[Molecular diagnosis of human papillomaviruses (HPV): What test(s) in clinical practice?]

Prescription of an HPV test in practice will enable the clinician to optimize the monitoring and the management of patients, especially in the context of cervical cancer screening. Numerous HPV tests are available that present different analytical and clinical sensitivity and specificity. International recommendations on clinical performance of HPV tests used for cervical cancer screening have been published by a group of experts, and tests that meet these performance criteria should be used. Apart from the HPV detection kit, the whole circuit from sampling to report of the results must be considered. This implies that the pre-analytical (sampling, quality of sample collection medium, storage condition and sample transportation…) and post-analytical steps (quality of result reporting, providing expert advices…) are also standardized. For this purpose, medical-biology laboratories are subjected to a COFRAC certification, as defined by the international standard ISO 15189 providing quality criteria for any clinical laboratory test and HPV test in particular.

Benzodiazepine dependence in subjects with alcohol use disorders: what prevalence?

OBJECTIVE

To our knowledge, no studies have been conducted in France on benzodiazepine (BZD) dependence among outpatients with alcohol use disorders (AUD). Some international studies have been conducted on the consumption of BZD in this specific population, but the comparisons among them are difficult. We aimed to assess the current prevalence of probable benzodiazepine and BZD-like hypnotics (Z-drugs) dependence among outpatients seeking treatment for AUD.

METHODS

Participants were patients seeking treatment for AUD for the first time or repeating treatment after more than twelve months. Recruitment took place in seven addiction centres between January and December 2013 in the Nantes region (France). BZD/Z-drug dependence was assessed according to the DSM-IV diagnostic criteria for dependence. This information was gathered through a self-report questionnaire.

RESULTS

Among the 1005 patients included in this study, 413 were BZD/Z-drug users (41.1%). Among the 413 patients, 217 were probably dependent on at least one substance, which represents 21.6% of the total population and 52.5% of BZD/Z-drug users.

CONCLUSION

BZD/Z-drug dependence represents a public health concern. Prescribers should take the risks into account and keep treatment courses to a minimum.

Correlates of cocaine use during methadone treatment: implications for screening and clinical management (ANRS Methaville study)

Background

Cocaine use is frequent in patients receiving methadone maintenance treatment (MMT) and can jeopardize their treatment response. Identifying clinical predictors of cocaine use during methadone treatment can potentially improve clinical management. We used longitudinal data from the ANRS Methaville trial both to describe self-reported occasional and regular cocaine use during MMT and to identify clinical predictors.

Methods

We selected 183 patients who had data on cocaine (or crack) use at months 0 (M0), M6, and/or M12, accounting for 483 visits. The outcome was “cocaine use” in three categories: “no,” “occasional,” and “regular” use. To identify factors associated with the outcome over time, we performed a mixed multinomial logistic regression.

Results

Time on methadone was significantly associated with a decrease in occasional but not in regular cocaine use from 14.7 % at M0 to 7.1 % at M12, and from 10.7 % at baseline to 6.5 % at M12, respectively. After multiple adjustments, opiate injection, individuals screening positive for attention deficit hyperactivity disorder (ADHD) symptoms, and those presenting depressive symptoms were more likely to regularly use cocaine.

Conclusions

Although time on MMT had a positive impact on occasional cocaine use, it had no impact on regular cocaine use. Moreover, regular cocaine users were more likely to report opiate injection and to present ADHD and depressive symptoms. Early screening of these disorders and prompt tailored pharmacological and behavioral interventions can potentially reduce cocaine use and improve response to MMT.

Trial registration

The trial is registered with the French Agency of Pharmaceutical Products (AFSSAPS) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials, number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397, and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.

