Updates in the pathogenesis and management of immune-related enterocolitis, hepatitis and cardiovascular toxicities

Immune checkpoint inhibitors (ICIs) have become a cornerstone of treatment for many solid organ malignancies. Alongside increasing use, the occurrence of immune-related adverse events (irAEs) has also increased and remains a significant challenge when treating patients with ICI. The underlying pathophysiology of irAE development for many organ systems is yet to be elucidated, but may involve unmasking of latent autoimmunity, increased T-cell recognition of shared antigens on cancer and normal tissue and ICI-triggered immune dysregulation with overactivation of proinflammatory pathways and suppression of immune control pathways. Management strategies for irAEs have historically been borrowed from paradigms for conventional autoimmune conditions such as inflammatory bowel disease and autoimmune hepatitis; however, recent translational efforts have clearly demonstrated key differences in underlying immune signalling pathways. As we begin to understand these differences, we must adapt a more targeted approach to immunosuppression and exercise a more nuanced approach with the multiple biologic agents available to mitigate ICI-related toxicity without reversing the antitumour effect of ICI. In this review, we focus on three key immune-related toxicities where recent clinical and translational work has provided nuanced insights into pathogenesis and treatment strategies: enterocolitis, hepatitis and cardiovascular toxicity including myocarditis.

The ChoCO-W prospective observational global study: Does COVID-19 increase gangrenous cholecystitis?

BACKGROUND

The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not.

METHODS

Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not.

RESULTS

A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001].

CONCLUSIONS

The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands.

Incomplete recovery of takotsubo cardiomyopathy is a major determinant of cardiovascular mortality

Introduction

Although there is an apparent rapid and spontaneous recovery of left ventricular ejection fraction (LVEF) in patients with takotsubo cardiomyopathy, recent studies have demonstrated the long-lasting functional impairment in those patients.

Purpose

We sought to evaluate the predictors of incomplete recovery in chronic phase and its impact on cardiovascular mortality after takotsubo cardiomyopathy.

Methods

Patients with takotsubo cardiomyopathy between 2008 and 2018 were retrospectively enrolled in three different institutions. Takotsubo cardiomyopathy was diagnosed according to the European Society of Cardiology Heart Failure Association criteria. After exclusion of in-hospital deaths, 407 patients were split into 2 subgroups according whether their LVEF were &gt;50% (recovery group; n=333), or ≤50% (incomplete recovery group; n=74) at follow-up. The primary endpoint was the impact of incomplete recovery on cardiovascular mortality.

Results

Patients with incomplete recovery were more likely to be male, to have dementia, pacemaker, and supraventricular arrhythmia. C-reactive protein (CRP) levels on admission, at peak, and at discharge were significantly higher in patients with incomplete recovery. By multivariate logistic regression analysis, lower EF at discharge (odds ratio [OR]: 0.91; 95% confidence interval [CI]: 0.88 to 0.95; p&lt;0.001) and higher CRP levels (OR: 5.56; 95% CI: 1.86 to 16.61; p&lt;0.001) were independent predictors of incomplete recovery at follow-up. The cumulative event-free survival rate according to cardiovascular death was significantly lower in the incomplete recovery group (p&lt;0.001; log-rank test).

Conclusions

We demonstrate that incomplete recovery after takotsubo cardiomyopathy is characterized by a residual systemic inflammation and an increased cardiac mortality at follow-up. Altogether, our findings underline patients with persistent inflammation as a high-risk subgroup, to target in future clinical trials with specific therapies to attenuate inflammation.

Funding Acknowledgement

Type of funding source: None

P6485Incremental prognostic value of electrocardiographic strain after transcatheter aortic valve replacement for aortic stenosis

Background

Electrocardiographic (ECG) strain pattern has recently been associated with increased adverse outcome in aortic stenosis (AS) and after surgical aortic valve replacement (AVR). However, the relation linking ECG strain and cardiovascular MACE in patients with transcatheter aortic valve replacement (TAVR) has not been yet described.

Objectives

The aim of our study was to determine the impact and incremental value of ECG Strain pattern in predicting adverse outcome after TAVR.

Methods

585 patients with severe AS (mean age: 83±7 male 39.8%) were enrolled from November 2012 to May 2018. ECG strain pattern was defined as ≥1 mm concave down-sloping ST-segment depression and asymmetrical T-wave inversion in the lateral leads. Patients with baseline left bundle branch block (LBBB), right bundle branch block (RBBB) or ventricular paced rhythm were excluded. All patients underwent transthoracic echocardiography (TTE) before TAVR and at 30 days follow up. The primary endpoints of the study were the overall all-cause mortality after TAVR, rehospitalization for Hearth failure (HF), myocardial infarction and stroke.

