Development of an Immuno-SPECT/Fluorescent Bimodal Tracer Targeting Human or Murine PD-L1 on Preclinical Models

Detection of biomarkers to diagnose, treat, and predict the efficacy of cancer therapies is a major clinical challenge. Currently, biomarkers such as PD-L1 are commonly detected from biopsies, but this approach does not take into account the spatiotemporal heterogeneity of their expression in tumors. A solution consists in conjugating monoclonal antibodies (mAbs) targeting these biomarkers with multimodal imaging probes. In this study, a bimodal [111In]-DOTA-aza-BODIPY probe emitting in the near-infrared (NIR) was grafted onto mAbs targeting murine or human PD-L1 either in a site-specific or random manner. In vitro, these bimodal mAbs showed a good stability and affinity for PD-L1. In vivo, they targeted specifically PD-L1 and were detected by both fluorescence and SPECT imaging. A significant benefit of site-specific conjugation on glycans was observed compared to random conjugation on lysine. The potential of this bimodal agent was also highlighted, thanks to a proof of concept of fluorescence-guided surgery in a human PD-L1+ tumor model.

CBP-HSF2 structural and functional interplay in Rubinstein-Taybi neurodevelopmental disorder

Patients carrying autosomal dominant mutations in the histone/lysine acetyl transferases CBP or EP300 develop a neurodevelopmental disorder: Rubinstein-Taybi syndrome (RSTS). The biological pathways underlying these neurodevelopmental defects remain elusive. Here, we unravel the contribution of a stress-responsive pathway to RSTS. We characterize the structural and functional interaction between CBP/EP300 and heat-shock factor 2 (HSF2), a tuner of brain cortical development and major player in prenatal stress responses in the neocortex: CBP/EP300 acetylates HSF2, leading to the stabilization of the HSF2 protein. Consequently, RSTS patient-derived primary cells show decreased levels of HSF2 and HSF2-dependent alteration in their repertoire of molecular chaperones and stress response. Moreover, we unravel a CBP/EP300-HSF2-N-cadherin cascade that is also active in neurodevelopmental contexts, and show that its deregulation disturbs neuroepithelial integrity in 2D and 3D organoid models of cerebral development, generated from RSTS patient-derived iPSC cells, providing a molecular reading key for this complex pathology.

Congenital stationary night blindness in a patient with mild learning disability due to a compound heterozygous microdeletion of 15q13 and a missense mutation in TRPM1

The complete form of congenital stationary night blindness (cCSNB) represents a non-progressive retinal disorder characterized by night vision problems and often congenital nystagmus, reduced vision, high myopia, strabismus and normal fundus appearance. Clinically this form of CSNB can be diagnosed by full-field electroretinogram. The mode of inheritance can be X-linked and autosomal recessive with mutations in genes coding for proteins mainly present at the dendritic tips of ON-bipolar cells. Mutations in NYX, GRM6, GPR179, LRIT3 and TRPM1 lead to this condition. The latter gene defect represents the major form underlying cCSNBC. It codes for the melastatin-related transient receptor 1 expressed in the inner nuclear layer of the retina, with the protein localized in ON-bipolar cells. To date, various homozygous or compound heterozygous mutations in TRPM1 have been reported. Small chromosomal rearrangements are frequent cause of mental retardation. In rare cases deletions can overlap with a mutation on the remaining chromosome and lead to a recessive disorder. Here, we describe a patient with mild neurological deficiencies and cCSNB caused by a microdeletion on 15q32 overlapping with a TRPM1 variant.

Exosomal HSP70 for Monitoring of Frontotemporal Dementia and Alzheimer's Disease: Clinical and FDG-PET Correlation

We aimed to study the expression of circulating heat-shock protein HSP70 and exosomes in plasma of a cohort of patients with Alzheimer's disease (AD) and frontotemporal dementia (FTD) at different stages. We performed correlations with clinical scales and FDG-PET. HSP70 levels were higher within exosomes than free in plasma. Moderate correlations were found between exosomal HSP70 and CDR, FTLD-CDR, and extension of hypometabolism. Our results suggest modifications in the level of exosomal HSP70 during the course of neurodegeneration, regardless of AD or FTD, and therefore HSP70 could have a potential role in the follow-up of these disorders.

