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OBJECTIVE: To develop a screening test for xerostomia. METHODS: A cross-sectional study was conducted among 152 healthy subjects aged <20-60 yr, 30 patients with primary Sjögren's syndrome and 60 patients with other connective tissue diseases, sampled randomly. A validated screening questionnaire for sicca syndrome and the Schirmer-1 and wafer tests were carried out in all subjects. In addition, non-stimulated whole salivary flow was measured in a random sample of 113 participants. The main outcome was the time of dissolution of the wafer. RESULTS: Time of dissolution of the wafer was 2.8+/-2.1 min in the healthy group, 3.3+/-1.5 min in the connective tissue diseases group, and 9.2+/-3.9 min in the primary Sjögren's syndrome group (P<0.001). The correlation coefficient between the wafer test and non-stimulated whole salivary flow was -0.60 [95% confidence interval (CI) -0.47, -0.71]. A cut-off value of 4 min ('wafer 4') showed sensitivity of 92.9%, specificity of 71.7%, a positive predictive value of 31.7%, a negative predictive value of 98.6%, accuracy of 74.3%, an ROC (receiver operating curve) value of 82.3 and a likelihood ratio of 3.3 (95% CI 2.3, 4.6) for xerostomia. The proportion of patients with wafer 4 was 8% in the healthy group, 23% in the connective tissue diseases group and 93% in the primary Sjögren's syndrome group (P<0.001). Wafer 4 was a significant predictor of xerostomia after controlling for age, gender, temperature and relative humidity. CONCLUSION: The wafer test is valid and reliable for identifying subjects with xerostomia.
Assuntos
Salivação/fisiologia , Xerostomia/diagnóstico , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Programas de Rastreamento/métodos , México/epidemiologia , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sensibilidade e Especificidade , Método Simples-Cego , Síndrome de Sjogren/diagnóstico , Síndrome de Sjogren/metabolismo , Inquéritos e Questionários , Xerostomia/epidemiologia , Xerostomia/metabolismoRESUMO
BACKGROUND: Depressive symptoms and personality features of patients with mood disorders are supposed to have a strong variability in cross cultural studies. The clinical profile, the outcome and the treatment response seem to be different across the world. AIM: To investigate the differences and similarities of major depressive disorders in Chile and Germany. MATERIAL AND METHODS: Sixty seven Chilean and German depressive inpatients, without comorbidity on axis I or II were studied. Diagnosis of depression was based on DSM IV and ICD 10 criteria for major depression. Symptomatology was assessed using the self reporting questionnaire (SRQ-20), the Symptom checklist-90-revisited (SCL 90-R), the Beck inventory for Depression (BDI), and the Hamilton scale for depression (HAM-D). Personality was assessed with the Munich Personality Scale. RESULTS: Only the SRQ-20 shows significantly higher tendency towards depression among Chilean patients. At the personality level, Chileans exhibited higher scores in extroversion, neuroticism, esoteric and isolating tendencies. CONCLUSIONS: These results help to understand differences and similarities between depressive syndromes across cultures. They suggest that the relation between symptomatology, some personality traits and severe major depression has little variability across cultures.
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Comparação Transcultural , Depressão/etnologia , Etnicidade/psicologia , Adulto , Chile/etnologia , Depressão/psicologia , Feminino , Alemanha/etnologia , Humanos , Masculino , Pessoa de Meia-Idade , Inventário de Personalidade , Escalas de Graduação Psiquiátrica , PsicometriaRESUMO
OBJECTIVE: To investigate oral signs and symptoms in patients with Sjögren's syndrome (SS), and to compare results with a group of healthy individuals. METHODS. Each individual completed a questionnaire designed to investigate his/her perception of oral health and dryness, as well as a list of signs and symptoms associated with xerostomia. An oral clinical evaluation was performed. RESULTS: A total of 81 subjects were studied, 21 with primary SS, 29 with secondary SS, and 31 healthy individuals. Patients with SS considered that their oral health was poor. Oral dryness was perceived as intense. Symptoms most commonly expressed were: sensitivity to acids (68%), difficulty eating dry foods (66%), and sensitivity to spicy foods (58%). Dryness of the lips (76%) and the tongue (68%) were also among the most frequent complaints. Oral findings of patients with SS included cervical or atypical caries in 83%, fissured erythematous tongue in 70%, and oral candidiasis in 74%. Significant differences were found when results obtained from patients with SS were compared with the healthy group. CONCLUSION: The oral health of this group of patients with SS was deficient. Adequate management of dry mouth was not achieved, mainly for the modifiable components such as dental decay and oral candidiasis. Therefore. treatment and prevention plans are mandatory. These measures might help to reduce the discomfort associated with oral dryness and to reduce dental loss.