Results

178 (30.4%) patients were excluded from analyses owing to the presence of either LBBB (n=103) or RBBB (n=75). Among the 407 remaining patients, 106 had ECG strain pattern (26.04%). Patients with ECG strain were significantly younger (81.6±8 years vs 83.5±6.8 years; p=0.022), had lower BMI (23±4.5 kg.m2 vs 27.9±6.8 kg.m2; p=0.02) more severe AS (mean gradient 52.3±15.2 mmHg vs 47.9±11.8 mmHg; p=0.003), significant lower LVEF (51.8±15% vs 58.4±10.7%; p<0.001). Left ventricular hypertrophy (LVH) was more frequent in patients with ECG Strain (indexed left ventricular mass (135.9±33.4 g.m2 vs 123.6±31.9 g.m2; p=0.002)). Death from any cause (22 (20.8%) vs 61 (20.3%); p=0.508) did not differ significantly between groups. Major adverse cardiovascular events (MACE) including death, stroke and heart failure at 1 month showed similar incidence (7 (6.6%) vs 17 (5.6%), p=0.439). Rehospitalization for hearth failure (HF) was significantly higher (33 (31.1%) vs 33 (11%); p<0.001) in patients with ECG strain pattern. In univariate model, ECG Strain was a strong predictor of rehospitalization for HF (HR 2.621 95% CI (1.607–4.277), p=0.001), independently of LVH assessed either by ECG criteria (HR 1.181 95% CI (0.698–1.997; p=0.536) or TTE (HR 1.557 95% (CI 0.701–3.458; p=0.277). ECG Strain remained associated with a higher risk of rehospitalization for hearth failure in multivariate analyses (HR 2.747 95% (CI 1.614- 4.674); p<0.001)

Conclusion

In patients with AS eligible for TAVR, ECG Strain Pattern is frequent and associated with an increased risk of post interventional heart failure regardless of preoperative LVH. ECG Strain pattern represents an easy, objective, reliable and low-cost tool to identify patients who may benefit from an extend and intensified post-interventional follow-up.

Online Learning of Gait Models From Older Adult Data

This paper proposes a novel approach for online, individualized gait analysis, based on an adaptive periodic model of any gait signal. The proposed method learns a model of the gait cycle during online measurement, using a continuous representation that can adapt to inter- and intra-personal variability by creating an individualized model. Once the algorithm has converged to the input signal, key gait events can be identified based on the estimated gait phase and amplitude. The approach is implemented and tested on retirement home resident 6 min walk (6MW) data using wearable accelerometers at the ankle. The proposed approach converges within approximately four gait cycles and achieves 3% error in detecting initial swing events.11 An early version of this work was presented in [1]. A more extensive description of related work and an extended method, including optimization of learning rates, were added to this paper. Further, this paper applies and evaluates the method to a new and much larger gait dataset taken from older adults who each have a variety of medical conditions. Therefore, the experimental protocol was also updated and the results are entirely novel.

Trabecular bone score in adults with cerebral palsy

CONTEXT

Bone fragility in cerebral palsy (CP) is secondary to a complex interplay of functional, hormonal, and nutritional factors that affect bone remodelling. A greater understanding of bone microarchitectural changes seen in CP should assist therapeutic decision making.

OBJECTIVE

To examine the relationship between trabecular bone score (TBS), BMD and fractures in adults with CP; the influence of clinical factors and body composition on bone microarchitecture were explored.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

43 adults (25 male) with CP of median age 25 years (interquartile range 21.4-33.9) who had evaluable dual-energy X-ray absorptiometry imaging of the lumbar spine from a single tertiary hospital between 2005-March 2018.

RESULTS

24/43 (55.8%) of patients had TBS values indicating intermediate or high risk of fracture (<1.31). TBS correlated with areal BMD at the lumbar spine, femoral neck and total body. TBS was significantly associated with arm and leg lean mass, with adjustment for age, gender and height (adjusted R² = 0.18, p = 0.042 for arm lean mass; adjusted R² = 0.19, p = 0.036 for leg lean mass). There was no difference in TBS when patients were grouped by fracture status, anticonvulsant use, gonadal status or use of PEG feeding. TBS was lower in non-ambulatory patients compared with ambulatory patients (1.28 vs 1.37, p = 0.019).

