[Fertility preservation in cancer women: a multidisciplinary approach]

Over the past two decades, major advances in diagnostic modalities and treatment have markedly improved rates of cure for adult cancers. As a consequence, the number of long-term survivors is increasing, and fertility preservation has become a major issue for young patient about to start treatment for cancer. Whether fertility preservation is a promising option, most of the technologies currently used are far from being well established or are even still experimental. Patients should be aware that no method guarantees success. Psychological and ethical impacts of fertility preservation are major concerns and should be included in the multidisciplinary approach of the patients.

Anti-tumour necrosis factor treatment in patients with refractory systemic vasculitis associated with rheumatoid arthritis

OBJECTIVE

To assess anti-tumour necrosis factor (anti-TNF) agents in patients with refractory systemic rheumatoid vasculitis (SRV).

METHODS

1200 rheumatologists and internists were asked to provide medical files for patients with anti-TNF agents given as a second-line treatment for active SRV refractory to cyclophosphamide and glucocorticoids.

RESULTS

We identified nine cases in which anti-TNF drugs were given for active SRV, despite previous treatment with a mean cumulative dose of 8.4 g of cyclophosphamide in association with high-dose glucocorticoids. The mean prednisone dose before anti-TNF therapy was 29.6 mg/day. After 6 months, six patients were in remission (complete in five, partial in one). The treatment failed in one patient and two patients stopped taking the anti-TNF treatment due to side-effects. Mean prednisone dose was reduced to 11.2 mg/day. Severe infection occurred in three patients. Relapses were observed in two patients. Remission was re-established by reintroducing anti-TNF therapy in one case and increasing the dose in the other.

CONCLUSIONS

This study provides evidence of efficacy of anti-TNF therapy in adjunct to glucocorticoids for treating active refractory SRV. Remission was achieved in two-thirds of patients, with a significant decrease in prednisone dose, although there was a high rate of infection in these severely ill patients.

[Dupuytren's disease]

Dupuytren's disease is a contracture of the hand derived from the retractile fibrosis of the palmar aponeurosis, that leads to a progressive deformity in flexion of fingers. It has been named from the French surgeon Guillaume Dupuytren (1777-1835), that described it in 1831. In this note it is sketched a short biography of Dupuytren and the main clinical features of the disease are described, underlining some particular aspects of therapy.

[Preventive therapy for nausea and vomiting in patients on opioid therapy for non-malignant pain in rheumatology]

OBJECTIVE

To determine if systematic use of metoclopramide associated with opioids (Morphine sulfate SR) decreases the incidence of nausea and vomiting (N&V), established adverse effects of opioids.

METHOD

Open randomised study with 132 patients treated for non malignant pain (71 women, 61 men, mean age 53.4 years). One group (n = 76) was treated with morphine alone; the other (n = 56) with morphine plus metoclopramide. Mean duration of therapy: 6 days; mean dosage: 60 mg/d

RESULTS

In the 2 groups, N&V were present in the first 72 hours. The frequency of N&V in the morphine group was 38.1% (conform with the literature). The systematic use of metoclopramide decreases the frequency of N&V: p < 0.005. However the use of morphine > 60 mg/d decreases N&V: p = 0.036. High dosages of morphine can have an antiemetic effect by interaction with the mu receptors in the antiemetic center and not in the trigger zone which has an emetic effect.

CONCLUSION

The systematic use of metoclopramide with opioid therapy for non malignant pain in rheumatology decreases the risk of nausea and vomiting.

[Did Georges Bizet die of a acute articular rheumatism?]

As perhaps in the case of Mozart (1) or Malher (2), Georges Bizet may have died of an acute articular rheumatism or of its consequences.

Piroxicam concentrations in plasma and synovial fluid after a single dose of piroxicam-beta-cyclodextrin

AIMS

The efficacy of nonsteroidal anti-inflammatory drugs (NSAIDs) in rheumatic diseases depends on their concentrations within the joint. We determined piroxicam concentrations in plasma and synovial fluid (SF) after a single oral dose of 20 mg in the form of one tablet of piroxicam-beta-cyclodextrin.

METHODS

45 patients, aged 21 to 84 years, presenting with an effusion of the knee, related to degenerative or inflammatory joint disease, were included in this study after having given their written consent. One blood and one SF sample were drawn concomitantly in each patient from 0.5 to 48 h after NSAID administration. Piroxicam assays were performed by high performance liquid chromatography. Pharmacokinetic parameters were obtained from the mean plasma and synovial concentrations measured at various sampling times.

