Urinary tract infections in patients with neurogenic bladder

Urinary tract infections (UTIs) in patients with neurogenic bladder are a major public health issue due to their high incidence and major consequences. Despite their frequency and potential severity, their physiopathology and management are poorly known. We provide a narrative literature review on the epidemiology, physiopathology, diagnostic criteria, microbiology, antimicrobial management, and prevention. UTIs among patients with neurogenic bladder are associated with high morbidity and healthcare utilization. Risk factors for UTI among this population are: indwelling catheter, urinary stasis, high bladder pressure, and bladder stones. Their diagnosis is a major challenge as clinical signs are often non-specific and rare. A urinary sample should be analyzed in appropriate conditions before any antibiotic prescription. According to most guidelines, a bacterial threshold≥103CFU/ml associated with symptoms is acceptable to define UTI in patients with neurogenic bladder. The management of acute symptomatic UTI is not evidence-based. A management with a single agent and a short antibiotic treatment of 10 days or less seems effective. Antibiotic selection should be based on the patient's resistance patterns. Asymptomatic bacteriuria should not be treated to avoid the emergence of bacterial resistance. Regarding preventive measures, use of clean intermittent catheterization, intravesical botulinum toxin injection, and prevention using antibiotic cycling are effective. Bacterial interference is promising but randomized controlled trials are needed. Large ongoing cohorts and randomized controlled trials should soon provide more evidence-based data.

Multidisciplinary team meeting for complex bone and joint infections diagnosis: The PHICTOS study

BACKGROUND

In France, the most severe bone and joint infections (BJI), called "complex" (CBJI), are assessed in a multidisciplinary team meeting (MTM) in a reference center. However, the definition of CBJI, drawn up by the Health Ministry, is not consensual between physicians. The objective was to estimate the agreement for CBJI classification.

METHODS

Initially, five experts from one MTM classified twice, one-month apart, 24 cases as non-BJI, simple BJI or CBJI, using the complete medical record. Secondly, six MTMs classified the same cases using standardized information. Agreements were estimated using Fleiss and Cohen kappa (κ) coefficients.

RESULTS

Inter-expert agreement during one MTM was moderate (κ=0.49), and fair (κ=0.23) when the four non-BJIs were excluded. Intra-expert agreement was moderate (κ=0.50, range 0.27-0.90), not improved with experience. The overall inter-MTM agreement was moderate (κ=0.58), it was better between MTMs with professor (κ=0.65) than without (κ=0.51) and with longer median time per case (κ=0.60) than shorter (κ=0.47). When the four non-BJIs were excluded, the overall agreement decreased (κ=0.40).

CONCLUSION

The first step confirmed the heterogeneity of CBJI classification between experts. The seemingly better inter-MTM than inter-expert agreement could be an argument in favour of MTMs, which are moreover a privileged place to enhance expertise. Further studies are needed to assess these results as well as the quality of care and medico-economic outcomes after a MTM.

Abstract P4-10-17: Plasma metabolomic signatures associated with long-term breast cancer risk in the SU.VI.MAX prospective cohort

Purpose: Breast cancer is a major cause of death in occidental women. Mechanisms involved in its etiology remain misunderstood. Metabolomics is a powerful tool which may help elucidating novel biological pathways and identify new biomarkers in order to predict breast cancer well before symptoms appear. The aim of this study was to investigate whether untargeted metabolomic signatures from blood draws of healthy women could contribute to better understand and predict the long-term risk of developing breast cancer.

Methods: A nested case-control study was conducted within the SU.VI.MAX prospective cohort (13 years of follow-up) to analyze baseline plasma samples of 211 incident breast cancer cases and 211 matched controls by LC-MS mass spectrometry. Multivariable conditional logistic regression models were computed.

