Impact of heterozygous ALK1 mutations on the transcriptomic response to BMP9 and BMP10 in endothelial cells from hereditary hemorrhagic telangiectasia and pulmonary arterial hypertension donors

Heterozygous activin receptor-like kinase 1 (ALK1) mutations are associated with two vascular diseases: hereditary hemorrhagic telangiectasia (HHT) and more rarely pulmonary arterial hypertension (PAH). Here, we aimed to understand the impact of ALK1 mutations on BMP9 and BMP10 transcriptomic responses in endothelial cells. Endothelial colony-forming cells (ECFCs) and microvascular endothelial cells (HMVECs) carrying loss of function ALK1 mutations were isolated from newborn HHT and adult PAH donors, respectively. RNA-sequencing was performed on each type of cells compared to controls following an 18 h stimulation with BMP9 or BMP10. In control ECFCs, BMP9 and BMP10 stimulations induced similar transcriptomic responses with around 800 differentially expressed genes (DEGs). ALK1-mutated ECFCs unexpectedly revealed highly similar transcriptomic profiles to controls, both at the baseline and upon stimulation, and normal activation of Smad1/5 that could not be explained by a compensation in cell-surface ALK1 level. Conversely, PAH HMVECs revealed strong transcriptional dysregulations compared to controls with > 1200 DEGs at the baseline. Consequently, because our study involved two variables, ALK1 genotype and BMP stimulation, we performed two-factor differential expression analysis and identified 44 BMP9-dysregulated genes in mutated HMVECs, but none in ECFCs. Yet, the impaired regulation of at least one hit, namely lunatic fringe (LFNG), was validated by RT-qPCR in three different ALK1-mutated endothelial models. In conclusion, ALK1 heterozygosity only modified the BMP9/BMP10 regulation of few genes, including LFNG involved in NOTCH signaling. Future studies will uncover whether dysregulations in such hits are enough to promote HHT/PAH pathogenesis, making them potential therapeutic targets, or if second hits are necessary.

[Severe small bowel involvement and chronic intestinal pseudo-obstruction in systemic sclerosis (scleroderma): Pathophysiological, diagnostic and therapeutic basis, including parenteral nutrition]

Gastrointestinal involvement in systemic sclerosis can be severe, reaching the critical point of chronic intestinal pseudo-obstruction, secondary to major disorders of small bowel motility. It is associated with some clinical and biological characteristics, in particular the positivity of anti-fibrillarin/U3RNP antibodies. Chronic intestinal pseudo-obstruction (CIPO) is complicated by a small intestinal bacterial overgrowth that requires cyclic antibiotic therapy. CIPO leads to a reduction of the food intake, due to painful symptoms, nausea and vomiting caused by meals, and ultimately to severe malnutrition. Meal splitting is often transiently effective and patients require exogenous nutritional support, mostly parenteral. Systemic sclerosis is not an obstacle to initiation and long-term continuation of parenteral nutrition and central venous catheter implantation is not associated with an increased risk of cutaneous or infectious complications. However, continuation of long-term parenteral nutrition requires monitoring in an expert nutrition center in order to adapt nutritional volumes and intakes and to limit potentially fatal cardiac and hepatobiliary complications. In addition to nutrition, prokinetic treatments, whose side effects must be known, can be associated. Invasive procedures, whose risk-benefit ratio must be carefully assessed, can also be used to treat symptoms exclusively.

O-011 A prospective multicentre, non-interventional, real-world study to assess the pattern of use, effectiveness and safety of follitropin delta in routine clinical practice (the PROFILE study)

Study question

To observe real-world utilization of algorithm-based dosing of follitropin delta in women naïve to ovarian stimulation (OS) and undergoing either in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

Summary answer

Individualized dosing of follitropin delta in real-world clinical practice results in predictable ovarian response while minimizing risk of ovarian hyperstimulation syndrome (OHSS).

What is known already

Follitropin delta (REKOVELLE, Ferring Pharmaceuticals, Switzerland), is the first recombinant human follicle-stimulating hormone (FSH) to be produced in a human cell line. The algorithm-based individualized dosing regimen for follitropin delta was developed to target an ovarian response of 8–14 oocytes while reducing the risk of extreme ovarian hypo- and hyper-response as compared with conventional dosing strategies. The efficacy and safety of follitropin delta has been demonstrated in randomized controlled trials (RCTs) compared with a standard daily starting dose of 150 IU recombinant FSH. Real-world implementation of individualized follitropin delta dosing using the algorithm in OS cycles is currently unknown.