RESULTS

The peak concentration was higher in plasma (2.51+/-0.25 microg/ml) than in SF (1.31+/-0.76 microg/ml), but the elimination half-life was much longer in SF (90.7 h) than in plasma (32.5 h). The SF/plasma area under the concentration-time curve ratio (evaluating the quantity of NSAID transferred from the blood to the joint) was equal to 0.39.

CONCLUSIONS

Piroxicam contained in piroxicam-beta-cyclodextrin diffused well into the SF where its pharmacokinetic profile corresponded to that of a long half-life NSAID.

Drug-induced rheumatic disorders: incidence, prevention and management

The purpose of this article is to review the causes, the clinical manifestations and the management of the more frequent drug-induced rheumatic disorders. These include: (i) articular and periarticular manifestations induced by fluoroquinolones, nonsteroidal anti-inflammatory drugs, injections of corticosteroids, and retinoids; (ii) multisystemic manifestations such as drug-induced lupus and arthritis induced by vaccination, Bacillus Calmette-Guerin therapy and cytokines; (iii) drug-induced disorders of bone metabolism (corticosteroid-induced osteoporosis, drug-induced osteomalacia and osteonecrosis); and (iv) iatrogenic complex regional pain syndromes. Disorders caused by nonpharmacological and rarely used treatments have been deliberately excluded. Knowledge of these drug-induced clinical symptoms or syndromes allows an earlier diagnosis and treatment, and earlier drug withdrawal if necessary. With the introduction of new medications such as the recombinant cytokines and antiretroviral treatments, the number of drug-induced rheumatic disorders is likely to increase.

[Aspirin, pain and inflammation]

SUBJECT

Acetylsalicylic acid (ASA) is among the most commonly analgesic, antipyretic and anti-inflammatory used drugs. The anti-inflammatory effects of ASA are mediated by the inhibition of cyclooxygenase enzymes with the subsequent decrease of prostaglandin synthesis.

NEW DATA

However, since this discovery of Vane in 1971, much of other mechanisms of anti-inflammatory action, without relation with cyclooxygenases, have been proposed. ASA has peripheric analgesic properties by reducing prostaglandin biosynthesis. But there is evidence that the analgesic effects could be mediated by central mechanisms with changes in the monoaminergic and opioid systems. ASA is essentially used in moderate pains with an inflammatory component (rheumatological disorders, headaches, dental and postoperative pains).

PERSPECTIVES

The clinical use of ASA at anti-inflammatory dose is less frequent because the other non steroidal anti-inflammatory drugs are as effective as ASA, but they are associated with less side effects. Nevertheless, the synergism of ASA and morphine association and the possible involvement of the central serotonergic and opiatergic systems in the antinociceptive activity of ASA could confer a greater role of ASA in pain management.

Long-term cyclosporin continuation rates in rheumatoid arthritis patients

OBJECTIVE

To evaluate the continuation rate of cyclosporin therapy in rheumatoid arthritis patients followed for at least three years.

METHODS

Retrospective medical chart review of rheumatoid arthritis patients on cyclosporin. Treatment efficacy was assessed based on a visual analog scale pain score, Ritchie's articular index, and Lee's functional index. Nonparametric Kaplan-Meier survival curves were used to evaluate continuation rates.

RESULTS

24 cyclosporin-treated patients with a mean age of 58 years and a mean disease duration of ten years were included in the study; 87% had received three second-line drugs prior to cyclosporin. Mean cyclosporin treatment duration was 28 months (range, 1-103 months). Overall cyclosporin continuation rates were 75% after four months and 50% after 36 months. Toxicity and inefficacy caused 33% and 13% of cyclosporin discontinuations, respectively.

CONCLUSION

The continuation rate of cyclosporin was satisfactory and similar to that reported for other second-line drugs.

[Male osteoporosis]

AN UPCOMING PUBLIC HEALTH PROBLEM: There has been a considerable focus on osteoporosis in men recently. Bone mass is high in men who have larger bones than women. The frequency of fractures is also higher due to post-trauma lesions. Femoral neck fractures have also increased over the last few years although the F/M ratio remains about 2.8. Overall, there is a trend towards an increased incidence of masculine osteoporosis (and vertebral fractures) due to population aging. FAVORING FACTORS IN MEN: The most important factors are hypoandrogenism, hypoestrogenism (pre or post-puberty), the alcohol-smoking association, malnutrition, lack of sun exposure and chronic liver disease. Other causes of osteoporosis (hyperthyroidism, Cushing's disease, hemochromatosis, gastrectomy, inflammatory rheumatic disease, tubulopathy, hypercalciuria and iatrogenic causes) should also be taken into consideration. PRETHERAPY WORK-UP: All the different possible etiologies should be investigated. Therapeutic protocols should provide hormone replacement when required, withdrawal of causal drugs, better nutrition and reduced alcohol and tobacco use.

