Smartphone and Wearable Device-Based Digital Phenotyping to Understand Substance use and its Syndemics

Digital phenotyping is a process that allows researchers to leverage smartphone and wearable data to explore how technology use relates to behavioral health outcomes. In this Research Concepts article, we provide background on prior research that has employed digital phenotyping; the fundamentals of how digital phenotyping works, using examples from participant data; the application of digital phenotyping in the context of substance use and its syndemics; and the ethical, legal and social implications of digital phenotyping. We discuss applications for digital phenotyping in medical toxicology, as well as potential uses for digital phenotyping in future research. We also highlight the importance of obtaining ground truth annotation in order to identify and establish digital phenotypes of key behaviors of interest. Finally, there are many potential roles for medical toxicologists to leverage digital phenotyping both in research and in the future as a clinical tool to better understand the contextual features associated with drug poisoning and overdose. This article demonstrates how medical toxicologists and researchers can progress through phases of a research trajectory using digital phenotyping to better understand behavior and its association with smartphone usage.

Acceptance of digital phenotyping linked to a digital pill system to measure PrEP adherence among men who have sex with men with substance use

Once-daily oral HIV pre-exposure prophylaxis (PrEP) is an effective strategy to prevent HIV, but is highly dependent on adherence. Men who have sex with men (MSM) who use substances face unique challenges maintaining PrEP adherence. Digital pill systems (DPS) allow for real-time adherence measurement through ingestible sensors. Integration of DPS technology with other digital health tools, such as digital phenotyping, may improve understanding of nonadherence triggers and development of personalized adherence interventions based on ingestion behavior. This study explored the willingness of MSM with substance use to share digital phenotypic data and interact with ancillary systems in the context of DPS-measured PrEP adherence. Adult MSM on PrEP with substance use were recruited through a social networking app. Participants were introduced to DPS technology and completed an assessment to measure willingness to participate in DPS-based PrEP adherence research, contribute digital phenotyping data, and interact with ancillary systems in the context of DPS-based research. Medical mistrust, daily worry about PrEP adherence, and substance use were also assessed. Participants who identified as cisgender male and were willing to participate in DPS-based research (N = 131) were included in this subsample analysis. Most were White (76.3%) and non-Hispanic (77.9%). Participants who reported daily PrEP adherence worry had 3.7 times greater odds (95% CI: 1.03, 13.4) of willingness to share biometric data via a wearable device paired to the DPS. Participants with daily PrEP adherence worry were more likely to be willing to share smartphone data (p = 0.006) and receive text messages surrounding their daily activities (p = 0.003), compared to those with less worry. MSM with substance use disorder, who worried about PrEP adherence, were willing to use DPS technology and share data required for digital phenotyping in the context of PrEP adherence measurement. Efforts to address medical mistrust can increase advantages of this technology for HIV prevention.

Informing Acceptability and Feasibility of Digital Phenotyping for Personalized HIV Prevention among Marginalized Populations Presenting to the Emergency Department

For marginalized populations with ongoing HIV epidemics, alternative methods are needed for understanding the complexities of HIV risk and delivering prevention interventions. Due to lack of engagement in ambulatory care, such groups have high utilization of drop-in care. Therefore, emergency departments represent a location with those at highest risk for HIV and in highest need of novel prevention methods. Digital phenotyping via data collected from smartphones and other wearable sensors could provide the innovative vehicle for examining complex HIV risk and assist in delivering personalized prevention interventions. However, there is paucity in exploring if such methods are an option. This study aimed to fill this gap via a cross-sectional psychosocial assessment with a sample of N=85 emergency department patients with HIV risk. Findings demonstrate that although potentially feasible, acceptability of digital phenotyping is questionable. Technology-assisted HIV prevention needs to be designed with the target community and address key ethical considerations.

[French version of The Ottawa Statement on the Ethical Design and Conduct of Cluster Randomized Trials, in a French law context]

INTRODUCTION

There is growing evidence on the ethical challenges raised by cluster randomized trials. This specificity is not reflected in the legal texts regulating research, which creates difficulties for researchers implementing these experimental designs. The Ottawa Statement (Weijer et al. 2012) aims to provide detailed guidance on the ethical design, conduct and assessment of cluster trials. More broadly aims to help research stakeholders and decision-makers to make informed ethical decisions regarding the particularity of these experimental designs. It seems that this international statement, written in English, is not sufficiently accessible to all of the French professionals involved in health research. The aim of this article is to provide these professionals with a contextualized and illustrated French translation of the "Ottawa statement".

METHOD

. The "complex design" working group of the RECaP network (Research in Clinical Epidemiology and Public Health), carried out this work. A first version was discussed by the authors in several meetings. It was completed by contextual explanations and examples of French studies currently conducted by the authors. The final version was obtained by consensus and validated by the group.

RESULTS

. This work reports 15 recommendations grouped into 7 key questions: How to justify cluster design? How to submit an article to an ethics committee? How to identify research participants? How and when to obtain informed consent? Who are the gatekeepers? How to assess benefits and harm? How to protect vulnerable participants? Each of these recommendations is specific to cluster trials. The recommendations are explained and detailed through concrete examples.

CONCLUSION

Without interfering with current French laws, this work provides a framework for the organization, conduct and ethical assessment of cluster randomized trials in France. In the present-day context, it is essential that all concerned groups can base their decisions on recommendations in line with the elementary principles of health research ethics.

Patient navigation for colorectal cancer screening in deprived areas: the COLONAV cluster randomized controlled trial

BACKGROUND

The objective of this study was to assess the effectiveness of a Patient Navigation Intervention targeting deprived patients for Colo-Rectal Cancer (CRC) screening participation.

METHODS

A cluster randomized controlled trial was conducted in 5 districts. Peer Lay Patient Navigators were recruited to operate in deprived areas. Eligible participants had to be between 50 and 74 years old, live in these deprived areas and receive an invitation to the nationally organized Colo-Rectal Cancer (CRC) screening during the study period. The theory-driven navigation intervention was deployed for 18 months. A population Health Intervention Research assessment method was used to assess effectiveness and context interaction. The primary criterion was screening participation at 12 months.

