Training first-year medical residents to break bad news using healthcare role-play and trainees as simulated patients: Experience of the "ADIAMED" program from Lille University School of Medicine

INTRODUCTION

Several studies suggest the relevance of healthcare simulation to prepare future doctors to deliver bad news. A such, we designed a role-play workshop to train first-year residents enrolled in Lille University School of Medicine to break bad news. The objective of this work is to report on our experience of this training and to assess its educational value through its capacity to satisfy residents' expectations, to induce a feeling of ease towards bad news disclosure, and to change trainees' preconceptions regarding these situations.

METHODS

The training consisted of a 45-minute heuristic reflective activity, aimed at identifying residents' preconceptions regarding bad news disclosure, followed by 4 30-min role-plays in which they played the parts of the physician, the patient and/or their relatives. Trainees were asked to answer 2 questionnaires (pre- and post-training), exploring previous experiences, preconceived ideas regarding bad news disclosure and workshop satisfaction.

RESULTS

Almost all residents felt very satisfied with the workshop, which they regarded as formative (91%) and not too stressful (89%). The majority felt "more capable" (53% vs. 83%) and "more comfortable" (27% vs. 62%) to deliver bad news, especially regarding "finding the right words" (12% vs. 22%). Trainees tended to overestimate their skills before the workshop and lowered their assessment of their performance after attending the training, especially when they played the role of a patient in the simulation.

CONCLUSION

Healthcare role-play seems an interesting technique for training to breaking bad news. Placing residents in the role of patients or relatives is an active approach that encourages reflexivity.

Six medico-psycho-social dimensions of a pedagogical model used to define clusters of patients with Sjögren's syndrome and intentionality to participate in a patient education programme

OBJECTIVES

Sjögren's syndrome (SS) is an autoimmune disease with an impact on quality of life (QoL). The aim of patient education (PE) is to improve patients' QoL. The main objective of this study was to describe the medico-psycho-social characteristics defining the six spheres of an allosteric educational model in order to characterise clusters of patients with SS and intentionality for patients to participate in a programme of patient education.

METHODS

A self-administered questionnaire was proposed to 408 patients with SS followed in the Department of Internal Medicine of the University Hospital of Lille, France with the aim of assessing the six spheres of the allosteric model: intentional, perceptual, affective, cognitive, infra-cognitive and meta-cognitive. Sub objectives were to determine factors that can influence intentionality to participate in a PE programme and to determine, using cluster analysis, similar characteristics of patients with SS.

RESULTS

127 patients (31%) agreed to participate and were included in the study; 96% were women and the median age was 51 years (±14.5). They mostly reported dry syndrome and fatigue, had a good knowledge of SS, and presented anxiety symptoms. They mainly had problem-centred coping strategies, internal locus of control and low self-esteem. SS had an impact on their social interactions. Considering intentionality to participate in a PE programme, the patients were significantly younger, had a shorter duration of the disease, more frequently had disabled status, reported more fatigue, more self-reported symptoms and a poorer QoL. Two clusters of patients could be individualised, with one group including 75 (59%) patients presenting a higher global impact of the disease, including a more severe impairment for the scores of the perceptual, emotional and infra-cognitive spheres, worse physical QoL, and a higher intentionality to participate in a PE programme.

CONCLUSIONS

Our study described an SS population in terms of the different spheres of an allosteric model applicable to the practice of PE. A cluster of patients appeared to present more impact of the disease and more intentionality to participate in a programme of PE. There was no difference between the two groups in terms of the cognitive sphere (i.e. knowledge of the disease), thus indicating that motivation to participate in a PE programme is influenced by non-cognitive factors. Considering intentionality to participate in a PE programme, duration disease, age of the patient and QoL should be more considered to propose to patients to participate in a PE programme. Use of the allosteric model appears promising for future research in PE.

Activities of Clinical Expertise and Research in a Rare Disease Referral Centre: A Place for Telemedicine beyond the COVID-19 Pandemic?

INTRODUCTION

Rare disease referral centres are entrusted with missions of clinical expertise and research, two activities that have to contend with numerous obstacles. Providing specialist opinions is time-consuming, uncompensated and limited by difficulties in exchanging medical data. Clinical research is constrained by the need for frequent research protocol visits. Our objective was to determine whether telemedicine (TLM) can overcome these difficulties.

METHODS

To better characterise the activity of clinical expertise provided by our French centre, each opinion delivered by our team was reported on a standardised form. To investigate our clinical research activity, investigators and patients were asked to complete a questionnaire on the acceptability of research protocol teleconsultations.

RESULTS

Regarding clinical expertise, our team delivered 120 opinions per week (representing a total of 21 h), of which 29% were delivered to patients and 69% to medical practitioners. If these were delivered using TLM, it would represent a potential weekly income of EUR 500 (tele-expertise) and EUR 775 (teleconsultations). Regarding the research activity, 70% of investigators considered the frequency of visits to be a limiting factor for patient inclusions; nearly half of the patients surveyed would be in favour of having teleconsultations in place of (40%) or in addition to (56%) in-person visits.

CONCLUSION

Whereas TLM has become widely used as a back-up procedure to in-person consultations during the COVID-19 pandemic, the solutions it provides to the problems encountered in performing expertise and research activities have made it a new conventional follow-up modality for patients with rare diseases.

Atteintes coronariennes et artérite a cellules géantes : à propos de 2 cas et revue de la littérature

INTRODUCTION

Coronaritis is a rare but serious complication of giant-cell arteritis (GCA), with an estimated prevalence of less than 1%, however difficult to establish, and of early onset.

METHODS

We describe 2 cases of GCA presenting with coronaritis and present a review of the literature on this complication.

RESULTS

The first patient presented with stable angina on common trunk coronaritis with ostial stenosis. Corticosteroid combined with tocilizumab from the outset resulted in improvement. Angioplasty was performed at 6months with good outcome. The second patient presented with asymptomatic tritruncular ostial coronaritis. Corticosteroid allowed clinic-biological improvement of GCA. Two years later, he presented relapse with an acute coronary syndrome, with favorable evolution after angioplasty, increase of corticosteroids and addition of tocilizumab.

CONCLUSION

Patients presented were successfully treated with corticosteroids combined with tocilizumab and angioplasty of their coronary stenoses. Efficacy of tocilizumab in GCA has not been evaluated especially on coronaritis due to the rarity of this complication. Our experience and the cases reported in the literature suggest good results of angioplasty in this indication. Studies with long-term follow-up will be necessary to evaluate the risk of restenosis.

Giant cell arteritis-related cerebrovascular ischemic events: a French retrospective study of 271 patients, systematic review of the literature and meta-analysis

BACKGROUND

Cerebrovascular ischemic events (CIE) are among the most severe complications of giant cell arteritis (GCA). Heterogeneity between different studies in the definition of GCA-related CIE leads to uncertainty regarding their real prevalence. The aim of our study was to evaluate the prevalence and describe the characteristics of GCA-related CIE in a well-phenotyped cohort completed by a meta-analysis of the existing literature.

