M. Samson

Long-term follow-up of a randomized trial on 118 patients with polyarteritis nodosa or microscopic polyangiitis without poor-prognosis factors

The purpose of this study was to assess the long-term outcomes of patients with polyarteritis nodosa (PAN) or microscopic polyangiitis (MPA) without Five-Factor Score (FFS)-defined poor-prognosis factors (FFS=0) and enrolled in a prospective clinical trial. Patients were followed (2005-2012) under routine clinical care in an extended study and data were recorded prospectively. Long-term survival, disease-free survival (DFS), relapses, therapeutic responses and sequelae were analyzed. Mean±SD follow-up was 98.2±41.9months. After having initially received glucocorticoids (GC) alone, according to the study protocol, 82% (97/118) patients achieved remission but 18% (21/118) required ≥1 immunosuppressant(s) (IS) before 19/21 achieved remission. Two patients died before entering remission. After remission, 53% (61/116) patients relapsed 25.6±27.9months after starting treatment. The 5- and 8-year overall survival rates were 93% and 86%, respectively, with no difference between PAN and MPA, and between relapsers and nonrelapsers. DFS was shorter for MPA than PAN patients (P=0.02). Throughout follow-up, 47% of patients required ≥1 IS. At the last follow-up visit, 44% were still taking GC and 15% IS. The mean vasculitis damage index score was 1.9±1.9; the most frequent sequelae were peripheral neuropathy, hypertension and osteoporosis. For PAN or MPA patients without poor-prognosis factors at diagnosis and treated initially with GC alone, long-term survival was excellent. However, relapses remained frequent, requiring IS introduction for nearly half of the patients. To lower the frequencies of relapses and sequelae remains a challenge for FFS=0 PAN and MPA patients.

Mononeuritis multiplex predicts the need for immunosuppressive or immunomodulatory drugs for EGPA, PAN and MPA patients without poor-prognosis factors.

Patients with eosinophilic granulomatosis with polyangiitis (Churg-Strauss) (EGPA), non-HBV polyarteritis nodosa (PAN) or microscopic polyangiitis (MPA) without Five-Factor Score (FFS=0)-defined poor-prognosis factors were included in two prospective randomized-controlled trials and were initially treated with corticosteroids (CS) alone. Because some patients required subsequent add-on therapies, inclusion characteristics associated with their use were sought. Add-on treatments (cytotoxic agents, biotherapies, intravenous immunoglobulins and plasma exchanges) were subjected to univariate and multivariate analyses. The study included 193 patients (75 EGPA, 61 MPA and 57 PAN). Mean±SD follow-up was 97.6±39.6months. Subsequent add-on treatment(s) were required for 86/193 patients (24 PAN, 32 MPA and 30 EGPA) because of CS failure (37%), relapse (52%) or CS dependence (10%). Seven-year overall survival reached 90% and was comparable for patients given 0 vs ≥1 add-on therapies (P=0.564). However, the mean Vasculitis Damage Index was significantly higher for the latter: 2.93 vs 1.96 (P<0.001), reflecting more frequent sequelae. Initial mononeuritis multiplex was the only factor significantly associated with add-on therapy requirement in univariate (P=0.008) and multivariate analyses (hazard ratio=1.81 [95% CI: 1.12-2.93]; P=0.02). Although FFS=0 predicts good and comparable overall survival of EGPA, PAN or MPA patients, 45% of them required adjunctive treatments for relapse, CS failure or corticodependence, with most having more frequent initial mononeuritis multiplex and sequelae. These findings support prospective evaluation of initial immunosuppressant use combined with CS to prevent treatment failure, relapses and sequelae in FFS=0 patients with mononeuritis multiplex at diagnosis.

État des lieux de l’enseignement théorique et pratique de 3e cycle de médecine interne en France : résultats d’une enquête nationale

OBJECTIVE To make an inventory of training of Internal Medicine in France. METHOD This study was conducted between May and September 2015 with coordinators (interviews of 45minutes) of local Internal Medicine training and fellows (online questionnaire). RESULTS All coordinators (n=28) responded to the interviews. Local training of Internal Medicine exists in 86% of regions (3.1±3.1hours/month) and an interregional training in all interregions (34.7±13.9hours/year). When excluding Île-de-France, no correlation between the number of teachers and the amount of lessons was noted (P=0.61). Of the 550 fellows in Internal Medicine in 2014-2015, 223 (41%) responded to the online questionnaire. Mean level was 5.5±2.7 semesters. The rate of satisfaction (1=very dissatisfied and 5=very satisfied) was 3.0±1.0 and 3.8±0.8 for regional and interregional teaching, respectively (P<0.0001). Regional teaching satisfaction was correlated with the perceived expanse of diseases covered into the program (P<0.0001). In addition, 89% of fellows wish to evaluate themselves online, 66% wish to have a practical evaluation at the bedside and 70% in simulation centers. Finally, 91% of fellows support the establishment of a national program for the training of Internal Medicine. CONCLUSION This survey states for the first time an inventory of training of Internal Medicine dedicated to fellows in France. This report highlights that fellows wish to have a national program, be further evaluated and have access to more interactive approach of teaching.