French National Diagnostic and Care Protocol for antiphospholipid syndrome in adults and children

Antiphospholipid syndrome (APS) is a chronic autoimmune disease involving vascular thrombosis and/or obstetric morbidity and persistent antibodies to phospholipids or certain phospholipid-associated proteins. It is a rare condition in adults and even rarer in children. The diagnosis of APS can be facilitated by the use of classification criteria based on a combination of clinical and biological features. APS may be rapidly progressive with multiple, often synchronous thromboses, resulting in life-threatening multiple organ failure. This form is known as "catastrophic antiphospholipid syndrome" (CAPS). It may be primary or associated with systemic lupus erythematosus (associated APS) and in very rare cases with other systemic autoimmune diseases. General practitioners and paediatricians may encounter APS in patients with one or more vascular thromboses. Because APS is so rare and difficult to diagnosis (risk of overdiagnosis) any suspected case should be confirmed rapidly and sometimes urgently by an APS specialist. First-line treatment of thrombotic events in APS includes heparin followed by long-term anticoagulation with a VKA, usually warfarin. Except in the specific case of stroke, anticoagulants should be started as early as possible. Any temporary discontinuation of anticoagulants is associated with a high risk of thrombosis in APS. A reference/competence centre specialised in autoimmune diseases must be urgently consulted for the therapeutic management of CAPS.

POS1379 HYPERMETABOLIC BONE SARCOIDOSIS ON 18F-FDG PET-CT: IMPACT ON TREATMENT AND DISEASE RELAPSE IN A COHORT OF 165 PATIENTS FROM A SINGLE UNIVERSITY HOSPITAL

Background

Sarcoidosis is a multisystemic granulomatosis of unknown cause. Prevalence of bone sarcoidosis is estimated between 3 and 30%. Bone sarcoidosis is symptomatic in about half of the cases. 18F-fluorodeoxyglucose (FDG) positron emission tomography-computed tomography (PET-CT) is a useful imaging modality in sarcoidosis, to search for a biopsiable site, evaluate organ involvement or assess disease activity. It is a sensitive imaging modality to detect bone involvement. However, clinical and prognostic significance of hypermetabolic bone involvement of sarcoidosis is not well known.

Objectives

The aim of this study was to compare the characteristics of patients with and without hypermetabolic bone involvement of sarcoidosis and to evaluate the impact of metabolic bone involvement on treatments and outcomes.

Methods

This was an observational, comparative, retrospective monocentric study of prospectively collected data. Inclusion criteria were a diagnosis of sarcoidosis according to the World Association of Sarcoidosis and Other Granulomatous diseases (WASOG) criteria and at least one 18F-FDG PET-CT during follow-up. Metabolic bone involvement of sarcoidosis was defined as bone hypermetabolism for which alternative causes had been reasonably excluded, following the WASOG criteria of « at least probable » bone sarcoidosis. Characteristics of patients with and without bone involvement were compared using bilateral Fisher or Mann-Whitney tests. Relapse-free survival curves were constructed following the Kaplan-Meier method and compared using a log-rank test. A p-value < 0.05 was considered significant.

Results

Among 503 patients with sarcoidosis, 165 with definite sarcoidosis who had undergone at least one 18F-FDG PET-CT were included. Fourteen patients had positive bone PET-CT findings which were attributed to other cause than sarcoidosis. Metabolic bone involvement of sarcoidosis was found in 29 patients (18%), among which 9 (31%) had structural bone lesions on CT. Metabolic bone involvement of sarcoidosis was associated with more frequent intrathoracic lymph node involvement (28 [96%] and 107 [79%], p < 0.001), extrathoracic lymph node involvement (15 [52%] and 40 [30%], p = 0.03) and a higher number of organ involvements (median [interquartile range], 6 [4-7] and 4 [2-5], p < 0.001). Patients with metabolic bone involvement received more frequently corticosteroids (29 [100%] and 99 [73%], p < 0.001), methotrexate (26 [90%] and 66 [48%], p < 0.001), tumor necrosis factor (TNF) alpha inhibitors (22 [76%] and 41 [30%], p < 0.001), and a higher number of treatments (3 [3-4] and 2 [1-3], p < 0.001). Despite more intensive treatments, disease relapse occurred significantly sooner in patients with metabolic bone involvement of sarcoidosis (median time to the first relapse, 63 [44-84] months and 96 [72-156] months respectively, p = 0.01).

Conclusion

Metabolic bone involvement on PET-CT was present in 18% of patients with sarcoidosis. It was predominantly axial and without structural lesions. In this comparative study, patients with metabolic bone involvement received significantly more treatments and had a shorter time to relapse. It could therefore reflect a more severe multisystemic involvement and chronic evolution of the disease. This could help adjust individual therapeutic strategy for patients with sarcoidosis.

References

[1]Challenges of Sarcoidosis and Its Management. Drent M, Crouser ED, Grunewald J. N Engl J Med. 2021 Sep 9;385(11):1018-1032.

[2]Clinical Presentation and Treatment of High-Risk Sarcoidosis. Perlman DM, Sudheendra MT, Furuya Y, Shenoy C, Kalra R, Roukoz H, Markowitz J, Maier LA, Bhargava M. Ann Am Thorac Soc. 2021 Sep 15. doi: 10.1513/AnnalsATS.202102- 212CME

Figure 1.

