New Zealand experience with implementation of the ESO-ESMO consensus guidelines for advanced breast cancer-report of achievements and lessons learned

BACKGROUND

People with advanced breast cancer (ABC) in New Zealand (NZ) have a poorer five-year survival than their peers in other developed countries. Comparisons of ABC care in NZ with other countries suggest that NZ is sometimes out of line with international standards and that inequities exist within the NZ healthcare system. Our aim was to develop nationwide consensus guidelines for diagnosis and treatment of ABC that are uniquely suited for the NZ context and can be applied across the nation. We describe the process of creating, voting on, and disseminating the guidelines, and provide insight into how we can better optimize these processes for the NZ context in the future.

METHODS

The ABC5 ESO-ESMO consensus guidelines were used and adapted to the NZ clinical context. A panel of breast cancer clinicians voted on these guidelines using the same model of membership representation as ABC5.

OUTCOME

Overall consensus was equally high between ABC5 and ABC-NZ. Four NZ specific guidelines were introduced. The European-style panel discussion needs some adaptations for the NZ situation and a wider and more thorough consultation process, before voting begins, is preferred. The NZ Breast Special Interest Group has endorsed and agreed to take ownership of these and future guidelines and to facilitate the next iteration of the ABC-NZ guidelines meeting.

CONCLUSIONS

The process was successful in creating the guidelines but can be improved in future meetings to streamline the process of creating and updating guidelines in the manner most suited to the NZ context and audience.

Regional brain mGlu5 receptor occupancy following single oral doses of mavoglurant as measured by [11C]-ABP688 PET imaging in healthy volunteers

Mavoglurant binds to same allosteric site on metabotropic glutamate receptor 5 (mGluR5) as [¹¹C]-ABP688, a radioligand. This open-label, single-center pilot study estimates extent of occupancy of mGluR5 receptors following single oral doses of mavoglurant, using [¹¹C]-ABP688 positron emission tomography (PET) imaging, in six healthy males aged 20-40 years. This study comprised three periods and six subjects were divided into two cohorts. On Day 1 (Period 1), baseline clinical data and safety samples were obtained along with PET scan. During Period 2 (1-7 days after Period 1), cohort 1 and 2 received mavoglurant 25 mg and 100 mg, respectively. During Period 3 (7 days after Period 2), cohort 1 and 2 received mavoglurant 200 mg and 400 mg, respectively. Mavoglurant showed the highest distribution volumes in the cingulate region with lower uptake in cerebellum and white matter, possibly because myelinated axonal sheets maybe devoid of mGlu5 receptors. Maximum concentrations of mavoglurant were observed around 2-3.25 h post-dose. Mavoglurant passed the blood-brain barrier and induced dose- and exposure-dependent displacement of [¹¹C]-ABP688 from the mGluR5 receptors, 3-4 h post-administration (27%, 59%, 74%, 85% receptor occupancy for mavoglurant 25 mg, 100 mg, 200 mg, 400 mg dose, respectively). There were no severe adverse effects or clinically significant changes in safety parameters. This is the first human receptor occupancy study completed with Mavoglurant. It served to guide the dosing of mavoglurant in the past and currently ongoing clinical studies. Furthermore, it confirms the utility of [¹¹C]-ABP688 as a unique tool to study drug-induced occupancy of mGlu5 receptors in the living human brain.

Myocardial infarction rates overview during COVID-19 pandemic In France: Results of the MODIF registry

Background

The emergence of Coronavirus disease 2019 (COVID-19) has evolved into a global pandemic. Systems of care have been reorganized worldwide in an effort to preserve hospital bed capacity. In France, from March 17 to May 11 2020, government imposed a complete lockdown on the whole population. Only urgent cardiac procedures have been ensured such as ST-elevation myocardial infarction (STEMI) revascularization. Some previously published studies suggest a reduction of admission for STEMI in many countries. Nevertheless, strong evidences and data across different French regions that have been affected variously by the outbreak are still lacking.

Purpose

We aimed to describe the incidence rates and characteristics of patients presenting with STEMI in order to evaluate the impact of the COVID-19 outbreak on STEMI care in France covering the lockdown period compared to same period one year ago.

Methods

We performed a retrospective multicenter registry across 60 French interventional cardiology centers including all consecutive STEMI patients referred for urgent revascularization in the heart catheterization laboratory between two periods: March 1^st to May 31th 2020 compared with March 1^st to May 31th 2019. Comprehensive data, including clinical, biological, COVID status and angiographic variables including time taken for care were recorded at admission. The primary outcome was a composite of invasive mechanical ventilation support or in-hospital death. The secondary outcome was the occurrence of myocardial infarction related complications during hospitalization. Enrollement is not complete at the time of the abstract submission.

Conclusion

This data collection between two periods with and without COVID19 will gave insights for a complete descriptive cartography of STEMI patients among different French regions which have been variously impacted by the outbreak.

CCS patients with polyvascular disease are a high risk but heterogenous subset of patients: insights from the CLARIFY registry

Introduction

Polyvascular disease constitutes a powerful predictor of cardiovascular events, is found in 10 to 15% of chronic coronary syndromes (CCS) patient. Smoking and diabetes mellitus are strongly associated with polyvascular disease. Risk stratification is key to select the most appropriate therapeutic strategy for a given patient.

