Using Clinical Data Warehouse to Optimize the Vaccination Strategy Against COVID-19: A Use Case in France

Clinical Data Warehouses (CDW) are gold mines and may be useful to manage the COVID-19 outbreak. This article details the use of CDW in order to retrieve patients for vaccination purposes. A list of 34 diseases (or conditions) was published by French Health Authorities to target individuals at a high risk of developing a severe form of COVID. Using a multilevel search engine, 23 queries were built based on structured or unstructured data using natural language processing features. The Diagnosis Related Group coding system was used alone in three queries (13.0%), coupled with unstructured data in four queries (17.4%), and unstructured data were used alone in 16 queries (69.6%). Eleven diseases (conditions) were too broad to be translated into queries. Finally, 6,006 unique re-identified patients were retrieved. This use case demonstrates the usefulness of the Rouen University Hospital CDW in retrieving patients for other purposes than translational research.

Overview of meningococcal epidemiology and national immunization programs in children and adolescents in 8 Western European countries

BACKGROUND

In Europe, meningococcal (Men) vaccines are available against 5 of the 6 serogroups responsible of nearly all cases of invasive meningococcal disease (IMD). Meningococcal vaccination has been introduced in the national immunization programs (NIPs) for children and adolescents of numerous European countries, but with no consistent strategy across countries.

OBJECTIVES

To describe IMD epidemiology, NIPs, and vaccination coverage rates (VCRs) in children and adolescents in 8 Western European countries.

METHODS

Epidemiological data (from 1999 to 2019), NIPs regarding meningococcal vaccination status, and VCRs were collected from the European Centre for Disease Prevention and Control (ECDC) and/or national websites.

RESULTS

MenB was the most common serogroup. In Belgium, Spain, France, the Netherlands, the United Kingdom (UK), and Portugal, incidence was greater for MenW than MenC. In 2019, MenB risk was covered in 2 countries (Italy, UK). MenC risk was covered in all countries, via MenC only (countries: N = 3), MenACWY only (N = 2), or MenC (infants/children) and MenACWY (adolescents) (N = 3) vaccination. VCRs were higher in children than adolescents.

CONCLUSION

Our study confirmed the diversity of NIPs, including in neighboring European countries with similar factors like economic resources and epidemiological risk, thus indicating that other factors underlie NIPs. Convergence toward a more common immunization program including MenACWY and MenB vaccination would promote equity and safe travel regarding infectious diseases for young people, and possibly improve the understanding of vaccination by patients and healthcare professionals.

No booster dose for yellow fever vaccination: what are the consequences for the activity of vaccination in travel clinics?

In April 2013, the Strategic Advisory Group of Experts (SAGE) on immunization stated that a single dose of yellow fever (YF) vaccine is sufficient in the general population to confer a lifelong protection against YF. When the period of validity of the International Certificate of Vaccination (ICV) will be extended to a lifetime in June 2016, no booster dose will be needed. The objective of this prospective study was to determine the potential impact of the SAGE recommendations on the vaccination activity of our travel clinics. We showed that among 1,037 subjects seen in our three travel clinics for a YF vaccination in 2013, about 32.3% went for a booster dose that is no longer useful according to the SAGE. A drop in vaccination activity has to be expected by travel clinics in the next years, and changes in daily exercise have to be anticipated, as YF vaccination is a large part of the regular work of many healthcare providers specialized in travel medicine.

Safety and immunogenicity of yellow fever 17D vaccine in adults receiving systemic corticosteroid therapy: an observational cohort study

OBJECTIVE

To assess the safety and immunogenicity of live attenuated yellow fever (YF) 17D vaccine in adults receiving systemic corticosteroid therapy.

METHODS

All adult travelers on systemic corticosteroid therapy who had received the YF17D vaccine in 24 French vaccination centers were prospectively enrolled and matched with healthy controls (1:2) on age and history of YF17D immunization. Safety was assessed in a self-administered standardized questionnaire within 10 days after immunization. YF-specific neutralizing antibody titers were measured 6 months after vaccination in patients receiving corticosteroids.

RESULTS

Between July 2008 and February 2011, 102 vaccine recipients completed the safety study (34 receiving corticosteroids and 68 controls). The median age was 54.9 years (interquartile range [IQR] 45.1-60.3 years) and 45 participants had a history of previous YF17D immunization. The median time receiving corticosteroid therapy was 10 months (IQR 1-67 months) and the prednisone or equivalent dosage was 7 mg/day (IQR 5-20). Main indications were autoimmune diseases (n = 14), rheumatoid arthritis (n = 9), and upper respiratory tract infections (n = 8). No serious adverse event was reported; however, patients receiving corticosteroids reported more frequent moderate/severe local reactions than controls (12% and 2%, respectively; relative risk 8.0, 95% confidence interval 1.4-45.9). All subjects receiving corticosteroids who were tested (n = 20) had neutralizing antibody titers >10 after vaccination.

