[Management of EGFR mutated non-small cell lung carcinoma patients]. / Analyse de la prise en charge des cancers bronchiques avec mutation du gène de l'EGFR.

INTRODUCTION: Mutations in the epidermal growth factor receptor (EGFR) gene are commonly observed in non-small-cell lung cancer (NSCLC). Over the past decade, the management of NSCLC-carrying EGFR mutation has evolved considerably with the use of tyrosine kinase inhibitors (TKIs). The main objective of this retrospective study was to analyze the evolution of therapeutic strategies in a cohort of patients with metastatic or locally advanced EGFR- mutated NSCLC. METHODS: Data on patients with EGFR-mutated NSCLC, eligible for TKIs, and treated between 2010 to 2019 were collected. The main therapeutic strategies adopted following progression under TKIs and the prognostic factors for survival were analyzed. RESULTS: The median age of the 177 patients was included in the cohort was 70years. The majority of patients (77.4%) received TKIs as first-line treatment, while 16.4% received chemotherapy. Osimertinib initiation as second-line treatment was a factor for better prognosis (OR=0.5). Finally, change of chemotherapy line was the main therapeutic strategy adopted for 41.3% of the patients having relapsed under TKIs. DISCUSSION: Therapeutic management of EGFR-mutated NSCLC patients was in accordance with regional, national and international recommendations. The characterization of progression under TKI therapy has become systematic, allowing better adaption of therapeutic strategies.

[Geriatric assessment and treatment of nonmetastatic muscle-invasive bladder cancer in patients over 75 years of age. Retrospective and multicentric study of 121 cases]. / Pratique de l'évaluation oncogériatrique et traitements du cancer de vessie infiltrant localisé des patients âgés de plus de 75 ans. Étude rétrospective multicentrique de 121 cas.

OBJECTIVE: The aim of our study was to assess prevalence of geriatric assessment (GA) in patients over 75years with nonmetastatic invasive bladder cancer (MIBC). MATERIAL AND METHODS: We performed a retrospective study between 2000 and 2015. We assessed comobidity by Charlson score and ASA score, geriatric assessement (GA) and treatments. RESULTS: One hundred and twenty one patients were inclued. Median age was 81 (73-95) at diagnosis. Thirty nine patients (32%) were evaluated by GA, G8 screening tool was performed in 16% of patients. Patients without GA were older (82 vs. 81years) and had less comorbidities (Charlson≥2 à 61% vs. 69%). Seventy-four percent of patients received a curarive therapy: 60% were treated by RC, 9% by chemoradiotherapy, 26% received palliative therapy and 15% were only in observation. CONCLUSION: Patients with MIBC over 75years were less evaluated and less treated. Patients in pallative care received mostly observation. Although practices have improved, GA was underused. Care of these patients needs standardization in order to adapt therapeutic to their comorbidities and to treat them with curative intent. LEVEL OF PROOF: 4.

Thyroid surgery under hypnosis: A 50-case series.

OBJECTIVES: The study objective was to compare patient satisfaction after thyroid lobo-isthmectomy under hypnoanesthesia versus general anesthesia. METHODS: A retrospective study included 100 patients undergoing lobo-isthmectomy. A group of 50 patients under hypnoanesthesia was compared to a control group of 50 patients under general anesthesia. Satisfaction was assessed on questionnaire between three and six months after surgery. We also compared secondary criteria: procedure time, blood loss, intraoperative comfort, postoperative pain, postoperative complications and time to resumption of daily activities. RESULTS: Our study showed good overall satisfaction in patients operated under hypnoanesthesia, for equivalent operative safety and complications rate compared to general anesthesia. For comparable analgesia, postoperative pain was lower, but not significantly, in the Hypnosis group, while the rate of nausea and vomiting was significantly lower (p<0.05). Postoperative convalescence was shorter in the Hypnosis group: 3.7 versus 9.2 days (p<0.001). CONCLUSION: In thyroid surgery, hypnoanesthesia has real advantages over general anesthesia in that it places the patient at the center of the care team's attention. His or her active participation is essential during the process, bringing a new dimension to care, beneficial for the patient. However, it must be reserved for minimally invasive procedures in which organization is anticipated in full collaboration within teams that are willing and experienced.

Clinical ACO phenotypes: Description of a heterogeneous entity.