Purpose

We aimed to describe 5-year ischaemic risk of CCS patients according to vascular disease phenotype and diabetic or smoking status.

Method

We analyzed data from 32 703 consecutive CCS outpatients (45 countries) enrolled between November 2009 to June 2010 in the prospective observational CLARIFY registry. Three mutually exclusive groups were compared: Coronary artery disease (CAD) alone, CAD with peripheral artery disease (PAD) or cerebrovascular disease (CVD) (CAD+1), CAD with CVD and PAD (CAD+2). Primary outcome was a composite of cardiovascular death, myocardial infarction or stroke, adjusted on age, sex and geographic origin at 5 years.

Results

At baseline, 26440 (80.8%) patients were diagnosed with CAD alone, 4967 (15.2%) had CAD+1, 1296 (4%) had CAD+2. Overall, 9501 (29%) patients were diabetics, 19184 (58.7%) were smokers or ex-smokers and only 9220 (28.2%) were free of these two major cardiovascular risk factors. Primary outcome increasing gradually according to the number of arterial diseases locations from 8.4% (95% CI 8.09–8.73) in patients with CAD alone to 17.4% (95% CI 16.95–17.83) of CAD+2 patients (p<0.001). Subgroup analysis according to diabetes or smoking status further enriched risk stratification from 7% (95% CI 6.48–7.59) in non-diabetic, non-smoking CAD alone patients to 20.3% (95% CI 19.08–21.44) in diabetics and smokers CAD+ 2 patients (Figure 1). Diabetic CAD alone patients had a comparable risk to that of non-diabetic and non-smoking polyvascular patients, 9.8% (95% CI 8.82–10.68) vs 10.3% (95% CI 9.61–10.96), p=0.38. Outcome was similar between polyvascular diabetic patients, regardless of the number of arterial diseases, 15.5% (95% CI 14.31–16.60) for CAD+1 and 15.0 (95% CI 13.88–16.13) for CAD+2, p=0.83. Smoking increased 5-year risk proportionally to the number of symptomatic arterial bed, 8.2% (95% CI 7.72–8.68) vs 11.8% (95% CI 11.18–12.31) vs 17.9% (95% CI 17.18–18.54), respectively for CAD alone, CAD+1 and CAD+2.

Conclusion

CCS patients with polyvascular disease remain at high risk of ischaemic events in the contemporary practice with widespread secondary prevention therapies. Polyvascular is a very heterogenous subset of patients with ischaemic risk varying not only according to the number of vascular bed diseased but also according to smoking and diabetes status, two conditions present in the vast majority of CCS patients. Diabetes confers upfront a maximal increased risk. Identification of higher risk subsets in polyvascular patients can potentially identify those that could derived the greatest benefit from new secondary prevention strategies.

Figure 1

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Assistance Publique-Hôpitaux de Paris

Proteomics of transforming growth factor β1 (TGF β1) signaling in 184A1 human breast epithelial cells suggests the involvement of casein kinase 2α in TGF β1-dependent p53 phosphorylation at Ser392

AIM

Transforming growth factor β1 (TGF β1) is a potent regulator of breast tumorigenesis. It inhibits proliferation of carcinoma cells, but the strength of its inhibitory action varies for cells from benigh, non-metastatic or metastatic tumors. The aim of this work was to generate a proteome profile of TGF β1 action on non-tumorigenic human breast epithelial cells 184A1, and validate predicted involvement of casein kinase 2α (CK2α), p53 and structure-specific recognition protein-1 (SSRP1).

MATERIALS AND METHODS

Two-dimensional gel electrophoresis and mass spectrometry were used to identify TGF β1-regulated proteins in 184A1 human breast immortalized non-tumorigenic cells. 184A1 cells may serve as a model of benign breast neoplasia. These cells were obtained from normal mammary tissue, were immortalized but are not malignant, and were obtained from the American Type Culture Collection. The systemic analysis was performed by using the Cytoscape tool. Transfection of cells with CK2α construct and small interfering RNAs to CK2α and SSRP1 were used to assess an impact of CK2α and SSRP1 on phosphorylation of the p53 and cell proliferation.

RESULTS

Proliferation of 184A1 cells was transiently inhibited by TGF β1. We identified 100 and 47 unique proteins which changed their expression and/or ³⁵S-incorporation, respectively, upon treatment with TGF β1 for 2 h, 8 h or 24 h. Cell proliferation, death, migration, and metabolism were among the biological regulatory processes retrieved by the network analysis as affected by the identified proteins. The network analysis suggested that TGF β1 may affect the phosphorylation of p53 at Ser392 by engaging CK2α. This was confirmed by the immunoblotting and cell proliferation assays.

CONCLUSION

We report here the list of 147 TGF β1-regulated proteins in immortalized non-tumorigenic human breast epithelial cells, and show involvement of CK2α in the regulation of p53 Ser392 phosphorylation.