Monitoring HSP70 exosomes in cancer patients' follow up: a clinical prospective pilot study

Exosomes are nanovesicles released by all cells that can be found in the blood. A key point for their use as potential biomarkers in cancer is to differentiate tumour-derived exosomes from other circulating nanovesicles. Heat shock protein-70 (HSP70) has been shown to be abundantly expressed by cancer cells and to be associated with bad prognosis. We previously showed that exosomes derived from cancer cells carried HSP70 in the membrane while those from non-cancerous cells did not. In this work, we opened a prospective clinical pilot study including breast and lung cancer patients to determine whether it was possible to detect and quantify HSP70 exosomes in the blood of patients with solid cancers. We found that circulating exosomal HSP70 levels, but not soluble HSP70, reflected HSP70 content within the tumour biopsies. Circulating HSP70 exosomes increased in metastatic patients compared to non-metastatic patients or healthy volunteers. Further, we demonstrated that HSP70-exosome levels correlated with the disease status and, when compared with circulating tumour cells, were more sensitive tumour dissemination predictors. Finally, our case studies indicated that HSP70-exosome levels inversely correlated with response to the therapy and that, therefore, monitoring changes in circulating exosomal HSP70 might be useful to predict tumour response and clinical outcome.

Membrane-bound exosomal HSP70 as a biomarker for detection and monitoring of malignant solid tumours: a pilot study

Background

Cancer is the second leading cause of death globally. Early detection and disease management lead to a better survival rate. Consequently, discovery of novel methods in cancer early diagnosis is a field of active research. Minimally invasive liquid biopsies are generating growing interest. Circulating tumour cells (CTCs) have been identified in patients' blood; nevertheless, these cells are rare and heterogeneous. Exosomes are extracellular nanovesicles released into the extracellular environment via the endosomal vesicle pathway and found in different body fluids. Exosomes deliver bioactive cargo such as proteins, mRNA and miRNA to recipient cells in the tumour environment. We have recently shown that heat shock protein 70 (HSP70) is detected in the membrane of tumour-derived exosomes, in contrast to normal cells. One single cancer cell can release thousands of HSP70-exosomes, facilitating detection. The aim of the pilot study ExoDiag is to determine whether it is possible to detect and quantify HSP70-exosomes in blood in patients with solid cancers.

Methods

Bicentric pilot study that will include 60 adult patients with metastatic and non-metastatic solid tumours and 20 healthy volunteers. Exosomes will be isolated from blood and urine samples, and HSP70 concentration will be determined. Patients will be followed for 1 year. The study is sponsored by Georges-François Leclerc Centre and is currently ongoing.

Discussion

We expect to demonstrate that HSP70-exosomes could be a powerful tool to diagnose cancer and to guide clinicians in therapeutic decision-making, improving patient's care.

Trial Registration

ClinicalTrials.gov identifier NCT02662621. Registered 20 January 2016, https://clinicaltrials.gov/ct2/show/study/NCT02662621?term=NCT02662621&rank=1.

Tracking the evolution of circulating exosomal-PD-L1 to monitor melanoma patients

In the era of immunotherapies there is an urgent need to implement the use of circulating biomarkers in clinical practice to facilitate personalized therapy and to predict treatment response. We conducted a prospective study to evaluate the usefulness of circulating exosomal-PD-L1 in melanoma patients' follow-up. We studied the dynamics of exosomal-PD-L1 from 100 melanoma patients by using an enzyme-linked immunosorbent assay. We found that PD-L1 was secreted through exosomes by melanoma cells. Exosomes carrying PD-L1 had immunosuppressive properties since they were as efficient as the cancer cell from which they derive at inhibiting T-cell activation. In plasma from melanoma patients, the level of PD-L1 (n= 30, median 64.26 pg/mL) was significantly higher in exosomes compared to soluble PD-L1 (n= 30, 0.1 pg/mL). Furthermore, exosomal-PD-L1 was detected in all patients whereas only 67% of tumour biopsies were PD-L1 positive. Although baseline exosomal-PD-L1 levels were not associated with clinic-pathologic characteristics, their variations after the cures (ΔExoPD-L1) correlated with the tumour response to treatment. A ΔExoPD-L1 cut-off of> 100 was defined, yielding an 83% sensitivity, a 70% specificity, a 91% positive predictive value and 54% negative predictive values for disease progression. The use of the cut-off allowed stratification in two groups of patients statistically different concerning overall survival and progression-free survival. PD-L1 levels in circulating exosomes seem to be a more reliable marker than PD-L1 expression in tumour biopsies. Monitoring of circulating exosomal-PD-L1 may be useful to predict the tumour response to treatment and clinical outcome.

