Urine collection methods used for non-toilet-trained children in pediatric emergency departments in France: A medical practice analysis

INTRODUCTION

Since April 2015, the French Society of Pediatrics has encouraged suprapubic aspiration (SA) and urethral catheterization (UC) for urine collection in non-toilet-trained children suspected of having urinary tract infections (UTIs) and has tried to reduce the use of urine bag (UB).

OBJECTIVE

To analyze the medical practices concerning urine collection methods used for non-toilet-trained children in pediatric emergency departments in France.

METHODS

We conducted a descriptive medical practice study in October 2017. All members of the French Society of Pediatric Nephrology received two questionnaires about urine collection methods used for non-toilet-trained children, distinguishing between male and female patients, and about the corresponding analgesic protocols used in their pediatric emergency departments.

RESULTS

In total, 26 centers completed questionnaires concerning female patients. UC was performed in cases of fever associated with urinary tract malformations in 14 of 26 centers (54%). UB was used in cases of fever of unknown origin lasting for more than 48h in 17 of 26 centers (65%), in cases of fever associated with UTI symptoms in 14 of 26 centers (54%), and in cases of fever in infants under 3 months of age in 16 of 26 centers (61%). The questionnaires concerning male patients were completed by 30 centers. UB was the initially used urine collection method in all situations with, respectively, 22 of 30 (73%), 27 of 30 (90%), 23 of 30 (77%), and 22 of 30 (73%) centers. The analgesic protocol for urine collection is not well established in France.

CONCLUSION

UC for urine collection in pediatric emergency departments in France is underused despite the national recommendations and the greater diagnostic power of this method compared with UB.

CYP24A1 Mutations in a Cohort of Hypercalcemic Patients: Evidence for a Recessive Trait

CONTEXT

Loss-of-function mutations of CYP24A1 (which encodes the 25-OH-D3-24-hydroxylase) have recently been reported to cause hypercalcemia.

OBJECTIVES

The aims of this study were: 1) to evaluate the frequency of CYP24A1 mutations in patients with medical history of hypercalcemia; 2) to show the clinical utility of a simultaneous assay of serum 25-hydroxyvitamin D3 (25-OH-D3) and 24,25-dihydroxyvitamin D3 (24,25-[OH]2D3) by liquid chromatography tandem mass spectrometry (LC-MS/MS); and 3) to investigate biochemical parameters in heterozygous gene carriers with CYP24A1 mutations.

PATIENTS AND METHODS

We screened for CYP24A1 mutations in 72 patients with serum calcium levels > 2.6 mmol/L and PTH levels < 20 pg/mL and recruited 24 relatives after genetic counseling for subsequent investigations. Vitamin D metabolite concentrations were assessed in a subset of patients by LC-MS/MS and results expressed as a ratio (R) of 25-OH-D3:24,25-(OH)2D3.

RESULTS

Twenty-five patients with hypercalcemia (35%) harbored CYP24A1 variations. Twenty (28%) had biallelic variations, mostly found in subjects with nephrocalcinosis or renal stones (19/20). Five patients, all neonates, were heterozygous, without renal disease. We describe 15 new variations leading to loss-of-function according to pathogenicity prediction programs, and we functionally characterized 5 of them in vitro. A dramatic increase of R, usually >80, was found in patients harboring biallelic mutations providing evidence in vivo for the loss of CYP24A1 activity. In contrast, R value remains <25 in patients without CYP24A1 mutations. Subjects carrying one mutant allele, hypercalcemic individuals, as well as gene-carrier relatives, had a detectable 24,25-(OH)2D3 level and R < 25, indicating normal 24-hydroxylase activity.

CONCLUSION

CYP24A1 biallelic mutations are frequently found in patients presenting with hypercalcemia, low PTH, and renal disease. We confirm the accuracy and effectiveness of a novel blood test estimating the ratio between relevant vitamin D metabolites as a useful screening tool for CYP24A1 mutations. Haploinsufficiency is not associated with CYP24A1 deficiency.

Failure of bortezomib to cure acute antibody-mediated rejection in a non-compliant renal transplant patient

Bortezomib has appeared recently as a potential active treatment for acute AMR for few years. We reported a patient who received two courses of bortezomib for the treatment of an acute AMR associated with de novo HLA DSA that occurred 18 months after renal transplantation because of non-compliance. Graft biopsy revealed features of acute humoral rejection with plasmocyte infiltration and C4d staining. Bortezomib was associated with corticosteroid pulses, IVIgs, and PP. Despite this rapid management, the patient lost his graft and carried on dialysis. Bortezomib therapy in addition to current therapy of AMR is not always effective in the treatment for late acute AMR in renal transplantation. We discuss on the place of such a treatment and other therapeutic strategies in this indication.

[Haemophilus meningitis in properly vaccinated children: report of three cases]

The 1993 introduction in France of the vaccine against the serotype b of Haemophilus influenzae (Hib) resulted in a fast reduction of invasive infections caused by this species. However, despite the introduction of a booster dose, cases of Hib meningitis can still be observed, even if they are exceptional. We report here on 3 cases of Hib meningitis observed at Rennes University Hospital, which occurred during the winter seasons between 2007 and 2010, in properly vaccinated infants and children aged 9, 14, and 29 months. Progression after treatment was satisfactory in all 3 cases, and no immune deficiency was detected. After 18 years of the vaccination policy in France, these observations demonstrate that a risk, although much lower, of Hib meningitis persists in infants and children, including in vaccinated patients, and that strains still are circulating within the general population.