L’Ultrastructure des plaquettes thrombasthéniques (Effets de l’ADP et du fibrinogène bovin)

L’ultrastructure des thrombocytes de 7 patients atteints de thrombasthénie, préparés immédiatement après le prélèvement, a été étudiée systématiquement. Un nombre variable des thrombocytes de chacun de ces prélèvements contient des gouttelettes lipidiques et des granulations denses de morphologie inhabituelle, caractères qui ont été décrits précédemment par plusieurs auteurs comme « indices morphologiques d’un état pathologique des thrombocytes », et que l’on sait ne pouvoir être considérés comme pathognomoniques. Néanmoins, l’étude ultrastructurale permet d’envisager une subdivision de ces patients en 2 groupes distincts, subdivision comparable à celle que fournit l’étude enzymatique et immuno-électrophorétique des plaquettes des mêmes patients. De plus, une proportion élevée des thrombocytes de chaque prélèvement contient des organites inhabituels, tels que mitochondries de grande taille, vacuoles multivésiculaires et granulations denses « en oeil de boeuf », qui peuvent être considérés comme l’indice d’un trouble ou d’une déficience de la thrombopoïèse.

L’incubation de dix PRP thrombasthéniques en présence d’une forte quantité d’ADP met en évidence une certaine tendance à la micro-agrégation, variable de cas en cas, ainsi qu’une discrète modification de la structure de la membrane périphérique plaquettaire aux points d’accolement des thrombocytes entre eux.

L’incubation de deux PRP thrombasthéniques en présence de fibrinogène bovin provoque une « agrégation » particulière qui se manifeste, au microscope électronique, par la présence de dépôts d’une « substance-ciment » interthrombocytaire, sans modification de la structure des membranes périphériques plaquettaires.

Ces expériences paraissent confirmer que l’ADP agit réellement sur la plaquette thrombasthénique ; les rapports qui pourraient exister cependant entre ces modifications morphologiques et celles provoquées sur le profil protéique dell’extrait plaquettaire par ce même nucléotide restent encore à préciser.

Sur la présence de graisses neutres dans les thrombocytes humains normaux et pathologiques

La microscopie électronique a montré, dans les thrombocytes humains, la présence de gouttelettes lipidiques. Dans les plaquettes normales, le pourcentage de coupes présentant cette caractéristique ultrastructurelle est très faible; cette observation concorde avec les résultats des analyses biochimiques et cytochimiques. Par contre, dans les thrombopathies (surtout congénitales), leur proportion est significativement augmentée. Nous pouvons donc considérer que la mise en évidence d’une stéatose thrombocytaire notable est un des critères valables du diagnostic d’un état pathologique des thrombocytes.

L’aspect submicroscopique des gouttelettes lipidiques intrathrombocytaires permet de penser qu’elles sont constituées vraisemblablement de graisses neutres très riches en acides gras non saturés. Cette hypothèse est appuyée par des études cytochimiques récentes au microscope électronique des constituants lipidiques.

Nos observations montrent que la genèse des gouttelettes lipidiques n’est vraisemblablement pas liée à une lipophanérose, ni à une phagocytose de chylomicrons. Par contre, la diminution du taux de glycogène dans les plaquettes présentant une stéatose, nous permet de supposer que les gouttelettes lipidiques peuvent être considérées comme l’indice d’un trouble du métabolisme plaquettaire.

Differential innervation of superficial versus deep laminae of the dorsal horn by bulbo-spinal serotonergic pathways in the rat

Convergent data showed that bulbo-spinal serotonergic projections exert complex modulatory influences on nociceptive signaling within the dorsal horn. These neurons are located in the B3 area which comprises the median raphe magnus (RMg) and the lateral paragigantocellular reticular (LPGi) nuclei. Because LPGi 5-HT neurons differ from RMg 5-HT neurons regarding both their respective electrophysiological properties and responses to noxious stimuli, we used anatomical approaches for further characterization of the respective spinal projections of LPGi versus RMg 5-HT neuron subgroups. Adult Sprague-Dawley rats were stereotaxically injected into the RMg or the LPGi with the anterograde tracer Phaseolus vulgaris leucoagglutinin (PHA-L). The precise location of injection sites and RMg vs LPGi spinal projections into the different dorsal horn laminae were visualized by PHA-L immunolabeling. Double immunofluorescent labeling of PHA-L and the serotonin transporter (5-HTT) allowed detection of serotonergic fibers among bulbo-spinal projections. Anterograde tracing showed that RMg neurons project preferentially into the deep laminae V-VI whereas LPGi neuron projections are confined to the superficial laminae I-II of the ipsilateral dorsal horn. All along the spinal cord, double-labeled PHA-L/5-HTT immunoreactive fibers, which represent only 5-15% of all PHA-L-immunoreactive projections, exhibit the same differential locations depending on their origin in the RMg versus the LPGi. The clear-cut distinction between dorsal horn laminae receiving bulbo-spinal serotonergic projections from the RMg versus the LPGi provides further anatomical support to the idea that the descending serotonergic pathways issued from these two bulbar nuclei might exert different modulatory influences on the spinal relay of pain signaling neuronal pathways.

Ethnic sensitivity assessment of pharmacokinetics and pharmacodynamics of omalizumab with dosing table expansion

A three-part license expansion for omalizumab (Xolair(®)), humanized anti-IgE antibody, was recently made in Japan for paediatric use, additional higher doses and revised dosing frequency in allergic asthma. The dosing level and frequency of omalizumab are guided by a dosing table based on the total serum IgE and bodyweight. Nonlinear mixed-effect pharmacokinetic (PK) and pharmacodynamic (PD) modeling and simulation techniques described the binding between omalizumab and its target IgE. The population PKPD analysis was conducted using data from the nine studies included originally in the European application of dosing table expansion together with three Japanese clinical studies to assess the influence of the ethnicity. Statistically significant differences between the ethnic groups were detected. These were small, within or close to bioequivalence criteria. The model described the primary pharmacology in Caucasian and Japanese patients, both adult and paediatric, with simulations showing that the interplay between the clearance, volume and binding affinity parameters was such that there was no clinical impact of the Japanese ethnic differences on either drug PK or free IgE suppression and hence the required posology.

