Radio-iodine refractory thyroid cancer patients: a tailored follow-up based on clinicopathological features

OBJECTIVE

To report the experience of a single center for the selection of radioiodine-refractory (RAIR) thyroid cancer patients (RAIR-TC) who needed tyrosine kinase inhibitor (TKIs) treatment.

PATIENTS AND METHODS

We evaluated all features of 279 RAIR-TC patients both at the time of diagnosis and at the RAIR diagnosis.

RESULTS

Ninety-nine patients received indication to TKIs (Group A), while 180 remained under active surveillance (Group B). Group A had greater tumor size, more aggressive histotype, more frequent macroscopic extrathyroidal extension, distant metastases, advanced AJCC stage, and higher ATA risk of recurrence. After RAIR diagnosis, 93.9% of Group A had progression of disease (PD) after which TKIs' therapy was started. The remaining 6.1% of patients had a so severe disease at the time of RAIR diagnosis that TKIs' therapy was immediately started. Among Group B, 42.7% had up to 5 PD, but the majority underwent local treatments. The mean time from RAIR diagnosis to the first PD was shorter in Group A, and the evidence of PD within 25 months from RAIR diagnosis was associated with the decision to start TKIs.

CONCLUSIONS

According to our results, a more tailored follow-up should be applied to RAIR-TC patients. A too strict monitoring and too many imaging evaluations might be avoided in those with less-aggressive features and low rate of progression. Conversely, RAIR-TC with an advanced stage at diagnosis and a first PD occurring within 25 months from RAIR diagnosis would require a more stringent follow-up to avoid a late start of TKIs.

External validation of AF-BLEED for predicting major bleeding and for tailoring NOAC dose in AF patients: A post hoc analysis in the ENGAGE AF-TIMI 48

OBJECTIVE

AF-BLEED, a simple bleeding risk classifier, was found to predict major bleeding (MB) in patients with atrial fibrillation (AF) and identify AF patients at high risk of MB who might potentially benefit from a lower direct oral anticoagulant dose. This post hoc study aimed to externally validate these findings in the ENGAGE AF-TIMI 48 (Effective aNticoaGulation with factor Xa next Generation in Atrial Fibrillation-Thrombolysis in Myocardial Infarction study 48) trial.

METHODS

The ENGAGE AF-TIMI 48 trial randomized AF patients to higher-dose edoxaban regimen (HDER 60/30 mg) versus lower-dose edoxaban regimen (LDER 30/15 mg), with prespecified dose reduction criteria. AF-BLEED was calculated in the modified intention-to-treat cohort (n = 21,026 patients) used for primary outcome analysis. Annualized event rates and hazard ratios (HRs) were obtained for the primary composite outcome (PCO) and its single components (MB, ischemic stroke/systemic embolism and death) to compare LDER 30 mg with HDER 60 mg in both AF-BLEED classes.

RESULTS

AF-BLEED classified 2882 patients (13.7 %) as high-risk, characterized by a two- to three-fold higher MB risk than AF-BLEED classified low-risk patients. AF-BLEED classified high-risk patients randomized to LDER 30 mg demonstrated a 3.3 % reduction in MB at the cost of a 0.5 % increase in ischemic stroke/systemic embolism. LDER 30 mg resulted in a 3.1 % reduction of PCO compared to HDER 60 mg (HR of 0.81; 95%CI 0.65-1.01). Additional to existing dose reduction criteria, another 6 % of patients could potentially benefit of this dose adjustment strategy.

CONCLUSION

AF-BLEED could identify AF patients to be at high risk of major bleeding. Our findings support the hypothesis that LDER 30 mg might provide a reasonable option in AF patients with legitimate bleeding concerns.

Adrenal insufficiency in thyroid cancer patients treated with tyrosine kinase inhibitors and detected by ACTH stimulation test

PURPOSE

Advanced thyroid cancer patients treated with tyrosine kinase inhibitors (TKI) can develop several adverse events (AEs), including adrenal insufficiency (AI).

METHODS

We studied 55 patients treated with TKI for radioiodine-refractory or medullary thyroid cancer. The adrenal function was evaluated during follow-up by performing serum basal ACTH, and basal and ACTH-stimulated cortisol.

RESULTS

Twenty-nine/55 (52.7%) patients developed subclinical AI during TKI treatment as demonstrated by a blunted cortisol response to ACTH stimulation. All cases showed normal values of serum sodium, potassium and blood pressure. All patients were immediately treated, and none showed an overt AI. Cases with AI were all negative for adrenal antibodies and did not show any adrenal gland alteration. Other causes of AI were excluded. The onset time of the AI, as measured in the subgroup with a first negative ACTH test, was < 12 months in 5/9 (55.6%), between 12 and 36 months in 2/9 (22.2%) and > 36 months in 2/9 (22.2%) cases. In our series, the only prognostic factor of AI was the elevated, although moderate, basal level of ACTH when the basal and stimulated cortisol were still normal. The glucocorticoid therapy improved fatigue in most patients.

CONCLUSIONS

Subclinical AI can be developed in > 50% of advanced thyroid cancer patients treated with TKI. This AE can develop in a wide period ranging from < 12 to > 36 months. For this reason, AI must be looked for throughout the follow-up to be early recognized and treated. A periodic ACTH stimulation test, every 6-8 months, can be helpful.

Two-year quality of life after acute pulmonary embolism: results from the FOCUS study

Background/Introduction

No firm prospective evidence exists on the long-term course of disease-specific and generic quality of life (QoL) or their determinants in patients with acute pulmonary embolism (PE). Reliable data on this topic is essential for early identification of patients at risk of deviating from the expected course and prevention of clinical events affecting QoL recovery after PE.

Purpose

We examined the two-year course of QoL and the impact of events occurring after the acute phase of PE in patients from the prospective multicentre FOllow-up after aCUte pulmonary emboliSm (FOCUS) study.

Methods

All patients with complete QoL assessment at 3, 12 and 24 months (N=462) were included in the analysis of the two-year course of QoL; all patients with QoL assessment at 12 months, 24 months, or both (N=740) contributed to a multivariable linear mixed-effects regression for the investigation of determinants of long-term QoL. Disease-specific QoL was assessed with the Pulmonary Embolism Quality of Life (PEmb-QoL) instrument (global score: 0 = best, 100 = worst QoL), generic health-related QoL with the Euro Quality of life group (EuroQol) five-dimensions utility index (EQ-5D-5L; 0 = worst, 1 = best QoL) and the EuroQol visual analogue scale (0 = worst, 100 = best QoL). Incident events (recurrent PE, bleeding, stroke, new cancer diagnosis, and re-hospitalization) were modelled as time-varying covariates from discharge to month 12 and from month 12 to month 24.

Results

Among 462 patients with complete QoL assessment [200 (43.3%) women, median age 61.5 (IQR: 49–72) years, high-risk PE 15/462 (3.2%)], the median (IQR) PEmb-QoL score at 3, 12, and 24 months was 20 (9–36), 14 (5–30) and 13 (5–28), with a similar trend across all sub-dimensions (Figure 1); the mean (95% CI) EQ-5D-5L utility index 0.86 (0.84–0.88), 0.88 (0.87–0.90) and 0.87 (0.85–0.89); the mean (95% CI) EuroQoL visual analogue scale 74.2 (72.5–75.9), 76.8 (75.2–78.4) and 76.3 (74.6–78.0). Upon multivariable analysis in 740 patients with QoL data at 12 or 24 months, QoL according to all three scales was worse in women, patients of older age, with cardiopulmonary disease, with higher BMI, and in smokers, but did not change significantly at 24 vs 12 months. Incident PE recurrence or stroke did not considerably affect any of the QoL dimensions, whereas re-hospitalization for any cause worsened disease-specific QoL, a new cancer diagnosis worsened both scales of generic QoL, and bleeding worsened generic QoL as assessed by the Visual Analogue Scale (Table 1).

Conclusion

Generic and disease-specific QoL after PE improved in the first year and then plateaued in the second year. Disease-specific QoL was adversely affected by re-hospitalization for any cause but was robust to new cancer diagnosis and bleedings, which instead worsened generic QoL. These findings may support long-term management of patients with PE and contribute to design and interpretation of interventional studies.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bayer Health Care

Mortality related to pulmonary embolism in the United States before and during the COVID-19 pandemic: an analysis of the CDC Multiple Cause of Death database

Background

The COVID-19 pandemic caused a large number of excess deaths. COVID-19 emerged as a prothrombotic disease often complicated by pulmonary embolism (PE). In light of this, we hypothesized that PE-related mortality rates (stable before the pandemic) would be characterized by an increasing trend following the COVID-19 outbreak.

