Frequency and predictors of decompressive craniectomy in ischemic stroke patients treated by mechanical thrombectomy in the ETIS registry

BACKGROUND AND AIMS

Mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) is usually performed in a comprehensive stroke center with on-site neurosurgical expertise. The question of whether MT can be performed in a primary stroke center without a neurosurgical facility is debated. In this context, there is a need to determine the frequency, delay and predictors of neurosurgical procedures in patients treated by MT. This study aims to determine these factors.

METHODS

In total, 432 patients under 60years old, diagnosed with an acute ischemic stroke with a large vessel occlusion and treated by MT between January 2018 and December 2019 in six French stroke centers, were selected from the French clinical registry ETIS. Univariate and multivariate logistic regression models were used to identify predictive factors for decompressive craniectomy.

RESULTS

Among the 432 included patients, 43 (9.9%) patients with an anterior circulation infarct underwent decompressive craniectomy. Higher admission NIHSS (OR: 1.08 [95% CI: 1.02-1.16]), lower ASPECT (OR per 1 point of decrease 1.53 [1.31-1.79] P<0.001) and preadmission antiplatelet use (OR: 3.03 [1.31-7.01]) were independent risk factors for decompressive craniectomy. The risk of decompressive craniectomy increases to more than 30% with an ASPECT score<4, an NIHSS>16, and current antiplatelet use.

CONCLUSION

In this multicenter registry, 9% of acute ischemic stroke patients (<60years old) treated with MT, required decompressive craniectomy. Higher NIHSS score, lower ASPECT score, and preadmission antiplatelet use increase the risk of subsequent requirement for decompressive craniectomy.

[Evaluation of the success of medical abortion by a plasma hCG control threshold]

OBJECTIVES

In France, monitoring of the success of medical abortion is recommended 2 to 3 weeks after the procedure. However, there is no clear consensus on the modalities of this monitoring. The main objective of this study is to identify a threshold of serum hCG (human chorionic gonadotropin) control for medical abortions ≤7 weeks of gestation below which success can be confirmed without recourse to pelvic ultrasound.

METHODS

This is a retrospective multicenter study conducted over a 14-month period. The serum hCG level, measured between the 15th and 25th day following the abortion, was compared with the results of the pelvic ultrasound performed at the follow-up visit. Ultrasound failure was defined as retention or persistent pregnancy.

RESULTS

Among the 624 women included, the failure rate was 22.3%, including 86.3% of retentions, 8.6% of pregnancies stopped and 5% of pregnancies progressed. Using a ROC curve, the threshold value of hCG found to exclude failure at 95% was 253 IU/l (AUC=0.9202, sensitivity=84.17%, specificity=85.95% and positive predictive value [PPV]=63%).

CONCLUSIONS

A serum hCG level ≤253 IU/l is sufficient to affirm the efficacy of medical abortion. However, since PPV is only 63% for this threshold, ultrasound should be reserved for women with high hCG levels.

FRI0348 PERSISTENCE OF SECUKINUMAB AND USTEKINUMAB IN PSORIATIC ARTHRITIS: A REAL-WORLD MULTICENTRIC COHORT OF 409 PATIENTS

Background:

Real-world data are missing for Ustekinumab (UST) and secukinumab (SEK) in psoriatic arthritis (PsA).

Objectives:

To evaluate the characteristics of the patients (pts) with PsA treated by UST or SEK and to assess real world persistence of UST and SEK in PsA.

Methods:

This is a retrospective, multicenter study of pts with PsA (CASPAR criteria or diagnosis confirmed by a rheumatologist) initiating UST or SEK with a follow-up ≥ 6 months from January 2011 to April 2019. The comparison of persistence between UST and SEK was analysed using a Cox model with an inverse probability of treatment weighting propensity score including 11 confounding factors. Subgroup analyses (age>65 years, gender, Body Mass Index (BMI), Charlson score>2, psoriasis, CRP>5mg/L, number (nb) of prior biotherapies, proportion of pts on maximum dose of UST or SEK, combination with methotrexate (MTX), enthesitic and axial forms of PsA) were also performed to test the heterogeneity of UST and SEK persistence. Finally, 2 sensitivity analyses were performed, first excluding the pts treated before the marketing authorization of SEK, and then excluding the pts that underwent a molecule switch. Causes of discontinuation were also collected.

