Radiological Classification and Management Algorithm of Petrous Apex Cholesterol Granuloma

Background: Petrous apex cholesterol granulomas (PACGs) are benign inflammatory cystic lesions of the temporal bone. Usually, asymptomatic patients may develop symptoms as the lesions expand. The diagnosis is based on both CT and MRI scans and the management relies on "wait and scan" or surgery. This paper aims at evaluating surgical outcomes and proposing a CT-based classification and a management algorithm. Methods: Patients with PACGs who were surgically treated between 2014 and 2024 were included. Symptoms, imaging, approach type and complications were considered. CT scans were classified as Type A (preserved apex cellularity), Type B (erosion of the apex cellularity), and Type C (involvement of the noble structures bone boundaries). The possible connection of the lesion with the infracochlear, perilabyrinthine and sphenoidal cellularity was assessed. Results: Nineteen patients with symptoms like diplopia, headache and sensorineural hearing loss were included. According to our classification, 1/19 patients was Type A, 4/19 were Type B and 14/19 were Type C. Five patients underwent a total resection, seven a subtotal and seven a surgical drainage. Only two complications were recorded, and 17/19 patients showed symptom regression and stability during follow-up. Conclusions: While the management of PACGs is still controversial, according to our classification and surgical outcomes, Type A, being mostly asymptomatic, should be managed with "wait and scan", Type B should undergo surgery when symptoms are present, while Type C should always undergo surgery because of their invasiveness and potential complications. When possible, a drainage should be attempted; otherwise, a surgical resection is chosen, and its completeness depends on the preoperative general and hearing status.

Phase II trial of hypomethylating agent combined with nivolumab for acute myeloid leukaemia relapse after allogeneic haematopoietic cell transplantation-Immune signature correlates with response

Acute myeloid leukaemia (AML) relapse after allogeneic haematopoietic cell transplantation (allo-HCT) is often driven by immune-related mechanisms and associated with poor prognosis. Immune checkpoint inhibitors combined with hypomethylating agents (HMA) may restore or enhance the graft-versus-leukaemia effect. Still, data about using this combination regimen after allo-HCT are limited. We conducted a prospective, phase II, open-label, single-arm study in which we treated patients with haematological AML relapse after allo-HCT with HMA plus the anti-PD-1 antibody nivolumab. The response was correlated with DNA-, RNA- and protein-based single-cell technology assessments to identify biomarkers associated with therapeutic efficacy. Sixteen patients received a median number of 2 (range 1-7) nivolumab applications. The overall response rate (CR/PR) at day 42 was 25%, and another 25% of the patients achieved stable disease. The median overall survival was 15.6 months. High-parametric cytometry documented a higher frequency of activated (ICOS+ , HLA-DR+ ), low senescence (KLRG1- , CD57- ) CD8+ effector T cells in responders. We confirmed these findings in a preclinical model. Single-cell transcriptomics revealed a pro-inflammatory rewiring of the expression profile of T and myeloid cells in responders. In summary, the study indicates that the post-allo-HCT HMA/nivolumab combination induces anti-AML immune responses in selected patients and could be considered as a bridging approach to a second allo-HCT. Trial-registration: EudraCT-No. 2017-002194-18.

High-dimensional analysis of 16 SARS-CoV-2 vaccine combinations reveals lymphocyte signatures correlating with immunogenicity

The range of vaccines developed against severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) provides a unique opportunity to study immunization across different platforms. In a single-center cohort, we analyzed the humoral and cellular immune compartments following five coronavirus disease 2019 (COVID-19) vaccines spanning three technologies (adenoviral, mRNA and inactivated virus) administered in 16 combinations. For adenoviral and inactivated-virus vaccines, heterologous combinations were generally more immunogenic compared to homologous regimens. The mRNA vaccine as the second dose resulted in the strongest antibody response and induced the highest frequency of spike-binding memory B cells irrespective of the priming vaccine. Priming with the inactivated-virus vaccine increased the SARS-CoV-2-specific T cell response, whereas boosting did not. Distinct immune signatures were elicited by the different vaccine combinations, demonstrating that the immune response is shaped by the type of vaccines applied and the order in which they are delivered. These data provide a framework for improving future vaccine strategies against pathogens and cancer.

[Early access programs and managed entry agreements for medicines in Italy: results of a Focus Group (Early Access Programs and Managed Entry Agreement).]

BACKGROUND

Early access of medicines occurs with an uncertainty in the evidence even higher than the one experienced when price and reimbursement status is negotiated. Our aim is discussing the role of managed entry agreements (MEA) within early access programs (EAP) in Italy.

METHODS

The discussion relied on a Focus Group, participated by twelve experts, including clinicians and representatives of regulatory authorities, regional and local pharmaceutical departments, pharmaceutical companies, and an association advocating for active citizenship.

RESULTS

The Focus Group emphasised that the topic under discussion should be embedded into a more general reform of EAP in Italy. The 648 List mostly includes mature products and indications that are rarely launched into the market afterwards. The 5% Fund is affected by an important administrative burden uncertainty of the timing of reimbursement.

CONCLUSIONS

Starting from the discussion on MEA and EAP, the Focus Group recommended a new legislation better regulating EAP, that early access concerns specific classes of medicines selected on the grounds of the need to guarantee a rapid access and to collect real world data, that early access can be accompanied by outcome-based and population-based MEA, and that MEA are embedded into the subsequent price and reimbursement negotiation.

