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Wind power technology is now a reliable electricity production system. It presents an economically attractive possible solution for the continuously increasing energy demand of Lebanon. However, the stochastic behavior of wind speed leads to significant disharmony between wind energy production and electricity demand. Hence, the prospect of creating a combined wind-hydro energy station is found to be a vital issue. This paper is an attempt to analyze the design of a pumping station and the performance of a hybrid wind-hydro power plant, in two dams in Lebanon (Quaraoun and Chabrouh), in order to choose the most suitable dam to store the energy surplus produced by wind power at night. An evaluation of the amount of water that could be pumped in both dams and the energy that could be produced from the stored electricity surplus are carried out in this paper, in order to select the most suitable dam to implement the hydro pumped storage power plant and store the electricity surplus. It is shown that the energy that could be produced in the dam of Chabrouh varies between 17 MWh and 698 MWh, while in the dam of Quaraoun is between 17 MWh and 768 MWh. An analysis of the cost of the energy produced by wind turbines per kWh and the produced water per m3 are carried out in this paper as well.

This is the first case report of an omental torsion in a polar bear (Ursus maritimus). A captive, 23-yr-old, 250-kg, intact female polar bear presented to the University of Minnesota Veterinary Medical Center with a 2-day history of lethargy, depression, and vomiting. Abdominal ultrasound identified large amounts of hyperechoic free peritoneal fluid. Ultrasound-guided abdominocentesis was performed and yielded thick serosanguinous fluid compatible with a hemoabdomen. An exploratory laparotomy revealed a large amount of malodorous, serosanguineous fluid and multiple necrotic blood clots associated with a torsion of the greater omentum and rupture of a branch of the omental artery. A partial omentectomy was performed to remove the necrotic tissue and the abdomen was copiously lavaged. The polar bear recovered successfully and is reported to be clinically well 6 mo later. This condition should be considered as a differential in bears with clinical signs of intestinal obstruction and hemoabdomen.

Objective—To determine clinical, laboratory analysis, and necropsy findings for equids with oleander toxicosis and to identify factors associated with outcome. Design—Retrospective case series. Animals—30 equids. Procedures—Medical records of equids with detectable concentrations of oleandrin in serum, plasma, urine, or gastrointestinal fluid samples and equids that had not received cardiac glycoside drugs but had detectable concentrations of digoxin in serum were identified via a medical records database search. Descriptive statistics were calculated for medical history, physical examination, laboratory analysis, and necropsy variables. Logistic regression analysis was used to identify physical examination and laboratory analysis factors significantly associated with outcome. Results—3 of 30 (10.0%) equids died before or immediately after arrival at the hospital. Of the other 27 equids, 23 (85.2%) had gastrointestinal tract abnormalities, azotemia was detected for 19 (70.4%), and a cardiac arrhythmia was ausculted for 18 (66.7%). Mortality rate for all equids was 50.0%; mortality rate for hospitalized equids was 44.4%. The most common cause of death was cardiac dysfunction. Odds of survival to discharge from the hospital were lower for equids with cardiac arrhythmias versus those without arrhythmias and decreased with increasing Hct and serum glucose concentrations. Odds of survival increased with increasing serum chloride concentration and duration of hospitalization. Conclusions and Clinical Relevance—Equids with oleander toxicosis frequently had simultaneous gastrointestinal tract, cardiac, and renal problems. Oleander intoxication should be a differential diagnosis for equids with colic in geographic areas where oleander is found, especially when azotemia or cardiac arrhythmias are detected concurrently.

Objectif De nombreux patients suivis au Centre specialise de l'obesite sont touches par la precarite. Leur budget alimentation est tres reduit. De plus les personnes souffrant d'obesite pensent souvent qu'elles ne peuvent pas manger comme tout le monde. Nous avons recherche un support permettant l'application des conseils nutritionnels et respectant la problematique financiere, d'ou la creation d'un livret: « nos recettes preferees ». Materiels et methodes Les recettes nous ont ete fournies par des membres du service – dieteticien(ne)s, secretaires, infirmieres, medecins – et par des patient(e)s. Elles ont ete testees et approuvees ! Pour chacune d'elle des icones indiquent le cout (calcule avec les prix des sites de supermarches en ligne) et la composition nutritionnelle (table CIQUAL). Nous avons indique des variantes pour proposer des alternatives et encourager la creativite. Resultats Une preface explique l'origine du projet. Elle est suivie d'un calendrier des aliments selon les saisons. Une quarantaine de recettes sont categorisees: entrees, plats, desserts, snacks et sauces. Une rubrique presente les herbes aromatiques pour ameliorer des plats simples et des exemples pour reutiliser ses restes. Le livret se termine par un questionnaire de satisfaction – pour l'evaluer et le faire evoluer – et quelques pages blanches a completer avec leurs recettes. La distribution des livrets devrait debuter en 2015. Il devrait se composer de deux couvertures cartonnees, reliees en spirale, qui pourront se transformer en chevalet de cuisine. Il servira de base de discussion avec les patients en consultation dietetique. Conclusion Nous avons souhaite redonner des reperes alimentaires aux patients et leur permettre de poursuivre les efforts demandes grâce a un outil simple d'utilisation. Ce livret veut dedramatiser et simplifier la relation des patients avec la nourriture. Nous esperons que les patients proposeront de partager leurs propres recettes afin de continuer a alimenter cet outil qui est le leur. Declaration d’interet Les auteurs declarent ne pas avoir d'interet direct ou indirect (financier ou en nature) avec un organisme prive, industriel ou commercial en relation avec le sujet presente. Lilly.

