How to Evaluate Health in All Policies at the Local Level: Methodological Insights Within Municipalities From the WHO French Healthy Cities Network

BACKGROUND

This article proposes a method for analysing the degree of maturity of Health in All Policies (HiAP) among World Health Organization-French Healthy Cities Network (WHO-FHCN) as part of the GoveRnance for Equity, EnviroNment and Health in the City (GREENH-City) project. We focused on the creation or enhancement of health-promoting environments, and more specifically, public green spaces.

METHODS

We conducted a cross-sectional quantitative study guided by the evaluative framework of the HiAP maturity level developed by Storm et al mixed with a qualitative interpretation. A self-administered questionnaire was sent to elected officials and health department officers in the 85 member cities of the WHO-FHCN in 2017. Subsequently 58 cities were included in the analysis, which was based on a multiple correspondence analysis (MCA) and a hierarchical ascending classification (HAC).

RESULTS

Thirty-two criteria among a total of 100 were identified and were used to organize the cities into 8 groups which was then reduced to three profiles among the cities: a less advanced HiAP profile, an established HiAP profile and an advanced HiAP profile. This process allows us to identify 4 dimensions that make it possible to evaluate the level of maturity of cities in the HiAP process, namely: (1) the consideration of social inequalities in health and/or health issues in the policies/actions of the sector studied, (2) occasional intersectoral collaboration, ie, one-off initiatives between the health department and others sectors, (3) the existence of joint projects, ie, common projects between two or more sectors, (4) the existence of intersectoral bodies, in this case on the theme of urban green spaces including an intersectoral committee and/or working groups.

CONCLUSION

Four dimensions which allow to the measurement of the degree of progress in implementing health-all-policies are proposed. With a view to integrating knowledge into public action, this study carried out under real conditions offers a realistic method to evaluate HiAP.

Staying active during Covid-19 crisis: why it would have been important to keep public parks opened

Background

In 2020, the Covid 19 pandemic and associated restrictions, including limited access to public urban green space (UGS), have led to a decrease in the ability of city dwellers to engage in physical activity. In France, more than 52% people reported being physically active in urban parks. Based on the GREENH-City research carried out in cities of the French network of WHO healthy cities, this presentation aims to show that UGS, depending on different drivers, can support a wide variety of physical activities, but also offer multiple other functions that contribute more or less directly to the health of the population.

Methods

A qualitative survey was conducted among users of 3 different parks in each of the 6 selected cities with both observations and semi-directive interviews and a thematic analyzes were performed. Observed activities were classified into 8 groups including physical activity (non-sport, sports). Interview's analysis aimed to describe the reasons for coming and the type of activity made.

Results

186 observations and 591 recorded and unrecorded interviews with individuals or groups were conducted in the 18 parks. 24 types of physical activity have been described as possible uses of UGS. The most important, regardless of UGS location, is children activities in playgrounds. The most common activities are walking (with a social function) and jogging (individual function). Proximity and the accessibility are two reasons for use.

Conclusions

UGS are an open access amenity for physical activities. From a social justice perspective, policy makers should ensure that every neighborhood is sufficiently close to an UGS. In addition to promoting physical activity, UGS also serve an important social function and impact the collective physical and mental health of the population in many other ways (e.g., as environmental risk regulators). Their coping role during crisis for population would worth to be studied further.

Key messages

Proximity and accessibility should shape local policies related to UGS renewal towards more equity. Different typologies of urban parks at the city level can offer multiple functions, including facilitation of physical activity that contribute to the health of the population.

Colonization resistance against multi-drug-resistant bacteria: a narrative review

Colonization resistance by gut microbiota is a fundamental phenomenon in infection prevention and control. Hospitalized patients may be exposed to multi-drug-resistant bacteria when hand hygiene compliance among healthcare workers is not adequate. An additional layer of defence is provided by the healthy gut microbiota, which helps clear the exogenous bacteria and acts as a safety net when hand hygiene procedures are not followed. This narrative review focuses on the role of the gut microbiota in colonization resistance against multi-drug-resistant bacteria, and its implications for infection control. The review discusses the underlying mechanisms of colonization resistance (direct or indirect), the concept of resilience of the gut microbiota, the link between the antimicrobial spectrum and gut dysbiosis, and possible therapeutic strategies. Antimicrobial stewardship is crucial to maximize the effects of colonization resistance. Avoiding unnecessary antimicrobial therapy, shortening the antimicrobial duration as much as possible, and favouring antibiotics with low anti-anaerobe activity may decrease the acquisition and expansion of multi-drug-resistant bacteria. Even after antimicrobial therapy, the resilience of the gut microbiota often occurs spontaneously. Spontaneous resilience explains the existence of a window of opportunity for colonization of multi-drug-resistant bacteria during or just after antimicrobial therapy. Strategies favouring resilience of the gut microbiota, such as high-fibre diets or precision probiotics, should be evaluated.

Temporalités et appropriations des connaissances dans une démarche de recherche partenariale : les décalages à l’œuvre dans le projet GREENH-City

Cet article interroge les effets des modalités partenariales de recherche du projet GREENH-City associant des chercheur.e.s au Réseau français des Villes-Santé OMS (RfVS). Il propose une analyse de l’appropriation des connaissances scientifiques liées au projet par les villes membres du RfVS à partir du modèle de partage de connaissances. L’article montre qu’un décalage temporel peut s’opérer entre la production et l’utilisation des données liées au projet et interroge les modalités de partage de connaissances comme les pratiques de cette recherche interventionnelle.

