Reduced progression of bone erosion in cytomegalovirus seropositive rheumatoid arthritis patients.

BACKGROUND: Human cytomegalovirus (HCMV) seropositivity has been associated with higher inflammation during rheumatoid arthritis (RA). However, no data are available on the impact of HCMV seropositivity on bone erosion progression during RA. METHODS: We selected 487 individuals of ESPOIR cohort who fulfilled the 2010 ACR/EULAR criteria for RA. HCMV serology for these patients was determined using Architect CMV IgG assay. Baseline and 1-year central X-ray reading using modified Total Sharp Score (mTSS), Erosion Sharp Score, and joint space narrowing Sharp score were used to quantify structural damage progression. We performed univariate and multivariate analyses to investigate the association between HCMV status and bone erosion progression. RESULTS: We analyzed 273 HCMV seropositive (HCMV+) and 214 HCMV seronegative (HCMV-) RA patients. At inclusion, HCMV+ patients were less frequently ACPA+ (49.8% versus 58.9%, p < 0.0465) and had a higher DAS28-ESR (5.55 ± 1.24 versus 5.20 ± 1.14, p < 0.0013) in comparison with HCMV-. At 1 year, bone erosion progression (delta erosion Sharp score > 1 point) was lower in HCMV+ patients (16.1% versus 25.2%, p = 0.0128) in comparison with HCMV-. HCMV+ status remained independently associated with lower bone erosion progression in multivariate analysis. CONCLUSIONS: Our findings suggest that, independently of other confounding factors, HCMV seropositivity is associated with a lower progression of bone erosion during RA.

Normal FGF23 levels in adult idiopathic phosphate diabetes.

Fibroblast growth factor 23 (FGF23), a recently discovered phosphaturic substance playing a key role in genetic and oncogenic phosphate diabetes, is involved in the physiological regulation of phosphate metabolism. Moderate idiopathic phosphate diabetes (IPD) leading to male osteoporosis and diffuse pain resembling fibromyalgia has been described. The aim of our study was to define the role of FGF23 in the mechanism of IPD. The study concerned 29 patients with IPD, mean age 53 +/- 11 years, of whom 72% were men. Fifteen subjects without bone disease and with normal serum phosphate and calcium levels were used as controls. Phosphate diabetes was confirmed by phosphate reabsorption level <85% and phosphate reabsorption threshold (TmPO4/GFR) <0.83. Known causes of phosphate diabetes were excluded. Fasting level of FGF23, serum phosphate, 1-25(OH)2D3, and parathyroid hormone were measured in patients and compared with FGF23 and serum phosphate in healthy controls. Spinal and hip bone mineral density (BMD) were measured by osteodensitometry. Sixteen of 29 patients had diffuse pain, 10 had osteoporosis according to the World Health Organization criteria, and 11 had osteopenia. Serum phosphate was significantly lower in patients than in controls, but FGF23 levels did not differ. Compared to patients with normal bone status, patients with osteopenia and osteoporosis had significantly decreased FGF23 levels, whereas serum phosphate was identical in the two groups. In all patients, serum phosphate and FGF23 were positively correlated and FGF23 and 1-25(OH)2D3 were negatively correlated. FGF23 seems not be a cause of IPD, and the FGF23/phosphate/1-25(OH)2D3 axis appeared to be functional.

Management of diabetic patients by general practitioners in France 1997: an epidemiological study.

