Vertebroplasty increases trabecular microfractures in elderly female cadaver spines.

UNLABELLED: This study assessed whether vertebroplasty increases trabecular bone microfractures in adjacent vertebrae of elderly female cadavers. Results indicated microfractures were almost two times greater in superior adjacent vertebrae for vertebroplasty treated spines compared to non-treated controls. This finding may aid in developing improved treatments for osteoporotic women with vertebral fractures. INTRODUCTION: Although vertebroplasty may stabilize compression fractures and reduce pain, subsequent vertebral fractures occur in approximately 25 % of patients, reducing the overall safety of this procedure. This is particularly a concern in vertebrae surrounding the treated level where bone cement may cause abnormal transfer of forces to adjacent spinal structures. Therefore, the objective of this study was to quantify the effects of vertebroplasty on local trabecular bone damage in adjacent vertebrae. METHODS: Five level motion segments (T11-L3) from osteopenic/osteoporotic female cadaver spines (T-score -2.9 ± 1.0) were assigned into either vertebroplasty or control (no vertebroplasty) groups (n = 10/group) such that T-score, trabecular microarchitecture, and age were similar between groups. Compression fractures were created in the L 1 vertebra of all specimens and PMMA bone cement was injected into the fractured vertebra of vertebroplasty specimens. All spine segments were subjected to cyclic axial compression (685-1370 N) for 115,000 cycles. Post-testing, trabecular cubes were cut from adjacent (T12 and L2) vertebral bodies and histologically processed. Trabecular microfractures were identified and normalized by bone area in each section. RESULTS: There were significantly more trabecular microfractures (p < 0.001) in superior adjacent vertebral bodies of the vertebroplasty group (0.091 ± 0.025 microfractures/mm(2)) when compared to the control group (0.049 ± 0.018 microfractures/mm(2)). However, there was no difference in trabecular microfractures (p = 0.835) between vertebroplasty (0.045 ± 0.022 microfractures/mm(2)) and control groups (0.035 ± 0.013 microfractures/mm(2)) for inferior adjacent vertebral bodies. CONCLUSIONS: Vertebroplasty specifically impacts the superior adjacent vertebrae of elderly female spines resulting in almost two times more trabecular microfractures when compared to non-treated controls.

Preoperative high-dose glucocorticoids for early recovery after liver resection: randomized double-blinded trial.

BACKGROUND: Glucocorticoids modulate the surgical stress response. Previous studies showed that high-dose preoperative glucocorticoids reduce levels of postoperative inflammatory markers and specific biomarkers of liver damage compared with placebo, and suggested a reduced complication rate and shorter hospital stay after liver surgery. However, there are no studies with a clinical primary outcome or of early recovery outcomes. The aim of this study was to investigate whether a single high dose of preoperative glucocorticoid reduces complications in the immediate postoperative phase after liver surgery. METHODS: This was a single-centre, double-blinded, parallel-group RCT investigating preoperative methylprednisolone 10 mg/kg (high dose) versus dexamethasone 8 mg (standard-dose postoperative nausea prophylaxis) in patients scheduled for open liver resection. The primary outcome was number of patients with a complication in the postanaesthesia care unit; secondary outcomes included duration of hospital stay, pain and nausea during admission, and 30-day morbidity. RESULTS: A total of 174 patients (88 in high-dose group, 86 in standard-dose group) were randomized and analysed (mean(s.d.) age 65(12) years, 67.2 per cent men); 31.6 per cent had no serious co-morbidities and 25.3 per cent underwent major liver resection. Complications occurred in the postanaesthesia care unit in 51 patients (58 per cent) in the high-dose group and 58 (67 per cent) in the standard-dose group (risk ratio 0.86, 95 per cent c.i. 0.68 to 1.08; P = 0.213). Median duration of hospital stay was 4 days in both groups (P = 0.160). Thirty-day morbidity and mortality rates were similar in the two groups. CONCLUSION: A high dose of preoperative glucocorticoids did not reduce acute postoperative complications after open liver resection compared with a standard dose. Registration number: NCT03403517 (http://www.clinicaltrials.gov); EudraCT 2017-002652-81 (https://eudract.ema.europa.eu/).

[Interest of the chest CT scanning in head and neck cancer]. / Intérêt du scanner thoracique dans le bilan initial et le suivi des patients traités pour un cancer des voies aérodigestives supérieures.