Increased Levels of Interleukin-17A Exosomes in Psoriasis

Exosomes are involved in modulating the immune system and mediating communication between cells. The aim of this study was to investigate the involvement of exosomes in psoriasis. Exosomes from patients with psoriasis were analysed by nanoparticle tracking analysis and protein expression was analysed by western blotting. The concentration of HSP70 was determined by an enzyme-linked immunosorbent assay, and concentrations of interleukin (IL)-1β, IL-2, IL-6, IL-10, IL-17A and tumour necrosis factor alpha (TNF-α) were determined by flow cytometry. Based on the severity of psoriasis, evaluated by body surface area (≤ 10% vs. > 10%), 2 groups of patients were compared (49 with mild psoriasis and 71 with moderate-to-severe psoriasis). The number (2.52×1011 ± 2.29×1010 vs. 1.79×1011 ± 1.93×1010, p = 0.19) and size (94.44 ± 22.00 nm vs. 96.87 ± 28.30 nm, p = 0.72) of exosomes and the concentration of HSP70 in the exosomes were not significantly different in the 2 groups of patients. IL-17A exosome levels were significantly higher in patients with moderate-to-severe psoriasis compared with those with mild psoriasis (p = 0.02). There were no significant differences in levels of TNF-α, IL-1, IL-2, IL-6 and IL-10. This study shows, for the first time, the presence of circulating exosomes in patients with psoriasis. These data confirm the involvement of circulating exosomes in psoriasis, in particular in moderate-to-severe psoriasis, through IL-17A-producing exosomes.

Membrane-anchored heat-shock protein 70 (Hsp70) in cancer

Hsp70 is a highly conserved and inducible heat shock protein that belongs to the HSP70 family of molecular chaperones and plays a central role in protein homeostasis. The main function of Hsp70 is to protect cells from physiological, pathological and environmental insults, as it assists an ATP-dependent manner the process of protein folding. Since Hsp70 provides critical cell survival functions, cancer cells are assumed to rely on this chaperone. Strong evidence suggests that Hsp70 is upregulated in different type of cancers and is involved in tumor growth, invasion, migration and resistance to anti-cancer therapy. Interestingly, this Hsp70 upregulation induces Hsp70 re-location into plasma membrane. In this review, the role of Hsp70 in cancer will be discussed focusing particularly on the extracellular membrane-bound Hsp70. The mechanism by which Hsp70 is translocated to plasma membrane of tumor cells and the recent discoveries of drugs targeting this Hsp70 in cancer therapy will be also highlighted.

Circulating PD-L1-exosomes to monitor tumor response in melanoma patients

9517

Background: In the era of effective molecular targeted treatments and immunotherapies, there is an urgent need to implement the use of circulating biomarkers in the clinic to facilitate personalized therapy and predict treatment response. We conducted a retrospective study to demonstrate the involvement of circulating PD-L1 exosomes in melanoma patients. Methods: One hundred melanoma patients were included. Exosomes were isolated by ultracentrifugation and evaluated by nanoparticle tracking analysis using a NS300 Instrument (Nanosight, Amesbury, UK). Isolated exosomes were tested for the expression of exosomes markers such as TSG101. PD-L1 expression in plasma and in melanoma plasma-derived exosomes (ExoPD-L1) was measured using an enzyme-linked immunosorbent assay (PD-L1 Human ELISA Kit, Invitrogen). Results: First, ExoPD-L1 was assessed in melanoma cell lines. Exosomes may have a role in cancer immunosuppression mediated by T-cells since they were as efficient as cancer cells to inhibit T-cells activation. In melanoma patients, ExoPD-L1 (median 64,26 pg/mL) was significantly higher than free PD-L1 in the plasma which was barely detectable (0,1 pg/mL). Furthermore, ExoPD-L1 was detected in all patients whereas only 67 % were PD-L1 positive in tumor. Although baseline ExoPD-L1 levels were not associated with clinicopathologic characteristics and tumour burden, ExoPD-L1 variations (ΔExoPD-L1) after treatment correlated with tumor response and survival. A ΔExoPD-L1 cut-off of > 100 was defined, yielding a 83% sensitivity, a 70% specificity, a 91% positive predictive value and a 54% negative predictive values for disease progression. The use of this cut-off allowed stratification in two groups of patients statistically different in terms of overall survival and progression free survival. Conclusions: PD-L1 level in circulating exosomes may be a more reliable marker than PD-L1 expression in the tumor tissue. Monitoring of circulating exosomal PD-L1 may be a promising biomarker to predict tumor response and correlate with survival.

Exosomes in cancer theranostic: Diamonds in the rough

During the last 10 years, exosomes, which are small vesicles of 50-200 nm diameter of endosomal origin, have aroused a great interest in the scientific and clinical community for their roles in intercellular communication in almost all physiological and pathological processes. Most cells can potentially release these nanovesicles that share with the parent cell a similar lipid bilayer with transmembrane proteins and a panel of enclosed soluble proteins such as heat shock proteins and genetic material, thus acting as potential nanoshuttles of biomarkers. Exosomes surface proteins allow their targeting and capture by recipient cells, while the exosomes' content can modify the physiological state of recipient cells. Tumor derived exosomes by interacting with other cells of the tumor microenvironment modulate tumor progression, angiogenic switch, metastasis, and immune escape. Targeting tumor-derived exosomes might be an interesting approach in cancer therapy. Furthermore, because a key issue to improve cancer patients' outcome relies on earlier cancer diagnosis (metastases, as opposed to the primary tumor, are responsible for most cancer deaths) exosomes have been put forward as promising biomarker candidates for cancer diagnosis and prognosis. This review summarizes the roles of exosomes in cancer and clinical interest, focusing on the importance of exosomal heat shock proteins (HSP). The challenges of clinical translation of HSP-exosomes as therapeutic targets and biomarkers for early cancer detection are also discussed.

