Prognostic value of tumor mutational burden in patients with oral cavity squamous cell carcinoma treated with upfront surgery.

BACKGROUND: Oral cavity is the most prevalent site of head and neck squamous cell carcinomas (HNSCCs). Most often diagnosed at a locally advanced stage, treatment is multimodal with surgery as the cornerstone. The aim of this study was to explore the molecular landscape of a homogenous cohort of oral cavity squamous cell carcinomas (OCSCCs), and to assess the prognostic value of tumor mutational burden (TMB), along with classical molecular and clinical parameters. PATIENTS AND METHODS: One hundred and fifty-one consecutive patients with OCSCC treated with upfront surgery at the Institut Curie were analyzed. Sequencing of tumor DNA from frozen specimens was carried out using an in-house targeted next-generation sequencing panel (571 genes). The impact of molecular alterations and TMB on disease-free survival (DFS) and overall survival (OS) was evaluated in univariate and multivariate analyses. RESULTS: Pathological tumor stage, extranodal spread, vascular emboli, and perineural invasion were associated with both DFS and OS. TP53 was the most mutated gene (71%). Other frequent molecular alterations included the TERT promoter (50%), CDKN2A (25%), FAT1 (17%), PIK3CA (14%), and NOTCH1 (15%) genes. Transforming growth factor-ß pathway alterations (4%) were associated with poor OS (P = 0.01) and DFS (P = 0.02) in univariate and multivariate analyses. High TMB was associated with prolonged OS (P = 0.01 and P = 0.02, in the highest 10% and 20% TMB values, respectively), but not with DFS. Correlation of TMB with OS remained significant in multivariate analysis (P = 0.01 and P = 0.005 in the highest 10% and 20% TMB values, respectively). Pathological tumor stage combined with high TMB was associated with good prognosis. CONCLUSION: Our results suggest that a high TMB is associated with a favorable prognosis in patients with OCSCC treated with upfront surgery.

First European data from the network of severe allergic reactions (NORA).

BACKGROUND: Occurrence, elicitors and treatment of severe allergic reactions are recognized and reported differently between countries. We aimed to collect standardized data throughout Europe on anaphylaxis referred for diagnosis and counselling. METHODS: Tertiary allergy, dermatology and paediatric units in 10 European countries took part in this pilot phase of the first European Anaphylaxis Registry, from June 2011 to March 2014. An online questionnaire was used to collect data on severe allergic reactions based on the medical history and diagnostics. RESULTS: Fifty-nine centres reported 3333 cases of anaphylaxis, with 26.7% below 18 years of age. Allergic reactions were mainly caused by food (children and adults 64.9% and 20.2%, respectively) and insect venom (20.2% and 48.2%) and less often by drugs (4.8% and 22.4%). Most reactions occurred within 30 min of exposure (80.5%); a delay of 4+ hours was mainly seen in drug anaphylaxis (6.7%). Symptom patterns differed by elicitor, with the skin being affected most often (84.1%). A previous, usually milder reaction to the same allergen was reported by 34.2%. The mainstay of first-line treatment by professionals included corticoids (60.4%) and antihistamines (52.8%). Only 13.7% of lay- or self-treated reactions to food and 27.6% of insect anaphylaxis received on-site adrenaline. CONCLUSION: This pilot phase of a pan-European registry for severe allergic reactions provides for the first time data on anaphylaxis throughout Europe, demonstrates its potential functionality and allows a comparison of symptom patterns, elicitors and treatment habits between referral centres and countries.

Cryoglobulin detection from blood and peritoneal fluid smears.

Laboratory identification of cytoplasmic inclusions in leucocytes as unusual manifestation of cryoglobulinemia has been previously reported (Maitra et al., 2000 American Journal of Clinical Pathology, 113, 107-112; Fohlen-Walter et al., 2002 American Journal of Clinical Pathology, 117, 606-614.). We would like to add two observations highlighting the following: (i) the peculiar picture of cryoglobulins in neutrophils and monocytes but sparing other white blood cell (WBC) and (ii) possibility of deposit occurrence with morphological identification in body fluids.

[Anaphylactic shock due to recombinant human insulin: follow-up of a desensitization protocol by basophil activation test]. / Choc anaphylactique à l'insuline humaine recombinante: suivi d'un protocole d'accoutumance par tests d'activation des basophiles.

