Calcium and friggin Iron absorption

In an effort to understand a vegetarian family member's persistent anemia and osteopenia, i came to suspect that they could be inter-related. Nutrition was defiinitely an under-represented component in my training.

Calcium supplementation in clinical practice: a review of forms, doses, and indications.
"Most Americans do not meet the adequate intake (AI) for calcium; calcium supplements can help meet requirements...Calcium carbonate, the most cost-effective form, should be taken with a meal to ensure optimal absorption. Calcium citrate can be taken without food and is the supplement of choice for individuals with achlorhydria or who are taking histamine-2 blockers or protein-pump inhibitors...The maximum dose of elemental calcium that should be taken at a time is 500 mg. U.S. ..Absorption from calcium-fortified beverages varies and in general is not equal to that of milk...The risk of advanced and fatal prostate cancer has been associated with calcium intakes from food or supplements in amounts >1500 mg/d."

The inhibitory effect of dietary calcium on iron bioavailability: a cause for concern?"high intakes of dietary calcium can inhibit iron absorption if both are present in the same meal. The mechanism for the calcium-iron interaction is not known. A recent study has demonstrated that separating foods high in calcium from meals high in iron can prevent some of the calcium-induced inhibition of iron absorption."

Effect of tea and other dietary factors on iron absorption.
Several dietary factors can influence this absorption. Absorption enhancing factors are ascorbic acid and meat, fish and poultry; inhibiting factors are plant components in vegetables, tea and coffee (e.g., polyphenols, phytates), and calcium.

Pigmented Villonodular Synovitis

Recently a friend was diagnosed with PVNS as a cause of knee pain. It's a fascinating disease. I have compiled and plagerized some of my readings. References at the end.

• Epidemiology: Uncommon but not necessarily rare (1.8 cases per 1 million people per year). Affects synovial lined joints, bursae, and tendon sheaths. The knee is the most commonly affected joint, followed by the hip, ankle, small joints of the hands and feet, shoulder and elbow. more often in patients aged 20-50 years the knee (approximately 80%),usually is monoarticular. localized form occurs most frequently in the fingers—in particular, in the volar aspect of the first 3 fingers. It is the most common soft-tissue tumor of the hand.
  

• Etiology controversial, several theories based on histology (Localized lipid metabolic derangement, Repeated nontraumatic inflammation, A benign neoplastic process, A response to blood or blood products within the joint)
  

  "For unknown reasons, some or all of the synovial lining tissue of a joint occasionally undergoes a change and becomes diseased, wherein the joint lining tissue becomes thick and overgrown and accumulates a rust-colored, iron pigment known as hemosiderin. Strange, foamy cells and large (so-called "giant") cells with many nuclei also appear. The overgrowth of the joint lining tissue can occur diffusely throughout a joint by way of a generalized thickening of the entire lining membrane, or a localized area of synovial membrane can overgrow and form a discrete nodule (tissue mass) that remains attached to the rest of the internal joint lining by way of a stalk."ref

• 2 forms:
  
• Diffuse joint involvement: affects the entire synovial lining of a (typically involves the large joints) joint, bursa, or tendon sheath,
  
• The rare localized form of the disease usually has a female predominance and presents as a pain-free, slowly enlarging mass most frequently occurring on the flexor aspect of the fingers. rare focal localized form typically occurs around the small joints of the hands and feet. Often appears around tendon sheaths, in which case it is termed giant cell tumor of the tendon sheath. Rarely, the localized form may develop around large joints. (The term PVNS is used when the condition, in either diffuse or localized form, affects a joint.)
  

• History: insidious onset, slow progression, nonspecific presentation (Intermittent swelling and stiffness, diffuse discomfort rather than severe focal pain, usually not preceded by trauma, occasionally a "popping" sensation). The swelling is disproportionate to the degree of pain. Acute pain may occur with nodular torsion and/or infarction. Most common incorrect working diagnoses were patellofemoral syndrome and meniscal lesion (also inflammatory arthritis, ligament instability).

• Exam: 96% have distention of the suprapatellar pouch and a large warm tender effusion. 40% have a diffuse palpable synovial mass, one or more palpable nodules. Slightly decreased ability to flex and extend the joint. mild to moderate tenderness, mainly over the medial patellofemoral area. Arthrocentesis usually yields blood-tinged synovial fluid without preceding traum.


• Imaging: plays an important role in the diagnosis, treatment, and follow-up monitoring of the disorder.

• Xray is often normal and can not determine the extent of disease.
  
• may see effusion (Occasionally dense from hemosiderin).
• may see periarticular soft tissue density
• expansion of the suprapatellar pouch and patellofemoral osseous changes (abnormal tracking as synovial mass lifts/stretches extensor mech)
• sometimes osteopenia and secondary degenerative changes may occur later (concentric cartilage space narrowing, subchondral cyst, and osteophyte formation)
• Calcifications are NOT a usual feature. Rarely, foci of dystrophic calcification. Differentiating calcifications from hemosiderin-laden foci may be difficult on MRI, XRAY should be used in this setting to confirm or deny.
  
• Well-corticated pressure erosions (saucerization) and cysts may occur on either side or both sides of the joint.
• Nodular form most commonly results in localized swelling of the palmar aspect of a finger.
  
• Arthrography demonstrates multiple, irregular, nodular filling defects of variable sizes. These produce the typical cobblestone appearance of the synovium.
  
