Mononeuritis multiplex: the yield of evaluations for occult rheumatic diseases

We identified 35 patients who had electrodiagnostic evidence of mononeuritis multiplex and did not have diabetes or multiple nerve compressions. Their charts were reviewed to determine the etiologies of the mononeuritis multiplex and to determine how often the laboratory examination revealed a rheumatic disease in patients whose initial history and physical examination did not suggest that a rheumatic disease was present. In 11/35 (31%; CI = 17-49) a disorder capable of causing mononeuritis multiplex was diagnosed before the symptoms of mononeuritis multiplex began. Ten had a rheumatic disease; 1 had lymphoma. Nine of the other patients were suspected, on the basis of the history and physical examination, of having new onset of a rheumatic disease. Subsequent laboratory evaluation showed that 5/9 (56%; CI = 21-86) had a rheumatic disease, and 4/9 (44%; CI = 14-79) were unknowns. In 15/35 (43%; CI = 26-61) patients with mononeuritis multiplex, no rheumatic disease was suspected on the basis of the initial history and physical examination. The subsequent laboratory examination revealed an underlying rheumatic disease in 0/15 (0%; CI = 0-18). Mean clinical follow-up of 16 +/- 16 months in the patients with mononeuritis multiplex of unknown cause also failed to identify a rheumatic disease. Overall 19/35 (54%; CI = 37-71) did not have a rheumatic disease or any other known cause. Of the 14 patients with mononeuritis multiplex associated with a rheumatic disease, 5/14 (36%; CI = 13-15) had systemic lupus erythematosus; an additional patient had both lupus and the CREST syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)     

Significant ethnic variation in total and free testosterone concentration

OBJECTIVE: Measurement of serum testosterone is an integral part of the assessment of men presenting to endocrine clinics. Little is known about the variation of total bound or bioavailable testosterone by ethnic group. The principal determinant of testosterone bioavailability is SHBG, which itself is a marker for insulin sensitivity. Our aim was to examine variations in testosterone and SHBG levels across three ethnic groups in relation to ethnic differences in insulin sensitivity. DESIGN: Men of three ethnic groups living in Manchester, UK, were sampled randomly from population registers being of white European (n = 55), Pakistani (n = 50) and African-Caribbean (AfC) origin (n = 75). Circulating serum testosterone and SHBG concentrations were measured and free testosterone calculated. Insulin sensitivity (HOMA-S) and insulin secretory capacity (HOMA-B) were determined from fasting plasma intact insulin and glucose values. RESULTS: Testosterone levels were lower in Pakistani men (mean 14.6 nmol/l, 95% confidence interval 12.6-16.6 nmol/l) than in Europeans (18.7, 16.8-20.6 nmol/l) or AfCs (18.0, 16.4-19.6 nmol/l) (F = 4.8, P = 0.009). Despite SHBG levels also being lower in Pakistani men (22.9, 19.4-26.5 nmol/l) compared with Europeans (28.7, 25.7-31.8 nmol/l) and AfCs (26.9, 23.9-30.0 nmol/l) (F = 3.0, P < 0.05), circulating free testosterone was significantly lower in the Pakistani group (367, 326-408 pmol/l) than in Europeans (455, 416-494 pmol/l) or AfCs (458, 424-492 pmol/l) (F = 6.8, P = 0.001). Pakistani men were on average 4 cm shorter than other groups. However, the lower free testosterone persisted even when adjusted for height or waist-hip ratio. The lower SHBG in the Pakistani men was paralleled by a lower HOMA-S (0.40, 0.25-0.56) compared with Europeans (0.77, 0.61-0.93) and AfCs (0.80, 0.66-0.93) (F = 8.2, P < 0.0001). SHBG correlated positively with HOMA-S (rho = 0.28, P < 0.001) and strongly with total testosterone (rho = 0.54, P < 0.001). There was no difference in insulin secretory capacity (HOMA-B) in Pakistani men compared with Europeans and AfCs. Multiple linear regression analysis showed that total testosterone was independently and negatively related to ln fasting insulin (beta = -0.28, P < 0.001) and age (beta = -0.17, P = 0.02) and positively to ln SHBG (beta = 0.23, P < 0.001) and height (beta = 0.22, P = 0.001). There was no relationship with ethnicity or waist-hip ratio. CONCLUSION: Both total bound and calculated free testosterone were lower in Pakistani men. SHBG levels were also lower in Pakistani men, in keeping with poorer insulin sensitivity. We propose that further work is necessary to establish ethnic-specific ranges for the interpretation of total circulating and free testosterone levels in men.     

