Combination of serum and peritoneal 1.3-beta-D-glucan can rule out intra-abdominal candidiasis in surgical critically ill patients: a multicenter prospective study

BACKGROUND

Intra-abdominal candidiasis (IAC) is difficult to predict in critically ill patients with intra-abdominal infection, leading to the overuse of antifungal treatments. Serum and peritoneal 1.3-beta-D-glucan (sBDG and pBDG) have been proposed to confirm or invalidate the diagnosis of IAC, but clinical studies have reported inconsistent results, notably because of heterogeneous populations with a low IAC prevalence. This study aimed to identify a high-risk IAC population and evaluate pBDG and sBDG in diagnosing IAC.

METHODS

This prospective multicenter noninterventional French study included consecutive critically ill patients undergoing abdominal surgery for abdominal sepsis. The primary objective was to establish the IAC prevalence. The secondary objective was to explore whether sBDG and pBDG could be used to diagnose IAC. Wako® beta-glucan test (WT, Fujifilm Wako Chemicals Europe, Neuss, Germany) was used for pBDG measurements. WT and Fungitell® beta-D-glucan assay (FA, Associate of Cape Cod, East Falmouth, USA) were used for sBDG measurements.

RESULTS

Between 1 January 2020 and 31 December 2022, 199 patients were included. Patients were predominantly male (63%), with a median age of 66 [54-72] years. The IAC prevalence was 44% (87/199). The main IAC type was secondary peritonitis. Septic shock occurred in 63% of cases. After multivariate analysis, a nosocomial origin was associated with more IAC cases (P = 0.0399). The median pBDG level was significantly elevated in IAC (448 [107.5-1578.0] pg/ml) compared to non-IAC patients (133 [16.0-831.0] pg/ml), P = 0.0021. For a pBDG threshold of 45 pg/ml, the negative predictive value in assessing IAC was 82.3%. The median sBDG level with WT (n = 42) at day 1 was higher in IAC (5 [3.0-9.0] pg/ml) than in non-IAC patients (3 [3.0-3.0] pg/ml), P = 0.012. Similarly, median sBDG level with FA (n = 140) at day 1 was higher in IAC (104 [38.0-211.0] pg/ml) than in non-IAC patients (50 [23.0-141.0] pg/ml), P = 0.009. Combining a peritonitis score < 3, sBDG < 3.3 pg/ml (WT) and pBDG < 45 pg/ml (WT) yielded a negative predictive value of 100%.

CONCLUSION

In critically ill patients with intra-abdominal infection requiring surgery, the IAC prevalence was 44%. Combining low sBDG and pBDG with a low peritonitis score effectively excluded IAC and could limit unnecessary antifungal agent exposure.

TRIAL REGISTRATION

The study was registered with ClinicalTrials.gov (ID number 03997929, first registered on June 24, 2019).

Intravitreal Injection of Bevacizumab for the Prevention of Postoperative Proliferative Vitreoretinopathy in High-Risk Patients Selected by Laser Flare Photometry

INTRODUCTION

To evaluate the effect of an intravitreal injection of bevacizumab at the time of rhegmatogenous retinal detachment (RRD) surgery, on postoperative proliferative vitreoretinopathy (PVR) in high-risk patients selected by laser flare photometry.

METHODS

This single-center observational retrospective cohort study included 137 consecutive patients who underwent pars plana vitrectomy and gas tamponade for primary RRD with increased aqueous flare between July 2016 and June 2021. From June 2019, an intravitreal injection of bevacizumab was administered as an adjunct to RRD repair. Patients who underwent surgery before this time and who did not receive intravitreal bevacizumab served as controls. The main outcome was the rate of retinal redetachment due to PVR.

RESULTS

The median flare value was 22.0 (16.5-36.5) pc/ms in the control group and 28.2 (19.7-41.0) pc/ms in the bevacizumab group (p = 0.063). Eyes treated with bevacizumab were more likely to have macula-off RRD (p = 0.003), grade B PVR (p = 0.038), and worse visual acuity (p = 0.004) than controls. The rate of PVR redetachment was significantly lower in the bevacizumab group (11.1%) than in the control (30.1%) (p = 0.012). This difference was more pronounced after adjusting for potential confounding factors (p = 0.005); the risk of developing PVR was 4.5-fold higher in controls (95% CI, 1.6-12.8). After adjustment, the final median visual acuity was also significantly higher in eyes treated with bevacizumab (p = 0.025).

CONCLUSION

This pilot study provides preliminary evidence that bevacizumab may reduce the risk of PVR-related recurrent RRD and improve visual outcomes in high-risk patients selected by laser flare photometry.

Soluble TREM-1 plasma concentration predicts poor outcome in COVID-19 patients

BACKGROUND

The immuno-receptor Triggering Expressed on Myeloid cells-1 (TREM-1) is activated during bacterial infectious diseases, where it amplifies the inflammatory response. Small studies suggest that TREM-1 could be involved in viral infections, including COVID-19. We here aim to decipher whether plasma concentration of the soluble form of TREM-1 (sTREM-1) could predict the outcome of hospitalized COVID-19 patients.

METHODS

We conducted a multicentre prospective observational study in 3 university hospitals in France. Consecutive hospitalized patients with confirmed infection with SARS-CoV-2 were enrolled. Plasma concentration of sTREM-1 was measured on admission and then at days 4, 6, 8, 14, 21, and 28 in patients admitted into an ICU (ICU cohort: ICUC) or 3 times a week for patients hospitalized in a medical ward (Conventional Cohort: ConvC). Clinical and biological data were prospectively recorded and patients were followed-up for 90 days. For medical ward patients, the outcome was deemed complicated in case of requirement of increased oxygen supply > 5 L/min, transfer to an ICU, or death. For Intensive Care Unit (ICU) patients, complicated outcome was defined by death in the ICU.

RESULTS

Plasma concentration of sTREM-1 at inclusion was higher in ICU patients (n = 269) than in medical ward patients (n = 562) (224 pg/mL (IQR 144-320) vs 147 pg/mL (76-249), p < 0.0001), and higher in patients with a complicated outcome in both cohorts: 178 (94-300) vs 135 pg/mL (70-220), p < 0.0001 in the ward patients, and 342 (288-532) vs 206 pg/mL (134-291), p < 0.0001 in the ICU patients. Elevated sTREM-1 baseline concentration was an independent predictor of complicated outcomes (Hazard Ratio (HR) = 1.5 (1.1-2.1), p = 0.02 in ward patients; HR = 3.8 (1.8-8.0), p = 0.0003 in ICU patients). An sTREM-1 plasma concentration of 224 pg/mL had a sensitivity of 42%, and a specificity of 76% in the ConvC for complicated outcome. In the ICUC, a 287 pg/mL cutoff had a sensitivity of 78%, and a specificity of 74% for death. The sTREM-1 concentrations increased over time in the ConvC patients with a complicated outcome (p = 0.017), but not in the ICUC patients.

CONCLUSIONS

In COVID-19 patients, plasma concentration of sTREM-1 is an independent predictor of the outcome, although its positive and negative likelihood ratio are not good enough to guide clinical decision as a standalone marker.

A French single-center experience on allogeneic stem cell transplant cryopreservation during severe acute respiratory syndrome coronavirus 2 pandemic

BACKGROUND AIMS

Allogeneic hematopoietic stem cell transplantation (allo-SCT) is a curative treatment for chemo-resistant hematological malignancies. Because of transport restriction imposed by the coronavirus disease 2019 pandemic, regulatory bodies and societies recommended graft cryopreservation before recipient conditioning. However, the freezing and thawing processes, including washing steps, might impair CD34+ cell recovery and viability, thereby impacting the recipient engraftment. Over 1 year (between March 2020 and May 2021), we aimed to analyze the results of frozen/thawed peripheral blood stem cell allografts in terms of stem cell quality and clinical outcomes.

METHODS

Transplant quality was evaluated by comparing total nucleated cells (TNCs), CD34+ cells and colony-forming unit-granulocyte/macrophage (CFU-GM)/kg numbers as well as TNC and CD34+ cell viabilities before and after thawing. Intrinsic biological parameters such as granulocyte, platelet and CD34+ cell concentrations were analyzed, as they might be responsible for a quality loss. The impact of the CD34+ cell richness of the graft on TNC and CD34 yields was evaluated by designing three groups of transplants based on their CD34 /kg value at collection: >8 × 10 6/kg, between 6 and 8 × 106/kg and <6 × 106/kg. The consequences of cryopreservation were compared in the fresh and thawed group by evaluating the main transplant outcomes.

