The projected health and economic impact of increased colorectal cancer screening participation among Canadians by income quintile

OBJECTIVES

Disparities in colorectal cancer (CRC) screening uptake by socioeconomic status have been observed in Canada. We used the OncoSim-Colorectal model to evaluate the health and economic outcomes associated with increasing the participation rates of CRC screening programs to 60% among Canadians in different income quintiles.

METHODS

Baseline CRC screening participation rates were obtained from the 2017 Canadian Community Health Survey. The survey participants were categorized into income quintiles using their reported household income and 2016 Canadian Census income quintile thresholds. Within each quintile, the participation rate was the proportion of respondents aged 50-74 who reported having had a fecal test in the past two years. Using the OncoSim-Colorectal model, we simulated an increase in CRC screening uptake to 60% across income quintiles to assess the effects on CRC incidence, mortality, and associated economic costs from 2024 to 2073.

RESULTS

Increasing CRC screening participation rates to 60% across all income quintiles would prevent 69,100 CRC cases and 36,600 CRC deaths over 50 years. The improvement of clinical outcomes would also translate to increased person-years and health-adjusted person-years. The largest impact was observed in the lowest income group, with 22,200 cases and 11,700 deaths prevented over 50 years. Increased participation could lead to higher screening costs ($121 million CAD more per year) and lower treatments costs ($95 million CAD less per year), averaged over the period 2024-2073.

CONCLUSION

Increased screening participation will improve clinical outcomes across all income groups while alleviating associated treatment costs. The benefits of increased participation will be strongest among the lowest income quintile.

Treatment Patterns and Health Outcomes among Patients with HER2 IHC0/-Low Metastatic or Recurrent Breast Cancer

Improved understanding of the biological heterogeneity of breast cancer (BC) has facilitated the development of more effective and personalized approaches to treatment. This study describes real-world evidence on treatment patterns and outcomes for a population-based cohort of patients with human epidermal growth factor receptor (HER2) IHC0 and -low BC with de novo or recurrent disease from Alberta, Canada. Patients 18+ years old diagnosed with HER2 IHC0/-low, de novo/recurrent BC from 2010 to 2019 were identified using Alberta's cancer registry. Analyses of these patients' existing electronic medical records and administrative claims data were conducted to examine patient characteristics, treatment patterns, and survival outcomes. A total of 3413 patients were included in the study, of which 72.10% initiated first line hormonal and non-hormonal systemic therapy. The 1-year overall survival (OS) was 81.09% [95% CI, 79.52-82.69]. Recurrent patients had a higher OS compared to de novo patients: 54.30 months [95% CI, 47.80-61.90] vs. 31.5 months [95% CI, 28.40-35.90], respectively. Median OS was 43.4 months [95% CI, 40.70-47.10] and 35.80 months [95% CI, 29.00-41.70] among patients with HER2-low and HER2 IHC0 cancer, respectively. The study results provide real-world evidence regarding the clinical outcomes of HER2 IHC0/-low and de novo/recurrent disease.

The Association between Red Meat Consumption and Advanced Colorectal Adenomas in a Population Undergoing a Screening-Related Colonoscopy in Alberta, Canada

The association between red meat consumption and colorectal cancer has been rigorously examined. However, a more comprehensive understanding of how the intake of unprocessed red meat contributes to the development of early precancerous colorectal lesions, such as advanced colorectal adenomas (ACRAs), requires further investigation. We examined the associations between different types of red meat intake and ACRAs in a sample population of 1083 individuals aged ≥ 50 years undergoing an initial screening colonoscopy in Calgary, Alberta, Canada. Associations between grams per day of total, processed, and unprocessed red meat from diet history questionnaires and ACRAs were evaluated with multivariable logistic regression models. We also applied cubic spline models fitted with three knots (10th, 50th, and 90th percentiles) to identify potential nonlinear associations. We did not observe a meaningful association between unprocessed red meat intake and the presence of ACRAs. In contrast, for every 10 g/d increase in total and processed meat intake, we observed an increase in the odds of ACRAs at the screening colonoscopy (adjusted odds ratio (OR) = 1.05, 95% [CI = 1.01-1.09], p = 0.04) and (adjusted OR = 1.11, 95% [CI = 1.02-1.20], p = 0.02), respectively. This study highlights the importance of differentiating between types of red meat consumption in the context of dietary risks associated with ACRAs.

Exploring the Future of Cancer Impact in Alberta: Projections and Trends 2020-2040

The impact of cancer in Alberta is expected to grow considerably, largely driven by population growth and aging. The Future of Cancer Impact (FOCI) initiative offers an overview of the present state of cancer care in Alberta and highlights potential opportunities for research and innovation across the continuum. In this paper, we present a series of detailed projections and analyses regarding cancer epidemiological estimates in Alberta, Canada. Data on cancer incidence and mortality in Alberta (1998-2018) and limited-duration cancer prevalence in Alberta (2000-2019) were collected from the Alberta Cancer Registry. We used the Canproj package in the R software to project these epidemiological estimates up to the year 2040. To estimate the direct management costs, we ran a series of microsimulations using the OncoSim All Cancers Model. Our findings indicate that from 2020, the total number of annual new cancer cases and cancer-related deaths are projected to increase by 56% and 49% by 2040, respectively. From 2019, the five-year prevalence of all cancers in Alberta is projected to increase by 86% by 2040. In line with these trends, the overall direct cost of cancer management is estimated to increase by 53% in 2040. These estimates and projections are integral to future strategic planning and investment.

