Impact of Bariatric Surgery on Bone Mineral Density: Observational Study of 110 Patients Followed up in a Specialized Center for the Treatment of Obesity in France.

INTRODUCTION: Bariatric surgery is used to treat severe obesity. We aimed to investigate the incidence of clinically significant bone mineral density (BMD) loss at 6 and 12 months after bariatric surgery. METHODS: Observational study performed in a specialized center for the treatment of obesity at the University Hospital of Reims, France. Surface BMD was measured by dual x-ray absorptiometry (DEXA). A reduction of > 0.03 g/cm2 was considered clinically significant. RESULTS: A total of 110 patients were included. A clinically significant reduction in BMD was observed in 62.1% of patients at 6 months, and in 71.6% at 12 months after surgery. No case of osteoporosis was observed. There were four cases of osteopenia and one fracture post-surgery. BMD loss was related by univariate analysis to the reduction in body mass index (BMI) (p < 0.01), weight loss (p < 0.01), fat mass (p < 0.01), and lean mass (p < 0.01). Multivariable analysis found a significant association between the reduction in BMD and the excess weight loss percentage (odds ratio 1.11, 95% confidence interval (1.05-1.18), p < 0.001). CONCLUSION: There was a clinically significant reduction in BMD at 6 months after surgery in over 60% of patients undergoing bariatric surgery. BMD loss is persistent over time and predominantly situated at the femoral level, and strongly associated with weight loss. Systematic vitamin and calcium supplementation, as well as follow-up by DEXA scan seems appropriate. Systematic DEXA scan pre- and post-surgery, and annually thereafter until weight has stabilized seems appropriate.

[Efficacy and safety of ustekinumab in psoriatic arthritis after anti-TNFα failure in routine practice]. / Ustekinumab dans le rhumatisme psoriasique après échec des anti-TNFα en pratique courante.

PURPOSE: Evaluation of effectiveness and safety of ustekinumab in psoriatic arthritis after anti-TNFα failure. METHODS: We conducted a retrospective and monocentric study. The evaluation of articular and cutaneous effectiveness by the patient was made with numeric scale and satisfaction scale and by the physician during a rhumatological-dermatological consultation. The safety was analyzed by collecting the adverse effects. RESULTS: Nine patients with anti-TNF failure were included. Five of them stopped the treatment because of severe adverse effects. The mean duration treatment of ustekinumab was 24 months. Articular and cutaneous effectiveness were respectively 4.4/10 and 6.7/10. Two thirds of the patients were "satisfied" and one third could stop any analgesic treatment. The mean PASI score decreased from 8.4 to 1.7 after 3 months treatment. Only minor adverse effects were collected and there were no recidivism of the adverse effects observed with anti-TNFα. CONCLUSION: Ustekinumab is an effective and safe alternative for patients with anti-TNFα failure in psoriatic arthritis.

Diagnostic contribution of a second percutaneous needle biopsy in patients with spontaneous diskitis and negative blood cultures and first biopsy.

OBJECTIVES: The primary objective was to assess the diagnostic contribution of a second percutaneous needle biopsy in patients with spontaneous diskitis and negative findings from blood cultures and the first biopsy. We also assessed the sensitivity of the first biopsy and the diagnostic contribution of post-biopsy blood cultures. METHODS: Multicenter retrospective study of patients managed between 2004 and 2014. We excluded patients with postoperative diskitis. RESULTS: We identified 63 patients with spontaneous diskitis, negative blood cultures, and at least one percutaneous needle biopsy during the study period. The first biopsy established the diagnosis in 33 (52%) patients. Of the 30 remaining patients, 10 (33%) had a second biopsy, which was positive in 6 (60%), and 20 (67%) received probabilistic antibiotic therapy. There were 8 positive blood cultures after the first biopsy but, among them, 7 occurred in biopsy-positive patients. Biopsy yield varied with the guidance method (needle guidance software or imaging by computed tomography and/or fluoroscopy) and operators. Antibiotic therapy within the 6months preceding the first biopsy was significantly associated with having a negative first biopsy (15/30 versus 7/33; odds ratio, 3.13; 95% confidence interval, 1.07-9.13; P<0.05). CONCLUSION: In our study, a second needle biopsy was useful, providing the bacteriological diagnosis in 60% of cases of spontaneous diskitis with negative findings from blood cultures and the first biopsy.

Pituitary involvement in granulomatosis with polyangiitis: report of 9 patients and review of the literature.

