Search

This retrospective study evaluated treatment with sulfasalazine (SAS) in a mean dosage of 2.1 g/day in 95 patients with rheumatoid arthritis (RA) who were followed-up for 3 months to 4 years. Mean disease duration was 7 years; 79 patients had previously received at least one disease-modifying drug. Four per cent of patients were lost to follow-up. Mean duration of treatment was 15 months (3 weeks-50 months). Treatment continuation rates were 57% at one year, 40% at two years, and 26% at three years. Reasons for discontinuation of SAS included adverse effects (n = 24), inefficacy (n = 33), and death unrelated to SAS therapy (n = 2). In four patients, SAS was discontinued within three months of the first dose because of a severe adverse effect (diffuse erythematous rash, diffuse bullous rash, hepatitis with jaundice, agranulocytosis). SAS-induced biologic markers for lupus were seen in one patient. Furthermore, 12% of evaluable patients developed antinuclear antibodies during SAS therapy. The SAS treatment continuation rate was higher (p = 0.05) among patients under 40 years of age (n = 18) than among older patients. This difference was due to a correlation between age and tolerance with less SAS-induced side effects in patients under 40 years of age (p = 0.03). The SAS treatment continuation rate was unrelated to the duration of rheumatoid arthritis or number of previous maintenance treatments. This study suggests that rheumatoid arthritis patients under 40 years of age exhibit better tolerance to SAS therapy.

Cytokines are secreted by several cell types in the bone microenvironment. These peptides act on bone cells by a paracrine or autocrine mechanism and play an important role, although not completely clarified, in the regulation of bone remodeling. Postmenopausal osteoporosis could be due to a local overproduction of some osteoclast-stimulating cytokines in response to estrogen deficiency. During chronic inflammatory joint diseases, such as rheumatoid arthritis, synovial cells produce large amounts of cytokines leading to increased local bone resorption and juxta-articular bone destructions. The local action of cytokines is also involved for interactions between tumoral cells and bone cells. These are secreted by the tumoral (metastatic or hemopoietic) cells, bone marrow cells, bone cells, or even could be released from the bone matrix during bone resorption. Recent progress in our knowledge in the field of cytokines have improved the understanding of the pathogenesis of these diseases and let hope future promising developments for more specific treatments.

The pharmacology of fluoride is reviewed. Efficacy criteria of sodium fluoride in osteoporosis are analysed. An increase in bone mass of the order of 8 per cent per year is seen in 60-70 per cent of osteoporotics whether evaluated by histomorphometry or by bone densitometry in double-blind controlled trials. Fluoride has no effect on bone mass in 30 to 40 per cent of osteoporotics. The reason(s) for such resistance is/are not fully understood. It is not possible at present to state that there is a decrease in the incidence of vertebral fractures on the basis of data from double-blind trials. The incidence of bone fissures affecting the bones of the lower limbs is significantly increased in osteoporotics treated with fluoride, above all if doses of elemental fluoride are greater than 25 mg or in the presence of unrecognised renal insufficiency. The incidence of these fissures is of the order of 20 to 30 per cent.

More than 45 p. cent of patients with degenerative knee arthritis are obese. The overweight is more marked when the medial tibio-femoral and the lateral femoro-patellar aspects are affected. With the same degree of weight gain, the relationship between obesity and degenerative knee arthritis is more marked in women than in men. The significance of the overweight increases the probability of developing degenerative knee arthritis, increasing its functional severity. The obesity precedes the arthritis, and is not its consequence. It is a mechanical effect by increase of the articular strains. It is unknown how long the obesity must be present in order to be pathogenic for the knee and what functional and anatomical improvement may be expected from a weight loss.

The calcium concentration of the bones of the hand measured by neutron activity was lowered in 93% of osteoporotic women aged between 50 and 60 years and in 66% of women between 60 and 70 years, whereas from the 8th decade onwards, only 5% had a bone calcium concentration of the hand less than that of controls. In the male sex, nearly 80% of osteoporotic patients, had a calcium concentration of the hand less than that of controls whatever their age. Considering the radiological criterion retained for the diagnosis of osteoporosis, the existence of at least one fracture of a vertebral body, the authors discuss the significance of these facts.

The authors treated 17 patients with hypercalcaemia (which in 16 cases resulted from a malignant disease) by means of 1 to 3 daily perfusions of 25 g of mithramycin per kg body weight. In all patients the treatment resulted in reduction in the level of calcaemia. In 12 patients the level of calcaemia was reduced to less than 105 mg/litre; in 16 patients to less than 110 mg/litre. In no patient was the calcaemia reduced to less than 70 mg/litre. The only notable inconvenience of the treatment was vomiting during the perfusion. Mithramycin seems to be the treatment of choice for hypercalcaemia of cancerous origin.

