Single-nucleus and spatial landscape of the sub-ventricular zone in human glioblastoma

The sub-ventricular zone (SVZ) is the most well-characterized neurogenic area in the mammalian brain. We previously showed that in 65% of patients with glioblastoma (GBM), the SVZ is a reservoir of cancer stem-like cells that contribute to treatment resistance and emergence of recurrence. Here, we built a single-nucleus RNA-sequencing-based microenvironment landscape of the tumor mass (T_Mass) and the SVZ (T_SVZ) of 15 GBM patients and 2 histologically normal SVZ (N_SVZ) samples as controls. We identified a mesenchymal signature in the T_SVZ of GBM patients: tumor cells from the T_SVZ relied on the ZEB1 regulatory network, whereas tumor cells in the T_Mass relied on the TEAD1 regulatory network. Moreover, the T_SVZ microenvironment was predominantly characterized by tumor-supportive microglia, which spatially co-exist and establish heterotypic interactions with tumor cells. Lastly, differential gene expression analyses, predictions of ligand-receptor and incoming/outgoing interactions, and functional assays revealed that the IL-1β/IL-1RAcP and Wnt-5a/Frizzled-3 pathways are therapeutic targets in the T_SVZ microenvironment. Our data provide insights into the biology of the SVZ in GBM patients and identify specific targets of this microenvironment.

Novel scores relevant to antimicrobial resistance and hospital-acquired infections developed with data from a multi-hospital consortium in the Parisian region of France

PURPOSE

Indicators for comparing and understanding differences in antimicrobial resistance (AMR) and healthcare-associated infections (HAIs) for benchmarking are essential to identify priorities for hospitals.

METHODS

This study measured the incidence of hospital-acquired or resistant Gram-negative bacilli bloodstream infections (GNB-BSIs) in a large public healthcare consortium in the Parisian region of France.

RESULTS

Within each hospital, there was a strong positive correlation between the incidence of GNB-BSIs due to resistant GNB and the incidence of hospital-acquired GNB-BSIs. Two scores measuring AMR and HAI rates by combining different GNB-BSI incidence rates were developed as indicators. These scores were highly variable within the hospital consortium. On multi-variate analysis, AMR and HAI scores were significantly associated with the proportion of surgical beds, staff absenteeism and the consumption of alcohol-based hand rub, with the latter two characteristics being amenable to interventions. Carbapenem use was also linked to AMR, but this may be because carbapenems are the preferred drug for treating resistant infections.

CONCLUSION

These results shed light on the incidence of HAIs and AMR in the study hospitals, and suggest possibilities for targeted interventions at healthcare facility level.

A randomized controlled trial evaluating a theory driven, complex intervention centered on task sharing and mobile health to improve selfcare and outcomes in heart failure - The PANACEA-HF RCT: Design and rationale

Background

We developed a three-pronged complex intervention to improve selfcare and deliver whole person care for patients with heart failure, underpinned by the 'extant cycle' theory - a theory based on our formative work.

Methods

This is a 3 centre, 2-arm, 1:1, open, adaptive stratified, randomized controlled trial. We included patients aged ≥ 18 years with heart failure, taking any of the key guideline directed medical treatments, with a history of or currently on a high ceiling diuretic. We excluded end stage renal disease, clinically diagnosed severe mental illness or cognitive dysfunction and having no caregivers. Interventions included, (i) trained hospital based lay health worker mediated assessment of patients' current selfcare behaviour, documenting barriers and facilitators and implementing a plan to 'transition' the patient toward optimal selfcare. (ii) m-health mediated remote monitoring and (iii) dose optimization through a 'physician supervisor'.

Results

We recruited 301 patients between Jan 2021 and Jan 2022. Mean age was 59.8 (±11.7) years, with 195 (64.8 %) from rural or semi-urban areas and 67.1 % having intermediate to low health literacy. 190 (63.1 %) had an underlying ischemic cardiomyopathy. In the intervention arm, 142 (94.1 %) had a Selfcare in Heart Failure Index (SCHFI) score of ≤70, with significant barriers being 'lack of knowledge' 105 (34.5 %) and 'behavioural passivity' 23 (7.5 %).

Conclusion

This is the first South Asian trial evaluating a complex intervention underpinned by behaviour change theory for whole person heart failure care. These learnings can be applied to heart failure patient care in other resource constrained health systems.

Annual pulses of copper-enriched sediment in a North American river downstream of a large lake following the catastrophic failure of a mine tailings storage facility

Failures of mine tailings storage facilities (TSF) can have profound and long-lasting effects on the downstream receiving environment. Virtually all spills to date have been into river systems without large lakes that may buffer downstream impacts. In August 2014, the failure of the Mount Polley copper (Cu)-gold mine TSF in British Columbia, Canada, released ~25 × 10⁶ m³ of water and solids; globally, this is the second largest TSF spill in history. Over 18 × 10⁶ m³ was delivered to Quesnel Lake, which is ~9 km from the TSF and is the third deepest lake in North America, and a crucial habitat for Pacific salmon and trout populations. We determined the sediment-associated Cu concentrations and fluxes in Quesnel River, downstream of the lake, from August 2014 to February 2021 based on the analysis of >400 samples of sediment, mainly collected using a continuous-flow centrifuge. During each winter since the spill, Cu concentrations in the fluvial sediment in the upper reaches of the river (~35 km from the TSF) were elevated relative to regional background concentrations and samples collected before the spill. Maximum Cu concentrations were ~410 mg kg^-1 which exceeds Canadian sediment quality guidelines for the protection of aquatic organisms (197 mg kg^-1). Monitoring of Quesnel Lake since the spill shows that these annual pulses in the winter are due to resuspension of unconsolidated tailings and sediments at the bottom of Quesnel Lake, during autumnal lake turnover, which become mixed throughout the water column and subsequently flow into Quesnel River. Results show that while large lakes may buffer downstream aquatic systems from contaminated sediment, they may prolong the environmental impact. These findings are crucial in understanding how lake processes may modify the effects of TSF spills on downstream aquatic systems.

