Proposal and validation of a clinical trunk control test in individuals with spinal cord injury.

STUDY DESIGN: One of the problems that arise in spinal cord injury (SCI) is alteration in trunk control. Despite the need for standardized scales, these do not exist for evaluating trunk control in SCI. OBJECTIVE: To propose and validate a trunk control test in individuals with SCI. SETTING: National Institute of Rehabilitation, Mexico. METHODS: The test was developed and later evaluated for reliability and criteria, content, and construct validity. RESULTS: We carried out 531 tests on 177 patients and found high inter- and intra-rater reliability. In terms of criterion validity, analysis of variance demonstrated a statistically significant difference in the test score of patients with adequate or inadequate trunk control according to the assessment of a group of experts. A receiver operating characteristic curve was plotted for optimizing the instrument's cutoff point, which was determined at 13 points, with a sensitivity of 98% and a specificity of 92.2%. With regard to construct validity, the correlation between the proposed test and the spinal cord independence measure (SCIM) was 0.873 (P=0.001) and that with the evolution time was 0.437 (P=0.001). For testing the hypothesis with qualitative variables, the Kruskal-Wallis test was performed, which resulted in a statistically significant difference between the scores in the proposed scale of each group defined by these variables. CONCLUSION: It was proven experimentally that the proposed trunk control test is valid and reliable. Furthermore, the test can be used for all patients with SCI despite the type and level of injury.

Persistence on therapy is a major determinant of patient-, physician- and laboratory- reported outcomes in recent-onset rheumatoid arthritis patients.

OBJECTIVES: To evaluate impact of persistence on therapy on sustained major patient-, physician- and laboratory-reported outcomes (PROs, PHYROs and LAROs, respectively) in 112 recent-onset rheumatoid arthritis (RA) patients. METHODS: At each visit a rheumatologist interviewed patients regarding therapy, morning stiffness and fatigue, scored the 28-joint disease activity score and a visual analogue scale (VAS) and determined acute-phase-reactants. The patients completed the Hispanic version of the Rheumatoid Arthritis Disease Activity Index, the Medical Outcome Short Form 36 (SF-36), the Health Assessment Questionnaire (HAQ), a pain-VAS and an overall-disease activity-VAS. Persistence was defined by self-report through directed interview. Sustained major PROs, PHYROs and LAROs were defined according to cut-offs, when maintained for ≥6 months and until last follow-up. Descriptive statistics, Kaplan-Meier curves and Cox models were used. RESULTS: Total person-time of receiving therapy was of 375.5 patient-years. From February 2004 to June 2009, 36 (32.1%) patients were persistent. Baseline PROs/PHYROs/LAROs showed active disease and poor health status in both groups, but persistent patients (PP) had significantly lower HAQ (p=0.03) and overall-disease activity-VAS (p=0.01). More PP reached a sustained major SF-36-physical function-score (p=0.02). Persistence was the greatest independent risk factor for sustained major PROs (but absence of fatigue) and PHYROs, (p≤0.04). Time from baseline to major and sustained PROs (excluded absence of fatigue), PHYROs and C-reactive protein were shorter in PP (p≤0.04). CONCLUSIONS: Persistence was a strong predictor for major and sustained outcomes in early RA. Favourable outcomes appear earlier in persistent than in non-persistent patients.

Remission of systematic lupus erythematosus.

The occurrence and characteristics of remissions in patients with systematic lupus erythematosus (SLE) have not been determined. We therefore studied this in a cohort of 667 patients and found that 156 patients had achieved at least 1 period of 1 year or more of treatment-free clinical remission. This represents an incidence density of 0.028 new cases/person/year. Remission occurred within the first 2 years of disease in 62 patients. The mean duration of first remission was 4.6 years (range, 1-21 yr), and 81 patients were still in the initial remission up until cutoff time. Half of the remaining 75 patients who flared after achieving remission have not entered again in remission. Twenty-six of the 38 patients who did remained in remission, and the remaining 12 had subsequent flares and remissions. Treatment-free remission accounted for a mean of 5.8 years, corresponding to half the time of follow-up. Remission was not limited to patients with mild disease: at least 41 patients achieved remission despite renal involvement, 19 had had neuropsychiatric lupus, 15 had had thrombocytopenia, and 8 had had hemolytic anemia. We also found that the longer the time lapse between the initial manifestation and the diagnosis of SLE, the less likely it was for a patient to enter into remission. There was a continuous increase in likelihood of achieving a first remission from the beginning of disease up to 30 years of disease duration, when it reached 70%. Patients who achieved remission had increased survival, independently of the effect of other disease manifestations that cause increased mortality. We conclude that a significant proportion of patients with SLE, including those with severe organ involvement, may become symptom-free and in need of no more medication, perhaps indefinitely. Our findings support the notion that, in general, SLE is a more benign disease than previously considered.

