Impact de l’infection par le SARS-CoV2 chez la femme enceinte et ses conséquences en santé au travail

L’objectif de cette recommandation est de présenter à travers une revue narrative l’impact de l’infection par le SARS-CoV2 chez la femme enceinte et ses conséquences en santé au travail.

Histone Methylation: Achilles Heel and Powerful Mediator of Periodontal Homeostasis

The packaging of DNA around nucleosomes exerts dynamic control over eukaryotic gene expression either by granting access to the transcriptional machinery in an open chromatin state or by silencing transcription via chromatin compaction. Histone methylation modification affects chromatin through the addition of methyl groups to lysine or arginine residues of histones H3 and H4 by means of histone methyl transferases or histone demethylases. Changes in histone methylation state modulate periodontal gene expression and have profound effects on periodontal development, health, and therapy. At the onset of periodontal development, progenitor cell populations such as dental follicle cells are characterized by an open H3K4me3 chromatin mark on RUNX2, MSX2, and DLX5 gene promoters. During further development, periodontal progenitor differentiation undergoes a global switch from the H3K4me3 active methyl mark to the H3K27me3 repressive mark. When compared with dental pulp cells, periodontal neural crest lineage differentiation is characterized by repressive H3K9me3 and H3K27me3 marks on typical dentinogenesis-related genes. Inflammatory conditions as they occur during periodontal disease result in unique histone methylation signatures in affected cell populations, including repressive H3K9me3 and H3K27me3 histone marks on extracellular matrix gene promoters and active H3K4me3 marks on interleukin, defensin, and chemokine gene promoters, facilitating a rapid inflammatory response to microbial pathogens. The inflammation-induced repression of chromatin on extracellular matrix gene promoters presents a therapeutic opportunity for the application of histone methylation inhibitors capable of inhibiting suppressive trimethylation marks. Furthermore, inhibition of chromatin coregulators through interference with key inflammatory mediators such as NF-kB by means of methyltransferase inhibitors provides another avenue to halt the exacerbation of the inflammatory response in periodontal tissues. In conclusion, histone methylation dynamics play an intricate role in the fine-tuning of chromatin states during periodontal development and harbor yet-to-be-realized potential for the treatment of periodontal disease.

L3 Update of the OpACIN and OpACIN-neo trials: 36-months and 24-months relapse-free survival after (neo)adjuvant ipilimumab plus nivolumab in macroscopic stage III melanoma patients

Background

Before adjuvant checkpoint inhibition the 5-year overall survival (OS) rate was poor (<50%) in high-risk stage III melanoma patients. Adjuvant CTLA-4 (ipilimumab, IPI) and PD-1 (nivolumab, NIVO, or pembrolizumab) blockade have been shown to improve relapse-free survival (RFS) and OS (latter only for IPI so far). Due to a broader immune activation neoadjuvant therapy with checkpoint inhibitors might be more effective than adjuvant, as suggested in preclinical experiments. The OpACIN trial compared neoadjuvant versus adjuvant IPI plus NIVO, while the subsequent OpACIN-neo trial tested three different dosing schedules of neoadjuvant IPI plus NIVO without adjuvant therapy. High pathologic response rates of 74–78% were induced by neoadjuvant IPI plus NIVO. Here, we present the 36- and 24-months RFS of the OpACIN and OpACIN-neo trial, respectively.

Materials and Methods

The phase 1b OpACIN trial included 20 stage IIIB/IIIC melanoma patients, which were randomized to receive IPI 3 mg/kg plus NIVO 1 mg/kg either adjuvant 4 cycles or split 2 cycles neoadjuvant and 2 adjuvant. In the phase 2 OpACIN-neo trial, 86 patients were randomized to 2 cycles neoadjuvant treatment, either in arm A: 2x IPI 3 mg/kg plus NIVO 1 mg/kg q3w (n=30), arm B: 2x IPI 1 mg/kg plus NIVO 3 mg/kg q3w (n=30), or arm C: 2x IPI 3 mg/kg q3w followed immediately by 2x NIVO 3 mg/kg q3w (n=26). Pathologic response was defined as <50% viable tumor cells and in both trials centrally reviewed by a blinded pathologist. RFS rates were estimated using the Kaplan-Meier method.

