Discontinuation of biologic therapy in patients with rheumatoid arthritis and ankylosing spondylitis: analysis from multicenter cohort study.

Despite of the availability of several effective bDMARDs, a significant proportion of rheumatoid arthritis (RA) and ankylosing spondylitis (AS) patients discontinued bDMARDs. The aims of this study were to analyze causes of bDMARDs discontinuation in RA and AS included in the Moroccan registry RBSMR. A historical prospective multicenter cohort study based on the RBSMR database at 12 months of follow-up, which included 225 RA and 170 AS. Using T student, Mann-Whitney U, chi-squared or Fischer exact tests, baseline demographic and clinical features were compared between patients discontinuing bDMARDs and patients remaining on initiated bDMARDs or switching bDMARDs. Logistic regression models were used to identify factors associated with drugs discontinuation. 61 RA discontinued bDMARDs and 47 AS interrupted anti-TNF. The most common reasons for drugs discontinuation were adverse events (7.5%) in RA patients and social security reimbursement problems (16.8%) in AS. RA patients discontinuing bDMARDs were more frequently first-line biological drugs users, more frequently female and had more comorbidities and lower DAS28 CRP than RA patients remaining on initiated bDMARDs or switching bDMARDs (p < 0.001, p = 0.01, p < 0.001 and p < 0.001 respectively). Female sex and comorbidities were the significant predictors of bDMARDs discontinuation in RA patients. Higher baseline BASDAI had a protective role on anti-TNF interruption in AS patients. Adverse events and social security reimbursement problems were the main reasons for drugs discontinuation in RA and AS patients respectively. Female sex and comorbidities in RA patients, baseline BASDAI in AS patients impacted bDMARDs discontinuation in real-life settings.

Nonresonant Polarized Raman Spectra Calculations of Nitrogen-Doped Single-Walled Carbon Nanotubes: Diameter, Chirality, and Doping Concentration Effects.

Raman spectra of nitrogen-doped single-walled carbon nanotubes are calculated using the spectral moment's method combined with the bond polarizability model. The influence of the nanotube diameter and chirality is investigated. We also address the important question of the effect of the N-doping concentration, and we propose an equation to estimate the doping concentration from the knowledge of the tube diameter and the frequency of the radial breathing mode.

Sarcopenia in rheumatoid arthritis: prevalence, influence of disease activity and associated factors.

Evaluate the prevalence of sarcopenia on patients with rheumatoid arthritis (RA), the influence of sarcopenia on disease activity and factors associated with sarcopenia. One hundred and twenty-three patients aged over 18 years with RA based on the 1987 ACR/EULAR classification criteria were enrolled. We performed a whole body DXA scan using a dual-energy X-ray absorptiometry (DXA) scanner lunar prodigy to measure fat mass, lean mass, and bone mass in the whole body and body parts. According to the anthropometric equation by Baumgartner et al., sarcopenia was defined as Relative skeletal mass index (RSMI) <5.5 kg/m2 on women and <7.26 kg/m2 on men. Body mass index (BMI) and waist circumference were measured and patients were classified according to World Health Organization. Disease activity was evaluated by: disease activity score 28 ESR (DAS28 ESR), disease activity score 28 CRP (DAS28 CRP), clinical disease activity index (CDAI), simplify disease activity index (SDAI). We measured functional disability by Health assessment questionnaire (HAQ). History and previous medication use including steroids were also checked, and comorbidities were recorded. We analyzed the relation between disease parameters and sarcopenia with the r of Pearson and Spearman. Factors associated and related to sarcopenia were assessed using multiple regression analysis and t independent test. We included 123 patients (107 women). 49 subjects (39.8%) where suffering from sarcopenia, of which 40 women. Most of the sarcopenic patients were between 41 and 50 years old. Sarcopenia on female subjects was not related to parameters of disease activity evaluated by DAS 28, CDAI and SDAI. Most of the sarcopenic patients had normal BMI and abnormal waist circumference. In simple regression analysis sarcopenia was related to BMI, DAS 28 ESR, bone erosion, waist circumference and HAQ. In multiple regression analysis, sarcopenia was positively related to an increase cardiometabolic risk [p = 0.025, OR 0.176, CI (0.038-0.980)], normal BMI [p = 0.004, OR 12.3, CI (2.27-67.6)], over fat BMI [p = 0.004, OR 12.3, CI (2.27-67.6)] and bone erosion [p = 0.012, OR 0.057 CI (0.006-0.532)]. No statistical difference was found according to disease duration and steroids use between sarcopenic and non sarcopenic patients. Sarcopenia is prevalent and related to age, bone erosion, normal/over fat BMI and high cardiometabolic risk according to waist circumference but not with disease activity.

