Anti-fibrotic effects of nintedanib on lung fibroblasts derived from patients with Progressive Fibrosing Interstitial Lung Diseases (PF-ILDs)

The tyrosine kinase inhibitor nintedanib has been recently approved for the treatment of Interstitial Lung Diseases (ILDs) that manifest a progressive fibrosis phenotype other than Idiopathic pulmonary Fibrosis (IPF). Nintedanib reduces the development of lung fibrosis in various animal models resembling features of PF-ILD and in vitro, it inhibits the fibrosing phenotype of human lung fibroblasts (HLFs) isolated from patients with IPF. To get insight on the cellular and molecular mechanisms that drive the clinical efficiency of nintedanib in patients with non-IPF PF-ILD, we investigated its effects on the fibrosing functions of HLFs derived from patients with PF-hypersensitivity pneumonitis (PF-HP, n = 7), PF-sarcoidosis (n = 5) and pleuroparenchymal fibroelastosis (PPFE, n = 4). HLFs were treated with nintedanib (10 nM-1 μM) and then stimulated with PDGF-BB (25-50 ng/ml) or TGF-β1 (1 ng/ml) for 24-72 h to assess proliferation and migration or differentiation. At nanomolar concentrations, nintedanib reduced the levels of PDGF receptor and ERK1/2 phosphorylation, the proliferation and the migration of PF-HP, PF-sarcoidosis and PPFE HLFs stimulated with PDGF-BB. Moreover, nintedanib also attenuates the myofibroblastic differentiation driven by TGF-β1 but only when it is used at 1 μM. The drug reduced the phosphorylation of SMAD2/3 and decreased the induction of collagen, fibronectin and α-smooth muscle actin expression induced by TGF-β1. In conclusion, our results demonstrate that nintedanib counteracts fundamental fibrosing functions of lung fibroblasts derived from patients with PF-HP, PF-sarcoidosis and PPFE, at concentrations previously reported to inhibit control and IPF HLFs. Such effects may contribute to its clinical benefit in patients suffering from these irreversible ILDs.

Early detection of chronic obstructive pulmonary disease in primary care: a randomised controlled trial

BACKGROUND

Worldwide, chronic obstructive pulmonary disease (COPD) remains largely underdiagnosed.

AIM

To assess whether the use of Global Initiative for Chronic Obstructive Lung Disease (GOLD) questions and COPD coordination, either alone or combined, would detect new COPD cases in primary care.

DESIGN AND SETTING

GPs in Brittany, France, systematically enrolled patients aged 40-80 years over a 4-month period in this French multicentre cluster randomised controlled study.

METHOD

GPs were randomly allocated to one of four groups: control (standard of care), GOLD questions (adapted from symptoms and risk factors identified by GOLD), COPD coordination, and GOLD questions with COPD coordination. New cases of COPD were those confirmed by spirometry: post-bronchodilator forced expiratory volume in 1 second over forced vital capacity of <0.7.

RESULTS

In total, 11 430 consultations were conducted by 47 GPs, who enrolled 3162 patients who did not have prior diagnosed asthma or COPD. Among these, 802 (25%) were enrolled in the control, 820 (26%) in the GOLD questions, 802 (25%) in the COPD coordination, and 738 (23%) in the GOLD questions with COPD coordination groups. In the control group, COPD was not evoked, and no spirometry was prescribed. All new cases of COPD diagnosed (n = 24, 0.8%) were in the intervention groups, representing 6.8% of patients who performed spirometry. Statistically significantly more new cases of COPD were detected with COPD coordination (P = 0.01).

CONCLUSION

Interventions that can be easily implemented, such as the GOLD questions and COPD coordination, can identify new cases of COPD. Studies are needed to identify the most appropriate case-finding strategies for GPs to detect COPD in primary care for each country.

Prognostic value and predictors of the alteration of the diffusing capacity of the lungs for carbon monoxide in systemic lupus erythematosus

OBJECTIVES

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease characterized by heterogeneous manifestations and severity, with frequent lung involvement. Among pulmonary function tests (PFT), the measure of the diffusing capacity of the lungs for carbon monoxide (DLCO) is a noninvasive and sensitive tool assessing pulmonary microcirculation. Asymptomatic and isolated DLCO alteration has been frequently reported in SLE, but its clinical relevance has not been established.

METHODS

This retrospective study focused on 232 SLE patients fulfilling the 2019 EULAR/ACR classification criteria for SLE. Data were collected from the patient's medical record, including demographic, clinical, and immunological characteristics while DLCO was measured when performing PFT as part of routine patient follow-up.

RESULTS

At the end of follow-up, DLCO alteration (<70% of predicted value) was measured at least once in 154 patients (66.4%), and was associated with a history of smoking as well as interstitial lung disease (ILD), but was also associated with renal and neurological involvement. History of smoking, detection of anti-nucleosome autoantibodies and clinical lymphadenopathy at diagnosis were independent predictors of DLCO alteration, while early cutaneous involvement with photosensitivity was a protective factor. DLCO alteration, at baseline or anytime during follow-up was predictive of admission in intensive care unit and/or of all-cause death, both mainly due to severe disease flares and premature cardiovascular complications.

CONCLUSION

This study suggests a link between DLCO alteration and disease damage, potentially related to SLE vasculopathy, and prognostic value of DLCO on death or ICU admission in SLE.

Prevalence and risk factors of asthma in dairy farmers: Ancillary analysis of AIRBAg

BACKGROUND

Prolonged occupational agricultural exposure is associated with an increase in asthma diagnosis. This study aimed to identify the prevalence and risk factors for asthma in dairy farmers.

METHODS

AIRBAg was a cross-sectional study including 1203 representative dairy farmers. They completed a self-administered questionnaire and underwent a health respiratory check-up. Referral to a pulmonologist was made for any participant with wheezing, dyspnoea, chronic bronchitis, a chronic cough or a FEV₁/FEV₆ ratio<80%. They underwent further examinations such as spirometry with a reversibility test. Controls (non-asthmatic dairy farmers and non-farm employees) were matched to each asthma case for sex and age (±5 years). The odds ratios (OR) between asthma and different risk factors were estimated using conditional multivariate logistic regression models.

