ANTIFON-CLIC®, a new clinical decision support system for the treatment of invasive aspergillosis: is it clinically relevant?

BACKGROUND

Invasive aspergillosis (IA) is increasing especially in new groups of patients. Despite advances in management, morbidity and mortality related to IA remain high. Thus, Clinical Decision Support System (CDSS) dedicated to IA are needed to promote the optimal antifungal for each group of patients.

PATIENTS AND METHODS

This was a retrospective multicenter cohort study involving intensive care units and medical units. Adult patients who received caspofungin, isavuconazole, itraconazole, liposomal amphotericin B, posaconazole, or voriconazole, for the treatment of IA were eligible for enrollment. The primary objective was the concordance between the clinician's prescription and the prescription recommended by the CDSS. The secondary objective was the concordance according to different hospitals, departments, and indications.

RESULTS

Eighty-eight patients (n=88) from three medical hospitals were included. The overall concordance was 97% (85/88) including 100% (41/41) for center A, 92% (23/25) for center B, and 95% (21/22) for center C. There was no significant difference in concordance among the hospitals (P=0.973), the departments (P=1.000), and the indications (P=0.799). The concordance was 70% (7/10) for isavuconazole due to its use as an empirical treatment and 100% (78/78) for the other antifungals.

DISCUSSION

The concordance rate was high whatever the hospital, the department, and the indication. The only discrepancy was attributed to the use of isavuconazole as an empirical treatment which is a therapeutic option not included in the CDSS.

CONCLUSIONS

This new CDSS dedicated to IA is meeting the clinical practice. Its implementation in routine will help to support antifungal stewardship.

Cancer outpatients during the COVID-19 pandemic: what Oncoral has to teach us about medical drug use and the perception of telemedicine

PURPOSE

The COVID-19 pandemic has disrupted healthcare access and telemedicine has been widely deployed. The aim of this study is to assess the impact of this health crisis on treatment consumption and telemedicine development in outpatients treated by oral anti-cancer agents and followed by the Oncoral hospital/community multidisciplinary program where continuity care is maintained by a pharmacist/nurse pair.

METHODS

A prospective monocentric study was conducted among cancer patients who received Oncoral telephone follow-up during the 1st lockdown in France using a 56-item questionnaire which covered sociodemographic data, patient medication management, and telehealth.

RESULTS

178 patients received Oncoral follow-up during the 1st lockdown and 67.4% responded to the questionnaire. During lockdown, 9.2% of patients took medication or CAM for fatigue, 6.7% for mood alteration, 10.8% for sleep disorder, 11.7% for stress and anxiety, and 12.5% to get more energy. Homeopathy consumption was triggered by the pandemic. Habits about getting drugs from the pharmacy changed significantly (p < 0.001), while other treatment habits did not. 83% of patients were satisfied by the telephone follow-up established, 69% would be in favor of repeating this in case of a new epidemic wave. Those most in favor of using telemedicine seemed to be the youngest (p < 0.001), with several dependent children (p < 0.007), high school degree or higher education (p = 0.023), and in work (p < 0.001).

CONCLUSION

Health system reorganization enables to limit the impact of the crisis on patients' drug use in oncology care. Telemedicine is a promising public health tool.

POS0862 INAUGURAL DROPPED HEAD SYNDROME AND CAMPTOCORMIA IN INFLAMMATORY MYOPATHIES

Background

The idiopathic inflammatory myopathies (IIMs) are a heterogeneous group of diseases that can affect the muscles, skin, lungs, heart, and joints. Increase knowledge about histopathological findings, clinical manifestations and auto-antibodies have allowed further novel classification of IIMs. Today, the main IMs subgroups are: dermatomyositis (DM), inclusion body myositis (IBM), immune-mediated necrotizing myopathies (IMNM), overlap myositis (OM) and immune-checkpoint inhibitor-related myositis (ICIrm). Axial muscle involvement results either in a “Dropped Head Syndrome (DHS)”, with a marked weakness of the neck extensors, or in a camptocormia (CC), with a weakness of the thoracolumbar paraspinal muscles. This atypical presentation is poorly described in the course of IMs while it may results in a major disability, and may lead to myositis diagnosis delay.

Objectives

This study aimed to describe IMs revealed by DHS and/or CC. Secondary outcomes were to define subgroups of patients according to clinical, biological and histopathological characteristics. Then, the effects of treatments used were analyzed.

