Secondary actionable findings identified by exome sequencing: expected impact on the organisation of care from the study of 700 consecutive tests

With exome/genome sequencing (ES/GS) integrated into the practice of medicine, there is some potential for reporting incidental/secondary findings (IFs/SFs). The issue of IFs/SFs has been studied extensively over the last 4 years. In order to evaluate their implications in care organisation, we retrospectively evaluated, in a cohort of 700 consecutive probands, the frequency and burden of introducing the search for variants in a maximum list of 244 medically actionable genes (genes that predispose carriers to a preventable or treatable disease in childhood/adulthood and genes for genetic counselling issues). We also focused on the 59 PharmGKB class IA/IB pharmacogenetic variants. We also compared the results in different gene lists. We identified variants (likely) affecting protein function in genes for care in 26 cases (3.7%) and heterozygous variants in genes for genetic counselling in 29 cases (3.8%). Mean time for the 700 patients was about 6.3 min/patient for medically actionable genes and 1.3 min/patient for genes for genetic counselling, and a mean time of 37 min/patients for the reinterpreted variants. These results would lead to all 700 pre-test counselling sessions being longer, to 55 post-test genetic consultations and to 27 secondary specialised medical evaluations. ES also detected 42/59 pharmacogenetic variants or combinations of variants in the majority of cases. An extremely low metabolizer status in genes relevant for neurodevelopmental disorders (CYP2C9 and CYP2C19) was found in 57/700 cases. This study provides information regarding the need to anticipate the implementation of genomic medicine, notably the work overload at various steps of the process.

[French residents' training in instrumental deliveries: A national survey]

OBJECTIVES

To evaluate French residents in Obstetrics and Gynaecology's training in instrumental deliveries in 2015.

PATIENTS AND METHODS

We conducted a national descriptive survey among 758 residents between December 2014 and January 2015. Respondents were invited by email to specify their University Hospital, their current university term, the number of instrumental deliveries performed by vacuum extractor, forceps or spatulas, and whether they made systematic ultrasound exams before performing the extraction.

RESULTS

Response rate was 34.7 % (n=263). There were important differences between regions in terms of type of instruments used. Vacuum extractor was the most commonly used instrument for instrumental deliveries by French residents (56.9 %), more than forceps (25.2 %) and spatulas (17.9 %). At the end of the residency, all the residents had been trained in instrumental deliveries with at least two instruments.

CONCLUSION

The training of difficult techniques as well as their perfect control is required for instrumental deliveries. Yet, we are forced to note that there are substantial differences in the French residents' training in instrumental deliveries depending on their region. So, teaching at least two techniques seems essential as well as improving the training capacities and standardizing practices. A greater systematization of the teaching of the mechanics and obstetric techniques might be a solution to be considered too.

[Training achieves an internal version and a total breech extraction at birth of second twin]

OBJECTIVES

To evaluate French residents in obstetrics and gynaecology's training to internal version and breech extraction during vaginal delivery of the second twin.

METHODS

A national descriptive survey conducted among 1064 residents between July and October 2014. Respondents were invited by email to specify the type of theoretical and practical training they had received, their university hospital obstetrical practices and the number of vaginal internal version and breech extraction of the second twin they had seen and performed.

RESULTS

Response rate was 38.7% (n=412). Regarding the type of theoretical training, 39.8% of residents (n=164) had received the obstetrical mechanics and techniques degree; 47.6% (n=196) had got a teaching during special education classes and 29.4% (n=121) a training on mannequin. There were important differences between regions. At the end of residency, 45.6% of residents (n=36) had practiced more than five vaginal internal version and breech extraction of the second twin.

CONCLUSION

Internal version and breech extraction are difficult but essential maneuvers for the management of twin delivery. The French residents in obstetrics and gynaecology's training for these maneuvers seems to be insufficient. It is necessary to improve their teaching, this teaching must also be equivalent between regions.

[Relevance of the sentinel lymph node biopsy in breast multifocal and multicentric cancer]

OBJECTIVES

The sentinel lymph node biopsy is a gold standard in the management of breast cancer. Its role in multifocal or multicentric tumors is still evolving. The aim of this study is to assess the feasibility and pertinence of sentinel lymph node biopsy in multifocal and multicentric tumors based on a systematic review of literature.