CONCLUSION

After YF17D immunization, moderate/severe local reactions may be more frequent in patients receiving systemic corticosteroid therapy. Immunogenicity seems satisfactory. Large-scale studies are needed to confirm these results.

[Assessment of vaccination coverage among travelers to areas where yellow fever is endemic (Senegal)]

This prospective survey, conducted at the Dakar airport from August 18, 2011, to May 8, 2012, asked a sample of travelers living in France and returning there after a stay in Senegal to complete a questionnaire. The aim of the study was to assess the determinants of vaccination coverage against yellow fever. The study included 10 298 travelers, with a median age of 48 years (interquartile range: 27-58); 52% were tourists, and 22% were traveling for business purposes. The measured level of anti-yellow fever vaccination coverage was 39.3%. Vaccination coverage was influenced by the travelers' level of knowledge and their perception of the risk.

Evolution of immune response against Neisseria meningitidis B:14:P1.7,16 before and after the outer membrane vesicle vaccine MenBvac

A meningococcal B:14:P1.7,16 outbreak in Normandy (France) was recently controlled using MenBvac, an outer membrane vesicle vaccine previously designed against the B:15:P1.7,16 strain. The further emergence of a new B:14:P1.7,16 outbreak in another district in Normandy led us to explore immunity against B:14:P1.7,16 before and after the MenBvac campaign using a 2+1 (day 0, week 6, month 8) schedule. Children (1-5 years) were sampled before, during and up to one year after vaccination. Serum bactericidal activity against B:14:P1.7,16 was titrated using human complement (hSBA) and immune response was defined by hSBA titer ≥4 as a surrogate for protection. The percentage of hSBA titer ≥4 was 10.8% before vaccination, raised to 84.1% 6 weeks after the completion of the schedule, but declined to 39.7% one year later. This level is lower than the targeted 60% level and suggests only short-term persistence of response against B:14:P1.7,16 using this schedule.

Towards the molecular elucidation of congenital myasthenic syndromes: identification of mutations in MuSK

Congenital myasthenic syndromes (CMS) are rare genetic diseases affecting the neuromuscular junction (NMJ) and characterized by a dysfunction of the neurotransmission. They are heterogeneous at the pathophysiological level and can be classified in three categories according to their origin: presynaptic, synaptic or postsynaptic. The strategy for the diagnosis and characterization of CMS relies on the clinic, EMG, muscle biopsy, identification of mutations in genes known to be responsible for CMS and the demonstration that the gene mutations are the cause of the disease by using experimental approaches. As an example of such strategy, we report briefly here the characterization of the first case of a human neuromuscular transmission dysfunction due to mutations in the gene encoding a postsynaptic molecule, the muscle-specific receptor tyrosine kinase (MuSK). Gene analysis identified two heteroallelic mutations, a frameshift mutation (c.220insC) and a missense mutation (V790M). The muscle biopsy showed marked pre- and postsynaptic structural abnormalities of the neuromuscular junction as well as a severe decrease in acetylcholine receptor epsilon-subunit and MuSK expression. In vitro and in vivo expression experiments were performed using mutant MuSK reproducing the human mutations. The results obtained strongly suggested that the missense mutation, in the presence of a null mutation on the other allele, was responsible for the severe synaptic changes observed in the patient and, hence, is causing the disease. However the molecular origin of a large number of CMS is still unknown. There are hundreds of molecules known to be present at the NMJ and mutations in the genes coding for these synaptic molecules are likely to be responsible for a neuromuscular block.

Clinical and histopathological aspects of central core disease associated and non-associated with RYR1 locus

We analysed the clinical, histochemical, ultrastructural and genetic data of patients affected by central core disease (CCD) studied during the last 20 years. From a total series of 86 CCD-families, we have identified 46 CCD families with RYR1 mutations (16 autosomal dominant, 8 autosomal recessive, 17 sporadic cases and 5 de novo mutations). Out of the other 40 CCD families, the RyR1 gene was entirely excluded in 7 families, by cDNA sequencing or linkage analysis, indicating a genetic heterogeneity of CCD.

Enhancing the MeSH thesaurus to retrieve French online health resources in a quality-controlled gateway

The amount of health information available on the Internet is considerable. In this context, several health gateways have been developed. Among them, CISMeF (Catalogue and Index of Health Resources in French) was designed to catalogue and index health resources in French. The goal of this article is to describe the various enhancements to the MeSH thesaurus developed by the CISMeF team to adapt this terminology to the broader field of health Internet resources instead of scientific articles for the medline bibliographic database. CISMeF uses two standard tools for organizing information: the MeSH thesaurus and several metadata element sets, in particular the Dublin Core metadata format. The heterogeneity of Internet health resources led the CISMeF team to enhance the MeSH thesaurus with the introduction of two new concepts, respectively, resource types and metaterms. CISMeF resource types are a generalization of the publication types of medline. A resource type describes the nature of the resource and MeSH keyword/qualifier pairs describe the subject of the resource. A metaterm is generally a medical specialty or a biological science, which has semantic links with one or more MeSH keywords, qualifiers and resource types. The CISMeF terminology is exploited for several tasks: resource indexing performed manually, resource categorization performed automatically, visualization and navigation through the concept hierarchies and information retrieval using the Doc'CISMeF search engine. The CISMeF health gateway uses several MeSH thesaurus enhancements to optimize information retrieval, hierarchy navigation and automatic indexing.

