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de Boysson H, Dumont A, Castan P, Gallou S, Boutemy J, Maigné G, Martin Silva N, Nguyen A, Deshayes S, Aouba A. Evolution of the Therapeutic Management of Giant Cell Arteritis: Analysis of Real-Life Practices over Two Timeframes (2014-2017 and 2018-2020). J Clin Med 2023; 12:7105. [PMID: 38002716 PMCID: PMC10672351 DOI: 10.3390/jcm12227105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 11/09/2023] [Accepted: 11/10/2023] [Indexed: 11/26/2023] Open
Abstract
Objectives: To determine how therapeutic strategies for giant cell arteritis (GCA), especially glucocorticoid (GC) management, evolved between 2014 and 2020. Patients and Methods: Consecutive GCA patients followed for at least 24 months in a single tertiary center were enrolled and separated into two groups: those diagnosed from 2014 to 2017 and those diagnosed from 2018 to 2020. GC doses (mg/kg/day) were analyzed at onset, at Month 3 (M3) and, if continued, at M6, M12, M18 and M24. Physicians' practices were also individually analyzed. Results: Among the 180 patients included, 96 (53%) were diagnosed in 2014-2017 and 84 (47%) in 2018-2020. All patients received GC at diagnosis without a difference in the initial dose between the two groups (p = 0.07). At M3, the daily dose was lower in patients treated after 2017 (p = 0.002). In patients who still received GC at M6 (p = 0.0008), M12 (p = 0.01) and M24 (p = 0.02), the daily GC dose was still lower in patients treated after 2017. The proportion of patients who definitively discontinued GC use before M18 (42% versus 21%, p = 0.003) was higher in those treated after 2017. The rates of immunosuppressant use were not different between the two time periods (31% versus 38%, p = 0.34), but tocilizumab replaced methotrexate. Significant differences were observed among practitioners regarding the GC doses at M6 (p = 0.04) and M12 (p = 0.04), the total GC duration (p = 0.02) and the ability to stop GC before M18 (p = 0.007). Conclusions: This real-life study showed a global change in GC management over time for GCA patients, with important variability among physicians' practices.
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Affiliation(s)
- Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
- UFR de Santé, University of Caen Normandie, 14000 Caen, France
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
| | - Paul Castan
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
| | - Sophie Gallou
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
- UFR de Santé, University of Caen Normandie, 14000 Caen, France
| | - Jonathan Boutemy
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
| | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
| | - Nicolas Martin Silva
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
| | - Alexandre Nguyen
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
- UFR de Santé, University of Caen Normandie, 14000 Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, 14000 Caen, France; (A.D.); (S.G.)
- UFR de Santé, University of Caen Normandie, 14000 Caen, France
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Sugihara T, Uchida HA, Yoshifuji H, Maejima Y, Naniwa T, Katsumata Y, Okazaki T, Ishizaki J, Murakawa Y, Ogawa N, Dobashi H, Horita T, Tanaka Y, Furuta S, Takeuchi T, Komagata Y, Nakaoka Y, Harigai M. Association between the patterns of large-vessel lesions and treatment outcomes in patients with large-vessel giant cell arteritis. Mod Rheumatol 2023; 33:1145-1153. [PMID: 36218378 DOI: 10.1093/mr/roac122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Revised: 08/24/2022] [Accepted: 09/26/2022] [Indexed: 11/14/2022]
Abstract
OBJECTIVES We aimed to identify associations between patterns of large-vessel lesions of large-vessel giant cell arteritis (LV-GCA) and treatment outcomes. METHODS We extracted data on 68 newly diagnosed patients with LV-GCA from a retrospective, multi-centric, nationwide registry of GCA patients treated with glucocorticoids between 2007 and 2014. Patients with aortic lesions were identified based on the findings from contrast-enhanced computed tomography, magnetic resonance imaging, or positron emission tomography-computed tomography (Group 2, n = 49). Patients without aortic lesions were subdivided into LV-GCA with or without subclavian lesions defined as Group 1 (n = 9) or Group 3 (n = 10), respectively. The primary outcome evaluation was failure to achieve clinical remission by Week 24 and/or relapse within 104 weeks. RESULTS The mean age and proportion of patients with cranial lesions and polymyalgia rheumatica in Group 2 were numerically lower than in the other two groups. Large-vessel lesions in Group 3 included carotid, pulmonary, renal, hepatic, or mesenteric lesions. The cumulative rate of poor treatment outcomes >2 years was 11.1%, 55.3%, and 88.0% in Groups 1, 2, and 3, respectively (by Kaplan-Meier analysis). The mean time to poor outcome was significantly different between the groups. CONCLUSIONS Classification by subclavian and aortic lesions may be useful to determine treatment strategy.