Direct clinical observation is the most common means of diagnosing algodystrophy. Further investigations may be helpful to rule out other pathological conditions, such as occult or stress fractures or avascular osteonecrosis and to obtain a better understanding of algodystrophy. Transient vascular hyperpermeability in the affected part is well demonstrated by the clinical findings, the MRI signs, and the three-bone scan features. 99m Technectium EHDP bone scan provides an evaluation of the vascular abnormalities and of the osteoblastic activity. Dermal microcirculation and its reactions to sympathetic stimuli are investigated by laser doppler fluximetry and videophotometric capillaroscopy. Perhaps the sweat test does unveil what might be specific about algodystrophy. The amount of bone loss in algodystrophy in a few weeks or months is what might be expected over 10 years during the natural history of uncomplicated osteoporosis. An initial fracture is undoubtedly an initiating event in the appearance of algodystrophy, but patients suffering from algodystrophy may still have significant osteoporosis for a long period and hence be at risk for fracture. Densitometry could be an aid to the diagnosis and probably to monitoring treatment as well. The local colonization of fibroblasts following the transient stage of hyperpermeability must be kept in mind to explain the results of joint, bone, muscles or neurological investigations in late algodystrophy.

A true recurrence at exactly the same site is quite unusual in algodystrophy. Local or regional extension is possible. The bone scan is an easy way to demonstrate that the areas successively affected are not the same. An apparent local recurrence could in fact be a microscopic compression fracture of trabecular bone or cortical fractures or part of a factitious disorder.

We conducted a medical record-based study of 169 patients with polyostotic involvement identified among 200 Paget's disease patients. Follow-up was 15 to 41 years in 31 cases. The pelvis was the only bone that was more likely than not to be involved bilaterally. All the other paired bones were more likely to be involved unilaterally and when both sides were involved the two lesions were very often frankly asymmetric. In a given patient, the duration of the various pagetic lesions, estimated from their size and from data provided by an earlier study on the rate of progression of pagetic lesions, was similar in some cases and showed marked differences in others. Aggregation of the lesions into two or three disease duration groups was seen in some patients, suggesting that Paget's disease may occur in two or three waves. When we reviewed the radiographs from 30 patients with a mean follow-up of 23 years, we found new lesions in ten patients. However, a review of bone scans from 18 patients with a mean follow-up of 11 years failed to uncover any firm evidence of new lesion development, perhaps because all these patients received bisphosphonate therapy (etidronate, tiludronate, pamidronate). We also found data suggesting that the disease process spread across a joint in some patients, even in the absence of degenerative joint disease. In particular, in several cases an extensive pagetic lesion was seen on one side of a joint and a considerably smaller lesion on the other side.

The mean annual rate of increase in the length of pagetic lesions was 8.5 mm for the skull and tibia and 9.4 mm for the femur, after a follow-up of nine to 16 years according to the bone. The fastest rate of progression was seen at the femur and was 24 mm per year. Thirty years were required for lesions to spread to the entire pelvis and 13 years to all the bones surrounding the obturator foramen. Saber shin deformity of the tibia without involvement of the distal fourth of the bone indicated a disease duration of 25 years, as did involvement of the entire skull. The annual rate of increase in the width of lesions varied widely across patients and was not influenced by gender. Thickening of the skull occurred at a rate of about 4 to 5 mm per decade after pagetization of the bone, although faster rates were seen in some patients; a sandwich-like appearance with a thickness exceeding 32 mm was seen in six of the 29 skulls studied. At the femur and tibia, the increase in width was 10% to 30% per decade after pagetization of the bone; faster thickening was seen in some tibias with saber shin deformity. The thickness of the ischial tuberosity increased by 3 to 4 mm per decade after pagetization. Determination of the degree of hypertrophy is useful for estimating the duration of pagetic lesions when the entire bone is involved at first presentation. Involvement of the entire pelvis indicates a disease duration of 30 to 40 years according to whether the bone is hypertrophied or not. An estimation of age at disease onset in 70 patients suggested that the first bone lesions probably appeared before the age of 30 years in 45 patients (64%), whereas the diagnosis was established before 30 years in only three patients. These data suggest that Paget's disease may be a disease of teenagers and young adults.