Results: 83 ions were significantly associated (corrected-pvalue <0.05) with breast cancer risk. Notably, we observed that a lower plasma level of O-succinyl-homoserine and higher plasma levels of valine/norvaline, glutamine/isoglutamine, 5-aminovaleric acid, phenylalanine, tryptophane, γ-glutamyl-threonine, ATBC, 2-amino-cyanobutanoic acid and pregnene-triol sulfate were associated with an increased risk of developing breast cancer during follow-up. Corrected-pvalues ranged from 0.009 (OR=1.43[1.14-1.78] for phenylalanine and OR=1.45[1.15-1.83] for valine/norvaline) to 0.03 (OR=1.28[1.03-1.58] for 2-amino-cyano-butanoic acid).

Conclusion: Several pre-diagnostic plasmatic metabolites are strongly associated with long-term breast cancer risk. If confirmed in other independent cohort studies, these results could help to identify healthy women at higher risk of developing breast cancer in the subsequent decade and to propose a better understanding of the complex mechanisms involved in its etiology.

Trial registration: SU.VI.MAX, clinicaltrials.gov NCT00272428. Registered 3 January 2006

Keywords: Metabolomics, breast cancer, mass spectrometry, plasma, prospective study

Citation Format: Lucie L, Céline D, Bernard L, Aicha D, Adrien R, Marie-Paule V, Mélanie P, Marie L, Tom F, Delphine C, Laurent Z, Pilar G, Serge H, Mélanie D, Valentin P, Bernard S, Paule L-M, Emmanuelle K-G, Nathalie D-P, Claudine M, Stéphanie D, Estelle P-G, Mathilde T. Plasma metabolomic signatures associated with long-term breast cancer risk in the SU.VI.MAX prospective cohort [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-10-17.

Primary healthcare providers' practices related to non-malarial acute febrile illness in Burkina Faso

Background

In Africa, fever is the main reason for consultation, with malaria playing a prominent role. Studies have reported that the widespread use of rapid diagnostic tests for malaria, implemented since 2010, has revealed an increasing proportion of non-malaria acute febrile illnesses (NMAFI). It is an important public health issue because evidence shows that mortality is higher among patients presenting with non-malarial fever than among those with malaria.

Methods

This cross-sectional study assessed the professional practices of healthcare providers in the management of NMAFI in urban and rural sites in Burkina Faso. Data was collected from 286 healthcare providers through a questionnaire based on the clinical situation in 2014. Factors have been associated using a hierarchical linear mixed model with random intercepts to model dependence of outcomes for healthcare providers working on the same site.

Results

Survey results showed limited knowledge about management of NMAFI, global survey score on General Practice Indicator being 60% (36.02/60.00). This gap was more evident at the admission and diagnosis level. The study's population from rural areas had better survey score than that of urban areas concerning the respect of adequacy diagnosis, treatment and use of antibiotics in NMAFI, 15.71 vs 13.93 mean score (p=0.01) (75 vs 66% on a 0 to 100% scale, with 100% being the best). Overall, more educated participants performed relatively better. A total of 46% (134/286) of participants felt that they needed training in at least one of the fever-related issues.

Conclusions

Increased awareness and knowledge of management for NMAFI are urgently required in Burkina Faso. This must be done through regular supervision and training courses targeted specifically at primary healthcare providers.

A preliminary prospective study: Could the labeling of a health-care message on a consumer product limit forgetfulness in parents confronted with immunization?

BACKGROUND

Parental hesitancy in immunization is an emerging and concerning problem owing to the serious consequences of a lack of vaccination. Few tools are available to combat this phenomenon.

AIMS

To evaluate the interest of parents in recording the vaccine schedule on a common consumer product as a solution to prevent immunization oversight.

METHOD

We conducted a preliminary prospective and monocentric study, in a parental population, using surveys to evaluate interest in this solution, and to define the sociodemographic characteristics of our population. Our population was clustered into three groups: against immunization, hesitant/negligent, and pro-immunization. This solution was evaluated using a univariate model between fearful and confident populations in respect of immunization, associated with a descriptive analysis of the population against immunization.