New approach for hair keratin characterization: use of the confocal Raman spectroscopy to assess the effect of a thermal stress on human hair fiber

OBJECTIVE

The objective of our research was to investigate the heat-protecting effect of a product ex vivo and in vivo on human hair fibers.

METHODS

A preparatory study was carried out in order to determine an optimal threshold of thermal stress. For this, the structure of cross-sections of the hair fiber was observed by optical microscopy. Then, Scanning Electron Microscopy (SEM) and Confocal Raman Spectroscopy (CRS) were applied to analyze ex vivo and in vivo morphological and molecular damage in hair structure after heat stress. Finally, in vivo tests were used to collect consumer perception.

RESULTS

The preparatory study enabled us to determine an optimal stress threshold of 10 heating cycle for SEM and 5 heating cycle for CRS. Based on spectral hierarchical classification using Ward's clustering algorithm, the ex vivo Raman results show that the spectral signature of the hair treated and heated is very close to the negative control. This shows that the product preserves the keratin structure after thermal stress. These results were also confirmed by an in vivo Raman analysis performed on hair samples from 5 donors. In concordance with Raman results, SEM show that treated hair present lesser "bubbles" and "crackling" on the hair surface. Finally, the in vivo studies proved that hair was more protected from the heat.

CONCLUSION

The authors concluded that the product shows protective properties with respect to morphological and molecular heat damage. We also demonstrate that the product promotes the α-helix keratin conformation and preserves the S-S disulfide bands.

POS0062 A RISK SCORE TO DETECT SUBCLINICAL RHEUMATOID ARTHRITIS-ASSOCIATED INTERSTITIAL LUNG DISEASE

Background

Despite a high morbi-mortality rate, there are no definite strategy for subclinical interstitial lung disease (ILD) screening in patients with rheumatoid arthritis (RA).

Objectives

Our objectives were: 1. to identify risk factors for subclinical RA-ILD in a prospective discovery cohort (ESPOIR) 2.to develop a risk score for subclinical RA-ILD and 3. to validate the risk score in an independent replication cohort (TRANSLATE 2).

Methods

Patients without pulmonary symptoms from 2 prospective RA cohorts who underwent chest HRCT scans were included. All patients were genotyped for MUC5B rs35705950. A risk score based on independent risk factors for subclinical RA-ILD was developed using multiple logistic regression in the discovery cohort. The risk score was tested for validation in the replication cohort.

Results

Discovery and replication cohorts included 163 and 89 patients, respectively. Subclinical ILD was detected in 19.0% and 16.9% of the patients, respectively. In the discovery cohort, independent risk factors for subclinical RA-ILD were the MUC5B rs35705950 T risk allele (odds ratio [OR]=3.74; 95% confidence interval [CI] [1.37–10.39], male sex (OR=3.93; 95%CI [1.40–11.39]), older age at RA onset (for each year, OR=1.10; 95%CI [1.04–1.16]) and increased mean DAS28-ESR (for each unit, OR=2.03; 95%CI [1.24–3.42]). We developed a risk score for subclinical RA-ILD with AUC=0.82; 95%CI [0.70–0.94] (sensitivity (Se)=71.0%) and specificity (Sp)=79.6%). The risk score was validated in the replication cohort with AUC=0.78; 95%CI [0.65–0.92] (Se=86.7%, Sp=62.2%).

Conclusion

Our risk score could help identifying patients at high-risk for subclinical RA-ILD before the onset of pulmonary symptoms.

Disclosure of Interests

Pierre-Antoine Juge Speakers bureau: AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Consultant of: Bristol Myers Squibb, Benjamin Granger: None declared, Marie-Pierre Debray: None declared, Esther Ebstein: None declared, Fabienne Louis-Sidney: None declared, Joanna KEDRA: None declared, Tracy Doyle: None declared, Raphael Borie: None declared, Arnaud Constantin Consultant of: Abbvie, Amgen, Biogen, BMS, Boehringer Ingelheim, Fresenius Kabi, Galapagos, Janssen, Lilly, Medac, MSD, Mylan, Novartis, Pfizer, Procter & Gamble, Roche, Sanofi, UCB, Viatris, Bernard Combe Consultant of: AbbVie, BMS, Eli-Lilly, Gilead, Janssen, Merck, Novartis, Pfizer, Roche-Chugai, Sanofi, UCB, René-Marc Flipo Consultant of: Abbvie, Janssen, MSD and Pfizer. He reports research grants from Abbvie, Janssen, Novartis and Pfizer, Xavier Mariette Consultant of: BMS, Gilead, Janssen, Pfizer, Samsung, UCB, Olivier VITTECOQ: None declared, Alain Saraux: None declared, Guillermo CARVAJAL ALEGRIA: None declared, Jean Sibilia Consultant of: AbbVie, Lilly, MSD, Amgen, Pfizer, BMS, Janssen, Roche, Sandoz, Sanofi-Genzyme, SOBI, UCB, Novartis, Grant/research support from: AbbVie, Lilly, MSD, Amgen, Pfizer, BMS, Janssen, Roche, Sandoz, Sanofi-Genzyme, SOBI, UCB, Novartis, Francis Berenbaum: None declared, Caroline Kannengiesser: None declared, Catherine Boileau: None declared, Jeffrey Sparks Consultant of: AbbVie, Boehringer Ingelheim, Bristol Myers Squibb, Gilead, Inova Diagnostics, Janssen, Optum, and Pfizer, Grant/research support from: National Institute of Arthritis and Musculoskeletal and Skin Diseases (grant numbers R01 AR077607, P30 AR070253, and P30 AR072577), The R. Bruce and Joan M. Mickey Research Scholar Fund, Bristol Myers Squibb,

