Prophylaxe und Therapie der Glukokortikoid-induzierten Osteoporose �C rezente Leitlinien im ��berblick

Several international guidelines for treatment and prophylaxis of glucocorticoid-induced osteoporosis (GIO) have been published. Consistent with the development of new therapeutic agents, a different approach to treatment can be recognized depending on the year of publication. Also, new insights for the postmenopausal osteoporosis leave their marks on recent guidelines. The working committee on Osteology of the Austrian Society for Rheumatology and Rehabilitation (?GR) sifted through actual guidelines and recent literature on the topic to develop recommendations for the prophylaxis and treatment of the GIO.     

Estimated incidence of influenza-virus-associated severe pneumonia in children in El Salvador, 2008�C2010

Objective

To estimate the incidence of influenza-virus-associated severe pneumonia among Salvadorian children aged < 5 years.

Methods

Data on children aged < 5 years admitted with severe pneumonia to a sentinel hospital in the western region were collected weekly. Nasal and oropharyngeal swab specimens were collected from a convenience sample of case patients for respiratory virus testing. A health-care utilization survey was conducted in the hospital catchment area to determine the proportion of residents who sought care at the hospital. The incidence of influenza-virus-associated severe pneumonia among all Salvadorian children aged < 5 years was estimated from surveillance and census data, with adjustment for health-care utilization. Influenza virus strains were characterized by the United States Centers for Disease Control and Prevention to determine their correspondence with northern and southern hemisphere influenza vaccine formulations.

Findings

Physicians identified 2554 cases of severe pneumonia. Samples from 608 cases were tested for respiratory viruses and 37 (6%) were positive for influenza virus. The estimated incidence of influenza-virus-associated severe pneumonia was 3.2 cases per 1000 person–years (95% confidence interval, CI: 2.8–3.7) overall, 1.5 cases per 1000 person–years (95% CI: 1.0–2.0) during 2008, 7.6 cases per 1000 person–years (95% CI: 6.5–8.9) during 2009 and 0.6 cases per 1000 person–years (95% CI: 0.3–1.0) during 2010. Northern and southern hemisphere vaccine formulations matched influenza virus strains isolated during 2008 and 2010.

Conclusion

Influenza-virus-associated severe pneumonia occurred frequently among young Salvadorian children during 2008–2010. Antigens in northern and southern hemisphere influenza vaccine formulations corresponded to circulating strains.     

Prenatal Methylmercury, Postnatal Lead Exposure, and Evidence of Attention Deficit/Hyperactivity Disorder among Inuit Children in Arctic Qu��bec

Background: Prenatal exposure to methylmercury (MeHg) and polychlorinated biphenyls (PCBs) has been associated with impaired performance on attention tasks in previous studies, but the extent to which these cognitive deficits translate into behavioral problems in the classroom and attention deficit/hyperactivity disorder (ADHD) remains unknown. By contrast, lead (Pb) exposure in childhood has been associated with ADHD and disruptive behaviors in several studies.Objectives: In this study we examined the relation of developmental exposure to MeHg, PCBs, and Pb to behavioral problems at school age in Inuit children exposed through their traditional diet.Methods: In a prospective longitudinal study conducted in the Canadian Arctic, exposure to contaminants was measured at birth and at school age. An assessment of child behavior (n = 279; mean age = 11.3 years) was obtained from the child’s classroom teacher on the Teacher Report Form (TRF) from the Child Behavior Checklist, and the Disruptive Behavior Disorders Rating Scale (DBD).Results: Cord blood mercury concentrations were associated with higher TRF symptom scores for attention problems and DBD scores consistent with ADHD. Current blood Pb concentrations were associated with higher TRF symptom scores for externalizing problems and with symptoms of ADHD (hyperactive-impulsive type) based on the DBD.Conclusions: To our knowledge, this study is the first to identify an association between prenatal MeHg and ADHD symptomatology in childhood and the first to replicate previously reported associations between low-level childhood Pb exposure and ADHD in a population exposed to Pb primarily from dietary sources.     

Management of ERCP-related small bowel perforations: the pivotal role of physical investigation

Background

Management of endoscopic retrograde cholangiopancreatography (ERCP)–associated duodenal perforation remains controversial. Some recommend surgery, while others recommend conservative treatment.

Methods

A retrospective chart review was conducted to identify patients treated at our institution for ERCP-related duodenal perforations. Study variables included indication for ERCP, clinical presentation, diagnostic procedures, time to diagnosis and treatment, location of injury, management, length of stay in hospital and survival.

Results

Between January 2000 and October 2009, 12 232 ERCP procedures were performed at our centre, and perforation occured in 11 patients (0.08%; 5 men, 6 women, mean age 71 yr). Six of the perforations were discovered during ERCP; 5 required radiologic imaging for diagnosis. Three perforations were diagnosed incidentally by follow-up ERCP. In 1 patient, perforation occurred 3 years after the procedure owing to a dislocated stent. Four of 11 perforations were stent-related; in 2 patients ERCP was performed in a nonanatomic situation (Billroth II gastroenterostomy). Free peritoneal perforation occurred in 4 patients; 1 was successfully managed conservatively. Four patients (36%) were treated surgically and none died. Five patients were managed conservatively with a successful outcome, and 2 patients died after conservative treatment (18%). Operative treatment included hepaticojejunostomy and duodenostomy (1 patient), suture of the perforation with T-drain (1 patient) and suture only (2 patients). The mean length of stay in hospital for all patients was 20 days.

