Variation in Structure and Process of Care in Traumatic Brain Injury: Provider Profiles of European Neurotrauma Centers Participating in the CENTER-TBI Study.

INTRODUCTION: The strength of evidence underpinning care and treatment recommendations in traumatic brain injury (TBI) is low. Comparative effectiveness research (CER) has been proposed as a framework to provide evidence for optimal care for TBI patients. The first step in CER is to map the existing variation. The aim of current study is to quantify variation in general structural and process characteristics among centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. METHODS: We designed a set of 11 provider profiling questionnaires with 321 questions about various aspects of TBI care, chosen based on literature and expert opinion. After pilot testing, questionnaires were disseminated to 71 centers from 20 countries participating in the CENTER-TBI study. Reliability of questionnaires was estimated by calculating a concordance rate among 5% duplicate questions. RESULTS: All 71 centers completed the questionnaires. Median concordance rate among duplicate questions was 0.85. The majority of centers were academic hospitals (n = 65, 92%), designated as a level I trauma center (n = 48, 68%) and situated in an urban location (n = 70, 99%). The availability of facilities for neuro-trauma care varied across centers; e.g. 40 (57%) had a dedicated neuro-intensive care unit (ICU), 36 (51%) had an in-hospital rehabilitation unit and the organization of the ICU was closed in 64% (n = 45) of the centers. In addition, we found wide variation in processes of care, such as the ICU admission policy and intracranial pressure monitoring policy among centers. CONCLUSION: Even among high-volume, specialized neurotrauma centers there is substantial variation in structures and processes of TBI care. This variation provides an opportunity to study effectiveness of specific aspects of TBI care and to identify best practices with CER approaches

Variation in general supportive and preventive intensive care management of traumatic brain injury: a survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study

Abstract Background General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of this survey was to assess and quantify variation in perceptions on intensive care unit (ICU) management of patients with TBI in European neurotrauma centers. Methods We performed a survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We analyzed 23 questions focused on: 1) circulatory and respiratory management; 2) fever control; 3) use of corticosteroids; 4) nutrition and glucose management; and 5) seizure prophylaxis and treatment. Results The survey was completed predominantly by intensivists (n = 33, 50%) and neurosurgeons (n = 23, 35%) from 66 centers (97% response rate). The most common cerebral perfusion pressure (CPP) target was > 60 mmHg (n = 39, 60%) and/or an individualized target (n = 25, 38%). To support CPP, crystalloid fluid loading (n = 60, 91%) was generally preferred over albumin (n = 15, 23%), and vasopressors (n = 63, 96%) over inotropes (n = 29, 44%). The most commonly reported target of partial pressure of carbon dioxide in arterial blood (PaCO2) was 36–40 mmHg (4.8–5.3 kPa) in case of controlled intracranial pressure (ICP) < 20 mmHg (n = 45, 69%) and PaCO2 target of 30–35 mmHg (4–4.7 kPa) in case of raised ICP (n = 40, 62%). Almost all respondents indicated to generally treat fever (n = 65, 98%) with paracetamol (n = 61, 92%) and/or external cooling (n = 49, 74%). Conventional glucose management (n = 43, 66%) was preferred over tight glycemic control (n = 18, 28%). More than half of the respondents indicated to aim for full caloric replacement within 7 days (n = 43, 66%) using enteral nutrition (n = 60, 92%). Indications for and duration of seizure prophylaxis varied, and levetiracetam was mostly reported as the agent of choice for both seizure prophylaxis (n = 32, 49%) and treatment (n = 40, 61%). Conclusions Practice preferences vary substantially regarding general supportive and preventive measures in TBI patients at ICUs of European neurotrauma centers. These results provide an opportunity for future comparative effectiveness research, since a more evidence-based uniformity in good practices in general ICU management could have a major impact on TBI outcome

Impact pronostique de la classification de Trouillas et collaborateurssur la récidive et la progression des adénomes hypophysaires opérés

Introduction : bien qu’habituellement indolents, les adénomes hypophysaires peuvent présenter des caractéristiques agressives et un risque évolutif. En 2013, une classification a été proposée sur la base de critères histopathologiques pour différencier les adénomes hypophysaires en tumeur proliférante (b) ou non (a) et invasive (2) ou non (1), le stade 3 correspondant aux carcinomes hypophysaires. A l’instar de travaux précédents, l’objectif de notre étude est de valider l’impact de cette classification sur la progression et la récidive des adénomes hypophysaires opérés.Matériels et méthodes : 158 patients (83♀/75♂) opérés entre janvier 1981 et 2019 et suivis au CHU de Marseille ont été inclus dans cette étude et évalués de manière rétrospective. Pour chacun d’entre eux, les données cliniques, biologiques, radiologiques (IRM), opératoires et histologiques étaient recueillies. Résultats : l’âge moyen au diagnostic était de 50.6 ± 14.5 ans, le suivi médian de 23 ± 31.4 mois. L’analyse histologique retrouvait 32 adénomes « null cell », 37 adénomes gonadotropes, 34 adénomes somatotropes, 20 adénomes somato-lactotropes, 19 adénomes corticotropes, 8 adénomes lactotropes, 1 adénome thyréotrope et 7 adénomes pluri-hormonaux répartis en grade 1a (n = 74), grade 1b (n = 10), grade 2a (n = 61) et grade 2b (n = 13). A 10 ans, 37 patients (23%) ont présenté une récidive ou une progression. Le risque de récidive/progression était de 11% (grade 1a), 10% (grade 1b), 31% (grade 2a) et 69% (grade 2b). En particulier, on retrouvait comme facteur de risque potentiel de récidive/progression le caractère invasif avec un hazard ratio à 6,00 (p<0,0001), les tumeurs de grade 2a et 2b avec des hazard ratio respectifs à 4,98 (p=0,0001) et 16,39 (p<0,0001), une exérèse chirurgicale non complète (présence d’un reliquat notifié sur le compte rendu opératoire) avec un hazard ratio à 4,10 (p<0,0001), et d’un résidu radiologique avec un hazard ratio à 4,69 (p<0,0001).Conclusion : sur une série indépendante, nos résultats suggèrent que la classification histopronostique de Trouillas et collaborateurs prédit le risque de progression/récurrence d’un adénome hypophysaire opéré