Methods

A historical cohort was designed using the register MYOLYON which includes all IMs followed at the University Hospital of Lyon (France) between 2000 and 2021. All patients with IM revealed by DHS and/or CC and having an histologically proven IMs were included, after exclusion of alternative (e.g., myasthenia gravis, motoneuron disease). Clinical, biological, immunological, histopathological data as well as outcome and care were collected through a standardized form. Agreement for the study was obtained from the French Ministry of the Research and the study was approved by the Local Research Ethics Committee.

Results

Twenty-two patients were fully characterized: DM (n=4), IBM (n=7), OM (n=8), ICIrm (n=2) and one myositis with anti-Hu antibodies. Two groups of patients were identified according to the age at first symptoms and to the type of muscle axial involvement (e.g, DHS and/or CC). Before the age of 70 (n=13/22), the two most common diagnoses (n=11/13) were DM (n=4/4) and OM (n=7/8). Axial muscle involvement was diffuse (DHS and CC) in 10/13 patients. After 70 years old (n=9/22), there were a majority of IBM (n=6/9) and all cases of ICIrm (n=2). Axial involvement was restricted to one group of muscles (DHS or CC) in 5/9 patients. Finally, 77% (17/22) of patients had refractory disease and required a second line treatment (e.g, immunoglobulins). All of these results are summarized in the Figure 1.

Figure 1.

Conclusion

While IM diagnosis is challenging in the presence of inaugural axial involvement, these results highlight the subset of IM to be considered according to the age at first symptoms and the type of axial involvement (e.g., DHS and/or CC).

References

[1]Mariampillai, K. et al. Development of a New Classification System for Idiopathic Inflammatory Myopathies Based on Clinical Manifestations and Myositis-Specific Autoantibodies. JAMA Neurol75, 1528-1537 (2018).

[2]Landon-Cardinal, O. et al. Recognising the spectrum of scleromyositis: HEp-2 ANA patterns allow identification of a novel clinical subset with anti-SMN autoantibodies. RMD Open6 (2020).

[3]Suarez, G.A. & Kelly, J.J., Jr. The dropped head syndrome. Neurology42, 1625-1627 (1992).

[4]Oerlemans, W.G. & de Visser, M. Dropped head syndrome and bent spine syndrome: two separate clinical entities or different manifestations of axial myopathy? J Neurol Neurosurg Psychiatry65, 258-259 (1998).

Disclosure of Interests

None declared

No significant clinical and radiological differences between fixed versus mobile bearing total knee replacement using the same semi-constrained implant type: a randomized controlled trial with mean 10 years follow-up

PURPOSE

The aim of this study was to compare the long-term clinical and radiological results between fixed (FB) and mobile bearing (MB) implants with identical design from the same manufacturer.

METHODS

From March 2007 to May 2009, we recruited 160 patients in a prospective, single centered, randomized controlled trial. The authors compared 81 FB total knee arthroplasty (TKA) versus 79 MB with medial compartment osteoarthritis. The same posterior stabilized HLS Noetos knee prosthesis (CORIN) was used in all patients. The two groups only differed by the tibial insert (fixed or mobile). The authors compared the postoperative Knee Society Score (KSS), the passive clinical and active radiological knee flexion, the implant survivorship, the complications, and the presence of radiolucent lines.

RESULTS

At mean 10.5 years' follow-up (range 8-12.1 years) no significant differences were found in clinical scores (KSS (p = 0.54), pain score (p = 0.77), stair climbing (p = 0.44), passive maximum flexion (p = 0.5)) or for radiological analyses (maximum active radiological flexion (p = 0.06), presence of progressive radiolucent lines (5 (MB group) versus 6 (FB group); p = 0.75)) between groups. No significant difference was found in overall implant survivorship (82% (MB group) versus 78% (FB group) p = 0.58) or complication rate (p = 0.32) at the last follow-up.

CONCLUSION

No significant clinical and radiological differences were found between fixed and mobile bearing TKA using the same semi-constrained implant type with comparable overall survivorship. The choice between a fixed or mobile bearing implant should be based on surgeon preference and experience with the selected implant.

LEVEL OF EVIDENCE

Prospective randomized controlled trial, Level II.

The TeloDIAG: how telomeric parameters can help in glioma rapid diagnosis and liquid biopsy approaches

BACKGROUND

In glioma, TERT promoter mutation and loss of ATRX (ATRX loss) are associated with reactivation of telomerase or alternative lengthening of telomeres (ALT), respectively, i.e. the two telomere maintenance mechanisms (TMM). Strangely, 25% of gliomas have been reported to display neither or both of these alterations.

