Septic sacroiliitis during the postpartal period. Diagnostic contribution of magnetic resonance imaging

Septic sacroiliitis is an uncommon condition that is often diagnosed late. Two cases in the immediate postpartal period are reported. Magnetic resonance imaging contributed decisively to the early diagnosis.

Insufficiency fractures of the ilium

Insufficiency fractures often occur in the sacrum and pubic rami but have rarely been reported in the ilium, where their frequency may be underestimated. We studied a series of 14 patients with insufficiency fractures of the ilium. Six patients had an oblique fracture through the wing of the ilium (which was bilateral in one case) and nine a supraacetabular fracture, with in one case a superomedial extension into the iliac wing. The initial radiographs were normal, making the diagnosis difficult. A linear area of sclerosis along the fracture line was seen after a few weeks. The radionuclide examination provided early detection and often demonstrated multiple insufficiency fractures (mean 2.1 per patient). Computed tomography missed some of the fractures, whereas magnetic resonance imaging proved a reliable diagnostic tool, especially in patients with supraacetabular fractures, showing the fracture as a line of low signal surrounded by an area of edema whose contours were exactly the same as those of the hyperactive focus on the radionuclide scan. Osteoporosis was a causative factor in all 14 patients and vitamin D deficiency in seven. Also, three patients had a history of fluoride therapy.

Hypertrophic osteoarthropathy following aortic surgery

Unilateral lower extremity hypertrophic osteoarthropathy may be the initial symptom of an infected aortic graft. Knowledge of this uncommon association should lead to early and accurate diagnosis and appropriate surgical management, thus avoiding the development of aortoenteric fistula, a complication that still carries a significant risk of mortality.

The 'small-patella' syndrome. Hereditary osteodysplasia of the knee, pelvis and foot

We describe a syndrome combining abnormalities of the pelvis, knee and foot in three related patients with a familial history of small dislocated patellae. The clinical and radiological appearance of the patella and pelvis is consistent with the 'small-patella' syndrome, a rare autosomal dominant disorder. There were also previously unreported deformities affecting the feet.

THE ‘SMALL-PATELLA’ SYNDROME

We describe a syndrome combining abnormalities of the pelvis, knee and foot in three related patients with a familial history of small dislocated patellae. The clinical and radiological appearance of the patella and pelvis is consistent with the ‘small-patella’ syndrome, a rare autosomal dominant disorder. There were also previously unreported deformities affecting the feet.

Development of a criterion for response to therapy at 6 months in multiple myeloma

To investigate the prognostic value of therapy at 6 months on survival in multiple myeloma, to develop a new criterion assessing response to initial therapy at 6 months, and to compare it to a current criterion. The types of initial and 6-month therapy were considered in a prognostic factor analysis in 70 patients treated in routine practice. Using the response to initial therapy defined by the clinician's decision as grouping variable in this group, a discriminant analysis identified the characteristics of responder patients. The validity of the resulting criterion was tested in another test group. Its prognostic ability was compared to the CLMTF criterion (50% M-component reduction from baseline). The therapy at 6 months, reflecting the clinician's appraisal of response to initial therapy, predicted survival significantly. A criterion combining two variables (M-component change and haemoglobin level at 6 months) classified 70% and 72.4% of patients correctly regarding response status in the training and test groups respectively. This criterion was shown to perform better than the CLMTF criterion in predicting survival.

CONCLUSION

A new criterion for response to therapy at 6 months, also presented in a nomogram, combines M-component change and haemoglobin level at 6 months.

