Laterally elevated wedged insoles in the treatment of medial knee osteoarthritis: a prospective randomized controlled study

OBJECTIVE

To compare the clinical effects of laterally wedged insoles and neutrally wedged insoles (used as control) in patients with medial femoro-tibial knee osteoarthritis (OA).

DESIGN

6-month prospective randomized controlled study.

PATIENTS

outpatients with painful medial femoro-tibial knee OA.

OUTCOME MEASURES

patient's overall assessment of disease activity (5 grade scale), WOMAC index subscales and concomitant treatments.

STATISTICAL ANALYSIS

Performed as an intention-to-treat analysis. Main criterion: improvement in the patient's assessment of activity (defined as a reduction of 1 grade or more at month 6 compared to baseline, and no intraarticular injection or lavage during the study). Secondary criteria for assessment: (a) improvement in the patient's assessment of activity at months 1 and 3 compared to baseline, (b) improvement in the WOMAC subscales at months 1, 3 and 6, compared to baseline (defined as an improvement of at least 30%, and no intraarticular injection or lavage during the study) and (c) concomitant therapies (analgesics and NSAIDs).

RESULTS

The baseline characteristics of the 156 recruited patients (41 males, 115 females, mean age 64.8 years) were not different in the two treatment groups. At months 1, 3 and 6 the percentages of patients with improvement in assessment of disease activity, in WOMAC pain, joint stiffness, and physical functioning subscales were similar in the two groups. The number of days with NSAIDs intake during the previous 3 months was decreased at month 6 compared with baseline in the group furnished with laterally wedged insoles (14.1 days+/-28 vs 9.9 days+/-27, P=0.04, Wilcoxon paired test), while it remained unchanged in the other group (15.5 days+/-24 vs 15+/-28, P=0.56). Compliance and tolerance were satisfactory. Compliance was different between the two groups at month 6, with a greater frequency of patients who wore insoles permanently in the laterally wedged insole group than in the other group (87.8% vs 74.3%;P=0.032).

CONCLUSION

This study failed to demonstrate a relevant short-term symptomatic effect of laterally-wedged insoles in medial femoro-tibial OA. However, the decrease in NSAIDs consumption together with better compliance in the treated group are in favor of a beneficial effect of laterally-wedged insoles in medial femoro-tibial OA.

[Diagnostic problems in brain abscess: 45 cases]

BACKGROUND AND PURPOSE

We analysed the difficulties encountered in the differential diagnosis between brain abscess and brain tumor and their influence on treatment and outcome.

METHODS

- Forty-five adults with brain abscess operated on between 1993 and 1999 were retrospectively reviewed. We studied preoperative diagnosis, clinical, radiological, bacteriological findings, surgical procedure, primary sources of infection and outcome.

RESULTS

Preoperative diagnosis was right in 55.6% (25/45), wrong in 22.2% (10/45) and doubtful in 22.2% (10/45). Diffusion-weighted MR imaging was successfully used in 4 doubtful cases to make the differential diagnosis between abscess and tumor. When the preoperative diagnosis was right, the surgical procedure was a burr-hole aspiration in 73.3% (22/25) whereas when it was wrong, an excision was performed in 60% (6/10) of the cases. Aspiration was the last diagnostic investigation in 80% (8/10) of doubtful cases. Microbacterial organisms were identified in 75.5% (34/45) of the cases and primary cause of infection in 62.2% (28/45). The outcome depended on clinical status on admission, preoperative diagnosis and surgical procedure. In four cases, diffusion-weighted MRI allowed differential diagnosis between brain abscess and tumor through calculation of the Apparent Diffusion Coefficient which is low in abscess and high in cystic tumor.

CONCLUSION

The diagnosis of brain abscess remains difficult in certain patients. Correct preoperative diagnosis influences the decision on the appropriate surgical procedure and helps improve outcome.

[Sentinel node involvement in T0-T1 breast cancers]

STUDY AIM

Determination of axillary lymph node status is crucial in diagnosis of early breast cancer. However thanks to an early diagnosis, an increasing number of axillary lymph node dissections are free of disease. This raises questions about the need for this procedure. The study aim was to report an experience with lymphadenectomy and sentinel node mapping in patients with T0-T1 carcinoma of the breast.

