French practical guidelines for the diagnosis and management of relapsing polychondritis

Relapsing polychondritis is a rare systemic disease. It usually begins in middle-aged individuals. This diagnosis is mainly suggested in the presence of chondritis, i.e. inflammatory flares on the cartilage, in particular of the ears, nose or respiratory tract, and more rarely in the presence of other manifestations. The formal diagnosis of relapsing polychondritis cannot be established with certainty before the onset of chondritis, which can sometimes occur several years after the first signs. No laboratory test is specific of relapsing polychondritis, the diagnosis is usually based on clinical evidence and the elimination of differential diagnoses. Relapsing polychondritis is a long-lasting and often unpredictable disease, evolving in the form of relapses interspersed with periods of remission that can be very prolonged. Its management is not codified and depends on the nature of the patient's symptoms and association or not with myelodysplasia/vacuoles, E1 enzyme, X linked, autoinflammatory, somatic (VEXAS). Some minor forms can be treated with non-steroidal anti-inflammatory drugs, or a short course of corticosteroids with possibly a background treatment of colchicine. However, the treatment strategy is often based on the lowest possible dosage of corticosteroids combined with background treatment with conventional immunosuppressants (e.g. methotrexate, azathioprine, mycophenolate mofetil, rarely cyclophosphamide) or targeted therapies. Specific strategies are required if relapsing polychondritis is associated with myelodysplasia/VEXAS. Forms limited to the cartilage of the nose or ears have a good prognosis. Involvement of the cartilage of the respiratory tract, cardiovascular involvement, and association with myelodysplasia/VEXAS (more frequent in men over 50years of age) are detrimental to the prognosis of the disease.

[Heart involvement in systemic lupus erythematosus and antiphospholipid syndrome]

Cardiac involvement in systemic lupus (SL) and antiphospholipid syndrome (APS) can be due to variables and involve different presentations. Pericarditis is the most common lupus manifestation and occurs in 16% to 25% of patients. While corticosteroids are usually very effective, colchicine may avoid steroids and prevent relapse. Myocarditis during SL is rare and often inaugural. They may manifest as chest pain, acute heart failure, arrhythmias or conduction disturbances, and may progress to dilated cardiomyopathy and/or permanent heart failure. Their prognosis is however generally good, even in the absence of treatment with cyclophosphamide for the less serious forms. Finally, coronary involvement in SL is most often due to atherosclerotic, thrombotic origin (generally in the context of associated APS), and exceptionally explained by coronary vasculitis. During APS, valve disease is frequent and usually asymptomatic. Thrombotic damage can be (1) coronary, typically manifesting as a myocardial infarction in a young subject with healthy coronary arteries, (2) much more rarely intracardiac, or (3) microcirculatory, generally as part of a catastrophic antiphospholipid syndrome (CAPS) leading to a multiorgan failure. Finally, iatrogenic cardiac manifestations can exceptionally be seen during treatment with cyclophosphamide or antimalarials characterized by conduction disorders and/or heart failure.

POS0722 CLONAL HEMATOPOIESIS OF INDETERMINATE POTENTIAL AND ACCELERATED ATHEROSCLEROSIS IN SYSTEMIC LUPUS ERYTHEMATOSUS (HEMATOPLUS STUDY)

Background

The detection of somatic mutations in genes of myeloid cells in asymptomatic patients - defining clonal hematopoiesis of indeterminate potential (CHIP) - predisposes to cardiovascular events (CVE) in the general population.

Objectives

We aimed to determine whether CHIP was associated with CVE in SLE patients.

Methods

The study is an ancillary study of the randomized, double-blind, placebo-controlled, multicenter trial PLUS study conducted from June 2007 through August 2010 at 37 centers in France involving 573 SLE patients. The search for somatic mutations by high-throughput sequencing of 53 genes involved in clonal hematopoiesis was performed on genomic DNA collected at PLUS inclusion. The CHIP prevalence was assessed in SLE and in a retrospective cohort of 479 patients free of hematological malignancy. The primary outcome was the incident CVE in SLE.

Results

Screening for CHIP was performed in 438 SLE patients (38 [29-47] years, 91·8% female). Overall, 63 somatic mutations were identified in 47 patients defining a CHIP prevalence of 10·7% in SLE. Most SLE patients (78·7%) carried a single mutation. Most variants (62·5%) were located in the DNMT3A gene. CHIP was associated with age, age at SLE diagnosis and a lower frequency of antiphospholipid antibodies. CHIP occurred more than 20-years earlier (p<0·00001) in SLE than in controls. The detection of CHIP at inclusion was not associated with the occurrence of CVE during follow up (HR= 0·42 (0·06 – 3·21), p=0·406).

Conclusion

The prevalence of CHIP is high in SLE with respect to age but was not associated with incident CVE.

Disclosure of Interests

None declared

AB0450 SOLUBLE CD163 IS A BIOMARKER FOR CARDIOVASCULAR EVENT IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS

Background

Prediction models based on traditional cardiovascular risk factors underestimate the risk of cardiovascular events (CVE) in systemic lupus erythematosus (SLE).

Objectives

We aimed to determine whether sCD163, a biomarker for SLE-associated atherosclerosis, may predict CVE in SLE.

Methods

All SLE patients included between 2007 and 2010 in the randomized, double-blind, placebo-controlled, multicenter PLUS trial were screened. Patients with no past history of CVE at inclusion and a follow-up period of >20 months were analyzed. sCD163 level was measured using enzyme-linked immunosorbent assay on serum collected at PLUS inclusion. The primary outcome was the incident CVE. Factors associated with incident CVE and sCD163 level were analyzed.

