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Seror R.,University Paris - Sud | Seror R.,University of Paris Descartes | Seror R.,Lille 2 University of Health and Law | Seror R.,Nimes University Hospital Center | Seror R.,Center Hospitalier Valenciennes
Annals of the rheumatic diseases | Year: 2014

OBJECTIVES: To evaluate the effect of adding a 10-week treatment of adalimumab to a standardised treatment with corticosteroids on the ability to taper more rapidly corticosteroid doses in patients with newly diagnosed giant cell arteritis (GCA).METHODS: Patients included in this double-blind, multicentre controlled trial were randomly assigned to receive a 10-week subcutaneous treatment of adalimumab 40 mg every other week or placebo in addition to a standard prednisone regimen (starting dose 0.7 mg/kg per day). The primary endpoint was the percentage of patients in remission on less than 0.1 mg/kg of prednisone at week 26. Analysis was performed by intention to treat (ITT).RESULTS: Among the 70 patients enrolled (adalimumab, n=34; placebo, n=36), 10 patients did not receive the scheduled treatment, seven in the adalimumab and three in the placebo group. By ITT, the number of patients achieving the primary endpoint was 20 (58.9%) and 18 (50.0%) in the adalimumab and placebo arm, respectively (p=0.46). The decrease in prednisone dose and the proportion of patients who were relapse free did not differ between the two groups. Serious adverse events occurred in five (14.7%) patients on adalimumab and 17 (47.2%) on placebo, including serious infections in three patients on adalimumab and five on placebo. Two patients died in the placebo arm (septic shock and cancer) and one in the adalimumab group (pneumonia).CONCLUSIONS: In patients with newly diagnosed GCA, adding a 10-week treatment of adalimumab to prednisone did not increase the number of patients in remission on less than 0.1 mg/kg of corticosteroids at 6 months.CLINICAL TRIAL REGISTRATION NUMBER: NCT00305539. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Guedj A.M.,Nimes University Hospital Center
Diabetes & metabolism | Year: 2010

To consider the arguments for screening outside the standard screening period of 24 to 28 weeks of gestation. A search of the literature between 1990 and 2010 was performed using the PubMed® and Cochrane® databases. Recommendations from learned societies in diabetology and obstetrics & gynaecology were consulted. Gestational diabetes mellitus screening is classically recommended between weeks 24 and 28 of pregnancy, the period during which glucose tolerance deteriorates. However, the increasing prevalence of type 2 diabetes in women of childbearing age with risk factors requires earlier screening. Fasting blood glucose should be measured at the fi rst visit during early pregnancy for these patients. The diagnostic threshold is the same as for patients who are not pregnant, i.e. blood glucose > 1.26 g/l. However, the benefit of screening for gestational diabetes during early pregnancy for women with risk factors has not been supported by prospective studies. Therefore oral glucose tolerance testing during early pregnancy is not currently recommended for the detection of gestational diabetes. Screening for gestational diabetes, regardless of the recommended screening policy, must be performed between weeks 24 and 28 of pregnancy. There are no reasons to consider subsequent screening for gestational diabetes at a later stage.

Corbeau P.,Nimes University Hospital Center | Corbeau P.,French National Center for Scientific Research | Corbeau P.,Montpellier University | Reynes J.,Montpellier University | Reynes J.,Montpellier University Hospital Center
Blood | Year: 2011

Although highly active antiretroviral therapy has enabled constant progress in reducing HIV-1 replication, in some patients who are "aviremic" during treatment, the problem of insufficient immune restoration remains, and this exposes them to the risk of immune deficiency-associated pathologies. Various mechanisms may combine and account for this impaired immunologic response to treatment. A first possible mechanism is immune activation, which may be because of residual HIV production, microbial translocation, co-infections, immuno-senescence, or lymphopenia per se. A second mechanism is ongoing HIV replication. Finally, deficient thymus output, sex, and genetic polymorphism influencing apoptosis may impair immune reconstitution. In this review we will discuss the tools at our disposal to identify the various mechanisms at work in a given patient and the specific therapeutic strategies we could propose based on this etiologic diagnosis. © 2011 by The American Society of Hematology.