Dermatose neutrophilique associée à des anticorps anticytoplasme des polynucléaires neutrophiles (p-ANCA) induits par le propylthiouracil

INTRODUCTION

We report on a patient who progressively developed polymorphic expressions of neutrophilic dermatosis (Sneddon-Wilkinson subcorneal pustulosis and pyoderma gangrenosum) associated with p-antineutrophil cytoplasmic antibodies (p-ANCA), while receiving propylthiouracil for hyperthyroidism. To our knowledge, such associations have never been published so far.

CASE-REPORT

A 40 year-old woman was treated with propylthiouracil for Graves'disease. After 16 months of therapy, she noted flares of pustular lesions surrounded with erythematous halo mainly localized on the trunk. The lesions became chronic, and were not improved by potent topical corticosteroids. When first seen in our department in February 2003, the eruption was typical of Sneddon-Wilkinson subcorneal pustulosis. This diagnosis was confirmed by the histological examination of a skin biopsy of a pustule. One month later, she developed an inflammatory progressively ulcerative lesion on the right ankle, typical of pyoderma gangrenosum. The diagnosis was confirmed by the histological examination of a skin biopsy taken on the evolving border of the lesion and showed polynuclear neutrophilic infiltration without vasculitis. Direct immunofluorescence was negative. The presence of serum anti-myeloperoxydase p-ANCA was known for this patient since October 2002. No IgA monoclonal gammapathy was revealed on extensive biological check-up. Systemic oral corticosteroid therapy (1 mg/kg/day) dramatically improved skin lesions with complete healing within 8 weeks.

DISCUSSION

Propylthiouracil is well known to induce the occurrence of ANCA in 20 to 64p. 100 of patients treated for Graves'disease. The mechanisms involved are badly recognized so far. Cutaneous vasculitis, glomerulonephritis and polychondritis may be clinically associated with those antibodies. Rare observations of neutrophilic dermatosis, mostly Sweet's syndrome, have been described in patients with propylthiouracil-induced ANCA. One case-report described a 44 year-old woman who developed pyoderma gangrenosum associated with propylthiouracil-induced p-ANCA. These manifestations usually appear within 2 years, as our patient. The data in the literature, allows us to report the polymorphic expressions of neutrophilic dermatosis in this patient with p-ANCA which could be related to propylthiouracil. Such association of Sneddon-Wilkinson subcorneal pustulosis and pyoderma gangrenosum with p-ANCA has never been described in this endocrinologic context so far. Furthermore we propose that neutrophilic dermatosis should be inscribed in the list of side effects induced by propylthiouracil therapy.

Topical imiquimod treatment of lentigo maligna: Clinical and histologic evaluation

We have treated extensive lentigo maligna in two elderly patients with Imiquimod 5% (Aldara). It was applied 3 times weekly, for 3 to 5 months. Clinical and histological remission was observed over 13 months of follow-up care. Tolerance was good. We suggest that topical imiquimod could be an interesting therapeutic alternative.

Zygomycosis caused by Cunninghamella bertholletiae in a kidney transplant recipient

Infections caused by Cunninghamella bertholletiae are rare but severe. Only 32 cases have been reported as yet, but in 26 of these this species was a contributing cause of the death of the patient. This opportunistic mould in the order Mucorales infects immunocompromized patients suffering from haematological malignancies or diabetes mellitus, as well as solid organ transplant patients. The lung is the organ most often involved. Two cases of primary cutaneous infection have been previously reported subsequent to soft-tissue injuries. We report a case of primary cutaneous C. bertholletiae zygomycosis in a 54-year-old, insulin-dependent diabetic man who was treated with tacrolimus and steroids after kidney transplantation. No extracutaneous involvement was found. In this patient, the infection may have been related to insulin injections. The patient recovered after an early surgical excision of the lesion and daily administration of itraconazole for 2 months. This case emphasizes the importance of an early diagnosis of cutaneous zygomycosis, which often presents as necrotic-looking lesions. Prompt institution of antifungal therapy and rapid surgical intervention are necessary to improve the prospects of patients who have contracted these potentially severe infections.