RESULTS

Of 825 surveys distributed, 709 were analyzed. There were 47 parents against immunization (6.6%), 284 hesitant/negligent parents (40%), and 378 pro-immunization parents (53.3%). We showed that the hesitant/negligent population reported more difficulties in remembering the immunization schedule (P<0.001; OR=0.36; 95% CI [0.25-0.51]), and was interested in discussions on immunization (P<0.001; OR=0.41; 95% CI [0.29-0.58]). This population prone to oversight was interested in the labeling of an everyday consumer product with the immunization schedule (P=0.03; OR=0.68; 95% CI [1.02-2.11]) to limit the number of missed injections.

CONCLUSION

There is no single or perfect solution to combat the current anti-immunization problem, although communication through everyday consumer products seems to be an interesting tool for raising parental awareness of the importance of immunization. Further studies are required to evaluate the effectiveness of this tool.

[Antibiotic prophylaxis in urodynamics: Clinical practice guidelines using a formal consensus method]

OBJECTIVE

The aim of this work was to issue clinical practice guidelines on antibiotic prophylaxis in urodynamics (urodynamic studies, UDS).

MATERIALS AND METHODS

Clinical practice guidelines were provided using a formal consensus method. Guidelines proposals were drew up by a multidisciplinary experts group (pilot group = steering group), then rated by a panel of 12 experts (rating group) using a formal consensus method, and then peer reviewed by a reviewing/reading group of experts (different from the rating group).

RESULTS

Urine (bacterial) culture with antimicrobial susceptibility testing is recommended for all patients before UDS (strong agreement). In patients with no neurologic disease, the risk factors for tract urinary infection (UTI) after UDS are age > 70 years, recurrent UTI, and post-void residual volume > 100ml. In patients with neurologic disease, the risk factors for UTI after UDS are recurrent UTI, vesicoureteral reflux, and intermicturition pressure > 40cmH₂O. If the urine culture is negative before UDS and there is no risk factor for UTI, antibiotic prophylaxis is not recommended (Strong agreement). If the urine culture is negative before UDS, but there are one or more risk factors for UTI, antibiotic prophylaxis is optional. If antibiotic prophylaxis is initiated, a single oral dose (3g) of fosfomycin-tromethamine two hours before UDS is recommended (Strong agreement). If there is bacterial colonization on UCB before UDS, antibiotic therapy is optional (Undecided). If prescribed, it should be adapted to the antimicrobial susceptibility of the identified bacterium or bacteria, started the day before and stopped after UDS (except for fosfomycin-tromethamine: a single dose the day before UDS is necessary and sufficient) (Strong agreement). In the event of UTI before UDS, the UTI should be treated and UDS postponed (Strong agreement). The proposed recommendations should not be changed for patients with a hip or knee replacement (Strong agreement). No antibiotic prophylaxis of bacterial endocarditis is necessary, including in high-risk patients with valvular heart disease (Strong agreement).

CONCLUSION

These new guidelines should help to harmonize clinical practice and limit exposure to antibiotics.

LEVEL OF EVIDENCE

4.

Antisense STAT3 inhibitor decreases viability of myelodysplastic and leukemic stem cells

Acute myeloid leukemia (AML) and myelodysplastic syndromes (MDS) are associated with disease-initiating stem cells that are not eliminated by conventional therapies. Transcriptomic analysis of stem and progenitor populations in MDS and AML demonstrated overexpression of STAT3 that was validated in an independent cohort. STAT3 overexpression was predictive of a shorter survival and worse clinical features in a large MDS cohort. High STAT3 expression signature in MDS CD34+ cells was similar to known preleukemic gene signatures. Functionally, STAT3 inhibition by a clinical, antisense oligonucleotide, AZD9150, led to reduced viability and increased apoptosis in leukemic cell lines. AZD9150 was rapidly incorporated by primary MDS/AML stem and progenitor cells and led to increased hematopoietic differentiation. STAT3 knockdown also impaired leukemic growth in vivo and led to decreased expression of MCL1 and other oncogenic genes in malignant cells. These studies demonstrate that STAT3 is an adverse prognostic factor in MDS/AML and provide a preclinical rationale for studies using AZD9150 in these diseases.

