Prospective use of intramuscular triamcinolone acetonide in pseudogout

OBJECTIVE: To prospectively assess the efficacy of intramuscular (i.m.) triamcinolone acetonide in the treatment of pseudogout. METHODS: Fourteen patients with crystal proven pseudogout presenting with an acute attack within 5 days of onset were treated with intramuscular triamcinolone acetonide 60 mg and followed for 30 days. Patients with inadequate response were eligible for a 2nd triamcinolone acetonide injection on Day 1-2. RESULTS: Twelve patients had contraindication to nonsteroidal antiinflammatory agents (NSAID). Acute arthritis was monoarticular in 10 patients, and involved 2 or more joints in 4 patients. All patients had good clinical response to triamcinolone acetonide based on restoration of near baseline joint range of motion and joint circumference, and at least 50% improvement in patient and physician global assessment. Major clinical improvement occurred by Day 1-2 (2 patients), Day 3-4 (11 patients), and Day 10-14 (one patient). Six patients required a 2nd triamcinolone acetonide injection on Day 1-2. Toxicities were not observed. CONCLUSION: I.m. triamcinolone acetonide appears to be safe, well tolerated, and effective in the treatment of pseudogout. It may be a reasonable alternative therapy when NSAID are contraindicated, and for polyarticular attacks where intraarticular corticosteroids are impractical.     

Diabetes and trigger finger

Trigger finger is a stenosing tenovaginitis in which there is a constriction of the annular sheath associated with a nodule in the digital flexor tendon. Clinically this can present as triggering or snapping of the nodule as it passes through the tight constricting tendon sheath. Although many triggering fingers settle spontaneously, and others respond to local anesthetic and steroid injection, others require surgical decompression. The association between diabetes and trigger finger, although not widely known, has been described and forms part of the "diabetic hand syndrome". We studied 100 adult patients in the group that required surgery. Eighteen of the 100 patients were diabetic with six insulin dependent diabetics (IDDM) and 12 non-insulin dependent diabetics (NIDDM). In the current climate of day case surgery this has significant implications both for the management of known diabetics as well as the preoperative detection of those with the condition.     

Intramuscular high-dose triamcinolone acetonide in the treatment of severe chronic asthma

We describe our experience with administering intramuscular triamcinolone acetonide to 22 steroid-dependent patients with asthma. These patients represent the minority of those with asthma whose disease is characterized by frequent emergency department visits, hospital admissions, and long-term dependency on oral corticosteroid therapy. The participants were randomly assigned to 2 treatment groups, one group receiving 120 mg of intramuscular triamcinolone acetonide, the second receiving 360 mg as a series of three 120-mg daily doses. We determined relative efficacy by comparing peak expiratory flow rates and incidents of emergency department visits, hospital admissions, and ventilatory failure of the study and during the 12 months before enrollment. Peak expiratory flow rates improved significantly in both groups. The mean (+/- standard deviation [SD]) monthly percentage of predicted peak expiratory flow on the study was 88.6 +/- 3.7% and 91.2 +/- 3.9% compared with 63 +/- 15.1% and 64 +/- 14.5% at entry in patients receiving 120 and 360 mg, respectively (P < 0.02). Patients receiving 120 mg required 8 hospital stays and 8 emergency department visits compared with 27 hospital stays and 72 emergency department visits in the previous year (P < 0.05). Patients receiving 360 mg required 5 hospital stays and 5 emergency department visits compared with 33 hospital stays and 34 emergency department visits in the previous year (P < 0.05). The average monthly interval (+/- SD) between exacerbations was 2.7 +/- 2.3 and 7.8 +/- 3.5 for patients receiving 120 mg and 360 mg, respectively. A total of 25 intubations was required in the previous year and only 1 during the study. The incidence of cushingoid facies, weight gain, and hypertension was reduced in both groups (P < 0.05). Total steroid use was reduced in both groups (P < 0.02). A dose of 360 mg produced a longer exacerbation-free period than 120 mg (P < 0.02).     

Treatment of urethral syndrome with triamcinolone acetonide

A new method for the treatment of the urethral syndrome is presented. Therapy involves the submucosal injection of triamcinolone acetonide around Skene's glands to decrease inflammation and scarring. It is a simple office procedure, while all other therapeutic modalities are surgical.     