Disclosure of Interests

None declared

Séquelles physiques et psychiques 3–6 mois après la COVID-19 : premiers résultats de la cohorte prospective ALCOVID

Introduction

Patients et méthodes

Résultats

Conclusion

[Importance of cognitive disorders in internal medicine: Pathophysiology, diagnosis, management. The example of systemic lupus erythematosus]

Systemic diseases, which are in France mainly monitored in internal medicine, affect multiple organs or tissues. While cutaneous or articular manifestations are the most common, neurological involvement is often associated with severity. Diagnosis of peripheral (e.g, neuropathies) or central (e.g, myelitis) nervous disorders is quite easy through clinical examination and dedicated complementary tests. However, neuropsychological manifestations that affect cognition, including memory, attention, executive functions or reasoning, are difficult to diagnose, sometimes trivialized by practitioners. Their causes are often numerous and interrelated. Nevertheless, these cognitive manifestations are closely related to patients' quality of life, affecting their social life, family dynamics and professional integration but also the treatment adherence. The purpose of this review, focused on the example of systemic lupus erythematosus, is to raise awareness of cognitive dysfunction in systemic diseases including their management from diagnosis to treatments. The final aim is to go further into setting up research groups and care programs for patients with cognitive impairment followed in internal medicine.

AB0323 INTIMA-MEDIA THICKNESS IS INDEPENDENTLY ASSOCIATED WITH STROKE IN PRIMARY ANTIPHOSPHOLIPID SYNDROME

Background:

Compared to secondary antiphospholipid syndrome (APS), little is known on intima-media thickness (IMT) in primary APS. Previous reports suggest that intima-media thickness may be associated with anti-cardiolipin antibodies, anti-β2-glycoprotein-1 antibodies, and with stroke in APS1.

Objectives:

To assess clinical significance of intima-media thickness in primary APS.

Methods:

We have included 29 patients with primary APS (defined according to international consensus criteria) seen, at least once, in our tertiary center for a cardiovascular risk assessment from April 2014 to November 2018.

Results:

29 patients were included (females 83%). Mean (SD) age at evaluation was 48 years (16.1). Mean APS duration before assessment was 9.1 years (6.2). 27 patients had thrombotic APS (93%), among which 13 (45%) had a history of arterial thrombosis (12 strokes and 1 myocardial infarction) and 16 (55%) of venous thrombosis. Obstetrical APS was present in 7 patients (24%). Positive APL antibodies were: anti-cardiolipin antibodies (aCL) n = 15 (54%), anti-β2-glycoprotein I (anti-β2GP1) n = 10 (36%), lupus-anticoagulant (LAC) n = 11 (39%) and anti-phospholipid antibodies (aPL) n = 19 (68%). Mean IgG levels (GPL) were 52.4 (80.3) UGPL, 52.2 (124) UI, 39.2 (40.5) UGPL for aCL anti-βG2P1, and aPL, respectively. 6 patients (21%) were simple positive, 3 (11%) were double positive, and 10 (36%) were triple positive.

Cardiovascular risk factors were: smoking n = 6 patients (21%), overweight n = 11 (39%), hypercholesterolemia n = 12 (43%), arterial hypertension n = 11 (38%), chronic kidney disease (defined by estimated glomerular filtration rate < 60 mL/mn) n = 5 (17%). No patient had diabetes mellitus. Median risk SCORE was 0.65 (0-2.4). Male sex, obesity, chronic kidney disease and risk SCORE were significantly more frequent in patients with arterial APS compared to patients with venous and/or obstetrical APS (38% vs 0%, P=0.01; 33% vs 0%, P=0.02; 38% vs 0%, P=0.01; 2.3 vs 0.7, P=0.03).

22 patients (76%) underwent an IMT measurement. Mean IMT was 0.57 (0.14) millimeters (mm). Median IMT was significantly higher in APS patient with stroke than in those without (0.63 IQR (0.55-0.77) mm versus 0.51 (0.44-0.55) mm, P=0.02) (Figure 1A). IMT was neither correlated with duration of APS nor with antibody titers.

Variables associated with IMT were studied on uni- and multivariate analysis (Table 1). On univariate analysis, age, aCL positivity and stroke were significantly associated with IMT and were included in the multivariate analysis. On multivariate analysis, there was a positive, independent and significant association between IMT and stroke (P=0.047) and between IMT and age (P=0.024). aCL positivity was not associated with IMT on multivariate analysis (Figure 1B).

Conclusion:

Intima-media thickness is independently associated with stroke in primary antiphospholipid antibody syndrome.

References:

[1]Medina G. Increased carotid artery intima-media thickness may be associated with stroke in primary antiphospholipid syndrome. Ann Rheum Dis. 2003;62(7):607-610. doi:10.1136/ard.62.7.607

Characters from table content including title and footnotes.

Table 1.

Predictors of intima-media thickness on uni- and multivariate analysis.

Univariate analysisMultivariate analysis*βP-valueβP-valueAge (years)0.006<0.0010.0040.024Female sex-0.1020.18APS duration (years)0.00040.31Smoker-0.050.61Overweight0.0660.39Arterial hypertension0.0470.48Hypercholesterolemia0.054290.412Anti-cardiolipin antibodies0.120.050.0840.076Anti-phospholipid antibodies0.0540.44Anti-β2GP10.0940.15Lupus-anticoagulant0.0440.49Anticoagulation-0.070.31Stroke0.1390.020.0990.047

β Linear regression coefficients

APS Antiphospholipid antibody syndrome

* Variables with a P-value <0.1 on univariate analysis were included

Figure 1.

A.Intima-media thickness according to stroke statusB.Multivariate analysis forest-plot of intima-media thickness predictorsOR Odds-ratioaCL anti-cardiolipin antibodies

Disclosure of Interests:

None declared

AB0772 JAK INHIBITORS IN REFRACTORY ADULT AND CHILDHOOD ONSET STILL’S DISEASE

Background:

Excessive and inappropriate production of pro-inflammatory cytokines such as interleukin (IL)-1, IL-6 or IL-18, is a pathogenic cornerstone in adult and childhood onset Still’s disease. Beyond therapies targeting IL-1 or IL-6, Janus kinases (JAK) inhibitors have been proposed for adult-onset Still’s disease (AOSD) patients refractory to or intolerant of treatment with biologicals. Recently, it has been suggested that JAK inhibitors might be efficient in refractory AOSD patients1.

