Changing the awareness of low vitamin D status in a rheumatology population: a pre/post-study.

INTRODUCTION: In 2009 hypovitaminosis D was highly prevalent in a population of Swiss rheumatology patients (86%). We aimed to evaluate the evolution of vitamin D status in the same population two years later, after the results of the first study were disseminated to local physicians and patients, in order to determine the evolution of the problem and the impact of physician information. METHOD: Patients in our rheumatology clinic were screened for 25-OH vitamin D. Results were categorised as: deficient (<10 ng/ml or <25 nmol/l), insufficient (10 to 30 ng/ml or 25 to 75 nmol/l) or normal (>30 ng/ml or >75 nmol/l). We also used another cut-off of 20 ng/ml (50 nmol/l). We evaluated the evolution of 25-OH vitamin D dosages and vitamin D3 prescriptions between 2008 and 2011 in our institution and the number of publications on vitamin D in three important medical journals of the French speaking part of Switzerland. RESULTS: Compared with 2009, significantly more patients had normal results in 2011. Fifty-two percent of patients had levels >20 ng/ml in 2009 and 66% in 2011, difference statistically significant (p = 0.001). During the years separating the two study periods the number of 25-OH vitamin D dosages and the prescription of high doses of vitamin D3 increased in our hospital. In addition the number of publications on vitamin D increased between 2008 and 2011. CONCLUSION: We concluded that lower prevalence in hypovitaminosis D is certainly related to better adherence to daily supplements, and to better information and awareness of the physicians about hypovitaminosis D.

Magnetic resonance coronary lumen and vessel wall imaging.

Coronary magnetic resonance angiography (MRA) is a technique aimed at establishing a noninvasive test for the assessment of significant coronary stenoses. There are certain boundary conditions that have hampered the clinical success of coronary MRA and coronary vessel wall imaging. Recent advances in hardware and software allow for consistent visualization of the proximal and mid portions of the native coronary arteries. Current research focuses on the use of intravascular MR contrast agents and black blood coronary angiography. One common goal is to create a noninvasive test which might allow for screening for major proximal and mid coronary artery disease. These novel approaches will represent a major step forward in diagnostic cardiology.

Surgery for ruptured thoracic and thoraco-abdominal aortic aneurysms.

OBJECTIVE: To assess the outcome of patients with ruptured descending thoracic and thoracoabdominal aortic aneurysms undergoing emergency repair, in comparison to elective surgery for chronic lesions. METHODS: A prospective study of 100 consecutive patients operated upon the descending aorta (1-8 segments) using proximal unloading and distal protection with partial cardiopulmonary bypass, heparin surface-coated perfusion equipment and low systemic heparinization (loading dose 100 IU/kg, activated coagulation time > 180 s), staged cross-clamping, sealed grafts and graft inclusion. RESULTS: Arteriosclerotic lesions were present in 53/100 patients (53%) for all, 30/53 (56%) for chronic, and 21/33 (63%) for ruptured, aneurysms (NS). Dissecting lesions were found in 38/100 patients (38%) for all, 20/53 (38%) for chronic, and 8/33 (24%) for ruptured aneurysms (NS). Preoperative hematocrit was 38 +/- 6% for all, 40 +/- 5% for chronic, and 33 +/- 5% for ruptured aneurysmal patients (P < 0.001 ruptured versus chronic). The extent of aortic repair (1-8 segments) was 3.3 +/- 1.6 for all, 3.5 +/- 1.5 for chronic, and 3.2 +/- 1.4 for ruptured, aneurysms (NS). Transdiaphragmatic repair was performed in 51/100 (51%) of all, 28/53 (53%) of chronic, and 17/33 (51%) of ruptured aneurysms (NS). Aortic cross-clamp time was 38 +/- 21 min for all, 39 +/- 24 min for chronic, and 38 +/- 17 min for ruptured, aneurysmal patients (NS). The amount of red cells washed and autotransfused was 2792 +/- 2239 ml in all, 3143 +/- 2531 ml in chronic, and 2074 +/- 1350 ml in ruptured, aneurysmal patients (P < 0.025). The amount of packed red cells required was 2181 +/- 1830 ml for all, 1736 +/- 1333 ml for chronic, and 2947 +/- 2395 ml for ruptured aneurysmal patients (P < 0.010). Thirty-day mortality was 9/100 (9%) for all, 3/53 (6%) for chronic, and 5/33 (15%) for ruptured aneurysmal patients (NS). Parapareses/plegias occurred in 9/100 (9%) of all, 6/53 (11%) of chronic, and 3/33 (9%) of ruptured, aneurysmal patients (NS). Stepwise regression analysis identified aortic cross-clamp time as a predictor of early mortality (P = 0.002) and parapareses and paraplegias (P = 0.001). Age (P = 0.001), extent of repair (P = 0.008) and preoperative hematocrit (P = 0.001) were predictors for homologous transfusion requirements. CONCLUSION: Emergency repair of ruptured descending thoracic and thoracoabdominal aortic aneurysms can be achieved with acceptable results.

