Ankylosing spondylitis and systemic lupus erythematosus: a rare HLA combination.

The condition of a 43-year-old man fulfilled the strict diagnostic criteria for both ankylosing spondylitis and systemic lupus erythematosus. To our knowledge, this is the fist verified report of the concurrence of these rheumatic diseases. An unusual combination of genetically determined markers seems to have caused an increased risk for the development of both disorders.

Cost-effective imaging approach to the nonbilious vomiting infant.

OBJECTIVE: To develop a cost- and time-effective algorithm for differentiating hypertrophic pyloric stenosis (HPS) from other medical causes of emesis in infants referred from community-based pediatricians and family practitioners to the imaging department of a tertiary children's care facility. METHODS: Eighty-nine vomiting infants (22 females, 67 males) between the ages of 11 and 120 days (mean, 43.5 days) had received nothing by mouth for at least 1 hour before the study. Each child was assessed for duration of vomiting, status of body weight, time and volume of last ingestion, and time of last emesis. A #8 French (Sherwood Medical, St Louis, MO) nasogastric feeding tube was placed in the child's stomach. The contents were aspirated and measured to determine likelihood of HPS. An aspirated volume >/=5 mL implicated gastric outlet obstruction, and ultrasonography (US) was performed. If this study was positive for HPS, the patient was referred for surgery. If US was negative, an upper gastrointestinal series (UGI) was performed. An aspirated stomach contents volume <5 mL suggested a medical cause for the emesis, and UGI was performed. Pediatric surgeons with no knowledge of the volume results palpated the abdomens of 73 of 89 infants (82%). RESULTS: Twenty-three of 89 patients (25%) had HPS. The aspirate criteria for HPS had a sensitivity of 91%, a specificity of 88%, and an accuracy of 89%. Of the false-positive studies (total = 8), six were related to recent significant ingestion (within 2 hours of the study), and two were attributable to antral dysmotility. The surgeons palpated the mass in 10 of 19 patients (53%). Sensitivity and specificity were 53% and 93%, respectively. Only 6 of 89 infants (7%) required both US and UGI to determine the etiology of the nonbilious vomiting. By performing the UGI in 66 patients, it was also found that 14% had slow gastric emptying and 79% had gastroesophageal reflux. Eighty-one percent of the gastroesophageal reflux was significant. CONCLUSION: The volumetric method of determining the proper imaging study is cost- and time-effective in the evaluation of the nonbilious vomiting infant for pyloric stenosis. If US was performed initially in all patients referred for imaging, two studies would have been performed in 68 of 89 patients (76%) to define the etiology of the emesis. Because we used the volumetric method, 62 fewer imaging studies were performed, representing a savings of $4464 and 30 hours of physician time. If children are given nothing by mouth for 3 to 4 hours before gastric aspiration, the specificity of the volumetric method improves to 94%, and the accuracy improves to 96%.

Muscle glycogen synthesis after exercise: effect of time of carbohydrate ingestion.

The time of ingestion of a carbohydrate supplement on muscle glycogen storage postexercise was examined. Twelve male cyclists exercised continuously for 70 min on a cycle ergometer at 68% VO2max, interrupted by six 2-min intervals at 88% VO2max, on two separate occasions. A 25% carbohydrate solution (2 g/kg body wt) was ingested immediately postexercise (P-EX) or 2 h postexercise (2P-EX). Muscle biopsies were taken from the vastus lateralis at 0, 2, and 4 h postexercise. Blood samples were obtained from an antecubital vein before and during exercise and at specific times after exercise. Muscle glycogen immediately postexercise was not significantly different for the P-EX and 2P-EX treatments. During the first 2 h postexercise, the rate of muscle glycogen storage was 7.7 mumol.g wet wt-1.h-1 for the P-EX treatment, but only 2.5 mumol.g wet wt-1.h-1 for the 2P-EX treatment. During the second 2 h of recovery, the rate of glycogen storage slowed to 4.3 mumol.g wet wt-1.h-1 during treatment P-EX but increased to 4.1 mumol.g wet wt-1.h-1 during treatment 2P-EX. This rate, however, was still 45% slower (P less than 0.05) than that for the P-EX treatment during the first 2 h of recovery. This slower rate of glycogen storage occurred despite significantly elevated plasma glucose and insulin levels. The results suggest that delaying the ingestion of a carbohydrate supplement post-exercise will result in a reduced rate of muscle glycogen storage.

