Hospital-based antimicrobial stewardship in Denmark, Greenland and the Faroe Islands - current landscape and barriers

OBJECTIVES

To describe the current organization and implementation of formalized, multi-disciplinary hospital-based antimicrobial stewardship (AMS) structures in Denmark, the Faroe Islands and Greenland.

METHODS

A structured electronic questionnaire was sent to all trainees and specialists in clinical microbiology (N=207) and infectious diseases (N=260), as well as clinical pharmacists (N=20) and paediatricians (N=10) with expertise in infectious diseases. The survey had 30 multiple-choice, rating-scale, and open-ended questions based on an international consensus checklist for hospital AMS, adapted to a Danish context.

RESULTS

Overall, 145 individual responses representing 20 hospitals were received. Nine hospitals (45%) reported a formal AMS strategy, eight (40%) a formal organizational multi-disciplinary structure and a multi-disciplinary AMS team, and six (30%) a designated professional as a leader of the AMS team. A majority of hospitals reported access to updated guidelines (80%) and regularly monitored and reported the quantity of antibiotics prescribed (70% and 65%, respectively). Only one hospital (5%) reported a dedicated, sustainable and sufficient AMS budget, three hospitals (15%) audited courses of therapy for specific agents/clinical conditions and four hospitals (20%) had a document clearly defining roles, procedures of collaboration and responsibilities for AMS. A total of 42% of all individual respondents had received formal AMS training. Main barriers were a lack of financial resources (52%), a lack of mandate from the hospital management (30%) and AMS not being a priority (18%).

CONCLUSIONS

Core elements important for multi-disciplinary hospital-based AMS can be strengthened in Danish hospitals. Funding, clear mandates, prioritization from the hospital management and the implementation of multi-disciplinary AMS structures may help close the identified gaps.

Radiation protection in CT-guided interventions: does real-time dose visualisation lead to a reduction in radiation dose to participating radiologists? A single-centre evaluation

AIM

To evaluate if real-time dose visualisation during computed tomography (CT)-guided interventions leads to a reduction in radiation dose to participating radiologists.

MATERIALS AND METHODS

The individual radiation dose radiologists are exposed to during CT interventions was measured using dedicated dosimeters (RaySafe i2-system, Unfors RaySafe GmbH, Billdal, Sweden) worn over the usual radiation protective apron. Initially, only the total radiation dose was measured, without visualisation (control group). In the following study period, the radiation dose was shown to participants on a live screen in real-time (experimental group). In both groups, the dose was recorded in 1-second intervals. The results collected were evaluated by comparison using descriptive statistics and mixed-effect models. In particular, the variables experience, gender, role, and position during the intervention were analysed.

RESULTS

In total, 517 measurements of 304 interventions (n=249 with and n=268 without live screen) performed by 29 radiologists acting as interventionalists or assistants were analysed. All CT-guided interventions were performed percutaneously, the majority of which (n=280) were microwave ablations (MWA). Radiation doses in the group without visualisation were comparable with usual dose rates for the corresponding intervention type. The mean total radiation dose was reduced by 58.1% (11.6 versus 4.86 μSv) in the experimental group (p=0.034). The highest reduction of 78.5% (15.55 versus 3.35 μSv) was observed in radiologists with the role of assistant (p=0.002). Sub-analysis showed significant dose reduction (p<0.0001) for the use of live screen in general; considering all variables, the role "assistant" alone had a statistically significant influence (p=0.002).

CONCLUSION

The real-time visualisation of active radiation dose during CT interventions leads to a relevant reduction in radiation dose to participating radiologists.

Ethnic endotypes in paediatric atopic dermatitis depend on immunotype, lipid composition and microbiota of the skin

BACKGROUND

Atopic dermatitis (AD) endotypes differ with ethnicity. We examined the skin microbiota, cytokine and lipid profiles in Greenlandic Inuit and Danish children with AD.

METHODS

Twenty-five Inuit children with AD and 25 Inuit control children were clinically examined and compared to previously collected data from 25 Danish children with AD. Skin tape strips and skin swabs were collected from lesional and non-lesional skin. Levels of cutaneous immune biomarkers, free sphingoid bases and their (glycosyl)ceramides were analysed. Skin swabs were analysed with 16S rRNA and tuf gene for characterization of bacterial species communities.

RESULTS

Bacterial β-diversity was significantly different between Inuit and Danish AD skin, in both lesional (p < 0.001) and non-lesional (p < 0.001) AD skin, and there was a higher relative abundance of Staphylococcus aureus in Danish compared to Inuit lesional (53% vs. 8%, p < 0.01) and non-lesional skin (55% vs. 5%, p < 0.001). Danish AD children had a higher α-diversity than Inuit children in non-lesional (p < 0.05) but not in lesional skin. Significantly higher levels of type 2 immunity cytokine interleukin (IL)-4 (p < 0.05) and IL-5 (p < 0.01) were identified in Inuit compared to Danish AD children. In contrast, IL-33 (p < 0.01) was higher in Danish lesional and non-lesional AD skin. Higher levels of long-chain glucosylceramide (GlcCER)[S](d26:1) were found in lesional (p < 0.001) and non-lesional (p < 0.001) Inuit skin compared with Danish AD skin. NMF levels were similar in Inuit and Danish AD skin.

CONCLUSION

Skin microbiota, cytokine and lipid composition differed significantly between Inuit and Danish children with AD and showed a stronger type 2 immune signature in Inuit children.

Five-Year Follow-Up of a Slowly Resorbable Biosynthetic P4HB Mesh (Phasix) in VHWG Grade 3 Incisional Hernia Repair

Objective

To assess the 5-year recurrence rate of incisional hernia repair in Ventral Hernia Working Group (VHWG) 3 hernia with a slowly resorbable mesh.

Summary Background Data

Incisional hernia recurs frequently after initial repair. In potentially contaminated hernia, recurrences rise to 40%. Recently, the biosynthetic Phasix mesh has been developed that is resorbed in 12-18 months. Resorbable meshes might be a solution for incisional hernia repair to decrease short- and long-term (mesh) complications. However, long-term outcomes after resorption are scarce.

Methods

Patients with VHWG grade 3 incisional midline hernia, who participated in the Phasix trial (Clinilcaltrials.gov: NCT02720042) were included by means of physical examination and computed tomography (CT). Primary outcome was hernia recurrence; secondary outcomes comprised of long-term mesh complications, reoperations, and abdominal wall pain [visual analogue score (VAS): 0-10].

Results

In total, 61/84 (72.6%) patients were seen. Median follow-up time was 60.0 [interquartile range (IQR): 55-64] months. CT scan was made in 39 patients (68.4%). A recurrence rate of 15.9% (95% confidence interval: 6.9-24.8) was calculated after 5 years. Four new recurrences (6.6%) were found between 2 and 5 years. Two were asymptomatic. In total, 13/84 recurrences were found. No long-term mesh complications and/or interventions occurred. VAS scores were 0 (IQR: 0-2).

Conclusions

Hernia repair with Phasix mesh in high-risk patients (VHWG 3, body mass index >28) demonstrated a recurrence rate of 15.9%, low pain scores, no mesh-related complications or reoperations for chronic pain between the 2- and 5-year follow-up. Four new recurrences occurred, 2 were asymptomatic. The poly-4-hydroxybutyrate mesh is a safe mesh for hernia repair in VHWG 3 patients, which avoids long-term mesh complications like pain and mesh infection.

Biopsies of caudal brainstem tumors in pediatric patients - a single center retrospective case series

OBJECTIVE

The indication for performing biopsies in patients with diffuse lesions in the brain stem is controversial. Possible risks associated with the technical challenging interventions need to be balanced against clarifying the diagnosis and possible therapeutic options. We reviewed the feasibility, risk profile and diagnostic yield of different biopsy techniques in a pediatric cohort.