Sterile Neutrino Constraints from the STEREO Experiment with 66 Days of Reactor-On Data

The reactor antineutrino anomaly might be explained by the oscillation of reactor antineutrinos toward a sterile neutrino of eV mass. In order to explore this hypothesis, the STEREO experiment measures the antineutrino energy spectrum in six different detector cells covering baselines between 9 and 11 m from the compact core of the ILL research reactor. In this Letter, results from 66 days of reactor turned on and 138 days of reactor turned off are reported. A novel method to extract the antineutrino rates has been developed based on the distribution of the pulse shape discrimination parameter. The test of a new oscillation toward a sterile neutrino is performed by comparing ratios of cells, independent of absolute normalization and of the prediction of the reactor spectrum. The results are found to be compatible with the null oscillation hypothesis and the best fit of the reactor antineutrino anomaly is excluded at 97.5% C.L.

Effect of diets supplemented with starch and corn oil, marine algae, or hydrogenated palm oil on mammary lipogenic gene expression in cows and goats: A comparative study

A direct comparison of cow and goat performance and milk fatty acid (FA) responses to diets that either induce milk fat depression or increase milk fat content in cows suggests species-specific regulation of lipid metabolism, including mammary lipogenesis. This experiment was conducted to highlight potential mechanisms responsible for the differences in mammary lipogenesis due to diet and ruminant species. Twelve Holstein cows and 12 Alpine goats were fed a basal diet containing no additional lipid (CTL) or a similar diet supplemented with corn oil [5% dry matter intake (DMI)] and wheat starch (COS), marine algae powder (MAP; 1.5% DMI), or hydrogenated palm oil (HPO; 3% DMI), according to a 4 × 4 Latin square design with 28-d experimental periods. Milk yield, milk composition, FA profile, and secretions were measured. On d 27 of each experimental period, the mRNA abundance of 21 genes involved in lipid metabolism or enzyme activities or both were measured in mammary tissue sampled by biopsy. The results showed significant differences in the milk fat response of cows and goats to the dietary treatments. In cows, fat content was lowered by COS (-45%) and MAP (-22%) and increased by HPO (+13%) compared with CTL, and in goats only MAP had an effect compared with CTL, with a decrease of 15%. In both species, COS and MAP lowered the yields (mmol/d per kilogram of body weight) of <C16 and C16 FA. With COS, this decrease was compensated by an increase of >C16 FA in goats but not in cows, and the >C16 FA yield decreased with MAP in both species. Supplementation of HPO increased the yield of milk C16 FA (mmol/d per kilogram of body weight) in cows. These variations in milk fat content and FA secretion were not associated with modifications in the mammary expression of 21 genes involved in major lipid pathways, except for 3 transcription factors: PPARA, INSIG1, and SP1. This absence of large changes might be due to post-transcriptional regulation of these genes and related to the time of sampling of the mammary tissue relative to the previous meal and milking or to differences in the availability of substrate for the corresponding proteins. However, the abundance of 14 mRNA among the 21 encoding for genes studied in the mammary gland was significantly different among species, with 5 more abundant in cows (FADS3, ACSL1, PPARA, LXRA, and PPARG1) and 10 more abundant in goats (FASN, CD36, FABP3, LPL, GPAM, LPIN1, CSN2, MFGE8, and INSIG1). These species specificities of mammary lipid metabolism require further investigation.