RESULTS

Active asthma was diagnosed in 107 (8.9%) farmers. Compared with control dairy farmers, there was a positive association with family history of allergy (OR = 8.68; 95% CI [4.26-17.69]), personal history of eczema (OR = 3.39; 95% CI [1.61-7.13]), hay manipulation (OR = 5.36, 95% CI [1.59-18.01]), and a negative association with farm area (OR = 0.92; 95% CI [0.85-0.99]) and handling treated seeds (OR = 0.47; 95% CI [0.23-0.95]). Compared with control non-farm employees, there was a positive association between asthma and family history of allergy (OR = 95.82, 95% CI [12.55-731.47]).

CONCLUSIONS

The prevalence of active asthma in dairy farmers was somewhat higher than the rate observed in the general population but may be controlled by reducing exposure to airborne organic contaminants through occupational adaptions on farms.

Prevalence and characteristics of persistent symptoms after non-severe COVID-19: a prospective cohort study

We performed a prospective cohort study of 311 outpatients with non-severe COVID-19 (187 women, median age 39 years). Of the 214 (68.8%) who completed the 6-week follow-up questionnaire, 115 (53.7%) had recovered. Others mostly reported dyspnea (n = 86, 40.2%), weight loss (n = 83, 38.8%), sleep disorders (n = 68, 31.8%), and anxiety (n = 56, 26.2%). Of those who developed ageusia and anosmia, these symptoms were still present at week 6 in, respectively, 11/111 (9.9%) and 19/114 (16.7%). Chest CT scan and lung function tests found no explanation in the most disabled patients (n = 23). This study confirms the high prevalence of persistent symptoms after non-severe COVID-19.

Use of the COPD Assessment Test (CAT) to screen for COPD in dairy farmers: AIRBAg study

OBJECTIVES

People at risk of chronic obstructive pulmonary disease (COPD) can benefit from appropriate medical management before severe symptoms appear. This study assesses the value of the COPD Assessment Test (CAT) questionnaire for screening dairy farmers, who tend to be slow or reluctant to seek health care.

METHODS

During the time period 2012-2017, 2089 randomly selected dairy farmers in Brittany (France) were invited to complete self-administered questionnaires (including the CAT) and to undergo an occupational health check-up using an electronic mini-spirometer and conventional spirometry. Those showing symptoms suggestive of COPD and/or a ratio FEV₁ /FEV₆ < 80% were sent to a pulmonologist for a further check-up, including spirometry with a reversibility test. Multivariate logistic models based on CAT scores and socio-demographic or work-related factors were developed to predict COPD.

RESULTS

The 1231 farmers who underwent the occupational health check-up included 1203 who met the inclusion/exclusion criteria. Pulmonologist identified 16 (1.3%) cases of COPD. A multivariate logistic regression model (covariates: CAT sum score, on-farm time, BMI, smoking status, free-stall mulching) provided an area under the receiver-operating characteristic curve (AUC) of 0.87 (95% CI: 0.75-0.98). Using a cut-off of 0.007 gave a sensitivity of 93.8% and a specificity of 62.4%. Another model that included CAT breathlessness and the same covariates performed marginally better (AUC = 0.88, 95% CI: 0.77-0.98).

CONCLUSION

Our predictive models can both benefit dairy farmers by providing early diagnosis and management of their COPD and avoid unnecessary, costly spirometry during the screening process.

Women and COPD: do we need more evidence?

The increasingly female face of chronic obstructive pulmonary disease (COPD) prevalence among women has equalled that of men since 2008, due in part to increased tobacco use among women worldwide and exposure to biomass fuels. This finding is supported by a number of characteristics. There is evidence of susceptibility to smoking and other airborne contaminants, along with epidemiological and phenotypic manifestations. COPD has thus become the leading cause of death in women in the USA. The clinical presentation is characterised by increasingly pronounced dyspnoea with a marked tendency towards anxiety and depression, undernutrition, nonsmall cell lung cancer (especially adenocarcinoma) and osteoporosis. Quality of life is also more significantly impacted. The theories advanced to explain these differences involve the role played by oestrogens, impaired gas exchange in the lungs and smoking habits. While these differences require appropriate therapeutic responses (smoking cessation, pulmonary rehabilitation, long-term oxygen therapy), barriers to the treatment of women with COPD include greater under-diagnosis than in men, fewer spirometry tests and medical consultations. Faced with this serious public health problem, we need to update and adapt our knowledge to the epidemiological changes.

The face of COPD is increasingly female. We need more evidence and a change in how the disease is managed. http://ow.ly/zueL30mWqlS

Prevalence and risk factors of chronic obstructive pulmonary disease in dairy farmers: AIRBAg study

BACKGROUND

The AIRBAg study was designed to assess the prevalence of chronic obstructive pulmonary disease (COPD) in dairy farmers and to define its associated risk factors.

METHODS

Between March 2012 and February 2017 randomly selected dairy farmers in the French region of Brittany were asked to complete a self-administered questionnaire and undergo an occupational health check-up with electronic mini-spirometry and standard spirometry. Those having one or more of the following features: chronic cough, chronic bronchitis, wheezing, dyspnea and/or a ratio FEV₁/FEV₆ < 80% were then referred to a pulmonologist for further check-up including spirometry with a reversibility test. Each COPD case was matched with three controls (dairy farmers and non-farm employees), for sex and age ( ± 5 years). Conditional multivariate logistic regression models were used to estimate the odds ratios between COPD occurrence and various risk factors.

RESULTS

The 1203 farmers examined included 525 (43.6%) who were "at risk of bronchial obstruction" and 432 (35.9%) of these saw the pulmonologist. This screening identified 16 (1.3%) cases of COPD, including eight non-smokers and five with an FEV₁ < 80% of predicted values. Their average age was 54.6 ( ± 7.7) years and 10 of them were men. None complained of illness before the study. Multivariate analyses revealed no significant occupational risk factors for COPD.