Results

Only 1 of 71 (1.4%) patients with a pathologic response on neoadjuvant therapy had relapsed, versus 16 of 23 patients (69.6%) without a pathologic response, after a median follow-up of 36 months for the OpACIN and 24 months for the OpACIN-neo trial. In the OpACIN trial, the estimated 3-year RFS rate for the neoadjuvant arm was 80% (95% CI: 59%-100%) versus 60% (95% CI: 36%-100%) for the adjuvant arm. Median RFS was not reached for any of the arms within the OpACIN-neo trial. Estimated 24-months RFS rate was 84% for all patients (95% CI: 76%-92%); 90% for arm A (95% CI: 80%-100%), 78% for arm B (95% CI: 63%-96%) and 83% for arm C (95% CI: 70%-100%). Baseline interferon-γ gene expression score and tumor mutational burden predict response.

Conclusions

OpACIN for the first time showed a potential benefit of neoadjuvant IPI plus NIVO versus adjuvant immunotherapy, whereas the OpACIN-neo trial confirmed the high pathologic response rates that can be achieved by neoadjuvant IPI plus NIVO. Both trials show that pathologic response can function as a surrogate markers for RFS.

Clinical trial information

NCT02437279, NCT02977052

Disclosure Information

J.M. Versluis: None. E.A. Rozeman: None. A.M. Menzies: F. Consultant/Advisory Board; Modest; BMS, MSD, Novartis, Roche, Pierre-Fabre. I.L.M. Reijers: None. O. Krijgsman: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; BMS. E.P. Hoefsmit: None. B.A. van de Wiel: None. K. Sikorska: None. C. Bierman: None. P. Dimitriadis: None. M. Gonzalez: None. A. Broeks: None. R.M. Kerkhoven: None. A.J. Spillane: None. J.B.A.G. Haanen: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; BMS, MSD, Neon Therapeutics, Novartis. F. Consultant/Advisory Board; Modest; BMS, MSD, Novartis, Pfizer, AZ/MedImmune, Rocher/Genentech, Ipsen, Bayer, Immunocore, SeattleGenetics, Neon Therapeutics, Celsius Therapeutics, Gadet, GSK. W.J. van Houdt: None. R.P.M. Saw: None. H. Eriksson: None. A.C.J. van Akkooi: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; Amgen, BMS, Novartis. F. Consultant/Advisory Board; Modest; Amgen, BMS, Novartis, MSD Merck, Merck-Pfizer, 4SC. R.A. Scolyer: F. Consultant/Advisory Board; Modest; MSD, Neracare, Myriad, Novartis. T.N. Schumacher: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; MSD, BMS, Merck. E. Ownership Interest (stock, stock options, patent or other intellectual property); Modest; AIMM Therapeutics, Allogene Therapeutics, Amgen, Merus, Neogene Therapeutics, Neon Therapeutics. F. Consultant/Advisory Board; Modest; Adaptive Biotechnologies, AIMM Therapeutics, Allogene Therapeutics, Amgen, Merus, Neon Therapeutics, Scenic Biotech. Other; Modest; Third Rock Ventures. G.V. Long: F. Consultant/Advisory Board; Modest; Aduro, Amgen, BMS, Mass-Array, Pierre-Fabre, Novartis, Merck MSD, Roche. C.U. Blank: B. Research Grant (principal investigator, collaborator or consultant and pending grants as well as grants already received); Modest; BMS, Novartis, NanoString. E. Ownership Interest (stock, stock options, patent or other intellectual property); Modest; Uniti Cars, Neon Therapeutics, Forty Seven. F. Consultant/Advisory Board; Modest; BMS, MSD, Roche, Novartis, GSK, AZ, Pfizer, Lilly, GenMab, Pierre-Fabre.

A National Study of Community Health Centers' Readiness to Address COVID‐19

Research Objective

Community health centers (CHCs) serve as the patient medical home for populations that are disproportionately more susceptible to COVID‐19; yet, there is a lack of understanding of the current efforts in place by CHCs across the United States working to prepare for and respond to the current pandemic. The purpose of this mixed‐methods assessment was to understand community health centers’ needs and readiness to address COVID‐19.

Study Design

We conducted a sequential explanatory mixed‐methods approach. A pilot‐tested, web‐based, cross‐sectional survey regarding organizational and individual staff needs, and best practices currently in place to prepare for and prevent spread of COVID‐19, was administered to and completed by 240 primary care employees from 201 organizations across 44 states, the District of Columbia, and Puerto Rico. Focus group interviews were subsequently conducted with a convenience sample (n = 39) from the survey respondents to understand the needs and current efforts in place by CHCs across the United States working to prepare for and respond to COVID‐19. We applied the transcript‐based analysis approach to the focus group data and derived themes using the constant comparative method.

