Hypovitaminosis D among rheumatology outpatients in clinical practice.

OBJECTIVES: A role for vitamin D in the pathogenesis of autoimmune and inflammatory diseases is emerging. We undertook an audit of 25-hydroxyvitamin D (25OHD) investigation and treatment in rheumatology outpatients. METHODS: Serum 25OHD requests were matched to electronic medical records from rheumatology and metabolic bone clinics (April 2006-March 2007). Data were analysed separately for two groups, 'Documented osteoporosis/osteopaenia' (Group 1) and 'General rheumatology outpatients' (Group 2, sub-divided by diagnosis). Hypovitaminosis D was defined by 25OHD levels <50 nmol/l. Values were compared with healthy adults to calculate geometric z-scores. RESULTS: A total of 263 patients were included (Group 1, n = 122; Group 2, n = 141) with an overall median 25OHD of 44 nmol/l. The 25OHD level among general rheumatology patients (median 39 nmol/l, mean z score -1.2, was statistically significantly lower than among osteoporotic/osteopaenic patients (median 49 nmol/l, mean z score of -0.9, p < 0.05 for the difference). 25OHD was lower in inflammatory arthritis and chronic pain/fibromyalgia than in other groups. Prescribing was recorded in 100 in Group 1 (of whom 95% were prescribed calcium/800 IU cholecalciferol) and 83 in Group 2 (91% calcium/800 IU). Only 31% of the patients with 25OHD <50 nmol/l would have been identified using general guidelines for screening patients at 'high risk' of hypovitaminosis D. CONCLUSIONS: Improved guidelines for managing hypovitaminosis D in rheumatology patients are needed. We found a high prevalence of hypovitaminosis D among secondary care patients in rheumatology and widespread supplementation with 800 IU cholecalciferol. Substantially reduced levels of serum 25OHD were identified among patients with inflammatory arthritis and chronic pain.

Referrals to hospital-based rheumatology and orthopaedic services: seeking direction.

OBJECTIVES: While both community and hospital-based services strive to cope with the considerable burden posed by musculoskeletal disorders, multidisciplinary-led, integrated approaches are frequently lacking. It has been suggested that referrals to musculoskeletal services are frequently misdirected to an orthopaedic surgeon when non-surgical advice/intervention is warranted, reducing the efficiency of hospital-based services and potentially affecting quality of care. Triage of referrals may help to prevent this, but this system is dependent upon accurate and thorough information being provided in the referral letter. Our aim was to assess the feasibility of triage of musculoskeletal referrals to rheumatology and orthopaedic services at a large teaching hospital. METHODS: One thousand and eighty-seven consecutive referral letters to orthopaedic and rheumatology services were reviewed by a consultant rheumatologist. Letters were assessed for both basic content and the appropriate destination for that referral. In order to evaluate the accuracy of the assessor's prediction of the most appropriate destination of the referrals, the number of patients who were ultimately listed for surgical intervention was calculated in a random sample of orthopaedic referrals, 1 yr after the initial hospital appointment was requested. RESULTS: Six hundred and eighty-two referrals were to orthopaedics and 393 to rheumatology. Referrals relating to spinal pain were excluded. The content of letters was scant and no diagnosis was volunteered in 63.4% of referrals. Fifty-eight per cent of referrals to orthopaedics were considered appropriate; 27% of referrals to orthopaedics were defined as 'should definitely see a rheumatologist' (12%) or 'should probably see a rheumatologist' (15%). Fifteen per cent of referrals to orthopaedics were defined as 'could see either a surgeon or a rheumatologist'. Ninety-four per cent of referrals to rheumatology were defined as appropriate, 2% were not and 4% were defined as 'could see either a surgeon or a rheumatologist'. One year later, in a random sample of 373 of the orthopaedic referrals, 42.2% of those who were categorized as 'should see surgeon' and 9.7% of the 'should see a physician' group were listed for surgical intervention. CONCLUSIONS: Many referrals to hospital-based musculoskeletal services are likely to be misdirected. Integrated referral and care pathways are required for efficient and optimal care of patients with musculoskeletal diseases. The development of such pathways will require significant support, education and training for general practitioners.

Bone density in chronic low back pain: a pilot study.