Pax5 regulates B cell immunity by promoting PI3K signaling via PTEN down-regulation

The transcription factor Pax5 controls B cell development, but its role in mature B cells is largely enigmatic. Here, we demonstrated that the loss of Pax5 by conditional mutagenesis in peripheral B lymphocytes led to the strong reduction of B-1a, marginal zone (MZ), and germinal center (GC) B cells as well as plasma cells. Follicular (FO) B cells tolerated the loss of Pax5 but had a shortened half-life. The Pax5-deficient FO B cells failed to proliferate upon B cell receptor or Toll-like receptor stimulation due to impaired PI3K-AKT signaling, which was caused by increased expression of PTEN, a negative regulator of the PI3K pathway. Pax5 restrained PTEN protein expression at the posttranscriptional level, likely involving Pten-targeting microRNAs. Additional PTEN loss in Pten,Pax5 double-mutant mice rescued FO B cell numbers and the development of MZ B cells but did not restore GC B cell formation. Hence, the posttranscriptional down-regulation of PTEN expression is an important function of Pax5 that facilitates the differentiation and survival of mature B cells, thereby promoting humoral immunity.

Distinct immunological signatures discriminate severe COVID-19 from non-SARS-CoV-2-driven critical pneumonia

Immune profiling of COVID-19 patients has identified numerous alterations in both innate and adaptive immunity. However, whether those changes are specific to SARS-CoV-2 or driven by a general inflammatory response shared across severely ill pneumonia patients remains unknown. Here, we compared the immune profile of severe COVID-19 with non-SARS-CoV-2 pneumonia ICU patients using longitudinal, high-dimensional single-cell spectral cytometry and algorithm-guided analysis. COVID-19 and non-SARS-CoV-2 pneumonia both showed increased emergency myelopoiesis and displayed features of adaptive immune paralysis. However, pathological immune signatures suggestive of T cell exhaustion were exclusive to COVID-19. The integration of single-cell profiling with a predicted binding capacity of SARS-CoV-2 peptides to the patients' HLA profile further linked the COVID-19 immunopathology to impaired virus recognition. Toward clinical translation, circulating NKT cell frequency was identified as a predictive biomarker for patient outcome. Our comparative immune map serves to delineate treatment strategies to interfere with the immunopathologic cascade exclusive to severe COVID-19.

An early Sox2-dependent gene expression programme required for hippocampal dentate gyrus development

The hippocampus is a brain area central for cognition. Mutations in the human SOX2 transcription factor cause neurodevelopmental defects, leading to intellectual disability and seizures, together with hippocampal dysplasia. We generated an allelic series of Sox2 conditional mutations in mouse, deleting Sox2 at different developmental stages. Late Sox2 deletion (from E11.5, via Nestin-Cre) affects only postnatal hippocampal development; earlier deletion (from E10.5, Emx1-Cre) significantly reduces the dentate gyrus (DG), and the earliest deletion (from E9.5, FoxG1-Cre) causes drastic abnormalities, with almost complete absence of the DG. We identify a set of functionally interconnected genes (Gli3, Wnt3a, Cxcr4, p73 and Tbr2), known to play essential roles in hippocampal embryogenesis, which are downregulated in early Sox2 mutants, and (Gli3 and Cxcr4) directly controlled by SOX2; their downregulation provides plausible molecular mechanisms contributing to the defect. Electrophysiological studies of the Emx1-Cre mouse model reveal altered excitatory transmission in CA1 and CA3 regions.

The rule of hydrogen peroxide long term rinse during a particular alveolar bone healing after ONJ injuries in a patient with periodontal disease: a 4-year radiological follow up report of a mental nerve emergence migration

Bisphosphonate Related Osteonecrosis of the Jaw (BRONJ) is a pathology initially described in the early 2000s that has become increasingly common in clinical dentistry and maxillofacial practice due to the frequent use of bisphosphonates medical drugs (BPs) to treat various diseases such as osteoporosis, Paget's syndrome, osteomyelitis and in bone metastases secondary to tumors. Supragingival irrigation applied as monotherapy and in combination with root planning or BFs related bone necrosectomy revealed that supragingival irrigation with a variety of agents reduced the gingival microbial load and gingival inflammation. In this 4-year follow-up study we analyze the use of hydrogen peroxide (H2O2) as an antimicrobial agent for maintenance periodontal health, improving the longevity of teeth and oral cavity healing process.

Zygomatic implants supported rehabilitations in atrophic maxilla: sinus complications, radiological, periodontal and prosthodontic evaluations: a one year follow up retrospective longitudinal study

The rehabilitation of maxillary bone atrophy represents one of the main challenges of modern oral implantology. The use of zygomatic implants in the prosthetic rehabilitation of the patient affected by severe maxillary bone atrophy is another therapeutic alternative, not exempt from complications. The present study included 19 patients with edentulous maxillae who were treated between 2013 to 2015 with at least two zygomatic implants at the Department of Maxillofacial Surgery, Verona, Italy. The purpose of this retrospective longitudinal study was to evaluate sinus complications and radiological, periodontal and prosthetic evaluations of zygomatic implants technique in severe atrophic. Implant-prosthetic rehabilitation of the upper jaw edentulous severely atrophic using zygomatic implants represents one safe and repeatable technique. In terms of implant survival from our study showed an implant CRS (common reporting standard) of 98.5% and a prosthetic CRS 100% with a mean follow-up period of 19.2 months (range). Both recorded data are superimposed on major reported studies in literature.