Population Studied

The majority of respondents (59%) held administrative leadership roles at their respective agencies, while the remainder of the participants served in patient‐facing roles as physicians (8%), nurses (13%), and medical support staff (20%). Over a third (38%) of the participants came from practices in the Northeast region of the country, with the rest of respondents coming from the West (19%), South (19%), and Midwest (23%) regions, and minor representation from Puerto Rico (1%).

Principal Findings

Respondents identified guidance regarding COVID‐19 infection prevention and control (77.1%), safety precautions (72.1%), and screening, diagnostic testing, and management of patients (67.1%) as their major educational needs. Findings from the focus groups highlighted five key themes relevant to foundational aspects of readiness: leadership, communication, formal policies and procedures, resources, and workforce capacity. Responses from the focus groups clearly reflected the difficulty imposed on an already stretched, understaffed workforce in pivoting to rapidly address the expected surge in demand from patients related to the pandemic.

Conclusions

The COVID‐19 pandemic has exacerbated long‐standing capacity issues that CHCs face, making it challenging for these safety‐net practices to adequately respond to the current disease outbreak. In addition to the more universal concerns about lack of testing and personal protective equipment, these findings highlight the special challenge posed by lack of staffing resources in CHCs as recruitment and retention of staff in rural and other medically underserved practice locations has burdened health centers long before the current pandemic.

Implications for Policy or Practice

The COVID‐19 pandemic is occurring at a time when CHCs nationwide are experiencing great economic uncertainty. There is a need for Congress to prioritize reauthorization of funding for CHCs in order to prevent major hiring freezes, layoffs, and reduced patient care services, especially during a pandemic. Similarly, greater Federal financial support for CHCs is needed to ensure these practices have the capacity to continue serving the most vulnerable members of society, thereby helping relieve the stress on hospitals and flatten the spread of COVID‐19.

[Factors related to severe neonatal acidosis in planned cesarean section. A case-control study]

OBJECTIVES

To identify factors related to the occurrence of severe neonatal acidosis in case of planned caesarean section.

METHODS

Case-control study conducted between 1997 and 2016 among women with planned caesarean delivery at term. Cases were women whose neonates had neonatal arterial pH<7,0. For each case, two planned caesarean sections with neonatal pH≥7,0 were selected as controls. Women whose fetus had a congenital malformation and those whose anesthesia was not spinal anesthesia were excluded.

RESULTS

Among the 5014 planned cesarean sections of the study period, 38 severe neonatal acidosis were observed (incidence of 0,76% CI95 [0,54-1,04]). Compared to 72 controls, the 36 caesareans with severe neonatal acidosis were associated with more frequent maternal obesity (BMI≥30kg/m²), higher ephedrine doses, longer time from skin incision to infant delivery, and more extraction difficulties. After logistic regression, only maternal obesity remained associated with a significant increase in the risk of severe neonatal acidosis, ORa=3,73, 95%CI (1,11-12,56).

CONCLUSIONS

In case of planned cesarean section, the main risk factor for severe neonatal acidosis is the existence of maternal obesity.

Does how you treat yourself affect your health? The relationship between health-promoting behaviors and self-compassion among a community sample

This study explores the relationship between self-compassion, or treating oneself with kindness and acceptance, using the Self-Compassion Scale, and health-promoting behaviors, using the Health-Promoting Lifestyle Profile II, among a community sample. Canonical correlation results indicate self-compassion and health-promoting behaviors share 76 percent of the variance within the data set. The positive components of self-compassion are strongly positively correlated with health-promoting behaviors, and the negative components of self-compassion are strongly negatively correlated with health-promoting behaviors. Hierarchical linear regression results indicate self-kindness and mindfulness are significant predictors of health-promoting behaviors after controlling for demographics.

P1418 Clinical profile and outcome of infective endocarditis patients transferred to a tertiary center

METHODS

Prospective observational study with a retrospective analysis of 468 episodes of infectious endocarditis admitted to our center from 2003 to 2018. Of these, 252 (54%) were admitted directly in our center and 216 (46%) were transferred from hospitals in the area of influence. We analyze the features and compare them.

RESULTS

The average age from transferred patients was lower (63 vs. 66 years; p = 0.015), from which 74% were men. Non-transferred patients had major comorbidity with a significant percentage of comorbidities (81 vs. 66%; p = 0.005), greater Charlson"s index (3.4 vs. 1.98; p 0.005) and EuroScore (logistic Euroscore I ; 27 vs. 22; 0.034). The diagnosis delay was similar (7.3 vs. 7.6 days) with a large number of clinical (84% vs. 73%) and echocardiographic (52 vs. 40; p = 0,012) complications in transferred patients with more need for surgery (81 vs. 61%, p = 0.002), and with more operated patients of those transferred. The mortality of non-transferred patients, admitted directly in the tertiary center, was higher (51 vs. 43%), but presenting no significant differences.

