The successful use of extra-corporeal membrane oxygenation in the management of a pregnant woman with severe H1N1 2009 influenza complicated by pneumonitis and adult respiratory distress syndrome.

We report a case of H1N1 2009 influenza A, in a previously fit woman at 24 weeks of gestation, who presented atypically with abdominal pain. The infection was complicated by severe respiratory failure and acute respiratory distress syndrome, requiring ventilatory support, including extra-corporeal membrane oxygenation (ECMO). This was one of the first cases of severe H1N1 disease presenting in the UK. Use of extra-corporeal membrane oxygenation for the complications of H1N1 resulted in full maternal recovery and subsequent delivery of a healthy infant.

Pneumonia due to antibiotic resistant Streptococcus pneumoniae and Pseudomonas aeruginosa in the HAART era.

Antibiotic resistance profiles are useful in directing therapeutic strategies during bacterial infections. Patterns of antimicrobial resistance in Streptococcus pneumoniae and Pseudomonas aeruginosa associated pneumonia were investigated in an HIV-1 infected cohort during the era of highly active antiretroviral therapy. The median CD4 count at presentation was significantly lower for cases of P aeruginosa than for S pneumoniae. However, the number of antibiotic resistant cases of P aeruginosa decreased throughout the study period, while the incidence of S pneumoniae remained unchanged. In contrast to pneumococcal pneumonia, we show that antiretrovirals have protected from pneumonia due to antibiotic resistant P aeruginosa. These findings have implications for the treatment of individuals presenting with serious infections in which antibiotic therapy needs to be instituted before identification and sensitivities are known.

Osteonecrosis of the knee in a patient receiving antiretroviral therapy.

A case of avascular osteonecrosis of the right knee is described in a patient with HIV infection. The patient had been receiving highly active antiretroviral therapy for two years prior to presentation. Osteonecrosis is an uncommon albeit serious complication of HIV infection and is associated with use of antiretroviral agents.

Acute demyelinating encephalomyelitis (ADEM) in a patient with HIV infection.

A case of acute demyelinating encephalomyelitis (ADEM) in a patient with HIV infection is reported. Although the diagnosis of ADEM is based on clinical and radiological findings, the potential for full recovery, with appropriate treatment, is highlighted by this case. A concise review of the subject is given in the discussion.

Alcohol availability and homicide in New Orleans: conceptual considerations for small area analysis of the effect of alcohol outlet density.

OBJECTIVE: To determine the geographic relation between homicide rate and two competing measures of exposure to alcohol outlets, alcohol outlets per square mile and alcohol outlets per person. METHOD: Homicides occurring in 1994 and 1995 and on-sale and off-sale alcohol outlets with active 1995 licenses were geocoded by address for aggregation at the census tract level. Ecologic analysis of the 155 urban residential census tracts in New Orleans was conducted with controls for potential sociodemographic confounders (% black, % adults unemployed, % unmarried households, and ratio males 15-24/males 35-44). RESULTS: After logarithmic transformation of all study variables, sociodemographic confounders alone accounted for 58% (R2 = .58) of the variance of homicide rates. Adding off-sale alcohol outlet density to the models, measured (beta +/- SE) either as outlets per square mile (beta = .211 +/- .062) or outlets per person (beta = .244 +/- .063), yielded strong geographic relations with homicide and increased the amount of variance explained (R2 = .62). A 10% higher off-sale outlet density accounted for a 2.4% higher homicide rate. CONCLUSIONS: Both off-sale alcohol outlets per square mile and off-sale outlets per person demonstrate strong geographic associations with homicide rates among urban residential census tracts in New Orleans. These findings suggest that communities faced with high rates of assaultive violence might consider policy interventions that address alcohol outlet related factors.

Effects of prolactin in stimulating disease activity in systemic lupus erythematosus.