131 RETROSPECTIVE DATA ANALYSIS OF HOLSTEIN HEIFER GROWTH IN EMBRYO PRODUCTION CENTERS

The reduction of the generation gap has become of main interest in the race for the genetic improvement of cattle and in reducing the environmental impact of dairy farms. Sexual precocity of high genetic merit heifers is therefore essential, as it allows the development of their potential as soon as possible thanks to embryo collection. Many factors influence the sexual precocity and embryos production of bovine females. A major effect of the calves’ growth rate has often been observed on puberty precocity in experimental trials. This study was carried out on data recorded from January 2010 to May 2015 on 617 Holstein heifers housed in 2 centers of embryos production with similar breeding conditions in France. The purpose was to find optimal breeding values of Holstein heifers for embryo production in these centers. The heifers entered at the centers between 4 to 15 months old (after a quarantine of 30 days) to produce in vivo embryos during 2 to 4 collections before to come back pregnant to their breeder owner. The first treatment of superovulation was programmed when a first heat was observed visually or via an activity sensor (Heatime R) or when a corpus luteum had been detected (ultrasound scans). The studied variables were the date of the first flushing as a precocity indicator and the collection results for the production of embryos (numbers of total and viable embryos). In this population, the average age at entry was 8.5 ± 2.3 months old (minimum = 3.4; maximum = 15.0), the average age at the first collection 14.3 ± 1.2 months (minimum = 11.0; maximum = 19.0), the average daily gain (ADG) between 0 and 12 months was 792 ± 86 g day–1 (minimum = 492; maximum = 1027), the average number of total structures by collection 9.3 ± 6.1, the mean number of viable embryos 5.5 ± 3.8. Data analysis by multivariate ANOVA test showed an effect on age at first collection for the center (P = 0.009), age at entry (P < 0.001), and ADG between 0 and 12 months (P < 0.001). Heifers with ADG between 0 and 12 months of <650 g day–1 had a delay of 70 days for the first collection compared to those with an ADG of >900 g day–1. The ADG between 0 and 12 months had also the strongest negative correlation found with the age at first collection (r = 0.52). Similarly, ADG between 0 and 6 months of the 40 heifers entered in the centers before the age of 6 months was significant for age at the first collection (P = 0.0001), whereas ADG between 6 and 12 months was not. Regarding the production of embryos, only the weight at the first collection tended (P = 0.07) to have an effect on the total number of collected structures: 10.1 ± 6.5 for heifers that weighted more than 420 kg v. 7.3 ± 4.0 for those that weighted less than 340 kg. No effect on the percentage of grade 1 or 2 embryos could be observed. In conclusion, this study conducted in production conditions confirmed the observations made in experimental trials and refined the recommendations and practices of the two centers to reduce the age at first embryo flushing.

Significant effect of VEGFA polymorphisms on the clinical outcome of metastatic colorectal cancer patients treated with FOLFIRI-cetuximab

AIM

The efficacy of a cetuximab-based regimen used to treat metastatic colorectal cancer (mCRC) could be influenced by VEGFA polymorphisms.

MATERIALS & METHODS

We studied the effects of five polymorphisms in the VEGFA gene (-2549D/I, -1154G/A, -460T/C, +405G/C and +936C/T) on the outcome of 98 mCRC patients treated with FOLFIRI plus cetuximab.

RESULTS

Patients homozygous for the -2549D, -1154G and -460T alleles did exhibit higher response rates to treatment and longer progression-free survival compared with others. In addition, the DGTGC and IGCGC haplotypes were significantly associated with a lower risk of disease progression.

CONCLUSION

These findings suggest that VEGFA genetic variations might influence response/resistance of FOLFIRI plus cetuximab treatment in mCRC patients.

Suicidal risk among patients enrolled in methadone maintenance treatment: HCV status and implications for suicide prevention (ANRS Methaville)

BACKGROUND

Suicide is a critical issue among opioid users. The aim of this study was to assess the relationship between HCV status and suicidal risk in patients receiving methadone treatment.

METHODS

We used data from Methaville, a multicenter, pragmatic randomized trial designed to evaluate the feasibility of methadone induction in primary care compared with induction in specialized centers. Suicidal risk was assessed at enrollment and after one year of methadone treatment using the suicidality module in the MINI International Neuropsychiatric Interview. Socio-demographic characteristics, drug and alcohol consumption, behavioral and personality factors, history of drug use and health indicators were also assessed.

RESULTS

A total of 195 individuals were enrolled from January 2009 to December 2010. Suicidal risk assessment was available at month 0 (M0) and M12 for 159 (72%) and 118 (73%) individuals, respectively. Forty-four (28%) were at risk of suicide at M0 and 17 (14%) at M12 (p=0.004). One patient attempted suicide by overdose during the one-year follow-up. The following three factors were associated with suicidal risk: hepatitis C virus (HCV) positive status (OR [95%CI]=17.25 [1.14-161.07]; p=0.04), receiving food assistance (OR [95%CI]=0.05 [0.00-1.05]; p=0.05) and a higher number of health problems (OR [95%CI]=1.24 [1.08-1.44]; p=0.003).

