The natural history of canine occult Grade II medial patellar luxation: an observational study

OBJECTIVES

To determine the risk of lameness and the rate of subsequent medial patellar luxation surgery in dogs that present with occult Grade II medial patellar luxation.

MATERIALS AND METHODS

Retrospective owner survey and review of clinical records of adult dogs diagnosed with Grade II medial patellar luxation that were initially asymptomatic and managed non-surgically that had a minimum of 4-year follow-up. Clinical notes and owner questionnaires identified dogs that subsequently developed lameness and required surgery on the previously asymptomatic stifle.

RESULTS

Thirty-eight dogs were included with an average follow-up of 51 months. Seventeen dogs re-presented for unscheduled contralateral medial patellar luxation surgery at an average of 15 months after initial presentation. A further two dogs had chronic contralateral limb lameness after an average of 33 months after initial surgery and may have been potential surgical candidates.

CLINICAL SIGNIFICANCE

Fifty percent of adult dogs presenting with occult Grade II medial patellar luxation subsequently developed chronic lameness or required surgery.

Adult-onset systemic autoinflammatory disorders: a clinical approach

Autoinflammatory disorders (AIDs) are a subgroup of immune-mediated syndromes that result from a primary dysfunction of the innate immune system. AIDs can be either monogenic or polygenic diseases. Unlike organspecific AIDs, systemic AIDs are characterized by fever and/or elevation of acute-phase reactants. This review aims to describe the most common adult-onset systemic AIDs, focusing mostly on polygenic and mixed-pattern diseases which are expected to be more prevalent in adult patients than monogenic AIDs overall. The literature was searched in Medline database. Organ-specific or childhood-onset systemic AIDs were excluded. AIDs were divided in three distinct groups: mixed-pattern, polygenic and adult-onset monogenic AIDs. Most adult-onset AIDs are polygenic but late-onset disease is not rare among monogenic AIDs such as familial Mediterranean fever (FMF). The diagnosis of systemic AIDs in adults is often delayed due to several factors and sometimes it is only established when amyloidosis or other complications are present. Therefore, it probably makes sense to primarily exclude common AIDs in adult patients with fever of unknown origin (and probably different presentations such as polyserositis) since a high prevalence of adult-onset Still's disease or FMF is usually expected. Colchicine, nonsteroidal anti-inflammatory drugs, steroids, immunosuppressive agents, interleukin-1 inhibitors and tumor necrosis factor antagonists constitute common therapeutic options for systemic AIDs.

Solidarity and reciprocity in data governance: information sharing among gamete donors and recipients

Background

Decreasing fertility rates have spiralled a growth in demand for assisted reproduction technologies, including reproduction through donated gametes. Gamete donation is grounded on solidaristic practices traditionally focused on the gift of gametes. However, solidarity and reciprocity between donors and recipients may also be enacted through the sharing of other types of information (e.g. donation outcomes, medical and identifying information). Little is known, however, about these stakeholders’ preferences regarding information sharing, which is crucial to promoting people-centred policy for data governance in gamete donation.

Methods

A self-report structured questionnaire was completed by 69 donors and 161 recipients (participation rate: 77.4%) between July 2017 and April 2018 at the Portuguese Public Bank of Gametes. Opinions about access to donation outcomes and medical, extended profile and identifying information about recipients, donors and children were analysed using descriptive statistics.

Results

Most participants considered that recipients should not have access to donors’ identifying (92%) and extended profile (79%) information, but that they should access donors’ medical information (58%). Donors stated more frequently that they should receive information about the outcomes of donation (e.g. pregnancies and births) than recipients (32% vs. 12%). Participants also disagreed with donors’ access to recipients’ medical (83%) and extended profile information (92%) and children’s identifying information (98%).

Conclusions

People-centred policy on data governance in gamete donation should be informed by donor and recipients’ preferences. Sharing donation outcomes with donors and medical information from donors with recipients can foster solidarity and reciprocity between them. This requires the development of a matching mechanism (via consent) to accommodate their preferences.

Key messages

Policy on data governance should be informed by gamete donors and recipients’ preferences. Sharing desired information with donors and recipients can foster solidarity and reciprocity between them.

Public participation in health data governance: a scoping review

Background

The sheer growth of the health data shared and traded globally holds great promise and menace to public health. Big health data can foster scientific advancements with potential to heal millions across the globe. However, inerasable digital footprints left by the use of apps and digital services challenge people’s privacy and autonomy in (un)foreseeable ways that may cause them to stop sharing data. While many argue that public participation in data governance is a right, others view it as a means to increase data subjects’ recruitment and amass large quantities of data. Little systematic knowledge exists, however, about the arguments for and impact of public participation on health data policy and management.