BACKGROUND AND OBJECTIVE: Levels of physical activity in chronic low back pain patients are relatively low due to their fear of provoking pain. This may have a secondary impact on maintenance of bone mass. The objective of this study is to determine if patients with chronic low back pain are at a higher risk of bone demineralization. DESIGN: Bone mineral density (BMD) was measured in 25 chronic low back pain patients at the lumbar spine, hip and distal forearm. SETTING: A university hospital. SUBJECTS: Twenty-five chronic low back pain patients (mean age 45 years) enrolled on a residential back pain rehabilitation programme. RESULTS: Thirteen patients (52%) were osteopenic or osteoporotic in one or more sites. BMD at the lumbar spine was generally lower than the mean BMD of age-matched subjects (p = 0.04). There was no significant relationship between BMD and duration of pain, disability, sex or previous surgical intervention. CONCLUSIONS: Chronic low back pain patients have an increased incidence of osteopenia and osteoporosis. This finding reinforces the importance of motivating patients to incorporate exercise into daily life. Given the limited set of subjects used in the present study, further studies are required.

A negative search for a paramyxoviral etiology of Paget's disease of bone: molecular, immunological, and ultrastructural studies in UK patients.

Paget's disease of bone is a common bone disease characterized by increased and disorganized bone remodeling at focal sites throughout the skeleton. The etiology of the disease is unresolved. A persistent viral infection has long been suggested to cause the disease. Antigen and/or nucleic acid sequences of paramyxoviruses (in particular measles virus [MV], canine distemper virus [CDV], and respiratory syncytial virus [RSV]) have been reported in pagetic bone by a number of groups; however, others have been unable to confirm this and so far no virus has been isolated from patients. Here, we reexamined the question of viral involvement in Paget's disease in a study involving 53 patients with established disease recruited from seven centers throughout the United Kingdom. Thirty-seven patients showed clear signs of active disease by bone scan and/or histological assessment of the bone biopsy specimens and 12 of these had not received any therapy before samples were taken. Presence of paramyxovirus nucleic acid sequences was sought in bone biopsy specimens, bone marrow, or peripheral blood mononuclear cells using reverse-transcription polymerase chain reaction (RT-PCR) with a total of 18 primer sets (7 of which were nested), including 10 primer sets (including 3 nested sets) specifically for MV or CDV. For each patient at least one sample was tested with all primer sets by RT-PCR and no evidence for the presence of paramyxovirus RNA was found in any patient. In 6 patients, bone biopsy specimens with clear histological evidence of active disease tested negative for presence of measles and CDV using immunocytochemistry (ICC) and in situ hybridization (ISH). Intranuclear inclusion bodies, similar to those described by others previously, were seen in pagetic osteoclasts. The pagetic inclusions were straight, smooth tubular structures packed tightly in parallel bundles and differed from nuclear inclusions, known to represent MV nucleocapsids, in a patient with subacute sclerosing panencephalitis (SSPE) in which undulating, diffuse structures were found, arranged loosely in a nonparallel fashion. In the absence of amplification of viral sequences from tissues that contain frequent nuclear inclusions and given that identical inclusions are found in other bone diseases with a proven genetic, rather than environmental, etiology, it is doubtful whether the inclusions in pagetic osteoclasts indeed represent viral nucleocapsids. Our findings in this large group of patients recruited from throughout the United Kingdom do not support a role for paramyxovirus in the etiology of Paget's disease.

The effect of pamidronate on lumbar spine bone density and pain in osteoporosis secondary to systemic mastocytosis.

Three patients with osteoporosis secondary to systemic mastocytosis are described. With the exception of the typical rash of urticaria pigmentosa, spinal pain caused by osteoporosis was the most prominent symptom. Intermittent single i.v. infusions of pamidronate have controlled pain an improved lumbar spine bone density.

Testosterone concentrations in men on chronic glucocorticosteroid therapy.

To determine whether free (or active) testosterone concentrations are reduced in men receiving glucocorticosteroids for chronic inflammatory diseases, 17 men (mean age 55.5 years) receiving a mean daily dose of 16.3 mg prednisolone, and 13 control patients (mean age 52.2 years) receiving no prednisolone, were studied. Serum testosterone and the testosterone/sex hormone binding globulin (SHBG) ratio were measured. The testosterone/SHBG ratio (a measure of free (active) testosterone) was significantly reduced in patients treated with prednisolone (p = 0.026), thus showing that glucocorticosteroids reduce free testosterone in male patients. This may be an important cause of glucocorticosteroid-induced osteoporosis, and suggests an additional approach to bone prophylaxis and treatment.

