Clinical aspects of vitamin D in the management of rheumatoid arthritis

There is an increasing interest in the role of vitamin D as a potential treatment for a number of disparate diseases. In addition to its role in calcium homeostasis, vitamin D has a plethora of effects including immunomodulation, pleiotropic effects, modulating propensity to infection and blood pressure regulation. Detection and treatment of vitamin D deficiency in selected patients with RA is relevant as deficiency is common. Vitamin D therapy may modify the increased risk of falls and fracture in this group, and possibly exert additional immunomodulatory effects on disease onset and activity although data are largely epidemiological. Currently, there is no consensus view on vitamin D replacement regimens, nor an agreed optimal level of serum 25-hydroxyvitamin D [25(OH)D] for health. Indeed levels may vary for different organ systems and the concept of 'tissue specific vitamin D deficiency' needs to be considered. Therefore, there is clinical uncertainty regarding both when and how to correct vitamin D deficiency. Older patients, particularly post-menopausal women, and others at high risk of vitamin D deficiency should be preferentially targeted since they are likely to benefit most from supplementation. Clinicians should be aware of the technical difficulties associated with measuring and interpreting 25(OH)D levels. The administration of high-dose vitamin D as an oral weekly bolus is safe and can rapidly correct vitamin D deficiency followed by regular lower doses to maintain adequate levels.

GPs' experience of managing chronic pain in a South Asian community--a qualitative study of the consultation process

BACKGROUND

Chronic pain is one of the most common reasons for seeking primary care consultations. GPs' experience of managing patients with pain from a multicultural community has not previously been examined.

OBJECTIVES

We explored GPs' experiences of managing patients with chronic pain from a South Asian community in Leicester.

METHODS

Qualitative semi-structured interviews were conducted with GPs from practices in two primary care trusts within Leicester. Eighteen GPs (11 males and 7 females) were interviewed in this study.

RESULTS

Several emerging themes were identified from the data including consulting behaviour, presentation of pain, GPs personal challenges, psychosomatic interpretations and communication. Overall, GPs find that managing South Asian patients with chronic pain can be challenging as a consequence of the way in which patients present with pain. Difficulties for GPs were created not only by language differences but also by cultural differences, which were not seen in second or third generation South Asians. GPs felt that self-management was difficult to address, and compliance with medication difficult to determine. In such consultations, GPs perceived that patients were more likely to present with psychosomatic symptoms.

CONCLUSIONS

Cultural influences play an important role in the consultation process where patients' behaviour is often bound in their cultural view of health care. Patients' presentation of their condition makes diagnosis difficult but can also lead to miscommunication. Whether South Asian people are more likely to present mental health problems as chronic pain is not clear and warrants further investigation.

Phenomic, convergent functional genomic, and biomarker studies in a stress-reactive genetic animal model of bipolar disorder and co-morbid alcoholism

We had previously identified the clock gene D-box binding protein (Dbp) as a potential candidate gene for bipolar disorder and for alcoholism, using a Convergent Functional Genomics (CFG) approach. Here we report that mice with a homozygous deletion of DBP have lower locomotor activity, blunted responses to stimulants, and gain less weight over time. In response to a chronic stress paradigm, these mice exhibit a diametric switch in these phenotypes. DBP knockout mice are also activated by sleep deprivation, similar to bipolar patients, and that activation is prevented by treatment with the mood stabilizer drug valproate. Moreover, these mice show increased alcohol intake following exposure to stress. Microarray studies of brain and blood reveal a pattern of gene expression changes that may explain the observed phenotypes. CFG analysis of the gene expression changes identified a series of novel candidate genes and blood biomarkers for bipolar disorder, alcoholism, and stress reactivity.

Recurrent multifocal primary amyloidosis of urinary bladder

Primary localized amyloidosis of bladder is rare. We report a case of recurrence of multifocal primary amyloidosis of urinary bladder. Cystoscopy revealed a diffuse left lateral wall lesion with normal surrounding mucosa. Histopathological examination of the specimen revealed urinary bladder amyloidosis with negative surgical margins. Recurrent urinary bladder amyloidosis was confirmed 3 months after the first resection. Close follow-up is recommended.

Atypical cystic meningioma of the trigeminal nerve in a pediatric patient

SUMMARY

We report an unusual case of atypical cystic meningioma of the trigeminal nerve proved by histology in a 15-year-old white girl. A review of the literature showed that this is only the second reported case of a meningioma of the trigeminal nerve without dural attachment and the first occurrence in a pediatric patient.

Immunoexpression of constitutive and inducible cyclo-oxygenase isoforms in the rat foetal and maternal digestive tract

Cyclo-oxygenase (COX), which catalyses the conversion of arachidonic acid to prostaglandin endoperoxide and prostanoids, is widely expressed in mammalian organs. The aim of the study was to evaluate the immunoexpression of the constitutive and inducible cyclo-oxygenase isoforms (COX-1 and COX-2 respectively) in the oesophagus, stomach and the small and large bowels of untreated rat dams and foetuses on gestational day 21. The localisation of the COX isoforms was similar in the maternal and foetal organs, although the intensity of the reaction for COX-2 was stronger in the foetuses. Cytoplasmic COX-1 immunostaining was found in myocytes of the muscularis propria, muscularis mucosae and the blood vessels. It was also positive in the endothelial cells, scattered stromal cells of the lamina propria and the ganglion cells of the nerve plexus in the bowels. Apart from the keratinised layer, a strong reaction was revealed in the stratified squamous epithelium of the oesophagus and forestomach. Negative or weakly positive staining was found in the mucus-secreting cells covering the surface, gastric pits and pyloric glands, as well as in the parietal cells and the chief cells. Weakly positive COX-1 immunostaining was observed in epithelial cells of the small intestine crypts, but in some cases enterocytes and goblet cells covering villi were also positive. In the colonic mucosa weak COX-1 staining was typical of the absorptive, and goblet cells. The COX-2 immunostaining was nuclear and/or cytoplasmic. An inconsistent positive reaction was seen in the muscle of the muscularis mucosae, muscularis propria and the blood vessels. Positive staining was also found in scattered stromal cells of the lamina propria and adventitia and the ganglion cells. Weak nuclear staining was found in the stratified squamous epithelium of the oesophagus and forestomach. Unlike the strong foetal reactivity in the epithelial cells of the glandular stomach, a negative or weakly positive reaction was seen in the maternal parietal and/or mucous-secreting surface stomach cells. Some epithelial cells of the crypts both in the small and large bowel were also COX-2 positive. In conclusion, constitutive and inducible COX isoforms were detected in the digestive tract of pregnant female and in foetuses. COX-1 was the predominant isoform in both the adult and foetal organs.