METHODS

A systematic review was conducted searching in the following electronic databases PubMed using "sentinel lymph node biopsy", "breast cancer", "multifocal tumor", "multicentric tumor" and "multiple tumor" as keywords. We included original articles published between 2000 and 2014, both French and English, studying feasibility of sentinel lymph node biopsy in invasive breast cancer, multicentric and/or multifocal tumors. The first end point was success rate and false negative rate.

RESULTS

Twenty-six articles were included in this literature review, with 2212 cases (782 multifocal, 737 multicentric and 693 multiple tumors). Percentage of tumors whose stage was higher than stage T2 ranged from 0 to 86.3%. Success rate average was 83.1%. False negative average was 8.2%. False negative rate was less than 10% in 15 articles. Mean of sentinel lymph node biopsy was 2 (1-9). The average rate of sentinel lymph node positive was 50.6%. Axillary recurrence rate was 0.5%.

CONCLUSION

Despite the methodological biases of the studies included in this review of literature, the false negative rate of sentinel node biopsy in multifocal and multicentric breast cancers are less than 10% with a low rate of axillary recurrence. Despite the lack of randomized study, this procedure can be routinely performed in accordance with rigorous technical process.

Does the PFNA™ nail limit impaction in unstable intertrochanteric femoral fracture? A 115 case-control series

INTRODUCTION

Femoral neck shortening after dynamic fixation of extra-capsular fracture may impair functional results, but is rarely assessed. The present study measured impaction in stable and unstable fractures (on the Ender classification) treated by PFNA™ nail. The objectives were: 1) to validate the Ender classification to assess fracture stability; 2) to determine whether neck shortening and head purchase quality varied with stability; and 3) to determine the functional impact of femoral neck shortening.

HYPOTHESIS

The study hypothesis was that the PFNA™ nail stabilizes unstable as well as stable fractures.

MATERIALS AND METHODS

One hundred and fifteen consecutive patients, aged over 70 years, operated on for intertrochanteric fracture using the PFNA™ nail were followed up prospectively for 6 months. Multivariate analysis, including age, gender, assembly quality and body-mass index, was applied to assess the predictive power of the Ender classification with respect to femoral neck shortening. Secondly, patients were grouped according to stable versus unstable fracture (n=70 and 45, respectively), and impaction and femoral head purchase were assessed on a dedicated radiographic protocol. Functional results were assessed on Parker score.

RESULTS

In the unstable fracture group, 3 assembly failures required revision by total hip replacement. Ender grade>2 was significantly predictive of>5mm neck shortening. Neck shortening was greater in unstable fracture: 8.1 ± 8.4mm (range, 4-32 mm), versus 2.5 ± 3.7 mm (range, 3-14 mm) (P=0.0004). Mean blade cut-through was 1.2 ± 2.9 mm (range, 1-12 mm) in unstable fracture, versus 0.3 ± 1.3 mm (range, 1-6mm) (P=0.02). Mean cut-out was 2.3 ± 6 mm (range, 2-21 mm) in unstable fracture, versus 0.5 ± 2.6 mm (range, 1-8mm) (P=0.03). Parker scores diminished comparably in the two groups, without significant difference at follow-up: 3.9 ± 2.6 (range, 0-9) in stable and 3.1 ± 1.9 (range, 0-8) in unstable fracture; reduction in Parker score showed no correlation with femoral neck shortening (r=0.013, P=0.88).

DISCUSSION

The PFNA™ nail provides poorer stabilization of unstable compared to stable fracture. Femoral neck shortening should be taken into account in assessing internal fixation hardware perfomances.

LEVEL OF EVIDENCE

Level III. Prospective case-control study.

Current state of anterior cruciate ligament registers

PURPOSE

The purpose of this work was to report the main characteristics and results of all active anterior cruciate ligament (ACL) reconstruction registers along with the differences between them.