Equine protozoal myeloencephalitis (EPM) is a debilitating protozoal disease of the CNS that is typically caused by infection with Sarcocystis neurona and less frequently with Neospora hughesi (Sellon and Dubey 2007). Although the epidemiology of S neurona has been well characterised, the diagnostic modalities, long-term implications and response to treatment are not fully understood. The diagnosis of EPM is often based on the presence of antibodies against S neurona in serum and/or cerebrospinal fluid (CSF; Furr and others 2002). The introduction of a quantitative indirect fluorescent antibody test (IFAT) for the detection of specific antibodies against S neurona has enabled equine veterinarians to better determine the likelihood of infection in a horse with neurological deficits (Duarte and others 2004). Many equine veterinarians routinely use the IgG IFAT for S neurona to aid in the diagnosis of EPM and also to help guide treatment duration and determine when successful treatment has been achieved. However, practicing veterinarians have reported that specific antiprotozoal treatment appears not to influence reduction of antibody levels against S neurona . The goal of this study was to determine the temporal trends in antibody levels against S neurona in seropositive horses following administration of ponazuril paste. The study was performed at one large farm located in northern California. The farm had previously had confirmed cases of EPM, but there were no current cases. Prior to study commencement, 61 adult healthy, warmblood horses with no …

The objective of this case-control questionnaire study was to determine whether a history of measles or of dog ownership occurred with different frequencies in Paget's disease patients and in age- and sex-matched controls. Clustering of Paget's disease cases in geographic foci was also looked for, as well as a difference in the prevalence of Paget's disease according to whether the subsoil was composed of rocks from the primary or the tertiary-quaternary geologic periods. Completed questionnaires were obtained from 247 Paget's disease patients and 281 controls. Paget's disease was significantly associated with a history of measles (odds ratio, 2.46) but not with a history of mumps (odds ratio, 0.79) or with dog ownership (odds ratio, 0.97). The 174 cases of Paget's disease in subjects from the study district were distributed throughout the district, with no geographic clustering. This result was confirmed by the analysis of the ratios of Paget's disease cases over the total population in each county in the study district. The incidence of Paget's disease was slightly higher in areas with a primary subsoil, but the difference was not statistically significant (chi-square, 0.79; P = 0.37).

