The Severity of Congenital Hypothyroidism With Gland-In-Situ Predicts Molecular Yield by Targeted Next-Generation Sequencing

INTRODUCTION

Congenital hypothyroidism with gland-in-situ (CH-GIS) is usually attributed to mutations in the genes involved in thyroid hormone production. The diagnostic yield of targeted next-generation sequencing (NGS) varied widely between studies. We hypothesized that the molecular yield of targeted NGS would depend on the severity of CH.

METHODS

Targeted NGS was performed in 103 CH-GIS patients from the French national screening program referred to the Reference Center for Rare Thyroid Diseases of Angers University Hospital. The custom targeted NGS panel contained 48 genes. Cases were classified as solved or probably solved depending on the known inheritance of the gene, the classification of the variants according to the American College of Medical Genetics and Genomics, the familial segregation, and published functional studies. Thyroid-stimulating hormone at CH screening and at diagnosis (TSHsc and TSHdg) and free T4 at diagnosis (FT4dg) were recorded.

RESULTS

NGS identified 95 variants in 10 genes in 73 of the 103 patients, resulting in 25 solved cases and 18 probably solved cases. They were mainly due to mutations in the TG (n = 20) and TPO (n = 15) genes. The molecular yield was, respectively, 73% and 25% if TSHsc was ≥ and < 80 mUI/L, 60% and 30% if TSHdg was ≥ and < 100 mUI/L, and 69% and 29% if FT4dg was ≤ and > 5 pmol/L.

CONCLUSION

NGS in patients with CH-GIS in France found a molecular explanation in 42% of the cases, increasing to 70% when TSHsc was ≥ 80 mUI/L or FT4dg was ≤ 5 pmol/L.

Hyperglycaemic hyperosmolar state and cerebral thrombophlebitis in paediatrics: A case report

INTRODUCTION

Hyperglycaemic hyperosmolar state (HHS) is a known complication of type 2 diabetes mellitus; however, carbonated carbohydrate fluid intake may precipitate a more severe presentation of type 1 diabetes mellitus with hyperosmolar state. The management of these patients is not easy and can lead to severe complications such as cerebral venous thrombosis.

METHODS

We present the case of a 21-month-old boy admitted for consciousness disorders revealing a hyperglycaemic hyperosmolar state on a new-onset type 1 diabetes and who developed cerebral venous thrombosis.

RESULTS AND CONCLUSION

Emergency physicians should be aware of HHS in order to start the appropriate treatment as early as possible and to monitor the potential associated acute complications. This case highlights the importance of decreasing very gradually the osmolarity in order to avoid cerebral complications. Cerebral venous thrombosis in HHS paediatric patients is rarely described, and it is important to recognize that not all episodes of acute neurological deterioration in HHS or diabetic ketoacidosis are caused by cerebral oedema.

Changes in the clinical management of 5α-reductase type 2 and 17β-hydroxysteroid dehydrogenase type 3 deficiencies in France

OBJECTIVES

To examine the changes in diagnostic practices and clinical management of patients with 5α-reductase type 2 (SRD5A2) or 17β-hydroxysteroid dehydrogenase type 3 (HSD17B3) deficiency since molecular diagnoses became available.

METHODS

Clinical, laboratory, and therapeutic data were retrieved from the medical records of 52 patients with a molecular diagnosis of SRD5A2 (n = 31) or HSD17B3 (n = 21) deficiency. Temporal trends regarding age at assessment and initial sex assignment over 1994-2020 were qualitatively analyzed. Age at molecular diagnosis was compared between two subgroups of patients according to their year of birth.

RESULTS

Fifty-eight percent (n = 30) patients were diagnosed during the perinatal period, 33% (n = 17) during infancy, and 9% (n = 5) during adolescence or adulthood. Over the studied period, the patients' age at initial assessment and diagnosis frankly decreased. The median (range) age at diagnostic confirmation was 10.5 (0-53.2) years for patients born before 2007 and 0.4 (0-9.3) years for those born in 2007 or later (P = 0.029). Genetic testing identified 27 different variants for the SRD5A2 gene (30% novel, n = 8) and 18 for the HSD17B3 gene (44% novel, n = 8). Before 2002, most patients were initially assigned as females (95%, n = 19), but this proportion dropped for those born later (44%, n = 14; P < 0.001). The influence of initial genital appearance on these decisions seemingly decreased in the most recent years. Therapeutic interventions differed according to the sex of rearing. Ten percent (n = 2) patients requested female-to-male reassignment during adulthood.

CONCLUSION

This study showed, over the past two decades, a clear trend toward earlier diagnosis and assignment of affected newborns as males.