Sexual dysfunctions are a quality of life main concern following prostate cancer treatment. After both radiotherapy and brachytherapy, sexual function declines progressively, the onset of occurrence of erectile dysfunction being 12-18 months after both treatments. The pathophysiological pathways by which radiotherapy and brachytherapy cause erectile dysfunction are multifactorial, as patient comorbidities, arterial damage, exposure of neurovascular bundle to high levels of radiation, and radiation dose received by the corpora cavernosa at the crurae of the penis may be important in the aetiology of erectile dysfunction. Diagnosis and treatment of postradiation sexual dysfunctions must integrate pretherapeutic evaluation and information to provide to the patient and his partner a multidisciplinary sexual medicine management. © 2010 Société française de radiothérapie oncologique (SFRO).

Nourissat C.,Christian Nourissat | Essig J.,Clinique MedipOle Garonne | Asencio G.,Nimes University Hospital Center
Journal of Arthroplasty | Year: 2013

We have evaluated 90 consecutive primary cementless ABG II total hip replacements. The bearings combined metal-on-polyethylene in 64 hips, and alumina-on-alumina in 26 hips. At the minimum 8-year follow-up, ten patients had died, seven had been lost to follow-up, two had undergone revision of either or both components, and 68 were still alive and had not been revised. With revision for any reason as the endpoint, the cumulative survival rate at 10. years was 97.5%±1.7%, and 98.7%±1.3% for the metal-back cup and the femoral component, respectively. No hip showed peri-acetabular osteolysis. The ABG II total hip arthroplasty has demonstrated favourable clinical and radiological outcomes as well as survival in the current series. Further follow-up is needed to confirm these mid-term results. © 2013 Elsevier Inc..

Borie F.,Nimes University Hospital Center
Surgical endoscopy | Year: 2013

Lesions involving the ampulla of Vater are rare entities (0.1-0.2 %) with high malignant potential (90 %) [1]. As a treatment, the surgical procedure known as duodenopancreatectomy was the main option, whatever the tumor's stage or nature. Yet with improvements of endoscopic diagnostic and therapeutic techniques, management of these lesions has been modified, enabling endoscopic removal of adenoma and adenocarcinoma-in situ. Thus, when endoscopic treatment is not possible, surgical ampullectomy is still an alternative option to duodenopancreatectomy [1, 2]. The continuous improvements in surgical techniques and instruments now allow the safe realization of laparoscopic ampullectomy, despite the few cases described in the literature [3, 4]. Here we present a surgical technique in a 52-year-old patient with an ampulloma. The ampulloma was discovered during a gastroscopy for abdominal pain. The endoscopic ultrasound with biopsy revealed a 15-mm adenoma with moderate-grade dysplasia. The thoracoabdominal CT scan was normal. The procedure was performed as shown. The tumor histology showed a R0 resection (5-mm surgical margin) of an adenoma with focal high-grade dysplasia. At 3-year follow-up, outcomes were unremarkable, without any complications.

Ripoche J.,Nimes University Hospital Center
Journal of visceral surgery | Year: 2011

The prevalence of parastomal hernia (PSH) varies considerably in the literature. This condition impacts negatively on quality of life. Yet there is no surgical consensus concerning treatment. The aim of the study was to determine treatment and recurrence rates of PSH in a large population of ostomy patients. This retrospective study was carried out by a self-administered questionnaire in a population drawn at random from the database of the French federation of ostomy patients (FSF). Seven hundred and eighty-two patients were eligible for the study. The mean duration of follow-up was 10.5 years. PSH was reported by 202 patients (25.6%) and appeared on average 18 months after creation of the stoma. In multivariate analysis, ileostomy had a lower risk of developing PSH than did colostomy; age mote than 60 years and peristomal complications at the time of stoma creation increased the risk. Only 24% of patients with PSH were free from symptoms related to the hernia. The main complaints were pain (35%), difficulties in fitting a stomal appliance with leakage (28%); 114 patients (56%) underwent operative repair. The morbidity rate of reoperation was 33%, and 57 patients (52%) had recurrence of PSH within an average of 6 months. Transposition of the stoma to another location and the use of prosthetic mesh decreased recidivism AF recurrence? PSH aggravates the inherently diminished quality of life of stoma patients. There are many proposed surgical treatments but recurrence occurs in more than half of patients. Randomized trials on the treatment of PSH are nonexistent. The use of a prosthetic mesh may reduce the risk of recurrence. The prophylactic use of prophylactic mesh at the time of initial stoma formation is a strategy worthy of consideration. Copyright © 2011. Published by Elsevier Masson SAS.

