External validation of biochemical recurrence definition to predict oncologic outcomes following focal therapy for localized prostate cancer using high intensity focused ultrasound

PURPOSE

This is an external validation of several biochemical recurrence definitions based on prostate specific antigen criteria (PSA). The purpose is to predict the need of additional treatment and failure after focal therapy using high intensity focused ultrasound (HIFU) for localized prostate cancer (PCa).

MATERIALS AND METHODS

A total of 343 consecutive patients who underwent HIFU with Ablatherm® and Focal One® devices between June 2001 and November 2020 were identified. Treatment failure was defined as clinically significant PCa on postoperative biopsy, the need for salvage radical or systematic treatment, metastasis, or PCa-related death. The biochemical recurrence definitions tested were PSA nadir, time to PSA nadir, percentage of PSA reduction, Huber et al. criteria defined as PSA nadir + 1 ng/mL at 12 months or PSA nadir + 1.5 ng/mL at 24-36 months. Multivariable Cox regression analysis and decision-curve analysis were used to validate and compare criteria. Kaplan-Meier analysis was used to assess criteria associated with the highest accuracy.

RESULTS

One hundred seventy-eight patients met the inclusion criteria and were analyzed. Overall, 61 (34%) and 41 (23%) patients had an additional treatment and failure with a median follow-up of 52 months. At multivariable analysis, model including Huber et al. criteria exhibited the highest Harrell's C-index for the prediction of the need of additional treatment (hazard ratio [HR]: 10, p < 0.001, c-index: 84%) and treatment failure (HR: 9.1, p < 0.001, c-index: 82%) as well as higher net benefit. The 60-months need of additional treatment and treatment failure-free survival were 89% and 98% compared to 26% and 49%, respectively, when stratified according to Huber et al. criteria (Log-rank test, p < 0.001). Similar results were found after excluding patient with non-clinically significant PCa at initial biopsy.

CONCLUSIONS

We report an external validation of biochemical recurrence definitions predicting the need of additional treatment and failure after focal therapy using HIFU for localized PCa. Huber et al. criteria were identified as the most accurate and could be used to guide clinicians toward further evaluation and salvage treatments.

Un nouveau Cas d’Anomalie constitutionnelle et familiale du Fibrinogène sans Diathese hémorragique

A new family with congenital dysfibrinogenemia without bleeding tendency has been discovered in Nancy. Identical laboratory abnormalities were found in the mother and son plasma: prolongation of thrombin and reptilase clotting time.

The abnormal fibrinogen affects, only a little, the normal plasma fibrinoformation.

The functional characterization of the defect is localized in fibrin monomer aggregation. The release of fibrinopeptides is normal.

The abnormal fibrinogen shows

a) an alteration in glucidic moiety of the molecule with a high level of sialic acid,

b) an disturbance of chromatography on D. E. A. E. cellulose and

c) of the electrophoretic mobility.

Epinephrine administration in non-shockable out-of-hospital cardiac arrest

BACKGROUND

Epinephrine is recommended for the treatment of non-shockable out of hospital cardiac arrest (OHCA) to obtain return of spontaneous circulation (ROSC). Epinephrine efficiency and safety remain under debate.

OBJECTIVE

We propose to describe the association between the cumulative dose of epinephrine and the failure of ROSC during the first 30 min of advanced life support (ALS).

METHODOLOGY

A retrospective observational cohort study using the Paris SAMU 75 registry including all non-traumatic OHCA. All OHCA receiving epinephrine during the first 30 min of ALS were enrolled. Cumulative epinephrine dose given during ALS to ROSC was retrieved from medical reports.