Purpose

To investigate the mortality rates associated with PE among deaths with or without COVID-19 during the 2020 pandemic in the United States (US).

Methods

For this retrospective epidemiological study, we analyzed public medically certified vital registration data (death certificates encompassing underlying and multiple causes of death) from the Mortality Multiple Cause-of-Death database provided by the Division of Vital Statistics of the US Centers for Disease Control and Prevention (CDC; US, 2018–20). We investigated the time trends in monthly PE-related crude mortality rates for 2018–2019 and for 2020 (the latter associated vs. not associated with COVID-19), utilizing annual national population totals from the US Census Bureau. Second, we calculated the PE-related proportionate mortality among COVID-19 deaths (overall and limited to autopsy-based diagnosis). We performed subgroup analyses based on age groups, sex and race.

Results

During 2020, 49,423 deaths in association with PE were reported, vs. 39,450 in 2019 and 38,215 in 2018. The crude PE-related mortality rate without COVID-19 was 13.3 per 100,000 population in 2020 compared to 11.7 in 2018 and 12.0 in 2019 (Figure 1A). The PE-related mortality rate with COVID-19 was 1.6 per 100,000 population in 2020. Among non-COVID-19-related deaths, the crude PE-related mortality rate was higher in women; among COVID-19-related deaths, it was higher in men. PE-related mortality rates were approximately two-fold higher among black (vs. white) general population irrespective of COVID-19 status (Figures 1B and 1C). Among COVID-19 deaths, PE-related deaths corresponded to 1.4% of total; the value rose to 6.0% when an autopsy was performed. This figure was higher in men and its time evolution is depicted in Figure 2A. The proportionate mortality of PE in COVID-19 deaths was higher for younger age groups (15–44 years) compared to non-COVID-19-related deaths (Figure 2B).

Conclusion

In 2020, an overall 20%-increase in PE-related mortality was reported, not being limited to patients with COVID-19. Our findings could be interpreted in the context of undiagnosed COVID-19 cases, uncounted late sequelae, and possibly sedentary lifestyle and avoidance of healthcare facilities during the pandemic that may have prevented timely diagnosis and treatment of other diseases. Whether vaccination programs had an impact on PE-associated mortality in the year 2021, remains to be determined.

Funding Acknowledgement

Type of funding sources: None.

Signs of chronic thromboembolic pulmonary hypertension in acute pulmonary embolism: results from the FOCUS study

Background/Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered to be a late complication of acute pulmonary embolism (PE). However, up to one third of CTEPH patients do not report prior symptomatic venous thromboembolism (VTE). Furthermore, a substantial proportion of patients presenting with an acute PE event may exhibit radiological signs of chronicity at baseline computed tomography pulmonary angiography (CTPA).

Purpose

To determine the prevalence of baseline radiological parameters indicating chronic thrombosis or pulmonary hypertension, and ultimately pre-existing CTEPH, among patients with acute PE enrolled in the prospective multicentre Follow-Up after Acute Pulmonary Embolism (FOCUS) cohort study.

Methods

Patients with acute symptomatic PE and absence of a known history of CTEPH, enrolled at two large FOCUS centres, were included. The assessment of index CTPA scans was conducted by two independent expert radiologists who were unaware of the clinical characteristics and the follow-up data of the patients. CTPA parameters indicating chronicity were prespecified on the basis of recently proposed criteria in the literature. A third independent expert radiologist provided an assessment in case of disagreement between the first two. Baseline radiological data were prospectively validated with the aid of two-year prospective clinical follow-up data focusing on CTEPH and the post-PE syndrome (co-primary outcomes of the FOCUS study).

Results

A total of 303 patients (median age: 63 years, 44.6% women) were included. In &gt;95% of the patients, the expert radiologists could confirm signs of acute PE at baseline CTPA. Radiological signs of chronic thrombi or pulmonary hypertension at baseline were detected in 46 (15.2%) patients. In 8 patients, the expert radiologists agreed on the presence of pre-existing CTEPH based on their interpretation of the overall radiological pattern. During follow-up, five (1.7%; 95% CI 0.7–3.8%) of 303 patients were diagnosed with CTEPH, over a median time of 95 days after baseline. Four of them were among the 8 patients in whom the radiological experts suspected pre-existing CTEPH at baseline, and among the 46 patients in whom CTPA findings suggesting chronic thrombi or chronic pulmonary hypertension were present at baseline. The use of the predefined individual parameters of chronicity from the literature also helped identifying patients with chronic disease, and could be used as a tool for screening acute PE patients for pre-existing CTEPH.

Conclusion

A substantial proportion of patients who are diagnosed with CTEPH during follow-up after acute PE may already have pre-existing CTEPH at the time of the index event. An intensified follow-up programme and focussed screening for CTEPH should be considered in patients with signs of chronicity at baseline CTPA.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Bayer Health Care

Cost-of-illness analysis of long-term healthcare resource utilization and disease burden in patients with pulmonary embolism: insights from the PREFER in VTE registry

Background

Pulmonary embolism (PE) is responsible for considerable personal and societal costs. Detailing this burden would support an efficient public health resource allocation. However, cost estimates so far have failed to account for both resource utilization and excess costs in its long-term management beyond the acute phase.

Purpose

To provide estimates for the economic and disease burden of PE in the European Union (EU) also accounting for long-term healthcare utilization and costs beyond the acute phase.

Methods

This is a cost-of-illness analysis, from a societal perspective, with a bottom-top approach and a time horizon of 12 months based on data from the PREFER in VTE registry. We calculated direct and indirect costs of an acute PE event and its 12-month follow-up. We used cost inputs derived from the literature and as directly reported in the PREFER in VTE registry and we adjusted them for inflation and purchasing power parity to 2020 Euros (€). Total average costs per PE patient comprised six general categories: costs for the index PE hospitalization; costs for clinical events during follow-up; costs for anticoagulation after the index event; costs for ambulatory visits during follow-up; the patient's own contribution; and costs related to productivity loss (using the friction cost method). A stratified analysis was performed according to the presence of active cancer, non-cancer provoked PE, and unprovoked PE. In addition, we used the EQ-5D health questionnaire to derive a disability weight for the post-PE state 12 months after the index event and the corresponding disability adjusted life years (DALYs) presumably due to PE.

Results

Annual disease-specific costs for each incident PE case ranged between 9,135 € and 10,620 €. Costs for patients with cancer (8,274 to 9,752 €) and patients with unprovoked PE (8,695 to 9,612 €) were lower than costs for non-cancer patients with provoked PE (10,423 to 11,307 €), mainly due to differences in productivity loss. The indirect costs were mainly driven by productivity losses and their proportion to total costs was 42–49% for the overall population (28–33% for cancer, 52–56% for non-cancer provoked PE and 43–47% for unprovoked PE) (Figure 1). Anticoagulation accounted for 18–21% of total costs for cancer patients (while only 5–6% for non-cancer patients) and was primarily driven by the use of low-molecular-weight heparins and fondaparinux (Figure 2). The calculated disability weight for cancer-free survivors of PE 12 months after the index event was 0.017 (bootstrapped 95% CI 0.0002–0.0344) and the estimated annual DALYs per incident case were 1.17 (bootstrapped 95% CI 0.75–1.59).

Conclusion

PE imposes a significant annual economic burden, for which productivity loss is the main driver. Total costs in the EU could range between 0.5 and 3.8 billion €. The disease burden from PE is notable and translates to the loss of roughly 1.2 years of healthy life per incident PE case per year.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): This study was supported by an unrestricted grant from Daiichi Sankyo (Title: “Filling the gaps of knowledge on healthcare outcomes during long-term anticoagulant treatment of pulmonary embolism”, grant number DSE-DE-CV-20001).

Lenvatinib as a salvage therapy for advanced metastatic medullary thyroid cancer

PURPOSE

Patients with advanced progressive metastatic medullary thyroid cancer (MTC), show poor prognosis and few available systemic therapeutic options. After the loss of clinical benefit with other tyrosine kinase inhibitors (TKI), we evaluated the use of lenvatinib as salvage therapy.

METHODS

Ten patients who experienced the loss of clinical benefit after treatment with at least one previous TKI, were treated with lenvatinib. We assessed patient's response immediately before, at the first (first-EV) and last (last-EV) evaluation, after the beginning of treatment.