MATERIALS AND METHODS

The C-circle (CC) assay was adapted to tumor (formalin-fixed paraffin-embedded and frozen) and blood samples to investigate the TMM.

RESULTS

We constructed a CC-based algorithm able to identify the TMM and reported a sensitivity of 100% and a specificity of 97.3% (n = 284 gliomas). By combining the TMM, the mutational status of the isocitrate dehydrogenase 1/2 (IDH) gene (IDHmt), and the histological grading, we propose a new classification tool: TeloDIAG. This classification defined five subtypes: tOD, tLGA, tGBM_IDHmt, tGBM, and tAIV, corresponding to oligodendroglioma, IDHmt low-grade astrocytoma, IDHmt glioblastoma, and IDHwt glioblastoma (GBM), respectively; the last class gathers ALT+ IDHwt gliomas that tend to be related to longer survival (21.2 months) than tGBM (16.5 months). The TeloDIAG was 99% concordant with the World Health Organization classification (n = 312), and further modified the classification of 55 of 144 (38%) gliomas with atypical molecular characteristics. As an example, 14 of 69 (20%) of TERTwt, ATRXwt, and IDHwt GBM were actually tAIV. Outstandingly, CC in blood sampled from IDHmt astrocytoma patients was detected with a sensitivity of 56% and a specificity of 97% (n = 206 gliomas and 30 healthy donors).

CONCLUSION

The TeloDIAG is a new, simple, and effective tool helping in glioma diagnosis and a promising option for liquid biopsy.

KS02.4.A Olaparib in Recurrent IDH-mutant High-Grade Glioma (OLAGLI)

BACKGROUND

There is a need to develop new treatments in IDH-mutant high-grade gliomas recurring after radiotherapy and chemotherapy. Based on preclinical studies showing that IDH-mutant tumors could be vulnerable to PARP inhibition we launched a phase II study to test the efficacy of olaparib (Lynparza) monotherapy in this population.

METHODS

Adults with recurrent high-grade IDH-mutant gliomas after radiotherapy and at least one line of alkylating chemotherapy (PCV or TMZ), KPS &gt; 60, normal organ function were enrolled. The primary endpoint was 6 months PFS according to RANO criteria. Patients were treated with olaparib 300 mg twice daily. We used a single-stage Fleming design with p0 = 30%, p1 = 50%, a type I unilateral error rate of 5% and a power of 80%.

RESULTS

35 patients with recurrent IDH-mutant gliomas (IDH1R132H-mutant n = 32, other IDH mutation n = 3, 1p/19 codeleted n = 16, 1p/19q non-codeleted n = 14) were enrolled (malignantly transformed low-grade gliomas n = 21, anaplastic gliomas n = 8, glioblastomas n = 6). Median time since diagnosis was 7.4 years (1–22 years), median time since radiotherapy was 2.8 years (0.6–18 years), median number of previous chemotherapy lines was 2 (1–5). With a median follow-up of 11 months, 30 patients had stopped treatment due to tumor progression and 2 patients were still on treatment 16 to 18 months after treatment start. At 6 months, 11/35 patients were progression-free (31 %). According to RANO criteria, based on local investigator analysis, 2 patients (5%) had a partial response and 14 patients a stable disease (37%) with a median duration of response of 9 months (4–18+). Median PFS and OS were 2.3 and 15.9 months and were similar in 1p/19q codeleted and non-codeleted patients. A grade 3 olaparib-related adverse event was observed in 5 patients (14%, lymphopenia n = 3, fatigue n = 2, diarrhea n = 1) and a grade 2 in 15 patients (43%), most frequently consisting in fatigue (23%), gastrointestinal disorders (20%) and lymphopenia (20%). No patient definitively stopped olaparib due to side effects.

CONCLUSIONS

In this heavily pre-treated population of recurrent IDH-mutant gliomas, olaparib monotherapy was well tolerated and resulted in some activity supporting its evaluation in association with alkylating chemotherapy in recurrent IDH-mutant gliomas in future studies.

