Evaluation of the relevance of the growth modulation index (GMI) from the FFCD 0307 randomized phase III trial comparing the sequence of two chemotherapeutic regimens

BACKGROUND

Precision medicine trials disrupted the paradigm of randomized controlled trials in large populations. Patient selection may be based on molecular alterations rather than on primary tumor location. In small patient populations, the growth modulation index (GMI) has been developed to evaluate treatment efficacy by using each patient as its own control. The FFCD 0307 randomized phase III trial compared two sequences of chemotherapy in advanced gastric cancer, which represents a unique opportunity to evaluate the relevance of the GMI.

PATIENTS AND METHODS

In the FFCD 0307 trial, patients with advanced gastric cancer were randomized between two chemotherapy sequences [ECX followed by FOLFIRI at disease progression (arm A) versus FOLFIRI followed by ECX (arm B)]. GMI was defined as the ratio of the progression-free survival on second treatment (PFS2) to the time to progression on first treatment (TTP1). Sequence benefit was defined as a GMI exceeding 1.3 (GMI-high). GMI was correlated with overall survival (OS). OS1 and OS2 were measured from first randomization and second-line failure to death.

RESULTS

Four hundred and sixteen patients were randomized (209 in arm A, 207 in arm B). One hundred and seventy-five patients (42%) received the two sequences and were assessable for GMI (97 in arm A, 79 in arm B). The median GMI was higher in arm A than in arm B (0.62 versus 0.47, P = 0.04). Patients with a high GMI had a longer OS1 (median 14.9 versus 11.5 months, NS). Median OS2 was doubled in the GMI-high group (3.4 versus 1.6 months, NS).

CONCLUSION

GMI analyses suggest that ECX followed by FOLFIRI might represent a better therapeutic strategy than FOLFIRI followed by ECX. High GMI was associated with prolonged survival.

Pediatric private practice in the Nord-Pas-de-Calais region: Demographics, organization, and challenges

While the needs for pediatric care are increasing and becoming more diverse, pediatric private practice in France is encountering difficulties linked to a growing medical demographic deficit. The objective of this study was to give an overview of pediatric private practice in the Nord-Pas-de-Calais region and to describe the main challenges encountered.

METHODS

For this descriptive observational survey, private practice pediatricians in the Nord-Pas-de-Calais region filled out an online questionnaire between April 2019 and October 2020.

RESULTS

The response rate was 64%. Most respondents practiced in an urban area (87%) and shared the practice with other physicians (59%). A majority (85%) had previously worked in hospital; 65% reported training in a subspecialty. Overall, 48% had other professional activities; 28% worked night shifts and 96% accepted urgent requests for consultations. A total of 33% reported having difficulties contacting specialists for consults, and 46% had difficulties in obtaining written reports of their patients' hospitalizations. All respondents participated in a form of ongoing medical education. The main difficulties were: lack of information about how to found a private practice (68%), lack of personal time (61%), balance between medical and administrative work (59%), and an excess of patients to care for (57%). The main satisfactions were: trusting relationships with patients (98%), freedom in their choice of practice (85%), and the diversity of problems and situations encountered (68%).

CONCLUSION

Our study underlines that private practice pediatricians are involved in healthcare provision, in particular regarding ongoing medical training, subspecialties, and continuity of care. It also highlights the problems encountered and the possible improvements: developing better communication between private practice and hospitals, reinforcing training during residency, and highlighting the importance and complementarity of private practice in children's healthcare.

Characteristics and outcomes of patients presenting with out of hospital cardiac arrest to a regional hospital

Funding Acknowledgements

Type of funding sources: None.

Introduction

Out of hospital cardiac arrest (OHCA) carries a high rate of mortality and can be due to cardiac or non-cardiac causes. We reviewed consecutive patients presenting with OHCA to the emergency department of a regional hospital in Australia, between January 2019 and March 2022. Medical records were reviewed to assess presenting rhythm, final diagnosis, risk factors known at time of presentation, results of cardiac investigations and survival to hospital discharge.