RESULTS

Over 1 year, 76 recipients were included in the study; 57 patients received a thawed and 19 patients a fresh allo-SCT. None received allo-SCT from a severe acute respiratory syndrome coronavirus 2-positive donor. The freezing of 57 transplants led to the storage of 309 bags, for a mean storage time (between freezing and thawing) of 14 days. For the fresh transplant group, only 41 bags were stored for potential future donor lymphocyte infusions. Regarding the graft characteristics at collection, median number of cryopreserved TNC and CD34+ cells/kg were greater than those for fresh infusions. After thawing, median yields were 74.0%, 69.0% and 48.0% for TNC, CD34+ cells and CFU-GM, respectively. The median TNC dose/kg obtained after thawing was 5.8 × 108, with a median viability of 76%. The median CD34+ cells/kg was 5 × 106, with a median viability of 87%. In the fresh transplant group, the median TNC/kg was 5.9 × 108/kg, and the median CD34+ cells/kg and CFU-GM/kg were 6 × 106/kg and 276.5 × 104/kg, respectively. Sixty-one percent of the thawed transplants were out of specifications regarding the CD34+ cells/ kg requested cell dose (6 × 106/kg) and 85% of them would have had this dose if their hematopoietic stem cell transplant had been infused fresh. Regarding fresh grafts, 15.8% contained less than 6 × 106 CD34+ cells /kg and came from peripheral blood stem cells that did not reach 6 × 106 CD34+ cells /kg at collection. Regarding the factor that impaired CD34 and TNC yield after thawing, no significant impact of the granulocyte count, the platelet count or the CD34+ cells concentration/µL was observed. However, grafts containing more than 8 × 10 6/kg at collection showed a significantly lower TNC and CD34 yield.

CONCLUSIONS

Transplant outcomes (engraftment, graft-versus-host disease, infections, relapse or death) were not significantly different between the two groups.

One reaction - double stereoinduction: C-H activation as a privileged route towards complex atropisomeric molecules

Expanding the importance of chirality and implementation of stereogenic information within complex molecular design has recently reached a new level: design of innovative enantiopure scaffolds bearing multiple chiral elements. In particular, regarding sustainability aspects and straightforward use of relatively simple substrates, the C-H activation strategy offers unique opportunities to assemble complex chiral molecules with unique topologies while controlling two stereoselective events in a single transformation. Herein, the emerging field of asymmetric C-H activation allowing rapid construction of atropisomeric molecules bearing a second chirality element, such as a stereogenic center, vicinal chiral axis or planar chirality, is described. Aiming at in-depth comprehension of such innovative systems, the emphasis is put on the nature of stereodiscriminant steps, allowing the simultaneous control of both chiral elements.

Impact of selective reporting of antibiotic susceptibility testing results for urinary tract infections in the outpatient setting: A prospective controlled before-after intervention study

OBJECTIVES

The use of selective reporting of antibiotic susceptibility testing (AST) results is a recommended antimicrobial stewardship strategy to improve the appropriateness of antibiotic prescriptions. We conducted a large, pragmatic, prospective, multicentre, controlled (selective reporting versus complete reporting) before-after intervention study to assess the impact of selective reporting of AST results for Escherichia coli-positive urine cultures on the prescription of broad-spectrum antibiotics carrying a higher risk of selection of resistance (i.e., amoxicillin-clavulanate, third-generation cephalosporins, and quinolones) in the outpatient setting. We also looked for possible unintended clinical consequences of the intervention leading to consultations and/or hospitalisations.

METHODS

We compared two groups of laboratories located in a French region. We collected data from the health insurance databases before (2017) and after the implementation of the intervention (2019). The primary outcome was the prescription proportions of broad-spectrum antibiotics.

RESULTS

We included 42,956 Escherichia coli-positive urine cultures with AST. The decrease of the proportion of broad-spectrum antibiotic prescriptions between 2017 and 2019 was significantly higher for selective reporting of AST, attributable to a decrease in the prescription proportion of third-generation cephalosporins (- 8.5% for selective reporting versus - 0.1% for complete reporting, p < 0.001). This impact was more marked for targeted therapy and female patients. Requests from clinicians for the complete reporting of AST results were infrequent (1.2% of all the selective AST results reported in 2019). No unintended consequences were observed.

CONCLUSION

The results showed a positive impact of the selective reporting of AST results, but room for improvement is still important.

REGISTRATION AT CLINICAL TRIALS

NCT03612297.

Dissociated Optic Nerve Fiber Layer Appearance after Macular Hole Surgery: A Randomized Controlled Trial Comparing the Temporal Inverted Internal Limiting Membrane Flap Technique with Conventional Peeling

PURPOSE

To evaluate the effect of the temporal inverted internal limiting membrane (ILM) flap technique compared with that of conventional ILM peeling on the extent of the dissociated optic nerve fiber layer (DONFL) and retinal sensitivity in patients undergoing macular hole (MH) surgery.

DESIGN

Single-center, prospective, open-label, randomized controlled clinical trial.

PARTICIPANTS

Patients requiring vitrectomy for MHs sized > 250 μm.

METHODS

Patients were randomly assigned (1:1) to 1 of the following 2 groups: (1) the control group undergoing standard ILM peeling and (2) the experimental group (flap group) undergoing the temporal inverted ILM flap technique.

MAIN OUTCOME MEASURES

The primary outcome measure was the total DONFL score at 3 months after surgery. Important secondary outcomes were microperimetry results, primary MH closure rate, external limiting membrane (ELM) and ellipsoid zone (EZ) recovery rates, and best-corrected visual acuity (BCVA).

RESULTS

Sixty-five patients were recruited between February 2018 and July 2020; primary outcome data were available for 60 patients. The median DONFL score was 7.0 (3.0-12.5) in the control group and 5.0 (1.5-8.5) in the flap group at 3 months after surgery (P = 0.145). The focal depressions characteristic of the DONFL were limited to the temporal side of the fovea in the flap group, whereas they were found all around the fovea in the control group on spectral-domain OCT images. The MH closure rate (P = 1), EZ and ELM recovery rates (P = 0.252), and BCVA (P = 0.450) were similar between the 2 groups. The 3-month overall median retinal sensitivity (MRS) (P = 0.142) and MRS improvement (P = 0.916) in the control group were comparable with those observed in the flap group. In addition, there was no significant difference between the 2 techniques when considering the temporal area (P = 0.105) or the nasal area (P = 0.468).

CONCLUSIONS

The temporal inverted ILM flap technique reduced the extent of the DONFL by preserving the nasal part of the fovea. However, the overall DONFL score was similar between the 2 techniques. In addition, the MRS and BCVA did not differ from those obtained after complete ILM peeling.

FINANCIAL DISCLOSURE(S)

The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Congenital hypothyroidism in children with eutopic gland or thyroid hemiagenesis: prognostic factors for transient vs. permanent hypothyroidism

OBJECTIVES

More than one third of children with congenital hypothyroidism (CH) and thyroid gland in situ (or eutopic gland) have transient hypothyroidism. It remains difficult to determine early on whether hypothyroidism will be transient which may cause overtreatment and its complications in these children. Our primary aim was to determine prognostic factors for transient hypothyroidism in children with congenital hypothyroidism and eutopic gland or thyroid hemiagenesis.

METHODS

We retrospectively reviewed medical records of 111 children, born between 1996 and 2017, diagnosed with congenital hypothyroidism and eutopic gland or hemiagenesis and treated at the Nancy Regional and University Hospital.

RESULTS

Fifty four infants (48.6%) had permanent congenital hypothyroidism (PCH) and 57 (51.4%) transient congenital hypothyroidism (TCH). Prognostic factors for TCH included prematurity, twin pregnancy, low birth weight and Apgar score <7, while low FT3 at diagnosis, maternal levothyroxine treatment, a family history of thyroid dysfunction and TSH ≥10 mUI/L while receiving treatment were associated with PCH. Knee epiphyses on X-ray at diagnosis were absent only in children with PCH. The median levothyroxine dose during follow-up was significantly lower in the TCH group compared to the PCH group. A levothyroxine dose of ≤3.95, ≤2.56, ≤2.19 and ≤2.12 μg/kg/day at 6 months, 1, 2 and 3 years of follow-up, respectively, had the best sensitivity-to-specificity ratio for predicting TCH.

CONCLUSIONS

Even though it remains difficult to predict the course of hypothyroidism at diagnosis, we were able to identify several prognostic factors for TCH including perinatal problems and lower levothyroxine requirements that can guide the physician on the evolution of hypothyroidism. Clinical Trial Registration Number: NCT04712760.

Relevance of sensitization to legumes in peanut-allergic children

BACKGROUND

Legume consumption has increased during the two past decades. In France, legumes are responsible for 14.6% of food-related anaphylaxis in children, with peanut as the main allergen (77.5%). Few studies have demonstrated cross-reactivities between peanut and other legumes. The aim of this study was to determine prevalence and relevance of sensitization to legumes in peanut-allergic children.

METHODS

All children, aged of 1-17 years, admitted to the Pediatric Allergy Department of the University Hospital of Nancy between January 1, 2017 and February 29, 2020 with a confirmed peanut allergy (PA) and a documented consumption or sensitization to at least one other legume were included. Data were retrospectively collected regarding history of consumption, skin prick tests, specific immunoglobulin E (IgE), prior allergic reactions, and oral food challenges for each legume.

RESULTS

Among the 195 included children with PA, 122 were sensitized to at least one other legume (63.9%). Main sensitizations were for fenugreek (N = 61, 66.3%), lentil (N = 38, 42.2%), soy (N = 61, 39.9%), and lupine (N = 63, 34.2%). Among the 122 sensitized children, allergy to at least one legume was confirmed for 34 children (27.9%), including six children who had multiple legume allergies (4.9%). Lentil, lupine, and pea were the main responsible allergens. Half of allergic reactions to legumes other than peanut were severe.