Prevalence and severity of insomnia in chronic low back pain patients.

The purpose of this study was to assess prevalence and severity of insomnia in participants diagnosed with chronic low back pain (CLBP) and to identify factors associated with this insomnia. One hundred CLBP consenting participants were recruited. Sociodemographic, CLBP features and sleep characteristics were collected. Patients answered validated measures of insomnia severity and fatigue. Statistical analysis examined the relationship between insomnia, sociodemographic characteristics of patients and CLBP parameters. Seventy-eight percent of patients suffered from insomnia. Insomnia due to back pain was reported in 64 % of cases. Insomnia was early, middle and late in, respectively, 39, 60 and 41 % of patients. Insomnia was sub-threshold, moderate and severe in, respectively, 34, 42 and 2 % of patients. ISI Global score was at 18.07 ± 7.3. ISI correlated significantly with pain intensity (r = 0.587; p < 0.0001), fatigue level (r = 0.495; p < 0.0001) and body mass index (r = -0.209; p = 0.03). Multiple linear regression models have revealed that pain intensity (ß = 1.984; 95 % CI (1.517-2.451); p < 0.0001) and fatigue (ß = 0.284; 95 % CI (0.192-0.377); p < 0.0001) were the strongest determinants for predicting insomnia in CLBP patients. Our study suggests that the prevalence of insomnia is important in CLBP patients, occurring especially at the middle of sleep. Insomnia was essentially sub-threshold or moderate. Back pain and fatigue experienced by patients were the strongest factors associated with this insomnia.

Evaluation and stability of the Patient Acceptable Symptom State (PASS) over time in patients with ankylosing spondylitis.

OBJECTIVES: The Patient Acceptable Symptom State (PASS) is the value beyond which patients consider themselves well. Our aim was to determine the PASS estimate for patients with AS by assessing pain, disease activity and functional impairment and evaluate whether the PASS is stable over time. METHODS: A 4-week prospective study of patients with AS was carried-out. The PASS was estimated at week 2 and 4 for the following patient reported outcomes: global and nocturnal pain measured on a visual analogue scale, disease activity (BASDAI), and functional impairment (BASFI). We used an anchoring method based on patients answering yes or no to, 'is your current condition satisfactory, when you take your general functioning and your current pain into consideration?' The PASS was defined as the 75th percentile of the score for patients who considered their state satisfactory. Pearson's chi square and binary logistic regression were used to analyse the data. RESULTS: A total of 200 patients were recruited of whom 110 (55%) were in PASS. The PASS estimates were 60 mm for global pain, 40 mm for night pain, 4.0 for BASDAI and 4.3 for BASFI. These PASS values were stable over time for all criteria except for pain. Significant contributors to PASS were low functional impairment ([BASFI]; p<0.001), low pain intensity (p=0.02), intensive physical activity (p=0.004) and high educational level (p=0.01). CONCLUSIONS: A high percentage of Moroccan patients with AS (55%) reported being in PASS. PASS threshold for pain was unexpectedly high, possibly suggesting a high level of patients' tolerance to pain.

The prevalence of vertebral fractures and health-related quality of life in postmenopausal women.