Results

Overall, 442 SLE patients (of the 573 included in the PLUS study) were analyzed for the primary outcome with a median follow up of 110 (interquartile range: 99–120) months. Among them, 29 (6.6%) experienced at least one CVE that occurred at a median of 67 (interquartile range: 31–91) months after inclusion. In the multivariate analysis, dyslipidaemia, age and increased sCD163 were associated with CVE onset. Multivariate Cox models analysis showed that a concentration of sCD163> 263 ng/mL at inclusion increased by 2.7 [hazard ratio 2.7 (95% CI: 1.0, 7.0)] the risk of CVE in SLE. Increased sCD163 was also associated with immunosuppressive treatment, higher body mass index (BMI) and SLEDAI score.

Conclusion

Macrophage-specific sCD163 serum level reflects lupus disease activity and predicts CVE in SLE.

Disclosure of Interests

None declared

Intra- and inter-rater consistency of dual assessment by radiologist and neurologist for evaluating DWI-ASPECTS in ischemic stroke

OBJECTIVES

To estimate the intra -and inter-rater consistency of radiologist and neurologist working in pairs attributing DWI-ASPECTS (Diffusion Alberta Stroke Program Early CT Score) in patients with acute middle cerebral artery ischemic stroke referred for mechanical thrombectomy, intravenous thrombolysis or bridging therapy.

METHODS

Five neurologists and 5 radiologists working in pairs and in hour period scored independently and in two reading sessions anonymized DWI-ASPECTS of 80 patients presenting with acute anterior ischaemic stroke in our center. We measured agreement between pairs using intraclass correlation coefficients (ICCs). A Fleiss kappa was used for dichotomized (0-6;7-10) and trichotomized (0-3;4-6;7-10) ASPECTS. The interrater distribution of the score in the trichotomized (0-3;4-6;7-10) ASPECTS was calculated. We determined the interrater (Cohen kappa) and intrarater (Fleiss kappa) agreement on the ASPECTS regions.

RESULTS

The average DWI-ASPECTS was 6.35 (SD±2.44) for the first reading, and 6.47 (SD±2.44) for the second one. The ICC was 0.853 (95%CI, 0.798-0.896) for the interrater, and 0.862 (95%CI, 0.834-0.885) for the intrarater evaluation. Kappa coefficients were high for dichotomized (k=0.75) and trichotomized (k=0.64) ASPECTS. Evaluators agreement on the ASPECTS category (0-3), (4-6) and (7-10) was 88, 76 and 93% respectively. The anatomic region infarcted was well identified (k=0.70-0.77), except for the internal capsula (k=0.57). Interrater agreement was fair for M5 (k=0.37), moderate for internal capsula (0.52) and substantial for the other regions (0.60-0.79).

CONCLUSIONS

Reliability of DWI-ASPECTS is good when determined by radiologist and neurologist working in pairs, which corresponds to our current clinical practice. However, discrepancies are possible for cut-off determination, which may impact the indication of thrombectomy, and for the determination of the exact infarcted region. Agreement to propose category (4-6) is lower than for (0-3) and (8-10) ASPECTS categories.

POS0724 GENDER DIFFERENCES IN THROMBOTIC PRIMARY ANTIPHOSPHOLIPID SYNDROME IN A LARGE COHORT OF PATIENTS FROM FOUR EUROPEAN CENTERS

Background:

Autoimmune diseases occur more frequently in females and their course and severity can be affected by gender. Antiphospholipid syndrome (APS) is a systemic autoimmune disorder in which antiphospholipid antibodies (aPL) exert a pathogenic role resulting in vascular thrombosis and/or pregnancy morbidities. Data about gender differences in thrombotic APS (t-APS) are still scarce1,2.

Objectives:

To evaluate the differences in frequency, disease expression and severity between females and males affected by primary t-APS.

Methods:

Retrospective study enrolling subjects with a formal diagnosis of primary APS (Miyakis 2006) with vascular thrombosis at onset. Women who presented with obstetric events as first aPL-related manifestation were excluded. All the patients were followed from 1967 to 2019 in four European centers: three French centers and one Italian center.

Results:

The study included 433 patients (68% females, 32% males). Median age at t-APS onset [31 (24-46) vs 41 (29-53) years, p<0.001] and at diagnosis [34 (27-50) vs 46 (34-57) years, p<0.001] was significantly lower in females.

The most common presenting manifestations were venous thrombosis (60%) followed by arterial events (37%) and catastrophic APS (3%). Venous events were more frequent in women as compared to men (64% vs 51% p:0.012 OR:1.7 [1.1-2.5]). Sites of venous thrombosis included: limbs (35%), pulmonary (17%), cerebral (3%), portal and inferior cava (2%) and retinal (1%) veins, without gender differences. The arterial events were more frequent among men (43% vs 34% p:0.053). Strokes (27%) and myocardial infarctions (4%) were the most frequent manifestations, followed by thrombosis of limbs (2%), retina (2%) and abdominal organs (1%). Noteworthy, only men presented with visceral ischemia.

During the follow-up, new thrombosis occurred in 41% of patients (179/433). 33% out of them had at least two episodes and these occurred especially among males (22% vs 10% p:0.001 OR:2.5 [1.3-4.8]). New events were mostly of the same type, but ⅓ of patients presented a switch from venous to arterial side and viceversa, with no gender differences.

Complete aPL profile was available in 357 subjects: 33% had single aPL positivity, 24% double positivity and 43% triple positivity, with no differences between women and men. About 80% of the patients had a concomitant risk factor (RF) for thrombosis. Established cardiovascular RFs were more represented among men as shown in table 1. In women, estrogenic exposure was the main RFs, present in almost 40% of them.

