Autoimmune Connective Tissue Diseases and the Risk of Rotator Cuff Repair Surgery: A Population-Based Retrospective Cohort Study

OBJECTIVES

Autoimmune connective tissue diseases (ACTDs) commonly involve the shoulder joint; however, clinical epidemiological studies investigating their association with tendons are scant. Rotator cuff (RC) tears can cause shoulder disability, and surgical intervention is usually required. The study investigated RC repair surgery risk in ACTD patients. The effect of anti-inflammatory medication on RC repair surgery risk was also investigated.

METHODS

We conducted a retrospective cohort study with a 7-year longitudinal follow-up period. Patients with systemic lupus erythematosus, systemic sclerosis, sicca syndrome, dermatomyositis and polymyositis diagnoses between 2004 and 2008 were enrolled. The control cohort comprised age- and sex-matched controls. The HR and adjusted HR (aHR) were estimated for the risk of RC surgery between ACTD and control cohorts after adjustment for confounders. Furthermore, the effects of steroid and non-steroidal anti-inflammatory drug (NSAID) use on the HR and aHR of RC surgery risk were analysed.

RESULTS

We enrolled 5019 ACTD patients and 25 095 controls in the ACTD and control cohorts, respectively. RC surgery incidence was 49 and 24 per 100 000 person-years in the ACTD and control cohorts, respectively. In the ACTD cohort, the crude HR for RC surgery was 2.08 (95% CI , 1.08 to 4.02, p<0.05), and the aHR was 1.97 (95% CI, 1.01 to 3.82, p<0.05). The ACTD patients who used NSAIDs had an aHR of 3.13 (95% CI, 1.21 to 8.07, p<0.05) compared with the controls, but the ACTD patients who used steroids did not have a significantly higher aHR than the controls.

CONCLUSIONS

ACTD patients had an increased risk of RC repair surgery. However, no difference was found in RC surgery risk when steroids were used compared with the control cohort. This could indicate that inflammation control may be a strategy for managing subsequent RC lesions.

Vitamin D deficiency in connective tissue disease-associated interstitial lung disease

OBJECTIVES

To determine and compare the prevalence of vitamin D deficiency in patients with connective tissue disease-associated interstitial lung disease (CTD-ILD).

METHODS

The level of vitamin D was determined by the serum levels of 1,25(OH)2D3. We evaluated 144 patients in our study, including 53 subjects in the CTD-ILD group and 91 subjects in the CTD group without ILD. CTD was diagnosed following the American College of Rheumatology criteria, and ILD was diagnosed by high-resolution computed tomography. Patients with other known causes of ILD and other pulmonary diseases were excluded. Vitamin D deficiency level was <20 ng/ml. This is a retrospective study.

RESULTS

Serum vitamin D levels were significantly lower in CTD-ILD patients (p<0.0001). Vitamin D deficiency was lower in the CTD-ILD group (mean±SD: 11.5±4.1 ng/ml) than in the control group (13.9±4.8 ng/ml, p=0.004). The CTD-ILD group was older (p=0.002), had higher levels of fibrinogen (p=0.028) and positive anti-CCP (p=0.026), faster ESR (p=0.001), lower serum levels of serum calcium (p=0.002), and more immunosuppressive therapies (p=0.011). Decreased serum albumin and higher positive antinuclear antibodies (ANA) were associated with reduced vitamin D levels in the vitamin D subgroups. When the odds ratio was adjusted for CTD-ILD, vitamin D deficiency was also a risk factor for CTD-ILD, whereas serum levels of calcium was a protective factor for CTD-ILD.

CONCLUSIONS

Serum vitamin D deficiency is associated with CTD-ILD and is a risk factor. Therefore, vitamin D may play a role in the pathogenesis of CTD-ILD.