Is there an optimal time to administer methotrexate in the treatment of rheumatoid arthritis?

OBJECTIVE

To determine the optimal time to administer methotrexate (MTX) in rheumatoid arthritis (RA).

METHODS

In a crossover study 23 patients were administered MTX intramuscularly at either 10 AM or 6 PM. A 2 week interval separated the 2 injections. MTX concentrations were measured using a fluorescence polarization immunoassay. Pharmacokinetic variables were estimated using a Bayesian approach. The morning and evening schedules were compared using analysis of variance to determine the optimal time of injection.

RESULTS

No statistical difference was found in the pharmacokinetics of MTX according to hour of injection. A difference in the creatinine clearance, however, was observed in the samples obtained at noon and 8 PM, but clearance of MTX was unchanged.

CONCLUSION

Pharmacokinetic variables suggest that MTX can be administered either in the morning (10 AM) or evening (6 PM) in the treatment of RA.

An epidemiological study of diagnostic and therapeutic strategies in office practice patients with subacute or chronic pain in the thoracic or low back. Comparison of practices in primary care and rheumatology settings

There is a paucity of epidemiological data on diagnostic and therapeutic practices in office practice patients with subacute or chronic pain in the thoracic or low back.

STUDY OBJECTIVE

to describe diagnostic and therapeutic strategies used in such patients.

PATIENTS AND METHODS

descriptive, prospective, two-month epidemiological study in 50 general practitioners and 50 rheumatologists. Each physician was asked to provide data on the demographics, clinical features, history of spinal disease, investigations, prior treatments and treatments prescribed on D0 and D30 in two patients with low back pain and two with thoracic back pain, of one to 12 months' duration.

RESULTS

A total of 352 patients were included. In the 217 patients with low back pain, including 107 women and 110 men, duration of the pain was 4.3 +/- 0.2 months and mean age was 49.6 +/- 1 years; 67% of these patients were economically active and 22% were retired; 59% were recruited by rheumatologists. In the thoracic back pain group, there were 135 patients, including 82 women (61%) and 53 men, with a mean duration of pain of 3.8 +/- 0.3 months and a mean age of 47.7 +/- 1.4 years; 60% were economically active and 22% were retired; 49% were recruited by rheumatologists. A history of conservatively-treated low or thoracic back pain was reported for 95.4% of patients in the low back pain group and 94% in the thoracic back pain group. Of the patients with low back pain, 6.3% had had spinal surgery. Investigations were as follows: roentgenograms in 85% of low back pain and 75% of thoracic back pain patients, computed tomography in 11% and 5.8%, magnetic resonance imaging in 2% and 1% and laboratory tests in 14% and 20%. Ninety-one per cent of low back pain and 84% of thoracic back pain patients were already under therapy on D0. Ninety-six per cent of patients overall were given a prescription at the end of the D0 visit, for a nonsteroidal antiinflammatory drug or an analgesic in 80% of low back pain and 63% of thoracic back pain patients, for muscle relaxants in 62% and 69%, for drugs aimed at preventing gastric side effects in 19% and 9.5%, for myotonic agents in 10% and 8% and for sedatives in 5% and 11%. A local steroid injection was given to 20% of low back pain patients. Twenty-four per cent of low back pain and 14% of thoracic back pain patients missed days of work (mean, 11 +/- 1.7 days and 13 +/- 4.6 days, respectively). Physical therapy was prescribed to 36% of low back pain and 27% of thoracic back pain patients and a lumbar support belt to 17% of low back pain patients. On D30, the pain had abated in 86% of low back pain and 89% of thoracic back pain patients and complete freedom from pain was reported by 28% and 32% of patients in these two groups, respectively. Treatments prescribed on D30 were physical therapy (43% and 31%), analgesics (40% and 36%) muscle relaxants (25% and 30%), and nonsteroidal antiinflammatory drugs (23% and 12%). Conclusion. This preliminary study provides data on common practices in subacute and chronic low back and back pain and may prove useful for health care cost estimations.

Evaluation of magnetic resonance imaging for the detection of sacroiliitis in patients with early seronegative spondylarthropathy

A prospective study was conducted in 23 patients to evaluate magnetic resonance imaging versus computed tomography and plain film radiography for the early detection of sacroiliitis in patients with spondylarthropathy and an Amor score of less than 6. Computed tomography was significantly better than the other two techniques despite some false-positive results, particularly in patients older than 40 years. Magnetic resonance imaging lacked sensitivity for detecting elementary lesions, particularly of the cartilage, but demonstrated clearly that the earliest abnormality was edema of the subchondral bone.