Table 1.MALESn= 137FEMALESn= 296POR [IC 95%]Traditional cardiovascular RFs, n (%)Smoke66 (48)81 (27)<0.0012.5 [1.6-3.8]Arterial hypertension59 (43)75 (25)<0.0012.2 [1.5-3.4]Dyslipidemia52 (38)72 (24)0.0041.9 [1.2-2.9]Diabetes16 (12)15 (5)0.0142.5 [1.8-5.1]Obesity13 (10)38 (13)nsOther thrombophilic factors, n (%)Estrogenic stimuli*0116 (39)-Trauma / surgery / immobilization21 (15)32 (11)nsCongenital thrombophilia9/94 (10)33/204 (16)ns

Data were compared using contingency tables, p value was calculated with Chi-Squared or Fisher exact test. *= hormonal therapy, pregnancy, post-partum

Conclusion:

This gender-oriented analysis of patients with primary t-APS showed that women had the first vascular event at a younger age and mostly on the venous side, while men presented mainly with arterial events, later in life and suffered from more recurrent events. No differences were observed in the distribution of the aPL profile. The different frequency of arterial and venous events in the two groups could be attributed mainly to the presence of additional RFs rather than to biological gender-specific issues. However, it should be underlined that some RFs, such as the use of estrogens or classic cardiovascular RFs, are exclusive or more represented in one gender rather than the other, making it difficult to assess the link of causality between gender and manifestations of t-APS.

References:

[1]JF de Carvalho. Rheumatol Int. 2011.

[2]LJ Jara. Lupus. 2005.

Disclosure of Interests:

None declared

OP0295 GR2 MULTICENTRIC PROSPECTIVE FRENCH STUDY’S RESULTS: DAMAGE BUT NOT REMISSION AT FIRST TRIMESTER PREDICTS ADVERSE PREGNANCY OUTCOME IN LUPUS PREGNANCIES

Background:

Active Systemic Lupus Erythematosus (SLE) during pregnancy is associated with poor obstetrical outcome but it is still not clear if remission, lupus low disease activity state (LLDAS) is the best target to achieve at conception. Besides, the effect of damage on pregnancy outcome has not been studied.

Objectives:

Our aim was to determine the 1st trimester risk factors for adverse pregnancy outcome (APO).

Methods:

Inclusion criteria were: 1) women≥18 years enrolled in the prospective GR2 study; 2) with SLE (SLICC criteria); 3) and an ongoing singleton pregnancy at 12 weeks (only 1 pregnancy per patient). We used the following definitions: DORIS1, DORIA2, clinical SLEDAI-2K=0, LLDAS3 (for SLE activity), SFI4 (for flares), and SLICC-damage index5 (for damage). APO included: foetal death, neonatal death, placental insufficiency with premature delivery<37 weeks, and small for gestational age (SGA:≤3rd percentile).

Results:

238 patients were included. 234 (98.3%) women were on hydroxychloroquine (HCQ) and 206 (86.5%) had a clinical SLEDAI-2K=0. Regarding pregnancy outcome, 230 (96.6%) patients had a live birth (mean term 37.7 weeks). Thirty-four (14.3%) patients developed at least 1 APO: placental insufficiency (n=22), foetal death (n=7), neonatal death (n=1), and SGA (n=5). Two different regression logistic models were assessed, one for DORIA and one for LLDAS. We found that only SLICC-Damage index and lupus anticoagulant (LAC) were associated with APO (p=0.02, OR 1.8, 95% CI: 1.1-2.9; p=0.001, OR 4.2, 95% CI: 1.8-9.7 respectively for DORIA model; p=0.03, OR 1.7, 95% CI:1.1-2.8; p=0.002, OR 3.7, 95% CI: 1.6-8.7 respectively for LLDAS model).

Conclusion:

We confirmed that LAC predicts APO. We found for the first time that chronic damage at 1st trimester also predicted APO. No effect of remission/LLDAS was observed in this cohort of patients on HCQ with a stable and well-controlled SLE.

References:

[1]van Vollenhoven R, et al. ARD 2017.

[2]Zen M, et al. ARD. 2015.

[3]Franklyn, K. et al. ARD 2016.

[4]Petri M, et al. NEJM 2005.

[5]Gladman DD, et al. Arthritis Rheum, 1997.

Table 1.Univariate analysis for APOMaternal featuresTotal (N=238)APO (N=34)Non-APO (N=204)P valueAge, mean (SD)31.6(4.5)30.7(4.8)31.7(4.4)0.22Secondary APS34(14.3)10(29.4)24(11.8)0.01Previous renal phenotype67(28.2)13(38.2)54(26.5)0.16At least 1 flare during pregnancy37(15.5)6(17.4)31(15.2)0.80Positive anti-DNA (N=222)104(46.8)21(67.7)83(43.5)0.01Hypocomplementemia (N=216)57(26.4)13(40.6)44(23.9)0.05LAC (N=232)41(17.7)15(44.1)26(13.1)<0.001Triple aPL (N=232)17(7.3)5(14.7)12(6.1)0.0824h-proteinuria>0.5g/day9(3.8)3(8.8)6(2.9)0.12Activity/DamageSLEDAI-2K, median (IQR) (N=212)2(0-3)2(2-4)2(0-2)0.01SLICC-DI, median (IQR) (N=236)0(0-0)0(0-0)0(0-0)0.007PGA, median (IQR)(N=235)0.1(0-0.2)0.1(0-0.41)0.1(0-0.2)0.06DORIA remission*154(64.7)17(50.0)137(67.2)0.05DORIS remission**147(61.8)17(50.0)130(63.4)0.13LLDAS (N=219)157(71.7)19(57.6)138(74.2)0.05Clinical SLEDAI-2K=0206(86.5)28(82.4)178(87.3)0.44TreatmentPrednisone (PDN)119(50.0)23(67.7)96(47.1)0.03PDN (mg/day) median (IQR)7(5-10)0(0-6)5(0-10)0.007Immunosuppressants57(24.0)13(38.2)44(21.6)0.04Hydroxychloroquine234(98.3)34(100.0)200(98.0)1.00Low dose aspirin165(69.3)29(85.3)136(66.7)0.03Low molecular weight heparin61(25.6)15(44.1)46(22.6)0.01