METHODS

We retrospectively included all patients under 18 years of age that received a biopsy of the caudal brainstem region (pons, medulla oblongata) at our pediatric neurosurgical center from 2009-2022.

RESULTS

We identified 27 children. Biopsies were performed using frameless stereotactic (Varioguide) (n=12), robotic assisted (Autoguide) (n=4), endoscopic (n=3) and open biopsy (n=8) technique. Intervention related mortality was not observed. Three patients experienced transient post-surgical neurological deficit. No patient showed intervention related permanent morbidity. Biopsy yielded histopathological diagnosis in all cases. Molecular analysis was feasible in 97% of cases. Most common diagnosis was H3K27M mutated diffuse midline glioma (60%). Low-grade gliomas were identified in 14%. Overall survival was 62.5% after 24 months of follow up.

CONCLUSION

Biopsies of the caudal brainstem in children were feasible and safe in the presented setup. The amount of acquired tumor material allowing integrated diagnosis and was obtained at reasonable risk. The selection of the surgical technique depends on tumor location and growth pattern. We recommend brainstem tumor biopsies in children being performed at specialized centers to better understand the biology and enable possible novel therapeutic options.

Development of placental lesions after recovery from COVID-19 during pregnancy: case-control study

OBJECTIVE

To study whether the occurrence and type of placental lesions vary according to the time of onset of COVID-19 in pregnant women.

DESIGN

Case-control study.

SETTING

Departments of Gynaecology-Obstetrics and Pathology, Strasbourg University Hospital, France.

POPULATION

Cases were 49 placentas of women with COVID-19. Controls were 50 placentas from women who had a past history of molar pregnancy. COVID-19 placentas were categorised based on whether birth occurred at more or less than 14 days post-infection.

METHODS

Comparison between case and controls.

MAIN OUTCOME MEASURES

Maternal and neonatal outcomes were recorded. Macroscopic and microscopic examination of the placentas was performed.

RESULTS

The rate of vascular complications was higher in the COVID groups than in the controls (8 [16.3%] versus 1 [2%], p = 0.02). Signs of fetal (22[44.9%] versus 13 [26%], p = 0.05) and maternal (44 [89.8%] versus 36 [72.0%], p = 0.02) vascular malperfusion and signs of inflammation (11 [22.4%] versus 3 [6.0%], p = 0.019) were significantly more common in the COVID-19 groups than in the control group. Fetal malperfusion lesions (9 [39.1%] versus 13 [50.0%], p = 0.45) and placental inflammation (4 [17.4%] versus 7 [26.9%], p = 0.42) rates were not significantly different between the two COVID-19 groups. Chronic villitis was significantly more common when the delivery occurred >14 days after infection than in the group that delivered <14 days after infection (7 [26.9%] versus 1 [4.4%], p = 0.05).

CONCLUSIONS

Our study suggests that SARS-COV-2 induces placental lesions that evolve after disease recovery, especially with the development of inflammatory lesions, such as chronic villitis.

[Inguinal hernia operations-Always outpatient?]

Inguinal hernia operations represent the most frequent operations overall with 300,000 interventions annually in Germany, Austria and Switzerland (DACH region). Despite the announced political willingness and the increasing pressure from the legislator to avoid costly inpatient treatment by carrying out as many outpatient operations as possible, outpatient treatment has so far played a subordinate role in the DACH region. The Boards of the specialist societies the German Hernia Society (DHG), the Surgical Working Group Hernia (CAH of the DHG), the Austrian Hernia Society (ÖHG) and the Swiss Working Group Hernia Surgery (SAHC) make inroads into this problem, describe the initial position and assess the current situation.

[Single dose of misoprostol for abortion until 9 weeks of gestation]

OBJECTIVES

The primary objective was to compare the efficacy of a single-dose misoprostol for abortion before 7 weeks of gestation and between 7 and 9 weeks of gestation. The secondary objectives were to compare the amount of misoprostol required for complete expulsion, the need for endo-uterine aspiration, and to assess pain and patient experience in these two groups.

METHODS

This was a single-centre prospective observational study conducted at the University Hospitals of Strasbourg from 1st October 2019 to 31st December 2020.

RESULTS

A total of 306 patients were included, 150 in the group before 7 weeks of gestation and 156 in the group between 7 and 9 weeks of gestation. There was no significant difference in the success rate of the single dose of misoprostol between the two groups with 34.7 and 37.8% respectively (P=0.63). After taking painkillers, there is no difference in terms of pain relief (EN ≤ 4 for 92 et 95% of patients P=0.37).

CONCLUSION

The single dose of misoprostol for in-hospital abortion is as effective between 7 and 9 weeks of gestation as it is before 7. By extension, therefore, we would suggest that there should be no difference in efficacy between home abortions before 7 weeks of gestation and between 7 and 9 weeks of gestation and therefore suggest that home abortions can be performed up to 9 weeks of gestation without fear of a decrease in the rate of complete expulsion and the efficacy of analgesia, with potentially less use of misoprostol compared with the hospital setting.

[Medical strategy for abortions between 14 and 16 weeks of gestation]

OBJECTIVE

To adapt the protocols for the management of voluntary termination of pregnancy following the new law extending the practice to 16 weeks of gestation.

MATERIAL AND METHOD

A systematic review of the literature in French and English concerning the management of patients requesting medically induced abortion was performed on PubMed, Cochrane Library and on the recommendations of international learned societies.

RESULTS

The efficacy of the medical method is greater than 95% when the protocols are adapted to the gestational age. The combination of mifepristone and misoprostol currently represents the "gold standard" of drug-based management. Mifepristone 200mg is sufficient, followed 24 to 48hours later by misoprostol 800μg administered sublingually or buccally. After the first dose, 400μg should be administered every 3hours buccally or sublingually until expulsion. Adverse effects (digestive and thermoregulatory disorders) during medical abortion are usually mild and short-lived. An anti-emetic treatment should be proposed as a prophylactic measure. For pain, ibuprofen is the analgesic treatment of choice, with the addition of level 2 analgesics if necessary.

CONCLUSION

Medical abortion is a safe and effective method up to 16 weeks of gestation, provided that the protocols, which differ according to gestational age, are respected. Women must be informed of the advantages and disadvantages of the methods according to the term and the side effects, which will allow them to choose the method that fits them best.

GLP-2 as an indicator and modulator of acute inflammation improves cardiac function and survival in sepsis

Purpose

GLP-1 and GLP-2 (glucagon-like peptide-1/2) are gut hormones secreted in response to food. While GLP-1 controls glucose metabolism, GLP-2 is a local gut growth factor regulating intestinal nutrient absorption. GLP-2 has been found to be upregulated in patients with colitis. We hypothesize that beyond its local intestinal function GLP-2 might be involved in systemic immune responses.