RESULTS

Twenty-four thousand two hundred eighty-one individuals were included inside 40 clusters. The increase in participation in the intervention group was estimated at 23%, (ORa = 1.23, CI95% [1.07-1.41], p = 0.003). For the subgroup of individuals who participated, the time delay to participating was reduced by 26% (ORa = 0.74, CI95% [0.57-0.96], p = 0.021). Main factors modulating the effect of the intervention were: closeness of navigator profiles to the targeted population, navigators' abilities to adapt their modus operandi, and facilitating attachment structure.

CONCLUSION

The ColoNav Intervention succeeded in demonstrating its effectiveness, for CRC screening. Patient Navigation should be disseminate with broader health promotion goals in order to achieve equity in health care.

TRIAL REGISTRATION

clinicaltrials.gov NCT02369757 24/02/2015.

Work outcomes of breast cancer survivors who returned to work after treatment: CANTO cohort

Background

As survival rates among breast cancer patients improve there is an increasing need to address breast cancer survivors’ (BCS) issues, professional life being a key aspect. Return to work (RTW) of BCS has been largely studied, but studies on job maintenance and its determinants are scarce. We aim to study job maintenance after RTW and the associated factors among BCS.

Methods

We used data from the CANTO cohort, a French prospective cohort of BCS. We included 1643 BCS aged <57 at diagnosis (dx) who returned to work two years after dx. We excluded self-employed BCS. Using multinomial logistic models, we assessed the association between activity status one year after they return to work. (i.e. active, sick leave, or unemployed, retired or invalidity) and sociodemographic, clinical, health status and work-related factors.

Results

Overall, 87% of BCS were active, 10% were on sick leave and 3% were on unemployment, retirement or invalidity one year after they return to work. In the fully adjusted model being on sick leave was associated with stage III at dx (OR: 1.89, 95% CI: 1.11-3.22), being severely fatigued at the moment of returning to work (OR: 1.53, 1.04-2.27), and having workplace accommodations (OR: 1.79, 1.14-2.81). The unemployed, retired, invalidity status was negatively associated with professional life being more than or as important as one’s personal life (OR: 0.51, 0.26-0.98) and being <50 years old (OR: 0.51, 0.27-0.96), and positively associated with having a fixed-term contract (OR: 2.69, 1.39-5.18) and working for a small company (OR: 2.73, 1.24-6.02).

Conclusions

A non-negligible proportion of BCS are non-active one year after they return to work. While clinical factors are associated with sick leave, work related factors are associated with the unemployed, retired, and invalidity status. RTW should not be regarded as the ultimate goal and future policies should focus on ensuring people are ready to return to work and maintain their jobs.

Key messages

• A non-negligible proportion of breast cancer survivors are non-active one year after they return to work.

• Future policies should ensure job maintenance along with return to work.

Transmission du SARS-CoV-2 lors d'une soirée en club fermée entre personnes vaccinées (ITOC-ANRS 0066S) : résultats préliminaires

Introduction

La pandémie de SARS-CoV-2 a conduit à la fermeture des lieux de clubbing pour réduire la transmission du virus. Les vaccins protègent en partie de l'infection et réduise ainsi sa transmission. L'étude "Indoor Transmission of COVID-19" (ITOC) a pour objectif de déterminer, parmi une population entièrement vaccinée, le risque de transmission du SARS-CoV-2 et d'autres pathogènes respiratoires lors d'un événement de clubbing en salle fermée dans une population vaccinée. Nous présentons ici les premiers résultats sur la transmission du SARS-CoV-2.

Matériels et méthodes

ITOC est une étude mono-centrique en cluster, randomisée en 2 :1 et contrôlée. L'intervention était un événement clubbing indoor de 8 heures sans port de masque, sans distanciation sociale, à jauge pleine, en octobre 2021 à Paris. Les participants étaient âgés de 18 à 49 ans avec un schéma vaccinal complet (sans le boost). Ils devaient fournir un échantillon salivaire le jour de l'expérimentation et sept jours plus tard, pour la recherche par PCR du SARS-CoV-2 et de 24 autres pathogènes respiratoires (dont VRS et autres Coronavirus). Ils ont également rempli des questionnaires en ligne à l'inclusion, un jour après l'événement et de 3 à 7 jours après pour y renseigner leurs symptômes et comportements au cours de la soirée.

Résultats

Parmi les 1216 participants randomisés, 755 ont suivis tout le protocole, 484 dans le groupe intervention et 271 dans le groupe contrôle. Les deux groupes étaient comparables sur le plan des caractéristiques socio démographiques, 53% des participants étaient des hommes, l'âge médian était de 29 ans, 22,7% était étudiant, 43,7% sortaient une à 2 fois par mois en discothèque. A J0, un participant dans chaque groupe a été testé positif au SARS-CoV-2 (Ct= 28 et 30 pour le groupe intervention et contrôle respectivement ), et à J7, un seul participant dans le groupe contrôle a été testé positif. Les analyses concernant les questionnaires et les virus respiratoires sont en en cours d'analyse.

Conclusion

La participation à une soirée en discothèque en milieu clos à pleine jauge avec une ventilation efficace (sans masque et sans distanciation physique) entre personnes vaccinés n'a pas été associée à l'apparition d'un cluster de SARS-CoV-2 à partir d'une personne contagieuse participante à la soirée. Le taux d'incidence et le nombre insuffisant de participants ne permet pas de calculer à un risque relatif de transmission du SARS-CoV-2.

Aucun lien d'intérêt

Lessons learned from an e-mental health intervention: The promotion of stopblues in 41 french cities

Introduction

For more than a decade, digital health has held promise for enabling a much broader population to have access to health information, education and services. However, the increasing number of studies on the subject show mixed results and currently, there is a certain disillusionment regarding its benefits. And yet, the Covid-19 crisis has revealed the importance of developing digital-based complementary support to existing resources.

Objectives

Factors associated with higher utilization rates among the target audience need to be investigated.

Methods

In 2018, 41 French cities enrolled in an intervention program aimed at promoting StopBlues®, a digital health tool that helps prevent mental distress and suicide among the general population. After two years of experimentation, a Multiple Correspondence Analysis (MCA) was performed using quantitative and qualitative data collection methods from institutional sources, questionnaires and web analytics tools.

Results

Finding trends show that higher utilization rates were associated with the involvement of general practitioners (GPs) in the promotion of StopBlues and the use of digital marketing channels. Context-specific characteristics also played an important role in the adoption of the tool.

