BMI. Decreased BMD can be a CV risk biomarker in SLE.

Combined mepacrine-hydroxychloroquine treatment in patients with systemic lupus erythematosus and refractory cutaneous and articular activity.

Aim The aim of this study was to evaluate the clinical response to combined therapy with hydroxychloroquine and mepacrine in patients with systemic lupus erythematosus and refractory joint and/or skin disease. Methods Mepacrine was added to 46 systemic lupus erythematosus patients unresponsive to treatment with the following drug combinations: hydroxychloroquine + prednisone + immunosuppressive drugs ( n = 24), hydroxychloroquine + prednisone ( n = 16), hydroxychloroquine + prednisone + retinoids ( n = 2), hydroxychloroquine alone ( n = 1), hydroxychloroquine + one immunosuppressive drug ( n = 1), hydroxychloroquine + prednisone + one immunosuppressive drug + belimumab ( n = 1) or hydroxychloroquine + prednisone + belimumab ( n = 1). The outcome variable was the clinical response, either complete or partial, based on clinical judgement. The Cutaneous Lupus Erythematosus Disease Area and Severity Index (CLASI) and the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) score were additionally used. Results A total of 91% patients showed complete/partial response, with similar rates among those with joint or skin disease. In patients with cutaneous activity, a statistically significant decrease in the CLASI was seen. There also was a statistically significant decrease in the SLEDAI. The mean daily dose of prednisone decreased from 5.8 to 3.4 mg/d ( p = 0.001). Prednisone could be discontinued in 20% of patients. No serious adverse events were seen. Smoking was the only predictor of complete response. Conclusion In the setting of refractory skin and/or joint disease, the addition of mepacrine to previous therapy including hydroxychloroquine was safe and effective in reducing disease activity and decreasing prednisone doses. The fact that smokers responded better opens the door to further studying the combination of mepacrine-hydroxychloroquine as a first-line therapy in such patients.

The midpoint between ventilatory thresholds approaches maximal lactate steady state intensity in amateur cyclists.

The aim was to determine whether the midpoint between ventilatory thresholds (MPVT) corresponds to maximal lactate steady state (MLSS). Twelve amateur cyclists (21.0 ± 2.6 years old; 72.2 ± 9.0 kg; 179.8 ± 7.5 cm) performed an incremental test (25 W·min-1) until exhaustion and several constant load tests of 30 minutes to determine MLSS, on different occasions. Using MLSS determination as the reference method, the agreement with five other parameters (MPVT; first and second ventilatory thresholds: VT1 and VT2; respiratory exchange ratio equal to 1: RER = 1.00; and Maximum) was analysed by the Bland-Altman method. The difference between workload at MLSS and VT1, VT2, RER=1.00 and Maximum was 31.1 ± 20.0, -86.0 ± 18.3, -63.6 ± 26.3 and -192.3 ± 48.6 W, respectively. MLSS was underestimated from VT1 and overestimated from VT2, RER = 1.00 and Maximum. The smallest difference (-27.5 ± 15.1 W) between workload at MLSS and MPVT was in better agreement than other analysed parameters of intensity in cycling. The main finding is that MPVT approached the workload at MLSS in amateur cyclists, and can be used to estimate maximal steady state.

Evolution of physiological and haematological parameters with training load in elite male road cyclists: a longitudinal study.

AIM: The aim of this study was to describe and evaluate physiological parameters as a control tool for the monitoring of training in a group of elite cyclists during one season of training. METHODS: The study is divided into two periods (winter or ''volume'' mesocycle and spring or ''intensity'' mesocycle) between the tests that they carried out in the laboratory, consisting of a ramp test to exhaustion (work load increases 25 W X min(-1)) and a maximal lactate steady state (MLSS) test on a cycle ergometer. Macronutrients and hematological variables were recorded during the test periods as were the volume and the intensity of training sessions during the whole period of the study. RESULTS: The physiological data were similar to those previously reported for professional cyclists (approximately 450 Watts, approximately 78 mL x kg(-1) x min(-1)) and the values for the MLSS also agree with previous studies (approximately 250 Watts). Subjects improved the first ventilatory threshold (VT(1)) (approximately 52% to approximately 60% VO(2max)) and the second ventilatory threshold (VT(2)) (approximately 82% to approximately 87% VO(2max)) after the first period of training even though its low intensity focused on the performance of VT(1) (77% training in ''zone 1'', under VT(1)). The MLSS improved after the first period (approximately 225 to approximately 250 Watts) and remained high in the second (approximately 255 Watts). High levels of creatine kinase (approximately 230 U x L(-1)) and urea (37 mg x L(-1)) were found, also a decrease in hemoglobin values (approximately 15.4 to approximately 14.7g x dL(-1)). CONCLUSION: The high level reached by the subjects after the first period of training suggests that two effort tests could be enough to plan training. On the other hand, the decrease in some red blood cell and nutrition parameters suggests that there should be greater control over them during the season.