Bruno Crestani Speakers bureau: Boehringer Ingelheim, AstraZeneca, Roche, Sanofi, Grant/research support from: MedImmune, Roche, Boehringer Ingelheim, Bruno Fautrel Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Fresenius Kabi, Janssen, Lilly, Medac, MSD, NORDIC Pharma, Novartis, Pfizer, Roche, SOBI, UCB, Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Philippe Dieudé Speakers bureau: Roche – Chugai, Bristol Myers Squibb, Consultant of: Pfizer, Roche – Chugai, Bristol Myers Squibb, Abbvie, MSD, Grant/research support from: Novartis

POS0095 DEVELOPPING A SCORE TO PREDICT PRECLINICAL INTERSTITIAL LUNG DISEASE IN PATIENTS WITH RHEUMATOID ARTHRITIS – A CROSS-SECTIONAL STUDY FROM THE ESPOIR COHORT

Background:

Interstitial lung disease (ILD) is an extra-articular manifestation of rheumatoid arthritis (RA) detected in 20% to 60% of patients with RA on high-resolution computed-tomography (HRCT) chest scan and is clinically significant in near 10%. Despite a high morbi-mortality rate, a definite strategy for preclinical ILD screening in patients with RA remains to be determined. To date, several factors have been reported to increase the risk of RA-ILD occurrence (i.e. older age at RA onset, ACPA positivity, male sex, RA disease activity, the MUC5B rs35705950 promoter variant...). However, none of these risk factors has been validated in a prospective cohort of patients with RA. The ESPOIR prospective cohort includes patients aged 18 to 70 years with recent arthritis (less than 6 months) and a definite or probable diagnosis of RA.

Objectives:

To identify in the ESPOIR cohort factors associated with ILD after at least 10 years of RA duration in order to develop a predictive score to identify patients with preclinical RA-ILD.

Methods:

An ILD detection by chest HRCT scan was systematically offered to every patient with definite RA after at least 10 years-follow-up. Chest HRCT scans were centrally reviewed by an experienced radiologist. Potential predictors of ILD were prospectively collected from baseline to the date of the HRCT scan, and all included patients were genotyped for MUC5B rs35705950. To take into account repeated measures, trajectories were determined for disease activity, C reactive protein, smoking, treatment exposure (i.e. prednisone, methotrexate [MTX] and biological disease modifying anti-rheumatic drugs [bDMARDs]). A logistic model was used to identify independent predictors for the occurrence of ILD on HRCT scans. Confidence intervals were estimated using sampling methods. A predictive score for preclinical ILD occurrence was developed based on the identified predictors.

Results:

163 RA patients according to 2010 ACR/EULAR classification criteria, none of whom had pulmonary symptoms, were investigated with a chest HRCT scan (128 women (78.5%), mean RA duration 13.7 ± 1.1 years, age at inclusion 47.6 y/o ± 10.4, mean disease activity score [DAS]-28 during follow up was 3.1 ± 1.0). ILD was detected in 31 patients (19.0%). The MUC5B rs35705950 minor allele frequency (MAF) was 22.2% and 10.0% in the RA-ILD and RA-noILD populations, respectively (OR univariate=2.6 CI95% [1.2-5.5], P=0.01). After logistic regression, independent predictors for preclinical RA-ILD were male sex (OR=3.9 CI95% [1.4-11.4]), older age at RA onset (OR=1.1 per year CI95% [1.0-1.2]), mean DAS-28 score during the follow-up (OR=2.0 CI95% [1.2-3.4]) and MUC5B rs35705950 T risk allele (OR=3.7 CI95% [1.4-10.4]) (Figure 1). No influence of the use of RA-related drugs (prednisone, MTX or bDMARDs) was identified as risk factor. The logistic model could predict preclinical ILD occurrence after 13 years of RA duration with an AUC=0.82 CI95% (0.72-0.91). A predictive score for preclinical RA-ILD based on the 4 identified predictive risk factors was developed (Sensitivity 80%, Specificity 56%).

Figure 1.

Factors independently associated with preclinical ILD after 13 years of RA duration

Conclusion:

In this cross-sectional study of the prospective ESPOIR cohort, we identified clinical and genetic predictors for ILD after 13 years of RA duration. We developed a predictive score that could improve risk stratification for preclinical RA-ILD and help physicians identify patients with RA in whom a HRCT scan should be performed.

Disclosure of Interests:

Pierre-Antoine Juge Consultant of: BMS, Benjamin Granger: None declared, Marie-Pierre Debray: None declared, Esther Ebstein: None declared, Fabienne Louis Sidney: None declared, Joanna KEDRA: None declared, Raphael Borie: None declared, Arnaud Constantin Consultant of: Bristol-Meyers Squibb, Chugai, Roche, Abbvie, MSD, Pfizer, and UCB, Bernard Combe Consultant of: Abbvie, Bristol-Meyers Squibb, Lilly, MSD, Janssen, Pfizer, Roche, Chigai, and Sanofi, Grant/research support from: Abbvie, Bristol-Meyers Squibb, Lilly, MSD, Janssen, Pfizer, Roche, Chugai, and Sanofi, René-Marc Flipo Consultant of: Bristol-Meyers Squibb, Roche, Chugai, Abbvie, and Pfizer, Grant/research support from: Roche, Chugai, Abbvie, and Pfizer, Xavier Mariette Consultant of: Bristol-Meyers Squibb, GSK, Janssen, Pfizer, and UCB, Olivier VITTECOQ Consultant of: Bristol Myers Squibb, Roche, Chugai, MSD, Novartis, Pfizer, Abbvie, and Lilly, Alain Saraux Consultant of: Roche, Chugai, and Bristol-Meyers Squibb, Grant/research support from: Roche, Chugai, and Bristol-Meyers Squibb, Guillermo CARVAJAL ALEGRIA: None declared, Jean Sibilia Consultant of: Roche, Chugai, Bristol-Meyers Squibb, UCB, GSK, LFB, Actelion, Pfizer, MSD, Novartis, Amgen, Hospira, AbbVie, Sandoz, Gilead, Lilly, Sanofi, Janssen, and Mylan, Francis Berenbaum Consultant of: Boehringer, Bone Therapeutics, Expanscience, Galapagos, Gilead, GSK, Elli Lilly, Merck Sereno, MSD, Nordic, Novartis, Pfizer, Regulaxis, Roche, Sandoz, Sanofi, Servier, UCB, Peptinov, TRB Chemedica, 4P Pharma, Caroline Kannengiesser: None declared, Catherine Boileau: None declared, Bruno Crestani Consultant of: Boehringer Ingelheim, Roche, Sanofi, Apellis, Astra-Zeneca, Grant/research support from: MedImmune, Boehringer Ingelheim, Bruno Fautrel Consultant of: AbbVie, Biogen, BMS, Celgene, Janssen, Lilly, Medac, MSD, NORDIC Pharma, Novartis, Pfizer, Roche, Sanofi-Aventis, SOBI, UCB, Grant/research support from: AbbVie, MSD, Pfizer, Philippe Dieudé: None declared

