BACKGROUND:The decision to close patent foramen ovale (PFO) depends on the size of PFO, the coexistence of interatrial septum aneurysm, and the importance of right-to-left shunt assessed by the number of bubbles on transcranial Doppler (TCD) and echocardiography after saline or glucose injection. The interventional threshold for the number of bubbles is considered to be the same for trans-thoracic and trans-esophageal echocardiography (TTE and TEE) and TCD. Our objective was to study whether the same thresholds can be used for TCD and echocardiography. PATIENTS AND METHODS:In this comparative, observational study, we modeled a linear relationship between the number of bubbles on TCD and echocardiography, which suggests a different threshold between TCD and TTE/TEE. RESULTS:We found a systematic difference between TTE/TEE and TCD for the number of bubbles in the same patient. From linear regression, we found the following equation: TCDEstimate = (7.2 (95% CI: -2.36-16.8) + (2.67 (95% CI: 1.85-3.49, p < 0.001)) × TTE/TEE). CONCLUSION:Different thresholds for the decision to close a PFO should be used for both techniques: 20 bubbles for echocardiography and 60 bubbles for TCD.

AIMS:To assess whether rivaroxaban is associated with a decreased risk of major adverse limb events (MALE), stroke, systemic embolism (SE), and major bleeding (MB) among patients with non-valvular atrial fibrillation (NVAF) and peripheral artery disease (PAD), compared with apixaban. METHODS AND RESULTS:We conducted a population-based cohort study using the UK Clinical Practice Research Datalink. Patients aged ≥45 years with incident NVAF and PAD who initiated rivaroxaban or apixaban between 2013 and 2021 were included. Primary effectiveness outcomes were MALE, and a composite of ischaemic stroke, transient ischaemic attack (TIA), or SE. The primary safety outcome was MB. The risk of major cardiovascular events (MACE) was assessed as a secondary outcome. Confounding was addressed using propensity score fine stratification and weighting. Weighted Cox proportional hazards models estimated hazard ratios (HRs) with 95% confidence intervals (CIs). The cohort included 6170 new users of rivaroxaban and 9990 new users of apixaban (44% female; mean [SD] age 78.5 [9.2] years). Incidence rates were similar for MALE (6.7 vs. 5.6/1000 person-years; adjusted HR (aHR): 1.20; 95% CI 0.87-1.65), stroke/TIA/SE (24.5 vs. 21.3/1000 person-years; aHR: 1.15; 95% CI 0.97-1.36), and MACE (40.1 vs. 35.9 per 1000 person-years; aHR 1.10: 95% CI 0.94-1.28). Major bleeding rates were higher with rivaroxaban (46.1 vs. 29.8/1000 person-years; aHR: 1.55; 95% CI 1.36-1.77). CONCLUSION:In patients with NVAF and PAD, rivaroxaban was associated with a similar risk of MALE and stroke/TIA/SE, but a higher risk of MB compared with apixaban. These findings support apixaban as a potentially safer anticoagulant in this high-risk population.

BACKGROUND:The main objective was to develop a clinical model to predict critical lower limb ischemia (CLI). Secondary objectives were to assess the reproducibility of clinical data and to create a predictive score for major amputation. METHODS:Prediction de l'ischémie critique des membres inférieurs was a French multicenter prospective observational study that included patients suspected of chronic limb threatening ischemia (CLTI). The first end point was hemodynamic confirmation of CLI according to the European consensus and Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC) II definitions. We created models from clinical data to predict CLTI and major amputation or vascular death at 1 year based on CLI classifications and clinical and hemodynamic data. RESULTS:Five hundred seventy-four patients were included. After a median follow-up of 22.3 months (Q1-Q3 10.8-34.7), 243 patients (42%) had died and 96 patients (16%) had undergone at least one major amputation. The clinical model poorly predicted objectively confirmed CLI (c index 0.610 [0.560-0.630]). However, a combination of clinical data and systolic toe pressure predicted the risk of major amputation (area under the curve 0.710 [0.647-0.760]). CONCLUSION:Classical classifications of CLI are not adequately predicted by clinical parameters. While purely clinical models also poorly predict vascular outcome, a model including clinical data and systolic toe pressure seems to predict major amputation or vascular death satisfactory.

