Vitamin D supplementation, bone turnover, and inflammation in HIV-infected patients.

OBJECTIVE: To assess whether vitamin D supplementation could be associated with a modification of inflammatory markers and bone turnover in HIV-1-infected patients. PATIENTS AND METHODS: Patients who participated in an initial survey in 2010 and who were followed in the same department were included in a new study in 2012. Between 2010 and 2012, vitamin D supplementation was offered to patients presenting with hypovitaminosis D as per appropriate guidelines. Clinical examinations were performed, and fasting blood samples were taken for inflammation and bone marker evaluations. RESULTS: Of the 263 patients who participated in the 2010 study, 198 were included in the 2012 study. Hypovitaminosis D was observed in 47% (36/77) of participants supplemented as per appropriate guidelines, in 78% (75/97) of transiently or incompletely supplemented participants, and in 71% (17/24) of non-supplemented participants (mainly because vitamin D levels in 2010 were normal). No significant correlation between vitamin D supplementation and the 2-year inflammation outcome (IL-6 and hsCRP) or C-terminal telopeptide levels was observed. However, a decrease in IL6 levels over the 2 years significantly correlated with reaching a normal vitamin D level (OR=0.89 per+1pg/mL IL6 increase, 95% CI=0.81-0.97, P=0.015). CONCLUSIONS: Vitamin D supplementation decreases the risk of hypovitaminosis D but does not decrease the risk of inflammation nor bone turnover, unless normal 25-OH vitamin D levels are reached.

Early decrease of serum biomarkers of type II collagen degradation (Coll2-1) and joint inflammation (Coll2-1 NO2 ) by hyaluronic acid intra-articular injections in patients with knee osteoarthritis: a research study part of the Biovisco study.

To measure the evolution of the serum levels of specific Osteoarthritis (OA) biomarker, Coll2-1 and Coll2-1 NO2 in knee osteoarthritic patients after viscosupplementation (VS). Fifty-one patients with unilateral symptomatic knee were recruited for this prospective open label study. They received three intra-articular injections of 2 ml of hyaluronic acid (Hylan GF-20) and were followed for 3 months. Walking pain was evaluated and serum samples were taken at each visit. Coll2-1 and Coll2-1 NO2 were measured in the serum using specific immunoassays. Variations over time of each parameter and predictive factor of response were studied. Forty-five patients were analyzed. The serum concentrations of Coll2-1 and Coll2-1 NO2 were significantly higher in KL III/IV patients compared to KL I/II patients at baseline and decreased systematically over time after VS. Its effect was ever more pronounced in patients with KL III/IV. The serum concentration of Coll2-1 was significantly lower at baseline in responders than in non-responders. This study suggests a rapid slowdown of type II collagen degradation and joint inflammation after VS with Hylan G-20 and gives additional information for the validation of accurate biomarkers for OA. The serum level of Coll2-1 appeared to be a predictive factor for response to treatment.

[Lung herniation after a single cough]. / Lungenhernie nach einmaliger Hustenattacke.

We present the case of an overweight male patient with a lung hernia caused by a single massive coughing attack. The diagnosis could only be verified by CT-scans. Following a conservative therapeutic approach, surgical intervention was necessary. Lung hernias are easy to detect using radiological diagnostic. Standard X-ray examinations where a subcutaneous air mass can be seen have become, since the inauguration of computed tomography, second line tests. Large traumatic lung hernias should be treated surgically. Spontaneous and especially cervical hernias should be handled conservatively and only must be surgically treated when complications or a progression in size should be observed.

Do multifilament alloplastic meshes increase the infection rate? Analysis of the polymeric surface, the bacteria adherence, and the in vivo consequences in a rat model.