CONCLUSIONS

Special attention should be given to HCV-positive patients through suicidal risk prevention strategies and routine suicide assessment as part of a comprehensive approach to prevention and care for opioid users. Our results represent a new and powerful argument for the expansion of access to HCV treatment to drug users with chronic infection.

150 USING A LUTEINIZING HORMONE SURGE DETECTION TEST, PREDI&apos;BOV&reg;, TO OPTIMIZE THE TIME OF ARTIFICIAL INSEMINATION DURING A SUPEROVULATION PROTOCOL IN A HOLSTEIN HEIFERS HERD

Insemination of superovulated bovine donors in due time is of central importance for fertilization and embryo viability. A preliminary test focusing on LH surge detection during superovulation (unpublished datas) indicated that one quarter of the donors present LH surges 12 to 24 h before heat observation (which could correspond, in the case of AI after heat observation, to post ovulation AI). Therefore, it was hypothesised that the average number of embryos per flush could be improved by inseminating donors with early LH surge 12 h after the beginning of the LH peak whenever the heat occurs.In a donor herd station, a trial was performed with 54 Holstein heifers, equipped with Heatime® tags (system detecting the peak activity linked to the heat) collected twice or 3 times after the following superovulation protocol: D-6 to D-11 = reference heat; D0 = input of an implant of norgestomet (Crestar®); D2 8:00 = first FSH (Stimufol®) injection (FSH1); D4 8:00 = cloprostenol (Estrumate®) injection; D4 16:00 = implant removal; D5 8:00 = FSH7 and first LH surge detection test (Predi'Bov®); D5 16:00 = FSH8 and 2nd Predi'Bov® test. Two AI's at interval of 8 to 16h were done (AI's were performed either at 9:00, or between 17:00 and 19:00). For the standard protocol (= STA), thefirst AI occurred after heat observation or activity peak detection by Heatime (whatever the Predi'Bov® test results were). For the adjusted protocol (= ADJ), the first AI occurred from 11 to 16 h after the first positive Predi'Bov® test result or like STA protocol if both results were negative. Heifers followed alternately the 2 protocols, 27 beginning with the ADJ protocol, 27 others with the STA one. LH surge precocity was not repeatable among donors. In the case of an early LH surge detection (one positive Predi'Bov® test), the heat activity peak occurred from 2 to 8 h after the FSH8 for 44% of the flushes, from 8 to 24 h after FSH8 for 54% of the flushes and never for 2% of the flushes. When no early LH surge was observed, the heat activity peak occurred more than 8 h after FSH8 for 78% of the flushes. Interval of heat activity peak-FSH8, IA1-heat activity peak and IA1-early LH surge were highly variable but did not effect the mean number of viable embryos. However, we observed a significant effect (P = 0.04) of the precocity of the heat on the average number of total embryos: 13.8 ± 8.4 v. 11.1 ± 8.1 when the interval heat activity peak-FSH8 had been respectively <8 h or ≥8 h, respecively. Among the 148 collections, 74 were done after the STA protocol, 74 after the ADJ protocol and 70 followed an early LH surge. The adjustment of the AI depending on the detection of an early LH surge (ADJ protocol) had a significant positive (P = 0.04) effect on the mean percentage of viable embryos per flush (52% ± 28 in STA group and 62% ± 31 in ADJ group). Nevertheless, regarding the mean number of viable embryos, this effect failed to reach significance (P = 0.23) (respectively 5.7 ± 5.1 in STA group and 6.7 ± 6.7 in ADJ group). A larger study on more animals is necessary to obtain a significant difference in the number of viable embryos.

Methadone induction in primary care for opioid dependence: a pragmatic randomized trial (ANRS Methaville)

Objective

Methadone coverage is poor in many countries due in part to methadone induction being possible only in specialized care (SC). This multicenter pragmatic trial compared the effectiveness of methadone treatment between two induction models: primary care (PC) and SC.

Methods

In this study, registered at ClinicalTrials.Gov (NCT00657397), opioid-dependent individuals not on methadone treatment for at least one month or receiving buprenorphine but needing to switch were randomly assigned to start methadone in PC (N = 155) or in SC (N = 66) in 10 sites in France. Visits were scheduled at months M0, M3, M6 and M12. The primary outcome was self-reported abstinence from street-opioids at 12 months (M12) (with an underlying 15% non-inferiority hypothesis for PC). Secondary outcomes were abstinence during follow-up, engagement in treatment (i.e. completing the induction period), retention and satisfaction with the explanations provided by the physician. Primary analysis used intention to treat (ITT). Mixed models and the log-rank test were used to assess the arm effect (PC vs. SC) on the course of abstinence and retention, respectively.