RESULTS

At first-EV, one patient died, while all the remaining 9 showed a stable disease (SD) in the target lesions. At last-EV, SD was still observed in seven patients, while partial response (PR) and progressive disease (PD), in one patient each. Conversely, analyzing all target and non-target lesions, at first-EV, we observed PR in one patient and SD in eight patients. At last-EV, PR was shown in two patients and SD was shown in seven. Bone metastases showed stable disease control at both first-EV and last-EV in only approximately 60% of cases. Tumor markers (CTN and CEA) decreased at first-EV, while they increased at last-EV. Seven patients experienced at least one dose reduction during treatment with lenvatinib.

CONCLUSIONS

In this real-life clinical experience, lenvatinib showed interesting results as salvage therapy in patients with advanced progressive metastatic MTC patients. Its usefulness could be effective in patients without any other available treatment, because previously used or unsuitable, especially with negative RET status with no access to the new highly selective targeted therapies.

SARS-CoV-2 contact tracing among disadvantaged populations during epidemic intervals should be a priority strategy: results from a pilot experiment in Barcelona

Objectives

The aim of this study was to trace contacts of coronavirus disease 2019 (COVID-19) hospitalised patients and determine the risk factors of infection in urban areas.

Study design

Longitudinal analysis of contacts identified from index cases.

Methods

A contact tracing study was carried out in the Northern Metropolitan area of Barcelona, Spain, during the inter-epidemic lapse of May to July 2020, a period of low SARS-CoV-2 incidence. Index cases were notified from the referral hospital. Contacts were traced and followed up for 14 days. Reverse transcription polymerase chain reaction was performed on day 0 and day 14 for contacts.

Results

In total, 368 contacts were identified from 81 index cases (median of seven contacts per index case), from which 308 were traced successfully. The median age of contacts was 28 years, 62% (223 of 368) were men. During the follow-up period, 100 contacts tested positive for COVID-19 (32.5% [95% confidence interval {CI} = 27.3–38.0]), with a secondary infection rate of 48.3% (95% CI = 40.8–55.9) among housemates. Clusters of index and respective contacts tended to aggregate within disadvantaged neighbourhoods (P < 0.001), and non-national index cases (N = 28, 34.1%) resulted in higher secondary infection rates compared with nationals (51.0% [95% CI = 41.0–60.9] vs 22.3% [95% CI = 16.8–28.8]; P < 0.001).

Conclusions

Disadvantaged communities experience a disproportionate burden of COVID-19 and may act as infection reservoirs. Contact tracing with a cross-cutting approach among these communities is required, especially during inter-epidemic periods.

Patients with Lemierre syndrome have a high risk of new thromboembolic complications, clinical sequelae and death: an analysis of 712 cases

BACKGROUND

Lemierre syndrome is characterized by head/neck vein thrombosis and septic embolism usually complicating an acute oropharyngeal bacterial infection in adolescents and young adults. We described the course of Lemierre syndrome in the contemporary era.

METHODS

In our individual-level analysis of 712 patients (2000-2017), we included cases described as Lemierre syndrome if these criteria were met: (i) primary site of bacterial infection in the head/neck; (ii) objectively confirmed local thrombotic complications or septic embolism. The study outcomes were new or recurrent venous thromboembolism or peripheral septic lesions, major bleeding, all-cause death and clinical sequelae.

RESULTS

The median age was 21 (Q1-Q3: 17-33) years, and 295 (41%) were female. At diagnosis, acute thrombosis of head/neck veins was detected in 597 (84%) patients, septic embolism in 582 (82%) and both in 468 (80%). After diagnosis and during in-hospital follow-up, new venous thromboembolism occurred in 34 (5.2%, 95% CI 3.8-7.2%) patients, new peripheral septic lesions became evident in 76 (11.7%; 9.4-14.3%). The rate of either was lower in patients who received anticoagulation (OR: 0.59; 0.36-0.94), higher in those with initial intracranial involvement (OR: 2.35; 1.45-3.80). Major bleeding occurred in 19 patients (2.9%; 1.9-4.5%), and 26 died (4.0%; 2.7-5.8%). Clinical sequelae were reported in 65 (10.4%, 8.2-13.0%) individuals, often consisting of cranial nerve palsy (n = 24) and orthopaedic limitations (n = 19).

CONCLUSIONS

Patients with Lemierre syndrome were characterized by a substantial risk of new thromboembolic complications and death. This risk was higher in the presence of initial intracranial involvement. One-tenth of survivors suffered major clinical sequelae.

Functional outcomes and quality of life during long-term follow-up after acute pulmonary embolism: analysis of the prospective multicentre FOCUS study

Background

It is unclear to which extent persistence of symptoms and/or residual haemodynamic impairment clinical course of pulmonary embolism are associated with worse quality of life (QoL).

Aims

To study the correlation between symptoms and haemodynamic impairment with QoL during the first year after acute pulmonary embolism (PE).

Methods

The Follow-Up after acute pulmonary embolism (FOCUS) study prospectively enrolled and followed consecutive adult patients diagnosed with acute symptomatic objectively diagnosed PE. In the present analysis, we considered patients who completed the Pulmonary Embolism QoL (PEmb-QoL) Questionnaire at predefined visits 3 and 12 months after acute PE. The PEmb-QoL score ranges from 0% (best QoL) to 100% (worst QoL). We evaluated at these two time points the correlation between persisting symptoms (group: symptoms), elevation of natriuretic peptides or residual right ventricular dysfunction (group: RVD), or their combination (group: symptoms + RVD) and QoL.

Results

A total of 617 patients were included; their median age was 62 years, 44% were women; 8% had active cancer, and 21% previous venous thromboembolism. At 3 months, patients with neither symptoms nor RVD (n=302) had the highest quality of life (median score 18%, 25th–75th percentile: 8%–34%), followed by those without symptoms but with RVD (n=255; median score 19%, 25th–75th percentile: 7%–34%), and by those with symptoms only (n=131; median PEmb-QoL 31%, 25th–75th percentile: 18%–49%). Patients with both symptoms and RVD (n=170) had the worst quality of life (median score 38%, 25th–75th percentile: 19%–53%); Figure 1A. At 12 months, we found an overall improvement of PEmb-QoL score. The degree of this QoL improvement varied across groups, being largest for patients who recovered from having symptoms + RVD at 3 months to normalization of at least one at 12 months. The change in QoL from 3 to 12 months was smaller both in patients who had neither symptoms nor RVD and in patients who had no recovery in either symptoms or RVD; Figure 1B.

Conclusions

Persistent symptoms after PE, especially in patients with elevated biomarkers or residual echocardiographic dysfunction, were the main drivers of QoL at 3 months as well as of the course of QoL over time.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): University Medical Center of the Johannes Gutenberg University, Mainz, Germany; German Federal Ministry of Education and Research

Quality of life 3 and 12 months after acute pulmonary embolism: analysis of 617 patients from the prospective multicentre FOCUS study

Background

Few data are available on the long-term course and predictors of quality of life (QoL) after acute pulmonary embolism (PE).

Aims

To evaluate the kinetics and determinants of QoL at 3 and 12 months after acute PE.

Methods

The Follow-Up after acute pulmonary embolism (FOCUS) study prospectively followed consecutive adult patients with objectively diagnosed PE. For this analysis, we considered patients who completed the Pulmonary Embolism QoL (PEmb-QoL) Questionnaire at two predefined visits 3 and 12 months after PE. PEmb-QoL, studied as total score and in its six dimensions, ranges from 0% (best QoL) to 100% (worst QoL). We studied the course of PEmb-QoL and the impact of baseline characteristics using multivariable linear regression.

Results

In 617 included patients (44% women, median age 62 years), overall QoL improved from 3 to 12 months, with a decrease of the mean PEmb-QoL score from 25.3% to 21.5% (p-value &lt;0.001). Intra-individual correlation between PEmb-QoL score at 3 and 12 months was high; Figure A. The improvement was consistent across all PEmb-QoL dimensions; Figure B. Female sex, cardiopulmonary diseases, and higher body mass index were the main factors associated with a worse QoL; Table. Age and smoking affected QoL only at 12 months. The improvement in QoL was faster in patients without cardiopulmonary diseases (−4.2%; 95% CI: −5.2% to −3.1%), without previous VTE (−4.3%; −5.5% to −3.2%), and in non-smokers (−4.2%; −5.3% to −3.1%).

