Successful management of multidrug-resistant tuberculosis under programme conditions in the Dominican Republic

SETTING

The Dominican Republic is a high-incidence area for multidrug-resistant tuberculosis (MDR-TB; 6.6% of initial cases). Standardised treatment regimens for MDR-TB may be a potential solution.

OBJECTIVE

To present the effectiveness of standard regimens under routine national conditions.

DESIGN

We reviewed all MDR-TB patients treated under routine conditions from 29 August 2006 to 30 June 2010, showing interim and final outcomes. Patients were treated with regimens that were standardised or individualised based on previously received second-line anti-tuberculosis drugs.

RESULTS

Population description and culture conversion data are reported for the 289 MDR-TB patients. The median patient age was 31 years. Most had failed first-line treatment (72.6%). Culture negativity was obtained within 4 months (median 2 months) in 78.6%. Among the 150 patients treated between 2006 and 2008, 74% had favourable results on standardised and 66% on individualised regimens (P = 0.211). The efficacy of the standardised and individualised regimens was respectively 92.8% and 81% (P = 0.056). The relapse rate was approximately 1%. A median of five drug side effects occurred per patient. More than 2 months to culture conversion and bilateral cavitation on chest X-ray were found to be unfavourable outcome risk factors.

CONCLUSIONS

Standardised MDR-TB regimens may be effective at the national level, even in resource-poor settings.

Lymphogranuloma venereum: a hidden emerging problem, Barcelona, 2011

From the beginning of 2007 until the end of 2011, 146 cases of lymphogranuloma venereum (LGV) were notified to the Barcelona Public Health Agency. Some 49% of them were diagnosed and reported in 2011, mainly in men who have sex with men. Almost half of them, 32 cases, were reported between July and September. This cluster represents the largest since 2004. This article presents the ongoing outbreak of LGV in Barcelona.

Factors influencing the case-fatality rate of Legionnaires' disease

SETTING

The extent of the public health problem posed by Legionnaires' disease (LD) is not always well- appreciated.

OBJECTIVE

To determine the characteristics and factors associated with the case fatality rate (CFR) of LD in Catalonia, Spain.

DESIGN

Confirmed cases of LD reported during 1993-2004 were studied. Age, sex, hospitalisation, the type of diagnostic confirmation test and the personal risk factors for LD of cases were collected. Comparative bivariate and multivariate analyses according to origin (community-acquired or nosocomial) and nature (sporadic or outbreaks) were performed.

RESULTS

Of 1938 cases reported, 164 died (case-fatality rate [CFR] 8.5%). The CFR fell from 35% in 1993 to 5.6% in 2004, and was higher in sporadic than in outbreak-associated cases (10% vs. 4.7%) and in nosocomial than community-acquired cases (31.7% vs. 6.8%). In community-acquired cases, the CFR was associated with age >70 years (OR 3.42, 95%CI 2.02-5.79), cancer (OR 4.58, 95%CI 2.36-8.90) and diagnostic confirmation methods other than Legionella urinary antigen test. The CFR of nosocomial cases was not associated with any of these factors.

CONCLUSIONS

The CFR of LD fell during the study period due to the incorporation of new diagnostic techniques and improved detection of outbreaks.

Measles outbreak in the Barcelona Region of Catalonia, Spain, October 2006 to February 2007

From 1 October 2006 to 31 January 2007, 213 confirmed cases of measles occurred in the Barcelona Region, resulting from the importation of one case.

Alterations of myocardial sympathetic innervation in response to hypoxia

The effects of altitude hypoxia on myocardial sympathetic nerve function were assessed in rats using metaiodobenzylguanidine (MIBG).