Results

In the ITT analysis (n = 155 in PC, 66 in SC), which compared the proportions of street-opioid abstinent participants, 85/155 (55%) and 22/66 (33%) of the participants were classified as street-opioid abstinent at M12 in PC and SC, respectively. This ITT analysis showed the non-inferiority of PC (21.5 [7.7; 35.3]). Engagement in treatment and satisfaction with the explanations provided by the physician were significantly higher in PC than SC. Retention in methadone and abstinence during follow-up were comparable in both arms (p = 0.47, p = 0.39, respectively).

Conclusions

Under appropriate conditions, methadone induction in primary care is feasible and acceptable to both physicians and patients. It is as effective as induction in specialized care in reducing street-opioid use and ensuring engagement and retention in treatment for opioid dependence.

Trial registration

Number Eudract 2008-001338-28; ClinicalTrials.gov: NCT00657397; International Standard Randomized Controlled Trial Number Register ISRCTN31125511

Factors associated with HCV risk practices in methadone-maintained patients: the importance of considering the couple in prevention interventions

BACKGROUND

One important public health issue associated with opioid use today is the risk of hepatitis C (HCV) infection. Although methadone maintenance may help to decrease HCV-related risk practices, HCV risk behaviors persist and are strongly associated with specific substance use patterns, mental status and social context. The ANRS-Methaville study gave us the opportunity to better disentangle the different relationships between these various factors and HCV risk practices.

METHODS

The ANRS-Methaville multisite randomized trial was designed to assess the feasibility of initiating methadone in primary care by comparing it with methadone initiation in specialized centers. This study recruited 195 participants initiating methadone maintenance and followed up for 12 months. Longitudinal data from this trial was used to acquire a greater understanding of HCV risk practices and their pattern of correlates in this population. We selected 176 patients who had data on HCV risk practices at M0 and M12, accounting for 312 visits. HCV risk practices were defined as follows: sharing needles or syringes, sharing drug paraphernalia, getting a tattoo or having a piercing in a non-professional context, sharing toiletry items. To identify factors associated with HCV risk practices, we performed a mixed logistic regression analysis.

RESULTS

HCV risk practices were reported by 19% and 15% of participants at baseline and M12, respectively. After adjustment for age, cocaine use and alcohol dependence as well as suicidal risk, living in a couple with a non-drug user and in a couple with a drug user were both independent predictors of HCV risk practices (OR[CI95%] = 4.16 [1.42-12.12]; OR[CI95%] = 9.85 [3.13-31.06], respectively).

CONCLUSIONS

Identifying individuals at risk of HCV transmission during methadone treatment such as stimulant users, alcohol dependent individuals, and those at suicidal risk is necessary to optimize response to treatment. Innovative prevention approaches tailored to couples are also urgently needed and could decrease HCV-risk in this population. The trial is registered with the French Agency of Pharmaceutical Products (ANSM) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials. Number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397 and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.

Genetic markers of toxicity from capecitabine and other fluorouracil-based regimens: investigation in the QUASAR2 study, systematic review, and meta-analysis

PURPOSE

Fluourouracil (FU) is a mainstay of chemotherapy, although toxicities are common. Genetic biomarkers have been used to predict these adverse events, but their utility is uncertain.

PATIENTS AND METHODS

We tested candidate polymorphisms identified from a systematic literature search for associations with capecitabine toxicity in 927 patients with colorectal cancer in the Quick and Simple and Reliable trial (QUASAR2). We then performed meta-analysis of QUASAR2 and 16 published studies (n = 4,855 patients) to examine the polymorphisms in various FU monotherapy and combination therapy regimens.

RESULTS

Global capecitabine toxicity (grades 0/1/2 v grades 3/4/5) was associated with the rare, functional DPYD alleles 2846T>A and *2A (combined odds ratio, 5.51; P = .0013) and with the common TYMS polymorphisms 5'VNTR2R/3R and 3'UTR 6bp ins-del (combined odds ratio, 1.31; P = 9.4 × 10(-6)). There was weaker evidence that these polymorphisms predict toxicity from bolus and infusional FU monotherapy. No good evidence of association with toxicity was found for the remaining polymorphisms, including several currently included in predictive kits. No polymorphisms were associated with toxicity in combination regimens.