Contemporary controversies in the management of congenital diaphragmatic hernia.

Congenital diaphragmatic hernia (CDH) has remained the most frustrating of the major birth defects to manage successfully. Despite the earlier detection of severe diaphragmatic defects by prenatal ultrasound, and the early recognition of CDH as a cause for respiratory distress presenting at birth, current mortality has improved little from the original series presented in 1940 by Ladd and Gross. This article discusses the difficulty in defining population with congenital diaphragmatic hernia, current controversies in the medical and surgical management of these patients, appropriate timing and usage of ECMO, a review of current, experimental therapies, and short-term and long-term outcomes of these patients.

Followup of psychoanalysis five to ten years after termination: II. Development of the self-analytic function.

Thirteen of seventeen patients in followup interviews five to ten years after the termination of analysis reported the development or refinement of a self-analytic capacity. According to the accounts of these patients, there did not appear to be a direct relation between the attainment of a self-analytic function and the extent of resolution of the transference neurosis or the maintenance of therapeutic gains after treatment.

Followup of psychoanalysis five to ten years after termination: III. The relation between the resolution of the transference and the patient-analyst match.

As part of a long-term followup study of the outcome of psychoanalysis, we examined the relation between the extent of resolution of the transference at termination and the characteristics of the patient-analyst match. For twelve of the seventeen patients interviewed five to ten years after termination of psychoanalysis, the researchers found that the patient-analyst match played a role in the outcome of the analysis. Illustrations of the influence of the match in cases where the transference was resolved and those where it was not are presented.

Followup of psychoanalysis five to ten years after termination: I. Stability of change.

Seven out of 17 patients interviewed in a long-term followup of psychoanalysis showed either improvement in psychological functioning or a retention of psychological gains they had made during the course of psychoanalysis. Six patients deteriorated in their psychological functioning, but their gains were restored with subsequent treatment. Four patients deteriorated in psychological functioning without restoration, whether or not treatment was reentered. Neither analysts' assessments at the time of termination nor patients' assessments of themselves or assessments based on psychological tests one year after termination predicted which patients would improve or retain psychological change. No causal generalizations about factors related to psychological change can be made from these data. Different factors in interaction are suggested to account for the stability and instability of psychological change.

Changes in the level and quality of object relations in psychoanalysis: followup of a longitudinal, prospective study.

As part of a prospective, longitudinal study of suitability for and outcome of psychoanalysis, 22 patients were evaluated for changes in the level and quality of their object relations. These patients had been accepted for supervised analysis with candidates in training by senior analysts who had diagnosed them as neurotic. The majority of these patients reported difficulties in relationships as at least one of their reasons for originally seeking psychoanalytic treatment. Prior to beginning analysis, each patient was given a battery of psychological tests. One year after the termination of analysis, the test battery was readministered and a followup interview was conducted separately with each patient and analyst. Ratings of change based on patient and analyst interviews and comparisons of psychological tests before and after treatment all showed statistically significant improvement in the level and quality of object relations for this patient group. The results of this study support what is often observed in clinical practice, that psychoanalysis has a positive effect on the level and quality of a patient's object relations.

The role of reality testing in psychoanalysis: followup of 22 cases.

As part of a prospective, longitudinal study of psychoanalytic outcome, 22 patients were evaluated for changes in their level of reality testing. These patients had been accepted for supervised psychoanalysis with candidates in training by senior analysts who had diagnosed them as neurotic. Psychological tests given prior to the beginning of analysis indicated, however, that more than one third of our sample demonstrated serious distortions in their perceptions of reality. When psychological tests administered one year after the completion of analysis were compared with these pretreatment tests, no significant improvement was found in the level of reality testing for the group as a whole. However, when excluding two patients who had suffered major traumas in the year following psychoanalysis, significant improvement in reality testing was found for the remaining 20 patients. Post-treatment interviews with the treating analysts revealed that in the course of analysis itself, approximately one third of these patients showed some disturbance in reality testing; only three of these patients showed significant improvement in the level of their reality testing during treatment. These findings suggest that while patients may not present clinically with evidence of impaired reality testing, such evidence may be available in psychological testing, and may become apparent in the course of the treatment.