Vertebral fractures are the hallmark of osteoporosis, responsible for increased back pain, impairment of mobility and functional limitations. These factors have an impact on patients' health-related quality of life (QOL). The aim of this study was to evaluate the prevalence of vertebral fractures in Moroccan postmenopausal women and to assess their QOL, using an Arabic validated version of QUALEFFO. The study recruited 347 postmenopausal women in obvious good health. We excluded women who had used a drug or who had chronic diseases affecting bone metabolism. All patients had density measurements and spinal radiography. Each vertebral body (T4-L5) was graded using the semiquantitative method of Genant. The mean age was 60 years. Forty-six percent of patients had at least one vertebral fracture. The prevalence ranged from 31% in patients 50-55 years to 69% in patients 65 years and older. Patients with vertebral fractures were older (61.6 ± 8 vs 57 ± 7 years, P < 0.001), had more frequent history of nonvertebral fractures, and had spine and hip BMD values significantly lower (P < 0.001) than patients without vertebral fractures. In multivariate analysis, older age and a history of nonvertebral fractures were the two independent clinical factors of vertebral fractures. The number of fractures was a determinant of a low QOL, as indicated by an increased score in physical function, social function, mental function, and general health [for all (P < 0.05)]. Patients with higher grades of vertebral deformities, i.e., more severe fractures, had low QOL in these four domains. Patient with thoracolumbar fractures had a worse general health than patients with thoracic or lumbar fractures. We found a high prevalence of vertebral fractures probably explained by socioeconomic factors in Morocco. QOL, assessed by an osteoporosis-specific instrument, is decreased in postmenopausal women as a function of both the number and the severity of the vertebral fractures. Treating women with prevalent fractures may avoid a further decrease in their quality of life.

Primary non-Hodgkin's lymphoma presenting as radicular syndrome: report of two cases.

We report two cases of primary Non-Hodgkin's Lymphoma in the spine leading to radicular compression secondary to infiltration of lumbar body vertebras. The two patients were free of either nodular or other extra-nodular disease. Treatment consisted of chemotherapy alone, one patient have had a cauda equina syndrome and surgical decompression was performed in emergency. The patients were in remission for 20 months after diagnosis. A review is given for the incidence of primary vertebral localization of lymphoma, its diagnosis, treatment and prognosis.

[Complete auriculoventricular block during chloroquine treatment]. / Bloc auriculoventriculaire complet au cours d'un traitement par chloroquine.

INTRODUCTION: The cardiac toxicity of antimalarial agents is rare, it includes conduction disorders which can be complicated by third atrioventricular block and hypertrophic cardiomyopathy. We report two observations of patients who presented a complete heart block after several years of treatment by chloroquine. CASE REPORT: Two patients followed for rheumatoid polyarthritis, treated by antimalarial agents for average 12 years and corticotherapy, presented a syncopal complete heart block which required an implantation of a pace maker. After having eliminated all the other underlying causes for complete heart block, the antimalarial agents were accused and were stopped. The clinical evolution after interruption of the treatment was favorable. CONCLUSION: Our observations illustrate rare cardiac side effects observed in our two patients after long-term treatment by antimalarial agents. The diagnosis of antimalarial agents responsibility was retained on clinical and biological arguments after having eliminated the other causes. The insidious character of these complications imposes vigilance during the use of long-term treatment by antimalarial agents.

[Leukemia revealed by polyarthritis]. / Polyarthrites révélatrices d'une leucémie.

INTRODUCTION: Ostéoarticular manifestation whose reveal leukaemia in 4% of the cases, regress completely with haematological remission. EXEGESIS: We report two observations of leukaemia revealed by polyarthritis. A 22-year-old woman has presented a polyarthritis 8 months before de diagnosis of acute leukaemia. A 34 years old men, has presented one month before admission an acute polyarthritis revealing chronic myeloid leukaemia. CONCLUSION: Polyarthritis may reveal an acute or chronic leukaemia. Systematic blood analysis can make a difference in diagnosis of recent polyarthritis.

[Cardiac manifestations of idiopathic hypereosinophilic syndrome]. / Manifestations cardiaques du syndrome hyperéosinophilique essentiel.