Syndromes myasthéniques congénitaux dus à des mutations du gène de la rapsyne

Congenital myasthenic syndromes (CMS) are genetic diseases characterized by dysfunctional neuromuscular transmission and usually start during the neonatal period. Most are due to postsynaptic abnormalities, specifically to mutations in the acetylcholine receptor (AChR) genes. In 2002, the group of A Engel reported the first cases of CMS with mutations in the gene coding rapsyn, a postsynaptic molecule which stabilizes AChR aggregates at the neuromuscular junction. Since this first publication, more than 30 other cases, including six in France, have been reported. Study of these published cases allows us to distinguish three classes of phenotypes: 1) severe neonatal cases; 2) more benign cases, starting during infancy; 3) cases with facial malformations, involving Jewish patients originating from the Near-East. Comparison of the observations of other groups with our own has led us to the following conclusions: the N88K mutation is frequent (homozygous in 50% of cases); besides the N88K mutation, the second mutation varies considerably; heterozygous allelic cases (N88K + another mutation) are severe; there is probably a founder effect in the European population. There is phenotypic variability in the homozygous N88K cases, with benign cases and severe cases of early expression. A Engel and colleagues report that the seven cases of benign CMS with facial malformation, previously described in the Jewish population of Iraq and Iran, were caused by mutation in the promoter region of the rapsyn gene.

[Muscle-localized tumorlike polyarteritis nodosa]

INTRODUCTION

Systemic vasculitis presenting as a tumorlike lesion are unusual and affect mainly the uro-genital system and breast. Muscle-localized tumorlike periarteritis nodosa are scarce.

EXEGESIS

We report localized tumorlike polyarteritis nodosa affecting the forearm muscles in a 90-year-old woman.

CONCLUSION

Other cases of polyarteritis nodosa localized to muscles are reviewed. This limited form has a benign clinical course and responds promptly to treatment with corticosteroids alone but relapses may occur.

[Trumpet nail deformity during the course of Dowling-Meara type epidermolysis bullosa simplex. A report of two cases]

INTRODUCTION

We report two patients with Dowling-Meara type epidermolysis bullosa simplex: who had trumpet nail deformity.

CASE REPORTS

Two 75 and 72 year-old sisters, had flare-ups of epidermolysis bullosa simplex since childhood. The aspect of the lesions and electron microscopy were in favour of the diagnosis of the Dowling-Meara variant of epidermolysis bullosa simplex. Both women had several fingernails with pincer and trumpet nail deformities. There were no such signs among the other siblings, who had never had epidermolysis.

DISCUSSION

Nail involvement is not rare during the course of superficial epidermolysis bullosa. The trumpet lesions appear to be relatively specific to the present two cases of epidermolysis bullosa simplex. The electron microscopic findings of these two cases were also noteworthy, with whisk-like but not round clumping of the perinuclear tonofilaments.

Doc'CISMEF: a search tool based on "encapsulated" MeSH thesaurus

In the year 2000, the Internet became a major source of health information for the health professional and the Netizen. The objective of Doc'CISMeF (D'C) was to create a powerful generic search tool based on an structured information model which â encapsulates' the MeSH thesaurus to index and retrieve quality health resources on the Internet. To index resources, D'C uses four sections in its information model: 'meta-term', keyword, subheading, and resource type. Two search options are available: simple and advanced. The simple search requires the end-user to input a single term or expression. If this term belongs to the D'C information structure model, it will be exploded. If not, a full-text search is performed. In the advanced search, complex searches are possible combining Boolean operators with meta-terms, keywords, subheadings and resource types. D'C uses two standard tools for organising information: the MeSH thesaurus and the Dublin Core metadata format. Resources included in D'C are described according to the following elements: title, author or creator, subject and keywords, description, publisher, date, resource type, format, identifier, and language.

Webmastering in academic institutions: a new job opportunity

In cyberspace, the health webmaster could be regarded as a virtual editor-in-chief, in charge of content and design. In this circumstance, he/she must follow quality criteria when building any resource. At the Rouen University Hospital (RUH), we have chosen "Net Scoring" as an effective tool to aid the design of a quality Web site. "Net Scoring" contains a list of 49 criteria which fall into eight categories: credibility, content, links, design, interactivity, quantitative aspects, ethics, and accessibility. The webmaster is the key element of the editorial board process. He/she must regularly monitor the Web site in order to retrieve information about whether the site is used and by whom: the method most commonly used is log analysis. At the RUH, an average of 9,000 unique machines visit our Web site each working day. Webmaster is a new job opportunity in academic institutions, in particular for medical informaticians and medical librarians both whom are information science professionals.

[Panniculitis and macrophage activation syndrome in a child with lupus erythematosus]

INTRODUCTION

Panniculitis is rarely presented in the course of systemic lupus erythematosus. When it occurs, it is mainly related to lupus profundus. However, when panniculitis is associated with a reactive hemophagocytic syndrome, panniculitis could be linked to this hemophagocytosis reaction.

CASE REPORT

We report a case of an 11-year-old girl treated for several years for systemic lupus erythematosus, who simultaneously presented panniculitis and an hemophagocytic syndrome. The reality of both diagnoses was based on the analysis of biological and histological data. Therapy with immunosuppressive drugs led to relief of the symptoms.