[Results of autopsy examination of the knee cartilage of 120 patients dying in the hospital. II. The femoro-tibial joint]

The authors have studied the autopsy results of both tibio-femoral joints in 120 patients: 57 women and 63 men, 112 of whom were over the age of 50. The condylar and tibial cartilages were classified into 5 categories: no lesion (0); slight fissure (I); severe fissure (II); slight deep ulceration (III); large ulceration (in more than 25 p. cent of the cartilage surface) exposing the sub-chondral bone (IV). In 120 patients, the 4 condyles in 58 patients (43.8 p. cent) and both tibio-femoral joints in 51 patients (42.5 p. cent) did not present any degenerative lesions beyond stage I. Stage III and IV cartilaginous lesions are rare before the age of 50. Their frequency suddenly increases after the ages of 70 in women and 80 in men. 44 p. cent of women and 31 p. cent of men presented tibio-femoral cartilaginous lesions of stages II or IV in at least one knee; 15.8 p. cent of women and 4.7 p. cent of men presented tibio-femoral lesions, stage IV, in at least one knee. In 58 p. cent of stage III and IV knee lesions, the menisci were abnormal: atrophic or torn. A menisco-chondrocalcinosis was found in 50 knees (20.8 p. cent of knees) of 28 patients (23.3 p. cent of patients). After the age of 60, the cartilaginous lesions were more severe and more extended in knees with menisco-chondrocalcinosis).

Solitary plasmacytoma of the spine. Long-term clinical course

The data for 19 patients with solitary plasmacytoma of the spine were reviewed with regard to clinical course and prognosis (median follow-up, 96 months). Eight patients presented with spinal cord compression. A monoclonal immunoglobulin was initially detected in seven of 15 evaluable patients. Treatment included radiotherapy (18 of 19) and/or surgery (11 of 19) and chemotherapy (eight of 19). Spinal cord compression was reversed in every patient. The expected survival rate was 85% at 10 years after diagnosis. Local recurrence or dissemination was observed in 13 patients. It occurred within 5 years of diagnosis in 11 patients and was localized (that is, local recurrence or single bone metastasis) in eight patients. It was always associated with the appearance or an increase of the M component. Dissemination frequently had a "metastatic" pattern with no diffuse bone marrow plasmacytosis. The incidence of local recurrence (five patients) and leukemia (four patients) was high. Local recurrence and/or dissemination were significantly more frequent in patients with the M component at diagnosis than in those without it (P less than 0.05; relative risk, R = 4). The effectiveness of surgery and chemotherapy combined with radiotherapy is also discussed.

[Lupus disease with antinuclear antibodies of the nucleolar type. Apropos of a series of 13 cases]

An exclusive or predominant nucleolar location of antinuclear antibodies is rare in the course of lupus disease: less than 1 p. cent of our patients. Thirteen cases of lupus disease with exclusive or predominant antinucleolar antibodies are analyzed: clinically, the only difference from other lupus diseases is the absence of pleurisy (p less than 0.03) and the frequent thrombopenia (p = 0.05). A proliferative glomerular lesion was found 4 times on renal biopsy. No patient presented any indications of overlapping sign with sclerodermia, polymyositis or Gougerot-Sjögren syndrome which are usually associated to a nuclear fluorescence of nucleolar type. 11 out of 13 patients have natural anti-DNA antibodies, including 9 with a very weak titer. Six patients present cytoplasmic anti-organic antibodies. Four patients have antibodies which precipitates on gelose, identifying nuclear or cytoplasmic antibodies: in 1 instance anti-SS-B et SS-A (Ro), in 1 instance anti-ribosomes associated with anti-ADN, in one instance anti-DNA. No serum contained anti-histones antibodies. The study of the sensitivity of nucleolar antigens to digestion by various enzymes (DNAse, RNAse and trypsin) showed that antinucleolar sera could be placed into three groups: 8/10 recognize a ribonucleic antigen, 1/10 a ribonucleoproteic antigen and 1/10 an antigen resisting to various enzymatic digestions. Therefore, in spite of its rarity, an exclusively nucleolar fluorescence should not rule out the diagnosis of lupus disease.

Anti-mitochondrial type 5 antibodies and anti-cardiolipin antibodies in systemic lupus erythematosus and auto-immune diseases

Twenty sera from patients with systemic lupus erythematosus (SLE) and high titre of IgG anti-cardiolipin antibodies (ACA) were studied in order to evaluate the prevalence of anti-mitochondrial type 5 antibodies (AMA 5). None of these sera were found to be AMA 5 positive but five of 18 were positive for VDRL. Twenty sera from patients with AMA 5 were studied in order to evaluate the prevalence of ACA: only six of 20 were positive for ACA. In contrast to this finding, 15 of the 20 sera positive for AMA 5 were also positive for VDRL (P less than 0.001). The six sera positive for ACA and AMA 5 were absorbed with cardiolipin micelles. This absorption eliminated the ACA activity but not the AMA 5 activity. Despite the clinical similarities between the two groups of patients with AMA 5 or ACA, these data suggest that patients with AMA 5 and patients with ACA belong to two different subsets of SLE or SLE-like syndromes and that AMA 5 antigen is different from cardiolipin.

