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.

150 - La cinétique des D-dimères pendant l'hospitalisation est un facteur pronostique majeur de décès chez les patients hospitalisés pour COVID-19

Contexte

La tendance évolutive des D-dimères pourrait être un facteur prédictif de la gravité de cette maladie mais est très peu étudié. Cette étude avait pour objectif d'identifier des phénotypes biologiques d’évolution des D-dimères et leur valeur pronostique sur le risque de décès ou de thrombose chez les patients hospitalisés pour COVID-19.

Méthodes

Étude monocentrique incluant 270 patients hospitalisés pour COVID-19 au CHRU de Nancy du 21/02/20 au 12/05/20. Les données biologiques et cliniques ont été́ recueillies à l'aide des dossiers médicaux informatisés des patients. Le dosage des D-dimères plasmatiques mesurés par méthode immuno-enzymatique. Le critère de jugement principal était la mortalité toutes causes et le critère secondaire était la survenue d’événements thrombotiques. Nous avons utilisé le modèle conjoint à classes latentes qui permet de modéliser simultanément les trajectoires latentes de D-dimères et le risque de décès ou de thrombose.

Résultats

Trois types de trajectoires de D-dimères ont été identifiés : trajectoire 1) « Niveau initial élevé puis décroisant » (n=65, 24,1 %); trajectoire 2) « Niveau initial bas puis augmentation rapide » (n=18, 6,6 %); trajectoire 3) « Niveau initial modéré puis stable » (n=187, 69,3 %). Dans l'ensemble de l’échantillon les taux de décès et de thromboses étaient de 14,4 % (38/270) et 12,2 % (32/263) respectivement. Comparée à la trajectoire 3, les patients des trajectoires 1 et 2 avaient un risque de décès 3,6 (HR=3,6 [1,1–12,3], p=0,037) et 18,1 (HR=18,1 [4,3–76,2], p<0,0001) fois plus élevées respectivement. Le risque de thrombose n’était pas significativement différent entre les trois trajectoires.

Conclusion

Cette étude a montré qu'un niveau très élevé de D-dimères à l'admission ou un niveau bas mais avec une augmentation rapide durant l'hospitalisation sont des facteurs pronostiques important de la sévérité de la COVID-19. Un suivi rapproché de la cinétique des D-dimères, notamment dès les premiers jours d'hospitalisation devrait être renforcé chez ces patients.

Déclaration de liens d'intérêts

Les auteurs déclarent ne pas avoir de liens d'intérêts.

Pseudoxanthoma elasticum overlaps hereditary spastic paraplegia type 56

PURPOSE

Pseudoxanthoma elasticum (PXE) is a recessive disorder involving skin, eyes and arteries, mainly caused by ABCC6 pathogenic variants. However, almost one fifth of patients remain genetically unsolved despite extensive genetic screening of ABCC6, as illustrated in a large French PXE series of 220 cases. We searched for new PXE gene(s) to solve the ABCC6-negative patients.

METHODS

First, family-based exome sequencing was performed, in one ABCC6-negative PXE patient with additional neurological features, and her relatives. CYP2U1, involved in hereditary spastic paraplegia type 56 (SPG56), was selected based on this complex phenotype, and the presence of two candidate variants. Second, CYP2U1 sequencing was performed in a retrospective series of 46 additional ABCC6-negative PXE probands. Third, six additional SPG56 patients were evaluated for PXE skin and eye phenotype. Additionally, plasma pyrophosphate dosage and functional analyses were performed in some of these patients.

RESULTS

6.4% of ABCC6-negative PXE patients (n = 3) harboured biallelic pathogenic variants in CYP2U1. PXE skin lesions with histological confirmation, eye lesions including maculopathy or angioid streaks, and various neurological symptoms were present. CYP2U1 missense variants were confirmed to impair protein function. Plasma pyrophosphate levels were normal. Two SPG56 patients (33%) presented some phenotypic overlap with PXE.

CONCLUSION

CYP2U1 pathogenic variants are found in unsolved PXE patients with neurological findings, including spastic paraplegia, expanding the SPG56 phenotype and highlighting its overlap with PXE. The pathophysiology of ABCC6 and CYP2U1 should be explored to explain their respective role and potential interaction in ectopic mineralization.

