Professionnels en établissements de santé infectés par le SARS-CoV-2 : le bilan après deux ans de pandémie

Introduction

Les professionnels travaillant en établissements de santé (PES) sont exposés au risque d'infection par le SARS-CoV-2. Une enquête a été mise en place afin d'objectiver l'impact de la pandémie dans cette population spécifique.

Matériels et méthodes

Un web questionnaire a été proposé mi-avril 2020 à tous les établissements de santé (ES) publics ou privés. Les ES volontaires saisissent de manière hebdomadaire le nombre de nouveaux cas de PES infectés et les décès attribuables. La région, la catégorie professionnelle, le service sont également recueillis. Les proportions de PES infectés ont été estimées en rapportant le nombre de cas aux données de la Statistique annuelle des établissements de santé 2019.

Résultats

1 450 des 3 636 ES ont participé au moins une fois à l'enquête, à savoir 74,7% des PES salariés en France. Au cours de la 5^ème vague, 337 ES ont participé à l'enquête soit 20,7 % des PES salariés en France. Du 1^er Mars 2020 au 15 Février 2022, 118 340 PES, correspondant à 12,1 % des PES exerçant dans les ES participants ont été infectés par le SARS-CoV2, avec 19 décès attribuables. La répartition hebdomadaire du nombre de cas montre 5 pics de contamination enregistrés durant les 5 vagues épidémiques successives, le 5^e pic étant le plus important.

Parmi ces PES, 62,8 % des cas étaient des soignants dont 22 % d'infirmiers et 18 % d'aides-soignants. Rapportés aux effectifs globaux par catégorie professionnelle dans ces ES, les aides-soignants et les kinésithérapeutes étaient les professions les plus infectées (respectivement 12,8 et 12,2 pour 100 professionnels travaillant dans les ES participants). Les PES contaminés travaillaient principalement dans des services de MCO (42,3 %) ou médicotechniques (25,4 %). Des disparités régionales dans la proportion de PES infectés étaient observées au cours des différentes vagues. Lors de la 5^ème vague, la Guadeloupe et l'Occitanie sont les régions où les PES sont les plus touchés par la COVID-19.

Conclusion

Cette enquête montre les mêmes tendances temporelles et géographiques qu'en population générale. L'augmentation du nombre de cas chez les PES lors de la 5^ème vague est en lien avec la diffusion rapide du variant Omicron. La participation des ES a varié au cours du temps. Malgré un protocole d'enquête reposant sur la déclaration volontaire, plus de 130 ES (20 % des PES salariés) participent régulièrement à l'enquête et permettent de considérer que ces résultats donnent une bonne estimation de la dynamique de contamination des PES. Bien que l'objectif de cette étude n'était pas de déterminer les circonstances de contamination, il semble que les professions ayant des contacts fréquents et prolongés avec les patients (aides-soignants, kinésithérapeutes) sont proportionnellement les plus touchées.

Aucun lien d'intérêt

Burden of COVID-19 on workers in hospital settings: The French situation during the first wave of the pandemic

We launched a survey in April 2020 to assess the number and proportion of hospital workers infected during the first wave of the COVID-19 pandemic in France, and to assess the attributable mortality. All French hospital settings (HS) were invited to declare new cases and attributable deaths by occupation category each week. Between March 1 and June 28, 2020, participating HS accounted for 69.5% of the total number of HS workers in France, and declared 31,088 infected workers; 16 died from the infection. We estimated that 3.43% (95% CI: 3.42–3.45) of French workers in HS, and 3.97% (95% CI: 3.95–3.99) of healthcare workers were infected during the first wave. Workers in regions with a cumulative rate of hospitalized COVID-19 patients equal or above the national rate, HS other than tertiary hospitals, or occupations with frequent patient contacts were particularly impacted. Targeted prevention campaigns should be elaborated.

