Drug dosage in end-stage renal disease (ESRD) patients undergoing haemodialysis. A predictive study based on a microcomputer program.

Drug dosage in end-stage renal disease (ESRD) patients undergoing haemodialysis is a very complex problem because of numerous variables relating to the patient, the type of drug administered and the type of dialysis and dialyser. We carried out a multifactorial study of these parameters using a microcomputer program written in BASIC. Three sets of data were fed into the computer: those relating to the biophysical characteristics of the patient, the type of dialysis and dialyser to be used, and others relating to the chemical and pharmacokinetic characteristics of the drug. From these, a predictive intravenous dosage regimen (bolus and infusion) was compiled for each ESRD patient. To check the program we used 2 drugs (tobramycin and vancomycin) and several types of dialyser. The findings were that, with tobramycin, an ESRD patient should be given different postdialytic doses, depending on the type of dialyser used. The maintenance doses calculated by the program were similar to those usually administered to patients receiving clinical treatment with this drug. In the case of vancomycin, the program calculated the clearance value in vivo through the 'Hemoflow F60' dialyser with a polysulphone membrane. The computer program calculated the maintenance dosage of vancomycin that should be given after each dialysis cycle so that its concentration did not fall below its minimum therapeutic concentration.

Relationship between low bone mineral density and highly active antiretroviral therapy including protease inhibitors in HIV-infected patients.

PURPOSE: The objectives of this study were to determine the prevalence of osteopenia and the factors associated with its presence in HIV-infected patients under highly active antiretroviral therapy (HAART) and to assess the changes of bone mineral density (BMD) in a population followed prospectively. METHOD: BMD was assessed by dual-energy X-ray absorptiometry (DEXA) scans at the lumbar spine and at the femoral neck in 78 HIV-infected patients who had previously received HAART as the first antiretroviral regimen and in 11 antiretroviral-naive HIV-infected patients. BMD measurements were repeated in 70 treated patients who had completed 1 year of follow-up. RESULTS: Thirty-seven (42%) patients showed osteopenia at any localization. The prevalence of osteopenia in PI-naive patients was 23% versus 49% in individuals who had received PI at any moment [p =.001; adjusted odds ratio (95% CI) = 0.11 (0.02-0.48)]. The frequency of osteopenia was significantly higher among men than among women [50% vs. 17%; p =.016; adjusted OR (95% CI) = 12.1 (2.22-66.20)]. The level of plasma albumin was independently associated with osteopenia [adjusted OR (95% CI) per each g/dL of plasma albumin decrease 2.55 (1.18-10)]. In patients in whom a second DEXA was done, no significant changes in BMD were found. CONCLUSION: The prevalence of osteopenia in HIV-infected patients on HAART is high. Loss of BMD is associated with PI therapy, low plasma albumin level, and male sex. Osteopenia does not progress after 1 year of continued HAART.

Pulmonary amyloidosis and unusual lung involvement in SLE.

The association of systemic lupus erythematosus (SLE) with amyloidosis is exceptional. We present a 37-year-old patient who was diagnosed five months earlier for SLE. She developed an acute episode of chest pain, cough and dyspnoea. Hypoxemia and obstructive changes in respiratory tests were present. The chest X-ray was repeatedly normal. Open lung biopsy revealed lupus pneumonitis with positive stain for immunoglobulins and complement, bronchiolitis obliterans, and pulmonary amyloidosis.

Juvenile neutrophilic eccrine hidradenitis: a vasculitis-like plantar dermatosis.

Neutrophilic eccrine hidradenitis is a variety of neutrophilic dermatosis described in patients with different neoplasms, most often leukaemia, and different chemotherapy regimens. It is characterised by neutrophilic infiltration of the eccrine coils of sweat glands. Recently it has been described in healthy juveniles, involving primarily the soles of the feet. We describe five new cases of juvenile neutrophilic eccrine hidradenitis all showing a good prognosis or a self-limiting course.

Cutaneous polyarteritis nodosa and Crohn's disease.

We report a case of a 57-year-old woman who presented simultaneously cutaneous polyarteritis nodosa and Crohn's disease of the colon. Although similar pathogenic hypotheses have been reported, the association of both diseases is exceptional.

HLA and Behçet's disease in northern Spain: their lack of correlation with arthritis pattern.

We have studied the characteristics of arthritis present in 32 patients with Behçet's disease (BD), and how this arthritis is related to the HLA markers class I. 84% of the patients presented arthritis, the most common being mono-arthritis as the initial presentation, and oligoarthritis in subsequent episodes. In 63% of the cases, the development was in episodes of acute/subacute arthritis. We found statistically significant association between antigens B-5 and B-51, and the group with BD, with a relative risk of 3.89 and 4.71 respectively. The attempt to relate markers B-5, B-51 and B-27 to the presence of arthritis as well as to its manifestation and further development was not conclusive.