Legend: APS: antiphospholipid syndrome; aPL: antiphospholipid; PGA: Physician global assessment. *: DORIA definition of remission = clinical SLEDAI=0 and prednisone ≤5 mg/day; **: DORIS definition of remission = clinical SLEDAI=0, prednisone ≤5 mg/day, and PGA<0.5.

Disclosure of Interests:

None declared.

Best practice recommendations: ENT consultations during the COVID-19 pandemic

These best practice recommendations for ENT consultations during the COVID-19 pandemic have been drawn up because ENT examinations and treatments are at risk of contamination by the SARS-Cov-2 virus in certain instances. Thus, ENT specialists are among the professionals who are most exposed to this infection. During the pandemic, insofar as an asymptomatic patient may be infected and contagious, the same precautions must be employed whether the patient is ill with, suspected of having, or without any clinical evidence of COVID-19 infection. According to the scientific data available, the examinations and procedures potentially exposing to projections/aerosolizations of organic material of human origin are considered to be at risk of staff contamination. For ENT examinations and procedures without exposure to such projections/aerosolizations, the professional is advised to a long sleeve clean outfit, a surgical mask and gloves in case of contact with the patient's mucosa. ENT examinations and procedures with exposure to these projections/aerosolizations require the so-called "airborne", "contact", and "droplets" additional precautions: FFP2/N95 respiratory protection device, eye protection, disposable headwear and long sleeve overgown.

Management strategies to minimize the use of synthetic chemical acaricides in the control of the cattle tick Rhipicephalus (Boophilus) microplus (Canestrini, 1888) in an area highly favourable for its development in Argentina

The aim of this work was to test the efficacy of winter-spring control strategies against Rhipicephalus (Boophilus) microplus (Canestrini, 1888) (Ixodida: Ixodidae) in an area highly favourable for its development in Argentina. Control schemes using three or four annual applications of synthetic acaricides were evaluated. Furthermore, the dynamics of the non-parasitic phases of R. microplus were analysed to provide a framework for the application of pasture spelling as a tool for tick control. The treatment schemes provided appropriate levels of efficacy against R. microplus and also prevented the occurrence of the major peak in abundance of this tick in autumn. A significant overall effect against R. microplus can be achieved when the control strategies tested in this study are applied within the area most ecologically favourable for this tick in Argentina. Analysis of the dynamics of the non-parasitic phase of R. microplus indicates that the spelling period required to achieve a significant reduction of larvae in pastures fluctuates between 12 and 17 weeks if spelling is initiated in spring or early summer, but between 20 and 28 weeks if spelling is started in late summer, autumn or winter.

SAT0201 ASSOCIATION OF CARDIAC TROPONIN T MEASURED WITH A HIGHLY SENSITIVE ASSAY WITH CARDIOVASCULAR EVENTS IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS (TROPOPLUS STUDY)

Background:

Mortality is still 2 to 5 times superior in SLE patients as compared to general population and is mainly due to cardiovascular event (CVE). Although cardiovascular traditional risk factors contribute to early-onset atherosclerosis in SLE, the phenomenon is not fully explained by a higher frequency of smoking habits, hypertension, or dyslipidemia and the Framingham risk equation usually underestimates the 10-year cardiovascular risk in this population. Thus, identification of biological markers able to better stratify cardiovascular risks in SLE patients is needed.

Objectives:

Our study aimed to determine whether serum cardiac troponin T measured with a highly sensitive assay (HS-cTnT) was associated with CVE in systemic lupus erythematosus (SLE) patients.

Methods:

All SLE patients included between 2007 and 2010 in the randomized, double-blind, placebo-controlled, multicenter PLUS trial were retrospectively screened. Patients with no past history of CVE and a follow-up period of > 20 months were analyzed. HS-cTnT concentration was measured using the electrochemiluminescence method on serum collected at PLUS inclusion. The primary outcome was the incident CVE. Factors associated with the primary outcome were identified and multivariate analysis was performed.

Results:

Overall, 442 SLE patients (of the 573 included in the PLUS study) were analyzed for the primary outcome with a median follow up of 110 (IQR: 99-120) months. Among them 29 (6.6%) experienced at least one CVE that occurred at a median of 67 (IQR: 31-91) months after inclusion. Six out of 29 patients had more than one CVE. In the multivariate analysis, dyslipidemia, duration of SLE disease and HS-cTnT were associated with the occurrence of CVE. Kaplan-Meier analysis showed that a concentration of HS-cTnT>4.27 ng/L at inclusion increased by 2.7 (HR 2.7 [1.3-5.6], p=0.0083) the risk of CVE in SLE.

Conclusion:

HS-cTnT measured in serum is the first identified biomarker independently associated with incident CVE in SLE patients

Disclosure of Interests:

Julie Chezel: None declared, Nathalie Costedoat-Chalumeau Grant/research support from: UCB to my institution, Diane Rouzaud: None declared, Véronique LE GUERN Grant/research support from: UCB for GR2 study (to our institution), Camille Gobeaux: None declared, Nathalie Morel: None declared, Micheline Pha: None declared, Zahir Amoura: None declared, Thomas Papo: None declared, karim sacre: None declared

THU0275 SEVERE PREECLAMPSIA RELATED TO ANTIPHOSPHOLIPID SYNDROME: AN EUROPEAN STUDY OF 40 WOMEN

Background:

One of the 3 features of obstetrical antiphospholipid syndrome (APS) is severe preeclampsia (PE). Its time of occurrence, the associated risk of thromboses and systemic lupus erythematosus (SLE) have not been reported yet.

