Predictive and Prognostic Role of Pre-Therapy and Interim 68Ga-DOTATOC PET/CT Parameters in Metastatic Advanced Neuroendocrine Tumor Patients Treated with PRRT

Simple Summary

Although a significant improvement has been achieved in the management of metastatic neuroendocrine tumor (NET), disease progression is observed in 20–30% of patients treated with peptide receptor radionuclide therapy (PRRT). Therefore, the early identification of patients who are at high risk of treatment failure is important to avoid futile therapy toxicities. The aim of this study was to identify biomarkers derived from baseline and interim 68Ga-DOTATOC PET/CT in patients undergoing PRRT. In 46 metastatic NET patients with available baseline and interim PET, only baseline total tumor volume (bTV) was able to discriminate responders to PRRT (partial response or stable disease) vs. non-responders. Patients with high bTV had also the worst overall survival. bTV, an imaging biomarker, integrated in the initial workup of NET patients could improve risk stratification and contribute to a tailored therapy approach.

Abstract

Peptide receptor radionuclide therapy (PRRT) is an effective therapeutic option in patients with metastatic neuroendocrine tumor (NET). However, PRRT fails in about 15–30% of cases. Identification of biomarkers predicting the response to PRRT is essential for treatment tailoring. We aimed to evaluate the predictive and prognostic role of semiquantitative and volumetric parameters obtained from the 68Ga-DOTATOC PET/CT before therapy (bPET) and after two cycles of PRRT (iPET). A total of 46 patients were included in this retrospective analysis. The primary tumor was 78% gastroenteropancreatic (GEP), 13% broncho-pulmonary and 9% of unknown origin. 35 patients (76.1%) with stable disease or partial response after PRRT were classified as responders and 11 (23.9%) as non-responders. Logistic regression analysis identified that baseline total volume (bTV) was associated with therapy outcome (OR 1.17; 95%CI 1.02–1.32; p = 0.02). No significant association with PRRT response was observed for other variables. High bTV was confirmed as the only variable independently associated with OS (HR 12.76, 95%CI 1.53–107, p = 0.01). In conclusion, high bTV is a negative predictor for PRRT response and is associated with worse OS rates. Early iPET during PRRT apparently does not provide information useful to change the management of NET patients.

Is early integration of palliative care feasible and acceptable for advanced respiratory and gastrointestinal cancer patients? A phase 2 mixed-methods study

BACKGROUND

There is evidence that early integration of palliative care improves quality of life, lowers spending and helps clarify preferences and goals for advanced cancer patients. Little is known about the feasibility and acceptability of early integration.

AIM

Assessing feasibility of early integration of palliative care, and exploring concerns perceived and problems encountered by patients, relatives and oncologists.

DESIGN

A phase 2 mixed-methods study ( ClinicalTrials.Gov :NCT02078700).

METHODS

Oncologists of two outpatient clinics offered a specialised palliative care intervention integrated with standard oncological care to all consecutive newly diagnosed metastatic respiratory/gastrointestinal cancer patients. We interviewed samples of patients, relatives and oncologists to explore strengths and weaknesses of the intervention.

RESULTS

The intervention was proposed to 44/54 eligible patients (81.5%), 40 (90.1%) accepted, 38 (95.0%) attended the first palliative care visit. The intervention was completed for 32 patients (80.0%). It did not start for three (7.5%) and was interrupted for three patients who refused (7.5%). The Palliative Care Unit performed 274 visits in 38 patients (median per patient 4.5), and 24 family meetings with relatives of 16 patients. All patients and most relatives referred to the usefulness of the intervention, specifically for symptoms management, information and support to strategies for coping. Oncologists highlighted their difficulties in informing patients on palliative intervention, sharing information and coordinating patient's care with the palliative care team.

CONCLUSION

Early integration of palliative care in oncological setting seems feasible and well accepted by patients, relatives and, to a lesser extent, oncologists. Some difficulties emerged concerning patient information and inter-professional communication.

The value of lactate dehydrogenase serum levels as a prognostic and predictive factor for advanced pancreatic cancer patients receiving sorafenib

Although lactate dehydrogenase (LDH) serum levels, indirect markers of angiogenesis, are associated with a worse outcome in several tumours, their prognostic value is not defined in pancreatic cancer. Moreover, high levels are associated even with a lack of efficacy of tyrosine kinase inhibitors, contributing to explain negative results in clinical trials. We assessed the role of LDH in advanced pancreatic cancer receiving sorafenib.

Seventy-one of 114 patients included in the randomised phase II trial MAPS (chemotherapy plus or not sorafenib) and with available serum LDH levels, were included in this analysis. Patients were categorized according to serum LDH levels (LDH ≤vs.> upper normal rate).

A significant difference was found in progression free survival (PFS) and in overall survival (OS) between patients with LDH values under or above the cut-off (PFS: 5.2 vs. 2.7 months, p = 0.0287; OS: 10.7 vs. 5.9 months, p = 0.0021).

