Treating strangeness: Medicine and human dignity at the time of COVID-19

The concomitance of a migratory wave and the hospital crisis once again raises the question of the care that the French healthcare system is able to provide to migrants. On the occasion of SFFEM's 19th annual day, we present a synthesis of the research work that has been communicated at that time. Firstly, we will discuss how doctors have been able to overcome strangeness to revive the notion of hospitality according to Levinas; secondly, we will discuss how the hospital is departing from its mission of institutional hospitality because of administrative injunctions; thirdly, we will discuss how ethnomedicine gives us keys to open up to other cultural norms; fourthly, we will see the inadequacy that exists between rights of access to medical care and their effectiveness; finally, the conclusion of Xavier Emmanuelli, founder of the social ambulance service, will remind us how much the values of the French Republic call us to the notion of care and openness to otherness.

Organization and first results of cervical cancer screening program in Mayotte, from 2010 to 2014

OBJECTIVES

Our main goal was to report the organization of individual screening for uterus cancer in Mayotte, the last French department since 2011, and its first results.

MATERIAL AND METHODS

Epidemiological and observational study describing the prior situation, the beginning of the screening with pap smears in 2010, the colposcopy consultations and the treatment of the patients by the Mayotte network for screening of cancers since 2010.

RESULTS

The screening allowed an improvement of the global cover rate from 5% to 24% in 5 years. The best results concern the woman from 25 to 39 years old, with a rate that rose from 14 to 46%.

CONCLUSION

This study confirms the possibility and the efficiency of a screening program on this island, which is French by law, by much closer to developing countries on many other sides.

A modular 256-channel micro electrode array platform for in vitro and in vivo neural stimulation and recording: BioMEA

In order to understand the dynamics of large neural networks, where information is widely distributed over thousands of cells, one of today's challenges is to successfully monitor the simultaneous activity of as many neurons as possible. This is made possible by using the Micro-Electrode Array (MEA) technology allowing neural cell culture and/or tissue slice experimentation in vitro. Thanks to development of microelectronics' technologies, a novel data acquisition system based on MEA technology has been developed, the BioMEA™. It combines the most advanced MEA biochips with integrated electronics, and a novel user-friendly software interface. To move from prototype (result of the RMNT research project NEUROCOM) to manufactured product, a number of changes have been made. Here, we present a 256-channel MEA data acquisition system with integrated electronics (BioMEA™) allowing simultaneous recording and stimulation of neural networks for in vitro and in vivo applications. This integration is a first step towards an implantable device for BCI (Brain Computer Interface) studies and neural prosthesis.

FES kinases are required for oncogenic FLT3 signaling

The closely related non-receptor tyrosine kinases FEline Sarcoma (FES) and FEs Related (FER) are activated by cell surface receptors in hematopoietic cells. Despite the early description of oncogenic viral forms of fes, v-fes, and v-fps, the implication of FES and FER in human pathology is not known. We have recently shown that FES but not FER is necessary for oncogenic KIT receptor signaling. Here, we report that both FES and FER kinases are activated in primary acute myeloid leukemia (AML) blasts and in AML cell lines. FES and FER activation is dependent on FLT3 in cell lines harboring constitutively active FLT3 mutants. Moreover, both FES and FER proteins are critical for FLT3-internal tandem duplication (ITD) signaling and for cell proliferation in relevant AML cell lines. FER is required for cell cycle transitions, whereas FES seems necessary for cell survival. We concluded that FES and FER kinases mediate essential non-redundant functions downstream of FLT3-ITD.

Impact of pain in health related quality of life of patients with systemic sclerosis

OBJECTIVES

Systemic sclerosis (SSc) has an heterogenous clinical pattern, with variable organ involvement and degrees of severity. Like in other rheumatic diseases, the self-questionnaires have been used to evaluate SSc globally. The aim of the study is as to evaluate the quality of life (QoL) in patients with either diffuse or limited SSc, and to examine the impact of pain on the QoL scores.

METHODS

Patients with SSc, either diffuse or limited SSc, were included in a cross-sectional study. The QoL was evaluated with the short-form 36 (SF-36) and the functional repercussion with the SSc-modified Health Assessment Questionnaire (S-HAQ).

