Determinants of radiological patterns and severity in immunocompromised adults with Metapneumovirus infection

BACKGROUND

Human Metapneumovirus (HMPV) belongs to the Pneumoviridae family and is responsible for respiratory infections. Mild infections are well-recognized in children, while its precise impact in various categories of immunocompromised adults has not been well addressed.

RESEARCH QUESTION

We retrospectively studied HMPV infections in immunocompromised adults followed in two large French university medical centers.

STUDY DESIGN AND METHODS

We identified immunocompromised adults with positive HMPV Polymerase Chain Reaction (PCR) for 36 months and reviewed their medical charts. For lung transplant recipients (LTR), FEV1 was collected at baseline, during and after infection. Imaging was centralized and chest involvement was categorized by dominant CT patterns. We compared severe patients (requiring oxygen or ventilation) and non hypoxemic patients.

RESULTS

Seventy-two patients were included, 27 were LTR, 25 had a hematological malignancy or were hematopoietic stem cell recipients, 20 had another immunocompromised status. Twenty patients (28%) presented a hypoxemic infection, requiring hospitalization and intensive care units transfers in 50/72 (69.4%) and 9/72 (12.5%) respectively, with only one death. Hypoxemia was less pronounced in LTRs (p = 0.014). Finally, age and dyspnea remained independent factors associated with hypoxemia (p < 0.005). The most frequent radiological patterns were bronchopneumonia (34.2%) and bronchiolitis (39.5% and 64.3% in the overall population and in LTRs respectively, p = 0.045). FEV1 improved in LTRs at one month and 85% had recovered their baseline FEV1 within 6 months.

INTERPRETATIONS

In immunocompromised adults, HMPV infections required frequent hospitalizations and ICU transfers, while mortality is low. In LTRs, bronchiolitis pattern was predominant with short and long-term favorable outcome.

[Pulmonary complications of Chronic Granulomatous Disease]

Chronic Granulomatosis Disease (CGD) is an inherited immune deficiency due to a mutation in the genes coding for the subunits of the NADPH oxidase enzyme that affects the oxidative capacity of phagocytic cells. It is characterized by increased susceptibility to bacterial and fungal infections, particularly Aspergillus, as well as complications associated with hyperinflammation and granulomatous tissue infiltration. There exist two types of frequently encountered pulmonary manifestations: (1) due to their being initially pauci-symptomatic, possibly life-threatening infectious complications are often discovered at a late stage. Though their incidence has decreased through systematic anti-bacterial and anti-fungal prophylaxis, they remain a major cause of morbidity and mortality; (2) inflammatory complications consist in persistent granulomatous mass or interstitial pneumoniae, eventually requiring immunosuppressive treatment. Pulmonary complications recurring since infancy generate parenchymal and bronchial sequelae that impact functional prognosis. Hematopoietic stem cell allograft is a curative treatment; it is arguably life-sustaining and may limit the morbidity of the disease. As a result of improved pediatric management, life expectancy has increased dramatically. That said, new challenges have appeared with regard to adults: difficulties of compliance, increased inflammatory manifestations, acquired resistance to anti-infectious therapies. These different developments underscore the importance of the transition period and the need for multidisciplinary management.

Role of statins in patients with MINOCA. A systematic review and meta-analysis

Background

Given the complex etiology and a limited amount of evidence, the medical treatment (including statin use) of myocardial infarction with non-obstructive coronary artery disease (MINOCA) remains uncertain. The objective of the present study was to evaluate the effect of statin therapy on major cardiovascular events (MACE) and mortality in MINOCA patients.

Methods

A systematic review and meta-analysis of time-to-event outcomes were performed from statin's studies therapy on MINOCA patients, reporting data from MACE or mortality, after searching the PubMed/MEDLINE, Embase, Science Direct, Scopus, Google Scholar, and Cochrane databases.

The Meta-analysis Of Observational Studies (MOOSE) and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were used to check the reporting of observational studies. The quality of the included studies was assessed by two independent review authors using the Newcastle-Ottawa Scale (NOS). The summary effect of statin therapy on the endpoints were calculated. Measures of effect size were expressed as HRs, and the I2 statistic was calculated to quantify between-studies heterogeneity and inconsistency. A fixed-effects meta-analysis model and sensitivity analysis was then applied. The level of statistical significance was set at a 2-tailed alpha of 0.05.

Results

Six observational studies of statin therapy on MINOCA, involving a total of 11171 patients, were identified and considered eligible for analysis (9129 subjects received statin therapy while 2042 patients were part of the respective control arms). Quantitative analysis (5 studies were included) showed that statin use was associated with lower mortality (HR: 0.65; 95% CI: 0.56–0.75, I2: 0%). Also, the meta-analysis showed that statin therapy was associated with a lower incidence of MACE (HR: 0.78; 95% CI: 0.69–0.88, I2: 27%).