Fetal biometry in ultrasound: A new approach to assess the long-term impact of simulation on learning patterns

CONTEXT

Simulation-based education (SBE) has demonstrated its acceptability and effectiveness in improving ultrasound training. Because of the high cost of its implementation (investment in equipment and supervision), a pragmatic assessment of the transfer of skills learned in SBE to clinical practice and the identification of its optimal scheduling conditions have been requested to optimize its input.

OBJECTIVES

To quantify the long-term impact of simulation-based education (SBE) on the adequate performance of ultrasound fetal biometry measurements (I). The secondary objective was to identify the temporal patterns that enhanced SBE input in learning (II).

METHODS

Trainees were arbitrarily assigned to a 6-month course in obstetric ultrasound with or without an SBE workshop. In the SBE group, the workshop was implemented 'before' or at an 'early' or a 'late-stage' of the course. Those who did not receive SBE were the control group. The ultrasound skills of all trainees were prospectively collected, evaluated by calculating the delta between OSAUS (Objective Structured Assessment of Ultrasound Skills) scores before and after the course (I). Concomitantly, the accuracy of trainees' measurements was assessed throughout the course by verifying their correlation with the corresponding measurements by their supervisors. The percentage of trainees able to perform five consecutive sets of correct measurements in the control group and in each SBE subgroup were compared (II).

RESULTS

The study included 61 trainees (39 SBE and 22 controls). Comparisons between groups showed no significant difference in the quantitative assessment of skill enhancement (difference in the pre- and post-internship OSAUS score: 1.09 ± 0.87 in the SBE group and 0.72 ± 0.98 in the control group) (I). Conversely, the predefined acceptable skill level was reached by a significantly higher proportion of trainees in the 'early' SBE subgroup (74%, compared with 30% in the control group, P<0.01)(II).

CONCLUSIONS

The quantitative assessment does not support the existence of long-term benefits from SBE training, although the qualitative assessment confirmed SBE helped to raise the minimal level within a group when embedded in an 'early' stage of a practical course.

OP0097 DEVELOPMENT OF NEW INTERNATIONAL CLASSIFICATION CRITERIA FOR ANTIPHOSPHOLIPID SYNDROME: PHASE III CASE COLLECTION RESULTS

Background:

An international multi-disciplinary effort is underway to develop rigorous, new, consensus- and evidence-based classification criteria for Antiphospholipid Syndrome (APS). The methodological approach includes four phases; we have previously presented phases I and II (item generation and reduction), which resulted in 27 candidate criteria1organized in laboratory and clinical domains.

Objectives:

Phase III (item weighting/threshold identification) is currently underway; here we report initial Phase III case collection results.

Methods:

We used REDCap, a secure data system, for Phase III international case collection. The candidate criteria of 27 items at the end of Phase II was represented in a standardized case collection form. We asked international physicians interested in APS to provide and rate cases using a Likert scale (+3 to -3: highly likely to highly unlikely to be APS). Cases with higher scores (+2 or +3) were categorized as “highly likely” APS, whereas lower scores (+1 to -3) were categorized as “equivocal or unlikely” APS.

Results:

We collected 314 potential APS cases (mean age 43.8±14.4 years; 79% female; and 77% white) between 6/2019-8/2019 from 17 sites in Europe (47%), North America (41%), and South America (11%). Majority of cases were potential primary APS (64%); 137 were rated as “highly likely” and 177 as “equivocal or unlikely” APS. Lupus anticoagulant, antiβ2glycoprotein-I antibody IgG/M, anticardiolipin antibody IgG, arterial thrombosis, venous thromboembolism, microvascular disease, fetal loss between 16-34 weeks, severe preeclampsia, severe placental insufficiency, cardiac valve disease, and low platelet count occurred with higher frequency in the APS cases categorized as “highly likely” (Table).

Conclusion:

International collection of cases spanning the spectrum of “highly likely” to “equivocal or unlikely” APS provide “real world” assessment of patients being referred for APS evaluation. In next steps, proposed candidate criteria will be further refined, organized, and weighted, and a preliminary threshold for APS classification will be determined.

References:

[1]Barbhaiya M et al. Phase II Results [abstract]. Arthritis Rheumatol. 2019;71 (suppl 10).

Table.