Conclusions

The local context has a strong influence on how digital tools are locally promoted and accepted. Further research is needed to understand how local actors and specifically GPs can be involved in suicide prevention. More broadly, the challenge today is to ensure acceptance of digital health technology among targeted populations by adapting the digital offer to their needs and promoting the available tools.

Disclosure

No significant relationships.

The influence of acute exercise on bone biomarkers: protocol for a systematic review with meta-analysis

BACKGROUND

Bone is a plastic tissue that is responsive to its physical environment. As a result, exercise interventions represent a potential means to influence the bone. However, little is currently known about how various exercise and participant characteristics interact to influence bone metabolism. Acute, controlled, interventions provide an in vivo model through which the acute bone response to exercise can be investigated, typically by monitoring circulating bone biomarkers. Currently, substantial heterogeneity in factors such as study design, quality, exercise, and participant characteristics render it difficult to synthesize and evaluate the available evidence. Using a systematic review and meta-analytic approach, the aim of this investigation is to quantify the effect of an acute exercise bout on circulating bone biomarkers as well as examine the potential factors that may moderate this response, e.g., variation in participant, exercise, and sampling characteristics.

METHODS

This protocol was designed in accordance with the PRISMA-P guidelines. Seven databases (MEDLINE, Embase, Sport Discus, Cochrane CENTRAL, PEDro, LILACS, and Ibec) will be systematically searched and supplemented by a secondary screening of the reference lists of all included articles. The PICOS (Population, Intervention, Comparator, Outcomes and Study Design) approach was used to guide the determination of the eligibility criteria. Participants of any age, sex, training, or health status will be considered for inclusion. We will select studies that have measured the bone biomarker response before and after an acute exercise session. All biomarkers considered to represent the bone metabolism will be considered for inclusion, and sensitivity analyses will be conducted using reference biomarkers for the measurement of bone resorption and formation (namely β-CTX-1 and P1NP). Multi-level, meta-regression models within a Bayesian framework will be used to explore the main effect of acute exercise on bone biomarkers as well as potential moderating factors. The risk of bias for each individual study will be evaluated using a modified version of the Downs and Black checklist while certainty in resultant outcomes will be assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

DISCUSSION

A better understanding of the bone metabolic response to an acute bout of exercise has the potential to advance our understanding of the mechanisms through which this stimulus impacts bone metabolism, including factors that may moderate this response. Additionally, we will identify current gaps in the evidence base and provide recommendations to inform future research.

SYSTEMATIC REVIEW REGISTRATION

This protocol was prospectively registered in the Open Science Framework Registry ( https://osf.io/6f8dz ).

Integration of eMental health technologies into traditional community-based interventions

Background

Very little research has been conducted to appraise the merits of including municipalities and their local health providers in the promotion of digital health programmes. While more and more municipalities have locally implemented a health strategic plan and have focused on building local network of professionals, how do the latter react to the implementation of innovative e-mental health community-based programmes?

Methods

In 2018, 42 French municipalities volunteered to promote StopBlues, a digital health tool aimed at preventing mental distress and suicide. In each municipality, a local delegate was responsible for the promotion of the tool. Using observations, questionnaires and interviews with the delegates, we analysed how the promotion of StopBlues® was conducted in each setting. 2/3 of these municipalities started the promotion directly, and in 2019, a second wave of municipalities launched the promotion with a stronger support from the research team backed by the French World Health Organization Collaborating Centre for Research and Training in Mental Health (WHOCC).

Results

The use of digital technology in the implementation of a mental health programme received a mixed reception from the local health professionals because of its innovative aspect. 2/3 of the delegates declared that they were struggling to create a stronger network of local partners including private medical practioners. 63% of the respondents stated that their municipalities got involved in the programme for networking purposes.

Conclusions

Digital technologies have initiated a paradigm shift in the way community-based health programmes are set up but need to strengthen their territorial anchorage in order to be accepted and used at the local level.

Key messages

Digital technology can be a strong lever against health inequities but its effectiveness has to be studied carefully. Digital technolgy has to be implemented in local settings with the collaboration of local actors in order to be accepted and used.

Increased intracellular survival of Salmonella Typhimurium ST313 in HIV-1-infected primary human macrophages is not associated with Salmonella hijacking the HIV compartment

BACKGROUND

Non-typhoidal Salmonella (NTS) causes a severe invasive syndrome (iNTS disease) described in HIV-positive adults. The impact of HIV-1 on Salmonella pathogenesis and the molecular basis for the differences between these bacteria and classical diarrhoeal S. Typhimurium remains unclear.

RESULTS

Here, we show that iNTS-associated S. Typhimurium Sequence Type 313 (ST313) bacteria show greater intracellular survival in primary human macrophages, compared with a 'classical' diarrhoeal S. Typhimurium ST19 isolate. The increased intracellular survival phenotype of ST313 is more pronounced in HIV-infected macrophages. We explored the possibility that the bacteria take advantage of the HIV-associated viral-containing compartments created in human macrophages that have low pH. Confocal fluorescence microscopy and focussed ion beam-scanning electron microscopy tomography showed that Salmonella did not co-localise extensively with HIV-positive compartments.

CONCLUSION

The capacity of ST313 bacteria to survive better than ST19 bacteria within primary human macrophages is enhanced in cells pre-infected with HIV-1. Our results indicate that the ST313 bacteria do not directly benefit from the niche created by the virus in HIV-1-infected macrophages, and that they might take advantage from a more globally modified host cell.

SIGNIFICANCE

A better understanding of the interplay between HIV-1 and Salmonella is important not only for these bacteria but also for other opportunistic pathogens.

Employment two years after breast cancer diagnosis: role of household characteristics, CANTO cohort

Background

Breast cancer is associated with a high 5-year survival rate and more than half women are still of working age at diagnosis. Many studies evaluated the clinical determinants of return to work (RTW) but few investigated RTW in relation to family factors. Our objective was to study the role of household characteristics in non-RTW two years after breast cancerdiagnosis.

Methods

We used data of a French prospective cohort of women diagnosed with stage I-III, primary breast cancer (CANTO, NCT01993498). Patients had to be under 57 and have a job at diagnosis. We performed logistic regressions to model non-RTW two years after diagnosis in relation to household characteristics at diagnosis (marital status, children, support from partner), adjusting for tumor characteristics, health status at baseline and one year after diagnosis, and household income at diagnosis. In a second step, we conducted analyses stratified for household income at diagnosis.