Results:

406 pts were included: 245 with UST and 161 with SEK. At baseline before propensity score-matching, the UST group has a higher BMI (28.9 ± 6.4 kg/m2vs. 27.4 ± 6.0 kg/m2), more peripheral forms (98% vs. 90.8%), a higher nb of active smokers (27.1% vs. 19.9%), a higher frequency of psoriasis (96.3% vs. 83.2%), less MTX users (38.9% vs. 44.2%), a higher nb of pts with CRP >5mg/L (54.3% vs. 47%), a higher nb of pts naïve to biotherapies (22% vs. 13%) and a higher nb of pts with recommended dosing (97.3% vs 50.9%). The median persistence was 9.4 months and 14.7 months for UST and SEK, respectively. The persistence rate was lower in the UST group compared to the SEK group (40.9% vs. 59.1% % at 1 year; 26.4% vs. 38.0% at 2 years; weighted HR=1.42; 95% CI 1.07 to 1.92; p=0.015) (Fig 1). In subgroup analysis, combination with MTX was associated with a higher persistence rate in the patients with SEK compared to those receiving UST: 43.6% vs. 23.2% (HR=2.20; 95% CI 1.30 to 3.51; p=0.001), whereas no difference was observed in SEK and UST monotherapy: 33.8% vs 28.4%, respectively (HR=1.06; 95% CI 0.74 to 1.53; p=0.75) (Fig 2). A similar difference was found in the sensitivity analyses, with however a difference at the limit of significance for the analysis excluding pts with a molecule switch (adjusted HR=1.35; IC95% 0.96 to 1.92; p=0.085). The causes of discontinuation were due to inefficacy in 85% of cases and an adverse event in 12% of cases (19% in the SEK group and 9% in the UST group).

Conclusion:

In this first real-world study comparing UST and SEK persistence in PsA, the persistence of SEK was longer than that of UST. Subgroup analysis revealed this difference of persistence was restricted to patients treated in combination with MTX.

Disclosure of Interests:

Jean-Guillaume Letarouilly Grant/research support from: Research grant from Pfizer, Benoît Flachaire: None declared, Céline Labadie: None declared, Nicolas Cohen Speakers bureau: Novartis, Janssen, Maeva Kyheng: None declared, Jérémie SELLAM: None declared, Pascal Richette: None declared, Philippe Dieudé: None declared, Pascal Claudepierre Speakers bureau: Janssen, Novartis, Lilly, Bruno Fautrel Grant/research support from: AbbVie, Lilly, MSD, Pfizer, Consultant of: AbbVie, Biogen, BMS, Boehringer Ingelheim, Celgene, Lilly, Janssen, Medac MSD France, Nordic Pharma, Novartis, Pfizer, Roche, Sanofi Aventis, SOBI and UCB, Eric Houvenagel Speakers bureau: Janssen, Novartis, Chi Duc Nguyen: None declared, Marie-Hélène Guyot: None declared, Nicolas Segaud: None declared, Frederic Maury: None declared, Laurent Marguerie: None declared, Xavier Deprez Speakers bureau: Novartis, Janssen, Jean-Hugues Salmon Speakers bureau: Novartis, Janssen, Guy Baudens: None declared, Corinne Miceli Richard: None declared, Elisabeth Gervais Speakers bureau: Novartis, Janssen, Roche, Pfizer, BMS, Abbvie, Isabelle CHARY VALCKENAERE: None declared, Pierre Lafforgue Speakers bureau: Novartis, Janssen, Damien LOEUILLE: None declared, Christophe Richez Consultant of: Abbvie, Amgen, Mylan, Pfizer, Sandoz and UCB., Thao Pham Speakers bureau: Novartis, Janssen, Lilly, Rene-Marc Flipo Speakers bureau: Novartis, Janssen, Lilly

TMJ related short-term outcomes comparing two different osteosynthesis techniques for bilateral sagittal split osteotomy

OBJECTIVES

Bilateral sagittal split osteotomy (BSSO) is a morpho-functional surgery and post-surgical osteosynthesis may influence temporomandibular joint (TMJ) health. Our objective was to evaluate temporomandibular disorders (TMD) and TMJ symptoms after orthognathic surgery according to the type of osteosynthesis used in a population of patients with dentofacial deformities.

MATERIALS AND METHODS

One hundred and eighty-three consecutive patients undergoing orthodontic and maxillofacial surgery treatment for correction of their malocclusion were recruited for a two-year period at Lille University Hospital. All patients had at least a mandibular BSSO using Epker's technique. Each patient was examined before and one year after orthognathic surgery. We compared osteosynthesis by miniplates fixed with monocortical screws (n=42) and the hybrid fixation with bicortical retro-molar screws used with miniplates (n=141). TMJ health was assessed by monitoring TMD signs and symptoms according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) and scores obtained from the "Jaw Pain Function" questionnaire.