Real-world impact of patient-reported outcome measurement on overall survival, healthcare use and treatment discontinuation in cancer patients

Aim: The purpose of this retrospective, population-based, observational cohort analysis was to assess whether routine patient-reported outcomes (PRO) monitoring alone has an impact on real-world overall survival (OS) and hospitalizations among individuals diagnosed with lung, breast or colorectal cancer. The importance of follow-up care in post-PRO data collection was also discussed. Patients & methods: Administrative databases covering 17 cancer centers from Alberta, Canada were queried and individuals ≥18 years old and diagnosed with lung, breast or colorectal cancer from 1 January 2016 to 31 December 2019 were included and followed until 31 December 2020. Patients were stratified by whether they received routine PRO monitoring initiated within 120 days of diagnosis and matched 1:1 with use of propensity scores based on baseline characteristics. OS was assessed from the index date to death, and the respective Kaplan-Meier curves were estimated along with hazard ratios from Cox Proportional Hazard Models. Linear and logistic regression models were used to estimate mean differences and odds ratios (OR) respectively for healthcare resource utilization events including cancer physician visits, emergency department visits and outpatient ambulatory care encounters. Results: 4800 patients were included in each matched cohort. There was no statistically significant difference between PRO monitoring and non-monitoring cohorts in OS (HR = 1.01; 95% CI: 0.93-1.09; p = 0.836) and treatment discontinuation (OR = 0.98; 95% CI: 0.85-1.12; p = 0.75). Median OS was 51.5 months for unmonitored cohort (95% CI: 47.5-NA) versus 50.6 months for monitored cohort (95% CI: 47.6-55.7). Compared with PRO-monitored patients, unmonitored patients were associated with lower hospitalization risks (OR = 1.12; 95% CI: 1.03-1.22; p = 0.01). However, PRO-monitored patients experienced significantly fewer physician visits in comparison to unmonitored patients (MD = -1.036; 95% CI: -1.288 to -0.784, p < 0.001). Conclusion: Our results show that capturing patient-reported symptoms alone reduced the number of physician visits but neither reduced hospitalizations nor improved OS in this real-world cancer population. To drive more meaningful clinical impact, PRO monitoring programs must be met with rigorous follow-up response to the identified symptoms.

Beyond Participation: Evaluating the Role of Patients in Designing Oncology Clinical Trials

Historically, subject matter experts and healthcare professionals have played a pivotal role in driving oncology clinical trials. Although patients have been key participants, their deliberate and active contribution to the design and decision-making process has been limited. This scoping review aimed to examine the existing literature to scope the extent of active patient engagement in the design of oncology clinical trials and its corresponding influence on trial outcomes. We conducted a systematic search using two databases, namely MEDLINE (Ovid) and EMBASE, to identify relevant studies exploring patient engagement in cancer-related clinical research design. We identified seven studies that met the eligibility criteria. The studies highlighted the benefits of active patient involvement, such as improved recruitment strategies, and the attainment of more patient-centered trial outcomes. The influence of patient involvement varied from tangible developments like patient-friendly resources to indirect impacts like improved patient experiences and potentially higher adherence to trial intervention. The future of clinical trials should prioritize patients' values and perspectives, with regulatory bodies fostering these practices through clear guidelines. As the concept of patient centricity takes root in oncology research, the involvement of patients should evolve beyond mere participation.

Comparative Effectiveness of Lurbinectedin for the Treatment of Relapsed Small Cell Lung Cancer in the Post-Platinum Setting: A Real-World Canadian Synthetic Control Arm Analysis

BACKGROUND

Based on findings from a single-arm, phase 2 basket trial (NCT02454972), lurbinectedin may be an effective treatment for individuals with small cell lung cancer (SCLC) who progressed on or after platinum-based chemotherapy.

OBJECTIVE

To estimate the comparative effectiveness of lurbinectedin versus the historical standard of care for relapsed SCLC in Canada.

METHODS

A synthetic control arm (SCA) analysis was conducted using real-world data. Population-level data were obtained from real-world databases in Alberta, Canada. Individuals diagnosed with SCLC who initiated post-platinum systemic therapy and met approximated eligibility criteria from the lurbinectedin trial were included in the SCA. Median overall survival (OS) in the SCA was estimated after adjusting for chemotherapy-free interval (CTFI; < 90 versus ≥ 90 days) and stage at initial diagnosis (extensive versus limited). The CTFI-adjusted hazard ratio was estimated using a Cox proportional hazards model.

RESULTS

One hundred seventy-four individuals were included in the SCA and 105 in the lurbinectedin trial. The adjusted median OS in the SCA was 6.1 months (95% CI 5.4-7.7 months; unadjusted: 6.7 months, 95% CI 6.0-7.7 months) versus 9.3 months (95% CI 6.3-11.8 months) in the lurbinectedin trial. The adjusted hazard ratio comparing lurbinectedin with the historical standard of care (referent group) was 0.61 (95% CI 0.45-0.82; unadjusted HR: 0.72; 95% CI 0.54-0.97). The hazard ratio was more pronounced among individuals with CTFI ≥ 90 days (HR: 0.49, 95% CI 0.33-0.73).

CONCLUSION

These findings suggest improved OS with lurbinectedin monotherapy versus the historical standard of care in Alberta, Canada.

Pan-Canadian survey on the impact of the COVID-19 pandemic on cervical cancer screening and management: cross-sectional survey of healthcare professionals

Background: The COVID-19 pandemic has caused disruptions to cancer care by delaying diagnoses and treatment, presenting challenges and uncertainties for both patients and physicians. We conducted a nationwide online survey to investigate the effects of the pandemic and capture modifications, prompted by pandemic-related control measures, on cervical cancer screening-related activities from mid-March to mid-August 2020, across Canada.

Methods: The survey consisted of 61 questions related to the continuum of care in cervical cancer screening and treatment: appointment scheduling, tests, colposcopy, follow-up, treatment of pre-cancerous lesions/cancer, and telemedicine. We piloted the survey with 21 Canadian experts in cervical cancer prevention and care. We partnered with the Society of Canadian Colposcopists, Society of Gynecologic Oncology of Canada, Canadian Association of Pathologists, and Society of Obstetricians and Gynecologists of Canada, which distributed the survey to their members via email. We reached out to family physicians and nurse practitioners via MDBriefCase. The survey was also posted on McGill Channels (Department of Family Medicine News and Events) and social media platforms. The data were analyzed descriptively.