After stratification according to LDH serum levels and sorafenib treatment, patients with low LDH serum levels treated with sorafenib showed an advantage in PFS (p = 0.05) and OS (p = 0.0012).

LDH appears to be a reliable parameter to assess the prognosis of advanced pancreatic cancer patients, and it may be a predictive parameter to select patients candidate to receive sorafenib.

Strong Notch activation hinders bevacizumab efficacy in advanced colorectal cancer

AIM

To assess the role of Notch activation in predicting bevacizumab efficacy in colorectal cancer (CRC).

MATERIALS & METHODS

Notch activation was evaluated by immunohistochemistry (IHC) on 65 CRC enrolled within randomized clinical trials assessing first-line bevacizumab-based chemotherapy and on 21 CRC treated with chemotherapy alone.

RESULTS

Strong Notch (IHC 3+) activation was negatively associated with response (18 vs 62% in low Notch cases [IHC 0, 1, 2+]; p = 0.016), progression-free survival (4.9 vs 12.1 months; p = 0.002) and overall survival (19.3 vs 30.4 months; p = 0.039). No correlation was found between Notch activation and clinical outcome in CRC treated with chemotherapy alone.

CONCLUSION

A potential role of Notch activation in the antitumor activity of bevacizumab could be hypothesized.

Expression of pERK and VEGFR-2 in advanced hepatocellular carcinoma and resistance to sorafenib treatment

BACKGROUND & AIMS

The study aimed to evaluate the tissue expression of molecules involved in intracellular signalling pathways as predictors of response to sorafenib in advanced hepatocellular carcinoma (HCC).

METHODS

We considered 77 patients enrolled into three prospective trials of sorafenib treatment for whom pretreatment tumour tissue was available. The tissue expression of β-catenin, glutamine synthetase (GS), phosphorylated extracellular signal regulated kinase (pERK), phosphorylated v-akt murine thymoma viral oncogene homolog (pAKT) and vascular endothelial growth factor receptor-2 (VEGFR-2) was analysed by immunostaining. Stains were scored semiquantitatively and compared with a reference group of 56 untreated HCCs.

RESULTS

Overall, the expression of antigens was comparable between treated and untreated patients. Shorter progression-free survival (PFS) and overall survival (OS) were associated with increased pERK staining (≥ 2+ scores) (PFS: 75th percentile 4.4 vs 8.4 months; P = 0.01; OS: 75th percentile 7.0 vs 15.0 months; P = 0.005) and VEGFR-2 staining (≥ 2+ scores) (PFS: 75th percentile 3.8 vs 7.0 months; P = 0.039; OS: 75th percentile 6.3 vs 15.0 months; P = 0.004). At multivariate analysis, both pERK and VEGFR-2 staining maintained an independent effect on OS (HR 2.09; 95% CI, 1.13-3.86, P = 0.019 and HR 2.28; 95% CI, 1.13-4.61, P = 0.021 respectively). No effect was observed for the other tested biomarkers.

CONCLUSIONS

Elevated tissue expression of pERK and VEGFR-2 was predictive of poor outcome in advanced HCC treated with sorafenib.

Impact of serodiagnosis on the management of Lyme borreliosis at Angers University Hospital

INTRODUCTION

Lyme borreliosis (LB) is an emerging arthropod-borne disease the diagnosis of which is made on clinical and biological data. We assessed the Angers University Hospital physicians' management of LB, in case of positive serology, and estimated their compliance to European recommendations (EUCALB).

METHODS

We retrospectively included 75 cases with positive ELISA serologies confirmed by Western-Blot, performed at the Angers University Hospital between 2008 and 2012.

RESULTS AND DISCUSSION

There were 4 cases of early localized phase, 26 of early-disseminated phase (including 17 cases of neuroborreliosis), and one case of late phase. The curative management complied with EUCALB guidelines in 28 cases out of 31.

CONCLUSION

Serology remains a reference diagnostic tool for LB, as long as the practitioner is aware of the main clinical and biological criteria.

A phase II randomized dose escalation trial of sorafenib in patients with advanced hepatocellular carcinoma

BACKGROUND

Sorafenib has proven survival benefits in patients with advanced hepatocellular carcinoma (HCC). The viability of continuing sorafenib at a higher dosage in patients who experienced radiologic disease progression was investigated.

METHODS

Patients who experienced disease progression while on sorafenib 400 mg twice daily were randomized to sorafenib 600 mg twice daily (n = 49) or best supportive care (n = 52). The primary end point was progression-free survival (PFS). Time to progression, overall survival, and safety were also evaluated.

RESULTS

The study did not meet its primary end point. The difference in PFS between the sorafenib arm (3.91 months) and the best supportive care arm (2.69 months) did not reach statistical significance (p = 0.086). Adverse events were mainly grade 1-2 and similar across both groups. In the sorafenib arm, the most frequent events were diarrhea (80%), weight loss (75%), fatigue (67%), hand-foot-skin reaction (49%), abdominal pain (37%), and stomatitis (26%).

