Beyond the First Year: Epidemiology and Management of Late-Onset Opportunistic Infections After Kidney Transplantation

Late opportunistic infections (OI) occurring beyond the first year after kidney transplantation (KT) are poorly described and not targeted by prophylactic strategies. We performed a ten-year retrospective monocentric cohort study describing epidemiology, risk factors and impact of late OI occurring 1 year after KT. We included clinically symptomatic OI requiring treatment besides BK virus nephropathy. Control groups included early OI occurring in the first year after KT, and KT recipients without OI since KT and alive with a functional allograft at 1 year. Among 1066 KT recipients, 185 (19.4%) presented a first episode of OI 21.0 (8.0-45.0) months after KT: 120 late OI (64.9%) and 65 early OI (35.1%). Late OI were mainly viral (N = 83, 69.2%), mostly herpes zoster (HZ) (N = 36, 43.4%). Pneumocystis represented most late fungal infections (N = 12/25, 48%). Compared to early OI, we reported more pneumocystis (p = 0.002) and less invasive aspergillosis (p = 0.01) among late OI. Patients with late OI were significatively younger at KT (54.0 ± 13.3 vs. 60.2 ± 14.3 years, p = 0.05). Patient and allograft survival rates between late OI and control groups were similar. Only age was independently associated with mortality. While late OI were not associated with higher mortality or graft loss, implementing prophylactic strategies might prevent such infections.

Real-world EGFR testing practices for non-small-cell lung cancer by thoracic pathology laboratories across Europe

BACKGROUND

Testing for epidermal growth factor receptor (EGFR) mutations is an essential recommendation in guidelines for metastatic non-squamous non-small-cell lung cancer, and is considered mandatory in European countries. However, in practice, challenges are often faced when carrying out routine biomarker testing, including access to testing, inadequate tissue samples and long turnaround times (TATs).

MATERIALS AND METHODS

To evaluate the real-world EGFR testing practices of European pathology laboratories, an online survey was set up and validated by the Pulmonary Pathology Working Group of the European Society of Pathology and distributed to 64 expert testing laboratories. The retrospective survey focussed on laboratory organisation and daily EGFR testing practice of pathologists and molecular biologists between 2018 and 2021.

RESULTS

TATs varied greatly both between and within countries. These discrepancies may be partly due to reflex testing practices, as 20.8% of laboratories carried out EGFR testing only at the request of the clinician. Many laboratories across Europe still favour single-test sequencing as a primary method of EGFR mutation identification; 32.7% indicated that they only used targeted techniques and 45.1% used single-gene testing followed by next-generation sequencing (NGS), depending on the case. Reported testing rates were consistent over time with no significant decrease in the number of EGFR tests carried out in 2020, despite the increased pressure faced by testing facilities during the COVID-19 pandemic. ISO 15189 accreditation was reported by 42.0% of molecular biology laboratories for single-test sequencing, and by 42.3% for NGS. 92.5% of laboratories indicated they regularly participate in an external quality assessment scheme.

CONCLUSIONS

These results highlight the strong heterogeneity of EGFR testing that still occurs within thoracic pathology and molecular biology laboratories across Europe. Even among expert testing facilities there is variability in testing capabilities, TAT, reflex testing practice and laboratory accreditation, stressing the need to harmonise reimbursement technologies and decision-making algorithms in Europe.

Comprehensive commissioning and quality assurance validation of Ethos™ therapy

PURPOSE

Adaptive radiotherapy with the Ethos® therapy Varian system has been recently implemented at the Montpellier Cancer Institute, France. This article details the commissioning performed before the implementation of this new treatment planning system (TPS).

MATERIAL AND METHODS

To validate the golden beam data of the machine (Halcyon linear accelerator), percentage depth doses (PDD) and profiles were measured for several field sizes and at different depths with a microdiamond chamber. The final doses calculated for different plan types with the Ethos Acuros XB algorithm and the Halcyon Eclipse Analytic Anisotropic Algorithm were compared using the gamma index method. Lastly, for the patient quality assurance (QA) process, the patient treatment plan results obtained with the Mobius3D QA platform (Varian) were compared with the portal dosimetry results obtained with Epiqa (Epidos).