Results

In total, 1874 women were eligible. Being in a relationship did not impact non-RTW (OR = 1.43 [95% CI 0.95-2.16]). Among the 1566 women in a relationship, being married was associated with elevated odds of non-RTW(OR = 1.37 [0.96-1.94]). Having children(OR = 1.17 [0.81-1.69]) or receiving support from their partner (OR = 1.17 [0.77-1.78]) was not associated with non-RTW. However, the situation differed in low-income households(&lt;2500€) among whom being married was associated with more elevated odds of non-RTW(OR = 1.94 [0.97-3.88]). No clear association was observed between having children (OR = 1.85 [0.85-4.03]) and non-RTW, but living with at least two children (OR = 2.76 [1.14-6.70]) and receiving support from their partner (OR = 2.28 [1.01-5.17]) was associated with increased odds of non-RTW.

Conclusions

The family environment is associated with non-RTW among the poorest women but not the others.

Key messages

Among the poorest women, the family environment is associated with non-RTW. Among all women, the family environment is not associated with non-RTW.

Patients' association programs for adolescents and young adults: The JAP study

INTRODUCTION

A dozen innovative care clinics have recently opened in France to support the transition of adolescents with chronic conditions between pediatric and adult healthcare units through various interventions. Some patients' associations have set up specific programs for adolescents and young adults (AYAs) in order to facilitate the transition process, but they are not well-known among healthcare professionals. Our aim was to describe these programs and to evaluate the quality of their implementation and transferability into transition clinics.

MATERIEL AND METHODS

We conducted semistructured interviews with representatives of associations that proposed interventions dedicated to AYAs with chronic conditions. We collected quantitative and qualitative data to describe these interventions. Descriptive statistics were run on quantitative data and a thematic analysis of the qualitative data was made.

RESULTS

A questionnaire was sent to 55 associations, 19 (36%) of them had established programs and were contacted; interviews were conducted with 16 of them. Thirteen were national associations, 11 focused on a specific chronic disease, three supported multiple chronic conditions, and two were available to any AYA with chronic disease. Programs were mainly camps (n=5; from 2days to 3weeks) and workshops (n=5). Educational considerations and hobbies were more frequently discussed when peers were directly involved in the program. Stakeholders were mainly other patients and peers (9/16). Fourteen out of 16 were perceived as successful (perceived improvement in AYA quality of life and/or positive feedback). Twelve out of 16 associations thought that their program could be transferable to transition clinics and all were interested in collaboration.

DISCUSSION

This work highlights five key points to be considered in the clinical care setting before building programs: unique tailoring and customization, complementarity with existing programs in patients' associations, viability based on peer involvement and evaluation, a common main goal, and using transition clinics' assets to direct AYAs towards the most suitable program.

Autologous bilayered self-assembled skin substitutes (SASSs) as permanent grafts: a case series of 14 severely burned patients indicating clinical effectiveness

Split-thickness skin autografts (AGs) are the standard surgical treatment for severe burn injuries. However, the treatment of patients with substantial skin loss is limited by the availability of donor sites for skin harvesting. As an alternative to skin autografts, our research group developed autologous self-assembled skin substitutes (SASSs), allowing the replacement of both dermis and epidermis in a single surgical procedure. The aim of the study was to assess the clinical outcome of the SASSs as a permanent coverage for full-thickness burn wounds. Patients were recruited through the Health Canada's Special Access Program. SASSs were grafted on debrided full-thickness wounds according to similar protocols used for AGs. The graft-take and the persistence of the SASS epithelium over time were evaluated. 14 patients received surgical care with SASSs. The mean percentage of the SASS graft-take was 98 % (standard deviation = 5) at 5 to 7 d after surgery. SASS integrity persisted over time (average follow-up time: 3.2 years), without noticeable deficiency in epidermal regeneration. Assessment of scar quality (skin elasticity, erythema, thickness) was performed on a subset of patients. Non-homogeneous pigmentation was noticed in several patients. These results indicated that the SASS allowed the successful coverage of full-thickness burns given its high graft-take, aesthetic outcome equivalent to autografting and the promotion of long-term tissue regeneration. When skin donor sites are in short supply, SASSs could be a valuable alternative to treat patients with full-thickness burns covering more than 50 % of their total body surface area.

Are dietary reports in a case-control study on thyroid cancer biased by risk perception of Chernobyl fallout?

BACKGROUND

In retrospective case-control studies performed following nuclear tests or nuclear accidents, individual thyroid radiation dose reconstructions are based on fallout and meteorological data from the residential area, demographic characteristics, and lifestyle as well as dietary information. Collecting the latter is a controversial step, as dietary declarations may be affected by the subjects' beliefs about their risk behavior. This report analyses the potential for such bias in a case-control study performed in eastern France.

METHODS

The study included 765 cases of differentiated thyroid carcinoma matched with 831 controls. Risk perceptions and beliefs of cases and controls were compared using Chi² tests and differences in dietary reports were analyzed using a two-way ANOVA.

RESULTS

In general, atmospheric pollution and living near a nuclear power plant were the two major risks that may influence thyroid cancer occurrence cited by cases and controls. When focusing in particular on the consequences of the Chernobyl accident, cases were more likely to think that the consequences were responsible for thyroid cancer occurrence than controls. Vegetable consumption during the two months after the Chernobyl accident was correlated with the status of subjects, but not to their beliefs. Conversely, consumption of fresh dairy products was not correlated with the status or beliefs of subjects.

CONCLUSION

We found no evidence of systematic bias in dietary reports according to the status or beliefs held by subjects about the link between thyroid cancer occurrence and Chernobyl fallout. As such, these dietary reports may be used in further studies involving individual dosimetric reconstructions.

[Well-being in adulthood of patients with chronic conditions in childhood: The GEDEPAC-2 questionnaire]

BACKGROUND

In France, chronic diseases affect 3 million children. In children with chronic conditions, long-term somatic outcome has been well described, but little is known about the psychosocial aspects of well-being.

METHODS

Our aim was to build a self-administered questionnaire of global well-being in adults who had a chronic disease since or during childhood using a multidimensional and nonspecific approach. The questionnaire was constructed by a multidisciplinary group (epidemiologists, clinicians, sociologist, statistician). Items were built in compliance with reference data from the French general population (national surveys, free access) to allow comparative analysis adjusted for age and sex (and eventually other confounding factors) by indirect standardization (qualitative variables) or Z-scores (quantitative variables).

