Influenza and pneumococcal vaccine coverage in 584 patients taking biological therapy for chronic inflammatory joint: A retrospective study.

OBJECTIVES: To evaluate influenza and pneumococcal vaccine coverage in patients taking biological therapy for chronic inflammatory joint disease and to identify factors associated with the decision to administer these two vaccines. METHODS: Retrospective cross-sectional questionnaire study of a cohort of 584 patients taking biological therapy for chronic inflammatory joint disease (rheumatoid arthritis or spondyloarthritis). We studied the influenza and pneumococcal vaccine coverage rates, information about these vaccines given to patients by the primary-care physician and rheumatologist, and reasons for not administering the vaccines. RESULTS: Overall vaccine coverage rates were 44% for influenza and 62% for pneumococcus. Factors associated with being vaccinated were patient age, previous influenza vaccination, and patient information. Concern about adverse effects and absence of patient information by the primary-care physician and rheumatologist were associated with very low coverage rates. CONCLUSION: This study showed insufficient vaccine coverage rates, particularly against influenza, in a population at high risk because of exposure to biological therapy. Patient information by healthcare professionals about influenza and pneumococcal vaccination has a major impact and should be renewed as often as possible.

Epidemiology, imaging, and treatment of giant cell arteritis.

Giant cell arteritis (GCA) is the most common vasculitis, and epidemiological data indicate a further increase in incidence over the last two decades. The disease predominates in individuals from Scandinavia and other Northern European countries. The impact of GCA on mortality remains unclear, although an increased risk of cardiovascular events has been reported. Most of the complications are related to the use of glucocorticoids to treat the disease. Recently introduced tools for diagnosing GCA include high-resolution Doppler ultrasonography and magnetic resonance imaging (MRI), whose performance remains to be determined. Glucocorticoids constitute the mainstay of the treatment of GCA. Other drugs have been evaluated, including dapsone, hydroxychloroquine, methylprednisolone pulse therapy, azathioprine, cyclosporine, cyclophosphamide, and methotrexate; however, the studies were methodologically flawed and produced conflicting results. No drug has been found effective in reducing glucocorticoid requirements. The role for biotherapies remains unclear, as the promising results obtained in open-label studies were not borne out by controlled trials.

Skin and joint infection by Mycobacterium chelonae: rescue treatment with interferon gamma.

INTRODUCTION: Atypical mycobacteria are environmental organisms that cause opportunistic infections in humans. CASE REPORT: A 50-year-old electronics engineer sought advice about starting TNFalpha antagonist therapy for ankylosing spondylitis. Disease duration was 23 years and current treatment was methylprednisolone 4 mg/d. Atypical skin lesions and knee arthritis were noted. Fluid aspirated from the knee showed inflammatory properties and a few acid-fast bacteria, which a line probe assay identified as Mycobacterium chelonae. The same organism was found in a skin biopsy from a thigh lesion. Antimicrobial treatment was started immediately. Inadequate results 6 months later prompted synovectomy of the knee followed by interferon gamma, 50 microg/m(2) body surface area subcutaneously 3 times a week. After 16 months, there were no new skin or joint lesions, and the antimicrobials and interferon gamma were therefore discontinued. CONCLUSION: This highly unusual case suggests that interferon gamma may be effective in patients with M. chelonae infection that fails to respond adequately to antimicrobials.

Investigations for bone metastasis from an unknown primary.

OBJECTIVES: To evaluate the respective contributions of various investigations used to identify the primary tumor in a cohort of patients referred for diagnostic evaluation of one or more bone metastases. METHODS: A single-center retrospective study was conducted in a cohort of patients admitted between October 1990 and January 2000 for evaluation of one or more bone metastases with no known primary. All patients underwent radionuclide bone scanning, a chest radiograph, and an abdominal ultrasound scan. Computed tomography (CT) of the chest and abdomen, CT of the brain, and tumor marker assays were performed as clinically indicated. Using the final diagnosis as the reference standard, we evaluated the diagnostic usefulness of each investigation. RESULTS: The 152 patients (104 men and 48 women) had a mean age of 63.5+/-12.5 years. The primary was located in the lung in 37 patients, prostate in 26, breast or female genital tract in 24, urinary system in 11, gastrointestinal tract in 11, head and neck in 6, and other organs in 4. In 33 patients, no primary was identified. The extraskeletal metastases were located chiefly in the liver (20.4%), lung (17.1%), pleura (13.2%), and brain (7.2%). Bone biopsies were performed in 107 patients: 84 had a single bone biopsy, 16 had two bone biopsies, and 7 had three bone biopsies. The first bone biopsy was taken in the rheumatology department with or without fluoroscopic guidance in 62 patients, in the radiology department under CT guidance in 6 patients, and in the surgery department in 32 patients; this information was unavailable for the 7 remaining patients. The first bone biopsy was taken from the iliac bone in 48 patients, spine in 32, sacrum in 10, rib in 3, and other sites in 7. The histological biopsy findings indicated adenocarcinoma in 58 cases, epidermoid carcinoma in 28 cases, undifferentiated carcinoma in 2 cases, and other histological patterns in 9 cases. In 80 patients, another metastatic site was easier to access than the bone metastasis. Tumor marker assays were of limited value for determining the site of the primary, with the exception of prostate-specific antigen. CONCLUSION: Bone biopsies performed by rheumatologists, generally under fluoroscopic guidance, usually indicate the site of the primary or at least the histological type. Tumor markers are often positive but are of limited usefulness for identifying the primary.

Incidence and nature of karate injuries.

OBJECTIVES: To determine the incidence and nature of karate injuries sustained in karate clubs and to identify risk factors for injuries. METHODS: One hundred eighty-six individuals from three karate clubs in Brest, France, were entered in a retrospective study extending from September 2002 to June 2003. Each athlete was asked to complete a questionnaire on karate injuries sustained during the previous year (type, location, mechanism, exercise during which the injury occurred, number of days off training and work, and medical care). Injury types were described by number of injuries and risk factors per number of injured athletes. RESULTS: Forty-eight (28.8%) of the 186 athletes sustained 83 injuries (63 while training and 20 while competing). The annual injury rate was 44.6 per 100 athletes. Incidence rates were similar in males and females and across the three clubs but increased with age, time spent training (3.6+/-1.7 vs. 2.9+/-1.5 h/week; P=0.001), rank (lower ranks vs. brown and black belts, P=0.015), and years of practice (7.3+/-5.5 years in athletes with injuries vs. 5.1+/-4.8 in those without injuries; P=0.03). Injuries consisted of 43 (53%) hematomas, 16 (19%) sprains, seven (7%) muscle lesions, six (7%) fractures, four (5%) malaise episodes, and seven (7%) miscellaneous lesions. Time off training occurred for 26 (31.3%) injuries and ranged from 8 to >30 days. The body region involved was the head in 22 (26.5%) injuries, the torso in eight injuries (9.6%), the upper limb in 24 (28.9%) injuries, and the lower limb in 29 (35%) injuries. CONCLUSION: Karate injuries are fairly common but usually minor. They are more likely to occur during competitions than while training. The head and limbs are the main regions involved. Longer training times per week and higher rank are associated with an increased risk of injury. Prevention seems crucial.