Objectives:

To assess the efficacy and safety of JAK inhibitors in the treatment of refractory systemic juvenile idiopathic arthritis (sJIA) or AOSD.

Methods:

This retrospective study was based on a national survey of the departments of rheumatology, paediatric rheumatology and internal medicine in all French hospitals from an online call of the “Club Rhumatismes et Inflammation” (www.cri-net.com). The data were collected using a standardized questionnaire, and analyzed at different time points (treatment initiation, M1, M3, M6 and end of the follow-up). The response to JAK inhibitors was categorized as: complete remission (resolution of all clinical and biologic signs), partial remission (clinical improvement with persistence of a few symptoms) or failure (lack of clinical or biological improvement).

Results:

6 patients (5 adults and 1 child) were recruited (Table 1). Mean age at treatment start was 39.6 years for the AOSD patient and 6 years for the sJIA patient, and mean disease duration was 5.3 years. The clinical expression was predominantly systemic in 5 five patients and chronic articular in one. Response to corticosteroids, conventional synthetic or biological Disease Modifying Anti-Rheumatic Drugs had been considered inadequate in all patients. Baricitinib was used in 3 patients, ruxolitinib in 2, and tofacitinib in 1. Steroids were concurrently used in all patients, anakinra in one, methotrexate and anakinra in one. At a mean (SD) follow-up of 9.5 months, partial response was observed in 4 (66.7%) cases (patients with ruxolitinib, tofacitinib or baricitinib) and failure in 2 (33.3%) (patients with baricitinib). No patient achieved complete remission. At the last visit, steroids could be decreased but not stopped in all patients. Patients with partial response had an average decrease of 72,8% (90% for tofacitinib, 70% for baricitinib, 58.5% for ruxolitinib between the start and the follow-up end date) and non-responder patients were yet able to reduce steroids by 60,5% (Table 1). Tolerance of JAK inhibitors was excellent, however patient 4 experienced an episode of infectious pulmonary disease.

Conclusion:

JAK inhibitors therapy may be helpful for some patients with refractory Still’s disease. However, no complete response was observed in this short series of cases. There might be a difference of response between the molecules, although the number of patients is too low to draw conclusions. Additional information is thus needed to evaluate more precisely the risk-benefit ratio of this treatment, and a possible difference in efficacy among the different groups of JAK inhibitors.

References:

[1]Hu Q, Wang M, Jia J, et al. Ann Rheum Dis 2020;0:1–3. doi:10.1136/annrheumdis-2019-216

Table 1.

Characteristics of the AOSD patient

No.SexAge (year)Main symptomsTreatments before JAKi onsetJAK inhibitorsSteroids at onset (mg/day)Concomitant treatmentResponse at last F-USteroids at the end of F-U (mg/day)F-U (months)1F6Fever, polyarthritis, rashAINS, ANAKI, TOCI, CANAKI, ADA, THALI, INFLIXRUXOLITINIB 5mgx2/day30P1232M28Fever, polyarthritis, rashANAKIBARICITINIB 4mg/day800N1013M32Fever, polyarthritis, rashTOCI+MTX, ANAKI+MTX, CANAKI+MTX, ADA, CICLO, IgIVBARICITINIB 4mg/day16MTX 20 mg/week ANAKINRA 100mg/dayP12194F40Fever, polyarthritis, rashMTX, IMUREL, CICLO, ETANERCEPT, ANAKI+MTX, TOCI+MTX, IgIVRUXOLITINIB 15mgx2/day60ANAKI 200mg/dayP3045F48Fever, polyarthritis, rashTOCI, ANAKI, CICLO, CANAKI, IMURELTOFACITINIB 5mgx2/day500P7.596F50Fever, polyarthralgia, rashANAKIBARICITINIB 4mg/day600N401

F-U: Follow-up

N: No response

P: Partial response

Acknowledgements:

I thank all the coauthors, particularly Stéphane Mitrovic and Bruno Fautrel. Also, a special thank to the CRI.

Disclosure of Interests:

None declared

FRI0157 EPSTEIN BARR VIRUS BLOOD REPLICATION INCREASES DURING ACTIVE SYSTEMIC LUPUS ERYTHEMATOSUS

Background:

A role for Epstein Barr Virus (EBV) infection in Systemic Lupus Erythematosus (SLE) pathogenesis is highly suspected. The frequency of EBV seroprevalence and DNA detection in peripheral blood mononuclear cells are increased in SLE patients compared to healthy controls.

Objectives:

To analyse the relationship between EBV blood replication and SLE disease activity.

Methods:

Monocentric, observational and retrospective study of SLE patients (ACR or SLICC criteria) who have had a blood EBV DNA assessment using Polymerase Chain Reaction (artus® EBV Virus QS-RGQ assay) between 2012 and 2018. Exclusion criteria were: organ or bone marrow transplant, absence of EBV seroconversion and insufficient data. SLE clinical features, the Safety of Estrogens in Lupus Erythematosus National Assessment–Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) flare index (SFI) and therapeutic regimen on the day of EBV DNA load assessment were recorded. A SELENA-SLEDAI score > 4 defined an active SLE. A blood EBV DNA load ≥125 IU/mL was defined as elevated.