RESULTS

The GEDEPAC-2 includes 108 items exploring 11 domains: education, employment, housing, material security, social links, civic engagement, leisure, environment, physical health/risky behavior, health-related quality of life and sex life. Factual questions and satisfaction scales jointly explore social well-being. Quality of life is analyzed in terms of physical quality of life, mental quality of life, fatigue and burden of treatment by 3 questionnaires validated in French (SF-12; MFI-20; Burden of Treatment Questionnaire). Experience of transition from pediatric to adult healthcare is described in 21 items. Paper and electronic versions were developed.

CONCLUSION

Built in a multidimensional approach to well-being and in line with the available reference data, GEDEPAC-2 will facilitate the implementation of future studies on impact in adulthood of chronic disease in childhood.

2-μm Ho emitter-based coherent DIAL for CO(2) profiling in the atmosphere

We report on the use of a thulium-fiber-pumped holmium-based emitter in a coherent differential absorption lidar (CDIAL) experiment for high time and space resolution of CO(2) absorption field in the atmosphere. The 2-μm high-power dual-wavelength single-mode Q-switched Ho:YLF oscillator delivers 10-mJ pulses with a duration of 40 ns at 2 kHz. Both short pulse duration and high repetition rate were chosen to increase the DIAL precision and time and space resolution in coherent detection. The CDIAL provides 150-m range and 15-min time-resolved CO(2) absorption coefficient with a calculated instrumental error of 0.5% at 500 m and less than 2% at 1 km. Dry-air CO(2) mixing ratio estimates from the DIAL system are compared with simultaneous in situ gas analyzer measurements during a 20-h-long experiment.

Educational trajectories after childhood cancer: When illness experience matters

With the increase in survival from childhood cancer, research has increasingly focused on the educational and professional achievements of childhood cancer survivors. Yet, if large-scale studies provide an acute description of the current situation of childhood cancer survivors, little is known about their trajectories and the social processes shaping these trajectories. Using a qualitative methodology, drawing from a life course perspective, this study sought to describe the role of childhood cancer and its side effects in educational trajectories, as perceived by the participants. We investigated related processes of social adjustment to cancer, that is to say, choices or decisions that survivors related to the illness in the making of their career plans. Eighty long-term French childhood cancer survivors participating in the Euro2K longitudinal study were interviewed through in-depth, face-to-face interviews undertaken in 2011-2012. There were various types of impact described by respondents of the diagnosis of cancer on their trajectories. These varied according to gender. In women, childhood cancer tended to result in poor educational achievement, or in steering the individual towards a health care or child care occupation. This was justified by a desire to return the support that had been offered to them as patients. In men, however, childhood cancer led to a shift in career plans, because of physical sequelae, or because of concerns about their future health. Paradoxically, this limitation had a positive impact in their occupational achievement, as most of these men disregarded blue-collar jobs and chose more qualified white-collar occupations. Overall, findings suggest that childhood cancer influenced educational trajectories and, thus, socioeconomic status in adulthood, through mechanisms embedded in gender norms. These mechanisms could explain gender inequalities in educational achievement after childhood cancer reported in large-scale cohort studies.

Ionic compatibilization of polypropylene/polyamide 6 blends using an ionic liquids/nanotalc filler combination: morphology, thermal and mechanical properties

In this study, room temperature ionic liquids (RTILs) based on phosphonium cations have been used as effective compatibilizers of polyolefin/polyamide 6/synthetic talc blends using a melt extrusion process.

[Pelvic and spinal MR follow-up of multiple myeloma patients after high-dose chemotherapy and autologous peripheral blood stem cell transplant]

PURPOSE

To evaluate the changes of bone marrow lesions on pelvic and spinal MR in patients with multiple myeloma after high-dose chemotherapy and autologous peripheral blood stem cell transplant.

PATIENTS AND METHODS

Pelvic and spinal MR examinations were obtained at presentation (myeloma diagnosis) and 1 year after transplant in 20 patients that were part of a group of 39 patients enrolled in a prospective study. The type of marrow replacement (classified in stages with stage 0: normal; stage 1: salt and pepper; stage 2: focal infiltration; stage 3: diffuse infiltration), the number and size of marrow lesions and the number of vertebral compression fractures were recorded. We have compared the findings prior to and following transplant, with correlation to the response to treatment and the use of biphosphonates.

RESULTS

The type of marrow replacement was improved following transplant in 65% of patients (not statistically significant). The number and size of nodules > 20 mm showed significant reduction (p = 0.0224 and p = 0.0237 respectively). Lesions on MR improved in 50% of patients with good response and 75% of patients with poor response to treatment. Patients receiving biphosphonates showed more vertebral compression fractures.

CONCLUSION

The evolution of marrow replacing lesions on MR is discordant compared to the biological and clinical response to treatment. Pelvic and spinal MR evaluation at the time of diagnosis does not appear to be a good predictive factor of response to treatment. Biphosphonates do not appear to prevent new vertebral compression fractures. Pelvic and spinal MR provides interesting data in the follow-up of patients with myeloma following autologous transplant, especially in the local evolution of marrow replacing lesions, but our results do not justify its use in routine clinical practice.

Bone mass and microarchitecture of irradiated and bone marrow-transplanted mice: influences of the donor strain

Total body irradiation and bone marrow transplantation induced dramatic trabecular bone loss and cortical thickening in mice. Transplanted cells were engrafted in bone marrow, along trabeculae, and in periosteal and endosteal envelopes. None of the osteocytes were of donor origin. Bone microarchitecture of transplanted mice changed to tend toward the donor phenotype.

INTRODUCTION

Osteopenia and osteoporosis are complications of bone marrow transplants (BMT) attributed to related chemotherapy. However, the specific influence of total body irradiation (TBI) is unknown.

METHODS

We investigated the effects of TBI and BMT on bone mass and microarchitecture by micro-CT. Eighteen C57Bl/6 (B6) mice receiving lethal TBI had a BMT with marrow cells from green fluorescent protein--transgenic-C57Bl/6 (GFP) mice. Transplanted (T(GFP)B6), B6, and GFP mice were euthanized 1, 3, and 6 months after BMT or at a related age.