Platelet rich plasma grafting technique combined with trans-sinusal post-extractive implants placement in the posterior maxilla: a technical report and brief literature review

The atrophic posterior ridges are usually characterized by poor bone quality and quantity: this situation requires the use of bone regenerative techniques. Other alternative surgical approaches are investigated. Nowadays the use of trans-sinus implants offers some advantages due to its feasibility. Today, bone grafting may be practical, but depends on many factors, such as the type of bone graft used (autogenous, alloplastic, or xenograft), host response, age of the patient, various complications associated with grafting procedures, infection, and, most importantly, the time spent while the grafted material matures and is taken up by the bone. So, this case report describes the feasibility of an alternative surgical technique associated to PRP (Platelet Rich Plasma).

Ketamine in dentistry: a useful way for non-compliant pediatric patients

The infant, like the young un-cooperative or odontophobic patient, constitute the most complex type of patient to be treated and it is frequent in modern society. The treatment of these patients is necessary to resolve the infectious-antalgic urgency and subsequently to build the patient/doctor relationship for continuing general dental care. Conscious sedation is the only way to approach this type of patient. Where therapeutic success with traditional sedation techniques is not achieved, as frequently happens in these patients, sedation with ketamine is the extreme ratio for the purpose of effective resolution of the dental problem, obviously carried out within facilities authorized for these anesthesiological modalities such as private outpatient surgery structures where, when necessary, it is possible to carry out the treatments also under general anesthesia as well as with ketamine.

New trends in adjunctive treatment and diagnosis in medication-related osteonecrosis of the jaw: A 10-year review

Medication-related osteonecrosis of the jaw (MRONJ) is a major disease under study for over the last twenty years. Different classifications have been proposed and many therapies for the different stages have been applied. The evolution of treatments lead to an increasingly conservative approach. Numerous adjuvant treatments have been proposed in the last decade. All these complementary treatments have been proposed mainly to resolve or reduce the painful stress, predominantly caused by bacterial infection, simplifying the wound healing process and improving patients' compliance. Nowadays "secondary" treatments, such as autologous platelet concentrates (APCs, more specifically PRP, PRGF or PRF), hyperbaric oxygen (HBO), Auto/tetracycline fluorescence-guided bone surgery (AF-GBS/TF-GBS), medical drugs like teriparatide or the combination between pentoxifylline and tocopherol, fluorodeoxyglucose positron emission tomography (FDG-PET), laser and/or low-laser therapy and ozone therapy are more or less well documented and known considering their clinical effectiveness. The aim of the present review is the evaluation of the quantity and quality of scientific studies concerning this specific topic.

Effects of the sander bite jumping appliance in patients with class ii malocclusion before growth peak

Sander bite jumping appliance (BJA) is a functional appliance used to correct Class II malocclusion in growing patients. The aim of this study was to identify the dento-skeletal effects in patients treated with BJA before growth peak and to compare these effects with the ones obtained in a similar group treated with the Andresen activator (AA). Twenty subjects with class II relationship of the skeletal bases and cervical vertebrae maturation stage 1 or 2 were enrolled in the study and treated with BJA. This group were compared to 14 subjects treated with AA. Cephalometric analyses were carried out using landmarks derived from the analyses of Pancherz, Ricketts, Tweed and Steiner. After treatment with BJA Pg/OLp increase was 7.40±3.81 mm (P<0.001); Pg/OLp+Co/OLp significantly heightened from T0 to T1 (T0: 82.20±4.65 mm vs T1: 89.62±4.27, P<0.001). Overjet (is/OLp - ii/OLp) significantly decreased from T0 to T1 (T0: 7.40±2.31 mm vs T1: 3.05±1.34 mm, P<0.001). Molar relationship improved passing from 1.46±1.68 mm at T0 to -3.56±2.04 mm at T1 (P<0.001). No statistically significant differences were found between BJA and AA groups at T0 and T1. BJA treatment determined a Class II malocclusion correction in all patients. The correction of molar relationship was mainly due to the increase in mandibular length; the correction of the overjet was due to the increase in mandibular length, to the slight pro-inclination of the lower incisors and the mild retro-inclination of the upper incisors. No significant differences were found in effectiveness between BJA and AA.

The use of computer-guided flapless dental implant surgery (Nobel guide®) and immediate function to support a fixed full-arch prosthesis in fresh frozen homologous bone grafted patients: a retrospective cohort study with 5 to 8-year follow-up

The introduction of computer-assisted and guided surgery has radically improved the possibility of using all available bone for implant support, reducing the need for extensive grafting procedures and allowing for better implant placement and restoration. Moreover, fresh frozen homologous bone (FFB) grafts have shown good osteoconductive properties and biocompatibility with results comparable to autologous bone patients. The purpose of this retrospective cohort study was to evaluate the survival and the success rate of implants and related fixed full arch prosthesis at the 5 to 8 years follow-up when performed with immediate function using a flapless surgical procedure and computer-aided technology (NobelGuide®, Nobel Biocare® AB, Goteborg, Sweden) in patients previously treated with FFB grafts; treated at the University of Verona with the NobelGuide® system from January 2007 to December 2012 with at least 5 years follow-up were reviewed. Survival implants and survival prosthesis' percentage reached 95% in a 5 to 8-year period. This study indicates that patients previously augmented with FFB graft for maxillary or mandibular bone atrophy can be safely treated with implant supported prosthesis based on the NobelGuide® protocol, with the aid of computer-generated guide.

