Deflazacort versus prednisone in patients with giant cell arteritis: effects on bone mass loss.

OBJECTIVE: To compare bone mass loss due to deflazacort versus prednisone in longterm treatment of patients with giant cell arteritis (GCA) in a randomized double blind comparative trial. METHODS: Seventy-four patients were included in a prospective multicenter study. Half received deflazacort (DFZ) and the other half prednisone (PR) for a minimum of 12 months. Calcium and vitamin D supplements were also provided to all subjects. Our intent was (1) to evaluate bone mineral density, using dual energy x-ray absorptiometry, at baseline and comparatively at 3, 6, and 12 mo; vertebral fractures by Meunier score and size variations after 12 mo treatments were also analyzed; (2) to assess calcium/phosphate metabolism modifications in both groups at baseline and after 12 mo. RESULTS: No significant difference was observed between the 2 groups in terms of treatment efficacy. Patients taking PR were slightly older on average versus the DFZ group (74 vs 70 yrs). Bone mass loss between entry and month 12 was not statistically different in the PR group (-0.026 +/- 0.007 g/cm2) compared to the DFZ group (-0.03 +/- 0.005 g/cm2). No significant difference was found in Meunier score variations (0.77 and 1.18 in the PR and DFZ groups, respectively; p = 0.3), nor in vertebral size variations (-0.4 and -0.2 in the PR and DFZ groups, respectively; p = 0.4). There was no difference in calcium/phosphate metabolism evaluations at month 12. CONCLUSION: In older patients taking longterm glucocorticoids who are at risk of osteoporosis, deflazacort did not result in less bone loss than prednisone.

Efficacy of epidural steroids in low back pain and sciatica. A critical appraisal by a French Task Force of randomized trials. Critical Analysis Group of the French Society for Rheumatology.

OBJECTIVE: Several randomized trials have suggested recently that epidural steroid injections may not be a valid treatment in common low back pain and sciatica. To clarify this issue, we conducted a critical appraisal of relevant randomized trials published up to 1997. Attention was directed to methodological quality, results, and clinical implications. METHOD: A Medline search identified 13 trials published between 1966 and 1997. Trial methodology was evaluated using a 100-point grid based on four groups of items, namely study population, therapeutic intervention, evaluation method, and data presentation and analysis. RESULTS: Methodology quality scores ranged from 12 to 84 and were unrelated to the results of epidural steroid therapy. Five trials demonstrated greater pain relief within the first month in the steroid group as compared to the control group. Eight trials found no measurable benefits. Obstacles to meaningful comparisons across studies included differences in the patient populations, steroid used, volume injected, and number of injections. None of the published studies used the injection modalities that are standard practice in France. CONCLUSION: Whether epidural steroids are effective in common low back pain and sciatica cannot be determined based on our review.

Effects of cyclical etidronate therapy on bone loss in early postmenopausal women who are not undergoing hormonal replacement therapy.

This study was carried out to investigate the effectiveness and tolerability of cyclical etidronate therapy in the prevention of bone loss occurring in early postmenopausal women who are not undergoing hormone replacement therapy (HRT). A total of 109 Caucasian women aged 45-60 years were treated with etidronate 400 mg/day or placebo for 14 days followed by calcium supplementation 500 mg/day for 77 days. Ninety-one women completed the 2 years of the study. After 2 years, the estimated difference between the two groups as regards lumbar spine bone mineral density (BMD) was 2.53% (SEM 1.07%; p = 0.01); BMD of the hip and wrist were not significantly different between treatment groups. A clear reduction in bone turnover was obtained as evidenced by a significant decrease in serum alkaline phosphatase level and in urinary N-telopeptide/ creatinine ratio in the etidronate group; the difference between the two groups was -12% +/- 3.2% for serum alkaline phosphatase level (p = 0.019) and -22.9% +/- 13.7% for the urinary N-telopeptide/creatinine ratio (p = 0.047). There was no statistically significant difference between the two groups in terms of the serum osteocalcin levels and urinary hydroxyproline/ creatinine and calcium/creatinine ratios. Etidronate was generally well tolerated and its adverse event profile was similar to that of placebo. The results of this study indicate that cyclic etidronate therapy can prevent trabecular bone loss, with no deleterious effect on cortical bone, in the first 5 years of menopause and that it has a very high safety margin.

Bone densitometry in patients with multiple myeloma.

PURPOSE, PATIENTS, AND METHODS: We performed dual-energy x-ray absorptiometry in 10 selected patients with aggressive multiple myeloma in whom substantial tumor mass reduction was achieved after high-dose chemoradiotherapy followed by autologous blood stem cell transplantation. RESULTS: In most cases, bone mineral density (BMD) of the spine was initially low (Mean Z score: -2.69, SEM 0.76) and dramatically increased after treatment (mean increase 16.4%; 7.7% with 95% confidence interval 2.2 to 12.2, excluding one patient whose spine BMD increased by 94.8%). In contrast, skeletal roentgenograms, computed tomographic scans, and magnetic resonance imaging did not reveal any significant improvement of patients' bone lesions. CONCLUSIONS: In patients with multiple myeloma, bone densitometry could be a useful way to assess the efficacy of treatment on bone status.

[Persistent pain following discal sciatica: reflex sympathetic dystrophy, an unusual complication to be examined. Apropos of 4 cases]. / Douleurs persistantes après sciatique discale: l'algodystrophie, une complication inhabituelle à rechercher. A propos de quatre cas.