Visceral leishmaniasis in Teresina, state of Piauí, Brazil: preliminary observations on the detection and transmissibility of canine and sandfly infections

A Leishmania donovani-complex specific DNA probe was usedto confirm the widespread dissemination of amastigotes in apparently normal skinof dogs with canine visceral leishmaniasis. When Lutzomyia longipalpis were fed on abnormal skin of five naturally infected dogs 57 of 163 (35 per cent) fliesbecame infected: four of 65 flies (6 per cent) became infected when fed on apparently normal skin. The bite of a single sandfly that had fed seven days previouslyon a naturally infected dog transmitted the infection to a young dog from a non-endemic area. Within 22 days a lesion had developed at the site of the infectivebite (inner ear): 98 days after infection organisms had not disseminated throughout the skin, bone marrow, spleen or liver and the animal was still serologically negative by indirect immunofluorescence and dot-enzyme-linked immunosorbent assay. When fed Lu. longipalpis were captured from a kennel with a sick dog known to be infected, 33 out of 49 (67 per cent) of flies contained promastigotes. In contrast only two infections were detected among more than 200 sandflies captured in houses. These observations confirm the ease of transmissibility of L.chagasi from dog to sandfly to dog in Teresina. It is likely that canine VL is the major source of human VL by the transmission route dog-sandfly-human. the Lmet2 DNA probe was a useful epidemiological tool for detecting L. chagasi in sandflies.

Leishmaniasis dissemineted by Leishmania braziliensis in a mare (Equus cabalus) immunotherapy and chemotherapy assays

Cutaneous disseminated lesions caused by Leishmania sp. were found in a pregnant mare (Equus cabalus) from a rural city in the State of rio de Janeiro, Brazil. Before delivering, treatment was undertaken by immunotherapy followed by chemotherapy. Histopatology and serology were performed during treatment, as well as the biochemical characterization of the parasite (L. braziliensis) that was isolated from one of the lesions.

Complication of carotid stenting: incomplete misdeployment of the stent in the femoral artery.

OBJECTIVES: The presence of intravascular foreign bodies is underreported in the literature and is more commonly encountered in clinical practice. We report on a case where an attempt to position a carotid stent resulted in misdeployment of the stent in the femoral artery and its surgical removal. METHODS: A 63-year-old patient admitted to hospital for cerebral stroke underwent thrombolysis for occlusive dissection of right carotid artery and was transferred to our hospital for additional thrombo-aspiration and carotid stenting. RESULTS: The carotid stent was misdeployed incompletely in the femoral artery and had to be removed surgically. CONCLUSIONS: Appropriate knowledge of intravascular migration and deployment failure management should be considered as important as the optimal device deployment.