Pituitary dysfunction is a rare manifestation of granulomatosis with polyangiitis (GPA) (Wegener). The main aim of this multicenter retrospective study was to describe the characteristics and outcomes of pituitary manifestations in patients with GPA included in the French Vasculitis Study Group database.Among the 819 GPA patients included in the database, 9 (1.1%) had pituitary involvement. The median age at diagnosis of GPA and pituitary involvement was 46 and 50.8 years, respectively. Pituitary involvement was present at onset of GPA in 1 case and occurred later in 8 patients after a median follow up of 58.5 months. When pituitary dysfunction occurred, 8 patients had active disease at other sites including ENT (n = 6), eye (n = 4), or central nervous system (n = 3) involvement. The most common hormonal dysfunctions were diabetes insipidus (n = 7) and hypogonadism (n = 7). Magnetic resonance imaging was abnormal in 7 patients. The most common lesions were an enlargement of the pituitary gland, thickening of the pituitary stalk, and loss of posterior hypersignal on T1-weighed images. All patients were treated with corticosteroid therapy and 8 patients received immunosuppressive agents for the pituitary involvement, including cyclophosphamide (n = 3), rituximab (n = 2), and methotrexate (n = 3). After a median follow-up of 9.2 years, GPA was in complete remission in 7 patients, but 8 patients were still under hormone replacement therapy. Among the 5 patients who had a subsequent MRI, 2 had complete resolution of pituitary lesions.By combining our study and the literature review, the frequency of hypogonadism and diabetes insipidus, among the patients with pituitary dysfunction, can be estimated at 78% and 71% respectively. Despite a high rate of systemic disease remission on maintenance therapy, 86% of the patients had persistent pituitary dysfunction. The patients who recovered from pituitary dysfunction had all been treated by cyclophosphamide.Pituitary disease in GPA occurs mostly several months or years after diagnosis. There is no correlation between hormonal, radiologic, and systemic outcome. Although immunosuppressive drugs improve the systemic disease, hormonal deficiencies usually persist. It is therefore important to shorten diagnostic delays and treat these patients early in the course of disease before irreversible damage occur.

Discitis and sacroiliitis diagnosed 15 years after iatrogenic Mycobacterium xenopi inoculation.

A patient was diagnosed with discitis and sacroiliitis due to Mycobacterium xenopi. He had a history of percutaneous nucleotomy performed 15 years earlier (in 1992) at the Clinique du Sport, Paris, France, during an outbreak of nosocomial M. xenopi infection at that institution. In 1997, magnetic resonance imaging performed as part of the routine follow-up program for patients who had surgery at the Clinique du Sport during the outbreak was not interpreted as indicating discitis; this assessment was confirmed by our review of the images. Bone and joint infections due to atypical mycobacteria are rare and can develop very slowly. To our knowledge, this is the first reported case of M. xenopi discitis with secondary extension to the sacroiliac joint in an immunocompetent patient.

Single-photon emission computed tomography combined with computed tomography (SPECT/CT) in bone diseases.

Radionuclide bone scanning was proven effective many years ago. Its main advantages are good sensitivity, limited radiation exposure, and noninvasiveness. However, increased radionuclide uptake by a lesion is not specific, and differentiating malignant from nonmalignant disorders may therefore be difficult. An additional structural imaging study is often needed to establish the final diagnosis. Furthermore, the limited resolution of radionuclide bone scanning images does not allow accurate localization of the lesions. Single-photon emission computed tomography (SPECT) combined with computed tomography (CT) provides both structural and functional information. SPECT/CT has been proven useful for interpreting radionuclide bone scan results in patients with bone malignancies, showing far better specificity than planar imaging or SPECT alone, most notably in the evaluation of spinal abnormalities. SPECT/CT provides an accurate evaluation of the site of the lesions and also supplies other information that can be useful in nonmalignant conditions such as injuries, infections, and degenerative disease. Nevertheless, there are only a few published studies on the usefulness of SPECT/CT in nonmalignant conditions. However, SPECT/CT is only starting to become available and may become a routine investigation for a number of rheumatic disorders.

Sarcoid-like granulomatosis in patients treated with tumor necrosis factor blockers: 10 cases.

OBJECTIVE: TNF blockers have been recently evaluated for treating refractory sarcoidosis and could be efficient. However, several cases of sarcoidosis have been diagnosed during anti-TNF therapy. Here, we report the largest series of sarcoid-like granulomatosis following TNF blocker treatment. METHODS: A call for observations of sarcoid-like granulomatosis following TNF blocker treatment was sent to the members of the French 'Club Rhumatismes et Inflammation'. Histological evidence of granulomatosis was required. RESULTS: Observations of 10 patients [seven females; median age 50.5 (range 27-72) years] with sarcoid-like granulomatosis while on anti-TNF treatment were collected: five were treated with etanercept and five with monoclonal antibodies; four patients received TNF blockers for RA and six for SpA. The median delay between anti-TNF agent introduction and granulomatosis diagnosis was 18 (range 1-51) months. Clinical symptoms were mainly pulmonary and cutaneous. Angiotensin-converting enzyme activity was increased in six cases. Lymph-node and/or lung involvement were observed by CT scan of the chest for eight patients. The median delay between drug discontinuation and remission was 6 (range 1-11) months for clinical signs and 6 (range 2-12) months for biological and radiographic findings. Improvement was observed in all patients after drug discontinuation with or without steroids. CONCLUSIONS: Sarcoid-like granulomatosis is rare but not exceptional in patients treated with TNF blockers (approximately 1/2800) and does not seem to be related to gender, rheumatic disease or in our series the type of anti-TNF drug used (monoclonal antibodies or soluble receptor). Discontinuation of anti-TNF usually leads to recovery.