Results:

A total of 105 patients (98 women and 7 men) were included in the study. At inclusion, median (quartiles) age and SLE duration were 34 (23.5-43) and 7 (2-14) years old, respectively. Treatment were hydroxychloroquine (HCQ) (n = 67; 64%), prednisone (n = 66; 63%) with an average (±Standard Deviation) dose of 11.3 (±16) mg/day and an immunosuppressant (n = 42; 40%). According to SFI, 57 SLE patients were experiencing a flare at the time of EBV assessment; flares were classified as severe and mild/moderate in 38 (36%) and 19 (18%) SLE patients, respectively. According to the SELENA-SLEDAI score, 60 patients (57%) were deemed active and 45 (43%) inactive. Main clinical manifestations were arthritis in 32 (30%) patients, constitutional symptoms (fever, weight loss, anorexia or lymphadenopathy) in 31 (30%), cutaneous involvement in 23 (22%), glomerulonephritis in 19 (18%), cytopenia in 14 (13%), neuropsychiatric involvement in 13 (12%) and serositis in 10 (16%). Blood EBV DNA was elevated in 54 (90%) of the 60 patients with active lupus versus 6 (13%) of the 45 patients with inactive SLE (p <10-4). It was increased in 34 (89%) of the 38 patients with severe flare, in 17 (89%) of the 19 patients with a mild/moderate flare (p = 1) and in 8 (17%) of the 48 patients without flare (p <10-4vs severe flare and p <10-4vs mild/moderate flare). EBV DNA load correlated with SELENA-SLEDAI score (r=0.58; p<0.0001). Elevated blood EBV DNA was not associated with HCQ, prednisone or immunosuppressant intakes. Eighteen patients with active SLE had a second assessment of blood EBV DNA load. For these patients, the median [range] of viral load was significantly higher during periods of active SLE (236 [0-2680] IU/mL) compared with periods with lower SELENA-SLEDAI score (0 [0-1537] IU/mL, p<10-4in paired analysis).

Conclusion:

Blood EBV viral load is dramatically increased in active phase of SLE, independently of the treatment. We were unable to demonstrate whether the replication of EBV was the cause or the consequence or just an epiphenomenon of the disease activity. Further studies are needed to study whether EBV viral load is linked with Interferons secretion or B lymphocyte activation.

Disclosure of Interests:

None declared

AB1056 SYMPTOMATIC SCLEROSING MESENTERITIS REVEALING ERDHEIM-CHESTER DISEASE: A RARE CONDITION MEDIATED BY BRAF

Background:

Sclerosing Mesenteritis (SM) refers to an entire spectrum of digestive inflammatory disorders. Diagnosis is based on imaging showing an increase of fat attenuation displacing bowel loops and is in most cases non-symptomatic. Several conditions (abdominal trauma/surgery, neoplasia, infectious and inflammatory diseases) are responsible for SM (1). Among neoplasia, Erdheim-Chester disease (ECD) is a rare clonal histiocytosis characterized by long bone involvement, peri-nephric fat infiltration and cardio-vascular involvement associated with compatible histology (2). Biopsy is mandatory to confirm tissue infiltration by histiocytes and detect somatic mutation. Almost 80% of ECDpatients harbor mutation in mitogen activated protein(MAP) kinase pathway especiallyBRAFV600Egene mutation in about 60% of cases(3). No series of patients presenting both pathologies has been reported. Furthermore, no correlation withBRAFmutation status has been described in patient harboring SM and ECD.

Objectives:

To describe the clinical, radiological and mutational status of patients harboring SM and ECD.

Methods:

We reviewed the database of patients with histiocytic disorders in Besancon University Hospital. Patient required one abdominal computed tomography showing sclerosing mesenteritis and clinical/histological features of ECD to fulfill the inclusion criteria. All biopsy samples were investigated for mutation ofMAPkinase pathway gene.

Results:

Four patients suffered from SM and ECD. The median age at the diagnosis of ECD was 68 years old (61-72). All patients described abdominal pain and the mean duration between first symptoms and diagnosis of ECD was 12 months (4-19). The mean CRP level at diagnosis was 40.75 mg/L (5-117). Two patients were found to have myeloid neoplasms (chronic myelomonocytic leukemia (#2) and essential thrombocythemia (#4)) concurrent with ECD diagnosis.

Regarding abdominal computed tomography, all patients had a mesenteric mass associated with hyper-attenuated mesenteric fat and a “fat halo sign”. One patient (#2) had ascites and one had splenomegaly (#4) but no patient had enlarged lymph nodes. CT also demonstrated peri-nephric fat infiltration (“hairy kidney”) (4/4), vascular sheathing of aortic branches (3/4), adrenal hypertrophy (1/4) or ureter dilation (1/4). The mean SUVmaxof the mesentery was 7.5 (4.1-10.9) at diagnosis on (18F)- fluorodeoxyglucose-PET. Three patients underwent mesentery fat biopsy and all samples exhibited ECD histology. Regarding mutational status, 75% (3/4) patients hadBRAFV600Emutation.

After initiation of therapies for ECD (targeted therapies for ¾ patients), all patients had improvement of digestive symptoms and decreased of SUVmaxon evaluation18FDG-PET during the follow up.

Conclusion:

ECD should be investigated in patient with symptomatic SM especially if it is associated with peri-nephric fat infiltration. This condition is rare and might be driven by BRAF gene.

TABLE 2.Full term pregnancyMultiple gestationPreconception CZP exposureLabor complicationsMaternal infectionsNeonatal infections (< 6 m after birth)Congenital malformationsBreast-feedingNeonates, n/N15/152/155/150/151/150/150/156/15

References:

[1]Danford CJ, Lin SC, Wolf JL. Sclerosing Mesenteritis. Am J Gastroenterol. 2019 Jun;114(6):867–73.

[2]Diamond EL, Dagna L, Hyman DM, Cavalli G, Janku F, Estrada-Veras J, et al. Consensus guidelines for the diagnosis and clinical management of Erdheim-Chester disease. Blood. 2014 Jul 24;124(4):483–92.

[3]Haroche J, Cohen-Aubart F, Rollins BJ, Donadieu J, Charlotte F, Idbaih A, et al. Histiocytoses: emerging neoplasia behind inflammation. Lancet Oncol. 2017 Feb;18(2):e113–25.

Disclosure of Interests:

None declared

AB0038 IMMUNE PHENOTYPING OF ERDHEIM-CHESTER DISEASE THROUGH MASS CYTOMETRY

Background:

The understanding of Erdheim-Chester Disease (ECD) pathogenesis has been greatly improved these past few years with the discovery of activating MAPK pathway mutations in most of ECD patients. However, the inflammatory phenotype of ECD remains widely unknown.