Giuliano F.,University of Versailles | Droupy S.,Nimes University Hospital Center
Progres en Urologie | Year: 2013

Introduction: Erectile dysfunction (ED) is the most commonly studied sexual disorder. ED is defined by a consistent or recurrent inability to attain and/or maintain penile erection sufficient for sexual activity. Methods: Medical literature was reviewed and combined with expert opinion of the authors. Results: A review of ED prevalence is less than 10% in men aged below 50, superior to 20% for men over 60. Age, cardiovascular diseases, diabetes, hypercholesterolemia, smoking, depression and psychiatric illness, psychological disorders, unfavorable socio-economic conditions are all risk factors for erectile dysfunction. Drug sexual side-effects must also be envisaged. Erectile dysfunction can be psychogenic, organic or a mix of both. The pathophysiological mechanisms are diverse and can implicate deterioration of the central or peripheral neural pathways, from the arterial supply to the penis, endothelial dysfunction, smooth muscle tone impairment, structural damage of the sinusoidal spaces of the erectile tissue, or even hormonal disorders. Psychological and sexological management can help some patients suffering from psychogenic erectile dysfunction, usually associated with pharmacological treatment. Phosphodiesterase type 5inhibitors (PDE5i) on demand or daily are an efficient symptomatic treatment in two thirds of patients with all forms of erectile dysfunction. Diabetic patients, after radical prostatectomy and/or with severe cardiovascular diseases respond poorly to PDE5i. Intracavernous injections of PGE1or vacuum pump provide second line treatment for most patients. Penile implants are third line treatment and when the indication is carefully established give excellent results. Discussion: ED work-up and treatment are highly standardized. Therapeutic success rates are high. © 2013 Elsevier Masson SAS.

Giuliano F.,University of Versailles | Droupy S.,Nimes University Hospital Center
Progres en Urologie | Year: 2013

Introduction: Sexual side effects of pharmacologiocal agents are not well known. Methods: Medical literature was reviewed and combined with expert opinion of the authors. Results: Confirmation of a drug iatrogenesis is made by intrinsic imputability based on the clinical history and extrinsic imputability based on published references. First ranking in the list of drugs responsible for adverse sexual effects in both sexes are the selective reuptake inhibitors (SSRI). They can cause erectile dysfunction and ejaculatory disorders, and in both sexes orgasmic and arousal disorders. Among the drugs whose mechanism is primordial are the neuroleptics firstly, among antalgics tramadol and strong opioid agonists are also potentially deleterious to different degrees on sexual function. Among antihypertensive drugs only thiazide diuretics increase the risk of erectile dysfunction. Among alpha blockers tamusolin and silodosin are frequently responsible for anejaculation. On a less serious level, 5α-reductase inhibitors are associated with sexual disorders in men treated for lower urinary tract symptoms (LUTS) linked to symptomatic benign prostatic hypertrophy. LH-RH antagonists and anti-androgens suppress desire in men, tamoxifen reduces this in women and can also cause dyspareunia and vaginal dryness. The drugs responsible for iatrogenic priapism are also described. A correlation between the pathology treated and the responsibility of the drug for sexual dysfunction can coexist. This is the case for depression, psychosis, hypertension, chronic pain and LUTS; sexual dysfunction is part of the clinical picture. Conclusion: Sexual side effects of pharmacological treatments are not unusual and must be systematically surveyed in men and women complaining about sexual dysfunction. © 2013 Elsevier Masson SAS.

Not all patients with core binding factor acute myeloid leukemia (CBF-AML) display a good outcome. Modern risk factors include KIT and/or FLT3 gene mutations and minimal residual disease (MRD) levels, but their respective values have never been prospectively assessed. A total of 198 CBF-AML patients were randomized between a reinforced and a standard induction course, followed by 3 high-dose cytarabine consolidation courses. MRD levels were monitored prospectively. Gene mutations were screened at diagnosis. Despite a more rapid MRD decrease after reinforced induction, induction arm did not influence relapse-free survival (RFS) (64% in both arms; P = .91). Higher WBC, KIT, and/or FLT3-ITD/TKD gene mutations, and a less than 3-log MRD reduction after first consolidation, were associated with a higher specific hazard of relapse, but MRD remained the sole prognostic factor in multivariate analysis. At 36 months, cumulative incidence of relapse and RFS were 22% vs 54% (P < .001) and 73% vs 44% (P < .001) in patients who achieved 3-log MRD reduction vs the others. These results suggest that MRD, rather than gene mutations, should be used for future treatment stratifications in CBF-AML patients. This trial was registered at EudraCT as #2006-005163-26 and at www.clinicaltrials.gov as #NCT 00428558.

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