Results

Over the study period, 107 patients presented with cardiac arrest, with an average age of 67 years (range 29 to 95 years). Most patients were male (70, 67%), although in those with a non-cardiac cause identified only 53% were male. An underlying cardiac cause was identified in 50 (47%), a non-cardiac cause was identified in 18 (17%), and 39 (36%) had no identifiable cause. The most common cardiac causes were ST-elevation myocardial infarction (18, 36%), followed by non-ischaemic cardiomyopathy (9, 18%) and scar-related arrhythmia (7, 14%). Overall, ischaemic heart disease was responsible for 31 (62%) cases. Coronary angiography was performed in 36 (72%) of cardiac cases. Those who were diagnosed with ST-elevation myocardial infarction had an average time from presentation to coronary angiography of 61 minutes while the average was 38 hours for all patients presenting with OHCA. The most common presenting rhythm was ventricular fibrillation (39, 38%). The overall mortality rate was 61% for all OHCA. Among those with a cardiac cause, a non-cardiac cause or no cause identified for the OHCA, the mortality rates were 32%, 87% and 87% respectively. Data published by the regional Ambulance Service show that the survival to discharge from hospital of 39% in our regional hospital is comparable with state-wide outcomes.

Discussion

These data reflect the significant mortality and wide spectrum of disease underlying OHCA, and thus the challenge of managing patients presenting with OHCA. Cardiac disease accounts for almost half of all cases of OHCA, and also encompasses a wide spectrum of disease. However, the mortality in patients with OHCA due to an underlying cardiac cause, while still significant, is better than those patients in whom no cardiac cause is identified.

Characterizing and predicting the relationship between translaminar fracture toughness and pull-out length distributions under distinct temperatures

The translaminar fracture toughness reflects the damage tolerance of a fibre-reinforced composite under longitudinal tension, which often governs the final failure of structures. One of the main energy-dissipation mechanisms that contributes to the translaminar toughness of composites is the fibre pull-out process. The present study aims to quantify and model the statistical distribution of fibre pull-out lengths formed on the translaminar fracture surface of composites, for the first time in the literature; this is done under different temperatures, so that the relationship between pull-out length distributions, micromechanical properties and the translaminar fracture toughness can be established. The fracture surfaces of cross-ply compact tension specimens tested under three different temperatures have been scanned through X-ray computed tomography to quantify the extent of fibre pull-out on the fracture surfaces; the distribution of pull-out lengths showed alarger average and larger variability with an increase in temperature, which also lead to an increase in translaminar fracture toughness. A similar trend has been captured by the proposed analytical model, which predicts the pull-out length distribution based on the analysis of quasi-fractal idealizations of the fracture surface, yielding an overall accuracy of more than 85%. This article is part of the theme issue 'Ageing and durability of composite materials'.

Technology Usage and Impacts by COVID-19 among Patients in a Radiation Oncology Clinic

Purpose/Objective(s)

Mobile devices provide platforms for consistent and real time symptom tracking for cancer patients, allowing for better symptom reporting and more timely interventions. There is limited research investigating barriers to adoption within the oncology setting and COVID-19 impacts on patent willingness to use health technology. Understanding these issues is key to successful development and implementation. We designed a survey to assess patient willingness and barriers to using mobile devices to report/track symptoms (e-report).

Materials/Methods

Two cohorts of adult patients completed a 21-question anonymized survey. The survey was administered to clinic patients before (PRE) and 18mo after (POST) the start of the COVID pandemic. Three additional questions were added to POST survey to investigate impacts from COVID. Demographics, technology usage, willingness to report data, barriers to utilization, and changes due to COVID were evaluated using descriptive statistics. Predictors of willingness to e-report, barriers to use, and changes due to the COVID-19 pandemic were analyzed using univariate and multivariate logistic regression (MVA).