Methods and results

To analyze whether GLP-2 secretion is modulated by the immune system, we measured circulating GLP-2 levels in 2 clinical cohorts. In the first cohort (n=34) GLP-2 levels increased over time following cardiac surgery as an inflammatory stimulus. In the second cohort 223 patients with sepsis had a 3.9 fold increase of GLP-2 plasma levels vs. 53 healthy controls (3.0 ng/mL vs. 11.4 ng/mL; p&lt;0.001). High GLP-2 levels were associated with markers of inflammation (IL-6, PCT, CRP), septic cardiomyopathy (NT-proBNP) and independently predicted mortality in humans with sepsis. Induction of sepsis in mice by endotoxin or cecal ligation puncture strongly increased GLP-2 levels independent from food intake. By injecting various proinflammatory cytokines and inducing sepsis in IL1R−/− and IL6−/− mice we identified that inflammation upregulates GLP-2 secretion through IL-6. To identify the source of GLP-2 secretion under inflammation, we induced sepsis in Gcg−/− mice lacking endogenous GLP-2 production with a tissue-specific reactivation of Gcg in gut L-cells (GcgRAΔvilCre) or pancretic alpha cells (GcgRAΔPDX1-Cre). We observed sepsis-induced GLP-2 secretion to be derived from the pancreas and not from the gut. Additional in-vitro and ex-vivo approaches revealed that IL-6 directly activates GLP-2 secretion from pancreatic alpha cells. Gcg−/− mice lacking GLP-2 production and Glp2r−/− mice show aggravated sepsis indicating that endogenous upregulation of GLP-2 is protective. Finally, we analyzed whether inflammatory upregulation of GLP-2 has immunomodulatory relevance. We administered GLP-2 or saline as control per central jugular vein catheter mice who underwent CLP. GLP-2 treatment improved LV-contractility (dp/dtmax) in septic cardiomyopathy (control 7361 vs. GLP-2 9500 mmHg/s; p&lt;0.01), inhibited sepsis-induced hypotension and reduced mortality (p=0.018). Mechanistically GLP-2 reduced myeloid immune cell infiltration into heart and liver tissue and decreased proinflammatory cytokine levels in various organs and the blood (TNF-α, IL-6 and IL-1β). After broad GLP-2 receptor profiling we found maximum mRNA expression in gut tissues with no expression on immune cells. By further mechanistic studies we found GLP-2 to protect against sepsis-induced gut barrier dysfunction.

Conclusions

Here we identified a counter-regulatory control system in which IL-6 derived upregulation of GLP-2 secretion limits excessive innate immune responses and protects against sepsis. These findings might open new avenues for the treatment of patients with inflammatory diseases.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): European Foundation for the Study of Diabetes, European Research Area Network on Cardiovascular Diseases (ERA-CVD and BMBF), Deutsche Forschungsgemeinschaft (DFG)

P04.03.B Rapid DNA methylation-based classification of pediatric brain tumors from ultrasonic aspirate specimens

Background

Cavitating ultrasonic aspirator (CUSA) devices are commonly used in neurosurgical procedures to carefully debulk tumor from adjacent healthy brain tissue. Here, we explore the feasibility of using ultrasonic minced tumor tissue to classify otherwise discarded sample material by DNA methylation according to the respective World Health Organization (WHO) Classification of Tumors of the Central Nervous System (CNS) using low pass nanopore whole genome sequencing.

Material and Methods

21 ultrasonic aspirated specimens from patients undergoing surgery in the department of pediatric neurosurgery at the Charité-Universitätsmedizin Berlin with either newly diagnosed cerebral lesions or pre-treated lesions were processed by nanopore sequencing to generate copy number profiles and ad-hoc random forest classification. Results were compared to microarray-based routine profiling. Tumor purity was assessed.

Results

In 19/21 (90.5 %) samples the minimum amount of 1,000 CpG sites were sequenced. In 20/21 (95.2 %) cases copy number variation profiles could be generated and matched microarray derived copy number profiles, allowing for identification of diagnostically or therapeutically relevant pathognomonic alterations. 12/17 (70.6 %) samples were concordantly classified to the corresponding microarray-based diagnosis by routine neuropathological workup. Applying recently defined thresholds for nanopore-based classification resulted in sensitivity of 64.7 % and specificity of 100 %.

Conclusion

CUSA referred sample material of pediatric brain tumors allows for methylation-based classification according to the respective WHO classification of CNS tumors with acceptable sensitivity and high specificity. Hereby, a promising opportunity for accurate classification of pediatric brain tumors by a time- and cost-efficient advanced molecular technique is offered using otherwise discarded tumor tissue.

P05.05.B A new IDH-wildtype glioma subtype characterized by highly diffuse growth pattern, distinct epigenetic profile and relatively favorable prognosis

Background

DNA methylation profiling has emerges as a powerful approach to CNS tumor classification and the discovery of novel, molecularly distinct entities. With the release of the 12.5 version of the Heidelberg Brain Tumor Classifier, some unclassifiable cases can be assigned to novel methylation classes. We retrospectively reviewed our databases and identified 16 previously unclassifiable cases, all of which belong to the provisional methylation class “adult-type diffuse high-grade glioma, IDH-wildtype, subtype F (HGG_F)”.

Material and Methods

We clinically, radiologically and morphologically characterized 16 HGG_F cases and compared them to 347 glioblastomas. We additionally analyzed copy-number alterations and performed DNA exome sequencing.

Results

Median age at diagnosis of the 12 males and 4 females was 65 years. Upon initial diagnostic workup, specimens were classified as CNS tissue with reactive changes (n=3) or suspicious for the infiltration zone of a diffuse glioma (n = 13). None of the cases demonstrated endothelial proliferation or necrosis and 10/16 tumors had flat copy number profiles. Radiological characteristics were reminiscent of gliomatosis cerebri in eight cases and 9/9 cases had normal FET-PET scans. Whole-exome sequencing revealed genetic alterations frequently found in IDH-wildtype glioblastomas, including TERT promoter mutations in 11/14 (78.6%) and PIK3 mutations (10/14, 71.4%). Outcome was significantly better compared to TCGA IDH-wildtype glioblastomas with a median progression-free survival of 58 months and overall survival of 73 months (both p&lt;0.001).

Conclusion

We provide evidence that TERT promoter mutations in diffusely infiltrating gliomas without further morphological or molecular signs of high-grade glioma should be interpreted in the context of the clinico-radiological presentation as well as epigenetic prolife and may not be suitable as standalone diagnostic marker for glioblastoma, IDH wildtype.

ViBiBa: Virtual BioBanking for the DETECT multicenter trial program - decentralized storage and processing

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ViBiBa is an open-source sample banking tool.

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ViBiBa was purpose built for liquid biopsy specimen.

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ViBiBa allows for decentralized storage while promoting collaboration.

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ViBiBa's plugin support requires no change in existing data structures.

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ViBiBa empowers translational research projects and cohort formation.

Background

Liquid Biopsy (LB) in the form of e.g., circulating tumor cells (CTCs) is a promising non-invasive approach to support current therapeutic cancer management. However, the proof of clinical utility of CTCs in informing therapeutic decision-making for e.g., breast cancer in clinical trials and associated translational research projects is facing the issues of low CTC positivity rates and low CTC numbers – even in the metastasized situation. To compensate for this dilemma, clinical CTC trials are designed as large multicenter endeavors with decentralized sample collection, processing and storage of products, making data management highly important to enable high-quality translational CTC research.

Aim

In the DETECT clinical CTC trials we aimed at developing a custom-made, browser-based virtual database to harmonize and organize both decentralized processing and storage of LB specimens and to enable the collection of clinically meaningful LB sample.

Methods

ViBiBa processes data from various sources, harmonizes the data and creates an easily searchable multilayered database.

Results

An open-source virtual bio-banking web-application termed ViBiBa was created, which automatically processes data from multiple non-standardized sources. These data are automatically checked and merged into one centralized databank and are providing the opportunity to extract clinically relevant patient cohorts and CTC sample collections.

