Clinical and Serological Follow-Up of 216 Patients with Hematological Malignancies after Vaccination with Pfizer-BioNT162b2 mRNA COVID-19 in a Real-World Study

Hematological malignancies (HMs) have heterogeneous serological responses after vaccination due to disease or treatment. The aim of this real-world study was to analyze it after Pfizer-BioNT162b2 mRNA vaccination in 216 patients followed up for 1 year. The first 43 patients had an initial follow-up by a telemedicine (TM) system with no major events reported. The anti-spike IgG antibodies were checked 3–4 weeks post-first vaccination and every 3–4 months, by two standard bioassays and a rapid serological test (RST). Vaccine boosts were given when the level was <7 BAU/mL. Patients who did not seroconvert after 3–4 doses received tixagevimab/cilgavimab (TC). Fifteen results were discordant between two standard bioassays. Good agreement was observed between the standard and RST in 97 samples. After two doses, 68% were seroconverted (median = 59 BAU/mL) with a median of 162 BAU/mL and 9 BAU/mL, respectively, in untreated and treated patients (p < 0.001), particularly for patients receiving rituximab. Patients with gammaglobulin levels < 5 g/L had reduced seroconversion compared to higher levels (p = 0.019). The median levels were 228 BAU/mL post-second dose if seroconverted post-first and second, or if seroconverted only post-second dose. A total of 68% of post-second dose negative patients were post-third dose positive. A total of 16% received TC, six with non-severe symptomatic COVID-19 within 15–40 days. Personalized serological follow-up should apply particularly to patients with HMs.

Determination of thresholds of risk in women at average risk of breast cancer to personalize the organized screening program

In France, more than 10 million women at "average" risk of breast cancer (BC), are included in the organized BC screening. Existing predictive models of BC risk are not adapted to the French population. Thus, we set up a new score in the French Hérault region and looked for subgroups at a graded level of risk in women at "average" risk. We recruited a retrospective cohort of women, aged 50 to 60, who underwent the organized BC screening, and included 2241 non-cancer women and 527 who developed a BC during a 12-year follow-up period (2006-2018). The risk factors identified were high breast density (ACR BI-RADS grading)(B vs A: HR = 1.41, 95%CI [1.05; 1.9], p = 0.023; C vs A: HR = 1.65 [1.2; 2.27], p = 0.02 ; D vs A: HR = 2.11 [1.25;3.58], p = 0.006), a history of maternal breast cancer (HR = 1.61 [1.24; 2.09], p < 0.001), and socioeconomic difficulties (HR 1.23 [1.09; 1.55], p = 0.003). While early menopause (HR = 0.36 [0.13; 0.99], p = 0.003) and an age at menarche after 12 years (HR = 0.77 [0.63; 0.95], p = 0.047) were protective factors. We identified 3 groups at risk: lower, average, and higher, respectively. A low threshold was characterized at 1.9% of 12-year risk and a high threshold at 4.5% 12-year risk. Mean 12-year risks in the 3 groups of risk were 1.37%, 2.68%, and 5.84%, respectively. Thus, 12% of women presented a level of risk different from the average risk group, corresponding to 600,000 women involved in the French organized BC screening, enabling to propose a new strategy to personalize the national BC screening. On one hand, for women at lower risk, we proposed to reduce the frequency of mammograms and on the other hand, for women at higher risk, we suggested intensifying surveillance.

[Cancers of the external genital organs of male in Hérault: Results from the Hérault tumor register (RTH) over a period of 30 years (1987-2016)]

AIM

The objective of this study is to present the history of cancers of the external genital organs of male in Hérault using data from the Hérault tumor register (RTH) over a period of 30 years.

PATIENTS AND METHODS

Using the RTH database, we studied the development of testicular germ cell tumors (TGCT) and penile cancer (PC) over 30 years, from 1987 to 2016. We analyzed the incidence and mortality data for these tumors. We compared these results to French, European and global data.

RESULTS

In 30 years of registration we have recorded 725 cases of TGCT and 175 cases of PC. The age standardized incidence rate (ASR) of TGCT has doubled between 1987 and 2016 (4.2 per 100,000 in 1987 and 9.3 per 100,000 in 2016). It was multiplied by 2.63 in the population of patients aged 30 to 44. There is a decrease of the mortality rate with a ASR of 0.8 deaths per 100,000 in 1987, and 0.4/100 000 in 2016. The PC incidence ASR was stable between 1987 and 2016 (0.4-0.9/100,000). Mortality is stable with a ASR between 0.1 and 0.3 deaths per 100,000 between 1987 and 2016.

CONCLUSION

The incidence of TGCT has increased sharply in the Hérault over the past 30 years, while a decrease in mortality has been observed. The proportion of seminomas is increasing; it has gone from 53 % to 60 % in 30 years in the Hérault. The incidence and mortality of PC shows a stability in the Hérault over the past 30 years.

"Doctor, how long will it take?" Results from an historical cohort on surgical pressure ulcer healing delay and related factors in persons with spinal cord injury

BACKGROUND

Flap surgery for deep pelvic pressure ulcers has already shown its effectiveness. Most studies relating to the postoperative period assessed complications rates and associated risk factors, but none focused on delayed wound healing. The objective of this study was to describe wound healing delay after primary flap surgery in patients with spinal cord injury (SCI) and to assess associated risk factors.

METHODS

This observational retrospective study based on medical charts included all persons with SCI operated for primary flap surgery for pelvic PU in the Hérault department of France between 2006 and 2014. Overall, 100 biomedical, psychological, socioeconomics and care management factors were studied. The primary outcome was wound healing delay, defined as time from surgery to complete cutaneous closure.

RESULTS

85 patients were included. Median healing time was 48 days (R: 20-406). Healing rate was 70% at 3 months and 90% at 4 months. After a multivariate analysis three factors were significantly associated with delayed wound healing: duration of hospitalization in the acute care unit (HR = 2.68; p = 0.004), local post-operative complication (HR = 10.75; p = 0.02), and post-operative sepsis (HR = 2.18; p = 0.02).

CONCLUSION

After primary skin flap surgery for PU in persons with SCI, delayed wound healing is related to local or general complications as well as care management organization. The risk of delayed wound healing justifies the implementation of a coordinated pre-operative management to prevent complications and a structured care network for an earlier transfer to a SCI rehabilitation center.

Ductoscopy Coupled to Duct Lavage and Duct Brushing in Pathologic Nipple Discharge: Our Experience

PURPOSE

to present our experience in the management of pathological nipple discharge using the procedure D.DL.DB: "ductoscopy" (D) coupled to "duct lavage" (DL) plus "duct brushing" (DB) for etiologic diagnosis. Also to compare the diagnosis obtained with D.DL.DB to the final histology.

MATERIAL AND METHOD

Eighty-five patients with organic unilateral nipple discharge were enrolled in two Breast Units. 82 of 85 patients were investigated successfully with D.DL.DB. Results:: The final histological results were: papilloma 46.3%, duct ectasia 36.5%, breast cancer 8.5%, precancer lesions 4.9%, and mixed benign lesions 3.8%. Pyramidectomy and radical ductectomy were performed in 76 and 6 cases respectively. In 80% of the cases, DLDB cytology results were identical to the final histology. (Kappa=0;69 CI=[0.56 -0.82]. The sensitivity of D.DL.DB versus pathology, for cancer or precancer lesions was 81.8% (CI=0.59 -1) and the specificity was 97.1% (CI=0.93 -1). Using Koch scale, the concordance between the two methods D.DL.DB and surgery was high and the sensitivity was in the upper range regarding the literature (58% to 90%).

CONCLUSION

Our experience confirms the high value of D.DL.DB in the management of organic nipple discharge.

Cachexia - sarcopenia as a determinant of disease control rate and survival in non-small lung cancer patients receiving immune-checkpoint inhibitors

PURPOSE

The metabolic changes associated with cachexia - sarcopenia syndrome might down-regulate antitumor immunity. We hypothesized that this syndrome reduces efficiency of immune checkpoint inhibitors (ICPI) in non-small cell lung cancer (NSCLC).

METHODS

The records of 142 consecutive NSCLC patients receiving first- or second-line anti-Programmed cell death protein 1) ICPI were reviewed. Response evaluation according to Response Evaluation Criteria in Solid Tumors 1.1 was performed at the eighth week of immunotherapy. Pretreatment cachexia was defined as a body-weight loss of 5% or more in the previous 6 months. Sarcopenia was estimated with the third lumbar skeletal muscle mass index (mSMI) and was evaluated before immunotherapy and at the eighth week. A decrease by 5% or more of the mSMI was considered as an evolving sarcopenia. The endpoints were disease control rate (DCR), progression-free (PFS) and overall survival (OS).Logistic regression model and Cox model took into account others covariables known to influence ICPI efficiency, particularly Programmed Death -Ligand 1 tumor cell score, Eastern Cooperative Oncology Group performance status and common somatic mutational status.