CONCLUSIONS

This unexpected result may be because Breton dairy farms began to modernize early (1950s), giving rise to conditions with much lower exposure to airborne contaminants.

[Targeted screening of COPD in primary care: Feasibility and effectiveness]

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a common but under-diagnosed pathology in primary care. The objective was to study the feasibility of a randomized controlled trial in general practice to detect new cases of COPD at an earlier stage.

METHODS

A cluster randomized, controlled, multicenter intervention study comparing, according to a 2×2 factorial plan, two case finding strategies: a systematic GOLD-HAS hetero-questionnaire and coordination of the patient's path to facilitate access to spirometry. The PIL-DISCO pilot study took place in 2017. Patients between 40 and 80 years old, with no previous history of COPD, consulting their GP on a given day regardless of the reason, were included.

RESULTS

176 patients were included in 1.5 days. Spirometry was performed in none of the control arm, in 13 (29.5%) of the questionnaire arm, in 22 (50%) in the coordination arm and in 32 (72.7%) with the combination of the two strategies. Two cases of stage 2 COPD and thirteen other respiratory diseases were diagnosed.

CONCLUSIONS

This study confirms the feasibility of the protocol in primary care in terms of speed of inclusion and acceptability. An extension phase aiming to include 3200 patients will assess the diagnostic value of the two strategies tested in general practice.

What are the best indicators to assess malnutrition in idiopathic pulmonary fibrosis patients? A cross-sectional study in a referral center

OBJECTIVES

Little is known about the indicators to assess malnutrition in patients with idiopathic pulmonary fibrosis (IPF). This study aimed to determine the following: 1) the prevalence of malnutrition in IPF patients; 2) the nutritional indicators predictive of low fat-free mass (FFM) as measured by bioimpedance analysis; 3) the IPF patients' characteristics associated with low FFM.

METHODS

The IPF patients were consecutively recruited in a referral center for rare pulmonary diseases. Malnutrition was defined as a fat-free mass index (FFMI) = FFM (kg) / (height [m]²) <17 (men) or <15 (women). Nutritional assessment included body mass index (BMI), mid-arm circumference (MAC), triceps skinfold thickness, analogue food intake scale, and serum albumin and transthyretin. The primary endpoint was FFMI. Area under the receiver operating characteristic curve (AUC) assessed low FFMI prediction from nutritional indicators. Multivariable logistic regression determined variables associated with low FFMI.

RESULTS

Eighty-one patients were consecutively recruited. Low FFMI prevalence was 28% (23 of 81). BMI AUC was 0.91 (95% confidence interval [CI], 0.84‒0.97) and MAC AUC was 0.85 (0.76‒0.94). Multivariable analysis associated BMI (odds ratio [OR] 0.26 [95% CI, 0.12-0.54], P = 0.0003), male sex (OR 0.02 [0.00-0.33], P = 0.005), and smoking (OR 0.10 [0.01-0.75], P = 0.024) with a lower risk of malnutrition.

CONCLUSIONS

Malnutrition occurred in nearly one-third of IPF patients. Malnutrition screening should become systematic based on BMI and MAC, which are good clinical indicators of low FFMI. We propose a practical approach to screen malnutrition in IPF patients.

Role of serum immunoglobulins for predicting sarcoidosis outcome: A cohort study

Background

Sarcoidosis is a systemic granulomatous disease which carries variable outcomes. Serum protein electrophoresis is an easily accessible and routinely performed examination at diagnosis, in order to search for hypergammaglobulinemia, which is frequently found, and to rule out other granulomatous diseases such as common variable immunodeficiency. We aimed to assess the impact of baseline immunoglobulin level on the outcome of sarcoidosis.

Methods

We conducted a retrospective cohort-study, at Rennes University Hospital, in which all newly diagnosed patients for whom a serum protein electrophoresis had been performed at baseline were enrolled, from 2006 to 2014. The main outcome was the need for corticosteroid treatment within 2 years from diagnosis, the secondary outcome was the occurrence of relapse among treated patients.

Results

Eighty patients were included in the study, and 41.25% of them exhibited an elevated globulins rate. In univariate analysis, an elevated ACE level >70 U/l, Afro-Caribbean origin, and extra-pulmonary involvement, were associated with the need for corticosteroid treatment. In multivariate analysis, only ACE elevation (OR = 1.03, IC95% 1.01–1.05, p = 0.009) and extra-pulmonary involvement (OR = 5.8, IC95% 1.4–24, p = 0.015) were significant. Immunoglobulin level was not associated with the main outcome. Regarding the secondary outcome, none of the studied features were predictive of relapse among the 34 treated patients followed for two years.

Conclusions

There was no relation between the immunoglobulin level at diagnosis and the evolution of sarcoidosis. An elevated ACE level and the presence of initial extra-pulmonary involvement were both associated with a more severe course of the disease necessitating a corticosteroid treatment.

Prevalence and risk factors for COPD in farmers: a cross-sectional controlled study

There are conflicting data regarding the magnitude and determinants of chronic obstructive pulmonary disease (COPD) risk in farmers.In a cross-sectional study of 917 nonfarming working controls and 3787 farmers aged 40-75 years, we assessed respiratory symptoms, tobacco exposure, job history (without direct exposure measurement) and lung function. COPD was defined by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criterion (post-bronchodilator forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.70) and by the Quanjer reference equation (post-bronchodilator FEV1/FVC <lower limit of normal (LLN)).The prevalence (95% CI) of COPD according to the GOLD criterion was 5.1% (4.4-5.8%) and 2.9% (1.8-4.0%) in farmers and controls, respectively (p=0.005), and 3.1% (2.5-3.6%) and 1.5% (0.7-2.3%), respectively, for the LLN criterion (p<0.01). For both COPD criteria after adjustment for age, sex and smoking status, COPD prevalence was similar in controls and crop farmers. Compared to controls, four job categories had a higher prevalence of COPD according to the GOLD criterion, namely, cattle breeders, swine breeders, poultry breeders and breeders of two or more livestock types. Among cattle breeders, only those from Franche-Comté had higher prevalence of COPD according to both GOLD and LLN criteria.The prevalence of COPD in farmers is higher than in nonfarming working controls, and depends on the farming activity, the region and the criterion used to define COPD.