Conclusion

Our data suggest that in a population with MINOCA, the use of statin therapy results in significant reduction on MACE and mortality. These results must be confirmed in future clinical trials.

Funding Acknowledgement

Type of funding sources: None. Mortality and MACESensitivity analysis

Non-statin lipid-lowering therapy in coronary atherosclerosis regression: a meta-analysis and meta-regression

Introduction

Several studies have investigated the association between non-statin lipid-lowering therapy and regression of atherosclerosis. However, the studies were mostly small and their results were not always robust.

Objectives

(1) to define if a dual lipid-lowering therapy (statin ± non-statin drugs) is associated with coronary atherosclerosis regression, estimated by intravascular ultrasound (IVUS); (2) to assess the association between dual lipid-lowering-induced changes in LDL-C and non-HDL-C levels and atherosclerosis regression.

Methods

We performed a meta-analysis including trials of non-statin lipid-lowering therapy, reporting C-LDL, non-HDL-C and total atheroma volume (TAV) with a minimum of 6 months of follow-up. The primary endpoint was defined as the change in TAV measured from baseline to follow-up, comparing groups of subjects on statins alone versus combination of statin and non-statin drugs. The random-effects model and meta-regression were performed.

Results

Eight eligible trials of non-statin lipid-lowering drugs (1759 patients) were included. Overall, the dual lipid-lowering therapy was associated with a significant reduction in TAV [−3.5 mm3 (95% CI: −4.5 to −2.6)]; I2=11%]. In the analysis stratified according to the lipid-lowering drug class (ezetimibe or PCSK9 inhibitors), the findings were similar. In a meta-regression, a 10% decrease in LDL-C or non-HDL-C levels, was associated, respectively, with 0.92 mm3 and 1.05 mm3 regressions in TAV.

Conclusion

Our data suggest the addition of ezetimibe or PCSK9 inhibitors to statin therapy results in significantly increased regression of TAV. When the LDL-C and non-HDL-C levels reached were lower, the observed effect was also greater.

Forest Plot by Drugs Group

Funding Acknowledgement

Type of funding source: None

Role of colchicine in stroke prevention: an updated meta-analysis

Background

Colchicine is a microtubule inhibitor with anti-inflammatory proprieties. As the body and quality of evidence regarding the efficacy of colchicine for cardiovascular prevention is controversial, the aims of this study was to evaluate the effect of colchicine therapy on vascular events.

Methods

A meta-analysis was performed of randomized controlled clinical trials of colchicine on high cardiovascular risk populations, reporting data from stroke, myocardial infarction, cardiovascular mortality and all-cause mortality, after searching the PubMed/MEDLINE, Embase and Cochrane Controlled Trials databases. A random-effects meta-analysis model was then applied.

Results

Nine eligible trials of colchicine therapy, involving a total of 6630 patients, were considered eligible for analysis (3359 subjects were allocated to receive colchicine while 3271 subjects were allocated to the respective control arms). The stroke incidence was lower in the colchicine group compared with placebo arm (OR, 0.33; 95% CI, 0.15–0.70; six studies evaluated). We did not find a significant reduction in the incidence of myocardial infarction, cardiovascular mortality or all-cause mortality.

Conclusion

Our data suggest that in a population with high cardiovascular risk, the use of colchicine results in significantly reduction on stroke risk. Colchicine is an accessible drug that could be successfully utilized for the prevention of atherosclerotic cerebrovascular disease. The tolerability and benefits should be confirmed in ongoing clinical trials.

Forest Plot Primary endpoint

Funding Acknowledgement

Type of funding source: None

MRI detected extaprostatic extension (EPE) in prostate cancer: Do all T3a patients have the same outcomes?

MRI-detected T3a prostate cancer is a heterogeneous disease. This post-hoc analysis of a prospective trial found that patients with T3a disease presenting obliteration of the recto-prostatic angle, contact-asymmetry of neuro-vascular bundle and periprostatic fat invasion, may be at higher risk of biochemical failure and metastases.

Perinatal mortality associated with congenital defects of the central nervous system in Colombia, 2005-2014

In Colombia, congenital anomalies are the second leading cause of death in children aged less than 1 year, and central nervous system (CNS) anomalies are the second most common cause within this group. The aim of the study is to determine the frequency of perinatal mortality attributable to CNS anomalies in Colombia between 2005 and 2014. Using data from the Integral Information System of Social Protection (SISPRO), we determined the perinatal mortality rate associated with CNS anomalies; we also determined frequency of mortality according to age, type of abnormality, year of presentation, and georeferencing. A total of 4706 deaths were recorded to be primarily caused by CNS anomalies (anencephaly and hydrocephalus) in departments and prominent urban centers. The perinatal mortality rate associated with CNS defects has remained relatively constant over the past several years. Major referral centers in the country registered the highest mortality rates. The impact of CNS defects increased with the decrease in infant mortality rates and other health issues. Reinforcement of primary and secondary prevention strategies is warranted for reducing its incidence.