RESULTS

In multivariate analysis, cachexia - sarcopenia syndrome reduced the probability of achieving a disease control and were associated with a shorter survival. Patients without cachexia had a better probability to achieve disease control in comparison with those who did not experience cachexia (59.9 % and 41.1 %, respectively; odds ratio 95 % (confidence interval [95 %CI]): 2.60 (1.03-6.58)). Patients with cachexia had a shorter OS when compared with those without cachexia (hazard ratios [HR] (95 %CI): 6.26 (2.23-17.57)). Patients with an evolving sarcopenia had a shorter PFS and OS, with HR (95 %CI): 2.45 (1.09-5.53) and 3.87 (1.60-9.34) respectively.

CONCLUSION

Cachexia - sarcopenia syndrome negatively influences patients' outcome during anti-PD-1 ICPI therapy.

Development and Validation of a Simplified Prognostic Score in SCLC

Introduction

This study aimed at generating a new simplified prognostic score (SPS) using common clinical and biological variables to discriminate a limited number of subgroups of patients with SCLC differing by their overall survival (OS).

Methods

The SPS was developed exploring the Montpellier University Hospital retrospective database of 401 patients over a 16-year period. All patients had received etoposide - platinum-based chemotherapy as first-line treatment. The SPS development took into account significant determinants of OS in the Cox model, weighted by their regression β coefficients. Validation of the consequent SPS has been done separately in a combined population of 213 patients accrued from two different published trials (NCT03059667 and NCT00930891).

Results

The significant independent determinants of OS included the following: (1) American Joint Committee on Cancer TNM stage IV (hazard ratio [HR]: 2.52; 95% confidence interval [CI]: 1.91–3.33); (2) Eastern Cooperative Oncology Group performance status greater than 1 (HR: 2.27; 95% CI: 1.79–2.87); (3) the presence of liver metastases (HR: 1.66; 95% CI: 1.29–2.15); and (4) neutrophil-to-lymphocyte ratio greater than 4 (HR: 1.39; 95% CI: 1.11–1.92). The SPS generated with these four variables, segregated three groups (good, intermediate, and poor prognosis) with respective median OS of 26.9 months (95% CI: 20.1–38.9), 11.5 months (95% CI: 9.8–13.0), and 6.8 months (95% CI: 5.8–8.3; log-rank p < 10^–4). Harrell's C statistic estimate was 0.68 ± 0.012, suggesting goodness of calibration. In the validation cohort, the SPS segregated the aforementioned three subgroups in a nearly similar manner, with respective median OS: 27.2, 12.3, and 8.6 months (log-rank p < 10^–3; Harrell’s C statistic: 0.58 ± 0.02).

Conclusions

The SPS is easy to calculate in real-life practice and efficiently discriminates three populations with different prognoses. This study deserves further validation of this score in patients with SCLC receiving immunochemotherapy.

[The Childhood Asthma Control Test improves the therapeutic adaptations recommended for asthmatics aged 6 to 11 years in primary practice. A Randomized comparative prospective study]

OBJECTIVES

Asthma is the leading chronic disease of the child; control and treatment remain inadequate. Our objective was to assess whether the use of the Childhood Asthma Control Test (C -ACT) in primary care had an impact on adapting therapy.

METHODS

The study was quantitative prospective and compared 2 groups of general practioners. All had the same reminders about childhood asthma management. The C-ACT was detailed to one group only. Doctors in the control group had to work as usual without C-ACT. Doctors included asthmatic children aged 6 to 11 years who were consulting for their asthma or any other reason. The primary endpoint was the adaptation of asthma treatment according to the Global Initative for Asthma (GINA). Evaluations of the control group were compared with the after consultation self-administered online C-ACT.

RESULTS

From April to October 2014, 61 physicians included 179 patients in two comparable groups. Although not significant statistically, doctors using C-ACT found 45% of uncontrolled asthma (vs. 31%). When the reason for consultation was not related to asthma, the figure was 25% (vs. 15%). Doctors using the C-ACT made twice less therapeutic adaptations not recommended by the GINA: 8% vs. 16%. 25% of evaluations of doctors in the control group were discordant with the internet C-ACT. After correction with the internet C-ACT of these imprecise initial assessments, the figure was 25%: 3 times more than in the C-ACT group (P=0.014).

CONCLUSION

The use in primary care of C-ACT should allow a better assessment of asthma control and adaptation of treatment in children.

S100-EPISPOT: A New Tool to Detect Viable Circulating Melanoma Cells

Metastatic melanoma is one of the most aggressive and drug-resistant cancers with very poor overall survival. Circulating melanoma cells (CMCs) were first described in 1991. However, there is no general consensus on the clinical utility of CMC detection, largely due to conflicting results linked to the use of heterogeneous patient populations and different detection methods. Here, we developed a new EPithelial ImmunoSPOT (EPISPOT) assay to detect viable CMCs based on their secretion of the S100 protein (S100-EPISPOT). Then, we compared the results obtained with the S100-EPISPOT assay and the CellSearch^® CMC kit using blood samples from a homogeneous population of patients with metastatic melanoma. We found that S100-EPISPOT sensitivity was significantly higher than that of CellSearch^®. Specifically, the percentage of patients with ≥2 CMCs was significantly higher using S100-EPISPOT than CellSearch^® (48% and 21%, respectively; p = 0.0114). Concerning CMC prognostic value, only the CellSearch^® results showed a significant association with overall survival (p = 0.006). However, due to the higher sensitivity of the new S100-EPISPOT assay, it would be interesting to determine whether this functional test could be used in patients with non-metastatic melanoma for the early detection of tumor relapse and for monitoring the treatment response.

Acute kidney injury during daptomycin versus vancomycin treatment in cardiovascular critically ill patients: a propensity score matched analysis

Background

Gram-positive organisms are a leading cause of infection in cardiovascular surgery. Furthermore, these patients have a high risk of developing postoperative renal failure in intensive care unit (ICU). Some antibiotic drugs are known to impair renal function. The aim of the study was to evaluate whether patients treated for Gram-positive cardiovascular infection with daptomycin (DAP) experienced a lower incidence of acute kidney injury (AKI) when compared to patients treated with vancomycin (VAN), with comparable efficacy.

Methods

ICU patients who received either DAP or VAN, prior to or after cardiovascular surgery or mechanical circulatory support, from January 2010 to December 2012, were included in this observational retrospective cohort study. We excluded patients with end stage renal disease and antibiotic prophylaxis. The primary endpoint was the incidence of AKI within the first week of treatment. Secondary endpoints were the incidence of AKI within the first 14 days of treatment, the severity of AKI including renal replacement therapy (RRT), the rates of clinical failure (unsuccessful infection treatment) and of premature discontinuation and mortality. To minimize selection bias, we used a propensity score to compare the 2 groups. Univariate and multivariate analysis were performed to determine factors associated with AKI.

Results

Seventy two patients, treated for infective endocarditis, cardiovascular foreign body infection, or surgical site infection were included (DAP, n = 28 and VAN, n = 44). AKI at day 7 was observed in 28 (64%) versus 6 (21%) of the VAN and DAP patients, respectively (p = 0.001). In the multivariate analysis adjusted to the propensity score, vancomycin treatment was the only factor associated with AKI (Odds Ratio 4.42; 95% CI: 1.39–15.34; p = 0.014). RRT was required for 2 (7%) DAP patients and 13 (30%) VAN patients, p = 0.035. Premature discontinuation and clinical failure occurred more frequently in VAN group than in DAP group (25% versus 4%, p = 0.022 and 42% versus 12%, respectively, p = 0.027).

Conclusions

Daptomycin appears to be safer than vancomycin in terms of AKI risk in ICU patients treated for cardiovascular procedure-related infection. Daptomycin could be considered as a first line treatment to prevent AKI in high-risk patients.

Family History is Underestimated in Children with Isolated Hypospadias: A French Multicenter Report of 88 Families

PURPOSE

While familial forms of complex disorders/differences of sex development have been widely reported, data regarding isolated hypospadias are sparse and a family history is thought to be less frequent. We aimed to determine the frequency of hypospadias in families of boys with hypospadias, to establish whether these familial forms exhibit a particular phenotype and to evaluate the prevalence of genetic defects of the main candidate genes.

MATERIALS AND METHODS

A total of 395 boys with hypospadias were prospectively screened for a family history with a standardized questionnaire, extensive clinical description, family tree and sequencing of AR, SF1, SRD5A2 and MAMLD1.

RESULTS

Family history of hypospadias was more frequent than expected (88 patients, 22.3%). In 17 instances (19.3%) familial hypospadias cases were multiple. Familial hypospadias was related to the paternal side in 59.1% of cases, consisting of the father himself (30.7%) as well as paternal uncles and cousins. Premature birth, assisted reproductive techniques, other congenital abnormalities and growth retardation were not more frequent in familial hypospadias than in sporadic cases. The severity of phenotype was similar in both groups. The results of genetic analysis combined with previous data on androgen receptor sequencing revealed that familial cases more frequently tend to demonstrate genetic defects than sporadic cases (5.68% vs 1.63%, p = 0.048).