INTRODUCTION: Despite the occurrence of a severe allergic reaction including an anaphylactic shock, a drug may remain essential and impossible to replace. This may be the case of insulin in a diabetic patient. We describe the case of an anaphylactic shock to human insulin in whom a desensitization protocol was successfully achieved. CASE REPORT: A 50-year-old type 2 diabetic man presented one year after initiation of the insulin therapy an anaphylactic shock following the subcutaneous administration of a human insulin containing protamine (Insulatard®). A desensitization protocol to human insulin was performed and allowed to use two human insulin analogues containing no protamine (asparte and glargine), with a two-year event-free follow-up. Positive skin tests with insulin and protamine, and the presence of insulin specific IgE were evidenced of an IgE-mediated mechanism. Desensitization was monitored by skin tests, Maunsell's test, measurement of specific IgE and IgG4, and the basophil activation test. The decrease of basophil sensitivity to insulin is an early marker for tolerance induction. CONCLUSION: The effectiveness of the desensitization to human insulin underlines the importance to define the modalities of such desensitization protocol and of the monitoring of the tolerance induction.

Towards a European registry of severe allergic reactions: current status of national registries and future needs.

The incidence of severe allergic reactions is largely unknown and information about triggering allergens, aggravating factors, demography of patients and medical care is lacking. A European wide registry could provide a powerful tool to improve the management of severe allergic reactions from both a medical and a public health perspective. Analysis of existing registries regarding the type and quality of data being collected was used to develop a plan for a pan-European registry, including the type of system to be used and the range of data to be entered. Surveillance will provide evidence for the efficacy of risk management measures and may identify the emergence of new allergenic foods, and aid monitoring of novel foods, ingredients and technologies. Patients need a clear indication of factors that may increase their risk of having an adverse reaction, which such a registry can help compile. Based on the collected data, food businesses will be able to develop educational programmes for allergen risk assessment and allergen risk communication. Finally, and most importantly preventive measures can be developed and government agencies receive population based data which may be relevant for legislative purposes.

Optimization of the use of ciprofloxacin.

AIMS: To compare mutant prevention concentration (MPC) of ciprofloxacin and time-killing curve with regards to 11 genotyped Escherichia coli. METHOD: MICs were determined using the E-test method. Time-killing studies were performed in accordance with the NCCLS guidelines. The genes gyrA, gyrB, parC, parE and marR were amplified by PCR and sequenced. The MPC was defined as the lowest antibiotic concentration preventing the growth of resistant colonies when 10(10) CFU/mL were spread on a solid medium. RESULTS: Strains with no genes gyrA, gyrB, parC, parE and marR mutation presented MIC less or equal to 0.023 mg/L and MPC less or equal to 0.25 mg/L. Strains with two mutations (gyrA and parC) presented MIC equal to 1.5 mg/L and MPC equal to 4 mg/L. Strains with one mutation (gyrA) presented MIC less or equal to 0.75 mg/L, but MPC ranged from 0.5 to 6 mg/L depending of the MIC of ciprofloxacin. The time-killing curves for ciprofloxacin showed a bactericidal activity of 0.25 mg/L in 1h for strains without mutation, compared with a bactericidal activity of 2 and 4 mg/L in 4h for strains with one and two mutations, respectively. CONCLUSION: For strains of E. coli resistant to nalidixic acid, it was necessary to evaluate the MIC of ciprofloxacin in order to asses the optimal dosage of ciprofloxacin.

Propionibacterium acnes contamination in lumbar disc surgery.

Previous studies have shown that Propionibacterium acnes may be responsible for low-grade infection of the intervertebral discs of patients with severe sciatica. The aim of this study was to prospectively investigate the presence of bacteria in disc fragment samples obtained during surgery for lumbar disc herniation. P. acnes was cultured from disc fragments in two (3.7%) of 54 patients studied. In addition, control cultures taken from ligamentum flavum and muscle from these two patients were also positive for P. acnes. Similar control cultures were positive for P. acnes from a further ten (18.5%) patients. Four air samples taken during surgery all contained P. acnes; the organism was also found from three of 54 laminar flow control cultures. Sample contamination appears the most likely cause for the presence of P. acnes in the lumbar disc fragment cultures.

The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology.