Summary

ViBiBa, which is a highly flexible tool that allows for decentralized sample storage of liquid biopsy specimens, facilitates a solution which promotes collaboration in a user-friendly, federalist and highly structured way. The source code is available under the MIT license from https://vibiba.com or https://github.com/asperciesl/ViBiBa

Atopic dermatitis among children and adolescents in the Arctic region - a systematic review and meta-analysis

The prevalence of atopic dermatitis (AD) varies across the globe, and the clinical phenotype with racial background and ethnicity. AD in the Arctic region has only been scarcely studied. We performed a systematic review and meta-analysis to examine the prevalence, clinical manifestations and risk factors for AD among children and adolescents in the Arctic. Three medical databases PubMed, Embase and Web of Science were screened. All studies published between 1990 to 2020 with epidemiologic data on AD in children and adolescents in the Arctic region, were included. Data were extracted and a meta-analysis was performed to obtain pooled proportions and incidences with 95% confidence intervals (CI). We identified 21 studies from 8 different Arctic regions with 31 403 participants. The cumulative incidence of AD was 23% (95% CI 20-26) and 1-year prevalence was 19% (95% CI 15-25). The incidence of AD was higher in the Arctic parts of Scandinavia and lower in Greenland and Russia. Children of indigenous descent had a slightly lower incidence of AD (19%, 95% CI 13-26) compared to the overall population. The dominant phenotype of AD was mild to moderate flexural dermatitis with facial involvement. Asthma and allergic rhinitis were common and observed in 20-30% of children with AD. In conclusion, AD is highly prevalent in the Arctic, but varies between regions and races. Indigenous children living in less urbanized countries appear to have a slightly lower risk of AD. Future studies should confirm this and examine whether this correlation relates to behavioural differences or genetic signature.

Development of a prognostic risk model for clear cell renal cell carcinoma by systematic evaluation of DNA methylation markers

BACKGROUND

Current risk models for renal cell carcinoma (RCC) based on clinicopathological factors are sub-optimal in accurately identifying high-risk patients. Here, we perform a head-to-head comparison of previously published DNA methylation markers and propose a potential prognostic model for clear cell RCC (ccRCC).

PATIENTS AND METHODS

Promoter methylation of PCDH8, BNC1, SCUBE3, GREM1, LAD1, NEFH, RASSF1A, GATA5, SFRP1, CDO1, and NEURL was determined by nested methylation-specific PCR. To identify clinically relevant methylated regions, The Cancer Genome Atlas (TCGA) was used to guide primer design. Formalin-fixed paraffin-embedded (FFPE) tissue samples from 336 non-metastatic ccRCC patients from the prospective Netherlands Cohort Study (NLCS) were used to develop a Cox proportional hazards model using stepwise backward elimination and bootstrapping to correct for optimism. For validation purposes, FFPE ccRCC tissue of 64 patients from the University Hospitals Leuven and a series of 232 cases from The Cancer Genome Atlas (TCGA) were used.

RESULTS

Methylation of GREM1, GATA5, LAD1, NEFH, NEURL, and SFRP1 was associated with poor ccRCC-specific survival, independent of age, sex, tumor size, TNM stage or tumor grade. Moreover, the association between GREM1, NEFH, and NEURL methylation and outcome was shown to be dependent on the genomic region. A prognostic biomarker model containing GREM1, GATA5, LAD1, NEFH and NEURL methylation in combination with clinicopathological characteristics, performed better compared to the model with clinicopathological characteristics only (clinical model), in both the NLCS and the validation population with a c-statistic of 0.71 versus 0.65 and a c-statistic of 0.95 versus 0.86 consecutively. However, the biomarker model had limited added prognostic value in the TCGA series with a c-statistic of 0.76 versus 0.75 for the clinical model.

CONCLUSION

In this study we performed a head-to-head comparison of potential prognostic methylation markers for ccRCC using a novel approach to guide primers design which utilizes the optimal location for measuring DNA methylation. Using this approach, we identified five methylation markers that potentially show prognostic value in addition to currently known clinicopathological factors.

The proliferative phase endometrium in IVF/ICSI: an in-cycle molecular analysis predictive of the outcome following fresh embryo transfer

STUDY QUESTION

Does an early proliferative phase endometrial biopsy harvested during ovarian stimulation harbour information predictive of the outcome following fresh embryo transfer (ET) in that same cycle?

SUMMARY ANSWER

Transcriptome analysis of the whole-tissue endometrium did not reveal significant differential gene expression (DGE) in relation to the outcome; however, the secretome profile of isolated, cultured and in vitro decidualized endometrial stromal cells (EnSCs) varied significantly between patients who had a live birth compared to those with an implantation failure following fresh ET in the same cycle as the biopsy.

WHAT IS KNOWN ALREADY

In the majority of endometrial receptivity research protocols, biopsies are harvested during the window of implantation (WOI). This, however, precludes ET in that same cycle, which is preferable as the endometrium has been shown to adapt over time. Endometrial biopsies taken during ovarian stimulation have been reported not to harm the chances of implantation, and in such biopsies DGE has been observed between women who achieve pregnancy versus those who do not. The impact of the endometrial proliferative phase on human embryo implantation remains unclear, but deserves further attention, especially since in luteal phase endometrial biopsies, a transcriptional signature predictive for repeated implantation failure has been associated with reduced cell proliferation, possibly indicating proliferative phase involvement. Isolation, culture and in vitro decidualization (IVD) of EnSCs is a frequently applied basic research technique to assess endometrial functioning, and a disordered EnSC secretome has previously been linked with failed implantation.

STUDY DESIGN, SIZE, DURATION

This study was nested in a randomized controlled trial (RCT) investigating the effect of endometrial scratching during the early follicular phase of ovarian stimulation on clinical pregnancy rates after IVF/ICSI. Of the 96 endometrial biopsies available, after eliminating those without fresh ET and after extensive matching in order to minimize the risk of potential confounding, 18 samples were retained to study two clinical groups: nine biopsies of patients with a live birth versus nine biopsies of patients with an implantation failure, both following fresh ET performed in the same cycle as the biopsy. We studied the proliferative endometrium by analysing its transcriptome and by isolating, culturing and decidualizing EnSCs in vitro. We applied this latter technique for the first time on proliferative endometrial biopsies obtained during ovarian stimulation for in-cycle outcome prediction, in an attempt to overcome inter-cycle variability.

PARTICIPANTS/MATERIALS, SETTING, METHODS

RNA-sequencing was performed for 18 individual whole-tissue endometrial biopsies on an Illumina HiSeq1500 machine. DGE was analysed three times using different approaches (DESeq2, EdgeR and the Wilcoxon rank-sum test, all in R). EnSC isolation and IVD was performed (for 2 and 4 days) for a subset of nine samples, after which media from undifferentiated and decidualized cultures were harvested, stored at -80°C and later assayed for 45 cytokines using a multiplex suspension bead immunoassay. The analysis was performed by partial least squares regression modelling.

MAIN RESULTS AND THE ROLE OF CHANCE

After correction for multiple hypothesis testing, DGE analysis revealed no significant differences between endometrial samples from patients who had a live birth and those with an implantation failure following fresh ET. However secretome analysis after EnSC isolation and culture, showed two distinct clusters that clearly corresponded to the two clinical groups. Upon IVD, the secretome profiles shifted from that of undifferentiated cells but the difference between the two clinical groups remained yet were muted, suggesting convergence of cytokine profiles after decidualization.

LIMITATIONS, REASONS FOR CAUTION

Caution is warranted due to the limited sample size of the study and the in vitro nature of the EnSC experiment. Validation on a larger scale is necessary, however, hard to fulfil given the very limited availability of in-cycle proliferative endometrial biopsies outside a RCT setting.

WIDER IMPLICATIONS OF THE FINDINGS

These data support the hypothesis that the endometrium should be assessed not only during the WOI and that certain endometrial dysfunctionalities can probably be detected early in a cycle by making use of the proliferative phase. This insight opens new horizons for the development of endometrial tests, whether diagnostic or predictive of IVF/ICSI treatment outcome.

STUDY FUNDING/COMPETING INTEREST(S)

This study was supported by Fonds Wetenschappelijk Onderzoek (FWO, Flanders, Belgium, 11M9415N, 1 524 417N), Wetenschappelijk Fonds Willy Gepts (WFWG G160, Universitair Ziekenhuis Brussel, Belgium) and the National Medicine Research Council (NMRC/CG/M003/2017, Singapore). There are no conflicts of interests.