METHODS

To estimate the change in uptake-1 function induced by hypoxia, three sets of rats were submitted to 5-, 7- and 21-day hypoxia (hypobaric chamber at 410 Torr) and one set of control rats was injected with 25 muCi of 123I-MIBG. Four hours later, the rats were killed and 123I activity was counted in both ventricles. The proportion of MIBG fixed in the myocardium through the norepinephrine (NE) transporter (uptake-1) was evaluated indirectly in 5-day hypoxic and controls rats by the injection of desipramine before 123I-MIBG administration. Myocardial perfusion was evaluated in 5-day hypoxic rats and controls by 201Tl injection.

RESULTS

Myocardial 123I-MIBG activity was 0.253% +/- 0.036% kg dose/g-1 in controls and was decreased (0.188% +/- 0.029% kg dose/g-1, p = 0.001) in 5-day hypoxic rats. This decrease was not related to a change in cardiac perfusion. The decrease in MIBG uptake existed before the appearance of cardiac hypertrophy. Desipramine decreased MIBG uptake by 48% in controls and 17% in hypoxic rats, suggesting that the decrease predominantly affected MIBG uptake by the NE transporter.

CONCLUSION

Chronic hypoxia leads to a decrease in myocardial NE-uptake-1 function. This finding suggests that altered tissue oxygen supply could play a role in the decreased cardiac MIBG uptake reported in human cardiomyopathies.

In vivo visualization of central muscarinic receptors using [11C]quinuclidinyl benzilate and positron emission tomography in baboons

The muscarinic antagonist, quinuclidinyl benzilate (QNB), labeled with carbon 11 was used as a radioligand to visualize in vivo by positron emission tomography (PET) the central muscarinic acetylcholine receptors (mAChR) in baboons (Papio papio). The binding characteristics of [11C]QNB showed its specific binding to central mAChR. [11C]QNB brain uptake was high in cerebral cortex and striatum, areas that are rich in mAChR, whereas it decreased rapidly in cerebellum, evidencing non-specific binding in this structure that is almost devoid of mAChR. These results are consistent with the known cerebral distribution of mAChR in primates. [11C]QNB specific cerebral binding was enhanced by pretreatment with methyl-QNB, a peripherally acting muscarinic antagonist. Specifically labeled binding sites alone were blocked by prior administration of dexetimide, a muscarinic antagonist. Specific radioactivity was driven out from mAChR-rich regions by atropine and dexetimide, drugs with high affinity for mAChR. This competition was stereospecific since only dexetimide, the pharmacologically active isomer of benzetimide, was able to compete with the radioligand on its binding sites. A relationship between the occupancy of [11C]QNB-labeled receptors by atropine or dexetimide and the concomitant induction of a pharmacological effect was also detected by simultaneous PET scanning and electroencephalographic recording. Since mAChR form an important part of choline receptors in the central nervous system, [11C]QNB appears to be a suitable radiotracer to monitor cerebral physiological or pathological phenomena linked to the cholinergic system in living subjects.

Cardiac beta-adrenergic receptor density measured in vivo using PET, CGP 12177, and a new graphical method

The in vivo quantification of myocardial beta-adrenergic receptor has been obtained in five closed-chest dogs using positron emission tomography (PET). The ligand was racemic (+/-)[11C] CGP 12177, a very potent hydrophilic antagonist of the beta-adrenergic receptor. A kinetic method appeared unsuitable because of the presence of metabolites which made the input function difficult to measure and also inaccurate. Therefore, a graphical method, based on a particular protocol, was proposed. The animals were injected with a trace amount of (+/-)[11C]CGP 12177, which was followed 40 min later by a second injection of radioligand with a low-specific activity. An additional injection of an excess of unlabeled CGP 12177 was administered after 90 min and allowed for the estimation of the dissociation rate constant. The main advantage of this graphical approach is that the results are obtained without having to measure the input function and therefore without estimating the metabolites. The average value of Bmax was 31 +/- 4 pmole/ml of tissue and the dissociation constant was 0.014 +/- 0.002 min-1.