Anaphylaxis is a growing paediatric clinical emergency that is difficult to diagnose because a consensus definition was lacking until recently. Many European countries have no specific guidelines for anaphylaxis. This position paper prepared by the EAACI Taskforce on Anaphylaxis in Children aims to provide practical guidelines for managing anaphylaxis in childhood based on the limited evidence available. Intramuscular adrenaline is the acknowledged first-line therapy for anaphylaxis, in hospital and in the community, and should be given as soon as the condition is recognized. Additional therapies such as volume support, nebulized bronchodilators, antihistamines or corticosteroids are supplementary to adrenaline. There are no absolute contraindications to administering adrenaline in children. Allergy assessment is mandatory in all children with a history of anaphylaxis because it is essential to identify and avoid the allergen to prevent its recurrence. A tailored anaphylaxis management plan is needed, based on an individual risk assessment, which is influenced by the child's previous allergic reactions, other medical conditions and social circumstances. Collaborative partnerships should be established, involving school staff, healthcare professionals and patients' organizations. Absolute indications for prescribing self-injectable adrenaline are prior cardiorespiratory reactions, exercise-induced anaphylaxis, idiopathic anaphylaxis and persistent asthma with food allergy. Relative indications include peanut or tree nut allergy, reactions to small quantities of a given food, food allergy in teenagers and living far away from a medical facility. The creation of national and European databases is expected to generate better-quality data and help develop a stepwise approach for a better management of paediatric anaphylaxis.

Arthroplastic and osteosynthetic infections due to Propionibacterium acnes: a retrospective study of 52 cases, 1995-2002.

The cases of 52 patients with Propionibacterium acnes infection of orthopaedic implants are summarized: 20 patients with definite infection (sepsis, with P. acnes recovered from multiple specimens per patient), 15 with probable infection (sepsis, with P. acnes recovered from one specimen), and 17 with possible infection (signs of prosthetic malfunction or pseudo-osteoarthritis, with P. acnes recovered from one specimen). The patient population consisted of 37 males and 15 females with a mean age of 51.8 years (range 17-88). Besides bone surgery, 21% of these patients had severe coexisting illness. The study population was very heterogeneous and clinical presentation very polymorphic; infections became clinically apparent through sepsis, prosthetic malfunction, or a delay in consolidation. The diagnosis was highly dependent on the quality of the samples taken and the methodology used by the microbiology laboratory to isolate this bacterium. Culture time was long, on average 11.4 days. Treatment involved a combination of antibiotic treatments (67% of cases) and ablation of the material (83% of cases). Although P. acnes is considered to be weakly pathogenic, this bacterium may be responsible for infections in patients with implanted orthopaedic material. Ablation of the arthroplastic or osteosynthetic material is necessary in the majority of cases.

Efficiency of blood culture bottles for the fungal sterility testing of corneal organ culture media.

BACKGROUND/AIM: The consequences of fungal contamination of an organ cultured cornea, though exceptional, are often disastrous for the recipient. Consequently, eye banks often quarantine corneas for 10 days or more before passing them for grafting. This period, though detrimental to the endothelial cell density of the delivered cornea, is necessary to detect contamination using conventional microbiological methods. The authors previously validated the use of a pair of aerobic and anaerobic blood bottles for sensitive and rapid detection of bacteria. To allow a short quarantine period, it remained only to optimise detection of fungi. The authors aimed to compare sensitivity and rapidity of fungal contamination detection by three methods: blood bottles, Sabouraud, and daily visual inspection of the organ culture medium. METHODS: Four inocula (10(6), 10(4), 10(2), 10 colony forming unit (CFU) per ml) of 11 fungi (Candida albicans, C tropicalis, C glabrata, Saccharomyces cerevisiae, Rhodotorula rubra, Cryptococcus neoformans, Fusarium oxysporum, Aspergillus niger, A fumigatus, A flavus, Acremonium falciforme) were inoculated in a commercial organ culture medium containing a coloured pH indicator (CorneaMax, Eurobio, Les Ulis, France). The real live fungal inoculum was verified immediately after inoculation. After 48 hours at 31 degrees C, samples of the contaminated media were inoculated in three blood bottles: Bactec Aerobic/F, Bactec Mycosis IC/F, and Bactec Myco/F Lytic (Becton Dickinson, Le Pont de Claix, France), then placed in a Bactec 9240 rocking automat, and in four Sabouraud media (solid and liquid, 28 degrees C and 37 degrees C) with daily observation. Contaminated organ culture media were also checked daily for any change in turbidity and/or colour. Experiments were performed in triplicate. RESULTS: Mycosis IC/F and Myco/F Lytic bottles were neither faster nor more sensitive than the aerobic bottle. The three methods were positive for all inocula, even the lowest (viable inoculum below 10 CFU/ml for each fungus). Contamination was detected within 24 hours by the aerobic bottles in 91% (40/44), by Sabouraud in 98% (43/44) (no significant difference) and by visual inspection in 66% of cases (29/44) (p<0.001 with the two others). Maximum times to detection were 46, 48 and 72 hours respectively. CONCLUSION: This study further counters the preconception that fungal contamination is hard to detect in corneal organ culture media. This study is the last step in validating the use of a pair of blood bottles for the sterility testing of organ culture media, this time for fungi. Their use should make it possible to shorten microbiological quarantine and thus deliver corneas with higher endothelial cell density, without increasing the risk of recipient contamination.