INTRODUCTION: The overall survival rate for patients with head and neck squamous cell carcinoma remains disappointingly static despite improved locoregional control. This has been attributed to the development of distant metastases and second primary malignancies in these patients, a large proportion of which occur in the thorax. The goal of this study is to determine the incidence of newly thoracic malignancies diagnosed initially and during the follow-up in head and neck patients by chest computed tomography. METHODS: We retrospectively analysed the incidence of thoracic malignancies in 77 patients presented newly diagnosed cancer of the head and neck. RESULT: 15/77 patients were found to have thoracic malignancies. In 10/77 patients (14%) the diagnosis was made at the same time that the initial head and neck cancer In 5/77 patients, the thoracic malignancies were diagnosed during the follow-up. In 3 of the 5 cases, the pulmonary lesion was diagnosed in patients with local recurrent tumours. The primary site or the stage had an effect on the incidence of simultaneous thoracic malignancies. CONCLUSION: The presence of distant metastases and second primary malignancies has major implications in the management and prognosis of patients presenting with head and neck carcinoma. We recommend a CT scanning of the thorax in the staging of patients presenting with head and neck cancer but also in the follow-up, particularly in patients with an advanced pharyngolaryngeal cancer.

A single injection of protein-loaded coacervate-gel significantly improves cardiac function post infarction.

After myocardial infarction (MI), the heart undergoes fibrotic pathological remodeling instead of repair and regeneration. With multiple pathologies developing after MI, treatment using several proteins is expected to address this range of pathologies more effectively than a single-agent therapy. A factorial design of experiments study guided us to combine three complementary factors in one injection: tissue inhibitor of metalloproteinases-3 (TIMP-3) was embedded in a fibrin gel for signaling in the initial phase of the treatment, while basic fibroblast growth factor (FGF-2) and stromal cell-derived factor 1-alpha (SDF-1α) were embedded in heparin-based coacervates for sustained release and distributed within the same fibrin gel to exert their effects over a longer period. The gel was then tested in a rat model of myocardial infarction. Contractility of rat hearts treated with the protein coacervate-gel composite stabilized and slightly improved after the first week while contractility continued to decrease in rats treated with free proteins or saline over the 8 week study period. Hearts receiving the protein coacervate-gel composite treatment also exhibited reduced ventricular dilation, inflammation, fibrosis, and extracellular matrix (ECM) degradation. Revascularization, cardiomyocyte preservation, stem cell homing, and increased myocardial strain likely all contributed to the repair. This study demonstrates the potential of a multifactorial therapeutic approach in MI, using three complementary proteins delivered sequentially for comprehensive healing. The study also shows the necessity of controlled delivery for growth factors and cytokines to be an effective treatment.

Low peak bone mineral density in healthy Lebanese subjects.

Osteoporosis is a major public health problem in Western countries and is projected to have a similar impact in the Middle East. It has been suggested that peak bone mineral density (BMD), a major determinant of osteoporotic fractures later in life, may be lower in this part of the world compared with the Western world. However, subjects have not been randomly selected or systematically screened to rule out secondary causes of bone loss. The purpose of this study was to determine peak bone mass and lifestyle risk factors for bone loss in a randomly chosen sample of healthy Lebanese subjects from the greater Beirut area. Subjects 25-35 years of age were randomly selected from greater Beirut, which comprises one third of the Lebanese at large, and studied during the Fall of 1999. BMD was measured at the lumbar spine, hip, forearm, and total body. A questionnaire on lifestyle factors was administered to all subjects. Results were compared with the database of subjects from the USA provided by the manufacturer, and to the NHANES database for the total hip. Two hundred thirteen subjects were studied; 45 subjects rotated at all three centers for cross-calibration purposes. Peak BMD in Lebanese subjects was 0.2-0.9 SD below that of peak BMD in American subjects, depending on skeletal site, gender, and densitometer. These differences persisted after attempting to adjust for body size. Osteoporosis and osteopenia were more prevalent than in healthy young Americans. Height, weight, and total body fat were the most significant correlates of BMD/bone mineral content (BMC), accounting for 0.3-0.7 of the variance in bone mass measurement. Lifestyle factors had a very modest but significant contribution to bone mass variance. This is the first population-based study from the Middle East demonstrating that peak BMD is slightly lower in Lebanese subjects compared as with an established database from the USA. Due to the selection of relatively healthier subjects in our study than in the NHANES study, the actual differences between the two populations may be even greater. The impact of our findings on the epidemiology of osteoporotic fractures in Lebanon remains to be determined.

Osteomalacia secondary to celiac disease, primary hyperparathyroidism, and Graves' disease.

