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The early detection of HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) is the basic condition for immediate therapeutic management, which mainly leads to prompt delivery. The classical symptoms despite the typical laboratory evaluation (hemolysis, elevated liver enzymes, low platelets) are epigastric or right upper quadrant pain and nausea and vomiting; the classical signs of preeclampsia (proteinuria and hypertension) may be absent in 20%. The differential diagnostic problems of HELLP syndrome arise in relation to the mimicry-symptomatic: upper abdomen pain can imitate gastroenterologic diseases (e.g. cholelithiasis, appendicitis), the elevated liver enzymes combined with hyperbilirubinemia liver diseases (e.g. viral hepatitis) and thrombocytopenia in combination with hemolytic anemia, neurological symptoms and renal failure other similar pathogenetic disorders due to the category of thrombotic microangiopathies. Regarding the common symptoms thrombocytopenia, hemolysis as well as signs of preeclampsia with or without renal failure the differentiation from various autoimmune diseases also can be difficult in special cases. Rare first manifestations and serious simultaneous diseases which can overlay the typical signs of HELLP syndrome show the variety of HELLP syndrome. Interdisciplinary detours and delay are the consequences of this differential diagnostic problems, which could imply deleterious effects on the mother and the fetus, until the final diagnosis is clear. Therefore all pregnant women with upper abdomen pain irrespective of symptoms of preeclampsia should be considered to have HELLP syndrome and immediate laboratory evaluation has to be done. If there is any doubt a interdisciplinary consultation is required!
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PMID:[Differential HELLP syndrome diagnosis]. 896 90

In China, health care delivery follows a three-tiered structure set up in the 1950s for rural and urban areas. In 1990, China set baseline criteria for primary health care in rural areas which is largely funded by a reestablished rural cooperative medical care financing system. Financing reform efforts in urban areas are using a model through which contributions are collected from salaries and from local governments and other public organizations. The overall incidence of infectious diseases is more than 500/100,000 people, but associated mortality has declined. Diseases covered by the Expanded Programme of Immunology have been controlled, but China is at high risk for viral hepatitis (epidemics of hepatitis A infections occurred in 1988), and incidence of tuberculosis has increased. In addition, the HIV/AIDS epidemic is spreading rapidly with an estimated 50,000-100,000 infected. Parasitic diseases are also widespread, and causes of death seen in developed countries (hypertension, stroke, coronary health disease, cancer, and diabetes) are increasing. With 510 million people living in iodine-deficient areas, iodine deficiency diseases have disabled an estimated 8 million people. China has promised to eradicate iodine-deficiency by the year 2000. The disabling Kaschin-Beck disease is also endemic in China. Occupational diseases threaten nearly 20 million Chinese people, and the prevalence of smoking and alcohol abuse is increasing, especially among young people. By the year 2000, 10% of the population will be older than 60, and 30% of this group will have health problems requiring care. The health care system is, thus, undergoing rapid change to meet its new challenges.
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PMID:Health care delivery system and major health issues in China. 898 46

The cardiac adverse effects of interferon (INF) treatment have been reported recently in various clinical trials of INF. In this study, the cardiac effects of recombinant INF-alpha treatment were evaluated prospectively in a group of patients with chronic active viral hepatitis (CAH). Sixteen patients with CAH type B, 14 patients with CAH type C and one patients with CAH type D were included in this study, and 4.5, 3 and 9 MU of recombinant INF-alpha-2a was administrated three times a week to these patients, respectively. The durations of treatment were 6 months for CAH type B and C, and 12 months for type D. The cardiac status of all patients was evaluated and monitored with a detailed medical history, physical examination, electrocardiography (ECG), telecardiography, echocardiography and heart rate variability tests at the beginning of the study and at the first and sixth months of INF therapy and also 6 months after ceasing the therapy. The clinical evaluation of patients before the treatment revealed that three had hypertension, one had a past medical history of myocardial infarction, one had a prosthetic mitral valve replacement and another had left hemiblock in her ECG record. No significant changes and adverse effects were detected in clinical examination and cardiovascular tests of all patients, either in pre-existing cardiovascular diseases, during therapy and after stopping the treatment. The cardiac adverse effects of INF reported in previous studies are questionable and we conclude that it can be used safely in CAH patients. Therefore, it should be kept in mind that fever and tachycardia may occur during the first and second weeks of INF therapy and patients with high risk for cardiac disease should be monitored closely in this period of treatment.
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PMID:Interferon-alpha does not cause significant cardiac dysfunction in patients with chronic active hepatitis. 913 80