Molecular Basis and Natural History of Medullary Thyroid Cancer: It is (Almost) All in the RET

Medullary thyroid carcinoma (MTC) is a rare neoplasm supported by a strong genetic determinism. This review summarizes the genetic landscape of MTC at both germline and somatic levels to understand the molecular basis and the natural history of the tumour, mainly but not exclusively, linked to RET proto-oncogene genetic abnormalities. RET is a tyrosine kinase receptor that represents a therapeutic target with encouraging results. However, some RET genetic variations could lead to treatment resistance

Current and Emerging Medical Therapies in Pituitary Tumors

International audiencePituitary tumors (PT) represent in, the majority of cases, benign tumors for which surgical treatment still remains, except for prolactin-secreting PT, the first-line therapeutic option. Nonetheless, the role played by medical therapies for the management of such tumors, before or after surgery, has evolved considerably, due in part to the recent development of well-tolerated and highly efficient molecules. In this review, our aim was to present a state-of-the-art of the current medical therapies used in the field of PT and the benefits and caveats for each of them, and further specify their positioning in the therapeutic algorithm of each phenotype. Finally, we discuss the future of PT medical therapies, based on the most recent studies published in this field

Celiac Disease and Obesity: Is Bariatric Surgery an Option?

International audienceCeliac disease is an immune-mediated enteropathy associated with malabsorptive syndrome and fat-soluble vitamin deficiencies. Celiac disease affects 1% of individuals but is largely underdiagnosed, as its multifaceted clinical presentations create challenging diagnostic scenarios. With the rise of the obesity epidemic, doctors are increasingly seeing celiac disease patients with overweight or obesity, which raises the question of bariatric surgery. However, few studies so far have investigated bariatric surgery in this patient population. Here, we provide a comprehensive review of the literature on celiac disease, its nutritional consequences and complications, and we discuss the possible impact of bariatric surgery on weight loss, nutritional deficiencies, response to gluten-free diet, and long-term post-operative complications. We also review the effect of bariatric surgery on the incidence of celiac disease

Letter to the Editor: The Somatic RET M918T Variant May Modify the Natural History of Germline RET L790F MEN2-Related Medullary Thyroid Carcinoma

No abstract availabl

Clinical management of difficult to treat macroprolactinomas

International audienceIntroduction: Prolactinomas represent the most common pituitary adenomas encountered in the clinic. While a majority of these tumors will be successfully treated by dopamine agonist (DA) such as cabergoline, their management becomes problematic since a resistance to DA can occur and/or if the tumor displays features of aggressiveness, two conditions that are closely related. Areas covered: Epidemiology and medical treatment of prolactinomas; resistance to DA and molecular basis of DA-resistance; therapeutical alternatives in case of DA-resistant Prolactinomas and therapies in development; summarizing conclusions. Expert opinion: The management of DA-resistant prolactinomas requires a multidisciplinary approach by an expert team. Along with discussions about surgery with or without gamma knife radiosurgery, genetic screening for multiple endocrine neoplasia type 1 (MEN1) syndrome is actively discussed in a case-by-case approach. In case of surgery, a careful analysis of the tumor sample can provide information about its aggressivity potential according to recent criteria. Ultimately, temozolomide can be indicated if the tumor is rapidly growing and/or threatening for the patient

SGLT2 inhibitors as potentially helpful drugs in PI3K inhibitor-induced diabetes: a case report

International audienceAbstract Background Hyperglycemia is the most common side-effect of phosphatidylinositol 3-kinase (PI3K) inhibitors that are approved for the treatment of some advanced or metastatic breast cancers. This side-effect is likely due to the central role of PI3K in insulin signalling. Here we report the use of a sodium-glucose cotransporter 2 (SGLT2) inhibitor to manage severe hyperglycemia. Case presentation We describe a 74-year-old woman who developed severe uncontrolled hyperglycemia after commencing alpelisib, a new oral PI3K inhibitor indicated for a metastatic breast cancer, despite taking oral anti-diabetic drugs, metformin and vildagliptin, combined with intravenous insulin infusion of up to 250 units/day. The introduction of the SGLT2 inhibitor dapagliflozin rapidly improved blood glucose with a drastic reduction in insulin dosage, from 250 to 12 units/day, and without significant side-effects. Conclusions We report the successful management of hyperglycemia induced by alpelisib using a SGLT2 inhibitor without the need to discontinue effective cancer treatment