[Response of tidal volume to inspiratory time ratio during incremental exercise]. / Respuesta de la relación volumen corriente-tiempo inspiratorio durante un esfuerzo incremental.

OBJECTIVE: There is some debate about the participation of the Hering-Breuer reflex during exercise in human beings. This study aimed to investigate breathing pattern response during an incremental exercise test with a cycle ergometer. Participation of the Hering-Breuer reflex in the control of breathing was to be indirectly investigated by analyzing the ratio of tidal volume (VT) to inspiratory time (tI). SUBJECTS AND METHODS: The 9 active subjects who participated the study followed an incremental protocol on a cycle ergometer until peak criteria were reached. During exercise, VT/ti can be described in 2 phases, separated by activation of the Hering-Breuer reflex (inspiratory off-switch threshold). In phase 1, ventilation increases because VT increases, resulting in a slight decrease in tI, whereas, in phase 2, increased ventilation is due to both an increase in VT and a decrease in tI. RESULTS: The mean (SD) inspiratory off-switch threshold was 84.6% (6.3%) when expressed relative to peak VT (mean, 3065 [566.8] mL) and 48% (7.2%) relative to the forced vital capacity measured by resting spirometry. The inspiratory off-switch threshold correlated positively (r=0.93) with the second ventilatory threshold, or respiratory compensation point. CONCLUSIONS: The inspiratory off-switch threshold and VT/ti are directly related to one another. The inspiratory off-switch threshold was related to the second ventilatory threshold, suggesting that the Hering-Breuer reflex participates in control of the breathing pattern during exercise. Activation of the reflex could contribute by signaling the respiratory centers to change the breathing pattern.

Prognostic value of histopathologic parameters and DNA flow cytometry in squamous cell carcinoma of the pyriform sinus.

A retrospective study of a group of 51 patients who underwent surgery for squamous cell carcinoma of the pyriform sinus was performed. Primary tumors and lymph nodes were reviewed histologically. The primary tumors were also examined by flow cytometry for DNA ploidy and cell cycle analysis. Sixteen (33%) of the cases were aneuploid and 64% had a moderate or high S-phase fraction. The overall 3-year survival rate was 49% (25/51). In the univariate analysis, tumor size, lymphatic invasion, inflammatory infiltrate, presence of lymph node metastases, clinical and histologic N status, size and number of lymph nodes involved, and presence of extracapsular extension all correlated with survival. When multivariate analysis was used, the only independent prognostic factors were tumor size, lymphatic invasion, and histologic N status. Ploidy and S-phase fraction did not contribute further prognostic information.

Mucormycosis of the sphenoid sinus in an otherwise healthy patient. Case report and literature review.

Paranasal and rhinocerebral mucormycosis refers to uncommon opportunistic fungal infections, reported to occur especially in association with diabetic acidosis (the most common), immunosuppressive therapy, malignancy, or other chronic debilitating disorders. However, patients who have no underlying disease have occasionally been affected. According to the literature reviewed, only 13 well-documented cases without any predisposing factor have been previously reported. We describe a unique case of sphenoidal mucormycosis in an otherwise healthy individual, and the first patient to present with headache as the only symptom. We emphasize the importance of a high index of suspicion for early diagnosis and prompt management.

[Simultaneous bilateral facial paralysis]. / Parálisis facial bilateral simultánea.

Simultaneous bilateral facial paralysis (SBFP) is very rare, but it can present itself as the first complaint in a wide spectrum of diseases and a comprehensive evaluation must be completed. Bilateral Bell's Palsy can be diagnosed only when all other possible causes have been excluded. The prognosis and treatment for SBFP is dependent upon the underlying etiology. We present four cases of SBFP seen in our department which were finally diagnosed as leukemic infiltration, sarcoidosis, Bell's Palsy and demyelinating polyneuropathy (probably Guillain-Barré syndrome). The most important etiologies of the SBFP and the management of this entity are discussed.

