Overview of dermatologic tele-expertise in areas of low physician density: A retrospective study at Le Mans general hospital.

BACKGROUND: In areas of low physician density, especially as regards dermatologists in France, there is an increasing interest in tele-expertise. This is particularly the case in the Sarthe department, where the number of physicians continues to decline and access to care was further limited by the COVID 19 epidemic. STUDY DESIGN: We retrospectively collected data from tele-expertise requests submitted to Le Mans General Hospital by general practitioners via a dedicated platform between May 6, 2019, and April 9, 2021. RESULTS: Six hundred and forty three requests relating to 90 different diagnoses were recorded during this period. One hundred and thirty four patients (20% of requests) were invited to attend a face-to-face consultation within an average of 29 days. DISCUSSION: Through the use of tele-expertise at Le Mans Genreal Hospital it was possible to introduce a means of tackling the problem of the lack of dermatologists in the Sarthe department. Rapid responses enabled the number of consultation requests to be reduced, leading to fewer population displacements in the context of the present pandemic. CONCLUSION: These initial results are encouraging and confirm that tele-expertise seems a satisfactory option to optimize access to care for populations in areas of low physician density.

[Regression of cutaneous basal cell and squamous cell carcinoma under pembrolizumab]. / Régression de carcinomes basocellulaire et épidermoïde cutanés sous pembrolizumab.

BACKGROUND: The recommended treatments for advanced squamous cell carcinoma (SCC) (chemotherapy, radiotherapy, anti-EGFR) and advanced basal cell carcinoma (BCC) (vismodegib and sonidegib) have many side effects. Nivolumab (anti-PD1 antibody) may be used as second-line therapy in SCC of the head and neck. We report the case of a patient with advanced SCC and BCC which regressed under pembrolizumab. PATIENTS AND METHODS: A 69-year-old man consulted for a large vertex SCC measuring 15cm in diameter. He also had BCC on the left nostril and sternal Bowen disease. Radiological assessment revealed cervical and parotid lymph node involvement. Treatment with pembrolizumab 2mg/kg every 3 weeks was decided at a Multidisciplinary Concertation Meeting. Tumor regression of the vertex SCC was noted at the third course of treatment, as well as regression of the nasal BCC and the sternal Bowen disease. A complete response was observed after 11 courses of treatment for SCC, 7 courses for BCC, and 10 courses for Bowen disease. CONCLUSION: We report an original case of cure of BCC with anti-PD1 (pembrolizumab) prescribed for locally advanced inoperable SCC. The place of this treatment in the therapeutic arsenal remains to be defined. Clinical trials are in progress concerning use of this treatment in advanced cutaneous SCC and inoperable BCC.

[Characteristics of chronic wounds in substance abuse: A retrospective study of 58 patients]. / Caractéristiques des plaies chroniques chez les toxicomanes : étude rétrospective de 58 patients.

BACKGROUND: Drug addiction causes chronic wounds (CW) responsible for severe complications. Very few studies are available on this topic. The aim of our study was to describe the demographic, clinical and etiological characteristics as well as the course of CW in drug addicts. PATIENTS AND METHODS: This was a retrospective and prospective multicenter study including all drug addicts with CW. RESULTS: We included 58 patients (17 prospectively), 84.5% of whom were male, of median age 43 years, presenting multiple CW as a result of intravenous (78.2%), inhaled (41.1%) and/or snorted (20%) drug abuse. Addiction to opioids (68.4%), cocaine (47.4%) and/or cannabis (40.4%) was ended and/or treated through substitution in 79.3% of patients. CW were fibrinous and necrotic (42.9 to 53.6%), recurrent (54.2%), and in some cases had been present for more than 1 year (61.5%). Intravenous drug addiction was associated with large, fibrinous, ulcers in a setting of venous and lymphatic insufficiency (74%). Only 23% of these wounds involved the upper limbs. Necrotic ulcers associated with clinical arteriopathy were described mainly with inhaled addiction. Abscesses (50%) and erysipelas (29.3%) were the most common cutaneous complications. After 3 months, 50% of CW were improved and 29.2% of patients were lost to follow-up. DISCUSSION: Drug abuse-related CW occurred preferentially in young men with history of intravenous abuse. For the most part, CW were seen on the legs and were associated with venous and lymphatic insufficiency, and the resulting major risk for cutaneous infection increased morbidity and mortality in this population in whom medical follow-up is inherently complicated.