Impact of socio-economic position on health and quality of care in adults with Type 2 diabetes in France: the Entred 2007 study

AIM

To describe the association between socio-economic position, health status and quality of diabetes care in people with Type 2 diabetes in France, where people may receive full healthcare coverage for chronic disease.

METHODS

Data from a national cross-sectional survey performed in people pharmacologically treated for diabetes were used. They combined data from medical claims, hospital discharge, questionnaires for patients (n = 3894 with Type 2 diabetes) and their physicians (n = 2485). Socio-economic position was assessed using educational level (low, intermediate, high) and ability to make ends meet (financial difficulties vs. financially comfortable).

RESULTS

People with diabetes reporting financial difficulties were more likely to be smokers (adjusted odds ratio 1.4; 95% CI 1.1-1.6) and obese (adjusted odds ratio 1.3; 95% CI 1.2-1.6) and to have poorer glycaemic control (HbA1c > 64 mmol/mol (8%); adjusted odds ratio 1.4; 95% CI 1.1-1.8), than those who were financially comfortable. They were more likely to have their diabetes diagnosed because of complications (adjusted odds ratio 1.6; 95% CI 1.3-2.0). They were also more likely to have coronary and podiatric complications (adjusted odds ratios 1.3; 95% CI 1.1-1.6 and 1.7; 95% CI 1.4-2.2, respectively). They benefited more often from full coverage (adjusted odds ratio 1.3; 95% CI 1.1-1.6), visited general practitioners more often (ratio of estimated marginal means 1.2; 95% CI 1.1-1.2) but specialists less often (adjusted odds ratio 0.7; 95% CI 0.6-0.8 for a visit to private ophthalmologist). They also felt less well informed about their condition.

CONCLUSIONS

Despite frequent access to full healthcare coverage, socio-economic position has an impact on the diagnosis of diabetes, health status and quality of diabetes care in France.

Design of a national and regional survey among French general practitioners and method of the first wave of survey dedicated to vaccination

OBJECTIVES

France is currently facing a vaccine-hesitancy crisis. We conducted a questionnaire-based telephone interview with a large sample of general practitioners (GPs) as they play a crucial role in the vaccination process. Our main objectives were to study the GPs' vaccination behaviors when it comes to their own vaccination and that of their relatives, and the vaccine recommendations made to their patients. We also aimed to understand their opinion related to the severity of vaccine-preventable diseases and to assess their trust in various sources of information. Finally, we enquired about their opinion in terms of vaccination-related tools that could help them in their daily practice. The article aimed to present the design of this panel and survey.

PATIENTS AND METHODS

Four samples of GPs (one national and three regional) were selected among all the French GPs (metropolitan France) using random sampling. Five cross-sectional surveys should be conducted with that panel. The mean targeted sample size is 2350 GPs for each survey. The survey dedicated to vaccination was conducted by telephone or on the Internet.

RESULTS

GPs were included in the survey between December 2013 and February 2014. The national sample included 1582 GPs (response rate: 46%) and the three regional samples included 1297 GPs (response rate: 44%). The survey dedicated to vaccination was conducted between April and July 2014; the national sample response rate was 92% (1582/1712).

CONCLUSION

The results of the first wave of surveys, conducted on a large sample of French GPs, provide important information to guide the French vaccination policy.

Employment and professional outcomes in 803 patients undergoing bariatric surgery in a French reference center for obesity

Background:

Very few studies have been performed on small populations about the links between employment and bariatric surgery.

Objective:

To determine if rates of employment are increased among patients who have undergone bariatric surgery, to assess their post-operative health consequences (post-prandial weakness, diarrhea), and patients' ability to maintain post-operative advice (ie, 30 minutes of daily physical activity, 6 small meals daily) compared to non-employed post-surgical patients.

Methods:

This cross-sectional study was performed in the Regional Reference Centre for Obesity, which is a partnership between the University Hospital and a clinic in Angers, France during 2012 using a self-administrated questionnaire completed by patients hospitalized for post-operative follow-ups after bariatric surgery. Issues investigated were their professional situation before and after the surgery, compliancy to post-operative advice, and any postoperative side effects.

Results:

Employment rates were 64.4% before and 64.7% after the surgery (p=0.94). Of these, 30.6% maintained 30 minutes of daily physical activity vs. 41.0% of non-workers (p=0.02). 50.5% of employed patients and 57.3% of non-workers maintained 6 small meals a day after surgery (p=0.09). 8% of working patients reported post-prandial weaknesses and 8% reported diarrhea that caused problems at work.

Conclusion:

Employment rate remained stable after surgery. Having a job seemed to be an obstacle to managing 30 minutes of daily exercise, especially among women, but not maintaining 6 small meals a day. Therefore, working environment needs to be assessed to improve job quality and retention for patients who have undergone bariatric surgery.

