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We tested the effect of dietary advice dedicated to increase intake in older patients at risk for malnutrition during chemotherapy, versus usual care, on one-year mortality. We conducted a multicentre, open-label interventional, stratified (centre), parallel randomised controlled trial, with a 1∶1 ratio, with two-year follow-up. Patients were aged 70 years or older treated with chemotherapy for solid tumour and at risk of malnutrition (MNA, Mini Nutritional Assessment 17-23.5). Intervention consisted of diet counselling with the aim of achieving an energy intake of 30 kCal/kg body weight/d and 1.2 g protein/kg/d, by face-to-face discussion targeting the main nutritional symptoms, compared to usual care. Interviews were performed 6 times during the chemotherapy sessions for 3 to 6 months. The primary endpoint was 1-year mortality and secondary endpoints were 2-year mortality, toxicities and chemotherapy outcomes. Between April 2007 and March 2010 we randomised 341 patients and 336 were analysed: mean (standard deviation) age of 78.0 y (4·9), 51.2% male, mean MNA 20.2 (2.1). Distribution of cancer types was similar in the two groups; the most frequent were colon (22.4%), lymphoma (14.9%), lung (10.4%), and pancreas (17.0%). Both groups increased their dietary intake, but to a larger extent with intervention (p<0.01). At the second visit, the energy target was achieved in 57 (40.4%) patients and the protein target in 66 (46.8%) with the intervention compared respectively to 13 (13.5%) and 20 (20.8%) in the controls. Death occurred during the first year in 143 patients (42.56%), without difference according to the intervention (p = 0.79). No difference in nutritional status changes was found. Response to chemotherapy was also similar between the groups. Early dietary counselling was efficient in increasing intake but had no beneficial effect on mortality or secondary outcomes. Cancer cachexia antianabolism may explain this lack of effect. ClinicalTrials.gov NCT00459589.

Background The present paper describes three cases where ER-REBOA® was used with partial aorta occlusion (AO), by performing a partial resuscitative endovascular balloon occlusion of the aorta or pREBOA, in an austere pre-hospital military environment. In addition, because no specific REBOA algorithm for pre-hospital environment exists yet, this paper seeks to fill this gap, proposing a new pragmatic REBOA algorithm. Methods Belgian Special Operations Surgical Team applied REBOA in three patients according to a decisional algorithm, based on the MIST acronym used for trauma patients. Only 3 ml, in the first instance, was inflated in the balloon to get AO. The balloon was then progressively deflated, and reperfusion was tracked through changes of end-tidal carbon dioxide (EtCO 2 ). Results Systolic blood pressure (SBP) before ER-REBOA® placement was not higher than 60 mmHg. However, within the first 5 min after AO, SBP improved in all three cases. Due to the aortic compliance, a self-made pREBOA was progressively achieved while proximal SBP was raising with intravenous fluid infusion. Afterwards, during deflation, a steep inflection point was observed in SBP and EtCO 2 . Conclusions ER-REBOA® is suitable for use in an austere pre-hospital environment. The MIST acronym can be helpful to select the patients for which it could be beneficial. REBOA can also be performed with pREBOA in a dynamic approach, inflating only 3 mL in the balloon and using the aortic compliance. Furthermore, while proximal SBP can be convenient to follow the occlusion, EtCO 2 can be seen as an easy and interesting marker to follow the reperfusion.

