PREMIUM: A French prospective multicenter observational study of factors impacting on efficacy and compliance to cetuximab treatment in first-line KRAS wild-type metastatic colorectal cancer

Background

Cetuximab improves progression-free survival (PFS) and overall survival (OS) in patients with KRAS wild type (wt) metastatic colorectal cancer (mCRC). Few data are available on factors impacting both efficacy and compliance to cetuximab treatment, which is, in combination with chemotherapy, a standard-of-care first-line treatment regimen for patients with KRAS wt mCRC.

Patients and methods

PREMIUM is a prospective, French multicenter, observational study that recruited patients with KRAS wt mCRC scheduled to receive cetuximab, with or without first-line chemotherapy, as part of routine clinical practice, between October 28, 2009 and April 5, 2012 (ClinicalTrials.gov Identifier: NCT01756625). The main endpoints were the factors impacting on efficacy and compliance to cetuximab treatment. Predefined efficacy endpoints were PFS and safety.

Results

A total of 493 patients were recruited by 94 physicians. Median follow-up was 12.9 months. Median progression-free survival was 11 months [9.6–12]. In univariate analyses, ECOG performance status (PS), smoking status, primary tumor location, number of metastatic organs, metastasis resectability, surgery, folliculitis, xerosis and paronychia maximum grade, and acne preventive treatment were statistically significant. In multivariate analysis (Hazard Ratios of multivariate stepwise Cox models), ECOG PS, surgery, xerosis and folliculitis were positive prognostics factors for longer PFS. Among all patients, 69 (14%) were non-compliant. In multivariate analysis, no variables were statistically significant. The safety profile of cetuximab was consistent with previous studies.

Conclusions

ECOG PS <2, surgical treatment performed, and maximum grade xerosis or folliculitis developed were predictive factors of cetuximab efficacy on KRAS wt mCRC patients. Unfortunately, we failed in identifying predictive factors for compliance in these patients.

Mortality Attributable to Nosocomial Infection: A Cohort of Patients With and Without Nosocomial Infection in a French University Hospital

Objective

To assess nosocomial infection (NI) as a risk factor for death and to estimate the population-attributable risk of death from NI.

Design.

A prospective cohort study of patients with and without NI.

Setting.

Nîmes University Hospital, Nîmes, France.

Patients.

Patients were recruited from May 7, 2001, to January 10, 2003. Patients in acute care and long-term care units who had NI were enrolled, and patients without NI were randomly selected and matched with patients with NI for age, sex, type of care (acute care vs. long-term care) and length of stay in hospital at study inclusion.

Outcome Measures.

Vital status within 60 days after study inclusion was assessed. We used conditional logistic regression to estimate the relative death risk from NI after adjusting for comorbidities, severity of the underlying disease, and all other confounding factors. The adjusted population-attributable risk was assessed using the Mantel-Haenszel method.

Results.

We recruited 1,914 patients with NI and 5,172 patients without NI. The median age of the patients with NI was 73 years; 1,045 (54.6%) were female. NI was associated with death within 60 days (adjusted odds ratio, 1.7 [95% confidence interval {CI}, 1.4—;2.2]; P-C.001). The adjusted population-attributable risk of death for all sites of infection was 1.7% (95% CI, 1.4-2.1). If we consider the NI incidence to be 3%-6% in French hospitals, the population-attributable risk of death from NI would range from 2.1% (95% CI, 1.7%-2.5%) to 4.0% (95% CI, 3.3%-4.9%).

Conclusion.

In this study, NI appeared to have a significant impact on mortality. Multicenter studies will be needed to confirm these results.

Climatic drivers of seasonal influenza epidemics in French Guiana, 2006-2010

OBJECTIVES

Influenza seasonality remains poorly studied in Equatorial regions. Here we assessed the seasonal characteristics and environmental drivers of influenza epidemics in French Guiana, where influenza surveillance was established in 2006.

METHODS

Sentinel GPs monitored weekly incidence of Influenza-like illnesses (ILI) from January 2006 through December 2010 and collected nasopharyngeal specimens from patients for virological confirmation. Times series analysis was used to investigate relationship between ILI and climatic parameters (rainfall and specific humidity).

RESULTS

Based on 1533 viruses identified during the study period, we observed marked seasonality in the circulation of influenza virus in the pre-pandemic period, followed by year-round activity in the post-pandemic period, with a peak in the rainy season. ILI incidence showed seasonal autoregressive variation based on ARIMA analysis. Multivariate dynamic regression revealed that a 1 mm increase of rainfall resulted in an increase of 0.33% in ILI incidence one week later, adjusting for specific humidity (SH). Conversely, an increase of 1 g/kg of SH resulted in a decrease of 11% in ILI incidence 3 weeks later, adjusting for rainfall.