Cyclophosphamide for connective tissue disease-associated interstitial lung disease

BACKGROUND

Approximately one-third of individuals with interstitial lung disease (ILD) have associated connective tissue disease (CTD). The connective tissue disorders most commonly associated with ILD include scleroderma/systemic sclerosis (SSc), rheumatoid arthritis, polymyositis/dermatomyositis, and Sjögren's syndrome. Although many people with CTD-ILD do not develop progressive lung disease, a significant proportion do progress, leading to reduced physical function, decreased quality of life, and death. ILD is now the major cause of death amongst individuals with systemic sclerosis.Cyclophosphamide is a highly potent immunosuppressant that has demonstrated efficacy in inducing and maintaining remission in autoimmune and inflammatory illnesses. However this comes with potential toxicities, including nausea, haemorrhagic cystitis, bladder cancer, bone marrow suppression, increased risk of opportunistic infections, and haematological and solid organ malignancies.Decision-making in the treatment of individuals with CTD-ILD is difficult; the clinician needs to identify those who will develop progressive disease, and to weigh up the balance between a high level of need for therapy in a severely unwell patient population against the potential for adverse effects from highly toxic therapy, for which only relatively limited data on efficacy can be found. Similarly, it is not clear whether histological subtype, disease duration, or disease extent can be used to predict treatment responsiveness.

OBJECTIVES

To assess the efficacy and adverse effects of cyclophosphamide in the treatment of individuals with CTD-ILD.

SEARCH METHODS

We performed searches on CENTRAL, MEDLINE, Embase, CINAHL, and Web of Science up to May 2017. We handsearched review articles, clinical trial registries, and reference lists of retrieved articles.

SELECTION CRITERIA

We included randomised controlled parallel-group trials that compared cyclophosphamide in any form, used individually or concomitantly with other immunomodulating therapies, versus non-cyclophosphamide-containing therapies for at least six months, with follow-up of at least 12 months from the start of treatment.

DATA COLLECTION AND ANALYSIS

We imported studies identified by the search into a reference manager database. We retrieved the full-text versions of relevant studies, and two review authors independently extracted data. Primary outcomes were change in lung function (change in forced vital capacity (FVC) % predicted and diffusing capacity of the lung for carbon monoxide (DLCO) % predicted), adverse events, and health-related quality of life measures. Secondary outcomes included all-cause mortality, dyspnoea, cough, and functional exercise testing. When appropriate, we performed meta-analyses and subgroup analyses by severity of lung function, connective tissue disease diagnosis, and radiological pattern of fibrosis. We assessed the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and created 'Summary of findings' tables.

MAIN RESULTS

We included in the analysis four trials with 495 participants (most with systemic sclerosis). We formed two separate comparisons: cyclophosphamide versus placebo (two trials, 195 participants) and cyclophosphamide versus mycophenolate (two trials, 300 participants). We found evidence to be of low quality, as dropout rates were high in the intervention groups, and as we noted a wide confidence interval around the effect with small differences, which affected the precision of results.The data demonstrates significant improvement in lung function with cyclophosphamide compared with placebo (post-treatment FVC % mean difference (MD) 2.83, 95% confidence interval (CI) 0.80 to 4.87; P = 0.006) but no significant difference in post-treatment DLCO (% MD -1.68, 95% CI -4.37 to 1.02; P = 0.22; two trials, 182 participants).Risk of adverse effects was increased in the cyclophosphamide treatment groups compared with the placebo groups, in particular, haematuria, leukopenia, and nausea, leading to a higher rate of withdrawal from cyclophosphamide treatment. The data demonstrates statistically significant improvement in one-measure of quality of life in one trial favouring cyclophosphamide over placebo and clinically and statistically significant improvement in breathlessness in one trial favouring cyclophosphamide compared with placebo, with no significant impact on mortality.Trialists reported no significant impact on lung function when cyclophosphamide was used compared with mycophenolate at 12 months (FVC % MD -0.82, 95% CI -3.95 to 2.31; P = 0.61; two trials, 149 participants; DLCO % MD -1.41, 95% CI -10.40 to 7.58; P = 0.76; two trials, 149 participants).Risk of side effects was increased with cyclophosphamide versus mycophenolate, in particular, leukopenia and thrombocytopenia.The data demonstrates no significant impact on health-related quality of life, all-cause mortality, dyspnoea, or cough severity in the cyclophosphamide group compared with the mycophenolate group. No trials reported outcomes associated with functional exercise tests.We performed subgroup analysis to determine whether severity of lung function, connective tissue disease diagnosis, or radiological pattern had any impact on outcomes. One trial reported that cyclophosphamide protected against decreased FVC in individuals with worse fibrosis scores, and also showed that cyclophosphamide may be more effective in those with worse lung function. No association could be made between connective tissue disease diagnosis and outcomes.