Within the last decade hernia surgery has changed from suture repair to mesh repair. Biomaterials, and multifilaments in particular, are thought to increase the risk of infection. Therefore, the aim of this study was to study the influence of the presence of either a monofilament or a multifilament mesh material on the bacterial infection risk. The filament surface of a monofilament and a multifilament mesh were calculated on the basis of a theoretical model. The adherence of Staphylococcus aureus was measured in vitro by fluorescence analysis. Additionally, the two mesh materials (8-mm platelets) were implanted subcutaneously in Sprague-Dawley rats with daily surveillance for clinical signs of infection. After 7 days the meshes were explanted for histological and microbiological analysis. Calculations of the mesh surface area revealed a higher level for the multifilament mesh. The extent of adherent bacteria corresponded to the estimated filament surface in vitro. In vivo, the implantation of meshes in the presence of 5 x 10(6) S. aureus did not show an increased infection rate in rats with either monofilament or multifilament material, compared to the control groups (mesh implantation without S. aureus contamination). However, after 7 days bacteria were still detectable in the majority of the implantation sites, and a clinically inapparent intensification of local inflammation and fibrosis was induced. The increased surface area of a multifilament meshes promotes the persistence of bacteria in the implant bed, though this alone is not sufficient to create a clinically apparent infection. This might explain the development of mesh-related infections after a delay of several months or even years. In vivo, the adherence of bacteria to the implant material depends on the surface area, which favors the use of monofilament materials.

A psychosocial analysis of women planning birth outside hospital.

Most of the women requesting out-of-hospital delivery considered delivery a natural process, not an illness requiring hospital care. The women cited freedom of choice concerning the delivery, less anxiety in the home than in the hospital environment, a more personal relationship with the midwife, and, as far as possible, making do without medical equipment. The interviewed women were a selected collective regarding age, parity, socioeconomic status and obstetric risk profile. Nonetheless, the results suggest ways that in-hospital obstetrics can be adapted to meet the requirements of pregnant women. Individualized, family-oriented obstetrics with judicious use of medical technology should be possible in the clinical setting.

Rheumatic disorders developed after hepatitis B vaccination.

OBJECTIVE: To obtain an overview of rheumatic disorders occurring after hepatitis B vaccination. METHODS: A questionnaire was sent to rheumatology departments in nine French hospitals. Criteria for entry were rheumatic complaints of 1 week's duration or more, occurrence during the 2 months following hepatitis B vaccination, no previously diagnosed rheumatic disease and no other explanation for the complaints. RESULTS: Twenty-two patients were included. The observed disorders were as follows: rheumatoid arthritis for six patients; exacerbation of a previously non-diagnosed systemic lupus erythematosus for two; post-vaccinal arthritis for five; polyarthralgia-myalgia for four; suspected or biopsy-proved vasculitis for three; miscellaneous for two. CONCLUSIONS: Hepatitis B vaccine might be followed by various rheumatic conditions and might trigger the onset of underlying inflammatory or autoimmune rheumatic diseases. However, a causal relationship between hepatitis B vaccination and the observed rheumatic manifestations cannot be easily established. Further epidemiological studies are needed to establish whether hepatitis B vaccination is associated or not with an incidence of rheumatic disorders higher than normal.

Refractory arthropathy after intravesical bacillus Calmette-Guérin therapy. Usefulness of isoniazide.

BACKGROUND: Arthritis associated with bacillus Calmette-Guérin immunotherapy usually responds dramatically to nonsteroidal antiinflammatory drug therapy. Isoniazid is generally reserved for other complications such as granulomatous hepatitis. CASE-REPORT: A 73-year-old man was admitted for fever, arthritis of the knees and right temporomandibular joint, an inflammatory swelling over the left Achilles tendon and bilateral conjunctivitis. The symptoms started in the wake of a course of intravesical bacillus Calmette-Guérin immunotherapy. Laboratory tests showed evidence of severe inflammation. Cultures of blood, urine and joint fluid specimens were negative, as were tests for autoantibodies and serologic tests for organisms known to cause reactive arthritis. Nonsteroidal antiinflammatory therapy was ineffective and glucocorticoid therapy produced only a partial response. All the symptoms resolved under isoniazid therapy in a dosage of 300 mg/day for three months. CONCLUSION: Use of antituberculous agents may be required in some cases of arthritis associated with bacillus Calmette-Guérin immunotherapy, most notably those with severe pyrexia.

Bone scintigraphy equipped with a pinhole collimator for diagnosis of avascular necrosis of the femoral head.