TRIAL REGISTRATION NUMBER

NCT02061228.

Necessary duration of follow-up to assess complications of mesh in hernia surgery: a time-lapse study based on 460 explants

PURPOSE

Risk of complications following hernia repair is the key parameter to assess risk/benefit ratio of a technique. As mesh devices are permanent, their risks are life-long. Too many reports in the past assessed mesh safety prematurely after short follow-ups. We aimed to explore what length of follow up would reveal the full extent of complications.

METHODS

Time lapses between implantation and excision were analyzed in 460 cases of meshes excised for complications after hernia repair. Patterns of percentage growth and time lapses at 50th and 95th percentiles were used to compare groups of different hernia type, age, gender and reason for excision.

RESULTS

The 50th and 95th case percentiles in the dataset were at 3.75 and 15.0 years between mesh implantation and excision. For hernia types, the longest time lapses were for groin hernias (4.0 and 16.11 years at 50th and 95th percentiles). The shortest were for umbilical hernias (2.16 and 9.68 years). Males had later excisions than females (4.11 and 16.1 vs. 2.47 and 9.79 years). Younger patients (< 45 y.o.) had later excisions than older patients (4.12 and 17.68 vs. 3.37 and 10.0 years). Out of all subgroups, the longest time lapses were for groin hernias in younger males (4.77 and 18.89 years) and for mesh erosion into organs (4.67 and 17.0 years).

CONCLUSIONS

Follow-up of more than 15 years is needed to fully assess complications after mesh hernia repair. Especially longer periods are needed to detect mesh erosion into organs and complications in younger males. Presently, short observations and lack of reporting standard in the literature prohibit accurate assessment of complication risks. We propose to use cumulative incidence for standardized risk reporting (y% risk at x years). This will show time-dependent patterns and allow comparisons between different techniques and studies of variable duration. Standardization will also help to predict long-term risks beyond shorter (practical) follow-ups and facilitate real-time monitoring during surveillance.

Ants resort to heuristics when facing relational-learning tasks they cannot solve

We humans sort the world around us into conceptual groups, such as 'the same' or 'different', which facilitates many cognitive tasks. Applying such abstract concepts can improve problem-solving success and is therefore worth the cognitive investment. In this study, we investigated whether ants (Lasius niger) can learn the relational rule of 'the same' or 'different' by training them in an odour match-to-sample test over 48 visits. While ants in the 'different' treatment improved significantly over time, reaching around 65% correct decisions, ants in the 'same' treatment did not. Ants did not seem able to learn such abstract relational concepts, but instead created their own individual strategy to try to solve the problem: some ants decided to 'always go left', others preferred a 'go to the more salient cue' heuristic which systematically biased their decisions. These heuristics even occasionally lowered the success rate in the experiment below chance, indicating that following any rule may be more desirable then making truly random decisions. As the finding that ants resort to heuristics when facing hard-to-solve decisions was discovered post-hoc, we strongly encourage other researchers to ask whether employing heuristics in the face of challenging tasks is a widespread phenomenon in insects.

[CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy-Short Text]

OBJECTIVES

To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy.

METHODS

Systematic review of the international literature. We identified papers published between January 2003 and April 2019 in Cochrane PubMed, and Embase databases with predefined keywords. All reports published in French and English relevant to the areas of focus were included and classified according the level of evidence ranging from 1 (highest) to 4 (lowest). The strength of the recommendations was classified according to the Haute Autorité de santé, France (ranging from A, highest to C, lowest).

RESULTS

"Counseling", involving globally all kind of non-pharmacological interventions, has a modest benefit on smoking cessation, birth weight and prematurity. Moderate physical activity did not show a significant effect on smoking cessation. The systematic use of feedback by measuring the expired air carbon monoxide concentration do not influence smoking abstinence but it may be used in establishing a therapeutic alliance. The use of self-help interventions and health education are recommended in helping pregnant smokers quit. The prescription of nicotine replacement therapies (NRT) may be offered to any pregnant woman who has failed stopping smoking without medication This prescription can be initiated by the health care professional taking care of the pregnant woman in early pregnancy. There is no scientific evidence to propose the electronic cigarette for smoking cessation to pregnant smokers; it is recommended to provide the same advice and to use methods that have already been evaluated. The use of waterpipe (shisha/narghile) during pregnancy is associated with decreased fetal growth. It is recommended not to use waterpipe during pregnancy. Breastfeeding is possible in smokers, but less often initiated by them. Although its benefit for the child's development is not demonstrated to date, breastfeeding allows the mother to reduce or stop smoking. The risk of postpartum relapse is high (up to 82% at 1 year). The main factors associated with postpartum abstinence are breastfeeding, not having a smoker at home, and having no symptoms of postpartum depression.

CONCLUSIONS

Smoking during pregnancy concerns more than hundred thousand women and their children per year in France. It is a major public health burden. Health care professionals should be mobilized for reducing or even eradicating it.

[N on-pharmacological management of smoking cessation during pregnancy- CNGOF-SFT Expert Report and Guidelines for Smoking Management during Pregnancy]

OBJECTIVES

To assess the benefit of non-pharmacological intervention promoting on smoking cessation, obstetric and neonatal outcomes, to offer pregnant women who smoke (PWS) optimal care.

METHODS

We searched Medline Database, Cochrane Library and consulted international guidelines.

RESULTS

"Counselling" involving globally all kind of non-pharmacological interventions has a benefit on smoking cessation (NP1) and a moderate benefit on birth weight and prematurity (NP2). The brief intervention seems ineffective on smoking cessation (NP2). The effects of motivational interviewing have not been demonstrated during pregnancy (NP2). Cognitive-behavioral interventions do not show superiority (NP2). Financial incentives have a benefit for smoking cessation and possibly for neonatal outcomes (NP1). Feedback interventions (Co tester) provide heterogeneous results (NP2). Self-help interventions (NP2) and health education (NP2) seem effective on smoking cessation. Hypnotherapy and acupuncture have been little or not studied in PWS. Moderate physical activity did not show a significant effect (NP2) on smoking cessation but seem to reduce craving for tobacco (NP3).

CONCLUSIONS

We recommend asking all PWS about their smoking consumption and detailing their smoking history, offering them different types of counselling according to their preferences and involving them multidisciplinary (grade A). The systematic use of feedback is not recommended (grade C) but experience suggests that the CO tester is important in establishing a therapeutic alliance (professional consensus). The use of self-help interventions (grade C) and health education (grade B) are recommended.

[What Policy for the Management of Smoking During Pregnancy? - CNGOF-SFT Expert Report and Guidelines on the management for Smoking Management During Pregnancy]

Smoking during pregnancy is a public health problem. Individual screening is carried out in France during pregnancy consultations, followed by non-systemic care (with or without nicotine replacement therapy). In the UK, pregnant smokers are routinely screened during pregnancy follow-up and then referred to smoking cessation services. In order to improve their adherence, and smoking cessation, patients can be contacted, in particular by phone. We therefore recommend to systematically screen for smoking during pregnancy by asking the question of smoking or by measuring the CO exhaled during the various consultations, to offer care in collaboration with a local smoking cessation service and renew the requests if necessary. We need to develop these care networks in France.

Smoking and smoking cessation in pregnancy. Synthesis of a systematic review

OBJECTIVES

To provide up-to-date evidence-based guidelines for the management of smoking cessation during pregnancy and the post-partum period.