BACKGROUND: The aim of our study is to describe the more common cardiac manifestations of idiopathic hypereosinophilic syndrome representing the major cause of mortality. MAIN POINTS: Current therapy consists of corticosteroid, hydroxyurea and interferon alpha. Recent publications confirm the activity of imatinib mesylate, a selective tyrosine kinase inhibitor, in patients with idiopathic hypereosinophilic syndrome. In cases with marked valvular compromise or with endomyocardial thrombosis or fibrosis, cardiac surgery can provide substantial benefits. PERSPECTIVES: A better understanding of the pathophysiology of this syndrome could lead to the development of new therapeutic agents.

[Bilateral uveitis in relapsing polychondritis. A case report]. / Uvéite bilatérale au cours d'une polychondrite atrophiante. A propos d'une observation.

We report a rare ocular manifestation of relapsing polychondritis. A 28-year-old woman presented with a 5-year history of relapsing polychondritis with chondritis of the nose, ears and tracheobronchial system. The ocular symptoms were bilateral uveitis with macular involvement and papillaedema. Ocular manifestations of relapsing polychondritis occur in 60% of patients. Uveitis is a rare symptom, sometimes severe, which can lead to blindness. This case report with a literature review sheds light on the features of this disease.

Atlantoaxial tuberculosis: three cases.

Tuberculosis of the craniocervical junction (CCJ) is exceedingly rare but carries a risk of compression of the medulla oblongata and upper spinal cord. Three cases among 63 patients with spinal tuberculosis are reported. Mean age was 51 years (range, 20-69) and mean time to diagnosis was 4.6 months (range, 1-8). Although atlantoaxial dislocation was a consistent feature, none of the patients had neurological deficits. Computed tomography of the CCJ disclosed a suggestive pattern combining osteolysis and an abscess anterior to the spine. The diagnosis was confirmed by microbiological studies in two cases and histology in one. The outcome was favorable after antituberculous therapy, immobilization of the neck, and surgical fusion. Although tuberculosis remains common in developing countries, involvement of the CCJ is rare. Tuberculosis of the CCJ carries a risk of instability and severe neuraxis compression. Consequently, early diagnosis and treatment are of the utmost importance.

[Childhood Behçet's disease: clinical and evolutive aspects. About 13 cases]. / La maladie de Behçet chez l'enfant, aspects cliniques et évolutifs Agrave; propos de 13 cas.

INTRODUCTION: Behçet's disease is a systemic vasculitis which rarely occurs in childhood. The aim of this study was to evaluate clinical characteristics and outcome of Behçet's disease in Moroccan children. MATERIAL AND METHODS: A retrospective study of 13 cases of children, 10 males and 3 females with Behçet's disease followed up between 1990 and 1998. The diagnosis of Behçet's disease was based on the criteria of the international study group for Behçet's disease. All patients were studied by a complete clinical, ophthalmological and laboratory staging and treated with appropriate therapy. RESULTS: The mean age at diagnosis of Behçet's disease was 13.9 years. Familial forms were found in 30.7% of cases. Oral aphtae were noted in all cases while genital ulcers were present in 76% of cases. Cutaneous lesions were found in only 1 case and 53.8% of children had a pathergy test. Articular involvement was found in 30.7%, neurological features in 46% and vascular manifestations in 38.4%. Only one case of intestinal involvement was noted. Ocular features (76%) were bilateral in all cases and were dominated by panuveitis complicated by macular edema ant retinal vasculitis. CONCLUSION: Behçet's disease seems to have particular characteristics in childhood. Familial forms, articular and digestive manifestations appear to be more frequent in early stages of Behçet's disease in children. Neurological and vascular involvement with panuveitis seems more frequent in the older children.

[Pubic tuberculous osteo-arthritis. Apropos of 2 cases]. / L'ostéoarthrite pubienne tuberculeuse. A propos de deux cas.