Background In patients with venous thromboembolism at high risk of recurrence for whom extended treatment with direct oral anticoagulants has been indicated, the optimal dose is unknown. We aimed to assess efficacy and safety of reduced-dose versus full-dose direct oral anticoagulants in patients in whom extended anticoagulation has been indicated. Methods RENOVE was a non-inferiority, investigator-initiated, multicentre, randomised, open-label, blinded endpoint trial done in 47 hospitals in France. Ambulatory patients aged 18 years or older with acute symptomatic venous thromboembolism (pulmonary embolism or proximal deep vein thrombosis) who had received 6-24 uninterrupted months of full-dose anticoagulation and for whom extended anticoagulation has been indicated were eligible. Eligible participants were categorised as having either a first unprovoked venous thromboembolism, recurrent venous thromboembolism, presence of persistent risk factors, or other clinical situations considered to be a high risk of recurrence. Participants were randomly assigned (1:1) to receive oral treatment with either a reduced dose of apixaban (25 mg twice daily) or rivaroxaban (10 mg once daily) or a full dose of apixaban (5 mg twice daily) or rivaroxaban (20 mg once daily) using a centralised randomisation procedure with an interactive web response system. The sequence generation method was a computerised random number generator and was balanced by blocks of different sizes. Randomisation was stratified by centre, type of direct oral anticoagulant, and antiplatelet drug. Physicians and participants were unmasked to treatment allocation; recurrent venous thromboembolism, clinically relevant bleeding, and all-cause death were adjudicated by an independent committee blinded to treatment allocation. The primary outcome was symptomatic recurrent venous thromboembolism, including recurrent fatal or non-fatal pulmonary embolism or isolated proximal deep vein thrombosis (non-inferiority hypothesis 90% power to exclude a hazard ratio [HR] of 17). The primary outcome and first two secondary outcomes were included in a hierarchical testing procedure. This trial is registered with ClinicalTrials.gov, NCT03285438. Findings From Nov 2, 2017, to July 6, 2022, 2768 patients were enrolled and randomly assigned to the reduced-dose group (n=1383) or the full-dose group (n=1385). 970 (350%) participants were female, 1797 (650%) were male, and one (<01%) had sex not reported. Median follow-up was 371 months (IQR 240-483). Recurrent venous thromboembolism occurred in 19 of 1383 patients in the reduced-dose group (5-year cumulative incidence 22% [95% CI 11-33]) versus 15 of 1385 patients in the full-dose group (5-year cumulative incidence 18% [08-27]; adjusted HR 132 [95% CI 067-260]; absolute difference 040% [95% CI -105 to 185]; p=023 for non-inferiority). Major or clinically relevant bleeding occurred in 96 patients in the reduced-dose group (5-year cumulative incidence 99% [95% CI 77-121]) and 154 patients in the full-dose group (5-year cumulative incidence 152% [128-176]; adjusted HR 061 [95% CI 048-079]). 1136 (821%) of 1383 patients in the reduced- dose group and 1150 (830%) of 1385 in the full-dose group had an adverse event; 374 (270%) patients in the reduced- dose group and 420 (303%) in the full-dose group has a serious adverse event. 35 (5-year cumulative incidence 43% [95% CI 26-60]) patients in the reduced-dose group and 54 (5-year cumulative incidence 61% [43-80]) patients in the full-dose group died during the study period. Interpretation In patients with venous thromboembolism requiring extended anticoagulation, reduction of the direct oral anticoagulant dose did not meet the non-inferiority criteria. However, the low recurrence rates in both groups and substantial reduction of clinically relevant bleeding with the reduced dose could support this regimen as an option. Further research will be needed to identify subgroups for whom the anticoagulation dose should not be reduced.