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Affiliation(s)
- Takahiko Sugihara
- Department of Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
- Department of Medicine and Rheumatology, Tokyo Metropolitan Geriatric Hospital, Tokyo, Japan
- Department of Internal Medicine, Division of Rheumatologyand Allergology, St. Marianna University Faculty of Medicine, Kawasaki, Japan
| | - Haruhito A Uchida
- Department of Chronic Kidney Disease and Cardiovascular Disease, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hajime Yoshifuji
- Department of Rheumatology and Clinical Immunology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Taio Naniwa
- Department of Internal Medicine, Division of Rheumatology, Nagoya City University Hospital, Nagoya, Japan
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Yasuhiro Katsumata
- Department of Internal Medicine, Division of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
| | - Takahiro Okazaki
- Department of Internal Medicine, Division of Rheumatologyand Allergology, St. Marianna University Faculty of Medicine, Kawasaki, Japan
- National Hospital Organization, Shizuoka Medical Center, Shimizu, Japan
| | - Jun Ishizaki
- Department of Hematology, Clinical Immunology and Infectious Diseases, Ehime University Graduate School of Medicine, Ehime, Japan
| | - Yohko Murakawa
- Department of Rheumatology, Shimane University Faculty of Medicine, Izumo, Japan
| | - Noriyoshi Ogawa
- Department of Internal Medicine 3, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Hiroaki Dobashi
- Department of Internal Medicine, Division of Hematology, Rheumatology and Respiratory Medicine, Faculty of Medicine, Kagawa University, Kagawa, Japan
| | - Tetsuya Horita
- Division of Rheumatology, Endocrinology and Nephrology, Hokkaido University Graduate School of Medicine, Sapporo, Japan
| | - Yoshiya Tanaka
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Shunsuke Furuta
- Department of Allergy and Clinical Immunology, Chiba University Hospital, Chiba, Japan
| | - Tsutomu Takeuchi
- Department of Internal Medicine, Division of Rheumatology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Komagata
- First Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Masayoshi Harigai
- Department of Internal Medicine, Division of Rheumatology, Tokyo Women's Medical University School of Medicine, Tokyo, Japan
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Brekke LK, Assmus J, Fevang BTS. Factors predicting death and cancer in patients with giant cell arteritis in Western Norway 1972-2012: a retrospective observational cohort study. Front Med (Lausanne) 2023; 10:1243791. [PMID: 37746078 PMCID: PMC10514500 DOI: 10.3389/fmed.2023.1243791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023] Open
Abstract
Objectives Evidence as to whether or not giant cell arteritis (GCA) confers added risk of cancer or death is conflicting. Our aim was to identify factors predicting death or cancer in a large Norwegian GCA-cohort. Methods This is a retrospective observational cohort study including patients diagnosed with GCA in Western Norway during 1972-2012. Patients were identified through computerized hospital records using the International Classification of Diseases coding. Medical records were reviewed and data about registered deaths and cancer occurrences were extracted from the Norwegian Cause of Death Registry and the Cancer Registry of Norway. We investigated predicting factors using Cox proportional hazards regression. Results We identified 881 cases with a validated diagnosis of GCA (60% biopsy-verified). 490 patients (56%) died during the study period. Among 767 patients with no registered cancer prior to GCA diagnosis, 120 (16%) were diagnosed with cancer during the study period. Traditional risk factors were the main predictors of death; age at time of GCA-diagnosis [hazard ratio (HR) 2.81], smoking (HR 1.61), hypertension (HR 1.48) and previous cardiovascular disease (HR 1.26). Hemoglobin (Hb) level was also associated with risk of death with increasing Hb-levels at time of GCA-diagnosis indicating decreased risk of death (HR 0.91). Other GCA-related factors were not predictive of death. We did not identify any predictors of cancer risk. Conclusion In our cohort of GCA-patients, the risk of death was predominantly predicted by age and traditional risk factors. We found no significant associations with regards to the risk of incident cancer.