CONCLUSIONS

Escalated-dose sorafenib in patients with advanced HCC who progressed while on sorafenib, failed to provide any clinical benefit. Second-line treatment still remains an open issue to be explored in appropriate clinical trials.

A phase II randomized dose escalation trial of sorafenib in patients with advanced hepatocellular carcinoma

BACKGROUND

Sorafenib has proven survival benefits in patients with advanced hepatocellular carcinoma (HCC). The viability of continuing sorafenib at a higher dosage in patients who experienced radiologic disease progression was investigated.

METHODS

Patients who experienced disease progression while on sorafenib 400 mg twice daily were randomized to sorafenib 600 mg twice daily (n = 49) or best supportive care (n = 52). The primary end point was progression-free survival (PFS). Time to progression, overall survival, and safety were also evaluated.

RESULTS

The study did not meet its primary end point. The difference in PFS between the sorafenib arm (3.91 months) and the best supportive care arm (2.69 months) did not reach statistical significance (p = 0.086). Adverse events were mainly grade 1-2 and similar across both groups. In the sorafenib arm, the most frequent events were diarrhea (80%), weight loss (75%), fatigue (67%), hand-foot-skin reaction (49%), abdominal pain (37%), and stomatitis (26%).

CONCLUSIONS

Escalated-dose sorafenib in patients with advanced HCC who progressed while on sorafenib, failed to provide any clinical benefit. Second-line treatment still remains an open issue to be explored in appropriate clinical trials.

Sorafenib in patients with Child-Pugh class A and B advanced hepatocellular carcinoma: a prospective feasibility analysis

BACKGROUND

Sorafenib has shown survival benefits in patients with advanced hepatocellular carcinoma (HCC) and Child-Pugh (CP) class A liver function. There are few prospective data on sorafenib in patients with HCC and CP class B.

PATIENTS AND METHODS

A consecutive prospective series of 300 patients with CP class A or B HCC were enrolled in a dual-phase trial to determine survival and safety data according to liver function (class A or B) in patients receiving oral sorafenib 800 mg daily. [Results of this study were presented in part at the ASCO 2012 Gastrointestinal Cancers Symposium, 19-21 January 2012. J Clin Oncol 2012; 30 (Suppl 4): abstract 306.]

RESULTS

Overall progression-free survival (PFS), time to progression (TTP) and overall survival (OS) were 3.9, 4.1 and 9.1 months, respectively. For patients with CP class A versus B status, PFS was 4.3 versus 2.1 months, TTP was 4.2 versus 3.8 months and OS was 10.0 versus 3. 8 months. Extrahepatic spread was associated with worse outcomes but taken together with CP class, liver function played a greater role in reducing survival. Adverse events for the two CP groups were similar.

CONCLUSION

Although patients with HCC and CP class B liver function have poorer outcomes than those with CP class A function, data suggest that patients with CP class B liver function can tolerate treatment and may still benefit from sorafenib.

A phase I study of continuous hepatic arterial infusion of Irinotecan in patients with locally advanced hepatocellular carcinoma

PURPOSE

Aim of this phase I study was to identify the maximum tolerated dose and dose limiting toxicity of continuous infusion of Irinotecan through a port-a-cath placed in the hepatic artery in patients with hepatocellular carcinoma and cirrhosis to explore new strategies in advanced hepatocellular carcinoma. Response rate and time-to-progression were analysed.

METHODS

Irinotecan was delivered as a five-day continuous infusion every 21 days, with increases of 2.5mg/m(2)/day every three patients, starting from 7.5mg/m(2)/day. Dose limiting toxicity corresponded to one patient in each triplet developing G4 haematological or G3 non-haematological toxicity, confirmed in two triplets. Twenty-eight patients (17 Child-Pugh A, 11 B) received treatment and tumour response was assessed after three courses completed by 22 patients.

RESULTS

Dose limiting toxicity was G3 diarrhoea in two patients, reached at 27.5mg/m(2)/day and the recommended dose was set at 25mg/m(2)/day. Nineteen of 30 patients experienced adverse events related to porth-a-cath placement and one died from liver ischemia and sepsis. Median time-to-progression was 11.3 months.

CONCLUSION

Intrarterial infusion of Irinotecan is feasible in patients with hepatocellular carcinoma on cirrhosis at a recommended dose of 25mg/m(2)/day, with no major adverse drug-related events, but with some concerns about the insertion and management of the intra-arterial device.

[Prenatal breastfeeding information: survey in Pays de Loire, France]

OBJECTIVES

The main aim of this study was to evaluate how well expectant mothers were informed on breastfeeding by healthcare professionals. The secondary objective was to determine the factors associated with the initiation of breastfeeding.

