Statins and giant cell arteritis : pharmacoepidemiological approach

Nous proposons une revue de la littérature approfondie sur la pharmacologie des inhibiteurs de l'HMG-CoA réductase et les résultats de nos études sur leur utilisation dans l'artérite à cellules géantes. Nous avons montré que l'exposition aux statines n'est pas associée au risque de survenue d'artérite à cellules géantes dans la population générale. Toutefois, une exposition aux statines jusqu'à 20 mois pourrait favoriser un sevrage plus rapide en corticoïdes. L'utilisation des statines au cours de l'artérite à cellules géantes ne doit pas être définitivement exclu. D'autant plus que nous avons également montré que les patients, diagnostiqués pour une artérite à cellules géantes, les plus âgés ou connus pour avoir des comorbidités cardiovasculaires présentent un risque élevé d'hospitalisation pour évènement cardiovasculaire majeur après la phase initiale de la maladie et doivent être étroitement surveillés en ce sens. Nous montrons qu'il existe un besoin non satisfait en terme de prévention cardiovasculaire dans l'artérite à cellules géantes. Les statines semblent efficaces pour prévenir les événements cardiovasculaires majeurs dans cette population.We propose a comprehensive review on HMG-CoA reductase inhibitors pharmacology and results of our studies on their use in giant cell arteritis. We showed that statins exposure was not associated with giant cell arteritis occurrence in the general population. However, exposure to statins up to 20 months may favor a quicker corticosteroid tapering. Based on those results statin impact on giant cell arteritis course should not be definitively ruled out. We also showed that older giant cell arteritis patients and those suffering from cardiovascular comorbidities present a high risk of cardiovascular hospitalization occurrence after the initial phase of the disease and should be closely monitored to prevent subsequent cardiovascular disease. This proves that there is an unmet need of cardiovascular prevention in giant cell arteritis patients. Statins seems highly efficient to prevent major cardiovascular events in this population

Morbi-mortalité cardiovasculaire dans l'artérite à cellules géantes (étude comparative en population générale chez 103 patients de la cohorte APOGEE)

TOULOUSE3-BU Santé-Centrale (315552105) / SudocSudocFranceF

Combining multi-antigenic immunodot with indirect immunofluorescence on HEp-2 cells improves the diagnosis of systemic sclerosis

International audienceSystemic sclerosis (SSc) is associated, in nearly all patients, with autoantibodies (Ab). Accordingly, and in order to identify major (anti-CEN A/B and anti-Topo I) but also minor Abs, the usefulness of combining indirect immunofluorescence (IIF) on HEp-2 cells with an 11 multi-antigenic SSc immunodot was explored. 1689 samples tested at the request of clinicians, were evaluated retrospectively. The positivity rate was 28.8% and the diagnosis of SSc was supported for 232 samples. Two groups of Abs were considered: group 1, Abs (anti-CENP A/B, anti-Topo I) present at elevated levels in SSc patients; group 2, Abs for which the Ab specificity (odds ratio and/or positive predictive value) was improved by using IIF on HEp-2 cells (RNA-Polymerase III, fibrillarin, Th/T0, PM-Scl). Altogether, this study highlights the utility of combining IIF on HEp-2 cells with the SSc immunodot as the first line of an SSc Abs detection/SSc diagnostic strategy

Additional costs of polymyalgia rheumatica with giant-cell arteritis

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Role of bronchoscopy for respiratory involvement in granulomatosis with polyangiitis and microscopic polyangiitis