Use and outcomes of emergency treatment strategies in patients with aortic valve stenosis

Introduction and aim

Current emergency treatment options for severe aortic valve stenosis include surgical aortic valve replacement (SAVR), transcatheter aortic valve replacement (TAVR) and balloon valvuloplasty (BV). So far no larger patient population has been evaluated regarding clinical characteristics and outcomes. Therefore we aimed to describe the use and outcome of the three therapy options in a broad registry study.

Method and results

Using German nationwide electronic health records, we evaluated emergency admissions of symptomatic patients with severe aortic valve stenosis between 2014 and 2017. Patients were grouped according to SAVR, TAVR or BV only treatments. Primary outcome was in-hospital mortality. Secondary outcomes were stroke, acute kidney injury, periprocedural pacemaker implantation, delirium and prolonged mechanical ventilation >48 hours. Stepwise multivariable logistic regression analyses including baseline characteristics were performed to assess outcome risks.

8,651 patients with emergency admission for severe aortic valve stenosis were identified. The median age was 79 years and comorbidities included NYHA classes III-IV (52%), coronary artery disease (50%), atrial fibrillation (41%) and diabetes mellitus (33%). Overall in-hospital mortality was 6.2% during a mean length of stay of 22±15 days. TAVR was the most common treatment (6,357 [73.5%]), followed by SAVR (1,557 [18%]) and BV (737 8.5%]).

Patients who were treated with TAVR or BV were significantly older than patients with SAVR (mean age 81.3±6.5 and 81.2±6.9 versus 67.2±11.0 years, p<0.001), had more relevant comorbidities (coronary artery disease 52–91% vs. 21.8%; p<0.001), worse NYHA classes III-IV (55–65% vs. 34.5%; p<0.001) and higher EuroSCORES (24.6±14.3 and 23.4±13.9 vs. 9.5±7.6; p<0.001) than SAVR patients. Patients treated with BV only had the highest in-hospital mortality compared with TAVR or SAVR (20.9% vs. 5.1 and 3.5%; p<0.001).

Compared with BV only, SAVR patients (adjusted odds ratio [aOR] 0.25; 95% confidence interval [CI] 0.14–0.46; p<0.001) and TAVR patients (aOR 0.37; 95% CI 0.28–0.50; p<0.001) had a lower risk for in-hospital mortality.

Conclusion

In-hospital mortality for emergency patients with symptomatic severe aortic valve stenosis is high. Our results showed that BV only therapy was associated with highest mortality, which is in line with current research. Yet, there is a trend towards more TAVR interventions and this study might imply that balloon valvuloplasty alone is insufficient. The role of BV as a bridging strategy to TAVR or SAVR needs to be further investigated.

Funding Acknowledgement

Type of funding source: Public hospital(s). Main funding source(s): Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Freiburg, Germany

Contexte de contamination des professionnels de santé par la COVID-19 : résultats préliminaires

Introduction

Afin de documenter les circonstances des contaminations par le SARS-CoV-2, une enquête nationale a été conduite auprès des professionnels de santé.

Matériels et méthodes

Un questionnaire a été mis en ligne le 17 avril 2020. Pouvait être inclus tout professionnel de santé (IDE, aide-soignant, médecin, kiné, technicien de laboratoire, pharmacien, manipulateur radio, brancardier, psychologue, diététicien, dentiste…) pour lequel un diagnostic de COVID-19 a été posé, quel que soit son mode d’exercice (établissement de santé, libéral, établissement médicosocial…).

Les données collectées portaient sur l’activité, le type de tâches réalisées, le port de protections et l’existence d’éventuels contacts avec des cas (professionnels, extra-professionnels), dans les 2 semaines précédant la date de début des symptômes.

