Laryngeal office-based procedures: A safe approach

PURPOSE

Laryngeal surgeries using a flexible nasopharyngoscope equipped with an operative channel has gained popularity, with gradual increase in the variety of interventional office-based procedures, under local anesthesia. The purpose of this study is to analyze the tolerance of such procedures.

MATERIALS AND METHODS

Retrospective cohort study. 337 cases were performed during 2 years. We collected the following data: type of pathology, type of procedure and modalities of anesthesia, adverse events.

RESULTS

19 % of the visits were for the purpose of Biopsy, 65 % for an injection, and Trublue Laser was utilized in 12 % of the procedures. Regarding the pathologies, 27 % were vocal fold paralysis, 18 % leukoplakia or another suspicious lesion, 15 % recurrent respiratory papillomatosis, 13 % neuromuscular disorder, 9 % vocal fold scarring, 7 % vocal cord atrophy and 6 % had an inflammatory presentation. Side effects were documented in 26 visits (7.7 %) and were minor in almost all the encounters: they included strong reflexive cough, deep throat pain, discomfort, gag reflex, anxiety, vagal discomfort, malaise, hypersalivation, nose pain, labile hypertension. More severe side effects were very rare and included septal wound and epistaxis, erythematous rash, dyspnea, and transient dysarthria. 13 procedures were either aborted, or canceled at initial steps, due to inability of the patient to tolerate the procedure and were rescheduled for general anesthesia. 97 % of the cases were released home after 1 h of surveillance.

CONCLUSION

Office-based flexible interventional laryngoscopy under local anesthesia is a safe and well-tolerated procedure, with abundance of various interventions feasible on ambulatory, office-based setup.

Effectiveness of a two-stage strategy using the 16-item Prodromal Questionnaire (PQ16/fPQ16) and the Comprehensive Assessment of At Risk Mental States (CAARMS) in the early detection of Ultra High Risk (UHR) patients in Lebanon: a cross-sectional pilot study

OBJECTIVES

This study aims to identify the prevalence of Ultra High Risk (UHR) adults in a sample of patients in Lebanon and to compare screening and diagnostic tools.

METHODS

This is a cross-sectional pilot study which targeted patients aged 17-30 years willingly seeking psychiatric care in a university hospital in Beirut, Lebanon. Participants were invited to fill either the English or the French version of the Prodromal Questionnaire (respectively, PQ16 or fPQ16). The abbreviated version of the "Comprehensive Assessment of At-Risk Mental States" (CAARMS) was then administered to all participants. The latter were subsequently sorted into one of the three UHR groups - vulnerability group, attenuated psychosis (APS), intermittent psychosis (BLIPS) - or were diagnosed as suffering from a psychotic disorder.

RESULTS

Thirty-one patients participated in this study. The prevalence of positive screening on the PQ16/fPQ16 and positive diagnosis of UHR on the CAARMS were respectively of 61.29% and 45%. The APS group was the most prevalent (71.42%). A positive psychosis screening on PQ16/fPQ16 was statistically related to a UHR diagnosis on CAARMS (p-value: 0.011 on Chi2 test), OR=8.5 (95% CI: 1.4-50.9; p-value: 0.018). No relation was found between PQ16/fPQ16 results and risk stratification or between the number of "True" responses on PQ16/fPQ16 and the intensity of symptoms on CAARMS. PQ16/fPQ16 statements 5, 9, 11 and 16 predicted a UHR diagnosis on CAARMS (p-value of 0.045, 0.006, 0.045 and 0.045, respectively).

CONCLUSION

This two-stage strategy for identifying UHR patients can be adopted in a tertiary health care center.

Durvalumab with or without tremelimumab versus the EXTREME regimen as first-line treatment for recurrent or metastatic squamous cell carcinoma of the head and neck: KESTREL, a randomized, open-label, phase III study

BACKGROUND

Patients with recurrent or metastatic head and neck squamous cell carcinoma (R/M HNSCC) have a poor prognosis. The phase III KESTREL study evaluated the efficacy of durvalumab [programmed death-ligand 1 (PD-L1) antibody] with or without tremelimumab [cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) antibody], versus the EXTREME regimen in patients with R/M HNSCC.

PATIENTS AND METHODS

Patients with HNSCC who had not received prior systemic treatment for R/M disease were randomized (2 : 1 : 1) to receive durvalumab 1500 mg every 4 weeks (Q4W) plus tremelimumab 75 mg Q4W (up to four doses), durvalumab monotherapy 1500 mg Q4W, or the EXTREME regimen (platinum, 5-fluorouracil, and cetuximab) until disease progression. Durvalumab efficacy, with or without tremelimumab, versus the EXTREME regimen in patients with PD-L1-high tumors and in all randomized patients was assessed. Safety was also assessed.