RESULTS

A total of 89 patients (67 with diffuse and 22 with limited SSc) were included. The SF-36 score values were lower in SSc patients than those reported in the general population. The physical component scores (PCS) of the SF-36 was significantly worse in diffuse compared with limited SSc (P < 0.05). The PCS was significantly negatively related to the number of clinical manifestations (ANOVA, P < 0.0001). The mental component score (MCS) was not influenced by the type of SSc or the number of clinical manifestations presented by the patient. The QoL of SSc patients was highly correlated with pain (R = 0.69) and disability (R = 0.70). Interestingly, the QoL of SSc patients was only slightly correlated with cutaneous (R = 0.42) and pulmonary involvement (R = 0.57).

CONCLUSION

The QoL of patients with SSc is strongly influenced by the type of SSc, the burden of clinical manifestations, the functional disability and by the pain, whatever its cause. The treatment of pain should be considered as priority to improve the QoL of SSc patients.

Resolution of symptomatic epidural fibrosis following treatment with combined pentoxifylline–tocopherol

Epidural fibrosis (EF) is a major cause of failed back surgery syndrome (FBSS), which induces disabling radiculopathy for which no effective medical treatment exists. Our understanding of the fibrosis mechanisms and our clinical and experimental results for the treatment of radiation-induced fibrosis prompted us to postulate that EF might respond to treatment with combined pentoxifylline (PTX)-tocopherol (Vit.E). 6 weeks after lumbar spine surgery, a 28-year-old man presented with recurrent left L5 sciatica without disc herniation on MRI in December 1993. From 1993 to 1997, he had unrelieved back and leg pain, which became increasingly resistant to intensive medical treatment and to a spinal cord stimulator, and confined him to bed as from December 1997. In 1998, a lumbar CT-scan showed an area of left L4-L5 EF measuring 12 mm x 12 mm, without disc herniation. From April 1998, oral PTX (800 mg day(-1)) and Vit.E (1000 IU day(-1)) were administered daily for 3.5 years and well tolerated. Clinical improvement began during the third month of treatment and continued until total regression of clinical symptoms April 2001. Lumbar MRI in November 2001 showed a surface area of residual EF half the size of the initial area. This is the first report to indicate that antifibrotic treatment using combined PTX-Vit.E may be of potential benefit in the treatment of post-operative EF. Additional studies are required to confirm this potential.

Validation of French version of the Scleroderma Health Assessment Questionnaire (SSc HAQ)

The modified Scleroderma Health Assessment Questionnaire (SSc HAQ) is a functional score to assess systemic sclerosis (SSc) comprising the HAQ disease index (HAQ-DI) plus five specific visual analogue scales (VAS). Since it was validated in English-speaking patients only, its general use in any other language necessitates prior cross-cultural adaptation and validation. We designed this study to assess its value in French-speaking patients and to validate the French version according to international recommendations. We elaborated a French version using the "forward-backward" method. We then validated its psychometric properties with 100 consecutive SSc French-speaking patients who had undergone simultaneous clinical and paraclinical examination. In addition, we calculated the SSc HAQ score, a new outcome measure, which is obtained by pooling the eight domains from the HAQ-DI with the five organ VAS. Our study confirmed the psychometric properties of the SSc HAQ in non-English-speaking patients with (a) structural validity: the major component analysis, performed on the HAQ-DI and the five VAS, yielding a two-factor structure; (b) convergent validity: with high correlation coefficients between the SSc HAQ score and the physical component score of the SF-36 (r=-0.74, p<0.0001); (c) discriminant validity: the SSc HAQ score was better in patients with limited than with diffuse SSc (0.5+/-0.5 vs 1.1+/-0.7, respectively, p<0.0001) in relation to the number of clinical involvements; (d) reproducibility was high using the test-retest procedure (r=0.98). This study showed the value of the SSc HAQ, which is a simple, discriminant, reproducible self-administered questionnaire to evaluate French-speaking SSc patients. In addition, we suggest the use of a new outcome measure, the SSc HAQ score, to assess this systemic disease more accurately.