Which pelvic ring fractures are potentially lethal?

PURPOSE

Global mortality of polytraumatised patients presenting pelvic ring fractures remains high (330%), despite improvements in treatment algorithms in Level I Trauma Centers. Many classifications have been developed in order to identify and analyse these pelvic ring lesions. However, it remains difficult to predict intra-pelvic haemorrhage. The aim of this study was to identify pelvic ring anatomical lesions associated with significant blood loss, susceptible to lead to life-threatening haemorrhage.

MATERIAL AND METHOD

This study focused on a retrospective analysis of patients' medical files, all of whom were admitted to one of the shock rooms of Grenoble University Hospital, France, between January 2004 and December 2008. Treatment was given according to the institutional algorithm of the Alps Trauma Center and Emergency North Alpine Network Trauma System (TRENAU). Different hemodynamical parameters at arrival were measured, and the fractures were classified according to Young and Burgess, Tile, Letournel and Denis. One hundred and ninety seven patients were analysed. They were subdivided into two groups, embolised (Group E) and non-embolised (Group NE).

RESULTS

Group NE included 171 patients with a mean age of 40.2 ± 8.7 years (15-90). Group E included 26 patients with a mean age of 41.6 ± 5.3 years (18-67). Twenty-six patients died during the initial treatment phase. Eleven belonged to Group E and 15 to Group NE. Mortality was significantly higher in Group E (42.3% vs 8.8% in Group NE) (p < 0.05). There were significantly many more Tile C unstable fractures in Group E (p = 0.0014), and anterior lesions, according to Letournel, with pubic symphysis disruption were significantly more likely to lead to active bleeding treated by selective embolisation (p = 0.0014). Posterior pelvic ring lesions with iliac wing fracture and transforaminal sacral fractures (Denis 2) were also more frequently associated with bleeding treated by embolisation (p = 0.0088 and p = 0.0369 respectively).

DISCUSSION/CONCLUSION

It appears that in our series the primary identification and classification of osteo-ligamentous lesions (according to Letournel and Denis' classifications) allows to anticipate the importance of bleeding and to adapt the management of patients accordingly, in order to quickly organise angiography with embolisation.

Detecting active pelvic arterial haemorrhage on admission following serious pelvic fracture in multiple trauma patients

BACKGROUND

The early diagnosis of pelvic arterial haemorrhage is challenging for initiating treatment by transcatheter arterial embolization (TAE) in multiple trauma patients. We use an institutional algorithm focusing on haemodynamic status on admission and on a whole-body CT scan in stabilized patients to screen patients requiring TAE. This study aimed to assess the effectiveness of this approach.

METHODS

This retrospective cohort study included 106 multiple trauma patients admitted to the emergency room with serious pelvic fracture [pelvic abbreviated injury scale (AIS) score of 3 or more].

RESULTS

Of the 106 patients, 27 (25%) underwent pelvic angiography leading to TAE for active arterial haemorrhage in 24. The TAE procedure was successful within 3h of arrival in 18 patients. In accordance with the algorithm, 10 patients were directly admitted to the angiography unit (n=8) and/or operating room (n=2) for uncontrolled haemorrhagic shock on admission. Of the remaining 96 stabilized patients, 20 had contrast media extravasation on pelvic CT scan that prompted pelvic angiography in 16 patients leading to TAE in 14. One patient underwent a pelvic angiography despite showing no contrast media extravasation on pelvic CT scan. All 17 stabilized patients who underwent pelvic angiography presented a more severely compromised haemodynamic status on admission, and they required more blood products during their initial management than the 79 patients who did not undergo pelvic angiography. The incidence of unstable pelvic fractures was however comparable between the two groups. Overall, haemodynamic instability and contrast media extravasation on the CT-scan identified 26 out of the 27 patients who required subsequent pelvic angiography leading to TAE in 24.

CONCLUSIONS

An algorithm focusing on haemodynamic status on arrival and on the whole-body CT scan in stabilized patients may be effective at triaging multiple trauma patients with serious pelvic fractures.

Influence of vitamin E acetate and other lipids on the phase behavior of mesophases based on unsaturated monoglycerides

The phase behavior of the ternary unsaturated monoglycerides (UMG)-DL-α-tocopheryl acetate-water system has been studied. The effects of lipid composition in both bulk and dispersed lyotropic liquid crystalline phases and microemulsions were investigated. In excess water, progressive addition of DL-α-tocopheryl acetate to a binary UMG mixture results in the following phase sequence: reversed bicontinuous cubic phase, reversed hexagonal (H(II)) phase, and a reversed microemulsion. The action of DL-α-tocopheryl acetate is then compared to that of other lipids such as triolein, limonene, tetradecane, and DL-α-tocopherol. The impact of solubilizing these hydrophobic molecules on the UMG-water phase behavior shows some common features. However, the solubilization of certain molecules, like DL-α-tocopherol, leads to the presence of the reversed micellar cubic phase (space group number 227 and symmetry Fd3m) while the solubilization of others does not. These differences in phase behavior are discussed in terms of physical-chemical characteristics of the added lipid molecule and its interaction with UMG and water. From an applications point of view, phase behavior as a function of the solubilized content of guest molecules (lipid additive in our case) is crucial since macroscopic properties such as molecular release depend strongly on the phase present. The effect of two hydrophilic emulsifiers, used to stabilize the aqueous dispersions of UMG, was studied and compared. Those were Pluronic F127, which is the most commonly used stabilizer for these kinds of inverted type structures, and the partially hydrolyzed emulsifier lecithin (Emultop EP), which is a well accepted food-grade emulsifier. The phase behavior of particles stabilized by the partially hydrolyzed lecithin is similar to that of bulk sample at full hydration, but this emulsifier interacts significantly with the internal structure and affects it much more than F127.

Long-term evaluation of respiratory status after esophageal atresia repair

RATIONALE

Esophageal atresia (EA) is a congenital malformation. Nowadays, its initial prognosis is excellent thanks to improvements in neonatal and surgical management. However, the assessment of long-term respiratory outcome has become necessary in affected children and was thus performed in this study. The benefits of cardiopulmonary function testing were also examined.