OS02.6.A The TeloDIAG: How telomeric parameters can help in glioma rapid diagnosis and liquid biopsies approaches

BACKGROUND

The integration of molecular markers into the WHO 2016 classification has clarified the complex diagnosis of gliomas. Among these biomarkers, the TERT promoter mutation and the loss of ATRX (ATRX loss) are mutually exclusive alterations associated with re-activation of telomerase or alternative lengthening of telomeres (ALT), respectively. Strangely, 25% of gliomas display neither or both these alterations, a situation referred to as abnormal telomere maintenance mechanism (aTMM).

MATERIAL AND METHODS

To investigate the TMM actually involved in gliomas, the C-circle (CC) assay was adapted to tumor (FFPE and frozen) samples.

RESULTS

We constructed a CC-based algorithm able to identify the TMM of 284 gliomas with either TERT or ATRX alteration, with a sensitivity of 100% and a specificity of 97.3%, and succeeded in deciphering the TMM involved in 122 aTMM gliomas. Additionally, the combination of the TMM, the mutational status of the Isocitrate dehydrogenase 1/2 (IDH) gene, and the histological grading was used as base for a new classification: TeloDIAG. Six subtypes are defined in this classification: tOD, tLGA, tGBM_IDHmt, tGBM, and tAIV, corresponding to oligodendroglioma, IDHmt low grade astrocytoma, IDHmt glioblastoma, and IDHwt glioblastoma, respectively, the last class gathers ALT+ IDHwt glioma. The TeloDIAG diagnosis is 99% concordant with the WHO classification for glioma displaying typical molecular characteristics (N=312). It modified the classification of 38% (N=156) discordant tumors, such as IDHwt Astrocytoma, aTMM tumors, or gliomas with unexpected TMM (e.g. TERTwt oligodendroglioma, ATRX loss GBM). Interestingly, 20% (N=69) of TERTwt, ATRXwt, or IDHwt GBM were actually tAIV, which is remarkable as tAIV-glioma patients’ survival tended to be longer (21.2 months) than tGBM patients’ survival (16.5 months). Importantly, CC in blood sampled from IDHmt astrocytoma patients was detected with a sensitivity of 56% and a specificity of 95% (N = 206).

CONCLUSION

In sum, the TeloDIAG is a new, simple, and efficient tool helping in glioma diagnosis and a promising option for liquid biopsy

Low expression of ANT1 confers oncogenic properties to rhabdomyosarcoma tumor cells by modulating metabolism and death pathways

Rhabdomyosarcoma (RMS) is the most frequent form of pediatric soft-tissue sarcoma. It is divided into two main subtypes: ERMS (embryonal) and ARMS (alveolar). Current treatments are based on chemotherapy, surgery, and radiotherapy. The 5-year survival rate has plateaued at 70% since 2000, despite several clinical trials. RMS cells are thought to derive from the muscle lineage. During development, myogenesis includes the expansion of muscle precursors, the elimination of those in excess by cell death and the differentiation of the remaining ones into myofibers. The notion that these processes may be hijacked by tumor cells to sustain their oncogenic transformation has emerged, with RMS being considered as the dark side of myogenesis. Thus, dissecting myogenic developmental programs could improve our understanding of RMS molecular etiology. We focused herein on ANT1, which is involved in myogenesis and is responsible for genetic disorders associated with muscle degeneration. ANT1 is a mitochondrial protein, which has a dual functionality, as it is involved both in metabolism via the regulation of ATP/ADP release from mitochondria and in regulated cell death as part of the mitochondrial permeability transition pore. Bioinformatics analyses of transcriptomic datasets revealed that ANT1 is expressed at low levels in RMS. Using the CRISPR-Cas9 technology, we showed that reduced ANT1 expression confers selective advantages to RMS cells in terms of proliferation and resistance to stress-induced death. These effects arise notably from an abnormal metabolic switch induced by ANT1 downregulation. Restoration of ANT1 expression using a Tet-On system is sufficient to prime tumor cells to death and to increase their sensitivity to chemotherapy. Based on our results, modulation of ANT1 expression and/or activity appears as an appealing therapeutic approach in RMS management.

Cutaneous adverse events: a predictor of tumour response under anti-PD-1 therapy for metastatic melanoma, a cohort analysis of 189 patients

INTRODUCTION

Cutaneous adverse events (AEs) are the most prevalent toxicity under checkpoint inhibitors in clinical trials. In 'real-life' conditions of use, skin toxicities under anti-PD-1 have not been described to date in a large cohort. The objective of this study was to determine the clinical features of skin toxicities in patients with advanced melanoma receiving anti-PD-1 therapy under 'real-life' conditions of use. Secondary objectives were to evaluate the characteristics of patients with skin toxicities and to analyse associated extra-cutaneous toxicities, progression-free survival (PFS) and overall survival (OS).