RESULTS

Durvalumab and durvalumab plus tremelimumab were not superior to EXTREME for overall survival (OS) in patients with PD-L1-high expression [median, 10.9 and 11.2 versus 10.9 months, respectively; hazard ratio (HR) = 0.96; 95% confidence interval (CI) 0.69-1.32; P = 0.787 and HR = 1.05; 95% CI 0.80-1.39, respectively]. Durvalumab and durvalumab plus tremelimumab prolonged duration of response versus EXTREME (49.3% and 48.1% versus 9.8% of patients remaining in response at 12 months), correlating with long-term OS for responding patients; however, median progression-free survival was longer with EXTREME (2.8 and 2.8 versus 5.4 months). Exploratory analyses suggested that subsequent immunotherapy use by 24.3% of patients in the EXTREME regimen arm contributed to the similar OS outcomes between arms. Grade 3/4 treatment-related adverse events (TRAEs) for durvalumab, durvalumab plus tremelimumab, and EXTREME were 8.9%, 19.1%, and 53.1%, respectively.

CONCLUSIONS

In patients with PD-L1-high expression, OS was comparable between durvalumab and the EXTREME regimen. Durvalumab alone, and with tremelimumab, demonstrated durable responses and reduced TRAEs versus the EXTREME regimen in R/M HNSCC.

The low dopamine hypothesis: A plausible mechanism underpinning residual urine, overactive bladder and nocturia (RON) syndrome in older patients

INTRODUCTION

Aging is associated with a combination of several lower urinary tract (LUT) signs and symptoms, including residual urine, overactive bladder and nocturia. One of the mechanisms of this LUT dysfunction that has not been discussed in dept so far is the role of dopamine (DA).

METHODS

In this narrative review, we explore the dopaminergic hypothesis in the development of this combination of LUT signs and symptoms in older adults.

RESULTS

DA is one of the neurotransmitters whose regulation and production is disrupted in aging. In synucleinopathies, altered DAergic activity is associated with the occurrence of LUTS and sleep disorders. Projections of DAergic neurons are involved in the regulation of sleep, diuresis, and bladder activity. The low dopamine hypothesis could explain the genesis of a set of LUT signs and symptoms commonly seen in this population, including elevated residual urine, Overactive bladder syndrome and Nocturia (discussed as the RON syndrome). This presentation is however also common in older patients without synucleinopathies or neurological disorders and therefore we hypothesise that altered DAergic activity because of pathological aging, and selective destruction of DAergic neurons, could underpin the presentation of this triad of LUT dysfunction in the older population.

CONCLUSION

The concept of RON syndrome helps to better understand this common phenotypic presentation in clinical practice, and therefore serves as a useful platform to diagnose and treat LUTS in older adults. Besides recognizing the synucleinopathy "red flag" symptoms, this set of multi-causal LUT signs and symptoms highlights the inevitable need for combination therapy, a challenge in older people with their comorbidities and concomitant medications.

Aqua: A new questionnaire assessing anticholinergic side effects in neurogenic population (Aqua: Anticholinergic side effects questionnaire)

AIMS

Validate a new questionnaire to assess the side effects secondary to anticholinergics in neurogenic population suffering from Adult neurogenic lower urinary tract dysfunction (ANLUTD).

METHODS

We conducted a prospective, monocentric study in a Neuro-urology Department of a University Hospital between February 2015 and April 2020. To allow a full psychometric validation of a questionnaire, the study protocol included 3 steps: qualitative interviews, feasibility study and validation study. The primary outcome was good psychometric properties defined with good internal consistency reliability (Cronbach's α>0.7) and good test-retest reliability (intraclass correlation coefficient (ICC)>0.7).

RESULTS

we included 64 patients with ANLUTD secondary to neurogenic disorders. Feasibility study demonstrate very good acceptation and comprehension for 97% of patients. Validation study showed good internal consistency with Cronbach's α=0,69 and very good ICC=0,73. AQUA is composed with 8 items scoring 0 (no side effect) to 2 (major side effect) for a total score between 0 to 16. Time to fulfill is very quick. Mean score in our population was 4,1 (sd 2,9).

CONCLUSION

AQUA is the first validated tool to assess side effects secondary to antimuscarinic treatment for neurogenic population suffering from ANLUTD.

LEVEL OF PROOF

2.

The prevalence of post-traumatic stress disorder in Syrian refugees increased after long-distance migration

Introduction

Refugees are forced migrants but there is a large variation in the distance that refugees cover and there is a knowledge gap on how this may affect refugees’ health and health care needs.