Domestic violence against patients with chronic neurologic disorders.

BACKGROUND: Violent behavior caused by some neurologic disorders has been widely studied. However, the inverse, violence suffered by patients with neurologic disorders, has not been reported. Brain disorders frequently produce a high frequency of social, psychological, or physical disabilities that could leave patients vulnerable to domestic violence. OBJECTIVES: To determine the prevalence of domestic violence among female patients with chronic neurologic disorders and to identify possible diagnoses associated with the battering syndrome. DESIGN: Cross-sectional, self-administered, anonymous survey. SETTING: Tertiary care center for neurologic disorders in Mexico. PATIENTS: One thousand consecutive adult female patients with neurologic disorders, separated by medical diagnosis of functional or structural disorders. MAIN OUTCOME MEASURES: A modified version of the Abuse Assessment Screen was administered. Statistical analysis was performed using Poisson regression to estimate the prevalence ratio by univariate and multivariate analysis. RESULTS: Overall, 31.2% of women with chronic neurologic disorders were survivors of domestic violence. When separated according to the nature of the disease, 35.3% of patients with functional disorders and 28.1% of patients with brain structural disorders were victims of domestic violence (P = .02). Risk increased in relation to duration of marriage, number of children, and work outside the home. CONCLUSIONS: One third of female patients with chronic neurologic disorders in Mexico suffer domestic violence. A higher frequency of domestic violence was endured by patients with diagnosis of functional disorders as essential epilepsy, headache, migraine, trigeminal pain, depression, or vertigo. The possibility of domestic violence should be routinely explored in patients with chronic neurologic disorders of functional origin.

Serum anti-beta2-glycoprotein-I and anticardiolipin antibodies during thrombosis in systemic lupus erythematosus patients.

PURPOSE: Antibodies to beta2-glycoprotein-I are more strongly associated with clinical antiphospholipid syndrome than are anticardiolipin antibodies. We previously found a decrease in anticardiolipin antibodies at the time of thrombosis in 6 patients with systemic lupus erythematosus (SLE). We therefore sought to determine the prevalence and levels of antibodies to beta2-glycoprotein-I and to cardiolipin before, during, and after thrombosis in patients with SLE, and to compare them with patients who did not have thrombosis. METHODS: We studied 24 patients with SLE who had at least one episode of thrombosis and 102 patients with SLE without thrombosis. Serum anticardiolipin antibodies were measured by conventional enzyme-linked immunosorbent assay (ELISA) using newborn calf serum as the blocking agent. Serum anti-beta2-glycoprotein-I antibodies were measured by ELISA on nonirradiated plates, using purified human beta2-glycoprotein-I without phospholipid. RESULTS: All patients with thrombosis had anti-beta2-glycoprotein-I antibodies, compared with only 17% of controls (P <0.0001). We observed a significant decrease in serum anti-beta2-glycoprotein-I levels at the time of thrombosis, as compared with previous and subsequent samples. The prevalence and levels of IgG and IgM anticardiolipin antibodies were similar in patients with and without thrombosis. A decrease in IgG or IgM anticardiolipin titers occurred during thrombosis in 6 patients. Anticoagulant, corticosteroid, and immunosuppressive treatments did not appear to affect anti-beta2-glycoprotein-I levels at the time of thrombosis. CONCLUSION: Anti-beta2-glycoprotein-I antibodies are strongly associated with thrombosis in patients with SLE. The decrease of anti-beta2-glycoprotein-I levels at the time of thrombosis may indicate a pathogenic role. This antibody may also be a marker of predisposition for thrombosis in these patients.

Counselling following diagnosis of a fetal abnormality: comparison of different clinical specialists in Mexico.