RESULTS

Among 1532 patients with OHCA, 776 (51%) had initial non-shockable rhythm. Fifty-four patients were excluded for missing data. The mean value of cumulative dose of epinephrine was 10 ± 4 mg in patients who failed to achieve ROSC (ROSC-) and 4 ± 3 mg (p = 0.04) for those who achieved ROSC. ROC curve analysis indicated a cut-off point of 7 mg total cumulative epinephrine associated with ROSC- (AUC = 0.89 [0.86-0.92]). Using propensity score analysis including age, sex and no-flow duration, association with ROSC- only remained significant for epinephrine > 7 mg (p ≤10-3, OR [CI95] = 1.53 [1.42-1.65]).

CONCLUSION

An association between total cumulative epinephrine dose administered during OHCA resuscitation and ROSC- was reported with a threshold of 7 mg, best identifying patients with refractory OHCA. We suggest using this threshold in this context to guide the termination of ALS and early decide on the implementation of extracorporeal life support or organ harvesting in the first 30 min of ALS.

Energy saving in flight formation

Many species of large bird fly together in formation, perhaps because flight power demands and energy expenditure can be reduced when the birds fly at an optimal spacing, or because orientation is improved by communication within groups. We have measured heart rates as an estimate of energy expenditure in imprinted great white pelicans (Pelecanus onocrotalus) trained to fly in 'V' formation, and show that these birds save a significant amount of energy by flying in formation. This advantage is probably a principal reason for the evolution of flight formation in large birds that migrate in groups.

Development of electronic personal neutron dosemeters: a European cooperation

The European Commission recently sponsored an international research and development project, in which three 'active' personal neutron dosemeters were developed. Comparative irradiation experiments showed good results with respect to sensitivity and energy dependence of the response.

Hemorheological and hemostatic parameters in children with nephrotic syndrome undergoing steroid therapy

Disturbances in hemostatic and hemorheological parameters have been investigated in a group of 29 children with nephrotic syndrome: 23 children classified as steroid-sensitive and 6 as steroid-resistant. Studies were performed before prednisone treatment and 3 weeks later, after initiation of steroid therapy. Before treatment, the alterations in hemostatic system involved moderate thrombocytosis with spontaneous aggregation in 19 patients. High levels of fibrinogen, factor VIII, Willebrand factor, protein C, protein S and alpha 2-macroglobulin (alpha 2M) were observed. Factor XII and alpha 1-antitrypsin (alpha 1AT) were lower than normal. Antithrombin III (ATIII) level was normal in the majority of patients. A plasma and blood hyperviscosity syndrome was also observed as well as an increase in erythrocyte aggregation. During treatment, an improvement in the hemostatic parameters was observed in the patients who responded to prednisone. The expected increase in factor VIII (frequently described in the literature) was not observed, while there was a significant increase in protein C. In the steroid-resistant patients, the only significant changes observed were decreased fibrinogen and increased protein C. The hemorheological parameters showed a tendency towards normality regardless of whether or not the treatment provided remission of NS. The relationship between hemorheological and hemostatic factors changes are discussed.

Interlaboratory evaluation of methods for the assay of Protein C in purified concentrates

Determination of the quantity and activity of the Protein C molecule is of the utmost importance in highly purified concentrates prepared for replacement therapy. A multicenter study was undertaken to evaluate the comparability and accuracy of Protein C assays from commercial sources. Significant between-assay and interlaboratory differences were found for both functional and immunological assays. The interlaboratory variability is explained in part by the use of different control plasmas. The results also indicate the importance of the diluent used. This study emphasizes the need for standardized methods for determining the characteristics of Protein C concentrates.

[Which assessment of coagulation, for which operation?]

Patient's bleeding history is an important part of preoperative evaluation but must be associated with hemostatic tests. The choice in between these different hemostatic tests will be made according to the knowledge of the bleeding history and; the type of surgery planned. In case of hemostatic abnormality, additional tests can be performed in order to determine a more precise state of the patient's hemostatic dysfunction. However, complete preoperative hemostatic evaluation (including patient's bleeding history and blood tests) may not entirely avoid per and post-operative hemostatic complications. Indeed, there is no absolute correlation between hemostatic screening and bleeding or thrombosis risks. Some other factors, completely independent from hemostatic function, such as shock, surgical bleeding, anoxia... may intervene.