Efficacy of melphalan and prednisone plus thalidomide in patients older than 75 years with newly diagnosed multiple myeloma: IFM 01/01 trial.

PURPOSE: Until recently, melphalan and prednisone were the standards of care in elderly patients with multiple myeloma. The addition of thalidomide to this combination demonstrated a survival benefit for patients age 65 to 75 years. This randomized, placebo-controlled, phase III trial investigated the efficacy of melphalan and prednisone plus thalidomide in patients older than 75 years with newly diagnosed myeloma. PATIENTS AND METHODS: Between April 2002 and December 2006, 232 previously untreated patients with myeloma, age 75 years or older, were enrolled and 229 were randomly assigned to treatment. All patients received melphalan (0.2 mg/kg/d) plus prednisone (2 mg/kg/d) for 12 courses (day 1 to 4) every 6 weeks. Patients were randomly assigned to receive 100 mg/d of oral thalidomide (n = 113) or placebo (n = 116), continuously for 72 weeks. The primary end point was overall survival. RESULTS: After a median follow-up of 47.5 months, overall survival was significantly longer in patients who received melphalan and prednisone plus thalidomide compared with those who received melphalan and prednisone plus placebo (median, 44.0 v 29.1 months; P = .028). Progression-free survival was significantly prolonged in the melphalan and prednisone plus thalidomide group (median, 24.1 v 18.5 months; P = .001). Two adverse events were significantly increased in the melphalan and prednisone plus thalidomide group: grade 2 to 4 peripheral neuropathy (20% v 5% in the melphalan and prednisone plus placebo group; P < .001) and grade 3 to 4 neutropenia (23% v 9%; P = .003). CONCLUSION: This trial confirms the superiority of the combination melphalan and prednisone plus thalidomide over melphalan and prednisone alone for prolonging survival in very elderly patients with newly diagnosed myeloma. Toxicity was acceptable.

Infliximab-induced hepatitis: absence of cross-toxicity with etanercept.

We describe a patient presenting with acute hepatitis while receiving infliximab for ankylosing spondylitis. A slight increase in serum aminotransferases was first observed in this patient after 4 infusions of infliximab. The treatment was stopped after the 6th infusion when laboratory work-up revealed a 10-fold increase in serum levels of aminotransferases. A liver biopsy showed interportovenular bridging necrosis with macrophage accumulation consistent with the diagnosis of acute toxic hepatitis. After infliximab discontinuation, hepatic abnormalities resolved and the patient was treated with etanercept for more than 2 years without recurrence of hepatitis. This case underlines the lack of hepatic cross-toxicity between infliximab and etanercept making possible the continuation of anti-TNF-alpha therapy with etanercept in patients who have presented infliximab-related hepatic dysfunction.

[Efficacy of percutaneous laser disc decompression for radiculalgia due to lumbar disc hernia (149 patients)]. / Efficacité de la nucléolyse laser dans le traitement des radiculalgies par hernie discale (149 patients).

OBJECTIVE: To assess the efficacy of percutaneous laser disc decompression for patients with radicular pain due to lumbar disc hernia and to identify factors that may predict outcome. METHODS: The study included all patients treated with percutaneous laser disc decompression from May 2003 through May 2005 at Reims University Hospital and the Courlancy Clinic of Reims. Each patient had previous undergone at least six weeks of conventional medical treatment. The same technique, with either a laser diode or Nd: YAG, was used under endoscopic control and with neuroleptanalgesia. They were seen at 1, 3, 6 and 12 months. The principal evaluation criteria were the course of radicular pain, return to work, and need for surgery. RESULTS: We reexamined 149 patients 1 month after the procedure, 135 after 3 months, 102 after 6 months and 59 a year after the procedure. At a month after surgery, radicular pain had decreased by at least half, and sometimes even completely disappeared in 63.1% of patients at 1 month, 66.6% at 3 months, 73.5% at 6 months, and 83.1% at 12 months, while 24%, 50,4%, 61.2%, and 67.3%, respectively, had returned to work. No patient had serious complications. Finally, 45 of the 149 (30.2%) patients chose to have a traditional surgical procedure after percutaneous laser disc decompression. CONCLUSION: Percutaneous laser disc decompression is effective, noninvasive and well tolerated for patients with radicular pain due to lumbar disc hernia.

