Colorectal cancer (CRC) monitoring by 6-monthly 18FDG-PET/CT: an open-label multicentre randomised trial

Background

[¹⁸F]2-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (¹⁸FDG-PET/CT) has high sensitivity for detecting recurrences of colorectal cancer (CRC). Our objective was to determine whether adding routine 6-monthly ¹⁸FDG-PET/CT to our usual monitoring strategy improved patient outcomes and to assess the effect on costs.

Patients and methods

In this open-label multicentre trial, patients in remission of CRC (stage II perforated, stage III, or stage IV) after curative surgery were randomly assigned (1 : 1) to usual monitoring alone (3-monthly physical and tumour marker assays, 6-monthly liver ultrasound and chest radiograph, and 6-monthly whole-body computed tomography) or with 6-monthly ¹⁸FDG-PET/CT, for 3 years. A multidisciplinary committee reviewed each patient’s data every 3 months and classified the recurrence status as yes/no/doubtful. Recurrences were treated with curative surgery alone if feasible and with chemotherapy otherwise. The primary end point was treatment failure defined as unresectable recurrence or death. Relative risks were estimated, and survival was analysed using the Kaplan–Meier method, log-rank test, and Cox models. Direct costs were compared.

Results

Of the 239 enrolled patients, 120 were in the intervention arm and 119 in the control arm. The failure rate was 29.2% (31 unresectable recurrences and 4 deaths) in the intervention group and 23.7% (27 unresectable recurrences and 1 death) in the control group (relative risk = 1.23; 95% confidence interval, 0.80–1.88; P = 0.34). The multivariate analysis also showed no significant difference (hazards ratio, 1.33; 95% confidence interval, 0.8–2.19; P = 0.27). Median time to diagnosis of unresectable recurrence (months) was significantly shorter in the intervention group [7 (3–20) versus 14.3 (7.3–27), P = 0.016]. Mean cost/patient was higher in the intervention group (18 192 ± 27 679 € versus 11 131 ± 13  €, P < 0.033).

Conclusion

¹⁸FDG-PET/CT, when added every 6 months, increased costs without decreasing treatment failure rates in patients in remission of CRC. The control group had very close follow-up, and any additional improvement (if present) would be small and hard to detect.

ClinicalTrials.gov identifier

NCT00624260

Indications and practices of Cesarean Sections in a French region – The Robson classification

Background

Cesarian-section (CS) deliveries, although sometimes vital, are associated with increasing immediate- and long-term maternal and/or neonatal risks. The objective was to describe the indications of scheduled CS, measure the potentially avoidable CS and study the rate variations between maternities in one French region, Centre Val-de-Loire (CVL).

Methods

A cross-sectional study was conducted from September 2016 to February 2017. Information about all CS performed in the maternities of the region was collected: medical history, indication, schedule. Data collection was completed with the 2016 regional birth data repository (25,864 deliveries, including 19.2% of CS, among which 7.0% were scheduled). CS were classified according to the pre-existing risk high or low of CS as defined by the Robson classification.

Results

During the study period, 1,979 CS (18.6% of deliveries) were performed, of which 762 were scheduled (7.1% of deliveries). The main indications for planning a CS were: scarred uterus (60%, of which 56% with only one previous CS) or breech presentation (25%), considered at high risk of CS according to the Robson classification. For these two contexts, the regional birth repository showed decreasing scheduled CS rates from high to low level of maternities’ expertise. Remarkly, 22 nulliparous women with a single cephalic pregnancy in spontaneous labor before term (Robson’s low risk of CS) had a CS performed for unfavorable pelvimetry (0.2% of deliveries).

Conclusions

This study allowed identifying specific potential interventions: targeted CS on scarred uterus with only one previous CS or breech presentation, as recommended by national guidelines, and targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices through cautious maternity comparisons to improve quality of care.

Key messages

Although potentially avoidable c-sections are rare, interventions were identified: targeted CS on uterus with one previous CS or breech presentation, targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices, in order to improve healthcare quality.

