[On the use of corticosteroids for critically ill patients with SARS-CoV-2 interstitial pneumonia]

The health crisis caused by SARS-Cov2 continues to question the scientific community on an effective treatment to combat the disease. To do this, understanding the pathophysiology is a key element of the research. Although the use of corticosteroids is debated, recent publications on pathogenesis and histologic pattern allow us to consider their use on a different way. Through these two case reports, it seemed interesting to take stock of the most recent data in the literature and on the potential interest of the corticotherapy in specific critically ill patient's cases.

SMILE: a predictive model for Scoring the severity of relapses in MultIple scLErosis

BACKGROUND

In relapsing-remitting multiple sclerosis (RRMS), relapse severity and residual disability are difficult to predict. Nevertheless, this information is crucial both for guiding relapse treatment strategies and for informing patients.

OBJECTIVE

We, therefore, developed and validated a clinical-based model for predicting the risk of residual disability at 6 months post-relapse in MS.

METHODS

We used the data of 186 patients with RRMS collected during the COPOUSEP multicentre trial. The outcome was an increase of ≥ 1 EDSS point 6 months post-relapse treatment. We used logistic regression with LASSO penalization to construct the model, and bootstrap cross-validation to internally validate it. The model was externally validated with an independent retrospective French single-centre cohort of 175 patients.

RESULTS

The predictive factors contained in the model were age > 40 years, shorter disease duration, EDSS increase ≥ 1.5 points at time of relapse, EDSS = 0 before relapse, proprioceptive ataxia, and absence of subjective sensory disorders. Discriminative accuracy was acceptable in both the internal (AUC 0.82, 95% CI [0.73, 0.91]) and external (AUC 0.71, 95% CI [0.62, 0.80]) validations.

CONCLUSION

The predictive model we developed should prove useful for adapting therapeutic strategy of relapse and follow-up to individual patients.

Stage I Melanoma of the Limbs. Immediate versus Delayed Node Dissection

553 patients with stage I malignant melanoma of the limbs entered a prospective randomized clinical trial carried out by the W.H.O. Collaborating Centres for Evaluation of Methods of Diagnosis and Treatment of Melanoma from September 1967 to January 1974. 286 patients were submitted to wide excision of primary and node dissection at the time as appearance of regional lymph node metastases and 267 to wide excision and immediate node dissection. Survival was identical in the 2 groups. Different subsets of patients were evaluated to assess whether some groups of patients may benefit from immediate node dissection. As regards sex, females and a significantly higher survival rate than males (p < 0.05), but results were not improved by immediate node dissection. Maximum diameter and elevation of primary melanoma were significantly related to survival but also in these cases immediate node dissection did not achieve better results. 63 patients had an excisional biopsy of their melanoma within 4 weeks before final treatment. This procedure did not worsen survival and also in this case immediate node dissection did not improve survival. 273 cases were classified according to histologic type: survival of superficial spreading and nodular melanoma was not different at a statistically significant level after the 2 treatment modalities. 325 cases were considered classifiable according to Clark's levels, out of these 165 were submitted to immediate node dissection. Neither level III nor level IV cases showed higher survival rate after immediate node dissection. Maximum tumor thickness according to Breslow was evaluated in 338 cases: 188 were submitted to wide excision and immediate node dissection. In no clusters of thickness did the enlarged surgical procedure achieve better results. The authors conclude that there is good evidence that in stage I melanoma of the extremities delayed dissection is as effective as the immediate one in the control of the disease if the patient can be kept under strict clinical control. Immediate node dissection is advisable if the quarterly follow-up is not guaranteed, at least for melanomas thicker than 2 mm.

Abstract P4-13-02: Exclusive fat grafting breast reconstruction after mastectomy: Aesthetic results, satisfaction and quality of life evaluation on 38 patients

Background: Autologous fat grafting has become a frequent, simply reproducible and low-risk technique in breast reconstruction. The potential risk of fat tissue transfer to the breast for oncologic patients remains to be discussed, but one must clearly distinguish the situation where there is a breast parenchyma left and where the whole gland has been removed, like in our study. Although lipotransfer has become very popular, only a limited number of case series have been reported up to date. The presented study evaluates aesthetic results and quality of life after exclusive fat grafting breast reconstruction.