Introduction et objectifs Les patients très âgés sont peu inclus dans les études portant sur l’AOMI, alors que c’est dans leur tranche d’âge que la pathologie est la plus fréquente, et que la population mondiale vieillit. Les données spécifiques à cette population, comme leurs caractéristiques et leur prise en charge, restent rares. L’évolution dans le temps de ces éléments est peu connue. L’objectif principal a été de déterminer les caractéristiques des patients très âgés pris en charge pour une AOMI. L’objectif secondaire a été de décrire les tendances de ces caractéristiques dans le temps. Méthodologie Les sujets de la cohorte COPART, des patients hospitalisés pour la prise en charge d’une AOMI dans 4 CHU depuis 2006, constituaient notre population. Ceux dans le 75e percentile pour l’âge étaient considérés comme très âgés ; ceci correspondait aux plus de 80 ans. Ils ont été comparés au 25e percentile pour l’âge, les moins de 62 ans. Des analyses descriptives avec test de Mann-Whitney et Chi2 de Pearson ont été menées. Ces analyses ont ensuite été réalisées sur le groupe de plus de 80 ans, comparant ceux inclus en 2006–2007 à ceux inclus en 2018–2023. Résultats Les plus de 80 ans comprenaient 787 sujets contre 785 chez les moins de 62 ans. Les plus de 80 ans présentent plus souvent une ischémie critique, mais une prise en charge chirurgicale (hormis l’amputation majeure) similaire et une prise en charge médicale optimale moins importante que les moins de 62 ans. Chez les plus de 80 ans inclus en 2018–2023, il y a une prise en charge à un stade d’AOMI encore plus avancé que chez les 2006–2007 (73,5 % d’ischémie critique vs 55,2 %, p=0,002) et une majoration des revascularisations dans ce groupe (63,4 % vs 29,8 %, p=0,0001). Il y a aussi une majoration de l’hypertension (93,2 % vs 75,9 %, p=0,0001), du diabète (50,8 % vs 31,4 %, p=0,006) et de la dyslipidémie (61,9 % vs 40,2 %, p=0,002). Le traitement médical optimal était plus prescrit lors de l’hospitalisation initiale (71,8 % vs 69,2 %, p=0,0001 pour les antiagrégants, 84,5 % vs 53,2 %, p=0,001 pour les statines et 54,8 % vs 51,9 %, p=0,0001 pour les IEC/ARA2), mais peu poursuivi à 1 an (51,8 % vs 40,0 %, p=0,308 pour les antiagrégants, 51,2 % vs 50,0 %, p=0,917 pour les IEC/ARA2) à l’exception des statines. Conclusion Il y a une amélioration dans l’instauration du traitement médical optimal chez les octogénaires et nonagénaires. Sa poursuite à 1 an reste faible, malgré un stade d’AOMI plus grave et plus de comorbidités cardiovasculaires. La revascularisation en cas d’ischémie critique s’est considérablement majorée.

OBJECTIVES:Systemic sclerosis (SSc) has a variable evolution but may be life-threatening owing to pulmonary, cardiac or renal involvement. Nailfold video capillaroscopy (NVC) is abnormal early in the disease and is crucial for diagnosis. An association between subtypes of scleroderma pattern and disease progression has been suggested. Therefore, we conducted a prospective study to assess whether capillaroscopy can identify SSc patients at risk of progression. METHODS:SCLEROCAP was a prospective multicentre observational study that included patients with a diagnosis of SSc followed up for three years. Each patient had yearly standard evaluation and NVC. Images were read by two observers blinded from each other and were classified into subtypes (2 for Maricq's and 3 for Cutolo's classification). Severe progression was defined as cardiac, pulmonary or renal involvement or progression and was assessed by a validation committee. RESULTS:Three hundred and eighty-seven patients were included of whom 369 were followed-up and 53 (14 %) had severe progression. A simple model using Cutolo's capillaroscopic late stage, short duration of disease and age was as powerful in predicting severe progression as a model using all the parameters known to be predictive (AUC[95 %CI] 0.74[0.67-0.82] vs 0.73[0.64-0.77] respectively. CONCLUSION:NVC is a predictor of severe progression and might be helpful for early therapeutic decisions in patients with SSc.

INTRODUCTION:The use of intravascular catheters is associated with a risk of catheter-related septic thrombosis (CRST), which management remains highly variable due to a lack of robust scientific evidence. This study aimed to describe current practices in France through a systematic survey. METHODS:A web-based survey was disseminated via 10 French medical societies between June and October 2024. RESULTS:Among 156 respondents, 69 were infectious disease specialists. For catheter-related bloodstream infections, ultrasound imaging is not routinely performed by 60 % of respondents but is typically performed in the presence of local inflammatory signs or antimicrobial therapy (AMT) failure. Over 60 % of respondents reported prescribing AMT for ≤ 21 days. In cases of CRST involving a deep vein (DV), more than 80 % of respondents considered the use of curative anticoagulation. For proximal DV CRST, 126 of 156 (81 %) respondents performed follow-up ultrasound imaging to assess venous repermeabilization. The most frequently cited research priorities included the need for and appropriate use of anticoagulation (n = 71/156; 46 %), as well as AMT optimal duration (n = 47/156; 30 %). CONCLUSION:Despite the heterogeneity in clinical practice, our findings highlight a prevailing trend toward prescribing AMT for ≤ 21 days and the use of curative anticoagulation in cases of DV thrombosis. However, these approaches require further investigation through well-designed studies to establish their benefit.

