A comparison between bisphosphonates and other treatments for osteoporosis.

Since their development 30 years ago, bisphosphonates are now one of the standard therapy in the management of osteoporosis. Improvements in terms of anti-resorptive potency have leaded to new molecules available either orally or intravenously, from weekly to yearly administration. Overall tolerance of bisphosphonates is good with regards to the risk of mandibular necrosis, not comparable with those observed in cancer treatment, and with no causal link yet established in osteoporotic patients. Compliance remains poor and should be improved by a better education of the patients about their treatment. Other treatments like teriparatide, raloxifene or strontium ranelate are now also available and give more therapeutic options but also more questions on the best molecule to choose for each patient. There is currently no valid basis for distinguishing in a formal and objective manner the different new-generation bisphosphonates, in terms of efficacy against either vertebral, peripheral or hip fractures. In a same way, comparison between bisphosphonates and the other treatments available for osteoporosis is hard in absence of proper randomised controlled study. This review gives an overview of the recent data on the efficacity and tolerance of bisphosphonates in the different forms of osteoporosis and compares them to the other treatments currently available.

Possible use of arthrodesis for intractable sacroiliitis in spondylarthropathy: report of two cases.

STUDY DESIGN: Two cases of successful sacroiliac joint arthrodesis for medically intractable aseptic sacroiliitis are reported. SUMMARY OF BACKGROUND DATA: Although successful arthrodesis of the sacroiliac joint had been reported previously for septic sacroiliitis, no report had shown the procedure to be effective for spondylarthropathy. METHODS: Two women with spondylarthropathy involving very painful sacroiliac arthritis for 18 and 24 months had been relieved only transiently by several injections of steroids into the sacroiliac joint under fluoroscopy and by Bermuda casts. Both patients underwent sacroiliac joint arthrodesis. RESULTS: Both patients showed dramatic improvement after sacroiliac joint arthrodesis. Moreover, no relapses had occurred, respectively, after 2 and 3 years of follow-up evaluation despite continuing spondylarthropathy in other joints. CONCLUSIONS: After a careful selection of patients, including positive blocks in the sacroiliac joint, arthrodesis of sacroiliac joint might be considered for so-called "intractable" aseptic sacroiliitis.

[Horton's disease in elderly patients aged over 75: clinical course, complications of corticotherapy. Comparative study of 164 patients. Towards a reduced initial dose]. / Maladie de Horton du sujet âgé de plus de 75 ans: particularites évolutives, complications de la corticothérapie. Etude comparative sur une série de 164 patients. Vers une dose d'attaque réduite.

PURPOSE: Our study compares clinical and therapeutic courses (corticosteroid response, corticosteroid amount, complications) in people with giant cell arteritis before and over 75 years, during the first year of treatment. METHODS: A series of 164 patients was retrospectively analysed (mean age: 73.3 years) among the two subgroups: before 75 and over 75 years. Patient received (monitoring of reduction in the corticosteroid dosage) a 240 mg intravenous bolus of methylprednisolone followed by 0.5 or 0.7 mg/kg/d of prednisone, or 0.7 mg/kg/d of prednisone without the bolus. RESULTS: Corticosteroid response was identical for the two groups, before and over 75 (patients with corticoresistance: 15% vs 11.4%; NS) and giant cell arteritis-related complications were equivalent (n = 2 vs n = 2; NS). Corticosteroid load was slightly lower in the elderly group (cumulative dose of corticosteroids during the first year of treatment 5.2 g vs 5.8 g; P = 0.03). Patients with rheumatic side effects (collapses of vertebral bodies, mainly) were more frequent in the elderly group (15.5% vs 4.3%; P = 0.01), in spite of a limited mean follow-up period (10.7 months). CONCLUSION: Even if steroid response was identical in the therapeutic course of giant cell arteritis, rheumatic side effects appeared more frequent in the elderly group (over 75 years). In order to obtain a corticosteroid-sparing effect, new studies are necessary to evaluate a reduced initial dosage of corticosteroids.

Do we use morphine often enough? An opinion survey in 100 rheumatology department patients.

PATIENTS AND METHODS: Shortly before their discharge from a rheumatology department, 100 patients with a mean age of 54 +/- 16 years completed a 20-item questionnaire on morphine therapy. Pain scale scores were 77.1 +/- 19 at admission and 44.2 +/- 24 at questionnaire completion. RESULTS: Thirty-three patients, including 27 with spinal or nerve root disorders, received morphine during their stay. Five of these patients had a malignancy. Among patients who received morphine, 21% (6/29) were disappointed with the drug. Only four of the patients who did not receive morphine (4%) wished they had. Thirty-six percent of patients (30/83) reported previous morphine therapy given by a primary care physician (10/30) or a specialist (14/30) and/or in a hospital (22/30). Only five patients (5/100, 5%) said they regretted not having received morphine for past pain; however, 45% (35/78) of patients agreed with the suggestion that French physicians do not use morphine often enough. Most patients (82%, 65/77) agreed that morphine can be used to treat pain due to rheumatic disorders, although 92% (83/90) felt that morphine should be reserved for "intolerable" pain. Only 37% (34/92) of the patients were apprehensive about using morphine, 57% (45/79) were aware of the risk of dependency, 66% (44/79) of the risk of behavioral or attention disorders, and 53% (41/78) of the risk of tolerance. CONCLUSION: Expectations of French rheumatology department patients about morphine use were roughly satisfactory. The mean pain scale score above which the patients felt morphine should be given was 70.5 +/- 20.