Type 2 diabetes prevalence, health status and quality of care among the North African immigrant population living in France

AIM

This report is an overview of type 2 diabetes (DT2) in the North African immigrant population living in France.

METHODS

Data were collected in two separate cross-sectional national surveys. DT2 prevalence was estimated using a population-based survey involving 13 959 people aged ≥ 45 years (EDS), while health status and quality of care were evaluated using a sample of 3894 DT2 patients (ENTRED).

RESULTS

Prevalence of DT2 and obesity was 14.0% [CI 95%: 9.9; 18.0] and 20.5% [15.7; 25.3], respectively, in participants born in North Africa (BNA) and 7.5% [7.0; 8.0] and 15.8% [14.7; 16.8], respectively, in those born in France (BIF). DT2 was associated with region of birth in women after adjusting for age, body mass index and income or occupation, but not after adjusting for education level. In men, DT2 was not associated with region of birth. BNA and BIF patients with diabetes frequently benefited from free medical coverage (88% vs. 84%, respectively), although BNA diabetic patients visited a general practitioner less frequently than BIF (8.5 vs. 9.0 visits/year, respectively). The percentage of BNA vs. BIF diabetes patients tested three times a year for HbA1c was lower (39% vs. 44%), while HbA1c was higher in BNA vs. BIF diabetics (> 8%: 30% vs. 15%). Ophthalmological complications were also more frequent in BNA vs. BIF patients with diabetes (25% vs. 18%, respectively).

CONCLUSION

The greater prevalence of DT2 in BNA women and the poorer glycaemic control observed in the BNA population overall both probably contribute to disparity in diabetes mortality compared with BIF diabetics, a fact that has been observed in previous studies.

Dramatic change in public attitudes towards vaccination during the 2009 influenza A(H1N1) pandemic in France

We investigated the potential impact of the 2009 influenza A(H1N1) pandemic on attitudes towards vaccination among people aged 18 to 75 years and living in metropolitan France. We used data from three national telephone surveys conducted on representative samples in 2000, 2005 and 2010 (n=12,256, n=23,931, n=8,573 respectively). In France, unfavourable attitudes towards vaccination in general dramatically increased from 8.5% in 2000 and 9.6% in 2005 to 38.2% in 2010. In 2010, among respondents who held unfavourable attitudes towards vaccination, 50% mentioned specifically their opposition to the influenza A(H1N1) vaccine. The sociodemographic profile associated with these attitudes also changed greatly. In particular, unfavourable attitudes towards vaccination in general became significantly more frequent among less educated people in 2010. These attitudes were also correlated with vaccination behaviours. For example, parents who were unfavourable towards vaccination in general were more likely to report that they had at least one child who did not get the measlesmumps- rubella vaccine. As this shift in attitude may have a significant impact on future vaccination coverage, health authorities should urgently address the vaccine confidence gap.

[Increasing trends in screening for addictives behaviors among general practitioners in France]

BACKGROUND

Make an inventory of screening of addictive behaviours among general practice since the end of the 1990s.

METHODS

A representative sample of 2,083 general practitioners was surveyed in 2008/2009. They were asked about their prevention practices.

RESULTS

Two thirds of the general practitioners (GPs) reported discussing tobacco consumption at least once with each patient. This assessment was less systematic for alcohol (23% of GPs) and cannabis (8% of GPs). Approximatively 70% reported addressing cannabis or alcohol use issues only with patients at risk. One third reported using tobacco smoking screening questionnaires, while there were only 6% in 2003. Only 13% of GPs used alcohol standardized questionnaires, a clear rise since 1998 (1.4% in 1998, 2.0% in 2003). Using alcohol standardized screening tests was more frequent among GPs belonging to a drug addiction network, but no significant link was found with gender, age or area. Only 2% of GPs used cannabis use screening tests. The care for cannabis users seemed particularly linked to the practitioners' inclination to discuss this issue without waiting for a demand arising from the patient. The proportion of practitioners reporting helping patients kick their nicotine addiction in the last seven days proved stable since 2003, after a very significant increase between 1998 and 2003. The proportion of GPs reporting seeing a patient for an alcoholic weaning (52%) was stable since 1998.

CONCLUSION

This study illustrates the development of addiction care practices integrating smoking cessation help and, to a more limited extent, screening of alcohol and cannabis abuse, evidenced by the expanded application of standardized questionnaires in general practice. Consideration given to cannabis and alcohol use assessment appeared correlated to GPs feeling at ease with addressing drug use issues, this feeling being linked to their ability to rely on institutional directives or validated screening tools. It seems thus important to encourage the implementation of a health educational approach including early screening and brief intervention during consultation.

[New outcome rates for random sampling telephone surveys]

BACKGROUND

Survey non-response rates are important quality indicators. Refusal rates can induce non-response bias in health survey estimates. However, comparisons across surveys highlight inconsistencies in the use of survey outcome categories and in the calculation of response rates. In this paper we discuss the relevance of these indicators and suggest other survey quality indicators.

METHODS

Outcome rates from two French random-digit dialing (RDD) telephone surveys are compared : the Nicolle survey on infectious diseases of 4112 individuals conducted in 2006, and the HIV knowledge, attitude, belief and practices (KABP) survey of 5071 individuals in 2004. Based on the same protocol, we describe in details the way the two RDD samples were drawn and how non-response rates were estimated.