RESULTS

There was no significant difference in pre-operative and one year post-operative RDC/TMD assessments (p≥0.91) or JPF score (p≥0.29) between the two types of osteosynthesis.

CONCLUSION

There was no difference in TMJ health between the two techniques of osteosynthesis after BSSO.

CLINICAL RELEVANCE

In our experience the hybrid technique fixation affords many advantages and does not influence postoperative TMD compared with osteosynthesis by miniplates.

Quality of life associated with orthotopic neobladder and ileal conduit in women: A multicentric cross-sectional study

PURPOSE

To compare quality of life and functional outcomes associated with orthotopic neobladder (ONB) and ileal conduit (IC) after anterior pelvic exenteration for bladder cancer in women, through a multicentric cross-sectional study.

METHODS

All women who have undergone an anterior pelvic exenteration associated with ONB or IC for a bladder cancer between January 2004 and December 2014 within the three participating university hospital centers and that were still alive in February 2016 were included. Three distinct auto-administered questionnaires were submitted to the patients: the EORTC QLQ-C30, the EORTC QLQ-BLmi30 and the SF-12. Comparison of response to these questionnaires between women with ONB and those with IC were studied with Mann-Whitney U tests, with a statistically significant P-value set at<0.05. The primary endpoint was the "global health status" sub-score extracted from the EORTC QLQ-C30 questionnaire. The secondary endpoints were the functional sub-scores and symptoms sub-scores obtained with the EORTC QLQ-C30 questionnaire as well as the sub-scores obtained with the EORTC QLQ-BLmi30 and the SF-12 questionnaires.

RESULTS

Forty women were included in the study (17 ONB, 23 IC). The primary endpoint was comparable between the ONB and IC women (83.3 vs. 66.7 P=0.22). Similarly, no significant statistical difference could be pointed between the ONB and IC women in terms of secondary endpoints.

CONCLUSION

The present study did not report any significance difference in terms of quality of life and functional outcomes between women with ONB and those with IC after pelvic exenteration for bladder cancer.

LEVEL OF EVIDENCE

3.

Long-term effects of pulmonary rehabilitation on daily life physical activity of patients with stage IV sarcoidosis: A randomized controlled trial

INTRODUCTION

Pulmonary rehabilitation (PR) is known to improve exercise tolerance, mood, and quality of life in patients with chronic respiratory diseases. The aim of this work was to determine whether PR provides long-term benefits in increasing daily life physical activity in patients with chronic sarcoidosis.

METHODS

This randomized prospective study (registered ClinicalTrials.gov NCT02044939) of 38 patients with stage IV chronic sarcoidosis was performed between 2012 and 2016. Patients were assigned to participate in a 2-month PR program (n=20) or receive counseling (n=18). Assessments were performed at baseline, 2 months (end of the PR program), 6months, and 12months, and included daily life physical activity parameters (measured for 5 consecutive days), exercise tolerance, dyspnea, anxiety, depression, fatigue, and quality of life. The primary outcome was the 12-month change in time spent in activities above an estimated energy expenditure of 2.5metabolic equivalents (METs). Secondary daily life physical activity outcomes included number of steps per day, total daily energy expenditure, and total energy expenditure above 2.5METs.

RESULTS

The primary outcome did not differ between the two groups; mean between-group differences were -13.2min (95% confidence interval [CI]: -76.3 to 49.8) at 6 months and -18.1min (95% CI: -55.7 to 19.4) at 12months. Although PR had no effect on secondary daily life physical activity outcomes, it did significantly increase exercise tolerance at 6 and 12 months and decrease the dyspnea score at 6 months and the fatigue score at 12months.

CONCLUSION

This trial failed to demonstrate a beneficial effect of PR on daily life physical activity in sarcoidosis patients, suggesting that long-term behavioral programs may be necessary to complement PR.

First-Line Sofia Aspiration Thrombectomy Approach within the Endovascular Treatment of Ischemic Stroke Multicentric Registry: Efficacy, Safety, and Predictive Factors of Success

BACKGROUND AND PURPOSE

After publications on the effectiveness of mechanical thrombectomy by stent retrievers in acute ischemic stroke with large-vessel occlusion, alternative endovascular approaches have been proposed using first-line aspiration catheters. Several devices are currently available to perform A Direct Aspiration First Pass Technique. The Sofia catheter aspiration has been widely used by interventionalists, but data are scarce about its efficacy and safety. Our aim was to report our multicenter thrombectomy experience with first-line Sofia catheter aspiration and to identify independent prognostic factors of clinical and procedural outcomes.