To describe the characteristics of diabetic patients, the associated risk factors, the complications of the disease and its management by general practitioners (GPs) in France, a randomised sample of French GPs was asked to record data on all consecutive diabetic patients attending a regular visit within 3 months. Data were obtained by interview, clinical examination and usual follow-up complementary examinations of the patients. Patients were classified into 3 groups:, patients treated with insulin and considered to have type 1 diabetes, [2i], insulin-treated patients expected to have type 2 diabetes, [2d], patients with type 2 diabetes and not treated with insulin. Data from 7540 diabetic out-patients were recorded by 3084 GPs: 657 patients (8.7%) belonged to group 1, 1383 patients (18.3%) to group 2i and 5351 (71.0%) to group 2d. Patients, including 53.7%, [2i] 54.1%, and [2d] 56.5% of men, were (mean +/- SE) 58.8 +/- 0.7, [2i] 63.4 +/- 0.3, and [2d] 63.9 +/- 0.2 years old, respectively. Duration of diabetes was 15.9 +/- 0.4, [2i] 11.4 +/- 0.2, and [2d] 10.1 +/- 0.1 yr. The last fasting blood glucose level (laboratory assay) was 1.61 +/- 0.02, [2i] 1.68 +/- 0.01, and [2d] 1.61 +/- 0.01 g/L, and the last HbA1c 8.5 +/- 0.1, [2i] 8.1 +/- 0.1, and [2d] 7.8 +/- 0.1%, respectively. Tobacco smoking was observed in 19.2%, [2i] 13.1%, and [2d] 12.6% of the patients, hypertension in 39.6%, [2i] 55.9%, and [2d] 58.6%, micro- or macro-albuminuria in 18.6%, [2i] 11. 2%, and [2d] 9.5%, retinopathy in 31.1%, [2i] 12.9%, and [2d] 8.6%, and history of coronary artery disease in 16.3%, [2i] 15.0%, and [2d] 12.8%. Self-monitoring of blood glucose was performed by 93.2%, [2i] 37.9%, and [2d] 16.9% of the patients. During the previous 12 months, a visit had been performed with a diabetologist in 54.0%, [2i] 20.7%, and [2d] 12.9% of the patients, with an ophthalmologist in 62.9%, [2i] 51.5%, and [2d] 49.4%. These results underline the specific characteristics of French diabetic patients. A high prevalence of uncontrolled risk factors, mainly hypertension, contrasts with a relatively low frequency of micro- and macro-angiopathy, maybe underestimated by non-systematic routine follow-up. Closer collaboration between GPs and specialists should be developed to improve the management and care of diabetic patients in France.

Mental health and substance abuse services in the era of health care reform.

In the face of the cost crisis in the U.S. health care delivery system and in the era of reform, mental health and substance abuse services are in jeopardy. As the Clinton health reform plan is being debated during the months ahead, however, advocates for mental health and substance abuse care can play an important role in preserving benefits. To do so, they must press on with research into the effectiveness and cost-effectiveness of all aspects of mental health and substance abuse treatment; they must focus energies on working with managed care companies to ensure the provision of only necessary care at the appropriate level and intensity; and they must strive toward understanding the reforms being proposed and the implications for mental health and substance abuse services. Successful integration of the full array of mental health and substance abuse services into a generic benefits package remains a realistic goal, but the challenge is formidable.

Managing CHAMPUS mental health care with public-private partnerships.

When faced with skyrocketing costs and utilization of mental health and substance abuse services covered by the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), the Department of Defense (DoD) turned to a managed care approach to seek improvements. This article provides brief background information on CHAMPUS and its experience in the area of mental health services, describes DoD's partnerships with private sector mental health care firms, and highlights the most successful features of each.

Nearly Optimal Foraging in Patches Under Nutrient Constraints.

Three feeding strategies with different rules for prey selectivity were evaluated by Monte Carlo computer simulation. The predator must obtain a minimum quantity of each of three different nutrients, and it sequentially encounters one of three kinds of prey that differ in both their nutrient compositions and their relative abundances. Within patches, prey may be randomly dispersed or aggregated with Markovian transition probabilities. Overall cost is the sum of search time plus consumption cost plus emigration (between-patch traverses) risk. The predator will emigrate if it is unsuccessful in acquiring a minimum of {Gamma} units of any needed nutrient within the T most recent prey encounters. The three strategies are (1) no discrimination-with potentially high consumption costs, (2) minimal consumption-with potentially very prolonged search times, and (3) a hybrid strategy that requires a physiological monitoring of net nutrient acquisition (or the bookkeeping of highly correlated gustatory cues). Each strategy has its characteristic dynamics and optima, but collectively these simulations show that no one strategy is superior and that over a large portion of the parameter space the differences in overall cost are relatively small.

The dynamics of cohort selection.

The dynamics of cohort selection in age-structured populations is explored in a series of computer simulations using a single-locus two-allele model. Cohort selection is a directional process which is a consequence of genetically determined inter-cohort variation in the magnitude of expression of interference behavior; its essential premise is that all genotypes of a given age are equally susceptible to interference and that no advantage accrues to the interfering genotype. In these simulations, allele frequency, population size, intensity of interference, and reproductive apportionment are all major determinants of evolutionary rates. The generality of this process is demonstrated and an analysis of the observed frequency-dependent effects is presented. Cohort selection is distinct from other kinds of selection and may be an important cause of the persistence of interference behavior (culminating in acts of spite) within animal populations.