CONCLUSION

A panel of genetic biomarkers for capecitabine monotherapy toxicity would currently comprise only the four DPYD and TYMS variants above. We estimate this test could provide 26% sensitivity, 86% specificity, and 49% positive predictive value-better than most available commercial kits, but suboptimal for clinical use. The test panel might be extended to include additional, rare DPYD variants functionally equivalent to *2A and 2846A, though insufficient evidence supports its use in bolus, infusional, or combination FU. There remains a need to identify further markers of FU toxicity for all regimens.

Predictors of non-prescribed opioid use after one year of methadone treatment: an attributable-risk approach (ANRS-Methaville trial)

BACKGROUND

The effectiveness of methadone as an opioid maintenance treatment (OMT) for opioid dependence has been widely demonstrated. However many patients continue to use other opioids while on methadone treatment. Studies assessing avoidable cases of continued non-prescribed opioid use during methadone treatment are sparse.

METHODS

At 12 months of treatment (M12), 158 subjects had available data on opioid use, measured using the Opiate Treatment Index. We identified variables associated with non-prescribed opioid use at M12, using a univariate logistic regression and two multivariate models, one incorporating only pre-treatment variables, the second adding the in-treatment variables. We also calculated attributable fractions for risk factors.

RESULTS

At M12, 32.3% of the patients had used non-prescribed opioids during the previous month. A good patient-physician relationship was the most influential factor associated with not using non-prescribed opioids after one year. Living with a heroin user after one year of treatment, using cocaine during treatment and hazardous alcohol consumption at enrolment were all associated with an increased risk of non-prescribed opioid use at M12. Analysis of attributable fractions indicated that living with a heroin user at M12 accounted for 21% of patients reporting non-prescribed opioid use at M12, while the lack of a good relationship with the physician accounted for 26%.

CONCLUSIONS

The attributable risk approach suggests that continued non-prescribed opioid use by a considerable proportion of individuals could potentially be reduced by improving patient-physician relationships, enhancing care for co-dependent patients and encouraging patients to modify their social network.

Dihydropyrimidine dehydrogenase and fluoropyrimidines: a review of current dose adaptation practices and the impact on the future of personalized medicine using 5-fluorouracil

SUMMARY 5-fluorouracil (5-FU) is widely used in chemotherapeutic treatments of solid tumors. However, adverse events after its administration occur in about 30% of patients. Dihydropyrimidine dehydrogenase (DPD) is the rate-limiting enzyme in the 5-FU catabolic pathway: several studies have focused on its genetics and/or pharmacokinetics in order to explain the wide interpatient variability in the DPD activity, including the rare event of its complete absence of activity. The pretreatment screening for DPD activity with a multiparametric approach (genotyping, phenotyping, clinico–pathological characteristics) shows the greatest specificity and sensitivity to avoid severe early-onset toxicity to fluoropyrimidines. In addition, using the pharmacokinetics of 5-FU, the dose adaptation can be used to properly dose each cycle for optimal efficacy and reduction of early-onset toxicities.

Performance and cost efficiency of KRAS mutation testing for metastatic colorectal cancer in routine diagnosis: the MOKAECM study, a nationwide experience

Purpose

Rapid advances in the understanding of cancer biology have transformed drug development thus leading to the approval of targeted therapies and to the development of molecular tests to select patients that will respond to treatments. KRAS status has emerged as a negative predictor of clinical benefit from anti-EGFR antibodies in colorectal cancer, and anti-EGFR antibodies use was limited to KRAS wild type tumors. In order to ensure wide access to tumor molecular profiling, the French National Cancer Institute (INCa) has set up a national network of 28 regional molecular genetics centers. Concurrently, a nationwide external quality assessment for KRAS testing (MOKAECM) was granted to analyze reproducibility and costs.

Methods

96 cell-line DNAs and 24 DNA samples from paraffin embedded tumor tissues were sent to 40 French laboratories. A total of 5448 KRAS results were collected and analyzed and a micro-costing study was performed on sites for 5 common methods by an independent team of health economists.

Results

This work provided a baseline picture of the accuracy and reliability of KRAS analysis in routine testing conditions at a nationwide level. Inter-laboratory Kappa values were >0.8 for KRAS results despite differences detection methods and the use of in-house technologies. Specificity was excellent with only one false positive in 1128 FFPE data, and sensitivity was higher for targeted techniques as compared to Sanger sequencing based methods that were dependent upon local expertise. Estimated reagent costs per patient ranged from €5.5 to €19.0.