CONCLUSIONS

Increased rainfall and low levels of specific humidity favour influenza transmission in French Guiana.

Could B-type Natriuretic Peptide (BNP) plasma concentration be useful to predict fluid responsiveness [corrected] in critically ill patients with acute circulatory failure?

BACKGROUND AND OBJECTIVES

As B-type Natriuretic Peptide (BNP) is a marker of ventricular wall stress, the present study was aimed at determining whether plasma BNP concentration could predict fluid responsiveness in critically ill patients with acute circulatory failure.

METHODS

This prospective and non randomized interventional study included 33 sedated, mechanically ventilated patients, with acute circulatory failure requiring cardiac output measurement and fluid challenge. Plasma BNP concentration was measured before and after fluid challenge (250 to 500 ml with infusion rate=999 ml/h). An increase in stroke index (SI) greater than or equal to 15% allowed separation of responders from nonresponders. Receiver operating characteristic (ROC) curves were generated for BNP and compared to that of central venous pressure (CVP) that is routinely considered as a marker of cardiac preload.

RESULTS

Among 33 patients, there were 24 responders. At baseline, BNP plasma values were less in responders (328 [35-1190] pg/ml versus 535 [223-5000] pg/ml, p<0.03). The area under the ROC curves was 0.74+/-0.11, that was similar to the area under the ROC curve for CVP (0.77+/-0.10). The best cut-off value of plasma BNP level for predicting fluid responsiveness was 193 pg/ml (sensitivity: 38%, specificity: 100%, positive predictive value: 100%, negative predictive value: 38%, accuracy: 55%). Fluid challenge did not increase plasma BNP concentrations in responders and nonresponders.

CONCLUSION

In critically ill patients with acute circulatory failure, BNP does not accurately predict fluid responsiveness.

Bone metastasis from endometrioid ovarian carcinoma: a case study and literature review

INTRODUCTION

Bone metastases from epithelial ovarian carcinoma are rare, usually discovered postmortem. The survival of these patients is poor. Furthermore, only two cases of endometrioid ovarian carcinoma with metastasis to the skeletal structures have been described in the literature.

CASE REPORT

We present the case of a 58-year-old woman with a lytic metastasis in the left iliac ramus from endometrioid ovarian carcinoma that occurred seven years after the initial diagnosis.

DISCUSSION

A review of the literature since 1966 on bone metastasis of ovarian cancer is also presented. In patients suffering from a neoplasm that rarely metastasises to bone, histological proof should be obtained to diagnose uncommon sites of disease relapse.

Impact of infection control interventions and antibiotic use on hospital MRSA: a multivariate interrupted time-series analysis

Hospitals in the northeast of Scotland have experienced methicillin-resistant Staphylococcus aureus (MRSA) outbreaks since 1997. Several infection control measures were introduced sequentially to control MRSA, and antibiotic use has been monitored. From January 1997 to December 2004, data on the monthly percentage of non-duplicate MRSA infections (%MRSA) were collated from an intervention hospital (IH) and a control hospital (CH). Both hospitals introduced the use of alcohol hand gel in November 2002. Furthermore, the IH introduced an environmental MRSA swabbing programme in March 2001, chlorine disinfection of the environment in September 2001, discharge screening in December 2001, admission screening in November 2003 and environmental audits in March 2004. Multivariate dynamic regression analysis was used to evaluate the longitudinal effects of these interventions as measured by new clinical cases of MRSA. At the IH, the %MRSA increased between January 1998 and January 2001 and then decreased. At the CH, the %MRSA increased from January 1997 to December 2004. Introduction of alcohol hand gel was associated with an absolute decrease in %MRSA of 21% and 30%, respectively, for the IH and CH. At the IH, introduction of chlorine disinfection and environmental swabbing were, respectively, associated with a decrease in %MRSA of 27% immediately and 32% 3 months later. Discharge screening and environmental audit did not significantly affect %MRSA, whereas admission screening was associated with a 22% decrease in %MRSA 4 months later. Increasing macrolide use was associated with increasing %MRSA in both hospitals, and increasing quinolone use was associated with increasing %MRSA in the CH. Implementation of stepwise infection control measures was associated with a decrease in %MRSA in the IH. Introduction of an alcohol gel for hand hygiene was associated with a decrease in %MRSA in both hospitals. Antibiotic use also affects %MRSA, in particular that of macrolides and quinolones.

