Facet joint block for low back pain: identifying predictors of a good response

This preliminary study was conducted to identify a facet joint syndrome in low back pain. Ninety maneuvers and symptoms were compared between patients relieved (responders) and those unrelieved (nonresponders) after intraarticular blocks. Fifty-one patients participated in the study; 11 were excluded from evaluation because of unsuccessful injection into the joints as planned. Of the 40 patients included, 20 had four joints anesthetized, 16 had two joints anesthetized, and four had three joints anesthetized. Twenty-two were responders, 17 of whom had more than 90% relief of pain. Only a few variables were more frequent in the responder group: older age, absence of exacerbation by coughing, relief when recumbent, absence of exacerbation by forward flexion and when raising from this flexion, absence of worsening by hyperextension, and extension-rotation. When four of these seven variables were present in the same patient, sensitivity was 81.8% and specificity 77.8%, but this discriminant power must be evaluated in a new population.

Effects of repetitive strains on vertebral end plates in young rats

A histologic study of vertebral end plates was performed on young rats' tails subjected to intensive passive motion. Seven six-week-old rats had two-hour motion cycles daily, for two months. Histologic changes of proximal caudal vertebrae in the experimental group were compared with those of a control group of seven rats of the same litter which were allowed to grow freely without mechanical stress. The main findings were three striking protrusions of disk tissue into end plates, not observed in the control animals. End plate axial bulges lacking spindle-shaped cells and an increase in chondrocytes in the adjacent articular cartilage were observed. The growth-plate thickness was uneven and was absent in some areas, with disorganization of chondrocyte columns. All of these findings were present to a lesser degree in the control group and appeared to be similar to histologic changes observed in Scheuermann's disease.

Plasma sex hormones and aromatase activity in tissues of patients with systemic lupus erythematosus

Clinical observations and experimental data suggest that sex hormones influence the development of systemic lupus erythematosus (SLE). An imbalance between androgen and estrogen plasma levels may suggest an abnormality in the aromatase activity involved in estradiol synthesis. Aromatase activity in skin and subcutaneous tissue and plasma sex-hormone levels (testosterone, androstenedione, estrone, estradiol, dehydrosterone sulfate, cortisol) were measured in 15 SLE patients (nine female, six male) who had never received corticosteroid treatment and in eight (four female, four male) healthy control subjects. There was a tendency toward an increase in aromatase activity in SLE patients when compared to control subjects. Among SLE patients the aromatase activity varied inversely with disease activity. Patients with SLE had decreased androgen and increased estrogen levels. Aromatase activity in SLE patients had significant direct correlation with estrogen levels. These data suggest that abnormal regulation of aromatase activity may partially explain the abnormalities of estrogen synthesis in SLE.

[Sciatica or herniated disk]

Lumbar radiculalgia may be due, beside the disc-nerve root conflict, to stenosis of osteoarticular canals, wide dural sac, epidural lipomatosis, segmental arachnoiditis, malignant or benign tumours and meningoradiculitis. Extraspinal truncular or radicular sciatica is usually due to compression by an expansive process. Some types of pain referred from articular structures may mimic sciatica.

[Lumbo-radicular pain caused by epidural lipomatosis in an obese patient: recovery after hypocaloric diet]

The case reported concerns an obese patient suffering from lumbo-radicular intermittent claudication due to lumbar epidural lipomatosis. Compression was revealed by magnetic resonance imaging which showed the existence of a hypersignal in weighted sequences in T1 situated in the epidural space and narrowing the dural sheath. Three cases of lumbar epidural lipomatosis related to obesity have already been described. Treatment in all three was surgical with the result assessed as good in one case and poor in two. The interest of the present case is demonstration of the cause and effect relationship between epidural lipomatosis and obesity as shown by complete restoration of the epidural space after a calorie-controlled diet, and the possibility of successful treatment by this technique.

Longitudinal radiologic evaluation of osteoarthritis of the knee

Radiologic assessment appears to be an objective standard for longterm evaluation of osteoarthritis (OA) and it is inexpensive, quick, simple and noninvasive. We conducted a one year followup study of patients with OA of the knee to evaluate the reproducibility and validity of this evaluation. The intra and interobserver reproducibility of the radiologic variables were evaluated on 275 and 539 patients, respectively, and found to be satisfactory (intraclass coefficient of correlation above 0.70 for the evaluation of the space narrowing of the joint). During the one year followup study, there was a slight but statistically significant deterioration of the joint space narrowing, evaluated on a 6 grade scale on 360 patients (p less than 0.001). The changes in the joint space narrowing were more closely correlated with treatments received by the patients for OA (nonsteroidal antiinflammatory drug (NSAID) intake, synovial fluid aspiration) than with changes in the recorded clinical variables (pain on a visual analog scale, Lequesne algofunctional index). Moreover, some factors such as obesity, generalized OA and flares of OA appeared to be correlated with the deterioration of joint space narrowing. Further studies are necessary to confirm and/or explain the relationship between the deterioration of the joint space narrowing and such factors (i.e., NSAID intake, obesity, flares of OA, generalized OA), which were detected in this study.