POPULATION AND METHODS

The survey was conducted in a group of 500 women who had delivered at the Angers Hospital (France), based on a questionnaire filled out by the postpartum women during their hospital stay.

RESULTS

The rate of breastfeeding was 61.2%. More than a quarter (26.9%) of the women did not receive any prenatal breastfeeding information. The survey showed that 77.8% of the women had been informed of breastfeeding advantages for infants and 51.5% of breastfeeding advantages for themselves. Only 27.5% had received the advice of exclusive breastfeeding for 6months. Only 5.2% had been informed of the uselessness of breast preparation during pregnancy and a minority had been informed of correct and incorrect breastfeeding contraindications. Only 15.4% of fathers had been involved in a discussion on infant feeding practices during prenatal consultations. Only 4.8% of the women had come to prenatal classes on breastfeeding with a relative. The maternal factors positively associated with breastfeeding initiation were age between 25 and 34 years, non-French origin, a high socioeconomic status, being married, having been breastfed, and having previous experience with breastfeeding. Breastfeeding initiation was negatively associated with maternal smoking. All the factors concerning prenatal breastfeeding information in women were associated with the choice of breastfeeding.

CONCLUSION

This study pointed out the populations at risk of not breastfeeding. Breastfeeding information given to pregnant women by healthcare professionals may influence them on whether or not they choose to breastfeed their newborn. However, this survey showed that women are insufficiently informed on prenatal breastfeeding. Therefore, prenatal breastfeeding information should be improved.

Hospital admissions related to influenza in France during the 2006/2007 epidemic

BACKGROUND

The data available on hospital admissions related to influenza mostly concern in-patients admitted via the emergency department. Severe cases have been collated by intensive care practitioners since 2009. For this survey, we searched French hospital admission databases to estimate the prevalence rate of hospital admissions related to influenza and to record qualitative data.

METHOD

All case studies identified between October 2006 and September 2007 were split into two groups: the first displaying symptoms of clinical influenza and the second suffering from influenza as an associated diagnosis.

RESULTS

We collected 6797 hospital admissions, 2126 of which were closely related to clinical influenza. Fifty percent of cases concerned the elderly and young people. Fifty-six hospital deaths were recorded in which influenza was the underlying cause in 21% of the cases (12). When influenza was an associated diagnosis (44/56), cardiovascular or respiratory diseases were the main causes (26/44).

CONCLUSION

During the same period (2006-2007), the French Sentinel Surveillance identified only 105 hospital admissions related to influenza. Our survey was therefore more exhaustive and was able to record qualitative data. Inclusion of hospital admissions with an associated diagnosis of influenza is debatable because this decreases specificity. The relationship between the principal diagnosis and all the associated diagnoses is difficult to study, although exclusion of this type of hospitalization could significantly underestimate these figures. Despite certain limitations, French hospital admissions databases should complement French Sentinel Surveillance data.

[Influence of smoking among family physicians on their practice of giving minimal smoking cessation advice in 2008. A survey of 332 general practitioners in Maine-et-Loire]

INTRODUCTION

Smoking among doctors would be an obstacle to effective smoking prevention, in particular the practice of minimal advice.

OBJECTIVES

To assess the smoking habits of general practitioners (GPs) in the department of Maine-et-Loire and to study the link between their smoking status and their practice of minimal smoking cessation advice in 2008 in a legislative context unfavourable to smokers.

METHODS

Three hundred and thirty-two GPs in the department of Maine-et-Loire answered a survey (response rate: 60%) investigating their own smoking habits and how they approach patients who smoke.

RESULTS

The prevalence of active smoking among general practitioners responders was 18%, 34% were former smokers and 47% had never smoked. Regular smokers (10%) smoked on average 14 cigarettes a day and 51% were nicotine dependent (9% strongly). When consulting, 32% of doctors systematically addressed smoking habits, 20% said that they gave minimal smoking cessation advice regardless of their smoking status. Doctors who smoked were less prone to ask their patients if they smoke (p=0.002) and they believed that their smoking does not influence their practice of giving minimal smoking advice. Moreover, the incentive and coercive measures introduced in 2006 had no influence on the smoking status of physicians, but allowed them to speak more frequently about smoking to their patients.

CONCLUSION

Minimal smoking cessation advice is applied systematically by only 20% of physicians regardless of their smoking status. Non-systematic smoking cessation advice benefited from the measures introduced in 2006.

[Tolerance of the contraceptive implant by prescription context (postabortion or not): Prospective study on 127 consultants]

AIM

While contraceptive methods increased in number, the number of abortions has remained stable. The aim of this study was to estimate the satisfaction of women toward a contraceptive implant (Implanon(®)) available in France in order to clarify prescription.

METHOD

The survey concerned 127 women who visited Angers and Nantes family planning centres between January2009 and January2010 in two implant prescription contexts (postabortion or not). They agreed to answer a first questionnaire describing the reasons for their choice. A second questionnaire was sent six months after to assess its tolerance.