Objectives: The digital ulcers (DU) of SSc are disabling and frequent. Their pathogenesis involves a capillary microangiopathy and a digital arterial disease that few studies were able to quantify up to now. A multicentre observational study about the predictive value of capillaroscopy in SSc offered us the opportunity to evaluate further the complementary information provided by both capillary and arterial evaluations. Methods: During the SCLEROCAP study, five out of the nine centres performed a systematic evaluation of the finger brachial pressure index (FBPI) in the last four fingers of both hands at baseline, using the same laser-Doppler device. In the present work, FBPI measurements were compared between fingers with vs without DU or scars, before and after adjusting for the capillaroscopic pattern and systemic factors. Results: FBPI measurements were performed in 2537 fingers from 326 patients. Active ulcers or scars were found in 10.8% of those fingers, more often on the right hand, and in the second and third fingers. FBPI was lower than 0.70 in 26% of all fingers and in 57.5% of those with ulcers. A strong association was found between a low FBPI and the presence of DU, even after adjusting for capillaroscopic pattern, ulcer location and the patient himself. Conclusion: These results confirm the importance of digital arterial disease in the pathogenesis of DU of SSc, which is independent from the microangiopathy. FBPI measurements complement the information provided by capillaroscopy and might have an important predictive value for subsequent DU.