Conclusion

Post-ERCP duodenal perforations are associated with significant morbidity and mortality. Immediate surgical evaluation and close monitoring is needed. Management should be individually tailored based on clinical findings only.     

MRI and ultrasonography in Morton's neuroma: Diagnostic accuracy and correlation

Background:

The diagnosis of Morton''s neuroma is based primarily on clinical findings. Ultrasonography (US) and magnetic resonance image (MRI) studies are considered complementary diagnostic techniques. The aim of this study was to establish the correlation and sensitivity of both techniques used to diagnose Morton''s neuroma.

Materials and Methods:

Thirty seven patients (43 intermetatarsal spaces) with Morton''s neuroma operated were retrospectively reviewed. In all cases MRI or ultrasound was performed to complement clinical diagnosis of Morton''s neuroma. In all cases, a histopathological examination confirmed the diagnosis. Estimates of sensitivity were made and correlation (kappa statistics) was assessed for both techniques.

Results:

Twenty seven women and 10 men participated with a mean age of 60 years. Double lesions presented in six patients. The second intermetatarsal space was affected in 10 patients and the third in 33 patients. An MRI was performed in 41 cases and a US in 23 cases. In 21 patients, both an MRI and a US were performed. With regard to the 41 MRIs performed, 34 were positive for Morton''s neuroma and 7 were negative. MRI sensitivity was 82.9% [95% confidence interval (CI): 0.679–0.929]. Thirteen out of 23 US performed were positive and 10 US were negative. US sensitivity was 56.5% (95% CI: 0.345–0.768). Relative to the 21 patients on whom both techniques were carried out, the agreement between both techniques was poor (kappa statistics 0.31).

Conclusion:

Although ancillary studies may be required to confirm the clinical diagnosis in some cases, they are probably not necessary for the diagnosis of Morton''s neuroma. MRI had a higher sensitivity than US and should be considered the technique of choice in those cases. However, a negative result does not exclude the diagnosis (false negative 17%).     

Methicillin-Resistant Staphylococcus aureus Sequence Type 239-III, Ohio, USA, 2007�C2009

Methicillin-resistant Staphylococcus aureus (MRSA) is a human pathogen that has diverse molecular heterogeneity. Most MRSA strains in the United States are pulsed-field gel electrophoresis USA100 sequence type (ST) 5 and USA300 ST8. Infections with MRSA ST239-III are common and found during health care–associated outbreaks. However, this strain has been rarely reported in the United States. As part of a study supported by the Prevention Epicenter Program of the Centers for Disease Control and Prevention (Atlanta, GA, USA), which evaluated transmission of MRSA among hospitals in Ohio, molecular typing identified 78 (6%) of 1,286 patients with MRSA ST239-III infections. Ninety-five percent (74/78) of these infections were health care associated, and 65% (51/78) of patients had histories of invasive device use. The crude case-fatality rate was 22% (17/78). Identification of these strains, which belong to a virulent clonal group, emphasizes the need for molecular surveillance.Staphylococcus aureus is a major human pathogen that possesses multiple toxins and virulence mechanisms (1). Antimicrobial drug resistance in S. aureus has added to the complexity of treating serious infections caused by this bacteria, and methicillin-resistant S. aureus (MRSA) appears to have greater virulence than methicillin-susceptible strains (2,3). Most MRSA strains in the United States are pulsed-field gel electrophoresis (PFGE) types USA100 and USA300, corresponding to multilocus sequence typing (MLST) ST5 and ST8, respectively (4). MRSA belonging to MLST ST239 and harboring staphylococcal cassette chromosome mec (SCCmec) type III (MRSA ST239-III) are associated with infections in health care settings, outbreaks, increased resistance to antimicrobial drugs, and capacity for invasive disease (5–7).MRSA ST239-III has a history of successful dissemination in many regions, leading to a diverse array of regionally prevalent clones. These clones include the Brazilian; British Epidemic 1, 4, 7, 9, and 11; Canadian Epidemic 3/Punjab; Czech; Eastern Australian 2 and 3; Georgian; Hungarian; Lublin; Nanjing/Taipei (ST241); Portuguese; and Vienna clones (8,9). Although it is common worldwide, MRSA ST239-III has not played any predominant role in the United States; infections with MRSA ST239-III have been rarely reported in the United States since the 1990s (9–13). Recently, only 2 reports of this strain in the United States involving sporadic nasal colonization and bloodstream infections have been published (13,14).In this study, we describe clinical epidemiologic characteristics and molecular analysis of clinical infections with MRSA ST239-III in the midwestern United States. Identification of a strain from such a virulent clonal group in the United States with wide dissemination in other parts of the world represents a potential public health concern.     