METHODS

In this retrospective study performed in the Lille University Hospital, all consecutive patients with GCA according to American College of Rheumatology (ACR) diagnostic criteria were included from January 1, 2010, to December 31, 2020. A systematic review of the literature using MEDLINE and EMBASE was performed. Cohort studies of unselected GCA patients reporting CIE were included in the meta-analysis. We calculated the pooled summary estimate of GCA-related CIE prevalence.

RESULTS

A total of 271 GCA patients (89 males, mean age 72 ± 9 years) were included in the study. Among them, 14 (5.2%) presented with GCA-related CIE including 8 in the vertebrobasilar territory, 5 in the carotid territory, and 1 patient having multifocal ischemic and hemorrhagic strokes related to intra-cranial vasculitis. Fourteen studies were included in the meta-analysis, representing a total population of 3553 patients. The pooled prevalence of GCA-related CIE was 4% (95% CI 3-6, I2 = 68%). Lower body mass index (BMI), vertebral artery thrombosis on Doppler US (17% vs 0.8%, p = 0.012), vertebral arteries involvement (50% vs 3.4%, p < 0.001) and intracranial arteries involvement (50% vs 1.8%, p < 0.001) on computed tomography angiography (CTA) and/or magnetic resonance angiography (MRA), and axillary arteries involvement on positron emission computed tomography (PET/CT) (55% vs 20%, p = 0.016) were more frequent in GCA patients with CIE in our population.

CONCLUSIONS

The pooled prevalence of GCA-related CIE was 4%. Our cohort identified an association between GCA-related CIE, lower BMI, and vertebral, intracranial, and axillary arteries involvement on various imaging modalities.

Cutaneous Involvement in Catastrophic Antiphospholipid Syndrome in a Multicenter Cohort of 65 Patients

Importance

Catastrophic antiphospholipid syndrome (CAPS) is a severe, rare complication of antiphospholipid syndrome (APS), but cutaneous involvement has not yet been adequately described.

Objective

To describe cutaneous involvement during CAPS, its clinical and pathological features, and outcomes.

Design, Setting, and Participants

This cohort study was a retrospective analysis of patients included in the French multicenter APS/systemic lupus erythematosus register (ClinicalTrials.gov: NCT02782039) by December 2020. All patients meeting the revised international classification criteria for CAPS were included, and patients with cutaneous manifestations were analyzed more specifically.

Main Outcomes and Measures

Clinical and pathological data as well as course and outcome in patients with cutaneous involvement during CAPS were collected and compared with those in the register without cutaneous involvement.

Results

Among 120 patients with at least 1 CAPS episode, the 65 (54%) with skin involvement (43 [66%] women; median [range] age, 31 [12-69] years) were analyzed. Catastrophic antiphospholipid syndrome was the first APS manifestation for 21 of 60 (35%) patients with available data. The main lesions were recent-onset or newly worsened livedo racemosa (n = 29, 45%), necrotic and/or ulcerated lesions (n = 27, 42%), subungual splinter hemorrhages (n = 19, 29%), apparent distal inflammatory edema (reddened and warm hands, feet, or face) (n = 15, 23%), and/or vascular purpura (n = 9, 14%). Sixteen biopsies performed during CAPS episodes were reviewed and showed microthrombi of dermal capillaries in 15 patients (94%). These lesions healed without sequelae in slightly more than 90% (58 of 64) of patients. Patients with cutaneous involvement showed a trend toward more frequent histologically proven CAPS (37% vs 24%, P = .16) than those without such involvement, while mortality did not differ significantly between the groups (respectively, 5% vs 9%, P = .47).

Conclusions and Relevance

In this cohort study, half the patients with CAPS showed cutaneous involvement, with a wide spectrum of clinical presentations, including distal inflammatory edema. Skin biopsies confirmed the diagnosis in all but 1 biopsied patient.

Determination of four homogeneous subgroups of patients with antiphospholipid syndrome: a cluster analysis based on 509 cases

OBJECTIVE

Antiphospholipid syndrome (APS) is a heterogeneous disease with different phenotypes. Using an unsupervised hierarchical cluster analysis, we aimed to determine distinct homogeneous phenotypes among APS patients.

METHODS

We performed an observational, retrospective study of APS patients enrolled in the French multicentre 'APS and SLE' registry who meet the Sydney classification criteria. The clustering process involved an unsupervised multiple correspondence analysis followed by a hierarchical ascendant clustering analysis; it used 27 variables selected to cover a broad range of APS clinical and laboratory manifestations.

RESULTS

These analyses included 509 patients, mainly women (77.8%). Mean (± SD) age at APS diagnosis was 36.2 ± 14.6 years, and mean follow-up since diagnosis 10.3 ± 8.5 years. This hierarchical classification cluster analysis yielded four homogeneous groups of patients: cluster 1, mostly with venous thromboembolism without any associated autoimmune disease; cluster 2, older, lowest proportion of women, history of arterial events, and/or with migraines, arterial hypertension, diabetes mellitus, or dyslipidaemia; cluster 3, younger, highest proportion of women, associated SLE or other autoimmune diseases, and a history of venous thromboembolism or pregnancy morbidity; and cluster 4, mainly with a history of catastrophic antiphospholipid syndrome, aPL-associated nephropathy, and pregnancy morbidity, with frequent triple positivity and more deaths (16.7%).

CONCLUSIONS

Our study applied an unsupervised clustering method to distinguish four homogeneous APS patient subgroups that were predominantly venous; arterial; associated with SLE or another autoimmune disease; and arterial microthrombotic. Heterogeneous pathophysiological mechanisms may explain these findings.

Association between Routine Laboratory Parameters and the Severity and Progression of Systemic Sclerosis

(1) Background: Systemic sclerosis (SSc) is a heterogeneous connective tissue disease with a high mortality and morbidity rate. Identification of biomarkers that can predict the evolution of SSc is a key factor in the management of patients. The aim of this study was to assess the association of routine laboratory parameters, widely used in practice and easily available, with the severity and progression of SSc. (2) Methods: In this retrospective monocentric cohort study, 372 SSc patients were included. We gathered clinical and laboratory data including routine laboratory parameters: C-reactive-protein (CRP), erythrocyte sedimentation rate (ESR), complete blood count, serum sodium and potassium levels, creatinin, urea, ferritin, albumin, uric acid, N-terminal pro-brain natriuretic peptide (NTproBNP), serum protein electrophoresis, and liver enzymes. Associations between these routine laboratory parameters and clinical presentation and outcome were assessed. (3) Results: Median (interquartile range) age was 59.0 (50.0; 68.0) years. White blood cell, monocyte, and neutrophil absolute counts were significantly higher in patients with diffuse cutaneous SSc and with interstitial lung disease (ILD) (p < 0.001). CRP was significantly higher in patients with ILD (p < 0.001). Hemoglobin and ferritin were significantly lower in patients with pulmonary hypertension (PH) including pulmonary arterial hypertension and ILD associated PH (p = 0.016 and 0.046, respectively). Uric acid and NT pro BNP were significantly higher in patients with PH (<0.001). Monocyte count was associated with ILD progression over time. (4) Conclusions: Overall, our study highlights the association of routine laboratory parameters used in current practice with the severity and progression of SSc.

Dyslipidemia is insufficiently treated in antiphospholipid syndrome patients

OBJECTIVES

Although dyslipidemia is a strong risk factor for thrombosis in antiphospholipid syndrome (APS), it has been poorly studied. This study aimed to assess lipids profile and risk factors for unachieved cholesterol levels in a real-life APS population.