Relationship between Urban Green Spaces and Cancer: A Scoping Review

This scoping study aims to explore the relationships between urban green spaces (UGSs) and the onset, remission and recovery of cancer. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for scoping reviews (protocol published in 2018). Eligibility criteria for papers were: (1) to be concerned with UGSs, (2) reporting effects of UGSs on cancer-related outcomes including direct or indirect measures, (3) reporting randomized controlled trials, prospective cohort studies, case studies, observational studies, non-comparative studies, (4) in English or French. The search covered primary studies in the published and unpublished (grey) literatures searching by hand and electronic databases (MEDLINE, Green File, Cumulative Index to Nursing and Allied Health Literature and ScienceDirect). Among 1703 records screened by two reviewers independently, 29 were included for qualitative synthesis. We classify the cancers concerned and the effects reported i.e., protective effect, risk or without association. The most investigated cancers are bladder, breast and lung cancer. Our study also identified contributing factors and their mediating effects between UGSs and cancer. Even though the strength of the evidence of the associations between UGSs and cancer is still weak due to the low number of studies and their design, results highlight the wide variety of possible mediating factors between the use of green spaces and cancer occurrence, remission and/or prevention. Knowledge gaps and future research perspectives should be oriented to qualitative research on protective factors with an attention to equity in UGS access and use.

Who, why, when and how do people use urban green spaces? A study of users from 18 parks in France

Introduction

Urban green spaces impact the individual and collective health of populations. At the city level, they act as regulators of environmental hazards and constitute collective protective factors. At the individual level, they constitute social spaces for encounters and rejuvenation. But, these functions depend on the use made of these green spaces which can be inequitable. This paper presents the results of the analysis of the use of green spaces in the 6 French cities selected in the WHO French Healthy City Network conducted as part of the GREENH-City research project.

Methods

Based on park profiles, a qualitative survey was conducted among users of 3 different parks in each of the 6 selected cities with both observations and semi-directive interviews. Thematic analyzes were performed. Observed activities were classified into 8 groups (supervised educational, food, activities i.e. calm, commercial, artistic and cultural, physical non-sport, sports) and related to a specific use (professional/ personal, individual/ collective, authorized/ not and conflictual/ not). The uses described by the individuals interviewed were classified into 4 categories: attendance, utility, opinions and activities.

Results

186 observations and 591 recorded and unrecorded interviews with individuals or groups were conducted in the 18 parks. Overall, calm activities are dominant. However, activities and uses differ between cities and within the city depending on the nature of the parks (ancient, new..), their management, their location (more or less central, located in a deprived area or not) and people expectations.

Conclusions

Park uses are only partially dependent on amenities within the park. The nature of the park itself, its geographical location and its landscape characteristics seem to be decisive for the uses observed. These data are essential to inform public decision-makers and guide the creation and development of green spaces in cities in a vision of social justice.

Key messages

Urban green spaces can improve population health but their uses may be inequitable. Study of population use of urban green spaces may help to shape local policies towards more equity.

Intervention research partnerships: enablers for activating health in all policies approach?

Introduction

Action on the determinants of health and equity involves the participation of all sectors, including non-health sectors. Understanding the opportunities and constraints to engage in the complex issue of health inequalities requires opening the black box of policy making. It also requires close interaction between field actors and researchers. This paper will aim to analyze the modalities of collaboration between researchers and field actors in the service of knowledge sharing, within the GREENH-City project.

Methods

The GREENH-City project was built in an interdisciplinary and intersectoral manner and involves close collaboration with the WHO French Healthy Cities Network (FHCN). Its objective is to characterize the most promising health interventions in all policies at the city level to promote equity through green space policies. Based on the knowledge sharing model and the theory of diffusion of innovations, we will analyze how this research allows initiating collaborations between the different municipal sectors on health issues.

Results

The intervention nature of the project seems to help the dissemination of collaborations, particularly between health services and green space services within the cities of the FHCN. The analysis, using theoretical models, of the body of empirical data collected from cities will make it possible to identify the levers and collateral effects activated by the research project.

Discussion

The GREENH-City project was built on the basis of an interventional research framework. This choice was made precisely because of the interaction it induces between researchers and practice environments. Initial empirical results suggest that it promotes the dissemination of knowledge, a necessary first step in the evolution of practices. Indeed, the effective appropriation of research results can only be assessed in the long term and must take into account the contextual elements specific to each FHCN involved in the research.

Key messages

Implementation of interventional research helps to engage fields collaborations. Health in all policies may be supported by a research project at the local level.

[Gender inequalities and health promotion at the local scale. The case of Gennevilliers (Paris region)]

Social inequalities in health and access to care remain significant in France. Cultural and socioeconomic dimensions of health inequalities are often studied, but gender-specific behaviors and local dynamics are rarely investigated. This article aims to examine the role of municipal representatives, public health policies and local communities in unequal access to prevention for men and women. We analyze the relationship between gender, space and health through the case study of health promotion in the town of Gennevilliers (Paris region). We rely on data from over six months of field work based on semi-structured interviews with elected officials, health professionals, social field and civil society actors as well as archival consultations and field observations. We show that the town of Gennevilliers, by the age of the inclusion of health in local policies, the dynamism of the associative network and local players or the number of innovative actions, is a relevant and inspiring example for analyzing the obstacles and means of health interventions. But, this article also demonstrates that the promotion of preventive health, rooted in long-term and complex territorial dynamics, can also contribute to the strengthening of gender roles and differences between men and women. Finally, this study pinpoints the need for an approach integrating both gender and territorial questions in the analysis as well as the development of health promotion campaigns.

