Tocilizumab controls bone turnover in early polymyalgia rheumatica

ObjectivesThis study explores changes in the bone homeostasis by testing the N-terminal collagen type I extension propeptide (PINP) marker for osteo-formation and the carboxy-terminal region of collagen type I (CTX-I) marker for osteo-resorption in patients taking tocilizumab for polymyalgia rheumatica (PMR).MethodsTwenty patients were included in the prospective open-label TENOR study (Clinicaltrials.gov NCT01713842) and received three monthly tocilizumab infusions, followed by corticosteroids starting at week (W) 12. PINP and CTX-I were tested at inclusion (W0), after tocilizumab but before steroid initiation (W12), at the end of the protocol (W24) and were compared to healthy controls. Information regarding disease activity, bone mineral density using scanographic bone attenuation correlation (SBAC), inflammatory parameters and interleukin (IL)-6 levels were collected during the follow-up of the patients.ResultsPMR patients were characterised by a reduction in bone mineral density and a higher level of CTX-I relative to healthy controls matched in age and sex at baseline. PINP levels increased at W12 (P < 0.001, versus W0) following tocilizumab introduction and CTX-I levels decreased at W24 and after steroid initiation (P = 0.001, versus W0). Such modifications explain the altered correlation observed between PINP and CTX-I at W0 (r = 0.255 at W0 versus r = 0.641 in healthy controls) and its correction after treatment (r = 0.760 at W12 and r = 0.767 at W24). Finally, greater changes in PINP were observed in patients whose circulating IL-6 levels decreased after tocilizumab therapy.ConclusionsControl of bone turnover, in part through the inhibition of the IL-6 axis, is observed during tocilizumab and subsequent steroid treatment of PMR.     

Laparoscopic repair of diastasis recti using the ‘Venetian blinds’ technique of plication with prosthetic reinforcement: a retrospective study

Background  Diastasis is a separation of the two recti due to various reasons, and can be measured as the ‘inter-recti distance’ (IRD). Surgery for diastasis is controversial, while laparoscopic repair has rarely been reported. We describe our method of laparoscopic plication—the ‘Venetian blinds’ technique combined with mesh reinforcement for patients with diastasis of the recti. Materials and methods  A total of 18 patients out of 35 that presented to us were operated. The common indications were cosmesis and discomfort while performing normal activities. Laparoscopic plication with the ‘Venetian blinds’ technique of the diastasis with prosthetic reinforcement was performed for all cases. Results  The mean body mass index (BMI) was 28.6 kg/m² (range 25–32.2) and obese patients had a larger IRD. The mean operating time was 113 min (range 72–154). Minor complications were present in five (27.77%) patients. The recurrence rate after 6–48 months follow up was 0% in this series. Discussion  Even though surgery for diastasis is controversial, we advocate repair for cosmesis and restoring function of the recti muscles. Our ‘Venetian blinds’ technique provides a solid repair and reduces the risk of seroma. The use of a prosthesis for the repair is mandatory to prevent recurrence. The adequacy of repair was assessed by measuring the IRD preoperatively and postoperatively with computed tomography (CT) scan. Laparoscopy provides all of the benefits of minimal access surgery.     

Liver tumor ablation: Percutaneous and open approaches

The global incidence of liver cancer is greater than a million cases a year. Surgical resection where applicable is still the standard of care for these patients. Various liver‐directed regional therapies have been developed in an effort to treat the vast majority of unresectable liver tumors. This article reviews the principles behind various ablation therapies currently available for malignant liver tumors and their outcomes. J. Surg. Oncol. 2009;100:619–634. © 2009 Wiley‐Liss, Inc.     

Incidence and Mortality of Physician-Diagnosed Primary Sjögren Syndrome: Time Trends Over a 40-Year Period in a Population-Based US Cohort

Objective

To estimate the incidence and mortality rates, and their evolution over time, of physician-diagnosed primary Sjögren syndrome (pSS) in residents of Olmsted County, Minnesota.

Sleep disorders in patients with postural tachycardia syndrome

Objective

Patients with postural tachycardia syndrome (POTS) often describe symptoms of fatigue, sleepiness, and lack of refreshing sleep. We aimed to provide further objective measures of sleep in patients with POTS.

Methods

POTS patients (n = 18) were selected based on autonomic testing and evaluation at our center. Controls (n = 16) of similar age, gender, and BMI were selected from new patients referred to the Stanford Sleep Disorders Clinic for any sleep-related complaint. All patients underwent polysomnography and completed several sleep questionnaires and a 2-week sleep diary.

Results

POTS patients and control subjects were of similar age (27 ± 10.2 vs. 29 ± 5.4 years, p = 0.92) and Body Mass Index (21 ± 3.8 vs. 24 ± 4.1, p = 0.14). The majority of subjects in both groups were females (72 % POTS vs. 81 % controls). POTS patients scored higher on subjective fatigue scales but not sleepiness scales. POTS patients scored in the normal range on the BDI and the “evening” category on the MEQ. Their sleep diaries were not different from controls. With the exception of mild OSA, slightly reduced %REM and prolonged REM latency, their PSG data were normal and no different from controls.

Conclusions

It is unlikely that the sleep-related complaints of POTS patients are the result of a primary sleep disorder unique to POTS. We propose that a combination of factors such as body fatigue, chronic pain, and other somatic symptoms common in POTS patients might be the underlying reason for sleep-related symptoms in POTS.

     

Knee and hip radiographic osteoarthritis predict total hip bone loss in older adults: A prospective study

The relationship between osteoarthritis (OA) and osteoporosis remains controversial. This study was designed to determine the association between hip and knee radiographic OA and change in total hip bone mineral density (BMD) over 2.6 years. A total of 867 population‐based randomly selected subjects (mean age 62 years, range 51 to 80 years, and 49% female) were included. Hip and knee joint space narrowing (JSN, 0 to 3) and osteophytes (0 to 3) in both lower limbs was assessed using Altman's atlas. Total hip BMD was measured by dual‐energy X‐ray absorptiometry (DXA). We found that radiographic OA (score of JSN or osteophytes > 0) was common in this sample (hip 45%, knee 68%). In multivariable analyses, percentage change in total hip BMD per year was predicted by right and left hip axial JSN (β = –0.25% and –0.29% per grade, respectively, both p < .05), right hip superior femoral osteophytes (grades 2 and 3 versus 0: β = –1.60, p < .05), combined right and left knee tibiofemoral JSN (β = –0.06 per grade from grades 0 to 12, p < .05), and osteophytes (β = –0.06 per grade from grades 0 to 14, p < .05) independent of each other and joint pain. In conclusion, older subjects with radiographic hip and knee OA have higher total hip bone loss over 2.6 years regardless of symptoms, suggesting that consideration should be given to the monitoring of bone mass in these subjects. © 2010 American Society for Bone and Mineral Research.