PATIENTS AND METHODS

Advanced melanoma patients treated with nivolumab or pembrolizumab between August 2014 and October 2017 were included. Patients lost to follow-up or receiving anti-PD-1 as part of a clinical trial were excluded.

RESULTS

One hundred and eighty-nine patients with metastatic melanoma (with 109 men (57.7%) were included. Cutaneous AE occurred in 39 patients (20.6%). The three most prevalent cutaneous AEs were skin eruption (macular-papular or eczematous) (n = 18, 9.5%), vitiligo (n = 16; 8.5%) and isolated pruritus (n = 5, 2.6%). Grade 3-4 skin toxicity was diagnosed in five patients (2.6%). Atopy (28.2% vs. 12.0%; P = 0.024), hypereosinophilia (20.5% vs. 8.7%; P = 0.046), thyroiditis (17.9% vs. 4.7%; P = 0.011) and renal toxicity (15.4% vs. 4%; P = 0.019) were significantly associated with cutaneous AE. Patients with skin eruption (log-rank = 0.001), vitiligo (log-rank = 0.001) and any type of cutaneous AE (log-rank < 0.001) had a better overall survival.

CONCLUSIONS

Cutaneous AEs are frequent and often manageable toxicity and were a predictor of tumour response in melanoma patients under anti-PD-1 therapy in this cohort.

[Long-term outcomes of intradetrusor botulinum toxin A in multiple sclerosis patients]

INTRODUCTION

The objective of this study was to analyze the long-term efficiency and tolerance of TB in the management of anticholinergic refractory hyperactive bladder in patients with MS.

MATERIAL AND METHOD

Retrospective mono-centric cohort study of all patients with MS who had a TB injection for anticholinergic refractory hyperactivity from 2005 to 2015. The primary endpoint was clinical efficiency based on the frequency of urinary leakage and symptomatic urinary tract infections.

RESULTS

One hundred and nineteen patients received the first injection. Median follow-up was 26.5 months. After an injection, there was a significant decrease in the number of leaks, with 69.7% of patients without leaks and 93.3% of patients without urinary tract infections. After 7 injections 44% of the patients were still dry and 62.07% had no symptomatic urinary tract infections. The failure rate was 24.37%, the average duration before discharge was 34.7 months. 19 (66%) patients stop treatment for loss of efficacy, 9 (31%) for disease progression and 1 (3%) for cessation of treatment without cause. Of the 774 injections performed, there were complications for 26 of them (3.35%).

CONCLUSION

Botulinum toxin remains the second-line reference treatment for detrusor overactivity of neurological origin. There is, at least in the short term, a good answer in a large number of cases. This response can be maintained for many years, especially if patients use intermittent catheterization, with excellent tolerance.

LEVEL OF EVIDENCE

4.

Posterior mandibular widening secondary to advancement sagittal split osteotomy: A retrospective study

INTRODUCTION

Patients sometimes spontaneously report a modification of the width of their lower face after an advancement bilateral sagittal split osteotomy (ABSSO). The main goal of our study was to assess the variation of the bigonial distance (BGD) before and after ABSSO in a group of patients. The second goal was to look for a possible relation between the variation of BGD and the amount of mandibular advancement.

MATERIALS AND METHODS

We conducted a retrospective radiological study on patients who underwent an isolated ABSSO (Obwegeser-Dal Pont II type osteotomy) for a class II malocclusion in our department over a 26 months period. The measures were made on standardized frontal and lateral teleradiographies taken before, one day and one year postoperatively.

RESULTS

Fifty patients (36 females, 14 males; mean age: 24) could be included. BGD was significantly increased one day (+9.8mm, P<10(-3)) and one year after surgery (+4mm, P<10(-3)). There was no relation between the amount of mandibular advancement and the increase of BGD.

DISCUSSION

Our results suggest that ABSSO is responsible for posterior mandibular enlargement which must be taken into account during the aesthetic preoperative assessment. Further studies are mandatory to identify the risk factors for this phenomenon.

Gut microbiota in preterm infants with gross blood in stools: A prospective, controlled study

OBJECTIVE

Gross blood in stools is a peculiar entity in preterm infants, but little is known about its etiology. As gut microbiota can be distorted in preterm infants, we aimed to evaluate the gut microbiota in infants with gross blood in stools.

