Allen M. Segal

Outcome of first-trimester exposure to low-dose methotrexate in eight patients with rheumatic disease

PURPOSE Methotrexate (MTX), when used to treat malignancy or psoriasis, has been implicated in anecdotal reports as a teratogen or abortifacient in the first trimester of pregnancy. We are unaware of any previous reports that describe the course of gestation and the effect on subsequent offspring in patients treated with low-dose oral MTX for rheumatoid arthritis, and therefore present our experience. PATIENTS AND METHODS We report on eight women experiencing 10 pregnancies. Mean number of weeks of gestation while taking MTX was 7.5 (range 2 to 20 weeks). Outcome of pregnancies included five full-term babies (FTB), three spontaneous abortions (SAB), and two elective abortions. RESULTS There were no significant differences in either the FTB or SAB group when considering risk factors including smoking, alcohol, concomitant medications, and age. One of three in the SAB group had recurrent abortions prior to MTX therapy. All five of the FTB group had uncomplicated pregnancies and deliveries. All offspring were of normal height and weight at birth with no physical abnormalities. All children reached growth, development, and intellectual stages normally, and their present mean age is 11.5 years. No observed learning disabilities or medical abnormalities have occurred in any of these children. CONCLUSION In this uncontrolled study we failed to demonstrate tertogenicity of MTX. However, the possibility of abortion due to MTX use remains.

Effectiveness of salmon calcitonin nasal spray in the treatment of lumbar canal stenosis: a double-blind, randomized, placebo-controlled, parallel group trial.

Study Design. Double-blind, randomized, placebo-controlled study to assess the effectiveness of calcitonin nasal spray on symptoms and function in patients with lumbar canal stenosis. Objective. To compare effectiveness of calcitonin administered by nasal spray with placebo in patients with clinically symptomatic lumbar canal stenosis. Summary of Background Data. Lumbar canal stenosis is the most common reason for spine surgery in individuals over 65 years of age. Nonoperative approaches have been not well studied and limited primarily to physical therapy exercises. Several small trials in the past have suggested that subcutaneous and intramuscular calcitonin is an effective nonsurgical option in treating the symptoms of spinal stenosis patients. Only three trials were randomized and placebo-controlled. Methods. Fifty-five patients with clinical lumbar canal stenosis (pseudoclaudication), confirmatory MR imaging, and pain intensity index (VAS) of ≥6 were randomized to either placebo or intranasal calcitonin daily for 6 weeks, followed by an open label 6-week extension, during which all patients received active drug. Outcome parameters performed at baseline, 6 weeks, and 12 weeks, included pain intensity index, walking time and distance to pain, SF-36, and Oswestry disability index. Results. Thirty-six patients received calcitonin, and 19 placebo. Eight (14.54%) calcitonin and 4 (7.27%) placebo patients withdrew from the study. The mean baseline pain score for calcitonin group was 7.8 and 7.5 for placebo. Comparisons at week 6 showed no statistically significant difference in the change in pain intensity (VAS) between calcitonin group (−2.9) and placebo (−2.4) (P = 0.4382) from baseline. There was no significant difference in walking time to pain (calcitonin −10.0 seconds; placebo +32.2 seconds; P = 0.5136). Walking distance to pain showed a mean improvement of +91.4 ft in the calcitonin group and +254.7 ft in the placebo group (P = 0.4948). Nosignificant difference was observed in the SF-36 score between the treatment groups. Using a threshold of at least 50% reduction in pain from baseline to 6 weeks, 12 of 29 (41.37%) of calcitonin patients were considered responders versus 7 of 18 (38.88%) of placebo patients (P = 0.4238) Conclusions. In this first ever largest randomized placebo-controlled parallel group trial of nasal calcitonin in spinal stenosis, nasal calcitonin was not superior to placebo in treating the symptoms of spinal stenosis at 6 weeks. Based on this study, nasal calcitonin does not appear to have a role in nonoperative treatment of lumbar canal stenosis.

Two Unusual Strains of Candida Arthritis

Candida arthritis is an uncommon cause of infectious arthritis that may occur in seriously ill or immunosuppressed patients. This report describes two patients, one who developed Candida tropicalis arthritis and another patient who developed C. parapsilosis arthritis. One patient developed nephrogenic diabetes insipidus secondary to amphotericin B therapy and was successfully treated with intravenous miconazole. The other was unsuccessfully treated with both intraarticular and intravenous amphotericin B.

Methotrexate and Rheumatoid Arthritis

Excerpt To the Editor:We were pleased to read the review on methotrexate treatment for rheumatoid arthritis by Tugwell and associates (1) and the position paper of the American College of Physician...

Lumbar canal stenosis.

Lumbar canal stenosis is an increasingly recognized condition in patients more than 65 years of age. The clinical syndrome is dominated by neurogenic claudication. The natural history of the Condition is not yet well described. Long-term results of surgical therapy are frequently disappointing, and reoperation is required in more than 10% of patients. Nonoperative treatment options include physical therapy exercise programs, calcitonin, analgesics, and epidural steroid injections. A clinical pathway for management of symptomatic stenosis, emphasizing an initial nonoperative approach, is suggested.