Calomys callosus: an alternative model to study fibrosis in Schistosomiasis mansoni: the pathology of the acute phase

Twenty Calomys callosus, Rengger, 1830 (Rodentia-Cricetidae) were studied in the early stage of the acute schistosomal mansoni infection (42nd day). The same number of Swiss Webster mice were used as a comparative standard. Liver and intestinal sections, fixed in formalin-Millonig and embedded in paraffin, were stained with hematoxilin and eosin, PAS-Alcian Blue, pH = 1.0 and 2.5, Lennert's Giemsa, Picrosirius plus polarization microscopy, Periodic acid methanamine silver, Gomori's silver reticulin and resorcin-fuchsin. Immunohistological study (indirect immunofluorescence and peroxidase labeled extravidin-biotin methods) was done with antibodies specific to pro-collagen III, fibronectin, elastin, condroitin-sulfate, tenascin, alpha smooth muscle actin, vimentin and desmin. The hepatic granulomas were small, reaching only 27 of the volume of the hepatic Swiss Webster granuloma. They were composed mainly by large immature macrophages, often filled by schistosomal pigment, characterizing an exsudative-macrophage granuloma type. The granulomas were situated in the parenchyma and in the portal space. They were often intravascular, poor of extracellular matrix components, except fibronectin and presented, sometimes alpha smooth muscle actin and vimentin positive cells. The C. callosus intestinal granulomas were similar to Swiss Webster, showing predominance of macrophages. Therefore, the C. callosus acquire very well the Schistosoma mansoni infection, without developing strong hepatic acute granulomatous reaction, suggesting lack of histopathological signs of hypersensitivity.

Repair of schistosomal intestinal vascular lesions after curative treatment

The process of repairing intestinal vascular lesions induced by schistosomiasis in mice was studied before and after curative chemotherapy, by means of histopathology coupled with injections of the mesenteric veins with India ink or plastic, in this case followed by corrosion in strong acid. The granulomas were avascular, mainly formed while within blood vessels, and were associated with distortion of the intestinal vasculature in their proximity, represented by tortuosities, focal dilatation, narrowing, and anastomosis of the mucosal and submucosal veins. Two to four months after cure of schistosomiasis involuting granulomas were seen to be slowly vascularized, a process going from the periphery toward the center of the granulomas. No intravascular granulomas were seen four months after treatment. The previously distorted mucosal and submucosal veins gradually regained their normal appearance, only a slight tortuosity remaining.

Tuberculosis in HIV-negative and HIV-infected patients in a low-incidence country: clinical characteristics and treatment outcomes.

BACKGROUND: In Switzerland and other developed countries, the number of tuberculosis (TB) cases has been decreasing for decades, but HIV-infected patients and migrants remain risk groups. The aim of this study was to compare characteristics of TB in HIV-negative and HIV-infected patients diagnosed in Switzerland, and between coinfected patients enrolled and not enrolled in the national Swiss HIV Cohort Study (SHCS). METHODS AND FINDINGS: All patients diagnosed with culture-confirmed TB in the SHCS and a random sample of culture-confirmed cases reported to the national TB registry 2000-2008 were included. Outcomes were assessed in HIV-infected patients and considered successful in case of cure or treatment completion. Ninety-three SHCS patients and 288 patients selected randomly from 4221 registered patients were analyzed. The registry sample included 10 (3.5%) coinfected patients not enrolled in the SHCS: the estimated number of HIV-infected patients not enrolled in the SHCS but reported to the registry 2000-2008 was 146 (95% CI 122-173). Coinfected patients were more likely to be from sub-Saharan Africa (51.5% versus 15.8%, P<0.0001) and to present disseminated disease (23.9% vs. 3.4%, P<0.0001) than HIV-negative patients. Coinfected patients not enrolled in the SHCS were asylum seekers or migrant workers, with lower CD4 cell counts at TB diagnosis (median CD4 count 79 cells/µL compared to 149 cells/µL among SHCS patients, P = 0.07). There were 6 patients (60.0%) with successful outcomes compared to 82 (88.2%) patients in the SHCS (P = 0.023). CONCLUSIONS: The clinical presentation of coinfected patients differed from HIV-negative TB patients. The number of HIV-infected patients diagnosed with TB outside the SHCS is similar to the number diagnosed within the cohort but outcomes are poorer in patients not followed up in the national cohort. Special efforts are required to address the needs of this vulnerable population.