[Differential diagnosis of bilateral progressive sensorineural loss. A report of a case secondary to neurofibromatosis 2]. / Diagnóstico diferencial de la hipoacusia neurosensorial bilateral progressiva. A propósito de un caso secundario a neurofibromatosis tipo II.

Progressive bilateral sensorineural hearing loss (BSNHL) was the first manifestation of type II neurofibromatosis in a young patient with no family or personal history of neurofibromatosis. The differential diagnosis of BSNHL is described and a diagnostic protocol is proposed.

[Sphenoidal metastasis of laryngeal carcinoma]. / Metástasis esfenoidal de un carcinoma de laringe.

Metastatic tumors to the nose and paranasal sinuses are very uncommon and metastases to the sphenoid sinus are exceedingly rare. The most common tumor sites from which sphenoid metastases arise are the kidney and the lung. Distant metastases from laryngeal carcinoma are rare, the most common sites being the lungs, skeletal system, and liver. We report a patient with a supraglottic laryngeal carcinoma who had metastases to the sphenoid sinus. The management of this entity is described and cases reported in the literature are reviewed.

[Nasal sinus adenocarcinoma in patients exposed to wood dust in the Community of Cantabria, Spain]. / Adenocarcinomas nasosinusales en pacientes expuestos al polvo de madera en la Comunidad de Cantabria.

OBJECTIVE: To study the incidence and clinical and histological features of sawdust-related nasosinusal adenocarcinoma (SRNA) in the Community of Cantabria. MATERIAL AND METHODS: A retrospective study was made of all patients diagnosed as SRNA in 9 years. RESULTS: Ten male patients, ranging in age from 56 to 64 years, were diagnosed as SRNA in this period. The most common location was the ethmoid. Histologically, six tumors were papillary and four were mucinous. Five patients received combined treatment (surgery and postoperative radiotherapy), one surgery alone, two radiotherapy, and one chemotherapy. The 5-year survival rate was 28.5%. The most frequent cause of death was local recurrence. CONCLUSIONS: The incidence of SRNA in the Community of Cantabria is less than 0.2 cases per 100,000 inhabitants/year. SRNA occurs almost exclusively in men and has an occupational origin. Papillary adenocarcinoma is the most frequent histological type. The treatment of choice is surgery associated with postoperative radiotherapy. The long-term prognosis is poor, so preventive measures to reduce exposure to sawdust are fundamental in risk groups.

[Cholesterol granuloma of the petrous apex]. / Granuloma de colesterol de punta de peñasco.

Cholesterol granuloma of the petrous apex is an inflammatory granulation tissue response to the presence of cholesterol crystals. It is not generally associated with middle-ear pathology. CT and MRI are fundamental for diagnosis. MRI is more specific and shows a well-circunscribed mass with high signal intensity on both T1 and T2 weighted images. We present a case of cholesterol granuloma of the petrous apex that was previously diagnosed as cholesteatoma. We emphasize the importance of preoperatory differentiation of the lesion from cholesteatoma. Cholesterol granuloma does not require full excision of the lesion. Drainage and permanent aeration is usually sufficient.

[Overexpression of p53 protein in epidermoid carcinoma of the pyriform sinus]. / Sobreexpresión de la proteína p53 en el carcinoma epidermoide de seno piriforme.

Mutation of the p53 protein may be the commonest genetic event in the development of malignant neoplasms in humans. We analyzed the immunohistological expression of p53 in tissue sections from 51 patients with squamous cell carcinoma of the pyriform sinus who were treated with surgery and postoperative radiotherapy. Overexpression of p53 was found in 37 (72.5%) tumors. No correlation was found between p53 overexpression and clinical and histopathological parameters. Recurrence and overall survival did not differ between p53-positive and p53-negative cases.

[Rendu-Osler-Weber disease (hereditary hemorrhagic telangiectasia). Report of 30 cases]. / La enfermedad de Rendu-Osler-Weber (telangiectasia hemorrágica hereditaria). Presentación de 30 casos.

OBJECTIVE: To study the prevalence and modes of presentation of hereditary hemorrhagic telangiectasia (HHT) in Cantabria, Spain. MATERIALS AND METHODS: A retrospective study was made of all patients diagnosed as HHT in Cantabria in the last 20 years (1976-1995). The presence/absence of family history, recurrent nosebleed, mucosal and cutaneous telangiectasia, visceral involvement, and course of the disease were evaluated. RESULTS: Thirty patients ranging in age from 17 to 75 years were diagnosed as HHT in the study period. Most of them had a family history of recurrent nasal bleeding. The main symptom was nosebleed. Pulmonary arteriovenous fistulas were found in 7 patients and gastrointestinal manifestations in 10 patients. Five patients died of complications directly attributable to the disease. CONCLUSIONS: The minimum prevalence of HHT in Cantabria is 1:12,200, Patients with recurrent nosebleed, particularly if a family history of epistaxis is present, should undergo exploration of the oral cavity for telangiectasia. Early diagnosis of HHT can help to avoid unnecessary diagnostic procedures and contribute to the early detection of associated visceral malformations. The treatment of HHT should be individualized.

