Comparison of the Health Assessment Questionnaire and Arthritis Impact Measurement Scale in patients with psoriatic arthritis

OBJECTIVE: To determine which of two instruments, the Health Assessment Questionnaire (HAQ) and the Arthritis Impact Measurement Scales (AIMS), was more closely correlated with the main parameters reflecting activity and severity of psoriatic arthritis. METHODS: Both instruments were administered to 72 consecutive patients with psoriatic arthritis. RESULTS: Global HAQ and AIMS scores were closely correlated with each other (rs = 0.747; P < 0.00001). AIMS physical function scales--namely physical activity, dexterity, social activity and activities of daily living--were moderately or closely correlated with the main clinical disease activity parameters, most notably morning stiffness of axial joints (rs = 0.271-0.551). Scales measuring psychological status yielded weaker correlations with disease activity parameters (rs = 0.241-0.277) and were also correlated with the visual analog scale score for skin lesion severity. Morning stiffness of peripheral joints was correlated only with two AIMS scales, namely pain (rs = 0.532) and activities of daily living (rs = 0.303). Severity of radiological damage of peripheral and axial joints was most closely correlated with the scales of physical function, most notably physical activity. The global and scale HAQ scores showed moderate to close correlations with the main clinical disease activity parameters, most notably morning stiffness of axial joints. The global HAQ score was also correlated with radiological carpal involvement and with the radiological severity of peripheral joint involvement, whereas only the arising and hygiene scales were (moderately) correlated with the radiological severity of spinal involvement. CONCLUSION: Although both the HAQ and the AIMS were useful in assessing health status in psoriatic arthritis patients, only the AIMS captured some of the effects of the skin lesions. Our data also suggest that the AIMS may be more effective than the HAQ for evaluating the effect of radiological lesions produced by psoriatic arthritis.     

Measuring health status in psoriatic arthritis: the Health Assessment Questionnaire and its modification

OBJECTIVE: The Health Assessment Questionnaire (HAQ) has proven to be a reliable and valid measure of outcome for a variety of arthritides. A recent modification of HAQ for spondyloarthropathy (HAQ-S) has also been reported. Our purpose was to evaluate the HAQ and HAQ-S as outcome measures in the assessment of patients with psoriatic arthritis (PsA). METHODS: The HAQ, including HAQ-S was administered to all patients attending our Psoriatic Arthritis Clinic between June and December, 1993. Clinical and radiological assessments were performed according to a standard protocol that measures disease activity, fibrositic tender points (TP), disease severity and damage. Analysis was performed using SAS for the PC. RESULTS: The patient population included 114 patients, 70 men and 44 women with a mean age of 49.3 years and a mean arthritis duration of 15.1 years. The mean HAQ score was 0.50, while the mean HAQ-S score was 0.53 (scores range 0 to 3 for this instrument). The overall HAQ and HAQ-S disability scores were highly correlated with several clinical measures of function, including grip strength (r = -0.63 and -0.59, respectively). American College of Rheumatology functional class (r = 0.59 and 0.60, respectively), as well as the number of fibrositic TP (r = 0.54 and 0.57, respectively). These disability scores also correlated highly with the overall number of actively inflamed joints (r = 0.49 and 0.50, respectively); however, they correlated only moderately or poorly with other measures of disease activity such as morning stiffness, total number of joint effusions, erythrocyte sedimentation rate (ESR) and the PASI score for psoriasis and with all measures of disease severity. A similar pattern of correlations was found between the individual subscales of the HAQ and HAQ-S and the clinical measures of function, activity, and severity, as well as between the pain scale and the various clinical measures. However, the correlations are generally lower. CONCLUSION: Our data suggest that HAQ and HAQ-S capture clinical measures of function and pain in PsA but do not correlate with disease severity. The HAQ and its modification for spondyloarthropathy may reflect fibromyaglia as a measure of pain and tenderness in these patients. Thus, the clinical assessment of disease activity and both clinical and radiological assessments of joint damage remain important outcome measures in PsA.     