Warm Partner Contact Is Related to Lower Cardiovascular Reactivity

Abstract

The authors investigated the relationship between brief warm social and physical contact among cohabitating couples and blood pressure (BP) reactivity to stress in a sample of healthy adults (66 African American, 117 Caucasian; 74 women, 109 men). Prior to stress, the warm contact group underwent a 10-minute period of handholding while viewing a romantic video, followed by a 20-second hug with their partner, while the no contact group rested quietly for 10 minutes and 20 seconds. In response to a public speaking task, individuals receiving prestress partner contact demonstrated lower systolic BP, diastolic BP, and heart rate increases compared with the no contact group. The effects of warm contact were comparable for men and women and were greater for African Americans compared with Caucasians. These findings suggest that affectionate relationships with a supportive partner may contribute to lower reactivity to stressful life events and may partially mediate the benefit of marital support on better cardiovascular health.     

Relationship Between Juncturae Tendinum and Sagittal Bands

The juncturae tendinum and sagittal bands transmit precise forces through the dorsum of the hand. Both structures are integral in the mechanics of normal digital extension and in stabilization of the metacarpophalangeal (MCP) joints. Extensor tendon injury, or rupture/attenuation of sagittal bands and/or juncturae tendinum, may disrupt the kinematic chain and lead to a number of abnormal hand postures and motions. Early treatment of extensor tendon and/or sagittal band injury is dependent upon proper recognition of primary pathology. Proper evaluation and the use of special clinical tests should be implemented to rule out other pathologies. Once diagnosed, treatment may consist of relative motion splinting and standard pain/edema control measures to increase joint motion, tendon excursion, and functional use of the hand.     

Exacerbation of rheumatoid arthritis in patients treated with methotrexate after administration of folinic acid.

A double blind, placebo controlled trial examined the effects of folinic acid on the efficacy and toxicity of methotrexate in 27 patients with rheumatoid arthritis. Clinical and laboratory indices of disease activity worsened significantly in the 13 patients treated with folinic acid after four weeks of treatment, but not in the 14 patients treated with placebo. Exacerbation of rheumatoid arthritis led to withdrawal of the test drug in seven of the patients treated with folinic acid but in none of those treated with placebo. It is concluded that excerbation of rheumatoid arthritis is likely when folinic acid is given shortly after the weekly dose of methotrexate.     

Breaking Down Silos: Mapping Growth of Cross‐Disciplinary Collaboration in a Translational Science Initiative

The importance of transdisciplinary collaboration is growing, though not much is known about how to measure collaboration patterns. The purpose of this paper is to present multiple ways of mapping and evaluating the growth of cross‐disciplinary partnerships over time. Social network analysis was used to examine the impact of a Clinical and Translational Science Award (CTSA) on collaboration patterns. Grant submissions from 2007 through 2010 and publications from 2007 through 2011 of Institute of Clinical and Translational Sciences (ICTS) members were examined. A Cohort Model examining the first‐year ICTS members demonstrated an overall increase in collaborations on grants and publications, as well as an increase in cross‐discipline collaboration as compared to within‐discipline. A Growth Model that included additional members over time demonstrated the same pattern for grant submissions, but a decrease in cross‐discipline collaboration as compared to within‐discipline collaboration for publications. ICTS members generally became more cross‐disciplinary in their collaborations during the CTSA. The exception of publications for the Growth Model may be due to the time lag between funding and publication, as well as pressure for younger scientists to publish in their own fields. Network analysis serves as a valuable tool for evaluating changes in scientific collaboration.     

Mitral Valve Repair Using ePTFE Sutures for Ruptured Mitral Chordae Tendineae: A Computational Simulation Study

Mitral valve (MV) repair using expanded polytetrafluoroethylene sutures is an established and preferred interventional method to resolve the complex pathophysiologic problems associated with chordal rupture. We developed a novel computational evaluation protocol to determine the effect of the artificial sutures on restoring MV function following valve repair. A virtual MV was created using three-dimensional echocardiographic data in a patient with ruptured mitral chordae tendineae (RMCT). Virtual repairs were designed by adding artificial sutures between the papillary muscles and the posterior leaflet where the native chordae were ruptured. Dynamic finite element simulations were performed to evaluate pre- and post-repair MV function. Abnormal posterior leaflet prolapse and mitral regurgitation was clearly demonstrated in the MV with ruptured chordae. Following virtual repair to reconstruct ruptured chordae, the severity of the posterior leaflet prolapse decreased and stress concentration was markedly reduced both in the leaflet tissue and the intact native chordae. Complete leaflet coaptation was restored when four or six sutures were utilized. Computational simulations provided quantitative information of functional improvement following MV repair. This novel simulation strategy may provide a powerful tool for evaluation and prediction of interventional treatment for RMCT.