Pycnodysostosis: Natural history and management guidelines from 27 French cases and a literature review

Pycnodysostosis is a lysosomal autosomal recessive skeletal dysplasia characterized by osteosclerosis, short stature, acro-osteolysis, facial features and an increased risk of fractures. The clinical heterogeneity of the disease and its rarity make it difficult to provide patients an accurate prognosis, as well as appropriate care and follow-up. French physicians from the OSCAR network have been asked to fill out questionnaires collecting molecular and clinical data for 27 patients issued from 17 unrelated families. All patients showed short stature (mean = -3.5 SD) which was more severe in females (P = .006). The mean fracture rate was moderate (0.21 per year), with four fractures in total average. About 75% underwent at least one surgery, with an average number of 2.1 interventions per patient. About 50% required non-invasive assisted ventilation due to sleep apnea (67%). About 29% showed psychomotor difficulties and 33% needed a school assistant or adapted schooling. No patient had any psychological evaluation or follow-up. Molecular data were available for 14 families. Growth hormone administration was efficient on linear growth in 40% of cases. We propose several axis of management, such as systematic cerebral MRI for Chiari malformation screening at diagnosis and regular psychological follow-up.

[Functional diagnostics in pneumology]

Alongside imaging techniques, pulmonary function testing helps in the diagnosis of underlying disorders such as asthma and chronic obstructive pulmonary disease (COPD) or fibrosing lung disease. However, disease severity grading is also important, as well as disease follow-up under therapy. The value of spirometry as a first-line diagnostic test, whole-body plethysmography in advanced diagnostics, the measurement of transfer factor, as well as blood gas analysis are outlined. The importance of spiroergometry, echocardiography, and right-heart catheterization, particularly in the functional assessment of pulmonary vascular disorders, is described. Tests in respiratory sleep medicine, such as polysomnography, as well as tests for diagnosing chronic respiratory failure, are part of the respiratory physician's diagnostic armamentarium.

A randomized controlled trial protocol assessing the effectiveness, safety and cost-effectiveness of methotrexate vs. ciclosporin in the treatment of severe atopic eczema in children: the TREatment of severe Atopic eczema Trial (TREAT)

BACKGROUND

Oral systemic immunomodulatory medication is regularly used off-licence in children with severe atopic eczema. However, there is no firm evidence regarding the effectiveness, safety, cost-effectiveness and impact on quality of life from an adequately powered randomized controlled trial (RCT) using systemic medication in children.

OBJECTIVES

To assess whether there is a difference in the speed of onset, effectiveness, side-effect profile and reduction in flares post-treatment between ciclosporin (CyA) and methotrexate (MTX), and also the cost-effectiveness of the drugs. Treatment impact on quality of life will also be examined in addition to whether FLG genotype influences treatment response. In addition, the trial studies the immune-metabolic effects of CyA and MTX.

METHODS

Multicentre, parallel group, assessor-blind, pragmatic RCT of 36 weeks' duration with a 24-week follow-up period. In total, 102 children aged 2-16 years with moderate-to-severe atopic eczema, unresponsive to topical treatment will be randomized (1 : 1) to receive MTX (0·4 mg kg^-1 per week) or CyA (4 mg kg^-1 per day).

RESULTS

The trial has two primary outcomes: change from baseline to 12 weeks in Objective Severity Scoring of Atopic Dermatitis (o-SCORAD) and time to first significant flare following treatment cessation.

CONCLUSIONS

This trial addresses important therapeutic questions, highlighted in systematic reviews and treatment guidelines for atopic eczema. The trial design is pragmatic to reflect current clinical practice.

Should 45,X/46,XY boys with no or mild anomaly of external genitalia be investigated and followed up?

OBJECTIVE

Few studies of patients with a 45,X/46,XY mosaicism have considered those with normal male phenotype. The purpose of this study was to evaluate the clinical outcome of 45,X/46,XY boys born with normal or minor abnormalities of external genitalia, notably in terms of growth and pubertal development.

METHODS

Retrospective longitudinal study of 40 patients followed between 1982 and 2017 in France.

RESULTS

Twenty patients had a prenatal diagnosis, whereas 20 patients had a postnatal diagnosis, mainly for short stature. Most patients had stunted growth, with abnormal growth spurt during puberty and a mean adult height of 158 ± 7.6 cm, i.e. -2.3 DS with correction for target height. Seventy percent of patients presented Turner-like syndrome features including cardiac (6/23 patients investigated) and renal malformations (3/19 patients investigated). Twenty-two patients had minor abnormalities of external genitalia. One patient developed a testicular embryonic carcinoma, suggesting evidence of partial gonadal dysgenesis. Moreover, puberty occurred spontaneously in 93% of patients but 71% (n = 5) of those evaluated at the end of puberty presented signs of declined Sertoli cell function (low inhibin B levels and increased FSH levels).