Results: Unique responses were collected from 510 participants (16 November 2020 - 28 February 2021), representing 418 fully- and 92 partially- completed surveys. Responses were from Ontario (41.0%), British Columbia (21.0%), and Alberta (12.8%), and mostly comprised family physicians/general practitioners (43.7%), and gynecologist/obstetrician professionals (21.6%). Cancelled screening appointments were mainly reported by family physicians/general practitioners (28.3%), followed by gynecologist/obstetrician professionals (19.8%), and primarily occurred in private clinics (30.5%). Decreases in the number of screening Pap tests and colposcopy procedures were consistently observed across Canadian provinces. About 90% reported that their practice/institution adopted telemedicine to communicate with patients.

Conclusions: The area most severely impacted by the pandemic was appointment scheduling, with an important level of cancellations reported. Survey results may inform resumptions of various fronts in cervical cancer screening and management.

Funding: The present work was supported by the Canadian Institutes of Health Research (operating grant COVID-19 May 2020 Rapid Research Funding Opportunity VR5-172666 Rapid Research competition and foundation grant 143347 to Eduardo L. Franco). Eliya Farah and Rami Ali each received a MSc. stipend from the Department of Oncology, McGill University.

The impact of lag time to cancer diagnosis and treatment on clinical outcomes prior to the COVID-19 pandemic: A scoping review of systematic reviews and meta-analyses

Background

The COVID-19 pandemic has disrupted cancer care, raising concerns regarding the impact of wait time, or 'lag time', on clinical outcomes. We aimed to contextualize pandemic-related lag times by mapping pre-pandemic evidence from systematic reviews and/or meta-analyses on the association between lag time to cancer diagnosis and treatment with mortality- and morbidity-related outcomes.

Methods

We systematically searched MEDLINE, EMBASE, Web of Science, and Cochrane Library of Systematic Reviews for reviews published prior to the pandemic (1 January 2010-31 December 2019). We extracted data on methodological characteristics, lag time interval start and endpoints, qualitative findings from systematic reviews, and pooled risk estimates of mortality- (i.e., overall survival) and morbidity- (i.e., local regional control) related outcomes from meta-analyses. We categorized lag times according to milestones across the cancer care continuum and summarized outcomes by cancer site and lag time interval.

Results

We identified 9032 records through database searches, of which 29 were eligible. We classified 33 unique types of lag time intervals across 10 cancer sites, of which breast, colorectal, head and neck, and ovarian cancers were investigated most. Two systematic reviews investigating lag time to diagnosis reported different findings regarding survival outcomes among paediatric patients with Ewing's sarcomas or central nervous system tumours. Comparable risk estimates of mortality were found for lag time intervals from surgery to adjuvant chemotherapy for breast, colorectal, and ovarian cancers. Risk estimates of pathologic complete response indicated an optimal time window of 7-8 weeks for neoadjuvant chemotherapy completion prior to surgery for rectal cancers. In comparing methods across meta-analyses on the same cancer sites, lag times, and outcomes, we identified critical variations in lag time research design.

Conclusions

Our review highlighted measured associations between lag time and cancer-related outcomes and identified the need for a standardized methodological approach in areas such as lag time definitions and accounting for the waiting-time paradox. Prioritization of lag time research is integral for revised cancer care guidelines under pandemic contingency and assessing the pandemic's long-term effect on patients with cancer.

Funding

The present work was supported by the Canadian Institutes of Health Research (CIHR-COVID-19 Rapid Research Funding opportunity, VR5-172666 grant to Eduardo L. Franco). Parker Tope, Eliya Farah, and Rami Ali each received an MSc. stipend from the Gerald Bronfman Department of Oncology, McGill University.

Report from the Ready for the Next Round Thought-Leadership Roundtables on Building Resilience in Cancer Care and Control in Canada-Colorectal Cancer Canada; 2021

(1) Background: The COVID-19 pandemic illuminated vulnerabilities in the Canadian health care system and exposed gaps and challenges across the cancer care continuum. Canada is experiencing significant disruptions to cancer-related services, and the impact these disruptions (delays/deferrals/cancellations) have on the health care system and patients are yet to be determined. Given the potential adverse ramifications, how can Canada’s health care systems build resilience for future threats? (2) Methods: To answer this question, CCC facilitated a series of four thought-leadership roundtables, each representing the views of four different stakeholder groups: patients, physicians, health care system leaders, and researchers. (3) Results: Six themes of strength were identified to serve as a springboard for building resilience including, (1) advancing virtual care and digital health technologies to prevent future interruptions in cancer care delivery. (2) developing real-time data metrics, data sharing, and evidence-based decision-making. (3) enhancing public–private-non-profit partnerships to advance research and strengthen connections across the system. (4) advancing patient-centricity in cancer research to drive and encourage precision medicine approaches to care. (5) investing in training and hiring a robust supply of health care human resources. (6) implementing a national strategy and infrastructure to ensure inter-provincial collaborative data sharing (4). Conclusions: A resilient health care system that can respond to shocks and threats is not an emergency system; it is a robust everyday system that can respond to emergencies.

A Review of Canadian Cancer-Related Clinical Practice Guidelines and Resources during the COVID-19 Pandemic

(1) Background: Preventive measures taken in response to the coronavirus disease 2019 (COVID-19) pandemic have adversely affected an entire range of cancer-related medical activities. The reallocation of medical resources, staff, and ambulatory services, as well as critical shortages in pharmaceutical and medical supplies have compelled healthcare professionals to prioritize patients with cancer to treatment and screening services based on a set of classification criteria in cancer-related guidelines. Cancer patients themselves have been affected on multiple levels, and addressing their concerns poses another challenge to the oncology community. (2) Methods: We conducted a Canada-wide search of cancer-related clinical practice guidelines on the management and prioritization of individuals into treatment and screening services. We also outlined the resources provided by Canadian cancer charities and patient advocacy groups to provide cancer patients, or potential cancer patients, with useful information and valuable support resources. (3) Results: The identified provincial guidelines emphasized cancer care (i.e., treatment) more than cancer control (i.e., screening). For cancer-related resources, a clear significance was placed on knowledge & awareness and supportive resources, mainly relating to mental health. (4) Conclusion: We provided a guidance document outlining cancer-related guidelines and resources that are available to healthcare providers and patients across Canada during the COVID-19 pandemic.