Results

318 patients completed the survey (PRE= 144 patients; POST= 174 patients) with mean age 65y, 75% Caucasian, 55% male. Altogether, 75% used a smart phone (PRE=66.7%; POST=81.3%; p 0.003), 90% reported home internet access (PRE=87.5%; POST=91.4%; p 0.259), 86% used a computer (PRE=79.2%; POST=90.8%; p 0.004), and 26% used a wearable health tracker (PRE 25.7%; POST 26.4%; p 0.881). On MVA, age>65 (OR 0.32; p 0.001), annual income>50K (OR 2.16; p 0.032), smart phone ownership (OR 4.07; p 0.000), and new/current patient status (OR 2.15; p 0.020) were all significant factors impacting willingness to e- report. Limited tech literacy (p 0.024) and time commitment (p 0.048) were the only significant barriers. Privacy as a barrier was greater in PRE vs POST cohort (OR 2.3 vs OR 1.1) trending toward significance. Nearly all modes of tech usage were greater in POST vs PRE cohort. POST cohort was significantly more willing to e- report (81.1% vs 69.1%; OR 1.91; p 0.016). This remained significant on MVA after adjusting for age, concern for privacy, tech literacy, and patient status (OR 1.88; p 0.026). Furthermore, 51% of POST cohort reported the pandemic directly influenced their willingness to e-report (40% more, 11% less).

Conclusion

Radiation oncology patients are willing to use mobile technology to report symptoms. Willingness increases with decreasing age, increasing annual income, smartphone ownership, and new/current patient status. Significant barriers include tech literacy and time commitment. Post-pandemic patients are more willing to e-report and list fewer barriers. The COVID-19 pandemic appears to have had a positive impact on technology usage by patients. Efforts to develop and test mobile applications for this population are justified.

Differences in antimicrobial susceptibility testing complicating management of IMP carbapenemase-producing Enterobacterales infection

OBJECTIVES

IMP-type carbapenemases are rarely detected in Europe and limited information is available to guide the treatment of infections caused by carbapenemase-producing Enterobacterales (CPE) producing these carbapenemases. Accurate antimicrobial susceptibility testing (AST) results are essential for optimal antibiotic management. Here we report discrepancies in AST of IMP-producing Enterobacterales (IMP-CPE) complicating the management of severe sepsis.

METHODS

Antimicrobial susceptibilities were analysed by in-house VITEK® 2, Etest and broth microdilution (BMD). Carbapenemase-encoding genes were detected by PCR. Whole-genome sequencing (WGS) was performed using an Illumina MiSeq platform.

RESULTS

Minimum inhibitory concentrations (MICs) determined by VITEK® 2 for Enterobacter hormaechei and Klebsiella oxytoca blood culture isolates were ≥16 mg/L for meropenem and ≤0.5 mg/L for ertapenem. In contrast, Etest analysis and BMD returned MICs of 2 mg/L and 1 mg/L, respectively. Both isolates tested positive for IMP carbapenemase-encoding genes by PCR. WGS revealed that both isolates carried the same bla_IMP-4 gene. Based on VITEK® 2 susceptibilities, initial treatment was with tigecycline and amikacin. After subsequent deterioration, the patient was successfully treated with ertapenem and amikacin.

CONCLUSION

This case highlights that automated AST by VITEK® 2 can over-report meropenem resistance for IMP carbapenemase-producers compared with Etest and BMD. Clinicians need to be cautious deciding against carbapenem treatment based on VITEK® 2 susceptibility testing results for IMP-positive Enterobacterales. Tigecycline was inferior to carbapenem treatment for pyelonephritis caused by isolates expressing IMP carbapenemases, however specific evidence guiding the treatment of these infections is lacking.