[Immunological status of hemophiliacs: study of blood T-lymphocyte populations, serum immunoglobulins, and the prevalence of anti-LAV antibodies]

Blood T-lymphocyte subsets and serum immunoglobulin levels were studied in a group of 52 haemophiliacs (44 patients with haemophilia A and 8 patients with haemophilia B). None of the patients had AIDS or belonged to any AIDS high-risk group. Patients were exclusively treated with clotting fractions obtained from healthy volunteers in metropolitan France. As compared to a group of 52 normal donors, haemophiliacs had increased numbers of suppressor lymphocytes, which resulted in depressed helper/suppressor (H/S) ratios, and increased levels of serum IgG and IgA. 21 haemophiliacs (40,3%) had a H/S ratio less than 1.4. Among patients with haemophilia A a higher mean IgG level was found in patients presenting lymphadenopathy. Decreased mean H/S ratio and increased mean serum IgG level were found in patients receiving more than 50 000 U of factor VIII during the 2 years preceding the study. No striking difference in mean serum IgG, IgA and IgM levels was found in patients with haemophilia A when H/S ratios were higher and lower than 1.4 respectively. As AIDS and immunological abnormalities among haemophiliacs probably share a common viral origin, this study emphasize the need to discourage blood donation from donors who belong to any AIDS high-risk group, and to screen sera from the blood donor population for antibodies to LAV/HTLV III.

Prevalence of antibodies to lymphadenopathy-AIDS virus in French haemophiliacs

49 French haemophiliacs (haemophilia A: 41 patients; haemophilia B: 8 patients) were serologically testes for lymphadenopathy-AIDS virus antibodies: 10 patients (20.4%) were seropositive including 9 (21.9%) with haemophilia A and 1 (12.5%) with haemophilia B. Among haemophiliacs A, seropositive patients received significantly larger amounts of factor VIII concentrate during the 2 years preceding the study.

[Prevalence of anti-LAV antibodies in hemophiliacs, correlation with the immunological state]

49 french haemophiliacs (haemophilia A: 41 patients; haemophilia B: 8 patients) were serologicaly tested for LAV antibodies: 10 patients (20.4%) were seropositive including 9 (21.9%) with haemophilia A and 1 (12,5%) with haemophilia B. Between seronegative and seropositive patients total lymphocyte and T-lymphocyte sub-populations counts were not significantly different. The mean serum IgG level was higher and palpable lymphadenopathy more frequently encountered among seropositive patients.

[Blood T lymphocyte populations in the hemophiliac]

We have studied a group of 31 hemophiliac patients (hemophilia A: 26 patients, hemophilia B: 5 patients); 29 healthy men were used as controls. Hemophiliac patients had increased percentages of suppressor T-lymphocytes and depressed T4/T8 ratios. These abnormalities were found to be significantly correlated with the amount of F VIII used per year.

[Practical value of the determination of urinary fibrin degradation products in the early management of renal transplants]

We studied daily urinary excretion of fibrin degradation products (UFDP) during the first month following renal transplantation in 31 patients using the Merskey technique. After the 48 first hours a rise of UFDP was observed in 3 circumstances: 1) acute rejection: twenty-four acute rejections were observed in twenty-two patients. The increase of UFDP was constant. It preceeded the clinical diagnosis of rejection in 63 p. 100 of the patients. It has a predictive value in all cases. 2) Severe urinary infection. In 5 patients with urologic complications UFDP rose markedly. 3) Macroscopic hematuria. In 2 patients with gross hematuria very high rates of excretion were observed.