Journal of the European Academy of Dermatology and VenereologyEarly View LETTER TO THE EDITOR Demographic and clinical characteristics of patients with coexistence of systemic sclerosis and atopy: A cross-sectional study Julie Archimbaud, Julie Archimbaud orcid.org/0009-0008-7142-5088 Department of Dermatology and Pediatric Dermatology, National Reference Center for Rare Skin Disorders, Hôpital Saint-André, Bordeaux, FranceSearch for more papers by this authorThomas Barnetche, Thomas Barnetche Department of Rheumatology, Hôpital Pellegrin, Bordeaux, France Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, FranceSearch for more papers by this authorEstibaliz Lazaro, Estibaliz Lazaro Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, France Department of Internal Medicine, National Reference Center for Systemic Autoimmune Rare Diseases, Hôpital Haut Lévêque, Bordeaux University Hospital, Pessac, FranceSearch for more papers by this authorJoël Constans, Joël Constans Department of Vascular Medicine, Hôpital Saint André, Bordeaux University Hospital, Bordeaux, FranceSearch for more papers by this authorPierre Duffau, Pierre Duffau Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, France Department of Internal Medicine, Hôpital Saint André, Bordeaux University Hospital, Bordeaux, France Bordeaux University, CNRS, ImmunoConcept, UMR 5164, Bordeaux, FranceSearch for more papers by this authorMarie-Elise Truchetet, Marie-Elise Truchetet Department of Rheumatology, Hôpital Pellegrin, Bordeaux, France Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, France Bordeaux University, CNRS, ImmunoConcept, UMR 5164, Bordeaux, FranceSearch for more papers by this authorJulien Seneschal, Corresponding Author Julien Seneschal [email protected] orcid.org/0000-0003-1139-0908 Department of Dermatology and Pediatric Dermatology, National Reference Center for Rare Skin Disorders, Hôpital Saint-André, Bordeaux, France Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, France Bordeaux University, CNRS, ImmunoConcept, UMR 5164, Bordeaux, France Correspondence Julien Seneschal, Department of Dermatology, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France. Email: [email protected]Search for more papers by this author Julie Archimbaud, Julie Archimbaud orcid.org/0009-0008-7142-5088 Department of Dermatology and Pediatric Dermatology, National Reference Center for Rare Skin Disorders, Hôpital Saint-André, Bordeaux, FranceSearch for more papers by this authorThomas Barnetche, Thomas Barnetche Department of Rheumatology, Hôpital Pellegrin, Bordeaux, France Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, FranceSearch for more papers by this authorEstibaliz Lazaro, Estibaliz Lazaro Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, France Department of Internal Medicine, National Reference Center for Systemic Autoimmune Rare Diseases, Hôpital Haut Lévêque, Bordeaux University Hospital, Pessac, FranceSearch for more papers by this authorJoël Constans, Joël Constans Department of Vascular Medicine, Hôpital Saint André, Bordeaux University Hospital, Bordeaux, FranceSearch for more papers by this authorPierre Duffau, Pierre Duffau Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, France Department of Internal Medicine, Hôpital Saint André, Bordeaux University Hospital, Bordeaux, France Bordeaux University, CNRS, ImmunoConcept, UMR 5164, Bordeaux, FranceSearch for more papers by this authorMarie-Elise Truchetet, Marie-Elise Truchetet Department of Rheumatology, Hôpital Pellegrin, Bordeaux, France Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, France Bordeaux University, CNRS, ImmunoConcept, UMR 5164, Bordeaux, FranceSearch for more papers by this authorJulien Seneschal, Corresponding Author Julien Seneschal [email protected] orcid.org/0000-0003-1139-0908 Department of Dermatology and Pediatric Dermatology, National Reference Center for Rare Skin Disorders, Hôpital Saint-André, Bordeaux, France Fédération Hospitalo-Universitaire ACRONYM, Bordeaux, France Bordeaux University, CNRS, ImmunoConcept, UMR 5164, Bordeaux, France Correspondence Julien Seneschal, Department of Dermatology, Hôpital Saint-André, CHU de Bordeaux, Bordeaux, France. Email: [email protected]Search for more papers by this author First published: 04 October 2023 https://doi.org/10.1111/jdv.19549Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat Open Research DATA AVAILABILITY STATEMENT The authors confirm that the data supporting the findings of this study are available in the article. Datasets related to this article are available upon request ([email protected]) and are hosted by the University Hospital of Bordeaux. The data are not publicly available because they contain information that could compromise the privacy of research participants. REFERENCES 1Salmon-Ehr V. Expression of Interleukin-4 in scleroderma skin specimens and scleroderma fibroblast cultures: potential role in fibrosis. Arch Dermatol. 1996; 132(7): 802–806. 2Huang XL, Wang YJ, Yan JW, Wan YN, Chen B, Li BZ, et al. Role of anti-inflammatory cytokines IL-4 and IL-13 in systemic sclerosis. Inflamm Res. 2015; 64(3–4): 151–159. 3Kuzumi A, Yoshizaki A, Matsuda KM, Kotani H, Norimatsu Y, Fukayama M, et al. Interleukin-31 promotes fibrosis and T helper 2 polarization in systemic sclerosis. Nat Commun. 2021; 12(1): 5947. 4Langan SM, Irvine AD, Weidinger S. Atopic dermatitis. Lancet. 2020; 396(10247): 345–360. 5Wheatley LM, Togias A. Allergic rhinitis. N Engl J Med. 2015; 372(5): 456–463. 6Krishna MT, Subramanian A, Adderley NJ, Zemedikun DT, Gkoutos GV, Nirantharakumar K. Allergic diseases and long-term risk of autoimmune disorders: longitudinal cohort study and cluster analysis. Eur Respir J. 2019; 54(5):1900476. 7Daley E, Emson C, Guignabert C, de Waal MR, Louten J, Kurup VP, et al. Pulmonary arterial remodeling induced by a Th2 immune response. J Exp Med. 2008; 205(2): 361–372. 8Christmann RB, Hayes E, Pendergrass S, Padilla C, Farina G, Affandi AJ, et al. Interferon and alternative activation of monocyte/macrophages in systemic sclerosis-associated pulmonary arterial hypertension. Arthritis Rheum. 2011; 63(6): 1718–1728. 9Jouvray M, Launay D, Dubucquoi S, Sobanski V, Podevin C, Lambert M, et al. Whole-body distribution and clinical Association of Telangiectases in systemic sclerosis. JAMA Dermatol. 2018; 154(7): 796–805. 10Mihai C, Landewé R, van der Heijde D, Walker UA, Constantin PI, Gherghe AM, et al. Digital ulcers predict a worse disease course in patients with systemic sclerosis. Ann Rheum Dis. 2016; 75(4): 681–686. 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La maladie de Buerger est une cause non rare d'ischémie digitale (10 % des cas de la série nantaise). Il s'agit d'une artériopathie de mécanisme inconnu mais touchant exclusivement les fumeurs de tabac avec une surreprésentation de la consommation de cannabis. Initialement décrite comme artériopathie inflammatoire sur l'argument de thrombus riche en cellules sur les biopsies de veines superficielles thrombosées, elle ne s'accompagne ni de syndrome inflammatoire, ni de marqueurs biologiques particuliers ni de sensibilité aux corticoïdes ou aux immunosuppresseurs et le diagnostic repose non plus sur l'histologie, mais sur des critères cliniques (homme jeune de moins de 50 ans présentant une artériopathie sous-poplitée et des thromboses veineuses superficielles ou une atteinte du membre supérieur en l'absence d'autre facteur de risque cardiovasculaire majeur). Le diagnostic est confirmé par les mesures de pressions digitales, car les IPS peuvent être normaux au début et l'échographie-doppler. La résolution de l'artériographie pour ces lésions distales est supérieure à celle de l'angio-TDM ou de l'angio-IRM. L'évolution est étroitement liée au sevrage du tabac dont la poursuite conditionne le risque d'amputation. L'iloprost s'est montré plus efficace que l'aspirine en situation d'ischémie de repos. Il n'y a pas aujourd'hui d'autre traitement de fond à proposer que le sevrage tabagique, souvent très difficile chez ces patients souvent désocialisés avec addictions multiples. En dehors de la maladie de Buerger, l'ischémie digitale peut être secondaire à d'autres toxiques que le tabac comme la cocaïne, souvent associée au cannabis, médicaments…).