Mood improvement in elderly women after in-hospital physical rehabilitation

OBJECTIVE: To evaluate the relationship between change in depressive symptoms and in-hospital physical rehabilitation in elderly women. DESIGN: Longitudinal study. SETTING: Hospital facility (geriatric evaluation and rehabilitation unit). PATIENTS: One hundred twenty-three elderly inpatient women (mean age: 78.4+/-6.9 years, range 60 to 93) with good cognitive status (Mini Mental State Examination: 23.1+/-5.1) consecutively admitted over a 7-month period. INTERVENTION: Physical therapy tailored to individual needs (five sessions a week of 30 to 45 minutes each). MAIN OUTCOMES MEASURES: On admission: cognition (MMSE), depressive symptoms (Geriatric Depression Scale [GDS]), functional status (basic and instrumental activities of daily living [BADL, IADL], Tinetti scale), and somatic health. On discharge: depressive symptoms and gait and balance performances (Tinetti scale). RESULTS: Seventy-five patients (61%) did not show changes on Tinetti scale over the hospitalization period and 48(39%) had a change of 3 or more points. Nonresponders had no change of GDS over the hospitalization period for all levels of physical disability on admission, whereas responders had relevant improvement of depressive symptoms when markedly disabled on admission, and progressively smaller improvements of depressive symptoms with increasing function on admission. CONCLUSIONS: The study provides evidence that mood status changes synchronically with disability.     

Longitudinal bone mineral density changes in early rheumatoid arthritis

A prospective longitudinal study of patients with early RA was performed to examine the influence of disease duration, disease activity and physical activity on bone loss. Sixty-seven patients with non-steroid treated RA of less than 5 yr duration, including 16 patients with disease duration less than 6 months, had BMD measurements of the femoral neck and the lumbar spine over a 12-month period using dual energy X-ray absorptiometry. The BMD changes were compared with values from 72 control patients and were also correlated with serial measurements of disease activity (measured by the Stoke Index) and disability [measured by the Health Assessment Questionnaire (HAQ) score], at 3-monthly intervals over the 12-month period. No significant differences in BMD changes were found between RA patients and controls overall. Patients with disease duration of less than 6 months had significantly greater loss of BMD at the femoral neck (-3.9%, S.E.M. 1.5) than the remainder of the cohort (-0.2%, S.E.M. 0.7) (P = 0.02) and controls (-0.8%, S.E.M. 0.6). Lumbar spine BMD changes correlated with the initial Stoke Index (Rs-0.373, P = 0.01) but not mean Stoke Indices. There was no correlation of BMD changes with age or HAQ scores. These findings suggest that significant bone loss occurs within the first few months of disease in patients with RA.     

Excision of Ds1 from the genome of maize streak virus in response to different transposase-encoding genes

Reliability and validity of direct visual analogue scale (VAS) ratings of improvement were assessed in 162 patients with Seasonal Affective Disorder, Winter Depression type (W-SAD), after light treatment for 6 consecutive days. The patients were rated with the Montgomery-Asberg Depression Rating Scale (MADRS) and a scale for the 'atypical' symptoms hypersomnia, hyperphagia and carbohydrate craving (the ATYP scale) before and after treatment. After treatment the patients also self-rated their global improvement on a 10-cm VAS, with anchoring points of 'No improvement' and 'Complete improvement'. VAS ratings were repeated several times, with 1-4 weeks between assessments, in a follow-up period, always referring to improvement in relation to baseline, and accompanied by a statement whether there had been any change since the former VAS rating. Shortly after treatment there was a mean reduction of 59.8% on the MADRS and 57.1% on the ATYP score, and 58.4% improvement as measured by the VAS. VAS rating correlated highly with percentage reduction of MADRS scores (r=0.85) and somewhat less with reduction of ATYP scores (r=0.64). VAS ratings in the follow-up period showed an extremely high test-retest reliability (r=0.96) for two consecutive ratings between which the patient stated that there had been no definite change. The results support the use of VAS ratings for assessment of global improvement after light treatment in patients suffering from W-SAD; use in other kinds of depression and with other types of treatment remains to be explored.     

