American Hospital of Paris

Background & AimsHepatocellular carcinoma (HCC) surveillance programs are suboptimal. We aimed to design an ultrasound-based deep learning model for HCC risk stratification (STARHE-RISK) and early-stage HCC detection (STARHE-DETECT) in patients with compensated advanced chronic liver disease (cACLD).MethodsThis prospective multicentric study included 403 adult patients with cACLD of all causes enrolled in a surveillance program for at least 6 months without prior history of HCC. STARHE-RISK was trained on ultrasound cine clips of the non-tumoral liver parenchyma using two classes: cases (n = 152 patients with early-stage HCC; 137/152 [82%] male; median age 63 years) and controls (n = 170 patients without HCC at inclusion and during a subsequent 1-year follow-up; 120/170 [71%] male; median age 69 years). STARHE-DETECT was trained on tumour ultrasound cine clips. The training/validation and testing sets were stratified according to potential confounders, and 50 patients who were balanced in both groups were allocated to the independent testing set based on sample size calculation. Statistical analysis included classification and detection metrics.ResultsSTARHE-RISK achieved good prediction performances in the testing set with a 0.72 accuracy (95% CI 0.57–0.84) and an odds ratio of 6.6 (95% CI 1.9–22.7; p = 0.003). The combination of STARHE-RISK and the FASTRAK score, a multi-aetiology HCC risk stratification score, achieved a higher specificity (0.86 [95% CI 0.65–0.97]) and odds ratio (8.9 [95% CI 2.1–38.3; p = 0.004]) for predicting a patient at high risk of HCC development. STARHE-DETECT achieved a 0.67 mAP10, a 0.68 sensitivity (95% CI 0.47–0.85), and a 0.82 specificity (95% CI 0.69–0.91) for detecting early-stage HCC.ConclusionsSTARHE-RISK and STARHE-DETECT achieved robust performances for HCC risk stratification and early-stage HCC detection, respectively. They could become valuable surveillance tools and pave the way for a risk-based personalised surveillance program.Impact and implicationsSTARHE-RISK is a reliable ultrasound-based deep learning model for hepatocellular carcinoma (HCC) risk stratification in patients with compensated advanced chronic liver disease and can be associated with complementary scores integrating clinical and blood parameters. STARHE-DETECT could become a complementary tool to visual assessment for radiologists and sonographers in HCC surveillance. Both models are based on simple and easy-to-perform ultrasound cine clip acquisitions. This study paves the way for a risk-based personalised surveillance program that will not ultimately rely on a single test but rather on a combination of approaches mixing clinical, biological, and radiological data.Clinical Trials RegistrationThe study is registered at ClinicalTrials.gov (NCT04802954).

BackgroundInfertility is defined as the inability to achieve a live birth after 1 year of regular sexual intercourse, affecting 1 in 6 couples in France. The use of assisted reproductive technology (ART) for infertility issues has been steadily increasing in recent years, with in vitro fertilization being the most common type of ART. Infertility is frequently regarded as a significant life crisis for many individuals, potentially leading to depression, anxiety, social isolation, and sexual dysfunction. Couples experiencing infertility demonstrate a high prevalence of negative emotional responses and decreased life satisfaction as a result of infertility and its treatments. Social media have become key tools for finding and disseminating medical information.ObjectiveThis study aims to explore the most discussed topics among patients with infertility and to characterize the impact of infertility and ART on their quality of life (QoL) by analyzing social media data.MethodsThis retrospective observational study includes French messages from patients in France discussing their infertility between 2019 and 2022. A biterm topic model algorithm was applied to identify the topics discussed automatically. A QoL algorithm—based on the EQ-5D and SF-36 (Short Form 36 Health Survey) questionnaires—classified the messages according to 5 dimensions: physical, psychological, activity-related, social, and financial.ResultsAn analysis was conducted on a dataset of 26,919 messages written by 9807 patients. More than 80% (21,900/26,919) of the data were retrieved from 3 main sources: Doctissimo (9281/26,919, 34.5%), BabyCenter.fr (n=6949, 25.8%), and aufeminin.com (n=5670, 21.1%). Among the users who specified their gender (8813/9807, 89.9%), the majority were female (7942/8813, 90.1%) compared to male users (871/8813, 9.9%). The average age was 41 (SD 6.15) years. The most frequently discussed topics were the ART procedures, marked by miscarriages (5671/26,919, 21.1%), ovulation cycle monitoring (5068/26,919, 18.9%), and balancing attempts to conceive with work responsibilities (3476/26,919, 12.9%). In our study, 59% (5786/9807) of users expressed at least 1 impact on their QoL. Patients mainly reported a physical impact (3610/5786, 62.4%), particularly linked to miscarriages (2137/3610, 59.2%). The psychological impact (3020/5786, 52.2%), including fear and anxiety (1818/3015, 60.3%), was also mentioned. The social impact of infertility (n=654/5786, 11.3%)—notably its effects on the couple’s relationship (438/651, 67.3%)—the financial burden of infertility treatments (521/5786, 9%), and the impact on activities (503/5786, 8.7%) were also identified.ConclusionsPatients facing infertility share their experiences on social media. We observed a strong impact on their QoL, affecting their physical and psychological health, as well as their social, financial, and professional lives. These results underline the importance of taking into account the multiple dimensions of infertility when caring for patients and highlight the important role of social media in supporting and understanding this reality.