METHODS

Between November 1997 and December 1999, 84 consecutive women (T0-T1 N0 according to the 1987 UICC classification) with recently diagnosed breast cancer, were included in this study for identification of the sentinel lymph node (SLN). The SLN was removed and submitted for histological examination. All patients underwent axillary dissection; nodes from levels I and II (Berg's classification) were excised and submitted to histological examination.

RESULTS

The average tumor diameter was 12.7 mm (range, 3 to 25 mm). The lymphatic mapping technique was obtained after injection of the isotope into the breast around the tumor in 53/84 patients: the sentinel lymph node was the only positive node in 10 patients and it was positive in 5 patients with other axillary nodes. In 15/84 patients, an intradermal injection of blue dye was used; two sentinel nodes were positive and one falsely negative. In 16/84 patients, an interdermal injection of blue dye was used to make up for. In this study, the sentinel node was positive in three patients and falsely negative in one patient. The discrepancy was due to an important involvement of an axillary area excluded from the lymphatic channels. 22/84 patients (26%) had a metastatic spread to the axillary nodes. 30/84 patients had also an isotopic captation in another lymph node group (internal mammary).

CONCLUSION

This study confirms that lymphatic mapping is technically possible in the patients with T0-T1 breast cancer and that the histological characteristics of the sentinel node probably reflect the histological characteristics of the rest of the axillary lymph nodes, but do not provide any information about the other lymph node sites.

Relapse of Wegener's granulomatosis. Concerning a case after 20 years of remission

Immunosuppressive drugs have transformed the prognosis of systemic Wegener's granulomatosis. Nowadays, the main residual problem is illness relapses, for which management is largely undefined. We describe the case of a patient, aged 47 in 1977. The diagnosis of Wegener's granulomatosis was made when faced with polyarthralgias, cutaneous vasculitis, rhinitis, dyspnea, hemoptysis and global decline of her physical condition. The treatment associated high-dose corticotherapy and intramuscular cyclophosphamide for 1 year. This treatment led to a complete remission. Twenty years later, the patient was hospitalized for reoccurrence of rhinitis, dyspnea and right knee effusion associated with biological inflammatory syndrome, renal insufficiency and antibodies against polymorphonuclear neutrophil cytoplasm, type c-ANCA. Chest CT-scan disclosed parenchymal infiltrates. Wegener relapse was diagnosed and the combination of three methylprednisolone perfusions followed by oral prednisone (1 mg/kg/d) and a monthly bolus of cyclophosphamide led to a new remission. Nevertheless, 4 months after beginning the treatment the patient died from an infectious complication (Pneumocystis carinii and aspergillosis). Relapses of Wegener's granulomatosis are frequent and difficult to predict. Moreover, some cases occur very early. The remarkable efficiency of cyclophosphamide to induce remission is however shaded by the high rate of relapse. Other drugs are studied to identify more efficient therapy, able to both induce remission and prevent relapses, but reliable data are still missing to determine the best therapeutic regimen.

Health education groups for caregivers in an HMO

The short-term effectiveness of a Health Education Group (HEP) intervention program for spouses of frail older adults was compared to the usual care (UC) offered to the spouses of frail older persons in a staff model health maintenance organization. HEP is a multicomponent group program offered in eight weekly, two-hour group sessions, and ten monthly, two-hour follow-up group sessions. It includes emotion-focused and problem-focused coping strategies, education, and support. One-hundred and five spouses were recruited and randomly assigned to HEP (n = 58) or UC (n = 47). Spouse caregivers and care recipients were assessed within two weeks of intervention and within two weeks after the completion of the eight weekly group meetings. The results indicate that, for caregivers, HEP was more effective than UC in reducing depression, maintaining social integration, increasing effectiveness in solving pressing problems, increasing knowledge of community services and how to access them, changing caregivers' feelings of competence, and the way they respond to the care giving situation. No significant differences, however, were found between care recipients in the two arms of the study on any of the outcome measures.

Measurement of CP-violating asymmetries in B0 decays to CP eigenstates

We present measurements of time-dependent CP-violating asymmetries in neutral B decays to several CP eigenstates. The measurement uses a data sample of 23x10(6) Upsilon(4S)-->BbarB decays collected by the BABAR detector at the PEP-II asymmetric B Factory at SLAC. In this sample, we find events in which one neutral B meson is fully reconstructed in a CP eigenstate containing charmonium and the flavor of the other neutral B meson is determined from its decay products. The amplitude of the CP-violating asymmetry, which in the standard model is proportional to sin2beta, is derived from the decay time distributions in such events. The result is sin2beta = 0.34+/-0.20 (stat)+/-0.05 (syst).