[Recent eye surgery]

The evolution of eye surgery has been truly extraordinary since the last decades, with the development of machines and techniques more and more accurate and effective. In this article will be detailed the novelties in terms of cataract surgery and refractive surgery.

[Diagnosis of a sudden loss of vision (without redness nor eye pain)]

Sudden loss of vision without redness nor eye pain may come from numerous causes of varying severity. It presents a major source of anxiety for the patient who will seek for urgent consultation. The diagnostic approach is based on history and eye examination, eventually completed by a neurological examination. The purpose of this article is to provide general practitioners simple clues allowing them to quickly orientate the diagnosis. Following simple guidelines, they will be able to treat the condition correctly or refer to an adequate specialist when needed. True emergencies are retinal detachment, central retinal artery occlusion, intracranial hypertension, Horton giant cells arteritis, transient ischemic attack, stroke, pituitary apoplexy and cortical visual loss.

Treating diabetes with islet transplantation: lessons from the past decade in Lille

Type 1 diabetes (T1D) is due to the loss of both beta-cell insulin secretion and glucose sensing, leading to glucose variability and a lack of predictability, a daily issue for patients. Guidelines for the treatment of T1D have become stricter as results from the Diabetes Control and Complications Trial (DCCT) demonstrated the close relationship between microangiopathy and HbA1c levels. In this regard, glucometers, ambulatory continuous glucose monitoring, and subcutaneous and intraperitoneal pumps have been major developments in the management of glucose imbalance. Besides this technological approach, islet transplantation (IT) has emerged as an acceptable safe procedure with results that continue to improve. Research in the last decade of the 20th century focused on the feasibility of islet isolation and transplantation and, since 2000, the success and reproducibility of the Edmonton protocol have been proven, and the mid-term (5-year) benefit-risk ratio evaluated. Currently, a 5-year 50% rate of insulin independence can be expected, with stabilization of microangiopathy and macroangiopathy, but the possible side-effects of immunosuppressants, limited availability of islets and still limited duration of insulin independence restrict the procedure to cases of brittle diabetes in patients who are not overweight or have no associated insulin resistance. However, various prognostic factors have been identified that may extend islet graft survival and reduce the number of islet injections required; these include graft quality, autoimmunity, immunosuppressant regimen and non-specific inflammatory reactions. Finally, alternative injection sites and unlimited sources of islets are likely to make IT a routine procedure in the future.

Giant cell arteritis: the internist should not be a lone rider in this potentially blinding condition

We report the case of a 66-year-old woman with visual loss due to anterior ischaemic optic neuropathy. The diagnosis of giant cell arteritis was made on the basis of classic clinical characteristics and haematological abnormalities. Despite corticosteroid treatment, involvement of the other eye occured, resulting in a bilateral and permanent loss of vision. The follow-up was marked by two relapses within the 6 months after the first episode. In order to prevent blindness, ophthalmologists should be familiar with this disorder and should actively participate in the treatment, not leaving the internist deciding alone about tapering corticotherapy.

Fundus autofluorescence in a case of occult macular dystrophy

PURPOSE

To document for the first time intrinsic retinal pigment epithelium (RPE) fluorescence in occult macular dystrophy (OMD). This entity is characterized by a central cone dysfunction leading to a decline of visual acuity without visible fundus and fluorescein angiography abnormalities. A great variability in clinical findings and in the pattern of inheritance have been reported suggesting probably several etiologies of which some are well known but seen too early to detect significant changes.

METHODS

Fundus autofluorescence imaging is a recent method to detect early retinal pigment epithelial alterations. It may visualise disease specific abnormalities in the retinal pigment epithelium often not yet visible on ophthalmoscopy such as Stargardt disease, rod-cone dystrophy. This method was applied in a member of a family with OMD.

RESULTS

The normal fundus autofluorescence observed in our patient allowed the distinction between well-known maculopathies not yet visible on ophthalmoscopy but showing abnormal autofluorescence, and genuine occult macular dystrophy.

CONCLUSION

Fundus autofluorescence imaging in our case of dominant autosomal OMD suggests a healthy and functional RPE. This examination of RPE should therefore be added to the work-up of suspected OMD.

[Visual cortes--is it a concern?]

The visual cortex may be involved in adverse drug reactions, leading to three different clinical presentations: cortical blindness, visual hallucinations and visual aura without headache. The drugs with potential visual cortex toxicity are described.