CONCLUSIONS

Abnormal bone microarchitecture, as measured by TBS, was seen in >50% of young adults with CP. TBS correlated with both areal BMD and appendicular lean mass. Maintaining muscle function is likely to be important for bone health in young adults with CP and needs to be confirmed in further studies.

A genomic evaluation of taxonomic trends through time in coast horned lizards (genus Phrynosoma)

Determining the boundaries between species and deciding when to describe new species are challenging practices that are particularly difficult in groups with high levels of geographic variation. The coast horned lizards (Phrynosoma blainvillii, Phrynosoma cerroense and P. coronatum) have an extensive geographic distribution spanning many distinctive ecological regions ranging from northern California to the Cape Region of Baja California, Mexico, and populations differ substantially with respect to external morphology across much of this range. The number of taxa recognized in the group has been reevaluated by herpetologists over 20 times during the last 180 years, and typically without the aid of explicit species delimitation methods, resulting in a turbulent taxonomy containing anywhere from one to seven taxa. In this study, we evaluate taxonomic trends through time by ranking 15 of these species delimitation models (SDMs) using coalescent analyses of nuclear loci and SNPs in a Bayesian model comparison framework. Species delimitation models containing more species were generally favoured by Bayesian model selection; however, several three-species models outperformed some four- and five-species SDMs, and the top-ranked model, which contained five species, outperformed all SDMs containing six species. Model performance peaked in the 1950s based on marginal likelihoods estimated from nuclear loci and SNPs. Not surprisingly, SDMs based on genetic data outperformed morphological taxonomies when using genetic data alone to evaluate models. The de novo estimation of population structure favours a three-population model that matches the currently recognized integrative taxonomy containing three species. We discuss why Bayesian model selection might favour models containing more species, and why recognizing more than three species might be warranted.

Androgen receptor mutations in patients with castration-resistant prostate cancer treated with apalutamide

Background

Mutations in the androgen receptor (AR) ligand-binding domain (LBD), such as F877L and T878A, have been associated with resistance to next-generation AR-directed therapies. ARN-509-001 was a phase I/II study that evaluated apalutamide activity in castration-resistant prostate cancer (CRPC). Here, we evaluated the type and frequency of 11 relevant AR-LBD mutations in apalutamide-treated CRPC patients.

Patients and methods

Blood samples from men with nonmetastatic CRPC (nmCRPC) and metastatic CRPC (mCRPC) pre- or post-abiraterone acetate and prednisone (AAP) treatment (≥6 months' exposure) were evaluated at baseline and disease progression in trial ARN-509-001. Mutations were detected in circulating tumor DNA using a digital polymerase chain reaction-based method known as BEAMing (beads, emulsification, amplification and magnetics) (Sysmex Inostics' GmbH).

Results

Of the 97 total patients, 51 had nmCRPC, 25 had AAP-naïve mCRPC, and 21 had post-AAP mCRPC. Ninety-three were assessable for the mutation analysis at baseline and 82 of the 93 at progression. The overall frequency of detected AR mutations at baseline was 7/93 (7.5%) and at progression was 6/82 (7.3%). Three of the 82 (3.7%) mCRPC patients (2 AAP-naïve and 1 post-AAP) acquired AR F877L during apalutamide treatment. At baseline, 3 of the 93 (3.2%) post-AAP patients had detectable AR T878A, which was lost after apalutamide treatment in 1 patient who continued apalutamide treatment for 12 months.

Conclusions

The overall frequency of detected mutations at baseline (7.5%) and progression (7.3%) using the sensitive BEAMing assay was low, suggesting that, based on this assay, AR-LBD mutations such as F877L and T878A are not common contributors to de novo or acquired resistance to apalutamide.

ClinicalTrials.gov identifier

NCT01171898.

Impact of providing patients with copies of their medical correspondence: a randomised controlled study

BACKGROUND

In Australia, correspondence is routinely sent to general practitioners following a specialist consultation. Written communication is an important way to enhance patient experiences and understanding, yet most patients do not receive copies of their medical correspondence.

AIMS

To determine whether providing clinic correspondence and endoscopy reports to patients leads to improved understanding, satisfaction or anxiety.