OBJECTIVE: The authors report an exceptional site of tuberculous osteo-articular infection which must be diagnosed before the destructive stage. OBSERVATIONS: Case 1 : a 21 years old woman presented an inflammatory pubic pain after a trauma with weight loss of 4 kgs in 3 weeks. She presented also 2 satellite inguinal nodes. Erythrocyte sedimentation rate (ESR) was elevated, X-rays showed an important osteolysis of the left ischio-pubic rami, tuberculous skin test (TST) was positive, mycobacterium tuberculosis (MT) could not be found neither in sputtum nor in urine but the node biopsy showed the specific features of tuberculosis. Evolution under a 6 months antibiotic treatment was good. Case 2 : a 19 years old woman, with history of tuberculous contagion, presented in April 1996 cervical nodes and a month later inflammatory pubic and knee pain with weight loss and vesperal sudation. ESR was elevated, TST was phlyctenular, MT searching and HIV serology were negative. X rays showed irregular osteolysis of the pubic symphysis. Scintigraphy showed an increased fixation of pubis and left knee. Cervical nodes biopsy diagnosed tuberculosis. Evolution was good under a 6 months antibiotic treatment. DISCUSSION: Many factors can favorize the development of a pubic tuberculosis and are similar for all forms of tuberculous osteo-articular infection (trauma and contagion in our cases). Radiological features, characterized by a slow evolution, are note specific. Diagnostic confirmation must be bacteriologic or pathologic, and if possible far from the pubic foci. Any traumatic medical procedure has to be avoided because of painful outcome and local risk. Evolution under specific treatment, even of short course (6 months), is sufficient for a good outcome. CONCLUSION: One must think to pubic tuberculous osteo-arthritis in any pubic pain even if it is post-traumatic especially, in endemic countries of tuberculosis.

Discussing sexual concerns with chronic low back pain patients: barriers and patients' expectations.

This study aims to explore patient's concerns when discussing sexual problems caused by chronic low back pain with their healthcare provider. It also aims to identify factors influencing and limiting such communication. A cross-sectional analysis of 100 consenting chronic low back pain sexually active patients was carried out. Patients answered questions on their disease characteristics and sex life. They also mentioned prohibitions of discussing sex with their healthcare provider and their expectations of such discussion. Factors influencing patient's experiences were analyzed. Median of chronic low back pain duration was 36 (24-72) months and back pain intensity using visual analogical scale (0-100 mm) was 50 ± 10.7 mm. Eighty-one percent of our patients complained of sexual problems, 66 % have never discussed the subject with their healthcare provider. Barriers which prevent discussion on sex include the taboo character of the topic, inappropriateness of visit conditions, and patient disinterest in sex. Ninety-three percent of patients expressed the need of sexual problems' management in chronic low back pain consulting. Seventy-four percent expected information and advice from their healthcare provider about recommended intercourse positions so as to avoid pain. Thirty-three percent of patients wanted their partner to be involved in the discussion and 81 % preferred talking with a healthcare provider of the same gender. Ability to communicate on the topic was associated with the decrease of patient sexual satisfaction and limited by patient illiteracy. Our study evidences that sex discussion between patient and healthcare provider is restricted by several barriers and that patients expect more involvement from their healthcare provider on the subject. Illiteracy and level of sexual satisfaction seem to be the strongest factors influencing this communication.

[Antibiotic susceptibility of Staphylococcus aureus strains isolated in two university hospitals in Rabat, Morocco]. / Sensibilité aux antibiotiques des souches de Staphylocoques aureus isolées dans deux hôpitaux universitaires à Rabat, Maroc.

OBJECTIVES: The aim of this study was to assess the in vitro activity of several antimicrobial agents against Staphylococcus aureus (S. aureus). METHOD: This 2 year study was made in two Moroccan teaching hospitals. Four hundred and sixty-one non-repetitive clinical S. aureus strains were isolated and collected from various samples collected in several units between March 2006 and March 2008. The susceptibility of strains was determined by the agar disk diffusion method. RESULTS: The rate of methicillin resistance was 19.3% for S. aureus isolates. 53.93% of S. aureus strains were resistant to gentamycin, and all strains were susceptible to glycopeptides. CONCLUSION: The rate of MRSA was high. Resistance to methicillin is often associated with resistance to gentamycin and fluoroquinolones. Vancomycin and teicoplanin were still effective on S. aureus in the two university hospitals.

Increase in bone mineral density of patients with spondyloarthropathy treated with anti-tumour necrosis factor alpha.