Upper extremity disorders in a pork processing plant: relationships between job risk factors and morbidity

Thirty-two jobs at a pork processing plant were semi-quantitatively analyzed in terms of their ergonomic characteristics, then classified as "hazardous" or "safe" in terms of potential risk for elbow or hand/wrist disorders. The spectrum, number, and incidence of such disorders occurring during the preceding 20 months were then compared to the job analyses and hazard classifications. There were 104 disorders associated with 15 job categories. The disorders included epicondylitis (24), nonspecific hand/wrist pain (41), carpal tunnel syndrome (CTS) (21), trigger finger (12), trigger thumb (3), and De-Quervain's tenosynovitis (3). The strength demands of the jobs associated with morbidity were significantly greater than those of jobs without morbidity. Differences in wrist posture were less significant. Type of grasp and repetitiveness were not significantly different. Practically all morbidity (96%) was associated with the hazardous job categories and occurred with a characteristic pattern of co-morbidity. The hazard classification scheme correctly predicted risk of upper extremity morbidity for 13 (87%) of the 15 job categories associated with morbidity and correctly predicted a lack of risk of morbidity for 16 (94%) of the 17 job categories not associated with morbidity. Significantly elevated relative risks were observed for any upper extremity disorder (11.4), any disorder excluding CTS (39.4), all specific disorders (6.9), and all specific disorders excluding CTS (19.4). The relative risk for CTS was 2.8 and not statistically significant. The results of this study provide additional epidemiological evidence that upper extremity musculotendinous disorders and some cases of CTS may be causally associated with work. The exertional demands of a task best explained the occurrence of morbidity.     

Outcome of trigger finger treatment in diabetes

Trigger finger is an underdiagnosed hand disorder causing disability in longstanding diabetic patients. Sixty diabetic patients [39 insulin-dependent diabetes mellitus (IDDM) and 21 non-insulin-dependent diabetes mellitus (NIDDM)] and 60 nondiabetic patients were examined. All were initially treated by steroid injections: failure to alleviate symptoms was the indication for surgery. The incidence of multiple digit involvement was higher in IDDM patients as compared with the control group (p < 0.001). The diffuse type was 1.45 times more frequent in IDDM and NIDDM than in nondiabetic patients (p < 0.008). The diabetic patients had a relatively longer duration of symptoms (p < 0.003). Significantly, a higher recovery rate upon steroid injection was achieved in control patients as compared with the diabetic ones (p < 0.001). IDDM patients required more surgery compared with NIDDMs and, in 13.3% of diabetic patients, the surgical outcome was not successful. Diabetic patients should be diagnosed early for multiple and diffuse types of trigger digits. Steroid injection as the first mode of therapy is highly recommended although not always successful. Surgery is the definitive treatment but requires a long course of physiotherapy and may be associated with some complications.     

Treatment of persistent glaucoma secondary to periocular corticosteroids

PURPOSE: To describe two patients with uveitis who developed increased intraocular pressure that was unresponsive to maximum medical therapy eight and 13 months after periocular injection of triamcinolone acetonide. METHODS: Excised periocular tissue was analyzed for corticosteroid activity by gas chromatography and mass spectrometry. RESULTS: Excision of the periocular tissue, which contained visible triamcinolone acetonide, resulted in a normal intraocular pressure within 14 days in both patients. Analysis of the excised tissue disclosed residual corticosteroid in one of the two patients. CONCLUSION: Removal of periocular tissue containing injected corticosteroids may facilitate the management of patients developing increased intraocular pressure unresponsive to maximum medical therapy.     

Weight loss in the clinical setting: applications for cardiac rehabilitation

A 57-year-old man developed oligoarthritis of the right sacroiliac joint, knee and elbow in the wake of Clostridium difficile pseudomembranous colitis. He was HLA B27-positive and had a history of Reiter's syndrome. His joint manifestations resolved after a course of nonsteroidal antiinflammatory drug therapy and injection of the right knee with triamcinolone acetonide. Clostridium difficile should be recognized as a rare cause of reactive arthritis.     