Methods

A descriptive systematic scoping review was performed. Studies indexed in PubMed, WoS and PsycINFO published until March 2019 were searched. Only empirical, original, peer-reviewed studies reporting on public participation on health data governance were included. Eligibility and data extraction were performed by 3 researchers.

Results

The 21 studies analyzed point to public participation in several governance dimensions including data access, linkage, dissemination and policy. Involvement of (potential) data subjects in health data governance was substantiated by democratic arguments of legitimacy, transparency and accountability. However, the need to earn public support for data generation and use can override these arguments and foster utilitarian approaches that may transform participatory exercises into a technology of legitimation for a priori made decisions. Furthermore, although public participation in data governance can deliver instrumental benefits (e.g. participant-centred data policy), systematic assessment of participatory exercises’ impact is lacking.

Conclusions

Public participation in health data governance can promote public trust in and thrust for science. Further research is needed to fully assess its impact.

Key messages

Democratic-led participatory exercises in health data governance can foster public trust in science. Further research is needed to fully assess the impact of public participation in data governance.

Parental socioeconomic position and chronic inflammation during adolescence

Background

Early life adversity has been associated with increased risk of inflammation and inflammation-related diseases in adulthood. This study aimed to examine the association of parental socioeconomic position with chronic inflammation over adolescence.

Methods

We used information on 2942 members (1507 girls and 1435 boys) of the EPITeen cohort that was established in 2003 in Porto, Portugal, and included 13 years old adolescents that were further evaluated at 17 and 21 years. Mother’ and father’s education and occupation were used as indicators of parental socioeconomic position. High-sensitivity C-reactive protein (CRP) was measured at three points in time (13, 17 and 21 years). CRP levels were categorized in tertiles separately for each wave; chronic inflammation in adolescence was defined as having CRP levels in the highest tertile in at least 2 waves and never in the lowest tertile.

Results

Over adolescence, the prevalence of chronic inflammation was significantly higher among participants with low parental socioeconomic position. Low parental socioeconomic position was associated with chronic inflammation in adolescence, after adjustment for sex, perinatal and physical environment factors, health-related behaviours and health status in adolescence OR = 1.63; 95%CI: 1.11, 2.40 for lowest vs. highest mother’s education and OR = 1.61; 95%CI: 1.12, 2.30 for lowest vs. highest father’s education.

Conclusions

Low parental socioeconomic position is associated with chronic inflammation during adolescence. Our results suggest that the early life socioeconomic environment has an impact on inflammatory processes over adolescence.

Assessing the use and understanding of the Portuguese Heat–Health Warning System (ÍCARO)

Background

Heatwaves can lead to increased mortality. Portugal has a Heat-Health Warning System (HHWS) in place (ÍCARO system). Researchers at the Instituto Ricardo Jorge send a daily report with heat-related mortality forecasts to key stakeholders (e.g. Heat-Health Action Plans (HHAP) staff). HHAP practitioners issue warnings and implement measures to prevent heatwaves-related mortality. ICARO is amongst the recommended data sources to assess risk and issue warnings but its use and understanding is unknown. Therefore, we aimed to assess ÍCARO’s use and understanding by key HHAP practitioners.

Methods

We conducted semi-structured interviews with national and regional HHAP practitioners. Interviews were recorded, transcribed, and analysed using thematic content analysis. Intercoder reliability was applied to a sample of segments from 5 of 6 interviews.

Results

We conducted 6 interviews with 9 professionals (mean time 52 minutes). We identified 4 categories: Report’s content and presentation, Report’s reception and communication, ÍCARO and risk assessment, Other issues. Practitioners use ÍCARO and perceived it as very relevant tool. However, they mentioned several questions on its interpretation. Practitioners also felt their questions were not fully answered, given researchers’ use of statistical terms. Finally, practitioners referred the need to assess risk at the local level, information not currently provided. We also identified the need for improved communication and report’s clarity.

Conclusions

Our study stresses the need for an integrated collaboration between experts within HHWS and HHAP. Despite ICARO’s understanding being challenging, practitioners consider it a relevant tool. Researchers should use less statistical language and clarify ÍCARO interpretation. Practitioners’ needs should be considered when developing or revising tools. We are currently implementing some of these recommendations in an attempt to close the gap between researchers and practitioners.

Key messages

Portuguese Heat–Health Action Plans practitioners use heat-related mortality forecasts (ICARO) and perceived it as very relevant instrument. However there find ICARO’s interpretation challenging. Portuguese Heat/Health Action Plans Practitioners’ needs should be considered when revising or developing tools, and notes should be added to clarify statistical/technical concepts.

