Androgen Receptor CAG Repeat Length in Relation to Phenotype Among Females with Nonclassical 21-Hydroxylase Deficiency.

Nonclassical 21-hydroxylase deficiency (NC21OHD) manifests with various degrees of post natal virilization. The length of CAG repeats of the androgen receptor gene (AR) is inversely correlated to activity of the human androgen receptor (AR) and affects phenotype of several androgen-dependent disorders. The aim of the study was to investigate the associations between CAG repeat length and the phenotype of females with NC21OHD. CAG repeat length and AR inactivation were assessed in females with NC21OHD, and related to their clinical presentation. CAG repeat length and AR inactivation were assessed in 119 females with NC21OHD. Biallelic mean (BAM) of the CAG repeat length and the weighted BAM (WBAM) were related to various clinical parameters. Age at diagnosis and age of menarche positively correlated with BAM (r=0.22, p=0.02, and r=0.23, p=0.01, respectively). A shorter (<25) BAM was associated with younger age at diagnosis (14.8 vs. 21.4 years, p<0.01), at adrenarche (8.1 vs. 10.2 years, p<0.01) and gonadarche (9.9 vs. 11.2 years, p<0.01), and higher corrected height standard deviation score at diagnosis (0.77 vs. 0.15, p=0.01). Precocious pubarche and precocious puberty were more frequent in these with the shorter BAM. Results of WBAM were similar. The CAG repeat length of the AR gene contributes to the clinical diversity of the phenotype in females with NC21OHD.

Persistent fever as the only symptom of familial Mediterranean fever.

We describe a 54-year-old man who suffered from familial Mediterranean fever, but the fever has been the only symptom during a 10-year period. During this period, results of laboratory tests and roentgenographic studies were negative. On the basis of these findings we propose that familial Mediterranean fever can be included in the causes of persistent fever in patients with long periods of fever.

Insulin resistance in offspring of hypertensive subjects.

OBJECTIVE: To assess whether apparently healthy subjects with a family history of systemic hypertension have a higher risk of presenting the insulin resistance syndrome. SUBJECTS: Three hundred and eighty-six subjects aged 20-65 years. SETTING: A middle socio-economic class urban community from Mexico City. METHOD: All subjects and, when necessary, their first-degree relatives, answered a questionnaire and underwent a physical examination with measurement of height, weight and blood pressure. Serum insulin, glucose, cholesterol and triglycerides were measured during fasting and 2 h after an oral load of 75 g glucose. RESULTS: A family history of systemic hypertension was present for 167 (43%) of the subjects, of whom 123 (31%) were obese. Subjects with a family history of hypertension had higher systolic blood pressures than did those without such a history (120 +/- 15 versus 115 +/- 10 mmHg). In the logistic regression model, the body mass index and age showed statistically significant effects on the fasting glucose:insulin ratio and on serum insulin levels after an oral load of glucose. When men and women were analysed separately, only in men were higher systolic and mean blood pressures and lower glucose:insulin ratios observed. In the logistic regression analysis the body mass index was a significant predictor of the glucose:insulin ratio and serum insulin levels after an oral load of glucose, especially in men. CONCLUSION: Apparently healthy male offspring of hypertensive parents have higher blood pressure levels and lower insulin sensitivities than do offspring of normotensive parents. Insulin resistance was related to obesity, but not to a family history of hypertension, as had previously been reported by other research groups.

How to predict the immune status of poliovirus vaccinees? A comparison of virus neutralization at a very low serum dilution versus ELISA in a cohort of infants.