METHODS

The medical records of 77 children operated on for EA between 1990 and 2004 were reviewed. The results of respiratory function testing and cardiopulmonary response to effort were collected, together with neonatal and anthropometric data.

RESULTS

Acceptable measurements were obtained in 31 children with EA. These children were comparable to the ones lost during follow-up. The results of pulmonary function tests (PFTs) were abnormal in 21 cases (68%). A poor ventilatory response was detected in 14 children (45%) by cardiopulmonary function testing. Ten children who had abnormal results on PFTs were not under any anti-asthmatic treatment.

CONCLUSIONS

Impaired lung function was noted in children with repaired EA. Indeed, cardiopulmonary function tests results correlated with standard spirometric parameters and revealed minimal clinical symptoms. Moreover, many children with EA had a limited ventilatory reserve (VR). These results indicate that respiratory symptoms are often neglected in children with repaired EA and reinforce the need to provide adequate treatment.

Microbiological changes and diversity in autochthonous non-toxigenic Corynebacterium diphtheriae isolated in France

Autochtonous toxigenic Corynebacterium diphtheriae have disappeared in mainland France, but non-toxigenic C. diphtheriae are still circulating. Using phenotypic and molecular tools, we retrospectively characterized 103 non-toxigenic C. diphtheriae collected in mainland France and highlight several changes. The proportion of C. diphtheriae belfanti increased between 1977 and 2011 and it is the most frequent biotype recovered in recent years. Resistance to ciprofloxacin has increased and most isolates with decreased sensitivity belong to the belfanti biotype. Using multilocus sequence typing, we demonstrate that French isolates are distributed in a large number of sequence types and identify three distinct lineages. C. diphtheriae mitis and gravis form lineage I while C. diphtheriae belfanti forms lineages II and III. Almost all isolates of lineage II are part of a unique clonal complex or are very close to it. Most French isolates have a dtxR sequence homologous to that of toxigenic isolates, suggesting that if lyzogenised by a corynephage, they can express diphtheria toxin.

Insertion sequences shared by Bordetella species and implications for the biological diagnosis of pertussis syndrome

The molecular diagnosis of pertussis and parapertussis syndromes is based on the detection of insertion sequences (IS) 481 and 1001, respectively. However, these IS are also detected in the genomes of various Bordetella species, such that they are not specific for either B. pertussis or B. parapertussis. Therefore, we screened the genome of recently circulating isolates of Bordetella species to compare the prevalence of IS481, IS1001 and, also IS1002 with previously published data and to sequence all IS detected. We also investigated whether the numbers of IS481 and IS1001 copies vary in recently circulating isolates of the different Bordetella species. We used the polymerase chain reaction (PCR) method for screening the genome of circulating isolates and to prepare the fragments for sequencing. We used Southern blotting and quantitative real-time PCR for quantification of the numbers of IS. We found no significant diversity in the sequences of the IS harboured in the genomes of the Bordetella isolates screened, except for a 71-nucleotide deletion from IS1002 in B. bronchiseptica. The IS copy numbers in the genome of recently circulating isolates were similar to those in reference strains. Our results confirm that biological diagnosis targeting the IS481 and IS1001 elements are not specific and detect the species B. pertussis, B. holmesii and B. bronchiseptica (IS481), and B. parapertussis and B. bronchiseptica (IS1001).

Evolution of French Bordetella pertussis and Bordetella parapertussis isolates: increase of Bordetellae not expressing pertactin

Bordetella pertussis and Bordetella parapertussis are closely related bacterial agents of whooping cough. Whole-cell pertussis (wP) vaccine was introduced in France in 1959. Acellular pertussis (aP) vaccine was introduced in 1998 as an adolescent booster and was rapidly generalized to the whole population, changing herd immunity by specifically targeting the virulence of the bacteria. We performed a temporal analysis of all French B. pertussis and B. parapertussis isolates collected since 2000 under aP vaccine pressure, using pulsed-field gel electrophoresis (PFGE), genotyping and detection of expression of virulence factors. Particular isolates were selected according to their different phenotype and PFGE type and their characteristics were analysed using the murine model of respiratory infection and in vitro cell cytotoxic assay. Since the introduction of the aP vaccines there has been a steady increase in the number of B. pertussis and B. parapertussis isolates collected that are lacking expression of pertactin. These isolates seem to be as virulent as those expressing all virulence factors according to animal and cellular models of infection. Whereas wP vaccine-induced immunity led to a monomorphic population of B. pertussis, aP vaccine-induced immunity enabled the number of circulating B. pertussis and B. parapertussis isolates not expressing virulence factors to increase, sustaining our previous hypothesis.

Internal organisation in polyelectrolytes/oppositely charged surfactants colloidal complexes anticipating precipitated nanostructures

In this paper, we relate the periodic nanostructures found in the colloidal complexes and the concentrated phases obtained with polyelectrolyte/surfactant aqueous solutions. We present small-angle X-ray scattering studies of the self-organisation of the anionic polymer carboxymethylcellulose with three cationic quaternary ammonium surfactants with different head and tail groups: hexadecyl trimethyl, hexadecyl ethyl dimethyl and didodecyl dimethyl ammonium bromides. We investigated the mesophases obtained above a precipitation threshold. The mixed solutions with the double-chained surfactant led to lamellar phases, in which the repeat distance only depends on the surfactant/carboxyl charge molar ratio. We show that an internal lamellar organisation already takes place in the dilute phase containing colloidal complexes found below the precipitation threshold.