Life events and disability in rheumatoid arthritis: a European cohort

The objective was to study the relationship between life events (LE) and the clinical status of patients suffering from recently diagnosed rheumatoid arthritis (RA) in a 2 yr follow-up. As part of a multicentre European cohort study, 370 French and Dutch patients were questioned three times at 1 yr intervals about LE which had occurred in the previous year. Three criteria were used to quantify the degree of disease activity (Ritchie's index), the level of functional disability [Health Assessment Questionnaire (HAQ)] and perceived health [Overall Evaluation of Health (OEH)]. Total LE and desirable LE showed a weak negative correlation with the HAQ scores. On the other hand, death-related LE did not seem to modify patient status. The higher the number of health-associated LE, the greater the deterioration in HAQ and OEH scores. The results indicate that LE do not affect the course of early RA in a spectacular manner.     

Disseminated intravascular coagulation and sustained systemic inflammatory response syndrome predict organ dysfunctions after trauma: application of clinical decision analysis

OBJECTIVE: To compare the construct validity and sensitivity to change of 2 spondylitis-specific measures of functional disability, the Health Assessment Questionnaire Disability Index modified for the spondyloarthropathies (HAQ-S) and the Dougados Functional Index, with 2 more generic instruments, the Health Assessment Questionnaire (HAQ) and the Arthritis Impact Measurement Scales-2 (AIMS2), in patients with ankylosing spondylitis (AS). METHODS: Construct validity was assessed in 2 ways: (1) by comparisons of the cross sectional correlations between each functional disability instrument and 6 measures of physical impairment in 216 patients, and (2) by relating changes over time in the HAQ-S and the Functional Index with changes in patient reported pain and stiffness in 153 patients followed for at least 2 years. Sensitivity to change was measured from the responses of 155 patients who reported a qualitative change in the activity of their AS during followup. RESULTS: Most patients had mild functional disability, with median scores of 0.5 on the HAQ-S (possible range 0-3), 0.375 on the HAQ (possible range 0-3), 11 on the Functional Index (possible range 0-40), and 5 on the AIMS2 (possible range 0-60). Scores on the HAQ-S (R2 = 0.24) and the unmodified HAQ (R2 = 0.18) were more highly correlated with measures of physical impairment than were scores on the AIMS2 (R2 = 0.10) or the Functional Index (R2 = 0.09). Changes over time in the HAQ-S and HAQ were more closely related to changes in pain and stiffness than were changes in the Functional Index. The HAQ-S and HAQ were also more sensitive to change than the Functional Index. CONCLUSION: The HAQ-S showed greater construct validity and sensitivity to change than the Functional Index, but performed similarly to the unmodified HAQ.     

Prognosis in multiple sclerosis

Prognosis of the natural course of multiple sclerosis is most often measured on Kurtzke's "expanded disability status scale" (EDSS), a non-linear scale over 20 steps, heavily weighted on mobility. Optic neuritis and sensory disturbances as initial symptoms, lower age at onset of the disease, female sex and a longer interval between relapses are indicators of a more favorable prognosis. As a rule, disability as measured on this scale 5 years after onset corresponds to 3/4 of the disability status after 15 years. The number of relapses diminishes naturally over the course of the disease. Presence and extent of lesions on the initial MRI of the brain in clinically isolated syndromes are valuable predictors of dissemination of the disease process over the following 5-10 years. New therapies (e.g. interferon beta 1b and 1a, copolymer 1) reduce relapse frequency by 1/3 and diminish the extent of pathological lesions in brain MRI, but fail to show (as yet) significant influence on disability.     