RESULTS

T(GFP)B6 presented a dramatic bone loss compared with B6 and did not restore their trabecular bone mass over time, despite a cortical thickening 6 months after BMT. Serum testosterone levels were not significantly reduced after BMT. During aging, GFP mice have less trabeculae, thicker cortices, but a narrower femoral shaft than B6 mice. From 3 months after BMT, cortical characteristics of T(GFP)B6 mice differed statistically from B6 mice and were identical to those of GFP mice. GFP(+) cells were located along trabecular surfaces and in periosteal and endosteal envelopes, but none of the osteocytes expressed GFP.

CONCLUSION

Our findings suggest that engrafted cells did not restore the irradiation-induced trabecular bone loss, but reconstituted a marrow microenvironment and bone remodeling similar to those of the donor. The effects of irradiation and graft on bone remodeling differed between cortical and trabecular bone.

Free and total insulin-like growth factor (IGF)-I, -II, and IGF binding protein-1, -2, and -3 serum levels in patients with active thyroid eye disease

To determine whether serum levels of total (T) and free (F) IGF-I and -II and IGF binding protein (IGFBP),-1, -2, and -3 are normal in euthyroid patients with Graves' disease and active thyroid ophthalmopathy, we investigated the above-mentioned parameters in 21 patients (11 male, 10 female) aged 50.8 +/- 11.8 yr (range 35-70) and 19 healthy individuals matched for age, gender, and body mass index. All patients had active thyroid eye disease (TED) with clinical activity scores > or = 4 and positive orbital octreoscan in both eyes. Serum T and F IGF-I and IGF-II were determined using noncompetitive time-resolved monoclonal immunofluorometric assays, IGFBP-1 was determined by an in-house RIA, IGFBP-2 by a novel in-house time-resolved immunofluorometric assay, whereas IGFBP-3 by an immunoradiometric assay. All data are expressed as mean +/- SD. Our results show that T and F IGF-I, -II, and IGFBP-1, -2, and -3 levels in patients were similar to controls and did not show any significant difference. Specifically, mean T IGF-I for patients group was 131 (61), F IGF-I was 0.47 (0.16), T IGF-II was 1056 (300), F IGF-II was 1.45 (0.54), IGFBP-1 was 33 (14), IGFBP-2 was 848 (377), and finally IGFBP-3 was 3953 (1422). For controls, mean T IGF-I was 146 (51), F IGF-I was 0.85 (0.43), T IGF-II was 939 (197), F IGF-II was 1.53 (0.53), IGFBP-1 was 44 (24), IGFBP-2 was 764 (316) and finally IGFBP-3 was 3721 (1017). Furthermore, no statistically differences emerged in the ratio between molar weights of T IGF-I/IGFBP-3 and T IGF-II/IGFBP-3, as well as to the F/T IGF-I and F/T IGF-II. Finally, no relationship was found between the levels of the above-mentioned parameters and clinical activity scores, octreoscan scores, and thyroid hormones. Our data demonstrate for the first time that serum levels of IGFs (including free fractions) and IGFBPs are not increased in euthyroid Graves' patients with active TED. The increased IGF levels in retrobulbar tissues previously described, appear to be independent of serum IGFs concentration and probably represent autocrine and/or paracrine activity.

Mohs micrographic surgery of a plexiform fibrohistiocytic tumor

BACKGROUND

Plexiform fibrohistiocytic tumor (PFT) is a rare mesenchymal neoplasm first described by Enzinger and Zhang in 1988. Clinically it is characterized by slow growth, frequent local recurrences, and rare systemic metastasis. These tumors occur chiefly in children and young adults and are most commonly located on the shoulders and forearms.

OBJECTIVE

To present a case report of an incompletely excised PFT, its complete resection using simple excision and Mohs micrographic surgery, and review of the literature.

METHODS

An 11-year-old Hispanic girl was evaluated for the treatment of an incompletely excised plexiform fibrohistiocytic neoplasm located in the right axilla. Mohs micrographic surgery (MMS) was chosen because of the ill-defined borders and the need for tissue conservation. The patient underwent a two-stage, six section, micrographically controlled excision. Upon completion of the MMS a 2 mm final stage, taken as a peripheral and deep section around and underneath the cleared area, was submitted for paraffin embedding. Residual plexiform histiocytic tumor was found at the margin of resection in one location. Reevaluation of the Mohs slides demonstrated the possible presence of tumor at one deep focus. The tumor was reexcised with a 5 mm margin and repeat hematoxylin and eosin staining showed no residual tumor. There has been no evidence of recurrence in 4 years.

RESULTS

Complete resection of the PFT and absence of tumor recurrence 4 years later.

CONCLUSION

Over the past few years the list of neoplasms for which MMS is the treatment of choice has steadily grown. PFT is a recently described locally aggressive mesenchymal neoplasm with potential for distant metastasis. To our knowledge this is the first time MMS has been used to resect this tumor. To ensure the chance of complete extirpation we recommend the harvest of an additional stage for hematoxylin and eosin staining, as is done in some aggressive squamous cell carcinomas.

Immunohistochemical analysis of the interhemal membrane of the elephant shrew

The placenta of the elephant shrew, an African insectivore, was examined histochemically to resolve the controversy surrounding the nature of its interhemal membrane. Immunohistochemistry suggests that trophoblast abuts the maternal blood spaces, and evidence of maternal capillary basement membrane is lacking. The mature placenta of these species is thus hemochorial. Earlier developmental stages would require examination to rule out the possibility of a preceding endotheliochorial condition.

Early versus late extubation after coronary artery bypass grafting: effects on cognitive function

OBJECTIVE

To compare the effects of a short period of mechanical ventilation and sedation and a longer one on cognitive functioning of patients exposed to cardiopulmonary bypass (CPB).

DESIGN

A randomized, prospective study.

SETTING

Tertiary-care university hospital.

PARTICIPANTS

Forty-eight adult patients with surgical coronary artery disease.

INTERVENTION

Elective coronary artery bypass surgery.

MEASUREMENT AND MAIN RESULTS

Patients (n = 48; mean age, 60.12+/-9.30 years) were randomized to either group I (mean delay, 3.49+/-2.21 hours) or group II (mean delay, 10.32+/-1.75 hours). Cognitive functioning was evaluated before surgery, postoperatively, and at the 8-week follow-up. Tests included measures of central nervous system integrity, attention/concentration and psychomotor performance, verbal fluency, visual scanning speed, mental flexibility, auditory and visual attention, and verbal memory. Covariance analyses were used for group comparisons. Covariates were age, education, and baseline or postoperative performance. No differences in cognitive functioning were found between the two groups. Globally, performance deteriorated for 34.1% of the patients at the posttest evaluation, whereas 2.3% improved and 63.6% remained unchanged. At follow-up, nearly 40.5% of the patients showed an improvement from baseline, 2.4% still had deficits, and 57.1% had no change. None of the cognitive functions appeared to be more affected than others.