National epidemiological study reveals longer paediatric bone and joint infection stays for infants and in general hospitals

AIM

Published studies have suggested that two to five days of intravenous treatment could effectively treat paediatric bone and joint infections (PBJI), allowing a faster discharge. This study analysed the factors associated with PBJI hospital stays lasting longer than five days using the French National Hospital Discharge Database.

METHODS

We selected children under 15 years hospitalised in 2013 with haematogenous PBJIs using a validated French algorithm based on specific diagnosis and surgical procedure codes. Risk factors for stays of more than five days were analysed using logistic regression.

RESULTS

In 2013, 2717 children were hospitalised for PBJI, with 49% staying more than five days. The overall incidence of 22 per 100 000, was highest in males and toddlers. The main causes were septic arthritis (50%) and osteomyelitis (46%) and 50% of the pathogens were Staphylococci. The odd ratios for stays of five days or more were infancy, coded bacteria and sickle cell disease (7.0), having spondylodiscitis rather than septic arthritis (2.2) and being hospitalised in a general hospital rather than a teaching hospital (1.6).

CONCLUSION

Half of the hospital stays exceeded five days, despite scientific evidence supporting a shorter intravenous antibiotherapy regimen. Greater knowledge and widespread use of short treatment regimens are needed.

Diets supplemented with starch and corn oil, marine algae, or hydrogenated palm oil differentially modulate milk fat secretion and composition in cows and goats: A comparative study

A direct comparative study of dairy cows and goats was performed to characterize the animal performance and milk fatty acid (FA) responses to 2 types of diets that induce milk fat depression in cows as well as a diet that increases milk fat content in cows but for which the effects in goats are either absent or unknown. Twelve Holstein cows and 12 Alpine goats, all multiparous, nonpregnant, and at 86 ± 24.9 and 61 ± 1.8 DIM, respectively, were allocated to 1 of 4 groups and fed diets containing no additional lipid (CTL) or diets supplemented with corn oil [5% dry matter intake (DMI)] and wheat starch (COS), marine algae powder (MAP; 1.5% DMI), or hydrogenated palm oil (HPO; 3% DMI), according to a 4 × 4 Latin square design with 28-d experimental periods. Dietary treatments had no significant effects on milk yield and DMI in both species, except for COS in cows, which decreased DMI by 17%. In cows, milk fat content was lowered by COS (-45%) and MAP (-22%) and increased by HPO (13%) compared with CTL, and in goats only MAP had an effect compared with CTL by decreasing milk fat content by 15%. In both species, COS and MAP lowered the yields (mmol/d per kg of BW) of <C16 and C16 FA. With COS, this decrease was compensated by an increase of >C16 FA in goats, but not in cows, and the >C16 FA yield decreased with MAP in both species. HPO supplementation increased the milk yield of C16 FA in cows. Compared with CTL, COS induced an increase of trans-10,cis-12 conjugated linoleic acid by 18 fold in cows and 7 fold in goats and of trans-10 18:1 by 13 fold in cows and 3 fold in goats. Moreover, other conjugated linoleic acid isomers, such as trans-10,trans-12 and trans-7,cis-9, were increased to a greater extent in cows (8 and 4 fold, respectively) compared with goats (4 and 2 fold, respectively) on the COS treatment. In both species, the responses to MAP were characterized by a decrease in the milk concentration of 18:0 (3 fold, on average) and cis-9 18:1 (2 fold, on average) combined with a 3-fold increase in the total trans 18:1, with an increase in trans-10 18:1 only observed in cows. Compared with CTL, the response to HPO was distinguished by an increase in 16:0 (10%) in cows. This comparative study clearly demonstrated that each ruminant species responds differently to COS and HPO treatments, whereas MAP caused similar effects, and that goats are less sensitive than cows to diets that induce a shift from the trans-11 toward the trans-10 ruminal pathways.

Peanut gastrointestinal delivery oral immunotherapy in adolescents: Results of the build-up phase of a randomized, double-blind, placebo-controlled trial (PITA study)

BACKGROUND

Oral immunotherapy to peanut is effective in desensitizing patients but has significant side effects including anaphylaxis and gastrointestinal symptoms. In most protocols, peanut is administered in a vehicle food.