Résultats

Entre le 17 avril et le 9 juin 2020, 2129 questionnaires ont été renseignés. Les infirmiers (678), les médecins (477), et les aides-soignants (296) étaient les catégories les plus représentées. Ils exerçaient en établissements de santé (ES) pour 1446 d’entre eux et 403 en ville ; les autres répondeurs exerçaient dans le secteur médicosocial. La répartition géographique des déclarants se rapprochait des résultats du recensement national des cas de contamination limité au personnel soignant en ES. Dans les deux semaines précédant leurs symptômes, 287/2129 (13,5 %) des déclarants avaient exercé dans le cadre d’un intérim ou d’un renfort en établissement de santé. Lors des entretiens avec les patients (en face à face, à moins d’un mètre), 416/1446 (29 %) des soignants en ES, et 217/403 (53 %), en ville, ne portaient jamais de masque. En ville, 169/403 (42 %) des soignants contaminés réalisaient des visites à domicile. Parmi les 870/1146 (76 %) soignants qui ont déclaré avoir participé à des réunions de travail, 558/870 (64 %) ne portaient jamais de masque ou en portaient parfois à cette occasion. En salle de repos, lors des pauses, 1235/1446 (85 %) soignants ne portaient pas de masque ou le portaient occasionnellement. Six cent trois (28 %) répondeurs ont déclaré avoir été en contact, sans masque, avec un collègue ayant une infection confirmée à COVID-19, pendant ses symptômes ou durant les précédentes 72 h. En dehors de leur activité professionnelle, 278/2129 (13 %) professionnels contaminés ont été en contact avec au moins un cas suspecté ou confirmé d’infection à COVID-19.

Conclusion

Cette enquête reposait sur la participation volontaire des soignants ayant eu une COVID-19. Les résultats préliminaires montrent un défaut d’utilisation des mesures de protection parmi les tâches réalisées, notamment pour les professionnels de ville, quelle qu’en soit la raison. La reconnaissance d’un contact extra-professionnel paraît faible. En revanche, le rôle de la contamination entre soignants sur leur lieu d’exercice paraît être un déterminant important de la contamination des soignants.

Positive prostate biopsy following radiotherapy can predict metastasis-free survival in localized prostate cancer

Background/aims

To determine the impact of post-treatment biopsy results on 10-year metastasis-free survival (MFS), overall survival (OS) and cause-specific survival (CSS) in localized prostate cancer (PCa) patients treated with high-dose radiotherapy (RT).

Materials/Methods

Retrospective analysis of 232 patients with T1c-T3bN0M0 PCa who underwent a prostate biopsy 24-36 months after high-dose RT. Biopsies were categorized as positive biopsy (PB) if H&E staining showed evidence of residual malignancy and negative biopsy (NB) if no malignant cells were present. Kaplan-Meier estimates of 10-year MFS, OS and CSS rates were calculated for each group and Cox proportional-hazards models were used to estimate the hazard ratios. The median follow-up was 124 months (range 26-267).

Results

Sixty-two of 232 (26.7%) patients had post-treatment positive biopsies (PB). A positive post-treatment biopsy was significantly associated with a lower 10-year MFS (78.4% vs. 95.4%, p = 0.001, HR: 3.9, 95% CI: 1.8-8.3). Although patients with PB had worse outcomes that those with NB, we could not show a statistically significant difference in OS (81.0% vs. 87.9%, p = 0.282, HR: 1.3, 95% CI: 0.7-2.3) or CSS (96.2% vs. 99.4% (p = 0.201, HR. 2.4, 95% CI: 0.6-9.7). After multivariate analysis, the strongest predictor of MFS was the post-treatment biopsy status (p < 0.001, HR: 5.4, 95% CI 2.26-12.85) followed by Gleason score (p = 0.002, HR: 2.24, 95% CI 1.33-3.79).

Conclusion

A positive biopsy following RT can predict MFS in localized prostate cancer. These data highlight the relevance of achieving a local control and support the use of aggressive local therapeutic interventions for PCa.

Supercritical CO2-assisted deposition of NiO on (101)-anatase-TiO2 for efficient facet engineered photocatalysts

Deposition of NiO on the (101) facet of anatase nanocrystals by the SFCD route yields nanocomposites more efficient than pure anatase TiO₂ for the photodecomposition of both anionic and cationic dyes.