Characteristics of Potential APS Cases Categorized by Physician Assessment

Candidate Relative Criteria, n (%)Total(n=314)Highly Likely APS(n=137)Equivocal or Unlikely APS(n=177)LABORATORYLupus Anticoagulant Test208 (66)117 (85)91 (51)Anticardiolipin Antibody• IgG170 (54)90 (66)80 (45)• IgM138 (44)61 (45)77 (44)Antiβ2glycoprotein-I Antibody• IgG99 (32)66 (48)33 (19)• IgM79 (25)47 (34)32 (18)CLINICALMacrovascular• Superficial Vein Thrombosis15 (5)4 (3)11 (6)• Venous Thromboembolism95 (30)63 (46)32 (18)• Transient Ischemic Attack27 (9)13 (10)14 (8)• Arterial Thrombosis82 (26)58 (42)24 (14)Microvascular*86 (27)62 (45)24 (14)Obstetric**• Embryonic Loss (<10 weeks [w])85 (45)34 (42)51 (48)• Fetal Loss (10w–<16w)20 (11)9 (11)11 (10)• Fetal Loss (16w–34w)42 (22)32 (40)19 (18)• Severe Preeclampsia (<34w)27 (14)18 (22)9 (8)• Severe Placental Insufficiency (<34w)22 (12)13 (16)9 (8)Cardiac Valve Disease***32 (10)21 (15)11 (6)Thrombocytopenia <150 G/L72 (23)43 (31)29 (16)

*Livedo racemosa, livedoid vasculopathy, adrenal hemorrhage, acute ischemic enceophalopathy, cardiac microvascular disease, pulmonary hemorrhage, acute and/or chronic antiphospholipid-related nephropathy; **Total number of patients ever pregnant: 188 (highly likely APS: 81; unlikely APS: 107) ***Valve thickening and/or vegetation.

Acknowledgments:

The project is supported by ACR/EULAR

Disclosure of Interests:

Medha Barbhaiya: None declared, Doruk Erkan: None declared, Yasaman Ahmadzadeh: None declared, Karen Costenbader Grant/research support from: Merck, GSK, Consultant of: Merck, GSK, Lily, Astra Zeneca, Janssen, Raymond Naden: None declared, Stéphane Zuily: None declared

[Training in fetal ultrasound biometry: Prospective assesment of Objective Structured Assessment of Ultrasound Skills (OSAUS) efficiency]

BACKGROUND

Fetal biometry quality directly influences obstetrical care relevance. However, obstetrician proficiencies are heterogeneous in particular during initial training.

OBJECTIVES

To assess the predictive value of OSAUS scale to identify operators with enough command to perform a valid estimation of fetal weight (EFW) (I). This study also assesses OSAUS intra-operator inter-exams variability (II) and pass/fail score relevancy (III).

METHODS

Lecturers in Nancy University Hospital assessed trainees' proficiency for EWF systematically and prospectively through OSAUS scale. The trainee assessment was performed right after the one of the senior operator (reference EFW) on three consecutive patients during standard care ultrasounds. To ensure variability in proficiency within the sample, previous practice was taken into account during enrollment ("novices" and "intermediates" for<20 and 20 past exams, respectively). Correlation between mean OSAUS and validity of EFW (a valid EFW was defined by a difference with the reference EWF<0.8 Z-score) and variability between consecutive assessments were assessed.

RESULTS

The study population was constituted of 8 "novice" and 8 "intermediate" trainees. Association between OSAUS and EFW validity was significant (P<0.03) (I). Intra-operator inter-exams variability was majored in the "novice" group (coefficients of variation were 25% vs. 10% in "novice" and "intermediate" group respectively) (II). Within the sample, specificity and positive predictive value of a pass/fail score OSAUS>3.5 to predict EFW validity were 77% and 71%, respectively (III).

CONCLUSION

A 3.5 OSAUS pass/fail score could provide a relevant threshold to estimate operator proficiency in assessing fetal biometry in an autonomous and secure way.

Hydroxychloroquine in the primary thrombosis prophylaxis of antiphospholipid antibody positive patients without systemic autoimmune disease