Noninvasive quantification of muscarinic receptors in vivo with positron emission tomography in the dog heart

The in vivo quantification of myocardial muscarinic receptors has been obtained in six closed-chest dogs by using positron emission tomography. The dogs were injected with a trace amount of 11C-labeled methylquinuclidinyl benzilate (MQNB), a nonmetabolized antagonist of the muscarinic receptor. This was followed 30 minutes later by an injection of an excess of unlabeled MQNB (displacement experiment). Two additional injections of unlabeled MQNB with [11C]MQNB (coinjection experiment) and without [11C]MQNB (second displacement experiment) were administered after 70 and 120 minutes, respectively. This protocol allowed a separate evaluation of the quantity of available receptors (B'max) as well as the association and dissociation rate constants (k+1 and k-1) in each dog. The parameters were calculated by using a nonlinear mathematical model in regions of interest over the left ventricle and the interventricular septum. The average value of B'max was 42 +/- 11 pmol/ml tissue, the rate constants k+1, k-1, and Kd were 0.6 +/- 0.1 ml.pmol-1.min-1, 0.27 +/- 0.03 ml.pmol-1.min-1, and 0.49 +/- 0.14 pmol.ml-1, respectively, taking into account the MQNB reaction volume estimated to 0.15 ml/ml tissue. Although [11C]MQNB binding would appear irreversible, our findings indicate that the association of the antagonist is very rapid and that the dissociation is far from negligible. The dissociated ligand, however, has a high probability of rebinding to a free receptor site instead of escaping into the microcirculation. We deduce that the positron emission tomographic images obtained after injecting a trace amount of [11C]MQNB are more representative of blood flow than of receptor density or affinity. We also suggest a simplified protocol consisting of a tracer injection of [11C]MQNB and a second injection of an excess of cold MQNB, which is sufficient to measure B'max and Kd in humans.

[Bone scintigraphy in metastases]

The three fold interest of bone scintiscanning is discussed in relation to 182 cases of bone metastases of various origins. Firstly, this technic facilitates early diagnosis of invasion of the bone by the detection of metastatic lesions which, in 7.7% of cases are still infraradiologic, or even of reflex algodystrophy of the legs, which can be detected only from a scintiscan, long before X-ray plates can show the lumbar metastasis which is responsible. Secondly, the method is able to pick up more metastatic sites in 54.4% of cases than can be detected by X-ray; this is confirmed by investigation of the S/R ratio (ratio of the number of strongly binding sites to the number of sites showing radiologic damage) which is greater than unity for a considerable period. Thirdly, repeated scintiscanography provides a prognosis, because the survival time appears to be fairly closely correlated with the regression, stability or extension of strongly binding sites, although a "flare phenomenon" may give the erroneous impression that the metastatic process has deteriorated. Repeated scintiscanography also provides a good way of evaluating the efficacy of medical treatment, particularly in the case of bone metastases of mammary or prostatic origin. Sometimes, the decision for or against prophylactic or palliative orthopedic surgery may be based to a considerable extent on data provided by scintiscan.

Erosive arthritis of the costovertebral joint in seronegative spondyloarthropathy

A 50-year-old male presented with polyarthritis and pain of the right costovertebral angle in the cervicothoracic area. Radiological findings in a sacroiliac joint, the presence of a syndesmophyte, the HLA B-27 phenotype and negative serological studies prompted the diagnosis of HLA-B27 related seronegative spondyloarthropathy. Conventional and computerized tomograms disclosed an erosive arthritis of the 1st right costovertebral joint that was responsible for the pain in the costovertebral angle. We are unaware of previous CT scan documentation of such lesions.

[Unusual muscular involvement in ankylosing spondylitis]

Muscle involvement in ankylosing spondylitis has been little studied. The authors report two cases with marked muscular atrophy and functional impotence, which had directed the diagnosis towards a myopathy over a period of several years in the first case, and a suspected primary muscular disease associated with ankylosing spondylitis in the second. Muscle biopsies eliminated the diagnosis of myopathy in both cases, with rapid functional recovery with proper treatment. Following a review of the literature, two hypotheses can be considered to explain the muscular involvement in ankylosing spondylitis: one mechanism which appears well-established is a radiculitis with involvement of the paravertebral muscles: other authors suggest that there is nonspecific, generalized muscular involvement in this disorder.