STUDY DESIGN

A systematic review of the international literature was undertaken between January 2003 and April 2019. MEDLINE, EMBASE databases and the Cochrane library were searched for a range of predefined key words. All relevant reports in English and French were classified according to their level of evidence ranging from 1(highest) to 4(lowest). The strength of each recommendation was classified according to the Haute Autorité de Santé (French National Authority for Health) ranging from A (highest) to C (lowest).

RESULTS

"Counselling", including all types of non-pharmacological interventions, has a moderate benefit on smoking cessation, birth weight and prematurity. The systematic use of measuring expired air CO concentration does not influence smoking abstinence, however, it may be useful in assessing smoked tobacco exposure prior to and after quitting. The use of self-help therapies and health education are recommended in helping pregnant smokers quit and should be advised by healthcare professionals. Nicotine replacement therapies (NRT) may be prescribed to pregnant women who have failed to stop smoking after trying non-pharmacological interventions. Different modes of delivery and dosages can be used in optimizing their efficacy. Smoking in the postpartum period is essential to consider. The same treatment options as during pregnancy can be used.

CONCLUSION

Smoking during pregnancy concerns more than a hundred thousand women each year in France resulting in a major public health burden. Healthcare professionals should be mobilised to employ a range of methods to reduce or even eradicate it.

AB0496 AUTOANTIBODIES TARGETING COMPLEMENT RECEPTORS 3A AND 5A1 ARE DECREASED IN ANCA-ASSOCIATED VASCULITIS AND CORRELATE WITH HIGHER RELAPSE RATE

Background:

Activation of the alternative and final common pathways have been shown in ANCA-associated vasculitis (AAV) (1). Circulating titers of C5a are elevated and correlate with disease activity in AAV. Binding to the corresponding G protein-coupled receptor (GPCR) C5aR1 enhances the influx of neutrophils, leading to ROS generation and severe necrotizing of vascular walls (2). Moreover, subsequent interaction of C5a with C5aR1 may represent a proinflammatory amplification loop (3). Blocking of the receptor is protective in a murine model in AAV (4). In humans, avacopan, a C5aR1-inhibitor showed promising results as glucocorticoid-sparing agent in two randomized phase II and one ongoing phase III clinicals trials in AAV (NCT02994927). Notably, disease-specific anti-GPCR autoantibody (aab) signatures have been found in different autoimmune diseases (5).

Objectives:

The aim of the present study was to examine whether (patho)physiological anti-C3aR and anti-C5aR1 aabs correlate with clinical findings in AAV, and whether this is linked to the clinical outcome.

Methods:

Sera and plasma of AAV patients [granulomatosis with polyangiitis (GPA), n=64; microscopic polyangiitis (MPA), n=26; eosinophilic granulomatosis with polyangiitis (EGPA), n=11] were measured by Elisa for circulating autoantibodies against complement receptors C3a (anti-C3aR aab) and C5a (anti-C5aR1 aab) and plasma levels of C3a and C5a. Expression of C3aR and C5aR1 on T-cells was determined using flow cytometry. Clinical data were assessed at the time of serum sampling and during follow-up for 48 months

Results:

GPA displayed low titers of anti-C3aR aab (GPA:5.33±2.54vs. HD:6.47±2.61, P=0.0031). Anti-C5aR1 aab were decreased in AAV, especially in GPA (GPA:1.02±1.07vs. HD:6.63±2.91, P=<0.0001). Plasma levels of C5a and anti-C5aR aab yielded an inverse correlation in AAV (r=-0.6813, P=0.0127). C5aR1 expression was increased on T-cells in GPA (CD4+C5aR1+T-cells: GPA:10.76±2.55%vs. HD:3.44±0.68%, P=0.0021; CD8+C5aR1+T-cells GPA:9.74±2.10%vs.HD:4.11±0.92%, P=0.0198). Reduced titers of anti-C5aR1 aab <0.45U/ml displayed an increased relapse risk for major organ involvement in GPA (HR 12.85, P=0.0014).

Conclusion:

As potential diagnostic marker, anti-C5aR1 aab titer may additionally be useful to monitor disease activity in AAV.

References:

[1]Chen M et al.Complement deposition in renal histopathology of patients with ANCA-associated pauci-immune glomerulonephritis.Nephrol Dial Transpl. 2009;24:1247-1252

[2]Schreiber A et al.C5a receptor mediates neutrophil activation an ANCA-induced glomerulonephritis.J Am Soc Nephrol. 2009; 20:289-298

[3]Lamprecht P et al.: Pathogenetic and clinical aspects of Anti-Neutrophil Cytoplasmic Autoantibody-associated vasculitides.Front Immunol.2018 Apr 9;9-680

[4]Xiao H et al.C5a receptor (CD88) blockade protects against MPO-ANCA GN.J Am Soc Nephrol. 2014;25(2):225-31

[5]Klapa S et al. Decreased endothelin receptor A autoantibody levels are associated with early ischaemic events in patients with giant-cell arteritis.Ann Rheum Dis2019 Oct;78(19):1443-1444

Disclosure of Interests:

Sebastian Klapa Grant/research support from: Actelion, Consultant of: Pfizer, Abbvie, Antje Müller: None declared, Andreas Koch: None declared, Anja Kerstein-Staehle: None declared, Wataru Kaehler: None declared, Harald Heidecke Shareholder of: Cell Trend GmbH, Employee of: Cell Trend GmbH, Speakers bureau: Cell Trend GmbH, Susanne Schinke Speakers bureau: Pfizer, Markus Huber-Lang: None declared, Martin Nitschke: None declared, Silke Pitann: None declared, Christian Karsten: None declared, Gabriela Riemekasten Consultant of: Cell Trend GmbH, Janssen, Actelion, Boehringer Ingelheim, Speakers bureau: Actelion, Novartis, Janssen, Roche, GlaxoSmithKline, Boehringer Ingelheim, Pfizer, Peter Lamprecht: None declared

Effects of early childhood otitis media and ventilation tubes on psychosocial wellbeing - A prospective cohort study within the Danish National Birth Cohort

BACKGROUND

Otitis Media (OM) is one of the most common infections among children in developed countries and may result in temporary conductive hearing loss (HL) if accompanied by middle ear effusion (MEE). Ventilation tube insertion (VTI) is recommended as treatment for recurrent acute OM or chronic MEE with HL. HL may lead to impaired development of psychosocial skills. However, evidence for the developmental consequences of OM and the effect of VTI is inconsistent. The objectives of this study were to investigate 1) whether OM in early childhood is associated with long-term consequences of psychosocial development and 2) if VTI prevents the possible negative consequences of OM.

METHODS

This study examined prospectively collected data from 52.877 children registered in the Danish National Birth Cohort (DNBC). Information about previous OM-episodes and VTI was obtained through systematic follow-up interviews at seven years, and The Strength and Difficulties Questionnaire (SDQ) containing questions about psychological wellbeing was completed. Five groups were defined based on OM-exposure and the presence of VTI. Baseline characteristics were analysed, and comparison of mean SDQ-scores for the five exposure groups was conducted. Means were adjusted for à priori defined confounding factors.

RESULTS

Data from 52,877 children in the DNBC showed an association between OM and poorer SDQ-scores. VTI was associated with an additional increase, i.e. worsening, of the SDQ-score for boys, and only a slight beneficial effect on the girls' outcome. The groups differed in their baseline characteristics in e.g. maternal education, socio-economic status, breastfeeding, and prematurity.

CONCLUSION

Significant associations between parent-reported OM in early childhood and later psychosocial health difficulties were found. VTI did not resolve this association.

