Oral enzyme combination versus diclofenac in the treatment of osteoarthritis of the knee – a double-blind prospective randomized study

The aim of this study was to compare the efficacy and safety of an oral enzyme–rutosid combination (ERC) containing rutosid and the enzymes bromelain and trypsin, with that of diclofenac in patients with osteoarthritis (OA) of the knee. A total of 103 patients presenting with painful episodes of OA of the knee were treated for 6 weeks in two study centers in a randomized, double-blind, parallel group trial. Altogether, 52 patients were treated in the ERC group and 51 patients were treated in the diclofenac group. Primary efficacy criteria were Lequesnes Algofunctional Index (LFI) and a complaint index, including pain at rest, pain on motion and restricted function. The efficacy criteria were analyzed by applying the Wilcoxon–Mann–Whitney test that provides the Mann–Whitney estimator (MW) as a measure of relevance. Non-inferiority was considered to be proven if the lower bound of the 97.5% one-sided confidence interval (CI-LB) was higher than MW=0.36 (benchmark of not yet relevant inferiority). Both treatments resulted in clear improvements. Within the 6-week observation period, the mean value of the LFI decreased from 13.0 to 9.4 in the ERC group and from 12.5 to 9.4 in the diclofenac group. Non-inferiority of ERC was demonstrated by both primary criteria, LFI (MW=0.5305; CI-LB=0.4171) and complaint index (MW=0.5434; CI-LB=0.4296). Considerable improvements were also seen in secondary efficacy criteria, with a slight tendency towards superiority of ERC. The global judgment of efficacy by physician resulted in at least good ratings for 51.4% of the ERC patients, and for 37.2% of the diclofenac patients. In the majority of patients tolerability was judged in both drug groups as very good or good. The current study indicates that ERC can be considered as an effective and safe alternative to NSAIDs such as diclofenac in the treatment of painful episodes of OA of the knee. Placebo-controlled studies are now needed to confirm these results.Abbreviations ERC Enzyme–rutosid combination - LFI Lequesnes Algofunctional Index Dr. Mehnaz Rashid was the Clinical Trials monitor on behalf of Pacific Pharmaceuticals (Lahore, Pakistan) and Dr. W. Schiess played the same role on behalf of Mucos Pharma (Germany)     

Extubation failure in the elderly

To determine the causes, risk factors and complications of planned extubation failure of critically ill elderly patients, we conducted a prospective study of 175 consecutive patients (> or = 70 years old) admitted with respiratory failure. Thirty-six (21%) failed extubation within 72 h after planned extubation. Compared to a younger age group (< 70 years old) matched for severity of illness, inability to handle secretions (20%) was the most common reason of airway causes leading to extubation failure in the elderly while upper airway obstruction (22%) was the predominant cause in the control group. As for nonairway causes, COPD related hypercapnic respiratory failure accounted for the majority of cases in both groups. After adjusting for severity of illness, elderly patients who required reintubation had a higher risk of developing nosocomial pneumonia. The presence of underlying pulmonary disease (odds ratio (OR), 2.9; 95% confidence interval (CI) 1.2-6.9), length of intubation > 4 days (OR, 4.3; 95% CI 1.8-10.2), and albumin levels < 2.5 g/dl (OR, 2.7; 95% CI 1.2-6.7) were independently associated with extubation failure in the old. Objective measurements of cough strength and secretion volume are needed to reduce the morbidity of elderly patients at risk for extubation failure.     

Zinc in CSF of patients with febrile convulsion

OBJECTIVE: This prospective study was carried out from July-December 1999 to see the status of zinc in CSF of children with febrile convulsion and to compare this to that of control. METHODS: Forty-two cases of febrile convulsion and 30 controls (fever without convulsion) were enrolled into the study. CSF zinc was estimated by atomic absorption spectrophotometry (AAS) in Atomic Energy Center, Dhaka and compared between the two groups. RESULTS: The mean zinc level in CSF in the study sample was 40.19mgm/L and that in control was 74.98mgm/L. This difference was statistically significant (p<0.001). CONCLUSION: The study concludes that a significantly lower of zinc exists in CSF of children with febrile. However no relationship was found between CSF zinc status with age, sex, degree & duration of fever and time of lumbar puncture after convulsion.     

Rhabdomyolysis associated with gemfibrozil-colchicine therapy

OBJECTIVE: To report a case of rhabdomyolysis possibly due to combination therapy with colchicine and gemfibrozil. CASE SUMMARY: A 40-year-old man with amyloidosis and hepatitis B virus-related chronic liver disease was admitted to the university hospital because of fatigue, lack of appetite, dark brownish urine, and myalgia for 2 weeks. The patient was receiving colchicine and gemfibrozil. Elevations of serum creatine kinase, lactate dehydrogenase, and aspartate aminotransferase concentrations with myalgia were compatible with the diagnosis of rhabdomyolysis. DISCUSSION: To our knowledge, myopathy and rhabdomyolysis due to a combination of colchicine and gemfibrozil therapy have not been previously reported. Preexisting mild renal failure, hepatitis B-related chronic liver disease, and amyloidosis may be contributing risk factors for the development of rhabdomyolysis in this patient. An objective causality assessment revealed that the adverse drug event was possible. CONCLUSIONS: Patients receiving combination therapy with colchicine and gemfibrozil, especially those with renal and hepatic dysfunction, should be monitored for rhabdomyolysis, and concomitant colchicine and gemfibrozil therapy should be considered in the differential diagnosis of rhabdomyolysis.     

