Alain Prost

Interindividual variations in beliefs about the placebo effect: a study in 300 rheumatology inpatients and 100 nurses.

PATIENTS AND METHODS Three hundred patients admitted to a rheumatology department (mean age, 49.2+/-15.5 years) and 100 nurses working in the same teaching hospital (mean age, 36+/-8.6 years) completed a questionnaire on the placebo effect in the treatment of pain. RESULTS The patients believed that the percentages of subjects who responded occasionally or consistently to a placebo were 32% (+/- 22%) and 21% (+/- 17%), respectively. The figures given by the nurses were only slightly higher: 42% (+/- 23%) and 23% (+/- 17%), respectively. Only 27% of the patients and 58% of the nurses knew that pain could resolve completely under placebo therapy. The mean percentage improvement induced by placebo therapy as compared to the study analgesic was estimated at 21% (+/- 17%) by the patients and 30% (+/- 18%) by the nurses. Only 23% of patients and 24% of nurses knew about nocebo effects. CONCLUSION These data suggest that during double-blind placebo-controlled trials three-quarters of the placebo arm patients who experience a marked improvement or a nocebo effect may believe they received the active drug. This is likely to reduce the difference between the placebo and active drug groups. Furthermore, most patients and nurses have a negative perception of placebo therapy. It may be useful to include a brief description of placebo and nocebo effects into the patients information and informed consent documents used in double-blind placebo-controlled trials.

Possible use of arthrodesis for intractable sacroiliitis in spondylarthropathy : Report of two cases

Study Design. Two cases of successful sacroiliac joint arthrodesis for medically intractable aseptic sacroiliitis are reported. Summary of Background Data. Although successful arthrodesis of the sacroiliac joint had been reported previously for septic sacroiliitis, no report had shown the procedure to be effective for spondylarthropathy. Methods. Two women with spondylarthropathy involving very painful sacroiliac arthritis for 18 and 24 months had been relieved only transiently by several injections of steroids into the sacroiliac joint under fluoroscopy and by Bermuda casts. Both patients underwent sacroiliac joint arthrodesis. Results. Both patients showed dramatic improvement after sacroiliac joint arthrodesis. Moreover, no relapses had occurred, respectively, after 2 and 3 years of follow-up evaluation despite continuing spondylarthropathy in other joints. Conclusions. After a careful selection of patients, including positive blocks in the sacroiliac joint, arthrodesis of sacroiliac joint might be considered for so-called “intractable” aseptic sacroiliitis.

Rheumatoid arthritis as a bone marrow disorder

Both the concept of rheumatoid arthritis (RA) as an autoimmune process restricted to joints and the major role of T cells in its pathogenesis have been challenged in the literature. Fibroblastlike and macrophagelike synoviocytes play an important role in RA pannus, and these cells originate in or have their counterpart in bone marrow (BM). Yet the B cell autoimmunity characteristic of RA occurs early, and synovial tissue, like BM, favors the B cell response. Because BM is abnormal in RA, and because germinal centers are unique to RA synovium, RA could be regarded as a disorder of the microenvironments able to sustain B cell response. In fact, RA could even begin in BM, with its onset facilitated by stem cell abnormalities. Moreover, most viruses suspected of playing a role in RA share a BM tropism. This may explain why RA frequently overlaps with other autoimmune disorders and benign lymphoproliferations, such as large granular T lymphocytosis. Because remissions from RA have been reported after BM transplantation, careful studies of the rheumatological outcome of RA patients undergoing such therapeutic procedures are needed. Although RA is a complex process, it can be considered initially as a stem cell disorder requiring treatment similar to that administered to transplant patients. Animal models have provided convincing evidence for these assumptions.

Pseudomonas aeruginosa osteomyelitis of both ischia: a case report.

Osteomyelitis of the ischium is a very rare event; it usually occurs unilaterally and often is caused by tuberculosis1,2. To our knowledge, osteomyelitis of both ischia after a urological procedure has not been reported previously. In the case described here, Pseudomonas aeruginosa was identified by biopsy of one of the two ischial bones seven months after radical surgery of the bladder. Apreviously healthy fifty-six-year-old man underwent removal of the prostate and bladder, together with lymphadenectomy of the ilio-obturator lymph nodes, in September 1998, for the treatment of grade-III bladder cancer3. The lymph nodes were free of metastasis. The bladder was replaced by an ileal graft4. The findings on postoperative follow-up were normal, except for a transient infection of the urinary tract with Pseudomonas aeruginosa, which was diagnosed six days after surgery on the basis of urine culture. Antibiotic therapy was administered for ten days with use of gentamicin (150 mg twice daily) as well as ticarcillin and clavulanic acid (12 g and 800 mg daily, respectively). At the end of this treatment, the urine was sterile and the patient was discharged symptom-free. One month later, he complained of alternating pain in both buttocks. Bed rest and prednisone (40 mg daily for two weeks), together with morphine, were prescribed, despite obvious laboratory signs of systemic inflammation (9.74 109 polymorphonuclear leukocytes/L [normal range, 4 to 10 109 polymorphonuclear leukocytes/L], an erythrocyte sedimentation rate of 99 mm/hr in the first hour [normal value, £10 mm/hr], and a C-reactive protein level of 181 mg/L [normal range, 0 to 5 mg/L]). A dramatic reduction in pain was noted. The C-reactive protein level decreased to 16 mg/L, and the erythrocyte sedimentation rate decreased to 35 mm/hr. A urinary cytobacteriological examination performed at the end of November …