METHODS

This is a prospective, randomised controlled study conducted at an Australian tertiary hospital from October 2013 to February 2015. New adult referrals to the general gastroenterology clinic requiring an urgent endoscopic procedure were eligible for the study. The intervention group received a copy of their clinic correspondence and endoscopy report, while the control group received neither. Participants completed questionnaires, including visual analogue scales and the Hospital Anxiety and Depression Scale, at three time points. Primary outcomes were patient understanding, anxiety and satisfaction.

RESULTS

A total of 70 participants was included in the study. There was no reduction in anxiety levels (P = 0.52), no increase in understanding (P = 0.73) or any increase in satisfaction (P = 0.33) in participants receiving correspondence. However, 97% of participants indicated that they wished to receive correspondence in the future, and 94% of participants in the correspondence group reported that receiving correspondence had helped them to understand their medical condition.

CONCLUSION

Patients wish to receive copies of their correspondence and feel it improves their understanding of their medical condition. Although we were unable to demonstrate a measurable reduction in anxiety, increase in understanding or satisfaction, we recommend that patients be offered the choice of receiving copies of their clinic correspondence and endoscopy reports.

Fractures in spina bifida from childhood to young adulthood

This study assessed the prevalence and types of fractures in spina bifida and examined risk factors for fracture. Fracture prevalence was highest in childhood and reduced in adolescence and young adulthood. The importance of maintaining mobility is highlighted by the increased risk of fracture in those who are non-ambulatory.

INTRODUCTION

The aims of this study are to study the prevalence and types of fractures according to age group in spina bifida and examine risk factors associated with fracture.

METHODS

This is a retrospective cohort study of 146 individuals with spina bifida aged 2 years or older who attended the paediatric or adult spina bifida multidisciplinary clinic at a single tertiary hospital.

RESULTS

Median age at which first fracture occurred was 7 years (interquartile range 4-13 years). Fracture rates in children (ages 2-10), adolescents (ages 11-18) and adults (age > 18) were 10.9/1000 (95 % confidence interval 5.9-18.3), 5.4/1000 (95 % CI 1.5-13.8) and 2.9/1000 (95 % CI 0.6-8.1) patient years respectively. Childhood fractures predominantly involved the distal femur and femoral shaft; these fractures were rarely seen in adulthood. Non-ambulatory status was associated with a 9.8 times higher risk of fracture compared with ambulatory patients (odds ratio 9.8, p = 0.016, 95 % CI 1.5-63.0). Relative risk of re-fracture was 3.1 (95 % CI 1.4-6.8). Urological intervention with intestinal segments was associated with renal calculi (p = 0.037) but neither was associated with fracture.

CONCLUSIONS

The risk of fracture is lower in adults compared with children with spina bifida. The predominant childhood fracture affects the distal femur, and immobility is the most significant risk factor for fracture. Clinical factors contributing to fracture risk need to be elucidated to enable selection of patients who require investigation and treatment of osteoporosis.

PLANET TOPERS: Planets, Tracing the Transfer, Origin, Preservation, and Evolution of their ReservoirS

The Interuniversity Attraction Pole (IAP) 'PLANET TOPERS' (Planets: Tracing the Transfer, Origin, Preservation, and Evolution of their Reservoirs) addresses the fundamental understanding of the thermal and compositional evolution of the different reservoirs of planetary bodies (core, mantle, crust, atmosphere, hydrosphere, cryosphere, and space) considering interactions and feedback mechanisms. Here we present the first results after 2 years of project work.

Musculoskeletal and Endocrine Health in Adults With Cerebral Palsy: New Opportunities for Intervention

CONTEXT

Cerebral palsy (CP) increases fracture risk through diminished ambulation, nutritional deficiencies, and anticonvulsant medication use. Studies examining bone mineral density (BMD) in adults with CP are limited.

OBJECTIVE

To examine the relationship between body composition, BMD, and fractures in adults with CP. The effect of functional, nutritional, and endocrine factors on BMD and body composition is also explored.

DESIGN

Retrospective cross-sectional study.

SETTING AND PARTICIPANTS

Forty-five adults with CP (mean age, 28.3 ± 11.0 years) who had dual-energy x-ray absorptiometry imaging at a single tertiary hospital between 2005 and 2015.