CONCLUSION

The high prevalence of legume sensitization and the frequent severe reactions reported in children with PA highlight that tolerated legume consumption should be explored for each legume in the case of PA, and sensitization should be investigated if not.

Continuous wound infusion combined with intrathecal morphine for analgesia after Cesarean delivery compared with intrathecal morphine or continuous wound infusion alone

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT02279628); registered 31 October 2014.

A Magnetic Resonance Imaging Index to Predict Crohn's Disease Postoperative Recurrence: The MONITOR Index

BACKGROUND & AIMS

We developed and validated a magnetic resonance imaging-based index to predict Crohn's disease (CD) postoperative recurrence (POR).

METHODS

Patients with CD who underwent a postoperative evaluation for recurrence (with colonoscopy and MRI no longer than 105 days apart) were included between 2006 and 2016 in University Hospital of Nancy, France. MRI items with good levels of intra-rater and inter-rater agreement (Gwet's coefficient ≥0.5) were selected. The MRI in Crohn's Disease to Predict Postoperative Recurrence (MONITOR) index's performance was assessed in terms of the area under the receiver operating characteristic curve (AUROC) and accuracy, by considering the Rutgeerts score as the gold standard. The MONITOR index was validated with a bootstrap method and an independent cohort.

RESULTS

Seventy-three MRI datasets were interpreted by 2 radiologists. Seven items (bowel wall thickness, contrast enhancement, T2 signal increase, diffusion-weighted signal increase, edema, ulcers, and the length of the diseased segment) had a Gwet's coefficient ≥0.5 and were significantly associated with the Rutgeerts score, leading to their inclusion in the MONITOR index. All the items had a weighting of 1, except the "ulcers" item weighting 2.5, reflecting the higher adjusted odds ratio. The AUROC [95% confidence interval] for the prediction of endoscopic POR (Rutgeerts score >i1) was 0.80 [0.70-0.90]. The optimal threshold was a MONITOR index ≥1, giving a sensitivity of 79%, a specificity of 55%, a predictive positive value of 68%, and a predictive negative value of 68%. The bootstrap validation gave an AUROC of 0.85 [0.73-0.97]. In the validation cohort, a MONITOR index ≥1 gave a sensitivity of 87%, a specificity of 75%, a predictive positive value of 84.6%, and a predictive negative value of 75%.

CONCLUSIONS

The MONITOR index is an efficient, reliable, easy-to-apply tool that can be used in clinical practice to predict the POR of CD.

Évaluation de la prévalence des formes critiques de la COVID-19 parmi les patients hospitalisés porteurs d’une maladie respiratoire chronique

Introduction

Les infections virales respiratoires, dont l’infection à SARS-CoV-2, peuvent déclencher des symptômes respiratoires chez les patients souffrant de maladies respiratoires chroniques, entraînant des exacerbations et parfois des hospitalisations. Malgré le tropisme préférentiellement respiratoire du SARS-CoV-2, les études évaluant les maladies respiratoires chroniques comme facteurs de risque de forme critique de la COVID-19 sont controversées. L’objectif de cette étude était d’évaluer la prévalence de formes critiques de la COVID-19 chez les patients hospitalisés porteurs d’une maladie respiratoire chronique.

Méthodes

Cette étude rétrospective française bicentrique a inclus tous les patients hospitalisés du 15 mars au 30 juin 2020 pour motif respiratoire liée à la COVID-19, hors unités de soins intensifs et réanimation.

Résultats

Au total, 617 patients ont été inclus dont 125 présentant une maladie respiratoire chronique, principalement une bronchopneumopathie chronique obstructive (45 %) et un asthme (30 %) (Tableau 1). Le pourcentage de patients ayant obtenu un score de 6 ou plus sur l’échelle de progression clinique de l’Organisation mondiale de la santé 1 pendant leur hospitalisation était plus faible chez les patients atteints d’une maladie respiratoire chronique que dans la population générale (21,6 % contre 31,3 %, p = 0,03 %). Parmi les patients porteurs d’une maladie respiratoire chronique, une température supérieure à 38 °C à l’admission (OR 16,88 [IC 95 % 4,01–71,00]), une lymphopénie (OR 5,08 [1,25–20,72]), un traitement par pression positive continue (OR 4,46 [1,04–19,17]) et un âge élevé (OR 1,09 [1,02–1,16]) étaient associés à un risque accru d’atteindre un score de 6 ou plus.

Conclusion

Selon cette étude, les patients porteurs d’une maladie respiratoire chronique hospitalisés pour forme grave de la COVID-19 ont un risque plus faible de développer une forme critique de la maladie, en particulier les patients souffrant d’une broncho-pneumopathie chronique obstructive et d’un asthme. Des études prospectives pourraient permettre de confirmer nos résultats et d’éclaircir l’impact des traitements inhalés et notamment de la corticothérapie sur la sévérité des infections à SARS-CoV-2.

Progression to a severe form of COVID-19 among patients with chronic respiratory diseases

RATIONALE

Viral respiratory infections, including SARS-CoV-2 infection, can trigger respiratory symptoms among patients suffering from chronic respiratory diseases, leading to exacerbations and hospitalizations. Despite the tropism of SARS-CoV-2 into the respiratory tract, chronic respiratory diseases do not seem to be risk factors for severe forms of COVID-19.

OBJECTIVES

To assess whether hospitalized patients for COVID-19 with chronic respiratory diseases were at lower risk of developing a severe form than other patients.

METHODS

This French study included patients admitted to hospital in COVID-19 ward, suffering from a SARS-CoV-2 infection, diagnosed on RT-PCR or chest computed tomography associated with clinical symptoms, from March 15 to June 30, 2020. Ambulatory patients who were tested in the emergency department and patients with severe hypoxaemia requiring intensive care were not included. All data were collected from electronic medical records up to discharge of the patient.

MAIN RESULTS

617 patients were included: 125 with a chronic respiratory disease, mainly chronic obstructive pulmonary disease (45%) and asthma (30%). The percentage of patients scoring 6 or higher on the WHO Clinical Progression Scale during hospital stay was lower in patients with chronic respiratory disease compared to those without chronic respiratory disease (21.6% versus 31.3%, respectively, p = 0.03). Among patients with chronic respiratory disease, temperature above 38 °C on admission (OR 16.88 (95% CI 4.01-71.00)), lymphopenia (OR 5.08 (1.25-20.72)), CPAP therapy (OR 4.46 (1.04-19.17)) and age (OR 1.09 (1.02-1.16)) were associated with an increased risk to reach a score of 6 or above.

CONCLUSIONS

Hospital admissions in COVID-19 ward of patients suffering from chronic respiratory diseases are at lower risk of developing a severe form of COVID- 19, especially in patients with chronic obstructive pulmonary disease or asthma. Prospective studies would confirm our results and allow to better organize the follow-up of these patients in a pandemic period.

An Objective Structured Clinical Examination (OSCE) for French Dental Students: Feedback after 2 Years

The Objective Structured Clinical Examination (OSCE) is a practical examination that provides a standardized assessment of clinical competence. The aim of this study is to evaluate the objectivity and the reliability of an OSCE in dentistry. To this end, a retrospective monocentric observational study was conducted at the Faculty of Dentistry of Nancy by analyzing the exam results of 81 students. The study population consisted of the fifth-year students. The examination was broken down into six stations which were doubled, and different juries of examiners were constituted (installed in different rooms) according to the same composition. The p-value was set at 0.05. We found an equivalence of the results between the different rooms on the global mean score obtained at the six stations (p = 0.021). In terms of gender, women have statistically significantly higher overall scores than men (p = 0.001). The evaluation of a difference in the scores between full-time and part-time teachers does not find any statistically significant difference or equivalence in the station where it was possible to realize the comparison. However, the students’ waiting time before the exam seems to negatively influence the results. Compared with other international OSCE studies, the results presented seemed sufficiently objective and reliable, although some adjustments are still necessary.

Clinical significance of anti-Ro52 (TRIM21) antibodies in adult patients with connective tissue diseases

OBJECTIVES

Clinical significance of anti-Ro52 antibodies in connective tissue diseases (CTD) is controversial. Anti-Ro52 antibodies might be associated with a more severe CTD phenotype, especially interstitial lung disease (ILD). The aims of this study were to evaluate ILD prevalence and severity, the prevalence of micro- or macroangiopathy and CTD-associated cancers in CTD with anti-Ro52 antibodies.

METHODS

CTD patients with anti-Ro52 antibody screening by immunoblot at diagnosis were enrolled. Two groups were retrospectively formed according to the presence of anti-Ro52 antibodies with an unbiased 1:1 matching on CTD types. Unsupervised multiple correspondence analysis and hierarchical clustering analysis were used to aggregate anti-Ro52 positive patients in subgroups.