Patients and methods: A retrospective study was performed in two French centers with five surgeons between February 2011 and June 2015. We included patients with prior breast cancer, treated by mastectomy and with a finished breast reconstruction with exclusive fat grafting. We excluded patients with implant or flap. For each patient, the aesthetic evaluation was threefold, performed by the patient, the surgeon and an extra person, using the same questionnaire. For the analysis of the cosmetic results, the patients, surgeons and the other person were asked to grade the result on a 0 to 10 scale, ranging from "very bad" to "very good". They were questioned about the global esthetic result, symmetry between the two breasts and reconstructed breast texture. Satisfaction was evaluated using a Breast-Q adapted questionnaire, elaborated by psycho-oncologists and surgeons. Quality of life was evaluated using WHOQOL-BREF 26. Statistical analysis was performed using stata 13.1 SE.

Results: We sent a questionnaire to 48 patients and we obtained 38 responses. The mean age of the patients was 52 years, 31 patients (81,6%) lived in couple and 29 patients (76,3%) were employed. We performed 190 fat grafting procedures with an average of 4,2 per patient. The mean total quantity of fat injected was 904 ml per patient with a mean quantity per procedure of 219 ml. The mean time between two procedures was 4,3 months. The average grade obtained for the global esthetic result was 7,3 +/- 1,8 out of 10 for patients, 7,6 +/-2 for the extra person and 7,9 +/- 1,4 for surgeons. For symmetry between the two breasts, the result was 7,1 +/- 1,9 and for the texture, it was 6,8 +/- 2,6. To the question "did the final result meet your expectations?” 81,5% (31/38) of the patients and 79% (30/38) of the surgeons said yes. Among the 29 patients having a professional activity, 86% (25/29) of patients were able to work between each fat grafting session. The handicap evaluation in the professional life for these patients from 0 "no handicap "to 10 " important handicap” showed a score of 2,24 +/-2,7. As for global quality of life evaluation, to the question: "how would you grade your quality of life?" 92,3 % (35/38) of the patients answered "good" or "very good" (vs. 72,0 % in the general population - p = 0.004).

Conclusion: Autologous fat grafting can be offered as a good alternative for total reconstruction after mastectomy with good aesthetic results and no deleterious impact on quality of life.

Citation Format: Bordes V, Simorre M, Campion L, Lejeune F, Loirat Y, Dravet F, Bouffaut A-L. Exclusive fat grafting breast reconstruction after mastectomy: Aesthetic results, satisfaction and quality of life evaluation on 38 patients [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-13-02.

Abstract P3-14-04: Exclusive fat grafting breast reconstruction after mastectomy: Feasibility and complications on 54 patients

Backgrounds: Autologous fat grafting has become a frequent, simply reproducible and low-risk technique in breast reconstruction. The potential risk of fat tissue transfer to the breast in oncologic patients remains to be discussed, but one must clearly distinguish the situation where there is a breast parenchyma left and where the whole gland has been removed, like in our study. Although lipotransfer has become very popular, only a limited number of case series have been reported up to date. The presented study describes an optimized treatment and complications for breast reconstruction after total mastectomy by lipotransfer alone.

Patients and methods: A retrospective study was performed in two French centers with five surgeons between February 2011 and June 2015, including 54 patients. Inclusion criteria were patients with prior breast cancer, treated by mastectomy and with a finished breast reconstruction with exclusive fat grafting. Exclusion criteria were prior reconstruction with implant or flap. We used two technics for liposuction: manual aspiration with syringes (pouret kit®) or waterjet assisted liposuction (body-jet®). The BRAVA® could be combined with the reconstruction. Our study had 2 main objectives: evaluate the factors influencing the number of surgical procedures and study the complications and carcinologic evolution. Statistical analysis was performed using stata 13.1 SE.