Urban green spaces and cancer: a protocol for a scoping review

INTRODUCTION

Green space in the built environment is an important topic on the health agenda today. Studies have shown that access to green spaces is associated with better mental and physical health, yet green spaces can also be detrimental to health if they are not managed appropriately. Despite the increasing interest in urban green spaces, little research has so far been conducted into the links between green spaces and cancer.

OBJECTIVE

The purpose of this scoping review is therefore to map the literature available on the types of relationship between urban green spaces and cancer.

METHOD AND ANALYSIS

We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols 2015 guideline to report the protocol. To conduct this scoping review, we will use a structured search strategy based on controlled vocabulary and relevant key terms related to green space, urban space and cancer. We will search MEDLINE (PubMed), GreenFILE (EBSCOhost), Cumulative Index to Nursing and Allied Health Literature (EBSCOhost) and ScienceDirect as electronic database as well as hand-search publications for grey literature. This review will therefore provide evidence on this current topic, one which could have practical implications for policy-makers involved in choices which are more conducive to healthy living.

ETHICS AND DISSEMINATION

No primary data will be collected since all data that will be presented in this review are based on published articles and publicly available documents, and therefore ethics committee approval is not a requirement. The findings of this review will be presented at workshops and conferences, and will be submitted for publication in a peer-reviewed journal.

Assessment of long-term exposure to airborne dioxin and cadmium concentrations in the Lyon metropolitan area (France)

Identifying the long-term effects of airborne pollutants requires the computation of the spatial and temporal variability of their concentration in air to estimate the exposure of the population. To estimate exposure levels of individuals in a breast cancer case control study nested in a national prospective cohort, we determine here the differential impact of a variety of cadmium and dioxin sources on urban air over a large urban area and over a period of almost 20years. To that end, we couple an emission model, to estimate dioxin and cadmium atmospheric annual releases, with an urban dispersion model in order to compute pollutant concentration fields at a fine temporal (1h) and spatial (25m) resolution. The reliability of the modelling chain is compared to two types of measurement: i) localized industrial emissions and ii) dioxin and cadmium air monitoring data (from 2007 to 2008), collected at a fixed station, placed in the city centre, as well as at three mobile short-term dioxin monitoring stations, located in the suburbs (the latter providing dioxin data, only). Comparisons between measured and estimated emissions show non-negligible difference, with a correlations for dioxin (r_s=0.42) and cadmium (r_s=0.41). Despite this, mean values between estimated emissions and emission measurements are close to each other, in particular for cadmium. Weekly average modelled concentrations show an overall good agreement with weekly average measured concentrations in spring and summer but are generally lower than monitored data in winter due to peak concentrations from diffuse sources representing an important proportion of emissions in 2007/2008. The model provides better results for cadmium than for dioxin. Despite the relevant errors in the model predictions, the model meets the validation criteria, defined by Chang and Hanna for an urban dispersion model. Simulation scenarios of air pollutant concentrations, reconstructed over the last 20years, show the effects of the variability of the pollutant sources over time with decreasing levels of dioxin and cadmium concentrations in air. This is primarily due to the reduction in localized industrial releases, which results in a general trend of homogenization of the exposure of the population. The model further allows us to dissociate the contribution of different types of pollutant sources on the population exposure. The impact on local concentrations due to industrial emissions, which were originally responsible for the major impact on air quality, is shown to drop over the years by 99% and 92% for dioxin and cadmium, respectively. Today, the major contributions are due to diffuse miscellaneous sources in the case of dioxin and to traffic-related emissions for cadmium. Average modelled concentrations at the study subjects' residential locations range from 10.2 to 82.1fg-TEQ/m³ for dioxin and 0.10 to 1.6ng/m³ for cadmium and are comparable with data from the literature. The study results will be essential to increase the accuracy of the assessment of long-term airborne dioxin and cadmium exposure and improve the results of epidemiological studies.

Prognostic role of histological regression in primary cutaneous melanoma: a systematic review and meta-analysis

The prognostic significance of histological regression in primary melanoma has been debated for many years. We aim to review the evidence to see how histological regression may affect prognosis. A systematic review was performed by searching in MEDLINE, Scopus and the Cochrane Library from 1 January 1966 to 1 August 2015. All studies reporting hazard ratios or data on survival and histological regression were included. Primary random-effects meta-analyses were used to summarize outcome measures. Heterogeneity was assessed using the χ² -test and I² -statistic. To assess the potential bias of small studies we used funnel plots and the Begg and Mazumdar adjusted rank correlation method. Summaries of survival outcomes were measured as hazard ratios or relative risk of death at 5 years according to the presence of histological regression of primary melanoma. In total, 183 articles were reviewed out of 1876 retrieved. Ten studies comprising 8557 patients were included. Patients with histological regression had a lower relative risk of death (0·77, 95% confidence interval 0·61-0·97) than those without. Examination of the funnel plot did not provide evidence of publication bias. The results showed that histological regression is a protective factor for survival.