Intraarticular glucocorticosteroid injection into the lateral atlantoaxial joint under fluoroscopic control. A retrospective comparative study in patients with mechanical and inflammatory disorders.

OBJECTIVES: To evaluate the overall efficacy in various disorders of glucocorticoid injection into the lateral atlantoaxial joints, performed via the posterior route under fluoroscopic control. METHODS: Retrospective study of 26 patients including 16 (19 injections) with mechanical disorders and ten (16 injections) with inflammatory disorders. RESULTS: The response rate was 69.3%, the mean pain scale score decrease was 52.3 +/- 40.1%, and the mean duration of pain relief was 8.1 +/- 11.8 months. All three parameters were significantly (P < 0.005) better in the subgroup with inflammatory disorders than in the subgroup with mechanical disorders (response rate, 100% vs 50%; pain scale score decrease, 80 +/- 27% vs 34.2 +/- 40%, and pain relief duration, 16.9 +/- 14.9 months vs 24.5 months). A single patient developed a side effect (moderately severe hypertension). CONCLUSION: Glucocorticoid injection into the lateral atlantoaxial joints is a valid treatment alternative in patients who fail to respond to conventional noninvasive therapy.

Reasons for rheumatology department admission in 125 patients with disk-related sciatica.

OBJECTIVES: To identify medical and nonmedical reasons for admission of disk-related sciatica patients. PATIENTS AND METHODS: 125 patients were evaluated prospectively using a 25-items questionnaire, including seven items on medical reasons, four on psychological reasons, four on work-related reasons, six on social and family reasons, and four on miscellaneous reasons. RESULTS: Severe nerve root pain (34%), motor loss (17%), atypical clinical manifestations (13%), severe low back pain (8%), and/or sphincter dysfunction (4%) were recorded in only 55% of patients, and only 16% had at least two of these reasons. A minority of patients were admitted to avoid premature surgery (13%) or to try one more conservative approach prior to surgery (15%). Seventy-five per cent of patients reported at least one of the psychological reasons listed in the questionnaire (irritability/fatigue, 66%; anxiety, 42%; depression, 26%; panic disorder, 21%), 50% reported at least one work-related reason (workaholism, 21%; job offer, 16%; self-employed, 14%; fear of losing their job, 11%), 66% reported at least one social or family reason (living alone, 34%; one or more dependents younger than seven years of age, 32%; too many demands from household members, 22%; one or more dependents older than seven years of age, 8%; need to care for another person, 9%; important upcoming family or personal event, 6%), and 26% reported at least one miscellaneous reason (firm belief that sciatica can be cured only by inhospital treatment, 10%; desire to put pressure on the employer or on an expert, 7% and 6%, respectively; admission via the emergency room without prior medical advice, 6%). CONCLUSION: In France, the reason for admission of patients with disk-related sciatica is frequently a mixture of physical, psychological, and social problems, with only 55% of patients having a symptom requiring inhospital management.

[Tomodensitometric image of the lumbar spine. Study of 150 patients hospitalized for discal sciatica]. / Perception de la tomodensitométrie lombaire. Etude chez 150 patients hospitalisés pour sciatique discale.

OBJECTIVES: There would be some discordance between patient expectations and expert recommendations concerning computed tomography (CT) of the spine for discal disorders. We analyzed patient opinion. PATIENTS AND METHODS: At admission, a 25-item questionnaire was given to 150 patients hospitalized in a rheumatology unit for discal sciatica. Patients were asked to express their expectations concerning the CT exploration. RESULTS: Seventy percent of the patients had already undergone CT explorations requested by a general practitioner (55%) or a specialist (45%), 20% had had two CT explorations and 20% magnetic resonance imaging. Seventy-five percent felt they should have had a CT scan earlier, 85% thought a CT should be performed for back pain of less than one month duration and 96% in case of sciatica for 2 months or more. Patients felt their exploration came "late" because the physician was under financial pressure (52%), had incorrectly appreciated the patient's need (28%) or was incompetent in the matter (22%). Nevertheless, 15% of the patients recognized that the CT scan could be useless and 89% knew that all cases of hernia are not operable. Thirty percent recognized that hernias can go undetected on the CT scan and 78% that they may remain asymptomatic. Finally, 56% of the patients thought that the CT scan would not change their treatment and only 23% expected to undergo surgery sooner because of the CT exploration. DISCUSSION: Several factors would explain what patients expect from CT exploration of the spine: patient understanding that causes other than discal hernia can cause back pain (98%) or sciatic (77%); their fear of having another disorder (56% wanted to be reassured, which would explain in part why 27% hoped the CT would improve pain, 50% wanted to "see" their discal hernia, and 30 wanted to eliminate another cause of their pain); patient distrust of clinical diagnosis which they felt was less pertinent than CT (80% of the patients for generalists and 70% for specialists). Patient expectations did not appear to be limited by fear of irradiation (unrecognized by 90% of the patients) nor the cost of the exploration which was overestimated by 70% of them.