The new direct oral anticoagulants in special indications: rationale and preliminary data in cancer, mechanical heart valves, anti-phospholipid syndrome, and heparin-induced thrombocytopenia and beyond.

The present review will briefly summarize the interplay between coagulation and inflammation, highlighting possible effects of direct inhibition of factor Xa and thrombin beyond anticoagulation. Additionally, the rationale for the use of the new direct oral anticoagulants (DOACs) for indications such as cancer-associated venous thromboembolism (CAT), mechanical heart valves, thrombotic anti-phospholipid syndrome (APS), and heparin-induced thrombocytopenia (HIT) will be explored. Published data on patients with cancer or mechanical heart valves treated with DOAC will be discussed, as well as planned studies in APS and HIT. Although at the present time published evidence is insufficient for recommending DOAC in the above-mentioned indications, there are good arguments in favor of clinical trials investigating their efficacy in these contexts. Direct inhibition of factor Xa or thrombin may reveal interesting effects beyond anticoagulation as well.

Treatment of atypical hemolytic uremic syndrome and thrombotic microangiopathies: a focus on eculizumab.

Uncontrolled complement activation is central to the occurrence of atypical hemolytic uremic syndrome (aHUS) and can result in thrombotic microangiopathies (TMAs).These terms encompass a group of heterogenic inherited or acquired diseases that recent research suggests may be triggered by the complement cascade. Pathogenetic triggers of complement activation include immunologic disorders, genetics, infections, systemic diseases, pregnancy, drug administration, metabolic diseases, transplantation, or triggers of mixed cause. Hallmarks of aHUS and other TMAs include increased vascular endothelium thromboresistance, leukocyte adhesion to damaged endothelium, complement consumption, coagulation abnormalities, and vascular shear stress, whereas common end points of these mechanisms include hemolytic anemia, thrombocytopenia with microvascular infarction, and predisposition for decreased kidney function and other organ involvement. The central role of the complement cascade as a disease trigger suggests a possible therapeutic target. Eculizumab, a first-in-class humanized monoclonal anti-C5 antibody that has been successful in the treatment of paroxysmal nocturnal hemoglobinuria, a disorder of complement-induced hemolytic anemia, received approval for the treatment of aHUS in the United States and Europe in late 2011. We review the treatment of aHUS and other TMAs, focusing on the role of eculizumab, including its pharmacology, mechanism of action, and approved dosing recommendations and health economic considerations. Finally, the potential for future indications for eculizumab use in other complement-driven diseases is discussed.

Lufaxin, a novel factor Xa inhibitor from the salivary gland of the sand fly Lutzomyia longipalpis blocks protease-activated receptor 2 activation and inhibits inflammation and thrombosis in vivo.