Results: We included 54 patients, 49 delayed reconstructions including two bilateral reconstructions and 5 immediate reconstructions. The morphologic data showed: a normal BMI for 70,3 % (38/54) patients and a bra cup A or B for 72,2 % (39/54). 39 patients had radiotherapy during the cancer treatment and the mean time between radiotherapy and reconstruction was 19 months. For the patients without radiotherapy, the mean time between mastectomy and reconstruction was 22 months. 6 patients (11%) were smoker or diabetic. We used manual aspiration in 37 patients (68,5 %) and hydro dissection in 17 patients (31,5%). 10 patients received BRAVA system in complement. We performed 231 fat grafting procedures with an average of 4,2 per patient. The mean total quantity of fat injected was 904 ml per patient with a mean quantity per procedure of 219 ml. The mean time between two procedures was 4,3 months. Only the prior radiotherapy treatment increases the number of fat grafting procedures significantly (p=0,02) and the use of hydro dissection with bodyjet decreases the number of fat grafting procedures significantly (p=0,04). We observed one failure of procedure requiring an implant and three patients with metastatic disease without local recurrence with a mean follow of 5, 2 years. We also observed 3% of infectious complications (7/231) and 19 patients presented fat necrosis (34%). Of these 19 cases of fat necrosis, 6 (11 %) required a surgery.

Conclusion: Autologous fat grafting can be proposed as an alternative for total reconstruction after mastectomy with a low level of complications and no local recurrence in our study. Only anterior radiotherapy increases the number of procedures probably due to fibrosis and lack of cutaneous flexibility.

Citation Format: Bordes V, Campion L, Lejeune F, Loirat Y, Boiffard F, Brillaud-Meflah V, Dravet F, Bouffaut A-L. Exclusive fat grafting breast reconstruction after mastectomy: Feasibility and complications on 54 patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-14-04.

Caspases shutdown nonsense-mediated mRNA decay during apoptosis

Nonsense-mediated mRNA decay (NMD) is an mRNA surveillance mechanism that plays integral roles in eliminating mRNAs with premature termination codons to prevent the synthesis of truncated proteins that could be pathogenic. One response to the accumulation of detrimental proteins is apoptosis, which involves the activation of enzymatic pathways leading to protein and nucleic acid cleavage and culminating in cell death. It is not clear whether NMD is required to ensure the accurate expression of apoptosis genes or is no longer necessary since cytotoxic proteins are not an issue during cell death. The present study shows that caspases cleave the two NMD factors UPF1 and UPF2 during apoptosis impairing NMD. Our results demonstrate a new regulatory pathway for NMD that occurs during apoptosis and provide evidence for role of the UPF cleaved fragments in apoptosis and NMD inhibition.

[Development of executive functions in preterm children]

The rate of children born prematurely has increased considerably in the last few decades, and their developmental outcome remains of great concern. The literature on the impact of prematurity has reported a wide range of cognitive and behavioral problems that may be related to deficits in executive function (EF) skills. EF refers to a series of high-level processes (selective attention, inhibition, set shifting, working memory, planning, goal setting) that develop throughout childhood and adolescence and play an important role in cognitive and social development as well as in school achievement. EF skills have been linked to the prefrontal cortex, as well as to other neural networks and brain regions including the basal ganglia and cerebellum. This paper focuses on studies related to the development of EF and social behavior in children born preterm. The preschool period is a critical time to perform neuropsychological assessment in addition to IQ testing, and to detect the child's specific needs in order to adapt effective intervention to enhance the development of executive processes in these high-risk children.

[Eyebrow reconstruction]

The eyebrow is an essential anatomical area, from a social point of view, so its reconstruction, in case of skin defect, must be as meticulous as possible, with the less residual sequela. Capillary density extremely varies from one person to another and the different methods of restoration of this area should absolutely take this into consideration. We are going to review the various techniques of reconstruction, according to the sex and the surface to cover.

Surgical management of melanoma: an EORTC Melanoma Group survey

Objectives:

The objective of the article is to explore the surgical practices and views in the treatment of melanoma within members and non-members of the EORTC Melanoma Group (MG) during the years 2003–2005.

Methods:

An e-mail questionnaire (see appendix) developed within the EORTC MG was sent to all melanoma units (MUs) of the EORTC (180) and to selected international centres between 2003 and 2005. The questionnaire investigated the different practices regarding surgical management of melanoma patients at all stages.