Cyclophosphamide and prednisolone for chemotherapy naïve B cell multicentric lymphoma in dogs: 32 cases (2017-2021)

OBJECTIVES

The aim of this study was to characterise the response rate and toxicity profile of cyclophosphamide and prednisolone given to dogs with newly diagnosed, chemotherapy naïve, B cell multicentric lymphoma.

MATERIALS AND METHODS

Dogs with diagnosed with B cell lymphoma naïve to chemotherapy treatment were prospectively identified at the author's institution (2017 to 2021) and given cyclophosphamide as their initial chemotherapeutic agent in combination with prednisolone with owner's consent. Signalment, laboratory findings, stage, treatment response and toxicity were recorded.

RESULTS

Thirty-two dogs were included in the study. The overall response rate in this population of dogs was 84%. Twenty dogs (62%) had a partial response, three dogs (9%) had a complete response, four dogs (12%) had stable disease and five dogs (15%) had progressive disease. Side effects were noted in 47% of patients, with neutropaenia being the most commonly reported.

CLINICAL SIGNIFICANCE

Cyclophosphamide and prednisolone were well-tolerated with limited side effects. The response rate observed in this cohort of dogs with chemotherapy-naïve B cell multicentric lymphoma is promising. Further comparative studies are required to confirm the safety and effectiveness of this intervention.

Séroprévalence SARS-Cov-2 chez les professionnels de santé : étude multicentrique avec analyse des facteurs de risque professionnels et extraprofessionnels

Introduction

L’objectif de notre étude était d’évaluer la séroprévalence SARS-Cov-2 chez les professionnels de santé, après la première vague Covid-19, et d’analyser les facteurs professionnels et extraprofessionnels modifiant cette prévalence.

Matériels et méthodes

Suite aux instructions gouvernementales proposant de réaliser une sérologie Covid-19 à tout professionnel de santé après la première vague, nous avons réalisé une étude transversale, multicentrique. Tous les professionnels volontaires des quatre centres participants étaient invités à réaliser une sérologie et à remplir un questionnaire concernant leurs données démographiques, leurs caractéristiques professionnelles, l’utilisation des équipements de protection individuelle et l’exposition extra professionnelle au Covid-19. Nous avons calculé la prévalence SARS-Cov-2 et utilisé une régression logistique en appliquant un effet centre.

Résultats

Un total de 3454 professionnels ont participé à l’étude dont 83,4 % de femmes. L’âge moyen était de 40,6 ans [31,8–50,3]. En médiane, la prévalence sérologique SARS-Cov-2 était de 5 % (95 % IC, 4,3 %–5,8 %). Les facteurs associés à une plus forte séroprévalence étaient : l’âge < 30 ans (aOR = 1,59, (95 % IC, 1,06–2,37)), le statut d’étudiant (aOR = 3,38, (95 % IC, 1,62–7,05)) avec une séroprévalence de 16,9 % dans cette catégorie. L’unité de travail, y compris le fait d’avoir travaillé en unité Covid ou en réanimation, ainsi que l’exposition à des patients (quel que soit leur statut infectieux) n’étaient pas associé à une augmentation de la séroprévalence. Par contre les professionnels rapportant un contact avec un patient Covid, sans protection adaptée, ou ayant pratiqué des taches aérosolisantes, y compris avec un masque FFP2, avaient un surrisque d’infection Covid-19 (respectivement aOR à 1,66 et 1,7). Enfin, l’exposition à un collègue infecté ou à un cas familial était également associée à une augmentation de la prévalence sérologique.

Conclusion

Les mesures mises en place pour limiter la transmission du SARS-Cov-2 des patients aux professionnels de santé semblent efficaces. En complément de la vaccination, l’éviction systématique des professionnels infectés, la formation des étudiants et le rappel des mesures d’hygiène durant les temps de pause pourraient limiter la contamination des professionnels de santé.