RESULTS

408 CTD patients were included. Anti-Ro52 antibodies were detected in 33 % of CTD patients. Anti-Ro52 antibodies were associated with ILD at CTD diagnosis (47.8% vs. 23.0%, OR 3.3 95% IC 1.4 to 8.0, p = 0.008), even after adjusting for the presence of anti-Ro60 antibodies, especially in patients with antisynthetase syndrome, primary Sjögren syndrome and systemic sclerosis. Micro- or macroangiopathy was more frequent in anti-Ro52 positive CTD patients (18.6% vs. 9.7%, p = 0.02) and CTD patients with anti-Ro52 antibodies experienced more frequent relapses and required more immunosuppressive drugs. Clusters 4 and 5 identified anti-Ro52 positive CTD patients with severe ILD and with clinical features of systemic sclerosis or antisynthetase syndrome respectively.

CONCLUSIONS

We found that anti-Ro52 antibodies were independently associated with ILD in CTD patients irrespective of CTD type. Anti-Ro52 antibodies could be associated with severity and a more relapsing disease course in CTD patients.

On Behalf of the SFGM-TC: Retrospective Comparison of Reduced and Higher Intensity Conditioning for High-Risk Myelodysplastic Syndrome Treated With Allogeneic Stem-Cell Transplantation

BACKGROUND

Allogeneic hematopoietic stem-cell transplantation (allo-HSCT) remains the best curative option for high-risk myelodysplastic syndrome . We retrospectively compared patient outcomes after allo-HSCT according to the intensity of the conditioning regimen.

PATIENTS AND METHODS

Three conditioning regimens were compared in 427 patients allografted for high-risk myelodysplastic syndrome: reduced-intensity conditioning (RIC), fludarabine (150-160 mg/m²) and busulfan (6.4 mg/kg); sequential FLAMSA-RIC, fludarabine, amsacrine, and aracytine followed by RIC; and myeloablative with reduced toxicity (RTC), fludarabine and busulfan (9.6 mg/kg or 12.8 mg/kg).

RESULTS

The patients in the 3 conditioning groups were different in regards to the number of treatment lines (P< .001), percentage of blasts in bone marrow (P< .001), and disease status at transplantation (P< .001). No significant differences in outcomes (overall survival, progression-free survival, nonrelapse mortality, relapse incidence, and graft versus host disease relapse-free survival) were observed between the 3 groups. Using propensity score analysis to overcome baseline imbalances, we compared 70 patients receiving FLAMSA-RIC to 260 patients receiving RIC, and compared 83 patients receiving RTC to 252 patients receiving RIC. The only factor influencing overall and progression-free survival was cytogenetic risk at transplantation. After the covariate adjustment using propensity score to reduce baseline imbalances, the only factor influencing overall and progression-free survival was still cytogenetic risk at transplantation.

CONCLUSION

Overall survival appears to be similar with the 3 conditioning regimens. The only factor influencing survival is cytogenetic risk at transplantation, suggesting that new promising drugs in the conditioning and/or early interventions after transplantation are needed to improve outcomes in these patients.

Dermatological opinions are imperative in ambulatory and acute care settings for pediatric skin disorders - HL-SkinPed

BACKGROUND

Children with skin disorders usually receive care from a pediatrician, despite their limited training in this discipline. The advice of a dermatologist is frequently requested.

OBJECTIVES

To estimate the degree of concordance in the diagnosis, treatment, advice, and recommended follow-up of skin disorders between pediatricians (in private practice or a pediatric emergency department [PED]) and a dermatologist.

METHODS

This prospective study was carried out between June 25 and September 13, 2018. All patients younger than 18 years consulting at the PED of the University Children's Hospital or a pediatric private practice in Nancy, France, for a dermatological disorder (primary complaint) were included. Photographs, medical data, diagnosis, treatment, advice and follow-up recommended by the pediatricians were recorded in a dedicated anonymous medical file. Clinical data and photographs were subsequently reviewed by a dermatologist who provided a diagnosis.

RESULTS

A total of 103 patients were included and 99 were analyzed: 53 from the PED and 46 from private practice (three patients were excluded because of unclear photographs and one was referred for maxillofacial advice). The median age was 4 years and there was a slight predominance of females (53.5%). The seven main diagnoses were: atopic dermatitis, insect bites, nonspecific viral rash, viral urticaria, hand-foot-and-mouth disease, impetigo, and contact dermatitis. The rate of agreement between the pediatricians and the dermatologist was 55% for diagnosis (73% for atopic dermatitis, 53% for insect bites, 33% for nonspecific viral rash), 40% for treatment, 54% for advice, and 58% for recommended follow-up. Reinterpretation by the dermatologist changed patient management in 15% of cases.

CONCLUSIONS

The significant discordance between the pediatricians and the dermatologist suggests the need for a greater emphasis on dermatological disorders in medical training programs and for closer collaboration between disciplines for the benefit of younger patients.

Influence of the Obesity Phenotype on the Adequacy of Antibiotic Prophylaxis with Cefoxitin for Obese Patients Undergoing Bariatric Surgery: Lessons Learnt and Future Considerations

BACKGROUND AND OBJECTIVES

A high inter-individual variability in pharmacokinetic parameters in obese patients is observed. The objective of this study was to evaluate the effect of obesity parameters on the pharmacokinetics of cefoxitin administered for antibiotic prophylaxis during bariatric surgery.

METHODS

This a secondary analysis of a pharmacokinetic study involving 174 obese patients scheduled for bariatric surgery and receiving a 4-g dose of cefoxitin. Blood samples were collected at incision and wound closure. The total plasma concentrations were assessed utilising a validated high-performance liquid chromatography-tandem mass spectrometry method. The pharmacokinetic and pharmacodynamic target was defined as an estimated free concentration of cefoxitin at the time of wound closure >8 mg/L. Specific evaluated obesity parameters were fat body mass, fat body mass/height², lean body mass, lean body mass/height², visceral adipose tissue and presence of a metabolic syndrome.

RESULTS

A total of 174 patients (median age 47 years) with a majority of women (75.3%) and a median BMI of 44 kg/m² were analysed. The percentage of patients who met the pharmacokinetic and pharmacodynamic target was 85.1%. In the whole population, a tendency to fail to reach the target was observed with a higher lean mass over height² [OR = 0.79; 95% CI (0.62-1.01); P = 0.060]. In the female subgroup, higher lean mass over height² [OR = 0.63; 95% CI (0.41-0.97); P = 0.037] and the presence of a metabolic syndrome [OR = 0.17; 95% CI (0.03-0.83); P = 0.030] were associated with failure to reach the pharmacokinetic and pharmacodynamic target.

CONCLUSION

Obese patients with a higher lean mass and a metabolic syndrome could constitute a subgroup at risk for cefoxitin under-dosage.

Serum and peritoneal exudate concentrations after high doses of β-lactams in critically ill patients with severe intra-abdominal infections: an observational prospective study

BACKGROUND

Critically ill patients with severe intra-abdominal infections (IAIs) requiring surgery may undergo several pharmacokinetic (PK) alterations that can lead to β-lactam underdosage.

OBJECTIVES

To measure serum and peritoneal exudate concentrations of β-lactams after high doses and optimal administration schemes.

METHODS

This observational prospective study included critically ill patients with suspicion of IAI who required surgery and a β-lactam antibiotic as empirical therapy. Serum and peritoneal exudate concentrations were measured during surgery and after a 24 h steady-state period. The PK/pharmacodynamic (PD) target was to obtain serum β-lactam concentrations of 100% fT>4×MIC based on a worst-case scenario (based on the EUCAST highest epidemiological cut-off values) before bacterial documentation (a priori) and redefined following determination of the MIC for the isolated bacteria (a posteriori). Registered with ClinicalTrials.gov (NCT03310606).

RESULTS

Forty-eight patients were included with a median (IQR) age of 64 (53-74) years and a SAPS II of 40 (32-65). The main diagnosis was secondary nosocomial peritonitis. Piperacillin/tazobactam was the most administered β-lactam antibiotic (75%). The serum/peritoneal piperacillin/tazobactam ratio was 0.88 (0.64-0.97) after a 24 h steady-state period. Prior to bacterial documentation, 16 patients (33.3%) achieved the a priori PK/PD target. The identification of microorganisms was available for 34 patients (71%). Based on the MIC for isolated bacteria, 78% of the patients achieved the serum PK/PD target.

CONCLUSIONS

In severe IAIs, high doses of β-lactams ensured 100% fT>4×MIC in the serum for 78% of critically ill patients with severe IAIs within the first 24 h. In order to define optimal β-lactam dosing, the PK/PD target should take into account the tissue penetration and local ecology.

Effectiveness of the e-Tabac Info Service application for smoking cessation: a pragmatic randomised controlled trial

OBJECTIVE

To compare the effectiveness of the mobile e-Tabac Info Service (e-TIS) application (app) for helping adult smokers quit smoking with current practices.

DESIGN

Pragmatic randomised controlled trial with a 1-year follow-up (2017-2018).

SETTING

France, population-wide level.

PARTICIPANTS

2806 adult smokers who wished to quit smoking were recruited via the website of the French National Mandatory Health Insurance fund. Of them, 1400 were randomised to the e-TIS app arm and 1406 were randomised to the current practices arm (control).