Study on the efficiency of dsRNAs with increasing length in RNA-based silencing of the Fusarium CYP51 genes

Previously, we have demonstrated that transgenic Arabidopsis and barley plants, expressing a 791 nucleotide (nt) dsRNA (CYP3RNA) that targets all three CYP51 genes (FgCYP51A, FgCYP51B, FgCYP51C) in Fusarium graminearum (Fg), inhibited fungal infection via a process designated as host-induced gene silencing (HIGS). More recently, we have shown that spray applications of CYP3RNA also protect barley from fungal infection via a process termed spray-induced gene silencing (SIGS). Thus, RNAi technology may have the potential to revolutionize plant protection in agriculture. Therefore, successful field application will require optimization of RNAi design necessary to maximize the efficacy of the RNA silencing construct for making RNAi-based strategies a realistic and sustainable approach in agriculture. Previous studies indicate that silencing is correlated with the number of siRNAs generated from a dsRNA precursor. To prove the hypothesis that silencing efficiency is correlated with the number of siRNAs processed out of the dsRNA precursor, we tested in a HIGS and SIGS approach dsRNA precursors of increasing length ranging from 400 nt to 1500 nt to assess gene silencing efficiency of individual FgCYP51 genes. Concerning HIGS-mediated disease control, we found that there is no significant correlation between the length of the dsRNA precursor and the reduction of Fg infection on CYP51-dsRNA-expressing Arabidopsis plants. Importantly and in clear contrast to HIGS, we measured a decrease in SIGS-mediated Fg disease resistance that significantly correlates with the length of the dsRNA construct that was sprayed, indicating that the size of the dsRNA interferes with a sufficient uptake of dsRNAs by the fungus.

[Pharmacotherapy for Smoking Cessation During Pregnancy - CNGOF-SFT Expert Report and Guidelines for Smoking Management During Pregnancy]

OBJECTIVE

To review and describe available pharmacotherapy interventions for smoking cessation during pregnancy: nicotine replacement therapy (NRT) and non-nicotine replacement therapy.

METHODS

The PubMed, Medline®, and Cochrane databases® (1/01/2003 au 5/04/2019) were accessed to identify relevant studies, using the search terms "tobacco use cessation devices", "nicotine replacement product or therapy", "smoking cessation", "pregnancy", "pregnant women", "varenicline", "bupropion".

RESULTS

There is no data on the impact of NRT on the rate of smoking cessation during pre conception period. According to randomised studies versus placebo, the prescription of NRT during pregnancy (16-hours patches and gums being mainly studied) is not associated with smoking cessation during pregnancy or at the end of pregnancy (LE1). Based on the analysis of all available studies, the prescription of NRT during pregnancy is associated with smoking cessation during pregnancy and at the end of pregnancy (LE2). Coadministration of different galenic forms of pharmacotherapy during pregnancy could improve efficacy subject to tolerance and remains to be studied. The prescription of NRT during pregnancy (patches and gums being mainly studied) is not associated with postpartum smoking cessation (LE1). The prescription of NRT may be associated with the occurrence of non-serious adverse reactions (headache, nausea, vomiting, etc.) (LE2). The risk of adverse effects from NRT is not increased by pregnancy (LE2). The prescription of NRT is not associated with spontaneous abortion (LE2). There is insufficient data to establish an excess risk of congenital malformations in case of the prescription of NRT. The prescription of NRT versus placebo is associated with a reduction in the risk of preterm delivery (LE2). There is insufficient data on the prescription of NRT and neonatal outcomes. The prescription of NRT (by decreasing smoking) could be associated with better development scores at 2 years of age in children born to smoking women who received NRT versus placebo (LE2). The prescription of NRT may be offered to any pregnant woman who has failed a spontaneous smoking cessation without NRT (grade B). The data of the literature do not allow recommending one form more than another (forms of rapid action versus transdermal) nor an optimal duration of treatment (professional consensus). This prescription can be initiated by the professional taking care of the pregnant woman in early pregnancy (professional consensus). It is recommended to refer the pregnant woman to a tobacco specialist to assess and adapt the initial prescription (professional consensus). Maintenance of NRT in case of misstep is associated with a reduction in smoking (LE3). These elements suggest that in the event of a misstep or resumption of smoking, it is recommended to continue nicotine substitution (grade C). In the absence of data, second-line non-nicotinic prescriptions, nortriptyline and clonidine, are not recommended during pregnancy (professional consensus). There is insufficient data and low level of evidence to assess the impact of bupropion during the three trimesters of pregnancy, and in particular the neonatal consequences. Because of its amphetamine properties, bupoprion is not recommended for smoking cessation assistance in pregnant women (grade C). The available data are very inadequate and low level of evidence to assess the impact of varenicline during pregnancy. For this reason, varenicline cannot be recommended for smoking cessation during pregnancy (professional consensus).

CONCLUSIONS

The prescription of NRT may be offered to any pregnant woman who has failed a spontaneous smoking cessation without NRT, taking into account the lower risks of premature birth in the case of NRT (grade B). This prescription can be initiated by the professional taking care of the pregnant woman in early pregnancy (professional consensus).

Recovery, relapse, or else? Treatment outcomes in gambling disorder from a multicenter follow-up study

Purpose:

Gambling disorder is associated with various adverse effects. While data on the immediate effectiveness of treatment programs are available, follow-up studies examining long-term effects are scarce and factors contributing to a stable therapy outcome versus relapse are under-researched.

Materials and methods:

Patients (n = 270) finishing inpatient treatment for gambling disorder regularly participated in a prospective multicenter follow-up study (pre-treatment, post-treatment, 12-month follow-up). Criteria for gambling disorder, psychopathology, functional impairment were defined as endpoints. Changes in personality were defined as an additional parameter.

Results:

At follow-up, three groups were identified: subjects maintaining full abstinence (41.6%), patients still meeting criteria for gambling disorder (29.2%), and subjects still participating in gambling without meeting the diagnostic criteria for gambling disorder (29.2%). Every group had improvements in functional impairment, abstinent subjects showed the lowest psychopathology. Significant decreases in neuroticism and increases in both extraversion and conscientiousness were found among abstinent subjects but not in patients still meeting criteria for gambling disorder.

Discussion:

One year after treatment, a considerable percentage of patients kept on gambling but not all of them were classified with gambling disorder leading to the question if abstinence is a necessary goal for every patient.

Conclusions:

The changes of personality in abstinent patients indicate that after surmounting gambling disorder a subsequent maturing of personality might be a protective factor against relapse.

Study on the efficiency of dsRNAs with increasing length in RNA-based silencing of the Fusarium CYP51 genes

Previously, we have demonstrated that transgenic Arabidopsis and barley plants, expressing a 791 nucleotide (nt) dsRNA (CYP3RNA) that targets all three CYP51 genes (FgCYP51A, FgCYP51B, FgCYP51C) in Fusarium graminearum (Fg), inhibited fungal infection via a process designated as host-induced gene silencing (HIGS). More recently, we have shown that spray applications of CYP3RNA also protect barley from fungal infection via a process termed spray-induced gene silencing (SIGS). Thus, RNAi technology may have the potential to revolutionize plant protection in agriculture. Therefore, successful field application will require optimization of RNAi design necessary to maximize the efficacy of the RNA silencing construct for making RNAi-based strategies a realistic and sustainable approach in agriculture. Previous studies indicate that silencing is correlated with the number of siRNAs generated from a dsRNA precursor. To prove the hypothesis that silencing efficiency is correlated with the number of siRNAs processed out of the dsRNA precursor, we tested in a HIGS and SIGS approach dsRNA precursors of increasing length ranging from 400 nt to 1500 nt to assess gene silencing efficiency of individual FgCYP51 genes. Concerning HIGS-mediated disease control, we found that there is no significant correlation between the length of the dsRNA precursor and the reduction of Fg infection on CYP51-dsRNA-expressing Arabidopsis plants. Importantly and in clear contrast to HIGS, we measured a decrease in SIGS-mediated Fg disease resistance that significantly correlates with the length of the dsRNA construct that was sprayed, indicating that the size of the dsRNA interferes with a sufficient uptake of dsRNAs by the fungus.