Most geneticists agree that counselling should be nondirective, and studies report that genetic counselling by geneticists is performed largely in a neutral style. However, couples at risk of having a child with a genetic condition may seek the advice of other physicians. The purpose of the present study was to describe the answers of four groups of specialists from Mexico City (internists, pediatricians, obstetricians, and neurologists) regarding how they would counsel a couple when prenatal diagnosis has shown that a fetus is affected by one of 17 different genetic disorders and to analyze the role of several variables in the development of their opinion. Our results show that physicians in these specialties are more likely to counsel directively than neutrally. Other variables did not influence the directiveness. With respect to direction of influence, internists, pediatricians, and neurologists are more likely to counsel terminating affected pregnancies than are obstetricians (P = 0.0002). Similarly, clinicians older than 37 years of age and those reporting that religion is not important to them counsel terminating affected pregnancies (P = 0.005 and P = 0.003, respectively). Physicians' gender and clinical experience with genetic diseases did not show statistically significant differences. Strong consensus among specialists was reached only on terminating pregnancies in anencephaly. A lowered and moderate consensus (51-75% agreement) was reached on continuing pregnancies with cleft lip and plate. A moderate measure of consensus for nondirective counselling was found among obstetricians regarding 14 of the 17 diseases in the study, whereas neurologists expressed a moderate measure of consensus on counselling the termination of pregnancies when the fetus was affected by neurological disorders. Hence, the approach to counselling was related in part to the fetal condition and in part to the clinician's specialty and age and the self-reported importance of religion. The data presented herein may not be representative of all Mexican physicians within the selected specialties; however, it is important to gather their opinions because they are involved in the care and treatment of genetic diseases and may have an important influence on the demand and availability of prenatal diagnosis and abortion.

Attitudes of Mexican geneticists towards prenatal diagnosis and selective abortion.

Prenatal diagnosis (PD) provides the physician information on whether the unborn fetus has a genetic or chromosomal disorder, and offers patients a new option: selective abortion. In the present study, we analyzed the answers Mexican geneticists provided to a few selected questions from a multinational survey designed by Wertz and Fletcher [1988: Am J Hum Genet 42:592-600]. The selected questions were related to the use of PD, the acceptance of selective abortion, and the self-reported directiveness of counselling following the diagnosis of a fetal anomaly. Our results show that the great majority of Mexican geneticists participating in the study agree with PD when medically indicated, but not on free demand. Specific cases stimulated the group on thinking more than the general statements provided in the survey. Although the majority agreed that PD should be available to all women, when faced with cases of nonmorbid maternal anxiety, paternity testing, and sex selection, the proportion of geneticists willing to perform the test decreased substantially. When counselling patients on a fetal anomaly, the minority would be as unbiased as possible, and this seems to be the tendency in developing countries where counselling, as stated in the respondents' comments, reflects the belief that the goal of genetics is the prevention of or opposition to abortion. Counselling was influenced by the severity of the disorder. The geneticists' personal attitude toward abortion in the same situations was stronger than when counselling others. Analysis of directiveness in counselling for fetal anomaly showed that older geneticists, with more years of experience in medical genetics, were more likely to be neutral. When counselling directively, the group showed an overall direction toward continuing affected pregnancies. However, older geneticists and those with more than 10 years of practice were more likely than their younger counterparts to counsel towards terminating affected pregnancies. In personal situations of fetal disorder, the general tendency was to abort; however, geneticists seeing more than 5 patients per week, and those who believe that religion is important, were more likely to reject abortion. The sample is representative of Mexican geneticists, and the main limitation of this study is that the geneticists have very little experience in PD, and that their responses were mostly based on theory. However, their opinions may influence the demand and the availability of PD and abortion, as well as the possibility of legalization of abortion on the basis of a fetal defect.

Preliminary classification criteria for the antiphospholipid syndrome within systemic lupus erythematosus.