En France, les directives anticipées (DA) se sont vues reconnaître un statut légal en 2005, renforcé en 2016, toutefois une minorité de personnes fait le choix d’en rédiger. Dans le contexte de la maladie grave, quel est leur contenu ? Quelles informations relatives à leur prise en charge ou leur fin de vie y déposent-elles ? L’objectif de cette recherche qualitative est d’analyser le contenu des DA rédigées par des patients atteints d’hémopathies malignes afin de mieux comprendre leur appropriation. L’étude s’est déroulée en deux étapes sur une durée totale de huit ans et deux mois : un travail préliminaire, rétrospectif et monocentrique et une seconde étape prospective et multicentrique dans six sites français. L’analyse qualitative des DA a été accomplie par un binôme composé d’un hématologue sénior et d’un chercheur en sciences humaines et sociales. Une analyse thématique a été réalisée avec identification des principaux messages et mots clés. Les 35 DA collectées sont investies de trois façons différentes : l’appropriation est 1) purement juridique avec une citation de la loi in extenso sans personnalisation de l’écrit ; 2) centrée sur les actes et traitements médicaux souhaités ou refusés ; 3) un moyen de transmettre des messages personnels à l’attention de leurs proches comme leur confiance, l’amour qu’il leur porte ou les modalités d’obsèques souhaitées. En conclusion, nos résultats objectivent que la rédaction de DA ne se limite pas aux patients en fin de vie et qu’au-delà de la transmission d’informations relatives aux actes ou traitements médicaux, les patients les utilisent pour y déposer des messages personnels à leurs proches. Ce nouveau rôle des DA pourrait favoriser la communication intrafamiliale même si ce n’est pas leur finalité première. Faire évoluer les DA vers un concept plus large, comme une planification anticipée des soins, pourrait être un moyen de repenser l’outil et de toucher un plus grand nombre de personnes. In France advance directive (ADs) legislation has been in place since 2005, strengthened in 2016, however a minority of people made the choice to write them. In the context of critical illness, what about their content? What information relating to their care or their end of life do they write there? The aim of this qualitative research is to analyze the content of the ADs written by patients with hematological malignancies in order to better understand how they are put into practice. The study was conducted in two steps over a total duration of 8 years and 2 months: a preliminary work retrospective and monocentric and a second step of prospective and multicenter in 6 French sites. The qualitative analysis of the ADs was carried out by two people: a senior hematologist and a researcher in Humanities and Social Sciences. A thematic analysis was done with identification of the main messages and keywords. The 35 ADs collected were used in three different ways by patients. The appropriation is either 1) purely legal with law articles cited in extenso without personalization of the writing, or 2) to focus on medical acts and treatments desired or refused and 3) to transmit personal messages for their loved ones such as their confidence, their love or funeral arrangements. In conclusion, our results show that the writing of ADs is not limited to end-of-life patients and that beyond the transmission of information about medical acts or treatments, patients use them to write personal messages to their loved ones. This new role of ADs could foster intrafamilial communication even if it is not their primary purpose. Moving ADs to a broader concept, such as advance care planning, could be a way to rethink the tool and reach more people.

Background In France, advance directives are favourably perceived by most of the population, although the drafting rate is low. This ambivalence is challenging because advance directives are meant to promote the autonomy and freedom of choice of patients. The purpose of this study was to analyse the content of advance directives written by patients suffering from malignant haemopathies to better understand how patients put them into practice. These could be relevant as early as the initial diagnosis of haematological malignancies because of the uncertain course of the disease. Methods This was a multicentre, qualitative, descriptive study. The advance directives written by patients with malignant haemopathies treated in one of the six French hospital departments were included in the study from 01/06/2008 to 15/04/2016. A thematic analysis of the advance directives was performed by two researchers: a senior haematologist and a research assistant. Results The median age of the patients was 69. Most were women (sex ratio: 0.59), living as a couple (57%), with lymphoid pathologies (66%), who were still alive two years after the instructions were written (63%) and had nominated a health care proxy (88.6%). Free texts (62.9%) were richer in content than pre-defined forms. The advance directives were used in three ways: for a purely legal purpose, to focus on medical treatments or actions, or to communicate a message to the family. Three main themes emerged: (1) refusal of medical treatment (100%), in which patients express refusal of life-sustaining care (97.1%). The actual treatments or the moment when they should be limited or stopped were not always mentioned in detail. (2) A desire for effective pain relief to avoid suffering (57.1%) and (3) messages for their family (34.3%), such as funeral arrangements (17.1%) and messages of love or trust (14.3%). Conclusions Patients who write advance directives are not necessarily at the end of their lives. Their content mainly conveys treatment wishes, although patients also use them to pass on personal messages to their close family. This emerging role of advance directives to communicate messages within the family should be valued, even if it is not their original purpose.