PurposeNon-obstructive azoospermia (NOA) is a common, but complex problem, with multiple therapeutic options and a lack of clear guidelines. Hence, there is considerable controversy and marked variation in the management of NOA. This survey evaluates contemporary global practices related to medical and surgical management for patients with NOA.Materials and MethodsA 56-question online survey covering various aspects of the evaluation and management of NOA was sent to specialists around the globe. This paper analyzes the results of the second half of the survey dealing with the management of NOA. Results have been compared to current guidelines, and expert recommendations have been provided using a Delphi process.ResultsParticipants from 49 countries submitted 336 valid responses. Hormonal therapy for 3 to 6 months was suggested before surgical sperm retrieval (SSR) by 29.6% and 23.6% of participants for normogonadotropic hypogonadism and hypergonadotropic hypogonadism respectively. The SSR rate was reported as 50.0% by 26.0% to 50.0% of participants. Interestingly, 46.0% reported successful SSR in <10% of men with Klinefelter syndrome and 41.3% routinely recommended preimplantation genetic testing. Varicocele repair prior to SSR is recommended by 57.7%. Half of the respondents (57.4%) reported using ultrasound to identify the most vascularized areas in the testis for SSR. One-third proceed directly to microdissection testicular sperm extraction (mTESE) in every case of NOA while others use a staged approach. After a failed conventional TESE, 23.8% wait for 3 months, while 33.1% wait for 6 months before proceeding to mTESE. The cut-off of follicle-stimulating hormone for positive SSR was reported to be 12–19 IU/mL by 22.5% of participants and 20–40 IU/mL by 27.8%, while 31.8% reported no upper limit.ConclusionsThis is the largest survey to date on the real-world medical and surgical management of NOA by reproductive experts. It demonstrates a diverse practice pattern and highlights the need for evidence-based international consensus guidelines.

PurposeNon-obstructive azoospermia (NOA) represents the persistent absence of sperm in ejaculate without obstruction, stemming from diverse disease processes. This survey explores global practices in NOA diagnosis, comparing them with guidelines and offering expert recommendations.Materials and MethodsA 56-item questionnaire survey on NOA diagnosis and management was conducted globally from July to September 2022. This paper focuses on part 1, evaluating NOA diagnosis. Data from 367 participants across 49 countries were analyzed descriptively, with a Delphi process used for expert recommendations.ResultsOf 336 eligible responses, most participants were experienced attending physicians (70.93%). To diagnose azoospermia definitively, 81.7% requested two semen samples. Commonly ordered hormone tests included serum follicle-stimulating hormone (FSH) (97.0%), total testosterone (92.9%), and luteinizing hormone (86.9%). Genetic testing was requested by 66.6%, with karyotype analysis (86.2%) and Y chromosome microdeletions (88.3%) prevalent. Diagnostic testicular biopsy, distinguishing obstructive azoospermia (OA) from NOA, was not performed by 45.1%, while 34.6% did it selectively. Differentiation relied on physical examination (76.1%), serum hormone profiles (69.6%), and semen tests (68.1%). Expectations of finding sperm surgically were higher in men with normal FSH, larger testes, and a history of sperm in ejaculate.ConclusionsThis expert survey, encompassing 367 participants from 49 countries, unveils congruence with recommended guidelines in NOA diagnosis. However, noteworthy disparities in practices suggest a need for evidence-based, international consensus guidelines to standardize NOA evaluation, addressing existing gaps in professional recommendations.