DISCUSSION

We emphasize our discussion on the pathophysiology of lupus profundus and hemophagocytosis with regards to the role of cytokines and circulating immune complexes in both diseases. They may enhance the hypodermal necrosis observed in lupus profundus and induce macrophage cell dysregulation through cytotoxic cells known in hemophagocytosis. The immunomodulative action of immunosuppressive therapy with inhibition of cells involved in immune response, may explain its efficacy.

[Inclusion body myositis associated with sacroidosis: a report of 3 cases]

Inclusion body myositis (IBM) is a severe form of idiopathic inflammatory myopathy. A predominantly T CD8+ lymphocytic infiltrate, with focally non-necrotizing muscular fiber invasion, and rimmed-vacuoles are specific histological signs. A few cases of IBM associated with other dysimmune diseases have been reported, but only once with systemic sarcoidosis. We report three cases of muscular sarcoidosis associated with IBM. This very uncommon observation suggests that major complex of histocompatibility, soluble factors, cytokines and adhesion molecules could be involved. Our cases are a novel example of associated dysimmune diseases.

The detection of Tel-TrkC chimeric transcripts is more specific than TrkC immunoreactivity for the diagnosis of congenital fibrosarcoma

The t(12;15)(p13;q25) translocation, a recurrent chromosomal abnormality of congenital fibrosarcoma, leads to the expression of a Tel-TrkC fusion transcript. To determine whether detection of the chimeric protein may be helpful for the diagnosis of congenital fibrosarcoma, immunohistochemistry was performed with an anti-TrkC antibody on 26 spindle cell tumours of newborn or young children (n=19) or adults (n=7). Four out of five congenital fibrosarcomas showed TrkC immunoreactivity with cytoplasmic paranuclear staining. However, TrkC immunoreactivity was not restricted to congenital fibrosarcoma and was observed in infantile myofibromatosis, congenital haemangiopericytoma, desmoid tumour, nodular fasciitis, fibrous hamartoma, inflammatory myofibroblastic tumour, and adult fibrosarcoma. RT-PCR analysis was performed on nine cases, including four congenital fibrosarcomas, for which frozen material was available. Tel-TrkC transcripts were detected by RT-PCR in the four congenital fibrosarcomas analysed, but not in the five other spindle cell tumours. Furthermore, several Tel-TrkC transcripts encoding for kinase isoforms of the Tel-TrkC protein were detected in congenital fibrosarcoma and may be involved in oncogenesis. The reciprocal TrkC-Tel transcript was detected in only one congenital fibrosarcoma. While the detection of a Tel-TrkC fusion transcript is a recurrent feature of congenital fibrosarcoma, TrkC immunoreactivity does not appear specific for the diagnosis of fibromatous paediatric tumours.

Pyodermitis of genital areas: an atypical manifestation of eosinophilic pustulosis of childhood

Eosinophilic pustulosis of the scalp was first described in 1984. It has also been described in other sites than the scalp. We report a case in which the lesions exclusively involved the genitals. A 4-month-old boy presented with papulopustular lesions of the genitals in the form of pyodermitis with a favourable course over several days but which subsequently recurred. A smear of a pustule revealed no signs of scabies or viral, fungal or bacterial infection. Histology showed a non-follicular eosinophilic pustulosis. This case emphasizes the ubiquitous and sometimes misleading nature of eosinophilic pustulosis and the non-follicular nature of the lesions.

[Lymphoma involving the temporal artery]

Involvement of the temporal arteries, considered to be the hallmark of giant cell arteritis, is rather rare in other pathologic processes. We describe a patient with lymphoma involving temporal artery. A 68-year-old man has been followed closely without therapy since 1989 for a low-grade non-Hodgkin lymphoma. He presented in 1995 with asymptomatic nodules on the temporal artery with preservation of the pulse. Temporal artery biopsy showed periarterial infiltration of mononuclear cells in keeping with follicular mixed cell lymphoma. The differential diagnosis of temporal arteritis must therefore, include other vasculitides, light chain amyloidosis but also lymphoma and emphasize the need for a temporal artery biopsy.

Phosphonocationic lipids in protein delivery to mice lungs

Cationic liposomes constitute one of the main approaches currently investigated to introduce a gene with therapeutic properties into a cell. Another alternative consists in directly introducing the normal protein of concern to, for example, restore the deleted function. We report here on in vitro and in vivo results obtained with GLB73, one of the phosphonolipids investigated as gene transfer agents. In previous studies this cationic lipid had shown its DNA-transfer efficacy in vitro and in vivo. We also confirmed the feasibility of protein/cationic lipid delivery in epithelial cells of mice lungs after intratracheal administration by use of a reporter gene (beta-galactosidase). Two quantitative tests (i.e., a chemiluminescent assay and a flow cytometry assay) were used to determine the amount of beta-galactosidase found in the lungs and the percentage of transfected cells. They showed that 50% of the cells of mice lungs were still positive at day 4 after protein/GLB73 delivery. Immunohistochemistry and electron microscopy studies allowed us to determine the spatial distribution and visualize the penetration of our complex into the lungs.