AUTHORS' CONCLUSIONS

This review, which is based on studies of varying methodological quality, demonstrates that overall, in this population, small benefit may be derived from the use of cyclophosphamide in terms of mean difference in % FVC when compared with placebo, but not of the difference in % DLCO, or when compared with mycophenolate. Modest clinical improvement in dyspnoea may be noted with the use of cyclophosphamide. Clinical practice guidelines should advise clinicians to consider individual patient characteristics and to expect only modest benefit at best in preserving FVC. Clinicians should carefully monitor for adverse effects during treatment and in the years thereafter.Further studies are required to examine the use of cyclophosphamide; they should be adequately powered to compare outcomes within different subgroups, specifically, stratified for extent of pulmonary infiltrates on high-resolution computed tomography (HRCT) and skin involvement in SSc. Studies on other forms of connective tissue disease are needed. Researchers may consider comparing cyclophosphamide (a potent immunosuppressant) versus antifibrotic agents, or comparing both versus placebo, in particular, for those with evidence of rapidly progressive fibrotic disease, who may benefit the most.

Four Cases of Pneumatosis Cystoides Intestinalis Complicated by Connective Tissue Diseases

Pneumatosis cystoides intestinalis (PCI) is a rare disease that involves the presence of gas in the intestinal wall. Connective tissue disease (CTD) is a major cause of secondary PCI. In addition to the nature of CTDs, the use of prednisolone and some immunosuppressants, and the presence of complicating diseases such as diabetes mellitus, constipation and pulmonary diseases are involved in the development of PCI. This report describes four cases of PCI with different CTDs (granulomatosis with polyangiitis, rheumatoid arthritis, dermatomyositis, and overlap syndrome) and discusses the background of each patient and common risk factors for the occurrence of PCI.

Effects of rituximab in connective tissue disorders related interstitial lung disease

OBJECTIVES

Interstitial lung disease (ILD) is a key prognostic factor in connective tissue disorders (CTDs). The aim of our study was to assess the changes in pulmonary functional tests (PFTs) in various CTDs, including anti-synthetase syndrome (SYN), systemic sclerosis (SSc) and mixed connective tissue disorder (MCTD), following the use of rituximab therapy.

METHODS

A multicentre retrospective analysis of patients with ILD secondary to SYN (n=15), MCTD (n=6) and SSc (n=23). PFTs were performed at baseline and at 1 and 2 years of follow-up. The primary outcome was the change in forced vital capacity (FVC) at 1 year.

RESULTS

In the SYN population, median FVC changed from 53.0% (42.0-90.0) at baseline to 51.4% (45.6-85.0) at 1 year and 63.0 (50-88) (p=0.6) at 2 years (p=0.14). In SSc, FVC changed from 81.0% (66.0-104.0) at baseline to 89.0% (65.0-113.0) at 1 year (p=0.1) and 74.5 (50-91) at 2 years (p=0.07). In the MCTD population, FVC changed from 64.5% (63.0-68.0) at baseline to 63.0% (59.0-71.0) at 1 year (p=0.6) and 61 (59-71) after 2 years (p=0.8). DLCO showed a trend for improvement in the SYN population (p=0.06 at 1 year and 0.2 at years) while changes remain non-significant in the SSc and MCTD patients. In SYN patients, the percentage of responders at 1 year for FVC (33.3%) was greater than in SSc (9.5%) (p=0.07) and MCTD (17%) (p=0.45). RTX showed a satisfactory safety profile.

CONCLUSIONS

A trend of improvement of PFTs was observed in SYN patients although not reaching significance, while SSc and MCTD patients were stabilised.