Systemic lupus erythematosus (SLE), a chronic autoimmune illness, is influenced by hormones. High prolactin concentrations were associated with early death from autoimmune renal disease in NZB/NZW mice, an animal model of severe SLE. NZB/NZW mice that delivered and nursed pups and those that underwent pseudopregnancy had changes in serum IgG and autoantibodies. NZB/NZW mice treated with the prolactin-suppressing drug bromocriptine had prolonged lives. Elevated serum prolactin concentrations are reported in SLE patients of both sexes. We found four women with long-standing hyper-prolactinemia who developed SLE. A survey of premenopausal women whose sera were submitted for autoantibody testing showed that 20% with anti-ds-DNA antibodies also had high prolactin levels. Many hyperprolactinemic patients whose sera were referred to an endocrinology laboratory had positive FANA tests (women 33%, men 53%) but did not have SLE. Disease activity was suppressed in six of seven SLE patients treated with bromocriptine. All had elevated disease activity and five became unexpectedly hyperprolactinemic after treatment stopped. Manipulating serum prolactin affords a means of treating clinical SLE activity.

Bone mineral density and biochemical markers of bone metabolism in ankylosing spondylitis.

OBJECTIVE: To determine (1) bone mineral density (BMD) of the axial and appendicular skeleton in men with moderate and severe ankylosing spondylitis (AS), and (2) associations between BMD and bone metabolism variables. METHODS: Nineteen men with AS and 19 healthy male controls were evaluated for osteoporosis by dual energy x-ray absorptiometry in both the hip and the lateral and posterior-anterior (PA) projections of the lumbar spine. Calcium homeostasis was evaluated by measuring minerals, calcitropic hormones, and markers of remodeling. Total testosterone levels were also measured. RESULTS: Osteopenia was noted in both the hip and spine of the subjects with AS. The lateral projection of L3 was a more sensitive indicator of the vertebral BMD compared to the PA projection. Calciuin homeostasis and testosterone levels were normal in subjects with AS. In most subjects, markers of bone formation and resorption were normal. CONCLUSION: BMD of subjects with AS is decreased, in spite of normal calcium homeostasis and bone remodeling indices.

Bone mineralization and bone mineral metabolism in children with juvenile rheumatoid arthritis.

OBJECTIVE: To identify mechanisms of the osteopenia associated with juvenile rheumatoid arthritis (JRA) by determining parameters of bone mineralization, and bone mineral content and density (BMC and BMD), in children with JRA. METHODS: BMC and BMD were measured by dual x-ray absorptiometry in 41 children with JRA and 62 healthy children. Serum samples were analyzed for concentrations of minerals, vitamin D, parathyroid hormone, osteocalcin, bone-specific alkaline phosphatase (BAP), procollagen I carboxy-terminal propeptide, and tartrate-resistant acid phosphatase (TRAP), and urinary excretion of deoxypyridinoline crosslinks and calcium. RESULTS: BMD was decreased in all sites in JRA patients. BMD, corrected for age, height, weight, and bone area, was decreased at cortical bone sites (1/3 radius, upper and lower extremities, and whole body). Low concentrations of osteocalcin and BAP suggested reduced bone formation, and low TRAP levels suggested decreased resorption. Clinical scales of disease severity were negatively correlated with measures of bone mass. Laboratory markers of disease severity were highly correlated with decreases in markers of bone formation, but not with those of resorption. Although laboratory findings were similar for children with oligoarticular and polyarticular disease, differences in bone mass were greater in children with polyarticular disease. CONCLUSION: These data suggest an association between decreased bone mineralization in JRA and low bone formation that is related to disease severity. Efforts to stimulate bone formation, therefore, need to be considered clinically in prepubertal children with active JRA.

Prolactin levels and antinuclear antibody profiles in women tested for connective tissue disease.