Study design, size, duration

PROFILE was a prospective, open-label, non-interventional, multinational study conducted between March 2018 and October 2020 in which 1258 women were screened, 1013 met the inclusion/exclusion criteria and 944 women initiated their first OS cycle. No study drugs were reimbursed or provided by the study sponsor. All IVF/ICSI treatment protocols were conducted according to routine clinical practice, including how to prescribe follitropin delta and undertaking fresh/frozen transfers. Participants were followed for up to three OS cycles.

Participants/materials, setting, methods

All participants met inclusion criteria: ≥18 years, were naïve to IVF/ICSI treatment and the decision had made before enrolment to use follitropin delta for OS. Main exclusion criteria were any contraindication(s) preventing prescription of follitropin delta, and undergoing OS for oocyte donation or fertility preservation. The main outcomes were use of dosing algorithm, follitropin delta dosing patterns, ovarian response and pregnancy for first OS cycle, and adverse drug reactions (ADRs) for up to three cycles.

Main results and the role of chance

Baseline demographics for 944 women who initiated Cycle 1 were: age, 33.5±4.7 years; bodyweight, 67.1±13.6 kg; anti-Müllerian hormone, 20.3±16.1 pmol/L (2.84 ng/mL) (mean±standard deviation). Cycles 2 and 3 were initiated by 156 and 29 women, respectively. In Cycle 1, clinicians used the dosing algorithm to calculate the follitropin delta starting dose for 893/944 women (94.5%), although some clinicians adjusted the prescribed daily starting dose. The difference between the calculated and prescribed daily dose was small (0.2±1.40 µg); most women (822/944, 87.1%) were prescribed a daily dose of follitropin delta within 0.33 µg (1 click of pen) of the algorithm-calculated dose. The mean daily starting dose was 10.4 µg and mean total dose administered was 104 µg over 10.1 days. A mean of 10.1±7.03 oocytes were retrieved per woman. A fresh transfer was performed for 592/944 women (62.7%) and subsequent positive β-human chorionic gonadotropin (βhCG) reported for 352/944 women (37.3%). Ongoing pregnancy rate after fresh transfer was 27.0% (n = 255) and cumulative ongoing pregnancy rate after fresh/frozen transfer was 36.4% (n = 344). Four women discontinued follitropin delta due to ADRs. OHSS was reported for 37 women (3.9%); 12 (1.3%) OHSS events were reported as serious ADRs. No new safety signals were reported.

Limitations, reasons for caution

There may be bias towards IVF/ICSI treatment protocols used in countries with highest enrolment. Reasons for prescribing follitropin delta as part of a mixed FSH regimen in 33/944 women (3.5%) were not reported.

Wider implications of the findings

In real-world clinical practice, nearly all clinicians use the dosing algorithm to calculate individualized daily follitropin delta dose. Despite some women being prescribed dose deviations, first cycle ovarian response was predictable with good ongoing pregnancy rates. OHSS incidence was within expected range. PROFILE confirms efficacy and safety from pivotal RCTs.

Trial registration number

NCT03393780

Factors associated with tuberculosis-associated haemophagocytic syndrome: a multicentre case-control study

SETTING: Tuberculosis (TB) is a potential trigger of haemophagocytic syndrome (HS) but little is known about the features of TB-associated HS.OBJECTIVE: To assess the risk factors associated with HS in patients with TB.DESIGN: We performed a multicentre case-control study assessing the medical records of adult patients diagnosed with proven TB with (TB/HS+) or without (TB/HS-) associated HS.RESULTS: Twenty-one patients with TB/HS+ (24% women, median age, 37 years [IQR 30-48]) were included in the study. Eleven patients (52%) were infected with human immunodeficiency virus and seven patients (33%) were immunocompromised due to other reasons. TB was disseminated in 17 patients (81%). Compared with 50 control TB patients (TB/HS-), patients with TB/HS+ were more likely to be immunocompromised (86% vs. 18%; P < 0.001) and to present with disseminated TB (80% vs. 12%; P < 0.001). The outcome was poorer in patients with TB/HS+, with a higher admission rate to intensive care (71% vs. 0%; P < 0.001) and a higher risk of death (38% vs. 7%; P = 0.005).CONCLUSION: TB/HS+ occurred more likely in immunocompromised patients and severely impaired the prognosis of TB. Further studies are needed to devise therapeutic strategies for patients with TB/HS+.