Diagnostic value for rheumatoid arthritis of antiperinuclear factor at the 1:100 threshold. Study of 600 patients and meta-analysis of the literature.

Six hundred sera from patients with chronic rheumatic diseases including 429 with rheumatoid arthritis were tested in a blind fashion for IgG antiperinuclear factor using an indirect fluorescent antibody assay on buccal cells. Using the dilution of 1:100 found to be optimal in an earlier study, 283 of the 429 (66%) rheumatoid arthritis sera and 22 of the 171 (13%) control sera were positive for antiperinuclear factor. Titers were higher in the rheumatoid arthritis group than in the control group. A meta-analysis of studies that used sera diluted 1:80 or 1:100 (2853 sera including 939 from patients with rheumatoid arthritis, 1539 from patients with other rheumatic diseases and 375 from healthy controls or patients with unclassified rheumatic diseases) yielded a sensitivity of 0.75, a specificity of 0.93, and a positive predictive value of 0.87. These data demonstrate that antiperinuclear factor testing contributes usefully to the diagnosis of rheumatoid arthritis.

Algodystrophy (reflex sympathetic dystrophy syndrome) and causalgia: novel concepts regarding the nosology, pathophysiology, and pathogenesis of complex regional pain syndromes. Is the sympathetic hyperactivity hypothesis wrong?

Concepts regarding the nosology, pathophysiology and pathogenesis of reflex sympathetic dystrophy syndrome are currently in a state of flux. Causalgia and reflex sympathetic dystrophy syndrome are now generally felt to be on the same continuum and as a result interest for defining criteria for the latter condition has waned. The pathogenic role of adrenergic sympathetic activity has been so successfully challenged that the last international consensus conference judged inappropriate any reference to the sympathetic system in the terms used to designate these conditions, thus confirming the position long defended by most French authors. The vasomotor abnormalities may be due to antidromic release of neuromediators by the endings of polymodal C fibers. These fibers do not belong to the sympathetic system but often travel with sympathetic nerves, a characteristic that may explain the efficacy of sympathetic nerve blocks, although other possibilities exist including a placebo effect. Also, efferent sympathetic fibers may undergo activation by nonadrenergic mediators. The mechanisms capable of initiating and perseverating activation of polymodal C afferents are being actively investigated and have been found to exhibit similarities with the mechanisms underlying peripheral and central sensitization of pain-producing afferents. Growth factors, such as nerve growth factor, may play an important role in causalgia. In "reflex sympathetic dystrophy syndrome", microcirculatory stasis may contribute to the initiation or perpetuatation of the disorders. Further work on the nerve supply to the venular network and on the venoarterial reflex is needed.

Enalapril-induced vasculitis resembling rheumatoid arthritis, lupus, sicca syndrome, and giant cell arteritis.

We report a case of vasculitis in a 67-year-old woman who successively developed over a four-month period clinical manifestations suggestive of rheumatoid arthritis, lupus, sicca, syndrome and finally giant cell arteritis. All her symptoms resolved promptly upon discontinuation of enalapril and none recurred over the five-year follow-up period. The only residual manifestation is Jaccoud's arthropathy of the hands.

[Treatment with low dose methotrexate in rheumatoid arthritis: risk factors for severe complications]. / Traitements à faibles doses par le méthotrexate dans la polyarthrite rhumatoïde: facteurs de risque des complications graves.

Treatment with low dose methotrexate in rheumatoid arthritis is associated with serious side effects in about 5 per cent of cases (respiratory, haematological or infectious). The goal of a null risk seems unrealistic because of the idiosyncrasy of some of the risks and our poor understanding of others (enzymatic polymorphisms might be operational, and infectious agents could act as co-factors). However, risk can be greatly reduced by a careful selection of patients. Some contraindications are strict: poor compliance and the possibility of mistake in the timing of the administration; pregnancy or desire for pregnancy; treatment with trimetoprim; haemodialysis; renal insufficiency (clearance < or = 50 ml/min) (and therefore old age), alcoholism. Others remain relative although well established; hypoalbuminaemia, diabetes mellitus, obesity, past infection with hepatitis virus. Others are dubious: starvation, macrocytosis, surgical stress, NSAIDs. An extensive large study of side effects is warranted.