Female solid organ recipients with good graft function generally tolerate pregnancy well. However, the combination of mother, fetus, transplanted organ, and immunosuppressive and other medications increases the complexity of management and raises the specter of adverse outcomes. For the mother, considerations include the nature of the original disease (i.e. genetic risk of transmission), co-morbid conditions which increase pregnancy risk (i.e. hypertension, diabetes, renal insufficiency), and long-term maternal prognosis. For the fetus, questions include the adequacy of maternal physiology (cardiac, renal, glycernic control, etc.), exposure to medications, and exposure to infectious agents. The transplanted organ must accommodate the increased workload of pregnancy and the needs of the fetus. The delicate balance between immunosuppression and rejection may be altered by the pregnancy. The impact of pregnancy on recurrent disease can also be an issue. Medication issues include changes in drug pharmacokinetics and the potential for adverse effects on the fetus. These effects could include chromosomal aberrations, structural malformations, organ-specific toxicity, intrauterine growth retardation, and immune system development. For female kidney recipients there are sufficient data to demonstrate a direct relationship between creatinine levels before and during pregnancy and risk of graft loss in the postpartum period. Pregnancy itself does not appear to adversely affect stable graft function. Among liver recipients, those with recurrent viral hepatitis may have deterioration of graft function with subsequent pregnancies. These recipients should be apprised accordingly, as maternal deaths have occurred in this setting. Postpartum depression and potential for medication noncompliance require vigilance. The safety of pregnancy from the NTPR analysis to date has been largely derived from the experience with CsA-based regimens. For recipients on CsA there have been good maternal outcomes without any specific or predominant malformation patterns in the offspring. For the general population, malformations occur in approximately 3% of live births. To date, there is no indication that this incidence has increased despite the complex medical regimens of transplant recipients. Data are accruing with tacrolimus and Neoral. Continuing data entry and continued follow-up of off-spring will allow for further recommendations, especially in light of the new medications and combinations. Recipients should be advised to wait one to 2 years after transplant before considering pregnancy. Those with stable graft function, and with no rejection, graft dysfunction, or deterioration should still be apprised of the high risk of prematurity and low birthweight, although maternal risks appear low. These are high-risk pregnancies, requiring close communication and cooperation between the high-risk obstetrician and the transplant team. The use of the FDA pregnancy categories should not be the sole reason for choosing a particular immunosuppressive drug. Agents such as Neoral and tacrolimus would appear to offer some advantage as blood levels can be measured. At present, no safety guidelines can be given for mycophenolate mofetil, OKT3, or ATG. Identification of prepregnancy factors predictive of higher risks and appropriate counseling and management guidelines are major NTPR goals, and depend on the continued assistance and cooperation of the transplant community.
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PMID:Report from the National Transplantation Pregnancy Registry (NTPR): outcomes of pregnancy after transplantation. 991 94