Profile and cross-reactivities of antiphospholipid antibodies in systemic lupus erythematosus and syphilis

Antiphospholipid antibodies have been determined in two groups of 48 sera from patients with systemic lupus erythematosus (SLE) and syphilis. Using an ELISA, IgG anticardiolipin (CL), antiphosphatidyl serine (PS) and antiphosphatidyl ethanolamine (PEA), antibodies have been detected with the same frequency in both groups of patients. Titres of antiphosphatidyl serine (PS) (p less than 0.005) and PEA antibodies (p less than 0.05) were significantly higher in the syphilitic sera compared to the SLE sera. Anticardiolipin binding activity of both groups of sera could be inhibited by preincubation with phosphatidic acid, phosphatidyl serine, phosphatidyl glycerol and cardiolipin antigens, but the inhibiting ratio of phosphatidyl antigen was significantly higher (p less than 0.01) in the SLE group. These data suggest that anticardiolipin auto-antibodies present in SLE sera are very similar to the "reagins" or antibodies to cardiolipin seen in syphilitic sera. IgG anticardiolipin antibodies may be an epiphenomenon and are probably not implicated in the pathogenesis of the thrombotic diathesis seen preferentially in some patients with SLE.

Antiphospholipid antibodies: a disease marker in 25 patients with antinuclear antibody negative systemic lupus erythematosus (SLE). Comparison with a group of 91 patients with antinuclear antibody positive SLE

Twenty-five antinuclear antibody (ANA) negative patients with systemic lupus erythematosus (SLE) or lupus-like disease were compared to 91 ANA positive patients with SLE for clinical and biological symptoms. Cutaneous symptoms were infrequent in ANA negative patients (p less than 0.03). Thrombocytopenia (p less than 0.001), venous or arterial thrombosis (p less than 0.02) as well as cerebral infarction (p less than 0.001) were more frequent. Three types of antiphospholipid antibodies were determined by different methods; the VDRL, the lupus anticoagulant and an ELISA for IgG anticardiolipin antibody (aCL). The frequency of a positive VDRL test was significantly higher in the ANA negative group (p less than 0.05). Correlation studies suggest that the 3 methods are not redundant and detect overlapping but not identical antibodies. Of the 3 antiphospholipid antibody assays, only the IgG aCL test was significantly associated with thrombosis in the ANA negative group (p less than 0.02).

HLA haplotypes in non-familial rheumatoid arthritis

The frequencies of HLA-A, B, C, DR, and BF haplotypes in 44 unrelated Caucasian patients with definite seropositive rheumatoid arthritis (RA) were compared with haplotype frequencies in controls. Overall, the patients had an increased risk for HLA-DR4, DR3, and DR2 antigens, but frequencies of certain DR4 or DR3 haplotypes were not increased, suggesting the importance of other HLA loci for the evaluation of risk. The presence of DR4 alone was not found to produce an increased risk for RA since the frequencies of certain DR4 haplotypes were similar in patients and controls. Increased frequencies of HLA-B18, DR4, HLA-B15, DR4, and HLA-A1, B8, Cw7, DR3 haplotypes were found in patients. RA susceptibility has been found to be associated with the last two haplotypes in some studies of multiple case families, suggesting that similar genetic mechanisms may underlie the disease in familial and sporadic forms.

[The principle antinuclear and anti-cytoplasmic antibodies in polymyositis and dermatomyositis. Study of 42 cases]

Using indirect immunofluorescence methods on rat liver sections and HEp-2 cells, combined with immunoprecipitation in agar, we were able to detect antinuclear antibodies in 76% of sera from 42 patients with polymyositis or dermatomyositis. In addition, 7% of the patients had anti-cytoplasmic antibodies without antinuclear antibodies. With immunofluorescence, the most common pattern was a nuclear fluorescence that was homogeneous on rat liver sections (11 cases) and speckled on HEp-2 smears (16 cases). The frequency of antinuclear antibodies was the same in the different categories of myositis as classified by Pearson. Precipitating antibodies were observed in 15 cases (36%). Two specific antibodies were frequently encountered: anti-Jo1 in 8 cases (19%) and anti-Pm-Scl in 5 cases (12%). Anti-Jo1 antibodies were present in both polymyositis and dermatomyositis. Seven out of the 8 patients with anti-Jo1 antibodies had pulmonary fibrosis (P less than 0.03).

[Alizarin red staining of articular fluids. Comparison of the results with electron microscopy and clinical data]

Coloration of articular fluids with alizarin S red has been proposed as a method of sensitive detection of calcium microcrystals, especially apatite crystals. We are reporting the results of a study of 230 non-selected fluids. The results of the coloration were quantified into negative, slightly positive, moderately positive and strongly positive. Study of X-Rays of the tapped joint and of the hospital file was done in 199 patients. Electron microscope study, of 44 fluid samples, shows that the coloration with alizarin red permits a reliable detection of calcium microcrystals in the articular fluid, only if the strongly positive results are taken into account. But the coloration is not specific for apatite: 5 strongly positive fluids out of 14 contain only, in electron microscopy, crystals of dihydrated calcium pyrophosphate. 10.8% of the stained fluids give a strongly positive result. In two cases, it concerns destructive arthropathies of the shoulder with periarticular calcifications. The other strongly positive results are found in chondrocalcinosis (52 p. cent), in arthrosis (17 p. cent) and in rheumatoid polyarthritis (15 p. cent). As a whole, the results are correlated with age and the degree of radiological destruction. The similar percentage of strongly positive fluids observed in arthrosis and rheumatoid polyarthritis, is not in favor of a specific role of apatite microcrystals in the pathogenesis of arthrosis. Since the majority of strongly positive fluids come from joints which are very destroyed, regardless of the arthropathy concerned (rheumatoid polyarthritis, chondrocalcinosis or arthrosis), it is possible to think that it is mostly the destruction of the sub-chondral bone which explains these results.

