[Impact of a coordinated regional organization to secure the management of patients on oral anticancer drugs: CHIMORAL, a comparative trial]. / Impact d'une organisation régionale coordonnée pour sécuriser la prise en charge des patients sous anticancéreux oraux : CHIMORAL, une étude comparative.

INTRODUCTION: Oral anticancer drugs have disrupted hospital and community practices. A better coordination and patient support for medication and adverse events management by primary care providers (general practitioner, community pharmacist and liberal nurse) could improve the situation. The CHIMORAL study evaluated a model of coordination by territorial health networks. METHODS: A here and elsewhere, prospective and multicentric study, comparing coordinated care with standard care. Primary outcome was the use of the hospital structure for adverse events within 6 months of initiating treatment. RESULTS: In all, 283 patients were included. 92% had at least one adverse event, with a higher median number in the coordinated group (12.5 vs. 9.0, P=0.02). No difference in hospital use by arm (P=0.502). Increase in the use of community care for adverse events in the coordinated group (27% vs. 16%, P=0.009). No observed impact on progression rates, quality of life and treatment adherence. The overall survival rate at 6 months is numerically higher in the coordinated group (87% vs. 76%, P=0.064). DISCUSSION: This model does not show any difference on the primary endpoint. The lack of randomization, patient selection, power loss, and local initiatives to monitor these patients may have biased the analysis. A large number of uses of the healthcare system were observed. These results confirm the need for a dedicated care pathway for the patient with oral anticancer drugs.

Paradoxical anti-TNF-associated TB worsening: Frequency and factors associated with IRIS.

OBJECTIVES: Paradoxical tuberculosis (TB) worsening, an example of the immune reconstitution inflammatory syndrome (IRIS), is an increasing phenomenon now described in several settings, including anti-tumor necrosis factor (TNF) discontinuation during biotherapy-induced TB. To better recognize it, we analyzed the frequency and factors associated with anti-TNF-induced TB-IRIS. METHODS: Case-control study on anti-TNF-associated TB patients. IRIS cases, defined with the following consensus criteria, were matched to two controls (anti-TNF-associated TB without IRIS). IRIS frequency was based on the French RATIO registry. Conditional logistic-regression identified IRIS risk factors. RESULTS: Fourteen patients developed anti-TNF-associated TB-IRIS within medians of 45 [IQR 22-131] days after starting anti-TB therapy and 110 [IQR 63-164] days after the last anti-TNF infusion. Each case was matched to two controls by year of TB diagnosis. IRIS-associated factors were (odds ratio [95% CI]): disseminated TB (11.4 [1.4-92.2], P=0.03), history of Mycobacterium tuberculosis exposure (12.7 [1.6-103.0], P=0.02) and steroid use at the time of TB diagnosis (4.6 [1.2-17.2], P=0.02). The RATIO registry IRIS frequency was 7%. CONCLUSION: After stopping biotherapy, paradoxical anti-TNF-associated TB worsening occurred most often in patients with disseminated TB. Although diagnosis remains difficult, physicians must be aware of IRIS because prolonged anti-TB treatment is not needed but, paradoxically, immunosuppressant reintroduction may be.

Comparison of nutritional consequences of conventional therapy of obesity, adjustable gastric banding, and gastric bypass.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) is more efficient than adjustable gastric banding (AGB) in weight loss and relieving co-morbidities, but nutritional complications of each surgical procedure have been poorly evaluated. METHODS: A cross-sectional study was performed to compare nutritional parameters in 201 consecutive obese patients, who had been treated either by conventional behavioral and dietary therapy (CT, n=110) or by bariatric surgery, including 51 AGB and 40 RYGBP. RESULTS: BMI was similar after AGB (36.6 +/- 5.3 kg/m2) and RYGBP (35.4 +/- 6.3 kg/m2), but patients in the RYGBP group had lost more weight and had less metabolic disturbances than those in the AGB group. On the other hand, the prevalence of nutritional deficits was significantly higher in the RYGBP group than in the 2 other groups (P<0.01), whereas the AGB group did not differ from CT. Particularly, the RYGBP group presented an unexpected high frequency of deficiencies in fat-soluble vitamins. Moreover, vitamin B12, hemoglobin, plasma prealbumin and creatinine concentrations were low in the RYGBP group. CONCLUSION: RYGBP is more efficient than AGB in correcting obesity, but this operation is associated with a higher frequency of nutritional deficits that should be carefully monitored.