In situ detection of AE2 anion-exchanger mRNA in the human liver

The aim of this study was to examine the effect of long-term treatment with glucocorticoids on the uterine response to oestradiol. Ovariectomized rats were treated with crystal triamcinolone acetonide (0.1 mg/100 g, i.m.) or saline (0.1 ml/100 g i.m.) for 29 days. Over this period five injections were administered, one per week. On the second day after the last triamcinolone injection, rats were treated with a single injection of oestradiol dipropionate (5 micrograms/100 g, s.c.) or vehicle (olive oil, 0.1 ml/100 g, s.c.). The effects of oestradiol in the uterus were determined by measuring mitotic index, bromodeoxyuridine (BrdU)-labelling index (BrdU was injected 2 h before the rats were killed; 2 mg/100 g, i.p.), and proliferating cell nuclear antigen (PCNA)-labelling index 24, 36 and 48 h after the injection of oestradiol or vehicle. Long-term treatment with glucocorticoids resulted in dissimilar changes in oestradiol-induced proliferation in epithelial and connective-tissue (stroma) components of the uterus. In luminal and glandular epithelia, there was an initial reduction in proliferation at 24 h, followed by an increase at 36 h and a further reduction at 48 h after the oestradiol injection. In stromal cells of the endometrium, triamcinolone treatment caused a large constant increase in oestradiol-induced proliferation throughout the experiment. The glucocorticoid treatment had no effect on the parameters without oestradiol administration.     

Noninflammatory destruction of actinic keratoses by fluorouracil

Sequential topical application of fluorouracil and 0.5% triamcinolone acetonide cream is as effective in the treatment of actinic keratoses as fluorouracil alone, but the combination obviates the unpleasent irritation caused by fluorouracil. Diluted (0.1%) triamcinolone acetonide cream preparations are ineffective in the suppression of the associated inflammation. There is no detectable difference in the number of new actinic keratoses between the combination therapy and fluorouracil alone. These findings demonstrate that the degree of success with fluorouracil therapy in actinic keratosis is not related to the degree of inflammation associated with the treatment and are consistent with a chemotherapeutic explanation of fluorouracil's effect on actinic keratosis.     

Prolonged weakness after cisatracurium infusion: a case report

OBJECTIVE: To present the first documented case report of myopathy persisting for >48 hrs in a patient treated with cisatracurium and concomitant high-dose corticosteroids. DESIGN: Anecdotal observations in one patient. SETTING: Medical-respiratory intensive care unit (ICU) at a tertiary care, university teaching hospital. PATIENT: A 45-yr-old female admitted status for post-bilateral total knee replacement complicated by aspiration pneumonitis and acute respiratory distress syndrome (ARDS). INTERVENTIONS: The patient required pressure control ventilation and sedation with midazolam and fentanyl infusions. On ICU day 2, the patient was placed on inverse ratio ventilation and paralyzed with cisatracurium. On ICU day 6, methylprednisolone 125 mg i.v. every 6 hrs was initiated for fibroproliferative ARDS. On ICU day 11, methylprednisolone was reduced to 60 mg i.v. every 6 hrs and tapered over several weeks. Cisatracurium infusion rates ranged from 6.3 to 10.5 microg/kg/min, with an average of 8.0 microg/kg/min. MEASUREMENTS AND MAIN RESULTS: Train-of-Four was assessed before initiation of therapy and every 4 hrs, thereafter. Train-of-Four values were maintained from 1 to 4 throughout therapy and a value of 4 was recorded when therapy was discontinued. On day 13, neuromuscular blocking agent therapy was discontinued, but severe proximal and distal muscle weakness was observed bilaterally. Creatinine kinase concentrations on 3 and 13 days after discontinuation of the paralytic agent were 181 and 96 units/L, respectively. On day 24, the patient moved her fingertips. On ICU day 30, the patient was weaned from the mechanical ventilator. The patient was transferred to the ward on day 33. Extensive rehabilitation with physical and occupational therapy was required for several months. CONCLUSION: Clinicians should remember that irrespective of chemical structural, neuromuscular blocking agents might produce prolonged paralysis in predisposed patients.     