Objectives

Herein, we investigate the association between long-distance migration and post-traumatic stress disorder (PTSD), a serious psychiatric disorder associated with deteriorating mental and somatic health and highly prevalent in refugees.

Methods

Included were 712 adult Syrian refugees and asylum seekers in Lebanon and Denmark arriving no more than 12 months prior to inclusion. The Harvard Trauma Questionnaire was used to assess PTSD and the estimate of association was obtained by multiply imputing missing data and adjusting for confounding by propensity score-weighting with covariates age, sex, socioeconomic status, trauma experience, and WHO-5-score, reporting the bootstrap 95-percentile confidence interval (95% CI). Additionally, a number of sensitivity analysis were carried out.

Results

The prevalence of PTSD was high in both Lebanon (55%) and Denmark (60%) and long-distance migration was associated with a 9 percentage point (95% CI [-1; 19]) increase in the prevalence of PTSD among newly arrived Syrian refugees and asylum-seekers.

Conclusions

In the present study the prevalence of PTSD increased after long-distance migration which may support considering “long-distance migration” in refugee health screenings and in particular when assessing the risk of post-traumatic stress disorder. This is a first step in examining the health effects of migration on refugee health.

Disclosure

No significant relationships.

[Prioritization of risk situations in neuro-urology: Guidelines based on the Delphi method from Association française d'urologie (AFU), Association francophone internationale des groupes d'animation de la paraplégie (AFIGAP), Groupe de neuro-urologie de langue française (GENULF), Société française de médecine physique et de réadaptation (SOFMER) and Société interdisciplinaire francophone d'urodynamique et de pelvi-périnéologie (SIFUD-PP)]

PURPOSE

During the COVID-19 pandemic, a care reorganization was mandatory, and affected patients in different areas, including management of neurogenic lower urinary tract dysfunction. This work aims to provide validated schedule concerning the assessment and management of patients in neuro-urology.

METHODS

Based on a literature review and their own expertise, a steering committee composed of urologists and physical medicine and rehabilitation practitioners generated a comprehensive risk-situation list and built a risk scale. A panel of French-speaking experts in neuro-urology was asked to define the timing for each clinical situation and validated these new recommendations through a Delphi process approach.

RESULTS

The 49 experts included in the rating group validated 163 propositions among the 206 initial items. The propositions were divided into four domains - diagnosis and assessment, treatment, follow-up, and complications - and two sub-domains - general (applicable for all neurological conditions) and condition-specific (varying according to the neurological condition (spinal cord injury, multiple sclerosis, brain injury, Parkinsonism, spinal dysraphism, lower motor neuron lesions)).

CONCLUSIONS

This multidisciplinary collaborative work generates recommendations based on expert opinion, providing a validated timing for assessment and management of patients in neuro-urology which may help clinicians to reorganize their patients' list with a personalized medicine approach, in a context of health crisis or not.

Fecal incontinence subtype assessment (FI-SA): A new tool to distinguish among subtypes of fecal incontinence in a neurogenic population

INTRODUCTION

Two subtypes of fecal incontinence (FI) are defined in the literature (urge and passive FI). The pertinence of this classification is unknown due to conflicting findings and heterogeneity of definitions. However, no questionnaire is available to clearly classify patients among subtypes. The objective of the present study was to develop and validate a new tool (Fecal incontinence subtype assessment, FI-SA) in order to better classify patients among the different subtypes of FI.

METHODS

A prospective monocentric study was conducted in consecutive patients with FI according to Rome IV criteria. To validate psychometric properties of the FI-SA questionnaire, a literature review and qualitative interviews were performed and discussed with an expert panel. A feasibility study was realized to assess acceptability and comprehension of items. The reproducibility was investigated in a validation study.

RESULTS

Comprehension and acceptability were excellent in 90% of patients in the feasibility study (n = 30). Validation study (n = 100) showed a good reproducibility with an intra-class correlation coefficient of 0.91 and 0.89 for questions 1 and 2. Time to fill the questionnaire was 40.0 s. 98.0% patients were classified among subtypes of FI: 34.0% passive FI, 32.0% urge FI and 32.0% mixed FI.

CONCLUSION

FI-SA is the first questionnaire to classify patients among subtypes of FI with good psychometric characteristics and the first questionnaire introducing the concept of mixed FI. FI-SA could help to determine the pertinence of this classification of FI in the management of these patients.

Adherence to transanal irrigation in older adults: first-year assessment

BACKGROUND

While the prevalence of chronic constipation and fecal incontinence increases with age, few data on transanal irrigation in older adults are available. The aim of this study was to assess the adherence and predictive factors for adherence to transanal irrigation during the first year of use in older adults.