The Effect of Price on Surgeons' Choice of Implants: A Randomized Controlled Survey

PURPOSE

Surgical costs are under scrutiny and surgeons are being held increasingly responsible for cost containment. In some instances, implants are the largest component of total procedure cost, yet previous studies reveal that surgeons' knowledge of implant prices is poor. Our study aims to (1) understand drivers behind implant selection and (2) assess whether educating surgeons about implant costs affects implant selection.

METHODS

We surveyed 226 orthopedic surgeons across 6 continents. The survey presented 8 clinical cases of upper extremity fractures with history, radiographs, and implant options. Surgeons were randomized to receive either a version with each implant's average selling price ("price-aware" group), or a version without prices ("price-naïve" group). Surgeons selected a surgical implant and ranked factors affecting implant choice. Descriptive statistics and univariate, multivariable, and subgroup analyses were performed.

RESULTS

For cases offering implants within the same class (eg, volar locking plates), price-awareness reduced implant cost by 9% to 11%. When offered different models of distal radius volar locking plates, 25% of price-naïve surgeons selected the most expensive plate compared with only 7% of price-aware surgeons. For cases offering different classes of implants (eg, plate vs external fixator), there was no difference in implant choice between price-aware and price-naïve surgeons. Familiarity with the implant was the most common reason for choosing an implant in both groups (35% vs 46%). Price-aware surgeons were more likely to rank cost as a factor (29% vs 21%).

CONCLUSIONS

Price awareness significantly influences surgeons' choice of a specific model within the same implant class. Merely including prices with a list of implants leads surgeons to select less expensive implants. This implies that an untapped opportunity exists to reduce surgical expenditures simply by enhancing surgeons' cost awareness.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic/Decision Analyses I.

Indications and outcome of splenectomy in hematologic disease

Splenectomy is part of the therapeutic arsenal for benign or malignant hematological disorders that constitute the main indication for elective splenectomy. With the development of minimally invasive approaches, and in particular, laparoscopy, as well as the advent of monoclonal antibody therapy, the indications and the outcomes of splenectomy for hematologic disease have changed in recent years. Nonetheless, splenectomy has its place in hemoglobinopathies and hemolytic diseases, improves thrombocytopenia in refractory immune thrombocytopenic purpura, can reverse sequelae linked to voluminous splenomegaly secondary to myelofibrosis, or can be used for diagnostic purposes or for splenomegaly in lymphoproliferative syndromes.

Testing Hadronic Interactions at Ultrahigh Energies with Air Showers Measured by the Pierre Auger Observatory

Ultrahigh energy cosmic ray air showers probe particle physics at energies beyond the reach of accelerators. Here we introduce a new method to test hadronic interaction models without relying on the absolute energy calibration, and apply it to events with primary energy 6-16 EeV (E_{CM}=110-170  TeV), whose longitudinal development and lateral distribution were simultaneously measured by the Pierre Auger Observatory. The average hadronic shower is 1.33±0.16 (1.61±0.21) times larger than predicted using the leading LHC-tuned models EPOS-LHC (QGSJetII-04), with a corresponding excess of muons.

Pre-transplant donor CD4- invariant NKT cell expansion capacity predicts the occurrence of acute graft-versus-host disease

Clinically useful pre-transplant predictive factors of acute graft-versus-host-disease (aGVHD) after allogeneic hematopoietic stem cell transplantation (allo-SCT) are lacking. We prospectively analyzed HSC graft content in CD34⁺, NK, conventional T, regulatory T and invariant natural killer T (iNKT) cells in 117 adult patients before allo-SCT. Results were correlated with occurrence of aGVHD and relapse. In univariate analysis, iNKT cells were the only graft cell populations associated with occurrence of aGVHD. In multivariate analysis, CD4^- iNKT/T cell frequency could predict grade II-IV aGVHD in bone marrow and peripheral blood stem cell (PBSC) grafts, while CD4^- iNKT expansion capacity was predictive in PBSC grafts. Receiver operating characteristic analyses determined the CD4^- iNKT expansion factor as the best predictive factor of aGVHD. Incidence of grade II-IV aGVHD was reduced in patients receiving a graft with an expansion factor above versus below 6.83 (9.7 vs 80%, P<0.0001), while relapse incidence at two years was similar (P=0.5).The test reached 94% sensitivity and 100% specificity in the subgroup of patients transplanted with human leukocyte antigen 10/10 PBSCs without active disease. Analysis of this CD4^- iNKT expansion capacity test may represent the first diagnostic tool allowing selection of the best donor to avoid severe aGVHD with preserved graft-versus-leukemia effect after peripheral blood allo-SCT.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