Hypothesis/Objectives To describe the clinical, histological and immunological findings of an equine case of pemphigus vulgaris, including the demonstration of antidesmoglein (anti-Dsg) autoantibodies. Case report The diagnosis of pemphigus vulgaris was confirmed in a 9-year-old Welsh pony stallion with both direct and indirect immunofluorescence and immunoprecipitation studies, the latter identifying circulating anti-Dsg3 IgG. Treatment with immunosuppressive medications was initiated. Lesions were seen in the perineal area, sheath, mane, tail, eyelids, coronary bands and mucosa of the mouth and oesophagus. Initial corticosteroid treatment improved the clinical signs, but the onset of laminitis necessitated a reduction in dosage, which was associated with a recurrence of lesions and development of oral ulcers. A corneal ulcer developed after 60 days of treatment. Despite treatment with azathioprine, gold salts and dapsone, the disease progressed and the pony was euthanized. Postmortem examination showed additional lesions of the cardia of the stomach. Conclusions and clinical importance Pemphigus vulgaris is rarely diagnosed in equids. We describe a case that was substantiated by the demonstration of anti-Dsg3 IgG. Response to treatment was poor, with the best response to high doses of prednisolone. Equine pemphigus vulgaris is likely to carry a poor prognosis and if there is no response to treatment, humane euthanasia is warranted. Resume Hypotheses/Objectifs Decrire les donnees cliniques, histologiques et immunologiques d'un cas de pemphigus vulgaire chez un cheval, ainsi que la mise en evidence d'auto-anticorps antidesmogleine (anti-Dsg). Cas clinique Le diagnostic de pemphigus vulgaire a ete confirme chez un poney etalon Welsh par des etudes d'immunofluorescences directe et indirecte et d'immunuprecipitations, ces dernieres mettant en evidence des IgG circulant anti-Dsg3. Le traitement a ete initie a l'aide d'immunosuppresseurs. Les lesions etaient localisees dans la region perineale, le fourreau, la criniere, la queue, les paupieres, les couronnes et la muqueuse de la bouche et de l’œsophage. Le traitement initial corticoide a ameliore les signes cliniques mais l'apparition d'une boiterie a necessite une diminution de la dose associee a une recidive des lesions et au developpement de nouveaux ulceres oraux. Un ulcere corneen s'est developpe apres 60 jours de traitement. Malgre un traitement a base d'azathioprine, de sels d'or et de dapsone, la maladie a progresse et le poney a ete euthanasie. L’examen post mortem a montre des lesions supplementaires du cardia de l'estomac. Conclusions et importance clinique Le pemphigus vulgaire est rarement diagnostique chez les chevaux. Nous decrivons un cas confirme par la presence d’IgG anti-Dsg3. La reponse au traitement a ete faible, la meilleure etant celle liee a de fortes doses de prednisolone. Le pemphigus vulgaire equin est de mauvais pronostic et en cas d'absence de reponse au traitement, l'euthanasie est recommandee. Resumen Hipotesis/objetivos Describir los hallazgos clinicos, histologicos e inmunologicos de un caso de penfigo vulgaris, incluyendo la demostracion de los autoanticuerpos frente a desmogleina (anti-Dsg). Informe de caso el diagnostico de penfigo vulgaris se confirmo en un macho pony Gales de 9 anos de edad mediante inmunofluorescencia directa a indirecta y estudios de inmunoprecipitacion. Esta ultima tecnica identifico IgG circulantes frente a Dsg-3. Se inicio el tratamiento inmunosupresor. Se observaron lesiones en la zona del perineo, vaina del pene, crin, cola, parpados, banda coronaria y mucosa de la boca y del esofago. El tratamiento inicial con corticosteroides mejoro los signos clinicos, pero la aparicion de laminitas forzo una reduccion en la dosis, lo cual produjo una recidiva de los signos clinicos y el desarrollo de ulceras en la cavidad oral. Se desarrollo una ulcera corneal tras 60 dias de tratamiento. A pesar del tratamiento con azatioprina, sales de oro y dapsona, la enfermedad progreso y el pony fue finalmente eutanasiado. Conclusiones e importancia clinica penfigo vulgaris se diagnostica raramente en equinos. Describimos un caso de esta enfermedad apoyado por la demostracion de inmunoglobulinas IgG frente a Dsg-3. La respuesta al tratamiento fue pobre, siendo la respuesta mejor con altas dosis de predinosolona. El penfigo vulgaris en equinos parece asociarse con un pronostico pobre y si no hubiera respuesta al tratamiento, se recomienda la eutanasia humanitaria. Zusammenfassung Hypothese/Ziele Eine Beschreibung der klinischen, histologischen und immunologischen Befunde eines Pferdes mit Pemphigus vulgaris, sowie auch der Veranschaulichung von Antidesmoglein (anti-Dsg) Auto-Antikorpern Fallbericht Die Diagnose Pemphigus vulgaris wurde bei einem 9 Jahre alten Welsh Ponyhengst mittels sowohl direkter, als auch indirekter Immunfluoreszenz und mit Immunprazipitationsstudien nachgewiesen, wobei letztere Methode zirkulierendes anti-Dsg3 IgG identifiziert. Eine Behandlung mit immunsupprimierenden Medikamenten wurde eingeleitet. Lasionen bestanden in der Perinealgegend, Praputium, Mahne, Schweif, Augenlider, Kronsaum und an der Schleimhaut von Maul und Speiserohre. Ursprunglich verbesserte eine Therapie mit Kortikosteroiden die klinischen Symptome, aber das Auftreten von Hufrehe machte eine Dosisreduktion erforderlich, was wiederum zum neuerlichen Auftreten der Hautveranderungen und der Entwicklung von oralen Ulzera fuhrte. Ein Hornhautulkus entwickelte sich 60 Tage nach der Behandlung. Trotz der Behandlung mit Azathioprin, Goldsalzen und Dapson verschlechterte sich die Erkrankung und das Pony wurde euthanasiert. Eine Postmortem Untersuchung zeigte zusatzliche Veranderungen an der Cardia des Magens. Schlussfolgerung und klinische Bedeutung Pemphigus vulgaris wird bei Equiden selten diagnostiziert. Hier beschreiben wir einen Fall, der durch die Darstellung von anti-Dsg3 IgG abgesichert wurde. Auf die Behandlung wurde schlecht angesprochen, wobei die deutlichste Besserung bei hohen Dosen an Prednisolon zu sehen war. Es ist wahrscheinlich, dass der Pemphigus vulgaris der Equiden eine schlechte Prognose hat und folglich ist die Euthanasie, wenn nach Behandlung keine Besserung eintritt, aus humanitaren Grunden berechtigt. 要約 仮説/目的 馬の尋常性天疱瘡の臨床的、組織学的、免疫組織学的な所見を抗デスモグレイン抗体の証明を含めて解説すること。 症例報告 尋常性天疱瘡の診断を9歳のウェルッシュポニー種牡馬で直接および間接免疫蛍光法の両方ならびに免疫沈降法を用いて行った。後者では循環血中の抗Dsg3IgGを特定した。免疫抑制剤による治療を開始した。病変は会陰部、包皮、たてがみ、尾、眼瞼、蹄冠帯、口腔と食道粘膜にみられた。最初のコルチコステロイド治療により臨床症状が改善したが、蹄葉炎の発症により減量が必要となり、それに関連して病変が再発し口腔内に潰瘍を生じた。角膜潰瘍が治療開始60日後に生じた。アザチオプリン、金塩、ダプソンを用いた治療にも関わらず、病変は進行し、ポニーは安楽死された。剖検により胃の噴門部の病変が明らかにされた。 結論と臨床的重要性 尋常性天疱瘡はウマ科の動物ではまれに診断されない。著者らは抗Dsg3 IgGの証明によって立証した症例を報告した。治療への反応は乏しく、最も反応したのは高用量のプレドニゾロンであった。馬の尋常性天疱瘡はおそらく予後は悪いため、治療に全く反応しないようなら人道的な安楽死が正当な理由となる。 摘要 假设/目的 描述寻常天疱疮患马的临床、组织学和免疫学发现,包括证明抗桥粒芯蛋白(抗Dsg)自体抗体的存在。 病例报告 用直接和简介免疫荧光和免疫沉淀反应,确诊了一匹9岁威尔士矮种马为寻常天疱疮。后者识别循环的抗Dsg3 IgG。开始免疫抑制药物治疗。可见会阴部、腱鞘、鬃毛、尾部、眼睑、冠状带与口腔和食道粘膜病变。初期的皮质醇治疗改善了临床症状, 但出现蹄叶炎迫使减少剂量。病变复发和口腔溃疡与之有关。治疗60天后角膜溃疡发展。尽管用硫唑嘌呤、金盐和氨苯砜治疗, 但疾病仍恶化, 矮种马被安乐死。尸体剖检显示胃部贲门额外的病变。 结论和临床价值 马很少被诊断出寻常天疱疮。我们描述了一个通过证明抗Dsg3 IgG存在而确诊的病例。治疗反应不良, 高剂量泼尼松龙的反应最好。马寻常天疱疮可能预后不良, 如果对治疗无反应, 应当实施人道安乐死。