Anticoagulation withdrawal in antiphospholipid syndrome: a retrospective matched-control study.

Background/Purpose Long-term anticoagulation is the standard treatment for thrombotic antiphospholipid syndrome (APS). However, in daily practice, the question of withdrawing anticoagulation may arise, without any evidence-based recommendations. This study aimed to assess outcomes in APS patients after anticoagulation withdrawal. Methods Thrombotic APS patients followed in our centre, whose anticoagulation was withdrawn after APS diagnosis, were retrospectively selected, and were match-controlled with patients under anticoagulation, based on sex, age, APS clinical phenotype and disease duration. Results Thirty cases with anticoagulation withdrawal were included. Median follow-up was 51 months (12-124). The risk of thrombotic relapse was higher in cases compared to controls (7.3% versus 1.5% patient-year ( p = 0.01); hazard ratio 4.8; 95% confidence interval (1.4-16.7)). Male gender, anti-ß2GP1 and triple positivity at inclusion were predictive factors for thrombotic relapse. Conversely, aspirin prescription was a protective factor against relapses. Persistence of LA, anti-ß2GP1 and triple positivity over time were associated with a higher risk of thrombosis and aPL disappearance with a lower risk. Conclusion In our study, anticoagulation withdrawal was associated with an increased risk of thrombotic relapse. Our findings emphasize the influence of anti-ß2GP1 and triple positivity persistence over time on the risk of relapse and the benefit of aspirin prescription when anticoagulation has been withdrawn.

Persistent triple antiphospholipid antibody positivity as a strong risk factor of first thrombosis, in a long-term follow-up study of patients without history of thrombosis or obstetrical morbidity.

Introduction The long-term risk of first thrombosis and benefit of prophylaxis in antiphospholipid antibody (aPL) carriers without history of thrombosis or obstetrical morbidity is poorly known. This study aimed to evaluate the long-term rate and risk factors associated with a first thrombosis in those patients. Patients and methods After a prior study ended in December 2005 and was already published, we extended the follow-up period of our cohort of aPL carriers. Results Ninety-eight of the 103 patients of the previous study were included. The annual first thrombosis rate was 2.3% per patient-year during a median of 13 years (6-17). None of the baseline characteristics was predictive of risk of first thrombosis, but persistent aPL over time were associated with an increased risk. The stronger association was found in triple aPL-positive carriers: OR 3.38 (95% CI: 1.24-9.22). Of note, conversely to our previous findings, no benefit of aspirin prophylaxis was observed. Conclusion The risk of first thrombosis in aPL carriers without history of thrombosis or obstetrical morbidity was significant, persisted linearly over time and was associated with persistent aPL. This risk was especially increased in triple aPL-positive carriers, in whom a close follow-up seems to be necessary. Nevertheless, the benefit of aspirin prophylaxis remained unclear.

Long term use of metformin in idiopathic cyclic edema, report of thirteen cases and review of the literature.

INTRODUCTION: Idiopathic cyclic edema (ICE) is a rare cause of edema. To date, there is no standard of care. The physiopathology of ICE could be explained by an impairment of capillary permeability. In 1995, a study demonstrated the efficacy of metformin on symptoms and capillary permeability. We evaluated ICE-patients who were treated with metformin in our department. METHODS: We retrospectively included patients diagnosed for ICE between January 1997 and October 2013. ICE was diagnosed in the presence of edema after excluding other etiologies. LANDIS test was used to support ICE diagnosis in all patients. The absence of edema at follow-up was considered as complete response (CR), partial decreased was considered as partial response (PR). Adverse events were recorded. RESULTS: Thirteen patients have accepted to use metformin. The median treatment duration was 28.5 months [8-167] and the median follow-up of treated patients was 40.5 months [14-167]. CR was reached in 10 patients (77%), and PR in 2 patients (15%). Two patients reported side-effects as diarrheas and one of them stopped the treatment due to mild diarrhea. CONCLUSION: We report the interest and tolerance of the long-term use of metformin in ICE. No severe adverse events were noticed. A prospective study is needed to confirm the efficacy of metformin in ICE-patients.