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Síndrome de Sjogren/complicações , Xerostomia/etiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Saúde BucalRESUMO
OBJECTIVE: To determine the prevalence of oral candidiasis (OC) in patients with Sjögren's syndrome (SS), to identify oral signs and symptoms associated with OC, and to compare them with a healthy group. METHODS: Patients with primary SS, and with SS associated with autoimmune disease were identified according to established criteria. Each individual had: (1) a questionnaire, (2) an oral clinical evaluation, (3) a set of microbiological tests: tongue smear, culture of tongue smear, and saliva sample. Diagnosis of OC was established with 2 positive results and the presence of any sign or symptom. RESULTS: A total of 81 subjects were studied, 21 with primary SS, 29 secondary SS, and 31 healthy subjects. We diagnosed OC in 74% of patients with SS, which was statistically significant compared to the healthy group (23%) p < 0.001. Frequent symptoms associated with OC were increased sensitivity to spicy foods (58%) and unpleasant metallic taste (40%). Common signs of OC were erythematous lesion on the dorsum of the tongue (68%) and angular cheilitis (24%). CONCLUSION: Prevalence of OC was high in patients with SS. The frequency of signs and symptoms associated with OC may explain some of the clinical manifestations. If chronic erythematous OC is found in patients with SS an oral assessment at every appointment may help provide appropriate treatment.
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Candidíase Bucal/complicações , Síndrome de Sjogren/complicações , Candidíase Bucal/epidemiologia , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Xerostomia/etiologiaRESUMO
Suffering is a universal experience. In everyday practice, physicians and patients confront and deal with this phenomenon. It is surprising that, despite its obvious and inexorable presence, there is no universal understanding of the real significance of suffering. In the same context, it seems that the measure of suffering could be an option, an instrument, for evaluating the efficacy of treatment. No doubt, it is easier to compare laboratory or x-ray results than to follow clinically the severity of the disease. However, patients do not understand this language, and, often, physicians do not explain to patients how they determine that treatment is efficacious. In fact, it is common to hear patients complain that they do not feel better despite the doctors' opinion that they should.Often, we must accept that our capabilities are limited and must offer some help to mitigate our patients' suffering. Empathy, and the responsibility of doctors to understand the different meanings of suffering, can help patients. Because of their skills, because they know the meaning of disease, and because of their commitment, doctors are obliged to comprehend the position of the patients who are suffering. In the middle of the storm of science, doctors need to look for disease in the voices and in the eyes of their patients. In fact, there should be no conflict between science and empathy. The magic link must rest in the intelligence and sensitivity of doctors.
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The experience of the human being towards death is reviewed in this essay. Some historical, medical and psychological points of view are analyzed. It is disquieting to note that the death theme, as well as the experience of patients who confront their own death, are forgotten topics and occasionally even vetoed by patients and physicians. We consider that is timely and important to reflect about death. The advancement of medical technology must walk in parallel with physician-patient relationship. Who, if not the doctor, is to help his patient to die in comfort?
