Recurrent FUO (fever of unknown origin) is a rare subtype of FUO for which diagnostic procedures are ill-defined and outcome data are lacking.
We performed a retrospective multicentre study of ...patients with recurrent FUO between 1995 and 2018. By multivariate analysis, we identified epidemiological, clinical and prognostic variables independently associated with final diagnosis and mortality.
Of 170 patients, 74 (44%) had a final diagnosis. Being ≥ 65 years of age (OR = 5.2; p < 0.001), contributory history (OR = 10.4; p < 0.001), and abnormal clinical examination (OR = 4.0; p = 0.015) independently increased the likelihood of reaching a diagnosis, whereas lymph node and/or spleen enlargement decreased it (OR = 0.2; p = 0.004). The overall prognosis was good; 58% of patients recovered (70% of those with a diagnosis). Twelve (7%) patients died; patients without a diagnosis had a fatality rate of 2%. Being ≥ 65 years of age (OR = 41.3; p < 0.001) and presence of skin signs (OR = 9.5; p = 0.005) significantly increased the risk of death.
This study extends the known yield of recurrent FUO and highlights the importance of repeated complete clinical examinations to discover potential diagnostic clues during follow-up. Moreover, their overall prognosis is excellent.
To assess the effect of sildenafil, a phosphodiesterase type 5 inhibitor, on digital ulcer (DU) healing in systemic sclerosis (SSc).
Randomised, placebo-controlled study in patients with SSc to ...assess the effect of sildenafil 20 mg or placebo, three times daily for 12 weeks, on ischaemic DU healing. The primary end point was the time to healing for each DU. Time to healing was compared between groups using Cox models for clustered data (two-sided tests, p=0.05).
Intention-to-treat analysis involved 83 patients with a total of 192 DUs (89 in the sildenafil group and 103 in the placebo group). The HR for DU healing was 1.33 (0.88 to 2.00) (p=0.18) and 1.27 (0.85 to 1.89) (p=0.25) when adjusted for the number of DUs at entry, in favour of sildenafil. In the per protocol population, the HRs were 1.49 (0.98 to 2.28) (p=0.06) and 1.43 (0.93 to 2.19) p=0.10. The mean number of DUs per patient was lower in the sildenafil group compared with the placebo group at week (W) 8 (1.23±1.61 vs 1.79±2.40 p=0.04) and W12 (0.86±1.62 vs 1.51±2.68, p=0.01) resulting from a greater healing rate (p=0.01 at W8 and p=0.03 at W12).
The primary end point was not reached in intention-to-treat, partly because of an unexpectedly high healing rate in the placebo group. We found a significant decrease in the number of DUs in favour of sildenafil compared with placebo at W8 and W12, confirming a sildenafil benefit.
NCT01295736.
Neurologic involvement occurs in approximately 20% of patients with primary Sjögren syndrome (SS). However, the diagnosis of SS with neurologic involvement is sometimes difficult, and central nervous ...system (CNS) manifestations have been described rarely. We conducted the current study to describe the clinical and laboratory features of SS patients with neurologic manifestations and to report their clinical outcome. We retrospectively studied 82 patients (65 women and 17 men) with neurologic manifestations associated with primary SS, as defined by the 2002 American-European criteria. The mean age at neurologic onset was 53 years. Neurologic involvement frequently preceded the diagnosis of SS (81% of patients). Fifty-six patients had CNS disorders, which were mostly focal or multifocal. Twenty-nine patients had spinal cord involvement (acute myelopathy n = 12, chronic myelopathy n = 16, or motor neuron disease n = 1). Thirty-three patients had brain involvement and 13 patients had optic neuropathy. The disease mimicked relapsing-remitting multiple sclerosis (MS) in 10 patients and primary progressive MS in 13 patients. We also recorded diffuse CNS symptoms: some of the patients presented seizures (n = 7), cognitive dysfunction (n = 9), and encephalopathy (n = 2). Fifty-one patients had peripheral nervous system involvement (PNS). Symmetric axonal sensorimotor polyneuropathy with a predominance of sensory symptoms or pure sensory neuropathy occurred most frequently (n = 28), followed by cranial nerve involvement affecting trigeminal, facial, or cochlear nerves (n = 16). Multiple mononeuropathy (n = 7), myositis (n = 2), and polyradiculoneuropathy (n = 1) were also observed. Thirty percent of patients (all with CNS involvement) had oligoclonal