Propranolol reduces IFN-γ driven PD-L1 immunosuppression and improves anti-tumour immunity in ovarian cancer

The immune system plays an important role in controlling epithelial ovarian cancer (EOC). EOC is considered to be a "cold tumour," a tumour that has not triggered a strong response by the immune system. However, tumour infiltrating lymphocytes (TILs) and the expression of programmed cell death ligand (PD-L1) are used as prognostic indicators in EOC. Immunotherapy such as PD-(L)1 inhibitors have shown limited benefit in EOC. Since the immune system is affected by behavioural stress and the beta-adrenergic signalling pathway, this study aimed to explore the impact of propranolol (PRO), a beta-blocker, on anti-tumour immunity in both in vitro and in vivo EOC models. Noradrenaline (NA), an adrenergic agonist, did not directly regulate PD-L1 expression but PD-L1 was significantly upregulated by IFN-γ in EOC cell lines. IFN-γ also increased PD-L1 on extracellular vesicles (EVs) released by ID8 cells. PRO significantly decreased IFN-γ levels in primary immune cells activated ex vivo and showed increased viability of the CD8⁺ cell population in an EV-immune cell co-incubation. In addition, PRO reverted PD-L1 upregulation and significantly decreased IL-10 levels in an immune-cancer cell co-culture. Chronic behavioural stress increased metastasis in mice while PRO monotherapy and the combo of PRO and PD-(L)1 inhibitor significantly decreased stress-induced metastasis. The combined therapy also reduced tumour weight compared to the cancer control group and induced anti-tumour T-cell responses with significant CD8 expression in tumour tissues. In conclusion, PRO showed a modulation of the cancer immune response by decreasing IFN-γ production and, in turn, IFN-γ-mediated PD-L1 overexpression. The combined therapy of PRO and PD-(L)1 inhibitor decreased metastasis and improved anti-tumour immunity offering a promising new therapy.

Health services gaps experienced by non-standard workers in Ontario, Canada: Policy implications

Background

While the Canadian universal health system provides access to basic services, key health benefits are employer dependent. Given that non-standard workers (NSWs) only rarely have access to such benefits they have increased vulnerability to the many insecurities derived from their precarious employment, as clearly seen during the pandemic. The growing problem of non-standard work and workers’ heightened risk for health status deterioration, followed by a possible accentuation of health inequities, is a population health concern. This study summarizes several health services gaps experienced by NSWs and discusses policy implications and possible solutions.

Methods

From January to July 2021, we conducted semi-structured interviews with a purposive sample of 40 NSWs in Ontario, Canada, part of a larger mixed-methods six-country study, including three European countries. The target population consisted of workers aged 25 to 55 who, at the time of the survey, were in non-standard employment or lost their job due to the COVID-19 pandemic.

Results

Our findings highlight complex physical and mental health problems and an overall high burden of disease facing NSWs during the pandemic as linked to a combination of constant stress and worry arising from their employment insecurity, the limited and inconsistent income available to cover their basic needs, and the inadequate and unsafe working conditions they are afraid to challenge. Despite their increased health needs, given that specialized health services are not available to them for free they face financial barriers in accessing much needed health services that could help improve their health status and as a result, delay seeking care or avoid it altogether.

Conclusions

Sustainable multi sectorial policy solutions are needed including the adoption of relevant labour market legislation and increases in social and health expenditures along with re-adjustments in the ways in which health services are delivered.

Key messages

• During the pandemic non-standard workers in Ontario, Canada experienced complex health problems and, despite increased health needs, encountered barriers in accessing specialized health services.

• The growing problem of non-standard work and workers’ heightened risk for health status deterioration, followed by a possible accentuation of health inequities, is a population health concern.

Hustle: Experiences of making work ‘work’ for non-standard and precariously employed workers in NYC

Background

Precarious and non-standard employment (NSE) has negative implications for workers’ health. As part of a six-country comparative mixed methods case study, this research explores US-based workers’ experiences in NSE and its influences on their health and well-being in a context of weak labor regulations and social welfare programs.

Methods

To understand US policy context, we analyzed country-level labor regulatory and social protection frameworks using 2019 Organization for Economic Cooperation and Development data. To understand workers’ experiences, we conducted in-depth interviews with NSE workers in various occupations in New York City (N = 40) between January and May 2021. We recruited and screened eligibility via Facebook advertisements and an online questionnaire, respectively. We used deductive and inductive thematic analysis for interview data.