METHODS

We systematically searched on Google and Medline via PubMed to identify ACL registers. National or regional registers were included if they were active and took into account ACL reconstructions. The main results and characteristics, namely the number of inclusions, exhaustivity, data collection methods and results dissemination methods were determined. The collected information was then submitted to each register for validation.

RESULTS

Four registers (3 national, 1 regional) were identified that routinely included every ACL reconstruction procedure. Register data were collected either through dedicated websites or on paper forms. All the registers used the same two outcome measures, namely the revision rate and a subjective patient score (KOOS score). Register results were made available through scientific publications or annual reports. The main differences between registers were in the graft choice and presence of associated meniscus and cartilage injuries.

CONCLUSIONS

Although there are only a few ACL reconstruction-specific registers, their scientific contribution is undeniable thanks to the quality of the collected data and the organization and collaboration between registers. Their impact on health care and science should grow in the future.

Results of angular-stable locked intramedullary nails in the treatment of distal tibia fractures

INTRODUCTION

Intramedullary nailing in distal tibial fracture is controversial because of a lack of stability. The present study sought to assess radiological and clinical results for a new "angular-stable" locking system in difficult indications for intramedullary nailing.

MATERIAL AND METHOD

A prospective study recruited 41 patients (41 tibias) with distal tibial fracture consecutively managed using angular-stable locked intramedullary nails. Radiologic assessment comprised AP and lateral lower-limb views, taken postoperatively and through to last follow-up. The mean distance was measured between fracture and joint line. Fusion, with or without malunion, primary reduction defect, non-union and secondary displacement were recorded, as were all complications.

RESULTS

Mean follow-up was 18 ± 5 months; 3 patients were lost to follow-up. Mean fracture distance from the joint line was 63 ± 25 mm. Fusion was achieved within 3 months in 29 cases (76%); delayed fusion in 7 patients (18%) required secondary dynamization at a mean 3 months, with favorable evolution. Revision surgery was required in 2 cases: 1 for secondary displacement exceeding 10°, and 1 for non-union at 7 months. Other complications mainly comprised 4 malunions of less than 10° due to primary reduction defect.

CONCLUSION

Angular-stable locked lower-limb intramedullary nailing provided a very satisfactory fusion rate, with few complications. It is, however, a demanding procedure, especially as regards fracture reduction and nail positioning in the distal fragment.

PROSPECTIVE COHORT STUDY

level IV.

Satisfactory long-term MRI after autologous chondrocyte implantation at the knee

PURPOSE

Autologous chondrocyte implantation (ACI) to address isolated condylar lesions is supposed to limit degenerative deterioration in neutrally aligned knees. Here, we report long-term results of the first-generation ACI technique with periosteal flap.

METHODS

Twelve patients, 29 years old on average, were included on the basis of pre-operative MRI selection of lesions >2 cm2. Cartilage carrots were harvested arthroscopically, then cultured and finally re-implanted within a mean time interval of 12 weeks. Ten-year MRI results were analysed according to a semi-quantitative scale, along with functional assessment based on International Knee Documentation Committee score, Lysholm et al. score and the Tegner et al. activity scale.

RESULTS

One patient secondarily required valgus tibial osteotomy with mosaic plasty. Another incurred graft hypertrophy that necessitated arthroscopic peeling. MRI showed that cartilage repair filled more than 50% of the initial defect in 9 patients. Standard radiographs revealed slight narrowing of the joint line. Overall, functional scores improved durably by 50%, although activity level decreased substantially.

CONCLUSION

ACI contained degenerative changes within moderate stages while maintaining durable functional improvement. However, in the absence of controls, it was difficult to differentiate between these findings and the spontaneous evolution of non-treated lesions.

LEVEL OF EVIDENCE

Case series, Level IV.

Fifth metacarpal neck fracture fixation: Locking plate versus K-wire?

INTRODUCTION

Neck fractures of the fifth metacarpal bone can leave sequelae. Surgery is indicated when the displacement of the head in flexion exceeds 45° and/or rotation is impaired. Among available techniques, non-locking mini-plates have the most drawbacks; recently developed locking plates may, however, challenge the preference for K-wires.

HYPOTHESIS

The present study compared results between locking plates and intramedullary K-wires.