INTERVENTION

The app involved personalised interactive contacts that included questionnaires, advice, activities and text messages. All contacts were individually tailored and based on each smoker's progress.In the control group, recommended practices for quitting smoking were described on a non-interactive website.

PRIMARY AND SECONDARY OUTCOMES MEASURES

The primary outcome was 7-day point prevalence abstinence (PPA) at 6 months. The secondary outcomes included continuous abstinence rates at 6 and 12 months, minimum 24-hour point abstinence at 3 months, minimum 30-day point abstinence at 12 months and number and duration of quit attempts.

RESULTS

There was no difference between the e-TIS and control arms for the primary outcome (12.6% vs 13.7% for 7-day PPA at 6 months, p=0.3949, intention-to-treat analysis). However, e-TIS participants with high levels of exposure to the app, which was defined by the completion of at least eight activities or questionnaires, showed higher rates of smoking cessation than the control participants (17.6% vs 12.9% for 7-day PPA at 6 months, p=0.0169, per-protocol analysis).

CONCLUSION

Use of the e-TIS app was not associated with a higher rate of smoking cessation. However, high level of exposure to the e-TIS app may have been more effective than current practices.

TRIAL REGISTRATION NUMBER

NCT02841683.

Bowel Damage at Diagnosis Using the Lémann Index Score in Saudi Arabian Patients With Crohn's Disease

Background

Advanced bowel damage caused by Crohn’s disease (CD) in the form of strictures and penetrating lesions has been associated with future surgical resection. However, in general, the degree of bowel damage in patients with CD is not examined at the time of diagnosis, and the natural history of CD may differ phenotypically between patients from Arabic countries as compared to patients from Europe and North America. Thus, we aimed to assess the degree of structural bowel damage in Saudi Arabian CD patients at diagnosis. We used the Lémann Index (LI) score, an instrument that measures cumulative digestive tissue damage by magnetic resonance enterography (MRE) and endoscopy, to establish any possible association between the duration of symptoms and the degree of bowel damage.

Method

This retrospective study was conducted by reviewing the data of all CD patients following up at King Abdulaziz University Hospital (KAUH) that were investigated by endoscopy and MRE at baseline. MRE-LI was calculated by scoring previous surgery, disease location and extension, and intestinal complications. A LI score of >2.0 was set as the cut-off point for bowel damage. Descriptive statistics were used to provide an overview of demographic and clinical characteristics, and hypothesis testing was applied to identify associations.

Result

Eighty-three patients with CD were included in this study. Fifty point six percent (50.6%) of the cohort comprised females and the median age was 27 years. With regards to CD location and extension, 34.9% showed ileal disease (L1), 9.6% showed colonic CD (L2), whereas 55.4% had ileocolonic involvement (L3). Moreover, 48.2% of patients presented with non-complicated behavior (B1), 25.3% had at least one stricture (B2), and 26.5% showed a penetrating phenotype (B3). Perianal CD was observed in 2.4% of subjects and 62.7% had undergone bowel resection. Mean LI was 2.4 (±2.6) with 34 patients (39.8%) exhibiting an LI score indicative of advanced bowel damage at the time of diagnosis. The duration of symptoms did not correlate with the degree of bowel damage according to the LI score.

Conclusion

A significant proportion of patients with CD presented with advanced bowel damage at the time of diagnosis, suggesting that a severe form of CD may be endemic in Saudi Arabia.

THU0097 PREDICTIVE VALUE OF IMMUNOLOGICAL AND IMAGING BIOMARKERS ON ACHIEVING GOOD CLINICAL RESPONSE AT 6 MONTHS IN RHEUMATOID ARTHRITIS PATIENTS TREATED BY INTRAVENOUS BDMARDS

Background:

RA is the most prevalent chronic inflammatory rheumatism, responsible of functional impairment.

Objectives:

To investigate the value of biological and imaging biomarkers on predicting good clinical response at 6 months, in RA patients initiating IV bDMARD.

Methods:

From 2008 to 2017, 317 RA patients fulfilling ACR 1987 and/or ACR-EULAR 2010 criteria for RA, initiated IV bDMARDs in our department of Rheumatology. Patients were excluded in cases of lack of information on disease activity assessment before and at 6 months of treatment and on immunological status and titers (ACPA, RF, ANA) at baseline. For patients receiving successive IV bDMARDs during this time period (n=30), a randomization permitted to select 1 treatment sequence for the analysis. On 173 patients eligible to the study, 4 were loss to follow-up and 14 stopped treatment due to adverse events before 6 months. Clinical, biological and imaging (US and RX) data were collected when available at baseline. US examination was performed on 12 joints (wrist, MCP2-3-5 and MTP2-3-5) with qualitative and quantitative evaluation on B mode and Power Doppler (PD) for synovitis, tenosynovitis and erosion. The modified Sharp/van der Heijde erosion score was performed by 2 independent readers blindly from clinical and US informations. Good clinical response was defined by a DAS 28 < 3.2 and/ or DAS 28 decrease > 1.2 at 6 months. Only variables with a p<0.2 in univariate analysis were included in the multivariate model.

Results:

On 155 RA patients, 11 present a disease duration < 2 year, 44 (28.3%) were on first line of IV bDMARDs and 111 patients received at least one IV bDMARD (mean 2.5 (1.3)).

Table 1.

Characteristics of the patients (n=155) at baseline

VariablesN (%)Mean (SD)Clinical characteristicsAge (years)54.8 (12.2)Female113 (72.9)Disease duration (months)166.9 (118.8)DAS 285.2 (1)TreatmentCorticosteroids / dose (mg/day)99 (85.3)10.9 (6)Monotherapy56 (36.1)IV bDMARDAbatacept27 (17.4)Infliximab11 (7.1)Rituximab84 (54.2)Tocilizumab33 (21.3)ImmunologyACPA + /titer(IU)132 (85.2)618.5 (791.0)RF + /titer (IU/ml)114 (74.5)184.7 (351.3)ANA + / level87 (56.1)1453 (3836)RadiographySharp’s erosion score (n=110)49.4 (46.2)USNb Erosion (n=95)3.0 (2.3)Nb B mode Synovitis (n=128)6.0 (4.1)Nb PD+ Synovitis (n=130)4.8 (3.8)Nb B mode Tenosynovitis (n=129)1.6 (2)Nb PD+ Tenosynovitis (n=129)1.3 (2.1)

At 6 months, 87 patients (56.1%) were in good clinical response. Predictive values of biomarkers are presented in table 2.

Table 2.

Variables predictive of a good clinical response at 6 months

BiomarkersResponseMultivariate Logistic regression AnalysisAllN = 101Response(N=60)OR (CI95%)P valueImmunology RF +7551 (68.0%)5.1 (1.8-14.4)0.002 ACPA +8756 (64.4%) ANA +5536 (65.5%)Radiography Erosive RA7448 (64.9%)Ultrasonography Erosive RA8855 (62.5%) Nb B mode synovitis10160 (59.4%)1.2 (1.1-1.4)0.002 Nb PD+ synovitis10160 (59.4%)

All qualitative variables with a p value <0.2 on bivariate analysis were incorporated in the multivariate model (RF +, ACPA +, US erosive RA, Nb B mode synovitis, Nb PD+ synovitis, RX erosive RA). Only patients with all data available are incorporated in the multivariate logistic regression analysis (n=101/155)

Conclusion:

We showed that positive RF was predictive of good clinical response to IV bDMARDs. For the first time, we demonstrated that number of US B-mode synovitis was also predictive to good clinical response.

Disclosure of Interests:

Stephane Giuliani Grant/research support from: BMS, Benjamin Laurent Grant/research support from: BMS, Hella MEZGHANI Employee of: BMS, Isabelle Duprat-Lomon Employee of: BMS, Amandine Luc Grant/research support from: BMS, Marcelo De carvalho Bittencourt Grant/research support from: BMS, Cedric BAUMANN Grant/research support from: BMS, Isabelle CHARY VALCKENAERE: None declared, Damien LOEUILLE: None declared

SAT0042 PREDICTIVE VALUE OF IMMUNOLOGICAL AND IMAGING BIOMARKERS ON ACHIEVING REMISSION AT 6 MONTHS IN RHEUMATOID ARTHRITIS PATIENTS TREATED BY INTRAVENOUS BDMARDS

Background:

RA is the most prevalent chronic inflammatory rheumatism, responsible of functional impairment.

Objectives:

To investigate the value of biological and imaging biomarkers on predicting DAS 28 remission at 6 months, in RA patients initiating IV bDMARD.

Methods:

From 2008 to 2017, 317 RA patients fulfilling ACR 1987 and/or ACR-EULAR 2010 criteria for RA, initiated IV bDMARDs in our department of Rheumatology. Patients were excluded in cases of lack of information on disease activity assessment before and at 6 months of treatment and on immunological status and titers (ACPA, RF, ANA) at baseline. For patients receiving successive IV bDMARDs during this time period (n=30), a randomization permitted to select 1 treatment sequence. On 173 patients eligible to the study, 4 were lost to follow-up and 14 stopped treatment due to adverse events before 6 months. Clinical, biological and imaging (US and RX) data, were collected when available at treatment initiation. US examination was performed on 12 targeted joints (wrist, MCP2-3-5 and MTP2-3-5) with qualitative and quantitative evaluation on B mode and Power Doppler (PD) for synovitis, tenosynovitis and erosion. The modified Sharp/van der Heijde erosion score was performed by 2 independent readers blindly from clinical and US informations. Remission was defined by a DAS 28 < 2.6 at 6 months. Only variables with a p<0.2 in univariate analysis were included in the multivariate model.