Objectives:

We analyzed severe PE in a series of women with APS.

Methods:

We retrospectively collected data of female patients from 5 French internal medicine and 1 Italian rheumatology units. Inclusion criteria were: a severe PE/eclampsia(1), that occurred before 34 weeks of gestation (WG) in patients who met the APS classification criteria(2).

Results:

40 patients were enrolled (Table 1). Because of known APS/positive aPL/previous obstetrical complications, 23(57.5%) patients were treated during the index PE: 4 with low dose aspirin (LDA), 4 with low molecular weight heparin (LMWH), and 15 with a combination of both. 7 patients were also treated with hydroxychloroquine, 8 with corticosteroids and 3 with immunosuppressants. 17(42.5%) patients received no treatment. 24(60%) live births were observed. During a follow-up period of 3 years, 26(65%) patients had at least 1 new pregnancy, with a total of 38 pregnancies which resulted in 33(86.8%) live births. 57.5% pregnancies who resulted in live births occurred without any maternal or fetal complications. All 26 patients who had at least 1 pregnancy after index PE were treated with LDA; LMWH was given at prophylactic and therapeutic dosage in 13(50%) patients, respectively. No patient experienced 3 consecutive miscarriages.

Table 1.

40 APS patients with severe PE

Overall features (n, %)Patients40 (100)Age at PE, (median, IQR)30.5 (27-33)PE term, WG (median, IQR)25.5 (23-29) Live births24 (60) Birth term, WG (median, IQR)25.5 (23.7-30.3) Associated SLE12 (30)Maternal complications (n, %)25 (62.5) HELLP18 (45) E6 (15) CAPS3 (7.5) Placental abruptions3 (7.5)Fetal complications (n, %)31 (77.5) IUGR18 (45) IUFD11 (2.5) Preterm delivery22 (55)Obstetrical history (n, %) Primiparous21 (52.5) Index PE before APS12 (30)Thrombosis (n, %) Thrombosis before PE index14 (35.0) Thrombosis after PE index2 (5.0)Abs at APS diagnosis (n, %) aPL triple positivity21 (52.5) IgG/IgM anti-cardiolipin34 (85.0) IgG/IgM anti-β2GPI25 (62.5) LAC33 (82.5)

Legend to Table 1:PE: preeclampsia; APS: antiphospholipid syndrome; IQR: interquartile range; WG: weeks of gestation; SLE: systemic lupus erythematosus; HELLP: Hemolysis, elevated liver enzymes, low platelet; E: eclampsia; CAPS: catastrophic APS; IUGR: intrauterine growth restriction; IUFD: intrauterine fetal death; CHB: congenital atrioventricular block; aPL: antiphospholipid antibodies; LAC: lupus anticoagulant.

Conclusion:

Among the APS criteria, “3 consecutive miscarriages criterion” was not found. The majority of patients also experienced thrombosis and SLE before the index PE.

References:

[1]Diagnosis and Management of preeclampsia and eclampsia. International Journal of Gynecology &Obestetrics 2002;77:67-75.

[2]Miyakis S, et al. International consensus statement on an update of the classification criteria for definite antiphospholipid syndrome (APS). J Thromb Haemost 2006;4:295e 306.

Disclosure of Interests:

Maddalena Larosa: None declared, Nathalie Morel: None declared, Meriem BELHOCINE: None declared, Amelia Ruffatti: None declared, Nicolas Martin Silva: None declared, Romain Paul: None declared, Luc Mouthon: None declared, Michel DREYFUS: None declared, Jean-Charles PIETTE: None declared, Odile Souchaud-Debouverie: None declared, Catherine Deneux-Tharaux: None declared, Vassilis Tsatsaris: None declared, Emmanuelle Pannier: None declared, Gaêlle Guettrot Imbert: None declared, Véronique LE GUERN Grant/research support from: UCB for GR2 study (to our institution), Andrea Doria Consultant of: GSK, Pfizer, Abbvie, Novartis, Ely Lilly, Speakers bureau: UCB pharma, GSK, Pfizer, Janssen, Abbvie, Novartis, Ely Lilly, BMS, Nathalie Costedoat-Chalumeau Grant/research support from: UCB to my institution

COVID-19 and ENT Surgery

In Otorhinolaryngology – Head and Neck Surgery, clinical examination and invasive procedures on the respiratory tract and on airway-connected cavities, such as paranasal sinuses and the middle ear, expose people to direct transmission of SARS-CoV-2 by inhalation or ocular projection of contaminated droplets, and to indirect transmission by contact with contaminated hands, objects or surfaces. Estimating an R₀ of COVID-19 at around 3 justified postponing non-urgent face-to-face consultations and expanding the use of teleconsultation in order to limit the risks of SARS-CoV-2 infection of patients or health workers and comply with the lockdown. The health authority recommends cancellation of all medical or surgical activities, which are not urgent as long as this does not involve a loss of chance for the patient. The purpose of this cancellation is to significantly increase critical care capacity, prioritise the reception of patients with COVID-19, prioritise the allocation of staff and provision of the equipment necessary for their medical or surgical management, and contribute to the smooth running of downstream critical care within their establishment. Another goal is to reduce the risks of patient contamination within healthcare facilities. This document provides guidance on how to proceed with and adapt ENT surgery in the current pandemic context, as well as on the management of postponed operations. This best practice advice must of course be adapted in each region according to the development of the epidemic and pre-existing arrangements. Their local application can only be decided within the framework of collaboration between the ENT teams, the operational hygiene units and all the other specialties concerned.