Pseudallescheria boydii knee arthritis in a young immunocompetent adult two years after a compound patellar fracture

Pseudallescheria boydii arthritis of the knee developed in a 32-year-old immunocompetent man 2 years after a compound patellar fracture contaminated with soil. No other potential portal of entry was identified, suggesting that the fungus remained latent for 2 years. Pseudallescheria arthritis often occurs after a prolonged latency period, causing minimal symptoms that contrast with the frequently severe radiological changes. Although this organism often shows limited sensitivity to most antifungal agents, our patient achieved a full recovery after surgical synovectomy and 6 months of itraconazole therapy (400 mg/ d). This case illustrates the importance of testing for fungi in patients with torpid arthritis, particularly when mild clinical symptoms contrast with severe bone and joint destruction.

Hypercalcemia in a patient with tuberculous adrenal insufficiency

OBJECTIVES To raise awareness of hypercalcemia as a rare and at times inaugural manifestation of adrenal insufficiency. CASE REPORT Evaluation of hypercalcemia in a 43-year-old man showed adrenal insufficiency. Biopsies of the testes and adrenal glands revealed epithelioid and giant cell lesions indicating tuberculosis. Although tuberculosis can contribute to hypercalcemia, this possibility was ruled out in our patient by the low serum 1,25-dihydroxy-vitamin D3 levels and return to normal of serum calcium and renal function under hormone replacement therapy. It should be noted, however, that a course of pamidronate was given. CONCLUSION The mechanism of hypercalcemia associated with adrenal insufficiency is controversial. Hyperparathyroidism was ruled out in our patient. Adrenal insufficiency should be considered in some patients with hypercalcemia.

Super-acute aseptic spondylitis as the first manifestation of round calcifying nucleopathy in a 77-year-old man: A case report

Study Design. This is a report of an unusual case of very late onset, symptomatic, round calcifying nucleopathy. Objective. To describe this unusual case of calcifying nucleopathy in a 77‐year‐old man who had no previous back problems, but had a history of diffuse skeletal hyperostosis. Summary of Background Data. The resorption of calcifying nucleopathy associated with reactional spondylitis is a classic occurrence in children but is rare in adults. Methods and Results. Spondylitis was diagnosed on the basis of pain, a transient Babinskis sign, and systemic inflammation. Radiographs, a bone scan, and magnetic resonance imaging revealed a large calcified nucleopathy of the T12‐L1 disc associated with spondylitis of T12. The calcification disappeared within 3 weeks, and recovery was clinically and biologically complete after treatment consisting of only rest and analgesics. Conclusion. A diagnosis of resorption of a round calcifying nucleopathy is not to be excluded in the elderly patient. This event can mimic an infectious spondylitis clinically and biologically.

Dorsal scalloping by calcified disc herniation.

Summary of Background Data Disc herniation responsible for scalloping of vertebral body had been reported only at the lumbar level. Results The authors report on an unusual etiology of dorsal scalloping. A voluminous and calcified dorsal disc herniation was responsible for this, and within the center of the mass there was an unexpected hypersignal on nuclear magnetic resonance imaging. Conclusion Scalloping does not preclude disc herniation, even at the dorsal level. Hyperintensity in T1-weighted images can reveal calcifications, as indicated in previous studies.

Hypercalcémie associée à une insuffisance surrénalienne d'origine tuberculeuse

Resume Objectifs. Rappeler que si l’insuffisance surrenalienne n’est qu’une etiologie exceptionnelle d’hypercalcemie, elle ne doit pas etre oubliee, d’autant que l’hypercalcemie peut parfois etre revelatrice de l’atteinte surrenalienne. Patient et resultat. Nous rapportons le cas d’un patient chez qui le bilan d’une hypercalcemie a contribue a la decouverte d’une insuffisance surrenalienne. Celle-ci a ete rapportee a une origine tuberculeuse en raison de la presence de lesions epithelioides et gigantocellulaires sur des biopsies testiculaires et surrenales. L’infection tuberculeuse aurait pu etre un cofacteur de l’apparition de l’hypercalcemie, mais cette eventualite n’a pas ete retenue du fait de l’absence d’elevation de la 1,25(OH)2D3 (qui etait au contraire effondree) et de la normalisation de la calcemie et de la fonction renale sous opotherapie substitutive, associee il est vrai a une cure de pamidronate. Conclusion. Le mecanisme de cette hypercalcemie est discute, l’eventualite d’une hyperparthyroidie ayant ete eliminee. Il est important d’evoquer une insuffisance surrenalienne devant certaines hypercalcemies.

Approche épidémiologique de la maladie de Still de l'adulte. Étude pilote

We have carried out an epidemiological study of adult Stills disease in West of France for ten years (62 cases). Incidence may be evaluated to 0.16/100 000 habitants and in some cases the allergenic responsability is discussed.