High neutrophil to lymphocyte ratio measured before starting ipilimumab treatment is associated with reduced overall survival in patients with melanoma.

BACKGROUND: There is an unmet need to identify markers predictive of response to ipilimumab in patients with melanoma because the number of responders to ipilimumab is low and its cost is very high. An increase in absolute lymphocyte count (ALC) or low neutrophil/lymphocyte ratio (NLR) just before the third infusion has been reported to be associated with better overall survival (OS). OBJECTIVES: Our aim was to determine whether NLR measured before the first infusion was associated with OS. PATIENTS AND METHODS: Data were collected on a consecutive series of 58 patients treated with ipilimumab in four hospitals, including 51 at stage M1c and four at stage M1b. The influences of the NLR and other factors such as lactate dehydrogenase (LDH), performance status, ALC, absolute neutrophil count (ANC) and corticosteroids on survival were studied. We also assessed this association with NLR categorized as a binary variable. The cut-off value for the NLR was determined with time-dependent receiver operating characteristic (ROC) analysis. Univariate and multivariate analyses were performed using Cox regression models. RESULTS: High NLR (≥) 4, high ANC LDH levels (>2), performance status ≥2, symptomatic brain metastases, and corticosteroids before week 1 were associated with poorer survival on univariate analysis. Using multivariate analysis, a significant association between high NLR (continuous variable) and poorer survival was demonstrated and remained significant after adjustment on potential confounders [hazard ratio (HR) = 1·21, 95% confidence interval (CI) 1·07-1·36]. NLR ≥4 was an independent prognostic factor (HR = 2·2, 95% CI 1·01-4·78). Intake of corticosteroids before week 1 was not an independent prognostic factor (HR = 1·28, 95% CI 0·54-3·06). CONCLUSIONS: High NLR (≥4) before initiating ipilimumab treatment in patients with metastatic melanoma is an independent prognostic indicator of poor survival.

Metabolic comorbidities and hypertension in psoriasis patients in France. Comparisons with French national databases.

INTRODUCTION: Several studies have shown a high prevalence of cardiovascular and metabolic comorbidities in psoriasis. Our study aimed to evaluate the association of psoriasis with key comorbidities such as smoking, obesity, hypertension, dyslipidaemia and diabetes comparatively with French national data. MATERIAL AND METHODS: This multicentre noninterventional observational study of adults with psoriasis was conducted in 29 dermatology centres in France. A total of 2210 patients were included. The prevalence of comorbidities in psoriatic patients was compared to data from the French national databanks "ObEpi 2012" (obesity, hypertension, dyslipidaemia and diabetes) and "Baromètre Santé 2010" (smoking). RESULTS: We reported a higher prevalence of all metabolic comorbidities and high blood pressure in psoriatic patients. Smoking: 32.5% were active smokers; the age of onset and the prevalence of familial psoriasis were significantly lower in the smoking group but the severity of psoriasis was significantly higher. The frequency of smoking was higher than in the general population, particularly among young female patients. Obesity: 24% of patients with psoriasis were obese. Multivariate analysis showed obesity to be significantly associated with other comorbidities, severity of psoriasis and psoriatic arthritis. The incidence of obesity was higher than in general population, occurring chiefly in subjects aged over 45 years. HYPERTENSION: 26% of patients with psoriasis had hypertension. The age of onset of psoriasis and the prevalence of psoriatic arthritis were significantly higher in the hypertension group, although there was less familial psoriasis. The incidence of hypertension was higher than in general population. Dyslipidaemia: 27.5% of patients with psoriasis had dyslipidaemia. The age of onset in the dyslipidaemia group was higher although there was less familial psoriasis. The incidence of dyslipidaemia was higher than in general population. Diabetes: 11.0% of patients with psoriasis had diabetes. The age of onset of psoriasis was significantly higher in the diabetes group although there was less familial psoriasis. The incidence of diabetes was higher than in general population particularly after the age of 35 years. CONCLUSION: These results confirmed that psoriasis is associated with significant metabolic comorbidities and hypertension compared to the general population in France, with certain epidemiological differences for each.

[Innovative therapy for leg ulcers: Electrostimulation]. / Une thérapie innovante des ulcères de jambe : l'électrostimulation.