bands. Visual evoked potentials were abnormal in 61% of the patients tested. Fifty-eight patients had magnetic resonance imaging (MRI) of the brain. Of these, 70% presented white matter lesions and 40% met the radiologic criteria for MS. Thirty-nine patients had a spinal cord MRI. Abnormalities were observed only in patients with spinal cord involvement. Among the 29 patients with myelopathy, 75% had T2-weighted hyperintensities. Patients with PNS manifestations had frequent extraglandular complications of SS. Anti-Ro/SSA or anti-La/SSB antibodies were detected in 21% of patients at the diagnosis of SS and in 43% of patients during the follow-up (mean follow-up, 10 yr). Biologic abnormalities were more frequently observed in patients with PNS involvement than in those with CNS involvement (p < 0.01). Fifty-two percent of patients had severe disability, and were more likely to have CNS involvement than PNS involvement (p < 0.001). Treatment by cyclophosphamide allowed a partial recovery or stabilization in patients with myelopathy (92%) or multiple mononeuropathy (100%). The current study underlines the diversity of neurologic complications of SS. The frequency of neurologic manifestations revealing SS and of negative biologic features, especially in the event of CNS involvement, could explain why SS is frequently misdiagnosed. Screening for SS should be systematically performed in cases of acute or chronic myelopathy, axonal sensorimotor neuropathy, or cranial nerve involvement. The outcome is frequently severe, especially in patients with CNS involvement. Our study also underlines the efficacy of cyclophosphamide in myelopathy and multiple neuropathy occurring during SS.
La médecine polyvalente (MP), spécialité transversale, se développe actuellement dans de nombreux centres hospitaliers et constitue l’un des piliers de la prise en charge multidisciplinaire de l’aval ...des urgences et des patients polypathologiques de proximité.
Nous rapportons l’expérience de la création d’un pôle inter-établissement (PIE) en direction commune entre un service de MP de CH et un Service de médecine interne (MI) de CHU.
L’idée de ce pôle est née il y a plus de 5ans, la direction des établissements souhaitant renforcer un service de MP de 24 lits qui avait progressivement perdu ces agréments de spécialités du fait des départs en retraite de spécialistes de MI. La Direction des 2 hôpitaux a été très facilitatrice dans l’organisation du projet et a su temporiser une volonté rapide de ré-ouverture de lits à la structuration progressive d’un projet de service abouti et porté par des praticiens volontaires. Deux praticiens de médecine générale dont l’un avec un DIU de soins palliatifs ont été recrutés pour ce projet et un poste d’assistant partagé, soutenu financièrement par l’Agence régionale de santé, a été créé.
L’interaction entre les 2 services est bilatérale avec :
Du CHU vers le CHG : la venue d’un PUPH, chef du pôle inter-établissements, de MI en MP 2 demi-journées par semaine, la création d’une consultation avancée de MI, le confortement de l’équipe sur place par des temps partagés fixes (mises à disposition) ou des remplacements ponctuels via le dispositif de prime de solidarité territoriale afin d’assurer la continuité des soins, la création d’une consultation dédiée de médecine complémentaire et alternative en MI ainsi que le transfert de patient pour rapprochement géographique sur lits identifies soins palliatifs (LISP).
Du CHG vers le CHU : la venue une demi-journée par semaine d’un PH pour l’animation d’une réunion éthique et de soins de support et le transfert de patients instables vers le secteur de soins continus de MI, ou nécessitant un plateau technique adapté.
Le service de MP a depuis un an ré-obtenu l’agrément pour l’accueil de 2 internes de médecine générale. Le chef de service de MP et un PUPH de MI co-aminent localement la FST de médecine polyvalente. Le service de MP développe actuellement, outre l’accueil d’aval des urgences, une activité d’hospitalisations programmées en conventionnel et en hôpital de jour destinées aux médecins généralistes de proximité. Un projet de recherche commun aux 2 services sur la place de l’aromathothérapie dans l’accompagnement des patients hospitalisés est en cours d’élaboration.
Les pôles de territoire incluant services de MI hospitalo-universitaires et MP de proximité peuvent être un challenge réussi, s’articulant sur des collaborations bilatérales et pérennes.