MATERIAL AND METHODS

The series comprised 38 fifth metacarpal fractures: 18 were managed by locking plate (group I) and 20 by intramedullary K-wire (group II). Results were analyzed on subjective and objective criteria (pain, DASH, strength, mobility, time off work, radiology).

RESULTS

No significant differences were found for pain, DASH, strength, time off work or head displacement at last follow-up. Active mobility, however, was significantly greater in the K-wire group, with mean relative metacarpophalangeal flexion 59% of healthy-side values in group I vs. 98% in group II, and mean relative extension 89% in group I vs. 99% in group II. Group I showed six complications (three cases of stiffness, one of head necrosis, two of delayed consolidation) vs. seven in group II (three cases of wire migration, three of neurologic lesion, one of esthetic blemish).

DISCUSSION

Locking plates with immediate mobilization paradoxically provided poorer mobility at end of follow-up than intramedullary K-wire with 6 weeks' immobilization. The extra cost of locking plates was thus not justified by results. Intramedullary K-wire nailing remains the reference technique for the management of displaced fracture of the fifth metacarpal neck.

LEVEL OF EVIDENCE

Level IV continuous prospective comparative study.

[Menopause, hormone replacement treatment (HRT), stomatologic pathologies]

Oral discomfort is a common symptom of menopause which is improved by HRT. HRT may be also beneficial in preventing tooth loss and the need for dentures in post-menopausal women.

Referential set presentation effects on complementation by 6-year-olds

What difficulties do children encounter when responding to complementation instructions? The responses of 50 children to six complementation requests were examined. For half of the children, the objects in the referential set were pooled, and for the other half, they were physically separated by category (pencils were presented in a pencil box, buttons in a sewing kit, and balls of yarn in a knitting basket). Reinforcing the identifying status of the semantic property by separating the objects into categories led to an increase in the number of responses bearing on the subset designated in the instructions (e.g., in response to "Give me everything that is not a black button," the children handed over only the nonblack buttons). In contrast, older children gave responses based on the entire set. The meaning attributed by children to object properties and the effects of that attribution on processing mode merit further study.

Changes in cytokeratin expression during the development of the human oral mucosa

The changes in cytokeratin expression by the developing oral mucosa of 10 to 23-week-old human fetuses were studied by indirect immunofluorescence using a panel of 15 monoclonal antibodies. The lining and masticatory mucosae were incompletely differentiated in 10-wk fetuses, since they expressed identical patterns of cytokeratins (CK 4, 5, 8, 13, 18, 19 and probably CK 14, 16, 17) very similar to that of adult alveolar mucosa. The main difference was the presence of cytokeratins 8, 18 and 19 in embryonic tissues. Cytokeratins 1, 2, 10 and 11 began to appear in gingival and hard palate epithelium from wk 11, predicting the differentiation of the masticatory mucosa by wk 16. The patterns of cytokeratin expression in the 23-wk fetus in the lining and masticatory mucosae appear to be different. In lining mucosa, the only difference from the 10th wk is a decrease in cytokeratins 8, 18 and 19, whereas the pattern of cytokeratin expression in masticatory mucosa (CK 1, 2, 4, 5, 8, 10, 11, 13, 18, 19 and probably CK 14, 16 and 17) is now very near that of adult gingiva. This pattern appears, as in the adult, to be similar to that of the epidermis in the same period.

[Allergic manifestations]

Physiologic principles, mediators, drugs and biologic agents involved in allergic reactions such as skin eruptions, local swelling and anaphylaxis are exposed. Then, clinical manifestations, diagnosis, treatment and preventive modalities are described.

[Translaryngeal trocar, alternative to tracheotomy in the dental office]

The emergency tracheotomy is indicated when there is a respiratory distress caused by the complete obstruction of the upper airway and when the etiological and symptomatic treatments have failed. However, it is not an easy procedure for a non specialist outside the hospital environment. The translaryngeal stem maintains a minimal ventilation while waiting for the emergency medical unit.

[Emergency drugs]

After setting the essential rules of the emergency prescription in the dental office, the authors consider successively from a standpoint of properties, indications, contra-indications, danger of associating medications, presentation, use and posology. The medicines used in order to treat the different emergency situations that can arise in a dental practice.