METHODS

This retrospective study included all patients over 65 years old, who had therapeutic education for transanal irrigation with the Peristeen® device between January 2010 and July 2019 in a neuro-urology department of a university hospital in France. The adherence rate was assessed at 1, 3, 6, and 12 months. Predictive factors for adherence were looked for by comparing persistent population and non-persistent population at 1, 3, 6, and 12 months.

RESULTS

Sixty-nine patients over 65 years old were included. The adherence rate was 73.9% at 1 month, 55.1% at 3 months, 46.4% at 6 months, and 40.1% at 1 year. No predictive factor for adherence to transanal irrigation was identified.

CONCLUSIONS

Adherence to transanal irrigation during the first year in older adults remains close to that in the adult general population. Predictive factors of adherence remain unclear.

Prevalence of comorbidities in multiple sclerosis patients with neurogenic bladder

AIMS

The aim of this study was to define the prevalence of comorbidities among multiple sclerosis patients with lower urinary tract symptoms.

METHODS

A retrospective study of data collected prospectively from January 2000 to March 2016 was carried out using a database. Comorbidities were divided into several classes according to the International Classification of Diseases (ICD-10).

RESULTS

One hundred and fifty-five patients were included. All had a neurogenic bladder with 150 (96%) overactive bladder. EDSS score was≥6 in 44 patients (28%). Comorbidities were present in 79 (50,9%) and the most frequent ones were cardiovascular (14,2%), endocrinological (10,3%), urological (8,4%), abdominal (7,7%). Overweight (BMI≥25) was observed in 63 (40%). A strict relationship was found for BMI and stress urinary incontinence (P<0.001) as well as voiding dysfunction (P=0.003) without significant association for BMI and overactive bladder.

CONCLUSION

Prevalence of comorbidities is important in MS (more than 50%). A significant association is found between overweight, stress urinary incontinence and voiding dysfunction. Knowledge of these comorbidities in MS is important since the presence of these urinary symptoms not related to neurogenic bladder must lead to a specific treatment.

LEVEL OF EVIDENCE

3.

Systematic review and meta-analysis efficacy and safety of immune checkpoint inhibitors in advanced melanoma patients with anti-PD-1 progression: a systematic review and meta-analysis

BACKGROUND

More than half of melanoma patients taking first-line anti-PD-1 therapy either express transient or no response at all. The efficacy and safety of secondary treatments for these patients are still not well established. Here, we evaluate the efficacy and safety of different melanoma FDA-approved ICI modalities used in post-anti-PD-1 refractory settings.

MATERIALS AND METHODS

We searched the PubMed database and the ASCO meetings library for studies on advanced melanoma patients with cancer progression on anti-PD-1 therapy and were then treated with ipilimumab, nivolumab/ipilimumab combination, or retreated with anti-PD-1. Primary and secondary endpoints were efficacy and toxicity, respectively. Pooled estimates for each treatment group were obtained using a random or fixed effects model according to detected heterogeneity.

RESULTS

Fourteen studies, of which 10 on ipilimumab, 2 on anti-PD-1 treatment, and 6 on combination therapies, were included, involving a total of 1460 patients. Twelve studies reported objective response rates (ORRs) and nine of them reported immune-related adverse events (irAEs). As for ORR, patients experienced a response that was inferior compared to the same therapy in treatment -naïve patients, with combination therapy having the best ORR of a pooled 23.08% (95% CI: 16.75% to 30.03%), followed by ipilimumab with a pooled ORR of 8.19% (95% CI: 5.78% to 10.92%). Survival data were also inferior in the ipilimumab cohort (mOS: 5.1 to 7.4 months) compared to ipilimumab in anti-PD-1 naive patients. As for grade 3/4 irAE occurrence, the ipilimumab cohort showed an estimate of 43.77% (95% CI 22.55% to 66.19%).

CONCLUSION

Our findings provide the best current evidence that patients who progress on anti-PD-1 can still respond to different ICI modalities (ipilimumab with or without nivolumab, and retreatment or continuation beyond progression with anti-PD-1) with tolerable grade 3/4 irAEs. However, more prospective clinical trials are needed to confirm these results.

Comparison of clinical and paraclinical characteristics of patients with urge, mixed, and passive fecal incontinence: a systematic literature review

PURPOSE

Two subgroups of fecal incontinence (FI) are described in literature and used in clinical practice. However, the pertinence of this classification of FI is still unknown as there are no clear established guidelines. To a better understanding, we performed a systematic review to characterize the different types of FI (active, passive, or mixed) on the basis of clinical presentation and complementary explorations.