Vestibular impact of Friedreich ataxia in early onset patients

Background

Friedreich ataxia (FRDA) is the most frequent form of inherited ataxias. Vestibular and auditory assessments are not commonly part of the check up for these patients despite hearing and balance complaints. Screening of vestibular and auditory function was performed in a large group of young patients with genetically confirmed FRDA.

Methods

Our study included 43 patients (7–24 years of age). A complete vestibular assessment was performed including the canals function evaluation at 3 head velocities (bithermal caloric test, earth vertical axis rotation (EVAR) and head impulse test (HIT)) and otolith function evaluation (cervical vestibular evoked myogenic potentials). Information regarding the hearing evaluation of the patients were also retrieved including impedance tympanometry, distortion product otoacoustic emissions (DPOAEs), air and bone conduction audiometry and auditory brainstem response (ABR).

Results

Vestibular responses were impaired for canal responses (only at high and middle head velocities) and vestibulospinal otolithic responses. Abnormal neural conduction in the central auditory pathways was frequently observed. Oculomotor abnormalities were frequent, mostly hypermetric saccades and gaze instability. Inhibition of the vestibulo-ocular reflex by fixation was normal.

Conclusions

We show that Friedreich ataxia, even at onset, frequently associate saccadic intrusions, abnormal ABRs and decreased vestibulo-ocular and vestibulospinal responses progressing over time. These sensory impairments combined with ataxia further impair patient’s autonomy. These vestibular, auditory and visual impairments could be used as markers of the severity and progression of the disease. Adding vestibular and auditory testing to Friedreich patient’s evaluation may help physicians improve patient’s management.

Variations in the use of caesarean section: a Comparison between France and Australia

Background

There has been a rise in obstetric intervention during labour and birth including rates of caesarean section around the world. The rates of caesarean section are lower in France (20%) than Australia (34%). Both countries have universal health care systems. Australia has a well-established program of obstetric benchmarking and national data collection for comparing maternal and perinatal outcomes taking into account maternity units and maternal characteristics. Although the optimal caesarean section rate is not known, variation in caesarean section rates raise questions about what is driving variation in practice and whether the right care is being delivered. The World Health Organisation has recently released non-clinical recommendations aiming to reduce unnecessary caesarean sections, including that births are classified by Robson classification for easier comparison.

Methods

We aim to compare rates of mode of birth in 2 tertiary hospitals- one in France and one in Australia using Robson classification. This project will investigate differences in patient casemix, and obstetric management that may lead to differences in outcome. In addition, we will try to explore differences in the health systems including clinical activity, induction rates, staffing (number, type (medical, nursing, midwifery)), and models of care.

Outcomes

Caesarean section is one of the most common operations performed in hospitals. Important variations of surgical rates raise question regarding whether access to this procedure is optimized. Determining current practice and outcomes of women in two different settings will provide important data to inform hospital practice and further research. In addition, this research may inform national guidelines about indications for caesarean section.

Impact of deprivation on hospital efficiency and financial balance in paediatrics

Background

In healthcare systems where hospital tariffs are based on average national length of stay (LOS), deprived patients may be a source of inefficiency for hospitals as deprivation has been shown to be associated with increased LOS. They may also negatively impact hospitals’ financial balance as few hospital payment methods include deprivation. Our objective was to study the impact of deprivation on hospital efficiency and financial balance.

Methods

A study was carried out using an exhaustive national hospital discharge database. All inpatient stays in mainland France between 2012 and 2014 by children over 28 days and under 18 in hospitals with a paediatric ward were included. Deprivation was estimated with an ecological deprivation index divided into national quintiles. Efficiency was assessed by variations in patients’ LOS compared to different mean national LOS (paediatric LOS, LOS of admissions for a similar condition...). Financial balance was assessed at the admission level through the ratio of production costs and revenues and at the hospital level with the difference between all revenues and production costs for said hospital. Multivariate models assessed the association between those indicators and deprivation.

Results

4,124,510 inpatient stays were included. LOS was shorter than national means for less deprived patients and longer for the more deprived, and the difference was higher for diagnosis-related groups (DRGs) that included both adult and paediatric patients compared to paediatric-only DRGs. The multivariate model confirmed those significant associations. Deprivation also had a significant impact on hospitals’ financial balance, especially for hospitals with a percentage of paediatric patients in the two most deprived quintiles between 20% and 60%.

Conclusions

Measures to reform hospital payment methods must be encouraged to improve resource allocation efficiency and equity in access to good paediatric care.

Key messages

A reform of hospital funding to better account for deprivation is needed. A modulation of tariffs using an allocation key at the patient level must be considered to mitigate the effect of deprivation. DRGs specific to children should be encouraged to become the norm rather the exception to provide an adequate picture of resources used during admission and therefore an appropriate tariff.