3D printing of face shields to meet the immediate need for PPE in an anesthesiology department during the COVID-19 pandemic

Background

Anesthesia providers are at risk for contracting COVID-19 due to close patient contact, especially during shortages of personal protective equipment. We present an easy to follow and detailed protocol for producing 3D printed face shields and an effective decontamination protocol, allowing their reuse.

Methods

The University of Nebraska Medical Center (UNMC) produced face shields using a combination of 3D printing and assembly with commonly available products, and produced a simple decontamination protocol to allow their reuse. To evaluate the effectiveness of the decontamination protocol, we inoculated bacterial suspensions of E. coli and S. aureus on to the face shield components, performed the decontamination procedure, and finally swabbed and enumerated organisms onto plates that were incubated for 12-24 hours. Decontamination effectiveness was evaluated using the average log10 reduction in colony counts.

Results

Approximately 112 face shields were constructed and made available for use in 72 hours. These methods were successfully implemented for in-house production at UNMC and at Tripler Army Medical Center (Honolulu, Hawaii). Overall, the decontamination protocol was highly effective against both E. coli and S. aureus, achieving a ≥4 log10 (99.99%) reduction in colony counts for every replicate from each component of the face shield unit.

Discussion

Face shields not only act as a barrier against the soiling of N95 face masks, they also serve as more effective eye protection from respiratory droplets over standard eye shields. Implementation of decontamination protocols successfully allowed face shield and N95 mask reuse, offering a higher level of protection for anesthesiology providers at the onset of the COVID-19 pandemic.

Conclusions

In a time of urgent need, our protocol enabled the rapid production of face shields by individuals with little to no 3D printing experience, and provided a simple and effective decontamination protocol allowing reuse of the face shields.

Retour d’expérience de deux structures d’urgences de centres hospitaliers généraux pendant la crise de la Covid-19

La Covid-19 s’est abattue sur l’Alsace en quelques jours, mettant à mal les hôpitaux de Mulhouse et de Colmar. Bien que proches, des différences notables existent au sein de ces deux structures en termes architecturaux et de ressources humaines. Comment cette vague a-t-elle modifié les organisations de chacun ? Quelles alternatives ont pu être mises en place ? Après la présentation de chaque site sont analysées les adaptations nécessaires afin d’absorber les flux de patients et leur proposer une prise en charge décente malgré des conditions parfois très dégradées. Nouvelles filières, modifications organisationnelles, renforts de personnel en interne puis en externe, augmentation capacitaire nette, recherches de solutions alternatives aux voies classiques d’approvisionnement des matériels… ont été une partie de la solution. Malgré les alertes du terrain, l’action nationale est restée en décalage de compréhension de la gravité de la situation locale, avec des recommandations et des actions soit inapplicables, soit trop tardives. Les établissements et professionnels de santé ont eu un sentiment d’isolement, renforcé par l’absence de représentant des tutelles et notamment de l’Agence régionale de santé sur le terrain. Deux éléments majeurs peuvent être mis en avant : une cohésion majeure de l’ensemble du centre hospitalier avec travail d’équipe et de terrain entre soignants et direction, et une implication de l’ensemble des acteurs de la médecine d’urgence (public, privé, libéraux, service départemental d’incendie et de secours) ; ils ont été les déterminants dans notre capacité à faire face à cet événement inédit.

Susceptibility (re)-testing of a large collection of Listeria monocytogenes from foods in China from 2012 to 2015 and WGS characterization of resistant isolates

OBJECTIVES

Our aim was to determine the antimicrobial susceptibilities of 2862 Listeria monocytogenes cultured from various foods in China and to use WGS to characterize the antimicrobial resistance and virulence genotypes of those expressing a resistance phenotype.

METHODS

The susceptibilities of 2862 L. monocytogenes were determined by broth microdilution. Twenty-eight L. monocytogenes were found to be resistant to one to four antibiotics. All 28 resistant isolates were subsequently sequenced using short-read high accuracy protocols. The corresponding genomes were assembled and further analysis was carried out using appropriate bioinformatics pipelines.