Objectives This study describes data from bronchoscopy performed at the diagnosis of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Methods We conducted a retrospective study between 2004 and 2019 in patients aged >18 years with a diagnosis of microscopic polyangiitis (MPA) or granulomatosis with polyangiitis (GPA) who underwent bronchoscopy at onset of the disease. We collected bronchoalveolar lavage (BAL) and histological findings obtained during bronchoscopy. Results 274 patients with AAV were identified. Among 92 bronchoscopies, 62 were performed at diagnosis, and 58 procedures were finally analysed. Cough was more frequent in patients with MPA than GPA (p=0.02). The presence of endobronchial lesions (24.1%) was found to be significantly associated with GPA (p<0.0001) and proteinase 3-ANCA (p=0.01). The most frequent endobronchial lesions were inflammation and hyperaemia of the bronchial mucosa (50%), followed by stenoses (28%), ulcerations (21%) and mass-like granulomatosis (7%). The diagnostic yield of bronchial biopsies was useful for visible lesions (66.6% versus 0%; p=0.006). On BAL, diffuse alveolar haemorrhage (DAH) was detected in 31 (53.4%) patients and was more frequent in MPA patients (70.4% versus 38.7%; p=0.016). In 16.1% of DAH cases, BAL confirmed the diagnosis despite the absence of clinical or biological arguments. The incidence of microbial infections on BAL (38%) was similar between MPA and GPA (p=0.54). Conclusion Bronchoscopy is an informative procedure at the onset of AAV disease in patients with respiratory manifestations. Endobronchial lesions are more frequently found in GPA and should be biopsied. BAL can be used to confirm DAH or diagnose superadded infection

Reproducibility and utility of the 6-minute walk test in systemic sclerosis

Objective: To assess the reproducibility and the utility of the 6-minute walk test (6MWT) in systemic sclerosis (SSc). Methods: All patients with SSc who underwent at least two 6MWT within a minimum 3-month interval plus simultaneous routine clinical, biological, and functional evaluations were consecutively enrolled in this observational study over 6 years. Following American Thoracic Society guidelines, each 6MWT was repeated twice to assess the 6-minute walk distance (6MWD) reproducibility, with the highest value being reported for subsequent analysis. Results: Among 56 (38 female) included patients aged 46 +/- SD 12.7 years, with 17 +/- 10 modified Rodnan skin score (mRSS) and 1 +/- 0.8 Scleroderma Health Assessment Questionnaire (SHAQ) at first referral, 277 6MWT evaluations (5 +/- 3.9 6MWT per patient) were performed over 23 +/- 225 months followup. Meanwhile, 8 deaths (87.5% SSc-related) occurred. The mean 6MWD absolute value was 457 +/- 117 m with a 4 +/- 2.2 mean Borg dyspnea score. The 6MWD intraclass correlation coefficient was 0.996 (95% CI 0.995-0.999, p < 0.0001). In multivariate linear regression analysis, these factors were independently associated with a lower 6MWD: sex (R-2 = 0.47, p < 0.0001), mRSS (R-2 = 0.47, p = 0.008), tendon friction rub (R-2 = 0.47, p = 0.003), SHAQ (R-2 = 0.47, p = 0.02), muscle disability score (R-2 = 0.47, p = 0.03), DLCO% (R-2 = 0.47, p = 0.0008), and left ventricular ejection fraction (R-2 = 0.47, p = 0.006). The 6MWD at first referral was an independent predictor for the overall mortality (IIR 0.99, 95% CI 0.988-0.999) and the SSc-related mortality (HR 0.99, 95% CI 0.988-0.999). Conclusion: We show strong reproducibility for the 6MWD and confirm the 6MWT utility to assess the overall prognosis of patients with SSc

De l’art dramatique à l’art de l’entrevue médicale : retour d’une expérience auprès d’étudiants en médecine

Contexte : Tant l’enseignement du savoir-faire que celui du savoir-être, en particulier la communication médecin-patient peuvent être améliorés. Objectifs : Décrire et documenter l’intérêt des étudiants pour des dispositifs de formation à la communication et à la relation médecin-patient associant l’art dramatique et la simulation. Méthodes : Trente-trois étudiants en médecine (diplôme de formation approfondie en sciences médicales 1 et 2) ont participé à des ateliers de communication associant successivement une approche théâtrale comportant plusieurs exercices et une mise en situation professionnelle de communication en situation de consultation avec un patient simulé. Résultats : La grande majorité (92 %) des étudiants ayant participé à ces ateliers ont estimé que l’expérience leur a été bénéfique tant sur le plan du savoir-faire que du savoir-être et 94 % ont validé l’intérêt de ces ateliers pour leur pratique ultérieure. Les exercices théâtraux les plus plébiscités étaient l’histoire en cercle, l’histoire à plusieurs et l’histoire avec contrainte. Conclusion : L’association d’outils pédagogiques contextualisants, comme l’expérience théâtrale, le recours aux patients simulés en situation de problématiques cliniques fréquentes ou complexes, à des étudiants observateurs, le recours à la vidéo, et le débriefing entre les différents acteurs, recueille une très forte adhésion et détermine un grand bénéfice ressenti auprès des apprenants. Les résultats très positifs de cette expérience nous encouragent à étendre cette approche pédagogique intégrative à l’ensemble des étudiants du deuxième cycle des études médicales