Results

With heavy reliance on market competition in the US, minimal state regulation and flexible labor markets create less secure employment along with limited government-funded social supports. Workers’ experiences center on the Hustle, i.e., figuring out how to make NSE work for them and their families. They lack healthcare coverage and have low expectations of other supportive employment and social protections (e.g., paid leave). While NSE payoffs (e.g., perceived flexibility) were common for most, almost all experience NSE tradeoffs (e.g., job insecurity and instability) that create stress and overwork, negatively implicating overall health and well-being. These impacts differ by access to resources associated with social location (e.g., immigration status). COVID-19 exacerbated these experiences.

Discussion

Low expectations of supportive policies of US workers in NSE are linked to the individualized hustle, as they attempt to counter NSE tradeoffs often relying on family to fill those gaps. Over-reliance on privatization for social supports such as healthcare coverage can be detrimental to workers’ health.

Key messages

Labor and social protection gaps impacting health of non-standard workers: An international study

Background

Labor regulations and social protection structures are intended to protect workers, but the needs of those in precarious and non-standard employment (NSE) are often missed, which may negatively impact health and well-being. The aim of this research is to document how workers in NSE in six countries - Belgium, Canada, Chile, Spain, Sweden, and the US - with varying policy contexts experience aspects of employment that are linked to health.

Methods

We employed a mixed methods approach for this study. To understand policy contexts, we analyzed country-level labor regulatory and social protection frameworks using 2019 Organization for Economic Cooperation and Development data. To understand the experiences of workers in NSE, we conducted 250 in-depth interviews with workers at different levels of employment precariousness between January and June 2021.

Results

Overall, European countries have the most social expenditures and North American countries have the weakest labor market regulations. In all these varying contexts, workers in NSE reported multiple unmet needs, e.g., inadequate paid sick and parental leave and unemployment compensation. These unmet needs occur due to various barriers, including poor enforcement, legal loopholes, or required minimum employment time. Workers’ living accommodations are also affected, as home financing or rental contracts are dependent on permanent employment. In response, they tended to rely disproportionately on individual or family resources for financial and social support rather than on government or employer resources.

Conclusions

Findings suggested that diverse labor regulatory and welfare regime contexts are unsupportive of workers in NSE due to multiple gaps in policies essential to public health. The shifting of responsibility for key employment and social supports to individuals and their families is likely to increase health inequities for workers in NSE.

Key messages

• Our study documents multiple policy gaps affecting key employment-related social determinants of health among workers in NSE.

• This occurred across diverse labor and social structure contexts in six countries.

The various insecurities experienced among non-standard workers across different policy-contexts

Background

Over the last decades, the prevalence of non-standard employment (NSE) has increased in many countries, with negative implications for worker health and well-being. Research at the micro level, mostly quantitative, has linked NSE with poor health through insecurity. Macro-level studies investigating whether political economic factors buffer the harms of NSE have generated mixed results. This study describes how various types of insecurity are experienced by workers in NSE, in general and during COVID-19, and how this influences their health and well-being, in six countries with different welfare states: Belgium, Canada, Chile, Spain, Sweden and the United States.

Methods

In-depth interviews with 250 workers in NSE were analysed using a multiple-case study approach and using the welfare state typology as a macro-level framework.

Results

Despite differences in welfare states, workers in all six countries experienced multiple forms of insecurity as well as relational tension with employers or clients, with clear negative effects on their well-being, in ways that were shaped by broader social inequalities (e.g., related to gender, age, and access to family support). Simultaneously, differences in welfare states were reflected in the level of workers’ exclusion from social protections, the temporality of difficulties they faced in planning their lives (e.g., threats to daily survival or to longer-term life planning), and their ability to derive control from NSE despite the insecurity it created. Workers in less generous welfare states experienced heightened insecurity and greater stress from the COVID-19, but the severity of the health and economic crisis was felt by workers in all study countries.

Conclusions

This study sheds light on the ways that welfare regimes can support - or fail to support - workers in NSE, and suggests the need in all six countries for stronger state responses to NSE, a pressing social determinant of health.

Key messages

Safety of Inulin and Sinistrin: Combining Several Sources for Pharmacovigilance Purposes

Introduction: Inulin and its analog sinistrin are fructose polymers used in the food and pharmaceutical industries. In 2018, The French National Agency for the Safety of Medicines and Health Products (ANSM) decided to withdraw products containing sinistrin and inulin due to several reports of serious hypersensitivity reactions, including a fatal outcome.

Objective: To assess the safety of inulin and sinistrin use in France.