Ten percent of 667 consecutive systemic lupus erythematosus (SLE) patients were considered to have definite antiphospholipid syndrome (aPLS) because they had two or more antiphospholipid (aPL)-related clinical manifestations and aPL titers more than 5 SD above the mean of normal controls. Another 14% had either one aPL-related manifestation but high titers of the antibody or two manifestations and low aPL titers (probable aPLS). One fourth of the patients had no manifestations but high titers, one manifestation and low titers, or two or more manifestations and negative aPL titers ("doubtful" aPLS); the other half were considered negative for aPLS. In patients with high-titer aPL, the number of aPL-related manifestations was influenced by disease duration and number of pregnancies, indicating potential mobility of category with time or with risk of recurrent pregnancy loss. Patients with two or more manifestations but variable aPL levels differed in immunosuppressive treatment and in the number of times they had been tested, indicating potential mobility of category with lower treatment and/or further aPL testing. Patients with definite aPLS had increased risk of cutaneous vasculitis, peripheral neuropathy, seizures, psychosis, transient ischemic attacks, and leukopenia. In 11 of 52 SLE patients with definite aPLS the initial manifestation was related to aPL, and in 16 it concurred with an unrelated one. Only two patients fulfilled criteria for aPLS before having other evidence of SLE. The authors conclude that aPLS occurring within SLE is part of the disease rather than an associated condition and propose the use of definite and probable classification categories. These criteria, with appropriate follow-up and clinical and serological exclusion clauses for potential primary conditions, could also be applied to primary aPLS.

The prevalence of diabetes and associated coronary risk factors in urban and rural older Mexican populations.

OBJECTIVE: To determine the prevalence of diabetes and examine its association with food intake, anthropometric and metabolic variables, and other coronary risk factors in urban and rural older Mexican populations. DESIGN: A cross-sectional study. SETTING: Three Mexican communities (urban areas of medium and low income and a rural area). PARTICIPANTS: A total of 121 men and 223 women aged 60 years and older and 93 men and 180 women aged 35 to 59 years were selected randomly for inclusion in the survey, which was derived from the CRONOS study (Cross-Cultural Research on Nutrition in the Older Adult Study Group) promoted by the European Economic Community. MEASUREMENTS: A personal interview assessed demographic information, personal medical history, and functional status, and a 24-hour diet recall was obtained. A physical examination included anthropometric and blood pressure measurements. A fasting blood sample was obtained for measurements of lipids, insulin, and glucose. RESULTS: Diabetes prevalence was higher in men than in women for all age groups: 16.7% versus 9.5% in younger adults and 30.8% versus 22.8% in older adults. For all age groups, diabetes was more highly prevalent in urban communities. Using a multivariate stepwise logistic regression, variables associated independently with diabetes in older individuals were: gender (male sex: OR = 2.1; P < .009); diminished carbohydrate intake in the diet (OR = 0.77; P < .03); central distribution of adiposity (OR = 1.9; P < .03); and functional disability (OR = 2.3; P < .01). This relationship was not observed with living area, income, education, fiber and alcohol intake, body mass index, or age. Individuals 80 years and older had a diminished atherogenic risk profile. Diabetes in older people was associated significantly with hypertriglyceridemia, impaired functional status, and an increased prevalence of ischemic heart disease; in younger adults diabetes was associated with low density lipoprotein (LDL) hypercholesterolemia, hypertriglyceridemia, and a proportionally higher fat intake. CONCLUSION: This survey confirms the high prevalence of diabetes in the older Mexican population - particularly in men and in individuals living in urban areas - associated with an increased prevalence of other coronary risk factors. Diabetes was associated with higher fat, low carbohydrate, low fiber diets and increased prevalence of central distribution of adiposity. In the older subjects, diabetes was associated significantly with hypertriglyceridemia, impaired functional status, and increased prevalence of ischemic heart disease. A bias produced by early mortality and a survivorship effect must be considered in studies of older individuals. The health situation in the older Mexican population presents a complex problem that needs correct diagnosis and better strategies to benefit those segments of the population at increased risk.

Lipids, apoprotein B, and associated coronary risk factors in urban and rural older Mexican populations.