Objective The objective of this study was to determine the efficacy of hydroxychloroquine (HCQ) in the primary thrombosis prevention of antiphospholipid antibody (aPL)-positive patients with no other systemic autoimmune diseases. Methods Under the auspices of Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking, a multicenter, international, randomized controlled trial (RCT) was initiated, in which persistently aPL-positive but thrombosis-free patients without systemic autoimmune diseases were randomized to receive HCQ or no treatment in addition to their standard regimen. The primary objective was the efficacy of HCQ in preventing the first thrombosis. The secondary objectives were the thrombosis incidence rate, and the effects of HCQ on aPL profile and mortality rate. Patients were risk-stratified based on antiplatelet agent use. The goal was to follow patients every 6 months for 5 years. Results We recruited 20 persistently aPL-positive patients (female: 19, mean age: 46.6 ± 9.9 years, and baseline antiplatelet medication: 14); 9/20 were randomized to HCQ. During the mean follow-up of 1.7 years, no patients developed thrombosis or a serious adverse event. The study was terminated early due to the low recruitment rate, exacerbated by the prolonged manufacturing shortage and significant price increase of HCQ in the United States. Conclusion Given that a small number of patients with a relatively short follow-up were enrolled in our RCT, and no patients developed thrombosis, we cannot accurately assess the effectiveness of HCQ for primary thrombosis prevention in persistently aPL-positive patients with no other systemic autoimmune diseases. Our experience suggests that conducting an international RCT, especially without pharmaceutical support, is an extremely challenging undertaking.

Extensive lymph node dissection during pancreaticoduodenectomy: a risk factor for hepatic steatosis?

PURPOSE

The first reports of hepatic steatosis following pancreaticoduodenectomy (PD) were published several years ago; however, clear risk factors remain to be identified. Therefore, the aim of this study was to identify the risk factors for hepatic steatosis post-PD.

METHODS

We studied 90 patients who had undergone PD between September 2005 and January 2015. The inclusion criteria were as follows: available unenhanced CT within one month before PD and at least one unenhanced CT acquisition between PD and chemotherapy initiation. Using scanners, we studied the liver and spleen density as well as the surface areas of visceral (VF) and subcutaneous fat (SCF). These variables were previously identified by univariate and multivariate analyses.

RESULTS

Hepatic steatosis occurred in 25.6% of patients at 45.2 days, on average, post-PD. Among the patients with hepatic steatosis, the average liver density was 52 HU before PD and 15.1 HU post-PD (p < 0.001). The Patients with hepatic steatosis lost more VF (mean, 28 vs. 11 cm²) and SCF (28.8 vs. 13.7 cm²) (p < 0.01 and p = 0.01, respectively). Portal vein resection and extensive lymph node dissection were independent risk factors in the multivariate analysis (odds ratio [OR] 5.29, p = 0.009; OR 3.38, p = 0.04, respectively).

CONCLUSION

Portal vein resection and extensive lymph node dissection are independent risk factors for post-PD hepatic steatosis.

Reversible drug-induced antiphospholipid syndrome

We report an original case of reversible antiphospholipid syndrome (APS) due to minocycline in a young male patient who experienced recurrent strokes while taking minocycline. He started minocycline therapy (50 mg twice daily) at 15 years old for acne. After three years of treatment, the patient experienced a lateral medullary syndrome. He was treated with aspirin while minocycline was continued. Eighteen months later, the patient complained about horizontal binocular diplopia. MRI revealed an infarct of the oculomotor nerve nucleus. Laboratory investigations revealed high titers of anti-beta 2 glycoprotein 1 (antiβ2GP1) antibodies of 470 U/ml (normal range <15 U/ml) and antiphosphatidylethanolamine antibodies of 137.4 U/ml (normal range <18 U/ml). Other laboratory tests were normal. Six weeks after discontinuation of minocycline, anti-β2GP1 antibodies decreased to 335 U/ml and to 36 U/ml at six months and then remained negative for six years. Many drugs have been considered as possibly causing APS but only in a limited number of patients. To our knowledge this is the first case of drug-induced APS with complete disappearance of high titers of anti-β2GP1 antibodies after minocycline withdrawal. This case also illustrates the need to monitor the levels of antiphospholipid antibodies, even though initial values are high and confirmed after 12 weeks.

[Development of an objective structured clinical examination (OSCE) for evaluating clinical competence in vascular medicine]

OBJECTIVES

Vascular medicine is now a clinical specialty in France. During their studies, students will acquire clinical reasoning in addition to technical skills. An Objective Structured Clinical Examination (OSCE) is considered as the gold standard for evaluating clinical competence. Our main objective was to evaluate the feasibility and acceptability of OSCE for the evaluation of students, secondarily their performance.

METHODS

Three representative clinical cases of the specialty were developed. The OSCE consisted of a sequence of clinical situations presented in three stations of 7minutes each. The role of the simulated patient was played by medical students. At the end of the OSCE, observers and students completed the evaluation form. We compared the performances between junior and senior vascular medicine students. Written questionnaires were used to measure OSCE satisfaction.