RESULTS

Minor differences were observed for the PDD and profile curves (mean difference of 0.2% and 2%, respectively). The χ index pass rate was above 98% for all measures using the 1%/1mm and 2%/2mm criteria for PDD and profile evaluations. The Ethos AXB algorithm was validated for every configuration (fixed fields, standard IMRT and VMAT fields, and clinical plans) with 2D/3D gamma index values>99%. Seventy-three 3-arcs-VMAT QA plans and 27 9-fields-IMRT QA plans were evaluated. Both showed excellent agreement with the TPS calculations (mean gamma pass rate higher than 99%). No difference was observed between IMRT and VMAT.

CONCLUSION

The beam delivery, the Ethos AXB algorithm, and the patient QA were comprehensively validated using independent tools.

Random auxetics from buckling fibre networks

Auxetic materials have gained increasing interest in the last decades, fostered by auspicious applications in various fields. While the design of new auxetics has largely focused on meta-materials with deterministic, periodically arranged structures, we show here by theoretical and numerical analysis that pronounced auxetic behaviour with negative Poisson's ratios of very large magnitude can occur in random fibre networks with slender, reasonably straight fibre segments that buckle and deflect. We further demonstrate in experiments that such auxetic fibre networks, which increase their thickness by an order of magnitude and more than quintuple their volume when moderately extended, can be produced by electrospinning. Our results thus augment the class of auxetics by a large group of straightforwardly fabricable meta-materials with stochastic microstructure.

Correlating diameter, mechanical and structural properties of poly(l-lactide) fibres from needleless electrospinning

The development and application of nanofibres requires a thorough understanding of the mechanical properties on a single fibre level including respective modelling tools for precise fibre analysis. This work presents a mechanical and morphological study of poly-l-lactide nanofibres developed by needleless electrospinning. Atomic force microscopy (AFM) and micromechanical testing (MMT) were used to characterise the mechanical response of the fibres within a diameter range of 200-1400 nm. Young's moduli E determined by means of both methods are in sound agreement and show a strong increase for thinner fibres below a critical diameter of 800 nm. Similar increasing trends for yield stress and hardening modulus were measured by MMT. Finite element analyses show that the common practice of modelling three-point bending tests with either double supported or double clamped beams is prone to significant bias in the determined elastic properties, and that the latter is a good approximation only for small diameters. Therefore, an analytical formula based on intermediate boundary conditions is proposed that is valid for the whole tested range of fibre diameters, providing a consistently low error in axial Young's modulus below 10%. The analysis of fibre morphology by differential scanning calorimetry and 2D wide-angle X-ray scattering revealed increasing polymer chains alignment in the amorphous phase and higher crystallinity of fibres for decreasing diameter. The combination of these observations with the mechanical characterisation suggests a linear relationship between Young's modulus and both crystallinity and molecular orientation in the amorphous phase. STATEMENT OF SIGNIFICANCE: Fibrous membranes have rapidly growing use in various applications, each of which comes with specific property requirements. However, the development and production of nanofibre membranes with dedicated mechanical properties is challenging, in particular with techniques suitable for industrial scales such as needleless electrospinning. It is therefore a key step to understand the mechanical and structural characteristics of single nanofibres developed in this process, and to this end, the present work presents changes of internal fibre structure and mechanical properties with diameter, based on dedicated models. Special attention was given to the commonly used models for analyzing Young's modulus of single nanofibers in three-point bending tests, which are shown to be prone to large errors, and an improved robust approach is proposed.

Performance analysis of walking of 10,000 regular users of a connected activity tracker

BACKGROUND

According to the World Health Organization, individuals should walk 10,000 per day. Our aim was to determine the factors influencing this objective by using connected activity trackers.