Objectives:

We aimed to explore the inflammatory phenotype of Erdheim-Chester disease (ECD) using mass cytometry.

Methods:

We analyzed peripheral blood mononuclear cells from 13 ECD patients and 11 healthy donors (HD) using mass cytometry with 29 metal-conjugated antibodies.

Results:

Compared to HD, untreated ECD patients had increased proportion of classical monocytes (90.8 [87.1-96.5] vs 81.6 [76.2-87.5] %, p=0.02) and decreased proportion of non-classical monocytes (4.7 [3.4-9.7] vs 11.8 [6.6-17.2] %, p=0.047). Untreated ECD patients had more circulating Th17 cells compared to HD (3.3 [3-5.3] vs 1.3 [0.4-2.3] %, p=0.015) and ECD patients treated with BRAF or MEK inhibitors (3.3 (3-5.3] vs 1.9 [0.6-2.4] %, p=0.005). Moreover Treg cells were lower in ECD patients than HD, with an increased Th17/Treg ratio (1.37 [0.74-1.9] vs 0.34 [0.19-0.43], p=0.0004). There was no difference regarding Th1 cells, Th2 cells, B cells, NK cells and circulating dendritic cells.

Conclusion:

ECD monocyte profile seems similar to what have been described in CMML. Inflammation observed in ECD may be driven through Th17 cells, and might be targeted with specific treatment.

Disclosure of Interests:

None declared

First Component of Complement and Thrombosis

The previous demonstration of an association between the collagen-like region of Clq (subcomponent of the first component of complement) and human platelets and of the inhibitory properties of C1q on platelet adhesion and aggregation to or by collagen has led us to consider the first component of complement as a possible modulator of the platelet-collagen interaction. Since collagen represents a major component of the vessel wall, the modification of Cl could play a role in the development of thrombosis.

We have therefore studied two patients with abnormalities of complement (low or undetectable C1, C4, C2 and deficiency in C1 inhibitor) who presented with acquired angioneurotic oedema. Both patients had a history of multiple episodes of arterial and/or venous thrombosis.

Platelet associated C1q was decreased or undetectable, and this condition was associated with a specific increase of collagen induced aggregation thereby suggesting a possible mechanism for the recurrent thromboembolic episodes.

Geometrical Determinants of Neuronal Actin Waves

Hippocampal neurons produce in their early stages of growth propagative, actin-rich dynamical structures called actin waves. The directional motion of actin waves from the soma to the tip of neuronal extensions has been associated with net forward growth, and ultimately with the specification of neurites into axon and dendrites. Here, geometrical cues are used to control actin wave dynamics by constraining neurons on adhesive stripes of various widths. A key observable, the average time between the production of consecutive actin waves, or mean inter-wave interval (IWI), was identified. It scales with the neurite width, and more precisely with the width of the proximal segment close to the soma. In addition, the IWI is independent of the total number of neurites. These two results suggest a mechanistic model of actin wave production, by which the material conveyed by actin waves is assembled in the soma until it reaches the threshold leading to the initiation and propagation of a new actin wave. Based on these observations, we formulate a predictive theoretical description of actin wave-driven neuronal growth and polarization, which consistently accounts for different sets of experiments.

Efficacy of anti-TNF alpha in severe and/or refractory Behçet's disease: Multicenter study of 124 patients

OBJECTIVE

To report the efficacy and safety of anti-TNF agents in patients with severe and/or refractory manifestations of Behçet's disease (BD).

METHODS

We performed a multicenter study of main characteristics and outcomes of anti-TNF alpha treatments [mainly infliximab (62%), and adalimumab (30%)] in 124 BD patients [48% of men; median age of 33.5 (28-40) years].

RESULTS

Overall response (i.e. complete and partial) rate was 90.4%. Clinical responses were observed in 96.3%, 88%, 70%, 77.8%, 92.3% and 66.7% of patients with severe and/or refractory ocular, mucocutaneous, joint, gastro-intestinal manifestations, central nervous system manifestations and cardiovascular manifestations, respectively. No significant difference was found with respect to the efficacy of anti-TNF used as monotherapy or in association with an immunosuppressive agent. The incidence of BD flares/patient/year was significantly lower during anti-TNF treatment (0.2 ± 0.5 vs 1.7 ± 2.4 before the use of anti-TNF, p < 0.0001). The prednisone dose was significantly reduced at 6 and 12 months (p < 0.0001). In multivariate analysis, retinal vasculitis was negatively associated with complete response to anti-TNF (OR = 0.33 [0.12-0.89]; p = 0.03). The efficacy and relapse free survival were similar regardless of the type of anti-TNF agent used. After a median follow-up of 21 [7-36] months, side effects were reported in 28% of patients, including infections (16.3%) and hypersensitivity reactions (4.1%). Serious adverse events were reported in 13% of cases.

CONCLUSION

Anti-TNF alpha therapy is efficient in all severe and refractory BD manifestations. Efficacy appears to be similar regardless of the anti-TNF agent used (infliximab or adalimumab).

[Pathological features of radiofrequency ablation (RFA) renal scar CT-imaging in a swine model]

PURPOSE

To analyze the changes in vicinal kidney parenchyma after percutaneous RFA.

MATERIALS AND METHODS

[corrected] Twenty-four CT-guided RFA procedures were performed on six pigs using 2 cm LeVeen coaxial needles. We studied volume, morphology, cavitation and enhancement of the ablation zones (AZ) before and after the procedure on contrast-injected CT-scans. The kidneys were removed four weeks later and studied in the path lab.

RESULTS

All the procedures were successfully completed. Four weeks later, the CT-scans showed AZ that were either clearly circumscribed or with unclear borders, heterogenous areas associating necrosis and infarct tissue and mesenchyma showing a process of apoptosis around the edges. A treatment considered as incomplete on the CT-scan (presenting as an enhancement) was always associated with necrosis on the histology slides, although the necrotic areas behaved in various different ways on the CT-scan after injection of contrast medium: an enhancement of more than 10 HU did not mean that no necrotic tissue was present.