Efficacy of winter-spring strategic control against Rhipicephalus (Boophilus) microplus infestations on cattle in an area with ecological conditions highly favourable for the tick in northeast Argentina

This work was performed to test the efficacy of winter-spring control strategies against Rhipicephalus (Boophilus) microplus (Ixodida: Ixodidae) infestations on cattle in the area ecologically most favourable for the development of this tick in Argentina. Two control schemes using three and four annual applications of acaricides, respectively, were evaluated. Animals in Group 1 were treated with ivermectin 3.15% on day 0, fluazuron on day 34, and fipronil on day 85. Animals in Group 2 were treated with ivermectin 3.15% on day 0, fluazuron on day 34, flumethrin on day 85, and fipronil on day 114. Animals in Group 3 represented the control group. Both treatment schemes provided appropriate levels of efficacy against R. microplus and also prevented the occurrence of the major peak in the frequency of this tick in autumn. The two treatment schemes were similar in terms of efficacy and thus the addition of a fourth treatment does not seem to confer any further advantage. The results of this work indicate that these strategic control methods provide appropriate levels of control against R. microplus.

Reduced mortality by meeting guideline criteria before using recombinant activated factor VII in severe trauma patients with massive bleeding

BACKGROUND

Management of trauma patients with severe bleeding has led to criteria before considering use of recombinant activated factor VII (rFVIIa), including haemoglobin >8 g dl^-1, serum fibrinogen ≥1.0 g l^-1, platelets >50,000 x 10⁹ l^-1, arterial pH ≥ 7.20, and body temperature ≥34 °C. We hypothesized that meeting these criteria is associated with improved outcomes.

METHODS

In this prospective cohort study of 26 French trauma centres, subjects were included if they received rFVIIa for persistent massive bleeding despite appropriate care after severe blunt and/or penetrating trauma.

RESULTS

After surgery and/or embolization as haemostatic interventions, 112 subjects received a first dose of 103 μg kg^-1 rFVIIa (82-200) (median, 25^th-75^th percentile) at 420 min (285-647) post-trauma. Of these, 71 (63%) "responders" were still alive at 24h post-trauma and had their transfusion requirements reduced by > 2 packed red blood cell units after rFVIIa treatment. Mortality was 54% on day 30 post-trauma. There were 21%, 44% and 35% subjects who fulfilled 0-1, 2-3 or 4-5, respectively, of the guidelines before receiving rFVIIa. Survival at day 30 was 13%, 49% and 64% and the proportion of responders was 39%, 64% and 82%, when subjects fulfilled 0-1, 2-3 or 4-5 conditions, respectively (both P <0.01).

CONCLUSIONS

In actively bleeding trauma patients, meeting guideline criteria before considering rFVIIa was associated with lower mortality and a higher proportion of responders to the rFVIIa.

Bleeding complications and antithrombotic treatment in 264 pregnancies in antiphospholipid syndrome

Purpose The purpose of this study was to evaluate the safety of antithrombotic treatments prescribed during pregnancy in patients with antiphospholipid syndrome (APS). Methods This international, multicenter study included two cohorts of patients: a retrospective French cohort and a prospective US cohort (PROMISSE study). Inclusion criteria were (1) APS (Sydney criteria), (2) live pregnancy at 12 weeks of gestation (WG) with (3) follow-up data until six weeks post-partum. According to APS standard of care, patients were treated with aspirin and/or low-molecular weight heparin (LMWH) at prophylactic (pure obstetric APS) or therapeutic doses (history of thrombosis). Major bleeding was defined as abnormal blood loss during the pregnancy and/or post-partum period requiring intervention for hemostasis or transfusion, or during the peripartum period greater than 500 mL and/or requiring surgery or transfusion. Other bleeding events were classified as minor. Results Two hundred and sixty-four pregnancies (87 prospectively collected) in 204 patients were included (46% with history of thrombosis, 23% with associated systemic lupus). During pregnancy, treatment included LMWH ( n = 253; 96%) or low-dose aspirin ( n = 223; 84%), and 215 (81%) patients received both therapies. The live birth rate was 89% and 82% in the retrospective and prospective cohorts, respectively. Adverse pregnancy outcomes occurred in 28% of the retrospective cohort and in 40% of the prospective cohort. No maternal death was observed in either cohort. A combined total of 45 hemorrhagic events (25%) occurred in the retrospective cohort, but major bleeding was reported in only six pregnancies (3%). Neither heparin nor aspirin alone nor combined therapy increased the risk of hemorrhage. We also did not observe an increased rate of bleeding in the case of a short interval between last LMWH (less than 24 hours) or aspirin (less than five days) doses and delivery. Only emergency Caesarean section was significantly associated with an increased risk of bleeding (odds ratio (OR) 5.03 (1.41-17.96); p=.016). In the prospective cohort, only one minor bleeding event was reported (vaginal bleeding). Conclusion Our findings support the safety of antithrombotic therapy with aspirin and/or LMWH during pregnancy in high-risk women with APS, and highlight the need for better treatments to improve pregnancy outcomes in APS. PROMISSE Study ClinicalTrials.gov identifier: NCT00198068.

[TIMMA: Ultrasonographic scale of carotid atherosclerosis by vascular neurologists]

BACKGROUND

Carotid atherosclerosis is a powerful predictive factor of vascular risk at the individual patient level. Ultrasonography is a reference technique for the evaluation of this condition. However, its use in common practice remains difficult due to a lack of standardization and inter-operator variability. We present a new and simple technique for the assessment of carotid atherosclerosis; and evaluate the ability of vascular neurologists to obtain results consistent with those of an expert in vascular ultrasound.