Enhancement of antigen presenting ability in the leukemic plasmacytoid dendritic cell line (PMDC05) by lentiviral vector-mediated transduction of CD80 gene (P5059)

[Aim] PMDC05, a leukemic plasmacytoid dendritic cell (pDC) line which was established from CD4+CD56+ leukemia cells in our laboratory, showed a capacity of generating antigen-specific cytotoxic T lymphocytes (CTLs). In order to enhance an antigen presenting ability of PMDC05, PMDC05 was transduced with CD80 gene by lentiviral vector, which was named as PMDC11. We investigated whether PMDC11 could enhance allogeneic T cell response. [Materials and Methods] Surface antigen presentation-associated molecules and antigen presenting ability were analyzed in PMDC05 and PMDC11 with or without stimulation by phorbol 12-myristate 13-acetate (PMA) plus calcium ionophore (CI) by flow cytometry or mixed leukocyte culture (MLC). [Results] CD80 gene transduction induced a definite up-regulation of CD1a and HLA-DR in addition to CD80. In original PMDC05 cells, which had antigen presenting ability without any stimulation, PMA/CI could enhance the ability significantly. PMDC11 cells without stimulation had an antigen presenting ability equivalent to PMA/CI-stimulated PMDC05. Measurement of IFN-γ in supernatant of MLC demonstrated that PMDC11 stimulated allogeneic lymphocyte to produce much more IFN-γ compared with PMDC05. [Conclusion] Our data suggested PMDC11 cells, which were established by transducing CD80 gene into PMDC05 cells, could be efficiently applied as antigen presenting cells in adoptive cellular immunotherapy for tumors and severe infections.

Vaccinal status of healthcare students in Lille

INTRODUCTION

Vaccine recommendations are the same for healthcare students than for other health care workers. The aim of this study was to describe mandatory and recommended vaccinal coverage and evaluate the benefit of systematic monitoring by a medical team in the Lille Medical School.

POPULATION AND METHODS

A survey was performed from June 2011 to August 2011 on all students in the first year of Health Care Studies. The personal immunization record was considered as evidence of vaccination. The reference vaccinal schedule was the one recommended by the French High Council for Public Health in 2011.

RESULTS

We analyzed the personal immunization records of 553 students. The vaccination coverage was 96.7% (535) for DTP, 74.7% (413) for hepatitis B, and 92.2% (510) of the students had a tuberculin test result. Concerning the recommended vaccinations, 78% (431) were covered for measles, and 78.9% (436) had a history of either chickenpox or its immunization. About 72.7% (402) of students were vaccinated for Haemophilus influenzae and Bordetella pertussis. Respectively, 24.2% (134) and 81% (448) had previously been vaccinated for Neisseria meningitis and tuberculosis. The monitoring of students allowed improving hepatitis B vaccination coverage by 22.28% (123). The student's vaccinal coverage was still inadequate for hepatitis B and measles. The systematic monitoring allowed significantly improving vaccinal coverage for hepatitis B.

Unraveling the mystery of the disorder of keratinization: the path of syndromic ichthyoses

In the last few years the progresses in molecular analysis allow better definitions of ichthyoses and lead to the necessity of a new classification and a review of nomenclature of inherited ichthyoses. So, in 2007 the First Consensus Conference on Ichthyoses was performed. We present here a short review of the new classification of syndromic ichthyoses together with clinical and molecular features.

Enhancement of antigen presenting ability in the leukemic plasmacytoid dendritic cell line (PMDC05) by lentiviral vector-mediated transduction of CD80 gene

PMDC05, a leukemic plasmacytoid dendritic cell (pDC) line which was established in our laboratory, showed a capacity of generating antigen-specific cytotoxic T lymphocytes (CTLs). In order to enhance an antigen presenting ability of PMDC05, PMDC05 was transduced with CD80 gene by lentiviral vector, which was named as PMDC11. PMDC11 displayed a strong antigen presenting ability even without any stimulation, and by culturing with stimulators such as calcium ionophore PMDC11 gained a more potent antigen presenting ability. Our data suggested PMDC11 could be applied as antigen presenting cells more efficiently in adoptive cellular immunotherapy for tumors and severe infections in comparison with PMDC05.

A green and bio-inspired process to afford durable anti-biofilm properties to stainless steel

A bio-inspired durable anti-biofilm coating was developed for industrial stainless steel (SS) surfaces. Two polymers inspired from the adhesive and cross-linking properties of mussels were designed and assembled from aqueous solutions onto SS surfaces to afford durable coatings. Trypsin, a commercially available broad spectrum serine protease, was grafted as the final active layer of the coating. Its proteolytic activity after long immersion periods was demonstrated against several substrata, viz. a synthetic molecule, N-α-benzoyl-DL-arginine-p-nitroanilide hydrochloride (BAPNA), a protein, FTC-casein, and Gram-positive biofilm forming bacterium Staphylococcus epidermidis.

Biomolecule-based antibacterial coating on a stainless steel surface: multilayer film build-up optimization and stability study

The goal of this paper was to establish the durability profile of antibacterial multilayer thin films under storage and usage conditions. Thin films were built on stainless steel (SS) by means of a layer-by-layer process alternating a negatively charged polyelectrolyte, polyacrylic acid, with a cationic antibacterial peptide, nisin. SS coupons coated with the antibacterial film were challenged under environmental and usage conditions likely to be encountered in real-world applications. The change in antibacterial activity elicited by the challenge was used as an indicator of multilayer film resistance. Antibacterial SS samples could be stored for several weeks at 4°C in ambient air and antibacterial films were resistant to dipping and mild wiping in water and neutral detergent. The multilayer coating showed some weaknesses, however, that need to be addressed.