RESULTS

In our study, 82% of patients were using a contraceptive method prior to implant (68% in postabortion and 88% in the other group). The first reason for choosing the implant was the fear of forgetting - it was more important in the postabortion group (88% vs. 61%). The main side effects were amenorrhea (50%), weight gain (30%) and mood disorders (19%). More than one in two women (54%) was very satisfied by the implant. It should be noted that in one quarter of cases, women seek early withdrawal of the contraceptive implant (23% in postabortion and 21% in the other group), a rate that is 39% in patients under 25years and 47% in patients who reported a mood disorder.

CONCLUSION

There is a tendency to better tolerance of the implant out of a context of abortion. Furthermore, mood disorders appear to be poorly tolerated. These elements encourage greater caution in prescribing the contraceptive implant in postabortion, situation in which patients have already psychological disorders, and even more among younger patients.

[Renal leiomyosarcoma, rheumatoid arthritis and methotrexate]

Leiomyosarcoma of the renal vein is a rare and malignant tumor difficult to diagnose. No standard treatment has been defined and prognosis is poor. We described the case of a 68-year-old woman with rheumatoid arthritis treated by methotrexate who developed a leiomyosarcoma of the left renal vein with a fatal outcome in less than 1 year. Association of a leiomyosarcoma and rheumatoid arthritis raises the question of a casual association or of a predisposing factor since studies have shown increased risk of cancer with this rheumatism.

[General practitioners' (GPs) practice regarding the line to take in case of missed pill]

OBJECTIVE

To explore general practitioners' (GPs) practice face of missed pill and prevention of such missings.

MATERIAL AND METHOD

Twenty-five GPs from Sarthe Department (Western France) took part in semistructured interview during which they expressed themselves on the prevention of missed pill and its consequences.

RESULTS

Twelve out of 20 physicians stated positively that their female patients often forget their pill. However, they noted that missed pill was seldom a reason for phone call or consultation. During the initial pill prescription, GPs insisted on how to take the pill (14/25) as well as advice in case of a missed pill (22/25), their availability (12/25) and the instruction leaflet (16/25). But only five quoted the importance of involving women in the choice of contraception. On prescription renewal, only nine out of 25 ask their patients about observance defect and eight out of 25 repeated the information. If patients asked for further explanation, only two doctors out of 25 had practices in line with the French National Authority for Health's (HAS) recommandation guidelines.

CONCLUSION

GPs' attitudes are partly due to a lack of practice's knowledge in primary and emergency contraception methods. It seems essential to promote GPs' training and to take into account their expectations and needs. Furthermore, female patient must be actor of the choice of her contraceptive method in order to improve compliance and, therefore, effectiveness.

[Impact of exhaled CO measurement. A randomised study among 578 smoking patients in general practice]

Nicotine addiction (NA) is a serious public health problem and helping patients to stop consumption is a major concern for general practitioners (GP). The positive effects of "brief advice" are well known. The aim of our paper is to evaluate the effectiveness of adding exhaled carbon monoxide (CO) measurement using a CO analyser to a normal smoking cessation practice in a GP's office.

METHODS

This was a descriptive study, using a questionnaire, among randomised smoking patients; one group receiving brief advice and the other brief advice plus exhaled CO analysis in their GP's office.

RESULTS

Five hundred and seventy-eight questionnaires were analysed: 60% of smoking patients wished to stop smoking and 72% within the next 6 months, without significant difference between the two groups. In the group "minimal advice plus CO analyser" (282), 60% of the smokers reported that they had been influenced by the results of the level of CO in the exhaled air and were more motivated to quit because of this.

CONCLUSION

Measuring the level of exhaled CO in smokers helps to inform them of the dangers of their addiction and helps to motivate them to quit.

Clinical qualitative evaluation of the diagnosis of acute otitis media in general practice

OBJECTIVES

Assess the quality of the diagnosis of acute otitis media (AOM) given by general practitioners (GPs) on a daily basis and compare it with the diagnosis of ear, nose and throat specialist (ENTS) which is considered as the gold standard.

METHODOLOGY

Every GP had to include six children aged 1-4 years for whom he suspected or diagnosed that they were suffering from AOM. Parents had to accept to see the ENTS participating in the survey within 48 h.

RESULTS

Twenty-four GPs took part in the survey and included at least one child, which amounts to a final 57% acceptability rate. Two hundred and eight eardrums were included in the survey. 21.9% of assumptions or diagnosis's of AOM (30/137) were declared null by the ENTS. GPs diagnose AOM without any doubt only in 54% of all cases. The diagnosis and the assumption of AOM were respectively confirmed in 83.8% of all cases and 71.4% by the ENTS. The combination of redness and bulge, and isolated redness accounted for respectively 44.3% and 26.2% of the main otoscopical factors reminiscent of the AOM according to GPs. In the case of redness and bulge, the diagnosis was confirmed in 83% of all cases by the ENTS as opposed to 75% regarding the isolated redness. An AOM was suspected in 57.1% of the eardrums barely or not visible or without any sign of infection and not confirmed in 25% of all cases.