METHODS

This systematic literature review was performed in reference to recommendations for systematic review using PRISMA guidelines without date restriction, until May 2020. This systematic review was performed without temporal limitation using MEDLINE-PubMed, Cochrane Library, and Google Scholar databases.

RESULTS

Six hundred nine unique citations were identified from all the databases combined. Of those, 21 studies met the inclusion criteria, with 8 retrospective observational studies and 13 prospective observational studies. There was a lack of homogeneity in definitions of passive and urge (active) FI among studies. Prevalence of passive and urge FI was respectively of 4.0-5.0 and 15.0-35.0%. Clinical characteristics, physical examination, and endoanal imaging were not evaluated in most studies. In anorectal manometry, maximal squeeze pressure was higher in passive FI subgroup in most studies and results regarding maximal resting pressure remain discordant. There seemed to be no difference regarding first sensation volume and maximal tolerable volume among subgroups. A few studies evaluated pudendal terminal nerve motor latency with no difference among subgroups.

CONCLUSION

There is a lack of well-conducted prospective studies comparing the different subtypes of FI with validated definitions in both clinical and paraclinical examinations.

[Neurological complications of coitus: Review of literature]

INTRODUCTION

Sexual activity is composed of different phases (excitation, plateau, resolution). Each phase is associated with cardiovascular, respiratory, muscular and hormonal modification which can have an influence on the nervous system. This impact has been studied many times in literature, but no study has synthetized the complications related to coitus or orgasm.

METHOD

Systematic review of literature on neurological complications, except headache, of coitus based on Medline and Embase.

RESULTS

We screened 1424 articles and selected 46 for this review. 7 (15 %) were clinical or epidemiologic studies, 6 (13 %) were reviews of literature and 33 (72 %) were cases or series of cases reports. 12 articles (26 %) talked about strokes, 10 (22 %) about subarachnoid hemorrhage, 9 (20 %) about reversible cerebral vasoconstriction syndrome. We found 3 (7 %) articles for each of the following complication: intraparenchymal, hematoma and epilepsy. Autonomic hypereflexia was treated in 3 articles (7 %). Only 1 article was included concerning ictus, spinal cord injury, neuralgia and cataplexia. These events can be considered as rare as emergencies related to sexual activity represent only 0.1 % of all emergencies and among these, 12 % are neurological. 31 of the reported cases concerned vascular events (stroke or hemorrhage) and 18 (58 %) of these patients had a patent malformation (aneurism, intracardiac shunt, foramen ovale).

CONCLUSION

This is one of the first review of literature trying to synthetise the neurological complications of coitus. Many articles exist in literature. It is necessary to prevent the occurrence of these complications in a population already at risk of neurological events.

[Urethral reflexes: A review]

INTRODUCTION

The urethrosphincter complex is involved not only in maintaining urinary continence, particularly during effort, but also for the achievement of a complete and effective micturition. Indeed, the urethra is not a simple passive channel for the evacuation of urine from the bladder to the urethral meatus, since its resistive capacities and its possibilities of modulation of the micturition reflex depend on its reflex role either as a sensory afferent or as a neuro-muscular effector. It also participates in many genito-sexual and ano-rectal réflexes.

MATERIAL AND METHOD

This review of the literature describes the various reflexes of the urethra as a sensory stimulus or a neuromuscular effector. All articles referenced in this review were obtained from articles indexed on Pubmed-Medline, using the keywords: "urethral reflexes; "reflex bladder"; "urination reflex"; "intravaginal; vaginal"; "anorectal; sphincter"; "Storage and voiding"; "reflexes sneezing"; "cough reflex". Other articles were selected through references of the articles issued from the first research. Only articles in English and French have been selected. The articles concerned animal and human experiments.

RESULTS

Eight hundred and sixty-four referenced articles were founded and a total of 75 articles were included, describing the various reflexes mediated by the urethra acting as a sensory afferent or mechanical effector. We differentiated the known data in humans and animals.

CONCLUSION

The urethra is a complex anatomical structure ensuring, through numerous reflex mechanisms, urinary continence. Urethral resistances are modulated during efforts and depends on the bladder capacity and the intensity of the efforts. During micturition, the coordination between the bladder and the urethra is mediated by reflex pathways organized at the cerebral, spinal and lumbosacral levels. The modulation of the micturition in term of efficacy and velocity, is due in part, to the re-afferentation of the spinal reflex by continuous stimulus of the urethral canal. Many of these reflexes are imperfectly described. Finally, the urethra is implicated in reflex loops of anal continence and sexual functions.