Selective expression of two types of 28S rRNA paralogous genes in the chaetognath Spadella cephaloptera

Significant intra-individual variation in the sequences of the ribosomal RNA (rRNA) genes is highly unusual in animal genomes; however, two classes of both 18S and 28S rRNA gene sequences have been detected in chaetognaths, a small phylum of marine invertebrates. One species, Spadella cephaloptera Busch, 1851, is well-suited to the methods of in situ analysis of gene expression, since it is totally transparent. To test our hypothesis of a possible functional division of the two classes of genes, we carried out in situ hybridization. Our results indicated that 28S class II genes are expressed intensively in the oocytes of chaetognaths. In contrast, hybridization using an heterologous probe of 28S class I genes revealed only a single and relatively weak signal in a distinct area of intestinal cells. Our results suggest that the S. cephaloptera genome contains at least three different types of rRNA 28S genes; however, those which are expressed during housekeeping conditions could not be detected in our experiments.

Comparison of chaetognath mitochondrial genomes and phylogenetical implications

Two complete mitochondrial genomes (mtDNAs) of chaetognaths, Spadella cephaloptera and Paraspadella gotoi, have been recently published. These genomes are highly unusual. They are the smallest metazoan mtDNAs so far known; atp6 and atp8 genes are missing; lastly, our reanalysis has evidenced that, contrarily to what has been previously published for one sequence, both contain a unique transfer RNA (tRNA(Met)) evidencing that both have the same gene content. Indeed, even if the gene order seems very different, two gene blocks are conserved. In addition, comparison of gene arrangement suggests phylogenetical relationships between chaetognaths and some lophotrochozoa like annelids and molluscs.

Alternative peptide-fusion proteins generated by out-of-frame mutations, just upstream ORFs or elongations in mutants of human hepatitis B viruses

By various means including out-of-frame mutations, just upstream ORFs and elongations, additional peptide fusions could be generated by mutants of Human Hepatitis B Virus (HBV). Numerous frameshift mutations inducing long alternative open reading frames have been evidenced in all HBV genes. Interestingly, these mutants are frequently detected in severe liver diseases, but seldom in asymptomatic carriers. The high level of conservation of some of these sequences in spite of the fact that they could be generated by different types of mutations, as their presence in mutants found on various continents, suggest that these mutations could play a role. These mutants could combine two advantages, that related to the loss of a part of a wild-type protein and that related to the putative advantage conferred by the additional sequences. In addition, in numerous Asian genomes (more than 300 to date) pre-X or pre-pre-S regions were found just upstream to, respectively, the X and the pre-S1 genes. These two regions are translated with their respective genes in frame and recent studies have evidenced the transactivating role of the corresponding proteins. With some exceptions, these regions are genotype- and serotype-specific (C/adr). In addition, these mutants have been found principally in patients with severe hepatitis diseases, for example, hepatocarcinoma in more than one third of the cases. As additional sequences generated by HBV variants may be relevant for viral life cycle, persistence and pathogenesis, further investigations are necessary to give a clearer picture of the subject.

Multiple sclerosis and hepatitis B vaccination: Could minute contamination of the vaccine by partial Hepatitis B virus polymerase play a role through molecular mimicry?

Reports of multiple sclerosis developing after hepatitis B vaccination have led to the concern that this vaccine might be a cause of multiple sclerosis in previously healthy subjects. Some articles evidenced that minor Hepatitis B virus (HBV) polymerase proteins could be produced by alternative transcriptional or translational strategies. Their detection is very difficult because they are in minute concentration and probably enzymatically inactive, however, it was shown that they could be exposed on the outside of the virus particles and also be immunogenic. In addition, HBV polymerase shares significant amino acid similarities with the human myelin basic protein. We hypothesise that some of the apparent adverse reactions to the vaccine could be due to a process called of molecular mimicry, the HBV polymerase, which could be a contaminant in the recombinant or plasma-derived vaccines, could act as autoantigens and induce autoimmune demyelinating diseases such as multiple sclerosis.

Factors associated with early atrial fibrillation after ablation of common atrial flutter. A single centre prospective study

BACKGROUND

The occurrence of early atrial fibrillation (< or = 6 months) after ablation of common atrial flutter is of clinical significance. Variables predicting this evolution in ablated patients without a previous atrial fibrillation history have not been fully investigated.

OBJECTIVES

The aim of the present study was: (1) to identify predictive factors of early atrial fibrillation (< or = 6 months) in the overall population following atrial flutter catheter ablation; (2) to identify predictive variables of early atrial fibrillation following (< or = 6 months) atrial flutter catheter ablation within a subgroup of patients without documented prior atrial fibrillation.

METHODS

This study prospectively included 96 consecutive patients (age 65 +/- 13 years; 18 women) over a 12-month period. Their counterclockwise flutter was ablated by radiofrequency, by the same operator, with an 8-mm-tip catheter. Clinical, electrophysiological and echocardiographic data were collected and 27 variables were retained for analysis: age; gender; type of atrial flutter (permanent vs paroxysmal); symptom duration (months +/- SD); pre-ablation history of atrial fibrillation; structural heart disease; left ventricular ejection fraction (%); left atrial size (mm); cava--tricuspid isthmus dimension; septal isthmus dimension; systolic pulmonary pressure > or < or = 30 mmHg; right atrial area; left atrial area; isthmus block; number of radiofrequency applications (+/- SD); antiarrhythmic drugs at discharge; left ventricular diastolic diameter; left ventricular systolic diameter; left ventricular telediastolic volume; left ventricular telesystolic volume; A-wave velocity (cm . s(-1)); E-wave velocity (cm . s(-1)); E/A; isovolumetric relaxation time; E-wave deceleration time; significant mitral regurgitation and flutter cycle length (ms).