[Secondary eyelid pockets: Pitfalls in blepharoplasty surgery]

INTRODUCTION

Requests for cosmetic eyelid surgery are frequent. The surgeon must carry out a complete clinical examination in order to rule out any orbital pathologies responsible for eyelid pockets.

METHODS

Study of ten patients who have consulted in the oculopalpebral surgery department of La Fondation Ophtalmologique de Rothschild for cosmetic surgery of the eyelid pockets and in whom an underlying pathology was diagnosed.

RESULTS

The clinical examination allows to look for signs of alarms, such as medical history, unilateral involvement, pain and the presence of exophthalmos. These should lead to perform orbital imaging and surgical biopsy if an orbital mass has been identified for histological analysis which will make the diagnosis. We identified four cases of orbital lymphoma, one foreign body granuloma, chronic bilateral dacryoadenitis, sarcoidosis involvement, AAPOX syndrom, cavernous hemangioma, and simple fatty hernia.

CONCLUSION

These cases shows the importance of not ignoring an underlying orbital pathology before proposing cosmetic surgery for eyelid pockets.

A triple-drug nanotherapy to target breast cancer cells, cancer stem cells, and tumor vasculature

Triple-negative breast cancer (TNBC) is the most aggressive subtype of breast cancer, accounting for the majority of breast cancer-related death. Due to the lack of specific therapeutic targets, chemotherapeutic agents (e.g., paclitaxel) remain the mainstay of systemic treatment, but enrich a subpopulation of cells with tumor-initiating capacity and stem-like characteristics called cancer stem cells (CSCs); thus development of a new and effective strategy for TNBC treatment is an unmet medical need. Cancer nanomedicine has transformed the landscape of cancer drug development, allowing for a high therapeutic index. In this study, we developed a new therapy by co-encapsulating clinically approved drugs, such as paclitaxel, verteporfin, and combretastatin (CA4) in polymer-lipid hybrid nanoparticles (NPs) made of FDA-approved biomaterials. Verteporfin is a drug used in the treatment of macular degeneration and has recently been found to inhibit the Hippo/YAP (Yes-associated protein) pathway, which is known to promote the progression of breast cancer and the development of CSCs. CA4 is a vascular disrupting agent and has been tested in phase II/III of clinical trials. We found that our new three drug-NP not only effectively inhibited TNBC cell viability and cell migration, but also significantly diminished paclitaxel-induced and/or CA4-induced CSC enrichment in TNBC cells, partially through inhibiting the upregulated Hippo/YAP signaling. Combination of verteporfin and CA4 was also more effective in suppressing angiogenesis in an in vivo zebrafish model than single drug alone. The efficacy and application potential of our triple drug-NPs were further assessed by using clinically relevant patient-derived xenograft (PDX) models. Triple drug-NP effectively inhibited the viability of PDX organotypic slide cultures ex vivo and stopped the growth of PDX tumors in vivo. This study developed an approach capable of simultaneously inhibiting bulk cancer cells, CSCs, and angiogenesis.

Lactoferrin plus health education versus total dose infusion (TDI) of low-molecular weight (LMW) iron dextran for treating iron deficiency anemia (IDA) in pregnancy: a randomized controlled trial

BACKGROUND

Iron deficiency anemia (IDA) is one of the most common medical disorder disturbing pregnancies particularly in low resources countries, and contributes significantly to morbidities and mortalities. Thus, early diagnosis and prompt management of IDA is highly recommended.

AIM

To Test the efficacy and safety of oral lactoferrin plus health education provided by a nurse versus total dose infusion (TDI) of low-molecular weight (LMW) iron dextran for treating IDA in the second and third trimester of pregnancy.

DESIGN

A prospective interventional, randomized, parallel-group, single-center longitudinal study.

SETTING

Woman's Health Assiut University Hospital, Assiut, Egypt, at the outpatient clinic and inpatient unit. It comprised 120 cases divided into two groups as pineapple flavored lactoferrin oral sachets 100 mg twice daily with health education (group A) and TDI of LMW iron dextran (group B).

MAIN OUTCOME MEASURES

The primary efficacy parameter was clinical improvement and the amount of increase in hemoglobin concentration by 4 weeks after therapy, secondary outcome measures included measurement of the rest of RBC, and iron indices, the adverse effects related to iron therapy and the patient compliance to the treatment.

RESULTS

There was insignificant difference between both groups regarding sociodemographic data, parity and mean gestational age. Both groups showed a significant clinical improvement of anemia 4 weeks post-therapy. There was no statistically significant difference in mean Hb level improvement in both groups after 1 month of therapy. However, mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) improved significantly more in group B than A while iron indices (serum iron and serum ferritin) were significantly more in group A than group B.

CONCLUSIONS

Pineapple flavored lactoferrin oral sachets plus health education can be widely used as an alternative to TDI iron dextran supplementation due to clinical as well as laboratory improvement of IDA during pregnancy after 1 month of treatment. Proper health education of the pregnant women with nurse recommendations of balanced diet containing good sources of iron would increase awareness of pregnant women and help eradicate IDA with its serious sequel during pregnancy.