Bone histological heterogeneity in postmenopausal osteoporosis: a sequential histomorphometric study

We studied sequential bone biopsies performed at 6 to 24 month intervals from 14 untreated osteoporotic women (64 +/- 7). Subgroups were defined, respectively, by increased osteoclastic resorption surfaces and decreased osteoblastic surfaces +/- 2 S.D. Normal values were obtained from bone biopsy of 23 normal women (61 +/- 8). When patients were divided into subgroups according to the above criteria the first biopsy showed that 3 out of the 14 patients had high resorption surfaces and 6 had low osteoblastic surfaces. Eight patients spontaneously changed during the study. In 2 patients there was a change in resorption surfaces, in 3 in osteoblastic surfaces and in 3 a change in both osteoblastic and resorption surfaces was observed. Considering the first or second bone biopsy results the patient variance was higher than the control subject's variance; however the variance between the first and second bone biopsy of one patient was not different from the variance inside the group of patients. The average intraindividual variation of the parameters on sequential biopsies was of the same order as the one we previously observed on simultaneous bone biopsies of normal and hemodialyzed patients. We concluded that if osteoporosis is a heterogeneous disorder, subgroups cannot be definitively defined on the basis of cellular parameters of bone remodelling assessed on bone biopsies.

[Occult fractures of the sacrum in aged osteoporotic patients]

We are reporting 4 cases of unnoticed sacral fractures in osteoporotic women. Their mean age was 73 years. Only in one case the fracture was seen on a standard X-Ray. On the other hand, hyperfixation with isotopes on the sacrum formed a very characteristic H-shaped image. In two of these patients, the sacral fracture was confirmed by tomodensitometry, but this examination was unavailing in the third patient. In the 4th case, hyperfixation of the isotope was not significant. Only a guided bone biopsy and the favorable evolution of the disease enabled the diagnosis of sacral fracture.

[Results of autopsy examination of knee cartilage in 120 patients dying in the hospital. I. Femoro-patellar joint]

The authors have performed the pathological examination of the knees of 57 women and 63 men or 112 patients over the age of 50, who died in the hospital. The lesions of the patellar and trochlear cartilages were studied and classified according to four categories: stage I: non extended fissures; stage II: fissures extending over 25 p. cent of the articular surface; stage III: fissures associated with small deep ulcerations of the cartilage; stage IV: deeps and extended ulcerations of the articular cartilage exposing the sub-chondral bone. Cartilage alterations were found in 93.3 p. cent of the patellas; 26.2 p. cent of stage I; 22.5 p. cent of stage II, 27.1 p. cent of stage III; 17.5 p. cent of stage IV. These alterations are bilateral and symmetrical, most of the time. Their frequency and severity increase with age. Thus, deep and extended ulcerations (stage IV) of the patellar cartilage have a frequency of 1.9 p. cent before the age of 60.8 p. cent between 60 and 70 years, 13.6 p. cent between 70 and 80 years and 38.9 p. cent after 80 years. Alterations of the patellar cartilage are more frequent and more severe in women than in men. In 85.7 of the patellas they occupy both facets, overriding the patellar crest; more seldom, they are exclusively localized to the medial patellar facet (11.6 p. cent) or lateral facet (3.1 p. cent). Alterations of the trochlear cartilage, although more common are less frequent than that of the patellar cartilages. Patellar osteophytosis is very frequent.(ABSTRACT TRUNCATED AT 250 WORDS)

[HLA system and complications of the treatment of rheumatoid polyarthritis with D-penicillamine]

The data of the literature concerning the relationship between complications of D-penicillamine treatment and the HLA system are discussed. This relationship particularly concerns the renal complications which are associated with HLA antigens B8 and DR3, although this relation is not sufficiently strong to be used in practice in the indications for treatment with D-penicillamine.

[Antiphospholipid antibodies, thrombosis and lupus disease. Value of the assay of anticardiolipin antibodies by the ELISA technic]

The authors have developed a sensitive immunoenzymatic method for assaying anti-cardiolipin antibodies in the serum of patients with lupus (SLE). These antibodies were present in the serum of 43/108 SLE patients, particularly in those patients with either false syphilis serology (p less than 0.02) or circulating anticoagulant (p less than 0.05). The mean titre of anti-cardiolipin antibodies was higher in the group with positive VDRL (less than 0.03). The anti-cardiolipin antibody titre was independent of the anti-native DNA antibody titre, but there was a correlation with the anti-denatured DNA antibody titre (p less than 0.02). This correlation can be partially explained by the antigenic similarity (phosphodiester bridge) between the two molecules. The preliminary clinical studies have not shown any correlation between the presence of anti-cardiolipin antibodies and the presence of signs such as thrombocytopenia, haemolysis, cerebral vascular accident, venous thrombosis, recurrent abortion. A longitudinal study of certain patients suggests that the anti-cardiolipin antibodies may disappear at the time of thrombotic accidents, which induces fixation of these antibodies to a platelet or vascular target and as a result of corticosteroid therapy.