RESULTS

Seventeen (38%) had a past history of fragility fracture; 43% had a Z-score of ≤ -2.0 at the lumbar spine (LS) and 41% at the femoral neck (FN). In nonambulatory patients, every one unit decrease in FN Z-score increased the risk of fracture 3.2-fold (95% confidence interval, 1.07-9.70; P = .044). Stepwise linear regression revealed that the Gross Motor Function Classification System was the best predictor of LS Z-score (R(2) = 0.550; β = -0.582; P = .002) and FN Z-score (R(2) = 0.428; β = -0.494; P = .004); 35.7% of the variance in BMD was accounted for by lean tissue mass. Hypogonadism, present in 20% of patients, was associated with reduced lean tissue mass and reduced LS BMD. Lean tissue mass positively correlated with BMD in eugonadal patients, but not in hypogonadal patients.

CONCLUSIONS

Low BMD and fractures are common in adults with CP. This is the first study to document hypogonadism in adults with CP with detrimental changes in body composition and BMD.

[Usefulness of diastolic deceleration time assessed by transthoracic Doppler measurement in the detection of sustained microvascular obstruction in STEMI patients treated by primary PTCA]

AIMS

To assess the value of coronary flow measurement by transthoracic Doppler technique in the detection of "no-reflow" phenomenon.

METHODS

Fourteen patients with first anterior wall infarction treated by successful (TIMI3) primary percutaneous angioplasty and left descending coronary artery stenting were investigated. Myocardial perfusion following PCI was assessed by (i) ST-segment resolution, (ii) MRI-detected microvascular obstruction (early hypoenhancement), (iii) coronary flow pattern measurement by transthoracic Doppler technique.

RESULTS

Sustained impairment of myocardial perfusion following PCI was observed in a large proportion of the cohort (36% by MRI, 43% by ST regression analysis). Patients with a diastolic deceleration time inferior to 482 ms had higher troponin and CK peak value, higher wall motion index score, lower ST resolution and lower LVEF assessed by MRI. The concordance of the three methods was 80%.

CONCLUSION

The measurement of diastolic deceleration time by transthoracic Doppler technique is a reliable technique to identify microvascular obstruction following PCI in acute anterior STEMI. A DDT inferior to 482 ms is associated with sustained "no-reflow" phenomenon.

[Value of left atrial dilation in the diagnosis of silent myocardial ischemia in diabetes mellitus patients]

BACKGROUND

Accelerated atherothrombosis is a common feature in diabetes mellitus patients (DM), which can be related to abnormalities in vascular cell apoptosis and activation leading to the release of procoagulant microparticles (MPs). In DM patients, we hypothesized that circulating levels of biomarkers involved in atherothrombosis processes as well as cardiac and carotid echocardiography variables could be useful in the detection of silent myocardial diagnosed by myocardial perfusion imaging.

METHODS AND RESULTS

We investigated, in 55 patients with diabetes (mean age 62+/-10 years) and 15 nondiabetics (46+/-14 years) patients the prevalence of silent myocardial ischemia (SMI) detected by a treadmill exercise or dipyridamole (99m)Tc-sestamibi stress test. Echocardiographic and -carotid variables were obtained using standardized methods. Biomarkers assessing endothelial apoptosis or activation (CD31+-MPs, CD62+-MPs, VCAM-1), inflammatory status (CD11a +/- MPs, MCP-1, CRP), platelet activation (GPIb+/-MPs, CD40-L, P-selectin, GPV) ventricular stretch (BNP) were measured in the plasma. SMI was diagnosed in 23/55 (42%) diabetics patients and in 3/15 (20%) nondiabetics patients. Enhanced inflammatory status and leukocyte damage (CD11a+-MPs) were evidenced in diabetic patients. Within the diabetic population, biomarkers levels of atherothrombosis were not significantly associated to the detection of SMI. In multivariable analyses adjusted for LV hypertophy, left atrial surface (LA) remained independent predictor of silent myocardial ischemia (OR 4.14; IC [1.7-16.13]; P=0.039).

CONCLUSIONS

In diabetes mellitus patients, LA surface independently predicted silent myocardial ischemia after adjustment for established echocardiographic, and inflammatory risk factors. This simple measure of LA dilation could be helpful in the identification of diabetes mellitus patients at heightened cardiovascular risk.

[Cardiac consequences of subclinical dysthyroidism. Experimental, clinical, and epidemiologic data]

KEY POINTS

Although the cardiovascular consequences of clinical or "overt" dysthyroidism are well known and treatment relatively well established, subclinical dysthyroidism remains a controversial topic, both regarding its cardiovascular effects and the best methods for its management. Subclinical hyperthyroidism is frequent among the elderly, usually associated with multinodular goiter. Although several epidemiologic studies have demonstrated that subclinical hyperthyroidism is associated with an increased risk of atrial fibrillation and high cardiovascular mortality, solid practical data on which management can be based are not currently available. The risks related to subclinical hypothyroidism appear essentially vascular but a conclusive assessment must await further epidemiologic surveys.