Predictors of 18-month outcome for patients with borderline personality disorder

Introduction

For quite a long time, borderline personality disorder (BPD) has been viewed as a chronic disorder and borderline patients as extremely difficult to treat. However, those views are changing and there is an increasing recognition that the BPD has a far more benign course than previously thought, but predictors of its outcome remain poorly explored.

Objective and aims

The purpose of this study was to determine the most clinically relevant predictors of the outcome of BPD at the 18-month follow-up.

Methods

Borderline patients (n = 75) were compared to patients with other personality disorders (OPD) (n = 40). All subjects were assessed at baseline and 6, 12, and 18 months with a series of semi structured interviews (personality disorders, global functioning, mental disorders, life events, …) and self-report measures (alexithymia and impulsivity). Logistic regression was used to estimate hazard ratios.

Results

At the 18-month follow up, 57 BPD patients and 22 with OPD have been evaluated, 45% of borderline subjects and 50% of the OPD subjects achieved remission. Low impulsivity, low alexithymia, good global functioning, and older age at onset of symptoms were found to be significant predictors of good outcome of BPD. Our clinical data suggest that life events and the quality of current relationships are determinant in the outcome of BPD.

Conclusions

45% of patients with BPD are likely to improve in 18-months. Specific factors, such as impulsivity, alexithymia, life events and quality of current relationships, determine the short-term outcome of this disorder.

Athletic pubalgia: Return to play after targeted surgery

BACKGROUND

Surgery for athletic pubalgia usually consists in abdominal wall repair combined with routine bilateral adductor tenotomy. We currently confine the surgical procedure to the injured structure(s) (abdominal wall only, adductor tendon only, or both) to limit morbidity and expedite recovery. Outcomes of this à la carte approach are unclear. The objectives of this retrospective study were to determine the return to play (RTP) time, evaluate the potential influence of injury location, and assess the frequency of recurrence or contralateral involvement.

HYPOTHESIS

À la carte surgery for athletic pubalgia is associated with similar RTP times as the conventional procedure and is not followed by recurrence.

MATERIAL AND METHODS

Consecutive adults younger than 40 years of age who underwent surgery for athletic pubalgia with injury to the abdominal wall and/or adductor attachment sites between 2009 and 2015 were included. Patients with intra-articular hip disorders, isolated pubic symphysis involvement, or herniation were not eligible. The diagnosis was established clinically then confirmed by at least one imaging technique (ultrasonography plus either a radiograph of the pelvis or magnetic resonance imaging of the pelvis). The criterion for performing surgery was failure of appropriate conservative therapy followed for at least 3 months.

RESULTS

Of the 27 included patients, eight had abdominal wall involvement only, seven adductor tendon involvement only, and 12 both. Overall, 25 (92.6%) patients returned to play at their previous level, after a mean of 112±38 days (range, 53-223 days), and experienced no recurrence during the 1-year follow-up. Mean RTP time was significantly shorter in the group with abdominal wall injury only (91.1±21.0 days) compared to the groups with adductor tendon injury only (101.7±42.0 days) or combined injuries (132.5±39.0) (p=0.02).

DISCUSSION

In patients with athletic pubalgia, à la carte surgery confined to the injured structure(s) produces excellent RTP outcomes. RTP time is shortest in patients with isolated lower abdominal wall injuries.

LEVEL OF EVIDENCE

IV, retrospective study with no control group.

Early strength recovery after anterior cruciate ligament reconstruction using the fascia lata

INTRODUCTION

After undergoing anterior cruciate ligament (ACL) reconstruction, patients must recover at least 80% of their hamstring and quadriceps strength to be able to return to sports without risk to the graft. Harvesting of the patellar tendon leads to large deficits in quadriceps strength, while harvesting the hamstring tendons leads to large deficits in hamstring strength. However, there are no published studies on the strength deficit after ACL reconstruction with the fascia lata. The objective of this study was to evaluate the results of isokinetic testing in patients who underwent ACL reconstruction with a fascia lata graft and to analyze the individual factors affecting these results. The hypothesis was that preserving the quadriceps and hamstrings would lead to satisfactory isokinetic testing results by preserving the physiological balance between the flexor and extensor mechanisms in the leg.

MATERIALS AND METHODS

In this retrospective, single-center study, 53 patients had their quadriceps and hamstring strength recovery evaluated 6 months and 1 year post-ACL reconstruction by concentric isometric testing at a slow (90°/s) and fast velocity (240°/s). These results were analyzed as a function of individual characteristics such as age, sex, preinjury level and type of sports activity, and IKDC and Lysholm scores.

RESULTS

The quadriceps strength deficit at the slow and fast velocities was 27.5% and 22.5% at 6 months and 15.5% and 11% at 1 year, respectively. The hamstring strength deficit at the slow and fast velocities was 12.1% and 7% at 6 months and 8% and 6.4% at 1 year, respectively. The quadriceps to hamstring ratio at the slow and fast velocities was 66.7±16.5 and 71.3±15.5 at 6 months, and 61.1±14.9 and 67.6±12.5 at 1 year. Being less than 25 years of age, having a subjective IKDC grade or Lysholm score above 90, and being a professional athlete were significant predictors of better muscle strength recovery.