Conclusions

In a large cohort of patients with pulmonary embolism, we quantified the improvement of QoL between 3 and 12 months after diagnosis. We identified factors independently associated with lower QoL and slower recovery of QoL that may reflect special patient needs. These estimates may facilitate the planning and interpretation of clinical trials with QoL as a study outcome.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): University Medical Center of the Johannes Gutenberg University, Mainz, Germany; German Federal Ministry of Education and Research

P4767VTE-BLEED score predicts major bleeding in patients with atrial fibrillation

Background

Bleeding risk scores in atrial fibrillation (AF) are used to identify risk factors for bleeding but not to determine anticoagulant therapy since high bleeding risk strongly correlates to high risk of stroke. VTE-BLEED is a simple bleeding risk score (Klok FA Eur Respir J 2016) that predicts major bleeding (MB) in patients with venous thromboembolism, but has never been evaluated in AF.

Aims

To evaluate VTE-BLEED in AF and whether dabigatran dose reduction in VTE-BLEED high-risk patients would result in a lower incidence of MB and the composite endpoint of MB plus stroke/systemic embolism.

Methods

Assessment of VTE-BLEED in 18040 patients of the RE-LY trial (Connolly SJ NEJM 2009) that compared dabigatran (both 150mg BID and 110mg BID) to warfarin. The score was calibrated to fit the AF population. Hazard ratios (HR) were obtained for the VTE-BLEED high-risk patients randomized to dabigatran. The risk ratios for MB and the composite outcome of MB plus stroke/systemic embolism between dabigatran 150mg and 110mg were calculated for the VTE-BLEED high-risk group.

Results

The adapted VTE-BLEED score classified 4060 patients (22.5%) as high-risk. A high score indeed predicted MB in patients treated with dabigatran 150mg BID or 110mg BID, for HRs of 2.48 (95% CI 1.96–3.13) and 2.61 (95% CI 2.04–3.33), respectively. In VTE-BLEED high-risk patients, the risk ratio between the two dabigatran doses was 0.53 (95% CI 0.35–0.78) for MB and 0.55 (95% CI 0.38–0.79) for the composite outcome, both in favor of dabigatran 110mg BID (Figure 1). Compared to the current European label of dabigatran, application of VTE-BLEED to determine dabigatran dosing would result in a different dose for 21% of patients.

Figure 1

Conclusions

VTE-BLEED was validated for AF. Our data suggest that dabigatran dose reduction in VTE-BLEED bleed high-risk patients -in addition to targeting individual modifiable risk factors for bleeding- may lower the risk of MB and improve patient outcome. This finding could have important clinical implications but should be confirmed in future studies.

P3449Revealing the burden of acute cardiac and arterial complications in 715 patients diagnosed with Lemierre syndrome

Background

Lemierre syndrome is a potentially life-threatening condition occurring in otherwise healthy children and adolescents with head/neck bacterial infections (usually tonsillitis due to anaerobe bacteria). Peculiar complications are neck vein thromboses contiguous to the site of infection and multiple septic embolization. Arterial thrombosis and cardiac complications have been described as possible clinical manifestations of Lemierre syndrome: however, in light of the rarity of this condition (one case/1,000,000 person-years), no comprehensive analysis has ever been conducted.

Purpose

To describe the frequency and the patterns of acute cardiac and arterial complications in patients with Lemierre syndrome.

Methods

We identified 715 cases of Lemierre syndrome (years 2000–2016) and retrieved complete individual patient-level data. Study outcomes assessed on admission or during hospitalization were: i) objectively diagnosed ischemia or arterial infarction/thrombosis, arterial stenosis due to inflammatory process, and septic aneurysms; ii) new objectively diagnosed cardiac complications; iii) all-cause death.

Results

Of the 715 patients with Lemierre syndrome, 56 (7.6%, 95% confidence interval [CI]: 6.1%–10.0%) experienced cardiac or arterial complications. Median age was 19 (interquartile range [IQR]: 16–25) years and 35 (62.5%) were men. Intracranial ischemia or infarction was found in 23 patients, corresponding to 3.2% of the whole study population. Carotid artery thrombosis, stenosis, or septic aneurysm occurred in 28 (3.9% of total), pericardial disease in 11 (1.5% of total), and infective endocarditis in 5 (0.7% of total) (Figure). A total of 32 (57.1%) patients developed these complications during the course of hospitalization after a median of 6 (IQR: 3–12 days) days from admission. A total of 37 (66.1%) patients received anticoagulation. Fatality rate was 10.7% (95% CI: 5.0%–21.4%; n=6).

Cardiac and arterial complications.

Conclusions

An unexpectedly high proportion of patients with Lemierre syndrome developed acute cardiac or arterial complications. In this group, the fatality rate was substantial. Our observation that most of the cardiovascular events occurred during the course of hospitalization may have implications for the development of diagnostic and management strategies. It remains unclear whether antithrombotic therapies may influence prognosis.

P3850Impact of sex and risk factors for venous thromboembolism on the clinical course of first acute venous thromboembolism. Insights from the PREFER in VTE

Introduction

The interaction between sex and specific provoking risk factors for venous thromboembolism (VTE) may influence initial presentation and prognosis.

Purpose

We investigated the impact of sex on the risk of recurrence across subgroups of patients with first VTE classified according to baseline risk factors.

Methods

PREFER in VTE was an international, non-interventional registry (2013–2015) including patients with a first episode of acute symptomatic objectively diagnosed VTE. We studied the risk of recurrence in patients classified according to baseline provoking risk factors for VTE consisted of i) major transient (major surgery/trauma, >5 days in bed), ii) minor transient (pregnancy or puerperium, estroprogestinic therapy, prolonged immobilization, current infection or bone fracture/soft tissue trauma); iii) unprovoked events, iv) active cancer-associated VTE.

Results

A total of 3,455 patients diagnosed with first acute VTE were identified, of whom 1,623 (47%) were women. The percentage of patients with a major transient risk factor was 22.2% among women and 19.7% among men. Minor transient risk factors were present in 21.3% and 12.4%, unprovoked VTE in 51.6% and 61.6%, cancer-associated VTE in 4.9% of women and 6.3% of men, respectively. The proportions of cases treated with Vitamin-K antagonists (VKAs) and direct oral anticoagulants (DOACs) were similar between sexes. Median length of treatment of VKAs was 181.5 and 182.0 days and of DOACs was 113.0 and 155.0 days in women and men, respectively. At 12-months of follow-up, VTE recurrence was reported in 74 (4.8%) women and 80 (4.5%) men. Table 1 shows the sex-specific proportion of recurrences by VTE risk factor categories.

Table 1 Major Transient (n=722) Minor transient (n=573) Cancer-associated (n=195) Unprovoked (1965) Women (361) Men (361) OR (95% CI) Women (346) Men (227) OR (95% CI) Women (79) Men (116) OR (95% CI) Women (837) Men (1128) OR (95% CI) One-year follow-up, n (N%)   Recurrent VTE, 21 (6.2) 10 (2.9) 0.46 (0.2; 0.9) 9 (2.7) 12 (5.4) 2.09 (0.9; 5.0) 6 (8.0) 5 (4.5) 0.54 (0.2; 1.9) 38 (4.7) 53 (4.7) 1.03 (0.7; 1.6)   Major bleeding, 6 (1.8) 5 (1.5) 0.83 (0.3; 2.7) 5 (1.5) 1 (0.5) 0.30 (0.1; 2.6) 1 (1.3) 3 (2.7) 2.07 (0.2; 20) 10 (1.2) 15 (1.4) 1.11 (0.6; 2.4)   All-cause death, 37 (10.2) 31 (8.5) 0.82 (0.5; 1.4) 10 (2.9) 14 (6.2) 2.21 (0.9; 5.1) 26 (32.9) 49 (42.2) 1.49 (0.8; 2.7) 33 (3.9) 30 (2.7) 0.66 (0.4; 1.1)

Conclusions

The proportion of patients with recurrent VTE events after first acute symptomatic VTE provoked by transient risk factors was not negligible during the first year of follow-up during in both women and men. These results may have implications on the decision whether to consider extended anticoagulant therapy in selected patients with provoked events.

Acknowledgement/Funding

This study was funded by Daiichi Sankyo.

