B. Granel

Safety, tolerability and potential efficacy of injection of autologous adipose-derived stromal vascular fraction in the fingers of patients with systemic sclerosis: an open-label phase I trial

Background In patients with systemic sclerosis (scleroderma, SSc), impaired hand function greatly contributes to disability and reduced quality of life, and is insufficiently relieved by currently available therapies. Adipose tissue-derived stromal vascular fraction (SVF) is increasingly recognised as an easily accessible source of regenerative cells with therapeutic potential in ischaemic or autoimmune diseases. We aimed to measure for the first time the safety, tolerability and potential efficacy of autologous SVF cells local injections in patients with SSc with hand disability. Methods We did an open-label, single arm, at one study site with 6-month follow-up among 12 female SSc patients with Cochin Hand Function Scale score >20/90. Autologous SVF was obtained from lipoaspirates, using an automated processing system, and subsequently injected into the subcutaneous tissue of each finger in contact with neurovascular pedicles. Primary outcome was the number and the severity of adverse events related to SVF-based therapy. Secondary endpoints were changes in hand disability and fibrosis, vascular manifestations, pain and quality of life from baseline to 2 and 6 months after cell therapy. Findings All enrolled patients had surgery, and there were no dropouts or patients lost to follow-up. No severe adverse events occurred during the procedure and follow-up. Four minor adverse events were reported and resolved spontaneously. A significant improvement in hand disability and pain, Raynauds phenomenon, finger oedema and quality of life was observed. Interpretation This study outlines the safety of the autologous SVF cells injection in the hands of patients with SSc. Preliminary assessments at 6 months suggest potential efficacy needing confirmation in a randomised placebo-controlled trial on a larger population. Funding GFRS (Groupe Francophone de Recherche sur la Sclérodermie). Clinical Trials number NCT01813279.

Male microchimerism and HLA compatibility in French women with sclerodema: a different profile in limited and diffuse subset

OBJECTIVES Male microchimerism (Mc) persisting from pregnancy has been found at greater frequencies and/or higher quantities in women with scleroderma (SSc) compared with controls, suggesting a possible role in disease development. Moreover, women with an HLA-compatible child have a higher risk to develop SSc. We tested the hypothesis, on our French SSc cohort, that women with lcSSc and dcSSc, two distinct clinical subsets, have a different profile in terms of Mc and HLA compatibility in families. METHODS We studied 98 women (52 lcSSc and 46 dcSSc) for male Mc, by real-time PCR, in their whole blood and/or peripheral blood mononuclear cells (PBMC). Similarly, 91 matched healthy women were analysed. Complete HLA-DRB1 typing was obtained for 58 SSc and 68 control families (proband/children). RESULTS Women with lcSSc (N = 50) had male Mc more often in their whole blood than women with dcSSc (N = 40, 20 vs 5%, P = 0.038), but not significantly more than controls. By contrast, women with dcSSc (N = 36) hold Mc more often in PBMC (25 vs 9%), but not significantly and have greater quantities than controls (N = 82, P = 0.048). This contrast is also visible in feto-maternal HLA-DRB1 compatibility, which was increased only among women with lcSSc (N = 33) compared with controls (N = 68, P = 0.003). CONCLUSION For the first time, we showed that women with lcSSc and dcSSc hold male Mc in different blood compartments. Furthermore, a distinct pattern between the two SSc subtypes is observed for feto-maternal HLA-DRB1 compatibility. These results suggest a different mechanism behind each type of disease.

Autologous adipose-derived stromal vascular fraction in patients with systemic sclerosis: 12-month follow-up

OBJECTIVE Impaired hand function greatly contributes to disability and reduced quality of life in SSc patients. Autologous adipose-derived stromal vascular fraction (ADSVF) is recognized as an easily accessible source of regenerative cells. We reported positive 6-month safety and efficacy results from an open-label clinical trial assessing s.c. injection of autologous ADSVF into the fingers in SSc patients. The objective of this report is to describe the effects at 12 months. METHODS Twelve females, mean age 54.5 years (s.d. 10.3), were assessed 1 year after ADSVF injection. Patients were eligible if they had a Cochin Hand Function Scale score >20/90. ADSVF was obtained from lipoaspirate using an automated processing system and subsequently injected into the s.c. tissue of each finger in contact with neurovascular pedicles in a one-time procedure. Endpoints were changes in hand disability and skin fibrosis, vascular manifestations, pain and quality of life at the 12 month follow-up. During the visit, patients estimated the benefit of the procedure with a specific self-completed questionnaire. RESULTS A significant decrease from baseline of 51.3% (P < 0.001) for Cochin Hand Function Scale score, 63.2% (P < 0.001) for RP severity and 46.8% (P = 0.001) for quality of life (Scleroderma Health Assessment Questionnaire) was observed. A significant improvement of finger oedema, skin sclerosis, motion and strength of the hands and of the vascular suppression score was also noted. The reduction in hand pain approached statistical significance (P = 0.052). The questionnaire revealed a benefit in daily activities, housework and social activities. CONCLUSION ADSVF injection is a promising therapy and appears to have benefits that extend for at least 1 year.