Thoracic disk herniation mimicking renal crisis

A 45-year-old-woman presented with a mimicking renal stone colicky pain that was finally attributed to radiculalgia T12 caused by a calcified T11-T12 disk herniation.

Évaluation de la qualité de vie par le MOS-SF36 dans la sclérodermie systémique

OBJECTIVE

To investigate the metric properties and the validity of the Medical Outcome Study Short Form 36 (SF-36), a questionnaire to assess the quality of life, in patients with either diffuse or limited systemic sclerosis (SS), and to examine the effect of the disease on quality of life.

METHODS

Cross sectional study of 86 patients with a SS (64 diffuse SS, 22 limited SS). Disease severity was assessed by clinical examination, pulmonary functional tests and Health Assessment Questionnaire (HAQ) modified for scleroderma.

RESULTS

The SF-36 scores values were lower in diffuse than in limited sclérodermie systémique. The Physical Component Score was worse in patients with than without any clinical involvement. This score increased in relation with the number of clinical involvements. The quality of life of patients with SS was correlated to its functional repercussion.

CONCLUSION

The quality of life in SS patients is correlated with the clinical severity of the disease. The use of SF-36 to measure the quality of life is useful for the clinical evaluation of patients with SS.

Systematic esophageal endoscopy screening in patients previously treated for head and neck squamous-cell carcinoma

BACKGROUND

An attempt was made to improve metachronous oesophageal cancer prognosis through bi-annual systematic esophageal endoscopy screening in patients treated for head and neck cancer.

PATIENTS AND METHODS

Bi-annual esophageal endoscopy, without a staining procedure, was performed in 1560 patients from 1987 to 1997. The distribution of previous head and neck cancer was oral cavity (20%), oropharynx (30%), hypopharynx (34%), and larynx (16%). All patients had initial panendoscopic inspection before HNSCC treatment. Esophageal tumors were considered to be second synchronous primaries when discovered within the first six months of initial tumor diagnosis.

RESULTS

Fifty metachronous esophageal asymptomatic cancers (42 T1 and 7 in situ carcinomas) were diagnosed by endoscopy. The median time between the HNC and the esophageal carcinoma was 43 months (7-137 months). Metachronous esophageal carcinoma was discovered in 2.6% of patients with oral cavity tumor, 5.7% of patients with oropharynx tumor, 2.3% of patients with hypopharynx tumor, and 1.7% of patients with larynx tumor. Causes of death were: 41.1% related to esophageal tumor with tumor progression, metastatic evolution, or treatment toxicity; 28.9% related to non malignant causes; 26.6% related to a cancer that was not of esophageal origin.

CONCLUSIONS

Over a 10-year period, systematic bi-annual esophageal endoscopy uncovered metachronous esophageal tumors in 3.2% of 1560 patients originally treated for head and neck carcinoma, developing in a median time of 47 months. Patients with initial oropharyngeal tumors had a significantly higher risk of metachronous esophageal SCC, compared to the other tumor sites (P < 0.02 with Fisher exact test). Given the elevated death rate not related to the esophageal cancer and the median survival of 16 months, any potential benefit from this time-consuming procedure is debatable.

Thermal stability of acetylcholinesterase from Bungarus fasciatus venom as investigated by capillary electrophoresis

Previous studies on the conformation of the monomeric acetylcholinesterase (AChE) from the krait (Bungarus fasciatus) venom showed that the protein possesses a large permanent dipole moment. These studies predicted that thermal irreversible denaturation must occur via partially unfolded states. The thermal stability of Bungarus AChE was determined using capillary electrophoresis (CE) with optimized conditions. Runs performed at convenient temperature scanning rates provided evidence for an irreversible denaturation process according to the Lumry and Eyring model. The mid-transition temperature, T(m), and the effective enthalpy change, DeltaH(m) were determined at different pH. The temperature dependence of the free energy, DeltaG, of Bungarus AChE unfolding was drawn using values of T(m), DeltaH(m) and DeltaC(p) determined by CE. The thermodynamic parameters for the thermal denaturation of the monomeric snake enzyme were compared with those of different dimeric and tetrameric ChEs. It was shown that the changes in the ratio of DeltaH(cal/)DeltaH(vH) and DeltaC(p) reflect the oligomerization state of these proteins. All these results indicate that wild-type monomeric Bungarus AChE is a stable enzyme under standard conditions. However, designed mutants of this enzyme capable of degrading organophosphates have to be engineered to enhance their thermostability.