METHODS

Inclusion criteria were: APS diagnosis according to international classification criteria, referring to the out-patients clinic of our tertiary care center for their follow-up, and having a blood sample collection for lipids levels determination. Cholesterol level targets for each patient were defined according to 2019 ESC/EAS guidelines for the management of dyslipidemia.

RESULTS

Between January 2020 and April 2021, 114 APS patients were included (male 37 (32.5%); mean age 49 ± 14 years). Among them, 40 (35.1%) had a history of dyslipidemia, 48 (42.1%) were under lipid-lowering therapies, and 59 (51.8%) had a history of cardiovascular disease (CVD). Mean levels of low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and triglyceride were, respectively, 110 ± 40 mg/dL, 60±20 mg/dL, and 120 (80-190) mg/dL. Unachieved LDL-C levels were found in 77 (67.5%) patients of whom 53 had history of CVD. Overall, 90 (78.9%) had protective HDL-C and 31 (27.2%) had hypertriglyceridemia. In the multivariate analysis, independent risk factors for unachieved LDL-C levels were older age and history of CVD; triple aPL negativity, defined as complete disappearance of aPL over time in APS patients who were previously positive in accordance to international criteria, was an independent protective factor for unachieved LDL-C.

CONCLUSION

Our finding suggested that dyslipidemia is frequent in APS patients and mainly insufficiently treated, especially in patients with history of CVD, who are at highest risk of future CV events.

Neuralgic amyotrophy triggered by cytomegalovirus: to be aware of this clinical diagnosis

Neuralgic amyotrophy (NA) is a multifocal inflammatory neuropathy. Although the exact etiopathogenesis of the latter is unknown, the literature reports frequent associations with immunological events such as different infectious diseases. Our case reveals a rarely described etiology of NA. NA is mainly a clinical diagnosis. The etiology shown in our case study is interesting for the scientific community, because CMV is an ubiquitous disease. NA is frequently under-recognized and misdiagnosed. This is particularly common in the early phase of the disease, when neurologic signs have not yet developed.

AB1120 PSYCHOLOGICAL ASSESSMENT IN PATIENTS WITH CHRONIC RHEUMATIC, SYSTEMIC AUTOIMMUNE, OR AUTOINFLAMMATORY DISEASES PRESENTED WITH COVID-19: THE MentCOVRMD STUDY

Background

The COVID-19 pandemic has raised concerns about its psychological effects. Sleep disturbances, anxiety and/or depressive symptoms, post-traumatic stress symptoms have been reported in general population. Patients with chronic rheumatism, systemic autoimmune disease or auto-inflammatory disease, due to immunosuppression, are at risk of severe forms of infection. Currently, there is little information on psychological impact of the pandemic on the mental health of these more vulnerable patients.

Objectives

To compare psychological assessment between patients with chronic rheumatic, autoimmune and/or autoinflammatory diseases who presented with COVID-19 infection between March and September 2020, first wave of French pandemic, and patients with same diseases who did not presented with infection to date.

Methods

The MentCOVRMD study was a multicenter descriptive study. Cases were patients with chronic rheumatic, autoimmune and/or autoinflammatory diseases from the French RMD cohort who presented COVID-19 infection between March and September 2020. Controls were patients with same diseases who did not develop infection. The study is registered in Clinical Trials under number 2020-A02058-31.

For participants, following criteria were collected: demographics (age, gender, smoking status); psychological assessment questionnaires: Insomnia Severity Index (ISI); Post-traumatic stress disorder (PTSD) checklist; Patient Health Questionnaire (PHQ9) Depression; Generalized Anxiety Disorder (GAD7) Anxiety; Patient Health Questionnaire-15 (PHQ-15) and Somatic Symptom Disorder (SSD)-12.

Results

Between February and December 2021, 60 cases (46 (76.7%) women), median age 52.0 (39.0; 63.0) were included, of which 15 (25%) had been hospitalized during infection, and 169 controls (148 (87.6%) women), median age of 52.0 (38.0; 63.0). There were more smokers in the group of cases 12 (20%) than controls 14 (9.1%) (p=0.028) as well as more cases on ARA2 treatment (8 (13.3%)) than controls (7 (4.5%)) (p=0.035) with no statistically significant difference in others comorbidities or treatments.

There was no statistically difference concerning the ISI scores between cases (11.83 ± 7.31) of which 60% had sleep disorders and controls (11.64 ± 6.82) of which 70.4% had sleep disorders. There was no statistically significant difference in PTSD scores of 15.5 (5.0 to 28.0) for cases and 18.0 (8.0 to 35.0) for controls, of which respectively 12 (20%) had values indicating possible PTSD for cases and 50 (29.6%) for controls. There was no statistically significant difference in PHQ-9 scores (5.5 (1.5 to 11.0)) of which 50% had depressive symptoms and controls (6.0 (2.0 to 11.0)) of which 54.5% had symptoms. There was no statistically significant difference in GAD-7 scores (3.5 (0.0 to 8.0)) of which 40% had anxiety symptoms and controls (4.0 (0.0 to 8.0)) of which 43.2% had symptoms. There was no statistically significant difference in PHQ-15 scores (11.4 ± 6.7), 85% of whom reported presence of symptoms, and controls (10.9 ± 6.2), 82.3% of whom reported symptoms. There was no statistically significant difference in SSD scores between cases (17.7 ± 10.9) and controls (18.4 ± 10.9).

There was a statistically significant difference in reported VAS scores of pain related to inflammatory rheumatism in cases with a median of 4.5 (3.0 to 6. 0) compared to controls with a median of 4.0 (1.0 to 6.0) (p=0.011).

There was no statistically significant difference in any of the psychological assessment scores between the inpatient and outpatient COVID cases.

Conclusion

There was no statistically significant difference between COVID cases and controls in the evaluation of these psychological parameters. Prevalence of all these variables were high in the whole study population, testifying to the need to manage these psychological aspects for patients with chronic rheumatisms, autoimmune and/or autoinflammatory diseases.

Disclosure of Interests

None declared

[Impact of disease on daily activities, emotions and quality of life of patients with hereditary angioedema]

INTRODUCTION

Hereditary angioedema (HAE) is characterized by recurrent attacks of swelling of various locations and severity. An impaired quality of life of patients with HAE has been reported by several studies. We aimed at examining the overall impact of the disease in patients followed for type I HAE, particularly its impact on daily life activities, emotions and quality of life.

METHODS

A questionnaire was distributed to patients consulting for type I HAE, collecting demographics, disease characteristics, impact on professional life, Hospital Anxiety and Depression score (HAD), SF-36 score and the McMaster Toronto Arthritis Patient Preference Disability Questionnaire (MACTAR).

RESULTS

The 33 patients included reported an average of 5.17 attacks over the last year. Stress was the main trigger A long-term treatment was reported by 58% of patients, 72% received specific treatment in the event of a serious attack. Sick days were reported by 33% of patients during their studies, and by 34% during work. One patient suffered from depressive symptoms and ten from anxious symptoms, according to the HAD score. The areas most impacted on the SF-36 score were general health and vitality. The mean score for MACTAR was low.