Comparison of arsenic concentrations in simultaneously-collected groundwater and aquifer particles from Bangladesh, India, Vietnam, and Nepal

One of the reasons the processes resulting in As release to groundwater in southern Asia remain poorly understood is the high degree of spatial variability of physical and chemical properties in shallow aquifers. In an attempt to overcome this difficulty, a simple device that collects groundwater and sediment as a slurry from precisely the same interval was developed in Bangladesh. Recently published results from Bangladesh and India relying on the needle-sampler are augmented here with new data from 37 intervals of grey aquifer material of likely Holocene age in Vietnam and Nepal. A total of 145 samples of filtered groundwater ranging in depth from 3 to 36 m that were analyzed for As (1-1000 mug/L), Fe (0.01-40 mg/L), Mn (0.2-4 mg/L) and S (0.04-14 mg/L) are compared. The P-extractable (0.01-36 mg/kg) and HCl-extractable As (0.04-36 mg/kg) content of the particulate phase was determined in the same suite of samples, in addition to Fe(II)/Fe ratios (0.2-1.0) in the acid-leachable fraction of the particulate phase. Needle-sampler data from Bangladesh indicated a relationship between dissolved As in groundwater and P-extractable As in the particulate phase that was interpreted as an indication of adsorptive equilibrium, under sufficiently reducing conditions, across 3 orders of magnitude in concentrations according to a distribution coefficient of 4 mL/g. The more recent observations from India, Vietnam and Nepal show groundwater As concentrations that are often an order of magnitude lower at a given level of P-extractable As compared to Bangladesh, even if only the subset of particularly reducing intervals characterized by leachable Fe(II)/Fe >0.5 and dissolved Fe >0.2 mg/L are considered. Without attempting to explain why As appears to be particularly mobile in reducing aquifers of Bangladesh compared to the other regions, the consequences of increasing the distribution coefficient for As between the particulate and dissolved phase to 40 mL/g for the flushing of shallow aquifers of their initial As content are explored.

Comparison of arsenic concentrations in simultaneously-collected groundwater and aquifer particles from Bangladesh, India, Vietnam, and Nepal

One of the reasons the processes resulting in As release to groundwater in southern Asia remain poorly understood is the high degree of spatial variability of physical and chemical properties in shallow aquifers. In an attempt to overcome this difficulty, a simple device that collects groundwater and sediment as a slurry from precisely the same interval was developed in Bangladesh. Recently published results from Bangladesh and India relying on the needle-sampler are augmented here with new data from 37 intervals of grey aquifer material of likely Holocene age in Vietnam and Nepal. A total of 145 samples of filtered groundwater ranging in depth from 3 to 36 m that were analyzed for As (1-1000 mug/L), Fe (0.01-40 mg/L), Mn (0.2-4 mg/L) and S (0.04-14 mg/L) are compared. The P-extractable (0.01-36 mg/kg) and HCl-extractable As (0.04-36 mg/kg) content of the particulate phase was determined in the same suite of samples, in addition to Fe(II)/Fe ratios (0.2-1.0) in the acid-leachable fraction of the particulate phase. Needle-sampler data from Bangladesh indicated a relationship between dissolved As in groundwater and P-extractable As in the particulate phase that was interpreted as an indication of adsorptive equilibrium, under sufficiently reducing conditions, across 3 orders of magnitude in concentrations according to a distribution coefficient of 4 mL/g. The more recent observations from India, Vietnam and Nepal show groundwater As concentrations that are often an order of magnitude lower at a given level of P-extractable As compared to Bangladesh, even if only the subset of particularly reducing intervals characterized by leachable Fe(II)/Fe >0.5 and dissolved Fe >0.2 mg/L are considered. Without attempting to explain why As appears to be particularly mobile in reducing aquifers of Bangladesh compared to the other regions, the consequences of increasing the distribution coefficient for As between the particulate and dissolved phase to 40 mL/g for the flushing of shallow aquifers of their initial As content are explored.

Nanostructures of colloidal complexes formed in oppositely charged polyelectrolyte/surfactant dilute aqueous solutions

Small-angle neutron scattering measurements were performed on dilute solutions of carboxymethylcellulose/DTAB complexes in water in order to determine their size, shape and internal structures. At low polymer content, the complexes are spherical, rather monodisperse and probably made of polymer chains intercalated between surfactant micelles. Moreover, we show that these micelles have a similar cubic arrangement than found in polymer/surfactant precipitates formed at higher surfactant concentrations. At larger polymer content, in the semi-dilute polyelectrolyte regime, the complexes are larger, softer and polydisperse. However, they possess a similar internal structure in both regimes. Carboxymethylcellulose/CTAB complexes are also large, soft and polydisperse but do not seem to exhibit well-defined internal structures.

Circulation of a type 1 recombinant vaccine-derived poliovirus strain in a limited area in Romania

After intensive immunisation campaigns with the oral polio vaccine (OPV) as part of the Global Polio Eradication Initiative, poliomyelitis due to wild viruses has disappeared from most parts of the world, including Europe. Here, we report the characterization of a serotype 1 vaccine-derived poliovirus (VDPV) isolated from one acute flaccid paralysis (AFP) case with tetraplegia and eight healthy contacts belonging to the same small socio-cultural group having a low vaccine coverage living in a small town in Romania. The genomes of the isolated strains appeared to be tripartite type 1/type 2/type 1 vaccine intertypic recombinant genomes derived from a common ancestor strain. The presence of 1.2% nucleotide substitutions in the VP1 capsid protein coding region of most of the strains indicated a circulation time of about 14 months. These VDPVs were thermoresistant and, in transgenic mice expressing the human poliovirus receptor, appeared to have lost the attenuated phenotype. These results suggest that small populations with low vaccine coverage living in globally well-vaccinated countries can be the origin of VDPV emergence and circulation. These results reaffirm the importance of active surveillance for acute flaccid paralysis and poliovirus in both polio-free and polio-endemic countries.

Increased extracellular matrix metalloproteinase inducer (EMMPRIN) expression in pulmonary fibrosis

Extracellular matrix metalloproteinase inducer (EMMPRIN) was examined on bronchoalveolar lavage fluids (BALFs) and lung tissue from patients with fibrosis (usual interstitial pneumonia-idiopathic pulmonary fibrosis [UIP-IPF], n = 15; diffuse parenchymal lung diseases without IPF characteristics on computerized tomography scan, n = 8) and without fibrosis (n = 6). In UIP-IPF, EMMPRIN staining was increased in areas of fibrosis, mainly in macrophages and in epithelial cells. EMMPRIN was also found in the extracellular medium with significant levels in patients with lung fibrosis compared to subjects without fibrosis. Moreover, macrophages from patients with lung fibrosis spontaneously produce EMMPRIN. These findings show that EMMPRIN is increased in lung fibrosis.