Background: In the latest American Heart Association guidelines, influenza vaccination is recommended for patients with peripheral arterial disease (PAD). The vaccination coverage in this specific population is currently unknown. This study aims to determine the adherence to influenza vaccination in a PAD population and identify associated determinants. Patients and methods. Hospitalized patients and outpatients with PAD from two university departments of vascular medicine were prospectively included. A questionnaire was administered to collect sociodemographic data, cardiovascular risk factors, influenza vaccination status, history of cardiovascular disease, and perception and knowledge about vaccination. Logistic regression was conducted to assess vaccination determinants. Results: Over a six-month period, 494 patients were included (median age 69.5, IQR [63-77], 78% male). Overall, 60.1% were either vaccinated or intended to be (Group 1). Vaccination was associated with age (odds-ratio [OR]=1.055, 95% confidence intervals [95%CI]: 1.035-1.075, p<0.0001), abdominal aorta aneurysm (OR=0.390, 95%CI: 0.229-0.664, p=0.001), chronic obstructive pulmonary disease (OR=0.545, 95%CI: 0.367-0.810, p=0.003), chronic renal disease (OR=0.630, 95%CI: 0.400-0.993, p=0.046), and valvulopathy (OR=2.444, 95%CI: 1.122-5.326, p=0.025). Only 25.3% received vaccination information mainly from their general practitioners. Among patients against vaccination, 59.9% considered themselves not concerned about potential influenza consequences on their PAD, and 37.6% did not intend to change their decision. Conclusions: This study highlights the low adherence to influenza vaccination in the PAD population of 2 university hospital centers. Vaccination is often related to age, and there is a need for adapted information regarding influenza consequences on cardiovascular disease overall, particularly on PAD. Addressing common information and advice about vaccination will be a challenge.

OBJECTIVE:To evaluate the performance of machine learning and then deep learning to detect a systemic scleroderma (SSc) landscape from the same set of nailfold capillaroscopy (NC) images from the French prospective multicenter observational study SCLEROCAP. METHODS:NC images from the first 100 SCLEROCAP patients were analyzed to assess the performance of machine learning and then deep learning in identifying the SSc landscape, the NC images having previously been independently and consensually labeled by expert clinicians. Images were divided into a training set (70 %) and a validation set (30 %). After features extraction from the NC images, we tested six classifiers (random forests (RF), support vector machine (SVM), logistic regression (LR), light gradient boosting (LGB), extreme gradient boosting (XGB), K-nearest neighbors (KNN)) on the training set with five different combinations of the images. The performance of each classifier was evaluated by the F1 score. In the deep learning section, we tested three pre-trained models from the TIMM library (ResNet-18, DenseNet-121 and VGG-16) on raw NC images after applying image augmentation methods. RESULTS:With machine learning, performance ranged from 0.60 to 0.73 for each variable, with Hu and Haralick moments being the most discriminating. Performance was highest with the RF, LGB and XGB models (F1 scores: 0.75-0.79). The highest score was obtained by combining all variables and using the LGB model (F1 score: 0.79 ± 0.05, p < 0.01). With deep learning, performance reached a minimum accuracy of 0.87. The best results were obtained with the DenseNet-121 model (accuracy 0.94 ± 0.02, F1 score 0.94 ± 0.02, AUC 0.95 ± 0.03) as compared to ResNet-18 (accuracy 0.87 ± 0.04, F1 score 0.85 ± 0.03, AUC 0.87 ± 0.04) and VGG-16 (accuracy 0.90 ± 0.03, F1 score 0.91 ± 0.02, AUC 0.91 ± 0.04). CONCLUSION:By using machine learning and then deep learning on the same set of labeled NC images from the SCLEROCAP study, the highest performances to detect SSc landscape were obtained with deep learning and in particular DenseNet-121. This pre-trained model could therefore be used to automatically interpret NC images in case of suspected SSc. This result nevertheless needs to be confirmed on a larger number of NC images.

IntroductionSystemic sclerosis (SSc) is a serious life-threatening tissue disease. A significant aspect of its mortality arises from comorbid conditions. Our study aimed at mapping out the prevalence of these comorbidities and their relation to mortality, thus creating a ‘comorbidome’.MethodsIn our retrospective, single-centre observational study, we recorded each patient’s data, including demographic informations, vital stats and SSc-related organ involvement, along with the presence or absence of 14 predefined comorbidities. We also documented the dates of their initial and most recent visits. To construct survival curves, we used the Kaplan-Meier method, followed by a Cox regression model for multivariate analysis.ResultsOur study involved 400 participants, 74 of whom unfortunately passed away. It is important to note that three specific comorbidities showed significant correlation to mortality: neoplasia, cardiovascular diseases and polypharmacy, as well as two SSc-specific organ involvements (lung and cardiac).ConclusionOur research led to the successful creation of the SSc comorbidome. Comorbidities are a major concern for patients suffering from SSc, particularly cardiovascular diseases and neoplasms. Our study highlights the effects of polypharmacy. The resultant comorbidome offers a comprehensive and analytical perspective on this complex issue and underscores the inter-relatedness of the data. Our study, however, was limited by a small sample size. Therefore, to confirm our findings, validation on a larger scale is necessary. This could potentially contribute to the creation of a future mortality scoring tool.