Chronic wounds can take a long time to heal despite appropriate therapy based upon aetiology and use of suitable dressings. The success of electrostimulation is based upon the existence within the skin of the endogenous currents involved in the wound healing process. Where skin continuity is broken by a wound, these electrical potentials are short-circuited, resulting in leakage of electrical current. Woundel(®) therapy is the only such treatment currently available in France and is based on the use of continuous pulsed current that generates an electrical field near the endogenous electrical fields. It utilises a console to deliver the electrical impulses, a dressing electrode and a dispersion electrode. The electrode dressing is left on the wound for 3 days, and venous compression bandaging may be applied to the leg, taking care to leave the connector free. Negative polarity stimulates migration of fibroblasts, resulting in elimination of fibrin. Positive polarity causes keratinocyte migration, which in turn leads to epidermisation. Electrostimulation is of recognised utility in the healing of chronic wounds: it has been assigned a high-level recommendation in the European and American guidelines for the treatment of venous ulcers and bedsores with proof level of A. Further, the analgesic effect of electrostimulation has been demonstrated in several studies. Electrostimulation is already well developed in France among wound specialists, but prospective studies are planned so that it may be used at patients' homes.

[Negative pressure therapy: NPT]. / La thérapie à pression négative : la TPN.

Negative pressure therapy or treatment (NPT) is used very frequently in hospitals in both surgical and medical departments. NPT consists of maintaining the wound surface at a pressure below ambient atmospheric pressure by means of a specially designed dressing attached to a depressurisation device as well as a system to drain exudate. NPT has been shown to be beneficial in increasing blood flow, thanks to feedback resulting from the decreased oxygen pressure, angiogenesis and reduction of the wound surface area. The French Health Authority (HAS) has issued recommendations for good use in a specific and limited series of applications. NPT may be used in post-traumatic or post-surgical wounds, burns, and in chronic wounds, such as bedsores and ulcers. It is also effective as an adjuvant treatment for infected wounds. In recent years, various different NPT devices have become commercially available.

[Management of hyperhidrosis]. / Prise en charge d'une hyperhidrose.

Hyperhidrosis continues to be undertreated in our view, despite its propensity to considerably impair quality of life. We shall break down therapeutic approaches to hyperhidrosis into several steps: (a) determine the physiological causes of excess sweating; (b) establish the type of hyperhidrosis involved and screen for causes of secondary hyperhidrosis before diagnosing essential hyperhidrosis; (c) evaluate the severity of the hyperhidrosis by means of a validated scale (HDSS score), Minor's starch-iodine test or gravimetric analysis; (d) select one of the medical therapies currently available, i.e. topical therapy (antiperspirants, iontophoresis or botulinum toxin injection), systemic therapy (oxybutynin) or surgery (thoracic sympathectomy).

[Remote dermatological advice: a survey in three French regions]. / Avis dermatologiques à distance : une enquête interrégionale.

BACKGROUND: General practitioners and specialists often seek advice from dermatologists based on digital pictures. This time-consuming activity is currently not valued nor well-established. We therefore conducted a survey to assess the extent and nature of such requests. PATIENTS AND METHODS: A questionnaire was sent to dermatologists working either at university hospitals or in private practice in three regions of France (Loire Atlantique, Rhone Alpes and Normandy). For two months, the dermatologists completed the same questionnaire for each specialized request. The following items were recorded: status of the dermatologist asked to provide a specialized opinion, region in which the request was made, status of the requesting practitioner, mode of request, type of disease, question asked, time taken to answer the request and result of the specialized advice. RESULTS: Thirty dermatologists, including 11 in private practice, participated in this study. We identified 287 requests. The majority of these requests came from general practitioners (30%) and dermatologists working in private practice (29%). These requests were sent by e-mail using a non-secure professional e-mail address in 49% of cases or via smartphone in 29% of cases. The purpose of the requests was either diagnostic/therapeutic (36%) or solely therapeutic (39%). Relevant requests concerned dermatological manifestations in paediatric or cancer patients (23% and 21% respectively), general dermatological diseases (21%) and wound management (14%). Nearly half of the specialized advice was provided in under 5minutes, and in 60% of cases a consultation with a dermatologist was avoided. CONCLUSION: Despite the small number of physicians taking part in the study, this non-exhaustive survey confirms the usefulness of remote dermatological reviews and consultations, and identifies the main intervening physicians involved in this type of procedure. The study also raises potential medico-legal issues regarding the lack of data security covering medical information. There is thus a need for dermatologists to organize their activity in order to respond to such requests without exposing themselves to medico-legal consequences.