Multifocal adult rhabdomyoma of the head and neck: case report and systematic review of the literature

Adult-type rhabdomyoma (ARM) is the most frequent extracardiac subtype of rhabdomyoma. In very rare instances ARM presents as multiple cervical lesions, an entity known as multifocal ARM. The aim of this study was to review the clinical characteristics and the best therapeutic options for multifocal ARM. The case of a 73-year-old patient recently diagnosed with multifocal ARM and managed in our institution is reported, followed by a systematic review of the literature. The review was conducted using the PubMed, Scopus, and Google Scholar databases, according to the PRISMA guidelines. All case reports and case series related to multifocal ARM written in English or French were included. A total of 29 cases were included in the qualitative analysis. Mean age at presentation was 65.0 years and the male to female ratio was 13.5:1. Dysphagia was the most common presenting symptom. ARM was most frequently found in the submandibular spaces. In conclusion, multifocal ARM are benign tumours with a predilection for the head and neck region. They become symptomatic with gradual compression of the adjacent structures. No cases of malignant transformation were reported in the literature. We suggest a 'watchful wait' approach for small asymptomatic tumours and excision of large symptomatic ones.

Durvalumab with or without tremelimumab in patients with recurrent or metastatic head and neck squamous cell carcinoma: EAGLE, a randomized, open-label phase III study

BACKGROUND

Targeting the programmed cell death protein 1 (PD-1)/programmed cell death ligand 1 (PD-L1) axis has demonstrated clinical benefit in recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC). Combining immunotherapies targeting PD-L1 and cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) has shown evidence of additive activity in several tumor types. This phase III study evaluated the efficacy of durvalumab (an anti-PD-L1 monoclonal antibody) or durvalumab plus tremelimumab (an anti-CTLA-4 monoclonal antibody) versus standard of care (SoC) in R/M HNSCC patients.

PATIENTS AND METHODS

Patients were randomly assigned to receive 1 : 1 : 1 durvalumab (10 mg/kg every 2 weeks [q2w]), durvalumab plus tremelimumab (durvalumab 20 mg/kg q4w plus tremelimumab 1 mg/kg q4w × 4, then durvalumab 10 mg/kg q2w), or SoC (cetuximab, a taxane, methotrexate, or a fluoropyrimidine). The primary end points were overall survival (OS) for durvalumab versus SoC, and OS for durvalumab plus tremelimumab versus SoC. Secondary end points included progression-free survival (PFS), objective response rate, and duration of response.

RESULTS

Patients were randomly assigned to receive durvalumab (n = 240), durvalumab plus tremelimumab (n = 247), or SoC (n = 249). No statistically significant improvements in OS were observed for durvalumab versus SoC [hazard ratio (HR): 0.88; 95% confidence interval (CI): 0.72-1.08; P = 0.20] or durvalumab plus tremelimumab versus SoC (HR: 1.04; 95% CI: 0.85-1.26; P = 0.76). The 12-month survival rates (95% CI) were 37.0% (30.9-43.1), 30.4% (24.7-36.3), and 30.5% (24.7-36.4) for durvalumab, durvalumab plus tremelimumab, and SoC, respectively. Treatment-related adverse events (trAEs) were consistent with previous reports. The most common trAEs (any grade) were hypothyroidism for durvalumab and durvalumab plus tremelimumab (11.4% and 12.2%, respectively), and anemia (17.5%) for SoC. Grade ≥3 trAE rates were 10.1%, 16.3%, and 24.2% for durvalumab, durvalumab plus tremelimumab, and SoC, respectively.

CONCLUSION

There were no statistically significant differences in OS for durvalumab or durvalumab plus tremelimumab versus SoC. However, higher survival rates at 12 to 24 months and response rates demonstrate clinical activity for durvalumab.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02369874.

[Sexual dysfunctions after traumatic brain injury: Systematic review of the literature]

BACKGROUND

Sexual dysfunction (SD) is common in the general population, up to 50% in women and with no clearly defined prevalence in men but up to 30% in erectile dysfunction. Sexual dysfunctions (SD) are common after a traumatic brain injury (TBI) but remain underrated in clinical practice, yet it is a crucial aspect of the person with consequences for the relationship with the other, psychological wellbeing and quality of life.

OBJECTIVE

To determine, through a systematic literature review, the epidemiology, assessment tools and treatment of SD in the TBI population.

SOURCES

(keywords, languages): Medline, COCHRANE and OVID databases were used with specific keywords (MeSH), combined with Boolean operators: "sexual dysfunction", "sexuality", "erectile dysfunction" and "traumatic brain injury".

STUDY SELECTION

Only studies published in French or English, and with full-text available, have been included. Articles have been independently reviewed and extracted.