CONCLUSION

Early extubation and a shortened period of anesthesia/analgesia do not appear to positively or negatively affect cognitive functioning at 3 to 5 days and 8 weeks postoperatively. Early extubation is suggested because it has no deleterious effect (besides the low risk for reintubation) and it may facilitate patients' care in the intensive care unit.

Retrograde replacement of the thoracic aorta under circulatory arrest and retrograde cerebral perfusion

Single-stage replacement of the ascending, transverse and descending thoracic aorta remains a noteworthy surgical intervention associated with significant morbidity. Aside from the surgical aspects, brain preservation during the circulatory arrest period, which is generally needed to perform the procedure, is a constant preoccupation for the surgeon. A 43-year-old man had an extensive thoracic aneurysm 4 years after an initial type A aortic dissection involving the entire thoracic aorta. The Cooley technique of retrograde replacement of the thoracic aorta was performed along with retrograde cerebral perfusion. The combined sternal and thoracic approach suggested for this technique provided excellent exposure and, despite a circulatory arrest time of 88 minutes, the patient's cognitive abilities were found to be well preserved at follow-up 2 months after the surgery, indicating the efficacy of the cerebral retrograde perfusion. The authors conclude that retrograde replacement of the thoracic aorta combined with cerebral retrograde perfusion are convenient procedures that allow extensive aortic replacement without brain damage.

Diffuse hyperplasia of the peribiliary glands

Diffuse, severe, macroscopically recognizable dilatation and hyperplasia of the peribiliary glands of intrahepatic and extrahepatic bile ducts is an extremely rare condition. To our knowledge, this is the first such case reported in the literature. We encountered this condition in a patient with massive hepatic necrosis. The pathogenesis of the condition is discussed. Unfamiliarity with this pathology could lead to an erroneous diagnosis of a well-differentiated cholangiocarcinoma.

V2 receptor antagonism of DDAVP-induced release of hemostasis factors in conscious dogs

The synthetic arginine vasopressin (AVP) analog 1-desamino-8-D-arginine vasopressin (DDAVP) is used in a variety of hemorrhagic disorders. The present experiments were designed to further characterize the mechanism of DDAVP-induced release of hemostasis factors. The [3H]AVP-labeled AVP receptor in canine renomedullary membranes exhibited an AVP V2 profile because the V2 receptor agonist DDAVP displayed similar subnanomolar affinities as the natural hormone AVP, whereas the two selective V1a compounds SR 49059 and d(CH2)5Tyr(Me)AVP as well as the selective V1b agonist D-Pal and oxytocin were much less potent. The rank order of the binding affinities of three V2 receptor antagonists was SR 121463 (a newly described selective V2 receptor antagonist) > OPC 31260 >> d(CH2)5D-Ile2,Ile4AVP. In conscious dogs, DDAVP (0.1-1 microg/kg I.V.) caused a dose-related increase (maximum, 43-52% at 30 min) in plasma levels of factor VIII (FVIII), von Willebrand factor (vWF) and tissue-type plasminogen activator (t-PA), but not in levels of plasminogen activator inhibitor-1. A DDAVP-induced hemostasis factor release was also observed in bilaterally nephrectomized dogs. Pretreatment with SR 121463 inhibited DDAVP-induced (1 microg/kg I.V.) increases in FVIII, vWF and t-PA plasma levels in a dose-dependent manner (ID50 = 14.0 +/- 4.0, 12.4 +/- 3.0 and 16.7 +/- 1.0 microg/kg I.V., respectively). OPC 31260 (300 microg/kg I.V.) revealed a lower activity than SR 121463, and d(CH2)5[D-Ile2,Ile4]AVP (30 microg/kg I.V.) was without effect on the DDAVP response. Pretreatment with SR 49059 (1 mg/kg I.V.) and SR 27417 (a platelet-activating factor receptor antagonist) (1 mg/kg I.V.) had no effect on the DDAVP-induced (1 microg/kg I.V.) increases in FVIII, vWF and t-PA plasma levels. The present results, therefore, strongly suggest that the effect of DDAVP on hemostasis factors occurs via a specific interaction with extrarenal V2 receptors.

The synthetic pentasaccharide SR 90107A/Org 31540 does not release lipase activity into the plasma

The present study was designed to find out whether the synthetic pentasaccharide SR 90107A/Org 31540, which is presently being evaluated in clinical trials as an antithrombotic agent, influences lipoprotein metabolism in rats as determined by plasma triglyceride (TG) lipase activity. A comparison with three clinically used sulphated polysaccharides-unfractionated heparin (UFH), low molecular weight heparin (LMWH) and pentosan polysulphate (PPS)- was performed. UFH evoked a dose-dependent increase in plasma TG lipase activity which plateaued at doses > or = 1 mg/kg i.v.. PPS and LMWH demonstrated a lower efficacy than heparin at 0.3 and 1 mg/kg i.v., but the maximum lipase releasing effect at 3 mg/kg i.v. was identical for UFH, PPS and LMWH. SR 90107A/Org 31540 did not release TG lipase activity at single i.v. doses up to 3 mg/kg. Repeated-dose experiments with SR 90107A/Org 31540 (1 mg/kg s.c. for 9 days) revealed no influence on the lipase releasing effect of UFH (1 mg/kg i.v. on day 10). These results demonstrate that SR 90107A/Org 31540 does not influence lipid metabolism in rats through lipase release, suggesting that SR 90107A/Org 31540 may offer an advantage over UFH and LMWH in clinical situations where an anticoagulant/antithrombotic effect is desired, but both an increase in plasma free fatty acids and atherogenic alterations of lipoprotein metabolism are considered harmful.