Dermoid cysts: epidemiological,clinical and pathological studies

We retrospectively analyzed 31 cases of dermoid cysts surgically treated between January 1992 and October 2000. Mean patient age was 18.9 years. The preseptal localization predominated, with 29 cases. Two cases of intraorbital localization required orbitotomy. The surgical result was excellent.     

Discrepancy between myocardial ischemia and luminal stenosis in patients with left internal mammary artery grafting to left anterior descending coronary artery

BACKGROUND: Left internal mammary artery (LIMA) grafting to the left anterior descending artery (LAD) is known to have long-term patency. However, myocardial ischemia in the territories supplied by LIMA to LAD is still demonstrated. The aim of this study is to examine the relationships between the extent, location, and clinical outcome of myocardial ischemia in LAD territories (ILAD) by use of myocardial perfusion imaging (MPI) and angiographic characteristics of such a bypass conduit. METHODS AND RESULTS: We studied 38 consecutive patients with prior coronary artery bypass grafting who showed stress-induced ischemia in LIMA to LAD territories by MPI single photon emission computed tomography between the years 1996-2000. All patients underwent quantitative coronary angiography within 6 months of the nuclear study. Single photon emission computed tomography parameters of ILAD were assessed by location (septum, apex, anterior, and anterolateral) and included extension score (1-4 per patient), severity score (0-3 per territory), and total sum score. LIMA to LAD quantitative coronary angiography parameters included minimal lumen diameter, lesion length, reference diameter, and diameter stenosis (percentage). LAD and LIMA diameters and ratio (in normal segments) were determined within 10 mm proximal and distal to the anastomotic site. The study group was compared with 18 control subjects without ischemia or stenosis treated with LIMA to LAD. The patients were followed up for cardiac death at an interval of 3.2 +/- 1.5 years from the time of MPI testing. The patients' mean age was 66 +/- 12 years (31 men and 7 women); the mean period after surgery was 6.2 +/- 1.5 years. The ILAD distribution was as follows: septum, 12 (32%); apex, 20 (52%); anterior, 24 (63%); and anterolateral, 18 (47%). The mean extension score was 1.9 +/- 1.0, and the mean total sum score was 3.4 +/- 2.3. Of 38 patients with ILAD, only 17 (45%) had greater than 50% luminal stenosis (2 LIMA and 15 anastomosis or distal). Among clinical variables during stress testing, the prevalence of angina was significantly higher in the luminal stenotic patients versus patients without stenosis (P =.04). A significant correlation was found between anterior wall ischemia and reference diameter (r = -0.7, P =.002) and between total sum score and minimal lumen diameter (r = -0.48, P =.05). Of note, the LAD-to-LIMA ratio was significantly lower in patients with ILAD and without luminal stenosis compared with the control group (0.73 +/- 0.16 vs 0.87 +/- 0.15, P =.004). Cardiac death occurred in 8 patients (21%), 5 patients with luminal stenosis versus 3 patients without stenosis (P = not significant). CONCLUSIONS: In patients with LIMA to LAD anastomosis, myocardial ischemia could occur even without angiographic luminal stenosis and apparently reflects a mismatch between LAD and LIMA diameters at distal anastomotic sites. Regarding the similar prevalence of cardiacdeath, invasive evaluation and aggressive treatment are recommended in all patients with ischemia in LIMA/LAD territories.     

Hairy cell leukemia: report of 8 cases

Hairy cell leukemia haemopathy is a rare lympho?d haemopathy type B. 8 cases are reported and diagnosed at H?pital Aziza Othmana over a period of 20 years between 1979 and 1999, 7 men and one women. The mean age of the patients is 51 years, with externe ages from 42 to 81 years. 4 patients consulted for an infections and, or anaemia syndrome. The disease was revealed due to the presence of an isolated splenomegaly in other cases. At the clinical examination, the spleen is hypertrophied in 7 patients out of 8. Pancytopenia is observed in 50% of the patients. Only one patient has presented a moderated hyperleukocytosis at 11,000/mm3 related to the presence of moving on tricholeukocytes. The myelogramme is pocr. It allowed to mention the diagnosis in 6 cases out of 8. Bone Marrow biopsy revealed a diffuse infiltration by TCL with a reticulinic fibrosis in all patients. 4 patients out of 8 have been splenectomized. Cytopenies have been corrected in all patients. Only one patient has been treated by alpha Interferon for 3 years with a partial hematological response. A relapse was observed once the Interferon was stopped. With the introduction of new drugs such purine analogues. The HCL treatment has been revolutionarized thanks to the improvement of the rate of complete response (from 10% to 80% of CR). If splenectomy is still observed in HCL for splenomegalic and or severe cytopenia, our findings could be improved thanks to new purine analogues.