Evaluation of risk factors for body weight increment in psoriatic patients on infliximab: a multicentre, cross-sectional study.

BACKGROUND: A significant weight gain has been reported in patients with psoriasis treated with anti-tumour necrosis factor-alpha agents. Among these patients, there are contradictory results about risk factors for weight gain. OBJECTIVE: Assessing risk factors for weight increment in psoriatic patients on infliximab (IFX). METHODS: This study was a 4-month, non-interventional, cross-sectional, multicentre study on adults with psoriasis performed in 19 French dermatological centres. All the patients who received IFX for at least 1 year were prospectively included, with retrospective analysis of data. Impact of sex, age, severity of the disease, cardiovascular and metabolic comorbidities, and previous and simultaneous systemic treatments on weight changes, was analysed. Weight gain was defined as an increment of more than 2% of baseline weight. RESULTS: Overall, 191 psoriatic patients (males: 68.6%; mean age: 46.9 years) were included. Mean weight gain was 1.6 kg (2.1%) after 1 year of IFX. Half (48.2%) suffered from a weight gain, and 9.9% from a weight increment of 10% or more. Baseline weight and Body Mass Index, and cardiovascular and metabolic comorbidities did not influence weight. Men (P=0.007) and patients with severe psoriasis (BSA, P=0.005) had a tendency to put on weight. Patients with a hospital dietary follow-up (P=0.01; OR=0.36 [0.16-0.79]) and patients on methotrexate (P=0.03; OR=0.41 [0.18-0.93]) during IFX treatment are thinner, in a multivariate analysis. CONCLUSION: Severe weight increment is frequent on IFX treatment, mainly in men, and patients with severe psoriasis. Dietary follow-up or simultaneous use of methotrexate could limit this weight increment.

[Port-wine stains treated by pulsed-dye laser with sedation: A retrospective observational efficacy and safety in 18 children]. / Étude observationnelle rétrospective du traitement des angiomes plans par laser colorant pulsé sous sédation : efficacité et tolérance chez 18 enfants.

BACKGROUND: Pulsed-dye laser (PDL) is the gold standard treatment for port-wine stains but it is painful. To limit pain in small children, sedation may be given. OBJECTIVE: We sought to determine the efficacy of this approach and the risks of sedation, as well as the level of satisfaction of parents. PATIENTS AND METHODS: A retrospective study was conducted in our dermatology department in children treated with PDL while under sedation. The efficacy of treatment was evaluated by comparing pictures of lesions before and after treatment and using a questionnaire sent to the parents. RESULTS: 18 children were included between 2003 and 2011. In all, 111 laser sessions were performed with sedation. Comparison of photographs showed an improvement rate of 6.2/10 (in terms of colour and area). The mean parent satisfaction score was 6.6/10. Adverse events were reported in 27.8 % of children and for 4.5 % of PDL sessions, with one case of severe hypoxemia that resolved without sequelae. DISCUSSION: In our study, PDL for port-wine stains was effective, with good improvement of lesions. Pain was controlled thanks to sedation with one serious adverse event. The parents indicated a positive impression. This study suggests that the procedure may be proposed for small children in order to reduce pain, with a good risk-benefit ratio for sedation. More studies are needed to better qualify pain management for children under PDL treatment.

[T-cell prolymphocytic leukemia: potential diagnostic pitfalls]. / Leucémie prolymphocytaire T : un piège diagnostique à connaître.