CISMeF: cataloque and index of French speaking health resources

In 1999, the Internet has become a major source of health information. The objective of CISMeF is to catalogue and index the main French-speaking sites and documents concerning health. Currently, the number of resources already totalled over 6,100 with a mean of 75 new sites each week. CISMeF contains a thematic index, including medical specialities and an alphabetic index. CISMeF uses two standard tools for organising information: the MeSH (Medical Subject Heading) thesaurus from the Medline bibliographic database (National Library of Medicine) and the Dublin Core metadata format. A brief description of the site is systematically added. CISMeF respects the Net Scoring, criteria to assess the quality of health information on the Internet. The CISMeF project fulfils a valuable tool for the French-speaking health community: 2,500 machines visit the Web site each working day.

Systemic administration of cationic phosphonolipids/DNA complexes and the relationship between formulation and lung transfection efficiency

Performances of cationic lipid formulations for intravenous gene delivery to mouse lungs have been previously reported. We report in this study that cationic phosphonolipids, when appropriately formulated, can be good synthetic vectors for gene delivery to lung after intravenous administration. One of our reagents, GLB43, was capable of mediating a 500-fold higher expression in the lungs of mice than could be obtained with free pDNA alone (P=0.018). We demonstrate that the most important parameters for cationic phosphonolipid transfection activity after systemic administration are the chemical structure of the cationic phosphonolipid, the lipid to DNA charge ratio and the inclusion of co-lipid in the formulation. We report using a luciferase reporter gene that transfection activity in vivo 24 h after cationic phosphonolipid systemic administration could not be predicted from in vitro analysis. In contrast to in vitro studies, cationic phosphonolipids including the oleyl acyl chains (GLB43) were more effective than its analogue with the myristyl acyl chains (GLB73). Using pathological analysis of animal livers, we demonstrate that the toxicity level was correlated with the lipoplex formulation and the lipid to DNA ratio.

CISMeF: a structured health resource guide

In 1999, the Internet has become a major source of health information. The objective of CISMeF is to catalogue and index the main French-speaking health resources. In September 1999, the number of indexed resources totaled over 7,100 with a mean of 75 new sites per week. CISMeF uses two standard tools for organizing information: the Medline bibliographic database MeSH thesaurus and the Dublin Core metadata format. Resources included in CISMeF are described by the following: title, author or creator, subject and keywords, description, publisher, date, resource type, format, identifier, and language. To index resources, CISMeF uses five levels of hierarchy: "meta-term", category, keyword, subheading, and resource type. CISMeF contains a thematic index, including medical specialities and an alphabetic index. CISMeF respects the Net Scoring, criteria to assess the quality of health information on the Internet. The CISMeF project offers a valuable tool for the French-speaking health community: 2,500 computer users visit the Web site each working day.

[Miyoshi distal myopathy: specific signs and incidence]

We report 21 French patients (12 males and 9 females), presenting a distal myopathy of Miyoshi type. The main clinical features of these patients were 1) onset in late adolescence or early adulthood (mean age: 20.3 years), 2) early and predominant involvement of the posterior compartment muscles of legs, 3) marked elevation of serum CK (from 10 to 50 times the normal value), 4) dystrophic features with a necrotic regeneration pattern without vacuole in muscle biopsy. All cases were sporadic and a consanguinity of parents was found in five cases. The clinical course was relatively mild: twelve patients could walk without aid; However four patients were severely disabled. Four patients were initially considered as having polymyositis; corticosteroids and immunosuppressive drugs were always inefficient. A genetic linkage to chromosome 2 was ascertained in five cases. In our experience the Miyoshi distal myopathy is the most common form of distal myopathy, particularly in young patients.

[Polyradiculoneuropathy in an adult with primitive hyperoxaluria]

From the age of 31 a patient began to suffer from recurrent calcium oxalate urolithiasis. Liver biopsy showed a decrease in catalytic activity of the hepatic peroxisomal enzyme alanine: glyoxilate aminotransferase (AGT), which was mistargeted from peroxisomes to mitochondria. The genetic analysis revealed a mutation of the AGT gene. At age 47 he developed end-stage renal failure and underwent hemodialysis. After 12 months of hemodialysis he presented a rapidly declining clinical condition, a decrease of the residual renal function, a livedo reticularis with painful of extremities, and shortly thereafter a general weakness, which predominated on lower limbs. Apart from renal failure, routine biological examination and CSF were normal. Nerve conduction studies and electromyography supported the diagnosis of polyradiculoneuropathy. Pathological studies revealed mixed demyelinating-axonal lesions and deposits of calcium oxalate crystals within the media and the intima of epineural arterioles. A combined liver-kidney transplant was rapidly performed. The patient's condition improved in a few months and motor signs completely disappeared.