StopBlues: a French e-health device to prevent suicide in the general population

Background

France is one of the Western European countries most affected by suicide, an epidemiological burden and high societal cost of several million euros/year. Several European projects have either implemented web-based interventions for care of mental disorders or recommended online actions which have demonstrated their effectiveness for suicide prevention.

The objective of the project was the construction of an application and website to prevent suicide in the general population, with its promotion being supported at the local authority level.

Methods

The detailed content of the devices and promotional tools available to local authorities was determined through literature reviews and expert groups (psychiatrists, local authorities’ workers and potential users).

Results

An application and website were constructed with two parts: a public interface with videos (psychological suffering, coping strategies and help available), an emergency button, a map with local resources and contact information (psychiatrists, psychologists, associations...), tips and videos to overcome a period of psychological suffering; and a private interface requiring registration giving access to self-assessment questionnaires and a safety plan to fill in case of crisis. 40 local authorities are involved in StopBlues promotion, with a referent each, responsible of contact with our team, and local organization of promotion.

Conclusions

Since 04-2018, StopBlues is available at www.stopblues.fr and can be downloaded on iOs and Android. Its promotion is part of a cluster randomized trial with 3 arms: a control group with no promotion, a group with promotion by local authorities, and a group with promotion by local authorities and general practitioner’s waiting room. As promotion could have different intensities depending on budgets and referent’s involvement, we decided to extend it for another year, with local authorities of group control receiving additional financial and organizational support.

Key messages

As the first e-health program for suicide primary prevention in the French general population, StopBlues’ main goal is to help people find solutions that suit them and direct them to the right help. Local authorities are a key level to promote primary health prevention programs.

A randomised controlled trial of amnioexchange for fetal gastroschisis

OBJECTIVE

Morbidity in fetuses affected by gastroschisis is mainly the result of bowel ischaemic and inflammatory processes. Experimental studies on animal models show that clearing amniotic fluid from the digestive secretions by amnioexchange procedures reduces the inflammatory process. We evaluated the benefit of the amnioexchange procedure for fetal gastroschisis in humans.

DESIGN

Prospective, interventional, randomised study.

SETTING

Eight referral centres for fetal medicine.

POPULATION

Pregnant women carrying a fetus with gastroschisis.

METHODS

We compared, in utero, amnioexchange with a sham procedure. The protocol included, in both arms, steroid injections at 30 weeks of gestation and the use of postnatal minimal enteral feeding.

MAIN OUTCOME MEASURES

The primary outcome was a composite variable based on the duration of ventilation and parenteral nutrition. Secondary outcomes were the effectiveness and safety of the amnioexchange procedure, including the rate of perinatal death, time to full enteral feeding, primary closure, and late feeding disorders.

RESULTS

Sixty-four patients were randomised. There was no difference in the composite criteria between the amnioexchange and control groups. Based on an intention-to-treat analysis, there were no significant between-group differences in pregnancy outcome or complications. When studying the relationship between digestive compounds and amniotic fluid inflammatory markers, a clear correlation was found between bile acid and both ferritin and interleukin 1β (IL1β).

CONCLUSIONS

In humans, amnioexchange, as described in our protocol, is not an option for fetal care; however, we provide supplementary proof of the involvement of inflammation in the pathogenicity of gastroschisis and suggest that future research should aim at reducing inflammation. ClinicalTrials.gov: NCT00127946.

TWEETABLE ABSTRACT

A prospective, interventional, randomised study shows no benefit of amnioexchange for fetal gastroschisis in humans.

dfpk: An R-package for Bayesian dose-finding designs using pharmacokinetics (PK) for phase I clinical trials

BACKGROUND AND OBJECTIVE

Dose-finding, aiming at finding the maximum tolerated dose, and pharmacokinetics studies are the first in human studies in the development process of a new pharmacological treatment. In the literature, to date only few attempts have been made to combine pharmacokinetics and dose-finding and to our knowledge no software implementation is generally available. In previous papers, we proposed several Bayesian adaptive pharmacokinetics-based dose-finding designs in small populations. The objective of this work is to implement these dose-finding methods in an R package, called dfpk.

METHODS

All methods were developed in a sequential Bayesian setting and Bayesian parameter estimation is carried out using the rstan package. All available pharmacokinetics and toxicity data are used to suggest the dose of the next cohort with a constraint regarding the probability of toxicity. Stopping rules are also considered for each method. The ggplot2 package is used to create summary plots of toxicities or concentration curves.

RESULTS

For all implemented methods, dfpk provides a function (nextDose) to estimate the probability of efficacy and to suggest the dose to give to the next cohort, and a function to run trial simulations to design a trial (nsim). The sim.data function generates at each dose the toxicity value related to a pharmacokinetic measure of exposure, the AUC, with an underlying pharmacokinetic one compartmental model with linear absorption. It is included as an example since similar data-frames can be generated directly by the user and passed to nsim.

CONCLUSION

The developed user-friendly R package dfpk, available on the CRAN repository, supports the design of innovative dose-finding studies using PK information.