Hyperprolactinemia has been reported in some patients with active systemic lupus erythematosus (SLE). To determine if there was an association between selected autoantibodies and hyperprolactinemia, we assayed prolactin concentrations in sera from women submitted to a reference antinuclear antibody laboratory. Autoantibody-positive samples were separated into groups that contained antibodies to double-stranded DNA (anti-DNA), antibodies to SSA/Ro (anti-SSA/Ro), or antibodies to both SSA/Ro and SSB/La (anti-SSA/Ro-SSB/La). Results were compared with autoantibody-negative sera from age-matched women, submitted to the same laboratory. We also compared the study groups with a separate cohort of 84 healthy women who were not referred for autoantibody testing. Elevated prolactin levels were clustered in 20% of sera from anti-DNA-positive women < or = 50 years of age. Twenty-one percent of anti-SSA/Ro-SSB/La-positive women < 50 years of age were hyperprolactinemic. Four of the 15 hyperprolactinemic women identified in this survey had no known cause of elevated prolactin. In the other 11 individuals secondary causes such as hypothyroidism, pregnancy, chronic renal failure, and medications may have accounted for high serum prolactin values. We also examined sera by Western blot, to determine if immunoblot patterns were associated with elevated serum prolactin concentrations. The hyperprolactinemic sera yielded novel bands migrating at 70 kd, 32 kd, and 16.5 kd. This study confirmed the reported associations of hyperprolactinemia with SLE and Sjögren's syndrome. Multiple factors appeared to contribute to elevated serum prolactin levels in women with connective tissue diseases, and the presence of hyperprolactinemia was related to unique findings on immunoblot analysis.

Efficacy of bromocriptine in an open label therapeutic trial for systemic lupus erythematosus.

OBJECTIVE: To investigate the efficacy of bromocriptine in suppressing active systemic lupus erythematosus (SLE) in a therapeutic trial. METHODS: We conducted an open label investigation of bromocriptine treatment in 7 patients with active non-life threatening SLE. Patients received bromocriptine daily during the treatment phase of 6 to 9 months and were followed for 5 months after bromocriptine was discontinued. Disease activity was assessed by determination of the SLE activity Measure (SLAM) and the Toronto SLE Disease Activity Index (SLEDAI). Serum prolactin concentrations and a battery of serologic and urine tests were obtained at baseline and at monthly intervals during and after bromocriptine treatment. RESULTS: Serum prolactin concentration was suppressed from (mean +/- SEM) 11.2 ng/ml +/- 1.9 to 3.1 ng/ml +/- 1.7 after 6 months of bromocriptine treatment. The mean pretreatment SLAM score was 11.3 +/- 0.9;6 months of bromocriptine treatment significantly decreased the mean SLAM score to 6.0 +/- 1.6 (p = 0.03 compared to pretreatment measure). The mean SLEDAI score decreased from 16.0 +/- 2.0 to 5.9 +/- 0.8 (p = 0.02) during the same period. Bromocriptine treatment was associated with transient suppression of anti-dsDNA, and serum cholesterol was reduced significantly through the treatment period. After bromocriptine was discontinued, all patients had increased disease activity associated with rising serum prolactin concentrations. CONCLUSION: These findings justify controlled trials to study the efficacy of bromocriptine in treating patients with active SLE.

Bone mineral metabolism in children with juvenile rheumatoid arthritis.

Osteopenia has emerged as a major determinant of the outcome of children with juvenile rheumatoid arthritis. Although vertebral compression fractures and fractures of long bones were recognized historically as important clinical developments in the course of disease, a decrease in skeletal mass could only be quantitated and documented early in disease by the recent introduction of bone absorptiometry. This article is limited to recent data from studies on osteopenia in juvenile rheumatoid arthritis and suggests directions of future research that have relevance to current unanswered questions in prevention or management.

Relative value of femoral and lumbar bone mineral density assessments in patients with ankylosing spondylitis.

The objective of this study was to examine the relative sensitivity of femoral and lumbar bone mineral density (BMD) measurements in patients with ankylosing spondylitis (AS) and to identify the most appropriate test site for detection of osteopenia in these patients. Fourteen patients with ankylosing spondylitis had femoral and lumbar bone mineral density studies using dual energy x-ray absorptiometry. Significant osteopenia was found in 93% of patients when the femoral hip was examined and in 29% of patients when the lumbar region was examined. Moreover, femoral measurements exhibited greater severity of osteopenia than lumbar measurements when average T and Z scores were compared. Bone loss was most marked at Ward's triangle and the neck of the femur. When the lumbar measurements are insensitive and inappropriate, femoral neck and Ward's triangle measurements provide a more reliable indication of the presence and severity of osteopenia in patients with AS. Interpretation of BMD at the trochanter and intertrochanter, as well as total hip BMD, yielded no additional information in the diagnosis of osteopenia.