Providing health care for Minnesota's uninsured population continues to be both a clinical and political challenge. Between October 1, 1991, and September 30, 1993, 1,260 previously uninsured people received charity health care in Duluth. No one was excluded because of pre-existing conditions. Their utilization of services and associated costs can help project the health care needs and costs of care for uninsured Minnesotans. This group of uninsured people used a different mix of health care services compared with insured Minnesotans, and their total costs (including prescriptions) were about 15% greater. A large proportion of these uninsured Minnesotans had chronic health conditions and a "pent-up need" for services and medications. This experience demonstrated that it is possible to administer a limited benefits plan in coordination with existing public and private resources.

We sought to assess efficacy and safety of a new oral formulation (tablet) of tiludronate in Paget's disease of bone. We studied 128 patients with Paget's disease in an open-label uncontrolled trial. Patients received a daily dose of 400 mg oral tiludronate (two tablets). Treatment was for 6 months. Serum alkaline phosphatase activity (SAP) and fasting urinary excretion of hydroxyproline/creatine (OH/Cr) were measured every 3 months, as were biochemical parameters reflecting renal, hepatic, and hematologic functions. Analgesic efficacy was self-evaluated from a visual analog scale (VAS). Statistical analysis revealed a significant reduction from baseline in SAP and OH/Cr levels, as well as VAS scores. In the whole population with evaluation under treatment, there was a reduction in initial SAP activity after 3 months (47.2 +/- 2.2%, mean +/- SEM) and 6 months (58.3 +/- 2.3%). In the population with SAP levels above twice the upper limit at inclusion and with evaluation at month 3 and month 6 (n = 96), the reduction in SAP levels was 49.3 +/- 2.4% after 3 months and of 59.5 +/- 2.6% after 6 months (ANOVA time effect, p = 0.0001). Aside from mild gastrointestinal disturbances, as experienced with other oral bisphosphonates, clinical tolerance was good. Exhaustive biochemical investigation failed to reveal significant toxicity of tiludronate tablets at the dose of 400 mg/day. The dose of 400 mg daily of this new formulation appears to be a satisfactory tiludronate regimen for the treatment of Paget's disease of bone.

A 62 year old male developed transient osteoporosis algodystrophy successively in several sites of the lower limbs (8 episodes of involvement of one or two sites over an 8-year period) three years after surgery for a chromophobic pituitary adenoma. Two stress fractures developed, during the sixth and seventh years, respectively, in bones previously affected by osteoporosis. A biopsy specimen from the distal tibia showed thin bone trabeculae and reduced cellular activity. The only etiologic factor was the patient's psychological profile characterized by anxiety and introversion.

The purpose of this study was to evaluate as accurately as possible, in a well-defined population subgroup, the prevalence and incidence of lower back pain, the impact of this symptom on professional activities and personal life, and the influence of risk factors. Members of the medical profession were considered particularly apt to accurately and reliably report their personal experience with lower back pain and were therefore selected for this survey. Five hundred 93-item questionnaires were sent to a representative sample of physicians in the Maine-et-Loire district, France. Response rate was 93%. Prevalence of lower back pain at the time of the survey was 32% and cumulative prevalence was 62%. Static spinal disorders (exaggerated lordosis, scoliosis, unequal length of lower limbs) and injury to the spine were found to be risk factors. Occupation-related stresses to the spine reported as being responsible for lower back pain included bending forward for prolonged periods, lifting weights, driving, and prolonged sitting.

From a series of 67 sera containing anticentromere antibodies we endeavoured to determine the principal clinical or biological peculiarities of these antibodies. The titers of anticentromere antibodies were usually high, with few differences between patients. Humoral immunity was frequently perturbed, with antinuclear autoantibodies (without anti-Scl 70), anti-mitochondria antibodies, rheumatoid factors, circulating immune complexes, etc. The disease predominated in women (97%) whose age and duration of symptoms varied considerably. The most frequent clinical manifestation noted in the 47 reports analyzed was Raynaud's phenomenon (93%) which in most cases (90%) was part of a complete or incomplete CREST syndrome. Telangiectasias, calcinosis and acrosclerosis were the main witnesses to the duration of these sclerodermas. Our findings were concordant with those of previous studies. However, the frequency of sicca syndrome (76%) was unexpected, and must be related to 2 laboratory results: the quasi-absence of anti-SSA and anti-SSB antibodies in our patients and the presence of two monoclonal immunoglobulins (IgM kappa and IgG lambda). There may be some degree of independence between the sicca syndrome and the sclerodermal manifestations.