METHODS

Anonymized data of 10,000 regular users of the Withings pulse O_x over a 3-month period.

RESULTS

Ratio men/women was 2.2, mean age 44.9±10.6 years, mean BMI 27.0±5.3kg/m², proportion of individuals living in big towns 21.4%, proportion of physical activity<2 METs 66%. The frequency of achieving 10,000 daily steps was similar for work days, weekends and whole weeks. Mean number of daily steps, mean daily covered distances and slopes were higher during work days (P<0.0001); mean speed was higher during the weekends (P<0.0001). According to a quartile-repartition (percentages of use-days with 10,000 steps), the goal was more often achieved during work days (P<0.0001), if BMI<25kg/m² (P<0.001), in individuals living in big towns (P<0.001) or having≥2 acquaintances to take up challenges (P<0.001).

CONCLUSION

Connected activity trackers represent a valuable tool for evaluating the number of daily steps and for providing feedback to promote walking.

[Validity and reproducibility of two direct observation assessment forms for evaluation of internal medicine residents' clinical skills]

INTRODUCTION

The revision of the French medical studies' third cycle ought to be competency-based. In internal medicine, theoretical and practical knowledge will be assessed online with e-learning and e-portfolio. In parallel, a reflection about clinical skills assessment forms is currently ongoing. In this context, our aim was to assess the reproducibility and validity of two assessment forms based on direct clinical observation.

METHOD

A prospective and multicentric study has been conducted from November 2015 to October 2016 aiming at evaluating the French translations of the MINI-Clinical Examination Exercice (MINI-CEX) and the Standardized Patient Satisfaction Questionnaire (SPSQ). Included residents have been assessed 2 times over a period of 6 months by the same binoma of judges.

RESULTS

Nineteen residents have been included. The inter-judge reproducibility was satisfactory for the MINI-CEX: intraclass coefficients (ICC) between 0.4 and 0.8 and moderate for the SPSQ: ICC between 0.2 and 0.7 with a good internal coherence for both questionnaires (Cronbach between 0.92 and 0.94). Significant differences between the distributions of the scores given by the judges and a significant inter-center variability have been found.

CONCLUSION

If the absolute value of the scores should not be taken into account in the evaluation process given its high variability, it could be of interest for the follow-up of the progression in the competencies. These forms could support the residents' debriefing based on the general trends given by the scores.

Adjudication of osteonecrosis of the jaw in phase III randomized controlled trials of denosumab: a systematic review

PURPOSE

Denosumab (an anti RANKL antibody) is known to be associated with an increased risk for osteonecrosis of the jaw (ONJ). Due to the variety of clinical presentation, many ONJ definitions are used. Evaluation of ONJ's frequency during phase III randomized controlled trials (RCTs) is crucial to assess benefit-risk ratio. We verified that phase III RCTs involving denosumab reported the definition of ONJ used.

METHODS

We systematically searched in Central, Medline, Cochrane, and Scopus, until 31 August 2015. We included original phase III RCTs, involving denosumab. Post hoc analysis and trial extension were excluded. Articles that did not mention ONJ in their methods or results were excluded. The primary outcome was the prevalence of a complete definition of ONJ. When no definition was provided, ONJ adjudication process was analyzed.

RESULTS

Of 313 articles found, 13 RCTs were included. A definition of ONJ was detailed in two RCTs (15%). For the remaining 11 RCTs, adjudication process was mentioned for nine. In those processes, "blinded," "expert," and "independent" were the most used words.

CONCLUSION

Most of the published phase III RCTs involving denosumab did not specify the definition of ONJ used to adjudicate events in the study. Instead of definition, non-scientific and non-reproducible expressions were used. Because the chosen definition could impact the ONJ estimated frequency, it should be mandatory to give the precise definition used in each RCT publication involving denosumab.

[Molecular diagnosis of human papillomaviruses (HPV): What test(s) in clinical practice?]

