Altered quality of life in Rendu-Osler-Weber disease related to recurrent epistaxis

OBJECTIVES

Development and validation of an epistaxis-specific quality-of-life questionnaire (EQQoL) to evaluate the impact on quality of life of epistaxis, during hereditary hemorrhagic telangiectasia (HHT).

STUDY DESIGN

Prospective clinical study using QoL instruments administered twice in HHT patients.

PATIENTS AND METHODS

In total, 109 patients who had epistaxis and a clinical diagnosis of HHT according to Curacao criteria were included. Invoice of the questionnaire in 2004 and 2006 included SF-36, Jenkins` sleep scale and the new epistaxis-specific13-item EQQoL.

RESULTS

EQQoL uptake rate was 98%, mean score 58/100 +- 27, and Cronbach alpha 0.96. EQQoL was sensitive to change with a strong correlation with the course of epistaxis. Factorial analysis showed that EQQoL was clearly distinct from SF-36 and Jenkins sleep scales. In stepwise multivariate ordinal logistic regression, frequency and duration of epistaxis were both associated with lower EQQoL. Conversely, visceral involvement and comorbidity had independent impact on SF-36 scores, but not on EQQoL.

CONCLUSIONS

This new epistaxis-specific EQQoL questionnaire provides complementary information on the impact of HHT on patients quality of life relative to the SF-36 generic questionnaire. After international validation, the EQQoL might prove a useful tool for treatment evaluation.

Automated classification of free-text pathology reports for registration of incident cases of cancer

OBJECTIVE

Our study aimed to construct and evaluate functions called "classifiers", produced by supervised machine learning techniques, in order to categorize automatically pathology reports using solely their content.

METHODS

Patients from the Poitou-Charentes Cancer Registry having at least one pathology report and a single non-metastatic invasive neoplasm were included. A descriptor weighting function accounting for the distribution of terms among targeted classes was developed and compared to classic methods based on inverse document frequencies. The classification was performed with support vector machine (SVM) and Naive Bayes classifiers. Two levels of granularity were tested for both the topographical and the morphological axes of the ICD-O3 code. The ability to correctly attribute a precise ICD-O3 code and the ability to attribute the broad category defined by the International Agency for Research on Cancer (IARC) for the multiple primary cancer registration rules were evaluated using F1-measures.

RESULTS

5121 pathology reports produced by 35 pathologists were selected. The best performance was achieved by our class-weighted descriptor, associated with a SVM classifier. Using this method, the pathology reports were properly classified in the IARC categories with F1-measures of 0.967 for both topography and morphology. The ICD-O3 code attribution had lower performance with a 0.715 F1-measure for topography and 0.854 for morphology.

CONCLUSION

These results suggest that free-text pathology reports could be useful as a data source for automated systems in order to identify and notify new cases of cancer. Future work is needed to evaluate the improvement in performance obtained from the use of natural language processing, including the case of multiple tumor description and possible incorporation of other medical documents such as surgical reports.

Does plasma IGF-BP3 measurement contribute to the diagnosis of growth hormone deficiency in children?

OBJECTIVE

To audit the contribution of plasma IGF-PB3 measurement to the diagnosis of growth hormone deficiency (GHD) in children.

POPULATION AND METHODS

Retrospective case study including boys and girls aged 0 to 18 years who attended our paediatric endocrinology clinic for short stature and/or post-irradiation follow-up, and had at least one GH provocative testing. Children with hypothyroidism, Laron or Kowarski syndromes, severe malnutrition, chronic renal failure and liver failure were excluded.

RESULTS

Fifty-eight children were enrolled and grouped as GHD [+] (19 cases) and GDH [-] (39 cases). IGF-I and IGF-BP3 assay was carried out in 88% and 62% cases respectively, both groups were comparable for age, sex, BMI, target height, pubertal stage and bone age. There was a significant difference in peak GH between GDH [-] and GHD [+] groups (41.8 mUI/L ± 21.7 versus 11.5 ± 5.9 mUI/L, P<0.00001, respectively). No difference was found between groups with regards to IGF-I Z-scores and IGF-BP3 Z-scores. There was, however, a positive correlation between IGF-I Z-scores and IGF-BP3 Z-scores (r=0.50; P<0.0016). IGF-BP3 measurement could not differentiate between GHD [+] and GHD [-] groups.