Rhythmic external compression of the limbs: a method for healing cutaneous ulcers in systemic sclerosis

OBJECTIVE: To evaluate the usefulness of rhythmic external compression (REC) of the limbs on the healing of ischemic cutaneous ulcers in systemic sclerosis (SSc). METHODS: A prospective study analyzing 17 patients with SSc with symptomatic ischemic cutaneous ulcers in the limbs of more than 4 weeks' duration, who submitted to 20 sessions of REC, each session of one hour duration, 3 times a week. Patients were assessed at study entry, at the end of REC sessions, and at 30, 60, and 90 days after treatment. We also conducted a retrospective analysis of the outcome of ischemic vascular ulcers in a group of 20 patients with SSc who did not undergo REC. RESULTS: Twenty-eight ischemic vascular ulcers were submitted to REC. There was complete healing of 20 ulcers (71%) at the end of REC sessions. The healing was statistically more frequent in the distal ulcers (fingers and toes) (p = 0.0289), independent of SSc variant. There was a statistically significant correlation between pain resolution until the 15th session of REC and future ulcer healing (p < 0.0001). At followup, there were relapses in 2 ulcers 30 days after treatment. In the 20 patients with SSc who did not undergo REC, at followup, after 90 days of conventional treatment, there was healing of 7 ulcers (35%). CONCLUSION: REC could represent a therapeutic option in the treatment of ischemic cutaneous ulcers in SSc.     

Doctors and patients don't agree: cross sectional study of patients' and doctors' perceptions and assessments of disability in multiple sclerosis

OBJECTIVES: To compare the judgments of clinicians on which domains of health in the short form questionnaire (SF-36) would be most important to patients with multiple sclerosis with the opinions of patients themselves; to compare assessment of physical disability in multiple sclerosis by a clinician using Kurtzke's expanded disability status scale and a non-clinically qualified assistant using the Office of Population Census and Surveys' (OPCS) disability scale with self assessment of disability and other domains of health related quality of life by patients using the SF-36 and the EuroQol questionnaire; and to compare the scores of patients for each domain of the SF-36 with control data matched for age and sex. DESIGN: Cross sectional study. SETTING: Clinical department of neurology, Edinburgh. SUBJECTS: 42 consecutive patients with multiple sclerosis attending a neurology outpatient clinic for review or a neurology ward for rehabilitation. MAIN OUTCOME MEASURES: Scores on the SF-36; EuroQol; Kurtzke's expanded disability status scale; the OPCS disability scale. RESULTS: Patients and clinicians disagreed on which domains of health status were most important (chi 2 = 21, df = 7, P = 0.003). Patients' assessment of their physical disability using the physical functioning domain of the SF-36 was highly correlated with the clinicians' assessment (r = -0.87, P < 0.001) and the non-clinical assessment (r = -0.90, P < 0.001). However, none of the measures of physical disability correlated with overall health related quality of life measured with EuroQol, Quality of life correlated with vitality, general health, and mental health in the SF-36, each of which patients rated as more important than clinicians and for each of which patients scored lower than the controls. CONCLUSIONS: Patients with multiple sclerosis and possibly those with other chronic diseases are less concerned than their clinicians about physical disability in their illness. Clinical trials in multiple sclerosis should assess the effect of treatment on the other elements of health status that patients consider important, which are also affected by the disease process, are more closely related to overall health related quality of life, and may well be adversely affected by side effects of treatment.     

Assignment of absolute stereochemistry to an insect pheromone by chiral amplification

We assessed the replicability of reliability and validity of a brief self-report disability scale, adapted from the Medical Outcomes Survey (short form), in a 15-center, cross-national, multilingual study of psychological illness among primary care patients (n = 5438). Across all 15 centers in the World Health Organization Collaborative Study of Psychological Problems in General Health Care, the reliability of the disability scale was high and individual items were responsive at similar levels of disability. Self-report disability was consistently correlated with disability in work role (including housework) as rated by interviewers according to the Groningen Social Disability Schedule, a semistructured method taking local norms into account. Disability as measured by the self-report questionnaire was also consistently correlated with depressive symptoms as measured by the General Health Questionnaire. At each center, the disability items formed a moderately to strongly hierarchical (Guttman-like) scale. These findings support the feasibility of using self-report disability scales in cross-national primary care research.     