Delivery of MicroRNAs by Chitosan Nanoparticles to Functionally Alter Macrophage Cholesterol Efflux in Vitro and in Vivo

The prevention and treatment of cardiovascular diseases (CVD) has largely focused on lowering circulating LDL cholesterol, yet a significant burden of atherosclerotic disease remains even when LDL is low. Recently, microRNAs (miRNAs) have emerged as exciting therapeutic targets for cardiovascular disease. miRNAs are small noncoding RNAs that post-transcriptionally regulate gene expression by degradation or translational inhibition of target mRNAs. A number of miRNAs have been found to modulate all stages of atherosclerosis, particularly those that promote the efflux of excess cholesterol from lipid-laden macrophages in the vessel wall to the liver. However, one of the major challenges of miRNA-based therapy is to achieve tissue-specific, efficient, and safe delivery of miRNAs in vivo. We sought to develop chitosan nanoparticles (chNPs) that can deliver functional miRNA mimics to macrophages and to determine if these nanoparticles can alter cholesterol efflux and reverse cholesterol transport in vivo. We developed chNPs with a size range of 150-200 nm via the ionic gelation method using tripolyphosphate (TPP) as a cross-linker. In this method, negatively charged miRNAs were encapsulated in the nanoparticles by ionic interactions with polymeric components. We then optimized the efficiency of intracellular delivery of different formulations of chitosan/TPP/miRNA to mouse macrophages. Using a well-defined miRNA with roles in macrophage cholesterol metabolism, we tested whether chNPs could deliver functional miRNAs to macrophages. We find chNPs can transfer exogenous miR-33 to naïve macrophages and reduce the expression of ABCA1, a potent miR-33 target gene, both in vitro and in vivo, confirming that miRNAs delivered via nanoparticles can escape the endosomal system and function in the RISC complex. Because miR-33 and ABCA1 play a key role in regulating the efflux of cholesterol from macrophages, we also confirmed that macrophages treated with miR-33-loaded chNPs exhibited reduced cholesterol efflux to apolipoprotein A1, further confirming functional delivery of the miRNA. In vivo, mice treated with miR33-chNPs showed decreased reverse cholesterol transport (RCT) to the plasma, liver, and feces. In contrast, when efflux-promoting miRNAs were delivered via chNPs, ABCA1 expression and cholesterol efflux into the RCT pathway were improved. Over all, miRNAs can be efficiently delivered to macrophages via nanoparticles, where they can function to regulate ABCA1 expression and cholesterol efflux, suggesting that these miRNA nanoparticles can be used in vivo to target atherosclerotic lesions.

Combining Multiple Magnetic Resonance Imaging Sequences Provides Independent Reproducible Radiomics Features

To evaluate the relative contribution of different Magnetic Resonance Imaging (MRI) sequences for the extraction of radiomics features in a cohort of patients with lacrimal gland tumors. This prospective study was approved by the Institutional Review Board and signed informed consent was obtained from all participants. From December 2015 to April 2017, 37 patients with lacrimal gland lesions underwent MRI before surgery, including axial T1-WI, axial Diffusion-WI, coronal DIXON-T2-WI and coronal post-contrast DIXON-T1-WI. Two readers manually delineated both lacrimal glands to assess inter-observer reproducibility, and one reader performed two successive delineations to assess intra-observer reproducibility. Radiomics features were extracted using an in-house software to calculate 85 features per region-of-interest (510 features/patient). Reproducible features were defined as features presenting both an intra-class correlation coefficient ≥0.8 and a concordance correlation coefficient ≥0.9 across combinations of the three delineations. Among these features, the ones yielding redundant information were identified as clusters using hierarchical clustering based on the Spearman correlation coefficient. All the MR sequences provided reproducible radiomics features (range 14(16%)−37(44%)) and non-redundant clusters (range 5–14). The highest numbers of features and clusters were provided by the water and in-phase DIXON T2-WI and water and in-phase post-contrast DIXON T1-WI (37, 26, 26 and 26 features and 14,12, 9 and 11 clusters, respectively). A total of 145 reproducible features grouped into 51 independent clusters was provided by pooling all the MR sequences. All MRI sequences provided reproducible radiomics features yielding independent information which could potentially serve as biomarkers.

Plk1 phosphorylation of Numb leads to impaired DNA damage response

Although Numb is well-recognized as a cell-fate determinant in stem/progenitor cells, accumulating evidence supports that Numb also has a critical role in adult tissues and cancers, in particular, in the context of regulation of tumor suppressor p53. Herein, we identified Numb as a novel substrate of Polo-like kinase 1 (Plk1). Of significance, we showed that Plk1-mediated phosphorylation of Numb leads to its enhanced proteasomal degradation and impaired Numb/p53 pathway, thus providing another mechanism how Plk1 antagonizes p53 during DNA damage response. In addition, the novel phosphorylation event identified by us further supports the notion that post-translational modifications of Numb uncouple Numb from p53 and lead to p53 destabilization. Finally, our data generated from both human cancer cell lines and mouse xenograft model showed that cancer cells carrying the unphosphorylated form of Numb by Plk1 are more sensitive to doxorubicin, a classical chemotherapeutic drug. Therefore, our work may provide future strategies for improving the efficacy of chemotherapy by targeting Numb phosphorylation by Plk1.

Dérivation pancréaticojéjunale dans le traitement des pancréatites chroniques

INTRODUCTION

The aim of this retrospective study was to evaluate the immediate and long-term outcome of pancreaticojejunostomy (PJ) in the treatment of chronic pancreatitis. MATERIAL AND METHODS. - From 1980 to 1997, 140 patients with chronic pancreatitis with dilated Wirsung duct were treated by PJ and were studied retrospectively. There were 123 men and 17 women, with a mean age of 46 years (range: 18-79 years). Ongoing alcoholic addiction was present in 116 patients (83%). Chronic pain uncontrolled by major analgesics was the indication of PJ in 126 patients (90%).