STUDY DESIGN

In a prospective, controlled, single-center study, we enrolled all infants born before 34 weeks of gestational age presenting gross blood in stools that was either completely isolated or associated with mild clinical symptoms or radiological signs. Each case was paired with two controls who were hospitalized in the same unit and were matched for gestational age and birth weight. The diversity of the gut microbiota was analyzed using 16S rRNA gene PCR and temporal temperature gel electrophoresis. We calculated a diversity score corresponding to the number of operational taxonomic units present in the microbiota.

RESULTS

Thirty-three preterm infants with gross blood in stools were matched with 57 controls. Clinical characteristics were similar in cases and controls. There was no statistically significant difference in the diversity score between the two groups, but microbiota composition differed. The proportion of infants with Escherichia coli was significantly higher in cases than in controls (p=0.045) and the opposite pattern occurred for Staphylococcus sp. (p=0.047).

CONCLUSION

Dysbiosis could be a risk factor for gross blood in stools in preterm infants. Additional, larger studies are needed to confirm the implications of the presence of different genotypes of E. coli and to evaluate preventive actions such as the prophylactic use of probiotics and/or prebiotics.

French adaptation of the new Knee Society Scoring System for total knee arthroplasty

INTRODUCTION

In November 2011, the Knee Society published its new KSS score to evaluate objective clinical data and also patient expectations, satisfaction and knee function during various physical activities before and after total knee arthroplasty (TKA). We undertook the French cross-cultural adaptation of this scoring system according to current recommendations.

HYPOTHESIS

The French version of the new KSS score is a consistent, feasible, reliable and discriminating score.

PATIENTS AND METHODS

Eighty patients with knee osteoarthritis were recruited from two centers: one group of 40 patients had a TKA indication, while the other group of 40 patients had an indication for conservative treatment. After the new KSS score was translated and back-translated, it was compared to three other validated instruments (KOOS, AMIQUAL and SF-12) to determine construct validity, discriminating power, feasibility in terms of response rate and existence of floor or ceiling effect, internal consistency with Chronbach's alpha and reliability based on reproducibility and sensitivity to change (responsiveness).

RESULTS

Due to missing data, two cases were eliminated. We found that the score could discriminate between groups; it had a nearly 100% response rate, a ceiling effect in the "expectations" domain, satisfactory Chronbach's alpha, excellent reproducibility and good responsiveness.

DISCUSSION

These results confirm that the French version of the new KSS score is reliable, feasible, discriminating, consistent and responsive. The novelty of this scoring system resides in the "expectations" and "satisfaction" domains, its availability as a self-assessment questionnaire and the evaluation of function during various activities.

LEVEL OF PROOF, TYPE OF STUDY

Level III.

Systemic lupus erythematosus-associated acute transverse myelitis: manifestations, treatments, outcomes, and prognostic factors in 20 patients

Background

Transverse myelitis is a rare complication of systemic lupus erythematosus (SLE). This retrospective multicentre study identifies the prognostic factors in a relatively large patient series.

Patients and methods

Twenty patients fulfilled the SLE criteria of the ACR classification and the Transverse Myelitis Consortium Working Group. A severe neurological flare was defined as muscle strength grade <3/5 in more than half the muscle groups at the motor neurological level. Inability to run or another significant ambulation-unrelated disability was considered as ‘unfavourable neurological outcome’.

Results

Myelitis was the first SLE symptom in 12 patients; in the eight others, it occurred 8.6 years (median delay) after SLE onset. Eleven patients presented severe neurological impairments. The treatment included corticosteroids in all patients associated with intravenous cyclophosphamide in 11 and/or hydroxychloroquine in 14. Unfavourable outcomes were observed in 53% of the patients at six months and in 28% at end of follow-up (median: 5.9 years). An initial severe neurological impairment and no cyclophosphamide use were associated with unfavourable neurological outcomes at six months and at end of follow-up, respectively.

Conclusion

Transverse myelitis may reveal SLE or occur more than 10 years after SLE diagnosis. The initial severity of the neurological flare (with paraplegia) is the main prognostic marker. The study provides arguments for cyclophosphamide use.

