A French Preoperative Cholesteatoma Management: Current Preoperative Consultation and Tendencies.

Objectives: This study aimed to characterize the information delivery during preoperative consultations for cholesteatoma removal surgery in 2024. The secondary objective was to identify any factors influencing the information delivered. Methods: This study was a practice survey which included 33 closed-ended questions and 1 open-ended question. Seven questions concerned the participants' characteristics and 2 questions concerned the physiopathology of cholesteatoma. Nine questions focused on surgical information, six questions focused on the procedure modalities and ten questions focused on the risks of complications from the intervention. Results: Eighty-two surgeons answered the survey. In 75% of the cases, an information form written by a professional society was provided. The risk of recurrence or residual post-operative cholesteatoma was systematically stated in 78% of cases (n = 64), while the risk of aesthetic sequelae was only stated in 1% (n = 1). Participants working in a university hospital were more likely to inform patients about the risks of vertigo (p = 0.04), aesthetic risks (p = 0.04), poor functional outcomes (p = 0.04), surgical revision (p = 0.05) and the risk of peripheral facial paralysis (p = 0.05). Surgeons who mainly practiced otology were more likely to inform patients about the risks of recurrence and/or residual cholesteatoma (p = 0.02) and taste disturbances (p = 0.02). Conclusions: Cholesteatoma surgery was well explained to patients during the preoperative consultation, mostly with written support, even if the information given was not the same for all complication risks. It could be useful to create an information form dedicated to cholesteatoma surgery to improve comprehensive information and maintain a trustworthy relationship with patients.

Efficacy, safety, and cost of pomalidomide in relapsed and refractory multiple myeloma.

OBJECTIVES: To investigate the efficacy, safety, and cost of a pomalidomide-dexamethasone regimen in patients with relapsed and refractory multiple myeloma (RRMM). METHODS: All patients (n = 63) treated with pomalidomide-dexamethasone for RRMM in our university hospital between August 2013 and October 2015 were included. RESULTS: Pomalidomide was discontinued early due to progression (before the 4th cycle) in 17 (27%) patients. No case was discontinued for intolerance. The only independent factor that predicted early pomalidomide discontinuation was time from diagnosis to pomalidomide initiation <3 years. Overall response rate was 51% including complete response in 8%, very good partial response in 25%, and partial response in 19% patients. Thirteen (33%) patients showed stable disease. Median overall survival was 6.4 months in the 17 patients who discontinued pomalidomide early vs 26.8 months in the 14 patients with stable disease vs not achieved in the 32 responders (log-rank; P < 10-3 ). The most common grade ≥3 adverse events were neutropenia (14%) and infections (25%). The incremental cost-effectiveness ratio of pomalidomide-dexamethasone compared with dexamethasone alone was estimated at €39 911 per life-year gained. CONCLUSIONS: The study demonstrated that pomalidomide-dexamethasone regimen has a long-term favorable safety-efficacy profile in RRMM patients. The survival benefit is substantial even in patients with stable disease.

Medicoeconomic analysis of lobectomy using thoracoscopy versus thoracotomy for lung cancer: a study protocol for a multicentre randomised controlled trial (Lungsco01).

INTRODUCTION: In the last decade, video-assisted thoracoscopic surgery (VATS) lobectomy for non-small cell lung cancer (NSCLC) has had a major effect on thoracic surgery. Retrospective series have reported benefits of VATS when compared with open thoracotomy in terms of postoperative pain, postoperative complications and length of hospital stay. However, no large randomised control trial has been conducted to assess the reality of the potential benefits of VATS lobectomy or its medicoeconomic impact. METHODS AND ANALYSIS: The French National Institute of Health funded Lungsco01 to determine whether VATS for lobectomy is superior to open thoracotomy for the treatment of NSCLC in terms of economic cost to society. This trial will also include an analysis of postoperative outcomes, the length of hospital stay, the quality of life, long-term survival and locoregional recurrence. The study design is a two-arm parallel randomised controlled trial comparing VATS lobectomy with lobectomy using thoracotomy for the treatment of NSCLC. Patients will be eligible if they have proven or suspected lung cancer which could be treated by lobectomy. Patients will be randomised via an independent service. All patients will be monitored according to standard thoracic surgical practices. All patients will be evaluated at day 1, day 30, month 3, month 6, month 12 and then every year for 2 years thereafter. The recruitment target is 600 patients. ETHICS AND DISSEMINATION: The protocol has been approved by the French National Research Ethics Committee (CPP Est I: 09/06/2015) and the French Medicines Agency (09/06/2015). Results will be presented at national and international meetings and conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT02502318.

De-escalation chemotherapy and hematological profiles in patients with advanced Hodgkin's lymphoma.