[Imaging of osteomedullary infarctions and their complications]

Radiographic, CT, bone scan and MR patterns of the infarcts of the metaphyses and diaphyses of tubular bones and their main complications are presented. Bone marrow infarcts are located in the medullary cavity of long bones. They most often involve the lower limbs. They are commonly associated with necrosis of the epiphyses and have common origin. In contrast to necrosis of the epiphyses, bone infarcts may present specific complications. They are most often detected incidentally, because of their clinical latency. Radiographic and CT changes appear late, showing localized areas of increased density with irregular rims, or sharply demarcated shells of calcification. Earlier changes are demonstrated by bone scan and MRI. MR pattern is characteristic, showing an area of hyposignal on T1- and T2-weighted sequences, with irregular rims, and sometimes small areas of fat signal. Their complications include cystic formation and malignant degeneration (sarcoma and particularly malignant fibrous histocytoma). An unusual complication, infection involving bone infarcts is also presented.

Enthesitis of the ligamentum teres during ankylosing spondylitis: histopathological report

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Plasma and cerebrospinal fluid concentrations of paracetamol after a single intravenous dose of propacetamol

Since the antipyretic and probably the analgesic effects of paracetamol are, at least in part, centrally mediated, its plasma and cerebrospinal fluid (CSF) concentrations were measured in 43 patients with nerve-root compression pain. Each subject was given a short i.v. infusion of 2 g propacetamol, a prodrug which is hydrolysed to paracetamol within 7 min. Single blood and CSF samples were drawn concomitantly in each patient at intervals between 20 min and 12 h. Maximum CSF drug concentrations were observed at the 4th hour, subsequent concentrations exceeding those in plasma. The elimination half-life of paracetamol calculated from pooled data was shorter in plasma (2.4 h) than in CSF (3.2 h). The time-course of paracetamol in CSF may parallel that of analgesic effect.

[Multiple calcifications and ossifications of tendons]

Multiple calcifications and ossifications of tendons are, as a rule, associated with similar lesions of other articular and/or periarticular structures. The nature and multiplicity of these lesions gives them an unquestionable diagnostic and nosological value. Multiple calcifications are part of the apatite arthritis or of diffuse articular chondrocalcinosis. Multiple ossifications of tendons often suggest Forestier's disease and ankylosing spondylitis.

[Tumor cell death as reflected by the SCC-antigen level?]

The serum levels of squamous cell carcinoma (SCC) associated antigen are related to the course of the therapy in 91 cases of advanced head and neck cancers. Without statistical significance the findings may lead to the following statements: 1. Serum levels below 2 ng/ml before treatment are not related to tumour growth. 2. Serum levels above 2 ng/ml before treatment are likely to be regarded as tumour-associated. 3. High and low level curves of not operated patients show a quantitatively different reaction to the course of a combined simultaneous radiochemotherapy. 4. Initially increasing serum levels under combined therapy may be interpreted as related to cell death or result of a production or proliferation stimulus. 5. High serum levels and low serum levels in tumour patients might be regarded as an expression of different biological activities in the tumour. 6. The comparison of the survival rates of high level tumours to low level tumours raises the question as to whether this different biological activity might be related to clinical malignancy.

[Squamous cell carcinoma-associated antigen (SCC) as a tumor marker in the initial diagnosis of carcinomas of the head and neck region. Results of a prospective study after 24 months]

The serum--SCC antigen levels of patients with head and neck tumors were studied prospectively to determine their value in the initial diagnosis of head- and neck-cancer patients. Serum concentrations above 2 ng/ml are considered abnormal. Preliminary results of the study after a 12-month period have been reported elsewhere (1). The final results of the study show an increased percentage (53%) of pathologic findings, mostly due to the increasing number of advanced stage tumors. High serum levels were found in 60% of the T4-tumors (Fig. 4a). Well differentiated carcinomas seem to be associated with the antigen more frequently than poorly differentiated tumors (Fig. 5). SCC antigen levels were examined as many as five times before the start of treatment (85 patients), and in one-third of those cases the differences between the serum levels exceeded 1 ng/ml. As far as 85% specificity is concerned, the ROC-curve shows a sensitivity of only 40% (Fig. 2) which, in addition to the fact that the antigen was most frequently found in cases of advanced tumors, indicates that the usefulness of the SCC antigen as a tumor marker for head and neck cancer must still be regarded as low.