RESULTS

Non-response rates were different: 36% in Nicolle survey and 18% in KABP survey. However, the quantity of telephone numbers required to obtain one interview was higher in the KABP survey: 2.8 telephone numbers versus 2.1 in the Nicolle survey. The participation rates, aggregating together refusals, break-off and non-reachable numbers, were equivalent for the two surveys. This result occurred because of a greater proportion of unreached calls in the KABP surveys, which is not integrated into the non-response rates commonly used.

CONCLUSION

Survey non-response rate is insufficient to estimate the quality of a survey. The need for other indicators has been previously stressed in the literature, notably with the adoption and utilization of the American Association for Public Opinion Research (AAPOR) standard definitions of four indicators. But these indicators are quite complex for evaluating non-response bias between surveys. In addition to the classical refusal rate, two other indicators are proposed in this paper: participation rate (number of complete interviews divided by the number of eligible and of unknown eligibility units) and a liking contact rate (number of unreachable units because of a long absence, break-off or non-answer divided by the number of eligible and of unknown eligibility units). The sum of these three indicators is equal to 100% and thus easier to manipulate when comparing surveys.

Impact of alginate type and bead diameter on mass transfers and the metabolic activities of encapsulated C3A cells in bioartificial liver applications

Liver-assist devices have been developed in the last few decades to support patients with liver failure on the road to recovery or transplantation. Fluidised bed bio-artificial livers--where liver cells are encapsulated within alginate beads--appear to be a valuable alternative to hollow fibre devices for improving mass transfers and enhancing treatment efficacy. This approach nevertheless deserves optimization in terms of bead production. The aim of this study was to investigate the impact of alginate type and of two bead diameters (1000 µm and 600 µm) on mass transfers within beads and on the biological functions of encapsulated C3A cells. After assessing the effect of the encapsulation process on bead quality, we investigated cell viability and metabolic activities (ammonia, albumin, alpha-fetoprotein synthesis and glucose consumption). They were successfully maintained over 48 h within fluidised bed bioreactors, independently of alginate type and bead diameter. Mass transfers were not significantly influenced by the latter parameters. Finally, suggestions are made for improving the entrapment process as a means of enhancing the treatment efficiency of the fluidised bed bioartificial liver.

Delineation of 15q13.3 microdeletions

The increasing use of array-comparative genomic hybridization (array-CGH) to identify copy number variations (CNVs) in patients with developmental delay (DD), mental retardation and/or dysmorphic features has allowed the recent recognition of numerous genomic imbalances, including the 15q13.3 microdeletion. Patients with this microdeletion generally present with relatively consistent breakpoints at BP4 and BP5, which include the CHRNA7 gene. About 100 index cases have been reported since the first publication in 2008. This large number of patients ascertained through highly variable samples has been necessary to describe the full phenotypic spectrum of this microdeletion, ranging from mental retardation with dysmorphic features, epilepsy, neuropsychiatric disturbances with or without cognitive impairment to complete absence of anomalies. Here, we describe a collaborative study reporting a new cohort of 12 index patients and 13 relatives carrying a heterozygous BP4-BP5 microdeletion out of a series of 4625 patients screened by array-CGH for DD. We confirm the clinical expressivity of the disease as well as the incomplete penetrance in seven families. We showed through a review of the literature that males are more likely to be symptomatic. Sequence analysis of CHRNA7 yielded no data to support the unmasking of recessive variants as a cause of phenotypic variability. We also report the first patient carrying a 15q13.3 homozygous microdeletion inherited from both parents. He had severe epileptic encephalopathy with retinopathy, autistic features and choreoathetosis. Besides the classical approximately 1.5 Mb BP4-BP5 microdeletion, we also describe three index patients and two relatives with a smaller 500 kb microdeletion, including the CHRNA7 gene.

Risk factors for incident type 2 diabetes in individuals with a BMI of <27 kg/m2: the role of gamma-glutamyltransferase. Data from an Epidemiological Study on the Insulin Resistance Syndrome (DESIR)

AIMS/HYPOTHESIS

Risk factors for incident type 2 diabetes, in particular, hepatic markers, have rarely been studied in leaner individuals. We aimed to identify the metabolic and hepatic markers associated with incident diabetes in men and women with a BMI of <27 kg/m(2) and to compare them with those in individuals with a BMI of >or=27 kg/m(2).

METHODS

Risk factors for 9 year incident diabetes were compared in the French Data from an Epidemiological Study on the Insulin Resistance Syndrome (DESIR) cohort. Comparisons were made between the 2,947 participants with a BMI of <27 kg/m(2) and the 879 with a BMI of >or=27 kg/m(2).

RESULTS

There were 92 incident cases of diabetes in individuals with a BMI of <27 kg/m(2) and 111 in those with a BMI of >or=27 kg/m(2). Among those who were not markedly overweight, classical biological markers were associated with 9 year incident diabetes, glycaemia being the strongest predictor. gamma-Glutamyltransferase (GGT), either considered as a continuous variable or at levels >or=20 U/l, was associated with incident diabetes, with a stronger effect in the BMI <27 kg/m(2) group: OR 1.59 (95% CI 1.29-1.97, p < 0.001) in comparison with OR 1.07 (95% CI 0.82-1.38, p = 0.63) for those with a BMI of >or=27 kg/m(2) (results after adjustment for alcohol intake, alanine aminotransferase, waist circumference and the HOMA insulin resistance index).