[Practical interest of the determination of urinary fibrin degradation products in the early monitoring of kidney transplants]

We studied daily urinary excretion of fibrin degradation products (UFDP) during the first month following renal transplantation in 31 patients using the Merskey technique. Passed the 48 first hours a rise of UFDP was observed in 3 circumstances: 1) acute rejection: twenty four acute rejections were observed in twenty two patients. The increase of UFDP was constant. It preceded the clinical diagnosis of rejection in 63 p. 100 of the patients. It has a predictive value in all cases. 2) Severe urinary infection. In 5 patients with urologic complications UFDP rose markedly. 3) Macroscopic hematuria. In 2 patients with gross hematuria very high rates of excretion were observed.

HLA typing in a new family with Fletcher factor deficiency

In a nonrelated white family, the Fletcher factor level in the father was 0.41 U/ml and in the mother, 0.30 U/ml (controls, 0.75-1.25 U/ml). One sibling with recurrent epistaxis had a level of 0.012 U/ml, whereas the other without tendency to spontaneous bleeding had levels between 0.75 and 0.32 U/ml. This suggests autosomal recessive transmission with clinical symptoms when the defect is homozygous. HLA antigens were studied to determine whether characters of the histocompatibility system and this defect are linked: we determined that the gene(s) of the disease is (are) not shared on the HLA complex.

Bond strength of three orthodontic adhesives

A method was devised to study the bond strength of direct-bonding orthodontic adhesives. A shear load was applied parallel to the tooth-adhesive-bracket interface by means of an Instron Universal Testing Machine. The bond strength was found to increase for some products after 27 days. However, no significant differences could be detected 1 day after placement. The interface was studied to determine the mode of failure. In all cases bond failure occurred as mixed adhesive-cohesive phenomena.

Recurring thrombo-embolic accidents caused by family-related deficiency of the fibrinolysis system

Several members of the same family underwent examinations on the coagulation and fibrinolysis systems after recurring thrombo-embolic disease was observed in one of the members of the family. The results of biological examinations revealed normal coagulation factors, but a high level of plasminogen activation inhibitors accompanied by an increase in platelet aggregation was observed. These results are compared with the few similar cases reported by other authors. The exact part played in this particular case by the platelets and the inhibitor in the patient's predisposition to venous thrombosis and the spread of the disease is discussed. It would seem that the platelet abnormality merely accompanys the increase in inhibitors which is passed on by recessive autosomal transmission. The authors consider that in all cases of thrombosis, particularly recurring thrombosis, an investigation, comprising a study of the fibrinolysis factors and particularly the inhibitors, must be carried out on the patient's close family.

[Acquired coagulation inhibitors. 10 cases (author's transl)]

A circulating anticoagulant with antiprothrombinase activity was detected in 10 patients, 4 of whom had systemic lupus erythematosus. Clinically, haemorrhages occurred only in patients with associated thrombopenia; some developed thrombosis. Recalcification time and activated partial thromboplastin time were prolonged in the patients' plasma and in mixed patients' and control plasma. In 5 cases the anticoagulant was isolated by chromatography as IgG or IgM.

[Systemic lupus erythematosus manifested by thrombophlebitis of the lower limbs]

The diagnosis of systemic lupus erythematosus was made in a 9 year old boy who had presented two months earlier with an extensive thrombosis of the inferior vena cava and femoral veins. Haemostatic abnormalities were detected as follows: a moderate thrombocytopenia, increased platelet aggregation and stickiness, and a circulating anticoagulant (antithromboplastin).

[Acute renal failure and consumption coagulopathy in the puerperium]

Disseminated intravascular coagulation accompanied 18% of cases of acute renal failure during puerperal disorders. We studied in particular 31 cases of disseminated intravascular coagulation with renal failure due to obstetric disorders : 12 post-abortion infections, 3 retentions of a dead foetus, 5 infections, 6 cases of toxemia, 2 retroplacental hemorrhages, two hemorrhages during the third stage, one uremohemolytic syndrome. For diagnosis one relies on the clinical data (bleeding, purpura, shock, hemolysis, visceral involvement) and laboratory data, (coagulation should be supervised throughout the course). The renal lesions are either cortical necrosis, or interstitial nephritis. The analogies with experimental phenomena suggest a human equivalent of the Schwartzmann-Sanarelli syndrome.