Methods: We searched multiple sources to identify adverse reactions (ARs) to inulin or sinistrin: first, classical pharmacovigilance databases including the French Pharmacovigilance (FPVD) and the WHO Database (VigiBase); second, data from a clinical trial, MultiGFR; third, data regarding current use in an hospital. All potential ARs to inulin or sinistrin were analyzed with a focus on hypersensitivity reactions and relationships to batches of sinistrin.

Results: From 1991 to 2018, 134 ARs to inulin or sinistrin were registered in the FPVD or VigiBase. Sixty-three cases (47%) were classified as serious, and 129 cases (96%) were hypersensitivity reactions. We found an association between a batch of sinistrin and the occurrence of hypersensitivity reactions. During the MultiGFR clinical trial, 7 patients (7/163 participants) had an Adverse reaction; of these, 4 were hypersensitivity reactions including one case of grade 4 anaphylactic shock. In the hospital, no ARs were observed. In the literature, ARs to inulin and sinistrin are very rarely reported and mostly benign.

Conclusion: Most ARs to inulin and sinistrin are hypersensitivity reactions that appear to be associated with sinistrin batches.

Presenting features and molecular genetics of primary hyperparathyroidism in the paediatric population

AIM

To describe the presenting features and molecular genetics of primary hyperparathyroidism (PHPT) in the paediatric population.

METHODS

Retrospective study of 63 children diagnosed with primary PHPT from 1998 to 2018.

RESULTS

Compared to older children, infants were often asymptomatic (54% vs 15%, P = 0.002) with a milder form of PHPT. When symptomatic, children and adolescents mostly presented with non-specific complaints such as asthenia, depression, weight loss, vomiting or abdominal pain. A genetic cause of PHPT was identified in about half of this cohort (52%). The infancy period was almost exclusively associated with mutation in genes involved in the calcium-sensing receptor (CaSR) signalling pathway (i.e. CaSR and AP2S1 genes, 'CaSR group'; 94% of infants with mutations) whereas childhood and adolescence were associated with mutation in genes involved in parathyroid cell proliferation (i.e. MEN1, CDC73, CDKN1B and RET genes, 'cell proliferation group'; 69% of children and adolescents with mutations). Although serum calcium levels did not differ between the two groups (P = 0.785), serum PTH levels and the urinary calcium/creatinine ratio were significantly higher in 'cell proliferation group' patients compared to those in the 'CaSR group' (P = 0.001 and 0.028, respectively).

CONCLUSION

Although far less common than in adults, PHPT can develop in children and is associated with significant morbidity. Consequently, this diagnosis should be considered in children with non-specific complaints and lead to monitoring of mineral homeostasis parameters. A genetic cause of PHPT can be identified in about half of these patients.

Effects of advanced carbohydrate counting on glucose control and quality of life in children with type 1 diabetes

OBJECTIVE

The effect of advanced carbohydrate counting (ACC) on metabolic and quality of life (QOL) outcomes is uncertain in children with type 1 diabetes. Our aim was to determine whether ACC would improve HbA1c and QOL scores as compared with standard nutrition in this population.

METHODS

We randomized 87 patients using pump and rapid-acting analogs in a 1 year randomized multicenter study (age 9.6 ± 3.5 years, diabetes duration 4.6 ± 2.7 years, HbA1c 7.8 ± 0.5% [62 ± 5 mmol/mol]). The ACC group received CC education and the control group received traditional dietary education. HbA1c was measured every 3 months. At 0 and 1 year, general, diabetes-specific, and diet-related QOL were respectively assessed by the KIDSCREEN and WHO-5 questionnaires, the diabetes-specific module of the DISABKIDS, and the diet restriction items of the DSQOLS.

RESULTS

Mean HbA1c was lower in the ACC than the control group at 3 months (P < .05) and tended to be lower at 6 months (P = .10), 9 months (P = .10), but not at 12 months. The mean of individual average HbA1c during the one-year study period (from M3 to M12) was 7.63 ± 0.43 in the ACC vs 7.85 ± 0.47% in the control group (60 ± 5 vs 62 ± 5 mmol/mol)(P < .05). ACC was associated with significantly higher scores at 1 year on the KIDSCREEN children's psychological scale and the KIDSCREEN parents' physical scale, the DISABKIDS children's treatment scale, and the children's and parents' dietary restriction scales of the DSQOLS (indicating better QOL or lower perceived diet restriction).

CONCLUSIONS

ACC may be associated with small improvements in metabolic control and QOL scores in children.