[Re-emergence of tuberculosis and socioeconomic uncertainty]

INTRODUCTION

Infectious diseases are the main cause of morbidity and mortality among socially deprived patients. In 1988-89 the secular decrease in tuberculosis stopped in France as in other industrial countries, and new emergence of the disease has been observed since then, especially among socially deprived patients.

CURRENT KNOWLEDGE AND KEY POINTS

Clinical characteristics of tuberculosis remain classical among these patients, but advanced, even historical forms of the disease, are often observed, with frequent extra-pulmonary localizations. Diagnostic and therapeutical procedures must be adapted to the patients' living conditions, including their education and social support. Directly observed therapy is rarely used in France, but the development of adequate strategies for effective primary care management with adapted cost/efficiency ratios in the respect of human rights is essential.

FUTURE PROSPECTS AND PROJECTS

Early tracking down of patients lost from follow-up and detailed evaluation of treatment results and social care remain priorities.

Utility of indium-111-antimyosin scintigraphy for diagnosis of myocardial damage in systemic sclerosis

The diagnosis of myocardial disease related to systemic sclerosis is often difficult, but it is clinically relevant since the occurrence of a specific ventricular dysfunction is of poor prognosis. This article reports a case of systemic sclerosis with a subacute episode of myocardial disease assessed by 111In-antimyosin antibody, a specific marker of the necrotic myocardial fiber.

Pyoverdin is essential for virulence of Pseudomonas aeruginosa

The role of pyoverdin, the main siderophore in iron-gathering capacity produced by Pseudomonas aeruginosa, in bacterial growth in vivo is controversial, although iron is important for virulence. To determine the ability of pyoverdin to compete for iron with the human iron-binding protein transferrin, wild-type P. aeruginosa ATCC 15692 (PAO1 strain) and PAO pyoverdin-deficient mutants were grown at 37 degrees C in bicarbonate-containing succinate medium to which apotransferrin had been added. Growth of the pyoverdin-deficient mutants was fully inhibited compared with that of the wild type but was restored when pyoverdin was added to the medium. Moreover, when growth took place at a temperature at which no pyoverdin production occurred (43 degrees C), the wild-type PAO1 strain behaved the same as the pyoverdin-deficient mutants, with growth inhibited by apotransferrin in the presence of bicarbonate and restored by pyoverdin supplementation. Growth inhibition was never observed in bicarbonate-free succinate medium, whatever the strain and the temperature for growth. In vivo, in contrast to results obtained with the wild-type strain, pyoverdin-deficient mutants demonstrated no virulence when injected at 10(2) CFU into burned mice. However, virulence was restored when purified pyoverdin originating from the wild-type strain was supplemented during the infection. These results strongly suggest that pyoverdin competes directly with transferrin for iron and that it is an essential element for in vivo iron gathering and virulence expression in P. aeruginosa. Rapid removal of iron from [59Fe]ferritransferrin by pyoverdin in vitro supports this view.

High-molecular-mass, iron-repressed cytoplasmic proteins in fluorescent Pseudomonas: potential peptide-synthetases for pyoverdine biosynthesis

High molecular-mass cytoplasmic proteins were detected in iron-starved, pyoverdine-producing Pseudomonas aeruginosa, P. chlororaphis, P. fluorescens, P. putida, P. aptata and P. tolaasii. They appeared to be specifically located in the cytoplasm and thus were termed 'IRCPs', for iron-repressed cytoplasmic proteins. A strain-dependent gel electrophoresis pattern with multiple bands of M(r) values ranging from 180 to 600 kDa was usually observed for these proteins. Strains synthesizing pyoverdines differing in their peptide part presented different IRCP gel electrophoresis profiles, whereas strains synthesizing identical pyoverdines had identical IRCP gel electrophoresis profiles. Some mutants affected in pyoverdine biosynthesis presented a perturbed IRCP pattern, and no IRCPs were detected in non-fluorescent Pseudomonas strains either unable to synthesize siderophores or synthesizing non-peptidic siderophores. The data strongly suggest that the IRCPs could be related to peptide synthetases involved in the biosynthesis of the peptidic part of pyoverdine-type siderophores.