Osteoclast abnormalities in idiopathic osteopetrosis. Reference to the ultrastructural histochemistry study

In order to investigate skeletal abnormalities in a case of idiopathic osteopetrosis, a bone biopsy was taken from the anterior iliac crest and prepared for ultrastructural and histochemical study. There was a drastic reduction in osteoclastic bone resorption. The ruffle border and sealing zone, which are the osteoclast cell surface markers of bone resorption, were absent. The cells were highly vacuolated, and the vacuoles contained large amounts of a residual organic material which reacted strongly with acid phosphatase. Acid phosphatase activity was never found outside the cell, and in particular, not at the bone-cell interface. This suggests that the defect in bone resorption is caused by cell membrane abnormalities and the lack of ruffle border formation, rather than the inability of the lysosomal enzymes to digest the bone matrix.

Amyloid deposits in human knee and hip joints

A systematic search for articular amyloidosis was carried out on both knees of 53 autopsy cases and on 26 femoral heads resected during surgery for hip prosthesis. Typical amyloid deposits exhibiting green apple birefringence following Congo red staining and thioflavin T fluorescence were found in 58.5% and 29% of the cases, in the knee and hip joint respectively. They occurred more frequently in articular cartilage than in the synovium, and in elderly subjects more than young ones. In the knee joint, the osteoarthritic changes and to a minor extent synovial inflammation appear to be positively correlated for the presence of intraarticular amyloid deposits. Such a correlation was not observed for the presence of calcium pyrophosphate dihydrate crystal deposits.

HLA antigens and seronegative rheumatoid arthritis

HLA antigens and clinical features in a series of 46 Caucasian patients (40 females, 6 males) and definite repeatedly seronegative rheumatoid arthritis (RA) of more than two years' duration (mean 11.6 years) were compared with those in 77 seropositive RA patients and 110 controls of the same ethnic and geographic origin. Seronegative RA appeared to be less often erosive than seropositive RA, and seronegative patients had fewer extra-articular features. The frequency of the HLA antigen DR1 was raised in seronegative patients as compared with controls (p = 0.006, relative risk = 3) and with seropositive patients (p less than 0.05). HLA-DR4 was slightly increased in seronegative patients compared with controls (p less than 0.05) but was clearly less so than in seropositive patients (p less than 0.005). Early onset of disease was very significantly associated with HLA-DR1 in seronegative patients (p = 0.007), whereas HLA-DR4 was present more frequently in seropositive patients with onset prior to age 35 (p less than 0.05). No correlation between HLA antigens and intolerance to drugs was found in seronegative patients, whereas in seropositive patients side effects to gold salts were associated with DR3. These results suggest that seropositive and seronegative RA have distinct HLA-DR associations, especially in disease of early onset, in addition to well established clinical differences.

[Determination of anti-native DNA antibodies by immunofluorescence on Crithidia luciliae. Correlation between renal involvement and the presence of high-avidity anti-native DNA antibodies in lupic disease]

Low avidity native DNA - anti-native DNA complexes dissociate at alkaline pH and in high molarity solutions. This property was used to modify the indirect immunofluorescence reaction on Crithidia luciliae in order to assay high avidity anti-native DNA antibodies resistant to alkaline and strongly saline solutions. Assays were performed in the sera of 36 patients (31 women and 5 men) with systemic lupus erythematosus (SLE). Seventeen of these patients had histologically significant lupus nephritis (WHO types III, IV and V) and 19 had no renal, urinary or biochemical abnormalities. The mean titer of total anti-native DNA antibodies was similar in both groups, but the titer of high avidity anti-native DNA antibodies was significantly higher in patients with lupus nephritis. The percentage of patients with high avidity antibodies was 87% in the group with renal involvement and 28% in the group with no kidneys involvement. Thus, lupus nephritis should be feared when anti-native DNA antibodies with high dissociation constant are found in the sera of SLE patients.

[Cellular aspects of the aging of the articular cartilage. II. Condylar cartilage with fissured surface taken from normal and arthritic knees]

The authors studied the cellular density (number of cells per mm2) of cartilage taken from the femoral condyles of 46 cadavers (73 knees). In each case, the cartilage was taken from the summit of the condyle and, in 46 joints (27 subjects), a sample was also taken from the posterior surface (non weight-bearing zones). The fragments of non-calcified cartilage were sectioned with a cryostat and the sections (10 micrometers) were stained with hematein-eosin and solid red-Alcian blue. This study demonstrates: 1) a decrease in the cellular density of fissured cartilage compared to normal cartilage; this decrease appears to be proportional to the degree of fibrillation; 2) a decrease in the cellular density of apparently normal cartilage from arthrotic joints compared with normal cartilage from healthy joints; 3) with the age of the subjects, an increase in the density of the clones (number of clones per mm2) and the density of clonal cells (number of clonal cells per mm2) together with a decrease in the mean number of chondrocytes per clone. In fissured cartilage, the density of the clones, the density of the clonal cells and the number of chondrocytes per clone are slightly higher on the posterior surface of the condyles than on the summit of the condyles. These results emphasise the importance of the role that might be played by cellular phenomena in the mechanisms of deterioration of cartilage with aging and with arthrosis.