Plasma and cerebrospinal fluid concentrations of indomethacin in humans. Relationship to analgesic activity

Plasma and cerebrospinal fluid (CSF) concentrations of indomethacin have been determined in 52 patients hospitalized for nerve-root compression pain. Samples of blood and CSF were collected at the same time in each subject, 0.5 to 12 h after a single intramuscular injection of 50 mg indomethacin. Analgesic effect was assessed by the absolute and percentage variation in Huskisson's visual analogue scale between dosing and sampling. According to its high lipid solubility, indomethacin rapidly crossed the blood-brain barrier, being detected in CSF 0.5 h after administration. After attainment of equilibrium within 2 h, the CSF level exceeded the free plasma level. Since the drug was extensively bound to serum albumin (99.7 +/- 0.1%), this phenomenon may represent a slight degree of binding of indomethacin in CSF. The analgesic activity was not related to either the plasma or CSF concentration of indomethacin.

[Experiences with the palisade technic of tympanoplasty]

This article analyses the advantages of the autogenous cartilage from the tragus split into multiple parallel pieces for the closure of big tympanic perforations and for the reconstruction of the middle ear after treatment of ventilation diseases like tympanic retraction or atelectasis. The cartilage is more stable than any other material and gives a better protection against recurrent retraction process. Dispersion into fractioned pieces produces very good functional results, as has been shown in this study.

Studies on type II collagen induced arthritis in rats: an experimental model of peripheral and axial ossifying enthesopathy

It was suggested that type II collagen induced arthritis in rats may be considered an experimental model for rheumatoid arthritis (RA) because of clinical, histological, and immunological similarities. However, some features separate it from RA. We studied 40 inbred female Wistar Furth rats. Two weeks after immunization with native human type II collagen, they had polyarthritis which progressed to ankylosis associated with ossifying enthesopathy and periosteal new bone formation. Inflammatory nodules of the tail appeared after 2 months, with radiological and histopathological aspects of multistage spondylodiscitis. Our findings suggest that collagen induced arthritis may be a relevant model of peripheral and axial ossifying enthesopathy.

[Magnetic resonance imaging of bone infarction. Apropos of 2 cases]

Bone infarcts, generally clinically latent, are only identified late in there course on x-rays, which reveal dense, irregular shadows resembling puffs of smoke situated in the metaphyso-diaphyseal regions of the long bones. Occasionally, they may be responsible for pain and are suggestive of neoplastic degeneration. MRI examination is valuable in these cases. Like necrosis of the femoral head, bone infarcts are demonstrated early in their course by MRI, which reveals zones of reduced signal with irregular margins with scattered areas of increased signal of fat intensity.

[Sternocostoclavicular hyperostosis. Nosological concepts]

The term sternocostoclavicular hyperostosis groups affections of different pathogenicity. These result from an ossifying enthesiopathy, either inflammatory, isolated to the thoracic wall anteriorly or combined with a spondylarthropathy, particularly ankylosing spondylitis, or degenerative, the anterior thoracic hyperostosis usually being part of an ensheathing vertebral hyperostosis. A differential diagnosis is anterior thoracic hyperostosis due to an inflammatory osteopathy occurring in young patients and often associated with other bone lesions of pelvis and spine or long bones.

