Protocol for clinical monitoring of juvenile idiopathic arthritis

The development of new and more efficacious therapeutic agents, though expensive and potentially toxic, helped to implement objective measures to quantify the improvement and to monitor the evolution of inflammatory rheumatic diseases. The aim of our protocol (PMAIJ) is to supply rheumatologists and paediatricians with a useful tool for follow-up of juvenile arthritis patients using validated instruments for the evaluation of activity, functional capacity and response to treatment. PMAIJ has 2 pages. The first page is filled only at the initial evaluation; the second page is filled at first and in all the appointments after that. The application of this protocol would contribute to the standardization of procedures in different Paediatric Rheumatology Centres and would help to obtain useful information on the clinical evolution of JIA patients followed in Portugal.     

Recommendations for the diagnosis and treatment of latent and active tuberculosis in patients with inflammatory joint diseases treated with tumour necrosis factor alpha inhibitors

The Portuguese Society of Rheumatology (SPR) and the Portuguese Society of Pulmonology (SPP) have developed guidelines for the diagnosis and treatment of latent tuberculosis infection (LTBI) and active tuberculosis (AT) in patients with inflammatory joint diseases (IJD), namely rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis, treated with tumour necrosis factor alpha (TNF-alpha) antagonists. Due to the high risk of tuberculosis (TB) in patients with IJD, LTBI and AT screening should be performed as soon as possible, ideally at the moment of IJD diagnosis. Even if TB screening was performed at the beginning of the disease, the evaluation should be repeated before starting anti-TNF-alpha therapy. When TB (LTBI orAT) treatment is indicated, it should be performed before the beginning of anti-TNF-alpha therapy. If the IJD activity requires urgent anti-TNF-alpha therapy, these drugs can be started after two months of antituberculosis therapy in AT cases, or after one month in LTBI cases. Chest X-ray is mandatory for all patients. If abnormal, e.g. Gohn complex, the patient should be treated as LTBI; residual lesions require the exclusion of AT and patients with history of untreated or incomplete TB treatment should be treated as LTBI. In cases of suspected active lesions, AT diagnosis should be confirmed and adequate therapy initiated. Tuberculin skin test (TST), with two units of RT23, should be performed in all patients. If induration is less than 5 mm, the test should be repeated after 1 to 2 weeks, on the opposite forearm, and should be considered negative if the result is again inferior to 5 mm. Positive TST implicates LTBI treatment. IfTST is performed in immunosupressed IJD patients, LTBI treatment should be offered to the patient before starting anti-TNFalpha therapy, even in the presence of a negative test.     

Juvenile cutaneous polyarteritis nodosa associated with streptococcal infection

Polyarteritis nodosa is a rare vasculitis of small and medium arteries. It can occur in a systemic form with multi-organ involvement, or as a limited form confined to the skin, muscles, joints and peripheral nerves called cutaneous polyarteritis nodosa. Both forms are rare in adults and even more in children. The caues of this vasculitis remain unknown but some viruses and bacteria have been implicated, specially, Streptococcus. We present the case of a 6-year-old child who developed cutaneous polyarteritis nodosa following a probable streptococcal infection.     

内皮前体细胞自体移植促进缺血心肌血管的新生

目的:观察内皮前体细胞自体移植后能否促进血管新生、改善心肌灌注、进而改善心脏功能。方法:实验于2004-01/05在解放军总医院心内科实验室完成。①实验分组:雄性新西兰白兔32只,体质量3.0～3.5kg,随机分为治疗组和对照组,每组16只。②实验方法:治疗组自骨髓获取内皮前体细胞培养扩增。结扎动物冠状动脉前降支根部。心电图检测至少5个胸前导联出现ST段显著抬高作为模型制作成功标志。2.5g/L胰蛋白酶消化细胞,洗涤干净后5mL磷酸盐缓冲液悬浮细胞,结扎前降支2h后将细胞悬液从耳静脉注入动物体内,移植细胞数量为(9.8±2.9)×106个/只。对照组注射磷酸盐缓冲液5mL。饲养5周。③实验评估:分别行超声心动图检查和左心室压力曲线检测心脏功能和心肌组织的梗死情况以及通过免疫组织化学检测观察血管密度。结果:纳入新西兰白兔共32只,因前降支细小排除2只。对照组因心功能衰竭和腹泻各死亡1只。治疗组结扎前降支后突发室性心律失常死亡1只。最终27只进入实验。①体外培养的内皮前体细胞生长迅速,能够在2～3周达到预定移植细胞数量。②内皮前体细胞移植5周后,超声心动图检测显示治疗组动物心肌功能指数显著降低(P<0.01),左心室射血分数显著高于对照组(P<0.01),左心室舒张末压明显低于对照组(P<0.05),而等容收缩期左室压力最大上升速率显著升高(P<0.05)。③治疗组心肌梗死面积显著减小(P<0.01),而血管密度明显高于对照组(P<0.01)。④标记细胞主要位于梗死心肌组织,大部分整合至毛细血管中,参与血管新生。结论:内皮前体细胞自体移植能促进缺血心肌血管新生,有效改善缺血心肌的灌注,进而改善心脏功能。     