Neuroendocrine Differentiation in Prostatic Malignancy

Neuroendocrine differentiation in prostatic malignancy is receiving considerable attention; this occurs commonly as a “focal” histological variant and, most rarely, in the form of small cell carcinoma (“oat cell carcinoma”) and carcinoid tumor. In prostate cancer, neuroendocrine differentiation may be the response to androgen deprivation and neuroendocrine products, either biogenic amines or peptides, have been shown to stimulate proliferation of androgen-ablation refractory cancer cells. Serum chromogranins, neuron-specific enolase and other neuroendocrine products as well as 111-In-chromogranin A “three step” immunoscintigraphy and somatostatin-receptor scintigraphy may be useful for predicting tumor behaviour and patient prognosis.

Several of the neuroendocrine products, particularly somatostatin analogues, are candidates for new therapeutic approaches. The paper aims to outline the advances in this field on the basis of the review of the literature.

Cell-type specific sequencing of microRNAs from complex animal tissues

MicroRNAs (miRNAs) play an essential role in the post-transcriptional regulation of animal development and physiology. However, in vivo studies aimed at linking miRNA function to the biology of distinct cell types within complex tissues remain challenging, partly because in vivo miRNA-profiling methods lack cellular resolution. We report microRNome by methylation-dependent sequencing (mime-seq), an in vivo enzymatic small-RNA-tagging approach that enables high-throughput sequencing of tissue- and cell-type-specific miRNAs in animals. The method combines cell-type-specific 3'-terminal 2'-O-methylation of animal miRNAs by a genetically encoded, plant-specific methyltransferase (HEN1), with chemoselective small-RNA cloning and high-throughput sequencing. We show that mime-seq uncovers the miRNomes of specific cells within Caenorhabditis elegans and Drosophila at unprecedented specificity and sensitivity, enabling miRNA profiling with single-cell resolution in whole animals. Mime-seq overcomes current challenges in cell-type-specific small-RNA profiling and provides novel entry points for understanding the function of miRNAs in spatially restricted physiological settings.

The research gap in chronic paediatric pain: A systematic review of randomised controlled trials

BACKGROUND AND OBJECTIVE

Chronic pain is associated with significant functional and social impairment. The objective of this review was to assess the characteristics and quality of randomized controlled trials (RCTs) evaluating pain management interventions in children and adolescents with chronic pain.

METHODS

We performed a systematic search of PubMed, Embase and the Cochrane Library up to July 2017. We included RCTs that involved children and adolescents (3 months-18 years) and evaluated the use of pharmacological or non-pharmacological intervention(s) in the context of pain persisting or re-occurring for more than 3 months. Methodological quality was evaluated using the Cochrane Risk of Bias (ROB) Tool.

RESULTS

A total of 58 RCTs were identified and numbers steadily increased over time. The majority were conducted in single hospital institutions, with no information on study funding. Median sample size was 47.5 participants (Q1,Q3: 32, 70). Forty-five percent of RCTs included both adults and children and the median of the mean ages at inclusion was 12.9 years (Q1,Q3: 11, 15). Testing of non-pharmacological interventions was predominant and only 5 RCTs evaluated analgesics or co-analgesics. Abdominal pain, headache/migraine and musculoskeletal pain were the most common types of chronic pain among participants. Methodological quality was poor with 90% of RCTs presenting a high or unclear ROB.

CONCLUSIONS

Evaluation of analgesics targeting chronic pain relief in children and adolescents through RCTs is marginal. Infants and children with long-lasting painful conditions are insufficiently represented in RCTs. We discuss possible research constraints and challenges as well as methodologies to circumvent them.

SIGNIFICANCE

There is a substantial research gap regarding analgesic interventions for children and adolescents with chronic pain. Most clinical trials in the field focus on the evaluation of non-pharmacological interventions and are of low methodological quality. There is also a specific lack of trials involving infants and children and adolescents with long-lasting diseases.

Prostate Cancer Progression and Surrounding Microenvironment

Bidirectional cellular interactions between prostate cancer and prostate or bone stroma are needed for local tumor growth and distant metastasis. The genetics of cancer cells is affected by the host microenvironment and, reciprocally, permanent gene expression changes occur in the stroma surrounding epithelial cancer cells. The immune-mediated micromilieu also affects the progression of prostate cancer; the role of the immune system in controlling the growth of prostate cancer cells is complex, with immune escape mechanisms prevailing over effective antitumor response. Moreover, tumor stem cell models to explain the origin and progression of prostate cancer require appropriate environmental conditions. On the basis of a review of the literature, this article aims to outline the recent advances in the elucidation of the molecular mechanisms underlying the interactions between prostate cancer and its microenvironment.

What's in the Pipeline about Bladder Reconstructive Surgery? Some Remarks on the State of the Art

The fusion of engineering with cell biology and advances in biomaterials may lead to de novo construction of implantable organs. Engineering of neobladder from autologous urothelial and smooth muscle cells cultured on biocompatible, either synthetic or naturally-derived substrates, is now feasible in preclinical studies and may have clinical applicability in the near future. The development of a bioartificial bladder would warrant the prevention of both the metabolic and neoplastic shortcomings of the intestinal neobladder. Two tissue-engineering techniques for bladder reconstruction have been tested on animals: 1) the in vivo technique involves the use of naturally-derived biomaterials for functional native bladder regeneration 2) the in vitro technique involves the establishment of autologous urothelial and smooth muscle cell culture from the host's urinary tract, after which the cells are seeded on the biodegradable matrix-scaffold to create a composite graft that is implanted into the same host for complete histotectonic regeneration. Waiting for the creation of a complete tissue-engineered bladder with a trigone-shaped base, we suggest, in surgical oncology after radical cystectomy, the realization of conduit or continent pouch using tissue-engineered material.