A cohort of children from Gaza was observed from birth to the age of one year. Blood specimens were collected at birth, before and after poliovirus vaccination and at one year of age. Poliovirus immunity before and after vaccination was assessed by ELISA and virus neutralization (NT). Positive predictive values for ELISA were between 81.5% and 90.8%. However, ELISA revealed a high frequency of false negatives, and unacceptably low negative predictive values between 28.6% and 55.4%. The history of poliovirus immunity in the cohort was further investigated by NT. A high level of seropositivity to poliovirus type 1 (PV-1) was found. In cord blood, 83.3% had a NT titre greater than or equal to 4 and 99.0% had a titre greater than or equal to 2. Similarly, by one year of age, 85.7% had a titre greater than or equal to 4 and 90.5% had a titre greater than or equal to 2. Seropositivity to PV-2 and PV-3 were slightly lower, ie 80.8% of children had a PV-2 titre greater than or equal to 4 and 75.4% had a PV-3 titre greater than or equal to 4. As for other developing areas, poliomyelitis eradication in Gaza will come about when universal vaccination fills all 'immunity gaps' and improved sanitation and housing reduces the endemicity of wild polioviruses.

Fever: friend or foe?

Fever is one of the most common manifestations of disease. The patient's relatives and physicians' concern about it is due to the fact that fever reflects that something in the body is not working well. However, the question on fever as convenient or harmful is not yet completely answered. The purpose of this paper is to examine the arguments on both sides and to guide on the convenience of antipyretic treatment.

Changes in human serum antioxidant capacity and peroxidation after four months of exposure to air pollutants.

Twenty-one adult volunteers (aged 27-32 years), who had been living in Mexico City for four continuous months (physicians working as fellows) were studied the first and sixteenth week of their stay in order to learn the effects of the pollutants contained in Mexico City's atmosphere on some serum biochemical parameters. The activity of serum superoxide dismutase (SOD) decreased after 16 weeks in comparison with the values obtained the first week (109.6 to 56.9 mU/mg protein; 50% less). In contrast, the inhibitory capacity of serum vs. induced in vitro lipoperoxidation increased in relation to the length of stay (22%). The serum levels of thiobarbituric-reactive material also decreased in almost 30% (from 6.10 to 4.12 nmol). The other lipoperoxides measured were unchanged (chromolipids and diene conjugation). We propose that this may be as a result of the adaptative capacity of the human organism, within a pollutant atmosphere in which the ozone levels might participate in a decrease of SOD activity during chronic exposure, to air pollution.

Metabolic profile and insulin sensitivity in healthy young Mexicans with a strong family history of non-insulin-dependent diabetes mellitus in the paternal branch.

The objective was to identify early metabolic defects and insulin sensitivity in a group of healthy young Mexicans with a family history of NIDDM in first and second degree on the paternal branch. The design was a cross-sectional study, and the setting was a hospital and a school of medicine in Guadalajara, Jalisco, Mexico. The subjects were 20 healthy, non-obese, young (age 19-20 years), born in Mexico, with family history of NIDDM in first and second degree in the paternal branch, and 20 controls. Measurements were serum values of creatinin, uric acid, total cholesterol, high-density lipoprotein cholesterol, triglycerides, glucose, and insulin, insulin tolerance test, glucose/insulin ratio, LDL cholesterol, VLDL cholesterol, total cholesterol/HDL cholesterol ratio and LDL cholesterol/HDL cholesterol ratio. In terms of results, only the total cholesterol was slightly, although significantly (p = 0.05) higher in probands (4.3 +/- 0.5 mmol/L) than in control subjects (3.9 +/- 0.5 mmol/L). In conclusion, healthy young Mexicans with a strong family history of NIDDM in the paternal branch were not different in insulin sensitivity from those without family history of NIDDM, and only showed a slight increase in serum total cholesterol.

Predictive value of signs and symptoms in the diagnosis of subarachnoid hemorrhage among stroke patients.