Role of obesity on the thickness of primary cutaneous melanoma

BACKGROUND

Thick primary cutaneous melanoma (PCM) is associated with older age, male sex, being single, a low educational level, self-detection and general practice detection, nodular melanoma (NM) and acral lentiginous melanoma (ALM) types; and are found in the head-neck and lower limb locations. Obesity plays a direct role on melanoma tumour growth, as it has been shown in animal models, but its role in the thickness of PCM remains unknown.

OBJECTIVES

We investigated the impact of obesity on the thickness of invasive PCM.

METHODS

A cross-sectional study was performed in a prospective cohort for which we collected several clinical and histological data already known to be associated with thick PCM and the Body Mass Index from new cases of invasive PCM which were referred to the dermatology department in Valence.

RESULTS

Four hundred and twenty-seven patients were studied. In an univariate analysis, thick PCM was associated with low educational level, obesity, identification by the patient or the general practitioner (GP), location on the cephalic extremity, in a non-visible area of the body, the NM and ALM type, and an ulceration. In a multivariate analysis, NM, ulceration, topography of the melanoma and identification of the melanoma by the patient or GP were significantly associated with thick melanoma. When including only clinical features in the model, low educational level, mode of melanoma identification and obesity were significantly associated with a risk of thick melanoma.

CONCLUSIONS

Obesity is a clinical independent risk factor of thick PCM. For health policies, governments should pay greater attention to detect melanoma in obese patients. Our results encourage the basic research on tumoural growth mechanisms due to obesity in melanoma.

Can we identify response markers to antihypertensive drugs? First results from the IDEAL Trial

Current antihypertensive strategies do not take into account that individual characteristics may influence the magnitude of blood pressure (BP) reduction. Guidelines promote trial-and-error approaches with many different drugs. We conducted the Identification of the Determinants of the Efficacy of Arterial blood pressure Lowering drugs (IDEAL) Trial to identify factors associated with BP responses to perindopril and indapamide. IDEAL was a cross-over, double-blind, placebo-controlled trial, involving four 4-week periods: indapamide, perindopril and two placebo. Eligible patients were untreated, hypertensive and aged 25-70 years. The main outcome was systolic BP (SBP) response to drugs. The 112 participants with good compliance had a mean age of 52. One in every three participants was a woman. In middle-aged women, the SBP reduction from drugs was -11.5 mm Hg (indapamide) and -8.3 mm Hg (perindopril). In men, the response was significantly smaller: -4.8 mm Hg (indapamide) and -4.3 (perindopril) (P for sex differences 0.001 and 0.015, respectively). SBP response to perindopril decreased by 2 mm Hg every 10 years of age in both sexes (P=0.01). The response to indapamide increased by 3 mm Hg every 10 years of age gradient in women (P=0.02). Age and sex were important determinants of BP response for antihypertensive drugs in the IDEAL population. This should be taken into account when choosing drugs a priori.

Cryptococcosis in sarcoidosis: cryptOsarc, a comparative study of 18 cases

AIM

To describe the main characteristics and the treatment of cryptococcosis in patients with sarcoidosis.

DESIGN

Multicenter study including all patients notified at the French National Reference Center for Invasive Mycoses and Antifungals.

METHODS

Retrospective chart review. Each case was compared with two controls without opportunistic infections.

RESULTS

Eighteen cases of cryptococcosis complicating sarcoidosis were analyzed (13 men and 5 women). With 2749 cases of cryptococcosis registered in France during the inclusion period of this study, sarcoidosis accounted for 0.6% of all the cryptococcosis patients and for 2.9% of the cryptococcosis HIV-seronegative patients. Cryptococcosis and sarcoidosis were diagnosed concomitantly in four cases; while sarcoidosis was previously known in 14/18 patients, including 12 patients (67%) treated with steroids. The median rate of CD4 T cells was 145 per mm(3) (range: 55-1300) and not related to steroid treatment. Thirteen patients had cryptococcal meningitis (72%), three osteoarticular (17%) and four disseminated infections (22%). Sixteen patients (89%) presented a complete response to antifungal therapy. After a mean follow-up of 6 years, no death was attributable to cryptococcosis. Extra-thoracic sarcoidosis and steroids were independent risk factors of cryptococcosis in a logistic regression model adjusted with the sex of the patients.

CONCLUSIONS

Cryptococcosis is a significant opportunistic infection during extra-thoracic sarcoidosis, which occurs in one-third of the cases in patients without any treatment; it is not associated to severe CD4 lymphocytopenia and has a good prognosis.