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Affiliation(s)
- Lene Kristin Brekke
- Department of Rheumatology, Haugesund Hospital for Rheumatic Diseases, Haugesund, Norway
- Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease (BEaBIRD), Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
| | - Jörg Assmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Bjørg-Tilde Svanes Fevang
- Bergen Group of Epidemiology and Biomarkers in Rheumatic Disease (BEaBIRD), Department of Rheumatology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
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Lavrard-Meyer P, Gomes De Pinho Q, Daumas A, Benyamine A, Ebbo M, Schleinitz N, Harlé J, Jarrot P, Kaplanski G, Berbis J, Granel B. Hospitalisation pour infection chez les patients suivis pour une artérite à cellules géantes : étude monocentrique rétrospective. Rev Med Interne 2023; 44:212-217. [PMID: 37029032 DOI: 10.1016/j.revmed.2023.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 04/08/2023]
Abstract
INTRODUCTION Infections are associated with morbimortality of patients with giant cell arteritis (GCA). The aim of this work was twofold: the identification of factors predisposing to the risk of infection and the description of patients hospitalized with an infection occurring during the treatment period of CAG. METHODS A monocentric retrospective study was conducted in GCA patients, comparing patients hospitalized for infection with patients without infection. The analysis included 21/144 (14.6%) patients with 26 infections (cases) and 42 control matched on sex, age, and diagnosis of GCA. RESULTS Both groups were similar except for a higher frequency of seritis in cases (15% vs. 0%, p=0.03). Relapses of GCA were less common in cases (23.8% vs 50.0%, p=0.041). Hypogammaglobulinemia was present during infection. More than half of the infections (53.8%) occurred in the first year of follow-up with an average dose of 15mg/day of corticosteroids. Infections were mainly pulmonary (46.2%) and cutaneous (26.9%). CONCLUSION Factors associated with infectious risk were identified. This preliminary monocentric work will continue with a national multicentre study.
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Lavergne A, Dumont A, Deshayes S, Boutemy J, Maigné G, Silva NM, Nguyen A, Gallou S, Philip R, Aouba A, de Boysson H. Efficacy and tolerance of methotrexate in a real-life monocentric cohort of patients with giant cell arteritis. Semin Arthritis Rheum 2023; 60:152192. [PMID: 36963127 DOI: 10.1016/j.semarthrit.2023.152192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 02/28/2023] [Accepted: 03/15/2023] [Indexed: 03/26/2023]
Abstract
OBJECTIVES To assess the indications, efficiency and tolerance profiles of methotrexate (MTX) in patients with giant cell arteritis (GCA) in a real-life setting. METHODS From a monocentric database of >500 GCA patients, we retrospectively selected 49 patients who received MTX between 2010 and 2020. Cumulative glucocorticoid (GC) doses, the number of relapses and GC-related adverse events were recorded before, during and after MTX. We separately analyzed the 3 main indications of MTX, i.e., disease relapse, GC-sparing strategy, and GCA presentation. RESULTS With a median follow-up of 84 [10-255] months, 25 (51%) and 18/41 (44%) patients relapsed during MTX treatment and after its discontinuation, respectively. Among the 40 patients who relapsed before MTX, 26 (65%) experienced a new relapse after MTX introduction. Once MTX was introduced, 24 (49%) patients were able to discontinue GC after 20.5 [7-64] months. No significant difference in cumulative GC doses were noted before and after MTX introduction with a total GC dose of 14.7 [1.05-69.4] grams. At the last follow-up, MTX was discontinued in 41 patients, including 13 (32%) due to clinicobiological remission, 12 (30%) due to treatment failure and 15 (36%) due to side effects. CONCLUSION Our real-life study showed a modest beneficial effect of MTX on relapse in patients with GCA. However, we did not observe any GC-sparing effect in this study. Other studies are needed to assess the GC-sparing effect in patients in whom GC management is adapted from recent recommendations.