The relationship of current psychiatric disorder to functional disability and distress in patients with inflammatory bowel disease

Although prior theories about psychiatric disorders causing inflammatory bowel disease (IBD) have largely been discredited, these same disorders have at times been associated with functional gastrointestinal symptoms such as those found in irritable bowel syndrome. Since functional gastrointestinal symptoms can also occur in patients with organic pathology, we hypothesized that a current psychiatric disorder might amplify or produce additional gastrointestinal symptoms in patients with organic gastrointestinal diseases such as IBD, leading to additive functional disability and decreased quality of life. This pilot study evaluated a sequential sample of 40 IBD patients using the NIMH Diagnostic Interview Schedule, structured interviews for functional gastrointestinal symptoms, and prior episodes of emotional, physical, and sexual abuse as well as self-report measures of personality and disability. We compared IBD patients with and without a current psychiatric disorder while controlling for disease severity. Eight patients with major depression were treated with antidepressants. Patients with a current psychiatric disorder had significantly higher 1) mean number of lifetime psychiatric diagnoses, 2) prevalence rates of prior sexual and physical victimization, and, 3) mean numbers of both gastrointestinal and other medically unexplained symptoms despite no differences in severity of IBD. Significant and trend level differences were apparent on several measures of functional disability. A regression analysis showed that number of psychiatric diagnoses, number of functional gastrointestinal symptoms, and dissociation scale scores significantly discriminated the groups. Treatment of current major depression decreased functional disability despite no objective changes in gastrointestinal disease severity. It was concluded that the presence of a current psychiatric disorder appears to alter the perception of disease severity in patients with IBD. Nonrecognition of the psychiatric disorder may lead to unnecessary and aggressive interventions for IBD patients such as medication changes, invasive testing, or surgery. The presence of a current psychiatric illness also appears to be associated with increased functional disability. Psychiatric evaluation and treatment, therefore, have an important role in the ongoing management of IBD patients with distressing gastrointestinal symptoms not directly attributable to their IBD.     

Imaging approaches to the correlation of structure and function in the kidney

OBJECTIVES: To translate into Argentine Spanish and cross-culturally adapt the Childhood Health Assessment Questionnaire (CHAQ) and validate the adapted instrument in Argentine patients with juvenile rheumatoid arthritis (JRA). METHODS: Five bilingual Argentine pediatric rheumatologists translated into Argentine Spanish and cross-culturally adapted the United States English CHAQ. Pretesting was done in a sample of 23 parents using a probe question technique. Parents of 70 patients with JRA and 21 healthy children (controls) participated in the validation phase. All were from Argentina. RESULTS: The mean disability index (DI) scores for patients with systemic, polyarticular, or pauciarticular onset JRA were 0.64, 0.32, and 0.1, respectively. Healthy controls averaged 0.2. Intercomponent correlations were between 0.4 and 0.9, suggesting internal consistency, but also some redundancy. Test-retest reliability, studied at a 1-week interval, was moderate (mean DI 0.44 [in clinic] and 0.29 [one week later], Pearson's correlation = 0.82). We compared CHAQ scores from 15 parents with those of their children > 10 years of age. Significantly higher DI scores were given by patients than their respective parents (P > 0.019), but the pairwise scores (parent-patient) were highly correlated (r = 0.986). CONCLUSIONS: Cross-cultural adaptation of the US CHAQ to Argentina required few changes. Although DI scores for all patient subgroups were higher than for controls subjects, the scores were low, particularly for those with pauciarticular disease. Prospective studies designed to examine the sensitivity to change and predictive validity will help to assess further the usefulness of the adapted CHAQ in the Argentine population.     