CONCLUSION

RFA causes heterogenous tissue changes, associating necrotic and ischemic zones and an apoptotic reaction. The mechanisms of these changes and their therapeutic significance should be studied. CT-scans performed immediately after RFA procedure and one month later are not predictive of the efficacy of the treatment because an enhancement of the AZ does not mean that it is not necrotic. The value of a CT-scan performed one month after the procedure is debatable, because the tissue remodeling that occurs in the kidneys is not definitive at this time-point.

Multi-locus HLA class I and II allele and haplotype associations with follicular lymphoma

Follicular lymphoma (FL) is an indolent, sometimes, fatal disease characterized by recurrence at progressively shorter intervals and is frequently refractive to therapy. Genome-wide association studies have identified single nucleotide polymorphisms (SNPs) in the human leukocyte antigen (HLA) region on chromosome 6p21.32-33 that are statistically significantly associated with FL risk. Low to medium resolution typing of single or multiple HLA genes has provided an incomplete picture of the total genetic risk imparted by this highly variable region. To gain further insight into the role of HLA alleles in lymphomagenesis and to investigate the independence of validated SNPs and HLA alleles with FL risk, high-resolution HLA typing was conducted using next-generation sequencing in 222 non-Hispanic White FL cases and 220 matched controls from a larger San Francisco Bay Area population-based case-control study of lymphoma. A novel protective association was found between the DPB1*03:01 allele and FL risk [odds ratio (OR) = 0.39, 95% confidence interval (CI) = 0.21-0.68]. Extended haplotypes DRB1*01:01-DQA1*01:01-DQB1*05:01 (OR = 2.01, 95% CI = 1.22-3.38) and DRB1*15-DQA1*01-DQB1*06 (OR = 0.55, 95% CI = 0.36-0.82) also influenced FL risk. Moreover, DRB1*15-DQA1*01-DQB1*06 was highly correlated with an established FL risk locus, rs2647012. These results provide further insight into the critical roles of HLA alleles and SNPs in FL pathogenesis that involve multi-locus effects across the HLA region.

[Improvement of pulmonary angiography in the framework of a maintenance of certification]

PURPOSE

This evaluation of clinical practices (pulmonary embolus) was performed to evaluate the quality of CT pulmonary angiograms for suspected acute pulmonary embolus.

MATERIALS AND METHODS

Five validated criteria evaluating both the acquisition technique and the quality of image interpretation were selected: slice thickness, pulmonary arterial enhancement over 250 HU, caudocranial acquisition, visualization of fifth order pulmonary arterial branches, and right-left ventricular ratio in the presence of pulmonary embolus. Forty CT pulmonary angiograms were reviewed before and after implementation of a practice quality improvement program: modification of acquisition protocol, training of medical and paramedical staff, and implementation of a standardized radiology report.

RESULTS

Thin collimation was already implemented. The implementation of two other technical parameters significantly improved the technical quality of the examinations. The detection of findings with adverse clinical outcome was also significantly improved. Only the accuracy of detection of embolus involving fifth order pulmonary arterial branches could not be improved, a criteria allowing formal exclusion of pulmonary embolus.

CONCLUSION

This study resulted in an improvement in the quality of CT pulmonary angiograms and increased awareness of radiologists for the prognostic value of right ventricular dilatation. It has also underscored the need for quality control of a CT pulmonary angiogram prior to interpretation.

[Urokinase in the management of occluded PICC lines]

PURPOSE

To determine the efficacy and safety of urokinase in the management of occluded PICC lines.

MATERIALS AND METHODS

A total of 587 PICC lines were placed over an 11 month period. During this period, 28 PICC lines (4.8%) became occluded: 12 occluded PICC lines were successfully managed by simple flushing with normal saline while 16 PICC lines were thrombolyzed with urokinase.

RESULTS

After urokinase, 93.8% (15/16) of occluded PICC lines were completely patent. A single infusion of urokinase, 20,000 IU over 30 minutes, was used in all cases. No secondary occlusion or complication was noted after urokinase.

CONCLUSION

Urokinase is effective and safe to restore patency to occluded PICC lines. The procedure is simple, and could be performed at the bedside by nursing staff after medical prescription. It is an alternative to over the wire PICC line exchange, that could reduce the risk of complication related to manipulations, patient discomfort and cost.

[Imaging of mediastinal tumors]

Imaging of mediastinal tumors is an important part of the diagnostic workup in patients presenting symptoms suggestive of compression of one or more of the mediastinal components. In other cases, lesions growing within the mediastinum remain asymptomatic and are diagnosed when chest X-ray or CT are routinely performed for other indications. CT remains the most available and reliable tool among the different imaging methods. Due to its permanent technical improvements, it can be used as the one-step answer to all the requirements of the pretherapeutic evaluation of a mediastinal mass. Chest plain film is still needed as the first line examination in order to carefully select the acquisition protocol for CT. MR did not demonstrate any superiority to CT except for the preoperative workup of lesions arising in the posterior part of the mediastinum. MR remains an interesting tool for tissue characterisation. Topography of mediastinal lesions (based upon the definition of mediastinal compartments) is one of the guides through the diagnostic pathway in imaging these tumors. The other one is their main tissue component, so that cystic, fatty and soft tissue masses can be differentiated.

Management of cervical lymph node recurrence of melanoma of the head and neck

OBJECTIVES

To compare the diagnostic accuracy between Positron emission tomography using 2-[fluorine-18] fluoro-2-deoxy-D-glucose (FDG-PET scan) and conventional work-up such as ultrasound (US) and/or Computed tomography (CT) in the detection of cervical lymph node recurrences of melanoma of the head and neck after initial cervical lymph node surgery.