The objective of this comparative cross-sectional study was to determine the prevalence of dyslipidemias and examine its association with food intake and metabolic variables in urban and rural elder Mexican populations. Three different communities (urban areas of medium and low income and a rural area) were studied. A total of 344 subjects aged 60 years and older and 273 aged 35 to 59 years were included. The evaluated parameters were personal medical data, 24-hour diet recall, and fasting plasma lipids, insulin, and glucose levels. Older subjects, especially men, living in the rural area had lower cholesterol levels (5.02 +/- 0.97 v 5.6 +/- 1.07 mmol/L; P <.05) and insulin levels (12 +/- 10 v 42 +/- 68 mU/mL) and higher high-density lipoprotein cholesterol concentrations (1.31 +/- 0.36 v 1.07 +/-0.28 mmol/L) than the elders from the urban medium-income group. Possible explanations for these differences are found in the dietary habits of the groups. Rural elders had higher amounts of fiber (20 +/- 11 v 10 +/- 6 g/d) and carbohydrate (70% +/- 0.08% v 52% +/- 0.11% of calories) and lower fat (18% +/- 0.07% v 33% +/- 0.1% of calories) in their diets. In the urban groups, low-density lipoprotein hypercholesterolemia was present in 17.8% of adult and 39.1% of elderly women (P =.00001). In conclusion, environmental factors still play a prominent role in the pathophysiology of the dyslipidemias in the elderly.

Salt intake and blood pressure in rural and metropolitan Mexico.

A selected group of 155 Mexican adults aged 20-64 years were studied to investigate the role of sodium (Na) intake in explaining blood pressure (BP) differences in a rural town and urban Mexico City. The subjects had their BP, height, weight and skinfolds measured and they collected 3 continuous 24 h urines. Adjusted for age differences, average BPs were significantly higher (p < .05) for the urban (112.7 systolic: 73.6 diastolic mmHg) than for the rural group (108.4 systolic: 70.8 diastolic mmHg). They were also higher for men (111.8 systolic: 74.3 diastolic mmHg) than for women (109.6 systolic: 70.2 diastolic mmHg), the diastolic BP difference being significant (p < 0.05). The average daily Na excretion was also higher in the urban (122.2 mmol/day) than in the rural community (98.0 mmol/day) (p < 0.01). Potassium excretion rates showed similar differences. The differences in sodium excretion and blood pressure among communities were particularly marked in those over 30 years of age. The means for the four community-sex groups had the same rank order for both BP and Na. However, although some large surveys have suggested that half the observed differences in BP might be explained by different Na intakes, in this study the relationship between Na excretion and BP did not achieve statistical significance. Differences in the body mass index (BMI) accounted for 41% of the observed variance in BP.

Unusually high prevalence rates of obesity in four Mexican rural communities.

OBJECTIVE: To establish the nutritional status of previously studied rural populations. DESIGN AND SUBJECTS: A total of 139 households with 245 males and 301 females from four relatively isolated Mexican rural communities were randomly selected to be surveyed in 1996. RESULTS: Underweight was not a problem in either children or adults. In children <5 y only three (4.2%) were stunted but the age- and sex-specific distributions of body mass index (BMI) in children showed 17% of boys and 19% of girls exceeded the proposed International Obesity Task Force limits for classifying the overweight. Triceps skinfold values were similar to NHANESI values for white USA children. Of the adult men 42% were overweight (BMI 25.0-29.9) and 9% obese; 40% of adult women were overweight and a further 33% obese. Adjusting BMI values with corrected total heights by relating them to measured knee height reduced the BMI of women >50 y by 2.0 units; the male data were essentially unchanged. The prevalence of abdominal obesity in women, based on waist measurements and WHO cut-off points was high with 25% of women having elevated values despite a normal BMI; 43% of the overweight women had substantial increases in waist measurements, indicative of high risk, as did 91% of obese women. The men's waist measurements were greater in relation to both BMI and body fat but the prevalence of values in excess of the suggested sex-specific WHO limits was less than half that of women. CONCLUSIONS: The high prevalence of overweight and obesity is now evident in poor and relatively isolated rural communities of Mexico. SPONSORSHIP: The Chronic Disease Office, from the Ministry of Health in Mexico partially financed this study.

Autoantibodies, mortality and ageing.

Immunological failure may be the cause of predisposition to certain infections, neoplasms, and vascular diseases in adulthood. Mortality risks through life may reflect an undetermined number of causes. This study describes the prevalence of positivity of autoantibodies through life, along with general and specific mortality causes in three countries with different socioeconomic development (Guatemala, Mexico and the United States). Prevalence of autoantibodies by age was obtained from previous reports. In spite of having involved different ethnic groups, the observed trends in prevalence of autoantibodies, as well as mortality through life, showed a similar behavior. Thus, both the increase in autoantibody production and death risk as age rises, may share physiopathological phenomena related to the ageing process.