Accurate prediction of X-ray pulse properties from a free-electron laser using machine learning

Free-electron lasers providing ultra-short high-brightness pulses of X-ray radiation have great potential for a wide impact on science, and are a critical element for unravelling the structural dynamics of matter. To fully harness this potential, we must accurately know the X-ray properties: intensity, spectrum and temporal profile. Owing to the inherent fluctuations in free-electron lasers, this mandates a full characterization of the properties for each and every pulse. While diagnostics of these properties exist, they are often invasive and many cannot operate at a high-repetition rate. Here, we present a technique for circumventing this limitation. Employing a machine learning strategy, we can accurately predict X-ray properties for every shot using only parameters that are easily recorded at high-repetition rate, by training a model on a small set of fully diagnosed pulses. This opens the door to fully realizing the promise of next-generation high-repetition rate X-ray lasers.

Women who give birth before arriving at National District Hospital in Bloemfontein, Free State

Background: Birth before arrival (BBA) contributes to the neonatal death rate in South Africa. This study aimed to determine the profile of and reasons for women giving birth prior to arrival at National District Hospital, Bloemfontein. Methods: This was a descriptive study of women, 18 years or older, presenting with BBA at National District Hospital between October 2015 and January 2016. Consenting women were interviewed by the discharging doctor who completed the questionnaire. Results: Of the 68 mothers with BBAs, 61 were included (response rate 90%). The highest percentage (38%) lived less than 5 km from a healthcare facility. The median parity was three and 67% gave birth unexpectedly. Common factors were poor antenatal clinic booking and limited antenatal clinic visits. Most mothers (89%) depended on Emergency Medical Services and 69% had made no prior arrangements with a hospital. Conclusion: Better education on antenatal care and delivery planning is recommended. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: 10.1080/20786190.2017.1313485

Band alignment investigations of heterostructure NiO/TiO2 nanomaterials used as efficient heterojunction earth-abundant metal oxide photocatalysts for hydrogen production

Earth-abundant NiO/TiO₂ heterostructures lead to enhanced H₂ production by methanol photoreforming due to favorable band bending at the interface of the NiO/anatase TiO₂ p–n heterojunction.

On the existence of finite-dimensional filters for Markov-modulated traffic

A Markov-modulated Poisson process (MMPP) is a Poisson process whose rate is a finite Markov chain. The Poisson process is a simple MMPP. An MMPP/M/1 queue is a queue with MMPP arrivals, an infinite capacity, and a single exponential server. We prove that the output of an MMPP/M/1 queue is not an MMPP process unless the input is Poisson. We derive this result by analyzing the structure of the non-linear filter of the state given the departure process of the queue. The practical relevance of the result is that it rules out the existence of simple finite descriptions of queueing networks with MMPP inputs.

Computer vision tools to optimize reconstruction parameters in x-ray in-line phase tomography

In this article, a set of three computer vision tools, including scale invariant feature transform (SIFT), a measure of focus, and a measure based on tractography are demonstrated to be useful in replacing the eye of the expert in the optimization of the reconstruction parameters in x-ray in-line phase tomography. We demonstrate how these computer vision tools can be used to inject priors on the shape and scale of the object to be reconstructed. This is illustrated with the Paganin single intensity image phase retrieval algorithm in heterogeneous soft tissues of biomedical interest, where the selection of the reconstruction parameters was previously made from visual inspection or physical assumptions on the composition of the sample.

Development and psychometric validation of a brief comprehensive health status assessment scale in older patients with hematological malignancies: The GAH Scale

OBJECTIVES

The purpose of this study was to develop a new brief, comprehensive geriatric assessment scale for older patients diagnosed with different hematological malignancies, the Geriatric Assessment in Hematology (GAH scale), and to determine its psychometric properties.