Four patients who developed unilateral reflex sympathetic dystrophy of a lower limb associated with a bout of sciatica due to lumbar disc herniation are reported herein. In two cases, reflex sympathetic dystrophy developed after resolution of the sciatica, whereas the two conditions were concomitant in the two other patients. In all four patients, the diagnosis of reflex sympathetic dystrophy was missed. Surgery to release the root was considered in two cases. The reflex sympathetic dystrophy resolved within 1 to 3 months in every case. In view of the incidences of these two conditions, their concomitant occurrence seems rare. To avoid unwarranted therapeutic procedures, reflex sympathetic dystrophy should be considered in patients with chronic painful manifestations accompanying root involvement.

[Septic arthritis caused by Campylobacter fetus]. / Les arthrites septiques à Campylobacter fetus.

The ten published cases of septic arthritis due to Campylobacter fetus and two more recent cases, one of which was a delayed septic complication of a total hip replacement, are discussed. In 83% of cases, febrile monoarthritis occurred which in 7 out of the 12 cases involved an already diseased joint in a subject over 70 years of age (half of the patients), who was frequently alcoholic and presented either cancer or hepatic cirrhosis and/or diabetes. Hyperleukocytosis of the blood was variable (55% of cases). The joint fluid, which contained a high level of deteriorated polynuclear cells, was routinely cultured on an enriched medium in an anaerobic or microerophilic atmosphere and in 10 out of 12 cases Campylobacter fetus was isolated within 15 days, even in the absence of previous antibiotic therapy. The arthritis, which showed little sign radiographically of destructiveness, was cured, leaving no sequellae in most cases. Treatment usually involved ampicillin or the tetracyclines, either alone or in association with the aminoglycosides.

[Acute sphenoid sinusitis in adults]. / Les sinusites sphénoïdales aiguës de l'adulte.

Seven cases of acute sphenoid sinusitis were reviewed. Two happened after deep sea diving. Headache of variable location and fever were the most predominant presenting symptoms (5/7). Purulent discharge in the cavum was present in three. Correct diagnosis was delayed from six to twenty-four days after beginning of symptoms, when a neurologic deficit became apparent : mainly paralysis of the sixth and third cranial nerves. Computed axial tomography was the most useful radiologic procedure for demonstrating sinus opacification in every patient. Two patients died, three had complete recovery, one had persistent epileptic focus after brain abscess. Last patient had paraparesis and incontinence of urine after study of cerebrospinal fluid (C. S. F.) flow with methylene blue. Cannulation of the sphenoid sinus was performed in two patients and surgical drainage in three. Gram negative microorganisms and Staphylococcus aureus were isolated from the sphenoid sinus of only three patients. Blood cultures were negatives in every cases and C. S. F. in six. First choice antibiotics was an association of aminoglucosides and broad-spectrum penicillin in six cases. It always had to be changed.

[Carcinoid tumor of the ampulla of Vater and Recklinghausen's neurofibromatosis]. / Tumeur carcinoïdienne vatéro-duodénale et neurofibromatose de Recklinghausen.

We report the fifth case of carcinoid tumour of Vater ampulla with Von Recklinghausen's neurofibromatosis. We have reviewed the literature and discussed the significance of such an association which seems fortuitous.

[Septicemia in cirrhotic patients]. / Septicémies chez le cirrhotique.

The clinical features of 22 patients with cirrhosis of the liver complicated by septicaemia were studied retrospectively and compared with a control group of 52 patients with septicaemia without cirrhosis. The incidence of septicaemia was higher in the cirrhotic group (4.25 p. 100) than in the control group (0.64 p. 100). The overall incidence of cirrhosis in patients with septicaemia was 19 p. 100. Nine of the 22 cirrhotic patients and 16 patients in the control group died. Prognostic factor common to both groups of patients were: shock, coma, delayed apyrexia and the isolation of more than one infecting organism on blood culture. Poor prognostic factors specific to the cirrhotic patients were the presence of ascites, especially if infected, and signs of hepatocellular failure.

[Attacks of gout and thromboembolic disease: role of heparin therapy]. / Crise de goutte et maladie thrombo-embolique: rôle de l'héparinothérapie.

The authors report 4 cases of acute gout in the lower limb occurring soon after starting heparin therapy for venous thromboembolic disease. As none of the usual factors which induce gout were present, the possible roles of the venous thrombosis and the heparin therapy were examined. Intra-articular thermic and acid-base changes secondary to the thrombosis could have explained the site of the attacks of gout in 3 of our 4 patients; the fourth patient had normal phlebography; the relationship between the attack and the start of heparin therapy suggested that the heparin may have induced the gout, possibly by an interaction with the synovial proteoglycans leading to the precipitation of urate crystals in the joint. In the absence of references in the literature, these hypotheses need further confirmation.

[Hypercalcemia in large cell lymphoma. Possible role of prostaglandins E2 (author's transl)]. / Hypercalcémie et lymphome à grandes cellules. Rôle possible des prostaglandines E2.

Hypercalcemias in lymphomas without bone involvement are exceptional. The mechanism of hypercalcemia, very rarely determined, results from release of parathyroid hormone like (PTH) or osteoclast activating factor like substances. Prostaglandins were not reported high in lymphomas with hypercalcemia. We report a case of hypercalcemia in large cell lymphoma with non-cleaved cell and without bone involvement. Plasma PGE2 were 775 pg/ml (normal 7,8 +/- 1,5 pg/ml), plasma PTH was 12 ng/prot./ml (normal 10-30 ng/prot./ml), calcemia was 3,7 mmol/l (normal 2,2-2,6 mmol/l). Ten days after the first chemotherapy, calcemia was normal, plasma PTH was undetectable and plasma PGE2 were 349 pg/ml. Nine months after the beginning of treatment, PGE2 were 16,8 pg/ml and calcemia 2,37 mmol/l. The possible roles of PGE2 in hypercalcemia and as tumor marker are discussed.