Targeted Therapy in Thyroid Cancer: State of the Art

Thyroid cancer typically has a good outcome following standard treatments, which include surgery, radioactive iodine ablation for differentiated tumours and treatment with thyrotropine hormone-suppressive levothyroxine. Thyroid cancers that persist or recur following these therapies have a poorer prognosis. Cytotoxic chemotherapy or external beam radiotherapy has a low efficacy in these patients. 'Target therapy' with tyrosine kinase inhibitors (TKIs) represent an important therapeutic option for the treatment of advanced cases of radioiodine refractory (RAI-R) differentiated thyroid cancer (DTC), medullary thyroid cancer (MTC) and possibly for cases of poorly differentiated (PDTC) and anaplastic thyroid cancer (ATC). In the last few years, several TKIs have been tested for the treatment of advanced, progressive and RAI-R thyroid cancers and some of them have been recently approved for use in clinical practice: sorafenib and lenvatinib for DTC and PDTC; vandetanib and cabozantinib for MTC. The objective of this overview is to present the current status of the treatment of advanced DTC, MTC, PDTC and ATC with the use of TKIs by describing the benefits and the limits of their use. A comprehensive analysis and description of the molecular basis of these drugs and the new therapeutic perspectives are also reported. Some practical suggestions are also given for the management to the potential side-effects of these drugs.

COPD in HIV-Infected Patients: CD4 Cell Count Highly Correlated

Background

COPD is a frequent and significant cause of respiratory morbidity in HIV-infected patients despite the control of HIV. We aimed to analyze the factors correlated with COPD in this population to evaluate the existence of specific indicators of vulnerability in this population.

Methods and Findings

623 HIV-infected outpatients were enrolled during one year. This population was characterised by a dedicated questionnaire and electronic patient records. COPD screening was performed according to recommended spirometric criteria. The prevalence of COPD was 9.0%. Age and smoking were independently correlated with COPD (OR, 1.61 per 10 years increase, P = 0.007; OR, 1.28 per 10 pack-year increase, P = 0.003, respectively). Body mass index (BMI) and CD4 cell-count were independently and negatively correlated with COPD (OR, 0.78, P < 0.001; 0R, 0.77 per 100 cell/mm³ increase, P < 0.001, respectively). Among COPD patients, 77% did not know their diagnosis. Five COPD-patients never smoked and 44.2% did not have any respiratory symptoms and so were not eligible to perform a spirometry according to the guidelines.

Conclusions

In addition to known risk factors, immune defect through CD4 cell count was independently and strongly correlated with COPD. COPD is largely underdiagnosed and thus unmanaged. However, early management and urgent smoking cessation are essential to improve prognosis. Clinicians’ awareness on the particular vulnerability for COPD in HIV-infected patients is crucial. Moreover, indications to perform conventional spirometry to diagnose COPD may include more parameters than tobacco-smoking and respiratory complaints with a particular concern toward patients with a profound CD4 cell count defect.

Predictors of failure after single faecal microbiota transplantation in patients with recurrent Clostridium difficile infection: results from a 3-year, single-centre cohort study

OBJECTIVES

Faecal microbiota transplantation (FMT) is an effective treatment for recurrent Clostridium difficile infection (CDI). Although a single faecal infusion is usually sufficient to eradicate CDI, a considerable number of patients need multiple infusions to be cured. The aim of this study was to identify predictors of failure after single faecal infusion in patients with recurrent CDI.

METHODS

We included patients with recurrent CDI prospectively treated with FMT by colonoscopy. By means of univariate and multivariate analysis, variables including female gender, age, number of CDI recurrences, severity of CDI, hospitalization, inadequate bowel preparation, unrelated donor, and use of frozen faeces, were assessed to predict failure after single faecal infusion.

RESULTS

Sixty-four patients (39 women; mean age 74 years) were included. Of them, 44 (69%) were cured by a single faecal infusion, whereas 20 (31%) needed repeat infusions. Overall, FMT cured 62 of 64 (97%) patients. In the subgroup of patients with severe CDI, only eight of 26 (30%) were cured with a single infusion. At multivariate analysis, severe CDI (OR 24.66; 95% CI 4.44-242.08; p 0.001) and inadequate bowel preparation (OR 11.53; 95% CI 1.71-115.51; p 0.019) were found to be independent predictors of failure after single faecal infusion.

CONCLUSIONS

Severe CDI and inadequate bowel preparation appear to be independent predictors of failure after single faecal infusion in patients treated with FMT by colonoscopy for recurrent CDI. Our results may help to optimize protocols and outcomes of FMT in patients with recurrent CDI.

First Measurement of Electron Neutrino Appearance in NOvA

We report results from the first search for ν_{μ}→ν_{e} transitions by the NOvA experiment. In an exposure equivalent to 2.74×10^{20} protons on target in the upgraded NuMI beam at Fermilab, we observe 6 events in the Far Detector, compared to a background expectation of 0.99±0.11(syst) events based on the Near Detector measurement. A secondary analysis observes 11 events with a background of 1.07±0.14(syst). The 3.3σ excess of events observed in the primary analysis disfavors 0.1π<δ_{CP}<0.5π in the inverted mass hierarchy at the 90% C.L.

Has the economic crisis led to a new risk profile for international travellers?

INTRODUCTION

The economic world crisis has led to the migration of European workers to developing countries with a high incidence of infectious diseases. The objective of this study was to assess whether this context has produced an increase in the risks to international travellers for work reasons (TWR).

METHODS

Observational, retrospective study. The study population included TWR who were attended before travelling at an International Health Unit in the year 2007 (the year before the initiation of the European crisis) and in the year 2012 (when the structural crisis was established). A comparative socioeconomic analysis was performed as well as an analysis of the risk factors present in both groups.

RESULTS

In 2007 and 2012 a total of 9,197 travellers were attended. Of these, there were 344 TWR (3.4%); 101 TWR (2.8%) in 2007 and 243 TWR (4.5%) in 2012 (p<0.001). The average age of the travellers was 38.1 years (SD: 10.57). The most common destination was Sub-Saharan Africa, in 164 (47.6%) of the cases. Malaria chemoprophylaxis was prescribed to 152 travellers (44%) and 80 presented comorbidity (23.25%). The TWR from 2012 presented a significantly greater age (p=0.05), more comorbidity (p=0.018) and a greater proportion of stays in rural areas (p=0.0009) for longer time periods (p=0.001).

CONCLUSIONS

At 5 years from the start of the economic crisis, there was a change in the profile of TWR. Their number has increased significantly, as has the proportion who present risk factors for contracting imported diseases. The International Health Units should adapt to these new circumstances and adopt preventive measures for this population.

Immunosuppression and Chagas disease; experience from a non-endemic country

Reactivation of Chagas disease in the chronic phase may occur when immunosuppression is established, sometimes resulting in high parasitaemia and severe clinical manifestations such as meningitis and meningoencephalitis. Although this situation is being increasingly described, there is still scarce information. This retrospective observational study was performed in three Tropical Medicine Units of Barcelona (Spain) included in the International Health Programme of the Catalan Health Institute (PROSICS). The objective of the study was to describe epidemiological, clinical, microbiological, prognostic and therapeutic data from patients with Chagas disease and any kind of immunosuppressive condition attended in these three institutions from January 2007 to October 2014. From 1823 patients with Chagas disease attending these three centres during the study period, 38 (2%) had some kind of immunosuppressive condition: 12 patients had human immunodeficiency virus infection, 8 patients had neoplasia, 4 patients underwent organ transplantation and 14 patients had an autoimmune disease. Eight (21.1%) patients had cardiac involvement, and six (15.8%) patients had gastrointestinal involvement. Acute Trypanosoma cruzi infection was detected in two Spanish patients. Thirty-one (81.6%) patients received treatment with benznidazole, of whom 17 (54.8%) had some kind of adverse event. No patient had a severe manifestation or reactivation of Chagas disease. Patients with Chagas disease under immunosuppressive conditions are being increasingly described, especially in non-endemic countries. More information about this topic is required and international consensus in the diagnosis, treatment and follow up of these patients must be established to reduce the morbidity and mortality.

Prophylactic central compartment lymph node dissection in papillary thyroid carcinoma: clinical implications derived from the first prospective randomized controlled single institution study

BACKGROUND

The benefits of prophylactic central compartment lymph node dissection (pCCND) in papillary thyroid cancer (PTC) are still under investigation. This treatment seems to reduce PTC recurrence/mortality rates but has a higher risk of surgical complications. The lack of prospective randomized trials does not allow definitive recommendations. The aim of this prospective randomized controlled study was to evaluate the clinical advantages and disadvantages of pCCND.

PATIENTS

A total of 181 patients with PTC without evidence of preoperative/intraoperative lymph node metastases (cN0) were randomly assigned to either Group A (n = 88) and treated with total thyroidectomy (TTx) or Group B (n = 93) and treated with TTx + pCCND.

RESULTS

After 5 years of followup, no difference was observed in the outcome of the two groups. However, a higher percentage of Group A were treated with a higher number of (131)I courses (P = .002), whereas a higher prevalence of permanent hypoparathyroidism was observed in Group B (P = .02). No preoperative predictors of central compartment lymph node metastases (N1a) were identified. Only three patients were upstaged, and the therapeutic strategy changed in only one case.