• bone scan is not very helpful. Hypervascularity and areas of erosion may result in increased radionuclide uptake. Soft-tissue masses often demonstrate increased uptake on blood-pool images.
• CT does not completely show extent of disease and other pathology around or within the joint. Useful for needle biopsy guidance and for preoperative planning. Findings invariably are diagnostic:
• lesions appear hyperdense due to the presence hemosiderin,
  
• valuable in delineating bone cysts and erosions.
• Affected synovium is hypervascular and generally enhances following administration of radiographic contrast.
  
• MRI is imaging modality of choice in the evaluation of synovial and soft-tissue lesions. Variable appearance, depending on relative composition proportions of hemosiderin, lipid, fibrous tissue, cyst formation, and cellular elements. MRI findings are diagnostic >95% of patients. Rarely, confused with synovial osteochondromatosis (xrays can help). MRI findings:
• nodular intra-articular masses Low signal intensity (T1-, T2-, and proton density) due to hemosiderin deposits within the affected tissue and is accentuated on T2.
• lipid-laden macrophages, resulting in focal regions of high T1 and intermediate T2.
• Hyperplastic and hypervascular synovium enhances with gadolinium.
• Bony erosions (when present) and extra-articular extension of the lesion are well demonstrated on MRI.

• 

• Differential Diagnosis: Osteoarthritis, Inflammatory arthritis, Rheumatoid arthritis, Psoriatic arthritis, tuberculosis, hemophilic arthropathy, synovial hemangioma, amyloid arthropathy, Systemic lupus erythematosus, Septic arthritis, Synovial chondromatosis, Pigmented villonodular synovitis, Benign or malignant bone tumor
• Definitive Diagnosis: synovial biopsy

• Pathology: Grossly, large effusions, bony erosions, proliferative hyperplastic synovium with brownish villonodular fronds. Two types of villi are present in the diffuse form of PVNS, including coarse villi with a "shag carpet" appearance, and fine or fernlike villi. The nodular component is seen predominantly in tendinous or extra-articular lesions. The nodules are well demarcated and may be sessile or pedunculated, although they lack a true capsule. Histologically, mononuclear/histiocytic infiltrate in fibrous stroma of synovial membrane Hemosiderin-laden macrophages give the characteristic brown color; also lipid-laden foam cells and multinucleated giant cells. Hemosiderin lends the tissue a characteristic pigmented appearance. The lesions tend to be hypervascular and demonstrate synovial hyperplasia.

• Treatment: Synovectomy. Curettage/bone grafting as necessary.. high rate of local recurrence. Synovectomy may not relieve all symptoms in patients with significant destructive changes in the joint. In these situations, arthrodesis or total joint replacement should be considered. Radiotherapy can be considered in patients with previous adequate resection of disease who experience local relapse and in patients with a large amount of disease in whom complete resection is not possible.(13 of 14 were disease-free at a mean follow-up period of 69 months).
  

"Clinicians should always keep in mind the possibility of PVNS when presented with a patient who is suffering from unexplained, recurrent fluid accumulations in one of their joints, especially when the joint fluid has a slightly more orange-brown color to it than normal." ref

References:

1. Emedicine
2. AAFP
3. Kneeandshoulder
4. Interesting patient experiences

Most Patients Prefer Their Physicians to Greet Them With a Handshake and Introduction

Arch Intern Med. 2007;167:1172-1176.

"Physicians should be encouraged to shake hands with patients but remain sensitive to nonverbal cues that might indicate whether patients are open to this behavior," the authors write. "Given the diversity of opinion regarding the use of names, coupled with national patient safety recommendations concerning patient identification, we suggest that physicians initially use patients' first and last names and introduce themselves using their own first and last names. Greetings create a first impression that may extend far beyond what is conventionally seen as 'bedside manner.'"...More women than men and African Americans than whites preferred that the physicians use both first and last names when introducing him or herself...Other physician characteristics of value to patients interviewed by telephone included smiling, being friendly, being warm and respectful, and being attentive and calm.

Intervertebral Disk Transplantation Shows Promise in Spine Disease

Lancet. 2007;369:993-999, 968-967.

March 22, 2007 — Preliminary experience in 5 patients with degenerative spine disease suggests that transplantation of fresh-frozen intervertebral disks preserved motion and stability of the spinal unit, despite some signs of mild degeneration in the disks over follow-up. Neurologic symptoms in all patients were also improved compared with before-surgery levels...The authors report that by the end of 3 months after surgery, good union of the graft end plates was seen in all patients...One patient with incomplete paraplegia caused by trauma, for example, improved to Frankel Grade D at final follow-up, from Grade B prior to surgery....No patient had any signs of immunoreaction to the graft. There was no olisthesis, but some mild degenerative changes were seen in the transplanted disks, they note..."I think this is a feasible surgical alternative to spinal fusion or artificial disk replacement," Dr. Luk told Medscape. "In a fusion, the motion of the segment will be lost. For artificial disk replacement, the major concern is the long-term outcome and the difficulties and risks with revision surgery. This biological approach enables the body to remodel the graft according to biomechanical laws."

Introduction to EOVA Geek Club

People participate in journal clubs or book clubs. Geek Club is my affectionate term for documenting summaries of all the geeky stuff I read.

I work at the East Orange VA hospital in NJ. This may also serve as a resource for the residents who rotate through there.

I hope you will enjoy.