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Affiliation(s)
- Amandine Lavergne
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Anael Dumont
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Samuel Deshayes
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France
| | - Jonathan Boutemy
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Gwénola Maigné
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | | | - Alexandre Nguyen
- Department of Internal Medicine, Caen University Hospital, Caen, France
| | - Sophie Gallou
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France
| | - Rémi Philip
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France
| | - Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Caen, France; Caen University-Normandie, Caen, France.
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Misra DP, Sharma A, Karpouzas GA, Kitas GD. Cardiovascular risk in vasculitis. Best Pract Res Clin Rheumatol 2023; 37:101831. [PMID: 37302927 DOI: 10.1016/j.berh.2023.101831] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 04/06/2023] [Accepted: 04/16/2023] [Indexed: 06/13/2023]
Abstract
The present review summarizes the burden, risk factors, biomarkers of and therapeutic consideration for cardiovascular disease in systemic vasculitis. Ischemic heart disease (IHD) and stroke are intrinsic features of Kawasaki disease, Takayasu arteritis, Giant Cell Arteritis (GCA), and Behcet's disease. The risk of IHD and stroke is increased in anti-neutrophil cytoplasmic antibody-associated vasculitis (AAV) and cryoglobulinemic vasculitis. Behcet's disease could present with venous thromboembolism. The risk of venous thromboembolism is increased in AAV, polyarteritis nodosa, and GCA. The risk of cardiovascular events is greatest at or immediately after the diagnosis of AAV or GCA, therefore, controlling vasculitis disease activity is of utmost importance. Traditional as well as disease-related risk factors drive the heightened cardiovascular risk in vasculitis. Aspirin or statins reduce the risk of IHD or stroke in GCA or the risk of IHD in Kawasaki Disease. Venous thromboembolism in Behcet's disease should be treated with immunosuppressive therapy rather than with anticoagulation.
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Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, 226014, India.
| | - Aman Sharma
- Clinical Immunology and Rheumatology Wing, Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Sector-12, Chandigarh, 160012, India.
| | | | - George D Kitas
- Research & Development, Dudley Group NHS Foundation Trust and University of Birmingham, UK.