Clinical pharmacokinetics of D-penicillamine

Penicillamine exists as 2 stereoisomers, but only the D-isomer is used therapeutically. Its chemical reactivity derives from its functional groups, of which the thiol group seems the most important. It is difficult to determine penicillamine in biological fluids because of its instability, the presence of endogenous compounds with a thiol function, and the various chemical forms in which it occurs, namely reduced free penicillamine, penicillamine bound to proteins, and internal (P-S-S-P) and mixed (P-S-S-C) disulphides. The earliest assay methods (colourimetry, isotopic methods, gas-phase chromatography) were neither sensitive nor specific. High performance liquid chromatography with electrochemical detection has led to a more specific assay for D-penicillamine, with detection based on either derivatisation reactions or on electro-oxidisation of the thiol function. With dual-electrode detectors (Au/Hg) disulphides can be assayed directly. D-penicillamine is absorbed rapidly but incompletely (40 to 70%) in the intestine, with wide interindividual variations. Food, antacids and, in particular, iron reduce absorption of the drug. Its bioavailability is also dramatically decreased in patients with malabsorption states. The peak plasma concentration occurs at 1 to 3 hours after ingestion, regardless of dose, and is of the order of 1 to 2 mg/L after an oral dose of 250 mg; some investigators have reported a double peak in plasma, which is probably not due to an enterohepatic cycle. The concentration in plasma then decreases rapidly, generally following a biphasic curve. When long term treatment is discontinued, there is a slow elimination phase lasting 4 to 6 days, which suggests that there is a 'deep compartment' or 'slow pool of the drug reversibly bound to tissues', particularly the skin. This may explain the persistence of its therapeutic effect and the occurrence of undesirable side effects after treatment has been stopped. During long term treatment plasma concentrations are highly variable between individuals. They do not seem to be correlated with the activity or the toxicity of D-penicillamine in patients with rheumatoid arthritis. More than 80% of plasma D-penicillamine is bound to proteins, particularly albumin. The rest is mainly in the free reduced form or as disulphides. Only a small portion of the dose is metabolised in the liver to S-methyl-D-penicillamine. The route of elimination is mainly renal; disulphides represent the main compounds found in the urine. Faecal excretion corresponds mainly to the non-absorbed fraction of the drug.

[Spondylarthropathies or ossifying polyenthesitis. Scintigraphic and scanographic evidence]

Ossifying enthesites present an undeniable diagnostic value in every chronic inflammatory rheumatism at an early stage, not only in adults but also in children. Bony scintigraphy discovers them in most localizations at a preradiological stage, as soon as they cause pain. The scanner examination enables to follow the anatomical evolution of the ossifications. It is perfectly suitable for the study of sacro-iliac and interapophyseal joints. Ossifying enthesites, the evolution of which spreads over several years, often depend on mechanical, professional or athletic constraints. Ossifying enthesitis is a common characteristics of "classic" spondylo-arthropathies which are all ossifying polyenthesites: ankylosing spondylarthritis, psoriasic rheumatism, rheumatism of enteropathies, Fiessinger-Leroy-Reiter syndrome and juvenile spondylo-arthropathies.

[Bone angioscintigraphy]

Classical bone scintigraphy can be completed by a dynamic study of the blood supply of a previously defined anatomical region. Our protocol consists of the recording of early images in the histogram mode, centred on the selected pathological region and on the symmetrical region which acts as a control. One film is taken every 3 seconds for 3 minutes following an intravenous injection of 20 mci of Tc99m MDP into a cubital fossa vein. More limited symmetrical zones of interest are visualised on the image obtained by summation of all of the information obtained during the second minute following the arterial passage of the radioactive bolus. The curve reflecting the variation in activity for each zone of interest over these three minutes can therefore be obtained. The first part of the curve, until the first slope change, corresponds to the arterial phase (blood flow), the second part, which includes a brief venous phase, corresponds to the vasculo-tissue phase (blood pool). The value of these bone image, which allow a very detailed analysis of the topography and intensity of the uptake, is above all diagnostic, while the early, vascular images and the resulting curves are essentially of pathophysiological interest. Bone angioscintigraphy is a triple examination and one of its best applications is in reflex sympathetic dystrophy. It is able to distinguish very objectively between "hot" and "cold" forms and it can indicate the most appropriate treatment for each case and follow the effects of treatment. The other indications for bone angioscintigraphy also include Paget's disease, especially the monitoring of treatment, osteomyelitis, sarcomas and osteonecrosis.