Impact of restricting fluoroquinolone prescription on bacterial resistance in an intensive care unit.

The purpose of this study was to assess the effect of reducing prescription of fluoroquinolones in an intensive care unit (ICU) upon bacterial resistance, particularly as regards Pseudomonas aeruginosa. For six months between January 2001 and June 2001, administration of fluoroquinolones was kept to a minimum. A bacteriological screening of patients was performed to assess the incidence of fluoroquinolone-resistant bacteria. There was a 75.8% restriction in prescriptions of fluoroquinolones. There was no significant change in bacterial ecology between the periods preceding (12 months) and following (12 months) restriction. There was a significant recovery of sensitivity of P. aeruginosa to ciprofloxacin (P

[Optimizing microbiological controls of corneal organ culture media]. / Optimisation du contrôle microbiologique des milieux d'organoculture des greffons cornéens.

BACKGROUND/AIMS: To compare the efficiency of an automated method using blood bottles with conventional microbiological tests for controlling sterility in cornea organ culture media. METHODS: Two complementary studies were conducted. Experimental study: standard organ culture media were contaminated with four different inocula of 14 bacteria and 3 fungi. The bactericidal activity of organ culture media were evaluated after 48 hours of incubation at 31C. Observational study: 357 samples of organ culture media were collected over 1 year in our cornea bank. For both studies, media were inoculated in three blood bottles (aerobic, anaerobic, fungal) placed in an automat with automated detection every 10 minutes, and in three conventional microbiological media as a control. Changes in organ culture medium color and growth on conventional broth were checked daily by visual inspection. All samples were observed experimentally for 14 days. The sensitivity and rapidity of contamination detection were compared across the three methods: blood bottles, conventional method, and visual inspection of medium color. RESULTS: Experimental study: organ culture medium eradicated five bacteria: S. pneumoniae, B. catarrhalis, E. coli, P. acnes and H. influenzae. For the others, (Methicillin-resistant S. aureus, Methicillin-sensitive S. aureus, S. epidermidis, S. haemolyticus, P. aeruginosa, A. baumannii, B. subtilis, K. pneumoniae, E. faecalis, C. albicans, C. kruzei, A. fumigatus) the blood bottle method, the conventional microbiological method, and the visual inspection detected microbiological growth respectively in 100%, 76.5%, and 70% of cases. Mean detection time using blood bottles was 15.1 hours (standard deviation, 13.8; range, 2-52). In cases of detection by the blood-bottle method and the conventional method, the former was always faster: 95.5% versus 65.2% detection within 24 hours (p=0.022). Observational study: the global contamination rate was 8% (29/357 analysis). The gain in sensitivity with blood bottles was 25% compared with the conventional method. Five bacteria (three coag. neg Staphylococcus, one E. faecalis, one P. paucimobilis) were detected only by the blood bottles. In addition, these were always detected more quickly with, respectively, 66.6% versus 26.6% detection with 24 hours (p=0.028). CONCLUSIONS: Blood bottles detect contaminations of cornea organ culture media more efficiently and faster than conventional microbiological methods. They make it possible to reduce the quarantine period with an equally high security level. Consequently, they should be recommended in cornea preservation guidelines.

Sensitivity and rapidity of blood culture bottles in the detection of cornea organ culture media contamination by bacteria and fungi.

AIMS: To test the bactericidal activity of standard organ culture medium, and to compare the sensitivity and rapidity of blood culture bottles with conventional microbiological methods for detection of bacteria and fungi inoculated in a standard cornea organ culture medium. METHODS: The bactericidal activity of contaminated standard organ culture medium containing 100 IU/ml penicillin, 0.1 mg/ml streptomycin, and 0.25 micro g/ml amphotericin B was evaluated after 48 hours of incubation at 31 degrees C with five inocula of 14 bacteria. Two yeasts (Candida spp) and one Aspergillus were also tested. Contaminated media were then inoculated in three blood bottles (aerobic, anaerobic, fungal) placed in a Bactec 9240 automat; three conventional microbiological broths were the control. Changes in colour of organ culture medium and growth on conventional broth were screened daily by visual inspection. The sensitivity and rapidity of detection of contamination were compared between the three methods: blood bottle, conventional, and visual. RESULTS: Organ culture medium eradicated five bacteria irrespective of the starting inoculums: Streptococcus pneumoniae, Branhamella catarrhalis, Escherichia coli, Propionibacterium acnes, and Haemophilus influenzae. For micro-organisms where the medium was ineffective or bactericidal only (methicillin resistant Staphylococcus aureus, methicillin sensitive Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus haemolyticus, Pseudomonas aeruginosa, Acinetobacter baumannii, Bacillus subtilis, Klebsiella pneumoniae, Enterococcus faecalis, Candida albicans, Candida kruzei, Aspergillus fumigatus), the blood bottle, conventional, and visual methods detected microbial growth in 100%, 76.5%, and 70% of cases respectively. Mean detection time using blood bottles was 15.1 hours (SD 13.8, range 2-52). In cases of detection by the blood bottle method and the conventional method, the former was always faster: 95.5% against 65.2% detection within 24 hours (p=0.022) respectively. CONCLUSIONS: Blood bottles detect more efficiently and more rapidly a wider range of bacteria and fungi than the conventional microbiological method and the visual inspection of organ culture media.