BACKGROUND: Because ACO (Asthma-COPD-Overlap) does not fill out asthma or COPD (Chronic Obstructive Pulmonary Disease) criteria, such patients are poorly evaluated. The aim of this study was to screen asthma and COPD for an alternative diagnosis of ACO, then to determine subgroups of patients, using cluster analysis. MATERIAL AND METHODS: Using GINA-GOLD stepwise approach, asthmatics and COPD were screened for ACO. Clusterization was then performed employing Multiple Correspondent Analysis (MCA) model, encompassing 9 variables (age, symptoms onset, sex, BMI (Body Mass Index), smoking, FEV-1, dyspnea, exacerbation, comorbidity). Finally, clusters were compared to determine phenotypes. RESULTS: MCA analysis was performed on 172 ACO subjects. To better distinguish clusters, the analysis was then focused on 55 subjects, having at least one cosine squared >0.3. Six clusters were identified, allowing the description of 4 phenotypes. Phenotype A represented overweighed heavy smokers, with an early onset and a severe disease (27% of ACO patients). Phenotype B gathered similar patients, with a late onset (29%). Patients from Phenotypes C-D were slighter smokers, presenting a moderate disease, with early and late onset respectively (respectively 13% and 31%). CONCLUSIONS: By providing evidences for clusters within ACO, our study confirms its heterogeneity, allowing the identification of 4 phenotypes. Further prospective studies are mandatory to confirm these data, to determine both specific management requirements and prognostic value.

[The global cardiovascular risk of patients with schizophrenia hospitalized in psychiatry at the university hospital of Saint-Étienne]. / Le risque cardiovasculaire global des patients atteints de schizophrénie hospitalisés en psychiatrie au CHU de Saint-Étienne.

CONTEXT: Patients suffering from schizophrenia present with a risk of cardiovascular death which is two to three times as high as the general population. OBJECTIVES: Our study aims to evaluate the global cardiovascular risk according to SCORE and Framingham on patients suffering from schizophrenia who have been hospitalized in psychiatric institutions and also to assess whether being under the care of a physician affects that risk. METHODS: A prospective descriptive epidemiologic study was conducted from April 2005 to March 2016. The study population consisted of adult patients suffering from schizophrenia who were hospitalized in the psychiatric unit of the CHU de Saint-Étienne. The data was collected during the clinical admission examination. The software CARDIORISK was used to compute the global cardiovascular risk according to SCORE and Framingham. RESULTS: The average cardiovascular risk was about four times as high for males as it was for females according to the SCORE model and twice as high according to the Framingham model. According to the SCORE model, 16.5 % of the patients presented a high cardiovascular risk versus 6.6 % according to the Framingham model. There was no statistically significant difference between patients who were under the care of a physician and those who were not, both in terms of the prevalence of the risk factors and in terms of the global cardiovascular risk. CONCLUSION: Using the global cardiovascular risk approach as a primary prevention measure could allow patients suffering from schizophrenia to be admitted earlier. Also, regularly reevaluating that risk could allow initiation of behavioral changes and/or important cardiovascular treatments.

Reflectance confocal microscopy identification of subclinical basal cell carcinomas during and after vismodegib treatment.

BACKGROUND: Recently, it has been shown that reflectance confocal microscopy (RCM) could identify subclinical basal cell carcinoma (BCC) during vismodegib treatment of locally advanced BCC. OBJECTIVES: To evaluate specificity and sensitivity of clinical, dermoscopic and RCM examination for BCC in patients with multiple BCCs treated by vismodegib. METHODS: Ninety four BCCs had 710 clinical, dermoscopic and RCM examinations during 72 weeks of vismodegib treatment. Thirty-eight were biopsied at the end of the treatment. Sensitivity and specificity for these 38 lesions were calculated. BCC diagnoses of clinical, dermoscopic and RCM examination on all the 710 investigations were compared using chi-square test. RESULTS: Reflectance confocal microscopy was extremely more sensitive than dermoscopy and clinical examination and slightly less specific (sensitivity of 95%, 35% and 33% and specificity of 81%, 88% and 86% for RCM, dermoscopy and clinical examination, respectively) for the identification of residual BCC in the 38 biopsied cases. Considering all the 710 observations, RCM correctly diagnosed more BCCs than dermoscopy and clinical examination. CONCLUSION: Reflectance confocal microscopy is a non-invasive technique that can detect subclinical residual BCC during and after vismodegib treatment helping the clinician to identify incomplete tumour regression.

Mucosal melanoma: clinical, histological and c-kit gene mutational profile of 86 French cases.