Conclusion

The INCa has set-up a network of public laboratories dedicated to molecular oncology tests. Our results showed almost perfect agreements in KRAS testing at a nationwide level despite different testing methods ensuring a cost-effective equal access to personalized colorectal cancer treatment.

Prevention of 5-FU-induced health-threatening toxicity by pretherapeutic DPD deficiency screening: Medical and economic assessment of a multiparametric approach

3601

Background: While 5-FU is the foundation of many in GI oncology treatments, pts with DPD deficiency can experience early-onset severe (5%) even fatal (0.3%) toxicities. This study aimed to confirm the pharmaco-economic benefits of pre-therapeutic screening for DPD deficiency using a multiparametric approach in a multicenter prospective cohort study (NCT01547923). Methods: Two parallel cohorts of pts treated with 5-FU-based chemotherapy for colorectal carcinoma were compared: Group A: initial DPD deficiency screening; Group B: no evaluation. Enrollment was based on 5-FU administration guidelines of each institution. DPD deficiency screening combined genotyping and phenotyping (ODPM Tox) (1,2,3). The 2 groups were to be compared in terms of early 5-FU-induced toxicity grade, toxicity cost and DPD screening cost. The enrollment was to be immediately closed in the case of proven 5-FU-related toxic death. Results: 1,130 pts were included from 06/01/2008 to 07/31/2012. Group A: no severe toxicity despite 1 pt with complete deficiency (pt not treated with 5-FU), 20 pts with partial deficiency had safe PK-monitored 5-FU (ODPM Protocol) with only one hospitalization due to toxicity. Group B: One death due to complete DPD deficiency, confirmed retrospectively. Enrollment prematurely closed after experts’ unanimous decision citing ethical concerns. 21 pts with partial DPD deficiency. 5 reported toxicity-related hospitalizations. Data treatment is ongoing. Conclusions: One complete deficiency occurred in both groups: Group A pt had safe treatment whereas Group B pt died due to 5-FU toxicity. Pre-therapeutic DPD deficiency screening using this multi-parametric approach should be performed before 5-FU-based treatment and PK-guided dose adaptation allows for safe treatment of even partially DPD deficient patients. Clinical trial information: NCT01547923. [Table: see text]

Prevention of 5-FU-induced toxicities using pretherapeutic DPD deficiency screening: Medical and economic assessment of a multiparametric approach

351

Background: 5-FU is the backbone of most chemotherapy regimens in GI oncology. Patients with DPD deficiency can experience early onset severe (5%) even fatal (0.3%) toxic side-effects. We decided to confirm the medical and economic interest of pre-therapeutic screening of DPD deficiency using a multiparametric approach in a multicenter prospective cohort study (Eudract n°2008-000026-39). Methods: Two parallel cohorts of patients treated with 5-FU-based chemotherapy for colorectal carcinoma were compared: Group A: initial DPD activity evaluation; Group B: no evaluation. Enrollment in either group was based on 5-FU administration guidelines at each institution. DPD deficiency screening combined genotyping and phenotyping (ODPM Tox) as well as other patient characteristics (1,2,3). The 2 groups were compared in terms of early 5-FU-induced toxicity grade, toxicity cost and DPD screening cost. The enrollment was to be immediately closed if 5-FU-induced toxic death occurred. Results: 1,130 patients were included from to 16/06/2008 to 07/31/2012. Group A: no severe toxicity despite 1 patient with complete deficiency (5-FU replaced by another TS inhibitor), 17 patients with partial deficiency safely received PK-monitored 5-FU (ODPM Protocol). Group B: 1 death: 65 y.o. patient, adjuvant FOLFOX 4, 5-FU-induced SAE at day 6: grade 4 febrile neutropenia, septicemia, diarrhoea, mucositis and secondary dehydration, renal failure, then death. 5-FU imputable Grade 5 SAE declared by investigator. Complete DPD deficiency retrospectively confirmed. The enrollment was prematurely closed after unanimous experts’ decision for ethical reasons. Data treatment is ongoing. Conclusions: One complete deficiency occurred in both groups: Group A patient had safe treatment whereas Group B patient died due to 5-FU grade 5 toxicity. DPD deficiency screening by a multiparametric approach (ODPM Tox) should be performed before 5-FU treatments. Clinical trial information: 2008-000026-39. [Table: see text]