Rituximab: Uses in Dermatology

Rituximab is an anti-CD20 monoclonal antibody with considerable potential in dermatology due to an increase in off-label indications. Chronic graft-versus-host disease and pemphigus vulgaris are two of the most promising indications for off-label use of rituximab. It is a generally safe alternative that should be considered when traditional therapy with corticosteroids or immunosuppressants has failed or caused significant intolerance. Currently, rituximab is only FDA-approved for treatment of follicular and diffuse large B-cell non-Hodgkin's lymphoma, rheumatoid arthritis, chronic lymphocytic leukemia, granulomatosis with polyangiitis (formerly Wegener's granulomatosis) and microscopic polyangiitis. Herein, off-label uses of rituximab and its efficacy in the treatment of cutaneous diseases are reviewed.

Benefit of adjunctive tacrolimus in connective tissue disease-interstitial lung disease

We evaluated the safety and effectiveness of adjunctive tacrolimus therapy with conventional immunosuppression in patients with severe connective tissue disease-related interstitial lung disease (CTD-ILD). We included patients from our interstitial lung disease (ILD) registry with CTD-ILD, in whom tacrolimus was added to corticosteroids and an additional immunosuppressive agent. Demographic data, clinical features, lung function, radiographic images, and pathologic findings were reviewed. Effectiveness was assessed by comparing pulmonary function tests (PFTs) closest to tacrolimus initiation to PFTs approximately 6-12 months later. Corticosteroid dose at these time points was also evaluated. We report adverse events attributed to tacrolimus. Seventeen patients with CTD-ILD were included in adverse event analysis; twelve were included in efficacy analysis. Length of tacrolimus therapy ranged from 6 to 110 months (mean 38.8 months ± 31.4). The mean improvement in percent predicted total lung capacity was 7.5% ± 11.7 (p = 0.02). Forced vital capacity mean improvement was 7.4% ± 12.5 (p = 0.06). The average decrease in corticosteroid dose at follow-up was 20.3 mg ± 25.2 (p = 0.02) with complete discontinuation in six patients. No patients experienced a life-threatening adverse event attributed to tacrolimus. Tacrolimus can be effective and is well tolerated as an adjunctive therapy and allows tapering of corticosteroids.

Efficacy and Safety of Grapefruit Juice Intake Accompanying Tacrolimus Treatment in Connective Tissue Disease Patients

Objective It is well known that grapefruit juice (GFJ) elevates the blood tacrolimus (TAC) concentration. We investigated the efficacy and safety of GFJ intake with TAC in cases of connective tissue diseases in which the TAC blood concentration was insufficiently high for clinical improvement, even when 3 mg/day or more of TAC was administered. Methods Seven patients took 200 mL of GFJ every day. The trough levels of the TAC blood concentration were measured before and after GFJ intake and the clinical courses were monitored thereafter. Results First, we surveyed the blood TAC trough levels of 30 recent patients who took 3 mg/day of TAC, and found that 21 patients (70%) did not achieve the minimum target TAC concentration (>5 ng/mL). Seven patients took GFJ due to a lack of efficacy and a relatively low TAC blood concentration. GFJ increased the TAC level from 4.3±2.4 ng/mL to 13.8±6.9 ng/mL (average increase: 3.3-fold). GFJ was also effective in achieving a clinical improvement in most cases without causing any severe adverse events, and it helped to decrease the dosages of glucocorticoid and TAC. In some cases, the blood TAC concentration fluctuated for no apparent reason. Conclusion GFJ intake was effective for the elevation of TAC concentration by approximately three fold and clinical improvement, but special care is required for monitoring its influence on concomitantly used drugs as well as TAC concentration. The addition of GFJ to TAC treatment could be an efficacious treatment option, when the plasma TAC concentration does not reach the minimal target concentration.

The role of biologics in treatment of connective tissue disease-associated interstitial lung disease

With an increased understanding of the molecular pathways of inflammation and autoimmunity, the development of targeted biological agents has revolutionized the management of connective tissue diseases (CTDs). There has been an explosion in the development of these drugs in the last decade, targeting diseases in diverse fields including: allergic disorders, oncology, neuroinflammatory disorders, inflammatory bowel disease, macular degeneration and CTDs. In this last field, commonly applied biologics fall into two categories: cytokine inhibitors and lymphocyte-targeted therapies. The former group includes the antitumour necrosis factor alpha (TNF-α), anti-interleukin (IL)-6 receptor monoclonal antibodies and IL-1 receptor antagonists, whilst the latter encompasses the anti-CD20, B-cell depleting, monoclonal antibody (mAb), Rituximab and the anti-T-cell activation agent, Abatacept. This review will examine our developing experience in the use of these agents in the treatment of CTD-related interstitial lung diseases, with a particular focus on B-cell depletion.