Retour d’expérience d’un hôpital pédiatrique pendant la crise Covid-19 en Île-de-France

La crise sanitaire de la Covid-19 du printemps 2020 a peu touché les enfants avec peu d’hospitalisations dans les hôpitaux pédiatriques. Le défi a été d’apporter une aide aux hôpitaux adultes avec un personnel principalement formé à la pédiatrie tout en maintenant la permanence des soins urgents pour les enfants atteints ou non de la Covid-19. À l’hôpital universitaire Armand-Trousseau, nous avons créé des unités dédiées pour les enfants atteints de la Covid-19, identifié les spécificités des enfants atteints de la Covid-19 et notamment les formes de Kawasaki like ou PIMS (paediatric multisystem inflammatory syndrome), créé une unité de réanimation adulte au pic de l’épidémie pour augmenter les capacités en lits de réanimation dans notre région, mutualisé notre centre de dépistage pour le personnel d’hôpitaux adultes. Enfin, nous avons envoyé plus de 140 personnels médicaux et paramédicaux dans les hôpitaux adultes de notre groupe hospitalier. Cette aide a pu être organisée grâce aux liens étroits établis par des cellules de crises communes avec les hôpitaux adultes de notre groupe hospitalier. Nous rapportons ainsi un retour d’expérience d’un hôpital pédiatrique au cours de la crise de la Covid-19 en Île-de-France.

[From fibrogenesis towards fibrosis: Pathophysiological mechanisms and clinical presentations]

Fibrogenesis is a universal and ubiquitous process associated with tissue healing. The impairment of tissue homeostasis resulting from the deregulation of numerous cellular actors, under the effect of specific cytokine and pro-oxidative environments can lead to extensive tissue fibrosis, organ dysfunction and significant morbidity and mortality. This situation is frequent in internal medicine, since fibrosis is associated with most organ insufficiencies (i.e. cardiac, renal, or hepatic chronic failures), but also with cancer, a condition with common pathophysiological mechanisms. Finally, fibrosis is a hallmark of numerous systemic autoimmune diseases such as connective tissue disorders (in particular systemic sclerosis), vasculitides, granulomatoses, histiocytoses, and IgG4-associated disease. Although the process leading to tissue fibrosis may be in part irreversible, new pharmacological approaches or cell therapies bring hope in the field of fibrotic conditions.

Usefulness of the results of a surveillance program for uncompensated work-related diseases in France

Background

French employees receive compensations for diseases officially recognized as professionnal disease. Reimbursment data are thus used to produce statistics. Such data do not integrate uncompensated work-related diseases (UUWRD) defined as likely to be of occupational origin but not recognized as well. In 2003, the National Public Health Agency implemented a surveillance program on UWRD. This program is a complement to the compensation system for occupational diseases.

This communication presents results UWRD program can provide.

Methods

Twice a year, a network of volunteer occupational physicians (OP) reports ill health and associated work exposures of employees. Employee sociodemographics are notified. In 2018, half of French regions are integrated in the program.

Prevalence rates are calculated for UWRD. Chi-squared tests are used to compare prevalence rates between groups. Multivariate logistic regressions are conducted to evaluate:1- risks to report UWRD between groups, 2- prevalence rates trends. Underreporting rates of UWRD are approximated using an indicator capturing differences between figures produced by UWRD program and the compensation system.

Results

Over the 2009-2014 period, women working in mass food retail were observed at higher risk to present musuculoskeletical disorders than women of other sectors (ORa = 2.0). Same results were noted for men (ORa = 1.3). In mass food retail, decreases in musculoskeletal disorder prevalence rates were reported. Estimated average annual change rates were of 7.0 % for women and 11.0% for men. In 2011, UWRD data highlighted that between half and three-quarter of work-related musculoskeletal disorders were unreported by the compensation system.

Conclusions

UWRD data are used to identify vulnerable groups, analyse temporal trends and evaluate underreporting of professionnal disease.