Primary hyperparathyroidism is seldom associated with other autoimmune disorders. The presence of normocalcemia in primary hyperparathyroidism should prompt the physician to look for vitamin D deficiency. This observation concerns a 34-year-old vegetarian woman with combined primary hyperparathyroidism, Graves' disease, and celiac disease. The patient presented with severe bone deformities; she was unable to walk, and had severe muscular weakness and weight loss. Biochemical findings revealed severe hyperparathyroidism with normocalcemia, hypophosphatemia, very low urinary calcium, and low 25-hydroxy vitamin D level. Thyroid tests showed hyperthyroidism with positive thyroid receptor antibodies, confirming the presence of Graves' disease. Positive antigliadin and antireticulin antibodies and complete villous atrophy on duodenal biopsy established the presence of celiac disease. The patient underwent a near-total thyroidectomy, with the removal of a parathyroid adenoma. To our knowledge, this observation is the first finding of an association between celiac disease, Graves' disease, and primary hyperparathyroidism. It emphasizes the need to rule out intestinal malabsorption in the case of normocalcemic hyperparathyroidism.

Danazol induced pancreatitis and hepatitis.

Danazol, a C17 alkylated anabolic steroid, has been tried as a hormonomodulator in the management of systemic lupus erythematosus. We report the case of a patient receiving 400 mg of danazol per day who developed mild pancreatitis associated with hepatitis, both induced by danazol.

Clinical, radiological, and laboratory findings in Lebanese spondylarthropathy patients according to HLA-B27 status.

UNLABELLED: To evaluate clinical, radiologic, and laboratory features in Lebanese spondylarthropathy patients according to HLA-B27 status. METHODS: We retrospectively compared demographic, clinical, radiologic, and severity data in 40 HLA-B27-positive and 58 HLA-B27-negative patients. All 98 patients met Amor's or European Spondylarthropathy Study Group criteria for spondylarthropathy, and 51.7% met New York modified criteria for ankylosing spondylitis. RESULTS: Onset before 16 years of age, hip involvement, and an elevated mean erythrocyte sedimentation rate were significantly associated with the presence of the HLA-B27 (32.5 vs 13.8%, P=0.02; 45 vs 7.5%, P=0.001; and 47.7 vs 25.4, P=0.02; respectively). The two groups were comparable for age, sex ratio, prevalence and distribution of spondylarthropathy types, family history, sacroiliitis, bamboo spine, syndesmophytes, peripheral joint involvement, enthesopathies, extra-articular involvement, response to nonsteroidal anti-inflammatory drugs, and need for other medications. CONCLUSION: In Lebanon, spondylarthropathy patients positive for HLA-B27 experience disease onset at an earlier age, are more likely to develop hip involvement, and have laboratory evidence of more severe inflammation than their HLA-B27-negative counterparts. None of the other clinical and radiologic parameters are modified by HLA-B27 status.

[Incidence of fractures after the age of 50 years in the Lebanese population and implications in terms of osteoporosis]. / Incidence fracturaire après 50 ans et implications en termes d'ostéoporose dans la population libanaise.

BACKGROUND: No comprehensive population-based data is available on the incidence of fractures in Lebanon and the Middle-East. The aim of this study was to estimate the incidence of osteoporotic fractures in the Lebanese population aged 50 years and over. METHODS: In 1997, a cross-sectional population-based random sample of individuals aged 50 years and over was selected using a multiple level cluster sampling technique. Selected individuals responded to an Arabic version of the EULAR questionnaire. A fracture was defined as incident if it had occurred within the last year. The lifetime risk of osteoporotic fracture was estimated using the incidence rate by ten-year age groups assuming that each individual counts on the average for half the interval. RESULTS: 1003 individuals were included. There were 496 men (49.5%) and 507 women (50.5%). Mean age was 61.3 years (CI: 60.8-61.8) with a maximum of 88 years. The observed number of fractures was 111, giving an absolute risk of osteoporotic fractures of 11.1% (CI: 9.1-12.9). It was higher in women, 13.0% (CI: 10.9-15.1) than in men, 8.6% (CI: 6.9-9.3). Female to male ratio was 1.6. The estimated annual incidence was 2.6% (CI: 2.0-3.2), higher in women, 3.8% (CI: 2.2-5.5) than in men, 1.4% (CI: 0.4-2.5). Incident cases were distributed as follows: 4-hip, 4-forearm, 3-spine, and 15 other sites. Annual incidence was higher in women than in men for all sites. Estimated lifetime risk of osteoporotic fracture was 9.3% (CI: 6.7-11.9) in men and 16.7% (CI: 13.4-19.9) in women. CONCLUSION: Our figures are lower than those found in Northern Europe but are higher than in Asian countries, possibly reflecting a west-east gradient in risk factors.