Zoster after Cyclophosphamide for Systemic Lupus Erythematosus or Vasculitis: Incidence, Risk Factors, and Effect of Antiviral Prophylaxis

International audienceObjective: To assess the incidence and the risk factors for zoster in patients exposed to intravenous cyclophosphamide (CYC) for systemic vasculitis or systemic lupus erythematosus (SLE), as well as the protective effect of prophylaxis by valacyclovir (VCV).Methods: This retrospective study included all adults treated by intravenous CYC for SLE or systemic vasculitis between 2011 and 2015 at Toulouse University Hospital, France. Zoster occurrence was recorded using medical chart review, laboratory data, and patient interviews. Univariate Cox models were computed to assess the risk factors for zoster and the protective effect of prophylaxis by VCV.Results: The cohort consisted of 110 patients (81 systemic vasculitis and 29 SLE). During a mean followup of 3.4 years after CYC initiation, 10 cases of zoster occurred, leading to an overall incidence of 27.9/1000 patient-years (95% CI 15.2-50.6); it was 59.4/1000 patients (95% CI 27.5-123.6) during the year after CYC initiation. Four patients experienced persistent postherpetic neuralgia. Probable risk factors were lymphopenia < 500/µl at CYC initiation (HR 5.11, 95% CI 0.94-27.93) and female sex (HR 4.36, 95% CI 0.51-37.31). The incidence was higher in patients with SLE (HR as compared with systemic vasculitis patients = 2.68, 95% CI 0.54-13.26). None of the 19 patients exposed to VCV during the followup developed zoster.Conclusion: The incidence of zoster is high in systemic vasculitis and in patients with SLE exposed to intravenous CYC. CYC may favor postherpetic neuralgia. Prophylaxis by VCV should be considered, particularly in cases of lymphopenia < 500/µl at CYC initiation and during the year after

Impact of micronutrient deficiency & malnutrition in systemic sclerosis: Cohort study and literature review

International audienceObjectives: The purpose of our study was to determine the prevalence and risk factors associated with malnutrition, and selenium (Se) and vitamin C (vitC) deficiencies in systemic sclerosis (SSc) patients.Methods: We included adult SSc patients fulfilling the 2013 ACR/EULAR criteria from the Toulouse University Hospital cohort who underwent a micronutrient workup (including vitC, Se or thiamine levels) between 2011 and 2016.Results: 82 patients were included, mostly women (76%), with a median age of 60 years. SSc was limited in 76% of the cases, with Scl-70 and centromere antibodies in 32% and 44%, respectively. Median disease duration was 7.4 years. Cardiac involvement was noticed in 19% and gastrointestinal tract in and 95%; 9% had pulmonary artery hypertension (PAH) and 63% had interstitial lung disease. Overt malnutrition was present in 14 (17%) patients. Micronutrient deficiencies included Se (35%), vitC (31%) and/or thiamine (6%). Malnourished patients had significantly a higher summed Medsger disease severity scales (7.5 vs. 5, P = .003), lower hemoglobin (10.6 vs. 12.9 g/dL, P < .0001) and vitC levels (3.6 vs. 10.6 mg/L, P = .003). Cardiac involvement was significantly associated with Se deficiency (OR 6.2, IC 95%[1.48-32.70], P = .05). The factors associated with vitC deficiency were malnutrition (OR 8.57, IC 95%[2.16-43.39], P = .003), modified Rodnan skin score ≤ 14 (OR 0.33, IC95[0.11-1], P = .05), PAH (27% in deficient vs. none in non-deficient patients, P = .0006) and esophagitis or Barrett's mucosa (OR 4.05, IC95[1.27-13.54], P = .02).Conclusions: Se testing should be considered as soon as cardiac involvement is suspected. VitC testing should be considered in malnourished SSc patients, especially if skin involvement is extensive

IgG4-related uveitis. A French cohort and literature review

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