Background: Anti-filaggrin antibodies (AFA) are among the most specific antibodies for rheumatoid arthritis, so procedures for their detection should be included in early biological diagnoses. AFA ...can be detected by indirect immunofluorescence (anti-keratin antibodies, AKA) or by new enzyme immunoassays (EIA). Their comparative performance needs to be established. Objective: To compare these technical procedures to optimise the serological diagnosis of rheumatoid arthritis. Methods: Results obtained using AKA and EIA were compared in 271 sera from 140 patients with rheumatoid arthritis at various stages, 98 patients with other autoimmune diseases, and 33 healthy subjects. EIA were successively undertaken with citrullinated linear filaggrin peptide (home made EIA) or cyclic citrullinated peptide (CCP2, commercial kits). Rheumatoid factor (RF) was assessed by EIA in all patients. Results: Anti-CCP2 kits showed the best sensitivity and specificity (65% and 96%, respectively). Among the 140 patients with rheumatoid arthritis, those with very recent disease (less than six months’ duration, n = 21) were studied as a separate group. In this group, the sensitivity of anti-CCP2 kits decreased to ~50%. Nevertheless this assay remained the most accurate when compared with AKA or home made EIA using linear filaggrin peptides. The combination of anti-CCP2 and RF only slightly increased the sensitivity of the diagnosis of very early rheumatoid arthritis. Conclusions: Kits using citrullinated cyclic peptides (CCP2) were more suitable than either AKA or EIA using linear filaggrin peptides for the diagnosis of early rheumatoid disease.
Background and importanceDrug supply shortages that have increased over the past decade were worsened by the SARS-CoV-2 health crisis. Among the products affected are immunoglobulins (IG), essential ...for substitution in primary immune deficiencies in particular. In contrast with some plasmatic proteins, IG are only produced from blood donations that have decreased. Recently, IG supply was reduced, 42% in our case, mostly affecting intravenous IG (IVIG).Aim and objectivesTo identify, among the existing clinical situations, those that should benefit from IG (subcutaneous IG (SCIG) preferentially in primary substitutions; IVIG treatment to as many patients as possible for whom there is no alternative).Material and methodsMeet physicians representing the most important prescribing departments. Take stock of consumption and supply. Identify ways to optimise the use of available IG.ResultsThe neurology, clinical haematology, internal medicine and paediatrics representatives were brought together at a Medicinal Products and Medical Devices Commission (MPMDC) session.First 6 months of 2021, data on IVIG:Patient number: 168. IVIG mass: 27.8 kg (70.4% of total IG). Treatment number: 510. On average: 27.6 g/patient/month; 3 cures/patient over 6 months.IVIG use: off-label, 27.4%; immune deficiencies, 41.6% (secondary 9 times; primary 1 time); immunomodulation, 31% (of which: idiopathic thrombocytopenic purpura (ITP), 42.3%; Guillain-Barré syndrome, 9.6%; Kawasaki disease, 3.8%; chronic inflammatory demyelinating polyradiculopathy (CIDP), 38.5%; multifocal motor neuropathies, 5.8%).Discussions at MPMDC led to the development of the following ways to cope:‘Switch’ as many patients as possible to SCIG.As the dosage of 2 g/kg/cure is indicative, lower the doses gradually and/or space out the courses.Use corticosteroids whenever possible.Use IVIG for life–threatening authorised situations (eg, acute ITP).Reactivate the plasma exchange pathway for immunomodulations.Reduce off–label use.For off–label indications, include patients in therapeutic trials of IVIG.If life–threatening emergency immunomodulation off–label, treat with molecules such as rituximab and use IVIG only during the latency period.Conclusion and relevanceThe implementation of these suggestions, while awaiting the publication of the IG indications’ hierarchy by the relevant authorities, should optimise management of the shortage. European, or even international, recommendations would be welcome because of the globalisation of supply.References and/or acknowledgementsWe acknowledge (in alphabetical order): Mélodie Billac, Carole Nivet and Martine Raymondeau.Conflict of interestNo conflict of interest
To analyse iatrogenic events in elderly people and determine the part of unplanned admission in postemergency units directly related to thus iatrogenic events.
The authors conducted a prospective ...chart review on treatments and potentials adverse drug-related events of all elderly consecutively hospitalized between January and Marsh 2003 in a postemergency department. A 6 months prospective evaluation after discharge was made for all elderly with adverse drug-related event.