Comment on: "A novel approach to peatlands as archives of total cumulative spatial pollution loads from atmospheric deposition of airborne elements complementary to EMEP data: Priority pollutants (Pb, Cd, Hg)" by Ewa Miszczak, Sebastian Stefaniak, Adam Michczyński, Eiliv Steinnes and Irena Twardowska

A recent paper by Miszczak et al. (2020) examines metal contamination of mires in Poland and Norway. The authors conclude that lead (Pb) records in ombrotrophic peatlands cannot be used to reconstruct the chronological history of anthropogenic activities due to post-depositional mobility of the metal. We contest this general conclusion which stands in contrast with a significant body of literature demonstrating that Pb is largely immobile in the vast majority of ombrotrophic peatlands. Our aim is to reaffirm the crucial contribution that peat records have made to our knowledge of atmospheric Pb contamination. In addition, we reiterate the necessity of following established protocols to produce reliable records of anthropogenic Pb contamination in environmental archives.

[Cesarean sections in the Centre-Val de Loire region: Practices and indications-the Robson Classification]

BACKGROUND

To study the cesarean section (c-section) practices in the French Centre-Val de Loire region: incidence of planned c-section and rate variations between maternities, incidence of potentially avoidable cesarean sections.

METHODS

The data were extracted from the 2016 regional birth register, which permitted classification of each planned c-section according to the pre-existing risk of c-section (high or low) as defined by the Robson classification. To enhance the data, especially the indications for c-section, which are not included in the register, a survey was conducted from September 2016 to February 2017 in all of the 20 maternities in the region.

RESULTS

In 2016, nearly 26,000 women gave birth in the CVL region, of whom 19.2% by c-section (7.0% planned c-sections). The planned c-section rate was higher for breech presentation and scarred uterus, and decreased according to level of the maternity (I 41% - II 35% - III 32%). Concerning the c-section indications, 1,979 c-sections were studied during the period (18.6% of births), including 762 planned c-sections (7.1% of births). Among them, 246 (32%) were potentially avoidable, mainly isolated indications of scarred uterus with only one previous c-section or breech presentation, and 17 due to unfavorable radiologic pelvimetry in nulliparous women.

CONCLUSION

Specific actions were identified: targeted use of radiologic pelvimetry, targeted c-section on scarred uterus with only one previous cesarean section or breech presentation, as recommended by the national guidelines. The Robson classification should be widely used to evaluate and enhance practices, in particularly through painstakingly interpreted inter-maternity comparisons.

92 Relocation in Care Homes (RICH) Study: The Experience of Different Stakeholders

Introduction

In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes.

Methods

In the UK, care homes in unsuitable older buildings are closing. Involuntary relocation is associated with increased mortality and negative emotions among residents. Extensive planning can mitigate this. The aim was to understand the experience of a planned relocation between two care homes.

Results

Seven themes were identified and organised under three stages: pre-move (communication and involvement; preparation for the move; and attitudes towards the move), day-of-the-move (organisation of the move), and post-move (environmental change and impact; staff organisation and management; and settling in). Family and staff members reported that the pre-move information provided was inconsistent and staff did not feel involved in the planning and design process. Pre-move visits and staff and family support were beneficial for residents’ preparation for the move. All participants expressed sadness about the closure, and reported apprehension about moving. The moving day felt disorganised and stressful to staff who had to spread between the two homes. Post-move, the new care home was perceived by many participants as a ‘hotel’ rather than a home. Its larger size and confusing layout impacted negatively on residents and staff. New staff and changes in management structure were perceived by the different stakeholders to cause increased staff workload. Residents adjusted variably to the new home, with family support and staff continuity of care proving to be facilitators.

Conclusions

Despite extensive planning, relocation and adjustment was challenging. Recommendations for future relocations include: increasing involvement of staff in the planning and design of the home; ensuring consistent communication and organising staff rotas to maintain continuity of care.

High Diagnostic Yield of Targeted Next-Generation Sequencing in a Cohort of Patients With Congenital Hypothyroidism Due to Dyshormonogenesis

OBJECTIVE

To elucidate the molecular cause in a well-characterized cohort of patients with Congenital Hypothyroidism (CH) and Dyshormonogenesis (DH) by using targeted next-generation sequencing (TNGS).

STUDY DESIGN

We studied 19 well-characterized patients diagnosed with CH and DH by targeted NGS including genes involved in thyroid hormone production. The pathogenicity of novel mutations was assessed based on in silico prediction tool results, functional studies when possible, variant location in important protein domains, and a review of the recent literature.

RESULTS

TNGS with variant prioritization and detailed assessment identified likely disease-causing mutations in 10 patients (53%). Monogenic defects most often involved TG, followed by DUOXA2, DUOX2, and NIS and were usually homozygous or compound heterozygous. Our review shows the importance of the detailed phenotypic description of patients and accurate analysis of variants to provide a molecular diagnosis.