Effects of cefixime or co-amoxiclav treatment on nasopharyngeal carriage of Streptococcus pneumoniae and Haemophilus influenzae in children with acute otitis media

A multicentre, open-label, randomized study was performed in 501 out-patients with acute otitis media, aged 6-36 months, to study the impact of treatment with either cefixime suspension 8 mg/kg/day bd or co-amoxiclav suspension 80 mg/kg/day tds for 10 days on nasopharyngeal carriage of Streptococcus pneumoniae and Haemophilus influenzae. Of 426 patients with nasopharyngeal cultures at entry to the trial, end of treatment and at follow-up visit (35 days after inclusion), significant changes in carriage of S. pneumoniae were observed. The proportion of penicillin-resistant S. pneumoniae was higher in the samples taken at the end of treatment and follow-up than in those taken at inclusion, while the total number of children with this microorganism was lower. The difference at the end of treatment was greater with co-amoxiclav than with cefixime. For H. influenzae the resistance rate remained steady while the number of children with this microorganism decreased. At follow-up there was no significant difference between the two groups in terms of nasopharyngeal positive culture for S. pneumoniae or H. influenzae. Despite these differences, successful clinical responses were similar at the end of treatment and at follow-up.

[On the use of the gastroepiploic artery in myocardial revascularization]

Between 1985 and 1992, the gastroepiploic artery was used for coronary bypass surgery in 80 consecutive patients. Revascularisation was totally arterial in 62.5% of cases, the gastroepiploic being associated with single or double internal mammary artery grafts. The gastroepiploic graft was used to revascularise the inferior myocardial regions. The postoperative morbidity was essentially due to respiratory complications: 6 patients had objective pulmonary complications and 11 patients had relative transient postoperative hypoxia. The early gastrointestinal complications were related to ulceration (5 patients) complicated by haemorrhage in 2 patients. This morbidity was responsible for a significant increase in the period of intensive care. The hospital mortality was 6.2%, observed mainly in the first third of the author's experience and in patients with preoperative poor prognostic factors. These relatively high morbidity and mortality rates have led to a cautious use of the right gastroepiploic artery for coronary bypass surgery in patients over 70 years of age, in those with unstable angina operated as an emergency and in those with associated pathology, especially respiratory problems. The choice of a complex surgical option should not be synonimous with an increased postoperative mortality.

Acute otitis media in children: a study of nasopharyngeal carriage of potential pathogens and therapeutic efficacy of cefixime and amoxicillin-clavulanate

We conducted a large, multicenter, randomized, open-label study throughout France comparing the efficacy and safety of cefixime suspension (8 mg/kg/day, b.i.d., for 10 days) versus amoxicillin-clavulanate suspension (80 mg/kg/day, t.i.d., for 10 days) in 510 children (ages 6 to 36 months) with acute otitis media. The most frequent microorganisms colonizing the nasopharynx at the start of treatment were Streptococcus pneumoniae (51.5%), Haemophilus influenzae (45%) and Moraxella catarrhalis (30.2%). Rates of beta-lactamase positivity were 32.1% and 95.3% for H. influenzae and M. catarrhalis, respectively. Decreased susceptibility of S. pneumoniae to penicillin was found in 39.7% of isolates. Clinical efficacy was 87.8% (223/254) for cefixime and 87.0% (215/247) for amoxicillin-clavulanate. At the 5-week follow-up visit, relapse had occurred in 15.7% (31/197) of cefixime-treated patients and in 15.6% (32/205) of those treated with amoxicillin-clavulanate. We conclude that these two regimens are equally effective in acute otitis media in children.

Mitral valve tumor revealed by stroke

Valvular tumors are uncommon and usually benign lesions, discovered accidentally or when neurological or cardiological complications occur. We report a case of mitral valve papillary fibroelastoma measuring less than 1 cm and revealed by stroke. Transesophageal echocardiography was the best method to establish the diagnosis as it provided higher discriminative power than the transthoracic echocardiography or nuclear magnetic resonance. The embolic risks justify the surgical treatment of these lesions while anticoagulation therapy can be suggested as a substitute to surgery for the high risk patients.