MATERIAL AND METHODS

The TIMMA scale is an acronym for the five classes of carotid atherosclerosis in French, VIMMA in English: very important, important, moderate, minimal and absent. Combined, the first two classes make up the group "significant atheroma" and the last three classes make up the group "no significant atheroma". This scale was evaluated in 38 patients (76 carotid arteries) suffering from ischemic stroke or transient ischemic attack by five operators who are competent in carotid echocardiography: one TIMMA-trained (40 hours of training) vascular neurologist physician (VNP), three VNPs informed on the measurement method (1 hour of information) and one specialized vascular physician (SVP) who was considered to be the reference examiner. We evaluated the concordance between the VNPs and the SVP in classifying patients, firstly into the significant or not atheroma group and, secondly, into the five TIMMA classes.

RESULTS

The evaluation of the two-group clustering scale found a concordance between the informed VNPs and the SVP on 76 carotid arteries of 86% (kappa=0.7) and between the trained VNP and the SVP on 58 carotid arteries of 90% (kappa=0.8). The positive and negative predictive values for significant atheroma diagnosis were 100% and 81%, respectively, for the informed VNPs, and 100% and 80% for the trained VNP. The evaluation of the Five-Class Scale showed a concordance between the informed VNPs and the SVP of 46% (kappa=0.3), and between the trained VNP and the SVP of 74% (kappa=0.7).

CONCLUSION

TIMMA allows VNPs who are competent in carotid ultrasonography to reproducibly identify subjects with significant carotid atheroma. The contribution of this scale to the determination of cardiovascular risk should be evaluated.

Regulation of calcium channels in smooth muscle: new insights into the role of myosin light chain kinase

Smooth muscle myosin light chain kinase (MLCK) plays a crucial role in artery contraction, which regulates blood pressure and blood flow distribution. In addition to this role, MLCK contributes to Ca(2+) flux regulation in vascular smooth muscle (VSM) and in non-muscle cells, where cytoskeleton has been suggested to help Ca(2+) channels trafficking. This conclusion is based on the use of pharmacological inhibitors of MLCK and molecular and cellular techniques developed to down-regulate the enzyme. Dissimilarities have been observed between cells and whole tissues, as well as between large conductance and small resistance arteries. A differential expression in MLCK and ion channels (either voltage-dependent Ca(2+) channels or non-selective cationic channels) could account for these observations, and is in line with the functional properties of the arteries. A potential involvement of MLCK in the pathways modulating Ca(2+) entry in VSM is described in the present review.

Muscle recovery after ACL reconstruction with 4-strand semitendinosus graft harvested through either a posterior or anterior incision: a preliminary study

INTRODUCTION

Harvesting of a 4-strand semitendinosis (ST4) graft during anterior cruciate ligament (ACL) reconstruction can be performed through either a posterior or anterior approach. The objective of this study was to evaluate the recovery of the quadriceps and hamstring muscles as a function of the graft harvesting method. We hypothesized that posterior harvesting (PH) would lead to better recovery in hamstring strength than anterior harvesting (AH).

METHODS

In this prospective study, the semitendinosus was harvested through an anterior incision in the first group of patients and through a posterior one in the second group of patients. The patients were enrolled consecutively, without randomization. Isokinetic muscle testing was performed three and six months postoperative to determine the strength deficit in the quadriceps and hamstring muscles of the operated leg relative to the uninjured contralateral leg.

RESULTS

Thirty-nine patients were included: 20 in the AH group and 19 in the PH group. The mean quadriceps strength deficit after three and six months was 42% and 26% for AH and 29% and 19% for the PH, respectively (P=0.01 after three months and P=0.16 after six months). The mean hamstring strength deficit after three and six months was 31% and 17% for AH and 23% and 15% for the PH, respectively (P=0.09 after three months and P=0.45 after six months). After three months, the PH group had recovered 12% more quadriceps muscle strength than the AH group (P=0.03).

CONCLUSION

Our hypothesis was not confirmed. Harvesting of a ST4 graft for ACL reconstruction using a posterior approach led to better muscle strength recovery in the quadriceps only after three months.

CASE CONTROL STUDY

Level 3.

Colchicine: a simple and effective treatment for pericarditis in systemic lupus erythematosus? A report of 10 cases

OBJECTIVES

Pericardial involvement is a frequent manifestation of systemic lupus erythematosus (SLE). Growing evidence suggests that colchicine may be useful for acute or recurrent pericarditis. We report for the first time a series of 10 consecutive cases of SLE with pericarditis treated with colchicine.

METHODS

Inclusion criteria in this retrospective study were diagnosis of SLE, pericarditis and receiving colchicine.

RESULTS

We included 10 consecutive cases of SLE with pericarditis treated with colchicine (nine women, mean age at the index pericarditis 35 ± 12 years). Pericarditis was the initial manifestation of SLE for two patients, whereas eight patients had SLE lasting for a median of 2.5 years (15 days to 13 years) and had received prednisone (n = 7, 2-30 mg/d), hydroxychloroquine (n = 7), azathioprine (n = 3), methotrexate (n = 2), and mycophenolate mofetil (n = 1). For six patients, pericarditis was associated with other SLE manifestations. Altogether, colchicine avoided the use (n = 2) or increase in dosage (n = 5) of steroids in seven cases; the increase in steroids dosage was minimal for two patients. Colchicine 1 mg was given for a median of 39 days (10 days to 54 months). Symptoms completely resolved after a median of 2.5 days (1-30 days) after initiation of colchicine. Colchicine was maintained or resumed in six patients to prevent recurrence, with no further relapse.