血管内皮生长因子对梗阻性肾病中肾小管周围毛细血管的调节作用

目的:观察刚断乳雄性SD大鼠单侧输尿管完全梗阻模型中血管内皮生长因子对肾小管周围毛细血管形态学变化的调节作用,探讨血管内皮生长因子在肾病进展中的生物活性作用。方法:实验于2005-03/2006-05在苏州大学儿科研究所完成。①实验材料:30只清洁级刚断乳雄性SD大鼠,体质量50～70g。②实验过程:结扎SD大鼠左侧输尿管建立单侧输尿管完全梗阻模型。于术后0,1,7,14,28d,分别随机选择6只模型大鼠,收获肾脏标本。③实验评估:采用苏木精-伊红染色观察肾积水的严重程度;Masson染色观察肾小管间质纤维化程度;PAS染色观察肾小管萎缩程度;免疫组织化学方法检测肾小管周围毛细血管的密度和血管内皮生长因子的表达水平;原位末端标记法对肾小管周围毛细血管和肾小管上皮细胞进行原位凋亡测定;透射电镜显示超微结构变化;血管内皮生长因子蛋白的表达强度和间质纤维化程度采用Leica图像分析系统检测。结果:①梗阻第1周,肾小管上皮细胞胞浆里的血管内皮生长因子染色在局部有增强,胎肝激酶1阳性肾小管周围毛细血管数量变化不显著,肾小管上皮细胞凋亡很少见,间质纤维化轻。第2,4周,血管内皮生长因子表达逐渐下降,直至在一些肾小管内完全消失。与此同时,胎肝激酶1阳性的肾小管周围毛细血管数量减少,肾小管扩张或萎缩明显,间质纤维化严重。②电镜显示肾小管上皮细胞、肾小管周围毛细血管内皮细胞的死亡形式主要为凋亡。③原位末端标记法显示肾小管上皮细胞凋亡在第14天达到高峰,然后迅速下降。④在梗阻第2周时,原位末端标记法阳性的肾小管周围毛细血管内皮细胞数与血管内皮生长因子表达面积百分比负相关(r=-0.668,P<0.05);肾小管周围毛细血管密度与血管内皮生长因子表达面积百分比正相关(r=0.707,P<0.05),而与肾小管上皮细胞凋亡负相关(r=-0.863,P<0.01)。结论:肾小管周围毛细血管减少与肾小管上皮细胞内血管内皮生长因子的表达不足相关,并与肾小管上皮细胞凋亡相关。     

A scoring tool to predict mortality and dependency after cerebral venous thrombosis

Background and purpose

A prognostic score was developed to predict dependency and death after cerebral venous thrombosis (CVT) to identify patients for targeted therapy in future clinical trials.

Methods

Data from the International CVT Consortium were used. Patients with pre-existent functional dependency were excluded. Logistic regression was used to predict poor outcome (modified Rankin Scale score 3–6) at 6 months and Cox regression to predict 30-day and 1-year all-cause mortality. Potential predictors derived from previous studies were selected with backward stepwise selection. Coefficients were shrunk using ridge regression to adjust for optimism in internal validation.

Results

Of 1454 patients with CVT, the cumulative number of deaths was 44 (3%) and 70 (5%) for 30 days and 1 year, respectively. Of 1126 patients evaluated regarding functional outcome, 137 (12%) were dependent or dead at 6 months. From the retained predictors for both models, the SI₂NCAL₂C score was derived utilizing the following components: absence of female-sex-specific risk factor, intracerebral hemorrhage, infection of the central nervous system, neurological focal deficits, coma, age, lower level of hemoglobin (g/l), higher level of glucose (mmol/l) at admission, and cancer. C-statistics were 0.80 (95% confidence interval [CI] 0.75–0.84), 0.84 (95% CI 0.80–0.88) and 0.84 (95% CI 0.80–0.88) for the poor outcome, 30-day and 1-year mortality model, respectively. Calibration plots indicated a good model fit between predicted and observed values. The SI₂NCAL₂C score calculator is freely available at www.cerebralvenousthrombosis.com .

Conclusions

The SI₂NCAL₂C score shows adequate performance for estimating individual risk of mortality and dependency after CVT but external validation of the score is warranted.     

Diagnostic imaging in a patient with an isolated blunt traumatic gallbladder injury

Isolated gallbladder injuries are very uncommon in blunt abdominal trauma due to its small size. Further, they are well protected by the surrounding liver, omentum, and the rib cage. A case of traumatic gallbladder injury in a 47-year-old man with progressive right hypochondrial pain is presented. The gallbladder injury was caused due to a blunt abdominal trauma after a motor vehicle accident. The patient had a history of chronic alcoholism and narcotics abuse. The patient was also human immunodeficiency virus-positive and was on stable treatment for tuberculosis. A diagnosis of gallbladder contusion with intramural dissection was made after an ultrasound and computed tomography scan. However, the patient refused surgery and thus, an ultrasound-guided percutaneous transhepatic drainage of the gallbladder was performed as a temporary treatment. Subsequently, a successful cholecystectomy was performed. Isolated traumatic gallbladder injury has been reviewed due to the rarity of this condition and the diagnostic challenges it poses.