RESULTS

All 28 resistant L. monocytogenes were classified into five STs (ST3, ST8, ST9, ST155 and ST515). Both ST9 and ST155 were dominant and their genotypes correlated with their resistance phenotypes. All ST9 isolates were MDR and could be phylogenetically classified into two clusters. One was relatively close to clinical origins and one to food. Downstream analysis of the genetic contexts in which these resistance genotypes were found suggested that these may have been acquired from other bacteria by horizontal transfer or insertion into the chromosome. All isolates harboured Listeria pathogenicity island (LIPI)-1 and LIPI-2, and only two harboured LIPI-3.

CONCLUSIONS

This study reported on the antimicrobial susceptibilities of 2862 foodborne L. monocytogenes along with the genomic characterization of 28 resistant isolates, 11 of which expressed an MDR phenotype. These data showed that this bacterium can acquire resistance by horizontal gene transfer in and between species. This study may necessitate a re-evaluation of risk to public health, associated with this bacterial species.

The Secretion of Toxins and Other Exoproteins of Cronobacter: Role in Virulence, Adaption, and Persistence

: Cronobacter species are considered an opportunistic group of foodborne pathogenic bacteria capable of causing both intestinal and systemic human disease. This review describes common virulence themes shared among the seven Cronobacter species and describes multiple exoproteins secreted by Cronobacter, many of which are bacterial toxins that may play a role in human disease. The review will particularly concentrate on the virulence factors secreted by C. sakazakii, C. malonaticus, and C. turicensis, which are the primary human pathogens of interest. It has been discovered that various species-specific virulence factors adversely affect a wide range of eukaryotic cell processes including protein synthesis, cell division, and ion secretion. Many of these factors are toxins which have been shown to also modulate the host immune response. These factors are encoded on a variety of mobile genetic elements such as plasmids and transposons; this genomic plasticity implies ongoing re-assortment of virulence factor genes which has complicated our efforts to categorize Cronobacter into sharply defined genomic pathotypes.

Letrozole and palbociclib versus chemotherapy as neoadjuvant therapy of high-risk luminal breast cancer

Background

Palbociclib is a CDK4/6 inhibitor with demonstrated efficacy and safety in combination with endocrine therapy in advanced luminal breast cancer (LBC). We evaluated the respective efficacy and safety of chemotherapy and letrozole-palbociclib (LETPAL) combination as neoadjuvant treatment in patients with high-risk LBC.

Patients and methods

NeoPAL (UCBG10/4, NCT02400567) is a randomised, parallel, non-comparative phase II study. Patients with ER-positive, HER2-negative, Prosigna®-defined luminal B, or luminal A and node-positive, stage II-III breast cancer, not candidate for breast-conserving surgery, were randomly assigned to either letrozole (2.5 mg daily) and palbociclib (125 mg daily, 3 weeks/4) during 19 weeks, or to FEC100 (5FU 500 mg/m2, epirubicin 100 mg/m2, cyclophosphamide 500 mg/m2)×3 21-day courses followed by docetaxel 100 mg/m2×3 21-day courses. Primary end point was residual cancer burden (RCB 0-I rate). Secondary end points included clinical response, proliferation-based markers, and safety.

Results

Overall, 106 patients were randomised [median Prosigna® ROR Score 71 (22-93)]. RCB 0-I was observed in four and eight patients in LETPAL [7.7% (95% CI 0.4-14.9)] and chemotherapy [15.7% (95% CI 5.7-25.7)] arms, respectively. Pathological complete response rates were 3.8% and 5.9%. Clinical response (75%) and breast-conserving surgery rates (69%) were similar in both arms. Preoperative Endocrine Prognostic Index 0 scores (breast cancer-specific survival) were observed in 17.6% and 8.0% of patients in LETPAL and chemotherapy arms, respectively. Safety profile was as expected, with 2 versus 17 serious adverse events (including 11 grade 4 serious AEs in the chemotherapy arm).