CONCLUSIONS

Familial forms of hypospadias are far more frequent than previously reported. Even minor and isolated forms justify a full clinical investigation of the family history. Detecting these hereditary forms may help to determine the underlying genetic defects, and may improve followup and counseling of these patients.

Antiphospholipid and Antiprotein Syndromes in Non-thrombotic, Non-autoimmune Women with Unexplained Recurrent Primary Early Foetal Loss

Various antiphospholipid and/or antiprotein antibodies have been suspected to be associated with recurrent early foetal loss in absence of any habitual aetiology. We conducted a hospital-based case control study on women with no antecedent of thromboembolic or autoimmune disease. We studied 3 groups of 518 women: patients with unexplained primary recurrent early foetal loss, patients with explained episodes and mothers with no previous obstetrical accident. Matching the 3 groups was carried out on the basis of age, number or pregnancies and time elapsed since the end of the last pregnancy. Significant biological markers were then prospectively tested.

The various antibodies were shown to be dependent on parity and on the presence of previous foetal loss: cut-off values were thus calculated using data obtained from the group of explained accidents, and adjusted for parity. Only anti-phosphatidylethanolamine IgM [odds ratio: 6.0, 95% confidence interval (2.3–15.7), p = 0.0003], anti-β2-glycoprotein I IgG [4.4, (1.6–11.7), p = 0.0035] anti-annexin V IgG antibodies [3.2 (1.2–8.1), p = 0.015] and lupus anticoagulant [3.0, (1.3–6.8), p = 0.009], were found to be independent retrospective risk factors for unexplained early foetal loss. These four markers were subsequently found to be, during the following pregnancy, associated with a significant risk of foetal loss despite a low-dose aspirin treatment.

In non-thrombotic, non-auto-immune women with unexplained primary reccurent early foetal loss, subgroups of patients with positive anti-phosphatidylethanolamine IgM antibodies, or positive anti- β2-glycoprotein-I IgG antibodies, or positive anti-annexin V IgG anti-bodies or lupus anticoagulant must be particularised. This should allow therapeutic trials to be carried in well-defined patients.

Age and stage specific prevalence estimate of cancer from population based Cancer Registry using inhomogeneous Poisson process

A multi stage model is described for estimating the age and two stage specific prevalence of cancer. The disease evolution is considered as an inhomogeneous Poisson process in the Lexis diagram. Prevalences are estimated from the basic epidemiological measures (stage specific incidences and survivals). A piecewise constant hazard model is used to estimate the transition rates constructing a finite partition of age and, where it is the case, of duration. Moreover, variance calculations are described. An application to breast cancer in the Hérault (France) population is presented.

A Prospective Study on Skin-Sparing Mastectomy for Immediate Breast Reconstruction with Latissimus Dorsi Flap After Neoadjuvant Chemotherapy and Radiotherapy in Invasive Breast Carcinoma

BACKGROUND

Skin-sparing mastectomy (SSM) with immediate breast reconstruction (IBR) is increasingly used in invasive breast cancer. However, adjuvant chemotherapy (CT) and radiotherapy (RT) can increase the rate of local complications.

OBJECTIVE

The aim of this study was to assess the morbidity of SSM-IBR after neoadjuvant CT and RT.

METHODS

A French prospective pilot study of women aged 18-75 years with invasive breast cancer requiring mastectomy after CT and RT. Reconstruction was performed using autologous latissimus dorsi flap with or without prosthesis. The primary endpoint was the skin necrosis rate within 6 months, while secondary endpoints included pathological complete response rate (pCR) and global morbidity.

RESULTS

Among 94 patients included in this study, 83 were analyzed (mean age 45.2 ± 9.5 years, T1 23.6 %, T2 55.6 %, T3 18.1 %). All but one patient received anthracyclines and taxanes, and all patients received RT (49.3 ± 5.2 Gy) before SSM-IBR. Prostheses were used for IBR in 32 patients (mean volume 256 ± 73 mm(3)). Five patients had necrosis (≤2 cm(2), 2-10 cm(2) and >10 cm(2), in three, one, and one cases, respectively), and they all recovered without revision surgery. Among 50 patients who underwent upfront mastectomy, 36 % achieved pCR.

CONCLUSIONS

SSM-IBR performed after CT and RT is safe, with an acceptable local morbidity rate. Long-term data are needed to evaluate recurrence rates.

Mortality Attributable to Nosocomial Infection: A Cohort of Patients With and Without Nosocomial Infection in a French University Hospital

Objective

To assess nosocomial infection (NI) as a risk factor for death and to estimate the population-attributable risk of death from NI.

Design.

A prospective cohort study of patients with and without NI.

Setting.

Nîmes University Hospital, Nîmes, France.

Patients.

Patients were recruited from May 7, 2001, to January 10, 2003. Patients in acute care and long-term care units who had NI were enrolled, and patients without NI were randomly selected and matched with patients with NI for age, sex, type of care (acute care vs. long-term care) and length of stay in hospital at study inclusion.

Outcome Measures.

Vital status within 60 days after study inclusion was assessed. We used conditional logistic regression to estimate the relative death risk from NI after adjusting for comorbidities, severity of the underlying disease, and all other confounding factors. The adjusted population-attributable risk was assessed using the Mantel-Haenszel method.

Results.

We recruited 1,914 patients with NI and 5,172 patients without NI. The median age of the patients with NI was 73 years; 1,045 (54.6%) were female. NI was associated with death within 60 days (adjusted odds ratio, 1.7 [95% confidence interval {CI}, 1.4—;2.2]; P-C.001). The adjusted population-attributable risk of death for all sites of infection was 1.7% (95% CI, 1.4-2.1). If we consider the NI incidence to be 3%-6% in French hospitals, the population-attributable risk of death from NI would range from 2.1% (95% CI, 1.7%-2.5%) to 4.0% (95% CI, 3.3%-4.9%).

Conclusion.

In this study, NI appeared to have a significant impact on mortality. Multicenter studies will be needed to confirm these results.

Outcomes after (90) Yttrium-ibritumomab tiuxetan-BEAM in diffuse large B-cell lymphoma: a meta-analysis

High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is a standard therapy in patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL) who are chemosensitive. The combination of carmustine, etoposide, cytarabine, and melphalan (BEAM) is commonly used as a conditioning regimen. The addition of yttrium-90 ((90) Y)-ibritumomab tiuxetan (Zevalin(®)) to BEAM (Z-BEAM) is increasingly being used to improve outcomes and overcome refractory disease. We conducted a literature review and meta-analysis in order to evaluate the clinical effects of Z-BEAM followed by ASCT in patients with DLBCL. A literature search was conducted for randomized controlled trials and observational studies of Z-BEAM as a conditioning regimen for ASCT in adult patients with DLBCL. Extracted data included baseline patient demographics, overall response (ORR), complete response (CR), overall survival (OS), progression-free survival (PFS), nonrelapse mortality (NRM), median time to ANC and platelet engraftment, and rate of myelodysplastic syndrome. Mixed-effects models were used to determine estimates. Ten studies (N = 328) were included in the meta-analysis. The 2-year OS and PFS were 84.5% (n = 328) and 67.2% (n = 285), respectively. Outcomes were superior in patients with nontransformed lymphoma. Posttransplant, ORR and CR rates were 72.6% and 68.5%, respectively. The NRM rate was 6.3% and the incidence rate of myelodysplastic syndrome was 2.5%. Two-year OS was significantly associated with pretransplant ORR (P = 0.008, τ(2) = 0). There was no significant association between PFS and pretransplant response. Z-BEAM is safe and effective as a conditioning regimen in relapsed/refractory DLBCL.

New Neonatal Classification of Unilateral Cleft Lip and Palate—Part 1: To Predict Primary Lateral Incisor Agenesis and Inherent Tissue Hypoplasia

Objectives

To bring a neonatal classification system of unilateral cleft lip and palate (UCLP) and to correlate this classification with the distribution of the primary lateral incisor.

Design

Retrospective with longitudinal follow-up.

Setting

Tertiary.

Patients

One hundred twenty-one patients with treated UCLP. Thirteen plaster casts were used as controls.

Main Outcome Measures

The UCLP patients were classified anatomically into four categories: class 1 corresponds to a maxillary arch with a narrow alveolar cleft, class 2 corresponds to a balanced form, class 3 corresponds to a wide cleft and short maxilla, and class 4 corresponds to a wide cleft and long maxilla. Clinical validity was evaluated with a concordance analysis (intra- and interexaminer). This anatomical classification was also corroborated with an automatic classification determined by morphometric parameters measured on neonatal maxillary plaster casts. The class was finally correlated with the distribution of the primary lateral incisor.

Results

Clinical classification of UCLP found 12 cases of class 1 (9.9%), 36 cases of class 2 (29.8%), 47 cases of class 3 (38.8%), and 26 cases of class 4 (21.5%). The clinical classification was validated with a good intra- and interexaminer concordance analysis (κ > .6). The automatic classification was close to the clinical classification in 84%. The correlation was ideal in class 1 (100%), almost perfect in class 4 (92%), but lower for class 2 (74%) and class 3 (70%). The primary lateral incisor was usually duplicated in class 1, whereas class 2 and class 4 were correlated with a primary lateral incisor located on the lateral palatal segment. Class 3 was associated with an agenesis of the primary lateral incisor ( P < .001).