CONCLUSIONS

In a clinically well-characterized cohort, TNGS had a diagnostic yield of 53%, in accordance with previous studies using a similar strategy. TG mutations were the most common genetic defect. TNGS identified gene mutations causing DH, thereby providing a rapid and cost-effective genetic diagnosis in patients with CH due to DH.

Colorectal cancer (CRC) monitoring by 6-monthly 18FDG-PET/CT: an open-label multicentre randomised trial

Background

[¹⁸F]2-fluoro-2-deoxy-d-glucose positron emission tomography/computed tomography (¹⁸FDG-PET/CT) has high sensitivity for detecting recurrences of colorectal cancer (CRC). Our objective was to determine whether adding routine 6-monthly ¹⁸FDG-PET/CT to our usual monitoring strategy improved patient outcomes and to assess the effect on costs.

Patients and methods

In this open-label multicentre trial, patients in remission of CRC (stage II perforated, stage III, or stage IV) after curative surgery were randomly assigned (1 : 1) to usual monitoring alone (3-monthly physical and tumour marker assays, 6-monthly liver ultrasound and chest radiograph, and 6-monthly whole-body computed tomography) or with 6-monthly ¹⁸FDG-PET/CT, for 3 years. A multidisciplinary committee reviewed each patient’s data every 3 months and classified the recurrence status as yes/no/doubtful. Recurrences were treated with curative surgery alone if feasible and with chemotherapy otherwise. The primary end point was treatment failure defined as unresectable recurrence or death. Relative risks were estimated, and survival was analysed using the Kaplan–Meier method, log-rank test, and Cox models. Direct costs were compared.

Results

Of the 239 enrolled patients, 120 were in the intervention arm and 119 in the control arm. The failure rate was 29.2% (31 unresectable recurrences and 4 deaths) in the intervention group and 23.7% (27 unresectable recurrences and 1 death) in the control group (relative risk = 1.23; 95% confidence interval, 0.80–1.88; P = 0.34). The multivariate analysis also showed no significant difference (hazards ratio, 1.33; 95% confidence interval, 0.8–2.19; P = 0.27). Median time to diagnosis of unresectable recurrence (months) was significantly shorter in the intervention group [7 (3–20) versus 14.3 (7.3–27), P = 0.016]. Mean cost/patient was higher in the intervention group (18 192 ± 27 679 € versus 11 131 ± 13  €, P < 0.033).

Conclusion

¹⁸FDG-PET/CT, when added every 6 months, increased costs without decreasing treatment failure rates in patients in remission of CRC. The control group had very close follow-up, and any additional improvement (if present) would be small and hard to detect.

ClinicalTrials.gov identifier

NCT00624260

Indications and practices of Cesarean Sections in a French region – The Robson classification

Background

Cesarian-section (CS) deliveries, although sometimes vital, are associated with increasing immediate- and long-term maternal and/or neonatal risks. The objective was to describe the indications of scheduled CS, measure the potentially avoidable CS and study the rate variations between maternities in one French region, Centre Val-de-Loire (CVL).

Methods

A cross-sectional study was conducted from September 2016 to February 2017. Information about all CS performed in the maternities of the region was collected: medical history, indication, schedule. Data collection was completed with the 2016 regional birth data repository (25,864 deliveries, including 19.2% of CS, among which 7.0% were scheduled). CS were classified according to the pre-existing risk high or low of CS as defined by the Robson classification.

Results

During the study period, 1,979 CS (18.6% of deliveries) were performed, of which 762 were scheduled (7.1% of deliveries). The main indications for planning a CS were: scarred uterus (60%, of which 56% with only one previous CS) or breech presentation (25%), considered at high risk of CS according to the Robson classification. For these two contexts, the regional birth repository showed decreasing scheduled CS rates from high to low level of maternities’ expertise. Remarkly, 22 nulliparous women with a single cephalic pregnancy in spontaneous labor before term (Robson’s low risk of CS) had a CS performed for unfavorable pelvimetry (0.2% of deliveries).

Conclusions

This study allowed identifying specific potential interventions: targeted CS on scarred uterus with only one previous CS or breech presentation, as recommended by national guidelines, and targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices through cautious maternity comparisons to improve quality of care.

Key messages

Although potentially avoidable c-sections are rare, interventions were identified: targeted CS on uterus with one previous CS or breech presentation, targeted use of radiologic pelvimetry. The Robson classification must be widely used to assess practices, in order to improve healthcare quality.