[Role of chemotherapy in the treatment of bone metastases of breast cancer]

This study was made on 98 patients with breast cancer, whose first discovered metastasis was to the bone, a mean of 2.8 years following the initial diagnosis. It is most often a lytic lesion, and the majority of patients have more than two areas on bone scintiscan. About half of the patients received palliative radiotherapy; 16 had to undergo surgery for or to prevent pathologic fractures. All patients underwent chemotherapy with vincristine or vinblastine, methotrexate or cyclophosphamide, 5-fluorouracil and, in 37 cases, the addition of adriamycin. Half of the patients also received tamoxifen. Present studies show a mean survival of 31 months with 24% survival at five years. Age, the interval to the discovery of the first metastasis, the use of additional chemotherapy following surgery for the breast lesion, the sedimentation rate, and the number of bony metastases do not play any prognostic role. However, the prognosis is significantly improved by adding tamoxifen, and even more so by adding adriamycin to the chemotherapeutic protocol since mean survival improves from 26 to 52 months. The reduced incidence of bony metastases with chemotherapy following surgery had led some authors to believe that prevention is the best method of treating bony metastases from breast cancer.

[Studies of the kinetics of bone concentration of mdp-tc 99m in Paget's disease and various treatment methods]

We did 27 bone scintiscans in 20 patients, 15 of whom had Paget's disease. Early variations of isotopic activity were analyzed in the pagetic bone, and in normal bone and muscle tissue using 3 parameters: A1 or the period of maximum activity obtained when the isotope was first injected into the circulation, A2 or the isotopic activity at 30 minutes, and P or slope of the curve in the change of activity between 15 and 30 minutes. These scintigraphic parameters, which seem to reflect the importance of the vascular phase (parameter A1) and of the metabolic activity of the bone (parameter A2/A1 and P) proved to be a good guide in following the course of Paget's disease. In 6 patients with Paget's disease who were treated with calcitonin (5 cases) or by etidronate disodium (1 case), we compared the changes in these isotopic parameters with the clinical and laboratory findings before and after treatment. We were able to note a good correlation between the clinical course of the illness and the scintiscans in most cases.

[Clinical study of Bi-Profenid in rheumatologic practice]

The effectiveness and tolerance of Bi-Profenid as 150 mg tablets were analyzed in a multicenter study. Each of the 288 patients entered in the study had one of the main conditions found in rheumatologic practice: arthrosis of the hip or knee, rheumatoid arthritis or ankylosing spondylarthritis. Each patient was given one 150 mg Bi-Profenid tablet twice daily for 30 days. Overall effectiveness, as assessed by the pain scale test, produced improvement in 87.3% of cases. In degenerative rheumatic diseases, nocturnal pain, pain upon mobilization and walking distance were very significantly improved. In inflammatory rheumatic diseases, the significantly improved parameters were nocturnal pain, morning stiffness and functional indexes of rheumatoid arthritis. Tolerance was outstanding or very good in 77.1% of cases and the dropout rate was only 7.6%.

[5 cases of chondrosarcoma. Review of the literature]

Five cases of chondrosarcoma are reported. Some specific characteristics of this tumor are recalled : prevalence is approximately 10% of primary malignant bone lesions, onset usually occurs between 40 and 70 years of age, prevalence is higher in males, elective sites are the proximal long bones and pelvis, pain is often the initial symptomatology, the patient's general condition remains satisfactory over a long period of time, sedimentation rates have no diagnostic or prognostic value, medullary arteriography and computed tomography are helpful for evaluation the topography and the extension of a vertebral localization, and the course is protracted. Prognosis is dependent on both the surgical possibilities and the characteristics of the tumor (site, size, histologic grade). Conversely to metastases which occur electively in grade III tumors, recurrences are not necessarily correlated with the histologic grade; they often occur in tumors whose localization precluded radical surgery and may be the occasion of development into a higher grade of malignancy. Inasmuch as it is feasible, carcinologic surgery is the only effective therapy; it carries hope for 10 year survival times in approximatley 70% of patients.