RESULTS

The mortality rate was 1.4% (n = 2). The morbidity rate was 11% (n = 16). Mean hospital stay was 16 days (range: 8-25 days). The mean follow-up was 7.4 years (range: 2-15 years) in 94 patients. Functional results were good or mild in 93% of cases (n = 87). In seven patients (7%), the results were bad with persistence of chronic pain requiring major analgesics. A mean weight increase of 5.8 kg (range: 1-16 kg) was observed in 74 patients (79%). Twelve patients (13%) developed de novo diabetes mellitus. In the 43 patients with preoperative diabetes, 24 patients suffered deterioration of their status. No patient recovered from exocrine insufficiency.

CONCLUSIONS

In case of dilated Wirsung, PJ must be indicated preferentially because of its good efficiency on pain relief with low mortality and morbidity rates.

[Monitoring expired oxygen fraction in preoxygenation of patients with chronic obstructive pulmonary disease]

OBJECTIVES

To compare the rate of preoxygenation before induction of anesthesia in patients with no lung disease and in patients with chronic obstructive pulmonary disease (COPD).

PATIENTS AND METHODS

End-tidal fractional oxygen concentration (FEO2) was monitored using a paramagnetic oxygen analyzer, during a 5 minute-period of preoxygenation (tidal breathing of 100% oxygen) in 16 control patients (control group) and in 15 patients with COPD. COPD was defined and its severity was characterized by clinical criteria and by respiratory functional tests. FEO2 increase was compared between groups using Anova.

RESULTS

The increase in FEO2 was slower in the COPD group than in control group (p < 0.05). After 2 and 3 minutes of preoxygenation, FEO2 was significantly lower in COPD group as compared to control group, but was not different at 5 minutes. Mean time to reach a FEO2 equal to 0.90 was significantly longer in COPD than in control group (COPD: 261 +/- 130 s; control: 165 +/- 90 s, p < 0.05). SpO2 measured during room air breathing was moderately lower in COPD group, but this difference was no more significant after 30 s of preoxygenation (SpO2 after 30 s: control: 98.8 +/- 1.0%; COPD: 98.2 +/- 1.9%, NS).

CONCLUSION

These results suggest that preoxygenation monitoring may be useful in patients with COPD, to ensure adequate preoxygenation is achieved.

[Vertebral actinomycosis: case report and review of the literature]

In this article, the case of a 32-year-old man with a paravertebral actinomycosis is discussed. Initially, the diagnosis was not obvious but it was confirmed later with the repetitive radiologic procedures, the elimination of other etiologies (purulent, mycobacterial or mycotic infections and neoplasia) and the biopsy. Treatment with penicillin initially and then with tetracycline for a long term led to a very good outcome at a 3-year follow-up with a radiologic remission. Following the discussion of the case, a review of the literature concerning the paravertebral actinomycosis, its diagnostic clues and treatment is undertaken.

[Interference between a dual-chamber pacemaker and argon electrocautery device during hepatectomy]

We report an unusual electromagnetic interference induced by an argon electrocautery device during a left hepatectomy on a dual chamber pacemaker, implanted for sinus node dysfunction in 87-year-old patient. Argon electrocautery induced inhibition of atrial stimulation and occurrence of irregular ventricular triggered activity. Normal pacemaker function resumed after electrocautery interruption. This case illustrates the need to focus on cardiac rhythm when a new electrical device is used in a pacemaker patient.

End-tidal oxygraphy during pre-oxygenation in patients with severe diffuse emphysema

We hypothetised that the rate of pre-oxygenation could be altered by the increase in lung volume and airflow obstruction observed in emphysema. End-tidal oxygen concentration was monitored, using a paramagnetic oxygen analyser, during 10-min pre-oxygenation (tidal breathing of 100% oxygen) in 10 normal patients and in 10 patients with severe diffuse emphysema documented by computerised tomography. Emphysema was characterised by an important increase in functional residual capacity of the lungs [190 (23)% of predicted values] and a decrease in expiratory flow. The increase in end-tidal oxygen concentration was slower in the emphysema group than in the control group (p = 0.0024). After 3 and 5 min of pre-oxygenation, the end-tidal fractional oxygen concentration was significantly lower in the emphysema group than the control group [mean (SD); value at 3 min: emphysema: 0.83 (0.06) vs. control: 0.91 (0.02), p = 0.0005]. Individual values of end-tidal oxygen concentration measured after 3, 5 and 10 min of pre-oxygenation were negatively correlated with functional residual capacity in the emphysema group, whereas no such correlation was found in the control group. These results suggest that pre-oxygenation should be monitored in patients with diffuse emphysema to ensure that adequate pre-oxygenation is achieved.

[Pseudo-Takayasu in Behcet's disease]

Behcet's disease is a chronic multisystem vasculitis that is frequent in Lebanon. The great arteries involvement is rare. We report here an unusual case of subclavian artery occlusion (pseudo-Takayasu) with a literature review.

Guidelines for perioperative cardiac evaluation from the American College of Cardiology/American Heart Association task force are effective for stratifying cardiac risk before aortic surgery

PURPOSE

We assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) task force guidelines for perioperative cardiac evaluation could reliably stratify cardiac risk before aortic surgery.

METHODS

We retrospectively applied the guidelines to a closed database, set up prospectively. The setting was a referral center in an institutional practice with hospitalized patients. The closed database included 133 patients who had a routine cardiac examination, which comprised an estimation of functional capacity and noninvasive testing, before aortic surgery. This cardiac evaluation led to the proposal of coronarography in 23 patients and to treating an underlying coronary artery disease in 21 patients (including three myocardial revascularizations). One patient died after myocardial revascularization, and two patients died of cardiac causes after aortic surgery. The algorithm of the ACC/AHA guidelines was applied independently by two investigators to each patient's file that was included in the existing database. The main outcome measure was a comparison between cardiac risk stratification with the ACC/AHA guidelines and the results of the routine cardiac evaluation.

