Cardiovascular events (CVE) are the leading cause of mortality for patients living with systemic lupus erythematosus (SLE). Besides the traditional cardiovascular risk factors, the impact of subclinical atherosclerosis on the clinical cardiovascular risk is yet to be determined in the specific population.
Objectives:
Our aim was to evaluate the association between subclinical atherosclerosis defined as the presence of an atherosclerotic carotid plaque > 1.5 mm in thickness, and the risk of future cardiovascular events in SLE.
Methods:
We performed a prospective study including consecutive patients with SLE followed in our reference center. We excluded patients with a known coronary disease or symptoms suggestive of cardiovascular disease (angina, arrhythmia, congestive heart failure, stroke, and peripheral arterial disease). All patients were evaluated for carotid plaque by a single evaluator. At inclusion, we collected demographic characteristics, morphometric parameters such as body mass index (BMI) and waist circumference, disease characteristics and treatment history. The main outcome was a cardiovascular event defined as the occurrence during a 11-years follow-up of myocardial infarction, ischemic stroke or symptomatic peripheral arterial disease. We examined the association between carotid plaque and cardiovascular event onset using uni- and multivariable logistic regression using Firth's correction for separated data.
Results:
We included 63 SLE patients (82.5% female), with an age of (median [1st quartile-3rd quartile]) 39 [32-44.5] years. Among them, 24 (38.1%) had a carotid plaque > 1.5 mm at baseline and 7 (11.1 %) experienced a cardiovascular event during a median follow-up of 10.7 [8.2-11.0] years. All the cardiovascular events occurred in the group of patients with a carotid plaque at baseline. The univariable analysis of the factors associated with the occurrence of a cardiovascular event are presented in Table 1 (see below). The survival without cardiovascular event in this population, according to the presence of a carotid plaque at baseline is presented as a Kaplan-Meier curve in Figure 1 (see below). In the multivariable analysis, we observed that, after adjusting for the Framingham score and the body mass index, the presence of a carotid plaque remained significantly associated with the occurrence of a cardiovascular event: odds ratio [95% confidence interval] = 15.6 [1.02, 2226]; p= 0.048.
Conclusion:
Subclinical atherosclerosis defined as a carotid plaque > 1.5 mm is significantly associated with the clinical cardiovascular risk in SLE. Subclinical atherosclerosis should be regularly assessed in this population as part of the global cardiovascular risk evaluation.
In showing no correlation between adrenal insufficiency risk and dose or duration of steroid treatment, previous reference papers have blurred our comprehension and practice (1).
Objectives
To determine the extent to which long-term corticosteroid therapy damages the pituitary-adrenal axis in patients treated with prednisone medication for systemic disorders.
Methods
We retrospectively studied all consecutive patients followed in our department from January 2011 to August 2012 in whom short synacthen test (SST) was assessed when withdrawal of prednisone was planned. Age, sex, disease status, duration and cumulative dose of glucocorticoid therapy were systematically recorded. SST was considered blunted when the 60 minutes plasma cortisol concentration was below 550 nmol per liter.
Results
Sixty consecutive patients suffering various systemic diseases were studied (Table 1). The mean daily dose of prednisone at study time was 7 (±2) (range: 5-10) mg. Median duration and cumulative dose of prednisone were 3.8 years (range: 0.3-32) and 16.6 grams (1-132), respectively. The SST response was blunted in 29 patients (48.3%) and normal in 31. Blunted responses were associated with higher cumulative prednisone dose (p=0.04) and treatment duration (p=0.04) (Table1 and 2). Basal cortisol concentrations negatively correlated with both duration (r=-0.33, p=0.01) and cumulative dose (r=-0.28, p=0.03) of prednisone. Steroids were stopped in 29/31 (93.5 %) patients showing a normal response to SST. In this case, no patient required hydrocortisone replacement for a mean follow-up of 10 (± 6) months.
Conclusions
Adrenal insufficiency is frequent in patients treated with long-term glucocorticoid for systemic disorders. Adrenal insufficiency risk may be appraised adequately on the basis of cumulative dose and duration of glucocorticoid therapy.
References
Schlaghecke R, et al. N Engl J Med 1992;326:226-230.
Autoimmune disorders, including immune cytopenia, are encountered in the setting of chronic myelomonocytic leukemia (CMML). The aim of our study was to analyze the association of immune thrombocytopenia (ITP) with chronic myelomonocytic leukemia (CMML).We carried out a retrospective cohort study on 565 patients with immune thrombocytopenia (ITP) followed in the French referral center for adult's immune cytopenia. A literature review using MEDLINE (National Library of Medicine, Bethesda, MD) was also performed.Eight patients (5 male, 76.3 + 9.8 yr old) with ITP-associated CMML were identified in our national cohort. Thirteen cases were reported in literature from 1984 to 2013. Mean age was 65.3 ± 18.5 yr. Sex ratio (M/F) was 1/0.6. ITP unveiled CMML in all but four cases (17/21; 80.9%). ITP occurred in the setting of low-grade CMML in all cases, with neither reported progression nor acute myeloid leukemia transformation during follow-up. Overall, karyotype analysis revealed cytogenetic abnormalities in six cases (6/16; 37.5%). ITP had a chronic course in most cases and shares, according to the low level of bleeding complications and the high response rate to treatment such as corticosteroids and splenectomy, the usual characteristics of primary ITP.Although the association of a well-defined ITP and CMML is rare, our study suggests that CMML-associated ITP should be treated according to current guidelines for primary ITP.
On ne cesse de vous parler de la reforme des etudes medicales (REM), pourtant rien ne semble avancer dans un sens ou dans un autre. Cependant, certaines facultes parisiennes ont accueilli leurs etudiants de PCEM 2 en leur annoncant qu’ils ne passeraient pas le concours d’Internat. Nous avons rencontre le Professeur J. Rey, conseiller technique de M. Allegre, le 17/12/98, qui nous a expose le projet de reforme en nous specifiant qu’elle ferait partie de la prochaine loi sociale de mai-juin 1999. Malgre les differentes reunions de travail avec J. Rey, B. Varet et G. Levy (responsables au ministere du groupe de travail sur la REM), auxquelles nous avons participe, nos preoccupations et nos differentes remarques n’ont ete que partiellement prises en compte.
