Breast cancer time to treatment in Martinique: predictive factors and effect on survival

BACKGROUND

Martinique is the second French Region with the lowest physician-to-population ratio, which may affect waiting times for access to care.

OBJECTIVES

To assess (i) factors influencing waiting times from diagnosis to cancer-related treatments in breast cancer women in Martinique, and (ii) the impact of waiting times on patients' survival.

STUDY DESIGN

Retrospective observational study.

METHODS

Data on women diagnosed with invasive breast cancer between 1st January 2013 and 31st December 2017 and initially treated by surgery were extracted from the Martinique population-based registry. A cox model was performed to find predictive factors for waiting times. A log-rank test was used to compare time-to-treatment between groups.

RESULTS

In total, 713 patients were included (mean age: 58 ± 13). Median time from diagnosis to surgery was 40 [25-60] days. Age at diagnosis was found to predict variations in waiting times. Patients > 75 had longer waiting time to surgery than those < 40 or [40-50] (P = 0.016 and P < 0.001, respectively). Women with a time-to-treatment ≥ 4 months had a significant lower survival (P < 0.01).

CONCLUSIONS

Specific interventions are needed to improve waiting time from diagnosis to initial treatment, as they are longer than recommended and affect survival time.

Soluble urokinase plasminogen activator receptor levels are predictive of COVID-19 severity in Afro-Caribbean patients

Aim: To investigate association between soluble urokinase plasminogen activator receptor (suPAR) plasma levels at admission and incidence of complications in COVID-19 patients. Patients & methods: We considered Afro-Caribbean patients (n = 64) admitted to the hospital between 1 February 2020 and 28 February 2021. Primary outcome was time from the hospital admission until intensive care unit care or death. Results: Primary outcome (hazard ratio, HR [95%CI]) was associated with higher CT scan severity score (3.18 [1.15-8.78], p = 0.025), National Early Warning Score (NEWS2; 1.43 [1.02-2.02], p = 0.041) and suPAR (1.28 [1.06-2.06], p = 0.041). Kaplan-Meier analysis indicated patients with suPAR level above 8.95 ng/ml had a worse outcome (7.95 [3.33-18.97], p < 0.001). Conclusion: Our study suggests that COVID-19 patients with increased baseline suPAR levels are at a high risk of complications.

Post-exposure prophylaxis completion and condom use in the context of potential sexual exposure to HIV

OBJECTIVES

Post-exposure prophylaxis (PEP) care remains a challenge for individuals with potential sexual exposure to HIV in terms of PEP completion and ongoing risk behaviours.

METHODS

A retrospective analysis was carried out on data from the French Dat'AIDS prevention cohort (NCT03795376) for individuals evaluated for PEP between 2004 and 2017. A multivariable analysis was performed of predictors of both PEP completion and condom use [odds ratios (ORs)] and their associated probabilities (P, with P > 95% being clinically relevant).

RESULTS

Overall, 29 060 sexual exposures to HIV were evaluated for PEP [36% in men who have sex with men (MSM) and 64% in heterosexuals]. Overall, 12 different PEP regimens were offered in 19 240 cases (46%). Tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) was the preferred backbone (n = 14 304; 74%). We observed a shift from boosted protease inhibitor-based regimens to nonnucleoside reverse transcriptase inhibitor- or integrase inhibitor-based regimens in recent years. Overall, 20% of PEP prescriptions were prematurely discontinued. Older age, MSM, intercourse with a sex worker, rape and intercourse with a known HIV-infected source patient were factors associated with increased rates of PEP completion (OR > 1; P > 98%). None of the 12 PEP regimens was associated with premature discontinuation. We also found 12 774 cases of unprotected sexual intercourse (48%). Condom use decreased (OR < 1; P > 99%) with the year of exposure, and was lower in MSM and rape victims. Condom use increased (OR > 1, P > 99%) with age, and was higher in those who had intercourse with a sex worker or with a female partner and in those with knowledge of the partner's HIV status.

CONCLUSIONS

We provide new insights into how rates of condom use and PEP completion might be improved in those receiving PEP by targeting certain groups of individuals for interventions. In particular, youth and MSM at risk should be linked in a prevention-to-care continuum.

Factors associated with deaths from suicide in a French nationwide HIV-infected cohort

OBJECTIVES

People living with HIV (PLHIV) are at a higher risk of dying by suicide than the general population. Epidemiological data regarding determinants of suicide in PLHIV are scarce. The aim of this study was thus to study demographic, socio-economic, psychiatric history and immunovirological characteristics associated with death from suicide in the French multicenter Dat'AIDS cohort, from January 2000 to July 2013.

METHODS

This was a nested case-control study. All deceased PLHIV during the study period who died by suicide and whose medical files could be checked were included as cases. Controls were selected using incidence density sampling. For each case, up to four controls were selected among all actively followed PLHIV at the index date (date of death of cases). Controls were matched for time from HIV diagnosis (5-year periods) and clinical centre.

RESULTS

Seventy cases and 279 controls were included in the study. By multivariable analysis, the factors significantly associated with death from suicide were: not having children, active or substituted drug consumption, alcohol intake > 20 g/day or history of alcohol abuse, history of depressive disorder and/or of attempted suicide, and psychotropic drug intake. Conversely, age, gender, country of birth, positive HCV serology and HIV-related factors, such as AIDS status, use of combination antiretroviral therapy (cART), nadir and current CD4 counts and HIV viral load, were not significantly associated with the risk of death from suicide.