OBJECTIVE: Blood-sucking arthropods' salivary glands contain a remarkable diversity of antihemostatics. The aim of the present study was to identify the unique salivary anticoagulant of the sand fly Lutzomyia longipalpis, which remained elusive for decades. METHODS AND RESULTS: Several L. longipalpis salivary proteins were expressed in human embryonic kidney 293 cells and screened for inhibition of blood coagulation. A novel 32.4-kDa molecule, named Lufaxin, was identified as a slow, tight, noncompetitive, and reversible inhibitor of factor Xa (FXa). Notably, Lufaxin's primary sequence does not share similarity to any physiological or salivary inhibitors of coagulation reported to date. Lufaxin is specific for FXa and does not interact with FX, Dansyl-Glu-Gly-Arg-FXa, or 15 other enzymes. In addition, Lufaxin blocks prothrombinase and increases both prothrombin time and activated partial thromboplastin time. Surface plasmon resonance experiments revealed that FXa binds Lufaxin with an equilibrium constant ≈3 nM, and isothermal titration calorimetry determined a stoichiometry of 1:1. Lufaxin also prevents protease-activated receptor 2 activation by FXa in the MDA-MB-231 cell line and abrogates edema formation triggered by injection of FXa in the paw of mice. Moreover, Lufaxin prevents FeCl(3)-induced carotid artery thrombus formation and prolongs activated partial thromboplastin time ex vivo, implying that it works as an anticoagulant in vivo. Finally, salivary gland of sand flies was found to inhibit FXa and to interact with the enzyme. CONCLUSIONS: Lufaxin belongs to a novel family of slow-tight FXa inhibitors, which display antithrombotic and anti-inflammatory activities. It is a useful tool to understand FXa structural features and its role in prohemostatic and proinflammatory events.

Selectin ligands on leukemic cells

RESUME L'infiltration tissulaire par les cellules leucémiques, responsable de leucostase, est une complication grave de la leucémie aiguë hyperleucocytaire. Elle peut entraîner une détresse respiratoire et des troubles neurologiques de mauvais pronostic. Pendant longtemps, la prolifération intravasculaire des cellules leucémiques et l'augmentation de la viscosité étaient considérées comme en étant responsables, et le traitement reposait sur une cytoréduction rapide par leucaphérèse. Actuellement, l'interaction entre les cellules leucémiques et l'endothélium vasculaire est plutôt considérée comme la cause de ce phénomène. En effet, les cellules leucémiques peuvent induire l'expression des sélectives endothéliales. Les sélectives initient le roulement des leucocytes avant leur adhésion ferme et leur migration dans les tissus. Elles reconnaissent des ligands spécifiques exprimés à la surface des leucocytes, comme PSGL-1 qui est un ligand commun des sélectives. Cependant, plusieurs études suggèrent que d'autres ligands de la E-sélective soient exprimés par les leucocytes. L'interaction des cellules leucémiques avec la E- et la P- sélective est corrélée avec l'expression de la molécule CLA, reconnue par l'anticorps HECA-452. L'immunopurification des ligands de la E-sélective avec cet anticorps a permis d'isoler, des cellules THP1 et U937, une protéine de 170 kDa, ainsi qu'une autre protéine de 250 kDa des cellules U937, en plus de PSGL-1. Ces protéines ont également été purifiées avec la protéine de fusion Esélective/IgM. CD43 et CD44 semblent être des ligands de la E-sélective sur certaines lignées, mais leur interaction avec la E-sélective n'est pas toujours retrouvée. De plus, cette étude a permis de montrer que ces ligands de la E-sélectiné sont exprimés dans les rafts lipidiques, comme PSGL-1 et la L-sélective des neutrophiles. Ces deux nouveaux ligands sont en cours d'identification. Ils pourraient représenter une nouvelle cible dans le traitement de la leucostase, mais aussi lors d'inflammation chronique ou de métastases. ABSTRACT Leukostasis is alife-threatening complication of acute leukemia, that results from tissue infiltration of leukemic blasts that migrate out of blood flow and interfere with normal tissue functions. The process leading to these complications has been attributed to the overcrowding of leukemic cells in the microcirculation. However, leukostasis more likely results from the adhesive interactions between leukemic blasts and the endothelium. Activated endothelium express adhesion molecules like P- and E-selectin, and leukemic cells themselves can induce the expression of E-selectin on endothelial cells. Selectins are essential in initiating the rolling of intravascular cells on endothelium before firm adhesion and transmigration outside of blood vessels. They interact with specific ligands on leukocyte cell surface. P-selectin glycoprotein ligand-1 (PSGL-1) is common ligand for E-, P- and L-selectin. Recently, CD44, ESL-1 and CD44 were shown to cooperate. ìn supporting mouse neutrophil adhesion to E-selectin. Other E-selectin ligands remain to be identified in humans. Leukemic cells were screened in order to characterize human E-selectin ligands. The interactions of E- and P-selectin correlate with the expression of CLA epitope. Therefore, HECA-452 mAb that recognizes CLA was used for immunopurification. Aglycoprotein of 170 kDa was purified from THP1 and U937 cells, and a protein of 250 kDa from U937 cells. These proteins were also purified by affinity binding to E-selectin/IgM chimera. PSGL-1 bound to E-selectin as expected, but CD43 and CD44 were not always adsorbed on E-selectin chimera, depending on cell types. E-selectin ligands were also shown to be in lipid rafts in leukemic cells, like PSGL-1 and L-selectin in human neutrophils. The 170 kDa protein has been sequenced, and three interesting ligands were among the candidates: ESL-1, CD44 and podocalyxin. These ligands are under investigation, and may represent a new therapeutic target in leukostasis, inflammation or cancer metastasis.