Results:

A total of 75 questionnaires were returned from centres in Europe (70), Israel (3), Australia (1) and the United States (1). Resection margins on primary melanoma vary according to AJCC 2002 staging. Sixty three of 75 MUs perform Sentinel node biopsy. Modified radical neck dissection is performed in 82% of MUs for macrometastases and in 80% of MUs for micrometastases. Most MUs surveyed perform all three levels of Berg axillary dissection whether for macrometastases (79%) or micrometastases (62%). An ilio inguinal-obturator dissection is proposed with macrometastases (41% of MUs), whereas 33% of MUs perform a pelvic dissection only if the Cloquet node is positive. Twenty five of 75 MUs perform an isolated limb perfusion with a therapeutic indication; three also as an adjuvant. The majority of MUs perform surgery for distant metastases including superficial (53 of 75 [71%]) or solitary visceral metastases (52 of 75[69%]) or for palliation (58 of 75[77%]).

Conclusion:

The adequacy of surgery appears to be the most important milestone in the therapeutic approach of melanoma. Even if surgery is fundamental in the different stages of the disease, there is quite a variability concerning the extension of the surgical treatment related to primary and lymphnodal disease. Phase III randomised trials have shown that wide margins, elective lymph node dissections, and prophylactic isolated limb perfusions have not improved survival and cannot be considered the standard of care in the routine management of primary melanoma. The surgical subgroup of the EORTC Melanoma Group is developing a new version of the surgical survey questionnaire including new treatment modalities like isolated limb infusion and electrochemotherapy, which were not frequently in use some years ago, to obtain new data to be compared to the nearly ten-year-old data.

Regional administration of recombinant tumour necrosis factor-alpha in cancer, with special reference to melanoma

Recombinant tumour necrosis factor-alpha (rTNFalpha) possesses the unique property of activating and selectively destroying the tumour-associated microvasculature. Systemic application of rTNFalpha has shown that the maximum tolerated dose (MTD) is 10 times lower than the efficient dose in animals. The main toxicity corresponds to the systemic inflammatory response syndrome (SIRS), with a decrease of vascular resistance and hypotension. We found that it is possible to administer rTNFalpha at 10 times the MTD in an isolated limb perfusion system, using a heart-lung machine, for advanced melanoma and sarcoma of the limbs. Our results, using the combination of high dose rTNFalpha, interferon-gamma and melphalan (TIM), produced an overall objective response rate of 100% in 2 successive studies on melanoma, with 90% and 78% complete response, respectively. In sarcoma, there was an overall response rate of 64%, with 36% complete response. Angiographic and immunohistological studies demonstrated selective and early damage of the tumour-associated microvasculature, preceded by upregulation of adhesion molecules and intratumoural leak of von Willebrand factor. Tumour invasion by platelets and, in some cases, by polymorphonuclear cells, appeared within hours after the application of rTNFalpha, long before the lysis of the tumour. Systemic changes after rTNFalpha treatment included the production of soluble TNFalpha receptors and of interleukin-6. A typical acute phase reaction was observed within 3 days, with increase of C-reactive protein parallelled by an increase of tenascin-C. A selective effect on intratumoural endothelial cells seems to be involved in the mechanism of the impressive antitumour effect of rTNFalpha, but the role of acute phase protein production is not fully understood. In selected cases of melanoma, specific cytotoxic T lymphocytes were increased after perfusion.

Depression and Bipolar Disorder: Is Prevention of Mania Possible? Critical Issues on Diagnostic Criteria

Diagnostic criteria for bipolar disorder in DSM IV require the occurrence of a manic or hypomanic episode. The scant appropriateness of these criteria compared with Kraepelin"s concept of manic depressive insanity has been repeatedly reported and the concept of bipolar spectrum has been proposed for more than 30 years. The negative consequences of pure adherence to operational diagnostic criteria on clinical needs are presented in terms of community epidemiology results and in terms of clinical evidences and the inadequate treatment of depressive and anxiety episodes and the risk of manic switch with antidepressant drugs are discussed.

The epidemiological survey conducted in Sesto Fiorentino showed that depressive episodes in patients with subthreshold mania or hypomania were different from the clinical presentation of pure unipolar depressives episodes confirming not only the numeric impact but also qualitative differences between these groups of patients.

Our clinical study where predictors of mania have been prospectively evaluated in a trans nosographic sample of outpatients demonstrated that aspects related to bipolarity predicted manic shift regardless of the diagnosis. DSM IV criteria seem not to be able to detect and describe a group of patients relevant both on epidemiological and on clinical level. These findings underline the need of a careful examination of patients treatment and validate the rule of further research in definition of mood disorders boundaries for prevention strategies.