[Toxicity of recent and less recent drugs on the optic nerve. Does Viagra cause blindness?]

The optic nerve is quite vulnerable to the toxic effect of drugs. Since the last thirty years new drugs have appeared that are potentially harmful to the optic nerve. They are described.

[Classification and profile of adverse drug effects]

It is necessary to classify adverse drug reactions by grading the certainty of causal relationship between the drug administration and the adverse reaction. The most widely used classification is the one of the World Health Organization (WHO).

Étude comparative de la cycloplégie par cyclopentolate en gouttes et en spray chez des enfants

INTRODUCTION

Instillation of cyclopentolate drops with their irritant effect is difficult for children to bear. The purpose of this study was to compare the tolerance and efficacy of cyclopentolate spray versus drops.

MATERIAL AND METHODS

The cycloplegic effect of cyclopentolate spray prepared and conditioned in the hospital was compared with drops in 62 eyes of 32 children consulting in our department. The nonparametric Wilcoxon test for paired data was used to assume there was no significant difference between the refractive measurements with spray or drops.

RESULTS

The mean age of our patients was 6.3 years (SD, 3.4 years). The refractive values ranged from -17.3 diopters to +8 spheric diopters and -4 to 0 cylindric diopters. The nonparametric Wilcoxon test for paired data showed no significant difference between cycloplegic measurements with drops or spray.

CONCLUSION

Cyclopentolate spray is a good alternative to traditional drops, leading to equal cycloplegic efficacy but greater tolerance in children and easier administration by the nursing staff.

Screening for amblyogenic factors in preschool children with the retinomax hand-held refractor: do positive children have amblyopia and is treatment efficacious?

PURPOSE

To determine the visual acuity (VA) in a group of preschool children who were true positives for refractive screening (positive group) in order to compare it with the VA of a sample of children without any refractive anomaly (control group); also, to investigate if true-positive treated children can achieve the VA of the control group within what delay.

METHODS

Fifty seven children without any refractive anomaly were tested with the VA child chart if the Nidek SCP 670 projector; 47 children presenting with the refractive anomalies were tested with the same chart. A Kruskal Wallis exact test for singly ordered tables were used to compare VA between those groups and a non-parametric Wilcoxon test for paired samples was used to compare pre- and post-treatment VA in 27 children of the positive group. The mean time necessary to achieve the post-treatment VA was calculated.

RESULTS

Median VA: 20/20 in the control group, 20/33 in the positive group. The VA difference between the two pre- and post-treatment VA are highly significant. Among the 27 treated children, pre-treatment median VA was 20/50, post-treatment 20/20. The differences between the pre- and post-treatment VA was 9 months.

CONCLUSION

The positive group had a significantly lower VA than the control group. In the treated group, treatment initiated at a mean age of 4 years resulted in an increase in VA to that of the control group after an average time of 9 months, encouraging early screening and treatment before VA is measureable in order to shorten this delay.

Comparison between two hand-held autorefractors: the Sure-Sight and the Retinomax

PURPOSE

To compare the results of manifest refraction obtained with two different hand-held autorefractors (Sure-Sight, Welch Allyn Co. and Retinomax 1, Nikon Inc.) and with the Topcon RMA 6000 on-table autorefractor in order to estimate any potential bias between these refractometers and to compare the diagnostic performances of these two hand-held autorefractors as screening devices.

METHODS

Ninety-eight children were refracted under manifest conditions with the three above-mentioned refractometers and under cycloplegic conditions with the Topcon on-table autorefractor, or by means of retinoscopy. The agreement between the manifest measurements obtained with the three different autorefractors was studied using the method of Bland and Altman. The validity of several thresholds of manifest refractive anomalies as measured with the Sure-Sight and with the Retinomax was estimated by receiver operating characteristic (ROC) curves using cycloplegic measures as reference. results There is a spherical positive bias of 1 D between the Sure-Sight and the Retinomax and better agreement between the Topcon and the Retinomax. The surface area indexes of the ROC curves and the diagnostic performances in term of sensitivity and specificity are better with the Retinomax in cases of hyperopia, astigmatism and anisometropia. For myopia, the Sure-Sight has better performance.

CONCLUSIONS

The results suggest that either device may be sufficient for assessing refractive errors in children in a screening setting. However, because of a bias between both refractometers in measuring the sphere, distinctive referral criteria must be chosen for the detection of hyperopia and myopia. The diagnostic performance is slightly in favor of the Retinomax.

[Detection of ocular disorders in children in the context of school medicine and general practice]

After brief anatomical and terminological considerations, several steps of the child's visual development are mentioned as well as the ocular diseases important to diagnose and how to track them down with what sort of materials and tests. Several aspects of amblyopia and its risk's factors are then emphasized together with the arguments to justify amblyopia screening.