Measurement of the Radiation Energy in the Radio Signal of Extensive Air Showers as a Universal Estimator of Cosmic-Ray Energy

We measure the energy emitted by extensive air showers in the form of radio emission in the frequency range from 30 to 80 MHz. Exploiting the accurate energy scale of the Pierre Auger Observatory, we obtain a radiation energy of 15.8±0.7(stat)±6.7(syst)  MeV for cosmic rays with an energy of 1 EeV arriving perpendicularly to a geomagnetic field of 0.24 G, scaling quadratically with the cosmic-ray energy. A comparison with predictions from state-of-the-art first-principles calculations shows agreement with our measurement. The radiation energy provides direct access to the calorimetric energy in the electromagnetic cascade of extensive air showers. Comparison with our result thus allows the direct calibration of any cosmic-ray radio detector against the well-established energy scale of the Pierre Auger Observatory.

Treatment of acute leukemia in children with ataxia telangiectasia (A-T)

Early onset ataxia telangiectasia (A-T) is a neurodegenerative DNA-instability disorder, which presents early in childhood. Hallmarks of A-T are progressive ataxia and a dramatic increased risk of developing malignancies (25%), especially of hematological origin. In children these malignancies mainly concern aggressive Non-Hodgkin lymphoma, acute leukemias and Hodgkin lymphoma. Of the acute leukemias, T-cell lymphoblastic leukemia (T-ALL) is by far the most common. Since patients with A-T experience increased toxicity to radio- and chemotherapeutic treatment, the optimal treatment strategy of acute leukemia remains subject of debate. Review of literature of treatment of T-ALL in patients with A-T (n = 18) showed that many patients are not diagnosed with A-T at time of presentation of T-ALL. This implicates that physicians must be aware of symptoms of A-T in young patients presenting with T-ALL. Complete remission rates are high following upfront modified as well as unmodified treatment strategies. Treatment of ALL in children with A-T is feasible and should be performed. Definitive treatment strategy must be determined by shared decision making with patient, caretakers and medical team. Future prospective studies are needed to elucidate optimal treatment strategy.

Search for patterns by combining cosmic-ray energy and arrival directions at the Pierre Auger Observatory

Energy-dependent patterns in the arrival directions of cosmic rays are searched for using data of the Pierre Auger Observatory. We investigate local regions around the highest-energy cosmic rays with [Formula: see text] eV by analyzing cosmic rays with energies above [Formula: see text] eV arriving within an angular separation of approximately 15[Formula: see text]. We characterize the energy distributions inside these regions by two independent methods, one searching for angular dependence of energy-energy correlations and one searching for collimation of energy along the local system of principal axes of the energy distribution. No significant patterns are found with this analysis. The comparison of these measurements with astrophysical scenarios can therefore be used to obtain constraints on related model parameters such as strength of cosmic-ray deflection and density of point sources.

Reconstructive procedures for treating peri-implantitis: a systematic review

This review aimed at evaluating the effectiveness of reconstructive procedures for treating peri-implantitis. Searches of electronic databases and cross-referencing were performed for human comparative clinical trials with ≥ 10 implants for ≥ 12 months of follow-up, reporting radiographic defect fill and at least one of the following parameters: probing depth reduction, clinical attachment level gain, bleeding on probing reduction, and mucosal recession. The searches retrieved 430 citations. Only 1 randomized controlled trial was identified, which compared reconstructive therapy and open flap debridement. Case series studies were also included to evaluate the overall performance of the reconstructive procedures. Twelve studies were finally included. Meta-analysis revealed that the weighted mean radiographic defect fill was 2.17 mm (95% confidence interval [CI]: 1.46-2.87 mm), probing depth reduction was 2.97 mm (95% CI: 2.38-3.56 mm), clinical attachment level gain was 1.65 mm (95% CI: 1.17-2.13 mm), and bleeding on probing reduction was 45.8% (95% CI: 38.5%-53.3%). Great variability in reparative outcomes was found, attributed to patient factors, defect morphology, and reconstructive agents used. Currently, there is a lack of evidence for supporting additional benefit of reconstructive procedures to the other treatment modalities for managing peri-implantitis.

[Diagnosis and treatment of CMV and EBV Reactivation as well as Post-transplant Lymphoproliferative Disorders following Allogeneic Stem Cell Transplantation: An SFGM-TC report]

In the attempt to harmonize clinical practices between different French transplantation centers, the French Society of Bone Marrow Transplantation and Cell Therapy (SFGM-TC) set up the third annual series of workshops which brought together practitioners from all member centers and took place in October 2012 in Lille. Here the SFGM-TC addressed the issue of post-transplant CMV and EBV reactivation, and EBV-related Lymphoproliferative Disorders.