CONCLUSIONS

Colchicine may be safe and effective in treating SLE pericarditis and used as a steroids-sparing agent. These preliminary results need to be confirmed in a larger study with longer follow-up.

[In vitro fertilization and systemic lupus erythematosus or antiphospholipid syndrome: An update]

Fertility is not impaired in systemic lupus erythematosus or antiphospholipid syndrome, but, similarly to the general population, these patients may undergo in vitro fertilization. This type of treatment increases the risk of lupus flare, thrombosis, and ovarian hyperstimulation syndrome. This review will focus on in vitro fertilization in systemic lupus erythematosus or antiphospholipid syndrome. Literature data are relatively scant with only 3 reported studies. The first one included 17 patients and 63 cycles of induction ovulation/in vitro fertilization leading to 25 % of lupus flare, no thrombosis, and 3 % of ovarian hyperstimulation syndrome. The second study included 10 patients and 40 cycles of in vitro fertilization showing 31 % of lupus flare, no thrombosis and no ovarian hyperstimulation syndrome. The last one included 34 patients and 83 procedures of in vitro fertilization leading to 8 % of flares, 5 % of thrombosis and no ovarian hyperstimulation syndrome. Interestingly, in this last study, half of the complications were explained by poor adherence to treatment. These data are reassuring but it is important to remember that in vitro fertilization should be scheduled and carefully supervised in the same way as the high-risk pregnancies occurring in these patients.

The Ca(2+) /calmodulin-dependent kinase kinase β-AMP-activated protein kinase-α1 pathway regulates phosphorylation of cytoskeletal targets in thrombin-stimulated human platelets

BACKGROUND

Platelet activation requires sweeping morphologic changes, supported by contraction and remodeling of the platelet actin cytoskeleton. In various other cell types, AMP-activated protein kinase (AMPK) controls the phosphorylation state of cytoskeletal targets.

OBJECTIVE

To determine whether AMPK is activated during platelet aggregation and contributes to the control of cytoskeletal targets.

RESULTS

We found that AMPK-α1 was mainly activated by thrombin, and not by other platelet agonists, in purified human platelets. Thrombin activated AMPK-α1 ex vivo via a Ca(2+) /calmodulin-dependent kinase kinase β (CaMKKβ)-dependent pathway. Pharmacologic inhibition of CaMKKβ blocked thrombin-induced platelet aggregation and counteracted thrombin-induced phosphorylation of several cytoskeletal proteins, namely, regulatory myosin light chains (MLCs), cofilin, and vasodilator-stimulated phosphoprotein (VASP), three key elements involved in actin cytoskeletal contraction and polymerization. Platelets isolated from mice lacking AMPK-α1 showed reduced aggregation in response to thrombin, and this was associated with defects in MLC, cofilin and VASP phosphorylation and actin polymerization. More importantly, we show, for the first time, that the AMPK pathway is activated in platelets of patients undergoing major cardiac surgery, in a heparin-sensitive manner.

CONCLUSION

AMPK-α1 is activated by thrombin in human platelets. It controls the phosphorylation of key cytoskeletal targets and actin cytoskeletal remodeling during platelet aggregation.

Myosin light chain kinase controls voltage-dependent calcium channels in vascular smooth muscle

The Ca(2+)-dependent kinase myosin light chain kinase (MLCK) is the activator of smooth muscle contraction. In addition, it has been reported to be involved in Ca(2+) channel regulation in cultured cells, and we previously showed that the MLCK inhibitor ML-7 decreases arginine vasopressin (AVP)-induced Ca(2+) influx in rat aorta. This study was designed to investigate whether MLCK is involved in Ca(2+) regulation in resistance artery smooth muscle cell, which plays a major role in the control of blood pressure. As ML compounds were shown to have off-target effects, MLCK was downregulated by transfection with a small interfering RNA targeting MLCK (MLCK-siRNA) in rat small resistance mesenteric artery (RMA) and in the rat embryonic aortic cell line A7r5. Noradrenaline-induced contraction and Ca(2+) signal were significantly depressed in MLCK-siRNA compared to scramble-siRNA-transfected RMA. Contraction and Ca(2+) signal induced by high KCl and voltage-activated Ca(2+) current were also significantly decreased in MLCK-siRNA-transfected RMA, suggesting that MLCK depletion modifies voltage-operated Ca(2+) channels. KCl- and AVP-induced Ca(2+) signals and voltage-activated Ca(2+) current were decreased in MLCK-depleted A7r5 cells. Eventually, real-time quantitative PCR analysis indicated that in A7r5, MLCK controlled mRNA expression of CaV1.2 (L-type) and CaV3.1 (T-type) voltage-dependent Ca(2+) channels. Our results suggest that MLCK controls the transcription of voltage-dependent Ca(2+) channels in vascular smooth muscle cells.

[Erythrocytes and microvascular tone during acute traumatic haemorrhagic shock]

Haemorrhagic shock remains a leading cause of death in trauma patients. The concept of haematologic damage control is gradually taking place in the management of traumatic haemorrhagic shock. It is based primarily on the early implementation of a quality blood transfusion involving erythrocytes, plasmas and platelets transfusion. Red blood cell transfusion is mainly supported by the oxygen carrier properties of erythrocytes. However, it appears that erythrocytes ability to modulate the bioavailability of nitric oxide (NO) plays a major role in capillary opening and perfusion. Erythrocytes are also actively involved in the processes of hemostasis and coagulation. In this context, it seems difficult to define a threshold of hemoglobin concentration to determine the implementation of a blood transfusion in traumatic haemorrhagic shock.