BACKGROUND: Mucosal melanomas are rare and highly aggressive tumours. Few studies evaluated mucosal melanomas of locations other than the head and neck region, and other than those of the Asian population. OBJECTIVES: The objective of this study was to analyse the clinical and histological features, as well as the mutational status of c-kit and b-raf gene of mucosal melanoma in any localization in a French series. METHODS: We investigated clinical (sex, age, performance status, survival, treatment of the patients and lack of pigmentation of the tumours) and histopathological features (ulceration, Breslow's index, mitotic rate), as well as the mutational status of c-kit and b-raf of 86 mucosal melanomas diagnosed in 15 years in four French University Hospitals. RESULTS: Most melanomas affected women (72%) and the genital region (46.5%). A fifth of melanomas were amelanotic. 81% of melanomas had a Breslow's index ≥1, whereas all glans melanomas, and most vulvar melanomas had a Breslow index ≤1 mm. Overall survival was 54% at 3 years; 11.6% of the 43 tested mucosal melanomas were c-kit-mutated while the 15 tested genital melanomas were not. The c-kit gene mutation did not influence the overall survival. Age ≥ 50, amelanotic type and performance status ≥1 were not poor prognostic factors in our series. CONCLUSION: This study confirmed that mucosal melanomas are rare and could be difficult to diagnose being often amelanotic and in hidden sites. Most melanomas were thick at the diagnosis, but glans and vulvar melanomas were thinner probably because of their greater visibility. The frequency of the c-kit mutation varied depending on the initial tumour site. In our series, the prognosis was poor, independently from c-kit mutations and the patient's general health and age. The presence of metastasis at diagnosis was associated with a worse prognosis indicating the importance of an early diagnosis.

Skin graft secured by VAC (vacuum-assisted closure) therapy in chronic leg ulcers: A controlled randomized study.

INTRODUCTION: Leg ulcers are a common condition. There have been very few studies of combined therapy involving VAC (vacuum-assisted closure) and skin graft. METHODS: We performed a randomized controlled trial of VAC therapy vs. hydrocolloid dressings over 5 days following autologous grafting on chronic leg ulcers. The primary objective was to assess the difference in success (defined as a reduction in wound area of at least 50% at 1 month) between the two dressing methods. Forty-six patients with ulcers present for over one month were included. Following a 7-day hospitalization period, follow-up was performed for 3 months on an outpatient basis. RESULTS: Our study does not demonstrate a statistically significant difference, with a 45.8% success rate in the VAC group vs. 40.9% in the conventional dressing group (P=0.73). In the venous ulcer group, the success rate was 57.9% for VAC vs. 40% for conventional dressings (P=0.3). The difference in favor of VAC in this group was not statistically significant, most likely due to an insufficient number of patients studied. CONCLUSION: Our study does not demonstrate superiority of VAC associated with skin graft over conventional dressings. We observed more complications with VAC (40%) than with conventional dressings (23%) (P=0.06).

Reflectance confocal microscopy for quantification of Sarcoptes scabiei in Norwegian scabies.

BACKGROUND AND OBJECTIVES: In vivo reflectance-mode confocal microscopy (RCM) can be used for the diagnosis of scabies. This study quantifies S. scabiei and its eggs and droppings in a patient affected by Norwegian Scabies (NS), and describes their distribution within the epidermis and in different body areas. METHODS: Different skin sites were randomly chosen in four sections (head, upper limbs, trunk and inferior limbs) of the body surface area (BSA) to acquire a total of 60 RCM z-stacks. The number of mites and eggs, the presence of droppings, as well as the minimum epidermal depth at which mites, eggs and faeces were detectable, was established for each z-stack. The total number of mites and eggs on the entire BSA was calculated considering the weighted mean for the four sections of the BSA. RESULTS: A total of 15.8 millions of S. scabiei and 7.2 millions of eggs were calculated. Mites, eggs and faeces were homogeneously distributed all over the body surface. Droppings, easily recognized by the RCM, were present in more than an half of the analyzed cutaneous sites and were associated with the presence of parasites (chi-squared test, P = 0.002). CONCLUSIONS: Our study illustrates the ability of RCM to identify, locate, and quantify the various forms of S. scabiei in human skin. NS is an extremely contagious disease, considering that the number of mites can be around 15.8 millions. Moreover, all areas of the body are parasitized in NS, including the face.

[Possibility to screen COPD in emergency department]. / Faisabilité d'un dépistage de la BPCO aux urgences.

INTRODUCTION: The COPD is a stake of public health because of its prevalence in the world, its morbi-mortality and its considerable cost (2,2 billion euros/year in France). An early screening allows for a fast and effective intervention. MATERIAL AND METHOD: The prospective study with in the emergency department of Roanne included smokers and ex-smokers, more than 10PY for the 40 years old and older, more than 20PY for the others, and/or symptomatic of COPD. Screening rested on a questionnaire filled out by the patient. Are excluded patients already diagnosed with COPD. This screening is carried out with the FEV1/FEV6. The criterion of principal judgment rests on the time taken for screening and acceptability by the patients. RESULTS: One hundred and twenty-two patients were included, 6.5% refused screening. The average time of screening was 4.8 minutes. There were 27 positive patients with the FEV1/FEV6, 14 came to make the classic spirometry. Only 10.53% have a FEV1/FEV6<0.73. On the whole, 15.86% do not have a COPD, 75,25% are at the risk of COPD, 5,94% have a COPD stage 1, 1,98% are stage 2, 0.99% stage 3 and none stage 4. DISCUSSION: The study thus showed that a screening of the COPD in the emergency rooms is possible because of the simple and reproductible process. Its shows, however its limits since the number of inclusion decrease during days of strong attendance in emergency rooms. CONCLUSION: The screening of the COPD as foreseen in the study is possible.