RESULTS

The ACC/AHA guidelines were successfully applied to all 133 files by the two investigators. After applying the algorithm, 73 patients were stratified as low cardiac risk, and 60 patients were stratified as high risk. The 21 patients who had undergone a preoperative coronary artery disease optimization were stratified as high risk by means of the ACC/AHA guidelines. The patients who died from cardiac causes were stratified as high risk by means of the ACC/AHA guidelines, whereas none of the patients stratified as low risk died during hospitalization.

CONCLUSION

The ACC/AHA guidelines were effective in stratifying cardiac risk by using clinical predictors and an estimate of the physical capacity of the patient. Their use may allow a reduction in unnecessary noninvasive testing in patients stratified as being at low risk, while permitting the selection of all patients likely to benefit from preoperative coronary artery disease optimization.

Acute cocaine intoxication in a smuggler. One case report and a review of the literature

The smuggling of cocaine into many countries by ingestion of wrapped cocaine packets and gastro-intestinal concealment is a common and well-recognized practice. This is a report of the case of a smuggler carrying 14 ingested packets of cocaine and who presented an acute intoxication with a rare complication, rhabdomyolysis, which were managed medically and the packets removed surgically. A discussion and a review of the literature are undertaken.

Placebo-controlled study of inhaled nitric oxide to treat hypoxaemia during one-lung ventilation

The aim of this prospective, placebo-controlled study was to assess if unilaterally inhaled nitric oxide 20 ppm could treat hypoxaemia during one-lung ventilation. Sixty patients undergoing pulmonary resection using a lateral thoracotomy were allocated randomly to a control or nitric oxide group (NO group). During one-lung ventilation in the lateral decubitus position, the lungs were ventilated mechanically with 90% oxygen--10% nitrogen. After randomization, if PaO2 decreased to less than 9.3 kPa during one-lung ventilation, nitric oxide 20 ppm or nitrogen was added to the inspired gas. The criterion for treatment efficacy was an increase in PaO2 to greater than 9.3 kPa after gas administration. Eight patients in the control group and eight in group NO experienced hypoxaemia during one-lung ventilation. PaO2 was not significantly different in the two groups at the time of gas administration (control group mean 8.0 (SD 0.6) kPa; NO group 8.5 (0.5) kPa). The efficacy criterion was reached in two of eight patients in the control and NO groups. The results of this study showed that inhaled nitric oxide 20 ppm, administered in the dependent lung, was not superior to nitrogen in the treatment of hypoxaemia during one-lung ventilation. Nitric oxide should not be recommended as an alternative to conventional management of hypoxaemia in this condition.

[Prognosis of reoperation for prosthesis dysfunction]

Between 1969 and 1990, 75 adults living in mainland France underwent reoperation for bioprosthetic valve dysfunction. The average time between the initial operation and reoperation was 65 +/- 41 months. The average age was 44 years and half of the patients were severely symptomatic (NYHA Stages III or IV in half the cases). Dysfunction of an aortic valve prosthesis was observed in 65% of cases (N = 49) and of a mitral valve prosthesis in 35% of cases (N = 26). The causes of reoperation were: 50 primary degenerations (67%), 19 infectious endocarditis (25%) and 6 perivalvular leaks (8%). Valve replacement was performed in 74 cases and suture of the sewing ring in 1 case. An associated procedure was performed in 24 cases: 12 drainage of abscess, 10 double valve replacements and 2 tricuspid valvuloplasties. The operative mortality was 9.3% and early morbidity was 46%. Univariate and multivariate analysis identified two factors predictive of operative mortality: the duration of cardiopulmonary bypass and the cardiothoracic ratio. During follow-up, which lasted 36 +/- 31 months, there were 12 deaths, 4 of cardiac failure; 4 sudden deaths, 3 deaths related to the prosthesis and 1 extracardiac death. The 6 year actuarial survival rate was 71%. The cardiothoracic ratio, the preoperative ejection fraction and the bypass time were factors predictive of global showed bypass time and the cardiothoracic ratio to be prognostic factors. The 6 year survival without cardiac events was 40%.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis of left atrial thrombi in mitral stenosis--usefulness of ultrasound techniques compared with other methods

The purpose of this study was to evaluate various methods of diagnosis of left atrial thrombi (LAT) in patients (pts) with mitral stenosis (MS). From 1980 to 1990, 581 pts with MS have undergone open mitral commissurotomy (n = 169) or valve replacement (n = 412). All pts had transthoracic 2D echocardiography (TTE), 101 transoesophageal echocardiography (TEE), 192 a left atrial angiography (A) (from a left ventricular injection if associated mitral regurgitation grade 3 (n = 154) or from an injection in the pulmonary artery (n = 38) and 229 a coronary angiography (CA). Tomodensitometry (TD), nuclear magnetic resonance (NMR) and 111 Indium platelet imaging (IPI) were performed in some cases, 2, 8 and 5 respectively. All these examinations were carried out in the month before surgery. LAT was found by the surgeon in 43 pts (7%). The site was left atrial appendage in 26 cases (60%) and left atrial cavity in 17 cases. Sensitivity (Se), specificity (Sp) of TTE/TEE/A/CA were the following: TTE, Se% 28, Sp% 99; TEE, Se% 83, Sp% 97; A, Se% 28, Sp% 99; CA, Se% 14, Sp% 100. Specificity was high with all methods but sensitivity was high only with TEE and poor with other methods because of difficulty in detecting thrombi of the left atrial appendage. Specificity and sensitivity of TD, NMR and IPI require more information. False-negative cases are possible with NMR (1 case) and IPI (1 case) in well established LAT. We conclude: TEE is the easiest way to detect LAT, particularly when located in the left atrial appendage. It should be carried out systematically before percutaneous mitral valvuloplasty or surgery.

Treatment of calcified aortic stenosis: surgery or percutaneous transluminal aortic valvuloplasty?