Effects of 6alpha-methylprednisolone acetate on an equine osteochondral fragment exercise model

OBJECTIVE: To determine effects of intra-articularly administered 6alpha-methylprednisolone acetate (MPA) in exercised horses with carpal osteochondral fragmentation. ANIMALS: 18 horses: 3 groups of 6 each. PROCEDURE: An osteochondral (chip) fragment was created in 1 randomly chosen middle carpal joint of each horse. Polyionic fluid (PF) was injected into both middle carpal joints of horses in the control group. In horses of the MPA-control group, MPA was injected into the middle carpal joint without an osteochondral fragment; a similar volume of PF was injected into the contralateral middle carpal joint. In the MPA-treated group of horses, 100 mg of MPA was injected into the middle carpal joint containing the osteochondral fragment; a similar volume of PF was injected into the contralateral joint. Injections were administered on postsurgical days 14 and 28, and horses were exercised on a high-speed treadmill for 8 weeks, starting on postsurgical day 15. RESULTS: Clinical improvement in degree of lameness was not associated with MPA administration. Joints that contained an osteochondral fragment and were treated with MPA had lower prostaglandin E2 concentration in synovial fluid, and lower scores for intimal hyperplasia and vascularity in synovial membrane, compared with PF-treated joints. However, articular cartilage erosion and morphologic lesions suggested possible deleterious effect of intra-articular MPA administration. CONCLUSIONS: Some beneficial effects of MPA administration on synovial fluid and synovial membrane were identified; however, the deleterious findings contrast with those associated with triamcinolone acetonide used in a similar model, but agree with other results of MPA administration in normal and abnormal joints.     

Inhibition of Salmonella enteritidis by oleuropein in broth and in a model food system

OBJECTIVE: To compare the pharmacokinetics of methylprednisolone in renal transplant recipients on 2 occasions separated by at least 1 month during chronic immunosuppression. DESIGN: A prospective unblinded trial. PATIENTS: Ten renal transplant recipients (aged 25-62 years) evaluated in a public university-affiliated hospital clinic. INTERVENTIONS: All patients received their chronic oral dose of methylprednisolone as a 10-20-minute intravenous infusion during the 2 study periods. MAIN OUTCOME MEASURES: Serum methylprednisolone concentrations were determined by HPLC and were used to generate the pharmacokinetic parameters of the drug. RESULTS: During study 1, which ranged from 1.2 to 24 months posttransplant, the mean +/- SD methylprednisolone dose was 13.2 +/- 6.4 mg. In study 2 (2.5-38.5 mo posttransplant), the mean dose was 10.6 +/- 3 mg. During both study periods, methylprednisolone concentrations exhibited a monoexponential decline. Considerable variability in methylprednisolone clearance was observed between periods in certain patients. Four of the 10 patients demonstrated a reduction in clearance from study 1 to study 2, which ranged from a 28% to a 53% decrease. Two patients exhibited an increase in clearance of 40% and 49%. The mean +/- SD total body clearance in study 1 was 363 +/- 330 mL/min/kg, whereas the mean volume of distribution was 1.18 +/- 0.53 L/kg. The mean elimination rate constant was 0.29 +/- 0.14 h-1, with a mean serum half-life of 2.87 +/- 1.15 h during the first phase. In study 2, the mean methylprednisolone clearance was 261 +/- 150 mL/min/kg (p > 0.05) and the mean volume of distribution was 0.89 +/- 0.31 L/kg (p > 0.05). The mean serum half-life of methylprednisolone was 2.91 +/- 0.60 h (p > 0.05), with the mean elimination rate constant of 0.25 +/- 0.06 h-1 (p > 0.05). CONCLUSIONS: These data demonstrate that intrapatient variability in methylprednisolone clearance exists among certain renal allograft recipients. As a result of the observed variability, patients who are continued on the same dose of methylprednisolone during the posttransplant period of chronic immunosuppression will be subjected to a changing pattern of exogenous glucocorticoid exposure. The impact of these changing patterns requires further prospective evaluation.     

Topical corticosteroid injection for 'trigger finger': good short-term results, but fairly high risk of recurrence

OBJECTIVE: To determine the short and long term results of trigger fingers treated with a local injection of corticosteroid. DESIGN: Prospective analysis. SETTING: 'Zuiderziekenhuis', Department of General Surgery, Rotterdam, the Netherlands. METHOD: In 55 patients with 62 trigger fingers the affected flexor sheath was injected with a long-acting corticosteroid. All patients were followed up for at least one year. RESULTS: With one or two steroid injections 60 of the 62 trigger fingers were treated successfully. During the follow-up period the cumulative recurrence rate was 33% after one year. CONCLUSION: The treatment of trigger fingers with a local injection of steroids is a simple and safe procedure but the risk of recurrence in the first year is considerable.     