[Cellular aspects of the aging of articular cartilage. I. Condylar cartilage with a normal surface sampled from normal knees]

The authors studied the cellular density of articular cartilage taken from the femoral condyles of 77 autopsy subjects at Hôpital Lariboisière in Paris. This study showed a decrease in the cellular density (number of chondrocytes per mm2) going from the superficial zone towards the calcified zone of the cartilage in all layers, as a function of the age of the subjects. The decrease in cellular density is in the order of about 50% of the total chondrocyte number when subjects younger than 40 are compared with those older than 80. The demonstration of a regular increase in the number of empty lacunae per mm2 with the age of the subjects, i.e. lacunae without chondrocytes, suggest that the cause of this decrease in cellular density of the cartilage with age could be a physiological necrosis due to "exhaustion" of the chondrocytes. The metabolic activity of the chondrocytes may also decrease with age, as suggested by the increasing proportion of alcianophobic cells, cells which are weakly or not at all labeled by radioactive sulfates which indicate the sites of biosynthesis of proteoglycans. These cellular modifications could play a role of senile fibrillation of articular cartilage and in arthrosis.

Tumoral calcinosis: light and electron microscopic study with electron diffraction and x-ray microanalysis of the mineral deposit

Samples of deposits taken from sites close to articulations in a young black African suffering from tumoral calcinosis with hyperphosphoraemia were studied by light and electron microscopy techniques. Light microscopy demonstrated lesions of a foreign body granuloma type in contact with calcium salt deposits suggesting that the process was of an active nature. Electron microscopy, and the demonstration of acid phosphatase activity, led to the identification of two cell types: mono or multinuclear macrophage type cells which phagocytose the deposit, and fibroblastic type cells. No signs of damage to the microvessels or the interstitial collagen were noted which could serve as a basis or a physiopathological explanation of the deposition. The deposits were analysed by energy dispersive X-ray microanalysis and by electron diffraction and were considered to be hydroxyapatite.

[IgG-type antihistone antibodies. Diagnostic value in rheumatoid polyarthritis, scleroderma, spontaneous and drug-induced lupus]

IgG anti-histone antibodies were detected by indirect immunofluorescence in 6 out of 70 sera from rheumatoid arthritis with antinuclear factors, in 1 out of 13 from scleroderma, in 14 out of 25 from spontaneous systemic lupus erythematosus (SLE) and in 11 out of 14 from drug induced lupus. Rheumatoid arthritis patients with IgG anti-histone antibodies were characterized by the severity of joint involvement and by the high frequency of extraarticular features of the disease. SLE patients with anti-histone antibodies only differed from patients without such antibodies by a higher frequency of Raynaud phenomenon (p less than 0.05). Longitudinal studies of spontaneous SLE showed that IgG anti-histone antibodies correlated with disease activity (p less than 0.001). A significant correlation was demonstrated between anti-histone IgGs and anti-ds-DNA antibodies assessed by the Farr binding assay (p less than 0.0001). IgG anti-histone antibodies were rarely found in sera from patients with drug induced antinuclear antibodies without symptoms of SLE (1 out of 6 sera). In drug induced lupus, IgG anti-histone antibodies were found in the absence of high titers of anti-ds-DNA antibodies, and this discrepancy appeared to suggest the diagnosis of drug induced lupus. Finally, anti-histone antibodies were present in 5 out of 7 sera from acebutolol induced lupus.

Extended treatment of primary osteoporosis by sodium fluoride combined with 25 hydroxycholecalciferol

Nineteen patients suffering from primary osteoporosis, all having at least one vertebral collapse, initially received 50 mg of sodium fluoride alone per day for 6-18 months. Subsequently fluoride was associated with 25-50 micrograms of 25 OH cholecalciferol (calcifediol) per day for 6-18 months in 12 of these patients and 9 were treated for 31-58 months. As control group, 9 patients were given placebo for 6-18 months. The effect of the treatment was assessed by three methods: 1) the metacarpal index (MI) determined by radiogrammetry, 2) the calcium content of the hand bone (Ca) measured by local neutron activation, 3) the iliac bone histomorphometry. MI and (Ca) did not change significantly at any time in any group. In each group there was a significant increase in trabecular bone volume, osteoid volume, osteoid surfaces and a significant decrease in mineralization fronts. On the other hand, the changes in osteoblastic surfaces, osteoclastic surfaces, number of osteoclasts/mm2 were not significant in any group. No change was observed in the placebo group. These data suggest that the increase in the trabecular volume of fluorided bone is mainly due to the increase in osteoid which itself is due to a bone mineralization defect despite the association of calcifediol. This is probably one of the reasons why (Ca) does not change significantly.

[Changes in vascular endothelial cells induced by serum from scleroderma and other connective tissue diseases]

The growth inhibition of in vitro vascular endothelial cell cultures by sera from patients with connective tissue disease was studied. Seven out of 30 sera from patients with progressive systemic sclerosis (PSS) exhibited a cytotoxic effect. The cytotoxic serum factor(s) was not specific to patients with symptoms (11 out of 27 sera from patients with a mixed connective tissue disease, MCTD; 5 out of 34 sera from patients with a systemic lupus erythematosus, SLE). The cytotoxic effect was not specific for vascular endothelial cells, it was also found on fibroblast cells cultures. Inhibitor(s) of cell growth in vitro was independent of antinuclear and anticytoplasmic antibodies and appeared as a common feature of all connective tissue disease with vascular symptoms.