CONCLUSION

This study emphasizes the need to identify and follow-up 45,X/46,XY patients born with normal male phenotype until adulthood, as they present similar prognosis than those born with severe genital anomalies. Currently, most patients are diagnosed in adulthood with azoospermia, consistent with our observations of decreased testicular function at the end of puberty. Early management of these patients may lead to fertility preservation strategies.

Key features of bone and joint infections following the implementation of reference centers in France

OBJECTIVES

French reference centers for bone and joint infections (BJI) were implemented from 2009 onwards to improve the management of complex BJIs. This study compared BJI burden before and after the implementation of these reference centers.

PATIENTS AND METHODS

BJI hospital stays were selected from the 2008 and 2013 national hospital discharge database using a validated algorithm, adding the new complex BJI code created in 2011. Epidemiology and economic burden were assessed.

RESULTS

BJI prevalence increased in 2013 (70 vs. 54/100,000 in 2008). Characteristics of BJI remained similar between 2008 and 2013: septic arthritis (50%), increasing prevalence with age and sex, case fatality 5%, mean length of stay 17.5 days, rehospitalization 20%. However, device-associated BJIs increased (34 vs. 26%) as well as costs (€421 million vs. €259 in 2008). Similar device-associated BJI characteristics between 2008 and 2013 were: septic arthritis (70%), case fatality (3%), but with more hospitalizations in reference centers (34 vs. 30%) and a higher cost per stay. Among the 7% of coded complex BJIs, the mean length of stay was 22.2 days and mean cost was €11,960.

CONCLUSIONS

BJI prevalence highly increased in France. Complex BJI prevalence assessment is complicated by the absence of clinical consensus and probable undercoding. A validation of clinical case definition of complex BJI is required.

Connaissances, attitudes et pratiques des parents face à la vaccination contre la poliomyélite à Abéché-Tchad

Introduction

au Tchad, la transmission de la poliomyélite a été interrompue en 2000, mais les importations à partir du Nigéria et la faiblesse des couvertures vaccinales constituent un risque majeur de relance de la maladie. L'objectif de ce travail était d'analyser les connaissances, attitudes et pratiques des parents vis-à-vis de la vaccination contre la poliomyélite des enfants âgés de 0 à 5 ans au Tchad.

Méthodes

cette étude transversale a été réalisée dans les six arrondissements d'Abéché. Seuls les ménages qui avaient des enfants de moins de 5 ans ont été inclus. Les données ont été recueillies par des entretiens avec les parents et tuteurs d'enfants éligibles à l'aide d'un questionnaire testé et validé.

Résultats

nous avons interrogé 210 ménages. Aucune famille ne possédait de carnet de vaccination de leurs enfants. Cependant, 97% ont déclaré avoir des enfants ayant participé aux campagnes de vaccination de masse. Près de 97% connaissaient la poliomyélite et 98% avaient entendu parler des campagnes de vaccination. Les canaux d'information les plus cités étaient la radio (98%) et les agents vaccinateurs (72%). Seul 3% des parents interrogés ont déclaré avoir refusé la vaccination. Il existait une association entre l'influence négative de l'entourage et la non vaccination des enfants (p = 0,005).

Conclusion

les connaissances sur la maladie et le vaccin sont bonnes au Tchad malgré l'existence de rumeurs concernant notamment les effets des vaccins. L'absence de carnet de vaccination a limité l'analyse des résultats de l'enquête, uniquement déclarative avec un taux de vaccination très élevé déclaré. Dans le cadre de l'éradication, le carnet est indispensable pour accompagner la politique de prévention.

Sex chromosome aneuploidies and copy-number variants: a further explanation for neurodevelopmental prognosis variability?

Sex chromosome aneuploidies (SCA) is a group of conditions in which individuals have an abnormal number of sex chromosomes. SCA, such as Klinefelter's syndrome, XYY syndrome, and Triple X syndrome are associated with a large range of neurological outcome. Another genetic event such as another cytogenetic abnormality may explain a part of this variable expressivity. In this study, we have recruited fourteen patients with intellectual disability or developmental delay carrying SCA associated with a copy-number variant (CNV). In our cohort (four patients 47,XXY, four patients 47,XXX, and six patients 47,XYY), seven patients were carrying a pathogenic CNV, two a likely pathogenic CNV and five a variant of uncertain significance. Our analysis suggests that CNV might be considered as an additional independent genetic factor for intellectual disability and developmental delay for patients with SCA and neurodevelopmental disorder.