Prescription of an HPV test in practice will enable the clinician to optimize the monitoring and the management of patients, especially in the context of cervical cancer screening. Numerous HPV tests are available that present different analytical and clinical sensitivity and specificity. International recommendations on clinical performance of HPV tests used for cervical cancer screening have been published by a group of experts, and tests that meet these performance criteria should be used. Apart from the HPV detection kit, the whole circuit from sampling to report of the results must be considered. This implies that the pre-analytical (sampling, quality of sample collection medium, storage condition and sample transportation…) and post-analytical steps (quality of result reporting, providing expert advices…) are also standardized. For this purpose, medical-biology laboratories are subjected to a COFRAC certification, as defined by the international standard ISO 15189 providing quality criteria for any clinical laboratory test and HPV test in particular.

Benzodiazepine dependence in subjects with alcohol use disorders: what prevalence?

OBJECTIVE

To our knowledge, no studies have been conducted in France on benzodiazepine (BZD) dependence among outpatients with alcohol use disorders (AUD). Some international studies have been conducted on the consumption of BZD in this specific population, but the comparisons among them are difficult. We aimed to assess the current prevalence of probable benzodiazepine and BZD-like hypnotics (Z-drugs) dependence among outpatients seeking treatment for AUD.

METHODS

Participants were patients seeking treatment for AUD for the first time or repeating treatment after more than twelve months. Recruitment took place in seven addiction centres between January and December 2013 in the Nantes region (France). BZD/Z-drug dependence was assessed according to the DSM-IV diagnostic criteria for dependence. This information was gathered through a self-report questionnaire.

RESULTS

Among the 1005 patients included in this study, 413 were BZD/Z-drug users (41.1%). Among the 413 patients, 217 were probably dependent on at least one substance, which represents 21.6% of the total population and 52.5% of BZD/Z-drug users.

CONCLUSION

BZD/Z-drug dependence represents a public health concern. Prescribers should take the risks into account and keep treatment courses to a minimum.

131 RETROSPECTIVE DATA ANALYSIS OF HOLSTEIN HEIFER GROWTH IN EMBRYO PRODUCTION CENTERS

The reduction of the generation gap has become of main interest in the race for the genetic improvement of cattle and in reducing the environmental impact of dairy farms. Sexual precocity of high genetic merit heifers is therefore essential, as it allows the development of their potential as soon as possible thanks to embryo collection. Many factors influence the sexual precocity and embryos production of bovine females. A major effect of the calves’ growth rate has often been observed on puberty precocity in experimental trials. This study was carried out on data recorded from January 2010 to May 2015 on 617 Holstein heifers housed in 2 centers of embryos production with similar breeding conditions in France. The purpose was to find optimal breeding values of Holstein heifers for embryo production in these centers. The heifers entered at the centers between 4 to 15 months old (after a quarantine of 30 days) to produce in vivo embryos during 2 to 4 collections before to come back pregnant to their breeder owner. The first treatment of superovulation was programmed when a first heat was observed visually or via an activity sensor (Heatime R) or when a corpus luteum had been detected (ultrasound scans). The studied variables were the date of the first flushing as a precocity indicator and the collection results for the production of embryos (numbers of total and viable embryos). In this population, the average age at entry was 8.5 ± 2.3 months old (minimum = 3.4; maximum = 15.0), the average age at the first collection 14.3 ± 1.2 months (minimum = 11.0; maximum = 19.0), the average daily gain (ADG) between 0 and 12 months was 792 ± 86 g day–1 (minimum = 492; maximum = 1027), the average number of total structures by collection 9.3 ± 6.1, the mean number of viable embryos 5.5 ± 3.8. Data analysis by multivariate ANOVA test showed an effect on age at first collection for the center (P = 0.009), age at entry (P < 0.001), and ADG between 0 and 12 months (P < 0.001). Heifers with ADG between 0 and 12 months of <650 g day–1 had a delay of 70 days for the first collection compared to those with an ADG of >900 g day–1. The ADG between 0 and 12 months had also the strongest negative correlation found with the age at first collection (r = 0.52). Similarly, ADG between 0 and 6 months of the 40 heifers entered in the centers before the age of 6 months was significant for age at the first collection (P = 0.0001), whereas ADG between 6 and 12 months was not. Regarding the production of embryos, only the weight at the first collection tended (P = 0.07) to have an effect on the total number of collected structures: 10.1 ± 6.5 for heifers that weighted more than 420 kg v. 7.3 ± 4.0 for those that weighted less than 340 kg. No effect on the percentage of grade 1 or 2 embryos could be observed. In conclusion, this study conducted in production conditions confirmed the observations made in experimental trials and refined the recommendations and practices of the two centers to reduce the age at first embryo flushing.