Table 1.

Characteristics of the patients (n=155) at baseline

Table 2.

Variables predictive of a DAS 28 remission at 6 months for IV bDMARDs

BiomarkersUnivariateAnalysisBivariate Logistic regression AnalysisDAS 28 remission(n= 33)No Remission(n=122)p valueOR (CI95%)Clinical dataNb of sequence >119 (57.6%)92 (75.4%)0.0520.4 (0.2-1.0)Radiography (n=110)Erosive RA22 (88.0%)61 (71.8%)0.1180.3 (0.1-1.3)US (n=127)Erosive RA28 (96.6%)82 (83.7%)0.1170.2 (0.0-1.4)Nb B mode synovitis7.7 (4.5)5.5 (3.9)0.0130.9 (0.8-1.0)Nb PD+ synovitis6.5 (5.0)4.3 (3.3)0.0310.9 (0.8-1.0)

All qualitative variables with a p value <0.2 on bivariate analysis were incorporated in the multivariate model (RF +, ACPA +, US erosive RA, Nb B mode synovitis, Nb PD+ synovitis, RX erosive RA). Only patients with all data available were incorporated in the multivariate logistic regression analysis (n=103/155). In multivariate analysis only the number of B mode synovitis was still significant with OR =1.1 (CI 95%: 1.0-1.3) (p<0,019).

Results:

On 155 RA patients, 11 had a disease duration < 2 year, 44 (28.3%) were on first line of IV bDMARDs and 111 patients received at least one IV bDMARD (mean 2.5 (1.3)).

Conclusion:

In RA patients treated by IV bDMARDs, number of PD+ synovitis on ultrasonography was the only predictive biomarker of DAS 28 remission.

Disclosure of Interests:

Benjamin Laurent Grant/research support from: BMS, Stephane Giuliani Grant/research support from: BMS, Hella MEZGHANI Employee of: BMS, Isabelle Duprat-Lomon Employee of: BMS, Amandine Luc Grant/research support from: BMS, Marcelo De carvalho Bittencourt Grant/research support from: BMS, Cedric BAUMANN Grant/research support from: BMS, Isabelle CHARY VALCKENAERE: None declared, Damien LOEUILLE: None declared

[Psychological impacts of follow up for occupational asbestos exposure. Consequences after compensation for occupational disease in the SPP-A cohort]

INTRODUCTION

In France, long-term follow-up after occupational exposure to asbestos is recommended. This study looked at the psychological consequences in the longer term following a CT-scan, in particular the impact of having received compensation for an occupational disease.

METHODS

As part of an asbestos post-exposure survey study (APExS), volunteers from Normandy were asked to complete self-assessment questionnaires about their psychological condition at different points during follow-up, including a psychological questionnaire before, then 6 months, and finally 18 to 24 months after their chest CT-scan. Information collected from 622 individuals were analyzed based on information provided as to the result of the screening and whether they had received compensation for having an occupational disease.

RESULTS

The identification of an occupational disease eligible for compensation is associated with a long term increase in psychological distress. The impact of psychological state during follow-up is greater in men who reported receiving occupational disease compensation. The discovery of an asbestos-related disease during the screening is associated with a negative perception of general health and an increase in psychological distress.

CONCLUSION

The receipt of compensation of an occupational disease does not seem to compensate for the negative psychological impact related to the discovery of a disease during the asbestos post-exposure follow-up.

Impact of the French Infectious Diseases Society's (SPILF) proposals for shorter antibiotic therapies

OBJECTIVE

To compare the practices of French infection specialists related to antibiotic therapy duration between 2016 and 2018.

METHODS

We conducted two identical surveys (in 2016 and 2018) targeting hospital-based infection specialists (medical physicians, pharmacists) who gave at least weekly advice on antibiotic prescriptions. The questionnaire included 15 clinical vignettes. Part A asked about the durations of antibiotic therapies they would usually advise to prescribers, and part B asked about the shortest duration they would be willing to advise for the same clinical situations.

RESULTS

We included 325 specialists (165 in 2016 and 160 in 2018), mostly infectious disease specialists (82.4%, 268/325), members of antibiotic stewardship teams in 72% (234/325) of cases. Shorter antibiotic treatments (as compared with the literature) were advised to prescribers in more than half of the vignettes by 71% (105/147) of respondents in 2018, versus 46% (69/150) in 2016 (P<0.001). Guidelines used by participants displayed fixed durations for 77% (123/160) of cases in 2018 versus 21% (35/165) in 2016. Almost all respondents (89%, 131/160) declared they were aware of the 2017 SPILF's proposal.

CONCLUSION

The release of guidelines promoting shorter durations of antibiotic therapy seems to have had a favourable impact on practices of specialists giving advice on antibiotic prescriptions.

Effectiveness of a type 2 diabetes prevention program combining FINDRISC scoring and telephone-based coaching in the French population of bakery/pastry employees

Background/objectives

Preventive actions targeting the risk of type 2 diabetes mellitus (T2D) and deployed from the workplace are scarce. This study aimed to measure this T2D risk in a large sample of the bakery/pastry employees in France and to assess the effectiveness of a telephone coaching program in participants with the highest risk.

Subjects/methods

A screening survey using the FINDRISC score was conducted by phone among the employees. Those with a moderate risk (score ≥ 12 and <15; body mass index ≥ 25 kg/m²) or high/very high risk (score ≥ 15) were invited to participate in a 6-month coaching program including 6 monthly interviews together with a final evaluation interview three months later. The effects and impact were evaluated using 8 questions on dietary knowledge/behavior as well as the GPAQ (physical activity) and SF-12 (quality of life) questionnaires.

Results

There were 19,951 employees eligible for screening (age: 38.0 ± 13.5 years, men 49.6%, mean FINDRISC score 5.9 ± 4.4). A high/very high score was found in 4% of individuals. Overall, 1,348 (among 2,018) eligible employees agreed to participate in the coaching program, 630 of whom participated in all interviews. Of the latter, dietary knowledge/behavior (+1.60) and quality of life (+1.83) improved (P < 0.0001), with a favorable trend for physical activity (+0.06, P = 0.0756). Dietary knowledge/behavior continued to improve in the 581 completers (+0.17, P = 0.0001).

Conclusions

This two-step prevention program associating T2D risk estimation and a 6-month telephone coaching was deployed in the French craft bakery/pastry sector with significant adhesion. Such program appears beneficial for enhancing knowledge and mobilizing skills associated with T2D prevention.

[Parental representations of children's acute appendicitis and impact on its surgical management in three departments]

INTRODUCTION

Appendicitis is well known by the general and medical population. Yet, the number of appendectomies varies by a factor of one to four depending on French departments.Purpose of research: This study aimed to compare, according to French schooling departments, the representations and attitudes of parents facing abdominal pain of their children, and their use of health care system. We selected three departments which have different proportions of use of appendectomy according to the DRESS's rapport of 2014. Meurthe-et-Moselle's rank is between 15.65 and 23.48/10 000 people, Seine-et-Marne's rank is between 23.48 and 31.30/10 000, and Jura's rank is superior to 31/10 000.

RESULTS

797 questionnaires were analyzed (45.2%). Significant differences exist in the answers of the three departments. Residents of the Jura region and, in a lesser measure, Seine-et-Marnaises answered differently than Meurthe-et-Mosellanses. The first two were the populations who experienced the most appendectomies and the Meurthe-et-Mosellanses the least. Parents who lived in departments of high rank of appendectomy thought more of acute appendicitis when confronted with their children's abdominal pain, and feared less of appendectomy. They were also more in favor of surgical treatment than parents from Meurthe-et-Moselle.

CONCLUSION

Knowledge, attitude and use of health care system seem to influence management of acute appendicitis in children's population and can explain, at least partially, the variations of the appendectomy rate in France. Targeted information for physicians may improve the understanding of patients and reassure them if needed in the purpose of reducing this factor of influence of practices.

Are infection specialists recommending short antibiotic treatment durations? An ESCMID international cross-sectional survey

Objectives

To evaluate the current practice and the willingness to shorten the duration of antibiotic therapy among infection specialists.

Methods

Infection specialists giving at least weekly advice on antibiotic prescriptions were invited to participate in an online cross-sectional survey between September and December 2016. The questionnaire included 15 clinical vignettes corresponding to common clinical cases with favourable outcomes; part A asked about the antibiotic treatment duration they would usually advise to prescribers and part B asked about the shortest duration they were willing to recommend.