METHODS

A retrospective review was performed on patients who presented with clinical and/or radiological suspicion of isolated cervical lymph node recurrence after lymph node surgery from April 2004 to January 2007. All patients underwent CT and/or US of the neck, and FDG-PET scan before salvage neck dissection. None of included patients had clinical or radiological detectable distant metastases at the time of the lymph node dissection. Performances of conventional imaging and FDG-PET scan in detection of lymph node recurrence were calculated and compared by using the histopathological results of lymphadenectomy as gold standard with Fischer's exact test.

RESULTS

Of the twelve cases in included in the study (9 patients, 3 of them had 2 consecutive lymph node redissection for a second lymph node recurrence), melanoma recurrence was found in 10 cases (83%). Sensitivity, specificity, positive predictive value and negative predictive values were 78.6%, 40%, 78.6%, and 40% respectively for conventional imaging and 85.7%, 40%, 80% and 50% for FDG-PET scan. No statistically significant difference was found between the 2 methods.

CONCLUSION

This is the first study that compares the diagnostic accuracy between FDG-PET scan and conventional imaging in the detection of cervical lymph node recurrence of melanoma of the head and neck. Our results showed that FDG-PET scan is actually not better than conventional imaging to detect these cervical lymphatic recurrences.

[Cervical lymph nodes]

Imaging plays a chief role in the care and monitoring of patients in cervico-facial oncology. The radiologist must know the anatomy of different lymph nodes as well as signs of malignancy (hypertrophy, enhancement, necrosis, capsular rupture, etc.). CT is still the first-line examination because of its high reliability, its accessibility and its ability to make an assessment of the upper aero digestive ways at the same time. Ultrasound is very accuracy, and allows the realization of cytoponction, but does not provide a complete exploration of the neck. MRI does not appear to be indicated for the first intention, but the new rapid sequences (STIR, diffusion) seem interesting. The PET-CT is useful in post-therapeutic management of patients, and probably in the initial staging, but its accessibility is poor.

[Role of diffusion weighted MR in the diagnosis of parotid tumours]

OBJECTIVE

To evaluate the contribution of sequences of diffusion for the diagnosis of nature of the tumours of the parotid.

METHODS

Retrospective study based on 29 patients all operated of a parotid tumour They had a MRI in conventional acquisition (T1, T1 Gadolinium, T2) and in sequences of diffusion. An ADC cartography (apparent coefficient of diffusion) and an ADC ratio between the tumoral area and the healthy controlateral parotid were successively analyzed by two experienced radiologists. We calculated the effectiveness of these MRI sequences, focusing more particularly on the diagnosis of the malignant tumours. We also determined the sensitivity and the specificity of the sequences of diffusion, with their positive and negative predictive values.

RESULTS

On the 7 malignant tumours, 3 had been classified wrongly like benign thanks to the only cartography of diffusion. We obtained a sensitivity of this examination for the diagnosis of malignity of 57%. Out of the 22 benign tumours, 1 only was classified wrongly like malignant. The specificity of the diffusion for the diagnosis of malignity thus rose with 95%, its positive predictive value with 80% and its negative predictive value to 87%. It should be noted that all the malignant tumours had an ADC ratio lower or equal to 1.8.

CONCLUSIONS

The histological characteristics of the malignant tumours of the parotid are very variable. Generally, they have large nuclei associated with a hypercellularity involving a decrease of the ADC. The results of this MRI sequence are encouraging even if they remain not very reliable in front of cystic or necrotic tumours.

Stereoselection in the Prins-pinacol synthesis of acyltetrahydrofurans

[reaction: see text]. Depending upon the nature of the alkene and allylic substituents, acid-promoted rearrangements of acetals derived from anti allylic diols give 12 or stereoisomeric acyltetrahydrofurans 13. Stereoelectronic effects of the allylic substituents and the extent of bonding in the Prins cyclization transition state are central features of a proposed new model for predicting stereoselection in the Prins-pinacol synthesis of acyltetrahydrofurans.

Recall bias in a prospective cohort study of acute time-varying exposures: example from the herpetic eye disease study

Recall bias is possible in a prospective cohort study when exposure status is transient and must be periodically recalled, and ascertainment occurs after symptom onset. We know of no published demonstration of such bias at play in a prospective cohort study. In a substudy of a randomized clinical trial, 308 participants were prospectively followed to investigate potential acute triggers of ocular herpes simplex virus (HSV) recurrences. Participants reported on the presence of systemic infection or high psychological stress (exposures) on a home log that was completed weekly for up to 15 months and mailed to the study's coordinating centers. By protocol, exposure reporting was to occur on the last day of the week (Sunday) so that a prospective 1-week lag period between exposure and outcome in the following week could be assessed. The study outcome was development of a recurrence of ocular HSV disease documented by clinical examination. Using 35 weekly reports of exposure properly completed before the week of an outcome, there was no evidence of higher risk of HSV recurrence associated with systemic infection (rate ratio = 0.62, 95% confidence interval [CI]: 0.19-2.02) or high psychological stress rate (ratio = 0.0, 95% CI: 0.0-undefined). In contrast, when the analysis was based on 26 weekly reports of exposure improperly completed on or after the date of outcome, the risk of recurrence associated with systemic infection was estimated to be 4-fold (rate ratio = 4.07, 95% CI: 1.84-8.98), and there was a suggestion of a 2-fold risk associated with high psychological stress (rate ratio = 2.02, 95% CI: 0.69-5.91). Without real-time monitoring of exposure reporting, preservation of the temporal exposure-disease relationship-an implicit assumption of the prospective cohort study design-may be particularly tenuous when transient exposures are investigated longitudinally.

Effects of surgery type and attention focus on children's coping

BACKGROUND

How children cope with minor or major surgery is influenced by their attention focus appraisals. Although factors that predict children's coping with surgery have been identified (i.e., age, locus of control, parent-doctor information, worry), it still is not known whether the type of surgery per se affects the coping strategies used and influences previously established predictors of coping. Furthermore, questions remain concerning the relation among type of surgery, attention focus, and coping.