CONCLUSION

The global over diagnosis is 21.9% and 25% when the otoscopy is hindered by the presence of cerumen or when the eardrums are only inflammatory. Even though the over diagnosis is inferior to the one mentioned in published writings, post-graduate teaching on the various cerumen removal techniques and the use of pneumatic otoscopy could contribute to improving the quality of diagnosing AOM.

Un abcès du sein à Salmonella typhi et revue de la littérature

We report the case of a 54-year-old woman who presented with breast abscess, which appeared through a common alimentary toxi-infection with Salmonella Typhi, infection, which implied twelve patients having attended the same restaurant. With around hundred native cases a year in France, typhoid fever is not a very frequent toxi-infection. Among the known extra-intestinal manifestations of Salmonella infections, the breast abscess remains rare and the literature revealed less than ten published cases, including some revealed the disease. In our observation, the imputability of S. Typhi was retained based on the chronology of the clinical signs, specific treatments, and the successful outcome under antibiotherapy, in spite of the negativity of the breast abscess bacteriological samples. We also analyze rare cases of breast abscess due to S. Typhi found in the literature.

Metronomic capecitabine in advanced patients with hepatocellular carcinoma (HCC): Preliminary results

15163

Background: No standard therapies are available for HCC patients (pts) ineligible for curative treatments. HCC has a rich neovasculature and neoangiogenesis is a negative prognostic factor: a high density of microvessels and hyperexpression of VEGF correlates with an increased propensity for invasion and metastatization and with a decreased DFS after resection. High level of circulating endothelial progenitors cells (CEPc) are related with insurgence and progression of HCC. Phase II trials with antiangiogenic agents in monotherapy had a response rate lower than 10% but stable disease (SD) is encouraging ranging between 30 and 60%. Retrospective analysis of standard capecitibine showed a response of 11% and similar SD rate. Experimental data on solid tumors suggest that metronomic CT prolongs inibihition of tumor growth, avoiding CEPc mobilization. Methods: Starting in september 2006, twenty-two patients were started on treatment (19 male; median age 63.7, range 47–82 ). BCLC (Barcelona Consensus Liver Cancer): 5 pts = B; 17 pts = C; Child: 12 pts =A, 8=B, 2=C. 14 pts had portal thrombosis. 15 pts were treated in front line, 7 in second line (4 pts previously treated with Sorafenib and 3 with experimental protocol of CPT-11 HAI; ASCO 2006 Abs 14061 ). The first cycle was carried out with standard capecitabine (2000 mg/sq.mt; 14 over 21 days), followed by metronomic capecitabine (1300 mg) without interruption. To compare the angiogenic role of metronomic capecitabine versus standard administration, VEGF and trombospondine have been dosed at baseline and after the first cycle of standard capecitabine and after one month of metronomic capecitabine. The response has been assessed by CT scan every three months. Results: Five out of 22 patients have been dismissed for toxicity (liver failure) during the standard capecitabine treatment. Among the 17 remaining patients, two have discontinued the treatment due to toxicity (liver failure) during the metronomic treatment and 10 have accomplished at least the first month of metronomic schedule. 6 patients have been evaluated for response: 2 PR (one second line), 3 SD (all in second line), 1 PD (second line). Conclusions: Metronomic capecitabine seems to have a better tolerability than standard schedule and promises good efficacy.

No significant financial relationships to disclose.

[Postpartum contraception: medical guidelines, women's point of view]

PURPOSE

Postpartum contraception is subjected to specific medical guidelines related to the suckling mode. The practitioner must conciliate prescription rules with women's expectations. The purpose of this work was to estimate the medical practice in the maternity centre at a local hospital and the actual practice of women at home, in immediate postpartum and during the year that followed the childbirth.

METHOD

One hundred and four new mothers from the maternity centre, in September 2004, took the survey. During their stay after birth, they filled a questionnaire on contraception. Various data have been collected from their obstetrical file. The analysis allowed the synthesis of medical guidelines on postpartum contraception. One year later, patients answered a telephone survey about their contraceptive practice.

RESULTS

In our survey, two-third of the new mothers (61.5%) chose breast-feeding. Seventy percent of them received progestins as contraceptives. Three out of four women (78%) followed this prescription after they left the hospital. Two-third (62.5%) of the women who had chosen artificial suckling received a prescription of estroprogestin. The majority of them (96%) used it after their return home. A high number of women (87.5%) estimated that these contraceptions were efficient, but more than a third of them thought they were uneasy to use (38.9%). Half of the women (52.8%) forgot their contraception during postpartum and the majority of them (86%) changed it within a year. A quarter (23.1%) of the contraception follow-up during this time was made by a general practitioner.