The objective was to compare the sensitivities for diagnosis of avascular necrosis of the femoral head of bone scintigraphy equipped with a pinhole collimator and with an high resolution parallel collimator. Bone scintigraphy equipped with a pinhole collimator and with an high resolution parallel collimator were performed in 16 patients with bilateral (n=7) or unilateral (n=9) avascular necrosis of the femoral head. Bone scintigraphy equipped with a pinhole collimator documented a photopenic defect in 78.3% of the necrotic hips, while bone scintigraphy equipped with an high resolution parallel collimator documented a defect in 47.8%. There was no false-positive diagnosis of avascular necrosis of the femoral head on either bone scintigraphy equipped with a pinhole or with an high resolution parallel collimator. In conclusion, bone scintigraphy equipped with a pinhole collimator has a greater sensitivity for diagnosis of avascular necrosis of the femoral head than bone scintigraphy equipped with an high resolution parallel collimator.

Multifocal malignant fibrous histiocytoma of the spine.

A 40-year-old patient was seen because of a three-month history of low back pain unresponsive to standard therapy. Crush fractures of T12 and L2 were seen on plain radiographs. A magnetic resonance imaging study disclosed lesions of all the vertebral bodies from T12 to the sacrum sparing the disks and epidural space. Histologic features of a vertebral biopsy specimen was consistent with malignant fibrous histiocytoma of the bone. The multifocal distribution caused some reluctance to accept this diagnosis, which was, however, confirmed by detailed immunohistochemical studies and reevaluation of the histologic slides by independent observers who were unaware of the initial diagnosis. Chemotherapy with doxorubicin and cisplatin was started but the patient died 15 months after the diagnosis. Malignant fibrous histiocytoma mainly affects the metaphyses of the long tubular bones. The spine is a very uncommon site of localization of this tumor. The multifocal spinal lesions in our patient may have been produced by metastases from an unidentified primary or by direct spread via the perivertebral soft tissues of a primary located in a vertebral body. The management of malignant fibrous histiocytoma relies on a combination of surgery and chemotherapy. Although complete excision of the tumor can be followed by prolonged survival, the prognosis is bleak in unresectable forms.

Prevalence of ANCA in a hospitalized elderly French population.

OBJECTIVE: The prevalence of some autoantibodies in the elderly population has been reported to be greater than in younger controls. The prevalence of ANCA has been shown to be low in a generally healthy population, but has not been established in the elderly. Thus, the presence of ANCA in elderly patients might not have the same clinical significance as in younger people. The aim of this study was to evaluate the prevalence of ANCA in elderly subjects. PATIENTS AND METHODS: Serum samples from 137 subjects (96 females, 41 males; mean age = 82.2 years +/- 6.97 SD) were evaluated. Criteria for exclusion included suspected or established systemic vasculitis, connective tissue or neoplastic diseases, acute infection, HIV infection, current therapy with corticosteroids or cytotoxic drugs, and recent blood transfusion. ANCA were detected by indirect immunofluorescence on ethanol-fixed normal human neutrophils. Fluorescence patterns were classified as c-ANCA, p-ANCA or nuclear. Sera exhibiting p-ANCA or nuclear fluorescence were further tested by IIF on formalin-acetone fixed normal human neutrophils. Sera whose reaction pattern was cytoplasmic were considered as positive for "true" pANCA. Additionally, sera were tested for the presence of antinuclear antibodies (IIF), anti-double-stranded DNA (enzyme immunoassay) and IgM rheumatoid factors (enzyme immunoassay). RESULTS: The prevalence of c-ANCA was 0% (95% CI = 0-2.66), the prevalence of p-ANCA was 2.2% (95% CI = 0.45-6.3), and the prevalence of "true" p-ANCA was 0.73% (95% CI = 0.02-4). The prevalence of ANA, anti ds-DNA and RF were respectively 38%, 3.6%, and 11.7%. CONCLUSION: The prevalence of ANCA is not increased in elderly people. Thus, the presence of ANCA in elderly subjects may have the same clinical significance as in younger people.

Vertebral osteomyelitis due to Capnocytophaga.

The first case of vertebral Capnocytophaga infection in an immunocompetent subject is reported. The patient was a 75-year-old woman with low back pain and a decline in general health. Plain roentgenograms disclosed erosions in the upper endplate of L4 and the lower endplate of L3 with no lesions of the intervening disk. Magnetic resonance imaging confirmed that the disk was normal. The organism was identified only by a repeat vertebral biopsy with bacteriologic cultures in a CO2-enriched atmosphere. The patient achieved a full recovery. Patients with suspected bone infections should be evaluated for portals of entry (Capnocytophaga is a normal inhabitant of the oral cavity) and should undergo multiple microbiological studies aimed at detecting a broad range of organisms.