Changing criteria of access to gamete donation: the views of donors and recipients

Background

Differences on the use of sexual orientation and marital status as criteria to define access to gamete donation persist in Europe, contributing to the search of cross border reproductive care (CBRC). The lack of international policy and norms on CBRC highlight the need for surveillance to ensure quality and equitable access to reproductive care, namely by assessing donors’ and recipients’ views. This study aims to analyze the opinion of donors and recipients about the use of marital status and sexual orientation as priority criteria for accessing gamete donation, and its associated factors.

Methods

Between July 2017 and June 2018, 72 donors and 171 recipients completed a self-report questionnaire at the Portuguese Public Bank of Gametes. Opinion about the use of marital status and sexual orientation as priority criteria was assessed through a 5-point Likert scale of agreement, ranging from “totally disagree” to “totally agree”. Descriptive statistics and multinomial logistic regression were used.

Results

Most participants disagreed with a priority of access to gamete donation for heterosexual couples (61%) and married women (60%). Participants who agreed with priority to heterosexual couples were more likely to be males (OR = 2.5, CI95% 1.2-5.3) and married or living with a partner (OR = 3.5, CI95% 1.1-10.8). Males (OR = 3.18, CI95% 1.5-6.9) and those with lower white collar (OR = 3.0, CI95% 1.2-7.4) or blue collar occupations (OR = 4.3, CI95% 1.4-13.1) were more likely to agree with priority for married women.

Conclusions

Donors and recipients agree with equitable access to gamete donation, independently of sexual orientation and marital status. However, a heterosexual marriage hierarchy is particularly observed on male, married/living with a partner, and with lower white or blue collar occupations participants. Policy on reproductive care needs to be especially mindful of equity in access to gamete donation.

Key messages

Donors and recipients agree with access to gamete donation independent of sexual orientation and marital status. Policy on reproductive care needs to be mindful of equity in access to gamete donation.

Le réanimateur au cœur du débat sociétal sur la fin de vie, trois ans après la loi Claeys-Leonetti

La loi Claeys-Leonetti a trois ans. Elle consacre la sédation profonde et continue jusqu’au décès dans certaines circonstances, elle rend contraignantes les directives anticipées pour le corps médical, et elle établit un vrai contrat de confiance entre le patient et sa personne de confiance. Dans un contexte de méconnaissance de cette loi, un sentiment de « mal mourir » persiste. Notamment, le choix d’un terme de pronostic vital engagé à quelques heures ou jours est perçu comme trop restrictif pour certains patients souffrant psychiquement ou physiquement dans les suites d’une maladie aiguë ou chronique. L’arrêt de la nutrition et de l’hydratation pose également des problèmes d’interprétation qui mériteraient d’être précisés. Cela conduit à une demande d’évolution législative vers l’euthanasie ou l’assistance au suicide. Une telle évolution, déjà pratiquée au Benelux depuis presque 20 ans non sans que le débat y persiste, doit être bien soupesée pour éviter les pièges d’une conception utilitariste de la vie. Mais elle doit aussi être posée en regard de la demande croissante d’autonomie qui ne constitue qu’une réponse logique et respectable aux progrès vertigineux de la médecine. Les priorités actuelles sont, d’une part, d’informer et de discuter des possibilités données par la loi actuelle et, d’autre part, de mettre en œuvre une politique globale diminuant les situations où le sentiment d’indignité de la fin de vie est prégnant. Les équipes de réanimation, par les conséquences proches comme plus lointaines de leur décision, sont et doivent rester au cœur de cette réflexion.

Functional outcomes in adult patients with herpes simplex encephalitis admitted to the ICU: a multicenter cohort study

PURPOSE

We aimed to study the association of body temperature and other admission factors with outcomes of herpes simplex encephalitis (HSE) adult patients requiring ICU admission.

METHODS

We conducted a retrospective multicenter study on patients diagnosed with HSE in 47 ICUs in France, between 2007 and 2017. Fever was defined as a body temperature higher or equal to 38.3 °C. Multivariate logistic regression analysis was used to identify factors associated with poor outcome at 90 days, defined by a score of 3-6 (indicating moderate-to-severe disability or death) on the modified Rankin scale.