A total of 546 patients with severe aortic stenosis (AS) were retrospectively reviewed to assess the efficacy of percutaneous transluminal valvuloplasty (PTV) and valve replacement (VR). Of these, 490 underwent VR between 1968 and 1986 (mean age 62 +/- 12 years, 71.7% were in NYHA class III or IV), 68.8% received mechanical prostheses, and in 11.8% a bypass graft was associated. The operative mortality was 6.9% (4% since 1983). The mean follow-up was 57.6 months. The actuarial survival rate was 77% at five years, 60% at 10 years, and 40% at 15 years. Over 70 years of age, operative mortality was 6.2% since 1983, and the actuarial survival rate was 67.5% at five years. From February 1986 to May 1987, PTV was attempted in 56 patients and was effective in 52 patients (mean age 79 +/- 5 years, 93% in Class III or IV). Immediate mortality was 7.1%. The morbidity was due to tamponade (1.8%), myocardial infarction (3.6%), vascular trauma (5.3%), or cerebrovascular accident (9%). Forty three patients were followed after PTV (mean value 4.2 +/- 3, range 1-14 months): 12 patients (28%) died and 46% were functionally improved in NYHA Class II. PTV significantly improved the aortic valve area as shown by haemodynamics (0.49-0.75 cm2; P less than 0.0001) and these findings were corroborated by Doppler study (0.46-0.70 cm2, P less than 0.001). In conclusion, this series shows that surgery provides satisfactory results in AS with a low mortality and good long-term results, even in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)

Plasma beta-thromboglobulin in patients with valvular heart disease with or without valve replacement: relationship with thromboembolic accidents

Plasma beta-thromboglobulin (BTG) was measured in 132 patients with valvular heart disease: 43 were studied before, 89 after surgery (78 mechanical valves and 11 bioprostheses). In this group of 89 selected patients, a history of thromboembolism was present in 53 (5 of them had bioprosthesis). Some abnormalities have been observed in patients with valvular heart disease as compared with controls: decreased platelet count and retention on glass column, and increased BTG. There is no statistically significant difference in BTG level between patients with (m +/- SD: 62.4 +/- 42.0 ng ml-1), or without (59.5 +/- 41.0 ng ml-1) a prosthesis; in the small series of 11 patients with a bioprosthesis, BTG was slightly lower than in other patients (44.5 +/- 14.1 ng ml-1), but still higher than in controls (26.8 +/- 13.3 ng ml-1). In the patients with a history of thromboembolism, BTG was significantly higher (66.7 +/- 47.9 ng ml-1 than in patients without this complication (49.9 +/- 21.0 ng ml-1). Thus, BTG evaluation may have some value in valvular heart disease but, at present, it should be confined to systematic research including prospective studies.

Recurrent systemic embolic events with valve prosthesis

Among 1436 patients who underwent valve replacement, the 400 first cases were studied to assess the features of recurrent systemic embolic event. The mean follow-up was 87 months. Three groups of patients were compared: groups A-289 patients without any thromboembolic event (72.25%); group B-78 patients with only one embolic event (19.5%); group C-33 patients with several embolic events (8.25%). The frequency of recurrence was high: one patient out of three (linearized mean 8.9% in group C considering only one recurrence, vs 3.8% in group B). The recurrence have the same location in 45% of patients. The consequences of these embolisms are serious; each event has a 30 to 40% risk of death or major disability. Four variables seem statistically to promote the occurrence of embolic events: mitral prostheses, pre-operative fibrillation, left atrial enlargement, poor anticoagulant therapy. 54 months after the first embolic event, 60% of the patients with poor anticoagulant therapy experience a recurrent thromboembolism vs 20% with adequate therapy. Twenty-six patients of groups B and C had a pathological study of prostheses. Thrombosis of the prostheses was found in 12 out of 18 patients in group B and in 7 out of 8 patients; in group C. Strict observance of anticoagulant therapy is the better way to prevent thromboembolism and especially recurrences. A reoperation is sometimes necessary. Valve re-replacement was performed in 27 cases out of 1436 patients.

Thromboembolic and haemorrhagic risk in mechanical and biological aortic prostheses

Thromboembolism, valve thrombosis and haemorrhagic events have been compared in 356 Starr-Edwards (SE) 1260, 113 Björk-Shiley (BS), and 178 aortic bioprostheses operated upon between 1968 and 1982, and reviewed by the same group with less than 2% of patients lost of follow-up. Expressed in actuarial rate at 7 years the percentage of patients free of thromboembolism event is 87% for SE, 86% for BS, 94% for bioprostheses; the linearized rate is 2.9%/patient/year for SE, 2.2 for BS, 1.9 for bioprostheses (NS). Valve thrombosis was not observed in bioprostheses; 97.9% of patients with mechanical valves were free of valve thrombosis at 6.5 years. Haemorrhagic risk was lower with bioprostheses than with mechanical valves 0.2% patient/year vs 2.33 (P less than 0.005). The most important factor influencing thromboembolic and haemorrhagic risks is the quality of anticoagulant therapy. Other contributing factors are the date of the operation and associated mitral disease.

[Late thrombosis of mitral valve prosthesis in 27 cases]

Twenty seven cases of late thrombosis of ball and floating or tilting disc prostheses were studied. All patients were on anticoagulant therapy which appeared to be well adapted in 33% patients. Signs suggestive of thrombosis were inconsistant and the diagnosis was made on the association of severl of the following features: -- systemic embolism (44%); -- radiographic signs of left ventricular failure (51%); -- absence of opening click, variable A2 -- opening click intervals, apparition or aggravation of a systolic regurgitant murmur or a distolic murmur suggestive of obstruction on the phonocardiogramme; -- delayed opening of the mobile component or the presence of abnormal echos between the ball and anterior cage echo on the echocardiogramme; -- a gradient of over 12 mmHg across the prosthesis. An isolated episode of systemic embolism when the rest of the work-up is negative may be managed by the addition of a platelet antiaggregant and reinforcement of the anticoagulant therapy; further investigaton is advisable in the face of progressive symptoms. Fibrinolytic treatment and/or surgery is justified when systemic emboli recur or if the work-up is positive.