Clinical diagnosis of subarachnoid hemorrhage (SAH) is frequently misdiagnosed with intracerebral hemorrhage (ICH) or cerebral infarction (CI), which delays appropriate referral. This study was undertaken to create a clinical index to select, among stroke patients, those with the highest probability of having a SAH. Clinical data of patients with acute stroke were evaluated with the X2 and the Fisher exact test; a p value < 0.05 was considered significant. Significant variables were included in a "log-lineal regression analysis" where those with an odds ratio (OR) 95% confidence limits not including the unit were considered to construct an index using the odds ratio coefficient (C). The results indicated that of 197 records which were included, 22 cases of SAH and 175 of ICH or CI were demonstrated. Kappa coefficients for observer variation in clinical data retrieval was 0.91. After "log-lineal regression analysis" was carried out the following variables were significant: neck stiffness (C = 3, OR = 21); lack of focal neurologic signs (C = 2, OR = 6.88); and age < or = 60 years (C = 1.5, OR = 4.35). A fourth variable, seizures (C = 1, OR = 3.25), was marginally significant (p = 0.07), but added predictive value to the index. The positive predictive values of the sum of the coefficients were: 0 = 0%; 1-2 = 3%; 2.5-3.5 = 21%; 4-5 = 40%; 6.5 = 75%; 7.5 = 100%. In conclusion, when a stroke patient shows neck stiffness, or any combination of young age, lack of focal neurologic signs or seizures (a score > or = 2.5, the index has a 91% sensitivity and 82% specificity), he/she must be referred to a tertiary care center.

Possible effect of air pollutants (Mexico City) on superoxide dismutase activity and serum lipoperoxides in the human adult.

The action of air pollutants, through their constituents, (O3, NO2, tobacco smoke) are capable of causing damage due to their lipoperoxidative properties or, indirectly, by inducing production of free radicals. As a consequence of photochemical processes, the ozone levels in the atmosphere of Mexico City are generally higher (mean of 0.325 ppm; period between 1987-1992) and may be harmful to health. Sixty two volunteers (medical doctors), aged 27-32 years, were divided into three groups. Group A was composed of those persons (17) who had never lived in Mexico City; a second group (B) (21) had recently arrived in Mexico City (1-8 days); and a third group (C) (24) who had permanently resided in Mexico City. Serum was obtained from fresh whole blood. Superoxide dismutase (SOD) activity and thiobarbituric acid-reactive materials were higher in group B while chromolipids and the serum inhibitory capacity (for lipoperoxidation) was higher in group C. The acute exposure to pollutants in group B apparently may have induced SOD as an antioxidant defense and was responsible for the increased level of TBA reactive material. In group C, the significant finding is better antioxidative defenses and slightly higher chromolipids.

Circadian variation of human acute phase response.

Circadian variation of temperature, both normal and febrile, is a well known fact. Mediators of fever are also regulators of acute phase response and are associated with stimulation of pituitary hormone production related with defervescence and with a circadian pattern of secretion. Acute phase response may consequently have circadian variations in its components. Measurements of temperature, erythrocyte sedimentation rate, complete blood cell count, serum cortisol and fibrinogen were made at 7:00, 15:00, and 23:00 h during two consecutive days in 35 patients with fever and acute infection, 15 patients with clinically active ankylosing spondylitis without fever and 10 healthy volunteers. Temperature curves showed statistically significant circadian rhythms, with higher values at night and lower ones during early morning. Erythrocyte sedimentation rate, leukocyte count and fibrinogen also showed statistically significant circadian rhythms, but with higher values at 15:00 h. Serum cortisol also showed statistically significant circadian rhythmicity but with a higher rhythm adjusted mean (MESOR), and a 100 degrees (6 h) phase shift in patients with fever, as compared to patients with ankylosing spondylitis and healthy controls. In conclusion, components of acute phase response, including fever, have circadian rhythmicity, but asynchronically. Differences between fever and ankylosing spondylitis can be due to the intensity of acute phase response stimulation.

A rating system for prompt clinical diagnosis of ischemic stroke.