RESULTS

We were able to develop and organize this examination without difficulties. Fifteen students were evaluated. All participants agreed that the clinical situations were representative of vascular medicine practice, the cases were realistic and standardized patients were convincing. The performance of senior students was statistically higher than junior students in one case.

DISCUSSION

Our study demonstrates the feasibility and acceptability of the OSCE in students in vascular medicine. The small number of stations and candidates requires further studies on a larger scale to evaluate their performance.

Impairment of quality of life in patients with antiphospholipid syndrome

OBJECTIVES

Health-related quality of life (HRQoL) has not been fully explored in antiphospholipid syndrome (APS); therefore, we compared HRQoL between APS patients and the general population and assessed the impact of thromboembolic history.

METHODS

HRQoL was measured in a multicentre cohort study by the Medical Outcomes Study Short-Form 36 (MOS-SF-36) questionnaire. HRQoL scores were compared to the French general population norms. Factors significantly associated with an impaired HRQoL were identified.

RESULTS

A total of 115 patients with aPL and/or systemic lupus erythematosus (SLE) were included (mean age 42.7 ± 14.1 years old, 86 women). In 53 patients APS was diagnosed. Compared to general population norms, patients with APS had an impaired HRQoL. SLE-associated APS patients had the worst HRQoL scores (physical component summary (PCS)=40.8 ± 10.6; mental component summary (MCS)=40.6 ± 16.5) in comparison with SLE or aPL patients without thromboembolic history. In APS patients, history of arterial thrombosis significantly impaired HRQoL (PCS score: 42.2 ± 9.4 vs 49.2 ± 8.5; MCS score: 33.9 ± 13.7 vs 44.6 ± 10.3).

CONCLUSION

Compared to the general population, APS patients experienced a lower HRQoL. In these patients, a history of arterial thrombosis significantly impaired HRQoL. Therefore, measurements of HRQoL should be included in APS patient management to assess the burden of the disease from a patient's perspective and to provide patients with the support they need.

[Ocular manifestations in chronic granulomatous disease]

Chronic granulomatous disease (CGD) is a rare genetic immune deficiency due to defective oxygen metabolism in phagocytic cells. It results in recurrent severe bacterial and fungal infections in patients from an early age on. Inflammatory lesions are also observed, with the formation of granulomas. Diagnosis relies on the demonstration of a deficiency in the oxidative properties of phagocytes. Pulmonary infections are the most frequent clinical manifestations of the disease, yet all organs can be involved, such as the eye, with either infections or inflammatory chorioretinal lesions. The treatment of CGD relies on prophylaxis to avoid infections, and on the rapid management of infectious and inflammatory episodes. The only cure to date is allogenetic bone marrow transplant, which requires a compatible donor and can only be considered in certain clinical situations.

Definition and significance of high positivity aCL ELISA

We conducted a prospective study of anticardiolipin antibody (aCL) testing, performed in our university hospital. Among 6321 consecutive patients tested for both IgG and IgM aCL, 91 patients with medium or high positivity (>99th percentile) had a subsequent confirmatory test. Among them, 53 had a persistent positivity at 12 weeks. In this real world setting, patients with transient positivity had lower values than patients with persistent positivity.

Thrombin generation in antiphospholipid syndrome

Our objective was to study acquired Activated Protein C (APC) resistance in patients with antiphospholipid antibodies (aPL) using a thrombin generation based assay. We compared patients with and without lupus (systemic lupus erythematosus, SLE). A parameter summarizing APC inhibition of thrombin generation with increasing APC concentrations (IC50-APC) was increased in all patient groups compared to controls: median values were 15.3 (interquartile range, IQR, 9.7 to 34.0) in patients with primary antiphospholipid syndrome (APS), 27.3 (IQR 23.5 to 43.5) in patients with SLE without APS, 64.1 (IQR 25.9 to 65.0) in patients with SLE/APS compared to 10.4 [IQR 8.5 to 15.8] in controls, respectively p = 0.003, p = 0.0001 and p = 0.0001.

In conclusion, patients with SLE and primary APS displayed a hypercoagulable state characterized by APC resistance.

Acute myocardial infarction secondary to platelet apheresis in a 57-year healthy donor

Platelet donation by plateletpheresis is known to induce platelet and coagulation activation but there is no clear relationship between this acquired pre-thrombotic state and acute coronary syndrome in healthy donors. We report an acute myocardial infarction immediately following plateletpheresis in a 57-year-old donor with low atherosclerotic risk profile and no angiographic evidence of atherosclerotic disease strongly suggesting a causal relationship.