Key messages

URWD program is a complement to the compensation system and let to better monitor health status of communities. Such informations are of interest to guide prevention policies.

Economic burden of cardiovascular diseases from 2012 to 2017 based on French national claim database

Background

The purpose of this study was to assess the economic burden of cardiovascular diseases (CVDs) in France by analysing the structure and the growth of expenditure attributed to these diseases between 2012 and 2017.

Methods

For each year, 11 CVDs were identified from SNDS data using algorithms based on long-term disease registry and hospitalization diagnoses, applied to the population of national health insurance general scheme beneficiaries. The individuals’ expenditure (26 different items) reimbursed for hospitalisations, ambulatory care and cash payments were included. A top-down method was used to attribute expenditure to each considered groups of diseases based on the average expenditure by disease calculated for individuals with only one disease. To analyse trends, we applied the same methodology from 2012 to 2017.

Results

In 2017, of the €140.1 billion reimbursed, €14.0 billion (10.0%) were attributed to the care of 4.0 million people with a CVD (7.0% of the population). Short-stay hospitalisations accounted for 33% of this total expenditure. This proportion was higher for acute CVD (coronary syndrome: 64%, stroke: 56%, heart failure: 65%, pulmonary embolism: 69%) but also for valvular heart disease (50.0%). Medications represented almost 13% of the expenditure attributed to all CVDs, and up to 25% for chronic coronary heart disease. Disability pension essentially concerned sequelae of stroke (12% of the expenditure attributed to this disease). Between 2012 and 2017, the total expenditure attributed to CVDs increased by 3.3% per year, mainly due to the annual mean increase of the number of patients over the period (+3.1%).

Conclusions

These results demonstrate the high economic burden of CVDs in France with a detailed analysis of expenditures and their main drivers. The developed tool will help decision makers to monitor the burden of these diseases but also to provide stake holders with a better understanding of trends and regulating actions.

Key messages

Economic burden of CVD in France is high: 10% of healthcare expenditure. Implementation of public health policy to prevent CVD and control risk factors must be a priority.

Work-related diseases in temporary workers in France between 2009 and 2014

Background

The percentage of temporary workers in the workforce has increased in many European countries. The working environments of temporary workers are often characterized by job insecurity and exposure to hazardous working conditions. Studies have investigated the health status of this population but few of them have specifically investigated work-related diseases. The aim of this study is to compare the risk of uncompensated work-related diseases (UWRD) in temporary workers with permanent contract workers in France between 2009 and 2014.

Methods

UWRD and suspected associated exposure factors were notified by occupational physicians involved in French UWRD surveillance programme. Sociodemographic and professional characteristics were recorded for all salaried workers consulted by occupational physicians. We analysed musculoskeletal (MSD) disorders (elbow, hand/wrist, shoulder, back) and mental health disorders (MHD) according the type of consultation (periodic check-up, hiring...) using logistic regression. The distributions of notified exposure factors for MSD and MHD were compared between temporary and permanent workers.

Results

Of the 433 148 salaried workers consulted as part of the surveillance programme, 5.3% and 80.2% had temporary and permanent contracts, respectively. Temporary workers were as likely to have work-related shoulder, elbow and hand/wrist MSD as permanent workers. The former had a lower risk of MHD irrespective of the type of consultation ([OR] = 0.4, 95 % CI 0.3-0.5) and a lower risk of back MSD during on-demand/return-to-work consultations ([OR] = 0.2, 95% CI 0.1-0.5) and during periodic check-ups ([OR] = 0.3, 95% CI 0.2-0.7).

Conclusions

Temporary workers were not at a higher risk of UWRD (MSD and MHD) than permanent workers. This suggests that the generally poor health status found in temporary workers in previous studies may be linked more to their general health status and perceived job insecurity than to poorer working conditions.

Key messages

In our study, the risk of work related musculoskeletal disorders and mental health disorders in temporary workers was no greater than that in permanent workers. Poor general health known in temporary workers, may be linked more to their general health status, job insecurity and decreasing career trajectory than to poorer working conditions.