How do French rheumatologists treat early rheumatoid arthritis?

Although factors that appear to predict long-term outcomes of rheumatoid arthritis have been identified, there is no consensus about the treatment early in the disease. To determine how French office- and hospital-based rheumatologists treat early rheumatoid arthritis, we created three clinical vignettes corresponding to different levels of severity of early rheumatoid arthritis (less than six months' disease duration). Cases 1 and 2 were relatively young patients (35 and 50 years), and Case 1 had numerous poor prognosis factors. Case 3 was 80 years of age. Rheumatologists were asked to indicate which medications they would use at presentation and after one year of a favorable or unfavorable course. The study was conducted by questionnaire (response rate, 58%). Of the 185 rheumatologists who completed the questionnaire, 81% were male and 19% female; mean age was 42 +/- 8 years. In Cases 1 and 2, nonsteroidal antiinflammatory drugs were given by 99% of respondents; second-line drugs were prescribed at presentation by 93% of respondents in Case 1 and 86% in Case 2, and methotrexate was more likely to be used in the presence of poor prognosis factors (23% in case 1 and 7% in Case 2). In the event of an unfavorable course after one year, a larger proportion of rheumatologists prescribed glucocorticoid therapy (65% in Case 1 and 20% in Case 2), and there was a shift from "conventional" to "modern" second-line drugs, with more widespread use of methotrexate (65% in case 1 and 18% in case 2). In the 80-year-old patient, glucocorticoid therapy was used more often than nonsteroidal antiinflammatory drugs and second-line drugs (gold salts, hydroxychloroquine, sulfasalazine) were prescribed by 40% of rheumatologists at presentation and by 67% after one year of an unfavorable course; in the latter situation, methotrexate was selected in 24% of cases. In contrast to conventional recommendations, many French office- or hospital-based rheumatologists use second-line drugs very early and base their choice of medications on the estimated risk of severe disease and on the age of the patient.

[Prospective study of the analgesic action of clomipramine versus placebo in refractory lumbosciatica (68 cases)]

The authors sought to determine the analgesic activity of clomipramine (CMP) versus placebo, efficacy and side-effects according to the time of administration, long term clinical results and the relationship between plasma levels and analgesic effect. This double-blind randomised trial involved the infusion of 250 ml of glucose solution morning and evening versus placebo. CMP was administered at progressive doses for 8 days (maximum dosage 75 mg), either in the morning at 8 a.m. or in the evening at 6 p.m. Sixty eight patients accepted to be treated, all suffering from low back pain with or without sciatica. Maintenance treatment at the dose of 75 mg/day was then administered. CMP had a statistically significant analgesic action independent (rapidity of action) of its antidepressant activity. CMP was more effective and better tolerated (sedative and tranquilizer effect) in the evening. Long term results were poor (75% of cases). There was no link between plasma levels and clinical response. The authors noted that the analgesic activity of CMP was rapid, but for a duration limited to the short term and that this efficacy compared with the quite good results obtained with the placebo could be explained by a possible methodological bias (patients hospitalised and treated by intravenous infusions). The finding that CMP was better tolerated in the evening, without any loss of efficacy, is a positive feature (chronotherapeutic trial). Poor long term results could be partially explained by side-effects (66%). There was no relationship between analgesic effect and plasma levels.

[Sulfasalazine or salazosulfapyridine in the treatment of rheumatoid polyarthritis. An open study of 46 patients. Review of the literature]

The SASP was studied in 46 patients with rheumatoid arthritis. The efficacy criteria which were selected (decrease of the sed rate by more than 50 p. cent during the first hour, morning stiffness under 20 minutes, Ritchie's index inferior to 10 and decreased cortisone and NSAID doses), explain that 25 p. cent of the patients are considered as satisfied after 12 months of trial. The patients selected, present severe forms of the disease or forms resistant to other treatments. The improvement appears significant after the first month. Half of the patients left the trial either because of ineffectiveness, or evolutive relapse (21.73 p. cent) or because of side-effects (28.26 p. cent). The most frequently observed disorders and intolerances are of digestive nature. No serious accident is to be deplored. Such results are in accordance with the data from the literature. The SASP must therefore be considered as the fundamental treatment of rheumatoid arthritis. The new galenic forms, dissolving in the gastro-intestinal tract, have enabled to markedly improve the digestive tolerance.