CONCLUSIONS

cN0 patients with PTC treated either with TTx or TTx + pCCND showed a similar outcome. One advantage of TTx + pCCND was a reduced necessity to repeat (131)I treatments, but the disadvantage was a higher prevalence of permanent hypoparathyroidism. Almost 50% of patients with PTC had micrometastatic lymph nodes in the central compartment, but none of the presurgical features analyzed, including BRAF mutation, was able to predict their presence; moreover, to be aware of their presence does not seem to have any effect on the outcome.

In vitro hemodynamics and valve imaging in passive beating hearts

Due to their high complexity, surgical approaches to valve repair may benefit from the use of in vitro simulators both for training and for the investigation of those measures which can lead to better clinical results. In vitro tests are intrinsically more effective when all the anatomical substructures of the valvular complexes are preserved. In this work, a mock apparatus able to house an entire explanted porcine heart and subject it to pulsatile fluid-dynamic conditions was developed, in order to enable the hemodynamic analysis of simulated surgical procedures and the imaging of the valvular structures. The mock loop's hydrodynamic design was based on an ad-hoc defined lumped-parameter model. The left ventricle of an entire swine heart was dynamically pressurized by an external computer-controlled pulse duplicator. The ascending aorta was connected to a hydraulic circuit which simulated the input impedance of the systemic circulation; a reservoir passively filled the left atrium. Accesses for endoscopic imaging were located in the apex of the left ventricle and in the aortic root. The experimental pressure and flow tracings were comparable with the typical in vivo curves; a mean flow of 3.5±0.1l pm and a mean arterial pressure of 101±2 mmHg was obtained. High-quality echographic and endoscopic video recordings demonstrated the system's excellent potential in the observation of the cardiac structures dynamics. The proposed mock loop represents a suitable in vitro system for the testing of minimally-invasive cardiovascular devices and surgical procedures for heart valve repair.

The current status of decision-making procedures and quality assurance in Europe: an overview

The 2005 Report on Social Responsibility and Health of the UNESCO International Bioethics Committee (Ibc) proposes a new approach to implementing the right to healthcare and suggests a number of Courses of Action to be followed in various fields. Based on the latest available data, we intend to present an overview of the current state of European health systems in two of those fields-decision-making procedures and quality assurance in health care-and to attempt a comparison of the situation with the Report's provisions, in order to pave the way for the identification of what still has to be done to bridge international recommendations and the reality of policy and practice in Europe's health care.

Clinical, electrocardiographic and echocardiographic abnormalities in Latin American migrants with newly diagnosed Chagas disease 2005-2009, Barcelona, Spain

Following Latin American migration, Chagas disease has inevitably appeared in non-endemic countries in Europe and elsewhere. New policies are necessary to prevent transmission in those countries but the long, often undetected chronic period of the early stages of the disease also renders epidemiological studies important. The main objective of our study was to determine the presence of clinical, electrocardiogram (ECG) and echocardiographic abnormalities in a population of Latin American migrants infected with Trypanosoma cruzi at the moment of diagnosis. We performed a hospital-based observational study of 100 adult patients with newly diagnosed Chagas infection between January 2005 and December 2009. Thirty-seven patients were classified within the Brazilian Consensus on Chagas cardiomyopathy early cardiac stages (A or B1) and 49 presented pathological findings (stage B2) according to the Panamerican Health Organization Classification. Overall, 49 patients showed ECG and/or echocardiographic alterations. The presence of ECG and ecocardiographic alterations were significantly associated (p=0.038). The most frequent ECG and echocardiographic findings were right bundle branch block (12 cases) and impaired left ventricular wall relaxation (24 cases), respectively. In conclusion, ECG and echocardiographic alterations coherent with Chagas cardiomyopathy were found in a large proportion of newly diagnosed Latin American migrants infected with T. cruzi. In the mid-term, Chagas disease might become an important cause of chronic cadiomyopathy in our attendance area.

Etanercept compared to intraarticular corticosteroid injection in rheumatoid arthritis: double-blind, randomized pilot study

OBJECTIVE

To compare etanercept (anti-tumor necrosis factor-α) with intraarticular (IA) corticosteroid injections to treat rheumatoid arthritis (RA).

METHODS

Patients with RA who had persistent monoarthritis received etanercept or IA corticosteroid injections. Efficacy was compared at Weeks 4 and 24.

RESULTS

Thirty-four patients were included (8 dropped out). Mean age was 58.8 years. No difference between groups was found at Weeks 4 or 24, but both groups showed significant improvement at Weeks 4 and 24 compared to baseline.

CONCLUSION

Etanercept and IA steroid injections resulted in significant improvement at Week 4 that persisted to Week 24. There was no significant difference in outcome between the groups.

[Learning use of spatulas: risks of perineal injuries and newborns morbidity]

OBJECTIVES

To examine the acute neonatal and maternal perineal morbidity due to resident training on spatulas assisted deliveries.

MATERIAL AND METHODS

We conducted a retrospective observational study of succesful spatulas-assisted deliveries at Nice University Hospital between January2003 and December2006. We performed univariate analysis and logistic regression to assess risk of severe perineal injuries, vaginal laceration and newborn hospitalization according to operator status, controlling for confounders.

RESULTS

Among 1004 deliveries, 86.4% were performed by residents. No significant difference was found on incidence of severe perineal tears between the 872 extractions performed by residents and the 132 performed by an attending physician (6.9% versus 7.9% p=0.706; OR=0.86 IC95% [0.41-1.81]), but extraction performed by young residents were associated to more severe perineal tears than those performed by senior residents (8.0% versus 4.5% p=0.035; OR=2.10 IC95% [1.16-3.77]). There was no difference between groups concerning newborn morbidity and hospitalisation in special care units (6.4% versus 9.8% p=0.149; OR=1.49 IC95% [0.73-304]).

CONCLUSION

According to our data, training of resident do not increase the incidence of severe perineal injuries, neonatal complications and hospitalisation linked to spatulas assisted delivery.

Biogeographical origin and varicella risk in the adult immigration population in Catalonia, Spain (2004-2006)

Immigrants to the European Union may have a higher susceptibility to varicella-zoster virus primo-infection than the indigenous population. There is no evidence as yet that this is caused by genetic or social factors. Therefore, susceptibility could be due to a lesser transmission of the virus in their ecosystems of origin. A multicentre observational study was performed from July 2004 to June 2006 in four primary healthcare centres in Catalonia, Spain, monitoring varicella incidences and comparing standardised incidence rates and standardised rate ratios among different populations classified according to their biogeographical origin (holarctic, Asian paleotropical, African paleotropical or neotropical). Overall, 516 varicella cases were recorded. The standardised incidence rates per 1,000 inhabitants per year were: holarctic: 2.17 (95% confidence interval (CI): 1.95-2.39); autochthonous 2.26 (95% CI: 2.03-2.49); immigrants 3.59 (95% CI: 2.92-4.26); neotropical 4.50 (95% CI: 3.28-5.71); non-holarctic 5.38 (95% CI: 4.27-6.14); Asian paleotropical 7.03 (95% CI: 4.77-9.28); and African paleotropical 7.05 (95% CI: 1.12-23.58). The difference to the autochthonous population was greatest in immigrants of neotropical origin (standardised rate ratio = 2.07 (95% CI: 1.61-2.64) or 4.5 excess cases per 1,000 inhabitants per year) and Asian paleotropical origin (standardised rate ratio = 3.24 (95% CI: 2.47-4.11) or 9.6 excess cases per 1,000 inhabitants per year). Biogeographical origin may therefore account for the vulnerability of certain immigrant populations to varicella, in particular those from Asian paleotropical (Indostan and Southest Asia) and neotropical (South America and the Caribbean) ecosystems. Vaccination of immigrants at high risk (fertile women, healthcare workers) could be recommendable.