Nucleotide sequence of the first cosmid from the Mycobacterium leprae genome project: structure and function of the Rif-Str regions

The nucleotide sequence of cosmid B1790, carrying the Rif-Str regions of the Mycobacterium leprae chromosome, has been determined. Twelve open reading frames were identified in the 36716bp sequence, representing 40% of the coding capacity. Five ribosomal proteins, two elongation factors and the beta and beta' subunits of RNA polymerase have been characterized and two novel genes were found. One of these encodes a member of the so-called ABC family of ATP-binding proteins while the other appears to encode an enzyme involved in repairing genomic lesions caused by free radicals. This finding may well be significant as M. leprae, an intracellular pathogen, lives within macrophages.

Iron metabolism in Pseudomonas: salicylic acid, a siderophore of Pseudomonas fluorescens CHAO

Under iron-starvation conditions of growth, Pseudomonas fluorescens CHA0, a soil isolate involved in phytopathogenic fungi antagonisms, produced, together with pyoverdine, a second iron-chelating compound which was purified and identified by spectroscopy, HPLC and 1H-NMR to be salicylic acid. Mutants unable to synthesize pyoverdine overproduced this compound by a factor of 9-14. The biosynthesis of salicylic acid was under iron control; it was fully inhibited by 5 microM added iron in the growth medium. In contrast, salicylic acid of either bacterial or commercial origin facilitated labeled iron incorporation in iron-starved cells. Based on these two relationships observed with bacterial iron metabolism it is concluded that salicylic acid has a siderophore function for this strain.

[Acute respiratory failure: comparison of spontaneous ventilation with continuous positive airway pressure (CPAP) and mechanical ventilation with positive and expiratory pressure (CPPV) in 6 cases (author's transl)]

The hemodynamic and respiratory effects of spontaneous ventilation with continuous positive airway pressure (CPAP) and mechanical ventilation with positive and expiratory pressure (CPPV) were compared in six patients with acute respiratory failure. Arterial and mixed venous gases, cardiac output, oxygen delivery and consumption, airway and oesophageal pressures were measured, with each patient on intermittent positive pressure ventilation (IPPV), CPAP and CPPV with the same level of positive and expiratory pressure (PEEP = 20 cmH2O). CPAP was as efficient as CPPV for improving arterial oxygenation. Cardiac output was higher on CPAP than on CPPV due to a lower intra-thoracic pressure with spontaneous ventilation, thus oxygene transport was higher with this methode. However total oxygene consumption and PaCO2 were slightly increased with CPAP due to a higher breathing's work. So, CPAP is as efficient as CPPV at the same level of PEEP in improving intra-pulmonary shunt and PaO2, without adversely affecting cardiac output.

[Coronary angiography in the preoperative exploration of non-ischemic acquired valve diseases]

One hundred and fifty-nine patients with aortic valve disease (86 cases), mitral valve disease (58 cases) or mitral and aortic disease (15 cases) underwent a pre-operative haemodynamic study, including coronary arteriography either as a routine (age greater than 50 years) or because of chest pains. Coronary arteriography is easy to do during left heart catheterisation and nowadays carries minimal risk. In the cases of chest pains, it showed stenotic lesions of the coronary vessels in 22% of patients with aortic valve disease and in 35% of those with mitral disease. In the absence of angina, coronary arteriography showed no evidence of coronary artery disease in the cases of mitral regurgitation and of aortic valve disease. In contrast, it showed stenotic lesions in three cases of mitral stenosis. In the whole of the series, coronary artery disease proved a contra-indication to surgery in three cases, and was an indication for aorta-coronary by-pass grafting, in addition to valve surgery, in seven other cases. In the absence of angina, coronary arteriography has only a slight influence on the decision to operate. It does however give additional security, which justifies its routine use in patients over 50 years of age, particularly those with mitral valve disease.