MATERIALS AND METHODS

The 30-item GAH scale was designed through a multi-step process to cover 8 relevant dimensions. This is an observational study conducted in 363 patients aged≥65years, newly diagnosed with different hematological malignancies (myelodysplasic syndrome/acute myeloblastic leukemia, multiple myeloma, or chronic lymphocytic leukemia), and treatment-naïve. The scale psychometric validation process included the analyses of feasibility, floor and ceiling effect, validity and reliability criteria.

RESULTS

Mean time taken to complete the GAH scale was 11.9±4.7min that improved through a learning-curve effect. Almost 90% of patients completed all items, and no floor or ceiling effects were identified. Criterion validity was supported by reasonable correlations between the GAH scale dimensions and three contrast variables (global health visual analogue scale, ECOG and Karnofsky), except for comorbidities. Factor analysis (supported by the scree plot) revealed nine factors that explained almost 60% of the total variance. Moderate internal consistency reliability was found (Cronbach's α: 0.610), and test-retest was excellent (ICC coefficients, 0.695-0.928).

CONCLUSION

Our study suggests that the GAH scale is a valid, internally reliable and a consistent tool to assess health status in older patients with different hematological malignancies. Future large studies should confirm whether the GAH scale may be a tool to improve clinical decision-making in older patients with hematological malignancies.

Antioxidants delay clinical signs and systemic effects of ENU induced brain tumors in rats

According to our previous study suggesting that antioxidant properties of phytochemicals in the diet decrease glioma aggressiveness, we used a SUVIMAX-like diet ("Supplementation en VItamines et Minéraux AntioXydants") (enriched with alpha-tocopherol, beta carotene, vitamin C, zinc, and sodium selenite), adapted to rats. The present results showed that each of the antioxidants inhibited growth of glioma cells in vitro. When used in combination for in vivo studies, we showed a highly significant delay in the clinical signs of the disease, but not a statistical significant difference in the incidence of glioma in an Ethyl-nitrosourea (ENU)-model. The SUVIMAX-like diet decreased candidate markers of tumoral aggressiveness and gliomagenesis progression. The mRNA expressions of 2 common markers in human glioma: Mn-SOD (Manganese Superoxide Dismutase) and IGFBP5 (insulin growth factor binding protein) were reduced in the tumors of rats fed the antioxidant diet. In addition, the transcripts of two markers linked to brain tumor proliferation, PDGFRb (platelet-derived growth factor receptor beta) and Ki-67, were also significantly decreased. On the whole, our results suggest a protective role for antioxidants to limit aggressiveness and to some extent, progression of gliomas, in a rat model.

USE OF MICRO-DAMS IN POTATO FURROWS TO REDUCE EROSION AND RUNOFF AND MINIMISE SURFACE WATER CONTAMINATION THROUGH PESTICIDES

The use of micro-dams in potato furrows is an interesting technology to reduce erosion and runoff in hilly areas. These phenomena are major sources of surface water contamination by nutrients and plant protection products (Gillijns et al., 2005). In 2011 Bayer CropScience set up a trial in collaboration with the Walloon Agricultural Research Centre (CRA-W) and ULg-Gembloux Agro-Bio Tech in Huldenberg (Belgium) to demonstrate this technique in potatoes. Micro-dams create barriers between furrows in order to encourage rainwater to infiltrate in the soil rather than to run off. The results from the trial over this year confirm that the application of micro-dams is effective in reducing erosion and runoff significantly. The total loss of plant protection products (PPP) to surface water is dramatically reduced and also strongly depends on the physic-chemical characteristics of the active ingredients. In addition, the technique tends to produce a higher yield of potato tubers as an effect of an optimised utilisation of the available rainwater and nutrients.

A pharmacogenomic approach to the treatment of children with GH deficiency or Turner syndrome

OBJECTIVE

Individual sensitivity to recombinant human GH (r-hGH) is variable. Identification of genetic factors contributing to this variability has potential use for individualization of treatment. The objective of this study was to identify genetic markers and gene expression profiles associated with growth response on r-hGH therapy in treatment-naïve, prepubertal children with GH deficiency (GHD) or Turner syndrome (TS).