BACKGROUND: There is a need to develop treatment strategies that are less toxic than BEACOPPescalated x6 cycles, the standard-of-care in advanced Hodgkin's lymphoma patients. OBJECTIVE: To compare short-term hematological toxicity in advanced Hodgkin's lymphoma patients treated with either BEACOPPescalated x6 cycles (standard group) or BEACOPPescalated x2 followed by ABVD x4 cycles (experimental group). METHOD: In 27 patients, we compared injections of erythropoiesis stimulating agent and granulocyte colony-stimulating factor, transfusions, hospitalization days, as well as hemoglobin, platelet, leukocyte levels. Method In 27 patients, we compared injections of erythropoiesis stimulating agent and granulocyte colony-stimulating factor, transfusions, hospitalization days, as well as hemoglobin, platelet, leukocyte levels. RESULTS: The mean number of erythropoiesis stimulating agent and granulocyte colony-stimulating factor injections, platelet transfusions and hospitalization days was significantly lower in the experimental group (erythropoiesis stimulating agents: mean difference -6.6 ± 2.4, p = 0.005; granulocyte colony-stimulating factors: mean difference -8.3 ± 3.6, p = 0.020, platelet transfusions: mean difference -0.6 ± 0.3, p = 0.035; hospitalization days: mean difference: -8.5 ± 1.7 days, p < 10(-3)). There were no differences in terms of red cell transfusions, platelet counts or leukocyte levels between the two groups. From the 3rd chemotherapy cycle, hemoglobin levels decreased to a significantly lesser extent in the experimental group. CONCLUSION: We demonstrated an overall better short-term hematological profile in advanced Hodgkin's lymphoma patients who received a de-escalation chemotherapy regimen with significant differences mainly in terms of hemoglobin levels, erythropoiesis stimulating agent injections, and hospitalization days.

Usefulness and limitations of contractile reserve evaluation in patients with low-flow, low-gradient aortic stenosis eligible for cardiac resynchronization therapy.

AIMS: In low-flow, low-gradient aortic stenosis (LF/LG AS), the assessment of contractile reserve (CR) by dobutamine stress echocardiography (DSE) is recommended for risk stratification and treatment strategy. However, DSE may show limitations in cases of left ventricular dyssynchrony (LVD). The impact of LVD in LF/LG AS, and the feasibility of CRT in this setting have never been evaluated. We aimed to assess: (i) the proportion of LF/LG AS patients with LVD; (ii) the influence of LVD on CR at DSE; and (iii) the effects of CRT in these patients. METHODS AND RESULTS: Thirty consecutive patients with LF/LG AS underwent DSE with study of CR. The operative risk for aortic valve replacement (AVR) was assessed using the logistic EuroSCORE. Twenty-one of the 30 patients had LVD. They were significantly older, more symptomatic, had a higher EuroSCORE, and a lower prevalence of CR than those with a narrow QRS (47% vs. 100%, P = 0.009). A CRT pacemaker was implanted in 19 of the 21 patients with LVD. All 19 (except for one patient who died suddenly) experienced significant clinical and echocardiographic improvement. Fourteen CRT patients underwent subsequent AVR with a low event rate. Four CRT patients refused AVR; two of them worsened again 1-2 years post-CRT. CONCLUSION: LVD is common in LF/LG AS patients and may be a major mechanism of afterload mismatch, as well as a cause of underdetection of CR. CRT in this population is feasible and may be proposed as a bridge to surgery.

Predictive factors of transarterial chemoembolisation toxicity in unresectable hepatocellular carcinoma.

BACKGROUND: Transarterial chemoembolisation (TACE) is an effective treatment for unresectable hepatocellular carcinoma (HCC), but can cause severe toxicity. AIM: To identify predictive factors of severe TACE-related toxicity in patients with unresectable HCC. METHODS: All HCC patients who underwent TACE at the Dijon University Hospital between 2008 and 2011 were included in this retrospective study. Severe TACE-related toxicity was defined as the occurrence of any adverse event grade ≥ 4, or any adverse event that caused a prolongation of hospitalisation of >8 days, or any additional hospitalisation within 1 month after TACE. Factors predicting toxicity were identified using a logistic regression model. The robustness of the final model was confirmed using bootstrapping (500 replications). RESULTS: 124 patients were included, median age was 67 years and 90% were male; 22 patients (18%) experienced severe TACE-related toxicity. Factors that independently predicted severe TACE-related toxicity in multivariate analysis were total tumour size (OR, 1.15 cm(-1); 95%CI, 1.04-1.26; p=0.01), and high serum AST levels (OR, 1.10 per 10 IU/l; 95%CI, 1.01-1.21; p=0.04). The results were confirmed by bootstrapping. CONCLUSIONS: Total tumour size and high serum AST levels were predictive factors of severe TACE-related toxicity in this hospital-based series of patients with unresectable HCC.

Candidemia in critically ill patients: difference of outcome between medical and surgical patients.

OBJECTIVE: Candidemia is increasingly encountered in critically ill patients with a high fatality rate. The available data in the critically ill suggest that patients with prior surgery are at a higher risk than others. However, little is known about candidemia in medical settings. The main goal of this study was to compare features of candidemia in critically ill medical and surgical patients. DESIGN: Ten-year retrospective cohort study (1990-2000). SETTING: Medical and surgical intensive care units (ICUs) of a teaching hospital. PATIENTS: Fifty-one patients with at least one positive blood culture for Candida species. MAIN RESULTS: Risk factors were retrieved in all of the patients: central venous catheter (92.1%), mechanical ventilation (72.5%), prior bacterial infection (70.6%), high fungal colonization index (45.6%). Candida albicans accounts for 55% of all candidemia. The overall mortality was 60.8% (85% and 45.2% in medical and surgical patients, respectively). Independent factors associated with survival were prior surgery (hazard ratio [HR] =0.25; 0.09-0.67 95% confidence interval [CI], p<0.05), antifungal treatment (HR =0.11; 0.04-0.30 95% CI, p<0.05) and absence of neutropenia (HR =0.10; 0.02-0.45 95% CI, p<0.05). Steroids, neutropenia and high density of fungal colonization were more frequently found among medical patients compared to surgical ones. CONCLUSIONS: Candidemia occurrence is associated with a high mortality rate among critically ill patients. Differences in underlying conditions could account for the poorer outcome of the medical patients. Screening for fungal colonization could allow identification of such high-risk patients and, in turn, improve outcome.