Distribution of 'promoter' sandflies associated with incidence of classic Kaposi's sarcoma

The patchy geographical distributions of classic Kaposi's sarcoma (KS) and human herpesvirus type 8 (HHV-8), better known as Kaposi's sarcoma-associated herpesvirus (KSHV) remain unexplained. It has been proposed that certain species of bloodsucking insects ('promoter arthropods') promote the reactivation of HHV-8/KSHV and facilitate both HHV-8/KSHV transmission and KS development. This hypothesis was tested by sampling the presence and density of human-biting Diptera with CDC light traps in two areas of Sardinia with contrasting incidence rates of classic KS. In total, 11,030 specimens (99.9% sandflies and 0.1% mosquitoes) belonging to 10 species were collected from 40 rural sites. Five of these species are considered to be possible promoter arthropods because of the irritation their bites cause: Phlebotomus perniciosus Newstead; Phlebotomus perfiliewi Parrot (Diptera: Psychodidae); Aedes berlandi Seguy; Culiseta annulata (Schrank) and Culex theileri Theobald (Diptera: Culicidae). Five species are probable 'non-promoters' because their bites are not particularly irritating: Culiseta longiareolata (Macquart); Culex pipiens s.l.; Anopheles algeriensis Theobald; Anopheles maculipennis s.l., and Anopheles plumbeus Stephens. A significant correlation was found between the geographical distribution of promoter arthropods and incidence rates of KS (Spearman's r = 0.59,P < 0.01). Promoter arthropods were more likely to be caught in areas with cutaneous leishmaniasis and a past high prevalence of malaria, and in areas of limestone, acid volcanic soil and cereal cultivation. The study supports the association between promoter arthropods and classic KS, which may explain the geographic variability of KS and HHV-8/KSHV, and highlights the links with a number of variables previously associated with the incidence of KS.

The role of topical retinoids in the treatment of pigmentary disorders: an evidence-based review

Topical retinoids have been used in the treatment of pigmentary disorders such as melasma, actinic lentigines, and postinflammatory hyperpigmentation. This article evaluates the clinical efficacy and tolerability of retinoid treatment for pigmentary disorders through an evidence-based approach. We searched the MEDLINE and The Cochrane Library databases using the keywords 'retinoid' combined with 'melasma,' 'lentigines,' or 'postinflammatory hyperpigmentation.' For each study, the methodology and outcomes were assessed according to specific criteria. There is fair evidence to support the use of topical tretinoin as a monotherapy in the treatment of melasma as well as in the treatment of lentigines (grade B). Adverse effects of topical retinoids are quite frequent, and include local skin irritation, erythema, and peeling, and their severity is mild to moderate. There is evidence to support the use of topical tretinoin in a fixed, triple-combination therapy (hydroquinone 4%/tretinoin 0.05%/fluocinolone acetonide 0.01%) for the treatment of melasma (grade B). There is poor evidence (grade C) to support the use of combination formulations for the treatment of lentigines, and large, randomized, double-blind, controlled trials are needed to further evaluate their use for this indication. In conclusion, there is evidence to support the use of topical retinoids as monotherapy or in combination with other topical agents in the treatment of pigmentary disorders.

Blood-feeding preferences of Aedes albopictus (Diptera: Culicidae) in urban and rural settings within the province of Rome, Italy

We here report the results of field trials carried out in Rome with the aim to obtain data on the feeding behaviour of Aedes albopictus, in relation to different availability and abundance of putative hosts. Human Blood Index values were found higher than 75% in urban areas, where humans represented the most abundant hosts, and lower than 60% in rural areas, where host alternative to humans were frequent. The overall results confirm the generalist feeding-behaviour shown by this species in its original range of distribution and highlighting its high potential as vector of human pathogens in urban areas of Italy.

Development of a novel sticky trap for container-breeding mosquitoes and evaluation of its sampling properties to monitor urban populations of Aedes albopictus

Collection methods currently used for large-scale sampling of adult Stegomyia mosquitoes (Diptera: Culicidae) present several operational limitations, which constitute major drawbacks to the epidemiological surveillance of arboviruses, the evaluation of the impact of control strategies, and the surveillance of the spreading of allochthonous species into non-endemic regions. Here, we describe a new sticky trap designed to capture adult container-breeding mosquitoes and to monitor their population dynamics. We tested the sampling properties of the sticky trap in Rome, Italy, where Aedes (Stegomyia) albopictus is common. The results of our observations, and the comparison between sticky trap catches and catches made with the standard oviposition trap, are presented. The sticky trap collected significantly larger numbers of Ae. albopictus females than any other Culicidae species representing >90% of the total catches. A maximum of 83 An. albopictus females was collected in a single week. A high correlation (Pearson correlation coefficient r= 0.96) was found between the number of females and the number of eggs collected by the traps. The functional relationship between the number of eggs and the number of adult females was assessed by major axis regression fitted to log(1 +x)-transformed trap counts as y= 0.065 + 1.695x. Trap samples significantly departed from a random distribution; Taylor's power law was fitted to the trap samples to quantify the degree of aggregation in the catches, returning the equations s(2)= 2.401 m(1.325) for the sticky trap and s(2)= 13.068 m(1.441) for the ovitrap, with s(2) and m denoting the weekly catch variance and mean, respectively, indicating that eggs were significantly more aggregated than mosquitoes (P < 0.0001). Taylor's power law parameters were used to estimate the minimum number of sample units necessary to obtain sample estimates with a fixed degree of precision and sensitivity. For the range of densities encountered in our study area during the Ae. albopictus breeding season, the sticky trap was more precise and sensitive than the ovitrap. At low population densities (c. < 0.1 mosquito/trap), however, the ovitrap was more sensitive at detecting the presence of this species. Overall, our results indicate that our new model of sticky trap can be used to sample Ae. albopictus females in urban environments, and, possibly, other container-breeding Stegomyia mosquitoes (e.g. Aedes aegypti). The technical properties of the new trap are discussed with respect to its possible application in monitoring the population dynamics of container-breeding mosquitoes, in studying their bionomics, and in vector surveillance and, possibly, control.

Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears

BACKGROUND

Lesions of the long head of the biceps tendon are often associated with massive rotator cuff tears and may be responsible for shoulder pain and dysfunction. The purpose of this study was to evaluate the clinical and radiographic outcomes of isolated arthroscopic biceps tenotomy or tenodesis as treatment for persistent shoulder pain and dysfunction due to an irreparable rotator cuff tear associated with a biceps lesion.

METHODS

We conducted a retrospective study of sixty-eight consecutive patients (mean age [and standard deviation], 68 +/- 6 years) in whom a total of seventy-two irreparable rotator cuff tears had been treated arthroscopically with biceps tenotomy or tenodesis. A simple tenotomy was performed in thirty-nine cases, and a tenodesis was performed in thirty-three. No associated acromioplasty was performed. All patients were evaluated clinically and radiographically by an independent observer at a mean of thirty-five months postoperatively.

RESULTS

Fifty-three patients (78%) were satisfied with the result. The mean Constant score improved from 46.3 +/- 11.9 points preoperatively to 66.5 +/- 16.3 points postoperatively (p < 0.001). A healthy-appearing teres minor on preoperative imaging was associated with significantly increased postoperative external rotation (40.4 degrees +/- 19.8 degrees compared with 18.1 degrees +/- 18.4 degrees ) and a significantly higher Constant score (p < 0.05 for both) compared with the values for the patients with an absent or atrophic teres minor preoperatively. Three patients with pseudoparalysis of the shoulder did not benefit from the procedure and did not regain active elevation above the horizontal level. In contrast, the fifteen patients with painful loss of active elevation recovered active elevation. The acromiohumeral distance decreased 1.1 +/- 1.9 mm on the average, and glenohumeral osteoarthritis developed in only one patient. The results did not differ between the tenotomy and tenodesis groups (mean Constant score, 61.2 +/- 18 points and 72.8 +/- 12 points, respectively). The "Popeye" sign was clinically apparent in twenty-four (62%) of the shoulders that had been treated with a tenotomy; of the sixteen patients who noticed it, none were bothered by it.

CONCLUSIONS

Both arthroscopic biceps tenotomy and arthroscopic biceps tenodesis can effectively treat severe pain or dysfunction caused by an irreparable rotator cuff tear associated with a biceps lesion. Shoulder function is significantly inferior if the teres minor is atrophic or absent. Pseudoparalysis of the shoulder and severe rotator cuff arthropathy are contraindications to this procedure.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Exantema hemorrágico por virus dengue inducido por ácido acetil-salicílico

Dengue fever, a viral infectious disease characteristic of tropical climates, is considered to be a re-emergent pathology responsible for several serious outbreaks in the last decade. Some factors have been involved in the spread of the virus and its vectorial mosquito carrier: human alteration of the ecosystems, improvement and speed in the transit of goods and people and climate changes. As a reflection of this, an increase in imported cases is probable, especially in tourists coming from endemic areas, considering its short period of incubation (7-10 days). The recognition of personal antecedents of journeys, the main symptoms of the disease and the potential presence of complications (haemorrhagic dengue) should be included in the examination of fever of unknown origin or feverish exanthema. The case of a patient is presented whose clinical picture of classic dengue fever was worsened by self-treatment with acetylsalicylic acid.