New fat-derived products for treating skin-induced lesions of scleroderma in nude mice

IntroductionScleroderma is characterized by cutaneous manifestations that mainly affect the hands, arms and face. As of today, there is no treatment for fibrotic skin lesions of scleroderma. Previously we generated and validated a model of scleroderma-like skin sclerosis in nude mice, appropriate to inject human derived products. We showed that the subcutaneous injection of micro-fat (MF), purified and injected using small caliber cannulas, have anti-fibrotic and pro-angiogenic effects and appears more suitable for the treatment of skin lesions of scleroderma compared to the gold standard (Coleman’s technique or macro-fat). Here we compared the long-term efficacy of micro-fat “enriched” with other therapeutic products including the stromal vascular fraction (SVF) of fat and platelet-rich plasma (PRP) from blood in our murine model of scleroderma.MethodsWe used 72 nude mice in this study. We formed six experimental groups: Macro-fat, MF, SVF, PRP, MF + SVF, MF + PRP. This project has three phases: i) Induction of skin sclerosis by daily subcutaneous injections of bleomycin (BLM) for 4 weeks in nude mice; ii) Purification and injection of the different cell therapy products; iii) Histological analyses done 8 weeks post-injections.ResultsMF + SVF and MF + PRP significantly reversed dermal and epidermal sclerosis (P <0.01). Macro-fat, SVF, PRP only corrected the dermal sclerosis (P <0.05). Epidermal sclerosis was reduced in treatments containing MF (P <0.01). MF was more stable. Products containing the SVF were associated with a significant increase of the local vascularization (P <0.01).ConclusionsAll tested substances were effective in treating skin-induced lesions of scleroderma with different levels of fibrosis and vascular improvement; MF derived products are more stable and SVF demonstrated better pro-angiogenic effects. The observed efficacy of this combination of products in the animal model provides a rationale for potential clinical applications to treat human disease.

Genetic susceptibility to systemic sclerosis from clinical aspect to genetic factor analyses.

BACKGROUND Systemic sclerosis is a rare autoimmune disease mainly characterized by vascular alteration and fibrosis involving skin but also visceral organs such as lungs, digestive tract, and heart. This disease leads to high morbidity and mortality. Its pathogenesis remains unclear, but recent attention has focus on genetic factors. OBJECTIVE We first recall the main manifestations associated with systemic sclerosis and leading to its diagnosis and prognosis. Then we propose an overview on human genetics studies, as a number of genetic loci have been identified that appear to be associated with the disease. METHODS Articles concerning association studies with candidate genes encoding for extracellular matrix proteins, cytokines, growth factors, chemokines, and proteins involved in vascular tone and immune regulations are presented and discussed. RESULTS/CONCLUSION Systemic sclerosis is a multigenic complex disorder. Genetic associations are observed in distinct phenotypes such as the diffuse cutaneous form or the limited form, or in association with specific autoantibody pattern. Promising candidate genes are those involved in pathways that lead to the vascular damage and fibrosis. A better knowledge of crucial mediators involved in systemic sclerosis could in the future provide new therapeutic strategies to control the disease.

Potentialités et intérêt du tissu adipeux dans la sclérodermie

Systemic sclerosis is a disorder involving the connective tissue, arterioles and microvessels. It is characterized by skin and visceral fibrosis and ischemic phenomena. Currently, therapy is limited and no antifibrotic treatment has proven its efficacy. Beyond some severe organ lesions (pulmonary arterial hypertension, pulmonary fibrosis, scleroderma renal crisis), which only concern a minority of patients, the skin sclerosis of hands and face and the vasculopathy lead to physical and psychological disability in most patients. Thus, functional improvement of hand motion and face represents a priority for patient therapy. Due to its easy obtention by fat lipopaspirate and adipocytes survival, re injection of adipose tissue is a common therapy used in plastic surgery for its voluming effect. Identification and characterization of the adipose tissue-derived stroma vascular fraction, mainly including mesenchymal stem cells, have revolutionized the science showing that adipose tissue is a valuable source of multipotent stem cells, able to migrate to site of injury and to differentiate according to the receiver tissues needs. Due to easy harvest by liposuction, its abundance in mesenchymal cells far higher that the bone marrow, and stroma vascular fractions ability to differentiate and secrete growth angiogenic and antiapoptotic factors, the use of adipose tissue is becoming more attractive in regenerative medicine. We here present the interest of adipose tissue use in the treatment of the hands and face in scleroderma.