DESIGN

A prospective, multicenter, international, open-label pharmacogenomic study.

METHODS

The associations of genotypes in 103 growth- and metabolism-related genes and baseline gene expression profiles with growth response to r-hGH (cm/year) over the first year were evaluated. Genotype associations were assessed with growth response as a continuous variable and as a categorical variable divided into quartiles.

RESULTS

Eleven genes in GHD and ten in TS, with two overlapping between conditions, were significantly associated with growth response either as a continuous variable (seven in GHD, two in TS) or as a categorical variable (four more in GHD, eight more in TS). For example, in GHD, GRB10 was associated with high response (≥ Q3; P=0.0012), while SOS2 was associated with low response (≤ Q1; P=0.006), while in TS, LHX4 was associated with high response (P=0.0003) and PTPN1 with low response (P=0.0037). Differences in expression were identified for one of the growth response-associated genes in GHD (AKT1) and for two in TS (KRAS and MYOD1).

CONCLUSIONS

Carriage of specific growth-related genetic markers is associated with growth response in GHD and TS. These findings indicate that pharmacogenomics could have a role in individualized management of childhood growth disorders.

[Epignathus teratoma: diagnostic and neonatal management; a case report]

Epignathus teratoma is a rare tumor whose prognosis essentially depends on its resectability and on neonatal care. When it is undiagnosed prenatally, mortality is close to 100 % at birth, because of obstruction of the upper airways. We present a case of epignathus teratoma detected during obstetrical ultrasound screening. Diagnosis enabled planning for a safe delivery in a suitable multidisciplinary unit and use of the EXIT procedure.

Thrombin receptor antagonism in antiplatelet therapy

Activated platelets play a crucial role in the pathogenesis of atherothrombotic disease and its complications. Even under treatment of antiplatelet drugs, such as acetylsalicylic acid and P2Y12 antagonists, morbidity and mortality rates of thromboembolic complications remain high. Hence, the therapeutic inhibition of protease-activated receptor (PAR)-1, which is activated by thrombin, is a novel promising approach in antiplatelet therapy. Recent data suggest that PAR-1 is mainly involved in pathological thrombus formation, but not in physiological hemostasis. Therefore, PAR-1 inhibition offers the possibility to reduce atherothrombotic events without increasing bleeding risk. So far, two emerging PAR-1 antagonists have been tested in clinical trials: vorapaxar (SCH530349; Merck & Co., Whitehouse Station, NJ, USA) and atopaxar (E5555; Eisai, Tokyo, Japan). Although in TRA-CER vorapaxar showed an unfavorable profile for patients with acute coronary syndrome in addition to standard therapy, it revealed promising results for patients with prior myocardial infarction in TRA 2P-TIMI50. Depending on the status of clinical approval, vorapaxar might be an option for patients with peripheral arterial disease to reduce limb ischemia. The second PAR-I antagonist, atopaxar, tended towards reducing major cardiovascular adverse events in acute coronary syndrome patients in a phase II trial. However, although statistically not significant, bleeding events were numerically increased in atopaxar-treated patients compared with placebo. Furthermore, liver enzymes were elevated and the relative corrected QT interval was prolonged in atopaxar-treated patients. Currently, the development of atopaxar by Eisai is discontinued. The future of this novel class of antithrombotic drugs will depend on the identification of patient groups in which the risk–benefit ratio is favorable.

3D characterization of pores in the cortical bone of human femur in the elderly at different locations as determined by synchrotron micro-computed tomography images

Diaphysis, inferior, and lateral superior regions of the femoral neck are subjected to diverse mechanical loads. Using micro-CT based on synchrotron radiation, three-dimensional morphology and connectivity of the pore network are location dependent, underlying different remodeling mechanisms.

INTRODUCTION

The three-dimensional (3D) morphology and connectivity of the pore network at various locations in human femurs subjected to diverse mechanical loads were assessed using micro-CT based on synchrotron radiation.