RESULTS

Of the 96 consecutive ablated patients, early atrial fibrillation was documented in 16 patients (17%). Atrial fibrillation occurred 30 +/- 46 days (range 1 to 171 days) after ablation. Univariate analysis associated an early occurrence of atrial fibrillation with: atrial fibrillation history, left ventricular ejection fraction, left atrial size, left ventricular telesystolic volume, A-wave velocity, significant mitral regurgitation and flutter cycle length. Multivariate analysis using a Cox model found that the only independent predictors of early atrial fibrillation were left ventricular ejection fraction and pre-ablation history of atrial fibrillation. In the subgroup without prior atrial fibrillation history (n=63; 66%), the only independent predictor of early atrial fibrillation was the presence of a significant mitral regurgitation.

CONCLUSIONS

In a subgroup of patients without atrial fibrillation history, 8% of patients revealed an early atrial fibrillation. Mitral regurgitation is a strong predictive factor of early atrial fibrillation occurrence with 80% sensitivity, 78% specificity and 98% negative predictive value. These data should be considered in post-ablation management.

[Skeletal muscle metastases from non small cell lung]

We report a case of metastatic spread to skeletal muscle in a patient with an inoperable NSCLC complaining of a painful swelling of the right thigh. The treatment included muscle resection, radiotherapy to the thigh and chemotherapy, and resulted in complete pain relief There was no local recurrence, but the patient developed multiple systemic metastases and died 11 months after the muscle resection. Skeletal muscles metastases from lung cancer are rare and although indicative of a poor prognosis, local aggressive treatment may be worthwhile.

Chlamydial heat shock protein 60 activates macrophages and endothelial cells through Toll-like receptor 4 and MD2 in a MyD88-dependent pathway

Active inflammation and NF-kappaB activation contribute fundamentally to atherogenesis and plaque disruption. Accumulating evidence has implicated specific infectious agents including Chlamydia pneumoniae in the progression of atherogenesis. Chlamydial heat shock protein 60 (cHSP60) has been implicated in the induction of deleterious immune responses in human chlamydial infections and has been found to colocalize with infiltrating macrophages in atheroma lesions. cHSP60 might stimulate, enhance, and maintain innate immune and inflammatory responses and contribute to atherogenesis. In this study, we investigated the signaling mechanism of cHSP60. Recombinant cHSP60 rapidly activated NF-kappaB in human microvascular endothelial cells (EC) and in mouse macrophages, and induced human IL-8 promoter activity in EC. The inflammatory effect of cHSP60 was heat labile, thus excluding a role of contaminating LPS, and was blocked by specific anti-chlamydial HSP60 mAb. In human vascular EC which express Toll-like receptor 4 (TLR4) mRNA and protein, nonsignaling TLR4 constructs that act as dominant negative blocked cHSP60-mediated NF-kappaB activation. Furthermore, an anti-TLR4 Ab abolished cHSP60-induced cellular activation, whereas a control Ab had no effect. In 293 cells, cHSP60-mediated NF-kappaB activation required both TLR4 and MD2. A dominant-negative MyD88 construct also inhibited cHSP60-induced NF-kappaB activation. Collectively, our results indicate that cHSP60 is a potent inducer of vascular EC and macrophage inflammatory responses, which are very relevant to atherogenesis. The inflammatory effects are mediated through the innate immune receptor complex TLR4-MD2 and proceeds via the MyD88-dependent signaling pathway. These findings may help elucidate the mechanisms by which chronic asymptomatic chlamydial infection contribute to atherogenesis.

Toll-like receptor-4 is expressed by macrophages in murine and human lipid-rich atherosclerotic plaques and upregulated by oxidized LDL

BACKGROUND

Inflammation is implicated in atherogenesis and plaque disruption. Toll-like receptor 2 (TLR-2) and TLR-4, a human homologue of drosophila Toll, play an important role in the innate and inflammatory signaling responses to microbial agents. To investigate a potential role of these receptors in atherosclerosis, we assessed the expression of TLR-2 and TLR-4 in murine and human atherosclerotic plaques.

METHODS AND RESULTS

Aortic root lesions of high-fat diet-fed apoE-deficient mice (n=5) and human coronary atherosclerotic plaques (n=9) obtained at autopsy were examined for TLR-4 and TLR-2 expression by immunohistochemistry. Aortic atherosclerotic lesions in all apoE-deficient mice expressed TLR-4, whereas aortic tissue obtained from control C57BL/6J mice showed no TLR-4 expression. All 5 lipid-rich human plaques expressed TRL-4, whereas the 4 fibrous plaques and 4 normal human arteries showed no or minimal expression. Serial sections and double immunostaining showed TLR-4 colocalizing with macrophages both in murine atherosclerotic lesions and at the shoulder region of human coronary artery plaques. In contrast to TLR-4, none of the plaques expressed TLR-2. Furthermore, basal TLR-4 mRNA expression by human monocyte-derived macrophages was upregulated by ox-LDL in vitro.