[Tetany crisis]

The acute crisis of tetany appears generally on spasmophilic backgrounds, triggered most often by stress and anxiety. Always benign, it can however be quite annoying because of its length. The authors study that crisis successively from an etiological, therapeutical and preventive point of view.

Characterization of cytokeratin patterns in the developing human tongue

The characterization of cytokeratin (CK) in adult oral mucosa and developing teeth have been well documented in human. Cytokeratin distribution in developing oral mucosa has not yet been described. The aim of this study was to identify the expression of CK in human fetal tongue (week 10 to week 23) and to correlate the results with morphological maturation. Simple epithelial CK are expressed in all cell layers during the early stages, essentially in peridermal cells. From the 14th week, CK 18 is present only in the taste buds, making this polypeptide a reliable marker for this sensory organ. CK 4 and 13 are expressed from the 10th to the 23rd week by both ventral and dorsal lingual epithelia. Terminal differentiation keratins (CK 1, 2 and 10-11) can only be detected immunohistochemically at the 14th week in some cells on the external surface of some papillae. The number of these papillae and positive cells increase at the 19th and 23rd weeks. The terminal differentiation markers are expressed several weeks earlier than the formation of a well-distinguished keratinized layer.

Evolution of cytokeratin expression in developing human tooth germ

Cytokeratin expression by the developing human enamel organ between the 10th and the 23rd gestational week was studied by indirect immunofluorescence microscopy technique using a panel of 15 monoclonal antibodies. The results showed that five antibodies (RKSE 60, Kk 8-60, EE 21-6, 6B10 and 1 C-7) were never reactive, that five antibodies (RCK 102, 42.39.13.1, Ks 19 and Pan 1-8) were always positive and that five antibodies (KB 37, RPN 11-62, Ks 13.1, Ks 8-12 and Ks 18.174) obtained or increased their positivity between weeks 12 and 13. It was concluded that a switch in cytokeratin expression occurred around the 12th-13th weeks. No further important change could be noticed after this period. So it is suggested that final cell differentiation was initiated at weeks 12-13.

[Syncope]

Syncopes related to cerebral or cardio-vascular lesions, or resulting from a reflex or from a mixed origin should remain exceptional. Adequate knowledge of their possible etiology and of the curative and preventive measures to use, are very important. To avoid an irreversible issue every practitioner should master the resuscitation technics. Each office should have an adequate equipment for resuscitation and CPR courses should be taken every year.

[Oral manifestations of acquired bullous dermatoses]

The authors suggest studying the principal oral manifestations of acquired bullous dermatosis, such as malignant pemphigus, bullous pemphigoid, cicatricial pemphigoid, bullous polymorphe erythema, pluri-orificial ectodermosis, Lyell's syndrome, bullous toxidermia, bullous lichen planus and porphyria. These diseases will be described for the following aspects: clinical manifestations, diagnosis, evolution and treatment.

[Herpetic manifestations: diagnosis, treatment, prevention]

Herpes virus infection is an extremely common disease that affects between 90 to 100% of the population above the age of 15. The authors propose studying successively the clinical and virological diagnosis of this infection, it's treatment, and finally it's prevention in the dental clinic where there is a large possibility of transmitting the infective diseases.

[Physiology of hemostasis]

After having remained the essential modalities leading haematologic anamnesis and clinical examination, first we describe, for each of the three haemostasis steps, the routine laboratory tests and secondly, a more specific schedule prescribed only after having found abnormalities in the first tests.

[Convulsive manifestations]

The convulsive crisis (involuntary muscular contractions, tonic then clonic, associated to a sudden loss of conscience) occur on comitial persons or represent the expression of a prolonger cerebral suffering following a deficiency of one or several nutrients, necessary to the function of the nervous system (glucose, oxygen...) or an drug intoxication (local anesthetics) of the nervous centers. Following the etiology, the following aspect will be studied: the different clinical forms, the differential diagnosis, the emergency treatment of the crisis according to their possible evolution and finally their prevention.