Effects of oral administration of phosphorus on phosphorus and calcium parameters and on bone metabolism hormones were investigated in two studies: in the first, 12 young female adults and 8 females over 50 years of age took a single oral load dose of 780 mg elemental phosphorus, whereas in the second study assays were performed 5 and 15 days after initiation of twice-daily phosphorus supplements in 19 young adults, 14 subjects above 50 years of age who were free of osteoporosis, and 12 patients with osteoporosis also over 50 years of age. The phosphorus load was associated with an increase in intact parathyroid hormone levels (iPTH 1-84), which was more marked in subjects above 50 years of age than in younger adults. On the 15th day of phosphorus supplementation, there was no significant increase in baseline iPTH and no change in baseline dihydroxyvitamin D or osteocalcin levels; during the Nordin tests, the fractional calcium excretion index (CaU/CrU) and the fractional hydroxyproline excretion index (OH Pro/CrU) remained unchanged. In contrast, the phosphorus load was followed by a decrease in the maximum phosphorus reabsorption threshold (TMP/DFG), which was more marked on the 5th day than on the 15th day; a slight fall in serum phosphorus levels was also seen on the 15th day. These findings suggest that phosphorus supplementation should be intermittent rather than continuous. Analysis of subjects aged 50 to 69 years failed to disclose any significant differences between patients with and without osteoporosis.

Toxopachyosteosis, a rare bone disease, was described in 1954 by Weissmann-Netter and Stuhl. This congenital osteopathy, which may be familial, is defined by an anteroposterior curvature (toxon = arc) and thickening (pachus = thick) of the shafts of both leg bones. Other bones may be affected. Short stature and delayed walking are other important special features of the disease. It is most often diagnosed late and by chance because of the minimal functional consequences of the deformities. Sequelae of vitamin D-deficient rickets are the main differential diagnosis. The aim of this study undertaken by the Bone and Calcium/Phosphorus Metabolism Section of the Société Française de Rhumatologie (French Society of Rheumatology) was an overall assessment of the disease. The authors report 30 cases of toxopachyosteosis and evaluate their main characteristics on the basis of data from the literature.

Bone mineral content (BMC in g) as well as bone mineral density (BMD in g/cm2) were measured by dual photon absorptiometry in 20 black africans and 20 white individuals of the same age and sex. The BMC of african males, as well as their body mass index (BMI), were significantly less than those of the whites. In contrast, neither BMD nor the ratio of BMC to BMI differed between the two groups. These results suggest that morphotype plays a greater role than the ethnic factor in the determination of bone mass in the young adult.

The authors present a reminder of the methods used to evaluate the bone mass and density and, with population studies, specify the profile and significance of the physiological osteopenia in both sexes. Analysis of these studies shows that the age of onset of the bone loss and its percentage vary markedly between the various sites of the skeleton, according to the type of bone, cortical or trabecular. It seems that the "smooth" aspect of the physiological osteopenia curves obtained is women during population studies, essentially results from the disparity between the times of menopause. A general protocol of the physiological osteopenia, synthesizing all data collected with nine different methods of measurement of the mineral bone content, is presented for educational purposes.

Introduction of antiosteoclastic drugs, calcitonin and etidronate, has profoundly changed the treatment of active Paget's disease of bone. Nevertheless, the use of these drugs is limited in some patients by the occurrence of side-effects or by a resistance to therapy. We report the results of an open, nonrandomized study with a new bisphosphonate, (chloro-4 phenyl) thiomethylene bisphosphonate (Cl-TMBP), given orally to 35 patients with active Paget's disease of bone. At two different dosages this new bisphosphonate induced a significant decrease in disease activity. Patients receiving a mean dosage of 5 mg/kg/d (n = 14) showed a significant reduction of serum alkaline phosphatase levels to 43% of pretherapeutic values (from 499 +/- 91 to 214 +/- 41 IU/l) while hydroxyproline/creatinine ratio decreased to 43% of baseline (from 93 +/- 21 to 40 +/- 11). A second group of patients (n = 21) receiving a mean dosage of 11 mg/kg/d exhibited a similar response: serum alkaline phosphatase activity was reduced to 42% of initial values (from 1384 +/- 209 to 584 +/- 111 IU/l) while hydroxyproline/creatinine ratio fell to 48% of baseline (from 144 +/- 27 to 69 +/- 15). This was accompanied by a reduction in radionuclide uptake in pagetic areas. A prolonged beneficial effect was observed in most patients. In patients receiving the highest dosage significant reduction in serum calcium and rise in parathyroid hormone were observed. Otherwise no clinical or biological side-effect occurred throughout the study.