Affect availability, tolerance, complexity, and modulation in psychoanalysis: followup of a longitudinal, prospective study.

Evaluation of 22 patients in supervised psychoanalysis showed that affect availability and tolerance changed in a positive direction during the course of psychoanalysis. In this study, we have defined criteria of change that can be clinically observed. The changes observed were present one year following the completion of psychoanalysis. Ratings of analysts' and patients' interviews, and ratings of psychological tests all revealed that patients had derived "therapeutic benefit" in relation to affect experience and management. Discriminations were made among changes in affect modulation, which reflected both loosening and tightening of controls, changes in affect availability, changes in experience of painful affects, and changes in experience of affect complexity. Analysts' interviews and psychological test data reflected notable changes in affect modulation in the direction of increased control, while patients' interviews more often reflected changes in the direction of increased expressiveness.

The patient-analyst match and the outcome of psychoanalysis: a pilot study.

This paper presents a pilot study in which we explore the possibility that the match between analyst and analysand is a factor of central importance in the analytic situation. It is an attempt to look at the issue of match across a large number of patients. The data we used were not collected for studying this topic; thus, the study has serious limitations. Nevertheless, certain patterns emerged which support our thesis that patient-analyst match plays a significant role in the outcome of psychoanalysis. We present this work as a first step in developing concepts and methods which will be pursued in a more systematic and rigorous fashion in a later study.

Septic arthritis in the geriatric population.

Septic arthritis has emerged as an important infection in geriatric patients. Between 25% and 50% of all cases of nongonococcal bacterial arthritis in nonprosthetic joints occur in patients over the age of sixty years. Thirty-three percent of nongonococcal septic arthritis occurs in the geriatric population. In this retrospective study of geriatric septic arthritis, 22 patients were reviewed. The major predisposing factor was prior history of arthritis, with the knee being the most commonly affected joint. Staphylococcus aureus was the major pathogen, with gram-negative organisms accounting for a significant number of infections. We think that empiric antibiotic coverage for gram-negative organisms should be initiated at the time of treatment only in patients with multiple predisposing factors for septic arthritis. The disease also may be more indolent than previously reported, leading to delayed diagnosis, treatment, and increased morbidity and mortality.

Medical management of pneumococcal arthritis involving a knee prosthesis.

Septic arthritis involving prosthetic joints has been frequently reported, with Staphylococcus species being the pathogen most commonly noted. We report a case of septic arthritis of a prosthetic knee caused by Pneumococcus, a previously unreported pathogen in this condition, which uniquely responded to treatment with antibiotics.

Exercise and diet reduce muscle insulin resistance in obese Zucker rat.

Two treatments that increase skeletal muscle insulin action are exercise training and high-carbohydrate diet. The purpose of the present study was to determine whether exercise training and a diet high in carbohydrates could function synergistically to reduce the muscle insulin resistance in the obese Zucker rat. Obese rats 4 wk of age were randomly assigned to an exercise or sedentary group. Each group was subdivided by diet with one-half of the rats fed a high-carbohydrate diet and one-half fed a high-fat diet. Lean Zucker rats fed the high-fat diet were used as controls. Muscle insulin resistance was assessed during hindlimb perfusion with a submaximally stimulating concentration of insulin. Exercise training and the high-carbohydrate diet increased the rate of muscle glucose uptake in the obese rat by 46 and 53%, respectively. More importantly, the combined effect of exercise training and high-carbohydrate diet was greater than the sum of their individual effects. Glycogen synthesis paralleled glucose uptake and was the major pathway for intracellular glucose disposal. Muscle glucose uptake for exercise-trained, high-carbohydrate fed obese rats was comparable with that of lean controls. It is concluded that exercise training and the high-carbohydrate diet functioned synergistically to reduce the muscle insulin resistance in the obese rat.