Pycnodysostosis: Natural history and management guidelines from 27 French cases and a literature review

Pycnodysostosis is a lysosomal autosomal recessive skeletal dysplasia characterized by osteosclerosis, short stature, acro-osteolysis, facial features and an increased risk of fractures. The clinical heterogeneity of the disease and its rarity make it difficult to provide patients an accurate prognosis, as well as appropriate care and follow-up. French physicians from the OSCAR network have been asked to fill out questionnaires collecting molecular and clinical data for 27 patients issued from 17 unrelated families. All patients showed short stature (mean = -3.5 SD) which was more severe in females (P = .006). The mean fracture rate was moderate (0.21 per year), with four fractures in total average. About 75% underwent at least one surgery, with an average number of 2.1 interventions per patient. About 50% required non-invasive assisted ventilation due to sleep apnea (67%). About 29% showed psychomotor difficulties and 33% needed a school assistant or adapted schooling. No patient had any psychological evaluation or follow-up. Molecular data were available for 14 families. Growth hormone administration was efficient on linear growth in 40% of cases. We propose several axis of management, such as systematic cerebral MRI for Chiari malformation screening at diagnosis and regular psychological follow-up.

[Functional diagnostics in pneumology]

Alongside imaging techniques, pulmonary function testing helps in the diagnosis of underlying disorders such as asthma and chronic obstructive pulmonary disease (COPD) or fibrosing lung disease. However, disease severity grading is also important, as well as disease follow-up under therapy. The value of spirometry as a first-line diagnostic test, whole-body plethysmography in advanced diagnostics, the measurement of transfer factor, as well as blood gas analysis are outlined. The importance of spiroergometry, echocardiography, and right-heart catheterization, particularly in the functional assessment of pulmonary vascular disorders, is described. Tests in respiratory sleep medicine, such as polysomnography, as well as tests for diagnosing chronic respiratory failure, are part of the respiratory physician's diagnostic armamentarium.

A randomized controlled trial protocol assessing the effectiveness, safety and cost-effectiveness of methotrexate vs. ciclosporin in the treatment of severe atopic eczema in children: the TREatment of severe Atopic eczema Trial (TREAT)

BACKGROUND

Oral systemic immunomodulatory medication is regularly used off-licence in children with severe atopic eczema. However, there is no firm evidence regarding the effectiveness, safety, cost-effectiveness and impact on quality of life from an adequately powered randomized controlled trial (RCT) using systemic medication in children.

OBJECTIVES

To assess whether there is a difference in the speed of onset, effectiveness, side-effect profile and reduction in flares post-treatment between ciclosporin (CyA) and methotrexate (MTX), and also the cost-effectiveness of the drugs. Treatment impact on quality of life will also be examined in addition to whether FLG genotype influences treatment response. In addition, the trial studies the immune-metabolic effects of CyA and MTX.

METHODS

Multicentre, parallel group, assessor-blind, pragmatic RCT of 36 weeks' duration with a 24-week follow-up period. In total, 102 children aged 2-16 years with moderate-to-severe atopic eczema, unresponsive to topical treatment will be randomized (1 : 1) to receive MTX (0·4 mg kg^-1 per week) or CyA (4 mg kg^-1 per day).

RESULTS

The trial has two primary outcomes: change from baseline to 12 weeks in Objective Severity Scoring of Atopic Dermatitis (o-SCORAD) and time to first significant flare following treatment cessation.

CONCLUSIONS

This trial addresses important therapeutic questions, highlighted in systematic reviews and treatment guidelines for atopic eczema. The trial design is pragmatic to reflect current clinical practice.

Should 45,X/46,XY boys with no or mild anomaly of external genitalia be investigated and followed up?

OBJECTIVE

Few studies of patients with a 45,X/46,XY mosaicism have considered those with normal male phenotype. The purpose of this study was to evaluate the clinical outcome of 45,X/46,XY boys born with normal or minor abnormalities of external genitalia, notably in terms of growth and pubertal development.

METHODS

Retrospective longitudinal study of 40 patients followed between 1982 and 2017 in France.

RESULTS

Twenty patients had a prenatal diagnosis, whereas 20 patients had a postnatal diagnosis, mainly for short stature. Most patients had stunted growth, with abnormal growth spurt during puberty and a mean adult height of 158 ± 7.6 cm, i.e. -2.3 DS with correction for target height. Seventy percent of patients presented Turner-like syndrome features including cardiac (6/23 patients investigated) and renal malformations (3/19 patients investigated). Twenty-two patients had minor abnormalities of external genitalia. One patient developed a testicular embryonic carcinoma, suggesting evidence of partial gonadal dysgenesis. Moreover, puberty occurred spontaneously in 93% of patients but 71% (n = 5) of those evaluated at the end of puberty presented signs of declined Sertoli cell function (low inhibin B levels and increased FSH levels).