One hundred (and) eighty-six elderly (mean age 83+/-5.7 years) were prospectively included. Eighty-one per cent are ambulatory with a self-medication administration in spite of a real disability (activity of daily-living: 4.5+/-1.8). The number of medications consumed ranged from 0 to 15 and averaged 6, with to different source of prescriptions in 34% of the cases. The treatment was recently modified in 41 cases (22%). Adverse drug related events accounted in 55 cases (29%) and hospitalization was directly related to iatrogenic event in 32 cases (17%). Adverse drug related events could be avoided in half cases. There was no death directly related with adverse drug reactions. Follow up after discharge was obtained in 47 cases and pointed out elderly disability: 34 were again hospitalized, 14 admitted in nursing home facilities and 12 died. Treatment was equivalent to our prescription only in 35% of the cases; on the other hand, we found only four elderly with medication directly related to previous adverse event.
Theses results pointed out once again polymedication observed in frail elderly people leading to extreme difficulty to prescription due to polypathology. Prescription renewal could be related to adverse drug related events and precipitated elderly people in disability leading to institutionalization.
Postprandial hypotension (PPH) is increasingly recognized as a common cause of falls and syncope in elderly persons. Noninvasive ambulatory blood pressure monitoring (ABPM) has been recommended for ...detecting PPH. This study investigates postprandial blood pressure (BP) changes by means of ABPM in elderly patients experiencing falls or syncopes.
Twenty-four-hour ABPM was performed in 156 inpatients (111 women, mean age 80.4 +/- 8.1 years). Among them, 45 had been admitted for falls and 75 for syncope; 36 with no history of falls or syncope served as controls. Postprandial change in systolic blood pressure (deltaSBP) was calculated by subtracting the mean SBP within the 2 hours following the meal from the mean SBP within the 2 hours preceding the meal. PPH was defined by a deltaSBP > or = 20 mm Hg.
For the entire group, mean SBP decreased after the three meals. On average, the decline in SBP was greater after breakfast than after lunch or dinner, and the number of patients experiencing PPH was greater after breakfast. Average maximal deltaSBP was significantly larger in the syncope group than in the other groups ( p < .05). Moreover, the number of patients experiencing PPH was significantly higher in the syncope/fall group than in the control group (23% vs 9%; p = .03). Compared with patients without PPH, patients with PPH were more likely to have a history of diabetes mellitus (p < .01) or to use more than three different drugs daily ( p = .04), and they showed greater daytime SBP variability (p < .0001). Furthermore, there was a strong positive correlation between preprandial SBP and deltaSBP after breakfast.
About one out of four elderly patients with falls or syncope experiences PPH, usually after breakfast. Postprandial decline in BP contributes to BP variability. deltaSBP and preprandial SBP are positively correlated.
Primary Sjögren's syndrome in men Gondran, G.; Fauchais, A. L.; Lambert, M. ...
Scandinavian journal of rheumatology,
01/2008, Volume:
37, Issue:
4
Journal Article
Peer reviewed
Objective: To determine whether there were any clinical and biological differences between male and female patients with primary Sjögren's syndrome (pSS) in a large bicentric series of patient.
...Methods: We studied 419 consecutive patients (mean age at onset 53.6 years, mean disease outcome 73 months) with pSS according to American-European criteria, attending two different Departments of Internal Medicine in France. The 42 (9%) male patients in this cohort comprised the male group described in this study.
Results: Extraglandular manifestations during the course of the disease were present in 37 (89%) of our male patients with pSS. The extraglandular manifestations were similar among the two groups except that the male patients showed a lower frequency of depression or asthaenia (5% vs. 20%, p = 0.014) compared with the females. A significantly greater percentage of women reported lymphopaenia (26% vs. 8%, p = 0.02) and leucopaenia (18% vs. 3%, p = 0.015) at onset, but thrombopaenia was more common in the male patients (21% vs. 6%, p = 0.001). Lymphoma development was slightly more common in the male patients, but with no statistical significance (10% vs. 3%, p = 0.06), and occurred earlier after the SS diagnosis (log rank test p = 0.04).
Conclusion: Although pSS is typically a disease affecting women, clinicians should be aware that it may be diagnosed in male patients. Except for haematological presentation, we could not find any notable differences in clinical and immunological characteristics between male and female patients with pSS.
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