Diagnostic value of ferritin and glycosylated ferritin in adult onset Still's disease

OBJECTIVE

To determine the usefulness of serum ferritin and glycosylated ferritin (GF) levels in diagnosing adult onset Still's disease (AOSD).

METHODS

We performed a retrospective multicenter study of 205 patients who had ferritin and GF assays in one hospital laboratory. Records of all patients were reviewed, and a standardized questionnaire used to extract all data available at the time of the assay. The clinicians' final diagnosis was also recorded. Patients were classified as having "certain AOSD" (based on Yamaguchi's criteria) or a control disease. The concordance of ferritin and GF levels with final diagnosis was evaluated.

RESULTS

In total 49 AOSD and 120 control patients were eligible. The mean ferritin value was significantly higher in the AOSD group (4,752 +/- 9,599 microg/l) than in the control group (1,571 +/- 3,807 microg/l), p = 0.029. GF was significantly lower in AOSD patients (15.9 +/- 11.9%) than in the control group (31.5 +/- 18.7%), p < 0.001. The combination of a GF level of < or = 20% with ferritin above the upper limit of normal yielded a sensitivity of 70.5% and specificity of 83.2%. The combination of a GF level < or = 20% with ferritin 5 times normal produced a sensitivity of 43.2% and specificity of 92.9%. This latter combination allowed an AOSD diagnosis to be ruled out for 6 of the 8 control patients who met Yamaguchi's positive criteria.

CONCLUSION

Ferritin and GF levels are powerful diagnostic markers of AOSD. They may be helpful in clinical practice for excluding differential diagnoses.

The hypereosinophilic syndrome after residence in a tropical country: report of 4 cases

Severe eosinophilia may be complicated by acute or chronic visceral damage. The underlying origin of the hypereosinophilia may be infectious, allergic, toxic, malignant or systemic (the secondary or reactive hypereosinophilic syndrome), but in a number of cases no cause can be found (the idiopathic hypereosinophilic syndrome). We describe 4 cases with hypereosinophilia and secondary visceral damage after residence in a tropical region. In three cases a helminthic infection was the obvious cause, the brain and the heart were the target organs. After treatment of the infection both the hypereosinophilia and the neurological and cardiac lesions disappeared. The fourth patient died of multi-organ disease. No definite trigger of the hypereosinophilia could be found. We discuss clinical findings, necessary investigations and therapeutic strategies.

[Rheumatic disorders. Overview]

Of all rheumatic diseases, osteoarthritis (OA) and rheumatoid arthritis (RA) are the most frequently occurring. Although they differ in pathophysiology and the molecular mechanisms responsible for the destruction of cartilage (since RA is an inflammatory disease and OA is not), there are, however, a certain number of similarities and common pathways in the inflammatory processes of both diseases: mild inflammatory phenomena have been observed during OA, and both interleukin-1 and tumour necrosis factor-alpha seem to play key roles, as in RA. Although there is a dramatic difference between the 2 diseases in the intensity of inflammation, the inflammatory process is responsible for the synthesis of metalloproteinases and free oxygen radicals, and, subsequently, for progressive cartilage destruction. Both OA and RA engender important costs for the healthcare system. Direct costs result from practitioner visits, drug purchase and management, drug-related adverse effects, management or hospital care; indirect costs are linked to progressive functional disability. Although RA leads to significant individual costs, OA is more problematical for the healthcare system, since its prevalence is far higher than that of RA. Thus, rheumatic diseases have become a major public health problem. Optimal therapeutic strategies need to be determined in order to define the most effective procedure for controlling disease symptoms such as pain, stopping or slowing down disease progression and, finally, keeping patients active. But it is of paramount importance that the gain in efficacy be associated with a gain in drug safety.

[Suprasellar arachnoid cyst associated with syringomyelia. Case report]

We present a case of suprasellar arachnoid cyst which was revealed by visual impairement and hypopituitarism. Neuroradiological imaging showed the peculiar association of the suprasellar cyst with cerebellar tonsillar herniation and a large asymptomatic cervical syringomyelic cavity. Surgical treatment of the suprasellar cyst allowed the reduction of both the cyst and the syrinx. A common pathophysiological mechanism of these lesions is discussed. We suggest the possibility that an initial obstruction of the basal cisterns caused the suprasellar cyst formation which led to medullar cavity formation.