Combined PRP and microfat graft for facial disability in systemic sclerosis

Introduction Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibrosis and microvascular damage. Facial signs are frequent and include perioral skin thickening, facial atrophy and microstomia. Facial handicap is overlooked by physicians but when patients are questioned, they frequently declare discomfort and distress due to their facial disability and appearance. As ideal autologous filler, fat graft has previously been considered in the treatment of facial handicap in SSc. To enhance fat graft survival, we combined fat graft and autologous platelet-rich plasma. Cases Description Two patients suffering from SSc with facial disability, facial skin thickening and aesthetic discomfort were treated with combined subcutaneous microinjection of autologous fat and platelet-rich plasma. Conclusions Regular follow-up until 12 months showed that facial disability decreased, skin texture appeared softer, and mouth opening increased. Patients declared to be very satisfied from a functional and aesthetic point of view until their last follow-up at 12 months. Fat grafting is beneficial in the improvement of facial symptoms of patients with SSc, and the addition of platelet-rich plasma is a feasible, simple and safe method. Further studies are required to better assess the advantage on fat graft retention, trophicity and the lasting effect offered by this combined therapy.

ImageDouleur thoracique brutale après vomissementsSudden thoracic pain after vomiting efforts

Une femme, âgée de 18 ans, sans antécédent, consultait en rgence pour une douleur thoracique de survenue brutale au écours d’un effort de vomissement. Depuis trois jours, elle préentait une douleur abdominale, des vomissements profus (jusqu’à 0 fois par jour) et une diarrhée liquidienne sans fièvre. À l’examen linique, elle était apyrétique et avait des constantes hémoynamiques normales. Il existait un emphysème sous-cutanée xillaire gauche, sus-claviculaire, pectoral et cervical. À la palation, l’abdomen était sensible dans son ensemble. Le reste de ’examen clinique était sans particularité. La biologie montrait : gloules blancs à 31 G/L, polynucléaires neutrophiles à 29 G/L, protéine -réactive supérieure à 360 mg/L (N < 10) et fibrinogène à 7,7 g/L N < 4). L’ionogramme, la fonction rénale et le bilan hépatique taient normaux. Les bêta-HCG étaient négatives. Un diagnostic tait suspecté cliniquement et sur la radiographie thoracique, onfirmé en urgence par un scanner thoracique (Fig. 1).

Douleur thoracique brutale après vomissements

Une femme, âgée de 18 ans, sans antécédent, consultait en rgence pour une douleur thoracique de survenue brutale au écours d’un effort de vomissement. Depuis trois jours, elle préentait une douleur abdominale, des vomissements profus (jusqu’à 0 fois par jour) et une diarrhée liquidienne sans fièvre. À l’examen linique, elle était apyrétique et avait des constantes hémoynamiques normales. Il existait un emphysème sous-cutanée xillaire gauche, sus-claviculaire, pectoral et cervical. À la palation, l’abdomen était sensible dans son ensemble. Le reste de ’examen clinique était sans particularité. La biologie montrait : gloules blancs à 31 G/L, polynucléaires neutrophiles à 29 G/L, protéine -réactive supérieure à 360 mg/L (N < 10) et fibrinogène à 7,7 g/L N < 4). L’ionogramme, la fonction rénale et le bilan hépatique taient normaux. Les bêta-HCG étaient négatives. Un diagnostic tait suspecté cliniquement et sur la radiographie thoracique, onfirmé en urgence par un scanner thoracique (Fig. 1).

Une cause rare d’accident vasculaire cérébral

Un homme, âgé de 66 ans, consultait aux urgences pour une aisse de l’acuité visuelle brutale bilatérale au réveil accompagnée ’une diplopie et d’un flou visuel. Il se plaignait également d’un rouble de l’équilibre à la marche, d’une paralysie faciale inférieure auche et d’une intense asthénie. Il avait présenté cinq jours aupaavant un épisode aigu régressif en quelques minutes caractérisé ar une ataxie et un flou visuel. Ses facteurs de risque cardiovasulaires étaient une hypertension artérielle, une dyslipidémie, un iabète de type 2 et un tabagisme actif à 40 paquets-années. Le raitement d’entrée comprenait : metformine 1700 mg par jour, glilazide 60 mg par jour, ramipril 5 mg par jour, simvastatine 20 mg ar jour et paroxétine 10 mg par jour. L’examen clinique retrouvait une pression artérielle à 00/70 mmHg, un pouls à 66 battements par minute, sans fièvre. es bruits du cœur étaient réguliers, sans souffle. On notait une émiparésie droite cotée à 4/5, une paralysie faciale gauche cenrale, une paralysie bilatérale de la verticalité du regard (syndrome e Parinaud), une marche ataxique sans déficit proprioceptif ni yndrome cérébelleux. L’hémogramme, l’ionogramme, la fonction