[Heat stroke and disseminated intravascular coagulation. Apropos of 2 cases]

Two cases of fatal heat stroke, concerning a 20 year-old soldier and a 44 year-old psychiatric patient, treated with neuroleptics, are reported. The clinical picture, starting suddenly with coma and hyperthermia, was quite identical for both. Secondarily, while hyperthermia decreases and the conscience improved partially, an hemorrhagic syndrome similar to a consumption coagulopathy, acute renal insufficiency and acute hepatic failure appear. Death occurred after aggravated neurological disorders and respiratory distress. The anatomical lesions spread on all the viscera include tubular nephritis, and hepatic centro-lobular necrosis and an interstitial and alveolar oedema with hemorrhages and hyaline membranes in the lungs.

[Acute consumption coagulopathies. 120 cases]

Consumption coagulopathy is frequently observed in a resuscitation department. 120 cases of various etiologies are reviewed: complications of pregnancy (61 cases), infections (23 cases) or various stresses: acute hemolysis, shock, severe hepatic failure, intoxications, acidosis, heat-stroke... Consumption coagulopathy is intricated with the general stress which induces it, and with the visceral lesions induced by the stress and which can be aggravated by the consumption coagulopathy. The state of shock is observed in 76% of the cases, the haemorrhagic syndrome in 73%. Acute hemolysis and the clinical signs evocative of disseminated intravascular coagulation (cutaneous signs) are more rare. Following the initial manifestations, visceral complications may develop: renal, hepatic, respiratory, neurological, digestive. The evolution of the biology must be carefully studied. The diagnosis is made on both clinical and biological data. Etiological and pathophysiological treatment should be carried out. In our series, controlled and adapted heparin therapy was given systematically.

[Consumption coagulopathy and acidosis in the diabetic patient (author's transl)]

Four cases of intravascular coagulation associated with a state of acidosis in diabetics were observed in 57 patients with diabetic acidosis and 19 with lactic acidosis, in a series of 112 cases of consumption coagulopathy admitted to a department of medical resuscitation. In three cases the coagulopathy was found only on investigation; in one there were clinical and anatomic signs. The coagulopathy may be found either during the phase of recovery from ketoacidosis, or during the course of severe lactic acidosis, particularly during a recurrence of this form of acidosis. In spite of the unfavorable outcome in 3 of the 4 cases, the abnormal findings of coagulopathy reverted toward normal along with successful metabolic corrections. The factors responsible for consumption coagulopathy are acidosis, collapse, generalised systemic reactions and alterations of platelet function, of coagulation, of the balance between fibrin deposition and lysis and of lipid levels, all characteristic of diabetes. The clinical effects of this coagulopathy seldom become apparent but provide a possible explanation of some of the complications of diabetic ketoacidosis, particularly certain hemorrhagic or thrombotic events, as well as certain visceral complications, especially those affecting renal, pulmonary and cerebral areas.

[Study of the osmotic behaviour of human platelets]

Observation of the behaviour of platelets in hypotonic media affords an approach to the evaluation of their fragility. It should be possible to apply such a test to various fields such as the study of rheological properties of platelets, the investigation of certain pathological cases and eventual alterations during storage. The curve obtained reflects a continuous distribution of platelet osmotic fragility.

[Capillary blood coagulation in the healthy premature newborn]

Blood coagulation of healthy premature newborns, since birth, was studied for 45 days by a method of capillary blood sampling in a plastic tube. The most often measured clotting factors allowed to establish control coagulation times for the tests performed in premature sick infants. In this study, the clotting factors were identical in at-term and premature children. Vitamin-K dependent factors showed the most important deficits; however, at birth their levels seemed higher in at-term newborns. They reached control values after one month, with a progressive evolution. The other blood-clotting factors were normal.