RESULTS

Of the 199 articles reviewed after exclusion of duplicates, 86 articles were reviewed in their full text. A total of 40 studies were included in the final analysis. After TBI, 6% to 83% of patients report SD: decreased frequency of sexual intercourse (47-62%), desire and/or arousal (24-86%), erectile dysfunction (24,2-57%), difficulties with orgasm (29-40%), inappropriate sexual behaviour (8,9%). There is no consensus method for evaluating SD in this population, with 16 tools identified. Among them, only two questionnaires were validated in this population, the Brain Injury Questionnary of Sexuality - not validated in French - and the Overt Behavior Scale, the latter being intended for the evaluation of sexual behaviour disorders. Several factors are significantly and positively associated with SD: age (P≤0.01), severity of TBI (P≤0.002), depression (P<0.001), anxiety (P<0.001), and fatigue (P=0.042). Others are negatively associated: time since injury (P=0.01), perceived physical health status (P<0.001) and social participation (P<0.001). There is little data on the treatment of SD outside of case studies.

LIMITS

Quantitative analysis could not be performed due to differences in the studies included in their design, evaluation tools, choice of TBI severity criteria, and post-TBI timeframes. Four unavailable articles could not be consulted.

CONCLUSION

SD are common after TBI but remain poorly evaluated in clinical practice, despite their impact on patients and their partners. Their evaluation and treatment should be part of the overall management of patients after TBI. Nevertheless, there is currently no validated tool in French to evaluate these SD, nor are there any guidelines on their treatment.

Abstract P3-01-15: Circulating tumor cell subset analysis to assess lifestyle interventions for breast cancer patients after neoadjuvant chemotherapy

Background:Circulating tumor cells (CTCs) are an independent predictor of survival in patients with breast cancer. In addition, mesenchymal (EMT-CTC) and stem-like (Stem-CTC) CTCs contribute to disease progression. The objective of the overall study is to determine whether a comprehensive lifestyle intervention program started prior to radiotherapy can modulate changes in CTC subsets that are correlated with disease recurrence and progression. For these analyses we examined the association between medical and treatment-related factors and CTCs.

Patients and Methods: Seventy-eight patients with stage II/III breast cancer were recruited and randomized to either the intervention group or a standard care group. The intervention group (n=42) had in-person lifestyle counseling across the 4-6 weeks of radiotherapy (XRT) followed by video counseling for the subsequent 12 months. The standard care group (n=36) was provided patient-education materials for cancer prevention including information on diet, exercise, and stress management, without counseling. Blood samples were collected prior to initiation of XRT, end of XRT, and at 3-month intervals thereafter for up to 5 years. CTC subsets were detected by AdnaTest EMT2 kit (Qiagen, Venlo, Netherlands). Samples were considered positive for CTCs if any one of breast (EPCAM, MUC1, and HER2), EMT (TWIST1), or stem cell-related (ALDH1, AKT2, and PI3Kalpha) genes were detected by PCR above the manufacturer's suggested threshold.

Results: The median age of patients was 49 years (range 26-82 years). Thirty-four patients were overweight (BMI 24.4-30) and 44 patients were obese (BMI &gt;30). Forty-five patients were HR+Her2-, 12 patients were HR+Her2+, 5 patients were HR-Her2+, and 16 patients were TNBC. Sixteen patients were stage IIA or IIB, 34 patients were stage IIIA or IIIB, 27 patients were stage IIIC, and 1 was stage IV. Sixty-seven of 78 patients received neoadjuvant chemotherapy (NACT); 13 patients achieved a complete pathological response (pCR). The median follow-up was 21.6 months. CTC data of both intervention and standard groups were similar at baseline. Presence of CTCs at baseline or follow-up time points was not correlated to HR/Her2 status, stage, obesity, or pCR, but was significantly correlated with receiving NACT. Patients without NACT had significantly higher CTCs than patients who underwent NACT (Fisher Exact Test p=0.010). Furthermore, CTCs by the detection of any gene 3 months after completing XRT was associated with shorter PFS (log-rank p=0.016) and OS (p=0.03).

Conclusions:This is an interim analysis of the prognostic potential of CTCs detected by AdnaTest EMT2 kit in non-metastatic breast cancer. We observed a lower proportion of patients with CTCs following neoadjuvant chemotherapy. However, the relative small sample size and short follow-up time preclude drawing conclusions to the efficacy of using CTCs as surrogate measures for lifestyle interventions, although the presence of CTCs in peripheral blood of patients 3 months after radiation therapy can be a promising indicator of disease relapse and overall survival.

Citation Format: Gao H, Cohen EN, Yang P, Austin TA, Haddad R, Wu Q, Basen-Engquist KM, Ochoa JM, Arun BK, Perkins GH, Tin S, Vallone VS, Mallaiah SG, West CB, Thompson AS, Chaoul A, Cohen L, Reuben JM. Circulating tumor cell subset analysis to assess lifestyle interventions for breast cancer patients after neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-01-15.