Polyarteritis nodosa (PAN) is a necrotizing arteritis of small and medium-sized vessels. It may present with hypertension and/or renal insufficiency. Peripheral neuropathy, myopathy, joint pains, testicular pain, and ischemic myalgias may also be seen. Gastrointestinal involvement may lead to gangrene of the bowel, peritonitis, perforation, intra-abdominal hemorrhage, and pancreatitis. The cutaneous manifestations include tender subcutaneous nodules grouped along the course of superficial arteries of the lower extremities, with or without an overlying livedo reticularis. Although multisystem involvement is characteristic, sometimes only one organ or system may be involved. Associations with viral hepatitis (both B and C) and streptococcal infection have been established for PAN. Recurrent strep infections of the upper respiratory tract, streptococcal glomerulonephritis and rheumatic fever have previously been linked to PAN. This report extends the spectrum of associated streptococcal infections to include necrotizing fasciitis.
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PMID:Cutaneous polyarteritis nodosa after streptococcal necrotizing fasciitis. 1151 22

Contraindications to the use of estroprogestational agents must be critically and completely evaluated before any oral contraceptive (OC) prescription. Antecedents of cholestasis during pregnancy, jaundice, vascular lithiasis, hepato-cellular adenomas, or viral hepatitis are sure contradindications to OC use because of possible hepatic pathology, while antecedents of thromboembolic or cardiovascular accidents are contraindications because of the possible cardiovascular pathology. In the adolescent and premenopausal women any irregularities in the menstrual cycle would advise against OC prescription, just as any form of benign or malignant gynecological tumor would be a contraindication at any age. Prescription of OC is contraindicated in patients under treatment with several kinds of analgesics, anticoagulants, anticonvulsants, barbiturates, and tranquilizers, since such drugs usually interfere with the contraceptive action of OCs. Another absolute contraindication to OC treatment is pregnancy, even if it is not proven that OC treatment immediately before or during pregnancy can increase the risk of teratogenic effects. OCs can diminish the volume and duration of lactation in breastfeeding women; it is also possible that steroids and their metabolites can pass into maternal milk in minimal doses. The most important factors of risk are smoking, especially in women over 40, hypertension, hyperlipemia and diabetes, whether latent or real. It must be remembered, however, that risk of maternal mortality in Western Europe is 5-35/100,000 births, while risk of mortality because of OC treatment is only 3/100,000.
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PMID:[The contraindications of estroprogestagens]. 1227 52

The measurement of anti-double-stranded DNA (anti-dsDNA) antibodies is a useful tool for the diagnosis and the follow-up of systemic lupus erythematosus (SLE). Anti-dsDNA antibodies are involved in the pathogenesis of lupus nephritis and they are, specially the high-avidity antibodies, the most specific antibodies associated with SLE nephritis and active SLE. The aim of the present study was to assess the clinical utility of an enzyme-linked immunosorbent assay (EUSA) that utilizes a circular double-stranded plasmid DNA as a nucleic acid source, adapted to an automated fluorescence immunoassay (EliA dsDNA, Pharmacia, Freiburg, Germany). Also, we compared this method with other immunoassays used in clinical laboratories. We have measured anti-dsDNA antibodies in the serum of 179 patients with a positive result for antinuclear antibodies (ANA). Seventy six sera were from SLE patients (14 men and 62 women), and the other 103 sera (from 20 men and 83 women) constituted the control group. This latter group includes nine Sjogren's syndrome patients, six patients with rheumatoid arthritis and 88 with various other diseases, including connective tissue diseases (n=34), hepatopathies (n= 17; 11 primary biliary cirrhosis and 6 autoimmune hepatitis), and 37 patients with nonautoimmune diseases (viral hepatitis, renal disease, diabetes, exanthema and hypertension). Methods used were "EliA dsDNA" (Pharmacia, Germany), "Varelisa dsDNA" (Pharmacia, Germany), Farr (Amersham, UK) and Chritidia luciliae immunofluorescence test (Vitro-Immun, Germany). We assessed sensitivity, specificity, positive predictive value and negative predictive value in the clinical study, and kappa index and scatter plots in the comparative study. The results show a low concordance between methods (kappa < 0.6). The evaluated EliA method shows a very good specificity for SLE (93.2%) and a good sensitivity for active SLE (70.8%).
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PMID:Clinical evaluation of a new automated anti-dsDNA fluorescent immunoassay. 1247 49