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Morte , Adolescente , Idoso , Atitude do Pessoal de Saúde , Atitude Frente a Morte , Negação em Psicologia , Eutanásia , História do Século XVII , História do Século XIX , História do Século XX , História Antiga , História Medieval , Humanos , México , Pacientes/psicologia , Médicos/psicologia , Psicanálise , Isolamento Social , Ciências Sociais , Suicídio Assistido , Assistência Terminal/métodos , Assistência Terminal/tendências , Tanatologia/históriaRESUMO
PURPOSE: To evaluate the prevalence of autoimmune thyroid disease and thyroid dysfunction in patients with primary Sjögren's syndrome. PATIENTS AND METHODS: Thyroid function of 33 patients with primary Sjögren's syndrome was clinically and biochemically evaluated. Thyroid hormones and autoantibodies against thyroid peroxidase, thyroglobulin, and thyroid hormones were measured. RESULTS: Autoimmune thyroid disease and thyroid dysfunction were found in 15 cases (45%): autoimmune thyroiditis in 8 (24%); autoimmune hyperthyroidism in 2 (6%); and reversible iodine-induced hypothyroidism in the remaining 5 (15%). One or more of the evaluated autoantibodies were detected in 8 euthyroid patients (24%). Overall, the prevalence of autoantibodies against thyroid peroxidase, thyroglobulin, thyroxine, and triiodothyronine was 45%, 18%, 42%, and 36%, respectively. CONCLUSIONS: The high prevalence of autoimmune thyroid disease and thyroid dysfunction found in primary Sjögren's syndrome, using sensitive immunologic and thyroid function tests, suggest that both diseases are more frequently associated than it was previously thought, and should be sought clinically and by laboratory tests in all patients with primary Sjögren's syndrome.
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Doenças Autoimunes/complicações , Síndrome de Sjogren/complicações , Doenças da Glândula Tireoide/complicações , Adulto , Autoanticorpos/sangue , Doenças Autoimunes/sangue , Doenças Autoimunes/imunologia , Feminino , Humanos , Hipertireoidismo/complicações , Hipotireoidismo/complicações , Iodeto Peroxidase/imunologia , Masculino , Pessoa de Meia-Idade , Prevalência , Síndrome de Sjogren/sangue , Síndrome de Sjogren/imunologia , Tireoglobulina/imunologia , Doenças da Glândula Tireoide/sangue , Doenças da Glândula Tireoide/imunologia , Hormônios Tireóideos/sangue , Hormônios Tireóideos/imunologia , Tireoidite Autoimune/complicaçõesRESUMO
Euthanasia should be considered one of the main philosophical topics of today's medical practice. In view of the technological advances in medicine, the economic pressure in the majority of our medical systems, and a deep alteration and modification in the patient-physician relationship, the status of some patients in their final days should be reconsidered. The increased awareness of the public about euthanasia and related topics (pain, assisted suicide, dying with dignity, etc.) suggests that a urgent dialogue between lay persons and physicians is needed.
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Eutanásia , HumanosRESUMO
OBJECTIVE: To report rheumatologic or rheumatologic-like manifestations of the visceral larva migrans (VLM) syndrome. METHODS: We carried out a prospective study of patients with VLM seen in a private practice setting in Mexico City between 1990 and 1993. RESULTS: From a population of 600 patients we identified 6 patients (5 women) with VLM. Three patients complained of arthralgia; in 4 a history of migratory cutaneous lesions was elicited, and in one monoarthritis of the right knee was found. One patient had deep edema that suggested thrombophlebitis of the right arm; the man in our series had right testicular swelling during followup. In 2 cases, panniculitis was documented by biopsy and in one, small vessel vasculitis. Four patients had frequent contact with dogs and one with cats; 4 patients frequently ate raw fish. The diagnosis of VLM was confirmed either by the clinical picture, biopsy, or ELISA: CONCLUSION: The spectrum of rheumatological manifestations in VLM may be wider than previously thought.