CONCLUSIONS

In the cART era, HIV-related factors are not associated with a higher risk of suicide mortality. Suicide prevention measures should target PLHIV with the psychological morbidities observed in our cohort.

High Soluble CD14 Levels at Primary HIV-1 Infection Predict More Rapid Disease Progression

The soluble CD14 (sCD14) level was found associated with mortality during the chronic phase of human immunodeficiency virus (HIV) infection. Here we assessed its prognostic value in 138 patients with primary HIV infection. Higher sCD14 levels were associated with death, from myocardial infarction, but this was based on 3 deaths only. Among 68 untreated patients, those with higher sCD14 levels had more rapid spontaneous CD4 cell decline during the first 18 months following primary infection. This association persisted after adjustment for age, the CD4 cell count, and HIV viral load at diagnosis.

Outbreak of leptospirosis among canyoning participants, Martinique, 2011

Two gendarmes who participated in canyoning activities on 27 June 2011 on the Caribbean island of Martinique were diagnosed with leptospirosis using quantitative real-time polymerase chain reaction (qPCR), 9 and 12 days after the event. Among the 45 participants who were contacted, 41 returned a completed questionnaire, of whom eight met the outbreak case definition. The eight cases sought medical attention and were given antibiotics within the first week after fever onset. No severe manifestations of leptospirosis were reported. In seven of the eight cases, the infection was confirmed by qPCR. Three pathogenic Leptospira species, including L. kmetyi, were identified in four of the cases. None of the evaluated risk factors were statistically associated with having developed leptospirosis. Rapid diagnostic assays, such as qPCR, are particularly appropriate in this setting – sporting events with prolonged fresh-water exposure – for early diagnosis and to help formulate public health recommendations. Participants in such events should be made specifically aware of the risk of leptospirosis, particularly during periods of heavy rainfall and flooding.

Mean cost of a first combination antiretroviral therapy in HIV-infected patients in France, and determinants of expensive drugs prescription

To estimate the cost of the first combination antiretroviral drug therapy (cART) in HIV-infected patients and to determine factors associated with expensive prescriptions, 1698 patients starting cART between September 2002 and September 2007 were selected from the Dat'AIDS cohort. A multivariate linear regression model was used to assess associations between the cost of first cART and patient characteristics, clinical centre and cART adequacy. At cART initiation, the median age was 39 years, median CD4 count was 223 cells/mm3, median viral load (VL) was 5.2 log copies/mL and 18.3% presented with AIDS. cART was concordant with the French guidelines in 88.7%. The mean cost of cART varied from €26.69/day/person in 2002-2003 to €32.23 in 2006-2007 ( P < 0.0001), cost was associated with previous AIDS diagnosis (€31.83/day/person) versus (29.49; P < 0.0001), baseline VL > 5 log copies/mL (€30.99/day/person) versus (28.33; P < 0.0001) and centre. cART regimen not concordant with guidelines were more expensive (€38.31/day/person) versus (29.07; P < 0.0001). After adjusting for the year of initiation, the previous AIDS diagnosis, VL and recommended cART regimen, differences were still found between centres (from €27.81/day/person) to (33.12; P < 0.0001). Cost should be considered when choosing a first cART regimen, especially when considering clinically equivalent regimens.

[Occupational exposure to syphilis during venous ulcer curettage in Martinique]

The purpose of this report is to describe the first case of occupational exposure to syphilis. This accident occurred during curettage of a venous ulcer in a 68-year-old woman in Martinique Island. The patient presented primary syphilis without HIV. This case points out the need for enhanced syphilis screening in epidemic areas.

[Efficacy and good tolerance of cotrimoxazole as treatment of cerebral toxoplasmosis in AIDS]

OBJECTIVE

Non-viral opportunistic infections involving the central nervous system in AIDS patients most commonly result from toxoplasmic encephalitis (TE). Combination pyremethamin (pyr)/sulfadiazine (sulf) is the mainstay treatment for TE, but many patients experience severe adverse events occasionally requiring discontinuation of this antitoxoplasmic medication. This investigation assessed the effects of an open, prospective trial of alternative trimethroprim/sulfamethoxazole: cotrimoxazole (CTX) therapy for TE in AIDS patients.

PATIENTS AND METHODS

The subjects were 18 AIDS patients with a first presumptive attack of TE (Group 1) and 9 relapsing patients, including 6 out of Group 1 (Group 2). We gave CTX as a therapy at the dose of 960 mg four times a day for 48 hours, then 960 mg three times a day for two weeks, followed by 960 mg twice daily until computed tomography showed complete disappearance of active TE lesions. Life-long maintenance therapy consisted to CTX 960 mg daily.

RESULTS

Group 1: Seventeen patients improved clinically and achieved complete resolution on computed tomography scars over a mean period of 33 days (range: 21-56). Only one patient was withdrawn from the study at day 18 due to a severe skin rash. Neither serious hematologic nor liver toxicity were observed. Under maintenance therapy, 7 patients relapsed after an average duration of 15.5 months. Relapses were precipitated either by poor compliance (5/7) or erronenous CTX protocol (2/7). Group 2: There were 15 relapses affecting 9 patients who were treated successfully with CTX. CTX was discontinued in one relapsing patient who experienced a Stevens-Johnson syndrome on day 13. This patient had previously experienced cutaneous intolerance to sulfadiazine.

CONCLUSION

A relative low dose regimen of CTX appears to be strongly efficient and safe treatment for toxoplasmic encephalitis in AIDS. Such a study is of particular interest for developing countries where TE is highly prevalent, given the wide availability of CTX which could be proposed as an economic first line therapy.