BACKGROUND: When a CT scan is not available, an early accurate clinical diagnosis of ischemic stroke is essential to initiate prompt therapy. Our objective was to construct a clinical index that is easy to use when stroke patients are first evaluated at the hospital, to identify those who probably are experiencing an acute ischemic episode. The study was conducted at a university-affiliated medical referral center and two community general hospitals in Mexico. METHODS: Clinical records were reviewed for 801 patients with sudden onset of a focal or global neurologic dysfunction, presumably of vascular origin lasting more than 24 h. Eligibility criteria for this study were admission to the hospital within the first 24 h after symptomatic onset, CT scan diagnosis between 24 and 72 h, and age >45 years. Ischemic stroke included cases of arterial brain infarction, while nonischemic stroke included subarachnoid or intraparenchymatous hemorrhage, mass lesion, venous infarction, and in cases without a CT scan evidence that could explain the clinical manifestations. Data excerpted for analysis were age, sex, history of diabetes mellitus or previous stroke/transient ischemic attack (TIA), time of onset of symptoms, presence of headache, vomiting, neck stiffness, hemiplegia, leukocytosis or atrial fibrillation, diastolic blood pressure, and Glasgow coma scale (GCS) rating. Two multivariable analyses were used: 1) step-wise multiple logistic regression (SMLR), and 2) conjunctive consolidation (CC). RESULTS: After appropriate exclusions, the study proceeded with 83 ischemic and 42 nonischemic stroke patients. With SMLR, six variables were selected as predictive for ischemic stroke, including neck stiffness, diastolic blood pressure, previous history of stroke/TIA, hemiplegia, GCS, and atrial fibrillation. An appropriate sum of weighted ratings had a positive predictive value (PPV) of 100% for ischemic stroke. With consolidated categories, the PPV was 97% when patients had the following: no neck stiffness; no atrial fibrillation but history of stroke/TIA and GCS > or =12, or no neck stiffness but atrial fibrillation. CONCLUSIONS: Among patients with acute stroke, clinical data can be used to identify a group with a high probability of ischemic stroke. There are slightly different results between both methods; while SMLR includes the four variables selected by CC, the latter included neither diastolic blood pressure nor hemiplegia/hemiparesia. However, CC results seem easier to understand and interpret than with SMLR.

An assessment of cerebrospinal fluid's total creatine-kinase activity in the differential diagnosis of metabolic and organic causes of coma.

The objective of the study was to assess total cerebrospinal creatinine-kinase activity (CSF-CK) measurement in differential diagnosis of "metabolic" and organic causes of coma. The setting for the study was a tertiary care reference medical center and community general hospital. The design of the study was a series of consecutive patients with profound coma (Glasgow scale ratings between 3 and 6) as the presenting complaint to the emergency room and controls. Measurements and main results were as follows: CSF-CK was measured in 103 consecutive patients including 18 patients with metabolic causes of coma, 27 patients with organic causes of coma, 18 patients scheduled for elective orthopedic surgery with epidural anesthesia and 27 patients with compressive myelopathy and radiculopathy. CSF-CK activities were significantly different between groups (H = 29.48, p < 0.001, Kruskal-Wallis test), controls had a median of 0 mU/ml (range 0-16 mU/ml), patients with metabolic causes of coma had a median of 0 mU/ml (range 0-65 mU/ml), patients with compressive myelopathy or radiculopathy had a median of 19 mU/ml (range 0-80 mU/ml), and patients with organic causes of coma had a median of 20 mU/ml (range 0-400 mU/ml). The test sensitivity was 83% (95% confidence interval (CI 65-100%) specificity 62% (CI 43-80%) positive predictive value 60% (CI 49-79%) and negative predictive value 85% (CI 75-95%). The conclusion of the study was that the test is useful for ruling out metabolic causes of coma when CSF-CK activity is high (i.e., above 16 mU/ml).

The perception of teratogenic risk by women with nausea and vomiting of pregnancy.

This study determined the advice reported to be received by women suffering from nausea and vomiting of pregnancy (NVP) from their caregivers regarding management, the teratogenic risk perception of these women and their choice of antiemetic drug use in pregnancy. A secondary objective was to determine prospectively the effect of counseling on malformation risk perception in women with NVP. The women were prospectively followed-up and questioned about the use of pharmacotherapy or other management choices as well as their perception of teratogenic risk through structured telephone interviews. The results showed that at the initial call, around 6 weeks of gestation, over three quarters of the 260 participants reported that therapy of NVP increased their teratogenic risk. This risk perception was decreased significantly after counseling. Women who reported their physicians' advice to change their diet and/or lifestyle attributed an increased risk for major malformations with antiemetics for NVP (P = 0.001), whereas women who reported advice to take antiemetic medications known to be safe to the fetus attributed no change in risk for major malformations with drugs for NVP (P = 0.002). We came to the conclusion that women are commonly hesitant to treat NVP pharmacologically due to unfounded fears of teratogenic risk. Evidenced-based counseling resulted in reduced numbers of women who considered drug therapy for NVP to increase the risk of major malformations.