CONCLUSIONS

Patients transferred from other centers have a profile with less comorbidity but high need for surgery, possibly related to well-stablished selection and derivation criteria, with a slightly lower mortality, although with no significant differences in comparison to patients admitted directly to the tertiary referral hospital.

Blood CD9+ B cell, a biomarker of bronchiolitis obliterans syndrome after lung transplantation

Bronchiolitis obliterans syndrome is the main limitation for long-term survival after lung transplantation. Some specific B cell populations are associated with long-term graft acceptance. We aimed to monitor the B cell profile during early development of bronchiolitis obliterans syndrome after lung transplantation. The B cell longitudinal profile was analyzed in peripheral blood mononuclear cells from patients with bronchiolitis obliterans syndrome and patients who remained stable over 3 years of follow-up. CD24^hi CD38^hi transitional B cells were increased in stable patients only, and reached a peak 24 months after transplantation, whereas they remained unchanged in patients who developed a bronchiolitis obliterans syndrome. These CD24^hi CD38^hi transitional B cells specifically secrete IL-10 and express CD9. Thus, patients with a total CD9⁺ B cell frequency below 6.6% displayed significantly higher incidence of bronchiolitis obliterans syndrome (AUC = 0.836, PPV = 0.75, NPV = 1). These data are the first to associate IL-10-secreting CD24^hi CD38^hi transitional B cells expressing CD9 with better allograft outcome in lung transplant recipients. CD9-expressing B cells appear as a contributor to a favorable environment essential for the maintenance of long-term stable graft function and as a new predictive biomarker of bronchiolitis obliterans syndrome-free survival.

P2684Blood pressure lowering by using a self-care focused smartphone application for patients after myocardial infarction

Background

We have previously shown that complementing traditional cardiac rehabilitation (CR) with a web-based smartphone application designed to support self-control of risk factors can improve secondary prevention outcomes, including lower blood pressure (BP).

Purpose

To explore possible explanations for better BP control among patients with myocardial infarction (MI) receiving access to a smartphone application as a complement to traditional CR, compared to patients receiving traditional CR alone.

Methods

Data from a multi-centre randomized controlled trial that included 150 patients with MI (81% men, 60.4±8.8 years) was used. All patients participated in traditional CR. In addition, patients in the intervention group (APP, n=101) had access to the application. Patients received automated positive feedback on normal values and all registered data was viewed by CR nurses twice weekly. As previously reported, APP patients achieved a 9 mmHg larger reduction in systolic BP than usual care (UC) patients at 2-months follow-up (p=0.02). In the current analysis we assessed differences between APP and UC patients in the number of visits and telephone contacts with the CR clinic, number of reported BP measurements and number and type of interventions on account of out-of-range BP during the first 6 months of follow-up, using Mann-Whitney and chi-square tests.

Results

There was no difference in the median (IQR) number of visits to a CR nurse or physician (APP 2 (2–3) vs UC 2 (2–3), p=0.8) or telephone contacts ((APP 2 (1–4) vs UC 2 (1–4), p=0.8) between the groups. Approximately one in ten telephone contacts were initiated because of BP, with no difference between the groups (p=0.8). Out of 101 APP patients 75 reported BP values through the application, ranging from 1–175 BP values/patient (median 6 (IQR 0–34)). Most measurements (90%) were normal. Grouping clinic visits, telephone contacts due to BP and BP reports through the application as a composite for the number of BP measurements the CR personnel were exposed to during follow-up, there was a significant difference between the groups (APP 9 (4–36) vs UC 3 (2–3), p<0.0001). There was a small non-significant difference between the groups in the proportion of patients where an intervention was performed by the CR nurse on account of out-of-range BP (i.e. medication adjustments, new measurement scheduled) (APP 22% vs UC 12%, p=0.1).

Conclusion

While CR personnel were exposed to significantly more BP measurements from patients using a self-care focused smartphone application as a complement to traditional CR, most BP measurements reported through the application were normal and there was no difference in the number of interventions performed on account of out-of-range BP values. Automated positive feedback on in-range BP measurements, increased patient responsibility with better adherence to BP lowering medication could be possible explanations to improved BP control.

Acknowledgement/Funding

The faculty of Medicine, Lund University, Lund, Sweden