Conclusions

UCLP can be classified into four different classes at birth, which can all give information about the inherent tissue hypoplasia and the distribution of the primary lateral incisor.

Breast conserving surgery in multicentric breast cancer, preliminary data of our experience

INTRODUCTION

It is widely supported that multicentric disease of the breast (MCDB) is a contraindication of breast conservative surgery (BCS).

MATERIALS AND METHODS

This is a multicentric study (two breast cancer units from Greece, one from France) involving patients with at least two primary tumors in separate quadrants of the breast and no diffuse suspicious microcalcifications on mammography. Sixty-one patients were included in the study, but 49 were followed up to the end. Patients were randomly assigned in total mastectomy (TM) and BCS groups. End point of the study was disease-free survival rates three and five years after initial operation.

RESULTS

Three years after BCS, local recurrence (LR) was observed in two patients (7%) and one after five years (total recurrence rate: 11%). A TM was performed in these patients, and in two there was no LR or distant metastasis (DM) five years after. The third patient was disease free two-years later. Three years after TM, eight patients (36.4%) had DM and 14 (63.6%) did not (p = 0.004). Five years after TM, eight patients (36.4%) had DM and 14 patients (63.6%) di not (p = 0.03).

CONCLUSION

The results showed that conservative surgery was an alternative surgical option in multicentric breast cancer with good results regarding disease-free survival and recurrence.

New neonatal classification of unilateral cleft lip and palate part 2: to predict permanent lateral incisor agenesis and maxillary growth

Objectives : To bring a neonatal classification system of unilateral cleft lip and palate and to correlate this classification with the distribution of the permanent lateral incisor and maxillary growth. Design : Retrospective with longitudinal follow-up. Setting : Tertiary. Patients : A total of 112 individuals with treated unilateral cleft lip and palate and 30 controls. Main Outcome Measures : Unilateral cleft lip and palate neonatal casts were classified anatomically in four categories, in which Class 1 corresponds to a maxillary arch with a narrow alveolar cleft; Class 2 corresponds to a balanced form; Class 3 corresponds to a wide cleft and short maxilla; and Class 4 corresponds to a wide cleft and long maxilla. The classification was correlated with the distribution of the permanent lateral incisor. Maxillary growth was evaluated using a cephalometric analysis after the age of 10 years. Results : Clinical classification of unilateral cleft lip and palate found 10 cases of Class 1 (8.9%), 34 cases of Class 2 (30.4%), 46 cases of Class 3 (41.1%), and 22 cases of Class 4 (19.6%). The permanent lateral incisor was most often present in narrower clefts (Classes 1 and 2); whereas, large clefts (Classes 3 and 4) were relatively more frequently associated with an agenesis of the permanent lateral incisor (P = .019). Maxillary growth impairment was most severe in Class 3, with a mean sella-nasion-A point angle at 71.9° ± 4.6° (P < .001). Conclusions : Using the cleft width, arch form, and shape of the nasal septum, unilateral cleft lip and palate can be classified into four different classes at birth, which can all give information about permanent lateral incisor agenesis and maxillary growth.

A literature-based approach to evaluate the predictive capacity of a marker using time-dependent summary receiver operating characteristics

Summary

Meta-analyses are popular tools to summarize the results of publications. Prognostic performances of a marker are usually summarized by meta-analyses of survival curves or hazard ratios. These approaches may detect a difference in survival according to the marker but do not allow evaluation of its prognostic capacity. Time-dependent receiver operating characteristic curves evaluate the ability of a marker to predict time-to-event. In this article, we describe an adaptation of time-dependent summary receiver operating characteristic curves from published survival curves. To achieve this goal, we modeled the marker and the time-to-event distributions using non-linear mixed models. First, we applied this methodology to individual data in kidney transplantation presented as aggregated data, in order to validate the method. Second, we re-analyzed a published meta-analysis, which focused on the capacity of KI-67 to predict the overall survival of patients with breast cancer.

Excessive alcohol consumption after liver transplantation impacts on long-term survival, whatever the primary indication

BACKGROUND & AIMS

Beyond 5 years, poorer survival, related to alcohol relapse, is observed in patients with liver transplant for alcohol-related liver disease (ALD). However, alcohol consumption has been significantly understudied in non-ALD transplant recipients. We aimed at analyzing the impact of alcohol consumption on long-term survival irrespective of the indication for transplantation.

METHODS

This observational study included consecutive adult recipients of a primary liver graft between 1991 and 2007 in our hospital, who survived >6 months. Patients without ALD as primary indication, but with a history of excessive alcohol consumption before transplantation, were classified as secondary indication ALD. We studied the impact on survival of excessive consumption of alcohol after transplantation and several other variables.

RESULTS

The 441 patients had mean follow-up of 81.7 months. Among the 281 patients with excessive alcohol consumption before transplantation, 206 had ALD as primary indication. After transplantation, alcohol consumption was reported by 32.3% of the study population, 43.7% in primary indication ALD, and 24.3% in non-ALD patients. Survival was 82% at 5 years and 49% at 10 years for patients with excessive alcohol relapse, compared with 86% and 75%, respectively, for patients without persistent excessive alcohol relapse. By multivariable analysis, the independent risk factors of death were: excessive alcohol relapse, age >51 years, post-transplantation diabetes mellitus, cyclosporine-based immunosuppression, and non-hepatic cancer.

CONCLUSIONS

Excessive alcohol consumption has a negative impact on long-term survival after liver transplant, irrespective of the primary indication. Death is mainly due to recurrence of liver disease and non-hepatic cancer.

P2-12-16: HER2 Expression Is the Major Risk Factor for Recurrence in pT1a-b,N0 Breast Cancer: A French Regional Population-Based Study of 671 Patients

Background: To evaluate the prognostic impact of HER2 overexpression in patients with pT1a-b, node negative, breast cancers.

Patients and Methods: A population of1127 patients whose diseases were staged as pT 1a-b, pN0 and who were treated in the Languedoc-Roussillon (ONCO LR Southern French regional network) from 1999 to 2004, was identified. 95% of patients had conservative management, no patient received adjuvant trastuzumab, 5% received chemotherapy and 80% anti-estrogen endocrine therapy. HER 2 status was retrospectively assessed by immunohistochemistry in 671 patients (122 pT1a/549 pT1b). Kaplan-Meier method was used to estimate disease-free survival (DFS). Cox proportional hazard models were used to determine associations between HER2 status and disease-free survival adjusting on variables significantly linked to it.

Results: 9-year Overall survival was 95%. HER2 overexpression (3+) was observed in 5.2% of the patients (n=35).

HER2 3+ category was most frequently identified in the following sub groups: pT1a lesion (12.3% vs 3.6%; p: 0.0001), mastectomies (14% vs 4.4%; p:0.023), Grade 2–3 (91% vs 50%; p&lt;0.0001), estrogen receptor (ER) negative (−) tumors (57% vs 30%; p&lt;0.0001), progesterone receptor (PR) - tumors (74% vs 42%; p: 0.0002). HER2 3+ was less frequent with adjuvant hormonal treatment (43% vs 80%; p&lt;0.0001). 33 relapse (5%) were observed with a median follow-up of 6.4 years (range, 0.3 to 9.9 years). The 5-year DFS rates were 78% and 95% in patients with HER2−positive and HER2−negative tumors, respectively (p:0.017).

According to the immunohistochemical phenotype DFS5 were 95%, 94%, 85%, 73.6% for ER+/PR+/HER2− (n:502/75%), ER-/PR-/ HER2− (n:134/20%), ER+/PR+/HER2 3+ (n:15/2%) and ER-/PR-/ HER2 3+ tumors (n:20/3%), respectively (p:0.02).

In univariate analysis, HER2 positive tumors (p:0.017), phenotype classification (p:0.02) and adjuvant treatment (p:0.013) were significant prognostic factors. In multivariate analysis, only patients with HER2 3+ tumors had higher risks of recurrence (hazard ratio [HR], 2.41; 95% CI: [1.06−5.53]; p&lt;0.05) than those with HER2 -tumors.

Discussion: Node-negative, pT1a-b, breast cancer patients overexpressing HER2 have a significant risk of recurrence at 6 years median follow-up. In our series of small breast tumors, HER2 status seems to be a better prognostic factor than ER status. In patients with hormone receptor-positive diseases, HER2 positivity is associated with a worse DFS despite an anti-estrogen treatment.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-12-16.

Polymorphisms of MAMLD1 gene in hypospadias

PURPOSE

Mastermind-like domain containing 1 (MAMLD1) is a causative gene for the fetal development of male external genitalia. Almost 10% of patients with both severe and non-severe hypospadias exhibit mutations of MAMLD1. The aim of this work was to determine whether polymorphisms of MAMLD1 are a genetic risk factor for hypospadias.