Malignant neoplasms in autoimmune rheumatic diseases: examination of the risk of developing a malignancy among five different rheumatic diseases in one institution.

Relationships between autoimmune rheumatic diseases and malignant neoplasms have been discussed, but there is no study of the different rheumatic diseases examining the risk of developing cancer. Our study has examined probabilities for developing malignancy among patients with connective tissue diseases seen in a single institution. Patients with autoimmune rheumatic disease and malignancy were compared with patients with the same autoimmune rheumatic diseases without malignancy. All cases identified through record-linkage from 1964 to 1996 were selected. Four controls per case were randomly selected from a pool of 3228 patients. The rheumatic diseases considered were rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), primary Sjögren's syndrome (pSS), dermatomyositis-polymyositis (DM-PM), and systemic sclerosis (Scl). The statistical analysis was conducted by conditional logistic regression, testing rheumatic disease as main effect. We identified 72 cases and 288 controls. Fifty-three of the cases had solid tumors, and 19 had lymphoproliferative neoplasms. The risk of developing a malignancy was considerably higher in DM-PM than in SLE (odds ratio [OR] = 17.5, 95% confidence interval [CI] 4.1-75.7), in pSS than in SLE (OR = 5.7, 95% CI 2.2-15.1), and in Scl than in SLE (OR = 5.4, 95% CI 1.6-18.0). These risks persisted after controlling for rheumatic disease duration, the time the disease was active, and anti-rheumatic treatment. RA had an OR of 1.8 (95% CI 0.9-3.4) with respect to SLE. This is the first study which describes the magnitude of risks among rheumatic diseases associated with the probability of developing a malignant neoplasm whether lymphoproliferative or solid. The risks in this series depend on the primary rheumatic disease, with DM-PM, pSS, and Scl all having greater risk than SLE.

Comparing easy and accessible parameters of glycemic control in type 2 diabetes.

BACKGROUND: HbA1c is considered the gold standard of long-term glycemic control and is recommended as a routine test for every diabetic patient. However, its common use in clinical practice has some problems related to lack of standardization and its relative cost. Recent studies have suggested, that postprandial blood glucose could be better than a fasting sample, as a marker of diabetes control. The objective of the present study was to evaluate the relative value of plasma glucose samples at different times of the day, and easy and accessible programs for home blood and urinary glucose measurements compared with HbA1c in assessing the mean glycemic control of type 2 diabetic patients. METHODS: Sixty type 2 diabetic patients were instructed to do home blood and urine glucose monitoring for two months, at the end, plasma glucose profiles were obtained. RESULTS: The mean of all the capillary BG measurements had the best correlation with the HbA1c (r = 0.84, p < 0.001), followed by the mean of the capillary BG measurements before breakfast and supper (r = 0.82, p < 0.001), and the 2 hr. postbreakfast plasma glucose (r = 0.79 p < 0.001). The fasting PG had a low correlation (r = 0.65, p < 0.001), but a good sensitivity to predict a fair or a poor metabolic control. Diabetes duration and type of treatment explained 17% and 28% of variance in HbA1c levels. CONCLUSIONS: A bimonthly fasting PG correlated well with the glycosylated hemoglobin and is the easiest and cheapest way of monitoring glycemic control in type 2 diabetic patients with some preserved insulin reserve (diabetes for less than 10 years and on treatment with only one hypoglycemic agent). A sample of capillary BG, fasting, once per week correlates better with the HbA1c than a fasting PG every 2-3 months. The 2 hr and 5 hr postbreakfast PG have a good correlation with the HbA1c, but are not a substitute for doing BG monitoring. Glycosuria may be a useful parameter to rule out a fair or poor metabolic control in some patients.

Nutrition and cataract in low-income Mexicans: experience in an Eye camp.