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Dumont A, Labombarda F, Gallou S, Deshayes S, Nguyen A, Boutemy J, Martin-Silva N, Maigné G, Aouba A, de Boysson H. Preventive effect of beta-blockers in the development of aortic dilation in giant cell arteritis-related aortitis. Semin Arthritis Rheum 2022; 57:152117. [DOI: 10.1016/j.semarthrit.2022.152117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/17/2022] [Accepted: 10/19/2022] [Indexed: 11/19/2022]
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Bond M, Tomelleri A, Buttgereit F, Matteson EL, Dejaco C. Looking ahead: giant-cell arteritis in 10 years time. Ther Adv Musculoskelet Dis 2022; 14:1759720X221096366. [PMID: 35634351 PMCID: PMC9136445 DOI: 10.1177/1759720x221096366] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 04/01/2022] [Indexed: 12/15/2022] Open
Abstract
Although great improvements have been achieved in the fields of diagnosing and treating patients with giant-cell arteritis (GCA) in the last decades, several questions remain unanswered. The progressive increase in the number of older people, together with growing awareness of the disease and use of advanced diagnostic tools by healthcare professionals, foretells a possible increase in both prevalence and number of newly diagnosed patients with GCA in the coming years. A thorough clarification of pathogenetic mechanisms and a better definition of clinical subsets are the first steps toward a better understanding of the disease and, subsequently, toward a better use of existing and future therapeutic options. Examination of the role of different imaging techniques for GCA diagnosing and monitoring, optimization, and personalization of glucocorticoids and other immunosuppressive agents, further development and introduction of novel drugs, identification of prognostic factors for long-term outcomes and management of treatment discontinuation will be the central topics of the research agenda in years to come.
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Affiliation(s)
- Milena Bond
- Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Brunico, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
| | - Frank Buttgereit
- Department of Rheumatology and Clinical Immunology, Charitè University Medicine Berlin, Berlin, Germany
| | - Eric L. Matteson
- Division of Rheumatology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Christian Dejaco
- Professor, Department of Rheumatology, Hospital of Brunico (SABES-ASDAA), Via Ospedale 11, 39031 Brunico, Italy
- Department of Rheumatology and Immunology, Medical University of Graz, Auenbruggerplatz 15, 8036 Graz, Austria
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de Boysson H, Aouba A. An Updated Review of Cardiovascular Events in Giant Cell Arteritis. J Clin Med 2022; 11:1005. [PMID: 35207277 PMCID: PMC8878095 DOI: 10.3390/jcm11041005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 02/09/2022] [Accepted: 02/15/2022] [Indexed: 02/01/2023] Open
Abstract
Giant cell arteritis (GCA) is a systemic vasculitis with a direct and indirect increased risk of acute and chronic vascular events, affecting large and medium vessels, and responsible for most of the morbidity and mortality of this disease. We aimed in this review to provide an updated synthesis of knowledge regarding cardiovascular events observed in GCA. By definition, GCA patients are over 50 and often over 70 years old, and subsequently also present age-related cardiovascular risk factors. In addition, the systemic and vascular inflammation as well as glucocorticoids (GC) probably contribute to an accelerated atherosclerosis and to vascular changes leading to arterial stenoses and aortic dilations and/or dissections. GCA-related ischemic complications, especially ophthalmologic events, stroke or myocardial infarcts are mostly observed within the first months after the diagnosis, being mainly linked to the vasculitic process. Conversely, aortic complications, including dilations or dissections, generally occur several months or years after the diagnosis, mainly in patients with large-vessel vasculitis. In these patients, other factors such as atherosclerosis, GC-related endothelial damage and vascular wall remodeling/healing probably contribute to the vascular events. GCA management includes the detection and treatment of these previous and newly induced cardiovascular risk factors. Hence, the use of cardiovascular treatments (e.g., aspirin, anticoagulation, statins, anti-hypertensive treatments) should be evaluated individually. Aortic structural changes require regular morphologic evaluations, especially in patients with previous aortitis. The initial or secondary addition of immunosuppressants, especially tocilizumab, an anti-IL-6 receptor antibody, is discussed in patients with GCA-related cardiovascular complications and, more consensually, to limit GC-mediated comorbidities.
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Affiliation(s)
- Hubert de Boysson
- Department of Internal Medicine, Caen University Hospital, Avenue de la Côte de Nacre, 14000 Caen, France;
- Caen University-Normandie, 14000 Caen, France
| | - Achille Aouba
- Department of Internal Medicine, Caen University Hospital, Avenue de la Côte de Nacre, 14000 Caen, France;
- Caen University-Normandie, 14000 Caen, France
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