The use of standardized reporting systems for non-gynecologic cytopathology has made enormous gains in popularity during the past decade, including for thyroid fine-needle aspiration, urine cytology, serous effusions, pancreas, lymph nodes, lung, and more. In February 2018, the first edition Atlas of the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) was published. The MSRSGC defines six diagnostic fine-needle aspiration categories encompassing the spectrum of non-neoplastic, benign, and malignant lesions of the salivary glands. The goal of the MSRSGC is to combine each diagnostic category with a defined risk of malignancy and a specific clinical and/or surgical management algorithm. Since its initial publication in 2018, more than 200 studies and commentaries have been published confirming the role of the MSRSGC. The second edition of the MSRSGC, published in July 2023, includes refined risks of malignancy based on systematic reviews and meta-analyses, a new chapter summarizing the use of salivary gland imaging, new advances in ancillary testing, and updates in nomenclature.

Although adjuvant cancer treatments increase cure rates, they may induce clonal selection and tumor resistance. Information still lacks as whether (neo)adjuvant anti-HER2 treatments impact the patterns of recurrence and outcomes of HER2-positive (HER2+) metastatic breast cancer (MBC). We aimed to assess this in the large multicenter ESME real-world database. We examined the characteristics and outcomes (overall survival (OS) and progression-free survival under first-line treatment (PFS1)) of HER2+ patients with MBC from the French ESME program with recurrent disease, as a function of the previous receipt of adjuvant trastuzumab. Multivariable analyses used Cox models adjusted for baseline demographic, prognostic factors, adjuvant treatment received, and disease-free interval. Two thousand one hundred and forty-three patients who entered the ESME cohort between 2008 and 2017 had a recurrent HER2+ MBC. Among them, 56% had received (neo)adjuvant trastuzumab and 2.5% another anti-HER2 in this setting. Patients pre-exposed to trastuzumab were younger, had a lower disease-free interval, more HR-negative disease and more metastatic sites. While the crude median OS appeared inferior in patients exposed to adjuvant trastuzumab, as compared to those who did not (37.2 (95%CI 34.4-40.3) versus 53.5 months (95% CI: 47.6-60.1)), this difference disappeared in the multivariable model (HR = 1.05, 95%CI 0.91-1.22). The same figures were observed for PFS1. Among patients with relapsed HER2+ MBC, the receipt of adjuvant trastuzumab did not independently predict for worse outcomes when adjusted to other prognostic factors.

Sperm DNA fragmentation (SDF) has been associated with male infertility and poor outcomes of assisted reproductive technology (ART). The purpose of this study was to investigate global practices related to the management of elevated SDF in infertile men, summarize the relevant professional society recommendations, and provide expert recommendations for managing this condition. An online global survey on clinical practices related to SDF was disseminated to reproductive clinicians, according to the CHERRIES checklist criteria. Management protocols for various conditions associated with SDF were captured and compared to the relevant recommendations in professional society guidelines and the appropriate available evidence. Expert recommendations and consensus on the management of infertile men with elevated SDF were then formulated and adapted using the Delphi method. A total of 436 experts from 55 different countries submitted responses. As an initial approach, 79.1% of reproductive experts recommend lifestyle modifications for infertile men with elevated SDF, and 76.9% prescribe empiric antioxidants. Regarding antioxidant duration, 39.3% recommend 4-6 months and 38.1% recommend 3 months. For men with unexplained or idiopathic infertility, and couples experiencing recurrent miscarriages associated with elevated SDF, most respondents refer to ART 6 months after failure of conservative and empiric medical management. Infertile men with clinical varicocele, normal conventional semen parameters, and elevated SDF are offered varicocele repair immediately after diagnosis by 31.4%, and after failure of antioxidants and conservative measures by 40.9%. Sperm selection techniques and testicular sperm extraction are also management options for couples undergoing ART. For most questions, heterogenous practices were demonstrated. This paper presents the results of a large global survey on the management of infertile men with elevated SDF and reveals a lack of consensus among clinicians. Furthermore, it demonstrates the scarcity of professional society guidelines in this regard and attempts to highlight the relevant evidence. Expert recommendations are proposed to help guide clinicians.