Intérêts et difficultés d’interprétation du coefficient de transfert du CO (TLCO/VA)

INTRODUCTION

Interpreting measurements of carbon monoxide can be problematic.

STATE OF THE ART

The transfer factor (TLCO) is usually calculated by multiplying the decrease in alveolar CO concentration between the beginning and the end of a 10 second breath hold (KCO) by the alveolar volume (VA). Thus a reduced TLCO may occur due to either a low KCO, a reduced VA, or a combination of both.

PERSPECTIVES

A careful examination of KCO and VA will usually suggest a specific explanation for a reduction in TLCO. In restrictive lung diseases from extrapulmonary origin, TLCO is low but TLCO/VA [[/INF 120% of the reference values. In interstitial lung disease, the value of TLCO/VA depends on whether the loss of lung units is diffuse or not, and probably also on the status of the microcirculation. In airflow obstruction, a low VA is caused by uneven distribution of inspired He/CO mixture within the breath-hold time.

CONCLUSIONS

The transfer factor for carbon monoxide is best interpreted in terms of its components, alveolar volume and carbon monoxide transfer coefficient.

Advances and prospects on biosynthesis, structures and functions of venom proteins from parasitic wasps

Molecular and biochemical properties of parasitoid Hymenoptera's venom proteins are currently receiving an increasing interest. In this review, we will highlight the progress that has been made over the past 10 years in fundamental research on this field. Main knowledge acquired on the structural features of parasitoid venom peptides, proteins and enzymes will be summarized and discussed and several examples showing the diversity of their biological functions will be given with respect to future prospects and applications.

[Diffusing capacity for carbon monoxide (T(LCO)) and oxygen saturation during exercise in patients with cystic fibrosis]

OBJECTIVES

To estimate the value of diffusing capacity for carbon monoxide (T(LCO)) in patients with cystic fibrosis and to evaluate its ability to predict arterial desaturation during exercise.

METHOD

Fourty-four patients (9-30 years) with cystic fibrosis performed pulmonary function tests with measure of T(LCO) and a bicycle incremental exercise test. They represent a wide variation in disease severity: mean Shwachman score: 77.8 (range: 40-100), mean FEV1%: 72.8 (range: 17-131). This study investigated the relationship between T(LCO), lung volumes and exercise data.

RESULTS

T(LCO) remained normal for a long time in patients with cystic fibrosis: 82% of them show a normal T(LCO) (mean value: 91.3% of predicted). T(LCO) was significantly correlated with FEV(1), residual volume, maximal work load and maximum oxygen uptake. A fall in arterial oxygen saturation was uncommon in our study (five patients) and not significantly correlated with T(LCO).

CONCLUSIONS

T(LCO) is a good criter of severity of cystic fibrosis but remains unreliable to predict values above which physical activity is safe, without arterial desaturation. Exercise tests should be proposed in order to evaluate exercise adaptation of each patient and determine which factor limits maximal performance.

Asobara, braconid parasitoids of Drosophila larvae: unusual strategies to avoid encapsulation without VLPs

Ichneumonoidae parasitoids have been well described for their regulatory effects on host physiology which are usually associated with the activity of polydnaviruses (PDVs) or viruslike-particles (VLPs) injected by the female wasps at oviposition. Among them, parasitoids of the braconid families display specific characteristics like the required activity of secretions from the maternal venom glands or of teratocytes from embryological origin. However, none of these features were observed in two braconid species of the Asobara genus parasitizing Drosophila hosts. In the absence of PDVs and VLPs, the two species A. tabida and A. citri seem to have developed unique strategies to avoid immunity defenses and to succeed in their Drosophila larval hosts. The aim of this study is to report on the complex relationships of braconid parasitoids with their hosts and to present some of the insights from studying Drosophila parasitoids.

[The spread of the wild Poliovirus in the rural environment, the case of the Adzopé health district, Côte d'Ivoire]

Wild Poliovirus spreading in rural environment in Adzopé, Côte d'Ivoire In order to determine the level of wild Poliovirus spreading among rural children in an endemic poliomyelitis country 469 stools samples, from children aged between three weeks and twelve years old were processed according to WHO procedures for transportation, conservation, isolation and identification of Poliovirus. Intratypic differenciation was performed by an antigenic method using monoclonal antibodies and a genomic RFLP (Restriction Fragment Length Polymorphism). 50 Poliovirus strains (10.7%) were isolated and analyzed: 15 vaccine-like Poliovirus type 1 (30%), 30 vaccine-like Poliovirus type 2 (60%), 4 vaccine-like Poliovirus type 3 (8%) and one wild Poliovirus type 3 (2%). As expected, in the major cases the duration of post-vaccinal viral excretion did not exceed two months. However, in 14% of cases, it varied between 3 and 9 months after the third OPV dose. This long excretion could be due to an inefficient local intestinal immunity or no local immunity at all, in spite of the three OPV doses. These results argue in favor of an increase of the number of OPV doses in such endemic zones. Moreover, OPV strains are well-known to revert to pathogenicity in vaccinees, therefore, the long term excretion of pathogenic OPV derived strains by a certain amount of vaccinees needs to be considered quite seriously.