OBJECTIVE: To determine the changes in bone mineral density (BMD) in patients with spondyloarthropathy (SpA) treated with infliximab. PATIENTS AND METHODS: 29 patients (six women; 23 men) aged 22-68 years, with persistently active SpA despite a high dose of non-steroidal anti-inflammatory drug and/or treatment with methotrexate or sulfasalazine, were studied. Median duration of disease was 13 years (range 3-30). Twenty five patients were treated with 5 mg/kg and four with 3 mg/kg of infliximab at weeks 0, 2, 6 and then received either no infusion (n=3), or additional infusion of infliximab every other month (n=6), and the remainder received one infusion only in the case of a relapse. Lumbar and femoral BMD was measured by dual energy x ray absorptiometry at baseline and six months later. Serum osteocalcin and urinary deoxypyridinoline were measured in 19 patients at weeks 0, 2, 24, and in 13 patients at all visits. RESULTS: In six months there was a significant increase in BMD at the spine (3.6%, p=0.001), total hip (2.2%, p=0.0012), and trochanter (2.3%, p=0.0012). A trend for increase (1.1%) was observed at the femoral neck. There was an increase in osteocalcin between baseline and week 6 (third infusion)-median 1.45 micro g/l (p=0.013). No change in marker of bone resorption was observed at the same time. There was no change in biochemical markers between baseline and final visits. There was a trend for a correlation between the decrease at six months in erythrocyte sedimentation rate, and lumbar spine BMD change (r(s)=-0.35, p=0.06). CONCLUSION: These data suggest that a benefit of anti-tumour necrosis factor alpha therapy on BMD in patients with SpA may be through an uncoupling effect on bone cells.

[Results of oocyte donation in women with different indications, ages and therapeutic strategies]. / L'analyse des résultats du don d'ovocyte en fonction de l'indication, de l'âge et de la stratégie thérapeutique.

PURPOSE: Compare the effectiveness of oocyte donation for various indications, ages and treatments. METHODS: Retrospective analysis of 319 transfers for 184 couples (243 with fresh embryos and 76 with frozen embryos). Transfers are divided into: -7 groups according to indication: premature ovarian failure (POF) with normal caryotype n = 122, surgical POF n = 26, postchemotherapy and postradiation therapy POF n = 23, genetic disease carrier n = 11, IVF failure n = 69, primary amenorrhea n = 58, POF with abnormal caryotype n = 10. -2 groups according to the recipient's age (Group I < or = 40 years, Group II > 40 years); -3 groups according to the dose and the mode of administration of the treatment. Oocytes were donated by volunteer donors of less than 38 years having at last one child. RESULT: According to the recipient's age 31.3% clinical pregnancies (CP) and 24.2% ongoing pregnancies (OP) for group I, versus 19.4% CP and 11.9% OP for group II. The results according to the indication were similar except for postchemotherapy and postradiation therapy POF for which the rate of CP as well as the rate of OP were particularly low. For the treatment groups there is a significant reduction of CP and OP as the treatment dose increases. CONCLUSION: The recipient's age plays an important role for the development of pregnancy and this shows that apparently uterine ageing also plays an undeniable role for the decline of female fertility. Increasing doses of estradiol reduces the rate of CP and OP. Postchemotherapy and postradition therapy POF has much lower results than other indications.

Behçet's disease in Moroccan children: a report of 12 cases.

We report 12 cases of Behçet's disease (BD) in children. The mean age of symptom onset was 12.4 years. Four patients (33.3%) had a past familial history of BD. Clinical manifestations were: oral aphtosis (n = 12), genital aphtosis (n = 9), ocular involvement (n = 9), neuro-Behçet (n = 6), venous thrombosis (n = 4), articular involvement (n = 3), and entero-Behçet (n = 1). All patients but one were initially treated with steroids; three cases with ocular involvement were treated with chlorambucil; and three other cases of neuro-Behçet were treated with cyclophosphamide. After a mean follow-up of 4 years, four patients with neurological involvement developed steroid-dependence with recurrence of symptoms. Four patients had optic atrophy with blindness.