Annales de médecine interne
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Ann Med Interne (Paris) · Apr 2001
Multicenter Study Clinical Trial[Two-year follow-up of an opioid-user cohort treated with high-dose buprenorphine (Subutex)].
Care for opioid users changed greatly in France in 1996 when general practitioners (GP) were allowed to prescribe high-dose sublingual buprenorphine (Subutex((R))) for maintenance treatment of major opioid dependence. In order to evaluate treatment benefits, a prospective epidemiological 2-year follow-up was initiated in May 1996 with the participation of 105 French GPs. ⋯ This two-year follow-up of 909 opioid users showed that nearly 70% of the patient remained within the healthcare system, mainly with the same GP or more rarely with another practitioner. Among the 508 patients still followed by the same GP, maintenance treatment with high-dose buprenorphine was observed in more than 80% of the patients. These patients had a significantly improved social status, a significant decrease in drug intake and a significant improvement in their social adaptation and severity of drug abuse.
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Sarcoidosis is a systemic granulomatous condition of unknown origin. It is defined by histological features of epithelioid and giant-cell granuloma without caseous necrosis. Skin manifestations are observed in 25% of the cases of sarcoidosis, sometimes appearing as the inaugural symptom. ⋯ General corticosteroid therapy remains the mainstay treatment for severe skin disorders in sarcoidosis. APS and local corticoid therapy can be useful when systemic corticosteroids are not needed or to achieve a steroid-sparing effect. Indications for methotrexate and new compounds such as thalidomide or certain antibiotics with an immunomodulator effect remain to be evaluated.
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A neurological localization is observed in 20% of the cases of sarcoidosis. Involvement of the central and/or peripheral nervous system is generally observed in Caucasians while cranial nerve localization predominates in blacks. Beside these particular elements, lymphocytic meningitis, psychiatric disorders, insipid diabetes, and cranial nerve palsy are the most frequent signs. ⋯ Histological proof of sarcoidosis granuloma is required for diagnosis but may be difficult to obtain when neurological signs are not associated with another localization. Systemic treatment is indicated, based on steroids, sometimes associated with another immunosuppressive agent. After acute treatment, chronic therapy must be maintained for years, and sometimes for life.
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It is now well established that sarcoidosis is a granulomatous disorder resulting from an uncontrolled cell-mediated immune reaction in response to unknown antigens. This reaction is characterized by the presence of typical granulomas at the sites of the disease, made of activated macrophages (epithelioid cells) and T lymphocytes. The interactions between both cell types lead to the production of numerous inflammatory mediators which are essential for the development of granulomas. ⋯ Recent data have emphasized in some patients the expression of particular HLA haplotypes, the polymorphism of various genes, and the presence of oligoclonal T lymphocytes. The characterization of the antigenic specificity of these T cells could be helpful in identifying agents responsible for the disease. The role of mycobacterial agents is still controversial.