Surgical Eye-camps for cataract treatment of low-income adult Mexicans have been undertaken over the last 10 years. Despite the high prevalence of cataracts among these subjects, no assessment of their nutritional or health status has ever been made. We compare the results obtained for 81 adults (44 men and 37 women) who received treatment in May 1997 with those for a "control" group of age and sex-matched but affluent individuals in Mexico City. alpha-Tocopherol and beta-carotene were assessed and analysed by HPLC and colorimetric procedures, respectively. The plasma tocopherol to cholesterol ratio did not reveal deficiencies of this vitamin, and only 5 patients (2 men and 3 women) had low beta-carotene plasma levels. The patients had high BMI values, with 32% of men and 30% of women overweight, and 2% and 14%, respectively, obese, with higher glucose, cholesterol and triglyceride values reflecting enhanced insulin resistance and lipid abnormalities. The alkaline phosphatase values were elevated suggesting that many of these blind patients are osteomalacic because they now remain indoors. Although it has been suggested that an adequate intake of carotenes and tocopherol are associated with absence of cataract, this appears not to be the case in our study population. Surveys in Mexico have revealed, however, a highly prevalent deficiency of other vitamins such as niacin and riboflavin, both of which have been proved to be protective against cataract. It appears that nutritional deficiencies, obesity, incipient diabetes and lipid disorders co-exist in modern Mexico. We have identified a need for research to aid the design of preventive nutritional approaches at the population level that could be applied in parallel with ongoing surgical treatment.

Presence of a 16/6 related human anti-DNA common idiotype (SA1) in the anticardiolipin antibodies of patients with primary antiphospholipid syndrome.

Patients with primary antiphospholipid syndrome (PAPS) have few or no autoantibodies, other than the antiphospholipid antibodies (aPL) that could be natural autoantibodies encoded by germline genes. Some of the autoantibodies marked by the human anti-DNA common idiotype 16/6 have been found to be encoded by unmutated germline genes. Hence, we tested the sera of 19 patients with PAPS for the presence of the 16/6 idiotype which has also been found to be expressed on antibodies that bind cardiolipin. For this we used an ELISA method with antiserum against the SA1 idiotype which recognizes the 16/6. Five of our patients had the idiotype in at least one serum. Among the patients there was one with a variant of PAPS with hemolytic anemia and an IgM antibody to phosphatidylcholine that is akin to the natural autoantibody of normal mice encoded by germline genes VH11 and VH12. Inhibition studies with ssDNA, dsDNA and cardiolipin revealed that all 3 antigens decreased the serum levels of the SA1 idiotype despite absence of detectable anti-DNA antibodies by other methods. Our findings suggest that within the B cell clones that produce aPL in patients with PAPS there are some that produce immunoglobulins bearing 16/6 related idiotypes. This could indicate that some of the aPL present in patients with PAPS derive from natural autoantibody producing cell clones.

Influence of the antiphospholipid syndrome in the survival of patients with systemic lupus erythematosus.

OBJECTIVE: To determine prognostic factors for mortality in a cohort of 667 patients with systemic lupus erythematosus (SLE) including those variables associated with the presence of antiphospholipid antibodies (aPL) as well as antiphospholipid syndrome (APS) itself. METHODS: Analysis of the cohort under a nested case control design by means of Cox proportional hazards regression with and without stepwise method. RESULTS: During the 2039 person-years of followup, there were 49 deaths (cases). Thrombocytopenia, arterial occlusions, and hemolytic anemia were the aPL related manifestations that were associated with decreased survival in univariate analyses. The first 2 were also selected among risk factors for mortality in stepwise Cox multivariate analysis. The syndrome itself was also associated with increased mortality rates, independently of other variables. CONCLUSION: APS is among the variables that confer decreased survival on patients with SLE. This decreased survival is due to some (e.g., thrombocytopenia or arterial occlusions), but not all, of the manifestations of APS.

Myositis in primary Sjögren's syndrome. Report of 3 cases.

OBJECTIVE: To describe the findings and course of myositis in primary Sjögren's syndrome (SS). METHODS: We studied myositis in SS when clinically indicated. Of 104 patients with SS, we identified 3 cases. In all, the diagnosis was made according to clinical data, biochemical, electromyographic and biopsy criteria. Other autoimmune diseases were excluded. RESULTS: We found a prevalence of 3% of myositis secondary to SS. There were no significant associations between myositis and other clinical or laboratory variables. CONCLUSION: Although rare, myositis must be considered a part of the spectrum of SS. In our experience, treatment with steroids and immunosuppressive drugs was successful.