CONCLUSION

This study emphasizes the need to identify and follow-up 45,X/46,XY patients born with normal male phenotype until adulthood, as they present similar prognosis than those born with severe genital anomalies. Currently, most patients are diagnosed in adulthood with azoospermia, consistent with our observations of decreased testicular function at the end of puberty. Early management of these patients may lead to fertility preservation strategies.

Key features of bone and joint infections following the implementation of reference centers in France

OBJECTIVES

French reference centers for bone and joint infections (BJI) were implemented from 2009 onwards to improve the management of complex BJIs. This study compared BJI burden before and after the implementation of these reference centers.

PATIENTS AND METHODS

BJI hospital stays were selected from the 2008 and 2013 national hospital discharge database using a validated algorithm, adding the new complex BJI code created in 2011. Epidemiology and economic burden were assessed.

RESULTS

BJI prevalence increased in 2013 (70 vs. 54/100,000 in 2008). Characteristics of BJI remained similar between 2008 and 2013: septic arthritis (50%), increasing prevalence with age and sex, case fatality 5%, mean length of stay 17.5 days, rehospitalization 20%. However, device-associated BJIs increased (34 vs. 26%) as well as costs (€421 million vs. €259 in 2008). Similar device-associated BJI characteristics between 2008 and 2013 were: septic arthritis (70%), case fatality (3%), but with more hospitalizations in reference centers (34 vs. 30%) and a higher cost per stay. Among the 7% of coded complex BJIs, the mean length of stay was 22.2 days and mean cost was €11,960.

CONCLUSIONS

BJI prevalence highly increased in France. Complex BJI prevalence assessment is complicated by the absence of clinical consensus and probable undercoding. A validation of clinical case definition of complex BJI is required.

Connaissances, attitudes et pratiques des parents face à la vaccination contre la poliomyélite à Abéché-Tchad

Introduction

au Tchad, la transmission de la poliomyélite a été interrompue en 2000, mais les importations à partir du Nigéria et la faiblesse des couvertures vaccinales constituent un risque majeur de relance de la maladie. L'objectif de ce travail était d'analyser les connaissances, attitudes et pratiques des parents vis-à-vis de la vaccination contre la poliomyélite des enfants âgés de 0 à 5 ans au Tchad.

Méthodes

cette étude transversale a été réalisée dans les six arrondissements d'Abéché. Seuls les ménages qui avaient des enfants de moins de 5 ans ont été inclus. Les données ont été recueillies par des entretiens avec les parents et tuteurs d'enfants éligibles à l'aide d'un questionnaire testé et validé.

Résultats

nous avons interrogé 210 ménages. Aucune famille ne possédait de carnet de vaccination de leurs enfants. Cependant, 97% ont déclaré avoir des enfants ayant participé aux campagnes de vaccination de masse. Près de 97% connaissaient la poliomyélite et 98% avaient entendu parler des campagnes de vaccination. Les canaux d'information les plus cités étaient la radio (98%) et les agents vaccinateurs (72%). Seul 3% des parents interrogés ont déclaré avoir refusé la vaccination. Il existait une association entre l'influence négative de l'entourage et la non vaccination des enfants (p = 0,005).

Conclusion

les connaissances sur la maladie et le vaccin sont bonnes au Tchad malgré l'existence de rumeurs concernant notamment les effets des vaccins. L'absence de carnet de vaccination a limité l'analyse des résultats de l'enquête, uniquement déclarative avec un taux de vaccination très élevé déclaré. Dans le cadre de l'éradication, le carnet est indispensable pour accompagner la politique de prévention.

Sex chromosome aneuploidies and copy-number variants: a further explanation for neurodevelopmental prognosis variability?

Sex chromosome aneuploidies (SCA) is a group of conditions in which individuals have an abnormal number of sex chromosomes. SCA, such as Klinefelter's syndrome, XYY syndrome, and Triple X syndrome are associated with a large range of neurological outcome. Another genetic event such as another cytogenetic abnormality may explain a part of this variable expressivity. In this study, we have recruited fourteen patients with intellectual disability or developmental delay carrying SCA associated with a copy-number variant (CNV). In our cohort (four patients 47,XXY, four patients 47,XXX, and six patients 47,XYY), seven patients were carrying a pathogenic CNV, two a likely pathogenic CNV and five a variant of uncertain significance. Our analysis suggests that CNV might be considered as an additional independent genetic factor for intellectual disability and developmental delay for patients with SCA and neurodevelopmental disorder.