CONCLUSION

HAE still has a significant impact on the daily and emotional lives of patients, despite the availability of prophylactic and crisis treatments.

Activités de recours et de recherche d’un service de Médecine Interne : une place pour la télémédecine, au-delà de la pandémie COVID-19 ?

Introduction

Les services de Médecine Interne mènent une importante activité de recours expert et de recherche, grevée par plusieurs obstacles. L’activité d’avis spécialisés est chronophage, non valorisée, et limitée par l’impossibilité d’échanger simplement les éléments du dossier médical. L’activité de recherche clinique est limitée par la fréquence des visites protocolaires. L’objectif de ce travail est de déterminer si la télémédecine (TLM) peut contribuer à résoudre ces difficultés.

Patients et méthodes

Concernant l’activité de recours, nous avons demandé aux médecins de déclarer les avis donnés à l’aide d’un formulaire standardisé, afin de déterminer s’ils validaient les critères de téléconsultation (TLC) ou de télé-expertise (TLE). Concernant l’activité de recherche, nous avons remis aux investigateurs et à 50 patients un questionnaire sur l’acceptabilité de TLC protocolaires.

Résultats

Concernant l’activité de recours, on dénombrait 120 avis (soit 21 h) hebdomadaires, dont 29 % aux patients et 69 % à des médecins. Soixante et un pour cent des avis aux patients validaient les critères de TLC ; 18 % des avis aux médecins ceux de TLE. Concernant l’activité de recherche, 70 % des investigateurs considéraient la fréquence des visites comme limitant les inclusions ; près de la moitié des patients serait favorable au recours à des TLC à la place (40 %) ou en plus (56 %) des visites présentielles. En termes de facturation, la TLM représente un revenu potentiel de 300 € hebdomadaires pour le TLE et 616€ hebdomadaires pour le TLC.

Conclusion

Si le recours à la TLM comme procédure dégradée au présentiel s’est démocratisé avec la pandémie, les solutions qu’elle apporte aux difficultés rencontrées dans les activités d’avis et de recherche peuvent contribuer à intégrer pleinement son usage dans le suivi standard des patients. Si tel était le cas, on pourrait tout à fait imaginer avec ce budget (47 632 €/an) pouvoir financer un praticien hospitalier supplémentaire à temps partiel.

POS1454-HPR AESTHETIC IMPAIRMENT IN PATIENTS WITH SYSTEMIC SCLEROSIS: A CASE CONTROL STUDY USING A SEMI-QUANTITATIVE SCALE FOR BODY IMAGE ASSESSMENT

Background:

Systemic sclerosis (SSc) is a fibrotic autoimmune disease characterized by dermatological involvement. Skin involvement can alter appearance, which can have a psychological impact(1). Assessment of body image could be central in optimizing care. Yet, data are scarce(2).

Objectives:

The main objective of our study was to assess aesthetic impairment measured on a visual aesthetic scale (AES) (3) in patients with SSc compared to a group of healthy subjects. Secondary objectives were to assess associations between aesthetic impairment and standardized questionnaires for aesthetic impairment as well as clinical, biological, psychological/quality of life, and functional parameters of SSc.

Methods:

The “Sclero-esthet” study is a descriptive single-center study of two populations: patients with SSc, included in a referral center for systemic and autoimmune diseases at Lille Hospital, France, and healthy controls.

Results:

This study, from January 2017 to October 2017, included 88 patients (69 [78.4%] women) with a median age of 52 years (range: 43 to 59) and 88 controls (49 [55.7%] women) with a median age of 45 years (range: 32 to 55). Perception of physical changes assessed using the AES was greater in cases than in controls (3.7 ± 0.3 vs 2.8 ± 0.3, p=0.028), with statistical correlation with ASWAP. SSc patients with anxiety or depressive symptoms had significantly higher AES scores. Cases presented poorer quality of life than controls.

Conclusion:

The AES appears to be a good tool to evaluate aesthetic impairment. Correlations found with psychological and quality of life parameters support the need to improve patient management in this field.

References:

[1]Cash TF. Body image: past, present, and future. Body Image 2004;1(1):1–5.

[2]Benrud-Larson LM, Heinberg LJ, Boling C, Reed J, White B, Wigley FM. Body image dissatisfaction among women with scleroderma: extent and relationship to psychosocial function. Health Psychol mars. 2003;22(2):130–9.

[3]Nguyen C, Ranque B, Baubet T, Bérezné A, Mestre-Stanislas C, Rannou F, et al. Clinical, Functional and Health-Related Quality of Life Correlates of Clinically Significant Symptoms of Anxiety and Depression in Patients with Systemic Sclerosis: A Cross-Sectional Survey. PLoS ONE 2014;9(2).

[4]Heinberg LJ, Kudel I, White B, Kwan A, Medley K, Wigley F. Assessing body image in patients with systemic sclerosis (scleroderma): Validation of the Adapted Satisfaction with Appearance Scale. Body Image 2007;4(1):79–86.

Disclosure of Interests:

None declared

Fatal Enterovirus-related Myocarditis in a Patient with Devic's Syndrome Treated with Rituximab

Enteroviruses are a frequent source of infection and among the most common central nervous system viral pathogens. Enteroviruses – in particular, the Coxsackie B viruses – are a known cause of myocarditis. Rituximab is a genetically engineered chimeric anti-CD20 monoclonal antibody. Many reports in the literature suggest a higher risk of infection following repeated rituximab therapy, including viral infection. However, observations of enterovirus-related myocarditis in the context of rituximab treatment are scarce. The authors describe the case of a patient with neuromyelitis optica spectrum disorder who developed severe and fatal enterovirus-related myocarditis after rituximab therapy with a difficult differential diagnosis of autoimmune or giant-cell myocarditis. This case highlights the importance of complete diagnostic workup in difficult cases of myocarditis, including endomyocardial biopsies.

Adalimumab and myositis: A case report and review of the French and international Pharmacovigilance Databases

TNFα inhibitors, including adalimumab, are widely used in inflammatory rheumatologic and bowel diseases. Well-known adverse effects include: opportunistic infections, immunogenicity and new inflammatory manifestations. Myositis is an inflammatory disease, which manifests with muscle symptoms and can be life-threatening. Little is known about drug-induced myositis. We aimed to describe a case of myositis induced by adalimumab and reviewed national and international pharmacovigilance databases for other cases until 01/02/2019. This was a 63 years old woman with Crohn's disease, who developed muscle weakness, and rhabdomyolysis 3 months after starting adalimumab. Diagnosis of myositis was suspected and confirmed with electromyography and muscle biopsy. Improvement in muscle symptoms was observed after stopping adalimumab and starting corticosteroids. Muscular adverse effects are well-known and usually benign with adalimumab. However, five cases of myositis during treatment with adalimumab were registered in French PharmacoVigilance Database (FPVD) with muscle symptoms observed 3 months to 7 years after starting adalimumab. In VigiBase^Ⓡ, 90 cases of myositis associated with adalimumab with some similar characteristics were registered. When a patient treated with adalimumab complains of muscular symptoms, inflammatory myopathies should be considered. This adverse effect should be mentioned in a 'Summary of Product Characteristics' to alert healthcare professionals.