Renal Hyperfiltration Is a Determinant of Endothelial Function Responses to Cyclooxygenase 2 Inhibition in Type 1 Diabetes

OBJECTIVE

Our aim was to examine the effect of cyclooxygenase 2 (COX2) inhibition on endothelial function in subjects with type 1 diabetes analyzed on the basis of renal filtration status.

RESEARCH DESIGN AND METHODS

Flow-mediated dilation (FMD) was determined in type 1 diabetic subjects and hyperfiltration (glomerular filtration rate ≥135 ml/min/1.73 m², n = 13) or normofiltration (glomerular filtration rate ≥135 ml/min/1.73 m², n = 11). Studies were performed before and after celecoxib (200 mg daily for 14 days) during euglycemia and hyperglycemia.

RESULTS

Baseline parameters were similar in the two groups. Pretreatment, FMD was augmented in normofiltering versus hyperfiltering subjects during clamped euglycemia (10.2 ± 5.3% vs. 5.9 ± 2.3%, P = 0.003). COX2 inhibition suppressed FMD in normofiltering (10.2 ± 5.3% to 5.8 ± 3.4%, P = 0.006) versus hyperfiltering subjects (ANOVA interaction, P = 0.003).

CONCLUSIONS

Systemic hemodynamic function, including the response to COX2 inhibition, is related to filtration status in diabetic subjects and may reflect general endothelial dysfunction.Renal hyperfiltration is associated with an increased risk of progression to diabetic nephropathy in many, but not all, studies (1). Diabetic hyperfiltration may in part be due to cyclooxygenase 2 (COX2) upregulation (2,3). We have previously identified a cohort of subjects with uncomplicated type 1 diabetes who exhibit hyperfiltration (glomerular filtration rate [GFR] ≥135 ml/min/1.73 m²) or normofiltration (GFR <135 ml/min/1.73 m²) during clamped euglycemia (4). In hyperfiltering subjects, COX2 inhibition reduces GFR, whereas in subjects with normofiltration, COX2 inhibition is associated with an opposite GFR rise and an exaggerated suppression of vasodilatory prostaglandins (4). Together with previous observations (4–6), these findings suggest that hyperfiltering and normofiltering individuals are physiologically distinct.Previous studies have suggested that early type 1 diabetes is characterized by a state of generalized vasodilation due to nitric oxide upregulation (7). The role of COX2 in the systemic vasculature in humans with early type 1 diabetes is, however, incompletely understood (8–11). Accordingly, our goal was to study the effect of COX2 inhibition on endothelial function in diabetic subjects with hyperfiltration or normofiltration. Our hypothesis was that renal hemodynamic differences would also be reflected in the systemic circulation.     

Pneumonie im Alter

Background

Is the time to diagnosis and to start antibiotic therapy a major factor contributing to the outcome in geriatric patients?

Methods

In 2006, a program for documentation and improvement for diagnostic and therapeutic procedures in patients with community-acquired pneumonia was introduced in German hospitals. The analyses were performed centrally by an independent board.

Setting

Tertiary geriatric department with 70?beds for acute care and rehabilitation in a hospital, also including a department of neurology and neurological rehabilitation.

Results

In Lower Saxony (LS), 81,853 patients were treated between 2006?C2009 in our geriatric department (GD). In LS, 55.3% of the population was male, while 45.2% of the patients in the GD were male (p=0.063). Throughout an age of 79?years, the distribution was equal; however in the age groups 80?C89?years (LS vs GD: 32.3 vs 47.6%) and >90?years (LS vs GD: 10.2 vs 15.5%, p<0.001) there were a higher proportion of male patients in the GD. The proportion of male nursing home patients was 46.8% vs 24.3%, hospital or rehabilitation unit 6.2% vs 40.5%, and status of confinement to bed was 47% vs 35.1% (LS vs GD, p<0.001). Delirium caused by pneumonia occurred in 24.4% vs 9.3% and a status of chronic delirium (dementia) was assessed by 75.6% vs. 90.7% of all cases (LS vs GD, p=0.021). The distribution about the risk classes 1/2/3 of the CRB-65 score was 14.9/76.9/8.2% in LS and 3.6/89.3/7.1% in the GD (p=0.011). The time to starting antibiotics (no therapy, <4, 4?C8, and >8 h) was 2.2/83.0/7.6/7.2% in LS and 15.4/47.4/10.3/26.9% in GD patients (p<0.001). Overall mortality rates did not differ significantly (LS 14.6% vs GD 11.9%, p=0.53).

Conclusions

Patients in the GD were older and more functionally dependent. The distribution of the risk index CRB-65 shows that these patients were at higher risk, were more often cognitively impaired (not caused by pneumonia), and time to starting antibiotics was longer. However, none of these differences had an influence on total mortality. The results are limited by the number of patients, potential differences of the treatment groups, and the quality of data in general as a result of a quality improvement program.