MATERIAL AND METHODS

This study included 150 hypospadias with a range of severities and 150 controls. Direct sequencing of the MAMLD1 coding exons and their flanking splice sites was performed. In silico secondary and tertiary structure prediction and accessibility of changed amino acids were evaluated using JPred, Netsurf and PHYRE software. Functional studies of the transactivation of haplotypes on Hes3 promoter were performed in vitro using cDNAs of missense variants of MAMLD1.

RESULTS

The p.P286S polymorphism was identified in 17/150 patients and 12/150 controls (11.3% vs. 8.0%, p = 0.32). The p.N589S polymorphism was identified in 22/150 patients and 12/150 controls (14.6% vs. 8.0%, p = 0.068). The double polymorphism (S-S haplotype) was present in 16/150 patients and 6/150 controls (10.6% vs. 4.0%, p = 0.044, OR = 2.87, CI from 1.09 to 7.55). The association of polymorphisms consistently revealed a modification in the structure prediction or amino acid accessibility in all three in silico models. The P286S, N589S and P286S + N589S proteins did not exhibit reduced transactivating activity on Hes3 promoter.

CONCLUSION

Polymorphisms of MAMLD1 gene are frequent in patients with hypospadias. Although no change in transactivation was noted on Hes3 promoter, the in silico studies and the significantly increased incidence of the S-S haplotype in hypospadiac patients raise the hypothesis of a particular susceptibility conferred by these variants.

Assessment of allergen sensitization in a general population-based survey (European Community Respiratory Health Survey I)

PURPOSE

Exposed to a common environment, the IgE-mediated immune response differs, for instance, among sensitized subjects, some of them reacting toward one allergen (monosensitized) whereas others are sensitized to a wide array of allergens (polysensitized). However, a better phenotypic characterization is needed for epidemiologic studies. Using the data collected during the ECRHS I (European Community Respiratory Health Survey), several assessments of skin prick tests and serum-specific IgE to identify mono- and polysensitized patients were compared.

METHODS

Subjects took part in the ECRHS-I. The CAP-System was used for serum allergen-specific IgE, and allergen-coated Phazet was used for prick tests. Four allergens (Dermatophagoides pteronyssinus, cat, timothy grass, and Cladosporium) were measured using IgE and nine (the same ones plus olive pollen, birch, Alternaria, Parietaria, and ragweed) were skin tested. One to two local allergens were also tested, depending on countries.

RESULTS

Prevalence of sensitization in 11,355 subjects (34.0 [27.9-40.1] years, 49.9% men) ranged from 32.3% (four specific IgE, 19.3% mono- and 13.0% polysensitized) to 41.8% (four specific IgE combined to nine prick tests, 19.6% mono- and 22.2% polysensitized). Concordance between four specific IgE and four prick tests was weak (weighted κ 0.65 [0.64-0.66]). Concordance between seven and nine prick tests was high (weighted κ 0.99 [0.98-1.00]). Local allergens induced small changes in the prevalence of sensitization, and reclassified some subjects from mono- to polysensitized.

CONCLUSIONS

Skin tests or serum-specific IgE may be chosen to identify allergenic sensitivity, mono- and polysensitized subjects without being strictly interchangeable.

Oncological patterns of care and outcome for 952 patients with newly diagnosed glioblastoma in 2004

This report, an audit requested by the French government, describes oncological patterns of care, prognostic factors, and survival for patients with newly diagnosed and histologically confirmed glioblastoma multiforme (GBM) in France. The French Brain Tumor DataBase, which is a national multidisciplinary (neurosurgeons, neuropathologists, radiotherapists, neurooncologists, epidemiologists, and biostatisticians) network, prospectively collected initial data for the cases of GBM in 2004, and a specific data card was used to retrospectively collect data on the management and follow-up care of these patients between January 1, 2004, and December 1, 2006. We recorded 952 cases of GBM (male/female ratio 1.6, median age 63.9 years, mean preoperative Karnofsky performance status [KPS] 79). Surgery consisted of resection (RS; n = 541) and biopsy (n = 411); 180 patients did not have subsequent oncological treatment. After surgery, first-line treatment (n = 772) consisted of radiotherapy (RT) and temozolomide (TMZ) concomitant +/- adjuvant in 314 patients, RT alone in 236 patients, chemotherapy (CT) alone in 157 patients, and other treatment modalities in 65 patients. Median overall survival was 286 days (95% CI, 266-314) and was significantly affected by age, KPS, and tumor location. Median survival (days, 95% CI) associated with these main strategies, when analyzed by a surgical group, were as follows: RS + RT-TMZ((n=224)): 476 (441-506), biopsy + RT-TMZ((n=90)): 329 (301-413), RS + RT((n=147)): 363 (331-431), biopsy + RT((n=89)): 178 (153-237), RS + CT((n=61)): 245 (190-361), biopsy + CT((n=96)): 244 (198-280), and biopsy only((n=118)): 55 (46-71). This study illustrates the usefulness of a national brain tumor database. To our knowledge, this work is the largest report of recent GBM management in Europe.

The CONSORT statement checklist in allergen-specific immunotherapy: a GA2LEN paper

The methodology of randomized clinical trials is essential for the critical assessment and registration of therapeutic interventions. The CONSORT (Consolidated Standards of Reporting Trials) statement was developed to alleviate the problems arising from the inadequate reporting of randomized controlled trials. The present article reflects on the items that we believe should be included in the CONSORT checklist in the context of conducting and reporting trials in allergen-specific immunotherapy. Only randomized, blinded (in particular blinding of patients, health care providers, and outcome assessors), placebo-controlled Phase III studies in this article. Our analysis focuses on the definition of patients' inclusion and exclusion criteria, allergen standardization, primary, secondary and exploratory outcomes, reporting of adverse events and analysis.

Gene expression profile of multipotent mesenchymal stromal cells: Identification of pathways common to TGFbeta3/BMP2-induced chondrogenesis

Multipotent mesenchymal stromal cells (MSC) display a high potential for the development of novel treatment strategies for cartilage repair. However, the pathways involved in their differentiation to functional non hypertrophic chondrocytes remain largely unknown, despite the work on embryologic development and the identification of key growth factors including TGFbeta, Hh, Wnt and FGF. In this study, we asked if we could identify specific biological networks common to the growth factors used (TGFbeta3 or BMP-2). To address this question, we used DNA microarrays and performed large-scale expression profiling of MSC at different time points during their chondrogenic differentiation. By comparing these data with those obtained during the differentiation of MSC into osteoblasts and adipocytes, we identified 318 genes specific for chondrogenesis and developed a new algorithm to classify the genes according to their kinetic profile. We distributed the selected genes in five classes according to their kinetic of expression. We could reconstruct three phases characterized by functional pathways. The first phase corresponds to cell attachment and apoptosis induction; the second phase is characterized by a proliferation/differentiation step, and the third phase is characterized by a differentiation/hypertrophy pathway. Indeed, these data propose new pathways to understand the complexity of MSC differentiation to chondrocytes.

Comparative clinical outcomes of submuscular and subcutaneous transposition of the ulnar nerve for cubital tunnel syndrome

PURPOSE

To determine retrospectively whether the technique of ulnar nerve transposition (subcutaneous versus submuscular) is associated with clinical sensory and motor recovery in cubital tunnel syndrome, and whether recovery is influenced by prognostic factors such as preoperative McGowan stage, age, and duration of symptoms.

METHODS

Twenty-five patients (average age, 53 years; follow-up, 7 years) with cubital tunnel syndrome had submuscular transposition, and 24 patients (average age, 46 years; follow-up, 3 years) were treated by subcutaneous transposition. There were 11 McGowan stage II and 14 stage III patients in the submuscular group and 14 stage II and 10 stage III patients in the subcutaneous group. Preoperatively, all patients presented with diminished 2-point discrimination. Postoperative sensory and motor recovery was evaluated clinically.

RESULTS

There was no significant difference between subjective results in the submuscular and subcutaneous groups: 20 of 25 patients in the submuscular group versus 17 of 24 patients in the subcutaneous group were clearly improved, and 3 of 25 patients in the submuscular group versus 6 of 24 patients in the subcutaneous group partially improved. The logistic multivariate regression analysis indicated that sensory and motor function were both significantly improved following both surgical techniques. Sensory function recovered (2-point discrimination <6 mm) in 17 of 25 patients in the submuscular group and in 17 of 24 patients in the subcutaneous group, and motor function recovered (intrinsic strength grade 5) in 19 of 25 patients in the submuscular group and in 19 of 24 patients in the subcutaneous group. Symptoms lasting more than 6 months were associated with a poor prognosis.

CONCLUSIONS

Sensory and motor recovery for patients with McGowan stages II and III of cubital tunnel syndrome were similar following submuscular and subcutaneous transposition techniques, and patients with symptoms lasting longer than 6 months had a worse prognosis regardless of surgical technique.