Integrating the Modelling of EN 1828 and Galen CCAM Ontologies with Protégé: towards a Knowledge Acquisition Tool for Surgical Procedures.

The presentation assess the usability of the ontology platform protégé integrated with the terminology reasoning tool RACER to represent different terminology systems as the CEN European standard EN 1828 which is a categorical structure and the extensive French coding system CCAM supported by a GALEN representation. We present the 2 systems and some results showing the easiness to test the consistence of the ontology or of instances of terminology systems.This type of software tool which is accessible as open source could support a convergent "reference terminology representation" approach. Based on a formal representation development and allowing diversity in linguistic expressiveness of end users this approach can associate shared knowledge acquisition in the public domain and competing systems, software developers and researchers.

[Missing data mechanisms of the questionnaire SF-36's items in the SU.VI.MAX study]. / Non-réponses aux questionnaires de qualité de vie SF-36 dans un échantillon de l'étude SU.VI.MAX.

BACKGROUND: Health related quality of life is becoming of greater importance in the medical field. Nevertheless, methodological problems persist, and particularly when it comes to processing missing data on quality of life questionnaires. In fact, this leads to three difficulties: (i) loss of power; (ii) bias; (iii) choice of the most adequate method for treating missing data. Prevention is the best recommendation in order to avoid unanswered questions. Unfortunately, this does not guarantee the absence of missing data. Therefore, the treatment of missing data depends on: i) identification of the missing data mechanism and ii) choice of the most appropriate method to correct the data. The main objective of this article is to illustrate the identification of non-response items as described in the SF-36 questionnaire items in the SU.VI.MAX study. METHODS: A logistic regression on the characteristics of the subjects was used to distinguish between two missing data mechanisms: missing completely at random (MCAR) and missing at random (MAR). Two global Chi-2 tests on MCAR mechanism were proposed. The missing data not at random (MNAR) mechanism was also analysed considering the questionnaire features. RESULTS: The percentage of non-responses was small (1.7%), with a maximum equal to 3% for four questions of the General Health dimension (GH2 to GH5). Both global Chi-2 tests rejected the hypothesis that all SF-36 non-responses were MCAR. As to the 32 items with less than 2.3% of non-responses, the mechanisms were: MCAR for 29 items, MAR for 2 items, and probably MNAR for 1 item. The logistic regression indicates that the factors related to non-responses were gender (female), age (> or =50 years), attention problem, and number of children (> or =3). The hierarchical feature of item PF5 (climb one flight of stairs) in relation to PF4 (climb several flights of stairs) would be a generator MNAR non-responses. The "I don't know" response modality of bloc GH2 to GH5 would also be generator of non-responses of the MNAR type. CONCLUSION: The identification of missing data mechanisms through statistical analysis and through further reflection on the questionnaire's features is a necessary preliminary in the treatment of non-responses.

[Does a particular risk associated with papillomavirus infections exist in women with lupus?]. / Existe-t-il un risque particulier lié aux infections à papillomavirus chez les femmes lupiques?

PURPOSE: There is strong evidence that papillomavirus infections (HPV), especially infections with HPV 16/18, are involved in the development of dysplasia and cancers. Cervical cancer is thought to be increased in women with systemic lupus erythematosus (SLE). METHODS: To assess this risk we studied cervical smears from 11 women with SLE and determined the prevalence of HPV infection by in situ hybridization. RESULTS: Dysplasia was found in 9% of women with SLE and in 0.03% of control subjects (non significant difference). Dysplasia was found to be six times more frequent in women with SLE (18% versus 3%, P < 0.01). HPV prevalence in normal smears was 37.5% in women with SLE versus 14.7% in control subjects (non-significant difference). Identified HPV genotypes were those for which intermediate or high risk is well established. No correlation was found between infection or dysplasia risk and the lymphocyte count or a previous treatment with cyclophosphamide. CONCLUSION: We conclude that women with SLE would be at increased risk of HPV infection, dysplasia and cervical cancer. We suggest that women with SLE should be regularly tested for cervical cancer by colposcopy, especially in case of HPV 16 infection.