[The ophthalmology department]

The main clinical activities developed during the first 25 year of the department are described. Topics of fundamental and also clinical research are briefly reviewed.

[Optic neuropathy in Strumpell-Lorrain disease: presentation of a clinical case and literature review]

This report describes a 36-year-old female with bilateral optic atrophy. Physical examination was normal except for subclinical signs of lower limbs spasticity. Her father was affected of Strumpell-Lorrain disease. The clinical characteristics of Hereditary Spastic Paraplegia or Strumpell-Lorrain disease are: progressive spasticity of the lower limbs and pathological reflexes. Pathologically, this disease is characterized by a degeneration or demyelinization of the cortico-spinal system and, to a lesser extent, of the posterior cord and the spino-cerebellar system. Optic neuropathy and dyschromatopsy have already been reported in a small group of patients. Visual acuity ranged from 20/20 to 20/200. Visual field alterations consisted of superior bitemporal amputation. Fundus examination showed optic atrophy. The incidence of optic neuropathy in Strumpell-Lorrain disease is quite high but its presence is often overlooked. Most patients are asymptomatic, but signs of optic nerve dysfunction are evident at clinical examination. According to some authors, there is an inverse relationship between the impairment of walking and the visual dysfunction. This was also noted in our case.

[Superior oblique myokymia secondary to neurovascular compression]

In a patient with superior oblique myokymia, a contact is visualised between the right trochlear nerve and a vascular structure by high resolution thin slices magnetic resonance images coupled to angio-MR. A similar contact is not visualised on the left side. This suggests that the neuro-vascular contact is the cause of this superior oblique myokymia and offers the possibility of neuro-surgical decompression if necessary.

[Are the principles of treatment of chronic osteitis applicable to the diabetic foot?]

OBJECTIVE

The interest of the management of bone infections in the diabetic foot, inspired by the recommendations for the treatment of chronic osteitis, was assessed in this study.

METHODS

Twenty bone infections in 17 diabetic patients with moderate to mild infections of the feet were confirmed by the results of X-ray and/or scintigraphic studies and bone surgery biopsy cultures revealing one or more bacteria sensitive to standard osteitis treatment (rifampicine + fluoroquinolone). The patients had received this treatment per os for a median duration of 6 months (3 to 10 months). Clinical follow-up was carried out during a consultation at 1, 3 and 6 months during treatment and then by telephone every six months after the end of treatment. Clinical success was defined as the disappearance of any local sign of infection and by the absence of relapse during the post-treatment follow-up period. The evolution of the bone infection was also assessed by the results of a control conducted 3 to 6 months after initiation of the antibiotic treatment.

RESULTS

At the end of the treatment, all signs of infection had disappeared in 15/17 patients (88.2%) and no relapse had occurred in 14 (82.3%) patients at the end of a median post-treatment period of 22 months (12 to 41 months). Resection of necrotic bone was performed at the same time as the bone biopsy in 2 patients. The median duration of hospitalisation was of 14 days (3 to 53 days). During the study, a multi-resistant germ was isolated in 4 patients (1 Pseudomonas aeruginosa, 3 Staphylococcus aureus). During the post-treatment follow-up, 3 patients dies from causes unrelated to the infection treated. No serious adverse event was reported during the study.

DISCUSSION

The results of this pilot study support the rationale of applying the treatment regimens of chronic osteitis to diabetic lesions of the feet, but are only applicable to comparable patients presenting with non-severe lesions of the feet. Moreover, the use of antibiotics with potent selection of resistance such as rifampicine and fluoroquinolone, requires that bone biopsies be taken, which is not easy in all the diabetic foot care centres. We are presently conducting a study to identify the sub-populations of diabetic patients who could benefit from such treatment.

Rifampicin-ofloxacin oral regimen for the treatment of mild to moderate diabetic foot osteomyelitis

Seventeen diabetic patients with moderate to mild foot lesions associated with 20 osteomyelitic bones diagnosed by both bone scan and bone biopsy received rifampicin plus ofloxacin for a median duration of 6 months. Cure was defined as disappearance of all signs and symptoms of infection at the end of the treatment and absence of relapse during follow up. At the end of the treatment period, cure was achieved in 15 patients (88.2%) and was maintained in 13 patients (76.5%) at the end of an average post-treatment follow-up of 22 months. No serious drug-related adverse events were recorded.

Non-cycloplegic screening for refractive errors in children with the hand-held autorefractor Retinomax: final results and comparison with non-cycloplegic photoscreening

AIMS

To establish the results of refractive screening of preschool children with the hand-held autorefractor Retinomax under non-cycloplegic conditions, and to compare these results with those of photoscreening.