HLA-DR genotype risks in seropositive rheumatoid arthritis

We studied the distribution of HLA-A, B, C, and -DR antigens in 77 Caucasian patients with sero-positive rheumatoid arthritis. Forty-four patients were genotyped and compared with the control panel of 110 unrelated Caucasian genotyped donors. The data obtained confirm the association of DR4 with RA, and reveal an increased risk of disease for patients carrying DR1, DR2, and DR3, compared to the risk for those carrying other antigens, such as DR5, DRw6, and DR7. There is a higher risk for DR4/4 homozygotes than for DR4/1, DR4/2, or DR4/3 heterozygotes. DR4/5, DR4/6, and DR4/7 have a lower risk than the previously mentioned genotypes. The genotype risks are compatible with the inheritance of a single, linked genetic determinant of disease susceptibility, but we are unable to distinguish between recessive and dominant inheritance of susceptibility using the "antigen-frequencies-amongst-diseases" method. DR4 seems to be more frequent in patients in whom onset occurs before the age of 35 (79% vs. 54% DR4 positive). A significant excess of DR3 + is observed in patients with toxic complications following treatment with gold salts (X2(1) = 8.96).

[Levels of anti-nDNA using immunofluorescence on Crithidia luciliae. II. Prognostic value of complement-fixing anti-nDNA. Longitudinal study of 16 lupus disorders]

Measurements of the hemolytic complement level and titrations of anti dS DNA antibodies by immunofluorescence using Crithidia luciliae and by the Farr binding assay were performed in 13 females and 3 males suffering from systemic lupus erythematosus (SLE). In each patient, 2 to 5 serum samples were analyzed during a mean follow up time of 16.6 months. The complement fixing ability of the anti dS DNA antibodies was also investigated. In this longitudinal study the titers of the dS DNA antibodies detected by immunofluorescence correlated with the Farr binding assay results. Mean anti dS DNA antibody titers were significantly higher and CH 50 levels were lower when SLE was active. Among sera with anti dS DNA antibodies, only sera with high titers (greater than or equal to 1/80), fixed complement. Study of individual cases disclosed that an increase in complement fixing anti dS DNA antibodies could occur in the absence of disease activity. Sera from patients with severe organ involvement, in particular with nephritis had low titers of anti dS DNA antibodies with no complement fixation activity. There was no relationship between falls in serum complement level and the complement fixation ability of anti dS DNA antibodies. Thus, complement fixation capacity of anti dS DNA antibodies correlates better with antibody titer than with SLE severity or activity.

A study of microvasculature in normal and inflammatory synovial membranes in the rabbit using light and electron microscopy and freeze fracture

The Authors made a study of microvasculature in normal and inflammatory synovial membranes in the rabbit, by light and electron microscopy and with the use of freeze fracture. The synovial membrane of the knee was studied in 15 normal rabbits and in 22 rabbits in whom immunization with mycobacterium tuberculosis crude cytoplasmic water soluble extract had provoked inflammatory synovitis. A comparison between normal and inflammatory synovia by light microscopy showed, in inflammatory synovitis, a significant increase in the number of congested and obliterated microvessels (p less than 0.001) and in the number of endothelial nuclei per microvessel (p less than 0.0001). By electron microscopy no specific alteration of synovial microvessels was observed. A significant increase was found in the number of venules in inflammatory synovitis (p less than 0.01). The number of simple interendothelial tight junctions, defined by 1 or 2 interendothelial contacts, and of complex interendothelial tight junctions, defined by 3 or more interendothelial contacts, was similar in venules and in capillaries of inflammatory synovitis and of normal controls. The mean number and mean spacing of junctional strands in interendothelial tight junctions was similar in the microvessels of inflammatory synovitis and of normal controls. The Authors conclude that inflammation does not provoke specific alterations in synovial microvasculature but could induce an adaptative state resulting in increased synovial permeability.

[Determination of anti dsDNA antibodies by immunofluorescence using Crithidia luciliae. I--Diagnostic and prognostic value in systemic lupus erythematosus. Comparison with the Farr radioimmunoassay]

Antibodies to double stranded (ds) DNA were sought by the indirect immunofluorescence method using Crithidia luciliae in 196 sera from patients suffering from hepatic, thyroid or inflammatory rheumatic disorders. Anti ds DNA antibodies were demonstrated in 29 out of 45 systemic lupus erythematosus (SLE) sera. Lower titers were found in 3 out of 7 sera from drug-induced SLE, 2 out of 6 from mixed connective tissue diseases, 1 out of 60 from scleroderma, 2 from unclassified arthritis, 8 out of 40 from rheumatoid arthritis with antinuclear factors, and in 4 out of 15 sera from chronic hepatitis. For SLE diagnosis the sensitivity of the method was 73 percent, its specificity was 87 percent. 84 percent of these results were in agreement with those obtained with the Farr method, but titers did not correlate well. The sensitivity of the Farr method was 64.5 percent, its specificity was 85 percent. In this study, high titers of anti ds DNA antibodies demonstrated on Crithidia Luciliae did not correlate with disease severity. Low titers of anti14C labelled DNA antibodies demonstrated by the Farr assay correlated with inactive SLE without nephritis. The immunofluorescence assay using Crithidia luciliae is a valid method to detect anti ds DNA antibodies but does not allow prognostic conclusions in SLE.