[Use of botulinum toxin A in pelvic floor dysfunctions in the elderly: A review]

INTRODUCTION

The present article is the final report of a multi-disciplinary meeting supported by the GRAPPPA (group for research applied to pelvic floor dysfunctions in the elderly). The objective was to conduct a comprehensive review on the role of botulinum toxin A (BonTA) in the treatment of pelvic floor dysfunctions in the elderly.

METHODS

The present article, written as a comprehensive review of the literature, combines data issued from the scientific literature with expert's opinions. Review of the literature was performed using the online bibliographic database MedLine (National Library of Medicine). Regarding intra-detrusor BonTA injections, only articles focusing on elderly patients (>65 yo) were included. Regarding other localizations, given the limited number of data, all articles reporting outcomes of BonTA were included, regardless of studies population age. In case of missing or insufficient data, expert's opinions were formulated.

RESULTS

Although, available data are lacking in this specific population, it appears that BonTA could be used in the non-fraily elderly patients to treat overactive bladder or even neurogenic detrusor overactivity, with a success rate comparable to younger population at 3 months (88.9% vs. 91.2%), 6 months (49.4% vs. 52.1%) and 12 months (23.1% vs. 22.3%), as well as a significant decrease in number of voids per day (11.4 vs. 5.29 P<0.001) and in the number of pads per day (4.0 vs. 1.3, P<0.01). Furthermore, BonTA is likely to be offered in the future as a treatment of fecal incontinence and obstructed defecation syndrome symptoms. Concerning bladder outlet obstruction/voiding dysfunction symptoms, intra-urethral sphincter BonTA should not be recommended.

CONCLUSION

BonTA injections are of interest in the management of various pelvic floor dysfunctions in the elderly, and its various applications should be better evaluated in this specific population in order to further determine its safety and efficacy.

Efficacy of posterior tibial nerve stimulation (PTNS) on overactive bladder in older adults

INTRODUCTION

The main objective of this retrospective study is to determine the efficacy of transcutaneous posterior tibial nerve stimulation (TPTNS) in older patients with overactive bladder (OAB) syndrome. The secondary objective is to look for predictive factors of efficacy of this treatment.

METHODS

All patients aged over 65 years with OAB syndrome for which TPTNS was introduced between 2010 and 2016 in two neuro-urology centers were included. Age, gender, etiology of OAB, urinary symptoms and detrusor overactivity (DO) were retrospectively collected. The main outcome was efficacy of TPTNS (i.e., purchase of the device between 3 and 6 months).

RESULTS

A total of 264 patients were included (mean age 74.1 ± 6.5 years; 63.3% of women), of whom 53% had neurogenic OAB. Urinary incontinence was reported by 83.7% of patients and DO was found on urodynamic studies in 154 patients. The overall efficacy of TPTNS was 45.1%. None of the tested factors were significantly predictive of efficacy, especially age (≥ 75 years, p = 0.62), associated stress urinary incontinence (p = 0.69) and presence of DO (p = 0.60), whether neurogenic or not.

CONCLUSION

TPTNS is an effective treatment in older patients with OAB syndrome. No predictive factors of efficacy were found, especially age and DO. This treatment seems to be a good alternative to antimuscarinics against overactive bladder in older adults.

Endotoxin binding on capillary endothelium and myocyte plasma membranes in perfused rat heart

This work uses a novel heart-perfusion technique to measure [3H]-lipopolysaccharide ([3H]-LPS) binding on capillary endothelium and myocyte cell membranes in Sprague-Dawley rats. Free or serum-containing Ringer-Lock buffer was infused at a rate of 1 ml/min and in the presence of 20 mM K+ and [ 3H]-LPS through an aortic cannula, and the effluent was collected through a catheter introduced into the right atrium cavity. The capillary endothelial lining was removed by CHAPS treatment to expose the cardiac myocyte surface. A physical model describing 1:1 binding stoichiometry of [3H]-LPS with its receptors is proposed and the mathematical equations derived allow for the calculation of binding constants (kn), reversal constants (k-n), dissociation constants (kd), and residency time constants (τ). The results showed that the presence of serum in the perfusate, slowed the binding of [3H]-LPS with the endothelial lining and myocytes, but increased the residency time by 3- and 50-fold, respectively. Hence, the endothelium and myofiber may contain LPS receptors that can bind more strongly with the ligand in association with sCD14-like and LBP-like molecules in rat serum. Thus it is postulated that the affinity of LPS to its receptor subtypes is not strictly and specifically dependent on the CD14 binding profile.