CONCLUSIONS/INTERPRETATION

In individuals with a BMI of <27 kg/m(2), GGT was the strongest predictor of diabetes after fasting hyperglycaemia. This association with incident diabetes remained after adjustment for conventional markers of insulin resistance, suggesting potential interactions between GGT, enhanced hepatic neoglucogenesis and/or early alterations of insulin secretion.

Artificial and bioartificial liver devices: present and future

Liver failure is associated with high morbidity and mortality without transplantation. There are two types of device for temporary support: artificial and bioartificial livers. Artificial livers essentially use non-living components to remove the toxins accumulated during liver failure. Bioartificial livers have bioreactors containing hepatocytes to provide both biotransformation and synthetic liver functions. We review here the operating principles, chemical effects, clinical effects and complications of both types, with specific attention paid to bioartificial systems. Several artificial support systems have FDA marketing authorisation or are CE labelled, but the improvement they provide in terms of patient clinical outcome has not yet been fully demonstrated. At present, different bioartifical systems are being investigated clinically on the basis of their promises and capacity to provide and replace most liver functions. However, important issues such as cost, cell availability, maintenance of cell viability and functionality throughout treatment, and regulatory issues, as well as difficult challenges, including implementing cell-housing devices at the patient's bedside on an emergency basis, have delayed their appearance in intensive care units and on the market. Bioreactors are, nevertheless, when combined with artificial components, a pragmatic approach for future treatment of liver failure.

Evidence of genetic recombination in wheat yellow rust populations of a Chinese oversummering area

Wheat yellow rust (Puccinia striiformis f.sp. tritici) (PST) has been described as a strongly clonal species in both European and Australian populations, with very limited molecular diversity but rapidly evolving virulences. Contrastingly, marked genetic diversity has been reported in Chinese PST populations. To test whether such variability could originate from oversummering areas, we assessed the diversity of virulence and molecular markers (AFLP and SSR) using 412 PST isolates from the highlands of Tianshui county in Gansu province. Very marked phenotypic and genotypic diversity (38% and 89%, respectively) was found. No genetic structure dependent on the sites sampled (Fst=0.004) or altitude distribution (Fst=0.0098) was detected, indicating important gene flow at the county scale. This study also revealed genetic recombination between molecular markers and thus strongly suggests the existence of a sexual or parasexual cycle in PST in Tianshui county. The observations of higher rates of sexual spore production in genotypes originating from Tianshui are the very first elements suggestive of the existence of a sexual cycle in this species.

Geography, plants, and growing systems shape the genetic structure of Tunisian Botrytis cinerea populations

Botrytis cinerea, considered for a long time as a generalist fungal pathogen of a multitude of plants, was recently shown to exhibit significant population structure in France according to the host, suggesting sympatric specialization. Recent models also showed that adaptation to new hosts may facilitate the process of sympatric speciation in fungal plant pathogens. The present work aimed at investigating if host plants, combined with geographic origin and growing systems, shape the diversity and structure of Tunisian populations of B. cinerea. We genotyped 153 isolates with 9 microsatellites. In all the investigated populations, the fungus reproduced mainly sexually. Gene flow was significantly reduced between greenhouses and open fields from strawberry but not from grapevine. Populations from tomatoes, sampled under greenhouses only, exhibited a low genotypic diversity. The effects of plant and geography from open fields were investigated on a sample of 74 isolates. Six populations were inferred, mainly structured according to a geographic barrier corresponding to the Grande Dorsale Mountain. However, this effect could not be separated from the host plant origin of isolates. The analysis of 63 isolates recovered from strawberries and faba beans in the Cap Bon and Centre regions did not reveal any significant effect of plant on pathogen population differentiation.

Spectrum of SCN1A gene mutations associated with Dravet syndrome: analysis of 333 patients

INTRODUCTION

Mutations in the voltage-gated sodium channel SCN1A gene are the main genetic cause of Dravet syndrome (previously called severe myoclonic epilepsy of infancy or SMEI).

OBJECTIVE

To characterise in more detail the mutation spectrum associated with Dravet syndrome.

METHODS

A large series of 333 patients was screened using both direct sequencing and multiplex ligation-dependent probe amplification (MLPA). Non-coding regions of the gene that are usually not investigated were also screened.

RESULTS

SCN1A point mutations were identified in 228 patients, 161 of which had not been previously reported. Missense mutations, either (1) altering a highly conserved amino acid of the protein, (2) transforming this conserved residue into a chemically dissimilar amino acid and/or (3) belonging to ion-transport sequences, were the most common mutation type. MLPA analysis of the 105 patients without point mutation detected a heterozygous microrearrangement of SCN1A in 14 additional patients; 8 were private, partial deletions and six corresponded to whole gene deletions, 0.15-2.9 Mb in size, deleting nearby genes. Finally, mutations in exon 5N and in untranslated regions of the SCN1A gene that were conserved during evolution were excluded in the remaining negative patients.

CONCLUSION

These findings widely expand the SCN1A mutation spectrum identified and highlight the importance of screening the coding regions with both direct sequencing and a quantitative method. This mutation spectrum, including whole gene deletions, argues in favour of haploinsufficiency as the main mechanism responsible for Dravet syndrome.