Nonspecific interstitial pneumonia overlaps organizing pneumonia in lung-dominant connective tissue disease

Here, we reported two cases of nonspecific interstitial pneumonia overlap organizing pneumonia (NSIP/OP) with lung-dominant connective tissue disease (LD-ILD). The first case is a patient with hands of chapped skin, right-sided pleuritic chest discomfort, weakness, positive ANA and antibodies to Ro/SS-A (+++) and Ro-52 (++). In the second case, there were Reynaud's disease, and nucleolus-ANA increased (1:800). Chest high resolution CT scan in both cases showed ground-glass opacifications, predominantly in basal and subpleural region and the pathologic manifestation were correlated with NSIP/OP, which were previously discovered in Sjogren syndrome, PM/DM and other rheumatic diseases. The two cases of NSIP/OP with LD-CTD we reported expand disease spectrum of NSIP/OP pathological types in ILD. However, it is necessary to process large-scale studies.

Effect of CYP3A5 and ABCB1 polymorphisms on the interaction between tacrolimus and itraconazole in patients with connective tissue disease

PURPOSE

The aim of this study was to investigate the effect of itraconazole (ITCZ), a potent inhibitor of CYP3A4 and P-glycoprotein, on the blood concentration 12 h after tacrolimus administration (C 12h) in relation to CYP3A5 6986A>G and ABCB1 3435C>T genotype status in patients with connective tissue disease (CTD).

METHODS

Eighty-one CTD patients taking tacrolimus (Prograf®) once daily at night (2100 hours) were enrolled in this study. Whole blood samples were collected 12 h after tacrolimus administration at steady state.

RESULTS

The dose-adjusted tacrolimus C 12h with or without ITCZ co-administration was significantly higher in patients with CYP3A5*3/*3 than in those with the CYP3A5*1 allele [CYP3A5 *1/*1 vs. *1/*3 vs. *3/*3 = 1.67 vs. 2.70 vs. 4.83 ng/mL/mg (P = 0.003) and 0.68 vs. 0.97 vs. 2.20 ng/mL/mg (P < 0.001), respectively], but differences were not observed for ABCB1 genotypes. However, there was no difference in the increase rate of the dose-adjusted C 12h of tacrolimus between CYP3A5 or ABCB1 genotypes (P = 0.378 and 0.259). On the other hand, reduction of the estimated glomerular filtration rate exhibited a correlation with the C 12h of tacrolimus after ITCZ co-administration (r = -0.482, P = 0.009).

CONCLUSIONS

In CYP3A5*3/*3 patients, because the metabolic pathway for tacrolimus occurs only through CYP3A4, the combination with ITCZ seems to lead to a higher risk of acute renal dysfunction. Therefore, we suggest that the target blood tacrolimus concentration be set as low as possible through dose-adjustment for patients with the CYP3A5*3/*3 allele.

Cardiovascular involvement in connective tissue disease: the role of interstitial lung disease

Objective

The aim of this study was to assess cardiovascular involvement in patients with connective tissue disease (CTD), and determine whether interstitial lung disease (ILD) in these patients is associated with elevated cardiovascular risk.

Methods

This study evaluated a retrospective cohort of 436 CTD patients admitted to a large teaching hospital in Zhejiang province, China, along with an additional 436 participants of an annual community health screening conducted in the physical examination center who served as age- and gender-matched controls. Demographic, clinical, serologic and imaging characteristics, as well as medications used by each participant were recorded. Cardiovascular involvement was defined by uniform criteria. Correlations between clinical/serologic factors and cardiovascular involvement were determined by univariate and multivariate analyses.