OBJECTIVE

In an exclusively adolescent population, we tested a new approach using sealed capsules of peanut (gastrointestinal delivery oral immunotherapy or GIDOIT) to bypass the upper gastrointestinal tract. The primary aim was to assess the efficacy of the oral build-up phase of GIDOIT and the secondary aim to analyse its safety.

METHODS

Adolescents with a history of a clinical allergic reaction after peanut ingestion were included in a 2-armed, parallel-design, individually randomized, double-blind, placebo-controlled, multicentre trial after a positive double-blind placebo-controlled oral food challenge (DBPCFC1). A central randomization centre used computer-generated tables to allocate treatments. Peanut (or placebo) capsules were ingested daily over a period of 24 weeks with increments every 2 weeks from 2 to 400 mg of peanut protein (pp). Primary outcome was tolerance of 400 mg of pp at DBPCFC2.

RESULTS

Thirty patients were included between September 2013 and May 2014. At DBPCFC2, unresponsiveness to 400 mg of pp was achieved in 17/21 peanut group patients (2 withdrawn patients) and 1/9 in the placebo group (Intention-to-treat analysis, P < .001, absolute difference = 0.7, 95%IC 0.43 0.96). Oropharyngeal symptoms were equally frequent in both groups. No dysphagia or other signs of eosinophilic oesophagitis occurred. Digestive adverse events (AE) were more frequent in the treated group (P = .02), but mild and without compliance issues. Only one severe advent event led to withdrawal in a patient who ingested twice the investigated treatment. Peanut-specific humoral immune responses were modulated.

CONCLUSION

The GIDOIT protocol demonstrated clinical and immunological efficacy and had an acceptable level of safety with weak oropharyngeal symptoms, no dysphagia, mild digestive events and few severe systemic AE.

Efficacy and safety of a T-type calcium channel blocker in patients with neuropathic pain: A proof-of-concept, randomized, double-blind and controlled trial

BACKGROUND

T-type calcium channels have been shown to play an important role in the initiation and maintenance of neuropathic pain and represent a promising therapeutic target for new analgesic treatments. Ethosuximide (ETX), an anticonvulsant and a T-type channel blocker has shown analgesic effect in several chronic pain models but has not yet been evaluated in patients with neuropathic pain.

METHODS

This proof-of-concept, multicentre, double-blind, controlled and randomized trial compared the efficacy and safety of ETX (given as add-on therapy) to an inactive control (IC) in 114 patients with non-diabetic peripheral neuropathic pain. After a 7-day run-in period, eligible patients aged over 18 years were randomly assigned (1:1) to ETX or IC for 6 weeks. The primary outcome was the difference between groups in the pain intensity (% of change from the baseline to end of treatment) assessed in the intention-to-treat population. This study is registered with EudraCT (2013-004801-26) and ClinicalTrials.gov (NCT02100046).

RESULTS

The study was stopped during the interim analysis due to the high number of adverse events in the active treatment group. ETX failed to reduce total pain and showed a poor tolerance in comparison to IC. In the per-protocol analysis, ETX significantly reduced pain intensity by 15.6% (95% CI -25.8; -5.4) from baseline compared to IC (-7.8%, 95% CI -14.3; -1.3; p = 0.033), but this result must be interpreted with caution because of a small subgroup of patients.

CONCLUSION

Ethosuximide did not reduce the severity of neuropathic pain and induces, at the doses used, many adverse events.

SIGNIFICANCE

This article shows that ETX is not effective to treat neuropathic pain. Nevertheless, per-protocol analysis suggests a possible analgesic effect of ETX. Thus, our work adds significant knowledge to preclinical and clinical data on the benefits of T-type calcium channel inhibition for the treatment of neuropathic pain.

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.