Extended myositis-specific and -associated antibodies profile in systemic sclerosis: A cross-sectional study

OBJECTIVE

In systemic sclerosis (SSc) and idiopathic inflammatory myopathies (IIM), auto-antibodies are used in daily practice as potent biomarkers of clinical phenotypes. This study aimed at estimating the prevalence of myositis-specific (MSA) and myositis-associated (MAA) auto-antibodies in a well-characterised SSc patients cohort using two different immunoblot assays, and studying their clinical associations.

METHODS

In this cross-sectional study, the sera of 300 consecutive patients were tested at the same time with myositis antibodies Euroimmun® and D-tek® immunoblot assays.

RESULTS

Prevalence of MSA/MAA, MSA and MAA were 17.0%, 8.0% and 9.7%, respectively. When combining results of both tests, anti-PM/Scl 100 were found in 5.0% (95% confidence interval 2.8; 8.1); anti-PM/Scl 75 and anti-TIF1γ in 3.7% (1.8; 6.5); anti-Ku 3.0% (1.4; 5.6); anti-MDA5 in 1.3% (0.4; 3.4); anti-Mi-2 β, anti-NXP2, anti-PL-7 and anti-SRP in 0.7% (0.08; 2.4); anti-EJ and anti-PL-12 in 0.3% (0.01; 1.8) of patients. No reactivity against SAE1, Jo-1 or OJ was observed. Anti-PM/Scl 75 antibodies were associated with interstitial lung disease (80% vs. 42%) and myositis (27% vs. 3%); anti-Ku antibodies were associated with myositis (33% vs. 3%).

CONCLUSION

In this cross-sectional study of 300 SSc patients, the prevalence of MSA/MAA, MSA and MAA using immunoblot assays were 17.0%, 8.0% and 9.7%, respectively. MAA positivity was associated with ILD and myositis, but this study did not highlight any clinical associations with MSA positivity.

Consideration of coping strategies for patients suffering from systemic lupus erythematosus: reflection for a personalised practice of patient education

OBJECTIVES

Systemic lupus erythematosus (SLE) is a chronic autoimmune multi-organ disease with an unpredictable course. SLE causes functional disability, changes in body appearance, and psychological distress. When faced with SLE, patients have to implement coping strategies. Therefore, the aim of this study was to describe patients' coping strategies, consider the implications for a personalised practice of patient education and evaluate patients' adherence to HCQ treatment.

METHODS

One hundred and fifty-eight SLE patients receiving hydroxychloroquine (HCQ) treatment entered a prospective, non-comparative, longitudinal study aimed at describing patients' coping strategies and evaluating their adherence to the HCQ regimen. Coping strategies were evaluated using an abbreviated French version of the WCC-27 exploring 3 dimensions of coping: problem-centered coping, emotion-centered coping and search for social support. Adherence was assessed by the MASRI, the MMAS-8 and also objectively assessed by the patient's serum level of HCQ. Data collected at study entry also included disease activity: SLEDAI, and disease extent: SLICC damage index. The prevalence of anxious and depressive symptoms was evaluated with the HADS. Quality of life was evaluated using the LupusQoL questionnaire.

RESULTS

Patients were clustered using an unsupervised hierarchical classification based on coping strategies. Four clusters of patients were individualised. The cluster of patients with low problem-centered coping, high emotion-centered coping and the lowest search for social support had worse quality of life and more psychological distress. We did not find any inter-cluster differences in terms of compliance to HCQ.

CONCLUSIONS

Patients' knowledge is not the only parameter to consider for a personalised educational therapy: psychological parameters such as coping must also be considered to ensure the best possible quality of life. For educational therapy purposes, it is important not to group patients with the same coping style; heterogenous groups will enable patients to share their experiences and learn from the coping strategies of others.

Raising rare disease awareness using red flags, role play simulation and patient educators: results of a novel educational workshop on Raynaud phenomenon and systemic sclerosis

BACKGROUND

As lack of awareness of rare diseases (RDs) among healthcare professionals results in delayed diagnoses, there is a need for a more efficient approach to RD training during academic education. We designed an experimental workshop that used role-play simulation with patient educators and focused on teaching "red flags" that should raise the suspicion of an RD when faced with a patient with frequently encountered symptoms. Our objective was to report our experience, and to assess the improvement in learners' knowledge and the satisfaction levels of the participants.

RESULTS

The workshop consisted of 2 simulated consultations that both started with the same frequent symptom (Raynaud phenomenon, RP) but led to different diagnoses: a frequent condition (idiopathic RP) and an RD (systemic sclerosis, SSc). In the second simulated consultation, the role of the patient was played by a patient educator with SSc. By juxtaposing 2 seemingly similar situations, the training particularly highlighted the elements that help differentiate SSc from idiopathic RP. When answering a clinical case exam about RP and SSc, students that had participated in the workshop had a higher mean mark than those who had not (14 ± 3.7 vs 9.6 ± 5.5 points out of 20, p = 0.001). Participants mostly felt "very satisfied" with this training (94%), and "more comfortable" about managing idiopathic RP and SSc (100%). They considered the workshop "not very stressful" and "very formative" (both 71%). When asked about the strengths of this training, they mentioned the benefits of being put in an immersive situation, allowing a better acquisition of practical skills and a more interactive exchange with teachers, as well as the confrontation with a real patient, leading to a better retention of semiological findings and associating a relational component with this experience.

CONCLUSIONS

Through the use of innovative educational methods, such as role-play simulation and patient educators, and by focusing on teaching "red flags", our workshop successfully improved RP and SSc learning in a way that satisfied students. By modifying the workshop's scenarios, its template can readily be applied to other clinical situations, making it an interesting tool to teach other RDs.

AB1273 TEACHING RARE DISEASES THROUGH ROLE PLAY: RESULTS OF AN EXPERIMENTAL WORKSHOP ON RAYNAUD PHENOMENON

Background:

Systemic autoimmune diseases are mostly taught through theoretical lectures, which do not allow for the acquisition of physical examination skills and semiologic confrontation.

Objectives:

We report herein the results of a pilot experiment using role-play to teach how to manage patients with Raynaud phenomenon (RP).

Methods:

We developed a workshop that consisted of two 30-minute OSCE (Objective and Structured Clinical Examination) stations. Students were divided into groups of 4 to 5 persons. On each station, 2 students were actors and 2 were observers. After a short briefing, students played a 15-minute scenario and then had a 15-minute debriefing.

The first station simulated the case of a 26-year old woman referred for suspected RP. Students were instructed to perform clinical history taking and physical examination of the patient, formulated relevant diagnosis hypotheses and prescribe any additional necessary exams. Students had to suspect the diagnosis of idiopathic RP. The simulated patient was played by a trained facilitator with expertise on RP.

The second station simulated the case of a 56-year-old woman referred for RP complicated by digital ulcers. Students received the same instructions as before. They had to suspect the diagnosis of systemic sclerosis. The patient role was held by a real patient with systemic sclerosis, followed by the physician who was supervising the station, who had received prior training and who agreed to participate in this training.

At the end of the workshop, the students had to complete a satisfaction questionnaire.