Hand flexor tenosynovitis in rheumatoid arthritis. Prevalence, distribution, and associated rheumatic features

Tenosynovitis of one or more flexor tendons of the hand (mean 3.1 tendons per patient) was noted in 55% of 100 patients with rheumatoid arthritis (RA) examined periodically during a mean period of 5 years. The third flexor tendon was involved most frequently (71% of patients), followed by the second (62%), fourth (53%), fifth (27%), and first (13%). Patients with flexor tendonitis (FT) had a significantly higher prevalence of rheumatoid nodules (56% vs 33%), carpal tunnel syndrome (47% vs 13%), wrist extensor tenosynovitis (47% vs 9%), and elbow epicondylitis (22% vs 7%) than patients without FT. Dupuytren's contracture, DeQuervain's tenovaginitis, flexor carpi radialis and ulnaris tendonitis, and Achilles tendonitis were found exclusively in patients with FT. A control group of 50 non-RA patients with FT had statistically fewer diseased tendons per patient (mean 1.5) and a different digital distribution, the thumb being affected more frequently (P less than 0.05) than in RA patients.     

The relationship between regional blood flow and contractile function in normal, ischemic, and reperfused myocardium

We administered streptozotocin (STZ) and alloxan (AL) to the musk shrew (Suncus murinus, Insectivora) to determine the effective diabetogenic dose of the two toxins for this species. A single intraperitoneal (i.p.) injection of 75 mg/kgBW or the consecutive 5-day s injection of 25 mg/kgBW of STZ to non-fasted shrews, effectively (100%) induced hyperglycemia (> or = 300 mg/dl) with hypoinsulinaemia (< 30% of control level) in male shrews at 10 days after administration. Morphological studies showed cytological changes of B cells in the pancreatic islets of diabetic shrews. Hyperglycemic shrews induced by STZ were thus in IDDM (insulin dependent diabetes mellitus), and showed high susceptibility to the diabetogenic effect of STZ as compared with rodents. Shrews showed a sex difference in the diabetogenic susceptibility to STZ as do mice (male > female). They also showed a species specific resistance to the diabetogenic effect of AL. Of the eight shrews (with 8-hr fasting) that has been treated with a single injection of 200 mg/kgBW of AL, seven (88%) survived at least 10 days, showing no signs of hyperglycemia. All shrews died within 3 day s after injection of 250 or 300 mg/kgBW. These results indicated that the STZ-induced diabetic shrew is a unique animal model and may be useful for IDDM research. On the other hand, the musk shrew was highly resistant to the diabetogenic effects of AL.     

Human COL6A1: genomic characterization of the globular domains, structural and evolutionary comparison with COL6A2

We studied nephrotic patients hospitalised in internal medicine service at Treichville Teaching hospital from September 1986 to February 1993 for precising the aetiological aspects of black adult patients and their evolutive biological, clinical and epidemiological profile. Secondary Nephrotic syndrome represented 18% of the whole patients with Nephrotic syndrome hospitalised during the same period. In aetiological field it was about: diabetic nephropathy 11 cases (33%); lupus nephritis 7 cases (21%); renal amyloidosis 5 cases (15%); HIV nephropathy 5 cases (15%); schistosomiasis nephrotic syndrome 1 case (3%); pregnancy nephrotic syndrome 1 case (3%); cryoglobulinemia 1 case (3%); malignancy nephrotic syndrome 1 case (3%); nephrosclerosis 1 case (3%).     

Correction of long term joint contractures of the hand by distraction. A case report

Joint contractures are a common complication of hand trauma. The conventional treatment consists of arthrolysis, tenolysis and occasionally arthrodesis. Frequently, this does not achieve a good result, particularly when there has been a long delay in presentation. Progressive lengthening of a joint by distraction (joint distraction) allows the release of joint contractures even in cases of failure of traditional methods.We present a case of a delayed (20 years) work related traumatic flexion deformity of the PIP joint of the left index and middle fingers. This was the result of a complete division of both flexor tendons of both fingers.The range of movements, both active and passive, was limited to 90/100° in the index finger and 95/100° in the middle finger. Following joint distraction using our lengthening device (Antão™, Portugal) the patient was able to achieve an active and passive range of movements of 10/100° for the PIP joint of the index finger and 40/100° of the middle.This clinical case shows the simplicity and application of our technique for the correction of joint contractures.     