[Bi-symptomatic CINCA syndrome with inaugural urticaria and major articular lesions]

BACKGROUND

CINCA syndrome (chronic infantile neurological cutaneous and articular syndrome) observed in young children associates chronic urticaria and rheumatological disorders which may cause deformation of the larger peripheral joints. Neurological signs develop later leading to severe prognosis: chronic meningitis, deafness, mental retardation. We present a bisymptomatic case which was distinctive by the absence of central nervous system involvement after 11 years of course.

CASE REPORT

Since the age of six months a female child experienced chronic urticaria with nearly daily episodes. At two years limping was also observed. At nine years, the child had highly deformed knee joints giving a tumoral radiological aspect. The diagnosis of CINCA was made. At the age of 11 years, the child had normal psychomotor development and neurological and biological tests were normal. The knee deformations stablized and the child suffered little from the urticaria.

DISCUSSION

This case of infantile chronic urticaria inaugurated a CINCA syndrome, a condition described in France and termed NOMID (neonatal onset multisystem inflammatory disease) in the English literature. Our case was similar to those reported in the literature showing characteristic skin, biological and rheumatological disorders. The absence of neurological involvement is exceptional and has been confirmed by regular surveillance to 11 years of age. Bone pathology showed a pseudotumoral aspect which has not been described previously.

[CISMeF: catalog and index of French-speaking medical sites]

The Internet has now become a major source of health information. The aim of CISMeF is to catalogue and index the main French-speaking sites and documents concerning health. This project was initiated by Rouen University Hospital. Its URL is http://www.chu-rouen.fr/cismef. CISMeF covers all areas of health care and medical sciences, and is indexed both alphabetically and according to subject. It was set up on a Sun workstation under the Sun UNIX operating system and is entirely based on static HTML. By May 1999, the number of sites and documents indexed was already over 6,500, with a mean of 75 new sites added each week. CISMeF is updated via a five-step process: resource collection, filtering, description, classification, and indexing. The Net Scoring criteria are used to assess the quality of health information on the Internet. These criteria concern eight categories: credibility, content, links, design, interactivity, quantitative aspects, ethics and accessibility. CISMeF uses two standard tools to organize information: the MeSH (medical subject heading) thesaurus from the Medline reference database (National Library of Medicine, USA) and the Dublin core metadata format. The sites and documents included in CISMeF are described using the following elements from the Dublin core project: title, author or creator, subject and keywords, description, publisher, date, resource type, format, identifier, and language.

Cationic phosphonolipids as nonviral gene transfer agents in the lungs of mice

With the aim of developing new gene transfer tools for treating CF with gene therapy, we have synthesized a novel family of molecules named cationic phosphonolipids. The most efficient among them were selected by in vitro screening to compare their activities in vivo in mouse lungs. We used a reporter gene whose activity was measured cytofluorimetrically (FACS-Gal assay) and by means of a chemiluminescence technique. These tests allowed us to identify the percentage of transfected cells and to quantify total beta-galactosidase in the lungs. This enabled us to identify two molecules, significantly efficient in comparison with DNA alone: GLB73 (p = 0.0015) and GLB253 (p = 0.007). Their use resulted in a time lag between transfection and maximum efficiency: maximum efficiency was observed 4 days after transfection with GLB73, whereas it was noticeable only on day 7 with GLB253. Moreover, from toxicity studies carried out in vivo, GLB73 seems to be nontoxic. In vivo results were correlated with in vitro results obtained with CF epithelial cell lines. Consequently, GLB73 is a potential candidate for phase I clinical trials in humans.

[Universal dyschromatosis: a familial case]

INTRODUCTION

Universal dyschromatosis is a generalized leucomelanodermia recognised in Japan in 1933. We report a family with universal dyschromatosis, demonstrating the mode of transmission. The ultrastructural aspects are compatible with a functional melanogenesis anomaly.

CASE REPORT

A 9-year-old girl was hospitalized for recently diagnosed insulin-dependent diabetes mellitus. She was born to non-consanguinous parents and her past medical history was uneventful. Her father was of mixed ethnic origin. The physical examination revealed generalized leukomelanoderma identified since the first year of life. Zones of small achromatic maculae alternated with zones of pigmented maculae of variable size and color. Lesions were diffuse but predominated on the trunk and did not involve the face, the hands or the feet. Neither the child nor her father who also has leukomelanoderma were photosensitive. A skin biopsy from the gluteal region revealed alternating zones of hyper- and hypopigmentation. The ultrastructural analysis showed that the number of melanocytes was not significantly different in the different pigmented zones and the pigment transfer to adjacent keratinocytes was intact. There were three other girls in the kinhood and two, as well as a few other individuals in the family, had a localized form of the disease.