Results:

A total of 21 students participated in the workshop and 17 completed the survey. The students were “very satisfied” (Likert 4/4) of this training in 94%. They considered this workshop “not very stressful” (Likert 2/4) and “very formative” (Likert 4/4) in 71%, but “a little short” (Likert 2/4) in 88%. After taking this training, all students felt “a little” (Likert 3/4, 24%) or “much more comfortable” (Likert 4/4, 76%) to manage patients with idiopathic RP; and “a little” (Likert 3/4, 65%) or “much more comfortable” (Likert 4/4, 35%) to manage patients with systemic sclerosis. All would recommend this workshop to other students.

When asked about the strengths of this training, the students mentioned the benefits of being put in an immersive situation, which allowed for a better acquisition of practical skills (especially physical examination) and a more interactive exchange with teachers; as well as the confrontation with a real patient, which allowed for a better retention of semiologic findings and associated a relational component to this experience. The main weak points reported were its short duration and the stress induced by being observed during the simulation.

Conclusion:

This workshop suggests the interest and feasibility on a small group of students of a rare diseases awareness workshop using role-play. The evaluation of its pedagogical efficiency and its generalization on large student promotions are being considered.

Acknowledgments:

None

Disclosure of Interests:

Sebastien SANGES: None declared, Sandrine Morell-Dubois: None declared, Meryem-Maud Farhat: None declared, Morgane Assaraf: None declared, Marc Lambert: None declared, Vincent Sobanski: None declared, David Launay Grant/research support from: Dr. Launay reports personal fees from Actelion, grants and personal fees from Takeda, grants and personal fees from CSL Behring, outside the submitted work., Eric Hachlla: None declared

Low hormone levels during an attack of systemic capillary leak syndrome normalizing after treatment

We report herein the case of a patient with low blood levels of different hormones during a systemic capillary leak syndrome (Clarkson's disease) attack.

Clinical Characteristics and Outcome of Patients with Infective Endocarditis Diagnosed in a Department of Internal Medicine

Clinical manifestations of infective endocarditis (IE) can be highly non-specific. Our objective was to describe the clinical characteristics of patients initially referred to a department of internal medicine for a diagnostic work-up, and eventually diagnosed with IE. We retrospectively retrieved adult patients admitted to the department of internal medicine at Lille University Hospital between 2004 and 2015 who fulfilled Duke Classification criteria for definite IE. Thirty-five patients were included. The most frequently involved bacteria were non-hemolytic streptococci. Most patients presented with various systemic, cardiac, embolic, rheumatic, and immunological findings, with no sign or symptom displaying high sensitivity. The first transthoracic echocardiogram was negative in 42% of patients. Furthermore, definite diagnosis required performing at least 2 transesophageal examinations in 24% of patients. We observed a trend towards decreased survival in the subgroup of patients in whom the delay between onset of symptoms and diagnosis was >30 days. In conclusion, patients who are initially referred to internal medicine for a diagnosis work-up and who are ultimately diagnosed with IE have non-specific symptoms and a high percentage of initial normal echocardiography. Those patients require prolonged echocardiographic monitoring as a prolonged delay in diagnosis is associated with poorer outcomes such as death.

Styloidogenic compression of the internal jugular vein, a new venous entrapment syndrome?

Internal jugular vein (IJV) thrombosis is mainly related to central venous catheter, malignancy, and ovarian hyperstimulation syndrome. We report a case of IJV thrombosis possibly related to IJV compression between the styloid process and the first cervical vertebra (C1) transverse process. To support this hypothesis, we perform radiological assessment of the IJV and examine its relationship with the styloid process and C1 transverse process in 34 controls. Our results showed a strong correlation between IJV diameter and styloid process-C1 transverse process distance. Compared to control subjects, our patient had a short styloid process-C1 transverse process distance, which suggests its involvement in IJV thrombosis.

Whole-Body Distribution and Clinical Association of Telangiectases in Systemic Sclerosis

Importance

In systemic sclerosis (SSc), to date, no study has precisely described the total number and fine distribution of telangiectases (TAs), their clinical association with the disease, and the biological mechanisms causing their development.

Objectives

To describe the whole-body distribution of TAs and assess the association between the whole-body TA number and the characteristics of patients with SSc.

Design, Setting, and Participants

A single-center, cross-sectional study was conducted between July 11, 2016, and March 15, 2017, at the National Referral Centre for Rare Systemic and Autoimmune Diseases in France. A population-based sample of 106 adults who fulfilled the 2013 American College of Rheumatology/European League Against Rheumatism criteria for SSc were included; 8 patients who had previously received laser treatment for TAs were excluded.

Main Outcomes and Measures

The number of TAs on the whole body (total and those >5 mm) and TA distribution in different areas were recorded. The association with clinical and biological data was studied using univariate and multivariate linear regression.

Results

A total of 106 patients (83 [78.3%] women) were enrolled, including 12 with precapillary pulmonary hypertension (PH). Mean (SD) age was 60.6 (13.5) years. Telangiectasia distribution was 37.2% on the face, 33.2% on the upper limbs, including 26.4% on the hands, 28.1% on the trunk, including 17.1% for the upper part of the trunk, and 1.5% on the lower limbs. In analysis using the multivariate linear regression model, the whole-body TA number was independently associated with male sex (percentage change, 144.4%; 95% CI, 7.5% to 455.9%; P = .03), PH (162.8%; 95% CI, 5.6% to 553.8%; P = .04), history of pulmonary embolism (336.4%; 95% CI, 39.0% to 1270.1%; P = .01), glomerular filtration rate (-1.6%; 95% CI, -3.2% to -0.1% per 1-mL/min/1.73 m2 increase; P = .04), and soluble endoglin level (28.2%; 95% CI, 1.2% to 62.5% per 1-ng/mL increase; P = .04). Receiver operating characteristic analyses assessing the ability of TAs to identify the presence of PH revealed that the area under the curve was significant for the TA number on the whole body (0.77; 95% CI, 0.57 to 0.88), on the hands and face (0.81; 95% CI, 0.57 to 0.91), and on the hands (95% CI, 0.77; 95% CI, 0.57 to 0.89).

Conclusions and Relevance

In the patients in this study with SSc, TAs were predominantly located on the face, hands, and the upper part of the trunk. Telangiectases appeared to be associated with vasculopathy features of SSc, particularly with PH and soluble endoglin levels.

Factors associated with the 6-minute walk distance in patients with systemic sclerosis

Background

There is an ongoing debate regarding the relevance of the 6-minute walking distance (6MWD) in systemic sclerosis (SSc) assessment, widely used as a usual test in these patients as well as an outcome measure in clinical trials. In this work, we aimed to assess the associations between the 6MWD and various disease parameters in patients with SSc.

Methods

Consecutive patients followed in our SSc National Reference Centre were included in this cross-sectional study if they fulfilled the 2013 American College of Rheumatology/European League Against Rheumatism criteria for SSc. Data were systematically collected during a comprehensive standardized evaluation that included a 6-minute walk test, clinical assessment, biological results, pulmonary function tests, transthoracic echocardiography, composite scores (European Scleroderma Study Group Activity Index, Medsger severity score, Health Assessment Questionnaire–Disability Index (HAQ-DI)) and treatments.

Associations of the 6MWD with various disease parameters were assessed by linear regression in univariate and multivariate analyses.