The electroencephalogram in adult patients with fever.

In order to determine if adult patients have reversible EEG abnormalities concurrent with fever, EEGs were recorded during fever in patients without neurologic disease or systemic disease capable of involving the central nervous system, and these were compared blindly with EEGs from the same patients taken at least 30 days after the febrile illness had disappeared. Fourteen patients completed the study, 10 men and 4 women, between the ages of 24 and 56 years, with fever secondary to localized infection. The global frequency of abnormal EEGs was high compared with the general population, since only 6 patients had both records completely normal; in 4 of these 6 cases during fever there were sleep patterns, mainly the first phase of slow wave sleep. Patients with localized abnormalities during fever showed the same abnormality in the EEG taken without fever, with two exceptions, one in which the abnormal finding disappeared and one in which another abnormality replaced the first one. Two patients had normal EEGs during fever and paroxysmal theta waves with predominance in their EEGs taken one month later. Fever in adults seems not to provoke rapidly reversible EEG changes. The high proportion of abnormal EEGs in these patients, and the appearance of new abnormalities in two cases after fever, deserves further research concerning the long-term effects of febrile illness on the EEG in adult patients.

Increased adhesiveness of peripheral blood leukocytes corresponds to the appearance of expansion following anterior wall myocardial infarction.

The appearance of increased leukocyte adhesiveness/aggregation as an inflammatory marker in the peripheral blood of patients with anterior wall myocardial infarction was monitored. Of the 26 patients included in the study, 7 had infarct expansion as shown by an enlargement of left ventricular end-diastolic volume. The percent of aggregated leukocytes in the peripheral blood of patients with expansion (29.7 +/- 15.5%) was significantly higher (p = 0.01) than that obtained from patients with no expansion (18.5 +/- 6.8%). The lack of significant differences in peak creatine kinase concentrations between patients with and without expansion suggests that infarct size is not necessarily the main determinant for the appearance of expansion; an increased inflammatory reaction could be a contributory factor.

Improved high-intensity microwave discharge lamp for atomic resonance absorption and fluorescence spectrometry.

An unusually good combination of high intensity and narrow line has been achieved in a microwave discharge lamp by placing the optical window in the center of the microwave cavity. Construction details and performance characteristics are described.

[Treatment of enteropathy in AIDS with a gluten-free diet. Preliminary communication]. / Tratamiento de la enteropatía del SIDA con una dieta sin gluten. Comunicación preliminar.

We present five patients with AIDS and enteropathy in whom the chronic diarrheal syndrome disappeared with a gluten-free diet. We hypothesize on the interrelations between celiac disease and enteropathy in AIDS, and propose that in similar cases, it may be a useful therapeutic alternative.

[Trends in medical education]. / Tendencias de la educación médica.

Trends in medical education include those occurring in medical practice, related with its contents, and in the educational sciences, related with methods and technics that could be employed. Trends in medical practice are related to epidemiologic, demographic and economic transitions, with the overwhelming influence of medical technology, specially molecular biology, the increasing social regulation, evidence based medicine and transdisciplinary contributions. In the field of pedagogy, trends include the acceptance of the strategic value of medical education, the importance of quality-and not only of covering, the attention to educational necessities, the recognition of the adulthood of most of the learners, the importance of its individual differences and the application of new educational technics.

[Learning clinical medicine]. / El aprendizaje de la clínica.

Conceived as a skill and an attitude more than as knowledge, contemporary clinics includes issues such as patient-doctor relationship, collecting and analysing information, diagnostic reasoning and therapeutic decisions. Clinics is learned through significant experiences in responsible patient care, with a critical analysis of each of them, and a real link between theory and practice in order to learn a method more than to acquire isolated knowledge, and through clinical investigation as a way of learning. Teaching clinics is based on faculty example and on supervision and feedback.