OBJECTIVES

The purpose of this study was to determine whether the type of surgery (minor vs. major) would have a differential effect on coping, and whether coping can be predicted better if it is known what type of attention focus (appraisal) the child has.

METHODS

Data from three studies of children (n = 189) undergoing minor or major surgery were combined to examine the effects that type of surgery and attention have on coping. Measures included the Preoperative Mode of Coping Interview, Locus of Control Scale for Children, Parent-Doctor Information Interview, and a measure for worry.

RESULTS

The results showed that the factors previously found to predict coping were upheld in the combined sample and accounted for 50% of the variance in coping. Type of surgery was significantly associated with coping: Children undergoing minor surgery were somewhat more vigilant than children undergoing major surgery. The inclusion of attention in the analysis significantly improved the variance explained in coping (66%), and children who had a concrete-objective focus of attention were found to be more vigilant. Significant interactions were found between attention focus and type of surgery, locus of control, and age. Type of surgery also had a significant interaction with worry. Children who focused on the concrete-objective aspects of the situation were more vigilant if they were having minor rather than major surgery. Also, children who had an internal locus of control and a concrete-objective focus of attention were more vigilant in coping. Regardless of age, children who had a concrete-objective focus of attention were more vigilant. Furthermore, at low levels of worry, children undergoing major surgery were more vigilant than children undergoing minor surgery.

CONCLUSIONS

Coping with surgery is influenced by multiple factors. Children's ability to focus attention on the concrete-objective aspects of surgery may help to reduce feelings of threat that could impede their use of vigilant coping.

Asymmetric total synthesis of batzelladine D

[formula: see text] The first enantioselective total synthesis of a batzelladine alkaloid is described. The central reaction in the synthesis of (-)-batzelladine D (2) is a tethered Biginelli condensation of a guanidine aldehyde and an acetoacetic ester to generate a 7-substituted-1-iminohexahydropyrrolo-[1,2-c]pyrimidine intermediate having the anti stereochemistry of the methine hydrogens flanking the pyrrolidine nitrogen.

Both raloxifene and estrogen reduce major cardiovascular risk factors in healthy postmenopausal women: A 2-year, placebo-controlled study

Currently raloxifene, a selective estrogen receptor modulator, is being investigated as a potential alternative for postmenopausal hormone replacement to prevent osteoporosis and cardiovascular disease. We compared the 2-year effects of raloxifene on a wide range of cardiovascular risk factors with those of placebo and conjugated equine estrogens (CEEs). Analyses were based on 56 hysterectomized but otherwise healthy postmenopausal women aged 54. 8+/-3.5 (mean+/-SD) years who entered this double-blind study and who were randomly assigned to raloxifene hydrochloride 60 mg/d (n=15) or 150 mg/d (n=13), placebo (n=13), or CEEs 0.625 mg/d (n=15). At baseline and after 6, 12, and 24 months of treatment, we assessed serum lipids, blood pressure, glucose metabolism, C-reactive protein, and various hemostatic parameters. Compared with placebo, both raloxifene and CEEs lowered the level of low density lipoprotein cholesterol by 0.53 to 0.79 mmol/L (all P<0.04) and lowered, at 24 months, the level of fibrinogen by 0.71 to 0.86 g/L (all P<0.05). The effects of raloxifene and CEEs did not differ significantly. In contrast to raloxifene, from 6 months on CEEs increased high density lipoprotein cholesterol by 0.25 to 0.29 mmol/L and reduced plasminogen activator inhibitor-1 antigen by 30.6 to 48.6 ng/mL (all P<0.02 versus both placebo and raloxifene). CEEs transiently increased C-reactive protein by 1.0 mg/L at 6 months (P<0.05 versus placebo) and prothrombin-derived fragment F1+2 by 0. 79 nmol/L at 12 months (P<0.001 versus placebo). Finally, from 12 months on, CEEs increased triglycerides by 0.33 to 0.56 mmol/L (all P<0.05 versus both placebo and raloxifene). Our findings suggest that in healthy postmenopausal women, raloxifene and estrogen monotherapy have similar beneficial effects on low density lipoprotein cholesterol and fibrinogen levels. These treatments differ, however, in their effects on high density lipoprotein cholesterol, triglycerides, and plasminogen activator inhibitor-1 and possibly in their effects on prothrombin fragment F1+2 and C-reactive protein.

Persistent stress as a predictor of genital herpes recurrence

BACKGROUND

Results of several studies suggest that psychological stress and negative mood can trigger genital herpes recurrences, but results are inconsistent.

OBJECTIVE

To determine whether short-term or persistent psychological stress or specific negative moods are predictive of genital herpes recurrences in women.

METHODS

A prospective cohort study followed up participants for 6 months using weekly assessments of stress and mood, monthly assessments of life change events, and diary reports of genital herpes recurrences confirmed by medical examination when feasible. The community sample consisted of 58 women, aged 20 to 44 years, with a 1- to 10-year history of visible genital herpes recurrence and at least 1 recurrence in the previous 6 months.

RESULTS

Persistent stress predicted recurrence in the subsequent week (odds ratio, 1.08 per unit increase in stress; 95% confidence interval, 1.01-1.15; P=.03). After adjusting for recurrence in the previous week, the more weekly persistent stress reported, the greater the likelihood of recurrence the following week. Also, an increased recurrence rate occurred after the month during which participants experienced their highest levels of anxiety (P =.03). There were no significant associations between recurrence and short-term stress, life events, depressive mood, anger, or phase of menstrual cycle.

CONCLUSIONS

Persistent stressors and highest level of anxiety predicted genital herpes recurrence, whereas transient mood states, short-term stressors, and life change events did not. Women with herpes can be reassured that short-term stressful life experiences and dysphoric mood states do not put them at risk for increased outbreaks of recurrent genital herpes.