DISCUSSION

Isokinetic testing at 6 months and 1 year after ACL reconstruction surgery using the fascia lata showed that the quadriceps to hamstring ratio is close to physiological standards.

LEVEL OF EVIDENCE

IV retrospective study.

Return to sports and functional results after revision anterior cruciate ligament reconstruction by fascia lata autograft

INTRODUCTION

The surgical revision rate following anterior cruciate ligament (ACL) surgery is 3% at 2 years and 4% at 5 years. Revision ACL surgery raises the question of the type of graft to be used. The present study assessed return to sports and functional results after revision ACL reconstruction by fascia lata graft. The hypothesis was that fascia lata provides a reliable graft in revision ACL surgery.

MATERIAL AND METHODS

A single-center retrospective continuous study included 30 sports players with a mean age of 26.8±8 years undergoing surgical revision for iterative ACL tear between 2004 and 2013. Multi-ligament lesions were excluded. Type and level of sports activity were assessed preoperatively, after primary surgery and at end of follow-up. Clinical assessment used subjective IKDC, Lysholm and KOOS scores.

RESULTS

At a mean 4.6±1.6 years' follow-up, all patients had resumed sport activity, but only 12 with the same sport at the same level. Median subjective IKDC score increased from 57 [54.3; 58.5] preoperatively to 82 [68.3; 90] at last follow-up, and Lysholm score from 46 [42.3; 51] to 90.5 [80.8; 96.8]; KOOS score at last follow-up was 94.7 [83; 100].

CONCLUSION

Functional results in revision ACL reconstruction by fascia lata graft were satisfactory, with similar return-to-sports rates as with other techniques. Fascia lata provides a reliable graft in revision ACL surgery.

LEVEL OF EVIDENCE

IV, retrospective study.

Head and neck adenoid cystic carcinoma: A prospective multicenter REFCOR study of 95 cases

OBJECTIVES

To describe the clinical, histological and therapeutic characteristics of a prospective multicenter series of 95 head and neck adenoid cystic carcinoma patients, and to determine any prognostic factors for disease-free survival.

PATIENTS AND METHODS

Ninety-five patients with adenoid cystic carcinoma were included in the Réseau d'Expertise Français Des Cancers ORL Rares (REFCOR, French Rare Head and Neck Cancer Expert Network) database between 2009 and 2012. The primary site was the salivary glands in 39 cases, sinus cavities (including hard palate) in 36 cases, pharynx-larynx-trachea in 14 cases, and lips and oral cavity in 4 cases. The tumor was stage I in 15% of cases, stage II in 23%, stage III in 26% and stage IV in 36%. Nine patients had cervical lymph node involvement and 5 had metastases at diagnosis. Fifty-six percent of patients were managed by surgery with postoperative radiation therapy. During follow-up, 3 patients died, 9 developed metastases and 12 showed recurrence or local progression.

RESULTS

Mean follow-up was 18 months. On univariate analysis, disease-free survival correlated with T stage (P=0.05), N stage (P=0.003), resection margins (P=0.04), lymph node involvement on histology (P=0.01), and absence of chemotherapy (P=0.03). On multivariate analysis, disease-free survival correlated with T stage (P=0.01), N stage (P=0.09) and surgery (P=0.005).

CONCLUSION

The essential issue in adenoid cystic carcinoma is long-term control. The present results confirm that the reference attitude is radical surgical resection for optimal local control. Adjuvant radiation therapy did not emerge as a prognostic factor. This study also provides a starting-point for translational studies in pathology and genetics.

Liver preservation with SCOT 15 solution decreases posttransplantation cholestasis compared with University of Wisconsin solution: a retrospective study

BACKGROUND

SCOT 15 is a new solution to preserve abdominal organs for transplantation. Its principal characteristic is the use of polyethylene glycol. Herein We report our experience using SCOT 15 compared with the reference University of Wisconsin (UW) solution for hepatic transplantation.

METHODS

We compared 2 groups: SCOT 15 (n = 33; 2009-2010) versus UW (n = 34; 2008-2010), which were paired for cold and warm ischemic times, donor ages, and graft weights. Endpoints were biologic tests in the first 2 months after the operation. A linear mixed model was used to evaluate longitudinal changes and influences of each solution.

RESULTS

No primary failure was observed. At postoperative day 0, transaminase values were higher in the SCOT 15 than in the UW group: aspartate transaminase: 2,435 ± 399 vs 589 ± 83 IU/L (P < .01); alanine transaminase: ALT: 1,207 ± 191 vs 484 ± 64 IU/L (P < .05), then returned to low levels in both groups. From day 0 to 8, coagulation factors reached normal values; there was no difference between the 2 groups. Total bilirubin decreased similarly in the 2 groups. However, from the second postoperative week (W1) to W8, the SCOT 15 group showed a slow decrease in the mean values of gamma-glutamyltranspeptidase (gGT) from 233 ± 125 to 130 ± 161 IU/L, which were significantly lower than those in the UW group, where the gGT remained around 300 IU/L (P < .01). The End-Stage Liver Disease, Child-Pugh, or United Network for Organ Sharing scores, primary liver diseases, hepatitic C virus status, arterial or biliary complications, and male/female ratio, which was different in the 2 groups, did not statistically influence these results.

CONCLUSIONS

The main effect of cold storage of human liver using SCOT 15 compared with UW solution was to decrease cholestasis following transplantation.

Dynamics of psychotherapy-related cerebral haemodynamic changes in obsessive compulsive disorder using a personalized exposure task in functional magnetic resonance imaging

BACKGROUND

Cognitive behavioural therapy (CBT) is a successful treatment of obsessive compulsive disorder (OCD). It is known to induce changes in cerebral metabolism; however, the dynamics of these changes and their relation to clinical change remain largely unknown, precluding the identification of individualized response biomarkers.

METHOD

In order to study the dynamics of treatment response, we performed systematic clinical and functional magnetic resonance imaging (fMRI) evaluation of 35 OCD patients immediately before a 3-month course of CBT, halfway through and at its end, as well as 6 months after. To sensitize fMRI probing, we used an original exposure task using neutral, generic and personalized obsession-inducing images.