Diversity and combinations of infectious agents in 38 adults with an infection-triggered reactive haemophagocytic syndrome: a multicenter study

Reactive haemophagocytic syndrome (HS) is a rare condition that occurs in patients with infections, haematological malignancies or autoimmune diseases. Although various microorganisms are thought to trigger HS, most of the literature data on this topic have been gathered in single-centre case series. Here, we sought to characterize infectious triggers in a large, multicentre cohort of patients with HS. Patients were included in the present study if HS was solely due to one or more infections. Detailed microbiological data were recorded. Of the 162 patients with HS in the cohort, 40 (25%) had at least one infection and 38 of the latter (including 14 women, 36.8%) were included. The median age was 46 years. Seven patients were presumed to be immunocompetent (18.4%), whereas 19 patients (50%) were infected with human immunodeficiency virus and 12 patients (31.6%) were immunocompromised for other reasons. Twenty-seven patients (71.1%) had a single infection, whereas six (15.8%) and five (13.1%) patients had, respectively, two and three concomitant infections. We observed pyogenic bacterial infections (n = 7), tuberculosis (n = 10), non-tuberculous mycobacteriosis (n = 3), viral infections (n = 17: 11 cytomegalovirus, three Epstein-Barr virus, two human herpesvirus 8, one herpes simplex virus 2), parasitic infections (n = 8: four disseminated toxoplasmosis, one leishmaniasis, three malaria), fungal infections (n = 5: four pulmonary pneumocystosis and one candidaemia). Eighteen patients (47.4%) received corticosteroids and/or etoposide. Twelve patients died (31.6%). All multiple infections and all deaths occurred in immunocompromised patients. When compared with patients suffering from malignancy-associated HS, patients with infection-triggered HS were younger and more likely to be immunocompromised, and had a better outcome.

[Diagnostic value of selective anorexia in pathological weight loss]

PURPOSE

The diagnostic value of selective anorexia is debated. Some authors have suggested an association between meat aversion and cancer, but most do not use it as a diagnostic tool. We aimed to characterize anorexia of different diseases to search for an association between selective aversions and diagnostic groups.

METHODS

All the patients admitted to three departments of a teaching hospital were included consecutively for 22months if they had more than 10 % weight loss in less than one year. Patients were excluded if history taking was not reliable, or if they suffered from anorexia nervosa. We compiled diagnoses at discharge and validated them six months later. We used logistic regression to identify independent factors associated with selective anorexia.

RESULTS

Inclusion criteria were met in 106patients (female 44 %, median age 65years). Most frequent diagnoses were: cancer (36 %), infection (35 %), digestive diseases (19 %), non organic diseases (21 %). Recent selective anorexia was found in 46 % of the cases. It was significantly associated with female gender (P=0.002), marginally with young age (P=0.069) and long duration of weight loss (P=0.079). Opioid use at admission was negatively associated with selective anorexia (P=0.001). No specific diagnostic category was found to be associated.

CONCLUSION

Selective anorexia does not appear to be a useful symptom to investigate pathological weight loss. It behaves more like a non-specific reactivation by current disease of earlier latent personal food aversions.

[Use of pulmonary function tests and biomarkers studies to diagnose and follow-up interstitial lung disease in systemic sclerosis]

Interstitial lung disease (ILD) is becoming one of the main causes of death of patients with systemic sclerosis (SSc). The prevalence of ILD associated with SSc (SSc-ILD) varies from 33% to 100% according to diagnostic methods. Clinical features such as dyspnea on exertion, dry cough, and chest pains are not specific and usually late-appearing, implying more specific tests in the diagnostic, prognosis, and follow-up of ILD in patients with SSc. High resolution thoracic CT scanner (HRCT) is more sensitive than chest X-ray in the detection of SSc-ILD. Pulmonary function tests (PFT) are non-invasive and periodically used to assess the impacts of SSc on respiratory function. Diagnostic values of bronchoalveolar lavage and histological examination on lung biopsy are controversial. However, these techniques are essential for studying cellular and molecular mechanisms underlying the pathophysiology of SSc-ILD. Several biomarkers such as surfactant-A (SP-A), -D (SP-D), mucin-like high molecular weight glycoprotein (KL-6), and chemokine CCL-18 have been implicated in SSc-PID. Serum levels of these proteins are correlated with the severity of SSc-ILD, as assessed by HRCT and/or PFT. Finally, alveolar concentration of exhaled nitric oxide can be used to screen SSc patients with high risk of deterioration of respiratory function, in whom immunosuppressant treatment could be useful in preventing the evolution to irreversible lung fibrosis.