Risk of infections in bronchiectasis during disease-modifying treatment and biologics for rheumatic diseases

<p>Abstract</p> <p>Background</p> <p>Bronchiectasis is frequently associated (up to 30%) with chronic inflammatory rheumatic diseases and leads to lower respiratory tract infections. Data are lacking on the risk of lower respiratory tract infections in patients treated with biologic agents.</p> <p>Methods</p> <p>Monocenter, retrospective systematic study of all patients with a chronic inflammatory rheumatic disease and concomitant bronchiectasis, seen between 2000 and 2009. Univariate and multivariate analyses were performed to evidence predictive factors of the number of infectious respiratory events.</p> <p>Results</p> <p>47 patients were included (mean age 64.1 ± 9.1 years, 33 (70.2%) women), with a mean follow-up per patient of 4.3 ± 3.1 years. Rheumatoid arthritis was the main rheumatic disease (90.1%). The mean number of infectious events was 0.8 ± 1.0 event per patient-year. The factors predicting infections were the type of treatment (biologic vs. non biologic disease-modifying treatments), with an odds ratio of 8.7 (95% confidence interval: 1.7-43.4) and sputum colonization by any bacteria (odds ratio 7.4, 2.0-26.8). In multivariate analysis, both factors were independently predictive of infections.</p> <p>Conclusion</p> <p>Lower respiratory tract infectious events are frequent among patients receiving biologics for chronic inflammatory rheumatic disease associated with bronchiectasis. Biologic treatment and pre-existing sputum colonization are independent risk factors of infection occurrence.</p

Case Reports1. A Late Presentation of Loeys-Dietz Syndrome: Beware of TGFβ Receptor Mutations in Benign Joint Hypermobility

Background: Thoracic aortic aneurysms (TAA) and dissections are not uncommon causes of sudden death in young adults. Loeys-Dietz syndrome (LDS) is a rare, recently described, autosomal dominant, connective tissue disease characterized by aggressive arterial aneurysms, resulting from mutations in the transforming growth factor beta (TGFβ) receptor genes TGFBR1 and TGFBR2. Mean age at death is 26.1 years, most often due to aortic dissection. We report an unusually late presentation of LDS, diagnosed following elective surgery in a female with a long history of joint hypermobility. Methods: A 51-year-old Caucasian lady complained of chest pain and headache following a dural leak from spinal anaesthesia for an elective ankle arthroscopy. CT scan and echocardiography demonstrated a dilated aortic root and significant aortic regurgitation. MRA demonstrated aortic tortuosity, an infrarenal aortic aneurysm and aneurysms in the left renal and right internal mammary arteries. She underwent aortic root repair and aortic valve replacement. She had a background of long-standing joint pains secondary to hypermobility, easy bruising, unusual fracture susceptibility and mild bronchiectasis. She had one healthy child age 32, after which she suffered a uterine prolapse. Examination revealed mild Marfanoid features. Uvula, skin and ophthalmological examination was normal. Results: Fibrillin-1 testing for Marfan syndrome (MFS) was negative. Detection of a c.1270G > C (p.Gly424Arg) TGFBR2 mutation confirmed the diagnosis of LDS. Losartan was started for vascular protection. Conclusions: LDS is a severe inherited vasculopathy that usually presents in childhood. It is characterized by aortic root dilatation and ascending aneurysms. There is a higher risk of aortic dissection compared with MFS. Clinical features overlap with MFS and Ehlers Danlos syndrome Type IV, but differentiating dysmorphogenic features include ocular hypertelorism, bifid uvula and cleft palate. Echocardiography and MRA or CT scanning from head to pelvis is recommended to establish the extent of vascular involvement. Management involves early surgical intervention, including early valve-sparing aortic root replacement, genetic counselling and close monitoring in pregnancy. Despite being caused by loss of function mutations in either TGFβ receptor, paradoxical activation of TGFβ signalling is seen, suggesting that TGFβ antagonism may confer disease modifying effects similar to those observed in MFS. TGFβ antagonism can be achieved with angiotensin antagonists, such as Losartan, which is able to delay aortic aneurysm development in preclinical models and in patients with MFS. Our case emphasizes the importance of timely recognition of vasculopathy syndromes in patients with hypermobility and the need for early surgical intervention. It also highlights their heterogeneity and the potential for late presentation. Disclosures: The authors have declared no conflicts of interes

Efficacité du changement d anti-TNF dans les spondylarthropathies (étude de 222 patients)

Les spondylarthropathies désignent un groupe de rhumatismes inflammatoires chroniques comprenant la spondylarthrite ankylosante, le rhumatisme psoriasique, le SAPHO, les spondylarthrites associées aux MICI et les spondylarthropahties indifférenciées. La multiplicité des formes cliniques rend compte de leur hétérogénéité en pratique clinique et de la difficulté à trouver des critères diagnostiques et de classification.L arrivée des anti-TNF dans les années 2000 a révolutionné la prise en charge des spondylarthropathies. L efficacité de ces molécules est remarquable avec près de 70% des patients répondeurs la première année. Cependant, une partie des patients stoppent l anti-TNF pour diverses raisons, principalement l inefficacité ou l intolérance.Les connaissances actuelles sur l intérêt de changer pour un second anti-TNF sont peu nombreuses et présentent quelques réserves : études non réalisées en France, limitées aux patients ayant une spondylarthrite selon les critères de New York modifiés Ce travail est la première étude française évaluant l efficacité du deuxième anti-TNF dans les spondylarthropathies définies par les critères d Amor.Parmi les 222 patients ayant débuté un premier anti-TNF entre 2004 et 2009, 72 ont switché pour un deuxième anti-TNF. Il n existait pas de différence entre le maintien thérapeutique du premier et du deuxième anti-TNF. Aucun facteur prédisposant au maintien du deuxième anti-TNF n a été retrouvé par ailleurs.Ce travail corrobore les données actuelles de la littérature et confirme l attitude actuelle de changer d anti-TNF en cas d arrêt du premier pour les patients ayant une spondylarthropathie.PARIS6-Bibl.Pitié-Salpêtrie (751132101) / SudocSudocFranceF

