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Reading Wallace Daniel's 'The church under Putin' (Dec. 9) right after reading John Buchanan's fine column 'Zechariah's problem,' I was struck by the contrast between Zechariah and Orthodox Patriarch Kirill. [...]

OBJECTIVE: To examine a cohort of patients with systemic sclerosis (SSc) and pulmonary hypertension (PH) for ethnic disparities in clinical presentation, disease detection, or management. METHODS: Encounters of patients with SSc seen at the Medical University of South Carolina were recorded in a computerized database from November 1997 through January 2004. Patients were evaluated for discrepancy in disease manifestation and treatment. Evaluation criteria included patient ethnicity (by self report), age, disease duration from onset of first non-Raynaud's symptom, presence or absence of PH, incidence of diastolic dysfunction and left ventricular hypertrophy among patients with PH, severity of interstitial lung disease, and treatment course. RESULTS: African Americans were more likely than Caucasians to have diffuse cutaneous SSc (dcSSc) (69.9% vs 42.9%, p < 0.001) and they presented with PH (defined as right ventricular systolic pressure > 40 mm Hg by echocardiogram or mean pulmonary artery pressure > 25 mm Hg by right heart catheterization (RHC) at a younger age (60.9 yrs vs 49.0 yrs, p < 0.001). There were no ethnic disparities in time from onset of the first non-Raynaud's symptom to detection of PH, method of PH detection, or treatment modalities. Patients with PH were more likely to have diastolic dysfunction than those without PH (52.3% vs 35.9%, p = 0.011). CONCLUSION: In this cohort of patients, African Americans were more likely to have dcSSc. Among patients with PH, African Americans presented at a younger age than their Caucasian counterparts. Incidence of diastolic dysfunction was higher in the PH population. There were no significant ethnic disparities in time of progression to PH or in treatment modalities employed in our cohort.

OBJECTIVE: Microvascular disease is one of the hallmarks of systemic sclerosis (SSc, scleroderma), but macrovascular involvement also exists in some patients. Patients with SSc may have severe Raynaud's phenomenon (RP) characterized by refractory digital ulcerations. We investigated if large artery involvement, that is, ulnar artery occlusion, has a role in the development of refractory digital ulcerations, and if both screening for this involvement and revascularization of the ulnar artery occlusive disease may improve digital ulcer healing. METHODS: A retrospective chart review was performed of 15 patients with SSc, all of whom had severe RP and digital ulceration, together with a positive Allen test and ulnar artery occlusive disease documented by angiography. RESULTS: Women outnumbered men 2:1, with limited disease predominating (7), 5 patients having diffuse cutaneous disease and 3 overlap syndromes. All patients had positive antinuclear antibody and capillary microscopy findings consistent with SSc. Antiphospholipid antibodies were present in 4 of 6 patients tested. Tobacco use was seen in 5 patients, only 2 of whom were current smokers. All patients failed conventional medical therapy (nitrates, calcium channel blockers, antiplatelet agents) for RP and digital ulceration. Only 1/8 patients improved with stellate ganglion block, and one patient had no improvement following digital sympathectomy. Eight patients underwent ulnar artery revascularization combined with digital sympathectomy, and 8 experienced dramatic improvement in RP and healing of digital ulcers. CONCLUSION: An Allen test should be performed routinely on all SSc patients with severe RP and refractory digital ulceration to investigate the possibility of ulnar artery occlusive disease. If suspected ulnar artery occlusion is confirmed by angiography or ultrasonography, ulnar artery revascularization with or without digital sympathectomy should be considered in patients who fail conventional medical therapy.

The data bearing on these three cases are quite sufficient to rule out Bacillus abortus as the agent. Not only the cultures and guinea pig tests of fetal tissues and contents of the digestive tract, but also the agglutination and guinea pig tests of the milk, were negative. The same is true of the agglutination tests of the blood serum. Only in one case was the placenta obtained in part. The stained films and the sections from various regions showed no abortion bacilli. Guinea pig tests of placental tissue were negative for Bacillus abortus. On the other hand) minute organisms resembling vibrios were detected in the cytoplasm of endothelial cells within capillaries in the edematous subchorionic tissue. Subsequently the agglutination titer of the blood serum of one of these cases rose to a level indicating infection with Bacillus abortus during the second pregnancy. The peculiar distribution of abortions due to Vibrio fetus among older cows and heifers in this herd, resulting at first in cases among older cows and latterly passing to young stock, may be explained by certain occurrences in the herd itself. It may be assumed that the infection was originally brought in by purchased cows. The young stock is kept segregated from these in a special barn, and when 6 months old it is pastured on outlying farms until returned in an advanced stage of pregnancy. The heifers during the first pregnancy were thus kept away from vibrio carriers until after the first calf was born. In June and July, 1919, 55 older cows, purchased and native, were placed on the young stock pasture. The three cases of abortion in heifers due to Vibrio fetus occurred October 24, November 9, and December 2, 1919. The age and condition of the fetuses accord very well with the assumption that Vibrio fetus was introduced among the young stock in June or July of the same year. The information gathered thus far concerning vibrionic abortion in this herd enables us to formulate a tentative hypothesis subject to modification with increasing knowledge of this type of infectious abortion. The infectious agent was probably introduced by purchased cows in 1917 or earlier. It gained a certain headway up to 1919, then the number of cases declined so that between May, 1919, and May, 1920, only the above three cases in heifers, and one case of mixed infection with Bacillus abortus in an older cow, were detected. During the same period cases due to Bacillus abortus continued undiminished. The greater resistance of Bacillus abortus manifested in cultures as compared with Vibrio fetus is thus reflected in its behavior in nature. The temporary dying out of the infection indicates that natural immunization of a herd to Vibrio fetus proceeds quite rapidly. Another outbreak may be expected when the immunity of the herd has declined in the absence of the infecting agent and the latter is reintroduced from without, or it may reappear at any time when a vibrio of higher virulence is brought in.

Twenty-two fetal and two calf strains of spirilla have been studied chiefly with regard to the problem of identity. Twenty-one fetal strains are probably specifically the same. One fetal strain differs slightly from these, but in its agglutination affinities it belongs to the same group. Of two strains isolated from calves one has definite agglutination relations with the fetal strains, the other none. In the morphological and biological characters so far investigated all the strains agree closely with one another.