Iloprost has been proposed as an alternative to amputation when revascularization was unsuccessful or not possible for critical limb ischemia (CLI) patients. Nevertheless, there is limited evidence of its benefit in CLI patients. Our main objective was to evaluate the effectiveness of iloprost in CLI patients; the secondary objective was to evaluate its safety. We performed a cohort study using data collected prospectively from the French multicentre COPART (COhorte des Patients ARTériopathes) registry of patients hospitalized with CLI from 01/10/2006 to 31/12/2020. Patients exposed to iloprost were matched with up to three unexposed patients according to age, sex and propensity score (PS) for exposure to iloprost. The main outcome combined the occurrence of all-cause death and major amputation; survival was assessed over 1 year using Kaplan-Meier Curve and multivariate Cox models. The safety analysis outcome was major adverse cardio-vascular events (MACE); its association to iloprost use was estimated using a logistic regression model. Among the 1850 COPART patients included in the study, 201 were exposed to iloprost (71.6% men, median age : 72 years vs. 72.13% men, median age: 75 years for unexposed). One hundred and forty-six exposed patients were matched to 397 unexposed patients. Regarding effectiveness analysis, 14 major amputations and 24 deaths occurred in exposed patients (26%) vs. 33 and 46 respectively in unexposed patients (20%). unadjusted hazard ratio (HR) for the association to iloprost was of 1.49 (95% Confidence Interval: 1.01–2.2) and adjusted HR of 1.46 (0.98–2.18). Regarding safety analysis, 21 (10.7%) exposed patients experienced MACE vs. 146 (9.41%) in the unexposed group. The association to iloprost was non-significant (unadjusted Odds Ratio [OR]: 1.17 [0.72-1.90], adjusted OR: 1.23 [0.72-2.11]). The risk of major amputation and all-cause death was increased in the iloprost group. Iloprost is assumed to improve circulation by dilating systemic vascular beds but its pharmacodynamic effects in serious patients as CLI patients is uncertain. Our study did not evidence benefit of iloprost treatment in CLI in real-world setting and do not support the use of iloprost in CLI patients.

BACKGROUND:A French intersociety consensus on behalf the Société Française de Médecine Vasculaire and the Société de Chirurgie Vasculaire et Endovasculaire was proposed in 2021 for the management of patients with lower extremity peripheral artery disease (LEAD). Recent studies have been published and an update of this consensus about the management of low-density lipoprotein cholesterol (LDLc) and hypertriglyceridemia was required. METHODS:A steering committee of 12 vascular physicians and surgeons defined questions of interest about LDLc and hypertriglyceridemia management. A French expert panel voted the proposals. Consensus was considered to have been achieved if more than 80% of the responses corresponded to either "Agreement" or "Disagreement". RESULTS:Among the 56 experts who were asked to participate, 46 (82%) accepted. After the first round of the Delphi procedure, the 4 proposals reached consensus. The following suggestions and recommendations were approved: 1. For LEAD patients treated by the highest tolerated statin dose ± ezetimibe and who have an LDLc ≥0.70 g/L, we recommend adding a proprotein convertase subtilisin/kexin type 9 inhibitor. 2. For LEAD patients treated by statin and who have elevated triglyceride level between ≥150 mg/dL and ≤500 mg/dL, we suggest adding Icosapent Ethyl. 3. Before adding Icosapent Ethyl in LEAD patients treated with statin, we suggest looking for symptoms that may suggest atrial fibrillation. 4. For LEAD patients treated by Icosapent Ethyl and who have symptoms that suggest atrial fibrillation, we recommend performing an electrocardiogram. CONCLUSIONS:This update will help clinicians to improve LEAD patient management.