MATERIALS AND METHODS

We performed a retrospective analysis of the prospectively maintained Endovascular Treatment of Ischemic Stroke multicentric registry. Data from consecutive patients who benefited from thrombectomy with a first-line Sofia approach between January 2013 and April 2018 were studied. We excluded other first-line approaches (stent retriever or combined aspiration and stent retriever) and extracranial occlusions. Baseline characteristics, procedural data, and angiographic and clinical outcomes were analyzed.

RESULTS

During the study period, 296 patients were treated. Mean age and initial NIHSS score were, respectively, 69.5 years and 16. Successful reperfusion, defined by the modified TICI 2b/3, was obtained in 86.1% (n = 255; 95% CI, 81.7%-89.9%). Complete reperfusion (modified TICI 3) was obtained in 41.2% (n = 122; 95% CI, 35.5%-47.1%). A first-pass effect was achieved in 24.2% (n = 71; 95% CI, 19.4%-29.6%). A rescue stent retriever approach was required in 29.7% (n = 88; 95% CI, 24.6%-35.3%). The complication rate was 9.5% (n = 28; 95% CI, 6.4%-13.5%). Forty-three percent (n = 122; 95% CI, 37.1%-48.9%) of patients presented with a favorable 3-month outcome (mRS ≤ 2). Older age, M1-occlusion topography, and intravenous thrombolysis use prior to thrombectomy were independent predictors of the first-pass effect.

CONCLUSIONS

The first-line contact aspiration approach appeared safe and efficient with Sofia catheters. These devices achieved very high reperfusion rates with a low requirement for stent retriever rescue therapy, especially for M1 occlusions.

[Cervical ripening and labor induction: Evaluation of single balloon catheter compared to double balloon catheter and dinoprostone insert]

OBJECTIVE

To compare the effectiveness of single balloon catheter with double balloon catheter and dinoprostone insert for cervical ripening and labor induction on unfavourable cervix.

METHODS

this is a comparative, retrospective, one-center trial. Were included singleton pregnancy in cephalic presentation. Were excluded cicatricial uterus. The outcomes were vaginal delivery rate, caesarean section rate, modification in Bishop score, time from induction to delivery, second time prostaglandin E2 resort, oxytocin administration resort, maternal or neonatal adverse events.

RESULTS

Were included 108 patients: 45 in single balloon catheter group, 32 in double balloon catheter group, 31 in dinoprostone insert group. Vaginal delivery rate was similar in single balloon catheter group (78 %) compared with others groups (75 % in double balloon catheter and 71 % in dinoprostone insert group respectively). Oxytocin administration resort was superior in single balloon catheter group. There was no significant difference on others outcomes. Labor induction costs were 9euros in single balloon catheter group, versus 55 and 81 euros in double balloon catheter group and dinoprostone insert group respectively.

CONCLUSIONS

Single balloon catheter seems just as effective as double balloon catheter and dinoprostone insert with its major asset the low cost for labor induction.

MRI of the cervical spinal cord predicts respiratory dysfunction in ALS

For patients with amyotrophic lateral sclerosis (ALS), the primary therapeutic goal is to minimize morbidity. Non-invasive ventilation improves survival. We aim to assess whether Magnetic Resonance Imaging (MRI) of the cervical spinal cord predicts the progression of respiratory disorders in ALS. Brain and spinal MRI was repeatedly performed in the SOD1^G86R mouse model, in 40 patients and in healthy controls. Atrophy, iron overload, white matter diffusivity and neuronal loss were assessed. In Superoxide Dismutase-1 (SOD1) mice, iron accumulation appeared in the cervical spinal cord at symptom onset but disappeared with disease progression (after the onset of atrophy). In ALS patients, the volumes of the motor cortex and the medulla oblongata were already abnormally low at the time of diagnosis. Baseline diffusivity in the internal capsule was predictive of functional handicap. The decrease in cervical spinal cord volume from diagnosis to 3 months was predictive of the change in slow vital capacity at 12 months. MRI revealed marked abnormalities at the time of ALS diagnosis. Early atrophy of the cervical spinal cord may predict the progression of respiratory disorders, and so may be of value in patient care and as a primary endpoint in pilot neuroprotection studies.