CONCLUSIONS

Our study demonstrates that TLR-4 is preferentially expressed by macrophages in murine and human lipid-rich atherosclerotic lesions, where it may play a role to enhance and sustain the innate immune and inflammatory responses. Moreover, upregulation of TLR-4 in macrophages by oxidized LDL suggests that TLR-4 may provide a potential pathophysiological link between lipids and infection/inflammation and atherosclerosis.

Abnormal function of astroglia lacking Abr and Bcr RacGAPs

Experiments in cultured cells have implicated the molecular switch Rac in a wide variety of cellular functions. Here we demonstrate that the simultaneous disruption of two negative regulators of Rac, Abr and Bcr, in mice leads to specific abnormalities in postnatal cerebellar development. Mutants exhibit granule cell ectopia concomitant with foliation defects. We provide evidence that this phenotype is causally related to functional and structural abnormalities of glial cells. Bergmann glial processes are abnormal and GFAP-positive astroglia were aberrantly present on the pial surface. Older Abr;Bcr-deficient mice show spontaneous mid-brain glial hypertrophy, which can further be markedly enhanced by kainic acid. Double null mutant astroglia are hyper-responsive to stimulation with epidermal growth factor and lipopolysaccharide and exhibit constitutively increased phosphorylation of p38 mitogen-activated protein kinase, which is regulated by Rac. These combined data demonstrate a prominent role for Abr and Bcr in the regulation of glial cell morphology and reactivity, and consequently in granule cell migration during postnatal cerebellar development in mammals.

Long-term follow-up of contralateral lobe in patients hemithyroidectomized for solitary follicular adenoma

OBJECTIVES

Since there are no available conclusive studies on the long-term evolution of remnant thyroid tissue after hemithyroidectomy in patients who undergo surgery for solitary follicular adenomas, we searched for such cases in our records to elucidate this issue.

DESIGN

Search criteria were as follows: (i) presence of a single palpable thyroid nodule with the remainder of the gland normal on palpation; (ii) clinically euthyroid status at the time of surgery; (iii) histological diagnosis of nodule as follicular adenoma; (iv) a hemithyroidectomy operation, sparing the contralateral lobe; (v) normal macroscopic aspect of the contralateral lobe at the time of surgery; and (vi) at least 4 years of postoperative follow-up.

PATIENTS

Only 47 female cases were found to meet above criteria, with a mean age of 45.9 years (range: 23-79) at the time of surgery and a mean follow-up of 7.2 years (range: 4-32). Besides evaluating the presence or absence of antithyroid antibodies and the extranodular histology of tissue removed during surgery, a preoperative TRH test also allowed patients to be classified into two groups: normal extranodular thyroid (NET) (n = 32) and abnormal extranodular thyroid (AET) (n = 15).

RESULTS

Eleven of the 15 patients with AET had thyroid autoimmunity, with or without overt histological thyroiditis, and the remaining four had subclinical hypothyroidism with negative antithyroid antibody titres. In the entire study population, only 28 patients received treatment with L-T4 immediately after surgery, none of whom had any alterations in the contralateral lobe. However, six of the nineteen patients not treated with T4 (31.6%) developed overt abnormalities in the contralateral lobe, including the only three with AET who had not received L-T4 treatment. The remaining three were two patients with NET, who showed postoperative TSH hyper-responsiveness to TRH (peak TSH > 25 mU/l), and one who developed a new follicular adenoma 32 years later. To date, none of the patients with NET, who had a normal TRH test after surgery, have developed any kind of alterations in the contralateral lobe, even those who received no L-T4 prophylactic treatment.

CONCLUSIONS

The findings of this study suggest that: (i) there is a higher risk of follicular adenomas developing in a gland affected by thyroid autoimmunity than in a previously normal gland; (ii) L-T4 therapy may prevent the formation of new nodules or the development of goitre in the contralateral lobe; and (iii) in the absence of prophylactic treatment after surgery, the contralateral lobe of subjects with thyroid autoimmunity and/or previous subclinical hypothyroidism develops morphological abnormalities.

Decreased expression of Toll-like receptor-4 and MD-2 correlates with intestinal epithelial cell protection against dysregulated proinflammatory gene expression in response to bacterial lipopolysaccharide

The lumenal surface of the colonic epithelium is continually exposed to Gram-negative commensal bacteria and LPS. Recognition of LPS by Toll-like receptor (TLR)-4 results in proinflammatory gene expression in diverse cell types. Normally, however, commensal bacteria and their components do not elicit an inflammatory response from intestinal epithelial cells (IEC). The aim of this study is to understand the molecular mechanisms by which IEC limit chronic activation in the presence of LPS. Three IEC lines (Caco-2, T84, HT-29) were tested for their ability to activate an NF-kappaB reporter gene in response to purified, protein-free LPS. No IEC line responded to LPS, whereas human dermal microvessel endothelial cells (HMEC) did respond to LPS. IEC responded vigorously to IL-1beta in this assay, demonstrating that the IL-1 receptor signaling pathway shared by TLRs was intact. To determine the reason for LPS hyporesponsiveness in IEC, we examined the expression of TLR4 and MD-2, a critical coreceptor for TLR4 signaling. IEC expressed low levels of TLR4 compared with HMEC and none expressed MD-2. To determine whether the low level of TLR4 expression or absent MD-2 was responsible for the LPS signaling defect in IEC, the TLR4 or MD-2 gene was transiently expressed in IEC lines. Transient transfection of either gene individually was not sufficient to restore LPS signaling, but cotransfection of TLR4 and MD-2 in IEC led to synergistic activation of NF-kappaB and IL-8 reporter genes in response to LPS. We conclude that IEC limit dysregulated LPS signaling by down-regulating expression of MD-2 and TLR4. The remainder of the intracellular LPS signaling pathway is functionally intact.