Protein biochip array technology to monitor rituximab in rheumatoid arthritis

In rheumatoid arthritis (RA) there are currently no good indicators to predict a clinical response to rituximab. The purpose of this study was to monitor and determine the role of peripheral blood cytokine profiling in differentiating between a good versus poor response to rituximab in RA. Blood samples were collected at baseline and at 3 months from 46 RA patients who were treated with rituximab. Responders are defined by the presence of three of four American College of Rheumatology criteria: >or=20% decrease in C-reactive protein, visual analogical score of disease activity, erythrocyte sedimentation rate and improvement of the disease activity score (28) (four values) by >or=1.2 obtained at 3 months. Twelve cytokines were measured from serum collected on days 0 and 90 by proteomic array, including interleukin-6 (IL-6), tumour necrosis factor-alpha, IL-1a, IL-1b, IL-2, IL-8, interferon-gamma, IL-4, IL-10, monocyte chemoattractant protein-1, epidermal growth factor and vascular growth factor. We showed that C-reactive protein and IL-6 levels decrease significantly at 3 months in the responder group compared with baseline. At day 90 we identified a cytokine profile which differentiates responders and non-responders. High serum levels of two proinflammatory cytokines, monocyte chemoattractant protein-1 and epidermal growth factor, were significantly higher in the responder group at day 90 compared with non-responders. However, we were not able to identify a baseline cytokine profile predictive of a good response at 3 months. These findings suggest that cytokine profiling by proteomic analysis may be a promising tool for monitoring rituximab and may help in the future to identify responder RA patients.

Bronchial obstructive phenotypes in the first year of life among Paris birth cohort infants

As the natural history of respiratory and allergic manifestations is unclear, our ongoing Paris birth cohort study prospectively assesses the onset of these symptoms in early childhood. Data were collected by five questionnaires sent at regular intervals during the first year of life. Partitioning around medoids (PAM) was used to classify infants according to their bronchial obstructive symptoms. A polytomous logistic regression was performed to assess the eventual predictable power of various respiratory events and perinatal factors. Results are given for 2698 infants. Atopic dermatitis occurred in 17.9% of infants. The main respiratory symptoms in infancy were wheeze in the chest (22%), dyspnoea responsible for sleep disturbance (23.7%), nocturnal dry cough (14.5%) and shortness of breath (4.2%). The PAM method identified three groups of infants. Apart from the G0 group of infants mostly asymptomatic, two distinct clinical phenotypes (G1 and G2: 8.7% and 23.5% of total infants respectively) emerged. G2 was defined by severe bronchial obstructive disorders as all cases of dyspnoea with sleep disturbance were included in this group, while all infants assigned in G1 suffered from nocturnal dry cough. G2 group infants had significantly higher rates of respiratory events while a parental history of asthma, symptoms suggestive of rhino-conjunctivitis and birth season clearly differentiated the G1 group. Finally, G1 and G2 group infants should be closely followed up as they are expected to develop allergic and asthmatic phenotypes, possibly in relation to environmental and behavioural risk factors.

Factors determining a DMARD initiation in early inflammatory arthritis patients. The ESPOIR cohort study

BACKGROUND

To describe the rate and timing of DMARD start in patients with early inflammatory arthritis in France, and to determine the factors leading to this treatment start.

METHODS

The ESPOIR cohort study collects data on patients presenting with early arthritis. Baseline characteristics were assessed, and Cox regression analysis was performed to estimate the likelihood of starting DMARD treatment over time, adjusting for patient-, disease- and physician characteristics.

RESULTS

Of the 775 analysed patients, 598 (77.2%) received at least 1 DMARD during the follow-up period, after a median time of 4.0 months. In general, a higher tender joint count, involvement of the hands, involvement of more than 3 joint groups, presence of abnormal CRP-levels or CCP-antibodies significantly increased the likelihood of being treated (p<0.01 for all determinants), as well as a positive result on the bilateral foot-squeeze test (p<0.04). In addition, a significant hetero-geneity in therapeutic strategy across the 14 tested French regions was found: adjusted hazard ratios for DMARD start ranged from 1 to 2.15 (p<0.01), depending on the region where a patient was followed. For anti-CCP test and swollen joint count we demonstrated a statistically significant interaction with geographic region, implying that these tests are interpreted differently across regions. The same factors that increased the likelihood to start a DMARD were related to an earlier start.

CONCLUSION

Rate and timing of treatment start with DMARDs in patients with early inflammatory arthritis in France is determined by well known clinical and biochemical variables. Apart from these variables, however, unknown and intangible factors that seem to cluster geographically are responsible for important variations in practice performance.

Coronary heart disease and HRT in France: MISSION study prospective phase results

OBJECTIVE

To determine the morbidity incidence associated with Hormone Replacement Therapy (HRTs) in postmenopausal women. This paper presents the results concerning the incidence of coronary heart disease (CHD).

DESIGN

MISSION study started on 5 January 2004, the cutoff for data collection was June 2006 (follow-up no. 1). 'Exposed group': postmenopausal women currently on HRT, commonly prescribed in France or stopped < or =5 years previously. 'Unexposed group': never received HRT or stopped >5 years previously.

RESULTS

Data were available for 4949 patients (without CHD at the beginning of the follow-up): 2693 Exposed group and 2256 Unexposed group. The incidence during follow-up no. 1 of postmenopausal CHD was not significantly different in the Exposed group (0.11%) compared with the Unexposed group (0.13%). In the Exposed group the time between start of HRT and menopause was 2.93 +/- 4.46 years in those who experienced CHD and 1.53 +/- 3.20 years in those who had no incidence of CHD (p = 0.3).

CONCLUSION

In the MISSION cohort, no increased risk of CHD was found in the Exposed group compared with the Unexposed group.

A flexible semi-Markov model for interval-censored data and goodness-of-fit testing

Multi-state approaches are becoming increasingly popular to analyse the complex evolution of patients with chronic diseases. For example, the evolution of kidney transplant recipients can be broken down into several clinical states. With this application in mind, we present a flexible semi-Markov model. The distribution functions are fitted to the durations in states and the relevance of the generalised Weibull distribution is shown. The corresponding likelihood function allows for interval censoring, i.e. the times of transitions and the sequences of states are not available during the elapsed times between two visits. The explanatory variables are introduced through the Markov chain and through the probability density functions of durations. A goodness-of-fit test is also defined to examine the stationarity of the semi-Markov model.

Anatomy and Growth of the Fetal Soft Palate: A Cadaveric Study to Improve Its Ultrasonographic Observation

Objective:

To determine the anatomy of the soft and hard palate during fetal growth in order to improve its ultrasonographic prenatal visualization.

Design:

Anatomic study in human formalin-fixed fetus.

Methods:

The heads of 18 second and third trimester fetuses were studied in the median sagittal plan. Measurements of the soft palate, the velopharynx, the root of the tongue, and the oral floor were taken. The hard palate/soft palate angle and the anterior cranial base/soft palate angle were measured.

Results:

The growth of the hard palate was linear, and the growth of the soft palate was polynomial (second order) during the period studied. The hard palate/soft palate angle was 150.33° ± 7.62 and 150.20° ± 6.67 in the second and third trimester, respectively. The anterior position of the soft palate in relation to the anterior cranial base was 48.8° ± 3.13 in the second trimester and 52.26° ± 3.31 in the third trimester. Its posterior position was 89.66° ± 5.51 in the second trimester and 92.97° ± 4.01 in the third trimester. Throughout the fetal period, the soft palate moved downward relative to the clivus and cervical spine.

Conclusions:

Despite the nonlinear growth and downward displacement of the soft palate during fetal life, its position remains stable. These results may be useful to explore the fetal soft palate using 2D and 3D ultrasonography and to improve the prenatal diagnosis of isolated cleft palate.

Protein biochip array technology for cytokine profiling predicts etanercept responsiveness in rheumatoid arthritis

In rheumatoid arthritis (RA) there are currently no useful indicators to predict a clinical response to tumour necrosis factor-alpha (TNF-alpha) blockade. The purpose of this study was to determine the role of peripheral blood cytokine profiling in differentiating between a good versus poor response to etanercept in RA. Peripheral blood samples were collected at baseline and at 3 months from 33 patients with active disease who were treated twice weekly by etanercept therapy. Responders are defined by the presence of three of four American College of Rheumatology criteria: > or =20% decrease in C-reactive protein (CRP), visual analogue score of disease activity, erythrocyte sedimentation rate and improvement of the disease activity score (28; four values) by > or =1.2 obtained at 3 months. Twelve cytokines were measured from serum collected on days 0 and 90 by proteomic array (protein biochip array, Investigator Evidence, Randox France), including interleukin (IL)-6, TNF-alpha, IL-1a, IL-1b, IL-2, IL-8, interferon-gamma, IL-4, IL-10, monocyte chemoattractant protein (MCP)-1, epidermal growth factor (EGF) and vascular endothelium growth factor. Our results showed that high serum levels of MCP-1 and EGF were associated with a response to etanercept. In addition, the increase of two combined parameters CRP and EGF was predictive of a response to etanercept treatment at 3 months (sensitivity: 87.5% and specificity: 75%, accuracy: 84.4%). These findings suggest that cytokine profiling by proteomic analysis before treatment initiation may help to identify a responder patient to TNF-alpha blocking agents in RA.