Cyclical etidronate increases lumbar spine bone density in patients on long-term glucocorticosteroid therapy.

To determine whether cyclical etidronate modifies bone density in patients on chronic glucocorticosteroid therapy, annual bone density measurements were performed on 55 patients receiving glucocorticosteroids who were randomised to either continuous calcium supplementation or cyclical etidronate plus calcium supplementation in this secondary prevention study. Median L1-L4 lumbar spine bone density decreased by 0.7% in the calcium treated group after one year but increased by 3.1% in the group treated by calcium and etidronate (p = 0.00116). Median L1-L4 bone density decreased by 2.8% from baseline after two years in the calcium treated group but increased by 4.7% from baseline in the group treated by calcium and etidronate (p = 0.04). There were no significant effects of treatment on femoral neck density. Cyclical etidronate and calcium increased lumbar spine bone density in patients established on prednisolone treatment over a two-year period but had no effect on femoral density.

Pulmonary Mycobacterium kansasii infection: comparison of radiological appearances with pulmonary tuberculosis.

BACKGROUND: A study was undertaken to determine if there are differences in the radiological appearances at presentation between pulmonary infections caused by Mycobacterium kansasii and Mycobacterium tuberculosis. Correct recognition of the organism has important implications with regard to initial therapy and contact tracing. METHODS: The initial chest radiographs of 28 patients with pulmonary M kansasii infection were compared with those of 56 age, sex, and race matched patients with M tuberculosis infection. All patients in both groups were culture positive and none was known to be HIV positive. The radiographs were analysed independently by two radiologists who were unaware of the causative organism. RESULTS: Radiographic abnormalities in patients with M kansasii infection were more frequently unilateral and right side predominant, while those with tuberculosis more frequently involved a lower lobe. Air space shadowing involving more than one bronchopulmonary segment and pleural effusions were seen less frequently in M kansasii infection (four of 28 (14%) versus 30 of 56 (54%) and none of 28 versus 15 of 56 (27%)). Cavitation (21 of 28 (75%) versus 34 of 56 (61%) was seen to a similar extent in patients with M kansasii infection and in those with tuberculosis. Cavities tended to be smaller in patients with M kansasii infection (p < 0.01). CONCLUSIONS: Differences are seen in the radiographic appearances of pulmonary infection caused by M kansasii and M tuberculosis. These differences are not sufficient to allow a positive diagnosis on the basis of radiographic findings alone, but the presence of a pleural effusion or lower lobe involvement makes M kansasii infection very unlikely.

Pulmonary Mycobacterium kansasii infection: comparison of the clinical features, treatment and outcome with pulmonary tuberculosis.

BACKGROUND: In the United Kingdom Mycobacterium kansasii is the most common pulmonary non-tuberculous mycobacteria to cause disease in the non-HIV positive population. METHODS: The clinical features, treatment, and outcome of 47 patients (13 women) of mean (SD) age 58 (17) years with culture positive pulmonary M kansasii infection were compared with those of 87 patients (23 women) of mean (SD) age 57 (16) years with culture positive pulmonary M tuberculosis infection by review of their clinical and laboratory records. Each patient with M kansasii infection was matched for age, sex, race and, where possible, year of diagnosis with two patients with M tuberculosis infection. RESULTS: All those with M kansasii infection were of white race. Haemoptysis was more common in patients infected with M kansasii but they were less likely to present as a result of an incidental chest radiograph or symptoms other than those due to mycobacterial infection. Patients with M kansasii were also less likely to have a history of diabetes, but the frequency of previous chest disease and tuberculosis was similar. An alcohol intake of > 14 units/week was less frequent in those with M kansasii, but there were no significant differences in drug history, past and present smoking habit, occupational exposures, social class, or marital status. Patients with M kansasii received a longer total course of antimycobacterial therapy and, in particular, extended treatment with ethambutol and rifampicin was given. There was no significant difference in outcome between pulmonary M kansasii or M tuberculosis infection. CONCLUSIONS: There are group differences between the clinical features of the two infections but, with the possible exception of diabetes and alcohol intake, these features are unlikely to be diagnostically helpful. Treatment of M kansasii infection with ethambutol, isoniazid, and rifampicin in these patients was as effective as standard regimens given to patients infected with M tuberculosis.