[Rheumatological manifestations associated with myelodysplastic and myeloproliferative syndromes]

In 8 patients, an inflammatory polyarthropathy simulating rhizomelic pseudo-rheumatoid arthritis or early RA was the presenting feature of a myeloproliferative or myelodysplasic syndrome. Clinical, radiological, joint cytology and synovial histology findings are analysed. They suggested a link between joint and hematological disorders. Eleven similar cases were found in the literature. The pathophysiological mechanisms are discussed. Anemia, thrombocythemia and excessive monocytosis may be suggestive of myelodysplasia, in particular if the onset of the inflammatory rheumatic disorder is atypical.

The European Spondylarthropathy Study Group preliminary criteria for the classification of spondylarthropathy

Classification criteria for most of the disorders belonging to the spondylarthropathy group already exist. However, the spectrum of spondylarthropathy is wider than the sum of these disorders suggests. Seronegative oligoarthritis, dactylitis or polyarthritis of the lower extremities, heel pain due to enthesitis, and other undifferentiated cases of spondylarthropathy have been ignored in epidemiologic studies because of the inadequacy of existing criteria. In order to define classification criteria that also encompass patients with undifferentiated spondylarthropathy, we studied 403 patients with all forms of spondylarthropathy and 674 control patients with other rheumatic diseases. The diagnoses were based on the local clinical expert's opinion. The 403 patients included 168 with ankylosing spondylitis, 68 with psoriatic arthritis, 41 with reactive arthritis, 17 with inflammatory bowel disease and arthritis, and 109 with unclassified spondylarthropathy. Based on statistical analysis and clinical reasoning, we propose the following classification criteria for spondylarthropathy: inflammatory spinal pain or synovitis (asymmetric or predominantly in the lower limbs), together with at least 1 of the following: positive family history, psoriasis, inflammatory bowel disease, urethritis, or acute diarrhea, alternating buttock pain, enthesopathy, or sacroiliitis as determined from radiography of the pelvic region. These criteria resulted in a sensitivity of 87% and a specificity of 87%. The proposed classification criteria are easy to apply in clinical practice and performed well in all 7 participating centers. However, we regard them as preliminary until they have been further evaluated in other settings.

The defective in vitro expression of interferon-gamma messenger RNA in rheumatoid arthritis is recovered by cycloheximide

Circulating T lymphocytes from patients with rheumatoid arthritis (RA) were found to produce low concentrations of interferon-gamma (IFN-gamma) and express low amounts of this messenger RNA (mRNA) in response to stimulation with phytohemagglutinin (PHA). In this study, we have examined the superinduction effect of cycloheximide (CHX) on the IFN-gamma mRNA expression in PHA-stimulated T lymphocytes from nine patients with active RA compared to three healthy individuals. When CHX was added 6 hr postactivation, the expression of IFN-gamma mRNA in RA patients increased significantly at 24 and 48 hr (P less than 0.01) and reached levels similar to those observed in controls. We suggest that posttranscriptional events could play a role in the defective production of IFN-gamma observed in RA.

[Desensitization by autologous saliva and Behçet's disease]

Among 240 patients with Behçet's disease seen in the Internal Medicine Department of the Ibnou Rochd University Hospital, Casablanca, between January 1981 and April 1988, 44 were selected to study the effects of desensitization by autologous saliva on oral and genital aphthae and on articular manifestations. Thirty of these 44 patients received gradually decreasing dilutions of their own saliva, and 14 control patients received physiological saline. Injections were administered intradermally twice a week during 15 weeks, then once a week during one year, so that the study lasted one and a half year, from October 1986 to April 1988. No improvement of the arthritis was observed, whereas the oral aphthae were improved in 50% of the patients desensitized by their own saliva. This percentage would have raised some hopes for the treatment of these sometimes disabling lesions were it not for the fact that 50% of the controls were similarly improved. This suggests that desensitization by saliva has a placebo effect.