[Antimicrobial susceptibility of Proteus mirabilis urinary tract isolates from 1999 to 2005 at Nîmes University Hospital]

AIM OF THE STUDY

To analyse antimicrobial resistance trends of Proteus mirabilis urinary tract isolates from 1999 to 2005 at the Nîmes University hospital.

MATERIALS AND METHODS

We retrospectively collected non-duplicate urinary tract infections and colonization isolates from inpatients between 1 January 1999 and 31 December 2005.

RESULTS

One thousand and eight non-duplicate urinary tract isolates were studied, 63.1% were from females and the mean age was 76 years. The mean resistance rate was 59.0% for amoxicillin (AMX), 48.0% for piperacillin (PIP), 3.9% for cefotaxim, 33.9% for amoxicillin plus clavulanic acid (AMC) and 2.8% for piperacillin plus tazobactam (TZP). A significant increase in resistance was observed for AMC and TZP. The mean resistance rate was 35.0% for norfloxacin, 34.8% for ofloxacin and 23.5% for ciprofloxacin. No significant increase in resistance to fluoroquinolones was seen except for ciprofloxacin whereas a significant increase was observed for aminoglycosides. The mean rate resistance for cotrimoxazole was 33.2% with a significant decrease in the resistance during the study period.

CONCLUSION

P. mirabilis stilled sensitive to cefotaxim or ceftazidim and to TZP. The significant increase in the rate resistance to AMC and TZP could be explained by production of beta-lactamases and in particular extended-spectrum beta-lactamases. The increase in resistance observed for fluoroquinolones become a major concern. Amikacine was the most active aminoglycosides. These data suggested for the re-enforcement of the antimicrobial susceptibility surveillance in order to optimise the rational use of antibiotics.

Évaluation de la relation consommation de fluoroquinolones et émergence de résistance chez Escherichia coli : rôles respectif et comparatif des études observationnelles et quasi expérimentales

The emergence of Escherichia coli (E. coli) resistance to fluoroquinolones (FQs) increased and spread gradually worldwide since the early 1990s. The selective pressure of FQs is the main mechanism responsible for the emergence of FQ resistance as shown by in vitro studies. Clinical trials are required to prove the causality between exposure to FQs and emergence of resistance. But this would not be ethical in humans. Non experimental studies must answer several principles to establish causality: association, anteriority, and directional change. We described and compared the contribution of observational and quasi-experimental studies implemented to answer several of these principles. Quasi-experimental studies using interventional models (ARIMA models with transfer function), can answer several of these principles, unlike observational studies. Thus, in addition to assessment of the association, they were able to show that the exposure to FQs precedes the emergence of FQ resistance to E. coli. They were also able to estimate the time necessary for the emergence of resistance and the dose effect, and to show if this association was reversible.

Evolution of fluoroquinolone resistance among Escherichia coli urinary tract isolates from a French university hospital: application of the dynamic regression model

Escherichia coli urinary tract isolates were collected in 1997-2003 from Nimes University Hospital in order to investigate long-term trends in antibiotic resistance and to explore the relationship between antibiotic use and the emergence of resistance. Time-series analysis (ARIMA models) and dynamic regression models were used to investigate relationships between antibiotic use and resistance to ofloxacin and ciprofloxacin. Significant increases were seen in the frequency of ofloxacin (8.9 to 16.7%) and ciprofloxacin resistance (6.2 to 10.1%) (p < 0.001). Using multivariate dynamic regression analysis, it was found that an increased use of one defined daily dose (DDD)/1000 patient-days for ofloxacin, ciprofloxacin and norfloxacin induced average increases of 0.81%, 0.65% and 0.53% in E. coli ofloxacin resistance (p < 0.01), with average delays of 4, 4 and 6 months, respectively. An increase of 1 DDD/1000 patient-days of ciprofloxacin, ofloxacin and norfloxacin use induced increases of 0.73%, 0.82% and 0.63% in E. coli ciprofloxacin resistance (p < 0.01), with average delays of 4, 4 and 5 months, respectively. The use of nalidixic acid was not associated significantly with an increase in resistance to fluoroquinolones by multivariate analysis.

Risk factors for multidrug-resistant Pseudomonas aeruginosa nosocomial infection

A case-control study was conducted in a university hospital to determine the risk factors for nosocomial infection with multidrug-resistant Pseudomonas aeruginosa (MDR-PA) among all hospitalized patients and among those with a nosocomial infection due to P. aeruginosa. Eighty patients infected with MDR-PA, 75 infected with a non-MDR phenotype and 240 random controls were included in the 12-month study. Among all hospitalized patients, age, severity index, having a bedridden condition, transfer from other units, nasogastric feeding, urinary catheterization and exposure to beta-lactams (OR=2.5) or fluoroquinolones (OR=4.1) in the seven days before infection were linked to nosocomial infection due to MDR-PA. Among patients infected by P. aeruginosa, exposure to fluoroquinolones (OR=4.7) or surgery (OR=0.5) were linked to the isolation of MDR-PA. This study showed that, in addition to urinary catheterization, nasogastric feeding is an important risk factor in MDR-PA infection. Indeed, an imbalance in gut flora, modifications to the mucous membranes due to the use of nasogastric feeding and the selection pressures exerted by antibiotics were implicated in the occurrence of this infection.