[Sciatica in the elderly. Apropos of 27 cases operated after the age of 70]

From a study of 27 operations for common vertebral sciatica in the elderly, certain specific features stand out. L5 sciatica is predominant though curiously, the pain relieving posture is less frequent than in the S1 variety. The condition is usually most painful at night. In 50% of cases there is a motor deficit which to a great extend determines the decision to operate. Finally, there is very good correlation between clinical features and the discovery of a prolapsed disc. Osteoarthrotic lesions are much more common than in the general sciatica population but the disc protrusion always keeps its localising value. Surgical intervention reveals that the disc plays an equally important role at this age as a prolapsed disc was found in 26 cases (11 extruded herniated discs and 2 ruptured). These lesions are less common in the general sciatica population. In about two thirds of patients a herniated disc alone is found and in the others, it is associated with osteoarthrotic lesions although these do not appear to compromise the success of the operation. Amongst the 9 post-operative complications, there was one death due to pulmonary emboli and 2 cases of reflex algodystrophy of the foot on the operated side. With a mean delay of more than 1 year, a frank improvement was noted in 85% of cases as against 80% immediately following surgery. Only one case of recurrence was reported.

[Hemarthrosis of articular chondrocalcinosis. Apropos of 28 cases. Importance of treatment by isotopic synoviorthesis]

32 cases of hemarthrosis observed in 26 patients suffering from articular chondrocalcinosis are used as a basis for a review of the principal clinical anc paraclinical findings. Special mention is made of the fact that hemarthrosis occurs in the shoulder much less rarely than has been classically reported. The diagnostic value of finding microcristals of calcium pyrophosphate in hemorrhagic fluid is also emphasized. In addition to standard treatment, isotopic synoviortheses is shown to be effective for treatment of recurrent hemarthrosis. After an average of 3.3 years of follow-up, this treatment, although lacking certain analgesic effect, frequently leads to lasting cessation of the hemarthrosis, more often it seems, in the shoulder than in the knee.

[Muscular metastasis, first symptom of bronchial carcinoma (author's transl)]

One case of bronchial carcinoma in which a muscular metastasis was the presenting symptom is reported. Clinical features included pain and gradual swelling of left musculus supra-spinatus. Surgical biopsy showed intra-muscular metastasis of bronchial origin. Radiotherapy provided transient pain relief, but the patient died 15 months after the first symptoms. Metastatic tumors of skeletal muscles are found in some cases, when carefully searched for in routine autopsy surveys. Most of these tumors remain asymptomatic; in other cases clinical picture includes pain, swelling and diffuse or nodular induration of the involved muscles. Biopsy shows metastatic tumor in these muscles, which generally retains the same growth pattern as seen in the primary tumor.

[Controlled trial of levamisole in rheumatoid arthritis. Clinical and immunological study of 22 cases (author's transl)]

The results of a controlled trial in 22 patients indicated that levamisole, administered in a dose of 150 mg per day for 2 months, was more effective than a placebo on the clinical symptoms and signs of rheumatoid arthritis. Side effects were seen in 8 of the 12 patients treated with levamisole. They necessitated the premature interruption of treatment in three, but were never serious (no cases of agranulocytosis were seen). In the group treated with levamisole, there was a slight decrease in sedimentation rate, a significant fall in levels of the C3 fraction of serum complement and of circulating immune complexes (detected by polyethylene glycol), and a significant increase in cutaneous reaction to tuberculin and to candidin. By contrast, there were no significant variations in levels of rheumatoid factor, serum immunoglobulins, C4 fraction of complement, lymphocyte transformation indices in the presence of six dilutions of phytohaemagglutinin, nor in the percentages of T and B lymphocytes. The effectiveness of levamisole in rheumatoid arthritis would appear to be demonstrated, but its mode of action remains open to discussion, in the absence of any definite correlation between therapeutic activity and the immunostimulant effects of the drug.