Clinical characteristics, aetiological factors and long-term prognosis of myocardial infarction with an absolutely normal coronary angiogram; a 3-year follow-up study of 91 patients

OBJECTIVES

The purpose of this study was to evaluate the clinical outcome of a large cohort of patients who suffered an acute myocardial infarction with absolutely normal epicardial coronary arteries at the post-myocardial infarction coronary angiogram. The aetiological and prognostic factors in this population were also analysed.

BACKGROUND

Few data exist concerning the outcome, and aetiological and prognostic factors, of patients with myocardial infarction and angiographically absolutely normal coronary arteries.

METHODS

Ninety-one patients (34 females/57 males; mean age 50+/-13 years, range 24--78 years) admitted with an acute myocardial infarction had absolutely normal coronary arteries at the angiogram performed 6.2+/-4 days (range 1--15 days) after the myocardial infarction, defined by smooth contours and no focal reduction (NC). Of the 91 NC patients, 71 were evaluated prospectively, alongside a systematic search of all aetiological factors reported in the literature. The NC patients were matched for age, sex, and the same period of myocardial infarction onset with a group of 91 patients with coronary artery stenosis (>50% diameter stenosis) at the angiogram performed 7.3+/-4 days (range 1--15 days) after the myocardial infarction (SC).

RESULTS

The percent of smokers was similar between the two groups; higher prevalence rates of coronary heart disease family history, obesity, hypertension, hypercholesterolaemia and diabetes mellitus were found in SC (P=0.043 to 0.0001). In NC, coronary spasm was found in 15.5%, congenital coagulation disorders in 12.8%, collagen tissue disorders in 2.2%, embolization in 2.2%, and oral contraceptive use in 1.1%. Left ventricular ejection fraction at hospital discharge was higher in NC (60%+/-13%) than in SC (55%+/-13%, P=0.04). The mean follow-up was 35 months (range 1--100 months). Kaplan-Meier event-free survival, with the combined end-point defined as death, reinfarction, heart failure and stroke was 75% in NC vs 50% in SC (P<0.0001). Survival rate was 94.5% in NC compared to 92% in SC (ns). Univariate predictors of events in NC were left ventricular ejection fraction (P=0.03), age (P=0.02), diabetes (P=0.01), and smoking (P=0.03). Using Cox multivariate analysis, independent predictors of long-term outcome in NC patients were left ventricular ejection fraction (P=0.003) and diabetes (P=0.004).

CONCLUSION

Aetiological factors, predominantly coronary spasm and inherited coagulation disorder, can be detected in only one third of the patients with myocardial infarction and absolutely normal coronary angiograms despite a systematic search in a prospective population. Mortality rates are similar but morbidity is lower in myocardial infarction patients with absolutely normal coronary angiography compared with those with coronary artery stenosis. The only two independent factors predictive of poor outcome in myocardial infarction patients with normal coronary arteries are left ventricular function and diabetes.

Cooperation of Toll-like receptor 2 and 6 for cellular activation by soluble tuberculosis factor and Borrelia burgdorferi outer surface protein A lipoprotein: role of Toll-interacting protein and IL-1 receptor signaling molecules in Toll-like receptor 2 signaling

Toll-like receptor 2 (TLR2) and TLR4 play important roles in innate immune responses to various microbial agents. We have previously shown that human dermal endothelial cells (HMEC) express TLR4, but very little TLR2, and respond to LPS, but not to Mycobacterium tuberculosis 19-kDa lipoprotein, unless transfected with TLR2. Here we report that HMEC are unresponsive to several additional biologically relevant TLR2 ligands, including, phenol-soluble modulin (PSM), a complex of three small secreted polypeptides from the skin commensal Staphylococcus epidermidis, soluble tuberculosis factor (STF), and Borrelia burgdorferi outer surface protein A lipoprotein (OspA-L). Expression of TLR2 renders HMEC responsive to all these ligands. We further characterized the signaling pathway in response to STF, OspA-L, and PSM in TLR2-transfected HMEC. The TLR2 signaling pathway for NF-kappaB trans-activation shares the IL-1R signaling molecules. Dominant negative constructs of TLR2 or TLR6 inhibit the responses of STF and OspA-L as well as PSM in TLR2-transfected HMEC, supporting the concept of functional cooperation between TLR2 and TLR6 for all these TLR2 ligands. Moreover, we show that Toll-interacting protein (Tollip) coimmunoprecipitates with TLR2 and TLR4 using HEK 293 cells, and overexpression of Tollip inhibits NF-kappaB activation in response to TLR2 and TLR4 signaling. Collectively, these findings suggest that there is functional interaction between TLR2 and TLR6 in the cellular response to STF and OspA-L in addition to S. epidermidis (PSM) Ags, and that engagement of TLR2 triggers a signaling cascade, which shares the IL-1R signaling molecules, similar to the TLR4-LPS signaling cascade. Our data also suggest that Tollip may be an important constituent of both the TLR2 and TLR4 signaling pathways.