Walter Esselinckx

Primary prevention of glucocorticoid-induced osteoporosis with intravenous pamidronate and calcium: a prospective controlled 1-year study comparing a single infusion, an infusion given once every 3 months, and calcium alone.

The aim of this study was to compare the action of two regimens of intravenous (iv) pamidronate in the primary prevention of glucocorticoid‐induced osteoporosis (GC‐OP). The primary purpose of the study was to determine whether any differences in bone mineral density (BMD) appeared after 1 year. A secondary endpoint aimed at assessing the remodeling parameters in order to better understand the mechanisms of action of the various regimens. Thirty‐two patients, who required first‐time, long‐term glucocorticoid therapy at a daily dose of at least 10 mg of prednisolone, were studied. Simultaneously with the initiation of their glucocorticoid treatment, patients also were randomly allocated to receive a single iv infusion of 90 mg of pamidronate at the start (group A); a first infusion of 90 mg of pamidronate followed, subsequently, by an iv infusion of 30 mg pamidronate every 3 months (group B); and a daily 800‐mg elemental calcium supplement given as calcium carbonate (group C), which also was taken by patients in groups A and B. Patients were matched for starting glucocorticoid doses, sex, menopausal status, and hormonal replacement therapy. Lumbar spine and hip (total and subregions) BMDs were measured at the outset and repeated at 6‐month intervals by dual‐energy X‐ray absorptiometry (DXA; Hologic QDR‐2000). Bone turnover was assessed by measurement of total and bone‐specific serum alkaline phosphatase activity (B‐ALP), serum osteocalcin (OC), and serum C‐telopeptide cross‐links of type I collagen (CTX). After 1 year, the mean BMD changes for groups A, B, and C were, respectively, 1.7, 2.3, and −4.6% at the lumbar spine; 1.2, 1.2, and −3.1% at the femoral neck; 1.0, 2.6, and −2.2% for the total hip region. No difference was observed between pamidronate regimens but a highly significant difference was observed between both pamidronate regimens and the control group at the lumbar spine (p < 0.001), at the femoral neck (p < 0.01), and for the total hip (p < 0.05). A significant decrease of serum C‐telopeptide was observed, after 3 months, in groups A and B (p = 0.029), but a sustained decrease of bone resorption over time was observed only in group B. As far as BMD evolution over 1 year was concerned, iv pamidronate, given either as a single infusion or once every 3 months, effectively achieved primary prevention of GC‐OP.

Adult onset of multifocal eosinophilic granuloma of bone: a long-term follow-up with evaluation of various treatment options and spontaneous healing.

Abstract: We report a case of multifocal–monosystemic Langherhans cell histiocytosis (LCH), formerly usually referred to as eosinophilic granuloma (EG) of bone. The condition developed in a 36-year-old man. A notable infrequent thoracic spine location and two successive distinct costal lesions were observed. Both the first costal site and the vertebral location healed spontaneously; the second costal lesion underwent biopsy resection. The patient’s disease course with an 8-year follow-up is discussed with reference to various treatment options, emphasising in selected cases a watchful conservative approach, in view of the widely documented potential for spontaneous healing.

Abdominal wall weakness and lumboabdominal pain revealing neuroborreliosis: a report of three cases.

Abstract: The authors report three cases of thoracic radiculoneuropathy disclosing neuroborreliosis. All three patients had low back and abdominal pain and two had marked abdominal wall paresis. EMG confirmed a motor involvement of the lower thoracic roots and CSF analysis revealed a lymphocytic meningitis in all three cases. Antibodies against Borrelia burgdorferi were present in both the serum and the CSF. A favourable outcome was obtained in all three patients with appropriate antibiotherapy. The differential diagnosis of this misleading presentation is discussed.

New Modes of Administration of Salmon-calcitonin in Pagets-disease - Nasal Spray and Suppository

In volunteers the activity of various doses of a nasal spray and of a suppository of salmon calcitonin was compared to a placebo and to the parenteral route of administration. Both new modes of administration were found to be active on the kidney (and the suppository was found to affect bone turnover as well). The parenteral route proved more effective, but the nasal and/or rectal routes were devoid of systemic side effects and had minimal local intolerance. The nasal spray was used at 200 units daily in 15 patients with Pagets disease, and at 400 units daily in another nine patients, both trials lasting one year. The two regimens proved active on the parameters of bone turnover and the higher dose was more effective than the lower one. Similarly, a 300 unit suppository was given to another 12 patients. This trial is still being completed at this time. At the third month of therapy, the parameters of bone turnover were significantly depressed. Both new modes of therapy were able to improve the focal bone balance of the osteolytic lesions monitored on sequential roentgenograms. Systemic side effects were absent and local side effects were minimal. Only one patient interrupted the nasal spray therapy, and no one interrupted the suppository therapy.

Axillary schwannoma masquerading as cervical radiculopathy.