RESULTS

As expected, CBT produced a significant improvement in OCD. This improvement was continuous over the course of the therapy; therefore, outcome could be predicted by response at mid-therapy (r 2 = 0.67, p < 0.001). Haemodynamic response to the task was located in the anterior cingulate and orbitofrontal cortices and was stronger during exposure to personalized obsession-inducing images. In addition, both the anxiety ratings and the haemodynamic response to the obsession-inducing images in the anterior cingulate and the left but not the right orbitofrontal clusters decreased with symptom improvement. Interestingly, haemodynamic activity continued to decrease after stabilization of clinical symptoms.

CONCLUSIONS

Using an innovative and highly sensitive exposure paradigm in fMRI, we showed that clinical and haemodynamic phenotypes have similar time courses during CBT. Our results, which suggest that the initial CBT sessions are crucial, prompt us to investigate the anatomo-functional modifications underlying the very first weeks of the therapy.

Dynamique des modifications d’activités cérébrales au cours d’une thérapie cognitive et comportementale dans le trouble obsessionnel compulsif : étude en IRMf avec une tâche personnalisée de provocation de symptômes

Contexte

La thérapie cognitive et comportementale (TCC) est un traitement efficace pour soigner le trouble obsessionnel compulsif (TOC). Elle est connue pour induire des changements dans le métabolisme cérébral, mais la dynamique de ces changements et leur relation avec l’évolution clinique restent encore largement inconnues. Leur caractérisation représente une étape cruciale vers l’identification de biomarqueurs individualisés de réponse au traitement.

Methods

Nous avons procédé à l’évaluation clinique et à l’examen en IRMf de 35 patients atteints de TOC avant une TCC, à mi-thérapie (1,5 mois), à la fin (3 mois), ainsi que 6 mois après la fin de la thérapie. Pendant les examens en IRMf, nous avons utilisé une tâche originale d’exposition aux symptômes en utilisant trois types d’images : des images neutres, des images génériques induisant des obsessions et des images personnalisées induisant des obsessions.

Résultats

La TCC a entraîné une amélioration significative des symptômes obsessionnels compulsifs. La réponse à mi-thérapie s’est avérée être prédictive de l’amélioration finale (r2 = 0,67, p < 0,001). Initialement, les patients étaient plus sensibles aux images personnalisées qu’aux images génériques et neutres, ce en proportion avec de plus fortes activations dans le cortex cingulaire antérieur, le cortex orbitofrontal et pariétal. Dans le groupe de patients hauts-répondeurs (ΔYBOCS > 45 %), la sensibilité a été réduite à l’issue de la thérapie pour les images génériques et encore plus pour les images personnalisées. L’amélioration clinique a été associée avec une baisse de l’activité dans le cortex cingulaire antérieur et dans le cortex orbitofrontal gauche.

Conclusion

L’utilisation d’une tâche d’exposition novatrice et hautement sensible en IRMf montre que les symptômes et les marqueurs métaboliques ont des évolutions parallèles au cours de la TCC. Nos résultats, qui suggèrent que les premières séances de TCC sont cruciales, nous incitent à étudier les modifications anatomofonctionnelles qui sous-tendent les premières étapes de la thérapie.

The French Pompe registry. Baseline characteristics of a cohort of 126 patients with adult Pompe disease

Pompe disease is a rare autosomal recessive muscle lysosomal glycogenosis, characterised by limb-girdle muscle weakness and frequent respiratory involvement. The French Pompe registry was created in 2004 with the initial aim of studying the natural history of French patients with adult Pompe disease. Since the marketing in 2006 of enzyme replacement therapy (alglucosidase alfa, Myozyme(®)), the French Pompe registry has also been used to prospectively gather the biological and clinical follow-up data of all adult patients currently treated in France. This report describes the main clinical and molecular features, at the time of inclusion in the French registry, of 126 patients followed up in 21 hospital-based neuromuscular or metabolic centres. Sixty-five men and 61 women have been included in the registry. Median age at inclusion was 49 years, and the median age at onset of progressive limb weakness was 35 years. Fifty-five percent of the patients were walking without assistance, 24% were using a stick or a walking frame, and 21% were using a wheelchair. Forty-six percent of the patients needed ventilatory assistance, which was non-invasive in 35% of the cases. When performed, muscle biopsies showed specific features of Pompe disease in less than two-thirds of the cases, confirming the importance of acid alpha-glucosidase enzymatic assessment to establish the diagnosis. Molecular analysis detected the common c.-32-13T>G mutation, in at least one allele, in 90% of patients. The French Pompe registry is so far the largest country-based prospective study of patients with Pompe disease, and further analysis will be performed to study the impact of enzyme replacement therapy on the progression of the disease.

Repeatability and variability of baropodometric and spatio-temporal gait parameters--results in healthy subjects and in stroke patients

AIMS OF THE STUDY

Our purpose was to determine the repeatability and variability of baropodometric and spatio-temporal gait parameters in both hemiparetic patients and healthy subjects.

HYPOTHESIS

parameters with a good repeatability and a low variability could be used to follow gait evolution.

POPULATION AND METHOD

Twelve stroke patients and 10 healthy subjects were included. Each participant performed trials (F-Scan® system and Bessou Locometer) at 48 h intervals under identical conditions. The following parameters were analyzed: displacement of the center of pressure (COP), peaks of pressure under forefoot and hindfoot, step length, single and double support time, and walking velocity. Comparisons were made within and between sessions, inter-trials and between sides.

RESULTS

Neither visit effects in either population nor side effects in healthy subjects were observed. Repeatability assessed by the intraclass correlation coefficient ("ICC agreement" ICC) was excellent to adequate overtime for anterior-posterior (AP) displacement of the COP, step length, simple support time and walking velocity in both hemiparetic patients (ICC 0.92; 0.84; 0.91; 0.94) and healthy subjects (ICC 0.85; 0.44; 0.64; 0.56). The coefficient of variation (CV) was low in paretic side for AP and single support time, and at a less degree for the lateral deviation of the COP (ML) and the posterior margin (PM).