Female sex as independent risk factor for chronic pain following elective incisional hernia repair: registry-based, propensity score-matched comparison

Introduction

To date, little attention has been paid by surgical scientific studies to sex as a potential influence factor on the outcome. Therefore, there is a sex bias in the surgical literature. With an incidence of more than 20% after 3 years, incisional hernias are a common complication following abdominal surgical procedures. The proportion of women affected is around 50%. There are very few references in the literature to the influence of sex on the outcome of elective incisional hernia repair.

Materials and methods

In all, 22,895 patients with elective incisional hernia repair from the Herniamed Registry were included in the study. The patients had undergone elective incisional hernia repair in a laparoscopic IPOM, open sublay, open IPOM, open onlay or suture technique. 1-year follow-up was available for all patients. Propensity score matching was performed for the 11,480 female (50.1%) and 11,415 male (49.9%) patients, creating 8138 pairs (82.0%) within fixed surgical procedures.

Results

For pain on exertion (11.7% vs 18.3%; p < 0.001), pain at rest (7.53% vs 11.1%; p < 0.001), and pain requiring treatment (5.4% vs 9.1%; p < 0.001) highly significant disadvantages were identified for the female sex when comparing the different results within the matched pairs. That was also confirmed on comparing sex within the individual surgical procedures. No sex-specific differences were identified for the postoperative complications, complication-related reoperations or recurrences. Less favorable intraoperative complication results in the female sex were observed only for the onlay technique.

Conclusions

Female sex is an independent risk factor for chronic pain after elective incisional hernia repair.

Determination of Sucralose in Soft Drinks by High-Performance Thin-Layer Chromatography: Interlaboratory Study

An interlaboratory comparison was carried out to evaluate the effectiveness of a method based on HPTLC in which reagent-free derivatization is followed by UV/fluorescence detection. The method was tested for the determination of sucralose (C12H19Cl3O8; (2R,3R,4R,5S,6R)-2- [(2R,3S,4S,5S)-2,5-bis(chloromethyl)-3,4-dihydroxyoxolan- 2-yl]oxy-5-chloro-6-hydroxymethyl)oxane-3, 4-diol; CAS Registry No. 56038-13-2) in carbonated and still beverages at the proposed European regulatory limits. For still beverages, a portion of the sample was diluted with methanolwater. For carbonated beverages, a portion of the sample was degassed in an ultrasonic bath before dilution. Turbid beverages were filtered after dilution through an HPLC syringe filter. The separation of sucralose was performed by direct application on amino-bonded (NH2) silica gel HPTLC plates (no cleanup needed) with the mobile phase acetonitrilewater. Sucralose was determined after reagent-free derivatization at 190C; it was quantified by measurements of both UV absorption and fluorescence. The samples, both spiked and containing sucralose, were sent to 14 laboratories in five different countries. Test portions of a sample found to contain no sucralose were spiked at levels of 30.5, 100.7, and 299 mg/L. Recoveries ranged from 104.3 to 124.6 and averaged 112 for determination by UV detection; recoveries ranged from 98.4 to 101.3 and averaged 99.9 for determination by fluorescence detection. On the basis of the results for spiked samples (blind duplicates at three levels), as well as sucralosecontaining samples (blind duplicates at three levels and one split level), the values for the RSDr ranged from 10.3 to 31.4 for determinations by UV detection and from 8.9 to 15.9 for determinations by fluorescence detection. The values for the RSDR values ranged from 13.5 to 31.4 for determinations by UV detection and from 8.9 to 20.7 for determinations by fluorescence detection.

Tuberculosis in the Circumpolar Region, 2006-2012

SETTING

The northern circumpolar jurisdictions Canada (Northwest Territories, Nunavik, Nunavut, Yukon), Finland, Greenland, Norway, Russian Federation (Arkhangelsk), Sweden and the United States (Alaska).

OBJECTIVE

To describe and compare demographic, clinical and laboratory characteristics, including drug resistance and treatment completion, of tuberculosis (TB) cases in the northern circumpolar populations.

DESIGN

Descriptive analysis of all active TB cases reported from 2006 to 2012 for incidence rate (IR), age and sex distribution, sputum smear and diagnostic site characteristics, drug resistance and treatment completion rates.

RESULTS

The annual IR of TB disease ranged from a low of 4.3 per 100 000 population in Northern Sweden to a high of 199.5/100 000 in Nunavik, QC, Canada. For all jurisdictions, IR was higher for males than for females. Yukon had the highest proportion of new cases compared with retreatment cases (96.6%). Alaska reported the highest percentage of laboratory-confirmed cases (87.4%). Smear-positive pulmonary cases ranged from 25.8% to 65.2%. Multidrug-resistant cases ranged from 0% (Northern Canada) to 46.3% (Arkhangelsk). Treatment outcome data, available up to 2011, demonstrated >80% treatment completion for four of the 10 jurisdictions.

CONCLUSION

TB remains a serious public health issue in the circumpolar regions. Surveillance data contribute toward a better understanding and improved control of TB in the north.

Personalizing post-treatment cancer care: a cross-sectional survey of the needs and preferences of well survivors of breast cancer

Background

Improved treatments resulting in a rising number of survivors of breast cancer (bca) calls for optimization of current specialist-based follow-up care. In the present study, we evaluated well survivors of bca with respect to their supportive care needs and attitudes toward follow-up with various care providers, in varying settings, or mediated by technology (for example, videoconference or e-mail).

Methods

A cross-sectional paper survey of well survivors of early-stage pT1-2N0 bca undergoing posttreatment follow-up was completed. Descriptive and univariable logistic regression analyses were performed to examine associations between survivor characteristics, supportive care needs, and perceived satisfaction with follow-up options. Qualitative responses were analyzed using conventional content analysis.

Results

The 190 well survivors of bca who participated (79% response rate) had an average age of 63 ± 10 years. Median time since first follow-up was 21 months. Most had high perceived satisfaction with in-person specialist care (96%, 177 of 185). The second most accepted model was shared care involving specialist and primary care provider follow-up (54%, 102 of 190). Other models received less than 50% perceived satisfaction. Factors associated with higher perceived satisfaction with non-specialist care or virtual follow-up by a specialist included less formal education (p < 0.01) and more met supportive care needs (p < 0.05). Concerns with virtual follow-up included the perceived impersonal nature of virtual care, potential for inadequate care, and confidentiality.

Conclusions

Well survivors of bca want specialists involved in their follow-up care. Compared with virtual follow-up, in-person follow-up is perceived as more reassuring. Certain survivor characteristics (for example, met supportive care needs) might signal survivor readiness for virtual or non-specialist follow-up. Future work should examine multi-stakeholder perspectives about barriers to and facilitators of shared multimodal follow-up care.

LOCALIZED CUTANEOUS NON-TOXIC DIPHTHERIA (CASE REPORT)

The authors report on a clinical case of 91-year-old female patient presented with a two-year history of an enlarging forehead lesion with exudation and bleeding, suspicious of squamous cell carcinoma. Histology ruled out the suspected diagnosis, however the microbiology culture and polymerase chain reaction assay identified non-toxic Corynebacterium diphtheriae. Therefore the diagnosis of localized cutaneous diphtheria was confirmed. The patient was treated with penicillin regimen V 3 x 1 mio IU/ day for 10 days in complex with topical povidone-iodine. The chosen treatment achieved complete healing of the ulcer and no relapse has been reported during the 9-month follow-up. Cutaneous non-healing chronic ulcers can be caused by diphtheroid corynebacteria. Immediate diagnosis is important to exclude toxic variants, which need patient isolation and treatment of persons in close contact.