A framework for understanding the roles of miRNAs in animal development

MicroRNAs (miRNAs) contribute to the progressive changes in gene expression that occur during development. The combined loss of all miRNAs results in embryonic lethality in all animals analyzed, illustrating the crucial role that miRNAs play collectively. However, although the loss of some individual miRNAs also results in severe developmental defects, the roles of many other miRNAs have been challenging to uncover. This has been mostly attributed to their proposed function as tuners of gene expression or providers of robustness. Here, we present a view of miRNAs in the context of development as a hierarchical and canalized series of gene regulatory networks. In this scheme, only a fraction of embryonic miRNAs act at the top of this hierarchy, with their loss resulting in broad developmental defects, whereas most other miRNAs are expressed with high cellular specificity and play roles at the periphery of development, affecting the terminal features of specialized cells. This view could help to shed new light on our understanding of miRNA function in development, disease and evolution.

Equimolar mixture of nitroux oxyde and oxygen during post-operative physiotherapy in patients with cerebral palsy: A randomized, double-blind, placebo-controlled study

BACKGROUND

The administration of an equimolar mixture of nitrous oxide and oxygen (N2O) is recommended during painful procedures. However, the evaluation of its use during physiotherapy after surgery has not been reported, although pain may hamper physiotherapy efficiency. This study investigated whether the use of N2O improves the efficacy of post-operative physiotherapy after multilevel surgery in patients with cerebral palsy.

METHOD

It was a randomized 1:1, double-blind, placebo-controlled study. All patients had post-operative physiotherapy starting the day after surgery. Patients received either N2O or placebo gas during the rehabilitation sessions. All patients had post-operative pain management protocol, including pain medication as needed for acute pain. The primary objective was to reach angles of knee flexion of 110° combined with hip extension of 10°, with the patient lying prone, within six or less physiotherapy sessions. Secondary evaluation criteria were the number of sessions required to reach the targeted angles, the session-related pain intensity and the analgesics consumption for managing post-operative pain.

RESULTS

Sixty-four patients were enrolled. Targeted angles were achieved more often in the N2O group (23 of 32, 72%, vs. Placebo: 13/ of 32, 41%; p = 0.01).

CONCLUSION

The administration of N2O during post-operative physiotherapy can help to achieve more quickly an improved range of motion, and, although not significant in our study, to alleviate the need for pain medication. Further studies evaluating the administration of N2O in various settings are warranted.

SIGNIFICANCE

During this randomized placebo-controlled double-blind study, children receiving nitrous oxide and oxygen (N2O) achieved more often the targeted range of motion during physiotherapy sessions after multilevel surgery. Compared to placebo, nitrous oxide and oxygen (N2O) enabled a better management of acute pain related to physiotherapy procedures.

[Well-being in adulthood of patients with chronic conditions in childhood: The GEDEPAC-2 questionnaire]

BACKGROUND

In France, chronic diseases affect 3 million children. In children with chronic conditions, long-term somatic outcome has been well described, but little is known about the psychosocial aspects of well-being.

METHODS

Our aim was to build a self-administered questionnaire of global well-being in adults who had a chronic disease since or during childhood using a multidimensional and nonspecific approach. The questionnaire was constructed by a multidisciplinary group (epidemiologists, clinicians, sociologist, statistician). Items were built in compliance with reference data from the French general population (national surveys, free access) to allow comparative analysis adjusted for age and sex (and eventually other confounding factors) by indirect standardization (qualitative variables) or Z-scores (quantitative variables).

RESULTS

The GEDEPAC-2 includes 108 items exploring 11 domains: education, employment, housing, material security, social links, civic engagement, leisure, environment, physical health/risky behavior, health-related quality of life and sex life. Factual questions and satisfaction scales jointly explore social well-being. Quality of life is analyzed in terms of physical quality of life, mental quality of life, fatigue and burden of treatment by 3 questionnaires validated in French (SF-12; MFI-20; Burden of Treatment Questionnaire). Experience of transition from pediatric to adult healthcare is described in 21 items. Paper and electronic versions were developed.

CONCLUSION

Built in a multidimensional approach to well-being and in line with the available reference data, GEDEPAC-2 will facilitate the implementation of future studies on impact in adulthood of chronic disease in childhood.

Methodology used in comparative studies assessing programmes of transition from paediatrics to adult care programmes: a systematic review

OBJECTIVE

To explore the methodologies employed in studies assessing transition of care interventions, with the aim of defining goals for the improvement of future studies.

DESIGN

Systematic review of comparative studies assessing transition to adult care interventions for young people with chronic conditions.

DATA SOURCES

MEDLINE, EMBASE, ClinicalTrial.gov.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

2 reviewers screened comparative studies with experimental and quasi-experimental designs, published or registered before July 2015. Eligible studies evaluate transition interventions at least in part after transfer to adult care of young people with chronic conditions with at least one outcome assessed quantitatively.

RESULTS

39 studies were reviewed, 26/39 (67%) published their final results and 13/39 (33%) were in progress. In 9 studies (9/39, 23%) comparisons were made between preintervention and postintervention in a single group. Randomised control groups were used in 9/39 (23%) studies. 2 (2/39, 5%) reported blinding strategies. Use of validated questionnaires was reported in 28% (11/39) of studies. In terms of reporting in published studies 15/26 (58%) did not report age at transfer, and 6/26 (23%) did not report the time of collection of each outcome.