BACKGROUND: Sezary syndrome (SS) presents clinically as erythroderma, which may be pigmented, and pruritic, associated with peripheral lymphadenopathies. Erythroderma may also occur in a broad range of reactive and malignant conditions including T-cell prolymphocytic leukemia (T-PLL). We report a case initially diagnosed as SS but ultimately diagnosed as T-PLL based upon skin involvement. CASE REPORT: A 70-year-old man was referred by his hematologist for management of SS. Physical examination revealed lymphadenopathies and mild diffuse erythema without infiltration. His WBC count was elevated at 8.3 G/L. A peripheral blood smear showed Sezary-like cells. Flow cytometry of peripheral blood revealed prolymphocytic T-cells staining positively for CD2, CD3, CD4 and CD7. Cytogenetic studies showed chromosomal abnormalities in terms of number and structure with missing chromosomes 6 and13, as well as deletion of chromosome 17. Finally, a diagnosis of T-PLL was made. Pentostatin was initiated pending treatment with alemtuzumab, but the patient's overall condition deteriorated rapidly and he died 10 days later. DISCUSSION: Diagnosis of LPLT is based upon a number of factors. In the case presented herein, the clinically atypical nature of the skin lesions prompted the dermatologist to review the diagnosis. The morphology of the circulating T-lymphocytes and their immunologic and phenotypic characteristics finally ruled out the diagnosis of Sezary syndrome, while their association with compatible cytogenetic anomalies enabled a diagnosis of prolymphocytic leukemia to be made instead. CONCLUSION: Prolymphocytic leukemia involves complex differential diagnosis with regard to Sezary syndrome, posing potential pitfalls for hematologists and dermatologists.

Genome sequencing identify chromosome 9 inversions disrupting ENG in 2 unrelated HHT families.

Hereditary hemorrhagic telangiectasia (HHT), also known as Rendu-Osler-Weber disease, is a dominant inherited vascular disorder. The clinical diagnosis is based on the Curaçao criteria and pathogenic variants in the ENG and ACVRL1 genes are responsible for most cases of HHT. Four families with a negative targeted gene panel and selected by a multidisciplinary team were selected and whole-genome sequencing was performed according to the recommendations of the French National Plan for Genomic Medicine. Structural variations were confirmed by standard molecular cytogenetic analysis (FISH). In two families with a definite diagnosis of HHT, we identified two different paracentric inversions of chromosome 9, both disrupting the ENG gene. These inversions are considered as pathogenic and causative for the HHT phenotype of the patients. This is the first time structural variations are reported to cause HHT. As such balanced events are often missed by exon-based sequencing (panel, exome), structural variations may be an under-recognized cause of HHT. Genome sequencing for the detection of these events could be suggested for patients with a definite diagnosis of HHT and in whom no causative pathogenic variant was identified.

[HYPNOSTRESS study: Interest of medical hypnosis in the evaluation of perceived stress and the experience of hospitalization in an internal medicine department]. / Étude HYPNOSTRESS : intérêt de l'hypnose médicale dans l'évaluation du stress ressenti et le vécu d'une hospitalisation dans un service de médecine interne.

BACKGROUND: Patients with chronic illnesses, especially rare autoimmune and/or systemic diseases associated with significant diagnostic uncertainty, have a representation of their illness and a sometimes prolonged hospitalization experience that can be traumatic and anxiety-provoking. OBJECTIVE: The aim of this study was to evaluate the impact of a non-medicinal medical hypnosis intervention in reducing the stress state and improving the experience of patients hospitalized in an internal medicine department. METHODS: We conducted a prospective study of 24 patients hospitalized in the Internal Medicine Department of Lille University Hospital in 2023. Twelve patients received a non-drug medical hypnosis intervention known as the "place of safety" (case group) and were compared with 12 patients who did not (control group). Stress was assessed by the STAI questionnaire and hospitalization experience by a satisfaction questionnaire. RESULTS: The 24 patients, 13 of whom were women, had a mean age of 55±17 years at inclusion. On admission to hospital, the median STAI-ETAT between the two groups was 43.5 (38.0; 56.6) in the case group versus 42.0 (37.0; 48.5) in the control group (P=0.45). In the case group, the median STAI-ETAT questionnaire taken immediately after the hypnosis session was significantly lower than at the start of hospitalization (30.0 [25.5; 36.5] vs. 43.5 [38.0; 56.5] P=0.003), indicating a significant reduction in stress. At the end of hospitalization, there was also a significant persistence of the median significant reduction between cases and controls (29.5 [26.5; 35.0] for cases vs. 41.5 [33.5; 45.5] for controls P=0.002). Experience of hospitalization was better in the case group (median 5.0 [4.5; 5.0] vs. 4.0 [4.0; 4.5], P=0.016). CONCLUSION: This study suggests that medical hypnosis is a promising non-medicinal supportive intervention for reducing perceived stress and improving the experience of stress in patients hospitalized on an internal medicine ward.