Results

CTD patients had a significantly higher cardiovascular involvement rate than controls (64.7% vs 23.4%), with higher rates of diabetes, hypertension, and hyperlipidemia, elevated systolic and diastolic pressures, C-reactive protein, total cholesterol, and low-density lipoprotein cholesterol, and lower albumin and high-density lipoprotein cholesterol (all p < 0.05). Furthermore, CTP patients with cardiovascular involvement were significantly older, had higher systolic and diastolic pressures, C-reactive protein, glucose, and uric acid, higher rates of diabetes, hypertension, and use of moderate- to high-dose glucocorticoids, and longer disease duration compared to patients without involvement (all p < 0.05). Moreover, CTD in patients with cardiovascular involvement was more likely to be complicated by ILD (p < 0.01), which manifested as a higher alveolar inflammation score (p < 0.05). In the multivariate analysis, cardiovascular involvement in CTD patients was associated with age, systolic pressure, body mass index, uric acid, disease duration > 2 years, use of moderate- to high-dose glucocorticoids, and ILD with a high alveolar inflammation score.

Conclusion

Cardiovascular involvement is increased in CTD patients, and is associated with ILD with a higher alveolar inflammation score. Thus, early-stage echocardiography and CT scans should be used to detect potential cardiovascular complications in these patients.

[Discontinuation of immunosuppressive and immunomodulatory drugs in connective tissue diseases]

Remission in connective tissue diseases became a realistic goal of therapy nowadays. However, there is lack of recommendations on the management after achieving a remission. Chronic exposure to immunosuppressive or immunomodulatory drugs may be associated with adverse events, that is why temporal withdrawal or discontinuation of treatment is advisable. In patients with rheumatoid arthritis (RA) who achieve sustained remission lasting for 6-12 months, an attempt to withdraw biological disease modifying antirheumatic drugs (bDMARDs) may be considered. In most patients with established RA discontinuation of bDMARDs is accompanied by a disease flare, butthe risk of loss of good therapeutic response is lower in case of slowly tapering by expanding the interval between doses or reducing the dose of bDMARDs. Patients with early RA are more likely to have successful discontinuation of therapy. Discontinuation of conventional DMARDs (cDMARDs) is usually associated with a disease flare, that is why tapering of doses is advised rather than stopping cDMARDs. DMARDs free remission occurs relatively rare, more often in patients with seronegative RA and with early onset of modifying treatment. In lupus nephritis (LN) patients with persistent, long-term remission, progressive tapering of doses of immunosuppressive drugs and glucocorticoids is recommended, with treatment discontinuation as a goal. An attempt of treatment withdrawal may be taken in patients remaining in LN complete remission as a consequence of maintenance therapy for 3 years.The process of slow tapering of doses preceding discontinuation of drugs, may last several months. The therapy with antimalarial drugs may be helpful to maintain remission after the treatment discontinuation. There is few data on treatment discontinuation in patients with systemic lupus erythematosus (SLE) without kidney involvement. Immunosuppressive drugs withdrawal is usually performed in patients with stable serological and clinically asymptomatic disease lasting for ≥ 2 years, on maintenance antimalarial therapy. Discontinuation of immunomodulatory treatment seems unlikely in primary systemic vasculitis.

Bone status of children born from mothers with autoimmune diseases treated during pregnancy with prednisone and/or low molecular weight heparin

BACKGROUND

To evaluate bone status in children born from mothers followed for autoimmune diseases and treated during pregnancy with low molecular weight heparin (LMVH) and/or prednisone.

FINDINGS

History, physical examination, laboratory tests and phalangeal ultrasonography were performed. Demographic, clinical, and laboratory data were entered into a customized database, and results were analyzed with SPSS software. In children whose mothers were treated with LMWH, we retrieved dried blood spots taken for newborn screening, and analyzed the presence of heparin with tandem mass spectrometry. We enrolled 27 females and 14 males born from 31 mothers with SLE or connective tissue diseases. These women were continuously treated during pregnancy with LMWH (n = 10), prednisone (n = 16), or both (n = 15). Bone ultrasound revealed low values (≤ 3 centile for age) in ten patients. In a multistep regression analysis, age at examination resulted the single predictor of low ultrasound values (p < 0.004). Tandem mass spectroscopy failed to determine traces of heparin in newborn blood.