Chronic monoarthritis and previous history of cancer: think about synovial metastasis.

Synovial metastases are rare events. Only 37 cases diagnosed by synovial fluid cytologic examination and/or by microscopic investigation of synovial biopsies have been previously reported in the literature. We report another case of shoulder chronic arthritis due to a recurrence of rectal adenocarcinoma and review previous published observations. Generally, this condition carries a poor prognosis with average patients survival of less than 5 months. The possibility of metastatic disease should be considered when an elderly person or patient with a history of previous malignancy presents with a chronic arthritis.

[Tuberculosis during treatment by TNFalpha-inhibitors]. / Tuberculose lors d'un traitement par agents inhibiteurs du TNF alpha.

The clinical forms of tuberculosis that occur during anti-TNFalpha treatment are frequently extrapulmonary or even disseminated and life-threatening. The paradoxical reactions that can occur under appropriate treatment after stopping TNFalpha inhibitors raise the question of an immune restoration phenomenon. Adverse drug reaction reporting and epidemiologic studies, despite their methodological limitations, appear to show an excess risk of tuberculosis. Experimental studies reinforce these data. The French drug agency (Afssaps) has issued guidelines for the prevention and management of tuberculosis occurring under anti-TNFalpha treatment. Analogous guidelines in Spain led to a reduction in the incidence of these cases.

Dexamethasone-based regimens versus melphalan-prednisone for elderly multiple myeloma patients ineligible for high-dose therapy.

Dexamethasone alone increases life expectancy in patients with relapsed multiple myeloma (MM); however, no large randomized study has compared dexamethasone and dexamethasone-based regimens with standard melphalan-prednisone in newly diagnosed MM patients ineligible for high-dose therapy. In the Intergroupe Francophone du Myélome (IFM) 95-01 trial, 488 patients aged 65 to 75 years were randomized between 4 regimens of treatment: melphalan-prednisone, dexamethasone alone, melphalan-dexamethasone, and dexamethasone-interferon alpha. Response rates at 6 months (except for complete response) were significantly higher among patients receiving melphalan-dexamethasone, and progression-free survival was significantly better among patients receiving melphalan (P < .001, for both comparisons), but there was no difference in overall survival between the 4 treatment groups. Moreover, the morbidity associated with dexamethasone-based regimens was significantly higher than with melphalan-prednisone, especially for severe pyogenic infections in the melphalan-dexamethasone arm and hemorrhage, severe diabetes, and gastrointestinal and psychiatric complications in the dexamethasone arms. Overall, these results indicated that dexamethasone should not be routinely recommended as first-line treatment in elderly patients with MM. In the context of the IFM 95-01 trial, the standard melphalan-prednisone remained the best treatment choice when efficacy and patient comfort were both considered. These results might be useful in the context of future combinations with innovative drugs.

Factors useful for predicting survival of myeloma patients in everyday practice. A 10-year study of 148 patients older than 55 years.

OBJECTIVE: The objective of this study was to identify prognostic factors in a uniform population of older patients with myeloma. METHODS: Thirty-one study centers in France included 148 patients who were older than 55 years at diagnosis and were followed up until death or for at least 10 years. The following tests were available for all patients: blood cell counts; serum, and urinary protein electrophoresis; and serum levels of creatinine, calcium, beta2 microglobulin (beta2m), lactic dehydrogenase (LDH), and C-reactive protein (CRP). RESULTS: Mean age was 71.9 years, median survival was 34 months, and mean survival was 47 months. In the univariate analysis, factors significantly associated with higher mortality were male gender (odds ratio [OR], 1-2.12), age older than 70 years (OR, 1.10-2.28), serum albumin<30 g/l (OR, 1.16-3.28), serum creatinine>100 micromol/l (OR, 1.34-2.81), beta2m>6 mg/l (OR, 1.78-4), CRP>6 mg/l (OR, 1.44-3.06), hemoglobin<10 g/dl (OR, 1.8-2.23). In the multivariate analysis, only two factors significantly predicted a higher risk of death: beta2m>6 mg/l (OR=2.439 [1.59-3.76]) and CRP>6 mg/l (OR=1.76 [1.18-2.63). beta2m level was >6 mg/l in 41 (27.7%) patients and CRP was >6 mg/l in 61 (43.6%) patients. Other potential prognostic factors such as chromosome 13 deletion were not investigated because they were not available for all study patients. CONCLUSIONS: The strength of this study is the 10-year follow-up in a uniform patient cohort. beta2m and CRP independently predicted the risk of death.