Canine experimental infection: intradermal inoculation of Leishmania infantum promastigotes

Five mixed breed dogs were inoculated intradermally (ID) with cultured virulent stationary phase promastigotes of Leishmania infantum Nicole, 1908 stocks recently isolated. Parasite transformations in the skin of ID infected dogs were monitored from the moment of inoculation and for 48 h, by skin biopsies. Anti-Leishmania antibody levels were measured by indirect immunofluorescence assay, counterimmunoelectrophoresis and direct agglutination test, and clinical conditions were examined. Thirty minutes after ID inoculation the first amastigotes were visualised and 3 to 4 h after inoculation the promastigotes were phagocyted by neutrophils and by a few macrophages. These cells parasitised by amastigotes progressively disappeared from the skin and 24 h after inoculation parasites were no longer observed. Local granulomes were not observed, however, serological conversion for antibodies anti-Leishmania was achieved in all dogs. Direct agglutination test was the only technique positive in all inoculated dogs. Amastigotes were found in the popliteal lymph node in one dog three months after inoculation. This work demonstrates that, with this inoculum, the promastigotes were transformed into amastigotes and were up taken by neutrophils and macrophages. The surviving parasites may have been disseminated in the canine organism, eliciting a humoral response in all cases.

Whole-heart coronary vein imaging: a comparison between non-contrast-agent- and contrast-agent-enhanced visualization of the coronary venous system.

The feasibility of three-dimensional (3D) whole-heart imaging of the coronary venous (CV) system was investigated. The hypothesis that coronary magnetic resonance venography (CMRV) can be improved by using an intravascular contrast agent (CA) was tested. A simplified model of the contrast in T(2)-prepared steady-state free precession (SSFP) imaging was applied to calculate optimal T(2)-preparation durations for the various deoxygenation levels expected in venous blood. Non-contrast-agent (nCA)- and CA-enhanced images were compared for the delineation of the coronary sinus (CS) and its main tributaries. A quantitative analysis of the resulting contrast-to-noise ratio (CNR) and signal-to-noise ratio (SNR) in both approaches was performed. Precontrast visualization of the CV system was limited by the poor CNR between large portions of the venous blood and the surrounding tissue. Postcontrast, a significant increase in CNR between the venous blood and the myocardium (Myo) resulted in a clear delineation of the target vessels. The CNR improvement was 347% (P < 0.05) for the CS, 260% (P < 0.01) for the mid cardiac vein (MCV), and 430% (P < 0.05) for the great cardiac vein (GCV). The improvement in SNR was on average 155%, but was not statistically significant for the CS and the MCV. The signal of the Myo could be significantly reduced to about 25% (P < 0.001).