Results

We included 866 participants, mostly clinical microbiologists (22.8%, 197/863) or infectious diseases specialists (58.7%, 507/863), members of an antibiotic stewardship team in 73% (624/854) of the cases, coming from 58 countries on all continents. Thirty-six percent of participants (271/749) already advised short durations of antibiotic therapy (compared with the literature) to prescribers for more than half of the vignettes and 47% (312/662) chose shorter durations in part B compared with part A for more than half of the vignettes. Twenty-two percent (192/861) of the participants declared that their regional/national guidelines expressed durations of antibiotic therapy for a specific clinical situation as a fixed duration as opposed to a range and in the multivariable analysis this was associated with respondents advising short durations for more than half of the vignettes (adjusted OR 1.5, P = 0.02).

Conclusions

The majority of infection specialists currently do not advise the shortest possible duration of antibiotic therapy to prescribers. Promoting short durations among these experts is urgently needed.

EYESI surgical simulator: validity evidence of the vitreoretinal modules

PURPOSE

To investigate the validity of six vitreoretinal modules on the Eyesi Surgical Simulator.

METHODS

Fifteen residents with no vitreoretinal experience and six trained vitreoretinal surgeons (>100 procedures per year) were included in the study. Four modules were selected in agreement with an experienced surgeon: the navigation (Nav), forceps (For), vitrector (Vit) and epiretinal membrane (ERM) peeling modules. The first level of the basic training modules (Nav1 and For1) and the first two levels of the more procedural modules (Vit1, Vit2, ERM1 and ERM2) were completed twice by both groups in the above order. The performance parameters for each task were calculated by the simulator software. The results from both iterations were recorded for analysis.

RESULTS

Experienced vitreoretinal surgeons outperformed residents with regard to the overall score on the Nav1 (p = 0.01), For1 (p < 0.01), ERM1 (p = 0.02) and ERM2 (p = 0.04) modules. No differences in overall score were found between the two groups on the Vit1 (p = 0.17) and Vit2 modules (p = 0.26).

CONCLUSION

Validity for the simulator metrics was found on four vitreoretinal modules not previously investigated, with regard to construct validity, content and the response process. These exercises could be included in a future competency-based training programme that could potentially be applied in the standard ophthalmological curriculum.

[EyeSi surgical simulator: Construct validity of capsulorhexis, phacoemulsification and irrigation and aspiration modules]

PURPOSE

To compare performance on the EyeSi surgical simulator in 3 training modules by users with different levels of experience in ophthalmology.

METHODS

We included 18 surgeons (6 residents with no cataract experience, 6 residents with little experience (1 to 10 cases) and 6 experienced cataract surgeons (over 500 cases). Three modules were selected (capsulorhexis, phacoemulsification-cracking and irrigation and aspiration). All subjects completed 12 levels of increasing difficulty twice, and the results of the second trial were analyzed according to the surgeon's experience.

RESULTS

For the capsulorhexis module, experienced surgeons achieved higher total scores than the other 2 groups in exercise 1 (P=0.0102). For the phaco-cracking module, experienced surgeons achieved higher total scores in exercise 8 (P=0.0495) and a tendency toward significance in exercises 3 (P=0.0934) and 5 (P=0.0938). Participants with greater experience had lower total task time in exercises 1 (P=0.0444), 4 (P=0.06) and 5 (P=0.0189).

CONCLUSION

Experienced surgeons outperformed residents with regard to overall score in 4 exercises of the capsulorhexis and phaco-cracking modules. Our results confirm previously demonstrated construct validity for these modules on the EyeSi simulator. These findings will help in the development of relevant training programs that could potentially be applied to the standard ophthalmological curriculum.

Nasal fibroscopy as a routine screening procedure of sinonasal adenocarcinoma of woodworkers: French longitudinal case study

BACKGROUND

The purpose of this study was to assess the relevancy of flexible nasoendoscopy as a routine screening procedure of sinonasal adenocarcinoma among people occupationally exposed to wood dust.

METHODS

This study included woodworkers, occupationally exposed to wood dust. Evaluations were scheduled at the time of inclusion (T0) and after a 2-year period (T1). A questionnaire was used for standardized data collection. The score was based on anatomic landmarks on each side that are parts of the olfactory clefts: the area of middle turbinate, the anterior part of the olfactory cleft, the top of the choanal arch, the spheno-ethmoidal recess, the posterior part of the olfactory cleft, and the middle part of the olfactory cleft.

RESULTS

A total of 965 nasoendoscopies (T0+T1) were performed. Olfactory clefts were visualized in 72% of the cases. Nasoendoscopies revealed pathological findings in 33.6% of cases: polyps, thick nasal secretion aspect, mucous edema, retractile scars and synechia, crusts, mucous erythema, and growth. One case of carcinoma was confirmed. Adverse effects (epistaxis, blood mark on the endo-sheath, sneezing, or rhinorrhea) after the medical procedure occurred in 30% of cases without severe complications.

CONCLUSION

Flexible nasoendoscopy offers meaningful efficacy and a promising safety profile, and, therefore, could become the new cornerstone of the routine screening procedure of sinonasal adenocarcinoma among woodworkers.

Plasma mSEPT9: A Novel Circulating Cell-free DNA-Based Epigenetic Biomarker to Diagnose Hepatocellular Carcinoma

Background

Patients with cirrhosis are at high risk of hepatocellular carcinoma (HCC). The SEPT9 gene is a key regulator of cell division and tumor suppressor whose hypermethylation is associated with liver carcinogenesis. The primary aim of this study was to evaluate the diagnostic accuracy of a PCR-based assay for the analysis of SEPT9 promoter methylation in circulating cell-free DNA (mSEPT9) for diagnosing HCC among cirrhotic patients.

Methods

We report two phase II biomarker studies that included cirrhotic patients with or without HCC from France (initial study) and Germany (replication study). All patients received clinical and biological evaluations, and liver imaging according to current recommendations. The primary outcome was defined as the presence of HCC according to guidelines from the American Association for the Study of Liver Diseases. The diagnosis of HCC was confirmed by abdominal contrast-enhanced computed tomography scan and systematically discussed in a multidisciplinary consultation meeting. HCC-free cirrhotic patients were recruited if the screening abdominal ultrasound showed no evidence of HCC at the time of blood sampling for the mSEPT9 test and on the next visit six months later. The adjudicating physicians were blinded to patient results associated with the mSEPT9 test.

Findings

We included 289 patients with cirrhosis (initial: 186; replication: 103), among whom 98 had HCC (initial: 51; replication: 47). The mSEPT9 test exhibited high diagnostic accuracy for HCC diagnosis, with an area under the receiver operating characteristic curve (AUROC) of 0.944 (0.900–0.970, p < 0.0001) in the initial study (replication: 0.930 [0.862–0.971, p < 0.0001]; meta-analysis: AUROC = 0.940 [0.910–0.970, p < 0.0001], no heterogeneity: I² = 0%, p = 0.67; and no publication bias). In multivariate logistic regression analysis, the number of positive mSEPT9 triplicates was the only independent variable significantly associated with HCC diagnosis (initial: OR = 6.30, for each mSEPT9 positive triplicate [2.92–13.61, p < 0.0001]; replication: OR = 6.07 [3.25–11.35, p < 0.0001]; meta-analysis: OR = 6.15 [2.93–9.38, p < 0.0001], no heterogeneity: I² = 0%, p = 0.95; no publication bias). AUROC associated with the discrimination of the logistic regression models in initial and validation studies were 0.969 (0.930–0.989) and 0.942 (0.878–0.978), respectively, with a pooled AUROC of 0.962 ([0.937–0.987, p < 0.0001], no heterogeneity: I² = 0%, p = 0.36; and no publication bias).

Interpretation

Among patients with cirrhosis, the mSEPT9 test constitutes a promising circulating epigenetic biomarker for HCC diagnosis at the individual patient level. Future prospective studies should assess the mSEPT9 test in the screening algorithm for cirrhotic patients to improve risk prediction and personalized therapeutic management of HCC.

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Patients with cirrhosis are at high risk of hepatocellular carcinoma (HCC).

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Accurate tumor biomarkers for the diagnosis and early detection of HCC need to be developed.

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The circulating, cell-free, epigenetic biomarker mSEPT9 is a promising biomarker for diagnosing HCC in patients with cirrhosis.

Patients with cirrhosis are at high risk of hepatocellular carcinoma (HCC). Several circulating epigenetic markers are under evaluation in HCC, notably those identified through “omics” approaches. However, to date, no circulating epigenetic biomarker has been shown to be useful for HCC diagnosis at the individual patient level. Through initial and replication phase II biomarker studies, we showed that the circulating, cell-free, DNA-based epigenetic biomarker mSEPT9 is a promising biomarker for diagnosing HCC in patients with cirrhosis. Future prospective studies should assess the mSEPT9 test in a screening algorithm for patients with cirrhosis to improve risk prediction and the personalized therapeutic management of HCC.

Survival Impact of Stations of Pathological Lymph Nodes in N2 Non-small Cell Lung Cancer in a French Hospital

BACKGROUND

The prognosis of lung cancer remains poor; only 20% of patients can undergo surgery. N2 non-small cell lung cancer (NSCLC) is a heterogeneous disease. We conducted a retrospective study to analyze the impact of N2 location on survival.

METHODS

This study included 342 NSCLC with N2 involvement between 1988 and 2014. Patient-related data were collected through the CRB biobank and included demographic, therapeutic, and survival data. Survival was analyzed according to Kaplan-Maier method. Cox's regression analysis and analysis of variance (ANOVA) were used to determine factors significantly associated with survival.