Superior vena cava syndrome due to a leiomyosarcoma of the anterior mediastinum: A case report and literature overview.

INTRODUCTION: Leiomyosarcomas are an infrequent cause of malignant superior vena cava syndrome (VCS). PRESENTATION OF CASE: A 51-year old male patient was admitted for a three-day history of dyspnoea, dysphagia and erythema of the head and neck. Computed tomography and magnetic resonance imaging showed a lesion arising on the anterior mediastinum, which was in close proximity with a thrombus in the superior vena cava. Surgical excision was performed, including open resection of the primary tumour and an atrio-innominate vein bypass with 8-mm polytetrafluoroethylene (PTFE). Histology confirmed a leiomyosarcoma and postoperative radiotherapy sessions were performed. Due to evidence of enlargement of the thrombus, a second intervention was undertaken. In this procedure, a remainder of the primary tumour was resected and the superior vena cava reconstructed with an autologous pericardium patch. The patient recovered satisfactorily and was discharged on the seventh postoperative day, with no evidence for relapse after 10 months of follow-up. DISCUSSION: Leiomyosarcomas comprise less than 2% of the tumours of the mediastinum and are a rare cause of paraneoplastic VCS. Male patients in their sixties are most commonly affected. Relapses seem to be common, and thus a careful follow-up is often recommended. CONCLUSION: In spite of the limited data on the management of thoracic leiomyosarcomas, surgery is currently considered the mainstay of treatment.

Laparoscopic-assisted vaginal hysterectomy versus abdominal hysterectomy in stages I and II endometrial cancer. Operating data, follow up and survival.

OBJECTIVE: To assess the feasibility of laparoscopy in the treatment of early stage endometrial carcinoma and follow up outcomes compared to classic laparotomy. METHODS: A retrospective review of 90 consecutive patients with endometrial cancer managed between January 1997 and December 2003. Two groups were defined whether they had been treated by laparoscopy (N = 38; LPS group) or by laparotomy (N = 37; LPM group). Nine patients treated by vaginal hysterectomy and 6 cases with stages III-IV were excluded from the study. RESULTS: Both groups were comparable in mean age and mean BMI. Mean operating time was longer for LPS group, 164.91 +/- 5.60 (77-240) vs. 129.97 +/- 5.08 (60-180) min (P < 0.05). Intraoperative complications were seen in 7 patients (18.9%) from LPM and in 5 cases (13.2%) in the laparoscopic group. Two patients (5.2%) initially evaluated by laparoscopy were converted into laparotomy due to an increasing and uncontrollable hypercapnia. There were more post-operative complications in patients managed by laparotomy (14 cases; 38.8%), than by laparoscopy (7 cases; 18.4%) (P < 0.05). Blood transfusion was necessary in 4 patients (10.8%) in LPM group while none was required in LPS group (P < 0.01). Hospital readmission was only recorded in 3 patients treated by laparotomy (6.7%) (P < 0.05). Hospital stay was longer in LPM group 7.06 +/- 0.58 (4-21) vs. LPS 5.04 +/- 0.73 (2-17) days (P < 0.05). With a median follow up of 53.21 +/- 4.32 months for LPM (5-90) and 36.31 +/- 2.75 months for LPS (9-65) there was no significant difference in disease recurrence between the two groups. CONCLUSION: Laparoscopic staging combined with vaginal hysterectomy appears to be a feasible alternative to classical surgical approach in patients with early stage I or II endometrial carcinoma.

Comparison of two copper IUDs: the MLCu375 and the Nova-T.

A comparative randomized trial was carried out on two intrauterine contraceptive devices: the Nova-T and the MLCu375. The IUDs were used by 1116 and 1237 women respectively, over a period of 2 years. The reasons for IUD removal were analyzed after one and two years using the life-table method. Statistically significant differences were found in the rates for pregnancy, expulsion and removal for bleeding and/or pain favoring the MLCu375 IUD.