METHODS

The cortex from 20 human femurs (mean age, 78.3 ± 12.4 years) was taken from the diaphysis (D), the inferior (IN), and the lateral superior (LS) regions of the femoral neck. The voxel size of the 3D reconstructed image was 7.5 μm. Cortical thickness and pore volume/tissue volume (Po.V/TV), pore diameter (Po.Dm) and spacing (Po.Sp) were determined. The pore surface/pore volume ratio (Po.S/Po.V), the number of pores (Po.N), the degrees of anisotropy (DA), and the connectivity density (ConnD), the degree of mineralization (DMB) were also determined.

RESULTS

The characteristics of the pore network in femoral cortical bone were found to be location dependent. There was greater porosity, Po.Dm, and Po.N, and more large (180-270 μm), extra-large (270-360 μm) and giant pores (>360 μm) in the LS compared to the IN and D. The difference in porosity in between the periosteal and endosteal layers was mostly due to an increase of Po.Dm rather than Po.N. There was a lower DMB of bone in the LS, which is consistent with a higher remodeling rate.

CONCLUSION

The results provide evidence for large variations in the structure of the internal pore network in cortical bone. These variations could involve different underlying remodeling mechanisms.

Optimal Order of Markov Models Applied to Bankchecks

The aim of this study is to show that the optimal order of Markov Model of cursive words can be rigorously stated in order to fit the structural properties of the observed data using Akaike information criterion. The method has been tested on French Postal check amounts up to order 4. An original structural representation of cursive words based on graphemes is used. The conditional probability to have a word model given an observed sequence of graphemes is computed independently of the length of the sequence. The recognition results obtained confirm the optimal order found using Akaike criterion.

Multicentre randomised controlled trial examining the cost-effectiveness of contrast-enhanced high field magnetic resonance imaging in women with primary breast cancer scheduled for wide local excision (COMICE)

OBJECTIVES

To determine whether the addition of magnetic resonance imaging (MRI) to current patient evaluation by triple assessment would aid tumour localisation within the breast and thus reduce the reoperation rate in women with primary breast tumours who are scheduled for wide local excision (WLE), and to assess whether the addition of MRI would be cost-effective for the UK NHS.

DESIGN

A multicentre, randomised controlled, open, parallel group trial with equal randomisation. The main design was supplemented with a qualitative study to assess patients' experiences of the treatment process and care pathway, and involved the development of a non-scheduled standardised interview (NSSI).

SETTING

The study took place at 45 hospitals throughout the UK.

PARTICIPANTS

Women aged 18 years or over with biopsy-proven primary breast cancer who had undergone triple assessment, were scheduled for WLE, and were capable of providing written informed consent.

INTERVENTIONS

Patients were randomised to receive MRI or no MR1. Randomisation was performed using minimisation, incorporating a random element. All MRI was performed at 1.5 T or 1.0 T with a dedicated bilateral breast coil.

MAIN OUTCOME MEASURES

The primary end point of the trial was the reoperation rate. Secondary outcome measures included discrepancies between imaging and histopathology, and the effectiveness of using both procedures; change in clinical management after using MRI; the clinical significance of MRI-only-detected lesions; the rate of interventions; the ipsilateral tumour recurrence rate; patient quality of life (QoL); and cost-effectiveness.

RESULTS

From a total of 1623 patients, 816 were randomised to MRI and 807 to no MRI. No differences in reoperation rates were found between the two groups of patients [MRI patients 18.75%, no MRI 19.33%, difference 0.58%, 95% confidence interval (CI) -3.24 to 4.40]. Therefore, the addition of MRI to conventional triple assessment was not found to be statistically significantly associated with a reduced reoperation rate (odds ratio = 0.96, 95% CI 0.75-1.24, p = 0.7691). The best agreement between all imaging modalities and histopathology with regard to tumour size and extent of disease was found in patients over 50 years old with ductal tumours NST and who were node negative. In the imaging arm, mastectomy was found to be pathologically avoidable for 16 (27.6%) out of 58 patients who underwent the procedure. There were no significant differences between the groups regarding the proportion of patients receiving chemotherapy, radiotherapy or additional adjuvant therapies, as well as for local recurrence-free interval rates and QoL. An acceptable NSSI was developed for use in this population of patients. Economic analysis found no difference in outcomes between the two trial arms.