[Sicca syndrome caused by large granulated lymphocytes in rheumatoid arthritis]. / Síndrome seco por linfocitos grandes granulados en la artritis reumatoide.

The proliferation of large granulated T lymphocytes (LGL) with neutropenia and splenomegaly can be observed in patients with rheumatoid arthritis (RA), in a similar way to Felty's syndrome. We report a female with long standing AR, xerophthalmia, xerostomia, neutropenia and LGL lymphocytosis. The phenotype of the latter was CD3+, CD8+, HNK1+. She was treated with methotrexate and corticosteroids. The genetic rearrangement study did not show monoclonality. Although LGL lymphocytosis can infiltrate several organs, salivary glands infiltration has not been reported. The development of a sicca syndrome can be a feature of LGL lymphocytosis and induce diagnostic mistakes in RA.

[Multiple aneurysms and cerebral vasculitis in systemic lupus erythematosus]. / Aneurismas múltiples y vasculitis cerebral en el lupus eritematoso sistémico.

A female in whom systemic lupus erythematosus had been diagnosed 5 years before suddenly developed headache and recurrent vomiting. Cranial computed tomography (CT) was consistent with subarachnoid hemorrhage, and cerebral arteriography disclosed cerebral aneurysms, multiple microaneurysms and cerebral vasculitis. After 7 days she developed left hemiparesis, and a cerebral infarct area was apparent in a new CT scan. Despite the poor prognosis of these lesions, the patient had a favorable outcome, without residual neurological deficit, after having been treated with intravenous corticosteroid boluses and oral cyclophosphamide.

[Peripheral tuberculous arthritis in Galicia]. / Artritis tuberculosa periférica en Galicia.

We have evaluated the cases of tuberculous arthritis in peripheral joints (TAPJ) that had been diagnosed in our unit during the last twelve years. The diagnosis was made by synovial biopsy in 26 of 33 cases, and by synovial fluid culture in the remaining 7. TAPJ accounted for 2.4% of all forms of tuberculosis and for 6% of extrapulmonary cases diagnosed in our hospital during those years. In 54% of cases there were risk factors of tuberculous infection. The mean time from the onset of symptoms to the confirmation of the diagnosis was longer than one year. All cases had clinical features of monoarthritis, and the knee was the most commonly involved joint (42%). In the 16 investigated synovial fluids the mean cellular rate was 11060 cells/mm3. The most reliable diagnostic procedure was the histological confirmation with synovial biopsy, whereas the yield of synovial culture was 64% and that of staining techniques 40%. In 97% of cases the treatment was effective. Orthopedic surgery was required in 36% of cases, and 48% had sequelae.

[Cerebral infarct in systemic lupus erythematosus]. / Infarto cerebral en el lupus eritematoso sistémico.

INTRODUCTION AND OBJECTIVE: Systemic lupus erythematosus is a syndrome of variable clinical and immunological expression, which may affect any organ. Stroke is an uncommon complication of systemic lupus erythematosus, attributed to many different etiopathogenic mechanisms such as early atherosclerosis, coagulopathy, vasculitis, cardiogenic embolism, etc. Our objectives were to analyze the incidence, clinical and immunological characteristics of this condition and to evaluate the therapeutic approach and evolution. CLINICAL CASES: We present the cases of six patients with cerebral infarcts who also had systemic lupus erythematosus. The frequency of cerebral infarct in our series of systemic lupus erythematosus was 6%. The average age was 45 years (range 13-67). All the cerebral infarcts occurred whilst the systemic lupus erythematosus was active. There were positive antiphospholipid antibodies in three of the patients and two patients had potentially embologenic cardiopathy (33%). Fifty percent of the patients required treatment with cyclophosphamide for their severe systemic disease and 66% received anticoagulants for an antiphospholipid syndrome and/or suspected thromboembolism. The clinical course was satisfactory in all cases but the one who died. CONCLUSIONS: The incidence of cerebral infarct in relation to systemic lupus erythematosus is low, and generally appears during advanced, active phases of the disease. The many etiopathogenic mechanisms involved generally act together so that it is difficult to say which is the main cause, especially in elderly patients. Amongst these mechanisms is the presence of antiphospholipid antibodies, detection of which is essential in this condition, and cardiogenic embolism. The evolution depends mainly on the multi-organ involvement and how early immunosuppressive and/or anticoagulant treatment is started.

[Reactive arthritis caused by Yersinia enterocolitica and Chlamydia trachomatis]. / Artritis reactivas por Yersinia enterocolitica y Chlamydia trachomatis.