CONCLUSIONS

Children born from mothers with autoimmune diseases are at risk to develop reduced bone mass. The administration of LMWH and of prednisone seems to be safe with regard to children's bone health.

Hair disorders associated with autoimmune connective tissue diseases

Hair disorders are frequently observed in various systemic diseases, including autoimmune connective tissue diseases (CTDs), with predilection of lupus erythematosus (LE), followed by dermatomyositis (DM) and scleroderma. Hair disorders in CTDs may manifest as various clinical patterns, such as telogen hair loss, diffuse thinning or fragility of hair, and scarring alopecia. Less common hair disorders include anagen effluvium, alopecia areata, and trichomegaly. Some drugs used to treat CTDs may cause hair loss in a drug-related manner or hyperthrichosis. In the assessment of common hair loss patterns, such as telogen effluvium, the possible association with CTDs must be borne in mind and should not be overlooked. Alopecia appears to be a significant sign in the course of LE and especially systemic LE. In DM, the involvement of the scalp is common, and is often characterized by a diffuse, violaceous, scaly, non-scarring and symptomatic hair loss. Linear scleroderma en coup de sabre is an uncommon localized form of morphea with involvement of the paramedian forehead and frontal scalp, where it is associated with cicatricial alopecia. The most important variant of scarring alopecia in the context of CTDs is that associated with discoid lupus erythematosus (DLE). In the diagnostic work-up of DLE-related cicatrical alopecia, histopathological and immunopathological studies are useful, and a relevant role has been attributed to dermatoscopy (trichoscopy) over the last years. Hair loss has been reported in several other CTDs, including mixed and undifferentiated CTDs, and primary Sjögren's syndrome, although it is likely to be underestimated in such diseases.

Skin cancer risk in autoimmune connective tissue diseases

Cutaneous malignancies have been significantly associated with autoimmune connective tissue diseases (ACTDs). This review focuses on the current state of knowledge on skin cancer risk in the most prevalent ACTDs in dermatology including lupus erythematosus, scleroderma, dermatomyositis and Sjögren syndrome. Potential pathogenetic mechanisms for the association between ACTDs and malignancy involve disease-related impairment of immune system, sustained cutaneous inflammation, drug-associated immune suppression and increased susceptibility to acquired viral infections. An additional causal role might be played by environmental factors such as UV exposure and smoking. The occurrence of skin cancer can have a profound impact on the already compromised quality of life of ACTD patients. Therefore, effective screening and monitoring strategies are essential for ACTD patients as early detection and prompt therapeutic intervention can reduce morbidity and mortality in these patients.

[Pleiotropic activity of 3-hydroxy-3-methyl-glutharyl-coenzyme a inhibitors (statins). therapeutic potential in connective tissue diseases ]

3-Hydroxy-3-Methyl-Glutharyl-Coenzyme A reduct- ase inhibitors, known as statins, form a group of chemical compounds that are characterized by the ability to inhibit cholesterol synthesis. Statins have proved their efficacy as potent drugs in the primary and secondary prevention of cardiovascular events. It has also been shown that the thera- peutic effects of statins go beyond reduction of cholesterol level. These properties, which are separate from the influ- ence on cholesterol synthesis, are sometimes called the pleio- tropic effect. This effect comprises immunomodulation, an anti-inflammatory effect, and endothelial function recovery.

[Management of borderline pulmonary arterial hypertension associated with connective tissue diseases]

The prognosis of connective tissue disease (CTD)-associated pulmonary arterial hypertension (PAH) is so poor that early therapeutic intervention is advisable. Borderline PAH (21-24 mmHg mean pulmonary arterial pressure) is a concept created to distinguish cases that would become definite PAH. It is controversial whether borderline PAH cases with no symptoms should be treated, but therapeutic intervention in the case of borderline PAH is justified when systemic sclerosis (SSc) is in the background, because SSc-associated PAH shows an especially poor prognosis compared to PAH associated with other CTDs, while 42-55% of SSc-associated borderline PAH cases become definite PAH within several years. However, cautious attention should be paid when pulmonary vasodilators are administered to SSc-associated PAH cases, because complications caused by SSc such as lung lesions, left heart diseases and pulmonary venous lesions can be obstacles to the success of the therapy. There is very little evidence of the efficacy of therapeutic intervention in borderline PAH. Clinical trials should be planned.