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Larva Migrans Visceral/diagnóstico , Doenças Reumáticas/diagnóstico , Adulto , Biópsia , Diagnóstico Diferencial , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Larva Migrans Visceral/patologia , Larva Migrans Visceral/fisiopatologia , Masculino , Pessoa de Meia-Idade , Estudos ProspectivosRESUMO
OBJECTIVE: Patients with connective tissue diseases (CTD) are prone to infections, either from the disease itself or secondary to treatment. The incidence of listeriosis in immunosuppressed patients is increasing. We therefore evaluated the frequency of listeriosis, an otherwise rarely reported infection in the rheumatologic literature, in patients with CTD. METHODS: Retrospective analysis of listeria positive cultures in patients with CTD between 1982 and 1992 at a tertiary care center in Mexico City. RESULTS: We identified 8 patients: 7 with systemic lupus erythematosus and one with dermatomyositis. At the time of the infection, 5 had active disease, 6 were receiving prednisone and/or other immunosuppressive drugs and 2 were receiving hemodialysis. L. monocytogenes was isolated from cerebrospinal fluid (5 patients), from blood (one patient) and from both sites (2 patients). Patients had bacteremia without a known focus of infection or meningitis as the 2 most common clinical forms of listeriosis. In spite of appropriate antibiotic therapy, 4 patients died. CONCLUSION: As in other immunosuppressed individuals, listeriosis is an aggressive infection in patients with CTD. Although rare, listeriosis should be included in the differential diagnosis of meningitis in patients with CTD and appropriate aggressive therapy rapidly instituted. To determine its frequency in rheumatic patients, multicentric prospective studies are required.
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Doenças do Tecido Conjuntivo/complicações , Listeriose/complicações , Adulto , Idoso , Dermatomiosite/complicações , Feminino , Humanos , Listeriose/diagnóstico , Listeriose/epidemiologia , Lúpus Eritematoso Sistêmico/complicações , Masculino , Meningite por Listeria/complicações , Meningite por Listeria/diagnóstico , Meningite por Listeria/epidemiologia , México/epidemiologia , Pessoa de Meia-Idade , Infecções Oportunistas/complicações , Infecções Oportunistas/diagnóstico , Infecções Oportunistas/epidemiologia , Estudos RetrospectivosRESUMO
OBJECTIVE: To describe the findings and course of myositis in primary Sjögren's syndrome (SS). METHODS: We studied myositis in SS when clinically indicated. Of 104 patients with SS, we identified 3 cases. In all, the diagnosis was made according to clinical data, biochemical, electromyographic and biopsy criteria. Other autoimmune diseases were excluded. RESULTS: We found a prevalence of 3% of myositis secondary to SS. There were no significant associations between myositis and other clinical or laboratory variables. CONCLUSION: Although rare, myositis must be considered a part of the spectrum of SS. In our experience, treatment with steroids and immunosuppressive drugs was successful.
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Miosite/etiologia , Síndrome de Sjogren/complicações , Adulto , Biópsia , Feminino , Humanos , Pessoa de Meia-Idade , Músculos/patologia , Miosite/diagnóstico , Miosite/patologiaRESUMO
In chronic renal failure, the concentration of blood urea increases as the residual function of the kidney decreases, CAPD provides therapy to manage the patient and maintain urea levels at a steady state concentration appropriate for each patient. Although urea is not considered to be a uraemic toxin, cyanate that forms spontaneously from urea reacts with the amino group of amino acids and proteins to form carbamoylated molecules. N-carbamoyl-tyrosine (N-C-Tyr) was measured in a longitudinal study of chronic renal failure and was compared in patients from the U.W.I., Jamaica, managed conservatively with patients from the University of Tennessee, Memphis, managed by CAPD. In post-prandial blood of 5 patients managed by CAPD, the urea mean ñ SD was 22.1ñ4.3 mmol/l and the mean ñ SD for N-C-Tyr was 70 ñ 35 umol/l. The months on CAPD ranged from 7 to 24. The patients managed without dialysis showed a gradual increase in blood urea accompanied by an increase in N-C-Tyr until the time of death. In one patient, the urea level increased from 25 to 82 mmol/l and the N-C-Tyr increased from 51 to 87 umol/l in 10 months. In a second patient, the blood urea level increased from 54 to 77 mmol/l and the N-C-Tyr increased from 59 to 220 in 4 months. In normal individuals, with a blood urea level of 3.6 to 5.7 mmol/l, N-C-Tyr is not found in plasma. This study indicates that CAPD therapy may provide additional benefits by decreasing levels of carbamoylated moieties in patients with chronic renal failure (AU)
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Humanos , Insuficiência Renal Crônica/terapia , Diálise Peritoneal Ambulatorial Contínua , JamaicaRESUMO
Snakes constitute the main reservoir of Salmonella arizona, which are opportunistic pathogens in patients with serious underlying diseases. The 2 may meet when such patients ingest uncooked snake flesh, most often as a folk remedy for arthritis or other conditions. We have seen 11 patients in whom Salmonella arizona infection was documented. Six had systemic lupus erythematosus and another had dermatomyositis and are described in detail. All 7 had received prednisone, which was combined with azathioprine in 3. Five developed septic arthritis, including the site of a hip prosthesis in one patient. A history of dessicated rattlesnake ingestion as a "natural" remedy in either capsule or powder form was obtained in all but one of the 7 patients. Patients often think that if natural or folk remedies are not helpful they also are not harmful and, therefore, safe and worth trying. We disprove that belief and call attention to the perils of one such remedy: dessicated rattlesnake, particularly when ingested by patients with connective tissue diseases who may be immunocompromised.