Changes in bone mineral density and markers of bone remodeling during lactation and postweaning in women consuming high amounts of calcium.

A randomized clinical intervention trial to determine effects of lactation and 1 g of calcium (Ca) on bone remodeling was conducted in 15 women (calcium = 7, placebo [P] = 8) consuming 1.3-2.4 g of Ca/day from diet + prenatal supplement. Study periods were baseline, < or = 2 weeks postpartum; lactation, 3 months lactation; and postweaning, 3 months postweaning. Bone mineral density (BMD) corrected for body weight was determined by dual-energy X-ray absorptiometry (DXA). Indicators of calcium metabolism, bone turnover, and lactation were measured: calcium metabolism, parathyroid hormone (PTH), 25-hydroxyvitamin D (25[OH]D), 1,25-dihydroxyvitamin D (1,25[OH]2D); bone turnover, formation, procollagen I carboxypeptides (PICP), osteocalcin, and bone alkaline phosphatase (B-ALP), resorption, tartrate resistant acid phosphatase (TRAP); and lactation, prolactin (PRL). Mean BMD changes differed by site: baseline to lactation -4.3% (P) (p < 0.04) and -6.3% (Ca) (p < 0.01) at the lumbar spine (L2-L4) and 5.7% gains of the ultradistal (UD) radius (Ca) (p < 0.04); lactation to postweaning, -6% to -11% at all sites of the radius and ulna (Ca, P) (p < 0.04) +3% at L2-L4 (Ca) (p < 0.03); baseline to postweaning, (UD) radius -5.2% (P) (p < 0.03), UD radius + ulna -6% to -8% (Ca, P) (p < 0.04) but no significant loss of L2-L4 or total body. Bone turnover markers were higher at lactation than postweaning: PICP (+34%, p < 0.001), osteocalcin (+25%, p < 0.01), TRAP (+11%, p < 0.005) as well as PRL (+81%, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Elevated serum prolactin levels in children with juvenile rheumatoid arthritis and antinuclear antibody seropositivity.

OBJECTIVE: To determine if antinuclear antibody seropositivity in girls with juvenile rheumatoid arthritis (JRA) is associated with elevated serum levels of the anterior pituitary hormone prolactin. METHODS: Nineteen premenarchal girls meeting ACR classification criteria for JRA were evaluated for disease activity, antinuclear antibodies (ANA) seropositivity, and serum concentrations of prolactin, estrogen, and thyroid stimulating hormone. RESULTS: The mean serum prolactin concentration of ANA seropositive patients with JRA (10.9 +/- 1.9 micrograms/l) was significantly higher than that for ANA negative patients (5.7 +/- 1.0 micrograms/l; p = 0.043) and an age matched control group (5.8 +/- 1.3 micrograms/l; p = 0.048). CONCLUSION: Children with ANA seropositive JRA have elevated serum levels of the immunostimulatory hormone prolactin.

Calcium homeostasis and bone metabolism during pregnancy, lactation, and postweaning: a longitudinal study.

Ten women were followed serially to determine the effect of stages of reproduction on calcium and bone metabolism. The study periods were nonpregnant nonlactating, the end of each trimester of gestation, 3 mo lactation, and postweaning. Comparisons were with nonpregnant nonlactating status for each individual. Fractional calcium absorption (P < 0.0001) and concentrations of 1,25-dihydroxyvitamin D (P < 0.01) were higher in the second and third trimesters. Total urinary calcium was higher during pregnancy and lower postweaning. Parathyroid hormone (PTH) concentrations were higher only postweaning (P < 0.01). Markers of bone turnover increased at the third trimester and during lactation: serum tartrate resistant acid phosphatase and bone specific alkaline phosphatase, and urinary deoxypyridinoline (P < 0.01). Serum procollagen I carboxypeptides increased only in the third trimester (P < 0.01). Bone mineral density by single-photon absorptiometry did not differ by period. We conclude that absorption and urinary excretion of calcium increase during pregnancy whereas bone turnover increases during late pregnancy and lactation; only renal changes consistent with an increase in PTH were seen postweaning.