CONCLUSIONS

The addition of MRI to triple assessment did not result in a reduction in operation rates, and the use of MRI would thus consume extra resource with few or no benefits in terms of cost-effectiveness or HRQoL. However, MRI showed potential to improve tumour localisation, and preoperative biopsy of MRI-only-detected lesions is likely to minimise the incidence of inappropriate mastectomy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN57474502.

Topoisomerase IIalpha expression rather than gene amplification predicts responsiveness of adjuvant anthracycline-based chemotherapy in women with primary breast cancer

INTRODUCTION

Adjuvant anthracycline-based chemotherapy (AbCTX) is a standard treatment for patients with primary breast cancer. Its main target is topoisomerase IIalpha (TopIIa), a nuclear protein which is important for DNA replication and mitosis. We propose that the overexpression of the TopIIa protein or amplification of the TopIIa gene may be useful in predicting increased responsiveness towards AbCTX.

METHODS

Tumor tissues of 118 patients who received adjuvant AbCTX were examined by immunohistochemistry (IHC) and fluorescence in situ hybridisation (FISH) for TopIIa and HER2. For IHC, the primary antibodies 485 (Dako) and NCL-TOPOIIA (Novocastra) were used. FISH analysis was performed with the SPEC HER2/CEP 17 Dual Color Probe (Zytovision) and LSI TOP 2A Spectrum Orange/CEP 17 Spectrum Green probe (Abbott). TopIIa IHC was evaluated by the immunoreactive score (IRS). FISH amplification was stated at an HER2-TopIIa/CEP 17 ratio > or = 2, deletion of TopIIa at a ratio <0.8.

RESULTS

The median age of the patient population was 50 years (range 23-77), 76 (64%) had tumors >2 cm in size, 98 (85%) were nodal positive, and 72 (66%) estrogen-receptor positive. Chemotherapy regimes consisted of epirubicin-cyclophosphamide (EC 40 pts), EC-CMF (18 pts), FAC/FEC (33 pts), anthracycline-taxane combinations (23 pts) and others (4 pts). After IHC, it was found that 19% of the tumors were positive for HER2 (3+) and the median IRS for TopIIa staining was 2 (49% positive); 28 (24%) tumors showed HER2 amplification, therefrom 20/22 (91%) within the HER2 3+ group. TopIIa gene was amplified in 17 cases (16%) and deletion was seen in 6 (5%) tumors. Of all cases with HER2 gene amplification, 14 (50%) cases of TopIIa co-amplification and one case of deletion were seen. Looking at histological parameters, TopIIa IHC correlated with nodal status (P = 0.018) and high grading (G3) (P = 0.047). After a median follow-up of 42 months (range 1-242), a significant prognostic factor for local recurrence was HER2 positivity (IHC P = 0.013 and FISH P = 0.023). Thirty-two patients developed metastasis (27%), which was correlated with HER2 FISH positivity (P = 0.024) and, as a trend, Top IIa IHC negativity (P = 0.094); 25 (21%) patients died from the disease. Negative prognostic parameters were the lack of estrogen-receptor expression (P = 0.008), lymphangiosis (P = 0.02), and TopIIa IHC negativity (P = 0.03).

CONCLUSION

In this cohort of patients, HER2 positivity indicated higher rates of local and distant recurrence. In contrast, TopIIa IHC positivity predicted lower risk of metastases and death, thus being a positive-predictive factor for the responsiveness to AbCTX. TopIIa gene amplification did not add predictive information. Therefore, we conclude that TopIIa protein expression might rather be the target of anthracyclines independent from gene copy number.