Giant congenital nevocellular nevus overlying an encephalocele

OBJECTIVE: To compare patients with knee osteoarthritis (OA) who have and do not have back pain, and evaluate the prevalence, characteristics, and consequences of back pain among knee OA patients. METHODS: During a 3-year period, consecutive patients attending an outpatient rheumatology clinic were evaluated for the presence of back pain, and 368 were found to have OA of the knee. Clinical status was evaluated by the Clinical Health Assessment Questionnaire, radiographs, and joint examinations. RESULTS: Back pain was present in 54.6% of patients with OA of the knee. Almost every clinical status measure was worse among those reporting back pain, including Health Assessment Questionnaire (HAQ) disability, pain, global severity, fatigue, and psychological status. Back pain was more common in women and the obese, but was not associated with age, marital status, formal education, smoking history, or knee radiographic scores. In multivariate analyses the strongest correlates of back pain in knee OA patients were anxiety, night pain, HAQ disability, and global severity. CONCLUSION: Back pain is prevalent among OA clinic patients, more common than in rheumatoid arthritis or population studies, is linked to body mass index, and is associated with clinically significant increases in pain and other measures of clinical distress.     

What constitutes cerebral palsy?

OBJECTIVE: To determine whether a newly developed disability scale for patients with neck pain demonstrated acceptable reliability and validity. METHODS: Testing was conducted using three different samples of patients with neck pain (n = 162). Test-retest reliability of the scale was carried out on the same day with one sample (n = 39), and between-day reliability was carried out with another (n = 21). Differential item functioning with regard to the influence of gender and age was carried out with these two patient groups, as was construct validity. Responsiveness was measured using patients participating in a clinical trial involving patients with chronic neck pain (n = 102). Additionally, scale scores were compared with a wide range of physical measurements using the patients in the clinical trial. RESULTS: Short-term, between-day and postal questionnaire reliability coefficients were all extremely high. The Cronbach's alpha coefficient for internal consistency was 0.9 for the entire scale, and the coefficients for individual items were all greater than 0.88. Disability scale scores correlated strongly to pain scores as well as to doctor and patient global assessments, indicating good construct validity. Relative changes in disability scores demonstrated a moderately strong correlation to changes in pain scores after treatment. Scale scores correlated weakly to all physical measurements. CONCLUSIONS: The disability scale demonstrated excellent practicality and reliability. The scale accurately reflects patient perceptions regarding functional status and pain as well as doctor's global assessment and is responsive to change over long periods of time. We feel that this scale can be a valuable tool for the assessment of patients in future clinical trials and quality of care studies.     

Inflammatory polyarthritis in the community is not a benign disease: predicting functional disability one year after presentation

OBJECTIVE: To predict which patients with early inflammatory polyarthritis presenting to primary care will be functionally disabled one year after presentation, in order to inform treatment and referral decisions. METHODS: The study population consisted of 381 patients notified to the Norfolk Arthritis Register, a primary care based inception cohort of patients with inflammatory polyarthritis. Patients were regarded as functionally disabled if they had a Health Assessment Questionnaire (HAQ) score of one or more. Clinical, laboratory, and demographic variables easily measured at baseline were analyzed for their ability to predict future disability. Recursive partitioning was used to create a simple decision tree to predict those patients who would be disabled at one year. A logistic regression model was generated on a sample of 277 patients and tested on an independent sample of 104 patients. This was compared with other models, one of which consisted of the 1987 ARA criteria. RESULTS: 112 (29%) patients had a HAQ score of at least 1 at one year. The strongest predictors of future disability were a high baseline HAQ, large joint involvement, female sex, and longer disease duration. The decision tree predicted disability accurately in 67% of patients. CONCLUSION: It is possible to predict functional outcome at one year among patients with early inflammatory polyarthritis presenting to primary care using simple clinical variables measured at baseline. Satisfying the 1987 ARA criteria could not be used to predict future disability.     

Warfarin or acenocoumarol: which is better in the management of oral anticoagulants?