Lanreotide in the treatment of patients with thyroid eye disease

Octreotide, a potent synthetic somatostatin (SM) analogue, was recently evaluated and found to have a beneficial effect in thyroid eye disease (TED), mostly in those patients with a positive Octreoscan-111. Lanreotide (LRT; Somatuline-Ipsen), a new SM long-acting analogue, is more active than natural SM and shows a much longer duration of action. The aim of the present preliminary study was to evaluate the therapeutic effect of LRT in the treatment of TED. Five patients, three males and two females, mean age 50.6 +/- 7.6 S.D. (45-64) years, all with severe symptoms of TED were studied. A similar number of patients, matched for age, sex and severity of ophthalmopathy served as controls. All the patients and controls were investigated with orbital scintigraphy using 111 In DTPA-D-Phe1-octreotide (Octreoscan-111) and selected on the basis of positive octreoscan. The NOSPECS system, as adapted by Donaldson et al. (Journal of Clinical Endocrinology and Metabolism 1973 37 276-285) and a disease activity score, as proposed recently by an International Workshop, have been followed in this study in order to evaluate the response to treatment. The five patients who comprised the treatment group received 0.04 g LRT i.m. once every 2 weeks over a period of 3 months, after which the Octreoscan-111 was repeated. The control patients were given an injection of water i.m., also once every 2 weeks for 3 months, after which they were evaluated clinically. No Octreoscan-111 was performed in the controls. All patients and controls were evaluated by the same physician, who was unaware of the type of treatment used. A decrease in the NOSPECS score and the clinical activity score was regarded as a positive response, while no change or an increase in the NOSPECS score along with no clinical improvement was regarded as a negative response. After 3 months of treatment with LRT, four patients showed a statistically significant improvement in ophthalmopathy in both eyes and one in one eye. Three of the control patients with TED did not show any change, one showed a minor improvement in one eye and no change in the other and one showed deterioration in both eyes. An interesting finding was that orbital Octreoscan-111 activity was absent in all the patients after LRT treatment. In conclusion, these preliminary results show that LRT has a beneficial effect on patients with TED, and that since it has to be given only once every 2 weeks, it is probably superior to any other form of SM treatment. However, as the number of patients was small, further studies are needed to confirm our results.

Somatostatin receptor scintigraphy and octreotide treatment in patients with thyroid eye disease

OBJECTIVE

Octreotide, a potent long-acting synthetic somatostatin analogue, has been reported to have a beneficial effect in thyroid eye disease (TED), but the precise mechanism of action remains unexplained. 111In-DTPA-D-Phe1-octreotide (Octreoscan-111) has been used to localize a number of endocrine tumours and visualize somatostatin receptors in the retrobulbar tissue of patients with TED. Furthermore, this technique can predict the inhibitory effect of octreotide on hormone secretion by endocrine tumours, as there is a close relation between the clinically observed inhibition and visualization of the tumour using Octreoscan-111. The aims of the present study were to confirm the beneficial effect of octreotide in patients with TED, to investigate the presence of somatostatin receptors in the orbital area and also, if possible, to ascertain whether this technique could select those patients with TED who might benefit from treatment with octreotide.

DESIGN

A prospective study.

SETTING

An endocrine clinic of a national hospital.

PATIENTS

Twenty treated thyrotoxic patients with TED, 5 treated thyrotoxic patients without TED and 5 normal individuals were studied. In 12 patients with TED, 5 without TED and 5 normal individuals, Octreoscan-111 scintigraphy of the orbits was performed. The remaining 8 patients with ophthalmopathy served as controls. In patients with TED who were investigated with Octreoscan-111, 300 micrograms octreotide daily was given for 12 weeks.

RESULTS

Six patients in both eyes and one patient in one eye showed an improvement in ocular manifestations as assessed by clinical criteria and changes in the NOSPECS score, while the rest showed no improvement. The patients who showed an improvement had a high number of somatostatin receptors and positive orbital scans, while with one exception the patients who did not respond had a low number of receptors and negative orbital scans (P < 0.02). None of the 5 patients without TED nor the normal individuals had a positive orbital scan. Seven out of 8 control patients with TED showed no change in the disease during the trial, while 1 deteriorated.

CONCLUSIONS

We conclude that octreotide has a beneficial effect in thyroid eye disease and that Octreoscan-111 could predict those patients with thyroid eye disease who might benefit from this treatment.

Effect of aspirin and clopidogrel on platelet-dependent tissue factor expression in endothelial cells

Tissue factor is an ubiquitous membrane-anchored glycoprotein that initiates blood coagulation by forming a complex with circulating factors VII and VIIa. Under normal circumstances, endothelial cells do not express tissue factor but, in some pathological situations, when the endothelium or the monocytes are exposed to inflammatory mediators, they can acquire procoagulant properties. When rat platelets were incubated with cultured bovine aortic endothelial cells, a significant increase in tissue factor expression was obtained. When added simultaneously, thrombin or 2-methylthio-ADP, a stable analogue of ADP, potentiated in a time and dose-dependent manner the effect obtained with platelets alone. In order to determine if antiplatelet agents can modulate these effects, the activity of two compounds was evaluated. When administered orally at the dose of 25 mg/kg, clopidogrel, a potent and selective analogue of ticlopidine, was able to inhibit platelet-induced tissue factor expression whereas aspirin (100 mg/kg, p.o.) was ineffective. These effects were closely correlated to their respective anti-aggregatory and antithrombotic activities showing that platelet activation which has already been shown to be mainly involved in arterial-type thrombosis could also play an important role in the initiation of venous thrombosis where tissue factor expression is thought to play a major role.

Chelerythrine, a selective protein kinase C inhibitor, counteracts pyrogen-induced expression of tissue factor without effect on thrombomodulin down-regulation in endothelial cells

Endotoxin, interleukin 1 beta (IL-1 beta) and tumor necrosis factor alpha (TNF-alpha) dose-dependently increased the expression of tissue factor and at the same time induced thrombomodulin down-regulation on the surface of cultured bovine aortic endothelial cells. Chelerythrine, a selective protein kinase C inhibitor, strongly reduced endotoxin-, IL1 beta- and TNF alpha-induced tissue factor expression but remained without effect with regard to thrombomodulin down-regulation measured in parallel. On the contrary, staurosporine, a highly potent, non-selective PKC inhibitor, simultaneously abolished tissue factor expression and thrombomodulin down-regulation induced by endotoxin, IL1 beta and TNF alpha. These results show that protein kinase C is deeply involved in the process leading to pyrogen-induced tissue factor expression and suggest that thrombomodulin down-regulation is regulated by a different pathway.