Measurement of the femorotibial angle was performed in 244 patients (134 women and 110 men) without knee arthrosis with roentgenograms taken in the upright position. The values were grouped according to sex and to decade of life. The average value was approximately 0. As defined by the average upper and lower values of the two types of angulation, the normal value in women was 4 degrees of varus and 4 degrees of valgus. In men, the normal value of the right leg was 5 degrees of varus and 5 degrees of valgus; the left leg demonstrated up to 6 degrees of varus and 5 degrees of valgus. After sixty years of age, 5 percent of patients had angulation above these normal values in valgus and varus.

We are reporting 4 cases of unnoticed sacral fractures in osteoporotic women. Their mean age was 73 years. Only in one case the fracture was seen on a standard X-Ray. On the other hand, hyperfixation with isotopes on the sacrum formed a very characteristic H-shaped image. In two of these patients, the sacral fracture was confirmed by tomodensitometry, but this examination was unavailing in the third patient. In the 4th case, hyperfixation of the isotope was not significant. Only a guided bone biopsy and the favorable evolution of the disease enabled the diagnosis of sacral fracture.

18 patients with Paget's disease resistant to calcitonin and/or to EHDP (ethane-hydroxy bisphosphonate) were treated with APD (disodium amino-hydroxypropylidene-bisphosphonate). The efficacy of the product was judged by the decrease in serum alkaline phosphatases and of hydroxyproline in the 24-hour urine specimen. The treatment lasted for a maximum of 6 months. Administration of APD was stopped before six months if he hydroxyproline content in the urine returned to normal (except in the case of four patients where the early interruption of treatment was due to lack of supplies). Of the 14 patients who followed the regular course of treatment, the urine hydroxyproline became normal between the first and the sixth month of treatment in 11 patients: at the start, all had a 24-hour urine hydroxyproline content equal to or less than 2.1 mmol/l 24 h (275 mg/24 h). The baseline 24-hour urine hydroxyproline in the remaining three patients was higher (3.55; 2.30; 3.28 mmol/24 h), but the level was reduced by 50% after 6 months of treatment. Alkaline phosphatases were reduced in the same proportions but the decrease occurred at a slightly later date. The residual activity was evaluated in 9 subjects who had not received any treatment for one year: in 8 out of the 9 patients the parameters used for measuring bone activity had not appreciably altered. Treatment with APD was restarted in 4 patients after a period of 12 to 36 months without therapy, and its efficacy was found to be comparable to that of the drug's first use. In all, APD demonstrated remarkable efficacy in pagetic patients resistant to both calcitonin and/or EHDP.

vitamin compounds to the basic dialytic treatment of renal osteodystrophy is of contestable interest. Because 1) optimum conditions of dialysis without D vitamin addition prevent efficiently the progress of severe gyperparathyroidism and osteomalacia 2) the D vitamin compunds could render the phosphatemia control more difficult thus contributing to aggravate the histologic lesions of hyperparathyroidism.

Hyperphosphataemia with levels of 65 mg/l was found in a black African aged 20 with a 10-year history of tumour calcinosis. Levels of blood calcium, plasma ionised calcium, serum alkaline phosphatase, 24-hour urinary calcium and phosphate were all normal, as was renal function. Tubular phosphate reabsorption (TmP) was greater than 90 mg per litre of glomerular filtrate (N = 22-42). Levels of circulating parathyroid hormone, nephrogenic cAMP and serum vitamin D metabolites [25 OH D3, 24,25 (OH)2 D3 and 1,25 (OH)2 D3] were normal. The TmP fell by 36% on exogenous PTH stimulation (N = 30.25 +/- 6.7), and by 7.9% 120 min. after injection of acetazolamide. Our results confirm the conclusions of recent studies: patients with tumour calcinosis have disordered renal phosphate excretion with normal PTH secretion, normal PTH action on the renal tubule and normal vitamin D metabolism. In fact in these hyperphosphataemic patients, circulating 1,25 (OH)2 D3 levels would be expected to be low, whereas they were normal in our patient. An attempt at treatment with acetazolamide and phosphate chelating agents gave no significant results.