Pemphigus vulgaris and lymphoma in a patient with scleroderma.

The coexistence of scleroderma and malignancy is well documented. The case presented here is unique, however, as it is the first report of the occurrence of diffuse histiocytic lymphoma and pemphigus vulgaris in a patient with scleroderma. Because of this unusual triad of diseases, the possibility of a common pathogenetic basis was examined. A review of the literature confirms that each disorder does have immunologic abnormalities. It is suggested that an aberrant immune response, specifically impaired T-cell function, is responsible for the emergence of disease of this patient.

Glucose transport: locus of muscle insulin resistance in obese Zucker rats.

The purposes of this study were to determine whether the muscle insulin resistance of the obese rat is due to a defect in the glucose transport process and whether the insulin resistance is fiber-type specific. The hindlimbs of fasted, 14-wk-old obese (fa/fa) and lean (fa/?) Zucker rats were perfused with perfusate containing 8 mM glucose and no insulin or 8 mM glucose and either a physiological (0.15 mU/ml), a submaximal (1.50 mU/ml), or a maximal (15.0 mU/ml) insulin concentration. Glucose uptake was determined after which the initial rate of glucose transport was determined using 3-O-methyl-D-glucose (3-OMG). Glucose uptake of the obese rats was depressed by 40, 33, 42, and 47% in the absence of insulin and in the presence of the physiological, submaximal, and maximal insulin concentrations, respectively, when compared with lean littermates. Glucose transport in the absence and in the presence of the three insulin concentrations was significantly lower in the soleus (slow-twitch, oxidative fibers), red quadriceps (fast-twitch, oxidative, glycolytic fibers), and gastrocnemius (mixed fibers) of the obese rats when compared with lean rats. Glucose transport in the white quadriceps (fast-twitch, glycolytic fibers) was significantly lower in the obese rats in the absence of insulin and in the presence of the submaximal and maximal insulin concentrations. The glycogen concentration and the activity of hexokinase were the same and the glycogen synthase activity was higher in the muscles for the obese rats when compared to lean rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac malposition, redistribution of fetal cardiac output, and left heart hypoplasia reduce survival in neonates with congenital diaphragmatic hernia requiring extracorporeal membrane oxygenation.

OBJECTIVE: To evaluate cardiac position, left ventricular (LV) mass, and distribution of fetal cardiac output in infants with congenital diaphragmatic hernia (CDH) who required extracorporeal membrane oxygenation (ECMO), and in control subjects. STUDY DESIGN: Echocardiograms were performed on 23 neonates with CDH shortly after birth, and repeated within 5 days of repair on ECMO in 21 infants,aand on 12 infants receiving ECMO for other diagnoses, and on 10 healthy, term neonates. Cardiac angle between the midline saggital plane and the interventriculak septum was measured, and deviation from normal (45 degrees) was determined. The ratio of cross-sectional areas (proportional to flows) across the pulmonary (PV) and aortic (AV) valves was determined (PV2/AV2) in 19 infants with CDH and in the healthy control subjects. RESULTS: Thirteen (57%) infants with CDH survived and 10 (43%) died, with no difference in cardiac deviation before surgical repair (35 +/- 13 degrees vs Cardiac deviation persisted after repair in nonsurvivors (27 +/- 14 degrees vs 800.01 and LV mass was significantly less (1.68 +/- 0.39 vs 3.05 +/- 1.20 gm/kg, p00.0005). Neonates requiring ECMO for other diagnoses and well term babies did not have cardiac angle deviations; both these groups had a greater LV mass than did the infants with CDH. The PV2/AV2 flow ratios were higher in infants with CDH (median, 1.73; range, 1.25 to 16.50) compared with those of the healthy infants (0.96, 0.79 to 1.69, p < 0.0002). CONCLUSIONS: Cardiac malposition persisted despite CDH repair in nonsurvivors with low LV mass, and fetal cardiac output was redistributed away from the left ventricle. Lung hypoplasia with reduced pulmonary flow returning to the left atrium and altered left atrial hemodynamics may result in LV hypoplasia