Results

The study population comprised 298 patients (females 81%; mean age 58.2 ± 13.3 years; limited cutaneous SSc 82%; interstitial lung disease (ILD) 42%; pulmonary arterial hypertension (PAH) 6%). The 6MWD was significantly and independently associated with gender, age, body mass index, baseline heart rate (HR), HR variation during the test, PAH, history of arterial thrombosis and C-reactive protein levels, as well as with the HAQ-DI score in a sensitivity analysis. Muscle involvement, joint involvement and ILD were not independently associated with the 6MWD.

Conclusions

During SSc, the 6MWD is independently associated with initial HR and HR variation; with PAH but not ILD, suggesting that pulmonary vasculopathy may have a greater impact than parenchymal involvement on functional limitation; and with global markers of disease activity and patient disability. These results give clinicians further insight into how to interpret the 6MWD in the context of SSc.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1489-4) contains supplementary material, which is available to authorized users.

Predictors of lung function test severity and outcome in systemic sclerosis-associated interstitial lung disease

Systemic sclerosis-related interstitial lung disease (SSc-ILD) is the leading cause of death in SSc. In this study, we aimed to describe the baseline severity and evolution of forced vital capacity (FVC) and diffusing capacity for carbon monoxide (DLCO) in patients with SSc-ILD and to assess the baseline clinical, biological and high-resolution CT scan (HRCT) predictors of this evolution. Baseline and serial FVC and DLCO were collected in 75 SSc-ILD patients followed during 6.4±4.2 years (n = 557 individual data). FVC and DLCO evolution was modelled using a linear mixed model with random effect. During follow-up, FVC was stable while DLCO significantly decreased (-1.5±0.3%/year (p<0.0001). Baseline NYHA functional class III/IV, extensive SSc-ILD on HRCT and DLCO<80% were associated with a lower baseline FVC. Absence of digital ulcers extensive SSc-ILD, and FVC<80% and were associated with a lower baseline DLCO. Presence or history of digital ulcers and presence of pulmonary hypertension at baseline or during follow-up were associated with a faster decline of DLCO overtime. Neither age, gender, subtype of SSc nor specificity of autoantibodies were associated with baseline severity or outcome of lung function tests. In this SSc-ILD population, FVC was therefore stable while DLCO significantly declined over time. ILD extension was associated with baseline FVC and DLCO but not with their evolution. Presence or history of digital ulcers and pulmonary hypertension were predictors of a faster decline of DLCO over time.

Persistent triple antiphospholipid antibody positivity as a strong risk factor of first thrombosis, in a long-term follow-up study of patients without history of thrombosis or obstetrical morbidity

Introduction The long-term risk of first thrombosis and benefit of prophylaxis in antiphospholipid antibody (aPL) carriers without history of thrombosis or obstetrical morbidity is poorly known. This study aimed to evaluate the long-term rate and risk factors associated with a first thrombosis in those patients. Patients and methods After a prior study ended in December 2005 and was already published, we extended the follow-up period of our cohort of aPL carriers. Results Ninety-eight of the 103 patients of the previous study were included. The annual first thrombosis rate was 2.3% per patient-year during a median of 13 years (6-17). None of the baseline characteristics was predictive of risk of first thrombosis, but persistent aPL over time were associated with an increased risk. The stronger association was found in triple aPL-positive carriers: OR 3.38 (95% CI: 1.24-9.22). Of note, conversely to our previous findings, no benefit of aspirin prophylaxis was observed. Conclusion The risk of first thrombosis in aPL carriers without history of thrombosis or obstetrical morbidity was significant, persisted linearly over time and was associated with persistent aPL. This risk was especially increased in triple aPL-positive carriers, in whom a close follow-up seems to be necessary. Nevertheless, the benefit of aspirin prophylaxis remained unclear.

Digestive-tract sarcoidosis: French nationwide case-control study of 25 cases

Digestive tract sarcoidosis (DTS) is rare and case-series are lacking. In this retrospective case-control study, we aimed to compare the characteristics, outcome, and treatment of patients with DTS, nondigestive tract sarcoidosis (NDTS), and Crohn disease.We included cases of confirmed sarcoidosis, symptomatic digestive tract involvement, and noncaseating granuloma in any digestive tract. Each case was compared with 2 controls with sarcoidoisis without digestive tract involvement and 4 with Crohn disease.We compared 25 cases of DTS to 50 controls with NDTS and 100 controls with Crohn disease. The major digestive clinical features were abdominal pain (56%), weight loss (52%), nausea/vomiting (48%), diarrhea (32%), and digestive bleeding (28%). On endoscopy of DTS, macroscopic lesions were observed in the esophagus (9%), stomach (78%), duodenum (9%), colon, (25%) and rectum (19%). As compared with NDTS, DTS was associated with weight loss (odds ratio [OR] 5.8; 95% confidence interval [CI] 1.44-23.3) and the absence of thoracic adenopathy (OR 5.0; 95% CI 1.03-25). As compared with Crohn disease, DTS was associated with Afro-Caribbean origin (OR 27; 95% CI 3.6-204) and the absence of ileum or colon macroscopic lesions (OR 62.5; 95% CI 10.3-500). On the last follow-up, patients with DTS showed no need for surgery (versus 31% for patients with Crohn disease; P = 0.0013), and clinical digestive remission was frequent (76% vs. 35% for patients with Crohn disease; P = 0.0002).The differential diagnosis with Crohn disease could be an issue with DTS. Nevertheless, the 2 diseases often have different clinical presentation and outcome.

Musculoskeletal symptoms in patients with cryopyrin-associated periodic syndromes: a large database study

OBJECTIVE

To determine the type and frequency of musculoskeletal symptoms at onset and during followup of cryopyrin-associated periodic syndromes (CAPS).

METHODS

We retrospectively recorded the articular and muscular symptoms of patients with CAPS followed up in French hospitals. Data were presented as frequencies or the median (range), and patient groups were compared using chi-square test, Fisher's exact test, and Mann-Whitney test.

RESULTS

The study included 133 patients (33 children), 20 with familial cold autoinflammatory syndrome, 88 with Muckle-Wells syndrome, 22 with chronic infantile neurologic, cutaneous, articular syndrome, and 3 with unclassified CAPS. The median age was 35 years (range 0-78 years) at the time of the study, 1 year (range 0-41 years) at symptom onset, and 23 years (range 0-58 years) at diagnosis. The disease was sporadic in 17% of the patients. Cutaneous symptoms predominated at onset (77%), followed by articular symptoms (30%). The p.Thr348Met and p.Arg260Trp NLRP3 mutations were significantly associated with the presence and absence of articular symptoms at onset, respectively. During followup, 86% of the patients had musculoskeletal symptoms, 88% had arthralgia, and 58% had arthritis, but only 9% had joint destruction. Tendinopathies occurred in 21.5% of the patients, tender points in 16.5%, and myalgia in 33%. Only 3 patients had typical knee deformities. Radiographs were rarely obtained. Except for bone deformities, osteoarticular symptoms occurred at similar frequencies in the different CAPS phenotypes.

CONCLUSION

Joint manifestations were frequent in all CAPS phenotypes. Bone deformities were rare. Musculoskeletal manifestations varied within given families but tended to worsen over time.