Cost-effectiveness analysis in colorectal cancer using a semi-Markov model

Cost and effectiveness are usually modeled according to one studied event or one health state with parametric or non-parametric methods. In this paper, we propose an original method for assessing total costs while incorporating the dynamics of change in the health status of patients. A semi-Markov model in which the distributions of sojourn times are explicitly defined is developed. The hazard function of sojourn times is modeled by Weibull distributions specific to each transition. A vector of covariates is incorporated into the hazard function of each transition. From a regression model for costs, a cumulative cost function is derived. An estimation of the mean cost per patient in each state defined in the semi-Markov model could thus be made, and this enables us to identify the determinants of direct costs. The results of incremental net benefit (INB) are assessed using the bootstrap method. A cost-effectiveness analysis is performed in order to compare two strategies of follow-up in the colorectal cancer study. Two hundred and forty patients were enrolled in this study. Three health states are defined for patients with curative resection of colorectal cancer: alive without relapse, alive with relapse, and dead. The mean survival is 4.35 and 4.12 years, respectively, in the standard and moderate follow-up groups. We show that mean cost differs significantly by follow-up strategy and Dukes stage. Finally, the INB is assessed and this indicates that neither of the strategies compared was more cost-effective than the other.

A semi-Markov model for multistate and interval-censored data with multiple terminal events. Application in renal transplantation

The semi-Markov assumption emphasizes the importance of time spent in a state. In order to compute this type of multistate model, most transition times are always considered to be exactly identified or right censored. However, in the longitudinal analysis of chronic diseases, investigators are often confronted with interval-censored data (transition times are known to have occurred in some interval). Thus, the two key issues are the modeling of the duration dependence and the interval censoring. In this article, we define a semi-Markov model, allowing for interval censoring, for parametric hazard functions with a union or logical sum- or intersection-shape and for determination of initial states according to covariates. Our modeling approach is specific to each transition, so as to obtain a more coherent model. Parallel to competing risks models, the multistate model takes into account several final events. We consider an example of kidney transplant recipient follow-up to illustrate the utility of the method.

Skeletal age assessment from the olecranon for idiopathic scoliosis at Risser grade 0

BACKGROUND

The main progression of idiopathic scoliosis occurs during peak height growth velocity, which is between the ages of eleven and thirteen years in girls and thirteen and fifteen years in boys and corresponds to the accelerating phase of pubertal growth. The Risser sign remains at grade 0 during this stage of growth. Triradiate cartilage closure occurs at approximately twelve years of age in girls and fourteen years in boys, which is in the middle of this phase. In addition to regular height measurements, a more detailed evaluation of skeletal maturity would be desirable prior to the identification of Risser grade 1. From the method of Sauvegrain et al., Diméglio derived a simplified method based on the radiographic appearance of the olecranon, which allows skeletal age to be assessed in six-month intervals. The purpose of this study was to determine the accuracy and the value of this simple method for the follow-up of patients with scoliosis.

METHODS

Five radiographic images demonstrate the typical characteristics of the olecranon during pubertal growth: two ossification nuclei, a half-moon image, a rectangular shape, the beginning of fusion, and complete fusion. This classification method was evaluated by three experienced and independent observers from lateral radiographs of the elbow in 100 boys and 100 girls with idiopathic scoliosis during the time of peak height velocity. Skeletal ages were correlated with the integral Sauvegrain method. The degree of interobserver concordance was determined, and skeletal age was compared with chronological age and the time of triradiate cartilage closure.

RESULTS

For the three observers, the average concordance between the Sauvegrain and olecranon methods was excellent (r = 0.977 for boys and r = 0.938 for girls). The interobserver agreement was also excellent (r = 0.987 for the olecranon method and r = 0.958 for the Sauvegrain method for boys, and r = 0.992 and r = 0.985, respectively, for girls). Skeletal and chronological age were considered to correspond to each other within a six-month range for 49% of the boys and 51% of the girls, while 25% of the boys and 26% of the girls had an advanced skeletal age and 26% of boys and 23% of girls had a delayed skeletal age. Triradiate cartilage closure occurred at the same time as the appearance of the rectangular shape of the olecranon in 65% of the boys and 61% of the girls, corresponding to skeletal ages of fourteen and twelve years, respectively. In 91% of the boys and 88% of the girls, the triradiate cartilage fused within six months before to six months after the appearance of the rectangular shape of the olecranon, which occurred between the half-moon image and the beginning of fusion of the olecranon.

CONCLUSIONS

The method of assessing skeletal age from the olecranon allows skeletal maturity to be evaluated in regular six-month intervals during the phase of peak height velocity. This method is simple, precise, and reliable. It complements the Risser grade-0 and the triradiate cartilage evaluation.

Ten-Year Follow-Up of a Consecutive Series of Children With Multichannel Cochlear Implants

OBJECTIVES

To assess a group of children who consecutively received implants more than 10 years after implantation with regard to speech perception, speech intelligibility, receptive language level, and academic/occupational status.

STUDY DESIGN

A prospective longitudinal study.

SETTING

Pediatric referral center for cochlear implantation.

PATIENTS

Eighty-two prelingually deafened children received the Nucleus multichannel cochlear implant.

INTERVENTIONS

Cochlear implantation with Cochlear Nucleus CI22 implant.

MAIN OUTCOME MEASURES

The main outcome measures were open-set Phonetically Balanced Kindergarten word test, discrimination of sentences in noise, connective discourse tracking (CDT) using voice and telephone, speech intelligibility rating (SIR), vocabulary knowledge measured using the Peabody Picture Vocabulary Test (Revised), academic performance on French language, foreign language, and mathematics, and academic/occupational status.

RESULTS

After 10 years of implant experience, 79 children (96%) reported that they always wear the device; 79% (65 of 82 children) could use the telephone. The mean scores were 72% for the Phonetically Balanced Kindergarten word test, 44% for word recognition in noise, 55.3 words per minute for the CDT, and 33 words per minute for the CDT via telephone. Thirty-three children (40%) developed speech intelligible to the average listener (SIR 5), and 22 (27%) developed speech intelligible to a listener with little experience of deaf person's speech (SIR 4). The measures of vocabulary showed that most (76%) of children who received implants scored below the median value of their normally hearing peers. The age at implantation was the most important factor that may influence the postimplant outcomes. Regarding educational/vocational status, 6 subjects attend universities, 3 already have a professional activity, 14 are currently at high school level, 32 are at junior high school level, 6 additional children are enrolled in a special unit for children with disability, and 3 children are still attending elementary schools. Seventeen are in further noncompulsory education studying a range of subjects at vocational level.

CONCLUSION

This long-term report shows that many profoundly hearing-impaired children using cochlear implants can develop functional levels of speech perception and production, attain age-appropriate oral language, develop competency level in a language other than their primary language, and achieve satisfactory academic performance.

Impact of infection control interventions and antibiotic use on hospital MRSA: a multivariate interrupted time-series analysis

Hospitals in the northeast of Scotland have experienced methicillin-resistant Staphylococcus aureus (MRSA) outbreaks since 1997. Several infection control measures were introduced sequentially to control MRSA, and antibiotic use has been monitored. From January 1997 to December 2004, data on the monthly percentage of non-duplicate MRSA infections (%MRSA) were collated from an intervention hospital (IH) and a control hospital (CH). Both hospitals introduced the use of alcohol hand gel in November 2002. Furthermore, the IH introduced an environmental MRSA swabbing programme in March 2001, chlorine disinfection of the environment in September 2001, discharge screening in December 2001, admission screening in November 2003 and environmental audits in March 2004. Multivariate dynamic regression analysis was used to evaluate the longitudinal effects of these interventions as measured by new clinical cases of MRSA. At the IH, the %MRSA increased between January 1998 and January 2001 and then decreased. At the CH, the %MRSA increased from January 1997 to December 2004. Introduction of alcohol hand gel was associated with an absolute decrease in %MRSA of 21% and 30%, respectively, for the IH and CH. At the IH, introduction of chlorine disinfection and environmental swabbing were, respectively, associated with a decrease in %MRSA of 27% immediately and 32% 3 months later. Discharge screening and environmental audit did not significantly affect %MRSA, whereas admission screening was associated with a 22% decrease in %MRSA 4 months later. Increasing macrolide use was associated with increasing %MRSA in both hospitals, and increasing quinolone use was associated with increasing %MRSA in the CH. Implementation of stepwise infection control measures was associated with a decrease in %MRSA in the IH. Introduction of an alcohol gel for hand hygiene was associated with a decrease in %MRSA in both hospitals. Antibiotic use also affects %MRSA, in particular that of macrolides and quinolones.

Dorsal arthrodesis of thoracic spine and effects on thorax growth in prepubertal New Zealand white rabbits

STUDY DESIGN

Dorsal arthrodesis of thoracic spine in a prepubertal New Zealand White rabbit model.