CONCLUSION

In this study, baropodometric (AP and PM) and spatio-temporal gait (step length, single support time and walking velocity) parameters were found to show good repeatability overtime; these parameters are the ones most likely to be useful in assessing the effects of treatments that are proposed to improve gait in stroke patients.

Genetics for understanding and predicting clinical progression in multiple sclerosis

INTRODUCTION

Multiple sclerosis (MS) is a dys-immune disease of the central nervous system with highly variable and unpredictable long-term outcome.

STATE OF THE ART

In the early 1970s association between HLA alleles and MS was established. Very recently, the power of Genome Wide Association Studies (GWAS) enabled the identification of several loci involved in immune functions as genetic risk factors in MS. Recent data suggest that common genetic variations might modulate the clinical phenotype of MS through a regulation of key pathophysiological pathways.

PERSPECTIVES

Identification of modifier genes might offer an opportunity to explore new relevant therapeutic targets and early prognostic markers. To date, studies of modifier genes in MS are numerous but results are still unclear. This research field may now benefit from large cohorts of patients available for association studies.

CONCLUSION

In this context, we propose a review of epidemiological and association studies of genetic modifying effect in MS.

Bevacizumab and irinotecan for recurrent oligodendroglial tumors

2054

Background: Treatment with a regimen of bevacizumab/irinotecan has been shown to be effective in recurrent grade 3 and 4 gliomas, but the effect of this regimen against recurrent oligodendroglial tumors has not been specifically studied. Methods: The bevacizumab/irinotecan regimen was retrospectively evaluated in a consecutive series of 25 patients with recurrent oligodendroglial tumors. All patients had failed previous treatment with radiation therapy and at least one line of temozolomide chemotherapy. Bevacizumab (10 mg/kg) and irinotecan (125 or 340 mg/m2 according to the antiepileptic regimen) were delivered every 14 days. Response was measured clinically and on monthly MRI. Results: The objective response rate was 72% (20% complete response, 52% partial response). After a median follow-up (from the first cycle) of 310 days (95% CI, 47–499), the median progression-free survival was 174 days (95% CI, 116–342), and the median overall survival was 328 days (95%CI, 217-not reached). The 6-month progression-free survival was 42 % (95 % CI, 26% to 67%). Among the 20 patients who progressed at the time of the analysis, the radiological pattern of progression was atypical in seven patients with an isolated multifocal or diffuse spread of the FLAIR signal, or an isolated meningeal spread or FLAIR abnormalities preceding contrast-enhancement recurrence. Among the 10 patients who are still alive, two are still on follow-up since 6 months with a complete response after, respectively, 10 and 12 months of treatment. Among the 17 patients in whom the status of the main molecular alterations of gliomas could be evaluated (search for deletions of chromosomes 1p, 19q, 9p, 10q, and amplification of EGFR, MDM2, CDK4), no relation could be found between the response rate and the type of genetic change (including 1p-19q co-deletion). The profile of tolerance was fair, with treatment discontinuation in 20% of patients. Intratumoral hemorrhages occurred in six patients (24%), but the treatment had to be discontinued because of symptomatic bleeding in only one patient (4%). Conclusions: This regimen is effective in recurrent oligodendrogliomas, and the overall tolerance is acceptable.

[Table: see text]

[Monocentric evaluation of the skin and cardiac toxicities of the concomitant administration of trastuzumab and radiotherapy]

PURPOSE

Prospective monocentric study of the skin and heart tolerance of a concurrent administration of trastuzumab (T) and radiotherapy (RT) for breast cancer (BC).

PATIENTS AND METHODS

From February 2004 to January 2007, 57 patients (pts), were treated by a concomitant administration of T and normo-fractionated RT of either whole breast (+/-boost) or chest. The perfusion of T started either with or after chemotherapy (CT). Left ventricular ejection fractions (LEVF), assessed at baseline, before start of RT, after completion of RT and then every four to six months with either echocardiography or multiple gated acquisition scanning, were considered normal if greater or equal to 50% or stated so by the cardiologist. Inclusion criteria included a normal LVEF at baseline. Skin toxicity was evaluated using CTCAEV3. Median age was 49 years (25-80). CT with anthracycline was administered in 84% (total dose 300 mg/m(2)). All but one patient (treated weekly) received T every three weeks (8 mg/kg followed by 6 mg/kg) for a median duration of 12 months (6-33). The internal mammary chain was irradiated in 88% of cases. Median follow-up for LVEF assessment was 13 months (2-33).

RESULTS

LVEF at pre-RT were normal in 54 pts (100%, three Missing Data [MD]), at post-RT in 56 pts (98%, no MD) and at last follow-up in 53 pts (95%, one MD). There were two grade 0, 44 grade I and 11 grade II skin reactions. For the 27 patients with a skin toxicity assessment after six months, late skin toxicity was grade 0 in 22 pts, grade 1 in four, grade 2 in one.

CONCLUSION

Provided that the technique is adapted, the acute skin and heart toxicities of the concomitant administration of T-RT appeared satisfactory. More patients and longer follow-up are still mandatory.