Abstract: A 58-year-old woman, suffering from radicular-like pain in the left arm for 3 years, presented an entirely negative cervical imaging. Careful clinical examination disclosed Tinel’s sign in the axilla. This clinical finding led to further investigation of this region. Computed tomography and magnetic resonance imaging disclosed a small tumour highly suggestive of a schwannoma. Surgical exploration and microscopic examination confirmed a diagnosis of schwannoma located on the radial trunk of the left brachial plexus. After tumour excision, the patient had immediate relief of pain without sensitive or motor sequelae. No recurrence has been observed after 3 years.

Non-hormonal Treatment of Osteoporosis

groups lose bone at about the same rate.3 We have in our files more than 50 000 radiographs to show this, including radiographs from six central American nations, 10 states in the United States, and radiographs from the Tecumseh community health survey. Nor is adult bone loss a recent phenomenon. Prehistoric populations suffered from adult bone loss much as we do, whether they were hunters and gatherers, early agriculturalists, or maize intensive agriculturalists. These prehistoric and protohistoric peoples lost bone whether they lived in sunny climates or in cold and wet climates.4 5 So decreased cortical thickness, reduced trabecular numbers, vertebral biconcavity, and vertebral collapse are not of recent origin, nor are they limited to European and western peoples. Moreover, adult bone loss takes place regardless of the calcium intake, from levels below 400 mg!day to well over 1000 mg/day. This is evident in population data, in maize eaters and rice eaters, and at various levels of quality protein.7 Within populations there is no significant relation between calcium intake and bone quality.8 Among 870 older individuals in the ten state nutrition survey of the United States the correlation between calcium intake and per cent cortical area was 0-08. Highest levels of skeletal mass were observed among American blacks, whose calcium intakes were systematically lower than for whites. Elderly American black women had calcium intakes that were only 65% of those of white women of the same age, yet their rates of bone loss were lower than those in their white counterparts.8 So population comparisons and studies within populations do not confirm a linkage between calcium intake and adult bone loss. Moreover, the universality of adult bone loss at all levels of calcium intake raises serious concern about the meaning of positive calcium balances in people aged 40 and over.

Adrenocortical Function and Responsiveness To Tetracosactrin Infusions After Intra-articular Treatment With Triamcinolone Acetonide and Hydrocortisone Acetate

SummaryThe urinary free cortisol (UFC) output, considered a parameter of the action of the exogenous corticosteroid on the hypothalamo-pituitary axis, was followed in five patients who received a total of 12 intra-articular (i.a.) injections of 40 mg of triamcinolone acetonide (TCA) distributed over eight treatment sessions. The effect of intra-articular TCA injections on UFC output was null after three treatment sessions, transient (48 hr) after another three, and more prolonged (6 days), although slight, after the remaining two sessions. These results contrast with the lasting and profound inhibition of the UFC output induced either by the same TCA dose given intramuscularly, or by oral administration of dexamethasone to 30 normal subjects, 0.75 mg at 8-hourly periods for 48 hours.Adrenocortical reactivity, as measured by the response to synthetic ACTH (tetracosactrin) of both plasma cortisol levels and UFC output, was studied in another five patients prior to and after eight i.a. injections of 40 mg of TCA, and in three patients after six i.a. injections of 25–100 mg of hydrocortisone acetate. No decrease was observed after the i.a. injections of HCA. Considered as a group the response to tetracosactrin after TCA injections was not significantly altered. Two patients showed a decreased response of both UFC and plasma cortisol, although their values remained within the limits of those obtained in 44 normal control subjects. In contrast, profound inhibition of the tetracosactrin induced response occurred in a control group of 30 sujects given 0.75 mg of dexamethasone orally at 8-hourly periods for 48 hours.

La maladie de Still de l'adulte. Une revue de 19 cas. Comparaison avec 25 observations de maladie de Still de l'enfant. Sa place dans les températures d'origine indeterminée.

SummaryThe authors report 19 cases of adult onset Still’s disease (AOSD) and compare them with 25 cases of juvenile systemic Still’s disease. They emphasize the diagnostic difficulties in the early stages of the disease, the various systemic complications and the common evolution to chronic erosive joint lesions. In the authors’ experience, AOSD represents about 5 per ccnt of cases admitted for fever of unknown origin.

Paget's sarcoma — with two illustrative cases

SummaryTwo cases of Pagets sarcoma of bone are described. The first one is mainly characterized by the almost simultaneous degeneration of the only two existing locations of the underlying Pagets disease. The second case is one of monostotic Pagets disease of the scapula disclosed by the malignant degeneration.

Treatment of Postmenopausal Osteoporosis With Vitamin-d and Severe Hypercalcemia

SummarySodium fluoride, calcium and cholecalciferol were given to a patient, suffering from a postmenopausal age related osteoporosis. The treatment led to severe hypercalcemia and acute renal failure. Clinical investigations disclosed enventually the presence of sarcoidosis.We suggest that the use of vitamin D in the treatment of osteoporosis requires a careful monitoring of blood calcium and/or calciuria.