CONCLUSION

The practice in the maternity centre generally follows medical guidelines. However, it seems important to adapt postpartum contraception to the real practice of women. The general practitioner plays a major role in this management, especially during well-baby visits.

[Reliability of the diagnosis of acute otitis media by general practitioners]

OBJECTIVES

To assess reliability of the diagnosis of Acute Otitis Media (AOM) given by General Practitioners (GPs) compared with the diagnosis of Otorhinolaryngologists (ORLs) considered as the reference diagnosis.

METHODOLOGY

Every GP had to include 6 children aged 1 to 4 years for whom he suspected or diagnosed AOM. Parents had to accept to consult the ORL participating in the survey within 48 h.

RESULTS

24 GPs took part in the survey and included at least 1 child, which amounts to a final 57% acceptability rate. Two hundred and eight eardrums were included in the survey. 21.9% of assumptions or diagnosis of AOM (30/137) were declared null by the ORL. GPs diagnose AOM with certainty only in 54% of all cases. The diagnosis and the assumption of AOM were respectively confirmed in 83.8% of all cases and 71.4% by the ORL. The combination of redness and bulge and isolated redness accounted for respectively 44.3% and 26.2% of the main otoscopical factors reminiscent of the AOM according to GPs. In the case of redness plus bulge, the diagnosis was confirmed in 83% of all cases by the ORL as opposed to 75% regarding the isolated redness. AOM was suspected in 57.1% of the eardrums little or not visible with no sign of infection and was not confirmed in 25% of all cases.

CONCLUSION

The global overdiagnosis was 21.9% and 25% when the otoscopy is hindered by the presence of cerumen or when the eardrums show inflammation alone. Even though the overdiagnosis was lower than the reported one in literature, post-graduate teaching on the various cerumen removal techniques and the use of pneumatic otoscopy should contribute to improve the quality of diagnosing AOM.

Phase II study of temozolomide and celecoxib in the treatment of metastatic melanoma

18015

Background: There is increasing evidence that the expression of Cyclo-oxygenase 2 correlates with development and progression of malignant melanoma. Celecoxib (C) has demonstrated some kind of activity in monotherapy in melanoma. Temozolomide (T) has consistent activity in melanoma, either as monotherapy or in combination. We designed a phase II study to determine the efficacy and toxicity of the combination of Celecoxib and Temozolomide in advanced melanoma as first line of therapy Methods: From January 2004 to October 2005, 13 patients with metastatic melanoma were enrolled in the study. There were 4 males and 9 females. The median age was 59 years. Patients received Temozolomide 200/mg/mq day po for 5 days every 4 weeks and Celecoxib 400 mg BID for 10 days every 4 weeks. Results: Among 12 evaluable patients there were 4 partial responses (30.8%), no complete response or disease stabilization. Progression occurred in 8 patients (61.5%). The median TTP was 3.14 months and the median survival was 9.06 months. The median number of cycles was 2, only 2 patients completed four cycles of treatment. Most commonly seen toxicities were nausea/vomiting (46%), fatigue (93%), thrombocytopenia (15.3%), leukopenia (7.6%). Two patients discontinued the treatment due to grade 4 thrombocytopenia. Conclusions: The combination of Temozolomide and Celecoxib is safe, manageable and provides clinical benefit, but its activity is not superior to standard therapy.

No significant financial relationships to disclose.

Acute cytomegalovirus infection and venous thrombosis: role of antiphospholipid antibodies

Cytomegalovirus (CMV)-induced thrombosis has been reported in immunocompromised patients, such as transplant recipients and patients with AIDS. Recent cases also describe thrombotic phenomena in immunocompetent patients with CMV infection. Various mechanisms may explain the role of CMV in thrombosis: this virus can damage endothelial cells, activate coagulation factors, and induce production of antiphospholipid (aPL) antibodies. We present a case report of a previously healthy white woman with a pulmonary embolism associated with CMV infection and the presence of aPL antibodies, and we discuss the role of the aPL antibodies associated with CMV infection in the pathogenesis of thrombosis.

Predictive value of oral colonization by Candida yeasts for the onset of a nosocomial infection in elderly hospitalized patients