[The fragmentation of representational space in schizophrenia]

Existent neurocognitive models of schizophrenia converge towards a core of impairments involving working memory, context processing, action planning, controlled and intentional processing. However, the emergence of this core remains itself difficult to explain and more specific hypotheses do not explain the heterogeneity of schizophrenia. To overcome these limits, we propose a new paradigm based on representational theory from cognitive science. Some recent developments of this theory enable us to describe a subjective universe as a representational space which is displayed from memory. We outline a conceptual framework to construct such a representational space from analogical -representations that can be activated in working memory and are connected to a network of symbolic structures. These connections are notably made through an analytic process of the analogical fragments, which involves the attentional focus. This framework allows us to define rigorously some defense processes in response to traumatic tensions that are expressed on the representational space. The fragmentation of representational space is a consequence of a defensive denial based on an impairment of the analytic process. The fragmentation forms some parasitic areas in memory which are excluded from the main part of the representational space and disturb information processing. The key clinical concepts of paranoid syndromes can be defined in this conceptual framework: mental automatism, delusional intuition, acute destructuration, psychotic dissociation, and autistic withdrawal. We show that these syndromes imply each other, which in return increases the fragmentation of the representational space. Some new concepts emerge naturally in this framework, such as the concept of "suture" which is defined as a link between a parasitic area and the main representational space. Schizophrenia appears as a borderline case of fragmentation of the representational space. This conceptual framework is compatible with numerous etiological factors. Multiple clinical forms can be differentiated in accordance with the persistence of parasitic areas, the degree of fragmentation, and the formation of sutures. We use this approach to account for an empirical study concerning the analysis of analogical representations in schizophrenia. We used the Parallel Visual Information Processing Test (PVIPT) which assesses the analysis of interfering visual information. Subjects were asked to connect several small geometric figures printed on a transparency. The transparency was displayed above four photographs which were the interfering material. Then, subjects completed three tasks concerning the photographs: a recognition task, a recall task, and an affective qualification task. Using a case-by-case study, this test allows us to access the defense processes of the subjects, which is not possible with the usual methods in cognitive psychopathology. Twelve clinically-stable schizophrenic subjects participated in the study which also included a self-assessment of alexithymia by the Toronto Alexithymia Scale. We obtained 2 main results: (a) creation of items in recall or false recognition by 8 subjects, and (b) lack of the usual -negative correlations between the alexithymia score and the recall, recognition and affective qualification scores in the PVIPT. These 2 results contrast with what has been previously observed for alexithymia using the same methodology. The result (a) confirms an interfering activation in schizophrenic memory, which can be interpreted in our framework as indicative of parasitic areas. The creation of items suggests the formation of sutures between the semantic content of photographs and some delusional fragments. The result (b) suggests that the apparent alexithymia in schizophrenia is a defense against interfering activation in parasitic areas. We underline the interest of individual protocols to exhibit the dynamic interplay between an interfering activity in memory and a defensive flattening of affects.

The benefit of implementing a heart failure disease management program

BACKGROUND

To handle the increasing complexity of congestive heart failure (CHF) care, several new models for the care of patients with CHF have been developed to replace traditional strategies. We undertook this study to evaluate the potential benefit of implementing a CHF disease management program at a tertiary care center, particularly in terms of beta-blocker use and cost to the health care system.

METHODS

After reviewing the literature regarding therapies and management strategies for patients with CHF, we developed the Duke Heart Failure Program. All enrolled patients had 1 of the following: recent CHF hospitalization, ejection fraction less than 20%, or symptoms consistent with New York Heart Association class III or IV. We compared preenrollment and postenrollment medication use and resource utilization.

RESULTS

We enrolled 117 patients from July 1998 to April 1999. Mean enrollment time was 4.7 months. beta-Blocker use and dose significantly increased (52% vs 76% for beta-blocker, P<.01; 6% vs 13% of target dose, P<.01). The hospitalization rate decreased (1.5 vs 0 hospitalizations per patient-year, P<.01), while the number of clinic visits increased (4.3 vs 9.8 clinic visits per patient-year, P<.01). The Duke University Health System saved a median of $8571 per patient-year.

CONCLUSIONS

Implementing a CHF disease management program was associated with improved CHF medication dosing and with decreased hospitalization for patients with CHF. A CHF disease management program is an effective method for a health care system to care for patients with CHF.

[Cognitive and emotional approach to assertiveness]

Assertiveness is an individual function which allows adaptation to social interaction. It needs an heterogeneous psychological processus using behavioral, cognitive and emotional components in its expression. Dysfunction in assertiveness contributes to anxious, depressive and personality disorders, representing a frequent impairment for patients. Assertiveness was measured in a population of patients with anxious disorders (n = 33) without concomitant major depression. Rathus Assertiveness Schedule was used for the clinical evaluation, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory and Coopersmith Inventory was also used for clinical measure of depression, anxiety and self-esteem. Global score to Rathus Assertiveness, correlated no specifically with all the others emotional factors. This multidimensional function would benefit to a more discriminant approach, measuring first behavioral and cognitive skills employed in social adaptation and secondly the emotional component of the processus.

Disease management of congestive heart failure

AUDIENCE

This article is designed for primary care physicians, cardiovascular specialists, medical directors, and other managed care administrators responsible for heart failure patients.

GOAL

To provide the reader with a basic understanding of heart failure epidemiology, heart failure management, and different strategies for the management of this particular patient population.

OBJECTIVES

1. To describe the impact of heart failure on the healthcare system in the United States. 2. To briefly describe the current practice for managing heart failure. 3. To describe the evidence for care by cardiologists of heart failure patients. 4. To describe the different disease management strategies being utilized in heart failure management.

[The discovery of haloperidol]

Haloperidol was synthesized on the 11th of February 1958 by Bert Hermans at the Janssen Laboratories, Beerse, Belgium. Simple but ingenuous methods of animal pharmacology suggested to Paul Janssen and his collegues that this butyrophenone derivative, called R1625, then halop-peridol, would be of great interest: qualitatively, the pharmacological action of R1625 was similar to chlorpromazine, but R1625 was very more powerful since it produced effects with much smaller doses than chlorpromazine. Soon after the synthesis and animal studies, haloperidol was administered in humans by Divry, Bobon et Collard, psychiatrists at the Liege Hospital. The first clinical publication, on the 28th of October, 1958, described the effects of haloperidol in agitation states. The subsequent clinical studies, including those of the prestigious French school of Sainte-Anne hospital, confirmed that haloperidol belongs to the pharmacological family of neuroleptics, as it was defined by J. Delay and P. Deniker in 1955. These clinical studies demonstrated also that haloperidol was particularly active against delusions and hallucinations. Numbers of chronically inpatients were able to leave hospital and to live home thanks to this new drug, which remains one of the more prescribed neuroleptics 40 years after its discovery.