RESULTS

Overall, 259 patients with a score on the Glasgow coma scale of 9 (6-12) and a body temperature of 38.7 (38.1-39.2) °C at admission were studied. At 90 days, 185 (71%) patients had a poor outcome, including 44 (17%) deaths. After adjusting for age, fever (OR = 2.21; 95% CI 1.18-4.16), mechanical ventilation (OR = 2.21; 95% CI 1.21-4.03), and MRI brain lesions > 3 lobes (OR = 3.04; 95% CI 1.35-6.81) were independently associated with poor outcome. By contrast, a direct ICU admission, as compared to initial admission to the hospital wards (i.e., indirect ICU admission), was protective (OR = 0.52; 95% CI 0.28-0.95). Sensitivity analyses performed after adjustment for functional status before admission and reason for ICU admission yielded similar results.

CONCLUSIONS

In HSE adult patients requiring ICU admission, several admission factors are associated with an increased risk of poor functional outcome. The identification of potentially modifiable factors, namely, elevated admission body temperature and indirect ICU admission, provides an opportunity for testing further intervention strategies.

Phenotype and Variant Spectrum in the LAMB3 Form of Amelogenesis Imperfecta

Amelogenesis imperfecta (AI) is a heterogeneous group of inherited disorders characterized by abnormal formation of dental enamel, either in isolation or as part of a syndrome. Heterozygous variants in laminin subunit beta 3 ( LAMB3) cause AI with dominant inheritance in the absence of other cosegregating clinical features. In contrast, biallelic loss-of-function variants in LAMB3 cause recessive junctional epidermolysis bullosa, characterized by life-threatening skin fragility. We identified 2 families segregating autosomal dominant AI with variable degrees of a distinctive hypoplastic phenotype due to pathogenic variants in LAMB3. Whole exome sequencing revealed a nonsense variant (c.3340G>T, p.E1114*) within the final exon in family 1, while Sanger sequencing in family 2 revealed a variant (c.3383-1G>A) in the canonical splice acceptor site of the final exon. Analysis of cDNA from family 2 revealed retention of the final intron leading to a premature termination codon. Two unerupted third molar teeth from individual IV:5 in family 2 were subject to computerized tomography and scanning electron microscopy. LAMB3 molar teeth have a multitude of cusps versus matched controls. LAMB3 enamel was well mineralized but pitted. The architecture of the initially secreted enamel was abnormal, with cervical enamel appearing much less severely affected than coronal enamel. This study further defines the variations in phenotype-genotype correlation for AI due to variants in LAMB3, underlines the clustering of nonsense and frameshift variants causing AI in the absence of junctional epidermolysis bullosa, and highlights the shared AI phenotype arising from variants in genes coding for hemidesmosome proteins.

Insuffisances rénales aiguës : actes du 5e Séminaire de recherche translationnelle de la Société de réanimation de langue française (Paris, 4 décembre 2018)

Le séminaire annuel de la commission de recherche translationnelle de la SRLF a eu lieu à Paris le 4 décembre 2018. Ce séminaire a pour but de réunir des cliniciens et scientifiques autour de grandes thématiques de recherche en médecine intensive et réanimation. La cinquième édition a porté sur l’insuffisance rénale aiguë, problématique quotidienne importante des réanimateurs. Les interventions se sont intéressées à la physiopathologie des diverses formes d’insuffisance rénale aiguë, à la récupération rénale, aux modèles expérimentaux, à l’hémodynamique régionale ou encore aux innovations technologiques en épuration extrarénale.

Mesures de prévention non pharmacologiques du delirium de réanimation

Le delirium est défini par un changement brutal ou rapidement progressif de l’état mental ou une modification de l’humeur associés à une baisse des capacités de concentration, à une désorganisation de la pensée, à une confusion et à une altération du niveau de conscience. L’incidence du delirium en réanimation est variable d’environ 4 à 83 %, selon les études. Cela est probablement lié à la variété des outils de mesure employés, au niveau d’entraînement des professionnels de santé établissant ces scores, à la profondeur de la sédation et aux différences de populations étudiées. Son étiologie semble être multifactorielle. Il a été montré que la survenue du delirium a un fort impact sur le pronostic vital et fonctionnel des patients en réanimation, car son incidence est associée à une augmentation de la mortalité hospitalière précoce et tardive, et le déclin cognitif qui lui est associé peut persister à distance du séjour en réanimation. Il est important de souligner que la prise en charge dans les soins critiques est très hétérogène. Néanmoins, de nouvelles données de la littérature apportent des éléments concrets sur la prise charge de ce syndrome et fournissent un guide utile à la pratique paramédicale dans la prévention et le dépistage de ce trouble cognitif. L’objectif de ce travail est d’apporter une synthèse autour de la littérature disponible dans ce domaine, mettant en lumière le rôle clé de la profession paramédicale dans ce contexte afin d’identifier des éléments diagnostiques et thérapeutiques susceptibles de modifier pertinemment les pratiques soignantes.