Effets hémodynamiques du sérum salé hypertonique au cours du choc septique et du sepsis sévère

OBJECTIVE

Assessment of haemodynamic effects of 250 ml hypertonic saline 7.5% (HS) perfusion in critically ill patients with severe sepsis or septic shock.

STUDY DESIGN

Observational study.

PATIENTS

Twelve mechanically ventilated patients with severe sepsis or septic shock requiring a pulmonary artery catheter and volume loading.

INTERVENTION

Two hundred and fifty millilitres HS were given over 15 min. Were measured: heart rate (HR), mean arterial pressure (MAP) and pulmonary artery pressure (MPAP), pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), cardiac index (CI), indexed systemic vascular resistance (ISVR), indexed pulmonary vascular resistance (IPVR), plasma sodium, chloride, protein and haemoglobin concentrations and arterial blood lactate. Studied parameters were assessed at baseline (T(0)) and 5 (T(0)) and 105 min (T(120)) after the end of HS infusion.

RESULTS

MAP, HR and RAP were not altered. HS increased PAPM (25 +/- 5-30 +/- 6 mmHg), PCWP (13 +/- 3-18 +/- 4 mmHg) and CI (3.5 +/- 1.2-4.6 +/- 1.1 l/min per m(2)) at T(20) (P < 0.05). ISVR and IPVR were decreased at T(20). Protein and haemoglobin were decreased at T(20). Sodium and chloride were increased at T(20) (from 136 +/- 4 to 147 +/- 4 and from 110 +/- 6 to 123 +/- 6 mmol/l, respectively, P < 0.01) and T(120).

CONCLUSION

In patients with severe sepsis or septic shock, 250 ml HS transiently (<120 min) increases CI and PCWP and induces an increase in sodium and chloride concentrations.

Low plasma levels of dehydroepiandrosterone sulphate in HIV-positive patients coinfected with hepatitis C virus

OBJECTIVES

To evaluate plasma levels of dehydroepiandrosterone sulphate (DHEAS) in a cohort of HIV-infected patients and to analyse factors associated with DHEAS levels.

METHODS

We conducted a cross-sectional survey in the Nîmes University Hospital cohort of HIV-infected patients in south-eastern France. All HIV-infected patients with at least one outpatient visit between 1 January and 1 September 2002 were included in the study. Sociodemographic, clinical, therapeutic, immuno-virological and plasma DHEAS level data were collected during this period. Hepatitis C virus (HCV) coinfection was defined as the presence of HCV antibody with positive RNA. To identify factors associated with plasma DHEAS levels, Spearman's rank correlation and univariate and multivariate linear regression analyses were used.

RESULTS

The DHEAS plasma level was measured in 137 patients (104 men and 33 women), 37 (27.0%) of whom were HCV coinfected. The median age of the patients was 39.1 years [interquartile range (IQR): 34.9-48.7] for women and 41.8 years (36.5-47.7) for men. The median DHEAS level was 5.5 micromol/L (IQR: 2.3-8.8) for the whole sample of 137 patients, and was lower in women (2.4 micromol/L; 1.5-6.6) than in men (6.1 micromol/L; 2.5-9.0) (P<0.01), and lower in patients coinfected with HCV (2.1 micromol/L; 0.6-6.7) than in those not coinfected (6.6 micromol/L; 3.0-9.1) (P<0.01). Of all prognostic factors studied in the variance covariance analysis, three factors were associated with DHEAS: age, gender and HCV coinfection. Subgroup analysis revealed that the age-adjusted mean of the DHEAS level was lower in HCV coinfected patients for both women (1.3+/-1.1 micromol/L) and men (4.0+/-0.7 micromol/L), compared with patients not HCV coinfected (women, 5.3+/-0.7 micromol/L; men, 7.2+/-0.4 micromol/L) (P<0.01).

CONCLUSIONS

This is the first report of the determination of DHEAS plasma levels in HIV/HCV coinfected patients. When age and sex were taken into account, the DHEAS plasma level was found to be significantly lower in HCV coinfected patients. To date, the pathophysiology of such findings is unknown.