We studied the clinical course, microbiological investigations and laboratory parameters in 10 patients with reactive arthritis (ReA). The number of patients with arthritis included was 10. Triggering agents were: seven patients had positive agglutinating antibody against Yersinia enterocolitica. Three cases had positive antibody test against Chlamydia trachomatis. In all patients antibody test were recovered. The clinical finding were: 4 patients with polyarthritis, 4 mono-oligoarthritis and two cases sacroileitis. The mean of index active joints were 6 (1-14). More frequent pattern were episodes of arthritis with lower limbs joints involvement. Outcome were of 12.1 (2-24) months. All of culture were negative. The laboratory parameters were unremarkable, except ESR were higher, HLA B-27 were positive in 70% of patients. The radiological signs and synovial biopsy studies were not conclusive. Eight patients were treated with antibiotics, not did antibiotics affect over duration of ReA.

["Sacroiliitis" as the initial manifestation of hepatocarcinoma]. / "Sacroileítis" como manifestación inicial de un hepatocarcinoma.

The hepatocellular carcinomas rarely develop in absence of a previous hepatopathy and their first clinical manifestations are not related, in general, to the metastasis located at the bones of the pelvic girdle. We present a multifocal hepatocarcinoma in a 17-year-old woman without known risk factors, whose initial manifestation was a clinical radiological picture suggesting left sacroiliitis. We stress this rare manifestation preceding the diagnosis of neoplasia two years later.

[Reiter's syndrome. A study of 25 cases]. / Síndrome de Reiter. Estudio de 25 casos.

The laboratory, radiological and clinical features of 25 cases of Reiter's syndrome were studied. Most of the subjects were between the 2nd and 4th decade of life (p less than 0.05). We observed a high incidence in females: 92% (p less than 0.01) and a high rate of alcoholism: 24%. Knees (72%) and ankles (44%) were the most afflicted joints. Urethritis (87.5%) and eye problems (87.5%), predominantly conjunctivitis (76%), were the more frequent extra-articular manifestation. HLA-B27 were positive in 81.8% (18/22). Sacroiliitis was confirmed radiologically in 8 patients (32%), being asymmetric in 6 of them. "Fluffy" periostitis (20%) was the more frequent peripheral articulation. The treatment used was indomethacin; we obtained good results in 20 subjects; the remaining 5 had to be treated with steroids to control ocular and joint symptoms. Two or more episodes occurred in a low rate of patients: 28%.

[Osteoporosis as the first manifestation of minor beta-thalassemia]. / Osteoporosis como primera manifestación de la beta-talasemia minor.

We present the case of a 48-year-old premenopausal woman with right lumbosciatalgia secondary to osteoporosic vertebral collapses. Two of her three offsprings, a 31-year-old man and a 16-year-old woman, had chronic dorsolumbalgia, the study of which suggested the diagnosis of minor beta-thalassemia. As opposed to thalassemic osteoarthropathy, frequently observed in the forms of "major" and "minor" beta-thalassemia, rheumatic manifestations have almost never been described in the "minor" forms. We highlight the possibility of symptomatic osteoporosis as the first manifestation and we review the locomotive disorders associated to this hemoglobinopathy.

[Epidemiological study of Reiter's syndrome in a health service area]. / Estudio epidemiológico del Síndrome de Reiter en un área sanitaria.

A higher incidence of Reiter's Syndrome (RS) is observed among young white men. We have conducted an epidemiological study of RS cases from our current health area and diagnosed in our hospital between 1975 and 1989. Twenty-four patients were included in this study, with a relation between men and women of 12:1 and an average age of 33.4 years. The annual incidence rate was 2.66 for men and 0.65 for women per 100,000 population during the study period. We have observed a tendency towards younger ages in the recent years and we have detected the presence of the HLA B-27 marker in 79% of patients.

Thrombolytic therapy in pulmonary embolism of Behçet's disease.

We report the case of a patient with Behçet's disease who presented with deep vein thrombosis and pulmonary embolism. In spite of being treated initially with anticoagulants, corticosteroid and oral cyclophosphamide, the patient presented again with a new pulmonary embolism. This critical situation made us initiate thrombolytic therapy with a urokinase "bolus' followed by continuous infusion through a catheter into the pulmonary artery. Treatment response was good and 2 years later there was no evidence of new thrombotic episodes.

Experimental equations to calculate aminoglycoside clearances through cuprophan dialyzers.

Aminoglycosides are a group of antibiotics of particular interest because of their widespread use in the treatment of infections caused by gram-negative bacteria. However, they are difficult to dose accurately because of their narrow therapeutic range and overdosing produces a large number of toxic effects. This paper describes a study carried out with the aim of ensuring the accurate administration of these antibiotics in end-stage renal disease patients undergoing hemodialysis, by developing equations which enable the dosage for individual patients to be calculated according to the dialyzer being used and the operational conditions set up during the dialysis session.