METHODS

Among 1218 children undergoing non-cycloplegic refractive screening, 302 (25%) were also refracted under cycloplegia using the same refractor and were used as controls. Our criteria for a positive screening test were based on the spherical or cylinder values and were: myopia over 3D, astigmatism > or = 2D, spherical or cylindrical anisometropia > or = 1.5D, and hyperopia > or = 1.5D. Absolute myopia over 3D, absolute astigmatism > or = 2D, absolute anisometropia > or = 1.5D and absolute hyperopia > 3.5D were considered as true positives. The sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated within the group of controls for each refractive anomaly. On the basis of Bayes' theorem, these figures were then corrected to yield the true screening results that would be expected in a population without verification and selection bias. To determine the usefulness of this screening technique, the likelihood ratios for positive test results (+LR) were also calculated. The results of this screening in terms of sensitivity, specificity and predictive values were then compared with those of photoscreening.

RESULTS

The basic results of screening with the hand-held autorefractor were as follows: -EHyperopia: sensitivity 46%, specificity 97%, PPV 55%, NPV 96%, +LR 15; -EAstigmatism: sensitivity 37%, specificity 99%, PPV 69%, NPV 96%, +LR 37; -EAnisometropia: sensitivity 66%, specificity 93%, PPV 19%, NPV 99%, +LR 9; -EMyopia: sensitivity 87%, specificity 99%, PPV 33%, NPV 100%, +LR 87. The comparison with photoscreening revealed a similar performance when screening for hyperopia, but the hand-held autorefractor yielded much better figures when screening for astigmatism. In the case of myopia and anisometropia, the lack of consistent information concerning photoscreening invalidates any comparison.

CONCLUSION

The hand-held autorefractor Retinomax appears to have potential as a screening device. Our experience with the non-cycloplegic screening of preschool children for refractive anomalies indicates definite usefulness and reasonable accuracy of the Retinomax for detecting myopia, astigmatism and hyperopia. The weak point of this screening technique is the diagnosis of anisometropia, with only moderate utility and poor accuracy.

[Cure of post-traumatic bilateral paralysis of the cranial nerve IV]

We relate our own experience about bilateral inferior rectus recession as first surgery for traumatic bilateral superior oblique palsy. An adjustable suture is performed on one side. This procedure is combined or not with an inferior oblique recession. Measurements of ocular deviation and torsion, Lancaster tests and binocular single vision fields are reported pre- and postoperatively. Reduction of diplopia, cyclodeviation and V esotropia with an expansion of the binocular single vision field is achieved in all cases, relieving patients' complaints. This surgery is easy to perform and free of important secondary effects. We think it represents a valuable choice for that kind of pathology.

Screening for refractive errors in children: accuracy of the hand held refractor Retinomax to screen for astigmatism

AIMS

To assess the reliability of the hand held automated refractor Retinomax in measuring astigmatism in non-cycloplegic conditions. To assess the accuracy of Retinomax in diagnosing abnormal astigmatism in non-cycloplegic refractive screening of children between 9 and 36 months.

METHODS

Among 1205 children undergoing a non-cycloplegic refractive screening with Retinomax, 299 (25%) had repeated non-cycloplegic measurements, 302 (25%) were refracted under cycloplegia using the same refractor, and 88 (7%) using retinoscopy or an automated on table refractor. The reproducibility of non-cycloplegic cylinder measurement was assessed by comparing the cylindrical power and axis values in the 299 repeated measurements without cycloplegia. The influence of the quick mode on cylinder measurement was analysed by comparing the cylinder and axis value in 93 repeated measurements without cycloplegia where normal mode was used in one measurement and quick mode in the other. Predictive values of the refractive screening were calculated for three different thresholds of manifest astigmatism (> or = 1.5, > or = 1.75, and > or = 2 D) considering as a true positive case an astigmatism > or = 2 D under cycloplegic condition (measured by retinoscopy, on table, or hand held refractor).

RESULTS

The 95% limits of agreement between two repeated manifest cylinder measurements with Retinomax attained levels slightly less than plus or minus 1 D. The 95% limits of agreement for the axis were plus or minus 46 degrees. The comparison of non-cycloplegic measurements in the quick and normal mode showed no significant difference and 95% limits of agreement plus or minus 0.75 D. The mean difference between non-cycloplegic and cycloplegic cylinder values measured by Retinomax reached 0.17 D and was statistically significant. Manifest thresholds of > or = 1.5 D, > or = 1.75 D, > or = 2 D cylinder value diagnosed 2 D of astigmatism under cyclplegia respectively with 71-84%, 59-80%, 51-54% of sensitivity (right eye-left eye) and 90-92%, 95%, 98% of specificity.