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Artrite Infecciosa/complicações , Doenças do Tecido Conjuntivo/complicações , Medicina Tradicional , Infecções Oportunistas/complicações , Infecções por Salmonella/complicações , Salmonella arizonae/isolamento & purificação , Sepse/complicações , Serpentes/microbiologia , Adolescente , Adulto , Animais , Artrite Infecciosa/tratamento farmacológico , Azatioprina/uso terapêutico , Quimioterapia Combinada , Feminino , Humanos , Hospedeiro Imunocomprometido , Lúpus Eritematoso Sistêmico/complicações , Masculino , Pessoa de Meia-Idade , Infecções Oportunistas/tratamento farmacológico , Prednisona/uso terapêutico , Infecções por Salmonella/tratamento farmacológico , Sepse/tratamento farmacológico , Inquéritos e QuestionáriosRESUMO
Air in the esophagus is unusual because it is collapsible. Its finding on a chest roentgenogram, particularly when not associated with a fluid level indicative of stricture, should strongly suggest systemic sclerosis (scleroderma). We describe a patient with scleroderma with intestinal pseudoocclusion and an air esophagogram. Study of chest roentgenograms of 83 patients with scleroderma, including those of 7 with pseudoocclusion, revealed no other instance of air esophagogram. This radiological sign, although rare, should suggest scleroderma and may be particularly useful in patients with "systemic sclerosis sine scleroderma."
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Esôfago/diagnóstico por imagem , Pseudo-Obstrução Intestinal/complicações , Escleroderma Sistêmico/complicações , Ar , Feminino , Humanos , Pseudo-Obstrução Intestinal/patologia , Pessoa de Meia-Idade , Radiografia , Escleroderma Sistêmico/diagnóstico , Escleroderma Sistêmico/diagnóstico por imagemRESUMO
Four patients who fulfilled criteria for adult onset Still's disease were treated sequentially with increasing doses of acetylsalicylic acid, nonsteroidal antiinflammatory drugs (NSAID) and prednisone to control their fever and systemic manifestations. Persistence of the fever led us to treat them with small doses of methotrexate (MTX) with excellent response. Low dose MTX should be considered in patients unresponsive to antiinflammatory drugs before using high doses of prednisone.
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Artrite Juvenil/complicações , Febre/complicações , Metotrexato/uso terapêutico , Adolescente , Adulto , Fatores Etários , Anti-Inflamatórios não Esteroides/uso terapêutico , Artrite Juvenil/tratamento farmacológico , Aspirina/uso terapêutico , Relação Dose-Resposta a Droga , Feminino , Febre/tratamento farmacológico , Humanos , Masculino , Pessoa de Meia-Idade , Prednisona/uso terapêuticoRESUMO
We describe a 51-year-old woman with Wegener's granulomatosis who developed diabetes insipidus 7 months after the onset of her granulomatous disease and despite apparently good clinical response to prednisone and trimethoprim-sulphametoxazole treatment. A brain computerized tomographic scan taken soon after the onset of polyuria disclosed an enlarged pituitary gland that completely returned to its normal size after 5 months of cyclophosphamide therapy. We review 6 other published cases of diabetes insipidus secondary to Wegener's granulomatosis and discuss the potential pathogenetic mechanisms of this rare combination.