CONCLUSIONS

Measurement of plasma IGF-BP3 level contributes poorly to the diagnosis of GHD. We do not recommend it in routine use.

Adolescents consulting a GP accompanied by a third party: comparative analysis of representations and how they evolve through consultation

BACKGROUND

Adolescents are frequently accompanied by a third party in consultation. Their stated reason for consulting is rarely psychological. However, many adolescents experience distress or impaired well-being that practitioners fail to detect.

OBJECTIVES

To study the ability of adolescents to express personal concerns in general medicine consultations depending on if an accompanier is present and to explore perceptions of participants and how they evolved.

METHODS

Six hundred and seventy-four adolescent consultations with 53 GPs were studied. The adolescents and any persons accompanying completed self-administered questionnaires before and after the consultation, the GPs only afterwards. Analyses compared responses before and after consultation and between participants.

RESULTS

Six per cent of the adolescents were consulting for a psychological reason, but, among the others, 17% reported having personal concerns they would like to talk about. Among adolescents aged 14-17 years, those consulting alone more frequently reported personal worries but were more satisfied with the consultation than the others. A third party's presence did not appear to hinder expression for those that consulted accompanied. The representations of the third party and practitioner concerning the adolescent differed, although they tended to converge following the consultation: accompaniers overestimated the adolescents' well-being and freedom to talk, while GPs underestimated their well-being, readiness to confide and feelings of being understood.

CONCLUSIONS

GPs could be more optimistic about adolescent consultations: their role is viewed more positively than they think, especially by adolescents consulting alone. The majority of adolescents wishing to say something do so, even when an accompanier is present.

Determinants of participation in colonoscopic screening by siblings of colorectal cancer patients in France

Background

Targeted colonosocopic screening is recommended for first-degree relatives of colorectal cancer patients diagnosed before the age of 60 and offers the possibility of reducing morbidity and mortality, but participation remains too low. The objective of this study was to determine in a French population the factors that affect siblings' participation in screening, notably those relating to the individuals, their medical care, their family and their social network.

Methods

A cross sectional survey was conducted in siblings of index patients having undergone surgery for colorectal cancer between 1999 and 2002 in two French counties. Siblings were contacted during 2007 and 2008 through the index patient. The factors affecting participation in colonoscopic screening were studied by logistic regression taking into account family cluster effect.

Results

172 siblings of 74 index cases were included. The declared rate of undergoing at least one colonoscopy among siblings was 66%; 95%CI 59-73%. Five variables were independently associated with colonoscopic screening: perceiving fewer barriers to screening (OR = 3.2; 95%CI 1.2-8.5), having received the recommendation to undergo screening from a physician (OR = 4.9; 1.7-13.7), perceiving centres practising colonoscopy as more accessible (OR = 3.2, 1.3-7.8), having discussed screening with all siblings (OR = 3.9; 1.6-9.6) and being a member of an association (OR = 2.6; 1.0-6.6).

Conclusions

The factors independently associated with participation in CRC screening by an individual at increased risk belonged to each of four dimensions relating to his individual psychosocial characteristics, to his relationship with a physician, within the family and social environment. The relevance of these results to clinical practice may help to improve compliance to recommendations in a global preventive strategy including all stages of the information pathway from the physician to the index patient and his relatives.

[Accidents in a population of 350 adolescents and young adults: circumstances, risk factors and prediction of recurrence]

Accidents among adolescents and young adults are a public health issue, and present two main characteristics: a strong association with sporting activities, and frequent recurrence. Sports accidents are generally relatively benign, but they show a marked tendency to recur Young people engaging in sporting activities do not generally exhibit psychological traits different from the general population. In contrast, the other types of accident, and particularly domestic and traffic accidents, appear to have specific features: they are often more serious, but above all they are associated with psychopathologic features, including depression, anxiety, disorders due to life events, and thrill-seeking These psychopathological features are strongly associated with recurrence. The authors describe a simple self-administered questionnaire (ECARR) designed to assess the risk of accident recurrence in this population.