BACKGROUND:Iloprost has been proposed as an alternative to amputation in Critical Limb Ischemia (CLI) patients when revascularization was unsuccessful or not possible. Nonetheless, there is limited evidence of its benefit. The main objective was to evaluate the effectiveness of iloprost and the secondary objective was to evaluate its safety.METHODS:In this cohort study including CLI patients from the COPART registry from 2006/10 to 2021/01, patients exposed to iloprost were matched with up to three unexposed patients according to age, sex, and Propensity Score (PS) for exposure to iloprost. The main outcome combined the occurrence of all-cause death and major amputations; survival was assessed over one-year using Kaplan-Meier estimates and Cox model analyses. Major Adverse Cardiovascular Events (MACE) were chosen as the safety outcome; the association with iloprost was estimated using a logistic regression model.RESULTS:Among 1850 CLI patients, 201 were exposed to iloprost (71.6% men; median age: 72 years vs. 72.1%; 75 years for unexposed). In 134 exposed patients matched to 375 unexposed patients, 14 major amputations and 24 deaths occurred in exposed patients (28.4%) vs. 33 and 46 respectively in the unexposed patients (20.9%). The hazard ratio (HR) was of 1.49 (95% Confidence Interval: 1.01-2.20). The association remained in the subgroup of "no option" patients (HR: 1.74; [1.01-2.20]). Regarding safety, 21/201 (10.7%) exposed patients experienced MACE vs. 146/1649 (9.41%) unexposed patients (unadjusted Odds Ratio [OR]: 1.17 [0.72-1.90]; adjusted OR: 1.23 [0.72-2.11]).CONCLUSION:The study did not find any benefit of iloprost in CLI patients and even suggested a deleterious effect.

Background:Hypertrophic cardiomyopathies (HCM) can be complicated by left ventricular outflow-tract obstruction (LVOTO) responsible for disabling exercise symptoms, a phenomenon influenced by hemodynamic factors including venous return. Methods:We aimed to evaluate venous dysfunction in obstructive HCM patients compared to healthy controls, and to investigate the relationship between venous dysfunction parameters and LVOTO in HCM. This is a clinical, monocentric, prospective, pilot study, in a tertiary care center. We investigated venous function using venous air plethysmography, and endothelial function. Results:Among the 30 symptomatic obstructive HCM patients, 30% (n = 9) presented abnormal venous residual volume fraction (RVFv) which translates in elevated ambulatory venous pressure vs. 0% in the 10 healthy controls (p < 0.05). Comparing obstructive HCM patients with abnormal RVFv (n = 9) to other obstructive HCM patients with normal RVFv (n = 21), there were no significant differences in terms of age, sex (67% male), and classical echocardiographic parameters both at rest and during exercise, except for left ventricular end-diastolic volume index which was significantly lower in the group with abnormal RVFv compared to the other HCM patients (40.1 ± 9.0 ml/m2 vs. 50.2 ± 10.6 ml/m2, p = 0.01). Fifty six percent of obstructive HCM patients with abnormal RVFv had an absolute increase in Willebrand factor (vs. 26% of other obstructive HCM patients, p < 0.05). Conclusions:In this pilot monocentric study, venous insufficiency was observed in about 30% of symptomatic obstructive HCM patients. Patients with venous insufficiency had more frequently a smaller LV cavity volume. Due to the small sample size, this study is only hypothesis-generating, and further investigations are needed.

Introduction: Clinical and immunological features of patients with cancer-associated systemic sclerosis: an observational study. Objective: Several studies have reported an increased incidence of cancer in patients with systemic scle-rosis (SSc). The presence of RNA polymerase III antibodies (anti-RNA Pol 3) associates with an increased risk of cancer, but other risk factors need yet to be identified. We aimed to assess clinical and immuno-logical predictive factors of cancer-associated SSc to guide clinicians when setting up selective cancer screening.Methods: We conducted a monocentric, retrospective, observational study of SSc patients with and with-out associated malignancy. Clinical, laboratory and imaging data were collected, as well as SSc treatment. Subgroup analyses were performed according to the type of cancer and the time of diagnosis.Results: Of 464 SSc patients, 74 (16%) had cancer, with breast (n = 26) and lung cancer (n = 13) being the most frequent. Diagnosis of cancer was made less than 3 years before or after SSc diagnosis for 23 patients (31%). In a multivariate analysis, anti-RNA Pol 3 and anti-SSA antibodies were significantly associated with an increased overall risk of cancer with an odds ratio (OR) of 4.12 (95% CI [1.6-10.7]; P < 0.01) and 2.43 (95% CI [1.1-5.4]; P < 0.05), respectively. Age at diagnosis of SSc and delay from the SSc diagnosis were also independent risk factors of cancer. Interstitial lung disease and anti-topoisomerase antibodies were associated with an increased risk of lung cancer and cancer occuring more than three years after SSc diagnosis. Conclusion: In addition to anti-RNA Pol 3 antibodies, anti-SSA antibodies associated with an increased risk of cancer in SSc patients. Interstitial lung disease was a risk factor specifically for lung cancer and cancers diagnosed more than 3 years after SSc diagnosis. For these patients, a systematic and regular cancer screening should be considered.(c) 2023 Soci ete franc,aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.