[Phosphorus metabolism in a case of tumoral calcinosis]

Hyperphosphataemia with levels of 65 mg/l was found in a black African aged 20 with a 10-year history of tumour calcinosis. Levels of blood calcium, plasma ionised calcium, serum alkaline phosphatase, 24-hour urinary calcium and phosphate were all normal, as was renal function. Tubular phosphate reabsorption (TmP) was greater than 90 mg per litre of glomerular filtrate (N = 22-42). Levels of circulating parathyroid hormone, nephrogenic cAMP and serum vitamin D metabolites [25 OH D3, 24,25 (OH)2 D3 and 1,25 (OH)2 D3] were normal. The TmP fell by 36% on exogenous PTH stimulation (N = 30.25 +/- 6.7), and by 7.9% 120 min. after injection of acetazolamide. Our results confirm the conclusions of recent studies: patients with tumour calcinosis have disordered renal phosphate excretion with normal PTH secretion, normal PTH action on the renal tubule and normal vitamin D metabolism. In fact in these hyperphosphataemic patients, circulating 1,25 (OH)2 D3 levels would be expected to be low, whereas they were normal in our patient. An attempt at treatment with acetazolamide and phosphate chelating agents gave no significant results.

Lipid peroxides in human articular cartilage

The hypothesis that increased generation of lipid peroxides (LP) causes articular cartilage damage in older patients and in those with osteoarthritis was tested by directly measuring LP tissue levels in various layers of human articular cartilage. The LP content was significantly greater in the superficial than in the deeper portion of the cartilage, but lower in cartilage than in liver, kidney, adrenal glands and synovium. When LP were related to the total lipid content of these tissues, a high peroxide per lipid ratio was obtained for articular cartilage. The relevance of these findings to the mechanism of cartilage fibrillation is discussed.

Evidence for defective osteoblastic function. A role for alcohol and tobacco consumption in osteoporosis in middle-aged men

In a group of 11 men ranging in age from 35 to 50 years with idiopathic osteoporosis, most were mild alcoholics and heavy smokers. Two had absorptive hypercalciuria. Histomorphometry showed that the patients had low trabecular bone volume and mean trabecular thickness when compared with age-matched control subjects. Mean wall thickness was also markedly reduced in patients as compared with control subjects. The quantity of resorbed bone was extrapolated from the calculated mean interstitial bone thickness. Resorption was not significantly different in patients and control subjects. Consequently, in this group of patients with severe osteoporosis, the pathogenesis was characterized by markedly decreased bone formation.

Cell density of adult human femoral condylar articular cartilage. Joints with normal and fibrillated surfaces

Cell and clonal density, lacunar and clonal diameters, and mean number of cells per single clone were studied in human femoral condylar cartilage of normal and osteoarthrotic joints. The values were related to the age of the subjects, the sampling site within the joints, and the depth from the articular surface. Cell density in every zone of both normal and diseased tissue decreased with increasing distance from the surface and increasing age. Cell density was significantly lower in age-matched osteoarthritic articular cartilage with an intact surface than in that of normal joints. The age-related decrease in the cell density accompanied an increase in the density of empty lacunae. The density of Alcian blue-stained cells, which actively synthesize proteoglycans as demonstrated by histoautoradiography, diminished with advancing age in all zones of articular cartilage. The percentage of these cells consistently decreased in the superficial and increased in the deep layers of the tissue in both normal and osteoarthritic joints. The clonal density was higher in the nonweight-bearing than in weight-bearing areas, and it increased with age, whereas the mean clone diameter and clonal cell number decreased.

[Anti-collagen antibodies. Their detection in rheumatoid polyarthritis, chronic atrophic polychondritis and various chronic inflammatory rheumatism]

The authors administered by passive haemagglutination, natural or denatured type I and II anticollagen antibodies in the serum of 83 rheumatoid polyarthritis, 20 ankylosing spondylarthritis, 30 relapsing polychondritis, 13 diffuse sclerodermics, 12 Gougerot-Sjögren syndrome patients. Type II natural anti-collagen antibodies are common in relapsing polychondritis (37 percent). They are rarer in rheumatoid polyarthritis (15 percent) and the frequency is identical to that found in patients suffering from gonarthrosis and coxarthrosis. Natural type II anti-collagen antibodies may be occur in etiopathogenesis of relapsing polychondritis. Denatured II ant-collagen antibodies are common during ankylosing spondylarthritis (35 percent) and diffuse sclerodermia, and are found in rheumatoid polyarthritis (23 percent) and in Gougerot Sjögren syndrome (25 percent). They possibly play a pathological role in these diseases although this has not been proved. They are detected almost as often in the synovial fluid of inflammatory rheumatisms (53 percent) and in gonarthrosis (41 percent).

[Significance of anti-centromere antibodies. Clinical value]

The authors report 38 cases of patients with antinuclear antibodies directed against the centromere of the chromosomes. These were 32 cases of scleroderma, 2 cases of Raynaud's syndrome, 2 cases of rheumatoid arthritis, 1 case of polymyositis and 1 case of disseminated lupus erythematosus. In the cases of scleroderma, anti-centromere antibodies were detected in 54 p. cent of cases of Crest syndrome, for which they are a good laboratory marker; they were found more rarely in case of sclerodactyly (26 p. cent of cases) and acrosclerosis (14 p. cent of cases) and not at all in cases of localized scleroderma, diffuse scleroderma or eosinophilic fasciitis. Anti-centromere antibodies may be the only antinuclear antibodies in these patients. They can be detected using rapidly dividing cell cultures.