[Interactions between teenagers and general practitioners during consultations: progression of felt disquiet and impact of physicians' training. SOCRATE 1 study]

OBJECTIVE

This study aimed at assessing the frequency of adolescents'ill-being beyond their complaint during a general practitioner's (GP) consultation, analyzing the progression of their feeling during an ordinary consultation, comparing it to the physician's feeling and checking whether this feeling could correlate a short and specific training received by the physician.

METHOD

53 physicians were divided into 2 groups: 29 physicians experienced with adolescents and 24 control physicians from a non-adjacent department. 665 consultations involving adolescents aged 12-20 years were analyzed using 2 questionnaires filled in by adolescents before and after the consultation as well as a questionnaire filled in by physicians at the end of the consultation.

RESULTS

Among adolescents consulting for "non-psychological" complaints, one out of six acknowledged having other problems. Sixty percent of them considered talking about these problems during the consultation. During a single GP's consultation, the adolescents'sensation of feeling good about themselves, being understood and listened to significantly improved. However, such an improvement did not depend on the physician's experience in adolescents. Nevertheless, experienced physicians are more circumspect than control physicians regarding the level of well-being felt or put forward by adolescents.

CONCLUSION

The study reveals that a short awareness program is sufficient to sustainably draw general practitioners' attention on teenagers' disquiet, but insufficient to induce an improvement of teenagers' feeling, which is anyhow recorded during a consultation. Measuring an impact on teenagers requires a probably more thorough training for physicians and a longer-term analysis by teenagers.

General practitioner and specialist views on colonoscopic screening of first-degree relatives of colorectal cancer patients

INTRODUCTION

Barriers to targeted colonoscopic screening of first-degree relatives of colorectal cancer patients have been the subject of considerable literature, always as seen from the patient's viewpoint. In the specific context of screening individuals with a family history, physicians may also play a predominant role in motivating their colorectal cancer patients to pass on screening information to their relatives. The aim of this study was to examine the views of general practitioners and specialists regarding barriers and facilitators affecting participation of relatives in colonoscopic screening.

METHODS

A qualitative study was conducted to collect and analyse information from two focus groups of 4 general practitioners and 9 gastroenterologists respectively, and from semi-structured individual interviews with 10 general practitioners, 2 surgeons and 3 oncologists. An extended focus group of 36 gastroenterologists was organized to validate the results.

RESULTS

The main barriers to colonoscopic screening of FDRs were associated with lack of direct communication between physicians and FDRs. Physicians needed support in the task of informing index patients and persuading them to transfer information on screening to their FDRs. The general practitioners spoke of their expectations in terms of training in and motivation for promoting screening and the gastroenterologists expressed the wish for patient education material specific to colonoscopy and for systematic post-colonoscopy consultations to inform patients about their results, follow-up and screening their relatives.

CONCLUSION

The findings, notably the need for specific education materials and for training to improve the motivation of physicians, will help to develop effective interventions intended to increase participation in screening.

Liver fibrosis staging with contrast-enhanced ultrasonography: prospective multicenter study compared with METAVIR scoring

We prospectively assessed contrast-enhanced sonography for evaluating the degree of liver fibrosis as diagnosed via biopsy in 99 patients. The transit time of microbubbles between the portal and hepatic veins was calculated from the difference between the arrival time of the microbubbles in each vein. Liver biopsy was obtained for each patient within 6 months of the contrast-enhanced sonography. Histological fibrosis was categorized into two classes: (1) no or moderate fibrosis (F0, F1, and F2 according to the METAVIR staging) or (2) severe fibrosis (F3 and F4). At a cutoff of 13 s for the transit time, the diagnosis of severe fibrosis was made with a specificity of 78.57%, a sensitivity of 78.95%, a positive predictive value of 78.33%, a negative predictive value of 83.33%, and a performance accuracy of 78.79%. Therefore, contrast-enhanced ultrasound can help with differentiation between moderate and severe fibrosis.