OBJECTIVE

Evaluating the consequences of dorsal arthrodesis on the growth of the spine, sternum, and thorax in prepubertal rabbits, through the study of CT scans.

SUMMARY OF BACKGROUND DATA

Vertebral arthrodesis in the treatment of progressive idiopathic scoliosis in prepubertal patients is not ideal, but is still a choice in treating major deformities of the spine. Postoperative assessment of spinal deformity is essential, feasible, and recordable through CT scans.

METHODS

Twelve female rabbits, 9 weeks old, were subjected to surgery for dorsal arthrodesis of the upper thoracic spine. Surgery involved the implant of 2 "C"-shaped titanium bars, which were placed beside the spinous processes of the thoracic vertebrae. Three CT scans were performed, 10 (T1), 55 (T2), and 139 (T3) days after surgery. Measures were obtained by Myrian Pro software for 3 different groups: G1 with complete fusion, G2 with incomplete fusion, and G3 sham-operated.

RESULTS

The average of the dorsoventral/laterolateral thoracic diameter ratio at fused levels is lower than 1 in G1 as well as in G2; on the contrary, in G3 is higher than 1. The average growth of the sternum length between T1 and T2 and between T2 and T3 is minor in G1 than in G2 and G3. The dorsal and ventral lengths of thoracic vertebral bodies in the spinal segment D1-D6 is smaller in G1 and G2 than in G3, whereas no differences were observed between the 3 groups in the D7-D12 segment without arthrodesis.

CONCLUSION

Dorsal arthrodesis in prepubertal rabbits changes thoracic growth patterns. In operated rabbits, the dorsoventral thoracic diameter grows more slowly than the laterolateral thoracic diameter. The sternum as well as the lengths of thoracic vertebral bodies in the spinal segment D1-D6 grow less. The crankshaft phenomenon is evident at the fused vertebral levels where there is a reduction of thoracic kyphosis.

Breast cancer incidence and hormone replacement therapy: results from the MISSION study, prospective phase

BACKGROUND

The MISSION Study (Menopause: Risk of Breast Cancer, Morbidity and Prevalence) is a historical-prospective study with random patient selection to determine breast cancer incidence in postmenopausal women with or without hormone replacement therapy (HRT). The first prospective follow-up phase started on 5 January 2004 and the cut-off date for data collection was 30 June 2006.

PARTICIPANTS

Patients were divided into two groups: an 'exposed group' of women on HRT regimens commonly prescribed in France or who had stopped < or =5 years previously; and an 'unexposed group' of women who had never received HRT or stopped >5 years previously. In total 6755 patients were included; and prospective data were available for 4949 patients: 2693 in the exposed group and 2256 in the unexposed group. Women in the exposed group were younger, less overweight, and had fewer first-degree family histories of breast cancer than women of the unexposed group. Mean duration of HRT exposure was 8.3 years, with 31% being exposed for > or =10 years.

RESULTS

The incidence of new breast cancer cases was 0.64% in the exposed group and 0.70% in the unexposed group (relative risk RR(exposed/unexposed) = 0.914, 95% confidence interval = 0.449-1.858; not modified when adjusted for age). Mean age at breast cancer diagnosis was similar in both groups. Breast cancer incidence in the exposed group was not significantly affected by the route of estradiol administration (cutaneous 0.69%; oral 0.52%) or HRT type (estradiol alone 0.28%; estradiol + progesterone 0.40%; estradiol + synthetic progestin 0.94%).

CONCLUSION

No evidence was found for an increased risk of breast cancer in women exposed to HRT compared with non-exposed women.

Treating allergic rhinitis in pregnancy

Numerous pregnant women suffer from allergic rhinitis, and particular attention is required when prescribing drugs to these patients. In addition, physiologic changes associated with pregnancy could affect the upper airways. Evidence-based guidelines on the management of allergic rhinitis have been published. Medication can be prescribed during pregnancy when the apparent benefit of the drug is greater than the apparent risk. Usually, there is at least one "safe" drug from each major class used to control symptoms. All glucocorticosteroids are teratogenic in animals but, when the indication is clear (for diseases possibly associated, such as severe asthma exacerbation), the benefit of the drug is far greater than the risk. Inhaled glucocorticosteroids (eg, beclomethasone or budesonide) have not been incriminated as teratogens in humans and are used by pregnant women who have asthma. A few H1-antihistamines can safely be used as well. Most oral decongestants (except pseudoephedrine) are teratogenic in animals. There are no such data available for intranasal decongestants. Finally, pregnancy is not considered to be a contraindication for the continuation of immunotherapy.

Factor V Leiden mutation and pregnancy-related venous thromboembolism: what is the exact risk? Results from a meta-analysis

The magnitude of the association of factor V Leiden mutation with pregnancy-related venous thrombosis remains unclear. Our objective was to undertake a systematic review and a metaanalysis of the literature to estimate precisely the association of factorV Leiden mutation with the risk of first, or recurrent, pregnancy-related venous thromboembolism. Studies published before October 2005 were identified by Medline((R)). Using both fixed and random effect models, odds ratios (OR) with accompanying 95% confidential intervals (CI) were calculated for the factor V Leiden mutation and the clinical end-point (Yusuf-Peto adaptation of the Mantel-Haenszel, DerSimonian and Laird method). We identified 13 studies including 7 cohorts and 6 casecontrol studies relating to factor V Leiden and pregnancy-related venous thrombosis. The results from the cohorts showed a pooled OR of 4.46 (95% CI, 1.82-10.94; 7,879 pooled women), with no evidence of statistical heterogeneity (p = 0.36), for the risk of a first venous thromboembolism during pregnancy or the postpartum period associated with the factor V Leiden mutation. Case-control studies revealed a higher risk (OR 8.6, 95% CI, 5.85-12.63; 1,433 [corrected] pooled women) with significant heterogeneity (p < 0.005). Because of insufficient data, an analysis for the risk of recurrence could not be performed. Our findings emphasize the fact that limited data are available on this topic. This meta-analysis provides clinicians with an estimate of the average risk of a first thrombosis occurring during pregnancy in women carrying the factor V Leiden to assist the management of such women.

Low doses of GM-CSF (molgramostim) and G-CSF (filgrastim) after cyclophosphamide (4 g/m2) enhance the peripheral blood progenitor cell harvest: results of two randomized studies including 120 patients

The use of a combination of G-CSF and GM-CSF versus G-CSF alone, after cyclophosphamide (4 g/m2) was compared in two randomized phase III studies, including 120 patients. In study A, 60 patients received 5 x 2 microg/kg/day of G-CSF and GM-CSF compared to 5 mug/kg/day of G-CSF. In study B, 60 patients received 2.5 x 2 microg/kg/day G-CSF and GM-CSF compared to G-CSF alone (5 microg/kg/day). With the aim to collect at least 5 x 10(6)/kg CD34 cells in a maximum of three large volume leukapherises (LK), 123 LK were performed in study A, showing a significantly higher number of patients reaching 10 x 10(6)/kg CD34 cells (21/29 in G+GM-CSF arm vs 11/27 in G-CSF arm, P=0.00006). In study B, 109 LK were performed, with similar results (10/27 vs 15/26, P=0.003). In both the study, the total harvest of CD34 cells/kg was twofold higher in G-CSF plus GM-CSF group (18.3 x 10(6) in study A and 15.85 x 10(6) in study B) than in G-CSF group (9 x 10(6) in study A and 8.1 x 10(6) in study B), a significant difference only seen in multiple myeloma, with no significant difference in terms of mobilized myeloma cells between G-CSF and GM-CSF groups.

Radiological damage in patients with rheumatoid arthritis on sustained remission

OBJECTIVE

To assess the radiological damage progression in patients with recent rheumatoid arthritis in sustained remission.

METHODS

A cohort of 191 patients with active early (<1 year) rheumatoid arthritis was prospectively assessed at baseline, 3 and 5 years by the Disease Activity Score (DAS) and the Sharp-van der Heijde Score (SHS) for radiographic damage. Patients in remission (DAS<1.6) at the 3-year and 5-year time points were compared with patients with a persistently active rheumatoid arthritis by Wilcoxon's signed rank test.

RESULTS

57 patients died, were lost to follow-up or had incomplete data; 30 (15.7% of those who completed) patients were in remission at 3 and 5 years. The SHS in these two groups was not significantly different at baseline (p = 0.15), but was lower in the remission group at 5 years (p = 0.0047). The median (IQR) radiographic score increased from 0.5 (0-7) at baseline to 2.5 (0-14) after 5 years for the remission group (p = 0.18) and from 2 (0-7) to 13 (3-29) in the group with active rheumatoid arthritis (p<0.001). 5 (16.7%) patients in remission had relevant progression of radiographic damage (ie, progression >4.1 points) and 6 (20%) presented new erosions in a previously unaffected joint between the third and the fifth years.

CONCLUSION

Patients with early rheumatoid arthritis in sustained remission did not present statistically significant radiographic degradation at the group level; nevertheless, 16.7% of these patients did present degradation. Absence of progression should be part of the remission definition in rheumatoid arthritis.