Pernicious anemia presenting as catatonia: correlating vitamin B12 levels and catatonic symptoms

Pernicious anemia has been associated with various psychiatric manifestations, such as depression, mania and psychosis. Psychiatric symptoms can sometimes occur without hematological and neurological abnormalities and can be prodromal of vitamin B12 deficiency. We report a case of autoimmune B12 deficiency presenting as catatonia without signs of anemia or macrocytosis, in which a correlation was found between the patient's B12 blood levels and catatonic symptoms over time. This catatonic episode was successfully treated with only lorazepam and adequate doses of cyanocobalamin.

[Screening and management of cardiovascular risk factors in systemic lupus erythematosus: Recommendations for clinical practice based on the literature and expert opinion]

PURPOSE

To develop French recommendations about screening and management of cardiovascular risk factors in systemic lupus erythematosus (SLE).

METHODS

Thirty-nine experts qualified in internal medicine, rheumatology and nephrology have selected recommendations from a list developed based on evidence from the literature. For each recommendation, the level of evidence and the level of agreement among the experts were specified.

RESULTS

Experts recommended an annual screening of cardiovascular risk factors in SLE. Statins should be prescribed for primary prevention in SLE patients based on the level of LDL-cholesterol and the number of cardiovascular risk factors, considering SLE as an additional risk factor. For secondary prevention, experts have agreed on an LDL-cholesterol target of <0.7 g/L. Hypertension should be managed according to the 2013 European guidelines, using renin-angiotensin system blockers as first line agents in case of renal involvement. Aspirin can be prescribed in patients with high cardiovascular risk or with antiphospholipid antibodies.

CONCLUSION

These recommendations about the screening and management of cardiovascular risk factors in SLE can be expected to improve clinical practice uniformity and, in the longer term, to optimize the management of SLE patients.

Seronegative polyarthritis revealing antisynthetase syndrome: a multicentre study of 40 patients

OBJECTIVE

The aim of this study was to determine the frequency and characteristics of antisynthetase syndrome (ASS) revealed by polyarthritis.

METHODS

First we conducted a retrospective single-centre study to assess the frequency of ASS patients who presented with polyarthritis without pulmonary and/or muscle symptoms. Secondly, we conducted a larger, multicentre study in order to describe the clinical characteristics of these patients. Exclusion criteria were the presence of RF, the presence of ACPA and overlap with another CTD.

RESULTS

In the single-centre study, polyarthritis was the first manifestation in 12 of 45 ASS patients (27%). An additional 28 patients were collected for the multicentre study, resulting in a total population of 40 ASS patients who presented with polyarthritis. The mean delay from polyarthritis onset to ASS diagnosis was 27 months (s.d. 40). Pulmonary and muscle symptoms were uncommon at ASS diagnosis (40% and 32.5%, respectively) and were dramatically delayed [mean delay after polyarthritis onset of 41 months (s.d. 53) and 21 months (s.d. 14), respectively]. Mechanic's hands and cutaneous signs of DM occurred in 25% and 22.5%, respectively, with a mean delay of 10 months (s.d. 10) and 31 months (s.d. 21), respectively. When present (32%), RP was the earliest non-articular manifestation [mean delay 3 months (s.d. 23) after polyarthritis onset]. On HEp-2 cells, antinuclear and/or cytoplasmic fluorescence was found in 70% of cases, with specificity for various anti-aminoacyl tRNA synthetase (anti-ARS) antibodies.

CONCLUSION

ASS may be revealed by polyarthritis. To decrease the delay in diagnosis of ASS, pulmonary and muscle symptoms and anti-ARS antibodies might usefully be searched for in seronegative polyarthritis patients, especially in those with RP.

Prevalence of anti-RNA polymerase III antibodies in systemic sclerosis: New data from a French cohort and a systematic review and meta-analysis

OBJECTIVE

Studies assessing the prevalence of anti-RNA polymerase III (anti-RNAP III) antibodies in systemic sclerosis (SSc) have yielded a wide range of results. The aim of the present study was to describe a new SSc cohort tested for presence of anti-RNAP III and perform a systematic review and meta-analysis to assess the prevalence of anti-RNAP III in patients worldwide and the potential factors of variability.

METHODS

Seropositivity for anti-RNAP III was evaluated in a French cohort of SSc patients. A systematic review of the literature was carried out in PubMed and EMBase. Meta-analysis was performed using available data on prevalence, clinical characteristics of SSc patients, and the types of assays used for anti-RNAP III testing.

RESULTS

One hundred thirty-three French SSc patients were tested for anti-RNAP III, and a prevalence of 6-9% was found in these patients. Thirty studies representing a total population of 8,437 SSc patients were included in the meta-analysis. Prevalence of anti-RNAP III in this population was highly variable (range 0-41%). The overall pooled prevalence of anti-RNAP III was 11% (95% confidence interval 8-14), but heterogeneity was high among studies (I(2) = 93%, P < 0.0001). Geographic factors such as continent or country of study origin partially explained this heterogeneity and correlated with the prevalence. No other baseline SSc characteristics were significantly correlated with the prevalence of anti-RNAP III.

CONCLUSION

Data on our new cohort and our meta-analysis of the literature confirmed that anti-RNAP III prevalence in SSc varies among centers. Geographic factors were significantly associated with prevalence, which underscores the probable implication that genetic background and environmental factors play a role. Heterogeneity among studies remained largely unexplained.

Clinical, functional and health-related quality of life correlates of clinically significant symptoms of anxiety and depression in patients with systemic sclerosis: a cross-sectional survey

Objectives

To identify clinical, functional and health-related quality of life (HRQoL) correlates of clinically significant symptoms of anxiety and depression in patients with systemic sclerosis (SSc).

Methods

Three-hundred-and-eighty-one patients fulfilling the American College of Rheumatology and/or the Leroy and Medsger criteria for SSc were assessed for visceral involvement, disability and HRQoL (assessed by SF-36). Clinically significant symptoms of anxiety and depression were evaluated with the Hospital Anxiety Depression Scale (HAD) (defined cut-off≥8).

Results

9.2% the patients had limited SSc, 50.5% limited cutaneous SSc (lcSSc), and 40.3% diffuse cutaneous SSc (dcSSc). Overall, 40.4% and 58.8% of the patients had clinically significant symptoms of depression and anxiety, respectively. Compared to patients without clinically significant symptoms of depression, patients with clinically significant symptoms of depression had poorer health status, HRQoL mental and physical component, and greater global disability, hand disability and aesthetic impairment. Compared to patients without clinically significant symptoms of anxiety, patients with clinically significant symptoms of anxiety had poorer SF-36 mental and physical component scores. On multivariable analysis, excluding mental component score of SF-36, variables independently associated with clinically significant symptoms of depression and anxiety were global disability and physical component of SF-36, plus female gender for clinically significant symptoms of anxiety only. Remarkably, patients with and without clinically significant psychiatric symptoms were comparable for all disease-related clinical features assessed.

Conclusion

High levels of clinically significant symptoms of anxiety and depression are observed among SSc patients. Clinically significant psychiatric symptoms are rather associated with increased disability and altered HRQoL, than with disease-specific organ manifestations.