The human insula: Architectonic organization and postmortem MRI registration

The human insula has been the focus of great attention in the last decade due to substantial progress in neuroimaging methodology and applications. Anatomical support for functional localization and interpretations, however, is still fragmented. The aim of the present study was to re-examine the microanatomical organization of the insula and relate cytoarchitectonic maps to major sulcal/gyral patterns by registration to high-resolution MR images of the same brains. The insula was divided into seven architectonic subdivisions (G, Ig, Id1-3, Ia1-2) that were charted on unfolded maps of the insula following a method used previously in monkeys. The results reveal overall similar patterns of Nissl, and to some extent also, myelin and parvalbumin (PV), as in monkeys, with a postero-dorsal to antero-ventral gradient of hypergranular to granular, dysgranular and agranular fields. Reversals occur ventrally along the inferior peri-insular sulcus (IPS), at the margin with the temporal operculum, and anteriorly at the limit with orbitofrontal cortex (OFC). A large portion of agranular cortex is characterized by a dense accumulation of the spindle-shaped von Economo neurons (VENs) in layer V. The distribution of VENs is not restricted to agranular insula but also extends into the anterior part of dysgranular fields. The patterns of intracortical myelin and of PV neuropil in the middle layers follow decreasing gradients from postero-dorsal granular to antero-ventral agranular insula, with particularly strong staining in posterior and dorsal insula. A separate PV enhanced area in the middle-dorsal insula corresponds in location to the presumed human gustatory area. Projections of the cytoarchitectonic maps onto high-resolution stereotactic MRI reveal a near concentric organization around the limen insula, with each cytoarchitectonic subdivision encompassing several major insular gyri/sulci. The dysgranular domain is the largest, taking up about half of the insula. The present study of the human insula provides a new anatomical basis for MR imaging and clinical applications.

153 DETECTING PRE-OVULATORY LUTEINIZING HORMONE PEAKS IN ORDER TO OPTIMIZE THE RATIO OF VIABLE EMBRYOS USING PREDI′BOV®, A NEW ON-FARM OVULATION TEST

The LH peak in cattle is the most precise event for predicting ovulation beginning 24 h later, and thus, AI time. Previous studies demonstrated that embryo production was improved when AI was conducted 12 h before ovulation; that is, 12 h after LH peak. This study aimed to evaluate the benefit of LH peak monitoring with Predi′Bov® (ReproPharm®, Nouzilly, France) following superstimulation in order to optimize numbers of viable embryos (VE). Predi′Bov® is a rapid (40 min) and easy to use on-farm test allowing LH peak detection from a few drops of blood. The test was also used to estimate the variability in the time of the LH peak and onset of oestrus. This study was conducted by the embryo transfer teams of 3 French cooperatives, in collaboration with UNCEIA. Forty heifers in stations (Creavia, Midatest) and 23 cows on farms (GEN′Iatest) were superstimulated by 8 injections IM of Stimufol® or Pluset® (FSH1 to FSH8) over 4 days in 2011–2012. Donor station heifers were treated twice in a Latin square design with a reference protocol where AI was conducted 12 and 24 h after onset of oestrus, and in an experimental protocol where AI was conducted 12 and 24 h after a positive Predi′Bov® test. Semen of different sires was used for both protocols. The Predi′Bov® test was carried out on 3 blood samples (BS1,2,3) collected every 6 h beginning at FSH7 in stations and FSH8 on farms to detect the earliest LH peaks. To determine late LH peaks, Predi′Bov® test was carried out on BS4 collected 24 h after FSH8. Univariate statistical analysis was performed to look at the relationship between qualitative (chi-square) and quantitative (t-test) variables. The difference was considered significant when P < 0.05. The Predi′Bov® test showed that 37.5% (15/40) of LH peaks occurred during the last day of FSH treatment (BS1 or BS2) in stations and 26.1% (6/23) at BS1 on farms. At Creavia station (n = 24), the LH peak was detected anytime from 24 h before to 9 h after the onset of oestrus. In stations, the VE percentage did not differ whether AI was done following oestrus or LH peak detection (63.1% and 61.8% in reference and experimental protocols, respectively). In stations, the VE percentage from 9 females with an LH peak detected at FSH7 (BS1; 41%) in the reference protocol did not differ from the experimental protocol (50%). On farms, the VE percentage was numerically higher but not significant in the experimental protocol (65.4%, n = 16) compared to the reference protocol (47.2%, n = 7). Further investigations are needed, taking into account the effect of collection rank, sire, and female effects, to confirm the trends shown by these results. In conclusion, Predi′Bov® can be used as easily on farms as in stations. Its use allows the detection of animals that have early or late LH peaks, which in turn provides the opportunity of carrying out AI at the optimal time for such females.