[Use of a pair of blood culture bottles for sterility testing of corneal organ culture media]. / Intérêt de l'utilisation de flacons à hémoculture pour le contrôle de stérilité microbiologique des greffons cornéens.

PURPOSE: To test the effectiveness and rapidity of a pair of blood culture bottles in the diagnosis of bacterial and fungal contamination of corneal organ culture media. MATERIAL: and methods: Seven hundred and sixty one microbiological analysis of storage media (Inosol(R) and Exosol(R), Opsia, Toulouse, France), sampled in all phases of the organ culture at 31 degrees C of 410 consecutive corneas, were analyzed. Each medium was inoculated in a pair of Bactec Plus Aerobic/F(R) and Bactec Lytic/10 Anaerobic/F(R) blood bottles (Becton Dickinson, Cockeysville, MD) and placed in a Bactec 9240 incubator for 14 days at 37 degrees C and in a Sabouraud broth at 20 degrees C. Changes in color or turbidity of storage media were evaluated daily at the corneal bank. Recipients were screened after graft for signs of infection. RESULTS: The overall contamination rate was 2.4% (18/761). Contamination was detected in less than 1 day in 78% (14/18) and in less than 2 days in 94% (17/18). Positivity of the microbiological controls of starting media preceded medium color changes in 10 out of 14 cases. Bactec blood bottles allowed detection of bacteria as well as Candida sp. yeasts. DISCUSSION: The use of a pair of aerobic and anaerobic blood culture bottles is a simple, effective and rapid method for the diagnosis of a wide range of microbiological contaminations of organ-cultured corneas during banking. CONCLUSION: The validation of this protocol will require a prospective study to compare it with the conventional microbiological method.

Evaluation of BacT/Alert 3D liquid culture system for recovery of mycobacteria from clinical specimens using sodium dodecyl (lauryl) sulfate-NaOH decontamination.

A total of 52 mycobacterial isolates were recovered from 1,197 clinical specimens decontaminated by a sodium dodecyl (lauryl) sulfate (SDS)-NaOH protocol. Of these, 94% were recovered with the BacT/Alert 3D system (Organon Teknika, Durham, N.C.) and 79% were recovered on Löwenstein-Jensen (LJ) medium. Mean times to detection of organisms of the Mycobacterium tuberculosis complex (n = 47) were 22.8 days with LJ medium and 16.2 days with the system. The BacT/Alert 3D system is a rapid and efficient detection system which can be used with an SDS-NaOH decontamination procedure.

Use of a pair of blood culture bottles for sterility testing of corneal organ culture media.

AIMS: To test the effectiveness and rapidity of a pair of blood culture bottles in the diagnosis of bacterial and fungal contamination of corneal organ culture media. METHODS: 761 microbiological analyses of storage media (Inosol and Exosol, Opsia, Toulouse, France), sampled in all phases of the organ culture at 31 degrees C of 410 consecutive corneas, were analysed. Each medium was inoculated in a pair of Bactec Plus Aerobic/F and Bactec Lytic/10 Anaerobic/F blood bottles and placed in a Bactec 9240 incubator for 14 days at 37 degrees C and in a Sabouraud broth at 20 degrees C. Changes in colour or turbidity of storage media were evaluated daily at the corneal bank. Recipients were screened post-graft for infectious signs. RESULTS: Overall contamination rate was 2.4% (18/761). Contamination was detected in less than 1 day in 78% (14/18) and less than 2 days in 94% (17/18). Positivity of the microbiological controls of starting media preceded changes medium colour in 10 out of 14 cases. Bactec blood bottles allowed detection of bacteria as well as yeasts. CONCLUSION: The use of a pair of Bactec blood culture bottles appears reliable for the rapid diagnosis of a wide range of microbiological contaminations of organ cultured corneas during banking.