Chronic liver disease is a major cause of morbidity and mortality in the United States. Although often used to detect liver disease, the prevalence and etiology of elevated aminotransferases are unknown. We analyzed data on adults ages 17 yr and older (N = 15,676) from the Third National Health and Nutrition Examination Survey (1988-1994). Participants were classified as having elevated aminotransferase levels if either aspartate aminotransferase or alanine aminotransferase was elevated above normal. Aminotransferase elevation was classified as "explained" if there was laboratory evidence of hepatitis B or C infection, iron overload, or if there was a history of alcohol consumption. Analyses were weighted to provide national estimates. The prevalence of aminotransferase elevation in the United States was 7.9%. Aminotransferase elevation was more common in men compared to women (9.3% vs 6.6%, p = 0.002), in Mexican Americans (14.9%) and non-Hispanic blacks (8.1%) compared to non-Hispanic whites (7.1%, p < 0.001). High alcohol consumption, hepatitis B or C infection and high transferrin saturation were found in only 31.0% of cases. Aminotransferase elevation was unexplained in the majority (69.0%). In both men and women, unexplained aminotransferase elevation was significantly associated with higher body mass index, waist circumference, triglycerides, fasting insulin, and lower HDL; and with type 2 diabetes and hypertension in women (all p < 0.05). Aminotransferase elevation was common in the United States, and the majority could not be unexplained by alcohol consumption, viral hepatitis or hemochromatosis. Unexplained aminotransferase elevation was strongly associated with adiposity and other features of the metabolic syndrome, and thus may represent nonalcoholic fatty liver disease.
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PMID:The prevalence and etiology of elevated aminotransferase levels in the United States. 1280 14

Morphological examination of 2 renal biopsy specimens obtained from a 69-year-old woman with a nephrotic syndrome, high blood pressure, and a reduced glomerular filtration rate revealed, in ultrastructural study, a type of a glomerulonephritis with fibrillar deposits in a subendothelial position which were unusual in their immunoglobulin components (mainly IgM). The fibrillar components were of irregular size, 13 to 18 nm in diameter and presented a very particular "barbed wire" morphological aspect, not hitherto described. Diffraction studies and image analysis, revealed spiraled fibrils with regular alternating elements that we suggest may correspond to IgM molecules. The clinical (isolated renal symptoms) and laboratory (traces of 3 monoclonal components in the serum and 2 normal bone marrow biopsy specimens) data provided no evidence of hematopoietic malignancy, viral hepatitis or cryoglobulinemia.
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PMID:Unusual IgM fibrillar deposits in glomerulonephritis: ultrastructural and diffraction studies in a case report. 1469 23

The effect of interferon alpha in chronic viral hepatitis and common side effects are well known, but axonal polyneuropathy and hearing loss have been rarely reported. A 58-year-old woman was administered interferon alpha-2a (9 MU/3 times a week) and lamividin (100 mg daily) with the diagnosis of chronic hepatitis B. At the fifth month of the treatment gait disturbance and tinnitus developed. In her neurological examination tandem gait was ataxic on the right side. Cerebral magnetic resonance imaging performed to elucidate a probable cerebral pathology revealed nonspecific millimetric hyperintense lesions thought to be related with her hypertension anamnesis. Electroneuromyography demonstrated mild axonal polyneuropathy. The finding of pure-tone audiometry was sensorineural hearing loss in her left ear. Our diagnosis was axonal polyneuropathy and sensorineural type hearing loss as a side effect of interferon. In conclusion, the development of polyneuropathy and sensorineural hearing loss in the same patient may suggest autoimmunity as the cause of these side effects.
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PMID:Axonal neuropathy and hearing loss associated with alpha interferon treatment in chronic hepatitis B: a case report. 1533 19


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