[Chronic subdural hematoma in patients over 80 years of age]

Eighty cases of chronic subdural haematomas (SDH) in elderly patients (over 80 year-old) are reported retrospectively. The estimated incidence of the disease is 17 cases per 10(5) per year. The main presenting symptoms were confusion and impaired mentation. Surgical treatment was performed in all patients. Biological disorders deserved particular attention in the elderly SDH population. Complications occurred in 10% of patients, and recurrence of SDH was noted in 5% of patients. After their hospital discharge, 85% of patients returned to their previous neurological status. In this study, the age of patients did not appear to be a poor prognostic factor.

Lignans from the Seeds of Hernandia sonora

The seeds of HERNANDIA SONORA L. (Hernandiaceae) yielded eight lignans. Five of them have already been described from other species of the HERNANDIA genus, namely podophyllotoxin ( 1), picropodophyllin ( 2), deoxypodophyllotoxin ( 3), hernandin ( 4), and podophyllotoxin acetate ( 5). 5-Methoxypodophyllotoxin ( 6), 5-methoxypodophyllotoxin acetate ( 7), and a dibenzylbutyrolactone ( 8) are new. Their structures are presented in this publication.

Corticosteroid sparing effect of low dose methotrexate treatment in adult Still's disease

OBJECTIVE

Adult Still's disease (ASD) is a rare chronic polyarthritis, usually treated with corticosteroid therapy. Because some patients become dependent on high dose prednisone or are refractory to that treatment, and because adverse events are frequent with corticosteroid, we evaluated the efficacy of low dose methotrexate (MTX) as a second-line drug.

METHODS

We retrospectively studied 26 patients with ASD treated with low dose MTX because their disease was either resistant to or dependent on corticosteroids.

RESULTS

The group included 13 women and 13 men, with a mean age of 32.6 years at onset of ASD. Mean disease duration at the beginning of MTX treatment was 59.9 mo (range 7 to 444). Evaluation took place at the maximum followup, which averaged 48.9 mo (range 8 to 136). The mean dose of MTX was 11.5+/-3.6 mg/week (range 7.5 to 17.5). Twenty-three patients responded to MTX; 18 had complete remission. No difference was seen between patients with or without extraarticular manifestations. Leukocyte and neutrophil counts and erythrocyte sedimentation rate were significantly reduced (p = 0.0001). Daily prednisone intake decreased by 69% (21.5 mg) (p = 0.0001). Eleven patients were able to stop taking corticosteroids. One patient with AA amyloidosis renal failure died of neutropenia: this was the only serious adverse event.

CONCLUSION

MTX is an effective second-line treatment of ASD that does not respond to prednisone. It allows significant reduction of corticosteroid doses, which is beneficial to these patients, who have frequent and numerous corticosteroid related adverse events.

[Complications of colonic diverticular disease during rheumatoid polyarthritis: 7 cases]

INTRODUCTION

Among the gastrointestinal adverse effects of nonsteroidal anti-inflammatory drugs (NSAID) and corticoids are mentioned complications of colonic diverticular disease. However, very few studies have described their consequences in rheumatoid arthritis.

EXEGESIS

We report on seven patients who were admitted in our department between 1984 and 1997. All patients received corticoids and another antirheumatic drug (gold salts, hydroxychloroquine, immunosuppressive drugs); treatment also included NSAID in four cases. Two patients had a necrotizing vasculitis accompanying rheumatoid arthritis. Intestinal accompanying diseases were the following: one diverticulitis, three colonic perforations with pelviperitonitis, one colovesical fistula, one pelvic abscess, and one diverticular hemorrhage. All patients underwent surgery with positive results.

CONCLUSION

Combination of the four following symptoms: fever, abdominal pain, diarrhea, and hemorrhage, can uncover a complication of colónic diverticular disease occurring in the course of rheumatoid arthritis. It should be investigated, even if no history of diverculosis may be evidenced.

The physical treatment of upper limb edema

BACKGROUND

Edema of the upper limb, without any doubt, constitutes the most invalidating complication of breast carcinoma treatment. The swelling of the limb results from decreased liquid evacuation by surgical intervention at the axillary level and also by the eventual treatment by cobaltotherapy.