DISCUSSION

Universal dyschromatosis is a rare genodermatosis. The familial cases reported here illustrate the variable clinical presentations of this pigmentary abnormality. The pedigree in this family demonstrated incomplete penetrance of hereditary leukomelanoderma with autosomal dominant inheritance. The localized forms reported to date under different names would actually appear to correspond to incomplete expression of the dermatosis. The skin manifestations in universal dyschromatosis would appear to be similar to those in a few other skin diseases, mainly xeroderma pigmentosum, especially the localized forms; for generalized forms however, there is little room for confusion as photosensitivity is absent and lesions predominate in unexposed zones. The ultrastructure investigations showed different levels of melanocyte activity without abnormal pigment production or transfer. This abnormality has variable expression, explaining the multitude of clinical presentations.

[Cutaneous lesions, viral risk and marine bird ticks, a world wide problem; apropos of 1 case with pseudo-zoster lesions]

Dermatological injuries provoked by tick bites deserve more attention. The authors present the clinical observation of a young woman bitten in Brittany by the marine bird associated tick Ornithodoros (A.) maritimus and presenting pseudo-zoster skin lesions. Two other individuals working together with the patient and also bitten by this tick showed symptoms of prurigo, fever and vomiting. Marine bird associated ticks bites may also be responsible for the inoculation of a number of arboviruses along all the coasts of the world including those of islands of Indian Ocean. Pathogenesis of the skin lesions is discussed according to the authors' histo-pathological findings.

[Massive poisoning by African bee stings]

BACKGROUND

Bee stings can cause severe toxic effects when envenomation is massive.

CASE REPORT

While touring in Casamance (Southern Senegal) a white male was severely stung by a swarm of African bees. The massive envenomation caused rhabdomyolysis, hemolysis and acute renal failure. Pathology examination of kidney and bladder specimens showed vasculitis affecting both arteries and veins. The patient was treated with several hemodialysis sessions and renal function returned to normal three months after the incident.

DISCUSSION

Bees in Africa, known as "killer bees", are particularly aggressive. They have recently been imported from tropical zones in America where a large number of deaths have been reported. Most cases of massive envenomation have shown acute tubular necrosis or renal involvement with myoglobinuria or hemoglobinuria. The renal pathology observed in our case is not usually described.

The binding of some human antiendothelial cell antibodies induces endothelial cell apoptosis

The pathogenic role of antiendothelial cell antibodies (AECA) remains unclear. They are frequently associated with antibodies to anionic phospholipids (PL), such as phosphatidylserine (PS), which is difficult to reconcile with the distribution of PL molecular species within the plasma membrane. Since it is already known that PS is transferred to the outer face of the membrane as a preclude to apoptosis, the possibility exists that apoptosis is initiated by AECA. AECA-positive/anti-PL antibody-negative sera from eight patients with systemic sclerosis (SS) and 21 control patients were evaluated. Endothelial cells (EC) were incubated with AECA and the exposure of PS was established through the binding of annexin V. Hypoploid cell enumeration, DNA fragmentation, and optical and ultrastructural analyses of EC were used to confirm apoptosis. Incubation of EC with AECA derived from six of eight patients with SS led to the expression of PS on the surface of the cells. This phenomenon was significantly more frequent in SS (P < 0.04) than in control diseases. The redistribution of plasma membrane PS preceded other events associated with apoptosis: hypoploidy, DNA fragmentation, and morphology characteristic for apoptosis. Apoptosis-inducing AECA did not recognize the Fas receptor. We conclude that AECA may be pathogenic by inducing apoptosis.

Transgene expression kinetics after transfection with cationic phosphonolipids in hematopoietic non adherent cells

Cationic lipids are considered to be capable of efficiently and safely mediating DNA transfer into cells, although expression is transient. A new family of cationic lipids, called phosphonolipids, has been developed, with the relationship between the hydrophobic domain of the lipid molecules and the significant enhancement of transduction efficiency in a non-adherent cell line characterised in the present study. The kinetics of transfection efficiency were also investigated. Our results demonstrate that the peak of the transient expression of these reporter genes mediated by cationic lipids occurred within 3 to 14 days, depending on the aliphatic chain length of the complex used and on its formulation in the presence or absence of DOPE. Furthermore, the kinetics of transgene expression were found to differ in adherent and non-adherent cells. These results were obtained using three different techniques: CPRG, luminescence, and FACS-gal, and were in agreement with electron microscopy studies. We thus hypothesized that the plasma membrane composition of cells could affect the efficiency of transfection with cationic lipids. Our results suggest that phosphonolipids constitute a promising class of compounds for gene transfer protocols, and that galenic optimization should improve and modify the transfection efficiency of these DNA-lipid complexes.

Lymphoma with regression after methotrexate withdrawal in a patient with rheumatoid arthritis. Role for the Epstein-Barr virus

We report a new case of large T-cell lymphoma in a rheumatoid arthritis patient under low-dose methotrexate (cumulative dose: 750 mg). Serologic tests for the Epstein-Barr virus were positive, and the viral RNA was demonstrated in the lymphoma cells. As in a few other cases reported in the literature, the clinical and laboratory test abnormalities resolved promptly after methotrexate withdrawal without anticancer therapy. The patient was still in complete remission at last follow-up four years later.