[Validation of choice of experts for the spondylarthropathy study in Lebanon]. / Validation du choix d'experts pour l'étude des spondylarthropathies au Liban.

A study of the spondylarthropathies, their recent diagnostic criteria and the prevalence of HLA B27 in these affections in Lebanon will soon be started. Experts will have to include patients, prospectively, and to classify them as having or not a spondylarthropathy, according solely to their clinical judgement. The decision of the expert is of major importance in including patients in the study. We performed a clinical evaluation of inter-observer variability to select experts according to a significant concordance in the clinical diagnosis of different rheumatic diseases, especially spondylarthropathies. Results of the evaluation are presented and discussed.

Isolated septic arthritis of a lumbar facet joint.

This is a report of an isolated septic arthritis of a lumbar facet joint where the infectious agent was Bacteroides sp. and where an early diagnosis was made using MRI.

Minimum clinically important improvement and patient acceptable symptom state in pain and function in rheumatoid arthritis, ankylosing spondylitis, chronic back pain, hand osteoarthritis, and hip and knee osteoarthritis: Results from a prospective multinational study.

OBJECTIVE: To estimate the minimum clinically important improvement (MCII) and patient acceptable symptom state (PASS) values for 4 generic outcomes in 5 rheumatic diseases and 7 countries. METHODS: We conducted a multinational (Australia, France, Italy, Lebanon, Morocco, Spain, and The Netherlands) 4-week cohort study involving 1,532 patients who were prescribed nonsteroidal antiinflammatory drugs for ankylosing spondylitis, chronic back pain, hand osteoarthritis, hip and/or knee osteoarthritis, or rheumatoid arthritis. The MCII and PASS values were estimated with the 75th percentile approach for 4 generic outcomes: pain, patient global assessment, functional disability, and physician global assessment, all normalized to a 0-100 score. RESULTS: For the whole sample, the estimated MCII values for absolute change at 4 weeks were -17 (95% confidence interval [95% CI] -18, -15) for pain; -15 (95% CI -16, -14) for patient global assessment; -12 (95% CI -13, -11) for functional disability assessment; and -14 (95% CI -15, -14) for physician global assessment. For the whole sample, the estimated PASS values were 42 (95% CI 40, 44) for pain; 43 (95% CI 41, 45) for patient global assessment; 43 (95% CI 41, 44) for functional disability assessment; and 39 (95% CI 37, 40) for physician global assessment. Estimates were consistent across diseases and countries (for subgroups ≥20 patients). CONCLUSION: This work allows for promoting the use of values of MCII (15 of 100 for absolute improvement, 20% for relative improvement) and PASS (40 of 100) in reporting the results of trials of any of the 5 involved rheumatic diseases with pain, patient global assessment, physical function, or physician global assessment used as outcome criteria.

Cardiac troponin T: a useful early marker for cardiac and respiratory dysfunction in neonates.

BACKGROUND: Cardiac troponin T (cTnT) has been proposed as specific biochemical marker for myocardial infarction in adults. Cardiac function in neonates could be influenced by the severity of respiratory distress and its ventilatory management. OBJECTIVES: To establish a normal range of cTnT in healthy neonates, compare troponin concentrations among healthy neonates and those in respiratory distress (sick) and detect whether any correlation occurs between severity of respiratory distress and troponin concentrations. METHODS: Concentrations of cTnT were compared between sick and healthy infants, accounting for confounding variables in a prospective investigation manner. Age at sampling, need for ventilation, duration of respiratory support, and inotropic use in addition to neonatal and maternal characteristics were assessed. RESULTS: Samples were collected from 164 neonates (116 healthy and 48 sick). The medians [interquartile ranges] of cTnT in healthy and sick infants were 0.044 [0.027-0.073]mug/l and 0.121 [0.065-0.238] microg/l, respectively, with p < 0.0001. The 99th percentile for healthy neonates was 0.244 microg/l. Comparing both groups, there were significant differences concerning gestation, birth weight, Apgar at 5 min and admission to neonatal intensive care unit. Troponin concentrations in subgroups of sick infants including hypotensive, ventilated and dead infants were higher than other infants of the same subgroup. CTnT was positively correlated to the duration of respiratory support in ventilated neonates. CONCLUSION: CTnT may prove to be a useful early marker for cardiac and respiratory dysfunction in newborns.