RESULTS

The population average age was 61.6 years; 82.2% were men, a majority were former smokers (87.1%), and 45.3% had adenocarcinoma. The main prognostic factors were male gender (p = 0.01), number of nodes (p < 0.0001), and tumor size (p < 0.0001). N2 disease had a poor survival (16 months) compared with N0 (32 months) and N1 (21.1 months) disease (p < 0.0001). The patients with involvement of station 4 (survival = 17.8 months) seemed to have a prognosis between those with station 7 (survival = 10.5 months) and N1 (survival = 22.6 months), p = 0.0005.

CONCLUSIONS

N2 location has a prognostic impact in surgically NSCLC, and station 4 involvement has a better prognostic than station 7.

Management of bloodstream infections by infection specialists: an international ESCMID cross-sectional survey

Bloodstream infections (BSIs) are common, however international guidelines are available only for methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and candidaemia. This international ESCMID cross-sectional survey, open from December 2016 to February 2017, explored the management of BSIs by infection specialists. All infection specialists (senior or trainees) giving at least weekly advice on positive blood cultures could participate. Their practices were evaluated using six clinical vignettes presenting uncomplicated BSI cases. A total of 616 professionals from 56 countries participated [333/616 (54%) infectious diseases specialists, 188/616 (31%) clinical microbiologists], of whom 76% (468/616) were members of an antimicrobial stewardship team. Large variations in practice were noted, in particular for the Escherichia coli, Enterococcus faecalis and Pseudomonas aeruginosa vignettes. Echocardiography was considered standard of care by 81% (373/459) of participants for MRSA, 78% (400/510) for methicillin-susceptible S. aureus and 60% (236/395) for Candida albicans. Antimicrobial combination therapy was recommended by 2% (8/360) of respondents for C. albicans, 11% (43/378) for E. coli, 27% (114/420) for MRSA and 39% (155/393) for E. faecalis. Intravenous-to-oral switch was considered in 68% (285/418) for MRSA, 79% (306/388) for E. faecalis, 72% (264/366) for P. aeruginosa and 75% (270/362) for C. albicans. In multivariable analysis, IDSA guideline-compliant practice was more frequent among participants belonging to an antimicrobial stewardship team (aOR = 1.7, P = 0.018 for the MRSA vignette; and aOR = 2.0, P = 0.008 for the candidaemia vignette). This survey showed large variations in practice among infection specialists. International guidelines on management of BSI are urgently needed.

[Stained amniotic fluid and meconium amniotic fluid: Should they change our obstetric management ?]

OBJECTIVES

To assess if a stained or meconial amniotic fluid during labor is correlated with a greater risk of neonatal metabolic acidosis.

METHODS

In a retrospective case-control study carried out in a level 3 maternity from 1st of January to 31st of December 2014, all patients who delivered a singleton eutrophic fetus in cephalic presentation after 37WG and with a stained or meconial amniotic fluid during labor were included. Obstetrical and neonatal outcomes were compared according to the amniotic fluid's color.

RESULTS

At all, 302 patients in the group « Abnormal amniotic fluid» (198 patients with stained amniotic fluid, 104 with meconial amniotic fluid) vs. 302 in the group « clear amniotic fluid» were included. No significant difference on the rate of neonatal severe acidosis between the two groups were found. Fetal heart rhythm abnormalities were more frequent in case of meconial amniotic fluid (11,3% vs. 31,7%, P<0,0001). The composite endpoint, defined by the association of umbilical arterial pH <7,0±base excess ≥12mmol/L±Apgar score at 5min <7, was more frequent in case of meconial amniotic fluid (4,0% vs. 12,5%, P=0,0018).

CONCLUSION

The occurrence of severe neonatal metabolic acidosis was not more frequent in case of stained or meconial amniotic fluid, but with an increase in the use of fetal scalp pH and cesaerian deliveries when the fluid was meconial.

Cancer of the esophagus and asbestos exposure

BACKGROUND

Our study aimed at analyzing incidence and mortality from esophageal cancer within a cohort of workers with previous occupational asbestos exposure (ARDCo Program).

METHODS

A 10-year follow-up study was conducted in the 14 515 male subjects included in this program between October 2003 and December 2005. Follow-up began when exposure stopped. Asbestos exposure was analyzed by industrial hygienists using data from a standardized questionnaire. The Cox model was used, with age as the time axis variable adjusted for smoking, time since first exposure (TSFE) and cumulative exposure index (CEI) of exposure to asbestos.

RESULTS

We reported a significant dose-response relationship between CEI of exposure to asbestos and esophageal cancer, in both incidence (hazard ratio [HR] 1.26, 95% confidence interval [CI] 1.00-1.58), and mortality (HR 1.40, [95%CI 1.12-1.75]).

CONCLUSIONS

This large-scale study suggests the existence of a relationship between asbestos exposure and cancer of the esophagus.

Incidence, indications and predicting factors of permanent pacemaker implantation after transcatheter aortic valve implantation: A retrospective study

BACKGROUND

As the number of transcatheter aortic valve implantation (TAVI) procedures is constantly increasing, it is important to consider common complications, such as pacemaker (PM) implantation, and their specific risk factors.

AIMS

Echocardiographic, computed tomography and electrocardiographic data were analysed to determine the predicting factors, if any, associated with PM implantation.

METHODS

This retrospective study included patients referred to Nancy University Hospital for a TAVI procedure from January 2013 to December 2015. Both Medtronic CoreValve and Edwards SAPIEN valves were implanted. Patients with preprocedurally implanted PMs and/or referred from another institution were excluded.

RESULTS

Of 208 TAVI patients, 23 had a pre-existing PM and were excluded. A new PM was required in 38 patients (20.5%). Pre-existing right bundle branch block (RBBB), the use of the Medtronic CoreValve and large prostheses were identified as predictors of PM implantation (P=0.0361, P=0.0004 and P=0.0019, respectively). Using logistic regression, predictors of PM implantation included first-degree atrioventricular block (odds ratio 3.7, 95% confidence interval 1.5-9.1; P=0.0054) and large aortic annulus diameter in echocardiography (odds ratio 1.2, 95% confidence interval 1-1.4; P=0.0447), with a threshold of 24.1mm. For the combination of preTAVI PR duration >220ms and QRS duration >120ms, the positive predictive value for PM implantation reached 80%.

CONCLUSION

Use of the Medtronic CoreValve, RBBB and first-degree atrioventricular block are major risk factors for post-TAVI PM implantation. In addition, large aortic annulus and large valvular prosthesis are independent risk factors for PM implantation. The combination of preTAVI prolonged PR interval and increased QRS duration could be used as a marker for periprocedural PM implantation.

Occupational Asbestos Exposure and Incidence of Colon and Rectal Cancers in French Men: The Asbestos-Related Diseases Cohort (ARDCo-Nut)

BACKGROUND

The relationships between asbestos exposure and colorectal cancer remain controversial.

OBJECTIVES

We examined the association between asbestos exposure and colorectal cancer incidence.

METHODS

Volunteer retired workers previously exposed to asbestos were invited to participate in the French ARDCo screening program between 2003 and 2005. Additional data on risk factors for colorectal cancer were collected from the ARDCo-Nut subsample of 3,769 participants in 2011. Cases of colon and rectal cancer were ascertained each year through 2014 based on eligibility for free medical care following a cancer diagnosis. Survival regression based on the Cox model was used to estimate the relative risk of colon and rectal cancer separately, in relation to the time since first exposure (TSFE) and cumulative exposure index (CEI) to asbestos, and with adjustment for smoking in the overall cohort and for smoking, and certain risk factors for these cancers in the ARDCo-Nut subsample.

RESULTS

Mean follow-up was 10.2 years among 14,515 men, including 181 colon cancer and 62 rectal cancer cases (41 and 17, respectively, in the ARDCo-Nut subsample). In the overall cohort, after adjusting for smoking, colon cancer was significantly associated with cumulative exposure (HR = 1.14; 95% CI: 1.04, 1.26 for a 1-unit increase in ln-CEI) and ≥ 20-40 years since first exposure (HR = 4.67; 95% CI: 1.92, 11.46 vs. 0-20 years TSFE), and inversely associated with 60 years TSFE (HR = 0.26; 95% CI: 0.10, 0.70). Although rectal cancer was also associated with TSFE 20-40 years (HR = 4.57; 95% CI: 1.14, 18.27), it was not associated with ln-CEI, but these findings must be interpreted cautiously due to the small number of cases.

CONCLUSIONS

Our findings provide support for an association between occupational exposure to asbestos and colon cancer incidence in men. Citation: Paris C, Thaon I, Hérin F, Clin B, Lacourt A, Luc A, Coureau G, Brochard P, Chamming's S, Gislard A, Galan P, Hercberg S, Wild P, Pairon JC, Andujar P. 2017. Occupational asbestos exposure and incidence of colon and rectal cancers in French men: the Asbestos-Related Diseases Cohort (ARDCo-Nut). Environ Health Perspect 125:409-415; http://dx.doi.org/10.1289/EHP153.