The levels of circulating 25 OH-D were determined by a direct radio-competition methods both in normal subjects and in subjects with various pathological conditions. In normal subjects, the average level of 25 OH-D was higher in summer (42.3 ng/ml) than in winter (29.1 ng/ml), P less than 0.005. Monthly variations in the 25 HO-D levels were found in relation to insolation The level of 25 OH-D was practically normal in osteoporosis (28.9 ng/ml), clearly lower in the mixed forms called "osteoporomalacia" (13.5 ng/ml, P less than 0.005) and very low in osteomalacia (5.8 ng/ml, P less than 0.001). In cases of cortisone osteopathy the average level was 22.8 ng/ml (NS). The level of 25 OH-D was also found to be lower in hepatic cirrhosis (11.7 ng/ml, P less than 0.01), in subjects treated with anticonvulsants (P less than 0.01), and in the course of hyperparathyroidism (P less than 0.002). There was no corelation between the level of 25 OH-D and calcaemia, phosphoraemia, circulating immunoreactive parathyroid hormone, or the relative osteoid volume. In contrast, there seemed to be a good correlation with the level of alkaline phosphatasaemia. The level of 25 OH-D was also determined in 4 subjects with vitamin-resistant osteomalacia: in 3 cases hepatic hydroxylation seemed normal, indicating the possibility of a subsequent disorder of vitamin D metabolism; in one case the absence of hepatic hydroxylation was noted.

The authors report on the clinical, biological and radiological anomalies observed in a series of 42 cases of idiopathic hypercalciuria. An histological bone study showed "osteomalacia" type changes (an increase in the osteoid volume and a decrease in the mineralization speed). The Ca45 isotope studies showed that there was an exchangable pool of calcium and a turnover, which was generally low. A study of the kidney functions revealed a decrease in the tubular reabsorption of calcium, while that of phosphorous remained within normal limits. There was no case of hyperparathyroidism in this series. The authors pose the question of whether the failure of calcium to settle on the tissues and the lack of tubular reabsorption of calcium, does not result from the relatively ineffective action of the endogenous circulating parathyroid hormone.

The authors report three cases of bronchiolitis obliterans occurring during treatment of rheumatoid arthritis with D-penicillamine after 4, 6 and 8 months of treatment and when the rheumatoid arthritis was in a state of remission. None of these patients (2 sero-positive and 1 sero-negative) present any past history of pulmonary or bronchial disease. The daily dosage of D-penicillamine never exceeded 600 mg. High dose corticosteroid therapy was unable to improve the clinical signs or the respiratory function tests, which were severely disturbed. After 15 months to 3 years, the respiratory signs deteriorated in 2 of the 3 patients. The onset of dyspnea and cough, in the absence of a seasonal infection, in a subject treated with D-penicillamine should raise the possibility of this very serious complication.

The authors report clinical, laboratory, and radiological results obtained by immunodepresant treatment of 78 patients suffering from rheumatoid polyarthritis, over a period of more than 4 years. In 27 of the patients the treatment had been followed for 4 to 8 years. Clinically the results were excellent in 36 cases, reasonably good in 23 cases; in 19 cases therapy was unsuccessful or had to to be stopped. There was a reduction in the sedimentation rate in cases with good results and in half the cases there was a reduction in the titre of the Waaler-Rose reaction. Studies on the evolution of radiological signs in 34 patients showed definite deterioration in only 2 cases out of 19 subjects having very good clinical results and definite deterioration in 7 of 15 subjects with less good clinical results or failure. Thus the immunodepressant treatment appeared capable of stopping or slowing down the osteoarticular destruction. The cessation of treatment in 28 patients was followed by a relapse in 14 patients (7 within 6 months, and 7 within 6 months to 2 years). In 14 patients there was no relapse and in 8 of these the improvement has lasted for more than 3 years. With the doses used, there were few short-term complications of treatment. Haematological tolerance appeared to vary according to the patient ; for prolonged treatment the dose should be adapted to the individual.

The authors propose to study parathyroid hormone receptors in humans by means of a test "inspired by the Ellsworth-Howard test" using the active synthetic 1-34 fragment of the hormone PTH-1-34. The use of this test in 44 patients (29 healthy subjects, 7 patients with idiopathic hypercalciuria 5 cases of Paget's disease, 1 patient with idiopathic hypoparathyroidism, 2 cases of basal cell nevus syndrome) who received different doses of this substance intravenously, revealed a marked dose-dependent stimulation of adenyl-cyclase as objectified by an increase in urinary excretion of cyclic AMP (AMPcU). Distal tubular calcium reabsorption was also significantly affected as demonstrated by a decrease in urinary calcium in the first hours following administration of the 1-34 fragment even in the case of idiopathic hypercalciuria. In comparison to the "classical" Ellsworth-Howard test, however, no significant urinary phosphate response was observed during the present test. Similarly, urinary hydroxyproline and phosphate and calcium blood levels remained stable. As the results obtained for the case of hypoparathyroidism demonstrate, this easily performed test is useful for valuating parathormone receptors in kidney by means of two sensitive parameters (AMPcU and the ratio of fractional urinary calcium to urinary creatinine). In addition to its action, synthetic fragment h PTH-1-34 offers the advantage of being totally innocuous.

Monoclonal gammopathy (MG) occurs in the course of rheumatoid arthritis (RA) in approximately 3.7% of cases. Twelve such cases were compared to two-hundred and fifteen controls with RA. RA was of later onset in patients with MG. Patients with MG had lower latex and Rose-Waaler titers; a decrease in these titres heralded onset of MG. The twelve patients with both RA and MG were then compared to nine-hundred and seventy-one controls with monoclonal gammopathy. As in previous studies, we recorded both IgM excess and unexplained lambda light chain excess.