An audit of bone densitometry practice with reference to ISCD, IOF and NOF guidelines.

INTRODUCTION: The impact of osteoporosis guidelines on clinical practice has not been fully evaluated. OBJECTIVES: To estimate the positive predictive value (PPV) of the National Osteoporosis Foundation (NOF), the International Osteoporosis Foundation (IOF) and the International Society for Clinical Densitometry (ISCD) guidelines for osteoporosis and compare it to the PPV of clinical judgement alone. METHODS: All subjects tested for bone mineral density during the fall of 2001 in three teaching hospitals in Beirut were invited to participate. The reference databases used for the calculation of the T-score were the NHANES database for the hip and the manufacturer's database for the spine. The impact of using guidelines was measured by the increment in PPV. Osteoporosis was defined as a T-score < or =-2.5 at either the spine or hip. RESULTS: A total of 307 post-menopausal women were tested with dual-energy X-ray absorptiometry (DXA). In current practice (clinical judgement alone), the PPV for osteoporosis was 42.4%; using NOF guidelines, 236 women would have been tested, and the PPV would have been 46.2%. Similarly, using IOF or ISCD guidelines, 236 women would have been tested, and the PPV would have been 47.1%. CONCLUSION: Compared to current clinical practice, application of the ISCD, IOF and NOF guidelines may increase the predictive value of a central DXA for osteoporosis.

Overweight children in Beirut: prevalence estimates and characteristics.

OBJECTIVE: To estimate, for the first time, overweight prevalence and associated characteristics in a representative sample of prepubertal children in Beirut, Lebanon's capital. DESIGN: A cross-sectional study with a home interview including measurements of weight and height and a structured questionnaire. SUBJECTS: A total of 234 children aged 6-8 years in Beirut: 131 boys, 103 girls. METHODS: Prevalence of overweight and obesity was based on the international cut-off points for body mass index (BMI) by age and gender proposed by the International Obesity Task Force. The characteristics of overweight examined were: age, gender, household and family size, single- vs. two-parent family, parents' level of education and profession, physical activity and dietary intake of children. RESULTS: Prevalence of overweight and obesity was 26% and 7% respectively in boys, 25% and 6% in girls. Overweight was significantly associated with low physical activity (P < 0.05) and mother's BMI (P < 0.05). CONCLUSIONS: This study identified a high proportion of overweight in 6- to 8-year-old children in Beirut. Reduced physical activity was the most significant factor associated with childhood overweight. Further studies in different regions in Lebanon are necessary to identify national characteristics; prevention efforts will be designed accordingly.

Cyclosporin in rheumatoid arthritis: a double blind, placebo controlled study in 52 patients.

The efficacy and safety of cyclosporin A (CyA) for patients with rheumatoid arthritis were assessed in a four month double blind, placebo controlled study using an initial dosage of 5 mg/kg daily. Six patients withdrew from the study (two in the placebo group because of inefficacy of treatment and four in the CyA group because of side effects). These six patients were considered therapeutic failures. At the end of the trial the study treatment was considered as good or very good by 14 out of the 26 CyA group patients and by only two out of the 26 placebo group patients. Moreover, in the CyA group significant improvement was observed in five of the seven clinical assessment criteria. Clinical improvement was correlated with a decrease in C reactive protein, alpha 1 glycoprotein levels, and platelet count but not with erythrocyte sedimentation rate or rheumatoid factor titres. Renal toxicity (13 cases) remained the major problem in the management of these patients. This study shows that CyA is effective in active rheumatoid arthritis but requires close monitoring for toxicity.

Assessment of efficacy and acceptability of low dose cyclosporin in patients with rheumatoid arthritis.

The efficacy of cyclosporin in a double blind, placebo controlled trial of four months' duration has previously been reported by us. To assess the benefit-to-risk of cyclosporin this study was followed by a one year open trial including 49 of the previous 52 patients. Cyclosporin was given at an initial dosage of 5 mg/kg/day and then modulated on the basis of efficacy and renal toxicity. During the study the drug had to be discontinued in 32 patients: because of inefficacy in 10, side effects in 11, both in nine, and in two because of unrelated events. The significant clinical improvement noted at four months persisted through one year in the 17 patients who continued to receive treatment. Nephrotoxicity of the drug (24 patients) required constant and close monitoring as well as modulation of daily drug dosage during the trial. This study indicated that cyclosporin might be valuable in the treatment of patients with advanced rheumatoid arthritis, in whom other second line agents have failed.