Right axis deviation as a criterion for echocardiographic evaluation of aircrew candidates.

BACKGROUND: Significant pressures exist in the resource-limited environment of military aviation to select only those candidates for flight training who are both physically able to withstand the demands of the flight environment and likely to complete a career in aviation. As medical technology has advanced, uncertainty has arisen regarding the appropriate use of additional studies in the screening of aircrew candidates. At the Naval Operational Medicine Institute (NOMI), where all U.S. Navy aviation duty candidates' medical qualifications are reviewed, current policy is to perform 2D-echocardiography on all candidates who exhibit a right axis deviation of +95 degrees or greater on their initial electrocardiogram. METHODS: The records of all aircrew candidates referred to the Department of Internal Medicine for evaluation of right axis deviation during the years 1993, 1994, and 1995 were reviewed. A cost benefit analysis was performed to assess the cost effectiveness of using echocardiography to screen candidates suspected of having disqualifying physical defects based on a finding of right axis deviation on electrocardiogram. RESULTS: Of the 69 cases reviewed, only 1 candidate was disqualified due to cardiovascular disease. He suffered from a large atrial septal defect initially discovered on physical examination. CONCLUSIONS: It is not cost effective to use 2D-echocardiography to screen aircrew candidates for disqualifying cardiac defects based on a finding of a right axis deviation of +95 degrees or greater on electrocardiogram.

Treatment of early rheumatoid arthritis with minocycline or placebo: results of a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: To determine if minocycline is an effective therapy for seropositive rheumatoid arthritis (RA) when used within the first year of disease. METHODS: The Rheumatoid Arthritis Investigational Network enrolled 46 patients with RA of <1 year duration into a 6-month study of minocycline (100 mg twice daily) versus placebo. All patients were rheumatoid factor positive. The primary end point of the study was successful completion of 6 months of treatment with no drug toxicity while maintaining 50% improvement in composite symptoms of arthritis. RESULTS: Eighteen of the 46 patients who were enrolled met 50% improvement criteria at 3 months, and maintained at least a 50% improvement for 6 months with no significant drug toxicity. Among them were 15 of the 23 patients (65%) treated with minocycline and 3 of 23 patients (13%) treated with placebo (P < 0.001). CONCLUSION: In patients with early seropositive RA, therapy with minocycline is superior to placebo.

Treatment of rheumatoid arthritis with methotrexate alone, sulfasalazine and hydroxychloroquine, or a combination of all three medications.

BACKGROUND: Rheumatoid arthritis is a common disease that causes substantial morbidity and mortality. The responses of patients with rheumatoid arthritis to treatment with a single so-called disease-modifying drug, such as methotrexate, are often suboptimal. Despite limited data, many patients are treated with combinations of these drugs. METHODS: We enrolled 102 patients with rheumatoid arthritis and poor responses to at least one disease-modifying drug in a two-year, double-blind, randomized study of treatment with methotrexate alone (7.5 to 17.5 mg per week), the combination of sulfasalazine (500 mg twice daily) and hydroxychloroquine (200 mg twice daily), or all three drugs. The dose of methotrexate was adjusted in an attempt to achieve remission in all patients. The primary and point of the study was the successful completion of two years of treatment with 50 percent improvement in composite symptoms of arthritis and no evidence of drug toxicity. RESULTS: Fifty of the 102 patients had 50 percent improvement at nine months and maintained at least that degree of improvement for two years without evidence of major drug toxicity. Among them were 24 of 31 patients treated with all three drugs (77 percent), 12 of 36 patients treated with methotrexate alone (33 percent, P < 0.001 for the comparison with the three-drug group), and 14 of 35 patients treated with sulfasalazine and hydroxychloroquine (40 percent), P = 0.003 for the comparison with the three-drug group). Seven patients in the methotrexate group and three patients in each of the other two groups discontinued treatment because of drug toxicity. CONCLUSIONS: In patients with rheumatoid arthritis, combination therapy with methotrexate, sulfasalazine, and hydroxychloroquine is more effective than either methotrexate alone or a combination of sulfasalazine, and hydroxychloroquine.

Efficacy of triple DMARD therapy in patients with RA with suboptimal response to methotrexate.

Rheumatoid arthritis (RA) has a profound effect on patients, producing significant morbidity and in some cases mortality. Because of this, most rheumatologists are moving to disease modifying antirheumatic drug (DMARD) therapy earlier in the course of RA. Methotrexate (MTX) has become the initial DMARD of choice for most rheumatologists. Unfortunately, treatment of RA with a single DMARD, including MTX, often results in a suboptimal response. Therefore, most rheumatologists are now using combinations of DMARD to treat patients with RA who have had incomplete responses to single DMARD therapy. The Rheumatoid Arthritis Investigational Network (RAIN) reported the results of a double blind, controlled comparison of triple drug therapy (MTX-sulfasalazine-hydroxychloroquine) against MTX alone, and against the combination of hydroxychloroquine and sulfasalazine. Twenty-eight patients who had suboptimal responses to MTX or the combination of sulfasalazine and hydroxychloroquine were then treated with triple therapy in an open label study. Fourteen had previously failed MTX therapy, and 14 had previously failed combination therapy with sulfasalazine and hydroxychloroquine. Both groups had statistically significant improvements in sedimentation rates, morning stiffness, swollen joint scores, tender joint scores, patient global status assessment, and physician global status assessment. Statistical significance was reached for all these variables for patients in both groups, but improvement was greater for the patients in the sulfasalazine-hydroxychloroquine group. Patients with RA who have had suboptimal responses to MTX, or to the combination of sulfasalazine-hydroxychloroquine, show both statistical and clinically significant improvement in multiple clinical variables when treated with the combination of MTX 17.5 mg/week, sulfasalazine 500 mg bid, and hydroxychloroquine 200 mg bid.

Adverse experience with methotrexate during 176 weeks of a longterm prospective trial in patients with rheumatoid arthritis.

Adverse experience occurred with a high frequency in a longterm (greater than 3 years), prospective, double blind, followed by an open trial of methotrexate (MTX) therapy in 45 patients with rheumatoid arthritis (RA). Adverse experiences occurred in 96% of patients, and the discontinuation rate was 44% over 176 weeks. No hepatic or pulmonary fibrosis occurred. Unusual toxicities included weight loss (2 patients), systemic fungal infections (2 patients), and transient noncirrhotic ascites (1 patient). Baseline white blood cell counts and creatinine may help predict adverse experiences. The full dose-toxicity spectrum of MTX RA is not yet fully defined.

Cutaneous anergy and marrow suppression as complications of gastroplasty for morbid obesity.

Although serious morbidity from gastric restriction for morbid obesity is rare, outflow tract dilation after gastroplasty has become a well-recognized complication, and reoperation to decrease outflow tract size has become increasingly common. We report the case of a patient who developed outflow tract obstruction with subsequent malnutrition, recurrent infections, and marrow suppression. Extensive immunologic evaluation revealed impaired cutaneous reactivity to a battery of recall antigens. Other in vitro T cell functions, B cell functions, neutrophil respiration, and quantification of complements were within normal limits. The patient's immunodeficiency was attributed to protein-calorie malnutrition and was corrected with total parenteral nutrition. Recovery of immune function with renutriture was demonstrated, and coincident resolution of infection and marrow suppression also occurred. Because of the reversibility of the immunologic abnormality with appropriate nutritional therapy, it is important to consider and treat malnourishment in connection with any operation in which oral intake is severely limited.