Three-dimensional growth of human hepatoma C3A cells within alginate beads for fluidized bioartificial liver

OBJECTIVES

Alginate beads allow cultivation of cells in a 3-dimensional environment. The aim of our study was to assess the influence of a 3-dimensional culture in alginate microbeads, on hepatic cell metabolism.

METHODS

We used 2 types of alginate: low viscosity (LV) and medium viscosity (MV). The hepatic cell line C3A was encapsulated in alginate beads. Cells were cultured for 2 weeks. Using scanning electron microscopy, the morphology of 3D structures and the surfaces of cells were analyzed. Fluidized bed bioartificial liver experiments were performed 24 hours, 7, and 14 days after bead formation.

RESULTS

Two different cell growth types in alginate beads were observed: channel-like structures and spherical aggregates characteristic of LV and MV alginate, respectively. A significant increase in albumin synthesis was observed in long-term culture. Formation of characteristic hepatic cell microvilli on cell surfaces was observed under scanning electron microscopy for both types of alginate. Prolonged static cultivation of C3A cells within the alginate beads in both types of alginates caused significant increases in albumin production in the fluidized bioreactor.

CONCLUSIONS

Cultivation of the hepatic C3A cells within the alginate microbeads significantly improved bioreactor effectiveness in albumin production. The presence of extensions of cell membranes on the surface of hepatoma cells in 3-dimensional culture within the alginate beads indicated formation of microvilli-like structures characteristic of normal hepatocytes.

Mandatory immunization: the point of view of the French general population and practitioners

This survey studies the opinion of the French general population, general practitioners and pediatricians regarding mandatory immunization. Data were collected through standardized telephone questionnaires administered to representative samples of the French population (n=4112) and of French general practitioners and pediatricians (1285 general practitioners (GPs) and 742 pediatricians). 56.5% of the general population is in favor of mandatory vaccination. Being in favor of hepatitis B vaccination, agreeing that "it would be important to continue immunizing against diphtheria in case immunization was made optional" or saying that "if immunization against diphtheria was discontinued, the disease would spread again", are some of the main determinants of a favorable opinion regarding mandatory immunization. The percentage of GPs and pediatricians in favor of mandatory immunization is 42%. Female pediatricians and those who would "insist on families in the importance of continuing immunizing all children against diphtheria in case this vaccination was only recommended" more often declare themselves in favor of mandatory immunization. The adoption of the principle of mandatory immunization seems to stem from the adoption of immunization as an individual and collective prevention tool.

The place of adsorption and biochromatography in extracorporeal liver support systems

Artificial and bioartificial liver devices aim at replacing some or all liver functions in the cases of end stage or fulminant disorders. Among all of its function, liver plays a key role in detoxification of substances that are hydrosoluble or bound to albumin. In this paper, the authors first reviewed the requirements for temporary liver support, then the adsorption-based systems that can be found on the market and finally propose new applications of biochromatography using perfusion-based bioartificial systems.

Long-term efficacy and cost-effectiveness of polyethylene glycol 3350 plus electrolytes in chronic constipation: a retrospective study in a disabled population

OBJECTIVES

The efficacy and safety of treatments for constipation in severely intellectually disabled patients and their associated cost-effectiveness are an under-investigated area of clinical practice. Aiming to address this, the objectives of the study were to evaluate the efficacy and tolerability of polyethylene glycol 3350 plus electrolytes (Movicol; PEG+E) by comparing clinical data collected before and after its introduction to a stable population of residents of a mental health care, long-stay institution. The study also attempted an economic evaluation of the use of PEG+E in this setting.

RESEARCH DESIGN AND METHODS

This was a retrospective study of 54/66 severely intellectually and physically disabled residents of a specialist unit at La Milétrie University Hospital, Poitiers, France, who suffered regularly from constipation. A total of 54 residents were treated with PEG+E (1-3 sachets a day) for 24 months. The number of stools, episodes of diarrhoea (defined as frequent stools, not necessarily watery), body weights and blood biochemistry were recorded. Data were compared with those recorded during the 21 months preceding the introduction of PEG+E for 16/54 residents who had been treated regularly with a range of other interventions for the relief of constipation. The monthly use and costs of laxatives, enemas and suppositories was obtained from hospital pharmacy records, and the total hospital costs before and after the introduction of PEG+E treatment was calculated.

RESULTS

The mean (+/- standard deviation) number of stools per patient per month was significantly greater following the introduction of PEG+E (24.9 +/- 6.3) compared to before its use (12.4 +/- 3.4) (p < 0.001). The mean (+/- standard deviation) monthly number of episodes of diarrhoea per patient before and after the introduction of PEG+E was 0.1 +/- 0.1 and 6.3 +/- 2.9, respectively (p < 0.001). Treatment with PEG+E was not associated with adverse effects on body weight or blood biochemistry values. Introduction of PEG+E and its increasing use reduced the total hospital medical ward expenditure on laxatives from 3788 to 1767 Euros per month.

CONCLUSIONS

PEG+E is effective in the clinical management of constipation in an institutional setting. Furthermore, long-term intensive therapy with PEG+E was not associated with adverse effects on body weight or blood biochemistry values. Although the time periods over which the economic data and the efficacy and safety data were collected did not directly correspond, this study indicates that use of PEG+E in the management of constipation in people with severe intellectual disability may be cost-effective, reducing hospital laxative costs.