150 USING A LUTEINIZING HORMONE SURGE DETECTION TEST, PREDI&apos;BOV&reg;, TO OPTIMIZE THE TIME OF ARTIFICIAL INSEMINATION DURING A SUPEROVULATION PROTOCOL IN A HOLSTEIN HEIFERS HERD

Insemination of superovulated bovine donors in due time is of central importance for fertilization and embryo viability. A preliminary test focusing on LH surge detection during superovulation (unpublished datas) indicated that one quarter of the donors present LH surges 12 to 24 h before heat observation (which could correspond, in the case of AI after heat observation, to post ovulation AI). Therefore, it was hypothesised that the average number of embryos per flush could be improved by inseminating donors with early LH surge 12 h after the beginning of the LH peak whenever the heat occurs.In a donor herd station, a trial was performed with 54 Holstein heifers, equipped with Heatime® tags (system detecting the peak activity linked to the heat) collected twice or 3 times after the following superovulation protocol: D-6 to D-11 = reference heat; D0 = input of an implant of norgestomet (Crestar®); D2 8:00 = first FSH (Stimufol®) injection (FSH1); D4 8:00 = cloprostenol (Estrumate®) injection; D4 16:00 = implant removal; D5 8:00 = FSH7 and first LH surge detection test (Predi'Bov®); D5 16:00 = FSH8 and 2nd Predi'Bov® test. Two AI's at interval of 8 to 16h were done (AI's were performed either at 9:00, or between 17:00 and 19:00). For the standard protocol (= STA), thefirst AI occurred after heat observation or activity peak detection by Heatime (whatever the Predi'Bov® test results were). For the adjusted protocol (= ADJ), the first AI occurred from 11 to 16 h after the first positive Predi'Bov® test result or like STA protocol if both results were negative. Heifers followed alternately the 2 protocols, 27 beginning with the ADJ protocol, 27 others with the STA one. LH surge precocity was not repeatable among donors. In the case of an early LH surge detection (one positive Predi'Bov® test), the heat activity peak occurred from 2 to 8 h after the FSH8 for 44% of the flushes, from 8 to 24 h after FSH8 for 54% of the flushes and never for 2% of the flushes. When no early LH surge was observed, the heat activity peak occurred more than 8 h after FSH8 for 78% of the flushes. Interval of heat activity peak-FSH8, IA1-heat activity peak and IA1-early LH surge were highly variable but did not effect the mean number of viable embryos. However, we observed a significant effect (P = 0.04) of the precocity of the heat on the average number of total embryos: 13.8 ± 8.4 v. 11.1 ± 8.1 when the interval heat activity peak-FSH8 had been respectively <8 h or ≥8 h, respecively. Among the 148 collections, 74 were done after the STA protocol, 74 after the ADJ protocol and 70 followed an early LH surge. The adjustment of the AI depending on the detection of an early LH surge (ADJ protocol) had a significant positive (P = 0.04) effect on the mean percentage of viable embryos per flush (52% ± 28 in STA group and 62% ± 31 in ADJ group). Nevertheless, regarding the mean number of viable embryos, this effect failed to reach significance (P = 0.23) (respectively 5.7 ± 5.1 in STA group and 6.7 ± 6.7 in ADJ group). A larger study on more animals is necessary to obtain a significant difference in the number of viable embryos.