CONCLUSIONS

Few evaluative studies exist and their level of methodological quality is variable. The complexity of interventions, multiplicity of outcomes, difficulty of blinding and the small groups of patients have consequences on concluding on the effectiveness of interventions. The evaluation of the transition interventions requires an appropriate and common methodology which will provide access to a better level of evidence. We identified areas for improvement in terms of randomisation, recruitment and external validity, blinding, measurement validity, standardised assessment and reporting. Improvements will increase our capacity to determine effective interventions for transition care.

Whyever bladder tissue engineering clinical applications still remain unusual even though many intriguing technological advances have been reached?

To prevent problematic outcomes of bowel-based bladder reconstructive surgery, such as prosthetic tumors and systemic metabolic complications, research works, to either regenerate and strengthen failing organ or build organ replacement biosubstitute, have been turned, from 90s of the last century, to both regenerative medicine and tissue engineering.Various types of acellular matrices, naturally-derived materials, synthetic polymers have been used for either "unseeded" (cell free) or autologous "cell seeded" tissue engineering scaffolds. Different categories of cell sources - from autologous differentiated urothelial and smooth muscle cells to natural or laboratory procedure-derived stem cells - have been taken into consideration to reach the construction of suitable "cell seeded" templates. Current clinically validated bladder tissue engineering approaches essentially consist of augmentation cystoplasty in patients suffering from poorly compliant neuropathic bladder. No clinical applications of wholly tissue engineered neobladder have been carried out to radical-reconstructive surgical treatment of bladder malignancies or chronic inflammation-due vesical coarctation. Reliable reasons why bladder tissue engineering clinical applications so far remain unusual, particularly imply the risk of graft ischemia, hence its both fibrous contraction and even worse perforation. Therefore, the achievement of graft vascular network (vasculogenesis) could allow, together with the promotion of host surrounding vessel sprouting (angiogenesis), an effective graft blood supply, so avoiding the ischemia-related serious complications.

Out-of-Hospital screening for HIV, HBV, HCV and Syphilis in a vulnerable population, a public health challenge

We explored rates of Hepatitis B virus (HBV), Human Immunodeficiency Virus, Hepatitis C virus and Syphilis in a vulnerable population (mostly intravenous drug users, sex workers and homeless people) and focused on factors associated with failure to return for results (FTR) and with having a false perception (FP) of Immunization against HBV. We performed a prospective multicenter observational study in nine mobile (Out-of-Hospital) areas of screening located in Paris from 1 January 2014 through 31 December 2014. A total of 341 patients were recruited. The proportion of FTR for results was 38.75%. In multivariate analysis, unemployment was significantly associated with FTR (OR = 4.29; IC = [1.12; 16.39]), as well as having been screened in the past (OR = 4.32, IC = [1.70; 10.97]); 18.03% of patients had a FP of an Immunization against HBV. In multivariate analysis, having one's own place of residence protected against FP (OR = 0.33, [0.12; 0.95]), while being screened in the past enhanced the risk of FP (OR = 3.28, IC = [1.06; 10.11]). The rate of FTR is a problem and use of currently available technologies, such as phone texting, might be a partial solution in conjunction with rapid tests for diagnosis. In addition, more information and comprehension of the results should be provided together with specific anti-HBV vaccination campaigns targeting these specific populations.

Urology pertinent neuroendocrine tumors: focusing on renal pelvis, bladder, prostate located sympathetic functional paragangliomas

Urology pertinent neuroendocrine neoplasias are more and more driving to research attractive contributions mainly as regards the urinary tract paragangliomas, besides the prostate cancer neuroendocrine differentiation. About such visceral sympathetic paragangliomas, a considerable attention is aroused by those concerning the renal pelvis, urinary bladder and, particularly, the prostate gland. Essential catecholamine/adrenergic signal-mediated pathophysiological implications and outlined diagnostic approaches are here taken into consideration. Particularly, to reach an accurate functional diagnostic assessment, both plasma and urine catecholamine level tests are required together with ¹²³I or ¹³¹I-meta-iodobenzylguanidine (MIBG) scan while ¹³¹I-, instead of ¹²³I-, labeled MIBG, proving to be also useful to targeted radionuclide therapy of sympathetic paragangliomas. Nevertheless, a thorough diagnostic confirmation should be obtained by a proper histologic/ immunohistochemical study, so that it respectively highlighting the typical "zellballen" cell setting and neuroendocrine tumor cell specific biomarkers such as chromogranin-A, synaptophysin, neuron-specific enolase. Open/laparoscopic/robot-assisted surgical procedures are performed under α1 (doxazosin, prazosin) - and β(propranolol)-adrenergic blockade to avoid the risk of an intraoperative adrenergic signal-triggered hypertensive crisis, what moreover may occur also during cystoscopy and biopsy in case of bladder or prostate paraganglioma. Given a conceivable likeness, about some adrenergic-mediated pathophysiological implications, between prostate paraganglioma and prostate cancer neuroendocrine transdifferentiation - although as regards two obviously different diseases - a reliable pathogenetic matter concerning prostate paraganglioma is requiring novel research approaches.