Morphological differences associated with sex or stage, together with total lipids and carotenoids, were studied in Euphausia superba as possible indicators of physiological condition. E. superba displays sexual dimorphism during growth. A group of mature males, called Males II herein, has a greater abdominal length, suggesting that they are faster swimmers, a feature implying higher metabolic rates and a higher demand for protecting pigments like carotenoids. Mature Males II have proportionally lower lipids but higher total lipid-soluble carotenoids, a counterintuitive finding. Males II also have bigger eyes. Significant regressions with carotenoids were found for wet weight, abdominal length, and eye diameter. On a spatial analysis, population composition reflects reproductive activity. Males II would be in search of females for fecundation and, thus, are dominant in some areas. The PCA analysis of 10 allometric and biochemical variables show a distinct Males II group differing in morphology, carotenoids, and lipid contents. The carotenoid:lipid ratio was highest for Males II, supporting the hypothesis of the role of carotenoids in the activity of the species. Mature males may experience physiological stress during reproduction and probably die shortly afterwards. A relationship between activity, morphometrics, and carotenoid content seems evident, deserving further investigation.

The spatial distribution of heterotrophic prokaryotes was investigated during the Tokyo–Palau cruise in the western part of the North Pacific subtropical gyre (NPSG) along a north–south transect between 33.60 and 13.25° N. The cruise was conducted in three different hydrological areas identified as the Kuroshio region, the subtropical gyre area and the transition zone. Two eddies were crossed along the transect: one cold-core cyclonic eddy and one warm-core anticyclonic eddy and distributions of the heterotrophic prokaryotes were recorded. By using analytical flow cytometry and a nucleic acid staining protocol, heterotrophic prokaryotes were discriminated into three subgroups depending on their nucleic acid content (low, high and very high nucleic acid contents labelled LNA, HNA and VHNA, respectively). Statistical analyses performed on the data set showed that LNA, mainly associated with low temperature and low salinity, were dominant in all the hydrological regions. In contrast, HNA distribution seemed to be associated with temperature, salinity, Chl a and silicic acid. A latitudinal increase in the HNA / LNA ratio was observed along the north–south transect and was related to higher phosphate and nitrate concentrations. However, the opposite relationship observed for the VHNA / HNA ratio suggested that the link between nucleic acid content and oligotrophic conditions is not linear, underlying the complexity of the biodiversity in the VHNA, HNA and LNA subgroups. In the Kuroshio Current, it is suggested that the high concentration of heterotrophic prokaryotes observed at station 4 was linked to the path of the cold cyclonic eddy core. In contrast, it is thought that low concentrations of heterotrophic prokaryotes in the warm core of the anticyclonic gyre (Sta. 9) are related to the low nutrient concentrations measured in the seawater column. Our results showed that the high variability between the various heterotrophic prokaryote cluster abundances depend both on the mesoscale structures and the oligotrophic gradient.

The distribution of ultraphytoplankton was investigated in the western North Pacific Subtropical Gyre (NPSG) during La Niña, a cold phase of El Niño Southern Oscillation (ENSO). Observations were conducted in a north-south transect (33.6–13.25° N) along the 141.5° E meridian in order to study the ultraplankton assemblages in various oligotrophic conditions. Analyses were performed at the single cell level by analytical flow cytometry. Five ultraphytoplankton groups (Prochlorococcus, Synechococcus, picoeukaryotes, nanoeukaryotes and nanocyanobacteria-like) defined by their optical properties were enumerated in three different areas visited during the cruise: the Kuroshio region, the subtropical Pacific gyre and a transition zone between the subtropical Pacific gyre and the Warm pool. Prochlorococcus outnumbered the other photoautotrophs in all the investigated areas. However, in terms of carbon biomass, an increase in the relative contribution of Synechococcus, picoeukaryotes and nanoeukaryotes was observed from the centre of the subtropical gyre to the Kuroshio area. In the Kuroshio region, a peak of abundance of nanoeukaryotes observed at the surface suggested an increase in nutrients likely due to the vicinity of a cold cyclonic eddy. In contrast, in the salinity front along the isohaline 35 and anticyclonic eddy located around 22.83° N, the mainly constant distribution of Prochlorococcus from the surface down to 150 m characterised the dominance by these microorganisms in high salinity and temperature zone. Results suggested that the distribution of nanocyanobacteria-like is also closely linked to the salinity front rather than low phosphate concentration. The maximum abundance of ultraphytoplankton was located above the SubTropical Counter Current (STCC) at depths > 100 m where higher nutrient concentrations were measured. Finally, comparison of the ultraphytoplankton concentrations during El Niño (from the literature) and La Niña (this study) conditions seems to demonstrate that La Niña conditions lead to higher concentrations of Synechococcus in the Subtropical gyre and a lower abundance of Synechococcus in the Kuroshio region. Our results suggest that the west part of NPSG is a complex area, where different water masses, salinity fronts and eddies lead to a heterogeneous distribution of ultraphytoplankton assemblages in the upper layer of the water column.