Statistical comparison of the weight index of patients presenting arthritis of the knee with that of a control group of matching sex and age, has enabled to demonstrate a definite weight gain in the most frequent topographical varieties of knee arthritis in women: lateral femoro-patellar, medial femoro-tibial, combination of the two. In men, the excess weight was only demonstrated in medial femoro-tibial arthritis.

The measurement of the mineral content of bone by localised neutron activation was performed in the hand in 58 women aged between 23 and 87 years and simultaneously in the hand and the thoracic spine (from the 5th to the 9th thoracic vertebra) in 46 women aged between 50 and 80 years, all free of any bone disease. The neutron flow was emitted by Californium 252. The bone calcium mass was calculated from the peak of radioactivity emitted by Ca 49 with an energy of 3.10 MeV, measured by means of a sodium iodide scintillation detector. The bone volumes were estimated indirectly by planimetry. The results were expressed as the volumic concentration of calcium in the bones of the hand and the vertebrae. The calcium concentration of the bones of the hand decreases with age, especially between 50 and 60 years. The calcium concentration of the vertebrae decreases more markedly with a significant negative correlation (r = - 0.550; p less than 0.05). The correlation is particularly significant (r = - 0.878) in the 16 women aged between 50 and 65 years with a calcium concentration in the bones of the hand within the normal range. The correlation between the calcium concentration in the vertebrae and age was no longer significant after the age of 65 years, whatever the value of the calcium concentration of the bones of the hand. A significant correlation (r = 0.660; p less than 0.05) was observed between the vertebral calcium and the calcium in the bones of the hands in women aged between 50 and 65 years, which disappeared after this age.(ABSTRACT TRUNCATED AT 250 WORDS)

We report the clinical and biological picture of 34 primary hyperparathyroidism (PHT) cases, diagnosed in rheumatology. It concerned 25 women and 9 men, aged 61 + 11 years. The PHT was often asymptomatic (47 p. cent of cases) at the time of diagnosis. The clinical manifestations were dominated by asthenia (50 p. cent) and renal lithiasis (47 p. cent). We found a chondrocalcinosis in 29 p. cent of patients. No patient presented any bony manifestations of cystic osteitis; 7 out of 34 patients (including 6 women between 57 and 74 years) presented vertebral compression. The mean calcemia was 117 +/- 9 mg/l. There were no hypercalcemic attack. The dosage of PTH and cyclic AMP were elevated in 29 out of 32 and 28 out of 31 patients respectively. In all patients, the level of either of these two tests was increased. The chloremia/phosphoremia ratio was also extremely predictive of HBP, since it was increased, exceeding 3.3 in 33 out of 34 patients. The 25-hydroxyvitamin D levels (25 (OH) D) were normal. The levels of 1,25 (OH) 2D were markedly spread (37 +/- 16 pg/ml) and not significantly different from the reference group. Patients with lithiasis did not present a higher level of 1,25 (OH) 2D. A bone histomorphometry carried out in 15 patients showed a bone trabecular volume similar to that of the reference with the same age. The osteoclastic resorption was increased in all cases and was not correlated with the PTH level, but was significantly correlated with the level of 1,25 (OH) 2D (r = 0.79 p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report the results they obtained by bone scintigraphy using technetium pyrophosphate. In a study of 142 patients with cancer, the authors show, as others have done, that bone scintigraphy makes it possible to find bone metastases that are radiologically undetectable and they emphasize the importance of this discovery. In 7 patients with spondylodiscitis, of whom 1 was without radiological signs at the time the scintigraphy was carried out, the authors always observed localized vertebral hyperfixation and they noted that this examination can be valuable for distinguishing spondylodiscitis from pseudo-Pott's discarthroses and from the lesions of vertebral epiphysitis, which in their experience do not result in isotopic hyperfixation. In 7 patients with epiphyseal osteonecrosis, the authors observed isotopic hyperfixation before the appearance of radiological signs. In 12 patients with osteoporosis, the authors observed hyperfixation in bone in certain compressed vertebrae, whereas other vertebrae that had probably been compressed some considerable time earlier did not fix the isotope excessively. They never observed hyperfixation in vertebrae that were not compressed. Among 5 patients with ankylosing spondylitis with radiological signs of sacro-iliac arthritis, the authors observed sacro-iliac hyperfixation in only 3 cases. Two other patients who had signs indicating ankylosing spondylarthritis, but were without radiological signs of sacro-iliac arthritis did not show sacro-iliac hyperfixation of the isotope. Among 7 patients with Paget's disease, the authors observed hyperfixation in all the bones with radiological signs of disease; in addition, in 3 patients, there was also hyperfixation in certain bones that were radiologically clear.