Distribution of mosquito species in areas with high and low incidence of classic Kaposi's sarcoma and seroprevalence for HHV-8

The 'promoter-arthropod' hypothesis, which postulates that exposure to the bites of certain species of haematophagous arthropods is an environmental risk cofactor linked to human herpes virus 8 (HHV-8) and Kaposi's sarcoma, was investigated in the Po River valley, northern Italy. The presence and density of adult female mosquitoes (Diptera: Culicidae) was determined by CDC light trap catches in two adjacent districts, at variance with respect to Kaposi's sarcoma incidence and HHV-8 seroprevalence. A total of 3910 specimens belonging to 11 species was collected in 34 rural sites (six municipalities) representative of the two districts. Five of these species are considered to be possible 'promoters' because of the irritation their bites cause humans: Aedes vexans (Meigen) and Ae. caspius (Pallas) (87% of sampled promoters), Culex modestus Ficalbi, Culiseta annulata (Schrank) and Coquillettidia richiardii (Ficalbi). Six are probable 'non-promoters': Cx. pipiens s.l., Cx. martinii Medschid, Anopheles claviger (Meigen), An. maculipennis s.l., An. plumbeus Stephens and Uranotaenia unguiculata Edwards. The density of promoters by site was correlated with the incidence rates of Kaposi's sarcoma at the district level (Pearson's r = 0.33, P = 0.06) and at the municipal level (r = 0.50, P< 0.01). Similar correlations emerged for non-promoters (r = 0.48, P< 0.01 and r = 0.42, P = 0.01, respectively). The density of promoters was higher than that of non-promoters in sites with livestock (odds ratio, OR = 2.8, 95% CI 2.2-3.6) and in municipalities with Kaposi's sarcoma cases (OR = 2.5, 95% CI 1.7-3.5). The study provides additional evidence of the association between the density of some mosquito species and Kaposi's sarcoma.

[Codevelopment and health. Prevention of HIV transmission in Ghana: the Brothers in Work Programme]

OBJECTIVE

To design a health programme, as part of a codevelopment programme, aimed at reducing the occurrence of HIV-AIDS in a rural African population.

DESIGN

The Catalan Society of Community and Family Medicine developed the Brothers in Work Health Programme (BWP) through a working party of Spanish and Ghanaian doctors. The programme has two consecutive stages. The first ("being safe") aims to stop transmission of the virus caused by accidents with health material. The second, intervention stage ("being active") focuses on introducing voluntary antenatal screening for HIV, counselling and a protocol for administering nevirapine to a cohort of 600 seropositive women whilst giving birth. The results will be compared with another cohort of 600 seronegative pregnant women.

SETTING

Three Area Hospitals in the Central Region of Ghana.

PARTICIPANTS

876,000 people from 3 districts.

MAIN MEASUREMENTS

Assessment of HIV-AIDS prevalence and survival of newborns at 18 months. Monitoring of the cost-efficiency relationship of the interventions.

RESULTS

Estimated direct costs are: a) for diagnosis of each seronegative patient, 2.43 euros (1.75 co-payment), and b) for diagnosis, counselling, and nevirapine treatment of each seropositive patient, 6.6 euros (4.65). Estimated cost-efficiency relationship of the programme is: a) for every patient diagnosed, counselled and included in the programme, 23.5 euros (15.3), and b) for each case of intra-delivery infection of baby avoided, 20.03 euros (15.5). HIV transmission to 54 children would be avoided (9% of the deliveries of seropositive women; 6.3 of the total women tested).

CONCLUSIONS

The BWP has a good cost/benefice relationship in the interruption of HIV transmission.

Rubella outbreak in young adults of Brazilian origin in a Barcelona suburb, October-December 2005

A possible case of rubella in a 24 year old woman in her eighth week of pregnancy was reported in the Barcelona region on 21 November 2005

[Tropical medicine consultation]

Tropical medicine consultations are fully justified in settings with the latest modern technology, where specific complementary tests are available and there are professionals with experience in tropical questions. That is to say, in tertiary hospitals. If such consultations took place in secondary hospitals or in primary care, they could be considered inefficient or unjustifiable from the point of view of the volume of patients attended to. However, there is a care deficit with respect to preventive activities concerning travellers or immigrants who have recently arrived from countries with a low income and where there is a high prevalence of imported diseases that are less recognised in our normal health milieu. Thus, international health units, which combine preventive and curative activities in a framework of public health provision and in a functional situation between the hospital level and that of primary care, offer a more efficient and suitable profile for the characteristics of the Spanish population. Their implementation depends on policy makers, the offer of a realistic portfolio of services, the existence of quality control monitoring and the possibility of managing information through a computer network.

Comparison between monofilament and multifilament polypropylene tapes in urinary incontinence

OBJECTIVE

We compare the efficacy and late complications between a polypropylene monofilament tape (TVT) and a polypropylene multifilament tape (IVS) in the surgical implant of sub-urethral, tension free tape for the treatment of stress urinary incontinence (SUI).

METHODS

It is a non-randomised, monocentric retrospective study. Two questionnaires were sent to the patients. The first questionnaire determined the efficacy of the tape and the tolerance of the urinary process. The second questionnaire evaluated discomfort and consequences linked to urinary incontinence and associated urinary troubles.

RESULTS

The study included 313 female patients and 256 (82%) responded to the questionnaire (137 TVT, 119 IVS). Patient satisfaction was 88.3% for the TVT tape and 73.5% for the IVS tape (p < 0.005). The improvement of the quality of life was also higher for the polypropylene monofilament tapes. "De novo" urge incontinence was more common in the TVT group. However, the rates of dysuria and infection of tapes were more common in the IVS group.

CONCLUSION

The type of tape appears to influence efficacy and the emergence of late complications. Our results point at the greater efficacy of the polypropylene monofilament tape.

Lopinavir/ritonavir combination and total/HDL cholesterol ratio

OBJECTIVES

To describe the evolution of the lipidic profile among LPV/r treated patients in a 'real life' situation.

METHODS

Lipids measurements at LPV/r initiation time and every 3 months, and pharmacological measurements at M3 and M6 were collected retrospectively in 142 patients attending our clinic. Dyslipidaemia was defined as total cholesterol > or =6.2 mmol/l, HDL-cholesterol > or =1 mmol/l, total/HDL-cholesterol ratio > or =6.5 and triglycerides > or =2.3 mmol/l.

RESULTS

Eighty-nine percent of patients had previously received a regimen with protease inhibitors, 4% were treatment naive. At baseline, 17% of patients had high total cholesterol, 49% high triglycerides, 63% low HDL-cholesterol, 25% a high total/HDL-cholesterol ratio. At M12, the mean HDL-cholesterol increase per patient was 21%. Lipids levels significantly increased over the study period, as early as the 3rd month (6th month for ratio) and continuously until the 12th month. Among the patients with available LPV/r plasma determinations at M3, a higher lopinavir residual concentration was observed in those with high triglycerides (6.78 vs 3.02 mg/l, p = 0.05) as, at M6, in those with an elevated ratio (9.19 vs 0.96 mg/l, p = 0.02).

CONCLUSIONS

Those results suggest that LPV/r may induce a significant rise in the total/HDL-cholesterol ratio, despite an increase in HDL-cholesterol levels. The association between triglycerides and total/HDL-cholesterol ratio elevated levels and high residual concentrations of lopinavir may also argue for systematic drug monitoring.

[Evaluation of the TVT technique according to age]

OBJECTIVE

To compare efficacy and long-term morbidity of the TVT between patients younger than 70 years and patients older than 70 years.

METHOD

Retrospective monocentric study from January 2000 to May 2001. A postal questionnaire was sent to patients to evaluate their satisfaction and their functional status after surgery.

RESULTS

The study included 154 patients, and 137 (89%) answered the questionnaire. Seventy-two were less than 70 years old (52.5%) and 65 were more than 70 years old (47.5%). The satisfaction rate in the total population was 88.3%. Amongst the patients younger than 70 years, 97.5% were cured or improved, versus 78.5% of the oldest patients (p=0.001). The study within age groups showed that the satisfaction rate between 70-74 years was higher (92.6%) than in the total population and lower after 75 years (66.7%). This difference is linked to the rates of de novo and persistent urge incontinence, which increase after 75 years.

CONCLUSION

The TVT seems to be a good treatment for urinary incontinence in women younger than 75 years. Patients should be warned that preoperative urge incontinence may persist after surgery.