Decreased health-related quality of life (HRQoL) is common in patients with cancer. We investigated the effects of dietary intervention and baseline nutritional status on worsening of HRQoL in older patients during chemotherapy. In this randomized control trial assessing the effect on mortality of dietary advice to increase dietary intake during chemotherapy, this post hoc analysis included 155 patients with cancer at risk of malnutrition. The effects of dietary intervention, baseline Mini Nutritional Assessment item scores, weight loss, and protein and energy intake before treatment on the worsening of HRQoL (physical functioning, fatigue) and secondary outcomes (Timed Up and Go test, one-leg stance time, depressive symptoms, basic (ADL), or instrumental (IADL) activities of daily living) were analyzed by multinomial regressions. Dietary intervention increased total energy and protein intake but had no effect on any examined outcomes. Worsening of fatigue and ADL was predicted by very low protein intake (< 0.8 g kg−1 day−1) before chemotherapy (OR 3.02, 95% CI 1.22–7.46, p = 0.018 and OR 5.21, 95% CI 1.18–22.73, p = 0.029 respectively). Increase in depressive symptomatology was predicted by 5.0–9.9% weight loss before chemotherapy (OR 2.68, 95% CI 1.10–6.80, p = 0.038). Nutritional intervention to prevent HRQoL decline during chemotherapy should focus on patients with very low protein intake along with those with weight loss.

Background To obtain reliable clinical data of human immunodeficiency virus type 1 group O (HIV-1/O) infection, and immunovirological responses to combination antiretroviral therapy (cART), in a large series of 101 patients. Methods Piecewise linear models were used to estimate CD4 count before and after cART initiation. Kaplan-Meier survival curves were used to estimate time to reach clinical stage C before antiretroviral therapy (ART) and to analyze time to achieve a plasma viral load (pVL) <40 copies/mL following cART initiation. Immunovirological response was assessed at the most recent visit in patients on active follow-up. Results Data showed a 16.6% cumulative probability of reaching stage C within 5 years following diagnosis, and a mean CD4 decrease of –30.5 cells/μL/year. cART initiation in ART-naive patients led to a mean CD4 gain of 147 cells/μL after 12 months, and to a median pVL of <40 copies/mL after 3.8 months for 89.3%. Initiation with a nonrecommended nonnucleoside reverse transcriptase inhibitor–based vs a ritonavir-boosted protease inhibitor–based regimen resulted in a much smaller gain of around 100 CD4 cells/μL after 1 year. Patients on follow-up since 2007 had a median CD4 count of 498 cells/μL, and 87% had a pVL <40 copies/mL at the most recent follow-up visit. Conclusions This work provides unique data on HIV-1/O infection, in favor of a milder natural evolution than HIV-1 group M (HIV-1/M) and of a highly efficient current management, based on HIV-1/M guidelines, despite genetic divergence. Studies of comparable HIV-1/M and HIV-1/O populations are needed to confirm these results.

We evaluated the impact of cytomegalovirus (CMV)—induced immune responses, autoimmune-induced immune responses, and microbial translocation on immune activation in 191 human immunodeficiency virus type 1—infected patients from the ANRS CO3 Aquitaine Cohort. All enrolled subjects had achieved long-term virological suppression during receipt of combination antiretroviral therapy (cART). HLA-DR + /CD38 + expression was 16.8% among CD8 + T cells. Independent of age, CD4 + T-cell count, 16S ribosomal DNA load, and regulatory T-cell count, positive results of Quantiferon CMV analysis (P = .02), positive results of CMV-pp65 enzyme-linked immunosorbent spot analysis (P = .01), positive results of CMV-pp65—specific CD8 + T-cell analysis (P = .05), and CMV seropositivity (P = .01) were associated with a higher percentage of CD8+ T cells that expressed HLA-DR+/CD38+. Autoimmune response and microbial translocation were not associated with immune activation. Therefore, the CMV-induced immune response seems to be associated with chronic immune activation in cART recipients with sustained virological suppression.