Gout and hyperlipidaemia. Effect of overweight on the levels of circulating lipids

A study of the serum lipids in 90 patients with gout and 90 controls matched for age and weight index demonstrated that in gout there was a significant elevation of the mean serum levels of cholesterol (282 +/- 55 mg/100 ml), triglycerides (183 +/- 161 mg/100 ml) and phospholipids (270 +/- 61 mg/100 ml) compared with the controls whose mean values were respectively 243 +/- 41 mg, 95 +/- 53 mg and 245 +/- 36 mg. Hyperlipidaemia of mixed type was the most common lipid defect in the patients with gout; there was no difference in the frequency of pure hypercholesterolaemia (without hypertriglyceridaemia) between gout and the controls. The frequency of anomalies of blood lipid levels in gout does not result from (or not solely from) obesity since patients with gout and controls were matched for their weight and height. There was a correlation between the serum lipid levels and obesity in the controls but this was not demonstrable in the patients with gout.

[Hyperlipemias and their manifestations in the rheumatological sphere]

It is fairly frequent to encounter hyperlipemia on a rheumatic unit. Firstly the symptoms of certain idiopathic hyperlipemias sometimes include rheumatic changes. The latter include firstly, arthritis and tendinitis, above all observed in Type II hyperlipoproteinemia but also mentionned in Type IV, and secondly, exceptional bony lesions (generally of xanthoma type) which seem to occur exclusively in severe hyperglyceridemia. A few bone and joint diseases, such as gout or aseptic necrosis, frequently coexist with dyslipemia. Furthermore, various diseases may be simultaneously responsible for secondary hyperlipemia and involvement of the locomotor apparatus. Finally, the iatrogenic manifestations of the locomotor system appear mainly due to hypolipemic drugs, e.g. the muscle disorders seen in a few patients treated with clofibrate.

A controlled trial of ketoprofen (administered rectally) in arthritis of the hip and knee

A double-blind therapeutic trial carried out by the sequential method has demonstrated clearly a significant difference in efficacy between ketoprofen (given rectally at a dosage of 200 mg daily) and a placebo in a group of patients suffering from osteoarthritis of the hip or knee. The interest in this type of study lies in the fact that it will often given the answer to a simple question using a relatively small number of patients.

[4 cases of osteomalacia during anticonvulsant or sedative treatment]

The authors report osteomalacia in 3 cases of epilepsy and one case of coronary heart disease treated with phenobarbitone, either alone or associated with other anticonvulsants. There were clinical signs in all cases and typical radiological signs in 3 cases, a characteristic laboratory syndrome in 4 cases. In the 3 cases where it was estimated, serum levels of parathormone were high. Finally, in 3 cases where it was measured, daily urinary excretion of glucaric D acid was increased. The bony histological signs studied in 3 cases, were similar to those in deficiency osteomalacia. A study of Ca45 metabolism in one case, showed the characteristic changes found in osteomalacia. Finally, a study of the metabolism of tritiated vitamin D, or tritiated 25 OH CC, carried out in 3 cases, gave 3 different patterns; only one of them was characteristic of enzyme induction under the dependency of anticonvulsant. Started in 2 cases, treatment with 125 OH2CC, brought about a rapid fall in blood PTH levels which then rose again before falling progressively in one case, under treatment with 25 OH CC. The bony histological signs of hyperparathyroidism then regressed whilst serum PTH levels remained high. Phosphorous and calcium balance improved in only one case. Treatment with 25 OH CC in high dosage brought about clinical, radiological and laboratory cure of osteomalacia in both cases, reducing the frequency of fits in the epileptic patient.