Conclusion

LETPAL combination was associated with poor pathological response but encouraging clinical and biomarker responses in Prosigna®-defined high-risk LBC. Contemporary chemotherapy regimen was associated with poor pathological and biomarker responses, with a much less favourable safety profile. LETPAL combination might represent an alternative to chemotherapy in early high-risk LBC.

Clinical Trial Number

NCT02400567.

Association between hydroxychloroquine levels and disease activity in a predominantly Hispanic systemic lupus erythematosus cohort

OBJECTIVES

Hydroxychloroquine (HCQ) is a key therapy in systemic lupus erythematosus (SLE). Medication non-adherence is reported in up to 80% of lupus patients and results in increased morbidity, mortality, and health care utilization. HCQ levels are a sensitive and reliable method to assess medication adherence. Our study evaluated the role of HCQ level measurement in routine clinical care and its association with disease activity in a predominantly Hispanic population.

METHODS

SLE patients from the Columbia University Lupus cohort treated with HCQ for ≥ 6 months and reporting medication adherence were included. HCQ levels were measured by whole blood high performance liquid chromatography. Non-adherence was defined as an HCQ level <500 ng/ml. The association between HCQ levels and disease activity measured by Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2K) was evaluated.

RESULTS

One hundred and eight patients were enrolled; the median age was 38 years, 91% were female, and 63% were Hispanic. The median SLEDAI-2K was 4.3 (0-20). Forty-one percent of patients had an HCQ level <500 ng/ml consistent with non-adherence, of which 19% had undetectable levels. A higher SLEDAI-2K score was associated with low HCQ levels (p = 0.003). This association remained significant after adjusting for depression (p = 0.0007).

CONCLUSION

HCQ levels < 500 ng/ml were associated with higher disease activity and accounted for 32% of the SLEDAI-2K variability. HCQ blood measurement is a simple and reliable method to evaluate medication adherence in SLE. Reasons for non-adherence (levels < 500 ng/ml) should be further explored and addressed.

Prognostic factors in patients treated with second-line chemotherapy for advanced gastric cancer: results from the randomized prospective phase III FFCD-0307 trial

AIM

The aim of this study was to determine prognostic factors in patients treated with second-line therapy (L2) for locally advanced or metastatic gastric and gastro-esophageal junction (GEJ) adenocarcinoma in a randomized phase III study with predefined L2.

METHODS

In the FFCD-0307 study, patients were randomly assigned to receive in L1 either epirubicin, cisplatin, and capecitabine (ECX arm) or fluorouracil, leucovorin, and irinotecan (FOLFIRI arm). L2 treatment was predefined (FOLFIRI for the ECX arm and ECX for the FOLFIRI arm). Chi square tests were used to compare the characteristics of patients treated in L2 with those of patients who did not receive L2. Prognostic factors in L2 for progression-free survival (PFS) and overall survival (OS) were analyzed using a Cox model.

RESULTS

Among 416 patients included, 101/209 (48.3%) patients in the ECX arm received FOLFIRI in L2, and 81/207 (39.1%) patients in the FOLFIRI arm received ECX in L2. Patients treated in L2, compared with those who only received L1 had : a better ECOG score (0-1: 90.4% versus 79.7%; p = 0.0002), more frequent GEJ localization (40.8% versus 27.6%; p = 0.005), and lower platelet count (median: 298000 versus 335000/mm³; p = 0.02). In multivariate analyses, age < 60 years at diagnosis (HR 1.49, 95% CI 1.09-2.03, p = 0.013) and ECOG score 2 before L2 (HR 2.62, 95% CI 1.41-4.84, p = 0.005) were the only significant poor prognostic factors for OS.

CONCLUSION

Age ≥ 60 years at diagnosis and ECOG score 0/1 before L2 were the only favorable prognostic factors for OS.