The incidence of nosocomial yeast infections has increased markedly in recent decades, especially among the elderly. The present study was therefore initiated not only to determine the predictive value of oral colonization by yeasts for the onset of a nosocomial Candida infection in elderly hospitalized patients (>65 years), but also to clarify the factors that promote infection and to establish a relationship between the intensity of oral carriage and the onset of yeast infection. During this prospective cohort study, 256 patients (156 women and 100 men with a mean age of 83±8 years) were surveyed for yeast colonization or infection. Samples were collected every 4 days from day 0 to day 16 from four sites in the mouth, and intrinsic and extrinsic factors that might promote infection were recorded for each patient. Pulsed field gel electrophoresis was performed on Candida albicans isolates from all infected patients. Poor nutritional status was observed in 81 % of the patients and hyposalivation in 41 %. The colonization level was 67 % on day 0 (59 % C. albicans) and a heavy carriage of yeasts (>50 c.f.u.) was observed for 51 % of the patients. The incidence of nosocomial colonization reached 6·9 % on day 4 (6·1 % on day 8 and 2·7 % on day 12), and that of nosocomial infection was 3·7 % on day 4 (6·8 % on day 8, 11·3 % on day 12 and 19·2 % on day 16). Of the 35 patients infected, 57 % were suffering from oral candidiasis. The principal risk factors for colonization were a dental prosthesis, poor oral hygiene and the use of antibiotics. The risk factors for infection, in addition to those already mentioned for colonization, were endocrine disease, poor nutritional status, prolonged hospitalization and high colony counts. Genotyping revealed person-to-person transmission in two patients. Thus, this study demonstrates a significant association between oral colonization and the onset of yeast infections in elderly hospitalized patients. Therefore, oral samples should be collected at admission and antifungal treatment should be administered in cases of colonization, especially in patients presenting a heavy carriage of yeasts. Genotyping of the strains confirmed the possibility of person-to-person transmission.

[Evaluation of a university hospital unit specialising in treating adults at risk of suicide]

In France, suicide prevention has been a public health priority since 1992. Half of all suicide attempts are repeated attempts made by people who have already tried to commit suicide, and the risk of death increases by 1% after the first attempt. Today, hospitalisation has become an unavoidable consequence for those who have attempted suicide, and recommendations for best practice were recently issued in France (1998). The objective of this study was two-fold: 1) to assess the quality of management and care provided for patients hospitalised in a university hospital in Angers after having attempted suicide, an evaluation that was based in part on the criteria of the National Agency on Health Accreditation and Evaluation (ANAES); and 2) the demonstrate the value and high utility of such a unit specialising in caring for patients recovering from attempted suicide. The unit has now been in existence for over 5 years, and has treated 42% of such patients who require hospitalisation. One investigator was responsible for asking 251 patients (on the day of their release) who had been hospitalised anytime during the given 6 month period (November 2002 - May 2003) to complete a questionnaire containing approximately 100 items. In order to be eligible for the study, patients had to be older than 16 years and hospitalised for at least 48 hours. 155 questionnaires were completed (62%), and there were 96 patients were notable to participate on the day of their release. Nine of the 14 criteria recommended by the ANAES were met in over 65% of the cases, and three in less than 40%. Following the analysis of the data through logic regression, it remained clear that unit specialising in the care of people who have attempted suicide was better able and equipped to meet the standards of the ANAES' recommendations than a standard hospital medical unit. Visits with a psychiatrist or psychiatric nurse occurred more frequently in the specialised unit (p < 0.04), interviews with the patients' family members were more frequent (p < 0.01), the confidentiality of the discussions from the interviews was more often respected and maintained (p < 0001), and the information provided by the caregivers and staff was more effective in the specialised unit (p < 0.03). One of the main benefits and results of these aforementioned differences is that the patients in the suicide unit more often perceived a distinct improvement in their depression (p < 0.007). All of these arguments indicate that hospitalisation in a special unit provides real benefits to patients, and the results of this study advocate strongly in favour of increasing the capacity of the unit, which is currently limited to only 6 beds.

Conséquences de l’obésité maternelle sur le déroulement du travail et l’accouchement

AIMS

The aim of this survey was to analyze the effects on labor, delivery, afterbirth, and neonatal status of maternal obesity, independently of other diseases that might modify obstetrical management.

POPULATION AND METHODS

Cross-sectional survey of cases during one year in the obstetrics department of a university hospital center. The inclusion criterion was obesity, defined as BMI > 30. The exclusion criteria were hypertension, pregnancy-related hypoxemia, diabetes (pre-existing or pregnancy-related), maternal cardio-pulmonary disease, uterine scar, multiple pregnancy, and non-cephalic presentation. Two groups, one obese and the other not, were matched for age and parity.

RESULTS

The rate of post-term deliveries was higher among obese women (p = 0.04), induction of labor more frequent (p = 0.05), and the duration of its first phase longer (p = 0.003); the cesarean rate was seven times higher (14.6% versus 2.1%) and the mean weight of the newborns significantly higher (p = 0.01). Multivariate analysis found the following factors to be significantly associated with maternal obesity: longer duration of the first phase of labor, less frequent spontaneous vaginal delivery, higher cesarean rate, and higher rate of lack of progress in dilatation.

CONCLUSION

This study shows that maternal obesity is a risk factor for complications during pregnancy, independently of its standard complications--pregnancy-related diabetes and hypertension. It compromises the smooth progression of labor and delivery. Pregnancy in obese women must be considered to be "at risk", regardless of any complications of obesity. It is thus important to help obese women become more aware of the importance of a balanced diet for themselves and their children. The presence of an obese adult in the household quadruples the risk of obesity in children.