Epstein-Barr virus genotypes in multiple sclerosis

BACKGROUND

Multiple sclerosis (MS) is associated with Epstein-Barr virus (EBV) infection, but the relationship between the virus and the disease is not clear. As many different types of EBV exist, it is possible that MS is caused by one particular type of EBV. Objectives - The aim of this study was to determine whether MS is associated with a particular genotype of EBV.

MATERIALS AND METHODS

We collected blood from MS patients and controls, amplified and sequenced the latent membrane protein-1 (LMP-1) gene, and compared the groups.

RESULTS

We found a variety of LMP-1 sequences in both MS and controls, with no significant differences between the groups. Conclusion - We conclude that MS is not associated with a particular genotype of EBV.

Open access colonoscopy in the training setting: which factors affect patient satisfaction and pain?

BACKGROUND AND STUDY AIM

Patient satisfaction with colonoscopy is important for quality assurance; it may be affected by various factors, including patient characteristics, physician training level, and procedural or organizational features. We aimed to analyze how these factors influenced patient satisfaction and pain in an outpatient training setting.

METHODS

Consecutive patients for open access colonoscopy (OAC) were enrolled in a prospective, single-blinded, controlled study. Primary and secondary outcomes were satisfaction and pain scores with and without trainee participation. A multivariate analysis was designed to achieve an 80 % power with an alpha value of 0.05.

RESULTS

368 patients were enrolled. Satisfaction with the procedure was high (mean score 1.36; 1 = best to 5 = worst). In the multivariate analysis only waiting time in the endoscopy suite was significantly associated with lower satisfaction scores ( P = 0.024). Satisfaction was unaffected by patient factors (gender, American Society of Anesthesiologists' [ASA] score, anxiety, etc). Higher pain scores were associated with higher anxiety levels ( P = 0.02), female gender ( P = 0.02), longer procedure ( P< 0.001), and lower sedation levels ( P = 0.001); trainee involvement (49 % of procedures) did not adversely affect satisfaction or pain scores.

CONCLUSIONS

Patient satisfaction with OAC using sedation appears to depend primarily on organizational factors (waiting time beforehand). In contrast, pain is associated with patient characteristics (female gender, anxiety) and procedural factors (lower sedation, longer procedure). Trainee participation did not affect satisfaction or pain scores, a finding which may help to reassure patients undergoing OAC with trainee participation.

Interventions for replacing missing teeth: hyperbaric oxygen therapy for irradiated patients who require dental implants

BACKGROUND

Dental implants offer one way to replace missing teeth. Patients who have undergone radiotherapy and those that have also undergone surgery for cancer in the head and neck region may benefit particularly from reconstruction with implants. Hyperbaric oxygen therapy (HBO) has been advocated to improve the success of implant treatment in patients who have undergone radiotherapy but this remains a controversial issue.

OBJECTIVES

To compare success, morbidity, patient satisfaction and cost effectiveness of dental implant treatment carried out with and without HBO in irradiated patients.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Handsearching included several dental journals. We checked the bibliographies of relevant clinical trials and review articles for studies outside the handsearched journals. We wrote to authors of the identified randomised controlled trials (RCTs), to more than 55 oral implant manufacturers; we used personal contacts and we asked on an internet discussion group in an attempt to identify unpublished or ongoing RCTs. No language restriction was applied. The last electronic search was conducted on 13 June 2007.

SELECTION CRITERIA

Randomised controlled trials of HBO therapy for irradiated patients requiring dental implants.

DATA COLLECTION AND ANALYSIS

Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Results were expressed as random-effects models using mean differences for continuous outcomes and risk ratios for dichotomous outcomes with 95% confidence intervals.

MAIN RESULTS

Only one RCT was identified and included. Thirteen patients received HBO therapy while other 13 did not. Two to six implants were placed in fully edentulous mandibles to be rehabilitated with bar-retained overdentures. One year after implant loading four patients died from each group. One patient, treated with HBO, developed an osteoradionecrosis and lost all implants so the prosthesis could not be provided. Five patients in the HBO group had at least one implant failure versus two in the control group. There were no statistically significant differences for prosthesis and implant failures, postoperative complications and patient satisfaction between the two groups.

AUTHORS' CONCLUSIONS

Despite the limited amount of clinical research available, it appears that HBO therapy in irradiated patients requiring dental implants may not offer any appreciable clinical benefits. There is a definite need for more RCTs to ascertain the effectiveness of HBO in irradiated patients requiring dental implants. These trials ought to be of a high quality and reported as recommended by the CONSORT statement (http://www.consort-statement.org/). Each clinical centre may have limited numbers of patients and it is likely that trials will need to be multicentred.