[Analysis of disorders of the principal pathways of calcium metabolism in Paget's disease. Effects of calcitonin administration. 26 cases]

Analysis of the principal routes of calcium metabolism by means of calcium-45 in 26 patients suffering from Paget's diseases sometimes showed, in agreement with data from the literature, a considerable increase in the common stocks of calcium in 25 cases, and an elevation in the anabolism (Vo+) in bone and in the catabolism (Vo-) in bone in all cases. The calcium balance was sometimes equal, but often clearly positive (10 cases) or negative (10 cases) and the level intestinal absorption of calcium was usually within the normal limits. An elevation in the endogenous fecal calcium (Vf) noted in half of the cases, although no value was below normal, seemed to represent an metabolic anomaly of abnormally high frequency in patients with Paget's disease, even though this fact has never been emphasized before. Statistically significant correlations were shown between the values of different kinetic and metabolic parameters in the group of patients studied. A second kinetic study carried out after several weeks of treatment with porcine calcitonin showed a statistically significant diminution in the values of Vo +, Vo -, endogenous fecal calcium, calciuria, hydroxyprolinuria, and in alkaline phosphatasaemia, as well as significant variations in the calcium balance in a positive direction. The common calcium stocks did not show a significant diminution, contrary to the findings of other authors. The level of intestinal absorption of calcium increased more often than it decreased, but the magnitude of the variations was slightly less than the level of statistical significance.

[Paget's disease and vertebral blocks (apropos of 7 cases)]

The authors observed 10 blocks of from 2 to 8 vertebrae in 7 patients whose spines were affected by Paget's disease. The morphological characteristics of these blockages were for the most part similar to those of acquired synostoses, the corresponding articular apophyses appearing to be fused in the majority of cases. Even without a radiograph taken before the formation of the blocks, the fact that there had been progression of the synostosis between certain vertebrae indicates the probability of an acquired origin. The prevalence of these vertebral blocks in a group of 76 patients suffering from Paget's disease of the spine (12 percent, or 9 patients with 13 blocks) was significantly higher than that found in a population of 200 persons not suffering from Paget's disease, (3 percent, or 6 patients with 6 blocks) and among the 13 blocks discovered in the patients with Paget's disease only 3 were formed of vertebrae unaffected by deforming osteitis. These facts suggest that the formation of a vertebral block may be favoured by Paget's disease localized in the vertebral column. This is a little recognized idea even though it was formulated in Schmorl's work at the beginning of this century.

Pyogenic infection of the sacro-iliac joint. Report of thirteen cases

Thirteen cases of infectious sacro-iliitis caused by pyogenic organisms are reported and compared with thirty-four cases in the literature. Staphylococcus was the commonest infecting organism (six cases). Two clinical patterns were noted, acute (nine cases) and subacute (four cases). Treatment was by antibiotics and bed rest in all patients. Surgery was indicated for diagnosis in three patients and for abscess in three patients. All of our patients had very good functional recovery.

[Thymoma and lupus disease (apropos of 2 cases]

Two new cases of association between a thymoma and a lupus illness are reported. The first was a women aged 42 years in whom were discovered simultaneously systemic lupus erythematosus (SLE) and a slowly invading thymoma, the histology of which was characterized by the predominance of epithelial cells; excision of this tumour did not appear to affect the evolution of the SLE. In the second case, a patient aged 60 years suffered from SLE ten months after the removal of a benign thymoma in which there was a predominance of lymphocytes. The SLE in this patient was easily controlled for more than a year by small doses of corticoids, but resulted in death after three years when anuria was associated with meningeal signs after the cessation of corticotherapy. The comparision of the data from these cases with those from eleven other cases in which there was association between a thymoma and SLE, brought to light several interesting facts. It is rare that SLE clearly precedes the discovery of the thymoma; it usually occurs afterwards or the two are discovered almost simultaneously. Collagenosis is of importance only when it coexists with a thymoma : starting later much more often than is usual in cases of SLE. The tumours were, in all but two cases, benign thymomas of different histological types, and their removal did not apparently influence the evolution of the SLE.