[Myeloma and epidural invasiveness. Clinical and therapeutic aspects (a study of 22 cases)]

The authors have retrospectively studied 22 cases of spinal cord compression among 184 patients having multiple myeloma or plasmocytoma. Neurological signs were the initial symptoms of the malignant plasmocytosis in 32% of the cases. Seven patients had paraplegia, 13 paraparesia and three had no motor involvement. A laminectomy was performed in half of the cases (with or without local radiotherapy and/or chemotherapy); the 11 other patients were treated by radiotherapy and/or chemotherapy alone. Sixteen patients (72%) improved, 10 in the laminectomy group and six in the other. The improvement seemed to be better after the laminectomy (and/or radiotherapy or chemotherapy) but to a lesser extend if the patients were paraplegic, in case of sudden onset and of compression at the thoracic level. The median of survival was 30 months. They emphasize the utility of magnetic resonance imaging for the diagnosis of epidural involvement before the occurrence of objective neurological complications.

The effect of cisapride on gastro-oesophageal dysfunction in systemic sclerosis: a controlled manometric study

1. Cisapride is a novel prokinetic drug which facilitates or restores motility throughout the gastrointestinal tract. Its mechanism of action is thought to involve enhancement of acetylcholine release in the myenteric plexus of the gut. 2. The effect of intravenous cisapride 10 mg on gastro-oesophageal dysfunction was investigated in 20 patients with systemic sclerosis, using a double-blind, randomised, cross-over, placebo-controlled manometric study design. 3. The increase in lower oesophageal sphincter pressure was significantly higher after cisapride (mean +/- s.e. mean, 8.3 +/- 2.1 cm H2O) than after placebo (mean +/- s.e. mean. 0.1 +/- 0.3 cm H2O) (P less than 0.001). The increase in the number of fundic gastric contractions during the 30 min study period was significantly higher after cisapride (mean +/- s.e. mean, 7.7 +/- 2.3) than after placebo (mean +/- s.e. mean, 0.9 +/- 0.6) (P less than 0.01). 4. No serious clinical adverse effects were observed. 5. The study demonstrates that intravenous cisapride induces a significant increase in lower oesophageal sphincter pressure and in the number of fundic gastric contractions, which may be beneficial in the treatment of scleroderma gastro-oesophageal dysfunction. Further long-term studies of the effect of oral cisapride in patients with systemic sclerosis are warranted.

Abnormalities of T lymphocyte subsets in systemic sclerosis demonstrated with anti-CD45RA and anti-CD29 monoclonal antibodies

T cell subpopulations were assessed by two colour flow cytometry with phycoerythrin conjugated anti-CD45RA and anti-CD29 and fluorescein conjugated anti-CD4 and anti-CD8 monoclonal antibodies, on peripheral blood lymphocytes from 12 patients with systemic sclerosis and from nine control subjects. The percentage of CD4+CD29+ cells was significantly higher in patients with systemic sclerosis than in controls (mean (SEM) 68.8 (3.1) v 47.9 (4.1) respectively). CD4+CD45RA+ cells were not significantly different in patients and controls. CD8+CD29+ and CD8+CD45RA+ subpopulations were significantly higher in patients with systemic sclerosis than in controls (83.0 (3.2) v 58.7 (6.8) and 80.2 (3.0) v 66.9 (3.2) respectively). The increase in the percentage of CD29+ cells suggests an activation of memory cells in patients with systemic sclerosis, which may play an important part in the pathogenesis of the disease.

The effect of nifedipine on myocardial perfusion and metabolism in systemic sclerosis. A positron emission tomographic study

We assessed the effect of nifedipine on myocardial perfusion and metabolism in 9 patients with systemic sclerosis, using positron emission tomography with a perfusion tracer (potassium-38) and a metabolic tracer (18F-fluorodeoxyglucose [18FDG]). Nifedipine, 20 mg 3 times daily for 1 week, induced a significant increase in 38K myocardial uptake, a significant decrease in 18FDG myocardial uptake, and a significant increase in the myocardial 38K: 18FDG ratio. These results indicate that the increase in myocardial perfusion is associated with modifications in myocardial energy metabolism, which probably result from a beneficial anti-ischemic effect of nifedipine in patients with systemic sclerosis.

Interferon-gamma mRNA expression upon in vitro T lymphocyte activation is decreased in rheumatoid arthritis patients

A decreased production of interferon-gamma (IFN-gamma) and interleukin-2 (IL-2) upon in vitro stimulation by phytohemagglutinin (PHA) peripheral blood leucocyte in active rheumatoid arthritis (RA) patients has been described as an important immunological abnormality in this disease. However, the molecular level at which this defect might occur has not been fully documented. We have investigated the kinetics of IFN-gamma, interleukin-2 receptor (IL-2 R), and interleukin-1 beta (IL-1 beta) messenger RNA (mRNA) expression in RA patients (n = 9) and normal controls (n = 5) after PHA leucocyte activation. We demonstrate here a significantly decreased expression of IFN-gamma mRNA in RA patients without modification of its kinetics associated with a similar IL-1 beta mRNA expression.

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.