Exercise considerations for postmenopausal women with osteoporosis.

Individuals with osteoporosis are at an increased risk of fracture due to a net loss of bone mass. The cellular mechanisms causing decreased bone mass are increased osteoclast-mediated bone resorption and/or decreased osteoblast-mediated bone formation. Clinical studies have shown that bone loss can be prevented by estrogen replacement therapy and calcium supplementation. Weight-bearing and strengthening exercise may also play a role in retarding bone loss in the postmenopausal woman, and it may even increase bone mass. The essential components of an exercise program include intensity, duration, frequency, and type of activity. Additional goals of a therapeutic exercise program are to improve flexibility and balance, and to prevent falls. Structure-function relationships in normal and osteoporotic bone and the effects of exercise on bone are reviewed. A rational approach for exercise strategies is discussed.

Estrogen replacement therapy at menopause. How benefits outweigh risks.

Bone loss and cardiovascular disease are the most important complications of menopause. Because estrogen has been shown to prevent bone loss and also reduce fracture rates in menopausal women, the authors recommend early replacement therapy. They also examine evidence that estrogen replacement may offer these women protection from cardiovascular disease and discuss the risks of estrogen-related endometrial and breast cancer.

Vitamin D metabolism and bone mineralization in children with juvenile rheumatoid arthritis.

OBJECTIVE: To examine bone mineralization and bone mineral content in a cross-sectional population of children with juvenile rheumatoid arthritis (JRA). METHODS: Bone mineral content was measured by single-photon absorptiometry in 44 children with JRA and 37 control children. Serum concentrations of minerals, vitamin D, parathyroid hormone, osteocalcin, bone alkaline phosphatase, and tartrate-resistant acid phosphatase, and urinary concentrations of minerals, were determined. RESULTS: Bone mineral content was decreased in children with JRA. Significantly lower concentrations of osteocalcin (7.4 +/- 3.4 vs 12.5 +/- 2.5 micrograms/L) and bone alkaline phosphatase (78.8 +/- 36.4 vs 123.0 +/- 46.0 IU/L) suggested reduced bone formation; lower levels of tartrate-resistant acid phosphatase (10.3 +/- 4.1 vs 14.4 +/- 5.8 IU/L) and a lower urinary calcium/creatinine ratio (0.07 +/- 0.06 vs 0.12 +/- 0.09) suggested decreased bone resorption. The serum calcium concentration was significantly lower (9.3 +/- 1.0 vs 10.0 +/- 0.4 mg/dl), as was the parathyroid hormone concentration (19.8 +/- 8.6 vs 26.7 +/- 9.3 ng/L); 1,25-dihydroxyvitamin D values (30.1 +/- 10.5 vs 30.4 +/- 9.3 pg/ml) were normal. CONCLUSION: These data suggest that decreased mineralization in JRA is related to low bone turnover; parathyroid hormone and 1,25-dihydroxyvitamin D levels may be inappropriately normal for the decreased serum calcium concentration in children with JRA.

Longstanding hyperprolactinemia associated with systemic lupus erythematosus: possible hormonal stimulation of an autoimmune disease.

OBJECTIVE: To describe 4 women in whom hyperprolactinemia was associated with the development of systemic lupus erythematosus (SLE). METHODS: Clinical assessment and followup (2 cases). Chart review and interviews with the attending rheumatologist (2 cases). Detailed review and reassessment of multiple imaging studies of the pituitary. RESULTS: One patient had idiopathic hyperprolactinemia, and 3 had pituitary microadenomas. Serum 17 beta-estradiol concentrations were normal in all women, but serum testosterone was suppressed in 2. SLE flares occurred in 2 individuals, one and 6 months after bromocriptine therapy was discontinued, and reinstitution of bromocriptine therapy in a patient who refused corticosteroids resulted in resolution of her SLE disease activity. CONCLUSION: Hyperprolactinemia, which has the potential to exacerbate autoimmunity, may coexist with SLE. In these instances, bromocriptine may afford therapeutic benefit.