In this double blind, crossover trial, 40 patients with ankylosing spondylitis were treated during two successive periods of 4 weeks each with either pirprofen 800 mg/day or ketoprofen 300 mg/day administered orally in a randomized order. The efficacy of pirprofen and ketoprofen was comparable, the results, as assessed by the clinician, were excellent or satisfactory in 53% of both groups. Pirprofen was well tolerated by 71% of the patients and ketoprofen by 59%.

Recent advances in the physiology of the parathyroid hormone permit a better demonstration of the mechanisms of inappropriate hypersecretion which characterizes hyperparathyroidism, even through the etiology of primary forms still remains unknown. There have been also some progress achieved understanding and evaluating the impact od hypersecretion on target organs, especially bone and kidney. Some studies give an indication of the therapeutic modalities which would enable to reduce the excess of secretion, to counteract the effect of the hormone on its receptor sites or finally limit its consequences on osteopenia.

Paget's bone disease is a chronic and usually benign bone disorder mainly found in people over fifty. The condition is characterized by excessive bone remodelling related to bone cell overactivity leading to abnormal bone structure. The viral origin of the disease, first proposed on the basis of ultrastructural observations, is now supported by immunocytological and molecular hybridization studies. Genetic and environmental elements may be involved, favouring and modulating the expressivity of this slow virus infection.

The prevalence of rheumatoid arthritis is generally estimated to be 1 per cent, despite the marked differences between the various results published according to the survey techniques and the epidemiological criteria employed. The present survey consisted of patients from the target population (the 248,009 inhabitants of Angers over the age of 15 years), who had been examined by one of the hospital or private rheumatologists working in Angers between 1960 and 1984 and who were considered to be suffering from inflammatory rheumatism. The cases of rheumatoid arthritis included in this survey were still alive and were living in Angers between January 1 and June 30 1984 and corresponded to at least two of the New York criteria. The prevalence determined according to this technique was 0.17 per cent for two criteria and 0.11 per cent for three criteria. After discussing the bias and the particular conditions of the study, it appears that these particularly low levels are essentially related to: a recruitment bias due to the limitation of the survey to patients seen by rheumatologists, to the choice of New York criteria and more especially of 3 criteria which increases the specificity of the survey at the expense of the sensitivity, to the long observation (mean of 10.4 years) which contributed to a reduction in the number of false positives. The validity of this study is supported by the comparison with the study by O'Sullivan et al. also based 2 New York criteria with a follow-up of 3 to 5 years, which concluded on a prevalence of 0.24 per cent compared with 0.17 per cent in Angers.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report the variations in calcaemia and in circulating immunoreactive PTH produced by the intramuscular injection of 5 units of porcine calcitonin in normal subjects and in patients suffering from osteoporosis or Paget's disease. After having determined the levels of 25-hydroxy-vitamin D circulating in the different groups, the authors note that comparison of these variations makes it possible to regroup the different types of reaction following the injection of the hypocalcaemic hormone. In patients suffering from pure osteoporosis, hypocalcaemia was slow to appear, was of moderate intensity, but was prolonged. The osteoporo-malacia patients did not produce a specific reaction and certain of them appeared "insensitive" to calcitonin. Results obtained in patients with Paget's disease confirm the hypocalaemic action of calcitonin even at a low dosage. With this test, the authors hope to contribute to studies of demineralizing affections and to overcoming them.

A combined study organised by the French Society of Rheumatology was devoted to the investigation of bone and phosphoro-calcium metabolism in cases of reflex sympathetic dystrophy. The following observations were made: the usual phosphoro-calcium parameters are not altered, apart from a slight elevation of the urinary calcium in multifocal forms of the disease, during the 3rd and 4th months; the level of PTH, studied in 11 patients, was normal in each case; the examination of 8 bone biopsies, one performed in the 7th week and six others performed during the 3rd and 4th months of the disease, showed, initially, invasion of the spongy tissue by oedema, signs of marrow stress and bone stress, with a reduction in the number of osteoblasts, without any marked alteration of bone remodelling. At a later stage, the biopsy shows intense bone remodelling with hyperosteoclastosis and hyperosteoblastosis and the formation of irregular bone tissue which later becomes lamellar. Electron microscopic study of two biopsies revealed signs of acellular demineralisation with normal appearance of the osteoblasts and osteoclasts.

The first part of this report is devoted to the functional anatomy of the lumbar spine, and reminds of the morphology, structure and proper physiology of each lumbar vertebral component, and then of each flexible element linking the lumbar vertebrae with one another. In this tripod system, the column of vertebral bodies and discs play an essential role, while the two columns of posterior articular processes have a supplementary, but nevertheless effective role in spinal stability and mobility. The intervertebral disc, because of the strong osmotic pressure of the nucleus and the dual direction fibrillar structure of the annulus, is in a pre-stress condition and constitutes a very strong visco-elastic shock-absorber; besides, it is a flexible structure allowing free motion. Under certain circumstances, it is supported by the abdominal wall. The second part of this report shows how spinal mobility in all directions, and absorbing of the load in all body postures, are effected by the lumbar spine.