Intra-articular injections in thumb osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

International audienceObjectivesThe objective was to assess the efficacy of intra-articular injections of corticosteroids or hyaluronic acid in thumb osteoarthritis.MethodsA systematic review of the literature was performed until August 2014. All controlled trials reporting the efficacy on pain, functional capacity and pulp pinch force of hyaluronic acid or corticosteroids in thumb osteoarthritis were selected. Pooled standardized response means (SRMs) were assessed by meta-analysis.ResultsSix trials were included and contributed to 3 meta-analyses (hyaluronic acid versus placebo, corticosteroids vs. placebo and hyaluronic acid vs. corticosteroids). Among the 428 patients included, 169 were treated with hyaluronic acid, 147 with corticosteroids and 74 with placebo. Versus placebo at week 12, hyaluronic acid (2 trials, 148 patients) lead to better functional capacity (SRM −1.14 [−1.69; −0.60]) with no difference on pain; corticosteroids (2 trials, 164 patients) lead to no difference on pain or function. When comparing hyaluronic acid vs. corticosteroids (4 trials, 304 patients), no difference was evidenced until week 12. At week 24, pain was significantly lower in the corticosteroids group (SRM 1.44 [0.14; 2.74]) and pulp pinch force higher in the hyaluronic acid group (SRM −0.75 [−3.87; −1.97]).ConclusionThis meta-analysis shows great heterogeneity. Hyaluronic acid may be useful to increase functional capacity and corticosteroids to decrease pain in thumb osteoarthritis at week 24

Primary inefficacy of TNF inhibitors in patients with axial spondyloarthritis: a long-term follow-up of 25 patients

International audienceObjectives. Primary inefficacy of TNF inhibitors (TNFi) for axial spondyloarthritis (axSpA) is infrequent. The objective of this study was to assess the long-term evolution and final diagnosis of patients with primary inefficacy of TNFi for axSpA.Methods. This was a systematic retrospective study of all patients receiving a TNFi for axSpA in one tertiary referral centre. Patients had axSpA confirmed by a rheumatologist and were started on a first course of TNFi according to usual practice. If the rheumatologist interrupted treatment at 3 months for inefficacy, this was defined as primary inefficacy. Five to 10 years later, these patients were re-evaluated.Results. Of 222 patients receiving a first TNFi for axSpA, 27 (12%) were considered as having primary inefficacy. These patients were more often females (48 vs 27%, P = 0.04), had higher functional impairment [BASDAI (0–100) 68 vs 42, P = 0.001] and less increased CRP (50 vs 78%, P = 0.008.) At the follow-up, 25 (92%) patients were re-evaluated: the diagnosis of axSpA was confirmed for 21/25 (84%) patients according to the Assessment of SpondyloArthritis criteria and 20/25 (80%) patients according to the rheumatologist; but 18/25 (72%) had at least one other cause of their symptoms from among OA, widespread pain syndrome or depression. A second TNFi was prescribed for 16 patients and was efficacious for 9 (56%).Conclusion. Most patients with primary inefficacy had a confirmed diagnosis of axSpA, but they often had other causes of pain. We suggest that patients with primary inefficacy to TNFi should be screened for comorbidities that may interfere with axSpA activity assessment

Mortality in rheumatoid arthritis over the last fifty years: systematic review and meta-analysis

Mortality rates in patients with rheumatoid arthritis (RA) have been reported to be higher than for the general population. Fortunately, efficient therapies have reduced disease activity and may be able to diminish the excess mortality risk. This study was designed to investigate RA mortality over the last 50 years by systematic review of the literature and meta-analysis

Exploring remission concept in axial spondyloarthritis through the perception of rheumatologists using vignettes and priority ratings

International audienceObjectivesThe optimal treatment target in axial spondyloarthritis (axSpA) is remission; however, a consensual definition of remission is lacking. Our objective was to explore rheumatologists’ perception of remission using vignette cases and a priority exercise.MethodsA cross-sectional survey of rheumatologists’ perceptions of remission in axSpA was performed in 2020 using (a) 36 vignette cases, with a single clinical picture and 3 varying parameters (axial pain [ranging from 2 to 5 on a 0–10 scale], fatigue [2–8], and morning stiffness [<15 min, 30 min or 1 h], assessed as remission yes/no; (b) prioritization of elements to consider for remission from a list of 12 items: BASDAI, ASDAS, elements of BASDAI and ASDAS including CRP, NSAIDs use, extra-articular manifestations (EAMs), and other explanations of symptoms e.g. fibromyalgia. Analyses were descriptive.ResultsOverall, 200 French rheumatologists participated in 2,400 vignette evaluations. Of these, 463 (19%) were classified as remission. The 6 vignette cases representing 56% of all remission cases had <15 min duration of morning stiffness and axial pain ≤3/10, regardless of fatigue levels. Prioritized items for remission were: morning stiffness (75%), EAMs (75%), NSAID use (71%), axial pain (68%), and CRP (66%).ConclusionsWhen conceptualizing remission in axSpA, rheumatologists took into account morning stiffness and axial pain as expected; the link between remission and fatigue was much weaker. Furthermore, rheumatologists also included EAMs and NSAID use in the concept of remission. Consensus is needed for definition of remission in axSpA