METHOD

The physical treatment for edema of the limb consists of a combination of therapies that were tested for their effectiveness in laboratories on healthy students and also on patients who underwent surgery for breast carcinoma. The treatment consists of the application of manual lymphatic drainage (type Leduc), the use of multilayered bandages, and the use of intermittent pneumatic compression. The population studied was represented by 220 patients who underwent breast surgery. The authors followed their evolution during the first 2 weeks of treatment. Patients were not hospitalized. The edema was measured by using marks tattooed on the skin.

RESULTS

The limb that developed edema was compared with the healthy limb. The most important reduction was obtained in the first week. The decrease was equivalent to 50% of the average of the difference between both upper limbs. During the second week, the results obtained stabilized; however, there was a slight decrease at the end of the second week.

CONCLUSIONS

The physical treatment of edema represents the preferred therapeutic approach. However, it must answer to well-defined criteria to be efficient and for long-lasting effects. The physical treatment is used to treat outpatients, allowing them to follow a normal lifestyle.

Imaging techniques in the management and prevention of posttherapeutic upper limb edemas

BACKGROUND

Upper limb edema remains the most frequent complication after treatments for breast carcinoma. Various imaging techniques can be used to prevent these complications, to manage them, and to diagnose the possible lymphonodal evolution that may underlie these events. In the present paper, these techniques are reviewed.

METHODS

Based on clinical experience as well as on the data from the literature, these imaging techniques are presented, and their contributions are analyzed.

RESULTS

The pre- and post-operative imaging and research techniques of the so-called sentinel nodes (using blue dye, and/or lymphoscintigraphy, and/or gamma probe) appear to be very promising for defining patients in whom axillary node clearance either might be avoided or is indicated. Lymphoscintigraphic investigations also can be used after surgery and/or radiation therapy to define patients who either are at risk to develop upper limb edema or present with latent edema. In patients with clinically obvious edema, even if it is limited, lymphoscintigraphic techniques can provide a morphologic and functional definition of the condition. Venous echo Doppler can be used when abnormalities of the venous return are suspected. In diagnosing the lymphonodal evolution of the disease, techniques like immunoscintigraphy, positron emission tomography (using 18-fluoro-2-deoxy-D-glucose), X-ray computed tomography, and nuclear magnetic resonance imaging can contribute.

CONCLUSIONS

Various imaging techniques can be used to prevent and/or to manage the upper limb edema that may complicate the treatment(s) of the patients with breast carcinoma.

Subcutaneous sumatriptan compared with usual acute treatments for migraine: clinical and pharmacoeconomic evaluation

Cost-effectiveness and cost per successful treatment has been evaluated in 186 outpatients randomised to treat moderate to severe migraine attacks either with subcutaneous sumatriptan 6 mg (n = 97) or with their current therapy (n = 89) during an open, multicentre study of 3 months. Within 2 hours, headache severity decreased to none/mild in 86% of all attacks in the sumatriptan group (STG) compared to 25% in the customary group (CTG). Migraine was alleviated earlier in the STG than in the CTG (median 3.78 vs. 13.39 hours, p < 0.0001). The direct and total cost of treatment was 133 and 2012 BF, respectively, in the CTG and 1400 and 2522 BF, respectively, in the STG. Measuring the effectiveness of earlier pain relief with sumatriptan, the incremental cost-effective ratios for direct and total cost were 132 and 53 BF per hour of relieved pain, respectively. For this price, significantly more sumatriptan patients improved their quality of life by more than 20% (61.6 vs. 20.6% patients, p < 0.001) and less sumatriptan patient consulted a medical professional (11.3 vs. 29.2% patients, p < 0.01), used less medication for adverse events (6.2 vs. 22.5%, p < 0.001) and suffered less from associated migraine symptoms. The median number of hours of diminished work-efficiency (3 vs. 7 hours, p < 0.01) or of suspension of non-professional activity (10 vs. 24 hours, p < 0.001) was also significantly lower in the STG. The total cost per successfully treated patient was lower in the STG. Sumatriptan is more effective, provides a better quality of life, reduces health care resource utilisation, and improves work productivity as compared to the CTG, thereby resulting in a favourable cost-effectiveness ratio.