[Lead poisoning by fishing sinker ingestion]

INTRODUCTION

Lead colic is a rare cause of abdominal pain. The diagnosis of lead poisoning is most often mentioned in at risk populations (children, psychotic patients).

CASE REPORT

We report a 21-year-old man who presented with colicky abdominal pain. Abdominal plain radiograph showed multiple intracolonic metallic bodies. Markedly elevated lead and zinc protoporphyrin serum levels confirmed the diagnosis of lead poisoning. The patient reported that he commonly chewed fishing lead sinker and may sometimes swallow them during the preparation of fishing rod. Clinical outcome was favourable with chelation therapy.

CONCLUSION

Lead poisoning following fishing sinker ingestion is very uncommon. Diagnosis may be discussed in the presence of foreign metallic bodies on plain abdominal radiograph and confirmed by high serum level of lead. A prompt treatment with chelation therapy and digestive emptying is usually effective.

DPD deficiency: Medicoeconomic evaluation of pretreatment screening of 5-FU toxicity

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Background: Deficiency of DPD activity is associated with severe toxicity or even death after the first two cycles 5-fluorouracil (5-FU) based of chemotherapy. The objective of this study was to assess the cost-effectiveness of a screening test before treatment of the deficiency of DPD activity combining two approaches (genetic and phenotype (UH2 / U)). The main measure of effectiveness was the number of avoided severe toxicities (grade 3-4), but the number of quality adjusted life days was the secondary endpoint.

Methods: The analysis was based on retrospective data from a population of patients treated for colorectal cancer. 856 patients were screened (5-FUODPM Tox, ODPM, France) before being treated with adjusted doses (5-FUODPM Protocol, ODPM, France) versus a population of 886 patients treated according to standard doses (2400 mg/m²). The main point of view was society perspective and the time horizon was 2 cycles of chemotherapy. A multi-state Markov-type was used to estimate the mean cost and results for each of the two strategies. The cost of the strategy with screening was composed of the cost of the screening test and the cost of remaining toxicities, the cost of the standard strategy was just the cost of toxicities. The incremental cost-effectiveness ratio (ICER) was calculated: (COSTStandard - COSTWithScreening)/(EffStandard - EffWithScreening) COSTA : Cost of the strategy A, EffA : Effectiveness of the strategy A.

Results: In the screened and adapted arm, the prevalence of severe toxicities at 1 cycle of chemotherapy was 0.5%, at 2 cycles was 0.9%. In the arm with standard doses, they were 5.80% and 6.90%, respectively. Any toxicity associated death was observed in the screened arm versus 1 death in the standard arm. The screening strategy was dominant, it allowed avoiding toxicities and saving money. The avoided cost per patient screened was 313 € for two cycles of treatment and a saving of 2780 € per toxicity avoided. The incremental net benefit (INB) per patient screened is 426 €.

Conclusions: Pre-treatment screening test combining genetic and phenotype reduced the incidence of toxicities associated with 5-FU, it avoided deaths due to 5-FU and its additional cost was less than the cost of care of toxicity that it avoided.

The insula of Reil revisited: multiarchitectonic organization in macaque monkeys

The insula of Reil represents a large cortical territory buried in the depth of the lateral sulcus and subdivided into 3 major cytoarchitectonic domains: agranular, dysgranular, and granular. The present study aimed at reinvestigating the architectonic organization of the monkey's insula using multiple immunohistochemical stainings (parvalbumin, PV; nonphosphorylated neurofilament protein, with SMI-32; acetylcholinesterase, AChE) in addition to Nissl and myelin. According to changes in density and laminar distributions of the neurochemical markers, several zones were defined and related to 8 cytoarchitectonic subdivisions (Ia1-Ia2/Id1-Id3/Ig1-Ig2/G). Comparison of the different patterns of staining on unfolded maps of the insula revealed: 1) parallel ventral to dorsal gradients of increasing myelin, PV- and AChE-containing fibers in middle layers, and of SMI-32 pyramidal neurons in supragranular layers, with merging of dorsal and ventral high-density bands in posterior insula, 2) definition of an insula "proper" restricted to two-thirds of the "morphological" insula (as bounded by the limiting sulcus) and characterized most notably by lower PV, and 3) the insula proper is bordered along its dorsal, posterodorsal, and posteroventral margin by a strip of cortex extending beyond the limits of the morphological insula and continuous architectonically with frontoparietal and temporal opercular areas related to gustatory, somatosensory, and auditory modalities.