Intravenous nitroglycerin for prevention of pancreatitis after therapeutic endoscopic retrograde cholangiography: a randomized, double-blind, placebo-controlled multicenter trial

BACKGROUND AND STUDY AIMS

Several studies have suggested that nitroglycerin promotes pancreatic drainage and thereby helps to prevent pancreatitis occurring after endoscopic retrograde cholangiography (ERC). We performed a multicenter, double-blind, randomized, placebo-controlled trial to evaluate the efficacy of intravenous nitroglycerin for preventing acute pancreatitis in moderate- to high-risk patients undergoing ERC.

PATIENTS AND METHODS

The patients underwent therapeutic ERC for gallstone removal, bile duct stenosis, or sphincter of Oddi dysfunction (SOD). They were randomly allocated to receive an intravenous nitroglycerin bolus of 0.1 mg, then 35 microg/kg per minute intravenously (maximum dose 9 mg) for 6 h, or an identical placebo regimen. Serum amylase and lipase levels were determined before and 24 h after ERC.

RESULTS

The study was terminated after the interim analysis. The intention-to-treat population consisted of 208 patients enrolled in 20 centers, of whom 105 received nitroglycerin and 103 placebo therapy. Post-ERC pancreatitis (mild/moderate/severe) occurred in 25 patients, comprising 10 (3/5/2) in the nitroglycerin arm and 15 (5/6/4) in the placebo arm (OR 0.62, 95 % CI 0.26 - 1.45; P = 0.26). Pancreatitis-related hospital stays were similar in the two groups (median 4 days, range 2 - 13 days in the nitroglycerin group; median 5 days, range 2 - 20 days in the placebo group). The incidence of pancreatitis in patients with SOD did not differ between the groups (4/11 in the nitroglycerin arm, and 4/15 in the placebo arm). Adverse events were more frequent in the nitroglycerin group and led to cessation of drug infusion in 10 patients in the nitroglycerin arm and in 2 patients in the placebo arm ( P = 0.019).

CONCLUSION

In this study, nitroglycerin offered a limited and clinically nonsignificant benefit for the prevention of post-ERC pancreatitis. Its use did not improve the technical success rate of ERC.

Assessing 2-month clinical prognosis in hospitalized patients with advanced solid tumors

PURPOSE

The aim of this study was to assess clinical, laboratory, and subjective (patient's preferences) prognostic factors in hospitalized patients with advanced solid tumors.

PATIENTS AND METHODS

This prospective study surveyed 177 patients from two French hospitals who had not reached the stage of active dying but had an estimated survival of less than 6 months (median survival, 58 days).

RESULTS

Univariate analysis showed that 10 of the 13 clinical and laboratory factors reported in the literature affected survival at 2 months. Poor prognostic factors were number of metastatic sites, cerebral metastasis, low Karnofsky index, dyspnea at rest, anorexia, edema, confusion, low serum albumin, extremely high leukocyte counts, and high lactate dehydrogenase (LDH) levels. The patient's desire to continue curative treatment was also associated with survival. The multivariate analysis selected four independent criteria: Karnofsky index (in three classes: <or= 30%, 40% to 60%, or >or= 70%), number of metastatic sites (>or= two or < two), low serum albumin (in three classes: <or= 24, 24 to 33, and >or= 33 g/L), and LDH concentration (>or= 600 IU or < 600 IU). The combination of these four criteria assessed prognosis better than the Karnofsky index alone, producing three prognostic profiles: one with short survival (< 2 months: no patient survived to 4 months); one with an expectation of intermediate survival (25% were alive at 4 months), and a final group surviving for several months (80% were alive at 4 months).

CONCLUSION

The prognostic profiles defined by combinations of these four factors may be potentially useful but need further validation before their application in the daily practice.