OBJECTIVE: To assess neuropsychiatric sequelae 1 year after minor head injury in a cross sectional study using home interviews with patients and their relatives at 1 year after head injury. METHODS: The study cohort included 148 adults who were admitted to hospital after a minor head injury between 1 July 1994 and 30 June 1995 and showed clinical or radiological evidence of brain injury. Main outcome measures used in the study were the Glasgow outcome scale, Edinburgh rehabilitation status scale, Barthel index, clinical interview schedule-revised, mini mental state examination, and assessment of symptoms of postconcussional syndrome. RESULTS: At one year follow up, four (2.9%) patients had a severe disability, 35 (25.5%) had a moderate disability, and 95 (69.3%) had no disability according to the Glasgow outcome scale. A slightly higher proportion (33.3%, n=45) showed disability according to the Edinburgh rehabilitation status scale. Thirty one patients (23.1%) scored <24 in the mini mental state examination. These were mostly patients over the age of 65. Twenty three patients (17.2%) were diagnosed as psychiatric cases according to the clinical interview schedule-revised scale. Seventy four (55.2%) patients showed one of the symptoms of postconcussional syndrome. The most commonly shown neurobehavioural problems were irritability (30%), sleep disturbance (29%), and impatience (27%). CONCLUSION: One year after a minor head injury, a substantial proportion of patients showed neuropsychiatric sequelae.     

Factors predictive of stroke outcome in a rehabilitation setting

We describe the first case of hypothenar hammer syndrome followed by accelerated systemic sclerosis (SSc). A sawmill worker with repeated wrist trauma presented with bilateral digital ischemia and fingertip ulcerations. Hypothenar hammer syndrome involving both hands was diagnosed based on classic angiographic studies showing occlusion of the ulnar arteries at the level of the hamate and occlusions of multiple digital arteries. He also had minimal digital swelling, telangiectatic lesions on the fingers, and a positive FANA test. Resected ulnar arteries showed clearcut changes compatible with both microtrauma and SSc. After surgical repair of both ulnar arteries, he rapidly developed severe SSc with significant cardiopulmonary involvement.     

Lung disease in systemic sclerosis (scleroderma)

Scleroderma (SSc) is a disease characterized by skin fibrosis but it is the end-organ effect of microvascular injury and fibrosis that is important prognostically. Pulmonary involvement in SSc patients, either of parenchymal fibrosis and/or pulmonary hypertension, is a major cause of morbidity and mortality. Interstitial lung disease occurs more commonly in patients with diffuse SSc and is associated with a loss of lung volume, as well as a defect of gas exchange. Parenchymal fibrosis may also cause pulmonary hypertension. Isolated pulmonary hypertension occurs exclusively in patients with limited SSc and is detectable by a reduced DCO. The early identification of either manifestation is difficult. Patients may have minimal symptoms, unremarkable physical findings, normal chest radiographs and/or minimally abnormal pulmonary function tests at a time when significant lung pathology is present. It is essential to attempt to identify pulmonary disease early, at a potentially reversible stage. Multiple therapeutic endeavours have yielded only short-term or minimal benefits in symptoms and pulmonary function, and thus a major alteration in SSc pulmonary prognosis has not been achieved. Further study of the pathogenesis of this disease manifestation will be helpful in its earlier identification and intervention.     

Use of single dose low-molecular-weight heparin in long hemodialysis

BACKGROUND AND OBJECTIVES: Granuloma Inguinale (GI) is an endemic sexually transmitted disease (STD) in India. With increasing prevalence of human immunodeficiency virus (HIV) among patients with STD at a clinic in Mumbai, a study was conducted to determine clinico-epidemiologic features of GI and HIV. GOAL: To determine possible interaction between GI and HIV. STUDY DESIGN: Prospective follow-up of 21 consecutive cases (GI in HIV-seropositive individuals) and 29 controls (GI in HIV-seronegative individuals) to determine time to heal. All cases and controls received a standard treatment regimen of erythromycin, 2 g po daily, under supervision until healing occurred. RESULTS: Although GI ulcers at recruitment were not significantly larger among HIV-seropositive individuals as compared with those seen among HIV-seronegative individuals (mean size 4.4 cm2 vs. 3.6 sq2; odds ratio [OR] 1.22, confidence interval [CI] .95, 0.63, 2.40; p = 0.52), the former took longer time to heal completely (mean 25.7 days vs. 16.8 days; OR 1.82, CI .95, 0.99, 3.36; p = 0.03) and tended to produce greater tissue destruction (as included in results). CONCLUSION: These findings are important because slow-healing GI ulcers with underlying HIV infection, which may be caused by their interaction, will lead to increased transmission of both the infections.