CONCLUSION

Without cycloplegia, Retinomax is able to measure cylinder power with the same reproducibility as cycloplegic retinoscopy. No significant difference was found in the cylinder values obtained with the quick and the normal modes. Therefore, the quick mode of measurement is recommended as it is more feasible in children. No difference, which is significant from a screening point of view, exists between the non-cycloplegic and the cycloplegic cylinder value (< 0.25 D). Retinomax diagnoses abnormal astigmatism (> or = 2 D) in a non-cycloplegic refractive screening at preschool ages with 51-84% sensitivity rates and 98-90% specificity rates, depending on the chosen threshold of manifest astigmatism. If 2 D of manifest astigmatism is chosen as a positive test, the positive predictive value of the screening reaches 81-84% and the negative predictive value 91-90% (right eye-left eye).

[Non-traumatic method of intubation of the lacrimal duct using a silicone tube: synergism between the ophthalmologist and the anesthetist]

The authors evaluate an atraumatic catheterisation of the lacrymal system by using a prolene silastic intubation and a standard nasal aspiration probe. After recovery of both prolene end and nasal probe out of the throat the prolene was threaded into the aspiration probe and both were taken off back out of the nose.

Screening for abnormal levels of hyperopia in children: a non-cycloplegic method with a hand held refractor

AIMS

High hyperopia constitutes the majority of refractive errors in large scale visual screening at preschool ages. The authors aimed to assess the validity of the Retinomax hand held refractor to detect high hyperopia in a refractive screening performed without cycloplegia and carried out on children aged 9-36 months. They considered +1.5 D of manifest hyperopia to be the threshold value and abnormal absolute hyperopia to be above +3.5 D.

METHODS

Of the 897 children screened without cycloplegia, 220 were refracted with cycloplegia. The validity of several thresholds of manifest hyperopia was estimated by receiver operating characteristic (ROC) curves using cycloplegic measures as a reference. The reproducibility of Retinomax measurements was assessed. Normal and quick mode measurements were compared using the Wilcoxon test.

RESULTS

The manifest threshold of +1.5 D offered the best combination of sensitivity (70.2%), specificity (94.6%), positive predictive value (78.6%), and negative predictive value (91.9%) to disclose abnormal absolute hyperopia. A good agreement was obtained between the various measurements using Retinomax on the same subject. In the results of this survey, there is no evidence that accommodation is minimised in the normal mode of measurement compared with the quick mode.

CONCLUSION

The Retinomax hand held infrared autorefractor is a suitable instrument to diagnose abnormal hyperopia (manifest hyperopia > +1.5 D) in noncycloplegic refractive screening at preschool ages. It is suggested as the quick mode of measurement as it is more feasible in children (success rate 98.5%).

How accurate is the hand-held refractor Retinomax(R) in measuring cycloplegic refraction: a further evaluation

AIMS To assess the agreement between the hand-held autorefractor Retinomax(R) and three different on-table autorefractors when measuring cycloplegic refraction in subjects with small and high ametropia. To assess the agreement between the cycloplegic refraction using the Retinomax(R) and by retinoscopy in children with small and high ametropia. METHODS Part A.276 subjects were refracted under cycloplegia using both the Retinomax(R) and an on-table infrared automated refractor (Topcon RM-A 6000, Nidek AR 800 or Nikon NR 5000). They were separated into subjects withsmall ametropia (mean sphere </= 3.5 D hyperopia, </= 3 D myopia) and high ametropia (mean sphere > 3.5 D hyperopia, > 3 D myopia). The agreement between both types of refractors regarding the different refractive components was assessed for the whole group and for the two subgroups of small and high ametropia. Part B. 48 infants were refracted under cycloplegia by retinoscopy and by the Retinomax(R). The agreement between both methods of refraction was analyzed in the same manner as in part A. RESULTS Part A. No significant bias was found between the two types of refractors with regard to the spherical equivalent. The 95% limits of agreement were +/- 1 D. Although no clinically significant bias was found with regard to the cylinder power in the 276 subjects, it was found that the 95% limits of agreement were much better (+/- 0.75 D) in small ametropia subjects than in high ametropia subjects (-2.1 to +1.3 D). No significant bias was found with regard to the axis determination. Part B. No significant bias was found between the Retinomax(R) and retinoscopic measurements with regard to the spherical equivalent. The 95% limits of agreement were -1.36 to +1.76 D. However, the mean difference for spheres and cylinders showed a positive bias and a negative bias, respectively, suggesting more positive spheres and larger cylinders when measured by the Retinomax(R) compared to retinoscopy. This was particularly obvious in cases of high ametropia. CONCLUSION Compared to retinoscopy and on-table autorefraction, the hand-held refractor Retinomax(R) is accurate in any ametropia with respect to the spherical equivalent. In small ametropia, there is a good accuracy when measuring the three refractive components (sphere, cylinder and axis). The accuracy decreases in high ametropia, especially with regard to the cylinder power.