Genomic features of intertypic recombinant sabin poliovirus strains excreted by primary vaccinees

The trivalent oral poliomyelitis vaccine (OPV) contains three different poliovirus serotypes. It use therefore creates particularly favorable conditions for mixed infection of gut cells, and indeed intertypic vaccine-derived recombinants (VdRec) have been frequently found in patients with vaccine-associated paralytic poliomyelitis. Nevertheless, there have not been extensive searches for VdRec in healthy vaccinees following immunization with OPV. To determine the incidence of VdRec and their excretion kinetics in primary vaccinees, and to establish the general genomic features of the corresponding recombinant genomes, we characterized poliovirus isolates excreted by vaccinees following primary immunization with OPV. Isolates were collected from 67 children 2 to 60 days following vaccination. Recombinant strains were identified by multiple restriction fragment length polymorphism assays. The localization of junction sites in recombinant genomes was also determined. VdRec excreted by vaccinees were first detected 2 to 4 days after vaccination. The highest rate of recombinants was on day 14. The frequency of VdRec depends strongly on the serotype of the analyzed isolates (2, 53, and 79% of recombinant strains in the last-excreted type 1, 2, and 3 isolates, respectively). Particular associations of genomic segments were preferred in the recombinant genomes, and recombination junctions were found in the genomic region encoding the nonstructural proteins. Recombination junctions generally clustered in particular subgenomic regions that were dependent on the serotype of the isolate and/or on the associations of genomic segments in recombinants. Thus, VdRec are frequently excreted by vaccinees, and the poliovirus replication machinery requirements or selection factors appear to act in vivo to shape the features of the recombinant genomes.

[Spontaneous resolution of a giant pulmonary bulla]

There are different causes leading to formation of pulmonary bullae, in particular tuberculosis. There is some debate concerning the pathophysiology of bullae extension although two mechanisms are put forward: partial obstruction of the airways and elastic recoil of adjacent lung parenchyma with a negative pressure in the bullae. Pulmonary function tests are highly perturbed in patients with giant bullae. The natural history of bullae is enlargement although spontaneous regression is rarely described. Bullae should be resected in selected patients, others require careful follow-up. We present the case of a man with tuberculosis who developed a giant pulmonary bulla that regressed spontaneously in a few years.

Natural genetic exchanges between vaccine and wild poliovirus strains in humans

In a previous study of poliovirus vaccine-derived strains isolated from patients with vaccine-associated paralytic poliomyelitis (VAPP) (9, 11), we reported that a high proportion (over 50%) of viruses had a recombinant genome. Most were intertypic vaccine/vaccine recombinants. However, some had restriction fragment length polymorphism (RFLP) profiles different from those of poliovirus vaccine strains. We demonstrate here that five such recombinants, of 88 VAPP strains examined, carried sequences of wild (nonvaccine) origin. To identify the parental wild donor of these sequences, we used RFLP profiles and nucleotide sequencing to look for similarity in the 3D polymerase-coding region of 61 wild, cocirculating poliovirus isolates (43 type 1, 16 type 2, and 2 type 3 isolates). In only one case was the donor identified, and it was a wild type 1 poliovirus. For the other four vaccine/wild recombinants, the wild parent could not be identified. The possibility that the wild sequences were of a non-poliovirus-enterovirus origin could not be excluded. Another vaccine/wild recombinant, isolated in Belarus from a VAPP case, indicated that the poliovirus vaccine/wild recombination is not an isolated phenomenon. We also found wild polioviruses (2 of 15) carrying vaccine-derived sequences in the 3' moiety of their genome. All these results suggest that genetic exchanges with wild poliovirus and perhaps with nonpoliovirus enteroviruses, are also a natural means of evolution for poliovirus vaccine strains.

[Intense campaign for vaccination with the oral polio vaccine: what are the repercussions on the enterovirus world?]

To eradicate poliomyelitis and poliovirus, intensive vaccination campaigns with oral polio-vaccine (OPV) have been organised. Eradication campaigns may well be successful because the antiviral immunity and the local intestinal immunity due to OPV in particular avoids and/or limits poliovirus circulation. These campaigns give interesting opportunities for studying the impact of viral vaccines on the viral world in terms of ecological and genetic virology. The pre-eradication phase we are now entering brings with it two kinds of problems. First, the major disadvantage of OPV is the genetic and phenotypic variability of the vaccine strains. This variability leads to the spread of potentially pathogenic strains, which can be implicated in vaccine-associated paralytic poliomyelitis (VAPP). Genetic changes are characterised by point mutations and by genetic exchanges among OPV strains, between OPV and wild strains and perhaps between poliovirus and non-polio enteroviruses (ENPV). The fact that a few OPV mutant strains have been shown to multiply and/or to circulate for long periods suggests that OPV could sustain a reservoir of pathogenic poliovirus strains. Second, there are ecological considerations. The disappearance of wild poliovirus through OPV vaccination could be due not only to antiviral local immunity but also to competition between OPV strains and wild strains for infecting the digest tract. Moreover, a competition between OPV and other enteroviruses may take place in a common ecological niche. To our knowledge, the possible impact of intensive OPV vaccination campaigns on the ENPV populations has never been considered. Because the goal of poliovirus eradication may be reached in the near future, there is worry as to the possible evolution of ENPV towards highly epidemic and pathogenic strains. This is leading those laboratories involved in poliomyelitis surveillance not only to search for remaining wild poliovirus strains but also to study the possible long-term circulation of OPV strains and to develop efficient ENPV surveillance.

Molecular epidemiology of poliovirus infection in Tunisia

This report is an overview of poliomyelitis surveillance in Tunisia from 1991 to 1996. In all, 2088 stool specimens, collected from 152 acute flaccid paralysis (AFP) cases and from 1747 of their healthy contacts were investigated. Virus isolation was done systematically in RD and HEp-2C cell lines and isolated viruses were typed by sero-neutralisation as polioviruses or non-polio enteroviruses. Poliovirus isolates were analysed systematically for their wild or vaccine-related origin by two methods--one based on antigenic differences and one on genetic differences between strains. All type 2 polioviruses were vaccine-related and most wild viruses belonged to polio serotype 3. Wild polio type 3 viruses were detected in 1991 and 1992 in six cases of paralytic polio. A silent circulation of wild polio 1 and wild polio 3 was detected in 1994. No wild virus was detected in Tunisia from 1995 onwards. Wild polioviruses were sequenced and compared with Tunisian wild strains isolated during the 1980s, as well as other genotypes from the international database. These investigations revealed a single Tunisian polio 3 genotype that has been circulating from 1985 to 1994 and two different polio 1 genotypes. These results reflect effective control strategies within the country and contribute to the improvement of the polio eradication programme effectiveness at national and global levels.