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Pariente B.,University Paris Diderot | Laharie D.,Bordeaux University Hospital Center
Alimentary Pharmacology and Therapeutics | Year: 2014

Background Therapeutic objectives are currently evolving in inflammatory bowel diseases (IBD) from control of symptoms towards improvement of long-term disease outcomes. In patients achieving remission, safety concerns - infections or neoplasia - and economic issues are prompting de-escalation strategies. Aim To give a complete overview of studies on de-escalating therapy in IBD. Methods A structured search in Pubmed, the Cochrane Library and EMBASE was performed using defined key words (inflammatory bowel diseases, Crohn's disease, ulcerative colitis, immunosuppressants, azathioprine, methotrexate, anti-TNF, infliximab, adalimumab, de-escalation, dose reduction, cessation, stopping, withdrawal), including full text articles and abstracts in English language. Results Eleven studies were identified, investigating cessation of immunosuppressants (IS) and/or anti-TNF treatments. Patients exposed to a combination of IS and anti-TNF have an increased risk for infections, especially due to opportunistic agent, without any clear signal for associated cancers when compared to those receiving single therapy. In patients receiving IS alone, relapse rate at 12 months following IS cessation is close to 20% and 30% in Crohn's disease (CD) and ulcerative colitis (UC) respectively. There is no study specifically evaluating anti-TNF treatment withdrawal in case of scheduled anti-TNF monotherapy in IBD. In patients receiving combination therapy with IS and infliximab (IFX) for at least 6 months, relapse rate of IFX failure following IS cessation is near to 20% at 24 months and seems to be similar in patients who maintained combination therapy. In case of anti-TNF therapy, cessation in CD patients in combo-therapy proportion of relapse is high, close to 40% and 50% over 1 year and 2 years respectively. Regarding higher risk of adverse events, some special situations - young males, pregnancy and elderly - should be managed specifically and de-escalating treatment considered. Conclusions De-escalating treatment strategy should be mainly considered in patients with high risk of severe adverse events and low relapse risk (patients in deep remission) after drug withdrawal. For these reasons, cessation of anti-TNF treatment and/or immunosuppressants should be a case by case decision in highly selected patients. © 2014 John Wiley & Sons Ltd.

Lafitte M.,Bordeaux University Hospital Center
European journal of preventive cardiology | Year: 2013

After an acute coronary syndrome (ACS), optimal medical therapy (OMT) has been shown to be effective in reducing subsequent cardiovascular (CV) events. However, even in populations that reach recommended secondary prevention goals, there is a subset of patients that experience subsequent CV events. To identify biological or clinical predictors of residual risk of CV events in post-ACS patients receiving OMT. A total of 990 post-ACS patients benefited from OMT (optimized treatment during the acute and chronic post-ACS phase, along with a therapeutic and dietary education programme). Traditional CV risk factors and atheroma disease markers (intima-media thickness measurement, carotid atheroma, peripheral arterial disease (PAD) measured by ankle brachial index, and the number of coronary arteries with a >50% stenosis) were evaluated at 3 months post ACS. Cardiovascular events were recorded at follow up. At 20-month follow up, >80% of the patients reached the recommended secondary prevention goals. In this population, diabetes was the only CV risk factor significantly associated with CV events in multivariate analysis including traditional risk factors (HR 1.61, p = 0.017). In multivariate analyses including CV risk factors and atheroma disease markers, only PAD remained significantly associated with CV events (HR 1.83, p = 0.04). The number of vascular beds involved was associated with poorer prognosis (HR for disease in 3-vascular-beds 3.85, p = 0.001, using disease in 1-vascular-bed as a reference group). In post-ACS patients with OMT, atheroma burden is a powerful prognostic marker of recurrent CV events, while diabetes remains the only independent marker of CV events among traditional CV risk factors.

Bourdel-Marchasson I.,Bordeaux University Hospital Center
Journal of the American Medical Directors Association | Year: 2010

Nutritional problems are frequent in nursing homes including undernutrition, obesity, and diabetes mellitus, mainly related to disability and behavior troubles. Adequate nutritional care relies both on the quality of menus for regular and modified diet (texture-modified and enriched food) and on the staff knowledge of nutritional problems, particularly undernutrition. Self-assessment of professional practices for all staff categories that are involved in this area can be used to increase training of staff and quality of nutritional care. © 2010 American Medical Directors Association.

Mahon F.-X.,Bordeaux University Hospital Center | Mahon F.-X.,French Institute of Health and Medical Research
Annals of Hematology | Year: 2015

Over the past decade, a broad array of drugs designed to selectively inhibit protein tyrosine kinases (tyrosine kinase inhibitors or TKIs) have emerged as novel therapies for cancer patients. Chronic myeloid leukemia (CML) is one of the best examples of successful targeted therapy with a TKI. The overall survival of CML patients who respond to treatment is close to that of the healthy population. The response in many patients is so profound that it is possible to consider stopping their treatment and with time, the number of patients in this group has increased to the point where the issue of treatment cessation has become of utmost importance. This has led to the development of a new concept in the evaluation of CML entitled treatment-free remission. It will be the criterion to evaluate the success of future clinical trials, especially if we want to improve the management of the disease to the point where we can claim to have cured CML. © 2015, Springer-Verlag Berlin Heidelberg.

Bioulac-Sage P.,Bordeaux University Hospital Center
The American journal of surgical pathology | Year: 2012

Phenotypic identification of focal nodular hyperplasia (FNH) and hepatocellular adenoma (HCA) subtypes using immunohistochemical markers has been developed from their molecular characteristics. Our objective was to evaluate the sensitivity of these markers in the definitive diagnosis of these lesions by core needle biopsies. A total of 239 needle biopsies paired with their surgical resection specimen (group A) or without an associated resection specimen (group B) were reviewed. Using a step-by-step algorithm after standard staining, appropriate immunostaining analyses were performed to determine the certainty of diagnosis of FNH, HNF1α-inactivated HCA, inflammatory HCA, β-catenin-activated HCA, or unclassified HCA. The diagnosis of FNH was certain or probable on routine stains in 53% of needle biopsies of group A, whereas after glutamine synthetase staining, the diagnosis was certain in 86.7% as compared with 100% on the corresponding surgical specimen (P=0.04). In needle biopsies of group A, the diagnosis of HCA was certain on routine stains in 58.6% as compared with 94.3% on surgical specimens. After specific immunostaining, diagnosis was established on biopsies with 74.3% certainty, including all HCA subtypes, with similar distribution in surgical specimens. For each "certain diagnosis" paired diagnostic test (biopsy and surgical specimen), a positive correlation was observed (P<0.001). No significant difference was observed between groups A and B for FNH (P=0.714) or for HCA subtypes (P=0.750). Compared with surgical specimens, immunohistochemical analysis performed on biopsies allowed the discrimination of FNH from HCA and the identification of HCA subtypes with good performance.

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