[Possible applications bisoprolol for heart rate control in young patients with connective tissue dysplasia]

To assess the efficacy and safety of bisoprolol to monitor heart rate (HR) in young patients with connective tissue dysplasia (CTD) examined 58 patients (22,3 + 3,47 years, 38 men). Bisoprolol drug was administered at an initial dose of 1.25 mg/day, with a further increase to 2.5 mg/day in 2 weeks, etc. to achieve the level of heart rate 59-69 beats/min. Average effective dose was 7.27 ± 2.08 mg/day. Target heart rate,improvement of health and the pumping function of the heart, reducing the activation of the sympathetic nervous system and of anxiety achieved the absolute majority of patients. During treatment unit observed transient manifestations of general weakness, headache, episodes of vertigo in the selection of the dose, cases of bradycardia and hypotension pathological registered for the time of ingestion. Thus, the use of mandatory bisoprolol gradual careful titration, starting with 1.25 mg/day as a means to control the heart rate in young patients with CTD with sinus tachycardia, the manifestations of autonomic nervous system dysfunction, safely and effectively in relation to adverse orthostatic reactions.

Corticosteroid use in the intensive care unit: a survey of intensivists

OBJECTIVE

The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of corticosteroids in clinical practice.

DESIGN

Self-administered paper survey.

POPULATION

Intensivists in academic hospitals with clinical trial expertise in critical illness.

MEASUREMENTS

We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing. We administered the survey to experienced intensivists practicing in selected North American centres actively enrolling patients in the multicentre Oscillation for ARDS Treated Early (OSCILLATE) Trial (ISRCTN87124254). Respondents used a four-point scale to grade how frequently they would administer corticosteroids in 14 clinical settings. They also reported their opinions on 16 potential near-absolute indications or contraindications for the use of corticosteroids.

MAIN RESULTS

Our response rate was 82% (103/125). Respondents were general internists (50%), respirologists (22%), anesthesiologists (21%), and surgeons (7%) who practiced in mixed medical-surgical units. A majority of respondents reported almost always prescribing corticosteroids in the setting of significant bronchospasm in a mechanically ventilated patient (94%), recent corticosteroid use and low blood pressure (93%), and vasopressor-refractory septic shock (52%). Although more than half of respondents stated they would almost never prescribe corticosteroids in severe community-acquired pneumonia (81%), acute lung injury (ALI, 76%), acute respiratory distress syndrome (ARDS, 65%), and severe ARDS (51%), variability increased with severity of acute lung injury. Near-absolute indications selected by most respondents included known adrenal insufficiency (99%) and suspicion of cryptogenic organizing pneumonia (89%), connective tissue disease (85%), or other potentially corticosteroid-responsive illnesses (85%).

CONCLUSIONS

Respondents reported rarely prescribing corticosteroids for ALI, but accepted them for bronchospasm, suspected adrenal insufficiency due to previous corticosteroid use, and vasopressor-refractory septic shock. These competing indications will complicate the design and interpretation of any future large-scale trial of corticosteroids in critical illness.

[Connective tissue diseases: news in therapy, role of biologics agents]

Systemic lupus erythematosus and primary Sjögren's syndrom are the two major connective tissue diseases. A better knowledge of their physiopathology allows us today to propose an adapted therapy. Moreover progress concerns the oldest treatment, hydroxychloroquine, and biotherapy. Hydroxychloroquine is still an actual treatment for lupus, its positive effects are better understood today. Nevertheless it does not seem to be efficient to treat primitive Sjögren. Biotherapy targeting B lymphocytes seems efficient in these two connective tissue diseases. Anti TNF therapy is not recommended and seems to induce connective tissue diseases. The real news is the recent approval and reimbursement in Switzerland of the new drug belimumab (Benlysta) in case of moderate lupus.