Assessment of conversational pragmatics: A screening tool for pragmatic language impairment in a control population of children aged 6-12 years

Pragmatics can be defined as the way in which language is used to communicate in a given social context. Although there is a lack of a standardized assessment, healthcare professionals find themselves confronted with pragmatic language skill impairments in children with neurodevelopmental disorders or brain injuries. The characterization of language use causes problems in social interactions, which has clinical implications in daily life. However, this is still underestimated because there is currently no quick, easy-to-use screening device to rank these deficits. We have developed a pragmatic deficits screening chart that has been tested on a control population of children aged 6-12 years. The chart comprises 26 items exploring seven areas of pragmatics (intentionality, governance of exchange, organization of information, adaptation strategies, conversational implicit language, nonverbal skills, and paralinguistic aspects). Parents select one of four possible answers to describe how frequently their child demonstrates each type of behavior ("never, rarely, sometimes, often"). We distributed 1666 charts; 760 were returned, of which 552 could be analyzed. Internal consistency as measured with Cronbach's alpha coefficient (0.88) was satisfactory. There was no influence of age on total score, nor of the department/type of schooling. The population distribution was non-Gaussian so the results are presented in percentiles. We propose a first-line screening tool that is quick and easy to complete by family, which facilitates referral to specialists for further investigations into the etiological implications of pragmatic language impairment.

Daptomycin versus Vancomycin as Post-Operative Empirical Antibiotic Treatment for Prosthetic Joint Infections: A Case-Control Study

Purpose: To compare safety and efficacy of Vancomycin (Van) versus Daptomycin (Dap) as post-operative empirical antibiotic treatment (PEAT) in patients with periprosthetic joint infections (PJIs).

Methods: Medical charts of patients treated empirically with Van or Dap in the post-operative period of total hip/knee prosthesis septic revision until the results of intra-operative culture were reviewed. Cefotaxime, cefepime or aztreonam were used in combination with Dap or Van.

Results: Twenty Dap patients were matched with 20 other Van patients according to the age and type of prosthesis. The ASA score and the distribution of the pathogens was similar in the two groups especially regarding the number of methicillin-resistant staphylococci. The mean duration of the PEAT was 6.07 ± 0.85 days. A total of 17 episodes of adverse events (AE) in 10 patients (25%) were recorded during the PEAT which led to discontinue the treatment in 5 patients, all of them treated with Van (P=0.02). At the end of a mean post-treatment follow-up of 618 +/- 219 days, 36 patients remained in remission of infection; 2 patients failed in each group.

Conclusions: Our observations suggest that PEAT with Van for septic revision of PJIs is associated with a higher discontinuation rate due to AE but with a similar outcome than it is with Dap.

Increased Virulence of Bloodstream Over Peripheral Isolates of P. aeruginosa Identified Through Post-transcriptional Regulation of Virulence Factors

The factors influencing the virulence of P. aeruginosa in the development of invasive infection remain poorly understood. Here, we investigated the role of the host microenvironment in shaping pathogen virulence and investigated the mechanisms involved. Comparing seven paired genetically indistinguishable clinical bloodstream and peripheral isolates of P. aeruginosa, we demonstrate that isolates derived from bloodstream infections are more virulent than their peripheral counterparts (p = 0.025). Bloodstream and peripheral isolates elicited similar NF-kB responses in a THP-1 monocyte NF-kappaB reporter cell line implicating similar immunogenicity. Proteomic analysis by mass spectrometry identified multiple virulence and virulence-related factors including LecA and RpoN in significantly greater abundance in the bacterial supernatant from the bloodstream isolate in comparison to that from the corresponding peripheral isolate. Investigation by qPCR revealed that control of expression of these virulence factors was not due to altered levels of transcription. Based on these data, we hypothesize a post-transcriptional mechanism of virulence regulation in P. aeruginosa bloodstream infections influenced by surrounding microenvironmental conditions.