Randomized controlled trial for hepatocellular carcinoma with portal vein thrombosis: intra-arterial iodine-131-iodized oil versus medical support

Portal vein thrombosis is a poor prognostic factor in patients with hepatocellular carcinoma (HCC) and a contraindication for chemoembolization. Intra-arterial injection of 131I-iodized oil which does not modify arterial flow, is feasible in this condition. The aim of this prospective randomized controlled trial was to compare the efficacy of treatment with radiolabeled oil (treated group) versus medical support (control group) in patients with stage I or II HCC (classification of Okuda) with portal vein thrombosis. METHODS: Twenty-seven HCC patients (26 males, 1 female), aged 53-79 yr, with portal vein thrombosis were randomly assigned to Lipiocis group (n = 14) or Control group (n = 13). Additional injections of radiolabeled oil were given 2, 5, 8 and 12 mo after initial therapy. Medical support treatment consisted of: tamoxifen (n = 5), 5 FU intravenously (n = 1), NSAIDs or corticosteroids (n = 5). Efficacy was evaluated according to survival rate (Kaplan-Meier method; log rank test), AFP serum values (measured at 2, 5, 8 and 12 mo) and angiography. RESULTS: The two groups were comparable (Child's classification, Okuda's classification, liver function tests, location of the thrombus). Tolerance was excellent in the Treated group. The actuarial survival curves were significantly different (p < 0.01) between the two groups, the survival rates (Cl 95%) at 3, 6 and 9 mo being 71% (48%-95%), 48% (12%-55%), 7% (1%-31%) for the Treated group; and 10% (1%-33%), 0% and 0% for the Control group. CONCLUSION: Intra-arterial hepatic injection of 131I-labeled iodized oil is a safe and effective palliative treatment of HCC with portal vein thrombosis.     

Treatment of cisplatin-related nausea and vomiting with a combination of ondansetron and metoclopramide: a pilot study

Forty chemotherapy-naive patients receiving high-dose cisplatin were included in a pilot study of a combination of ondansetron plus metoclopramide as antiemetic therapy. Patients received ondansetron 16 mg plus metoclopramide 0.5 mg/kg in 250 cm3 of normal saline i.v. 15 min before cisplatin administration on day 1; then ondansetron 8 mg was given orally b.i.d. and metoclopramide 0.5 mg/kg was given intramuscularly t.i.d. for 4 days. This combination was given to all patients receiving the first cycle of chemotherapy. At the second cycle of chemotherapy all patients received the same antiemetic treatment as above plus methylprednisolone 125 mg i.v. on day 1 and the intramuscularly once a day for 4 days. There were 20 females and 20 males with a mean performance status of 1 (range 0-2) and a mean age of 58 years (range 36-68). Ten patients had ovarian carcinoma, eight patients had uterine adenocarcinoma and 22 and non-small cell lung carcinoma. The mean cisplatin dose was 96 mg/m2. All patients denied significant alcohol consumption. At cycle 1, complete protection against acute emesis was achieved in 22 patients (55%), major protection in 12 cases (30%), minor protection in four patients (10%) and failure in two cases (5%). On the other hand, the efficacy of this combination on delayed vomiting was not striking. For delayed vomiting, complete protection was observed in nine patients (23%), major protection in 13 cases (33%), minor protection in 10 patients (25%) and failure in eight cases (20%). At cycle 2, patients also received methylprednisolone showing complete protection from vomiting in 19 cases (47%) and major protection on 12 cases (30%). Results achieved with ondansetron plus metoclopramide are in the range reported for ondansetron alone in the medical literature. Although this study was not prospectively carried out in a randomized fashion, the results are not suggestive of a possible positive effect of metoclopramide addition to ondansetron. On the other hand, these results stress the role that corticosteroids may play in the control of delayed emesis. Toxicity was predictable and the frequency of side-effects was in the range reported in other studies with ondansetron.